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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
History of Present Illness:
___ male with history of metastatic pancreatic cancer to
the lungs and liver presenting with right side pain. The pain
began abruptly the morning of presentation, was present in the
axilla and chest, not associated with palpitations, chest
pressure. It is associated with dyspnea on exertion and
pleuritic chest pain. No fevers, chills, or cough. Patient had
C2D8 Gemzar/Abraxane on ___. Has been using his oral
analgesics at home without significant relief. Has had multiple
episodes of non-bloody vomiting, unchanged from the week in
clinic, and a 3 lb weight loss in 3 days. Vitals in the ER:
99.1 57 ___ 100% RA
Pt received Zofran 4mg IV x2, Dilaudid 1mg IV, and IV heparin
ggt with a bolus (ER did not have a reason for choosing Heparin
over Lovenox)
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, Denies headache, sinus tenderness, rhinorrhea
or congestion. Denies cough, chest pain, chest pressure,
palpitations, diarrhea, constipation, abdominal pain. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes. All other ROS negative
.
Past Medical History:
ONCOLOGIC HISTORY: He presented to his primary care physician
on
___, with epigastric pain that was unrelieved with
antacids Prilosec or Protonix. Abdominal ultrasound at ___ on ___, showed multiple circumscribed
lesions
in both liver lobes that were suspicious for neoplasm. The
largest was 3.4 x 2.2 x 3.4 cm in the right lobe. He met with
Dr. ___ on ___, and started
hydrochlorothiazide for hypertension and a Prevpac for positive
H. pylori as was detected on routine screening labs that were
drawn on ___. A CT of the abdomen and pelvis was
performed and showed numerous hypoenhancing liver lesions
without
biliary dilatation. There is an ill-defined soft tissue
abutting
the pancreatic head and neck, measuring 3 x 2.8 x 4 cm with a
similar focus of tissue along the periphery of the distal
pancreatic body without pancreatic ductal dilatation. He had
extensive peripancreatic aortocaval and left paraaortic
lymphadenopathy that appeared to be causing at least a partial
gastric outlet obstruction. His labs were remarkable for an ALT
of 391 and AST of 151 and alkaline phosphatase of 392 and a
total
bilirubin of 2.88, CEA was 37.2 and his CA ___ was
approximately
45,000. On ___, an ERCP showed a 2 cm stricture in
the common bile duct consistent with a prestenotic biliary
dilatation, a biliary stent was placed, and common bile duct
brushings were performed. These were negative for malignant
cells. On ___, he underwent an endoscopic
ultrasound with Dr. ___ demonstrated a mass measuring
3.2 x 2.4 cm in the pancreatic neck, which was hypoechoic and
heterogeneous in echotexture with irregular and poorly defined
borders. There was suspicion for invasion into the splenic vein
and SMV as well. Multiple liver lesions were seen in the left
lobe. FNA of the pancreatic head mass as well as the celiac
lymph node demonstrated positive cytology for adenocarcinoma,
poorly differentiated and cell block was consistent with a
signet
ring morphology. We initially saw him on ___, he
had significant abdominal pain despite frequent p.r.n.
oxycodone,
and he was jaundiced with a bilirubin of 7.1 and unable to
tolerate any oral liquids. In addition, he had had no bowel
movement for three weeks. He was admitted to the hospital and
eventually discharged on ___. ERCP was performed
with removal of his common bile duct stent and replacement of
the
right and left hepatic ducts stents with improvement in his
total
bilirubin to 3. He had a bowel movement after enemas and was
able to tolerate p.o.s without nausea and vomiting. An
attempted
celiac plexus neurolysis was made, but not performed due to
inability to identify the plexus due to surrounding adenopathy.
He was initiated on long-term oxycodone and p.r.n. Dilaudid.
He began cycle 1, day 1 of gemcitabine and Abraxane
chemotherapy,
which were both dose reduced by 20% because of his total
bilirubin of 2.5. Chemo was held on cycle 1, day 8 because his
platelet count was 68,000. His serum sodium was also 126. He
received two liters of IV fluid and stopped hydrochlorothiazide.
He returned for second dose of gentamicin and Abraxane on
___, and had significant pruritus and evidence for
cellulitis on his nose, pain control was better. He was
admitted
to ___ on ___, through ___, with
nausea, vomiting, and diarrhea that resolved with supportive
care. C. difficile and norovirus testing was negative. This
was
felt to be most likely a viral gastroenteritis. He was seen
again on ___, for the institution of cycle 2, day 1 of
gemcitabine and Abraxane therapy
Past Medical Hx:
Hypertension
.
Social History:
___
Family History:
Patient denies family h/o GB, pancreatic CA. Father died of MI
at ___. Brother and mother are healthy.
Physical Exam:
Admission:
Vitals: T 97.9 bp 96/70 HR 84 RR 18 SaO2 98 RA Wt 181.8 lbs,
70.5"
GEN: ill-appearing, uncomfortable, awake
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions; right cheek has redness with pustule
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, diffusely tender and distended without rebound or
guarding. bowel sounds present
EXT: normal perfusion
SKIN: warm, dry, jaundiced
NEURO: no focal sensory or motor deficits
PSYCH: cooperative
Discharge:
VITALS: 98.1, 109/76. 83. 17 93% RA
GEN: ill-appearing, comfortable, awake
HEENT: alopecia, supple neck, moist mucous membranes, no
oropharyngeal lesions; right cheek has redness with pustule
PULM: normal effort, CTAB, no rales, wheezes or rhonchi
CV: RRR II/VI systolic murmur throughout precordium, no gallops
or rubs
ABD: soft, no tenderness to palpation, no rebound or guarding,
no HSM
EXT: normal perfusion, no C/C/E, 2+ DP, no cords along lower
legs, negative ___ signs bilaterally
SKIN: warm, dry
NEURO: no focal sensory or motor deficits
PSYCH: cooperative
Pertinent Results:
Admission:
___ 03:01AM ___ PTT-29.2 ___
___ 11:43PM LACTATE-1.8
___ 11:35PM GLUCOSE-102* UREA N-6 CREAT-0.6 SODIUM-130*
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-22 ANION GAP-19
___ 11:35PM cTropnT-<0.01 proBNP-89
___ 11:35PM WBC-8.7 RBC-3.77* HGB-11.7* HCT-34.5* MCV-92
MCH-31.1 MCHC-33.9 RDW-15.9*
___ 11:35PM NEUTS-80.3* LYMPHS-15.9* MONOS-0.8* EOS-2.7
BASOS-0.2
___ 11:35PM PLT COUNT-226
Discharge:
___ 08:00AM BLOOD WBC-2.1* RBC-2.91* Hgb-8.9* Hct-26.7*
MCV-92 MCH-30.8 MCHC-33.5 RDW-15.6* Plt ___
___ 08:00AM BLOOD Glucose-98 UreaN-4* Creat-0.6 Na-139
K-3.6 Cl-103 HCO3-29 AnGap-11
___ 08:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.6
Imaging:
Radiology Report CHEST (PA & LAT) Study Date of ___ 11:41
___ FINDINGS: There is minimal bilateral lower lobe atelectasis.
The lungs are otherwise clear. The heart size is normal. The
mediastinal contours are normal. There are no pleural
effusions. No pneumothorax is seen.
IMPRESSION: No acute cardiac or pulmonary findings
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of ___ 12:25 AM
CHEST CT: There are widespread bilateral pulmonary emboli, with
thrombus seen along the distal aspects of both the right and
left main pulmonary arteries, extending into multiple bilateral
segmental and subsegmental branches of all pulmonary lobes.
There is no leftward bowing of the intraventricular septum to
suggest right heart strain. The right ventricular outflow tract
is normal in caliber. The thoracic aorta is normal in caliber.
Scattered aortic calcifications are seen. There are also
scattered coronary artery
calcifications. The heart is normal in size. There is no
pericardial
effusion. Small mediastinal lymph nodes do not meet CT size
criteria.
Prominent bilateral hilar lymph nodes measure up to 8 mm on the
right and 7 mm on the left, increased in size compared to the
prior CT from ___, likely reactive. There are no
pathologically enlarged axillary lymph nodes. Lymph nodes
within the epipericardial space measure up to 13 x 6 mm (2:81),
not significantly changed.
There is biapical pleuroparenchymal thickening/scarring, right
greater than left, not significantly changed. Scattered
bilateral pulmonary nodules measuring up to 5 mm in the right
upper lobe (3:69, 74, 94, 132) are not significantly changed
compared to the prior CT from ___. There is
subsegmental bilateral upper and lower lobe dependent
atelectasis. There is also paraseptal emphysema as well as mild
centrilobular emphysema, similar in appearance to the prior
study. The tracheobronchial tree is patent to the segmental
level bilaterally. There are no pleural effusions.
This study was not optimized for evaluation of the
subdiaphragmatic contents. Limited assessment of the upper
abdomen demonstrates innumerable hepatic
metastases, increased in size and number compared to prior CT
from ___. A biliary stent is partially imaged, new
compared to the prior study. A 14-mm lymph node is seen along
the celiac axis.
BONE WINDOW: No suspicious lytic or blastic lesions are
identified.
Degenerative changes of the thoracic spine are noted.
IMPRESSION:
1. Widespread pulmonary emboli within the distal aspects of the
right and left pulmonary arteries as well as segmental and
subsegmental arteries throughout all lobes of the lungs. No
evidence of right heart strain.
2. Scattered pulmonary nodules, measuring up to 5 mm in the
right upper lobe, not significantly changed compared to the
recent CT from ___. Attention on followup studies
is warranted.
3. Innumerable hepatic metastases, increased in size and
number.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
2:25 AM
FINDINGS: There is no evidence of hemorrhage, edema, shift of
normally
midline structures, hydrocephalus, or infarction. Calcifications
are seen of the bilateral cavernous carotid arteries. The
visualized portions of the orbits are unremarkable. Minimal
mucosal thickening is seen within bilateral ethmoidal air cells.
The remainder of the visualized portions of the paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION: Normal study.
___ Radiology BILAT LOWER EXT VEINS : Preliminary L common
femoral into great saphenous clot ** Final Read Pending **
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
2. Morphine SR (MS ___ 90 mg PO Q8H
3. Lorazepam 0.5 mg PO Q6H:PRN Nausea
4. Ondansetron 8 mg PO Q8H:PRN Nausea
5. Prochlorperazine 10 mg PO Q6H:PRN Nausea
6. Senna 1 TAB PO BID:PRN constipation
7. PredniSONE 5 mg PO DAILY
8. traZODONE 100 mg PO HS:PRN insomnia
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Omeprazole 40 mg PO DAILY
11. Cephalexin 250 mg PO Q12H
started ___ for 10 days for facial abscess
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
2. Lorazepam 0.5 mg PO Q6H:PRN Nausea
3. Morphine SR (MS ___ 90 mg PO Q8H
4. Omeprazole 40 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. PredniSONE 5 mg PO DAILY
7. Prochlorperazine 10 mg PO Q6H:PRN Nausea
8. Senna 1 TAB PO BID:PRN constipation
9. traZODONE 100 mg PO HS:PRN insomnia
10. Ondansetron 8 mg PO Q8H:PRN Nausea
11. Mirtazapine 7.5 mg PO HS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
12. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL ___very twelve (12) hours
Disp #*60 Syringe Refills:*0
13. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 2 capsule(s) by mouth every six (6)
hours Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: pancreatic cancer, pulmonary emboli (blood clot in
lungs)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of metastatic pancreatic cancer, now with right chest and
axillary pain as well as shortness of breath. Evaluate for pulmonary
embolism.
COMPARISON: CT chest from ___. CT abdomen and pelvis from
___.
TECHNIQUE: MDCT axial images were acquired through the chest during the
administration of 100 cc of intravenous Omnipaque contrast material.
Multiplanar reformats were performed, including maximum intensity projection
oblique images.
TOTAL DLP: 494 mGy-cm.
CHEST CT: There are widespread bilateral pulmonary emboli, with thrombus seen
along the distal aspects of both the right and left main pulmonary arteries,
extending into multiple bilateral segmental and subsegmental branches of all
pulmonary lobes. There is no leftward bowing of the intraventricular septum
to suggest right heart strain. The right ventricular outflow tract is normal
in caliber. The thoracic aorta is normal in caliber. Scattered aortic
calcifications are seen. There are also scattered coronary artery
calcifications. The heart is normal in size. There is no pericardial
effusion. Small mediastinal lymph nodes do not meet CT size criteria.
Prominent bilateral hilar lymph nodes measure up to 8 mm on the right and 7 mm
on the left, increased in size compared to the prior CT from ___,
likely reactive. There are no pathologically enlarged axillary lymph nodes.
Lymph nodes within the epipericardial space measure up to 13 x 6 mm (2:81),
not significantly changed.
There is biapical pleuroparenchymal thickening/scarring, right greater than
left, not significantly changed. Scattered bilateral pulmonary nodules
measuring up to 5 mm in the right upper lobe (3:69, 74, 94, 132) are not
significantly changed compared to the prior CT from ___. There
is subsegmental bilateral upper and lower lobe dependent atelectasis. There
is also paraseptal emphysema as well as mild centrilobular emphysema, similar
in appearance to the prior study. The tracheobronchial tree is patent to the
segmental level bilaterally. There are no pleural effusions.
This study was not optimized for evaluation of the subdiaphragmatic contents.
Limited assessment of the upper abdomen demonstrates innumerable hepatic
metastases, increased in size and number compared to prior CT from ___. A biliary stent is partially imaged, new compared to the prior study.
A 14-mm lymph node is seen along the celiac axis.
BONE WINDOW: No suspicious lytic or blastic lesions are identified.
Degenerative changes of the thoracic spine are noted.
IMPRESSION:
1. Widespread pulmonary emboli within the distal aspects of the right and
left pulmonary arteries as well as segmental and subsegmental arteries
throughout all lobes of the lungs. No evidence of right heart strain.
2. Scattered pulmonary nodules, measuring up to 5 mm in the right upper lobe,
not significantly changed compared to the recent CT from ___.
Attention on followup studies is warranted.
3. Innumerable hepatic metastases, increased in size and number.
Radiology Report
INDICATION: History of metastatic pancreatic cancer, evaluate for brain
metastases prior to administration of heparin for pulmonary embolism.
COMPARISON: None.
TECHNIQUE: Sequential axial images were acquired through the head without the
administration of intravenous contrast material. Multiplanar reformats were
performed. CTDIvol 63, DLP 1026
FINDINGS: There is no evidence of hemorrhage, edema, shift of normally
midline structures, hydrocephalus, or infarction. Calcifications are seen of
the bilateral cavernous carotid arteries. The visualized portions of the
orbits are unremarkable. Minimal mucosal thickening is seen within bilateral
ethmoidal air cells. The remainder of the visualized portions of the
paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION: Normal study.
Radiology Report
INDICATION: ___ male with bilateral pulmonary embolism. Question
DVT.
COMPARISON: CTA dated ___.
FINDINGS: Grayscale and color Doppler sonograms were performed of bilateral
lower extremities. There is normal compressibility and color flow in the
right common femoral, superficial femoral, and popliteal veins, as well as
posterior tibial and peroneal veins.
On the left, there is expansion and near occlusive thrombosis of the common
femoral vein extending into greater saphenous vein. However, more distally,
there is normal color flow in the common femoral, superficial femoral, and
popliteal veins, as well as in the posterior tibial and peroneal veins.
IMPRESSION:
1. Left common femoral vein thrombosis extending into greater saphenous vein.
Distal extremity veins are patent.
2. Patent right lower extremity veins.
Findings reported to Dr. ___ at 10:05 a.m. via phone on ___ by Dr. ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RIGHT SIDE PAIN
Diagnosed with PULM EMBOLISM/INFARCT, MALIG NEO PANCREAS NOS, SECOND MALIG NEO LIVER
temperature: 99.1
heartrate: 57.0
resprate: 18.0
o2sat: 100.0
sbp: 108.0
dbp: 76.0
level of pain: 10
level of acuity: 2.0 | The patient is a ___ yo man with metastatic pancreatic cancer,
admitted with pleuritic chest pain and found to have widespread
pulmonary emboli.
# Bilateral multiple pulmonary emboli: Patient presented with
pleuritic R sided chest pain and was found to have multiple
bilateral pulmonary emboli. He was initially started on heparin,
which was quickly transitioned to lovenox. Patient remained
hemodynamically stable without an oxygen requirement. A lower
extremity ultrasound was performed on ___ which showed L
sided clot, final report pending at discharge. Patient
discharged on enoxaparin 80 mg every 12 hours. An IVC filter
could be considered as an outpatient, particularly if patient
fails anticoagulation.
# Pancreatic cancer: Pt with known pancreatic cancer and
metastases to lung, lymph nodes, and liver. He is on cycle 2 of
Gemzar/Abraxane and ___. MD is his oncologist.
Surveillance CT is scheduled for ___. He has transaminitis
due to liver metastases.
# Moderate malnutrition: Patient was prescribed prednisone
outpatient for apptetite. Nutrition consult placed. Patient
started on mirtazepine for appetite.
# Nausea and vomiting - Unclear if related to chemo, per recent
Onc note, it is not likely due to chemo or gastric obstruction
which is not complete. Acutely may be secondary to PO
antibiotics so Keflex was changed to Clindamycin for cellulitis.
# Cheek cellulitis - Keflex changed to clindamycin due to nausea
with Keflex. He will complete a total of 10 days of antibiotics
(end date ___.
# HTN: No longer on previous outpatient meds, but has been
normotensive. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / heparin
Attending: ___.
Chief Complaint:
tachypnea and respiratory distress
Major Surgical or Invasive Procedure:
___: Intubation and ventilation
___: ___ placement
History of Present Illness:
___ year old ___ lady with history of CAD (s/p
NSTEMI and new diagnosis of systolic CHF vs Takotsubo
cardimyopathy in ___, recent history of cold symptoms 4
days ago, who was brought in by ambulance to the ___ ED with
subjective fevers and chills, cough productive of sputum x3-4
days, and dyspnea. She is on intermittent oxygen at home but has
required constant oxygen ___ over last several days.
She denies chest pain and leg swelling. Comfortable on nasal
cannula until ___, became more tachycardic, hypoxic, and
tachypneic after a coughing fit. Her respiratory rate increased
to 32. She was placed on bipap and did not tolerate this, as
such she was intubated in the ED. Afterwards she was hypotensive
___, which was prolonged given that sedation was a
difficult (agitated, attempting to pull out ET tube). By the
time of transfer her BP was in mid ___, though was 130s/60s
before intubation. She was given 3.5 L NS, vanc/cefepime/azithro
for HCAP, and started on versed and fent drips.
In the ED, initial vitals: 08:32 0 98.7 103 125/52 18 99% 15L
Non-Rebreather.
On arrival to the MICU, she was intubated and sedated. Further
history was obtained from her two daughters (there is no HCP, so
they share joint decision making responsibility). She had cold
symptoms 4 days ago and seemed feverish. Cough was bothersome
and she couldn't lie down without coughing. No weight gain and
went to see Dr. ___ weeks ago and daughters note her
health has been stable.
Review of systems:
(+) Per HPI - recent subj fever, chills. No headache, diarrhea,
nausea, or vomiting. No NEW rash. No chest pain or palpitations.
Past Medical History:
Fall with head trauma ___, discharged AMA
Diabetes mellitus type II, A1c 6 in ___
Hypertension
Prior NSTEMI in ___ and ___, medically managed w/o
catheterization. NSTEMI ___ at ___, cardiac cath showed
moderate CAD: 50% ___ LAD lesion, 40% mid RCA lesion.
Systolic CHF with EF of 25% in ___ - concern for Takotsubo
Cardiomyopathy ___ fall (previously diagnosed with dCHF, EF 55%
in ___
HIT in ___ though has been on heparin products without incident
since that time
legally blind
Hard of hearing (L ear is good ear)
Past Surgical History:
-Open cholecystectomy, ___
-Appendectomy
-Total abdominal hysterectomy
-Incisional hernia repair x3 (___). Procedure in
___ performed at ___ (___): exlap w/ primary repair of
incarcerated incisional hernia
-SBO with LOA, complex abdominal closure ___ c/b surgical
site infection
-MVA (pedestrian vs. car, ___, small SAH)
Social History:
___
Family History:
Per OMR, father with CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM
98.0 - 70/50 (-->93/52) - 90 - 22 - 100% on AC w/ RR 22, Vt 400,
PEEP 12, FiO2 75. I/o urine output 175
GENERAL: obese lady, intubated, sedated
HEENT: Sclera anicteric, PERRL, MM dry
NECK: supple, JVP not elevated, no cervical LAD
LUNGS: mechanical breath sounds bilaterally, no crackles or
wheeze
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
EXT: extremities are warm, well perfused, no clubbing, cyanosis
or edema
SKIN: large flesh-colored discrete non-confluent plaques w/o
scale or crust on abdomen and under breasts. 1x2 cm erosion on L
anterior abdomen w/o surrounding erythema.
NEURO: unable to follow commands, EOM appear to be intact. face
symmetric at rest. 2+ patellar reflexes.
DISCHARGE PHYSICAL EXAM
Vitals: 97.5 | 138/55 | 71 | 20 | 95%/1L
Is: 470
Os: 1000
Balance: -530
General: Heavy set elderly lady, sleeping comfortably in bed
with nasal cannula.
HEENT: Sclera anicteric, pale conjunctiva, dry MM, oropharynx
clear
Neck: supple, no LAD
Lungs: Limited due to adiposity. Improved breath sounds w/less
ronchi and crackles.
CV: Limited due to adiposity. Regular rate and rhythm, normal S1
+ S2.
Abdomen: Non-distended, 8x10 RLQ eventration covered by dry
dressings, BS+, soft,mildly tender on LLQ, limited deep
palpation.
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis. Ne
edema.
Skin: Dry, distally cold, non-elastic
Neuro: AOx3, diffuse muscular atrophy and weakness. Normal
sensation to light touch.
Pertinent Results:
ADMISSION LABS
___ 09:50AM GLUCOSE-159* UREA N-19 CREAT-1.0 SODIUM-137
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-19* ANION GAP-20
___ 09:50AM WBC-12.1*# RBC-4.68 HGB-10.9* HCT-35.2*
MCV-75* MCH-23.4* MCHC-31.1 RDW-17.1*
___ 09:50AM proBNP-464
___ 09:50AM cTropnT-<0.01
___ 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
DISCHARGE LABS
___ 05:24AM BLOOD WBC-6.7 RBC-4.30 Hgb-10.0* Hct-33.5*
MCV-78* MCH-23.2* MCHC-29.8* RDW-17.5* Plt ___
___ 05:24AM BLOOD Glucose-124* UreaN-35* Creat-1.1 Na-141
K-3.9 Cl-98 HCO3-35* AnGap-12
___ 05:24AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.4
Cr TRENDS
___ 05:24 1.1
___ 06:34 1.3*
___ 12:45 1.3*
___ 06:24 1.4*
___ 05:52 1.2*
___ 02:31 0.8
___ 16:24 0.8
___ 06:00 0.8
___ 21:00 0.8
___ 03:38 0.8
___ 19:31 0.7
___ 04:02 0.9
___ 02:44 0.9
___ 09:50 1.0
Studies
___
Bilateral scattered opacities in the lungs, most notable in the
left lung base and right upper lobe concerning for pneumonia.
___
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 hypokinesis
of the distal ___ of the left ventricle, most consistent with
Takotsubo cardiomyopathy, although LAD-territory infarction
cannot be excluded. The remaining segments contract normally
(LVEF delineated to be 40%). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets are mildly thickened (?#).
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
most c/w Takotsubo cardiomyopathy. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of ___, LV
function has substantially improved.
CHEST (PORTABLE AP) Study Date of ___ 3:47 AM
There is a right-sided PICC line with distal lead tip in the
distal SVC.
There is a left retrocardiac opacity and bilateral pleural
effusions which are moderate in size. There is mild pulmonary
edema. There are no
pneumothoraces. Overall, these findings are stable.
___ 9:54 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH. x2
___ 11:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 6:10 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH.
___ 1:40 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.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. GlyBURIDE 2.5 mg PO BID
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL EVERY ___. Torsemide 40 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
9. Warfarin 2 mg PO DAILY16
10. Isosorbide Mononitrate 30 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H
5. Artificial Tears ___ DROP BOTH EYES TID
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
7. Guaifenesin ___ mL PO Q6H
8. GlyBURIDE 2.5 mg PO BID
9. Nitroglycerin SL 0.3 mg SL EVERY ___. Ipratropium Bromide Neb 1 NEB IH Q6H
11. Miconazole Powder 2% 1 Appl TP BID:PRN yeast
12. Polyethylene Glycol 17 g PO DAILY
13. Milk of Magnesia 30 mL PO DAILY
14. Torsemide 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
#Hypoxic respiratory failure
#Healthcate Associated Pnemonia
#Decompensated Systolic Heart Failure
#Acute Kidney Failure
SECONDARY:
#Type 2 Diabetes Mellitus
#Severe constipation
___ Skin Infection
#Large Abdominal Incisional Hernia
#Deconditioning
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: ___ female with shortness of breath and hypoxia.
COMPARISON: Chest radiograph dated ___.
FINDINGS: AP upright frontal and lateral chest radiograph demonstrates
opacification of the left lung base concerning for atelectasis or aspiration.
Within the right upper lobe, there is a subtle opacity which is concerning for
pneumonia. There are mildly increased bronchovascular markings within the
upper lobes bilaterally. The cardiomediastinal and hilar contours are
unchanged since ___ examination with a heart size which is top
normal. There is no pleural effusion or pneumothorax.
IMPRESSION: Bilateral scattered opacities in the lungs, most notable in the
left lung base and right upper lobe concerning for pneumonia.
Radiology Report
HISTORY: Post-intubation.
TECHNIQUE: Portable frontal chest radiograph was obtained.
COMPARISON: Chest radiographs from ___ and ___.
FINDINGS: There has been interval placement of an endotracheal tube and
nasogastric tube. The endotracheal tube appears to be in appropriate position
terminating 4.5 cm above the carina. The nasogastric tube is seen passing
below the diaphragm. There continues to be a right upper and lower lobe
opacification and a possible retrocardiac opacity.
IMPRESSION: Appropriate position of ET tube and nasogastric tube. No
significant change in pulmonary opacities.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pneumonia and respiratory failure, now
intubated // interval change in RUL opacity
IMPRESSION:
In comparison with the study ___, the area of increased opacification in
the right upper zone has substantially cleared. Bibasilar opacifications
persist. Monitoring and support devices are unchanged.
Radiology Report
INDICATION: ___ year old woman with new R PICC // 41cm R brachial DL PICC -
___ ___ Contact name: ___: ___
TECHNIQUE: Portable chest x-ray.
COMPARISON: Multiple prior radiographs of the chest dated ___
through ___.
FINDINGS:
Portable semi upright radiograph of the chest demonstrates low lung volumes
which results in bronchovascular crowding. Bibasilar opacifications are
unchanged as compared to the prior study. The cardiomediastinal and hilar
contours are unchanged. The endotracheal tube ends 2.8 cm from the carinal. A
nasogastric tube courses into the stomach and out of field of view. A
right-sided PICC line ends at the cavoatrial junction.
IMPRESSION:
Right-sided PICC line ends at the cava atrial junction.
Radiology Report
INDICATION: ___ year old woman with acute respiratory distress // Assess for
interval change
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph ___ and ___.
FINDINGS:
The patient is now extubated. Enteric tube has been removed. Allowing for
differences in projection small bilateral pleural effusions are likely
slightly larger. Streaky opacity in the right upper lobe is resolved. There
may be increased pulmonary vascular congestion and mild interstitial pulmonary
edema. The heart is slightly larger. The mediastinal contours are normal.
IMPRESSION:
1. Increased heart size, now with moderate cardiomegaly and worsening mild to
moderate pulmonary edema.
2. Small bilateral pleural effusions are also likely larger.
Radiology Report
INDICATION: ___ year old woman with hypoxemic respiratory failure from
pneumonia and chf // assess for interval change
TECHNIQUE: Portable chest x-ray.
COMPARISON: Multiple prior radiographs of the chest dated ___
through ___.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates low lung volumes
results in bronchovascular crowding. There are moderate size bilateral pleural
effusions with adjacent atelectasis. Soft tissues of the head and neck overly
the lung apices. The cardiomediastinal and hilar contours are unchanged.
There is no pneumothorax. A right-sided PICC line is in unchanged position.
There has been interval removal of the endotracheal tube.
IMPRESSION:
Moderate bilateral pleural effusions with adjacent atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y/o F with pneumonia and CHF // Assess for interval change
Assess for interval change
IMPRESSION:
In comparison with the study ___, there is again enlargement of the
cardiac silhouette with evidence of pulmonary vascular congestion and
bilateral pleural effusions with compressive atelectasis at the bases. The
basilar opacification is less prominent than on the previous study, which
could either reflect decreasing pleural effusions or a more upright position
of the patient.
Radiology Report
STUDY: AP chest performed on ___.
CLINICAL HISTORY: ___ woman with shortness of breath. Evaluate for
pleural effusion versus pneumonia.
FINDINGS: Comparison is made to prior study from ___.
There is a right-sided PICC line with distal lead tip in the distal SVC.
There is a left retrocardiac opacity and bilateral pleural effusions which are
moderate in size. There is mild pulmonary edema. There are no
pneumothoraces. Overall, these findings are stable.
Radiology Report
STUDY: Portable abdomen, ___.
CLINICAL HISTORY: ___ woman with no stool for eight days. Evaluate
for ileus or small bowel obstruction.
FINDINGS: Comparison is made to radiographs of the pelvis from ___.
Images are somewhat limited as the patient could not lie supine and thus
decubitus radiographs were performed. These demonstrate air within the
stomach. There is also air within loops of colon, which are nondilated.
Stool is seen throughout the sigmoid colon. There are few air-filled loops of
small bowel within the left abdomen, which are mildly prominent. There is no
definite free intra-abdominal gas. Degenerative changes of the lower lumbar
spine and bilateral hip joint spaces are seen.
IMPRESSION:
Nonspecific bowel gas pattern with air and stool seen throughout the colon
extending into the rectum and sigmoid colon. There also appears to be
air-filled loops of mildly dilated loops of small bowel within the left
abdomen.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with CHF, pleural effusions // assess for
changes in effusions assess for changes in effusions
IMPRESSION:
In comparison with the study ___, there is again enlargement of the
cardiac silhouette with bilateral pleural effusions and compressive
atelectasis and mild to moderate pulmonary edema.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOXEMIA
temperature: 98.7
heartrate: 103.0
resprate: 18.0
o2sat: 99.0
sbp: 125.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old ___ lady with history
of CAD (s/p NSTEMI with sCHF - likely Takotsubo cardiomyopathy
___, recent history of viral URI, who initially
presented with subjective fevers and chills, cough productive of
sputum x3-4 days, and dyspnea. She was found to have HCAP and
acute systolic CHF exacerbation contributing to respiratory
failure (requiring intubation in the ICU).
# Acute hypoxemic respiratory failure, ___ HCAP and acute
systolic CHF exacerbation.
- Regarding HCAP: She was admitted with low grade fevers,
productive cough, and respiratory distress. She has a CXR which
was notable for bilateral opacifications within the left lung
base and right upper lobe concerning for pneumonia. Her BNP was
not elevated on admission, and initial CXR did not show evidence
of pulmonary edema. She was intubated in the ED for respiratory
distress since she was unable to tolerate bipap. She was
treated with Vanc/Cefepime and levofloxacin to cover HCAP and
atypicals. PICC placed. She was extubated on HD2 without
difficulty. She continued antibiotics for 8 days (day 1 =
___, course ending ___.
- Regarding pulmonary edema ___ acute systolic CHF exacerbation:
after extubation, patient continued to desat and was unable to
bring up secretions, also became tachycardic up to 140s with
episodes and likely had flash pulmonary edema in the setting of
being 4L LOS positive and having diuretic held. Improved with
diuresis and now stable on high flow and with diuresis. Once she
was called out to the floor she was gently diuresed until her
oxygen requirement was ___.
# CHF with EF 40%: Repeat echo showed improved EF of 40%.
Although she did not appear to have acute exacerbation of CHF on
admission; she likely had flash pulmonary edema above in the
setting of tachycardia, IVFs, and holding home diuretic.
Improvement with diuresis. She was diuresed with IV furosemide
(up to 80mg) with good response. Of note, she had likely
diagnosis of Takotsubo cardiomyopathy on prior admission in
___ but left AMA and without cardiology follow-up. Cardiology
was consulted during this admission, anticoagulation for LV
thrombus prevention was no longer recommended given improved EF
since last admission.
# Intermittent SVT: Treated with Metoprolol.
# Constipation: Patient did not have BM during first 9 days of
admission. When called out to the floor initial concern for SBO
given extensive surgical history and large ventral hernia but
had normal bowel sounds and soft/non-tender abdomen. She
received aggressive bowel regimen with PEG 17g tid and Mg
Citrate and 4x tap water enema. After this had ___ large loose
BMs for 1 day. Prior to discharge, did not have a BM in 24
hours. If continued diarrhea, should check c diff if concerned.
CHRONIC ISSUES
==================
# CAD with history of NSTEMIs, more recently ___: Negative
troponins on admission, negative for chest pain. Continued
aspirin, atorvastatin, beta blocker.
# Diabetes mellitus type II, A1c 6 in ___: Humalog ISS while
inpatient.
# History of HIT in ___. We used pneumoboots for prophylaxis.
# Hypertension: Held home Ace-I; restarted BB as above.
TRANSITIONAL ISSUES
======================
#Warfarin was stopped given improved EF from 25% to 40%, no
longer at high risk for LV thrombus, Cardiology consult agreed
with decision.
#Tenous volume status: Difficult balancing renal function
preservation with diuresis for O2 requirement. Requires daily
weights and close monitoring of volume status and titration of
diuresis.
#Needs weekly Chem-7 + Mg, Phos. More frequent if changes in
weight >3 lbs or increase in O2 requirement >3L. Baseline weight
88-89kg.
#When renal function and respiratory status stable may
progressively restart isosorbide dinitrate as well as lisinopril
pending BP.
#Discharged on PEG 17g qd and Milk of Mg 30mL qd, can uptitrate
to mininimum of 1BM q2d, if longer than that responds well to Mg
Citrate 150mL. Poor response to docusate, sennosides, bisacodyl.
#Needs to establish care with outpatient cardiologist.
#Is on home ___ intermittently, being discharged on ___
titrating to O2 sat of 92% (not higher to avoid hypercarbia).
#Bladder scan daily prn straight caths.
#Code Status: DNR, OK to intubate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, vomiting, ab pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with a history of pancreatic cancer s/p gemcitabine
. On further
interview w/ daughter who lives w/ pt, she was taken into BIN
clinic for IVF hydration as she was persistently nauseous and
not
eating for several days after receiving chemo. She had also had
fevers >100 on two occasions earlier in the week but none since
___. Prev treated for UTIs over past months but denied any
dysuria recently. Did have some ab pain but was not primary
cause
for bringing her in. On arrival she was transferred to ED, had
hypoxia to mid ___, developed restlessness thought to have
wheezing and respiratory distress and was placed on bipap
briefly
but then weaned to NC. She had CT ab that showed extensive
disease involving primary panc mass as well as celiac axis,
peritoneal nodules and umbilicus, new liver met, new possible
mets to endometrium and L ovary and unchanged abdominal LAD.
She
received IVF and IV antibiotics and was transferred to ___ for
further eval. On arrival she was afebrile w/o any ab pain or
SOB, NC weaned to RA.
she is eating, denies any nausea although does not have much
appetite, per daughter she has been forcing herself to eat for
several weeks. overall doing well since yest. remains on RA.
denies SOB but does have cough, w/ white phlegm, afebrile since
admission. cr up today and UOP decreased.
REVIEW OF SYSTEMS:
No fever/chills, chest pain, lightheadedness, melena,
hematochezia, sore throat, rhinorrhea, sinus pain/pressure. no
dysuria
remainder of 10 pt ROS negative other than HPI above.
REVIEW OF SYSTEMS:
- All reviewed and negative except as noted in the HPI.
Past Medical History:
Pancreatic Cancer
- Ms. ___ sustained a mechanical fall while walking her dog
on
___. She landed on her buttocks and then developed pain in
the left low back/left flank, which prompted her to present to
the ___ Emergency Department. CT abdomen/pelvis
incidentally identified a 2.9 cm mass in the pancreatic
head/body, multiple bilateral lung lesions concerning for
metastases as well as peripancreatic and retroperitoneal
lymphadenopathy. Also notable was a thickened endometrium. She
was discharged and met with her PCP who obtained ___ CA ___ on
___ which was elevated at 682. CT chest on ___ showed
widespread pulmonary nodules consistent with pulmonary
metastases. She underwent ___ biopsy of a right lower lobe
lung nodule on ___. Pathology showed adenocarcinoma with
immunostains positive for CK7, CEA, CDX2, focally positive for
CK20 and negative for TTF-1, and Napsin. The phenotype was
consistent with a pancreatico-biliary origin.
- Gemcitabine C1 ___.
PAST MEDICAL HISTORY:
-Hypertension.
-GERD.
-Depression.
-Status post cholecystectomy.
Social History:
___
Family History:
The patient's mother died at ___ years and her
father ___ years. She has five siblings. One brother died in a
war
at ___ years. Another brother died at ___ years of old age. A
brother died of pancreatic cancer at ___ years. A sister died of
___ disease at ___ years and another died at ___ years.
She
has a daughter who has asthma and a son without health concerns.
Physical Exam:
General: NAD
VITAL SIGNS: 98.1 110/70 78 18 98%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: decreased at bases o/w CTAB, nonlabored
ABD: mod distended but soft and tympanitis, BS active, firm 2cm
nodule palpable at umbilicus
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficitis.
Pertinent Results:
ADMISSION LABS:
___ 09:30AM BLOOD ___-15.5*# RBC-3.70* Hgb-10.5* Hct-32.0*
MCV-87 MCH-28.4 MCHC-32.8 RDW-14.5 RDWSD-45.5 Plt ___
___ 09:30PM BLOOD Neuts-93* Bands-5 Lymphs-1* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-10.58*
AbsLymp-0.11* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.00*
___ 09:30AM BLOOD UreaN-35* Creat-1.4* Na-128* K-4.5 Cl-94*
HCO3-20* AnGap-19
___ 09:30AM BLOOD ALT-21 AST-29 AlkPhos-90 TotBili-1.1
___ 09:30AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.7
DISCHARGE LABS:
___ 05:13AM BLOOD Glucose-100 UreaN-49* Creat-1.3* Na-131*
K-4.4 Cl-101 HCO3-20* AnGap-14
___ 05:13AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1
IMAGING:
CT abdomen;
CT Abdomen:
1. There is again seen a large hypo enhancing pancreatic mass
causing upstream pancreatic dilatation. There is increased
abnormal soft tissue now tracking up to encased the trifurcation
of the celiac artery and abutting the superior mesenteric
artery.
The splenic vein is occluded. Appearances are consistent with
local progression of disease.
2. No significant interval change in the numerous bibasal
pulmonary metastases.
3. Moderate right, small left pleural effusions increased when
compared the prior study.
4. Small volume ascites. Multiple peritoneal soft tissue
deposits have increased in size consistent with progressive
peritoneal metastatic disease. A soft tissue nodule is seen
within the umbilicus also.
5. New segment 5 liver lesion consistent with a metastasis. A
linear hypo enhancing structure also in segment 5 has increased
compared to the prior study but is of unclear etiology.
6. No significant interval change in the retrocrural,
retroperitoneal and mesenteric lymphadenopathy.
7. Fluid in the endometrial cavity with an apparent soft tissue
mass, this could reflect either a primary endometrial mass such
as a polyp or carcinoma versus metastatic disease. New
enlargement of the left ovary also concerning for metastatic
disease.
8. Enlarged gonadal vessels, particularly on the left, likely
related to occlusion of the splenic vein.
9. New hypo enhancing lesion within the spleen may reflect an
infarct versus an additional area of metastatic disease.
CT chest
IMPRESSION:
1. Numerous pulmonary nodules consistent with metastasis are
larger compared
to ___.
2. Small to moderate right and small left pleural effusions are
new.
3. Prominent pericardial lymph nodes are larger.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 12.5 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Meclizine 25 mg PO DAILY:PRN Dizziness
4. Omeprazole 20 mg PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN Nausea
6. Prochlorperazine 10 mg PO Q6H:PRN Nausea
7. Aspirin 81 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Albuterol Inhaler 1 PUFF IH DAILY
11. Mirtazapine 7.5 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Mirtazapine 7.5 mg PO QHS
3. Multivitamins 1 TAB PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN Nausea
5. Vitamin D ___ UNIT PO DAILY
6. Benzonatate 200 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID prn Disp #*90
Capsule Refills:*0
7. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 10 mL by
mouth every 6 hours as needed Refills:*0
8. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing, SOB
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 3 mL
inhaled every 4 hours as needed Disp #*30 Ampule Refills:*1
9. Meclizine 25 mg PO DAILY:PRN Dizziness
10. Omeprazole 20 mg PO DAILY
11. Prochlorperazine 10 mg PO Q6H:PRN Nausea
12. Ensure Clear (nut.tx.impaired digest fxn) 0.035-1
gram-kcal/mL oral TID W/MEALS
RX *nut.tx.impaired digest fxn [Ensure Clear] 0.035 gram-1
kcal/mL 200 mL by mouth TID w/ meals Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Severe nausea and vomiting
Dehydration
Acute kidney injury
Metastatic pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with metastatic pancreatic cancer and new
hypoxia. // Evaluate for cause of hypoxia.
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: Acquisition sequence: 1) Spiral Acquisition 5.1 s, 33.4 cm; CTDIvol =
5.4 mGy (Body) DLP = 177.5 mGy-cm. Total DLP (Body) = 178 mGy-cm.
COMPARISON: Chest CT without contrast ___
FINDINGS:
The thyroid is normal. Supraclavicular, axillary, and mediastinal lymph nodes
are not enlarged. Prominent pericardial lymph nodes are larger than before.
A 0.7 cm pericardial node (5:217) was 0.2 cm before. A Right jugular venous
line terminates in low SVC. Aorta and pulmonary arteries are normal size.
Heavy coronary artery calcification is noted. Trace pericardial effusion is
physiologic.
Evaluation of lung parenchyma is limited due to motion artifact. Numerous
pulmonary metastasis appear overall larger than before. For example, a 1.1 cm
lesion in the left upper lobe (5:120) was 0.9 cm before. A 1.6 cm lesion in
the lingula (5:152) was 1.0 cm before. Small to moderate right and small left
pleural effusions are new.
Limited evaluation of upper abdomen is notable for small ascites. Hypodensity
lesions in the liver were better evaluated on CT abdomen and pelvis with
contrast from 1 day ago.
Sclerotic lesions in T7 and 8 vertebral bodies are unchanged.
IMPRESSION:
1. Numerous pulmonary nodules consistent with metastasis are larger compared
to ___.
2. Small to moderate right and small left pleural effusions are new.
3. Prominent pericardial lymph nodes are larger.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Dyspnea
Diagnosed with Unspecified abdominal pain, Dyspnea, unspecified
temperature: 99.4
heartrate: 94.0
resprate: 24.0
o2sat: 100.0
sbp: 110.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | ___ yo female with a history of pancreatic cancer s/p gemcitabine
who transferred from ___ w/ N/V, ab pain and episode of
respiratory distress.
#N/V - timing consistent w/ chemo side effect. now resolved w/o
further intervention. No bowel obstruction or other acute cause
on ab CT.
#Ab pain - likely related to underlying disease, notable mass at
umbilicus and extensive peritoneal and pelvic implants.
currently
intermittent only, declines pain meds at this time
#Respiratory distress - Transient, arrived from BIN on bipap due
to dyspnea, quickly weaned to RA here. CXR at OSH concerning for
infiltrates she was given IV zosyn and levaquin. On CT chest
infiltrates c/w worsening pulm metastatic burden, no further abx
given. also has small bilat pleural effusions
___ - Cr elevated on presentation to BIN to 1.3, likely
prerenal
from dehydration. Received IVF at BIN. Cr further elevated to
2.1,
likely contrast nephropathy exacerbated by losartan use. FENA
0.24. Was given IVF hydration and resolved the following day
d/c losartan.
#Hyponatremia - Na drop 128 from 135 one week ago. likely
hypovolemic given hx vomiting, also possible SIADH precipitated
by nausea. stable to improved after IVF hydration
#Metastatic Pancreatic Cancer - extensive disease involving
peritoneum, lungs, pelvis also 2 likely liver mets.
- S/p C1 gemcitabine on ___.
- cont creon
- cont remeron for appetite stimulation
- Continue home Zofran
- pt will f/u w/ Dr ___ week
HTN
- pt on losartan and atenolol, ___ was held due to ___ as above
and BP remained low normal. She will hold all BP meds on
discharge and daughter will monitor BP at home and when she has
clinic visits
GERD
- cont PPI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pravachol / Lipitor
Attending: ___.
Chief Complaint:
SOB, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is an ___ with h/o Alzeihmer's dementia who p/w SOB
and new onset productive cough that started as a dry cough 3
days prior. She has had this since awakening this AM, worsening
throughout the day. EMS called for rr30's, SaO2 80's, but
afebrile by report. No O2 sat recorded there but 86% on RA per
EMS. Pt denies CP. States never been SOB previously. Per family,
no hx of CHF. Denies increased ___ edema. States she felt well
when she went to bed yesterday evening. Never had these symptoms
before.
.
In the ED, initial VS were: 96.4 104 168/84 36 95% 10L
Non-Rebreather. CXR showed lower lobe, ___ opacities c/w PNA,
aspiration, or atelectasis. Some vascular prominence concerning
for mild edema. BNP 4300. WBC 13 with neutrophil predominence.
Initial cardiac enzymes show CK-MB 11, MBI 5.4, troponin 0.11.
Discussed with cardiology who thought that MICU would be
appropirate given absence of cardiac history and no evidence of
ischemic changse on EKG. Given ASA, nitro SL, lasix 40mg IV x1,
vanc/ceftriaxone for HCAP.
.
On arrival to the MICU, the patient has advanced dementia and
can not participate in the interview. Talking to her son and
HCP, he says that she has been in her USOH until this AM. She
lives in an Alzheimers community. Her PMH is only significant
for hyperlipidemia and ? silent MI in the past. Her vitals on
admission are 99.9 ax, 94, 95% on CPAP ___.
.
Review of systems: (+) Per HPI
The rest is unable to be elicited by the patient
Past Medical History:
Advanced Alzheimers Dementia
Hyperlipidemia
Silent MI in the past (inferior Q-waves)
Critical Aortic Stenosis - valve area 0.6 cm
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM
98.2 ___ 143/82 rr24 on cpap CPAP 5cmH2O
General: Agitated, trying to get out of bed, AOx1
HEENT: Sclera anicteric, on BIPAP mask
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, loud ejection
murmur of AS, possible MR, no rubs, gallops
Lungs: Scattered rhonchi at bases, bibasilar crackles, no
wheezes, no increased work of breathing
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: nonfocal
.
On discharge:
Alert, pleasantly demented. Oriented only to self. Lungs with
diffuse rales but mostly clear, unlabored/no wheezing. On room
air. Soft, nontender abdomen. Harsh systolic murmur.
Pertinent Results:
ADMISSION LABS:
___ 05:35PM BLOOD WBC-13.2* RBC-4.43 Hgb-12.8 Hct-38.3
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.7 Plt ___
___ 05:35PM BLOOD Neuts-89.1* Lymphs-7.6* Monos-2.5 Eos-0.5
Baso-0.3
___ 05:35PM BLOOD Glucose-200* UreaN-22* Creat-0.7 Na-134
K-4.2 Cl-99 HCO3-23 AnGap-16
___ 05:35PM BLOOD CK(CPK)-202*
___ 05:35PM BLOOD CK-MB-11* MB Indx-5.4 proBNP-4350*
___ 01:40AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0
___ 10:22PM BLOOD Type-ART Temp-37.2 Rates-/27 Tidal V-400
PEEP-5 FiO2-100 pO2-85 pCO2-42 pH-7.44 calTCO2-29 Base XS-3
AADO2-603 REQ O2-96 Intubat-NOT INTUBA Vent-SPONTANEOU
Comment-NIV
___ 05:42PM BLOOD Lactate-2.2* K-4.0
.
MICRO DATA:
___ URINE Legionella Urinary Antigen: negative
___ BLOOD CULTURE x 2 (pending)
.
CXR ___:
IMPRESSION: Basilar opacities worrisome for pneumonia in the
appropriate
clinical setting although lower airway inflammation, atelectasis
or even
aspiration are other etiologies that could be considered in the
appropriate clinical setting. Although there is perhaps minimal
vascular prominence, since opacities are focal in the lower
lungs, pulmonary edema is doubted as the primary etiology but
could be seen with an atypical pattern.
.
TTE ___:
IMPRESSION: Critical aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Pulmonary artery hypertension. Mild aortic
regurgitation. Increased PCWP.
.
CTA ___:
IMPRESSION:
1. No evidence for PE.
2. Multifocal pneumonia involving the right upper, middle and
both lower
lobes with bilateral hilar lymphadenopathy.
3. No evidence for a mass.
.
Bladder ultrasound:
IMPRESSION: Foley catheter present within a collapsed bladder.
Superior to
the bladder there is a large cystic structure with no internal
nodules
identified. This may represent a paraovarian or ovarian cyst or
peritoneal
inclusion cyst. MRI pelvis is suggested for further
characterization
.
On discharge:
___ 06:50AM BLOOD WBC-10.8 RBC-3.51* Hgb-10.1* Hct-30.7*
MCV-88 MCH-28.7 MCHC-32.9 RDW-13.4 Plt ___
___ 05:40AM BLOOD ___ PTT-31.9 ___
___ 05:50AM BLOOD Glucose-92 UreaN-22* Creat-0.7 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
Medications on Admission:
MED LIST FROM ___
Seroquel 25mg BID
Seroquel 12.5mg daily PRN
Namenda 10mg BID
Donepezil 10mg daily
Citalopram 15mg daily
vitamin D 800IU daily
Nystatin cream
Discharge Medications:
1. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for agitation.
3. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. citalopram 10 mg Tablet Sig: 1.5 Tablets PO once a day.
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain/fever.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Pneumonia
Critical aortic stenosis
Rectal bleeding
NSTEMI
Peritoneal cyst
.
Secondary:
Advanced Alzheimers
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Has been getting
1-person assitance here.
Followup Instructions:
___
Radiology Report
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST
INDICATION: ___ woman with hypoxic respiratory distress, also with
smoking history and tracheal deviation. Evaluate for mass, pulmonary embolus.
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST, TECHNIQUE: Multidetector
scanning is performed from the thoracic inlet through the diaphragm prior to
and during dynamic injection of 100 cc of Omnipaque. No prior studies are
available for comparison.
There are small peritracheal lymph nodes, the largest node measures 0.9 x 0.8
cm. These do not meet CT criteria for pathologic enlargement. There is no
axillary lymphadenopathy. There is prominent soft tissue in the hilum
bilaterally. In the left hilum, this measures 1.1 x 1.1 cm. Right hilar
lymphadenopathy measures 1.5 x 1.4 cm. There are no pleural effusions. On
lung windows, there are focal opacities in the upper lobes, right more than
left, in the right middle lobe and both lower lobes. While some of these
areas enhance normally with IV contrast and thus represent atelectasis, other
foci are less enhancing (series 3, image 59 in the left lower lobe and series
3, image 55 in the right lower lobe). The trachea is somewhat deviated to the
right; however, this is due to the aortic arch. There is no mass causing
tracheal deviation.
The depicted portions of the liver and spleen are unremarkable.
On bone windows, there are no concerning osteolytic or osteosclerotic lesions.
CT ANGIOGRAPHY: The ascending aorta is normal in caliber measuring 2.7 cm.
There is no filling defect in the pulmonary arteries or its branches.
IMPRESSION:
1. No evidence for PE.
2. Multifocal pneumonia involving the right upper, middle and both lower
lobes with bilateral hilar lymphadenopathy.
3. No evidence for a mass.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pneumonia, oxygen requirement, evaluation for progression.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the pre-existing volume
loss in the middle lobe has improved. However, the pre-existing right basal
opacity, predominantly in peribronchial location and displaying multiple air
bronchograms, unchanged. Minimal improvement of a pre-existing retrocardiac
atelectasis, a pre-existing plate-like atelectasis at the left lung base has
resolved. Unchanged moderate cardiomegaly, no indication for pleural
effusions. Signs of mild fluid overload might be present.
Radiology Report
INDICATION: Advanced Alzheimer's and pneumonia. Please evaluate for urinary
retention as nursing continues to show greater than 700 cc on the bladder
scanner despite placement of a Foley catheter.
COMPARISON: None.
FINDINGS: The bladder is distended, with a calculated volume of 713 mL.
There is no Foley catheter identified within the bladder.
IMPRESSION: Distended bladder to 713 mL. No Foley catheter is seen within
the bladder.
Radiology Report
ULTRASOUND:
INDICATION: ___ woman with pneumonia and bladder over 70 mL. Please
evaluate disease. Foley balloon is visualized and bladder are not seen on
exam yesterday ? concern for cyst.
COMPARISON: Comparison is made to previous ultrasound dated ___.
FINDINGS: A Foley catheter is identified within a collapsed bladder.
Superior to the bladder, there is a 10.6 x 8.8 x 11.9 cm cystic structure with
no internal nodules or suspicious features, which is deviating the uterus
anteriorly.
There are multiple calcified fibroids within the uterus, the largest measuring
1.9 x 1.7 x 1.8 cm within the lower uterine segment. The uterus measures 4.5
x 2.7 cm in transverse dimension. Normal endometrial thickness of 4 mm. The
ovaries were not visualized bilaterally.
IMPRESSION: Foley catheter present within a collapsed bladder. Superior to
the bladder there is a large cystic structure with no internal nodules
identified. This may represent a paraovarian or ovarian cyst or peritoneal
inclusion cyst. MRI pelvis is suggested for further characterization.
Findings were discussed with Dr. ___ by phone with Dr. ___
___ at 1:46pm on ___.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Shortness of breath.
COMPARISONS: None.
TECHNIQUE: Chest, portable semi-upright AP portable.
FINDINGS: The heart is mild to moderately enlarged. Mild unfolding of the
thoracic aorta is noted. The pulmonary vascularity is minimally prominent.
Streaky left mid and lower lung opacities are probably compatible with minor
atelectasis, but there is also a vague retrocardiac opacity. There is more
widespread but patchy opacification involving the right lower lung, probably
in the right middle lobe, raising concern for pneumonia.
IMPRESSION: Basilar opacities worrisome for pneumonia in the appropriate
clinical setting although lower airway inflammation, atelectasis or even
aspiration are other etiologies that could be considered in the appropriate
clinical setting. Although there is perhaps minimal vascular prominence,
since opacities are focal in the lower lungs, pulmonary edema is doubted as
the primary etiology but could be seen with an atypical pattern.
Radiology Report
AP CHEST, 3:36 A.M., ___
HISTORY: ___ woman with cough, fever and hypoxia.
IMPRESSION: AP chest compared to ___, 5:24 p.m.:
Volume loss has developed in a region of prior consolidation in the right
lower lobe, probably in the course of developing pneumonia with retained
secretions. Atelectasis in the left mid lung is more linear. Moderate
cardiomegaly and mediastinal vascular engorgement have increased suggesting a
component of mild cardiac decompensation. Pleural effusions are small, if
any. No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with RESPIRATORY ABNORM NEC, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: 96.4
heartrate: 104.0
resprate: 36.0
o2sat: 95.0
sbp: 168.0
dbp: 84.0
level of pain: 0
level of acuity: 1.0 | Hospitalization Summary:
Ms. ___ is an ___ lady with advanced Alzheimer's dementia
who presented with sudden-onset SOB, cough, and slight fever.
She was admitted to the MICU, ruled out for PE, and was treated
for multifocal PNA. She completed an 8-day course of
broad-spectrum antibiotics for pneumonia and improved greatly
from a respiratory standpoint - breathing comfortably on room
air upon discharge and afebrile. She developed rectal bleeding
late in her hospital course on ___, likely diverticular or
hemorrhoidal bleed, but was stable from a hemodynamic and
hematocrit standpt for 5 days. GI recommended against
intervention and her family was in agreement with this plan.
.
ACTIVE ISSUES:
#. Pneumonia: Imaging was concerning for multifocal pneumonia
and the patient presented with a significant oxygen requirement,
was on BiPAP in the ICU. She was treated initially with
vancomycin/levofloxacin, but was broadened to
vancomycin/cefepime on ___ due to continued high oxygen
requirements. There was concern for aspiration pneumonia,
however, the patient did pass her speech and swallow evaluation
- recommended regular diet and thin liquids. She continued to
improve and an 8-day course of broad-spectrum antibiotics was
completed. The patient was breathing comfortably on room air on
discharge and was afebrile.
.
# Critical Aortic Stenosis: On echo, critical aortic stenosis
was discovered with value area of 0.6 cm2. The patient was
started on a low-dose beta-blocker (Toprol 25 mg qday). On
presentation, she was found to be in mildly decompensated CHF
and was gently diuresed. Discussion was held with her son and
daughter-in-law who did not want aggressive interventions -
valvuloplasty/valve replacement - considered. They agreed with
cardiology outpatient follow-up and this was arranged.
.
#. Troponin leak: Likely in the setting of illness/demand with
critical AS and LVH. The patient never complained of chest pain
and cardiac enzymes trended down (trop peaked at 0.25). She was
started on ASA 81 mg per day and BB.
.
# Rectal bleeding: The patient developed rectal bleeding on
___. She continued to have ___ episodes of bleeding per day.
She remained completely hemodynamically stable. Her Hct was also
stable for 5 days - ~ 30. She did not require any blood
transfusions. The bleeding was discussed with gastroenterology,
who recommended against intervention - they did not want to
perform colonoscopy. They thought the bleeding was likely either
related to hemorrhoids or diverticulum. The bleeding was also
discussed with the patient's family - HCP - ___ - who did
not want aggressive interventions. She has been consented for
blood (with son as HCP). ___ is attached with paperwork.
Would only transfuse if Hct drops below 25 (has not required any
transfusions here). Blood count should be checked every ___ days
as long as rectal bleeding is ongoing. This was discussed with
Dr. ___ at ___. Rectal bleeding
in the absence of acutely worsening anemia or hemodynamic
changes should not warrant rehospitalization - son requested
this be communicated.
.
# Bladder or ovarian cyst: There was initially concern for
urinary retention in this patient after the bladder ultrasound
continued to read high residual bladder volumes. A foley was
placed. Bladder ultrasound revealed a 10.6 x 8.8 x 11.9 cm
cystic structure. Final read: Superior to the bladder there is a
large cystic structure with no internal nodules identified. This
may represent a paraovarian cyst or peritoneal inclusion cyst.
The family did not want further intervention for this problem.
The cyst likely accounts for this patient's urinary urgency.
.
#. Dementia: Advanced Alzheimers.
She lived at ___. Per family, this
is her mental status baseline (alert, interactive, not
oriented). She was un-tethered (d/c foley, pneumoboots) and was
kept on her home dose of Seroquel, Namenda, and Donepezil. She
did intermittently and extra doses of prn seroquel. QTc was
normal.
.
# Bilateral hilar LAD: Seen on CXR. No mass was seen on CT scan.
.
# Transitional Issues:
- code status was DNR/DNI
- CONTACT: son ___: ___
- cardiology follow-up for aortic stenosis
- please read section above on rectal bleeding re: criteria for
rehospitalization |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Allopurinol And Derivatives
Attending: ___.
Chief Complaint:
AMS, fever
Major Surgical or Invasive Procedure:
___ Central venous line
History of Present Illness:
History of Present Illness: ___ year old male with history of
mild cognitive impairment, hyperlipidemia, BPH, and gout
presents with altered mental status, vomiting, and shaking
chills. He was watching ___ speak at the ___ and he
began to feel very cold and started vomiting. As the night went
on, he became more tired and less responsive and the wife called
EMS. She reported to them that he was not acting like himself
and was talking nonsense. On transfer, he became more lethargic
and even less responsive. Patient triggered on arrival for
altered mental status. ___ sugar was normal. He took his
first dose of donepezil tonight, but did not make any other
medication changes. No other localizing symptoms to speak of.
Per urgent care note from Dr. ___ experienced malaise with
numbness in his fingers and chills while in ___, ___
___ about 4 weeks ago. He was taken to the local emergency
room in that area (___) and
his symptoms of fever and malaise resolved since then. No
definite cause of this acute illness was found. There was a
concern about possible Lyme disease because of exposure to deer
near his home. The patient denies any tick bite and claims that
he rarely goes out in his yard, where they do have deer. He was
started on doxycycline for concern of potential Lyme exposure
given that they live in a wooded area. Lyme serology eventually
returned negative. The wife reports that his current symptoms
are very similar to this presentation, but he appeared more
confused this time.
In the ED, initial vitals were: 122 102/55 28 91% 2L NC. He
was following basic commands on arrival. Rectal temp of 103.
Labs were notable for low WBC at 3.5 and otherwise normal CBC.
Creatinine on 1.3 close to baseline and LFTs within normal
limits. Lactate originally at 4.3, then repeated at 5.7 after
2L NS. Urinalysis unremarkable and CXR clear. Head CT without
acute intracranial process and moderate paranasal sinus disease,
similar to prior. CT abd/pelv showed a hiatal hernia,
cholelithiasis w/o cholecystitis, nonspecific perinephric
stranding, enlarged prostate, small left fat-containing inguinal
hernia (similar to prior CT in ___. Without obvious
infectious cause, he was covered empirically with vanc/zosyn +
ceftriaxone. LP refused by wife. ___ pressures have trended
down to the SBPs ___ but wife also refused ___ placement so
patient was started on peripheral norepinephrine. 4th liter
hanging prior to transfer and SBPs in ___ with normal
oxygenation.
On arrival to the MICU, he continued to be hypotensive despite
uptitration of levophed and another 1L NS bolus. The wife is
amenable to a central line placement here in the unit and
willing to discuss further procedures needed for his care. The
patient is having word-finding difficulties per his baseline and
has trouble completing sentences. Orientation is therefore
difficult to assess.
Past Medical History:
PMH:
Uric acid nephrolithiasis s/p GU interventions in the past
Hypercholesterolemia
Gout (last attack ___ years ago)
PSH:
L URS with laser and cystolithalopaxy with ___ in ___
Cystolithalopaxy in ___
Social History:
___
Family History:
- Diabetes in uncles
- ___ Cancer in father
Physical ___: T: 98.2, BP:85/60, P: 101 R: 9, O2: 93% on 3L
General: eyes closed, responds to command intermittently but is
responsive to question, has difficulty forming his answers, no
acute respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Fasciculations evident in calves bilaterally (patient
unaware)
Neuro: CNII-XII intact, difficult to assess strength/sensation
given inability to follow commands reliably.
Pertinent Results:
___ 08:13PM LACTATE-5.4*
___ 07:24PM GLUCOSE-206* UREA N-19 CREAT-1.4* SODIUM-138
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-18* ANION GAP-21*
___ 07:24PM ALT(SGPT)-20 AST(SGOT)-27 ALK PHOS-29* TOT
BILI-0.3
___ 07:24PM CALCIUM-7.0* PHOSPHATE-3.8# MAGNESIUM-1.6
___ 07:24PM WBC-38.7* RBC-4.29* HGB-12.8* HCT-38.3*
MCV-89 MCH-29.8 MCHC-33.3 RDW-13.7
___ 02:52PM URINE ___ NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
___ 02:52PM URINE RBC-137* WBC-4 BACTERIA-FEW YEAST-NONE
EPI-0
___ 02:21PM LACTATE-6.8*
___ ___ Culture: GNR
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
MEROPENEM------------- S
TOBRAMYCIN------------ S
Imaging:
Echo ___
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen. Normal global and regional biventricular
systolic function.
___: NO GROWTH.
KUB ___:
IMPRESSION: No signs of obstruction or intraperitoneal free
air.
Prostate US ___
IMPRESSION:
1. No evidence of an abscess within the prostate.
2. Substantial BPH with a prostatic volume of 72 mL,
correlating with a
predicted PSA of 8.6.
___ CT abdomen, pelvis
IMPRESSION:
1. No acute intra-abdominal process; moderate colonic fecal
burden.
2. Hiatal hernia.
3. Enlarged prostate and left fat- and bladder-containing
inguinal hernia.
4. Mildly thickened left renal pelvis urothelium of unclear
significance; no
evidence of hydronephrosis or pyelonephritis.
___ CT head w/o contrast
IMPRESSION: Minimal paranasal sinus mucosal thickening.
Otherwise normal
study.
CXR ___
IMPRESSION: Low lung volumes but no evidence of pneumonia.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Meclizine 50 mg PO X1 PRN vertigo
2. Clotrimazole Cream 1 Appl TP QHS
to feet
3. Ibuprofen 200 mg PO DAILY pain
4. Donepezil 10 mg PO AT NOON WITH LUNCH
5. tadalafil *NF* 20 mg Oral q72h PRN erectile dysfunction
6. Probenecid ___ mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: E. Coli septic shock.
Secondary: Acute confusion on chronic mild cognitive impairment.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with fever and altered mental status.
STUDY: Portable AP upright chest radiograph.
COMPARISON: ___ chest radiograph.
FINDINGS: The heart size is within normal limits. Mediastinal contours
demonstrate calcified atherosclerotic disease of the aortic knob. The lung
volumes are low but clear of consolidation. There is no large pleural
effusion or pneumothorax.
IMPRESSION: Low lung volumes but no evidence of pneumonia.
Radiology Report
HISTORY: ___ male with increased lethargy, confusion, and vomiting.
STUDY: CT of the head without contrast; images were acquired in the soft
tissue and bone algorithms. Coronal and sagittal reformatted images were also
generated.
COMPARISON: ___.
FINDINGS: There is no evidence of hemorrhage, edema, or mass effect. The
gray-white matter differentiation is intact. The ventricles and sulci are
normal for age.
Moderate mucosal thickening is present in the lower frontal and ethmoid
sinuses. The mastoid air cells are clear. Mucosal thickening is also present
in the base of the maxillary sinuses bilaterally.
IMPRESSION: Minimal paranasal sinus mucosal thickening. Otherwise normal
study.
Radiology Report
HISTORY: ___ male with vomiting, fever, and lethargy.
STUDY: CT OF THE ABDOMEN AND PELVIS WITH CONTRAST; 130 cc of Omnipaque
intravenous contrast was administered without adverse reaction or
complication. Coronal and sagittal reformatted images were also generated.
COMPARISON: Abdomen CT from ___, and abdomen and pelvis CT from
___.
FINDINGS:
ABDOMEN: Bibasilar atelectasis is present as well as a small hiatal hernia.
Calcified atherosclerotic disease is present in the coronary arteries, and
mitral valve calcifications are also present.
The liver shows no focal lesion or intrahepatic biliary dilatation. The
gallbladder shows a single calcified layering stone, but no wall edema or
pericholecystic fluid. Spleen is normal in size. The pancreas is markedly
atrophic with a punctate calcification, possibly representing a degree of
chronic pancreatitis. The adrenal glands are normal appearing bilaterally.
The kidneys enhance with and excrete contrast symmetrically. Small
subcentimeter hypodensities in each kidney are too small to characterize, but
likely represents cysts. Mild urothelial thickening is present in the left
renal pelvis. Non-specific perinephric stranding is present bilaterally.
The small and large bowel show no evidence of wall edema or obstruction. The
colon demonstrates a moderate fecal burden. The aorta is of a normal caliber
along its course with areas of calcified and non-calcified atherosclerotic
disease present. Scattered subcentimeter retroperitoneal lymph nodes are seen
in the periaortic stations, but none meet pathologic size criteria. There is
no free air or free fluid.
PELVIS: The bladder is decompressed around a Foley balloon with herniation of
the left aspect of the bladder into the primarily fat-containing left inguinal
hernia. The prostate continues to be enlarged. There is no pelvic
lymphadenopathy or free fluid, and the rectum appears unremarkable.
BONES: There are no aggressive-appearing lytic or sclerotic lesions.
Mild-to-moderate degenerative changes are seen throughout the thoracolumbar
spine.
IMPRESSION:
1. No acute intra-abdominal process; moderate colonic fecal burden.
2. Hiatal hernia.
3. Enlarged prostate and left fat- and bladder-containing inguinal hernia.
4. Mildly thickened left renal pelvis urothelium of unclear significance; no
evidence of hydronephrosis or pyelonephritis.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Altered mental status, hypotension, new PICC line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient shows increased
vascular diameters and markings, likely reflecting mild pulmonary edema. The
patient has received a right internal jugular vein catheter. The tip projects
over the low SVC. There is no evidence of complication, notably no
pneumothorax. Normal size of the cardiac silhouette. No pleural effusions.
Radiology Report
INDICATION: Sepsis with increasing lactate and no localizing source. Concern
for occult prostatitis.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS: The seminal vesicles are full and symmetric. The central portion
of the prostate is expanded, consistent with benign prostatic hypertrophy.
Within the right lateral aspect of the prostate, there are two small cysts,
each measuring approximately 5 mm. There is no fluid collection within either
the prostate or seminal vesicles to suggest an abscess. The prostate measures
5.6 x 4.2 x 5.9 cm, yielding a volume of 72 mL. A Foley catheter is in place.
IMPRESSION:
1. No evidence of an abscess within the prostate.
2. Substantial BPH with a prostatic volume of 72 mL, correlating with a
predicted PSA of 8.6.
Radiology Report
INDICATION: ___ man with rapidly rising lactate and WBC count to 34,
evaluate for acute abdominal pathology.
COMPARISON: CT abdomen and pelvis from earlier today.
FINDINGS: AP supine and left lateral decubitus views of the abdomen and
pelvis show gas-filled non-distended loops of bowel with no signs of
obstruction. No definitive free air is seen on the lateral decubitus
position. Degenerative changes are seen in the lumbar spine and the hips. No
significant soft tissue calcifications.
IMPRESSION: No signs of obstruction or intraperitoneal free air.
Radiology Report
INDICATION: ___ male with Gram-negative bacteremia and right upper
quadrant pain.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS: The liver demonstrates normal echotexture. A 1.2-cm echogenic left
hepatic lobe lesion, likely represents a hemangioma. There is no intra- or
extra-hepatic biliary dilatation. CBD is normal measuring 4 mm. The
gallbladder is mildly distended, and contains two mobile gallstones. There is
no gallbladder wall thickening or pericholecystic fluid to suggest acute
cholecystitis. The main portal vein has normal hepatopetal flow.
IMPRESSION:
1. Cholelithiasis in a distended gallbladder. No signs of acute
cholecystitis.
2. Left hepatic lobe hemangioma.
Radiology Report
HISTORY: Sepsis.
FINDINGS: In comparison with the study of ___, there is increasing pulmonary
vascular congestion. The right hemidiaphragm is not well seen, suggestive of
a developing pleural effusion with atelectasis at the right base. In the
appropriate clinical setting, supervening pneumonia would have to be
considered.
Radiology Report
ABDOMEN AND PELVIC CT
INDICATION: ___ man with gram-negative rod sepsis, now improving,
looking for etiology.
COMPARISON: Comparison was performed with prior CT study from ___.
TECHNIQUE: Multidetector axial CT images were acquired through abdomen and
pelvis and reconstructed into coronal and sagittal planes. Study was
performed after intravenous contrast was administered with 130 cc and scanning
was performed in the portal venous phase.
DLP: 885 mGy-cm.
FINDINGS:
ABDOMEN: Moderate right pleural effusion and small left pleural effusions are
noted, accompanied by secondary atelectasis. Aortic valve calcifications. A
small hiatal hernia is seen. The liver demonstrates no focal lesions
throughout. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains a dependent stone. There is no evidence
of gallbladder wall thickening. The spleen is of normal size and attenuation
throughout. The pancreas is mildly atrophic, but without evidence of focal
lesions throughout. The adrenals are unremarkable bilaterally. The right
kidney is unremarkable. The left kidney shows a focal 1-cm lesion in the
anterior mid pole (2:38), which is too small to characterize on the current
study. Small retroperitoneal lymph nodes are noted. Diffuse atherosclerosis
of the abdominal aorta is seen. The visualized small and large bowel loops
are within normal limits.
PELVIS: The urinary bladder is catheterized. The bladder is extending into
the left inguinal hernia (2:96). The inguinal hernia also contains fat. The
rectum is unremarkable. There is no evidence of pelvic lymphadenopathy.
Small amount of fluid is seen along the bilateral flanks. Degenerative
changes in the lumbar spine are noted.
IMPRESSION:
1. Left inguinal hernia containing urinary bladder and fat.
2. Small hiatal hernia.
3. Bilateral pleural effusions, moderate on the right and small on the left,
accompanied with secondary atelectasis.
4. No abscess or source of occult infection identified.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LETHARGIC
Diagnosed with SEPTICEMIA NOS, FEVER, UNSPECIFIED, SEPSIS , ACCIDENT NOS
temperature: nan
heartrate: 122.0
resprate: nan
o2sat: 91.0
sbp: 102.0
dbp: 55.0
level of pain: nan
level of acuity: 1.0 | Assessment and Plan: ___ year old male with prior history of mild
cognitive impairment, gout, BPH, and hyperlipidemia presenting
with worsening mental status, vomiting, and hypotension after
similar presentation 1 month prior. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Right hip pain.
Major Surgical or Invasive Procedure:
___ - Operative treatment right intertrochanteric hip
fracture with sliding hip screw.
History of Present Illness:
Patient is a ___ y.o. female who had a fall from standing
while walking to the bathroom earlier this evening. Denies
prodromal sx, denies syncopal type episode. Was taken to the ED
and complained about hip pain. Denies pain to other anatomic
areas. Denies LOC.
Past Medical History:
CARCINOMA, SKIN, SQUAMOUS CELL
DIFFUSE LARGE B CELL LYMPHOMA
___ RCHOP x 6
GASTROESOPHAGEAL REFLUX
HYPERLIPIDEMIA
HYPOTHYROIDISM
LYMPHOMA NEC, MLIG INTRATHORACIC
MONOCLONAL GAMMOPATHY
URINARY TRACT INFECTION
PRIMARY MEDIASTINAL B CELL LYMPHOMA
HIP FRACTURE
H/O TRANSIENT ISCHEMIC ATTACK
Social History:
___
Family History:
Non-contributory (M died at ___, F died at ___, both of CAD; does
not know cause of death of her siblings).
Physical Exam:
EXAM ON ADMISSION:
VS: AVSS
Gen: NAD, AAO x 3
CV: Non-labored breathing. RRR
MSK:
RLE: Leg externall rotated and slightly shortened. Skin intact.
Compartments soft. ___ pulse. ___. Foot warm,
well
perfused.
EXAM ON DISCHARGE:
VS: AVSS
Gen: NAD, AAO x 3
CV: Non-labored breathing. RRR
ABD: Soft, non-tender, non-distended, BS+
RLE: Incisions clean/dry/intact. DP pulse 1+.
___. Foot warm, well perfused.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 06:22 7.0 3.10* 9.8* 29.7* 96 31.5 33.0 13.6 161
Medications on Admission:
Levothyroxine
Lansoprazole
Aspirin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
5. Enoxaparin Sodium 30 mg SC Q12H
6. Calcium Carbonate 500 mg PO TID
7. Multivitamins 1 CAP PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
9. Senna 1 TAB PO BID:PRN Constipation
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
11. Vitamin D 400 UNIT PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric hip fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Right hip pain after fall. Evaluation for fracture.
TECHNIQUE: Single AP view of the pelvis. Additional two views of the right
hip and distal femur.
COMPARISON: ___.
FINDINGS: There is an intertrochanteric fracture to the right proximal femur
with mild displacement. No fracture is seen in the distal femur.
Intramedullary rod and fixing screw in the left proximal femur is again noted
along with remote avulsion fracture of the left lesser trochanter.
Non-obstructive bowel gas pattern obscures the sacrum. The SI joints and
pubic symphysis are unremarkable.
IMPRESSION: Mildly displaced intertrochanteric fracture of the right proximal
femur.
Radiology Report
INDICATION: Right hip pain after fall. History of lymphoma on prior
radiation.
COMPARISON: CTA chest, ___. Multiple prior chest radiographs most
recently on ___.
FINDINGS: Frontal chest radiograph again demonstrates scarring and
opacification in the right apex from prior radiation along with the deviation
of the trachea to the right. The left apex is more opacified than on prior
imaging. The lungs are hyperexpanded. Hiatal hernia is again noted. There
is no pleural effusion or pneumothorax.
IMPRESSION:
1. Chronic changes from prior radiation along the right lung apex.
2. Left apical opacity raises question of infection. Recommend obtaining PA
and lateral radiographs for better charachterization of this finding.
Radiology Report
HISTORY: ORIF.
FINDINGS: Images from the operating suite show placement of a fixation device
about previous fracture. Further information can be gathered from the
operative report.
Radiology Report
RIGHT HIP FILMS ON ___
HISTORY: Status post dynamic hip screw.
FINDINGS: There is interval placement of a right-sided dynamic hip screw
spanning the right-sided intertrochanteric fracture. The alignment is much
improved. The intramedullary rod and fixation screw in the left proximal
femur again noticed with old avulsion fracture in this region.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MECHANICAL FALL
Diagnosed with INTERTROCHANTERIC FX-CL, ACC POISONING-DRUG NEC, HYPOTHYROIDISM NOS
temperature: 97.6
heartrate: 124.0
resprate: 18.0
o2sat: 98.0
sbp: 160.0
dbp: 100.0
level of pain: 9
level of acuity: 2.0 | The patient was admitted to the orthopaedic surgery service on
___ with a right intertrochanteric fracture. The patient
was taken to the operating room and underwent fixation with a
dynamic hip screw. The patient tolerated the procedure without
difficulty and was transferred to the PACU, then the floor in
stable condition. Please see operative report for full details.
Musculoskeletal: Prior to her injury, the patient was
ambulatory without assist. After procedure, patient's
weight-bearing status was transitioned to weight bearing as
tolerated in the right lower extremity. Throughout the
hospitalization, patient worked with physical therapy.
Neuro: post-operatively, patient's pain was initially controlled
with IV medications, and was subsequently transitioned to
oxycodone with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was transfused 1 unit of blood for
acute blood loss anemia, and responded with an appropriate bump
in hemoglobin/hematocrit.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A PO diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement, including
suppositories and an enema with good effect. She expressed
feeling a decrease in appetite, but outside of the immediate
___ period she had no emesis and was able to tolerate
a regular diet. Intake and output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #3, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, voiding without assistance, and pain was well
controlled. The incision was clean, dry, and intact without
evidence of erythema or drainage; the extremity was NVI distally
throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chills, malaise
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M w/ h/o afib (on warfarin), syncopal events s/p PPM, DM
(not on insulin), COPD, HTN, and newly diagnosed unresectable
cholangiocarcinoma s/p p/w chills and feeling unwell.
He underwent exploratory laparotomy ___ and biopsy of a portal
mass, that showed gallbladder hard w/ adherent omentum, large
portal mass extended the length of porta hepatis, tumor of the
right side of the port as well as tumor involving the left side
of the porta and a shelf of tumor along the surface of the
caudate lobe. Biopsy showed adenocarcinoma c/w
pancreaticobiliary origin.
He was referred to ERCP, done ___. Previously placed plastic
stent placed in the biliary duct was found in the major papilla,
and was removed. He was also found to have single irregular
stricture of malignant appearance that was 2 cm long was seen at
the common hepatic duct, w/ post-obstructive dilation. A biliary
stent was placed in the common hepatic duct and main duct. He
was given cipro.
The next day he felt chillish/hot on and off and generally
unwell. He has mild discomfort around incision site. He denies
n/v, d/c, melena, hematochezia. He has on/off back discomfort
for years, denies weakness, urine/bowel inc.
In the ED: VS T99.1, HR95, BP134/67, RR16, O2 98% RA.
Labs: ALT: 120 AP: 500 Tbili: 2.5 Alb: 3.8 AST: 78 Lactate: 2.4
WBC: 9.7.
Lines & Drains: 20g R AC
Fluids: 500ml NS
Drips: Vanc/Unasyn
Surgery was consulted.
.
Currently, he has back discomfort ___ in the lumbar area,
non-radiating and w/o parasthesias.
.
ROS: 12 point ROS is otherwise negative.
Past Medical History:
-Atrial fibrillation, on warfarin
-s/p PPM for episodes of "passing out"
-Hypertension
-Diabetes mellitus type 2
-COPD
-HLD, previously on a statin but d/c due to jaundice
-Newly diagnosed unresectable cholangiocarcinoma: ___
Exploratory laparotomy and biopsy of a portal mass. ERCP w/
biliary stent placed ___. Is to start chemo tx at the
___.
Social History:
___
Family History:
One brother had melanoma, another brother had lung cancer. No
family history of pancreatic or hepatobiliary cancer.
Physical Exam:
Vitals: T 98, BP 138/96, HR 96, RR 18 100% RA
GEN: well appearing NAD
HEENT: NC/AT, PERRLA, EOMI, MMM, OP clear
NECK: supple, no thyromegaly
HEART: RR, nl S1-S2, no MRG
LUNGS: CTAB, no r/rh/wh
ABDOMEN: +BS, well healed incision c/d/i, NT/ND, no
guarding/rebound tenderness
EXTREMITIES: wwp, no edema
NEURO: awake, oriented x3, CN2-12 intact, ___ strength at ___
bl, sensation to light touch intact throughout, tenderness in
the paraspinal area of the lumbosacral spine
Discharge exam:
VSS, afebrile during hospital course
GEN: well appearing NAD
HEENT: NC/AT, PERRLA, EOMI, MMM, OP clear
NECK: supple, no thyromegaly
HEART: RR, nl S1-S2, no MRG
LUNGS: CTAB, no r/rh/wh
ABDOMEN: +BS, well healed incision c/d/i, NT/ND, no
guarding/rebound tenderness
EXTREMITIES: wwp, no edema
NEURO: awake, oriented x3, CN2-12 intact, ___ strength at ___
bl, sensation to light touch intact throughout
Pertinent Results:
___ 01:15PM WBC-9.7 RBC-3.79* HGB-12.1* HCT-36.1* MCV-95
MCH-32.1* MCHC-33.7 RDW-14.5
___ 01:15PM NEUTS-87.4* LYMPHS-6.1* MONOS-5.5 EOS-0.5
BASOS-0.4
___ 01:15PM PLT COUNT-186
___ 01:15PM ALBUMIN-3.8
___ 01:15PM LIPASE-18
___ 01:15PM estGFR-Using this
___ 01:15PM GLUCOSE-196* UREA N-13 CREAT-0.9 SODIUM-135
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
___ 01:23PM LACTATE-2.4*
___ 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5
LEUK-NEG
___ 04:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:20PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
Discharge labs:
WBCRBC Hgb Hct MCVMCH MCHCRDW Plt
Ct
6.63.61*11.3*34.7*9631.2 32.514.7 171
GlucoseUreaNCreatNaKClHCO3AnGap
100 13 1.0 1403.7102 27
15
ALTASTAlkPhos TotBili
9053 440* 2.5*
___ blood cultures pending
CXR:
There is an unchanged left-sided pacemaker with leads ending in
the right
atrium and right ventricle. The lungs are clear, the
cardiomediastinal
shilouette and hila are normal. There is no pleural effusion
and no
pneumothorax
Medications on Admission:
propanolol 10mg bid
coumadin 5mg daily
metformin 500mg bid
spiriva
advair
albuterol
omeprazole 40mg bid
cipro 500mg bid x5 days
*nolonger taking triamteren/hctz
Discharge Medications:
1. Propranolol 10 mg PO BID
hold for sbp<100, hr<60
2. Warfarin 2 mg PO DAILY16
RX *Jantoven 2 mg 1 tablet(s) by mouth daily Disp #*30 Unit
Refills:*3
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Tiotropium Bromide 1 CAP IH DAILY
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
7. Omeprazole 40 mg PO BID
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*28 Unit Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*42 Unit Refills:*0
10. Outpatient Lab Work
Please check INR and AST, ALT, Total bilirubin, and alk phos on
___. Fax results to Dr. ___ at ___ and Dr.
___ at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
cholangitis
cholangiocarcinoma
Secondary Diagnosis:
atrial fibrillation on warfarin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with rigors, sweats. Please assess for pneumonia.
TECHNIQUE: Frontal and lateral radiographs of the chest were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
There is an unchanged left-sided pacemaker with leads ending in the right
atrium and right ventricle. The lungs are clear, the cardiomediastinal
shilouette and hila are normal. There is no pleural effusion and no
pneumothorax.
IMPRESSION: No acute cardiothoracic process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER S/P CATH
Diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC, ATRIAL FIBRILLATION, DIABETES UNCOMPL ADULT
temperature: 99.1
heartrate: 95.0
resprate: 16.0
o2sat: 98.0
sbp: 134.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | ___ yo M w/ h/o afib (on warfarin), syncopal events s/p PPM, DM
(not on insulin), COPD, HTN, and newly diagnosed unresectable
cholangiocarcinoma s/p p/w chills and malaise after biliary
stent placement post ERCP ___.
# Chills, malaise: LFTs mildly up from prior. No documented
fever, leukocytosis, exam and hemodynamics are stable. Pt has
already received doses of iv vanc/unasyn in the ED. Given his
current clinical picture, will hold off on further iv abx and
continue to assess. LFTs trended down during observation period
in hospital. Patient remained afebrile without elevated WBC.
Patient tolerated full diet on day of discharge. Continued
ciprofloxacin, and added metronidazole, both to be taken for two
week course at home. Repeat LFTs at ___'s office on ___ to
ensure continued improvement.
# Back discomfort: Per pt chronic. No focal neurologic findings,
and alarming symp by history. Resolved during admission.
# Cholangiocarcinoma- Outpatient f/u at the ___
# Atrial fibrillation- Continue coumadin, bb. Discharged on
lower dose of warfarin (2 mg instead of 5 mg) given interaction
with cipro and Flagyl. Recheck INR on ___, with dose
adjustment as needed by ___'s office.
# COPD- Continued inhalers
# DM- ISS while in house, restarted metformin at discharge.
FEN: NPO -> regular diet, no IVFs
Access: piv
PPx: coumadin
CODE: Full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ultram / Seroquel / ketorolac
Attending: ___.
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ y/o female with history of HCV and EtOH cirrhosis (reportedly
c/b varices and ascites) who presents with report of BRBPR in
setting of month-long alcohol binge.
Pt states she had bloating of her abdomen on ___ associated
with numerous episodes of vomiting but no hematemesis or coffee
ground emesis. She was able to sleep ___ night but awoke
___ morning with multiple epsiodes of BRBPR which brought
her to the ED.
In the ED, initial vitals: T 98.6, 87, 113/59, 16, 96% RA
- Exam: FAST exam negative, no ascites on ultrasound, rectal
exam with external hemorrhoids but no melena or BRBPR
- Labs: Hgb 7.8 (slightly down from 8's), WBC 3.6, Plts 39, INR
1.4, K 3.0, Cr 0.5.
- Medications given:
--- Lorazepam 0.5mg PO
--- Folic acid and thiamine
--- Potassium chloride 40meq PO
--- Protonix 40mg IV
--- Ceftriaxone 1g IV
Patient was admitted to ___ service for further
management of her BRBPR and for determination of whether there
was an underlying infectious process.
On arrival to floor, patient reports that her last drink was
___ at about 10AM. Was drinking about 0.5-1.0 pint of vodka
each day. Has been drinking that much daily for almost 1 month.
Has barely been eating due to her drinking habits. Has had EtOH
withdrawal in the past: endorses seizures from EtOH withdrawal
___ years ago at ___; denies hallucinations. Had nausea and
vomiting the day prior to presentation but none the day of
admission. Denies any hematemesis.
She's unsure what medications she takes regularly -- the ones
she can name are ___, trazodone, Zoloft, folic acid.
She denies fevers, chills, dysuria, chest pain, shortness of
breath.
Past Medical History:
- EtOH use/abuse
- hx of IV opiate abuse in past
- chronic hepatitis C
- "metal" in her right forearm and L knee
- hx of appendectomy
- cervical surgery
Social History:
___
Family History:
mom - esophageal cancer
Physical Exam:
ADMISSION EXAM:
=============================
Vitals: 98.3, 130 / 81, 87, 18, 96% RA
Weight: 59.2kg standing on admission (up 8 lbs from admission)
GEN: Chronically ill appearing woman, uncomfortable/restless in
appearance but in NAD.
HEENT: Anicteric sclera, MMM
COR: RRR w/o m/r/g
LUNGS: CTAB
ABD: Soft, non-distended. Mildly tender mostly in RUQ. No
suprapubic tenderness.
Rectal: external hemmorhoids, no melena or BRBPR
DISCHARGE EXAM:
=============================
VS: 99.5 138 / 90 83 16 94 RA
GENERAL: Chronically ill appearing woman, uncomfortable/restless
in appearance but in NAD.
HEENT: Anicteric sclera, MMM
NECK: Supple
HEART: RRR, S1+S2, no m/r/g
LUNGS: CTAB, no wheezing or rales
ABDOMEN: Soft, non-distended, non-tender in all regions.
NEURO: AOx3, CN2-12 intact
PSYCH: Pleasant, relaxed
Pertinent Results:
ADMISSION LABS:
===============================
CBC:
___ 09:45PM BLOOD WBC-3.6* RBC-3.05* Hgb-7.8* Hct-25.7*
MCV-84 MCH-25.6* MCHC-30.4* RDW-27.5* RDWSD-82.4* Plt Ct-39*
___ 09:45PM BLOOD Neuts-41.3 ___ Monos-6.1 Eos-1.4
Baso-0.3 NRBC-0.6* Im ___ AbsNeut-1.50* AbsLymp-1.82
AbsMono-0.22 AbsEos-0.05 AbsBaso-0.01
COAGS:
___ 09:45PM BLOOD ___ PTT-32.9 ___
CHEM:
___ 09:45PM BLOOD Glucose-90 UreaN-9 Creat-0.5 Na-142
K-3.0* Cl-106 HCO3-23 AnGap-16
___ 07:15AM BLOOD Albumin-2.9* Calcium-7.5* Phos-2.3*
Mg-2.3
LIVER:
___ 07:15AM BLOOD ALT-24 AST-103* AlkPhos-161* TotBili-1.1
TOX:
___ 07:15AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICRO:
===============================
___ 4:55 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:15 am IMMUNOLOGY
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
1,340,000 IU/mL.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
IMAGING:
===============================
___ ABDOMINAL ULTRASOUND:
1. Cirrhotic liver, without evidence of focal lesion.
2. Patent portal veins.
3. Trace perihepatic ascites which is not amenable to
aspiration.
4. Mild splenomegaly.
5. 1.7 cm exophytic cyst arising from the left kidney is
difficult to
visualize but shows some complex features that are concerning
for wall
thickening or nodularity. MRI is recommended for further
evaluation.
DISCHARGE LABS:
===============================
CBC:
___ 09:15AM BLOOD WBC-3.4* RBC-3.22* Hgb-8.0* Hct-28.1*
MCV-87 MCH-24.8* MCHC-28.5* RDW-27.4* RDWSD-85.1* Plt Ct-UNABLE
TO
COAGS:
___ 09:15AM BLOOD ___ PTT-33.3 ___
CHEM:
___ 05:40AM BLOOD Glucose-95 UreaN-7 Creat-0.5 Na-134 K-4.9
Cl-101 HCO3-22 AnGap-16
___ 05:40AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.7
LIVER:
___ 04:24AM BLOOD ALT-23 AST-95* LD(LDH)-274* AlkPhos-176*
TotBili-1.6*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO QHS
2. Gabapentin 300 mg PO TID
3. Sertraline 25 mg PO DAILY
4. TraZODone 150 mg PO QHS:PRN sleep
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
4. Gabapentin 300 mg PO TID
5. Gabapentin 300 mg PO QHS
6. Sertraline 25 mg PO DAILY
RX *sertraline 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. TraZODone 150 mg PO QHS:PRN sleep
RX *trazodone 150 mg 1 tablet(s) by mouth before bed Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Alcohol abuse
- Hemorrhoidal bleed
SECONDARY DIAGNOSIS:
- Alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with cirrhosis p/w BRBPR // ? portal vein
thrombosis, ? presence of ascites pocket amenable to diagnostic paracentesis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: The report from the CT abdomen ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with known cirrhosis. There is no focal liver
mass. The main, right and left portal vein is patent with hepatopetal flow.
There is trace perihepatic ascites that is not amenable to aspiration.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 0.3
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 12.3 cm.
KIDNEYS: The right kidney measures 11.5 cm. The left kidney measures 12.0 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys. A simple renal cyst is seen in the interpolar region of the right
kidney measuring 1.3 x 0.9 x 1.1 cm. An exophytic cyst is seen arising from
the interpolar region of the left kidney measuring 1.7 x 1.1 x 1.3 cm which is
difficult to visualize but shows features are concerning for wall thickening
or nodularity. MRI is recommended for further evaluation.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion.
2. Patent portal veins.
3. Trace perihepatic ascites which is not amenable to aspiration.
4. Mild splenomegaly.
5. 1.7 cm exophytic cyst arising from the left kidney is difficult to
visualize but shows some complex features that are concerning for wall
thickening or nodularity. MRI is recommended for further evaluation.
RECOMMENDATION(S): MRI for further evaluation of the left renal cyst.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BRBPR
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.6
heartrate: 87.0
resprate: 16.0
o2sat: 96.0
sbp: 113.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ year old female with a history of HCV
and alcoholic cirrhosis (complicated by varices and ascites) who
presented with report of BRBPR in setting of a month-long
alcohol binge. She did not have any further hematochezia once in
the hospital. Continued frequent, but small and formed bowel
movements, and there was no concern for C. Diff. She did have
some weakness, and was evaluated by ___ who said she was OK to go
home with home ___ to check in on her.
Her individual problems were assessed, diagnosed, and treated as
follows: |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
___ Left hemicraniectomy
History of Present Illness:
___ transferred from ___ with ___. Was drinking and smoking
marijuana last evening when he fell backward while running. His
girlfriend was present and noted he did have LOC for a brief
period of time, awoke and was confused. He was taken to ___
where he was reportedly awake and alert but intermittently
confused / somnolent. A CT scan demonstrated L-sided SDH with
3mm of midline shift. He was transferred to ___ for further
evaluation.
On arrival to ___, per ED staff he was initially somnolent /
lethargic and then agitated / purposeful when foley catheter was
placed. On my exam, he was lethargic, minimally responsive to
vocal or painful stimuli; however, he purposefully moves all
extremities in order to avoid being examined. He is
uncooperative with the exam. A repeat CT head demonstrates
interval increase in the SDH and midline shift.
Past Medical History:
None
Social History:
___
Family History:
noncontributory
Physical Exam:
On Admission:
AVSS
Gen somnolent, minimally arousable
RRR
CTAB
And S/NT/ND
Ext WWP
Neuro
- PERRLA, does not open eyes to voice
- responds intermittently to vocal stimulation with ___ words
- spontaneously moves all extremities, no commands
On Discharge:
the patient was alert and oriented to person/place/time
strength is full
sensation intact
pupils are equal and reactive
no pronator drift
incision is well approximated - staples are removed
Pertinent Results:
CT HEAD W/O CONTRAST ___
1. Previously visualized left fronto-parieto-temporal subdural
hematoma has enlarged, particularly overlying the temporal lobe
where it measures up to 21-mm from the inner table of the skull
compared to 6-mm previously. There is increased mass effect with
11-mm rightward shift of midline structures compared to 6-mm
previously. Additionally, there is increased mass effect on the
left lateral ventricle with relative dilatation of the right
lateral ventricle raising suspicion for obstruction at the level
of the third ventricle. Continued followup is recommended.
2. Again noted is a nondisplaced fracture of the right portion
of the
occipital bone is again noted with extension to the right
occipital condyle.
3. Stable left parafalcine subdural hematoma. Blood is again
noted layering along the left leaflet of the tentorium.
CT HEAD W/O CONTRAST ___
1. Expected postsurgical changes status post left
hemicraniectomy, with
interval improvement of midline shift and effacement of left
lateral
ventricle.
2. Nondisplaced fracture of the right occipital bone, unchanged
from prior
___ ___ ___
Cardiovascular Report ECG Study Date of ___ 2:47:08 ___
Sinus rhythm with sinus arrhythmia. Normal ECG. No previous
tracing available
for comparison.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 164 96 372/396 37 -18 10
___ CXR
Two serial chest radiographs were performed. The initial one
demonstrates an orogastric tube with side port above the GE
junction. The
second image demonstrates advancement into the stomach, which is
moderately distended. Endotracheal tube is in standard position
on both radiographs. Cardiomediastinal contours are within
normal limits. Lungs are clear except improving atelectasis in
the left lower lobe.
___ CT Head:
1. Increased extra-axial hyperdensity in the left
hemicraniectomy defect,
suggesting increased blood products.
2. Mild herniation of the brain parenchyma through the left
hemicraniectomy defect appears new compared to ___, but
comparison is limited by differences in patient positioning.
3. Stable mild rightward shift of midline structures and partial
effacement of the left lateral ventricle.
4. Stable large left and small right inferior frontal
hemorrhagic contusions.
5. Right occipital bone fracture extending to the right
occipital condyle is again seen.
___ CT Head:
1. Minimal increase in extra-axial hyperdensity in the left
hemi craniectomy defect suggesting minimal increased blood
products. Stable mild rightward shift of midline structures and
partial effacement of the left lateral ventricle.
2. Stable appearance of herniation of brain parenchyma through
the left he hemi craniectomy defect.
3. Stable left temporal, left inferior frontal, and right
inferior frontal hemorrhagic contusions with minimal increase in
left inferior frontal lobe edema.
4. Right occipital bone fracture extending to the right
occipital condyle
again noted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications.
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
contains tylenol- do not exceed 4 grams in 24 hours
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every six (6) hours Disp #*60 Tablet
Refills:*0
2. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
3. OLANZapine 5 mg PO HS
RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Capsule Refills:*1
5. TraMADOL (Ultram) 50 mg PO Q12H:PRN headache, pain
RX *tramadol 50 mg 1 tablet(s) by mouth q12 Disp #*60 Tablet
Refills:*0
6. Outpatient Physical Therapy
7. Outpatient Speech/Swallowing Therapy
8. Outpatient Occupational Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Left Subdural hematoma with midline shift
Traumatic brain injury
Cerebral edema
Suicidal ideation
Discharge Condition:
Mental Status: alert and oriented to person/place/time- needs
reminders and can be impulsive
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires helmet at all times.
strength is full
staples removed
incision well approximated
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with s/p L hemicraniectomy for left subdural
hematoma and left temporal hemorrhagic contusion. Evaluate for interval change
s/p drain pull.
TECHNIQUE: Noncontrast head CT with sagittal and coronal reformatted images.
DL P ___ mGy-cm.
COMPARISON: ___
FINDINGS:
Left hemicraniectomy is again seen. Previously noted left subdural drain has
been removed. There is decreased air and increased hyperdensity in the
hemicraniectomy defect, suggesting increased blood products. There is mild
herniation of the brain parenchyma through the hemicraniectomy defect, which
was not clearly seen on ___, but comparison is limited by the tilt of
the patient's head on the present exam. Allowing for differences in patient
positioning, mild rightward shift of midline structures and partial effacement
of the left lateral ventricle are unchanged. There is persistent edema and
trace blood at the site of the left temporal hemorrhagic contusion, where
blood products have been resected. Large left and small right inferior frontal
hemorrhagic contusions are stable allowing for differences in patient
position. No new parenchymal edema is seen. Basal cisterns are stable in size.
Right occipital bone fracture extending to the right occipital condyle is
again seen. A mucous retention cyst is again seen in the left sphenoid sinus.
Fluid in the right sphenoid sinus and left ethmoid air cells is new, likely
related to prolonged supine positioning.
IMPRESSION:
1. Increased extra-axial hyperdensity in the left hemicraniectomy defect,
suggesting increased blood products.
2. Mild herniation of the brain parenchyma through the left hemicraniectomy
defect appears new compared to ___, but comparison is limited by
differences in patient positioning.
3. Stable mild rightward shift of midline structures and partial effacement of
the left lateral ventricle.
4. Stable large left and small right inferior frontal hemorrhagic contusions.
5. Right occipital bone fracture extending to the right occipital condyle is
again seen.
Radiology Report
HISTORY: Status post left hemicraniectomy for left subdural hematoma and left
temporal hemorrhagic contusion with worsening exam.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformatted images were prepared and
reviewed.
DLP: 891.93 mGy-cm.
CTDIvol: 53.59 mGy.
COMPARISON: Multiple prior studies with the most recent CT Head from ___.
FINDINGS:
Post left hip hemi craniectomy changes are again noted. There is minimal
increase in width of blood products in the hemi craniectomy defect with
minimal increased hyperdensity suggesting minimal increased hemorrhage in this
region. Minimal herniation of the brain through the craniectomy defect is
again noted as seen previously. Again noted is 3 mm rightward shift of
midline structures with partial effacement of the left lateral ventricle as
seen previously. Persistent edema with minimal blood is again noted and left
temporal hemorrhagic contusion. Large left and small right inferior frontal
hemorrhagic contusions are stable with perhaps minimal increase in edema in
the left inferior frontal lobe. No new parenchymal hemorrhage is identified.
The basal cisterns are patent.
Again noted is a right occipital bone fracture extending from the to the right
occipital condyle. Mixed retention cyst is again noted in the left sphenoid
sinus. Fluid in the right sphenoid sinus and the ethmoid air cells is again
noted.
IMPRESSION:
1. Minimal increase in extra-axial hyperdensity in the left hemi craniectomy
defect suggesting minimal increased blood products. Stable mild rightward
shift of midline structures and partial effacement of the left lateral
ventricle.
2. Stable appearance of herniation of brain parenchyma through the left he
hemi craniectomy defect.
3. Stable left temporal, left inferior frontal, and right inferior frontal
hemorrhagic contusions with minimal increase in left inferior frontal lobe
edema.
4. Right occipital bone fracture extending to the right occipital condyle
again noted.
Radiology Report
HISTORY: Evaluation of patient with subdural hematoma
TECHNIQUE: Contigous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformatted images were prepared and
reviewed.
DLP: 1003.42 mGy-cm.
CTDIvol: 55.75 mGy.
COMPARISON: Outside hospital head CT from ___ at 1:51 AM.
FINDINGS:
Previously visualized left fronto-parieto-temporal subdural hematoma has
enlarged, particularly overlying the temporal lobe where it measures up to
21-mm from the inner table of the skull compared to 6-mm previously. Left
parafalcine subdural hematoma and blood layering along the tentorium appear
stable. There is increased mass effect with 11-mm rightward shift of midline
structures compared to 6-mm previously. Additionally, there is increased mass
effect on the left lateral ventricle with relative dilatation of the right
lateral ventricle raising suspicion for obstruction at the level of third
ventricle. There is no evidence of an infarction at this point.
A nondisplaced fracture of the right portion of the occipital bone is again
noted (3:35) with extension to the right occipital condyle.
There is mild opacification of the left sphenoid sinus with hyperdense fluid,
suggesting possible hemorrhage versus high-density mucous retention cyst. The
visualized mastoid air cells and paranasal sinuses are clear.
IMPRESSION:
1. Previously visualized left fronto-parieto-temporal subdural hematoma has
enlarged, particularly overlying the temporal lobe where it measures up to
21-mm from the inner table of the skull compared to 6-mm previously. There is
increased mass effect with 11-mm rightward shift of midline structures
compared to 6-mm previously. Additionally, there is increased mass effect on
the left lateral ventricle with relative dilatation of the right lateral
ventricle raising suspicion for obstruction at the level of the third
ventricle. Continued followup is recommended.
2. Again noted is a nondisplaced fracture of the right portion of the
occipital bone is again noted with extension to the right occipital condyle.
3. Stable left parafalcine subdural hematoma. Blood is again noted layering
along the left leaflet of the tentorium.
Findings were discussed by Dr. ___ with Dr. ___ telephone at the time
of discovery at 6:02 am on ___ 12, ___.
ATTENDING NOTE: Now apparent are bilateral temporal and sinferior frontal
hemorrhagic contusions. There is subfalcine herniation.
Radiology Report
HISTORY: Dural hematoma, for evaluation of endotracheal tube placement.
COMPARISON: Chest radiograph from the same day from outside hospital.
FINDINGS:
An endotracheal tube is noted in the upper trachea at 6.5 cm from the carina.
Enteric tube traverses to the stomach. The lungs are clear. There is no
pleural effusion or pneumothorax. No acute fractures are identified.
IMPRESSION:
The endotracheal tube is in the upper trachea at 6.5 cm from the carina.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with L SDH s/p L hemicraniectomy, please evaluate
for post op changes // ___ year old man with L SDH s/p L hemicraniectomy,
please evaluate for post op changes
TECHNIQUE: Signed report
DOSE: DLP: 891.93 mGy-cm
CTDI: 53.31 mGy
COMPARISON: Comparison is made with CT head from earlier the same day, ___.
FINDINGS:
The patient is status post left hemicraniectomy and evacuation of blood
products, with the expected postsurgical changes and pneumocephalus seen.
Hypodensity is noted at the site of the prior bleed. Frontal contusions are
seen, similar prior exam. There has been interval decrease in midline shift,
which now measures 5 mm rightward (previously 11 mm). Effacement of the left
lateral ventricle has improved from prior exam. There is no evidence of new
acute hemorrhage, edema, mass effect, or infarction.
A nondisplaced fracture of the right occipital bone including the right
occipital condyle is again seen. A mucous retention cyst is seen in the left
sphenoid sinus. Otherwise, the visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Expected postsurgical changes status post left hemicraniectomy, with
interval improvement of midline shift and effacement of left lateral
ventricle.
2. Nondisplaced fracture of the right occipital bone, unchanged from prior
exam.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: Study of earlier the same date.
FINDINGS: Two serial chest radiographs were performed. The initial one
demonstrates an orogastric tube with side port above the GE junction. The
second image demonstrates advancement into the stomach, which is moderately
distended. Endotracheal tube is in standard position on both radiographs.
Cardiomediastinal contours are within normal limits. Lungs are clear except
for improving atelectasis in the left lower lobe.
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: SDH
Diagnosed with CL SKL BASE FX/MENIN HEM, UNSPECIFIED FALL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | This is a ___ year old male presents with left SDH status post
question of fall onto head. Repeat imaging done showed increase
in midline shift. Patient was taken emergently to the OR for L
hemicraniectomy. There were no complications intraoperatively. A
JP drain was placed and patient was trasnferred to the ICU post
op. He remained intubated. Post op head CT showed post operative
changes. In the ICU, patient had rigors, question of seizures
and reveiced 2mg ativan. No more rigors were noted after patient
was reversed from anesthesia.
On ___ Patient was extubated. He was following commands. A
helmet was ordered. Physical therapy consult. JP drain had
minimal output and was discontinued. A repeat NCHCT revealed
increased extra-axial hyperdensity in the left hemicraniectomy
defect, suggesting increased blood products. Mild herniation of
the brain parenchyma through the left hemicraniectomy defect
appears new compared to ___, but comparison is limited
by differences in patient positioning. Stable mild rightward
shift of midline structures and partial effacement of the left
lateral ventricle. Stable large left and small right inferior
frontal hemorrhagic contusions. Right occipital bone fracture
extending to the right occipital condyle is again seen.
On ___, The patient had not voided and was bladder scanned.
The patient retained 1 liter of urine and a foley catheter was
replaced. The patients exam was inconsistent and a NCHCT was
performed. The Head CT was consistent minimal increase in
extra-axial hyperdensity in the left hemi craniectomy defect
suggesting minimal increased blood products. Stable mild
rightward shift of midline structures and partial effacement of
the left lateral ventricle. Stable appearance of herniation of
brain parenchyma through the left hemi craniectomy defect.
Stable left temporal, left inferior frontal, and right inferior
frontal hemorrhagic contusions with minimal increase in left
inferior frontal lobe edema. Right occipital bone fracture
extending to the right occipital condyle again noted. The
patients keppra was increased to 1gm BID. An aterial blood gas
to assess for CO2 retention. The arterial blood gas was found to
be normal. The helmet was delivered and the patient was
mobilized out of bed to the chair. The patient passed his speech
and swallow and was initiated on a regular diet. subcutaneous
heparin was started for deep vein thrombosis prophylaxsis. On
exam, The patient has difficulty understanding and following
commands, eyes were open to voice and the left eye was swollen
shut.upils 4-3mm brisk, incision closed with staples, right
drift, antigravity x4, repeats answers, perceverates
___: patient was transferred to the floor. He was evaluated
by physical therapy who recommended acute rehabilitation. He
received a helmet that is necessary to wear with all out of bed
activities. He expressed suicidal ideation to his mother and
___ was called. A 1:1 sitter was started. Haldol was given
prn. ___, he remained clinically stable. A 1:1 sitter
remained in use and Psych continued to follow. On ___, the team
received word that his bone flap grew 1 colony GPCs. He was
monitored carefully.
On ___, he once again expressed suicidal idealation and
psychiatry was made aware. He was started on trazodone for
sleep regimen optimization. Patient code purpled and eloped to
the elevator. He required haldol.
From ___ to ___, patient was clinically stable. Trazodone was
added to his medication regimen to assist in maintaining a sleep
regimen. Due to impulsivity and suicidal ideations, the patient
was assigned a sitter.
On ___, the patient slept through the night. The patient
complained of back pain while working with physical therapy. He
was encouraged to sit up in the chair as opposed to lying in
bed. Psychiatry did not make any changes to his current regimen.
His urine appeared cloudy, a urinalysis was sent and was
negative.
On ___, the patient was neurologically intact and tsable.
There was a large family meeting with both parents and two
brothers, social work, neurosurgery, ___ and OT. The family
decisded to take the patient home with 24 hour supervision and
plans for out patient ___ speech therapy. The patients
staples were removed without difficulty |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: Shortness of Breath
Reason for MICU transfer: Hypoxemia
Major Surgical or Invasive Procedure:
___ Intubation
___ bronchoscopy
___ Extubation
History of Present Illness:
Ms. ___ is a ___ y/o G2P1 who is 6 days post-partum (40w5d
- cesarian section) presented with shortness of breath. SOB
started the evening prior to admission. She stated that she used
her albuterol inhalers without relief, which prompted her to
call EMS. Per report, she was tachypnic to the ___, satting in
the ___, which only improved on NRB. She reported a history of 1
asthma exacerbation in her lifetime, had never required
intubation. Last asthma exacerbation was as a child. Only used
albuterol at home. She endorsed myalgias and cough in the days
preceeding admission.
In the ED, initial VS were:
T 98 HR 90 BP 159/109 RR 38 O2 Sat 91% RA
Labs were notable for ABG 7.5/___, lactate 1.0 and HCT 30
(baseline 37). She was cultured and given
Vanc/Ceftraixone/Azithro/Tamiflu and nebulizers. CTA was
performed and showed no e/o PE, but was notable for multifocal
PNA. She was admitted to the MICU for tachypnea. VS at the time
of transfer were: T 98 HR 90 122/69 RR ___ O2 Sat99% on NRB
On arrival to the MICU, initial VS were:
T 98 BP 120/80 HR 90 RR 60 O2 Sat 98% NRB
She was able to speak in short sentences and stated she was not
having significant pain with respirations.
Review of systems:
(+) Per HPI
(-) Denied fever, chills, night sweats, recent weight loss or
gain. Denied headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denied nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denied dysuria, frequency, or
urgency. Denied arthralgias or myalgias. Denied rashes or skin
changes.
Past Medical History:
POB: G2P1
- LTCS ___ for NRFHT after IOL for ?SROM, macrosomia, and
non-reassuring NST
- TAB x 1.
PGYN: Denies hx of STI/abnl Pap
PMH: Asthma, depression, obesity
PSH: D&C TAB
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
General- Obese Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Diminished air entry throughout, no wheezes, rales,
ronchi
CV- Tachycardic , normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Abd wound
stable
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge:
Gen: NAD
Lungs: CTAB
CV: RRR, nomral S1 S2
Abd: soft, NT, ND, normoactive BS, no r/g, inc c/d/i
GU: voiding spontaneously
Ext: WWP, no edema
Pertinent Results:
ADMISSION LABS
___ 06:17AM BLOOD WBC-9.9 RBC-4.11* Hgb-9.1* Hct-29.4*
MCV-72* MCH-22.0* MCHC-30.8* RDW-17.5* Plt ___
___ 06:17AM BLOOD Neuts-68.3 ___ Monos-5.3 Eos-2.3
Baso-0.4
___ 06:17AM BLOOD Plt ___
___ 06:44AM BLOOD ___ PTT-30.2 ___
___ 06:17AM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-141
K-3.8 Cl-106 HCO3-23 AnGap-16
___ 06:17AM BLOOD LD(LDH)-240
___ 03:03AM BLOOD GGT-43*
___ 06:17AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
___ 04:16AM BLOOD Triglyc-182*
___ 07:30PM BLOOD Vanco-8.5*
___ 06:41AM BLOOD ___ pO2-85 pCO2-28* pH-7.50*
calTCO2-23 Base XS-0 Comment-GREEN TOP
___ 10:44AM BLOOD Type-ART pO2-66* pCO2-36 pH-7.44
calTCO2-25 Base XS-0
___ 06:41AM BLOOD Lactate-1.0
___ 06:44AM BLOOD B-GLUCAN-Test negative
URINE
___ 03:05AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:05AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.5 Leuks-NEG
___ 03:05AM URINE RBC-0 WBC-0 Bacteri-MOD Yeast-NONE
___
MICROBIOLOGY
___ Blood culture X 2 PENDING
___ Urine NEGATIVE
___ BAL
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. ~1000/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- <=1 S
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
___ Rapid respiratory viral screen (BAL): no respiratory
viruses isolated (no Adenovirus, influenza A&B, parainfluenza
1,2,3 or respiratory synctial virus)
___ Sputum ___ with no microrganisms, commensal
respiratory flora, no legionella
___ Blood culture X 2 PENDING
___ Urine cx NEG
___ Urine cx NEG
___ Blood culture PENDING
PERTINENT IMAGING
ECHO ___:
Normal size and function of the left ventricle. The right
ventricle is mildly dilated with hypokinesis of the right
ventricular free wall with relative preservation of the RV apex
___ sign - due to RV overload of any cause such as
pulmonary embolism, pneumonia etc.). Unable to estimated
pulmonary artery systolic pressure. No significant valvular
abnormality.
CTA (___):
No evidence of pulmonary embolism. Findings most consistent with
multifocal pneumonia.
CXR ___
The patient has an endotracheal tube with the tip projecting
approximately 6 cm above the carina. The tip of the tube is
difficult to
visualize as it overlays with the nasogastric tube. The
nasogastric tube
shows a normal course and the tip is located in the stomach.
The lung volumes are low. Extensive bilateral mid and lower
lobe parenchymal
opacities and consolidation, likely associated to small pleural
effusions.
Moderate cardiomegaly, no overt pulmonary edema.
Medications on Admission:
Albuterol prn, percocet, ibuprofen
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Ibuprofen 600 mg PO Q6H:PRN pain
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
4. cefPODOXime 200 mg oral BID
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*2
Tablet Refills:*0
5. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Six days postpartum with tachypnea and shortness of breath and
decreased O2 saturation. Evaluate for pulmonary embolism.
COMPARISON: None available.
TECHNIQUE: MDCT images were obtained through the chest with IV contrast.
Coronal and sagittal reformations were performed. Right and left MIP
reconstructions were performed.
FINDINGS: The thyroid is unremarkable. The pericardium is unremarkable.
There is no significant pericardial effusion. The aorta is normal in caliber
and there is no evidence of aortic dissection. There is no filling defect in
the pulmonary arteries to the segmental level. The airways are patent to the
subsegmental level. The esophagus is normal.
There are diffuse patchy ground-glass and more confluent consolidations, worse
in the lower lobes, which is most consistent with multifocal pneumonia. No
pleural effusion or pneumothorax.
OSSEOUS STRUCTURES: No suspicious osseous lesions are identified.
IMPRESSION: No evidence of pulmonary embolism. Diffuse bilateral parenchymal
opacities most consistent with multifocal pneumonia.
Radiology Report
CHEST RADIOGRAPH.
INDICATION: Respiratory failure, multifocal pneumonia, assessment for
endotracheal tube.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The patient has an endotracheal tube with the tip projecting
approximately 6 cm above the carina. The tip of the tube is difficult to
visualize as it overlays with the nasogastric tube. The nasogastric tube
shows a normal course and the tip is located in the stomach.
The lung volumes are low. Extensive bilateral mid and lower lobe parenchymal
opacities and consolidation, likely associated to small pleural effusions.
Moderate cardiomegaly, no overt pulmonary edema.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Multifocal pneumonia, new line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient continues to be
intubated. The course of the nasogastric tube is unchanged. Patient received
a new right internal jugular vein catheter. The course of the catheter is
unremarkable, the tip of the catheter projects over the inflow tract of the
right atrium.
The preexisting parenchymal opacities, both on the left and on the right, have
minimally decreased in overall extent and severity. No evidence of larger
pleural effusions. No new opacities in the lung parenchyma.
Radiology Report
INDICATION: Respiratory failure and multifocal pneumonia.
___, CT ___.
FRONTAL PORTABLE CHEST: Endotracheal tube ends 3.4 cm above the carina.
Nasogastric tube extends to the stomach with the tip out of view. Right
internal jugular catheter projects over the right atrium, unchanged in
position. Lung volumes are lower than on the prior study. Allowing for this,
bibasilar opacities are unchanged. Re-examining the series of images,
including the CT, the patient may have concurrent pulmonary edema and
pneumonia. Small pleural effusions are probably present. Cardiac and
mediastinal silhouettes are stable. There is no pneumothorax.
IMPRESSION: No change from ___ at 6:34 p.m., allowing for differences
in inspiration.
Dr. ___ the findings with ___ by phone at 9:15 a.m. on
___.
Radiology Report
CHEST RADIOGRAPH:
INDICATION: Pneumonia, respiratory failure, fever.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is improved
ventilation at the left and right lung bases, as reflected by increase
radiolucency at both lung bases. However, the pre-existing parenchymal
opacities on both the left and the right remain clearly visible. Moderate
cardiomegaly. Unchanged position and course of the right internal jugular
vein catheter.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with OTH CURR COND-POSTPARTUM, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: 136.0
dbp: 90.0
level of pain: nan
level of acuity: 1.0 | Ms. ___ was admitted to the ICU on postoperative day 6
with multifocal pneumonia; she was intubated for increased
dyspnea and hypoxia, worrisome for impending respiratory
failure.
# CV/Respiratory: Her clinical picture indicated multifocal
pneumonia with inflammatory process based on CXR and CT scan.
Pulmonary embolism was ruled out, and TTE showed no evidence of
post-partum cardiomyopathy but did indicate RV overload, which
was though possibly secondary to pneumonia. She was successfully
extubated on HD #3 after diuresis. While she did develop a mild
fever to 100.7 on HD #2, she did not have localizing signs or
symptoms of infection, her cultures remained without growth and
she had no leukocytosis. She was transferred to the floor on HD
#4. There, she wean supplemental oxygen and maintained
excellent O2 saturation on room air without further dyspnea.
Pulmonary consultation was requested, which noted that her
imaging was consistent with a predominantly bronch-alveolar
pattern, but diffuse in lower lung bases. The rapidity of
improvement from requiring
mechanical ventilation to room air was rather fast and
distribution of ggos on ct raises concern for edema, but pt's LH
function was normal on echo. Although she technically met
criteria for HCAP, it was not felt that she required coverage
for mrsa or double gram negative coverage and that a respiratory
quinolone should be adequate.
For her multifocal pneumonia, she was treated with vancomycin,
cefepime, and cefepime, then transitioned to oral cefpodoxime
and azithromycin to complete a total 7 day course (which ended
___. She also completed a 5-day course of Tamiflu. Her
respiratory and blood cultures remained unremarkable, she
consented to HIV test which was negative.
For her history of asthma, she was given albuterol inhaler every
6 hours as needed and did not require steroids. It was felt
that her asthma was likely non-contributory to her overall
clinical picture and her poor response to albuterol prior to
hospitalization.
#GU: A foley was placed in the ICU. She initially retained urine
upon foley removal but after 24 hours of bladder rest
successfully passed a trial of void and continued to void
spontaneously without issue until discharge.
# Postpartum/postoperative: She continued pumping breastmilk
every 4 hours, and had a routine continuation of her postpartum
and postoperative course. She had mildly elevated blood
pressures on arrival which normalized spontaneously, and
intermittent headaches resolved with ketorolac. LFT's and CBC
did not show any indication of HELLP, and her clinical picture
was not attributed to pre-eclampsia given that her blood
pressures were normal throughout the rest of her admission.
# Transitional issues: She was instructed to follow up with PCP
___ at ___ in ___ days after discharge and to
obtain PFT's. Pulmonary consult did not otherwise recommend
repeat imaging or outpatient Pulmonary followup. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ who sustained a fall at home from the toilet. Found to
have 4 rib fractures. Otherwise well.
Past Medical History:
Hypothyroid
SVT with pacer
Anxiety
GERD
HTN (mild LVH on echo, cardiomegaly on CXR)
Psoriasis
Urinary incontinence
Mild CRI, baseline Cr ___
S/p cataract surgery
S/p chole
S/p right ___ toe distal amputation ___ infection
Osteoarthritis with DJD
Glaucoma
Social History:
___
Family History:
DM
Asthma
Physical Exam:
on day of discharge:
Gen: Appears consistent with stated age, AOx3, NAD
Cor: RRR without MRG
Res: Normal WOB, CTAB
Abd: Soft nt/nd
Ext: WWP without edema
Neuro: Without focal deficit
Pertinent Results:
___ 09:55AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 09:55AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:02AM GLUCOSE-126* UREA N-37* CREAT-1.3* SODIUM-139
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
___ 09:02AM estGFR-Using this
___ 09:02AM estGFR-Using this
___ 09:02AM NEUTS-77.3* LYMPHS-15.1* MONOS-6.7 EOS-0.8
BASOS-0.2
___ 09:02AM PLT COUNT-190
___ 09:02AM ___ PTT-31.6 ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isosorbide Mononitrate 15 mg PO DAILY:PRN angina
2. Omeprazole 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Verapamil SR 240 mg PO Q24H
6. Sertraline 50 mg PO DAILY
7. Acetaminophen 650 mg PO TID:PRN pain
8. Pilocarpine 1% 1 DROP BOTH EYES Q6H
9. latanoprost *NF* 0.005 % ___ HS
10. Citracal Plus Magnesium *NF* (cal cit-mag-D3-Zn-cop-man-bor)
250-40-125 mg-mg-unit Oral daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Citracal Plus Magnesium *NF* (cal cit-mag-D3-Zn-cop-man-bor)
250-40-125 mg-mg-unit Oral daily
4. Isosorbide Mononitrate 15 mg PO DAILY:PRN angina
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. Verapamil SR 240 mg PO Q24H
9. Pilocarpine 1% 1 DROP BOTH EYES Q6H
10. latanoprost *NF* 0.005 % ___ HS
11. Senna 1 TAB PO BID
12. Docusate Sodium 100 mg PO BID
13. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right ___ rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with walker and personal assistance.
Medically stable.
Followup Instructions:
___
Radiology Report
PELVIS AND RIGHT HIP FILMS: ___
HISTORY: ___ female with fall and right-sided posterior right rib
pain.
FINDINGS:
PELVIS: AP view of the pelvis. No prior. The bones are diffusely
demineralized. There is no evidence of displaced fracture. Pubic symphysis
and SI joints are unremarkable. Degenerative changes are seen at the
femoroacetabular joints with joint space loss and osteophyte formation.
Phleboliths are seen in the pelvis and scattered atherosclerotic
calcifications also noted. Degenerative changes are seen in the lower lumbar
spine.
RIGHT HIP: AP and frog-leg views of the right hip. No prior. There is no
fracture or acute osseous abnormality. Femoroacetabular joint is anatomically
aligned. Soft tissue calcifications seen adjacent to the greater trochanter
are likely dystrophic. Soft tissues are otherwise unremarkable.
IMPRESSION: No visualized fracture.
Radiology Report
PORTABLE CHEST, ___.
HISTORY: ___ female with fall and right-sided posterior rib pain.
FINDINGS: Single portable view of the chest is compared to previous exams
from ___. The lungs are clear of focal consolidation. There is no
pneumothorax. Cardiac silhouette is enlarged but stable in configuration.
Dual-lead pacing device is seen with lead tips over the right ventricle and
left atrium. Known right posterolateral rib fractures are better seen on
dedicated rib series. Otherwise, the included osseous structures are
unremarkable.
IMPRESSION: No acute cardiopulmonary process. Known right posterior rib
fractures, better seen on dedicated rib series. No visualized pneumothorax.
Radiology Report
RIGHT RIBS, MULTIPLE VIEWS.
HISTORY: ___ female with fall and right-sided posterior rib pain.
FINDINGS: Multiple oblique views of the right ribs were obtained. There are
acute minimally-angulated, but not significantly displaced fractures
identified through the posterolateral aspects of the right seventh through
tenth ribs. No other rib fractures identified. Hypertrophic changes are seen
in the spine. Dual-lead pacing device leads are partially visualized.
IMPRESSION: Acute, slightly-angulated posterior fractures to the right
seventh through tenth ribs.
Radiology Report
INDICATION: Fall, question bleed.
COMPARISON: Nonenhanced head CT from ___ and ___.
TECHNIQUE: Continuous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted images in coronal,
sagittal, and thin section bone algorithm reconstructed images were acquired.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large
vascular territory infarction. Prominent ventricles and sulci suggest
age-related atrophy. There is a small right periventricular white dystrophic
calcification, which is unchanged dating back to ___. The basal cisterns
appear patent and there is preservation of gray-white differentiation. There
is suggestion of a subcentimeter cystic structure in the posterior aspect of
the sella, unchanged.
No fracture is identified. There is mucosal thickening of the left maxillary
sinus. The remaining visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The lenses have been replaced bilaterally.
The globes are otherwise unremarkable.
CONCLUSION:
1. No evidence of acute intracranial process.
2. Mild mucosal thickening of the left maxillary sinus.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with SYNCOPE AND COLLAPSE, FRACTURE ONE RIB-CLOSED, UNSPECIFIED FALL
temperature: 97.7
heartrate: 78.0
resprate: 12.0
o2sat: 100.0
sbp: 229.0
dbp: 74.0
level of pain: 4
level of acuity: 3.0 | The patient was admitted to the trauma surgical intensive care
unit for pain control and observation given her advanced age and
our concern for high propensity to develop pulmonary
complications of rib fracture. However, on the second hospital
day she was noted to be doing very well. Her pain was
controlled with acceptable doses of analgesics and she was
judged to be doing well for transfer to the floor for
observation. One the floor she did well. She tolerated her
pain medication regimen of oxycodone 2.5 mg every four hours and
tramadol ___ ever 8 hours. She was also on tylenol. She made
progress with incentive spirometry, was tolerating a regular
diet, and able to ambulate.
EXPECTED LENGTH OF REHAB STAY IS LESS THAN 30 DAYS. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfatrim / Sulfa (Sulfonamide Antibiotics) / Tape ___
Attending: ___.
Chief Complaint:
Altered mental status, alcohol intoxication, back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with a pmhx. of HCV cirrhosis and
ETOH abuse with recent diagnosis of metastatic adenocarcinoma
(pancreaticobilliary source) who is admitted from the ED with
altered mental status. Apparently patient was found slumped
over on a bus and an ambulance was called.
In the ED, initial vitals were: 97.8 92 108/51 14 96%RA. Labs
were notable for WBC 5, Platelets 96, Cr 0.8, ALT 49, AST 96, AP
135, EtOH 237, lactate of 3.6. UA unremarkable. Remainder of tox
screens negative. CXR with an enlarged heart and atelectasis
?CHF. Patient received 3L of fluid and was given lorazepam and
haldol for agitation. Vitals prior to transfer were 97.6-103-16
127/92 98 RA.
Past Medical History:
Hep C
EtOH abuse
Depression
Cirrhosis
L humerus fracture s/p ORIF ___ s/p removal of hardware and
repair of left humerus nonunion w/ bone graft and locking plate
___ s/p washout and debridement on ___ and ___.
Social History:
___
Family History:
No family history of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.2, 121/59, 80, 20, 97% on RA
GENERAL: Slightly uncomfortable appearing, non-toxic
HEENT: Mucous membranes dry
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, ___ systolic murmur best heard at left lower
sternal boarder
ABDOMEN: +BS, non-tender, no fluid wave appreciated
SKIN: Spider angiomas
BACK: Paraspinal tenderness, no muscle spasms appreciated, no
vertebral tenderness
EXTREMITIES: No edema bilaterally
DISCHARGE PHYSICAL EXAM
VS: T 98.4 BP 122/70 P 91 RR 20 96%RA
General : appearing comfortable, sitting up in bed
HEENT: EOMI, anicteric sclera, Mucous membranes moist
CHEST: Clear to auscultation bilaterally no
wheezes/rhales/rhonci
HEART: nl S1 ___ holosystolic murmmur
ABDOMEN: soft , non-tender, non-distened, normoactive bowel
sounds
SKIN: multiple spider angiomas on face, chest and back
EXTREMITES: no lower extremity edema, 2+ BP and radial pulses
bilaterally
Pertinent Results:
ADMISSION LABS:
Utox: negative
___ 03:00PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:00PM WBC-5.0 RBC-3.99* HGB-12.1 HCT-38.6 MCV-97
MCH-30.3 MCHC-31.3 RDW-15.2
___ 03:00PM GLUCOSE-103* UREA N-13 CREAT-0.8 SODIUM-137
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-20* ANION GAP-15
___ 03:30PM LACTATE-3.6*
___ 03:00PM ALT(SGPT)-49* AST(SGOT)-96* ALK PHOS-135* TOT
BILI-1.3
___ 03:00PM ALBUMIN-3.5
___ 03:00PM LIPASE-29
___ 08:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
PERTINENT LABS:
___ 11:00PM BLOOD Lactate-3.4*
___ 07:59AM BLOOD CEA-72*
IMAGING:
CT SPINE- WET READ :
C-SPINE- NO NEW FRACTURE. NO ENHANCING SOFT TISSUE. SEVERAL
BILATERAL NODES NO OVERLY ENGLARGENED
T-SPINE/L-SPINE- NO OBVIOUS LYTIC METS. OLD POSTERIOR RIB
FRACTURE
DISCHARGE LABS:
___ 07:59AM BLOOD WBC-4.8 RBC-3.65* Hgb-11.5* Hct-35.6*
MCV-97 MCH-31.5 MCHC-32.3 RDW-15.0 Plt Ct-85*
___ 07:59AM BLOOD ALT-50* AST-98* AlkPhos-153* TotBili-1.9*
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lactulose Dose is Unknown mL PO Frequency is Unknown
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Fluoxetine 20 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain
hold for sedation
6. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Fluoxetine 20 mg PO DAILY
3. Gabapentin 600 mg PO TID
4. Lactulose 30 mL PO TID
Titrate to ___ BMs daily. ___ MD if change in mental status.
5. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain
hold for sedation
RX *oxycodone 10 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*6 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis- Alcohol intoxication
Secondary Diagnosis- Back pain
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: ___ female with history of alcoholic cirrhosis and new
diagnosis of liver adenocarcinoma, presenting with back pain. Evaluate for
metastases.
COMPARISONS: CT abdomen and pelvis of ___.
TECHNIQUE: 2.5 helical axial MDCT sections were obtained through thoracic and
lumbar spine. Axial images were interpreted in conjunction with coronal and
sagittal reformats. Images were obtained before and after administration of
70 cc of IV Omnipaque contrast.
FINDINGS:
Numbering used is shown on se 108b, im 44.
There is no evidence of fracture. Vertebral body heights are maintained.
Multilevel degenerative changes are present with anterior osteophytosis,
endplate degenerative changes in the lower thoracic spine, and vacuum disc
phenomenon at L4-5 and L5-S1. There is mild smooth anterior wedging of L4,
which is similar to ___ however, new since ___.
There is also mild wedging of L5 body with superior end-plate depression and
vacuum henomenon in adjacent discs, stable since ___ but new since ___.
Posterior disc bulges at L3-4, L4-5, and L5-S1 are similar to prior and cause
mild-moderate spinal canal narrowing.
There is mild depression of the superior end-plate of T3 with a thin linear
lucency underneath.
It is unclear if this is degenerative or related to recent trauma if any.
T11 and T12 chronic-appearing right posterior rib fractures are present.
No focal lytic or sclerotic osseous lesion concerning for malignancy.
Following injection of IV contrast, no enhancing soft tissue mass is seen
along the thoracic or lumbar spine to suggest metastatic disease in this
region. Subcutaneous soft tissue stranding posterior to L4 is nonspecific
(304:124), but similar to ___.
There is incomplete visualization of the intra-abdominal organs. The
visualized portion of the liver appears cirrhotic and nodular. There is a
small-to-moderate amount of ascites, which may be slightly increased since
___. A 1.8-cm calcified gallstone is seen at the neck of the
gallbladder, which is distended, although no overt wall thickening is present
seen. Numerous retroperitoneal and mesenteric nodes are present.
Splenomegaly is incompletely imaged.
IMPRESSION:
1. T3 body- Mild depression of superior end-plate with thin lucency
underneath- ? degenerative/ recent trauma. No soft tissue swelling.
No fracture or acute alignment abnormality in the lumbar spine. Lower lumbar
posterior disc bulges cause mild-moderate spinal canal narrowing, similar
torecent study of ___.
2. No evidence of lytic or sclerotic osseous metastasis. No enhancing soft
tissue lesion seen along the thoracic or lumbar spine to suggest metastasis to
this region. Correlate with other more sensitive modalities if needed.
3. Intra-abdominal organs are incompletely imaged but abdominal ascites
appears slightly increased since prior. Retroperitoneal and mesenteric
lymphadenopathy is present.
4. 1.8-cm calcified gallstone at the neck of gallbladder, which is
incompletely imaged. Please correlate with clinical symptoms for
cholecystitis.
4. Evaluation of lungs is limited due to artifacts. Cirrhosis.
NOTE ON ATTENDING REVIEW:
The present study was performed as the pt. did not want to have MRI as cannot
lie down longer. Details of the risks and limitations of CT study were
discussed with ___ by ___ in detail on the day of the study-
___.
Radiology Report
HISTORY: Elevated lactate. Rule out infiltrate.
CHEST, SINGLE AP PORTABLE VIEW:
There are low inspiratory volumes, though the possibility of background
hyperinflation/COPD cannot be excluded. Suspect cardiomegaly, though this may
be accentuated by low lung volumes. There is upper zone redistribution and
mild diffuse vascular blurring, suggesting mild CHF. There is patchy opacity
at the left lung base consistent with atelectasis, though an early pneumonic
infiltrate would be difficult to exclude. No effusion is identified.
At the edge of these films, hardware related to the left shoulder is noted.
Radiology Report
INDICATION: ___ female with history of alcoholic cirrhosis and new
diagnosis of liver adenocarcinoma presenting with back pain. Evaluate for
metastases.
TECHNIQUE: 2.5 helical axial MDCT sections were obtained through the cervical
spine from the skull base through the superior aspect of T2 vertebral body.
Axial images were interpreted in conjunction with coronal and sagittal
reformats. Images were obtained before and after administration of 70 cc of
Omnipaque IV contrast.
FINDINGS:
Vertebral body heights are maintained. There is minimal leftward rotation of
C1 on C2, which is similar to ___. This is likely positional.
Multilevel degenerative changes are again seen, all of which are grossly
similar to ___. Posterior disc-osteophyte complexes, most prominent
at C6-7, indent the thecal sac with mild canal stenosis at C3/4 to C6/7
levels. Multilevel left neural foraminal narrowing is present with
uncovertebral and facet hypertrophy, most pronounced at C3-4. Multilevel
intervertebral disc space loss, most severe at C5-6 and C6-7 , are similar to
prior.
Posterior arch of atlas is not fused.
No focal lytic or sclerotic osseous lesion is present to suggest osseous
metastatic disease. After administration of IV contrast, no enhancing soft
tissue lesion is seen in the cervical spine.
There is no evidence of fracture.
The prevertebral soft tissues are unremarkable. No cervical lymphadenopathy
is present. Several supraclavicular lymph nodes are present bilaterally, some
of which are borderline. The thyroid is prominent and the left lobe is
heterogeneous with a hypodense area posteriorly.
There is mild fullness in the left pirirform sinus.
Bilateral patchy ground-glass opacities are seen in the lung apices, right
greater than left, compatible with airtrapping.
Aortic arch and ascending aorta are ectatic.
IMPRESSION:
1. No evidence of fracture, acute alignment abnormality, or prevertebral soft
tissue abnormality.
2. No evidence of osseous metastatic lesion or enhancing soft tissue lesion
in the cervical spine. Correlate with other 1modalities if needed.
3. Several bilateral supraclavicular lymph nodes, some of which are
borderline.
4. Enlarged left lobe of thyroid with possible hypodense nodule-correlate with
ultrasound.
5. Prominent/ectatic aortic arch and ascending aorta- correlate with dedicated
imaging.
NOTE ON ATTENDING REVIEW:
The present study was performed as the pt. did not want to have MRI as cannot
lie down longer. Details of the risks and limitations of CT study were
discussed with ___ by ___ in detail on the day of the study-
___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ETOH/UNABLE TO AMBULATE
Diagnosed with ALCOHOL ABUSE-UNSPEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 3.0 | This is a ___ woman with a pmhx. significant for HCV
cirrhosis, ETOH abuse, and new diagnosis of metastatic
adenocarcinoma who is admitted with altered mental status,
elevated ETOH level, and elevated lactate.
# TOXIC METABOLIC ENCEPHALOPATHY: Likely in the context of
alcohol intoxication. Patient without asterixis and has been
compliant with her lactulose. Does not appear to have hepatic
encephalopathy. Urine tox negative for illicit substances. No
evidence of infection (elevated lactate most likely from
decreased hepatic clearance). Patient was given fluids and
tolerated PO, with significant improvement in mental status by
discharge. She is currently A&O x3 and appropriate in
conversation
# ACUTE UPPER AND LOWER BACK PAIN: The patient reported a 1 week
history of new onset back pain paraspinal in location. On exam
she was noted to have paraspinal tenderness without bony midline
tenderness. There was concern for spinal metastasis given her
new diagnosis of metastatic adenocarcinoma. The prelim read of
her CT spine showed no bony metastasis. Although MRI is a better
test to evaluate for spinal metastasis the patient's has
hardware in her left arm, that precludes her from undergoing
MRI. Given the negative finding on CT is very likely that her
pain is musculoskletal in origin was controlled with xxycodone.
She noted significant improvement in her back pain on discharge.
She was sent home with 6 pills of oxycodone to get her through
the weekend until her appoint on ___ with her hepatologist.
# ALCOHOL INTOXICATION: The patient presented with an alcohol
level > 200 on admission after drinking 1.5 pints of vodka in
reaction to her diagnosis of metastatic adenocarcinoma. The
patient reports sobriety for the past ___ years prior to the day
of admission. Given her period of abstinence, there was less
concern for withdrawl with this acute intoxication. She was
monitored closely overnight with no signs of symptoms of
withdrawal during her hospital course. Given her low risk for
withdrawl she was not placed on CIWA .
# ELEVATED LACTATE: The patient's lactate was most likely
elevated in the setting of dehydration and decreased clearance
secondary to cirrhosis. Her lactate was less concerning for
possible infection given that she was afebrile, no
leukocytosis, and no other clinical symptoms to suggest an
underlying infection. The patient remained clinically stable
with no indication to trend her lactate during her hospital
course.
# METASTATIC ADENOCARCINOMA: The patient has a new diagnosis of
metastatic adenocarcinoma. Immnohistochemical staining from
cytology on recent periportal lymph node was consistent with
pancreatic or intestinal cancer. The patient is to follow up
with her hepatologist Dr. ___ on ___ for follow-up. She
may also need heme/onc follow-up.
# DECOMPENSATED CIRRHOSIS: This is a chronic and stable issue.
The patient was continued on lactulose.
# Asthma- this is a chronic and stable issue. The patient was
continued on albuterol PRN
# Depression- This is a chronic and stable issue. The patient
was continued on fluoxetine
# Restless Leg syndrome- This is a chronic and stable issue. The
patient was continued on gabapentin
.
Transitional issues
#Follow-up final read of spine CT
#Follow-up tumor markers
#Arrange for heme/onc appointment
#Social work and ETOH counseling as outpatient |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Aspirin / Penicillins / Iodine / Motrin
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of an incarcerated ventral hernia s/p repair
with complex component separation in ___ who presents with
acute abdominal pain. The patient developed abdominal pain at
approximately 5AM this morning with associated nausea and
non-bloody emesis (he describes as greenish-yellow). He reports
recent constipation and has not had a bowel movement in ___
days,
but continues to pass gas. He denies fevers/chills, chest pain,
shortness of breath. He reports symptoms of heartburn, worse at
night and lying down, but denies regurgitation or dysphagia.
He presented to ___ for evaluation, where CT A/P was
concerning for high-grade SBO and he was transferred to ___
for
further evaluation. At time of surgical evaluation, he is
non-toxic in appearance and reports significant improvement in
abdominal pain and nausea. He continues to pass gas.
The patient has a complicated past surgical history. His first
exploratory laparotomy in ___ for a bowel obstruction, at the
___ per the patient he had an obstructive picture and there
was concern he had a parasite in the setting of recent travel.
He
had a subsequent bowel obstruction in ___ that also required
an
exploratory laparotomy. In ___, he presented to ___ with an
incarcerated ventral hernia and underwent extensive lysis of
adhesions and component separation with placement of both
underlay and overlay mesh. He also had an hiatal hernia repair
at
an unclear time. He has never had an EGD. He reports routine
surveillance colonoscopies without intervention.
Past Medical History:
Past Medical History:
-GERD
-iron Deficiency Anemia
- b12 deficiency
- nephrolithiasis
- h/o frequent UTIs
- h/o renal AVM s/p embolization
- h/o prostatitis
- gout
Past Surgical History: for narrative see above
Exploratory laparotomy, lysis of adhesions ___, ___
Exploratory laparotomy, lysis of adhesions ___, ___
Exploratory laparotomy with extensive lysis of adhesion, ventral
hernia repair with component separation and with underlay
(Ventralight) and overlay (Prolene) of mesh.
complex component
Social History:
___
Family History:
Mother has a history of AV malformation.
- h/o uric acidemia/gout
Physical Exam:
Admission Physical Exam:
Vitals: T97.8, HR84 , BP126/83, RR16 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes dry
CV: regular rate and rhythm
PULM: non-labored breathing, no respiratory distress
ABD: scaphoid appearance of abdomen, soft, mildly distended,
tender to palpation in LUQ without rebound or guarding, midline
surgical incision well-healed with palpable
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.0, 130/82 56 18 100 Ra
Gen: Ambulating in room, NAD
CV: HRR
Pulm: LS ctab
Abd: healing midline scar. palpable mesh in left side of
abdomen. Abd soft, reportedly mildly TTP over LLQ. No guarding
or rebound tenderness.
Ext: No edema
Pertinent Results:
___ 12:40PM BLOOD WBC-5.8 RBC-4.45* Hgb-13.0* Hct-38.7*
MCV-87 MCH-29.2 MCHC-33.6 RDW-12.2 RDWSD-38.9 Plt ___
___ 06:45AM BLOOD WBC-5.8 RBC-4.59* Hgb-13.5* Hct-41.3
MCV-90 MCH-29.4 MCHC-32.7 RDW-12.6 RDWSD-41.4 Plt ___
___ 11:17AM BLOOD WBC-7.4 RBC-4.96 Hgb-14.4 Hct-44.3 MCV-89
MCH-29.0 MCHC-32.5 RDW-12.9 RDWSD-42.1 Plt ___
___ 08:55PM BLOOD WBC-12.4*# RBC-5.23 Hgb-15.3 Hct-45.5
MCV-87 MCH-29.3# MCHC-33.6 RDW-12.6 RDWSD-39.8 Plt ___
___ 12:40PM BLOOD Glucose-82 UreaN-11 Creat-0.9 Na-141
K-3.9 Cl-101 HCO3-27 AnGap-13
___ 06:45AM BLOOD Glucose-86 UreaN-17 Creat-0.9 Na-147
K-4.7 Cl-107 HCO3-28 AnGap-12
___ 11:17AM BLOOD Glucose-76 UreaN-20 Creat-1.0 Na-141
K-4.3 Cl-102 HCO3-26 AnGap-13
___ 08:55PM BLOOD Glucose-111* UreaN-21* Creat-1.0 Na-141
K-4.6 Cl-105 HCO3-22 AnGap-14
___ 12:40PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.5*
___ 06:45AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.7
___ 11:17AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.8
Imaging:
CT A/P (OSH, 1PM): dilated jejunum in LUQ, decompressed ileum,
fecalization of large and small bowel (OSH interpretation
concerning for closed loop obstruction given "multiple loops of
dilated mid-small bowel)
CT A/P ___, 1AM): 1. No evidence of small-bowel obstruction
with contrast noted in the cecum and ascending colon. The there
is small bowel wall thickening and adjacent fat stranding of a
loop of small bowel in the mid abdomen, which may be
inflammatory
or infectious in etiology. Of note, this loop of bowel is deep
to
the area of prior ventral hernia repair.
2. Large hiatal hernia.
3. Diverticulosis without evidence of diverticulitis.
4. Bilateral punctate nonobstructing nephrolithiasis.
___ Abdomina1 XRay:
1. Residual contrast is again demonstrated throughout the colon
and rectum, which may show mild interval clearance, though no
significant change from prior radiograph.
2. Enteric tube remains in similar position with tip terminating
within the stomach.
3. No dilated loops of small or large bowel.
Medications on Admission:
Ranitidine 150 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO BID
4. Ranitidine 150 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: +PO contrast; History: ___ with abd pain+PO contrast// eval for
SBO
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 administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 48.1 cm; CTDIvol = 9.9 mGy (Body) DLP = 476.6
mGy-cm.
Total DLP (Body) = 477 mGy-cm.
COMPARISON: Outside CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. Bilateral punctate calcifications in bilateral kidneys are
consistent with nonobstructing renal stones the largest measuring up to 2 mm
(2; 25). There is no perinephric abnormality.
GASTROINTESTINAL: Moderate hiatal hernia. NG tube is partially visualized
with tip in the stomach. Small bowel loops demonstrate normal caliber without
evidence of small-bowel obstruction and oral contrast has been visualized in
the cecum and ascending colon. Of note, there is significant fat stranding
surrounding a loop of small bowel in the mid abdomen (2; 31) with small bowel
wall thickening. Diverticulosis of the sigmoid colon is noted, without
evidence of wall thickening and fat stranding. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are 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.
0.6 cm sclerotic focus within the right sacral ala is unchanged since ___ (2;
55), likely a bone island. Additional sclerotic foci within the left iliac
bone measuring up to 2 mm are also unchanged since ___ (2; 58).
SOFT TISSUES: A left inguinal hernia containing fat is noted. Patient status
post prior ventral hernia repair. Soft tissue stranding in the anterior
abdominal wall near the mid abdomen may be secondary to prior ventral hernia
repair.
IMPRESSION:
1. No evidence of small-bowel obstruction with contrast noted in the cecum and
ascending colon. The there is small bowel wall thickening and adjacent fat
stranding of a loop of small bowel in the mid abdomen, which may be
inflammatory or infectious in etiology and can be compatible with focal
enteritis.
2. Moderate hiatal hernia.
3. Diverticulosis without evidence of diverticulitis.
4. Bilateral punctate nonobstructing nephrolithiasis.
Radiology Report
INDICATION: ___ with bowel obstruction// Confirm NGT
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Enteric tube is seen with tip in the stomach, side-port however is likely
above the hiatus. Hiatal hernia seen on prior is not clearly delineated on
this portable view. The lungs are clear. Cardiomediastinal silhouette is
within normal limits. Enteric contrast noted in the colon. No acute osseous
abnormalities.
IMPRESSION:
Enteric tube tip below the diaphragm, side-port however likely above the
hiatus.
Radiology Report
INDICATION: ___ y/o M w/ SBO, received PO gastroview to evaluate for passage
of contrast through bowel. First abdominal x-ray was ordered to be performed
at 4 hours after gastrograph.// interval change from the first abdominal
(supine and erect) x-ray. Please obtain this x-ray 8 hours after the first
abdominal x-ray was performed to eval for the passage of contrast through the
bowel
TECHNIQUE: Supine and upright views of the abdomen
COMPARISON: CT scan of the abdomen and pelvis ___
FINDINGS:
There is a hiatal hernia with the enteric tube seen with the tip in the
stomach, this is better appreciated on the recent CT scan. Contrast is seen
throughout the colon. The colon is not dilated. A copious amount of stool is
noted in the rectum.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications in the region that is not
obscured by contrast.
IMPRESSION:
Hiatal hernia with the enteric tube within the stomach, seen to better
advantage on the recent CT scan. Contrast is seen throughout the colon.
Radiology Report
INDICATION: ___ y/o M w/ SBO. Evaluation for passage of gastroview, 8hrs
after contrast injection.
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiographs from ___. CT abdomen/pelvis
from ___.
FINDINGS:
Enteric tube is again seen, with tip terminating within the stomach.
Residual contrast is again demonstrated throughout the colon and rectum.
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Residual contrast is again demonstrated throughout the colon and rectum,
which may show mild interval clearance, though no significant change from
prior radiograph.
2. Enteric tube remains in similar position with tip terminating within the
stomach.
3. No dilated loops of small or large bowel.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SBO, Transfer
Diagnosed with Other intestnl obst unsp as to partial versus complete obst
temperature: 97.8
heartrate: 84.0
resprate: 16.0
o2sat: 98.0
sbp: 126.0
dbp: 83.0
level of pain: 6
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. CT from OSH
demonstrated a small bowel obstruction. Repeat admission
abdominal/pelvic CT revealed no evidence of small-bowel
obstruction
with contrast noted in the cecum and ascending colon. The
patient was hemodynamically stable. He was admitted for
non-operative management with bowel rest, IV fluids, nasogastric
tube for decompression, and serial abdominal exams.
Pain was resolving and the patient was having return of bowel
function. KUB on HD2 showed contrast in the colon and rectum,
clearing out. The NGT was removed and diet was progressively
advanced as tolerated to a regular diet with good tolerability.
On HD3, the patient was vomiting so NGT was replaced for 24
hours. Once it was removed, diet was again advanced as tolerated
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 had minimal
pain in left side of abdomen where the mesh was. 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: M
Service: SURGERY
Allergies:
morphine
Attending: ___.
Chief Complaint:
R hand clumsiness, dysarthria, and lower extremity weakness
Major Surgical or Invasive Procedure:
Carotid Endarterectomy (___)
History of Present Illness:
___ is a ___ old man with a history of MGUS,
hypertension and hyperlipidemia who presents with one week of
stuttering symptoms in right hand and right leg.
He was last in his normal state of health ten days ago. That
morning he had the abrupt onset of numbness in his right hand
extending up to his mid forearm. His hand was clumsy and would
not obey him correctly. This lasted for ten minutes and then
resolved. The next morning, he had an identical episode, again
lasting ten minutes and then resolving. These symptoms next
occurred last night, at which point they did not resolve, and
his
right hand has been clumsy since that time.
Over the past week he has also had intermittent symptoms of left
leg numbness. He first noticed this at work; he works as a
___ and walks for hours a day. He had the abrupt onset of
numbness in his left foot and ankle, extending partway up the
calf. This lasted for about 10 minutes and resolved. The leg
felt
"weak" but there were no specific functional deficits. He had
multiple episodes of left leg numbness over the course of the
next several days.
Over the course of the day today, which has largely been in the
hospital, he has had several episodes of lightheadedness on
standing, possibly with a vertiginous character. His wife has
also noted several episodes of slurred speech today but his
speech is currently back at baseline.
These symptoms brought him in to see his PCP, who sent him in to
the emergency department at ___. There, he underwent
CTA
head and neck which showed an 80% stenosis of the R ICA. He was
transferred to ___ for further evaluation and possible
treatment.
Past Medical History:
Hypertension
Hyperlipidemia
MGUS
Social History:
___
Family History:
- Mother with valve replacement. Grandparent with colon cancer.
Brother with blood clots in the legs.
Physical Exam:
ADMISSION EXAM:
General: Overweight man sitting up in no apparent distress.
HEENT: NC/AT
Neck: No carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR, no M/R/G.
Abdomen: Obese, soft, nontender, nondistended. Bowel sounds
present.
Extremities: No lower extremity edema
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Mildly inattentive, recites ___ backwards
slowly to ___ and gives up. Language is fluent and intact to
reading, writing, repetition, naming of high and low frequency
objects, and comprehension of cross-body, grammatically complex
and multi-step commands. Able to register 3 objects and recall
___ at 5 minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm with no RAPD. VFF to confrontation with
finger
counting. Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, temperature in all
distributions.
VII: Right nasolabial fold flattening but activation is full,
and
___ strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally, slightly harder
to hear on left.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is ___ bilaterally to
confrontation with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. R-sided pronation and
severe drift. No tremor or asterixis. RUE is weakest proximally
and in the hand.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ 4+ ___ 5 5 5 5
R 4 4+ 4+ 4- 4+ ___ ___ 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch, pinprick, cold sensation
throughout. Proprioception intact in the toes. Graphesthesia
intact in the hands bilaterally, can detect direction of touch
in
lower extremity. No extinction to DSS.
-Coordination: No intention tremor or dysmetria noted on FNF on
the left; on R, dysmetria appeared consistent with No intention
tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
-Gait: Good initiation. Medium to narrow-based, normal stride
and
arm swing. Able to walk in tandem after some practice. Romberg
absent.
DISCHARGE EXAM:
T 98.8, HR 78, BP 135/65, RR 18, O2 sat 97 RA
General: NAD, A&Ox3
HEENT: NC/AT
Neck: No carotid bruits
Pulmonary: Normal work of breathing. CTA ___, no w/r/r
Cardiac: normal S1/S2, RRR, no M/R/G.
Abdomen: Obese, soft, nontender, nondistended.
Pertinent Results:
___ 05:45AM WBC-12.2* RBC-4.48* HGB-14.5 HCT-42.2 MCV-94
MCH-32.4* MCHC-34.4 RDW-11.9 RDWSD-41.0
___ 05:45AM PLT COUNT-260
___ 05:45AM GLUCOSE-98 UREA N-14 CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
___ 05:45AM CALCIUM-9.7 PHOSPHATE-3.1 MAGNESIUM-2.1
CHOLEST-149
___ 10:39PM ALT(SGPT)-35 AST(SGOT)-37 ALK PHOS-59 TOT
BILI-0.8
___ 10:39PM cTropnT-<0.01
___ 10:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
CTA Head/Neck-OSH (___):
1. Study is moderately degraded by motion and dental streak
artifact.
2. Severe left internal carotid artery stenosis immediately
distal to origin, with greater than 80% narrowing.
3. 50% left external carotid artery narrowing.
4. 30% distal left common carotid artery narrowing.
5. 50% right internal carotid artery narrowing.
6. Additional cervical and intracranial atherosclerotic disease
as described.
7. No evidence of acute intracranial hemorrhage.
8. No evidence ofaneurysm greater than 3 mm, dissection or
vascular
malformation.
9. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
10. Periodontal disease as described, recommend correlation with
dental exam.
Doppler US Carotids (___):
Bilateral less than 40% carotid stenosis
MRI/MRA Head/Neck (___):
1. Study is mildly degraded by motion.
2. Right parasaggital parietal and left frontal, parietal, and
centrum
semiovale acute to subacute infarcts. Distribution suggestive
of bilateral
watershed territory infarcts, with differential considerations
of embolic
infarcts. No definite evidence of hemorrhagic conversion.
Recommend
correlation neurologic exam and attention on followup imaging.
3. Patent circle of ___ as described.
4. Paranasal sinus disease as described.
CTA Head/Neck (___):
1. Evolving left anterior cerebral artery distribution infarct,
better
characterized on prior head MRI, without evidence of hemorrhage.
No evidence
of new infarction.
2. Ulcerated, predominantly hypodense plaque at the left carotid
bulb with
intraluminal thrombus causing high-grade luminal stenosis
measuring 73% by
NASCET criteria.
3. Patent intracranial vasculature.
4. Right maxillary molar periapical lucency.
Echocardiogram (___):
Mild symmetric left ventricular hypertrophy with preserved
global and
regional biventricular systolic function.
DISCHARGE LABS:
___ 05:45AM %HbA1c-5.3 eAG-105
___ 05:45AM TSH-2.3
___ 05:45AM TRIGLYCER-121 HDL CHOL-44 CHOL/HDL-3.4
LDL(CALC)-81
___ 07:00PM INH SCR-POS
___ 07:00PM THROMBN-11.9
___ 09:00PM SERUM VIS-1.6
___ 07:00PM PEP-ABNORMAL B IgG-1757* IgA-88 IgM-101
IFE-MONOCLONAL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 10 mg PO QPM
2. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet by mouth QPM Disp #*30 Tablet
Refills:*2
3. Enoxaparin Sodium 115 mg SC BID anticoagulation /
lupus-anticoagulant
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 120 mg/0.8 mL 1 syringe SC every twelve (12)
hours Disp #*20 Syringe Refills:*0
4. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet by
mouth every 6 hours Disp #*40 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet by mouth two times per day
Disp #*30 Tablet Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth two times per
day Disp #*30 Tablet Refills:*0
8. Atenolol 25 mg PO DAILY
9. Warfarin 5 mg PO ONCE Duration: 1 Dose
RX *warfarin 5 mg 1 tablet by mouth daily Disp #*2 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Bilateral Acute Ischemic Strokes
Carotid Artery Stenosis
Hypertension
High Cholesterol
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CAROTID SERIES COMPLETE
CLINICAL HISTORY ___ year old man with carotid artery disease, CVA // eval
carotid disease eval carotid disease
FINDINGS:
Duplex was performed of bilateral carotid arteries. There is bilateral
homogeneous plaque in proximal ICA.
Right: Peak velocities are 79, 109, and 228 cm/sec in the ICA, CCA, and ECA
respectively. This is consistent with less than 40% stenosis
Left: Peak velocities are 113, 84, and 221 cm/sec in the ICA, CCA, and ECA
respectively. This is consistent with less than 40% stenosis.
Vertebral flow is antegrade bilaterally.
IMPRESSION:
Bilateral less than 40% carotid stenosis
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old man with stroke symptoms. Evaluate for acute infarct
or circle of ___ steno-occlusive disease.
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique.
Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: ___ outside head and neck CTA.
FINDINGS:
Study is mildly degraded by motion.
MR BRAIN:
Several foci of restricted diffusion within the left frontal lobe, centrum
semiovale, and left parietal lobe involving the cortex as well as gray-white
matter junction are associated with increased T2 and FLAIR signal. Additional
foci of restricted diffusion is identified at the vertex to the right of the
midline (4:29) as well as right frontal lobe (4:22), both within the right
anterior cerebral artery territory. Numerous of these foci associated with T2
and FLAIR hyperintensity. None of these lesions demonstrate associated
increase susceptibility. There is no evidence of acute hemorrhage. Minimally
prominent ventricles and sulci likely reflect age related volume loss. There
is no shift of normally midline structures.
The orbits are unremarkable bilaterally. Minimally mucosal thickening
involves the left maxillary sinus. Remaining imaged paranasal sinuses and
mastoid air cells are clear.
MRA BRAIN:
The right A1 is hypoplastic. The right vertebral artery terminates in a AICA
/ ___ complex and the left vertebral artery is dominant. Otherwise, the
intracranial vertebral and internal carotid arteries and their major branches
appear normal without evidence of stenosis, occlusion, or aneurysm formation.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Right parasaggital parietal and left frontal, parietal, and centrum
semiovale acute to subacute infarcts. Distribution suggestive of bilateral
watershed territory infarcts, with differential considerations of embolic
infarcts. No definite evidence of hemorrhagic conversion. Recommend
correlation neurologic exam and attention on followup imaging.
3. Patent circle of ___ as described.
4. Paranasal sinus disease as described.
RECOMMENDATION(S): Recommend correlation neurologic exam and attention on
followup imaging.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the ___ ___ at 4:04 ___, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: SECOND OPINION CT NEURO PSO1 CT
INDICATION: ___ male with carotid artery disease and episode of
numbness with word retrieval issues. Second read request for CTA head and
neck.
TECHNIQUE: Head and neck CTA was performed on ___ 14:29 at ___
___, and was submitted for second opinion review on ___..
DOSE: DLP: 4593.14 mGy-cm
CTDI: 76.77 mGy
COMPARISON: None.
FINDINGS:
Study is moderately degraded by motion and dental streak artifact. Within
these confines:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
0.7 x 0.5 cm hypodensity within the right putamina is most consistent with a
chronic infarct or prominent Virchow ___ space. The ventricles and sulci
are normal in size and configuration.
No fracture identified. Mild mucosal thickening of the left maxillary sinus
is noted. The additional visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable. Calcification of the cavernous portions of internal
carotid arteries are noted.
CTA HEAD:
The right V4 segment is hypoplastic and ends in a AICA / ___ complex. The
left vertebral artery is dominant. Atherosclerotic calcifications are noted
of bilateral carotid bifurcations. The right A1 segment is hypoplastic. The
vessels of the circle of ___ and their principal intracranial branches are
otherwise grossly patent without evidence of stenosis, occlusion or aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
Concentric noncalcified plaque just distal to the origin of the left internal
carotid artery demonstrates greater than 80% diameter reduction (5:141).
Similar noncalcified plaque is seen at the origin of the left external carotid
artery with approximately 50% narrowing. Noncalcified atheroma is seen within
the distal left common carotid artery causing mild narrowing of 30%.
Calcified and noncalcified plaque at the origin of the right internal carotid
artery is seen causing 50% narrowing. There is mild narrowing of the right
external carotid arteries. Minimal noncalcified atheroma along the right
common carotid artery without significant narrowing. Minimal nonocclusive
narrowing of the right vertebral artery origin is noted (see 701 8:92).
The internal carotid arteries, vertebral arteries and their major branches are
otherwise patent. No aneurysm greater than 3 mm or dissection. Calcified and
noncalcified atherosclerotic plaque within the aortic arch.
OTHER:
The visualized portion of the lungs demonstrate emphysematous changes. . The
visualized portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria. A punctate radiopacity within the right
parotid gland is consistent with a small sialolith. Periapical lucency
adjacent to right mandibular molar are noted (see ___.
IMPRESSION:
1. Study is moderately degraded by motion and dental streak artifact.
2. Severe left internal carotid artery stenosis immediately distal to origin,
with greater than 80% narrowing.
3. 50% left external carotid artery narrowing.
4. 30% distal left common carotid artery narrowing.
5. 50% right internal carotid artery narrowing.
6. Additional cervical and intracranial atherosclerotic disease as described.
7. No evidence of acute intracranial hemorrhage.
8. No evidence ofaneurysm greater than 3 mm, dissection or vascular
malformation.
9. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
10. Periodontal disease as described, recommend correlation with dental exam.
RECOMMENDATION(S): Periodontal disease as described, recommend correlation
with dental exam.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ male with multiple infarcts concerning for left
internal carotid artery stenosis. Evaluate for carotid artery 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 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
3) Spiral Acquisition 5.4 s, 42.4 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,315.2 mGy-cm.
Total DLP (Head) = 2,248 mGy-cm.
COMPARISON: ___ head and neck MRI and MRA. ___
carotid ultrasound. ___ outside head and neck CTA.
FINDINGS:
CT head: There is hypodensity at the left centrum semiovale, mid frontal
parietal and temporal occipital cortex corresponding to infarct better
characterized on prior MRI. There is no evidence of new infarction,
hemorrhage, or mass effect. The ventricles and cortical sulci are normal in
caliber configuration. The extra-axial spaces are unremarkable.
The orbits, calvarium, and soft tissues are unremarkable. The mastoid air
cells and middle ears are clear. There is mild mucosal thickening within the
bilateral maxillary sinuses with a small amount of aerosolized secretions at
the posterior aspect of the left maxillary sinus.
CTA head: There is calcification of the bilateral intracranial internal
carotid arteries, without significant stenosis. The anterior communicating
artery is visualized. The bilateral posterior communicating arteries are not
definitively seen. There is hypoplastic right A1 segment. There is a left
dominant vertebral artery with the right vertebral artery predominantly ending
in the posterior inferior cerebellar artery. The anterior and posterior
circulations are patent without occlusion, dissection, significant stenosis,
or aneurysm. The dural venous sinuses are patent.
CTA neck: There is a 3 vessel aortic arch. There is atherosclerosis of the
aortic arch and great vessel origins without significant stenosis. There is
calcific atherosclerosis at the right carotid bifurcation and bulb without
significant stenosis by NASCET criteria.
There is predominantly hypodense atherosclerosis involving the left distal
common, bifurcation, bulb, and proximal external carotid arteries. There is a
hypodense atheroma at the left carotid bulb with an irregular luminal surface
and intraluminal filling defect consistent with an ulcerated plaque with
intraluminal thrombus (3:184). This is causing 73% stenosis by NASCET
criteria.
The vertebral arteries are patent, with left dominance.
The pharynx, larynx, nasal cavity, and oral cavities are unremarkable. The
masticator and parapharyngeal spaces are unremarkable. New the thyroid and
salivary glands are unremarkable. There is no lymphadenopathy by CT criteria.
There is a right mandibular molar periapical lucency (03:20 9). There are
multilevel degenerative changes of the cervical spine without fracture or
osseous lesion. The lung apices are clear.
IMPRESSION:
1. Evolving left anterior cerebral artery distribution infarct, better
characterized on prior head MRI, without evidence of hemorrhage. No evidence
of new infarction.
2. Ulcerated, predominantly hypodense plaque at the left carotid bulb with
intraluminal thrombus causing high-grade luminal stenosis measuring 73% by
NASCET criteria.
3. Patent intracranial vasculature.
4. Right maxillary molar periapical lucency.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hand numbness, L Leg numbness
Diagnosed with Cerebral infarction, unspecified, Essential (primary) hypertension
temperature: 98.6
heartrate: 69.0
resprate: 16.0
o2sat: 98.0
sbp: 169.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted on ___ with ~10 day of
intermittent symptoms of R handed clumsiness, dysarthria, and ___
weakness. He was transferred from an OSH after CTA Head/Neck
demonstrated severe left internal carotid artery stenosis
immediately distal to origin, with greater than 80% narrowing.
There was also 50% left external carotid artery narrowing, 30%
distal left common carotid artery narrowing, 50% right internal
carotid artery narrowing, and additional cervical and
intracranial atherosclerotic disease. There was no definite
hypodensity or early infarct sign. Therefore, he was
transferred to ___ for further workup. Vascular surgery was
consulted and recommended Doppler US of the neck that
demonstrated less than 40% carotid stenosis, confounding the CTA
Head/Neck at the OSH. Furthermore, he was noted to have an
elevated PTT (50.6) and had not previously been given heparin,
raising concern for an underlying coagulopathy.
Mr. ___ was admitted to the Neurology service for further
workup up for the etiology of his multiple strokes. His BP
medications were initially held to allow him to autoregulate
given his recent ischemic strokes. Initial labs including CBC,
Chem, LFTs, Troponins, UA, Utox/Stox were unremarkable. He had
an MRI/MRA Brain that demonstrated right parasaggital parietal
and left frontal, parietal, and centrum semiovale acute to
subacute infarcts. Distribution was suggestive of bilateral
watershed territory infarcts, with differential considerations
of embolic infarcts; no definite hemorrhagic conversion. There
was a patent circle of ___. He also had an echocardiogram
that showed mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mr. ___ was worked up for other stroke risk factors and was
found to have a HgA1c of 5.3, LDL of 82, and TSH 2.2 all of
which are within normal. Although LDL was less than 100, given
the severity of carotid artery stenosis on CTA he was
transitioned from 20 mg Simvastatin daily to 80 mg Atorvastatin
daily.
Due to his history of MGUS, serum viscosity and SPEP were also
checked. Serum viscosity was within normal; SPEP showed
elevated IgG (1757).
Hematology was consulted for concern for coagulopathy and
recommended further workup for antiphospholipid syndrome
including lupus anticoagulant, B2 glycoprotein, and
anticardiolipin Abs. Due to his elevated PTT prior to being on
heparin, an inhibitor screen was also sent and returned
positive. Given the concern for severe carotid artery stenosis
and coagulopathy he was started on a heparin drip for
anticoagulation
Vascular surgery advised performing a repeat CTA Head/Neck at
___ to ensure the severity of his L ICA stenosis, which
demonstrated ulcerated, predominantly hypodense plaque at the
left carotid bulb with intraluminal thrombus causing high-grade
luminal stenosis measuring 73% by NASCET criteria, appearing
similar to the prior study. Also noted evolving left anterior
cerebral artery distribution infarct, without evidence of
hemorrhage. Therefore, he was taken for carotid endarterectomy
on ___. He tolerated the procedure well without
complication. He remained in the post-anesthesia care unit for
frequent neurological examinations and blood pressure control.
He was transferred to the floor for further care after 4 hours
of normal neuro exams, SBP<160, and adequate pain control. His
staples were removed on POD1 with steri strips placed. He was
discharged home with appropriate medications, care instructions,
and close follow up.
#ID:
- Started with diarrhea/vomiting but remains afebrile.
Norovirus +, C. Diff negative.
--------
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - heparin () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - heparin () No
4. LDL documented? (X) Yes (LDL = 81) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes -stroke packet () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: ()
Antiplatelet - (X) Anticoagulation] -() No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending: ___.
Chief Complaint:
Odynophagia, rash
Major Surgical or Invasive Procedure:
1. EGD with esophageal biopsy
2. Liver biopsy
3. Bone marrow biopsy
History of Present Illness:
Ms. ___ is a ___ with hx of AIDS (CD4 count 22, ___ not
on HAART, VL 208,000), HepC, asthma, female presenting from ___
w/ severe dyspnea, severe chest and abdominal pain. Of note, she
was recently discharged from ___ on after admission for PCP
PNA on ___. She had been feeling well until this past ___
when she began gradually developing pain with swallowing foods
and eventually liquids. She woke up on the morning of ___ with
severe epigastric and substernal chest pain which was not
relieved with tums or omeprazole. Over last 2 says she has
severe odynophagia when swallowing pills and liquids. She has
also had several episodes of non-bloody emesis. She was found to
have thrush during last admission and had been rx nystatin mouth
wash. She had been using it but doesnt think it was helping.
Prior to transfer, she received IV morphine with improvement in
pain.
Additionally, she was also found to have a fever to 102 and new
rash. She was recently started on Bactrim for PCP ___.
Rash is pruitic and non-painful. She denies any chills/sweats,
diarrhea, headache, or SOB.
In the ED, vitals were. She was orthostatic per note. Labs
notable for AST/ALT 323/563, AP 387, tbili 2.6 (2.2 direct), Na
132. CBC and UA normal. A CTA torso demonstrated improving lung
infiltrates
from prior study, mild to moderate inflammation of the
esophagus, and gonadal varices. ID was consulted and was
concerned for Bactrim allergy and recommended switching to clina
and primaquin. They also recommended empiric micafungin for
___ esophagitis.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HIV, recent CD4 of 22, complicated by PCP pneumonia ___
HepC
Asthma
Anxiety
Depression
PSH- cholecystectomy many years ago
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical:
===============
Vitals - T:98.3 BP:106/54 HR:91 RR:18 02 sat: 99% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
extensive thrush in mouth with no ulcerations appreciated
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: eccymosis (almost purpura appearings on b/l
popliteal regions, non painful, moving all extremities well, no
cyanosis, clubbing or edema.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no focal deficits
SKIN: Morbilliform rash over upper chest and b/l arms,
blanching.warm and well perfused.
Discharge Physical:
================
Afebrile, BP 100s/50s HR ___ RR 18 100%RA
General: Well appearing, comfortable, awake and alert
HEENT: MMM, Oropharynx clear without lesions
Cardiac: RRR, no m/r/g
Lungs: clear to auscultation bilaterally without wheezes or
crackles
Abd: Soft, nontender, nondistended
Extremities: WWP, no bruising or erythema
Neuro: Grossly intact, walking well
Skin: No rash
Pertinent Results:
Admission Labs:
===========
___ 02:20PM BLOOD WBC-5.8# RBC-3.78* Hgb-12.1 Hct-36.8
MCV-97 MCH-32.1* MCHC-33.0 RDW-15.0 Plt ___
___ 02:20PM BLOOD Neuts-67.8 ___ Monos-2.8 Eos-4.6*
Baso-0.3
___ 08:05AM BLOOD ___
___ 02:20PM BLOOD Glucose-101* UreaN-15 Creat-0.6 Na-132*
K-4.7 Cl-102 HCO3-21* AnGap-14
___ 02:20PM BLOOD ALT-325* AST-563* LD(LDH)-342*
AlkPhos-387* TotBili-2.6* DirBili-2.2* IndBili-0.4
___ 02:20PM BLOOD Lipase-51
___ 02:20PM BLOOD Albumin-2.4*
___ 02:45PM BLOOD Calcium-6.9* Phos-2.0* Mg-1.7
___ 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
LFT Trends:
=========
___ 08:05AM BLOOD ALT-325* AST-508* AlkPhos-370*
TotBili-4.5*
___ 06:30AM BLOOD ALT-151* AST-219* LD(___)-227
AlkPhos-278* TotBili-5.8* DirBili-4.9* IndBili-0.9
___ 06:50AM BLOOD ALT-103* AST-206* AlkPhos-402*
TotBili-4.5*
___ 06:10AM BLOOD ALT-59* AST-124* LD(LDH)-272*
AlkPhos-464* TotBili-2.7*
___ 06:30AM BLOOD ALT-50* AST-138* AlkPhos-420*
TotBili-2.1*
___ 06:40AM BLOOD ALT-53* AST-179* AlkPhos-447*
TotBili-1.6*
___ 07:05AM BLOOD ALT-71* AST-225* AlkPhos-473* TotBili-1.4
WBC Trend:
==========
___ 06:30AM BLOOD WBC-3.2* RBC-3.04* Hgb-10.0* Hct-29.9*#
MCV-98 MCH-33.0* MCHC-33.6 RDW-15.2 Plt ___
___ 06:30AM BLOOD WBC-2.4* RBC-3.06* Hgb-9.6* Hct-30.4*
MCV-99* MCH-31.4 MCHC-31.6 RDW-15.7* Plt ___
___ 06:50AM BLOOD WBC-1.9* RBC-3.18* Hgb-10.3* Hct-31.9*
MCV-100* MCH-32.3* MCHC-32.2 RDW-15.9* Plt ___
___ 05:55AM BLOOD WBC-1.3* RBC-2.68* Hgb-8.8* Hct-27.0*
MCV-101* MCH-33.0* MCHC-32.7 RDW-16.7* Plt ___
___ 06:30AM BLOOD WBC-2.2* RBC-2.71* Hgb-9.0* Hct-27.7*
MCV-102* MCH-33.3* MCHC-32.5 RDW-17.9* Plt ___
___ 06:55AM BLOOD WBC-1.6* RBC-2.64* Hgb-8.4* Hct-27.7*
MCV-105* MCH-31.9 MCHC-30.3* RDW-18.8* Plt ___
___ 06:10AM BLOOD WBC-2.5*# RBC-2.84* Hgb-9.8* Hct-30.1*
MCV-106* MCH-34.5* MCHC-32.6 RDW-18.1* Plt ___
___ 07:05AM BLOOD WBC-2.4* RBC-3.00* Hgb-10.1* Hct-31.9*
MCV-106* MCH-33.6* MCHC-31.6 RDW-18.8* Plt ___
___ 06:50AM BLOOD Neuts-29* Bands-3 Lymphs-48* Monos-8
Eos-6* Baso-0 Atyps-6* ___ Myelos-0 NRBC-1*
___ 06:30AM BLOOD Neuts-29.2* Lymphs-58.1* Monos-7.7
Eos-4.3* Baso-0.7
___ 06:55AM BLOOD Neuts-28.4* Lymphs-52.5* Monos-8.1
Eos-10.1* Baso-0.9
___ 06:10AM BLOOD Neuts-40.6* Lymphs-47.4* Monos-6.7
Eos-3.5 Baso-1.7
___ 06:10AM BLOOD Neuts-40.6* Lymphs-47.4* Monos-6.7
Eos-3.5 Baso-1.7
___ 07:05AM BLOOD Neuts-41.6* Lymphs-42.6* Monos-9.8
Eos-4.6* Baso-1.4
Sodium Trend:
============
___ 08:05AM Glucose-85 UreaN-11 Creat-0.6 Na-130* K-4.8
Cl-101 HCO3-19*
___ 02:45PM Glucose-107* UreaN-9 Creat-0.6 Na-125* K-4.5
Cl-100 HCO3-21*
___ 06:30AM Glucose-91 UreaN-9 Creat-0.4 Na-128* K-3.8
Cl-101 HCO3-24 AnGap-7*
___ 06:30AM Glucose-84 UreaN-8 Creat-0.4 Na-133 K-4.2
Cl-101 HCO3-26 AnGap-10
___ 07:00AM Glucose-112* UreaN-7 Creat-0.5 Na-130* K-4.2
Cl-100 HCO3-24
___ 06:10AM Glucose-90 UreaN-8 Creat-0.4 Na-135 K-4.3
Cl-104 HCO3-23 AnGap-12
___ 06:45AM Glucose-94 UreaN-9 Creat-0.4 Na-137 K-4.3
Cl-107 HCO3-24 AnGap-10
INR Trend:
========
___ 06:30AM BLOOD ___ PTT-55.5* ___
___ 06:30AM BLOOD ___
___ 06:50AM BLOOD ___ PTT-39.2* ___
___ 05:55AM BLOOD ___
___ 06:30AM BLOOD ___
Miscellaneous:
============
___ 06:00PM BLOOD IgG-1153 IgA-1204* IgM-176
___ 06:00PM BLOOD ___ * Titer-1:40
___ 06:00PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 03:45PM BLOOD IgM HAV-NEGATIVE
___ 10:30AM BLOOD Triglyc-264*
___ 10:30AM BLOOD ___ Ferritn-1033*
___ 10:30AM BLOOD D-Dimer-968*
___ 06:10AM BLOOD GGT-592*
___ 10:30AM BLOOD Ret Aut-4.2*
Discharge Labs:
===========
___ 11:00AM BLOOD WBC-3.6* RBC-3.56* Hgb-11.9* Hct-37.9
MCV-106* MCH-33.4* MCHC-31.4 RDW-18.5* Plt ___
___ 11:00AM BLOOD ___
___ 07:05AM BLOOD Glucose-90 UreaN-13 Creat-0.4 Na-138
K-4.2 Cl-108 HCO3-25 AnGap-9
___ 11:00AM BLOOD ALT-100* AST-308* AlkPhos-553*
TotBili-1.6*
Microbiology:
===========
Blood Cultures ___: Negative
Urine Culture ___ coag negative staph
CMV ___: CMV DNA detected, less than 137 IU/mL
Mycolytic cultures ___: pending
CMV IgG antibody ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA.
100 AU/ML.
Liver Biopsy ___: Gram stain w/o PMNs, no organisms, tissue:
NGTD, Anaerobic culture no growth, PCP: negative, fungal
culture: negative, viral culture: negative, CMV early antigen
test: negative
RPR: negative
Urine culture ___: mixed bacterial flora
Bone marrow biopsy ___: Fluid culture: No growth, AFB culture,
fungal culture: pending
Anti Actin IgG: Positive
EBV PCR blood: positive - ___ H
Hep E IgM: Negative
HSV 1 IGG TYPE SPECIFIC AB 2.59 H
HSV 2 IGG TYPE SPECIFIC AB <0.90
HSV ___ IgM: negative
___: CT Chest/Abd/Pelvis
1. Persistent but improving multifocal pulmonary opacities,
mostly
characterized by vague ground glass areas, more extensive in the
upper than
lower lungs. In the setting of HIV infection, differential
considerations
include improving pneumocystis pneumonia or other atypical forms
of infection; correlation with recent clinical circumstances is
recommended. Several coinciding small nodules are likely
incidental although potentially
inflammatory or infectious.
2. Similar mild lymphadenopathy in the chest.
3. No evidence of pulmonary embolism.
4. Prior cholecystectomy without biliary dilatation or definite
hepatic
parenchymal abnormality.
5. Mild distal esophageal thickening, equivocal, but
potentially due to an
inflammatory process.
6. Mild splenomegaly and retroperitoneal lymphadenopathy,
notably periportal lymph nodes, which can be an indication of
underlying liver disease or hepatic inflammation.
7. Large left gonadal varices.
Liver/Gallbladder US ___: Normal abdominal sonogram. Patent
portal veins.
MRI Head with and without contrast ___: Slightly prominent
sulci for the patient's age, likely related with the
immunological status, no focal lesions are identified, there is
no evidence of abnormal enhancement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Nystatin Oral Suspension 5 mL PO QID
3. Sulfameth/Trimethoprim DS 2.5 TAB PO TID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath or
chest tightness
5. PredniSONE 20 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath or
chest tightness
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 mL by mouth Daily Refills:*0
4. Dolutegravir 50 mg PO DAILY
RX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *emtricitabine-tenofovir [___] 200 mg-300 mg 1 tablet(s)
by mouth Daily Disp #*30 Tablet Refills:*0
6. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
7. QUEtiapine Fumarate 100 mg PO QHS
RX *quetiapine 100 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
9. ValACYclovir 1000 mg PO Q8H Duration: 3 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home with Service
Facility:
___
___ Diagnosis:
Primary Diagnoses:
1. ___ esophagitis
2. Bactrim Toxicity
3. Febrile neutropenia with HCAP
4. Elevated LFTs
5. Depression
6. Hyponatremia
Secondary Diagnoses:
1. HIV
2. Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: AIDS, hepatitis-C, transaminitis.
COMPARISON: None.
FINDINGS:
Grayscale and Doppler ultrasound images of the abdomen were obtained.
The liver is normal without focal or echotextural abnormality. Status post
cholecystectomy. The common duct measures 3 mm and there is no intra- or
extra-hepatic bile duct dilatation. The pancreas is unremarkable. The aorta
is of normal caliber throughout. The visualized portions of the IVC appear
normal.
Color flow and spectral Doppler waveform analysis were obtained. The main,
left, right anterior, and right posterior portal veins are patent with
hepatopetal flow.
IMPRESSION:
Normal abdominal sonogram. Patent portal veins.
Radiology Report
INDICATION: ___ year old woman with HIV/AIDS (CD4 22), HCV untreated here with
severe esophagitis, rising LFTs, fevers, concern for disseminated HSV or CMV,
bactrim reaction. Please do RUSH LIVER BIOPSY, prior to 10am for RUSH
pathology. Please send CMV, viral studies, PCP, ___, fungal cultures and
Pathology // ? HSV or CMV, ? bactrim reaction, ? cirrhosis
COMPARISON: Ultrasound dated ___.
PROCEDURE: Ultrasound-guided non-targeted core biopsy of the liver.
OPERATORS: Dr. ___, abdominal radiology fellow, and Dr. ___,
attending radiologist, who was present and supervising throughout the total
procedure time.
FINDINGS:
Limited pre-procedure 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 pre-procedure imaging, an appropriate skin entry site for the
biopsy was chosen in the right upper quadrant. 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 16 gauge core biopsy needle was then
advanced into the liver with two separate passes and two core biopsy samples
were obtained - one was placed in formalin while the other was placed in
sterile saline for cultures. The samples were brought to the lab for rush
analysis as per the team's orders. The skin was then cleaned and a dry sterile
dressing was applied. There were no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 50 mcg fentanyl by an indepent-trained radiology nurse
throughout the total ___ time of 12 minutes during which patient's
hemodynamic parameters were continuously monitored by an independent-trained
radiology nurse.
IMPRESSION:
Uncomplicated non-targeted core biopsy of the liver with two separate samples
sent for rush analysis as per the team's orders.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with HIV/AIDs, Hep C, PCP pneumonia and HSV
esophagitis with ongoing fevers and new SIADH // evaluate for opportunist
infection, cause of SIADH
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images. The T1 weighted
images were repeated after the administration of intravenous gadolinium
contrast.
COMPARISON: No prior examinations of the head are available here
FINDINGS:
There is no evidence of intracranial hemorrhage or mass effect, the ventricles
and sulci are slightly prominent for the patient's age, probably related with
the immunological status of this patient there is no evidence of abnormal
enhancement, no diffusion abnormalities are detected. The major vascular
arterial flow voids are present and demonstrate normal distribution. The
orbits are normal, the paranasal sinuses are notable for mucosal thickening in
the sphenoid sinus, ethmoidal air cells and right maxillary sinus, suggesting
an inflammatory process.
IMPRESSION:
Slightly prominent sulci for the patient's age, likely related with the
immunological status, no focal lesions are identified, there is no evidence of
abnormal enhancement.
NOTIFICATION: These findings were communicated via phone call to Dr. ___
by Dr. ___ on ___ at 15:10 hr.
Radiology Report
EXAMINATION: Abdominal MRI. MRCP.
INDICATION: ___ year old woman with HIV/AIDS, Hep C here with acute on chronic
hepatitis with elevated bili and alk phos. // ? AIDS cholangiopathy, ?
biliary obstruction, vanishing bile ducts
TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired
within a 1.5 Tesla magnet, including 3D dynamic sequences performed prior to,
during, and following the administration of 8 cc of Gadavist intravenous
contrast.
COMPARISON: Ultrasound from ___.
FINDINGS:
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Included views of the lung bases demonstrates a trace right pleural effusion
and moderate bibasilar atelectasis (series 5, image 6). The heart size is
normal. There is no pericardial effusion.
The hepatic parenchyma demonstrates mild signal drop-off on T1 weighted out of
phase images in comparison to in phase sequences, denoting steatosis. The
liver contour appears smooth, however, there is widening of the hilar
periportal space (series 13, image 16), measuring at least 11 mm, suggestive
of early cirrhosis. Moderate periportal edema is present. Peripheral arterial
hyper enhancement throughout the right hepatic lobe is superimposed over areas
of peripheral vascular crowding (series 13, image 13), suggestive of acute
hepatitis over mild background fibrosis. No concerning hepatic mass is
detected. There is no intra or extrahepatic bile duct dilation. A prominent
accessory right intrahepatic duct is present (series 9, image 4), further
assessment limited due to extensive motion artifact.
The spleen is mildly enlarged. The adrenal glands, kidneys, pancreas, stomach,
and intra-abdominal loops of small and large bowel are normal. There is no
mesenteric or retroperitoneal lymphadenopathy, and no ascites.
The abdominal aorta, celiac trunk, SMA, and renal arteries appear patent and
normal in caliber.
There are no bony lesions concerning for malignancy or infection.
IMPRESSION:
1. Mild hepatitis superimposed on mild cirrhosis and peripheral fibrosis. No
concerning hepatic mass.
2. Mild hepatic steatosis.
3. Examination limited by motion, however, no bile duct stricture or mass. No
intra or extrahepatic bile duct dilation.
4. Mild splenomegaly, mayy reflect chronic portal hypertension.
5. Trace right pleural effusion and moderate bibasilar atelectasis.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with AIDS recent PCP, ___, also
with hepatitis s/p liver biopsy now with severe abdominal pain. // ?hematoma
and evaluate hepatic flow
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: US guided liver biopsy dated ___ and CT of the abdomen
and pelvis dated ___.
FINDINGS:
LIVER: The echogenicity of the liver is homogeneous. The contour of the liver
is smooth. There is no focal liver mass. Main portal vein is patent with
hepatopetal flow. There is no ascites. There is no perihepatic hematoma.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: Status post cholecystectomy.
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: Mild splenomegaly, measuring 13.3 cm.
KIDNEYS: The right kidney measures 12.8 cm. The left kidney measures 11.6 cm.
Limited views of the kidneys are unremarkable.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
DOPPLER EXAMINATION: The main, right and left portal veins are patent with
normal flow. The main, right, and left hepatic arteries are patent with
appropriate waveforms. The hepatic veins are also patent.
IMPRESSION:
1. No evidence of perihepatic hematoma or other cause for right upper
quadrant pain.
2. Patent hepatic vasculature.
3. Mild splenomegaly.
Radiology Report
STUDY: AP CHEST, ___.
CLINICAL HISTORY: ___ with AIDS and new fever. Evaluate for
pneumonia.
FINDINGS: Comparison is made to previous study from ___.
Since the previous study, there has been improvement in the diffuse airspace
opacities throughout both lung fields. There remain residual areas of
consolidation within the bases. Heart size is prominent. There are no
pneumothoraces. There are no pleural effusions.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with HIV/AIDs, Hep C, and HSV esophagitis. Now
with worsening abdominal pain and peritoneal symptoms. ? abdominal abscess, ?
free air, abdominal perforation.
TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained with
intravenous and oral contrast . Sagittal and coronal reformats were prepared.
DLP: 768 mGy-cm
COMPARISON: Prior CT chest, abdomen and pelvis from ___, ultrasound
abdomen from ___ and MRCP from ___.
FINDINGS:
ABDOMEN:
New small right pleural effusion is identified. There is evidence bibasal
consolidation/ atelectasis. Mild persistent thickening of the distal
esophagus is noted.
Small perihepatic ascites is now identified. The liver demonstrates
homogeneous enhancement. No intrahepatic or extrahepatic biliary ductal
dilatation. Portal veins and hepatic veins are patent. The no suspicious focal
hepatic lesions are identified. Cholecystectomy clips are identified. The
pancreas and adrenal glands are unremarkable. There is persistent mild
splenomegaly, with the spleen measuring up to 14.9 cm. The kidneys demonstrate
symmetric enhancement and excretion of contrast. No hydronephrosis. No focal
renal lesions are identified. Caliber of small and large bowel is within
normal limits. Nonspecific mild fold thickening of distal small bowel loops
is noted (5:72). Colonic fecal loading is identified. Stomach is unremarkable.
Caliber of abdominal aorta is within normal limits, with no evidence of
abdominal aortic aneurysm. Few persistent nonspecific mildly enlarged
retroperitoneal lymph nodes are again identified (05:42). Few lymph nodes are
identified in the porta hepatis (05:31). Small of fluid tracts into the region
of the porta hepatis. No intraperitoneal free air.
PELVIS:
Urinary bladder is within normal limits. The uterus and rectum are
unremarkable. Persistent prominent bilateral gonadal vessels are identified.
No inguinal or pelvic lymphadenopathy. A few prominent pelvic lymph nodes are
identified, not meeting size criteria for pathologic enlargement (5:97). No
pelvic free fluid. Mild bilateral flank body wall stranding/ edema is noted.
Slightly ill-defined hypodensity is identified in the left hemipelvis medial
to the left external iliac vessels (5:69), likely in keeping with small amount
of fluid. Underlying lymph node is not excluded.
OSSEOUS STRUCTURES:
No suspicious osteolytic or osteoblastic lesions are identified. Small focus
of periarticular sclerosis at the left iliac bone (6b:37), likely relates to a
small bone island.
IMPRESSION:
1. No evidence of intra-abdominal fluid collections to suggest abscess. No
intraperitoneal free air.
2. Small right pleural effusion. Bibasal consolidation/atelectasis.
3. Mild persistent thickening of distal esophagus.
4. Small amount of perihepatic, abdominal and pelvic ascites. Slightly
ill-defined hypodensity in the left hemipelvis medial to the left external
iliac vessels likely in keeping with small amount of fluid. Underlying lymph
node is not excluded.
5. Persistent mild splenomegaly and mildly enlarged retroperitoneal lymph
nodes. Slightly prominent lymph nodes in the porta hepatis.
6. Persistent prominent bilateral gonadal vessels.
7. Colonic fecal loading.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ woman with HIV AIDS, hepatitis-C and persistent right
upper quadrant pain. Decreased breath sounds on the right. Suspect pleural
effusion.
COMPARISON: Chest radiographs ___
IMPRESSION:
Moderate right pleural effusion is responsible for elevation of the apparent
right hemidiaphragm. In addition there is a large to region of consolidation
in the right lower lung, localized to the middle lobe on the lateral view.
Small left pleural effusion is unchanged. A large region of atelectasis at the
left lung base, is unchanged since ___. The widespread pneumonia present
in ___ which it cleared by ___ has not returned.
Heart size is normal. Mediastinal contours reflect substantial central
adenopathy.
Radiology Report
CT TORSO
HISTORY: Shortness of breath, epigastric pain, elevated bilirubin after
cholecystectomy with fever.
COMPARISONS: Chest radiographs are available from ___.
TECHNIQUE: Multidetector CT images of the chest were obtained with
intravenous contrast in the pulmonary arterial phase. Sagittal and coronal
reformations were also performed.
This was followed by CT imaging of the abdomen and pelvis with intravenous
contrast. Sagittal and coronal reformations of the abdomen and pelvis were
also performed.
FINDINGS:
CT CHEST:
There is mild bilateral hilar and mediastinal lymphadenopathy. A cluster of
right hilar nodes measures up to 19 x 14 mm in axial ___. A left hilar
lymph node measures up to 9 mm in shortest dimension. A right subcarinal node
is borderline measuring up to 12 x 22 mm in axial ___. A prevascular
lymph node measures 16 x 9 mm. There are no enlarged supraclavicular or
axillary nodes.
No filling defects are visualized among the pulmonary arteries. There are no
pleural or pericardial effusions. The heart is normal in size.
Central airways suggest mild wall thickening which is likely inflammatory.
The upper lungs show heterogeneous opacification with predominantly
ground-glass opacities, which affect the lower lobes to a lesser degree.
Opacities, however, have markedly improved since the prior although probably
unchanged since the more recent radiographs. Streaky dependent opacities
suggest some degree of minor coinciding atelectasis.
In the right upper lobe, there is a very small solid nodule measuring 4 mm
(3:83). There is also a 2 mm solid nodule (3:86). An additional nodule in
the right middle lobe measures 4 mm (602B:17), while in the right upper lobe,
a further 4 mm nodule (3:97).
CT ABDOMEN:
The patient is status post cholecystectomy. There is no biliary dilatation.
The liver appears within normal limits. The spleen is mildly enlarged,
measuring up to 13.8 cm in length. The pancreas and adrenal glands appear
within normal limits. The kidneys are unremarkable.
The stomach, small and large bowel appear within normal limits. The wall of
the distal esophagus appears borderline thickened along the lower third.
There are several mildly prominent periportal nodes with vague attenuation
increase in the surrounding fat. Representative is a portacaval node
measuring up to 21 x 12 mm in axial ___ (2B:109), which is borderline.
There are also scattered small, probably reactive periaortic lymph nodes.
CT PELVIS:
The left gonadal vein is enlarged with striking left gonadal varices. The
major mesenteric arteries and veins appear patent. The uterus and adnexal
regions are otherwise unremarkable. The bladder appears within normal limits.
There is no ascites.
BONE WINDOWS: There are no suspicious lytic or blastic bone lesions. A
sclerotic focus in the left ilium is consistent with a benign bone island.
The appendix appears normal.
IMPRESSION:
1. Persistent but improving multifocal pulmonary opacities, mostly
characterized by vague ground glass areas, more extensive in the upper than
lower lungs. In the setting of HIV infection, differential considerations
include improving pneumocystis pneumonia or other atypical forms of infection;
correlation with recent clinical circumstances is recommended. Several
coinciding small nodules are likely incidental although potentially
inflammatory or infectious.
2. Similar mild lymphadenopathy in the chest.
3. No evidence of pulmonary embolism.
4. Prior cholecystectomy without biliary dilatation or definite hepatic
parenchymal abnormality.
5. Mild distal esophageal thickening, equivocal, but potentially due to an
inflammatory process.
6. Mild splenomegaly and retroperitoneal lymphadenopathy, notably periportal
lymph nodes, which can be an indication of underlying liver disease or hepatic
inflammation.
7. Large left gonadal varices.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with ESOPHAGITIS UNSPECIFIED, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, ASYMPTOMATIC HIV INFECTION
temperature: 98.8
heartrate: 94.0
resprate: nan
o2sat: 97.0
sbp: 99.0
dbp: 55.0
level of pain: 8
level of acuity: 3.0 | ___ w/ h/o AIDS (CD4 22, not on HAART, VL 208K), Hep C, asthma
with recent admission for PCP pneumonia treated with bactrim
readmitted ___ with severe chest and abdominal pain, elevated
liver enzymes.
#Esophagitis: Presented with severe thrush and odynophagia
concerning for esophagitis. Patient was started on micafungin
for ___ esophagitis. Pain treated with IV morphine. She was
taken for EGD which showed severe esophagitis with biopsies and
appearance consistent with HSV esophagitis. She was started on
IV acyclovir, BID PPI, carafate, maalox/lidocaine mouth wash and
continued on micafungin which was transitioned to fluconazole
once LFTs improving. She completed a 14 day course of antifungal
treatment for ___ esophagitis on ___. Patient was
transitioned to PO acyclovir and ultimately to valacyclovir at
discharge to complete total of 21 day course (___) of HSV
esophagitis treatment. Maalox/lidocaine mouthwash was
discontinued prior to discharge per hepatology after total of ___nd no further symptoms of odynophagia. Patient to
continue PPI and carafate until GI follow-up in ___.
#Hepatitis: Patient with significant LFT inflammation on
admission with elevation of direct bili concerning for
obstructive process. RUQ ultrasound, MRCP and CT abdomen all
without evidence of obstructive biliary process causing LFT
abnormalities. Patient with evidence of liver failure with
impaired synthetic function evidenced by elevated INR and low
albumin/platelets. Liver biopsy was performed which showed acute
on chronic inflammation with evidence of fibrosis. Ultimately,
with stopping bactrim, patient's LFTs downtrended suggesting
possible contribution from drug reaction vs ongoing effects of
patient's viremia. Following her liver biopsy, patient
experienced significant pain in RUQ which was felt to be due
ongoing inflammation. This resolved over several days. CT scan
showed no complications from biopsy. Her LFTs again started
trending up slowly following initiation of ARVs and will need to
be followed closely. Patient to follow-up with ID and Hepatology
for management of HIV and Hepatitis C.
#Fevers/neutropenia: patient admitted with fevers which were
initially attributed to bactrim toxicity. However, patient
became progressively neutropenic during hospitalization meeting
criteria for febrile neutropenia and was thus started on
vanc/meropenem which was narrowed to meropenem for 8 day course.
She was culture negative in multiple blood and urine cultures
(except 1 urine culture thought to be contaminant). Treated for
esophagitis as above. She had multiple scans of abdomen without
evidence of infection. CXR performed ___ with RLL infiltrate
concerning for HCAP and with fevers improving on meropenem, this
was thought to have contributed to fevers. Given neutropenia and
atypicals on smear, Heme/onc was consulted and thought this was
most likely secondary to viral infiltrative bone marrow process
given the high HCV viral load and EBV viral load. Alternative
etiologies included primaquine which patient received for
treatment of PCP. Bone marrow biopsy was performed ___, which
did not reveal hematologic malignancy or infiltrative process to
explain neutropenia. Patient's WBC count started to trend up as
of ___ and meropenem was stopped on ___ (afebrile for several
days) per ID recs. ___ 1170 on day prior to discharge. Patient
will need follow-up of WBC count/diff as outpatient (within 1
week of discharge).
#Hyponatremia: Patient with hyponatremia which developed shortly
after admission in setting of receiving fluids. Urine lytes were
sent and were consistent with SIADH. SIADH was worked up with
MRI of head given onset after initial PCP ___. MRI head
was unremarkable for cause of SIADH. Patient was fluid
restricted to 1.5L initially with improvement in sodium. Over
the course of her stay, fluid restriction was liberalized and
patient's sodium remained normal without further evidence of
SIADH.
#Drug rash: Patient with morbilliform rash on admission which
was thought to be secondary to bactrim reaction and resolved
with stopping bactrim. Patient should not be on bactrim in the
future given presumed significant reaction to this medication.
# PJP Pneumonia: Diagnosed during admission in ___ based on
elevated b-glucan and GGO on CT Chest though sputum was
negative. Treated with Bactrim and tapered course of prednisone.
CT chest this admission demonstrates improvement in infiltrates.
Given concern for bactrim toxicity, patient was transitioned to
clinda/primaquine to complete total of 3 week course. On ___,
PCP treatment was stopped and patient was transitioned to
atovaquone for PCP ___. Patient does not tolerate
atovaquone (due to taste) so may need to consider dapsone for
prophylaxis in the future.
# HIV/AIDS: CD4 count on last admission was 22. Patient had not
been on ARVT secondary to inability to comply with medication
regimen now with multiple AIDS related illnesses. Patient was
followed closely by ID and ultimately started on truvada and
dalutegravir on ___. She will follow-up with Dr. ___ in
___ clinic on ___ for ongoing management of HIV and Hepatitis
C.
# Anxiety/Depression: Patient with significant anxiety and
depression at baseline. She noted periods of hallucinations
(auditory) in nature which were initially thought to be
secondary to medication effect and improved with decreasing
morphine requirements. Seen by psychiatry and started on
increasing doses of seroquel qhs to help with sleep and
depressive symptoms. Patient's affect remained flat with
significant amotivation throughout hospitalization. On further
discussion with psychiatry, it was felt patient would benefit
from partial psychiatric hospitalization program to help assist
with her anxiety and depression. Patient provided with
information for Arbour partial program and will arrange for
intake on ___ or ___.
#Full Code
-- |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg and elbow pain after a fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a history of progressive dementia, atrial
fibrillation, and congestive heart failure, presenting after a
fall at home. The night prior to admission, the patient fell
after getting out of bed. His wife heard a thud and found the
patient lying ___ feet away from the bed, next to a wall. The
family thought the patient may have hit the wall while falling.
At that time the patient denied any pain and appeared in his
usual state of health. The next morning, the patient's wife and
son noticed that he was having difficulty walking and was
complaining of pain in his left leg and arm. He also had a left
elbow abrasion. He was brought to the ___ ED.
In the ED, initial vitals were: T 98.0, HR 88, BP 119/61, RR 16,
O2S 99% RA
Blood cultures x2 sent. He was given 1g tylenol and 1 L NS.
Labs were significant for:
10:50 AM: INR 3.6, WBC 12.6, Cr 2.3, BUN 112, glucose 214,
lactate 3.5
U/a: neg leuk, neg nitrite
Thorough trauma evaluation revealed a fracture of the greater
trochanter of the left proximal femur. He was evaluated by
orthopedics, who recommended conservative management.
He was admitted to medicine for pain control and ___ evaluation.
In speaking with the patient's son, the patient has fallen
several times in the past month. The falls occur at night as he
gets out of bed to urinate. He has a commode at his bedside but
prefers to use the bathroom. His wife finds him down and calls
their son to help move him. The patient and his wife have some
help at home during the day, but not at night.
Past Medical History:
Basal ganglion stroke ___: during 2 week period off warfarin)
h/o ALCOHOL USE. No current EtOH use
AORTIC INSUFFICIENCY
AFib
BPH
NHL - FOLLICULAR LYMPHOMA
GOUT
MENTAL STATUS CHANGES - likely vascular dementia
Hx OBESITY
OSTEOARTHRITIS
SENSORINEURAL HEARING LOSS - has hearing aid
SLEEP APNEA
Distant L elbow contusion with permanent decrease in ROM
Social History:
___
Family History:
Father had strokes and became forgetful in his ___. Both parents
died at ___
Physical Exam:
EXAM ON ADMISSION:
VS: 97.8 160/83 86 16 97%RA
GEN: Alert, lying in bed, no acute distress. AAOx1, stuttering
speech, aphasic, sometimes nonsensical speech
HEENT: Tacky MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema. L hip tender to
palpation. R shoulder without tenderness. Intact radial and
pedal pulses
NEURO: CN II-XII grossly intact, aphasic, interactive,
nonsensical speech. ___ R grip strength, ___ L grip strength.
Able pronate and supinate L arm.
EXAM AT DISCHARGE:
VS: T 97.1, Tm 98.4, HR 65 (65-90), BP 146/41 (115-146/39-64),
RR 20, O2S 96+ RA
GEN: Alert, lying in bed, no acute distress. oriented to self
only, stuttering speech, answers some questions appropriately,
alternating with nonsensical speech.
HEENT: Dry MMs, dark red oropharynx, anicteric sclerae, no
conjunctival pallor
NECK: Supple, JVP not elevated
PULM: CTA b/l without wheeze or rhonchi
COR: irregularly irregular, (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema. L lateral thigh w/ mild
tenderness to palpation. ___ strength in left hip flexor,
appears limited by pain. Winces on external rotation of L arm.
Limited ROM on straightening of L elbow.
SKIN: Multiple small ecchymoses on arms, excoriations on L elbow
NEURO: CN II-XII grossly intact, aphasic, interactive,
stuttering speech not comprehensible after ___ words
Pertinent Results:
ADMISSION LABS
___ 12:40PM URINE HOURS-RANDOM
___ 12:40PM URINE HOURS-RANDOM
___ 12:40PM URINE UHOLD-HOLD
___ 12:40PM URINE GR HOLD-HOLD
___ 12:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:52AM ___ COMMENTS-GREEN TOP
___ 10:52AM LACTATE-3.5*
___ 10:49AM GLUCOSE-214* UREA N-112* CREAT-2.3*
SODIUM-136 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-23 ANION GAP-18
___ 10:49AM estGFR-Using this
___ 10:49AM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-1.8
___ 10:49AM WBC-12.6* RBC-6.02 HGB-14.2 HCT-43.7 MCV-73*
MCH-23.6* MCHC-32.5 RDW-20.2* RDWSD-48.4*
___ 10:49AM NEUTS-92.2* LYMPHS-2.9* MONOS-4.2* EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-11.63* AbsLymp-0.36* AbsMono-0.53
AbsEos-0.00* AbsBaso-0.04
___ 10:49AM PLT COUNT-394
___ 10:49AM ___ PTT-49.6* ___
DISCHARGE LABS
___ 07:25AM BLOOD WBC-10.9* RBC-5.30 Hgb-12.3* Hct-39.7*
MCV-75* MCH-23.2* MCHC-31.0* RDW-20.0* RDWSD-51.9* Plt ___
___ 07:25AM BLOOD ___ PTT-46.9* ___
___ 07:25AM BLOOD Glucose-97 UreaN-105* Creat-2.6* Na-141
K-4.8 Cl-108 HCO3-18* AnGap-20
CT PELVIS
Acute fracture of the greater trochanter of the left proximal
femur.
Associated left hip and gluteal intramuscular hematoma. Small
amount of left intrapelvic hematoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Warfarin 5 mg PO DAILY16
3. Allopurinol ___ mg PO DAILY
4. Terazosin 5 mg PO QHS
5. Calcitriol 0.25 mcg PO 3X/WEEK (___)
6. Finasteride 5 mg PO DAILY
7. Torsemide 20 mg PO 5X/WEEK (___)
8. Torsemide 10 mg PO 2X/WEEK (MO,TH)
9. FoLIC Acid 1 mg PO DAILY
10. Pyridoxine 50 mg PO DAILY
11. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Finasteride 5 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. Terazosin 5 mg PO QHS
8. Thiamine 100 mg PO DAILY
9. Torsemide 20 mg PO 5X/WEEK (___)
10. Torsemide 10 mg PO 2X/WEEK (MO,TH)
11. Acetaminophen 650 mg PO TID
12. Docusate Sodium 100 mg PO BID
13. Senna 17.2 mg PO HS
14. TraMADOL (Ultram) 25 mg PO Q12H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q12h PRN
Disp #*30 Tablet Refills:*0
15. Warfarin 2.5 mg PO DAILY16
16. Caphosol 30 mL ORAL QID
17. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femur fracture, greater trochanter
Elbow contusion
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable at times
(especially mornings), then alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT PELVIS ORTHO
INDICATION: ___ year old man with history of AFib on Coumadin s/p fall,
negative vs equivocal L hip film
TECHNIQUE: MDCT axial images were acquired through the pelvis following
without intravenous contrast. Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 725 mGy-cm.
COMPARISON: Hip radiograph ___
FINDINGS:
There is an acute fracture of the greater trochanter (2:72, 300b:71) of the
left proximal femur. The left femoral neck is intact. No additional
fractures seen. Left hip and gluteal intramuscular hematoma noted, measures
at least 4.3 x 4.7 cm (2:84). Severe multilevel degenerative changes are
noted throughout the lumbar spine.
Also noted is a small amount of RP and left pelvic hematoma is seen tracking
along the lower aorta and the left iliac vessels (series 2, images 14- 45).
The partially visualized small and bowel loops demonstrate no gross
abnormalities. Appendix is normal. Left kidney is markedly atrophic, but
only partially imaged. Bladder is unremarkable. Prostate gland is enlarged.
IMPRESSION:
Acute fracture of the greater trochanter of the left proximal femur.
Associated left hip and gluteal intramuscular hematoma. Small amount of left
intrapelvic hematoma.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with dementia s/p fall, no neck ttp, L sided head ttp //
eval ? ICH, neck injury
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformats were also performed.
DOSE: Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
large mass. Prominence of the ventricles and sulci is suggestive of global
volume loss.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are essentially clear
besides partially opacified left ethmoids. The visualized portion of the
orbits are unremarkable. Cavernous carotid calcifications are severe.
IMPRESSION:
Global volume loss without acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with dementia s/p fall, no neck ttp, L sided head ttp //
eval ? ICH, neck injury
TECHNIQUE: Non-contrast helical multidetector CT was performed. Axial image
data was collimated to display separate 2.5 mm soft tissue and bone algorithm
axial images. Coronal and sagittal reformations were then constructed.
DOSE: Total DLP (Body) = 1,777 mGy-cm.
COMPARISON: CT C-spine ___
FINDINGS:
Alignment is normal. No fractures are identified. There is no prevertebral
soft tissue swelling. Atherosclerotic calcification of the carotid arteries
bilaterally is seen. Irregular dependent opacity in the trachea (03:59) is
likely debris. Multilevel degenerative changes are again seen.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
INDICATION: ___ with s/p fall and L sided injuries // eval ? shoulder /
elbow fx
TECHNIQUE: Three views of the left shoulder.
COMPARISON: Correlation made to CT torso from ___ and chest CT
from ___.
FINDINGS:
There is no acute fracture. Moderate degenerative changes noted at the
acromioclavicular joint. Glenohumeral joint is anatomically aligned. There
is lucent lesion within the left scapular body better seen on prior exams.
Included portion of the left ribs are unremarkable. Interstitial opacities in
the lungs are better seen on concurrent chest CT.
IMPRESSION:
No fracture or dislocation.
Radiology Report
INDICATION: ___ with s/p fall and L sided injuries // eval ? shoulder /
elbow fx
TECHNIQUE: Three views of the left elbow.
COMPARISON: ___.
FINDINGS:
Extensive heterotopic bone formation seen at the medial condyle and coronoid
process as on prior. This limits evaluation for subtle osseous abnormality.
No displaced fractures are identified. There is a linear lucency through the
region of the radial head on the oblique view (image 1) but given significant
overlap of adjacent osseous structures, is not definitive for fracture.
Cannot assess for elbow joint effusion given low positioning on the lateral
view.
IMPRESSION:
Heterotopic ossification which significantly limits evaluation. Linear
lucency through the radial head on one view could be due to overlapping
shadows although fracture would be difficult to exclude.
Radiology Report
INDICATION: ___ with s/p fall L sided hip and femur pain // eval ? L hip /
femur fx
TECHNIQUE: AP view of the pelvis. AP and lateral views of the proximal and
distal left femur.
COMPARISON: Scout view of prior PET-CT from ___.
FINDINGS:
There is slight cortical irregularityinvolving the lateral and medial aspect
of the left greater trochanter raising the possibility of fracture. The left
femur is otherwise unremarkable. Femoroacetabular joint is anatomically
aligned. Extensive degenerative changes partially visualized at the left knee
with joint space loss, osteophyte formation and subchondral sclerosis.
The pubic symphysis and SI joints are preserved. Mild degenerative changes
noted at the hips bilaterally. Degenerative changes are noted in the lower
lumbar spine.
IMPRESSION:
Cortical irregularity raising possibility of fracture involving the left
greater trochanter. If desired, CT scan could help further characterize.
Radiology Report
INDICATION: ___ s/p fall L sided injuries, T-spine ttp // eval ? rib
fractures, intrathoracic injury. Please obtain T-spine recons
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
without intravenous contrast. Reformatted coronal, sagittal, thin slice axial
images, and thoracic spine images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 726 mGy-cm.
COMPARISON: FDG PET-CT ___ and CT torso ___
FINDINGS:
The ascending aorta measures 4.5 cm at the level of the main pulmonary artery,
similar to prior PET-CT. Great vessels are unremarkable. The main pulmonary
artery measures up to 4.4 cm. Opacity in the trachea is partially aerated
and likely represents debris.
There is mild dependent atelectasis and paraseptal emphysema bilaterally.
Increased interstitial markings in a subpleural and basilar distribution
raises the possibility of underlying interstitial process such as fibrosis.
There is no pleural effusion or pneumothorax. The airways are patent to the
subsegmental level.
Coronary artery calcifications are significant. Cardiomegaly is moderate.
Small pericardial effusion is similar to prior. There is no supraclavicular,
axillary, or mediastinal lymphadenopathy. The thyroid is unremarkable.
The spleen is enlarged measures 17 cm. Ovoid hypodensities in the spleen, the
largest measuring up to 1.8 cm, are incompletely characterized. The left
kidney is atrophic.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Focal lucencies involving the C6 vertebral body and the left C6 pedicle appear
similar to CT torso ___. Lucent lesion in the left scapula is
unchanged from ___.
IMPRESSION:
1. No fracture or evidence of acute injury.
2. Changes in the lungs raise the possibility of underlying interstitial
process such as fibrosis.
3. Persistent small pericardial effusion.
4. Splenomegaly.
5. Enlarged main pulmonary artery suggests pulmonary hypertension.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Hip pain
Diagnosed with TROCHANTERIC FX NOS-CLOS, UNSPECIFIED FALL, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 98.0
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 119.0
dbp: 61.0
level of pain: 13
level of acuity: 3.0 | Mr. ___ is a ___ year old male with a history of
stroke, progressive dementia, atrial fibrillation on warfarin,
and congestive heart failure, who was admitted to ___
___ on ___t home at
night.
# Left femur greater trochanter fracture: The patient underwent
extensive orthopedic workup and was found to have an acute
fracture of the L femur trochanter, visible on CT scan. The
Orthopedics team has recommended non-operative management. He
can bear weight as tolerated with a walker. He should minimize
abduction of the left hip per trochanter precautions. He
received standing doses of acetominophen and PRN tramadol for
pain with good effect. He should receive tramadol prior to
sessions of physical therapy for maximal participation.
# Falls: The patient has had falls at home over the past month,
usually at night when he is trying to reach the bathroom. This
is likely related to deconditioning and lack of visual input
while walking in the dark. He has a bedside commode and walker,
but does not use these aids when he wakes up in in the middle of
the night, likely due to his baseline dementia. There is no
evidence of infection, CHF, unstable arrhtyhmia, orthostatic
hypotension, or any other acute medical condition.
# Possible elbow trauma: The patient presented with contusions
on his left elbow. X-rays could not rule out a fracture. He does
have range-of-motion limitations in the left elbow at baseline
due to an old injury. He was able to lean his weight on a walker
with no signs of arm pain, so this was not treated as a
fracture.
# Dementia, history of basal ganglia stroke: The patient's
mental status remained at baseline, per family. He is at high
risk of developing delirium in healthcare settings. Pain
medications were dosed carefully. His home atorvastatin was
continued for vascular disease.
# Chronic congestive heart failure: The patient had no evidence
of acute exacerbation during hospitalization. Continued home
torsemide.
# Atrial fibrillation, supratherapeutic INR: The patient takes
warfarin 5mg daily at home. His INR was found to be 3.6 on
admission and remained supratherapeutic throughout his
hospitalization. Warfarin was initially held, then resumed at a
lower dose of 2.5mg on ___. It is likely that poor PO intake
due to dementia and decreasing mobility, as well as
acetaminophen, both contribute to his anticoagulation effect.
# BPH: Continued home finasteride and terazosin
# Gout: Continued home allopurinol
TRANSITIONAL ISSUES
- The patient has severe deconditioning which contributes to his
falls and will benefit from rehab
- Warfarin was decreased to 2.5mg daily (from 5) since INR was
supratherapeutic during his inpatient stay. Please check daily
INR until stable w/ goal 2.0-3.0
- The patient's nutrition will need to be monitored since it is
likely contributing to both his deconditioning and his warfarin
overdosing. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ ___ female
with no cardiac history, but does have a history of hypertension
and blood pressures not uncommonly are elevated in the office
setting. In any event, she presents with chest discomfort that
started in the left scapular region last evening around 11
o'clock and she fell asleep with it, awakened with it, and had
developed discomfort around the left side of her chest and into
the left anterior chest and in the inframammary region and just
medial to it. This has been pleuritic in the back and in the
inframammary region anyway. It hurts more when she is supine
versus sitting up. It hurts more when she coughs or sneezes. She
denies chest wall trauma. She has had no blatant dyspnea,
but because it hurts to breathe in, the pattern of her breathing
may have been upset, but she is not huffing and puffing. It
hurts more when she leans forward too sometimes. She denies
nausea, vomiting, diaphoresis, or further radiation of the
symptoms. She had symptoms on the right side of her chest years
ago that was thought to be muscular. She denies exertional
symptoms and exercises regularly. She does the treadmill, does
___, all of which are without symptoms. Last time she
exercised was 2 weeks ago. She has history of hypertension, has
been maintained on labetalol 300 mg twice daily and nifedipine
extended release that was recently increased from 30 to 60 mg
daily.
She denies fevers, chills, coughing, exertional dyspnea, TIA
symptoms, claudication, palpitations, presyncope, or syncope.
Past Medical History:
hypertension
h/o uterine fibroids
Social History:
___
Family History:
Father had CHF in his ___. Otherwise negative.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.6 136/84 77 18 99% RA
General: well appearing woman in NAD, comfortable
Neck: unable to assess for JVD due to body habitus
CV: distant heart sounds, normal rate, regular rhythm, no m/r/g,
unable to appreciate friction rub
Lungs: CTAB
Abdomen: soft, NTND, NABS
GU: no Foley
Ext: wwp, no c/c/e
Pulses: 2+ DP and radial pulses b/l
DISCHARGE PHYSICAL EXAM:
VS: 98.6 154/88 87 18 97% RA, 131.2 kg
General: comfortable in NAD
Neck: unable to assess for JVD due to body habitus
CV: RRR, no murmurs or gallops, no rub appreciated, unable to
reproduce pain with palpation of inferior chest wall, axillary
region or scapular region
Lungs: CTAB, no adventitious sounds
Abdomen: soft, +BS, NT/ND
Ext: no cyanosis or edema
Pulses: 2+ radial, DP pulses bilaterally
Neuro: nonfocal
Pertinent Results:
PERTINENT LABS:
___ 08:00AM BLOOD WBC-6.1 RBC-4.62 Hgb-11.3* Hct-35.3*
MCV-76* MCH-24.5* MCHC-32.0 RDW-13.4 Plt ___
___ 10:30AM BLOOD Neuts-63.8 ___ Monos-4.2 Eos-5.3*
Baso-0.7
___ 10:30AM BLOOD ___ PTT-29.7 ___
___ 08:00AM BLOOD ESR-19
___ 08:00AM BLOOD Glucose-117* UreaN-11 Creat-0.9 Na-138
K-4.1 Cl-101 HCO3-24 AnGap-17
___ 10:50PM BLOOD cTropnT-<0.01
___ 04:32PM BLOOD cTropnT-<0.01
___ 10:30AM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
___ 11:55AM BLOOD D-Dimer-573*
___ 08:00AM BLOOD TSH-1.5
___ 10:30AM BLOOD HCG-<5
___ 08:00AM BLOOD CRP-13.8*
___ 08:00AM BLOOD ___
ECG:
nonspecific abnormalities with T-wave
abnormalities in aVL, V5, and V6, and slightest PR depression in
V1, II
IMAGING:
___ CXR
FINDINGS: Frontal and lateral radiographs were reviewed. Heart
size is top
normal. Mediastinal and hilar contours are stable. There is no
pleural
effusion or pneumothorax. Lungs are clear. Pulmonary
vasculature is within
normal limits.
IMPRESSION: No acute cardiopulmonary process.
___ CT-A
TECHNIQUE: MDCT images were taken through the chest in the
arterial phase
after the administration of 100 cc of Omnipaque intravenous
contrast material.
Coronal and sagittal reformats as well as oblique maximum
intensity projection
images were also examined.
FINDINGS:
CTA: The aorta and pulmonary arteries are well opacified. The
aorta
maintains a normal contour without evidence of acute aortic
syndrome. There
is no pulmonary embolism in the main, right, left, lobar, or
subsegmental
pulmonary arteries. The heart is normal size without
pericardial effusion.
The thyroid is normal. The airways are patent to the
subsegmental level.
There is no mediastinal, hilar, axillary, or supraclavicular
lymphadenopathy.
There is no concerning pulmonary nodule, mass, or confluent
consolidation.
Bibasilar atelectasis is present. There is no pleural effusion
or
pneumothorax. Soft tissue density in the anterior mediastinum is
compatible
with residual thymus.
A 1.8 x 1.6 fluid density lesion in the right medial breast is
noted (2:24).
The imaged portion of the upper abdomen is unremarkable. No
suspicious lesion
is seen in the visualized osseous structures.
IMPRESSION:
1. No pulmonary embolism or evidence of acute aortic syndrome.
2. Hypodense lesion in the right medial breast likely reflects a
cyst, but
correlation with breast ultrasound and possibly mammography is
suggested.
___ TTE
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality.Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NIFEdipine CR 60 mg PO DAILY
2. Labetalol 300 mg PO BID
3. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Labetalol 300 mg PO BID
2. NIFEdipine CR 60 mg PO DAILY
3. Ibuprofen 200 mg PO 3 TABLETS, THREE TIMES A DAY FOR 7 DAYS;
1 TABLET THREE TIMES A DAY FOR THE NEXT THREE DAYS; 1 TABLET
TWICE A DAY FOR THE NEXT THREE DAYS, THEN STOP pericarditis
Duration: 13 Days
RX *ibuprofen 200 mg 3 capsule(s) by mouth three times a day
Disp #*63 Tablet Refills:*0
RX *ibuprofen 200 mg 1 capsule(s) by mouth three times a day
Disp #*9 Tablet Refills:*0
RX *ibuprofen 200 mg 1 capsule(s) by mouth twice a day Disp #*6
Tablet Refills:*0
4. Prenatal Vitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth daily Disp #*13 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pericarditis, idiopathic vs viral
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left-sided chest pain.
COMPARISON: None.
FINDINGS: Frontal and lateral radiographs were reviewed. Heart size is top
normal. Mediastinal and hilar contours are stable. There is no pleural
effusion or pneumothorax. Lungs are clear. Pulmonary vasculature is within
normal limits.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: Chest pain.
COMPARISON: None.
TECHNIQUE: MDCT images were taken through the chest in the arterial phase
after the administration of 100 cc of Omnipaque intravenous contrast material.
Coronal and sagittal reformats as well as oblique maximum intensity projection
images were also examined.
FINDINGS:
CTA: The aorta and pulmonary arteries are well opacified. The aorta
maintains a normal contour without evidence of acute aortic syndrome. There
is no pulmonary embolism in the main, right, left, lobar, or subsegmental
pulmonary arteries. The heart is normal size without pericardial effusion.
The thyroid is normal. The airways are patent to the subsegmental level.
There is no mediastinal, hilar, axillary, or supraclavicular lymphadenopathy.
There is no concerning pulmonary nodule, mass, or confluent consolidation.
Bibasilar atelectasis is present. There is no pleural effusion or
pneumothorax. Soft tissue density in the anterior mediastinum is compatible
with residual thymus.
A 1.8 x 1.6 fluid density lesion in the right medial breast is noted (2:24).
The imaged portion of the upper abdomen is unremarkable. No suspicious lesion
is seen in the visualized osseous structures.
IMPRESSION:
1. No pulmonary embolism or evidence of acute aortic syndrome.
2. Hypodense lesion in the right medial breast likely reflects a cyst, but
correlation with breast ultrasound and possibly mammography is suggested.
Dr. ___ Dr. ___ item 2 in the Impression via telephone at 7:15
___ on ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Back pain
Diagnosed with CHEST PAIN NOS, HYPERTENSION NOS
temperature: 99.0
heartrate: 80.0
resprate: 16.0
o2sat: 97.0
sbp: 146.0
dbp: 86.0
level of pain: 6
level of acuity: 2.0 | ___ with hypertension presenting with pleuritic chest pain that
varies with position, most consistent with pericarditis.
# Pericarditis
Etiology includes idiopathic vs viral. She denied any viral
illness but did have what she refers to as an allergy flare the
previous week with congestion. She was started on ibuprofen 600
mg every eight hours and received one dose of colchicine. Her
pain improved from ___ to ___, and she felt comfortable going
home with close follow-up. A more thorough review of her
medications revealed that she was taking prenatal vitamins with
the intent to get pregnant, therefore her colchicine was
discontinued. She is discharged on a 7 day course of 600 mg
ibuprofen daily, then three days of 200 mg ibuprofen three times
daily, then three days of 200 mg ibuprofen twice a day. Her EKG
was stable between presentation and discharge.
# Hypertension
Her blood pressures were well controlled while inpatient,
generally in systolic 130s or less with one outlier. She was
continued on her outpatient regimen of labetalol and nifedipine
upon discharge.
# Transitional Issues
- She is provided with the phone number to call her PCP for an
appointment in follow-up
- She is counseled on procedure if her chest pain should persist
or worsen. PCP could consider ___ stress test
- She will take 13 days of ibuprofen total, no colchicine as she
is attempting to become pregnant. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Toe Pain
Major Surgical or Invasive Procedure:
___ RLE toe debridement (Podiatric Surgery)
___ FOCUSED EXAM: ___ pulses dopplerable. cap refill less than
3 sec to the digits. Normal proximal to distal cooling. Erythema
of the right ___ from ankle to proximal calf as well as localized
to the right hallux. There is a blood filled blister to the
right hallux which after debridement revealed an underlying
ulceration (2x2cm) which extended to the subcutaneous tissue.
There was a small amount of pus noted during debridement. There
is no probe to bone, tracking, nor fluctuance to the ulcerative
area. Light touch sensation diminished to the b/l ___. no pain to
the right hallux or RLE.
History of Present Illness:
___ year old ___ speaking woman with a history of HTN,
NIDDM2, and hypothyroidism presenting with right lower extremity
swelling and R first metatarsal pain and swelling. History is
limited by confusion and difficulty using the interpreter phone.
Pt reports that she first noticed redness and pain ___ the right
great toe at least 1 month ago. She denies trauma to the foot.
She is still able to ambulate, although is limited by pain. She
denies fevers/chills/nausea/vomiting
Collateral history was obtained form patient's HCP ___
___), who reports that the pt's legs have chronically
appeared "red" and "swollen". During ___ most recent visit
last week, the pt appeared to be doing well. She uses a walker
to ambulate short distances, but usually needs a wheelchair for
longer distances (i.e. down the corridor).
Reviewing documentation from ___, she received
Keflex for 5 days at end of ___ for unclear indication.
___ the ED, initial vitals: 97.6 63 149/49 18 99%RA
Exam notable for erythema, warmth and induration of both the
anterior and posterior RLE below the knee extending to the
ankle. The erythema stops there and then begins again at the mid
foot where it extends to the R ___ metatarsal where there is a
3cm blood blister (wet gangrene). Pulses present with Doppler.
Labs were significant for:
18.0 > 10.9/35.3 < 582
135|99|30
---------<254
4.7|22|1.0
Imaging showed
R Toes(s) radiograph ___ (PRELIMINARY REPORT):
IMPRESSION:
Soft tissue swelling about the right great toe without discrete
underlying bony erosion or fracture. Vascular calcifications and
osteopenia are also present. Please note that plain film is not
sensitive for detection of osteomyelitis. If further imaging
workup is required, MRI is recommended.
Chest Radiograph (PA and Lateral) ___:
IMPRESSION:
Low lung volumes, with interval resolution of moderate
interstitial pulmonary edema. No new focal consolidation
concerning for pneumonia.
Podiatric Surgery was consulted. They performed the following ___
exam:
___ FOCUSED EXAM: ___ pulses dopplerable. cap refill less than
3 sec to the digits. Normal proximal to distal cooling. Erythema
of the right ___ from ankle to proximal calf as well as localized
to the right hallux. There is a blood filled blister to the
right hallux which after debridement revealed an underlying
ulceration (2x2cm) which extended to the subcutaneous tissue.
There was a small amount of pus noted during debridement. There
is no probe to bone, tracking, nor fluctuance to the ulcerative
area. Light touch sensation diminished to the b/l ___. no pain to
the right hallux or RLE.
___ the ED, she received Cefepime 2gm IV, Vancomycin 1500mg IV
Vitals prior to transfer: 97.3 63 135/48 18 98% RA
Currently, the patient is unable to confirm the above history
due to confusion with the interpreter phone. She reports that
she is "tired" and would prefer to rest. She denies pain
currently ___ RLE.
ROS:
(+) as per HPI
(-) otherwise
Past Medical History:
Arthitis, NIDDM, HTN, Hypothyroidism
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98 BP 143/55 P 77 RR 20 O2 98% RA
GEN: Alert, lying ___ bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA bilaterally without wheezes or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: LLE: 2+ DP, biphasic ___ RLE: biphasic ___. There is
erythema, warmth and induration of both the anterior and
posterior RLE below the knee extending to the ankle. The
erythema stops there and then begins again at the mid foot where
it extends to the R ___ metatarsal where there is a 2x1cm ulcer
extending to subcutaneous tissue without drainage or purulence.
NEURO: Pt oriented to name and date ___ but not
location ("hotel"). CN II-XII grossly intact, motor function
grossly normal
DISCHARGE PHYSICAL EXAM:
=======================
VS: Tm 98.3 BP 148/65 P 64 (50-64) RR 18 O2 95% RA
GEN: Alert, lying ___ bed, no acute distress
NEURO: A&Ox3. CN II-XII grossly intact, motor function grossly
normal
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA bilaterally without wheezes or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: LLE: 2+ DP, biphasic ___ RLE: biphasic ___. Erythema
and warmth of RLE and R foot is improved. 2x1cm ulcer extending
to subcutaneous tissue is clean, with healthy granulation tissue
and minimal ss drainage without e/o purulent drainage or
surrounding erythema.
Pertinent Results:
ADMISSION LABS:
---------------
___ 10:30AM BLOOD WBC-18.0* RBC-3.67* Hgb-10.9* Hct-35.3
MCV-96 MCH-29.7 MCHC-30.9* RDW-12.8 RDWSD-44.7 Plt ___
___ 10:30AM BLOOD Neuts-82* Bands-0 Lymphs-16* Monos-1*
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-14.76*
AbsLymp-2.88 AbsMono-0.18* AbsEos-0.18 AbsBaso-0.00*
___ 10:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL
___ 10:30AM BLOOD Glucose-254* UreaN-30* Creat-1.0 Na-135
K-4.7 Cl-99 HCO3-22 AnGap-19
___ 06:28AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.5*
___ 06:28AM BLOOD VitB12-719
___ 06:28AM BLOOD TSH-3.7
DISCHARGE LABS:
------------
___ 06:04AM BLOOD WBC-11.6* RBC-3.62* Hgb-10.8* Hct-34.8
MCV-96 MCH-29.8 MCHC-31.0* RDW-12.7 RDWSD-44.6 Plt ___
___ 06:04AM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-138
K-4.4 Cl-102 HCO3-25 AnGap-15
___ 06:04AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.0
MICROBIOLOGY
------------
___ 12:01 pm SWAB Source: R Foot .
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ 12:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
TOE(S), 2+ VIEW RIGHT Study Date of ___ 12:06 ___
IMPRESSION:
Soft tissue swelling about the right great toe without discrete
underlying
bony erosion or fracture. Vascular calcifications and
osteopenia are also
present. Please note that plain film is not sensitive for
detection of
osteomyelitis. If further imaging workup is required, MRI is
recommended.
CHEST (PA & LAT) Study Date of ___ 12:07 ___
IMPRESSION:
Low lung volumes, with interval resolution of moderate
interstitial pulmonary edema. No new focal consolidation
concerning for pneumonia.
UNILAT LOWER EXT VEINS RIGHT Study Date of ___ 7:27 ___
IMPRESSION:
No evidence of deep venous thrombosis ___ the right lower
extremity veins. The peroneal veins were not identified by
ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. Docusate Sodium 100 mg PO BID
3. Senna 17.2 mg PO QHS
4. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY
5. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
6. Acetaminophen 650 mg PO TID
7. Atorvastatin 10 mg PO QPM
8. ciclopirox 0.77 % topical PRN
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU BID
11. Januvia (SITagliptin) 100 mg oral DAILY
12. MetFORMIN (Glucophage) 500 mg PO TID
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Sertraline 25 mg PO DAILY
15. Bisacodyl 5 mg PO DAILY
16. Levothyroxine Sodium 125 mcg PO DAILY
17. polyvinyl alcohol 1.4 % ophthalmic BID:PRN dry eyes
18. TraZODone 25 mg PO QHS insomnia
19. Meclizine 12.5 mg PO TID:PRN nausea
20. Omeprazole 20 mg PO BID
21. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
22. meloxicam 15 mg oral DAILY:PRN
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
2. Clotrimazole Cream 1 Appl TP BID
3. Sulfameth/Trimethoprim DS 2 TAB PO BID
4. Acetaminophen 650 mg PO TID
5. Atorvastatin 10 mg PO QPM
6. Bisacodyl 5 mg PO DAILY
7. ciclopirox 0.77 % topical PRN
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU BID
11. Januvia (SITagliptin) 100 mg oral DAILY
12. Levothyroxine Sodium 125 mcg PO DAILY
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
15. Meclizine 12.5 mg PO TID:PRN nausea
16. meloxicam 15 mg oral DAILY:PRN pain
17. MetFORMIN (Glucophage) 500 mg PO TID
18. Omeprazole 20 mg PO BID
19. polyvinyl alcohol 1.4 % ophthalmic BID:PRN dry eyes
20. Senna 17.2 mg PO QHS
21. Sertraline 25 mg PO DAILY
22. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY
23. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
24. TraZODone 25 mg PO QHS insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-----------------
Right lower extremity cellulitis
Superficial diabetic toe ulcer (R ___ hallux)
SECONDARY DIAGNOSIS:
-------------------
Altered mental status
Diabetes mellitus type 2
Hypertension
Onychomycosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: TOE(S), 2+ VIEW RIGHT
INDICATION: ___ with right great toe pain and discoloration. Evaluate for
osteomyelitis.
TECHNIQUE: Non-weightbearing frontal, oblique, and lateral view radiographs
of the right great toe.
COMPARISON: None available.
FINDINGS:
Hallux valgus deformity of the right great toe is present with moderate
degenerative changes of the first MTP, indicated by joint space narrowing and
osteophytes. There is diffuse osteopenia. No discrete fracture or bony
erosion is detected in the right great toe. No radiopaque foreign body.
Small vascular calcifications are present. There is likely a small amount of
soft tissue swelling about the right great toe.
IMPRESSION:
Soft tissue swelling about the right great toe without discrete underlying
bony erosion or fracture. Vascular calcifications and osteopenia are also
present. Please note that plain film is not sensitive for detection of
osteomyelitis. If further imaging workup is required, MRI is recommended.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with rt big toe pain and discoloration. Evaluate for
pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph of ___ and ___.
FINDINGS:
Mild cardiomegaly persists. Compared with the prior radiograph, mild to
moderate interstitial pulmonary edema has essentially resolved. No new focal
consolidation, pleural effusion, or pneumothorax.
IMPRESSION:
Low lung volumes, with interval resolution of moderate interstitial pulmonary
edema. No new focal consolidation concerning for pneumonia.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with erythematous, warm, and swollen RLE
concerning for cellulitis vs DVT. Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow is identified in 1 of
the posterior tibial veins. The peroneal veins were not identified by
ultrasound.
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 lower extremity veins. The
peroneal veins were not identified by ultrasound.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Toe pain
Diagnosed with Cellulitis of right lower limb, Type 2 diabetes mellitus with foot ulcer, Non-prs chronic ulcer oth prt right foot w unsp severity
temperature: 97.6
heartrate: 63.0
resprate: 18.0
o2sat: 99.0
sbp: 145.0
dbp: 49.0
level of pain: unable
level of acuity: 3.0 | ___ year old ___ speaking woman with a history of HTN,
NIDDM2, hypothyroidism, and recent hospitalization for falls c/b
subdural hematoma now presenting with right lower extremity
swelling and R first metatarsal pain and swelling.
ACTIVE ISSUES:
#RLE cellulitis/R hallux ulcer: The patient has a warm,
erythematous, and edematous right lower extremity with
leukocytosis to 18 ___ the setting of a peripheral toe ulcer,
most concerning for RLE cellulitis. Less likely is DVT
considering negative ___. With regards to the toe ulcer, the
patient has a history of DMII complicated by peripheral
neuropathy which places her at higher risk for forming an
infected toe ulcer and cellulitis. Wound Cx preliminarily
growing Coag negative staph. Pt clinically improved on
Vancomycin (___) and was transitioned to Bactrim/Keflex on
HOD2. She will complete Bactrim/Keflex for a 10 day course (D1 =
___, D10 = ___. Final wound, blood cultures will need to be
followed up. Wound care recs per podiatry include: WBAT RLE,
local wound care with adaptic and betadine and dry sterile
dressing, ___ Dr. ___ 1 week after d/c.
#Dizziness: Pt has a history of falls complicated by head
bleed/fractures. She continued to have subjective dizziness
here. ___ be iatrogenic given pt has had HRs consistently ___ ___
on metoprolol Succinate XL 100 for indication of hypertension.
EKG sinus bradycardia. Less likely orthostatic hypotension given
negative orthostatic VS. Metoprolol was held and discontinued on
discharge.
#Confusion: Collateral history per niece includes history of
confusion especially when "stressed" and not ___ home
environment. Pt also with likely source of infection that could
be contributing as well. Finally, pt has a history of falls
complicated by ___ (___) although no history of fall
prior to admission and so head imaging was deferred. Pt is
alert, oriented and attentive to interview during this
hospitalization. Pt clearly benefits from ___ interpreter
rather than over the phone. TSH, B12 wnl.
#DMII: blood glucose 254 on admission, improved to 120s on RISS.
Restarted home metformin and sitagliptin on discharge.
#HTN: mildly hypertensive to 150s sBP. Metoprolol discontinued
___ setting of dizziness as above.
#Onychomycosis: probable onychomycosis ___ bilateral feet,
increasing risk for superimposed bacterial infection ___ this pt
with DMII and diabetic foot ulcer. Started Clotrimazole cream
CHRONIC ISSUES:
#HLD: continued home atorvastatin.
#Hypothryoidism: continued home synthroid.
#Depression: continued home sertraline. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Ciprofloxacin / aspirin
Attending: ___
Chief Complaint:
dizziness, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
NEUROLOGY STROKE ADMISSION/CONSULT NOTE
No code stroke was called
The NIHSS was performed:
Date: ___
Time: 1600
___ Stroke Scale score was : 0
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
REASON FOR CONSULTATION:
Dizziness, unbalanced
HPI:
Mr. ___ is a ___ year old right handed-man with PMH of right
proximal stenosis of M1 with two previous stroke, including
right
frontal infarct (___) and right basal ganglia stroke
(unknown
when occurred), DMII complicated by nephropathy and neuropathy,
CKD (baseline creatinine of 2.5-3.0) hypertension, and
hyperlipidemia who neurology has been consulted for headache and
dizziness with concern for TIA/stroke.
Mr. ___ reports that he was doing well until yesterday evening
when he acutely developed dizziness which he defined as feeling
unbalanced. Mr. ___ was watching television in a chair and
did
not feel that he could sit further without falling over. He
does not feel like he was being pushed in one direction or
another. He got up and walked from his living room to his
bedroom. He normally walks with a cane, but had to depend on it
more so than normal and reports that he also had to use
furniture
and walls for support. He felt he was moving from side to side,
but did not feel he was veering preferentially in one direction
versus another. He was able to make it to his bed and felt that
after about five minutes he was much better, but continued to
feel as if something was wrong with him. He denied that his
dizziness was lightheadedness or vertigo.
Mr. ___ reports that he woke up this morning and felt normal.
He was having a bowel movement and in the context of such he
started to feel dizzy again. He also felt unbalanced. He
denied
lightheadedness and vertigo. He also developed a headache in
the
right frontoparietal region. The headache feels like pressure,
like someone is pushing on the area. He crawled back to his bed
from the restroom and laid down. He felt better in bed.
Mr. ___ nurse came to visit him. His blood pressure and
blood sugar was normal. She left. Mr. ___ decided to call
EMS
because he was concerned that he might have had a stroke.
Mr. ___ in the ___ denies that he has dizziness, but continues
to endorse mild headache in the right frontoparietal area. He
has no other complaints.
Pertinently, Mr. ___ was admitted to our stroke service from
___ after presenting with dizziness and generalized
weakness. He was found to have a new right frontal stroke. He
was also found to have right proximal M1 stenosis. He before
this admission was taking clopidogrel and the plan was to start
him on aspirin. He never started taking the aspirin because he
reports that it causes GI upset. In his discharge summary, it
is
documented that he should take aspirin with ranitidine, but he
reports that he was never given this message.
ROS:
On neuro ROS, the patient denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient 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:
Right proximal stenosis of M1 with two previous stroke including
right frontal infarct (___) and right basal ganglia stroke
(unknown when occurred)
DMII complicated by nephropathy and neuropathy
CKD (baseline creatinine of 2.5-3.0)
Hypertension
Hyperlipidemia
Obesity
Sleep apnea
Social History:
___
Family History:
maternal grandmother, maternal uncle, maternal aunt had DM.
Physical Exam:
EXAM ON ADMISSION:
=================
Presentation vitals:
Temperature: 96.6
Pulse: 76
Blood pressure: 155/78
Respiratory rate: 16
Oxygen saturation: 98% RA
General examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic examination:
Mental status:
Flat affect. He lacks intonation to his voice. He is awake,
alert, and cooperative with the exam. He says that he cannot do
months of the year backwards and makes no attempt to do so, but
can do days of the week backwards correctly. Fund of knowledge
is intact. He is oriented to place and date. Language is
fluent. Memory for recent and remote history is intact.
Cranial nerves:
Pupils are equal and reactive. Extraocular movements are full.
No nystagmus on fixation or with end gaze. Facial sensation and
movement are intact and symmetric. Hearing is intact to finger
rub bilaterally. Palate elevates symmetrically. SCM and
trapezius are full strength bilaterally. Tongue is midline.
Motor:
Tone is normal. He has no pronator drift. Strength is full.
Sensation:
He reports reduced appreciation of pinprick from about the ankle
downward. He can appreciate large upward and downward
excursions
of his giant toe, but not smaller ones.
Coordination:
No ocular dysmetria. He can suppress the vestibulocular reflex
with visual fixation. No rebound. No overshoot with mirroring.
Finger-nose-finger and finger-to-nose are intact without
dysmetria bilaterally. He has smooth and fast alternating
movements of both hands. He is accurate with finger tapping of
the index finger to crease of thumb He can hold a rhythm. HTS
without dysmetria. No truncal ataxia.
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 1 1 1
R 2 2 1 1 1
Plantar response was flexor bilaterally.
Gait:
He can walk in a straight line with his walker, he does not
appear to be veering or staggering.
Exam on discharge:
==================
VS:
24 HR Data (last updated ___ @ 400)
Temp: 98.0 (Tm 98.3), BP: 167/87 (152-171/87-98), HR: 72
(72-88), RR: 18 (___), O2 sat: 100% (99-100), O2 delivery: Ra
General examination:
General: Comfortable and in no distress, lying in bed
Head: MMM
CV: RRR, no m/g/r
Lungs: Unlabored breathing
Ext: Warm, no peripheral edema
Skin: No rashes or lesions
Neurologic examination:
Mental status:
Awake, alert, cooperative with exam.
Cranial nerves:
Pupils 3->2 bilaterally, right eye exotropia, EOMI with
difficulty burying on right, some saccadic breakdown on eye
movements, face symmetric, palate elevates symmetrically, visual
fields full.
Motor:
Tone is normal. Diminished bulk in bilateral hands and thighs.
Slight pronation on left side. IP ___ bilaterally, hamstrings
___
bilaterally.
Sensation:
Sensation intact to light touch throughout.
Coordination:
Both postural and intention tremor bilaterally, no dysmetria on
FNF R, slight dysmetria on L associated with known weakness.
Reflexes: deferred
Gait: deferred
Pertinent Results:
ADMISSION LABS:
===============
___ 09:45PM BLOOD WBC-4.4 RBC-3.28* Hgb-9.9* Hct-31.2*
MCV-95 MCH-30.2 MCHC-31.7* RDW-13.5 RDWSD-47.3* Plt ___
___ 09:45PM BLOOD ___ PTT-33.0 ___
___ 10:40AM BLOOD Glucose-140* UreaN-37* Creat-4.0* Na-145
K-4.7 Cl-111* HCO3-23 AnGap-11
___ 09:45PM BLOOD ALT-17 AST-16 LD(LDH)-179 CK(CPK)-225
AlkPhos-74 TotBili-0.2
___ 09:45PM BLOOD CK-MB-5 cTropnT-0.03*
___ 09:45PM BLOOD TotProt-5.7* Albumin-2.7* Globuln-3.0
Cholest-218*
___ 09:45PM BLOOD Triglyc-225* HDL-36* CHOL/HD-6.1
LDLcalc-137*
___ 09:45PM BLOOD TSH-1.8
___ 01:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ NCHCT - no large territory infarct
___ MRI brain, MRA head and neck
1. Small acute/early subacute right MCA infarct.
2. Large area of chronic right MCA infarct.
3. Occluded right M1 MCA, and nearly absent right MCA
arborization.
4. Normal neck MRA.
___ TTE
IMPRESSION: Normal left ventricular cavity size with low normal
systolic function. Normal right
ventricular cavity size/systolic function. No definite
structural cardiac source of embolism
identified.
DISCHARGE LABS:
___ 04:55AM BLOOD WBC-4.7 RBC-3.27* Hgb-9.7* Hct-30.9*
MCV-95 MCH-29.7 MCHC-31.4* RDW-13.3 RDWSD-46.0 Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-91 UreaN-39* Creat-3.6* Na-144
K-4.8 Cl-113* HCO3-22 AnGap-9*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Finasteride 5 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Tamsulosin 0.4 mg PO QHS
7. Ketoconazole 2% 1 Appl TP BID:PRN itching, fungal infection
8. Clopidogrel 75 mg PO DAILY
9. GlipiZIDE XL 5 mg PO DAILY
10. Propranolol 10 mg PO BID
11. B Complex 1 (vitamin B complex) 1 tablet oral DAILY
12. Ascorbic Acid ___ mg PO DAILY
13. Simethicone 80 mg PO QID:PRN gas
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Ascorbic Acid ___ mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. B Complex 1 (vitamin B complex) 1 tablet oral DAILY
5. Clopidogrel 75 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. GlipiZIDE XL 5 mg PO DAILY
8. Ketoconazole 2% 1 Appl TP BID:PRN itching, fungal infection
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Lisinopril 5 mg PO DAILY
11. Propranolol 10 mg PO BID
12. Ranitidine 150 mg PO BID
13. Simethicone 80 mg PO QID:PRN gas
14. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with dizziness// eval PNA; eval ischemia, bleed
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph from ___.
FINDINGS:
The cardiomediastinal and hilar contours are normal. No focal consolidations
are seen. There is no pulmonary edema or pleural abnormality.
IMPRESSION:
No evidence of acute intrathoracic process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111
INDICATION: History: ___ with lightheadedness// eval ischemia
TECHNIQUE: Multidetector CT images of the head were obtained without
intravenous contrast. Sagittal and coronal reformations were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 19.9 cm; CTDIvol = 45.5 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Prior study from ___.
FINDINGS:
Ventricles, cisterns and sulci appear stable. Areas of right cortical and
parietal encephalomalacia indicating prior infarcts appear stable. Volume
loss of the right caudate head is also unchanged. There is no evidence of
acute ongoing territorial infarction. No evidence of acute intracranial
hemorrhage. Surrounding soft tissue structures are unremarkable visualized
paranasal sinuses and mastoid air cells appear clear aside from minimal
opacification of a few cells on the left. No evidence of fracture or bone
destruction.
IMPRESSION:
No evidence of acute intracranial abnormality. Prior right frontal and
parietal infarcts, unchanged.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old man with episodes of unbalance// Stroke?
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Brain imaging was performed with diffusion, T1, FLAIR, T2, and gradient echo
technique.
Noncontrast 3D MRA of the neck was performed.
T1 and MPRAGE post contrast imaging was then performed. Multiplanar reformats
of the MPRAGE images were created.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: None.
FINDINGS:
MRI BRAIN:
Large chronic right MCA distribution infarct, involving middle, inferior
frontal gyrus, insula, operculum, right basal ganglia, lateral right temporal
lobe, right parietal lobe. Areas of punctate mineralization. Small focus of
restricted diffusion within chronic infarct, consistent with more recent
subacute infarct.
Right hemispheric brain parenchymal atrophy. Moderate chronic small vessel
ischemic changes. No mass, no acute hemorrhage. The paranasal sinuses are
essentially clear with the exception of mild anterior ethmoid air cell mucosal
thickening. The orbits are unremarkable.
MRA BRAIN:
The right M1 MCA is occluded, with trickle flow the proximal M2 and absent M2,
M3, M4 arborization on the right. Mild-to-moderate narrowing bilateral
paraclinoid ICA. Mild narrowing left paraclinoid ICA.
Remainder of the intracranial vessels are patent. No aneurysm.
MRA NECK:
Origin of great vessels are not adequately covered. The common, internal and
external carotid arteries appear normal. No ICA stenosis by NASCET criteria.
Patent visualized vertebral arteries.
IMPRESSION:
1. Small acute/early subacute right MCA infarct.
2. Large area of chronic right MCA infarct.
3. Occluded right M1 MCA, and nearly absent right MCA arborization.
4. Normal neck MRA.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with Acute kidney failure, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 2.0 | TRANSITIONAL ISSUES:
====================
[] Worsening renal function this admission. He should follow-up
with his nephrologist to further evaluate.
[] A creatinine should be checked in the outpatient setting
within ___ weeks. He was discharged with a creatinine of 3.6
which was downtrending from admission, but not back to his prior
discharge creatinine of 3.
[] He will need a repeat TTE that includes bubble to assess for
PFO given recurrent stroke.
[] He is being discharged with a ziopatch to monitor for cardiac
arrhythmias that could have contributed to his stroke. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
adhesive tape / Cat/Feline Product Derivatives / Dust & Pollen
Filter Mask / latex
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of multiple sclerosis and neurogenic bladder
s/p appendicovesicostomy (___), then exploratory laparotomy,
excision of Mitrofanoff, subtotal colectomy, creation of
colovesicostomy (___) due to
progression of her MS, colonic inertia, and progressive
inability to manage her bowel movements. She was discharged to
rehab and eventually returned to home.
The patient had been well until approximately one week ago when
she developed sudden onset of acute epigastric and periumbilical
abdominal pain associated with nausea and projectile bilious
vomiting. She presented to ___, where CT showed
SBO. She was also found to have an E-coli UTI (treated with
ceftriaxone, then nitrofurantoin). For her SBO, she was treated
conservatively (no NGT was placed) and she was discharged just
yesterday. However, this morning, she again experienced severe
abdominal pain, nausea, and dry heaves. She therefore went to
___ again where an NGT was placed, KUB taken (again showed
SBO) and she was transferred to ___ for further management.
Past Medical History:
Past Surgical History: Tonsillectomy, hysterectomy, placement
and removal of sacral nerve stimulator and the Botox injection.
C-section. Appendicovesicostomy (___)
Past Medical History: Multiple sclerosis and related symptoms.
carcinoma in situ of the cervix. Hypertension, depression.
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission:
VS - 98.8 104 147/94 20 97%
GEN - appears somewhat disheveled but NAD
___ - tachy, regular
PULM - no resp distress, CTAB
ABD - R ileostomy with scant bilious liquid and no gas, L
urostomy with fibrinous exudate in appliance and clear yellow
urine in bag; well-healed midline scar; abdomen is moderately
distended and tympanitic on exam; she has mild epigastric
tenderness to palpation, no rebound/guarding
EXTREM - contractures of the hands and feet
On discharge:
VS: 97.9 74 155/71 18 99%RA
Gen: NAD, A&Ox3
CV: RRR
Pulm: breathing comfortably on room air
Abd: soft, +BS, mildly distended, nontender. R ileostomy with
stool and air. L urostomy bac with urine.
ext: wwp, contractures of the hands and feet.
Pertinent Results:
KUB ___:
FINDINGS:
Small bowel is similarly dilated the previous examination with
scattered
air-fluid levels, possibly less prominent than on the previous
examination
which may relate to nasogastric tube decompression. No free
intraperitoneal
air is identified. Nasogastric tube is curled in the stomach.
Imaged lung
bases are unremarkable with note made of elevated left
hemidiaphragm.
IMPRESSION:
Unchanged bowel dilatation related to known obstruction. No free
intraperitoneal air. Satisfactory position of nasogastric tube.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID
2. Gabapentin 600 mg PO QID
3. Oxcarbazepine 450 mg PO TID
Discharge Medications:
1. Baclofen 10 mg PO TID
2. Gabapentin 600 mg PO QID
3. Oxcarbazepine 450 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with SBO. Air fluid levels? distention? free
air?
TECHNIQUE: Supine and left lateral decubitus abdominal radiographs.
COMPARISON: ___ from ___ hospital.
FINDINGS:
Small bowel is similarly dilated the previous examination with scattered
air-fluid levels, possibly less prominent than on the previous examination
which may relate to nasogastric tube decompression. No free intraperitoneal
air is identified. Nasogastric tube is curled in the stomach. Imaged lung
bases are unremarkable with note made of elevated left hemidiaphragm.
IMPRESSION:
Unchanged bowel dilatation related to known obstruction. No free
intraperitoneal air. Satisfactory position of nasogastric tube.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SBO
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.8
heartrate: 104.0
resprate: 20.0
o2sat: 97.0
sbp: 147.0
dbp: 94.0
level of pain: 3
level of acuity: 3.0 | Brief Hospital Course:
The patient was admitted to the Colorectal Surgery Service on
___ after being transferred from an outside hospital with a
small bowel obstruction. On admission, the patient's nasogastic
tube was placed to wall suction, she was made NPO, and kept on
IV fluids. A urinalysis was sent which was negative for
infection. Her ostomy had increased gas and stool on ___ and
NGT clamp trials were performed. Residuals were sufficiently low
and the NGT was removed on ___. She was started on sips,
which she tolerated without difficulty. The patient was a
advanced to a regular diet on ___ and her home medications
were restarted. The patient was able to tolerate a regular diet
without issue and continued to have bowel function.
She received heparin subcutaneously and pneumatic compression
boots for DVT prophylaxis.
On ___ the patient was discharged home with ___ in stable
condition, ambulating and voiding independently, and with
adequate pain control. The patient was given instructions to
follow-up in clinic with Dr. ___ as need and with PCP ___ ___
weeks. Pt was given detailed discharge instructions outlining
activity, diet, follow-up and the appropriate medication
scripts. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
adhesive / sutures
Attending: ___.
Chief Complaint:
Vomiting x 8 day; constipation; rash of left leg and left back
Major Surgical or Invasive Procedure:
___ ___ of J-tube
History of Present Illness:
HMED ATTENDING ADMISSION NOTE
DATE/TIME: ___
PCP: Dr. ___: Dr. ___ / ___: Dr. ___: Dr. ___
CC: rash
HPI:
___ yo M with stage IIB esophageal adenoCA, s/p neoadjuvant
chemo/XRT (___), s/p esophagectomy (___), s/p j-tube (___),
tube-feed dependent, has been having 8 days of vomiting at home
with decreased stool output. Was recently seen at ___ for
GI symptoms and CT imaging c/w constipation, now presents with
dislodged J-tube (since yesterday) and new rash on left leg, L
buttock, L groin x 48 hours, concerning for shingles/Zoster in
the L1-L3 dermatomes.
.
Recently seen in ED at ___ on ___ for abd pain, N/V.
There received IV Compazine, IV Zofran, CT chest - unremarkable,
CT A/P - moderate to large fecal load in right and transverse
colon, Mild leukocytosis WBC 12, otherwise routine labs
unremarkable, Discharged home same day with bowel regimen with
subsequent passage of bowel movements.
.
In ED here:
Triage VS: 98.8, 85, 132/82, 22, 95% on RA, pain ___. ED labs
notable for Na 130, Cl 92, lactate 2.9, WBC 10.1. KUB and CXR
unremarkable. Foley placed in J-tube tract, ___ consulted for
J-tube replacement and this was done prior to arrival to 12
___. IV Acyclovir was started in ER. Also received IVF 1L
NS, 1L LR. Additonal ED meds: IV Zofran, IV morphine, IV
Reglan, IV Ativan.
ROS: 10-point ROS negative except as noted above. Specifically,
no fever, chills, no abdominal pain or diarrhea. (+)
intermittent nausea, vomiting. (+) daily migraine headaches
unchanged from baseline. no pain/neuralgia, no CP, SOB. (+)
chronic cough unchanged (+) 4 lb wt loss last 8 days.
Past Medical History:
PMH:
Ulcerative colitis, in remission
Migraine
Asthma
Hypercholesterolemia
Esophageal CA stage IIB esophageal adenocarcinoma (T3N0M0)
- s/p neoadjuvant chemo, carboplatin/Taxol, (completed ___
- s/p XRT, 23 sessions (completed ___
- s/p esophgectomy
Gastric dysmotility
- s/p Botox injection
- currently on Reglan
Right inguinal hernia
PSH:
Minimally invasive ___ esophagectomy and pericardial fat
pad buttress (___)
s/p laprascopic J-Tube Placement (___)
s/p appendectomy ___
Social History:
___
Family History:
Father - died due to a blood clot
Siblings - brother with lung cancer, brother with CAD
Physical Exam:
ADMISSION EXAM:
98.1, 150/92, 96, 18, 97%RA
Anicteric, OP clear, neck supple no ___ CTA bilat
COR RRR ?___ mid LSB
ABD soft, NT/ND no R/G (+) J tube in place
EXT no edema
SKIN discrete vesicular rash in left L1-L3 (L upper & mid
anterior thigh, L high posterior buttock, L2 anterior groin
area) does NOT cross the midline,
NEURO fluent speech, nl cogntion, no hypesthesia
DISCHARGE EXAM:
VS: AF, 98.2, 126/85, 90, 16, 96% on RA
Pain: zero/10
Gen: NAD, comfortable
Resp: comfortable
Abd: soft, NT, + J-tube with dressing C/D/I
Skin: many vesicular lesions, in various stages of crusting,
distributed in left L1 - L3 dermatomal distribution, does not
cross mid-line.
Neuro: AAOx3, fluent speech
Pertinent Results:
ADMISSION LABS:
___ 06:40PM BLOOD
WBC-10.1* Hgb-16.6 Hct-47.7 MCV-86 RDW-13.2 RDWSD-41.0 Plt
Ct-UNABLE TO
Neuts-76.1* Lymphs-11.7* Monos-10.8 Eos-0.5* Baso-0.3 Im
___ AbsNeut-7.66* AbsLymp-1.18* AbsMono-1.09* AbsEos-0.05
AbsBaso-0.03
Glucose-107* UreaN-17 Creat-0.7 Na-130* K-4.2 Cl-92* HCO3-24
AnGap-18
Albumin-3.9 Calcium-9.5 Phos-2.6* Mg-2.5
ALT-32 AST-33 AlkPhos-85 TotBili-0.5
Lipase-17
cTropnT-<0.01
.
.
DISCHARGE LABS:
___ 10:30AM BLOOD
WBC-10.3* Hgb-14.9 Hct-43.6 MCV-88 RDW-13.7 Plt ___
___ 06:45AM BLOOD
Glucose-107* UreaN-10 Creat-0.7 Na-134 K-3.9 Cl-99 HCO3-29
AnGap-10
Calcium-8.7 Phos-3.4 Mg-2.2
.
.
MICROBIOLOGY:
___ Blood Culture x 2 sets: NGTD, final PENDING
___ Skin VZV and HSV culture: NGTD, final PENDING
.
.
IMAGING:
___ PA/LAT CXR
IMPRESSION:
No acute cardiopulmonary process.
.
___ Abdominal X-ray
IMPRESSION:
Nonobstructive bowel gas pattern.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation DAILY
2. Lactulose 15 mL PO TID
3. Metoclopramide 10 mg PO TID
4. Omeprazole 20 mg PO DAILY
5. Ondansetron 4 mg PO BID:PRN nausea
6. Acetaminophen 1000 mg PO Q6H:PRN headache
7. caffeine 200 mg oral DAILY:PRN headache
8. Polyethylene Glycol 17 g PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN headache
2. Lactulose 15 mL PO TID
3. Metoclopramide 10 mg PO TID
4. Omeprazole 20 mg PO DAILY
5. Polyethylene Glycol 17 g PO BID:PRN constipation
6. Ondansetron 4 mg PO BID:PRN nausea
7. caffeine 200 mg oral DAILY:PRN headache
8. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION DAILY
9. ValACYclovir 1000 mg PO Q8H Duration: 5 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every 8 hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dislodged J-tube
Constipation
Local zoster (shingles)
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 pulled out J tube // Please replace.
COMPARISON: ___ AND ___
TECHNIQUE:
OPERATORS: Dr. ___ resident) and Dr. ___
radiology attending) performed the procedure. The attending, Dr. ___ was
present and supervising throughout the procedure. Dr. ___
radiologist, personally supervised the trainee during the key components of
the procedure and reviewed and agreed with the trainee's findings.
ANESTHESIA: 50 mg of fentanyl were administered.
MEDICATIONS: Lidocaine jelly
CONTRAST: 15 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2 mins, 5 mGy
PROCEDURE: PROCEDURE: 1. Replacement of a MIC jejuostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. Contrast was injected through the
existing Foley demonstrating appropriate position. The Foley catheter was
removed after a glidewire was advanced through the tube into the jejunum.
This was exchanged for the same type of tube as the patient previously had
___ MIC jejunostomy tube, modified to a shorter length).
The balloon was inflated with 4 cc of contrast and contrast injection
confirmed position. The catheter was then flushed, capped and the retention
disk was cinched down and secured with 0-silk sutures. Sterile dressings were
applied. The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful replacement of a MIC jejunostomy tube. Balloon inflated to 4 cc
of contrast.
FINDINGS:
1. Successful placement of a MIC jejunostomy tube.
IMPRESSION:
Successful placement of a MIC gastrostomy tube. The catheter is ready to use
Gender: M
Race: ASIAN - ASIAN INDIAN
Arrive by WALK IN
Chief complaint: Abd pain, Dyspnea, Vomiting
Diagnosed with NONSPECIF SKIN ERUPT NEC, VOMITING, OTHER COLOSTOMY COMP, ABN REACT-EXTERNAL STOMA
temperature: 98.8
heartrate: 85.0
resprate: 22.0
o2sat: 95.0
sbp: 132.0
dbp: 82.0
level of pain: 5
level of acuity: 2.0 | ___ with stage IIB esophageal CA s/p chemo/XRT (___), J-tube
(___), esophagectomy (___), chronic constipation presents with
8 days N/V and increased constipation, 2 days left L1-L3 rash
consistent with Zoster, and spontaneous J-tube expulsion
yesterday.
.
# s/p J-tube dislodgement
Patient had his J-tube replaced by ___ prior to transfer from ED
to medical floor. He tolerated J-tube replacement without
difficulty. His tube feeds were initiated successfully, with
his home IsoSource 1.5 substituted with Jevity 1.5 during
hospitalization. He is being discharged to on a regimen of
IsoSource 1.5 at 90 ml/hr x 14 hr/daily. He should also have
free H2O flushes of 150 ml Q4 hr.
# Constipation
This was recently diagnosed at ___ by CT scan on ___
with ED visit. He was discharged to home with bowel regimen,
but only had scant BM's. On this hospitalization, he was kept
on Miralax and PO lactulose, but did not initially have BM's.
He received 1 Dulcolax suppository and 1 lactulose enema with
good effect. He will continue PO lactulose and Miralax on
discharge.
.
# Zoster, local
Patient had new onset vesicular rash in the L1 - L3 dermatome,
consistent with local zoster. Patient did not have any pain
(neuralgia) associated with the rash. He was treated as an
inpatient with PO Acyclovir for 48 hours. He was transitioned
to PO valacyclovir for an additional 5 days on discharge, to
complete a total of a 7 day course of anti-viral treatment for
local zoster. Prescription was called into his local ___
(___), co-pay of $1.50.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
naproxen / ___ pig
Attending: ___.
Chief Complaint:
short of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year old female with asthma (multiple episodes
requiring intubation), bronchiectasis, and tobacco use who
presents with 3 days of rapidly progressive wheezing and SOB not
responsive to her home nebs (recently filled prescription). She
says that things started getting worse about 2 weeks ago when
her eldest brother passed away. It seems at that time she
stopped closely adhering to her asthma regimen, but she did
apparently start a prednisone taper at 60 mg which she stopped
earlier this week at 20 mg. Since then her symptoms have gotten
worse. She has bad night-time coughing unresponsive to her nebs.
The day of presentation she was watching her ___ month old
granddaughter and felt that she couldn't keep up with her. Later
that day at work she continued to struggle with her breathing.
After coming home she decided to come to the ED here. She
reports that she hasn't been hospitalized since ___
when she was seen here. She denies fevers, chills, nausea,
vomiting, diarrhea and dysuria. She denies sick contacts. She
has seasonal allergies.
In the ED, initial VS 97.8, ___, 30, 97% on RA. By
report she was unable to speak in full sentences, tripoding, and
had diffuse wheezing. Labs were notable for WBC 12.3 with 9.2%
eosinophils (previously known to be elevated), normal chem 10
and lactate. CXR showed no acute process. She received 125mg IV
solumedrol x 1, Mag sulfate 2gm IV x 1, 1L NS, acetaminophen 1g
PO and albuterol/ipratropium nebs and was transferred to the
___ for further management.
On arrival to the ___, her vital signs were: 98.4, 111, 144/98,
15, 95% on face mask O2.
Past Medical History:
- Asthma (diagnosed in ___
- Brochiectasis
- Pulmonary nodules (detected in ___, follow-up CT in ___
showed no progression)
- positive PPD
Social History:
___
Family History:
Cancer (stomach and uterine per OMR) and T2DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.4, 111, 144/98, 15, 95% on face mask O2
General: Alert, oriented, mild respiratory distress, able to
speak comfortably
HEENT: Sclera anicteric
Lungs: Bilateral wheezing throughout with moderate-poor air
movement. No use of accessory muscles. Prolonged dry coughing
with inspiration
CV: Regular rhythm, tachycardic normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.1 135/90 76 18 96%RA
___: FSBS 128 (180-190)
General: no apparent distress, seated in bed reading on her
computer, appears well and eager for discharge. Appears well
ENT: MMM
Cardiovasc: rr, nl rate, no murmur
Resp: Breathing comfortably without accessory muscles or
retractions, no distress, no coughing, auscultration with
prolonged expiration and reduced air movement throughout with
mild wheezes at bases, no rales or rhonchi
Skin: No visible rash. No jaundice.
Neuro: AAOx3.
GU: No foley.
Pertinent Results:
Labs:
___ 08:05PM BLOOD WBC-12.3* RBC-4.77 Hgb-12.9 Hct-39.6
MCV-83 MCH-27.0 MCHC-32.5 RDW-15.2 Plt ___
___ 08:05PM BLOOD Neuts-59.5 ___ Monos-4.9 Eos-9.2*
Baso-0.4
___ 08:05PM BLOOD Glucose-120* UreaN-7 Creat-0.8 Na-137
K-3.7 Cl-100 HCO3-25 AnGap-16
___ 08:05PM BLOOD Calcium-9.6 Phos-3.2 Mg-2.1
Most recent labs prior to discharge:
___ 07:05AM BLOOD WBC-13.8* RBC-4.42 Hgb-12.0 Hct-36.6
MCV-83 MCH-27.0 MCHC-32.7 RDW-15.7* Plt ___
___ 07:05AM BLOOD Neuts-86.4* Lymphs-10.4* Monos-2.7
Eos-0.2 Baso-0.2
___ 07:20AM BLOOD Glucose-284* UreaN-21* Creat-0.9 Na-136
K-3.9 Cl-96 HCO3-26 AnGap-18
___ 07:20AM BLOOD Mg-2.0
___ 07:05AM BLOOD ALT-21 AST-14 AlkPhos-114* TotBili-0.4
Images:
CXR: No acute cardiopulmonary process
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Montelukast 10 mg PO DAILY
4. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
Daily
5. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Montelukast 10 mg PO DAILY
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
4. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
Daily
5. Tiotropium Bromide 1 CAP IH DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing, sob
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb IH Q2hours
Disp #*100 Vial Refills:*0
7. Azathioprine 100 mg PO QAM
RX *azathioprine 50 mg 2 tablet(s) by mouth QAM Disp #*60 Tablet
Refills:*0
8. Azathioprine 50 mg PO HS
RX *azathioprine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
9. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
10. PredniSONE 60 mg PO DAILY
Taper Prednisone by 10mg every 3 days starting ___
RX *prednisone 10 mg 6 tablet(s) by mouth Daily Disp #*65 Tablet
Refills:*0
11. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin [Glucophage] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Hyperglycemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with shortness of breath // ?pneumonia
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear. The cardiomediastinal silhouette is within normal limits
for technique. No acute osseous abnormality is identified.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Asthma exacerbation
Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION
temperature: 97.8
heartrate: 121.0
resprate: 30.0
o2sat: 97.0
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | ___ with refractory eosinophilic asthma requiring chronic
prednisone & azathioprine with frequent exacerbations & prior
intubation in ___, mild bronchiectasis, and prior tobacco use
who presented after not taking her prednisone & azathioprine
since ___ with subacutely worsening wheeze, cough and dyspnea
found to have a severe asthma exacerbation with persistent
peripheral eosinophilia.
# Asthma exacerbation:
# Eosinophilia:
She presented with a severe asthma exacerbation requiring ICU
admission. She improved and was called out to the general
medicine floor where she was followed by the pulmonary consult
team. She was treated with IV Solumederl, azathioprine, duonebs,
advair, singulair with slow improvement. Eventually she was
weaned to oral steroids with plan to continue a prednisone taper
as followed: 60mg PO Pred x3 days then taper by 10mg every 3
days to goal 10mg per day until she sees Pulmonary as an
outpatient. There was no evidene of pneumonia and so was never
treated with antibiotics.
# Hyperglycemia:
She had steroid induced hyperglycemia. She was kept on insulin
sliding scale and monitoring closely with decreased IV steroid
dose. While weaning steroids her ___ improved though still
remained in 150s-300 range prior to discharge. Since steroids
will continue to be weaned and ___ will continue to improve she
was not discharged on insulin due to hypoglycemic risks.
Discharged with Metformin until sterois can be weaned. Would
closely monitor ___ as an outpatient.
# HTN:
She was recently prescribed HCTZ which the patient reports not
taking. While in the hospital she had stage I-II hypertension
and was started on hydrochlorothiazide. This improved prior to
discharge to goal range. Potentially this will also improve with
wean of prednisone. She will follow up with her PCP for further
evaluation and management of her hypertension. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath, leg swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo female with history of recurrent DVT and PE
on intermittent coumadin who presents with leg pain and
shortness of breath.
Pt reports she had an upper respiratory illness 2 weeks ago with
associated shortness of breath. Her symptoms improved with
antibiotics but shortness of breath restarted on ___,
followed by leg pain on ___. She states that she is supposed
to be on life long coumadin, though she doesn't have her INR
checked reliably, last was several months ago. She has never
been evaluated for a clotting disorder, though states her PCP
did refer her to hematology for further evaluation. She
essentially titrates her coumadin dose to her vaginal bleeding
and will self- decrease her dose of coumadin when her bleeding
increases. She reports daily vaginal bleeding, which she
attributes to fibroids. She has followed with a gynecologist as
an outpatient, though states that she hasn't been offered any
definitive therapy for her fibroids and has been managing with
her bleeding for years.
In the ED, initial vitals: 97.9 98 178/86 20 90%. Pt had a CXR
without any acute processes. She had bilateral LENIs which
showed left sided DVT. Labs were notable for anemia with hct
31.6 (baseline), INR 1.4, otherwise unremarkable. She was noted
to be guaiac negative in the ED. She was started on a heparin
drip and admitted to the floor. Vitals prior to transfer: 98.1
97 176/83 20 99% RA
Currently, pt reports increasing in her vaginal bleeding,
soaking through 3 pads in 1.5 hours. She is a ___ witness
and will not accept blood products. She will take iron
supplements. She is unsure about other products such as albumin.
Past Medical History:
Obesity
DM type 2
Hyperlipidemia
Recurrent DVT/PE
Fibroid Uterus
Anemia
Social History:
___
Family History:
Family history of hypertension.
Denies any significant family history of blood clots, states
father had DVT in his ___.
Physical Exam:
ADMISSION EXAM:
===============
Vitals- 99.1 137/63 103 20 89%RA, 95% 2L
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding
GU- no foley, blood noted on underwear soaking through pad
Ext- warm, well perfused, 2+ pulses, 2+ pitting edema bilateral
to knees, R> L, tender to palpation left calf, healed wound on
right shin with chronic venous stasis changes
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
==============
VS 98.9 146/53 90 18 96%RA
General- Alert, oriented, no acute distress, morbidly obese and
pleasant
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, mild ttp over RUQ and mid-epigastrium, normal
bowel sounds, no rebound or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, ___ pitting edema
bilateral to knees, L>R, tender to palpation left calf, healed
wound on right shin with chronic venous stasis changes
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
================
___ 09:54AM BLOOD WBC-9.6 RBC-4.32 Hgb-8.8* Hct-31.6*
MCV-73* MCH-20.4* MCHC-27.8* RDW-18.1* Plt ___
___ 09:54AM BLOOD ___ PTT-31.4 ___
___ 09:54AM BLOOD Glucose-211* UreaN-9 Creat-0.7 Na-142
K-4.0 Cl-103 HCO3-27 AnGap-16
DISCHARGE LABS:
=================
___ 06:00AM BLOOD WBC-7.7 RBC-3.73* Hgb-8.4* Hct-27.1*
MCV-73* MCH-22.6* MCHC-31.2 RDW-19.0* Plt ___
___ 06:00AM BLOOD ___ PTT-50.6* ___
___ 06:00AM BLOOD Glucose-133* UreaN-8 Creat-0.7 Na-138
K-4.2 Cl-105 HCO3-27 AnGap-10
MISC LABS:
===========
___ 07:20AM BLOOD ALT-16 AST-26 LD(LDH)-308* AlkPhos-50
TotBili-0.2
___ 09:54AM BLOOD cTropnT-<0.01
___ 09:54AM BLOOD proBNP-663*
MICROBIOLOGY:
===============
___ 1:38 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
==========
# BILAT LOWER EXT VEINS Study Date of ___
IMPRESSION:
The distal left superficial femoral vein is distended with
echogenic contents, not compressible with transducer pressure
and has minimal flow on power Doppler. Findings represent acute
DVT of the left distal superficial femoral vein.
There is no DVT found in the right leg.
# CHEST (PA & LAT) Study Date of ___
IMPRESSION:
Non-specific left upper and right lower lung consolidation.
Consider repeat with improved inspiratory effort.
# PELVIS U.S., TRANSVAGINAL Study Date of ___
FINDINGS:
The uterus is anteverted and measures 10.8 x 8.9 x 14.6 cm.
Multiple
intramural fibroids are again identified, including 2 prominent
4.6 x 3.2 x 5.4 cm and 5.9 x 6.2 x 5.2 cm cm fundal fibroid,
enlarged since prior study. The ovaries were not visualized on
transabdominal or endovaginal imaging. The endometrium measures
0.7 cm visualized at the lower uterine segment.
There isnofree fluid.
IMPRESSION:
Multiple fibroids, enlarged since prior study. Ovaries not
identified. No adnexal masses.
# MRI ABDOMEN W/O CONTRAST Study Date of ___
Early termination of the examination due to claustrophobia.
Multiple
fibroids which are primarily intramural largest measuring up to
6.2 cm.
Severe degenerative disc disease at L5-S1 with disc protrusion.
# ABDOMEN US (COMPLETE STUDY) Study Date of ___
IMPRESSION:
1. Hepatic steatosis.
2. Normal gallbladder without stones.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 6 mg PO DAILY16
Discharge Medications:
1. Warfarin 3 mg PO DAILY16
RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abd pain
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___
tablespoons by mouth four times a day Refills:*0
3. Provera (medroxyPROGESTERone) 10 mg oral BID
Please start taking this medication once daily next ___
___
RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth twice daily
Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
DVT, likely PE
vaginal bleeding ___ fibroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Left leg pain.
TECHNIQUE: Grey scale, color and spectral Doppler evaluation was performed on
the bilateral lower extremity veins.
COMPARISON: Left lower extremity vein doppler on ___.
FINDINGS:
Left: The distal left superficial femoral vein is distended with echogenic
contents, and not compressible with transducer pressure. There is very
minimal flow detected the using power Doppler. Otherwise, there is normal
compressibility, flow and augmentation of the left common femoral, proximal
and mid femoral veins. Of note, these images of the left leg were initially
mislabeled as the 'right' leg. Clot is only found in the left leg.
Right: There is normal compressibility, flow and augmentation of the right
common femoral, proximal femoral, mid femoral, distal femoral, and popliteal
veins. The peroneal and posterior tibial veins are not visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
The distal left superficial femoral vein is distended with echogenic contents,
not compressible with transducer pressure and has minimal flow on power
Doppler. Findings represent acute DVT of the left distal superficial femoral
vein.
There is no DVT found in the right leg.
Radiology Report
HISTORY: Shortness of breath.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Multiple chest radiographs the most recent on ___.
FINDINGS:
The lung volumes are low. There is a subtle opacity in the left upper lung and
right lung base. The cardiomediastinal silhouette and hilar contours are
normal. The pleural surfaces are normal without effusion or pneumothorax.
The pulmonary vasculature is normal.
IMPRESSION:
Non-specific left upper and right lower lung consolidation. Consider repeat
with improved inspiratory effort.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with heavy vaginal bleeding on heparin drip.
Evaluate for fibroids.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: Prior CT abdomen and pelvis from ___ and pelvis
ultrasound from ___.
FINDINGS:
The uterus is anteverted and measures 10.8 x 8.9 x 14.6 cm. Multiple
intramural fibroids are again identified, including 2 prominent 4.6 x 3.2 x
5.4 cm and 5.9 x 6.2 x 5.2 cm cm fundal fibroid, enlarged since prior study.
The ovaries were not visualized on transabdominal or endovaginal imaging. The
endometrium measures 0.7 cm visualized at the lower uterine segment.
There isnofree fluid.
IMPRESSION:
Multiple fibroids, enlarged since prior study. Ovaries not identified. No
adnexal masses.
Radiology Report
EXAMINATION: MR pelvis
INDICATION: Multiple enlarged fibroids on pelvic ultrasound with vaginal
bleeding. Please evaluate fibroids in preparation for upcoming uterine artery
embolization.
TECHNIQUE: Localizer and sagittal T2 images of the pelvis were obtained
without contrast. The examination was terminated early due to patient
claustrophobia.
COMPARISON: Compared with prior CT abdomen pelvis from ___ and
prior pelvic ultrasound from ___.
FINDINGS:
There are multiple fibroids which are primarily intramural, the largest
measuring 6.2 x 6.2 cm. The uterus is anteverted. The ovaries appear grossly
unremarkable. The bladder appears unremarkable. There is no free fluid in the
pelvis. There is severe degenerative disc disease at L5-S1 with disc
protrusion.
IMPRESSION:
1. Early termination of the examination due to claustrophobia. Multiple
fibroids which are primarily intramural largest measuring up to 6.2 cm.
2. Severe degenerative disc disease at L5-S1 with disc protrusion.
Radiology Report
HISTORY: Right upper quadrant abdominal pain.
COMPARISON: CT abdomen and pelvis, ___.
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
abdomen.
FINDINGS: The liver is diffusely echogenic compatible with steatosis. There
are no focal hepatic lesions. There is no intrahepatic biliary ductal
dilatation. The CBD was not definitively visualized given limited
visualization of the hepatic hilum. The portal vein is shown to be patent
with hepatopetal flow, however. The gallbladder is thin-walled and
unremarkable without stones. The pancreatic head and proximal body is
unremarkable. The distal pancreas is not seen due to overlying bowel gas.
The abdominal aorta is normal in caliber, though the distal most abdominal
aorta was not visualized. The visualized portions of the IVC are
unremarkable. The spleen is homogeneous in echotexture, measuring 12.7 cm in
length, at the upper limits of normal size. The right kidney measures 12.8 cm
and the left kidney measures 11.7 cm. There are numerous non-obstructing
calculi in bilateral lower pole kidneys, measuring up to 8 mm on each side.
There is no ascites.
IMPRESSION:
1. Hepatic steatosis.
2. Normal gallbladder without stones.
3. Several non-obstructing renal stones bilaterally, measuring up to 8 mm.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY, HYPOXEMIA, PULM EMBOLISM/INFARCT
temperature: 97.9
heartrate: 98.0
resprate: 20.0
o2sat: 90.0
sbp: 178.0
dbp: 86.0
level of pain: 5
level of acuity: 2.0 | ___ yo female with history of recurrent DVT and PE, on coumadin
though not compliant with treatment, as well as recurrent
vaginal bleeding, presenting with new DVT and likely PE.
# DVT, likely PE: Pt has long history of DVT, unclear etiology
as she states she has never been evaluated for a clotting
disorder. Per review of the record, and in discussion with
patient, she has difficulty complying with INR monitoring and is
often subtherapeutic. Pt attributes this to her vaginal
bleeding, which she states limits the time she can spend
therapeutic. The DVT found on admission appears to be acute, or
at least relatively new since ___ in ___ was negative for
DVT. Although she did not have CTA performed, she most likely
has PE as well given new hypoxia and shortness of breath. She
was initiated on lovenox with transition to warfarin. Her INR
was > 2 for ~ 48 hours prior to discharge and so she was
discharged on warfarin alone. Further hypercoagulability work-up
was deferred to the outpatient setting.
# Vaginal bleeding: This has been a long standing issue for
patient and appears to limit her ability to be effectively
anticoagulated. Pelvic ultrasound was performed, and showed
multiple fibroids that were enlarged since the previous study.
Gynecology was consulted, but due to body habitus, unable to do
enometrial biopsy at bedside, and recommended Provera 10mg TID,
to be tapered down by 10mg weekly once her bleeding improves. Pt
is a Jehova's witness and declined the possibility blood
products, though they were not needed during this admission. She
received 3 days of IV iron. Interventional radiology saw the
patient to discuss uterine artery embolization (UAE) and
recommended pelvic MRI (and endometrial biopsy) prior to UAE.
Pelvic MRI showed multiple fibroids which are primarily
intramural largest measuring up to 6.2 cm, though there was
early termination of the examination due to claustrophobia. She
was encouraged to follow-up with gynecology as an outpatient for
endometrial biopsy and with interventional radiology for uterine
artery embolization.
# Abdominal pain: Pt developed RLQ pain overnight consistent
with pain similar to previous kidney stones. This improved with
passing of a few blood clots in the urine. Abd US showed
non-obstructing renal calculi which could be source of
discomfort. Pain was then located in epigastrum, which responded
to zofran and maalox.
# Iron Deficiency Anemia: Pt's HCT remained around baseline. As
above, she declined blood transfusion and received IV iron x 3
days
# DM2: This is diet controlled, and she was continued on a
diabetic diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Methotrexate / ciprofloxacin / chlorhexadine
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of rheumatoid
arthritis on prednisone and hydroxychloroquine, multiple prior
abdominal surgeries (hemicolectomy for diverticulosis in ___,
SBO's requiring lysis of adhesions), chronic right foot ulcer
status post debridements, chronic venous insufficiency, prior
lower extremity osteo-myelitis, prior C. difficile, restrictive
ventilatory defect due to right hemidiaphragmatic paralysis,
hypertension, hyperlipidemia who presents with abdominal pain
and
fevers.
Of note, she has had multiple recent hospitalizations.
___ for Strep group C bacteremia thought to be from
chronic ___ skin wounds in setting of chronic immunosuppression.
She then was admitted ___ for ___ complicated
cellulitis. During both hospitalizations she endorsed abdominal
pain though possibly d/t mesenteric ischemia iso hypotension for
sepsis. Both hospital stays were also c/b atrial tachycardia
possibly triggered by hypovolemia iso sepsis.
Since that discharge she was followed up by PCP where she
reported feeling well. She also followed up with cariology
outpatient for holter monitoring, which upon review showed some
episodes of atach. Plan was for further monitoring with Ziopatch
to determine burden with consideration for CCB as she was
previous intolerant of beta-blocker. She also followed up with
podiatry on ___ who completed in-clinic debridement.
On day of presentation to the ED, she reported having a HA and
104 fever for which prompted her to call EMS. She also reports
left sided abd pain. She denied any other symptoms during this
time.
- In the ED, initial vitals were:
100.4 | 74 | 20 | 95% RA
She later developed 104.4 with tachycardia to 110s. She then
developed a 4L O2 requirement but this was weaned to 2L.
- Exam was notable for:
Abdomen is tender in the left upper and lower quadrants without
rebound or guarding.
The right lower extremity is mildly swollen and erythematous
with
a foul odor relatively to the left. Pulses are intact in both
lower extremities.
- Labs were notable for:
\ 9.6 / 138 | 102 | 30
20.8 ----- 192 ----------------<102
/ 32.7 \ 4.8 | 24 | 0.9
Lactate 2.5 -> 1.7
Trop 0.06 -> 0.08 -> 0.08
EKG: Sinus tachycardia 109, though is in atrial fibrillation in
the room. Normal axis and intervals. T wave inversions and ST
depressions in inferior and lateral precordial leads. ST segment
changes are similar to those seen on ___, but the ST
depressions are more pronounced. No STEMI.
- Studies were notable for:
CXR:
Low lung volumes with lower lung atelectasis, no definite signs
of pneumonia.
FOOT AP,LAT & OBL RIGHT XRAY:
No signs of osteomyelitis. Soft tissue swelling along the
dorsum
of the midfoot may reflect cellulitis
CT ABD & PELVIS WITH CO:
1. No evidence of acute abdominal abnormality to explain
symptoms.
2. Pancolonic diverticulosis without evidence of diverticulitis.
3. 2 nonobstructive renal calculi in the right inter pole
measuring up to 3 mm.
4. Ectatic distal aorta measuring up 2.3 cm.
- The patient was given:
IVF X2L
Cefepime 2g
Vanc 1000mg
Metronidazole 500mg IV
Hydrocortisone 100mg IV
- No consults placed
On arrival to the floor, she was very somnolent and not
responding to questions. However she was able to follow simple
commands and state where she was and her name.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Rheumatoid arthritis on prednisone and hydroxychloroquine
Restrictive ventilatory defect ___ right diaphragmatic paralysis
(supplemental O2 at night)
Supraventricular tachycardia - Diagnosed ___
Hypertension
Hyperlipidemia
Diverticulosis s/p hemicolectomy, lysis of adhesions
History of left foot osteomyelitis
OSA on CPAP
PSH:
Left ___ toe amputation (___)
Excisional biopsy of left elbow mass (___)
Split-thickness skin graft from right thigh to right foot
(___)
Incision and drainage of abscess of right foot (___)
Incision and drainage of abscess, right foot (___)
hemicolectomy (___)
cholecystectomy
Social History:
___
Family History:
- Mother, MI, died ___
- Father, AAA, kidney cancer, died ___
- Brother, AF, living ___, Rheumatoid
- Sister, AF, living ___, Rheumatoid
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 0313 Temp: 97.4 PO BP: 111/61 L Lying HR: 75
RR:
20 O2 sat: 98% O2 delivery: 2 L
GENERAL: Ill appearance. Somnolent but arousable though.
HEENT: PERRL, EOMI. Dry mucous membrane.
CARDIAC: RRR. Soft S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales.
BACK: Mild tenderness to palpation along entire spine.
ABDOMEN: Non distended, non-tender to deep palpation in all four
quadrants.
EXTREMITIES: Hands with lateral displacement at the wrist. Left
___ toe distal joint amputation.
SKIN: Chronic venous stasis changes bilaterally. Erythema of RLE
with area of petechia-like pattern on medial and posterior calf,
no purulence. No difference in warmth between each ___. Stage 1
decubitus ulcer over coccyx
NEUROLOGIC: AOx2. Moving all 4 limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 742)
Temp: 97.9 (Tm 98.1), BP: 124/78 (110-142/78-88), HR: 77
(68-88), RR: 20 (___), O2 sat: 93% (93-95), O2 delivery: ra
HEENT: PERRL, EOMI. Dry mucous membranes.
CARDIAC: RRR. Soft S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB. Mild crackles at the bases bilaterally.
BACK: Mild tenderness to palpation along entire spine.
ABDOMEN: Non distended, tender to palpation along the left
abdomen, no masses or hepatosplenomegaly, no rebound or guarding
EXTREMITIES: Hands with lateral displacement at the wrist. Left
___ toe distal joint amputation.
SKIN: Chronic venous stasis changes bilaterally. RLE with area
of
petechia-like pattern on medial and posterior calf, no purulence
or erythema (improved). No difference in warmth between each ___.
Stage 1 decubitus ulcer over coccyx
NEUROLOGIC: AOx2. Moving all 4 limbs spontaneously.
Pertinent Results:
ADMISSION LABS:
==============
___ 04:40PM BLOOD WBC-20.8* RBC-3.73* Hgb-9.6* Hct-32.7*
MCV-88 MCH-25.7* MCHC-29.4* RDW-18.2* RDWSD-58.1* Plt ___
___ 04:40PM BLOOD Neuts-94.5* Lymphs-1.7* Monos-2.9*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-19.59* AbsLymp-0.36*
AbsMono-0.61 AbsEos-0.01* AbsBaso-0.02
___ 05:36PM BLOOD ___ PTT-23.6* ___
___ 04:40PM BLOOD Glucose-102* UreaN-30* Creat-0.9 Na-138
K-4.8 Cl-102 HCO3-24 AnGap-12
___ 04:40PM BLOOD ALT-19 AST-61* AlkPhos-66 TotBili-0.3
___ 04:40PM BLOOD Albumin-3.8 Calcium-8.9 Phos-2.4* Mg-1.7
___ 04:40PM BLOOD Lipase-36
___ 04:40PM BLOOD cTropnT-0.06*
___ 08:30PM BLOOD cTropnT-0.08*
___ 12:57AM BLOOD cTropnT-0.08*
___ 05:06PM BLOOD ___ pO2-35* pCO2-46* pH-7.42
calTCO2-31* Base XS-4
PERTINENT LABS:
=============
___ 05:10AM BLOOD Glucose-59* UreaN-32* Creat-1.3* Na-139
K-5.4 Cl-107 HCO3-13* AnGap-19*
___ 11:04AM BLOOD Type-ART Temp-36.7 pO2-81* pCO2-37
pH-7.43 calTCO2-25 Base XS-0 Intubat-NOT INTUBA Comment-NASAL
___
___ 04:46PM BLOOD Lactate-2.5*
___ 08:46PM BLOOD Lactate-1.7
___ 11:04AM BLOOD Lactate-1.0
___ 03:30PM BLOOD calTIBC-228* Ferritn-126 TRF-175*
___ 04:46PM BLOOD Hgb-9.9* calcHCT-30
___:30AM BLOOD ANCA-NEGATIVE B
___ 03:30PM BLOOD CRP->300*
___ 04:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:40PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:40PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 04:40PM URINE Mucous-RARE*
___ 10:10PM STOOL CDIFPCR-NEG
DISCHARGE LABS:
=============
___ 05:15AM BLOOD WBC-15.0* RBC-3.35* Hgb-8.5* Hct-29.6*
MCV-88 MCH-25.4* MCHC-28.7* RDW-18.4* RDWSD-58.6* Plt ___
___ 05:15AM BLOOD Glucose-102* UreaN-34* Creat-0.9 Na-142
K-4.4 Cl-108 HCO3-25 AnGap-9*
MICROBIOLOGY:
=============
___ 4:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 5:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 5:36 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 5:10 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 3:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 10:10 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
IMAGING:
===============
FOOT AP,LAT & OBL RIGHTStudy Date of ___ 5:54 ___
IMPRESSION:
No signs of osteomyelitis. Soft tissue swelling along the
dorsum of the
midfoot may reflect cellulitis.
CHEST (PA & LAT)Study Date of ___ 5:54 ___
IMPRESSION:
Low lung volumes with lower lung atelectasis, no definite signs
of pneumonia.
CT ABD & PELVIS WITH CONTRASTStudy Date of ___ 7:02 ___
IMPRESSION:
1. No evidence of acute abdominal abnormality to explain
symptoms.
2. Pancolonic diverticulosis without evidence of diverticulitis.
3. 2 nonobstructive renal calculi in the right inter pole
measuring up to 3
mm.
4. Ectatic distal aorta measuring up 2.3 cm.
EKG ___
Sinus rhythm Nonspecific intraventricular conduction delay Abnrm
T, consider ischemia, anterior precordial leads. compared to
previous ECG , ST/T wave changes are less pronounced.
CT LOW EXT W/O C RIGHTStudy Date of ___ 12:02 ___
IMPRESSION:
1. No CT evidence for acute osteomyelitis.
2. Postoperative changes throughout the foot.
HIP UNILAT MIN 2 VIEWS LEFTStudy Date of ___ 6:07 ___
IMPRESSION:
No acute osseous injury of the left hip or significant
degenerative change.
EKG ___
Sinus tachycardia ST & T wave abnormality, consider inferior
ischemia ST & T wave abnormality, consider anterolateral
ischemia When compared with ECG of ___ 10:26,
(Unconfirmed) premature atrial depolarizations are no longer
present the rate has increased and ST/T wave changes persist.
TTE ___
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/
global biventricular systolic function. Mild aortic
regurgitation with mildly thickened leaflets but
no discrete vegetation.
Compared with the prior TTE ___, the findings are ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carbidopa-Levodopa (___) 1 TAB PO QPM
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate NASAL 2 SPRY NU QHS
6. Hydroxychloroquine Sulfate 200 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
9. PredniSONE 4 mg PO QPM
10. Psyllium Wafer 1 WAF PO DAILY
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
12. Ursodiol 300 mg PO TID
13. Vitamin D ___ UNIT PO EVERY OTHER DAY
14. Calcium Carbonate 1500 mg PO DAILY
15. Diclofenac Sodium ___ 75 mg PO DAILY
16. GuaiFENesin ___ mL PO QHS:PRN cough
17. Indapamide 1.25 mg PO DAILY
18. Loratadine 10 mg PO QHS:PRN allergies
19. Vitamin B Complex 1 CAP PO BID
Discharge Medications:
1. Betamethasone Valerate 0.1% Ointment 1 Appl TP DAILY
2. Cephalexin 500 mg PO TID
3. Hydrocerin 1 Appl TP TID:PRN rash
4. Sulfameth/Trimethoprim DS 1 TAB PO BID
5. Omeprazole 40 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Calcium Carbonate 1500 mg PO DAILY
9. Carbidopa-Levodopa (___) 1 TAB PO QPM
10. Docusate Sodium 100 mg PO BID
11. Fluticasone Propionate NASAL 2 SPRY NU QHS
12. GuaiFENesin ___ mL PO QHS:PRN cough
13. Hydroxychloroquine Sulfate 200 mg PO DAILY
14. Indapamide 1.25 mg PO DAILY
15. Loratadine 10 mg PO QHS:PRN allergies
16. PredniSONE 5 mg PO DAILY
17. PredniSONE 4 mg PO QPM
18. Psyllium Wafer 1 WAF PO DAILY
19. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
20. Ursodiol 300 mg PO TID
21. Vitamin B Complex 1 CAP PO BID
22. Vitamin D ___ UNIT PO EVERY OTHER DAY
23. HELD- Diclofenac Sodium ___ 75 mg PO DAILY This medication
was held. Do not restart Diclofenac Sodium ___ ___
physician tells you that this is ok
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Sepsis
Right lower extremity cellulitis
Secondary Diagnosis
Hypokalemia
Anion gap metabolic acidosis
Abdominal pain
NSTEMI II
Chronic hypoxemic respiratory distress
Chronic anemia
Chronic foot ulcers
Coronary artery disease
Rheumatoid arthritis
Hypertension
History of atrial tachycardia
Gastroesophageal reflux
___
Chronic venous stasis
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 LOW EXT W/O C RIGHT Q61R
INDICATION: ___ year old woman with hx RA on immunosuppressants, p/w sepsis
unknown source, has chronic ulcers on RLE// osteomyelitis
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 69.7 cm; CTDIvol = 10.2 mGy (Body) DLP = 710.5
mGy-cm.
Total DLP (Body) = 711 mGy-cm.
COMPARISON: Foot radiographs from ___
FINDINGS:
There is no bony destruction to indicate CT evidence of acute osteomyelitis.
No acute fractures or dislocations are seen. There is a physiologic amount of
knee joint fluid.
There is demineralization. There are mild degenerative changes of the knee
joint. The patella is slightly subluxed laterally from the trochlea.
There are degenerative changes and clawtoe deformities of the toes.
Postoperative changes are seen at the MTP joints. There has been resection of
portion of the first metatarsal shaft. There is muscle atrophy.
IMPRESSION:
1. No CT evidence for acute osteomyelitis.
2. Postoperative changes throughout the foot.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT
INDICATION: ___ year old woman with sepsis of unknown source// septic joint?
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the left hip.
COMPARISON: ___, CT scan of the abdomen and pelvis dated ___
FINDINGS:
There is no fracture or dislocation. There are mild degenerative changes
about the hips bilaterally. Extensive degenerative changes in the lumbar
spine are incompletely evaluated. There is no suspicious lytic or sclerotic
lesion. No erosions. Soft tissue granulomas overlying the left buttocks are
unchanged. Excreting contrast material opacifies the bladder and enteric
contrast material is seen within the sigmoid colon and rectum.
IMPRESSION:
No acute osseous injury of the left hip or significant degenerative change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Sepsis, unspecified organism, Cellulitis of right lower limb, Unspecified abdominal pain
temperature: 100.4
heartrate: 74.0
resprate: 20.0
o2sat: 95.0
sbp: nan
dbp: nan
level of pain: 3
level of acuity: 3.0 | BRIEF HOSPITAL COURSE:
=====================
Ms. ___ is a ___ woman with a history of RA, multiple
abdominal surgeries, chronic right foot ulcers, prior lower
extremity osteo-myelitis, prior C. difficile, and recent
hospitalizations for sepsis and ___ cellulitis who presents with
abdominal pain and fevers, concerning for sepsis most likely due
to RLE cellulitis. She was treated with antibiotics with
improvement, and discharged to complete a PO course of
antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ year old male patient who presented after a fall,
patient
stated that he was drinking tonight, when he tried to pick up a
mail package, he tripped and fell forward, ? LOC, c/o headaches,
no vomiting or weakness
Social History:
+ETOH
Physical Exam:
PHYSICAL EXAM:
AVSS
Gen: WD/WN, comfortable, NAD.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
AxOx3
follows commadns throughout
PERRL, EOMI, FSTM
no drift
MAE x ___
sensation intact to light touch
EXAM ON DISCHARGE:
NEuro intact
+ abrasion to back of his head.
Pertinent Results:
HEAD CT: ___
IMPRESSION:
1. Interim enlargement of the right frontal hemorrhagic
contusion.
2. Small right superior frontal extra-axial hematoma adjacent to
the
nondisplaced frontal bone fracture is stable. This may represent
an epidural
hematoma.
3. Bilateral frontal and left temporal subdural hematomas are
stable.
Medications on Admission:
Not put in the system. List reviewed with pt prior to discharge
and advised pt to hold aspirin for 7 days.
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please do not drive mechanical machinery or have any alcohol
itake while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth Q 4hrs Disp #*20
Tablet Refills:*0
3. LeVETiracetam 500 mg PO BID
Only take for 7 days twice a day.
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*13 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right frontal lobe contusion and bilateral SDH.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male status post fall.
TECHNIQUE: Multi detector CT images through the brain were obtained in soft
tissue and bone algorithm windows. Coronal and sagittal reformations were
generated and reviewed.
DOSE: 892 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is an nondisplaced fracture of the frontal bone, located in the midline
at the vertex and taking a right parasagittal course inferiorly. No extension
into the frontal sinus orbit is seen. There is a small right frontal subgaleal
hematoma.
Best seen on sequence 2, images 26 and 25, as well as coronal sequence 601 b,
image 44, there is a 1.0 x 0.9 cm right superior frontal hemorrhagic contusion
with minimal edema. There is a small adjacent extracted hematoma without mass
effect, which may be epidural given the adjacent fracture.
There are bilateral anterior/inferior frontal subdural hematomas, larger on
the right, extending along the right anterior falx. On the left, the subdural
hematoma also extends into the middle cranial fossa along the lateral, medial,
anterior, and inferior temporal lobe.
There is no sulcal effacement or shift of midline structures. Ventricles and
sulci are prominent due to underlying age-related cerebral atrophy. Fluid
density space in the anterior aspect of the right middle cranial fossa is
suggestive of an arachnoid cyst. Basal cisterns are not compressed.
There is minimal mucosal thickening in anterior ethmoidal air cells
bilaterally. Other visualized paranasal sinuses are well aerated. Right
mastoid air cells are partially opacified. Left mastoid air cells are clear.
IMPRESSION:
1. Nondisplaced fracture involving the midline and right aspects of the
frontal bone.
2. Small right superior frontal hemorrhagic contusion. Adjacent small
extra-axial hematoma, without mass effect, may be were, given the proximity to
the frontal bone fracture.
3. Small bilateral subdural hematomas, along the frontal lobe on the right,
and along the frontal and temporal lobes on the left. No significant mass
effect due to underlying age-related cerebral atrophy.
4. Probable arachnoid cyst in the right middle cranial fossa.
NOTIFICATION: These findings communicated to the ED physician via telephone
at 6:05 am on ___ at the time findings were discovered.
Radiology Report
EXAMINATION: NON CONTRAST HEAD CT
INDICATION: Right frontal subdural hematoma.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head
without IV contrast. Sagittal, coronal and bone thin algorithm
reconstructions were generated.
Total exam DLP: 892 mGy-cm.
CTDI: 53 mGy.
COMPARISON: Head CT from ___ at 05:31.
FINDINGS:
Nondisplaced fracture involving the midline and right aspect of the right
frontal bone is again seen. Right superior frontal hemorrhagic contusion has
increased in size, now measuring 14 x 10 mm (series 2, image 23). There is
surrounding mild vasogenic edema. Small adjacent extra-axial hematoma, which
may be epidural given the proximity to the fracture, is stable in size.
Bilateral inferior frontal subdural hematomas, slightly larger on the right,
which extend along the anterior inferior falx, are stable. Small subdural
hematoma surrounding the left temporal lobe is stable. There is no associated
sulcal effacement, given the underlying age-related cerebral atrophy. There is
no shift of normally midline structures. The basal cisterns are not
compressed. A probable arachnoid cyst is again seen in the right middle
cranial fossa.
A small focus of hypodensity in the left caudate head likely reflects a prior
lacunar infarction (series 2, image 14). Areas of low density in the
periventricular and deep white matter of the cerebral hemispheres are likely
sequela of chronic small vessel ischemic disease in a patient of this age.
Partial right mastoid air cell opacification and mild mucosal thickening in
bilateral ethmoid air cells are again seen.
IMPRESSION:
1. Interim enlargement of the right frontal hemorrhagic contusion.
2. Small right superior frontal extra-axial hematoma adjacent to the
nondisplaced frontal bone fracture is stable. This may represent an epidural
hematoma.
3. Bilateral frontal and left temporal subdural hematomas are stable.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer, ICH
Diagnosed with SEMICOMA/STUPOR
temperature: 98.6
heartrate: 101.0
resprate: 18.0
o2sat: 97.0
sbp: 163.0
dbp: 98.0
level of pain: 2
level of acuity: 3.0 | Mr. ___ was admitted to the neurosurgical floor for further
monitoring on ___. He remained neurologically and
hemodynamically intact. A repeat head CT was obtained, which was
stable. The patient remained stable and expressed readiness to
go home. He was discharged home with his daughter in stable
conditions. The patient was advised to hold his ASA for 7 days
and continue with Keppra for 7 days. All discharge instructions
and follow up given prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Remicade / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
Compazine / lithium
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Sigmoidoscopy:
Impression: Evidence of previous colectomy with ileo-rectal
anastomosis. Mild erythema and staple noted, but no marginal
ulcers or bleeding.
Ulcers in the neo-TI
Ulcers in the rectum
Otherwise normal sigmoidoscopy to ileum
Recommendations: - continue steroids
- will need to discuss starting biologic, likely as outpatient.
- while he has active disease, it does not appear to be severe
enough to explain abdominal pain.
History of Present Illness:
___ h/o Crohn's Disease ___ years with recent hemicolectomy at
OSH 10 months PTA, presents with abdominal pain x5 days.
Patient states he has been having a "Crohn's Flair" x5 days PTA
described as abdominal pain, nausea and diarrhea c/w previous
flairs. He was seen by his outpatient gastroenterologist who
started him on Prednisone 40mg PO. Patient had a flex sig 4 days
PTA which confirmed a Crohn's flair. The patient continued his
prednisone, however, the next day due to his nausea and
abdominal pain the patient was unable to take PO. This persisted
over the next few days with worsening abdominal pain and nausea.
After discussing with his outpatient gastroenterologist, it was
decided that he should come to ___ for further evaluation
given that his disease has been difficult to manage, failing
"multiple biologic therapies", including anaphylaxis to
remicaide.
Regarding his Crohn's disease, he does not take any daily
medications. Per GI pt was diagnosed at age ___ and was treated
with 5ASA and prednisone. He had a PEG placed a few years later.
In his teens he was on IFX and either ___ or MTX (not clear,
probably the latter). He had issues with possible anaphylaxis
with IFX but was subsequently able to tolerate. At age ___ he was
flaring and switched to Cimzia and then Humira, but without
response. At some point he was on Imuran. At age ___, he
underwent what seems to be total colectomy with ileo-rectal
anastomosis for stricturing complications.He has tried multiple
biologic therapies (unable to name specifics).
No fevers/chills, no chest pain or shortness of breath.
+decreased PO. No mouth ulcers. Vomiting x1, non-bloody. No
melena or hematochezia. +blood on toilet paper after wiping
In the ED, initial vitals were:
97.8 103 140/84 16 100% RA
Patient was given:
IV Morphine Sulfate 4 mg
IV Ondansetron 4 mg
IVF 1000 mL NS 1000 mL
IV Morphine Sulfate 4 mg
IVF 1000 mL NS 1000 mL
IV MethylPREDNISolone Sodium Succ 32 mg
On the floor, patient was hemodynamically stable complaining of
abdominal pain and nausea
Past Medical History:
- Crohn's disease: diagnosed at age ___
- s/p partial colectomy in ___ in setting of bowel obstruction
- s/p G-tube at age ___ (later removed)
Social History:
___
Family History:
no family history of IBD
Physical Exam:
ADMISSION PHYSICAL
Vital Signs: 117/72 83 18 98ra
GEN: NAD
HEENT: sclerae anicteric. No oral ulcers. Poor dentition. No
precervical LAD. No tonsilar exudates. No PND or nasal discharge
___: RRR no MRG
LUNGS: CTAB, no increased WOB, no rhonchi or crackles
ABD: well healed central incision with some granulation tissue.
Generalized tenderness to palpation. No rebound or guarding.
EXT: Warm, no edema
NEURO: CN II-XII grossly intact. Strength ___ UE and ___ b/l
PSYC: Normal affect
DISCHARGE PHYSICAL
98.1 126/67 88 18 98ra
GEN: NAD
HEENT: sclerae anicteric.
___: RRR no MRG
LUNGS: CTAB, no increased WOB, no rhonchi or crackles
ABD: well healed central incision with some granulation tissue.
Generalized tenderness to palpation (unchanged from ___ per
pt). No rebound or guarding.
EXT: Warm, no edema
PSYC: Normal affect
Pertinent Results:
___ LABS
___ 05:11AM BLOOD WBC-7.0 RBC-4.24* Hgb-11.1* Hct-35.4*
MCV-84 MCH-26.2 MCHC-31.4* RDW-14.1 RDWSD-42.2 Plt ___
___ 05:11AM BLOOD Neuts-75.6* Lymphs-14.6* Monos-7.4
Eos-1.0 Baso-1.1* Im ___ AbsNeut-5.29 AbsLymp-1.02*
AbsMono-0.52 AbsEos-0.07 AbsBaso-0.08
___ 05:11AM BLOOD Glucose-87 UreaN-8 Creat-0.8 Na-138 K-3.5
Cl-103 HCO3-25 AnGap-14
___ 05:11AM BLOOD ALT-14 AST-17 LD(LDH)-165 AlkPhos-113
TotBili-0.9
___ 05:11AM BLOOD CRP-8.7*
PERTINENT LABS
___ 05:17AM BLOOD Lactate-1.4
___ 05:17AM BLOOD Lactate-1.4
___ 05:11AM BLOOD CRP-8.7*
DISCHARGE LABS
___ 04:30AM BLOOD WBC-7.9 RBC-3.88* Hgb-9.9* Hct-32.2*
MCV-83 MCH-25.5* MCHC-30.7* RDW-13.8 RDWSD-41.3 Plt ___
___ 04:30AM BLOOD Glucose-135* UreaN-14 Creat-0.8 Na-142
K-3.3 Cl-105 HCO3-27 AnGap-13
MICROBIOLOGY
__________________________________________________________
___ 1:43 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 1:46 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 12:23 pm URINE Source: ___.
**FINAL REPORT ___
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___:
Negative for Chlamydia trachomatis by PANTHER System,
APTIMA COMBO 2
Assay.
Validated for use on Urine Samples by the ___
___
Laboratory. Performance characteristics on urine samples
were found
to be equivalent to those of FDA- approved TIGRIS APTIMA
COMBO 2
and/or COBAS Amplicor methods.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___:
Negative for Neisseria gonorrhoeae by PANTHER System,
APTIMA COMBO 2
Assay.
Validated for use on Urine Samples by the ___
Microbiology
Laboratory. Performance characteristics on urine samples
were found
to be equivalent to those of FDA- approved TIGRIS APTIMA
COMBO 2
and/or COBAS Amplicor methods.
__________________________________________________________
___ 1:00 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
__________________________________________________________
___ 10:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:40 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:46 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
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 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
IMAGING
___ MRE
IMPRESSION:
1. Unchanged mild pouchitis.
2. No evidence of active Crohn's disease in the small bowel.
3. No fistula or abscess.
4. Stable longstanding probable sequelae of fat necrosis in
left upper
quadrant.
___ SIGMOIDOSCOPY
Impression: Evidence of previous colectomy with ileo-rectal
anastomosis. Mild erythema and staple noted, but no marginal
ulcers or bleeding.
Ulcers in the neo-TI
Ulcers in the rectum
Otherwise normal sigmoidoscopy to ileum
Recommendations: - continue steroids
- will need to discuss starting biologic, likely as outpatient.
- while he has active disease, it does not appear to be severe
enough to explain abdominal pain. ___ need to consider
evaluation for other causes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. PredniSONE 40 mg PO DAILY
3. Ondansetron 4 mg PO Q6H:PRN nausea
Discharge Medications:
1. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Ondansetron 4 mg PO Q6H:PRN nausea
3. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Take while you are on prednisone.
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*0
5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*16 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Crohn's Disease
SECONDARY DIAGNOSIS
Anxiety/depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with Crohn's disease with a rising lactate. //
evaluate for perforation
TECHNIQUE: Supine upright views of the abdomen.
COMPARISON: CT abdomen pelvis on ___.
FINDINGS:
No evidence of free air. Surgical clips project of the left upper quadrant.
Patient is status post total colectomy. A gas-filled loop of small bowel in
the right mid abdomen measures up to 4.5 cm in diameter, without air-fluid
levels.
IMPRESSION:
No evidence of free air. Focally dilated loop of small bowel in the right mid
abdomen. CT can be performed for further evaluation.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the ___ ___ at 5:41 ___, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: MR ___
INDICATION: History of Crohn's disease with worsening abdominal pain.
Evaluate for cause of pain.
TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis
were acquired within a 1.5 T magnet, including 3D dynamic sequences performed
prior to, during, and following the administration of 0.1 mmol/kg of Gadavist
intravenous contrast (8 cc). Oral contrast consisted of 900 mL of VoLumen. 1.0
mg of Glucagon was administered IM to reduce bowel peristalsis.
COMPARISON: CT of the abdomen and pelvis from ___. MR
enterography from ___.
FINDINGS:
MR ENTEROGRAPHY:
The patient is status post colectomy. The distal aspect of the ileal pouch
has mild wall hyperenhancement and surrounding fat stranding, compatible with
mild pouchitis. It is unchanged from the prior exam. The superior pouch wall
is normally enhancing without significant thickening or evidence of edema.
The anastomosis appears patent. There is no significant upstream dilation to
suggest obstruction, though the upstream ileum is mildly patulous, similar to
the prior exams, and likely due to chronic changes.
The remainder of the small bowel appears to be within normal limits. There is
no edema, mucosal hyperenhancement, or abnormal wall thickening. No fistula
or abscess is identified.
Adjacent to the stomach, there is nonenhancing soft tissue which is slightly
hypointense on the T2 weighted images (6, 1). This was better characterized
on the prior CT. There is no fluid within this region to suggest an abscess.
This likely represents post surgical changes, possibly chronic fat necrosis.
There are no abnormal mesenteric lymph nodes or mesenteritis. Trace free
fluid is identified in the perihepatic space, which is nonspecific (4, 18).
MRI OF THE ABDOMEN AND PELVIS:
The imaged portions of the liver are normal without a focal lesion. The
portal veins are patent. There is no intra or extrahepatic biliary duct
dilation. Note, the entire liver is not included in the field of view. The
gallbladder is underdistended, which limits its evaluation. Within the
limitations, it is normal. No stones are identified. The spleen is normal in
size, measuring 12.4 cm. There are no focal lesions. A 21 mm accessory
spleen is noted in the left upper quadrant. The pancreas is normal without
duct dilation or a mass. The bilateral adrenal glands and kidneys are normal.
There are no worrisome renal lesions, hydronephrosis, or perinephric
abnormalities. The abdominal aorta is normal in caliber without evidence of
an aneurysm or significant atherosclerotic plaque. Incidentally noted is an
accessory right renal artery. There is no retroperitoneal or periportal
lymphadenopathy.
The bladder is unremarkable without wall thickening or a mass. The imaged
portions of the seminal vesicles and prostate gland are within normal limits.
There is no pelvic or inguinal lymphadenopathy. No free fluid is identified
in the pelvis.
There are no concerning osseous lesions. Postsurgical changes are noted in
the anterior abdominal wall, with foci of susceptibility artifact and
scarring. No hernia or fluid collection is identified. The soft tissues are
otherwise unremarkable.
IMPRESSION:
1. Unchanged mild pouchitis.
2. No evidence of active Crohn's disease in the small bowel.
3. No fistula or abscess.
4. Stable longstanding probable sequelae of fat necrosis in left upper
quadrant.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new line // new right PICC 44 cm ___
___ Contact name: ___: ___
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Right PICC tip is in thecavoatrial junction. Cardiac size is normal. The
lungs are clear. There is no pneumothorax or pleural effusion.
Radiology Report
INDICATION: ___ year old male with Crohn's disease status post flexible
sigmoidoscopy on ___ with worsening abdominal abdominal pain. Evaluate
for acute intra-abdominal process or bowel perforation.
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 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 4.4 s, 47.5 cm; CTDIvol = 11.3 mGy (Body) DLP = 537.8
mGy-cm.
Total DLP (Body) = 545 mGy-cm.
COMPARISON: MRE from ___ and abdominal radiograph from ___.
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. There is a trace amount of hematoma,
similar to prior exam and likely post-surgical in nature. The gallbladder is
within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The patient is
status post colectomy and ileal pouch anastomosis. Surgical clips are noted
along the splenic flexure and anterior abdomen. There is mucosal hyperemia of
the reservoir pouch and just proximal to the anastomosis concerning for
Crohn's flare.
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. No significant
atherosclerotic disease is noted. The abdominal aorta and its major branches
are patent.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Anterior midline postsurgical changes are noted.
IMPRESSION:
Mucosal hyperemia of the reservoir pouch and proximal to the anastomosis
concerning for Crohn's flare.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, n/v/d
Diagnosed with Unspecified abdominal pain
temperature: 97.8
heartrate: 103.0
resprate: 16.0
o2sat: 100.0
sbp: 140.0
dbp: 84.0
level of pain: 8
level of acuity: 3.0 | ___ with h/o Crohn's disease s/p total colectomy with ileoanal
anastomosis with multiple failed biologic therapies presents
with abdominal pain due to Crohn's Flair.
#Crohn's Disease Flair: Patient presents with abdominal pain x5
days prior to admission which he states is c/w prior Crohn's
disease flairs. CT abdomen shows inflammation c/w Crohn's flair
as did his sigmoidoscopy 4 days PTA by his outpt GI. After
review of outside records of endoscopy and pathology there was
evidence of ileitis. Abdomen is tender, but no rebound or
guarding. Hemodynamically stable with mild anemia. No signs of
active bleeding at this time. Stool cx, noro, c. diff and
crypto/giardia all negative. Outside flex sig showed disease
extending to ileum while in house MRE showed unchanged mild
pouchitis with no evidence of active Crohn's disease in the
small bowel. Given persistent abdominal pain and conflicting
data, GI performed sigmoidoscopy while in house. This showed
active disease in rectum and no disease in ileum. The patient
was switched to oral steroids which will need to be tapered as
an outpatient. GI recommended discussing initiation of biologic
therapy as an outpatient.
Pt had negative hepatitis B serologies and should be immunized.
Quantiferon gold was collected but not performed ___ technical
error, and will need to be repeated.
#ANEMIA: Hgb on admission 11.1, unclear if new. Likely has
component of anemia of chronic disease, however pt is at risk
for GI bleeding given current flair and need for SQH. Hgb
continued to downtrend but stabilized around 9. Hemodynamically
stable. Will need further evaluation as an outpatient.
#ANXIETY/DEPRESSION
-cont. Gabapentin 800 mg PO/NG TID
-___ reviewed prior to discharge - no evidence of medication
misuse based on this review
=====================
TRANSITIONAL ISSUES
[ ] Patient requested expedited discharge with the plan to see
his outpatient gastroenterologist for further care. He will need
his prednisone tapered.
[ ] Outpatient workup of anemia
# CODE: Full
# CONTACT: ___Mother) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Chantix
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of COPD,
polysubstance abuse, IBS and gastritis who presents with
worsening epigastric pain associated with nausea/vomiting and
general malaise.
She notes chronic history of abdominal pain especially in
epigastrium in addition to nausea and vomiting and generally
just
feeling unwell for a while but more recently has had worsening
epigastric pain, has been feeling sleepy all the time, unsteady
on her feet and just overall doesn't feel well. She has h/o IBS
and states she's always had issues with her bowel movements
either not going or having loose stool. She was previously on
linzess but more recently she underwent ___ in late ___ and
since then has only been on BID PPI for gastritis noted on EGD.
The colonoscopy was normal and the EGD was otherwise reassuring
as well. She reports a history of alcohol abuse but denies
alcohol dependence or prior history of alcohol withdrawal. She
denies any other ingestions or illicit drug use. She denies a
history of pancreatitis, abdominal surgeries or pancreatic
insufficiency. She has noted darker urine recently but otherwise
denies dysuria, hematuria or blood in stool or vomitus. She
denies recent changes in her medications and currently just
takes
PPI bid and inhalers.
In the ED:
Vitals: Tmax 99.1, P ___ -->116-120, BP 120-150/70's, RR ___,
98-100% on RA
Exam: Uncomfortable, Abdomen Soft, minimally tender to palpation
diffusely, nondistended, no masses, fecal occult negative brown
stool. otherwise benign neuro and cardiopulm exam
Labs: CBC 18.6>15.9<336; vbg:7.24/___, lactate 2.5, serum bicarb
7, AG 38, Sosm 308 --> repeat vbg 7.38/19, lactate 1.9. BUN/Cr
33/1.4, mild transaminitis 41/48, normal Tbili, lipase 257, Utox
positive for benzo's and cocaine, serum tox negative
Imaging: 2vCXR without acute changes, RUQUS with stable PD
dilation, unable to exlude pancreatitis but visualized portion
appears normal
Impression: pt w/ ___ and pancreatitis and persistent
tachycardia
and odd acidosis
Interventions: GI cocktail and 3L of LR
Plan: Renal consult, treat for pancreatitis, admit
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Lyme disease, HTN, tobacco use, lung nodule, thyroid
nodule, spontaneous pneumothorax, GERD, abdominal pain
Social History:
___
Family History:
no history of MS, strokes, seizures
Physical Exam:
Admission Exam:
GENERAL: tired appearing but in no acute distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen somewhat firm but not tense and non-distended,
tender
to palpation in mid-epigastrium, a-peritoneal, no guarding or
rebound
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly
symmetric
SKIN: No obvious rashes or ulcerations noted on cursory skin
exam
NEURO: Sleepy, oriented but somewhat of a poor historian,
falling
asleep during conversation at times but somewhat volitional,
face
symmetric, speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Discharge Exam:
VITALS: ___ 0721 Temp: 97.6 PO BP: 130/70 Sitting HR: 77
RR: 16 O2 sat: 100% O2 delivery: RA
GENERAL: improved overall appearance, smiling, NAD
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: SNTND BS+
NEURO / PSYCH: Alert, oriented, pleasant appropriate affect
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. linaCLOtide 145 mcg oral DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Pantoprazole 20 mg PO Q12H
5. Metoclopramide 5 mg PO DAILY AT LUNCH
6. Align (Bifidobacterium infantis) 4 mg oral DAILY
7. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Align (Bifidobacterium infantis) 4 mg oral DAILY
3. amLODIPine 10 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. linaCLOtide 145 mcg oral DAILY
6. Metoclopramide 5 mg PO DAILY AT LUNCH
7. Pantoprazole 20 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
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 abd pain// ?pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest CT from ___ and chest radiograph from ___
FINDINGS:
Change sutures in emphysematous changes overlying the right upper lung are
re-demonstrated. No focal consolidation is seen. There is no pleural
effusion or pneumothorax. No pulmonary edema is seen. The cardiac and
mediastinal silhouettes are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with pancreatitis// ?gallstone/cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Liver, gallbladder ultrasound dated ___, and ___.
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: 7 mm and unchanged from prior
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. Could not exclude the presence of acute
pancreatitis.
SPLEEN: Normal echogenicity
Spleen length: 6.4 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.4 cm
Left kidney: 11.0 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No evidence of cholelithiasis or acute cholecystitis.
2. The common hepatic duct appears borderline to mildly dilated, but this is
similar compared to prior studies from ___ and ___.
Please correlate with liver function tests.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Tachycardia
Diagnosed with Bradycardia, unspecified
temperature: nan
heartrate: 145.0
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Ms. ___ is a ___ female with
history of COPD, polysubstance abuse, IBS and gastritis who
presents with worsening epigastric pain associated with
nausea/vomiting and general malaise found to have acute
pancreatitis and profound AGMA. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Demerol / Latex / Medazepam
Attending: ___
___ Complaint:
Left total knee replacement pain & infection
Major Surgical or Invasive Procedure:
Left total knee irrigation & debridement, liner exchange
History of Present Illness:
___ year old female with history of left knee replacement s/p MVC
___, Dr. ___ p/w atraumatic L knee pain and swelling x 4
days a/w subjective fevers. While pt is afebrile, no
leukocytosis, lactate 1.6, given her limited ROm as well as
effusion and elevated CRP concern for septic arthritis.
Past Medical History:
*S/P TOTAL KNEE REPLACEMENT
___ ESOPHAGUS
CHRONIC PAIN
DEPRESSION
HEPATITIS C
HEROIN ABUSE
HERPES SIMPLEX
MRSA CULTURE POSITIVE
S/P BREAST AUGMENTATION
S/P MVA
MYOCLONIC JERKS
GASTROESOPHAGEAL REFLUX
TENSION HEADACHES
H/O COMMUNITY ACQUIRED PNEUMONIA
H/O FOLLICULITIS
H/O URINARY RETENTION
RHEUMATOID ARTHRITIS
Social History:
___
Family History:
Mother: HTN.
MGM: Thyroid disease.
PGM: Lung CA.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 07:05AM BLOOD WBC-6.2 RBC-3.17* Hgb-8.6* Hct-27.8*
MCV-88 MCH-27.1 MCHC-30.9* RDW-16.3* RDWSD-52.9* Plt ___
___ 07:11AM BLOOD WBC-6.6 RBC-3.02* Hgb-8.3* Hct-26.2*
MCV-87 MCH-27.5 MCHC-31.7* RDW-16.8* RDWSD-53.1* Plt ___
___ 06:08AM BLOOD WBC-6.4 RBC-3.22* Hgb-8.9* Hct-28.6*
MCV-89 MCH-27.6 MCHC-31.1* RDW-16.9* RDWSD-55.2* Plt ___
___ 04:15AM BLOOD WBC-7.7 RBC-3.69* Hgb-10.0* Hct-31.0*
MCV-84 MCH-27.2 MCHC-32.3 RDW-16.8* Plt ___
___ 04:40PM BLOOD WBC-9.8 RBC-3.90* Hgb-10.7* Hct-32.3*
MCV-83 MCH-27.3 MCHC-33.0 RDW-16.8* Plt ___
___ 04:40PM BLOOD Neuts-61.0 ___ Monos-5.3 Eos-3.7
Baso-0.3
___ 07:05AM BLOOD Plt ___
___ 07:11AM BLOOD Plt ___
___ 06:08AM BLOOD Plt ___
___ 04:15AM BLOOD Plt ___
___ 04:40PM BLOOD Plt ___
___ 07:05AM BLOOD Glucose-124* UreaN-7 Creat-0.7 Na-137
K-4.2 Cl-102 HCO3-29 AnGap-10
___ 07:11AM BLOOD Glucose-111* UreaN-7 Creat-0.7 Na-136
K-4.1 Cl-104 HCO3-24 AnGap-12
___ 06:08AM BLOOD Glucose-127* UreaN-6 Creat-0.7 Na-143
K-4.6 Cl-107 HCO3-28 AnGap-13
___ 04:40PM BLOOD Glucose-124* UreaN-11 Creat-0.8 Na-138
K-5.3* Cl-105 HCO3-26 AnGap-12
___ 07:11AM BLOOD ALT-14 AST-17 AlkPhos-57
___ 06:50PM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:05AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
___ 07:11AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
___ 06:08AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.0
___ 04:40PM BLOOD CRP-159.5*
___ 07:11AM BLOOD HIV Ab-NEGATIVE
___ 07:10AM BLOOD Vanco-14.4
___ 07:05AM BLOOD Vanco-14.2
___ 07:00PM BLOOD Vanco-9.4*
___ 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:51PM BLOOD Lactate-1.6
Medications on Admission:
1. ClonazePAM 1 mg PO BID
2. CloniDINE 0.2 mg PO QHS
3. Cyclobenzaprine 10 mg PO TID:PRN spasm
4. Nicotine Patch 21 mg TD DAILY
5. QUEtiapine Fumarate 50 mg PO QHS
6. Ranitidine 150 mg PO DAILY
7. Sertraline 100 mg PO DAILY
Discharge Medications:
1. ClonazePAM 1 mg PO BID
2. CloniDINE 0.2 mg PO QHS
3. Cyclobenzaprine 10 mg PO TID:PRN spasm
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QD Duration: 28 Days
6. Gabapentin 600 mg PO TID
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
8. Morphine SR (MS ___ 15 mg PO Q12H
9. Nicotine Patch 21 mg TD DAILY
10. QUEtiapine Fumarate 50 mg PO QHS
11. Ranitidine 150 mg PO DAILY
12. Rifampin 300 mg PO Q12H
13. Sertraline 100 mg PO DAILY
14. Levofloxacin 750 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Left total knee infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ with pain in L knee s/p replacement
TECHNIQUE: Three views of the left knee.
COMPARISON: Tib-fib radiographs ___.
FINDINGS:
Again seen is evidence of prior left total knee arthroplasty. The prosthetic
components appear well seated, without evidence of hardware related
complication or periprosthetic fracture. A superior patellar enthesophyte is
noted, which appears slightly more conspicuous than on prior. There is a
small suprapatellar joint effusion.
IMPRESSION:
1. Status post left knee arthroplasty with small joint effusion.
2. Small suprapatellar enthesophyte.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC // Evaluate new R single-lumen
Power PICC 45cm ___ ___ Contact name: ___: ___
COMPARISON: ___
IMPRESSION:
The patient has received the new right-sided PICC line. The course of the
line is unremarkable, the tip of the line projects over the cavoatrial
junction. No complications, notably no pneumothorax.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Knee pain
Diagnosed with PYOGEN ARTHRITIS-LOWER LEG
temperature: 99.0
heartrate: 81.0
resprate: 15.0
o2sat: 100.0
sbp: 94.0
dbp: 56.0
level of pain: 10
level of acuity: 4.0 | The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine /
Heparin Agents / Levaquin / Bactrim / Lisinopril / Valsartan /
Intelence / Benadryl
Attending: ___
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of HCV cirrhosis (treated), HIV, presenting
with cough. Patient states that she is "feeling sick" overall
that brought her into the ED.
Patient reports that she originally thought she had a bacterial
infection because she had been frequently re-using a water
bottle
without cleaning it. She reports that she stopped doing this but
her symptoms (cough and headache) continued to worsen. She
reports after this she tried Theraflu and acetaminophen which
only temporarily broke her fever but it always came back.
Patient reports her cough has been ongoing for a week associated
with shortnesss of breath. Also has had some intermittent
nausea,
did have 1 episode of non-bloody emesis several days prior with
interval resolution. Also having soft stools did have several
episodes of diarrhea the other day however recently has been
soft. Also complaining of some burning on urination.
In the ED:
Initial vital signs were notable for:
T99.1 HR 98 BP 127/78 RR 19 O2Sat 92% RA. Tmax while in ED
101.5F
Exam notable for:
- Gen: Coughing with productive sputum
- Lungs: Clear, no wheezes, rales, or rhonchi
- Abd: Mildly distended, otherwise soft, no m/r/g
- Ext: 2+ peripheral pulses, no c/c/e
Labs were notable for: normal CBC, negative Flu panel, lactate
2.3
Studies performed include:
CXR: Findings worrisome for multifocal pneumonia; large area of
left lung opacity and streaky opacity in the inferior aspect of
the right upper lobe.
Patient was given: Levofloxacin 750 mg, 1 L NS, APAP 650 mg
Vitals on transfer:
24 HR Data (last updated ___ @ 1809)
Temp: 97.7 (Tm 97.7), BP: 120/78, HR: 100, RR: 19, O2 sat:
93%, O2 delivery: Ra, Wt: 154.0 lb/69.85 kg
Upon arrival to the floor, patient reports that she is feeling
better. Denies any acute complaints.
Past Medical History:
- HIV diagnosed in ___
- HCV genotype I
- HSV I
- Ppd pos, quant gold neg ___
- EGD ___ with salmon esophagus suggestive of barretts: bx neg
- Colonoscopy ___ with rectal carcinoid and adenoma; 5hiaa 24
hour urine and octreotide scan neg
- Papillary thyroid cancer T1bN1b s/p total thyroidecomy, left
modified radical neck dissection, and thyrogen stimulated I 131
treatment with 150 mCi
- Kidney disease proteinuria: segmental global
glomerulosclerosis, ___ sclerotic/remainder mod mesangeal
proliferation with patchy intersititial fibrosis (not
cryoglobulinemia)
- Prior polysubstance abuse (cocaine, etoh)
- Depression
- Tobacco
- HTN
- Fibroids
- Fsh high at 47/ postmenopausal
- Decreased hearing left ear, hearing aid
- Hoarse voice with large laryngoceles and vocal cord deviated
left: ___ right saccular cyst left after left removal
- Pancreatitis in ___
Social History:
___
Family History:
Both mother and father passed away from lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS:
24 HR Data (last updated ___ @ 1809)
Temp: 97.7 (Tm 97.7), BP: 120/78, HR: 100, RR: 19, O2 sat:
93%, O2 delivery: Ra, Wt: 154.0 lb/69.85 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Right eye with cataract and vision loss.
CARDIAC: RRR no m/r/g
LUNGS: Cough productive of brownish colored sputum. Decreased
breath sounds bilaterally.
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 grossly intact. ___ strength throughout.
AOx3.
DISCHARGE PHYSICAL EXAM
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Right eye with cataract
CARDIAC: RRR no m/r/g
LUNGS: CTAB, resolution of cough
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: clubbing on bilateral upper extremities
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 grossly intact. ___ strength throughout.
AOx3.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 02:45PM BLOOD WBC-9.4 RBC-5.03 Hgb-14.7 Hct-41.4 MCV-82
MCH-29.2 MCHC-35.5 RDW-18.4* RDWSD-53.4* Plt ___
___ 07:15AM BLOOD WBC-8.2 Lymph-16* Abs ___ CD3%-82
Abs CD3-1078 CD4%-17 Abs CD4-227* CD8%-63 Abs CD8-828*
CD4/CD8-0.27*
___ 04:43PM BLOOD Glucose-131* UreaN-22* Creat-1.7* Na-132*
K-4.2 Cl-101 HCO3-18* AnGap-13
___ 04:43PM BLOOD ALT-38 AST-121* CK(CPK)-219* AlkPhos-80
TotBili-2.2*
___ 04:43PM BLOOD Albumin-2.6* Calcium-8.6 Phos-2.2* Mg-2.1
DISCHARGE LAB RESULTS
=====================
___ 07:09AM BLOOD ___-6.7 RBC-4.25 Hgb-12.3 Hct-34.5
MCV-81* MCH-28.9 MCHC-35.7 RDW-17.0* RDWSD-50.1* Plt ___
___ 07:15AM BLOOD WBC-8.2 Lymph-16* Abs ___ CD3%-82
Abs CD3-1078 CD4%-17 Abs CD4-227* CD8%-63 Abs CD8-828*
CD4/CD8-0.27*
___ 07:09AM BLOOD Glucose-96 UreaN-17 Creat-1.5* Na-137
K-4.2 Cl-104 HCO3-18* AnGap-15
___ 07:09AM BLOOD ALT-29 AST-81* LD(LDH)-281* AlkPhos-88
TotBili-0.9
___ 07:09AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.2
IMAGING
=======
___ CXR
Findings worrisome for multifocal pneumonia; large area of left
lung opacity and streaky opacity in the inferior aspect of the
right upper lobe.
___ Renal Ultrasound
Mild cortical hyperechogenicity is unchanged, suggestive of
medical renal
disease. No etiology for hematuria identified.
___ Abdominal Ultrasound
Nodular cirrhotic liver with borderline splenomegaly. No
concerning liver
masses identified. No evidence of portal vein thrombosis.
MICROBIOLOGY
============
___ Urinary study
Legionella Urinary Antigen (Final ___: positive
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dolutegravir 50 mg PO DAILY
2. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
3. Gabapentin 600 mg PO QHS
4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___)
5. Levothyroxine Sodium 100 mcg PO 2X/WEEK (___)
6. Spironolactone 25 mg PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
Discharge Medications:
1. Azithromycin 500 mg PO/NG Q24H
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*11
Tablet Refills:*0
2. Levothyroxine Sodium 75 mcg PO DAILY
RX *levothyroxine 75 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
4. Dolutegravir 50 mg PO DAILY
5. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
6. Gabapentin 600 mg PO QHS
7. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Legionella pneumonia
Secondary diagnoses
HIV
CKD
Cirrhosis
Hypothyroidism
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 history of HCV cirrhosis, HIV, presenting with
fevers, worsening shortness of breath and cough// Eval for PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Large area of left mid to lower lung opacity is seen. There is also streaky
opacity in the inferior aspect of the right upper lobe. No large pleural
effusion or pneumothorax is seen. Cardiac silhouette size is mildly enlarged.
Mediastinal contours are unremarkable.
IMPRESSION:
Findings worrisome for multifocal pneumonia; large area of left lung opacity
and streaky opacity in the inferior aspect of the right upper lobe.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ history of HCV cirrhosis previously on treatment however did
not complete, HIV (last CD4 ___ VL 1.4 ___, presenting with
productive cough, subjective fevers and chills, concerning for CAP with
unexplained hematuria.// ?etiology of hematuria, evidence of CKD
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Mild cortical
hyperechogenicity is unchanged.
Right kidney: 11.1 cm
Left kidney: 10.8 cm
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Mild cortical hyperechogenicity is unchanged, suggestive of medical renal
disease. No etiology for hematuria identified.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with history of incompletely treated ___. Now
here with abdominal pain, diarrhea, nausea, elevated LFTs, elevated T bili,
and elevated lipase.// Please evaluate liver, gallbladder and pancreas given
lab abnormalities. Please perform WITH Doppler to evaluate for portal vein
thrombosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___
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. A
small 4 mm cyst is seen in the left lobe. There is no ascites.
Color flow on pulse Doppler assessment of the liver vasculature shows full
patency of the left right and main portal veins with normal Doppler waveforms.
Hepatic veins and arteries are also normal.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 11.6 cm. 1.3 cm splenic hemangioma unchanged from the prior
scan.
KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is no evidence of masses, stones, or hydronephrosis
in the kidneys.
Right kidney: 9.3 cm
Left kidney: 10.2 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Nodular cirrhotic liver with borderline splenomegaly. No concerning liver
masses identified. No evidence of portal vein thrombosis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ILI
Diagnosed with Pneumonia, unspecified organism
temperature: 99.1
heartrate: 98.0
resprate: 19.0
o2sat: 92.0
sbp: 127.0
dbp: 78.0
level of pain: 5
level of acuity: 3.0 | ___ history of HCV cirrhosis, HIV (last CD4 ___ VL 1.4
___ presented with cough and chills, and was diagnosed
with legionella pneumonia. She was started on antibiotics, and
she quickly improved. She was discharged to complete a 14 day
course of azithromycin.
#Legionella Pneumonia
The patient's Legionella urinary antigen came back positive. She
received a dose of levofloxacin in the ED, which treats this.
Given a questionable allergy to levofloxacin, she was
transitioned to 500 mg of azithromycin every 24 hours daily. She
will need to complete a 14-day course of antibiotics from
___ - ___. The ___ lab was contacted to
confirm that this case was reported to the state.
#Abdominal pain, nausea, vomiting
#Transaminitis
#Elevated lipase
#Hep C cirrhosis
Patient with abdominal pain, nausea, vomiting. Has known
cirrhosis from treated hepatitis C. Patient with mildly
elevated transaminases and direct hyperbilirubinemia.
RUQ ultrasound with cirrhosis, no PVT, no ascities. LFTs
downtrended.
___ on CKD
#Microscopic hematuria
Patient with Cr on admission 1.7. Renal ultrasound with medical
renal disease. Improved with IV fluids. Restarted home
spironolactone on day of discharge. Cr on discharge 1.5.
#HIV
HIV (last CD4 ___ VL 1.4 ___. After the patient was
discharged, the CD4 count returned at 227. Although this does
not warrant initiation of PCP prophylaxis, it should still be
monitored closely. The patient's PCP was made aware. It's
possible this was acutely lowered due to current illness.
# Possible drug allergy to levofloxacin: pt carries listed
allergy to levofloxacin (rash) but received a dose in ED.
Investigation ongoing as to how received this. Patient did not
develop rash on this medication. Can consider allergy evaluation
to assess whether she in fact has any allergy to this medication
(and others she is listed as allergic to)
>30 minutes spent on patient care and coordination on day of
discharge
TRANSITIONAL ISSUES
===================
-Patient should continue azithromycin antibiotics through
___.
-Given clubbing, please repeat CT of the lungs after acute
infection resolves to rule out lung malignancy.
-Given clubbing and cirrhosis, patient should have an
echocardiogram completed as an outpatient (after resolution of
current lung illness) to rule out portopulmonary hypertension.
-Please monitor LFTs as outpatient and ensure resolution.
-Patient should follow-up with nephrologist given hematuria and
now new proteinuria. It may be beneficial to start her on an ACE
inhibitor.
- Patient had elevated lipase but of unclear etiology, as her
pain was not characteristic of pancreatitis necessarily, and no
imaging evidence by RUQUS of pancreatitis, and no gallstones
noted on imaging.
- Patient's CD4 count was 227 during the admission. It may be
lowered in the setting of active legionella infection. Please
continue to monitor.
- COnsider allergy evaluation given multiple allergies and also
listed allergy to levofloxacin but tolerance during this
admission x1 dose in ED.
- Given elevated TSH and low T4 as checked just prior to
admission, in discussion with outpatient endocrinologist
patient's thyroid replacement medication was increased to 75mcg
po qd. Patient will have labs rechecked with endocrine per
endocrinologist |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Infected right proximal humeral pathologic fracture
Major Surgical or Invasive Procedure:
Irrigation & Debridement ___
History of Present Illness:
___ is a ___ female undergoing a work up for
right humeral pathologic fracture of unclear etiology. Had ___
biopsy done ___ which by report was purulent, but on microscopy
was without bacteria, although rich in WBC. Overnight ___
had fever to 100.2 (skin probe), called Dr. ___ was
advised to come here for eval.
Past Medical History:
Depression
No history of CA
Social History:
___
Family History:
non-contributory
Physical Exam:
NAD, AOx3
LUE skin clean and intact
No LUE tenderness, deformity, erythema, edema, induration or
ecchymosis.
RUE in splint, notable for warmth and tenderness to RUE about
deltoid, pain in anterior flexion, internal/external rotation,
and abduction.
incision closed w/ silk sutures; intact. Mild drainage at
previous drain site.
Arms and forearms are soft
No pain with passive motion
R M U SITLT b/l but slightly decreased to dorsum right thumb.
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Pertinent Results:
___ 10:50AM GLUCOSE-115* UREA N-13 CREAT-0.6 SODIUM-132*
POTASSIUM-4.0 CHLORIDE-92* TOTAL CO2-28 ANION GAP-16
___ 10:50AM CRP-GREATER TH
___ 10:50AM WBC-17.5* RBC-3.53* HGB-7.9* HCT-25.6*
MCV-73* MCH-22.4* MCHC-30.9* RDW-17.5*
___ 10:50AM NEUTS-84.9* LYMPHS-9.5* MONOS-5.1 EOS-0.2
BASOS-0.3
___ 10:50AM SED RATE-UNABLE TO
Medications on Admission:
Sertraline 25 mg PO DAILY
BuPROPion 150 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain or fever
2. Bisacodyl 10 mg PR HS:PRN if no BM 1300 on ___
pt may refuse
3. BuPROPion 150 mg PO DAILY
4. CefePIME 2 g IV Q12H Duration: 6 Weeks
RX *cefepime 2 gram infuse 2 g q12hr Disp #*60 Gram Refills:*0
5. Docusate Sodium 100 mg PO BID
hold for loose stool
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
RX *Heparin Lock 10 unit/mL infuse into picc every four (4)
hours Disp ___ Milliliter Refills:*0
7. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 6 Weeks
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
Hold for sedation, RR<12 or altered mental status. Ok to start
while on PCA
RX *oxycodone 5 mg ___ tablet(s) by mouth q3hr Disp #*90 Tablet
Refills:*0
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
daily until BM
10. Senna 2 TAB PO BID
hold for loose stool
11. Sertraline 25 mg PO DAILY
12. Outpatient Lab Work
Weekly CBC w/ differetial
weekly Chem 7
Weekly ESR/CRP
___ laboratory results should be faxed to the ___
R.N.s at ___. ___ questions regarding outpatient
parenteral antibiotics should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R arm fracture / infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female status post ORIF for pathological fracture.
COMPARISONS: None.
FINDINGS: Frontal and lateral views of the chest were obtained. The heart is
of normal size with normal cardiomediastinal contours. The lungs are clear
without focal or diffuse abnormality. No pleural effusion or pneumothorax is
identified. The known right humeral fracture is not visualized on this exam.
The osseous structures are otherwise unremarkable. No radiopaque foreign
body.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
REASON FOR EXAMINATION: PICC line placement.
Portable AP radiograph of the chest was compared to ___.
Left PICC line is malpositioned, continuing towards the left internal jugular
line with its tip above the superior margin of the radiograph, reposition is
required.
Heart size and mediastinum are stable. Lungs are essentially clear with no
pleural effusion or pneumothorax.
Radiology Report
INDICATION: ___ female with osteomyelitis, failed bedside PICC
placement. A midline was left in place.
OPERATORS: ___, M.D., supervised by ___, M.D, the
attending radiologist who was present and supervising.
PROCEDURE:
Exchange of left-sided midline with left-sided PICC.
PROCEDURE DETAILS: Appropriate time-out was performed. Patient was
positioned supine, and the left upper arm was prepped and draped in sterile
fashion. A 0.018'' guide wire was placed through the indwelling midline, and
over this, the midline was removed, and a breakaway sheath was placed. The
distance to the SVC was then measured with the wire tip positioned in the SVC
and the PICC was cut to size. The PICC was then placed over the wire, and the
breakaway sheath was removed. The PICC was affixed to the skin with adhesive
device and covered with the appropriate dressing. The PICC is a double lumen
PICC, cut to 45 cm, and is ready to use. Fluoroscopy was used intermittently
during the examination.
FLUORO TIME: 2.1 minutes, 3 mGy total dose.
IMPRESSION: Uncomplicated exchange of indwelling left-sided midline for a
PICC, 45 cm long, two lumens, tip in SVC, ready for use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER S/P BX ___ NOW FEVER
Diagnosed with POSTPROCEDURAL FEVER
temperature: 98.3
heartrate: 104.0
resprate: 16.0
o2sat: 98.0
sbp: 95.0
dbp: 52.0
level of pain: 2
level of acuity: 3.0 | The patient was admitted to the Orthopaedic Trauma Service for
I&D of R humerus fracture infection. The patient was taken to
the OR and underwent an uncomplicated R humerus I&D, closure,
and placement of JP. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty. Infectious disease was consulted
for antibiotic regimen.
Weight bearing status: nonweight bearing RUE.
The patient received ___ antibiotics. The incision
was intact without evidence of erythema and only with mild
drainage; the extremity was NVI distally throughout. The
patient was discharged in stable condition with written
instructions concerning precautionary instructions and the
appropriate follow-up care. The patient will be continued on IV
antibiotic coverage with a PICC line for 6 weeks
post-operatively. She will be followed by the infectious
disease clinic. ___ questions were answered prior to discharge
and the patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
L toe pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o IDDM, HTN, CKD stage III and peripheral neuropathy who
presents with worsening left foot pain and difficulty walking.
Pt diagnosed with frostbite in ___ after remaining out in
the cold for several hours and was evaluated by Podiatry. During
his follow up appt with Podiatry on ___ he was given a 10 day
course of amox/clavulanate, which he states he has been taking.
He reports persistent pain in his left foot in the area of the
frostbite without erythema or swelling. Denies any new exposures
or trauma to the foot. Denies fevers, chills, SOB, chest pain,
abdominal pain, N/V or diarrhea. He has not been taking his
insulin for the last several days because he "is neglecting"
himself. He gives himself short-acting insulin sometimes, but
not according to the sliding scale. Medication adherence,
especially insulin adherence has been a long-standing issue.
Endorsed polyuria in ED but denies on the floor, denies
increased thirst. Follows with ___ and ___ saw them ___.
In the ED, initial VS were: 97.4 64 172/95 18 94% RA.
Exam significant for well-defined area of eschar with purpuric
discoloration on left toes ___, mild erythema and linear area on
lateral left foot where blister previously removed by podiatry.
Initial labs were significant for Na of 129, BUN/Cr of ___, Hct
of 36.8, lactate of 1.7, and VBG of ___. Blood
cultures obtained. Left foot XR was negative for fracture or
dislocation, or obvious osteomyelitis. He received 1L of IV
normal saline, 1g of acetaminophen, and 20 units of insulin
lispro. He was evaluated by podiatry, with admission to medicine
advised for expedited vascular work-up, including ABIs/PVRs and
antibiotics.
Upon transfer vital signs were: 97.9 84 151/83 16 100% RA.
On arrival to the floor, patient reports intermittent shooting
pain, electric-like, as well as increased tenderness when he
stands on the foot. He reports falling this morning after losing
his balance and scraped his shin. Denies LOC, head strike,
lightheadedness or dizziness prior to the event.
Past Medical History:
H/o LBBB
Prostate ca
Salivary gland Hypertrophy
Sleep apnea
HTN
HLD
Heart murmur
Hearing loss
Thyroid nodules
Urinary incontinence
Lacunar stroke x2 R
DMII
CKD Stage III
Cardiomyopathy
Anemia
Constipation
Social History:
___
Family History:
No known heart disease, DM, cancer in family
Physical Exam:
Admission PE:
VITALS: 97.6 157/71 HR 91 18 100% RA ___ pain
GENERAL: thin elderly male in NAD, very mobile in the bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, moderate dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, soft systolic murmur, no gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, no suprapubic
tenderness
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally, dry eschar on R foot medial
aspect great toe, dry eschar on distal ___ toes on the L foot
with mild surrounding erythema, TTP, ulceration at sole with
increased warmth. L toes skin is thickened and hyperpigmented.
No fluctuance.
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
.
Discharge PE:
VS: 97.7 ___ 100/ra ___ 196
GENERAL: thin elderly male in NAD, very mobile in the bed
HEENT: AT/NC, EOMI, PERRL, nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, soft systolic murmur, no gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, nontender, +BS, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no edema
PULSES: 1+ DP and ___ pulses bilaterally. Dry eschar on the
medial aspect of the great toe of his R foot. Dry eschars on the
plantar aspect of toes ___ on his L foot without significant
erythema, fluctuance, or drainage.
NEURO: CN II-XII intact
SKIN: warm and well perfused, no rashes
Pertinent Results:
Admission Labs:
___ 03:00PM BLOOD WBC-7.0 RBC-4.50* Hgb-12.7* Hct-36.8*
MCV-82 MCH-28.2 MCHC-34.5 RDW-13.1 Plt ___
___ 03:00PM BLOOD Glucose-512* UreaN-27* Creat-2.0* Na-129*
K-4.3 Cl-94* HCO3-26 AnGap-13
___ 04:31PM BLOOD ___ pO2-21* pCO2-51* pH-7.41
calTCO2-33* Base XS-4
.
Discharge Labs:
___ 06:30AM BLOOD WBC-5.6 RBC-4.12* Hgb-11.2* Hct-33.2*
MCV-81* MCH-27.3 MCHC-33.9 RDW-13.1 Plt ___
___ 06:30AM BLOOD ___ PTT-30.0 ___
___ 06:30AM BLOOD Glucose-150* UreaN-26* Creat-1.6* Na-135
K-4.3 Cl-101 HCO3-26 AnGap-12
___ 06:30AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
.
>> IMAGING:
- ABIs, prelim: Right greater than left tibial disease. Exercise
test was not performed due to pain from foot ulcers.
.
- L foot x-ray: No acute fracture or dislocation.
.
>> MICRO:
- bl cx pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 55 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Aspirin 325 mg PO DAILY
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
7. Vesicare (solifenacin) 10 mg oral DAILY
8. Furosemide 20 mg PO DAILY
9. Metoprolol Succinate XL 200 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
Hold for SBP < 100
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Glargine 55 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
5. Metoprolol Succinate XL 200 mg PO DAILY
6. Acetaminophen 325-650 mg PO Q6H:PRN pain
7. Furosemide 20 mg PO DAILY
Hold for SBP < 95.
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Vesicare (solifenacin) 10 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis: Frostbite, poorly controlled IDDM
Secondary Diagnoses
- CKD Stage III
- HTN
- HLD
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: History: ___ with IDDM, HTN who presents with worsening foot pain
in area of previous ___, no trauma. // Assess for bony involvement,
fracture
TECHNIQUE: Left foot, three views
COMPARISON: ___
FINDINGS:
There has been no interval change from the prior exam. No acute fracture or
dislocation is present. Joint spaces are preserved. No concerning lytic or
sclerotic osseous abnormality is visualized. There are no radiopaque foreign
bodies or soft tissue calcifications. Tiny posterior calcaneal spur is
present.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: Noninvasive arterial evaluation.
INDICATION: ___ year old man with persistent foot ulceration and pain //
ABI/PVR/toe pressures
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,
superficial femoral and popliteal arteries. Biphasic posterior tibial artery
waveform and monophasic dorsalis pedis.
The right ABI was 0.79.
On the left side, triphasic Doppler waveforms are seen at the left femoral,
superficial femoral, popliteal arteries. Biphasic posterior tibial artery
waveform and monophasic dorsalis pedis.
The left ABI was 0.91.
Pulse volume recordings showed abnormal amplitude at the level of the right
ankle and metatarsal consistent with the right tibial disease. Normal
amplitude on the left.
IMPRESSION:
Right greater than left tibial disease.
Exercise test was not performed due to pain from foot ulcers.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: L Foot pain
Diagnosed with PAIN IN LIMB, DIABETES UNCOMPL JUVEN, HYPERTENSION NOS
temperature: 97.4
heartrate: 64.0
resprate: 18.0
o2sat: 94.0
sbp: 172.0
dbp: 95.0
level of pain: 6
level of acuity: 3.0 | ___ yo man with poorly controlled T2DM c/b diabetic nephropathy
(CKD stage III) and peripheral neuropathy with recent dx of L
foot frostbite who presents to ___ ED with worsening left foot
pain.
.
# L > R Toe eschars: Pt initially presented to the ED ___ with
bilateral pedal blisters after spending a lot of time outside
and was thought to have possible frostbite. He was seen by
podatry in ED then and then followed up with them ___ at which
time they drained some of the blisters and gave him Augmentin.
He came to the ED because of pain in his L foot, was noted to
have eschar on his lateral toes on the L and ___ toe on the R.
It seems that this may just be the natural history of the
frostbite as there is no signs of infection, he looked well and
has palpable pulses. We got ABIs to help determine potential for
problems with wound healing. He was initially on IV ABX but
based on exam by medical team, these were stopped as no signs of
infection on exam and no leukocytosis of fevers. Pt should f/u
with podiatry and also in the vascular surgery clinic to
evaluate for possible need for angiogram given abnormal ABIs.
.
# Mechanical Falls: Patient experience two falls in past 24
hours. Clinical history most consistent with mechanical fall,
most likely a result of pain from ulcers and diabetic
neuropathy. ___ evaluated and recommended rehab placement.
.
# DMII: Glucose in 500s on admission. A1c = 12.2% on ___.
Hyperglycemia ___ insulin non-adherence in setting of inability
to affort lantus. Patient also endorses non-adherence to his
sliding scale, generally taking smaller doses. ___ saw pt and
did education. Restarted home lantus and SSI. SW also saw the pt
to help with resources.
.
# Chronic Issues:
- CKD: Baseline Cr 1.7. Elevated on admisison but returned to
baseline with IVF in the ED.
- HTN: Continued home amlodipine and metop
- HLD: Continued home atorvastatin
.
>> Transitional issues:
# Code: Full (confirmed)
- ___ discharge. After rehab stay, please ensure pt can afford
all of his home medications.
- Podiatry f/u recommended weekly for close follow-up of
bilteral toe wounds
- Vascular f/u recommended given abnormal ABIs. Please arrange
this follow-up
- Please continue diabetes education to promote insulin
compliance |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
sulfadiazine
Attending: ___.
Chief Complaint:
Fever and fatigue
Major Surgical or Invasive Procedure:
PTC w ___
History of Present Illness:
___ h/o Metastatic Pancreatic Adenocarcinoma (progressed on
FOLFOX, awaiting discussion of next regimen), Recent EColi
Bacteremia (presumably ___ cholangitis, s/p ___ipro), and Recurrent C diff who presents from home with fevers
and fatigue. Patient noted that since his last hospitalization
he has felt well and discontinued his vancomycin/ciprofloxacin
dosing without any missed doses. He noted that yesterday he
went to play in a concert as he is a member of a band, but felt
extremely fatigued after the first saw and was very lightheaded
so went home to rest. He then took a single dose of medical
marijuana which was his first-ever and went to bed. This
morning patient noted that he continued to be fatigued and
checked his temperature found to be 102° so presented to the
emergency department. Denied any sore throat, cough, nausea,
vomiting, abdominal pain, dysuria, rash. He noted that he
intermittently has loose stools which is baseline for patient
and feels that his current stooling (varies between soft formed
and loose) is not consistent with similar C. difficile
infections in quantity or odor. Of note, patient noted he had
several pills left in vanco course as scheduled.
In the ED, initial vitals: 100.1 97 140/64 15 98% RA.
Temperature then increased to 102.9.
-Labs revealed WBC 11.5, Hgb 8.5 (baseline 10), INR 1.2, BUN/Cr
of ___ (baseline ___
-Patient was given 1 L NS, Vancomycin, Cefepime, Flagyl,
Tylenol.
-ERCP team consulted who record considering MRCP tomorrow if
further workup for infection is negative, but are not planning
on ERCP currently.
REVIEW OF SYSTEMS: as above otherwise 10point ROS negative
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: neoadjuvant FOLFIRINOX
-___: CyberKnife x 3 treatments
-___: pylorus preserving pancreaticoduodenectomy (Whipple).
-___: adjuvant Gemcitabine/capecitabine initially,
then d/c capecitabine and continue with gemcitabine alone
starting ___ d/t cytopenias.
-___: FOLFOX (first line tx of metastatic disease)
-___: patient was briefly treated with
investigational isoquercetin to prevent venous thromboembolic
events, came off trial d/t patient preference.
-___: Disease progression. Stopped FOLFOX
PAST MEDICAL HISTORY:
-Back pain since ___
-? colitis in the past (dx not confirmed), not autoimmune,
currently controlled since childhood 1960s
-Elevated PSA ___
-HTN, HLD
-R inguinal hernia repair in ___
-Basal Cell s/p removal from nose in ___
-Vasectomy ___
-Tonsillectomy ___ c/b hemorrhage
-Ocular migraines ___ years
-Arthroscopic knee surgery at age ___
-Chronic nasal congestion x ___ years
-Recurrent CDiff colitis (last ___
Social History:
___
Family History:
Father with squamous cell s/p removal, died ___ from Alzheimers
(alcoholic). Mother with lung CA, smoker, died age ___. Younger
sister with BCC and older sister (half-sister)s/p lumpectomy
("benign growths").
Physical Exam:
DISCHARGE EXAM
98.6 167/82 81
aox3
not jaundiced
ctab
rrr
soft abd no guarding or rebound, no focal tenderness or
organomegaly
no peripheral edema
Pertinent Results:
ADMISSION LABS
___ 05:55PM BLOOD WBC-11.5*# RBC-2.61* Hgb-8.5* Hct-26.4*
MCV-101* MCH-32.6* MCHC-32.2 RDW-14.2 RDWSD-51.3* Plt ___
___ 05:55PM BLOOD Neuts-77.7* Lymphs-10.0* Monos-11.1
Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.91*# AbsLymp-1.15*
AbsMono-1.28* AbsEos-0.06 AbsBaso-0.04
___ 06:21PM BLOOD ___ PTT-25.6 ___
___ 05:55PM BLOOD Glucose-106* UreaN-26* Creat-1.5* Na-141
K-4.4 Cl-98 HCO3-22 AnGap-21*
___ 05:55PM BLOOD ALT-47* AST-93* CK(CPK)-57 AlkPhos-665*
TotBili-0.6
___ 06:17AM BLOOD calTIBC-217* ___ Ferritn-789*
TRF-167*
___ 06:09PM BLOOD Lactate-2.4*
DISCHARGE LABS***
IMAGING/STUDIES:
-MRCP ___:
1. Increased size and number of extensive hepatic metastases.
Notably, all hepatic lesions demonstrate similar appearance
although in the setting of diffuse metastatic disease the
ability to completely exclude a small liver abscess is
difficult.
2. Mild segmental areas of biliary duct dilation in the left
hepatic lobe without MR evidence of cholangitis. The dilation
is likely from obstruction by metastases.
3. No interval change to recurrent pancreatic mass, necrotic
retroperitoneal and mesenteric lymphadenopathy, and mesenteric
soft tissue mass adjacent to the SMV/SMA.
-RUQ US ___: Mild intrahepatic biliary dilatation, primarily
in the left lobe of the liver which may be secondary to
malignant obstruction. Common bile duct measures 6 mm.
Innumerable hypoechoic masses in the liver consistent with known
metastatic disease. Pancreatic head mass, better seen on prior
CT. Patient status post cholecystectomy.
- RUQUS (___): No significant change in mild intrahepatic
biliary duct dilatation in the left hepatic lobe. No
extrahepatic
biliary duct dilatation. Grossly unchanged innumerable hepatic
metastases.
- Left UENIS (___): 1. Occlusive thrombus throughout the left
basilic vein. 2. No evidence of deep vein thrombosis in the left
upper extremity.
- US NECK (___): Occlusive thrombus within the noncompressible
right internal jugular vein, at the site of right neck pain and
swelling, as indicated by the patient.
- INCOMPLETE MRCP (___): 1. Despite incomplete examination,
there is no significant interval change compared to the recent
MRCP from ___ including to the extensive hepatic
metastases, recurrent pancreatic mass, lymphadenopathy, and soft
tissue mass adjacent to the SMV. 2. Unchanged severity of mild
segmental areas of intrahepatic biliary duct dilation, most
pronounced in the left lobe, likely a result of obstruction from
hepatic metastases.
- CT NECK (___): 1. Right-sided internal jugular clot with
extensive surrounding fluid which extends as far anterior as the
thyroid gland and posteriorly into the retropharyngeal space,
crossing the midline. The fluid extends in the prevertebral
space from C2 to C5.
- CTA CHEST (___): 1. New filling defects in bilateral lobar
pulmonary arteries, compatible with acute pulmonary emboli. No
evidence of right heart strain. 2. Numerous hepatic metastases
are better characterized on the MRCP from the same day. Known
right IJ thrombus reflected by expansion of the vein.
- NCHCT (___): There is no evidence of infarction, hemorrhage,
edema,or mass. Incidental note is made of cavum velum
interpositum. There is prominence of the ventricles and sulci
suggestive of involutional changes. There is no evidence of
fracture. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable. IMPRESSION:
1.
No evidence of hydrocephalus or intracranial hemorrhage.
- TTE (___): The left atrium is normal in size. Color-flow
imaging of the interatrial septum raises the suspicion of an
atrial septal defect, but this could not be confirmed on the
basis of this study. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>60%). 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. No masses or vegetations are seen on the
aortic valve. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. There is borderline
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No echo evidence of endocarditis. Color doppler
suggestive of small ASD/stretched PFO of no hemodynamic
significance given normal right ventricular size at age ___.
Mildly dilated thoracic aorta.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Creon 12 4 CAP PO TID W/MEALS
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Lisinopril 40 mg PO QHS
5. Multivitamins 1 TAB PO DAILY
6. NIFEdipine CR 60 mg PO DAILY
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
8. Pantoprazole 40 mg PO Q12H
9. Pravastatin 20 mg PO DAILY
10. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
11. Ciprofloxacin HCl 500 mg PO Q12H
12. Vancomycin Oral Liquid ___ mg PO BID
13. Ascorbic Acid ___ mg PO DAILY
14. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
15. Ferrous Sulfate 325 mg PO DAILY
16. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg oral BID:PRN heartburn
17. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*4 Tablet Refills:*0
3. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80 MG SC every twelve (12) hours
Disp #*30 Syringe Refills:*0
4. Gabapentin 300 mg PO QHS
take 100mg qAM and 100mg in afternoon and 300mg qHS
RX *gabapentin 100 mg 3 capsule(s) by mouth at bedtime Disp #*90
Capsule Refills:*0
5. LOPERamide 2 mg PO QID:PRN diarrhea
6. LORazepam 0.5 mg PO Q8H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*12 Tablet Refills:*0
7. OxyCODONE SR (OxyconTIN) 40 mg PO QAM
RX *oxycodone [OxyContin] 20 mg 2 tablet(s) by mouth qAM Disp
#*90 Tablet Refills:*0
8. OxyCODONE SR (OxyconTIN) 60 mg PO QPM
9. Simethicone 40-80 mg PO QID:PRN gas
10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
11. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth q3h Disp #*90 Tablet
Refills:*0
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
13. Ascorbic Acid ___ mg PO DAILY
14. Creon 12 4 CAP PO TID W/MEALS
15. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
16. Ferrous Sulfate 325 mg PO DAILY
17. Fluticasone Propionate NASAL 1 SPRY NU DAILY
18. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg oral BID:PRN heartburn
19. Lisinopril 40 mg PO QHS
20. Multivitamins 1 TAB PO DAILY
21. NIFEdipine CR 60 mg PO DAILY
22. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
23. Pantoprazole 40 mg PO Q12H
24. Pravastatin 20 mg PO DAILY
25. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
RX *prochlorperazine maleate 10 mg 10 tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
26. Vancomycin Oral Liquid ___ mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis/infection due to hepatobiliary source
Acute on chronic anemia
Metastatic pancreatic cancer
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 fever and RUQ abdominal pain// ?cholecystitis ?stone
?cholangitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma nodular with innumerable hypoechoic masses
consistent with known metastatic disease. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is mild intrahepatic biliary dilation primarily in the left
lobe of the liver which may be secondary to malignant obstruction. The CHD
measures 6 mm.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: There is a hypoechoic pancreatic head mass measuring 3.0 x 2.8 cm,
better seen on prior CT.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Mild intrahepatic biliary dilatation, primarily in the left lobe of the liver
which may be secondary to malignant obstruction. Common bile duct measures 6
mm. Innumerable hypoechoic masses in the liver consistent with known
metastatic disease. Pancreatic head mass, better seen on prior CT. Patient
status post cholecystectomy.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: ___ year old man with metastatic pancreatic cancer with recent
cholangitis + ecoli bacteremia now presents with fever, please r/o biliary
stricture or liver abscess// please r/o biliary stricture or liver abscess
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
COMPARISON: CT abdomen and pelvis ___, CTA abdomen and pelvis ___
FINDINGS:
Lower Thorax: The lung bases are clear. There is no pleural effusion.
Liver: Numerous T2 hyperintense hypoenhancing masses replacing much of the
liver parenchyma have progressed in number and size compared to prior. For
example, a hepatic segment VIII lesion measures 3.8 x 2.8 cm, previously 3.5 x
1.6 cm (series 5, image 13). All of these lesions demonstrate a similar
morphology. There is associated peripheral hyperenhancement with these
lesions, likely transient hepatic intensity differences. There is periportal
edema, as well as edema within the porta hepatis, similar to prior CT, likely
reflective of post treatment change.
Biliary: Gallbladder is surgically absent. There are multifocal segmental
areas of mild intrahepatic biliary duct dilation in the left lobe of the
liver, most pronounced in hepatic segment ___ (series 5, image 15). Areas of
intrahepatic biliary duct dilation are present in segment III and II (series
5, image 20, 18, 17). There is also thickening of the extrahepatic biliary
duct wall. There is no biliary duct hyperenhancement or restricted diffusion
to suggest cholangitis.
Pancreas: Patient is status post Whipple. There is dilation of the pancreatic
duct in the body and tail with an abrupt transition adjacent to a 4.0 x 3.3 cm
hypoenhancing partially necrotic T2 intermediate intensity mass in the
pancreatic body, unchanged from prior.
Spleen: The spleen is normal in size and signal intensity.
Adrenal Glands: The right and left adrenal gland are unremarkable.
Kidneys: The kidneys enhance symmetrically. There are bilateral renal cysts
measuring up to 3.5 x 3.4 cm in the left upper pole. There is a minimally
complex cyst in the right lower pole measuring 1.0 x 1.3 cm. There is no
hydronephrosis.
Gastrointestinal Tract: There is no hiatal hernia. Views of the small and
large bowel are unremarkable.
Lymph Nodes: There are enlarged and necrotic mesenteric and retroperitoneal
lymph nodes. Examples of enlarged necrotic retroperitoneal/mesenteric lymph
nodes include unchanged 1.1 cm aortocaval and 1.2 cm mesenteric node (series
5, image 34, 37). Bilobed necrotic soft tissue nodule adjacent to the SMV/SMA
causing narrowing but no occlusion of the the SMV measuring 3.2 x 2.2 cm is
essentially unchanged compared to prior.
Vasculature: The portal vein and hepatic veins are patent. Note is made of a
somewhat small left portal vein, which remains patent. There is no abdominal
aortic aneurysm. There is narrowing of the common hepatic artery secondary to
the large pancreatic mass. The SMA is patent. As described above, the distal
aspect of the SMA abuts the necrotic soft tissue mesenteric mass.
Osseous and Soft Tissue Structures: There is no superficial soft tissue
abnormality. There is no suspicious bony lesion.
IMPRESSION:
1. Increased size and number of extensive hepatic metastases. Notably, all
hepatic lesions demonstrate similar appearance although in the setting of
diffuse metastatic disease the ability to completely exclude a small liver
abscess is difficult.
2. Mild segmental areas of biliary duct dilation in the left hepatic lobe
without MR evidence of cholangitis. The dilation is likely from obstruction
by metastases.
3. No interval change to recurrent pancreatic mass, necrotic retroperitoneal
and mesenteric lymphadenopathy, and mesenteric soft tissue mass adjacent to
the SMV/SMA.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with pancreatic cancer, previous biliary
infection treated with abx, now worsening// please eval for progressive ductal
dilation
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound on ___, MRCP on ___
FINDINGS:
LIVER: The hepatic parenchyma is again nodular with innumerable hypoechoic
masses consistent with known metastatic disease. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: Mild intrahepatic biliary duct dilatation in the left hepatic lobe
is not significantly changed. The CHD measures 5 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 11.6 cm.
KIDNEYS: Limited views of the bilateral kidneys show no hydronephrosis.
Bilateral renal cysts, the largest measuring 4.2 cm in the right lower pole,
are not significantly changed.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
No significant change in mild intrahepatic biliary duct dilatation in the left
hepatic lobe. No extrahepatic biliary duct dilatation. Grossly unchanged
innumerable hepatic metastases.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL
INDICATION: ___ year old man with new superficial thrombosis on left
forearm.// Please eval for deeper clot, DVT in LUE
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial and cephalic veins are patent,
compressible and show normal color flow and augmentation.
There is occlusive thrombus throughout the left basilic vein.
IMPRESSION:
1. Occlusive thrombus throughout the left basilic vein.
2. No evidence of deep vein thrombosis in the left upper extremity.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with metastatic pancreatic cancer with recent
cholangitis now with worsening fever, RUQ pain, cholangitis by exam, eval for
biliary pathology, choledocholithiasis, need for stent or drainage
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
No intravenous contrast.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: MRCP ___
FINDINGS:
Incomplete examination.
LIVER: Again seen, are numerous metastatic lesions replacing the liver
parenchyma, overall unchanged in size and number compared to recent prior MRI.
No new lesions are identified. There is small volume ascites.
BILIARY: Gallbladder is surgically absent. There is unchanged thickening of
the extrahepatic common bile duct, as seen previously. Again seen is
segmental biliary duct dilation that is mild in severity, most pronounced in
the left lobe of the liver. There is also focal biliary duct dilation at the
hepatic dome. Overall, intrahepatic biliary duct dilation is unchanged in
severity and extent compared to the recent prior examination.
PANCREAS: Patient is status post Whipple. Again seen is in ill-defined
partially necrotic mass in the pancreatic body resulting in pancreatic
upstream severe pancreatic duct dilation. There is atrophy of the pancreatic
body and tail, as seen previously. Soft tissue mass mass adjacent to the SMV
and enlarged retroperitoneal/mesenteric lymph nodes that are also stable.
SPLEEN: The spleen is normal in size and signal intensity.
ADRENALS: The right and left adrenal glands are unremarkable.
KIDNEYS: There are bilateral simple renal cysts with the largest exophytic
cyst on the right measuring 4.6 cm. There is no hydronephrosis.
VASCULATURE: Flow voids are preserved. Unable to evaluate vessels adequately
secondary to no intravenous contrast.
OSSEOUS STRUCTURES: There is no superficial soft tissue abnormality. There is
no suspicious bony lesion.
IMPRESSION:
1. Despite incomplete examination, there is no significant interval change
compared to the recent MRCP from ___ including to the extensive hepatic
metastases, recurrent pancreatic mass, lymphadenopathy, and soft tissue mass
adjacent to the SMV.
2. Unchanged severity of mild segmental areas of intrahepatic biliary duct
dilation, most pronounced in the left lobe, likely a result of obstruction
from hepatic metastases.
Radiology Report
EXAMINATION: US NECK, SOFT TISSUE
INDICATION: ___ year old man with right neck pain. Please eval IJ/EJ for
clot, and for soft tissue masses, lymphadenitis, or fluid collection.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the soft
tissues of the right neck in the region of swelling and pain, as indicated by
the patient.
COMPARISON: Left upper extremity ultrasound from the prior day.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
At the site of right neck swelling and pain as indicated by the patient, there
is occlusive thrombus within the right internal jugular vein, which is
noncompressible and expanded. The imaged right subclavian vein is patent.
IMPRESSION:
Occlusive thrombus within the noncompressible right internal jugular vein, at
the site of right neck pain and swelling, as indicated by the patient.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 09:59 on ___, 2 minutes after discovery.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with known new IJ clot- c/o sudden onset
sensation of being unable to breathe. Evaluate for pulmonary embolism.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
2) Stationary Acquisition 0.8 s, 0.2 cm; CTDIvol = 13.6 mGy (Body) DLP =
2.7 mGy-cm.
3) Spiral Acquisition 5.5 s, 35.5 cm; CTDIvol = 6.0 mGy (Body) DLP = 208.2
mGy-cm.
Total DLP (Body) = 213 mGy-cm.
COMPARISON: Chest CT of ___. MRCP from the same day
FINDINGS:
The aorta and its major branch vessels are patent.
The known right internal jugular venous clot is not well assessed on current
exam, however the vein appears expanded reflecting the known thrombosis.
Compared with the prior study, there are new filling defects in bilateral
lobar pulmonary arteries, compatible with acute pulmonary emboli (5: 51, 79,
81, 88). There is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
There unchanged subcentimeter right thyroid nodules.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is mild bibasilar atelectasis. Subpleural less than 4 mm nodules along
the right major fissure are stable. The airways are patent to the
subsegmental level.
Limited images of the upper abdomen are notable for numerous hepatic
metastases, better characterized on the MRCP from the current day.
No aggressive osseous lesions demonstrated. Calcified loose bodies in the
glenohumeral joints are partially seen.
IMPRESSION:
1. New filling defects in bilateral lobar pulmonary arteries, compatible with
acute pulmonary emboli. No evidence of right heart strain.
2. Numerous hepatic metastases are better characterized on the MRCP from the
same day.Known right IJ thrombus reflected by expansion of the vein.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 16:52 on ___, 2 minutes after discovery.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old man with known new IJ clot- c/o sudden onset
sensation of something being stuck around throat and being unable to
breathe.// ? mass/ obstruction
TECHNIQUE: Imaging was performed without contrast administration.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.7 s, 30.2 cm; CTDIvol = 7.1 mGy (Body) DLP = 208.5
mGy-cm.
Total DLP (Body) = 209 mGy-cm.
COMPARISON: None.
FINDINGS:
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect.
Dental amalgam limits evaluation in the surrounding area. Within this
limitation: The salivary glands enhance normally and are without mass or
adjacent fat stranding. The thyroid gland appears normal. There is no
lymphadenopathy by CT criteria.
There is no flow in the right internal jugular vein, with hypodense clot seen
surrounded by enhanced wall. There is extensive surrounding fluid which
extends anteriorly to the thyroid gland and posteriorly into the
retropharyngeal space and crosses the midline. The fluid is also seen
extending in the prevertebral space from C2 to the lower margin of C4 and
upper margin of C5. The remaining vessels of the neck appear patent.
A central venous catheter is partially visualized. The imaged portion of the
lung apices are clear. There are no osseous lesions.
IMPRESSION:
1. Right-sided internal jugular clot with extensive surrounding fluid which
extends as far anterior as the thyroid gland and posteriorly into the
retropharyngeal space, crossing the midline. The fluid extends in the
prevertebral space from C2 to C5.
RECOMMENDATION(S): The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 5:14 pm, 15
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with IJ vclot, pancreatic cancer// brain met eval
pre-AC
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 49.8 mGy (Head) DLP =
752.0 mGy-cm.
Total DLP (Head) = 752 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema,or mass. Incidental
note is made of cavum velum interpositum. There is prominence of the
ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of hydrocephalus or intracranial hemorrhage.
Radiology Report
INDICATION: ___ year old man with biliary obstruction and persistent fevers//
PTBD
COMPARISON: ___ MRCP.
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: General anesthesia was administered by the anesthesiology
department.
MEDICATIONS: Please refer to anesthesia record. Ceftriaxone was given
pre-procedure as antibiotic prophylaxis.
CONTRAST: 25 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 6.7 min, 41 mGy
PROCEDURE:
1. Transabdominal ultrasound.
2. Ultrasound and Fluoroscopic guided right percutaneous transhepatic bile
duct access.
3. Right cholangiogram
4. Ultrasound fluoroscopic guided attempts to obtain left percutaneous
transhepatic bile duct access.
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 and mid
abdomen was prepped and draped in the usual sterile fashion.
Under Ultrasound and Fluoroscopic guidance, a 21G Cook needle was advanced
into the rightbiliary system. Images of the access were stored on PACS.
Gentle injection of dilute contrast opacified the biliary system, with rapid
transit through the central biliary ducts into the duodenum. No central
biliary obstruction was identified.
Subsequently, using ultrasound and fluoroscopic guidance, multiple attempts
were made to access the left biliary system using a 21 gauge Cook needle.
Given the nondilated biliary system, successful access was unable to be
obtained.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
Normal percutaneous cholangiogram of right and central bile ducts with brisk
drainage into bowel.
No dilated bile ducts identified on ultrasound. Extensive intrahepatic
metastases.
IMPRESSION:
Successful percutaneous transhepatic cholangiogram via a right-sided approach.
No central biliary obstruction was identified. No biliary drain placed.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 100.1
heartrate: 97.0
resprate: 15.0
o2sat: 98.0
sbp: 140.0
dbp: 64.0
level of pain: 1
level of acuity: 3.0 | SUMMARY: # Presumed Biliary Infection
# Sepsis: Previous MRCP w/o abscess, stricture, or cholangitis
as cause of fever. ___ previously felt no intervention
warranted. Fevers have returned on escalating antibiotics.
Source
presumed biliary but other sources could be CV or septic
thrombophlebitis (although BCx have remained negative). Bowel,
urine, blood, and lines sources seem less likely given BCx neg.
UA neg, and C. diff neg. TTE w/o veg. ID following. In
discussion
with ID, onc, ___ we felt that attempt at biliary drain is
reasonable to attempt source control. Cholangiogram revealed
patent central biliary ducts, but could not access the smaller
ducts for PTC drain placement.
- ID now signed off. Switched IV meropenem to PO augmentin on
___. remains afebrile. now off Tylenol. Continue PO augmentin
for
total 7 days (last day ___, then place pt on suppressive
Bactrim DS 1 tab daily indefinitely per ID recs
- Continue prophylactic PO vanco Q6H for history of cdiff until
he finished his course that was previously prescribed prior to
admission.
- TTE negative for valvular vegetation
- F/U BCx: thus far negative.
# IJ DVT
# Associated Edema and oropharyngeal mass effect and dysphagia
(now resolved after anticoagulation): Extensive fluid and
stranding surrounding IJ clot with mass effect caused patient to
have dysphagia. Symptoms are significantly improved. ORL has
evaluated patient; does not think abscess/infection or bleeding.
Discussed case with ___ - no role for thrombectomy.
- was on heparin gtt, but transitioned to lovenox on ___ since
no
plan for further procedures
# Abdominal Pain
# Metastatic adenocarcinoma of pancreas s/p Whipple w/
transaminitis/cholestasis, advancement of disease on FOLFOX,
chronic pain, poor PO intake/weight loss.
- pain regimen increased to oxycontin 40/60, continuing
oxycodone prn, added gabapentin ___ per palliative recs
to target neuropathic component
- Continue creon supplement.
- Palliative following; appreciate recs
- Dr. ___ is patient's primary oncologist, plans to start
chemotherapy later this week
# Bilateral PE: Seen on CTA. Patient has EWOB, no chest pain,
dyspnea, or tachypnea. mildly hypoxic with exertion No e/o right
heart strain on CTA or EKG.
- continue lovenox
- Continuous O2 monitoring, encourage IS use# ___:
Prerenal/hypovolemic improved with IV fluids. Lisinopril held
during admission, and then restarted
# HTN: Nifedipine and lisinopril initially held concerning for
hypotension/shock in setting of infection, which never occurred.
Nifedipine was resumed once patient became hypertensive and
lisinopril can be resumed on discharge with recovery of renal
function.
# Superficial Venous thrombosis: No e/o DVT. No evidence of
overlying phlebitis. much improved after Warm compresses and
anticoagulation
# Acute on chronic macrocytic anemia: Worsened recently,
possible
ISO worsened sepsis. s/p 1U PRBC ___, and ___.
# Elevated INR: Improved s/p vit K
>30 minutes spent on discharge planning |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
paper tape / Tegaderm / Triple Antibiotic Ointment
Attending: ___.
Chief Complaint:
Tunneled HD line accidental removal
Major Surgical or Invasive Procedure:
___ tunneled hemodialysis line placement
History of Present Illness:
Ms. ___ is a ___ with ESRD (MWF sessions) secondary to HTN
versus hepatitis C, and previous CVA who presents because she
accidentally removed her tunneled HD line in her sleep last
night and she has no current suitable HD access.
She was recently admitted to ___ ___ with a staph
epidermidis HD catheter related blood stream infection that was
treated with line removal, holiday, and replacement, followed by
4 weeks of vancomycin with HD ending on ___ (she sadly missed
many of her OPAT appointments). Prior to that she was
hospitalized from ___ with a Pantoea species
catheter-related BSI that required several weeks of ceftazidime
QHD. She has a poor followup compliance record- for this reason
it was felt that she needed inpatient admission for line
replacement and HD.
She has a complicated HD access history- She had a left upper
arm AV fistula that required multiple interventions and
ultimately thrombosed and was non-salvageable. A right
brachiobasilic fistula was created in ___ by Dr. ___,
___ the procedure to superficialize it was delayed due to
frequent hospitalizations for blood stream infections. It was
finally accomplished on ___.
In the ED, initial vitals were 97.8 78 137/79 17 98% ra. There
was no bleeding or erythema of the previous catheter site.
Transplant surgery evaluated the fistula site because it was
erythematous but concluded it was a local reaction possibly from
tape. She was admitted for ___ placement of the HD tunneled line.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
HCV
ESRD on HD since ___
Asthma
HTN - resolved after weight loss (not on meds now)
gout - on allupurinol, no attacks in ___ years.
CVA at age ___. Residual visual def.
AV-fistula ___. Was going to be superficialized in ___
(delayed because of line infection)
Social History:
___
Family History:
Mom - stroke @ ___
Dad - dies of "old age"
No DM, early MI
Physical Exam:
PHYSICAL EXAMINATION:
VS: 98.1 152/89 77 18 100% RA
GENERAL: Well appearing F NAD. Comfortable,
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender to palpation. No HSM or tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
___ bilaterally to knees.
Pertinent Results:
___ 11:00AM BLOOD WBC-7.1 RBC-3.70* Hgb-10.8* Hct-32.9*
MCV-89 MCH-29.2 MCHC-32.9 RDW-15.7* Plt ___
___ 05:15AM BLOOD ___ PTT-28.5 ___
___ 11:00AM BLOOD Glucose-95 UreaN-77* Creat-5.4* Na-139
K-4.3 Cl-107 HCO3-17* AnGap-19
___ 11:00AM BLOOD Calcium-8.2* Phos-5.7* Mg-2.1
___ 06:00AM BLOOD Vanco-13.1
___ 03:35PM BLOOD Vanco-19.1
___ 05:55AM BLOOD Vanco-15.6
___ 05:15AM BLOOD Vanco-15.1
.
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTURE NOT PROCESSED INPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ VANCOMYCIN RESISTANT
ENTEROCOCCUS-FINAL {ENTEROCOCCUS SP.}-carrier
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cinacalcet 30 mg PO QHS
5. Mirtazapine 15 mg PO HS
6. Bactroban *NF* (mupirocin;<br>mupirocin calcium) 2 % Topical
QHD
Apply to the exit site of dialysis catheter after each dialysis.
7. Vancomycin 1500 mg IV HD PROTOCOL
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
RX *albuterol 2 puffs Q6H:PRN Disp #*1 Inhaler Refills:*2
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
3. Mirtazapine 15 mg PO HS
RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
4. CefTAZidime 1 g IV QHD
LAST DOSE ___
RX *ceftazidime-dextrose (iso-osm) [Fortaz in D5W] 1 gram/50 mL
following HD on MWF Disp #*3 Bag Refills:*0
5. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*2
6. Bactroban *NF* (mupirocin;<br>mupirocin calcium) 2 % Topical
QHD
Apply to the exit site of dialysis catheter after each dialysis.
RX *mupirocin [Bactroban] 2 % Apply to the exit site of dialysis
catheter after each dialysis QHD Disp #*1 Tube Refills:*2
7. Cinacalcet 30 mg PO QHS
RX *cinacalcet [Sensipar] 30 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
-Accidental removal of HD line
-HCV
-ESRD on HD since ___
-Asthma
-HTN - resolved after weight loss (not on meds now)
-gout - on allupurinol, no attacks in ___ years.
-CVA at age ___. Residual visual def.
-AV-fistula ___. superficialized ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with end-stage renal disease and complicated
access history, now status post accidental removal of the hemodialysis line
from the left side, please replace.
PHYSICIAN: ___, M.D., fellow, performed the procedure. ___,
M.D., attending, was present and supervising the procedure.
MEDICATIONS: Moderate sedation was provided by administering divided doses of
fentanyl totalling 175 mcg and Versed totaling 3.5 mg throughout the total
intraservice time of 25 minutes, during which the patient's hemodynamic
parameters were continuously monitored.
PROCEDURE: Replacement of left IJ tunneled hemodialysis line through existing
tract.
PROCEDURE DETAILS: Informed consent was obtained from the patient. She was
positioned supine. The area was prepped and draped in sterile fashion. A
timeout was performed. Fluoroscopy was used intermittently.
Local anesthesia was applied. A micropuncture sheath was gently inserted into
the tunnel exit site, and local anesthesia was injected through this as well.
We then gently probed with a 0.018 wire through the micropuncture sheath to
enter into the venous structures. Over this wire, we then used the AccuStick
sheath, and with this sheath tip in the venous structures, we removed the
inner stiffener and the 0.018 wire and then placed a 0.035 wire all the way
into the inferior vena cava to confirm venous placement. We then performed
serial dilation over this wire and placed the peel-away sheath for the new
catheter over this wire through the tunnel, the tip of which was in the
superior vena cava. The new 27-cm tip-to-cuff length hemodialysis catheter
had been soaked in antibiotic solution. This was also flushed. This was then
pushed through the peel-away sheath to have its tip in the right atrium. It
was secured to the skin with suture and covered with an appropriate dressing.
Both lumens aspirated and flushed very easily. Heparin was left dwelling in
the line. The position was documented on the fluoroscopic scout image.
There were no complications.
CONCLUSION: Uncomplicated replacement of tunneled hemodialysis line through
the existing tract into the left internal jugular vein, tip in the right
atrium, 27-cm tip-to-cuff length.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST CATHETER PULLED OUT
Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ACCIDENT NOS
temperature: 97.8
heartrate: 78.0
resprate: 17.0
o2sat: 98.0
sbp: 137.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ with ESRD and a very complicated access
history highlighted by numerous catheter related blood stream
infections here s/p accidental removal of tunneled HD line.
# HD TUNNELED CATHETER REMOVAL: Patient reported removing her HD
catheter during sleep. Upon arrival to hospital, no signs of
bleeding, infection, hematoma, or other acute process. The area
was monitored closely without complication. A new catheter was
ultimately placed (see below)
# FISTULA SITE ERYTHEMA: Patient with recent fistula
superficialization. Surgical site was noted to have surrounding
erythema, bruising, and scabbing. One or two of the stitches
were missing, and patient noted she had picked at them. There
was no ongoing bleed. Given patient's complicated history of
repeated blood stream infections and erythema around the site,
vancomycin was continued and cefepime was also started. Patient
received final dose of vancomycin on the day of discharge
(___). Prior to discharge, cefepime was transitioned to
ceftazidime qHD, with a plan to continue through HD on ___.
# ESRD ON HD w HX OF BLOOD STREAM INFECTIONS: Patient was
without access when arrived. Blood cultures were drawn, which
remained negative throughout. Patient required a new tunneled
line because fistula is not ready for use. Patient was assessed
daily for need for hemodialysis (missed session on the day of
admission). New tunneled line was placed by ___ on ___.
Hemodialysis was resumed that day, and patient was discharged
with plan to resume normal dialysis schedule.
# GOUT: Continued allopurinol
# DEPRESSION: Contineud mirtazepine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Haldol
Attending: ___.
Chief Complaint:
L2 compression fracture after fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old woman who was transferred from
___ after a CT torso showed evidence of an L2 vertebral
fracture following a fall. According to Ms. ___, she was
having a "heated" conversation on the train platform in ___
when she fell backwards and landed on her back. She stood up
after the fall and was able to walk some distance, before police
picked her up and took her to ___. She reports no
weakness, no sensory loss and no radiating pain. She has had no
incontinence since the fall, and has noticed only the pain which
is just in her lower back at this time.
She states that she had a small amount of alcohol that evening,
and that she had recently started using IV heroin in the past
few
days. EtOH level at OSH was 48.
Past Medical History:
hx of IV drug abuse
Social History:
___
Family History:
Mother - she reports she died from a heroin overdose
Father - unknown
Physical ___:
___ at the time of admission
Exam:
99 86 124/77 18 97% ra
General: drowsy but easily aroused by voice, cooperative,
complianing of lower back pain.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes
Rectal: normal sphincter tone
Neurologic:
Mental Status: alert and oriented to place date and name.
Language fluent with some mild dysarthria with no paraphasias,
normal repetition and able to follow complex commands. Memory of
recent events inact.
Cranial Nerves: pupils small at 1mm b/l and minimally reactive
to
light. EOMI w/out nystagmus. Fields full to confrontation.
Sensation intact to pinprick b/l, face symmetric, hearing intact
to fingerrub b/l, tongue movements rapid and normal.
Motor: no pronator drift, full strength in upper and lower
extremities
Sensory: intact to pinprick throughout with intact
proprioception
at toes b/l
Reflexes: symmetric and normal throughout with flexion toes b/l
Coordination: intact FNF and HTS b/l
Gait: unable to ambulate due to back pain and level of sedation
On the day of discharge:
neurologically intact
Pertinent Results:
Radiology Report MR ___ SPINE W/O CONTRAST Study Date of ___
2:02 AM
IMPRESSION:
1. Transitional anatomy at the lumbosacral junction with
partial
lumbarization of the first sacral segment and numbering schema,
as above.
2. Acute compression fracture of the superior endplate of L2
with roughly 50% loss of height, anteriorly, and 5 mm
retropulsion of its dorsal cortex; while this narrows the
ventral canal, effacing the thecal sac, there is no definite
impingement upon the conus medullaris or the proximal cauda
equina nerve roots.
3. L5-S1: Disc degeneration with bulging and L5 inferior
endplate
spondylosis, eccentric to the left with neural foraminal
narrowing, but no
definite exiting L5 neural impingement.
COMMENT: Preliminary interpretation of "L2 compression
fracture. Minimal
retropulsion, indents thecal sac, but no spinal cord compression
or neural
foraminal narrowing." was posted to PACS by Dr. ___ at the
time of the
study.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
L2 compression fracture
Discharge Condition:
neurologically intact
Followup Instructions:
___
Radiology Report
EXAMINATION: Lumbar spine without contrast, ___.
HISTORY: ___ female status post fall with L2 compression fracture
with mild retropulsion (seen on CT torso).
TECHNIQUE: Routine ___ non-enhanced study with sagittal STIR FSE sequence.
FINDINGS: The study is compared with the prompting CECT of the torso
(___) obtained some six hours earlier.
There is transitional anatomy at the lumbosacral junction with partial
lumbarization of the first sacral segment. Based on numbering from the most
caudal rib-bearing thoracic vertebral body, the vertebra, bearing the
iliolumbar ligaments is numbered "L5." Using this schema, the thecal sac
terminates at the S2-3 level.
As on the prompting study, there is a markedly abnormal appearance to the L2
vertebral body which demonstrates relatively uniform STIR-hyperintensity
representing marrow edema centered about a low-signal fracture line involving
the superior endplate. There is anterior wedge deformity with approximately
50% loss of height, compared to its neighbors. There is 5 mm retropulsion of
the superior aspect of the dorsal cortex which slightly narrows the ventral
canal, effacing that aspect of the thecal sac, with no definite impingement
upon the proximal nerve roots of the cauda equina. There is only mild
kyphosis centered at this level. The conus medullaris is normal in morphology
and terminates immediately rostral to this site, at the L1-L2 level.
The remaining lumbar vertebrae demonstrate relatively uniform slight
T1-hypointensity, which may represent red marrow reconversion in response to
anemia (in a patient of this age and gender). Otherwise, there is only
relatively mild focal STIR-hyperintensity involving the right and left lateral
aspects of the L5 inferior and S1 superior endplates, representing ___ I
discogenic change related to degeneration of that intervening disc. There is
mild bulging, eccentric to the left which, with inferior endplate spondylosis,
narrows the caudal aspect of both neural foramina, without definite exiting L5
neural impingement. The lumbar intervertebral discs are otherwise preserved
in height and in signal intensity. The paraspinal and limited included
retroperitoneal soft tissues are unremarkable.
IMPRESSION:
1. Transitional anatomy at the lumbosacral junction with partial
lumbarization of the first sacral segment and numbering schema, as above.
2. Acute compression fracture of the superior endplate of L2 with roughly 50%
loss of height, anteriorly, and 5 mm retropulsion of its dorsal cortex; while
this narrows the ventral canal, effacing the thecal sac, there is no definite
impingement upon the conus medullaris or the proximal cauda equina nerve
roots.
3. L5-S1: Disc degeneration with bulging and L5 inferior endplate
spondylosis, eccentric to the left with neural foraminal narrowing, but no
definite exiting L5 neural impingement.
COMMENT: Preliminary interpretation of "L2 compression fracture. Minimal
retropulsion, indents thecal sac, but no spinal cord compression or neural
foraminal narrowing." was posted to PACS by Dr. ___ at the time of the
study.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, ETOH, Lower back pain
Diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL
temperature: 99.0
heartrate: 86.0
resprate: 18.0
o2sat: 97.0
sbp: 124.0
dbp: 77.0
level of pain: 13
level of acuity: 3.0 | This is a ___ year old patient that was admitted to the
Neurosurgery service from the emergency department on ___
for a L2 compression fracture. On ___ that patient was admitted
to the floor and neurological assessment was performed every 4
hours. The patient was neurologically intact.
On ___, The patient was measured for a TLSO brace. The patient
was tolerating a regular diet and a social work consultation and
nutrition consult was placed.
On ___, The patient was neurologically intact. The patient was
reported to smoke a cigarrete in her hospital room and run out
the back stairs to outside. The patient left the hospital
against medical advice. The patient did not take her TLSO brace
with her and did not have discharge instructions with her when
she left against medical advice. Security , the clinical advisor
and the Attending were all made aware. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Shellfish / Norvasc / Univasc / lisinopril
Attending: ___
Chief Complaint:
ICD shock, dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with infarct-related
cardiomyopathy and subsequent history of monomorphic VT s/p
substrate ablation in ___ (with appropriate ICD shock in
___ who presents following 2 ICD shocks earlier this
morning. He was on his way to a clinic appointment when he was
climbing up stairs and felt a shock. A few minutes later he sat
down and felt additional shock. He was experiencing dyspnea on
exertion at the time but denies any cp, lh, dizziness, or
sensation of palpations. He dyspnea on exertion has been
progressive over the last ___ months and is thought to be
secondary to amio toxicity vs. COPD. He recently had f/up PFTs
demonstrating mild COPD. He was started on tiotropium earlier
this week. A CTA chest did not show any abnormalities. He has
had a chronic cough over this time thought to be ___ post nasal
drip which has somewhat improved with flonase. He has had
intermittent sputum production but denies any recent sf, chills,
or sweats.
In the ED intial vitals were: 97.5 74 121/82 16 96% 2L Nasal
Cannula. Labs were all at baseline aside from slight pump in
trop to .03. He was seen by EP who recommended stopping amio and
admitting him to possibly start new antiarrythmic. He was found
to have VT on interrogation and have an appropriate shock. He as
also one sequence of AVT.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:coronary artery disease
s/p inferolateral MI in ___, s/p
LCx PCI with no progressive coronary disease on angiography
___
- PACING/ICD:
-s/p primary prevention ___ ICD placed in ___ after EP
study positive for inducible VT; Fidelis lead working well
-monomorphic VT, s/p VT substrate ablation in inferoapical scar
region in ___, on amiodarone for ___ years
3. OTHER PAST MEDICAL HISTORY:
infarct-related cardiomyopathy with LVEF 30% (inferior and
lateral hypokinesis)
OSA
AAA s/p repair
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
97.5 74 121/82 16 96% 2L HEENT: no conjunctival pallor. No
icterus. Dry mucous membranes
NECK: Supple, JVD not noted
CV: regular rhythm with normal S1/S2, I/VI holosystolic murmur
at apex
LUNGS: clear to ascultation bialterally
ABD: soft, nontender, AAA scar on abdomen, no hepatomegaly
EXT: no edema, warm, DP 2+ bilaterally
DISCHARGE EXAM:
VS:98.1 99-110/58-64 ___ 18 93/2L
HEENT: no conjunctival pallor. No icterus. Dry mucous membranes
NECK: Supple, JVD not noted
CV: regular rhythm with normal S1/S2, I/VI holosystolic murmur
at apex
LUNGS: clear to ascultation bialterally
ABD: soft, nontender, AAA scar on abdomen, no hepatomegaly
EXT: no edema, warm, DP 2+ bilaterally
Pertinent Results:
ADMISSION LABS:
___ 05:40PM BLOOD WBC-4.3 RBC-4.26* Hgb-14.2 Hct-43.0
MCV-101* MCH-33.3* MCHC-33.0 RDW-14.0 Plt ___
___ 05:40PM BLOOD Neuts-55.4 ___ Monos-11.1*
Eos-10.4* Baso-1.7
___ 05:40PM BLOOD Glucose-103* UreaN-24* Creat-1.1 Na-141
K-4.0 Cl-109* HCO3-24 AnGap-12
___ 05:55PM BLOOD cTropnT-0.03*
___ 05:40PM BLOOD Calcium-9.4 Phos-3.5 Mg-2.0
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-4.8 RBC-4.15* Hgb-14.2 Hct-41.4
MCV-100* MCH-34.2* MCHC-34.3 RDW-13.3 Plt ___
___ 05:45AM BLOOD Glucose-87 UreaN-22* Creat-1.2 Na-140
K-3.9 Cl-107 HCO3-26 AnGap-11
CXR ___
IMPRESSION: Similar to findings as compared to prior chest
radiograph,
perhaps increased opacity along the left lateral mid to lower
lung. Central opacities may be in part due to underlying
pulmonary edema; however, there may also be a component of
amiodarone toxicity or cryptogenic organizing pneumonia as
described on the recent prior chest CT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. QUEtiapine Fumarate 25 mg PO QHS
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Amiodarone 200 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Atorvastatin 40 mg PO HS
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
9. Ibuprofen 800 mg PO QAM
10. Ibuprofen 600 mg PO QHS
11. Aspirin 81 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. omega 3-dha-epa-fish oil unknown dosage oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. QUEtiapine Fumarate 25 mg PO QHS
7. Tiotropium Bromide 1 CAP IH DAILY
8. Ibuprofen 800 mg PO QAM
9. Ibuprofen 600 mg PO QHS
10. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet by mouth daily Disp #*30
Tablet Refills:*0
11. Vitamin D 1000 UNIT PO DAILY
12. Home oxygen
Please provide 2Liter via NC home oxygen, continuous, pulsed
dose for poratbility, RA sat 87% Dx COPD
13. omega 3-dha-epa-fish oil 0 dosage ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- recurrent ventricular tachycardia, ICD
Secondary diagnoses:
- COPD
- Hypertension
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: Dyspnea.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. Dual-lead
left-sided AICD is again seen, unchanged in position. Cardiac and mediastinal
silhouettes are stable. Haziness of the hila with perihilar opacities are
again seen, somewhat similar to prior, which may be due to pulmonary edema;
however, as also noted on the prior, amiodarone toxicity is also in the
differential. Bibasilar and peripheral right mid lung and left mid to lower
lung opacities are again seen, as was also the case on the prior study.
Mediastinal and hilar lymph nodes seen on chest CT from ___ are better
assessed on that study.
There is no large pleural effusion or evidence of pneumothorax, but there may
be trace fluid tracking along a fissure.
IMPRESSION: Similar to findings as compared to prior chest radiograph,
perhaps increased opacity along the left lateral mid to lower lung. Central
opacities may be in part due to underlying pulmonary edema; however, there may
also be a component of amiodarone toxicity or cryptogenic organizing pneumonia
as described on the recent prior chest CT.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, DEFIB FIRE X 2
Diagnosed with PAROX VENTRIC TACHYCARD, DUE TO OTHER CARDIAC DEVICE,IMPLANT,GRAFT, ABN REACT-ARTIF IMPLANT, HYPERTENSION NOS
temperature: 97.5
heartrate: 74.0
resprate: 16.0
o2sat: 96.0
sbp: 121.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | PRIMARY REASON FOR ADMISSION:
___ with infarct-related cardiomyopathy and a history of
monomorphic VT s/p substrate ablation in ___ who presents
with appropriate ICD therapy in the setting of recurrent VT. |
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, Presyncope
Major Surgical or Invasive Procedure:
EGD/Colonoscopy ___
History of Present Illness:
___ man with a past medical history significant for
NSTEMI (2 LAD DES on ___ and recent diagnosis of beta
thalassemia trait, transferred from ___
for
evaluation of presyncope, anemia and leukocytosis.
The patient has been in his usual state of health up until the
day prior to admission. He was on the bus commute home from
work,
and felt cold and clammy. He initially attributed this to the
air
conditioning on the bus. Then, he was walking home from the bus
stop, a 0.5 mile walk that usually takes him 15 minutes, and he
felt lightheaded. The walk took him 45 minutes as he felt weak
and lightheaded. No other associated symptoms. No palpitations,
chest pain, nausea, shortness of breath, or incontinence. No
falls. When he arrived home, he went straight to bed. Woke up 3
hours later and his wife was concerned for tactile fever. Gave
him 2 Tylenol and he went back to sleep. He awoke at 3 am and
called out to her as he felt lightheaded again. He then went
back
to sleep. On the morning of the day of admission, he reports
that
he felt lightheaded again, this time with clammy extremities.
___
daughter, ___ ___ from the ___, came over to take his BP. He
was mildly hypotensive with HR ___, SBP ___. He had very little
to eat or drink in the last 24 hours. He then went to the
___ to be evaluated.
When he presented to Urgent Care, there was concern for cardiac
etiology given his previous history of NSTEMI and anginal
equivalent of diaphoresis. EKG without overwhelming concerning
signs of ischemia, troponin negative. However, he was found to
have a hgb of 7.6 and to have a leukocytosis up to 17. He was
therefore transferred to the ___ ED for further evaluation and
management.
- In the ED, initial vitals were:
98.0 86 122/84 18 98% RA
- Exam was notable for:
Gen: Middle-aged man, seen sitting comfortably
Pulm: CTAB no WRR, unlabored breathing
CV: RRR no MRG
HEENT: Dry mucous membranes, PERRLA, EOMI, no scleral icterus
Abdomen: Soft NTND, no rebound tenderness
Extremities: FROM in all 4 extremities, 2+ pulses peripherally,
no significant edema
Skin: Warm, dry and intact
Neuro: No gross neurologic deficits, alert and oriented, moves
all extremities no obvious facial abnormalities
Rectal exam: Normal rectal tone. Black stool, no gross blood,
guaiac positive
- Labs were notable for:
7.6
17.1 > ------- < 197
24.4
137 | 109 | 48
--------------- < 108
4.3 | 19 | 1.1
Ca: 8.9 Mg: 2.1 P: 3.0
Lactate:1.4
Trop-T: <0.01
blood cx, urine cx pending
- Studies were notable for:
EKG new ectopic atrial rhythm, QTC ~400, T wave inversion in
anterolateral leads
CXR ___
IMPRESSION:
No acute intrathoracic process.
- The patient was given:
IV Pantoprazole 40 mg
2 L IVF
On arrival to the floor, the patient endorses the above history.
Additionally, he reports that he has been in very good health.
He
does report use of antibiotics at the beginning of ___ for
5
days, after his wife was diagnosed with PNA and he did have some
cough as well. He did not have fever. He has been taking all of
his medications as directed. He hasn't missed a dose. He has
continued his daily excessive and smoking cessation from ___.
Other than that, he has been feeling very well.
He denies PND, orthopnea, palpitations, and leg edema. He has
had
no other episodes of lightheadedness. He has no muscle aches. He
denies cough, dysuria, melena, BRBPR, GERD-symptoms, headaches,
visual changes. Bowel movements have been regular. He endorses a
decreased appetite over the last few 24 hours.
Past Medical History:
+ NSTEMI (2 LAD DES on ___
+ beta thalassemia trait
+ s/p cholecystectomy.
+ colonoscopy at ___ : (___) reportedly normal, was
told to return in ___ years
Social History:
___
Family History:
Father in ___, recently diagnosed with Type A aortic dissection.
No family history of early MI
No family history of sudden cardiac death.
Daughters and wife have beta thalassemia trait
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 1842 Temp: 98.0 PO BP: 120/77 HR: 90 RR: 18 O2
sat: 98% O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. JVD not elevated. No carotid
bruit appreciated
CARDIAC: rrr no m/r/g.
LUNGS: cta bilaterally
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. Warm.
SKIN: No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM
===========================
VITALS:24 HR Data (last updated ___ @ 2309)
Temp: 98.1 (Tm 98.2), BP: 150/92 (117-150/75-92), HR: 75
(62-75), RR: 19 (___), O2 sat: 97% (96-98), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: rrr no m/r/g.
LUNGS: cta bilaterally
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. Warm.
SKIN: grossly normal
NEUROLOGIC: grossly normal
Pertinent Results:
ADMISSION LABS
===================
___ 03:15PM BLOOD WBC-17.1* RBC-3.53* Hgb-7.6* Hct-24.4*
MCV-69* MCH-21.5* MCHC-31.1* RDW-16.1* RDWSD-39.1 Plt ___
___ 03:15PM BLOOD Glucose-108* UreaN-48* Creat-1.1 Na-137
K-4.3 Cl-109* HCO3-19* AnGap-9*
___ 05:29PM BLOOD Lipase-31
___ 05:29PM BLOOD cTropnT-<0.01
___ 03:15PM BLOOD cTropnT-<0.01
___ 03:15PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 Iron-236*
___ 03:15PM BLOOD calTIBC-257* Ferritn-692* TRF-198*
___ 05:44PM BLOOD Lactate-1.4
DISCHARGE LABS
===================
___ 01:11PM BLOOD WBC-11.1* RBC-3.59* Hgb-8.5* Hct-26.8*
MCV-75* MCH-23.7* MCHC-31.7* RDW-19.9* RDWSD-51.8* Plt ___
___ 05:03AM BLOOD Glucose-99 UreaN-15 Creat-1.1 Na-144
K-4.2 Cl-116* HCO3-19* AnGap-9*
IMAGING
============
COLONOSCOPY ___
- Normal mucosa was noted in the whole colon and 2cm into the
terminal ileum
- Medium non-bleeding internal hemorrhoids were noted
EGD ___
ESOPHAGUS A small hiatal hernia was seen
Normal mucosa was noted in the whole esophagus
STOMACH Normal mucosa was noted in the whole stomach. Multiple
cold
forceps biopsies were performed for histology in the
stomach.
DUODENUM Normal mucosa was noted in the whole examined
duodenum. Multiple
cold forceps biopsies were performed for histology.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with cough fever leukocytosis// PNA
COMPARISON: Prior CT of the chest from ___ and chest radiograph
from ___
FINDINGS:
PA and lateral views of the chest provided. Lungs are clear. There is no
focal consolidation, effusion, or pneumothorax. There are no signs of
congestion or edema. The cardiomediastinal silhouette is normal. Imaged
osseous structures are intact. No free air below the right hemidiaphragm is
seen.
IMPRESSION:
No acute intrathoracic process.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Dizziness, Presyncope
Diagnosed with Anemia, unspecified
temperature: 98.0
heartrate: 86.0
resprate: 18.0
o2sat: 98.0
sbp: 122.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | SUMMARY
============
Mr. ___ is a ___ year old man with pmhx NSTEMI s/p 2 DES ___,
beta
thalessemia trait, who presents with presyncope, found to have
anemia, leukocytosis concerning for occult GI bleeding. He
received 2u pRBCs on ___ and remained HDS throughout his
admission. He underwent EGD and colonoscopy on ___ which did not
demonstrate any bleeding lesions. GI recommended capsule study
as outpatient.
TRANSITIONAL ISSUES
=====================
[] Patient underwent EGD and colonoscopy on ___ for suspected
GIB but there was no observable bleed. Several biopsies were
taken and the results of these were pending at discharge.
[] GI recommended capsule study as outpatient to evaluated for
potential GI source of anemia. This should be ordered by PCP.
[] Patient noted to have elevated iron stores on admission prior
to transfusions. Patient with history of beta thalassemia trait.
No evidence of iron overload on exam. We have scheduled follow
up for patient with hematology.
[] Discussed with patient's outpatient cardiologist and decided
to hold ticagelor at discharge pending anemia workup. Patient
has already been on DAPT for >12 months.
ACUTE ISSUES
=====================
#Anemia
#+ Guaiac
#GIB
Patient with significant drop in hgb in the last 6 months, from
a
hgb of 13.2 ___ -> 11.5 ___ -> 7.6 ___. Most likely
etiology of anemia is an occult blood loss from a GI source. In
terms of the anemia, he does have a microcytosis which is known
to be secondary to his beta thalassemia trait, however recent
downtrend c/f blood loss. his RFs for worsening of an underlying
structural erosion include use of DAPT with ticagralol and
aspirin, though this acute drop in hgb occurred 6 months into
use of this medication. Patient was evaluated by GI, and he
underwent EGD and colonoscopy on ___. There was no evidence of
bleeding on these studies so GI recommended a capsule study as
an outpatient.
Also considering a degree of anemia may be secondary to
exacerbation of beta thalassemia in the setting of infection and
recent abx use.
# beta thalassemia trait
Pt was found to have microcytic anemia as well as an elevated
ferritin on routine bloodwork by his PCP. He is followed by
hematology. He has elevated ferritin and iron overload. per
chart review, liver and spleen US performed previously and wnl.
Given significant increase in iron loads, recommend follow up
hematology after discharge.
# leukocytosis:
Pt without focal infectious source. CXR negative. Potentially
stress response. Leukocytosis improving at discharge.
# Nongap hyperchloremic metabolic acidosis
Most likely secondary to fluid resuscitation with NS in the ED
and at Urgent Care.
# BUN increase
Consistent with slow GI bleed as well as hypovolemia. Improved
with resuscitation.
CHRONIC ISSUES
=====================
# CAD s/p 4 LAD DES ___
Followed by Cardiologist ___. Per last cardiology
note, prolonged course of DAPT given significant intervention.
Patient was continued on aspirin. Discussed with patient's
outpatient cardiologist and decision was made to hold ticagelor
at discharge until anemia workup was completed.
# HTN
- continue losartan 50mg daily
# HLD
- continue on atorvastatin 80mg daily
#CODE: Full
___ (daughter) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Somatostatin / Compazine / Meperidine / Percocet / Bactrim /
Fentanyl / OxyContin / Paxil / Demerol / Droperidol / Lactose /
Barium Sulfate / Iodine-Iodine Containing / Pantoprazole /
Omeprazole / Codeine / Sulfa (Sulfonamide Antibiotics) /
tramadol / Lovenox / Ambien / ondansetron / Dilaudid / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / aspirin
Attending: ___.
Chief Complaint:
Partial small bowel obstruction
Major Surgical or Invasive Procedure:
PICC line insertion Rt arm ___ (for difficult access)
History of Present Illness:
___ with PMHx of chronic abdominal pain, hepatitis C Ab
positivity (without detected viral load), sclerosing
mesenteritis
(s/p multiple abdominal surgeries), multiple small bowel
obstruction, chronic anemia, and line-associated DVT (on
rivaroxaban), with recent admission to ___ ICU for
sepsis, altered mental status, and liver failure who presents to
the ___ ED this evening with symptoms of obstruction.
The patient reports that she began to experience severe sharp
epigastric/left-sided periumbilical pain last night. She reports
that the pain would worsen after PO intake and was felt to be
progressing. She reports that her pain is very similar to her
previous bowel obstructions. She reports that her last bowel
movement was ___ morning, which is unusual for her as she
normally has multiple loose stools every day. She has also not
passed any flatus today. She denies any associated fevers,
chills, chest pain, shortness of breath, or changes in her
sensorium.
Past Medical History:
- sclerosing mesenteritis (dx'd in ___, s/p multiple abdominal
surgeries, including placement of decompressive G-tube)
- chronic SBO
- chronic GI dysmotility
- IBS
- NSAID-related gastritis and UGI bleed
- Hepatitis C (transmitted via transfusion in ___
- GERD
- Esophagitis
- multiple LOAs
- colonic decompressions
- small bowel resections - parts of duodenum, entire ileum
- repair of incisional hernias
- appendectomy
- open CCY
- G-tube placement ___ - report of recent removal
- extraction of duodenal bezoar
- multiple port-a-cath placements and removals
- recurrent DVTs, line associated
- anemia of chronic disease
- mitral valve prolapse
- asthma
- chronic tachycardia (HR in the 120s)
- nocturnal benign myoclonus
- migraine HAs w/ visual aura
- "seizures" - whole body twitching previously characterized as
pseudoseizures
- depression
- osteopenia
- sjogren's syndrome
- history of stroke
- hypothyroidism
- hypercalcemia
- recurrent UTIs
- sebaceous cysts
- L hemi-thyroidectomy
- breast reduction and multiple breast lumpectomies
- tooth extractions
- b/l knee arthroscopies
- b/l ankle reconstructions
- c-section
- tonsillectomy with adenoidecomty
- ganglion cyst removal
Social History:
___
Family History:
Mother deceased at ___ with premenopause, myelofibrosis, breast
cancer, DM2. Father deceased at ___ with coronary artery disease,
abdominal aortic aneurysm, myocardial infarction, triple bypass,
DM2, HTN. Sister living with breast cancer, lupus. Sister living
with breast cancer. Brother deceased at ___ with glioblastoma.
Two sons with celiac and one with JRA.
Physical Exam:
Discharge physical exam
Vitals: Temp: 97.9 HR: 94 BP: 111/76 Resp: 18 O(2)Sat: 97%
Gen: NAD, resting comfortably in bed
CV: RRR, palpable peripheral pulses
P: nonlabored breathing
GI: nondistended, soft, nontender; no
rebound or guarding. Multiple prior surgical scars are well
healed.
Ext: WWP, no CCE
Pertinent Results:
___ 07:32AM BLOOD WBC-3.8* RBC-3.40* Hgb-9.3* Hct-31.4*
MCV-92 MCH-27.4 MCHC-29.6* RDW-14.8 RDWSD-50.0* Plt ___
___ 04:42AM BLOOD WBC-4.2 RBC-2.88* Hgb-8.0* Hct-26.7*
MCV-93 MCH-27.8 MCHC-30.0* RDW-14.8 RDWSD-50.2* Plt ___
___ 08:20PM BLOOD WBC-5.2 RBC-3.25*# Hgb-9.0* Hct-29.8*
MCV-92 MCH-27.7 MCHC-30.2* RDW-14.7 RDWSD-49.5* Plt ___
___ 08:20PM BLOOD Neuts-60.4 ___ Monos-10.0 Eos-2.5
Baso-1.0 Im ___ AbsNeut-3.13 AbsLymp-1.33 AbsMono-0.52
AbsEos-0.13 AbsBaso-0.05
___ 07:32AM BLOOD Plt ___
___ 04:42AM BLOOD Plt ___
___ 04:42AM BLOOD ___ PTT-33.6 ___
___ 08:20PM BLOOD Plt ___
___ 08:20PM BLOOD ___ PTT-37.9* ___
___ 07:32AM BLOOD Glucose-85 UreaN-6 Creat-0.7 Na-135 K-4.5
Cl-98 HCO3-24 AnGap-18
___ 05:05AM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-138 K-4.8
Cl-103 HCO3-23 AnGap-17
___ 04:42AM BLOOD Glucose-75 UreaN-12 Creat-0.6 Na-135
K-3.5 Cl-99 HCO3-23 AnGap-17
___ 08:20PM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-134
K-4.5 Cl-96 HCO3-23 AnGap-20
___ 04:42AM BLOOD ALT-36 AST-42* AlkPhos-171* TotBili-0.4
___ 08:20PM BLOOD ALT-42* AST-50* AlkPhos-195* TotBili-0.5
___ 07:32AM BLOOD Calcium-8.5 Phos-4.9* Mg-1.9
___ 05:05AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.4
___ 04:42AM BLOOD Calcium-7.7* Phos-4.9* Mg-1.5*
___ 08:20PM BLOOD Albumin-3.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO BID
2. Rivaroxaban 10 mg PO BID
3. LamoTRIgine 200 mg PO DAILY
4. Abilify (ARIPiprazole) 20 mg oral DAILY
5. Furosemide 5 mg PO EVERY OTHER DAY
6. Potassium Chloride 20 mEq PO BID
7. Pantoprazole 20 mg PO Q12H
8. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB
9. Calcitriol 0.25 mcg PO DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, if
albuterol inhaler does not relieve symptoms
11. LOPERamide 8 mg PO QAM
12. TraZODone 25 mg PO QHS:PRN insomnia
13. Simethicone 80 mg PO DAILY
14. Cyanocobalamin 1000 mcg PO DAILY
15. Promethazine 25 mg PO Q6H:PRN nausea/vomiting
16. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN pain ___. onabotulinumtoxinA unknown strength injection Q3MONTHS for
migraine headaches; next injection due on ___
18. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
19. diphenhydrAMINE HCl 12.5 mg/5 mL oral Q6H:PRN itching
20. Vitamin D ___ UNIT PO 1X/WEEK (MO)
21. Calcium with Vitamin D (calcium carbonate-vitamin D3) 2
tabs oral BID
Discharge Medications:
1. Famotidine 20 mg PO Q12H
2. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN R arm pain
RX *lidocaine 5 % Apply to right arm for pain daily Disp #*7
Patch Refills:*0
3. Gabapentin 1200 mg PO BID
RX *gabapentin [Neurontin] 600 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
5. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
6. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB
7. ARIPiprazole 20 mg oral DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Calcium with Vitamin D (calcium carbonate-vitamin D3) 2
tabs oral BID
10. Cyanocobalamin 1000 mcg PO DAILY
11. diphenhydrAMINE HCl 12.5 mg/5 mL oral Q6H:PRN itching
12. Furosemide 5 mg PO EVERY OTHER DAY
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, if
albuterol inhaler does not relieve symptoms
14. LamoTRIgine 200 mg PO DAILY
15. LOPERamide 8 mg PO QAM
16. onabotulinumtoxinA unknown injection Q3MONTHS FOR MIGRAINE
HEADACHES; NEXT INJECTION DUE ON ___
17. Pantoprazole 20 mg PO Q12H
18. Potassium Chloride 20 mEq PO BID
19. Promethazine 25 mg PO Q6H:PRN nausea/vomiting
20. Rivaroxaban 10 mg PO BID
21. Simethicone 80 mg PO DAILY
22. TraZODone 25 mg PO QHS:PRN insomnia
23. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with h/o SBO, multiple surgeries and sclerosing
mesenteritis p/w abdominal pain and vomiting // evaluate for obstruction
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
There is mild elevation of the right hemidiaphragm. Spine catheter re-
demonstrated, similar in appearance. No evidence of free air is seen beneath
the diaphragms.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: History: ___ with h/o SBO, multiple surgeries and sclerosing
mesenteritis p/w abdominal pain and vomiting. Evaluate for obstruction.
TECHNIQUE: Supine and upright radiographic views of the abdomen.
COMPARISON: L wall radiographs of ___, and CT
abdomen and pelvis of ___.
FINDINGS:
Multiple air-fluid levels are identified on the upright view. There is no
free intraperitoneal air. Air and stool are identified in the distal large
bowel/rectum. Patient has known chronic dilatation of the jejunum.
Osseous structures are notable for mild degenerative changes of the bilateral
hips. Several surgical clips are scattered throughout the abdomen.
IMPRESSION:
1. Multiple air-fluid levels on the upright view. However, air and stool are
identified in the distal large bowel/rectum, and patient has known chronic
dilatation of the jejunum. Findings could indicate ileus. No high grade
obstruction or transition point detected.
2. No free intraperitoneal air.
Radiology Report
INDICATION: ___ year old woman with recurrent SBO, no IV access // please
place PICC, has required fluoro in past for placement
TECHNIQUE: OPERATORS: Dr. ___ radiologist 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: 0.3 min, 4 mGy
PROCEDURE:
1. Single lumen midline placement through the right brachial vein.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the right
brachial 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 single lumen midline measuring 14 cm
in length was then placed through the peel-away sheath with its tip positioned
in the right axillary 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. Brachialvein approach single lumen right midline with tip in the axillary
vein.
IMPRESSION:
Successful placement of a right 14 cm brachial approach single lumen midline
with tip in the axillary vein. The line is ready to use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Vomiting without nausea, Unspecified intestinal obstruction
temperature: 98.6
heartrate: 100.0
resprate: 16.0
o2sat: 98.0
sbp: 116.0
dbp: 76.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ was admitted to the floor from the ED on ___.
She was complaining of sharp epigastric pain associated with
nausea and vomiting.
At the time of admission, she had not had a bowel movement or
passed gas since ___ morning. Per patient, her baseline is
15 loose bowel movements per day due to her short bowel. The
patient underwent abdominal x-ray
in the ED that showed multiple air-fluid levels on the upright
view. However, air and stool are identified in the distal large
bowel/rectum, and patient has known chronic dilatation of the
jejunum. Findings could indicate ileus. No high grade
obstruction or transition point detected. She was made NPO and
placed on an NG tube with suction as treatment for ileus. Her
electrolytes were repleted. She was given IV dilaudid and
promethazine for pain and nausea control. On HD2, the patient
had 3 bowel movements and her NG tube output was 460 that day.
After a successful clamp trial of her NG tube on HD3, her NG
tube was removed. She was started on a clear diet and advanced
to fulls. There was also some difficulty with her IV access, and
so we inserted a PICC line on the same day. She then started to
complain of severe burning/sharp pain in the right upper
extremity that radiated to her hand and so neurology was
consulted. Per their recommendations, they believe that it was a
nerve irritation from the midline insertion and removing it
would not necessarily control it. They recommended a lidocaine
patch and IV Tylenol and also an increase in her home gabapentin
to 1200BID on HD4. She was also advanced to a regular diet that
day. The patient was tolerating a regular diet, her pain was
much improved and was stooling and urination, ambulating
independently and was ready to be discharged on ___. The
patient will follow up with Dr. ___ as an outpatient. |
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
Major Surgical or Invasive Procedure:
Intubation ___
Lumbar puncture ___
History of Present Illness:
___ with end stage multiple sclerosis c/b torticollis who
presents to ED from long-term care facility with AMS. Patient
with chronic indwelling foley, and she finished a course of
cipro on ___ for a UTI. She became increasing altered in the
days prior to admission and became unresponsive in the ED. She
was admitted to the ICU with BP of 86/40 and was intubated for
airway protection. She was fluid responsive, and never on
pressors. Initially she put on Vanc/Cefepime/Cipro for sepsis of
unknown source. Urine cx grew Vanc-sensitive enterococcus, and
abx were narrowed to Vanc alone. Due to persistent altered
state, EEG was ordered which showed concern for non-convulsive
status epilepticus. She was by neuro and started on Keppra with
resolution of seizure activity. LP, although difficult, was
negative for high OP, meningitis, and HSV. She remained
intubated until ___. Prior to extubation, tan secretions were
noted and she was placed on VAP protocol with Vanco, Tobra
(given no cipro for seizures), Zosyn. MiniBAL and sputum cx are
pending.
.
Currently, patient denies difficulty breathing or cough. She is
hungry, asking for doritos, and denies abdominal pain or nausea.
She has no headache.
Past Medical History:
- Multiple sclerosis diagnosed at age ___, wheel chair bound
since ___
- Torticollis
- Scoliosis s/p ___ rod placement
- Constipation
- Chronic pain
- Allergic rhinitis
- Depression
- Peripheral vascular disease
- Urinary incontinence
- Neurogenic bladder with chronic Foley catheter
- HTN
- Osteoporosis
- Obstructive hydrocephalus
- Insomnia
Social History:
___
Family History:
Parents lived till mid ___ w/o major medical ailments. Father
died of heart attack. Grandmother developed dementia at last
year of her life.
Physical Exam:
FEX ON MICU ADMISSION
Vitals: T: 101, BP: 130s-170s/40s-90s, P: 120s-130s, R: 15 O2:
100% on AC with TV=400, PEEP=5, FiOs=50%
General: Intubated/sedated, responds to painful stimuli
HEENT: Sclera anicteric, dry MM, ET tube in place, PERRL
Neck: muscle contractures with rightward head deviation from
torticollis
CV: Tachcardic, no murmurs, rubs, gallops
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place
Ext: Bilateral upper extremities appear mottled and cool to the
touch with good pulses. Lower extremities are warm, well
perfused, 2+ pulses, no clubbing or edema
Neuro: intubated/sedated, responds to painful stimuli, opens
eyes spontaneously, marked muscular contractures, rightward head
deviation from torticollis
FEX ON DISCHARGE
VS - 98.8 98.3 159/77 96 20 97%RA
General: Awake, alert, oriented and appropriate
HEENT: Sclera anicteric, MMM
Neck: Muscle contractures with rightward head deviation from
torticollis
CV: RRR, no murmurs, rubs, gallops
Lungs: Appears comfortable on RA. Limited posterior
ausculatation clear.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place
Ext: No CCE, no joint swelling or pain, RLE with anterior
bruising, no increased swelling or pain.
Neuro: awake, alert, and oriented. Good attention and follows
commands. Marked muscular contractures, rightward head deviation
from torticollis. Strength unchanged
Pertinent Results:
PERTINENT MICROBIOLOGY:
___ 12:04 pm Mini-BAL
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
Time Taken Not Noted Log-In Date/Time: ___ 11:54 am
BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
ENTEROCOCCUS FAECALIS.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin = 2.0 MCG/ML SENSITIVE Sensitivity testing
performed by
Etest. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 2 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON
___ - ___.
GRAM POSITIVE COCCI.
PAIRS AND SHORT CHAIN.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___. ___ ___ 12:18PM.
Time Taken Not Noted Log-In Date/Time: ___ 11:11 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
.
.
PERTINENT STUDIES:
___ Radiology CHEST PORT. LINE PLACEM
Rotated positioning. Previously seen left IJ catheter has been
removed. Left subclavian PICC line is present. The tip may be
partially obscured by the spinal hardware. However, I suspect it
is unchanged in position and likely lies at the SVC/RA junction.
No pneumothorax is detected. Again seen is obscuration of the
left diaphragm and increased retrocardiac density. There is more
pronounced patchy opacity at the right base. Suspect mild
pulmonary vascular plethora.
___ Radiology CHEST (PORTABLE AP)
Interval extubation. Stable bilateral pleural effusions, large
on the left and small on the right. Possible minimal pulmonary
edema.
___ Neurophysiology EEG
This is an abnormal continuous ICU monitoring study because
of frequent bifrontal and parasagittal generalized periodic
epileptiform discharges. Although some of the bifrontal
discharges have triphasic features but, given their evolution,
these are most likely related to earlier epileptiform activity.
These findings are indicative of focal cortical irritability and
potential epileptogenicity predominantly in the bifrontal
regions. In addition, the background is diffusely slow and
disorganized indicative of moderate to severe encephalopathy.
Compared to the prior day's recording, there is improvement with
fewer blunted discharges and longer periods of disorganized
theta activity without bifrontal discharges.
___ Radiology MR HEAD W & W/O CONTRAS
1. Unchanged ventriculomegaly with associated cerebellar
atrophic
changes, with no evidence of transependymal migration of CSF.
Scattered foci of high signal intensity are identified in the
subcortical and periventricular white matter, likely consistent
with chronic microvascular ischemic changes.
2. Chronic hydrocephalus, possibly communicating, is a
consideration, there is no evidence of leptomeningeal
enhancement to suggest arachnoiditis, the possibility of a
Dandy-Walker variant is also a consideration.
3. Unchanged opacity of the ethmoidal air cells and sphenoid
sinus suggesting an ongoing inflammatory process.
___ Cardiovascular ECHO
Poor image quality. 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%). There
is no ventricular septal defect. The RV is not well seen but
overall normal free wall contractility is probably normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. Mild to moderate (___) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. There is
moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.
___ Neurophysiology EEG
This is an abnormal continuous ICU monitoring study because of
frequent generalized periodic epileptiform discharges (GPEDs) at
times as frequent as one to two per second. These do not
evolvefurther into non-convulsive status epilepticus. However,
these findings are indicative of severe cortical irritability
and potential epileptogenicity in a generalized distribution.
The backgroundtowards the later portion of the recording is
diffusely slow and disorganized indicative of moderate to severe
encephalopathy.
___ Radiology BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in either lower extremity.
The study and the report were reviewed by the staff radiologist
.
___ Radiology CT HEAD W/O CONTRAST
1. No evidence for intracranial hemorrhage or other definite
acute process.
2. Moderate enlargement of all ventricles, more striking than
background cerebral atrophic changes, although cerebellar
atrophy is substantial. There is no hypodensity about the
ventricles to suggest transependymal edema. Correlation with
clinical history is recommended and comparison to prior head CT,
if available, may be helpful to assess for chronicity. Major
differential considerations include chronic hydrocephalus,
probably communicating, associated with a prior inflammatory
process such as arachnoiditis or perhaps in association with a
congenital lesion such as Dandy-Walker variant.
3. Opacification of the left sphenoid sinus with bony thickening
suggesting longer chronicity and hyperdense material suggestive
of fungal colonization.
Blood:
___ 12:54PM BLOOD WBC-20.3* RBC-4.26 Hgb-13.0 Hct-38.2
MCV-90 MCH-30.4 MCHC-33.9 RDW-12.6 Plt ___
___ 01:15PM BLOOD WBC-15.5* RBC-3.44* Hgb-10.1* Hct-29.0*
MCV-84 MCH-29.5 MCHC-35.0 RDW-13.1 Plt ___
___ 03:09AM BLOOD WBC-15.3* RBC-3.38* Hgb-9.8* Hct-28.3*
MCV-84 MCH-29.0 MCHC-34.6 RDW-13.1 Plt ___
___ 02:15AM BLOOD WBC-17.6* RBC-3.55* Hgb-10.3* Hct-30.6*
MCV-86 MCH-29.0 MCHC-33.7 RDW-13.1 Plt ___
___ 05:20AM BLOOD WBC-10.8 RBC-3.24* Hgb-9.4* Hct-26.5*
MCV-82 MCH-29.1 MCHC-35.5* RDW-13.5 Plt ___
___ 05:16AM BLOOD WBC-13.9* RBC-3.29* Hgb-9.9* Hct-27.5*
MCV-84 MCH-30.1 MCHC-36.1* RDW-14.0 Plt ___
___ 01:15PM BLOOD ___ PTT-31.9 ___
___ 04:31AM BLOOD ___ PTT-37.4* ___
___ 12:54PM BLOOD Glucose-149* UreaN-30* Creat-0.8 Na-145
K-3.7 Cl-112* HCO3-18* AnGap-19
___ 03:41AM BLOOD Glucose-125* UreaN-10 Creat-0.2* Na-142
K-3.2* Cl-106 HCO3-29 AnGap-10
___ 03:09AM BLOOD Glucose-131* UreaN-9 Creat-0.3* Na-144
K-3.7 Cl-101 HCO3-35* AnGap-12
___ 03:40AM BLOOD Glucose-135* UreaN-15 Creat-0.4 Na-137
K-4.2 Cl-100 HCO3-24 AnGap-17
___ 05:20AM BLOOD Glucose-112* UreaN-6 Creat-0.4 Na-141
K-2.9* Cl-104 HCO3-27 AnGap-13
___ 05:16AM BLOOD Glucose-100 UreaN-7 Creat-0.3* Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
___ 12:54PM BLOOD ALT-18 AST-30 LD(LDH)-367* CK(CPK)-171
AlkPhos-92 Amylase-111* TotBili-0.4
___ 01:15PM BLOOD ALT-18 AST-29 LD(LDH)-360* AlkPhos-94
Amylase-57 TotBili-0.5
___ 12:54PM BLOOD Lipase-26
___ 12:54PM BLOOD CK-MB-10 MB Indx-5.8 cTropnT-0.06*
___ 03:57PM BLOOD Calcium-9.1 Phos-1.2* Mg-1.8
___ 03:09AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9
___ 05:39AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.7
___ 05:16AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9
___ 03:41AM BLOOD Cortsol-8.3
___ 03:57PM BLOOD TSH-0.84
___ 09:09PM BLOOD Vanco-8.0*
___ 03:40AM BLOOD Vanco-32.0*
___ 02:15AM BLOOD Tobra-1.8*
___ 08:53PM BLOOD Vanco-14.5
___ 10:49AM BLOOD Type-ART pO2-160* pCO2-53* pH-7.31*
calTCO2-28 Base XS-0
___ 09:06AM BLOOD Type-ART pO2-67* pCO2-41 pH-7.34*
calTCO2-23 Base XS--3
___ 02:25PM BLOOD Type-ART PEEP-5 pO2-141* pCO2-40 pH-7.48*
calTCO2-31* Base XS-6 Intubat-INTUBATED
___ 11:08AM BLOOD Lactate-4.4*
___ 12:51PM BLOOD Lactate-1.8
___ 09:06AM BLOOD Glucose-148* Lactate-2.5* Na-143 K-4.4
Cl-115*
___ 01:24PM BLOOD Lactate-0.7
___ 02:25PM BLOOD Lactate-1.8
URINE:
___ 04:14PM URINE Color-AMBER Appear-Cloudy Sp ___
___ 04:14PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 04:14PM URINE RBC-121* WBC-62* Bacteri-MANY Yeast-NONE
Epi-1
___ 04:14PM URINE CastHy-8*
___ 10:07AM URINE Color-Straw Appear-Clear Sp ___
___ 10:07AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
CSF:
___ 03:46PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-1
___ ___ 03:46PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-85
___ 03:46PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-NEGATIVE
___ 2:09 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
Medications on Admission:
- Alendronate 70mg weekly on ___
- ASA 81mg daily
- Baclofen 10mg TID
- Bethanechol 50mg QID
- Calcium carbonate 500mg TID
- Cranberry 475mg daily
- Docusate 200mg BID
- Fish Oil daily
- Fleet enema rectally every day PRN constipation
- Loratadine 10mg daily
- Fiber daily
- Metoprolol succinate 150mg daily
- Multivitamin daily
- Miralax 17 grams twice daily
- Selenium 200mcg
- Senna 4 tabs twice daily every other day
- Vitamin B complex daily
- Vitamin C 500mg daily
- Vitamin D 1000 units daily
- Ibuprofen 600mg TID
- Lidoderm 5% patch topically to sternum (12 hrs on/12 hrs off)
- Tylenol ___ three times daily
- Morphine ER 30mg BID
- Tramadol 75mg every 6 hours prn pain
- Abilify 2.5mg at bedtime
- Citalopram 40mg daily
- Gabapentin 100mg every morning
- Gabapentin 300mg at 2PM and 8PM
- Risperdal 0.5mg BID prn agitation
- Trazodone 100mg at bedtime
- Voltaren 1% gel to chest every 4 hours PRN pain
- Lisinopril 10mg daily
- Flaxseed oil 1000mg daily
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
on ___.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
4. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO three times a day.
5. cranberry 475 mg Capsule Sig: One (1) Capsule PO once a day.
6. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Fish Oil Oral
8. Fleet Enema ___ gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
9. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
10. Fiber Supplement Powder Oral
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Miralax 17 gram/dose Powder Sig: One (1) pack PO twice a day
as needed for constipation.
14. selenium 200 mcg Capsule Sig: One (1) Capsule PO once a day.
15. senna 8.6 mg Capsule Sig: Four (4) Capsule PO every other
day.
16. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
17. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
19. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
21. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO three
times a day.
22. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
23. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
25. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Intravenous every four (4) hours for 3 days: Last dose ___ ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sepsis from a urinary source
Status epilepticus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: New oxygen requirement. Tachycardia. Poor mobility at baseline.
TECHNIQUE: Bilateral lower extremity Doppler ultrasound.
COMPARISON: None available.
FINDINGS: Grayscale and Doppler sonograms of the bilateral common femoral,
superficial femoral and popliteal veins were performed. Evaluation of the
calf veins is limited due to body habitus. There is normal compressibility,
flow and augmentation.
IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.
Radiology Report
HISTORY: Septic shock, recently intubated, question interval change.
CHEST, SINGLE AP PORTABLE VIEW: Rotated positioning, low lung volumes.
An ET tube is present, tip approximately 4.8 cm above the carina. An NG tube
is present, tip beneath diaphragm, overlying stomach. Extensive spinal
hardware noted.
The heart borders are obscured, but the heart is probably not enlarged. There
are diffuse opacities throughout both lungs, with denser left retrocardiac
opacity and obscuration of left-greater-than-right hemidiaphragms.
Possibility of small effusions cannot be excluded.
Compared with ___ at 20:18 p.m.and allowing for technical differences,
there has been possible increase in the degree of hazy opacity in the right
and left mid zones, reflecting worsening CHF. Otherwise, findings are overall
similar.
IMPRESSION:
1. ET tube as described.
2. Left lower lobe collapse and/or consolidation, unchanged.
3. Hazy opacity in both lungs, slightly worse in the midzones, most
suggestive of worsening CHF. Possibility of underlying infectious infiltrate
is difficult to exclude.
4. Possible small bilateral effusions.
Radiology Report
Indication: evaluate for meningitis.
Comparison: none
Technique:
The ICU patient is intubated and sedated. Risk, benefits and alternative
managment were explained to the ___, the patient's proxy, who gave us
the consent over the phone.The patient was brought to the fluroscopy room and
was placed on the table in prone position.
A pre-procedure timeout and huddle per ___ standard was performed prior to
the initiation of the procedure.
The lower back was prepped and drapped in the usual sterile fashion. After
subcutaneos administration of 1% lidocaine, a spinal needle was placed at the
level of L4 under fluoroscopic guidance, and 18 cc of CSF were extracted and
sent to the lab. No complications.
Dr. ___ was ___ during the entire procedure.
Radiology Report
HISTORY: Chest, single AP portable view. Rotated positioning. Note is made
of a wet reading provided by radiology resident, Dr. ___.
An ET tube is present, tip approximately 6 cm above the carina. Left IJ
central line is present, tip difficult to assess, but likely overlying right
atrium. An NG tube is present, tip extending beneath diaphragm, off film.
Bilateral spinal hardware noted.
There are very low inspiratory volumes, with hazy opacity throughout both
lungs. The appearance is grossly unchanged compared with ___ at 3:55
a.m., but, in this setting, it is difficult to distinguish pulmonary edema,
pleural fluid, infectious infiltrates, and even ARDS. Because findings have
progressed relatively rapidly compared with at ___ at 11:12 a.m., a
component of CHF should be considered.
Radiology Report
STUDY: MRI of the head with and without contrast.
CLINICAL INDICATION: ___ woman with non-conclusive status. Assess
for meningeal enhancement.
COMPARISON: Prior head CT dated ___.
TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained,
axial FLAIR, axial T2, axial magnetic susceptibility, and axial
diffusion-weighted sequences, the T1-weighted sequences were repeated after
the administration of gadolinium contrast in axial T1, sagittal MP-RAGE, axial
and coronal reformations were provided.
FINDINGS: Again in comparison with the prior examination, significant
enlargement of the infra- and supratentorial ventricular system is identified
with no evidence of transependymal migration of CSF. Scattered foci of high
signal intensity are noted in T2 and FLAIR, distributed in the subcortical and
periventricular white matter, which are nonspecific and may reflect chronic
microvascular ischemic disease. The sulci are slightly prominent, possibly
indicating mild cortical volume loss. No diffusion abnormalities are detected
to suggest acute or subacute ischemic changes. There is no evidence of
abnormal enhancement to suggest leptomeningeal disease or arachnoiditis. In
the posterior fossa, the inferior aspect of the cerebellum is small, possibly
atrophic and also there is loss of the cortical volume in both cerebellar
hemispheres. The superior aspect of the vermis appears complete and the
fourth ventricle is prominent, normal flow void signal is noted at the major
vascular structures. The orbits are grossly unremarkable. The paranasal
sinuses demonstrate bilateral mucosal thickening at the frontoethmoidal
recesses, ethmoidal air cells, and sphenoid sinus, possibly indicating an
ongoing inflammatory process, there is also patchy mucosal thickening at the
mastoid air cells, more significant on the right.
The visualized aspect of the cervical spine demonstrates mild degenerative
changes at C3/C4 and C4/C5 levels, partially evaluated in this examination.
IMPRESSION: 1. Unchanged ventriculomegaly with associated cerebellar atrophic
changes, with no evidence of transependymal migration of CSF. Scattered foci
of high signal intensity are identified in the subcortical and periventricular
white matter, likely consistent with chronic microvascular ischemic changes.
2. Chronic hydrocephalus, possibly communicating, is a consideration, there
is no evidence of leptomeningeal enhancement to suggest arachnoiditis, the
possibility of a Dandy-Walker variant is also a consideration.
3. Unchanged opacity of the ethmoidal air cells and sphenoid sinus suggesting
an ongoing inflammatory process.
Radiology Report
HISTORY: Intubated.
CHEST, SINGLE AP VIEW: Markedly rotated positioning. Allowing for this,
pulmonary findings are likely similar to the film obtained on ___ at 20:43
p.m. with low inspiratory volumes, cardiomegaly, extensive pulmonary edema,
and layering right-greater-than-left effusions. The CHF findings appear
asymmetric, more pronounced in the right lung likely due to patient position.
The carina is not well delineated, but the ET tube position is probably
unchanged. The NG tube extends beneath the diaphragm off the film. The left
IJ central line is unchanged and lies in the region of the cavoatrial
junction. No pneumothorax is detected. Spinal hardware again noted.
Radiology Report
AP CHEST, 3:32 A.M., ___
HISTORY: Intubated ___ woman.
IMPRESSION: AP chest compared to ___:
Tracheostomy tube is consistently positioned higher than desirable, which puts
the cuff in the larynx. The tip is no less than 9 cm above the carina with
the chin down. Standard positioning would require advancing the tube no less
than 7.5 cm.
Left lower lobe remains collapsed. Moderate right and small left pleural
effusion, unchanged. Moderate cardiomegaly, stable. Enteric drainage tube
passes to the distal stomach and out of view.
Findings were discussed by telephone with Dr. ___ at the time of
dictation.
Radiology Report
AP CHEST, 11:15 ___ ON ___
HISTORY: Central line pulled back.
IMPRESSION: AP chest compared to 10:36 a.m.:
Left internal jugular line projects over the upper SVC. ET tube, now less
than 5 cm above the upper margin of the clavicles and 8 cm from the carina has
been repositioned due to findings on subsequent chest radiographs and
conversations with the clinician following this study. Left lower lobe
collapse and moderate left pleural effusion have increased. Small right
pleural effusion is suspected as well. The heart is enlarged but margins are
obscured and comparison is not possible. No pneumothorax.
Radiology Report
INDICATION: Advancement of ET tube.
COMPARISON: Radiograph available from ___.
FRONTAL CHEST RADIOGRAPH:
The patient is severely rotated and kyphotic. Lower thoracic fusion hardware
is unchanged in orientation. A left-sided IJ catheter terminates at the mid
SVC.
The endotracheal tube has been advanced, now terminating 3.3 cm above the
carina. An orogastric tube terminates within the stomach. Severe left lower
lobe atelectasis is unchanged in appearance. Superimposed mild-to-moderate
pulmonary edema is stable. The heart is enlarged. There is no pneumothorax.
IMPRESSION:
1. ET tube advanced, now terminating 3.3 cm above the carina
2. Severe left lower lobe atelectasis and moderate edema, both stable.
Radiology Report
AP CHEST, 2:42 A.M., ___
HISTORY: ___ woman intubated. Assess interval change.
IMPRESSION: AP chest compared to ___:
With the chin down, the tip of the endotracheal tube is just above the upper
margin of the clavicles no less than 4 cm from the carina. Left internal
jugular line ends in the upper-to-mid SVC. Lung volumes are still quite low
though minimally improved since ___. Mild pulmonary edema has also
improved. Moderate right pleural effusion and moderate-to-severe left basal
atelectasis are also decreased. Heart size is indeterminate. No
pneumothorax.
Radiology Report
HISTORY: MS with urosepsis.
FINDINGS: In comparison with the study of ___, the patient has taken a
somewhat better inspiration. Monitoring and support devices remain in place.
There is continued enlargement of the cardiac silhouette. Right pleural
effusion is again seen. Opacification at the left base is consistent with
volume loss in the lower lobe and associated effusion.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Urosepsis, intubated.
Comparison is made to prior study ___.
Bilateral pleural effusions larger on the left are stable. They are
associated with left greater than right large atelectasis. Cardiomediastinal
contours are unchanged. Lines and tubes remain in stable standard position.
There are no new lung opacities. There is severe scoliosis. A spinal
hardware is noted.
Radiology Report
INDICATION: Recent extubation. Please assess for interval change.
COMPARISON: Comparison is made to multiple chest radiographs, most recently
dated ___.
FINDINGS: Portable chest radiograph demonstrates interval removal of
endotracheal tube and nasogastric tube. Stable bilateral pleural effusions,
left greater than right with unchanged associated atelectasis, left greater
than right. Possible minimal pulmonary edema is unchanged. Left heart border
is somewhat obscured by overlying colon; otherwise cardiomediastinal borders
are normal. No pneumothorax evident. Stable severe scoliosis and
thoracolumbar fusion hardware.
IMPRESSION: Interval extubation. Stable bilateral pleural effusions, large
on the left and small on the right. Possible minimal pulmonary edema.
Radiology Report
HISTORY: New left PICC line.
CHEST, SINGLE AP PORTABLE VIEW.
Rotated positioning.
A left subclavian PICC line is present -- the tip is not optimally visualized
but appears to lie in the region of the cavoatrial junction. A left
subclavian central line present, tip over proximal SVC. No pneumothorax
detected.
As before, the left hemidiaphragm is elevated, obscuring the cardiac
silhouette. There is hazy opacity at the right lung base, with improved
atelectasis at the right base. Opacity at the right base may relate to a
layering effusion. The left hemidiaphragm is elevated with patchy opacity at
the left base, also slightly improved. Small left effusion. Spinal rods
noted.
Radiology Report
HISTORY: PICC line status post IJ removal, assess PICC.
chest, 1 vw
Rotated positioning. Previously seen left IJ catheter has been removed. Left
subclavian PICC line is present. The tip may be partially obscured by the
spinal hardware. However, I suspect it is unchanged in position and likely
lies at the SVC/RA junction. No pneumothorax is detected.
Again seen is obscuration of the left diaphragm and increased retrocardiac
density. There is more pronounced patchy opacity at the right base. Suspect
mild pulmonary vascular plethora.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Intubation.
COMPARISONS: None.
TECHNIQUE: Chest, supine AP portable.
FINDINGS: An endotracheal tube terminates approximately 1.5 cm above the
carina. The lung volumes are low, obscuring cardiac borders, although the
heart is probably normal in size. There is moderate-to-severe elevation of
the diaphragm with coinciding dilatation of the viscus in the left upper
quadrant, probably the splenic flexure of the colon. A splenic shadow is not
clearly visualized. Patchy left basilar opacity may be associated with
atelectasis, but is not entirely specific or characterized here. In addition,
there is mild diffuse interstitial abnormalities suggesting pulmonary edema.
The patient has a leftward convex spinal curvature with fixation devices to
the partly imaged and characterized along the lower thoracic and upper lumbar
spines.
IMPRESSION:
1. Endotracheal tube terminating approximately 1.5 cm above the carina. If
clinically indicated, the tube could be retracted somewhat for more optimal
positioning.
2. Left basilar opacity with elevation of the left hemidiaphragm, suggestive
of volume loss.
3. Findings suggesting moderate pulmonary edema.
4. Prominent air-filled viscus in the left upper quadrant, suggesting
moderate distal colonic distension. Clinical correlation suggested.
Radiology Report
HEAD CT
HISTORY: Altered mental status.
COMPARISONS: None.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no mass effect or shift of the normally midline
structures. The cisterns and sulci are moderately prominent, suggesting mild
atrophic changes. Cerebellar hemispheres are more strikingly atrophic. All
of the ventricles are moderately dilated out of proportion to other findings
associated cerebral atrophy, but there sulci are not effaced and there is no
evidence for transependymal edema. The cisterna magna is enlarged with a
small vermis. There is no evidence for intra- or extra-axial hemorrhage. The
vertebrobasilar system is tortuous. Patchy vascular calcifications are
present. The sphenoid is bipartite with a dominant left-sided air cell, which
is almost completely opacified, including linear hyperdense striations
suggesting inspissated material and raising suspicion for fungal colonization.
The walls of the left side of the sphenoid sinus are also mildly thickened and
sclerotic suggesting longer chronicity to the process. Moderate patchy
ethmoid air cell opacification is also noted bilaterally, while the maxillary
and frontal sinuses appear clear aside from patchy right posterior mastoid
opacification. Aerosolized secretions are present within the nasopharynx,
which coincide with endotracheal intubation.
IMPRESSION:
1. No evidence for intracranial hemorrhage or other definite acute process.
2. Moderate enlargement of all ventricles, more striking than background
cerebral atrophic changes, although cerebellar atrophy is substantial. There
is no hypodensity about the ventricles to suggest transependymal edema.
Correlation with clinical history is recommended and comparison to prior head
CT, if available, may be helpful to assess for chronicity. Major differential
considerations include chronic hydrocephalus, probably communicating,
associated with a prior inflammatory process such as arachnoiditis or perhaps
in association with a congenital lesion such as Dandy-Walker variant.
3. Opacification of the left sphenoid sinus with bony thickening suggesting
longer chronicity and hyperdense material suggestive of fungal colonization.
Radiology Report
INDICATION: Patient with urosepsis.
COMPARISONS: Chest radiograph of ___.
FINDINGS:
Portable AP view of the chest demonstrates ET tube terminating 3.9 cm above
the carina. Nasogastric tube is positioned in the stomach. Low lung volumes.
Costophrenic angles is obscured, suggestive of small pleural effusions. No
pneumothorax is present. Hilar and mediastinal silhouettes are unremarkable.
Moderate pulmonary edema appears minimally progressed since prior, expecially
in the upper lobes. Left lung base consolidation likely represents
atelectasis. Spinal fixation hardware is noted.
IMPRESSION:
In comparison to ___ pleural exam, there is minimal interval progression
of moderate pulmonary edema. Stable small bilateral pleural effusions and
left lung base atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LETHARGY
Diagnosed with ALTERED MENTAL STATUS , MULTIPLE SCLEROSIS, HYPERTENSION NOS
temperature: 98.5
heartrate: 110.0
resprate: 14.0
o2sat: nan
sbp: 115.0
dbp: 72.0
level of pain: nan
level of acuity: 1.0 | PRINCIPLE REASON FOR ADMISSION
___ year old female with PMH of multiple sclerosis and
torticollis presenting from a long term care facility for
further evaluation of altered mental status and being
transferred to the ICU for likely urosepsis after intubation for
airway protection.
ACTIVE PROBLEMS
# Urosepsis: The patient has a known neurogenic bladder from her
underlying multiple sclerosis with a chronic indwelling Foley.
On admission, she was noted to be in septic shock with positive
UA, BP of 86/40 and altered mental status. Due to her
unresponsive state, she was intubated and placed on a vent in
the ED. Her septic shock was initally treated broadly with
vanco/cefepime/cipro; as further cultures came back, she was
discovered to have a Vancomycin sensitive enterococcus growing
from blood and urine. She did not require any pressors during
her hospitalization. The day prior to her discharge from the ICU
she was noted to have increased tan secretions, increasing WBC
count, and low grade fever concerning for VAP. She was initated
on VAP protocol with Tobramycin and Zosyn in addition to her
Vancomycin for VSE. However, she was rapidly extubated and
transferred to the floor with improving clinical status. All
BAL/sputum Cx returned negative for growth and decision was made
to discontinue VAP coverage. Pt was switched to ampicillin
alone to complete a 14 day course for VSE urosepsis, last dose
___ ___, then PICC line may be pulled.
# Respiratory Failure/VAP: She was intubated until 1 day prior
to her discharge from the ICU for concerns regarding her mental
status, as well as secretions. She was also a very difficult
intubation due to her torticollus. Given concern for VAP on ___
in setting of with new tan secretions and leukocytosis, she was
started on tobramycin and zosyn in addition to vanco on ___. She
was also started on hyoscyamine for secretions. Following
discharge from the ICU, patient's respiratory status was greatly
improved and she was satting well on room air. Given clinical
improvement and negative BAL cultures, VAP coverage antibiotics
were discontinued. Pt was monitored clinically on Ampicillin
alone for an additional 48hrs and remained afebrile with no new
respiratory symptoms, maintaining sats on RA.
# Altered Mental Status/Seizures: Patient noted on EEG
suggestive of non-convulsive status. Unclear how long patient
has been having seizures. An LP was performed, which was
predominately negative. Patient was started on acyclovir,
empirically. MRI showed chronic hydrocephalus and
ventriculomegaly with periventricular white matter changes.
Acyclovir was discontinued once CSF was negative for HSV.
Patient became much more alert and interactive following
extubation. She was maintained on Keppra and Risperdal was
stopped. On transfer to the floor, patient was alert and
oriented x3. She was discharged at her baseline mental status.
# Goals of care: Patient a DNR/DNI, confirmed in discussion with
patient once extubated and lucid; son and HCP ___ expressed
interest in the patient being made do not hospitalize with
palliative care. As of now, patient may be rehospitalized, but
the facility should contact ___ prior to transferring her to
hospital. ___ was advised to follow up with facility if the
patient decides those are her wishes.
#. Sinus Tachycardia. Patient had sinus tachycardia into the
120s while in the ICU. Patient was placed on lower dose
Metoprolol 37.5 mg TID while in the ICU. Prior to discharge,
metoprolol was increased to her home dose of 150mg daily and HR
remained in the ___.
# CT read of fungal sinusitis: Per ENT, CT was suggestive of a
chronic process and not invasive fungal disease. ENT recommended
an outpatient follow-up for possible resection if symptomatic.
Currently, fungal ball is not symptomatic.
CHRONIC PROBLEMS
# Hydrocephalus: Chronic, no changes during hospitalization.
#. Multiple Sclerosis. The patient has severe multiple
sclerosis with resultant muscle contractures; she has been
wheelchair bound since ___, and has a neurogenic bladder
requiring chronic Foley. We continued her on some of her home
medications, but not all given concerns for her mental status.
Her baclofen was decreased to 5mg tid, and her bethanechol was
discontinued.
#. Chronic pain. Seemingly related to contractures from
underlying multiple sclerosis. Patient denied pain during her
stay. We continued her on a lidoderm patch prn but have been
holding her home ibuprofen, MS ___, tramadol, gabapentin and
voltaren gel. She was doing well on this minimized regimen and
may not need this additional medications going forward.
#. HTN. Held home lisinopril while in ICU in setting of
urosepsis. After transfer to the floor, her home dose of
lisinopril was restarted. Metoprolol was also started at a lower
dose (37.5 mg TID) until uptitration to her home dosing of
150mg Toprol daily prior to discharge.
#. Osteoporosis. Held home alendronate. Continued Calcium
supplementation.
#. Constipation. Continued home docusate, senna, miralax.
#. Depression: Had been holding home medications given
intubation and altered mental status. Discontinued risperdol and
Tramadol given they can lower seizure threshold. We also held
her abilify and trazadone. We continued her citalopram.
MEDICATION CHANGES
Start Keppra 750mg po bid
Start ampicillin 2 IV q4 to complete 2 weeks
Decrease baclofen to 5mg tid
Stop bethanechol
Stop morphine
Stop Tramadol
Stop gabapentin
Stop Risperdal
Stop trazodone
Stop voltaren
TRANSITIONAL ISSUES
-Made a number of adjustments to her psychiatric and pain
medications. Would monitor closely
-Will need to complete 14 days of ampicillin to treat urosepsis
-Patient with apparent fungal ball in sinus on CT. Currently
asymptomatic. Would continue to monitor.
-Please talk to HCP and son ___ before any major changes to
patient's goals of care
***If patient becomes febrile, develops productive cough or
worsening respiratory status, low threshold to initiate
Vancomycin and Pip/Tazo for 7 day course for HCAP treatment.*** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin
Attending: ___.
Chief Complaint:
Fever/Chills
Major Surgical or Invasive Procedure:
Placement of PICC
History of Present Illness:
___ with h/o chronic ___ edema, AFib on coumadin, diastolic CHF,
s/p R-TKR in ___, CLL, and presumed right ankle osteomyelitis
in ___ and group B strep bacteremia in ___ with
presumed source right ankle, though imaging negative for
osteomyelitis, presenting with left ankle pain and swelling and
fevers.
He reports that he developed left ankle pain and swelling last
night. He was shaking but was unable to take his temperature,
however note from rheum says his temp was up to 103. He "shook
all night" and lost control of his bowels. In the morning, his
daughters saw him and brought him to the ER for further
evaluation. He denies trauma to the left ankle. He believes that
the left ankle is always more swollen than the right, but the
infections have been localized to the right ankle.
Denies SOB, chest pain, chest pressure.
Past Medical History:
# Lung adenocarcinoma
-- s/p resection of right upper lobe on ___ by Dr ___
-- ___ negative
# Atrial fibrillation
# Hypertension
# Hypercholesterolemia
# Chronic lymphocytic leukemia -- diagnosed ___
# Cervical radiculopathy
# Diverticulosis
# History of upper GI bleed, NSAID related, in ___
# Possible history of TIA
# Spinal stenosis
# Status post right total knee replacement, ___
# Status post appendectomy
# Status post pilonidal cyst removal
Social History:
___
Family History:
Father died of an MI at ___ yo. Mother was healthy, lived to ___
yo. Brother and sister had lung cancers as well.
Physical Exam:
ADMISSION:
98.1 60 96/47 16 98%
Chronically ill appearing elderly male
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: Irregularly, irregular rhythm, holosystolic murmur
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: Left leg with chronic venous stasis changes with
overlying erythema and warmth. Tenderness to palpation of calf.
2+ swelling starting at ankle extending up to knee, with
prominent swelling and warmth. No pain with passive ROM
DISCHARGE:
VS: Afebrile 98.6 136/71 58 18 98% RA
GEN Chronically ill appearing obese man. In good spirits this
morning.
CHEST/LUNGS: Clear to auscultation bilaterally
HEART: Irregularly irregular rhythm with ___ holosystolic murmur
ABDOMEN: Soft, obese, nontender, bowel sounds positive.
EXTREMITIES: b/l chronic venous stasis changes of ___. LLE w/
overlying erythema, warmer than RLE. Significant swelling from
foot to knee w/ 1+ pitting edema to knee on L. Ankle
architecture unable to be seen due to swelling. Mildly TTP over
R shoulder, R clavicle. Good ROM of R arm with minimal pain.
NEUROLOGIC: A+Ox3, sensation of lower extremities intact except
at plantar, distal toes.
SKIN: papular/vesicular erythematous rash over L clavicle and
neck; well-circumscribed, approx 5cm diameter. Non-tender.
Lesion overlying L wrist appears to be basal cell carcinoma.
Will encourage f/u with PCP.
Pertinent Results:
___ 06:45PM BLOOD WBC-17.6*# RBC-3.39* Hgb-10.0* Hct-32.5*
MCV-96 MCH-29.4 MCHC-30.7* RDW-17.5* Plt ___
___ 06:00AM BLOOD WBC-6.8 RBC-2.81* Hgb-8.2* Hct-27.0*
MCV-96 MCH-29.2 MCHC-30.5* RDW-17.5* Plt ___
___ 06:00AM BLOOD Neuts-91.6* Lymphs-4.1* Monos-3.9 Eos-0.2
Baso-0.2
___ 06:45PM BLOOD ___ PTT-45.5* ___
___ 06:00AM BLOOD ___ PTT-57.6* ___
___ 05:50AM BLOOD ___
___ 06:45PM BLOOD ESR-54*
___ 06:45PM BLOOD Glucose-76 UreaN-46* Creat-1.9* Na-135
K-4.3 Cl-98 HCO3-24 AnGap-17
___ 06:00AM BLOOD Glucose-97 UreaN-19 Creat-0.7 Na-140
K-3.6 Cl-108 HCO3-23 AnGap-13
___ 06:00AM BLOOD ___ 05:50AM BLOOD Calcium-8.2* Phos-2.1*# Mg-2.1
___ 06:45PM BLOOD CRP-143.8*
___ 06:00AM BLOOD %HbA1c-5.8 eAG-120
___ 06:00AM BLOOD PEP-NO SPECIFI
___ 06:45AM BLOOD Lactate-1.4
___ 06:51PM BLOOD Lactate-2.9*
Microbiology:
___ 8:00 pm BLOOD CULTURE #2.
Blood Culture, Routine (Preliminary):
BETA STREPTOCOCCUS GROUP G.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 7:02 pm JOINT FLUID Source: R SC joint.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final): NO GROWTH.
Imagining:
MRI LLE ___:
IMPRESSION:
1. Limited examination due to limited sequences and patient
motion during the examination.
2. Trace edema within the medial aspect of the talus. Mild
cortical irregulariy subjacent to the edema. The findings likely
reflect tractional changes or prior injury injury. No evidence
of acute osteomyelitis.
3. Mild bone marrow edema surrounding the calcaneocuboid joint,
likely degenerative.
4. Moderate-to-severe circumferential soft tissue edema
consistent with cellulitis in the appropriate clinical
circumstance, correlate clinically.
5. Mild tendinopathy and tenosynovitis of the posterior tibialis
tendon.
6. Mild tenosynovitis of the flexor hallucis longus and flexor
digitorum longus tendons.
7. Mild tenosynovitis of the peroneal tendons.
MRI R clavicle ___:
IMPRESSION:
1. Osteomyelitis of the right proximal clavicle with extensive
periosteal and soft tissue edema as well as joint fluid,
consistent with septic arthritis.
2. Small amount of fluid in the left sternoclavicular joint.
3. Left thyroid nodule can be evaluated on ultrasound.
TTE ___:
IMPRESSION: No vegetations seen. Normal global and regional left
ventricular systolic function. Dilated right ventricle with
borderline systolic function and evidence of pressure/volume
overload. Mild calcific aortic stenosis. Moderate to severe
tricuspid regurgitation. Severe pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
estimated aortic stenosis severity is less (measured LVOT
velocity was lower on the prior study). Pulmonary pressures are
significantly higher on the current study.
Discharge Labs:
___ 06:19AM BLOOD WBC-6.2 RBC-2.70* Hgb-7.9* Hct-25.6*
MCV-95 MCH-29.3 MCHC-30.9* RDW-18.4* Plt ___
___ 06:19AM BLOOD Plt ___
___ 06:19AM BLOOD ___ PTT-35.4 ___
___ 06:19AM BLOOD Glucose-87 UreaN-12 Creat-0.6 Na-137
K-3.5 Cl-101 HCO3-30 AnGap-10
___ 06:19AM BLOOD estGFR-Using this
___ 06:19AM BLOOD ALT-30 AST-27 LD(LDH)-234 AlkPhos-260*
TotBili-1.0
___ 06:19AM BLOOD Albumin-3.1*
Chest Xray ___:
IMPRESSION:
1. Left subclavian PICC line tip over proximal SVC.
2. Cardiomegaly and prominent hila.
3. Probable mild-to-moderate CHF with vascular plethora and
mild interstitial
edema.
4. Bibasilar atelectasis and increased retrocardiac density,
consistent with
left lower lobe collapse and/or consolidation.
5. Known sternoclavicular joint and clavicle abnormality is
not well
depicted.
___. ___
___: MON ___ 7:36 AM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Furosemide 60 mg PO DAILY
2. Colchicine 0.6 mg PO EVERY OTHER DAY
3. Aspirin 81 mg PO DAILY
4. Klor-Con *NF* (potassium chloride) 20 mg Oral TID
5. Gabapentin 100 mg PO TID
6. Allopurinol ___ mg PO DAILY
7. Warfarin 5 mg PO Q TUES WED THURS SAT SUN
5mg po daily on all days except ___ and ___
8. Warfarin 7.5 mg PO Q MON FRI
7.5 mg on ___ and ___ (5mg all other days)
9. Simvastatin 20 mg PO QHS
10. AcetaZOLamide 250 mg PO QHS
Discharge Medications:
1. Simvastatin 20 mg PO QHS
2. CeftriaXONE 1 gm IV Q24H
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Furosemide 60 mg PO DAILY
6. Enoxaparin Sodium 100 mg SC Q 12H
Continue until INR theraputic then for 5 more days
7. Nystatin Cream 1 Appl TP BID
Apply to groin b/l.
8. Sarna Lotion 1 Appl TP DAILY:PRN itching
Apply to right side of back as needed.
9. AcetaZOLamide 250 mg PO QHS
10. Gabapentin 100 mg PO TID
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
hold for sedation and rr<12
12. Outpatient Lab Work
Please draw CBC, BNP, LFTs, ESR, and CRP every ___ and fax
results to Infectious Disease at ___.
13. Outpatient Lab Work
Please draw ___ every ___ and use to titrate Coumadin
dosing.
14. Warfarin 5 mg PO Q TUES WED THURS SAT SUN
5mg po daily on all days except ___ and ___
15. Warfarin 7.5 mg PO Q MON FRI
7.5 mg on ___ and ___ (5mg all other days)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bacteremia
Cellulitis
Osteomyelitis
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
LEFT ANKLE AND LEFT FOOT RADIOGRAPHS: ___.
HISTORY: ___ male with history of osteomyelitis, gout, presents with
acute onset of pain. Question fracture or osteomyelitis.
FINDINGS:
LEFT ANKLE: AP, lateral and oblique views of the left ankle. No prior.
There is diffuse osteopenia of the bones about the ankle. Degenerative
changes are noted at the talonavicular joint; however, no definite acute
fractures identified. There is no definite area of focal osteolysis. Diffuse
atherosclerotic calcifications are noted. There is no subcutaneous gas.
LEFT FOOT: AP, lateral, and oblique views of the left foot are compared to
previous exam from ___. Diffuse osteopenia is seen. Degenerative
changes are noted at the talonavicular joint as well as the first
metatarsophalangeal joint, similar to prior. There is no evidence of more
focal osteolysis. There is no subcutaneous gas. Small vessel atherosclerotic
calcifications are noted. Small inferior calcaneal spur is noted.
IMPRESSION: Diffuse osteopenia and degenerative changes without evidence of
acute fracture or focal osteolysis.
Radiology Report
INDICATION: Acute pain, worsening swelling, erythema in left lower extremity.
Please assess for deep vein thrombosis.
COMPARISON: Comparison is made to right lower extremity ultrasound performed
___.
FINDINGS: Exam limited by body habitus. Within this limitation, gray-scale
and Doppler sonogram was performed of the left common femoral, superficial
femoral, popliteal, posterior tibial and peroneal veins. Normal
compressibility, flow and augmentation noted throughout.
IMPRESSION: No left lower extremity deep vein thrombosis.
Radiology Report
HISTORY: ___ male with history of chronic venous stasis, now
presenting with increasing left lower extremity edema. Patient with tiny
focal superficial ulcer at the tip of the left great toe. Assess for evidence
of osteomyelitis surrounding the left ankle.
COMPARISON: Left foot and ankle radiographs from ___
TECHNIQUE: Multiplanar MR images of the left ankle were acquired on a 1.5
Tesla magnet. Sequences include: axial T1, T2 and STIR images; coronal T1 and
STIR images. Axial T1-weighted images were repeated after the intravenous
administration of gadolinium contrast. Coronal sequences were also repeated
after contrast administration. No sagittal sequences were obtained as the
patient could no longer tolerate the exam.
MRI OF THE LEFT ANKLE WITH AND WITHOUT GADOLINIUM CONTRAST: The examination
is extremely limited due to patient motion. Sagittal sequences could not be
completed due to patient's inability to complete the examination.
There is circumferential soft tissue edema and skin thickening surrounding the
left ankle joint. There is irregularity of the skin surface at the level of
the medial malleolus, though no definite superficial ulcer or sinus tract is
evident. The musculature surrounding the left ankle appears diffusely
atrophic.
There is mild bone marrow edema at the calcaneocuboid joint (8:29) which is
likely degenerative. Additionally, there is minimal edema within the
anteromedial aspect of the talus adjacent to the subtalar joint (8:22). Mild
irregularity of the cortex of the medial talus is also noted but no edema at
this location to suggest acute osteomyelitis.
The tendons within the extensor compartment anteriorly appear normal in signal
intensity without signs of tendinopathy or tenosynovitis. Within the medial
compartment, there is mild thickening of the posterior tibialis tendon
distally and a small amount of fluid surrounding the tendon proximally,
findings consistent with distal tendinosis and mild proximal tenosynovitis.
Fluid is also seen surrounding the tendons present in the master knot of
___, findings consistent with mild tenosynovitis of the the flexor hallucis
longus and flexor digitorum longus tendons. The tendons of the lateral
compartment including the peroneus longus and brevis appear normal surrounded
by a small amount of fluid.
Evaluation of the syndesmotic ligaments is limited due to patient motion and
limited views, however, they are likely intact. Anterior talofibular,
posterior talofibular and calcaneofibular ligaments are not well seen on the
views provided. There are small focal ossific densities within the
anterolateral gutter.
IMPRESSION:
1. Limited examination due to limited sequences and patient motion during the
examination.
2. Trace edema within the medial aspect of the talus. Mild cortical
irregulariy subjacent to the edema. The findings likely reflect tractional
changes or prior injury injury. No evidence of acute osteomyelitis.
3. Mild bone marrow edema surrounding the calcaneocuboid joint, likely
degenerative.
4. Moderate-to-severe circumferential soft tissue edema consistent with
cellulitis in the appropriate clinical circumstance, correlate clinically.
5. Mild tendinopathy and tenosynovitis of the posterior tibialis tendon.
6. Mild tenosynovitis of the flexor hallucis longus and flexor digitorum
longus tendons.
6. Mild tenosynovitis of the peroneal tendons.
Dr. ___ communicated the above preliminary results to Dr.
___ at approximately 11:10 a.m. on ___ by telephone.
Radiology Report
INDICATION: ___ male with group G strep bacteremia and right shoulder
pain. Question osteomyelitis.
COMPARISON: CTA chest dated ___.
TECHNIQUE: MRI of the mediastinum was performed prior to and following the
administration of intravenous contrast with images acquired on a 1.5 Tesla.
Multiplanar T1- and T2-weighted images were acquired.
FINDINGS: Current exam is highly limited due to motion degradation of
multiple sequences. Allowing for such, there is abnormal T2 hyperintense and
T1 hypointense signal in the proximal right clavicle subjacent to the
sternoclavicular articulation, involving approximately 3.8 cm of the proximal
clavicle, with post-gadolinium enhancement, compatible with osteomyelitis. No
definite rim enhancement about interosseous increased T2 signal to suggest
interosseous abscess. There is extensive associated periosteal and soft
tissue edema. The sternum is difficult to assess due to motion degradation,
but there is likely reactive edema. There is fluid within the
sternoclavicular joint.
Small amount of fluid is also present in the left sternoclavicular joint. A
1.7-cm left thyroid nodule was noted on ___ CTA.
Allowing for significantly limited assessment due to motion, the lung apices
and mediastinal structures appear grossly intact. Assessment for
mediastinitis is limited.
IMPRESSION:
1. Osteomyelitis of the right proximal clavicle with extensive periosteal and
soft tissue edema as well as joint fluid, consistent with septic arthritis.
2. Small amount of fluid in the left sternoclavicular joint.
3. Left thyroid nodule can be evaluated on ultrasound.
Findings reported to Dr. ___ phone at 3 p.m. on ___.
Radiology Report
HISTORY: Check PICC line.
CHEST, SINGLE AP PORTABLE VIEW.
A left subclavian PICC line is present -- the tip overlies the distal SVC. No
pneumothorax is detected.
There are low inspiratory volumes. The right hemidiaphragm is elevated. The
cardiac contour is prominent and irregular, with prominent hila bilaterally,
similar to prior. Probable mild vascular plethora. Bibasilar atelectasis and
increased retrocardiac density, consistent with left lower lobe collapse
and/or consolidation. Minimal blunting of the right greater than left
costophrenic angle which is probably not new. The patient has known
abnormality of the right sternoclavicular joint and right proximal clavicle,
not well depicted on this film.
IMPRESSION:
1. Left subclavian PICC line tip over proximal SVC.
2. Cardiomegaly and prominent hila.
3. Probable mild-to-moderate CHF with vascular plethora and mild interstitial
edema.
4. Bibasilar atelectasis and increased retrocardiac density, consistent with
left lower lobe collapse and/or consolidation.
5. Known sternoclavicular joint and clavicle abnormality is not well
depicted.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LE ___
Diagnosed with CELLULITIS OF LEG, LEUKOCYTOSIS, UNSPECIFIED , HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.1
heartrate: 60.0
resprate: 16.0
o2sat: 98.0
sbp: 96.0
dbp: 47.0
level of pain: 6
level of acuity: 3.0 | # Bacteremia: Admission cultures grew group G strep bacteremia.
The infectious disease team was consulted was consulted and
recommended six weeks of IV ceftriaxone therapy. We had concern
for endocarditis given pt's already damamged and vulnerable
valves, so TTE was performed and was negative for vegetations.
It was decided not to perform TEE as the results would be
unlikely to change management as pt would already receive six
weeks of IV antibiotics. After initiation of ceftriaxone, pt was
never febrile and his blood pressures were stable. He received a
PICC for post-discharge antibiotic administration.
# Clavicular osteomyelitis: Pt complained of pain in his right
shoulder and clavicle. After blood cultures returned positive
for group G strep, ID recommended MRI of this area. MRI showed
osteomyelitis of R clavicle with edema at SC joint. Orthopedics
was consulted and the SC joint was tapped. Gram stain was
negative as was the joint fluid culture. Orthopedics did not
feel that washout or debridement of the SC joint for clavicle
was necessary. Thoracic surgery was consulted and agreed that no
surgical intervention was required. Patient's pain slowly
improved and this area was less tender to palpation at time of
discharge.
# Cellulitis: Pt presented with severe cellulitis of left lower
extremity with swelling and erythema extended from ankle to
below the knee. The ankle architecture was not able to be
visualized due to swelling, and although pt has full range of
motion without pain at this joint, MRI was obtained to rule-out
septic joint and osteomyelitis. MRI showed only soft tissue
involved without effusion at the ankle joint. Pt received IV
ceftriaxone for his infection and the swelling, erythema,
warmth, and pain in the area declined greatly. He was treated
with tramadol and acetaminophen for pain.
# Elevated INR: Mr. ___ INR became supratherapeutic
several days after admission, so coumadin with withheld. Despite
this, his INR continued to rise for three days, peaking at 6.0,
before beginning to trend down again. DIC was considered, but
fibrinogen was elevated. He had no signs or symptoms of
spontaneous hemorrahge. On ___, he was given a small dose of PO
vitamin K (2.5mg) so that INR would be in acceptable range for
placement of PICC line on ___. INR became subtheraputic and he
was re-started on coumadin with lovenox bridge until he again
becomes theraputic.
# Atrial fibrillation: Patient remained in atrial fibrillation
throughout hospitalization and was monitored on telemetry. His
beta-blocker was held due to concern for possible sepsis, but he
was never tachycardic. Coumadin being restarted with lovenox
bridge.
# Chronic diastolic CHF: Lasix and acetazolamide were initially
held due to concern for possible sepsis. Home Lasix was
restarted ___ when blood pressures were able to tolerate a
diuretic. BPs were stable after addition of this medication.
Acetazolamide was held throughout admission to avoid making
patient hypotensive but will be restarted upon discharge.
# Gout: Initial concern for possible ankle joint effusion
related to gout, but no effusion was shown on MRI and Mr.
___ uric acid level was within normal limits. Allopurinol
was continued throughout admission and disease was inactive.
Colchicine was held for concern for renal damage.
# Incidental thyroid nodules on CT: Mr. ___ was without
signs of hypo or hyperthyroidism. TSH was within normal limits.
Will require outpatient follow-up.
# L wrist tumor: Lesion noted on wrist highly suspicious for
basal cell ___ need to be followed 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:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year-old man with h/o dementia, DM, prior
CVA and HTN who presents with progressive confusion over 2
weeks.
Patient was seen by his neurologist this afternoon and referred
to the emergency department. He is accompanied by his daughter.
I interviewed them with the use of a translator. Denies any
fevers or chills. Denies any urinary incontinence. Denies any
falls. He has not complained of any headache, chest pain, pain
in extremities, cough, shortness of breath, swelling.
Per daughter, patient has not had bowel movement for one week
though he has not reported any abd pain. Patient does report
that he has not passed any gas though unclear if he completely
understands questions.
Of note, per neurology note, patient was hospitalized at ___ for
7 days for unclear reasons though daughter believes it may have
been secondary to ?stroke. He has not had any fevers or chills.
She thought he may have had some mild shortness of breath. He
had not complained of any chest pain, abdominal pain, diarrhea
or constipation.
She says that prior to the ___, admission to
___, he had been having increased
weakness of both legs and was "not able to move them." He was
also unable to talk for a period of two hours and subsequently
he was able to speak again and pronounce words.
In the ED, initial vitals were: 97.5 72 145/85 16 98% RA
- Labs were significant for anemia (H/H 10.7/33.9 - below
baseline), normal chem 7. Lactate initially 2.2, improved to 1.3
after fluid. UA with 11 WBCs, few bacteria, moderat leukocytes,
negative nitrates, trace ketones, 41 RBCs.
- CXR showed atelecatasis, no PNA. CT A/P showed no acute
process, small umbilical hernia and small bowel mal-rotation. CT
head unremarkable, CT C-spine without acute process. R shoulder
plain film negative for fracture, showed degenerative changes.
- The patient was given 500cc NS, 1g CTX and 50mg metoprolol.
Vitals prior to transfer were: 98.1 77 193/129 16 97% RA
Upon arrival to the floor, Patient coughed up dime sized amount
of blood. Caretaker at bedside and states that he has been
confused for one day. Seeing things. Uses wheelchair/walker but
hasnt' gotten up for few days. Per caretaker at the bedside,
patient is demented at baseline but appears more confused than
usual over the last 24 hours.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
Type 2 Diabetes
Hyperlipidemia
Diabetic Retinopathy
Glaucoma
Benign Hypertension
Prior Stroke
Peripheral Neuropathy
Social History:
___
Family History:
No family history of stroke
Physical Exam:
=================
ADMISSION EXAM:
=================
Vitals: T98.1 ___ Hr71 RR18 98%RA
General: Alert, oriented to self, at "her house", "date
unknown", no acute distress
HEENT: Sclera anicteric, dry MM, 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
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all extremities without
difficulty, gait deferred.
==================
DISCHARGE EXAM:
==================
VITALS: T 97.5 BP 150/83 HR 71 RR 20 98% RA
General: Somnnolent but arousable, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally
Abdomen: BS+, soft, non-tender, non-distended, no rebound or
guarding
Ext: Warm, well perfused, 2+ pulses, no edema, b/l shins wrapped
in gauze
Neuro: Moving all extremities without difficulty, gait deferred.
Pertinent Results:
=================
ADMISSION LABS:
=================
___ 06:15PM BLOOD WBC-8.6 RBC-3.47* Hgb-10.7* Hct-33.9*
MCV-98 MCH-30.8 MCHC-31.6* RDW-12.6 RDWSD-44.5 Plt ___
___ 06:15PM BLOOD Glucose-203* UreaN-20 Creat-1.1 Na-141
K-4.3 Cl-103 HCO3-28 AnGap-14
___ 06:28PM BLOOD Lactate-2.2*
========================
PERTINENT RESULTS:
========================
LABS:
========================
___ 08:17AM BLOOD calTIBC-239* Ferritn-57 TRF-184*
___ 04:20AM BLOOD calTIBC-252* Ferritn-58 TRF-194*
___ 10:31PM BLOOD Lactate-1.3
========================
MICROBIOLOGY:
========================
___ 6:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
===
___ 8:43 pm URINE
URINE CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
===
___ 10:27 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
=========================
IMAGING/STUDIES:
=========================
ECG Study Date of ___ 4:48:00 AM
Sinus rhythm. A-V conduction delay. Possible inferior wall
myocardial
infarction of indeterminate age. Possible anteroseptal
myocardial infarction of indeterminate age. Non-specific T wave
changes. Compared to the previous tracing of ___ the heart
rate is faster but other findings are similar.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
74 258 90 402 426 ___
===
ECG Study Date of ___ 4:58:23 ___
Sinus rhythm. A-V conduction delay. Inferior wall myocardial
infarction of
indeterminate age. Anterior wall myocardial infarction of
indeterminate age. Compared to the previous tracing of ___
the heart rate is slower. Other findings are similar.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
71 338 90 ___ ___
===
R GLENO-HUMORAL XRAY (___):
Degenerative changes without definite evidence for fracture or
dislocation.
===
CT C-SPINE W/O CONTRAST (___):
No acute fracture, malalignment, or prevertebral soft tissue
abnormality of the cervical spine.
===
CT HEAD W/O CONTRAST (___):
No acute intracranial abnormality. Motion limited exam.
===
CT ABD/PELVIS W/ CONTRAST (___):
1. No acute intra-abdominal abnormality to explain the patient's
presentation.
2. Small fat containing umbilical hernia.
===
CXR (___):
AP portable supine view of the chest. Low lung volumes limits
assessment. There is atelectasis in the right lung base. No
convincing evidence for pneumonia or edema. No large effusion
for supine evidence for pneumothorax. Cardiomediastinal
silhouette appears normal. Bony structures are intact.
IMPRESSION: No convincing evidence for pneumonia.
===
PORTABLE ABDOMINAL XRAY (___):
1. Nonobstructive nonspecific bowel gas pattern.
2. Large amount of stool throughout the colon.
===
CT ABD/PELVIS W/ CONTRAST (___):
No evidence of bowel obstruction with a large stool burden noted
in the colon.
===================
DISCHARGE LABS:
===================
___ 07:10AM BLOOD WBC-6.0 RBC-3.52* Hgb-10.9* Hct-33.9*
MCV-96 MCH-31.0 MCHC-32.2 RDW-12.7 RDWSD-44.6 Plt ___
___ 06:50AM BLOOD Glucose-166* UreaN-24* Creat-1.1 Na-141
K-4.3 Cl-104 HCO3-30 AnGap-11
___ 06:50AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9
Radiology Report
INDICATION: ___ with increasing confusion and right shoulder TTP /
COMPARISON: None
FINDINGS:
Three views of the right shoulder were provided. There is no definite
fracture or dislocation. Degenerative changes at the right AC joint evident
with bony hypertrophy. Spurring at the inferior glenohumeral joint noted. No
soft tissue calcifications.
IMPRESSION:
Degenerative changes without definite evidence for fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Evaluate for intracranial hemorrhage in a patient with increasing
confusion and right shoulder tenderness palpation concerning for trauma.
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: Total DLP (Head) = 1,405 mGy-cm.
COMPARISON: Noncontrast CT head from ___.
FINDINGS:
The exam is limited by motion artifact. There is no evidence of acute large
territorial infarction, hemorrhage, edema, or mass effect. Prominent
ventricles and sulci are suggestive of age-related involutional change.
Periventricular white matter hypodensities are consistent with chronic small
vessel ischemic disease. 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. Motion limited exam.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with increasing confusion and right shoulder TTP
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 743 mGy-cm.
COMPARISON: Noncontrast CT cervical spine from ___.
FINDINGS:
No acute fracture is identified.Mild retrolisthesis of the C3 on C4 vertebral
bodies is unchanged compared to ___ is no significant spinal canal
stenosis. Moderate neural foraminal narrowing, left greater than right, at
the C3-4 and C4-5 levels. Mild bilateral neural foraminal narrowing is seen
at the C5-6 level. There is no prevertebral soft tissue swelling. Thyroid
gland appears normal. The imaged lung apices are clear.
IMPRESSION:
No acute fracture, malalignment, or prevertebral soft tissue abnormality of
the cervical spine.
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS
INDICATION: Diffuse abdominal tenderness to palpation and confusion.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque. Oral contrast was
not administered.Coronal and sagittal reformations were performed and reviewed
on PACS.
DOSE: Total DLP (Body) = 919 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: The visualized lung bases are clear, without pleural or
pericardial effusion. Coronary artery calcifications are noted. The heart is
top normal in size.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no focal lesion or intrahepatic biliary duct dilation. The main
portal vein is patent. The gallbladder is within normal limits.
PANCREAS: The pancreas is diffusely atrophic. No focal lesion or ductal
dilation is identified. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are symmetric and normal in size, demonstrating normal
nephrograms and excreting contrast promptly. There is a large exophytic
simple renal cyst arising from the interpolar region of the right kidney.
Smaller hypodensities in the left kidney are too small to characterize, but
also likely represent simple renal cysts. There is no concerning focal lesion
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is decompressed, but there is no obvious wall
thickening or focal mass. Small bowel loops are normal in caliber, without
wall thickening or evidence of obstruction. The colon and rectum are within
normal limits. The appendix is not definitely visualized, but there are no
secondary signs of acute appendicitis.
PELVIS: Urinary bladder wall thickening may be related in part to chronic
obstruction as well as underdistention. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is markedly enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is a small fat containing umbilical hernia.
IMPRESSION:
1. No acute intra-abdominal abnormality to explain the patient's presentation.
2. Small fat containing umbilical hernia.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ with confusion // eval for pneumonia
COMPARISON: ___
FINDINGS:
AP portable supine view of the chest. Low lung volumes limits assessment.
There is atelectasis in the right lung base. No convincing evidence for
pneumonia or edema. No large effusion for supine evidence for pneumothorax.
Cardiomediastinal silhouette appears normal. Bony structures are intact.
IMPRESSION:
No convincing evidence for pneumonia.
Radiology Report
INDICATION: ___ year old man with no bowel movement for one week, reports not
passing flatus evaluate for stool burden or small bowel obstruction.
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: ___ CT of the abdomen and pelvis with contrast.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is a
large amount of stool seen in colon. Supine assessment limits detection for
free air; there is no gross pneumoperitoneum. Osseous structures are notable
for degenerative changes of the lumbar spine.
IMPRESSION:
1. Nonobstructive nonspecific bowel gas pattern.
2. Large amount of stool throughout the colon.
Radiology Report
INDICATION: ___ year old man with no stool x 17 days despite aggressive bowel
regimen. Evaluate for obstruction.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without intravenous contrast administration.
IV Contrast: None
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: DLP: 903 mGy-cm.
COMPARISON: Abdominal radiograph from ___ and CT abdomen pelvis
from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. Coronary artery calcifications
are noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: Fatty replacement of the pancreas is noted, and there is no evidence
of focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. A right lower pole
simple cyst is noted. There is no perinephric abnormality, and there is no
hydronephrosis bilaterally.
GASTROINTESTINAL: The stomach is minimally distended and unremarkable. Small
bowel loops opacified with oral contrast and demonstrate normal caliber and
wall thickness throughout without signs of obstruction. The colon and rectum
are within normal limits, and there is a large stool burden throughout the
colon. The appendix is not visualized.
PELVIS: The urinary bladder is collapsed due to a Foley catheter, and the
distal ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Degenerative changes are seen in the lumbar spine, most pronounced at
L5-S1 with a disc bulge.
SOFT TISSUES: A small fat containing umbilical hernia is noted.
IMPRESSION:
No evidence of bowel obstruction with a large stool burden noted in the colon.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Confusion
Diagnosed with Urinary tract infection, site not specified
temperature: 97.5
heartrate: 72.0
resprate: 16.0
o2sat: 98.0
sbp: 145.0
dbp: 85.0
level of pain: ua
level of acuity: 2.0 | Mr. ___ is an ___ man with h/o dementia, DM, prior
CVA and hypertension who presented with confusion. The patient
had a TIA/recrudescence of prior stroke symptoms in setting of
toxic metabolic encephalopathy 4 weeks prior to admission, for
which he was admitted to ___. Since that time, he has had
periods of confusion alternating with periods of lucidity. He
presented to his neurologist for a scheduled appointment, and
due to concern for his confusion he was admitted. His family
reports that his mental status on day of presentation was the
same as it has been over the past several weeks. His U/A was
concerning for possible urinary tract infection. He received a
few doses of ceftriaxone, although his cultures returned growing
coag-negative staph, which was thought to be contaminant.
Antibiotics were subsequently discontinued and repeat urine
cultures were normal. His blood pressures were also found to be
persistently elevated to the 180s. He was started on lisinopril
5 mg daily, but then his creatinine increased so this was
discontinued and amlodipine 5 mg daily was started with
improvement in his blood pressures. His creatinine on day of
discharge was 1.1. He also reported constipation for two weeks,
and was initiated on a bowel regimen to good effect. He also had
urinary retention up to 1.5L of urine, so a Foley was placed. At
baseline he is alert and oriented x ___ intermittently sleepy
at home. On day of discharge, he was alert and oriented x1-2
(baseline).
=================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
CHIEF COMPLAINT: Shortness of Breath
REASON FOR TRANSFER: Respiratory Distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o gentleman with a PMHX of non schemic sCHF
EF 15% s/p ICD, OSA on bipap, recent admission from ___ for
CHF exacerbation, now with chest pain and shortness of breath
c/w prior admission. With regards to his recent admission, he
was discharged at dry weight of 378 pounds and an NT BNP of
around 5500 which is near his baseline. He was seen at
cardiology clinic on ___ and was noted to be continued acute on
chronic systolic CHF. His weight was 383 at that admission and
it was noted that his first dose of Bumex post-discharge was
that day as he had not filled the prescription. Labs were
checked on ___ and showed hypokalemia to 2.9. He was advised to
hold his bumex and prn metolazone due to hypokalemia. Labs were
rechecked on ___ and K was < 2.0 for which he was given 60 mEq
K. Around noon today Mr. ___ developed ___ cp radiaiting to
r and left sides. About one hr prior to admission, he developed
siginificant sob and so called ___. EMS found the pt diaphoretic
in respiratory distress. He was given 2 nitro sprays and placed
on nrb and brought to ___ ED. He denies recent/current f/c,
abd pain, n/v/d, dysuria
In the ED, initial vitals were: 99.0 123 94/58 28 100% 15L NRB
-initial labs: Na/K 132/2.7; BUN/Cr ___ (baseline cr 1.0 in
___ CK 102, MB 3, Trop 0.08, proBNP 5815, WBC 11.5,
Hgb/Hct 12.5/36.6, Plt 345, INR 1.4, Lactate 4.4
- CXR: Cardiomegaly with mild pulmonary edema.
- ___ was negative for DVT
- Patient was given 80mEq potassium, Ativan 1 mg, 2g magnesium,
25 mg spirinolactone
On arrival to ICU, VS were: T 98.3, BP 108/71, HR 114, RR 20,
95% on 3L NC. Patient reported ongoing cp, abd discomfort, and
sob.
REVIEW OF SYSTEMS:
+ as per HPI. ALso reported orthopnea, ___ swelling (chronic per
patient) and palpitations. Denied f/c/ns, n/v,
light-headedness/dizziness, diarrhea, melena, BRBPR, or dysuria.
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.
Past Medical History:
CHF with nonischemic cardiomyopathy s/p ICD placement, EF 15%
Hyperlipidemia
Hypertension
Hypokalemia
Morbid Obesity
OSA on BiPAP
Social History:
___
Family History:
Mother died from an MI at age ___
Never knew his father
No family history of cancer.
Physical Exam:
Admission physical exam:
=============================
VS: T 98.3, BP 108/71, HR 114, RR 20, 95% on 3L NC.
Gen: Obese male, sitting up in bed, in NAD
HEENT: NC/AT, poor dentition, EOMI, sclera anicteric
NECK: JVP at angle of jaw
CV: Tachycardic, no r/m/g
LUNGS: CTAB, no wheezes or rhonchi
ABD: Protuberant abdomen, soft, NTTP, normal active bowel sounds
EXT: 2+ radial and DP pulses, ___ with 2+ pitting edema to knee
SKIN: No rashes or excoriations
NEURO: Moving all extremities, speech fluent, gait assessment
deferred
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS: 97.9 ___ 18 99RA
IO: ___
Wt: 171.7(d/c
6
/
3)->177.5kg(admission)->175.6->176.6->175.7->172.6->168.3->167.9
Gen: Obese male, sitting up in bed, in NAD
HEENT: NC/AT, EOMI, sclera anicteric
NECK: JVP not elevated
CV: Regular, normal S1, S2. No r/m/g
LUNGS: CTAB, no wheezes or rhonchi
ABD: Obese abdomen with large pannus, soft, NTTP, normal active
bowel sounds
EXT: 2+ radial and DP pulses, ___ with trace pitting edema to
knee, L>R. warm
SKIN: No rashes or excoriations
Pertinent Results:
Admission labs:
===============================
___ 08:45PM BLOOD WBC-11.5* RBC-4.67 Hgb-12.5* Hct-36.6*
MCV-79* MCH-26.7* MCHC-34.0 RDW-17.7* Plt ___
___ 08:45PM BLOOD Neuts-74.1* Lymphs-17.1* Monos-5.7
Eos-2.6 Baso-0.4
___ 08:45PM BLOOD ___ PTT-27.5 ___
___ 08:45PM BLOOD Glucose-165* UreaN-26* Creat-1.4* Na-132*
K-2.7* Cl-87* HCO3-29 AnGap-19
___ 08:45PM BLOOD CK(CPK)-102
___ 08:45PM BLOOD CK-MB-3 proBNP-5815*
___ 08:45PM BLOOD Mg-1.3*
___ 01:28AM BLOOD ___ pO2-72* pCO2-34* pH-7.52*
calTCO2-29 Base XS-4
___ 09:06PM BLOOD Lactate-4.4*
___ 03:19AM BLOOD Lactate-4.8*
___ 08:12AM BLOOD Lactate-3.1*
___ 08:12AM BLOOD freeCa-1.05*
___ 01:28AM BLOOD O2 Sat-93
STUDIES:
=======================
+ CXR (___): Left chest wall single lead pacing device is
again seen. Moderate cardiomegaly is stable in configuration.
There is mild pulmonary edema. No focal consolidation
identified. IMPRESSION: Cardiomegaly with mild pulmonary edema.
+ EKG (___): sinus tachycardia, delayed r-wave progression,
c/w prior, no ischemic changes
+ TTE (___): The left atrial volume index is normal. The
right atrium is moderately dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is severe global left ventricular hypokinesis (LVEF = 15
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall thickness is normal. The right ventricular
cavity is markedly dilated with severe global free wall
hypokinesis. 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.
There is no pericardial effusion. IMPRESSION: Suboptimal image
quality. Profound biventricular contractile dysfunction.
+ ___ (___): No evidence of deep venous thrombosis in the left
lower extremity veins. Nonvisualization of the calf veins.
DISCHARGE LABS:
========================
___ 04:30AM BLOOD WBC-10.0 RBC-5.05 Hgb-13.1* Hct-42.7
MCV-85 MCH-25.9* MCHC-30.7* RDW-19.9* RDWSD-58.2* Plt ___
___ 04:30AM BLOOD Glucose-79 UreaN-29* Creat-1.4* Na-136
K-3.4 Cl-86* HCO3-35* AnGap-18
___ 04:30AM BLOOD ALT-35 AST-35 AlkPhos-66 TotBili-1.6*
___ 04:30AM BLOOD Calcium-10.3 Phos-4.7* Mg-2.8* Iron-47
___ 04:30AM BLOOD calTIBC-564* Ferritn-160 TRF-434*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Amiodarone 200 mg PO DAILY
3. Bumetanide 5 mg PO BID
4. Clotrimazole Cream 1 Appl TP DAILY
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Spironolactone 25 mg PO BID
10. Magnesium Oxide 800 mg PO BID
11. Pravastatin 20 mg PO QPM
12. Pulmicort (budesonide) 0.25 mg/2 mL inhalation 1 puff daily
13. Sertraline 50 mg PO DAILY
14. Potassium Chloride (Powder) 30 mEq PO DAILY
15. Metolazone 5 mg PO PRN weight gain greater than 1kg in 24H
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Clotrimazole Cream 1 Appl TP DAILY
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. Lisinopril 40 mg PO DAILY
7. Magnesium Oxide 800 mg PO BID
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Potassium Chloride (Powder) 90 mEq PO DAILY
Hold for K >
RX *potassium chloride 40 mEq/15 mL 35 ml by mouth daily
Refills:*0
10. Pravastatin 20 mg PO QPM
11. Sertraline 50 mg PO DAILY
12. Spironolactone 50 mg PO BID
RX *spironolactone 50 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Bumetanide 5 mg PO BID
Hold this medication on ___, and restart on ___. Pulmicort (budesonide) 0.25 mg/2 mL inhalation 1 puff daily
15. Outpatient Lab Work
Please recheck electrolytes on ___. Please draw at ___
lab. Send results to Dr. ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Acute on Chronic Systolic Heart Failure Exacerbation
Secondary Diagnosis:
Hypokalemia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with hx sob. sudden onset cp, ___ swelling // eval for fluid
overload
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
Left chest wall single lead pacing device is again seen. Moderate
cardiomegaly is stable in configuration. There is mild pulmonary edema. No
focal consolidation identified.
IMPRESSION:
Cardiomegaly with mild pulmonary edema.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with unilateral left leg swelling, evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. The calf veins were not
visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Nonvisualization of the calf veins.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with HYPOKALEMIA, RESPIRATORY ABNORM NEC, CHEST PAIN NOS
temperature: 99.0
heartrate: 123.0
resprate: 28.0
o2sat: 100.0
sbp: 94.0
dbp: 58.0
level of pain: 6
level of acuity: 1.0 | ___ man with history of morbid obesity, systolic HF and
non-ischemic cardiomyopathy EF 15% s/p ICD, OSA on BIPAP,
recently dc'd on ___ for ___ exacerbation, now presenting with
SOB, abdominal discomfort and weight gain, in setting of holding
diuretics for severe hypokalemia.
# Acute on chronic systolic HF with nonischemic cardiomyopathy
s/p AICD: Patient presents with cp, sob, and weight gain in
setting of holding diuretics x 2 days due to hypokalemia. On
admission BNP was in the 5000s which was c/w prior admissions.
CXR with mild pulmonary edema. Pt with orthopnea and SOB, and
abdominal discomfort. Of note he has c/o abdominal discomfort in
the past during CHF exacerbations. Initial concern for
cardiogenic shock given elevated lactate, and poor urine output.
But lactate and symptoms improved with with diuresis to his
previous discharge weight via bumex gtt. He was transitioned to
oral bumex 5mg twice a day. He was continued on lisinopril and
spironolactone for afterload reduction. He will take a higher
dose of potassium repletion at home 90meq daily and will have
next potassium check on ___.
CHRONIC ISSUES:
# Depression: Continued home sertraline. Seen by social work
during hospitalization.
# OSA: Continued BiPAP. Of note, during last hospitalization
patient received a recall notice for home BIPAP machine stating
that it was associated with increased mortality in patients with
CHF. He no longer has BiPAP at home |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / codeine
Attending: ___.
Chief Complaint:
Left Intertrochanteric Fracture
Major Surgical or Invasive Procedure:
Long Trochanteric Fixation Nail
History of Present Illness:
___ year old male with past medical history per family notable
for
opioid abuse presents as a transfer from OSH status post
unwitnessed fall, possibly trip over cord onto cement patio,
with
laceration over left eye, left volar digit laceration, and left
intertrochanteric fracture. Per report, essentially
unresponsive
in the field. Given Narcan x2, and subsequently arousable by
sternal rub. In the ED, GCS 14. Patient was somnolent and
unable to fully cooperate with interview or exam.
Past Medical History:
Opioid Abuse
Chronic Back Pain
Social History:
___
Family History:
Non-contributory
Physical Exam:
AVSS
NAD, A&Ox3
Left Lower Extremity:
Incision well approximated. Dressing clean and dry. Fires FHL,
___, TA, GCS. SILT ___ n distributions. 1+ DP pulse,
wwp distally.
Discharge Physical exam:
VS: 97.4 PO 123 / 74 R Lying 74 18 97 Ra
Gen: NAD, AxOx3
HEENT: left eye ecchymosis
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended
Ext: L knee wrapped
Pertinent Results:
Radiology:
___ Ct head: 1. Left middle cranial fossa aneurysm clip
streak artifact limits examination. 2. Left temporal and left
periorbital soft tissue swelling. 3. Probable chronic left
orbital floor fracture versus suture, and with age-indeterminate
induration of left orbit fat inferior to left inferior
rectus muscle, which is noted to not be directly above area of
orbital floor fracture. 4. Age indeterminate left posterior
maxillary sinus wall fracture. 5. Left temporal craniotomy and
adjacent left temporal encephalomalacia. 6. Left frontal
craniotomy postsurgical changes. 7. Left middle cranial fossa
aneurysm clip. 8. Within limits of study, no definite evidence
of
acute intracranial hemorrhage. Please note MRI of the brain is
more sensitive for the detection of acute infarct.
9. Findings suggestive of left maxillary chronic sinus disease,
with differential considerations of hemosinus not excluded on
the
basis of this examination. 10. Additional paranasal sinus
disease, as described. 11. Probable right frontal
ventriculostomy
catheter postoperative changes as described.
___ Pelvis: 1. Immediate postsurgical changes of
cephalomedullary fixation of left femoral intertrochanteric
fracture.
___ Hip: Intraoperative images were obtained during femoral
intertrochanteric fracture fixation. Please refer to the
operative note for details of the procedure.
___ Hand: 1. No evidence of fracture or dislocation.
___ knee: Corticated ossicle adjacent to the medial femoral
metaphysis, favored related to remote trauma. Recommend
clinical
correlation. No definite acute fracture seen.
___ CXR:
Lungs are now clear. Cardiomediastinal and hilar silhouettes
and pleural
surfaces are normal.
LABORATORY:
___ 06:36AM BLOOD WBC-12.4* RBC-3.46* Hgb-10.4* Hct-31.1*
MCV-90 MCH-30.1 MCHC-33.4 RDW-14.2 RDWSD-44.7 Plt ___
___ 08:26AM BLOOD WBC-15.9* RBC-3.53* Hgb-10.6* Hct-31.9*
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.0 RDWSD-44.2 Plt ___
___ 07:55AM BLOOD WBC-13.1* RBC-3.15* Hgb-9.4* Hct-28.3*
MCV-90 MCH-29.8 MCHC-33.2 RDW-13.6 RDWSD-42.7 Plt ___
___ 09:19AM BLOOD WBC-10.3* RBC-2.97* Hgb-8.8* Hct-26.6*
MCV-90 MCH-29.6 MCHC-33.1 RDW-13.1 RDWSD-41.8 Plt ___
___ 06:37AM BLOOD WBC-9.4 RBC-2.94* Hgb-8.9* Hct-26.5*
MCV-90 MCH-30.3 MCHC-33.6 RDW-12.8 RDWSD-41.6 Plt ___
___ 07:50AM BLOOD WBC-10.4* RBC-2.90* Hgb-8.8* Hct-26.1*
MCV-90 MCH-30.3 MCHC-33.7 RDW-12.8 RDWSD-41.9 Plt ___
___ 10:04AM BLOOD WBC-14.5* RBC-3.22* Hgb-9.7* Hct-29.4*
MCV-91 MCH-30.1 MCHC-33.0 RDW-12.9 RDWSD-42.6 Plt ___
___ 08:00AM BLOOD WBC-18.6* RBC-4.01* Hgb-11.9* Hct-36.2*
MCV-90 MCH-29.7 MCHC-32.9 RDW-12.9 RDWSD-42.5 Plt ___
___ 08:00AM BLOOD ___ PTT-27.1 ___
___ 01:09AM BLOOD ___ PTT-27.1 ___
___ 07:55AM BLOOD Glucose-87 UreaN-17 Creat-0.6 Na-142
K-4.7 Cl-102 HCO3-25 AnGap-15
___ 09:19AM BLOOD Glucose-102* UreaN-11 Creat-0.6 Na-141
K-4.1 Cl-102 HCO3-27 AnGap-12
___ 06:37AM BLOOD Glucose-150* UreaN-10 Creat-0.5 Na-144
K-3.7 Cl-106 HCO3-22 AnGap-16
___ 07:50AM BLOOD Glucose-113* UreaN-11 Creat-0.5 Na-141
K-3.8 Cl-103 HCO3-27 AnGap-11
___ 10:04AM BLOOD Glucose-105* UreaN-12 Creat-0.6 Na-140
K-4.1 Cl-101 HCO3-28 AnGap-11
___ 08:00AM BLOOD Glucose-139* UreaN-13 Creat-0.7 Na-139
K-4.1 Cl-101 HCO3-24 AnGap-14
___ 09:19AM BLOOD ALT-22 AST-23 AlkPhos-58 TotBili-0.7
___ 01:09AM BLOOD Lipase-7
___ 07:55AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
___ 09:19AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.7
___ 06:37AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.8
___ 07:50AM BLOOD Calcium-9.1 Phos-2.4* Mg-1.8
___ 10:04AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.8
___ 08:00AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.7
___ 01:09AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:21AM BLOOD Glucose-135* Lactate-1.0 Creat-0.6 Na-140
K-3.9 Cl-100 calHCO3-25
___ 1:05 am URINE STROKE.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL DAILY
2. Sertraline 150 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 30 mg SC Q12H
4. Haloperidol 2.5 mg PO QHS
5. Haloperidol 2.5 mg PO TID:PRN agitation or insomnia
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Wean as tolerated. Patient may request partial fill.
7. Polyethylene Glycol 17 g PO DAILY
8. Senna 8.6 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
10. Atorvastatin 20 mg PO QPM
11. Sertraline 150 mg PO DAILY
12. HELD- Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL DAILY
This medication was held. Do not restart Buprenorphine-Naloxone
Film (8mg-2mg) until weaned off oxycodone.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Left ___ finger laceration
-Left ___ finger PIP dorsal dislocation with overlying wound
-Left hip fracture
-Traumatic Brain Injury with concussion
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: HIP NAILING IN OR W/FILMS AND FLUORO LEFT
INDICATION: Left hip fracture ORIF
COMPARISON: CT pelvis ___
FINDINGS:
10 intraoperative images were acquired without a radiologist present.
Images show intertrochanteric fracture fixation with a intramedullary gamma
nail.
IMPRESSION:
Intraoperative images were obtained during femoral intertrochanteric fracture
fixation. Please refer to the operative note for details of the procedure.
Radiology Report
EXAMINATION: PELVIS AP ___ VIEWS
INDICATION: ___ year old man s/p L TFN.// s/p L TFN, eval hardware/alignment
TECHNIQUE: 2 AP views of the pelvis.
COMPARISON: ___.
FINDINGS:
Interval postsurgical changes of cephalomedullary fixation of comminuted left
intertrochanteric femoral fracture.The alignment is near anatomic. Continued
moderate superior medial displacement of the lesser trochanteric
fragment.There are severe degenerative changes at L5-S1.Hip joints are
congruent.
IMPRESSION:
1. Immediate postsurgical changes of cephalomedullary fixation of left
femoral intertrochanteric fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ male with past medical history per family notable for opioid
abuse presents as a transfer from OSH status post unwitnessed fall, with left
intertrochanteric fracture s/p long TFN. Now with decreased interaction. C/f
SDH or other IC bleed.// Interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.5 cm; CTDIvol = 47.1 mGy (Head) DLP =
824.4 mGy-cm.
Total DLP (Head) = 838 mGy-cm.
COMPARISON: None.
FINDINGS:
Left middle cranial fossa aneurysm clipping postoperative changes noted with
surgical hardware streak artifact limiting examination.
Induration of the left temporal and left periorbital soft tissues is noted.
Within limits of study there is no definite evidence of acute intracranial
hemorrhage.
Left temporal craniectomy and adjacent encephalomalacia is seen. Otherwise,
the ventricles and sulci are grossly preserved in size and configuration.
Additional left frontal craniotomy postoperative changes are seen.
Postsurgical changes suggestive of prior right frontal burr hole and
ventriculostomy catheter placement are seen.
There is no evidence of acute large territorial infarction,acute intracranial
hemorrhage,edema,or mass.
There is no evidence of acute fracture. Within the left orbital floor a well
corticated defect is seen (see 602: ___. Question minimal nonspecific
induration of the left orbit medial intraorbital fat inferior to the inferior
rectus muscle (602:24).
An age indeterminate left maxillary sinus posterior wall defect is seen (see
3:6).
The left maxillary sinus is completely opacified and is asymmetrically smaller
than the right maxillary sinus. Question minimal bony sclerosis surrounding
the right maxillary sinus. Question areas of high density within the right
maxillary sinus opacification. Left frontal sinus mucosal thickening is
present. Minimal bilateral ethmoid air cell mucosal thickening is present.
The visualized portion of the middle ear cavities and mastoid air cells are
clear. The visualized portion of the right orbit is preserved.
IMPRESSION:
1. Left middle cranial fossa aneurysm clip streak artifact limits examination.
2. Left temporal and left periorbital soft tissue swelling.
3. Probable chronic left orbital floor fracture versus suture, and with
age-indeterminate induration of left orbit fat inferior to left inferior
rectus muscle, which is noted to not be directly above area of orbital floor
fracture.
4. Age indeterminate left posterior maxillary sinus wall fracture.
5. Left temporal craniotomy and adjacent left temporal encephalomalacia.
6. Left frontal craniotomy postsurgical changes.
7. Left middle cranial fossa aneurysm clip.
8. Within limits of study, no definite evidence of acute intracranial
hemorrhage. Please note MRI of the brain is more sensitive for the detection
of acute infarct.
9. Findings suggestive of left maxillary chronic sinus disease, with
differential considerations of hemosinus not excluded on the basis of this
examination.
10. Additional paranasal sinus disease, as described.
11. Probable right frontal ventriculostomy catheter postoperative changes as
described.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ found unresponsive with lac left eye, L hip fracture//
Interval change? Interval change?
IMPRESSION:
Compared to chest radiograph ___.
Lungs are now clear. Cardiomediastinal and hilar silhouettes and pleural
surfaces are normal.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with trauma// eval trauma
TECHNIQUE: Frontal view
COMPARISON: None
FINDINGS:
The lungs are well expanded and clear. No pleural effusion or pneumothorax.
Heart size is top-normal. The mediastinal silhouette is otherwise
unremarkable.
IMPRESSION:
No evidence of an acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with trauma// ?fx
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of the right knee.
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. There is a corticated ossicle
adjacent to the medial femoral metaphysis, favored related to remote trauma.
No significant soft tissue swelling seen. There are no significant
degenerative changes. There is no knee joint effusion. There is normal osseous
mineralization. No suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
Corticated ossicle adjacent to the medial femoral metaphysis, favored related
to remote trauma. Recommend clinical correlation. No definite acute fracture
seen.
Radiology Report
EXAMINATION: Noncontrast pelvis CT
INDICATION: ___ year old man with left hip fx// eval left hip fracture,
operative planning
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 7.3 s, 35.9 cm; CTDIvol = 25.0 mGy (Body) DLP = 897.4
mGy-cm.
Total DLP (Body) = 897 mGy-cm.
COMPARISON: None.
FINDINGS:
PELVIS: The partially visualized small and large bowel are unremarkable.
Normal appendix. There is a Foley catheter in the urinary bladder with a few
locules of intravesicular gas. Hyperdense material within the bladder is
seen. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Mild atherosclerotic disease is noted.
BONES: There is a moderately comminuted left intertrochanteric fracture with
superolateral apex angulation and mild impaction and lesser trochanter
displacement. An obliquely oriented fracture line extends to the posterior
cortex just inferior to the level of the lesser trochanter. No left hip
dislocation. No other fractures identified. There is grade 1 anterolisthesis
of L5 on S1 with bilateral L5 spondylolysis.
SOFT TISSUES: There is indistinct intramuscular hematoma and edema adjacent to
intertrochanteric fracture as evidenced by asymmetric expansion of the
adjacent musculature. There is a small, fat containing left inguinal hernia.
There is a small, fat containing umbilical hernia.
IMPRESSION:
1. Comminuted and mildly varus angulated, impacted and displaced left
intertrochanteric femoral fracture with superior medial displacement of the
lesser trochanter. No hip dislocation. No other fractures identified.
2. Hyperdense material within the bladder suggestive of possible blood
products. Recommend clinical correlation.
3. L5 spondylolysis with grade 1 spondylolisthesis.
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with dislocated finger// eval for post reduction
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left wrist
and hand.
COMPARISON: None.
FINDINGS:
A splint obscures assessment of fine osseous detail. No fracture or
dislocation is seen. Scattered degenerative changes most pronounced and mild
at the basal joints of the thumb and distal interphalangeal joints. No bone
erosion or periostitis is identified. No suspicious lytic or sclerotic lesion
is identified. No soft tissue calcification or radio-opaque foreign bodies are
detected.
IMPRESSION:
1. No evidence of fracture or dislocation.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: L Hip fracture, Transfer
Diagnosed with Altered mental status, unspecified
temperature: 100.2
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 124.0
dbp: 76.0
level of pain: 0
level of acuity: 1.0 | The patient presented to an outside emergency department and was
evaluated by the orthopedic surgery team. At the outside
hospital, he received meropenem, vancomycin and tetanus. Given
Narcan at OSH with improvement in mental status. In the ED here,
he received 1 dose of unasyn. He was admitted to the ICU for
concern of neuro status. CT head was negative.
Plastics was consulted for the left eye brow laceration, wound
was washed out and repaired with absorbable sutures. Hand
surgery was consulted for Left ___ finger laceration (tendons
intact) and Left ___ finger PIP dorsal dislocation with
overlying wound. Wound was irrigated thoroughly, reduced the
dislocation and repaired the lacerations. A dorsal blocking
splint was applied.
The patient was found to have a left hip fracture and he was
taken to the operating room by Orthopedic Surgery on HD1 for
ORIF left hip fracture with trochanteric fixation nail, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate.
The patient was initially written for CIWA scale and the patient
received valium prn CIWA >10. Addiction Medicine was consulted
for opioid management due to the patient's past medical history
of opioid abuse, on suboxone. Given the patient's altered
mental status, a CT head was obtained which showed chronic
findings and no definite evidence of acute intracranial
hemorrhage. On ___, the patient was acutely agitated and
required Haldol. Psychiatry was consulted and recommended
quetiapine standing and scheduled. The patient was in a veil
bed and this was removed as the patient was able to be
reoriented. He continued to have intermittent periods of
delirium/agitation that were ultimately managed with oral
Haldol. Physical and Occupational Therapy evaluated the patient
and recommended discharge to rehab.
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
WBAT in the RLE, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up Orthopedic surgery and
Hand surgery 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 and in agreement with plan.
The patient is not expected to stay at rehab for more than a 30
day period. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / metformin
Attending: ___.
Chief Complaint:
Multiple falls, right ___
Major Surgical or Invasive Procedure:
___ Right burr hole evacuation of ___
History of Present Illness:
___ yo M hx A-Fib on Coumadin who presents with multiple
falls in the last few months, 2 falls in the last 24 hours with
headtrikes. Pt feels that he fell due to weakness and
imbalance.
No LOC. Pt transferred from ___ where head CT
showed enlarging right SDH and stable left hygroma compared to
prior films. At OSH he was reversed with Vit K and KCentra for
an
INR 1.8. Troponin at OSH was 0.11. Pt denies HA, numbness,
weakness, vision changes, chest pain, shortness of breath. He
has baseline right arm weakness from right humerus fx ___ months
ago.
Past Medical History:
Essential tremor
atrial fibrillation, on coumadin
Pace maker (placed ___ yrs ago)
HTN
BPH
GERD
NIDDM
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
O: T:97.5 HR:92 BP:137/92 RR: 16 SAt:98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: decreased bulk and normal tone bilaterally. No abnormal
movements, tremors. Strength full power ___ throughout except
right upper weakness in Bi/tri/Delt 4+/5.
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
On Discharge:
___
Alert and oriented x3. PERRL. EOMs intact. Face symmetrical.
Mild left tongue deviation. Pain limited strength on RUE due to
humerus fracture. Improved ROM on Left shoulder, able to lift
arm over head. Full strength ___ on bilateral bi/tri/grip.
Deltoid ___ bilaterally. No pronator drift. LEs full strength
___. Staples post burr hole and post drain intact, well
approximated. No redness, no drainage.
Pertinent Results:
___ CT head : Right subacute on chronic SDH max thickness
3cm with
6mm MLS. Left hygroma.
Labs ___:
138/ 103/ 30
----------------<118
4.___/ 1.7
11.3
7.6>-----<218
34.4
N:73.1 L:15.1 M:10.2 E:0.8 Bas:0.4 ___: 0.4 Absneut: 5.57
Abslymp: 1.15 Absmono: 0.78 Abseos: 0.06 Absbaso: 0.03
___: 13.4 PTT: 28.3 INR: 1.2
Trop: 0.11
CXR ___:
A left chest cardiac conduction device generator is contiguous
with cardiac leads. Aortic arch calcifications are dense.
Biapical pleural calcifications are noted. There is no focal
consolidation. No pleural effusion or pneumothorax.
___ CT head 13:00:
1. The patient is status post right trans parietal subdural
catheter placement via a burr hole with pneumocephalus now
replacing the majority of a large right hemispheric acute on
chronic subdural hematoma. Trace amount of dependent hemorrhage
is noted along the right parietal lobe.
2. There remains prominent mass effect on the right hemisphere
resulting in approximately 10 mm leftward midline shift, similar
in appearance to prior examination.
3. Left subdural collection measuring approximately 10 mm in
greatest
thickness is unchanged.
4. No acute large territory infarct or new hemorrhage is
identified.
___ CT head 21:00:
1. Interval decrease in right pneumocephalus with resultant
decreased midline shift and mass effect. Otherwise no
significant interval change.
2. Mild nonspecific hypodensity of the right frontal lobe which
is felt likely to be secondary to sulcal effacement,
postoperative edema in changes. This does not appear to affect
the precentral gyrus and is improved in appearance from
immediate postoperative examination.
___ Shoulder Xrays:
FINDINGS:
THIS EXAM WAS READ IN CONJUNCTION WITH A SINGLE AXILLARY VIEW OF
THE LEFT
SHOULDER FROM ___ AT 12:50. ALTHOUGH THAT IMAGE IS
SUBOPTIMAL DUE TO POSITIONING, THE GLENOHUMERAL JOINT APPEARS
CONGRUENT. THE AC JOINT IS
CONGRUENT.
NO FRACTURE IS DETECTED ABOUT THE LEFT SHOULDER. THERE IS
PROBABLE DIFFUSE OSTEOPENIA. CURVILINEAR DENSITY EXTENDING
ALONG THE LATERAL EDGE OF THE SCAPULA INFERIOR GLENOID LIKELY
REPRESENTS VASCULAR CALCIFICATION.
THE ACROMIOHUMERAL DISTANCE IS PRESERVED.
MILD DEGENERATIVE CHANGES OF THE AC JOINT ARE NOTED.
THE LEFT-SIDED RIBS ARE PARTIALLY OBSCURED BY A PACEMAKER
BATTERY PACK, BUT, WHERE VISIBLE, APPEAR INTACT. NO SIGNIFICANT
PLEURAL FLUID OR THICKENING IS SEEN ALONG THE UPPER LEFT CHEST
WALL ADJACENT TO THE LEFT SHOULDER.
___ Echo TTE:
The left atrium is elongated. The right atrium is moderately
dilated. 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). Diastolic
function could not be assessed. Right ventricular chamber size
is normal with normal free wall contractility. The aortic root
is mildly dilated at the sinus level. 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 mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mildly
dilated aortic root. Mild pulmonary hypertension.
___ CT head:
1. Significant interval decrease in the right pneumocephalus
with resolution of the midline shift.
2. Persistent bifrontal and left posterior fossa subdural fluid
collections.
3. Slight hypodensity in the right frontal lobe is is
essentially resolved.
___ CT Head:
1. Subdural fluid collections along the bilateral frontal
convexity ribs with mild sulcal effacement are grossly unchanged
as compared to noncontrast head CT ___.
2. Left posterior fossa fluid collection with mild compression
upon the left cerebellum is grossly unchanged.
3. No intracranial hemorrhage.
4. No midline shift.
___ Non-contrast head CT:
IMPRESSION:
Interval removal of a right convexity subdural drain with mildly
increased
small amount of pneumocephalus along the convexity. Unchanged
size of
hypodense subdural fluid collections at the bilateral cerebral
convexities and the left cerebellopontine angle, as described.
Medications on Admission:
omeprazole 20 mg daily
cholecalciferol daily
Coumadin 2 mg daily
amlodipine 5 mg Daily
pravastatin 20 mg Daily
Flomax 0.4 mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
Do not exceed 4gm acetaminophen in 24 hours
2. amLODIPine 5 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
6. LevETIRAcetam 500 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 20 mg PO QPM
9. Senna 17.2 mg PO HS
10. Sodium Chloride 2 gm PO BID
11. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right Subdural Hematoma
Left Hygroma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with sdh // ? infectious process
TECHNIQUE: Single AP view
COMPARISON: None.
FINDINGS:
A left chest cardiac conduction device generator is contiguous with cardiac
leads. Aortic arch calcifications are dense. Biapical pleural calcifications
are noted. There is no focal consolidation. No pleural effusion or
pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with R SDH s/p burr hole evacuation. Please
perform at 1300. // evaluate interval difference
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 20.0 s, 20.9 cm; CTDIvol = 48.0 mGy (Head) DLP =
1,003.4 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: Outside hospital CT head of ___.
FINDINGS:
The patient is status post right trans parietal subdural catheter placement
via a burr hole with drain overlying the right frontal parietal convexity.
There is now pneumocephalus replacing the previously described acute on
chronic right hemispheric subdural hematoma with amount of dependent residual
hematoma adjacent to the right parietal lobe (series 2, image 26).
Essentially unchanged leftward midline shift now measuring approximately 10 mm
compared to previously described 9mm unchanged appearance of chronic left
hemispheric subdural collection measuring approximately 10 mm in greatest
thickness. Unchanged 5.7 x 2.5 cm (AP, TRV) CSF density focus in the left
posterior fossa resulting in mass effect on the left cerebellar hemisphere and
the brainstem. Prominent atherosclerotic calcification of the bilateral
internal carotid arteries and vertebral arteries are unchanged.
The ventricles are unchanged from prior exam. The basilar cisterns are
patent. There is no evidence of acute large territorial infarct. No new
hemorrhage. The orbits are unremarkable. Mild mucosal thickening along the
inferior aspects of the maxillary sinuses is noted. The remainder the
paranasal sinuses are essentially clear. The mastoid air cells middle ears
are clear.
IMPRESSION:
1. The patient is status post right trans parietal subdural catheter placement
via a burr hole with pneumocephalus now replacing the majority of a large
right hemispheric acute on chronic subdural hematoma. Trace amount of
dependent hemorrhage is noted along the right parietal lobe.
2. There remains prominent mass effect on the right hemisphere resulting in
approximately 10 mm leftward midline shift, similar in appearance to prior
examination.
3. Left subdural collection measuring approximately 10 mm in greatest
thickness is unchanged.
4. No acute large territory infarct or new hemorrhage is identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with new LUE weakness/pain s/p burr hole evac for
___ // evaluate for new changes since post-op head CT
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, 17.3 cm; CTDIvol = 46.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Nonenhanced head CT dated ___ at 13:06
FINDINGS:
Interval decreased right pneumocephalus measuring approximately 2.7 cm from
the inner table, previously 3.6 cm. The drainage catheter is seen overlying
the right cerebral convexity. There is decreased shift of midline structures
now all 5 mm, previously 10 mm. There is otherwise unchanged appearance
including the left subdural chronic collection and the CSF density collection
in the left posterior fossa a resulting in mass effect on the left cerebellar
hemispheres brainstem. There is decreased mass effect on the lateral
ventricles. The basal cisterns remain patent. There is mild hypodensity of
the right frontal lobe, which is felt to be likely secondary to sulcal
effacement, edema and postoperative changes, improved in appearance from prior
exam which does not involve the right precentral gyrus.
IMPRESSION:
1. Interval decrease in right pneumocephalus with resultant decreased midline
shift and mass effect. Otherwise no significant interval change.
2. Mild nonspecific hypodensity of the right frontal lobe which is felt likely
to be secondary to sulcal effacement, postoperative edema in changes. This
does not appear to affect the precentral gyrus and is improved in appearance
from immediate postoperative examination. However given the clinical
symptoms, if there is high clinical concern for infarct, MRI would be more
sensitive.
NOTIFICATION: The finding of impression #2 were discussed with NP ___ by
___, M.D. on the telephone on ___ at 8:00 AM, 1 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man with new L shoulder pain and Left upper extremity
weakness. // evaluate for fracture
FINDINGS:
THIS EXAM WAS READ IN CONJUNCTION WITH A SINGLE AXILLARY VIEW OF THE LEFT
SHOULDER FROM ___ AT 12:50. ALTHOUGH THAT IMAGE IS SUBOPTIMAL DUE TO
POSITIONING, THE GLENOHUMERAL JOINT APPEARS CONGRUENT. THE AC JOINT IS
CONGRUENT.
NO FRACTURE IS DETECTED ABOUT THE LEFT SHOULDER. THERE IS PROBABLE DIFFUSE
OSTEOPENIA. CURVILINEAR DENSITY EXTENDING ALONG THE LATERAL EDGE OF THE
SCAPULA INFERIOR GLENOID LIKELY REPRESENTS VASCULAR CALCIFICATION.
THE ACROMIOHUMERAL DISTANCE IS PRESERVED.
MILD DEGENERATIVE CHANGES OF THE AC JOINT ARE NOTED.
THE LEFT-SIDED RIBS ARE PARTIALLY OBSCURED BY A PACEMAKER BATTERY PACK, BUT,
WHERE VISIBLE, APPEAR INTACT. NO SIGNIFICANT PLEURAL FLUID OR THICKENING IS
SEEN ALONG THE UPPER LEFT CHEST WALL ADJACENT TO THE LEFT SHOULDER.
IMPRESSION:
NO FRACTURE OR DISLOCATION DETECTED ABOUT THE LEFT SHOULDER.
FINDINGS ARE CONCORDANT WITH THE WET READING DOCUMENTED BELOW.
Radiology Report
INDICATION: ___ year old man with multiple recent falls, shoulder pain and
limited ROM // Axillary view please
FINDINGS:
ALTHOUGH THIS IMAGE IS SOMEWHAT SUBOPTIMAL DUE TO POSITIONING , THE LEFT
GLENOHUMERAL JOINT APPEARS CONGRUENT. NO FRACTURE IS DETECTED. VASCULAR
CALCIFICATIONS ARE NOTED.
PLEASE SEE SEPARATE REPORT ON THE AP VIEWS OF THE LEFT SHOULDER UNDER CLIP
___.
IMPRESSION:
AS ABOVE.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with ___ s/p right crani for evacuation // eval
for interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.4 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: CT head without contrast ___
FINDINGS:
Patient is status post right craniotomy and drain placement. The drain is in
unchanged position in the right cerebral convexity. There has been
significant interval decrease in the right frontal pneumocephalus and
associated mass effect. Previously seen mild left shift of midline structures
has resolved. There is persistent right subdural fluid collection as well as
left posterior fossae subdural fluid collection causing mass-effect on the
left cerebellar hemisphere and the brainstem. Replacing the postoperative
pneumocephalus is a right frontal subdural fluid collection measuring
approximately 1.5 cm in greatest thickness. Previously described right
frontal hypodensity has now resolved.
IMPRESSION:
1. Significant interval decrease in the right pneumocephalus with resolution
of the midline shift.
2. Persistent bifrontal and left posterior fossa subdural fluid collections.
3. Slight hypodensity in the right frontal lobe is is essentially resolved.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ y/o man w/ Right subacute on chronic SDH s/p Right burr hole
evacuation of ___. Head CT without contrast to evaluate amount of residual
fluid. // CT Head without contrast to evaluate for amount of residual fluid
given increase in drain output.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 954 mGy-cm
CTDI: ___ MGy
COMPARISON: Noncontrast head CT ___
Noncontrast head CT ___ 21:13
Noncontrast head CT outside hospital study ___
FINDINGS:
Patient is status post right sided craniotomy and drain placement. The drain
terminating along the right cerebral convexity is unchanged in position since
comparison study. The subdural fluid collections along the bilateral frontal
convexities with mild local sulcal effacement are grossly unchanged in size
since ___. The left posterior fossa collection (3:9) mildly
compressing the left cerebellum is grossly unchanged since comparison study.
Previously seen pneumocephalus along the right frontal convexity has resolved
in the interval. There is no new or worsening intracranial hemorrhage. There
is no shift of midline structures. The imaged paranasal sinuses are clear.
Mastoid air cells and middle ear cavities are well aerated. The bony calvarium
is intact.
IMPRESSION:
1. Subdural fluid collections along the bilateral frontal convexity ribs with
mild sulcal effacement are grossly unchanged as compared to noncontrast head
CT ___.
2. Left posterior fossa fluid collection with mild compression upon the left
cerebellum is grossly unchanged.
3. No intracranial hemorrhage.
4. No midline shift.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ male status post right burr hole evacuation for
subdural hemorrhage. Evaluate for changes post drain discontinuation.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.8 cm; CTDIvol = 50.6 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: ___ and ___ head CTs.
FINDINGS:
There is a right frontal burr hole with overlying scalp emphysema and skin
staples. There is a right parietal burr hole with overlying scalp emphysema
and skin staples. There has been interval removal of previously seen right
cerebral convexity drain. There is a small amount of pneumocephalus within
the right cerebral convexity. There are bilateral hypodense subdural fluid
collections measuring up to 1.2 cm in depth on the right and 1.6 cm in depth
on the left. There is asymmetric prominence of the left cerebellopontine
angle extra-axial fluid which measures up to 2.7 cm in depth and causes mild
mass effect on the left cerebellar hemisphere (3:8). The size of these
extra-axial fluid collections are relatively unchanged comparison to prior
study.
The gray-white matter differentiation is intact without CT evidence of acute
territorial infarct, hemorrhage, or mass. The ventricles and cortical sulci
are unchanged in size, caliber, and configuration. There is calcification of
the intracranial vasculature.
The bilateral native lenses are absent, otherwise the orbits are unremarkable.
The visualized paranasal sinuses, mastoid air cells, and middle ears are
clear.
IMPRESSION:
Interval removal of a right convexity subdural drain with mildly increased
small amount of pneumocephalus along the convexity. Unchanged size of
hypodense subdural fluid collections at the bilateral cerebral convexities and
the left cerebellopontine angle, as described.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, SDH
Diagnosed with Syncope and collapse
temperature: 97.5
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 137.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the Neuro ICU for frequent
neurochecks and strict blood pressure control in the setting of
a right SDH with mass effect and 6mm of MLS with a plan for
surgical evacuation. In the setting of elevated troponin
without EKG changes cardiac clearance was requested prior to
surgery. Cardiology felt that the troponin elevation was not
likely cardiac origin and cleared the patient for surgery
without further urgent testing. They recommended nonurgent TTE
to evaluate left ventricular function and pacemaker
interrogation with EP as part of his near syncope work up.
On ___ he was taken to the operating room for Right Burr hole
evacuation of ___ under general anesthesia. Please refer to
operative note for details. A subdural drain was left in place
and attached to a bile bag, leveled at the shoulder. He was
extubated and transferred to the SICU for recovery. Initial
postoperative scan showed good evacuation of hematoma with
significant pneumocephalus. Subsequently the patient had
difficulty moving the left arm antigravity. He complained of
pain with movement of the shoulder. A STAT head CT was obtained
to rule out intracranial process and showed improvement of both
pneumocephalus and mass effect. Shoulder Xrays were obtained
and were negative for fracture.
On ___ the patient remained neurologically intact. The Subdural
Drain remained in place. TTE was completed and showed normal EF
of 55%. Orthopedic consult was called for continued left
shoulder pain with active and passive movement. In the setting
of negative Xrays rotator cuff injury was thought to be the
likely cause of his pain and immobility. No other urgent
imaging or intervention was recommended.
On ___ he remained stable. He worked with physical therapy. He
was stable and eligible for transfer to the Step Down Unit
however no beds were available.
On ___, the patient remained neurologically stable. His morning
dose of SQH was held in anticipation for removal of the subdural
drain. The drain output was up to 195cc by 1PM. A head CT was
performed and showed continued fluid collection, stable when
compared to the scan performed yesterday. His AM Na was 136 and
he continues on Salt Tabs 2g PO TID.
On ___, the patient remained neurologically stable. His drain
continued to put out thin serosanguinous/CSF drainage. His drain
was d/c'd at 10:30am. His post-drain pull NCHCT was stable. His
foley was d/c'd.
On ___, the patient remained neurologically and hemodynamically
stable. He was evaluated by ___ and OT who are recommending rehab
and patient is in agreement with this plan. He is OOB to chair
with assistance, tolerating POs, and voiding. His mag was
repleted. He was changed from step-down unit status to floor.
On ___, the patient remained neurologically and hemodynamically
stable. His sodium is WNL and his Na tabs were decreased from
2GM TID to 2GM BID. He will need to continue to have his sodium
level monitored. He is ready for discharge to rehab with
neurosurgery follow-up for staple removal ___ days after
surgery and is instructed to follow-up with a NCHCT in 1 week
with an appointment with Dr. ___. He should not resume his
Coumadin until cleared by his neurosurgeon. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lexapro / Aciphex
Attending: ___.
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Paracentesis ___
PleurX abdominal catheter placed ___
History of Present Illness:
Ms ___ is a ___ year old female with metastatic squamous cell
carcinoma of the cervix who presents with weakness after a
recent
hospitalization at ___.
The patient was discharged yesterday from ___ after she was
admitted for progressive back pain. Imaging demonstrated
bilateral hydronephrosis in addition to metastatic spine
disease.
She was given radiation and her pain medications were titrated.
She was then discharged home. Since discharge, the patient has
noted increased lethargy and poor PO intake. She was seen by her
___ who noted orthostasis with tachycardia to 155 (from 100)
upon
standing.
The patient has noted stable, neck pain for the last month
without radiation. In addition, she notes progressive pain in
her
lower spine and ribs. She has no perineal paresthesia or
bowel/bladder incontinence. No chest pain or dyspnea. Noted
nausea and vomiting x2 days. Last BM 2 days ago. No melena,
hemathochezia or dysuria.
Initial vitals in the ED were notable for:
T 97.9 HR 121 -> 98 BP 197/97 R 12 SpO2 100% RA
Labs were notable for:
Ca ___ Cr 0.5 Hgb 9.4 INR 1.3
Flu PCR negative
Patient received:
___ 20:01 IV Ondansetron 4 mg
___ 20:02 IV HYDROmorphone (Dilaudid) 1 mg
___ 21:24 IVF NS ( 1000 mL ordered)
___ 21:24 IV HYDROmorphone (Dilaudid) 1 mg
Imaging demonstrated:
___ 20:58 Chest (Pa & Lat)
IMPRESSION:
No pneumonia or acute cardiopulmonary process.
ECG: NSR. Normal intervals. QTc 419. TWI V1-V3 No J waves.
Increased QRS voltages comparted to prior ECG.
ROS: 10 point review of systems discussed with patient and
negative unless noted above
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: Began having heavy, persistent vaginal bleeding along
with severe pelvic pain radiating to her legs
-___ Exam under anesthesia: Pap smear and cervical
biopsies. Intraoperative findings were notable for "eroded
massive tissue that was the cervix with sloughing of tissue. The
cervix was noted to be completely eroded and friable and
bleeding. There is no distinctive anterior lip of the cervix or
posterior cul-de-sac. It appeared that the anterior vaginal
wall
was adhered to the cervical tissue. Cervical tissue was noted to
be very nodular and friable. The anterior vaginal wall was also
very nodular. A Pap smear was completed of the cervix. In
doing
so, 1 cm pieces of cervical tissue sloughed. This was sent for
frozen section. The frozen section came back as invasive
carcinoma without being able to identify the primary source
though it does appear to be cervical. Hysteroscopy was deferred
given the persistent cervical bleeding and tissue sloughing.
-___ CT A/P shows multiple liver lesions, retroperitoneal
and
pelvic LAD, focal lytic lesion in L5 vertebra.
-___: CT chest shows multiple asymmetric PE's
-___: liver biopsy confirms metastatic cervical CA
-___: C1D1 ___
-___: Noted to have extensive LLE DVT. Lovenox dosing
increased to 60 BID.
-___: C2D1 ___
-___: C3D1 ___
-___: CT Torso shows mixed response to treatment;
improvement in liver lesions, but multiple new bony mets and
worsening inguinopelvic LAD.
-___: C1 Pembrolizumab
-___: admitted for worsening pain; s/p pelvic XRT
PAST MEDICAL HISTORY:
Squamous Cell Cervical Cancer
Anxiety
Asthma
Depression
Hypothyroidism ___ pembro
Social History:
___
Family History:
-Breast cancer in maternal aunt
-___ cancer in maternal uncle
-stroke: father, maternal grandfather, maternal grandmother
-___: Father, maternal grandfather, mother
-Cardiac arrest: maternal grandfather
Physical ___:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.6 BP 115/76 HR 98 R 18 SpO2 97 RA
GENERAL: Thin, chronically ill appearing, NAD
HEENT: dry membranes, no lesions. No thrush
EYES: PERRL, anicteric
NECK: supple
RESP: CTAB, no increased WOB, no wheezing, rhonchi or crackles
___: RRR no MRG
GI: soft, diffuse TTP on palpation no rebound or guarding
SKIN: dry
NEURO: CN II-XII intact, strength ___ ___ b/l
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
T 99.5 PO, BP 114 / 73, HR 120, RR 20, O2 98 ra
General: Pleasant but ill and cachectic young woman.
HEENT: MMM, no thrush, no OP lesions. Tongue deviates to the
left. Symmetric palate.
CV: RRR
PULM: Respirations unlabored. Decreased BS at the bases
bilaterally with soft crackles. Speaks in full sentences
ABD: Soft, mild distension, mild tenderness in lower quadrants
with small amount of rebound tenderness.
LIMBS: 1+ LLE edema. Decreased bulk
SKIN: No rashes on extremities.
NEURO: Fatigued but oriented x3. Some psychomotor slowing, but
strength grossly intact.
PSYCH: Mood remains appropriately apprehensive and affect is
appropriate, congruent and full. Continues to have some
difficulty processing her advanced illness but her thought
process is linear and goal directed.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:55PM BLOOD WBC-8.9 RBC-3.33* Hgb-9.4* Hct-30.2*
MCV-91 MCH-28.2 MCHC-31.1* RDW-17.4* RDWSD-55.5* Plt ___
___ 09:00PM BLOOD ___ PTT-27.9 ___
___ 07:55PM BLOOD Glucose-98 UreaN-7 Creat-0.5 Na-136 K-4.2
Cl-94* HCO3-28 AnGap-14
___ 07:55PM BLOOD ALT-11 AST-23 AlkPhos-171* TotBili-0.3
___ 07:55PM BLOOD Albumin-3.2* Calcium-12.5* Phos-3.3
Mg-1.6
___ 07:55PM BLOOD TSH-83*
___ 07:30AM BLOOD T4-4.1* calcTBG-1.22 TUptake-0.82
T4Index-3.4* Free T4-0.5*
___ 07:55PM BLOOD Cortsol-20.3* 25VitD-18*
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-11.8* RBC-2.92* Hgb-8.4* Hct-27.3*
MCV-94 MCH-28.8 MCHC-30.8* RDW-18.6* RDWSD-61.4* Plt Ct-91*
___ 06:50AM BLOOD Glucose-68* UreaN-18 Creat-0.9 Na-132*
K-4.7 Cl-93* HCO3-27 AnGap-12
___ 06:50AM BLOOD ALT-25 AST-57* TotBili-0.2
___ 06:50AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1
IMAGING:
___ Imaging PERITONEAL DRAINAGE CAT
Technically successful peritoneal PleurX catheter placement
___ Imaging PARACENTESIS DIAG/THERA
1. Technically successful ultrasound guided diagnostic and
therapeutic paracentesis.
2. 2.5 L of fluid were removed and sent for requested analysis.
___HEST W/CONTRAST
1. Small to moderate bilateral pleural effusions with
compressive
atelectasis, new from prior.
2. Progression of diffuse osseous metastases, including a
pathologic compression fracture of T2, as seen on same day MR.
3. Please refer to separate report of CT abdomen and pelvis
performed same day for description of subdiaphragmatic findings.
___ Imaging CT NECK W/CONTRAST (EG:
1. Osseous metastases involving the cervical spine, with severe
pathologic compression fracture of C6. Mild retropulsion
results
in mild spinal canal narrowing.
2. Osseous metastases replacing much of the left mastoid, right
occipital condyle and left styloid process.
3. Asymmetric enlargement of the right tongue base, as seen on
prior MR, suggestive of denervation of the hypo glossal nerve
due
to aforementioned metastatic disease in the right occipital
condyle.
4. Please refer to separate report of CT chest performed same
day
for description of thoracic findings.
___BD & PELVIS WITH CO
1. Progression of disease, with numerous hepatic lesions and
scattered splenic lesions concerning for metastases, as well as
ascites and peritoneal thickening and enhancement suggestive of
peritoneal carcinomatosis.
2. Diffuse anasarca.
3. Diffuse osseous metastases, similar to prior, including lytic
lesions involving the right acetabulum and right iliac bone
which
predispose to pathologic fracture.
4. Moderate right hydronephrosis, similar to prior. Mild-to
moderate left hydronephrosis is new from prior.
5. Stable borderline enlarged left external iliac chain lymph
node.
6. Redemonstration of left external iliac and proximal left
femoral vein thrombus.
7. Please refer to separate report of CT chest performed same
day
for description of thoracic findings.
___ Imaging MR HEAD W & W/O CONTRAS
1. 2.2 cm likely mildly enhancing lesion in the left mastoid
with
apparent erosion of the left lateral mastoid wall, with
overlying
soft tissue enhancement, left mastoid effusion. Finding is
nonspecific however highly suspicious for metastasis from known
primary neoplasm. Differential consideration include infection
such as confluent otomastoiditis although there is no evidence
of
surrounding soft tissue enhancement or edema.
2. Expansile lesion of the right occipital condyle and osseous
lesion of the left occipital condyle. There appears to be
obliteration of the right hypoglossal canal.
3. Intrinsically T1 isointense small foci of the calvarium are
associated with diffusion-weighted hyperintensity, concerning
for
metastatic disease and/or hemangiomas.
4. No evidence of intracranial metastatic disease at this time.
No acute infarct.
___ Imaging MR ___ W/O CONTR
1. Diffuse cervical bony metastatic disease. Difficult to
exclude
early epidural extension into the anterior epidural space at
C6.
2. Moderate to severe compression deformity of C6 is likely
subacute, mild marrow edema, presumably pathologic in nature.
3. Mild central spinal canal narrowing at the level of the C6
fracture due to retropulsion of the buckled posterior cortex
into
the spinal canal by approximately 3 mm. No spinal cord contact
or cord signal abnormality.
4. Incidentally noted soft tissue fullness, right base of
tongue,
felt to be likely secondary to denervation secondary to
skullbase
lesion. There is also asymmetric fullness of the right lateral
oro- pharyngeal wall, incompletely characterized, and may be
artifactual. Recommend further evaluation with CT soft tissue
neck for further evaluation.
5. Layering biapical pleural effusions are partially visualized.
6. Mild cervical spondylosis.
7. Please see separate report for intracranial findings from
same-day MR ___.
___ Imaging UNILAT LOWER EXT VEINS
1. Interval improvement in clot burden from ___,
with resolution of previously seen nonocclusive thrombus in the
left mid to lower femoral, popliteal and calf veins.
2. Residual clot burden in the left common femoral vein is
mildly
improved and is now nonocclusive.
3. Non-occlusive thrombus in the left upper femoral vein appears
similar.
___ Imaging MR PITUITARY ___ CONT
1. The exam is limited secondary to patient motion.
2. Within the limitation of the exam, the pituitary gland is
within normal limits.
3. If there is concern for metastatic lesions within the brain
parenchyma, cervical spine or skull base, further evaluation
with
dedicated brain MRI with and without contrast and skullbase
protocol as well as dedicated MRI evaluation of the cervical
spine could be performed as clinically indicated.
___ Imaging CHEST (PA & LAT)
No pneumonia or acute cardiopulmonary process.
MICROBIOLOGY:
___ Influenza A/B PCR - Negative
___ Urine Culture - < 10,000 CFU/mL
___ Blood Culture - Negative
___: Blood Cx x2 - Negative
___: Urine Cx - <10K CFU
___ Peritoneal fluid - Gram Stain Negative; Culture - No
growth
___ Peritoneal fluid cytology - PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
2. Gabapentin 100 mg PO BID
3. Gabapentin 300 mg PO QHS
4. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 17.2 mg PO BID
7. Bisacodyl 10 mg PO DAILY
8. ClonazePAM 1 mg PO QHS
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
12. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Severe
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain or bloating
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth q8 hours Disp #*180 Tablet Refills:*0
2. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H Duration: 10
Days
RX *amoxicillin-pot clavulanate 200 mg-28.5 mg/5 mL 10 mL by
mouth q8 hours Disp #*300 Milliliter Refills:*0
3. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QPM cervical leison, pain
RX *lidocaine 5 % 1 patch q 24 hours Disp #*30 Patch Refills:*0
5. Methadone 15 mg PO QAM
8am
RX *methadone 5 mg 3 tabs by mouth qam Disp #*90 Tablet
Refills:*0
6. Methadone 10 mg PO BID
2pm and 8pm
RX *methadone 10 mg 1 tab by mouth twice a day Disp #*60 Tablet
Refills:*0
7. MethylPHENIDATE (Ritalin) 2.5 mg PO BID
8am and 2pm
RX *methylphenidate HCl 5 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
8. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone [Gas Relief] 80 mg 1 tab by mouth four times a
day Disp #*120 Tablet Refills:*0
9. Levothyroxine Sodium 100 mcg PO DAILY
RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice a day Disp #*48 Packet Refills:*0
11. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
12. ClonazePAM 1 mg PO QHS
RX *clonazepam 1 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
13. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
14. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
15. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Severe
RX *hydromorphone 4 mg 1 - 2 tablet(s) by mouth q4 hours Disp
#*240 Tablet Refills:*0
16. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First
Line
RX *ondansetron 8 mg 1 tablet(s) by mouth q8 hours Disp #*90
Tablet Refills:*0
17. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth q6 hours
Disp #*120 Tablet Refills:*0
18. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 bid po constipation Disp #*120
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Metastatic squamous cancer of the cervix
# Cancer associated cachexia
# Peritoneal carcinomatosis
# Secondary malignancy of bone
# Secondary malignancy of liver
# Hypercalcemia
# Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with tachycardia, weakness// Please evaluate for pneumonia
or effusion
TECHNIQUE: Chest PA and lateral views.
COMPARISON: Chest radiograph ___.
FINDINGS:
Lungs are clear without focal consolidation, pleural effusion, or
pneumothorax. Mediastinal and hilar contours are within normal limits. Heart
size is normal. No acute osseous abnormality.
IMPRESSION:
No pneumonia or acute cardiopulmonary process.
Radiology Report
EXAMINATION: MR PITUITARY ___ CONTRAST T___ MR HEAD SUB.
INDICATION: ___ with metastatic cervical cancer with bone mets s/p XRT and on
pembo who presents with fatigue, weakness, and orthostatis found to have
hypercalcemia, dehydration, and hypothyroidism. Labs were elevated prolactin,
low FSH/LH.// Evaluate for pituitary mass/met.
TECHNIQUE: Sagittal and coronal T1 weighted imaging were performed along with
coronal T2 imaging. Sagittal and coronal T1 weighted imaging were repeated
after the uneventful intravenous administration of 4 mL of ___ contrast
agent.
Exam is limited secondary to patient motion. Best possible images were
obtained.
COMPARISON MR thoracic spine ___. MR ___ ___.
FINDINGS:
Images of the pituitary gland are within normal limits. Pituitary signal
intensity is normal both before and after contrast administration. The
pituitary stock is normal in caliber and configuration. No masses are
identified within the pituitary gland. The parasellar, suprasellar cisterns,
and cavernous sinuses are within normal limits.
Limited evaluation of the brain parenchyma appears unremarkable.
No gross abnormalities are noted in the partially visualized tongue base,
incompletely evaluated.
Note is made of heterogeneous marrow signal in the partially visualized
cervical spine.
IMPRESSION:
1. The exam is limited secondary to patient motion.
2. Within the limitation of the exam, the pituitary gland is within normal
limits.
3. If there is concern for metastatic lesions within the brain parenchyma,
cervical spine or skull base, further evaluation with dedicated brain MRI with
and without contrast and skullbase protocol as well as dedicated MRI
evaluation of the cervical spine could be performed as clinically indicated.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old woman with h/o DVT now with increased swelling of
LLE// eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Bilateral lower extremity ultrasound from ___.
FINDINGS:
There is nonocclusive thrombus in the left common femoral vein, which is
improved from ___, where occlusive thrombus was noted.
Nonocclusive thrombus is again noted in the upper left femoral vein.
There is now normal compressibility and color flow of the left mid to lower
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. Interval improvement in clot burden from ___, with resolution
of previously seen nonocclusive thrombus in the left mid to lower femoral,
popliteal and calf veins.
2. Residual clot burden in the left common femoral vein is mildly improved and
is now nonocclusive.
3. Non-occlusive thrombus in the left upper femoral vein appears similar.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with metastatic cervical cancer with worsening malaise and
new fevers, undetermined source// evaluate for source of fever
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 9.3 s, 0.2 cm; CTDIvol = 157.8 mGy (Body) DLP =
31.6 mGy-cm.
3) Spiral Acquisition 11.4 s, 73.9 cm; CTDIvol = 9.7 mGy (Body) DLP = 708.9
mGy-cm.
Total DLP (Body) = 742 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed same day.
ABDOMEN:
HEPATOBILIARY: There are numerous ill-defined hypodensities throughout the
liver, measuring up to 2.4 cm, new from prior. 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. There are scattered subtle
hypoattenuating lesions measuring up to 1 cm (04:47, 53), new from prior.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There are no focal lesions. Moderate right hydronephrosis is similar to
prior. Mild-to-moderate left hydronephrosis is new from prior. 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. There is large
volume ascites, and peritoneal enhancement and thickening.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: Known cervical malignancy is not well evaluated on CT.
No adnexal abnormalities are demonstrated.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. A
left external iliac chain lymph node is unchanged, measuring 1.0 cm (4:109)
there is no inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted. An IVC filter is in place. The left external iliac vein and
proximal femoral vein is not opacified, consistent with known thrombus.
BONES: Extensive osseous metastases are again seen, including a 2.3 cm lytic
lesion in the left iliac bone (4:103), and a 2.5 cm lytic lesion in the
vertebral body of L1. A 1.1 cm lytic lesion in the right iliac bone
demonstrates apparent cortical break at the posterior aspect and cortical
thinning at the anterior aspect, and a 1.6 cm right acetabular lytic lesion
demonstrates at least near complete cortical breakthrough, both of which can
predispose to pathologic fracture. A chronic healed fracture of the right
lateral seventh rib is unchanged.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. There is
diffuse anasarca.
IMPRESSION:
1. Progression of disease, with numerous hepatic lesions and scattered splenic
lesions concerning for metastases, as well as ascites and peritoneal
thickening and enhancement suggestive of peritoneal carcinomatosis.
2. Diffuse anasarca.
3. Diffuse osseous metastases, similar to prior, including lytic lesions
involving the right acetabulum and right iliac bone which predispose to
pathologic fracture.
4. Moderate right hydronephrosis, similar to prior. Mild-to-moderate left
hydronephrosis is new from prior.
5. Stable borderline enlarged left external iliac chain lymph node.
6. Redemonstration of left external iliac and proximal left femoral vein
thrombus.
7. Please refer to separate report of CT chest performed same day for
description of thoracic findings.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with metastatic cervical cancer w/ failure to
thrive, now w/ inability to move her tongue in all directions// rule out brain
mets esp involving the hypoglossyl nerve
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: None available.
FINDINGS:
There is a 2.2 x 1.6 x 2.0 cm likely mildly enhancing lesion within the left
mastoid (16:50 and 52). There is apparent erosion through/dehiscence of the
lateral mastoid wall, with overlying soft tissue enhancement. There is a
partial left mastoid effusion.
There is diffusion-weighted hyperintense signal of the bilateral occipital
condyles more prominent on the right. There is associated enhancing soft
tissue expansion and apparent remodeling of the right occipital condyle
measuring approximately 1.4 x 1.3 cm (series 16, image 34; series 10, image
9), and abnormal signal of the right occipital condyle (series 10, image 13),
concerning for metastatic disease. There is presumed obliteration of the
right hypoglossal canal.
A few foci of intrinsically T1 isointense foci in the left and right frontal
calvarium (see series 11, image 23 and 22) demonstrate faint high signal on
diffusion-weighted images, raising concern for possible metastatic disease
and/or hemangiomas.
There is no evidence of hemorrhage, edema, brain parenchymal mass, mass
effect, midline shift or infarction. The ventricles and sulci are within
expected limits in caliber and configuration. There is no abnormal brain
parenchymal enhancement after contrast administration.
Right frontal developmental venous anomaly is noted.
Aside from dysconjugate gaze, the globes and orbits are unremarkable.
Major intracranial vascular flow voids are preserved. Major dural venous
sinuses are patent.
The visualized paranasal sinuses and right mastoid appears clear.
IMPRESSION:
1. 2.2 cm likely mildly enhancing lesion in the left mastoid with apparent
erosion of the left lateral mastoid wall, with overlying soft tissue
enhancement, left mastoid effusion. Finding is nonspecific however highly
suspicious for metastasis from known primary neoplasm. Differential
consideration include infection such as confluent otomastoiditis although
there is no evidence of surrounding soft tissue enhancement or edema.
2. Expansile lesion of the right occipital condyle and osseous lesion of the
left occipital condyle. There appears to be obliteration of the right
hypoglossal canal.
3. Intrinsically T1 isointense small foci of the calvarium are associated with
diffusion-weighted hyperintensity, concerning for metastatic disease and/or
hemangiomas.
4. No evidence of intracranial metastatic disease at this time. No acute
infarct.
RECOMMENDATION(S):
1. CT neck with contrast for impression 1 and 2.
2. Bone scan for further assessment of additional calvarial lesions,
indeterminate.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 2:49 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old woman with metastatic cervical cancer w/ failure to
thrive, now w/ inability to move her tongue in all directions// rule out
progressive cervical spine mets
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed. After administration
of Gadavist intravenous contrast, sagittal and axial T1 weighted imaging was
performed.
COMPARISON: MR ___ ___.
FINDINGS:
Images are moderately motion degraded, limiting assessment. Within these
confines:
There is multifocal T1 hypointense, faintly enhancing, STIR hyperintense
signal throughout the cervical spine involving multiple vertebral bodies
including C2, C3, C5, C6, as well as T1 and T2, compatible with cervical and
upper thoracic metastases, involving both the vertebral bodies and posterior
elements (For example see series 300, image 7). There is faint enhancement
posterior to the C6 vertebral body as well as C7, which may be normal
enhancing venous plexus, however slight epidural extension is difficult to
exclude given the degree of motion degradation (19:8). Osseous metastatic
disease of the right greater than left occipital condyles is also identified.
There is moderate to severe compression deformity of C6, with mild marrow
edema, possibly a subacute fracture, presumably pathologic in nature. There
is 3 mm bony retropulsion of the buckled posterior cortex into the spinal
canal without spinal cord contact, causing mild spinal canal narrowing
(05:29).
There is 2 mm of C4-5 anterolisthesis, likely degenerative. Alignment
elsewhere is normal. Aside from C6, vertebral body heights are preserved.
The cervical spinal cord is normal in caliber and signal intensity. There are
mild cervical spine degenerative changes. Aside from mild narrowing at C6 (as
above), no additional cervical central canal narrowing. There is mild
uncovertebral osteophytosis causing mild multilevel neural foraminal
narrowing, worst (mild) on the right at C4-5 (06:21).
Layering biapical pleural effusions are noted.
There is asymmetric enlargement of the right tongue base, felt likely sequela
of denervation secondary to skullbase lesion described in the MRI head.
However, the right lateral oropharyngeal wall also appears possibly
asymmetrically thickened, incompletely characterized (05:12 and 06:13).
Please see separate report for intracranial findings from same-day MRI head.
IMPRESSION:
1. Diffuse cervical bony metastatic disease. Difficult to exclude early
epidural extension into the anterior epidural space at C6.
2. Moderate to severe compression deformity of C6 is likely subacute, mild
marrow edema, presumably pathologic in nature.
3. Mild central spinal canal narrowing at the level of the C6 fracture due to
retropulsion of the buckled posterior cortex into the spinal canal by
approximately 3 mm. No spinal cord contact or cord signal abnormality.
4. Incidentally noted soft tissue fullness, right base of tongue, felt to be
likely secondary to denervation secondary to skullbase lesion. There is also
asymmetric fullness of the right lateral oro- pharyngeal wall, incompletely
characterized, and may be artifactual. Recommend further evaluation with CT
soft tissue neck for further evaluation.
5. Layering biapical pleural effusions are partially visualized.
6. Mild cervical spondylosis.
7. Please see separate report for intracranial findings from same-day MR head.
RECOMMENDATION(S): Recommend CT tissue neck for further evaluation of the
base of tongue/right lateral oropharyngeal wall.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ with metastatic cervical cancer with worsening malaise and
new fevers, undetermined source// evaluate for source of fever
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and
parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 9.3 s, 0.2 cm; CTDIvol = 157.8 mGy (Body) DLP =
31.6 mGy-cm.
3) Spiral Acquisition 11.4 s, 73.9 cm; CTDIvol = 9.7 mGy (Body) DLP = 708.9
mGy-cm.
Total DLP (Body) = 742 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Prior Chest CTs ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: Mediastinal lymph nodes are not enlarged.
HILA: Hilar lymph nodes are not enlarged.
HEART: The heart is not enlarged and there is no coronary arterial
calcification. There is a small pericardial effusion.
VESSELS: Aortic caliber is normal. The main, right, and left pulmonary
arteries are normal caliber.
PULMONARY PARENCHYMA: There is no evidence of infection or malignancy. There
is bilateral lower lobe atelectasis. There is no emphysema.
AIRWAYS: The airways are patent to the subsegmental level bilaterally.
PLEURA: There are small to moderate bilateral pleural effusions.
CHEST WALL AND BONES: There is a pathologic compression fracture of C6, as
seen on same day MR. ___ lytic osseous metastases are increased in size
from prior. For example, a lesion in the T2 vertebral body measures 1.3 cm,
previously 0.7 cm (05:58) and a lytic lesion in the sternum measures 2.5 cm in
transverse dimension (5:98), previously 2.0 cm. There is suggestion of the
lesion in the right inferior scapula (5:176) and in numeral rim lesions are
present..
UPPER ABDOMEN: Please see separately submitted Abdomen and Pelvis CT report
for subdiaphragmatic findings.
IMPRESSION:
1. Small to moderate bilateral pleural effusions with compressive atelectasis,
new from prior.
2. Progression of diffuse osseous metastases, including a pathologic
compression fracture of T2, as seen on same day MR.
3. Please refer to separate report of CT abdomen and pelvis performed same day
for description of subdiaphragmatic findings.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old woman with metastatic cervical SCC. Hypoglossal
paralysis, MRI with extesnsive osseous lesions, particularly ? erosive mastoid
lesion. Also with recurrent fever// Better eval lesions noted on CT.
Particularly erosoive mastoid lesion. Eval recurrent fever.
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 26.9 cm; CTDIvol = 7.1 mGy (Body) DLP = 185.2
mGy-cm.
Total DLP (Body) = 185 mGy-cm.
COMPARISON: MR ___ dated earlier same day.
FINDINGS:
As seen on prior MR, there is asymmetric enlargement of the right tongue base
(03:26).
The salivary glands enhance normally and are without mass or adjacent fat
stranding. The thyroid gland appears enlarged but homogeneous.There is no
lymphadenopathy by CT criteria. The neck vessels are patent.
There is a severe compression deformity of C6, which is extensively replaced
by lytic osseous metastasis, consistent with pathologic fracture. There is
mild retropulsion into the spinal canal, with mild spinal canal narrowing.
Additional lytic lesions are noted diffusely throughout the spine. Lytic
metastasis replaces much of the left mastoid (04:36), with cortical
destruction involving the medial and lateral aspects. The right occipital
condyle is partially replaced by soft tissue (06:34). The left styloid
process is discontinuous, suggestive of metastatic involvement.
Please refer to separate report for description of thoracic findings.
IMPRESSION:
1. Osseous metastases involving the cervical spine, with severe pathologic
compression fracture of C6. Mild retropulsion results in mild spinal canal
narrowing.
2. Osseous metastases replacing much of the left mastoid, right occipital
condyle and left styloid process.
3. Asymmetric enlargement of the right tongue base, as seen on prior MR,
suggestive of denervation of the hypo glossal nerve due to aforementioned
metastatic disease in the right occipital condyle.
4. Please refer to separate report of CT chest performed same day for
description of thoracic findings.
Radiology Report
EXAMINATION: Ultrasound guided paracentesis
INDICATION: ___ year old woman with metastatic cervical cancer and new
peritoneal carcinomatosis// eval for diagnostic/therapeutic paracentesis
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the left lower
quadrant was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic and therapeutic paracentesis
Location: left lower quadrant
Fluid: 2.5 L of clear, straw-colored fluid
Samples: Fluid samples were submitted to the laboratory the requested analysis
(cytology, chemistry, hematology, microbiology).
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of
the procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 2.5 L of fluid were removed and sent for requested analysis.
Radiology Report
INDICATION: ___ year old woman with metastatic cervical cancer and peritoneal
carcinomatosis; recurrent malignant ascites// eval for pleurX placement
COMPARISON: Paracentesis ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
Dr. ___ supervised the trainee during any key components of
the procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
1mcg of fentanyl and 50 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: 1 g of Ancef
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 1.2 minutes, 4 mGy
PROCEDURE:
1. Limited abdominal ultrasound
2. Peritoneal PleurX catheter placement
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained. The abdomen was cleaned
and draped in standard sterile fashion. A pre-procedure time-out was performed
as per ___ protocol.
Under ultrasound guidance, an entrance site was selected in the right lower
quadrant. 1% lidocaine was instilled for local anesthesia. Under direct
ultrasound guidance, a 5 ___ catheter was advanced into the ascitic fluid.
A ___ wire was passed through the catheter and crossed to the left side of
the abdominal cavity. A location for the subcutaneous tunnel was chosen and 1%
lidocaine was administered at the skin entry site and along the tunnel tract.
A skin incision was made and the catheter was tunneled to the peritonotomy
site. The 5 ___ catheter site was dilated and a peel-away sheath was
inserted. The wire and inner cannula were removed and the PleurX catheter was
passed through the peel-away sheath. Final position of the catheter was
confirmed with fluoroscopy. The ___ catheter site was closed with ___ Vicryl
subcuticular suture and Steri-Strips. 1100 cc of clear yellow fluid was
aspirated. The tube was then capped and the site was dressed. The patient
tolerated the procedure well without any immediate postprocedure
complications.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated small
volumeascites. A suitable target in the deepest pocket in the right lower
quad quadrant was selected for PleurX catheter placement.
IMPRESSION:
Technically successful peritoneal PleurX catheter placement
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Lethargy, N/V
Diagnosed with Weakness
temperature: 97.9
heartrate: 121.0
resprate: 12.0
o2sat: 100.0
sbp: 137.0
dbp: 97.0
level of pain: 6
level of acuity: 2.0 | PRINCIPLE REASON FOR ADMISSION:
___ with metastatic cervical cancer with bone mets s/p XRT and
on pembo who presented with fatigue, weakness, pain, and
orthostatis found to have hypercalcemia, dehydration, and
hypothyroidism. Course complicated by recurrent fevers,
worsening ascites, and neck, back and abdominal pain. Imaging
found widespread progression of her known metastatic disease.
Family meeting was held on ___ given lack of systemic
treatment options with plan to pursue home hospice discharge.
She underwent palliative paracentesis on ___ and pleurX
placement on ___. Radiation oncology has deferred radiation
treatment at present. We transitioned opioid regimen to
methadone and dilaudid. We also started Ritalin and
dexamethasone. Fevers persisted despite negative infectious
workup. Although felt to be due to tumor fever, we started
empiric augmentin to complete 10 day course on ___.
# Metastatic Squamous Cell Carcinoma of the Cervix:
# Secondary Malignancy of Bone:
# Secondary Malignancy of Liver: Most recently on C2
Pembrolizumab.
Now with progressive metastatic disease throughout appendicular
skeleton (including new acetablur met, occipital condyle mets,
known C6 lesion), liver lesions, and now peritoneal
carcinomatosis. After family meeting we decided to pursue
hospice discharge given lack of effective anticancer options
after failing second line pembrolizumab. We also started Ritalin
2.5 mg bid for cancer fatigue. Of note, extensive discussion
regarding end-of-life care was had, although was generally
ovewhelming for the patient. Although she is accepting of home
based, and ultimately residential based hospice care, MOLST form
was filled out indicating full code. This may need continued
discussion given apparent incongruence in care. However, to
facilitate appropriate emotional acceptance of news, we decided
to be accepting of patient's wishes at present. Furthers
symptoms addressed as below.
# Acute on Chronic Cancer-Related Pain: Increased pain with
progression of her osseous metastatic disease and new peritoneal
carcinomatosis. Hip lesions and C6 lesion are most symptomatic.
Transitioned oxycontin 120mg po q8 hours to methadone ___.
We used po and IV dilaudid for breakthrough. We also continued
home gabapentin tid, although switching to qhs dosing may be
beneficial to reduce pill burden. We generally held NSAIDS,
although very judicious NSAIDS may be beneficial for significant
symptoms if necessary.
# Peritoneal carcinomatosis: New. Underwent 2.5 L paracentesis
___ which was positive for poorly differentiated carcinoma.
PleurX also placedt on ___ with 1.1 L output. Would likely
benefit from drainage of ~2L 3x per week, but may titrate based
on patient's symptomatology.
# Secondary malignancy of bone: Pain was treated as above; she
also received IV bisphosphonate. Radiation oncology evaluated
patient - deferred any current
plans for radiation. Surgical oncology also evaluated acetabular
lesion given concern for impending fracture. She was cleared for
weight bearing as tolerated.
# Bilateral Hydronephrorsis:
# Urinary obstruction: Ultrasound at ___ showed new bilateral
hydronephrosis (right sided hydro previously seen), confirmed on
CT here. Also noted to have markedly elevated PVR suggesting
lower urinary obstruction. Now SP foley catheter placement.
After discussion with patient, she elected to continue foley
catheter despite infectious risks.
# Fevers: Patient with intermittent fevers throughout hospital
stay. Initial blood, urine, and peritoneal fluid cultures were
negative. Suspect tumor fever. However, given risks/benefits,
elected to initiate 10 day empiric course of augmentin, which
will complete on ___. She should continue APAP for fevers as
needed. Juducious use of NSAIDS could be beneficial as well.
Blood cultures and urine cultures from ___ are currently
pending.
# Hypothyroidism
Seen by endocrine, does not have central hypothyroidism rather
most consistent with chronic thyroiditis. Anti-TPO antibodies
positive. MRI of the pituitary gland is normal. SP levothyroxine
200 mcg x 2 days, and uptitrated home levothyroxine to 100 mcg
daily.
# Hypercalcemia of Malignancy: Patient received pamidronate 60mg
IV on ___ during last admission. Now recurrent. Appropriately
low PTH of 8 suggests hypercalcemia of malignancy. Received
another dose of 60 mg IV Pamidronate ___.
# Vitamin D Deficiency: Vitamin D low on admission. Repleted
Vitamin D prior to bisphosphonate admin. Level remains low
despite 5000 units daily. Patient had difficulty tolerating
oral vitamin D repletion, and ultimately was discontinued prior
to discharge.
# Orthostatic Tachycardia: ___ noted patient to have tachycardia
to 150s with movement/standing prior to admission. Tachycardia
improved in ED with IVF. Likely due to volume depletion in the
setting of calciuresis and malnutrition.
# Pulmonary Embolism/Bilateral Lower Extremity DVTs: She is s/p
IVC filter on lovenox. However, we ultimately discontinued this
given discharge to hospice with safety concerns of severe
bleeding with expected progressive malnutrition.
# Severe-Protein Calorie Malnutrition:
# Hypoglossal nerve palsy: Patient with weight loss and very
poor PO intake. Now complicated by CNXII palsy due to occipital
condyle lesion and dysphagia. SLP cleared patient for thin
liquids. We also started dex 4mg daily.
# Anemia in Malignancy: Continues to downtrend; likely
excarbated
by vaginal oozing. Transfused 1 unit pRBC ___ HGB otherwise
stable.
# Opiate-Induced Constipation:
# Abdominal Pain/Bloating: Likely due to opiates as well as
hypercalcemia. Uptitrated miralax and Bisacodyl as needed.
# Hypomagnesemia: Monitored and repleted as needed
TRANSITIONAL ISSUES
- Please evaluate and admit to hospice on discharge
- Augmentin through ___ to complete empiric 10 day course
- Stopped lovenox despite relatively recent DVT/PE given concern
for risk of bleeding on hospice care
- Changed oxycontin to methadone ___ started dexamethasone
and ritalin
- Adjust opioid regimen as needed
- Consider stopping unnecessary pill burden if needed - may stop
am and pm gabapentin, for instance
- Consider increasing Ritalin to 5mg bid if she tolerates well
- Con't to readdress end-of-life care, as she is full code per
MOLST, which may be incongruent with current plan of
transitioning to hospice home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Iodine-Iodine Containing / Meropenem / Ceftriaxone
/ Ciprofloxacin / Flagyl / Levaquin / Aztreonam / moxifloxacin /
Bactrim
Attending: ___
___ Complaint:
diarrhea/nausea/vomiting/palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo female w/ a hx of AML s/p alloSCT in
___, in remission since, course c/b GVHD of skin, lung, and
gut; CAD s/p 1v-CABG in ___, asthma (FEV1 40-45%), with recent
exacerbation of lung GVHD, currently on Prednisone 20 mg PO QD
with improvement in Sx, Afib on rivaroxiban and other issues
presents to the ED with palpitations.
Last night she noted acute onset palpitations (HR in the 120s)
around 1 am that woke her from sleep. She did not have chest
pain or shortness of breath. She has since vomited 2x, once at
home and once in the ED. Her palpitations intermittently
resolved but then worsened again. She denies recent
fever/chills, cough/SOB, dysuria/hematuria, or preceding
diarrhea. She does note having mutliple episodes of diarrhea.
She reports adequate PO intake (eating more lately ___
steroids).
In the ED, initial vital signs were: 96.3 85 124/56 18 96% RA
she received Zofran with good relief for he nausea.
Initially her HR was in the ___ and appeared to be sinus w/
frequent PACs; however, around 10:30a she was noted to be in
Afib with RVR with rates in the 120s-130s, occasionally up to
the 150s. SBP in the 100s (pt reports 110s normal for her), no
chest pain or SOB. ECG 8:38a: Sinus arrhythmia, old Q waves
inferolaterally, no new ST segment or T wave changes (TWIs in
V1-V3 are old). ECG 10:28a: Afib w/ HR 150s, with ST depressions
in V2-V4. CXR with no acute process. Cardiology was consulted
and recommended rate control, increased metoprolol succinate
from 25 mg PO QD to 50 mg PO QD, troponin was negative x2.
While in the ED HR shot up to the 150s while having a bowel
movement, then subsequently became bradycardic down to the ___
in sinus and became hypotensive to the ___ systolic. While
patient was being assessed, her HR improved to the ___ and
her BP recovered to the 120s. It was suspected this was a
vasovagal episode (given bradycardia and hypotension) in the
setting of a bowel movement. Non-con CT abd/pelvis was performed
to rule out colitis given chronic steroid use and new diarrhea.
Exam was notable for NAD, irreg irreg, no abd tenderness,
euvolemic.
Labs were notable for WBC 13, Cr of 1.4, TSH 4.9 troponins
negative x2, UA - small bacteria and positivenitrites but no
pyuria, given no Sx decision was made not to treat will not
treat.
Patient was given
___ 10:37 IV Metoprolol Tartrate 5 mg
___ 10:37 IVF 1000 mL NS 1000 mL
___ 11:20 PO Metoprolol Succinate XL 50 mg
___ 12:07 IV Magnesium Sulfate 2 gm
___ 18:24 IV Ondansetron 4 mg
On Transfer Vitals were: 72 117/57 18 100% RA
Since coming to the floor patient reports feeling fatigued,
nauseous and having loose stools. Denies SOB, chest pain,
palpitations and abdominal pain
Review of Systems: As per HPI
Past Medical History:
.
PAST ONCOLOGIC HISTORY:
- AML diagnosed ___ on routine bloodwork showing pancytopenia;
bone marrow biopsy showed myelodysplasia without cytogenetic
abnormalities
- repeat bone marrow biopsy showed acute erythroleukemia
- admitted ___ for induction 7+3 with cytarabine and
idarubicin, day 14 marrow showed no blasts
- ___ allogeneic transplantation from an HLA matched sibling
donor with pentostatin/TBI in ___ c/b mild GVHD
- post-transplant course complicated by STEMI ___ with DES to
RCA ___ and CABG (LIMA-LAD) ___
- complicated by GVHD of the skin and lungs, on Prednisone 7.5mg
currently
.
OTHER MEDICAL HISTORY:
- CAD s/p STEMI ___ with DES to RCA ___ and CABG (LIMA-LAD)
___
- Afib
- Diverticulitis, hx of perforated diverticulum ___ ___
complicated by multiple abdominal abscesses; sigmoidostomy with
___ pouch and colostomy; reversed ___
- CHF with EF 40-45%
Hypertension
- Hypercholesterolemia
- GERD
- Type two diabetes mellitus
- Diverticulosis
- Occasional bronchospasm
- History of SVC clot ___ PORT (s/p course of lovenox)
- History of C.Diff ___ & ___
- History of VRE
- History of Shingles
- History of Asthma
- basal cell carcinoma-s/p electrodessication and curettage on
___
- tonsillectomy at the age of ___;
- D&C for question of some polyps back in ___
- Hospitalization for pneumonia ___ - ___
- ADRENAL INSUFFICIENCY
.
Social History:
___
Family History:
The patient's mother with a history of stroke. Both of her
maternal and paternal grandmothers also had a history of CVA.
Father with history of colon ___. No other known history of
cancer in the family. No known blood disorders. Has a sister
with ___. She has 2 sisters, the other sister with
hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 118/52 76 18 98%RA
Wt 73.8 height 5'6
General: ill appearing, NAD
HEENT: dry mucus membranes, EOMI
CV: RRR no m/r/g
Lungs: CTA bilaterally no wheezes, rhonchi or rales
Abdomen: +BS, soft, NTTP, ND
Ext: WWP, no edema
Neuro: AOX3, strength and sensation grossly intact
Skin: warm no visible rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8 80 108/64 20 96%RA
I/O ___
Tele: Sinus rhythm, no alarms
General: patient appears more comfortable lying in bed, NAD
HEENT: MMM, EOMI
CV: RRR no m/r/g
Lungs: CTA bilaterally no wheezes
Abdomen: +BS, soft, no TTP, ND
Ext: WWP, no edema
Neuro: AOX3, strength and sensation grossly intact
Skin: warm, no visible rashes, erythema over chest, decresed
skin turgor
Pertinent Results:
ADMISSION LABS:
___ 09:25AM BLOOD WBC-13.8* RBC-4.95 Hgb-15.0 Hct-44.4
MCV-90 MCH-30.3 MCHC-33.8 RDW-17.3* Plt ___
___ 09:25AM BLOOD Neuts-66.3 ___ Monos-8.5 Eos-2.3
Baso-0.4
___ 09:25AM BLOOD Glucose-151* UreaN-25* Creat-1.4* Na-140
K-4.3 Cl-102 HCO3-25 AnGap-17
___ 09:25AM BLOOD ALT-22 AST-16 AlkPhos-52 TotBili-0.5
___ 09:25AM BLOOD Albumin-4.2 Calcium-9.9 Phos-2.9 Mg-1.8
___ 09:25AM BLOOD TSH-4.9*
___ 10:22PM BLOOD ___ pO2-220* pCO2-32* pH-7.37
calTCO2-19* Base XS--5 Comment-GREEN TOP
___ 10:22PM BLOOD Lactate-1.6
___ 01:00PM URINE Color-Straw Appear-Clear Sp ___
___ 01:00PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:00PM URINE RBC-0 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1
___ 01:00PM URINE Mucous-RARE
DISCHARGE LABS:
___ 05:49AM BLOOD WBC-4.8 RBC-3.68* Hgb-11.1* Hct-32.2*
MCV-87 MCH-30.1 MCHC-34.4 RDW-17.3* Plt ___
___ 05:49AM BLOOD Neuts-71* Bands-0 ___ Monos-7 Eos-1
Baso-0 ___ Myelos-0
___ 05:49AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Burr-1+ Tear
___
___ 05:49AM BLOOD Plt Smr-NORMAL Plt ___
___ 05:49AM BLOOD ___ PTT-31.8 ___
___ 05:49AM BLOOD Glucose-148* UreaN-12 Creat-1.0 Na-139
K-4.3 Cl-106 HCO3-25 AnGap-12
___ 05:49AM BLOOD ALT-35 AST-33 LD(LDH)-252* AlkPhos-36
TotBili-0.4
___ 05:49AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.7 Mg-1.9
___ 06:02AM BLOOD IgG-320*
IMAGING
CHEST (PA & LAT)Study Date of ___
No pneumonia or CHF. Known aortic pseudoaneurysm.
CT ABD & PELVIS W/O CONTRASTStudy Date of ___
1. No evidence of acute pathology within the abdomen or pelvis.
2. Extensive colonic diverticulosis without evidence of acute
diverticulitis.
3. 3.3 cm infrarenal abdominal aortic aneurysm, increased in
size since ___.
4. Cholelithiasis without evidence of acute cholecystitis.
MICRO
___ 1:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 5:36 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 20 mg PO DAILY
2. Lisinopril 2.5 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Atovaquone Suspension 750 mg PO DAILY
5. Lorazepam 0.5 mg PO Q4H:PRN anxiety, nausea, insomina
6. Metoprolol Succinate XL 25 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Docusate Sodium 100 mg PO DAILY
9. Rivaroxaban 20 mg PO DAILY
10. Famotidine 20 mg PO BID
11. Atorvastatin 80 mg PO QPM
12. Acyclovir 400 mg PO Q12H
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. Azithromycin 250 mg PO Q24H
15. Omeprazole 20 mg PO DAILY
16. Aspirin 81 mg PO DAILY
17. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
wheezing
18. GlipiZIDE 5 mg PO DAILY
19. Levothyroxine Sodium 25 mcg PO DAILY
20. Cyanocobalamin 500 mcg PO DAILY
21. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Atovaquone Suspension 750 mg PO DAILY
5. Azithromycin 250 mg PO 3X/WEEK (___)
6. Cyanocobalamin 500 mcg PO DAILY
7. Docusate Sodium 100 mg PO DAILY
8. Famotidine 20 mg PO BID
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Lorazepam 0.5 mg PO Q4H:PRN anxiety, nausea, insomina
12. Montelukast 10 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. PredniSONE 20 mg PO DAILY
15. Rivaroxaban 20 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. Vitamin D ___ UNIT PO DAILY
18. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
wheezing
19. GlipiZIDE 5 mg PO DAILY
20. Lisinopril 2.5 mg PO DAILY
21. MetFORMIN (Glucophage) 500 mg PO BID
22. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Rotovirus
UTI; Afib w/RVR; AML s/p allo BMT in ___ with skin and lung
GVHD
SECONDARY: T2DM, CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: Weakness, nausea, vomiting, palpitations. Assess for acute
process.
COMPARISON: Chest radiograph ___.
FINDINGS:
Frontal and lateral chest radiograph demonstrates well-expanded and clear
lungs, unchanged in appearance ___. Stable bulge at aortic arch
corresponds to patient's known pseudoaneurysm as seen on CT chest dated ___.
No pleural effusion or pneumothorax. Heart size, mediastinal contour and hila
are unremarkable.
IMPRESSION:
No pneumonia or CHF. Known aortic pseudoaneurysm.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ with paroxysmal Afib and new nausea/vomiting and diarrhea,
rule out colitis.
TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis without the
administration of IV contrast . Coronal and sagittal reformatted images were
also generated for review.
DOSE: 598 mGy-cm
COMPARISON: CT torso from ___
FINDINGS:
Evaluation of intra-abdominal soft tissues in organs is somewhat limited
without the administration of IV contrast.
LOWER CHEST: There is mild atelectasis at the lung bases bilaterally which
are otherwise clear.
LIVER: The liver demonstrates homogeneous attenuation. No focal liver lesion
is seen given the limitations of this noncontrast enhanced study. The
gallbladder contains small gallstones without pericholecystic fluid or wall
edema. There is no intra or extrahepatic biliary ductal dilatation.
PANCREAS: The pancreas does not demonstrate focal lesions or peripancreatic
stranding or fluid collection.
SPLEEN The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys do not show solid or cystic lesions and demonstrate
symmetric nephrograms and excretion of contrast. No pelvicaliceal dilatation
or perinephric abnormalities are present.
GI TRACT: The stomach, duodenum, and small bowel are within normal limits,
without evidence of wall thickening or obstruction. The colon is non-dilated
without obstructive lesions. There is extensive colonic diverticulosis
without evidence of acute diverticulitis. Anastomotic site suggesting prior
partial colectomy seen in the sigmoid. The appendix is not visualized but
there are no secondary signs of appendicitis.
VASCULAR: There is an infrarenal abdominal aortic aneurysm measuring 3.3 x
2.8 cm, increased in size since ___, when it measured 2.8 x 2.4 cm.
Atherosclerotic calcifications are seen at the origins of the celiac axis,
SMA, and bilateral renal arteries extending into the major branches of the
abdominal aorta.
RETROPERITONEUM AND ABDOMEN: There is no retroperitoneal or mesenteric lymph
node enlargement. No ascites, free air, or abdominal wall hernias are noted.
PELVIC CT: The urinary bladder and distal ureters are unremarkable. No
pelvic wall or inguinal lymph node enlargement is seen. There is no pelvic
free fluid. Uterus and adnexae are unremarkable.
OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy
present.
IMPRESSION:
1. No evidence of acute pathology within the abdomen or pelvis.
2. Extensive colonic diverticulosis without evidence of acute diverticulitis.
3. 3.3 cm infrarenal abdominal aortic aneurysm, increased in size since
___.
4. Cholelithiasis without evidence of acute cholecystitis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Palpitations
Diagnosed with ATRIAL FIBRILLATION, NAUSEA WITH VOMITING
temperature: 96.3
heartrate: 85.0
resprate: 18.0
o2sat: 96.0
sbp: 124.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ yo female w/ a hx of AML s/p alloSCT in
___, in remission since, course c/b GVHD of skin, lung, and
gut; CAD s/p 1v-CABG in ___, asthma (FEV1 40-45%), with recent
exacerbation of lung GVHD, currently on Prednisone 20 mg PO QD
with improvement in Sx, Afib on rivaroxiban and other issues
presented to the ED with palpitations, nausea, diarrhea and UTI.
Patient started on IV fluids, unasyn (given multiple allergies
to other antibiotics) and increased her metoprolol. She sinus
converted without intervention and her electrolytes improved
significantly with aggressive IVF resuscitation and electrolyte
repletion. The patient was continued on unasyn for 5 days with
complete resolution of chills and fevers. The patient was found
to have a IgG level less than 400 and given an infusion of IgG.
She had a mild reaction to the IgG after completion, which
resolved with hydrocortisone, benadryl and lasix. The patient's
diarrhea resolved prior to discharge and all bacterial studies
were negative. The patient was discharged home on her home
medications with instructions to continue oral rehydration after
discharge. The patient will follow up with Dr. ___
after discharge and is scheduled for a visit on ___.
ACUTE ISSUES
# Gastroenteritis- Patient presented with symptoms of nausea,
vomiting, and diarrhea. She had denied any fevers or chills, or
SOB prior to coming to the hospital. Her biggest concern was
the palpitations. She was evaluated by Oncology and cardiology
in the ED for her a.fib with RVR (see below) decision was made
to admit her to medicine. In the ED CT scan was negative for
colitis. On arrival to the floor patient continued to have loose
stools. Stool studies were sent and showed no signs of bacterial
infection. Rotavirus was pending at discharge. C.diff was
negative. Given her history of GVHD there was some concern of it
recurring however CT scan was reassuring as there was no sign of
colitis. It was suspected that the patient was suffering from
viral gastroenteritis, however she spiked the fever on hospital
day 1 to 102, and was subsequently started on IV unasyn. Given
her medical history and illness the decision was made to
transfer her to the bone marrow transplant service. The
patient's diarrhea improved with supportive care after multiple
days in the hospital. After bacterial studies returned negative
and patient finished 5 day course, Unasyn was stopped. Rotavirus
was pending at discharge.
#Urinary Tract Infection- Patient had a urinary analysis in the
ED that was concerning for nitrites and a few bacteria, she did
not have particular symptoms that were concerning. However given
her immunosuppression urine culture was sent and was positive
for pan-sensitive E.coli. She was empirically started on IV
unasyn (after discussion with pharmacy and infectious disease)
given her multiple drug allergies. She completed 5 day course of
unasyn and given no evidence of complicated UTI was not
transitioned to oral antibiotics.
# Atrial fibrillation- Patient has a history of atrial
fibrillation. In the emergency department she was found to be in
atrial fibrillation with rapid ventricular response, likely the
cause of her palpitations. She was evaluated by cardiology in
the ED and her home metoprolol increased from 25mg daily to 50mg
daily. She was hemodynamically stable apart from the vasovagal
hypotensive episode likely due to bowel movement. Patient
stabilized and was also continued on rivaraoxiban 20mg daily.
Patient sinus converted spontaneously in the hospital. At time
of discharge the patient was returned onto her home dose of
metoprolol given RVR was likely in the setting of infection. The
patient had no recurrent runs of RVR throughout hospitalization.
# Hx of AML s/p BMT complicated by GVHD of lung and skin:
Patient was continued on prednisone 20mg daily, acyclovir,
azithromycin and atovaquone for prophylasxis. She was continued
on spireva, advair and albuterol for her Hx of lung GVHD.
#Acute on chronic CKD (baseline 1.2)- Patient presented with a
creatinine elevated to 1.4. It was suspected to be due to
pre-renal etiology given her diarrhea and limited PO intake. The
patient was given IVF fluid boluses and encouraged PO intake.
The patients creatinine down trended to 0.9. Her lisinopril was
held in the setting of acute kidney injury and restarted on
discharge.
CHRONIC ISSUES
# DM2 - controlled on oral medications as outpatient, Held home
meds and started on SSI.
#CAD with hx of STEMI: patient was stable and continued on
aspirin, metoprolol, and atorvastatin. Lisinopril was held in
the setting of ___.
TRANSITIONAL ISSUES
========================
-patient will continue all home medications
-patient finished 5 day course of Unasyn for treatment of
uncomplicated UTI
-ROTOVIRUS POSITIVE PATIENT CONTACTED
-patient will follow up with Dr. ___ on ___
-patient will follow up with her pulmonology clinic after
discharge
-patient was instructed to continue oral rehydration and call
the clinic for fevers, chills, recurrent diarrhea, shortness of
breath, severe cough |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of metastatic
myxofibrosarcoma (to the lung) with a recent admission from
___ for a second cycle of inpatient chemotherapy (AIM) who
presents with febrile neutropenia.
To summarize his recent history, in ___, he
completed pre-operative chemoradiation with six
cycles of doxorubicin weekly (cumulative dose 95mg/m2; 211mg),
and total radiation dose of 50 Gy. In ___, he went resection.
Due to positive margins, he required further reoperation and
reconstruction, which was complicated by poor wound healing
(from radiation) in ___. Further irradiation was held.
In ___, imaging showed lung lesions, which were consistent
with high-grade malignancy, most consistent with metastatic
sarcoma. He started AIM chemotherapy and tolerated his second
cycle well. He was discharged home on ___.
On the day prior to presentation, he began to develop fevers,
mild headache, and fatigue. He presented to a outside hospital,
where CXR was concerning for a R middle lobe consolidation. ANC
was 500. He was given vanc/cefepime/levo and was transferred to
___ for further management.
In the ED, initial vitals: 98.3 110 112/70 20 98% RA. Labs
significant for: WBC 0.2 with 3% neutrophils (ANC 6), plt 47,
H/H 7.6/23.6, ALT 48, other electrolytes and LFT's WNL. He was
given vanc/cefepime and admitted to OMED. Vitals upon transfer:
97.9 93 123/72 18 100% RA.
Past Medical History:
===============================
PAST ONCOLOGIC HISTORY:
===============================
- ___: Noted mild increase in the size and discomfort in his
right thigh. He noticed while sitting that there was an
apparent mass, which impeded his ability to move the leg and
caused pain while he was sitting. He eventually sought care
with his primary care physician who ordered imaging studies.
These demonstrated a large heterogeneous enhancing mass in the
right thigh.
- ___, MRI right lower extremity showed a 32 cm
mass involving the medial aspect of the right upper thigh. The
mass enhances on contrast administration and is heterogeneous in
nature.
- ___, biopsy under image guidance. Pathology from
this procedure showed myxofibrosarcoma, intermediate grade;
cytokeratin, MNF116, S100, desmin and SMA were all negative.
- ___: Completed pre-operative chemoradiation
with doxorubicin weekly continuous infusion (cumulative dose
95mg/m2; 211mg), and total radiation dose of 50 Gy.
-___. Resection by Dr. ___, one area of
medial margin was focally positive.
- ___. Reoperation with reconstruction of right thigh
vascularized tissue, nerve coaptation, free muscle left thigh to
the right thigh extensor reconstruction. Fiducials also placed
at the site of positive margin at the time of surgery.
- ___: Post-operative planning for stereotactic
radiation to resection site was planned, however due to ongoing
poor wound healing in the previously irradiated flaps and prior
negative margins, decision made to hold off on further radiation
therapy
- ___: CT Chest reveals multiple pulmonary nodules up to
1.5cm mostly in the right lung, highly suspicious for metastatic
disease
- ___ Lung wedge pathology: metastatic high-grade malignancy
most consistent with metastatic sarcoma
.
===============================
PAST MEDICAL/SURGICAL HISTORY:
===============================
Intermediate grade myxofibrosarcoma of the right thigh s/p
excision ___
HTN
DM2
hyperlipidemia
arthritis
gout
s/p tonsillectomy (___)
Social History:
___
Family History:
Father: colon cancer
Other cancers in the family: Sister with breast cancer, brother
with skin cancer
Physical Exam:
=========================================
PHYSICAL EXAM ON ADMISSION
=========================================
VS: T 99.5, BP 122/74, HR 100, R 20, SpO2 99%/RA, weight 214.9
lbs, height 69"
GENERAL: NAD, comfortable in bed
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: borderline tachycardic, regular, normal S1 & S2,
without murmurs, S3 or S4
LUNG: remarkable only for faint R lung base crackles
ABD: +BS, soft, NT/ND, no rebound or guarding; inguinal incision
site mostly healed, without granulation tissue/open wound, but
honey-golden crusting easily removed
EXT: No lower extremity pitting edema; RLE in immobilizer with
large, well-healed scar over anterior R thigh, 2+ DP pulses
bilaterally
NEURO: face symmetric, palate elevates evenly, tongue protrudes
midline, gait not assessed
SKIN: Warm and dry, honey-crusting in R inguinal fold incision
(as described above); Port-A-Cath accessed over R chest -
appears uninfected
=========================================
PHYSICAL EXAM ON DISCHARGE
=========================================
VS: 97.8 (98.5) 102/52 88 18 97RA
GENERAL: NAD, comfortable in bed
HEENT: EOMI, PERRL, neck supple, no cervical LAD
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: CTAB
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema; RLE in immobilizer with
large, well-healed scar over anterior R thigh, 2+ DP pulses
bilaterally
NEURO: CN ___ intact, strength ___ and sensation intact
bilaterally upper and lower.
SKIN: Warm and dry, Port-A-Cath accessed over R chest - appears
uninfected
Pertinent Results:
ADMISSION LABS
==============
___ 03:45AM BLOOD WBC-0.2*# RBC-2.86* Hgb-7.6* Hct-23.6*
MCV-83 MCH-26.6 MCHC-32.2 RDW-13.5 RDWSD-40.7 Plt Ct-47*#
___ 03:45AM BLOOD Neuts-3* Bands-0 Lymphs-91* Monos-3*
Eos-3 Baso-0 ___ Myelos-0 AbsNeut-0.01*
AbsLymp-0.18* AbsMono-0.01* AbsEos-0.01* AbsBaso-0.00*
___ 03:45AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 03:45AM BLOOD ___ PTT-29.3 ___
___ 03:45AM BLOOD Glucose-153* UreaN-24* Creat-1.2 Na-134
K-3.6 Cl-101 HCO3-21* AnGap-16
___ 03:45AM BLOOD ALT-48* AST-26 LD(LDH)-112 AlkPhos-73
TotBili-0.6
___ 03:45AM BLOOD Albumin-3.9
___ 06:06AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0
___ 07:45AM URINE Color-Straw Appear-Clear Sp ___
___ 07:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:45AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
PERTINENT LABS
==============
___ 06:06AM BLOOD WBC-0.2* RBC-2.82* Hgb-7.6* Hct-23.2*
MCV-82 MCH-27.0 MCHC-32.8 RDW-13.3 RDWSD-40.2 Plt Ct-27*
___ 06:06AM BLOOD Neuts-7* Bands-0 Lymphs-74* Monos-15*
Eos-4 Baso-0 ___ Myelos-0 AbsNeut-0.01*
AbsLymp-0.15* AbsMono-0.03* AbsEos-0.01* AbsBaso-0.00*
___ 05:25AM BLOOD ALT-91* AST-40 LD(LDH)-104 AlkPhos-144*
TotBili-0.4
DISCHARGE LABS
==============
___ 05:08AM BLOOD WBC-3.1*# RBC-2.96* Hgb-8.1* Hct-24.5*
MCV-83 MCH-27.4 MCHC-33.1 RDW-13.2 RDWSD-40.0 Plt Ct-93*#
___ 05:08AM BLOOD Neuts-78* Bands-4 Lymphs-13* Monos-2*
Eos-0 Baso-0 ___ Metas-1* Myelos-1* Promyel-1* AbsNeut-2.54
AbsLymp-0.40* AbsMono-0.06* AbsEos-0.00* AbsBaso-0.00*
___ 05:08AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear
Dr-OCCASIONAL
___ 05:08AM BLOOD Glucose-103* UreaN-15 Creat-1.0 Na-140
K-3.4 Cl-102 HCO3-26 AnGap-15
___ 06:15AM BLOOD ALT-99* AST-39 AlkPhos-202* TotBili-0.5
___ 05:08AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.8
MICROBIOLOGY
============
___ 7:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:45 am BLOOD CULTURE (x2)
Blood Culture, Routine (Pending):
IMAGING
=======
___ CXR
IMPRESSION:
Moderate right pleural effusion and probable right middle lobe
collapse unchanged since ___. Left lung is clear. Heart
size normal. Mediastinum midline. Right supraclavicular dual
channel central venous infusion port catheter ends close to the
superior cavoatrial junction. No pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 600 mg PO QHS
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
10. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
11. Senna 8.6 mg PO BID:PRN constipation
12. Simvastatin 40 mg PO QPM
13. Loratadine 10 mg PO DAILY
14. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
15. irbesartan 300 mg oral DAILY
16. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN HEADACHE, PAIN, FEVER
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 600 mg PO QHS
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. irbesartan 300 mg oral DAILY
8. Loratadine 10 mg PO DAILY
9. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
13. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
14. Prochlorperazine 10 mg PO Q6H:PRN nausea
15. Senna 8.6 mg PO BID:PRN constipation
16. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses: metastatic myxofibrosarcoma, neutropenic
fever
Secondary diagnoses: diabetes mellitus, hypertension,
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with meta. mixofibrosarcoma, C1D11 of AIM chemo
regimen, p/w febrile neutropenia to OSH, with OSH CXR report of RML
consolidation? Pt. has h/o RLL wedge resection of met // eval for PNA?
eval for PNA?
COMPARISON: Prior chest radiographs ___.
IMPRESSION:
Moderate right pleural effusion and probable right middle lobe collapse
unchanged since ___. Left lung is clear. Heart size normal.
Mediastinum midline. Right supraclavicular dual channel central venous
infusion port catheter ends close to the superior cavoatrial junction. No
pneumothorax.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Fever, Neutropenia
Diagnosed with Pneumonia, unspecified organism
temperature: 98.3
heartrate: 110.0
resprate: 20.0
o2sat: 98.0
sbp: 112.0
dbp: 70.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a history of metastatic
myxofibrosarcoma (to the lung) with a recent admission from
___ for a second cycle of inpatient chemotherapy (AIM) who
presents with febrile neutropenia.
ACTIVE ISSUES
=============
# FEBRILE NEUTROPENIA: ANC 10 on admission, in the context of
receiving chemotherapy with AIM (C1D1 = ___. He also
received pegfilgrastim on ___. ROS remarkable only for
rhinorrhea and pharyngitis earlier this week (now resolved).
Lungs clear on exam, UA unremarkable/urine culture without
growth. CXR non-infectious. Blood and urine cultures were
collected at the OSH (___, ___) from which he
was transferred, with no growth after 5 days, and were redrawn
here, with no growth. He received vancomycin, cefepime and
levofloxacin at OSH (day 1, ___. He remained afebrile since
admission. Cefepime/vancomycin were discontinued ___,
following recovery of ANC to >1000. ANC recovered to 2.54 by
discharge on ___.
# METASTATIC MYXOFIBROSARCOMA. Day of admission was C1D11 of AIM
(discharged on ___. He has already completed 6 cycles of
doxorubicin early in ___, as well as multiple surgical
interventions for resection. Symptoms were managed with
oxycodone ___, gabapentin, lorazepam, prochlorperazine.
# DIABETES MELLITUS: Managed with home metformin and HISS. No
glipizide in the context of hypoglycemic episodes during his
previous admission.
INACTIVE/CHRONIC ISSUES
=======================
# HYPERTENSION. Held atenolol in the setting of adequate BP
control on home irbesartan and HCTZ.
# HYPERLIPIDEMIA. Continued home simvastatin.
TRANSITIONAL ISSUES
===================
# CHEMOTHERAPY. Will need follow up with Drs. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
acute onset word finding difficulty, garbled speech and right
hand parasthesiaes lasting ___ minutes.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old right-handed man with history
of hypertension who presented with acute onset word finding
difficulty, garbled speech and right hand parasthesiaes lasting
___ minutes.
Mr. ___ was in his usual state of health today until
approximately 2:45pm when he developed difficulty speaking to
his wife while lying in bed watching TV. His wife notes that he
tried to ask her about dinner, saying "are you making sauce?"
but he meant to say, "are you making rice." He also meant to ask
about dinner and said, "are you making the bed?" He had long
pauses in his speech when he would try to get words out, and
say, "umm and uhhh" when looking for the words he wanted to say.
His wife said that some of the words were made up and
unintelligible so she had trouble figuring out what he was
trying to say. He also called one of his daughters by the wrong
name.
During this time, he also noticed right hand numbness and pins
and needles, like a sensation of his hand falling asleep. This
did not extend past his hand. He grabbed a stress ball and
squeezed it with both hands to compare the sensation in both
hands and he was able to squeeze it with the right hand. He was
able to lift his right arm antigravity and bring the ball over
his head. His wife did not notice any facial droop. The right
side of his body did not feel weak. There were no other
parasthesiaes.
The whole episode lasted approximately 10 - 15 minutes, though
they are not sure about the exact timeline. His wife was
concerned about a stroke and told him they were going to the ED.
The patient walked down the stairs and took a shower before
coming. He also shaved with his right hand. By the time he was
out of the shower, he was back to normal.
He was able to recall the whole episode, though when asked about
feeling confused and realizing that he was saying the wrong
thing, he said he didn't notice the words were coming out
different.
He never had a headache, and nothing like this has happened to
him before. He does not take aspirin or any other anti-platelet.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
comprehending speech. Denies focal weakness. 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:
HTN
Social History:
___
Family History:
- Mother: HTN, patient states she "probably" had MI at ___
- Father: HTN, stroke at ___, patient states he "maybe" had
stroke at ___
Physical Exam:
Admission Exam:
Vitals:
T= 99.1 F, BP= 172/91, HR= 89, RR= 18, SaO2= 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Pulmonary: nonlabored breathing
Cardiac: RRR
Abdomen: soft, nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Fund of knowledge intact.
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 per stroke card. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Able to follow multi-step
commands. Attentive to exam. Pt. was able to register 3
objects and recall ___ at 5 minutes ___ with cues). 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. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions.
No extinction to double simultaneous light touch.
VII: No facial droop, no facial asymmetry, facial musculature
symmetric, eye closure not overcome 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.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, 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 withdrawal bilaterally.
- Crossed Adductors are absent.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally. No dysdiadochokinesia. No clumsiness on right
finger tap.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Able to walk
to toes and heels.
Discharge Exam:
Neurologic:
-Mental Status: Alert, oriented x 3. Fund of knowledge intact.
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 per stroke card. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Able to follow multi-step
commands. Attentive to exam. Pt. was able to register 3
objects and recall ___ at 5 minutes. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, both directly and consentually; brisk bilaterally.
VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions.
No extinction to double simultaneous light touch.
VII: No facial droop, no facial asymmetry, facial musculature
symmetric, eye closure not overcome 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.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, 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 withdrawal bilaterally.
- Crossed Adductors are absent.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally. No dysdiadochokinesia. No clumsiness on right
finger tap.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Able to walk
to toes and heels.
Pertinent Results:
___ 05:20PM WBC-7.3 RBC-4.87 HGB-14.9 HCT-45.0 MCV-92
MCH-30.6 MCHC-33.1 RDW-12.2 RDWSD-42.0
___ 05:20PM NEUTS-50.0 ___ MONOS-8.9 EOS-7.8*
BASOS-0.7 IM ___ AbsNeut-3.65 AbsLymp-2.35 AbsMono-0.65
AbsEos-0.57* AbsBaso-0.05
___ 05:20PM GLUCOSE-94 UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-31 ANION GAP-11
Imaging:
CTA head ___
IMPRESSION:
1. No acute intracranial abnormality.
2. Patent intracranial vasculature without significant stenosis,
occlusion, oraneurysm.
3. Patent cervical vasculature without significant stenosis,
occlusion, ordissection.
4. Periapical lucency around 2 left maxillary molars, suggestive
of
periodontal disease.
5. Multinodular enlargement of the right thyroid lobe with
nodules measuringup to 21 x 14 mm in the right lobe. The
___ College of Radiology guidelines suggest thyroid
ultrasound for further evaluation.
TTE ___
The left atrium and right atrium are normal in cavity size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. [A single
microbubble is seen in the left atrium 6 beats after RA
opacification and most c/w transpulmonic flow.] The estimated
right atrial pressure is ___ mmHg. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 69 %). 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) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
No valvular pathology or pathologic flow identified. No definite
structural cardiac source of embolism identified.
MRI Head non con ___
IMPRESSION:
1. No acute intracranial abnormality including hemorrhage,
infarct, or
suggestion of mass.
2. Paranasal sinus disease, as described.
TEE ___
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. Overall left ventricular
systolic function is normal (LVEF>55%). The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to 35cm from the incisors.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation.
IMPRESSION: No intracardiac source of embolism identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. Naproxen 500 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Naproxen 500 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
TIA or Stroke (Ischemic or Hemorrhagic)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with TIA symptoms lasting 10 min, dysarthria and aphasia,
evaluate for acute cardiopulmonary disease.
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
The cardiomediastinal contours are within normal limits. The bilateral hila
are unremarkable. The lungs are clear without focal consolidation. There is
no evidence of pulmonary vascular congestion. There is no pneumothorax or
pleural effusion.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT
INDICATION: 10 minutes of dysarthria and aphasia. Evaluate for bleed or
vascular stenosis.
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 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 5.2 s, 40.8 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,304.3 mGy-cm.
Total DLP (Head) = 2,223 mGy-cm.
COMPARISON: None.
FINDINGS:
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.
There is moderate polypoid mucosal wall thickening and/or mucous retention
cysts in the left maxillary sinus. There is mild mucosal thickening in the
inferior aspect of the right maxillary sinus as well as in the bilateral
ethmoid air cells. There is punctate mucous retention cyst in the left
sphenoid air cell. The v remainder of the isualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear patent without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
There is common origin of the brachiocephalic and left common carotid artery.
The carotid and vertebral arteries and their major branches appear patent with
no evidence of stenosis or occlusion or dissection. There is no evidence of
internal carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. There is heterogeneous
enlargement of the right thyroid lobe with multiple hypodense nodules
measuring up 21 x 14 mm on the right (5:72). There is no lymphadenopathy by CT
size criteria. There are periapical lucencies around 2 left maxillary molars,
suggestive of periodontal disease.
IMPRESSION:
1. No acute intracranial abnormality.
2. Patent intracranial vasculature without significant stenosis, occlusion, or
aneurysm.
3. Patent cervical vasculature without significant stenosis, occlusion, or
dissection.
4. Periapical lucency around 2 left maxillary molars, suggestive of
periodontal disease.
5. Multinodular enlargement of the right thyroid lobe with nodules measuring
up to 21 x 14 mm in the right lobe. The ___ College of Radiology
guidelines suggest thyroid ultrasound for further evaluation.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: Word-finding difficulty and right hand numbness for 10 min.
Evaluate for infarct.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head and neck ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. Minimal periventricular and deep white matter T2/FLAIR
hyperintensity, mainly around the occipital horns of the lateral ventricles is
in a configuration most suggestive of chronic small vessel ischemic disease.
There is no abnormal focus of slowed diffusion. The principal intracranial
vascular flow voids are preserved.
There is moderate mucosal wall thickening the left maxillary sinus, minimal
mucosal wall thickening the right maxillary sinus as well as minimal mucosal
wall thickening the left frontal sinus and bilateral ethmoid air cells.
IMPRESSION:
1. No acute intracranial abnormality including hemorrhage, infarct, or
suggestion of mass.
2. Paranasal sinus disease, as described.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with Transient cerebral ischemic attack, unspecified
temperature: 99.1
heartrate: 89.0
resprate: 18.0
o2sat: 100.0
sbp: 172.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ old right-handed man with history
of hypertension who presented with a transient episode of word
finding difficulty, garbled speech and right hand paresthesias
concerning for TIA. CTA head and neck showed patent vessels, and
no intracranial abnormality. MRI negative for acute stroke. TTE
negative for PFO. Subsequent TEE was also negative for PFO.
Etiology of his TIA is unclear at this time. He will be
discharged with an event monitor to further evaluate for cardiac
arrhythmia. Patient was started on ASA 81 mg daily for stroke
prevention. Statin was not initiated as his LDL was 81 and his
vessel imaging did not show evidence of atherosclerosis.
Of note, CTA neck showed heterogeneous thyroid gland which is
enlarged containing multiple hypodense nodules measuring up to
14 mm on the right. A follow up thyroid scan is recommended.
Patient has follow up with outpatient neurology scheduled. He
has been instructed to follow up with his PCP as well. His PCP
was contacted and a discharge summary was sent to the office. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Bactrim DS
Attending: ___.
Chief Complaint:
headache, nausea, vomiting, neck stiffness
Major Surgical or Invasive Procedure:
___ - Left craniectomy and wound washout
History of Present Illness:
___ yo female 10 days post-op from left craniotomy and
temporal meningioma resection. She was last seen in the office
___ for suture removal and was doing well at that time and
only c/o of some mild HAs since stopping decadron on ___.
She
presents to the ED today with 2 days of worsening HA, N/V,
photophobia, neck stiffness and diarrhea x 3 today. She denies
fevers, but does c/o chills. She denies any weakness or visual
changes.
Past Medical History:
IDDM
Temporal meningioma s/p resection ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs: intact
Neck: Neck stiffness and pain with chin to chest.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric, with
the exception of mild left nasolabial fold flattening..
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
===================
ON DISCHARAGE:
===================
Patient is alert and oriented to person, place and time.
Face symmetrical with mild left nasolabial flattening.
Tongue midline, EOMI, PERRL
No pronator drift and moves all extremities ___.
Incision is clean, dry and intact. Closed with sutures.
Pertinent Results:
Please refer to reports in OMR for pertinent lab and imaging
results.
Medications on Admission:
Humulin N 35units Q AM
Keppra 500mg BID
Regular insulin SS >200
Multivitamin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Do not exceed 4G of Acetaminophen is any form in a 24 hour
period.
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. NPH 30 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
5. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
7. Vancomycin 1250 mg IV Q 8H
RX *vancomycin 500 mg 1250 mg IV every eight hours Disp #*313
Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Wound infection
Hyperglycemia
skull defect
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/ AND W/O CONTRAST Q1212 CT HEAD
INDICATION: ___ T2DM, HTN, hx recent elective resection of meningioma who
presents with chills, nausea, vomiting, diarrhea.// please evaluate for acute
intracranial process
TECHNIQUE: Contiguous axial images of the brain were obtained before and
after the intravenous administration of 70 mL of Omnipaque contrast agent.
Thin bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
3) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 50.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 2,408 mGy-cm.
COMPARISON: MRI ___
FINDINGS:
There is a hypoattenuated extra-axial fluid collection along the left cerebral
convexity which measures 1.2 cm from the inner table (series 4:20) with
associated effacement of the left lateral ventricle an 8 mm rightward midline
shift is new as compared to MRI head ___. This could represent a
subdural hygroma or chronic subdural hematoma. In the surgical resection bed
of the previously characterized left temporal meningioma, there is no abnormal
enhancement or hemorrhage. There is also a presumed left epidural mixed
density collection measuring 5 mm from the inner table (series 2:15). There
is mild interval increased prominence of the bilateral temporal horns and
right lateral ventricle.
Left frontal craniotomy changes are noted. There is now a prominent
extracranial fluid collection overlying the craniotomy measuring approximately
6 mm in greatest thickness, not seen on prior examination. Correlation for
postoperative pseudomeningocele is recommended. There is no acute fracture.
Mucosal thickening bilateral ethmoid air cells are noted. Remaining paranasal
sinuses are clear. Middle ear cavities are patent.
IMPRESSION:
1. Hypoattenuated extra-axial fluid collection along the left cerebral
convexity measuring 1.2 cm from the inner table with associated effacement of
the leftlateral ventricle and 8 mm of rightward midline shift is new as
compared to MRI ___. This could represent a subdural hygroma versus
less likely a chronic subdural hematoma given that the surgical resection was
on ___. There is suggestion of mild increased prominence of the
right lateral ventricle and bilateral temporal horns, raising the possibility
of developing hydrocephalus. Continued close attention is recommended.
2. Left epidural mixed density collection along the left frontal convexity
measuring 5 mm from the inner table (series 2:15) compatible with a mixed age
epidural hematoma.
3. Extracranial CSF density collection measuring approximately 6 mm in
greatest thickness overlying the craniotomy site. Clinical correlation for
postoperative pseudomeningocele is recommended.
4. No definite abnormality in the left temporal resection bed.
5. No definite abnormal enhancement to suggest infectious process at this
time.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with meningitis// preop
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are slightly lower compared to the previous exams. Cardiac
silhouette size remains mildly enlarged. The mediastinal and hilar contours
are unremarkable. Pulmonary vasculature is not engorged. Lungs are clear.
No pleural effusion or pneumothorax is seen. No acute osseous abnormalities
present.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman s/p repeat craniotomy, wound washout// 10 days
s/p craniotomy and L frontal meningioma resection, repeat craniotomy and wound
washout today
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, 15.6 cm; CTDIvol = 45.1 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 702 mGy-cm.
COMPARISON: CT head without contrast ___ 03:22
FINDINGS:
New hemorrhage is identified at bilateral cerebellum, presumed to be
subarachnoid in nature. There is also trace sulcal hyperintensity involving
the right temporal parietal lobe (series 2, image ___ also likely
representing subarachnoid hemorrhage. There does appear to be mild edema
predominantly involving the left cerebellar folia.
Minimal apparent increased hypodensity of the left anterior temporal lobe when
compared to preoperative examination, likely artifactual in nature. However
clinical correlation is recommended.
Patient is post left frontal craniectomy and washout. Small amount fluid is
noted between the skin flap and left frontal lobe. A drain is left in place.
There is small amount of pneumocephalus. Left frontal subdural hematoma is
small. Leftward midline shift by 3 mm is improved from 5 mm 7 hours ago.
Previously described subgaleal fluid collection is no longer noted.
Small amount of fluid is noted in right sphenoid sinus. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. New hemorrhage is identified at bilateral cerebellum, compatible with
subarachnoid hemorrhage. There is edema of the cerebellar folia, most
prominent on the left.
2. Patient is post left frontal craniectomy and washout with expected
postoperative changes and improved mild leftward midline shift.
3. Previously described subgaleal fluid collection is no longer seen.
4. Apparent increased hypodensity of the left anterior temporal lobe when
compared to preoperative examination. This is likely artifactual in nature,
however clinical correlation is recommended.
5. Additional findings described above.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 11:57 pm, 15 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman Wound washout and L hemicraniectomy, epidural
hemovac drain with high output, increased HA, nausea// interval change
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 =
746.8 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head dated ___
FINDINGS:
There is a left frontal temporal craniectomy defect status post removal of an
infected craniotomy flap. There is unchanged dural thickening at the surgical
site. The distal end of the left frontal approach epidural drainage catheter
is located near the posterior margin of the craniectomy defect. The volume of
fluid within the left supra zygomatic masticator space external to the
craniectomy appear similar to the prior study.
Low attenuation within the left anterior temporal lobe appear similar to the
prior head CT and most likely reflects retraction injury, however cerebritis
is an alternative consideration given the known craniotomy flap related
infection.
The ventricular configuration appears similar to the prior study, without
hydrocephalus. There is 2 mm of midline shift, similar to the prior study.
The basilar cisterns are patent, without evidence of downward herniation.
The degree of blood products within the cerebellar fissures appear similar to
the prior study. No new intracranial hemorrhage is identified.
IMPRESSION:
1. Left frontal temporal craniectomy for resection of an infected craniotomy
flap. Low attenuation within the anterior left temporal lobe may reflect
retraction related injury, however superimposed cerebritis is difficult to
exclude.
2. The ventricular configuration and 2 mm rightward midline shift appear
similar to the prior study.
3. Acute blood products within the posterior fossa likely reflects
subarachnoid hemorrhage and appear similar to the prior study. No new
hemorrhage is identified.
4. Thickening adjacent to the left lateral dural surface of the cavernous
sinus, left petrous apex, and left dorsal surface of the clivus likely
reflects postoperative change.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with craniectomy and washout// interval change
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 from ___.
FINDINGS:
Patient is status post removal of infected craniotomy flap with a left
frontotemporal craniectomy defect. There is been interval replacement of the
previously seen left frontal approach epidural drainage catheter now with a
small simple fluid collection between the skin flap and the dura at the
surgical site. Dural thickening persists however has decreased from prior
study.
In comparison with prior study area of hypoattenuation of the left anterior
temporal lobe is unchanged.
There is re-demonstration of subarachnoid hemorrhage within the cerebellum not
signet changed from ___ study. No new intracranial bleed is identified.
The ventricles and sulci are stable in size and configuration with a small
rightward midline shift unchanged from prior. The basal cisterns are patent.
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. Patient is status post removal of infected craniotomy flap with left
frontotemporal craniotomy defect and interval removal of left frontal approach
epidural drainage catheter. Small simple fluid collection between skin flap
and dura at the surgical site likely sequela of catheter removal. Small
amount of blood products at the craniectomy site is unchanged. Small
left-sided subdural collection is more prominent since study and likely due to
the recent procedure.
2. Hypoattenuation of the left anterior temporal lobe is unchanged in
appearance from prior study.
3. Small stable rightward midline shift and stable ventricular configuration.
4. Stable cerebellar subarachnoid hemorrhage with no new intracranial bleed
identified.
5. Stable dural thickening adjacent to the surgical site likely postoperative.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with low grade temps, low fluid output,
sleepy// Eval for signs of PNA Eval for signs of PNA
IMPRESSION:
Compared to chest radiographs ___ status ___.
Top-normal heart size unchanged. Lungs grossly clear. No pleural effusion.
Slight leftward deviation of the trachea could be due to an enlarged right
lobe of the thyroid. Clinical correlation advised.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old woman with PICC// Pt had a R PICC,42cm, ___ ___
Contact name: ___: ___
TECHNIQUE: Single frontal view of the chest was obtained.
COMPARISON: ___
FINDINGS:
Since the prior examination, there is a new right-sided pleural effusion. The
cardiomediastinal silhouette and pulmonary vasculature are unchanged. A new
right-sided PICC terminates in the mid SVC. No pneumothorax.
IMPRESSION:
Right-sided PICC terminates in the mid SVC. New right-sided pleural effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Headache, N/V
Diagnosed with Headache
temperature: 97.7
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 157.0
dbp: 75.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ yo female s/p left craniotomy and temporal
meningioma resection ___ days ago who presents with N/V, HA, neck
stiffness. Head CT shows fluid collection/hygroma and worsening
MLS. Her WBC were 21.7 and there was concern for meningitis.
#Meningitis: A scalp collection tapped in the ED and sent for
cultures. Gram stain shows 4+PMNs and 2+ gram + cocci in pairs.
Patient was started on Vancomycin, Cefepime, and Flaygl. She was
taken to the OR on ___ for L Craniectomy and washout. Procedure
was well tolerated. Epidural hemovac drain was left. Post op
patient was neurologically intact. Post op CT showed expected
post surgical changes and new cerebellar SAH. Hemovac drain with
very high output POD0-1. Increased HA/nausea in AM on POD#1
prompted repeat CT head which was stable. Hemovac drain was
removed on POD#1. OR culture grew staphylococcus epidermidis.
She was narrowed to vancomycin only. PICC line was placed on
___. The patient was set up with home infusion therapy for her
discharge in ___.
#Diabetes:
Patient's fingersticks were monitored while inpatient. She was
initially started on her home dose of NPH and Regular insulin
sliding scale. POD#1 given poor PO intake NPH was held. ___
was consulted for continued management. They continued to make
adjustments to her insulin regimen. On ___, NPH was restarted.
On ___, she became hypoglycemic to the ___. She was treated and
it uptrended. ___ adjusted the patient's insulin sliding
scale again on ___. After a conversation with the patient,
___ changed the recommendations again after the patient
stated she would not be compliant with the changes. The patient
was explained the risks of poor blood sugar control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with PMH significant for ___
(most recent ___ EF 30%), poorly-controlled IDDM2, hx E. coli
urosepsis requiring nephrostomy placement ___ who presents
with nausea/vomiting.
Of note, the patient with several recent ___ system
hospitalizations. Of note patient recently admitted in ___
of this year at ___ with nausea, vomtiting, diarrhea and
hyperglycemia. CT abdomen/pelvis showed ampullary fullness,
which was followed up with an MRCP that showed normal ampulla
and no biliary tract dilatation. Gastric emptying study showed
no gastroparesis. Stool guaiac was negative. She was started on
metoclopramide and Zofran for symptomatic relief, and pain
improved.
She was also admitted at ___ from ___, through
___. Per an OMR note by Dr. ___, the
patient presented with a syncopal episode and hyperglycemia. Per
the report, the patient's fall was thought to be due to
orthostatic hypotension. EKG wasnoted to be unremarkable. Head
CT showed chronic CVA and microvascular change. It was thought
that her chronic hyperglycemia and her anorexia may have led to
volume depletion coupling with being on torsemide. She was asked
to stop Norvasc and torsemide. Her carvedilol dose was changed
from 25 mg b.i.d. to 12.5 mg b.i.d. Her lisinopril dose was
changed from 40 mg to 20 mg.
Patient states she has had a change in smell of her urine for
the past week but no associated dysuria or increased urinary
frequency. She developed nausea and vomiting since ___. She
denies diarrhea and state she had a normal BM this am. She
denies cp or sob. Patient denies travel or sick contacts.
In the ___ ED:
- Initial VS 97.2 ___ 16 100% RA
- Labs notable for Chem-7 with Glu 385 otherwise wnl (Cr 1.0 at
baseline), CBC with WBC 6.1 and H/H 9.2/27.7 (baseline Hct 28),
LFTS wnl, VBG with 7.36/58, lactate 1.6. UA with large
leukocytes, moderate blood, 1000 glc, 10 ketones, RBC 31, >182
WBC
- CXR with no acute intrathoracic abnormality. Abdominal KUB
with nonobstructive bowel gas pattern. Stool filled loops of
colon. Posttraumatic changes involve the right inferior pubic
ramus.
- The patient was administered
___ 16:35 IV Ondansetron 4 mg
___ 16:35 IVF 1000 mL NS 1000 mL
___ 18:11 PO/NG Carvedilol 6.25 mg
___ 18:11 PO/NG Lisinopril 40 mg
___ 18:31 IV CeftriaXONE 1 gm
___ 18:34 IVF 1000 mL NS 1000 mL
___ 19:41 SC Insulin 12 Units
- VS prior to transfer 98.5 95 184/89 18 100% RA
Upon arrival to the floor, VS 97.9 162/81 91 16 100%RA FSBG
290. The patient reports that he nausea/vomiting resolved after
administration of IV Zofran in ED and has been able to eat a
sandwich without subsequent symptoms.
Past Medical History:
- Hx H. Pylori
- T2DM: dx ___, c/b retinopathy, nephropathy, and cataracts
- sCHF (EF 50%)
- Hypertension
- Osteoporosis
- HLD
- s/p fibroid removal in ___
- Hx N/V with work-up notable for normal gastric emptying study
___, CT showing prominent ampulla, MRCP ___ with atrophic
panc, +H. pylori ___ rx'd but not compliant with treatment
- Anemia ___ iron and B12 deficiency
- Hx +PPD, s/p 6 months INH in 89
- Hx pyelonephritis ___ s/p ARDS/prolonged
intubation/critical illness
Social History:
___
Family History:
Mother and father with HTN
Aunt with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 162/81 91 16 100%RA FSBG 290
GENERAL: Cachectic woman, lying in bed, 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, soft II/VI holosystolic murmur, no
rubs/gallops
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Prior R urostomy scar well-healed C/D/I. No CVA
tenderness. 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:
VS - 98.5 145/82 85 16 100RA
GENERAL: Cachectic woman, lying in bed, 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, soft II/VI holosystolic murmur, no
rubs/gallops
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Prior R urostomy scar well-healed C/D/I. No CVA
tenderness. 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
Pertinent Results:
ADMISSION LABS
___ 04:05PM BLOOD WBC-6.1 RBC-3.16* Hgb-9.2* Hct-27.7*
MCV-88 MCH-29.1 MCHC-33.2 RDW-13.1 RDWSD-41.5 Plt ___
___ 04:05PM BLOOD Neuts-69.0 ___ Monos-6.8 Eos-0.7*
Baso-0.3 Im ___ AbsNeut-4.18 AbsLymp-1.39 AbsMono-0.41
AbsEos-0.04 AbsBaso-0.02
___ 04:05PM BLOOD Glucose-385* UreaN-25* Creat-1.0 Na-138
K-4.3 Cl-98 HCO3-31 AnGap-13
___ 04:05PM BLOOD ALT-11 AST-30 AlkPhos-61 TotBili-1.1
___ 04:05PM BLOOD Lipase-15
___ 04:05PM BLOOD cTropnT-<0.01
___ 04:05PM BLOOD Albumin-3.5
___ 04:22PM BLOOD ___ pO2-29* pCO2-58* pH-7.36
calTCO2-34* Base XS-3 Intubat-NOT INTUBA
___ 04:22PM BLOOD Lactate-1.6
DISCHARGE LABS
___ 07:40AM BLOOD WBC-5.2 RBC-2.69* Hgb-7.8* Hct-24.0*
MCV-89 MCH-29.0 MCHC-32.5 RDW-13.3 RDWSD-43.0 Plt ___
___ 07:40AM BLOOD Glucose-74 UreaN-27* Creat-1.1 Na-143
K-3.7 Cl-104 HCO3-29 AnGap-14
___ 07:40AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8
URINE
___ 04:40PM URINE Color-Straw Appear-Hazy Sp ___
___ 04:40PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 04:40PM URINE RBC-31* WBC->182* Bacteri-FEW Yeast-NONE
Epi-2
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >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-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
- ___ KUB: Nonobstructive bowel gas pattern. Stool filled
loops of colon. Posttraumatic changes involve the right inferior
pubic ramus.
- ___ CXR: No acute intrathoracic abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 12.5 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Lisinopril 40 mg PO DAILY
7. Pylera (bismuth subcit K-metronidz-tcn) ___ mg oral
TID W/MEALS
8. Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Pantoprazole 40 mg PO Q24H
10. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral BID W/ FOOD
11. Vitamin D ___ UNIT PO DAILY
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. Senna 8.6 mg PO DAILY:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 12.5 mg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 40 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp
#*60 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q24H
10. Senna 8.6 mg PO DAILY:PRN constipation
11. Vitamin D ___ UNIT PO DAILY
12. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral BID W/ FOOD
13. Pylera (bismuth subcit K-metronidz-tcn) ___ mg oral
TID W/MEALS
14. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 6 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Nausea
Urinary Tract Infection
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with vomiting, h/o chf // r/o chf, obstruction
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___
FINDINGS:
PA and lateral chest radiograph demonstrate clear lungs bilaterally.
Cardiomediastinal and hilar contours are within normal limits. There is no
evidence of pulmonary edema, pleural effusion, or pneumothorax. Imaged upper
abdomen is unremarkable. No air is seen under the right hemidiaphragm.
IMPRESSION:
No acute intrathoracic abnormality.
Radiology Report
INDICATION: ___ with vomiting, h/o chf // r/o chf, obstruction
TECHNIQUE: AP supine and upright radiographs
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
AP supine and upright radiographs through the abdomen demonstrates a
nonspecific bowel gas pattern. Stool fills the colon which is otherwise
unremarkable. Posttraumatic changes involve the right inferior pubic ramus
and better depicted on CT dated ___ and MR performed ___. There is no evidence of pneumobilia. Lung bases are clear.
IMPRESSION:
Nonobstructive bowel gas pattern. Stool filled loops of colon. Posttraumatic
changes involve the right inferior pubic ramus.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: N/V, Hyperglycemia
Diagnosed with Urinary tract infection, site not specified
temperature: 97.2
heartrate: 104.0
resprate: 16.0
o2sat: 100.0
sbp: 208.0
dbp: 108.0
level of pain: 0
level of acuity: 2.0 | ___ with sCHF (most recent ___ EF 30%), poorly-controlled
IDDM2, hx E. coli urosepsis requiring nephrostomy placement
___ who presented with nausea/vomiting, pyuria, hypertensive
urgency, and hyperglycemia. The patient's UA was concerning for
UTI although patient denied any symptoms, empirically treated
for complicated UTI given history of urosepsis. Patient was
initially treated with IV CTX and transitioned to PO Bactrim at
the time of discharge. The patient was also hypertensive SBPs
200s without any significant symptoms. Hypertensive urgency was
likely in the setting of medical non-compliance which resolved
with continuing her home anti-hypertensive medications. The
etiology of the patient's nausea and vomiting was likely
multifactorial: in the setting of UTI, running out of home
Zofran, hyperglycemia with possible underlying gastroparesis.
Her nausea and vomiting resolved with the interventions outlines
above. At the time of discharge, the patient was tolerating PO
intake without difficulty.
# NAUSEA/VOMITING: Baseline N/V for which patient is s/p
extensive work-up including N/V with work-up notable for normal
gastric emptying study ___, CT showing prominent ampulla
___, MRCP ___ with atrophic pancreas, +H. pylori ___
started on treatment but non-compliant. Patient reports that of
recent, she has been without nausea/vomiting until last ___.
Etiology of current acute N/V likely secondary to UTI, as LFTs
and lipase wnl. Patient's symptoms resolved with IV Zofran and
she was discharged with a refill of her home prescription
# KLEBSIELLA URINARY TRACT INFECTION, COMPLICATED: Hx of E.coli
urosepsis in ___ requiring R urostomy tube placement which
was recently removed. She presented with "bad-smelling urine"
but not dysuria/pyuria or fevers/leukocytosis. UA with moderate
blood, lg leuks with few bacteria. Given nausea/vomiting, prior
history, poorly-controlled DM, she was treated as complicated
UTI. Urine culture grew pansensitive Klebsiella which was
appropriately covered by her Bactrim course.
# HYPERTENSIVE URGENCY: Pt presented with sBP in the 200s
without symptoms of headache, vision changes, chest pain, or
SOB. UA with proteinuria at baseline levels, Troponin <0.01.
After administration of home BP meds, sBP reduced to 160, and
further 140. She was discharged on Lisinopril 40 mg daily and
Carvedilol 12.5 mg PO BID
# TYPE 2 DIABETES: Followed at ___, complicated by
nephropathy and retinopathy. Poorly-controlled with A1c 8.9%. On
presentation she had sugars >300. UA with 10 ketones but pH
normal, normal AG. She was discharged on home insulin with
further education and ___
# ANEMIA: Chronic, attributed to iron and B12 deficiency.
# CONGESTIVE HEART FAILURE: EF 25% ___ in setting of
urosepsis, improved to 50% as of ___. She maintained
euvolemia
# HYPERLIPIDEMIA: Continued atorvastatin 40mg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Darvocet-N 100 / levofloxacin
Attending: ___.
Chief Complaint:
N/V/D
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ aplastic anemia/hypoplastic MDS now day ___ ___
allogeneic BMT complicated by disseminated nocardiosis and
recently hospitalized ___ to ___ with abdominal pain, PO
intolerance and found have colitis noted on OSH imaging with
non-neutropenic culture negative fever, presents with ___ in
setting of ongoing diarrhea/vomiting.
Past Medical History:
PAST ONCOLOGIC HISTORY: per ___ is a ___ female with a history of
hypoplastic MDS/aplastic anemia, status post one cycle of ATG
cyclosporine in ___, followed by
a second cycle in ___. Course complicated by AVN of left
hip. Patient also with hx of hemolytic anemic. Recent DAT neg.
Patient required frequent HLA-matched platelets approximately
twice a week. There was a question of an immune component and
had been on and off Prednisone in this setting. Also has had
periodic course of Rituxan in this setting. Just prior to
transplant we had trial of Promacta but did not have any
significant improvement in platelet count. Due to refractory
disease proceed with bone marrow transplant. She is current day
+
___ ___ reduced intensity Bone "marrow" transplant from unrelated
donor with Fludarabine/Cytoxan/Campath for conditioning regimen.
Her transplant course was complicated by ICU admission with
dyspnea, hypoxia, elevated troponin and acute heart failure with
acute global cardiac dysfunction in setting of bone marrow
infusion. Etiology of Ms. ___ decompensation not
completely
clear though ? of some capillary leak process. She got pure
marrow--not peripheral stem cells--and it's likely that the
product contained hemolyzed cells, fat,
cellular debris, etc. that caused her to react. Although her
post-infusion labs looked like she was hemolyzing, the DAT was
negative and her hemoglobin did not drop. Most likely she had
been transfused lysed cells (?likely happened during harvesting
procedure) that gave her a transaminitis, elevated bili, blood
inurine, etc. Unfortunately however, even after washing the
bonemarrow, Ms. ___ continued to have this reaction and the
reaction was to the same bag. DAT was negative. It was felt that
she had some sort of endothelial, microvascular damage from the
bone marrow transplant. Was supported through this episode. EF
improved on repeat ECHO to 43% (from 20%). Also, of note, two
cultures that were done from stem cells came back + for
Propionibacterium species. Unclear if contaminant but covered
with antibiotics for this. Patient otherwise after this acute
event did well in the transplant setting and was discharged
from
hospital on ___ and has been followed closely in outpatient
clinic.
No other past medical history
Social History:
___
Family History:
Mother died of lung cancer in her ___ after heavy tobacco
use. Father died of CAD in his ___. 2 healthy brothers and 1
sister. Healthy son.
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
General: NAD, thin, resting in bed
VITAL SIGNS: 98.3 100/60 66 18 98% RA
Wt 111 (down from 116 on ___
HEENT: MMM, no OP lesions,
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: ___ strength throughout, alert and oriented x 4, ___,
EOMI, no nystagmus, face symmetric, no tongue deviation, full
hand grip, shoulder shrug and bicep flexion, full toe
dorsiflexion and hip flexion against resistance bilateral,
sensation intact to light touch, no clonus
DISCHAGE PHYSICAL EXAM:
General: NAD, thin, resting in bed
VITAL SIGNS: 98.5 100/62 64 16 98% RA
Wt on admit 111.6 (down from 116 on ___: 107.9
HEENT: MMM, no OP lesions
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric
Pertinent Results:
___ 06:25AM BLOOD WBC-3.9* RBC-2.54* Hgb-8.0* Hct-24.6*
MCV-97 MCH-31.4 MCHC-32.4 RDW-15.9* Plt ___
___ 10:15PM BLOOD Neuts-58.4 ___ Monos-7.3 Eos-5.7*
Baso-0.3
___ 06:25AM BLOOD Glucose-76 UreaN-19 Creat-1.2* Na-136
K-5.5* Cl-105 HCO3-24 AnGap-13
___ 10:15PM BLOOD Glucose-81 UreaN-26* Creat-1.5* Na-135
K-5.8* Cl-102 HCO3-21* AnGap-18
___ 06:25AM BLOOD ALT-21 AST-23 LD(LDH)-140 AlkPhos-65
TotBili-0.2
___ 10:15PM BLOOD ALT-32 AST-38 AlkPhos-80 TotBili-0.2
___ 06:25AM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.3 Mg-1.8
___ 10:15PM BLOOD Albumin-3.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. CycloSPORINE (Neoral) MODIFIED 125 mg PO Q12H
3. FoLIC Acid 5 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Sulfameth/Trimethoprim DS 2 TAB PO BID Nocardiosis
6. Ondansetron 4 mg PO TID 30 mins pre meals
7. Acetaminophen 325-650 mg PO Q6H:PRN mild pain, headache
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. FoLIC Acid 5 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Ondansetron 4 mg PO TID 30 mins pre meals
5. Sulfameth/Trimethoprim DS 2 TAB PO BID Nocardiosis
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Acetaminophen 325-650 mg PO Q6H:PRN mild pain, headache
8. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
hx MDS ___ MUD allo ___
diarrhea
+AFB stool culture
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: Weakness. Assess for infiltrate.
COMPARISON: Chest radiograph ___
FINDINGS:
Frontal and lateral chest radiograph demonstrates hyperinflated lungs with
persistent bilateral scattered areas of parenchymal opacities many of which
have nodular components, similar to ___. Chronic bronchiectasis
is stable.
Heart size, mediastinal contour, and hila are otherwise unremarkable. No
pleural effusion or pneumothorax.
Limited assessment of the upper abdomen is unremarkable.
IMPRESSION:
Persistent multifocal parenchymal with nodular components are similar dating
back to ___. No definite new focal opacity but subtle
abnormalities would be difficult to detect within the setting of complex
baseline abnormality. CT would be more sensitive and may be considered if
warranted clinically.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 10:41 AM.
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: ___ year old woman with ___ not responding to IVF completely //
r/o obstruction, please do with dopplers to r/o renal vein thrombus. please do
BOTH KIDNEYS
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10 cm. The left kidney measures 10 cm. There is no
hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally.
Renal Doppler: Within the right kidney the main renal artery and renal vein
are patent with normal waveforms. Intraparenchymal renal arteries demonstrate
normal waveforms with resistive indices ranging from 0.55-0.67. Within the
left kidney the main renal artery and renal vein are patent with normal
waveforms. Intraparenchymal renal arteries demonstrate normal waveforms with
resistive indices ranging from 0.64-0.65.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal doppler ultrasound.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Transfer
Diagnosed with OTHER MALAISE AND FATIGUE, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.6
heartrate: 58.0
resprate: 16.0
o2sat: 96.0
sbp: 93.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ F with a history of ITP, MDS/aplastic
anemia ___ RI MUD allo-BMT ___, disseminated nocardiosis
who was recently hospitalized with colitis and nonneutropenic
fever presumed viral gastroenteritis as other causes ruled out
who is readmitted with ongonig nausea, vomiting, diarrhea and
dehydration with ___ now with positive stool AFB.
___ - stable at Cr 1.2-1.3, baseline Cr 0.8-1.0 Improved from
Cr
elevated to 1.9 at OSH, 1.5 on BI arrival Thought prerenal
cause
in setting of GI losses and inadequate PO however still elevated
from baseline with adequate fluid intake. Other likely intrinsic
causes could be nephrotoxicity from bactrim or CSA, infection or
ATN from
hypotension (but no fever or other localizing sx). Making good
urine
- Stop fluids ___ and monitor I/Os and kidney function in am to
see if any difference, if worsening elevation likely dehydration
more of a cause, if not likely drug toxicity
- renal u/s shows no evidence of obstruction or other intrinsic
cause ___
- check U culture-neg (UA neg)
- resumed bactrim, per pharmacy continue home dosing
- CSA level low at admit, adjusted to 150mg BID from 125mg BID
per pharmacy, however may be contributing to ___
- taper CSA to 75mg BID ___, hope to decrease IS
and once this has stopped may have ability to decrease DS
Bactrim
for hx of nocardoisis.
#N/V/D: Resolved. present for at least past few weeks. Noted to
have colitis on OSH CT Resolved on most recent CT here ___.
Suspected viral gastroenteritis and overall pt is improved but
not completed resolved. Unclear etiology ? med related but
recently culture from last admit came back positive AFB culture.
Her last admission included a very thorough workup with neg
C.diff, CMV. EGD/colonoscopy per GI showed gastritis only, H
pylori negative, no GVH and intestine/colon normal.
- sent another stool AFP and C diff ___
- d/c scheduled zofran, no longer nauseated, restart if needed
- resumed PPI for chronic gastritis noted on recent
EGD as long as Cr remains stable
- ID consult regarding positive stool AFB-rec holding on tx for
now as symptoms improving, will send AFB stain from most recent
UGI/LGI bx and f/u
- will check CD4 count-ok at 244 no MAC ppx unless <100
- ID to send email to Dr. ___ the thought of
decreasing IS and hoping to eventually stop it and then decrease
DS Bactrim in setting of recurrent ___.
- Currently, keep DS Bactrim at same dosing per inpatient ID
team
- Patient to f/u with Dr. ___ week ___
#Hyperkalemia - 5.8 on admission, down to 5.1 after kayakelate,
repeated kayakelate 225 for K 5.7, now down to 5.0 ___. Lkely
___ ___ and possibly bactrim/csa effect?
- trend of requiring kayekalate is improving, last received 3d
prior. will receive ___ dose today for K 5.5 and d/c home. f/u
with level and appt on ___.
#Hypotension - stable. likely ___ hypovolemia. BP currently
improved to pts baseline of 100/50-60s. was NSR on tele in ED.
No
signs sepsis.
- check orthostatics-WNL
- cortisol WNL at 15 and echo stable from previous from ___. EF
>55%
# MDS ___ MUD allo ___: in CR. day 180 BM 99% donor,
normal
cytogenetics.
- no signs GVH thus far, cont on CSA, taper to 75mg BID ___ per
primary oncologist in hopes of decreasing cause of readmission
for continued infections, also to decrease toxic effect of drugs
that may be causing ___ and hyperkalemia.
- post transplant/campath HypoIg - got IVIG ___
- post transplant cytopenias - noted to be somewhat hypocellular
on last BM biopsy. counts overall stable. Hemolysis labs
unremarkable. would avoid transfusion if possible as has some
iron overload on recent liver imaging.
- transfuse Hgb <7, Plt <10
- worsening anemia noted overnight ___, asymptomatic, not fluid
overloaded clinically. guaic stool neg -does have some degree of
hypocellular marrow
# Hx nocardiosis - new lingular mass ___ and R and L parietal
lobe ring-enhancing lesions w/ BAL and infrahilar mass tissue Cx
___ +Cx nocardia farcinica. No cough or respiratory symptoms.
- remains on HD TMP-SMX. augmentin was stopped on last hospital
d/c per Dr ___.
- L perihilar mass has resolved, has persistent post-infectious
peribronchovascular opacities on CT chest ___ suggestive of
crptogenic organizing PNA. brain lesion w/ persistent
enhancement
but sl decreased R lesion and resolution of L lesion on most
recent MRI ___. ED CXR stable.
- touch base with ID in regards to decreasing IS to be able to
decrease Bactrim? consider Bactrim is cause of hyperkalemia and
___. Hold decreasing Bactrim dose for now per ID
FEN:
- Electrolytes per oncology scales
- Regular diet
DVT PROPHYLAXIS:
- will start heparin ppx given PLTS in ___ can tolerate,
ambulate
also
ACCESS:
- PIV
CODE STATUS:
- Full code
CONTACT INFORMATION:
- HCP ___, ___
DISPO: home will f/u with Dr. ___ Dr. ___ on
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Fevers
Hypotension
Major Surgical or Invasive Procedure:
central venous line placement
History of Present Illness:
Patient is ___ year old woman with PMH significant for CAD
(recent DES ___, afib on coumadin, ___, and DM presenting
with high fever and somnolence for 1 day. At ___ rehab she
was noted to be febrile to 103 and more somnolent over last 24
hrs. Labs there showed elevated LFTs with AST 434, ALT 159, alk
phos 250, tbili 2.1 with Trop I <0.06. WBC 6.3 HCT 40 plt 228,
INR 3 Cr 2.3 (baseline 1.6). She received 3g IV unasyn and
trasnfered to this instituation.
In the ED, initial VS were T 99.1, HR 90, BP 158/138, RR 18,
SaO2 98% 2L. She was complaining of abdominal and back pain. No
chest pain or shortness of breath. No cough. A bedside US showed
a negative FAST with RUQ US positive for gallbladder wall
thickening and IVC with >50% variation with inspiration. The
aorta was not visualized due to body habitus. ABX were
broadened with levaquin and ceftriaxone in addition to the
unasyn before presentation (pt is allergic to vanco). ERCP was
consulted and they recommended vitamin K and FFP to reverse INR
of 4.9. She was given the vitamin K but as procedure will be
delayed until at least the next morning FFP was held. Surgery
was also consulted. Pt received a non-con CT abdomen/pelvis and
was admitted to MICU for urosepsis vs cholangitis.
On arrival to the MICU, vital signs were T 98, HR 84, BP 135/73,
RR 10, satting 98% on 2L NC. Pt tired-appearing but
comfortable, no acute distress.
Past Medical History:
1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
1. Cardiac catheterization, ___: 30% ___ LAD, 30% mid
LAD, 90% D1 (status post BMS), increased LV filling pressure
(LVEDP 18).
2. Echocardiogram, ___: ___, mild LVH, LVEF 60%, cannot
assess regional wall motion, mildly dilated ascending aorta,
minimal AS, borderline pulmonary artery systolic hypertension.
3. Nuclear Persantine stress test, ___: No symptoms, no
ECG changes, normal wall motion, normal perfusion, LVEF 59%, no
change versus ___.
4. Holter monitor, ___: Normal sinus rhythm, normal
intervals, no significant pauses, rare isolated APBs, three
atrial couplets, one atrial triplet, trivial isolated
ventricular
ectopy, three or four symptomatic episodes showed normal sinus
rhythm without ectopy or ST-T wave changes.
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to D1 in ___ as above
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
ASTHMA
COLON POLYP, ___ polypectomy
CORONARY ARTERY DISEASE, s/p stent ___
DEPRESSION
DYSPEPSIA
HYPERCHOLESTEROLEMIA
HYPERTENSION
INSULIN DEPENDENT DIABETES MELLITUS
IRRITABLE BOWEL SYNDROME
OBESITY
OSTEOARTHRITIS
SLEEP STUDY-DIAGNOSTIC
CELLULITIS
PERIPHERAL NEUROPATHY
Social History:
___
Family History:
Her father died at age ___ of unknown causes. He
suffered from several strokes. He sustained his first MI in his
___ and also had diabetes. Her mother died at age ___ of a
stroke. She has two brothers, two sisters, and no children. All
of her siblings suffer from hypertension. She has one sister who
died of a myocardial infarction at age ___, she suffered from
diabetes. One brother has diabetes. There is no family history
notable for hyperlipidemia or sudden cardiac death.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PE:
Vitals: T: 98 BP: 135/73 P: 84 R: 10 O2: 98% on 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, obese, JVP difficult to assess, RIJ in place
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: distant breath sounds posteriorally, no wheezes, rales,
ronchi
Abdomen: soft, obese, mildly tender in LUQ, non-distended, bowel
sounds present, no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
DISCHARGE EXAM
98.9 ___ 82-120 (mostly in ___ 18 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, obese, JVP difficult to assess
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: distant breath sounds posteriorally, no wheezes, rales,
ronchi
Abdomen: soft, obese, nontender, non-distended, bowel sounds
present, no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing; 2+ pitting
edema to thighs; chronic venous stasis changes
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
Pertinent Results:
ADMISSION LABS:
___ 07:26PM BLOOD WBC-16.3*# RBC-4.20 Hgb-12.0 Hct-35.6*
MCV-85 MCH-28.5 MCHC-33.6 RDW-15.3 Plt ___
___ 07:26PM BLOOD Neuts-81* Bands-4 Lymphs-8* Monos-6 Eos-0
Baso-1 ___ Myelos-0
___ 07:26PM BLOOD ___ PTT-45.3* ___
___ 07:26PM BLOOD Glucose-185* UreaN-87* Creat-2.7*# Na-134
K-3.0* Cl-91* HCO3-24 AnGap-22*
___ 07:26PM BLOOD ALT-432* AST-933* LD(LDH)-912*
CK(CPK)-208* AlkPhos-239* TotBili-1.7*
___ 07:27PM BLOOD Lactate-5.5*
___ 10:58PM BLOOD Lactate-2.5* K-3.5
___ CXR
Limited study due to patient rotation and low lung volumes.
Mild pulmonary
edema and bibasilar atelectasis. Infection in the lung bases
however cannot
be completely excluded.
___ RUQ US
Cholelithiasis. Gallbladder wall thickening within a
non-distended
gallbladder is nonspecific and may be due liver disease, volume
overload, or
hypoproteinemia. Acute cholecystitis is considered unlikely
given the absence
of gallbladder distention.
___ CT ABD AND PELVIS W/O CONTRAST
1. Cholelithiasis. Gallbladder wall thickening is better
appreciated on the
ultrasound exam of the same date and is likely from
underdistension an
dchronic changes. No pericholecystic fluid collection. No
evidece of acute
cholecystitis
2. A 4.8 x 3.5 intermediate density left renal lesion, which
may represent an
underlying neoplasm, though hemorrhagic or proteinaceous cysts
are possible.
Further assessment with MRI is recommended on non-emergent
basis.
3. Small hiatal hernia.
4. Non-obstructive left renal stone.
MICRO
__________________________________________________________
___ 2:05 pm BLOOD CULTURE Source: Line-L-IJ.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:35 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 4:53 am BLOOD CULTURE Source: Line-RT IJ central
line.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 4:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
__________________________________________________________
___ 7:20 pm URINE
URINE CULTURE (Preliminary):
CITROBACTER KOSERI. >100,000 ORGANISMS/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.
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER ___
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 7:26 pm
BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
GRAM NEGATIVE ROD #2. SECOND MORPHOLOGY.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ AT 8:21AM ON
___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
DISCHARGE LABS
___ 07:12AM BLOOD WBC-9.8 RBC-4.05* Hgb-11.6* Hct-34.8*
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.3 Plt ___
___ 07:12AM BLOOD ___ PTT-58.3* ___
___ 07:12AM BLOOD Glucose-215* UreaN-58* Creat-1.6* Na-133
K-3.5 Cl-92* HCO3-25 AnGap-20
___ 06:03AM BLOOD ALT-177* AST-84* LD(LDH)-313*
AlkPhos-185* TotBili-0.7
___ 07:12AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Gabapentin 700 mg PO TID
3. Lovastatin *NF* 20 mg Oral daily
4. Ranitidine 150 mg PO BID
5. Digoxin 0.125 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough, sob
7. Align *NF* (bifidobacterium infantis) 4 mg Oral daily
8. Beano *NF* (alpha-d-galactosidase) 300 unit Oral daily gas
9. ___ Oil (Omega 3) 1000 mg PO DAILY
10. Lactaid *NF* (lactase) 3,000 unit Oral TID:prn with dairy
11. Multivitamins 1 TAB PO DAILY
12. Niacin SR 500 mg PO QHS
13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
14. Aspirin 81 mg PO DAILY
15. Clopidogrel 75 mg PO DAILY
16. Losartan Potassium 50 mg PO DAILY
17. Metolazone 2.5 mg PO 3X/WK
18. Metoprolol Succinate XL 200 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY
20. Senna 2 TAB PO BID:PRN constipation
21. Torsemide 100 mg PO DAILY
22. Warfarin 7.5 mg PO DAILY16
23. Furosemide 100 mg IV QD:PRN weight gain >3lbs in day
24. Acetaminophen 650 mg PO Q8H:PRN pain
25. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
26. Docusate Sodium 100 mg PO BID
27. Miconazole Powder 2% 1 Appl TP TID:PRN rash
28. Potassium Chloride (Powder) 10 mEq PO DAILY
Hold for K >5.0
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough, sob
4. Aspirin 81 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Digoxin 0.125 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Lovastatin *NF* 20 mg ORAL DAILY
10. Miconazole Powder 2% 1 Appl TP TID:PRN rash
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Ranitidine 150 mg PO BID
14. Senna 2 TAB PO BID:PRN constipation
15. Torsemide 100 mg PO DAILY
16. Warfarin 7.5 mg PO DAILY16
17. Lactaid *NF* (lactase) 3,000 unit Oral TID:prn with dairy
18. Losartan Potassium 50 mg PO DAILY
19. Metoprolol Succinate XL 200 mg PO DAILY
20. Align *NF* (bifidobacterium infantis) 4 mg Oral daily
21. Beano *NF* (alpha-d-galactosidase) 300 unit Oral daily gas
22. Potassium Chloride (Powder) 10 mEq PO DAILY
Hold for K >5.0
23. Lidocaine 5% Patch 1 PTCH TD DAILY back
24. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
25. Metolazone 2.5 mg PO 3X/WK diuresis
The patient may need this medication to diurese until she has no
___ edema - we held this medication in house as she was diuresing
well with torsemide 100 mg qday alone. Goal diuresis is ~ 1L per
day.
26. Furosemide 100 mg IV QD:PRN weight gain >3lbs in day
27. Heparin IV Sliding Scale
28. Ciprofloxacin HCl 500 mg PO Q12H
Complete ___ay ___, so until ___
29. Gabapentin 400 mg PO Q12H
30. 70/30 65 Units Breakfast
70/30 70 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Gram negative sepsis secondary to citrobacter UTI
- Acute on chronic systolic heart failure
- Shock liver
- Acute renal failure
- Atrial fibrillation with RVR
- 4.8 x 3.5 left renal lesion NOS
- Perivaginal and gluteal excoriations
- Right paraspinal pain (over ___ rib) NOS
Secondary:
- Ischemic cardiomyopathy EF 35%
- Coronary artery disease, BMS D1 ___ ___
- Insulin dependent diabetes mellitus
- Acute renal failure secondary to vancomycin
- Asthma
- Peripheral neuropathy
- Hypertension
- Hyperlipidemia
- Depression
- Arthritis
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: Abdominal pain and altered mental status.
COMPARISONS: Abdominal ultrasound exam with the same date, ___.
CT pelvis of ___.
TECHNIQUE: MDCT-acquired contiguous images through the abdomen were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images were provided.
FINDINGS:
CT ABDOMEN:
Bibasilar areas of dependent atelectasis are noted. There is no pleural
effusion. Heart is mildly enlarged without pericardial effusion. Aortic
valve calcifications are noted.
Evaluation of visceral organs is limited due to lack of intravenous contrast.
Within this limitation, the liver demonstrates homogeneous attenuation. There
is no intrahepatic biliary ductal dilatation. The gallbladder is mildly
distended. Gallbladder wall edema is better appreciated on the ultrasound
exam of the same date. Large gallstone is seen within its lumen, with
peripheral rim calcification. The spleen appears normal. Pancreas
demonstrates homogeneous attenuation without ductal dilatation or
peripancreatic fluid collection. The adrenal glands are normal. The
non-contrast appearance of the kidneys is unremarkable. A nonobstructive
renal stone is seen within the left interpolar region of the left kidney.
There is no hydronephrosis. There is a 4.8 x 3.5 cm isodense lesion arising
from the interpolar region of the left kidney measuring 33 Hounsfield units in
attenuation. This lesion was characterized as simple cysts on ___ ultrasound exam. Increased density may be attributed to internal
hemorrhage or protein content. Imaged small and large bowel loops are normal
in caliber without evidence of bowel wall thickening or obstruction. There is
no free air or free fluid within the abdomen. There are scattered mesenteric
and retroperitoneal lymph nodes, which do not meet CT criteria for pathologic
enlargement. Intra-abdominal aorta is normal in caliber.
CT PELVIS:
The bladder is collapsed around a Foley catheter. The rectum and sigmoid
colon are unremarkable. There is no pelvic lymphadenopathy. There is no free
air or free fluid within the pelvis.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen.
IMPRESSION:
1. Cholelithiasis. Gallbladder wall thickening is better appreciated on the
ultrasound exam of the same date and is likely from underdistension an
dchronic changes. No pericholecystic fluid collection. No evidece of acute
cholecystitis
2. A 4.8 x 3.5 intermediate density left renal lesion, which may represent an
underlying neoplasm, though hemorrhagic or proteinaceous cysts are possible.
Further assessment with MRI is recommended on non-emergent basis.
3. Small hiatal hernia.
4. Non-obstructive left renal stone.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVERS
Diagnosed with URIN TRACT INFECTION NOS
temperature: 99.1
heartrate: 90.0
resprate: 18.0
o2sat: 98.0
sbp: 158.0
dbp: 138.0
level of pain: unable
level of acuity: 1.0 | Pt is ___ year old woman with ___ significant CAD, CHF, DM, and
coumadin, recent hospitalization for decompensated CHF with
placement of drug eluding stent and was recovering at rehab
until developing fevers and altered mental status over the last
day.
#) Sepsis secondary to UTI: Patient received a total of 4L of
IVF and transiently required levophed in the ICU, which was
weaned. Patient was placed on Ceftriaxone. Blood cultures from
OSH and ___ growing GNRs which speciated out to pan-sensitive
Klebsiella and urine cultures showed pan-sensitive citrobacter.
Antibiotics were narrowed to cipro and planned for 14 day course
. Surveillance blood cultures still pending at time of
discharge.
#) Shock Liver. Pt with elevated liver enzymes with ALT/AST to
432/933, alk phos to 239, and tbili to 1.7. Initial concern for
cholangitis however imaging was without evidence of biliary duct
dilation. RCP was consulted and felt no need for procedure
Elevation was thought secondary to hypotension in setting
sepsis. LFTS downtrended in house but should be followed as
outpatient.
#) Acute on Chronic Renal Insuffiency: Pt with baseline
creatinine of 1.2-1.4, now up to 2.7 but improved to 1.6 prior
to discharge. Suspect due to sepsis as outlined above. Patient
received IVF (4L) with improvement. Her ___ was restarted prior
to discharge. Her digoxin was continued because the level was
therapeutic despite ARF. Her Cr should be followed as
outpatient.
#. Systolic Heart Failure. Patient with recent admission for
systolic dysfunction thought secondary to ischemia. Dry
weight/weight at time of d/c: 135kg. Admission weight 135mg.
Patient without need for supplemental O2 inhouse however
bilateral extremities with tense edema. In house daily weights
and close I/O were monitored.
Patient was continued on BB, dig; ___ restarted on ___. Her
dry weight of 135kg is likely an overestimation and patient
would benefit from continued diuresis until she has no
peripheral edema, but this may be limited by ___ or hypotension.
She is being discharged on torsemide 100 mg qday but may need
addition of metolazone 2.5 mg 3X/wk and/or lasix 100 mg IV. Goal
daily diuresis is 500 to 1L negative until dry.
#) Insulin Dependent Diabetes complicated by peripheral
neuropathy. Continued on 70/___ontinued on
gabapentin and oxycodine for pain control. Sugars were high
in-house; unfortunately patient did not receive her ___ ___
dose of insulin in error.
#) A-fib. Patient continued coumadin however received 10mg of
IV vitamin K on arrival due to concern that she would require an
ERCP. INR understandably became subtherapeutic and patient was
placed on a hep ggt to transition due to high CHADS of 4 until
therapeutic INR. INR on ___ was 1.5. She will need close
monitoring for bleeding given anticoagulation with aspirin,
plavix, heparin gtt and coumadin. She was rate controlled with
Toprol 200 mg qday.
#) Dyslipidemia: Patient continued on lovastatin; niacin and
___ oil were discontinued.
#) Hypertension: Initially held antihypertensives on arrival.
During hospitalization medications were gradually restarted. At
time of discharge patient was normotensive on Toprol and
Losartan.
#) ASTHMA: Continued albuterol PRN
#) CORONARY ARTERY DISEASE: Patient is s/p stent ___.
Additionally during ___ admission she had a 2-day pMIBI
which showed a new moderate, partially reversible defect in the
distal septum in the setting
of soft-tissue attenuation as well as new cavity dilation. As a
result she went for L heart cath on ___ and had a DES
placed in the mid LAD. (LMCA, LCX, and RCA had minimal disease.
In house patient was continued ASA, plavix, statin, and BB, ___
held in acute setting but restarted prior to discharge.
#) ISSUES TO DISCUSS AT FOLLOW UP:
- Heparin gtt until INR is between ___
- Continue torsemide 100mg PO and at ___, can use Lasix 100mg
IV and metolazone 2.5 mg as needed. Her reported dry weight is
135kg but she still appears fluid overloaded, so would continue
to diurese until limited by ___ or hypotension, as dry weight is
likely lower.
- can increase gabapentin back to home dose of 700mg TID if
needed; currently decreased in setting ___ to 400 mg TID
- Please trend cr and LFTs until normalized; patient likely has
shock liver and pre-renal failure due to hypotension.
- complete 14 day course of cipro for UTI causing sepsis.
- close monitoring of blood sugars
- f/u with Dr. ___ for CHF
- daily lytes and electrolyte repletion during active diuresis
# PENDING STUDIES: BLOOD CULTURES
# CONTACT ___
Relationship: sister
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Ceclor
Attending: ___.
Chief Complaint:
Altered mental status, acute kidney injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman transferred from outside
hospital with UTI, altered mental status. The patient had
undergone dental work more than one week ago, receiving incisor
implants. She also went to a hospital in the middle of the last
week for new-onset back pain. X-ray showed degenerative joint
disease and facet disease. She was prescribed Vicodin. The
patient noticed that she became "loopy" on the Vicodin on
___, with worsening mental status. She was taken today to
___, who reported:
___ female who presents with altered mental status and
back pain. Upon evaluation today the patient is confused with a
nonfocal neuro exam, nl rectal tone and sensation. Laboratory
analysis is notable for acute renal failure with a creatinine in
the fives. Patient has a white count of 11 with 10 bands;
however, reassuringly her lactate is 1.4. After 1 L of IV fluid,
the patient's blood pressure normalized to 120/70. Urinalysis is
notable for infection. The patient is also noted to have
hyperbilirubinemia, with a predominance of direct
bilirubin. CT imaging of the head notes a small hyperdensity
concerning for, but not diagnostic of, hemorrhage. The patient
has a normal INR at this time and platelets of 74. In the past
the patient has had altered mental status in the setting of
urinary tract infection. Concerned for possible underlying
malignancy. Patient was treated with broad-spectrum IV
antibiotics and fluid resuscitation. She'll be transferred to
the ___ in ___ for further
intensive medical evaluation and care. Of note, CT imaging of
the abdomen without contrast did not reveal any gross pathology
including ureteral obstruction, liver or abdominal mass."
In our ED, the patient was stable. She received a head CT, which
showed tiny hypodensity in right frontal lobe (different
location from ___. RUQ ultrasound also completed, with no
evidence of dilation. On transfer her vitals were T 97.9 HR 94
BP 127/76 96% RA RR 22.
Past Medical History:
Hypertension, degenerative disk disease with facet disease
Social History:
___
Family History:
Patient's son has diabetes. Patient's sister had ___ cancer.
Multiple family members have hypertension.
Physical Exam:
Admission physical exam:
Vitals: T: 97.9, BP: 124/75, P: 90, R: 25, O2: 95% RA
General: Oriented X 1, paranoid, will not answer many questions
HEENT: Sclera icteric as is frenulum of tongue, mucous membranes
dry, oropharynx clear, EOMI, PERRL, dried blood on roof of mouth
and near incisor on right maxilla
Neck: supple, no LAD
CV: S1 + S2, systolic murmur heard best at mitral listening
position
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, patient has non-blanching petechial rash on her arms
Neuro: CN III-XII intact, ___ strength upper/lower extremities,
2+ patellar reflexes
Discharge exam:
Vitals: Tc99.0 (Tm99.0), BP124/56, HR84, 95% on RA
General: Lying in bed comfortable appearing
HEENT: MMM, PEERLA, no oropharyngeal lesions
Neck: Supple, no LAD
CV: normal S1 and S2, no audible MRG apprecitaed
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: Foley removed, with prolapse organ protruding from vagina.
Ext: Right shoulder with decreased ROM, and weakness associated.
Petichaiel rash on her right forearm area. No visible stigmata
of endocarditis.
Neuro: AAOx3
Pertinent Results:
___ LABS:
WBC 11.3 Hgb 10.7 Hct 31.1 Plt 74, Bands 10%, PMNs 84%, 2%
Lymphs, Lactate 1.4 Na 129, K 3.1, Cl 88 Hco3 22, BUN 96, Cr
5.8, Glc 104; UA Nitrite positive, leuk estarase 500, WBCs ___
Albumin 2.8 Total protein 6.4 Total bili 6.9, Alk Phos 159, ALT
23, AST 23, lipase 41, troponin 0.012
___ IMAGING:
___ CT abdomen and pelvis:
IMPRESSION: 1. SPLENOMEGALY. 2. MILD BLUNTING OF THE RENAL
CALYCES BILATERALLY. 3. HYPODENSE RENAL AND LIVER LESIONS MAY
REPRESENT CYSTS BUT ARE NOT FULLY CHARACTERIZED. CONSIDER AN
ULTRASOUND FOR FURTHER CHARACTERIZATION. 4. SIGMOID
DIVERTICULOSIS WITHOUT DIVERTICULITIS. 5. HEAVY ATHEROSCLEROTIC
CALCIFICATION OF THE ABDOMINAL AORTA. 6. TRACE BILATERAL PLEURAL
EFFUSIONS.
___ CT head:
IMPRESSION: 1. FOCAL AREA OF HIGH ATTENUATION WITHIN THE CENTRUM
SEMIOVALE ON THE RIGHT CONCERNING FOR A SMALL HEMORRHAGE.
IMAGING FOLLOW UP IS RECOMMENDED WITHIN THE NEXT EIGHT HOURS.
IF NO CLINICAL CONTRAINDICATION, MRI IS ADVISED. 2. BILATERAL
CALCIFICATIONS OF BASAL GANGLIA, PLEASE CORRELATE CLINICALLY.
___ CXR:
IMPRESSION: NO EVIDENCE OF ACUTE CARDIOPULMONARY ABNORMALITIES.
==================
Admission labs:
___ 11:24PM GLUCOSE-104* UREA N-95* CREAT-5.1* SODIUM-136
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-21* ANION GAP-22*
___ 11:24PM CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-2.3 URIC
ACID-10.8*
___ 09:00PM ALT(SGPT)-28 AST(SGOT)-33 ALK PHOS-140* TOT
BILI-7.1*
___ 09:00PM ALBUMIN-3.1*
___ 11:24PM ___ PTT-25.6 ___
___ 09:00PM AMMONIA-22
___ 11:24PM SED RATE-66*
___ 11:24PM CRP-278.5*
___ 11:24PM HAPTOGLOB-218*
___ 11:24PM CK-MB-8 cTropnT-<0.01
___ 11:24PM LD(___)-281* CK(CPK)-202*
Discharge labs:
___ 06:12AM BLOOD WBC-10.6 RBC-3.04* Hgb-9.0* Hct-27.5*
MCV-91 MCH-29.6 MCHC-32.7 RDW-15.4 Plt ___
___ 06:12AM BLOOD Glucose-84 UreaN-18 Creat-1.0 Na-136
K-3.7 Cl-100 HCO3-26 AnGap-14
___ 06:12AM BLOOD ALT-20 AST-28 LD(___)-213 AlkPhos-115*
TotBili-3.1*
___ 06:12AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.9
IMAGING:
___ ABDOMINAL U/S:
IMPRESSION: 1. Segment VI liver cyst. 2. No biliary dilation.
___ NON-CONTRAST HEAD CT:
IMPRESSION: Stable tiny focus of hyperdensity in the right
frontal centrum semiovale white matter; no new hemorrhage.
___ TEE:
The left atrium is elongated. 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). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. IMPRESSION: Normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function. Mild mitral regurgitation with
normal valve morphology. Mild pulmonary artery systolic
hypertension.
___ RENAL U/S:
IMPRESSION: Unremarkable appearance of the kidneys with only a
tiny left renal simple cyst noted.
___ CXR:
FINDINGS: In comparison with study of ___, there has been
placement of an endotracheal tube with its tip approximately 3
cm above the carina.
Nasogastric tube extends to the mid body of the stomach, then
coils back on itself so that the tip lies in the fundus just
beneath the left hemidiaphragm. There has been the development
of increased opacification at the left base with silhouetting of
the hemidiaphragm and obliteration of the costophrenic angle.
This is consistent with substantial volume loss in the left
lower lobe and pleural effusion.
___ EEG:
IMPRESSION: Abnormal EEG due to the slow, disorganized, and
usually low
voltage background and due to the bursts of generalized slowing.
These
findings indicate widespread encephalopathy affecting both
cortical and
subcortical structures. Medications, metabolic disorders, and
infection are among the most common causes. There were no areas
of prominent focal slowing, but encephalopathies may obscure
focal findings. There were no epileptiform features.
___ MR SPINE:
IMPRESSION: 1. Endplate irregularity at L1/L2, with
hyperintense disc signal. Given the provided history, these
findings raise the possibility of discitis and osteomyelitis.
Note that sclerotic endplate changes are present at the
corresponding level on CT, suggesting that this is likely
related to degenerative findings. Nevertheless, if clinical
concern persists for infection, would recommend repeat imaging
with contrast if the patient's renal function will tolerate,
and/or with sagittal STIR/IDEAL sequences. 2. No other evidence
of spinal infection. 3. Lower lumbar spinal degenerative
findings, including severe narrowing on the left appearing to
impinge upon the traversing left L5 nerve root,
posterior to the L4/5 intervertebral disc. Note is also made of
a left
lateral disc protrusion at L5/S1, with disc material appearing
to contact the exiting left L5 nerve root.
___ MR BRAIN:
Note is made of a 7 x 5 mm focus of abnormally slow diffusion in
the right frontal lobe (series 4 and 5, image 17). There is no
other abnormally slow focus of diffusion to suggest infarction.
Ventricles and sulci are normal in size and configuration. The
focus of abnormally slow diffusion is bright on FLAIR and
T2-weighted images. Scattered smaller FLAIR hyperintense white
matter foci are also visualized, possibly reflecting prior
vascular insult. Primary intracranial flow voids are normal.
Incidental note is made of mineralization at the globus pallidus
bilaterally. A small amount of fluid is seen within the mastoid
air cells on the left, and minimally on the right. Note is made
of mild mucosal thickening of the ethmoid air cells bilaterally.
There is no intracranial hemorrhage, or mass effect.
___ MR ANGIOGRAPHY OF THE BRAIN:
Primary intracranial arterial structures show appropriate flow
related signal hyperintensity. There is no luminal caliber
regularity to suggest
thromboembolic filling defect, dissection or aneurysm. Note is
made of a
large fenestration at the base of the basilar artery. Anatomy
is otherwise conventional in orientation. IMPRESSION: 1. Small
right frontal infarct as described above, with no intracranial
hemorrhage. 2. Fenestration at the base of the basilar artery
and otherwise normal MR angiography of the brain.
___ TEE:
Overall left ventricular systolic function is normal (LVEF>55%).
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is a focal
thickening on the right coronary cusp of the aortic valve which
may be a vegetation (images #37, #41, #89 and #102 amont
others). No annular abscess seen. Mild (1+) centrally directed
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. IMPRESSION:
Possible vegetation on the aortic valve with mild aortic
regurgitation. No other echo evidence of endocarditis/abscess
seen. In comparison to the TTE of ___, on image #2 of the
prior study a similar thickening is seen on the aortic cusp.
___ SHOULDER PLAIN FILMS:
FINDINGS: No acute fracture or dislocation. Normal bone
mineralization, joint spaces, and alignment. Prominence of the
soft tissues in the region of the right shoulder. Imaged portion
of the right lung are clear. Imaged portions of the right ribs
are intact. Endotracheal tube terminates approximately 3.4 cm
proximal to the carina. Nasogastric tube extends below the left
hemidiaphragm. IMPRESSION: 1. No acute fracture or dislocation.
2. No radiographic evidence for osteomyelitis. 3. Support
lines and tubes, unchanged position.
Radiology Report
INDICATION: Right upper quadrant pain, fever, elevated bilirubin. Evaluate
for biliary dilation.
Correlation to CT from ___ Hospital dated ___ at 12:00.
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echogenicity, with a
1.4 x 1.2 x 1.2 cm cyst in segment VI. Normal hepatopetal flow in the portal
vein. There is no intra- or extra-hepatic biliary ductal dilation. The
common duct measures 4 mm. Gallbladder is normal without distention, stones,
sludge, wall edema, or pericholecystic fluid. Ultrasonographic ___ sign
is negative. Pancreatic head and body are normal, and the tail is not well
visualized due to shadowing bowel gas. Pancreatic duct measures 2 mm.
IMPRESSION:
1. Segment VI liver cyst.
2. No biliary dilation.
Radiology Report
INDICATION: ___ female with intracranial hemorrhage and altered
mental status.
COMPARISON: ___ at approximately 3 p.m.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast. Images through the top half of the head were repeated due to motion
artifact, with improvement. Coronal and sagittal reformatted images were
reviewed.
FINDINGS: Tiny focus of hyperdensity in the right frontal deep white matter
appears similar compared to recent prior exam. No focus of new intracranial
hemorrhage, large mass, mass effect, edema, or hydrocephalus is detected.
There is preservation of gray-white matter differentiation. The basal
cisterns appear patent. Mild white matter hypodensity is likely secondary to
sequela of chronic small vessel ischemic disease. Dense bilateral basal
ganglia mineralization is seen. The visualized portions of the paranasal
sinuses and mastoid air cells appear well aerated. No acute bony abnormality
is detected.
IMPRESSION: Stable tiny focus of hyperdensity in the right frontal centrum
semiovale white matter; no new hemorrhage.
Radiology Report
HISTORY: ___ female with AMS, ARF, evaluate for etiology renal
failure.
COMPARISON: Liver ultrasound ___.
FINDINGS:
The right kidney measures 13.0 cm and the left kidney measures 10.4 cm. There
is no hydronephrosis. A tiny simple exophytic cyst is noted at the lower pole
of the left kidney measuring 1.2 x 1.3 x 1.0 cm. No stone or concerning solid
renal mass is visualized. No perinephric fluid collection is identified.
IMPRESSION:
Unremarkable appearance of the kidneys with only a tiny left renal simple cyst
noted.
Radiology Report
HISTORY: Tube placement.
FINDINGS: In comparison with study of ___, there has been placement of an
endotracheal tube with its tip approximately 3 cm above the carina.
Nasogastric tube extends to the mid body of the stomach, then coils back on
itself so that the tip lies in the fundus just beneath the left hemidiaphragm.
There has been the development of increased opacification at the left base
with silhouetting of the hemidiaphragm and obliteration of the costophrenic
angle. This is consistent with substantial volume loss in the left lower lobe
and pleural effusion.
Radiology Report
INDICATION: Altered mental status.
COMPARISON: Head CT from ___.
TECHNIQUE: Multiplanar MR images are acquired through the brain without
intravenous contrast. Three-dimensional time-of-flight MR angiography is also
performed, from which dedicated 3D vascular reconstructions are created.
FINDINGS:
MR BRAIN:
Note is made of a 7 x 5 mm focus of abnormally slow diffusion in the right
frontal lobe (series 4 and 5, image 17). There is no other abnormally slow
focus of diffusion to suggest infarction. Ventricles and sulci are normal in
size and configuration. The focus of abnormally slow diffusion is bright on
FLAIR and T2-weighted images. Scattered smaller FLAIR hyperintense white
matter foci are also visualized, possibly reflecting prior vascular insult.
Primary intracranial flow voids are normal. Incidental note is made of
mineralization at the globus pallidus bilaterally. A small amount of fluid is
seen within the mastoid air cells on the left, and minimally on the right.
Note is made of mild mucosal thickening of the ethmoid air cells bilaterally.
There is no intracranial hemorrhage, or mass effect.
MR ANGIOGRAPHY OF THE BRAIN:
Primary intracranial arterial structures show appropriate flow related signal
hyperintensity. There is no luminal caliber regularity to suggest
thromboembolic filling defect, dissection or aneurysm. Note is made of a
large fenestration at the base of the basilar artery. Anatomy is otherwise
conventional in orientation.
IMPRESSION:
1. Small right frontal infarct as described above, with no intracranial
hemorrhage.
2. Fenestration at the base of the basilar artery and otherwise normal MR
angiography of the brain.
These results were discussed via telephone by Dr. ___ with Dr. ___
___ at 14:25 on ___.
Radiology Report
INDICATION: Altered mental status, concern for endocarditis and question of
septic emboli and/or epidural abscess.
COMPARISON: Comparison is made to an MR of the brain from the same date
dictated separately.
TECHNIQUE: Multiplanar MR images were acquired through the cervical,
thoracic, and lumbar spine without intravenous contrast. Note, the contrast
was withheld secondary to patient's decreased estimated glomerular filtration
rate.
FINDINGS:
MR CERVICAL SPINE: Vertebral body heights are normal. Alignment reveals a
mild scoliotic curvature which may be positional. Marrow signal reveals no
concerning focal abnormalities. Signal within the spinal cord is also normal.
Note is made of small posterior disc bulges at C3/C4 and C5/C6. The latter
results in minimal narrowing of the spinal canal, without evidence of
deformation of the spinal cord. Soft tissue structures of the neck reveal
fluid dependently in the oro- and nasopharynx, likely related to the known
endotracheal intubation.
MR THORACIC SPINE: Vertebral body heights are normal. Alignment is notable
for scoliotic curvature. Marrow signal reveals focal T1-weighted and
T2-weighted hyperintensities in T7 and T8 vertebral bodies, consistent with
hemangiomata. Signal within the spinal cord is normal. There is no spinal
canal stenosis or significant neural foraminal stenosis.
MR LUMBAR SPINE: Vertebral body heights are normal. Alignment is also
normal. Marrow signal reveals meningiomata at L1, 3 and 5. Note is made,
however, of mild endplate irregularity at L1/L2, as well as abnormally
T2-weighted hyperintense signal in the expected location of the L1/L2
intervertebral disc. The conus medullaris terminates posterior to the L1
vertebral body.
At L1/L2, there are abnormal disc endplate changes as described above. Note
is also made of bulging of the disc, as well as a right paracentral annular
fissure. These findings result in mild narrowing of the spinal canal. Note
is also made of moderate right neural foraminal narrowing and minimal left
neural foraminal narrowing.
At L2/L3, there is a circumferential disc bulge which does not narrow the
spinal canal. Both neural foramina are also patent. There is mild bilateral
facet arthropathy.
At L3/L4, there is moderate spinal canal narrowing (series 24, image 11)
related primarily to moderately severe bilateral facet arthropathy, as well as
a circumferential disc bulge. The left neural foramen is patent and the right
neural foramen is moderately narrowed.
At L4/L5, there is a circumferential disc bulge which is eccentric to the
left, as well as moderate bilateral facet arthropathy. Findings result in
mild spinal canal narrowing, as well as impingement of the traversing left L5
nerve root between the disc and the superior articular facet. There is no
neural foraminal stenosis.
At L5/S1, there is a circumferential disc bulge, with focal left lateral
protrusion. The spinal canal is appropriately patent. The right neural
foramen is normal and the left neural foramen is mildly narrowed, with lateral
disc protrusion material appearing to contact the exiting left L5 nerve root.
Incidental note is made of moderate bilateral hydronephrosis.
IMPRESSION:
1. Endplate irregularity at L1/L2, with hyperintense disc signal. Given the
provided history, these findings raise the possibility of discitis and
osteomyelitis. Note that sclerotic endplate changes are present at the
corresponding level on CT, suggesting that this is likely related to
degenerative findings. Nevertheless, if clinical concern persists for
infection, would recommend repeat imaging with contrast if the patient's renal
function will tolerate, and/or with sagittal STIR/IDEAL sequences.
2. No other evidence of spinal infection.
3. Lower lumbar spinal degenerative findings, including severe narrowing on
the left appearing to impinge upon the traversing left L5 nerve root,
posterior to the L4/5 intervertebral disc. Note is also made of a left
lateral disc protrusion at L5/S1, with disc material appearing to contact the
exiting left L5 nerve root.
These results were discussed via telephone by Dr. ___ with Dr. ___
___ at 2:25 p.m. on ___.
Radiology Report
HISTORY: ___ woman with shoulder pain. Evaluation for possible
septic arthritis.
TECHNIQUE: Four views of the right shoulder.
COMPARISON: Portable chest radiograph performed one day prior.
FINDINGS:
No acute fracture or dislocation. Normal bone mineralization, joint spaces,
and alignment. Prominence of the soft tissues in the region of the right
shoulder.
Imaged portion of the right lung are clear. Imaged portions of the right ribs
are intact.
Endotracheal tube terminates approximately 3.4 cm proximal to the carina.
Nasogastric tube extends below the left hemidiaphragm.
IMPRESSION:
1. No acute fracture or dislocation.
2. No radiographic evidence for osteomyelitis.
3. Support lines and tubes, unchanged position.
Radiology Report
INDICATION: Left PICC.
COMPARISON: Chest radiograph from ___.
ONE VIEW OF THE CHEST:
The lungs are low in volume and show mild bibasilar atelectasis. The
cardiomediastinal silhouette and hilar contours are normal. No pleural
effusion or pneumothorax is present. A left PICC terminates in the
brachiocephalic vein.
IMPRESSION:
Left PICC in the brachiocephalic vein. Advancement by 4 cm will place it in
in the lower SVC. Bibasilar atelectasis.
These findings were communicated to ___, RN via telephone at 9:29
a.m. on ___ after discovery at 9:28 p.m.
Radiology Report
INDICATION: New left PICC line exchanged over guidewire. Evaluate for PICC
position.
COMPARISON: Radiograph of the chest ___ and ___.
TECHNIQUE: Portable AP radiograph of the chest.
FINDINGS: A left PICC line terminates in the low SVC. Compared to chest
radiograph ___, there is improvement in vascular congestion and volume
loss and with relief of left lower lobe atelectasis. The endotracheal tube
and nasogastric tube have been removed. There is no vascular congestion or
pneumonia. The cardiomediastinal silhouette and hilar contours are normal.
No pleural effusion or pneumothorax is present.
IMPRESSION:
1. Left PICC in the low SVC.
2. Improvement in left lower lobe atelectasis and resolution of vascular
congestion compared to radiograph 5 days prior. Additionally, the ET tube and
gastric tube have been removed.
Gender: F
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by AMBULANCE
Chief complaint: ICH/RENAL FAILURE
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, FEVER, UNSPECIFIED, INTRACRANIAL HEMORR NOS, HYPERTENSION NOS
temperature: 97.2
heartrate: 90.0
resprate: 20.0
o2sat: 96.0
sbp: 118.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | SUMMARY: Ms. ___ is a ___ woman with a history of
hypertension who was transferred to ___ from ___ after
presenting with altered mental status one week after dental
work. She was found to have worsening creatinine, elevtaed
bilirubin, evidence of urinary tract infection, and a small area
of hypodensity on head CT; blood cultures from ___
ultimately grew group B streptococcus. Imaging (as above) was
consistent with aortic valve vegetation, L1
osteomyelitis/discitis, and septic emboli to the frontal lobe.
She received IV ceftriaxone to treat disseminated GBS infection.
1. Disseminated GBS infection: The patient presented with
altered mental status and acute renal failure as well as
abnormal LFTs of cholestatic profile following dental work. Her
blood cultures from ___ became positive for ___ bottles with
beta-hemolytic Group B strep. In addition, her urine cultures
were positive for E. coli. TTE and TEE were performed and
consistent with vegetation on aortic valve. ID was consulted and
the patient was started on ceftriaxone for endocarditis. RUQ
ultrasound did not reveal cause for elevated LFTs. Brain
MRI/MRA did show a small frontal lobe infarct, which was
presumed secondary to septic embolus. The patient's mental
status cleared over the course of her hospital stay, and she was
felt safe for direct discharge home. Her daughter is a nurse and
will assist with her post-hospital care.
2. L1 osteomyelitis: The patient's MRI had a site at ___
consistent with discitis or osteomyelitis. ID following, and
recommended ___ weeks of ceftriaxone therapy. She will be
followed as an outpatient in ___ clinic. Surveillence cultures
have been negative.
3. Acute kidney injury: The patient's creatinine on admission
5.8 from a presumed normal baseline. Creatinine rapidly
normalized with the administration of fluid and antibiotics and
was 1.1 at the time of discharge.
4. Shoulder/right-sided pain: Following extubation, the patient
complained of significant pain of her right shoulder and general
pain of her right side. Orthopedics was consulted. X-ray showed
no fracture or effusion of her right shoulder. Orthopedics
attempted to tap joint, but arthrocentesis was dry. The patient
had significant pain, which was not relieved with Dilaudid. The
acute pain service was called and recommended Dilaudid PO with
oxycontin. Toradol was added for presumed inflammatory pain,
which appeared to help significantly. At the time of discharge,
she was weaned to MS contin 30 mg PO BID and ___ mg PO dilaudid
Q3H PRN for breakthrough in addition to standing acetaminophen.
She was seen by the occupational therapy service who felt pain
may be secondary to tendonitis from overuse (occupational).
5. Hyperbilirubinemia, elevated alkaline phosphatase: Both are
suggestive of hepatic obstruction, although the patient's right
upper quadrant ultrasound was negative for dilation. Of unclear
etiology, though possibly related to disseminated infection.
LFTs were downtrending at the time of discharge but should be
monitored as an outpatient to ensure resolution.
6. Hypertension: Patient was on atenolol and HCTZ at home. Both
were held in setting of acute kidney injury. She was
normotensive at the time of discharge. Medications should be
resumed as an outpatient at the discretion of PCP.
7. Uterine prolapse: During this admission, the patient was
noted to develop ? uterine prolapse. She was able to urinate
normally and without pain. Follow up with urogynecology was
arranged at discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left sided weakness and numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with a history of HTN who
presented to an OSH with left sided weakness and numbness, found
to have a right basal ganglia bleed.
His symptoms began at 11pm last night (___) with a headache
after getting home from a dinner party. He took advil. At 1:30
am this morning he began to notice left hand numbness and
weakness. The symptoms then progressed to involve his entire arm
and leg as well as some facial numbness which is now improving.
He woke up his wife who thought he was having a stroke and
brought him to the ED. CT head at the OSH showed IPH. SBP was
noted to be 200. He was given keppra and vitamin K and
transferred to ___. At ___, BP was in the ___ systolic
and he was started on a nicardipine gtt.
He endorsed ongoing left sided weakness and sensation changes.
He has difficulty using his left hand and has not tried to walk
with his left leg weakness. He feels the sensation in his face
has improved. He also endorses some mild SOB.
Past Medical History:
HTN
HLD
Social History:
___
Family History:
- HTN in father. no strokes in the family
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vitals:
98.3 114 163/79 18 96% RA
___: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple
Pulmonary: CTABL
Cardiac: tachycardic, intermittently to 120s and 130s with
activity. RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language is fluent with ___ accent. Intact
repitition, comprehension and naming to high and low frequency
items. There were no paraphasic errors. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Attentive, able to name ___ backward without
difficulty. Had finger substitution with coming hair but not
with teeth brushing or unlocking a door.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch. pinprick is 50% on L
compared to R.
VII: No facial droop, facial musculature symmetric
VIII: Hearing intact to ___ bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in SCM bilaterally. Shoulder shrug is weak on
the left (4+/5)
XII: Tongue protrudes in midline
-Motor: Normal bulk throughout. Decreased tone on left. Marked
pronator drift on left. No adventitious movements, such as
tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- ___- ___- ___ 4 5- 4+
R ___ ___ ___ 5 5 5 5
-DTRs: noted to be 1 at patella bilaterally, 0 at achilles
- Plantar response was flexor on right, extensor on left.
-Sensory: Compared to the right, light touch is full on the
face,
80% in arm/leg; pinprick is 50% on face and 0% on arm/leg; cold
sensation is "mild" on left arm/leg. vibration and
proprioception
are intact.
-Coordination: No intention tremor, no dysmetria on FNF noted on
right; exam on left limited by weakness.
-Gait: deferred for fall risk
DISCHARGE PHYSICAL EXAM:
=================================
Vitals:
Tc: 97.7 Tm:98.3 BP: SBP ___ ___ RR:18 99% RA
___: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR, no M/R/G
Abdomen: soft, nontender, nondistended, +BS
Extremities: no edema
Neurologic:
-Mental Status: Alert, oriented. Language is fluent with
___ accent. Able to follow commands. Attentive. No
paraphasic errors.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, slight NLFF on Right.
VIII: Hearing intact to ___ bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in SCM bilaterally.
XII: Tongue protrudes in midline
-Motor: Normal bulk throughout. No adventitious movements, such
as
tremor, noted.
Delt Bic Tri WrE FFl IP Quad Ham
L ___ 5 5 ___
R ___ 5 5 ___
-Sensory: Light touch intact bilateral.
-Coordination: No intention tremor, no dysmetria on FNF noted on
right
-Gait: deferred
Pertinent Results:
ADMISSION LABS:
======================
___ 04:25PM BLOOD ___
___ Plt ___
___ 04:25PM BLOOD ___
___ Im ___
___
___ 04:25PM BLOOD ___ ___
___:25PM BLOOD ___
___
___ 04:25PM BLOOD ___
___
___ 04:30PM URINE ___
___
___ 04:30PM URINE ___ Sp ___
DISCHARGE LABS:
======================
___ 07:20AM BLOOD ___
___ Plt ___
___ 07:20AM BLOOD ___
___ Im ___
___
___ 07:20AM BLOOD ___ ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD ___
___
___ 07:20AM BLOOD ___
___ 07:20AM BLOOD ___
IMAGING:
=====================
CT HEAD W/O CONTRAST ___
IMPRESSION:
1. Slight enlargement of the 2.7 x 1.2 cm left putaminal
hematoma. Mild
surrounding edema.
2. No new areas of hemorrhage.
3. Minimal local ___.
MRI & MRA BRAIN AND MRA ___
IMPRESSION:
1. Left putaminal hematoma in a location most typical of a
hypertensive
hemorrhage.
2. Unremarkable MRA of the head and neck.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Sertraline 50 mg PO DAILY
3. Losartan Potassium 50 mg PO BID
4. Pravastatin 40 mg PO QPM
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Losartan Potassium 50 mg PO BID
3. Pravastatin 40 mg PO QPM
4. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left Basal Ganglia Bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with intracranial hemorrhage // please perform
repeat CT to eval for change in intracranial hemorrhage at 130 AM
___ year old man with intracranial hemorrhage, please repeat to evaluate for
change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.7 cm; CTDIvol = 48.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
Unenhanced head CT ___ at 13:37.
FINDINGS:
Again seen is a left putaminal hematoma measuring 2.7 x 1.2 cm in axial
___ (series 2, image 16), that appears slightly larger than on the
prior head CT from ___ at 13:37. There is mild surrounding edema.
There is no evidence of new or additional focus of hemorrhage elsewhere.
There is no evidence of infarction. There is minimal local mass effect. The
ventricles and sulci are stable and normal in caliber and configuration. The
visualized paranasal sinuses and mastoid air cells are clear. The globes and
bony orbits are intact and unremarkable.
IMPRESSION:
1. Slight enlargement of the 2.7 x 1.2 cm left putaminal hematoma. Mild
surrounding edema.
2. No new areas of hemorrhage.
3. Minimal local mass-effect.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old man with L basal ganglia bleed // assess etiology
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: Head CT from ___
FINDINGS:
MRI Brain:
Again seen is left putamen hematoma with associated surrounding FLAIR signal
abnormality and minimal mass effect causing effacement of the frontal horn of
left lateral ventricle.
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are patent and symmetric noting the
mild effacement of the frontal horn of left lateral ventricle.
Scattered foci of T2/FLAIR hyperintensity in the subcortical and
periventricular white matter and pons, nonspecific, likely secondary to small
vessel ischemic changes.
The orbits are unremarkable. Visualized paranasal sinuses and mastoid air
cells are clear.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation.
Incidentally seen is fetal origin of bilateral posterior cerebral arteries.
MRA neck: The common, internal and external carotid arteries appear normal.
There is no evidence of internal carotid artery stenosis by NASCET criteria.
The origins of the great vessels, subclavian and vertebral arteries appear
normal bilaterally.
IMPRESSION:
1. Left putaminal hematoma in a location most typical of a hypertensive
hemorrhage.
2. Unremarkable MRA of the head and neck.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified, Essential (primary) hypertension
temperature: 98.2
heartrate: 110.0
resprate: 18.0
o2sat: 98.0
sbp: 148.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ ___ man with HTN, HLD,
prior hypertensive right BG bleed ___, ___ Neurology) with
no residual ___ who presented on ___ with right
facial droop and dysarthria, found to have a new left basal
ganglia intraparenchymal hemorrhage on imaging.
#Neuro: Patient initially presented to ___
on ___emonstrated hemorrhage in the basal
ganglia. He was transferred to ___ for further management. On
initial exam (___), patient had a mild right facial droop
and dysarthria but no aphasia, and no new weakness. Repeat
___ CT (___) at ___ showed slight enlargement of
the 2.7 x 1.2 cm left putaminal hematoma. He was evaluated by
Neurosurgery who did not find an indication for surgical
intervention and was admitted to the Neurology service. We
suspected hypertension as the cause of his hemorrhage based on
location, clinical history and prior hypertensive ICH. MRI on
___ again showed left putaminal hematoma in a location most
typical of a hypertensive hemorrhage. MRA of the head and neck
(___) was unremarkable. His stroke workup also included
lipid panel which showed Cholesterol 187, Triglycerides 91, LDL
90. His TSH was 2.5. A1c was pending at the time of discharge.
During admission, aspirin, NSAIDS and all antiplatelet agents
were held and his BP was controlled with a goal SBP<140. On
discharge, patient had stable to improved exam with only slight
right nasolabial fold flattening.
#CV:
-We continued his home amlodipine 10mg daily, losartan 50mg BID
for goal SBP<140. He was monitored on telemetry without
significant events.
#ENDO:
-His blood sugars were monitored with routine finger sticks, and
controlled with an insulin sliding scale
#TOX/METAB: Patient received workup for underlying
___ derangements. His urine and serum tox screens
were negative. Urinalysis did not show e/o infectious process.
#TRANSITIONAL ISSUES:
=======================
- ___ with primary care physician
- ___ with outpatient Neurology |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
GTC seizure, respiratory/cardiac arrest
Major Surgical or Invasive Procedure:
Intubation ___
Left PICC Placement ___
___ Guided LP ___
___ guided ___ tube placement ___
History of Present Illness:
___ w/PMHx HTN and history of seizure who was transferred from
___ for seizure and is being admitted to the MICU
post-cardiac arrest. History is largely derived from notes, as
patient is intubated on arrival. Per report, patient was
watching TV during which time he had a witnessed GTC seizure
lasting approximately 1 minute. He bit his tongue and lost
bladder continence. Patient was smoking marijuana and drinking
alcohol at the time. He denied any trauma or headache. He denied
any significant alcohol history. When EMS arrived, pt was noted
to be post ictal and combative, requiring restraints and Haldol.
He was initially brought to ___.
At ___ 98.6; 90; 122/70; 18; 96% (unknown supplemental
oxygen). He was reportedly pleasant and cooperative on arrival.
Labs were notable for Na 119, K 2.8, Mg 1.3, H/H 11.5/31.9 (MCV
90.6), Prolactin 117.5 STox with positive marijuana, UTox with
EtOH level of 20. Patient was given 1L NS and brought to ___
for further evaluation.
___ the ED, initial vitals: 97.2; 88; 144/84; 18; 96% RA
On exam pt was noted to have an enlarged liver and swollen
tongue.
Labs were significant for:
Na 119
K 3.7
Bicarb 27
Mg 1.2
Phos 1.9
Imaging was significant for:
NCHCT
IMPRESSION:
1. No acute intracranial abnormality.
2. There is a 0.3 cm extra-axial calcified lesion adjacent to
the falx, which may represent a tiny meningioma.
3. There is a large polyp that extends from the right frontal
sinus into the anterior ethmoidal air cells and multiple mucous
retention cysts or polyps ___ the bilateral maxillary sinuses and
sphenoid sinuses.
After returning from his ___, pt called the emergency call
bell ___ the bathroom and was found slumped over on toilet and
cyanotic. It is no clear if there was a pulse. Chest
compressions started immediately and code called. Moved back to
stretcher, and was noted to have pulse and compressions stopped.
Per report, he underwent ___ rounds of compressions. Patient was
subsequently intubated.
Post arrest VBG was ___ with lactate 16.3. Repeat ABG was
7.40/34/295/22 and lactate 6.6.
On exam: There was no reported spontaneous movement afterward.
Patient was given
IV Calcium Gluconate (2 g ordered)
IV DRIP Fentanyl Citrate ___ mcg/hr ordered) Started 50
mcg/hr
IV DRIP Midazolam (0.5-2 mg/hr ordered) Started 2 mg/hr
IVF NS ( 1000 mL ordered)
IVF Sodium Chloride 3% (Hypertonic) - 500 mL
IV Magnesium Sulfate (4 gm)
Patient was also started on bicarb gtt at 150cc/hr.
Consults: Post-arrest Team recommended consideration of cooling.
On transfer, vitals were:
98.3; 82; 121/75; 100% (vent settings not recorded)
On arrival to the MICU, patient was breathing against the
ventilator and appeared to be pulling at lines and his clothing.
However, he did not follow commands, though he was notably on
fentanyl/midazolam gtt.
Past Medical History:
HTN
Seizure ___ setting of alcohol withdrawal
Evidence of seizure activity, even when not withdrawing
History of trauma to LLE as a teenager
EtOH abuse
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 137; 168/73; 39; 97% PSV FiO2 50% ___
GENERAL: Intubated, sedated. ETT ___ place. Withdraws to noxious
stimuli. Does not open eyes to command.
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-distended, bowel sounds present, firm liver with
edge approximately 5cm below costophrenic angle. No ascites
appreciated.
GU: Foley ___ place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Deformity of LLE, with well-healed scars.
SKIN: No lesions.
NEURO: Upgoing Babinski bilaterally. Sluggish pupils
bilaterally, equal. Withdraws to noxious stimuli. During exam,
patient began biting ETT and posturing, appearing to be having a
GTC. After this, patient appeared to be having jerking movements
of his lower jaw, consistent with myoclonus.
ACCESS: PIVs
DISCHARGE EXAM:
=====================
Vitals: 98.1 PO 142 / 95 98 20 96 Ra
GENERAL: Alert and interactive, oriented x 3, NAD
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: Clear to auscultation anteriorly without wheezes, rales,
rhonchi
ABDOMEN: Soft, non-tender, mildly-distended, bowel sounds
present, +firm hepatomegaly, no rebound or guarding
EXTREMITIES: Warm, well perfused, 2+ pulses
NEURO: Alert and oriented x 3. Mildly dysarthric. Finger to nose
intact. Heel to shin mildly impaired.
Pertinent Results:
ADMISSION LABS
==============
___ 05:19AM BLOOD WBC-8.3 RBC-3.08* Hgb-10.5* Hct-29.0*
MCV-94 MCH-34.1* MCHC-36.2 RDW-14.6 RDWSD-50.4* Plt ___
___ 05:19AM BLOOD Neuts-83.5* Lymphs-5.8* Monos-9.9
Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.91* AbsLymp-0.48*
AbsMono-0.82* AbsEos-0.01* AbsBaso-0.02
___ 08:31AM BLOOD ___ PTT-30.5 ___
___ 08:31AM BLOOD ___ 04:00AM BLOOD Glucose-122* UreaN-4* Creat-0.5 Na-119*
K-3.7 Cl-81* HCO3-27 AnGap-15
___ 05:30AM BLOOD ALT-88* AST-286* AlkPhos-197*
TotBili-3.8* DirBili-1.8* IndBili-2.0
___ 05:30AM BLOOD CK-MB-4 cTropnT-<0.01
___ 04:00AM BLOOD Calcium-8.6 Phos-1.9* Mg-1.2*
___ 05:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:37AM BLOOD ___ pO2-37* pCO2-93* pH-6.95*
calTCO2-22 Base XS--16
___ 05:37AM BLOOD Lactate-16.3*
___ 08:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:00AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.5 Leuks-NEG
___ 08:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT LABS
==============
___ 08:00AM BLOOD calTIBC-335 Ferritn-201 TRF-258
___ 08:00AM BLOOD Osmolal-253*
___ 08:00AM BLOOD TSH-4.1
___ 08:00AM BLOOD Free T4-1.7
___ 02:41AM BLOOD Cortsol-12.9
___ 07:00PM BLOOD Cortsol-12.8
___ 10:09PM BLOOD Cortsol-22.4*
___ 02:53PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-122*
Polys-65 ___ Macroph-20
___ 02:53PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-78
LD(LDH)-27
DISCHARGE LABS AND OTHER RELEVANT LABS
=======================================
___ 06:50AM BLOOD WBC-6.3 RBC-3.28* Hgb-11.1* Hct-33.9*
MCV-103* MCH-33.8* MCHC-32.7 RDW-15.9* RDWSD-60.7* Plt ___
___ 06:50AM BLOOD ___ PTT-35.1 ___
___ 06:50AM BLOOD Glucose-112* UreaN-3* Creat-0.4* Na-135
K-4.7 Cl-100 HCO3-22 AnGap-18
___ 06:50AM BLOOD ALT-33 AST-85* AlkPhos-274* TotBili-1.2
___ 06:50AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.5 Mg-1.7
___ 03:31AM BLOOD Vit___-___*
___ 08:00AM BLOOD calTIBC-335 Ferritn-201 TRF-258
___ 03:30AM BLOOD Triglyc-121
___ 08:00AM BLOOD TSH-4.1
___ 08:00AM BLOOD Free T4-1.7
___ 10:09PM BLOOD Cortsol-22.4*
___ 08:50AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
IMAGING
=======
CT HEAD ___:
1. Normal CT of the brain..
2. Extensive opacification of the left ethmoid and frontal
sinuses with
erosion of the ethmoid septae deep. This may represent a
mucocele, a polyp or a neoplasm. Further evaluation with direct
visualization and perhaps MR imaging may be helpful.
RIGHT UPPER QUADRANT U/S ___:
1. Nodular echogenic liver concerning for cirrhosis.
2. Splenomegaly and small volume ascites suggests portal
hypertension.
3. Main portal vein and central branches are patent with
hepatopetal flow.
CTA CHEST ___:
No evidence of pulmonary embolism or aortic abnormality.
Enteric tube is ___ place and terminates within the distal
esophagus, recommend advancement. Long segment distal
esophageal wall thickening, consider esophagitis.
Bibasilar moderate left lower lobe, mild right lower lobe
atelectasis, with areas of bilateral lower lobe mucous plugging.
Lung nodules, largest measures 0.4 cm, benign and no further
follow-up needed ___ the absence of history of smoking or
malignancy. If there is history of smoking, follow-up CT chest
without contrast ___ 12 months recommended.
Inhomogeneous attenuation of the liver, may be due to fatty
infiltration or underlying liver disease.
___ Guided LP ___
1. Lumbar puncture at L4-5 without complication.
2. Elevated opening pressure of 32 cm CSF.
Ankle XR ___
No radiopaque foreign bodies.
Chronic fracture deformity of the left tibia, fibula.
Foot XR b/l one view ___
Pin fixation third toe.
Bunion deformities first MTP joints bilaterally
Knee Single View b/l ___
No radiopaque foreign bodies.
Subtle lucency right tibial metaphysis, subacute fracture cannot
be excluded,
clinically correlate.
Fracture deformity of the left fibula.
Degenerative changes bilateral knees.
CXR ___
1. Interval removal of an enteric tube.
2. Low lung volumes with bronchovascular crowding and bibasilar
opacities, probably atelectasis. Concurrent pneumonia cannot
be excluded ___ the appropriate clinical setting, particularly ___
the right lung.
CT HEAD ___
No interval change from head CT ___. No evidence of
anoxic brain
injury.
MICROBIOLOGY
============
___ Culture, Routine-PENDING
___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
___ CULTURE-FINAL no growth
___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-FINAL no growth
___ CSF; SPINAL FLUID HSV1/HSV2 NEGATIVE
___ SCREEN-FINAL negative
___ Culture, Routine-FINAL no growth
___ Culture, Routine-FINAL no growth
___ CULTURE-FINAL no growth
NEUROPHYSIOLOGY
===============
EEG ___
This is an abnormal continuous ICU EEG monitoring study because
of a severely suppressed background. No epileptiform activity
was identified with the one pushbutton activation noted. The
presence of extended periods with muscle artifact could have
masked subtle findings. Interim results were provided to the
treatment team intermittently during this recording period.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lisinopril-hydrochlorothiazide ___ mg oral DAILY
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. CefTAZidime 2 g IV Q12H Duration: 8 Days
2. FoLIC Acid 1 mg PO DAILY
3. Keppra XR (levETIRAcetam) ___ mg oral DAILY
4. Lactulose 30 mL PO Q6H
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Rifaximin 550 mg PO BID
7. Thiamine 100 mg PO DAILY
8. Diltiazem Extended-Release 240 mg PO DAILY
9. HELD- Levothyroxine Sodium 50 mcg PO DAILY This medication
was held. Do not restart Levothyroxine Sodium until your doctor
says it is okay
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
======================
-Seizure (multifactorial, not only from EtOH withdrawal)
-Alcohol Abuse
-Hyponatremia
-New cirrhosis diagnosis
SECONDARY DIAGNOSES
=======================
-HTN
-Seizure ___ setting of alcohol withdrawal
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory arrest s/p ETT placement // Is
the ETT in the correct Is the ETT in the correct
IMPRESSION:
In comparison with the study of earlier in this date, the endotracheal tube
has been pushed forward so that the tip lies approximately 6 cm above the
carina. The tip of the nasogastric tube can only be followed definitely to
the lower esophagus. If this clinically a has been advanced beyond this
point, a repeat study could be obtained with the upper margin at the hilum
pain using abdominal technique.
Little change in the appearance the heart and lungs.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with firm hepatomegaly // Is there normal flow
through the liver? Is there evidence of mass in the liver?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma is diffusely heterogeneous and echogenic. The
degree of echogenicity makes it difficult to fully assess the hepatic
architecture. No gross liver lesion is identified. The contour of the liver
is nodular. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not visualized due to overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 12.7 cm.
KIDNEYS: The right kidney measures 12.2 cm. The left kidney measures 13.4 cm.
Visualization of the kidneys is limited. No hydronephrosis is seen
bilaterally.
DOPPLER EXAMINATION: The main and left portal veins are patent with
hepatopetal flow. The intrahepatic right portal vein is not well visualized
due to limited visualization of the liver. The hepatic veins are patent.
Appropriate arterial waveforms are seen in the main, right and left hepatic
arteries.
IMPRESSION:
1. Patent hepatic vasculature. Note is made of limited visualization of the
portal veins.
2. No gross liver lesion identified. The hepatic parenchyma is heterogeneous,
echogenic and nodular. No biliary dilatation.
3. The spleen is at the upper limits of normal.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ man with seizure, now post arrest. Starting cooling
protocol, evaluate for evidence of anoxic brain injury.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 926 mGy-cm.
COMPARISON: Head CT ___ 04:30.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The patient is intubated. Again seen, are
numerous bilateral maxillary sinus mucous retention cysts versus polyps.
There is a rim calcified polypoid lesion in the anterior right ethmoid air
cells resulting in erosion of the ethmoid septa. This lesion extends into the
right frontal sinus superiorly and superior nasal passage inferiorly. There
is mucosal thickening in the sphenoid sinus and ethmoid air cells. The
mastoid air cells are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Polypoid opacification of the right anterior ethmoid air cells causing
ethmoid septa erosion and extending into the frontal sinus and nasal passage,
as recommended previously, if clinically indicated and further
characterization is needed consider MR imaging or direct visualization.
RECOMMENDATION(S): If clinically indicated, direct visualization or MR
imaging to further characterize ethmoid sinus findings.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with picc // l dl picc 48cm iv ping ___
Contact name: ping, ___: ___ l dl picc 48cm iv ping ___
IMPRESSION:
Compared to chest radiographs earlier on ___.
New left PIC line ends in the low SVC close to the superior cavoatrial
junction. Tip of nasogastric tube just above the upper margin of the
clavicles, no less than 6 cm from the carina should not be withdrawn any
further. Nasogastric drainage tube ends in the low esophagus and is probably
looped in the hypopharynx. It would need to be advanced at least 15 cm to
move all the side ports into the stomach.
Borderline cardiomegaly is stable. Aside from mild right basal atelectasis,
lungs are clear. No pleural abnormality.
NOTIFICATION: PIC line placement was reported to the IV nurse by telephone at
13:00.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with hyponatremia with large variations in Na
level. // eval for cerebral edema
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 925 mGy-cm.
COMPARISON: Head CT ___ 09:55
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. There is no CT
evidence of osmotic demyelination syndrome.
There is no evidence of fracture. There multiple submucosal retention cysts
in bilateral maxillary, right frontal sinuses. There is ovoid fullness in the
right ethmoid sinus, stable since prior, causing expansion of the septa,
extending into the right nasal cavity. There is new fluid in the right
maxillary sinus, likely from tube use. Bilateral mastoid air cells, middle
ear cavities are patent. The The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. There are no new intracranial abnormalities.
2. Polypoid mass in the right ethmoid sinus, nasal cavity stable.
Radiology Report
EXAMINATION: CTA of the chest
INDICATION: ___ year old man with hypoxic event found in PEA. // Eval 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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 1.5 s, 1.0 cm; CTDIvol = 3.5 mGy (Body) DLP = 3.5
mGy-cm.
3) Spiral Acquisition 8.3 s, 31.8 cm; CTDIvol = 12.1 mGy (Body) DLP = 366.3
mGy-cm.
Total DLP (Body) = 379 mGy-cm.
COMPARISON: Chest x-ray ___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. Heart is mildly enlarged.
Coronary artery calcifications. There is no pleural effusion.
There is moderate right, mild left lower lobe mucous plugging. There is
moderate volume loss and consolidation the left lower lobe from atelectasis,
and mild atelectasis in the right lower lobe. There is 0.4 cm nodule in the
right lower lobe series 6, image 171. 0.3 cm nodule right middle lobe series
6, image 131. 0.2 cm nodule right upper lobe image 87.
Endotracheal tube is in place, the tip terminates 5 cm above the carina.
Enteric tube is in place. The tip is within the distal esophagus, as seen on
___ 11:57 radiograph, recommend advancement. Long segment distal
esophageal wall thickening, consider esophagitis. Visualized liver shows a
heterogeneous enhancement pattern, this may be due to fatty infiltration or
underlying liver disease. There is a small amount of perihepatic ascites.
Left PICC is in place, the tip terminates in the upper most SVC.
There are multiple nondisplaced subtle fractures of the anterior bilateral
ribs, of indeterminate age. Benign mid vertebral body hemangioma. There is
mild T11 compression fracture, age indeterminate, possibly chronic there is no
adjacent edema.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Enteric tube is in place and terminates within the distal esophagus, recommend
advancement. Long segment distal esophageal wall thickening, consider
esophagitis.
Bibasilar moderate left lower lobe, mild right lower lobe atelectasis, with
areas of bilateral lower lobe mucous plugging.
Lung nodules, largest measures 0.4 cm, benign and no further follow-up needed
in the absence of history of smoking or malignancy. If there is history of
smoking, follow-up CT chest without contrast in 12 months recommended.
Inhomogeneous attenuation of the liver, may be due to fatty infiltration or
underlying liver disease.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 5 EXAMS
INDICATION: ___ year old man with hypernatremia, post- ?seizure // NG tube
placement NG tube placement
IMPRESSION:
Compared to 3 chest radiographs on ___.
5 successive chest radiographs performed over 15 min show failure to advance
the esophageal drainage tube in beyond the level of the gastroesophageal
junction. Several of the images, including the final one in the series,
performed at 00:35 shows a proximal loop of the drainage tube in the
hypopharynx. Final radiograph in the series also shows top-normal heart size,
low lung volumes, no focal consolidation, mild pulmonary vascular engorgement,
but no edema or pleural effusion.
Tip of the ET tube above the upper margin of the clavicles is no less than 6
cm from the carina and could be advanced 2 cm for more secure positioning.
Radiology Report
EXAMINATION: PELVIS PORTABLE
INDICATION: ___ year old man found down, hx of trauma to bilateral legs //
any e/o residual surgical hardware?
TECHNIQUE: Pelvis single view
COMPARISON: None
FINDINGS:
Foley catheter in place. Mild degenerative changes lower lumbar spine,
bilateral hips. Pelvic phleboliths. No fractures.
IMPRESSION:
No fractures.
Radiology Report
EXAMINATION: KNEE( (SINGLE VIEW) BILATERAL
INDICATION: ___ year old man found down, hx of trauma to bilateral legs //
any e/o residual surgical hardware?
TECHNIQUE: Single AP view bilateral knees, one view each side.
COMPARISON: None
FINDINGS:
Right knee: Subtle mid diaphyseal lucency of the proximal tibia, subacute
fracture cannot be excluded. Degenerative arthritis of the right knee, with
hypertrophic changes. Arterial calcifications.
Left knee: Degenerative arthritis of the left knee, medial compartment
narrowing. Chronic fracture deformity of the fibular diaphysis, with
posttraumatic heterotopic calcification. Arterial calcifications.
IMPRESSION:
No radiopaque foreign bodies.
Subtle lucency right tibial metaphysis, subacute fracture cannot be excluded,
clinically correlate.
Fracture deformity of the left fibula.
Degenerative changes bilateral knees.
Radiology Report
EXAMINATION: ANKLE 1 VIEW BILATERAL
INDICATION: ___ year old man found down, hx of trauma to bilateral legs //
any e/o residual surgical hardware?
TECHNIQUE: Single AP view bilateral ankles
COMPARISON: None
FINDINGS:
Right ankle: Soft tissue calcification inferior to medial malleolus, well
___ be related to prior trauma, no adjacent soft tissue swelling.
There are benign soft tissue calcifications in the distal leg. There are no
fractures. Right ankle otherwise normal.
Left ankle: There is chronic, displaced healed fracture of the distal tibial
diaphysis,, with significant callus formation. Significant ossification
projects over distal tibia at the fracture site and distal to it, likely
posttraumatic. Chronic posttraumatic deformity of the mid fibular diaphysis.
The degenerative changes ankle. No soft tissue swelling. No radiopaque
foreign bodies.
IMPRESSION:
No radiopaque foreign bodies.
Chronic fracture deformity of the left tibia, fibula.
Radiology Report
EXAMINATION: FOOT 1 VIEW BILATERAL
INDICATION: ___ year old man found down, hx of trauma to bilateral legs //
any e/o residual surgical hardware?
TECHNIQUE: Single AP view of each foot, one view each side
COMPARISON: None
FINDINGS:
Right foot: Bunion deformity, degenerative changes first MTP joint. Mild
degenerative changes midfoot. No fractures.
Left foot: Pin fixation across PIP, DIP joint third toe. Bunion deformity,
degenerative changes first MTP joint. Scattered degenerative changes midfoot.
Posttraumatic or postsurgical change PIP joint fifth toe. No fractures.
IMPRESSION:
Pin fixation third toe.
Bunion deformities first MTP joints bilaterally
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE.
INDICATION: ___ year old man found down cyanotic with concern for central
infection // Please obtain CSF.
TECHNIQUE: After informed consent was obtained from the patient's healthcare
proxy over the phone explaining the risks, benefits, and alternatives to the
procedure, the patient was laid in prone position on the fluoroscopic table.
A pre-procedure time-out was performed confirming the patient's identity,
relevant history, procedure to be performed and labs.
Puncture was performed at L4-5.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 22 gauge, 13 cm spinal needle was inserted into
the thecal sac. There was good return of clear CSF. 16 mls of CSF were
collected in 4 tubes and sent for requested analysis.
Fluoroscopy time: 0.2 min
Air kerma: 8.1 mGy
Dose area product: 52.69 uGy cm 2
COMPARISON: None.
FINDINGS:
16 mls of clear CSF were collected in 4 tubes. Opening pressure was measured
at 32 cm CSF.
IMPRESSION:
1. Lumbar puncture at L4-5 without complication.
2. Elevated opening pressure of 32 cm CSF.
I, Dr. ___ supervised the trainee during the key components of
the above procedure and I reviewed and agree with the trainee's findings and
dictation.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with likely respiratory arrest, now positive
sputum gram stain, c/f PNA // interval change
TECHNIQUE: Portable semi upright view of the chest
COMPARISON: Chest radiograph from ___
FINDINGS:
The tip of an ETT is seen approximately 6.3 cm above the carina. Lung volumes
are low with bronchovascular crowding and bibasilar opacities, likely
representing atelectasis. Concurrent pneumonia cannot be excluded in the
appropriate clinical setting, particularly in the right lung. The enteric
tube has been removed. The cardiomediastinal silhouette and hilar contours
are likely unchanged. No pneumothorax or pulmonary edema. The left PICC has
been pulled back and is seen in the low SVC.
IMPRESSION:
1. Interval removal of an enteric tube.
2. Low lung volumes with bronchovascular crowding and bibasilar opacities,
probably atelectasis. Concurrent pneumonia cannot be excluded in the
appropriate clinical setting, particularly in the right lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with likely respiratory arrest, now positive
sputum gram stain, c/f PNA // interval change interval change
IMPRESSION:
Comparison to ___, 11:05. No relevant change is noted. Moderate
cardiomegaly. Mild retrocardiac atelectasis. No evidence of pneumonia. No
larger pleural effusions. No pulmonary edema. The monitoring and support
devices, including the endotracheal tube, are stable.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old man with AMS, intubated // interval change
TECHNIQUE: Single AP
COMPARISON: Chest radiograph ___.
FINDINGS:
Heart size within normal limits. A left PICC line terminates in the mid SVC.
An endotracheal tube ends in the mid thoracic trachea. Persistent ill-defined
opacities at the left lung base are unchanged. No significant pleural
effusion.
IMPRESSION:
Persistent ill-defined opacities at the left lung base are unchanged, but
improved from ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man s/p cardiac arrest, continued AMS, previous CT
with no e/o intracranial abnormalities however concerned for evolving process.
// interval change, e/o anoxic brain injury?
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 927 mGy-cm.
COMPARISON: CT head ___
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.
There are multiple mucous retention cysts in both maxillary sinuses and right
frontal sinus. There is ovoid fullness of the right ethmoid sinus with
rightward deviation of the nasal septum, unchanged. There is mild mucosal
thickening the sphenoid sinuses and left ethmoid air cells Mastoid air cells
and middle ear cavities are well aerated. The bony calvarium is intact.
IMPRESSION:
No interval change from head CT ___. No evidence of anoxic brain
injury.
Radiology Report
EXAMINATION: NASOINTESTINAL TUBE PLACEMENT WITH FLUOROSCOPY
INDICATION: ___ year old man with need for PO access and unable to place with
glidescope.// Please place NG or OG tube
DOSE: Acc air kerma: 42.1 mGy; Accum DAP: 1233.5 uGym2; Fluoro time: 4.1
minutes
COMPARISON: None.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, ___ feeding tube was placed into the
stomach and then advanced post-pylorically using a guidewire.
10 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the tip of the feeding tube in the
second portion of the duodenum.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Successful post-pyloric placement of ___ feeding tube. The tube
is ready to use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with alcohol abuse and increased secretions. //
interval changes interval changes
IMPRESSION:
Comparison to ___. The patient remains intubated and has
received a feeding tube. The course of this tube is unremarkable, the tip is
not displayed on the image. The left PICC line is unchanged. Minimally
increased fluid overload but no overt pulmonary edema. Atelectatic
retrocardiac lung zone. No larger pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new retrocardiac opacities, originally read
as atelectasis, continues to be febrile, c/f PNA // interval change
interval change
IMPRESSION:
Comparison to ___. No relevant change is noted. The monitoring
and support devices are stable. There is a stable retrocardiac opacity more
likely to reflect atelectasis but the presence of additional pneumonia cannot
be excluded on the basis of the radiographs alone. No larger pleural
effusions. Mild fluid overload but no overt pulmonary edema. Mild
cardiomegaly persists.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pseudomonal pneumonia// Eval for interval
change in consolidation Eval for interval change in consolidation
IMPRESSION:
In comparison with the study of ___, the Dobhoff tube has been removed
and the patient has taken a better inspiration. Cardiac silhouette remains at
the upper limits of normal in size and there is mild elevation of pulmonary
venous pressure. Minimal bibasilar atelectatic changes without evidence of
acute focal pneumonia.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with EtOH history, and uptrending alk phos//
hepatic congestion?
TECHNIQUE: Abdominal ultrasound
COMPARISON: Abdominal ultrasound from ___ and CT C-spine from ___
FINDINGS:
The liver appears enlarged, echogenic with nodular contour concerning for
cirrhosis. No discrete lesion is seen within the liver. Trace right pleural
effusion is suspected. Common bile duct is nondilated. Pancreas not well
visualized. No intrahepatic biliary ductal dilation. Gallbladder is
collapsed. No gallstones are seen. Spleen is mildly enlarged at 14.2 cm in
length. Limited views of both kidneys demonstrate no hydronephrosis. A small
cyst arising from the left renal midpole is noted measuring up to 2.3 cm.
Small volume ascites tracks into the lower quadrant.
Doppler: Main portal vein is patent with hepatopetal flow. The right and left
branches of the portal vein are patent with hepatopetal flow. The hepatic
arterial system appears patent with normal waveforms. Color flow is noted
within the hepatic veins.
IMPRESSION:
1. Nodular echogenic liver concerning for cirrhosis.
2. Splenomegaly and small volume ascites suggests portal hypertension.
3. Main portal vein and central branches are patent with hepatopetal flow.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with seizure // eval for intracranial mass/bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 48.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 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.
No fractures. There are multiple (greater than 15) mucous retention cysts or
polyps in the bilateral maxillary sinuses. There is erosion of the ethmoid
septae eye in the right ethmoid sinus and extending into the right frontal
sinus. This may represent an ethmoid sinus mucocele, one or several polyps, a
neoplasm or a combination of these factors. If the distinction between polyp
versus neoplasm and mucocele is clinically significant, magnetic resonance
imaging may be helpful. There are few small mucous retention cysts/ polyps in
the bilateral sphenoid sinuses. The mastoid air cells and middle ear cavities
are clear. The orbits are unremarkable.
IMPRESSION:
1. Normal CT of the brain..
2. Extensive opacification of the left ethmoid and frontal sinuses with
erosion of the ethmoid septae deep. This may represent a mucocele, a polyp or
a neoplasm. Further evaluation with direct visualization and perhaps MR
imaging may be helpful.
RECOMMENDATION(S): Centered or visualization and MR imaging for further
evaluation of the ethmoid sinus findings
NOTIFICATION: The recommendation of direct visualization and perhaps MR
imaging for further evaluation of the ethmoid sinus findings was emailed to
the Emergency Department QA nurses 10:12 ___ by Dr. ___
___ upon reviewing the study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with seizure // confirm endotracheal tube placement
TECHNIQUE: Single portable supine AP chest radiograph
COMPARISON: None.
FINDINGS:
The endotracheal tube terminates approximately 9.2 cm above the carina.
Heart and mediastinum are normal.
Lungs are clear.
No pleural effusion. No pneumothorax.
IMPRESSION:
1. The endotracheal tube terminates 9.2 cm above the carina.
2. No acute cardiopulmonary abnormality.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Seizure, Transfer
Diagnosed with Abn lev hormones in specimens from female genital organs, Epilepsy, unsp, not intractable, without status epilepticus, Cardiac arrest, cause unspecified
temperature: 97.2
heartrate: 88.0
resprate: 18.0
o2sat: 96.0
sbp: 144.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | ___ with alcohol use disorder and HTN who presented to ___
with alcohol withdrawal/hyponatremic seizure, long hospital
course complicated by further seizure activity, persistent
encephalopathy with eventual recovery and pseudomonal pneumonia.
Per report, the patient was at home drinking and had an episode
of loss of consciousness with rhythmic shaking and concern for
seizure. He was brought to an outside hospital where he was
found to have positive alcohol level and was hyponatremic (Na
116). He was transferred to ___ where he was again
hyponatremic and then found to be unresponsive ___ the ED
bathroom, cyanotic and without pulse. CPR was initiated and
after approximately 1 minute of chest compressions he regains a
pulse. He was admitted to the ICU for monitoring of seizures
related to hyponatremia/alcohol withdrawal. He was intubated and
sedated for airway protection and was initiated on phenobarbital
protocol for alcohol withdrawal. Patient's family endorsed ___
year history of heavy alcohol use, with accelerated use ___ the
last year. He had a history of alcohol withdrawal seizure 6
months prior. He subsequently had several subsequent episodes of
seizure activity ___ the ICU. Neurology was consulted and felt
that seizures were due to presenting hyponatremia as well as
alcohol withdrawal, but that subsequent seizures were unrelated
and possibly related to some degree of anoxic brain injury
related to his arrest. Throughout his ICU stay he was
persistently agitated and encephalopathic. He developed a
pseudomonal pneumonia treated with ceftazidime. He received
treatment for alcohol withdrawal with high dose thiamine, folate
and multivitamin repletion as well as phenobarbital taper which
actually repeated again after the pt was persistently delirious
and tachycardic. He was also noted to have cirrhosis on liver
imaging and started on treatment for hepatic encephalopathy.
After prolonged course his mental status recovered and he was
alert and oriented x3 without focal neurologic deficits on
discharge. He was discharged to rehab.
# Agitation:
# Encephalopathy
# Delirium
___ hospital course notable for severe agitation,
confusion. Etiology was felt to be multifactorial due to
hospital delirium, alcohol withdrawal, seizures, and hepatic
encephalopathy. Once transferred to the medical floor his
delirium resolved. He was treated for delirium with Seroquel,
lactulose and rifaximin, thiamine, folate and multivitamin
repletion, and phenobarbital taper. It was thought possible that
he had sustained some degree of anoxic brain injury during his
arrest, but MRI imaging was not performed as the patient had
improved so rapidly.
# Seizures: Head CT without abnormalities. Seizures initially
felt to be due to hyponatremia and alcohol withdrawal.
Subsequent seizures were felt to have been possibly related to
some degree of anoxic brain injury related to his cardiac arrest
(below). MRI imaging was not obtained due to the patient's rapid
improvement ___ mental status. He should be continued on Keppra
XR 2,000mg daily (or Keppra 1000mg BID) with follow-up with
Neurology.
# Alcohol use disorder: Per family report patient with very
heavy use of alcohol ("gallons"). He should engage ___ ongoing
alcohol rehabilitation. He was treated with high dose thiamine
repletion regimen as well as folate and multivitamins.
# Transaminitis:
# Nodular liver/cirrhosis
# Hepatitis
Patient's right upper quadrant ultrasound had evidence of liver
nodularity and on exam he had nontender hepatomegaly. He likely
has alcoholic cirrhosis with superimposed hepatitis. Ultrasound
also showed splenomegaly and mild ascites suggestive of
increased portal pressures. He should have follow-up ___
___ clinic for management of cirrhosis, screening for
varices and he also needs Hep B vaccine.
# Pseudomonas Pneumonia: Pt growing pseudomonas on sputum from
___ started on ceftazidime. Likely acquired during aspiration
event during seizure. Course is ceftazidime x14 days
(___). He had no pneumonia symptoms at time of discharge.
# Tongue injury: Pt bit tongue during seizure, large piece of
tongue now missing. Oral maxilofacial surgery was consulted and
he as placed on prophylactic antibitoics for 7 day course. These
were completed and he had no evidence of infection.
# Sinus tachycardia: He had persistent sinus tachycardia of
unclear origin with negative workup including negative CTA
chest. His heart rates improved as his agitation decreased. He
was palced on diltiazem as this was a home medication. He was
discharged on diliazem XL 240 mg daily.
# Elevated INR: He was noted to have an elevated INR to 1.6
which improved to 1.3 with vitamin K challenge. Likely component
of possible cirrhosis.
# Increased stool output: Had diarrhea which was negative for C
diff and other infectious studies. It resolved on its own
without changes to his antibiotics.
# HTN: Home lisinopril-HCTZ was held. He was continued on
diltiazem as above.
# Hypothyroidism: Patient was on levothyroxine at home. His TSH
was normal this admission and his levothyroxine was held. Please
reevaluate his TSH ___ 4 weeks and restart as appropriate.
# Anemia: ___ be related to alcohol. His iron studies, and B12
were not low. No evidence of bleeding.
# Respiratory Arrest:
# Cardiac Arrest:
# Acute hypoxic resp failure:
Patient with cardiac arrest ___ ___ ED. Etiology unclear. Per
report was found to be pulseless and cyanotic ___ ED bathroom,
CPR started and pt regained consciousness within 1 minute.
Downtime may have been up to 10 minutes per report. MRI was not
performed as patient was rapidly recovering neurologic function.
#Hyponatremia: Likely caused his initial seizures. Unclear
etiology, probably nutritional. Corrected and remained normal
during his stay.
#Shock. Hypotensive ___ the ICU to ___, treated with
Norepinephrine. Likely ___ pseudomonal PNA, see above.
# Healthcare proxy: a healthcare proxy form was signed this
admission by the patient naming the patient's sister ___
___ as his healthcare proxy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Effexor / codeine / amoxicillin / omeprazole /
arthrexa / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
New R facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with PMHx of ETOH abuse, IDDM, epilepsy,
Schizophrenia, and Hepatitis C, recent GIB (___)
presenting to the ED with weakness, right facial droop, and
fever.
As patient unable to give details prior to EMS arrival and
husband not at bedside, pre-admission details per Neurology
evaluation note.
Pt seen at baseline health this afternon following a trip from
beauty shop. Husband ___ became concerned when he
noted non-rhythmic upper body shaking and the pt felt warm to
touch. Pt able to respond appropriately to him, but called EMS
given recent admission.
EMS called by patient's husband due to shaking and altered
mental status. Per EMS, initial VS on assessmeent T: 103 BP:
170/80 with slow affect, abnormal R sided facial droop,
tremulous, weakness b/l grip strength, without slurred speech
GCS 15. Fingerstick WNL.
Pt transferred to ___ ED for concern for stroke.
Past Medical History:
Schizophrenia with auditory hallucinations
Type II DM (insulin dependent)
Hypertension
Hepatitis C (untreated), genotype 1b - Fibroscan score Metavir
Stage ___, per last GI note ___ anticipate initiation
of lediposuvir-sofosbuvir when approved by insurance
Seizure disorder, complex partial, on depakote (last seizure ___
years ago)
Collagenous enteritis and microscopic colitis
Chronic low back pain
EtOH abuse with hx of withdrawal hallucinations
Social History:
___
Family History:
Mother with colon cancer, father with leukemia, brother with
sickle cell and sister with lupus and lung cancer. No family
history of renal disease.
Physical Exam:
VS 97.6 155/68 78 20 96% RA
General: Alert, oriented x 3, slow affect but appropriate
HEENT: Sclera anicteric, MMM, EOMI, PERRL
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, no tenderness of lower abdomen with palpation. No
rebouund, guarding or rigidity. No suprapubic tenderness.
Non-distended, bowel sounds present
GU: No flank pain
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAO x3, moving all extremities
Pertinent Results:
___ 07:10AM BLOOD WBC-16.3* RBC-2.92* Hgb-8.5* Hct-24.7*
MCV-85 MCH-29.1 MCHC-34.4 RDW-15.6* RDWSD-46.0 Plt ___
___ 07:30PM BLOOD WBC-22.8*# RBC-3.16* Hgb-9.6* Hct-27.9*
MCV-88 MCH-30.4 MCHC-34.4 RDW-15.7* RDWSD-48.6* Plt ___
___ 07:10AM BLOOD Glucose-124* UreaN-12 Creat-0.7 Na-133
K-3.5 Cl-100 HCO3-21* AnGap-16
___ 07:30PM BLOOD ALT-20 AST-55* AlkPhos-177* TotBili-0.6
___ 07:25AM BLOOD Valproa-33*
___ 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q8H
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat discomfort
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 100 mg PO TID
5. HumaLOG (insulin lispro) 8 Units subcutaneous TID
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. LOPERamide 2 mg PO QID:PRN loose stools
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Nicotine Patch 21 mg TD DAILY
11. OLANZapine 10 mg PO QHS
12. Thiamine 100 mg PO DAILY
13. Tizanidine 2 mg PO QHS
14. Vitamin D 1000 UNIT PO DAILY
15. Amlodipine 5 mg PO DAILY
16. insulin glargine 30 units subcutaneous QPM
17. Lisinopril 40 mg PO DAILY
18. Magnesium Oxide 400 mg PO DAILY
19. Pantoprazole 40 mg PO Q12H
20. Phosphorus 500 mg PO BID
21. Divalproex (DELayed Release) 250 mg PO BID
22. LaMOTrigine 25 mg PO EVERY OTHER DAY
23. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat discomfort
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 100 mg PO TID
5. HumaLOG (insulin lispro) 8 Units subcutaneous TID
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Lisinopril 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. LOPERamide 2 mg PO QID:PRN loose stools
10. Magnesium Oxide 400 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Thiamine 100 mg PO DAILY
13. Phosphorus 500 mg PO BID
14. Pantoprazole 40 mg PO Q12H
15. Nicotine Patch 21 mg TD DAILY
16. Multivitamins 1 TAB PO DAILY
17. Amlodipine 5 mg PO DAILY
18. Divalproex (DELayed Release) 250 mg PO BID
19. insulin glargine 30 units subcutaneous QPM
20. OLANZapine 10 mg PO QHS
21. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain
22. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*20 Tablet Refills:*0
23. LACOSamide 100 mg PO BID
RX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
E. coli bacteremia
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 new right sided weakness after possible
seizure. Evaluate for mass/stroke/intracranial lesion.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo,
and diffusion-weighted images of the brain were obtained. 3D time-of-flight
MRA of the brain was obtained with multiplanar maximum intensity projection
angiographic reformatted images. 2D time-of-flight MRA of the neck was
obtained with multiplanar maximal intensity projection angiographic
reformatted images. 3D coronal T1 weighted gradient echo imaging of the neck
was obtained before, during, and after intravenous gadolinium administration
with multiplanar maximum intensity projection angiographic reformatted images.
COMPARISON: Brain MRI with intravenous contrast ___.
Noncontrast head CT ___. CTA head and neck ___.
FINDINGS:
BRAIN MRI: There is no acute infarction. Punctate focus of high signal in
the right anterior frontal cortex on the diffusion tracer sequence (image
17:16), without a correlate on the ADC map or FLAIR images, is consistent with
artifact.
There is no evidence for an intracranial mass, parenchymal edema, or blood
products. Few small foci of high T2 signal in the left frontal deep white
matter appear slightly progressed since ___, nonspecific but
compatible with sequela of mild chronic small vessel ischemic disease in a
patient of this age. A punctate focus of high T2 signal at the anterior
margin of the right internal capsule is unchanged. Ventricles and sulci are
prominent due to parenchymal volume loss, unchanged since ___ but
unexpected for age.
Major dural venous sinuses are patent on postcontrast MP RAGE images.
There is mild mucosal thickening in the maxillary sinuses.
NECK MRA: There is a 3 vessel aortic arch. Common carotid and bilateral
cervical carotid arteries are patent without stenosis by NASCET criteria.
Mild irregularity of the proximal right internal carotid artery, corresponding
to mild atherosclerotic plaque on the ___ CTA, is unchanged. Evaluation of
the right vertebral artery origin is limited by artifact. The remainder of
the right vertebral artery, as well as left vertebral artery, are widely
patent without stenosis.
BRAIN MRA: Images are moderately limited by motion artifact. Irregular
appearance of bilateral carotid siphons is likely exaggerated by artifacts, as
the demonstrate only minimal plaque on the ___ CTA. The major anterior
circulation branches, as well as the intracranial vertebral arteries and their
major branches, appear patent without evidence for flow-limiting stenosis.
Posterior circulation MIP images suggest a small right lateral outpouching of
the proximal basilar artery, but this is explained by tortuosity of the distal
right vertebral artery as well as artifact on the source data. No evidence
for an aneurysm greater than 3 mm is seen.
IMPRESSION:
1. No acute infarction and no evidence for other acute intracranial
abnormalities. No evidence for an intracranial mass.
2. Few small foci of high T2 signal in the left frontal deep white matter
appear slightly progressed since ___, nonspecific but compatible
with sequela of mild chronic small vessel ischemic disease in a patient of
this age.
3. Global parenchymal volume loss is unexpected for age but unchanged compared
to ___.
4. Limited evaluation of the right vertebral artery origin. Otherwise, no
evidence for flow-limiting arterial stenosis in the neck.
5. Moderately motion limited brain MRA demonstrates no evidence for
flow-limiting intracranial arterial stenosis. Irregularity of bilateral
carotid siphons is likely exaggerated by artifacts, as the demonstrated only
minimal plaque on the ___ CTA.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with GNR bacteremia from presumed urinary
source // assess for pyelonephritis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdomen ultrasound ___
FINDINGS:
The right kidney measures 10.8 cm. The left kidney measures 12.4 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is normal in appearance, with postvoid ___ of 6.1 x 3.2 x
4.2 cm.
IMPRESSION:
No renal stones, hydronephrosis or abscesses. Complete assessment for
pyelonephritis requires a contrast enhanced study such as CT or MRI.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Facial droop, Weakness
Diagnosed with SEPTICEMIA NOS, URIN TRACT INFECTION NOS, SEPSIS , ACCIDENT NOS, SEMICOMA/STUPOR
temperature: 101.0
heartrate: 123.0
resprate: nan
o2sat: nan
sbp: 126.0
dbp: 69.0
level of pain: nan
level of acuity: 1.0 | # R facial droop: She presented to the ED with weakness, right
facial droop, and fever. Code Stroke called in ED; per Neurology
evaluation unlikely vascular etiology given prior occurrences,
esp in setting of post-ictal ___ paralysis. On exam no facial
and extremity weakness noted. MRI and EEG were negative. Per
neuro, dc'd lamotrigine and depakote; added ativan PRN seizure
activity and vimpat 100mg BID. During hospital course she did
not develop seizures.
# Urinary Tract Infection w/ bacteremia: UA grossly positive,
blood cultures growing gram neg rods. She was started on
ceftriaxone 1g IV, sensitive. During hospitalization she
experienced rigors which resolved on own. She remained afebrile
during hospital course. WBC downtrending at time of discharge.
She was sent home with ciprofloxacin po to complete 14 day
course of antibiotic tx.
# ___: Cr elevated at 1.3 from baseline, down to 0.9 around time
of discharge. ___ was likely ___ UTI.
# Abdominal pain: h/o recent upper GIB, found to have multiple
stomach and duodenal ulcers. Elevated gastrin, no h.pylori
detected. No recurrent episodes of BRBPR or melena. No varices
on EGD. We continued pantoprazole and trended H/H daily.
# Back pain: She has chronic lower back pain. We gave her
lidocaine patch and tylenol prn, which relieved symptoms.
# Hx of EtOH use: Patient reported that she hadn't had a drink x
6 months (three months per recent d/c summary). She did not
develop signs of withdrawal during hospitalization.
# IDDM: Pt insulin dependent, continued home Glargine 30 units
QPM, Humalog 8 units TID, and administered an ISS while in
hospital
# Schizophrenia: Olanzapine and benztropine were held given c/f
intermittent AMS. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Gantrisin Pediatric / Keflex / Latex / Erythromycin
Base / Codeine / Percocet / Nitroglycerin / Darvocet-N 100 /
Epinephrine / Cortisone / Skelaxin / Ultram / Ciprofloxacin /
Meloxicam
Attending: ___.
Chief Complaint:
Severe epigastric pain radiating to back
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with asthma, IDDM, GERD, fibromyalgia, HLD,
HTN, PUD, and anxiety presents with acute onset of epigastric
pain radiating around both flanks and to her right shoulder
blade. She reports having daily epigastric pain ___ GERD, but
two days ago she began having abdominal pain that was slightly
worse. She also reports increased flatulence, and mildly foul
taste in her mouth. Yesterday she had a small supper of an
omelette, and soon after began having severe epigastric pain
that came on quickly. It was ___ and worse than any pain she
had experienced before. Nothing made the pain better, and she
tried moving in all positions. It radiated around both sides to
her back and up under her right shoulder blade. She denies CP or
positional changes. She felt it was slightly worse with
breathing. She denies fever, shortness of breath. She had no
nausea, or vomitting, but her stomach did not feel well and she
had a bad taste in her mouth persistently. She feels it was
slightly relieved with prilosec. She had a bowel movement last
night that she described as "yellow" and has been passing gas
regularly. She had no melena, or blood in her stool. The pain
persisted overnight and was relieved slightly after hours of not
eating. She came to the ED this morning still in severe pain.
She denies any history of gall stones, and does not drink
alcohol. She denies any history of hypercalcemia but does have
hyperlipidemia. She reports that last week she had elevated BP
related to stress and was taking hydrochlorothiazide more often
than regularly. She usually only takes ___ a tablet when she has
edema, but last week she took a full tab every day, which is
"more than I ever take."
In the ED, initial vs were T 97.6, HR 70, BP 203/84, RR 18, O2
99% on RA. She received atenolol for her elevated BP. Given
chest pain, had cardiac work up: EKG showed no change from
previous and initial troponins were negative. Found to have
elevated lipase and started on IVF, patient refused pain meds.
RUQ ultrasound was limited by body habitus but showed a normal
gall bladder with no distention or stones. Transfer VS T 97.9,
HR 60, BP 185/70, RR 14, O2 100% on RA
On arrival to the floor, patient reports that her pain is much
improved with oxycodone. She denies any headache or vision
changes, and reports her elevated BP is about where it has been
at home.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
- GERD
- DM type 2
- HLD
- HTN
- Peptic ulcer disease
- Diverticulosis
- Diverticulitis treated medically
- Anxiety
- Asthma
- DJD
- Osteoarthritis
- Chronic hives
- LBP
- Obesity
- Fibromyalgia
- Irritable bowel syndrome
- Herpes simplex
Social History:
___
Family History:
Mother - ___ cancer, GERD
Father - ___ died of a blood clot. Intractable HTN since he was
___. CAD
Physical Exam:
ADMISSION EXAM:
VS: 98.8, 201/88, 88, 98%RA
GEN: comfortable, NAD, laying in bed, Alert, oriented, recoutns
above story and very good historian
HEENT: Dry mucosa with poor dentition, sclera anicteric,
NECK: Pickwickian and large, supple
PULM: Good aeration, CTAB no wheezes, rales, ronchi, auscultated
posteriorly and anteriorly
CV: RRR normal S1/S2, no mrg
ABD: Obese, soft, mild tenderness on very deep epigastric
palpation,normoactive bowel sounds, no r/g
EXT: No ___ edema, 2+ pulses palpable bilaterally
NEURO: CNs2-12 intact, motor function grossly normal, sat up on
her own, no focal deficits
DISCHARGE EXAM:
VS T 97.9, BP 158/82, HR 56, 18 RR, O2 96%RA, FSBG 119-247
Is and Os: I PO not recorded but had liquids, IV 3.4Ls, O BRP
GEN Alert, oriented, no acute distress
HEENT EOMI, moist mucus membranes, sclera anicteric, OP clear
with no erythema, exudates or lesions
NECK supple, obese, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi. No dullness
to percussion. No sign of pleural effusion
CV RRR normal S1/S2, no mrg
ABD soft, obese, normoactive bowel sounds, non-distended. Mildly
tender to deep palpation in the epigastric region; worse in LUQ
than RUQ. Says pain is ___ when press. No rebound or guarding.
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers, leisions, rashes, or hives
Pertinent Results:
ADMISSION LABS:
___ 11:10AM BLOOD WBC-10.7 RBC-4.85 Hgb-14.1 Hct-43.0
MCV-89 MCH-29.0 MCHC-32.8 RDW-12.5 Plt ___
___ 11:10AM BLOOD Neuts-76.9* Lymphs-16.7* Monos-4.7
Eos-1.3 Baso-0.4
___ 11:10AM BLOOD Plt ___
___ 11:10AM BLOOD Glucose-267* UreaN-15 Creat-0.7 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-14
___ 11:10AM BLOOD ALT-9 AST-18 AlkPhos-76 TotBili-0.4
___ 09:10PM BLOOD cTropnT-<0.01
___ 11:10AM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.8 Mg-1.9
___ 11:10AM BLOOD Triglyc-160*
PERTINENT LABS:
___ 11:10AM BLOOD Lipase-129*
___ 09:10PM BLOOD cTropnT-<0.01
IMAGING:
___ CXR:
No acute cardiopulmonary process. Specifically, no evidence of
pleural effusion.
___ LIVER AND GB US:
IMPRESSION:
Limited study due to patient body habitus demonstrates no acute
findings. The gallbladder is normal with no evidence of stones
or distention.
___: MRI ABDOMEN W/O CONTRAST
IMPRESSION:
1. Mild acute pancreatitis with edema in the pancreatic head and
surrounding fat stranding. Compression of the pancreatic duct
within the head of the pancreas secondary to the pancreatic
edema. No evidence of pancreatic necrosis.
2. No evidence of biliary obstruction. No biliary calculi.
3. 1.8 x 1.2 cm right adrenal adenoma.
4. Multiple subcentimeter cystic lesions within the pancreatic
body which likely represent side-branch IPMNs. Follow-up MRI in
___ year is recommended.
.
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-8.7 RBC-4.54 Hgb-13.3 Hct-40.4 MCV-89
MCH-29.2 MCHC-32.8 RDW-12.6 Plt ___
___ 06:00AM BLOOD Glucose-119* UreaN-9 Creat-0.8 Na-141
K-3.9 Cl-101 HCO3-27 AnGap-17
___ 06:00AM BLOOD ALT-8 AST-17 LD(LDH)-198 AlkPhos-66
TotBili-0.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO BID
hold for sbp < 100, hr < 55
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. budesonide *NF* 0.25 mg/2 mL Inhalation Daily:PRN wheezing
4. Clotrimazole Cream 1 Appl TP BID:PRN rash
5. Hydrochlorothiazide 12.5 mg PO DAILY
hold for sbp < 100, hr < 55
6. NPH 30 Units Breakfast
NPH 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Lorazepam ___ mg PO Q8H:PRN anxiety
hold for sedation
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
10. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO QID
2. Clotrimazole Cream 1 Appl TP BID:PRN rash
3. NPH 32 Units Breakfast
NPH 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
5. Lorazepam ___ mg PO Q8H:PRN anxiety
hold for sedation
6. Omeprazole 20 mg PO BID
7. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. ZYRtec *NF* 10 mg Oral qd prn itchiness
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
10. Budesonide *NF* 0.25 mg/2 mL INHALATION DAILY:PRN wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Pancreatitis
SECONDARY:
- Hypertension
- Type 2 Insulin Dependent DM
- GERD
- Non insulin dependent Type 2 DM
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: Acute onset epigastric pain and tenderness, question
pleural effusion.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. No focal
consolidation, pleural effusion, or evidence of pneumothorax is seen. The
aorta is somewhat tortuous. The cardiac silhouette is top normal. No overt
pulmonary edema is seen. Some degenerative changes are seen along the spine,
stable.
IMPRESSION: No acute cardiopulmonary process. Specifically, no evidence of
pleural effusion.
Radiology Report
HISTORY: Elevated lipases with abdominal pain.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
The study is limited due to patient body habitus. Again noted is a 1.6 x 1.0 x
1.2 cm hypoechoic structure in segment 4B of the liver without flow,
consistent with a simple cyst. Otherwise, the remainder of the liver is
within normal limits. There is no intra or extrahepatic ductal dilatation with
the common bile duct measuring 4 mm. The main portal vein is patent with
hepatopetal flow. The gallbladder is normal with no evidence of stones or
distention. The spleen is limited in evaluation but appears normal where
seen.
IMPRESSION:
Limited study due to patient body habitus demonstrates no acute findings. The
gallbladder is normal with no evidence of stones or distention.
Radiology Report
HISTORY: Elevated lipase and signs and symptoms consistent with pancreatitis.
Right upper quadrant ultrasound benign. CBD obstruction/stone? Not looking
for abscess or fluid collection.
TECHNIQUE: Multiplanar T2 and axial T1 weighted sequences were acquired on a
1.5 Tesla magnet without intravenous contrast.
The patient states a history of previous contrast allergy to gadolinium.
FINDINGS:
There is T2 hyperintensity surrounding the head of the pancreas on the T2
weighted fat saturated sequence (sequence 6 image 15), consistent with edema.
There is also surrounding fat stranding. The pancreatic duct within the head
of the pancreas appears compressed (sequence 8 image 2) -which is likely
secondary to the edema in the pancreatic head. The remainder of the
pancreatic duct is within normal limits. Multiple subcentimeter pancreatic
cystic lesions are noted within the body of the pancreas (sequence 8 image 2)
with the largest measuring 6 mm in diameter (sequence 3 image 16). No focal
fluid collections. The pancreas is otherwise unremarkable. There is a mildly
enlarged lymph node superior to the pancreatic neck measuring 0.7 cm in short
axis diameter (sequence 6 image 11).
Multiple T2 hyperintense cystic lesions are noted within the liver, the
largest of which measures 1.3 cm in diameter in segment IVb (sequence 4 image
14) - these likely represent biliary hamartomas. The liver is otherwise
unremarkable. No intra or extrahepatic duct dilatation. The gallbladder is
normal.
There is a 1.8 x 1.2 cm lesion within the lateral limb of the right adrenal
gland which demonstrates signal loss on the out of phase sequences (sequence 5
image 13) consistent with a right adrenal adenoma. It is unchanged since the
previous CT dated ___. The left adrenal gland is within normal
limits. There is a subcentimeter simple cyst within the upper pole of the
right kidney. The kidneys are otherwise unremarkable. The spleen is within
normal limits. The visualized small and large bowel is unremarkable. No
retroperitoneal adenopathy. Bone marrow signal is normal. No destructive
osseous lesions.
IMPRESSION:
1. Mild acute pancreatitis with edema in the pancreatic head and surrounding
fat stranding. Compression of the pancreatic duct within the head of the
pancreas secondary to the pancreatic edema. No evidence of pancreatic
necrosis.
2. No evidence of biliary obstruction. No biliary calculi.
3. 1.8 x 1.2 cm right adrenal adenoma.
4. Multiple subcentimeter cystic lesions within the pancreatic body which
likely represent side-branch IPMNs. Follow-up MRI in ___ year is recommended.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with ACUTE PANCREATITIS
temperature: 97.6
heartrate: 70.0
resprate: 18.0
o2sat: 99.0
sbp: 203.0
dbp: 84.0
level of pain: 13
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with a history of GERD, PUD,
DM2, HLD, HTN, asthma and anxiety who presents with acute onset
severe epigastric pain that radiated to her flanks, back, and
under her right scapula. She was found to have an elevated to
lipase to 129. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Gluten / Percocet / sugar / adhesive tape / mosquito / Lactose /
onions / clindamycin
Attending: ___.
Chief Complaint:
urinary frequency/leg sweliing
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is a very pleasant ___ with PMHx breast
cancer, single kidney ___ prior TB infx, chronic dCHF not on
diuretics, hx SBO, hx Pott's disease, and recently diagnosed C.
diff (discharged ___ after admission for worsening cdiff while
on flagyl, was switched to PO vanc) presenting with urinary
frequency without dysuria, back pain and bilateral ___ edema.
Back pain is atraumatic, located in thoracic spine at site of
deformity, non-radiating and worse with position changes. No
perineal anesthesia, numbness/tingling/weakness or urinary/fecal
retention/incontinence. Pts urinary frequency occurred in
setting of increase in BMs, as pt states that she has urination
with every BM and this has increased in setting of cdiff. Leg
swelling is bilateral and pitting, accompanied by mild pain and
itching. She has had mild ankle swelling in the past which she
thinks improved with new diet started last ___, however has
never had ___. No recent increase in salt intake, no dietary
changes other than decrease in fruits/vegetables since diarrhea
began. No SOB, mild cough x1 month. No chest pain. Finally pt
endorses red spots on legs and hands, first noticed yesterday.
She states overall she is feeling better from the standpoint of
her c diff infection.
In the ED, initial vitals were: 99.1 64 130/80 14 94% RA. Exam
was notable for bilateral pitting edema to the knees, pulm exam
with RLL crackles. CXR showed possible small right pleural
effusion. Otherwise, no acute cardiopulmonary process.
Initially read was concerning for PNA, therefore patient was
given a dose of ceftriaxone and admitted to the medicine for
further management.
On the floor, pt states that her diarrhea has improved
significantly since switching to vanc, less explosive and more
formed, however still frequent and having 5, however at ___ has
4. Endorses constant nausea in last year-year and a half. Abd
pain persists since c. diff dx, however is stable. Endorses HA,
which is unusual for her, band like from forehead rading to back
of head, no photophobia, vision changes, now resolved. Pt also
states that she has recently been less active than prior due to
c. diff infx. Denies respiratory sxs.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies vomiting, constipation. No dysuria. Denies
arthralgias or myalgias. 10 pt ros otherwise negative.
Past Medical History:
migraines
H/o breast cancer ___ yrs s/p lumpectomy, refused chemo
Spondylosis
Celiac disease
Carpal tunnel syndrome
GERD
Pott's disease
Raynaud's
H/o TB, dx'd at age ___, pt states she never received treatment
Kyphosis
HFpEF
H/o SBO
H/o L hip replacement
s/p L nephrectomy
heart murmur
HLD
Hemorrhoids
s/p hip replacement x2
Social History:
___
Family History:
(per chart, confirmed with pt): Sister with jaw cancer. Mother
and father with heart problems, arthritis
Physical Exam:
ADMISSION EXAM:
Vitals: 97.9 PO107 / 71 63 18 93 RA
Constitutional: Alert, oriented, no acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENT: MMM, oropharynx clear
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, has faint
L-sided crackles which clear with inspiration
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, 2+ bilat pitting edema to knees
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: several small, faint red papules on dorsum of hands bilat
and bilat ___: severe kyphosis, thoracic spine abnormality with no TTP,
mild overlying erythema with no skin breakdown.
DISCHARGE EXAM:
Vitals: 98.1
PO 122 / 77 56 18 94 RA
Constitutional: Alert, oriented, no acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENT: MMM, oropharynx clear
Neck: Supple, JVP not elevated
CV: RRR, no m/r/g
Respiratory: clear bilaterally
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
EXT: Warm, well perfused, trace bilat pitting edema to knees
(after pulling down her compression stockings which she was
wearing)
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: several small, faint red papules on dorsum of hands bilat
and bilat ___: severe kyphosis, thoracic spine abnormality with no TTP,
mild overlying erythema with no skin breakdown. Mepilex
overlying the area of erythema
Pertinent Results:
Labs on admission:
___ 05:29PM URINE HOURS-RANDOM
___ 05:29PM URINE UHOLD-HOLD
___ 05:29PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:10PM GLUCOSE-106* UREA N-10 CREAT-0.9 SODIUM-140
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-31 ANION GAP-15
___ 05:10PM ALT(SGPT)-20 AST(SGOT)-35 CK(CPK)-79 ALK
PHOS-57 TOT BILI-0.4
___ 05:10PM cTropnT-<0.01
___ 05:10PM CK-MB-2 proBNP-231
___ 05:10PM ALBUMIN-4.2
___ 05:10PM WBC-4.8 RBC-4.36 HGB-13.0 HCT-41.7 MCV-96
MCH-29.8 MCHC-31.2* RDW-14.0 RDWSD-48.6*
___ 05:10PM NEUTS-70.1 ___ MONOS-6.9 EOS-2.9
BASOS-0.6 IM ___ AbsNeut-3.34 AbsLymp-0.91* AbsMono-0.33
AbsEos-0.14 AbsBaso-0.03
___ 05:10PM PLT COUNT-239
STUDIES:
CXR
Possible small right pleural effusion. Otherwise, no acute
cardiopulmonary
process given limitation detailed above.
EKG: TWI in inferlatoral leads, unchanged from prior.
Bilateral ___ Doppler ultrasounds ___:
INDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
0.9 x 1.0 x 0.4 cm ___ cyst is identified in left medial
popliteal fossa.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity
veins.
2. Small left ___ cyst.
Discharge Labs:
___ 06:25AM BLOOD WBC-6.3 RBC-3.70* Hgb-11.2 Hct-35.1
MCV-95 MCH-30.3 MCHC-31.9* RDW-13.9 RDWSD-48.2* Plt ___
___ 06:25AM BLOOD Glucose-79 UreaN-11 Creat-0.8 Na-138
K-4.8 Cl-101 HCO3-29 AnGap-13
___ 06:25AM BLOOD Calcium-8.9 Phos-4.6* Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vancomycin Oral Liquid ___ mg PO Q6H
2. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lower Extremity Swelling
___ Cyst
C diff infection
Immobility
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 bilateral lower extremity swelling // Please assess
for pulmonary congestion, pneumonia
TECHNIQUE: Chest radiograph dated ___.
COMPARISON: None.
FINDINGS:
Thoracic cavity is distorted due to patient's severe kyphosis noted at the
lower thoracic spine as on prior. Low lung volumes. There is obscuration of
the right lateral costophrenic angle suggesting underlying effusion. Patchy
opacities at the bases bilaterally likely reflect atelectasis. No additional
focal consolidations to suggest pneumonia. No pulmonary edema. Stable
appearance of the cardiomediastinal silhouette. No pneumothorax. Severe
kyphotic deformity of the thoracolumbar spine is re- demonstrated, unchanged.
IMPRESSION:
Possible small right pleural effusion. Otherwise, no acute cardiopulmonary
process given limitation detailed above.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with bilateral ___ swelling and pain. also
history of breast CA. // rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
0.9 x 1.0 x 0.4 cm ___ cyst is identified in left medial popliteal fossa.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Small left ___ cyst.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Urinary frequency, Diarrhea
Diagnosed with Diarrhea, unspecified
temperature: 99.1
heartrate: 64.0
resprate: 14.0
o2sat: 94.0
sbp: 130.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is an ___ yo F with hx breast cancer, single kidney
___ prior TB infx, chronic dCHF for which she is not on
diuretics, hx SBO, hx Pott's disease, and recently diagnosed C.
diff infection (discharged home ___ who presented with urinary
frequency without dysuria, back pain and bilateral ___ edema. UA
was unremarkable. She was given 10 IV Lasix however overall
there was no evidence for overt volume overload on CXR, labs, or
exam. Her presentation as felt more likely due to immobility
relating to her recent cdiff infection. Lower extremity dopplers
were done which were negative for clot. She was trialed on a
small dose of Lasix with moderate improvement of her ___
swelling. ___ stockings were also placed and she was ambulating
the hallways well although continued to complain of occasional
vague shooting LLE pains. A ___ cyst was also found on
ultrasound which may explain her LLE complaints. ___ was
consulted and felt she was felt ok to be discharged home.
.
Rest of hospital course/plan are outlined below by issue:
.
# ___ Edema/pain/history of chronic diastolic CHF. Edema was
noted to be relatively mild and trace on my exam the following
morning after admission. Pt also had a small pleural effusion
noted on CXR however no other signs of HF exacerbation, without
JVP elevation, SOB, pulm edema and nl BNP. While she likely has
some degree of dCHF, suspect that her edema is more likely due
to immobility in the setting of recent infection. Given her EKG
was unchanged, trops not elevated and pt had had an ECHO within
the last ___ m, echo was not repeated this admission. There was
low concern for renal etiology given no protein in her urine.
Wells score was low (although she had been less active than
usual) and bilateral nature also ___ DVT less likely. However,
given her reports of occasional unilateral L sided shooting pain
and history of breast cancer, we opted to rule out DVT with
bilateral lower extremity Doppler ultrasounds which were
negative for DVT however did show a small L Bakers cyst; which
was on the same side as her unilateral leg complaints and may
explain her paroxysms of discomfort.
-given Lasix 10 mg IV x1 total, will not continue diuretic
-she was provided TEDs, may have formal compression stockings
prescribed as outpatient if desired.
-recommended PRN Tylenol for pain control (although patient
declined any medication)
.
# Rash: Faint erythematous papules on dorsum of hands
bilaterally, difficult to distinguish from age-related changes.
Also with excoriations on legs likely secondary to scratching.
Of note, per PCP records, pt has had intermittent pruritus of
unclear etiology in the past, seen by derm. There was no
evolution of the rash this hospitalization. ___ with PCP
.
# Pulm effusion: mild, no e/o infx, possibly due to ___ or
perhaps mechanical restriction relating to her scoliosis.
Asymptomatic.
-s/p Lasix as above
-repiratory status remained good.
.
#diarrhea/cdiff: has chronic diarrhea however also recently dx'd
with cdiff. Overall seems to be improving with treatment.
-cont oral vanc, she was prescribed a 12 day supply on her last
discharge on ___ and should have more than enough to complete
her 2 weeks of therapy on ___.
.
# tooth abscess: started on clinda a few weeks ago, stopped
after cdiff, awaiting extraction. No worsening pain currently
or evidence of evolving infection. She was provided contact
number to schedule OMFS appointment.
.
# back pain: ___ kyphosis, with evidence of stage 1 pressure
ulcer overlying kyphotic regions. No red flag signs other than
thoracic location which is due to abnormal anatomy.
-mepilex applied
.
# Hx TB: per patient, developed TB as a child and was not
subsequently treated. She does not have finding that are
currently concerning for active TB, will follow up with her PCP
regarding this hx and any treatment that occurred.
.
# urinary frequency: UA unremarkable, likely due to frequent
urination in setting of diarrhea from cdiff. Urine culture was
pending at time of discharge which will need to be followed up
by PCP. Even if UCx positive, lack of pyuria makes UTI unlikely.
.
# Contacts:
-I communicated with her PCP via email who emailed back and I
updated with the plan.
-I called the patient's son's cell phone number in the chart but
there was no answer
.
# Transitional Issues:
-she has a PCP ___ appointment on ___ to follow up on her ___
edema to ensure it is improving and also monitor her after
completing therapy for her Cdiff infection
-continue PO vancomycin to complete 2 week course of therapy
(last day ___
-OMFS ___ on discharge to facilitate extraction which was
recommended.
.
# DISPO: Seen by ___ who recommended d/c home. ___ home
evaluation ordered for safety evaluation. Given her recent
issues with pain in her leg, we recommended that she not drive
home from the hospital (her car was parked near the hospital
that her son had driven here for her). A cab voucher was
provided and we recommended that her son pick up her car when he
was available to do so. We recommended that she avoid driving
until she was no longer having issue with pain in her leg.
.
___, MD
___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R Leg Pain
Major Surgical or Invasive Procedure:
___ - R Tibial Intramedullary Nailing
History of Present Illness:
___ female, otherwise healthy, presenting with the
above-mentioned fractures following a mechanical fall. Patient
states stepped off a curb, and slipped on acorn suture in the
street, falling and catching her right ankle so that it twisted
as she fell. She felt a pop and had immediate onset pain
preventing her from bearing weight. She had no head strike, no
loss of consciousness, no nausea or vomiting, no headache, no
confusion. Patient continues to have severe right lower leg
pain
but otherwise has no complaints.
Past Medical History:
Gastritis
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission:
Vitals: AVSS
General: Well-appearing female in no acute distress.
Right lower extremity:
- Skin intact
-Diffuse edema of the right lower leg with proximal lateral
point
tenderness in the anterior distal point tenderness
- No deformity, ecchymosis, erythema, induration
- Soft, non-tender thigh and leg
- Full, painless ROM at hip, knee
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
================================================================
On Discharge:
Vital Signs: stable
O2 delivery: RA
General: Well-appearing, breathing comfortably
MSK:
Dressing with small SS staining anteriorly on shin
ACB in place
Wiggles exposed toes
SiLT exposed toes
Well perfused
Pertinent Results:
___ 08:05AM BLOOD WBC-9.5 RBC-3.69* Hgb-10.4* Hct-32.3*
MCV-88 MCH-28.2 MCHC-32.2 RDW-15.3 RDWSD-49.0* Plt ___
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
Do not take more than 4000mg acetaminophen (Tylenol) total,
daily.
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg sc at bedtime Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Do not drink or drive on this medication. Hold for sedation.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hrs Disp #*30
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R Tibial Shaft Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX ___ AND ANKLE
INDICATION: ___ with R ankle and ___ pain after a fall// eval for fx
TECHNIQUE: Three views of the right tibia fibula and three views of the right
ankle joint.
COMPARISON: None
FINDINGS:
There is an oblique fracture of the proximal fibula involving the proximal
shaft with slight anterior and lateral displacement of the distal fragment.
The proximal tibia is intact. Degenerative changes at the right knee include
mild marginal spurring. No joint effusion is seen at the right knee. The
level of the distal shaft of the right tibia, there is an oblique fracture
with approximately 10 mm lateral displacement of the distal fracture fragment.
Linear fracture lucencies extend along the distal fragment into the tibial
plafond without significant displacement. There is also a fracture line
involving the posterior malleolus of the distal tibia best seen on the lateral
radiograph of the right ankle, nondisplaced. Ankle mortise is symmetric.
Talar dome is smooth. Distal fibula is intact. No heel spurs. No gross soft
tissue abnormalities detected.
IMPRESSION:
1. Oblique fracture involving the proximal shaft of the right fibula with mild
anterolateral displacement of the distal fragment.
2. Oblique fracture through the distal shaft of the right tibia with lateral
displacement of the distal fragment. Nondisplaced fracture lines extend along
the distal tibial fracture fragment to the tibial plafond and posterior
malleolus.
3. Ankle mortise remains symmetric.
Radiology Report
INDICATION: History: ___ with ANKLE FX// PREOP
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
The lungs are well expanded and clear. There is no focal consolidation,
pleural effusion or pneumothorax. The cardiomediastinal silhouette is within
normal limits. No pulmonary edema is seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old woman with distal tibial and proximal fibular
fractures// eval tib/fib fractures
TECHNIQUE: Multiple views 2.5 mm axial images were obtained through the lower
leg without the administration of intravenous contrast. Coronal and sagittal
reformatted images were obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 64.9 cm; CTDIvol = 10.2 mGy (Body) DLP = 662.0
mGy-cm.
Total DLP (Body) = 662 mGy-cm.
COMPARISON: Radiographs from ___
FINDINGS:
There is a comminuted predominantly spirally oriented fracture through the
distal tibia with extension to the ankle joint. Fracture lines extends to
involve the posterior malleolus. There is mild displacement of the distal
tibial shaft measuring 7 mm. In addition, there is also a fracture of the
proximal fibular shaft which is obliquely oriented.
There is a prominent exostosis along the posterolateral aspect of the tibia.
This may represent an osteochondroma or large osteophyte. There are moderate
to severe degenerative changes of the patellofemoral and medial compartments
of the knee. Ankle mortise is grossly preserved. There is mild prepatellar
tibial soft tissue edema.
IMPRESSION:
1. Small spirally oriented fracture of the distal tibia with extension into
the ankle joint and also involving the posterior malleolus
2. Oblique fracture of the proximal fibular shaft.
Radiology Report
EXAMINATION: Right tibia/fibula
INDICATION: ORIF.
COMPARISON: CT of the tibia/fibula ___.
FINDINGS:
22 intraoperative images were acquired without a radiologist present.
Images show intramedullary rod and screw placement for distal tibial shaft
fracture. Total fluoroscopic time 207.5 seconds.
IMPRESSION:
Please refer to the operative note for details of the procedure.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R Leg pain, s/p Fall
Diagnosed with Pain in right lower leg
temperature: 96.5
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 179.0
dbp: 92.0
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 R tibial shaft fracture with distal intra-articular
extension and was admitted to the orthopedic surgery service.
The patient was taken to the operating room on ___ for R
Tibial intramedullary nailing, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to a skilled facility 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
touch down weight bearing in the right lower extremity in an
aircast walking boot, and will be discharged on enoxaparin 40mg
nightly 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: SURGERY
Allergies:
Percocet / Lisinopril / Azithromycin / morphine / codeine /
latex
Attending: ___
___ Complaint:
Nausea, dehydration
Major Surgical or Invasive Procedure:
Laparoscopic sigmoid colectomy with takedown of splenic flexure
and temporary diverting loop ileostomy (___)
History of Present Illness:
Ms. ___ is a ___ lady who is status post
laparoscopic sigmoid colectomy with diverting loop ileostomy on
___ for diverticulitis with abscess. She presents to the ED
with persistent malaise, nausea, and poor PO intake. Her
creatinine has also been rising per her PCP.
She was discharged home with ___ on ___ after an
___ hospital stay. Since discharge, she has had
increasing fatigue. Additionally, for about 1 week, she has had
nausea and bloating which prevents her from drinking more than a
few sips at a time. She reports anorexia and dizziness. She
reports ileostomy output of 500-650 cc/day that is liquid
(typically greenish). She denies vomiting, fevers, chills,
abdominal pain aside from occasional cramping, change in urine
output, and any output from her rectum (no stool, blood, mucous,
air). She was called by Dr. ___ office on ___ at which
time she reported liquid stool and was advised to take Imodium.
She has taken 8 pills per day since with no real change in
output, possibly slight thickening in output though. She saw her
PCP ___ ___. At that time her creatinine was 1.6 (was 0.9 on
the day of discharge ___ so she was told to hold her
anti-hypertensives and was given PO zofran. She saw her PCP
again on the day of admission. Her creatinine was found to be
2.1 and her temperature was 100.8. Her PCP called Dr. ___
___ for Dr. ___, who told the patient to come in for
evaluation.
Past Medical History:
1) Diverticulitis/Diverticulosis
2) IBS
3) Osteoarthritis
4) Hyperlipidemia
5) Pulmonary nodules
6) Benign positional vertigo
7) Osteopenia at hip
8) Hypertension
9) GERD
10) Breast cancer - left atypical hyperplasia diagnosed in ___
right LCIS and DCIS diagnosed in ___ status post lumpectomy,
XRT, Tamoxifen therapy (for ___ years)
11) Carpal tunnel (right wrist)
12) Trigger finger (left hand)
13) Frozen shoulder
14) Game keeper's thumb/disease
15) Hiatal hernia (___)
16) Esophagitis treated with PPI
17) Scoliosis since age ___
18) Toxic multinodular goiter, followed by Dr. ___, has
had suppressed TSH recently
=============================
Past Surgical History:
1) Right thigh lipoma removal
2) Bilateral bunion removal with joint replacement
3) Right breast lumpectomy for DCIS/LCIS
Social History:
___
Family History:
Her father died of gastric cancer at age ___ (received radiation
to his tonsils twice as a child). No family history of
autoimmune diseases. Her first and second cousins have breast
cancer.
Physical Exam:
Vitals: Temp 98.7, HR 74, BP 108/50, RR 16, SpO2 100% on room
air
Gen: Pleasant lady in no acute distress, alert and oriented
CV: Regular rate and rhythm
Lungs: Clear to auscultation bilaterally, non-labored breathing,
no respiratory distress
Abd: Soft, non-distended, non-tender to palpation. Well-healed
laparoscopic incisions. Stoma beefy red. Ostomy bag in place
with gas and stool present.
Ext: Warm and well-perfused without edema
Pertinent Results:
CT ABDOMEN/PELVIS (___):
Focus of air and contrast adjacent to the anastomosis, given the
lack of surrounding fat stranding, this is more likely an
contrast within an outpouching of the surgical anastomosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO QAM
2. Lorazepam 1 mg PO QHS sleeping
3. Omeprazole 20 mg PO QAM
4. Paroxetine 15 mg PO LUNCH
5. Valsartan 80 mg PO QAM
6. Acetaminophen 1000 mg PO TID
7. Diclofenac Sodium ___ 50 mg PO BID
8. Hyoscyamine 0.375 mg PO BID
9. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
10. Docusate Sodium 100 mg PO BID:PRN constipation.
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO QAM
2. Omeprazole 20 mg PO QAM
3. Acetaminophen 1000 mg PO TID
4. Diclofenac Sodium ___ 50 mg PO BID
5. Docusate Sodium 100 mg PO BID:PRN constipation.
6. Hyoscyamine 0.375 mg PO BID
7. Lorazepam 1 mg PO QHS sleeping
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
9. Paroxetine 15 mg PO LUNCH
10. Valsartan 80 mg PO QAM
11. LOPERamide 2 mg PO QID
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by
mouth four times a day Disp #*56 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: 1 week of nausea, chills, fatigue, and low-grade temperatures in
a patient status post sigmoid colectomy with diverting ileostomy on ___, secondary to diverticulitis complicated by abscess.
TECHNIQUE: Non-contrast scan: 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. 120 cc of water-soluble contrast with was
administered per rectum.
Coronal and sagittal reformations were performed and reviewed on PACS.
No oral contrast was administered.
DOSE: DLP: 523.5 mGy-cm (abdomen and pelvis.
IV Contrast: None
COMPARISON: CT abdomen/pelvis from ___.
FINDINGS:
LOWER CHEST:
The visualized lung bases are clear. There is no pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The nonenhanced appearance of the liver is normal. There is no
obvious mass.. The gallbladder is within normal limits, without stones or
gallbladder wall thickening.
PANCREAS: No peripancreatic stranding or fluid collection is identified.
SPLEEN: The spleen is normal in size.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are symmetric and normal in size, without hydronephrosis
or stone..
GASTROINTESTINAL: Small bowel loops are normal in caliber, without obvious
wall thickening or evidence of obstruction. There is a diverting loop
ileostomy. Contrast administered per rectum extends to the level of the
cecum. The patient is status post sigmoid colectomy, with an anastomosis in
the pelvis. A focus of air and contrast adjacent to the anastomosis (2:60,
61b:38) . However, given the lack of surrounding fat stranding, this is more
likely air and contrast within an outpouching of the surgical anastomosis. No
fluid collection to suggest an abscess is identified at this location. A
normal appendix is visualized.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Calcified uterine fibroids are noted.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Other than at the diverting
ileostomy in the right lower quadrant, as noted above, the abdominal and
pelvic wall is unremarkable.
IMPRESSION:
Focus of air and contrast adjacent to the anastomosis, given the lack of
surrounding fat stranding, this is more likely an contrast within an
outpouching of the surgical anastomosis.
NOTIFICATION: Updated findings were discussed via telephone by Dr. ___
___ with Dr. ___ at 10:00 on ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with POSTPROCEDURAL FEVER, ABDOMINAL PAIN GENERALIZED, ABN REACT-SURG PROC NEC
temperature: 97.8
heartrate: 96.0
resprate: 18.0
o2sat: 95.0
sbp: 163.0
dbp: 73.0
level of pain: 3
level of acuity: 3.0 | The patient presented to the ___ ED on ___ with nausea
and dehydration. She was admitted to the colorectal surgery
service for further management.
Neuro: The patient's pain was well-controlled with oral
acetaminophen. She remained alert and oriented throughout this
hospitalization.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: Pulmonary toilet including incentive spirometry and
early ambulation were encouraged during this hospitalization.
She was stable from a pulmonary standpoint; vital signs were
routinely monitored.
GI/GU/FEN: The patient was provided sips on admission and slowly
advanced to a regular diet as tolerated. She continued to have
gas and stool in her ostomy bag. She was given loperamide 2 mg
four times a day with good effect. She received further ostomy
teaching on the day of discharge. Her magnesium was 0.9 on
hospital day #1. She was repleted with 4 mg IV magnesium
sulfate. Recheck in the evening was 2.5. Her intake and output
were closely monitored.
ID: The patient's temperature and white blood cell count were
closely watched for signs of infection, of which there were
none.
Prophylaxis: The patient received subcutaneous heparin during
this hospital stay and was encouraged to get up and ambulate as
early as possible.
On the day of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percodan
Attending: ___.
Chief Complaint:
right sided rib pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of dementia, multiple falls, CAD
s/p multiple stents on aspirin, Afib & recent thromboembolic
left PCA stroke (___)
s/p tPA & discharged to a rehabilitation center on ___ who
was found down at her bathroom yesterday night by the staff. She
does not know if she lost consciousness or hit her head and has
no knowledge of circumstances surrounding the fall. She was
brought to ___ ED and was complaining of right side pain so
she underwent panscan which showed right ___ rib fractures and
evolution of her known left PCA territorial stroke with no
evidence of hemorrhagic
conversion or acute hemorrhage
Past Medical History:
Dementia
NIDDM
HTN
CAD s/p multiple PCI, followed by Dr. ___ not previously on anticoagulation given multiple falls,
started ___ ___
L PCA stroke
HLD
collagenous colitis with chronic mild anemia on mesalamine
lumbar spinal stenosis
gait instability and frequent falls
L eye blind after cataract surgery
Shoulder impingement/rotator cuff tendinopathy
urinary incontinence
multinodular thyroid
Social History:
___
Family History:
Two children with epilepsy.
Physical Exam:
Physical Exam: upon admission: ___:
Vitals: 97.8 60 163/43 16 97% Nasal Cannula
GEN: Mildly confused but alert.
HEENT: No scleral icterus, mucus membranes dry. In c-collar
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Tender to palpation over right side ribs. No obvious
hematoma or swelling. Abdomen soft, nondistended, nontender, no
rebound or guarding,
DRE: Deferred
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE PHYSICAL EXAM:
VITALS: 97.7 PO 173/63 L Lying 54 18 97 RA
GENERAL: Alert, oriented x2 (knows self, hospital, not which
one), no acute distress
HEENT: NC/AT, Sclerae anicteric, MMM, oropharynx clear, EOMI,
PERRL, neck supple, JVP not elevated, no LAD, wearing a wig
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
CHEST: Lungs clear to auscultation bilaterally without wheezes,
rales, rhonchi, right sided rib pain directly above RUQ,
lidocaine patch in placeABDOMEN: Soft, non-tender,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding
SKIN: No bruising, hematoma, evidence of head trauma
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
NEURO: Face grossly symmetric. Moving all limbs with purpose
against gravity. Strength 4+/5 left sided, ___ right sided
upper and lower extremitis. No dysarthria.
Pertinent Results:
ADMISSION LABS:
---------------
___ 03:20AM BLOOD WBC-13.5* RBC-3.54* Hgb-10.6* Hct-33.4*
MCV-94 MCH-29.9 MCHC-31.7* RDW-13.0 RDWSD-44.6 Plt ___
___ 03:20AM BLOOD Neuts-41.6 ___ Monos-4.4* Eos-1.6
Baso-0.3 NRBC-0.1* Im ___ AbsNeut-5.62 AbsLymp-6.97*
AbsMono-0.60 AbsEos-0.21 AbsBaso-0.04
___ 03:20AM BLOOD ___ PTT-27.3 ___
___ 03:20AM BLOOD Plt Smr-NORMAL Plt ___
___ 03:20AM BLOOD Glucose-131* UreaN-27* Creat-1.1 Na-138
K-4.6 Cl-102 HCO3-21* AnGap-20
INTERIM LABS:
-------------
___ 05:22AM BLOOD WBC-10.1* RBC-3.39* Hgb-10.2* Hct-32.5*
MCV-96 MCH-30.1 MCHC-31.4* RDW-13.1 RDWSD-45.7 Plt ___
___ 05:22AM BLOOD ___ PTT-29.0 ___
___ 05:55AM BLOOD Glucose-132* UreaN-21* Creat-0.9 Na-139
K-4.7 Cl-102 HCO3-25 AnGap-17
___ 05:22AM BLOOD Glucose-112* UreaN-23* Creat-0.9 Na-141
K-5.2* Cl-103 HCO3-24 AnGap-19
___ 05:22AM BLOOD ALT-14 AST-20 LD(LDH)-224 AlkPhos-83
TotBili-0.2
___ 10:17PM BLOOD K-4.3
DISCHARGE LABS:
----------------
___ 05:55AM BLOOD WBC-10.4* RBC-3.45* Hgb-10.2* Hct-32.7*
MCV-95 MCH-29.6 MCHC-31.2* RDW-12.8 RDWSD-44.0 Plt ___
___ 05:55AM BLOOD Plt ___
___ 05:55AM BLOOD Glucose-132* UreaN-21* Creat-0.9 Na-139
K-4.7 Cl-102 HCO3-25 AnGap-17
___ 05:55AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0
MICROBIOLOGY:
-------------
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
IMAGING:
----------
___: CT c-spine:
1. No acute fracture or traumatic mal-alignment.
2. Extensive degenerative changes as described above most
pronounced at C3-C4 through C5-C6 with moderate spinal canal
stenosis at these levels.
3. Markedly enlarged nodular thyroid gland.
___: CT HEAD NON-CONTRAST
1. No acute intracranial hemorrhage.
2. Evolving infarcts involving the left temporal occipital lobe
and the left thalamus. No evidence of hemorrhagic conversion.
3. 2.3 x 1.3 cm left planum sphenoidale meningioma.
4. Left sphenoid mucocele
___: CT TORSO
1. Acute non-displaced fractures involving the right sixth
through eighth ribs laterally as well as the eighth and ninth
ribs posteriorly.
2. No intra-thoracic or intra-peritoneal hematoma. No evidence
of visceral organ injury.
3. Cholelithiasis with gallbladder wall edema in a mildly
distended
gallbladder. This is nonspecific. However, if there is concern
for acute cholecystitis, a HIDA scan may be obtained.
4. Significant but diffuse enlargement and thickening of the
right adrenal gland, new since ___. This is unlikely to
represent adrenal hemorrhage.
Consultation with Endocrinology can be done on a non-emergent
basis.
5. Markedly enlarged multi-nodular thyroid.
RECOMMENDATION(S): Endocrine evaluation for diffusely thickened
and enlarged right adrenal gland.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Digoxin 0.125 mg PO DAILY
4. Diltiazem Extended-Release 240 mg PO DAILY
5. FLUoxetine 20 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Apixaban 2.5 mg PO BID
9. Cholestyramine 4 gm PO BID
10. Fish Oil (Omega 3) 1000 mg PO BID
11. melatonin 5 mg oral QHS
12. Mesalamine 1.2 g oral DAILY
13. MetFORMIN (Glucophage) 1000 mg PO DAILY
14. Tolterodine 4 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Calcium Carbonate 1000 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
Day one ___, Day five ___. Lidocaine 5% Patch 1 PTCH TD QAM
5. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 4
hours as needed Disp #*4 Tablet Refills:*0
6. Vitamin D 1000 UNIT PO DAILY
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Apixaban 2.5 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. Cholestyramine 4 gm PO BID
12. Digoxin 0.125 mg PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO BID
14. FLUoxetine 20 mg PO DAILY
15. Lisinopril 10 mg PO DAILY
16. melatonin 5 mg oral QHS
17. Mesalamine 1.2 g oral DAILY
18. MetFORMIN (Glucophage) 1000 mg PO DAILY
19. Multivitamins W/minerals 1 TAB PO DAILY
20. Tolterodine 4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multiple right sided rib fractures, ___
bacteriuria, likely catheter-associated UTI
Gait instability, frequent falls
Diffuse enlargement and thickening of the right adrenal gland
Markedly enlarged multinodular thyroid
homogeneous intensely enhancing brain mass, likely meningioma
Cholelithiasis with gallbladder wall edema
Atrial fibrillation
Recent L PCA stroke
CAD, HTN, HLD, Depression, collagenous colitis
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: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ woman with fall and neck pain. Evaluate for cervical
spine fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence: 1) Spiral Acquisition 5.4 s, 21.1 cm; CTDIvol =
36.9 mGy (Body) DLP = 779.4 mGy-cm. Total DLP (Body) = 779 mGy-cm.
COMPARISON: Cervical spine CT from ___
FINDINGS:
There is no acute fracture or traumatic malalignment. There is no
prevertebral soft tissue swelling. There is mild anterolisthesis of C3 on C4
with retrolisthesis of C4 on C5, unchanged since the prior exam. There are
significant degenerative changes with disc space narrowing, endplate sclerosis
as well as osteophyte formation most pronounced at C3-C4 through C6-C7 levels.
At these levels there is extensive uncovertebral and facet hypertrophy causing
severe right neural foraminal narrowing at C4-C5, bilateral moderate neural
foraminal narrowing at C5-C6, and mild neural foraminal narrowing at C6-C7.
There are also posterior disc osteophyte complexes at C3-C4 through C5-C6
causing causing moderate spinal canal stenosis at these levels.
The lung apices are clear. Markedly enlarged and nodular thyroid gland is
again identified. There is no cervical lymphadenopathy.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Extensive degenerative changes as described above most pronounced at C3-C4
through C5-C6 with moderate spinal canal stenosis at these levels.
3. Markedly enlarged nodular thyroid gland.
Radiology Report
INDICATION: ___ found down, right chest and upper abdominal pain, on
anticoagulation. Evaluate for bleed.
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.1 s, 71.6 cm; CTDIvol = 9.4 mGy (Body) DLP = 673.2
mGy-cm.
Total DLP (Body) = 673 mGy-cm.
COMPARISON: CTA chest from ___
FINDINGS:
A markedly enlarged thyroid gland is again identified. There are prominent
axillary and mediastinal lymph nodes, slightly increased in size compared to
the prior study. There is no supraclavicular lymphadenopathy. Hilar lymph
nodes are also not enlarged. The heart is normal in size. There are heavy
atherosclerotic calcifications involving all coronary arteries.
Calcifications are also seen at the aortic arch. Valvular calcifications are
heavy involving the aortic as well as the mitral valves. There is a small,
likely physiologic pericardial effusion. The main pulmonary artery is not
enlarged.
The central airways are patent. There are multifocal areas of atelectasis. A
5 mm ground-glass nodule in the right apex is unchanged. There is no
consolidation, pleural effusion, or pneumothorax.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder contains
multiple large gallstones with gallbladder-wall edema, which is nonspecific.
The gallbladder itself is mildly distended. There is no pericholecystic
fluid.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The left adrenal gland is thickened with an indeterminate 1.2 cm
nodule, slightly increased since the prior study. There is diffuse
enlargement and thickening of the right adrenal gland, new since the prior
study.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Scattered cortically based hypodensities are identified, too small to fully
characterize but likely represent cysts. No hydronephrosis or perinephric
abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. The stomach is otherwise
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. The sigmoid is redundant. There is diffuse
moderate fecal loading. The appendix is visualized and normal. There is no
evidence of mesenteric injury. There is no free fluid or free air in the
abdomen.
PELVIS: The urinary bladder is distended and contains some air, possibly
related to prior instrumentation. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexal regions 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 or retroperitoneal hematoma.
Severe atherosclerotic disease is noted.
BONES: Hardware is noted at the L3-L4 spinous process. There are acute
nondisplaced fractures involving the right sixth through eighth ribs laterally
as well as the eighth and ninth ribs posteriorly. No other acute fracture is
identified. Degenerative changes are seen throughout the thoracic and lumbar
spine. No focal suspicious osseous abnormality.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Acute nondisplaced fractures involving the right sixth through eighth ribs
laterally as well as the eighth and ninth ribs posteriorly.
2. No intrathoracic or intraperitoneal hematoma. No evidence of visceral
organ injury.
3. Cholelithiasis with gallbladder wall edema in a mildly distended
gallbladder. This is nonspecific. However, if there is concern for acute
cholecystitis, a HIDA scan may be obtained.
4. Significant but diffuse enlargement and thickening of the right adrenal
gland, new since ___. This is unlikely to represent adrenal hemorrhage.
Consultation with Endocrinology can be done on a non-emergent basis.
5. Markedly enlarged multinodular thyroid.
RECOMMENDATION(S): Endocrine evaluation for diffusely thickened and enlarged
right adrenal gland.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman status post fall. Evaluate for intracranial
bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.7 cm; CTDIvol
= 48.0 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___ and MRI brain from ___
FINDINGS:
There is no acute intracranial hemorrhage. There are evolving infarcts
involving the left temporal occipital lobes as well as the thalamus. There is
no evidence of hemorrhagic conversion. There is prominence of the ventricles
and sulci compatible with age related parenchymal atrophy. Periventricular
and subcortical white matter hypodensities are nonspecific but likely reflect
sequelae of chronic small vessel ischemic disease. A 2.3 x 1.3 cm planum
sphenoidale meningioma is again identified.
There is no evidence of fracture. A left sphenoid sinus mucocele is again
identified. There is also mucosal thickening involving the bilateral
maxillary sinuses and the ethmoid air cells. The remaining visualized portion
of the paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. Bilateral lens replacements are identified. Dense atherosclerotic
calcifications of the carotid siphons and vertebral arteries are identified.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Evolving infarcts involving the left temporal occipital lobe and the left
thalamus. No evidence of hemorrhagic conversion.
3. 2.3 x 1.3 cm left planum sphenoidale meningioma.
4. Left sphenoid mucocele.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Multiple fractures of ribs, right side, init for clos fx, Other fall on same level, initial encounter
temperature: 98.0
heartrate: 67.0
resprate: 16.0
o2sat: 100.0
sbp: 139.0
dbp: 49.0
level of pain: 3
level of acuity: 3.0 | ___ w dementia, CAD s/p multiple stents, Afib not previously on
anticoagulation, on apixaban since recent admission ___
for L proximal PCA stroke s/p tPA, HLD, HTN, NIDDM, left eye
blindness, gait instability with frequent falls, returned from
rehab ___ after an unwitnessed fall, found to have multiple R
rib fractures and concern for UTI.
#Right sided Rib fractures
#Gait instability, frequent falls
#Probable osteoporosis:
Nondisplaced. Affecting ribs ___ laterally, ___ posteriorly.
Occurred secondary to fall, which was unwitnessed, but possibly
while she was attempting to get out of bed. No documented
history of osteoporosis but at high risk for fractures given
frequent falls, may benefit from further diagnosis and treatment
of osteoporosis. Started on calcium and vitamin D supplements.
Also noted to have degenerative changes at the C3-C4 through
C5-C6 spinal levels on imaging. Pain was treated with tylenol,
lidocaine patch, and prn Tramadol, which may require further
titration as activity level increases. Outpatient followup with
acute care surgery arranged for ___.
#Bacteriuria with probable catheter-associated urinary tract
infection from prior hospitalization:
Urine culture on admission grew pan-sensitive pseudomonas, and
patient presented with mild leukocytosis since discharge.
Despite denying urinary symptoms, due to patient having foley
catheter on previous admission and the recent fall that could
have been precipitated by infection, she was started 5 day
course of Ciprofloxacin 500 mg Q12H ___ (last day ___.
#Dementia
#Home situation:
Patient has history of dementia for approximately ___ years. Per
daughter, she has become increasingly dependent in her ADLs,
does not dress herself but can feed herself (does not prepare
food), and has consistently refused home help in the past. Her
husband, who is also in his ___ and suffers from mild dementia,
is her primary caretaker. Patient would likely benefit from more
supervision at home given that her husband is her primary
caretaker and they do not have consistent help at home. Social
work consult was obtained and the case manager is arranging to
follow-up for in home care.
#Diffuse enlargement and thickening of the right adrenal gland:
Incidental finding on CT, unlikely related to right sided pain.
Unlikely to represent adrenal hemorrhage per radiology report.
Outpatient endocrinology followup was arranged.
#Markedly enlarged multinodular thyroid:
Known since ___, TSH 0.8 on last admission, appears abnormally
low for her age group though in line with previous studies.
Outpatient endocrine followup arranged.
#Probable Meningioma:
Seen incidentally on imaging: homogeneous intensely enhancing
mass that is isointense to brain parenchyma on T1 and T2
weighted images and appears to arise from the left planum
sphenoidale measuring approximately 10 x 25 x 17 mm, likely
representing a meningioma (14:9). The mass displaces the
terminal segment of the left internal carotid artery and A1 and
M1 branches.
#Cholelithiasis with gallbladder wall edema:
Mildly distended gallbladder, patient had HIDA scan ___ with no
evidence of acute cholecystitis in the setting of unusual
pattern of uptake with more intensity in the region of the
cystic duct and less tracer within the gallbladder. The cause
of this pattern was unknown. Appeared unlikely to be the cause
of her pain as it is a chronic issue, and her abdominal exam was
benign. LFTs were WNL.
#Atrial fibrillation:
Longstanding atrial fibrillation, no previous anticoagulation,
was only on aspirin given high risk of falling. Started apixaban
during previous admission for stroke, which was continued. Home
digoxin and diltiazem were continued, however patient was
persistently bradycardic so diltiazem was decreased to 120 mg
extended release from 240 mg.
#Recent L PCA stroke ___: Suffered sudden onset right sided
weakness at home, brought in to ___, s/p tPA, discharged to
Rehab ___. Started on apixaban given likely cardioembolic
etiology. Continued aspirin. Has some residual right sided
weakness and will likely benefit from rehab. She reporting
tingling of her fingers on both hands to the surgery team but
did not complain of it later in her hospital course.
#CAD: s/p multiple stents, continued aspirin
#HTN: held lisinopril on admission for Cr 1.1 (presumed baseline
0.8), restarted on day of discharge (discharge Cr. 0.9).
#HLD: continued home atorvastatin, Cholestyramine
#Collagenous colitis: Mesalamine ___ 400 mg PO TID in hospital in
place of home mesalamine, continued on home version on discharge
#Depression: continued home Fluoxetine
- CONTACT: ___ (Husband/HCP) ___ ___
(daughter) ___
- CODE STATUS: full (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / Erythromycin Base
Attending: ___.
Chief Complaint:
lower back pain and fever
Major Surgical or Invasive Procedure:
___ Interventional radiology drainage of paraspinal soft
tissue abscess
History of Present Illness:
___ with history of DM, afib with RVR, diastolic heart failure,
PVD, COPD presents with severe low back pain (sacrum/buttocks)
and rectal temp of 103. He presented initially to ___ and
is now being transferred to ___ for MRI to rule out
epidural abscess.
Per patient history, he started having severe bilateral lower
back pain on ___ while golfing. Does not remember any trauma
or physical action that may have triggered his back pain. The
pain felt deep, throbbing, aching, and radiated across his
buttocks. It does not feel like any back pain that he has had
before. He had no chest pain, abdominal pain, dyspnea. He also
felt weak and "had a terrible game", then came home and went
straight to bed. At that point, his pain was ___. He has also
not had a BM x 1 week and recently has been having very weak
urinary stream. No knowledge of prostate issues. He denies
nausea/vomiting, fevers/chills/sweats. Yesterday, ___, he
presented to ___ for pain. At ___, he was noted to
have temp 103 and also noted to have urinary retention: urinated
100cc and put out 600cc more when catheterized. No stool
incontinence. No weakness. Has baseline lower extremity numbness
bilaterally. He had afib with RVR to 146 (he has not been taking
home meds, including home digoxin and metoprolol due to back
pain). This was treated with tylenol and Dilaudid and IVF
500cc bolus (CHF on CXR) with resolution of HR to 110s. Troponin
was found to be 0.05, thought to be demand ischemia from rate;
patient had no chest pain. Workup for fever included UA
(negative), CT abdomen/pelvis which showed acute cholecystitis
but the patient has no RUQ TTP or thoracic back pain and
question of L1 endplate erosion, infection vs degenerative
changes). No blood cultures were sent. At this point,
differential for back pain was atypical presentation of
cholecystitis versus epidural abscess or osteomyelitis. The
patient was treated with IV Vancomycin and ceftriaxone. Since
MRI cannot be done at ___, he was transferred to ___.
At ___ ED, initial vitals were: 98.4 82 116/64 16 98%
- Labs were significant for negative troponin, dig 0.5, lipase
61 otherwise normal LFT, Hct 37.7, INR 1.3. No leukocytosis but
left-shifted with 83% PMNs.
- Patient was given morphine 5mg
- Liver ultrasound: per attending radiologist, concerning for
acute cholecystitis.
-MRI spine: per neuroradiology, shows 2 fluid collections, L4-L5
posterior spinal canal fluid collection and paraspinal soft
tissue abscess
-He dropped his pressure at one point due to morphine, that
resloved with the gentle IV fluids. He then developed some rapid
afib and received metoprolol and Digoxin Po with good effect and
no BP issues.
Vitals prior to transfer were: HR 102 110/66 22 97% RA
On the floor, initial VS: 99, HR 100 afib, BP 124/82, 18 99% RA.
Over 8 hrs, made 600cc urine. The patient continues to have ___
back pain radiating across his buttocks. Does not change with
position or exertion. Feels very "deep".
Past Medical History:
1. New onset atrial fibrillation with RVR (___)
2. Acute respiratory failure on chronic respiratory failure.
3. Pneumonia.
4. Noncompliance.
5. Diabetes mellitus.
6. Acute diastolic heart failure.
7. Pulmonary hypertension.
8. Hyperlipidemia.
9. Carpal tunnel release.
10. Chronic constipation.
11. Rectal abscess.
12. History of hemorrhoids.
13. Gastroesophageal reflux disease.
14. History of peripheral vascular disease, status post bypass
___ ___.
15. History of mild CKD secondary to diabetic
nephropathy/hypertensive
nephrosclerosis,
baseline creatinine is around 1.2-1.3.
16. Status post appendectomy.
17. COPD.
18. Status post left arm fracture.
19. History of right knee surgery.
20. Degenerative joint disease.
21. Status post hemorrhoid resection.
22. History of GI bleeding before.
Social History:
___
Family History:
Not contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 99, HR 100 afib, BP 124/82, 18 99% RA
GENERAL: No acute distress but uncomfortable. Sitting still ___
bed.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition, nontender supple neck, no LAD, no JVD
CARDIAC: Irregular rate, S1 S2, no MRG
LUNG: Bibasilar crackles, otherwise CTAB
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
SPINE: No tenderness to palpation of midline or of flanks. Pain
does not change with position or palpation.
NEURO: CN II-XII intact. ___ plantarflexion and dorsiflexion,
4+/5 hip flexion. Has decreased sensation to light touch ___
bilateral feet to ankles (baseline).
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5/98.5, 148/86, 96, 18, 96% RA
GENERAL: Sitting ___ bed, eating breakfast, no acute distress
HEENT: AT/NC, EOMI, anicteric sclera, Mucous membranes moist,
nontender supple neck, no JVD
CARDIAC: Irregular rate, S1 S2, no MRG
LUNG: faint crackles @ bases, otherwise CTAB, no wheezes
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing,
b/l 1+ pitting edema around ankles
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 12:56AM BLOOD WBC-9.1 RBC-3.89* Hgb-12.2* Hct-37.7*
MCV-97 MCH-31.4 MCHC-32.5 RDW-14.5 Plt ___
___ 12:56AM BLOOD Neuts-83.4* Lymphs-10.5* Monos-5.6
Eos-0.2 Baso-0.3
___ 12:56AM BLOOD ___ PTT-27.2 ___
___ 11:10AM BLOOD ESR-75*
___ 12:56AM BLOOD Glucose-327* UreaN-18 Creat-0.9 Na-133
K-4.1 Cl-96 HCO3-27 AnGap-14
___ 12:56AM BLOOD ALT-14 AST-11 AlkPhos-60 TotBili-0.6
___ 12:56AM BLOOD Lipase-61*
___ 12:56AM BLOOD cTropnT-<0.01
___ 11:10AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7
___ 12:56AM BLOOD Albumin-3.6
___ 11:10AM BLOOD CRP-186.2*
___ 12:56AM BLOOD Digoxin-0.5*
DISCHARGE LABS:
___ 05:17AM BLOOD WBC-5.4 RBC-3.51* Hgb-10.5* Hct-33.8*
MCV-96 MCH-29.8 MCHC-31.0 RDW-14.2 Plt ___
___ 05:17AM BLOOD ___ PTT-32.3 ___
___ 05:17AM BLOOD Glucose-216* UreaN-20 Creat-1.0 Na-137
K-4.4 Cl-102 HCO3-30 AnGap-9
___ 05:17AM BLOOD Phos-3.7 Mg-1.9
MICROBIOLOGY:
___ Blood culture negative
___ Blood cultures x 2 negative
___ Paraspinal abscess drainage:
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by ___ ___ ___
___.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
IMAGING/STUDIES:
******* ___ MRI CSPINE, TSPINE, LSPINE *******
EXAMINATION: MR cervical, thoracic and lumbar spine.
INDICATION: ___ with fever, back pain, urinary retention. Rule
out epidural
abscess.
TECHNIQUE: Multiplanar, multi sequence MR images of the
cervical, thoracic
and lumbar spines were obtained before and after the
administration of
intravenous contrast.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
Cervical spine: Cervical spine alignment is maintained.
Vertebral body heights
are preserved. There is loss of disc space height most notable
at C5-C6. Bone
marrow signal is mildly heterogeneous without focal suspicious
abnormality.
No abnormal enhancement or epidural fluid collection is
identified. The
cervical cord is normal ___ signal intensity.
C2-C3: A small central disc protrusion is present without
significant spinal
canal narrowing. There is mild to moderate left neural foraminal
narrowing
secondary to uncovertebral and facet osteophytes. The right
neural foramen is
patent.
C3-C4: A small central disk protrusion mildly effaces the
ventral subarachnoid
space. The right neural foramen is patent. There is moderate to
severe left
neural foraminal narrowing secondary to uncovertebral and facet
osteophytes.
C4-C5: A broad-based disc osteophyte complex is present, and
there is
thickening of the ligamentum flavum contributing to moderate
spinal canal
narrowing. There is we moderate to severe left neural foraminal
narrowing and
mild to moderate right neural foraminal narrowing secondary to
uncovertebral
and facet osteophytes. The degree of neural foraminal narrowing
is difficult
to precisely determine secondary to patient motion artifact at
this level.
C5-C6: A broad-based disc osteophyte complex completely effaces
the ventral
subarachnoid space causing moderate spinal canal narrowing.
There is moderate
to severe bilateral neural foraminal narrowing secondary to
uncovertebral and
facet osteophytes.
C6-C7: A broad-based disc protrusion is present which effaces
the ventral
subarachnoid space and causes mild spinal canal narrowing. There
is mild right
and moderate left neural foraminal narrowing secondary to
uncovertebral and
facet osteophytes.
C7-T1: No significant spinal canal or neural foraminal narrowing
is present.
Thoracic spine: Thoracic spine alignment is preserved. There is
chronic loss
of anterior height of multiple vertebral bodies. Bone marrow
signal is
heterogeneous without focal suspicious abnormality. Chronic
degenerative
endplate changes are most pronounced at T8-T9 and T9-T10. There
is diffuse
loss of disc space height.
The thoracic cord is small ___ caliber. There is no abnormal cord
signal. No
abnormal enhancement or epidural fluid collection is identified.
Scattered small disc protrusions are present without significant
spinal canal
or neural foraminal narrowing.
Lumbar spine: There is grade 1, 4 mm anterolisthesis of L5 with
respect S1
with associated bilateral chronic pars defects. Lumbar spine
alignment is
otherwise preserved. Vertebral body heights are maintained.
There is diffuse
loss of disc space height and signal most notable at L1-L2,
L4-L5 and L5-S1.
Chronic degenerative endplate changes are noted at these levels
as well. The
conus medullaris is normal
___ morphology and signal intensity and terminates at the level
of T12-L1.
___ the left paraspinal soft tissues at the level of L4 and L5,
there is a rim
enhancing loculated collection measuring 2.9 cm AP x 1.0 cm TR
by 3.3 cm SI.
An additional rim enhancing collection is present ___ the
posterior spinal
canal at the levels of L4 and L5 which measures 1.4 cm AP x 1.4
cm TR x 3.4 cm
SI. Enhancing phlegmon extends into the sacral spinal canal. The
epidural
collection exerts mass effect on the posterior aspect of the
thecal sac. Edema
and enhancement is seen within the adjacent L4 and L5 spinous
processes and
left pedicles.
T12-L1 and L1-L2: There are mild diffuse disc bulges and facet
degenerative
changes without significant spinal canal or neural foraminal
narrowing.
L2-L3: There is a diffuse disc bulge which is slightly e centric
to the left
and narrows the left subarticular recess. Mild degenerative
facet changes are
present without significant spinal canal or neural foraminal
narrowing.
L3-L4: A small left foraminal disc protrusion is present which
mildly narrows
the left neural foramen. The spinal canal and right neural
foramen are patent.
Mild facet degenerative changes are present.
L4-L5: There is a mild diffuse disc bulge, facet degenerative
changes and
thickening of the ligamentum flavum. The disc bulge is slightly
centric to the
right and causes mild right neural foraminal narrowing. The left
neural
foramen is patent.
L4-L5: ___ addition to the anterolisthesis at this level there is
a disc bulge
and facet degenerative changes. The epidural collection at this
level causes
mild narrowing of the thecal sac. Mild bilateral neural
foraminal narrowing is
present.
Multiple T2 hyperintense lesions are present within both
kidneys, compatible
with renal cysts.
IMPRESSION:
1. Rim enhancing collection within the posterior spinal canal at
the levels of
L4 and L5 compatible with epidural abscess. Additional abscess
is seen within
the left paraspinal musculature at these levels. There is edema
and
enhancement within the adjacent left L4 and L5 pedicles and
spinous processes
which may indicate osteomyelitis. There is no evidence for
compression of the
cauda equina or cord compression.
2. Multilevel cervical, thoracic and lumbar spine degenerative
changes as
described.
******* ___ RUQ US *******
CLINICAL INDICATION: Cholecystitis per CAT scan. Evaluate for
cholecystitis.
TECHNIQUE: Gray-scale, spectral and color Doppler ultrasound
evaluation of
the abdomen.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS: The liver is normal ___ echotexture and contour. No
focal liver
lesions are identified. The portal vein is patent and
demonstrates normal
hepatopetal flow. There is no intrahepatic biliary duct
dilation. The common
bile duct measures 5 mm ___ diameter. The gallbladder is
distended and the
gallbladder wall is edematous. There is minimal pericholecystic
fluid. No
gallstones are identified. There are simple cysts ___ the right
kidney, the
largest measuring 1.9 cm. There is no hydronephrosis or stones.
The
visualized portions of the aorta and IVC appear normal.
IMPRESSION: Distended gallbladder with an edematous gallbladder
wall and
adjacent pericholecystic fluid. No gallstones. Considering
that the patient
is a diabetic these findings are concerning for acalculous
cholecystitis.
COMMENT: Changes to preliminary read communicated to ___ by
___ and
___ at 8:30 ___.
The study and the report were reviewed by the staff radiologist.
******* ___ CT ___ PARASPINAL ABSCESS DRAINAGE *******
INDICATION: ___ year old man with paraspinal and epidural
abscesses.
Aspirate paraspinal abscess and send material for culture
COMPARISON: CT abdomen and pelvis ___.
PROCEDURE: CT-guided aspiration of left posterior paraspinal
abscess.
OPERATORS: Dr. ___ fellow and Dr. ___,
___
radiologist, who was present and supervising throughout the
total procedure
time.
TECHNIQUE: The risks, benefits, and alternatives of the
procedure were
explained to the patient. After a detailed discussion, informed
written
consent was obtained. A pre-procedure timeout using three
patient identifiers
was performed per ___ protocol.
The patient was placed ___ a prone position on the CT scan table.
Limited
preprocedure CTscan of the intended site of aspiration was
performed. Based
on the CT findings an appropriate position for the aspiration
was chosen. The
site was marked.
The site was prepped and draped ___ the usual sterile fashion.
1% lidocaine
were administered to the subcutaneous and deep tissues for local
anesthetic
effect. Under CT guidance, a 18 gauge ___ needle was
introduced into the
left paraspinal abscess at L4-L5 level. Multiple attempts at
aspiration
yielded 4 cc of thick purulent material. Samples were sent to
microbiology as
requested.
The procedure was tolerated well and there were no immediate
post-procedural
complications.
DOSE: DLP: 338 mGy-cm
SEDATION: Divided doses of 50 mcg fentanyl throughout the total
intra-service
time of 30 minutes during which patient's hemodynamic parameters
were
continuously monitored by an independent trained radiology
nurse.
FINDINGS:
Limited non-contrast pre-procedure imaging demonstrates an
abscess ___ the left
paraspinal musculature (03:19). Extensive degenerative changes
of the imaged
lumbosacral spine is noted. Known epidural abscess is extremely
difficult to
visualized on this study.
Limited views of the pelvis demonstrate extensive aortoiliac
atherosclerosis.
IMPRESSION:
Technically successful CT-guided aspiration of a left paraspinal
abscess at
L4-L5 level. Samples sent for microbiology as requested.
The study and the report were reviewed by the staff radiologist.
******* ___ HIDA SCAN *******
RADIOPHARMACEUTICAL DATA:
4.4 mCi Tc-99m DISIDA ___
HISTORY: Back pain and fever.
TECHNIQUE:
Following the intravenous injection of tracer, serial one-minute
images of
tracer uptake into the hepatobiliary system were obtained for 60
minutes.
INTERPRETATION:
Serial images over the abdomen show homogeneous uptake of tracer
into the
hepatic parenchyma.
At 7 minutes, the gallbladder is visualized with tracer activity
noted ___ the
small bowel at 13 minutes.
IMPRESSION: Normal hepatobiliary scan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation Daily
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Digoxin 0.125 mg PO DAILY
6. PredniSONE 5 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. TraZODone 50 mg PO HS:PRN insomnia
9. Gabapentin 300 mg PO TID
10. Ezetimibe 10 mg PO DAILY
11. fenofibrate 150 mg oral daily
12. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous
TID
13. Levemir (insulin detemir) 100 unit/mL subcutaneous QHS
Discharge Medications:
1. Nafcillin 2 g IV Q4H
RX *nafcillin ___ dextrose iso-osm 2 gram/100 mL 2 g intravenous
Every 4 hours Disp #*252 Intravenous Bag Refills:*0
2. Rivaroxaban 15 mg PO BID Duration: 3 Weeks
After 3 weeks, this should be switched to 20mg daily for ___
months.
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth Twice per
day Disp #*42 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Digoxin 0.25 mg PO DAILY
RX *digoxin 250 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Ezetimibe 10 mg PO DAILY
6. Gabapentin 300 mg PO TID
7. PredniSONE 5 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. TraZODone 50 mg PO HS:PRN insomnia
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day
Disp #*60 Capsule Refills:*0
11. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth Once per day Disp #*30
Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
13. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth Twice per day
Disp #*60 Capsule Refills:*0
14. fenofibrate 150 mg oral daily
15. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous
TID
16. Levemir (insulin detemir) 100 unit/mL subcutaneous QHS
17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION DAILY
18. Tiotropium Bromide 1 CAP IH DAILY
19. Outpatient Lab Work
Please check Chem7, CBC, and LFTs weekly starting ___.
Please Fax results to:
OPAT (Outpatient antibiotic therapy) phone: ___, fax:
___
20. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 200 mg 1 tablet(s) by mouth
once per day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-------------------
PRIMARY DIAGNOSES
-------------------
- Paraspinal and epidural abscess L4-L5
- Sepsis
- Pulmonary embolism
- Right leg deep vein thrombosis
- Atrial fibrillation with RVR
- Acute on chronic diastolic congestive heart failure
exacerbation
-------------------
SECONDARY DIAGNOSES
-------------------
- COPD
- diastolic and systolic chronic congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILATERAL LOWER EXTREMITY ULTRASOUND
INDICATION: Lower extremity swelling. Dyspnea.
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both common
femoral veins, superficial femoral, popliteal and proximal calf veins were
obtained.
COMPARISON: None available.
FINDINGS:
There is normal respiratory variation in both common femoral veins.
Echogenic noncompressible clot is seen within the right posterior tibial vein
(image 13), demonstrating minimal adjacent flow. The right common femoral,
superficial femoral, and popliteal veins demonstrate normal compressibility.
Normal flow is demonstrated within the right peroneal vein.
Arising from the right popliteal fossa is a 4.5 x 2.2 x 1.2 cm collection.
There is normal flow, compressibility, and augmentation of the left common
femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins.
IMPRESSION:
1. Nonocclusive thrombus within the right posterior tibial vein (DVT).
2. 4.5 cm right popliteal fossa fluid collection.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
telephone at the time of interpretation, 11:57 AM, ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with dyspnea // Eval for edema, pneumonia
IMPRESSION:
In comparison with the earlier study of this date, there is little overall
change. Again there are low lung volumes which accentuate the transverse
diameter of the heart. No definite vascular congestion or pleural effusion.
Mild bibasilar atelectatic changes persist.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENTCHEST PORT. LINE PLACEMENTi
INDICATION: ___ year old man with 48cm right PICC. ___ ___ // 48cm right
PICC. ___ ___ Contact name: ___: ___
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
New right PIC line ends low in the SVC. Borderline cardiomegaly unchanged.
Lungs clear. No pleural abnormality.
Radiology Report
EXAMINATION: MR cervical, thoracic and lumbar spine.
INDICATION: ___ with fever, back pain, urinary retention. Rule out epidural
abscess.
TECHNIQUE: Multiplanar, multi sequence MR images of the cervical, thoracic
and lumbar spines were obtained before and after the administration of
intravenous contrast.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
Cervical spine: Cervical spine alignment is maintained. Vertebral body heights
are preserved. There is loss of disc space height most notable at C5-C6. Bone
marrow signal is mildly heterogeneous without focal suspicious abnormality.
No abnormal enhancement or epidural fluid collection is identified. The
cervical cord is normal in signal intensity.
C2-C3: A small central disc protrusion is present without significant spinal
canal narrowing. There is mild to moderate left neural foraminal narrowing
secondary to uncovertebral and facet osteophytes. The right neural foramen is
patent.
C3-C4: A small central disk protrusion mildly effaces the ventral subarachnoid
space. The right neural foramen is patent. There is moderate to severe left
neural foraminal narrowing secondary to uncovertebral and facet osteophytes.
C4-C5: A broad-based disc osteophyte complex is present, and there is
thickening of the ligamentum flavum contributing to moderate spinal canal
narrowing. There is we moderate to severe left neural foraminal narrowing and
mild to moderate right neural foraminal narrowing secondary to uncovertebral
and facet osteophytes. The degree of neural foraminal narrowing is difficult
to precisely determine secondary to patient motion artifact at this level.
C5-C6: A broad-based disc osteophyte complex completely effaces the ventral
subarachnoid space causing moderate spinal canal narrowing. There is moderate
to severe bilateral neural foraminal narrowing secondary to uncovertebral and
facet osteophytes.
C6-C7: A broad-based disc protrusion is present which effaces the ventral
subarachnoid space and causes mild spinal canal narrowing. There is mild right
and moderate left neural foraminal narrowing secondary to uncovertebral and
facet osteophytes.
C7-T1: No significant spinal canal or neural foraminal narrowing is present.
Thoracic spine: Thoracic spine alignment is preserved. There is chronic loss
of anterior height of multiple vertebral bodies. Bone marrow signal is
heterogeneous without focal suspicious abnormality. Chronic degenerative
endplate changes are most pronounced at T8-T9 and T9-T10. There is diffuse
loss of disc space height.
The thoracic cord is small in caliber. There is no abnormal cord signal. No
abnormal enhancement or epidural fluid collection is identified.
Scattered small disc protrusions are present without significant spinal canal
or neural foraminal narrowing.
Lumbar spine: There is grade 1, 4 mm anterolisthesis of L5 with respect S1
with associated bilateral chronic pars defects. Lumbar spine alignment is
otherwise preserved. Vertebral body heights are maintained. There is diffuse
loss of disc space height and signal most notable at L1-L2, L4-L5 and L5-S1.
Chronic degenerative endplate changes are noted at these levels as well. The
conus medullaris is normal
In morphology and signal intensity and terminates at the level of T12-L1.
In the left paraspinal soft tissues at the level of L4 and L5, there is a rim
enhancing loculated collection measuring 2.9 cm AP x 1.0 cm TR by 3.3 cm SI.
An additional rim enhancing collection is present in the posterior spinal
canal at the levels of L4 and L5 which measures 1.4 cm AP x 1.4 cm TR x 3.4 cm
SI. Enhancing phlegmon extends into the sacral spinal canal. The epidural
collection exerts mass effect on the posterior aspect of the thecal sac. Edema
and enhancement is seen within the adjacent L4 and L5 spinous processes and
left pedicles.
T12-L1 and L1-L2: There are mild diffuse disc bulges and facet degenerative
changes without significant spinal canal or neural foraminal narrowing.
L2-L3: There is a diffuse disc bulge which is slightly e centric to the left
and narrows the left subarticular recess. Mild degenerative facet changes are
present without significant spinal canal or neural foraminal narrowing.
L3-L4: A small left foraminal disc protrusion is present which mildly narrows
the left neural foramen. The spinal canal and right neural foramen are patent.
Mild facet degenerative changes are present.
L4-L5: There is a mild diffuse disc bulge, facet degenerative changes and
thickening of the ligamentum flavum. The disc bulge is slightly centric to the
right and causes mild right neural foraminal narrowing. The left neural
foramen is patent.
L4-L5: In addition to the anterolisthesis at this level there is a disc bulge
and facet degenerative changes. The epidural collection at this level causes
mild narrowing of the thecal sac. Mild bilateral neural foraminal narrowing is
present.
Multiple T2 hyperintense lesions are present within both kidneys, compatible
with renal cysts.
IMPRESSION:
1. Rim enhancing collection within the posterior spinal canal at the levels of
L4 and L5 compatible with epidural abscess. Additional abscess is seen within
the left paraspinal musculature at these levels. There is edema and
enhancement within the adjacent left L4 and L5 pedicles and spinous processes
which may indicate osteomyelitis. There is no evidence for compression of the
cauda equina or cord compression.
2. Multilevel cervical, thoracic and lumbar spine degenerative changes as
described.
NOTIFICATION: The results were discussed with Dr. ___ via telephone at
10:0 0 hr on ___ ___.
Radiology Report
CLINICAL INDICATION: Cholecystitis per CAT scan. Evaluate for cholecystitis.
TECHNIQUE: Gray-scale, spectral and color Doppler ultrasound evaluation of
the abdomen.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS: The liver is normal in echotexture and contour. No focal liver
lesions are identified. The portal vein is patent and demonstrates normal
hepatopetal flow. There is no intrahepatic biliary duct dilation. The common
bile duct measures 5 mm in diameter. The gallbladder is distended and the
gallbladder wall is edematous. There is minimal pericholecystic fluid. No
gallstones are identified. There are simple cysts in the right kidney, the
largest measuring 1.9 cm. There is no hydronephrosis or stones. The
visualized portions of the aorta and IVC appear normal.
IMPRESSION: Distended gallbladder with an edematous gallbladder wall and
adjacent pericholecystic fluid. No gallstones. Considering that the patient
is a diabetic these findings are concerning for acalculous cholecystitis.
COMMENT: Changes to preliminary read communicated to ___ by ___ and
___ at 8:30 ___.
Radiology Report
INDICATION: ___ year old man with paraspinal and epidural abscesses.
Aspirate paraspinal abscess and send material for culture
COMPARISON: CT abdomen and pelvis ___.
PROCEDURE: CT-guided aspiration of left posterior paraspinal abscess.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist, who was present and supervising throughout the total procedure
time.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CTscan of the intended site of aspiration was performed. Based
on the CT findings an appropriate position for the aspiration was chosen. The
site was marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 18 gauge ___ needle was introduced into the
left paraspinal abscess at L4-L5 level. Multiple attempts at aspiration
yielded 4 cc of thick purulent material. Samples were sent to microbiology as
requested.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: DLP: 338 mGy-cm
SEDATION: Divided doses of 50 mcg fentanyl throughout the total intra-service
time of 30 minutes during which patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse.
FINDINGS:
Limited non-contrast pre-procedure imaging demonstrates an abscess in the left
paraspinal musculature (03:19). Extensive degenerative changes of the imaged
lumbosacral spine is noted. Known epidural abscess is extremely difficult to
visualized on this study.
Limited views of the pelvis demonstrate extensive aortoiliac atherosclerosis.
IMPRESSION:
Technically successful CT-guided aspiration of a left paraspinal abscess at
L4-L5 level. Samples sent for microbiology as requested.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with history diastolic heart failure now with
acute SOB. // acute sob
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
HEART SIZE IS ENLARGED, UNCHANGED. MEDIASTINUM IS OVERALL STABLE. BIBASAL
ATELECTASIS IS UNCHANGED. NO OVERT PULMONARY EDEMA OR VASCULAR ENLARGEMENT IS
PRESENT. NO INTERVAL INCREASE IN PLEURAL EFFUSION OR DEVELOPMENT OF
PNEUMOTHORAX IS PRESENT.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, NEEDS MRI
Diagnosed with FEVER, UNSPECIFIED, LUMBAGO, RETENTION URINE UNSPECIFIED, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.4
heartrate: 82.0
resprate: 16.0
o2sat: 98.0
sbp: 116.0
dbp: 64.0
level of pain: 10
level of acuity: 3.0 | ___ with history of DM, afib with RVR, diastolic heart failure,
PVD, COPD presented with severe low back pain (sacrum/buttocks)
and fever, found to have L4-L5 epidural and paraspinal
abscesses. He underwent successful ___ drainage of paraspinal
abscess ___ with relief of pain and isolation of MSSA, for
which he will be treated with IV nafcillin 2g Q4H for 6 weeks.
Course was complicated by dyspnea, found to have DVT and
presumed pulmonary embolus, initially treated with IV heparin
and then transitioned to rivaroxaban. He is now being discharged
home with services.
# TACHYPNEA, DYSPNEA, concern for DIASTOLIC HEART FAILURE: The
patient had dyspnea at rest, on exertion, and orthopnea. The
etiology was likely driven primarily by pulmonary embolism. This
diagnosis was made based on clinical presentation of sudden
onset worsening of dyspnea, positive lower extremity doppler
showing DVT ___ right lower extremity, and TTE showing preserved
systolic function and some mild right-sided pressure elevation.
CXR negative, cardiac enzymes negative. Other contributing
etiologies could be acute on chronic diastolic heart failure
exacerbation, COPD, and anxiety. The patient was treated with IV
heparin initially and transitioned to rivaroxaban 15mg BID,
which he will need for 3 weeks prior to transitioning to 20mg
daily for ___ months. He was also treated with ipratropium
nebulizers and fluticasone inhaler; albuterol nebs were avoided
given his tendency to have afib/RVR. Heart rate was controlled
with increasing metoprolol from home dose of 50mg BID to 50mg
Q6H and increasing digoxin from 0.125mg to 0.25 mg daily.
Additionally, heart failure was treated with prn lasix.
Afterload control was achieved with lisinopril 5mg daily. THe
patient was never hypoxic while ___ house. On discharge,
respiratory status was stable but he still had some orthopnea.
He was counselled to sleep with head of bed up. He will also
need an outpatient sleep study.
# NIGHT TERRORS: The patient complained of poor sleep and
nighttime dyspnea also from night terrors. He had nightly dreams
that he was ___ ___ ___ combat and it was difficult to
know what was real or not real. These dreams have been ongoing
for the past month since his son passed away, and may represent
a normal grief reaction. He was evaluated and counseled by
Social Work and Psychiatry. They recommended regulating
patient's sleep-wake cycle to keep him awake and engaged during
the day to improve nighttime sleep. We continued home trazodone
50 mg PRN insomnia. Their recommendation was that the potential
benefit of additional medication for sleep is mitigated by the
patient's age, comorbidies and risk for delirium. This is an
ongoing issue that should be discussed with his PCP.
# FEVER, EPIDURAL abscesses, BACK PAIN: Patient has L4-L5
epidural and paraspinal abscesses s/p drainage of paraspinal
abscess ___ by ___, with improvement ___ back pain. Now on IV
nafcillin (switched from IV Vanc/Zosyn ___ since paraspinal
abscess culture growing MSSA. The patient will continue IV
nafcillin 2g Q4H (day 1 nafcillin ___ for 6 weeks and will
follow up with ___ ID team. His neuro exam remained normal
during his entire hospital stay. Because of this, Ortho Spine
elected not to do any surgical intervention.
# Afib/RVR: Patient had HR bursts into 140s-150s likely due to
active infection and PE. Digoxin subtherapeutic level 0.5 on
admission, so increased from home dose 0.125 mg to 0.25 mg.
Metoprolol was uptitrated from 50mg BID to 50mg Q6H. These
interventions achieved good rate control with HR ___. THe
patient was monitored on telemetry during his inpatient stay. |
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 and Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with a history of endometrial cancer who is
admitted
with weakness and nausea. The patient states she has been
feeling
fatigued, weak, and nauseated since her chemotherapy and
neulasta
last week. She states after she went home from her neulasta she
had a "deep sleep" all evening and night until the next morning.
She denies any vomiting. She denies any fever, shortness of
breath, congestion, or dysuria. She does have a yeast infection
under her breasts which she gets intermittently. She does have
an
intermittent non productive cough which she states she has had
for years. She states she had similar weakness of nausea with
his
prior doses of chemotherapy. Of not she admits to having some
diarrhea recently but it was after she took a large amount of
miralax after she had been taking Imodium and it has since
resolved.
Of note she was last admitted from ___ - ___ with weakness
that was thought to be from her chemotherapy and she was treated
supportively with improvement.
In the ED her vital signs were unremarkable. Labwork was notable
for leukocytosis. A UA and flu swab were negative. A chest X-ray
was unremarkable. She was given Zofran and IV fluids.
Past Medical History:
- T2DM on insulin
- Neuropathy of hands and feet b/l ___ diabetes
- Anxiety, depression, past history of suicide attempt and
hospitalizations
- Asthma, prior hospitalization, never intubated
- Osteoarthritis
- Hyperlipidemia
- Left adrenal mass
- s/p left breast lumpectomy, benign
Social History:
___
Family History:
Sister died breast cancer in ___. Brother died
throat cancer. Mother died lung cancer. Daughter died of
asthma/respiratory failure. Denies a known family history of
ovarian, uterine, cervical, or colon malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: T 97.8 BP 156/70 HR 91 RR 20 O2 96%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixi
SKIN: Erythema under breasts.
NEURO: Alert and oriented, no focal deficits.
DISCHARGE PHYSICAL EXAM:
98.2 150/72 88 20
General: NAD, sitting up in bed finished breakfast
HEENT: AT/NC, no OP lesions, MMM, EOMI, no JVD
CV: RRR, s1+s2 normal, no m/g/r appreciated
PULM: CTAB
ABD: +BS, soft, non-tender, non-distended, no organomegaly
appreciated
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: Erythema under breasts.
NEURO: No motor/sensory deficits elicited
Pertinent Results:
ADMISSION LABS:
___ 05:35PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 04:00PM URINE HOURS-RANDOM
___ 04:00PM URINE UHOLD-HOLD
___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 03:17PM LACTATE-1.2
___ 03:00PM GLUCOSE-102* UREA N-17 CREAT-0.9 SODIUM-142
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
___ 03:00PM estGFR-Using this
___ 03:00PM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-129* TOT
BILI-0.2
___ 03:00PM LIPASE-16
___ 03:00PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.3
MAGNESIUM-1.7
___ 03:00PM WBC-17.2* RBC-3.35* HGB-10.6* HCT-32.7*
MCV-98 MCH-31.6 MCHC-32.4 RDW-15.9* RDWSD-56.4*
___ 03:00PM NEUTS-74* BANDS-7* LYMPHS-11* MONOS-8 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-13.93* AbsLymp-1.89
AbsMono-1.38* AbsEos-0.00* AbsBaso-0.00*
___ 03:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-1+* MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL TEARDROP-1+*
___ 03:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-1+* MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL TEARDROP-1+*
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-10.6* RBC-3.03* Hgb-9.6* Hct-29.4*
MCV-97 MCH-31.7 MCHC-32.7 RDW-15.4 RDWSD-53.9* Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-221* UreaN-14 Creat-0.8 Na-144
K-4.5 Cl-107 HCO3-25 AnGap-12
___ 05:30AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.6
IMAGING:
___ CXR:
No signs of pneumonia.
MICRO:
___ 4:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___: Blood Cx x2: PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. BusPIRone 30 mg PO BID
4. FLUoxetine 40 mg PO DAILY
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. Gabapentin 1200 mg PO QHS
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath/wheezing
8. LamoTRIgine 25 mg PO QAM
9. LamoTRIgine 50 mg PO QPM
10. Lisinopril 5 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Oxybutynin 15 mg PO DAILY
14. Topiramate (Topamax) 75 mg PO QHS
15. TraZODone 200 mg PO QHS:PRN insomnia
16. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
17. Hydrocortisone Cream 2.5% 1 Appl TP BID
18. Ketoconazole 2% 1 Appl TP BID
19. Lactaid (lactase) 3,000 unit oral TID W/MEALS
20. LOPERamide 2 mg PO QID:PRN diarrhea
21. melatonin 3 mg oral QHS
22. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
23. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
24. Novolog 20 Units Breakfast
Novolog 20 Units Lunch
Novolog 20 Units Dinner
Tresiba 76 Units Bedtime
Discharge Medications:
1. Novolog 20 Units Breakfast
Novolog 20 Units Lunch
Novolog 20 Units Dinner
Tresiba 76 Units Bedtime
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. BusPIRone 30 mg PO BID
6. FLUoxetine 40 mg PO DAILY
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. Gabapentin 1200 mg PO QHS
9. Hydrocortisone Cream 2.5% 1 Appl TP BID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath/wheezing
11. Ketoconazole 2% 1 Appl TP BID
12. Lactaid (lactase) 3,000 unit oral TID W/MEALS
13. LamoTRIgine 50 mg PO QPM
14. LamoTRIgine 25 mg PO QAM
15. Lisinopril 5 mg PO DAILY
16. LOPERamide 2 mg PO QID:PRN diarrhea
17. melatonin 3 mg oral QHS
18. Montelukast 10 mg PO DAILY
19. Omeprazole 40 mg PO DAILY
20. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
21. Oxybutynin 15 mg PO DAILY
22. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
23. Topiramate (Topamax) 75 mg PO QHS
24. TraZODone 200 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Endometrial Cancer
Secondary Diagnosis
Weakness
Nausea
Diabetes Mellitus
Anxiety
Depression
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with productive cough, on chemo for uterine ca// pna?
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph dated ___. Dated ___.
FINDINGS:
Right chest wall Port-A-Cath terminates in the region of the cavoatrial
junction. The lungs are clear, though volumes are somewhat low. The
pulmonary vasculature is unremarkable. No pleural abnormalities. The
cardiomediastinal silhouette stable with dense mitral annular calcification
again seen. No acute osseous abnormalities.
IMPRESSION:
No signs of pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V, Weakness
Diagnosed with Nausea with vomiting, unspecified
temperature: 96.9
heartrate: 80.0
resprate: 20.0
o2sat: 95.0
sbp: 143.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | ___ with Stage II Grade 3 Mixed Serous and Endometrioid
Endometrial Cancer on C4 ___ who presented with weakness,
fatigue and lightheadedness one day after outpatient neulasta
injection.
ACTIVE ISSUES
=============
# Weakness/Fatigue
# Endometrial Cancer
Patient presented with non specific symptoms of weakness and
fatigue and nausea that started 24 hours after receiving her
scheduled neulasta injection as an outpatient. She received C4
carboplatin on ___ and received neulasta on ___ with symptom
onset on ___. Infectious work up was negative. She had
completed doxycycline treatment course for port site infection
and port site appeared c/d/I while inpatient. She was treated
with IV fluids and IV anti-emetics. She improved clinically and
was ready for discharge the following day, tolerating PO without
nausea and ambulating without imbalance. Etiology of symptoms
was thought possibly related to neulasta injection given time
correlation and less likely intolerance to chemotherapy regimen.
Outpatient oncologist was involved and will coordinate further
outpatient treatment as indicated.
CHRONIC ISSUES
==============
# Type 2 DM. She was continued on Lantus/Humalog regimen while
inpatient and will continue her home diabetic regimen upon
discharge.
# Anxiety/Depression. Continued on home buspirone, fluoxetine,
lamotrigine, Topamax, and trazadone.
# Asthma. Continued on home albuterol, duoneb, montelukast, and
fluticasone.
# HLD/HTN. Continued home atorvastatin, aspirin, and lisinopril.
# Overactive Bladder. Continued home oxybutynin.
TRANSITIONAL ISSUES
===================
- Outpatient oncology appointment ___
- Discharged with referral to home ___ assess for services |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ Stroke Scale Score: 0
NIHSS, GCS, and ICH score performed within 6 hours of
presentation at: ___ 7:45 pm
NIHSS Total: 0
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
GCS Score at the scene: 15
ICH Volume by ABC/2 method: 0.1 cc
ICH Score: 0
Pre-ICH mRS: 1
REASON FOR CONSULTATION: basal ganglia bleed
HPI:
___ yo female with recently diagnosed grade 3 invasive ductal
carcinoma of the left breast, thrombocyosis of unclear etiology,
chronic history of left foot drop s/p hip surgery, peripheral
vascular disease, chronic smoker, transferred from OSH after
presenting with headache and right-sided numbness, found to have
a left basal ganglia bleed.
Yesterday morning developed typical migraine with visual aura
("crimson halo"), which resolved after about 30 minutes
(typically resolves after 10 minutes). Took Excedrin and then
shortly after had recurrent migraine. Took second dose of
Excedrin. Had on-going intermittent headache throughout the day.
Then around 3:45 pm, when walking into a restaurant with her
partner, developed acute onset full right arm numbness, with the
sensation of a "pulse pounding" in her right hand. This slowly
improved over time. She took some aspirin and went to bed and
woke up again with worsening right arm numbness that seemed to
improve with movement.
This morning developed a recurrent headache and had two more
episodes of right arm numbness, without returning completely to
normal in between. Then at 1:30 pm, felt right facial numbness.
Given these symptoms presented to OSH, where she had a CT scan
notable for a small left basal ganglia hemorrhage.
Here she reports that her symptoms have largely resolved,
although she feels that the patch on her right arm near the PIV
still feels "funny". Denies any weakness, but may have had more
difficulty using the cane with her right arm.
ROS:
On neurological review of systems, the patient denies confusion,
difficulties producing or comprehending speech, vision changes,
or dizziness. Denies focal weakness. No bowel or bladder
incontinence or retention. Walks with cane at baseline for left
foot drop.
On general review of systems, the patient denies recent fever.
Denies cough, shortness
Past Medical History:
- Recently diagnosed grade 3 invasive ductal carcinoma of the
left breast. Upcoming oncologist appointment; planning for
chemo,
radiation, and surgery.
- Thrombocyosis of unclear etiology. Per hematology note,
patient
was taking aspirin, and patient initially reported being on a
"blood thinner" - but patient indicated that the cilostazol was
her blood thinner and did not list aspirin as a regular home
medication.
- Chronic history of left foot drop s/p hip surgery
- Peripheral vascular disease
Social History:
Lives with her partner of many years.
Adult son recently moved back in.
Retired, reports that she functions independently at baseline.
Quit smoking a few weeks ago. ___ year history of smoking, ___
ppd.
Drinks ___ times per week.
Denies any MJ, CBD, or other drug use.
- Modified Rankin Scale:
[] 0: No symptoms
[x] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Brother with intracranial bleed in the setting of trauma.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: T: 97.3 BP: 115/51 HR: 68 RR: 16 SaO2: 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
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.
Able to name both high and low frequency objects. No dysarthria.
Able to follow both midline and appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Decreased bulk, normal tone. Very mild right pronator
drift. Mild postural tremor.
[___]
L 5 5 5 5 5 5 5 5 5 3* 5 4*
R 5 5 5 5 5 5 5 5 5 5 5 5
*Baseline left foot drop
-Sensory: No deficits to light touch, pinprick. No extinction to
DSS. Reports subjective numbness over dorsal aspect of distal
right forearm.
-Reflexes:
[Bic] [___] [Pat]
L 2 2 2
R 2 2 2
Plantar response was flexor bilaterally.
-Coordination: Normal finger-tap bilaterally. No dysmetria on
FNF
bilaterally.
-Gait: Deferred. Walks with cane at baseline.
=================================================
DISCHARGE PHYSICAL EXAM:
As above except no subjective numbness.
Pertinent Results:
___ 07:13PM BLOOD WBC-11.0* RBC-3.95 Hgb-11.9 Hct-36.1
MCV-91 MCH-30.1 MCHC-33.0 RDW-14.6 RDWSD-48.8* Plt ___
___ 07:55PM BLOOD Neuts-50.1 ___ Monos-12.7 Eos-2.7
Baso-0.9 Im ___ AbsNeut-5.32 AbsLymp-3.51 AbsMono-1.35*
AbsEos-0.29 AbsBaso-0.10*
___ 07:13PM BLOOD ___ PTT-28.7 ___
___ 07:55PM BLOOD WBC-10.6* RBC-4.14 Hgb-12.3 Hct-37.8
MCV-91 MCH-29.7 MCHC-32.5 RDW-14.3 RDWSD-47.8* Plt ___
___ 07:55PM BLOOD ___ PTT-28.8 ___
___ 07:55PM BLOOD Glucose-86 UreaN-10 Creat-0.5 Na-138
K-4.3 Cl-107 HCO3-19* AnGap-12
___ 07:13PM BLOOD Glucose-102* UreaN-10 Creat-0.5 Na-136
K-4.4 Cl-104 HCO3-20* AnGap-12
___ 07:55PM BLOOD ALT-20 AST-24 CK(CPK)-67 AlkPhos-89
TotBili-0.2
___ 07:55PM BLOOD Lipase-52
___ 07:55PM BLOOD cTropnT-<0.01
___ 07:55PM BLOOD CK-MB-3
___ 07:13PM BLOOD Calcium-8.7 Phos-4.2 Mg-1.7 Cholest-159
___ 07:55PM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.4 Mg-1.7
___ 07:13PM BLOOD %HbA1c-5.0 eAG-97
___ 07:13PM BLOOD Triglyc-160* HDL-50 CHOL/HD-3.2
LDLcalc-77
___ 07:13PM BLOOD TSH-0.68
___ 07:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:00PM URINE Blood-NEG Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 09:00PM URINE RBC-7* WBC-38* Bacteri-FEW* Yeast-NONE
Epi-11
___ 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Imaging:
___ CTA head/neck:
1. 1.4 cm and 0.6 cm hyperdense foci in the left postcentral
gyrus and
posterior internal capsule, respectively, likely representing
metastatic
lesions.
2. No acute large territorial infarct.
3. Bilateral mastoid effusions.
4. Severe right maxillary sinus disease.
5. Atherosclerotic changes of the bilateral cavernous and
supraclinoid ICAs with mild bilateral narrowing with distal
patency.
6. 50% right and 30% left narrowing of the ICAs, by NASCET
criteria.
7. Multiple right pulmonary upper lobe and thoracic inlet
masses, most likely representing metastatic disease, given the
patient's history of breast cancer. These can be further
evaluated with a CT of the chest with contrast.
8. Cervical spondylosis with moderate to severe bilateral
foraminal narrowing at C4-5, C5-6 and C7 and mild-to-moderate
spinal canal narrowing at C4-5.
RECOMMENDATION(S): CT of the chest with contrast to further
evaluate the
masses seen in the thoracic cavity.
___ MRI brain w/wo contrast:
1. Study is mildly degraded by motion.
2. 1.5 cm and 0.7 cm enhancing lesions are seen in the left
postcentral gyrus and left internal capsule, respectively,
consistent with metastatic disease. The left basal ganglia
lesion demonstrates internal hemorrhage, consistent with the
hemorrhage seen on the prior CT of the head.
3. No acute infarct.
4. Severe right maxillary sinus disease and nonspecific
bilateral mastoid
fluid.
___ CT chest w/ contrast:
1. A 3.3 x 3.4 x 3.5 cm solid mass in the right upper lobe
correlates with the finding seen on prior breast MR, concerning
for second primary malignancy, less likely metastasis. Biopsy
is recommended.
2. Mediastinal and bilateral hilar lymphadenopathy is concerning
for disease involvement.
3. Known 2.7 cm left breast mass is better evaluated on prior
breast MR and mammography.
RECOMMENDATION(S): Biopsy is recommended for a 3.5 cm mass in
the right upper lobe.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cilostazol 100 mg PO BID
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Alendronate Sodium 10 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice daily Disp #*10 Capsule Refills:*0
2. Alendronate Sodium 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cilostazol 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute intraparenchymal hemorrhage
brain neoplasm
hemorrhagic metastasis
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 T___ MR HEAD
INDICATION: ___ year old woman with newly diagnosed breast cancer, presents
with left basal ganglia bleed.// Evaluate for source of bleed. With contrast,
given diagnosis of CA.
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: CTA of the head and neck with and without contrast dated ___.
FINDINGS:
Study is mildly degraded by motion.
A 1.5 cm x 1.4 cm enhancing lesion is seen in the left postcentral gyrus with
minimal surrounding edema.
A 7 mm heterogeneously enhancing lesion is seen in the left internal capsule
demonstrating internal hemorrhage.
There is no evidence of midline shift or infarction. There is mild prominence
of the ventricles and sulci suggestive of involutional changes. Few
periventricular and subcortical T2 and FLAIR hyperintensities are noted which
may represent small vessel ischemic changes.
There is complete opacification of the right maxillary sinus. Bilateral
mastoid fluid is present.
IMPRESSION:
1. Study is mildly degraded by motion.
2. 1.5 cm and 0.7 cm enhancing lesions are seen in the left postcentral gyrus
and left internal capsule, respectively, consistent with metastatic disease.
The left basal ganglia lesion demonstrates internal hemorrhage, consistent
with the hemorrhage seen on the prior CT of the head.
3. No acute infarct.
4. Severe right maxillary sinus disease and nonspecific bilateral mastoid
fluid.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with breast cancer and concern for mets// lung
mass
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and
parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.0 s, 32.2 cm; CTDIvol = 5.7 mGy (Body) DLP = 184.7
mGy-cm.
Total DLP (Body) = 185 mGy-cm.
COMPARISON: Breast MR dated ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: There is a coarse calcification in the left
lobe of the thyroid. The visualized thyroid is otherwise unremarkable.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: There are multiple enlarged mediastinal lymph nodes, including a
conglomerate at the thoracic inlet measuring 1.6 x 3.6 cm, and at the
subcarinal station measuring 2.1 x 3.3 cm.
HILA: There are multiple enlarged bilateral hilar lymph nodes, measuring up
to 1.4 cm in short axis on the right and 1.0 cm in short axis on the left.
HEART: The heart is not enlarged and there is moderate coronary arterial
calcification. There is no pericardial effusion.
VESSELS: Aortic caliber is normal. The main, right, and left pulmonary
arteries are normal caliber.
PULMONARY PARENCHYMA: There is a 3.3 x 3.4 x 3.5 cm round, slightly
spiculated mass in the right upper lobe. There is bilateral lower lobe
atelectasis. There is mild paraseptal and centrilobular emphysema.
AIRWAYS: The airways are patent to the subsegmental level bilaterally. There
is mild diffuse bronchial wall thickening in the lower lobes.
PLEURA: There is no pleural effusion.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are moderate. Irregularity of the sternum
likely represents healed fracture. A 2.7 x 1.9 cm soft tissue lesion in the
left breast correlates with known invasive ductal carcinoma, better evaluated
with dedicated mammography.
UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen is unremarkable.
IMPRESSION:
1. A 3.3 x 3.4 x 3.5 cm solid mass in the right upper lobe correlates with the
finding seen on prior breast MR, concerning for second primary malignancy,
less likely metastasis. Biopsy is recommended.
2. Mediastinal and bilateral hilar lymphadenopathy is concerning for disease
involvement.
3. Known 2.7 cm left breast mass is better evaluated on prior breast MR and
mammography.
RECOMMENDATION(S): Biopsy is recommended for a 3.5 cm mass in the right upper
lobe.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified
temperature: 97.2
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 117.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ yo female with recently diagnosed grade 3
invasive ductal carcinoma of the left breast, thrombocyosis of
unclear etiology, chronic history of left foot drop s/p hip
surgery, peripheral vascular disease, chronic smoker,
transferred
from OSH after presenting with headache and right-sided
numbness, found to have a left basal ganglia hyperdensity on CT.
This was further elucidated on MRI to likely reflect hemorrhagic
metastasis, and there is a second metastasis as well.
She had been planned for outpt chest CT based on possible nodule
seen on MRI breast, and this was also partially imaged on
admission CTA head/neck. Dedicated CT chest with contrast
performed this admission shows 3cm lesion, possible second
primary.
She has an appointment with her oncologist the day after
discharge. We have communicated these results with her
oncologist and will coordinate either neurology or
Neuro-oncology follow up for her.
Transitional issues:
[ ] Onc: Biopsy lung lesion
[ ] Neuro-oncology vs Oncology: plan for treatment of brain
metastases.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No.
If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status) Considered, but pt is at baseline
functional status. |
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, L facial puffiness, increased salivation, L facial
droop
Major Surgical or Invasive Procedure:
LP on ___, results pending for Cell Count and Differential;
Glucose; Protein, Total; CSF culture & gram stain; Acid Fast
(TB) Culture; Cytologic exam; Fungal culture; Angiotensin 1
Converting Enzyme; Immunophenotyping; Mycobacterium tuberculosis
Complex, Non-respiratory
History of Present Illness:
___ is a ___ F with h/o HTN, HLD, DM2 presenting with
new intermittent headaches over the past 2 weeks. The patient
states that the headaches are located on the left, start in the
occipital region and radiate to the forehead and sometimes to
the face. The quality is describes as constant and pressure
like. The headaches have occurred daily over the past two weeks
and tend to occur in the evenings around ___. They last for 30
minutes to 1 hour. The patient also states that over the past
few days she has noticed that the left side of her face feels
puffy and it is more difficult to chew on the left than the
right. She also describes some difficulty pronouncing words
intermittently, which she attributes to having more saliva in
her mouth than usual. She has not had any issues finding the
correct words and has not made any errors in language.
Past Medical History:
Breast cancer in ___ s/p chemo/radiation and lumpectomy
HTN
HLD
DM2
glaucoma
Social History:
___
Family History:
Mother with breast cancer, headaches, HLD, HTN. No family
history of stroke or other neurologic problems.
Physical Exam:
Admission Exam:
Vitals:
98.6 59 185/76 15 100%
GEN: Awake, cooperative, NAD.
HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx
NECK: Supple, no carotid bruits.
RESP: CTAB no w/r/r
CV: RRR, no m/r/g
ABD: soft, NT/ND
EXT: No edema, no cyanosis
SKIN: no rashes or lesions noted.
NEURO EXAM:
MS:
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.
Speech was not dysarthric.
Pt was able to name both high and low frequency objects.
Able to follow both midline and appendicular commands.
Good knowledge of current events.
No evidence of apraxia or neglect.
CN:
II:
PERRLA 3 to 2mm and brisk.
VFF to confrontation.
III, IV, VI: Patient states she is unable to follow the finger
to
either the left or right with her eyes, but frequently makes
full
lateral eye movements at other times throughout the exam. EOMI,
no nystagmus. Normal saccades. There is ptosis on the left,
which
the patient states has been present since birth
V: Sensation intact to LT.
VII: Facial musculature activates symmetrically.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ ___ 5 5
R ___ ___ ___ ___ 5 5
Sensory: No deficits to light touch, pinprick, vibratory sense,
proprioception throughout. No extinction to DSS.
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Toes downgoing bilaterally
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:
GEN: Awake, cooperative, NAD.
HEENT: NC/AT, anicteric, MMM, L tongue swollen
RESP: CTAB no w/r/r
CV: RRR, no m/r/g
ABD: soft, NT/ND
EXT: No edema, no cyanosis
NEURO EXAM:
MS:
Alert, oriented x 3.
Attention, language intact. Speech was not dysarthric.
Follows commands. No evidence of apraxia or neglect.
CN:
II:
PERRLA 3 to 2mm and brisk.
VFF to confrontation.
III, IV, VI: EOMI, no nystagmus. Normal saccades. There is
stable ptosis on the left.
V: Sensation intact to LT.
VII: Facial musculature activates symmetrically.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue with tip deviated to L.
Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements. No asterixis.
Strength ___ bilaterally.
Sensory: No deficits to light touch, pinprick, vibratory sense,
proprioception throughout.
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Toes downgoing bilaterally
Coordination:
No intention tremor. No dysmetria onFNF or HKS bilaterally.
Gait:
Narrow-based, normal stride and arm swing. Able to walk in
tandem without difficulty.
Pertinent Results:
CTA ___ ___
IMPRESSION:
1. Unremarkable unenhanced CT examination of the brain.
2. There is asymmetric fullness of the left base of tongue,
which effaces the vallecula, without evidence for a discrete
enhancing mass. This may represent denervation effect although
underlying mass lesion is not entirely excluded. Direct
visualization is recommended.
3. Essentially unremarkable CTA of the ___ and neck.
MR ___ ___
IMPRESSION:
1. No evidence of acute infarct. No acute intracranial process.
2. White matter changes, which are nonspecific, but commonly
seen in setting of small vessel ischemic disease.
MR ___ ___
IMPRESSION:
1. Finding consistent with the left hypoglossal nerve palsy with
enlargement of the tongue and effacement of the left vallecula,
a finding which may be seen on prior CTA of the ___ and neck
performed on ___. No solid lesions are noted.
2. This exam is not optimized for evaluation of the intracranial
facial nerve.
If there remains clinical concern, a dedicated ___ MRI, if there
no
contraindications may yield additional information.
3. The parotid glands are unremarkable.
4. Visualized brain is unremarkable.
CXR ___
IMPRESSION:
No previous images. The cardiac silhouette is mildly enlarged
and there is tortuosity of the descending aorta. No acute
pneumonia, vascular congestion, or pleural effusions. Surgical
clips are seen in the with right axillary region.
No evidence of hilar or mediastinal adenopathy or prominence of
interstitial markings to radiographically suggest sarcoidosis.
___ 08:25AM BLOOD ALT-198* AST-120* LD(LDH)-239
CK(CPK)-299* AlkPhos-119* TotBili-0.4
___ 08:25AM BLOOD Triglyc-87 HDL-71 CHOL/HD-2.2 LDLcalc-71
___ 04:00PM BLOOD ___ * Titer-PND
___ 04:00PM BLOOD CRP-2.3
___ 04:00PM BLOOD ANCA-NEGATIVE B
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Enalapril Maleate 20 mg PO BID
3. MetFORMIN XR (Glucophage XR) 2250 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
8. Aspirin EC 81 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Multivitamins 1 TAB PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Enalapril Maleate 20 mg PO BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 2250 mg PO DAILY
9. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Tongue hypertrophy of unclear etiology
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 headache, left facial droop hx of speech
difficulty // ? stroke vs other intracranial process
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 70 cc of Omnipaque
intravenous contrast material. Images were processed on a separate workstation
with display of curved reformats, 3D volume redendered images, and maximum
intensity projection images.
DOSE: DLP: 2230.62mGy-cm
COMPARISON: None on PACS.
FINDINGS:
Head CT: There is no intra or extra-axial mass effect, acute hemorrhage or
infarct. The gray-white differentiation is preserved. Sulci, ventricles and
cisterns are within expected limits. The paranasal sinuses are clear. The
orbits are unremarkable. The mastoid air cells and middle ear cavities are
well pneumatized and clear.
CTA head: There are symmetric approximately 1 mm outpouchings arising from the
lateral aspect of the cavernous segments of the internal carotid artery
(series 3, image 212 and 210) likely representing infundibulum. Mild
atherosclerotic calcifications of the carotid siphons are noted. Otherwise,
the ACA, MCA and their major branches are unremarkable. The intracranial
vertebral arteries are normal in course and caliber, noting a dominant left
vertebral artery. The remainder of the posterior circulation is unremarkable.
Small bilateral posterior communicating arteries are noted. There are no
intracranial aneurysms larger than 3 mm.
CTA neck: The carotid and vertebral arteries and their major branches are
patent with no evidence of stenoses, . The distal cervical internal carotid
arteries measure 7.7 mm in diameter on the left and 8.1 mm in diameter on the
right. There is no significant stenosis is based on NASCET criteria. There is
no evidence of aneurysm formation or other vascular abnormality.
The visualized lung apices are clear. The thyroid glands are unremarkable. No
osseous abnormalities. There is no cervical lymphadenopathy by CT size
criteria. Visualized parotid and submandibular glands are unremarkable.
Although evaluation of the oral cavity is slightly limited by beam hardening
artifact from dental hardware, there appears to be asymmetric fullness of the
left base of tongue which effaces the vallecula, contacting in the epiglottis.
There does not appear to be and discrete enhancing lesion. Direct
visualization/correlation is recommended.
IMPRESSION:
1. Unremarkable unenhanced CT examination of the brain.
2. There is asymmetric fullness of the left base of tongue, which effaces the
vallecula, without evidence for a discrete enhancing mass. This may represent
denervation effect although underlying mass lesion is not entirely excluded.
Direct visualization is recommended.
3. Essentially unremarkable CTA of the head and neck.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 6:02 ___, 60 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with transient facial droop // stroke?
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images .
COMPARISON: CTA head and CTA neck of ___.
FINDINGS:
There is no intra or extra-axial mass, acute hemorrhage or infarct. Sulci,
ventricles and cisterns are within expected limits. There are diffuse
punctate and areas of more patchy periventricular and subcortical white matter
nonspecific T2/FLAIR hyperintensities, which may be seen in setting of small
vessel ischemic disease. The major flow voids are preserved. The paranasal
sinuses are clear. The orbits are unremarkable. The mastoid air cells are
clear.
IMPRESSION:
1. No evidence of acute infarct. No acute intracranial process.
2. White matter changes, which are nonspecific, but commonly seen in setting
of small vessel ischemic disease.
Radiology Report
EXAMINATION: MRI SOFT TISSUE NECK, W/O AND W/CONTRAST
INDICATION: ___ year old woman with L facial swelling, possible transient L
facial droop, increased salivation // Please evaluate parotids and L facial
nerve coursing through gland
TECHNIQUE: Sagittal T1 precontrast, axial T1 precontrast, axial T1 IDEAL pre
and postcontrast contrast water, fat, in phase sequences, T2 pre contrast
IDEAL water, fat and inphase sequences and coronal T1 post water IDEAL of the
neck following administration of 6 cc Gadavist.
COMPARISON: MR head without contrast ___, CTA head and neck of ___.
FINDINGS:
There is asymmetric T2 hyperintense signal and trace increased enhancement of
the left tongue with enlargement of the left aspect of the tongue, which
effaces the left vallecula. No evidence of mass lesion. The findings are
suggestive of paralysis.
The parotid glands are unremarkable. Incidental note is made of a
nonpathologic appearing subcentimeter lymph node within the left parotid
gland. The submandibular glands are also unremarkable. The remainder of the
visualized aerodigestive tract is unremarkable. No cervical lymphadenopathy by
size criteria. Visualized lung apex is clear. The thyroid glands are
unremarkable. No osseous abnormalities.
The visualized paranasal sinuses are clear. The orbits are unremarkable. The
mastoid air cells are clear.
IMPRESSION:
1. Finding consistent with the left hypoglossal nerve palsy with enlargement
of the tongue and effacement of the left vallecula, a finding which may be
seen on prior CTA of the head and neck performed on ___. No solid
lesions are noted.
2. This exam is not optimized for evaluation of the intracranial facial nerve.
If there remains clinical concern, a dedicated ___ MRI, if there no
contraindications may yield additional information.
3. The parotid glands are unremarkable.
4. Visualized brain is unremarkable.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with hypoglossal palsy // Query sarcoid, TB,
ANCA vasculitis, other process Query sarcoid, TB, ANCA vasculitis, other
process
IMPRESSION:
No previous images. The cardiac silhouette is mildly enlarged and there is
tortuosity of the descending aorta. No acute pneumonia, vascular congestion,
or pleural effusions. Surgical clips are seen in the with right axillary
region.
No evidence of hilar or mediastinal adenopathy or prominence of interstitial
markings to radiographically suggest sarcoidosis.
Gender: F
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Weakness, Headache
Diagnosed with TRANS CEREB ISCHEMIA NOS, HYPERTENSION NOS, DIABETES UNCOMPL JUVEN
temperature: 98.6
heartrate: 59.0
resprate: 15.0
o2sat: 100.0
sbp: 185.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ yo F with a history of HTN, HLD, DM2, who
presented with pressure-like headaches on the L side for 2
weeks, with L face puffiness and increased salivation, with
possible transient L facial droop. Initial concern was for
TIA/stroke but clinically neurologic exam is normal and MR ___
did not indicate ischemic or hemorrhagic stroke. CTA shows a
small vertebral aneurysm. MR neck and clinical exam showed L
tongue swelling. ENT evaluated patient and recommends outpatient
biopsy. Also possible that this is due to neurologic condition,
full results of LP still pending. See below for details.
L tongue swelling/salivation
- MR neck to eval ___, but exam today and imaging indicates
L tongue swelling, including base of tongue.
- ENT consult to evaluate tongue and possible biopsy to evaluate
etiology of unilateral swelling (considerations include tumor,
infiltrative disease, lymphatic tissue swelling, or others).
Tongue pathology could also contribute to poor drainage of
saliva, leading to perception of increased salivation. Will
follow up in ___ clinic with possible outpatient biopsy (needs
to be done in OR due to bleeding risk).
- L tongue hypertrophy could also be caused by rare neurologic
conditions affecting innervation to the muscles of the tongue.
LP was performed on ___, with fluid sent for glucose,
protein, culture, fungal culture, TB AFB and PCR, flow
cytometry, cytology. Pending blood tests: ___, ANCA, SSA, SSB,
ESR, CRP, ACE.
Transient L facial droop
- unlikely to be TIA/stroke based on fast resolution of
symptoms, no MRI indication of stroke, and other exam findings
point to a non-neurologic primary etiology
- continue home aspirin
- hold atorvastatin (see below)
Dirty UA
- urine cx shows contamination with mixed genital flora
- will discontinue macrobid
Vertebral artery aneurysm
- repeat CTA in ___ year for surveillance
Elevated LFTs
- holding statin
- recheck LFTs as outpatient. PCP to consider restarting statin.
DM2
- continue lantus + SSI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LUQ/Epigastric abdominal pain x4 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of pancreas divisum and
recurrent pancreatitis at one point necrotizing with pseudocyst
formation status post pseudocyst gastrostomy in ___ who
presents with abdominal pain. He reports that he was in his
usual state of health until 4 days prior to admission, when he
developed gradual-onset intermittent "throbbing" left upper
quadrant/midepigastric pain, up to ___ in intensity and
radiating occasionally to the ipsilateral back. He is unable to
identify a clear precipitant, but does note that pain is
exacerbated by oral intake of any kind, with accompanying
nausea, or activity. Pain is reminiscent of prior
pancreatitis-associated pain in quality and intensity, but in
past episodes, pain was not localized primarily to the left
abdomen, wrapping instead across the epigastrum. While he does
experience acid reflux symptoms at baseline following
gastrostomy, for which he takes omeprazole, he denies chronic
abdominal pain. He consumes a mainly low-fat diet and avoids
NSAIDs, alcohol, and recreational substances. He denies recent
fevers, chills, sweats, vomiting, diarrhea, constipation,
melena, hematochezia, travel, or sick contacts. He recalls that
he last developed abdominal pain in ___, at which time he
presented to an outside hospital and underwent abdominal CT,
demonstrating persistent pseudocyst, but was not admitted.
In regards to his history of pancreatitis, the patient was in
good healthy until ___ when he was first hospitalized with
with acute
pancreatitis with a lipase > 15,000 and CT showing involvement
of the head, neck, and uncinate process of the pancreas.
Ultrasound did not show choledocholithiasis at that time.
Subsequently, he was hospitalized ___ more times for recurrent
pain with elevation of his lipase into the 100s. Based on review
of notes in our system, the etiology of his recurrent
pancreatitis is still unclear- he was a social drinker prior to
first episode of pancreatitis but no heavy EtOH, no stones
observed, IgG4 negative. Because stones possible etiology, he
underwent a laproscopic cholecystectomy ___. After the
procedure, he was discharged home but returned with continued
abdomin pain and CT showed 12.1cm pseudocyst. He was re-admitted
and treated with bowel rest, IVF, and IV analgesics and received
6wk TPN. Subsequent CT showed a necrotizing component as well.
Therefore, on ___ the patient underwent pancreatic
pseudocyst gastrostomy for necrotizing pancreatitis with
associated pseudocyst. The patient reports that after this
procedure, he has not had any additional hospitalizations. The
patient reports that he last developed abdominal pain in ___,
at which time he presented to an outside hospital ___
___ Outpatient ___ walk in clinic) and underwent
abdominal CT. Per patient report, the CT demonstrated a
persistent pseudocyst, but he was not admitted at that time. The
patient also had an EGD performed in ___ (___ Digestive
___ Ct), and he was told that there were no concerning
findings.
In the ED initial vital signs were as follows: 97.5, 58, 150/90,
17, 99% RA. Admission labs were notable for unremarkable CBC,
Chem7, and LFTs, and lipase of 108. CT abdomen/pelvis was
deferred, given benign abdominal exam and desire to avoid
further radiation. He received a total of 2mg IV hydromorphone
prior to transfer to the floor.
On the floor, he is comfortable with minimal abdominal pain
following opioid administration in the ED.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Pancreatitis, recurrent s/p laparoscopic cholecystectomy ___
and pseudocyst gastrostomy in ___
Afib with autoconversion
Acid reflux
ADHD
Social History:
___
Family History:
Grandparents (both maternal and paternal) required
cholecystectomy for gall stone disease at an older age, Prostate
cancer in mother's side, father has infrequent ___
Physical Exam:
Admission Physical Exam:
========================
VITALS: 97.8, 154/90, 53, 18, 98% RA
GENERAL: NAD
HEENT: EOMI, PERRL
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, left upper quadrant/midepigastric
tenderness without guarding/rebound, no CVAT
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
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: Tm98.1F Tc97.5F ___ 52-68 ___ 98-100%RA
GENERAL: Well-appearing gentleman lying in bed, no acute
distress
HEENT: NCAT, PERRL, moist mucous membranes
CARDIAC: RRR, S1/S2 clear and of good quality, no murmurs, rubs,
or gallops
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably on
room air without use of accessory muscles
ABDOMEN: Normoactive BS, soft, non-distended, mild tenderness
with deep palpation to midepigastric region / LUQ without
rebound or guarding, no hepatosplenomegaly. Midline and
laparaoscopic port scars from prior surgeries well-healed.
EXTREMITIES: Warm and well perfused, 2+ ___ pulses
bilaterally, no cyanosis, clubbing or edema
SKIN: No rashes, excoriations or lesions
Pertinent Results:
Admission Labs:
===============
___ 10:05PM BLOOD WBC-8.8# RBC-5.21# Hgb-15.1# Hct-45.3#
MCV-87 MCH-29.0 MCHC-33.4 RDW-12.3 Plt ___
___ 10:05PM BLOOD Neuts-72.5* ___ Monos-5.7 Eos-2.1
Baso-0.8
___ 05:03AM BLOOD ___ PTT-30.9 ___
___ 10:05PM BLOOD Glucose-114* UreaN-10 Creat-1.0 Na-141
K-4.1 Cl-101 HCO3-29 AnGap-15
___ 10:05PM BLOOD ALT-22 AST-27 AlkPhos-63 TotBili-1.0
___ 10:05PM BLOOD Lipase-102*
___ 10:05PM BLOOD Albumin-4.8
___ 05:03AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0
Discharge Labs:
===============
___ 05:03AM BLOOD WBC-7.8 RBC-5.04 Hgb-14.8 Hct-43.9 MCV-87
MCH-29.3 MCHC-33.7 RDW-12.4 Plt ___
___ 05:03AM BLOOD Glucose-114* UreaN-11 Creat-0.9 Na-139
K-4.2 Cl-100 HCO3-32 AnGap-11
___ 07:20AM BLOOD ALT-27 AST-22 AlkPhos-70 TotBili-1.4
___ 07:20AM BLOOD Lipase-41
___ 05:03AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0
Studies:
=======
MCRP ___:
1. Pancreatic duct stricture at the pancreatic neck, likely at
the site of prior cystgastrostomy, with distal pancreatic duct
dilatation. Recommend ERCP
2. Mild hepatic steatosis, predominantly surrounding the porta
hepatis.
3. Portal venous confluence/ superior SMV appears slit-like and
there is a large collateral vein seen adjacent to it.
Radiology Report
EXAMINATION: MRCP (MR ___
INDICATION: ___ year old man with pancreatic divism with history of
necrotizing pancreatitis complicated by pseudocyst s/p cystogastrostomy now
admitted with recurrent pancreatitis // Eval for biliary strictures and to
eval the cystogastrostomy
TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the abdomen were
obtained on a 1.5 Tesla magnet including dynamic 3D imaging prior to, during,
and after the administration of 7 mL Gadavist gadolinium based contrast. 1 mL
Gadavist mixed with 50 mL water was also administered for oral contrast.
COMPARISON: Reference abdominal CT on ___.
FINDINGS:
The lung bases are grossly clear. There is no ascites.
Liver: There is heterogeneous fatty deposition seen in the liver,
predominantly surrounding the porta hepatis. There are no suspicious hepatic
lesions identified. There is no significant intra or extrahepatic biliary
ductal dilatation.
Gallbladder: The gallbladder is normal. There is no evidence of
choledocholithiasis.
Pancreas: The pancreatic neck body and tail are uniformly T1 hypointense,
consistent with chronic pancreatitis due to duct obstruction. Additionally,
there is mild peripancreatic edema consistent with acute pancreatitis. There
is no peripancreatic fluid identified. Distal to the pancreatic neck there is
pancreatic ductal dilatation throughout the body and tail including side
branches as well as duct wall thickening. The duct is seen tapering and a
point in the pancreatic neck likely at the site were the duct formerly emptied
into the pseudocyst/ at the site of prior cystgastrostomy.
Spleen: The spleen is normal in appearance.
Kidneys and Adrenals: The adrenal glands are normal bilaterally. There is a
subcentimeter cyst in the lower pole of the left kidney. No suspicious renal
lesions are identified.
Bowel: The visualized bowel loops and mesentery are within normal limits.
Lymph Nodes: There is no significant mesenteric or retroperitoneal
lymphadenopathy.
Vessels: The aorta and its visualized branches are patent. The portal venous
confluence/superior SMV appears slit-like and there is a large collateral vein
seen adjacent to it.
Bones: The osseous structures are unremarkable.
IMPRESSION:
1. Pancreatic duct stricture at the pancreatic neck, likely at the site of
prior cystgastrostomy or just upstream from it, with upstream pancreatic duct
dilation. Recommend ERCP for further evaluation and possible stenting.
2. Mild hepatic steatosis, predominantly surrounding the porta hepatis.
3. Portal venous confluence, superior SMV, and medial splenic vein appear
slit-like and there are large collateral veins in the porta hepatis.
Gender: M
Race: UNKNOWN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ACUTE PANCREATITIS
temperature: 97.5
heartrate: 58.0
resprate: 17.0
o2sat: 99.0
sbp: 150.0
dbp: 90.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ with history of pancreas divisum and
recurrent pancreatitis including an episode of necrotizing
pancreatitis with pseudocyst formation requiring pseudocyst
gastrostomy in ___ who presents with abdominal pain likely
due to recurrent pancreatitis.
# Pancreatitis: The patient presented with 4d of
LUQ/midepigastric abdominal pain thought to be due to recurrent
pancreatitis w/ lipase elevated to 102. BISAP score 0. GI
consulted given complex history of recurrent pancreatitis,
recommended MRCP to better evaluate anatomy. MRCP ___ showed
a pancreatic duct stricture at the pancreatic neck, likely at
the site of prior cystgastrostomy, with distal pancreatic duct
dilatation. Per GI recommendations, decision made to treat this
episode of pancreatitis conservatively first, and then GI
follow-up as an outpatient to decide further management.
Therefore, pancreatitis treated conservatively during this
admission with bowel rest, IVF, and IV hydromorphone. Diet
advanced as tolerated and transitioned to PO pain medications
prior to discharge.
# HTN: Patient noted to have BP in 130s-150s/70s-90s in the ED
and on the floor. No treatement during this admission.
# ADHD: Chronic, stable. Continued home lisdexamfetamine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary angiogram s/p DES to LCx (___)
History of Present Illness:
___ is an ___ year old women with ischemic
cardiomyopathy, distant proximal LAD stenting, atrial
fibrillation, CKD, diabetes, and hypertension who is presenting
with a 1 day history of chest pain, now admitted with an NSTEMI.
Patient was in her usual state of health until this morning when
she suddenly developed left upper chest discomfort while reading
the newspaper. This was an intense stabbing sensation, 10 out of
10, and there was associated dyspnea. There were two episodes of
this severe pain, each lasting ___ minutes, she took a nitro x
2
with little to no relief and then called an ambulance. At some
point in the ED the pain went away and the breathing improved.
In the ED she presented with vitals signs of 97.5 80 136/84 20
100% RA. She appeared diaphoretic and uncomfortable. Serial EKGs
did not show any ST elevations, just evidence of an old anterior
infarct with a rhythm of sinus vs. junctional. Labs were
notable
for a rising troponin to 0.21, an elevated BNP to 4597, and a
stably elevated BUN/SCr. Her UA had pyuria, CXR with moderate
cardiomegaly, CTA showed no PE, no pericardial effusion, and no
aortic abnormality. She was given an aspirin load in addition to
doxycycline and ceftriaxone to treated both a cellulitis and a
UTI.
REVIEW OF SYSTEMS
Notable for requiring 2L of home oxygen, chronic urinary
incontinence, and chronic lower extremity wounds.
Past Medical History:
HTN
Hypercholestrolemia
Hypothyroidism
MI ___ - acute anterior MI. At CATH, she has a right dominant
system. The left main was free of any lesions. The LAD had
discrete 99% lesion in the proximal segment that was stented to
0% residual. The left circumflex coronary artery had a discrete
80% lesion. The right coronary artery had a mid 35% lesion and a
proximal 40% lesion. LVEF: 50% (___)
Coronary angioplasty w/ ___ reflux
CKD Stage III
CHF w/ normal EF
RLD ___ obesity
Sleep apnea
Asthma
Arthritis
Stress incontinence
Social History:
___
Family History:
Both parents passed away from ___. Family history of diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: 98.2 154/73 60 20 94 RA
Last weight ___ 167 pounds (was 183 pounds ___
Gen: comfortable, laying flat speaking in full sentances
Neck: JVP difficult to assess given obesity
Chest: lungs clear bilaterally
CV: RRR, S1S2, no MRG
Abd: soft, NTND
GU: wearing an adult diaper
Ext: warm, mild pitting in legs, pink erythema to left shin with
overlying scale, non tender to touch
DISCHARGE PHYSICAL EXAM
========================
___ 0535 Temp: 97.8 PO BP: 147/58 HR: 55 RR: 18 O2 sat: 96%
O2 delivery: RA
Fluid Balance (last updated ___ @ 528)
Last 8 hours Total cumulative 0ml
IN: Total 0ml
OUT: Total 0ml, Urine Amt 0ml
Last 24 hours Total cumulative 599ml
IN: Total 600ml, PO Amt 600ml
OUT: Total 1ml, Urine Amt 1ml
GEN: Sitting up in chair, NAD
LUNGS: CTAB in bilateral posterior fields
CV: RRR, normal S1/S2, no m/g/r
EXT: trace edema b/l ___ to mid-calf. venous stasis changes
bilaterally. Warm.
Pertinent Results:
ADMISSION LABS
===============
___ 10:40AM BLOOD WBC-8.5 RBC-3.47* Hgb-10.2* Hct-33.5*
MCV-97 MCH-29.4 MCHC-30.4* RDW-16.5* RDWSD-58.7* Plt ___
___ 10:40AM BLOOD Neuts-83.3* Lymphs-10.1* Monos-4.5*
Eos-1.3 Baso-0.4 Im ___ AbsNeut-7.11* AbsLymp-0.86*
AbsMono-0.38 AbsEos-0.11 AbsBaso-0.03
___ 10:40AM BLOOD ___ PTT-37.4* ___
___ 10:40AM BLOOD Glucose-315* UreaN-82* Creat-1.5* Na-141
K-4.4 Cl-99 HCO3-24 AnGap-18
___ 10:40AM BLOOD CK-MB-3 proBNP-4597*
___ 10:40AM BLOOD cTropnT-0.04*
___ 03:46PM BLOOD cTropnT-0.13*
___ 08:00PM BLOOD cTropnT-0.21*
___ 06:19AM BLOOD CK-MB-6 cTropnT-0.25*
___ 03:40PM BLOOD CK-MB-4 cTropnT-0.19*
___ 06:19AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.8
___ 04:03PM URINE Color-Straw Appear-Hazy* Sp ___
___ 04:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 04:03PM URINE RBC-2 WBC-145* Bacteri-FEW* Yeast-NONE
Epi-1
___ 04:03PM URINE CastHy-2*
___ 04:03PM URINE Mucous-RARE*
DISCHARGE LABS
===============
IMAGING
========
CXR (___)
--------------
IMPRESSION:
Cardiomegaly without superimposed acute cardiopulmonary process.
CTA CHEST (___)
-------------------
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
RIGHT KNEE X-RAYS (___)
IMPRESSION:
Tricompartmental osteoarthritis with a small right knee joint
effusion. No fractures, lytic or blastic bone lesions
identified.
RIGHT KNEE ASPIRATION (___)
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
DISCHARGE LABS:
___ 06:54AM BLOOD WBC-8.3 RBC-3.07* Hgb-9.1* Hct-29.4*
MCV-96 MCH-29.6 MCHC-31.0* RDW-16.0* RDWSD-56.0* Plt ___
___ 06:54AM BLOOD Plt ___
___ 06:54AM BLOOD ___ PTT-36.4 ___
___ 06:54AM BLOOD Glucose-86 UreaN-116* Creat-1.6* Na-134*
K-4.8 Cl-97 HCO3-23 AnGap-14
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Warfarin 2.5 mg PO DAILY16
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Losartan Potassium 25 mg PO BID
4. Torsemide 60 mg PO QAM
5. Gabapentin 100 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Omeprazole 40 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Oxybutynin XL (*NF*) 10 mg Other DAILY
12. amLODIPine 2.5 mg PO DAILY
13. Torsemide 40 mg PO QPM
14. Calcium Carbonate 500 mg PO DAILY
15. Glargine 17 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
16. Acetaminophen w/Codeine 1 TAB PO QHS
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY Duration: 2 Days
stop taking on ___
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Colchicine 0.3 mg PO DAILY
RX *colchicine 0.6 mg 0.5 (One half) tablet(s) by mouth once a
day Disp #*15 Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % 1 patch QAM Disp #*30 Patch
Refills:*0
5. Glargine 26 Units Dinner
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
4 units before breakfast, 4 units before lunch, 4 units before
dinner Disp #*2 Syringe Refills:*0
6. Acetaminophen w/Codeine 1 TAB PO QHS
7. amLODIPine 2.5 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Calcium Carbonate 500 mg PO DAILY
10. Gabapentin 100 mg PO DAILY
11. Levothyroxine Sodium 150 mcg PO DAILY
12. Magnesium Oxide 400 mg PO DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Omeprazole 40 mg PO DAILY
16. Oxybutynin XL (*NF*) 10 mg Other DAILY
17. Torsemide 60 mg PO QAM
18. Torsemide 40 mg PO QPM
19. Warfarin 2.5 mg PO DAILY16
20. HELD- Losartan Potassium 25 mg PO BID This medication was
held. Do not restart Losartan Potassium until you follow-up with
your doctor in 1 week
21.Outpatient Lab Work
N17: Acute kidney injury
Please check chemistry-7, calcium, magnesium, and phosphorus on
___. Please fax results to Pt's cardiologist ___,
___ and PCP ___, ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Non ST segment elevation myocardial infarction
SECONDARY DIGANOSES
====================
Heart failure with preserved ejection fraction
Gout
Atrial fibrillation
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with sudden onset chest pain// eval PTX
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Moderate cardiomegaly is unchanged. The lungs remain clear without
consolidation. No obvious effusion noting that the right costophrenic angles
excluded from the field of view. No pneumothorax. No acute osseous
abnormalities.
IMPRESSION:
Cardiomegaly without superimposed acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with sudden onset chest pain in left upper chest// eval
dissection
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 30.4 mGy (Body) DLP =
15.2 mGy-cm.
2) Spiral Acquisition 3.8 s, 29.8 cm; CTDIvol = 16.3 mGy (Body) DLP = 485.1
mGy-cm.
Total DLP (Body) = 500 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Mild cardiomegaly. The pericardium, and great vessels
are within normal limits. No pericardial effusion is seen. Coronary artery
calcifications and probable stent are noted.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: There is trace left pleural effusion. No right pleural
effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally. There is mild lower lobe bronchiolectasis.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Limited sections through the upper abdomen demonstrate a 2.3 x 1.4
cm, indeterminate nodule on the current exam but previously characterized as
an adenoma. A punctate calcification is noted in the anterior aspect of the
perihepatic space.
BONES: No suspicious osseous abnormality is seen.? Multilevel degenerative
changes noted. There is no acute fracture.
CHEST WALL: Surgical clips noted in the right breast.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ year old woman with sudden onset severe knee pain// Cause of
patient's severe knee pain?
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of right knee joint
COMPARISON: None
FINDINGS:
There is mild diffuse demineralization.
Decrease in tibiofemoral and patellofemoral joint compartment spaces with
marginal osteophytosis noted. There is cortical thickening of the proximal
shaft of the right fibula, possibly related to a chronic injury. Small right
knee joint effusions seen. No fractures, lytic or blastic bone lesions
identified.
Extensive atherosclerotic calcification is seen projecting around the right
knee joint.
IMPRESSION:
Tricompartmental osteoarthritis with a small right knee joint effusion. No
fractures, lytic or blastic bone lesions identified.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 97.5
heartrate: 80.0
resprate: 20.0
o2sat: 100.0
sbp: 136.0
dbp: 84.0
level of pain: 5
level of acuity: 2.0 | TRANSITIONAL ISSUES
===================
[ ] Her INR was labile while inpatient. She should be followed
closely in ___ clinic as an outpatient for warfarin
dosing.
[ ] She was started on aspirin post-catheterization, this should
be stopped on ___. She should continue taking clopidogrel and
warfarin after stopping aspirin.
[ ] Pt will likely need atherectomy for her LAD lesion given
complicated lesion.
[ ] Insulin regimen uptitrated given hyperglycemia in house, to
include addition of Humalog with meals and uptitration of
lantus.
[ ] Her losartan was held at the time of discharge because she
still had a slight ___. Her Cr at discharge was 1.6. Her Cr
should be re-checked approximately 1 week post-discharge and if
back at her baseline, her losartan should be re-started.
[ ] Heart rates in the 40-50's while on metoprolol succinate XL,
with good augmentation with physical activity. Please consider
reducing dose to lowest that is well tolerated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Sigmoid colectomy, then sigmoid colostomy and closure
distal stump.
___: Decompressive laparotomy, evacuation of
intraperitoneal clot, abdominal washout, packing, VAC placement.
___: Reopening of recent laparotomy. Removal of packs,
washout, and abdominal closure.
History of Present Illness:
This patient is a ___ year old male who complains of abdominal
distention.
this patient went to an outside hospital earlier today because
of ___ days of gradually increasing abdominal distention without
much pain. He has had a fair amount of constipation as well. No
fevers or chills. He has a history
of a ventral hernia repair. No cardiopulmonary symptoms. No
urinary tract symptoms.
At the outside hospital, he was found to have a large sigmoid
volvulus, got 500 mg of Flagyl and 1 g of Rocephin and
transferred here. He has severe rheumatoid arthritis.
Past Medical History:
PAST MEDICAL HISTORY:
1. Rheumatoid arthritis (he has not seen a rheumatologist in
___ years).
2. Chronic splenomegaly.
3. Osteopenia.
4. BPH.
5. Hiatus hernia.
6. Allergic rhinitis.
7. Overactive bladder.
8. Frozen shoulder status post fall.
PAST SURGICAL HISTORY:
1. Status post appendectomy.
2. Status post cataract surgery.
3. Status post hernia repair.
Social History:
___
Family History:
FAMILY HISTORY: No polycythemia.
Physical Exam:
Admission Physical Exam:
VS: 97.2 88 107/56 16 94% RA
Gen: NAD
CV: RRR
Resp: comfortable on room air
GI: marked abdominal distension, tympanitic, TTP diffusely, no
guarding, no peritonitis
Extrem: WWP
Discharge Physical Exam:
VS: T: 98.3, BP: 130/56, HR: 84, RR: 18, O2: 96% RA
GEN: A+Ox3, NAD
HEENT: atraumatic
CV: RRR
PULM: coarse rhonchi b/l, symmetric excursion, no acute
respiratory distress
GI: midline incision with steri-strips OTA, some erythema near
inferior portion of wound, no drainage from midline, no
induration. Reactive erythema from prior staples. Abd soft,
non-distended, non-tender to palpation
EXT: warm, well-perfused, no edema b/l
Pertinent Results:
IMAGING:
___: Portable Abdomen X-ray:
Interval placement of rectal tube. Multiple dilated colonic
loops, small
bowel loops, mildly improved since prior. Previously seen
dilated loop of
sigmoid has resolved. Degenerative changes spine. Arterial
calcifications.
IMPRESSION:
Mild improvement since prior.
PATHOLOGY: ___:
1. Colon, sigmoid, resection:
- Colon with transmural hemorrhagic infarction; ischemic changes
extend to one specimen margin.
2. Hernia sac and contents:
- Consistent with hernia sac.
3. Omentum, resection:
- Fibroadipose tissue with congestion and acute serositis.
___: Chest Port Line Placement:
In comparison with study of ___, this and placement of right
IJ catheter that extends to the right atrium. No evidence of
post procedure pneumothorax. Otherwise little change in the
appearance of the heart and lungs and the significantly dilated
loops of bowel in the abdomen.
___: Cest Port Line Placement:
No definite change compared 1 day earlier. CHF findings may be
slightly
improved. Tip of the ET tube is unchanged, but difficult to
confirm on the current film. Please see comments above.
___: EKG:
Probable atrial tachycardia with 2:1 conduction. Non-specific
inferolateral T wave flattening. Poor R wave progression. No
previous tracing available for comparison.
___: Portable Abdomen x-ray:
Multiple dilated loops of bowel measuring up to 7.7 cm, may
represent ileus or bowel obstruction.
___: ECHO:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
___: EKG:
Probable sinus tachycardia with premature atrial beats in a
trigeminal pattern. Poor R wave progression. Low QRS voltages in
the limb leads. Compared to tracing #1 atrial trigeminy is
present. The QRS changes in leads V3-V5 are probably due to lead
placement.
___: KUB:
No signs of retained surgical sponge.
___: Chest Port Line Tube:
In comparison the earlier study of this date, the tip of the
endotracheal tube now measures approximately 4.5 cm above the
carina. Other monitoring support devices are unchanged.
Continued opacification at the left base silhouetting the
hemidiaphragm,
consistent with substantial volume loss in left lower lobe and
small layering pleural effusion. The right lung is essentially
unchanged.
___: EKG:
Atrial flutter, probably typical. Low limb lead voltage.
Somewhat late
R wave progression. Other ST-T wave abnormalities. No previous
tracing
available for comparison.
___: CXR:
Comparison to ___. Stable appearance of the right
hemithorax.
Minimally improved ventilation of the left lung bases, with a
decrease in
extent and severity of the pre-existing left lower lobe
atelectasis and a
decrease in severity of the left pleural effusion. No new focal
parenchymal changes. Stable correct position of the monitoring
and support devices.
___: CXR:
Compared to chest radiographs ___ through ___.
Heterogeneous opacification has developed in the right lung,
worsened on the left. Some of this is due to increasing pleural
effusion, particularly in the left hemithorax, but the bilateral
nature of the abnormality suggests pulmonary edema. Careful
follow-up is recommended following attempts to improved
hemodynamic status because of the possibility of on alternative
explanation in bilateral pneumonia. No pneumothorax.
Nasogastric drainage tube passes through nondistended stomach to
the proximal duodenum.
___: Chest Port Line/Tube:
Dobhoff tube tip isin the stomach. No other interval change
from prior study.
___: CXR (PA&LAT):
Pleural effusions. Basilar atelectasis. Pulmonary edema.
___: CT Abdomen/Pelvis:
Areas of wall thickening involving large bowel, may be reactive,
consider
colitis. Major abdominal arteries, veins are patent.
Few foci of air in the pelvis may be postsurgical, there is
adjacent mild
linear areas of enhancement, no organized fluid collection.
Residual
infection cannot be excluded, if patient does not improve
clinically,
follow-up exam recommended to exclude development of an abscess.
Moderate
ascites.
Multiple dilated small bowel loops in the low abdomen, pelvis,
with gradual transition point, more likely represent adynamic
ileus than obstruction.
10 mm hypoattenuating nodule within the right adrenal gland is
indeterminate. Further evaluation with CT adrenal protocol or
MRI may be helpful.
Bilateral pleural effusions, atelectasis.
Indeterminate lesion lower pole left kidney, renal ultrasound
recommended.
Indeterminate retroperitoneal lymph nodes.
RECOMMENDATION(S): If the patient is low risk by ___
___
guidelines (minimal or absent history of smoking or other known
risk factors for primary lung neoplasm), recommend follow-up
dedicated chest CT at 12 months and if no change, no further
imaging needed. If the patient is high risk by ___
___ guidelines (history of smoking or other known risk
factors for primary lung neoplasm), recommend initial follow-up
chest CT at ___ months and then at ___ months if no change.
___: VIDEO OROPHARYNGEAL SWALLOW:
Penetration without aspiration. Moderate-severe pharyngeal
weakness.
Please refer to the speech and swallow division note in OMR for
full details, assessment, and recommendations.
___: CT Chest:
Penetration without aspiration. Moderate-severe pharyngeal
weakness.
Please refer to the speech and swallow division note in ___ for
full details, assessment, and recommendations.
___: CYTOLOGY:
SPECIMEN(S) SUBMITTED: PLEURAL FLUID, right pleural effusion
DIAGNOSIS:
Pleural fluid, right:
NEGATIVE FOR MALIGNANT CELLS.
- Mesothelial cells, lymphocytes, and histiocytes.
SPECIMEN DESCRIPTION:
Received: 1000 ml, cloudy, yellow fluid.and 1 heme slide. The
cytospin slide, prepared in Hematology, is labeled
___
Prepared: 1 cytospin, 1 monolayer, 1 cell block
___: CYTOLOGY:
SPECIMEN(S) SUBMITTED: PLEURAL FLUID, left pleural effusion
DIAGNOSIS:
Pleural fluid, left:
NEGATIVE FOR MALIGNANT CELLS.
- Mesothelial cells, lymphocytes and histiocytes.
SPECIMEN DESCRIPTION:
Received: 800 ml, yellow, clear fluid.and 1 heme
___: CXR:
In comparison with the study of ___, following
thoracentesis there is no evidence pneumothorax. Otherwise,
little overall change except for improved degree of inspiration.
___: CT Abdomen/Pelvis:
1. No organized fluid collection. Persistent but mild decrease
in fluid in the left hemipelvis containing likely Surgicel
(versus locules of air) with associated mild peritoneal
thickening.
2. Persistent, but decreased small volume ascites.
3. Decrease bilateral pleural effusions.
4. Indeterminate left lower pole renal lesion, nonemergent renal
ultrasound can be obtained for further characterization.
5. Splenomegaly and retroperitoneal lymphadenopathy, of
uncertain
significance.
RECOMMENDATION(S): Nonemergent renal ultrasound
LABS:
___ 06:50PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 06:50PM URINE RBC-41* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0
___ 06:50PM URINE HYALINE-42*
___ 06:50PM URINE MUCOUS-RARE
___ 05:09PM LACTATE-1.6
___ 04:50PM GLUCOSE-134* UREA N-28* CREAT-1.1 SODIUM-134
POTASSIUM-3.2* CHLORIDE-99 TOTAL CO2-19* ANION GAP-19
___ 04:50PM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-1.9
___ 04:50PM WBC-35.6* RBC-5.09 HGB-14.6 HCT-44.8 MCV-88
MCH-28.7 MCHC-32.6 RDW-16.4* RDWSD-52.4*
___ 04:50PM NEUTS-94.3* LYMPHS-0.8* MONOS-2.8* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-33.58* AbsLymp-0.27* AbsMono-0.98*
AbsEos-0.01* AbsBaso-0.08
___ 04:50PM PLT COUNT-232
___ 04:50PM ___ PTT-29.7 ___
MICRO:
___ 9:17 pm BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:30 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:24 pm PLEURAL FLUID LEFT PLEURAL EFFUSION.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 2:22 pm PLEURAL FLUID RIGHT PLEURAL EFFUSION.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 5:00 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 10:59 am URINE Source: Catheter.
URINE CULTURE (Preliminary):
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
TOBRAMYCIN------------ <=1 S
Medications on Admission:
Omeprazole 20mg daily
Doxazosin 8mg daily
Finasteride 5mg daily
Oxybutynin 5mg daily
ASA 81 daily
Iron 325 daily
Flaxseed oil 1000mg daily
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days
3. Docusate Sodium 100 mg PO BID
please hold for loose stool
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Glucose Gel 15 g PO PRN hypoglycemia protocol
6. Heparin 5000 UNIT SC TID
7. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using HUM Insulin
8. Metoprolol Tartrate 12.5 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Ramelteon 8 mg PO QHS:PRN Sleep (if pt having difficulty
sleeping)
11. RisperiDONE (Disintegrating Tablet) 0.5 mg PO BID
to Rehab: not a home medicine. Please consider weaning at
discretion
12. Senna 8.6 mg PO BID:PRN constipation
13. Doxazosin 8 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Oxybutynin 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sigmoid volvulus, necrotic sigmoid colon
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new CVL// CVL placement Surg: ___ (ex
lap) Contact name: ___: ___ CVL placement
IMPRESSION:
In comparison with study of ___, this and placement of right IJ catheter
that extends to the right atrium. No evidence of post procedure pneumothorax.
Otherwise little change in the appearance of the heart and lungs and the
significantly dilated loops of bowel in the abdomen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p Hartmans// postop, evaluate ETT postop,
evaluate ETT
IMPRESSION:
Compared to chest radiographs ___ and ___, most recently 09:59.
New ET tube in standard placement.
Nasogastric drainage tube ends in the intrathoracic stomach, partially
decompressed and now containing more fluid. Severe colonic distention has
worsened.
Bibasilar pulmonary consolidation is more severe, could be atelectasis alone.
Small left pleural effusion is larger. No pneumothorax. Heart size normal.
Upper lungs show vascular engorgement and probable mild edema.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with line repositioning// line place Contact
name: ___: ___
FINDINGS:
ET tube tip lies approximately 5.6 cm above the carina. NG tube is similar
configuration. However, the left hemidiaphragm gastric fundus are not well
delineated making it difficult to confirm its position. Prior study suggested
that it was in an elevated left hemidiaphragm. Right subclavian PICC right
right IJ line tip overlies the SVC/RA junction. No pneumothorax is detected.
There is dense retrocardiac density consistent with left lower lobe collapse
and/or consolidation, but the possibility elevated left hemidiaphragm cannot
be excluded. Platelike atelectasis at the right base. Mild vascular
plethora, though this is likely accentuated by low lung volumes. Doubt overt
CHF. No right-sided effusion. Small left effusion cannot be excluded.
Distended loops of bowel seen in the upper abdomen are similar to the prior
study. No free air is identified beneath the diaphragm.
Old healed right-sided rib fracture noted.
IMPRESSION:
No definite change compared 1 day earlier. CHF findings may be slightly
improved. Tip of the ET tube is unchanged, but difficult to confirm on the
current film. Please see comments above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ET tube
TECHNIQUE:
Chest x-ray from ___ at 23:52
FINDINGS:
Inspiratory volumes are low. The ET tube tip lies approximately 3.3 cm above
the carina. An NG tube is present, but loops, such that the tip overlies the
cardiac silhouette--question reflecting the presence of a hiatal hernia.
Right IJ central line tip overlies distal SVC/RA junction. No pneumothorax is
detected.
There is increased retrocardiac density consistent with left lower lobe
collapse and/or consolidation and a probable small to moderate left effusion.
There is subsegmental atelectasis at the right lung base. No gross right
effusion.
Prominent air-filled loops of small and large bowel are noted. Although very
prominent, they not meet formal criteria for dilatation.
IMPRESSION:
Left lower lobe collapse and/or consolidation and small to moderate size left
effusion., Without gross change compared with ___.
Atypical configuration of the NG tube suggests presence of a hiatal hernia.
Prominent air-filled loops of bowel in the abdomen again noted.
Radiology Report
INDICATION: ___ year old man with severe abdominal distension// ? ileus
TECHNIQUE: Portable AP supine abdominal radiograph.
COMPARISON: CT abdomen pelvis from outside hospital dated ___.
FINDINGS:
Right lateral hemiabdomen is excluded from the field of view limiting
evaluation.
Interval removal of previously seen rectal tube. Multiple metallic staples
project over the midline of the lower abdomen. Multiple metallic coils
projecting over the mid abdomen related to prior ventral hernia repair. There
are multiple dilated loops of large and small bowel, the largest of which
measures up to 7.7 cm in the left upper quadrant.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Multiple dilated loops of bowel measuring up to 7.7 cm, may represent ileus or
bowel obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with sigmoid volvulus s/p ___, intubated//
Interval change Interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lung volumes have improved. Nevertheless left lower lobe is probably still
collapsed. Moderate atelectasis has developed on the right as well. Small
left pleural effusion is stable. Heart size normal. No pneumothorax.
Indwelling cardiopulmonary support devices in standard placements.
Radiology Report
INDICATION: Question retained surgical instrument
COMPARISON: Prior dated ___
FINDINGS:
Two views of the abdomen/pelvis provided, patient positioned supine. A third
image depicting surgical sponge also provided. A nasogastric tube is seen
extending into the right upper abdomen. Mesh projects over the midabdomen.
There is no evidence of retained surgical sponge. Gaseous distention of bowel
noted.
IMPRESSION:
No signs of retained surgical sponge. Findings were discussed with Dr. ___
at the time of this dictation.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ with sigmoid volvulus, s/p GI decompression, plan for
sigmoidectomy this admission// advanced ET tube advanced ET tube
IMPRESSION:
In comparison the earlier study of this date, the tip of the endotracheal tube
now measures approximately 4.5 cm above the carina. Other monitoring support
devices are unchanged.
Continued opacification at the left base silhouetting the hemidiaphragm,
consistent with substantial volume loss in left lower lobe and small layering
pleural effusion. The right lung is essentially unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ p/w sigmoid volvulus s/p GI decompression followed by
hartmanns and delayed abdominal closure left intubated// ?interval change,
?fluid overload ?interval change, ?fluid overload
IMPRESSION:
Comparison to ___. Stable appearance of the right hemithorax.
Minimally improved ventilation of the left lung bases, with a decrease in
extent and severity of the pre-existing left lower lobe atelectasis and a
decrease in severity of the left pleural effusion. No new focal parenchymal
changes. Stable correct position of the monitoring and support devices.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p open hartmanns with left lower atelectasis
and effusion// interval change interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Heterogeneous opacification has developed in the right lung, worsened on the
left. Some of this is due to increasing pleural effusion, particularly in the
left hemithorax, but the bilateral nature of the abnormality suggests
pulmonary edema. Careful follow-up is recommended following attempts to
improved hemodynamic status because of the possibility of on alternative
explanation in bilateral pneumonia. No pneumothorax.
Nasogastric drainage tube passes through nondistended stomach to the proximal
duodenum.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old man with new dobhoff placement// assess dobhoff
placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Dobhoff tube tip isin the stomach. No other interval change from prior study.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man ___ s/p ___ for sigmoid volvulus with
persistent leukocytosis// please assess for atelectasis vs consolidation
TECHNIQUE: Chest two views
COMPARISON: ___
FINDINGS:
Feeding tube tip is in the proximal stomach, similar to prior. Stable heart
size. Mildly improved pulmonary vascularity. Stable pulmonary edema. Left
lower lobe consolidation, likely atelectasis. Mild pleural effusions are
stable. Few distended bowel loops in the upper abdomen, which are centralized
in location, suggestive of ascites. No pneumothorax.
IMPRESSION:
Pleural effusions. Basilar atelectasis. Pulmonary edema.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast.
INDICATION: ___ with sigmoid volvulus, with necrotic sigmoid on ex-lap, now
s/p ___ s/p decompressive laparotomy, clot evac, closed ___ now with
rising WBC// ?infectious source (PO contrast through dobhoff)
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.4 s, 54.2 cm; CTDIvol = 15.6 mGy (Body) DLP = 843.2
mGy-cm.
2) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP =
18.2 mGy-cm.
Total DLP (Body) = 861 mGy-cm.
COMPARISON: CT abdomen pelvis from outside hospital dated ___.
FINDINGS:
LOWER CHEST: A 3 mm pulmonary nodule is present in the right middle lobe.
Bilateral mild-to-moderate pleural effusions, right greater than left, with
associated compressive atelectasis, with significant volume loss in the left
lower lobe, and mild volume loss in the right lower lobe, lingula.
ABDOMEN:
Positioning of the arms across the upper abdomen causes significant streak
artifact limiting evaluation of the upper abdomen.
HEPATOBILIARY: Multiple hypoattenuating varying size lesions are scattered
throughout the liver, some of which are too small to accurately characterize
but likely represent cysts. Focal enhancement within hepatic segment 6
(02:35) is connects to a branch of portal ___ represent portal venous
shunt., measuring 2.1 cm.. Otherwise, the liver demonstrates homogenous
attenuation throughout. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is decompressed.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Moderate splenomegaly measuring up to 14 cm in the axial plane. No
focal lesion is identified within the splenic parenchyma.
ADRENALS: 10 mm hypoattenuating nodule within the right adrenal gland(02:30)
is indeterminate. Left adrenal gland is normal.
URINARY: Bilateral hypoattenuating structures are present in both kidneys, the
largest of which measures up to 1.8 cm at the interpolar region of the right
kidney. An exophytic structure at the lower pole of the left kidney measures
3.2 x 1.9 cm with an internal attenuation 35 ___ represent proteinaceous
or hemorrhagic cyst. Renal ultrasound recommended. Otherwise, the kidneys
are of normal and symmetric size with normal nephrogram. There is no
perinephric abnormality.
GASTROINTESTINAL: An enteric tube is present with the tip in the very proximal
stomach, just past GE junction. There is large esophageal hiatal hernia, with
nearly intrathoracic stomach as seen on prior. Patient is post sigmoid
colectomy with sigmoid colostomy and creation of ___ pouch. Multiple
prominent loops small bowel measuring up to 3.2 cm, without definite
transition point identified. This finding likely reflects postoperative ileus
or less likely a developing small bowel obstruction. There is mucosal
enhancement and mild mural thickening of the ascending colon. The appendix is
surgically absent. A rectal tube is present. There is moderate volume
ascites. Free fluid in the pelvis is complex, there is mild enhancement about
the surgical bed, few foci of air, findings may be postoperative, developing
infection cannot be excluded. If patient does not improve clinically,
follow-up scan could be obtained to exclude development of an abscess. There
is presacral fluid edema, with some complex contents along the right margin
series 2, image 77, which may represent prominent venous enhancement; there is
no organized presacral fluid.
PELVIS: Mild is circumferential thickening of the urinary bladder. Moderate
volume intraperitoneal ascites.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Few borderline retroperitoneal periaortic lymph nodes are stable
since prior, largest measures 1.3 cm, indeterminate..
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Stable appearance of L2-L3 vertebral bodies.
SOFT TISSUES: There is diffuse anasarca. Multiple surgical clips overlying
the mid abdomen are related to recent surgery. Small fat only containing
bilateral inguinal hernias.
IMPRESSION:
Areas of wall thickening involving large bowel, may be reactive, consider
colitis. Major abdominal arteries, veins are patent.
Few foci of air in the pelvis may be postsurgical, there is adjacent mild
linear areas of enhancement, no organized fluid collection. Residual
infection cannot be excluded, if patient does not improve clinically,
follow-up exam recommended to exclude development of an abscess. Moderate
ascites.
Multiple dilated small bowel loops in the low abdomen, pelvis, with gradual
transition point, more likely represent adynamic ileus than obstruction.
10 mm hypoattenuating nodule within the right adrenal gland is indeterminate.
Further evaluation with CT adrenal protocol or MRI may be helpful.
Bilateral pleural effusions, atelectasis.
Indeterminate lesion lower pole left kidney, renal ultrasound recommended.
Indeterminate retroperitoneal lymph nodes.
RECOMMENDATION(S): If the patient is low risk by ___ society
guidelines (minimal or absent history of smoking or other known risk factors
for primary lung neoplasm), recommend follow-up dedicated chest CT at 12
months and if no change, no further imaging needed. If the patient is high
risk by ___ society guidelines (history of smoking or other known risk
factors for primary lung neoplasm), recommend initial follow-up chest CT at
___ months and then at ___ months if no change.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with rising WBC and e/o pleural effusions on CT
A/P.// Pls eval chest for infectious etiology
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.9 s, 34.0 cm; CTDIvol = 8.8 mGy (Body) DLP = 286.0
mGy-cm.
2) Spiral Acquisition 8.9 s, 34.0 cm; CTDIvol = 8.8 mGy (Body) DLP = 284.6
mGy-cm.
Total DLP (Body) = 582 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Thyroid gland appears heterogeneous
and nodular. There is no supraclavicular adenopathy. There is no axillary
adenopathy. There is diffuse subcutaneous edema over the chest wall.
UPPER ABDOMEN: There is upper abdominal ascites. Hypoattenuating liver
lesions likely represent hepatic cysts. These are better evaluated on the CT
abdomen and pelvis.
There is a large hiatal hernia. The patient's enteric tube terminates in the
stomach.
MEDIASTINUM: There is no mediastinal adenopathy.
HILA: There is no gross hilar adenopathy.
HEART and PERICARDIUM: There is no pericardial effusion.
PLEURA: There are moderate to large bilateral pleural effusions. These appear
simple without definite evidence of loculation or enhancing septations.
LUNG:
1. PARENCHYMA: There is atelectasis/collapse of the entire left lower lobe
and most of the right lower lobe. Evaluation for underlying lung nodules is
limited due to patient respiratory motion.
2. AIRWAYS: The airways are patent to the segmental level.
3. VESSELS: Within normal limits.
CHEST CAGE: No suspicious focal osseous lesion.
IMPRESSION:
1. Moderate to large simple appearing bilateral pleural effusions with
resulting atelectasis/collapse involving most of both lower lobes.
2. Findings in the abdomen were better evaluated on the dedicated CT abdomen
and pelvis from ___.
Radiology Report
INDICATION: ___ y/o M ___ s/p Hartmans with dysphagia, aspiration// eval
swallow functioning in order to advance diet
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 4 min. 31 seconds
COMPARISON: None
FINDINGS:
There is moderate to severe pharyngeal weakness. There was deep penetration
with thin and nectar liquids. Barium passes through the oropharynx and
esophagus without evidence of obstruction. There was no gross aspiration. An
NG tube is visualized within the esophagus.
IMPRESSION:
Penetration without aspiration. Moderate-severe pharyngeal weakness.
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 man with heart failure, b/l thoracentesis// PTX?
PTX?
IMPRESSION:
In comparison with the study of ___, following thoracentesis there is no
evidence pneumothorax. Otherwise, little overall change except for improved
degree of inspiration.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST.
INDICATION: ___ year old man POD18 xlap ___ procedure with persistent
elevated WBC.// ?intraabdominal process? Fluid collections? Access?
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 3.5 s, 55.7 cm; CTDIvol = 14.7 mGy (Body) DLP = 815.7
mGy-cm.
2) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP =
18.2 mGy-cm.
Total DLP (Body) = 834 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: There are small to moderate bilateral pleural effusions,
decreased from prior. There is associated bibasilar atelectasis. There is a
3 mm right middle lobe pulmonary nodule.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There are multiple simple hepatic cysts. Subcentimeter hypodensities at the
hepatic dome are too small to characterize, but unchanged. There is a region
of hyperenhancement in segment VI of the liver 12 x 16 mm, likely a venous
varix (series 2, image 39). There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is decompressed. There is
small to moderate volume ascites, decreased from prior.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring 16.7 cm. Subcentimeter splenic
hypodensities are nonspecific, but unchanged.
ADRENALS: The left adrenal gland is unremarkable. There is nodularity adrenal
gland, as seen previously.
URINARY: The kidneys enhance and excrete contrast symmetrically. There are
bilateral simple renal and peripelvic cysts measuring up to 2.8 cm in the
right upper pole. There is a multilobulated intermediate density 2.8 cm
exophytic left lower pole renal cyst, likely a hemorrhagic cyst, but
incompletely characterized.
GASTROINTESTINAL: A nasoenteric tube is present in the stomach. There is a
large hiatal hernia. There is no bowel obstruction. Postsurgical changes
from ___ procedure are present. Left lower quadrant ileostomy appears
intact. There is no bowel obstruction. There remains free fluid containing
likely Surgicel in the left hemipelvis anterior to the pouch overall with
associated peritoneal thickening, mildly decreased compared to ___. No
organized collection is identified. There is extensive presacral edema and
fluid, as seen previously.
PELVIS: Air within the bladder is likely from instrumentation. Moderate
pelvic free fluid, as described above.
REPRODUCTIVE ORGANS: The prostate is mildly enlarged.
LYMPH NODES: Again seen, are enlarged retroperitoneal lymph nodes measuring up
to 11 mm (series 2, image 44). There is no pelvic sidewall or inguinal
adenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There are scattered sclerotic lesions involving the pelvis, unchanged,
likely bone islands. Is degenerative change of the lumbar spine with a mild
leftward scoliosis.
SOFT TISSUES: There is diffuse anasarca.
IMPRESSION:
1. No organized fluid collection. Persistent but mild decrease in fluid in
the left hemipelvis containing likely Surgicel (versus locules of air) with
associated mild peritoneal thickening.
2. Persistent, but decreased small volume ascites.
3. Decrease bilateral pleural effusions.
4. Indeterminate left lower pole renal lesion, nonemergent renal ultrasound
can be obtained for further characterization.
5. Splenomegaly and retroperitoneal lymphadenopathy, of uncertain
significance.
RECOMMENDATION(S): Nonemergent renal ultrasound
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:06 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ with sigmoid volvulus// pre-op eval
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___ at 14:42.
FINDINGS:
Enteric tube is seen with tip coursing through the chest with tip projecting
over left upper quadrant. There is tortuosity in the lower chest likely due
to hiatal hernia. Lung volumes are low with secondary bronchovascular
crowding. Air-filled loops of colon noted throughout the abdomen. No
definite free intraperitoneal air. Cardiomediastinal silhouette is within
normal limits. Relatively high-riding humeral heads raises possibility of
underlying rotator cuff abnormality.
IMPRESSION:
Enteric tube courses through the hiatal hernia with tip projecting over the
left upper quadrant.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: Sigmoid volvulus
TECHNIQUE: Abdomen single view
COMPARISON: CT ___
FINDINGS:
Interval placement of rectal tube. Multiple dilated colonic loops, small
bowel loops, mildly improved since prior. Previously seen dilated loop of
sigmoid has resolved. Degenerative changes spine. Arterial calcifications.
IMPRESSION:
Mild improvement since prior.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: SIGMOID VOLVULUS, Transfer
Diagnosed with Volvulus
temperature: 97.2
heartrate: 88.0
resprate: 16.0
o2sat: 94.0
sbp: 107.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | The patient presented to the emergency department with abdominal
pain on ___ and was evaluated by the Acute Care Surgery
Team. The patient was found to have a sigmoid volvulus and was
admitted to the Acute Care Surgery service.
The patient was taken to the operating room on ___ for
flexible sigmoidoscopy with rectal tube placement with GI. For
full details, please see the separate dictated procedure note.
Post-procedure, the patient was taken to the SICU for close
monitoring. On ___ the patient had worsening abdominal
distention and was taken back to the OR for exploratory
laparotomy and ___- the patient tolerated the procedure
well and for full details of the procedure please see the
separately dictated operative report. On ___ the patient
was noted to have worsening abdominal distention, and on lab
work was noted to be anemic. He was taken to the OR for ex-lap,
evac clot, packing, abthera w/ open abdomen. For full details
of the procedure please see the separately dictated operative
report. ECHO was performed on ___ (please refer to
"Pertinent Results" section for details). On ___ the
patient returned to the OR for exploratory laparotomy, washout
and abdominal closure, which the patient tolerated well. Upon
return to the SICU the patient's pressor requirement was weaned
as well as his ventilator support. On ___, the patient had
an episode of aflutter on telemetry and EKG. The patient
self-converted after ~45-50 minutes and Cardiology evaluated the
patient and deferred anticoagluation at this time. Cardiology
recommended follow-up TTE as an outpatient given evidence of
elevated pulmonary pressures on echocardiogram. They also
recommended starting metoprolol 12.5mg PO Q12 H if atrial
flutter returned, and increasing to 12.5mg Q6H if BP remained
stable. The patient had no further episodes of A-flutter
On ___ the patient was extubated, and had a bedside swallow
evaluation on ___. He was unable to pass his speech and
swallow due to aspiration risk and he was started on tube feeds.
He was transferred to the floor on ___. The nasogastric
tube was exchanged to a dobhoff and was evaluated by the speech
and swallow team who recommended a video swallow. The patient
was approved for a pureed solids, nectar thick liquids diet,
meds crushed in apple sauce and educated him with swallowing
strategies. Calorie counts were initiated, but the patient
failed to meet required calorie intake with regular diet alone,
so tube feeds continued as supplementation.
On ___ his white count uptrended to 22.8, a chest x-ray
was done and bilateral pleural effusions were found. A repeat
chest CT was done on ___ where larger bilateral pleural
effusions were found. On ___, he received bilateral
thoracentesis by the Interventional Pulmonary service (R drained
900cc, L drained 800cc)and cultures were sent with no bacterial
growth. On ___, there was a question of ST elevation on
telemetry. CK-MB and troponins were normal and EKG was within
normal limits. A c.diff study was sent for for workup of
leukocytosis which was negative. On ___, CT abdomen &
pelvis were ordered which was not concerning for infection. CXR
was stable and showed improved degree of inspiration. His foley
catheter was removed and he voided appropriately. He had a
positive UA and urine culture was sent which ultimately was
positive for pseudomonas aeruginosa. The patient was started on
Ciprofloxacin for UTI treatment and urine culture demonstrated
sensitivity to cipro.
Since being on the floor, the patient was alert. Pain was
controlled with acetaminophen. The patient remained stable from
a cardiovascular and pulmonary standpoint; vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
The patient tolerated a regular diet and tube feeds. The
patient's intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection. The patient's midline incision staples were removed
on ___ and steri-strips were applied. The patient's blood
counts were closely watched for signs of bleeding, of which
there were none. The patient received subcutaneous heparin and
___ dyne boots were used during this stay and was encouraged to
get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a
regular diet and tube feeds, OOB with assist, 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:
Hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Prior Colon Cancer (s/p right colectomy w/
anastomosis
___, Diverticulosis, Metastatic pancreatic adenocarcinoma
(liver mets s/p neoadjuvant FOLFIRINOX and CyberKnife), Recent
cholecystitis (s/p percutaneous cholecystostomy tube s/p
replacement ___, on augmentin), recent GI bleed (unknown
source), who presented 1 day after discharge with hematuria
Patient noted that since discharge yesterday he felt well but
noticed that he had new hematuria. Denied seeing any clots, has
difficulty describing how much blood was in his urine but he
noted that it was "bright red". He denied any increase in
urgency/frequency or dysuria. He noted that he has never had
bleeding like this before. Denied any fever/chills, flank pain,
nausea/vomiting.
Of note patient said he has had intermittent bloody tinged fluid
in cholecystostomy bag, unchanged from that which he had on past
admission. Patient noted that fluid output is unchanged. He
noted that his hematoma at right chest port site is unchanged,
denied discomfort there. Noted that he continues to pass maroon
colored stools but in much lesser amounts than prior
hospitalization
In the ED, initial VS were pain 8, T 98.1, HR 123, BP 110/65, RR
20, O2 100%RA. Initial labs notable for Na 140, K 5.0, HCO3 23,
Cr 1.0, Ca 7.6, Mg 2.1, P 3.0, Ca 7.6, Mg 2.1, P 3.0, ALT 26,
AST
85, ALP 519, TBili 1.7, DBili 0.6, Alb 2.2, INR 1.3. Lactate
3.8-->2.4. UA with >182 WBC and nitrate positive. RUQ US showed
perc chole tube well positioned in collapses gall bladder and no
evidence of intrahepatic dilation. CT a/p showed decompressed
gallbladder with appropriately placed cholecystosomy tube,
unchanged pneumobilia, and no intrahepatic dilation, and biliary
stent inplace. Patient was given 2LNS along with IV zosyn and
IV
dilaudid x1. VS prior to transfer were T 99.3 HR 110 BP 154/91,
RR 19, O2 100%RA.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY: ___ was previously treated
for
a pT1N0 stage I right-sided colon cancer resected in ___. Mr.
___ was diagnosed with diabetes mellitus in ___. Despite
initiation of metformin, when he represented in ___, his
weight had decreased 20 pounds and hemoglobin A1c was elevated
at 11.6. Given ongoing unintentional weight loss and associated
hyperglycemia, he was referred for CT torso performed ___.
This study revealed new pancreatic ductal dilatation and a
hypodense mass in the pancreatic head. He then underwent MRCP
___ which showed a 1.2 cm pancreatic head mass.
Endoscopic ultrasound was performed ___ which showed a 2 x
1.4 cm pancreatic head mass. Fine-needle aspirate showed
adenocarcinoma. CT angiogram showed a 2 cm mass with contact of
the portal vein and SMV greater than 180°. There was no
arterial involvement and no evidence of distant metastases per
torso CT. He was diagnosed with borderline resettable PDA and
began neoadjuvant FOLFIRINOX ___. Mr. ___ completed
three cycles of FOLFIFINOX as of ___ followed by CK SBRT
2400 cGy as of ___. On ___, CT scan showed liver
metastasis and he was admitted to the hospital with acute
cholecystitis and cholecystostomy tube was placed on ___.
Discharged on ___ with plan to complete Zosyn through
___.
Subsequently readmitted on ___ with GI bleed. Source
ultimately localized to biliary tree, although no acute source
localized - felt possibly due to oozing from tumor. Also had
antibiotics switched to augmentin and PCT dislodged. After PCT
dislodgement redeveloped hyperbilirubinemia and fever. PCT
replaced on ___.
PAST MEDICAL HISTORY:
1. pT1N0 right sided colon cancer resected ___
2. Hypertension
3. Hyperlipidemia
4. Elevated PSA rising since ___ referred to urology for
biopsy
5. Known complex right upper pole renal cyst
6. Obstructive sleep apnea status post uvulectomy
7. Status post hernia repair
8. type II diabetes mellitus
9. Pancreatic adenocarcinoma-as above
10. Cholecystitis s/p perc cholecystostomy (last replaced ___
11. GI bleed (unknown etiology as ___ negative, capsule
revealed possible bleeding around stent, possibly from his
malignancy)
Social History:
___
Family History:
The patient's mother died of tobacco associated
lung cancer at ___ years. His father had hepatitis C,
hypertension, coronary artery disease, and diabetes mellitus. He
has 2 brothers and 5 sisters and 4 children. Diabetes mellitus,
hypertension and asthma affect family members.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 100.0 124/82 hr 113 20 99RA
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
wife at bedside
EYES: PERRLA
HEENT: OP clear. MMM
CARDIAC: Tachycardic, regular rhythm, normal s1/s2, no m/r/g.
No
peripheral edema
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-distended, no tenderness to palpation, no
rebound,
normal bowel sounds. Right-sided percutaneous
cholecystostomy tube catheter with clotted blood on dressing and
bag draining slightly blood tinged yellow fluid, though new
drainage closest to abdomen is clear/yellow
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
Access: right chest port with palpable hematoma at site, no
oozing into dressing, unchanged from last admission
Pertinent Results:
ADMISSION LABS:
===============
___ 04:30AM BLOOD WBC-16.5* RBC-2.66* Hgb-7.7* Hct-23.1*
MCV-87 MCH-28.9 MCHC-33.3 RDW-16.0* RDWSD-50.4* Plt ___
___ 04:30AM BLOOD ___
___ 07:02PM BLOOD FDP-320-640*
___ 04:30AM BLOOD Glucose-102* UreaN-13 Creat-0.9 Na-138
K-4.2 Cl-100 HCO3-23 AnGap-15
___ 04:30AM BLOOD ALT-24 AST-65* LD(LDH)-589* AlkPhos-512*
TotBili-1.5
___ 04:30AM BLOOD Albumin-2.3* Calcium-7.6* Phos-2.7 Mg-2.0
___ 03:40PM BLOOD ___
___ 07:25AM BLOOD CEA-721.9*
___ 01:37PM BLOOD Lactate-3.8*
___ 04:19PM BLOOD Lactate-2.4*
___ 03:40PM BLOOD Fibrino-57*
IMAGING:
========
___ CHEST W/CONTRAST
- New right pleural effusion, small to moderate with adjacent
atelectasis
- Please review CT abdomen and pelvis in the corresponding
report that will discuss intra-abdominal findings and
involvement of the liver by metastatic disease.
___ ABD & PELVIS W & W/O
1. Metastatic and locally advanced pancreatic cancer, as
described above, not significant changed from prior study of ___.
2. Please refer to same-day CT chest for characterization of
thoracic
findings.
___ ABD & PELVIS WITH CO
1. The gallbladder is decompressed with a percutaneous
cholecystostomy tube present.
2. A common bile duct stent is present, with unchanged
pneumobilia in the left hepatic lobe. No evidence of
intrahepatic biliary duct dilatation.
3. Small perihepatic ascites is slightly increased from prior.
___ OR GALLBLADDER US
1. A percutaneous cholecystostomy tube appears well positioned
in the collapsed gallbladder.
2. Pneumobilia slightly limits evaluation of the bile ducts,
however there is no intrahepatic biliary duct dilatation.
3. Innumerable hepatic metastases are similar to prior.
4. Small ascites and small right pleural effusion.
MICRO:
======
-___
VIRAL CULTURE-PRELIMINARY;
VIRAL CULTURE: R/O CYTOMEGALOVIRUS-FINALINPATIENT
___
-URINE CULTURE-FINAL {YEAST}INPATIENT
___ CULTURE
Blood Culture, Routine-PENDINGINPATIENT
-___ CULTURE
Blood Culture, Routine-FINALEMERGENCY WARD
-___ CULTURE
Blood Culture, Routine-FINALEMERGENCY WARD
-___
URINE CULTURE-FINALEMERGENCY WARD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Simvastatin 40 mg PO QPM
3. Calcium Carbonate 500 mg PO QID:PRN GERD
4. Omeprazole 20 mg PO DAILY
5. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID
Discharge Medications:
1. Lactulose 30 mL PO TID
Patient may refuse
RX *lactulose 10 gram/15 mL 30 mL by mouth three times a day
Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 capsule(s) by mouth q6 hours Disp
#*60 Capsule Refills:*0
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Take through ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*8 Tablet Refills:*0
4. Calcium Carbonate 500 mg PO QID:PRN GERD
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth four times a day Disp #*60 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 hours Disp #*120
Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
8. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Disseminated intravascular coagulapathy
# Acute blood loss anemia
# Hematuria
# Metastatic pancreatic cancer
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: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with metastatic pancreatic cancer worsening right
upper quadrant pain in setting of recent cholecystitis with percutaneous tube
placement and history of pancreatic cancer// Abscess? Tube in the correct
position? Intrahepatic ductal dilation? biliary obstruction?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CTA abdomen and pelvis on ___
FINDINGS:
LIVER: Again seen are innumerable hypodense lesions throughout the liver
compatible with metastases. The main portal vein is patent with hepatopetal
flow. There is small ascites. There is a right pleural effusion.
BILE DUCTS: There is air within the common bile ducts, similar to recent CT,
and slightly limiting evaluation. No definite intrahepatic biliary duct
dilatation. The CHD measures 4 mm.
GALLBLADDER: A percutaneous cholecystostomy tube appears to terminate in the
collapsed gallbladder.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 8.6 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis. There is
a 5.8 cm right upper pole kidney cyst.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. A percutaneous cholecystostomy tube appears well positioned in the
collapsed gallbladder.
2. Pneumobilia slightly limits evaluation of the bile ducts, however there is
no intrahepatic biliary duct dilatation.
3. Innumerable hepatic metastases are similar to prior.
4. Small ascites and small right pleural effusion.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ with worsening right upper quadrant pain in setting of recent
cholecystitis with percutaneous tube placement and history of pancreatic
cancer// Abscess? Tube in the correct position? Intrahepatic ductal
dilation? biliary 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 not administered. Coronal and
sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 920 mGy-cm.
COMPARISON: CTA abdomen and pelvis on ___
FINDINGS:
LOWER CHEST: There is a small right pleural effusion and adjacent atelectasis
at the right lung base. Not significantly changed. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Again seen are numerous hypodense lesions throughout the liver,
not significantly changed in size and number compared with recent CT. A
common bile duct stent is stable in position, with no significant change in
pneumobilia in the left hepatic lobe. There is no evidence of intrahepatic
biliary duct dilatation. A percutaneous gastrostomy tube terminates in the
decompressed gallbladder. There is small perihepatic ascites, slightly
increased from prior. Loculated fluid in the falciform ligament is similar to
prior.
PANCREAS: A known hypodense pancreatic mass surrounding fiducials, with
upstream dilation of the pancreatic duct and associated vascular involvement,
is not significantly changed, better characterized on recent multiphasic
study. Narrowing at the portal splenic confluence by the pancreatic mass is
similar to prior.
SPLEEN: The spleen is normal in size. 2 splenic hypodensities measuring up to
1 cm are not significantly changed.
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 cyst renal cyst measuring up to 4.9 cm in the left upper pole are
not significantly changed. Multiple additional subcentimeter cortical
hypodensities are too small to characterize, however likely represent cysts.
No hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Patient is status post right
hemicolectomy and ileocolonic anastomosis, not significantly changed in
appearance.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the pelvis, similar to prior.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles 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: Subcutaneous fluid tracking along the bilateral abdominal walls,
right greater than left, is similar to prior. A left inguinal hernia
containing fat is noted.
IMPRESSION:
1. The gallbladder is decompressed with a percutaneous cholecystostomy tube
present.
2. A common bile duct stent is present, with unchanged pneumobilia in the left
hepatic lobe. No evidence of intrahepatic biliary duct dilatation.
3. Small perihepatic ascites is slightly increased from prior.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ year old man with locally advanced pancreatic cancer//
restaging study after chemotherapy and radiation- assess for progression vs
response to therapy
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) Spiral Acquisition 3.2 s, 35.6 cm; CTDIvol = 12.8 mGy (Body) DLP = 445.9
mGy-cm.
2) Spiral Acquisition 3.3 s, 36.6 cm; CTDIvol = 14.1 mGy (Body) DLP = 504.6
mGy-cm.
3) Spiral Acquisition 10.2 s, 66.1 cm; CTDIvol = 16.7 mGy (Body) DLP =
1,093.0 mGy-cm.
Total DLP (Body) = 2,044 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: There is a moderate left pleural effusion not significant changed
from prior. For further characterization of thoracic findings please refer to
separate report of CT chest performed on the same day.
ABDOMEN:
HEPATOBILIARY: Innumerable hypodense lesions are visualized throughout the
liver compatible with known metastatic disease burden. A CBD stent is
visualized with pneumobilia. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder decompressed with a
percutaneous cholecystostomy tube in place. Perihepatic ascites is visualized
and not significant changed from prior with fluid tracking along the falciform
ligament.
PANCREAS: There is a heterogeneously hypodense pancreatic head mass with
associated fiducial markers that measures approximately 4.6 x 4.6 cm with
pancreatic ductal dilatation, narrowing of the portal vein, encasement of the
hepatic artery, and abuts the SMA, not significant changed from prior study.
SPLEEN: The spleen shows normal size and attenuation throughout. 2 hypodense
cystic lesions are re-demonstrated not significantly changed from prior.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There are multiple subcentimeter hypodense renal cysts bilaterally.
Additionally there is a large renal cyst in the right kidney with a thin
internal hyperdensity (4:98) that may represent an internal calcification, as
well as a 2 cm simple renal cyst in the lower pole of the left kidney. There
is no evidence of hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Patient is status post right
hemicolectomy with the ileocolonic anastomotic site intact and free of
complications otherwise the 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
surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Diffuse soft tissue edema and thickening, as well as
subcutaneous fluid is visualized tracking along the flanks bilaterally.
IMPRESSION:
1. Metastatic and locally advanced pancreatic cancer, as described above, not
significant changed from prior study of ___.
2. Please refer to same-day CT chest for characterization of thoracic
findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Restaging study after chemotherapy and radiation for a locally
advanced pancreatic cancer
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: ___
FINDINGS:
Aorta and pulmonary arteries are unremarkable. Heart size is normal. There
is no pericardial effusion. There is right pleural effusion, moderate, new.
Image portion of the upper abdomen will be reviewed separately is part of the
CT abdomen and pelvis in the corresponding report will be issued
Airways are patent to the subsegmental level bilaterally. No new pulmonary
nodules masses or consolidations demonstrated except for right basal minimal
atelectasis secondary to right pleural effusion.
No pathologically enlarged mediastinal hilar or axillary lymph nodes
demonstrated.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
IMPRESSION:
New right pleural effusion, small to moderate with adjacent atelectasis
Please review CT abdomen and pelvis in the corresponding report that will
discuss intra-abdominal findings and involvement of the liver by metastatic
disease.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Hematuria
Diagnosed with Sepsis, unspecified organism, Urinary tract infection, site not specified, Right upper quadrant pain, Right lower quadrant pain
temperature: 98.1
heartrate: 123.0
resprate: 20.0
o2sat: 100.0
sbp: 110.0
dbp: 65.0
level of pain: 8
level of acuity: 3.0 | ___ PMH of prior colon cancer(s/p right colectomy w/ anastomosis
___, diverticulosis and metastatic pancreatic adenocarcinoma
(liver mets s/p neoadjuvant FOLFIRINOX and CyberKnife). Recent
course complicated by cholecystitis (s/p percutaneous
cholecystostomy), POC site hematoma, and GI bleed (unclear
source), who was admitted 1 day after discharge with hematuria
and persistent malaise, dyspnea on exertion, and tachycardia.
Intially treated empirically for UTI given positive UA and
hematuria with relatively normal bladder/kidney appearance on
CT. However, cultures were sterile, aside from yeast
colonization, and he was noted to have hemorrhage from multiple
sites (most prominently from the urine).
Ultimately found to have low fibrinogen, elevated FDP, and
chronic DIC. Family meeting held to offer salvage chemotherapy
vs hospice care. Patient elected to pursue home hospice with the
understanding that his life expectancy is likely days to weeks.
His DIC persisted despite frequent cryoglobulin transfusions and
he developed multiorgan dysfunction. We expedited home discharge
to allow him his wish of spending quality time at home before he
passes.
# Persistent blood loss anemia:
# Due to Disseminated intravascular coagulopathy: Initially
admitted with hematuria and tachycardia. Also with persistent
oozing from PTC insertion site, development of hematomas from
peripheral blood draw sites, and recent GI bleed and port site
hematoma. He was found to have elevated INR, low fibrinogen, and
elevated FDP consistent with DIC. He was transfused multiple
units of cryoglobulin and pRBC with persistent bleeding.
Underlying etiology thought to be aggressive and metastatic
pancreatic cancer. During family meeting on ___, salvage
chemotherapy was offered despite his worsening clinical status,
and family elected to pursue palliative care with hospice.
# Hematuria: On admission, patient was taking augmentin for
recent cholecystitis. He was broadened to zosyn then
cefepime/flagyl for possible resistant UTI. Urine cultures were
sterile, although repeat culture eventually grew yeast - thought
to be colonization. Antibiotics were narrowed back to augmentin
to complete prior course. CMV virus culture negative. Urology
was consulted who deferred intervention.
# Recent cholecystitis status post
# Percutaneous cholecystostomy: Continued to ooze blood from
around the site. However, drain appeared to be in a good
position and draining
clear bile. Antibiotics initially broadened to cefepime and
flagyl before narrowing back to unasyn, then augmentin, as
above.
# Elevated bilirubin with history of
# Biliary obstruction and now
# Acute liver injury and
# Hepatic encephalopathy: Has biliary stent in place; multiple
imaging early in hospitalization showed no evidence of stent
occlusion or new obstruction. Bilirubin rising by time of
discharge. Possibly due to recurrent obstruction, although his
clinical status would not tolerate ERCP or ___ procedure. ___
also be due to DIC and liver injury. He also appeared to be
developing hepatic encephalopathy but refused lactulose.
# Fever/Leukocytosis: Low grade fevers and rising
leukocytosis despite initial treatment with broad spectrum
antibiotics. Cultures were negative aside from yeast in urine -
suspect colonization as no evidence of fungemia. Favor fever and
leukemoid reaction were due to critical illness/DIC rather than
new infection. Plan to continue po augmentin through ___ per
priorantibiotics plan. Used Tylenol for comfort.
# Gastrointestinal hemorrhage: Noted on last admission, ___
without source. Source ultimately presumed to be ___ bleeding
from stent possibly ___ malignancy in setting of DIC. Negative
CTA on ___ and again CT on ___.
# Port associated hematoma:
Has had multiple issues with port malfunction. Replaced last
admission complicated by hematoma at the surgical site.Remained
stable this admission.
# Metastatic pancreatic cancer: Patient completed 3C FOLFIFINOX
as of ___ followed by CK SBRT 2400 cGy as of ___. On
___, CT scan revealed progressive hepatic metastatic disease
with rapidly rising CEA and now DIC. He has deferred salvage
chemotherapy, and given his current clinical status, would not
likely provide any benefit. Hospice services were arranged.
# Cancer associated pain: Continue home oxycodone. Also treated
with oxycontin for much of hospitalization before discontinuing
due to family request.
# Left upper arm swelling; right leg swelling. Negative Doppler
US on ___. Further imaging deferred, as we would not
anticoagulate.
# Diabetes: Lantus discontinued last admission. Stopped HISS
prior to discharge.
# Hyperlipidemia: Stopped simvastatin prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Poor pain control, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ year-old gentleman with a history of ___
Disease, L THR (___) at OSH, who presents for pain control
and change in mental status. Per pt's wife, after his THR he had
to stay in the ICU for 24 hours ___ narcotic-sensitivity (to
Dilaudid) and hypotension. Pt was discharged on celecoxib and
tylenol for pain control. Pt continued to be in pain, so on ___
pt started tramadol. After two doses, pt had an episode of
confusion in which he became enraged and started flailing and
kicking. Pt discontinued tramadol at that time. On ___, pt took
one dose of tylenol with codeine. This led to an episode of
hallucination in which he told his wife that he was seeing
people in the house. Hallucinations lasted into the next day.
The patient has since been on celecoxib and extra strength
tylenol, which resulted in unbearable ___ pain for the past
two nights.
Pt has also experienced persistent cough which started while he
was at the OSH after his surgery. Cough is nonproductive. He was
prescribed omeprazole, as it was thought to be secondary to
GERD. In addition, since his surgery pt has noticed an increase
in urination. Pt had to urinate every hour last night.
Otherwise, pt denies fevers, CP, SOB, dysuria, ___ weakness, or
___ numbness.
Initial VS in the ED were T 97.8, BP 148/80, HR 71, RR 16, O2
99%. Patient was noted to be alert, awake, and oriented x 3.
Chemistry panel was witin normal limits. CBC was significant for
elevated platelets to 442. UA was bland. CXR was without any
intrathoracic process. Patient was given morphine 5 mg IV x 1.
VS prior to transfer were T 98.5, BP 159/87, HR 89, RR 17, O2
100%.
On arrival to the floor, the patient was comfortable and
reported a ___ pain. He is accompanied by his wife.
Past Medical History:
___ Disease
Hyperlipidemia
Esophageal dilation procedure (___ for ___
Disease
L hip fracture ___ years ago, now s/p L THR
Social History:
___
Family History:
Mother had ___ Disease
Physical Exam:
Admission Physical Exam:
Vitals: T 98.5, BP 156/81, P 85, R 16, O2 99% RA
General: AOx3, NAD
HEENT: NC/AT, PERRL, EOMI, sclera anicteric, MMM, oropharynx
clear
Neck: Supple, no carotid bruits, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present x
4, no rebound tenderness or guarding, no organomegaly
Ext: WWP, 2+ UE and ___ pulses, no clubbing or cyanosis, dressing
over L hip c/d/i, ___ nonpitting, nontender L pedal edema
Neuro: CNs III-XII intact, muscle strength ___ RUE/LUE/RLE, ___
LLE, sensation intact throughout, rapid alternating movement
intact, slow and shuffling gait
Skin: Intact, no rashes, erythema, or lesions. Ecchymoses on
lateral sides of left foot, non-TTP.
Discharge Physical Exam:
Vitals: T 99.4, BP 141/73, P 82, R 18, O2 100% RA
General: AOx3, NAD
HEENT: NC/AT, PERRL, EOMI, sclera anicteric, MMM, oropharynx
clear
Neck: Supple, no carotid bruits, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present x
4, no rebound tenderness or guarding, no organomegaly
Ext: WWP, 2+ UE and ___ pulses, no clubbing, cyanosis, or edema,
dressing over L hip c/d/i
Neuro: CNs III-XII intact, muscle strength ___ RUE/LUE/RLE, ___
LLE, sensation intact throughout, rapid alternating movement
intact, slow and shuffling gait
Skin: Intact, ecchymoses on medial and lateral sides of left
foot, non-TTP
Pertinent Results:
ADMISSION LABS:
___ 02:35PM BLOOD WBC-8.9 RBC-3.60* Hgb-11.3*# Hct-33.4*
MCV-93 MCH-31.5 MCHC-34.0 RDW-13.3 Plt ___
___ 02:35PM BLOOD Neuts-72.5* Lymphs-17.5* Monos-3.2
Eos-6.1* Baso-0.7
___ 02:35PM BLOOD Plt ___
___ 02:35PM BLOOD Glucose-92 UreaN-13 Creat-0.7 Na-135
K-4.2 Cl-99 HCO3-29 AnGap-11
___ 02:35PM BLOOD Calcium-9.3 Phos-3.1 Mg-2.3
___ 02:35PM URINE Color-Straw Appear-Clear Sp ___
___ 02:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-9.6 RBC-3.48* Hgb-10.8* Hct-33.1*
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.3 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-33.8 ___
___ 07:30AM BLOOD Glucose-85 UreaN-16 Creat-0.8 Na-138
K-4.4 Cl-100 HCO3-30 AnGap-12
___ 07:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.2
IMAGING:
___ CXR PA/lat: Frontal and lateral views of the chest were
obtained. The heart is of normal size with normal
cardiomediastinal contours. Lungs are clear without focal or
diffuse abnormality. No pleural effusion or pneumothorax. The
pulmonary vasculature is unremarkable. No radiopaque foreign
body. Deformity of the left clavicle is compatible with an old
fracture.
IMPRESSION: No acute cardiopulmonary process.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Omeprazole 20 mg PO BID
2. Aspirin EC 325 mg PO DAILY Start: In am
3. Multivitamins 1 TAB PO DAILY Start: In am
4. celecoxib *NF* 200 mg Oral BID w/food
wtih breakfast and dinner
5. Azilect *NF* (rasagiline) 1 mg Oral daily
in the morning
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Trihexyphenidyl 2 mg PO TID
8. pramipexole *NF* 0.5 mg Oral TID
9. Warfarin 1 mg PO DAILY16
10. Docusate Sodium 200 mg PO HS
11. Simvastatin 10 mg PO HS
12. Senna 1 TAB PO HS
13. Acetaminophen 1000 mg PO Q8H:PRN pain
14. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin EC 325 mg PO DAILY
4. Azilect *NF* (rasagiline) 1 mg Oral daily
in the morning
5. Carbidopa-Levodopa (___) 1 TAB PO TID
6. celecoxib *NF* 200 mg Oral BID w/food
wtih breakfast and dinner
7. Docusate Sodium 200 mg PO HS
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. pramipexole *NF* 0.5 mg Oral TID
11. Senna 1 TAB PO HS
12. Simvastatin 10 mg PO HS
13. Trihexyphenidyl 2 mg PO TID
14. Warfarin 1 mg PO DAILY16
15. Morphine Sulfate ___ ___ mg PO Q4H:PRN breakthrough pain
hold for AMS, sedation or RR < 12
RX *morphine 15 mg ___ tablet(s) by mouth every four hours Disp
#*30 Tablet Refills:*0
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Bisacodyl 10 mg PR HS:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
remote L hip fracture s/p THR
encephalopathy
SECONDARY DIAGNOSES:
___ Disease
GERD
Hyperlipidemia
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: ___ male with mental status changes. Evaluate for
pneumonia.
COMPARISONS: None.
FINDINGS: Frontal and lateral views of the chest were obtained. The heart is
of normal size with normal cardiomediastinal contours. Lungs are clear
without focal or diffuse abnormality. No pleural effusion or pneumothorax.
The pulmonary vasculature is unremarkable. No radiopaque foreign body.
Deformity of the left clavicle is compatible with an old fracture.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MENTAL STATUS CHANGES ? D/T PAIN MEDS
Diagnosed with OTHER ACUTE POSTOPERATIVE PAIN , SEMICOMA/STUPOR, PARKINSON'S DISEASE, HYPERCHOLESTEROLEMIA
temperature: 97.8
heartrate: 71.0
resprate: 16.0
o2sat: 99.0
sbp: 148.0
dbp: 80.0
level of pain: 1
level of acuity: 3.0 | ___ year-old gentleman with a history of ___ Disease, L
THR (___) at OSH, who presents for pain control and change
in mental status. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zithromax / Penicillins
Attending: ___.
Chief Complaint:
Weakness/Hypotension
Major Surgical or Invasive Procedure:
R buttock decub debridement - ___
R buttock decub I&D, bone bx - ___
CTA with left colic artery embolization - ___
History of Present Illness:
___ with hx of alcohol abuse brought to the ED after found down
and admitted to ICU for sepsis workup. Per report, daughter
found her lying on the floor at home. EMS called. Pt was A&OX3,
but hypotensive 70/40 and tachycardic to 130s. Pt noted to have
large R decubitus ulcer. Brought to ___ ED. Per family, pt
lives alone and has been reporting not feeling well over the
last couple of weeks. Daughter reports that she last saw her
about two weeks ago and pt appeared well. Has been in contact
over the phone with pt. Daughter reports that the last person to
see pt was the neighbor on ___ where she came and opened the
door. Of note, has had new stool incontinence over the last
month.
In the ED, initial vitals: T 100 HR 136 BP 95/56 RR 20 96RA.
Tmax at ED 100.5. Labs notable for leukocytosis, transaminitis,
hypoNa, lactate 3.3. UA negative. CT head, abd/pelvis
unremarkable for source of infection. Was given 3L NS and vanc,
cefepime, flagyl.
On transfer, vitals were: HR 102 112/71 22 98RA.
On arrival to the MICU, pt A&OX3, but confused.
Past Medical History:
GERD
HTN
RA
Fibromyalgia
History of heart murmur
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PE:
Vitals: T:98.4 BP:91/52 P:91 R: 18 O2: 98RA
GENERAL: A&OX3 but confused, no acute distress
HEENT: Sclera icteric, 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
SKIN: R buttock ulcer 5mm deep, 5X5cm with yellowish drainage
around the edge, 1X1cm L buttock ulcer with no drainage, L
middle upper back 2X4cm gash
NEURO: CNII-XII intact, motor and sensory function grossly
intact
DISCHARGE PE:
VS: 98.0 111/63 83-110 94%RA
GENERAL: Alert, NAD
HEENT: Sclera anicteric, no injection, MMM
NECK: supple, no LAD
LUNGS: CTAB
CV: Tachycardic, regular rythm, normal S1 S2; ___ systolic
ejection murmur loudest at L ___ ICS, no rubs or gallops
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly; anasarca
GU: Foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis; 2+
pitting edema up to ankles bilaterally, 2+ to knees (R>L), 1+ in
thighs, dependent areas of edema along sacrum.
SKIN: R buttock with stage 4 ulcer w/ wound vac in place
NEURO: calm, non-focal, AOx3, cannot complete DOWB
Pertinent Results:
ADMISSION LABS:
===============
___ 12:30AM BLOOD WBC-17.2* RBC-3.64* Hgb-11.3 Hct-32.5*
MCV-89 MCH-31.0 MCHC-34.8 RDW-14.9 RDWSD-47.6* Plt ___
___ 12:30AM BLOOD Neuts-91.9* Lymphs-5.0* Monos-2.3*
Eos-0.0* Baso-0.4 NRBC-0.1* Im ___ AbsNeut-15.82*
AbsLymp-0.86* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.07
___ 12:30AM BLOOD Plt ___
___ 12:30AM BLOOD Glucose-143* UreaN-28* Creat-0.9 Na-129*
K-4.2 Cl-86* HCO3-30 AnGap-17
___ 12:30AM BLOOD ALT-106* AST-94* CK(CPK)-763*
AlkPhos-210* TotBili-4.4* DirBili-2.7* IndBili-1.7
___ 12:30AM BLOOD Albumin-3.0* Calcium-9.4 Phos-2.5* Mg-1.9
___ 12:49AM BLOOD Lactate-3.3* K-4.0
DISCHARGE LABS:
===============
___ 04:46AM BLOOD WBC-6.2 RBC-2.54* Hgb-7.7* Hct-24.7*
MCV-97 MCH-30.3 MCHC-31.2* RDW-18.6* RDWSD-65.7* Plt ___
___ 04:46AM BLOOD Glucose-107* UreaN-8 Creat-0.4 Na-137
K-4.6 Cl-105 HCO3-26 AnGap-11
___ 04:46AM BLOOD Albumin-1.7* Calcium-7.9* Phos-3.4 Mg-1.8
NUTRITIONAL LABS:
===============
___ 04:46AM BLOOD Albumin-1.7
___ 04:00AM BLOOD Albumin-2.0*
___ 06:20AM BLOOD Albumin-1.7*
___ 05:25AM BLOOD Albumin-2.1*
___ 12:30AM BLOOD Albumin-3.0*
IRON STUDIES:
==============
___ 04:51AM BLOOD calTIBC-101* VitB12-GREATER TH Hapto-223*
Ferritn-2504* TRF-78*
___ 03:49AM BLOOD Hapto-160
INFLAMMATORY MARKERS:
=====================
___ 04:51AM BLOOD CRP-171.6*, ESR 63
___ 04:46AM BLOOD CRP-19.0*, ESR pending
OTHER PERTINENT LABS:
=====================
___ 06:23AM BLOOD GGT-796*
___ 12:30AM BLOOD Lipase-229*
___ 04:00AM BLOOD CK-MB-2 cTropnT-<0.01 ___
___ 06:30PM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:51AM BLOOD TSH-6.1*
___ 04:51AM BLOOD T3-65* Free T4-1.3
___ 05:56AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
==========
MICRO:
==========
Blood Cultures:
==============
___: No growth
___: No growth, with the exception of
fungal/mycobacterial culture with NGTD, final report pending
___: NGTD, final report pending
Urine Cultures:
================
___: No growth
Stool:
=====
___ C. Diff Positive
Tissue:
=======
___ 1:54 pm TISSUE SACRAL BONE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
ESCHERICHIA COLI. SPARSE GROWTH.
Ertapenem Sensitivity testing per ___. ___
(___).
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
Ertapenem =INTERMEDIATE ( sensitivity testing performed
by ___
___ ). Cefepime Sensitivity testing performed by
Etest.
Interpretation of cefepime susceptibility is based on a
dose of 1
gram every 12h. This isolate is intermediate (I) to
cefepime, now
referred to as susceptible-dose dependent (SDD). SDD
isolates can
be treated with cefepime, but an optimized dosing
regimen should
be prescribed. Please contact the AST (pager ___ or
ID for
assistance in determining the appropriate SDD cefepime
dosing.
CEFTAZIDIME/AVIBACTAM Sensitivity testing per ___. ___
___
(___).
CEFTAZIDIME/AVIBACTAM SENT TO LABORATORY
SPECIALISTS,INC ___.
CEFTAZIDIME/AVIBACTAM ___ MCG/ML = SUSCEPTIBLE
(PERFORMED BY
THE ALLERGAN REFERENCE LAB).
ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE.
LINEZOLID AND Daptomycin AND CEFTAROLINE PER
___.
CEFTAROLINE ZONE SIZE IS 6MM Zone size determined using
a method
that has not been standardized for this drug- organism
combination
and for which no CLSI or FDA-approved interpretative
standards
exist. Interpret results with caution.
CEFTAROLINE sensitivity testing performed by ___
___.
Daptomycin = 4 MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
ENTEROCOCCUS SP.. SPARSE GROWTH. ___ MORPHOLOGY.
ADD ON Daptomycin AND LINEZOLID AND CEFTAROLINE PER
___ ___.
CEFTAROLINE ZONE SIZE 6MM Zone size determined using a
method that
has not been standardized for this drug- organism
combination and
for which no CLSI or FDA-approved interpretative
standards exist.
Interpret results with caution.
CEFTAROLINE sensitivity testing performed by ___
___.
Daptomycin = 4MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| | ENTEROCOCCUS
SP.
| | |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 8 I
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
DAPTOMYCIN------------ S S
GENTAMICIN------------ =>16 R
LINEZOLID------------- 2 S 2 S
MEROPENEM-------------<=0.25 S
PENICILLIN G---------- =>64 R =>64 R
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ =>32 R =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___:
THIS IS A CORRECTED REPORT (___).
ORIGINAL REPORT Reported to and read back by ___
___
___ @3:01 ___.
CORRECTED REPORT Reported to and read back by ___.
___ ___
@3:35 ___.
___. Yeast Susceptibility:.
Fluconazole RESISTANT. Voriconazole MIC 0.5 MCG/ML =
SUSCEPTIBLE.
Caspofungin MIC 0.5 MCG/ML = INTERMEDIATE.
Antifungal agents reported without interpretation lack
established
CLSI guidelines. Results were read after 24 hours of
incubation.
Sensitivity testing performed by Sensititre.
PREVIOUSLY REPORTED AS (___).
Caspofungin SUSCEPTIBLE-DOSE-DEPENDENT INSTEAD OF
INTERMEDIATE.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
SWAB R GLUTEAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
CITROBACTER FREUNDII COMPLEX. RARE GROWTH.
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.
PROTEUS MIRABILIS. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___:
CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C. SEPTICUM.
HEAVY GROWTH.
TISSUE R GLUTEAL TISSUE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by ___, ___ @
01:00AM
(___).
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
PROTEUS MIRABILIS. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___:
CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C. SEPTICUM.
HEAVY GROWTH.
==========
Pathology:
==========
Sacrum ulcer base, debridement ___:
Extensively necrotic tissue with bacterial overgrowth and foci
of acute inflammation; necrotic bone.
GI Mucosal biopsy, CSC ___:
1 A. Transverse polyp, polypectomy:Adenoma.
2 A. Sigmoid polyp, polypectomy:Hyperplastic polyp
=================
STUDIES/EXAMS:
=================
CARDIAC:
========
TTE ___:
Left Ventricle - Ejection Fraction: 65% to 70%
The left atrium is normal in 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%). 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 valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. Mild (1+)
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
IMAGING:
========
Liver/gallbladder US ___:
No biliary pathology identified.
Mildly echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
Trace right pleural effusion
CXR for PICC Placement ___:
Right-sided PICC terminating in the mid to low SVC. No
pneumothorax.
Previously described abnormal contour of the left hilum, which
may be due to pulmonary stenosis, can be further assessed with
comparison with old
radiographs or chest CT, if clinically indicated.
CXR: ___ Prominence of the left pulmonary arterial window
may reflect enlarged pulmonary artery or alternatively
adenopathy. No focal opacity convincing for pneumonia.
CT Head ___: No acute intracranial abnormality. Prominent
ventricles and sulci suggest involutional changes.
CT Abd/Pelvis ___:
1. Hepatic steatosis.
2. Prominent endometrium with possible trace fluid within the
endometrial
canal warrants non-emergent ultrasound evaluation.
3. Healed nondisplaced right ___, and ___ anterior right
rib fractures.
4. Locules of air within the subcutaneous tissues overlying the
right sacrum may reflect decubitus ulcer for which clinical
correlation advised.
Portable CXR ___:
Right paramediastinal opacity, may indicate pneumonia in the
right clinical
setting.
Portable CXR ___:
In comparison with the study of ___, there again are low
lung volumes. There is enlargement of the cardiac silhouette
with mild elevation of pulmonary venous pressure. Retrocardiac
opacification with obscuration of the hemidiaphragm is
consistent with volume loss in the left lower lobe and small
pleural he fusion. The opacification adjacent to the right
aspect of the mediastinum appears to have decreased.
Right PICC line again extends to the lower SVC and there is
again an
impression on the lower cervical trachea, suggestive of a right
thyroid mass.
KUB ___:
1. Nonspecific bowel-gas pattern.
2. Assessment for free intraperitoneal air is limited on supine
radiographs.
Recommend upright radiograph, left lateral decubitus radiograph,
or
cross-sectional imaging if there is clinical concern for
pneumoperitoneum.
Portable CXR ___:
Moderate pulmonary edema has worsened since ___. Lung
volumes are
lower, with persistent relative elevation of the right
hemidiaphragm. This may explain greater consolidation at the
right lung base due to a combination of dependent edema and
atelectasis, although pneumonia is not excluded.
Moderate to severe cardiomegaly has worsened since ___,
stable since ___. Pulmonary arteries are dilated probably
due to pulmonary arterial hypertension. Pleural effusions are
presumed, but not large. No
pneumothorax.
CT Chest ___:
1. Cardiomegaly, diffuse ground-glass opacities with
interlobular septal
thickening, small pericardial effusion and bilateral
nonhemorrhagic pleural effusions most likely reflect sequela of
pulmonary edema. Consolidative lung within the lower lobes
bilaterally most consistent with atelectasis although infectious
process cannot be entirely excluded.
2. Enlarged pulmonary artery is suggestive of though not
diagnostic for
pulmonary hypertension.
3. Extensive atherosclerotic calcifications involve the
coronary arteries.
Aortic valvular calcifications additionally noted.
4. For complete subdiaphragmatic findings, please refer to CT
abdomen and
pelvis performed on the same date, ___, clip number
___.
CT A/P ___:
1. Sacral decubitus ulcer with soft tissue defect exposing the
osseous
structures. There is no definite evidence for osteomyelitis.
MRI would be more sensitive for evaluation of osteomyelitis.
2. No evidence of intra-abdominal infectious process. No
abscess is
identified.
3. Small volume nonhemorrhagic abdominal free fluid, mild
periportal edema, and diffuse anasarca likely reflective of
volume status.
4. For complete intrathoracic findings, please refer to CT chest
dated ___, clip number ___.
KUB ___:
Embolization coils are projected over the left lower quadrant
from recent left colonic artery branch embolization.
Hemidiaphragms have not been included on this abdominal
radiograph.
Air is seen within the stomach and multiple loops of small
bowel, none of
which are overly dilated. Small amount of air seen within the
colon projected over the left hemipelvis. No bowel wall
thickening. On the second abdominal radiograph obtained, there
are streaks of linearly oriented air is noted overlying the the
left hemi abdomen, which may reflect material/sheets external to
the patient.
No acute or aggressive osseous lesions are demonstrated.
IMPRESSION: No dilated loops of large or small bowel..
GI PROCEDURES:
===============
SIGMOIDOSCOPY REPORT ___:
Diverticulosis of the sigmoid colon
Normal mucosa in the rectum
No active bleeding. Evidence of recent bleeding seen up to the
proximal descending colon with clean mucosa proximally.
Polyp in the sigmoid colon
Otherwise normal sigmoidoscopy to splenic flexure
EGD ___:
No blood or source of bleeding identified.
Esophageal ring
Otherwise normal EGD to third part of the duodenum
Colonoscopy Findings ___:
Diverticulosis of the left and right colon
Abnormal vascularity and petechiae in the proximal
sigmoid/descending colon compatible with ischemic changes likely
due to recent embolization
Polyps in the transverse colon (polypectomy)
Polyp in the colon (polypectomy)
Otherwise normal colonoscopy to cecum and terminal ileum
INTERVENTIONAL RADIOLOGY REPORTS:
=================================
MESENTERIC ARTERIOGRAM ___:
FINDINGS:
1. Inferior mesenteric arteriogram demonstrates brisk bleeding
from a branch of the left colic artery.
2. Left Colic arteriogram demonstrates brisk bleeding from a
branch of the
left colic artery, with delineation of the anatomy of the
feeding arterial
vessels.
3. Left Colic branch #1 arteriogram demonstrates brisk bleeding
from this
specific branch.
4. Left Colic branch #2 arteriogram demonstrates brisk bleeding
from this
specific branch.
5. Coil embolization of left colic artery branches 1 and 2 with
post
embolization left colic arteriogram demonstrating no further
active
extravasation.
6. Superior mesenteric arteriogram demonstrates no active
extravasation.
7. Right common femoral vein access, ultrasound guided.
Placement of a
triple-lumen central line via the right common femoral vein.
The line is
ready for use.
8. Right common femoral artery arteriogram demonstrates
appropriate puncture
site for use of an Angio-Seal device.
IMPRESSION: Brisk bleeding for multiple branches of the left
colic artery treated with coil embolization with good
angiographic result. No further bleeding angiographically upon
completion of the embolization.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY
2. Ranitidine 150 mg PO DAILY
3. Loratadine 10 mg PO DAILY:PRN allergies
4. diclofenac epolamine 1.3 % transdermal BID:PRN pain
5. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
6. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
dyspepsia
3. Ascorbic Acid ___ mg PO DAILY
4. Collagenase Ointment 1 Appl TP DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Meropenem 1000 mg IV Q8H
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Vancomycin Oral Liquid ___ mg PO Q6H
9. Zinc Sulfate 220 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Loratadine 10 mg PO DAILY:PRN allergies
12. Ranitidine 150 mg PO DAILY
13. Ondansetron 4 mg IV Q8H:PRN nausea
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
15. Phosphorus 500 mg PO TID
16. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
17. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
18. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-Severe sepsis secondary to osteomyelitis
SECONDARY DIAGNOSIS:
-Stage 4 decubitus ulcer of the right buttock
-Cdiff colitis
-anemia
-SA nodal reentrant tachycardia
-Diverticular bleed
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with weakness // eval for pna
COMPARISON: None available
FINDINGS:
Single portable semi supine AP radiograph demonstrates abnormal contour
involving the pulmonary arterial window either enlarged left pulmonary artery
or adenopathy. Heart size is upper limits of normal. No evidence of
pulmonary edema. No focal consolidation convincing for pneumonia is present.
There is no pleural effusion or evidence of pneumothorax. Imaged osseous
structures and upper abdomen are without an acute abnormality.
IMPRESSION:
Prominence of the left pulmonary arterial window may reflect enlarged
pulmonary artery or alternatively adenopathy. No focal opacity convincing for
pneumonia.
Radiology Report
INDICATION: History: ___ with sacral decubs, weakness // eval for fracture,
bony erosion to spine
COMPARISON: None available
FINDINGS:
AP supine and portable radiograph through the abdomen demonstrates a
nonspecific bowel gas pattern. Multilevel degenerative changes are present
and most pronounced within the lower lumbar spine. Bilateral femoral heads
appears seated in the acetabulum. No evidence of dislocation or acute
fracture. No osteolysis involves the bilateral ischial tuberosities or
sacrum. Linear density projects over the pubic symphysis in the midline
consistent with rectal thermometer. Allowing for suboptimal technique, no
evidence of pneumoperitoneum.
IMPRESSION:
Nonspecific bowel-gas pattern. Degenerative changes within the lower lumbar
spine.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with sepsis // eval for cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 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.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. No evidence of cholelithiasis or cholecystitis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with ams, transaminitis // eval for pancreatic
mass, obstructioneval for ich
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.7 mGy (Head) DLP =
802.7 mGy-cm.
4) Sequenced Acquisition 6.0 s, 6.1 cm; CTDIvol = 49.7 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Periventricular and scattered white matter hypodensities are nonspecific
though likely sequela of chronic small vessel ischemic disease. Basal
cisterns are patent. There is no shift of normally midline structures.
IMPRESSION:
No acute intracranial abnormality. Prominent ventricles and sulci suggest
involutional changes.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with ams, transaminitisNO_PO
contrast // eval for pancreatic mass, obstructioneval for ich
TECHNIQUE: Multi detector CT images through the abdomen and pelvis were
obtained after the administration of intravenous contrast. No oral contrast
was administered. Coronal and sagittal reformations were generated and
reviewed.
DOSE: 356 mGy-cm.
COMPARISON: None.
FINDINGS:
Chest: Bilateral atelectasis is mild and symmetric. Calcified nodule within
the right lower lobe is most consistent with calcified granuloma.There is no
pleural or pericardial effusion. Partially imaged mitral annular
calcifications as well as aortic valve calcifications are noted.
Abdomen: The liver is diffusely low in attenuation consistent with hepatic
steatosis. There is no intrahepatic biliary duct dilation. The portal veins
are patent. There is no radiopaque cholelithiasis.
Pancreas is homogeneous in attenuation. There is no peripancreatic stranding.
The spleen and bilateral adrenal glands are normal in appearance. The kidneys
present symmetric nephrograms and excretion of contrast. There is no focal
renal lesion, perinephric fluid collection or stranding.
The stomach, duodenum, and loops of small bowel are grossly normal. The
appendix is air-filled an normal. Scattered diverticular disease is present
in the absence of findings to suggest diverticulitis. There is no abdominal
free fluid or air.
The aorta demonstrates moderate to severe atherosclerotic calcifications
without aneurysmal dilatation. Bilateral common iliac arteries are dilated
bilaterally measuring up to 1.4 cm. There is no retroperitoneal or mesenteric
adenopathy.
Pelvis: The bladder is decompressed with a Foley catheter present. There is
no adnexal mass. The endometrium appears prominent with fluid present within
the endometrial canal. There is no pelvic free fluid. There is no inguinal
or pelvic sidewall adenopathy.
No osseous lesion worrisome for malignancy or infection is identified. Healed
nondisplaced anterior fifth, sixth and seventh right rib fracture (3:1) are
noted. Multilevel degenerative changes are moderate. Anterolisthesis of L5
on S1 is mild, Grade I. Mild compression deformity at T12 vertebral body is
additionally noted.
Locules of air within the subcutaneous fat overlying the right sacrum extends
into adjacent fascial planes may reflect decubitus ulcer.
IMPRESSION:
1. Hepatic steatosis.
2. Prominent endometrium with possible trace fluid within the endometrial
canal warrants non-emergent ultrasound evaluation.
3. Healed nondisplaced right ___, and ___ anterior right rib fractures.
4. Locules of air within the subcutaneous tissues overlying the right sacrum
may reflect decubitus ulcer for which clinical correlation advised.
RECOMMENDATION(S): Suggest non-urgent pelvic ultrasound for followup of
endometrial thickening and possible fluid.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with sepsis // r/o edema r/o edema
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
There has been no interval change. Swan-Ganz catheter intra-aortic balloon
pump are in standard placements respectively. Right PIC line ends at the
origin of the SVC, as before.
Moderate to severe cardiac enlargement is unchanged. The right pleural
abnormality and unidentified spherical lesion in the right midlung laterally
are unchanged. An the cardiac silhouette obscures the left lower lobe where
there could be infrahilar atelectasis or consolidation.
Pleural effusion is small if any. No pneumothorax.
Radiology Report
INDICATION: ___ year old woman with new line. New right PICC 40 cm, ___
___ Contact name: ___: ___
TECHNIQUE: Upright portable AP chest radiograph
COMPARISON: Chest radiographs from ___ and ___.
FINDINGS:
Right-sided PICC terminates in the mid to low SVC. The heart size is
top-normal. Engorged vasculature is seen. Abnormal contour of the left hilum
is not well seen on this exam. No pulmonary edema, effusion, consolidation or
pneumothorax is seen. Mild increased an right lobe interstitial markings is
likely due to atelectasis.
IMPRESSION:
Right-sided PICC terminating in the mid to low SVC. No pneumothorax.
Previously described abnormal contour of the left hilum, which may be due to
pulmonary stenosis, can be further assessed with comparison with old
radiographs or chest CT, if clinically indicated.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with sepsis and mixed pattern of elevated LFTs
// eval for hepatobiliary pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis ___, abdominal ultrasound ___
FINDINGS:
LIVER: The liver is diffusely mildly echogenic. The contour of the liver is
smooth. There is no focal liver mass. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 9.0 cm.
KIDNEYS: The partially visualized kidneys are unremarkable.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
Trace right pleural effusion.
IMPRESSION:
No biliary pathology identified.
Mildly echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
Trace right pleural effusion
Radiology Report
INDICATION: ___ year old woman with new fever. Please assess for new
infectious process, edema, effusion, consolidation.
TECHNIQUE: Semi upright portable AP chest radiograph.
COMPARISON: Chest radiographs from ___.
FINDINGS:
Compared to ___, the lung volumes have decreased. Lordotic views
accentuate the heart size and interstitial opacity. There is mild prominence
of the pulmonary vessels and increased interstitial opacities, right worse
than left, may suggest pulmonary edema. Right paramediastinal opacity may
suggest consolidation. Moderate to severe cardiomegaly appear grossly
unchanged. Right-sided PICC appear unchanged in position. There is a
right-sided indentation of the lower cervical trachea, which may be due to
enlarged thyroid.
IMPRESSION:
Right paramediastinal opacity, may indicate pneumonia in the right clinical
setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with h/o RA with sepsis ___ infected stage 4
decubitus ulcer c/b osteo, +c diff colitis with tachycardia and new oxygen
requirement. // eval for PNA, pulm edema eval for PNA, pulm edema
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes.
There is enlargement of the cardiac silhouette with mild elevation of
pulmonary venous pressure. Retrocardiac opacification with obscuration of the
hemidiaphragm is consistent with volume loss in the left lower lobe and small
pleural he fusion. The opacification adjacent to the right aspect of the
mediastinum appears to have decreased.
Right PICC line again extends to the lower SVC and there is again an
impression on the lower cervical trachea, suggestive of a right thyroid mass.
Radiology Report
INDICATION: ___ year old woman with h/o RA here w/ sepsis ___ stage 4 decub
c/b osteo and cdiff colitis, with persistent fevers, chills and abd pain. //
eval for colonic distenion, free air
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Assessment for free intraperitoneal air is limited on supine radiographs. If
there is clinical concern for pneumoperitoneum, advise upright or left lateral
decubitus radiograph, or cross-sectional imaging.
Osseous structures are unremarkable. Degenerative changes are noted in the
lumbosacral spine.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Nonspecific bowel-gas pattern.
2. Assessment for free intraperitoneal air is limited on supine radiographs.
Recommend upright radiograph, left lateral decubitus radiograph, or
cross-sectional imaging if there is clinical concern for pneumoperitoneum.
RECOMMENDATION(S): Upright radiograph, left lateral decubitus radiograph, or
cross-sectional imaging if there is clinical concern for pneumoperitoneum.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with sepsis // assess pulm edema assess
pulm edema
COMPARISON: Prior chest radiographs ___ through ___ at 15:12.
IMPRESSION:
Moderate pulmonary edema has worsened since ___. Lung volumes are
lower, with persistent relative elevation of the right hemidiaphragm. This
may explain greater consolidation at the right lung base due to a combination
of dependent edema and atelectasis, although pneumonia is not excluded.
Moderate to severe cardiomegaly has worsened since ___, stable since
___. Pulmonary arteries are dilated probably due to pulmonary arterial
hypertension. Pleural effusions are presumed, but not large. No
pneumothorax.
Right PIC line ends in the region of the superior cavoatrial junction.
Radiology Report
INDICATION: ___ year old woman with known sacral decub, persistent fevers //
r/o abscess
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
4) Spiral Acquisition 5.7 s, 62.9 cm; CTDIvol = 16.3 mGy (Body) DLP =
1,025.1 mGy-cm.
5) Spiral Acquisition 1.0 s, 11.0 cm; CTDIvol = 13.2 mGy (Body) DLP = 144.5
mGy-cm.
Total DLP (Body) = 1,179 mGy-cm.
COMPARISON: None.
FINDINGS:
Chest: For complete intrathoracic findings, please refer to CT chest dated ___, clip number ___.
Abdomen: The liver appears homogeneous in attenuation without a focal lesion
identified. There is mild periportal edema. There is no intrahepatic biliary
duct dilation. The gallbladder is without radiopaque cholelithiasis. The
pancreas, spleen, and bilateral adrenal glands are normal in appearance. The
kidneys present symmetric nephrograms and excretion of contrast. There is no
hydronephrosis or focal renal lesion.
The stomach, duodenum, and loops of small bowel are grossly normal in
appearance without evidence of bowel wall thickening or obstruction. The
appendix is visualized, air filled and normal. Mild diverticular disease
involves the sigmoid colon without evidence of diverticulitis. Small volume
abdominal fluid is nonhemorrhagic and layers within the pelvis.
The abdominal aorta demonstrates moderate atherosclerotic calcifications
without aneurysmal dilatation. There is no retroperitoneal or mesenteric
adenopathy.
A Foley catheter is present within a otherwise unremarkable bladder. Foci of
air anteriorly is iatrogenic. The uterus is unremarkable. There is no
adnexal mass. A rectal tube is present. There is no inguinal or pelvic
sidewall adenopathy.
A sacral decubitus ulcer is identified on series 2, ___ 91. With erosion of
soft tissues down to the osseous structures. There is no cortical disruption
to suggest osteomyelitis.
Diffuse anasarca is moderate. No osseous lesion worrisome for malignancy or
infection is identified.
IMPRESSION:
1. Sacral decubitus ulcer with soft tissue defect exposing the osseous
structures. There is no definite evidence for osteomyelitis. MRI would be
more sensitive for evaluation of osteomyelitis.
2. No evidence of intra-abdominal infectious process. No abscess is
identified.
3. Small volume nonhemorrhagic abdominal free fluid, mild periportal edema,
and diffuse anasarca likely reflective of volume status.
4. For complete intrathoracic findings, please refer to CT chest dated ___, clip number ___.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ female with persistent fevers.
TECHNIQUE: Multi detector CT images through the torso were obtained after the
administration of intravenous contrast. Coronal and sagittal reformations
were generated and reviewed. Axial maximum intensity projections sequences
were additionally acquired.
DOSE: DLP: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
4) Spiral Acquisition 5.7 s, 62.9 cm; CTDIvol = 16.3 mGy (Body) DLP =
1,025.1 mGy-cm.
5) Spiral Acquisition 1.0 s, 11.0 cm; CTDIvol = 13.2 mGy (Body) DLP = 144.5
mGy-cm.
Total DLP (Body) = 1,179 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: None prior
FINDINGS:
The imaged thyroid gland is homogeneous in attenuation without a focal lesion
identified. There is no axillary or supraclavicular adenopathy. Numerous
central nodes are present, the largest located within the right lower
paratracheal station which measures approximately 5 mm in short axis (02:16).
A subcarinal node measures approximately 1.1 x 2.5 cm (02:23). Right hilar
node measures 1.5 x 1.5 cm (02:20).
Heart size is borderline enlarged. A central venous catheter terminates
within the right atrium. The ascending aorta is non aneurysmal. The main
pulmonary artery is enlarged, suggestive of though not diagnostic for
pulmonary hypertension. Extensive atherosclerotic calcifications involve the
coronary arteries, predominantly the left anterior descending coronary artery.
Moderate aortic valvular calcifications are additionally noted. Trace
pericardial fluid is present, nonhemorrhagic. There is no esophageal
abnormality.
Lung windows demonstrate patent airways. Bilateral nonhemorrhagic and
layering pleural effusions, right greater than left, are small to moderate in
size.
Predominantly involving the right upper lobe, there are diffuse ground-glass
opacities with interlobular septal thickening, findings most likely reflect
pulmonary edema. Consolidated lung within the lower lobes bilaterally with
air bronchograms is likely reflective of atelectasis though infectious process
cannot be excluded.
Anterior fifth, sixth, and seventh right rib fractures are nondisplaced and
appear subacute. No suspicious lesion worrisome for malignancy or infection
is identified.
For complete subdiaphragmatic findings, please refer to CT abdomen and pelvis
performed on the same date, ___, clip number ___.
IMPRESSION:
1. Cardiomegaly, diffuse ground-glass opacities with interlobular septal
thickening, small pericardial effusion and bilateral nonhemorrhagic pleural
effusions most likely reflect sequela of pulmonary edema. Consolidative lung
within the lower lobes bilaterally most consistent with atelectasis although
infectious process cannot be entirely excluded.
2. Enlarged pulmonary artery is suggestive of though not diagnostic for
pulmonary hypertension.
3. Extensive atherosclerotic calcifications involve the coronary arteries.
Aortic valvular calcifications additionally noted.
4. For complete subdiaphragmatic findings, please refer to CT abdomen and
pelvis performed on the same date, ___, clip number ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ RA, fibromyalgia and htn, p/w hypotension and tachycardia
on ___, found to have a sig. R buttock DQ ulcer stage IV, s/p debridement,
and + c. diff infection, in ICU for respiratory distress thought ___ pulm
edema; now requiring more oxygen. // interval change
IMPRESSION:
As compared to ___ chest radiograph, cardiomegaly is stable,
pulmonary vascular congestion has slightly improved, with associated
decreasing asymmetrical pulmonary edema. Bibasilar areas of atelectasis and
or consolidation have also slightly improved along with near resolution of a
small left pleural effusion. No other relevant changes.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with stage IV decubitus ulcer complicated by
osteomyelitis, clostridium difficile colitis with elevated alkaline
phosphatase and positive GGT. Evaluate for biliary pathology.
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. There is no focal
liver mass. The main portal vein is patent with hepatopetal flow. There is a
small amount of ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 2 mm.
GALLBLADDER: The gallbladder relatively contracted. Gallbladder wall edema
and pericholecystic fluid is nonspecific and likely due to third spacing. No
gallstones are seen. There is a possible gallbladder polyp.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.0 cm.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits. A partially visualized right pleural effusion is noted.
IMPRESSION:
1. Gallbladder wall edema and pericholecystic fluid is consistent with third
spacing.
2. Small amount of ascites and partially visualized right pleural effusion.
Radiology Report
EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS
INDICATION: ___ year old woman with BRBPR s/p 3 U pRBCs, evaluate location of
bleed.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) CT Localizer Radiograph
4) Spiral Acquisition 4.5 s, 49.5 cm; CTDIvol = 3.7 mGy (Body) DLP = 185.2
mGy-cm.
5) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 9.6 mGy (Body) DLP = 4.8
mGy-cm.
6) Spiral Acquisition 6.1 s, 47.8 cm; CTDIvol = 15.8 mGy (Body) DLP = 755.1
mGy-cm.
7) Spiral Acquisition 6.1 s, 47.8 cm; CTDIvol = 15.8 mGy (Body) DLP = 756.8
mGy-cm.
Total DLP (Body) = 1,702 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: There are bilateral moderate nonhemorrhagic pleural effusions
with adjacent compressive atelectasis, unchanged since prior study
atherosclerotic calcifications of the coronary arteries are noted. There is a
trace pericardial effusion, similar to prior study.
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 nondistended. There is
gallbladder wall edema, likely reflective of third spacing. The portal vein
is patent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is grossly unremarkable. There is active
extravasation of contrast into the sigmoid colon (3A: 110) which becomes more
diffuse on the subsequent portal venous space compatible with active bleeding.
Other areas of hyperdensity within areas of small bowel (3a: 112, 94, 115, and
121) are present on the noncontrast phase without significant change in the
portal venous phase, and likely represent retained contrast from prior study
or ingested material as opposed to true active bleeding. Small and large
bowel are normal in caliber without dilatation or wall thickening. There is
mild diverticulosis of the sigmoid colon. The appendix is visualized and
normal.
There is no mesenteric or retroperitoneal lymphadenopathy. There is moderate
amount of ascites, increased since the prior study.
VASCULAR: The abdominal aorta is normal in caliber without aneurysmal
dilatation. There are moderate atherosclerotic calcifications. There are
atherosclerotic calcifications of the origin of the bilateral renal arteries
without significant distal flow limiting stenosis.
PELVIS: A Foley catheter is seen within a nondistended bladder. Air within
the bladder is likely related to Foley catheter manipulation. There is no
evidence of pelvic or inguinal lymphadenopathy. There is moderate amount of
free fluid within the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: A large sacral decubitus wound is again identified extending to
the bony sacrum. A wound VAC is identified overlying this defect. There is
diffuse anasarca within the subcutaneous soft tissues.
IMPRESSION:
1. Active contrast extravasation within the sigmoid colon compatible with
active bleeding. Mild sigmoid diverticulosis. Other areas of hyperdensity
throughout segments of small bowel seen on all phases are likely related to
prior retained contrast or ingested material as opposed to true active
bleeding.
2. Bilateral moderate nonhemorrhagic pleural effusions with compressive
atelectasis.
3. Moderate amount of intra-abdominal and intrapelvic ascites. Diffuse
anasarca.
4. Gallbladder wall thickening, likely related to third spacing.
5. Large sacral decubitus wound extending to the bony sacrum covered by wound
vac.
NOTIFICATION: Findings were discussed with ___ by ___ phone at
12:15pm on ___, 5 minutes following discovery.
Radiology Report
INDICATION: ___ year old woman with GI bleed // GI bleed
COMPARISON: CT abdomen pelvis dated ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site. 37.5 mcg fentanyl was administered.
MEDICATIONS: 1% lidocaine, 37.5 mcg fentanyl.
CONTRAST: 106 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 23:30 min, 956 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Inferior mesenteric arteriogram.
3. Left Colic arteriogram.
4. Left Colic branch #1 arteriogram.
5. Left Colic branch #2 arteriogram.
6. Embolization of left colic artery branches 1 and 2 with figure of 8 coils
and post embolization left colic arteriogram.
7. Superior mesenteric arteriogram.
8. Right common femoral vein access, ultrasound guided.
9. Placement of a triple-lumen central line via the right common femoral vein.
10. Right common femoral artery arteriogram.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient and her
daughter. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. Both groins were prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A RIM catheter was advanced over ___ wire into the aorta. The wire was
removed and the inferior mesenteric artery was selectively cannulated and a
small contrast injection was made to confirm position. A inferior mesenteric
artery arteriogram was performed.
An ___ micro catheter and Transcend micro wire were then carefully guided into
the left colic artery. The wire was removed, and a contrast injection was
performed to confirm positioning. A left colic arteriogram was performed.
The STC micro catheter and Transcend micro wire were then carefully guided
into the left colic artery branch 1. The wire was removed, and a contrast
injection was performed to confirm positioning. A left colic branch 1
arteriogram was performed.
Embolization of left colic artery branch 1 was then performed with 5 figure of
8 non detachable microcoils (2 mm x 5 mm). A post embolization angiogram was
performed.
The ___ micro catheter and Transcend micro wire were then carefully guided
into the left colic artery branch 2. The wire was removed, and a contrast
injection was performed to confirm positioning. A left colic branch 2
arteriogram was performed.
Embolization of left colic artery branch 2 was then performed with 3 figure of
8, 0.018 microcoils (2 mm x 5 mm). A post embolization angiogram was
performed.
The micro catheter and micro wire were then removed. The RIM catheter was
disengaged from the inferior mesenteric artery, and was exchanged for a C2
Cobra catheter over ___ wire. The C2 Cobra catheter was used to
carefully cannulate the superior mesenteric artery. A contrast injection was
performed to confirm positioning. A superior mesenteric arteriogram was
performed.
The right common femoral artery sheath was then injected with contrast,
performing a right common femoral arteriogram.
At the request of the medicine service, a central line was placed. US revealed
patency of the right common femoral vein. Sonographic images were aquired.
Using ultrasound and fluoroscopic guidance, the right common femoral vein was
punctured using a micropuncture set at the level of the mid femoral head. A
0.018 inch wire was then passed easily into the vessel lumen. A small skin
incision was made over the needle. Then the inner dilator and wire were
removed and ___ wire was advanced under fluoroscopy into the IVC. The
micropuncture sheath was exchanged for a triple lumen central catheter over
wire. The wire was removed. All 3 lumens were aspirated and flushed. The
catheter was secured to the skin with silk sutures. A sterile dressing was
applied.
All catheters and wires were removed. Right common femoral arterial access h
emostasis was achieved with a ___ Angio-Seal device and manual pressure.
Sterile dressings were applied. The patient tolerated the procedure well
without any immediate complications.
FINDINGS:
1. Inferior mesenteric arteriogram demonstrates brisk bleeding from a branch
of the left colic artery.
2. Left Colic arteriogram demonstrates brisk bleeding from a branch of the
left colic artery, with delineation of the anatomy of the feeding arterial
vessels.
3. Left Colic branch #1 arteriogram demonstrates brisk bleeding from this
specific branch.
4. Left Colic branch #2 arteriogram demonstrates brisk bleeding from this
specific branch.
5. Coil embolization of left colic artery branches 1 and 2 with post
embolization left colic arteriogram demonstrating no further active
extravasation.
6. Superior mesenteric arteriogram demonstrates no active extravasation.
7. Right common femoral vein access, ultrasound guided. Placement of a
triple-lumen central line via the right common femoral vein. The line is
ready for use.
8. Right common femoral artery arteriogram demonstrates appropriate puncture
site for use of an Angio-Seal device.
IMPRESSION:
Brisk bleeding for multiple branches of the left colic artery treated with
coil embolization with good angiographic result. No further bleeding
angiographically upon completion of the embolization.
RECOMMENDATION(S): Continue to monitor hematocrit. Keep the rigth leg
straight for 2 hr.
Radiology Report
INDICATION: ___ year old woman with ___ embolization of descending colon, with
left sided abdominal pain // evidence of ileus, free air under diaphragm
TECHNIQUE: Portable supine abdominal radiographs.
COMPARISON: Portable abdominal radiograph ___. CT abdomen and
pelvis ___.
FINDINGS:
Embolization coils are projected over the left lower quadrant from recent left
colonic artery branch embolization.
Hemidiaphragms have not been included on this abdominal radiograph.
Air is seen within the stomach and multiple loops of small bowel, none of
which are overly dilated. Small amount of air seen within the colon projected
over the left hemipelvis. No bowel wall thickening. On the second abdominal
radiograph obtained, there are streaks of linearly oriented air is noted
overlying the the left hemi abdomen, which may reflect material/sheets
external to the patient.
No acute or aggressive osseous lesions are demonstrated.
IMPRESSION:
No dilated loops of large or small bowel..
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Sepsis, unspecified organism, Other specified abnormal findings of blood chemistry, Essential (primary) hypertension
temperature: 100.0
heartrate: 136.0
resprate: 20.0
o2sat: 96.0
sbp: 96.0
dbp: 56.0
level of pain: 4
level of acuity: 1.0 | ___ with hx of alcohol abuse brought to the ED after found down
and admitted to ICU for sepsis workup found to have sacral
decubitus ulcer with concurrant osteomyelitis and C. Diff
infection.
# Severe sepsis in setting of infected sacral decub ulcer,
osteomyelitis: Presenting with fever, leukocytosis, tachycardia
and lactate elevation, admitted to MICU. Source felt to be
sacral decub. No other strong possibilities for source. CT
abd/pelvis negative, and CXR clear, and no findings on lung
exam. Lactate normalized, hemodynamically stable and with good
U.O. and hemodynamics responded well to fluid resuscitation and
initiation of broad-spectrum abx. Patient underwent debridement
with ACS ___ where the ulcer was noted to be open to bone.
Also had a wound vac placed. Patient initially treated with
broad spectrum antibiotics, but this was narrowed to vancomycin,
ceftriaxone and flagyl, and further to CTX/flagyl. Further I&D
and bone biopsy were obtained on ___. Clinically improved on the
floor, but following biopsy intermittently became septic with
fevers, rigors and tachycardia. Repeat blood and urine cultures
were negative. CXR neg. Sepsis was likely ___ osteo/decub ulcer
and poor source control given contamination of wound with stool
and urine given location, potentially transient bacteremia s/p
I&D. Rectal tube and foley were placed to improve hygiene, but
pt continued to be septic and was triggered several times for
sinus tachycardia to the 130s-150s. Her pressures were
intermittently soft to the ___ requiring IVF resusication, but
was fluid responsive. Bone cultures grew resistant E. coli, and
prior wound cultures were polymicrobial with p. mirabilis and
citrobacter with concern for resistance to ___ gen
cephalosporins, and antibiotics were switched to Vanc/meropenem.
Ultimately she became hypoxic, requiring up to 6L of oxygen,
likely ___ pulm edema from fluid resuscitation and leaky
pulmonary capillaries in setting of sepsis and low oncotic
pressure in the setting of hypoalbuminemia/poor nutritional
status. On ___, her tachycardia worsened and she was noted to
have altered mental status and due to nursing concern was
ultimately transferred back to the MICU for further management.
In the MICU, patient remained tachycardic to the 120's,
maintained pressures well with SBPs in the 100-110's without
pressors. Bone cultures from ___ grew ___ and ___
___. Vancomycin was stopped, PO linezolid was started
(___) and then switched to daptomycin (___)
for concern for hypoglycemia; meropenem (___-) was continued and
micafungin (___) was started. ___ and ___ were
ultimately thought to be contaminants, so was switched to
meropenem monotherapy on ___. DIscharged to ___ with OPAT f/u.
#BRBPR: On ___ triggered for 500cc BRBPR with flexiseal in
place. At that time, was hemodynamically stable, but with
tachycardia to the 110s. Flexiseal was removed. Given 500cc IVF
bolus and pressures remained stable. She continued to have
bloody BMs but remained stable, with H/H stable at 8.2. Several
hours later, she was noted to again have BRBPR but with
pressures dropping to the ___, symptomatic with
lightheadedness,diaphoresis but mentating well. She was bloused
1L LR via PICC and pressures improved to ___. On the floor,
unable to obtain peripheral large bore IV, so given likely need
for more aggressive resuscitation, she was transferred to the
MICU. In the MICU patient was mentating well. Denies light
headedness while laying flat. She was given 500cc NS, 3U of
PRBC. Patient has been tachycardic to 130s, BP improved from ___
to110s. CBC were trended and were stable. GI performed EGD/flex
sig which shows she likely bled from diverticula but no active
bleeding. On ___ she was found to have more BRBPR. CTA showed
bleeding from the sigmoid colon. Due to tachycardia and soft
BPs, and concern for active GIB, she was transferred to the
MICU. Patient underwent ___ embolization of a branch of the L
Colic artery with resolution of extravasation after
intervention. Trended CBC post procedurally, and while required
1U of pRBCs post procedure, CBC remained stable and patient also
remained HD stable (with exception of tachycardia described
below). Finally, as no further BRBPR, flexiseal replaced given
sacral decub/osteo. Labs were monitored closely and H/H
continued to be stable with no recurrent bleeding on the floor.
Screening colonscopy was done prior to discharge which showed
diverticula but no active bleeding. 3 small polyps were removed,
path pending on discharge.
#Tachycardia - in the MICU she was noted to have SA nodal
reentrant tachycardia. She abruptly improved to ___ for several
hours and then increased back to 120s, while maintaining
pressures Patient started on metoprolol 12.5mg TID, titrated up
to 12.5mg QID and was discharged on metop succinate 50mg daily.
#R buttock stage 4 decubitus ulcer: c/b osteomyelitis - stage
IV, reaching bone, s/p debridement by ACS on ___ with vound
vac placement and I/D, bone biopsy on ___. Wound care consulted
for further management. Wound with healthy appearing granulation
tissue, with wound vac in placed and draining appropriately. Pt
to follow-up with plastics as an outpatient once clinically
stabilized and nutritionally optimized for flap.
#Diarrhea/ loose stool: New since admission, though some reports
from family of stool incontinence and diarrhea at home. C. Diff
positive therefore was initially continued on IV flagyl and
started on PO vancomycin 125 mg QID (___).
Ultimately IV flagyl was discontinued and given sepsis PO
vancomycin was increased to 500mg q6hr (___-) in the setting of
continued sepsis, but was ultimately switched back to standard
dosing of 125mg q6hr. Loose stool continued, and rectal tube was
placed due to concern for contamination of R buttock wound with
feces. Pt was ultimately given more aggressive bowel reg to keep
stools soft to prevent further contamination, and on discharge
was continued on PO vanc 125mg q6hr with ID f/u.
# Delirium: While in the MICU, patient was agitated, mental
status altered, pulled at tubes and lines and had reversal of
her sleep wake cycle, likely from delirium in the setting of
infection, narcotics for pain control. Patient was started on
thiamine for concern for B1 deficiency. She was placed on
delirium precautions, started on Seroquel 12.5 mg that was
uptitrated to 25 mg with good result. The family was concerned
with her level of sedation therefore it was discontinued. Her
mental status continued to wax and wane in the setting of
ongoing infection and multiple transfers to the MICU in the
setting of infection and lower GI bleed. Mental status was
improved on the floor prior to discharge, pt alert and oriented
x3.
# Nutrition: Patient with poor PO intake prior to and during
admission with a history of alcohol abuse and now with large
sacral wound. Nutrition was consulted and patient was started on
vitamin C, zinc, thiamine, folate and multivitamins to optimize
wound healing. Per discussion with patient about feeding tube,
she prefers PO intake, nutrition agreed and she was able to
consume 4 ensures plus meals daily to meet her daily calorie
goal.
#Abnormal LFTs: ALT/AST elevation. Could be ___ alcohol abuse,
but AST/ALT ratio not classic. No intrahepatic process or
obstruction to explain the transaminitis. Could be from
hypoperfusion in the setting of sepsis. Trended and stable
during ICU stay, and on the floor Transaminitis resolved,
although was noted to have elevated alkaline phosphatase. GGT
was elevated, so RUQ US was obtained which showed third spacing
of fluids but was otherwise unremarkable. Alkaline phos
continued to downtrend.
# Hyperbilirubinemia: Direct with elevated alkphos suggestive of
obstruction but none identified on RUQ US or CT abd. Resolved.
# HTN: Held home antihypertensives in the setting of sepsis,
normotensive on discharge so continued to be held.
#Alcohol abuse: Monitored, no evidence of withdrawel in ICU. On
the floor, intermittently was noted to be tremulous, so was
monitored on CIWA but not scoring so ultimately was
discontinued. She was treated with high dose thiamine and
folate. Social work was consulted.
#Failure to thrive: Appears to be unable to take care of ADLs
independently and with frequent falls at home complicated by
alcohol abuse. SW, ___, case management following. Albumin
trended down likely in the setting of infection, poor PO intake.
Ultimately was discharged to ___ benefit from placement in
long term care facility/assisted living given precarious home
situation.
===============
Transitional Issues:
===============
-Fungal/mycobacterial blood culture from ___ with NGTD, final
report pending, blood culture from ___ with NGTD final report
pending
-Diverticular bleed this admission requiring MICU stay and CTA
with embolization of the left colic artery with coils. If has
recurrent bleed, consider referral to colorectal surgery for
colectomy
-Needs plastic surgery clinic f/u for eval for flap once
nutritional optimized, clinically improved
-RUQ US: Mildly echogenic liver consistent with steatosis. Other
forms of liver disease including steatohepatitis, hepatic
fibrosis, or cirrhosis cannot be excluded on the basis of this
examination. Consider further eval for liver pathology as
outpatient
-CT abd noted prominent endometrium with possible trace fluid
within the endometrial canal warrants non-emergent pelvic
ultrasound evaluation.
-Noted to have TSH 6.1, with T3 mildly decreased at 65 and Free
T4 1.3, difficult to interpret in setting of infection. Please
reassess when medically stable in the outpatient setting,
particularly given strong family history of thyroid disease.
-CXR with impression on the lower cervical trachea, suggestive
of a right thyroid mass.
-screening colonoscopy done prior to discharge with 3 small
polyps removed, path pending.
-Started on metop succinate 50mg daily for sinus nodal reentrant
tachycardia
-Discharged with ID/OPAT f/u on ___ to continue meropenem
(Day ___ and PO vanco (Day ___
-Poor nutritional status (Albumin 1.7 on discharge), please
continue nutritional supplements. If unable to meet caloric
needs PO, consider feeding tube
-Discharged with flexiseal and foley catheter in place to
prevent contamination of decub ulcer on R buttock. Should remain
in place until wound improves.
-Contact: HCP: Daughter ___ ___ Alternate HCP:
Daughter ___. ___ work: ___
-Code: Full, confirmed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y.o. woman with HTN, HL, CAD, diabetes
mellitus complicated by neuropathy who presents with R flank
pain. The patient reports that for the past ___ months, the
patient has been experiencing intermittent episodes of sharp
pain on her lower back. She reports that the pain would
occasionally radiate to her R flank and inner R thigh. She
describes the pain as a sharp, shooting pain that is worsened by
sitting down or lying flat. She is unable to identify any
triggers for the pain. The patient denies any recent falls or
injuries. The patient endorses decreased urinary output in the
past two weeks that is associated with burning on urination. The
patient denies any dyspepsia, diarrhea, or constipation.
Yesterday, the patient reports that the pain increased in
severity and became an ___ sharp constant pain that did not
radiate. She reports that Tylenol does not provide any relief.
She reports that she was febrile to 102.9 and this was
associated with nausea and poor appetite. The patient
subsequently presented to the ED where her VS were 98 HR: 111
BP: 153/73 Resp: 18 O(2)Sat: 99 % RA. Initial labs were notable
for normal electrolytes, Lactate 3.4, Glucose 139, normal LFTs,
and lipase. UA was notable for trace blood, 100 protein, but
negative for bacteria, nitrites, or leukocyte esterase. An
Abd/Pelvic CT was notable for layering sludge or small stones in
the gall bladder, but unremarkable for cholecystitis, renal or
ureteral stones, hydronephrosis, or perinephric abnormalities.
The patient was given IV fluids, Morphine, and Toradol and
transferred to the floor for further diagnostic workup and
management.
Past Medical History:
1. Diabetus mellitus
2. Hypertension
3. Hypercholesterolemia
4. Coronary Artery Disease
5. Asthma
6. S/p two C-sections
7. Abdominal cellulitis (over ___ years ago) s/p pannilectomy
8. Pulmonary infection (?PCP) at ___ ___
year ago)
Social History:
___
Family History:
Breast and ovarian cancer, mother had diabetes
Physical Exam:
Vitals: 98 98 ___ (119/50-143/65) ___ 93-99% RA
General- Resting in bed in pain. Appears short of breath.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- Supple, no JVD, no LAD. Acanthosis nigricans on neck.
Lungs- CTAB
CV- RRR, normal S1 + S2, no murmurs, rubs, gallops
Back: No spinal tenderness. R>L CVA tenderness. No focal
tenderness on palpation of posterior hips bilaterally.
Abdomen- Obese, no umbilicus. Scars under folds of skin at
pubis. No rashes. Soft, non-distended. +Normactive BS. No focal
tenderness, rebound tenderness, or guarding. Unable to assess
hepatomegaly or splenomegaly. No masses. No suprapubic
tenderness. No tenderness over RUQ on palpation with deep
inspiration
GU- Exam deferred.
Ext- Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Negative Psoas Sign. Negative Straight Leg Test.
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission Labs:
---------------
___ 01:05PM BLOOD WBC-8.8 RBC-5.15 Hgb-14.6 Hct-43.8 MCV-85
MCH-28.4 MCHC-33.5 RDW-13.3 Plt ___
___ 01:05PM BLOOD Neuts-61.2 ___ Monos-4.9 Eos-6.2*
Baso-0.5
___ 01:05PM BLOOD Plt ___
___ 01:05PM BLOOD Glucose-139* UreaN-13 Creat-0.8 Na-142
K-4.4 Cl-105 HCO3-23 AnGap-18
___ 01:05PM BLOOD ALT-23 AST-23 LD(LDH)-224 AlkPhos-60
TotBili-0.3
___ 01:05PM BLOOD Lipase-34
___ 01:05PM BLOOD Albumin-4.1
___ 01:12PM BLOOD Lactate-3.4*
Discharge Labs:
---------------
___ 06:55AM BLOOD WBC-8.4 RBC-4.61 Hgb-12.9 Hct-39.6 MCV-86
MCH-28.0 MCHC-32.7 RDW-13.3 Plt ___
___ 06:55AM BLOOD Glucose-175* UreaN-13 Creat-0.7 Na-140
K-4.6 Cl-106 HCO3-26 AnGap-13
___ 01:05PM BLOOD ALT-23 AST-23 LD(LDH)-224 AlkPhos-60
TotBili-0.3
___ 06:55AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.9
___ 01:05PM BLOOD Albumin-4.1
___ 01:38PM BLOOD Lactate-1.4
Imaging:
---------------
CT Urogram (ABD/PEL) W/O CONTR ___
IMPRESSION:
1. No evidence of renal or ureteral stones, hydronephrosis or
perinephric
abnormalities.
2. Tiny layering stones within the gallbladder with no evidence
of
cholecystitis.
Microbiology:
---------------
___ URINE URINE CULTURE-FINAL NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Lisinopril 40 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Amlodipine 10 mg PO DAILY
6. Gabapentin 600 mg PO TID
7. Pravastatin 20 mg PO DAILY
8. Zolpidem Tartrate 10 mg PO HS
9. QUEtiapine Fumarate 25 mg PO QAM
10. Lantus *NF* (insulin glargine) 50 units Subcutaneous HS
11. Victoza 2-Pak *NF* (liraglutide) 18 units Subcutaneous QAM
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. Pravastatin 20 mg PO DAILY
7. QUEtiapine Fumarate 25 mg PO QAM
8. Zolpidem Tartrate 10 mg PO HS
9. Tizanidine 2 mg PO BID
RX *tizanidine 2 mg 1 tablet(s) by mouth twice daily as needed
for back pain Disp #*6 Tablet Refills:*0
10. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) apply to lower back
once daily for 12 hours and then remove Disp #*4 Transdermal
Patch Refills:*0
11. Lantus *NF* (insulin glargine) 50 units Subcutaneous HS
12. Victoza 2-Pak *NF* (liraglutide) 18 units Subcutaneous QAM
13. Walker
V724.2 Lumbago
Please obtain a walker.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Muscle strain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: 3 months of right flank pain and fever. Evaluation for renal
stones.
TECHNIQUE: MDCT images were obtained of the abdomen and pelvis without the
administration of oral or intravenous contrast. The patient refused
intravenous contrast. Reformatted coronal and sagittal images were also
reviewed.
COMPARISON: Renal ultrasound from ___.
FINDINGS:
CT ABDOMEN WITHOUT IV CONTRAST: The bases of the lungs are clear. The liver
demonstrates no focal lesions. There is no intrahepatic biliary ductal
dilatation. There is some dependent layering high density material in the
gallbladder (2:35), likely small stones. There are no secondary signs of
cholecystitis. The pancreas, spleen, bilateral adrenal glands have an
unremarkable noncontrast appearance. Minimal atherosclerotic calcifications
are present within the abdominal aorta and renal arteries. There is no
evidence of renal or ureteral stones. There is no hydronephrosis. No
perinephric abnormalities are identified.
The stomach and duodenum are unremarkable and the intra-abdominal loops of
large and small bowel are of normal caliber and contour with no evidence of
obstruction. There is no intraperitoneal free air or free fluid.
CT PELVIS: The bladder is unremarkable. There is no evidence of stones
within the bladder or at the ureterovesicular junction. The rectum and
sigmoid colon are normal in appearance. There is no pelvic free fluid. The
uterus is unremarkable. No adnexal masses are identified. The appendix is
well visualized in the right lower quadrant and is normal.
OSSEOUS STRUCTURES: No lytic or blastic lesion suspicious for malignancy is
identified.
IMPRESSION:
1. No evidence of renal or ureteral stones, hydronephrosis or perinephric
abnormalities.
2. Tiny layering stones within the gallbladder with no evidence of
cholecystitis.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: R Flank pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.0
heartrate: 111.0
resprate: 18.0
o2sat: 99.0
sbp: 153.0
dbp: 73.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ y.o. woman with HTN, HL, CAD, diabetes
mellitus complicated by neuropathy who presents with R flank
pain found to have elevated lactate concerning for renal colic
vs nephrolithiasis.
# R Flank Pain: Musculoskeletal given time course (months),
negative CT abd/pelvis, and improvement with tizanidine and
toradol. Discharged with home ___ and lidocaine patch, written
for ___.
#Diabetes Mellitus: Poorly controlled, complicated by
neuropathy. On home Metformin, Victoza (Liraglutide), and Lantus
50 units ___. Metformin was stopped in house due to lactic
acidosis 3.1. ___ consulted, patient discharged off metformin
with ___ followup in 3 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___.
Chief Complaint:
unwitnessed fall
Major Surgical or Invasive Procedure:
orthopedic surgery: R patellar open reduction and internal
fixation
History of Present Illness:
The patient is a ___ w/ PMH HTN, HLD, DM, CAD s/p multiple MIs
on medical management, CHF with EF 30%, s/p CAV ___ w/
resultant aphasia and R sided weakness, PAD s/p toe amputation,
presenting after an unwitnessed fall. The paitient has
difficulty expressing himself, but says he was on his way to use
the bathroom (for both urination and bowels) when he fell down.
He denies tripping or mechanical fall, he denies any
pre-syncopal feelings such as CP, SOB, lightheadedness, or
palpitations. He is not sure whether or not he lost
conciousness, but he says he does not remember falling, and does
not remember why he fell. He patient injured his R knee during
the fall.
Per the patient's daughter, the patient's aide heard him fall
and came to find him on the bathroom floor, it seemed like he
had fallen when he was turning around to sit down on the toilet.
He was awake at that time.
In the ED, the patient's VS were T 99.6 HR 84 BP 143/74 RR 14
O2sat 97% ra. He got ondansetron and morphine 5 mg. R knee X-ray
showed patellar fracture, and orthopedics saw that patient in
the ED and placed an immobilizer. CT head and C spine were wnl.
CXR showed no acute process. R arm X-ray showed no fracture. He
had elevated troponins 0.73 and then 0.71 with negative MB. He
was admitted to cardiology for further workup of this syncopal
episode.
ROS: patient denies fever, chills, diarrhea, constipation,
dysuria, and blood in the stool. Denies CP or SOB. He says he
had some vomiting a week ago but feels better now. The patient's
daughter says he has been in his usual state of health recently.
Past Medical History:
-- CVA w/ expressive aphasia ___: Residual expressive aphasia
and right sided weakness, mostly wheelchair bound but gets up
for transfers, adamantly refused ___ in past.
-- CAD: S/p multiple MIs, including NSTEMI in ___ (attributed
to acute OM2 occlusion, medically managed for 3VD on cardiac
cath as not CABG candidate; followed by Dr. ___
-- Chronic systolic and diastolic CHF: EF 20% on ___ TTE
post-MI -> ___ on ___ echo.
-- CRF, likely ___ diabetes
-- Depression
-- Diabetes
-- Hypertension
-- HLD
-- PVD s/p toe amputation ___
-- retinopathy
-- glaucoma
___ doctor, had been unwilling to work with any mental health
professionals; not currently followed by psychiatrist
- H/o violence: Fired from ___ practice due to violence toward
staff
Social History:
___
Family History:
mother with diabetes and heart disease.
Physical Exam:
ADMISSION EXAM:
VS- T 98.2 BP 133/70 HR 81 RR 20 O2sat 100% ra
GENERAL- NAD, frustrated with inability to tell his story,
crying at one point, otherwise appropriate affect
HEENT- EOMI, PERRL
NECK- Supple with JVP of 10 cm.
CARDIAC- RRR S1S2 no murmurs
LUNGS- difficult to assess lung exam per patient cooperation and
pain with moving from knee fracture. No crackles aneriorly, good
air movement.
ABDOMEN- soft NTND, + BS
EXTREMITIES- no edema, vascular changes ___ arterial
insufficiency, with an ulcer on R great toe, R little toe
amputation. unable to feel pulses but extremeties warm b/l. R
leg is in a brace per ortho recs.
Neuro: alert and oriented, aphasic able to answer with few word
answers. can move all extremeties. can feel all extremeties.
EOMI.
DISCHARGE EXAM: unchanged, R knee s/p ortho repair in a new
mobile brace
Pertinent Results:
___ 09:45AM CK(CPK)-245
___ 09:45AM CK-MB-3 cTropnT-0.71*
___ 04:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 03:43AM GLUCOSE-179* UREA N-15 CREAT-1.3* SODIUM-134
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-13
___ 03:43AM estGFR-Using this
___ 03:43AM CK(CPK)-226
___ 03:43AM CK-MB-3 cTropnT-0.73*
___ 03:43AM WBC-9.8 RBC-4.39* HGB-13.5* HCT-38.8* MCV-88
MCH-30.8 MCHC-34.8 RDW-13.8
___ 03:43AM NEUTS-81.3* LYMPHS-13.0* MONOS-3.9 EOS-1.5
BASOS-0.3
___ 03:43AM PLT COUNT-331
IMAGING- ___
CT Head w and w/o contrast:
No acute intracranial process.
CT C-spine:
No acute fracture or malalignment.
R knee X-ray:
Transverse fracture of the patella.
CXR:
No acute cardiothoracic process.
R arm, forearm, wrist Xray:
No acute fracture or dislocation.
EKG: no significant change from prior. NSR. Left bundle branch
block with repolarization abnormalities.
ECHO ___:
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate to severe regional left
ventricular systolic dysfunction with inferior and apical
akinesis with a dyskinetic apical aneurysm.. There is an apical
left ventricular aneurysm. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Moderately dilated left ventricle with inferior and
apical akinesis. There is an apical aneurysm that is dyskinetic
- no evidence of thrombus seen with myocardial contrast. Mild
aortic regurgitation.
X ray Knee ___ (after surgery)
1. Status post open reduction internal fixation of previously
noted displaced, mildly comminuted transverse mid pole right
patellar fracture.
2. Surgical hardware intact.
3. Fragments of the patella are in near anatomical alignment.
Labs ___
Na 134-->130 (about at baseline, likely partially dilutional
after surgery)
Hb 13.5 --> 11.9 after surgery (likely ___ hemodilution and
blood loss)
patient refused all lab draws in between admission and
discharge.
Radiology Report
INDICATION: ___ with fall.
TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal
reformats were acquired.
COMPARISON: Head CT from ___.
FINDINGS:
CT OF THE HEAD:
Again seen is extensive multifocal cystic encephalomalacia related to chronic
infarcts in the left more than right frontal, parietal, and occipital lobes
and right cerebrallar hemisphere with associated ex vacuo dilatation of the
left lateral and fourth ventricles, respectively. Chronic microvascular
changes are again seen involving the centrum semiovale and periventricular
white matter and no change from ___. There is a small frontal
lipoma, unchanged. The paranasal sinuses and mastoid air cells are clear.
IMPRESSION: No evidence of hemorrhage or fracture. Extensive chronic
infarctions, unchanged since ___.
Radiology Report
INDICATION: ___ with fall.
TECHNIQUE: Contiguous MDCT images through the C-spine were obtained. Axial,
coronal, and sagittal reformats were acquired.
COMPARISON: CT of the C-spine from ___.
FINDINGS:
CT OF THE C-SPINE:
There is no evidence of fracture, malalignment or prevertebral soft tissue
swelling. Posterior osteophytes at C3-C4 and C6-C7 cause mild spinal canal
narrowing and left greater than right facet hypertrophy, unchanged from ___.
Emphysematous changes are seen at the lung apices.
IMPRESSION: No acute fracture or acute malalignment.
NOTE ADDED AT ATTENDING REVIEW: The large posterior osteophytes at C3-4 cause
severe narrowing of the right side of the spinal canal. Although poorly
characterized on non contrast CT, this appears to compress or displace the
spinal cord on the right.
There is a small midline protrustion at C4-5, and osteophytes significantly
narrowing the spinal canal at C6-7.
Radiology Report
INDICATION: ___ after fall.
TECHNIQUE: Four views of the right elbow were obtained.
COMPARISON: None.
FINDINGS: Extremely limited study due to difficult positioning. Enthesophyte
is seen at the olecranon process of the ulna. There is no elbow joint
effusion, dislocation or acute fracture.
IMPRESSION: No acute fracture or dislocation.
Radiology Report
INDICATION: ___ after fall.
TECHNIQUE: Frontal and lateral radiographs of the chest were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Low lung volumes. The cardiomediastinal silhouette and hila are normal.
There is no pleural effusion and no pneumothorax. No evidence of pneumonia.
IMPRESSION: No acute cardiothoracic process.
Radiology Report
INDICATION: ___ after fall.
TECHNIQUE: Three views of the right knee were obtained.
COMPARISON: None.
FINDINGS:
There is a displaced transverse fracture through the patella with prepatellar
soft tissue swelling and only a small knee joint effusion. No other fractures
are seen.
IMPRESSION: Transverse fracture of the patella.
Radiology Report
STUDY: Right wrist, ___.
CLINICAL HISTORY: ___ man status post fall.
FINDINGS:
THREE VIEWS OF THE RIGHT WRIST: There are degenerative changes of the first
CMC and triscaphe joints. There are no signs for acute fractures or
dislocation. Mineralization is normal.
RIGHT FOREARM: No acute fractures or dislocations are seen. There is normal
osseous mineralization. There is a prominent spur at the distal attachment of
triceps to the olecranon.
Radiology Report
HISTORY: ___ man who is status post right patellar fracture. Status
post open reduction and internal fixation.
TECHNIQUE: Four intraoperative fluoroscopic images of the right knee.
COMPARISON: Radiographs of the right knee performed on ___ at
0612 hours.
FINDINGS:
Two K-wires extend in vertical axis through the patella. Surgical cerclage
wire courses in a figure-of-eight pattern along the anterior aspect of the
patella.
Markedly improved alignment of the patient's previously noted mildly
comminuted transverse, displaced fracture of the patella. Fragments of the
patella are in near anatomical alignment at this time.
Distal right femur as well as the proximal right tibia and fibula are intact
and normal in appearance.
Please refer to the operative not for further description.
IMPRESSION:
1. Status post open reduction internal fixation of previously noted
displaced, mildly comminuted transverse mid pole right patellar fracture.
2. Surgical hardware intact.
3. Fragments of the patella are in near anatomical alignment.
Please refer to the operative not for further description.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: S/P SLIP AND FALL
Diagnosed with ABN SERUM ENZY LEVEL NEC, FRACTURE PATELLA-CLOSED, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 99.6
heartrate: 84.0
resprate: 14.0
o2sat: 97.0
sbp: 143.0
dbp: 74.0
level of pain: 9
level of acuity: 3.0 | ___ w/ PMH HTN, HLD, DM, CAD s/p multiple MIs on medical
management, CHF with EF 30%, s/p CAV ___ w/ resultant aphasia
and R sided weakness, PAD s/p toe amputation, presenting after
an episode of unwitnessed fall, on admission syncope was
suspected due to low EF.
# Unwitnessed fall: Syncope from ventricular arrythmia was
suspected on admission because of h/o CHF with low EF 30%.
However, tele showed no events during admission. Troponin-T was
trending down, and CK-MB was negative, he was not thought to
have experienced a cardiac event. The fall was thought likely to
be mechanical, occuring when the patient was trying to sit down
on the toilet. The idea of ICD placement was discussed with the
patient and family, but they did not feel it was something they
wanted to consider at this time, especially because there was no
objective evidence of arrythmia, the patient's EF was not low
enough to make a strong indication for ICD, and his quality of
life was not great after the stroke it was unclear that he would
derive benefit from ICD at this time. The patients home cardiac
meds were continued: amlodipine, atorvastatin, carvedilol,
plavix, lasix, imdur, lisinopril, ASA 81.
# R patellar fracture, displaced: Ortho recommended open
reduction and internal fixation to improve outcome. The
procedure was preformed without complications, with fixation of
the patella. The patient had a mobile brace at discharge, as
well as Abx for 10 days and Lovenox DVT prophylaxis for 2 weeks.
The family recieved teaching per lovenox. Pain was controlled
with dilaudid IV and oxycodone in house, and oxycodone at
discharge. F/U appts were made with PCP and orthopedics. He was
discharged with home ___.
# Behavioral issues: The patient was refusing meds, labs,
physical exam, even pain medication in house, and got somewhat
agitated with staff. He calmed down greatly with family members
around. It is important to keep the patient oriented, and very
helpful to have family around for important discussions or
treatment (decision to go to surgery, physical therapy). It was
thought the patient would do poorly in rehab and become
disoriented, likely refuse physical therapy, so the decision was
made to send him home with home ___ and services, ___ found this
plan to be good.
# Social issues: The patient's girlfriend lives with him, and is
a drug user. According to the brother, she does very little to
help in the care of the patient, leaving most of the burden to
the brother. However, the patient and brother said that she was
never physically abusive, and the he felt physically safe at
home.
# HTN: continued atenolol, carvedilol, lasix, imdur, lisinopril
# HLD: continued atorvastatin for CAD
# DM: on insulin at home, continued home regimin
# CRF: Cr 1.3, at baseline
# FEN- diebetic cardiac healthy diet/ replete lytes prn
# PROPHYLAXIS-
-DVT ppx with lovenox
-Pain management with tylenol, oxycodone
-Bowel regimen with senna, colace
# CODE- Full, confirmed with daughter (health care proxy)
# EMERGENCY CONTACT- ___ (daughter)- ___, ___
(brother) ___, ___ (girlfriend) ___
TRANSITIONAL ISSUES
--the patient's sodium was low during admission, has been low
chronically, we recommend re-check from PCP after discharge at
next appointment.
--further social work around girlfriend/IVDU |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
tremor; AMS.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ PMH ESRD on HD ___, ___, Type 2 DM,
seizure disorder after intracranial right hemispheric bleed
___, CVA in ___, ICH in ___ and recurrent UTIs who presents
to the ED with tremor.
The patient went to dialysis today. Daughter called to check up
on how dialysis went (received whole session). Dialysis center
said his hand shook on the left per daughter--just his hand, for
seconds-to-minutes. Looked a little tired per daughter. Reported
dry cough for months, but otherwise daughter noted no other
complaints.
Patient confirmed story in the ED, saying he remembers the whole
incident, had a few minutes of tremors, no post-ictal state.
The patient was taken to ___ where he was given
amp/gent/cefepime at 3pm for uti (UA showed 1 epi, 29 rbc, 23
wbc, large leuk, neg nitrite, few bact). The pto come to ___,
was told no beds for transfer, left AMA and came to ___.
Notably from ___ to ___ patient was admitted for complicated
urinary tract infection. The patient was admitted due to a
floridly positive UA concerning for a complicated UTI. The
patient was treated empirically treated with IV zosyn and
vancomycin. He was transitioned to Bactrim for total 14 day
course to end on ___. The patient's urine culture showed
10,000 CFU of GNR's thought to most likely be klebsiellae. Given
his past pan-sensitive klebsiellae infection he was discharged
on PO Bactrim to take 3 DS tabs post-hemodialysis on ___,
___.
No f/c/s. Noted mild diarrhea past few days.
In the ED, initial vital signs were: 98.0 64 156/72 18 98% .
- Exam notable for:
- Fistula good thrill
- LLL crackles
- Neuro NF except unable to assess OS due to blind and
irregular pupil, LUE weakness (recent neuro note documents LUE
weakness)
- Labs were notable for:
- Creatinine 4.3 (on HD)
- Lactate 1.0
- Studies performed include:
___ CXR- Predominantly linear opacities in the left lower
lobe may represent atelectasis. However, superimposed pneumonia
is difficult to exclude in the appropriate clinical setting.
- Patient was given:
___ 05:10 IV CeftriaXONE ___ Started
___ 06:17 IV CeftriaXONE 1 g ___ Stopped (1h
___
___ 09:26 SC Insulin 0 Units ___
___ 11:20 PO LevETIRAcetam 500 mg ___
___ 11:20 PO/NG Lisinopril 2.5 mg ___
___ 11:20 PO Metoprolol Succinate XL 50 mg
___
___ 11:26 PO/NG LACOSamide 150 mg ___
- Vitals on transfer: 98.3PO 179/68 83 18 97RA
Upon arrival to the floor, the patient states story as above.
Shaking in left hand during HD, otherwise felt fine, did not
feel like prior seizures. Falsely states he's anuric. Pan-denies
any symptoms such as chest pain, dyspnea, cough, abdominal pain,
fever, chills.
Review of Systems: A full 10-point ROS was performed and was
negative except as stated in HPI.
Past Medical History:
-- Chronic kidney disease, now on HD
- Recurrent UTIs, usually treated with nitrofurantoin. Has
previously had VRE UTI, but most recently has had enterococcus
and klebsiella sensitive to nitrofurantoin
- Diabetes mellitus, type 2: Complicated by nephropathy,
retinopathy, andneuropathy. He has left eye blindness as a
result of hisretinopathy. He is currently insulin-dependent
- Dyslipidemia
- Hypertension
- Possible coronary artery disease: ECG findings of anterior,
septal, and inferior distribution
- Peripheral vascular disease: S/p R tibialis stent ___ and
transmetatarsal amputation.
- Persistent opacification of left lung base, uncertain
etiology.
- Incidental right upper lobe 4mm nodule ___
- Seizure disorder: Followed by neurology. History of
parietotemporal intracranial hemorrhage in ___ status post
craniectomy secondary to alcohol and head trauma. Last seizure
___ in status epilepticus after levitiracetam was
underdosed.
- Cerebrovascular accident (___) with left sided paralysis
- Spindle cell carcinoma in his inguinal region, biopsy ___
- Asthma
- History of alcoholism, last drink ___
- Gangrenous cholecystitis, s/p cholecystectomy
- Malnutrition
Social History:
___
Family History:
Mom - no reported history
Dad - died from liver cirrhosis due to alcohol use
___ - died in a fire
Sister died of "heart trouble."
Physical Exam:
ADMISSION:
=========
Vitals- 98.3PO 179/68 83 18 97 RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Left eye blind, non-reactive.
CARDIAC: RRR, no m/r/g
LUNGS: CTAB
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation, no supra-pubic tenderness
EXTREMITIES: No clubbing, cyanosis, or edema; these is some
brusing on shins
NEUROLOGIC: CN2-12 grossly intact. 4+/5 strength througout. No
tremor.
DISCHARGE:
==========
Vitals: Tmax 99 BP 150/50-70s HR ___ RR 18 ___ on RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Left eye blind, non-reactive.
CARDIAC: RRR, no m/r/g
LUNGS: CTAB
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation, no supra-pubic tenderness
EXTREMITIES: No clubbing, cyanosis, or edema; these is some
bruising on shins
NEUROLOGIC: CN2-12 grossly intact. 4+/5 strength throughout. No
tremor.
LUE fistula: bruit and thrill +
Pertinent Results:
ADMISSION:
==========
___ 12:40AM BLOOD WBC-6.3 RBC-3.76* Hgb-10.4* Hct-34.0*
MCV-90 MCH-27.7 MCHC-30.6* RDW-14.0 RDWSD-46.4* Plt ___
___ 12:40AM BLOOD Neuts-72.6* Lymphs-12.7* Monos-11.3
Eos-2.9 Baso-0.3 Im ___ AbsNeut-4.57 AbsLymp-0.80*
AbsMono-0.71 AbsEos-0.18 AbsBaso-0.02
DISCHARGE:
==========
___ 08:15AM BLOOD Glucose-95 UreaN-26* Creat-5.6*# Na-142
K-4.4 Cl-100 HCO3-28 AnGap-18
___ 08:15AM BLOOD WBC-7.1 RBC-3.59* Hgb-10.2* Hct-33.0*
MCV-92 MCH-28.4 MCHC-30.9* RDW-14.6 RDWSD-48.5* Plt ___
MICRO:
=====
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
=======
CXR ___
Heart size is more prominent since prior. Normal pulmonary
vascularity. No edema. Left basilar consolidation is more
prominent, may represent
atelectasis or pneumonia. More prominent partially loculated
small left
pleural effusion. Right infrahilar opacity is more prominent,
may represent developing pneumonia. No right pleural effusion.
No pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ammonium lactate 12 % topical BID
2. Clopidogrel 75 mg PO DAILY
3. LACOSamide 150 mg PO BID
4. LACOSamide 75 mg PO 3X/WEEK (___) After HD, in addition
to standing dose
5. LevETIRAcetam 500 mg PO BID
6. LevETIRAcetam 250 mg PO 3X/WEEK (___) After HD, in
addition to standing dose
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Simvastatin 40 mg PO QPM
9. Lisinopril 2.5 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Doses
2. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
3. ammonium lactate 12 % topical BID
4. Clopidogrel 75 mg PO DAILY
5. LACOSamide 75 mg PO 3X/WEEK (___) After HD, in addition
to standing dose
6. LACOSamide 150 mg PO BID
7. LevETIRAcetam 500 mg PO BID
8. LevETIRAcetam 250 mg PO 3X/WEEK (___) After HD, in
addition to standing dose
9. Lisinopril 2.5 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- Community acquired pneumonia
Secondary diagnoses
- Seizure disorder
- End stage renal disease on HD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with llll crackles, dialysis// pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___, ___, ___
FINDINGS:
Predominantly linear opacities are seen in the retrocardiac region, which may
represent atelectasis. However, superimposed pneumonia cannot be excluded in
the appropriate clinical setting. Blunting of the left costophrenic angle may
be due to a small pleural effusion. There is no pulmonary edema or
pneumothorax. The cardiomediastinal silhouette and hilar contours are
unchanged.
Calcification seen projecting over the left lower lung may be due to pleural
calcifications. Vascular stent projects over the expected region of the left
axillary vein or artery.
IMPRESSION:
Predominantly linear opacities in the retrocardiac region may represent
atelectasis. However, superimposed pneumonia is difficult to exclude in the
appropriate clinical setting.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with ESRD on HD with recurrent fever and recent
CXR with ?basal consolidations.// please evaluate for interval change ie
progression of PNA?
TECHNIQUE: Chest two views
COMPARISON: ___
FINDINGS:
Heart size is more prominent since prior. Normal pulmonary vascularity. No
edema. Left basilar consolidation is more prominent, may represent
atelectasis or pneumonia. More prominent partially loculated small left
pleural effusion. Right infrahilar opacity is more prominent, may represent
developing pneumonia. No right pleural effusion. No pneumothorax.
IMPRESSION:
Interval mild worsening.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Tremor
Diagnosed with Urinary tract infection, site not specified, Pneumonia, unspecified organism
temperature: 98.2
heartrate: 93.0
resprate: 18.0
o2sat: 100.0
sbp: 169.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ ___ ESRD on HD TTS, type 2 DM, seizure
disorder after intracranial right hemispheric bleed ___, CVA in
___, ICH in ___ and recurrent UTIs who presented to OSH ED
after an episode of left hand shaking at hemodialysis. In the
setting of fever, found to have pneumonia on CXR.
# Community Acquired Pneumonia: Lungs exam with crackles,
febrile on ___, interval chest films suggestive of
possible evolving infiltrate and patient with chronic cough. Flu
swab negative. Started on azithromycin on ___ to be
completed ___. Also received ceftriaxone (D1 ___ for 6
days course (last day ___. Breathing well on room air with
afebrile > 24 hours at time of discharge.
# Left hand shaking
# Seizure disorder: Patient with left hand shaking at HD on
___. This episode was NOT consistent with his prior seizures.
Patient without recurrent tremor throughout stay and otherwise
no new neurological symptoms. Continued on home AEDs without
adjustment.
# Complicated urinary tract infection: PMH of multiple UTIs.
Most recently, in ___ the patient was treated for
10,000 CFU of GNR's thought to most likely be klebsiellae, and
was discharged on Bactrim. Found to have positive UA at OSH but
culture there negative, repeat UCx at ___ negative as well.
Asymptomatic, started on ceftriaxone initially which then
continued for treatment of CAP as above.
CHRONIC STABLE PROBLEMS
=======================
# End Stage Renal Disease on Dialysis (___):
- Continued HD (renal is following)
- Nephrocaps 1 CAP PO DAILY
# Chronic Anemia: Likely secondary to end stage renal disease.
10.4 on admission. Stable.
# Hypertension:
- Continued Lisinopril 2.5 mg PO/NG DAILY
- Continued Metoprolol Succinate XL 50 mg PO DAILY
# Type II Diabetes:
- continued SSI; FSBG well controlled throughout stay.
# CVD:
- Continued Clopidogrel 75 mg.
- Continued Simvastatin 40 mg.
TRANSITIONAL ISSUES
===================
[] Continue Azithromycin 250 mg PO DAILY (5 day course, last day
___
[] PCP appointment on ___ at 9:00 AM
# Code status: Full (confirmed with proxy)
# ADVANCE CARE PLANNING
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Tetracyclines
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Right femur retrograde nail.
History of Present Illness:
The patient is an ___ yo female with history of osteoporosis,
transfer from OSH with right midshaft femur fracture after fall
from standing into picnic table with direct strike on right
thigh. Over past two months patient had developed right hip and
upper thigh pain, xrays x 2 were negative. Unclear during this
episode whether trauma occurred as a result of hitting the bench
or as stress/insufficiency fracture causing her to fall into the
bench. She has history of Fosamax use but discontinued several
months ago because she no longer needed it. No head strike, LOC.
No pain elsewhere. Denies numbness/tingling distally.
Past Medical History:
HTN
Macular Degeneration (legally blind)
Osteoporosis
PSH:
Bilateral TKR in ___ by Dr. ___ at ___
___ in ___
Social History:
___
Family History:
NC
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Gen: alert and oriented, no acute distress
Cardio: RRR
Resp: breathing unlabored
RLE: Incisions clean/dry/intact, no excessive erythema,
swelling, or drainage, foot and toes WWP with good cap refill,
SILT saph/sural/tibial/sp/dp, fires ___
Radiology Report
INDICATION: Known right femur fracture. Evaluation of orthopedic hardware as
well as joints above and below the fracture.
TECHNIQUE: Right femur, two views.
FINDINGS: There is an oblique fracture of the femoral distal shaft, with 6cm
of fragment overrifing, and one shaft width medial displacement. The distal
fragment is angulated varus and anteriorly. The patient has a total right
knee arthroplasty. There is no evidence of hardware loosening. Prominent
vascular calcifications are noted.
IMPRESSION: Displaced angulated fracture of the distal femoral shaft.
Radiology Report
INDICATION: Femur fracture. ORIF.
COMPARISON: Radiographs from ___.
IMPRESSION:
Several fluoroscopic images of the right femur from the operating room
demonstrates placement of an intramedullary rod with proximal and distal
interlocking screws fixating a fracture involving the midshaft of the right
femur. There is improved anatomic alignment. There is also a right total knee
arthroplasty which appears grossly intact. The total intra service
fluoroscopic time was 105 seconds. Please refer the operative note for
additional details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FX FEMUR, Transfer
Diagnosed with FX FEMUR SHAFT-CLOSED, UNSPECIFIED FALL, HYPERTENSION NOS
temperature: 98.6
heartrate: 84.0
resprate: 18.0
o2sat: 97.0
sbp: 101.0
dbp: 66.0
level of pain: 4
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 right femoral shaft fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right femur retrograde nail, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#2. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated with
no range of motion restrictions in the right lower extremity,
and will be discharged on lovenox for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right hemiparesis, aphasia
Major Surgical or Invasive Procedure:
-Mechanical thrombectomy ___
-Percutaneous endoscopic gastrostomy (PEG) ___
History of Present Illness:
___ with PMH of AFIB on Eliquis (but non-adherent) s/p
cardioversion for AFIB with RVR on ___ presented with global
aphasia and right hemiparesis. She was last seen well on ___
at 2030 when she and her husband went to bed. He awoke at 1245
am
when he heard a "bang" and he found his wife on the floor. She
was immediately brought to ___ where she was found to
have a left MCA hyperdensity on CT and a left M1 cutoff on CTA.
She was not a ___ candidate do to being on Eliquis and arriving
outside of the window of tPA therapy. She was transferred to
___ for mechanical thrombectomy.
ROS:
Unable to obtain
Past Medical History:
AFIB
Depression
Social History:
former smoker (quit ___ years ago)
EtOH ___ glasses of wine per day 4 times a week
No illicit drug use
- Modified Rankin Scale:
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: T: 97.1 BP: 109/71 HR: 62 RR: 16 SaO2: 99% RA
General: Awake, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: in a hard collar
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, globally aphasic. Unable to say any
words.
Regards examiner.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. Eyes cross midline. No blink to
threat
on right. No facial droop, facial musculature symmetric.
-Motor/sensory: Normal bulk and tone throughout. Left hemibody
full strength. Left leg triple flex to noxious. Left arm does
not
move to noxious stimuli.
-Reflexes: deferred
-Coordination: unable to test due to aphasia
-Gait: deferred
DISCHARGE PHSYICAL EXAM:
=======================
General: awake, no distress
HEENT: Atraumatic
CV: well perfused
Lungs: no increased wob
Abdomen: non-distended.
Ext: no rash, no edema
Skin: no rash
Neuro:
MS- alerts to voice. awake. followed command to show teeth but
not others. Has
minimal speech output, then closed eyes and did not participate
CN- spontaneously looks left and right, but doesn't fully ___
sclera on right gaze, right facial droop minimal activation
Sensory/Motor- LUE and LLE spontaneously antigravity, RUE brief
flexion to noxious stimuli, RLE -no significant movement to
noxious appreciated. Grimaced to noxious stim in all 4
extremities but R significantly less than L
Reflexes-deferred
Coordination/Gait- could not assess
Pertinent Results:
ADMISSION LABS:
===============
___ 04:00PM URINE HOURS-RANDOM
___ 04:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:00PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 04:00PM URINE MUCOUS-RARE*
___ 06:08AM GLUCOSE-131* UREA N-17 CREAT-0.7 SODIUM-140
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-11
___ 06:08AM ALT(SGPT)-84* AST(SGOT)-43* LD(LDH)-185
CK(CPK)-81 ALK PHOS-65 TOT BILI-0.5
___ 06:08AM GGT-52*
___ 06:08AM CK-MB-2 cTropnT-<0.01
___ 06:08AM TOT PROT-6.1* ALBUMIN-3.6 GLOBULIN-2.5
CHOLEST-185
___ 06:08AM %HbA1c-5.2 eAG-103
___ 06:08AM TRIGLYCER-63 HDL CHOL-66 CHOL/HDL-2.8
LDL(CALC)-106
___ 06:08AM TSH-2.0
___ 06:08AM CRP-0.9
___ 06:08AM WBC-7.4 RBC-3.79* HGB-12.4 HCT-37.1 MCV-98
MCH-32.7* MCHC-33.4 RDW-12.5 RDWSD-44.8
___ 06:08AM NEUTS-82.8* LYMPHS-7.9* MONOS-8.1 EOS-0.4*
BASOS-0.4 IM ___ AbsNeut-6.10 AbsLymp-0.58* AbsMono-0.60
AbsEos-0.03* AbsBaso-0.03
___ 06:08AM PLT COUNT-219
___ 06:08AM ___ PTT-27.4 ___
___ 04:07AM COMMENTS-GREEN TOP
___ 04:07AM GLUCOSE-103 NA+-138 K+-4.2 CL--105 TCO2-23
___ 03:57AM CREAT-0.6
___ 03:57AM UREA N-18 CREAT-0.6
___ 03:57AM estGFR-Using this
___ 03:57AM estGFR-Using this
___ 03:57AM ALT(SGPT)-81* AST(SGOT)-45* ALK PHOS-62 TOT
BILI-0.3
___ 03:57AM cTropnT-<0.01
___ 03:57AM ALBUMIN-3.3*
___ 03:57AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 03:57AM WBC-8.4 RBC-3.58* HGB-11.4 HCT-35.5 MCV-99*
MCH-31.8 MCHC-32.1 RDW-12.4 RDWSD-45.1
___ 03:57AM NEUTS-82.8* LYMPHS-8.5* MONOS-7.3 EOS-0.5*
BASOS-0.4 IM ___ AbsNeut-6.92* AbsLymp-0.71* AbsMono-0.61
AbsEos-0.04 AbsBaso-0.03
___ 03:57AM PLT COUNT-169
___ 03:57AM ___ PTT-27.1 ___
DISCHARGE LABS:
==========
___ 06:10AM BLOOD WBC-8.9 RBC-3.73* Hgb-12.0 Hct-38.2
MCV-102* MCH-32.2* MCHC-31.4* RDW-12.6 RDWSD-47.2* Plt ___
___ 06:10AM BLOOD ___ PTT-28.3 ___
___ 06:10AM BLOOD Glucose-136* UreaN-25* Creat-0.5 Na-151*
K-4.2 Cl-109* HCO3-28 AnGap-14
___ 06:10AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.3
IMAGING:
=========
+ CTA head and neck pre-Thrombectomy
Noncontrast CT head:
Hyperdense appearance of the left proximal MCA is concerning for
thrombus. Irregular focal hypodensity involving the inferior
aspect of the left frontal lobe probably extending to the
subcortical region of the left insula may be concerning for
subacute area of infarction.
CTA head:
Partial filling defect involving the left clinoid ICA and
proximal left MCA are consistent with thrombus.
+___ ___ post thromebectomy
1. New large left intraparenchymal basal ganglia, temporal
hematoma.
2. 4 mm midline shift.
3. Left uncal herniation.
4. Subarachnoid hemorrhage extension.
+NCHCT ___ interval scan
1. Unchanged large left intraparenchymal basal ganglia and
temporal lobe hemorrhage resulting in unchanged 4 mm of
rightward midline shift and left uncal herniation.
2. Re-demonstrated left frontal, temporal, and parietal lobe
subarachnoid hemorrhage unchanged in extent from prior. No new
intracranial hemorrhage identified.
+NCHCT ___
IMPRESSION:
1. Similar appearance of intraparenchymal hemorrhage in left
frontal lobe with associated uncal herniation compared to ___. Some of the blood products are still quite dense
but some there does not seem to be an increase in the total
amount of hemorrhage, any new interval hemorrhage seems
doubtful.
2. No new hemorrhage or acute large territory infarct.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 20 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Sotalol 40 mg PO BID
5. Atorvastatin 40 mg PO QPM
6. Pantoprazole 20 mg PO DAILY
Discharge Medications:
1. Labetalol 200 mg PO Q8H
2. Lisinopril 20 mg PO DAILY
3. Rivaroxaban 20 mg PO DINNER
4. FLUoxetine 20 mg PO DAILY
5. HELD- Atorvastatin 40 mg PO QPM This medication was held. Do
not restart Atorvastatin until you follow up with neurology
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke with hemorrhagic conversion.
Discharge Condition:
Mental Status: Aphasic
Level of Consciousness: Alert
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111
INDICATION: ___ year old woman with left mca syndrome s/p thrombectomy. new
post op exam change with worsening right hemiparesis and aphasia// interval
change, assess for hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 748 mGy-cm.
COMPARISON: CT head from ___
FINDINGS:
A large intraparenchymal hemorrhage in the left MCA distribution, involving
left putamen, superior left temporal lobe. Basal ganglia component of
hemorrhage measures 4.2 cm. Temporal lobe component of hemorrhage measures
4.3 cm. There is hemorrhage extension to the sylvian fissure and subarachnoid
hemorrhage overlying left frontal, temporal, parietal lobes. Mild local mass
effect, 4 mm midline shift to the right, partial effacement left lateral
ventricle. Left uncal herniation, with obliteration of bilateral
perimesencephalic cisterns, superior cerebellar cistern, new since prior.
No evidence of left PCA distribution infarct. Patent prepontine cistern, no
tonsillar herniation.
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. New large left intraparenchymal basal ganglia, temporal hematoma.
2. 4 mm midline shift.
3. Left uncal herniation.
4. Subarachnoid hemorrhage extension.
NOTIFICATION: Updated findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 12:16 p.m.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with L MCA with hemorrhagic conversion//
interval change**1700 NCHCT**
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 748 mGy-cm.
COMPARISON: CT head from ___ at 10:30
FINDINGS:
There is re-demonstration of large intraparenchymal hemorrhage in the left MCA
distribution involving the left putamen, and superior left temporal lobe,
grossly unchanged in size or extent compared to prior study. Subarachnoid
hemorrhage along the left frontal, temporal, and parietal lobes and sylvian
fissure is unchanged. Resultant rightward midline shift of 4 mm is unchanged.
Left uncal herniation with effacement of the bilateral perimesencephalic
cisterns and superior cerebellar cistern is unchanged. No new intracranial
hemorrhage is identified.. There is unchanged effacement of the left lateral
ventricle
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. Unchanged large left intraparenchymal basal ganglia and temporal lobe
hemorrhage resulting in unchanged 4 mm of rightward midline shift and left
uncal herniation.
2. Re-demonstrated left frontal, temporal, and parietal lobe subarachnoid
hemorrhage unchanged in extent from prior. No new intracranial hemorrhage
identified.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with left mca syndrome// eval for degree of
infarct, interval change in hemorrhagic conversion.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT of the head dated ___.
FINDINGS:
A large 7.2 x 5.7 cm left basal ganglia and temporal lobe hematoma is seen,
effacing the body of the left lateral ventricle and causing a slightly worse
rightward midline shift now measuring 7 mm. No hydrocephalus. Mild edema
surrounding hematoma, extending into the internal capsule, left cerebral
peduncle., Cortical spinal tract.
Subarachnoid hemorrhage is again seen in the left frontal, parietal and
temporal lobes.
Additionally, a punctate focus of diffusion restriction is seen in the high
right parietal lobe. Small punctate foci of acute infarcts surrounding
hematoma. Preserved suprasellar cistern. Mass effect on the left cerebral
peduncle, upper midbrain. Partial effacement of the perimesencephalic
cisterns. Mild left uncal herniation, stable.
The paranasal sinuses, mastoid air cells and middle ear cavities are clear.
The intraorbital contents are normal.
IMPRESSION:
1. Large similar left basal ganglia, temporal lobe acute parenchymal
hematoma,.
2. Stable left uncal herniation. Minimally worsened midline shift, 7 mm.
3. Stable subarachnoid hemorrhage.
4. Small foci of acute infarct not associated with hemorrhage left hemisphere,
and single focus right vertex.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old woman with R IJ CVL// eval R IJ CVL Contact name:
___: ___
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 07:58.
FINDINGS:
There has been interval placement of a right internal jugular central venous
catheter with the tip terminating in the lower superior vena cava. Otherwise,
no significant interval change.
IMPRESSION:
The right internal jugular central venous catheter terminates in the lower
superior vena cava. Otherwise, no significant interval change.
Radiology Report
INDICATION: ___ year old woman with L MCA c/b hemorrhage// NGT placement
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The right IJ line is unchanged. The NG tube projects over the proximal
stomach. There is stable postsurgical and post radiation changes to the left
chest wall. Patchy parenchymal opacity in the left lower lobe is unchanged.
Small left pleural effusion stable. No pneumothorax is seen. Both apices not
included in the field of view.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with stroke// NGT replaced, please eval
NGT replaced, please eval
IMPRESSION:
Comparison to ___. The tip of the current feeding tube projects
over the gastroesophageal junction. The tube could be advanced by 5-10 cm.
Stable correct position of the right internal jugular vein catheter. No
pneumothorax or other complications. Stable appearance of the lung and of the
heart.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old woman with new NGT// NGT placement
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
There has been interval replacement of the nasogastric tube which now
terminates in the body of the stomach. The right internal jugular central
venous catheter is in stable position.
There are small bilateral layering pleural effusions (left greater than right)
which have increased in size compared to most recent prior study. There are
patchy opacities in the bilateral lower lobes, which have increased compared
to prior study and may represent atelectasis or aspiration pneumonitis. The
cardiomediastinal silhouette is unchanged. Surgical clips are seen in the
left axilla and left breast.
IMPRESSION:
1. The new nasogastric tube terminates in the body of the stomach.
2. Increasing small bilateral pleural effusions (left greater than right).
3. Increasing patchy opacities in the bilateral lower lobes, which may
represent aspiration pneumonitis or atelectasis.
Radiology Report
EXAMINATION: Frontal chest radiograph.
INDICATION: ___ year old woman with new dobhoff// Eval tube location
TECHNIQUE: Portable frontal chest radiographs.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Multiple exposures are seen demonstrating placement of an enteric tube. The
final image demonstrates the tip projecting over the left upper hemiabdomen,
likely within the stomach. A right central venous catheter is seen
terminating in the mid SVC. Multiple surgical clips are seen within the left
axilla and overlying the left breast.
There are small layering pleural effusions bilaterally with associated
atelectasis. Mild interstitial pulmonary edema, unchanged. No focal
consolidations. Unchanged appearance of cardiomediastinal silhouette. No
pneumothorax. Osseous structures are unremarkable.
IMPRESSION:
1. Appropriate position of the enteric tube, terminating within the stomach.
2. Mild interstitial pulmonary edema. Small bilateral pleural effusions with
associated atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with L Mca ischemic stroke, hemorrhagic
conversion 3 days ago, worsening exam// Worsening cerebral edema or hemorrhage
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 dated ___ from outside hospital, CT head
without contrast dated ___. MR head dated
___
FINDINGS:
Re-demonstrated, is the large intraparenchymal hemorrhage in the left MCA
distribution involving the left putamen and superior left temporal lobe.
There has been interval increase in surrounding vasogenic edema. The
subarachnoid hemorrhage along the left frontal, temporal, parietal lobes and
left sylvian fissure demonstrate appropriate evolution. No new hemorrhage
identified. Minimal decrease in the 0.3 cm rightward midline shift which
previously measured 0.4 cm on MR head dated ___. The degree of
effacement of the left and third ventricles are unchanged.
The left uncal herniation with effacement of the bilateral perimesencephalic
and cephalic cisterns in superior cerebellar cistern is unchanged.
Evaluation of the bones and sinuses is limited by motion artifact. Within the
previously mentioned limitation, 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. Relatively unchanged, large intraparenchymal hemorrhage in the left MCA
distribution.
2. Interval increase in surrounding vasogenic edema of the left
intraparenchymal hemorrhage.
3. No new areas of hemorrhage are identified.
4. Minimal decrease in the rightward midline shift.
5. Unchanged left uncal herniation.
6. The subarachnoid hemorrhage along the left cerebral hemisphere demonstrates
appropriate evolution.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with left MCA infarct and hemorrhagic
conversion. Interval scan.
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 =
747.5 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: Head CT obtained 4 days prior, and from ___. Head
MR from ___.
FINDINGS:
The intraparenchymal hemorrhage in the left MCA territory involving the left
putamen and superior left temporal lobe now measures 6.8 x 5.8 cm, previously
6.6 x 5.8 cm. The associated vasogenic edema is similar in distribution and
there is mass effect evidenced by diffuse left hemispheric sulci and left
lateral ventricle effacement, with a 8 mm rightward shift of normally midline
structures with uncal herniation, similar to prior.
Effacement of the quadrigeminal cistern is similar to slightly increased
compared to prior study. No evidence of new hemorrhage is demonstrated.
There is no large territorial infarction.
Limited evaluation of the bones at the base of the skull and paranasal sinuses
is limited by motion. Within this limitation, no gross abnormalities are
demonstrated.
IMPRESSION:
1. Overall stable appearance of intraparenchymal hemorrhage in the left MCA
distribution, associated with uncal herniation.
2. No evidence of new hemorrhage or large territorial infarction.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with stroke s/p NGT// NGT placement Contact
name: ___: ___
IMPRESSION:
In comparison with the study of ___, the Dobhoff tube is been removed.
A new nasogastric tube has its tip close to the esophagogastric junction,
though the side port is within the lower esophagus. The tube should be pushed
forward at least 5-8 cm for more optimal positioning.
The cardiomediastinal silhouette is stable and there is no evidence of
appreciable vascular congestion or acute focal pneumonia.
NOTIFICATION: Attempts to page Dr. ___ unsuccessful.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with acute stroke// NGT placement NGT
placement
IMPRESSION:
Comparison to ___. The course of the current nasogastric tube is
unremarkable. The tip projects over the central parts of the stomach. There
is no evidence of complications, notably no pneumothorax. Stable mild
cardiomegaly and moderate scoliosis. Although there is no pulmonary edema,
the diameter and visibility of the pulmonary vessels has increased in the
interval.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with stroke with hemorrhagic conversion.//
stability scan
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: Head CT dated ___.
FINDINGS:
Left intraparenchymal hemorrhage centered in the temporal lobe and centrum
semiovale is re-demonstrated, with continued evolution of blood products
measuring 6.5 x 5.6 cm using a similar measurement technique, which is
essentially unchanged from ___. Surrounding vasogenic edema is
similar. Mass effect upon the right lateral ventricle and effacement of left
cortical sulci is similar. 5 8 mm of rightward midline shift is similar,
along with subfalcine and uncal herniation. There is similar effacement of
the interpeduncular cistern and quadrigeminal plate cistern. No new
hemorrhage or evidence of acute infarction.
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. Similar appearance of intraparenchymal hemorrhage in left frontal lobe with
associated uncal herniation compared to ___. Some of the blood
products are still quite dense but some there does not seem to be an increase
in the total amount of hemorrhage, any new interval hemorrhage seems doubtful.
2. No new hemorrhage or acute large territory infarct.
Radiology Report
EXAMINATION: Mechanical thrombectomy for left internal carotid artery stroke
During the procedure the following vessels were selectively catheterized
angiograms performed:
Left common carotid artery
Left internal carotid artery after thrombectomy
Right common femoral artery
INDICATION: This is a ___ old female who was found down besides her bed with
right-sided weakness and aphasia. She is on Eliquis and aspirin for atrial
fibrillation. She was not a candidate for tPA. She was transferred from
___. Perfusion imaging showed a small choroidal large benign
bridge she was felt to be candidate for mechanical thrombectomy. CTA at the
outside hospital head revealed an ICA terminus occlusion.
ANESTHESIA: The patient was maintained under moderate sedation by the
anesthesia team. Please see separately dictated anesthesia documentation.
Patient's hemodynamic and respiratory parameters were monitored continuously
throughout the entirety of the case by a trained and independent observer.
TECHNIQUE: Mechanical thrombectomy
COMPARISON: CTA outside hospital
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. She was transferred to the fluoroscopic table supine. Moderate
sedation was administered. Bilateral groins were prepped and draped in
standard sterile fashion. An emergency time-out was performed. The right
common femoral artery was identified using anatomic and radiographic
landmarks. The right common femoral artery was accessed using standard
micropuncture technique after infiltration of local anesthetic. A long 8
___ sheath was introduced, connected to continuous heparinized saline
flush, and secured.
Next a ___ diagnostic catheter was introduced. It was advanced over
038 glidewire through the aorta into the aortic arch. The wire was used to
select left common carotid artery. The catheter was positioned over the wire
into the left common carotid artery. The wire was removed. Vessel patency
was confirmed via hand injection. Standard AP and lateral hand injection was
performed which revealed a left carotid terminus occlusion. The purpose of
the angiogram prior to the procedure was to confirm the location of the
thrombus. It was used to informed the interventional procedure the followed.
Smart mask was performed. Exchange length Glidewire was advanced in the
external carotid artery. The diagnostic catheter was removed and a neuron max
catheter was advanced into the left common carotid artery. The internal
dilator and exchange length wire were removed. The guide catheter was
connected to continuous heparinized saline flush. Vessel patency was
confirmed via hand injection. Next a ___ intermediate catheter was loaded
over an XT 27 microcatheter loaded with a synchro 2 standard wire. Both
catheters were placed on flush prior to being introduced. The microcatheter
was navigated over the microwire into the superior division of the left MCA.
The intermediate catheter was placed at the ICA terminus.
The microwire was removed. A 6 mm TRevo device was selected. It was
introduced into the rotating hemostatic valve and allowed to flush. It was
loaded into the microcatheter. It was deployed by unsheathed in the
microcatheter through the affected segment. The intermediate catheter was
connected to continuous mechanical suction. The microcatheter was removed
while the stentriever was in place. The stentriever remained deployed for
approximately 2 minutes. The stentriever was removed along with the ___
catheter in a single maneuver while aspiration was applied to the guide
catheter. There was significant clot burden identified within the stentriever.
Follow-up AP and lateral angiogram revealed complete reperfusion of the
affected territory. Standard AP and lateral final runs were obtained.
Next the guide catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Perclose. The patient was removed
from the fluoroscopy table and remained at her neurologic baseline without any
evidence of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Right common carotid artery: There is opacification of the carotid
bifurcation. There is sluggish flow to the carotid terminus. There is no
opacification of the MCA or ACA.
Right internal carotid artery after first pass: There is opacification of the
internal carotid artery as well as the MCA that was previously occluded.
There is complete reperfusion of the affected territory. There is flash
filling of the ACA. There is evidence of competitive flow and filling of the
ACA territory from the contralateral side. There is evidence of some
vasospasm within the petrous portion of the ICA that is not flow limiting.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
IMPRESSION:
TICI 3 of left internal carotid artery terminus occlusion with a single pass
of a stentriever
RECOMMENDATION(S):
1. Care per neurology
Radiology Report
EXAMINATION: CT BRAIN PERFUSION Q936 CT HEAD
INDICATION: Suspected stroke with acute neurological deficit. // Please
exclude ICH, signs of early ischemic stroke, large vessel occlusion, or other
vascular abnormality.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
Total DLP (Head) = 3,317 mGy-cm.
COMPARISON: CTA of the head neck dated ___ (3 hours prior).
FINDINGS:
A subtle left dense MCA sign is seen, much better seen on the prior CT of the
head. Decreased perfusion of the posterior left putamen on source images
consistent with acute infarct. There is matched decreased cerebral blood
volume, cerebral blood flow, in this area.
Cerebral perfusion analysis reveals increased mean transit time involving
nearly entire MCA territory, much larger than area of infarct, consistent with
large penumbra. Please note that there is large area of T-max greater than 10
seconds.
Small area of decrease in cerebral blood flow and cerebral blood volume,
consistent with an infarct.
T-max greater than 10 seconds volume is 112 mm.
T-max greater than 6 seconds volume is 211 mm.
See BF less than 30% volume 11 mm.
Mismatch volume T-max greater than 6 seconds, see BF, 200 mL.
Hyperdensity seen in the left cavernous sinus (series 2 image 10) causes
bulging of the lateral border. This is better seen on the most recent CTA of
the head as a vascular abnormality involving the cavernous segment of the left
ICA.
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. Acute small infarct left putamen.
2. Large penumbra. Please note large area of T-max greater than 10 seconds.
3. Left dense MCA sign consistent with thrombosis.
4. No hemorrhage.
NOTIFICATION: The findings were wet read into the electronic dashboard on
___ at 11:01 am, 5 minutes after discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with PMH AFIB with RVR and acute ischemic
stroke s/p thrombectomy// screening cxr
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. There is mild pulmonary
vascular congestion. Surgical clips are seen in the left axilla.
Cardiomediastinal silhouette is stable. No pneumothorax is seen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: 97.1
heartrate: 62.0
resprate: 16.0
o2sat: 99.0
sbp: 109.0
dbp: 71.0
level of pain: u/a
level of acuity: 1.0 | ___ year old woman with a PMH of atrial fibrillation on Eliquis
and recent cardioversion ___ who presented with
global aphasia and right hemiparesis s/p thrombectomy with TICI
III perfusion complicated by hemorrhagic conversion and midline
shift.
# L MCA infarct s/p Thrombectomy complicated by large
hemorrhagic
conversion
Patient presented with acute onset global aphasia and right
hemiparesis and was found to have a left hyperdense MCA sign on
CT and left M1 occlusion on CTA. She did not receive tPA because
she was on apixaban. She was transferred to ___ for
thrombectomy and had TICI III reperfusion but had a large
hemorrhagic transformation with 4mm midline shift. She was
treated with HTS, which was weaned off ___. On ___ she was
more
lethargic so stat CT head was done which showed slightly more
midbrain compression and she received a one time dose of
mannitol. Repeat head CT on ___ was stable without increasing
hemorrhage, edema or evidence of new infarction. Repeat head CT
___ was also stable, so she was started on rivaroxaban 20mg on
___. She was not restarted on apixaban because on further
history she was taking this consistently for at least 1 week
prior to stroke.
# Blood pressure manangement
Patient does not have a history of hypertension, but she was
hypertensive during admission. BP meds were adjusted for goal
SBP <150 given her hemorrhage. She was given prn labetalol and
hydral, but eventually was controlled on labetalol 200 mg q8h
and lisiniopril 20mg.
#Paroxysmal afib,
-Patient is s/p cardioversion on ___ and was also
cardioverted in ___. It was initially thought she was
non-compliant with her apixaban, but per family she was taking
it consistently at least for 1 week prior to stroke, so started
on rivaroxaban here 20mg. She was previously on Sotalol at home.
On labetalol during admission.
#Dysphagia
-Patient has ongoing dysphagia secondary to stroke. She received
a PEG on ___ without complications and tolerated tube feeds.
Her sodium was trending up in the days prior to discharge to a
high of 152, free water flushes were increased from 50 -> 100
q4h and on day of discharge sodium downtrending to 151, water
flushes further increased to 150 q4h on day of discharge, to be
followed by rehab.
#Presumed Urinary Tract Infection
-Afebrile, but leukocytosis. UA with leukocytes but no nitrites.
Was treated with 5 days of ceftriaxone.
=========================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ambien / Bactrim / Lasix / Gemfibrozil
Attending: ___
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy (___)
History of Present Illness:
Mr. ___ is a ___ year old ___ speaking male with a PMH of
SLE(serologies positive for ___, ds DNA, Ro/La, & Sm) with lupus
nephritis, history of alveolar hemorrhage and myopericarditis,
who presents with BRBPR.
History obtained from patient with assistance of phone
interpreter. Patient reports that for a little over a week he
has
had bloody bowel movements. He reports that the blood is bright
red, is normally separate from the stool, though occasionally
has
been mixed. Also blood when he wipes. The past few days his
bowel
movements have also been painful in the rectal area, and he
reports that his bottom is now so sore that he has to sleep on
his side or with a pillow for a cushion. He states that last
week
he was constipated, but in the past few days they have been
loose. He has not had nausea, fevers or chills. No dark, tarry
stools. Notes that he has had hemorrhoids "a long time ago" and
that this is similar. Of note, he states that he has not had any
abdominal pain until today, when he developed a mild pain in the
right lower quadrant.
In regards to his appetite, he states that when he was on
predisone 40-60mg he had a very good appetite, but as it has
been
tapered down his appetite has been worse. He reports no nausea,
fevers, or chills.
Per review of records, patient has been followed at ___ since
___ when he presented with weight loss and FUO, with workup
ultimately showing SLE. Most recently, he was admitted from
___ with a lupus flare, including acute on chronic
kidney injury and a pericardial effusion. Following discharge,
he
was again admitted from ___ with anasarca ___
renal
protein loss. He was discharged on Mycophenolate Mofetil 1000 mg
PO BID and prednisone 60mg. Since discharge, his MMF has been
uptitrated to 1500mg BID and his prednisone has been tapered to
5mg daily per patient. His atovaquone was stopped. It was also
noted that his creatinine has been worsening over the past
several weeks - on ___, Cr was 1.4, which has been
uptrending to 3.2 on ___.
In the ED:
Initial vital signs were notable for:
Exam notable for:
ABDOMINAL: Nontender, nondistended, no rebound/guarding, no
peritonitic signs
GU: no CVAT
RECTAL: light brown guaiac +. no obvious mass
Labs were notable for:
- CBC: WBC 7.8, Hgb 9.6, Plt 274
- Lytes:
___
--------------- 81
4.9 \ 23 \ 3.6
- LFTS: AST: 22 ALT: 21 AP: 33 Tbili: 0.3 Alb: 3.7
- lipase 271
- Lactate:0.7
- Coags: ___: 10.5 PTT: 29.1 INR: 1.0
- negative u/a
Studies performed include: CT a/p w/o contrast showing:
Peripancreatic extending along the head and uncinate process
compatible with pancreatitis. A focal hypodensity along the
body/tail of the pancreas measuring approximately 1.3 cm is
difficult to evaluate on a nonenhanced scan. No peripancreatic
fluid collection
Patient was given: 2L LR
Vitals on transfer: T 98.4, HR 91, BP 119/65, RR 16, 98% RA
Upon arrival to the floor, patient is hungry and would like to
know if he can have something to drink. He recounts history as
above. He reports some mild RLQ abdominal pain.
Past Medical History:
- SLE c/b stage IV/V glomerulonephritis
- history of diffuse alveolar hemorrhage and myopericarditis
- DMII
- Hypertriglyceridemia
- Lumbar radiculopathy
- GERD
- hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM:
GENERAL: Alert and in no apparent distress. Prominent tremor
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Overall
poor dentition
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mildly tender to palpation in
RLQ without rebound or guarding. 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
DISCHARGE EXAM:
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. Overall
poor dentition
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mildly tender to palpation in
RLQ without rebound or guarding. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation, ___ in
place
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:
ADMISSION LABS:
___ 09:40PM BLOOD WBC-7.8 RBC-3.31* Hgb-9.6* Hct-30.8*
MCV-93 MCH-29.0 MCHC-31.2* RDW-13.2 RDWSD-44.8 Plt ___
___ 09:40PM BLOOD Neuts-74.8* Lymphs-15.7* Monos-7.8
Eos-0.1* Baso-0.1 Im ___ AbsNeut-5.86 AbsLymp-1.23
AbsMono-0.61 AbsEos-0.01* AbsBaso-0.01
___ 10:02PM BLOOD ___ PTT-29.1 ___
___ 09:40PM BLOOD Glucose-81 UreaN-115* Creat-3.6* Na-145
K-4.9 Cl-106 HCO3-23 AnGap-16
___ 06:33AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.0
___ 09:40PM BLOOD Albumin-3.7
___ 09:40PM BLOOD ALT-21 AST-22 AlkPhos-33* TotBili-0.3
___ 09:40PM BLOOD Lipase-271*
___ 05:13PM BLOOD Iron-125
___ 05:13PM BLOOD calTIBC-316 ___ Ferritn-920*
TRF-243
___ 05:13PM BLOOD Ret Aut-0.9 Abs Ret-0.03
___ 09:40PM BLOOD CRP-1.7 dsDNA-NEGATIVE
___ 09:40PM BLOOD C3-130 C4-36
MICRO:
UCx (___): NO GROWTH.
C.diff negative (___)
CMV PCR stool pending ***
Stool cx (___): NO SALMONELLA OR SHIGELLA FOUND.
NO CAMPYLOBACTER FOUND.
NO OVA AND PARASITES SEEN.
NO VIBRIO FOUND.
NO YERSINIA FOUND.
No E. coli O157:H7 found.
IMAGING:
___ CT abd/pelvis with PO and IV contrast:
IMPRESSION:
1. Interval decrease in inflammation surrounding the pancreatic
head and uncinate process. A 1.2 x 0.9 cm hypoattenuating lesion
in the pancreatic body/tail is unchanged and could represent a
pancreatic pseudocyst versus IPMN. As before, MRI/MRCP is
recommended for further evaluation.
2. Mild bilateral hydronephrosis is presumably secondary to a
markedly distended urinary bladder.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Trace pelvic ascites.
- ___ CT a/p w/o contrast:
Peripancreatic extending along the head and uncinate process
compatible with pancreatitis. A focal hypodensity along the
body/tail of the pancreas measuring approximately 1.3 cm is
difficult to evaluate on a nonenhanced scan. No peripancreatic
fluid collection.
DISCHARGE LABS:
___ 06:33AM BLOOD WBC-6.2 RBC-2.67* Hgb-7.8* Hct-24.0*
MCV-90 MCH-29.2 MCHC-32.5 RDW-13.7 RDWSD-44.5 Plt ___
___ 06:35AM BLOOD Glucose-101* UreaN-21* Creat-1.2 Na-146
K-3.8 Cl-113* HCO3-20* AnGap-13
___ 06:35AM BLOOD ALT-12 AST-18 AlkPhos-25* TotBili-0.4
___ 06:35AM BLOOD Calcium-7.4* Phos-1.9* Mg-1.5*
___ 05:13PM BLOOD calTIBC-316 ___ Ferritn-920*
TRF-243
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Mycophenolate Mofetil 1500 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. PredniSONE 5 mg PO DAILY
6. Ranitidine 300 mg PO QHS
7. Vitamin B Complex 1 CAP PO DAILY
8. Ethacrynic Acid 75 mg PO QAM
9. HydrALAZINE 25 mg PO BID
10. Lisinopril 10 mg PO DAILY
11. dextran 70-hypromellose 0.1-0.3 % ophthalmic (eye) QID:PRN
12. Fenofibrate 160 mg PO DAILY
13. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
14. Ethacrynic Acid 50 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hemorrhoidal bleeding
Acute blood loss anemia
Gallstone pancreatitis
Gastroenteritis
Acute urinary retention
Acute kidney injury
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 ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with SLE and lupus nephritis presenting with
BRBPR, found to have new RLQ pain with guarding. concern for acute process as
above.// PO and IV contrast to eval for acute process in RLQ;
perf/appendicitis/diverticulitis
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 23.7 s, 0.2 cm; CTDIvol = 404.8 mGy (Body) DLP =
81.0 mGy-cm.
3) Spiral Acquisition 7.8 s, 50.9 cm; CTDIvol = 10.6 mGy (Body) DLP = 534.2
mGy-cm.
Total DLP (Body) = 617 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Aside from minimal bibasilar atelectasis, the 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 contains gallstones without
wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
pancreatic ductal dilatation. There has been interval decrease in soft tissue
stranding surrounding the pancreatic head and uncinate process. A 1.2 x 0.9
cm hypoattenuating lesion in the pancreatic body/tail is re-demonstrated, but
incompletely characterized on this exam. A punctate calcification is again
noted in the tail the pancreas, likely reflecting sequela of prior
pancreatitis. 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.
Mild bilateral hydronephrosis is noted, likely secondary to a full urinary
bladder. There is no evidence of obstruction. There is no evidence of focal
renal lesions. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There are few
scattered colonic diverticula without evidence of wall thickening or adjacent
fat stranding. The appendix is normal.
PELVIS: The urinary bladder is markedly distended. There is trace, simple
appearing fluid within the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture. A
1.8 cm area of sclerosis in the left femoral head is again noted and
unchanged.
SOFT TISSUES: There is diffuse soft tissue edema, consistent with anasarca.
IMPRESSION:
1. Interval decrease in inflammation surrounding the pancreatic head and
uncinate process. A 1.2 x 0.9 cm hypoattenuating lesion in the pancreatic
body/tail is unchanged and could represent a pancreatic pseudocyst versus
IPMN. As before, MRI/MRCP is recommended for further evaluation.
2. Mild bilateral hydronephrosis is presumably secondary to a markedly
distended urinary bladder.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Trace pelvic ascites.
RECOMMENDATION(S): MRI/MRCP.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with pancreatitis and BRBPRNO_PO
contrast// eval divertic/panc complication
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 10.1 mGy (Body) DLP = 510.7
mGy-cm.
Total DLP (Body) = 511 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: Bibasilar atelectasis is noted. There is no evidence of pleural
or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. Re-demonstrated are multiple gallstones within the gallbladder
including the neck of the gallbladder however, similar to the prior study from
___, however there is no significant gallbladder distention or wall
thickening.
PANCREAS: There is peripancreatic stranding along the head and uncinate
process. There is a focal hypodensity along the body/tail of the pancreas
measuring approximately 1.3 x 1.0 cm (02:21), difficult to evaluate on a
nonenhanced scan. A punctate calcification is noted along the tail of the
pancreas (02:21). There is no pancreatic ductal dilatation. There is no
peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: The urinary bladder is distended without wall thickening. There is no
free fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Sclerosis along the left femoral head is unchanged.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Findings of mild acute interstitial pancreatitis.
2. Cystic lesion in the body of the pancreas may represent a pseudocyst or
IPMN. Recommend MRI/MRCP for further definitive evaluation.
3. Redemonstration of cholelithiasis without cholecystitis.
RECOMMENDATION(S): Recommend MRI/MRCP.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:00 am, 20 minutes after
discovery of the findings.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: BRBPR
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 97.8
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 122.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | SUMMARY:
Mr. ___ is a ___ year old ___ speaking male with a PMH of
SLE(serologies positive for ___, ds DNA, Ro/La, & Sm) with lupus
nephritis, history of alveolar hemorrhage and myopericarditis,
who presented with BRBPR and ___ with course complicated by mild
pancreatitis likely ___ gallstones and acute blood loss anemia
___ likely hemorrhoidal bleeding. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
magnesium
Attending: ___.
Chief Complaint:
nausea/vomiting, concern for seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male, with a reported past medical
history of motorcycle accident accident in ___ causing a
traumatic brain injury, and subsequent seizures. Patient
reports
his baseline seizure rate is ___ seizures a year which are
tonic-clonic in etiology. He also reports his minor seizures
are
in the visual limb shaking happens sporadically.
Patient reports that on ___ he took his Depakote. On ___
he reported that he had 9 seizures, all tonic-clonic in
etiology.
On that same day he reports falling off the top of a 9 letter.
He reports that the time is in urgent care, where they diagnosed
him with a clavicular fracture. He reports persistent nausea
and
vomiting since then, he initially reported changes in vision but
on further questioning reports that his visual symptoms have
resolved. He reports that he also has residual muscle sensation
from time of the fracture in his thumb index finger middle
finger, approximately with a C6 nerve roots, and demonstrated
squeezing his finger with all his might to show that he had no
sensation. The same time if patient requested to not have his
left arm examined due to excruciating pain. He reports that he
has headaches, but are chronic in etiology, and no changes in
consistency or frequency.
When asked about his negative levels, exceptionally reported
that
he is not able to take his Depakote, and that he is only able to
get down some Pedialyte and Powerade since the tubes incident.
He reports having 3 seizures 2 days ago, and one seizure today.
He reports that he did take Zofran for his nausea
Is not sure if it helped.
He denies dizziness, lightheadedness, vertigo, speech
disturbance, diplopia, hearing change, dysarthria, dysphagia,
focal weakness, paresthesiae, bowel or bladder incontinence,
gait
disturbance, fevers, chills, unintended weight change, nausea,
vomiting, cough, dyspnea, chest discomfort, abdominal pain,
changes in bowel or bladder habits, myalgias, arthralgias, or
rash. Patient reports having good night sleep, no infection,
and
no triggers. This recent increase in seizure frequency.
Patient
reports no new emotional or physiological stressors.
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:
PHYSICAL EXAMINATION:
Vitals:
___ 1105 Temp: 98.5 PO BP: 122/79 R Sitting HR: 78 RR: 18
O2
sat: 97% O2 delivery: Ra
General: Awake, cooperative, in NAD.
HEENT: NC/AT, MMM
Pulmonary: no increased WOB on RA
Cardiac: warm and well perfused
Abdomen: Soft, ND, mild periumbilical TTP ___ rebound or
guarding
Extremities: No ___ edema.
Skin: Dirty, very thick calluses, rough.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive to examiner.
Language is fluent, no dysarthria. Follows simple & complex
commands. No evidence of apraxia or hemineglect.
-Cranial Nerves:
II, III, IV, VI: PERRL. EOMI.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk. (Of note, left arm was not examined
adequately, due to limitations from patient's reported injury
and reported severe and agonizing pain.) No pronator drift on
right. No adventitious movements, such as tremor, noted.
Delt Bic Tri FFl FE IP Quad Ham TA Gastroc
L NA NA NA ___ 5 4* 4+* 5
R 5 ___ ___ 5 5 5
*Limited by hip pain since fall.
-Sensory: Mild decreased sensation on left thumb and first 2
fingers and up lateral aspect of left arm to elbow.
-DTRs:
Bi ___ Pat
L NA NA 2
R 2 2 2
-Coordination: No intention tremor or dysmetria on R.
Pertinent Results:
___ 03:29AM BLOOD WBC-5.4 RBC-4.41* Hgb-13.2* Hct-40.4
MCV-92 MCH-29.9 MCHC-32.7 RDW-13.3 RDWSD-44.3 Plt ___
___ 03:29AM BLOOD Neuts-56.1 ___ Monos-9.7 Eos-3.0
Baso-0.9 Im ___ AbsNeut-3.00 AbsLymp-1.59 AbsMono-0.52
AbsEos-0.16 AbsBaso-0.05
___ 03:29AM BLOOD ___ PTT-29.9 ___
___ 02:19AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-139
K-5.1 Cl-105 HCO3-20* AnGap-14
___ 02:19AM BLOOD ALT-15 AST-35 AlkPhos-57 TotBili-0.4
___ 02:19AM BLOOD Albumin-4.3 Calcium-9.2 Phos-4.6* Mg-2.0
___ 02:19AM BLOOD Valproa-<3*
___ 02:00PM BLOOD Valproa-42*
___ 08:10AM BLOOD WBC-5.2 RBC-4.39* Hgb-13.1* Hct-39.3*
MCV-90 MCH-29.8 MCHC-33.3 RDW-13.0 RDWSD-42.6 Plt ___
___ 08:10AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-142
K-4.1 Cl-106 HCO3-25 AnGap-11
___ 03:40PM BLOOD CK(CPK)-78
___ 08:10AM BLOOD ALT-12 AST-14 AlkPhos-57
___ 03:40PM BLOOD CK-MB-1
___ 02:56AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 08:10AM BLOOD Albumin-3.8 Calcium-9.1 Phos-4.2 Mg-1.8
Imaging:
___ CT Cspine ___ contrast
IMPRESSION:
Normal study.
___ CT head ___ contrast
IMPRESSION:
Normal study.
___ CT chest ___ contrast
IMPRESSION:
1. No acute findings in the chest. No evidence for traumatic
injury
2. Unchanged mild splenomegaly.
___ Liver/gallbladder U/S
IMPRESSION:
Normal abdominal ultrasound. No evidence of cholelithiasis or
acute
cholecystitis.
___ Left clavicle Xray
IMPRESSION:
Unremarkable radiographs of the left clavicle.
___ Abd Xray
IMPRESSION:
Mildly dilated single loop of probable sigmoid colon and a large
amount of
stool is seen throughout the ascending and descending colon. No
abnormally
dilated loops of small bowel are seen.
___ MR shoulder ___ contrast
IMPRESSION:
1. Left acromioclavicular ligament rupture and disruption of
the
acromioclavicular capsule compatible with a grade 2 AC joint
separation.
2. Diminutive anteroinferior glenoid labrum and suggestion of
prior labral
surgery with cystic changes of the anterior glenoid
3. Strain at the myotendinous junction of the infraspinatus.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (EXTended Release) 500 mg PO BID
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath or
wheezing
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidocaine Pain Relief] 4 % place one patch on
left shoulder daily as needed Disp #*30 Patch Refills:*0
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath or
wheezing
3. Divalproex (EXTended Release) 500 mg PO BID
4.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
dual diagnosis epileptic and nonepileptic seizure disorder
gastritis with gastric and duodenal ulcer disease
traumatic left shoulder injury
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 Fall from 9 feet 3 days ago. Persistent
vomiting and seizures. Neck pain, T-spine and L-spine pain. Rib pain
bilaterally.// Intracranial hemorrhage, C-spine fracture, T-spine fracture,
rib fracture
TECHNIQUE: Contiguous axial images were acquired through the chest without
intravenous contrast. Multiplanar reformats were performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.5 s, 43.1 cm; CTDIvol = 23.0 mGy (Body) DLP = 990.9
mGy-cm.
Total DLP (Body) = 991 mGy-cm.
COMPARISON: CT torso from ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: A 1.5 cm low density lesion
superior to the left brachiocephalic vein at the thoracic inlet (06:40,
601:45) is unchanged and likely represents lipoma.
UPPER ABDOMEN: Splenomegaly of 14.1 cm unchanged. The remainder of the imaged
upper abdomen is grossly unremarkable.
MEDIASTINUM: Unremarkable.
HILA: Unremarkable.
HEART and PERICARDIUM: Unremarkable.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: There is minimal dependent atelectasis. The lungs are
otherwise clear.
2. AIRWAYS: Airways are patent to the segmental level bilaterally.
3. VESSELS: Thoracic aorta and main pulmonary artery normal in caliber.
CHEST CAGE: No acute fracture or suspicious osseous lesions. Mild anterior
wedging of several midthoracic vertebral bodies is unchanged.
IMPRESSION:
1. No acute findings in the chest. No evidence for traumatic injury
2. Unchanged mild splenomegaly.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with Fall from 9 feet 3 days ago. Persistent
vomiting and seizures. Neck pain, T-spine and L-spine pain. Rib pain
bilaterally.// Intracranial hemorrhage, C-spine fracture, T-spine fracture,
rib fracture
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Outside reference CT head from ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
Normal study.
Radiology Report
EXAMINATION: CT ___ W/O CONTRAST
INDICATION: History: ___ with Fall from 9 feet 3 days ago. Persistent
vomiting and seizures. Neck pain, T-spine and L-spine pain. Rib pain
bilaterally.// Intracranial hemorrhage, ___ fracture, T-spine fracture,
rib fracture
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.7 s, 22.5 cm; CTDIvol = 23.0 mGy (Body) DLP = 517.7
mGy-cm.
Total DLP (Body) = 518 mGy-cm.
COMPARISON: MR ___ from ___.
FINDINGS:
Alignment is normal. No fractures are identified.
There is no significant canal or foraminal narrowing.
There is no prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
Normal study.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with nausea, vomiting, RUQ pain// Eval for
cholelithiasis, bile duct/hepatic abnormalities
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 2 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 12.9 cm
KIDNEYS: Limited views of the right kidney shows no hydronephrosis.
RETROPERITONEUM: The visualized portions of IVC are within normal limits.
IMPRESSION:
Normal abdominal ultrasound. No evidence of cholelithiasis or acute
cholecystitis.
Radiology Report
EXAMINATION: CLAVICLE LEFT
INDICATION: ___ year old man with PMH TBI, seizures reports fall off ladder
and pain in L clavicle since a few days ago// ?fracture
TECHNIQUE: Two views of the left clavicle were obtained
COMPARISON: CT chest performed ___
FINDINGS:
There is no acute fracture of the left clavicle. The acromioclavicular joint
is not widened. No evidence of a left glenohumeral dislocation. The
visualized left lung apex is clear.
IMPRESSION:
Unremarkable radiographs of the left clavicle.
Radiology Report
INDICATION: This is a ___ man, with a past medical history of
motorcycle accident in ___ causing a traumatic brain injury, and subsequent
seizures who presents after fall vs seizure while on ladder in setting of 5ds
of persistent vomiting w/ inability to tolerate PO. Has significant L shoulder
pain related to recent trauma, which was reportedly associated w/ L clavicular
fracture per patient reports, which was not confirmed on shoulder/chest
imaging obtained on admission. Remains in sling for comfort per patient
request despite negative imaging. With unclear history, VPA undetectable, and
no increased seizure
TECHNIQUE: Upright and supine abdominal radiographs were performed
COMPARISON: ___
FINDINGS:
There are no abnormally dilated loops of small bowel. Stool and air is seen
within the ascending and descending colon. In the midline abdomen is a
redundant appearing and somewhat dilated air-filled loop of bowel possibly
reflecting sigmoid colon.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Mildly dilated single loop of probable sigmoid colon and a large amount of
stool is seen throughout the ascending and descending colon. No abnormally
dilated loops of small bowel are seen.
Radiology Report
EXAMINATION: MR SHOULDER ___ CONTRAST LEFT
INDICATION: This is a ___ man, with a past medical history of
motorcycle accident accident in ___ causing a traumatic brain injury, and
subsequent seizures who presents after fall vs seizure while on ladder in
setting of 5ds of persistent vomiting w/ inability to tolerate PO. Has
significant L shoulder pain related to recent trauma, which was reportedly
associated w/ L clavicular fracture per patient reports, which was not
confirmed on shoulder/chest imaging obtained on admission. Remains in sling
for comfort per patient request despite negative imaging. With unclear
history, VPA undetectable, and no increased seizure
TECHNIQUE: Noncontrast MRI of the left shoulder. Sequences include axial
proton density fat sat, sagittal T1, sagittal and coronal T2 fat sat.
COMPARISON: Prior radiograph dated ___.
FINDINGS:
Rotator Cuff: There is edema seen at the myotendinous junction of the
infraspinatus tendon, suggestive of muscle strain; however, no full-thickness
tear is seen. The supraspinatus, subscapularis, and teres minor tendons
appear intact. There is no rotator cuff muscle atrophy.
Acromio-clavicular joint: There is increased T2 hyperintensity around the
acromioclavicular joint with increased distance between the acromion and
clavicle, measuring approximately 8 mm, suggestive of disruption of the
acromioclavicular capsule and rupture of the acromioclavicular ligament
(series 6, image 11). The coracoclavicular ligaments are intact and there is
no widening of the CC interval.
Subacromial-subdeltoid bursa: Intact.
Joint effusion: No significant joint effusion.
Hyaline cartilage: Intact.
Glenoid labrum: The anterior-inferior glenoid labrum is diminutive; however,
no full-thickness tear is identified.
Biceps tendon: Small of edema seen around the biceps longus tendon, suggestive
of mild tenosynovitis.
Bone marrow: Cystic changes seen within the anterior glenoid suggestive of
prior surgery. Otherwise, bone marrow signal appears normal.
Axilla: No soft tissue abnormality in the visualized portion of the axilla.
IMPRESSION:
1. Left acromioclavicular ligament rupture and disruption of the
acromioclavicular capsule compatible with a grade 2 AC joint separation.
2. Diminutive anteroinferior glenoid labrum and suggestion of prior labral
surgery with cystic changes of the anterior glenoid
3. Strain at the myotendinous junction of the infraspinatus.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:42 pm, 5 minutes after discovery
of the findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, N/V, Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus, Nausea with vomiting, unspecified, Right upper quadrant pain
temperature: 99.5
heartrate: 62.0
resprate: 18.0
o2sat: 98.0
sbp: 134.0
dbp: 93.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ is a ___ year old man with history of motorcycle
accident in ___ causing a traumatic brain injury, and
subsequent seizures who presents after fall vs seizure while on
ladder in setting of 5ds of persistent vomiting with inability
to tolerate PO. Has significant L shoulder pain related to
recent trauma, which was reportedly associated with left
clavicular fracture per patient reports, which was not confirmed
on shoulder/chest imaging obtained on admission. Remains in
sling for comfort per patient request. With unclear history, VPA
undetectable, and no increased seizure
frequency despite discontinuation of AED, significant concern
for PNES (especially with nonepileptic event captured on cvEEG)
but may have dual diagnosis epileptic and nonepileptic seizures
with event leading to fall off ladder. Unclear etiology of
intractable N/V and periumbilical abdominal pain (possible
post-concussive syndrome), GI consulted. EGD with gastritis,
gastric ulcers, and duodenal erosions. GI recs for 8 weeks of
omeprazole and avoidance of NSAIDs. Nausea/vomiting improved
with IV anti-emetics, able to tolerate PO intake without IV meds
day prior to discharge. ___ eval w/ recs for home w/ otpt ___.
#Epilepsy
#PNES
-f/u cvEEG final read
-continue VPA 500 mg Q12H hrs
-follow-up with otpt neurologist within 4 weeks after discharge
#L shoulder pain from recent trauma
-lidocaine patch on discharge per patient request
-continue as needed tylenol for additional pain control
-will request ortho otpt f/u for further mgmt
-otpt ___ for shoulder ROM & strengthening
#intractable nausea/vomiting
#periumbilical abd pain
#gastritis, gastric ulcers, duodenal erosions
- BID PPI for 8 weeks
- follow-up with PCP ___ 4 weeks after discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ___
Allergies:
carbamazepine / donepezil / Penicillins
Attending: ___
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
___ ERCP with sphincteroplasty, stent placement
History of Present Illness:
HPI: The patient is a ___ male w/PMHx including mild dementia,
COPD, presenting with painless jaundice for weeks, associated
with dark urine, pale stools and fatigue, as well as ___ of
>100lb weight loss, mostly unintentional, but no significant
pain. He was seen at ___, a CT A/P showed biliary
dilation without pancreatic mass. Labs showed alk phos 700s,
Tbili 7, mild transaminitis. There is concern for
cholangiocarcinoma, and ERCP was consulted, recommending MRCP
and
NPO p MN for possible endoscopy on ___.
In the ED: noted to be "a+ox3 with mild dementia", per RNs had
mild R mid back pain, also endorsed night sweats. VS were: 98.6
70 143/86 18 98% RA
Seen on the floor, he was feeling ok. He very readily describes
how he has dementia and how he handles that -- "I just don't
stress out about it." We review his medical history, and he
directs me to his wife with any additional questions.
I speak with his wife to verify medications and other medical
history. She has not been told what we're planning to do, or
what we're concerned about. I explain that we're worried that
the bile ducts are blocked based on his clinical history, labs
and imaging and that we're getting an MRI. I also explain that
one of the things that can cause the blockage of the bile ducts
is cancer, and that's on our list. She understands.
ROS: [x] As per above HPI, otherwise reviewed and negative in
all
systems
Primary Care Provider: ___, NP at ___
outpatient clinic on ___.
Past Medical History:
PMHx:
COPD
HTN
Hyperlipidemia
Dementia
Recurrent UTIs
Seizure disorder ___ head injury after falling off a truck in
___, last seizure ___
Gout
Osteoarthritis
Headaches
Depression
Insomnia
Prior NIDDM -- now off meds given improved sugars
PSHx:
Removal of skin cancer from face
Eye surgery NOS
Social History:
___
Family History:
FHx:
Mother possibly had breast cancer
Father had dementia
Physical Exam:
Admission Physical Exam:
VS: T 97.5, HR 78, BP 128/64, RR 18, O2 sat 100% on RA
Lines/tubes: PIV
Gen: jaundiced, obese older man lying in bed, alert,
cooperative,
NAD
HEENT: icteric, MMM, PERRL
Neck: supple, no ___: equal chest rise, fair air movement, CTAB posteriorly, no
WOB or cough
Cardiovasc: distant sounds, regular
Abd: obese, soft, NTND apart from mild tenderness to deep RUQ
palpation
Extr: WWP, no pitting edema
Skin: jaundiced, otherwise no obvious lesions
Neuro: oriented to self, date, hospital, but cannot remember
details of his medical conditions, CN II-XII intact (IX and X
not
specifically tested), strength ___ throughout, sensation to
light
touch intact throughout, reflexes symmetric
Psych: normal affect
Discharge Exam:
T 98.1, BP 150/73, HR 70, RR 18, sat 99% on RA
Lines/tubes: PIV
Gen: jaundiced, obese older man seated on the edge of the bed,
alert, cooperative, NAD
HEENT: icteric, MMM
Chest: equal chest rise, fair air movement, CTAB posteriorly, no
WOB or cough
Abd: obese, soft, NTND
Extr: WWP, no pitting edema
Skin: jaundiced, otherwise no obvious lesions
Psych: normal affect
Pertinent Results:
Labs and Micro:
___: WBC: 3.6*
___: HGB: 13.4*
___: HCT: 40.4
___: Plt Count: 162
___: ___: 10.7
___: INR: 1.0
___: PTT: 31.8
___: Na: 136
___: K: 3.6
___: Cl: 99
___: CO2: 24
___: BUN: 35*
___: Creat: 1.2
___: eGFR: 60
___: Glucose: 106*
___: Ca: 9.2
___: Mg: 2.1
___: PO4: 2.7
___: ALT: 128*
___: AST: 95*
___: Alk Phos: 787*
___: Total Bili: 7.7*
___: Alb: 3.8
___ MRCP -- (Preliminary Report) "IMPRESSION:
Choledocholithiasis resulting in common bile duct and
intrahepatic duct dilatation. Gastroenterology consult for ERCP
is recommended. Multiple 1-2 mm cystic lesions in the body and
tail of the pancreas are most in keeping with side branch IPMN.
Follow-up MRI in ___ year to ensure stability is recommended.
RECOMMENDATION(S): Follow-up MRI in ___ year to ensure stability
of pancreatic cystic lesions most in keeping with side-branch
IPMN."
___ ERCP -- Impression: The scout film was normal.
A choledocho-duodenal fistula was noted above the major
papilla.
The fistula was deeply cannulated with the sphincterotome.
The CBD was 15 mm in diameter.
Multiple filling defects consistent with stones were identified
in the CBD.
A fistuloplasty was made with a with a CRE balloon from 10 to
12mm.
The biliary tree was swept with a 15 mm balloon starting at the
bifurcation. Multiple stones and sludge were removed.
A 5cm by ___ double pig-tail plastic biliary stent was placed
successfully.
Recommendations: Continue with antibiotics - Ciprofloxacin 500mg
BID x 5 days.
Repeat ERCP in ___ weeks with ___ stent pull and
re-evaluation.
Follow-up with Dr. ___ as previously scheduled.
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Discharge Day Labs
___ 06:05AM BLOOD WBC-3.5* RBC-4.09* Hgb-12.4* Hct-37.1*
MCV-91 MCH-30.3 MCHC-33.4 RDW-14.3 RDWSD-47.6* Plt ___
___ 06:05AM BLOOD Glucose-98 UreaN-24* Creat-1.0 Na-138
K-4.0 Cl-105 HCO3-23 AnGap-14
___ 06:05AM BLOOD ALT-81* AST-64* AlkPhos-562* TotBili-4.0*
___ 06:05AM BLOOD Lipase-34
___ 06:05AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Celebrex ___ mg oral DAILY
4. Citalopram 20 mg PO DAILY
5. Excedrin Extra Strength (aspirin-acetaminophen-caffeine)
250-250-65 mg oral BID:PRN headache
6. Flovent HFA (fluticasone) 44 mcg/actuation inhalation DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Ipratropium-Albuterol Inhalation Spray 2 INH IH BID
9. Lisinopril 40 mg PO DAILY
10. Oxcarbazepine 600 mg PO BID
11. Potassium Chloride 10 mEq PO BID
12. TraZODone 50 mg PO QHS
13. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Ipratropium-Albuterol Inhalation Spray 2 INH IH BID
4. Lisinopril 40 mg PO DAILY
5. Oxcarbazepine 600 mg PO BID
6. TraZODone 50 mg PO QHS
7. Aspirin 81 mg PO DAILY
8. Celecoxib 200 mg ORAL DAILY
9. Excedrin Extra Strength (aspirin-acetaminophen-caffeine)
250-250-65 mg oral BID:PRN headache
10. Flovent HFA (fluticasone) 44 mcg/actuation INHALATION DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
12. Potassium Chloride 10 mEq PO BID
Hold for K >
13. Simvastatin 40 mg PO QPM
14. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with weight loss, painless jaundice, CT at OSH
with biliary dilation // assess for cholangiocarcioma
TECHNIQUE: Following the administration of 10 mL of Gadavist, multiplanar
multisequence T1 and T2 weighted sequences were obtained in a 1.5 tesla magnet
as per the MRCP biliary protocol.
COMPARISON: CT abdomen dated ___
FINDINGS:
Lower thorax: The lung bases are clear. No pleural or pericardial effusion.
Liver: The liver is homogeneous in signal characteristics. No solid or
cystic lesions. No abnormal areas of restricted diffusion. The liver
contours are smooth.
Biliary: Surgical absence of the gallbladder is noted. There are multiple
calculi in the common bile duct measuring up to 13 mm. The common bile duct
is dilated measuring up to 15 mm. There is circumferential narrowing spanning
the most distal 2.2 cm of the common bile duct. There is no obstructing
extra-luminal mass. There is mild duct enhancement and high T2 signal in
keeping with edema. The narrowing is likely secondary to a benign stricture
from a recently passed stone. There is intra-hepatic duct dilatation.
Spleen: The spleen is mildly enlarged measuring up to 15.1 cm. No focal
lesions.
Pancreas: The pancreatic parenchyma maintains normal bulk, intrinsic
hyperintense T1 signal and enhancement pattern. No focal lesion or ductal
abnormality is seen. Multiple 1-2 mm cystic lesions in the body and tail of
the pancreas are most in keeping with side branch IPMN.
Adrenal glands: Unremarkable.
Kidneys: The kidneys are normal in signal characteristics. The
corticomedullary differentiation is well-maintained. There are no solid
lesions. Multiple bilateral cortical cysts are noted. The largest cyst is in
a lower pole of the left kidney measuring 2.3 cm. No hydronephrosis or
hydroureter.
GI tract: The GI tract is of normal caliber throughout.
Lymph nodes and mesenteric No significant mesenteric, retroperitoneal or porta
hepatis lymphadenopathy by size criteria.
Vasculature: The abdominal aorta is of normal caliber throughout without any
significant areas of narrowing or dilatation. There is mild atherosclerosis
noted in the distal abdominal aorta. Conventional hepatic arterial anatomy.
The portal and hepatic veins appear patent.
Bones: The bone marrow demonstrates normal signal characteristics. No
concerning osseous lesions.
IMPRESSION:
Choledocholithiasis resulting in common bile duct and intrahepatic duct
dilatation. Gastroenterology consult for ERCP is recommended.
Multiple 1-2 mm cystic lesions in the body and tail of the pancreas are most
in keeping with side branch IPMN. Follow-up MRI in ___ year to ensure stability
is recommended.
RECOMMENDATION(S): Follow-up MRI in ___ year to ensure stability of pancreatic
cystic lesions most in keeping with side-branch IPMN.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Jaundice, Transfer
Diagnosed with JAUNDICE NOS
temperature: 98.6
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 143.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | ___ man w/PMHx including mild dementia, COPD, now admitted with
biliary obstruction initially concerning for malignancy, but
MRCP showed stones. He underwent ERCP with removal of stones
and stent placement and should have follow-up as noted below.
On the day of discharge he felt well. No pain or nausea. Diet
was advanced to clears and then to regular, and was well
tolerated. He had no questions and was eager to go home.
Biliary obstruction initially concerning for malignancy, but
fortunately found to have choledocholithiasis
- s/p ERCP as above
- received usual post-ERCP care (NPO overnight with IVF, then
the next morning, got clears --> regular diet)
- counseled on no anti-platelet or anti-coagulant meds for 5d
afterwards
- ciprofloxacin x 5d today -- holding citalopram and trazodone
during that time given QTc prolonging interaction
- f/u for stent pull in ___ weeks
- trend LFTs daily
Likely IPMNs seen on MRCP
- needs f/u MRI in ___ year -- providing patient with this
information on his discharge paperwork, as well as in this
___, with instructions to ensure his PCP and wife learn about
this
Mild leukopenia, anemia
- suspect related to choledocholithiasis, were stable, suggest
non-urgent outpatient follow-up
COPD
- continued home inhalers
HTN, Hyperlipidemia
- held ASA given ERCP
- held HCTZ and lisinopril given he was NPO for a while in the
hospital -- ok to restart on discharge
- held simvastatin to allow for resolution of liver test
abnormalities -- ok to restart on discharge
Seizure disorder
- continued oxcarbazepine
Gout
- continued allopurinol
Osteoarthritis
- hold Celebrex for 5 days after the procedure, then restart
Depression, Insomnia
- hold citalopram, trazodone as noted above until done with
ciprofloxacin
On the day of discharge I spent >30min in discharge day services
and coordination of care.
___, MD
___
pager ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Augmentin / Biaxin / amitriptyline / electrode adhesive
Attending: ___.
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
n brief this is a ___ year old man with IBS, mitral valve repair
___, and VT arrest s/p ICD ___ who presents today with
hematochezia and abdominal cramping. Patient states that he
dropped off his son at the airport yesterday AM and stopped at
his son's office on the way home where he had sudden urge to
have a bowel movement. He had several, of which the first was
diarrhea and then he noted blood/mucus on subsequent voids (had
to make two stops on the way home from the airport and also
reports severe abdominal pain during the car ride, particularly
when going over bumps, reaching ___ in severity). The stools
have become progressively more "liquid" in nature with less
stool. He went home and had many more BMs (he estimates >25). He
has had significant urgency and also endorsed sweats and chills
during some of the bowel movements. Patient also reports
feeling increased fatigue and decreased appetite in the two days
prior to onset of his symptoms as well as subjective fever and
chills. He denies any abdominal pain or abdominal pain after
eating. THe patient does endorse taking ibuprofen every ___ days
though denies any dark stools.
He endorses a history of IBS with hemorrhoids and a little bit
of blood, on occassion. He denies history of CDiff, PUD, or
Hpylori. Also denies recent travel or new diet. Prior to the
onset of his symptoms, he had eaten a pasta dinner the night
before and a blueberry muffin from the freezer for breakfast
that morning. He had a colonoscopy (___) ___ years ago that
showed a polyp, but otherwise was normal. Also of note, he
recently finished 10 days of amoxicillin for sinusitis (last
dose ___.
He went to ___ in ___ where he had labs and
a CT scan showing diverticulosis without stranding, phlegmon,
free air. He was sent to ___ ED.
In the ED initial vitals were:
Time Pain Temp HR BP RR Pox Glucose
Yest 17:32 97.6 66 142/81 18 100% RA
Yest 20:05 98.3 65 153/76 16 97% RA
Yest 20:05 98.3 65 153/76 16 97% RA
Labs were significant for Hgb was stable x2. Cr was 1.4 from
baseline of 1.0. WBC 12.5.
Patient received fluids in the ED and was started on
cipro/flagyl for uncomplicated diverticulitis despite normal CT
findings (non-contrast).
GI recs: Large bore IV access, T+S, xmatch for 4 u, NPO for now
CTA if active bleeding
Review of Systems:
(+) per HPI
(-) night sweats, headache, vision changes, rhinorrhea, sore
throat, cough, shortness of breath, chest pain, constipation,
hematochezia, dysuria, hematuria.
Today, patient reports that he no longer has abdominal pain,
though his belly is a bit "sore." He continues to have watery
bloody bowel movements though much less frequent.
Past Medical History:
#V. tach arrest in the field with ROSC, s/p ICD placement with
EP study - ___ ___ ICD, Energen ICD D E140)
[The ICD is currently programmed with two tach zones. The VT
detection is between 170 and 210 while the VF detection is
greater than 210 beats per minute. The VT therapy equals
anti-tachy pacing followed by six shocks at 41 joules, whereas
the VF therapy equals anti-tachy pacing followed by 8 shocks at
41 joules. The bradycardic function of device is programmed VVI
mode with a lower rate of 40 beats per minute]
#Mitral valve repair (#32mm Physio ring) for severe MR/MVP on
___ (___)
#Asthma
#Chronic Constipation
#Frontal Lobe Cyst complicated by infected shunt
#Gastroesophageal Reflux Disease
#Hiatal Hernia
#Inguinal Hernia
#Irritable Bowel Syndrome
#Mitral Regurgitation
#Mitral Valve Prolapse
#Prostate Cancer
SURGICAL HISTORY:
#Frontal lobe cyst removal complicated by infected shunt, ___
#Hiatal Hernia Repair ___
#Fundoplication ___
#Hand Surgery
#Prostatectomy ___
Social History:
___
Family History:
Father - history of heart murmur, died of esophageal cancer
Mother - history of mental illness
Uncle - history of heart murmur, died of congestive heart
failure
Physical Exam:
Physical Exam on Admission:
====================
Vitals - T: 97.8 BP:123/87 HR: 67 RR:18 02 sat:98% RA
GENERAL: well appearing middle aged man in NAD
HEENT: anicteric sclera, pink conjunctiva, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: regular rate with ectopy, no murmurs/rubs/gallops
LUNG: CTAB, breathing without use of accessory muscles
ABDOMEN: Soft, nondistended, mildly tender in suprapubic area
without rebound or guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: Alert, oriented, good historian, CN II-XII intact, normal
gate, no pronator drift
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
RECTAL: notable for hemorrhoids, guaiac negative
Physical Exam on Discharge:
====================
VS: T 97.4-97.7, BP 119-122/72-93, HR 57-63, RR 16, O2 96RA
GENERAL: well appearing middle aged man in NAD
HEENT: anicteric sclera, pink conjunctiva, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: regular rate with ectopy, no murmurs/rubs/gallops
LUNG: CTAB, breathing without use of accessory muscles
ABDOMEN: Soft, nondistended, mildly diffuse tenderness to
palpation, no rebound or guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: Alert, oriented, good historian, CN II-XII intact, normal
gate, no pronator drift
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Labs on Admission:
================
___ 04:30PM BLOOD WBC-12.5*# RBC-5.10 Hgb-15.7 Hct-47.2
MCV-93 MCH-30.8 MCHC-33.3 RDW-13.7 Plt ___
___ 04:30PM BLOOD Glucose-127* UreaN-18 Creat-1.4* Na-142
K-4.3 Cl-104 HCO3-28 AnGap-14
___ 04:30PM BLOOD ALT-19 AST-28 AlkPhos-66 TotBili-0.6
Labs on Discharge:
==============
___ 05:30AM BLOOD WBC-5.2 RBC-4.26* Hgb-13.3* Hct-39.2*
MCV-92 MCH-31.3 MCHC-33.9 RDW-13.3 Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-82 UreaN-18 Creat-1.2 Na-140
K-3.9 Cl-105 HCO3-27 AnGap-12
___ 05:30AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1
___ 10:58 pm STOOL CONSISTENCY: NOT APPLICABLE
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI
0157:H7 FOUND.
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
Studies:
=========
CT abdomen Pelvis:
IMPRESSION:
Diverticulosis of the sigmoid colon is noted, without evidence
of wall thickening and fat stranding.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin EC 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. NexIUM (esomeprazole magnesium) 40 mg oral daily
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Dofetilide 250 mcg PO Q12H
6. Metoprolol Tartrate 12.5 mg PO BID
7. Temazepam 30 mg PO HS:PRN insomnia
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Dofetilide 250 mcg PO Q12H
3. Metoprolol Tartrate 12.5 mg PO BID
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Temazepam 30 mg PO HS:PRN insomnia
6. Docusate Sodium 100 mg PO BID
7. NexIUM (esomeprazole magnesium) 40 mg oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: infectious colitis
Secondary diagnoses: CAD s/p VT arrest, ICD implantation on
dofetilide
IBS
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 1 day of left sided abdominal pain and
bloody stool with CT abd/pelvis from ___ Urgent Care ___ // eval for
evidence of bowel ischemia vs diverticulitis
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
.Coronal and sagittal reformations were performed and submitted to PACS for
review. This is an outside hospital study for second read.
DOSE: This is an outside hospital study per second read.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN: Lack of IV contrast limits evaluation.
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of stones, focal suspicious renal lesions or hydronephrosis. Several renal
cysts are seen bilaterally. There are no urothelial lesions in the kidneys or
ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. Diverticulosis of the sigmoid colon is
noted, without evidence of wall thickening and fat stranding.. Appendix
contains air, has normal caliber without evidence of fat stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis. The 1.2 x 0.5 cm hypodense cystic lesion in the left pelvic sidewall
is of doubtful clinical significance. The prostate is absent with clips in
place.
BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal
and pelvic wall is within normal limits.
IMPRESSION:
Diverticulosis of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding. Bilateral renal cysts.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LLQ abdominal pain
Diagnosed with GASTROINTEST HEMORR NOS, HYPERTENSION NOS
temperature: 98.5
heartrate: 66.0
resprate: 16.0
o2sat: 98.0
sbp: 138.0
dbp: 90.0
level of pain: 3
level of acuity: 3.0 | ___ year old man with recent VT arrest s/p ICD, MV repair this
year for MVP, diverticulosis, NSAID use, and recent amoxicillin
course who presents with acute onset cramping hematochezia and
mild ___.
#Infectious Colitis:
Patient presented with episodes of explosive hematochezia
progressing to bloody mucus in the setting of leukocytosis of
12. CT scan notable for diverticulosis though without evidence
of diverticulitis. C. diff considered in setting of recent
amoxicillin use though was ruled out with negative toxin assay.
Other stool studies including E. Coli 0157:H7 also negative.
Campylobacter, vibrio, and yersenia pending at time of
discharge. Patient was initially started on cipro/flagyl on
admission in setting of concern over various causes of
infectious colitis including c. diff. However patient noted to
have prolongation of QTc in setting of ciproflaxacin and
dofetilide and given that above labs were notable for negative
results, patient remained afebrile with resolution of
leukocytosis all antibiotics were stopped prior to discharge.
___:
Patient presented with creatinine of 1.4 from his baseline of
1.0, thought to be secondary to pre-renal state in setting of
volume loss with diarrhea and poor PO intake. Creatinine
improved to baseline prior to discharge following 1L IVF and
adequate PO intake.
#CAD s/p VT ARREST:
Patient with history of VT arrest with recent ICD placement on
___ with noted inferior infarct on ECG and cMRI during
previous hospital course. EKG obtained this admission unchanged
with respect to inferior infarct. Patient was continued on
dofetilide with careful monitoring of QTc in setting of
ciprofloxacin use as above. Given gradual prolongation of QTc to
490, it was determined to stop ciprofloxacin prior to discharge.
Magnesium and potassium repleted and kept within normal range
during hospitalization. Aspirin continued.
#INSOMNIA
Home temazepan was continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with HIV (CD4 225, CD4/CD8 0.4, VL
78,000 ___, Refsum's disease, reactive airway disease,
restrictive lung disease who presents with dyspnea.
He complains of increasing dyspnea x 2 weeks with increased
albuteral inhaler usage, mostly because of the recent weather
change and worsening allergy symptoms. It was really bad on
___ that he was using his albuterol inhaler ever couple of
feet that he walks. He felt better on ___. However,
today, the dypsnea came back, especially with exertion, and he
was feeling a little lightheaded. These happened after he took
his morning pills including the new Atripla. He also feels very
dry. He reports minimal cough, non-productive, similar to
post-nasal drip cough. He reports no chest pain, palpitation,
N/V, sick contact, recent travel, recent TB exposure, abdominal
pain, fever or chill. He has never had asthma exacerbation
requiring intubation in the past.
Of note, patient just started his Atripla today.
Initial ___ VS were 99.4 113 178/86 20 93% RA. Labs were notable
for normal WBC, Hgb 12.3/Hcg 36.7, Plt 173, no left shift,
normal chemistry, Phos .3, Crt 0.9, UA negative, lactate 1.3,
AST 45, but LFT otherwise normal. CXR showed ? small LLL
consolidation. EKG showed sinus tachycardia, left axis
deviation and right atrial enlargement. He received albuterol
nebs x 2 and ipratropium neb, prednisone 20 mg, and ceftriaxone
1 g IV and most of the 500 mg IV azithromycin. ID fellow was
apparently paged from the ___. Peak expiratory flow was 220
after albuterol neb.
Past Medical History:
- Refsum's disease (hereditary motor and sensory neuropathy type
IV)
- HIV infection
- Knee replacements, bilateral
- Reactive airway disease
- Allergic rhinitis (recurrent)
- Otitis media (recurrent)
Social History:
___
Family History:
- Sister: ___ disease
- Mother: deceased, had metastatic breast cancer and Alzheimer's
disease
- Father: deceased, had throat cancer and had EtOH/smoking
history
Physical Exam:
Physical exam at admission:
VS - 99.1, 159/107, HR 114, 95-97% RA, RR 18
GENERAL - well appearing Caucasian male, NAD
HEENT - PERRLA, OP clear, MMM
NECK - supple, no LAD, no JVD
LUNGS - CTAB, no w/c/r, no accessory muscle use
HEART - regular tachycardic, normal S1 and S2, no m/r/g
ABDOMEN - soft, NT, ND, BS+, no HSM
EXTREMITIES - warm, dry, 2+ ___ pulses bilaterally, trace edema
to the ankles
NEURO - A&Ox3, + neuropathy, mostly peripheral, gait is normal,
CN III-XII intact, no motor deficit noted.
Physical exam at discharge:
Vitals: 98.4 150/91 112 20 95%RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - no use of accessory muscles while breathing, able to
speak in full sentences without gasping for air; + prominent end
expiratory wheezing in bilateral lungs, worse in middle lobes;
no egophony or dullness to percussion noted
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Labs at admission:
___ 04:55PM BLOOD WBC-5.1 RBC-4.38* Hgb-12.3* Hct-36.7*
MCV-84 MCH-28.1 MCHC-33.5 RDW-15.4 Plt ___
___ 04:55PM BLOOD Neuts-62.3 ___ Monos-5.0 Eos-9.8*
Baso-0.6
___ 04:55PM BLOOD Glucose-105* UreaN-14 Creat-0.9 Na-136
K-4.2 Cl-101 HCO3-26 AnGap-13
___ 04:55PM BLOOD ALT-20 AST-45* AlkPhos-94 TotBili-0.6
Labs at discharge:
___ 08:10AM BLOOD WBC-4.7 RBC-4.45* Hgb-12.4* Hct-36.9*
MCV-83 MCH-28.0 MCHC-33.7 RDW-15.8* Plt ___
___ 08:10AM BLOOD Glucose-87 UreaN-12 Creat-1.0 Na-138
K-3.7 Cl-100 HCO3-29 AnGap-13
___ 08:10AM BLOOD Calcium-10.0 Phos-2.8 Mg-2.3
IMAGING:
CXR ___:
Possible focal opacity at the inferior lingula, could represent
pneumonia in the correct clinical setting. Clinical correlation
is advised.
EKG ___:
Sinus tachycardia with sinus arrhythmia. Otherwise, within
normal limits. No major diagnostic interim change from the
previous tracing.
Medications on Admission:
The Preadmissions Medication list may be inaccurate and require
further investigation.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea/wheezing
2. ATRIPLA *NF* (efavirenz-emtricitabin-tenofov) ___ mg
Oral Once a day HIV
3. Hydrochlorothiazide 12.5 mg PO DAILY Hypertension
4. Lorazepam 0.5 mg PO HS:PRN Insomnia
5. Asmanex Twisthaler *NF* (mometasone) 220 mcg (120 doses)
Inhalation Twice a day
6. Nasonex *NF* (mometasone) 50 mcg/actuation NU Once a day
7. traZODONE 50 mg PO HS:PRN Insomnia
8. Zolpidem Tartrate 5 mg PO HS:PRN Insomnia
9. clemastine *NF* 1.34 mg Oral Daily:PRN Post-nasal drip
10. Fexofenadine 60 mg PO BID
11. Ibuprofen 400 mg PO Q8H:PRN arthritis
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Fexofenadine 60 mg PO BID
2. Hydrochlorothiazide 12.5 mg PO DAILY Hypertension
3. Lorazepam 0.5 mg PO HS:PRN Insomnia
4. Multivitamins 1 TAB PO DAILY
5. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
6. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea/wheezing
8. Asmanex Twisthaler *NF* (mometasone) 220 mcg (120 doses)
Inhalation Twice a day
9. ATRIPLA *NF* (efavirenz-emtricitabin-tenofov) ___ mg
Oral Once a day HIV
10. clemastine *NF* 1.34 mg Oral Daily:PRN Post-nasal drip
11. Ibuprofen 400 mg PO Q8H:PRN arthritis
12. Nasonex *NF* (mometasone) 50 mcg/actuation NU Once a day
13. traZODONE 50 mg PO HS:PRN Insomnia
14. Zolpidem Tartrate 5 mg PO HS:PRN Insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: bronchitis, dizziness/dehydration
Secondary: HIV, reactive airway disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Cough, question pneumonia.
FINDINGS: PA and lateral views of the chest provided. There is a small area
of opacity at the left lung base abutting the left heart border, could
represent pneumonia in the correct clinical setting. Otherwise, the lungs are
clear. No pleural effusion or pneumothorax. Heart and mediastinum contours
are unchanged. Bony structures are intact.
IMPRESSION: Possible focal opacity at the inferior lingula, could represent
pneumonia in the correct clinical setting. Clinical correlation is advised.
Findings discussed with Dr. ___ at the time of initial review.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ASTHMA EXACERBATION / SOB
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DEHYDRATION, ASYMPTOMATIC HIV INFECTION
temperature: 99.4
heartrate: 113.0
resprate: 20.0
o2sat: 93.0
sbp: 178.0
dbp: 86.0
level of pain: 3
level of acuity: 2.0 | ___ year old gentleman with HIV, Refsum's disease, reactive
airway disease, restrictive lung disease who presents to the ___
with dyspnea and lightheadness. There was concern that his
dyspnea was due to an acute worsening of his known reactive
airway disease. His CXR was suspicious for a possible pneumonia.
He was given steroids to help with the reactive airway disease
and a course of azithromycin for possible community acquired
pneumonia.
ACTIVE PROBLEMS
#) Dyspnea: At presentation the patient reported experiencing
dyspnea (worse than his baseline) intermittently for a few days.
The patient has a history of reactive airway disease which
worsens with weather changes and his seasonal allergies -- this
was thought to be at least a contributing factor to his acute
worsening dyspnea. In the ___ his oxygen saturation was good on
room air and there was no evidence of accessory muscle use with
breathing on his initial exam. His CXR in ___ showed a possible
infiltrate in the inferior lingula, and given his
immunocomropised state (last CD4 225) there was a higher
suspicion of an infectious process. He was started on
azithromycin and ceftriaxone in the ___ (and later transitioned
to azithromycin and cefpodoxime once he got to the general
medicine floor). On the medicine floor his exam was remarkable
for prominent end expiratory wheezing in bilateral lungs. He
was also given prednisone & albuterol and ipratropium nebulizer
treatments for concerns that his reactive airway disease was
contributing to his symptoms. Because he did not require
supplemental oxygen and he had a low CURB 65 score it was felt
that he could be discharged home. He was discharged on a
prednisone burst and azithrmycin for a 5 day course. Urine
legionella negative. Blood cultures no growth at time of
discharge.
#) Lightheadness: The patient reported feeling lightheaded the
morning of admission in addition to experiencing dyspnea. At
admission the differential included orthostasis, drug adverse
effect (given that he started Atripla the day of admission), or
alternatively a primary CNS process given immunocompromised
state. His neuro exam was unremarkable and his lightheadness
resolved while he was in the Emergency Department without
intervention. CBC, chem 10 and repeat EKGs were unremarkable.
He was not orthostatic. He was monitored on telemetry without
any concerning events. His feelings of lightheadness did not
reoccur. Possible that could be related to Atripla although
after discussion with ___. ___, this was continued. Further
workup of his this lightheadness was deferred to the outpatient
setting. |
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, 'foggyness', left sided sensory changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ F with history of right cavernous hemangioma
found in setting of severe migraines and complex partial
seizures, s/p resection in ___, with resolution of seizures,
who
was found to have new right cavernous hemangiom ain ___ in
setting of recurrence of migraine, who presents after episode of
left sided numbness/tingling three days ago and then migrain
this
morning associated with 'foggyness' as well as cold sensation on
left side of body.
Patient reports that in ___ she started having sever migraines
which were bifrontal throbbing, associated with photophobia and
phonophobia, nausea and sometimes vomiting, which could last the
entire day and were happening three to four times weekly. Around
the same time, she started having complex partial seizures
consisting of head and eye shaking with head turning to the left
and difficulty with speech production, but retained
consciousness
(could hear and see her surroundings). these would last ~
2minutes but were quite frequent, sometimes clustering three in
one day. In that setting, she underwent MRI brain which showed
right cavernous hemangioma. She was also started on Keppra for
seizure prophylaxis at that time, but continued to have seizures
despite Keppra. She had serial MRI's to monitor hemagioma and
this was find to have significantly grown and had hemorrhage in
3
months. That together with persistent seizures made surgeons
decide to recent the cavernous hemangioma in ___.
Post-operatively, patient reports initially she had left face
and
body paralysis, but no sensory loss. She underwent aggressive
rehab and ___ and recovered most function except her left hand
which is still very weak. After surgery, she continued on Keppra
but few months aftre had two GTC seizures, each brief ~ 1
minute.
A year afterwards, she was seizure free and weaned off Keppra.
Continued to be seizure and headache free for a long time.
However, starting ___, she started having severe
migraines which were very similar to her prior migraines in
quality and intensity. She saw her Neurologist at the time at
___ who recommended MRI brain. This
showed new, albeit smaller right cavernous hemangioma. Patient
was started on Topamax initially 25mg po BID just for headaches,
but then increased to 50mg po BID also for seizure prophylaxis.
She was also started on Sumatriptan 50mg prn severe migraine.
She
had repeat MRI at 6 months which showed stable hemangioma and no
hemorrhage. In the interim, she moved to ___ to go to college
to ___. She was lost to follow-up. She continues to
have migraines initially once weekly but now once every couple
of
months, last had been 1.5 months ago.
Patient now presents because three days ago she sat up from
laying down and had sudden sensation of numbness and tngling
over
the left side of her face and her left arm and leg. This lasted
through the night and dissipated by the next morning. This was
not associated with other symptoms and did not have a headache
with it. Patient states she has never had anything similar in
the
past. This morning, patient woke up with typical migraine and
took Sumatriptan. Afterwards at work, however, she felt very
'foggy' as if she were 'in a cloud' feeling 'sluggish' and with
slowed speech. The left side of her body also started feeling
cold. She was concerned because in pat before a seizure she
would
get a similar 'foggy' sensation. No abnormal movements or
shaking. Came to our ED for further eval.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness. 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:
-Right cavernous hemangioma s/p resection ___
-New right cavernous hemangioma diagnosed ___
-History complex partial seizures and GTCs x2 as per HPI
-Migraine headaches
Social History:
___
Family History:
No Fh seizures, migraines, vascular malformations,
brain tumors.
Physical Exam:
Physical Exam:
Vitals: T: 98.7 P: 73 BP: 107/66 RR: 16 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to name
___
backward without difficulty. 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. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Decreased LT and PP over V1-V3.
VII: Subtle left NLFF, 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 and has symmetric strengh.
-Motor: Normal bulk, tone throughout. No pronator drift. No
adventitious movements. No asterixis.
Delt Bic Tri WrE FFl FE FF IP Quad Ham TA ___
L 5- 4- 5- 4- ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: Decreased light touch, pinprick, cold sensation over
left arm and leg. Intact vibratory sense, proprioception
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2+
R 2 2 2 2 1
Plantar response was up on left, down on right.
-Coordination: No dysmetria on FNF or HKS bilaterally. UE RAMs
symmetric.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
___ 08:20PM BLOOD WBC-10.9 RBC-5.05 Hgb-12.9 Hct-40.2
MCV-80* MCH-25.5* MCHC-32.1 RDW-13.1 Plt ___
___ 08:20PM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-140
K-4.3 Cl-102 HCO3-26 AnGap-16
___ 08:20PM BLOOD Calcium-10.0 Phos-3.7 Mg-2.2
___ 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
NCHCT ___
Status post right frontal craniotomy and a cavernoma resection
with associated postsurgical changes. No definitive acute
intracranial hemorrhage is identified.
MRI brain ___. Encephalomalacic and gliotic changes in the right frontal
lobe, at the site of prior resection of known cavernoma as per
the history.
A small focus of negative susceptibility at the medial aspect,
can relate to prior blood products or any residual component of
the cavernoma; differentiation between the two can be difficult
on non-contrast imaging. This focus is not hyperdense on the
noncontrast CT to suggest obvious acute hemorrhage within. No
change in size compared to recent CT done a few hours earlier.
No remote studies are available to assess for interval change.
Consider close followup CT to assess for any interval change if
there is continued concern.
2. Small pituitary-? Normal Variant or abnormal. Correlate
clinically and with labs
3. Slightly hypointense marrow signal diffusely, may relate to
cellular
marrow. Correlate with hematology labs for anaemia, etc.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 50 mg PO BID
2. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
3. Loestrin Fe ___ (28) (norethindrone-e.estradiol-iron) 1
mg-20 mcg (21)/75 mg (7) oral daily
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills:*2
2. Verapamil 40 mg PO Q12H
RX *verapamil 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
3. Loestrin Fe ___ (28) (norethindrone-e.estradiol-iron) 1
mg-20 mcg (21)/75 mg (7) oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: paresthesias
Secondary Diagnosis: cavernous angioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with hx cavernous hemangioma p/w left sided numbness
// ?intracranial bleed?
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 53.84 mGy
DLP: 891.93 mGy-cm
COMPARISON: None available.
FINDINGS:
The patient is status post a right frontal cavernoma resection from ___ per
history.
A tract of the associated encephalomalacia noted along the upper margin of
this resection. A small region of adjacent hyperdensity likely reflects normal
cortical gray matter. There is extra-axial fluid collection or discrete
intracranial hemorrhage identified. The ventricles and sulci are normal in
size and configuration except for mild ex-vacuo dilation of right frontal horn
related to adjacent encephalomalacic changes. The basal cisterns appear patent
and there is preservation of gray-white matter differentiation.
Sella, pineal gland and the craniocervical junction regions are grossly
unremarkable.
The patient is status post right frontal approach craniotomy. The paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The partially
included globes are unremarkable.
IMPRESSION:
Status post right frontal craniotomy and a cavernoma resection with associated
postsurgical changes. No definitive acute intracranial hemorrhage is
identified.
Correlate clinically to decide on the need for further workup with MRI if not
contraindicated of followup.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with right cavernous hemangioma p/w severe
migraine and left sided sensory symptoms // evaluate cavernous hemangioma for
growth or bleeding
TECHNIQUE: MRI of the head without IV contrast
COMPARISON: CT head ___
FINDINGS:
Postsurgical changes are noted in the right frontal lobe, with
encephalomalacic and gliotic changes.
There is a small focus of negative susceptibility with T2 hypointense signal,
in the medial aspect adjacent to the right lateral ventricle series 7, image
15 and series 5, image 15 the can relate to prior blood products or any
residual component of the cavernoma; differentiation between the two can be
difficult on non-contrast imaging. This focus is not hyperdense on the
noncontrast CT to suggest obvious acute hemorrhage within.
No remote studies are available to assess for interval change.
No acute infarct, mass effect, shift of normally midline structures or
hydrocephalus.
Mild ex vacuo dilation of the right lateral ventricle, related to the
encephalomalacic changes.
Otherwise, the ventricles, the cerebral sulci and the cerebellar folia are
normal.
Minimal periventricular FLAIR hyperintense signal, non-specific
The pituitary is slightly small.
The pineal gland and the craniocervical junction regions are grossly
unremarkable.
Cerebellar tonsils are located at the level of the foramina magnum.
The major intracranial arterial flow voids are noted.
Venous sinuses are unremarkable.
Retention cysts in the right maxillary sinuses.
A few small nodes in the upper neck, not abnormally enlarged.
Mildly prominent adenoids.
Slightly hypointense marrow signal diffusely, may relate to cellular marrow.
IMPRESSION:
1. Encephalomalacic and gliotic changes in the right frontal lobe, at the
site of prior resection of known cavernoma as per the history.
A small focus of negative susceptibility at the medial aspect, can relate to
prior blood products or any residual component of the cavernoma;
differentiation between the two can be difficult on non-contrast imaging.
This focus is not hyperdense on the noncontrast CT to suggest obvious acute
hemorrhage within.
No change in size compared to recent CT done a few hours earlier.
No remote studies are available to assess for interval change.
Consider close followup CT to assess for any interval change if there is
continued concern.
2. Small pituitary-? Normal Variant or abnormal. Correlate clinically and
with labs
3. Slightly hypointense marrow signal diffusely, may relate to cellular
marrow. Correlate with hematology labs for anaemia, etc.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Numbness, PRE-SEIZURE
Diagnosed with SKIN SENSATION DISTURB
temperature: 95.3
heartrate: 98.0
resprate: 18.0
o2sat: 99.0
sbp: 128.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | This is a ___ yo woman with history of right cavernous hemangioma
found in setting of severe migraines and complex partial
seizures, resected in ___ with resultant left sided weakness,
with subsequent new cavernous hemangioma found in ___ in setting of recurrent migraines, currently on Topamax for
headaches and seizure prophylaxis, presents with episode of left
body numbness/tingling 3 days ago, and then severe migraine this
morning associated with sensation of feeling foggy and with
difficulty focusing and cold sensation in her left body. sensory
symptoms more consistant with migraine as the ___ of symptoms
was over 30min. Exam is notable for left sided weakness upper >
lower. Along with decreased PP and temp over left V1-3 and left
arm and leg, which is new per patient. Also baseline
hyperreflexia and upgoing toe on left. Sumatriptan was DCed
given concern for affects on her known vascula malformation.
Head CT and MRI were without acute pathology. EEG was abnormal
with periods of slowing over the right frontal-central regions
with some potential interictal discharges admixed. We also
discontinued her topiramate and started her on Verapamil which
can be upitrated if she gets more frequent migraines.
If she continues to have spells on the outside, ambulatory
monitoring by EEG was recommended to capture more data and
possibly start her on an anticonvulsant. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
eggs / environmental
Attending: ___.
Chief Complaint:
Right intertrochanteric femur fracture
Major Surgical or Invasive Procedure:
Right trochanteric fixation nail placement
History of Present Illness:
___ female hx developmental delay presents with right hip pain.
Per family, she was in her USOH until about 2 weeks ago, when
she had a fall. The circumstances of the fall are unknown, as
she was at her day program. 3 days ago, she began refusing to
walk. She was diagnosed with UTI (gets these frequently; is
incontinent of urine at baseline, but develops increased
frequency) and started on Bactrim. However, walking didn't
improve, and pt was grimacing when she tried to bear weight.
They also noted increased swelling in her legs. They therefore
brought her to the ED for further evaluation. In ED, she was
found to have a hip fracture, for which we were consulted.
Past Medical History:
PAST MEDICAL HISTORY:
- Mild/moderate mental retardation (with significant cognitive
decline over the past ___ years)
- Pyloric stenosis s/p repair as infant
- Ventricular septal defect s/p repair
- Laryngeal ?stenosis vs. web
- Chronic cough and congestion (vs. reflux?)
- Severe scoliosis, s/p thoracolumbar ___ rod
Social History:
___
Family History:
Negative for epilepsy or any other neurologic problems.
Pertinent Results:
ADMISSION LABS:
___ 07:33PM BLOOD WBC-13.0* RBC-4.18 Hgb-11.4 Hct-36.4
MCV-87 MCH-27.3 MCHC-31.3* RDW-14.1 RDWSD-44.9 Plt ___
___ 07:33PM BLOOD Neuts-81.0* Lymphs-8.2* Monos-9.2
Eos-0.2* Baso-0.3 Im ___ AbsNeut-10.51* AbsLymp-1.07*
AbsMono-1.19* AbsEos-0.03* AbsBaso-0.04
___ 07:33PM BLOOD ___ PTT-28.7 ___
___ 07:33PM BLOOD Plt ___
___ 07:33PM BLOOD Glucose-156* UreaN-15 Creat-0.6 Na-136
K-5.6* Cl-98 HCO3-23 AnGap-15
___ 07:33PM BLOOD ALT-16 AST-28 CK(CPK)-230* AlkPhos-175*
TotBili-0.4
___ 07:33PM BLOOD cTropnT-<0.01
___ 07:33PM BLOOD Lipase-22
___ 07:33PM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.7 Mg-2.0
DISCHARGE LABS:
IMAGING/STUDIES:
TTE ___:
CONCLUSION:
The left atrial volume index is normal. The right atrium is
mildly enlar
ged. There is no evidence for an
atrial septal defect by 2D/color Doppler
. The estimated right atrial pressure is ___ mmHg. There is
normal left ventricular wall thickness with a normal cavity
size. There is normal regional and global left
ventricular systolic function. There is no resting left
ventricular outflow tract gradient.
No abnormal
flow associated with ventricular septal defect or obvious
structural abnormality in the ventricular septum
are seen.
Tissue Doppler suggests an increased left ventricular filling
pressure (PCWP greater than
18mmHg). Normal right ventricular cavity size with normal free
wall motion. The aortic sinus diameter
is normal for gender with normal ascending aorta diameter for
gender
. The aortic valve leaflets (?#)
appear structurally normal. There is no aortic valve stenosis.
There is no aortic regur
gitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is a trivial
pericardial ef
fusion. There is a prominent anterior fat pad.
IMPRESSION:
Suboptimal image quality
. Normal biventricular wall thicknesses, cavity sizes, and
regional/global systolic function. Elevated PCWP suggested
CXR ___:
FINDINGS:
Improvement in bilateral mild pulmonary edema.
Stable mild cardiomegaly with unremarkable cardiomediastinal
silhouette.
Small bilateral pleural effusions.
No pneumothorax.
Spinal surgical material, unchanged.
IMPRESSION:
Interval improvement of mild bilateral pulmonary edema.
___ Knee XR:
FINDINGS:
No fracture or dislocation is seen. There is mild-to-moderate
medial
compartment joint space narrowing. A quadriceps tendon
enthesophyte is seen.
There is no knee joint effusion. There is normal osseous
mineralization. No
suspicious lytic or sclerotic lesions are identified. Radio
opaque material
seen overlying the anterior soft tissue of the thigh is likely
exterior to the
patient.
IMPRESSION:
No evidence of acute fracture or dislocation.
___ CXR:
IMPRESSION:
Compared to chest radiographs since ___ most recent ___.
Mild pulmonary edema is new. No pneumothorax or pleural
effusion. Moderate
cardiomegaly is stable.
This examination neither suggests nor excludes the diagnosis of
acute
pulmonary embolism.
___ CTA chest:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Constellation of diffuse ground-glass opacities, interlobular
septal
thickening, and small bilateral pleural effusions is most
compatible with mild
pulmonary edema.
___ CT A/P
1. Comminuted, laterally angulated intertrochanteric right
femoral neck
fracture.
2. Irregular thickening of the anterior and superior bladder
wall. Correlate
with urinalysis to exclude infection and consider further
evaluation with
cystoscopy on nonemergent basis.
3. No acute intra-abdominal process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY
2. Sertraline 100 mg PO DAILY
3. ALPRAZolam 0.5 mg PO TID:PRN anxiety
4. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Enoxaparin Sodium 40 mg SC QPM
end on ___. ALPRAZolam 0.5 mg PO TID:PRN anxiety
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Sertraline 100 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R intertrochanteric femur fracture
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.
INDICATION: ORIF RIGHT HIP FX IN O.R.
IMPRESSION:
Fluoroscopic documentation of right hip procedure. No radiologist was
present.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cough// ? consolidation ?
consolidation
IMPRESSION:
Compared to chest radiographs since ___ most recent ___.
Mild pulmonary edema is new. No pneumothorax or pleural effusion. Moderate
cardiomegaly is stable.
This examination neither suggests nor excludes the diagnosis of acute
pulmonary embolism.
NOTIFICATION: The findings were discussed with ___. by ___
___, M.D. on the telephone on ___ at 2:01 pm, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with new O2 req, tachycardia// ? 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) = 388 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Mild cardiomegaly. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: Small right and trace left pleural effusions. No
pneumothorax.
LUNGS/AIRWAYS: There is mild diffuse interlobular septal thickening throughout
the lungs bilaterally. In addition, there are ground-glass opacities within
the upper and lower lobes bilaterally. The constellation of these findings is
most compatible with mild pulmonary edema. There is mild diffuse bronchial
wall thickeing. 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 AND SOFT TISSUES: Thoracolumbar fixation hardware is partially imaged
without evidence of hardware complication. There is persistent severe
levoconvex scoliosis of the lumbar spine. No suspicious osseous abnormality
is seen.? There is no acute fracture. Coarse calcification within the right
breast.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Constellation of diffuse ground-glass opacities, interlobular septal
thickening, and small bilateral pleural effusions is most compatible with mild
pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with SOB// ? pulm edema
IMPRESSION:
In comparison with the study of ___, there is increasing pulmonary
edema with continued substantial enlargement of the cardiac silhouette.
Otherwise, little change.
Radiology Report
INDICATION: ___ year old woman with hypoxia, poss PNA// ? PNA vs pulm edema
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with mild interstitial edema. There is evidence of
internal fixation of the thoracic spine. Cardiomediastinal silhouette is
stable. Small left pleural effusions unchanged. No pneumothorax is seen
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT
INDICATION: ___ year old woman with knee pain// ? fracture ? fracture
TECHNIQUE: Frontal and lateral view radiographs of the left knee.
COMPARISON: Radiograph from ___
FINDINGS:
No fracture or dislocation is seen. There is mild-to-moderate medial
compartment joint space narrowing. A quadriceps tendon enthesophyte is seen.
There is no knee joint effusion. There is normal osseous mineralization. No
suspicious lytic or sclerotic lesions are identified. Radio opaque material
seen overlying the anterior soft tissue of the thigh is likely exterior to the
patient.
IMPRESSION:
No evidence of acute fracture or dislocation.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with likely iatrogenic pulmonary edema from
IVF// evaluate for interval change, ? pulm edema, ?PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recent ___.
FINDINGS:
Improvement in bilateral mild pulmonary edema.
Stable mild cardiomegaly with unremarkable cardiomediastinal silhouette.
Small bilateral pleural effusions.
No pneumothorax.
Spinal surgical material, unchanged.
IMPRESSION:
Interval improvement of mild bilateral pulmonary edema.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Leg swelling
Diagnosed with Displaced intertrochanteric fracture of right femur, init, Unspecified fall, initial encounter
temperature: 97.9
heartrate: 80.0
resprate: 20.0
o2sat: 99.0
sbp: 140.0
dbp: 97.0
level of pain: 5
level of acuity: 3.0 | SUMMARY:
========
___ woman with history notable for cognitive delay,
asthma, and dyslipidemia who was admitted for right
intertrochanteric hip fracture s/p ORIF (___) with hospital
course complicated by hypoxia due to pulmonary edema. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sudden onset R hip pain, fever
Major Surgical or Invasive Procedure:
right hip washout, exam under anesthesia, endometrial biopsy
History of Present Illness:
Ms. ___ a ___ s/p SVD on ___ who
presents as a transfer from ___ after experiencing
sudden onset severe R hip pain with limited ROM on ___ ___s a rash, with concern for septic arthritis. Pt presented to
___ and was noted to be febrile to 103. She underwent
a pelvic US which was normal and a pelvic CT which showed a
joint effusion of the R hip. She also had LENIs which were
negative. She also underwent a R hip XR which did not show
evidence of a fracture.
Aspiration of 13cc of synovial fluid of the R hip by ___ was
performed; fluid analysis revealed 22K WBCs, 3K RBCs, glucose 6,
gram stain growing +GPCs. The remainder of her labs showed WBC
of 11.2 with 21 bands. CRP 172, ESR 45. Lactate and BMP were
within normal limits. She was started on unasyn and vancomycin.
Decision was made to transfer to ___ for further evaluation
and workup.
Upon evaluation here, she was noted to be well appearing however
uncomfortable. She denied any recent traumatic injury to the
hip, no cough/cold/flu symptoms, no CP/SOB, no significant
breast engorgement or tenderness, no abdominal pain, no pain in
the calves. She reported that she had one day of slight increase
in lochia, no foul smelling discharge.
Past Medical History:
None
Social History:
Lives with children and husband; homemaker; no smoking, alcohol,
or drugs
Physical Exam:
___ ___ Temp: 98.3 PO BP: 116/72 R Lying HR: 68 RR: 18 O2
sat: 96% O2 delivery: RA
___ 0017 Temp: 98.3 PO BP: 121/79 L Sitting HR: 70 RR: 18
O2
sat: 96% O2 delivery: RA
___ 0017 Temp: 98.3 PO BP: 121/79 L Sitting HR: 70 RR: 18
O2
sat: 96% O2 delivery: RA
___ BP: 124/71
___ 1548 BP: 126/73
___ 1157 BP: 116/76 R Sitting
___ 0804 BP: 113/71 R Lying
General: NAD
Breasts: non-tender, no erythema, soft, nipples intact
Lungs: No respiratory distress
Abd: soft, nontender, fundus firm below umbilicus
Lochia minimal
Extremities: no calf tenderness, no edema
Pertinent Results:
___ 06:40PM WBC-12.0* RBC-3.58* HGB-11.6 HCT-35.6 MCV-99*
MCH-32.4* MCHC-32.6 RDW-14.1 RDWSD-51.7*
___ 06:40PM NEUTS-83* BANDS-9* LYMPHS-3* MONOS-3* EOS-2
BASOS-0 ___ MYELOS-0 AbsNeut-11.04* AbsLymp-0.36*
AbsMono-0.36 AbsEos-0.24 AbsBaso-0.00*
___ 06:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-1+* MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL
___ 06:40PM PLT SMR-NORMAL PLT COUNT-211
___ 01:01PM OTHER BODY FLUID CT-NEG NG-NEG
___ 12:51PM LACTATE-1.3
___ 11:44AM GLUCOSE-112* UREA N-6 CREAT-0.7 SODIUM-138
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-12
___ 11:44AM WBC-13.3* RBC-3.81* HGB-12.4 HCT-38.2
MCV-100* MCH-32.5* MCHC-32.5 RDW-14.2 RDWSD-52.0*
___ 11:44AM PLT COUNT-213
___ 04:02AM URINE HOURS-RANDOM
___ 04:02AM URINE UHOLD-HOLD
___ 04:02AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 04:02AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG*
___ 04:02AM URINE RBC-5* WBC-110* BACTERIA-FEW* YEAST-NONE
EPI-0
___ 04:02AM URINE MUCOUS-RARE*
___ 12:53AM LACTATE-1.1
___ 12:17AM GLUCOSE-77 UREA N-8 CREAT-0.6 SODIUM-139
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-17* ANION GAP-14
___ 12:17AM estGFR-Using this
___ 12:17AM CRP-233.6*
___ 12:17AM WBC-10.4* RBC-3.80* HGB-12.1 HCT-37.9
MCV-100* MCH-31.8 MCHC-31.9* RDW-13.8 RDWSD-50.2*
___ 12:17AM NEUTS-92* BANDS-2 LYMPHS-2* MONOS-0 EOS-1
BASOS-1 ___ METAS-2* MYELOS-0 AbsNeut-9.78* AbsLymp-0.21*
AbsMono-0.00* AbsEos-0.10 AbsBaso-0.10*
___ 12:17AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL BURR-1+*
___ 12:17AM PLT SMR-NORMAL PLT COUNT-199
___ 12:17AM ___ PTT-27.7 ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Mild Pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24 hour
Disp #*7 Intravenous Bag Refills:*6
4. Docusate Sodium 100 mg PO BID:PRN Constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
6. walker 1 device miscellaneous PRN
Dx: I&D of R hip with excision of posterior capsule for septic
arthritis
Px: good
___: 13 months
RX *walker daily Disp #*1 Each Refills:*0
7. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
septic arthritis, post-partum, group A strep infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: AP portable chest radiograph
INDICATION: PICC line
TECHNIQUE: AP portable chest radiograph
COMPARISON: None
FINDINGS:
The distal tip of the left PICC line terminates in the right atrium. Recommend
retracting by 2.5 cm.
There is no focal consolidation, pleural effusion or pneumothorax. The size
of the cardiac silhouette is enlarged.
IMPRESSION:
The distal tip of the left PICC line terminates in the right atrium. Recommend
retracting by 2.5 cm.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, R Hip pain
Diagnosed with Oth complications of the puerperium, NEC, Pyogenic arthritis, unspecified
temperature: 99.4
heartrate: 114.0
resprate: 18.0
o2sat: 96.0
sbp: 121.0
dbp: 70.0
level of pain: 4
level of acuity: 3.0 | Patient was transferred to the Emergency department on ___ and
was noted to be well-appearing and afebrile although with a
notable rash. Upon admission, was started on ceftazidime and
clindamycin for her right septic hip. On ___, she underwent an
irrigation and debridement with excision of posterior capsule
right hip by Orthopedic Surgery. While under anesthesia she also
went a pelvic exam. Please see operative report.
In immediate post-op period, Infectious Disease was consulted as
the joint fluid at outside hospital grew Group A Strep. She had
a known exposure to a child with GAS pharyngitis, and a new
erythematous rash, there was concern for possible Streptococcal
toxic shock syndrome. Decision was made to transfer patient to
the ICU for additional monitoring of evolving group A sepsis.
Patient was admitted to the ICU from ___. During her
stay, she remained hemodynamically stable with no skin
breakdown, endocarditis, or pharyngitis. An endometrial biopsy
was performed and blood cultures were followed. She was
transitioned to penicillin and clindamycin per ID recommendation
and remained on IVF and PO as tolerated.
After being transitioned to floor, her endometrial biopsy was
notable for scant group A strep and outside urine culture was
notable for GAS and citrobacter koerci. Clindamycin was
discontinued on Penicillin G 4 million with plans to transition
to IV ceftriaxone 2g daily for 6-week course via a PICC
placement.
During her stay, she continued to be followed by Orthopedic
surgery who monitored her HVAC. She was also continuously
followed by Physical and Occupational Therapy for assistance
with her activities of daily living and functional mobility.
Patient discharged to home in the rehabilitation program.
Patient followed with Social Work for coping and a Lactation
Consultant for additional support.
Upon discharge, patient was tolerating a regular diet, had
remained afebrile and Blood cultures with no growth. She was
discharged to home with services with close follow up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Penicillins / Aranesp (in polysorbate)
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F NH resident w/ IDDM, CHF, CKD, pulm HTN, AFib, UTIs w/
indwelling foley, recurrent left exudative pleural effusion s/p
pleuroscopy and pleural catheter placement ___ p/w
hemoptysis. Pt returned to ___ yesterday. Has been having
worsening cough since. Woke up this morning at 4am coughing
blood-streaked sputum a/w nausea. About a teaspoon worth of
blood. No vomiting. CP and dyspnea since discharge. CP is on
left side associated with catheter site. Also notes her legs
appear more swollen than usual. Subjective fever and sweats.
Coumadin was held for 5 days prior to procedure, then started on
lovenox bridge and coumadin restarted.
In the ED, initial vital signs were: 100.2 126 157/78 20 94%
Labs were notable for WBC 17.6, Cl 94, Bicarb 33, INR 1.5,
Lactate 3.1
Studies performed include CXR
Patient was given vancomycin 1 g, levaquin 750 mg, metoprolol
tartrate 50 mg, acetaminophen 500 mg x 4, oxycodone x 1, 500 cc
bolus. Coumadin held due to hemoptysis
Vitals on transfer: 98.8 89 132/70 19 99% 2L Nasal Cannula
Past Medical History:
1. Insulin Dependent diabetes.
2. Diabetic neuropathy.
3. Peripheral vascular disease.
4. Chronic kidney disease, stage 3.
5. Diastolic CHF, chronic.
6. Asthma, COPD.
7. Pulmonary hypertension, right heart failure.
8. Recurrent UTIs, including ESBL, E. coli, Proteus, and VRE.
9. History of GI bleed.
10. Morbid obesity.
11. Bipolar disorders.
12. Hypertension.
13. Iron-deficiency anemia.
14. Cirrhosis, with splenomegaly, of unknown etiology.
15. Dilated common bile duct, possible retained stone.
16. BSO, secondary to adhesions.
17. Depression.
18. Hemorrhoidal disease.
19. Vitamin D deficiency with osteopenia.
20. Paroxysmal atrial fibrillation, currently on Coumadin.
21. GERD.
22. Anasarca.
23. Gout.
24. Spastic urinary bladder
Social History:
___
Family History:
Father died of CVA, mother died of colon cancer at unknown age
Physical Exam:
Admission Physical Exam:
Vitals- 98.2 127/55 75 18 98 1L Wt 136.7 kg
General: NAD, resting comfortably in bed, appears stated age
HEENT: PERRL, EOMI, MMM, oropharynx clear
Neck: Supple, no LAD, no thyromegaly, unable for assess for JVP
due to large neck
CV: Irregularly irregular rhythm, ___ early peaking systolic
murmur, no rubs/gallops
Lungs: Crackles with lower dullness to percussion bilaterally
Abdomen: Obese, soft, NT, ND, +BS
Ext: DP pulses 1+, legs large with 2+ pitting edema
Neuro: AAOx3, CN2-12 intact, moving all extremities
Skin: Warm, well perfused, numerous seb kers, back sweaty
Drain: serosanguinois output. Area of skin around drain with
small erythema,
Discharge Physical Exam:
Vitals: Tm 99.2 BP 134/84 (110s-140s/40s-80s) P 69 (60s-80s) RR
18 (___) Sat 98% RA (94-98) Wt 132.3kg AM BG 174
General: NAD, resting comfortably in bed
HEENT: PERRL, EOMI, MMM,
Neck: Supple, unable for assess for JVP due to large neck
CV: Irregularly irregular rhythm, ___ early peaking systolic
murmur, no rubs/gallops
Lungs: Trace crackles bilaterally, some dullness to percussion
at bases bilaterally, improved from previous but poor effort
Abdomen: Obese, soft, NT, ND, +BS
Ext: DP pulses 1+, legs large with 1+ pitting edema
Neuro: AAOx3, CN2-12 intact, moving all extremities
Skin: Warm, well perfused, numerous seb kers
Drain: serosanguinous output. Area of skin around drain slightly
erythematous, improved from previous. Dressing c/d/i
Pertinent Results:
Admission Labs:
___ 06:30AM BLOOD WBC-17.1*# RBC-4.45 Hgb-12.9 Hct-40.7
MCV-91 MCH-29.0 MCHC-31.7 RDW-16.8* Plt ___
___ 06:30AM BLOOD Neuts-85.1* Lymphs-9.0* Monos-4.6 Eos-1.3
Baso-0.2
___ 06:30AM BLOOD ___ PTT-32.6 ___
___ 06:30AM BLOOD Glucose-260* UreaN-11 Creat-0.8 Na-137
K-3.5 Cl-94* HCO3-33* AnGap-14
___ 07:58AM BLOOD Lactate-3.1*
Pertinent Labs:
___ 07:05PM BLOOD Vanco-9.3*
___ 10:18AM BLOOD Lactate-2.5*
___ 06:30AM BLOOD proBNP-2325*
Discharge Labs:
___ 08:00AM BLOOD Glucose-194* UreaN-12 Creat-0.7 Na-140
K-3.7 Cl-97 HCO3-37* AnGap-10
___ 08:00AM BLOOD ___
___ 08:00AM BLOOD WBC-7.5 RBC-4.14* Hgb-11.9* Hct-37.5
MCV-91 MCH-28.8 MCHC-31.8 RDW-16.8* Plt ___
Imaging:
- CXR ___: As compared to the previous radiograph, the left
lung base has minimally increased in radiolucency, indicating a
decrease in extent of the pleural effusion and the subsequent
left basal and retrocardiac atelectasis. The vascular diameters
have also decreased, indicating a decrease in pulmonary fluid.
No new parenchymal opacities are visible. The patient is still
strongly rotated to the left. Mild cardiomegaly persists. No
pneumothorax.
- CXR ___: Heart size and mediastinum are unchanged. Mild
vascular congestion is re- demonstrated. No interval
accumulation of pleural effusion is per septated. Mild
interstitial pulmonary edema is noted with no substantial change
since the prior study
- CXR ___: 1. Vascular engorgement
2. Right basilar atelectasis and small effusion
3. Left atelectasis and moderate size effusion
- EKG ___: Atrial fibrillation with a rapid ventricular
response and a single ventricular premature beat versus aberrant
ventricular conduction. Non-specific ST-T wave changes. Delayed
R wave transition. Compared to the previous tracing of ___
the ventricular response is faster and QRS voltage has increased
Micro:
- Sputum cx ___: GRAM STAIN (Final ___:
___ 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.
- Blood cx x ___: Pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO TID
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Duloxetine 60 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Furosemide 80 mg PO DAILY
9. Gabapentin 800 mg PO TID
10. Lantus (insulin glargine) 100units/ml 22 subcutaneous daily
breakfast
11. Lantus (insulin glargine) 100unit/ml 20 subcutaneous daily
bedtime
12. HumaLOG (insulin lispro) 100 unit/mL subcutaneous prn
hypergly
13. Isosorbide Dinitrate 20 mg PO BID
14. Metoprolol Tartrate 100 mg PO BID
15. Omeprazole 40 mg PO BID
16. Pregabalin 50 mg PO BID
17. Senna 8.6 mg PO BID
18. Tiotropium Bromide 1 CAP IH DAILY
19. TraZODone 25 mg PO HS
20. TraMADOL (Ultram) 25 mg PO Q4H:PRN pain
21. Enoxaparin Sodium 120 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
22. Lidocaine 5% Patch 1 PTCH TD QAM
23. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
24. Ascorbic Acid ___ mg PO BID
25. Bismatrol (bismuth subsalicylate) 262 mg oral q4h:prn
diarrhea
26. Benzonatate 100 mg PO BID:PRN cough
27. Bisacodyl 10 mg PR HS:PRN constipation
28. Calcium Carbonate 500 mg PO TID:PRN indigestion
29. cranberry (cranberry extract) 450 mg oral BID
30. calcium polycarbophil 625 mg oral BID
31. Hydrocortisone Acetate Suppository ___AILY: PRN
constipation
32. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB
33. Lactulose 30 mL PO DAILY:PRN constipation
34. melatonin 6 mg oral daily
35. Milk of Magnesia 30 mL PO QHS
36. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
37. Nystatin Cream 1 Appl TP BID rash on back
38. Tears Naturale Forte (artificial tear(dxtrn-hpm-gly))
0.1-0.3-0.2 % ophthalmic q2h:prn dryness
39. Vitamin D 50,000 UNIT PO 2X/WEEK (___)
40. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Allopurinol ___ mg PO DAILY
3. Ascorbic Acid ___ mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Benzonatate 100 mg PO BID:PRN cough
7. Bisacodyl 10 mg PR HS:PRN constipation
8. Calcium Carbonate 500 mg PO TID:PRN indigestion
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Furosemide 80 mg PO DAILY
12. Gabapentin 800 mg PO TID
13. Hydrocortisone Acetate Suppository ___AILY: PRN
constipation
14. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB
15. Isosorbide Dinitrate 20 mg PO BID
16. Lactulose 30 mL PO DAILY:PRN constipation
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Metoprolol Tartrate 100 mg PO BID
19. Milk of Magnesia 30 mL PO QHS
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
21. Nystatin Cream 1 Appl TP BID rash on back
22. Omeprazole 40 mg PO BID
23. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
24. Pregabalin 50 mg PO BID
25. Senna 8.6 mg PO BID
26. Tiotropium Bromide 1 CAP IH DAILY
27. TraMADOL (Ultram) 25 mg PO Q4H:PRN pain
28. TraZODone 25 mg PO HS
29. Vitamin D 50,000 UNIT PO 2X/WEEK (___)
30. Azithromycin 250 mg PO Q24H Duration: 3 Days
31. Bismatrol (bismuth subsalicylate) 262 mg oral q4h:prn
diarrhea
32. calcium polycarbophil 625 mg oral BID
33. cranberry (cranberry extract) 450 mg oral BID
34. Duloxetine 60 mg PO DAILY
35. HumaLOG (insulin lispro) 100 unit/mL subcutaneous prn
hypergly
36. Lantus (insulin glargine) 100units/ml 22 subcutaneous daily
breakfast
37. Lantus (insulin glargine) 100 20 SUBCUTANEOUS DAILY BEDTIME
38. melatonin 6 mg oral daily
39. Tears Naturale Forte (artificial tear(dxtrn-hpm-gly))
0.1-0.3-0.2 % ophthalmic q2h:prn dryness
40. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
41. Warfarin 3 mg PO DAILY16
titrate to INR ___. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 10 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hemoptysis secondary to procedure
Pneumonia
Congestive heart failure
SECONDARY DIAGNOSES
Chronic pleural effusion
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: r/i infectious process
TECHNIQUE: Chest PA and Lateral
COMPARISON: Multiple prior exams including CT from ___ and
radiographs most recently from ___
FINDINGS:
In comparison to the most recent prior radiograph, there is increasing
right-sided pleural effusion along with right-sided platelike atelectasis.
There is also increasing opacities near the right middle lobe concerning for a
superimposed infectious process. On the left, there continues to be a pleural
effusion and atelectasis, and again pneumonia cannot be ruled out in this
area. Cardiomegaly remains. No vascular engorgement is also noted on today's
film.
IMPRESSION:
1. Vascular engorgement
2. Right basilar atelectasis and small effusion
3. Left atelectasis and moderate size effusion
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with recurrent pleural effusion, left pleur-x,
interval worsening since last d/c, ? CHF contribution, will be diuresing
overnight // ? improvement of cxr after diuresis
TECHNIQUE: CHEST (PA AND LAT)
COMPARISON: ___.
IMPRESSION:
Heart size and mediastinum are unchanged. Mild vascular congestion is re-
demonstrated. No interval accumulation of pleural effusion is per septated.
Mild interstitial pulmonary edema is noted with no substantial change since
the prior study
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with pleural effusion, new consolidate RML on
recent cxr // ? improvement after diuresis x 2 days
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the left lung base has minimally
increased in radiolucency, indicating a decrease in extent of the pleural
effusion and the subsequent left basal and retrocardiac atelectasis. The
vascular diameters have also decreased, indicating a decrease in pulmonary
fluid. No new parenchymal opacities are visible. The patient is still
strongly rotated to the left. Mild cardiomegaly persists. No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hemoptysis
Diagnosed with OTHER HEMOPTYSIS, DIABETES UNCOMPL JUVEN
temperature: 100.2
heartrate: 126.0
resprate: 20.0
o2sat: 94.0
sbp: 157.0
dbp: 78.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ presented with hemoptysis x 1 day after recent
discharge for pleural effusion drainage and pleur-x catheter
placement. In the interim she had daily cough and worsening
shortness of breath. Hemoptysis described as small amounts of
blood and blood-tinged sputum. She was admitted, found to have
worsening effusion on x-ray, ? right lung consolidation, fever,
leukocytosis, elevated BNP and weight gain since last discharge.
Pt started on antibiotics and diuresis, white count resolved, pt
afebrile, satting well on room air, with improvement of x-ray
and plan for outpatient interventional pulm follow up. Per IP,
some hemoptysis can be expected after such a procedure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Morphine / Sudafed
Attending: ___
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old R-handed man with recent admission to
the stroke service for a L cerebellar stroke who presents after
he was found to be dizzy at his rehab and an OSH NCHCT found
hemorrhagic conversion of his stroke. Please see recent D/C
summary for full details of his admission, but briefly, the pt
presented to ___ on ___ with vertigo, nausea and
unsteadiness and was transferred to ___, where he was found to
have a hypodensity of the left inferior medial cerebellar
hemisphere. He has a hx of afib, but at presentation was not on
anticoagulation, so he was started on aspirin and coumadin.
However, he had difficult to control afib and EP was consulted,
who recommended amiodarone and diltiazem, and given their
interaction with coumadin, also recommended that the pt be
switched to rivoroxabin, which he was. The patient was
discharged to ___ on ___ at which point he was no
longer vertiginous and requring less assistance to walk, but
still unsteady. He was doing well at rehab until today when he
was woken up from sleep by a very loud roommate who was agitated
and he felt palpitations and some chest pain. He was noted to
have a rapid heartbeat on palpation of his radial artery, and
because of his known difficult to control afib he was sent to
___. There, he was noted to be in aflutter with
some mild chest pain. He was given SL NTG and diltiazem and his
sx improved and his HR decreased to the low 100's. He had an
EKG that did not show any ischemia. He was not feeling dizzy
anymore after his HR decreased, but they did a NCHCT at the OSH,
which showed some hemorrhagic transformation of his known L
cerebellar stroke and he was transferred to ___ for further
evaluation and neurosurgical consultation. In the ED here, the
pt reported feeling "fine" and was without dizziness or CP. He
did report a mild frontal headache, but that it was "barely
there".
On neuro ROS, the pt reports headache as above, chronic facial
asymmetry from a childhood accident, and unsteadiness when
walking as above, but denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, current vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt reports recent CP and
palpitation as above, but denies ecent 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:
1.Atrial fibrillation, initially diagnosed in the setting of an
upper respiratory illness in ___, at which point he
had a successful cardioversion with recurrence of atrial
fibrillation 1 week later, at which point he converted to sinus
rhythm after a single dose of flecainide 300 mg p.o., previously
on Pradaxa, stopped on ___.
2.Bipolar on lithium
3.GERD.
4.Hyperlipidemia
5.Thyroid nodule with normal TFTs.
6.Esophagial stricture s/p dilatation.
7.Back fusion surgery
8.Large left cerebellar stroke thought to be embolic from afib
Social History:
___
Family History:
Noncontributory for sudden cardiac death, arrhythmia, or
coronary artery disease. There is no history of seizures,
developmental disability, learning disorders, migraine
headaches, strokes less than 50, neuromuscular disorders, or
movement disorders.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.6 P: 120 R: 20 BP: 148/82 SaO2: 99% on 2L
Orthostatics (pre-IVF) - lying HR 98, BP 98/59, sitting HR 113,
BP 89/58, standing HR 120, BP 85/59
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: irregularly irregular
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward w/ one
self-corrected error. 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. Pt. was able to register 3 objects and recall ___ at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to wiggling fingers.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: L ptosis, per pt this is his basline. facial asymmetry s/p
childhood accident
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.
Intention tremor bilaterally. 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
or
vibratory sense. Pt would not let me test proprioception in his
big toe on the R as he is having a gout flair and moving the toe
is incredibly painful. Very mild difficulty with proprioception
in the L big toe. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2 1 0
R 2+ 2 2 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, slowed fine finger mvmts on
the L. Mild dysmetria on FNF on the L, but not the R, with
bilateral intention tremor on FNF. Mild overshoot bilaterally on
mirroring tasks L > R.
-Gait: pt unsteady when standing with eyes open, Romberg
positive
for sway, did not attempt to walk more than a few steps as pt
very unsteady.
Pertinent Results:
ADMISSION LABS:
___ 03:15AM BLOOD WBC-13.1* RBC-4.58* Hgb-13.9* Hct-42.4
MCV-93 MCH-30.4 MCHC-32.8 RDW-13.3 Plt ___
___ 03:15AM BLOOD ___ PTT-45.0* ___
___ 10:45AM BLOOD ___ PTT-37.4* ___
___ 03:15AM BLOOD Glucose-112* UreaN-23* Creat-1.3* Na-138
K-4.6 Cl-102 HCO3-24 AnGap-17
___ 03:15AM BLOOD Calcium-9.9 Phos-3.5 Mg-2.1
RELEVANT LABS:
___ 03:15AM BLOOD cTropnT-<0.01
___ 10:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:15AM BLOOD Lithium-1.1
URINALYSIS:
___ 05:16AM URINE Color-Straw Appear-Clear Sp ___
___ 05:16AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG'
IMAGING:
OSH Head CT: some poorly defined hyperdensity in the left
cerebellar stroke.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO TID Duration: 1 Days
3. Amiodarone 200 mg PO BID
4. Atorvastatin 10 mg PO HS
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Lithium Carbonate 300 mg PO BID
8. Loratadine *NF* 10 mg Oral daily
9. Pantoprazole 40 mg PO Q24H
10. Rivaroxaban 20 mg PO DAILY
11. Senna 2 TAB PO HS
12. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 1,000 unit
Oral daily
13. Acetaminophen 650 mg PO Q6H:PRN pain/fever
14. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
15. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) Injection
prn anaphylaxis
16. Meclizine 25 mg PO Q12H:PRN nausea
17. Naproxen 500 mg PO Q8H:PRN pain
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. Sorbitol 30 mL QHS PRN dry mouth
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 10 mg PO HS
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Lithium Carbonate 150 mg PO TID
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Pantoprazole 40 mg PO Q24H
10. Senna 1 TAB PO BID:PRN constipation
11. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) Injection
prn anaphylaxis
12. Loratadine *NF* 10 mg Oral daily
13. Naproxen 500 mg PO Q8H:PRN pain
14. Sorbitol 30 mL QHS PRN dry mouth
15. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 1,000 unit
Oral daily
16. Metoprolol Tartrate 25 mg PO TID
17. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: hemorrhagic conversion of left cerebellar
infarct, atrial flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic Exam at Discharge: hypometric saccades on left gaze.
Intention tremor on finger-nose-finger on left. Remainder exam
nonfocal.
Followup Instructions:
___
Radiology Report
INDICATION: History of lightheadedness and new atrial flutter, question
infection.
COMPARISONS: Portable radiograph from ___ from ___
___ and portable radiograph from ___.
TECHNIQUE: PA and lateral chest radiographs were provided.
FINDINGS: There is no focal consolidation, pleural effusion or pneumothorax.
The cardiomediastinal silhouette is normal aside from leftward deflection of
the upper trachea most commonly due to thyroid enlargement, which has been
imaged in this patient's past. Osseous structures are intact.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: ___ male with atrial fibrillation on rivaroxaban, and recent
cerebellar stroke with hemorrhagic transformation; assess for interval change.
COMPARISON: Multiple head CTs dating back to ___, most recent
from ___ and MR ___ from outside hospital from ___.
TECHNIQUE: MDCT images of the brain were obtained without intravenous
contrast
NON-CONTRAST HEAT CT: Hemorrhagic transformation at the site of a known left
inferior medial cerebellar infarct appears slightly larger and more confluent
as compared to recent prior examination. Hemorrhage continues to cross the
midline resulting in severe mass effect upon the dorsal aspect of the fourth
ventricle (2:5). Ventricular size overall appears similar to prior with the
atria of the left lateral ventricle measuring 17 mm compared to 16 mm
previously (2:13). There is no evidence of developing obstructive
hydrocephalus. Cerebellar tonsils remain low-lying, though unchanged from
prior. No new intra- or extra-axial hemorrhage is identified. There is no
mass or acute large territorial infarction. There is no shift of usually
midline structures. Suprasellar and basilar cisterns are widely patent.
There is no scalp or osseous abnormality. Mucosal thickening within the
ethmoid air cells and imaged maxillary sinuses appear unchanged from prior.
Mastoid air cells remain well aerated.
IMPRESSION:
Hemorrhagic transformation of a left cerebellar infarct, slightly increased in
size with effacement of the fourth venticle. No current evidence of
obstructive hydrocephalus or further cerebellar tonsillar herniation.
Radiology Report
HISTORY: Evaluate for interval change of hemorrhagic conversion of left
cerebellar CVA.
COMPARISON: Head CT from ___.
FINDINGS:
The parenchymal hemorrhage in the left cerebellum appears slightly denser than
on the prior study from the ___, however the overall size and the
mass effect it causes appears unchanged. Once again noted is that the
hemorrhage crosses the midline resulting in effacement of the dorsal aspect of
the ___ ventricle. The remaining ventricles are unchanged in size, making
obstructive hydrocephalus unlikely at this point.
Otherwise, there is no new acute hemorrhage, vascular territorial infarction,
or mass. The basal cisterns are patent. Again noted is mucosal thickening in
the bilateral ethmoid and sphenoid air cells. The middle ear cavities and
mastoid air cells are clear.
IMPRESSION:
Overall stable size and mass effect caused by hemorrhagic conversion of left
cerebellar infarction.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ? HEAD BLEED
Diagnosed with INTRACRANIAL HEMORR NOS, ATRIAL FLUTTER, ATRIAL FIBRILLATION, ALTERED MENTAL STATUS
temperature: 97.6
heartrate: 120.0
resprate: 20.0
o2sat: 99.0
sbp: 148.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ yo RH man with history of bipolar disorder,
atrial fibrillation with recent left cerebellar stroke who was
discharged on rivaroxaban. At his rehab, he was found to have
palpitations and feeling dizzy, brought to ED where his symptoms
improved with better control of his heart rate. However, head CT
at OSH showed hemorrhagic conversion of his stroke.
He was admitted to neurology service for observation given the
blood on head CT. Repeat CT showed initial slight increase in
the hemorrhage, so Rivaroxaban was held. A repeat NCHCT
subsequently showed stability of hemorrhage. Plan is to restart
Rivaroxaban on ___.
For his difficult to control atrial fibrillation/flutter,
cardiology was consulted. Cardiology initially recommended that
he be continued on amiodarone, but he was noted to remain in
rapid atrial flutter, so cardiology decided to stop the
amiodarone and start metoprolol. He is on a dose of metoprolol
25 mg tid. His diltiazem dose was also increased to 360 mg
daily. His heart rate was noted to improve with these changes,
though he remained in atrial flutter.
He was re-evaluated by physical therapy given that he was very
close to the end of his rehab stay and they recommended that he
is stable for d/c home with home ___.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: 0100
_
________________________________________________________________
PCP: Dr. ___
.
CC: ___, abdominal pain, nausea, vomiting and light
headedness
_
________________________________________________________________
HPI:The patient is a ___ year old female with h/o recurrent
nephrolithiasis - path in ___ c/w Carbonate Apatite stones,
recurrent UTIs- proteus and Ecoli who was found to have a UTI
with a positive UA on ___. She was started on Bactrim but
now presents with abdominal pain. UA from that day with > three
colony types. Previous urine cultures with proteus and E coli
sensitive to Bactrim. S/p Cystoscopy, left ureteroscopy, laser
lithotripsy, left ureteral stent placement by Dr. ___ in
___. Not all stones could be removed and the plan was
for a repeat procedure which has been scheduled for ___.
Despite continuing on Bactrim bid she continued to have
worsening abdominal pain with sweats. She denies chills. She
then developed n/v and inability to tolerate po intake x 2 days.
She also developed LH which prompted her to come in. She denies
feves, chest pain, shortness of breath. She has lost 14 lbs
since ___. She has not had a bm "in a few days" which she
thinks is because she has not eaten but she does not feel
constipated. At baseline she has stress and overflow
incontinence and this has been exacerbated. She requires surgery
for this but she confesses to being "overwhelmed" and has not
scheduled it.
In ER: (Triage Vitals:9 |97.8 |102 |20| 134/93 100% RA )
Meds Given:
IV Morphine Sulfate 4 mg |Ondansetron 4 mg| cefepime and 4 LNS
Radiology Studies:CTU
consults called: None
Cr elevated to 1.5 with AG = 23 with HCO3 = 19
.
PAIN SCALE: ___ periumbilical
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: As per HPI
GU: [+] per HPI
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
HYPERTENSION
RECURRENT NEPHROLITHIASIS c/b RECURRENT UTI- S/P Cystoscopy,
left ureteroscopy, laser lithotripsy, left ureteral stent
placement- ___
OBESITY
S/P LAP CHOLE
SICKLE TRAIT
PYELONEPHRITIS
RECURRENT URINARY TRACT INFECTION
SMOKER
H/O BACK PAIN
H/O ELEVATED LFT
H/O ABDOMINAL PAIN
H/O URINARY RETENTION
Social History:
___
Family History:
Mother DIABETES ___ - died of DM complications at age ___
Father CORONARY ARTERY DISEASE- died age ___.
Brother COLON CANCER
MGM still alive at ___- now getting dementia- active, dancing and
singing.
Physical Exam:
Vitals: 98.1 PO |151 / 105 L| Lying ___ RA
CONS: She look uncomfortable but not toxic
HEENT: ncat anicteric MMM
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
GI: +bs, soft, + umbilical tenderness with palpation
GU: No CVAT B/l
MSK:no c/c/e 2+pulses
SKIN: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD: No cervical LAD
DISCHARGE EXAM
VS: T 98.2 BP 140 / 82 HR 87 RR 18 O2 sat 97 RA
Gen: NAD, resting
Eyes: EOMI, no scleral icterus
HENT: NCAT, trachea midline
CV: RRR, S1-S2, no m/r/r/g, no edema, 2+ ___ BLE
Lungs: CTA B, no w/r/r/c
GI: +BS, soft, NTTP, ND
GU: No foley
MSK: ___ strength bilaterally, intact ROM
Neuro: Moving all extremities, no focal deficits, A+Ox3
Skin: No rash or ecchymosis
Psych: Congruent affect, good judgment
Pertinent Results:
___ 07:05PM LACTATE-1.6
___ 06:55PM GLUCOSE-109* UREA N-19 CREAT-1.5* SODIUM-141
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-19* ANION GAP-23*
___ 06:55PM estGFR-Using this
___ 06:55PM WBC-7.9# RBC-4.74# HGB-10.2* HCT-34.2 MCV-72*
MCH-21.5* MCHC-29.8* RDW-19.6* RDWSD-49.1*
___ 06:55PM NEUTS-74.3* LYMPHS-17.0* MONOS-7.9 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-5.90 AbsLymp-1.35 AbsMono-0.63
AbsEos-0.01* AbsBaso-0.02
___ 06:55PM PLT COUNT-429*
___ 06:09PM URINE HOURS-RANDOM
___ 06:09PM URINE UHOLD-HOLD
___ 06:09PM URINE COLOR-DKMB APPEAR-Cloudy SP ___
___ 06:09PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-4* PH-8.5* LEUK-LG
___ 06:09PM URINE RBC-35* WBC-19* BACTERIA-FEW YEAST-RARE
EPI-6
___ 06:09PM URINE 3PHOSPHAT-OCC
___ 06:09PM URINE MUCOUS-RARE
============================
ABDOMINAL CTU
IMPRESSION:
1. Multiple bilateral large nonobstructing renal stones similar
to prior, with unchanged mild left hydronephrosis. No CT
evidence of pyelonephritis.
2. Extensive areas of renal cortical scarring bilaterally,
likely the sequela prior infection.
3. Diffuse mild bladder wall thickening is unchanged, and may be
due to
underdistention, however infection cannot be excluded.
Recommend correlation with urinalysis.
4. A 1.9 cm cystic lesion within the left adnexa is not changed
since ___, however could be better evaluated with pelvic
ultrasound if the patient is postmenopausal.
5. Left adrenal adenoma.
RECOMMENDATION(S): 1. Recommend correlation with urinalysis.
2. Pelvic ultrasound for 1.9 cm left adnexal cystic lesion the
patient is
postmenopausal.
DISCHARGE LABS
___ 06:43AM BLOOD WBC-5.1 RBC-3.80* Hgb-8.3* Hct-27.2*
MCV-72* MCH-21.8* MCHC-30.5* RDW-19.1* RDWSD-48.4* Plt ___
___ 06:43AM BLOOD Glucose-76 UreaN-11 Creat-1.3* Na-141
K-3.8 Cl-109* HCO3-23 AnGap-13
___ 06:43AM BLOOD ALT-14 AST-14 AlkPhos-80 TotBili-<0.2
___ 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous GLUCONATE 236 mg PO BID
2. Citalopram 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. NIFEdipine CR 90 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Medications:
1. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*12 Tablet Refills:*1
2. Citalopram 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ferrous GLUCONATE 236 mg PO BID
5. NIFEdipine CR 90 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
8. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do
not restart Lisinopril until ___ with PCP
___:
Home
Discharge Diagnosis:
Abdominal Pain
Constipation
Complicated Urinary tract infection
Nausea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT U with and without contrast
INDICATION: History: ___ with known bilateral nephrolithiasis s/p lithotripsy
in past, symptoms suggestive of pyelonephritis not improving with course of
Bactrim, left upper quadrant abdominal pain, nausea, vomiting // Please
evaluate for signs of pyelonephritis and/or obstructing ureteral stone, if
non-con phase is unrevealing, please proceed with contrast phase for
evaluation of alternative etiologies
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The contrast scan was performed with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,769 mGy-cm.
COMPARISON: CT abdomen and pelvis on ___, CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Subcentimeter hepatic hypodensities are too small to characterize, however not
significantly changed from prior, and likely represent hepatic cysts or
biliary hamartomas. Mild intrahepatic biliary duct dilatation is similar to
prior, and likely secondary to postcholecystectomy state. Common bile duct
appears normal in caliber. 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 adrenal gland is normal in size and shape. A 2.4 cm left
adrenal nodule is not significantly changed and has a measured density of 5.5
___ on noncontrast scan, consistent with an adenoma.
URINARY: Symmetric and normal nephrograms are noted bilaterally. Both
kidneys demonstrate multiple areas of cortical thinning, likely the sequela of
prior infectious insult. Multiple large bilateral nonobstructing renal stones
are again seen in the right upper and lower poles and left lower pole. There
is no ureterolithiasis. Mild left hydronephrosis is not significantly
changed. There is no perinephric abnormality. Subcentimeter cortical
hypodensities are too small to characterize, however likely represent cysts.
There is no evidence of gross urothelial lesions. The distal ureters are
unremarkable. Diffuse thickening of the bladder wall is similar to prior.
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 (4:59.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is within normal limits. A 1.9 cm cystic
lesion within the left adnexa is not changed.
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: Degenerative changes in lumbar spine, worst at L4-L5, are not
significantly changed. There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Multiple bilateral large nonobstructing renal stones similar to prior, with
unchanged mild left hydronephrosis. No CT evidence of pyelonephritis.
2. Extensive areas of renal cortical scarring bilaterally, likely the sequela
prior infection.
3. Diffuse mild bladder wall thickening is unchanged, and may be due to
underdistention, however infection cannot be excluded. Recommend correlation
with urinalysis.
4. A 1.9 cm cystic lesion within the left adnexa is not changed since ___, however could be better evaluated with pelvic ultrasound if the patient
is postmenopausal.
5. Left adrenal adenoma.
RECOMMENDATION(S): 1. Recommend correlation with urinalysis.
2. Pelvic ultrasound for 1.9 cm left adnexal cystic lesion the patient is
postmenopausal.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified abdominal pain
temperature: 97.8
heartrate: 102.0
resprate: nan
o2sat: 100.0
sbp: nan
dbp: nan
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ yo F with PMH recurrent
nephrolithiasis s/p lithotripsy with retained stones presented
to
___ ___ with persistent nausea/vomiting/abdominal pain found
to have nonobstructing nephrolithiasis and ___.
# N/V/Abdominal pain - CTU showed non obstructing
nephrolithiasis
and unchanged bladder wall thickening. UA was ___ WBC,few
bacteria but neg nitrite. Previously proteus was sensitive to
Bactrim/cefepime and E. Coli pansensitive. On Bactrim . WBC 7,
afebrile without clinical or imaging signs of recurrent
infection. CT without any findings for pyelonephritis (e/o old
infection)
- Tolerated Bactrim well. Abd pain improved on discharge and was
able to eat full diet without issues. Likely due to renal colic
and dehydration
- Zofran ODT 4 mg q8hr prn and resume Bactrim to complete ___nemia, microcytic with known SS trait as well as iron
deficiency in past. Not actively bleeding. Hgb 8.3 on discharge
which has been baseline in past. Will ask PCP to ___ with CBC to
ensure stable.
# Acute Renal Failure - cr 1.5-->1.4-->1.3 on discharge. Likely
dehydration
- notified PCP to see if recheck on Cr and restarting lisinopril
40 as outpatient.
# Essential Hypertension - controlled
- Hold lisinopril with ___, Continue nifedipine on discharge
# Adnexal mass - stable since ___ but will need pelvic u/s to
further differentiate. Will ___ with PCP. Pt is pre-menopausal.
# Depression - celexa
TOBACCO USE:
- pt counseled on tobacco cessation. Nicotine patch ordered.
# Functional status: Ambulating
# Consults: None
# Diet: Regular
# Code status: Full
# Contact: Daughter ___ is HCP
Phone number: ___
Cell phone: ___
Discharge to home
Discharge took <30 minutes to prepare |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute renal failure
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ female with medical history notable for EtOH cirrhosis
decompensated with esophageal varices and hepatic
encephalopathy,
IDDM, depression, and anemia with recent hospitalization
requiring an ICU stay for altered mental status attributed to
hepatic encephalopathy and possible polypharmacy complicated by
urinary tract infection referred by ___ clinic for worsening
___. While at rehab, patient's labs are notable for worsening
anemia as well as an elevated creatinine to 2.1 (baseline 1.0).
Patient was seen in ___ clinic where her creatinine was
elevated to 2.5, referred to the ED for evaluation. While in
rehab, the patient was having very frequent bowel movements up
to
10 daily secondary to lactulose, was down titrated to 3 bowel
movements daily. Reports feeling generally fatigued and dizzy
while standing up. Denies any falls, syncope. Denies chest pain,
shortness of breath, fever, chills.
Of note patient was recently admitted (___) for toxic
metabolic encephalopathy thought to be secondary to hepatic
encephalopathy and overmedication. Course complicated by Coag
negative staph bacteremia (completed x2 week course of
vancomycin
___ and was also treated for UTI with Ceftriaxone. She was
discharged to rehab.
Patient was seen in ___ clinic on ___ for follow up of
worsening renal function. Her Cr during her last admission
peaked
at 1.9 and was 1.4 at time of discharge. her Cr at rehab was 2.1
and increased to 2.4 when checked at ___ clinic. ___ thought to be prerenal secondary to diarrhea vs
hepatorenal syndrome in setting of cirrhosis. Her urine sediment
showed no e/o AIN or ATN. Recommended admission for ___ with
plan
to hold nadolol in favor of non-renally cleared beta blocker and
recommended IV fluid challenge.
In the ED, initial VS were: T97.4, HR 73, BP 155/78, RR 18, O2
100% RA
Exam notable for: suprapubic tenderness, guaiac positive
EKG: Rate 66, normal sinus rhythm, no ST changes
Labs showed: Hb 7.6, BUN 26, Cr 2.5
UA Mod leuks, few bacteria nitrite negative
Imaging showed: Renal US with There is mild fullness of the
right
renal pelvis without frank hydronephrosis.
No significant postvoid residual.
Consults: Hepatology
Patient received: 1L normal saline, rifaxamin, gabapentin,
acetaminophen, sertraline
Transfer VS were: T97.2, HR 68, BP 142/85, RR 18, O2 100% RA
On arrival to the floor, patient reports her main complaint is
dizziness that has been ongoing for the last month. The
dizziness
is most notable with positional changes- sitting up in bed or
going from sitting to standing. Occassionally she feels that the
room is spinning, but usually feels more lightheaded. Notes
occasional dots of blood in her stool. Reports her dysrusia has
been improving since discharge. Reports cough and nasal
congestion over the weekend that has subsequently improved.
Denies fevers, chills, blurred vision, chest pain, shortness of
breath, abdominal pain, constipation or leg swelling.
Past Medical History:
Cirrhosis likely ___ NASH and ASH.
Depression.
Obesity.
IDDM.
Hypothyroidism.
Peripheral neuropathy.
Asthma.
Iron-deficiency anemia.
History of nephrolithiasis.
History of cholecystectomy with LBX ___.
History of left breast abscess.
Social History:
___
Family History:
Mother, deceased, liver cancer, unknown if was primary or
secondary.
Father, deceased, alcohol-excess.
Sister, alive, DM.
Physical Exam:
ADMISSION EXAM:
===============
VS: 98.0 139 / 83 72 18 98 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: LLQ tenderness to palpation, nondistended, bowel sounds
present
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterexis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
===============
VS: 98.2 BP 132/85 Sitting 84 16 99 RA
GENERAL: NAD, sitting up on edge of bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: NT, ND. No rebound or guarding. Normoactive bowel
sounds. No organomegaly.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterexis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 08:47PM URINE HOURS-RANDOM
___ 08:47PM URINE HOURS-RANDOM
___ 08:47PM URINE UHOLD-HOLD
___ 08:47PM URINE GR HOLD-HOLD
___ 08:47PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG*
___ 08:47PM URINE RBC-1 WBC-11* BACTERIA-FEW* YEAST-NONE
EPI-6
___ 08:47PM URINE MUCOUS-RARE*
___ 03:57PM GLUCOSE-169* UREA N-23* CREAT-2.1* SODIUM-141
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17
___ 03:57PM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-1.9
___ 03:57PM WBC-5.0 RBC-3.09* HGB-7.7* HCT-24.0* MCV-78*
MCH-24.9* MCHC-32.1 RDW-21.9* RDWSD-61.8*
___ 03:57PM PLT COUNT-128*
___ 05:54AM GLUCOSE-91 UREA N-24* CREAT-2.1* SODIUM-142
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
___ 05:54AM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-71 TOT
BILI-0.3
___ 05:54AM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-3.1
MAGNESIUM-1.8
___ 05:54AM WBC-4.8 RBC-2.69* HGB-6.3* HCT-20.6* MCV-77*
MCH-23.4* MCHC-30.6* RDW-22.2* RDWSD-61.2*
___ 05:54AM PLT COUNT-123*
___ 05:54AM ___ PTT-31.2 ___
___ 10:30PM URINE HOURS-RANDOM
___ 10:30PM URINE UHOLD-HOLD
___ 10:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 10:30PM URINE RBC-1 WBC-4 BACTERIA-FEW* YEAST-NONE
EPI-2 TRANS EPI-<1
___ 07:19PM GLUCOSE-133* UREA N-26* CREAT-2.5* SODIUM-139
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16
___ 07:19PM ALT(SGPT)-16 AST(SGOT)-24 ALK PHOS-100 TOT
BILI-0.2
___ 07:19PM ALBUMIN-4.1
___ 07:19PM WBC-7.0 RBC-3.28* HGB-7.6* HCT-25.3* MCV-77*
MCH-23.2* MCHC-30.0* RDW-22.4* RDWSD-61.4*
___ 07:19PM NEUTS-73.7* LYMPHS-18.2* MONOS-6.3 EOS-1.1
BASOS-0.4 IM ___ AbsNeut-5.15 AbsLymp-1.27 AbsMono-0.44
AbsEos-0.08 AbsBaso-0.03
___ 07:19PM PLT COUNT-178
___ 07:19PM ___ PTT-32.3 ___
DISCHARGE LABS:
===============
___ 04:49AM BLOOD WBC-4.9 RBC-3.69* Hgb-9.4* Hct-29.2*
MCV-79* MCH-25.5* MCHC-32.2 RDW-22.5* RDWSD-64.0* Plt ___
___ 04:49AM BLOOD Glucose-94 UreaN-34* Creat-2.2* Na-140
K-3.2* Cl-95* HCO3-28 AnGap-17
___ 04:49AM BLOOD ALT-13 AST-19 LD(LDH)-155 AlkPhos-72
TotBili-0.3
___ 04:49AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.5*
MICROBIOLOGY:
=============
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING:
========
RENAL U/S ___:
IMPRESSION:
Minimal fullness of the right renal pelvis without frank
hydronephrosis.
No significant postvoid residual.
CT ABDOMEN PELVIS WITHOUT CONRAST ___:
IMPRESSION:
1. No acute intra-abdominopelvic abnormality.
2. Findings consistent with cirrhosis and portal hypertension.
New small
volume abdominopelvic ascites.
RENAL U/S ___:
FINDINGS:
The right kidney measures 11.2 cm. The left kidney measures 11.9
cm. There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
No hydronephrosis or nephrolithiasis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.9 s, 51.7 cm; CTDIvol = 12.3 mGy (Body) DLP = 636.4
mGy-cm.
Total DLP (Body) = 636 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There is hypertrophy of the left lobe of the liver in addition
to a diffusely nodular contour in keeping with known cirrhosis. There is no
evidence of focal lesions within the limitations of an unenhanced scan. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The CBD
measures up to 7 mm, unchanged since prior. The gallbladder is surgically
absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen measures up to 14 cm in craniocaudal dimension. No focal
lesions are seen on this nonenhanced study.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis. There is trace perihepatic free fluid as well as a
small amount of free fluid within the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There are shotty retroperitoneal and mesenteric lymph nodes.
There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. The paraumbilical vein is recanalized.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Nodular densities in the subcutaneous tissues of the anterior
abdominal wall are likely related to injections.
IMPRESSION:
1. No acute intra-abdominopelvic abnormality.
2. Findings consistent with cirrhosis and portal hypertension. New small
volume abdominopelvic ascites.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with unexplained ___ on CKD and prior fullness
noted in her kidney// Persistence of fullness in kidney, concern for possible
retroperitoneal fibrosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
The right kidney measures 11.2 cm. The left kidney measures 11.9 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
No hydronephrosis or nephrolithiasis.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Acute renal failure, Weakness
Diagnosed with Acute kidney failure, unspecified
temperature: 97.4
heartrate: 73.0
resprate: 18.0
o2sat: 100.0
sbp: 155.0
dbp: 78.0
level of pain: 8
level of acuity: 2.0 | PATIENT SUMMARY:
================
___ year old female with PMH notable for decompensated EtOH
cirrhosis with esophageal varices and hepatic encephalopathy,
IDDM, depression, and anemia with recent prolonged
hospitalization for hepatic encephalopathy, UTI, and staph
bacteremia referred by ___ clinic for evaluation and
management of ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydromorphone
Attending: ___
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ pmhx asthma, presenting with 1 day of n/v, inability to
tolerate PO.
Sudden onset night of ___, 20+ episodes of NBNB emesis. No PO
in
this time.
+ epigastric pain.
+ intermittent dyspnea
- hx abdominal surgeries
- dysuria, hematuria, diarrhea.
Patient reports usually drinks 1 glass of wine before bed. On
___ (2 night prior to onset of symptoms) she drank several
shots of hard liquor for her sister's birthday party. She does
not remember exactly how many.
She denies illicit drug use, IVDU.
Usually cooks at home, no raw seafood. No travel.
Sexually active with 1 partner, intermittent condom usage.
In the ED:
- Initial vital signs were notable for:
97.6, 99, 116/85, 18, 98% RA
Orthostatic positive:
146/104 sitting -> 117/94 standing
- Exam notable for:
Dry MM
+Nystagmus
+RUQ & epigastric TTP
- Labs were notable for:
AST/ALT: 200/103
Leukopenia
Mild thrombocytopenia
AG 21
UCG negative
- Studies performed include:
RUQUS
1. No acute findings.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
- Patient was given:
2L LR
Zofran 4mg IV
On my evaluation she gives the above history.
Past Medical History:
Asthma
Depression
Social History:
___
Family History:
Mother EtOH abuse
Physical Exam:
ADMISSION EXAM:
VITALS:
133/72, HR Mid-80's, 99% RA
GEN: tired appearing, not in distress
HEENT: MM tacky, scattered cervical LAD
CV: RRR s1s2 no mrg
PULM: CTA anteriorly
GI: Mild RUQ & epigastric tenderness
EXT: WWP non-edematous
DISCHARGE EXAM:
VITALS: 24 HR Data (last updated ___ @ 648)
Temp: 98.2 (Tm 98.2), BP: 124/86 (124-141/86-94), HR: 87
(74-87), RR: 16, O2 sat: 97%, O2 delivery: RA
GEN: tired appearing, not in distress
HEENT: MMM
CV: RRR s1s2 no mrg
PULM: CTA anteriorly
GI: Mild RUQ & epigastric tenderness
EXT: WWP non-edematous
Pertinent Results:
ADMISSION LABS:
___ 11:15PM PLT COUNT-143*
___ 11:15PM NEUTS-54.3 ___ MONOS-15.2* EOS-0.6*
BASOS-0.9 IM ___ AbsNeut-1.78 AbsLymp-0.94* AbsMono-0.50
AbsEos-0.02* AbsBaso-0.03
___ 11:15PM WBC-3.3* RBC-4.74 HGB-15.0 HCT-44.9 MCV-95
MCH-31.6 MCHC-33.4 RDW-15.0 RDWSD-52.2*
___ 11:15PM HCV Ab-NEG
___ 11:15PM HBsAg-NEG HBs Ab-NEG HBc Ab-NEG
___ 11:15PM ALBUMIN-5.1
___ 11:15PM LIPASE-41
___ 11:15PM ALT(SGPT)-103* AST(SGOT)-200* ALK PHOS-83 TOT
BILI-1.2
___ 11:15PM GLUCOSE-96 UREA N-9 CREAT-0.9 SODIUM-141
POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-27 ANION GAP-21*
___ 02:35AM URINE RBC-3* WBC-31* BACTERIA-MANY* YEAST-NONE
EPI-2
___ 02:35AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-80* BILIRUBIN-SM* UROBILNGN-8* PH-6.5
LEUK-LG*
___ 02:35AM URINE UCG-NEGATIVE
DISCHARGE LABS:
___ 09:38AM BLOOD WBC-2.9* RBC-4.33 Hgb-13.9 Hct-41.2
MCV-95 MCH-32.1* MCHC-33.7 RDW-14.6 RDWSD-51.3* Plt ___
___ 09:38AM BLOOD Glucose-97 UreaN-6 Creat-0.8 Na-142 K-4.0
Cl-99 HCO3-26 AnGap-17
___ 09:38AM BLOOD ALT-88* AST-162* AlkPhos-71 TotBili-1.0
___ 09:38AM BLOOD Calcium-9.8 Phos-2.4* Mg-1.6
___ 11:15PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-PND
___ 09:38AM BLOOD CMV IgG-PND CMV IgM-PND CMVI-PND EBV
IgG-PND EBNA-PND EBV IgM-PND EBVI-PND
IMAGING:
___ RUQUS
IMPRESSION:
1. No acute findings. Specifically, normal appearance of the
gallbladder
without sonographic findings to suggest acute cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
RECOMMENDATION(S): Radiological evidence of fatty liver does
not exclude
cirrhosis or significant liver fibrosis which could be further
evaluated by ___. This can be requested via the Liver
Center (FibroScan), or the Radiology Department with MR
___, in conjunction with a GI/Hepatology consultation"
*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
Discharge Disposition:
Home
Discharge Diagnosis:
#Nausea and emesis
#Transaminitis
#Leukopenia
#Thrombocytopenia
#Dehydration
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) PORT
INDICATION: History: ___ with ruq pain, vomiting// r/o cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: No relevant comparison study.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 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.
Spleen length: 7.7 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.5 cm
Left kidney: 9.9 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No acute findings. Specifically, normal appearance of the gallbladder
without sonographic findings to suggest acute cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
RECOMMENDATION(S): Radiological evidence of fatty liver does not exclude
cirrhosis or significant liver fibrosis which could be further evaluated by
___. This can be requested via the ___ (FibroScan), or the
Radiology Department with MR ___, in conjunction with a GI/Hepatology
consultation" *
* Chalasani et al. The diagnosis and management of nonalcoholic fatty liver
disease: Practice guidance from the ___ Association for the Study of
Liver Diseases. Hepatology ___ 67(1):328-357
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dizziness, Vomiting
Diagnosed with Dizziness and giddiness
temperature: 97.6
heartrate: 99.0
resprate: 18.0
o2sat: 98.0
sbp: 116.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | BRIEF HOSPITAL SUMMARY:
========================
___ with PMH of asthma, presenting with 1 day of n/v, inability
to
tolerate PO in setting of recent alcohol use. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
Pelvic Ultrasound - ___
History of Present Illness:
Ms. ___ is a ___ female with no pertinent past
medical history presented to outside hospital for abdominal
pain,
n/v, found to have liver mass.
Ms. ___ states symptoms started on ___ with
fatigue and vague RUQ pain. Over the course of the week she
developed associated lightheadedness and nausea/emesis on day
prior to presentation. Also endorses shaking chills and referred
pain to right scapula on day of admission. Denies chest pain,
cough, shortness of breath. Denies dysuria, urgency. She has had
a history of an appendectomy and breast mass excision as below.
At ___, bedside ultrasound at the OSH showed no gallstones
and a normal gallbladder wall. Chest x-ray without focal
infiltrate. Was febrile to 102.8 at outside hospital, labs
remarkable for WBC 7.8, hemoglobin 11.8, platelets 285, LFTs
within normal limits. Given Toradol and Zofran. CT abdomen with
indeterminate hepatic lesion segment 4B with no adjacent mass
effect, no size given. Transferred here for further w/u.
In the ED, initial vitals: 98.4 66 105/41 15 98% RA
Vitals remained stable in ED.
- Labs notable for: WBC 6.1, normal chem panel and lactate, flu
negative, UA unremarkable.
- Imaging notable for:
Abd U/S w/ Indeterminate mass at the bifurcation of the left and
right anterior portal veins, measuring 5.1 x 4.8 x 3.5 cm
without
significant internal vascularity. There is a small focus of
hypoechogenicity measuring 1.2 cm within the lesion. The lesion
is incompletely characterized CT and ultrasound, a hepatic MRI
would be warranted for further evaluation.
2. No ascites. The main portal vein is patent.
- Patient was given: IV zosyn, IV ___ @ 75/hr
- Consults: Hepatology consulted who recommended re-read of OSH
CT scan and do RUQUS
-- Ok to start empiric Abx for suspected abscess
-- Based on these findings, will see if additional imaging is
needed
-- obtain blood cultures
-- if desired, medicine team should formally consult hepatology
team once admitted
On arrival to the floor, patient reports the above history.
States nausea has not bothered her for several hours but still
with fatigue and ___ right upper quadrant pain described as
aching in nature. Denies ongoing fever, chills,
lightheadedness,
chest pain, palpitations, bright red blood per rectum, melena,
leg swelling. Patient states that she had a breast mass excised
at ___ last year and was taking ibuprofen
intermittently after that time but does not know much more
information about this. She states that she was told that she
should take another medication whose name she cannot remember if
breast symptoms recur. She has never taken oral contraceptives.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative less otherwise noted in the HPI.
Past Medical History:
- Breast mass, excised at ___ in ___. Patient does not recall
details
- Appendectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ Temp: 99.6 PO BP: 145/86 HR: 64 RR: 18 O2 sat:
100%
O2 delivery: RA
GENERAL: Pleasant, lying in bed comfortably with husband, sister
and kids at bedside. AAOx3
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nondistended, no splenomegaly.
Tenderness to moderate palpation in RUQ with no rebound or
guarding
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 717)
Temp: 98.6 (Tm 98.6), BP: 122/65 (114-130/61-78), HR: 59
(59-69), RR: 18, O2 sat: 98% (98-100), O2 delivery: Ra
GENERAL: Pleasant, lying in bed, AAOx3
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nondistended, no splenomegaly.
Tenderness to moderate palpation in RUQ with no rebound or
guarding
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 04:43AM BLOOD WBC-6.1 RBC-3.98 Hgb-10.3* Hct-33.3*
MCV-84 MCH-25.9* MCHC-30.9* RDW-16.9* RDWSD-51.5* Plt ___
___ 04:43AM BLOOD Neuts-50.1 ___ Monos-13.2*
Eos-12.6* Baso-0.7 Im ___ AbsNeut-3.03 AbsLymp-1.40
AbsMono-0.80 AbsEos-0.76* AbsBaso-0.04
___ 04:43AM BLOOD ___ PTT-29.3 ___
___ 04:43AM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-136 K-3.9
Cl-106 HCO3-22 AnGap-8*
___ 04:43AM BLOOD ALT-8 AST-13 AlkPhos-73 TotBili-0.3
___ 04:43AM BLOOD Lipase-27
___ 04:43AM BLOOD Albumin-3.4* Calcium-8.6 Phos-4.0 Mg-2.0
___ 06:23AM BLOOD Lactate-0.7
___ 05:57PM URINE Color-Straw Appear-Hazy* Sp ___
___ 05:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:25AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICROBIOLOGY:
=============
___ 5:57 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 6:15 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 6:10 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
DISCHARGE LABS:
===============
___ 04:52AM BLOOD WBC-6.2 RBC-4.24 Hgb-10.8* Hct-35.3
MCV-83 MCH-25.5* MCHC-30.6* RDW-16.9* RDWSD-50.8* Plt ___
___ 04:52AM BLOOD Neuts-37.4 ___ Monos-11.7
Eos-21.1* Baso-0.5 Im ___ AbsNeut-2.31 AbsLymp-1.79
AbsMono-0.72 AbsEos-1.30* AbsBaso-0.03
___ 04:52AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-139
K-4.3 Cl-106 HCO3-23 AnGap-10
___ 04:52AM BLOOD ALT-10 AST-18 LD(LDH)-209 AlkPhos-82
TotBili-<0.2
___ 04:52AM BLOOD Albumin-3.6 Calcium-9.1 Phos-4.5 Mg-2.1
IMAGING/STUDIES:
================
___ Abd US:
IMPRESSION:
1. Indeterminate mass at the bifurcation of the left and right
anterior portal veins, measuring 5.1 x 4.8 x 3.5 cm without
significant internal vascularity. There is a small focus of
hypoechogenicity measuring 1.2 cm within the lesion. The lesion
is incompletely characterized CT and ultrasound, a hepatic MRI
would be warranted for further evaluation.
2. No ascites. The main portal vein is patent.
___ Hepatic MRI
IMPRESSION:
1. The liver lesion correspond to a simple hemangioma.
2. Left external iliac lymphadenopathy measuring 11 x 25 mm.
3. T2 bright left adnexal lesion to be further characterized by
either pelvic ultrasound or pelvic MRI.
___ Pelvic US:
IMPRESSION:
1. No left adnexal abnormality. Previously seen T2 bright
signal in the left adnexa likely represents a small amount of
free fluid.
2. When read in conjunction with the same day MRI, cystic
spaces in the right adnexa likely represent an ovarian or
paraovarian cyst. However, hydrosalpinx could also be
considered. Significant shadowing from fibroid uterus obscures
fine detail of the right adnexa which is deep in the pelvis.
3. Fibroid uterus.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ female with no pertinent past medical history
presented to outside hospital for abdominal pain, nausea, and vomiting// eval
for liver pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside hospital CT ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. Within the left hepatic lobe, near the bifurcation of
the left and right anterior portal vein, there is a slightly hyperechoic round
mass measuring 5.1 x 4.8 x 3.5 cm, without significant internal vascularity.
Within the lesion, there is a focal area measuring approximately 1.2 cm of
hypoechogenicity. The main portal vein is patent with hepatopetal flow. The
left and right anterior portal veins appear patent where visualized. There is
no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The head and body of the pancreas was within normal limits. The
tail was not visualized.
SPLEEN: Normal echogenicity.
Spleen length: 10.1 cm
KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is no evidence of masses, stones, or hydronephrosis
in the kidneys.
Right kidney: 10.7 cm
Left kidney: 10.2 cm
IMPRESSION:
1. Indeterminate mass at the bifurcation of the left and right anterior portal
veins, measuring 5.1 x 4.8 x 3.5 cm without significant internal vascularity.
There is a small focus of hypoechogenicity measuring 1.2 cm within the lesion.
The lesion is incompletely characterized CT and ultrasound, a hepatic MRI
would be warranted for further evaluation.
2. No ascites. The main portal vein is patent.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: ___ year old woman with new liver mass on ___ ultrasound//
Eval liver mass
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 10 mL Gadavist.
COMPARISON: Abdominal pelvis CT from ___
FINDINGS:
Lower Thorax: No pleural effusion.
Liver: The liver is not cirrhotic and there is no hepatic steatosis. At the
junction of segment ___, there is a lobulated 4.1 x 6.2 cm lesion
demonstrating T2 hyper signal as well as peripheral progressive nodular
contrast enhancement. These features are suggestive of a hemangioma.
Biliary: No intra or extra biliary duct dilatation. The gallbladder is
unremarkable.
Pancreas: The pancreas is normal in signal and bulk. No main duct dilatation.
No focal pancreatic lesion.
Spleen: The spleen is normal in size and is homogeneous.
Adrenal Glands: Unremarkable. No focal lesion.
Kidneys: The kidneys are unremarkable. No hydronephrosis. No focal lesion.
Gastrointestinal Tract: No bowel obstruction. No ascites.
Lymph Nodes: There is a 11 x 25 mm left iliac adenopathy (series 2, image 18).
Vasculature: No abdominal aortic aneurysm. Left renal vein is retroaortic.
Osseous and Soft Tissue Structures: No concerning bone lesions. The adnexal
region is partially covered on this exam. However, there is a T2 bright
density in the pelvis measuring 6.5 x 2.9 cm likely originating from the left
adnexa. This is to be further characterized by pelvic ultrasound or pelvic
MRI.
IMPRESSION:
1. The liver lesion correspond to a simple hemangioma.
2. Left external iliac lymphadenopathy measuring 11 x 25 mm.
3. T2 bright left adnexal lesion to be further characterized by either pelvic
ultrasound or pelvic MRI.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with left adnexal mass and enlarged left
external iliac lymph node seen as incidental findings on MRI liver//
Characterize left adnexal mass seen on MRI
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: MRI performed earlier on the same date.
FINDINGS:
The uterus is anteverted and measures 10.3 x 8.3 x 7.9 cm. There are multiple
uterine masses consistent with fibroids. The largest measures 5.2 x 4.4 x 4.9
cm in the left anterior uterus. The second largest is an exophytic fibroid
arising from the right fundus measuring 4.1 x 4.1 x 3.6 cm. The endometrium
is distorted and partially obscured by adjacent fibroids, but where seen
appears normal and measures 1.0 cm.
The ovaries are not well seen due to shadowing from the adjacent fibroid
uterus. However, the left ovary is normal in appearance. In the right
adnexa, are anechoic, avascular cystic spaces, which may represent a ovarian
or paraovarian cyst versus a hydrosalpinx. There is a small amount of free
fluid.
IMPRESSION:
1. No left adnexal abnormality. Previously seen T2 bright signal in the left
adnexa likely represents a small amount of free fluid.
2. When read in conjunction with the same day MRI, cystic spaces in the right
adnexa likely represent an ovarian or paraovarian cyst. However, hydrosalpinx
could also be considered. Significant shadowing from fibroid uterus obscures
fine detail of the right adnexa which is deep in the pelvis.
3. Fibroid uterus.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Abnormal CT
Diagnosed with Unspecified abdominal pain
temperature: 98.4
heartrate: 66.0
resprate: 15.0
o2sat: 98.0
sbp: 105.0
dbp: 41.0
level of pain: 6
level of acuity: 3.0 | SUMMARY:
========
Ms. ___ is a ___ woman with no pertinent past
medical history who initially presented to ___ for
abdominal pain, n/v and was transferred to ___ for further
workup of liver mass. Found to have hepatic hemagioma on MRI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left arm pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with PMMhx of HTN, anxiety, bipolar who presented to
the ED yesterday with sharp left arm pain. He describes pain on
the entire left arm from left arm with radiation without
involvement of chest. Denies associated dyspnea or diaphoresis.
Symptoms failed to resolve after taking 2 tabs of ASA. Denies
recent injuries, falls, or heavy lifting.
He did not have any associated nausea, vomiting, abdominal pain,
and substernal chest discomfort. He did have some shortness of
breath that was transient earlier in the day. Reports an episode
like this before, but it was very transient and went away
shortly. His last stress test was in ___, which showed no local
inducible ischemia on TTE. At the time of evaluation, his pain
improved to a dull ache in his biceps area.
In the ED, initial vitals were 98.0 66 195/87 20 100% on room
air. Initial labs with WBC 7.8 Hbg/Hct 13.3/37.4 Plt 174.
Chemistries panel normal, with BUN/Cr ___.
Troponins and CKMB were negative x2. He was observed overnight
and had ETT stress test performed on ___, significant for
subjective "fluttering" and atypical symptoms with nonspecific
ST segment changes noted at peak exercise and transient ST
segment elevation noted inferiorly early post-exercise.
Cardiology recommended initiation of treatment for unstable
angina and admission to Cardiology Service for likely cardiac
catheterization.
He was given ASA 325mg, atorvastatin 80mg, metoprolol tartrate
12.5mg, and started on a heparin drip. He was also given his
home medications of lisinopril 20mg, divalproex ___, and
citalopram 60mg.
Upon arrival to the floor, pt complained of left bicep pain that
was reproducible upon palpation.
Past Medical History:
PMH: htn, hypercholesterolemia, depression
PSH: left rotator cuff ___, left knee ___ and right big toe
surgery in remote past
Social History:
___
Family History:
NC
Physical Exam:
General: Well developed male, NAD
HEENT: NCAT, scleral anicteric.
Neck: JVP at clavicle
CV: Distant heart sounds, grossly RRR, normal S1/S2
Lungs: CTABL
Abdomen: soft, NT/ND
Ext: No edema. 2+ pulses throughout. Reproducible left arm pain
upon palpation
Neuro: Alert, oriented
Skin: no rashes
PULSES: 2+ throughout
Pertinent Results:
___ 05:00AM BLOOD WBC-7.0 RBC-4.26* Hgb-12.8* Hct-37.1*
MCV-87 MCH-30.2 MCHC-34.6 RDW-13.6 Plt ___
___ 05:00AM BLOOD Glucose-97 UreaN-12 Creat-1.3* Na-140
K-4.2 Cl-101 HCO3-26 AnGap-17
___ 01:35AM BLOOD CK-MB-4 cTropnT-<0.01
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Omeprazole 40 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Divalproex (EXTended Release) 250 mg PO DAILY
5. Citalopram 60 mg PO DAILY
Discharge Medications:
1. Citalopram 60 mg PO DAILY
2. Divalproex (EXTended Release) 250 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Cyclobenzaprine 10 mg PO TID:PRN left arm pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth twice daily as
needed Disp #*20 Tablet Refills:*0
7. Indomethacin 50 mg PO TID Duration: 3 Days
RX *indomethacin 50 mg 1 capsule(s) by mouth 1 tablet every 8
hours for 3 days Disp #*9 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left arm pain, musculoskeletal etiology
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: ___ chest radiograph, CT torso ___
FINDINGS:
Heart size is normal. Aortic knob demonstrates minimal atherosclerotic
calcifications. Mediastinal and hilar contours are otherwise unremarkable. The
pulmonary vasculature is not engorged. Chronic interstitial opacities are re-
demonstrated in the lung bases, likely reflective of paraseptal emphysema as
seen on the prior CT torso. No focal consolidation, pleural effusion or
pneumothorax is present. No acute osseous abnormality is detected.
IMPRESSION:
No radiographic evidence for pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Arm pain
Diagnosed with PAIN IN LIMB, ABN CARDIOVASC STUDY NEC
temperature: 98.0
heartrate: 66.0
resprate: 20.0
o2sat: 100.0
sbp: 195.0
dbp: 87.0
level of pain: 5
level of acuity: 2.0 | # Left arm pain: Pt presented to the ED with sharp left arm
pain. Serial troponin and CK-MB were negative. No ischemic EKG
changes at rest. He underwent exercise tolerance test which was
indeterminate and was admitted initially for cardiac
catheterization. He was started on heparin gtt and full strength
ASA for heart protection.
Upon further examination, however, his left arm pain was very
reproducible on exam. Cardiac cath was thus deferred given
atypical presentation. Heparin gtt and ASA were also
discontinued. He was instead evaluated by nuclear stress test
with exercise, which was unremarkable.
Left arm pain is most likely MSK etiology. His ROM and
sensations were intact. He was discharged with a short course of
flexeril and was encouraged to follow-up with PCP. He was
advised against driving while taking flexeril due to drowsiness
side effects, esp given he is a ___.
# Gout: Pt with hx of gout not on maintenance medication.
Hospitalization course complicated by beginnings of gout flare.
He was discharged with 3 days of indomethacin and was
recommended to follow-up with PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizzyness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Interview in ___ and ___
Ms. ___ is a ___ woman with stage IIIC
high-grade serous ovarian carcinoma s/p suboptimal debulking and
adjuvant ___ most recently treated w/ Cycle 5 of
___ on ___.
She presents to ED today with 2 days of feeling "mareada".
primarily when she is walking she feels dizzy. Denies vertigo,
denies any presyncope or falls. no change in vision. has mild
HA
she attributes to anemia, improved w/ tylenol and drinking alot
of water. Also having nausea. No vomiting, sl ab pain in
epigastric region, no heartburn. BM regular to sl constipated
but
taking stool softeners. No chest pain or SOB. No numbness or
focal weakness.
Initial VS in ED 17:17 0 98.2 112 145/83 18 100%
Pt was given 1L NS and zofran and admitted to oncology
states her nausea improved with this but still feels lightheaded
w/ standing.
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No mouth sores, odynophagia, sinus tenderness,
rhinorrhea,
or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No vomiting, diarrhea, or abdominal pain. No hematochezia,
or
melena.
GU: No dysuria, hematuruia or frequency.
MSK: has chronic muscle aches and on prednisone, no joint pain
or
swelling
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness, paresthesias,
focal
weakness, or neurologic symptoms.
HEME: No bleeding or clotting
Past Medical History:
PAST ONCOLOGIC HISTORY: per OMR
Ms. ___ is a ___ woman with
ovarian carcinoma initially diagnosed in ___ after she
developed abdominal pain and vaginal discharge. Pelvic US showed
a complex right adnexal mass, and CA-125 was 555. MRI showed
large right adnexal lesion with heterogeneously
enhancing solid and cystic components, and moderate pelvic free
fluid. CT at ___ in ___ showed the mass as well as
retroperitoneal intercaval and left pelvic lymphadenopathy, and
a
nodular, thickened appearance of the omentum, two adjacent small
nodules in the left lower lung lobe, and a possible
pericardiophrenic lymph node. She underwent ex-lap, TAH/BSO,
radical resection of pelvic mass, appendectomy, and gastrocolic
omentectomy on ___. However, debulking was suboptimal; she
had residual disease along the right hemidiaphragm and the nodal
disease involving the aorta, vena cava, and left internal iliac
artery, as well as disease within the rectosigmoid colon.
Lymphovascular invasion was noted in the hilum of the left
ovary.
She received adjuvant carboplatin/Taxol from ___.
On ___, she reported back pain, constipation, gas, and
abdominal pains, as well as intermittent nausea and abdominal
swelling. Although her CA-125 had decreased slightly, it had not
normalized, and we obtained repeat imaging to assess for disease
recurrence. CT ___ showed signs of disease recurrence.
On ___ she was started on ___
___ - C1D1 ___
___ - C2D1 ___
___ - C3D1 ___
___ - C4D1 ___
OTHER PAST MEDICAL HISTORY:
-Back pain, since ___. MRI ___ showed
no
evidence of malignant lesions.
-Seasonal allergies
-Osteoarthritis
PAST SURGICAL HISTORY:
-Sinus surgery
-D&C x2
Social History:
___
Family History:
Patient does not have any biological children. She has limited
contact with her sister and half siblings.
She has only
reconnected with her mother since receiving this cancer
diagnosis w/ no knowledge of other malignancies in fmialy
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD,cushingoid
VITAL SIGNS: 98.6 122/80 80 99%RA
HEENT: MMM, no OP lesions
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no
clonus,
no dysmetria w/ FTN and HTS testing, gait slow but normal
DISCHARGE EXAM:
VS: 98.6 108/56 91 16 100 RA
General: NAD
HEENT: MMM, no OP lesions
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: grossly intact, ambulating and mentating well
Pertinent Results:
ADMISSION LABS:
___ 07:00PM BLOOD WBC-3.2* RBC-2.58* Hgb-8.5* Hct-24.7*
MCV-96 MCH-33.1* MCHC-34.5 RDW-20.3* Plt ___
___ 07:00PM BLOOD Neuts-61.9 ___ Monos-2.2 Eos-0.6
Baso-0.2
___ 07:00PM BLOOD Glucose-105* UreaN-15 Creat-0.7 Na-141
K-3.9 Cl-100 HCO3-26 AnGap-19
___ 07:00PM BLOOD Calcium-9.1 Phos-3.9 Mg-2.2
___ 10:55PM BLOOD Lactate-1.4
___ 09:54PM URINE Color-Straw Appear-Clear Sp ___
___ 09:54PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
DISCHARGE LABS:
___ 05:16AM BLOOD WBC-2.6* RBC-2.34* Hgb-7.5* Hct-22.5*
MCV-96 MCH-32.2* MCHC-33.4 RDW-19.8* Plt ___
___ 05:16AM BLOOD Neuts-43* Bands-0 Lymphs-57* Monos-0
Eos-0 Baso-0 ___ Myelos-0
CXR ___: No evidence of acute cardiopulmonary process.
BLOOD CULTURES X 2 NGTD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nasuea
2. PredniSONE 20 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Prochlorperazine 10 mg PO Q6H:PRN nasuea
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Omeprazole 40 mg PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nasuea
5. PredniSONE 20 mg PO DAILY
6. Prochlorperazine 10 mg PO Q6H:PRN nasuea
Discharge Disposition:
Home
Discharge Diagnosis:
Ovarian Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ with a history of ovarian cancer, presenting with malaise,
fatigue, on chemo // ? PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest dated ___.
FINDINGS:
There is no evidence of focal consolidation, pleural effusion, pneumothorax,
or pulmonary edema. The cardiomediastinal silhouette is within normal limits.
A rounded density in the superior portion of the left lower lobe correlates
with a calcified granulomas seen on recent CT. A right-sided Port-A-Cath is
noted with the tip terminating in the right atrium.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: HISPANIC/LATINO - SALVADORAN
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with NAUSEA, VOLUME DEPLETION, UNSPECIFIED, MALIGN NEOPL OVARY
temperature: 98.2
heartrate: 112.0
resprate: 18.0
o2sat: 100.0
sbp: 145.0
dbp: 83.0
level of pain: 0
level of acuity: 3.0 | Ms ___ is a ___ woman with stage IIIC high-grade
serous ovarian carcinoma s/p suboptimal debulking and adjuvant
___. Now w/ recurrent disease inc periaortic
lymphadenopathy and a sm paracolic mass currently treated w/
cycle 5 of ___ on ___. She was admitted w/
dizziness/malaise and anemia.
#Dizziness/malaise - most likely due to anemia. has difficult
time describing but does not appear to be vertigo more likely
lightheadedness vs nausea/malaise from chemo. has good po intake
and hydration. Improved with one unti of blood. lytes/LFTs ok,
BCx/Ucx pending from ED. EKG showed NSR. Orhtostatics negative.
#Symptomatic anemia - gradually downtrending. Likely BM
suppression from chemo but also at risk for microhemorrhage in
GI tract as on steroids and avastin. Continued PPI adn gave one
unit of pRBCs.
#Recurrent ovarian Ca - started on ___ with
plans to pursue maintenance bevacizumab, based on the OCEANS
trial. Just completed C5 as above.
#Hx myositis/inflammatory myositis - on maintenance pred 20mg
daily for morning stiffness/arthritis and prior CK elevation in
___ per Dr ___. Has MTX prescribed, per last note was to
start methotrexate weekly ___ but she denies taking this.
ACCESS: port
CODE STATUS: Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Stadol / Robaxin / Valium / Stadol / Robaxin / Valium / morphine
/ codeine / Vicodin / Percocet / Dilaudid / latex / Penicillins
/ Tetracycline / Septra / Keflex / Phenergan / Compazine / Tigan
/ Dilantin
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP with stent placement
History of Present Illness:
___ year old woman with CAD s/p prior MI, sjogren's, MS, athma,
recurrent abdominal pain associated with abnormal LFT's who
underwent ERCP on ___ who now returns with post ERCP
pancreatitis. She says that following her procedure she had mild
abdominal pain that responded to tylenol. After returning home,
she had worsening abdominal pain, nausea and vomiting. She saw
her PMD who referred her to her local ED who sent her to ___
where she had the procedure. Labs notable for lipase elevation
to 12,000. LFT's normal. She was admitted for management of
post-ERCP pancreatitis. She denies fevers or chills. No blood in
stool or in vomitus.
ROS: negative except as above
Past Medical History:
1. Coronary artery disease with MI status post stent in ___.
2. rheumatoid arthritis.
3. Sjogren's syndrome.
4. Multiple sclerosis.
5. Sciatica.
6. Asthma.
7. Trigeminal neuralgia.
8. Endometriosis.
9. Sensorineural hearing loss.
10. Migraine headaches.
11. Temporomandibular joint syndrome, status post surgery.
12. Osteoarthritis.
13. Postherpetic neuralgia.
15. Interstitial lung disease.
16. Status post cholecystectomy.
17. Status post appendectomy.
18. Status post hysterectomy and oophorectomy.
Social History:
___
Family History:
Multiple family members with CAD.
Physical Exam:
Vitals: 99.7 147/83 83 16 99%RA
Gen: uncomfortable but not distressed
HEENT: no jaundice, dry mm
CV: rrr, no r/m/g
Pulm: CTAB
Abd: soft, moderate epigastric tenderness
Ext: no edema
Neuro: alert and oriented x 3
Pertinent Results:
___ 08:20PM GLUCOSE-97 UREA N-16 CREAT-0.6 SODIUM-136
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
___ 08:20PM ALT(SGPT)-16 AST(SGOT)-31 ALK PHOS-171* TOT
BILI-0.4
___ 08:20PM ___
___ 08:20PM ALBUMIN-3.5
___ 08:20PM WBC-7.1# RBC-3.29* HGB-8.8* HCT-28.2* MCV-86
MCH-26.8* MCHC-31.3 RDW-15.0
___ 08:20PM PLT COUNT-450*
ERCP ___:
A mild dilation was seen at the main duct.
S/P cholecystectomy.
Otherwise normal biliary tree.
A biliary stent was placed successfully.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Restasis (cycloSPORINE) 0.05 % ophthalmic bid
4. Fentanyl Patch 25 mcg/h TD Q72H
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. FoLIC Acid 1 mg PO DAILY
7. HydrOXYzine 25 mg PO Q6H:PRN itch
8. Hyoscyamine 0.125 mg PO TID
9. Meperidine 100 mg PO Q6H:PRN pain
10. Metoprolol Succinate XL 12.5 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. FoLIC Acid 1 mg PO DAILY
5. Hyoscyamine 0.125 mg PO TID
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Restasis (cycloSPORINE) 0.05 % ophthalmic bid
10. Fentanyl Patch 25 mcg/h TD Q72H
11. HydrOXYzine 25 mg PO Q6H:PRN itch
12. Meperidine 100 mg PO Q6H:PRN pain
13. Methylprednisolone 4 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Post-ERCP pancreatitis
SECONDARY:
possible gouty arthritis, right great toe
possible erythema nodosum, BLE
rheumatoid arthritis
osteoarthritis
Sjogren's disease
spinal stenosis
CAD s/p PCI ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Abdominal pain after ERCP.
TECHNIQUE: Chest, AP upright and lateral.
COMPARISON: None.
FINDINGS:
The heart is normal in size. The mediastinal and hilar contours are
unremarkable. There is no pleural effusion or pneumothorax. The lungs appear
clear. No free air is identified. A biliary stent projects over the right
upper quadrant of the abdomen. There are also surgical clips projecting over
the right upper quadrant, mostly commonly seen after cholecystectomy.
IMPRESSION:
No evidence of acute disease. No free air identified.
Radiology Report
EXAMINATION: TOE(S), 2+ VIEW RIGHT
INDICATION: ___ year old woman with RA now with acute right great toe pain,
erythema, edema // r/o chondrocalcinosis, evaluate right great toe
TECHNIQUE: Three views right great toe.
COMPARISON: None
FINDINGS:
No erosion is seen. There is mild to moderate degenerative change at the first
metatarsophalangeal joint, with joint space narrowing and osteophyte
formation. There is degenerative change at the interphalangeal joints of the
second toe. No chondrocalcinosis is evident.
IMPRESSION:
Degenerative changes as above, no erosion or chondrocalcinosis is identified.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with CHRONIC PANCREATITIS
temperature: 98.4
heartrate: 77.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 76.0
level of pain: 7
level of acuity: 3.0 | ___ year old woman with CAD, recurrent abdominal pain who had
recent ERCP for evaluation who now returns with post-ERCP
pancreatitis.
# post-ERCP pancreatitis: Slow to improve on fentanyl PCA,
transitioned to home regimen of fentanyl patch with demerol po
prn breakthrough pain. Diet gradually advanced. GI followed.
Resolved by the day of discharge,
# ? acute gouty arthritis vs cellulitis: Developed acute
inflammation of distal right great toe on ___, consistent with
acute gout. XR without chondrocalcinosis. Did not definitively
exclude septic joint but no clear effusion to tap, and pt very
well-appearing clinically. Resumed outpatient methylprednisolone
4mg that same day, as her dx of RA was not known by the medical
team and therefore steroids had not been ordered. Rheumatology
was consulted and assessed this as possible cellulitis. She was
not treated with abx given very small, well-demarcated area with
some inconsistent features. She will f/u closely with her
regular rheumatologist next week. Pt very informed about her
health issues and will reliably f/u as recommended.
# new BLE nodules: Noted on same day ___ as above great toe
inflammation. Rheumatology also evaluated these and assessed
them as likely pancreatitis-associated panniculitis vs erythema
nodosum secondary to underlying autoimmune disease. In the
former case, they should resolve on their own. If they persist,
she will need further evaluation; pt expressed understanding and
will f/u with PCP and rheumatologist.
# CAD s/p PCI ___: stable on ASA, Plavix, metoprolol.
# Spinal stenosis, chronic back pain: stable on above analgesic
regimen, ambulating with cane
# Sjogren's: stable on restasis and hyoscyamine.
# Asthma: stable on home meds, IS.
Other chronic conditions were stable and there were no changes
in her previous medications.
PPX - heparin sc
Code - full
Contact - mother, ___ |
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, weakness, hypotension, acute renal failure, dehydration,
and chest pain.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ ___-speaking man with relapsed DLBCL s/p
cycle #1 DHAP last week admitted for nausea, weakness,
hypotension, acute renal failure, dehydration, and chest pain.
Completed cycle #1 ___. Over the last few days, he has
become gradually weaker with nausea, dizziness, and chest
pressure last a few minutes each time. He has not been taking
any analgesics. He also describes right eye blurriness which
started on the day of admission.
.
ROS: He has been constipated for several days. He denies F/C/S,
wght loss, headache, dyspnea, cough, abdominal pain, back pain,
diarrhea, hematochezia, hematuria, other urinary symptoms,
parasthesias, or rash. All other ROS were negative.
Past Medical History:
1. Non-Hodgkin's lymphoma.
2. Latent TB infection, consulted by Dr. ___ with
previous treatment.
3. Hep B core positivity.
4. Hypertension.
5. Atrial fibrillation, currently on metoprolol; warfarin
stopped for chemotherapy.
6. Glaucoma.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Admission Physical Examination:
VS: T 97.6F, BP 98/62, HR 78, RR 18, O2 Sat 94% RA, wght 134.4
lbs, ht 63in.
GEN: A&O, NAD.
HEENT: Sclerae non-icteric, EOM intact, o/p clear, dry MM.
Neck: Supple, no thyromegaly, no cervical LAD.
CV: S1S2, RRR, no MRG.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
BACK: No spine, rib, or iliac tenderness.
ABD: Soft, non-tender, non-distended, no HSM, no inguinal LAD.
EXTR: No edema or calf tenderness. No finger clubbing. No
axillary LAD.
DERM: No rash.
Neuro: Strength ___, sensation to touch normal, down-going
plantar reflexes, no focal deficits.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS:
___ 09:35AM BLOOD WBC-27.1*# RBC-4.91 Hgb-14.9 Hct-42.6
MCV-87 MCH-30.4 MCHC-35.1* RDW-11.7 Plt Ct-47*#
___ 09:35AM BLOOD Neuts-95.6* Lymphs-2.6* Monos-1.6*
Eos-0.2 Baso-0
___ 09:35AM BLOOD UreaN-63* Creat-2.3*# Na-128* K-3.4
Cl-82* HCO3-34* AnGap-15
___ 09:35AM BLOOD Albumin-3.8 Calcium-7.8* Phos-5.2* Mg-2.4
___ 09:35AM BLOOD ALT-27 AST-15 LD(LDH)-245 CK(CPK)-22*
AlkPhos-103 TotBili-2.7*
___ 09:35AM BLOOD cTropnT-<0.01
___ 12:49PM BLOOD Lactate-1.6
.
___ CXR: IMPRESSION:
1. No evidence of pneumonia. Chronic biapical scarring and
pleural thickening is stable.
2. Mild cardiomegaly is stable.
.
___ u/s:The liver is normal echogenicity with no
focal lesions present. The portal
vein is patent with hepatopetal flow. The CBD measures 8 mm and
is normal. The gall bladder is normal with no evidence of
cholelithiasis.
IMPRESSION: Normal liver, gall bladder ultrasound.:
.
Medications on Admission:
Amlodipine 10 mg PO once a day.
Lamivudine 100 mg PO DAILY.
Lisinopril 5 mg PO DAILY.
Metoprolol succinate 25 mg Tablet Extended Release 24 hr PO BID.
Codeine sulfate ___ mg PO q4HR PRN pain.
Allopurinol ___ mg PO DAILY.
Bactrim 400-80 mg PO once a day.
Acyclovir 400 mg PO q8HR.
Aspirin 81mg PO daily (NOT TAKING)
Warfarin stopped last admission for chemo.
Discharge Medications:
1. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q 8H
(Every 8 Hours).
Disp:*60 Tablet(s)* Refills:*0*
6. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*300 Tablet(s)* Refills:*0*
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
8. potassium & sodium phosphates ___ mg Powder in Packet
Sig: One (1) Powder in Packet PO twice a day for 10 days: Do not
take together with calcium.
Disp:*20 Powder in Packet(s)* Refills:*0*
9. prochlorperazine maleate 5 mg Tablet Sig: ___ Tablets PO Q6H
(every 6 hours) as needed for Nausea.
Disp:*30 Tablet(s)* Refills:*0*
10. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. pentamidine 300 mg Recon Soln Sig: One (1) Inhalation once
a month.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Acute renal failure
Atrial fibrillation with rapid ventricualr rate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Shortness of breath and increased white count, question
pneumonia.
COMPARISON: Chest radiograph on ___.
FINDINGS: PA and lateral views of the chest. The biapical fibrosis and
bronchiectasis, right greater than left, representing scarring is unchanged.
Mild cardiomegaly is stable. There is no evidence of pneumonia. No pleural
effusion. No pneumothorax. Mediastinal and hilar contours are normal and
stable.
IMPRESSION:
1. No evidence of pneumonia. Chronic biapical scarring and pleural
thickening is stable.
2. Mild cardiomegaly is stable.
Radiology Report
INDICATION: ___ year old man with DLBCL admitted for dehydration, chest pain.
New hyperbilirubinemia.
COMPARISON: CT from ___.
FINDINGS:
The liver is normal echogenicity with no focal lesions present. The portal
vein is patent with hepatopetal flow. The CBD measures 8 mm and is normal.
The gall bladder is normal with no evidence of cholelithiasis.
IMPRESSION: Normal liver, gall bladder ultrasound.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: CP/ LIGHTHEADEDNESS/HYPOTENSION
Diagnosed with CHEST PAIN NOS, LEUKOCYTOSIS, UNSPECIFIED
temperature: 98.5
heartrate: 90.0
resprate: 18.0
o2sat: 99.0
sbp: 106.0
dbp: 81.0
level of pain: 5
level of acuity: 2.0 | Assessment/Plan: ___ man with relapsed DLBCL s/p cycle #1 DHAP
last week admitted for nausea, weakness, hypotension, acute
renal failure, dehydration, and chest pain. Completed cycle #1
___.
.
#Acute renal failure:Likely due to dehyfration adn hypotension.
Recent cipslatin could also be the cause. Pt received IVF and
amlodipine and as well as lisinopril were held to avoid
hypotension. Nephrotoxins were held as well. Crea did trend down
and on d/c crea close to baseline. AM cortisol level was wnl.
.
# Neutropenia:On admission pt with leukocytosis likley due to
neulasta. During hospital stay he developed neutropenia and was
treated with neupogen with resolution of neutropenia.Pt was also
given was cipro ppx while he was neutropenic because of age and
risk of nosocomial infections.
.
#Low grade temp:Pt had a low grade temp after neutropenia
resolved. Blood cxs and urine cxs obtained and were negative.
.
# Thrombocytopenia:Appropriate response to plts on ___.
Most likely due to chemo as both neutropenic and
thrombocytopenia.
.
# Metabolic alkalosis: Due to contraction/dehydration. Resolved
with IV fluids.
.
# Hyperbilirubinemia: Resolved, likely due to volume
depletion/hypotension. HBV viral load ___ negative.RUQ U/S
was normal.
.
# DLBCL: Completed cycle #1 DHAP ___ was
continued during hospital stay (uric acid was slightly
elevated).TMP-SMX was held because of renal failure and pt
started on pentamidine ppx ( received first dose on
___ restarted prior to d/c.
.
# Chronic hepatitis B: Continue outpatient lamivudine.
.
# Atrial fibrillation:Pt with episodes of RVR and blood pressure
reamained relatively low. Metoprolol was changed to metoprolol
tartate 12.5 TID for better rate control. Anticoagulation was
discontinued priori to admission because of anticipated
thrombocytopenia.TSH wnl.
.
# Constipation: Laxatives PRN, stool softeners.
.
#CHF: No evidence of volume overload. Held lisinopril due to
hypotension. Cont metoprolol but changed scheduling and dosage ,
as above.
.
# Chest Pain (chest): On admission.Initial EKG
unremarkable.Telemetry a.fib. CEx2 negative. No recurrent
episodes during hospital stay.
.
#hypomagnesemia/hypokalemia/hypocalcemia: Likely all due to
cisplatin. Start continued oral repletions adn will be followed
closely as an outpt as well..
.
# FEN: Regular. Encourage po fluids.
.
# GI PPx: PPI and bowel regimen.
.
# DVT PPx: Pneumoboots.
.
# CODE: FULL.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
fluocinolone acetonide
Attending: ___.
Chief Complaint:
L leg weakness
Major Surgical or Invasive Procedure:
T5 laminectomy and T2-T7 posterior fusion
DL POC placement ___
History of Present Illness:
___ ___ speaking male with a PMH of HTN, T2DM, HLD,
Fe-deficiency anemia, L iliac lesion of unknown etiology;
presenting with L leg pain and weakness. Over past month,
patient
has needed to use a cane and then walker; has had two falls over
the past week. Also has BLE numbness which has contributed to
the
falls, initially weakness and numbness was on left side and
continues to be worse on that side but is bilateral now. No HS,
no LOC, no HA, no dbl vision, no n/v. Patient does have left
shoulder pain from his falls but no other pain in his body.
Patient has no numbness in his arms but does feel weak in the
left arm only after his fall.
In the ED, 97.1 107 141/63 18 98% RA.
Labs notable for BMP, CBC WBC 7.4, H/H 6.8/23.9, Plt 485.
Lactate
of 5.1 -> 4.8
Physical exam notable for LLE ___ strength, with intact rectal
pressure.
The patient 1L, acetaminophen 1000 mg, and 4 mg IV morphine.
Shoulder xray with destructive left mid/distal clavicle osseous
process.
MRI spine with enhancement of T3, T4, T5, T6, and T11 vertebral
bodies consistent with malignancy, likely representing
metastasis. There is intradural, extramedullary extension at the
level of T5-T6 causing severe cord compression, with tumor
extension at T11 without significant cord compression.
He was seen by neurosurgery who felt that his neurological
deficits were inconsistent with a lesion at the T5 level. They
recommended no surgical intervention at this time and
recommended
oncology work up.
Upon arrival to the floor, the patient is interviewed with a
___ interpreter via phone. He reports that he came to the
hospital because he had 2 falls, one occurring the night prior
to
admission and once on the morning of presentation. He reports
that the falls were mechanical, that he felt weak in both legs.
He denies lightheadedness. He reports that his legs have been
getting progressively weak, prompting him to begin using a
walker
over the past month. He also reports that he has pain in his
legs and his pelvic area. He endorses significant left shoulder
pain, slight headache which she attributes to not eating, nausea
without vomiting, 20 pound weight loss occurring over the last 3
months. He otherwise denies fevers, chills, shortness of
breath,
abdominal pain, difficulty urinating, urinary incontinence,
bowel
incontinence. He reports that he had a single episode of bloody
diarrhea which occurred in ___. He reports he had an EGD
which was negative and was asked to get a colonoscopy. On the
day of the colonoscopy, he was feeling very weak, so colonoscopy
was subsequently not performed. He reports he had a normal
colonoscopy approximately ___ years ago. He otherwise denies
hematuria, rashes, bruises.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Hypercholesterolemia
- Type 2 diabetes
- Hypertension
- Diabetic retinal microaneurysm
- GERD
- Nephritis and nephropathy
- Continue corporis
- Folliculitis
- Anemia
- Achilles tendinitis
- Unstable angina
- Constipation
- Iron deficiency anemia
- Prior removal of a skin lesion (noncancerous)
Social History:
___
Family History:
Denies relevant family history. Denies family
history of cancer. Denies family history of heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 98.3 PO 169 / 80 93 18 95 Ra
GENERAL: Alert and in no apparent distress, follows commands
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes moist
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GU: foley in place
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, 4+/5 RLE strength, 4+/5
___ strength, decreased sensation of the lateral shins noted
bilaterally, upper extremity strength 5 out of 5 bilaterally for
grip strength, biceps flexion, biceps extension, no spinal
tenderness, plus tenderness over the left clavicle
SKIN: No rashes or ulcerations noted
NEURO: CN II-XII, alert, oriented, face symmetric, gaze
conjugate
with EOMI, speech fluent, answers questions appropriately,
strength exam as noted above, +rectal tone
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1103)
Temp: 98.1 (Tm 98.9), BP: 133/69 (120-144/64-69), HR: 84
(76-92), RR: 20 (___), O2 sat: 95% (95-99), O2 delivery: RA
HEENT: MMM, thrush absent, R lower inside lip aphthous ulcer.
no
other lesions noted.
CV: RR, NL S1S2 no S3S4, no MRG. Chest tenderness over L
___ ribs
PULM: Normal work of breathing, CTAB
ABD: soft, nontender, distention, BS+
BACK: surgical incision, healing no dressing. No new hematoma
appreciated. normal w/o erythema or edema.
LIMBS: WWP. B/L trace ankle edema, tenderness at L HIP.
SKIN: White patchy discoloration on legs/groin, arms nontender,
nonpruitic.
ACCESS: DL chest port c/d/i
Pertinent Results:
ADMISSION LABS:
==============
___ 03:39PM LACTATE-4.8*
___ 02:47PM GLUCOSE-128* UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-25 ANION GAP-17
___ 02:47PM estGFR-Using this
___ 02:47PM ALT(SGPT)-24 AST(SGOT)-30 ALK PHOS-108 TOT
BILI-0.3
___ 02:47PM LIPASE-25
___ 02:47PM ALBUMIN-3.2* CALCIUM-9.9 PHOSPHATE-4.5
MAGNESIUM-1.8
___ 02:47PM WBC-7.4 RBC-4.89 HGB-6.8* HCT-23.9* MCV-49*
MCH-13.9* MCHC-28.5* RDW-22.9* RDWSD-35.1
___ 02:47PM NEUTS-81.5* LYMPHS-6.1* MONOS-9.7 EOS-1.7
BASOS-0.3 IM ___ AbsNeut-6.06 AbsLymp-0.45* AbsMono-0.72
AbsEos-0.13 AbsBaso-0.02
___ 02:47PM PLT COUNT-485*
___ 02:42PM LACTATE-5.1*
IMAGING:
========
CT ___ ___: No acute intracranial process.
CXR ___:
1. Left mid/distal clavicle destructive osseous process better
evaluated on thoracic spine CT and dedicated glenohumeral
radiograph from same day.
2. Bibasilar atelectasis and mild cardiomegaly.
Shoulder XR ___:
1. Destructive left mid/distal clavicle osseous process, with
likely underlying fractures.
2. Age-indeterminate, left posterolateral sixth rib deformity
likely representing a healing fracture is better assessed on
dedicated chest radiograph.
CT SPINE C/T/L ___
IMPRESSION:
1. T5 compression fracture without retropulsion, likely acute,
with small
perivertebral hematoma. Mottled lucency of the T3, T4 and T6
vertebral bodies
concerning for metastatic involvement.
2. Left clavicle destructive osseous process and additional
osseous lesions
as described above may represent malignancy/metastasis.
3. Morphologically abnormal enlarged mediastinal and
retrocrural lymph nodes.
Correlate with full oncology workup.
RECOMMENDATION(S): Dedicated oncology workup is recommended,
if not
previously performed.
IMPRESSION:
1. No cervical spine fracture or malalignment.
2. Partially imaged left destructive lesion of lateral/mid
clavicle.
IMPRESSION:
1. No acute fracture or traumatic malalignment of the lumbar
spine.
2. Retroperitoneal and partially imaged left pelvic sidewall
lymphadenopathy, which may be secondary to malignancy.
3. Partially imaged diffuse left iliac bone sclerosis which may
represent malignancy or metastasis.
RECOMMENDATION(S): Oncologic workup is recommended if not
previously
performed.
MRI spine C/T ___:
IMPRESSION:
1. Pathologic compression fracture of the T5 vertebral body with
approximately
50% vertebral body height loss.
2. Vertebral body metastatic disease involving the T3 through T6
and T11
vertebral bodies with posterior soft tissue component at T3, T5
and T11.
3. There is severe spinal canal stenosis at T5 caused by
retropulsed material
from the fracture and circumferential involvement of the spinal
canal.
4. Soft tissue obliteration of the bilateral T4-T5, bilateral
T5-T6 and right
T11-T12 neuroforamen.
5. Multilevel degenerative changes of the cervical spine with
disc protrusion
at C3-C4 resulting in remodeling of the ventral cord but no cord
signal
abnormality.
6. Mild degenerative changes along the lumbar spine without
significant spinal
canal stenosis or neural foraminal narrowing.
CT BIOPSY ___
IMPRESSION:
Technically successful CT-guided biopsy of the soft tissue
component of the
large left iliac lesion.
PATHOLOGIC DIAGNOSIS: ___
Left iliac mass, biopsy:
HIGH GRADE B-CELL LYMPHOMA MORPHOLOGICALLY CONSISTENT WITH
DIFFUSE LARGE
B-CELL LYMPHOMA; SEE NOTE.
Note: Sections show fibrotic tissue and skeletal muscle
FISH: POSITIVE for GAIN of MYC and REARRANGEMENT of MYC with
LOSS 3'MYC.
CT A/P ___:
1. Destructive lesion centered in left iliac bone with soft
tissue extension
into the adjacent iliacus and gluteal musculature may represent
metastatic
disease but is also concerning for primary malignancy such as
osteosarcoma.
2. Multiple hypoenhancing hepatic and splenic lesions concerning
for metastases.
3. Retroperitoneal, mesenteric, and pelvic lymphadenopathy.
Chest
IMPRESSION:
No evidence of primary it malignancy arising in the chest.
Lungs essentially clear. Mild mediastinal lymph node
enlargement, probably pathologic. No vital structures
compromised.
Extensive skeletal malignancy, detailed above. Important
features of thoracic spine involvement are detailed report of
the thoracic spine MRI performed on ___.
MR ___ ___:
IMPRESSION:
1. Approximately 2.4 x 2.3 cm enhancing soft tissue mass
centered at the right
greater wing of the sphenoid bone with underlying osseous
destruction as seen
on CT from ___ is concerning for metastasis. The
mass slightly
bulges into the right orbit contacting the right lateral rectus
muscle without
definitive evidence for tumoral invasion. The lesion does
extend into the
temporal fossa with involvement of the right temporalis muscle.
2. The lesion likely erodes through the inner table of the right
greater wing
of the sphenoid. There is thickening and enhancement of the
dura overlying
the right anterior temporal lobe adjacent to the greater wing of
the sphenoid,
potentially reactive in nature.
3. No evidence of intracranial metastasis. No acute
intracranial
abnormalities.
4. Additional findings described above.
___:
PATHOLOGIC DIAGNOSIS:
Epidural mass, biopsy:
HIGH GRADE B-CELL LYMPHOMA MORPHOLOGICALLY CONSISTENT WITH
DIFFUSE LARGE
B-CELL LYMPHOMA; SEE NOTE.
Note: Sections show fibrotic tissue
TSPINE XR ___:
IMPRESSION:
The patient is status post T2 through T7 posterior fusion with
vertical rods
and transpedicular screws at T 2, T3, T4, T6 and T7.
Re-demonstrated is a
compression deformity of T5. There is no evidence of hardware
related
complications or interval change in alignment. Skin staples
remain present.
The visualized lungs are grossly apart from probable atelectasis
seen in the
left lung base
TTE ___:
IMPRESSION: EF >75% Moderate symmetric left ventricular
hypertrophy with normal cavity size, and hyperdynamic
regional/global systolic function. No valvular pathology or
pathologic flow identified. Normal estimated pulmonary artery
systolic pressure.
LENIS ___: No evidence of deep venous thrombosis
in the left lower extremity veins.
CT pelvis ___:
IMPRESSION:
1. Overall unchanged large destructive lytic lesion encompassing
the left
hemipelvis. This was characterized CT examination from ___
and biopsied
on that same day, with pathology consistent with known DLBCL.
2. The patient is at high risk for left iliac pathologic
fracture from normal
weight bearing. Recommend orthopedic consultation regarding
weight bearing
restrictions.
3. Additional metastasis in the distal left femur is also noted.
4. Metastatic left iliac and retroperitoneal adenopathy are
again noted.
HIP XR ___
IMPRESSION:
There are extensive lytic lesions in the left ilium, ischium and
pubic bones.
Additional lytic lesions are also seen in the right inferior
trochanteric
region and proximal left femur. There is a pathological
fracture through the
right lesser trochanter with superior and anterior displacement.
No acute
fracture is seen in the left hip or pelvis. There is no evidence
of
dislocation. There are mild degenerative changes in the
bilateral hips and
lower lumbar spine.
KUB ___: IMPRESSION: Unremarkable.
CXR ___
IMPRESSION:
Heart size and mediastinum are stable. Spinal hardware has been
inserted in
the interim. Lungs overall clear. There is no pneumothorax.
There is no
appreciable pleural effusion.Central venous line tip terminates
in the proximal right atrium.No pulmonary edema. No pleural
effusion. No pneumothorax.
MR complete spine and pelvis ___:
IMPRESSION:
1. Extensive tumor involvement in the pelvis, with replacement
of nearly the
entire left hemipelvis by a large destructive lesion centered in
the left
iliac wing. A soft tissue component of the mass is within the
vicinity of the
sciatic nerve, however the nerve does not appear to be invaded.
There is bone
marrow involvement in the left hemi-sacrum, however there does
not appear to
be invasion of the sacral neuroforamen.
2. Bone marrow replacing lesion in the left femoral diaphysis.
3. Bone marrow replacing lesion in the right iliac bone
extending to the mid
to inferior aspect of the right SI joint as well as a lesion in
the right
lesser trochanter with redemonstration of a pathologic avulsion
fracture at
the right trochanter.
4. Extensive muscular edema in the bilateral hips, left greater
than right,
including partial tears of the left gluteus tendons, avulsion of
the proximal
left iliotibial band and partial-thickness injury of the distal
right gluteus
minimus tendon. Associated left greater than right greater
trochanteric
bursitis.
5. Left pelvic sidewall lymphadenopathy, not significantly
changed.
IMPRESSION:
1. Interval resolution of previously severe spinal canal
narrowing and cord
compression at T5 due status post interval T5 laminectomy and
posterior spinal
fusion, T2-T7. There is no longer any identifiable high-grade
spinal
narrowing, nor any spinal cord compression.
2. Possible short-segment cord signal abnormality in the right
aspect of the
cord at the level of T5 at the area prior compression, although
cord is
somewhat obscured due to mild artifact from hardware.
3. Re-demonstration of probable metastatic lesions within the
T3-T6 vertebral
bodies, with moderate height loss of T5, unchanged.
4. Unchanged T11 probable metastatic lesion.
5. Unchanged obliteration of the left T4-5 and bilateral T5-6
neural foramina
due to soft tissue extension of T5 tumor.
6. Mild right C4-5, moderate right T10-11, and mild right T11-12
neural
foraminal narrowing is unchanged.
7. No evidence of cervical or lumbar spine metastasis.
8. Small left layering pleural effusion.
IMPRESSION:
Postoperative changes as described.
CXR ___:
IMPRESSION:
There is a right chest wall Port-A-Cath with the tip terminating
in the upper
right atrium.Linear opacities in the lung bases most likely
represent subsegmental
atelectasis. There is no focal consolidation, pleural effusion
or
pneumothorax. The cardiomediastinal silhouette is stable in
appearance.
There is posterior spinal fusion hardware in the upper thoracic
spine.
Back US ___:
IMPRESSION: Heterogeneously echogenic, avascular collection in
the subcutaneous tissues along the surgical incision may reflect
a hematoma, more completely evaluated
on the recent MRI. Superinfection cannot be excluded.
CT C/T/L ___:
IMPRESSION:
1. Patient body habitus and partially visualized thoracic spinal
fusion
hardware limits examination.
2. Within limits of study, no definite evidence of acute
cervical spine
fracture.
3. Multilevel cervical spondylosis, better evaluated on ___ full
spine contrast MRI.
4. Partially visualized clavicles again demonstrate left
midclavicle
destructive lesion.
5. Approximately 1 cm right supraclavicular lymph node with
findings
concerning for malignancy, as described.
6. Within limits of study, no definite evidence of enhancing
paravertebral or
paraspinal mass.
7. Please see concurrently obtained contrast lumbar spine CT for
description
of lumbar spine structures.
IMPRESSION:
1. Study is limited secondary to patient body habitus and spinal
fusion
hardware streak artifact.
2. Postsurgical changes related to T2-T7 fusion with T5
laminectomy.
3. Interval enlargement of fluid collection overlying the
thoracic spine
surgical bed compared to prior MR, the superior extent of which
is
incompletely imaged, but extends inferiorly to the spinous
process of T9.
While findings may represent postoperative seroma, differential
considerations
of hematoma, or infectious or inflammatory etiologies are not
excluded on the
basis of this examination. If clinically indicated, consider
correlation with
fluid sampling. Recommend follow-up imaging to resolution.
4. Diffuse metastatic osseous involvement of the bilateral
clavicles, sternum,
thoracic vertebral bodies, and left scapula, with soft tissue
destruction of
the bilateral clavicles with associated comminuted fractures as
described.
5. Grossly stable narrowing at the left T4-5 and bilateral T5-6
neuroforamina,
better demonstrated on recent full spine MRI.
6. Left paraesophageal lymphadenopathy, with additional
nonspecific
mediastinal lymph nodes as described. Differential
considerations include
infectious, inflammatory, and neoplastic etiologies.
7. New thickening along the left major fissure. If clinically
indicated,
consider correlation with dedicated chest imaging.
8. Several regions of hypodensity within the visualized liver,
which were not
well evaluated on prior imaging studies. If concern for hepatic
metastatic
lesions, consider hepatic MRI for further evaluation.
9. Please see concurrently obtained cervical spine and lumbar
spine CT reports
for description of cervical and lumbar findings.
IMPRESSION:
1. New pathologic left iliac bone fracture likely extending into
the superior
acetabulum. The large underlying metastatic lesion is better
characterized on
pelvic MRI obtained 1.5 weeks prior.
2. Sacral and right iliac bone metastases are not definitely
seen on current
examination, which may be related to differences in technique.
3. Necrotic lymphadenopathy as described.
4. Multilevel lumbar spondylosis without definite evidence of
moderate or
severe bony vertebral canal narrowing, better evaluated on ___
full spine MRI
___ aspiration ___:
IMPRESSION: Successful US-guided aspiration of a heterogeneous
Fluid collection in the dorsal chest wall.
MICROBIOLOGY:
=============
All cultures negative
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-6.5 RBC-3.72* Hgb-7.9* Hct-25.8*
MCV-69* MCH-21.2* MCHC-30.6* RDW-UNABLE TO RDWSD-UNABLE TO Plt
___
___ 12:00AM BLOOD Neuts-94* Lymphs-4* Monos-1* Eos-0*
Baso-1 AbsNeut-6.11* AbsLymp-0.26* AbsMono-0.07* AbsEos-0.00*
AbsBaso-0.07
___ 12:00AM BLOOD Hypochr-3+* Anisocy-1+* Poiklo-1+*
Microcy-3+* Spheroc-2+* Target-2+* Schisto-1+* Tear Dr-1+* RBC
Mor-SLIDE REVI
___ 12:00AM BLOOD Glucose-94 UreaN-19 Creat-0.6 Na-143
K-4.5 Cl-105 HCO3-24 AnGap-14
___ 12:00AM BLOOD ALT-23 AST-13 LD(LDH)-402* AlkPhos-187*
TotBili-0.3
___ 12:00AM BLOOD Calcium-7.6* Phos-3.9 Mg-1.9
___ 12:01AM BLOOD calTIBC-242* Ferritn-2394* TRF-186*
___ 06:25AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 04:00AM BLOOD PEP-NO SPECIFI FreeKap-35.7*
FreeLam-31.4* Fr K/L-1.14 b2micro-3.0*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY
2. Alaway (ketotifen fumarate) 0.025 % (0.035 %) ophthalmic
(eye) DAILY
3. Loratadine 10 mg PO DAILY
4. Lidocaine 5% Ointment 1 Appl TP DAILY
5. Colchicine 0.6 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. GlipiZIDE 10 mg PO BID
8. Lisinopril 5 mg PO DAILY
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
10. Simvastatin 20 mg PO QPM
11. Polyethylene Glycol 17 g PO DAILY
12. Ferrous GLUCONATE 240 mg PO DAILY
13. Januvia (SITagliptin) 100 mg oral DAILY
14. Gabapentin ___ mg PO QHS
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Filgrastim-sndz 300 mcg SC Q24H
4. Glargine 14 Units Breakfast
Glargine 14 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Morphine SR (MS ___ 15 mg PO Q12H
6. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Mild
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Vitamin D ___ UNIT PO 1X/WEEK (TH) Duration: 7 Doses
Weekly, last dose is ___. Gabapentin 600 mg PO QHS
11. Gabapentin 300 mg PO BID
12. Alaway (ketotifen fumarate) 0.025 % (0.035 %) ophthalmic
(eye) DAILY
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
14. Lidocaine 5% Ointment 1 Appl TP DAILY
15. Loratadine 10 mg PO DAILY
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Polyethylene Glycol 17 g PO DAILY
18. Simvastatin 20 mg PO QPM
19. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Diffuse large Bcell Lymphoma
SECONDARY DIAGNOSIS:
===================
s/p T5 lamenectomy and T2-T7 fusion
pathologic Left iliac bone fracture
T2DM
Thrush
Cancer associated pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder
pain, fall.// eval fracture, bleed, infection
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: Total DLP (Head) = 903 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
There is no evidence of acute large territorial infarction, intracranial
hemorrhage, edema, or large mass.
There is prominence of the ventricles and sulci suggestive of age-related
cerebral volume loss.
No acute osseous abnormalities seen. There is a tiny mucous retention cyst in
the right maxillary sinus. Otherwise, the partially imaged paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The orbits demonstrate
no acute abnormalities.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder
pain, fall.// eval fracture, bleed, infection
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 470 mGy-cm.
COMPARISON: None.
FINDINGS:
Destructive changes are noted involving the of the left lateral/mid clavicle
likely complicated with a pathologic fracture, partially imaged concerning for
metastatic disease.
Cervical spinal alignment is normal. No definite cervical spine fracture.
There is no severe canal or foraminal narrowing.There is no prevertebral
edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
1. No cervical spine fracture or malalignment.
2. Partially imaged left destructive lesion of lateral/mid clavicle.
NOTIFICATION: Final report impression was discussed with ___, M.D.
by ___, M.D. on the telephone on ___ at 6:44 pm, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST
INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder
pain, fall.// eval fracture, bleed, infection
TECHNIQUE: Contiguous axial images obtained through the thoracic spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 1,234 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. There is a likely acute compression fracture of T5
without evidence of significant retropulsion a greater than 50% loss of
vertebral body height. Adjacent perivertebral soft tissue is noted possibly
representing hematoma. No additional thoracic spine fracture. However, a
mottled appearance of the T3, T4 and T6 vertebral bodies also concerning for
metastatic infiltration. There is a partially imaged destructive process of
the left mid and distal clavicle (2:9). Partial imaging of the right distal
clavicle demonstrates a moth-eaten appearance.
There are morphologically abnormal mediastinal and retrocrural lymph nodes may
represent malignancy.
IMPRESSION:
1. T5 compression fracture without retropulsion, likely acute, with small
perivertebral hematoma. Mottled lucency of the T3, T4 and T6 vertebral bodies
concerning for metastatic involvement.
2. Left clavicle destructive osseous process and additional osseous lesions
as described above may represent malignancy/metastasis.
3. Morphologically abnormal enlarged mediastinal and retrocrural lymph nodes.
Correlate with full oncology workup.
RECOMMENDATION(S): Dedicated oncology workup is recommended, if not
previously performed.
NOTIFICATION: Final impression was discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:46 pm, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST
INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder
pain, fall.// eval fracture, bleed, infection
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE:
Total DLP (Body) = 926 mGy-cm.
COMPARISON: None.
FINDINGS:
There is diffuse mixed sclerotic and lytic changes of the partially imaged
left iliac bone which may represent malignancy. No evidence annual lying
pathologic fracture.
Alignment is normal. No acute fractures are identified. There is no evidence
of severe spinal canal or neural foraminal stenosis. There is no prevertebral
soft tissue swelling.
Limited imaging of the abdomen and pelvis demonstrates retroperitoneal and
partially imaged left pelvic sidewall lymphadenopathy measuring up to 2 cm in
short axis diameter (for example pericaval and left pelvic sidewall nodes,
2:61, 101) which may represent malignancy. There is moderate aortic
atherosclerotic disease.
There is relative hypoattenuation of the blood pool which may represent
anemia.
IMPRESSION:
1. No acute fracture or traumatic malalignment of the lumbar spine.
2. Retroperitoneal and partially imaged left pelvic sidewall lymphadenopathy,
which may be secondary to malignancy.
3. Partially imaged diffuse left iliac bone sclerosis which may represent
malignancy or metastasis.
RECOMMENDATION(S): Oncologic workup is recommended if not previously
performed.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: *** CODE CORD *** History: ___ with LLE weakness, c/f
malignancyIV contrast to be given at radiologist discretion as clinically
needed// eval cord compression
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of Gadavist contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: CT of the entire spine from ___
FINDINGS:
CERVICAL:
There is mild retrolisthesis of C3 on C4 and C4 on C5. Vertebral body height
and alignment is otherwise preserved. There is multilevel degenerative disc
disease with grossly preserved disc space heights. Bone marrow signal
intensity is within normal limits.
At C2-C3, there is a shallow disc bulge, facet joint arthropathy and
uncovertebral hypertrophy but no spinal canal stenosis or significant neural
foraminal narrowing.
At C3-C4, there is a central/right paracentral disc protrusion with remodeling
of the ventral cord but no cord signal abnormality. In addition, there is
facet joint arthropathy, mild ligamentum flavum thickening and uncovertebral
hypertrophy but no spinal canal stenosis or significant neural foraminal
narrowing.
At C4-C5, there is a posterior disc osteophyte complex, facet joint
arthropathy, mild ligamentum flavum thickening and uncovertebral hypertrophy,
no spinal canal stenosis but mild right neural foraminal narrowing.
At C5-C6, there is a posterior disc osteophyte complex, facet joint
arthropathy and mild ligamentum flavum thickening as well as uncovertebral
hypertrophy but no spinal canal stenosis or significant neural foraminal
narrowing.
At C6-C7, there is a shallow disc bulge, facet joint arthropathy, mild
ligamentum flavum thickening and uncovertebral hypertrophy but no spinal canal
stenosis or significant neural foraminal narrowing.
THORACIC:
There is increased STIR signal intensity in the T3 through T6 and T11
vertebral bodies with extension into the posterior elements and patchy
enhancement after contrast administration.
There is a T5 compression fracture with approximately 50% vertebral body
height loss. There is discontinuity of the posterior cortical border of the
T3 and T5 vertebral bodies with extra-axial enhancing soft tissue extending
posteriorly and resulting in mild narrowing of the spinal canal at T3 and
severe spinal canal stenosis at T5. The soft tissue component at the T3 level
is slightly asymmetric and more pronounced along the right aspect of the
ventral cord. At the T5 level, there is circumferential involvement around
the spinal canal.
The bilateral T5-T6 neuroforamen appear obliterated by soft tissue material.
There is mild neural foraminal narrowing at T4-T5 bilaterally.
There is an indistinct posterior border of the T11 vertebral body with
possible soft tissue cortical breakthrough (series 9, image 9) and a tumor
infiltrating posteriorly through the right pedicle along the right extra-axial
aspect of the spinal canal (series 13, image 27). The right T11-T12
neuroforamen appears partially obliterated by soft tissue material.
At T11-T12, there is also a shallow disc bulge, facet joint arthropathy and
moderate ligamentum flavum thickening but no significant spinal canal
stenosis.
The remainder of the thoracic vertebral bodies show appropriate alignment and
preserved vertebral body heights. There is no spinal canal stenosis or
significant neural foraminal narrowing at the remaining thoracic levels.
LUMBAR:
Vertebral body heights and alignment is preserved. There is mild degenerative
disc disease predominantly involving the L3-L4 and L5-S1 levels with grossly
preserved disc space heights. Bone marrow signal intensity is within normal
limits.
The axial postcontrast images of the lumbar spine are degraded by motion
artifact. Allowing for this limitation, no definitive enhancement of the
conus or cauda equina nerve roots is identified.
There is no spinal canal stenosis or significant neural foraminal narrowing
along the lumbar spine.
OTHER:
IMPRESSION:
1. Pathologic compression fracture of the T5 vertebral body with approximately
50% vertebral body height loss.
2. Vertebral body metastatic disease involving the T3 through T6 and T11
vertebral bodies with posterior soft tissue component at T3, T5 and T11.
3. There is severe spinal canal stenosis at T5 caused by retropulsed material
from the fracture and circumferential involvement of the spinal canal.
4. Soft tissue obliteration of the bilateral T4-T5, bilateral T5-T6 and right
T11-T12 neuroforamen.
5. Multilevel degenerative changes of the cervical spine with disc protrusion
at C3-C4 resulting in remodeling of the ventral cord but no cord signal
abnormality.
6. Mild degenerative changes along the lumbar spine without significant spinal
canal stenosis or neural foraminal narrowing.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ ___ speaking male with a PMH of HTN, T2DM, HLD,
anemia, enhancement of left iliac bone, destructive lesion of the clavicle,
and spine with T5 lesion with severe cord compression, consistent with disease
of unknown primary.// brain lesions
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: Head CT dated ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are within expected
limits in caliber and configuration. No suspicious parenchymal FLAIR signal
abnormality. There is no abnormal intracranial enhancement after contrast
administration. The major intracranial flow voids are preserved. The dural
venous sinus is patent.
Centered at the right greater wing of the sphenoid bone is an approximately
2.4 x 2.3 cm enhancing soft tissue mass with underlying osseous destruction,
also seen on CT from ___, concerning for metastatic disease. The
mass appears to slightly bulging into the right orbit contacting lateral
rectus muscle, although no definite invasion of lateral rectus muscle
identified. There is likely erosion through the inner table of the right
greater wing of the sphenoid. The lesion does appear to invade into the right
temporalis muscle (series 9, image 69). There is dural thickening and
enhancement of the anterior middle cranial fossa (series 9, image 65), likely
reactive in nature. No additional suspicious osseous lesions. There is mild
mucosal thickening of the ethmoid air cells and right maxillary sinus. The
remaining paranasal sinuses and bilateral mastoid air cells are unremarkable.
Other than the abnormality described above, the orbits are unremarkable.
IMPRESSION:
1. Approximately 2.4 x 2.3 cm enhancing soft tissue mass centered at the right
greater wing of the sphenoid bone with underlying osseous destruction as seen
on CT from ___ is concerning for metastasis. The mass slightly
bulges into the right orbit contacting the right lateral rectus muscle without
definitive evidence for tumoral invasion. The lesion does extend into the
temporal fossa with involvement of the right temporalis muscle.
2. The lesion likely erodes through the inner table of the right greater wing
of the sphenoid. There is thickening and enhancement of the dura overlying
the right anterior temporal lobe adjacent to the greater wing of the sphenoid,
potentially reactive in nature.
3. No evidence of intracranial metastasis. No acute intracranial
abnormalities.
4. Additional findings described above.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ ___ speaking male with a PMH of HTN, T2DM, HLD,
anemia, enhancement of left iliac bone, destructive lesion of the clavicle,
and spine with T5 lesion with severe cord compression, consistent with disease
of unknown primary.// investigate primary lesion
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen without and with
IV contrast. Initially the abdomen was scanned without IV contrast.
Subsequently a single bolus of IV contrast was injected and the abdomen and
pelvis was scanned in the portal venous phase, followed by a scan of the
abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 32.4 cm; CTDIvol = 11.0 mGy (Body) DLP = 348.9
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 10.9 s, 0.2 cm; CTDIvol = 145.3 mGy (Body) DLP =
29.1 mGy-cm.
4) Spiral Acquisition 10.6 s, 68.9 cm; CTDIvol = 9.9 mGy (Body) DLP = 677.4
mGy-cm.
5) Spiral Acquisition 5.1 s, 32.9 cm; CTDIvol = 11.0 mGy (Body) DLP = 354.7
mGy-cm.
Total DLP (Body) = 1,412 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There are numerous poorly defined hypoenhancing lesions throughout the liver.
Near the largest in segment 6 measures up to 2.2 cm (06:56). There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
contains gallstones but is otherwise unremarkable.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Hypoenhancing lesion in the midportion of the spleen measures up to
1.4 cm (06:59). A similar lesion in the inferior tip of the spleen measures
up to 1.1 cm (6:68).
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
No hydronephrosis. A 1.0 cm simple cyst arises exophytically from the
interpolar region of the right kidney. Subcentimeter hypodensities in left
kidney are too small to characterize, but also likely represent simple cysts.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate and seminal vesicles are unremarkable.
LYMPH NODES: There are several enlarged periaortic lymph nodes measuring up to
1.5 cm in the aortocaval region (6:82). Enlarged peripancreatic node measures
up to 11 mm (6:62). Few enlarged mesenteric nodes are also noted with an
enlarged left pelvic sidewall lymph node measures up to 2.1 cm (6:103).
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES AND SOFT TISSUES: There is diffusely mottled appearance with several
areas of frank destruction of the anterior left iliac bone and left
acetabulum. A surrounding soft tissue mass measures 8 x 11cm. Internal
density is heterogeneous. Lesion centered in this location extends into the
surrounding gluteus and iliacus musculature which are expanded. Multiple
known thoracic vertebral metastases are better assessed on recent MRI of the
spine.
IMPRESSION:
1. Destructive lesion centered in left iliac bone with soft tissue extension
into the adjacent iliacus and gluteal musculature may represent metastatic
disease but is also concerning for primary malignancy such as osteosarcoma.
2. Multiple hypoenhancing hepatic and splenic lesions concerning for
metastases.
3. Retroperitoneal, mesenteric, and pelvic lymphadenopathy.
Radiology Report
EXAMINATION: CT guided biopsy
INDICATION: ___ ___ speaking male with a PMH of HTN, T2DM, HLD,
anemia, enhancement of left iliac bone, destructive lesion of the clavicle,
and spine with T5 lesion with severe cord compression, consistent with disease
of unknown primary.// Liver lesion bx
Note that the optimal site of biopsy was discussed with the primary team and a
decision was made to obtain tissue from the large left iliac bone lesion.
COMPARISON: CT abdomen pelvis ___
PROCEDURE: CT-guided left pelvic mass biopsy.
OPERATORS: Dr. ___, radiology resident and Dr. ___,
___ radiologist. Dr. ___ supervised the trainee during
the key components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the
CT findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the
lesion. An 18 gauge core biopsy device with a 22 mm throw was used to obtain
three core biopsy specimens, which were sent for pathology.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 25.4 cm; CTDIvol = 12.4 mGy (Body) DLP = 317.3
mGy-cm.
2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9
mGy-cm.
3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9
mGy-cm.
4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9
mGy-cm.
5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9
mGy-cm.
6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9
mGy-cm.
7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9
mGy-cm.
8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9
mGy-cm.
9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9
mGy-cm.
Total DLP (Body) = 349 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 12
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
The large destructive lesion of the left iliac bone extending into the
adjacent gluteal and iliacus musculature.
IMPRESSION:
Technically successful CT-guided biopsy of the soft tissue component of the
large left iliac lesion.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ ___ speaking male with a PMH of HTN, T2DM, HLD,
anemia, enhancement of left iliac bone, destructive lesion of the clavicle,
and spine with T5 lesion with severe cord compression, consistent with disease
of unknown primary.// investigate primary lesion
TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with
intravenous infusion of nonionic, iodinated contrast agent, following oral
administration of contrast agent for selected abdominal studies, and/or
followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0
or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm
MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck
will be reported separately. All images of the chest were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 32.4 cm; CTDIvol = 11.0 mGy (Body) DLP = 348.9
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 10.9 s, 0.2 cm; CTDIvol = 145.3 mGy (Body) DLP =
29.1 mGy-cm.
4) Spiral Acquisition 10.6 s, 68.9 cm; CTDIvol = 9.9 mGy (Body) DLP = 677.4
mGy-cm.
5) Spiral Acquisition 5.1 s, 32.9 cm; CTDIvol = 11.0 mGy (Body) DLP = 354.7
mGy-cm.
Total DLP (Body) = 1,412 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: No prior chest CT scans available. This study should be read in
conjunction with findings of extensive skeletal MR.
___:
CHEST PERIMETER: There are no thyroid lesions warranting further imaging.
Supraclavicular and and multiple subcentimeter left axillary and peripectoral
lymph nodes are not pathologically enlarged. Findings below the diaphragm will
be reported separately.
CARDIO-MEDIASTINUM: Above a small hiatus hernia, esophagus is unremarkable.
Atherosclerotic calcification is not apparent head neck vessels or coronary
arteries. Aorta and pulmonary arteries are normal size and pericardium is
physiologic.
THORACIC LYMPH NODES: Enlarged as follows:
Mediastinum, left upper paratracheal 11 mm, 06:17.
Mediastinum, right lower paratracheal, 10 mm, left lower paratracheal, 11 mm,
___.
Hilar nodes are not enlarged.
LUNGS, AIRWAYS, PLEURAE: Mild bibasilar subpleural atelectasis. Tiny left
pleural effusion.
No measurable nodules or focal lung lesions of consequence.
CHEST CAGE: Extensive malignant involvement of the thoracic spine, including
moderate to severe compression of the T5 vertebral body, with invasion of
neural elements is described in the report of the MRI performed ___.
Additional chest cage skeletal lesions of note are a nondisplaced pathologic
fracture mid body of the sternum with surrounding edema, expansile
destruction, distal ___ of the left scapula, and permeative destruction of the
body and tip of the left scapula, lateral aspect of at least one left middle
rib and the manubrium manubrium.
IMPRESSION:
No evidence of primary it malignancy arising in the chest. Lungs essentially
clear. Mild mediastinal lymph node enlargement, probably pathologic. No
vital structures compromised.
Extensive skeletal malignancy, detailed above. Important features of thoracic
spine involvement are detailed report of the thoracic spine MRI performed on
___.
Radiology Report
EXAMINATION: T-SPINE IN O.R.
INDICATION: T2-T9 fusion.
COMPARISON: Preoperative MRI cervical spine ___.
FINDINGS:
26 intraoperative images were acquired without a radiologist present.
Images show posterior fusion of the upper to midthoracic spine, for pathologic
fracture of T5. Total fluoroscopic time 28.1 seconds.
IMPRESSION:
Please refer to the operative note for details of the procedure.
Radiology Report
EXAMINATION: T-SPINE
INDICATION: ___ year old man POD#3 T5 lami, T2-T7 posterior fusion// Postop
eval, eval for retained drain
TECHNIQUE: Frontal and lateral view radiographs of the thoracic spine.
COMPARISON: Intraoperative images dated ___
IMPRESSION:
The patient is status post T2 through T7 posterior fusion with vertical rods
and transpedicular screws at T 2, T3, T4, T6 and T7. Re-demonstrated is a
compression deformity of T5. There is no evidence of hardware related
complications or interval change in alignment. Skin staples remain present.
The visualized lungs are grossly apart from probable atelectasis seen in the
left lung base.
Radiology Report
INDICATION: ___ year old man with DLBCL// please place DL chest port and leave
both access for chemo blanch aware, plt 418, INR 1
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
Dr. ___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
125mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service
time of 56 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: 1 g of Ancef
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 1 minutes, 5 mGy
PROCEDURE
1. Right internal jugular approach chest double lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
The right upper neck was examined under ultrasound, the internal jugular vein
was atretic. Attempts to access the internal jugular vein at the level of the
confluence with the subclavian vein were unsuccessful due to absence of a safe
window. Under continuous ultrasound guidance, the patent right external
jugular vein was compressible and accessed using a micropuncture needle.
Permanent ultrasound images were obtained before and after intravenous access,
which confirmed vein patency. Subsequently a Nitinol wire was passed into the
right atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The double lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
prolene sutures on either side. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the port was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. Steri-strips were used to close the
venotomy incision site. Steri-Strips were applied over the sutures. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The tip is in the right atrium.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a double lumen chest power Port-a-cath via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with s/p spine surgery ___ new dx of DLBCL with
altered sensation in LLE.// ?DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the left
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CT PELVIS W/CONTRAST
INDICATION: ___ year old man with new dx DLBCL s/p T5 lamenectomy and T2-T7
fusion ___ with worsening L leg pain// ?fluid collection, new lesions
TECHNIQUE: Multidetector CT images of the pelvis were acquired with
intravenous contrast.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 15.0 s, 64.9 cm; CTDIvol = 9.3 mGy (Body) DLP = 595.2
mGy-cm.
Total DLP (Body) = 595 mGy-cm.
COMPARISON: Abdominal pelvis CT from ___
FINDINGS:
PELVIS: The partially visualized small and large bowel are unremarkable. The
urinary bladder and distal ureters are unremarkable. There is air gas in the
bladder likely related to recent manipulation. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Unchanged large retroperitoneal and left iliac adenopathies. A
right para-aortic lymph node measures 16 x 21 mm (series 3, image 5). A left
internal iliac adenopathy measures 31 x 21 mm (series 3, image 53). A left
external iliac adenopathy measures 19 x 14 mm (series 3, image 47). Other
abnormal external iliac nodes are also noted on images 50 and 55 of series 3.
No new adenopathy in the interim.
VASCULAR: Mild atherosclerotic disease is noted.
BONES: Again noted is an extensive lytic aspect of the left iliac bone
extending to the left superior ramus pubic. There is a large soft tissue
component around the left iliac bone measuring 13.1 x 8.6 cm which is grossly
unchanged from recent prior.
In the distal diaphysis of the left femur, there is also an endosteal
scalloping with intramedullary soft tissue extending on 8.8 cm concerning for
a distal bone metastasis. No pathological fracture. No soft tissue
component.
SOFT TISSUES: Diffuse subcutaneous edema.
IMPRESSION:
1. Overall unchanged large destructive lytic lesion encompassing the left
hemipelvis. This was characterized CT examination from ___ and biopsied
on that same day, with pathology consistent with known DLBCL.
2. The patient is at high risk for left iliac pathologic fracture from normal
weight bearing. Recommend orthopedic consultation regarding weight bearing
restrictions.
3. Additional metastasis in the distal left femur is also noted.
4. Metastatic left iliac and retroperitoneal adenopathy are again noted.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:43 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS
INDICATION: ___ year old man with DLBCL with L Hip Lesion// ? pathological
fracture A/P pelvis and L hip
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of bilateral hips.
COMPARISON: CT pelvis ___.
IMPRESSION:
There are extensive lytic lesions in the left ilium, ischium and pubic bones.
Additional lytic lesions are also seen in the right inferior trochanteric
region and proximal left femur. There is a pathological fracture through the
right lesser trochanter with superior and anterior displacement. No acute
fracture is seen in the left hip or pelvis. There is no evidence of
dislocation. There are mild degenerative changes in the bilateral hips and
lower lumbar spine.
Radiology Report
INDICATION: ___ year old man with DLBCL s/p EPOCH// s/p vincristine dilated
loops of bowel?
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Prior CT abdomen pelvis from ___
FINDINGS:
Supine portable AP view of the abdomen provided. Bowel gas pattern is
unremarkable showing no signs of ileus or obstruction. Fecal loading is
moderate. Bony structures are intact. No worrisome calcification.
IMPRESSION:
Unremarkable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with DLBCL s/p EPOCH// ?PNA ?PNA
IMPRESSION:
Heart size and mediastinum are stable. Spinal hardware has been inserted in
the interim. Lungs overall clear. There is no pneumothorax. There is no
appreciable pleural effusion.
Central venous line tip terminates in the proximal right atrium.
No pulmonary edema. No pleural effusion. No pneumothorax.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: ___ year old man with DBLCL s/p T5 lamenectomy and T2-T5 fusion
with L leg weakness// s/p T5 lamenectomy and T2-T5 fusion with L leg weakness.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of Gadavist contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON:
1. Thoracic spine radiographs ___.
2. MRI total spine ___.
3. CT total spine ___.
FINDINGS:
CERVICAL:
Alignment is normal. Vertebral heights are maintained. Marrow signal is
unremarkable. Cervical spinal cord is normal in caliber and signal intensity.
There is no abnormal cervical spine enhancement or epidural collection. There
are mild to moderate cervical spine degenerative changes.
C2-3: Unremarkable.
C3-4: There is a right paracentral disc protrusion at C3-4 causing mild spinal
canal narrowing, contacting and remodeling the ventral spinal cord (09:13).
No neural foraminal narrowing.
C4-5: There is a posterior disc osteophyte complex at C4-5 causing mild spinal
canal narrowing and slight cord remodeling. Uncovertebral and facet
osteophytes cause mild-to-moderate bilateral neural foraminal narrowing.
C5-6: Mild posterior disc bulge causes mild spinal canal narrowing. Moderate
right and mild left neural foraminal narrowing due to uncovertebral and facet
osteophytes.
C6-7: Unremarkable.
C7-T1: Unremarkable.
There is mild edema in the lower cervical spine posterior paraspinal
musculature. Otherwise, the cervical prevertebral and paraspinal soft tissues
are unremarkable.
THORACIC:
There are new postsurgical changes from interval T5 laminectomy and T2-T7
posterior spinal fusion with bilateral vertical rods and transpedicular
screws. Hardware artifact somewhat limits evaluation of adjacent structures.
Within these confines:
Alignment is within normal limits. There is unchanged moderate anterior
height loss of T5. Remaining vertebral body heights are maintained. There is
unchanged T2/STIR hyperintense, T1 hypointense, enhancing marrow signal within
the T3, T4, T5, and T6 vertebral bodies. Abnormal, expansile signal is again
seen extending into the remaining T5 posterior elements. The STIR
hyperintense, enhancing lesion seen involving the posterior half of the T11
vertebral body extending into the pedicles, laminae, and spinous process,
consistent with metastasis, is unchanged. There may be slight posterior
epidural soft tissue extension of tumor on the right into the anterior
epidural space, similar in appearance to prior.
There is an equivocal short-segment focus of abnormal cord signal in the right
aspect of the spinal cord at the level of T5 at the prior compression (series
10, image 23 as well as series 3, image 9, 6:9). The remainder of the
thoracic spinal cord appears normal in caliber and signal intensity, within
limitations detailed above.
Previously severe spinal canal narrowing at T5 is markedly improved, with the
central spinal canal now widely patent at this level. There is no longer any
discernible cord compression at any level. No discernible high-grade spinal
canal narrowing the thoracic spine. There is unchanged obliteration of the
left T4-5 and bilateral T5-6 neural foraminal due to soft tissue extension of
T5 tumor. This also causes unchanged mild right T4-5 neural foraminal
narrowing. There is also unchanged moderate right T10-11 and mild right
T11-12 neural foraminal narrowing due to tumor involvement of the right T11
pedicle and pars (8:5).
Spanning essentially the entire length of the posterior spinal fusion hardware
is a posterior soft tissue midline fluid collection with peripheral rim
enhancement spanning up to 13.9 by 4.4 x 3.7 cm (SI by TV by AP) (6:10 and
10:7, 16:7). The collection overlies the midline laminectomy and extends
superiorly along the course of the hardware. There is no evidence of
contiguity with the thecal sac.
There is no evidence of an epidural fluid collection.
LUMBAR:
Alignment is normal. Vertebral heights maintained. Marrow signal is normal.
The distal spinal cord and conus medullaris is normal and terminates at L1.
The cauda equina nerve roots are normal. There is no abnormal lumbar spine
enhancement. There is no lumbar spine epidural collection.
Mild signal loss of the L3-4 intervertebral disc is consistent with
degenerative change. Mild posterior disc bulge, ligamentum flavum thickening
and small facet osteophytes at L4-5 cause minimal spinal canal and
subarticular zone narrowing. There is no significant neural foraminal
narrowing in the lumbar spine.
There is a moderate amount of dependent subcutaneous edema overlying the
lumbar spine. Otherwise, the lumbar prevertebral and paraspinal soft tissues
are unremarkable.
OTHER:
There is a small layering left pleural effusion and adjacent atelectasis.
IMPRESSION:
1. Interval resolution of previously severe spinal canal narrowing and cord
compression at T5 due status post interval T5 laminectomy and posterior spinal
fusion, T2-T7. There is no longer any identifiable high-grade spinal
narrowing, nor any spinal cord compression.
2. Possible short-segment cord signal abnormality in the right aspect of the
cord at the level of T5 at the area prior compression, although cord is
somewhat obscured due to mild artifact from hardware.
3. Re-demonstration of probable metastatic lesions within the T3-T6 vertebral
bodies, with moderate height loss of T5, unchanged.
4. Unchanged T11 probable metastatic lesion.
5. Unchanged obliteration of the left T4-5 and bilateral T5-6 neural foramina
due to soft tissue extension of T5 tumor.
6. Mild right C4-5, moderate right T10-11, and mild right T11-12 neural
foraminal narrowing is unchanged.
7. No evidence of cervical or lumbar spine metastasis.
8. Small left layering pleural effusion.
Radiology Report
EXAMINATION: MR PELVIS WANDW/O CONTRAST
INDICATION: ___ year old man with DBLCL s/p T5 lamenectomy and T2-T5 fusion
with L leg weakness// s/p T5 lamenectomy and T2-T5 fusion with L leg weakness,
DLBCL?
TECHNIQUE: Multiplanar imaging the pelvis was obtained with and without
contrast using a mass/infection protocol.
COMPARISON: Radiograph on ___, CT pelvis on ___, CT
abdomen and pelvis on ___
FINDINGS:
Again seen is extensive lymphomas involvement of the pelvic bones. There is a
large lesion centered in the left iliac wing with extension into the left
superior sacral ala, ilium and inferior pubic ramus with a soft tissue
component extending into the adjacent musculature including the iliacus,
obturator internus, piriformis, and overlying gluteal musculature. There is
altered bone marrow signal indicative of tumor involvement of the adjacent
left hemi sacrum, however there is no evidence of tumor invasion into the left
sacral neuroforamen. Soft tissue component of this mass abuts a portion of
the left sciatic nerve which has surrounding edema, however the nerve does not
appear to be invaded, with a preserved fat plane between the nerve and the
mass. There is diffuse edema in the left hip musculature, with
partial-thickness tears of the distal gluteus medius and minimus, as well as
obturator internus and piriformis. The iliotibial band is partially torn and
retracted off its insertion on the iliac crest which is invaded with tumor.
There is edema in the left iliopsoas which may be partially injured. There is
cortical destruction at the ischial tuberosity at the insertion of the
hamstring tendon, however there is no full-thickness retracted tendon tear.
There is associated mild-to-moderate left greater trochanteric bursitis.
There is an additional lesion in the left femoral diaphysis (10:17). No
pathologic fracture in the visualized portion of the femur.
There are lesion right iliac bone extending to the mid to inferior sacroiliac
joint, and in the right lesser trochanter with an associated pathologic
avulsion fracture with anterior and superior displacement of the fractured
component of the lesser trochanter (09:32). There is associated edema and
hematoma distal to the fracture fragment, and edema within the iliopsoas
tendon. There is edema in the right hip musculature, slightly less prominent
than on the left, including a partial tear of the gluteus minimus tendon.
Mild right greater trochanter bursitis.
There is left pelvic sidewall lymphadenopathy, the largest lymph node
measuring 3.0 x 2.1 cm, not significantly changed.
IMPRESSION:
1. Extensive tumor involvement in the pelvis, with replacement of nearly the
entire left hemipelvis by a large destructive lesion centered in the left
iliac wing. A soft tissue component of the mass is within the vicinity of the
sciatic nerve, however the nerve does not appear to be invaded. There is bone
marrow involvement in the left hemi-sacrum, however there does not appear to
be invasion of the sacral neuroforamen.
2. Bone marrow replacing lesion in the left femoral diaphysis.
3. Bone marrow replacing lesion in the right iliac bone extending to the mid
to inferior aspect of the right SI joint as well as a lesion in the right
lesser trochanter with redemonstration of a pathologic avulsion fracture at
the right trochanter.
4. Extensive muscular edema in the bilateral hips, left greater than right,
including partial tears of the left gluteus tendons, avulsion of the proximal
left iliotibial band and partial-thickness injury of the distal right gluteus
minimus tendon. Associated left greater than right greater trochanteric
bursitis.
5. Left pelvic sidewall lymphadenopathy, not significantly changed.
Radiology Report
EXAMINATION: T-SPINE
INDICATION: 66 with thoracic lesions and a T5 pathologiccompression fracture
underwent a T5 laminectomy with T2-T7 posterior instrumentation and fusionon
___, now with worsening left leg weakness, pls assess for hardware
malfunction// 66 with thoracic lesions and a T5 pathologiccompression fracture
underwent a T5 laminectomy with T2-T7 posterior instrumentation and fusionon
___, now with worsening left leg weakness, pls assess for hardware
malfunction
TECHNIQUE: AP and lateral views of the thoracic spine
COMPARISON: Chest radiograph obtained on the same date, thoracic spine
radiographs ___
FINDINGS:
Patient is status post posterior stabilization from approximately T2-T7 with
an unchanged compression deformity at T5 level. Surgical hardware appears
intact and unchanged in position when compared to the prior study. A dual
lumen Port-A-Cath right internal jugular Port-A-Cath terminates in the
cavoatrial junction. Chronic fracture of the right clavicle. Heterogenous
appearance of the left clavicle.
IMPRESSION:
Postoperative changes as described.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ w/ HTN, DM2 who p/w LLE pain and weakness, found to have
DLBCL with masses in thoracic spine w/ T5 pathologic compression fracture now
s/p T5 laminectomy and T2-T7 fusion. SP C1 EPOCH. New hypotension// eval
hypotension, infection
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There is a right chest wall Port-A-Cath with the tip terminating in the upper
right atrium.
Linear opacities in the lung bases most likely represent subsegmental
atelectasis. There is no focal consolidation, pleural effusion or
pneumothorax. The cardiomediastinal silhouette is stable in appearance.
There is posterior spinal fusion hardware in the upper thoracic spine.
Radiology Report
EXAMINATION: US UPPER BACK, SOFT TISSUE
INDICATION: ___ year old man with DLBCL s/p T5 laminectomy, T2-T7 fusion on
___ now with new tender mass adjacent to incision.// ?new mass next to
surgical incision on right thoracic back. ?fluid collection, new lymphoma
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the midline upper back in the region of a surgical incision.
COMPARISON: MRI spine dated ___.
FINDINGS:
There is a heterogenously echogenic avascular collection in the subcutaneous
tissues along the entire duration of the surgical incision measuring 2.7 x 20
x 5.7 cm.
IMPRESSION:
Heterogeneously echogenic, avascular collection in the subcutaneous tissues
along the surgical incision may reflect a hematoma, more completely evaluated
on the recent MRI. Superinfection cannot be excluded.
Radiology Report
EXAMINATION: CT T-SPINE W/ CONTRAST Q322 CT SPINE
INDICATION: ___ year old man with DLBCL s/p T5 lamenectomy and T2-T7 fusion
w/new mass on right of healing incision// pls eval mass adjacent to surgical
incision. ?fluid collection ?mass pls eval mass adjacent to surgical
incision. ?fluid collection ?mass
TECHNIQUE: Non-contrast helical multidetector CT was performed after the
intravenous administration of Omnipaque contrast agent. Soft tissue and bone
algorithm images were generated. Coronal and sagittal reformations were then
constructed.
DOSE: Please see concurrently obtained contrast cervical spine CT report for
dose information.
COMPARISON: CT T-spine ___.
Soft tissue ultrasound ___.
MR spine ___.
FINDINGS:
Study is limited secondary to patient body habitus and spinal fusion hardware
streak artifact.
Levels were established by counting down from the C2 level using concurrently
obtained cervical spine CT series 7.
There is dextroscoliosis of the thoracic spine.
Patient is status post T2-T7 fusion with T5 laminectomy. Metallic hardware
are present along the posterior aspect the spinous processes of T2 through T7,
with parallel rods oriented cranial caudally and pedal screws at T2, T3, T4
T6, and T7. The screws appear to be positioned intraosseously without
definite evidence of adjacent lucency. There is no definite evidence of
hardware fracture.
There is diffuse metastatic osseous involvement of the bilateral clavicles,
sternum, thoracic vertebral bodies, and left scapula. Within the lateral
aspects of the bilateral clavicles, there is soft tissue destruction with
associated comminuted fractures.
There is compression deformity of the vertebral body of T5, similar in extent
to prior MR with cortical irregularity, again suggestive of metastatic
disease. There is no evidence of bony thoracic spinal canal narrowing. There
is grossly stable osseous narrowing at the left T4-5 and bilateral T5-6 neural
foramina due to osseous disease. The disc heights are grossly preserved.
There is no prevertebral soft tissue swelling.
In the soft tissue overlying the thoracic spine surgical bed, there is a large
hypodense homogeneous fluid collection with a peripheral rim of calcification.
The most superior extent of this fluid collection is not fully captured on
current study, but is included on concurrently obtained cervical spine CT.
The fluid collection extends from the C7 spinous process to T9 spinous
process, measuring and measures 6.0 x 5.7 cm in its largest axial plane, and
appears to have had interval enlargement since prior MR.
___:
Within the visualized mediastinum, there are several conspicuous although not
pathologically enlarged lymph nodes in the paratracheal and paraesophageal
regions. However, there appears to have been interval growth of the largest
lymph node in the left paraesophageal region (Series 8, image 27) now
measuring 11 mm, previously 9 mm on prior CT T-spine. However, the remainder
of the lymph nodes appear unchanged to minimally decreased in size from prior.
A central venous catheter is seen terminating in the right atrium.
Within the visualized lung fields, the left major fissure appears mildly
thickened, new since prior exam.
Within the visualized abdomen, there is a 1.0 x 1.8 cm rounded region of
hypodensity adjacent to the right posterior portal vein (series 8, image 89),
not well evaluated on prior exam. There are 2 additional subcentimeter
regions of hypodensity within the right posterior segment of the liver. There
is also mild thickening of the body of the left adrenal gland, not
significantly changed since prior exam. There is a tiny 6 mm hypodense
rounded structure within the lower pole left kidney (series 8, image 143), too
small to characterize.
IMPRESSION:
1. Study is limited secondary to patient body habitus and spinal fusion
hardware streak artifact.
2. Postsurgical changes related to T2-T7 fusion with T5 laminectomy.
3. Interval enlargement of fluid collection overlying the thoracic spine
surgical bed compared to prior MR, the superior extent of which is
incompletely imaged, but extends inferiorly to the spinous process of T9.
While findings may represent postoperative seroma, differential considerations
of hematoma, or infectious or inflammatory etiologies are not excluded on the
basis of this examination. If clinically indicated, consider correlation with
fluid sampling. Recommend follow-up imaging to resolution.
4. Diffuse metastatic osseous involvement of the bilateral clavicles, sternum,
thoracic vertebral bodies, and left scapula, with soft tissue destruction of
the bilateral clavicles with associated comminuted fractures as described.
5. Grossly stable narrowing at the left T4-5 and bilateral T5-6 neuroforamina,
better demonstrated on recent full spine MRI.
6. Left paraesophageal lymphadenopathy, with additional nonspecific
mediastinal lymph nodes as described. Differential considerations include
infectious, inflammatory, and neoplastic etiologies.
7. New thickening along the left major fissure. If clinically indicated,
consider correlation with dedicated chest imaging.
8. Several regions of hypodensity within the visualized liver, which were not
well evaluated on prior imaging studies. If concern for hepatic metastatic
lesions, consider hepatic MRI for further evaluation.
9. Please see concurrently obtained cervical spine and lumbar spine CT reports
for description of cervical and lumbar findings.
RECOMMENDATION(S): Interval enlargement of fluid collection overlying the
thoracic spine surgical bed compared to prior MR, the superior extent of which
is incompletely imaged, but extends inferiorly to the spinous process of T9.
While findings may represent postoperative seroma, differential considerations
of hematoma, or infectious or inflammatory etiologies are not excluded on the
basis of this examination. If clinically indicated, consider correlation with
fluid sampling. Recommend follow-up imaging to resolution.
Radiology Report
EXAMINATION: CT C-SPINE W/CONTRAST Q312 CT SPINE
INDICATION: ___ year old man with DLCBL, s/p spine surgery// ?interval change
TECHNIQUE: Non-contrast helical multidetector CT was performed after the
intravenous administration of Omnipaque contrast agent. Soft tissue and bone
algorithm images were generated. Coronal and sagittal reformations were then
constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 23.8 cm; CTDIvol = 20.4 mGy (Body) DLP = 491.9
mGy-cm.
2) Spiral Acquisition 6.9 s, 36.6 cm; CTDIvol = 23.8 mGy (Body) DLP = 879.0
mGy-cm.
3) Spiral Acquisition 5.2 s, 27.6 cm; CTDIvol = 23.8 mGy (Body) DLP = 664.5
mGy-cm.
Total DLP (Body) = 2,035 mGy-cm.
COMPARISON: ___ contrast full spine MRI.
___ noncontrast cervical spine CT.
FINDINGS:
Spinal fusion hardware artifact and patient body habitus limits examination.
Vertebral body alignment is preserved. Vertebral body heights are preserved.
No definite acute cervical spine fracture is identified. Partially
visualized is patient's known thoracic spine posterior fusion with
transpedicular screws and rods imaged at T2 and T3 levels. Within limits of
study, there is no definite evidence of spinal fusion hardware fracture or
perihardware lucency.
Grossly stable probable degenerative calcification posterior dens is grossly
unchanged, and again demonstrates well corticated margins. Multilevel
degenerative changes of the cervical spine are again noted, better
demonstrated on 2 week prior full spine MRI. There is no definite evidence of
bony vertebral canal narrowing.
There is no prevertebral soft tissue swelling.
OTHER:
Again partially imaged is patient's known left midclavicle destructive lesion.
There is no definite evidence of paravertebral or paraspinal enhancing mass.
Atherosclerotic vascular calcifications are seen in bilateral carotid
bifurcations. Approximately 1 cm right supraclavicular node with suggested
central low density is noted (see 4:93).
IMPRESSION:
1. Patient body habitus and partially visualized thoracic spinal fusion
hardware limits examination.
2. Within limits of study, no definite evidence of acute cervical spine
fracture.
3. Multilevel cervical spondylosis, better evaluated on ___ full
spine contrast MRI.
4. Partially visualized clavicles again demonstrate left midclavicle
destructive lesion.
5. Approximately 1 cm right supraclavicular lymph node with findings
concerning for malignancy, as described.
6. Within limits of study, no definite evidence of enhancing paravertebral or
paraspinal mass.
7. Please see concurrently obtained contrast lumbar spine CT for description
of lumbar spine structures.
Radiology Report
EXAMINATION: CT L-SPINE W/ CONTRAST Q332 CT SPINE
INDICATION: ___ year old man with DLCBL, s/p spine surgery.
TECHNIQUE: Contrast enhanced helical multidetector CT was performed without
contrast. Soft tissue and bone algorithm images were generated. Coronal and
sagittal reformations were then constructed.
DOSE: Please see concurrently obtained cervical spine CT report.
COMPARISON: ___ total spine MRI
___ pelvic MRI
___ total spine MRI
___ lumbar spine CT
FINDINGS:
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level.
Vertebral body alignment is preserved. Vertebral body heights are preserved.No
definite lumbar spine fractures are identified.There is no prevertebral soft
tissue swelling. Multilevel degenerative changes of the lumbar spine are
again noted, better demonstrated on ___ full spine MRI.
OTHER:
A partially imaged large mass replacing most of the partially imaged left
iliac bone is better assessed on MRI obtained 1.5 weeks prior, but much more
lucent than 1 month prior. Compared to the ___ lumbar spine CT,
there is a new nondisplaced pathologic fracture extending throughout the
imaged portion of the left iliac bone, possibly into the superior left
acetabulum. Metastases in the sacrum and right iliac bone are not well
appreciated on CT, which may be related to differences in technique.
A partially necrotic left external iliac lymph node has decreased in size and
measures 1.5 cm, 1.8 cm 1 month prior and 2.1 cm 1.5 weeks prior. An
aortocaval lymph node has decreased in size and measures 0.7 cm, 1.7 cm 1
month prior. Small periampullary duodenal diverticulum. Atherosclerotic
vascular calcifications noted.
IMPRESSION:
1. New pathologic left iliac bone fracture likely extending into the superior
acetabulum. The large underlying metastatic lesion is better characterized on
pelvic MRI obtained 1.5 weeks prior.
2. Sacral and right iliac bone metastases are not definitely seen on current
examination, which may be related to differences in technique.
3. Necrotic lymphadenopathy as described.
4. Multilevel lumbar spondylosis without definite evidence of moderate or
severe bony vertebral canal narrowing, better evaluated on ___
full spine MRI.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:13 pm, approximately 30
minutes after discovery of the findings.
Radiology Report
EXAMINATION: Ultrasound-guided aspiration
INDICATION: ___ year old man with DLBCL s/p t5 lamenectomy and t2-t7 fusion.
Developed a egg shaped lump to R of incision which then progressed to half way
up incision and to L of incision. It is tender, but w/o erythema or overlying
edema. NSGY c/f infection we are requesting stat drain and fluid culture.//
please drain and culture fluid collection on back to the right of healing
surgical incision.
COMPARISON: Prior CTs and ultrasounds of the upper back, most recent ___..
PROCEDURE: Ultrasound-guided aspiration of superficial dorsal collection.
OPERATORS: Dr. ___, radiology trainee 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 left lateral position on the bed. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the aspiration was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, a sample of fluid was aspirated using
an 18 gauge needle. Approximately 10 cc of serosanguineous fluid was drained
with a sample sent for microbiology evaluation and cultures. Sterile dressing
was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: None.
FINDINGS:
Complex Fluid collection in the right paraspinal dorsal chest wall is
previously depicted by a thoracic spine CT from ___, suggestive of
a hematoma.
IMPRESSION:
Successful US-guided aspiration of a heterogeneous Fluid collection in the
dorsal chest wall.
Radiology Report
EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT
INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder
pain, fall.// eval fracture, bleed, infection
TECHNIQUE: frontal, lateral and oblique views of the left shoulder.
COMPARISON: None.
FINDINGS:
There is a destructive osseous process of the left mid to distal clavicle with
likely underlying fracture/comminution. A left posterolateral sixth rib
deformity, likely representing an healing fracture, is better assessed on
dedicated chest radiograph.
There is no dislocation involving the glenohumeral or AC joint.
There are moderate degenerative changes.
No periarticular calcification or radio-opaque foreign body is seen.
IMPRESSION:
1. Destructive left mid/distal clavicle osseous process, with likely
underlying fractures.
2. Age-indeterminate, left posterolateral sixth rib deformity likely
representing a healing fracture is better assessed on dedicated chest
radiograph.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder
pain, fall.// eval fracture, bleed, infection
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Lung volumes are well expanded. There is bibasilar atelectasis. Otherwise, no
large consolidation. The cardiomediastinal silhouette is mildly enlarged. No
large appreciable pneumothorax or pleural effusions.
There is a step-off of the posterolateral left sixth rib which likely
represents an old fracture.
The left mid/distal clavicle destructive osseous process better evaluated on
thoracic spine CT and dedicated glenohumeral radiograph from same day.
IMPRESSION:
1. Left mid/distal clavicle destructive osseous process better evaluated on
thoracic spine CT and dedicated glenohumeral radiograph from same day.
2. Bibasilar atelectasis and mild cardiomegaly.
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: Pelvic pain, Weakness
Diagnosed with Oth fracture of T5-T6 vertebra, init for clos fx, Unspecified fall, initial encounter
temperature: 97.1
heartrate: 107.0
resprate: 18.0
o2sat: 98.0
sbp: 141.0
dbp: 63.0
level of pain: 5
level of acuity: 2.0 | ___ Course (___)
Neurosurgery was consulted by the patient's primary service for
surgical intervention. The patient was evaluated and found to
have a pathologic T5 fracture wit metastatic lesions in T3, T4,
and T6. He was preoperatively prepared and expectantly monitored
until he was taken to the operating room on ___ for a T5
laminectomy and T2-T7 posterior fusion, 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 per routine,
and home medications were continued throughout this
hospitalization or adjusted appropriately for inpatient stay.
Tissue sample was sent for pathology which was preliminarily
thought to be a lymphoproliferative malignancy vs. lymphoma.
Patient received a postoperative blood transfusion for a low
Hgb/Hct. ___ Diabetes service following along assisting with
glycemic control. JP drain continued to drain serosanguenous
fluid and was discontinued on POD3 when output decreased and
stabilized. Post-drain removal XR showed no retained drain
fragments. SQH was started on POD4 (24hr post drain removal),
and the patient was transferred to the ___ service on ___.
On ___, the patient's staples were removed.
___ w/ HTN, DM2, HLD, Fe deficiency anemia who p/w LLE pain and
weakness, found to have diffuse lesions, most notably in his
thoracic spine w/ T5 pathologic compression fracture now s/p T5
laminectomy and T2-T7 fusion.
#hematoma adjacent to incision
pt with recent spinal surgery with appropriate healing now with
new paraspinal mass. Feels subcutaneous. ___ aspiration on ___
about 10cc removed and c/s hematoma. Aspirate studies negative.
# T5 pathological compression fracture, s/p T5 laminectomy,
T2-T7 fusion. Drain removed ___. Staples removed ___ & ___.
Neuro checks were continued to monitor for changes in strength
and sensation.
# DLBCL
# pathological left iliac bone fracture ___
New diagnosis complicated by extensive surgery for which NSGY
recommended no chemo nor xrt for 4 wks post-op in attempt to
allow his surgery to heal. DL port placement ___. Weight
bearing precautions per ortho onc are touch down on LLE. Started
treatment with DA-R-EPOCH ___. Transitioned to R-CHOP for
second cycle on ___. Continued on ppx of allopurinol,
acyclovir, bactrim. Palliative steroids were continued between
cycles to help with pain.
- Plan for close followup for intrathecal methotrexate.
- Neupogen started ___.
# hx of HTN:
Pt with asymptomatic low BP to 90/59 w/tachycardia with good
response to fluid bolus. Afebrile. Was continued on home
isinopril 10mg PO daily, eventually stopped due to soft BPs and
intermittent hyperkalemia.
#tinea vesicolor: started Ketoconazole 2% 1 Appl TP DAILY
Duration: 2 Weeks.
#hypocalcemia
#Vit D deficient
Started Vit D 50000U weekly for 8 wks, has not had bisphos
during this admission. Hypocalcemia likely secondary to cancer.
#constipation
#epigastric tenderness
Continue Aggressive Bowel reg given recent vincristine and
opioid use. Started PPI for epigastric discomfort and
Simethicone for gas.
#thrush: Patient developed thrush, likely secondary to steroid
use, completed a prolonged fluconazole course as well as oral
nysattin. Magic mouthwash was also used.
#T2DM:
#Hypoglycemia
#hyperglycemia
___ was consulted at patient has been on steroids since
admission. FSBG was monitored and insulin regimen was changed as
appropriate. Please review the diabetes regimen as below
# Cancer associated pain
Has been maintained on morphine ___ 7.5mg PO Q8H and morphine
2.5mg IV Q2H:PRN for breakthrough pain. Also on Tylenol 1g Q8H
and Gabapentin 300 mg BID and 600 mg qHS
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ ___ prostate CA sp radical prostatectomy, salvage radiation
and chemotherapy for rising PSA although with negative PET and
bone scan in ___ presents with right sided LBP for
approximately 10 days radiating to RLE. Patient states that on
___ he went to bend over and pick something up when he
experienced acute onset of a "popping" sensation along with
lower back pain located in the right paraspinal region. This
pain had some radiation into the right hip down along the
anterior thigh to about the level of tyhe knee.
Took ibuprofen with some relief. Reports pain has returned and
has gotten worse last few days, worse with standing. Reports
___ pain at rest up to ___ with ambulation. No loss of bowel
or bladder, no other complaints.
Initial Vitals in the ED were 97.8 74 145/84 18 100% RA. Plain
spine films showed no sign of acute fracture or other
abnormality. received Percocet 2 tabs - minimal relief. Received
IV toradol, morphine pain improved but still with difficulty
ambulating. In the ED exam was notable for minimal right sided
paraspinal tenderness in the L-spine region, no midline spinous
process tenderness. Negative straight leg raise bilaterally,
good rectal tone. Extreme discomfort with ambulation. will be
admitted for pain control and ___. Vitals prior to transfer to
floor were: pain ___ 97.8 81 133/73 18 100%
On arrival to the floor, reports pain ___ but ___ when stands
up. no other complaints.
REVIEW OF SYSTEMS:
(+) as in HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Gout
HL
HTN
prostate cancer s/p radical prostatectomy, salvage radiation and
chemotherapy
HCV - treated/cured per patient
Social History:
___
Family History:
Father had CABG in ___.
Physical Exam:
Admission Exam
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH - no cervical LAD
SPINE - mild left sided sacral paraspinal tenderness, no midline
tenderness.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, standing up painful back. straight leg raising test
bilaterally negative. feels some pain at the very low back right
sided when checking for hip flexion on the right side.
Discharge Exam
VS - 98.4, BP 94/58, HR 53, R 18, O2-sat 98% RA pain ___
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SPINE - mild left sided sacral paraspinal tenderness, no midline
tenderness.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric. straight leg raising test bilaterally negative. no
pain on bilateral hip abduction/adduction, flexion/extension.
Pertinent Results:
LABORATORY DATA
___ 08:40AM BLOOD WBC-4.9 RBC-4.61 Hgb-14.2 Hct-41.4 MCV-90
MCH-30.7 MCHC-34.2 RDW-14.3 Plt ___
___ 08:40AM BLOOD Glucose-122* UreaN-17 Creat-1.2 Na-140
K-3.8 Cl-102 HCO3-26 AnGap-16
___ 08:40AM BLOOD estGFR-Using this
___ 08:40AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2
___ 07:10PM URINE Color-Straw Appear-Clear Sp ___
___ 07:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
IMAGING
___ LUMBO-SACRAL SPINE (AP & LAT)
FINDINGS: Frontal and lateral views the lumbar spine: There are
5 non rib-bearing lumbar like vertebrae. There is no fracture
or malalignment. Mild degenerative changes of the lower lumbar
spine are noted with loss of intervertebral disc height seen
between L5-S1. Clips within the pelvis from prior prostatectomy
are noted. Calcifications within the aorta are seen. There is a
nonobstructive bowel gas pattern. IMPRESSION: No evidence of
acute fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. ALPRAZolam 0.5-1 mg PO QHS:PRN sleep disturbance
4. Aspirin 81 mg PO DAILY
5. Bicalutamide 50 mg PO DAILY
6. Citalopram 10 mg PO DAILY
7. Ibuprofen 200 mg PO QHS:PRN pain
8. Lisinopril 20 mg PO DAILY
9. Lorazepam 1 mg PO HS:PRN insomnia
10. Multivitamins 1 TAB PO DAILY
11. Pravastatin 40 mg PO DAILY
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
13. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
14. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. ALPRAZolam 0.5-1 mg PO QHS:PRN sleep disturbance
3. Aspirin 81 mg PO DAILY
4. Citalopram 10 mg PO DAILY
5. Colchicine 0.6 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Lorazepam 1 mg PO HS:PRN insomnia
8. Multivitamins 1 TAB PO DAILY
9. Pravastatin 40 mg PO DAILY
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
12. Acetaminophen 1000 mg PO Q8H pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
14. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth four times a day Disp
#*40 Tablet Refills:*0
15. Bicalutamide 50 mg PO DAILY
16. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
17. Ibuprofen 800 mg PO Q8H pain Duration: 5 Days
This medication can cause stomach upset so you should take it
with food. You should only take it around the clock for 5 days.
If you notice any black or bloody stools, stop taking the
medication and seek medical attention immediately.
RX *ibuprofen 800 mg 1 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
18. Outpatient Physical Therapy. Evaluate and treat for acute
lower back pain.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Acute lower back pain
SECONDARY
Prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Prostate cancer status post radical prostatectomy with rising PSA
now with acute right-sided low back pain.
COMPARISON: None.
FINDINGS:
Frontal and lateral views the lumbar spine: There are 5 non rib-bearing
lumbar like vertebrae. There is no fracture or malalignment. Mild
degenerative changes of the lower lumbar spine are noted with loss of
intervertebral disc height seen between L5-S1. Clips within the pelvis from
prior prostatectomy are noted. Calcifications within the aorta are seen.
There is a nonobstructive bowel gas pattern.
IMPRESSION:
No evidence of acute fracture.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: TRAUMATIC BACK/SPINE INJURY
Diagnosed with LUMBAGO
temperature: 97.8
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 145.0
dbp: 84.0
level of pain: 9
level of acuity: 3.0 | ___ with PMHx of prostate cancer, HTN, HLD, presenting for
management of acute lower back pain.
# Acute lower back pain: Patient presented with acute lower back
pain impeding his ambulation. He reports that he injured his
right lower back on both ___ and following ___,
while bending over and lifting things. Over the past few days,
he reports that the pain while walking became excruciating, thus
he presented to the ED. He also complained of numbness of his
right anterior thigh in an L2-4 distribution. He had no other
neurologic symptoms, such as loss of rectal tone, bladder, or
bowel continence. Straight leg raise was negative bilaterally.
His symptoms were thought to be due to acute lumbar strain as
well as a radiculopathy. A plain film of his lumbosacral spine
did not show any acute fracture. Of note, he had a bone scan on
___ that showed no evidence of bony metastatic disease. He
was evaluated by physical therapy, who determined that he was
safe to go home, but recommended that he start outpatient
physical therapy as soon as possible. For pain he received
standing tylenol and prn oxycodone. He was discharged on
standing tylenol ___ TID, a 5-day course of ibuprofen 800mg
TID, cyclobenzaprine 10mg TID prn muscle spasm, and a 10-day
supply of oxycodone 10mg QID prn. He was also given a stool
softener as needed. He was counseled to not to take the
oxycodone, flexeril, and benzodiazepenes together.
INACTIVE ISSUES
# Gout: Continued allopurinol and colchicine.
# HTN: Continued lisinopril.
# Insomnia: Continue alprazolam prn, lorazepam prn, zolpidem,
SSRI.
# HLD: Continue pravastatin.
# DVT Prophylaxis: Patient received heparin products during this
admission.
# Code status: Patient was confirmed full code. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
peanuts
Attending: ___.
Chief Complaint:
PICC line removed
Major Surgical or Invasive Procedure:
___ PICC line placement (___)
History of Present Illness:
This is a ___ with a PMHx of IDDM, HTN, s/p MVA with head plate,
s/p cholecystectomy c/b biliary duct leak and stent placement,
who presented to the ___ ED because of inadvertent PICC line
removal. Around 9pm on ___ the staff found the patient with
PICC line on his chest. He has never moved it before. There was
no bleeding. He had a prolonged admission from ___ for
incarcerated periumbilical hernia with high-grade obstruction.
His hospital course was complicated by sepsis secondary to bowel
perforation and he underwent small bowel resection. He had a
PICC line placed for TPN. He takes very minimal PO intake on his
own and per daughter and staff at nursing facility, he would not
want an NG tube.
In the ED:
- Initial vitals at 22:55 on ___ were T 98.2 HR 80 BP 133/77 RR
18 SpO2 97%
- Labs notable for: glucose of 206.
- ___ RN was unsuccessfuly placing the PICC line. She
recommended admission, and if the PICC line does not readjust by
morning, would need ___.
- Pt given:
___ 05:59 IVF 1000 mL ___ @ 100 mL/hr
___ 08:49 PO/NG Lisinopril 2.5 mg
___ 08:49 PO/NG Sertraline 50 mg
___ 08:49 PO/NG Aspirin 81 mg
___ 08:49 PO/NG Metoprolol Tartrate 25 mg
- Vitals prior to transfer: T 98.8 HR 77 BP 143/66 RR 16 SpO2
98%RA
On arrival to the floor, patient is asked why he is here and
says "I think I am sick." He says he feels cold. He reports no
pain or other symptoms. Denies fever, chills, shortness of
breath, chest pain, abdominal pain, nausea/vomiting,
diarrhea/constipation and urinary symptoms. Says he walks
without assistance.
Past Medical History:
Type II diabetes mellitus
Hypertension
Benign prostatic hypertrophy
Mild dementia
s/p MVA with plate in the head
s/p cholecystectomy, complicated by biliary duct leak requiring
ERCP and stent insertion
Social History:
___
Family History:
Noncontributory.
Physical Exam:
On Admission:
Vitals- T 98.3 BP 132/68 HR 82 RR 20 O2 97%RA
General- Alert, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear. 2cm keratotic
papule on R side of face.
Neck- supple, JVP not elevated
Lungs- CTAB no wheezes, rales, rhonchi
CV- Regular rate and rhythm, ___ holosystolic murmur
Abdomen- soft, NT/ND, normoactive bowel sounds present, no
rebound tenderness or guarding, no organomegaly; horizontal
surgical incision with 2 areas that probe 0.5cm deep, some
granulation tissue, no surrounding erythema or pus
GU- no foley. Patient has diaper.
Ext- warm, well perfused, no clubbing, cyanosis or edema; RUE
PICC is c/d/i
Neuro- EOMI, tongue midline, face symmetric, motor function
grossly normal. Oriented to self, but not time or place (thought
year was ___, place was ___.
On Discharge:
Vitals- T 97.3-98.3 BP 95-148/65-70 HR ___ RR ___ O2
93-96%RA
BS 104//124
General- Alert, no acute distress, lying comfortably under
blankets
HEENT- Sclerae anicteric, MMM, oropharynx clear. 2cm
hyperkeratotic patch on R side of face (patient says this is
longstanding).
Neck- supple, JVP not elevated
Lungs- Mild bibasilar rales, no wheezes or rhonchi
CV- Regular rate and rhythm, ___ holosystolic murmur
Abdomen- soft, NT/ND, normoactive bowel sounds present, no
rebound tenderness or guarding, no organomegaly; horizontal
surgical incision with 2 areas that probe 0.5cm deep, some
granulation tissue, no surrounding erythema or pus
GU- no foley. Patient has diaper.
Ext- warm, well perfused, no clubbing, cyanosis or edema; RUE
PICC is c/d/i
Neuro- EOMI, tongue midline, face symmetric, motor function
grossly normal. Oriented to self and knows he's in hospital. Not
oriented to time.
Pertinent Results:
On Admission:
___ 12:15PM BLOOD WBC-7.9 RBC-3.18* Hgb-9.0* Hct-29.5*#
MCV-93 MCH-28.3 MCHC-30.5* RDW-14.9 RDWSD-50.0* Plt ___
___ 12:15PM BLOOD Neuts-62 Bands-1 ___ Monos-6 Eos-4
Baso-0 Atyps-1* Metas-1* Myelos-0 AbsNeut-4.98 AbsLymp-2.05
AbsMono-0.47 AbsEos-0.32 AbsBaso-0.00*
___ 12:20PM BLOOD ___ PTT-32.4 ___
___ 12:15PM BLOOD Glucose-206* UreaN-16 Creat-0.6 Na-137
K-4.2 Cl-101 HCO3-21* AnGap-19
___ 08:55AM BLOOD Albumin-3.4* Calcium-9.2 Phos-4.6*#
Mg-1.9
Imaging/Studies:
___ CXR Portable
Interval placement of a right approach PICC, which courses
superiorly and
terminates in the right internal jugular vein. Per the notes in
the ED
dashboard, the team is aware of the malpositioned PICC.
___ CXR Portable
After flushing, the PICC line is now correctly positioned, with
the
tip in the mid SVC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. galantamine 8 mg oral DAILY
2. GlipiZIDE XL 10 mg PO DAILY
3. Januvia (sitaGLIPtin) 50 mg oral DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Mirtazapine 15 mg PO QHS
9. Simvastatin 20 mg PO QPM
10. Tamsulosin 0.4 mg PO QHS
11. TraZODone 25 mg PO QHS:PRN insomnia
12. Glargine 26 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
13. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
14. Hibiclens (chlorhexidine gluconate) 4 % topical DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using REG Insulin
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Mirtazapine 15 mg PO QHS
6. Simvastatin 20 mg PO QPM
7. Tamsulosin 0.4 mg PO QHS
8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
9. TraZODone 25 mg PO QHS:PRN insomnia
10. galantamine 8 mg oral DAILY
11. GlipiZIDE XL 10 mg PO DAILY
12. Hibiclens (chlorhexidine gluconate) 4 % topical DAILY
13. Januvia (sitaGLIPtin) 50 mg oral DAILY
14. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY
___ line placement
Wound care s/p bowel resection
SECONDARY
Dementia
Hypertension
Diabetes
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: Evaluate for retained PICC line, in a patient with dimension loop
pulled out her PICC.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Frontal views of the chest demonstrate no radiopaque foreign body to suggest
retained PICC fragment. Lung volumes are low, resulting in increased
prominence of the cardiac silhouette and bronchovascular crowding. Allowing
for this, heart size is likely normal. There is atelectasis in the bilateral
lower lobes, without concerning focal consolidation or pleural effusion.
There is no pneumothorax. The visualized upper abdomen is unremarkable.
IMPRESSION:
No radiopaque foreign body to suggest a retained PICC fragment.
Radiology Report
INDICATION: Evaluate PICC placement.
TECHNIQUE: None.
COMPARISON: Chest radiographs from ___ and ___.
FINDINGS:
A portable frontal chest radiograph demonstrates interval placement of a right
PICC, which courses superiorly into the right internal jugular vein. Lung
volumes are low, resulting in increased prominence of the cardiac silhouette
and bronchovascular crowding. Allowing for this, heart size is likely normal.
There is no focal consolidation, pleural effusion, or pneumothorax. The
visualized upper abdomen is unremarkable.
IMPRESSION:
Interval placement of a right approach PICC, which courses superiorly and
terminates in the right internal jugular vein. Per the notes in the ED
dashboard, the team is aware of the malpositioned PICC.
Radiology Report
INDICATION: Evaluate PICC placement.
COMPARISON: Chest radiographs from approximately 30 minutes and 7 hours prior
on the same day, as well as ___.
FINDINGS:
A portable frontal chest radiograph again demonstrates a right approach PICC,
which courses superiorly and terminates in the right internal jugular vein,
unchanged compared to prior exam. The remainder the exam is unchanged, with
slightly low lung volumes and bibasilar atelectasis.
IMPRESSION:
Unchanged right approach PICC, which courses superiorly and terminates in the
right internal jugular vein. According to the ED dashboard, the clinical team
is aware of the malpositioned PICC.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with dementia, HTN, IDDM, PICC line for TPN,
presenting for PICC line placement correction. // PICC line placement
correct? Contact name: ___: ___ PICC line
placement correct?
IMPRESSION:
In comparison with the earlier study of ___, there is no change in the
appearance of the right subclavian PICC line, which extends well up into the
neck in the jugular system. Little change in the appearance of the heart and
lungs.
Radiology Report
EXAMINATION: Chest radiograph
COMPARISON: ___, 07:22
IMPRESSION:
The right PICC line continues to be malpositioned in the right jugular vein.
No complications, notably no pneumothorax.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: PICC line eval
Diagnosed with DUE TO OTHER VASCULAR DEVICE,IMPLANT,GRAFT, ABN REACT-PROCEDURE NEC, DEHYDRATION
temperature: 98.2
heartrate: 80.0
resprate: 18.0
o2sat: 97.0
sbp: 133.0
dbp: 77.0
level of pain: 0
level of acuity: 4.0 | This is a ___ with a PMHx of type II diabetes, HTN, s/p MVA with
head plate, and recent admission for incarcerated periumbillical
hernia s/p bowel resection discharged on TPN who presented to
the ___ ED because of inadvertent PICC line removal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Prochlorperazine / Ambien / ciprofloxacin / sulfasalazine /
hydrochlorothiazide / leflunomide
Attending: ___.
Chief Complaint:
Right lower back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ female with Addison's disease on
prednisone who slipped down one stair 4 day landing on her left
arm and lower back. She immediately had severe lower back pains
ago, radiating to the right side. She did not hit her head or
lose consciousness. She went home and has been icing her back
with some benefit but continued severe pain. She went and saw
her PCP on ___ who prescribed Dilaudid and Valium which were
not particularly helpful. She presented to the emergency
department today for her ongoing severe pain. She received a CT
scan which demonstrated L2/3 right transverse process fractures
and mild perisplenic fluid consistent with a grade 1 splenic
laceration.
She reports that since her injury, she has had no incontinence,
lack of sensation, pain radiating down legs, weakness, or other
neurologic symptoms. She has had no abdominal pain,
nausea/vomiting, blood in urine or stool, and she continues to
tolerate a regular diet at home. She reports being hungry as
she has not eaten since she has arrived in the emergency
department.
Past Medical History:
Past Medical History:
- hypertension
- Addisons
- collagenous colitis? vs IBS
- gout
- GERD
- hyperlipidemia
- spinal stenosis s/p lumbar surgery
Past Surgical History:
Lumbar surgery L4-5 fusion ___ years
Social History:
___
Family History:
CAD in 1 sister. ___ cancer in 2 sisters. Mother with
dementia and arthritis. Father with hx of heart disease.
Physical Exam:
Admission Physical Exam:
Vitals: 98.0 93 129/92 96%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
no palpable masses
Back: Exquisite pain to palpation on lumbar palpation, 3x3cm
hematoma noted to right of lumbar spine, scattered ecchymoses
extending bilaterally around hematoma.
Ext: No ___ edema, ___ warm and well perfused. Left forearm
ecchymoses, full range of motion in all extremities.
Neuro: Intact sensation and strength in all extremities
Vital signs at time of discharge:
VS: T: 97.6 PO BP: 151/87 R Sitting Pulse: 82 RR: 18 O2: 99% Ra
Pertinent Results:
___: CXR:
No acute cardiopulmonary process.
___: CT Abdomen/Pelvis:
1. Fluid-filled colon suggests an ongoing diarrheal disease,
potentially viral enteritis, and correlation with clinical
symptoms is recommended.
2. Chronic fractures of the right L2 and L3 transverse process.
LABS:
___ 09:37PM WBC-10.3* RBC-2.90* HGB-9.1* HCT-28.8*
MCV-99* MCH-31.4 MCHC-31.6* RDW-12.3 RDWSD-44.3
___ 09:37PM PLT COUNT-272
___ 11:58AM K+-4.5
___ 08:59AM ___ PTT-25.0 ___
___ 08:38AM GLUCOSE-106* UREA N-24* CREAT-1.7*
SODIUM-129* POTASSIUM-6.3* CHLORIDE-95* TOTAL CO2-18* ANION
GAP-16
___ 08:38AM WBC-16.9* RBC-3.60* HGB-11.5 HCT-35.4 MCV-98
MCH-31.9 MCHC-32.5 RDW-12.3 RDWSD-44.7
___ 08:38AM NEUTS-87.8* LYMPHS-7.4* MONOS-4.0* EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-14.86* AbsLymp-1.25 AbsMono-0.68
AbsEos-0.01* AbsBaso-0.04
___ 08:38AM PLT COUNT-351
___ 07:55AM URINE COLOR-ORANGE* APPEAR-Clear SP ___
___ 07:55AM URINE BLOOD-NEG NITRITE-POS* PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:55AM URINE RBC-<1 WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 07:55AM URINE HYALINE-1*
___ 07:55AM URINE MUCOUS-RARE*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. ClonazePAM 0.5 mg PO QHS
3. Fludrocortisone Acetate 0.1 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. PredniSONE 5 mg PO DAILY
8. Esomeprazole ___ mg Other DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Urinary
tract infection
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
3. Allopurinol ___ mg PO DAILY
4. ClonazePAM 0.5 mg PO QHS
5. Esomeprazole ___ mg Other DAILY
6. Fludrocortisone Acetate 0.1 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Urinary
tract infection
12. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right L2 and L3 transverse process fractures
Grade 1 splenic laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fall, hematuria, flank pain, midline spinal pain// eval
for renal injury, spinal injury
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or pneumothorax.
The cardiomediastinal silhouette is within normal limits. No displaced rib
fractures.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with fall, hematuria, flank pain, midline spinal painNO_PO
contrast// eval for renal injury, spinal injury
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 47.1 cm; CTDIvol = 18.5 mGy (Body) DLP = 870.1
mGy-cm.
Total DLP (Body) = 870 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits besides mild
dependent atelectasis. There is no evidence of pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions or laceration. 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 or laceration. There is trace perisplenic free
fluid.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral renal hypodensities are too small to characterize though
statistically cysts. No evidence of laceration. There is no evidence of
focal renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are grossly within
normal limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild to moderate
atherosclerotic disease is noted.
BONES: There are acute minimally displaced right L2 and L3 transverse process
fractures. L4 laminectomy changes noted with L4 and L5 pedicle screws in
place without hardware related complication.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Acute right L2 and L3 transverse process fractures.
2. Trace perisplenic free fluid without underlying laceration or other
evidence of intra-abdominal injury.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Flank pain, s/p Fall
Diagnosed with Unspecified laceration of spleen, initial encounter, Fall (on) (from) unspecified stairs and steps, init encntr, Unsp fracture of third lumbar vertebra, init for clos fx, Unspecified abdominal pain
temperature: 97.4
heartrate: 83.0
resprate: 16.0
o2sat: 100.0
sbp: 111.0
dbp: 52.0
level of pain: 10
level of acuity: 4.0 | Ms. ___ is a ___ female with Addison's disease on
prednisone who slipped down one stair and landed her left arm
and lower back, no LOC. She received a CT
scan which demonstrated L2/3 right transverse process fractures
and a mild perisplenic fluid collection consistent with a grade
1 splenic laceration. She was admitted to the Acute Care
Surgery service for serial abdominal exams, trending of her
hematocrit and pain control.
She received oxycodone and acetaminophen for pain control.
Hematocrit remained stable. She remained stable from a
cardiopulmonary standpoint; vital signs were routinely
monitored. The patient was started on subcutaneous heparin when
hematocrit was stable. She was seen by Physical Therapy and was
cleared for discharge home.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___
Chief Complaint:
Fever, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo woman with AML s/p 7+3 induction ___
followed by MiDAC consolidation ___, who presents with a
few hours of fever and vomiting.
Mrs. ___ reports she has been feeling "great" until 6 am this
morning, when she woke up gagging. She vomited up approximately
half a cup of "foamy white" emesis. No blood, no bile. She felt
a little feverish but went back to bed.
2 hours later, she awoke again gagging and had another episode
of emesis. She checked her temperature and noted it was elevated
around ___. She also felt chilly. She called her oncologist and
presented to the ED for further evaluation.
She reports that otherwise she does not have night sweats, chest
pain, shortness of breath, cough, myalgias, cold symptoms,
dysuria, abdominal pain, diarrhea. No sick contacts. She has
been taking her medications including ciprofloxacin and
acyclovir ppx without any lapses.
Mrs. ___ recent clinical course is notable for Neutropenic
fever during her induction therapy in ___. She was treated
with cefepime. No clear source was identified although there was
a question of URI and CT showing bronchial wall thickening w/
scattered tree in ___ opacities.
In the ED, she spiked a temperature to TMax 102.6F. Labs showed
neutropenia (WBC 0.1) and mildly elevated lactate to 2.8 that
corrected to 1 with 1L NS. She received a CT A/P and CXR which
did not reveal an acute source of infection. She received
cefepime and vancomycin prior to admission.
When seen at bedside on the floor, Mrs. ___ reports she feels
generally unwell-- chilly, tired, and weak, without localizing
symptoms.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last clinic note by Dr ___
"- Recent breast imaging series as summarized in Dr. ___
notes with ___ radiology review as outlined below. Of note,
second right breast biopsy (done here on ___ was indicated
due to MRI finding of second area of concern.
- ___ right breast biopsy, performed at ___
(reviewed at ___: 0.5 cm grade 2 IDC, ER/PR pos, HER2 neg by
IHC
- ___ right breast CNB (11:00): 0.45 cm grade 2 IDC, ER/PR
pos, HER neg by FISH (ratio 0.8), also DCIS
- ___ right lumpectomy/SNB: 0.3 cm grade 2 IDC, node neg ___
- ___ finished RT (Dr. ___ and started anastrozole
- ___: held anastrazole per Dr. ___ in setting of
cytopenias"
PAST MEDICAL HISTORY:
- S/P hyst/BSO age ___ in context of ovarian cyst and heavy
periods, benign pathology per the pt
- HTN
- Bladder suspension
- Cataracts
- Osteopenia
- Osteoarthritis
Social History:
___
Family History:
No known history of breast or ovarian cancers or leukemia in the
family.
- Father lung ca (smoker)
Physical Exam:
ADMISSION PHYSICAL EXAM
=============================
VITALS: T 100.3 F | 121/70 | 103 | 97% RA
General: Well appearing pleasant elderly Caucasian woman resting
in bed comfortably
Neuro:
Alert, oriented to place and time. Provides crisp history
PERRL, face symmetric, hearing intact to finger rub bilaterally,
palate elevates symmetrically, tongue midline
HEENT: Oropharynx clear, no lesions, no palpable cervical or
supraclavicular adenopathy, no sinus tenderness
Cardiovascular: Slightly tachycardic, regular, no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally
Abdomen: Soft, nontender, nondistended. Bowel sounds are present
Extr/MSK: WWP, no peripheral edema
Skin: Slightly warm to the touch, no rashes seen
Access: L POC is c/d/I. Nontender to palpation, no surrounding
erythema
PHYSICAL PHYSICAL EXAM
=============================
VITALS: 98.3F PO BP: 139/81 HR: 92 RR: 18 O2 sat: 95% O2
delivery: RA
General: Well appearing Caucasian woman lying on bed
HEENT: Oropharynx clear, no lesions. No sinus tenderness.
Cardiovascular: RRR. No R/M/G.
Pulmonary: CTAB, no R/R/W
Abdomen: Soft, nontender, nondistended.
Extr/MSK: WWP, no peripheral edema
Skin: dry, no visible rashes.
Access: L POC is c/d/I. Nontender to palpation, no surrounding
erythema
Pertinent Results:
ADMISSIONS LABS
===============================
___ 01:00PM BLOOD WBC-0.1* RBC-2.20* Hgb-7.2* Hct-21.3*
MCV-97 MCH-32.7* MCHC-33.8 RDW-13.6 RDWSD-48.4* Plt Ct-10*
___ 01:00PM BLOOD Neuts-ND Lymphs-ND Monos-ND Eos-ND
Baso-ND AbsNeut-ND AbsLymp-ND AbsMono-ND AbsEos-ND
AbsBaso-ND
___ 01:00PM BLOOD ___ PTT-24.8* ___
___ 01:00PM BLOOD Glucose-105* UreaN-9 Creat-0.8 Na-139
K-3.7 Cl-101 HCO3-24 AnGap-14
___ 01:00PM BLOOD ALT-26 AST-25 AlkPhos-109* TotBili-0.6
___ 01:00PM BLOOD Lipase-14
___ 01:00PM BLOOD Albumin-3.6
___ 02:55PM BLOOD Calcium-7.6* Phos-4.1 Mg-1.3*
___ 01:12PM BLOOD Lactate-2.8*
RELEVANT LABS
===============================
___ 12:00AM BLOOD WBC-0.4* RBC-1.89* Hgb-6.3* Hct-18.4*
MCV-97 MCH-33.3* MCHC-34.2 RDW-13.6 RDWSD-48.8* Plt Ct-7*
___ 12:00AM BLOOD WBC-3.6* RBC-2.06* Hgb-6.6* Hct-19.2*
MCV-93 MCH-32.0 MCHC-34.4 RDW-14.6 RDWSD-50.0* Plt Ct-39*
___ 12:00AM BLOOD WBC-11.3* RBC-2.62* Hgb-8.2* Hct-24.0*
MCV-92 MCH-31.3 MCHC-34.2 RDW-15.6* RDWSD-52.4* Plt Ct-37*
___ 12:00AM BLOOD Neuts-10* Bands-4 Lymphs-76* Monos-10
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.06*
AbsLymp-0.30* AbsMono-0.04* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Neuts-51 Bands-0 ___ Monos-16*
Eos-1 Baso-0 Atyps-1* Metas-4* Myelos-0 AbsNeut-1.84
AbsLymp-1.01* AbsMono-0.58 AbsEos-0.04 AbsBaso-0.00*
___ 12:00AM BLOOD Neuts-72* Bands-6* Lymphs-7* Monos-15*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.81*
AbsLymp-0.79* AbsMono-1.70* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD ALT-40 AST-41* LD(LDH)-315* AlkPhos-125*
TotBili-2.1* DirBili-1.0* IndBili-1.1
___ 12:00AM BLOOD ALT-30 AST-24 LD(LDH)-443* AlkPhos-148*
TotBili-0.6 DirBili-0.2 IndBili-0.4
___ 12:12PM BLOOD ___ pO2-110* pCO2-43 pH-7.38
calTCO2-26 Base XS-0 Comment-GREEN TOP
___ 04:57PM BLOOD Lactate-1.0
RELEVANT IMAGING
===============================
___ CXR PA/LAT
No acute intrathoracic process. Proximal migration of the left
Port-A-Cath tip. This tip is still within the mid SVC
___ CT ABD/PELVIS WITH CONTRAST
No specific CT findings of infection in the abdomen or pelvis.
___ CXR AP
Pulmonary edema and cardiomegaly, new from prior, suggestive of
volume
overload. No evidence of pneumonia.
___ TTE
CONCLUSION: The left atrial volume index is normal. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. Quantitative 3D volumetric left ventricular
ejection fraction is 56 %. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract gradient. Normal right ventricular cavity size
with normal free wall motion. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets appear tructurally normal with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. 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 biventricular systolic
function. Mild mitral regurgitation with normal valve
morphology. Mild pulmonary artery systolic hypertension.
Compared with the prior TTE (images reviewed) of ___, the
estimated PA systolic pressure is now increased.
RELEVANT MICRO
===============================
___ BLOOD CULTURES X2: NGTD
___ BLOOD CULUTRES X2: NGTD
___ BLOOD CULTURE: NGTD
___ BLOOD CULTURE: NGTD
___ URINE CULTURE: NGTD
DISCHARGE LABS
===============================
___ 12:00AM BLOOD WBC-14.1* RBC-2.66* Hgb-8.3* Hct-24.3*
MCV-91 MCH-31.2 MCHC-34.2 RDW-15.4 RDWSD-51.7* Plt Ct-46*
___ 12:00AM BLOOD Neuts-81* Bands-1 Lymphs-8* Monos-7 Eos-0
Baso-0 Atyps-1* ___ Myelos-2* AbsNeut-11.56* AbsLymp-1.27
AbsMono-0.99* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-115* UreaN-8 Creat-0.7 Na-143
K-3.4* Cl-102 HCO3-25 AnGap-16
___ 12:00AM BLOOD ALT-25 AST-21 LD(LDH)-496* AlkPhos-170*
TotBili-0.3
___ 12:00AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.1 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q12H
2. Acyclovir 400 mg PO Q12H
3. amLODIPine 5 mg PO HS
4. Valsartan 160 mg PO DAILY
5. Anastrozole 1 mg PO DAILY
6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
7. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Lidocaine-Prilocaine 1 Appl TP PRN port irritation
RX *lidocaine-prilocaine 2.5 %-2.5 % apply to port site as
needed Disp #*1 Kit Refills:*0
2. Acyclovir 400 mg PO Q12H
3. amLODIPine 5 mg PO HS
4. Anastrozole 1 mg PO DAILY
5. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
6. Valsartan 160 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
#Febrile neutropenia
#Flash pulmonary edema
SECONDARY DIAGNOSES
#AML
#Chemotherapy induced pancytopenia
#HTN
#R breast CDIS
#Arthritis
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 neutropenic fever// ? PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: The prior chest radiographs, most recently from ___.
FINDINGS:
Dual-lumen left Port-A-Cath terminates in the upper SVC. The catheter has
migrated more proximally since the prior CT scan and there is a loop extending
more superiorly. The lungs are clear with no focal consolidation.
Cardiomediastinal silhouette is stable. No pleural effusion or pneumothorax.
IMPRESSION:
No acute intrathoracic process. Proximal migration of the left Port-A-Cath
tip. This tip is still within the mid SVC
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with neutropenic fever, N/VNO_PO
contrast// ? abd infection
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 2.0 s, 0.5 cm; CTDIvol = 9.6 mGy (Body) DLP = 4.8
mGy-cm.
2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 13.5 mGy (Body) DLP = 661.6
mGy-cm.
Total DLP (Body) = 666 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: With the exception of bibasilar subsegmental dependent
atelectasis, the lung bases are clear. 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.
Numerous bilateral peripelvic cysts are re-demonstrated, left greater than
right. Simple cysts on the right measure up to 6 cm, as before. Additional
subcentimeter hypodensities are too small to characterize, but most likely
reflect simple cysts. No suspicious renal lesion or hydronephrosis. There is
no perinephric abnormality.
GASTROINTESTINAL: There is a moderate hiatus hernia. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. The appendix is not definitely
seen, however no secondary inflammatory changes are noted in the right lower
quadrant to suggest acute appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not seen. No adnexal abnormality.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
The bones are diffusely demineralized. Mild multilevel lumbar spine
degenerative changes are noted, including grade 1 anterolisthesis of L4 on L5
and L5 on S1.
SOFT TISSUES: There is a small fat containing umbilical hernia.
IMPRESSION:
No specific CT findings of infection in the abdomen or pelvis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ AML s/p chemo here w/ Neutropenic fever, now w/ increased
hypoxia after receiving 1L IVF.// ?PNA vs. fluid overload
COMPARISON: Chest x-ray ___, chest CT ___
FINDINGS:
Single upright AP view of the chest is provided.
Again seen is a dual-lumen left chest wall Port-A-Cath with distal tip
terminating in the upper SVC. The catheter appears to have changed to a
horizontal orientation when compared to prior chest radiograph from 1 day
prior a which is oriented vertically. Compared to prior, increased
interstitial markings and enlarged cardiomediastinal silhouette are suggestive
of volume overload. No pleural effusion or pneumothorax. No focal
consolidation to suggest pneumonia.
IMPRESSION:
Pulmonary edema and cardiomegaly, new from prior, suggestive of volume
overload. No evidence of pneumonia.
Left Port-A-Cath distal tip has changed orientation from vertical to
horizontal.
Gender: F
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: Fever, Nausea, Tachycardia
Diagnosed with Neutropenia, unspecified, Fever presenting with conditions classified elsewhere
temperature: 102.6
heartrate: 124.0
resprate: 24.0
o2sat: 100.0
sbp: 130.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Outpatient Providers: ==================
SUMMARY
==================
___ with AML s/p MiDAC consolidation ___ who presented with
vomiting and neutropenic fever. No source was determined. Her
ANC recovered during this hospitalization, and she was
discharged off antibiotics.
==================
ACUTE ISSUES
==================
#Febrile neutropenia
Received MiDAC on ___. Received Neulasta on ___. Was on
prophylactic cipro at home. Presented on day ___ with fever at
home and vomiting. Fever of ___ in the ED. Underwent CT A/P and
CXR in the ED on presentation, which did not find any area of
infection. History suggests possible gastroenteritis given
vomiting. Early in this hospitalization, she developed URI-type
symptoms and myalgias, which suggest a possible viral process.
She underwent a nasopharyngeal extended spectrum PCR panel,
results pending. She was treated initially with vanc/cefepime.
Once she was afebrile for ~24 hours and her ANC recovered >500,
antibiotics were stopped, and she was monitored off it continued
clinical improvement. She was discharged home without
antibiotics.
#Flash pulmonary edema
Had hypoxia to 88% on RA after receiving 1L IVF over 2 hours.
CXR with pulmonary edema, exam with crackles. Improved after IV
Lasix 10mg. Unclear why she flashed. Repeat TTE ___, compared
to ___, showed new mild pulmonary artery hypertension. As her
hgb was 6.6 around the time of this flash pulmonary edema, it
was thought to be possibly related to transient ischemia.
# ___ trial
Patient was enrolled in trial in ED in a RCT comparing liberal
to restrictive fluid resuscitation management for sepsis. She
was randomized to the restrictive arm and did not receive IVF
until after 6pm on hospital day 2.
==================
CHRONIC ISSUES
==================
#AML
Normal karyotype, DNMT3A mutation and CUX1 mutation. FLT3
negative. Received 7+3 induction chemotherapy and then MiDAC
consolidation.
#Chemotherapy induced pancytopenia
Received induction with 7+3 starting ___. She was discharged 1
week prior to admission after receiving first round of MiDAC
consolidation (___). During this admission, she was continued
on acyclovir and transfused for hgb <7.
#HTN
Home amlodipine and valsartan were held initially given active
infection and intermittently soft BPs. She will restart both at
home.
#R Breast DCIS (ER/PR positive, HER-2 negative) s/p BCS in ___
Home anastrazole was continued.
#Arthritis
Home tramadol PRN was continued.
Emergency Contact: Elects husband ___ as HCP
Code Status: FULL, confirmed.
"I wouldn't want to be a vegetable, but if it just a temporary
thing I would want to be resuscitated"
==================
TRANSITIONAL ISSUES
==================
[] The patient had flash pulmonary edema this admission. TTE on
___ showed only new mild pulmonary arterial hypertension
compared to ___. Please consider further evaluation or
referral to cardio-oncology if 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:
abdominal pain, intractable nausea and vomiting
Major Surgical or Invasive Procedure:
EUS
ERCP
History of Present Illness:
PCP: ___
___ patient is an ___ year old man with known hypothyrodism, here
with an acute illness including abdominal pain and nausea with
vomiting. He notes that two days prior to presentation he
developed acute nausea and intractable vomiting several hours
after going out to dinner. He reports eating fried scallops and
soup, and felt well immediately after the meal. Subsequently he
noted acute onset of the n/v without fever, chills, diarrhea,
chest pain or shortness of breath. He notes that after several
hours to one day of vomiting, he did develop some mid-sternal
chest pain which felt like a 'lump' in his chest, without
radiation or association with exertion. He notes that the pain
persisted for several hours before resolving.
The patient notes that 5 weeks prior to admission, he had an
episode of nausea with vomiting and a 'migraine' headache with
blurry vision. These symptoms resolved, and he was seen
electively three days prior to this admission by his internist
and reports he was not told to change his medication or other
regimen.
ROS: Otherwise negative for changes in weight, sweats, prior
episodes like this one, diarrhea, chest pain with exertion,
shortness of breath, or other associated symptoms. The remainder
of a 10-system ROS is negative by patient report.
Past Medical History:
Hiatal hernia
Biopsy proven prostate adeno CA s/p seed implant brachytherapy,
Colonic polyps
Hyperthyroid (s/p radioiodine therapy for hyperthyroidism, now
on levothyroxine
Cholelithiasis
Surgical/Procedure History: Seed implant brachytherapy ___,
colonoscopy and benign polyp excision ___
Social History:
___
Family History:
Denies history of skin cancer, otherwise non-contributory.
Physical Exam:
Admission examination:
VS: 98.5F BP 106/53 HR 62 RR 18 95% on RA
Subsequent to initial exam: Patient developed a temp of ___
Gen: Patient comfortable, lying in bed in no distress, no
dyspnea
HEENT: No JVD (approx 7cm > RA), mmm, no scleral icterus
CV: Reg, S1S2, no murmurs, no rub
Lungs: Rales bibasilar ___ up, no rhonchi
Abd: moderately distended, slightly hypoactive but present bowel
sounds, diffuse upper quadrant tenderness without rebound.
Neuro: Alert and oriented, fluent speech, no tremor. Able to sit
up independently in bed.
Skin/LExt: trace pitting edema bilateral legs, warm and
well-perfused.
Pertinent Results:
___ 09:00AM GLUCOSE-97 UREA N-24* CREAT-1.2 SODIUM-139
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
___ 09:00AM ALT(SGPT)-19 AST(SGOT)-32 ALK PHOS-50 TOT
BILI-0.9
___ 09:00AM LIPASE-4010*
___ 09:00AM ALBUMIN-4.3 CALCIUM-9.5
___ 09:00AM cTropnT-<0.01
___ 02:00PM LACTATE-1.1
___ 09:10AM LACTATE-1.3
___ 09:00AM WBC-17.8*# RBC-4.97 HGB-14.7 HCT-45.1 MCV-91
MCH-29.5 MCHC-32.6 RDW-13.8
___ 09:00AM NEUTS-94.8* LYMPHS-2.4* MONOS-2.6 EOS-0
BASOS-0.1
CT abdomen: formal read pending, preliminary suggestive of
gallstones without intrahepatic ductal dilatation
Abdominal Ultrasound: formal read pending, suggestive of
pancreatic duct stone 6mm, within 4mm duct.
CXR ___: Cardiac size is top normal. There are low lung volumes
with large bibasilar
atelectasis, increased from prior study. There is no
pneumothorax or pleural
effusion or pulmonary edema.
EUS on ___:
Impression: 5 mm stone wedged into the distal pancreatic duct.
No definitive filling defects in the CBD.
After discussion with Dr. ___ was made not to
proceed to ERCP for biliary evaluation, but rather to reschedule
patient for ERCP with both biliary and pancreatic
sphincterotomy.
Recommendations: Recommend ERCP with likely biliary and
pancreatic duct sphincterotomy and stone extraction with Dr.
___ on ___.
ERCP: ___
Findings:
Esophagus:Limited exam of the esophagus was normal
Stomach:Limited exam of the stomach was normal
Duodenum:Limited exam of the duodenum was normal
Major Papilla:Significant edema of the duodenal mucosa was
noted suggestive of changes due to recent pancreatitis.
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Cannulation of the pancreatic duct was successful and deep with
a cannula using a free-hand technique. Contrast medium was
injected resulting in complete opacification.
Biliary Tree fluoroscopic interpretation:The CBD appeared to be
of normal size and measured 6 mm. No filling defects were noted
within the CBD. In order to expose the pancreatic orifice, it
was decided to perform a sphincterotomy.
Pancreas fluoroscopic interpretation:
There appeared to be a filling defect at the lower end of PD
suggesting of a stone. This stone could represent the stone seen
on recent imaging studies. The PD proximal to this area appeared
to be dilated uniformly. No changes suggestive of chronic
pancreatitis were seen in the PD. A 7cm by ___ single pigtail
pancreatic stent was placed successfully.
I supervised the acquisition and interpretation of the
fluoroscopic images. The quality of the fluoroscopic images was
good. Total flouro time: 7.4 min
Procedures:
A biliary sphincterotomy was performed successfully with a
sphincterotome at 12'o clock position.
Given the possibility of PD stone, a small pancreatic
sphincterotomy was carefully performed using a needle-knife over
the PD stent.
Impression:
Significant edema of the duodenal mucosa was noted suggestive of
changes due to recent pancreatitis.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique
The CBD appeared to be of normal size and measured 6 mm. No
filling defects were noted within the CBD. It was decided to
perform a sphincterotomy in order to expose the pancreatic
orifice
A biliary sphincterotomy was performed successfully with a
sphincterotome at 12'o clock position.
Cannulation of the pancreatic duct was successful and deep with
a cannula using a free-hand technique
There appeared to be a filling defect at the lower end of PD
suggesting stone. This stone could represent the stone seen on
recent imaging studies. The PD proximal to this area appeared to
be dilated uniformly. No changes suggestive of chronic
pancreatitis were seen in the PD.
A 7cm by ___ single pigtail pancreatic stent was placed
successfully.
A pancreatic sphincterotomy was carefully performed using a
needle-knife over the PD stent to allow fragmentation and
passage of the stone.
Otherwise normal ercp to third part of the duodenum
Recommendations:
Return to floor.
NPO tonight. If patient's condition remains clinically stable,
could advance diet as tolerated tomorrow.
Hydration with LR as tolerated hemodynamically.
Repeat ERCP in 2 months for PD stent pull and extraction of any
remaining PD stone fragments.
Medications on Admission:
Levothyroxine 125 mcg daily
OTC:
PRN ibuprofen
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*7 Tablet(s)* Refills:*0*
3. potassium chloride 10 mEq Capsule, Extended Release Sig: Two
(2) Capsule, Extended Release PO once a day.
Disp:*14 Capsule, Extended Release(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- gallstone pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ man with history of small-bowel obstruction a
few years ago presenting with abdominal distention, pain, nausea and vomiting.
Last bowel movement was two days ago.
___.
TECHNIQUE: MDCT-acquired axial images from the 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: Visualized lung bases demonstrate bilateral linear atelectasis
with volume loss in the lower lobes, similar to ___. There is no
pleural or pericardial effusion. Mild coronary artery calcifications are seen
in the LAD. Mild enlargement of the right main pulmonary artery to 28 mm
suggests underlying pulmonary arterial hypertension.
The liver is normal without focal liver lesion. There is minimal intrahepatic
bile duct dilation. The common duct is not dilated allowing for age,
measuring 8 mm. Gallstones are seen within the gallbladder without wall edema
or pericholecystic fluid. A stone in the gallbladder neck is unchanged from
___.
A 6-mm high-density stone is seen the pancreatic duct at the ampulla (2:42)
with mild pancreatic duct dilation to 4 mm (601b:28). There is mild adjacent
peripancreatic stranding at the body.
The kidneys enhance symmetrically and excrete contrast promptly without
hydronephrosis. Small hypodensities in the kidneys bilaterally are too small
to characterize, the largest measuring 7 mm in the right renal inferior pole,
statistically most likely representing cysts. The spleen and the right
adrenal gland are normal.
A 2.5 x 2.2 cm lesion on the left adrenal gland previously characterized as an
adenoma is minimally larger than in ___ when it measured 18 x 20 mm, and
essentially unchanged from ___.
The small and large bowel are normal in course and caliber without
obstruction. There are a few loops of nondilated fluid-filled small bowel
which are nonspecific, but can be seen in enteritis. There is no free fluid
and no free air. The aorta is of normal caliber throughout with mild
atherosclerotic calcifications. The main portal vein, splenic vein and SMV
are patent. No pathologically enlarged mesenteric or retroperitoneal lymph
nodes are seen.
CT PELVIS: The rectum is normal. Diverticula are seen throughout the sigmoid
colon without inflammatory changes. The bladder is normal. Brachytherapy
seeds are seen in the prostate. There is no free fluid and no pelvic or
inguinal lymphadenopathy. There is a small right inguinal fat containing
hernia. A fatty spermatic cord is seen on the left.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
IMPRESSION:
1. Mild pancreatitis probably related to a 6mm pancreatic ductal stone at the
ampulla, with mild pancreatic ductal dilation and minimal intrahepatic bile
duct dilation, new from ___.
2. Cholelithiasis without evidence of acute cholecystitis. No definite common
duct stones.
3. Nondilated fluid-filled loops of small bowel are nonspecific but can be
seen in enteritis in the appropriate clinical setting.
4. Diverticulosis without diverticulitis.
Radiology Report
CLINICAL HISTORY: ___ man with gallstone pancreatitis. Evaluate for
cholecystitis.
COMPARISON: CT abdomen ___.
FINDINGS: The left hepatic lobe is not well visualized due to overlying bowel
gas and its small size as seen on CT. The right hepatic lobe shows normal
textural abnormality without focal liver lesion identified. Doppler
assessment of the main portal vein shows patency and normal hepatopetal flow.
There is no intra- or extra-hepatic bile duct dilation. The common duct is not
dilated measuring 7 mm. Numerous shadowing mobile gallstones are seen within
the gallbladder, without pericholecystic fluid, wall edema or gallbladder wall
dilation to suggest acute cholecystitis. The pancreas is not visualized due
to overlying bowel gas. The spleen is normal measuring 11.1 cm.
IMPRESSION:
1. Cholelithiasis without evidence of acute cholecystitis.
2. Pancreas is not seen.
3. No intra- or extra-hepatic bile duct dilation.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Pancreatitis and cholangitis with new oxygen requirement.
Comparison is made with prior study abdomen CT from ___.
Cardiac size is top normal. There are low lung volumes with large bibasilar
atelectasis, increased from prior study. There is no pneumothorax or pleural
effusion or pulmonary edema.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ACUTE PANCREATITIS, CHOLEDOCHOLITHIASIS NOS
temperature: 98.8
heartrate: 67.0
resprate: nan
o2sat: 97.0
sbp: 132.0
dbp: 112.0
level of pain: 10
level of acuity: 2.0 | ___ year old man with known prostate cancer and hypothyroidism
here with acute onset abdominal pain, elevated lipase,
intractable nausea and vomiting, and a distended and tender
abdomen consistent with acute pancreatitis.
# Acute Gallstone pancreatitis: While his LFTs and total bili
were not elevated, his lipase elevation in the setting of
observed gallstones on his imaging and abdominal pain and
distension were strongly suggestive of gallstone pancreatitis.
The initial insult was several days prior to admission and
therefore his LFTs have since improved. It was also possible
that he has cholangitis, or early cholecystitis, or another
biliary pathology. Given the evolving fever, as well as
leukocytosis, he was started on cipro/flagyl and treated for
acute pancreatiits with IVF, NPO, and pain control. His
symptoms improved and he was able to tolerate a full diet.
Anbtx were discontinued as his lipase downtrended and he showed
no signs of infection. Because CT scan showed a pancreatic duct
stone with no evidence of chronic pancreatitis, the patient
underwent an EUS for further evaluation. DDX included possible
malignancy but there was no evidence for it. It was thought
that the patient's acute pancreatitis was more likely to be
secondary to a gallstone that passed rather than this pancreatic
stone. Its significance was unclear. GI recommended stone
retrieval and so the patient underwent ERCP which showed a
likely gallstone in the proximal CBD and a stent was place. A
sphincterotomy was performed. The patient may consider having a
cholecystectomy and was instructed to follow up with his PCP and
surgery. The patient also had a nutrition consult for further
education regarding a low fat low residue diet.
- f/u in 2 months time for biliary stent removal, to be
organized by ERCP team.
,
# ___ and Scrotal Edema: Pt received IVF while in house resulting
in bilateral ___ edema as well as scrotal pedal edema. No signs
of left sided failure. The patient received IV lasix (10mg and
subsequently 20mg IV) with good effect. The pt was discharged
with 1 week supply of PO lasix as well as potassium. This should
be further discussed with his PCP and to consider an ECHO.
#Chest pain/Palpitations: The patient initially complained of
some chest discomfort that seems most consistent with reflux
esophagitis. He was monitored on telemetry and cardiac enzmyes
were checked which were negative. EKG showed an old RBBB with
no acute ischemic changes. He was treated with a PPI with
improvement in symptoms.
.
#Hypothyroidism: He was continued on levothyroxine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lactose / shellfish derived
Attending: ___
Chief Complaint:
Abdominal distention, nausea and emesis, decreased ileostomy
output
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, lysis of adhesions, and
reduction of internal hernia, application of ABThera VAC.
___: Exploratory laparotomy with small bowel resection
and temporary vacuum-assisted closure.
___: Exploratory laparotomy, formation of an end ileostomy
and fascial closure.
History of Present Illness:
___ with h/o sigmoid volvulus s/p colectomy ___ and ex-lap,
loop ileostomy diversion presents ___ presents with
abdominal distention, nausea and NBNB emesis over the last 36
hours. She has limited ileostomy output (~100ml) and has
decreased urine output. She was seen at ___
where she was found to have lactic acidosis, leukocytosis, and
had a KUB with evidence of SBO. She was given 3L crystalloid
IVF, NGT was placed (1000ml gastric contents evacuated) and
transferred to ___ via the ED. Upon presentation she was found
to have WBC 11.1 lactate 5.2 and ___ of 3.8. She received 3L of
crystalloid in the ED and was placed on noriepinephrine drip for
hypotension of approximately 80/50. Although lucid during
evaluation, her partner ___ commented that she was confused
earlier.
Hypotension, symtpoms, and oliguria improved with IVF. CT AP w/
IV contrast concerning for high grade SBO just proximal to the
loop ileostomy with significant proximal SB distention without
evidence of pneumatosis intesinalis or perforation.
Digitalization at the bedside and ___ catheterization of the
loop ileostomy did not provide relief of pressure or evacuation
of any contents. NGT output in ED no more than 100ml.
Past Medical History:
PMH: obesity, lactose intolerance, bowel dysmotility & possible
bacterial overgrowth (Dr. ___, parastomal hernia
PSH:
___ - Colectomy for Sigmoid volvulus (reported as near total
colectomy and reanastomosis per patient)
Social History:
___
Family History:
DM, HTN, HLD in parents
Physical Exam:
Admission Physical Exam:
Afebrile HR 124 82/51-> 100/60, 21, 97%RA
Gen: AAOx3, affable, accompanied by partner ___
CV: tachycardic, no MRG
Pulm: CTAB ant lung fields
GI: diffuse abdominal distention, tympany diffusely, ttp on
right
abdomen, left ileostomy pink and healthy, digitalized with
minimal blood on glove and stool, no gas, diffusely tender but
non peritoneal, old ileostomy bag replaced previous had 100ml
liquid brown output w minimal gas
___: minimal b/l ___ edema
Discharge Physical Exam:
98.1 F | 120/61 | 98 | 18 | 98%RA
Gen: A&Ox3, NAD
CV: Normal rate regular rhythm, no MRG
Pulm: No respiratory distress, CTAB
GI: Soft, non-tender, non-distended, left ileostomy pink and
healthy with gas and brown stool, surgical incision with
dressing c/d/i
___: minimal b/l ___ edema
Pertinent Results:
___ 10:22PM TYPE-ART PO2-166* PCO2-36 PH-7.18* TOTAL
CO2-14* BASE XS--13
___ 10:22PM LACTATE-4.3*
___ 10:10PM GLUCOSE-127* UREA N-69* CREAT-2.6*#
SODIUM-136 POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-13* ANION
GAP-24*
___ 10:10PM CALCIUM-7.5* PHOSPHATE-4.8* MAGNESIUM-1.5*
___ 10:10PM WBC-5.5# RBC-5.83* HGB-16.9* HCT-49.9* MCV-86
MCH-29.0 MCHC-33.9 RDW-13.2 RDWSD-40.8
___ 10:10PM NEUTS-25* BANDS-20* LYMPHS-18* MONOS-9 EOS-6
BASOS-0 ATYPS-6* METAS-12* MYELOS-4* AbsNeut-2.48 AbsLymp-1.32
AbsMono-0.50 AbsEos-0.33 AbsBaso-0.00*
___ 10:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 10:10PM PLT SMR-UNABLE TO PLT COUNT-UNABLE TO
___ 10:10PM ___ PTT-45.8* ___
___ 08:33PM TYPE-ART PO2-115* PCO2-40 PH-7.14* TOTAL
CO2-14* BASE XS--15
___ 08:33PM GLUCOSE-104 LACTATE-4.1* NA+-133 K+-4.4
CL--109*
___ 08:33PM HGB-16.0 calcHCT-48 O2 SAT-96
___ 08:33PM freeCa-1.02*
___ 02:39PM LACTATE-5.2*
___ 02:30PM GLUCOSE-158* UREA N-69* CREAT-3.8*#
SODIUM-133 POTASSIUM-5.6* CHLORIDE-95* TOTAL CO2-11* ANION
GAP-33*
___ 02:30PM WBC-11.1*# RBC-6.87*# HGB-19.7*# HCT-59.1*#
MCV-86 MCH-28.7 MCHC-33.3 RDW-14.6 RDWSD-40.5
___ 02:30PM NEUTS-40 BANDS-26* LYMPHS-10* MONOS-10 EOS-0
BASOS-0 ATYPS-10* METAS-4* MYELOS-0 AbsNeut-7.33* AbsLymp-2.22
AbsMono-1.11* AbsEos-0.00* AbsBaso-0.00*
___ 02:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 02:30PM PLT SMR-NORMAL PLT COUNT-324
Imaging:
___: CT Abd/Pel:
Patient is status post subtotal colectomy, left lower quadrant
loop ileostomy, and ileal sigmoid anastomosis. There is a
high-grade small-bowel obstruction with a transition point in
the left mid abdomen as described above without CT evidence for
bowel wall ischemia.
___: Pathology:
Small intestine, resection :
- Small intestinal segment with subtotal transmural infarction;
mucosal and submucosal ischemia
extends to one margin.
- Seven unremarkable lymph nodes.
___: ECHO:
Mildly depressed left ventricular systolic function. Moderately
dilated right ventricular size. Mild right ventricular systolic
function.
___: CXR:
Comparison to ___. No relevant change. Moderate
cardiomegaly. Elevation of the left hemidiaphragm. Monitoring
and support devices are constant. The pre-existing parenchymal
changes and the moderate to severe cardiomegaly are unchanged.
No pneumothorax.
___: KUB:
No unexplained radiopaque foreign bodies in the abdomen.
___: CXR:
Moderate pulmonary edema which developed between ___ and
___ has improved although pulmonary vasculature is still
very engorged. Opacification at the lung bases, particularly
the left above the chronically elevated left hemidiaphragm, is
probably a combination of atelectasis and edema but there is no
way to exclude pneumonia. Moderate cardiomegaly which also
worsened after ___ and mediastinal vascular engorgement
are unchanged.
ET tube, right internal jugular line are in standard placements
and the
nasogastric tube is looped widely in the stomach.
___: CXR Portable PICC:
Type of tube tip is in the stomach. Right internal jugular line
tip at the level of lower SVC. Right PICC line tip is at the
level of proximal right atrium. Left pleural effusion and basal
consolidation are unchanged. Elevated hemidiaphragm with high
position of the colon is re- demonstrated.
___: Left Upper Extremity US:
No evidence of deep vein thrombosis in the left upper extremity.
___: CT Abd/Pel:
1. High-grade small-bowel obstruction with single abrupt
transition point just
proximal to the end ileostomy.
2. Inflammatory changes of the distal residual small bowel with
wall
thickening, surrounding stranding and trace free fluid.
3. No organizing abdominal fluid collection.
4. Apparent non opacification of a few subsegmental pulmonary
arterial
branches of the right lower lobe posterior basal segment may be
due to bolus timing which is not optimized for evaluating the
pulmonary arteries. However, if there is clinical concern for
pulmonary embolus, this would be best evaluated with dedicated
chest CTA.
5. Left hemidiaphragm elevation, likely paretic.
___: Liver or gallbladder u/s
1. Echogenic liver compatible with steatosis.
2. Normal appearance of the gallbladder with no stones or wall
thickening.
3. Trace perihepatic ascites and trace right pleural effusion.
___: CT Abd/Pel with contrast:
1. Mild improvement in distension of small bowel loops compared
to the most
recent prior study. Transition point remains near the ileostomy
2. New small amount of ascites without discrete fluid
collection.
3. Increased right pleural effusion, now moderate, and adjacent
atelectasis.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
3. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg/5 mL ___ mL by mouth every four (4) hours
Disp #*1000 Milliliter Refills:*0
4. Psyllium Powder 2 PKT PO TID
5. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q4H:PRN
pain
Do not drink alcohol or drive when taking this medication
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Simethicone 40-80 mg PO QID:PRN gas
8. Sodium Chloride 1 gm PO BID
Hold if nauseated
9. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 3 billion cell
oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Small-bowel obstruction
-Internal hernia
-High ostomy output
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year female with KUB showing small bowel obstruction, evaluate
for small bowel 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 not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,195 mGy-cm.
COMPARISON: Prior CTs of the abdomen and pelvis dated ___, and ___.
FINDINGS:
LOWER CHEST: The lung bases demonstrate stable elevation of the left
hemidiaphragm, rightward shift of mediastinal structures, and bibasilar
atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. Severe atrophy left lobe of the liver
is unchanged. 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.
Hyperenhancement of the adrenal glands suggests hypovolemia.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A low-density lesion in the anterior interpolar region of the right kidney is
unchanged from multiple prior studies, previously described as an
angiomyolipoma (02:51). There is no hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is decompressed with an enteric tube. Patient
is status post subtotal colectomy with left lower quadrant loop ileostomy and
distal ileosigmoid anastomosis. There are multiple dilated loops of small
bowel with a gradual transition from the decompressed loops in the left upper
quadrant to the chronically dilated loops of small bowel with an abrupt
transition point in the mid left abdomen (2:59, 601b:24). There is slight
swirling in this area but no convincing evidence for volvulus. Overall, the
degree of distention appears similar to the prior study of ___.
There is no pneumatosis, pneumoperitoneum, abnormal bowel wall enhancement or
thickening, or free fluid in the pelvis. There is no portal venous air. The
previously seen herniated loop of bowel within the ostomy site has resolved.
The ileosigmoid anastamosis appears unremarkable.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no
evidence of adnexal abnormality bilaterally.
LYMPH NODES: Scattered non pathologically enlarged lymph nodes are throughout
the central mesentery and retroperitoneum. There is no lymphadenopathy by CT
size criteria. 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: Aside from the previously described ostomy site, abdominal and
pelvic wall is within normal limits.
IMPRESSION:
Patient is status post subtotal colectomy, left lower quadrant loop ileostomy,
and ileal sigmoid anastomosis. There is a high-grade small-bowel obstruction
with a transition point in the left mid abdomen as described above without CT
evidence for bowel wall ischemia.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ in person on ___ at 3:40 ___, 2 minutes after the discovery of
the findings.
The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3:47 ___, 9 minutes after the discovery of the
findings.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with sbo s/p ij and intubation // eval line
placement eval line placement
IMPRESSION:
In comparison with study of ___, there has been placement of a
nasogastric tube that extends at least to the lower body of the stomach where
it crosses the lower margin of the image. Endotracheal tube tip lies
approximately 6 cm above the carina. Right IJ catheter extends to the mid to
lower SVC.
Continued elevation of the left hemidiaphragm with atelectatic changes above
it and blunting of the costophrenic angle. The right lung is clear and there
is no evidence of vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with history of several SBO's presenting with high grade SBO,
hypotension and elevated lactate now s/p ex-lap, SBR, left in discontinuity.
// Interval assesment Interval assesment
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are essentially unchanged. There are lower lung volumes, which accentuate the
size of the cardiac silhouette. Elevation of the left hemidiaphragmatic
contour is again seen with atelectatic changes above it. Central
opacifications on the left probably represent engorged pulmonary vessels
related to low lung volumes, essence on the right there is no evidence of
substantial vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with septic shock // assess ETT assess
ETT
IMPRESSION:
Comparison to ___. No relevant change. Moderate cardiomegaly.
Elevation of the left hemidiaphragm. Monitoring and support devices are
constant. The pre-existing parenchymal changes and the moderate to severe
cardiomegaly are unchanged. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with history of several SBO's presenting with high grade SBO,
hypotension and elevated lactate now s/p ex-lap. // Interval assesment
Interval assesment
COMPARISON: Prior chest radiographs one ___ through ___.
IMPRESSION:
Moderate pulmonary edema which developed between ___ and ___ has
improved although pulmonary vasculature is still very engorged. Opacification
at the lung bases, particularly the left above the chronically elevated left
hemidiaphragm, is probably a combination of atelectasis and edema but there is
no way to exclude pneumonia. Moderate cardiomegaly which also worsened after
___ and mediastinal vascular engorgement are unchanged.
ET tube, right internal jugular line are in standard placements and the
nasogastric tube is looped widely in the stomach.
Radiology Report
INDICATION: Intraoperative film to assess for missing sponge
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None.
FINDINGS:
An enteric tube is seen terminating in the stomach. Multiple vascular clips
are noted in the left upper quadrant, mid abdomen, and right lower quadrant.
Stoma is in the left lower quadrant. Sutures are seen in the left lower
quadrant. Suture-like material is also noted in the left upper quadrant.
Contrast material is seen in the rectum.
There are no unexplained radiopaque foreign bodies.
IMPRESSION:
No unexplained radiopaque foreign bodies in the abdomen.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the ___ ___ at 4:31 ___, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with picc // r dl power picc 48cm iv ___
___ Contact name: ping, ___: ___ r dl power picc 48cm iv ___
___
COMPARISON: ___
IMPRESSION:
Type of tube tip is in the stomach. Right internal jugular line tip at the
level of lower SVC. Right PICC line tip is at the level of proximal right
atrium. Left pleural effusion and basal consolidation are unchanged.
Elevated hemidiaphragm with high position of the colon is re- demonstrated.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with bowel resection, now left upper extremity
pain // ?DVT LEFT upper extremity
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: High-grade small bowel obstruction status post ex lap, reduction
internal hernia, small bowel resection, anastomosis, and end ileostomy with
abdominal pain. Evaluate for abscess or fluid collection.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 5.6 s, 61.9 cm; CTDIvol = 17.1 mGy (Body) DLP =
1,055.3 mGy-cm.
Total DLP (Body) = 1,070 mGy-cm.
COMPARISON: CT abdomen and pelvis examinations dating from ___
through ___.
FINDINGS:
Heart size is normal without significant pericardial fluid. There are
apparent areas of non opacification of of a few of the a subsegmental branches
of the posterior basal segmental pulmonary arteries of the right lower lobe
(2: 20). There is mild bibasilar atelectasis. There is prominent elevation
of the left hemidiaphragm.
CT abdomen with contrast: The lateral left lobe of the liver appears atretic.
Liver otherwise enhances homogeneously without focal lesion or biliary
dilatation. There is trace pericholecystic fluid, nonspecific. Gallbladder
is otherwise unremarkable. Portal vein is patent.
Spleen, pancreas and adrenal glands are unremarkable. There is a 13 mm right
lower pole simple renal cyst. Other scattered millimetric renal hypodensities
are too small to fully characterize by CT but likely represent cysts. Kidneys
otherwise present symmetric nephrograms and excretion of contrast without
hydronephrosis.
Stomach is distended with air and ingested material but is otherwise grossly
unremarkable. There is dilatation of the small bowel up to a diameter of
roughly 7 cm in portions with fecalization distally suggestive of slowed
motility with a single abrupt transition point just proximal to the end
ileostomy (2:77). Portions of the distal ileum appear thickened and
indistinct with relative hyper enhancement and surrounding stranding and trace
free fluid consistent with inflammatory change.
Abdominal aorta is normal in caliber. A few top-normal mesenteric lymph nodes
are identified. There is trace free fluid. No organizing fluid collection is
seen. No pneumoperitoneum.
CT pelvis with contrast: ___ pouch is identified, opacified with
contrast, likely from prior administration. Uterus, adnexa and bladder are
are unremarkable. There is no inguinal or pelvic sidewall lymphadenopathy by
CT size criteria.
Bones and soft tissues: There is no suspicious focal bone lesion.
IMPRESSION:
1. High-grade small-bowel obstruction with single abrupt transition point just
proximal to the end ileostomy.
2. Inflammatory changes of the distal residual small bowel with wall
thickening, surrounding stranding and trace free fluid.
3. No organizing abdominal fluid collection.
4. Apparent non opacification of a few subsegmental pulmonary arterial
branches of the right lower lobe posterior basal segment may be due to bolus
timing which is not optimized for evaluating the pulmonary arteries. However,
if there is clinical concern for pulmonary embolus, this would be best
evaluated with dedicated chest CTA.
5. Left hemidiaphragm elevation, likely paretic.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 5:21 ___, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with new onset RUQ pain and tenderness. // r/o
cholelithiasis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is trace perihepatic ascites. There is a trace right pleural
effusion.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 11 cm.
Limited images of the right kidney are normal with no hydronephrosis.
IMPRESSION:
1. Echogenic liver compatible with steatosis.
2. Normal appearance of the gallbladder with no stones or wall thickening.
3. Trace perihepatic ascites and trace right pleural effusion.
Radiology Report
INDICATION: ___ year old woman with abdominal pain/cramping // ? new
intra-abdominal process/fluid collection/abscess compare to prior study
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol
= 1.2 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 5.0 s, 1.0 cm;
CTDIvol = 11.6 mGy (Body) DLP = 11.6 mGy-cm. 3) Spiral Acquisition 16.1 s,
55.4 cm; CTDIvol = 20.7 mGy (Body) DLP = 1,113.8 mGy-cm. Total DLP (Body) =
1,140 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: There is a moderate right pleural effusion, larger on the prior
study, with adjacent atelectasis. Atelectasis is also present at the left lung
base. There is no pericardial effusion, and the visualized heart is normal in
size.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. The
lateral left lobe liver appears atretic. 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 hydronephrosis. A 13 mm hypodensity in the lower pole of the
right kidney is consistent with a simple cyst. Additional small hypodensities
in both kidneys are too small for further characterization. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Again seen are multiple dilated
loops of small bowel, slightly less distended than the prior study, with a
transition point near the ileostomy, similar in appearance the prior study.
The ileostomy itself is unremarkable in appearance. A ___ pouch is
again identified, opacified with oral contrast. The appendix is surgically
absent. There is a small amount of fluid in the paracolic gutters, slightly
increased compared to the prior study but nonspecific.
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: Multiple prominent mesenteric lymph nodes at the root of the
mesentery are noted. Several small retroperitoneal lymph nodes are noted
which are not pathologically enlarged. 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 aside from
left lower quadrant ileostomy.
IMPRESSION:
1. Mild improvement in distension of small bowel loops compared to the most
recent prior study. Transition point remains near the ileostomy
2. New small amount of ascites without discrete fluid collection.
3. Increased right pleural effusion, now moderate, and adjacent atelectasis.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ y/o F w/ RUE double-lumen PICC, now w/frequent clotting and
difficulty drawing back // please eval for current PICC position
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Right PICC tip is in themid SVC. Cardiac size is normal. There are bibasilar
atelectasis. The left hemidiaphragm is elevated. There is dilatation of
bowel projecting in the left upper quadrant. There are surgical clips in the
left upper quadrant of the abdomen. There is no pneumothorax or large pleural
effusion.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, SBO
Diagnosed with Unspecified intestinal obstruction
temperature: 99.5
heartrate: 76.0
resprate: 18.0
o2sat: 97.0
sbp: 92.0
dbp: 55.0
level of pain: 6
level of acuity: 2.0 | Ms. ___ is a ___ y/o F w/ a h/o sigmoid volvulus s/p
colectomy ___ and ex-lap, loop ileostomy diversion, who
presented to ___ on ___ with c/o abd pain, n/v and
decreased ileostomy output. She was initially seen at an OSH,
had a NGT placed and, upon presentation to ___, she was found
to have WBC 11.1 lactate
5.2 and ___ of 3.8. She received 3L of crystalloid in the ED and
was placed on noriepinephrine drip for hypotension of
approximately 80/50. CT AP w/ IV contrast concerning for high
grade SBO just proximal to the loop ileostomy with significant
proximal SB distention without evidence of pneumatosis
intesinalis or perforation.
Digitalization at the bedside and ___ catheterization of the
loop ileostomy did not provide relief of pressure or evacuation
of any contents. The patient was admitted to the Acute Care
Surgery service for further medical care.
On HD1, the patient was taken to the Operating Room and
underwent Exploratory laparotomy, LOA, and reduction of
internal hernia with application of an ABThera VAC. She was
transferred to the ICU for further monitoring. On POD1, the
patient was taken back to the OR and underwent an exploratory
laparotomy with small bowel resection and temporary
vacuum-assisted closure. On POD2, blood cultures were sent for
infectious workup. On POD3, the patient returned to the OR and
underwent an exploratory laparotomy, formation of an end
ileostomy and fascial closure.
On POD3, the patient required decreased presser support. On
POD4, the patient was extubated with decreasing need for presser
support. On POD5, trickle TF were trialed. On POD6, abx were
d/c'd. On POD7, an abdominal wound vac was placed and the
patient was transferred to the floor.
On POD9, the patient was noted to have high ostomy output and
she received 1L bolus x 2 for hydration. On POD10, the patient
received 2 additional boluses and immodium was started as well
as TPN. Vac was changed. On POD11, the patient was started on
Metamucil wafers. On POD12, the patient's NGT was d/c'd and she
received TPN and IVF.
On POD13, the patient was started on clears and her foley was
d/c'd. She tolerated clears and she voided without issue. On
POD15, the patient's pain was managed with liquid acetaminophen
and oxycodone. On POD16, the patient's ileostomy output
increased and she was started on immodium TID. On POD18, TPN
was d/c'd. On POD27, the patient was noted to by hyponatremic
and hyperkalemic and Renal was consulted. She was started on
salt tabs and IVF.
On POD28, the patient reported n/v and increased abd pain. She
received a CT abd/pel which was concerning for ileus. GI was
consulted and her anti-motility agents were held. Metamucil
packets were restarted once her ostomy output picked up. She
was restarted on a regular diet which was well-tolerated. She
required cycled IV fluids to maintain her fluid balance.
Rifaximin was started for small bowel microbial overgrowth and
patient completed a course of 10 days. She was also started on
probiotics to restore microbial balance in GI tract.
On POD34, patient c/o RUQ pain with no abnormalities on
ultrasound. A CT abd/pelvis was performed for continued
cramping and pain which showed no discrete drainable fluid
collection.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. She was discharged home with
visiting nurse services. |