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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
nitrofurantoin / Sulfa (Sulfonamide Antibiotics) / Cipro
Attending: ___.
Chief Complaint:
Generalized tonic-clonic seizure
Altered Mental Staatus
Major Surgical or Invasive Procedure:
Intubation (___)
R IJ CVL
NGT (discontinued ___
History of Present Illness:
MS. ___ is a ___ woman with past medical history of
hypertension,
hyperlipidemia, pulmonary fibrosis, and recently diagnosed stage
I lung cancer status post CyberKnife transfer to the ED
intubated and sedated after a generalized tonic-clonic seizure
lasting for minutes.
Per report, patient was last seen well at around 4 ___ on date of
admission. At 6 ___ she was home alone and her neighbor heard
her yell, he arrived to find her on the floor, confused (said
her age was ___ and told him an incorrect date). He immediately
called ___. On EMS arrival she was able to speak but somewhat
confused. At the time there were concerns of right upper
extremity weakness. There was no evidence of facial droop. As
they prepared to transport her she developed right gaze
deviation followed by generalized tonic-clonic seizure lasting 4
minutes and resolving spontaneously. She was not given
benzodiazepines. She was then taken to an OSH ED where
noncontrast ___ CT and CT C-spine were unremarkable. She was
given Keppra 1 g IV and
lorazepam 1 mg IV. As her alteration in mental status persisted
team became concerned that was unable to protect her airway so
they proceeded with endotracheal intubation. Prior to
intubation blood pressure was 220/102 so she was started on
nicardipine drip which was shortly discontinued when she became
hypotensive after intubation. She briefly required
Neo-Synephrine prior to
transport.
On further discussion with the patient's family at the bedside
they report at baseline she is able to walk with a cane, perform
all activities of daily living, manage her finances, and drive.
However, during the last ___ weeks she had experienced a
persistent bout of diarrhea. She finally visited her PCP and
was diagnosed with an intestinal parasite (family is unsure as
to which). She was treated with an antiparasitic medication
that she had difficulty tolerating per the family. During this
time he had become dizzy, and orthostatic so her HCTZ had been
held. They feel that in the last ___ weeks she had been somewhat
deconditioned and difficulties with cognition have become more
apparent.
Past Medical History:
Gout
Left upper lobe adenocarcinoma
Collagenous colitis
Vitamin D deficiency
Gouty arthropathy
GERD
Pulmonary fibrosis
Hypertension
Hyperlipidemia
Osteoarthritis
Cervical spine degenerative disc disease
Social History:
___
Family History:
Mother: Died of a stroke at age ___
Sister: Pulmonary fibrosis
There is no family history of seizures
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 94.1, 57, 137/63, 20,100% Intubation
General: Intubated
HEENT: ET tube in place, hard cervical collar in place
___: RRR
Pulmonary: Left lower lobe crackles
Abdomen: Soft
Extremities: Warm under Bair hugger
Neurologic Examination: (Off propofol and fentanyl)
Mental status: Opens eyes spontaneously, does not follow
commands
consistently.
Cranial Nerves: Pupils equally round and sluggishly reactive to
light at 1.5 mm. Blink to threat in all visual fields present.
Corneals present bilaterally. Spontaneous cough and gag
present.
No facial asymmetry around ET tube.
Motor: Vigorously moving bilateral upper and lower extremities
with good strength. Unable to cooperate with confrontational
exam.
Sensory: Withdraws appropriately to noxious stimulation in all
extremities
DTRs: 2+ at the knees. Plantar downgoing on the right and brisk
withdrawal on the left (patient become increasingly agitated at
this point)
DISCHARGE PHYSICAL EXAM
VS: 97.4 123/73 88 18 99%RA
GENERAL: Pleasant, cooperative, NAD.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: Nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: RLL>LLL crackles. Breathing comfortably
without use of accessory muscles. No wheezes or rhonchi.
ABDOMEN: nondistended, +BS, non-tender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
NEURO: Oriented to month, year, and location. CN II-XII
intact. No focal neurological deficits.
Pertinent Results:
LABS ON ADMISSION:
___ 11:50PM BLOOD WBC-9.3 RBC-4.09 Hgb-11.5 Hct-37.6 MCV-92
MCH-28.1 MCHC-30.6* RDW-14.5 RDWSD-49.0* Plt ___
___ 11:50PM BLOOD ___ PTT-28.8 ___
___ 11:50PM BLOOD Plt ___
___ 11:50PM BLOOD ___ 11:50PM BLOOD UreaN-13 Creat-0.7
___ 11:50PM BLOOD Lipase-10
___ 11:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:56PM BLOOD Rates-/___ Tidal V-400 O2 Flow-3 pO2-131*
pCO2-28* pH-7.46* calTCO2-21 Base XS--1 Intubat-INTUBATED
Vent-CONTROLLED Comment-GREEN TOP
___ 04:13AM BLOOD Type-ART pO2-142* pCO2-36 pH-7.44
calTCO2-25 Base XS-1
___ 11:56PM BLOOD Glucose-108* Lactate-1.9 Na-140 K-3.8
Cl-110*
___ 11:56PM BLOOD Hgb-12.9 calcHCT-39 O2 Sat-95 COHgb-4
MetHgb-0
___ 11:56PM BLOOD freeCa-0.89*
LABS ON DISCHARGE:
___ 07:35AM BLOOD WBC-7.9 RBC-4.08 Hgb-11.3 Hct-36.0 MCV-88
MCH-27.7 MCHC-31.4* RDW-14.2 RDWSD-45.7 Plt ___
___ 07:35AM BLOOD Glucose-86 UreaN-16 Creat-0.7 Na-140
K-3.9 Cl-100 HCO3-25 AnGap-15
MICROBIOLOGY
- Stool C. Diff (___) - negative
- Urine legionella antigen (___) - negative
- Blood culture (___) - negative
- Urine culture (___) - negative
- Blood culture (___) - negative
IMAGING:
CXR (___): Heart size and mediastinum are stable. Left
perihilar opacity in left basal opacity is similar to previous
examination consistent with provided history of pulmonary
fibrosis. On the other hand the left perihilar opacity is more
conspicuous in although might represent infectious process, it
also might reflect the previous pulmonary nodule seen on chest
CT from ___ and does assessment with chest CT is
required.
RECOMMENDATION(S): Chest CT for precise characterization of the
left
perihilar opacity.
CXR (___): chest AP view when compared to prior done on ___ shows stable position of the NG tube. The right IJ
line has been removed in the interim. Lungs continue to be low
volume with a stable parenchymal opacity in the left lower lobe
and left perihilar region and right lower lobe which could
represent multifocal pneumonia. Lungs are low volume with
stable interstitial prominence. Small left effusion is
unchanged. No pneumothorax is seen
EEG (___): This is an abnormal video EEG monitoring session
due to the
presence of diffuse background slowing, indicative of a moderate
encephalopathy, nonspecific as to etiology. This finding is
commonly caused by toxic metabolic, infections or medications
effects. There are rare triphasic appearing sharp waves
indicative of diffuse cortical irritability. This study captures
no pushbutton activation, or electrographic seizures. Compared
to yesterday's study, there is no significant change.
Abdominal XR (___): Nonobstructive bowel gas pattern. No
radiographic findings correlating to the reported history of new
abdominal pain.
L Upper Extremity US ___:
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Diffuse subcutaneous edema.
MR ___ W and ___ CONTRAST ___:
1. Moderately degraded exam due to motion artifact.
2. Small focus of subacute ischemia identified in the splenium
of the corpus
callosum detected in the DWI and FLAIR images (image 14, series
14, and series
18). There is no evidence of acute intracranial hemorrhage, or
mass effect.
No abnormal enhancement to suggest intracranial metastasis.
3. Old infarct within the left parietal lobe.
CXR (___): Right IJ in place in the right atrium without
pneumothorax. Ill-defined densities in the left lung, with some
component representing scarring, though not well evaluated
CTA ___ and Neck (___):
1. No acute intracranial process.
2. Mild to moderate atherosclerotic calcifications at the aortic
arch,
bilateral carotid bifurcations and bilateral cavernous carotid
arteries, with
50% stenosis of the right ICA and 33% stenosis of the left ICA
by NASCET
criteria.
3. Partially visualized bilateral pleural effusions, left
greater than right.
4. Partially visualized left upper lobe opacification, which may
represent
pneumonia in the appropriate clinical setting.
CXR ___ endotracheal tube terminates 4.6 cm above the
carina.
Left mid to lower lung opacity obscures the left heart border.
Findings
concerning for aspiration versus an infectious process.
Small left pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Simvastatin 20 mg PO QPM
5. Hydrochlorothiazide 25 mg PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Ranitidine 150 mg PO BID
8. Magnesium Oxide 400 mg PO DAILY
9. Hyoscyamine 0.125 mg SL QID:PRN pain
10. Lisinopril 40 mg PO DAILY
11. Aspirin 162 mg PO DAILY
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. Albuterol Inhaler ___ PUFF IH Q6H:PRN cough
Discharge Medications:
1. LevETIRAcetam Oral Solution 1000 mg PO Q12H
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN cough
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 162 mg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Hyoscyamine 0.125 mg SL QID:PRN pain
9. Lisinopril 40 mg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Ranitidine 150 mg PO BID
13. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
- GTC
- Posterior Reversible Encephalopathy Syndrome (PRES)
SECONDARY DIAGNOSIS
- Aspiration Pneumonia
- Hypertension
- Diarrea
- Pulmonary Fibrosis
- Hyperlipidemia
- L upper lobe adenocarcinoma s/p cyberknife
- GERD
- Gout
- Swallowing Difficulty
- Positive O&P Blastocystis homonis at PCP ___
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: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ with altered mental status// ? ICH ? stroke
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 9.5 s, 0.5 cm; CTDIvol = 103.5 mGy (Head) DLP =
51.7 mGy-cm.
3) Spiral Acquisition 0.6 s, 4.9 cm; CTDIvol = 23.9 mGy (Head) DLP = 117.6
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7
mGy-cm.
5) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
6) Spiral Acquisition 5.0 s, 39.7 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,229.8 mGy-cm.
Total DLP (Head) = 2,338 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 prominent, suggestive of volume loss.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are essentially clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
Mild to moderate atherosclerotic calcifications are seen of the aortic arch,
bilateral carotid bifurcations, and bilateral cavernous carotid arteries. 50%
stenosis of the right ICA 33% stenosis of the left ICA by NASCET criteria.
The vertebral arteries and their major branches appear otherwise normal with
no evidence of stenosis or occlusion.
OTHER:
The visualized portion of the lungs are notable for bilateral pleural
effusions, left greater than right, and partially visualized opacification at
the left upper lobe, which may represent pneumonia in the appropriate clinical
setting. The visualized portion of the thyroid gland is within normal limits.
There is no lymphadenopathy by CT size criteria.
IMPRESSION:
1. No acute intracranial process.
2. Mild to moderate atherosclerotic calcifications at the aortic arch,
bilateral carotid bifurcations and bilateral cavernous carotid arteries, with
50% stenosis of the right ICA and 33% stenosis of the left ICA by NASCET
criteria.
3. Partially visualized bilateral pleural effusions, left greater than right.
4. Partially visualized left upper lobe opacification, which may represent
pneumonia in the appropriate clinical setting.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with hx of HTN, pulmonary fibrosis and lung
carcinoma presenting with new onset GTC. Please assess for metastatic disease
vs stroke.// ___ year old woman with hx of HTN, pulmonary fibrosis and lung
carcinoma presenting with new onset GTC. Please assess for metastatic disease
vs stroke.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: None.
FINDINGS:
The exam is moderately degraded due to motion artifact.
Focus of subacute ischemia is identified in the splenium of the corpus
callosum (image 14, series 14 and 18), measuring approximately 2 x 3 mm in
transverse dimension, there is no evidence of acute intracranial hemorrhage,
or mass effect. No abnormal enhancement is identified.
There is moderate global parenchymal volume loss. There is an area of
encephalomalacia within the left superior and inferior parietal lobules,
consistent with an old infarct. Small areas of hyperintense signal on
T2/FLAIR within the subcortical periventricular white matter are nonspecific,
but likely reflect the sequela of mild chronic small vessel disease. The
major vascular flow voids are preserved.
Fluid within the right sphenoid sinus and bilateral mastoid air cells may be
related to endotracheal intubation.
IMPRESSION:
1. Moderately degraded exam due to motion artifact.
2. Small focus of subacute ischemia identified in the splenium of the corpus
callosum detected in the DWI and FLAIR images (image 14, series 14, and series
18). There is no evidence of acute intracranial hemorrhage, or mass effect.
No abnormal enhancement to suggest intracranial metastasis.
3. Old infarct within the left parietal lobe.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with stroke// R IJ placement
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: Chest radiograph ___. Whole-body PET-CT ___.
FINDINGS:
Lung volumes are low. Endotracheal tube is satisfactory. Right IJ catheter
terminates in the right atrium. Upper enteric tube terminates in the stomach
with tip outside of field-of-view. There is an area of left upper lobe
consolidation, corresponding to that seen on previous PET-CT, though may have
somewhat increased in prominence, with some component of this area likely
reflecting post radiation change. There is probable right lung base
bronchiectasis. There is no large effusion pneumothorax.
IMPRESSION:
Right IJ in place in the right atrium without pneumothorax. Ill-defined
densities in the left lung, with some component representing scarring, though
not well evaluated. All
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with seizures, intubated. swelling of L AC and
red// LUE U/S r/o DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation. Diffuse
subcutaneous edema is noted.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity.
2. Diffuse subcutaneous edema.
Radiology Report
INDICATION: ___ year old woman with PRES, presented with GTC// eval NG tube
placement
COMPARISON: Radiographs from ___
IMPRESSION:
Support lines and tubes are unchanged in position. Heart size is upper limits
of normal but stable. There is again seen a small left-sided pleural
effusion. Bilateral opacities more confluent on the left side remain
unchanged. There is minimal improvement of the pulmonary edema. There are no
pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with seizure likely s/t PRES, new NGT// NGT
placement
IMPRESSION:
In comparison with the study of ___, the new nasogastric tube extends
well into the stomach with the side port distal to the esophagogastric
junction. The endotracheal tube is not seen. Right IJ catheter again extends
to the upper right atrium.
There is increasing bilateral pulmonary opacifications. Given the clinical
history, this is worrisome for multifocal pneumonia with associated left
effusion.
Radiology Report
INDICATION: ___ year old woman with a history of lung cancer presents with new
onset abdominal pain// source of pain
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: PET-CT ___.
Portable chest radiograph ___
FINDINGS:
An enteric tube is seen projecting over the upper abdomen likely in the
stomach. There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air. Left total hip arthroplasty noted.
Degenerative changes of the lumbar spine noted.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonobstructive bowel gas pattern. No radiographic findings correlating to the
reported history of new abdominal pain.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with tachypnea, crackles on PE// Evaluate for
fluid overload Evaluate for fluid overload
IMPRESSION:
Comparison to ___. The course of the feeding tube is unremarkable,
stable position of the right internal jugular vein catheter. Minimal decrease
in extent and severity of the bilateral parenchymal opacities, mild to
moderate pulmonary edema continues to be present. No pneumothorax.
Radiology Report
EXAMINATION: Chest AP view
INDICATION: ___ year old woman with new fever// interval change
TECHNIQUE: Chest chest AP view
COMPARISON: ___
IMPRESSION:
chest AP view when compared to prior done on ___ shows stable
position of the NG tube. The right IJ line has been removed in the interim.
Lungs continue to be low volume with a stable parenchymal opacity in the left
lower lobe and left perihilar region and right lower lobe which could
represent multifocal pneumonia. Lungs are low volume with stable interstitial
prominence. Small left effusion is unchanged. No pneumothorax is seen
Radiology Report
INDICATION: ___ year old woman with new NG tube replaced// NG tube placement
eval Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the nasogastric tube projects over the stomach.
Bilateral parenchymal opacities are again seen within the left mid and left
lower lungs as well as the right perihilar region however the appear decreased
since prior and may reflect decreasing multifocal pneumonia. Unchanged
interstitial prominence and a small left pleural effusion. There is no
pneumothorax.
IMPRESSION:
The tip of a nasogastric tube projects over the stomach.
Interval decrease in extent of the parenchymal opacities presumed to reflect
multifocal pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with history of pulmonary fibrosis, HTN,
admitted after new onset seizures and AMS, found to have PRES, hospital course
c/b aspiration PNA s/p 5 day course of unasyn, discontinued on ___, still
with cough and productive white sputum and right lower lobe crackles greater
than left lower lobe.// ?PNA ?PNA
IMPRESSION:
Heart size and mediastinum are stable. Left perihilar opacity in left basal
opacity is similar to previous examination consistent with provided history of
pulmonary fibrosis. On the other hand the left perihilar opacity is more
conspicuous in although might represent infectious process, it also might
reflect the previous pulmonary nodule seen on chest CT from ___ and
does assessment with chest CT is required.
RECOMMENDATION(S): Chest CT for precise characterization of the left
perihilar opacity.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Seizure, Transfer
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: c
level of acuity: 2.0 | Ms. ___ is an ___ woman with a history of poorly
differentiated adenocarcinoma of the lung diagnosed in ___,
currently in remission s/p gamma knife therapy, as well as a
history of htn, osteoarthritis who was brought to OSH after 2
GTCs requiring ICU admission for management of GTC with
intubation for airway protection with hospital course including
MRI Brain showing likely PRES syndrome.
==============
ACUTE ISSUES
==============
# GTC
# Posterior Reversible Encephalopathy Syndrome - Initially found
confused after witnessed 4 min GTC seizure and presented with 2
GTCs requiring ICU stay with intubation for airway protection.
MRI Brain at OSH concerning for PRES. Etiology of seizure likely
secondary to PRES, which was possibly in setting of HTN with SBP
in 200s at OSH (she recently discontinued anti-hypertensives a
few weeks prior because of dizziness). She was initially
intubated for airway protection and admitted to the Neuro ICU.
She was started on keppra and placed on cvEEG. Patient had no
additional seizure activity and was successfully extubated on
___ and transferred to the floor. Patient was continued on
Keppra 1G PO BID and will require indefinitely until she
follows-up with neuro in ___ months.
#HTN - Patient was initially hypertensive. Her home metoprolol
50mg BID was initially increased to 37.5 TID and home lisinopril
40mg was continued. After additional titration re-starting HCTZ,
amlodipine, and adding lasix, patient became hypotensive to as
low as SBPs 60-70s. Metoprolol was decreased to 25mg BID and
other anti-hypertensives were stopped. Anti-hypertensives were
additionally titrated to lisinopril 40mg QDaily and
hydrochlorothiazide 25mg QDaily.
#Aspiration Pneumonia - Found to have multifocal PNA, initially
started on vancomycin and zosyn (___), however was
de-escalated to unasyn (___). Speech and Swallow
evaluated the patient. Was high aspiration risk, however
eventually started on thin liquids and pureed solids and
tolerated well. NGT was removed at time of discharge. CXR at
discharge demonstrating left lower lobe opacity, could reflect
pulmonary nodule identified on previous CT versus infectious
process, however patient has remained afebrile without
leukocytosis making infectious process at this time less likely.
Recommending CT Chest to further characterize left lung opacity
as outpatient.
#Diarrhea - After starting vancomycin and zosyn patient started
to have worsening diarrhea, possibly in setting of recent
antibiosis. C. diff was negative. Given persistent diarrhea,
tube feeds were stopped and stool cultures and O&P were sent
given resent blastocystis hominis treatment.
#Gout - was noted to have erythematous swollen right pinky
finger on ___ and was given 1.2mg colchicine followed by 0.6mg
daily.
#Agitation - Became agitated after extubation requiring haldol
PRN and standing seroquel. Improved over hospital course and end
of hospital course was on seroquel 25mg QAM and 50mg QHS.
==============
CHRONIC ISSUES
==============
#Pulmonary Fibrosis - Continued home albuterol and fluticasone
#HLD - Continued home simvastatin 20mg PO QD
#LUL adenocarcinoma s/p cyberknife: Has f/up CT chest scheduled
for ___
#GERD - continued ranitidine 150mg PO BID
#Positive O&P for blastocystis hominis: S/p Rx with flagyl 500mg
TID x 10d (___) per PCP ___
===================
TRANSITIONAL ISSUES
===================
DISCHARGE/TRANSITIONAL ISSUES
[ ] Continue levetiracetam 1000mg q12h on discharge
[ ] CXR on ___ showing left pulmonary opacity, might
reflect the previous pulmonary nodule seen on chest CT from ___ versus infectious process. Radiology recommending
Chest CT for precise characterization of the left perihilar
opacity.
[ ] Plan for outpatient repeat MRI prior to follow up
appointment with neurology. Please instruct patient to call
___ to schedule this for mid to late ___ or early
___.
>30 minutes spent coordinating discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is an ___ female with COPD, diastolic CHF,
atrial fibrillation on warfarin recently admitted with
respiratory failure who presented to the ___ ED on ___
with constipation and obstipation.
Patient presented from ___ after not having
a bowel movement or passing gas for 5 days (last BM ___.
She had a KUB done today which showed mild colonic dilatation
consistent with mild colonic ileus, moderate amount of rectal
stool.
She was recently admitted for acute hypoxic respiratory
failure, secondary to COPD, CHF, and pneumonia ___ to
___. Treated in the ICU and intubated. During this
admission she was given IV diuretics, treated with prednisone
for COPD, and treated with vancomycin, azithromycin and bactrim
for MRSA and stenotrophonas PNA. Discharged on 2 L nasal
cannula. She also developed ogilvies/ileus and was found to have
severe dilation on abdominal CT on ___. She was treated with
enemas and anticholinergic meds were reduced. On ___, GI
performed a colonoxcopy with decompression and placement of
colonic tube which was in place for about 24 hours with
improvement of sx. Antipsychotics were downtitrated and
diltiazem was transitioned to metoprolol given concern for
medication induced ileus.
In the ED, initial vitals were:
- Exam notable for: crackles and wheezes in lungs, soft
non-distended abdomen with hypoactive bowel sounds, 2+ lower
extremity edema
-->Rectal: no impacted stool, guiaic neg
- Labs notable for: Hb 6.9, Cr 1.2, INR 2.4, u/a with large
leukocytes, negative nitrites, 21 WBC and few bacteria
- Imaging was notable for: CT A/P showing prelim no acute
intra-abdominal process.
- Patient was given: 40mg pantoprazole IV x 1, 1 unit pRBCs
- Vitals prior to transfer: 98.6 74 113/46 16 96% Nasal Cannula
Upon arrival to the floor, patient reports that she is because
of "bowel problems." Pt notes that her last BM was many days
ago. She recalls that her BM pattern has not been normal since
she was discharged to rehab from the hospital. She denies
abdominal pain. She denies n/v. She has had no dysuria, urgency
or urinary incontinence. She does endorse frequent burning
reflux-like abdominal pain. Otherwise she is feeling well.
Denies worsening ___ edema. Denies CP and SOB with activity.
No orthopnea or PND.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) No fevers, chills, cough, congestion, rhinorrhea. No n/t of
the extremities. Energy level is good. No change in
hair/skin/nails. No dysphagia. Denies blood in her stools o
rblack stools. Appetite has been very good. No myalgias.
Past Medical History:
-Diastolic heart failure
-COPD
-Pulmonary hypertension
-CKD (chronic kidney disease), stage III
-PAF (paroxysmal atrial fibrillation)
-HLD
-HTN
-Breast cancer s/p chemoradiation in ___
Social History:
___
Family History:
Per husband:
History of cardiac disease in her father and brother. Otherwise
no known family history.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vital Signs: 97.5 101 / 52 59 18 92 2L
General: Elderly F, no acute distress, lying in hospital bed,
alert and oriented to person, place, time (year and month, not
date)
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated.
CV: Irregularly irregular, s1 and s2 heard, ___ murmur heard at
RUSB, no extra heart sounds
Lungs: Expiratory wheezing heard throughout, faint crackles at
bases b/l
Abdomen: Distended, soft, non-tender, bowel sounds present, non
tender to palpation in all four quadrants, no rebound or
guarding
GU: No foley
Ext: Warm, well perfused, 2+ pitting edema of the ___
DISCHARGE PHYSICAL EXAM
Vital Signs: 97.5 101 / 52 59 18 92 2L
General: Elderly F, no acute distress, lying in hospital bed,
alert and oriented to person, place, time (year and month, not
date)
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated.
CV: Irregularly irregular, s1 and s2 heard, ___ murmur heard at
RUSB, no extra heart sounds
Lungs: Expiratory wheezing heard throughout, faint crackles at
bases b/l
Abdomen: Distended, soft, non-tender, bowel sounds present, non
tender to palpation in all four quadrants, no rebound or
guarding
GU: No foley
Ext: Warm, well perfused, 2+ pitting edema of the ___
Pertinent Results:
LABS
====
___ 03:55PM BLOOD WBC-6.6 RBC-2.82* Hgb-6.9* Hct-22.6*
MCV-80* MCH-24.5* MCHC-30.5* RDW-28.6* RDWSD-80.0* Plt ___
___ 03:55PM BLOOD Neuts-71.1* Lymphs-15.7* Monos-9.8
Eos-2.6 Baso-0.3 Im ___ AbsNeut-4.72# AbsLymp-1.04*
AbsMono-0.65 AbsEos-0.17 AbsBaso-0.02
___ 05:05AM BLOOD WBC-5.3 RBC-3.12* Hgb-7.6* Hct-25.3*
MCV-81* MCH-24.4* MCHC-30.0* RDW-27.1* RDWSD-78.0* Plt ___
___ 03:55PM BLOOD Plt ___
___ 05:25PM BLOOD ___ PTT-29.3 ___
___ 05:05AM BLOOD ___
___ 05:05AM BLOOD Plt ___
___ 03:55PM BLOOD Glucose-130* UreaN-26* Creat-1.2* Na-135
K-3.4 Cl-94* HCO3-32 AnGap-12
___ 05:05AM BLOOD Glucose-104* UreaN-24* Creat-1.2* Na-136
K-3.6 Cl-96 HCO3-36* AnGap-8
___ 05:05AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.2
___ 03:55PM BLOOD TSH-0.54
MICRO
=====
___ URINE CULTURE-PENDING
IMAGING
=======
___ CT A/P:
1. Partially imaged left lower lobe consolidation may be due to
atelectasis but underlying pneumonia is not excluded. Right base
atelectasis and very trace right pleural effusion.
2. No evidence of bowel obstruction or bowel wall thickening. No
free fluid.
3. Extensive atherosclerotic disease.
4. Severe narrowing of the central canal at L2/L3 with prominent
posterior osteophyte causes severe narrowing.
___ Imaging CHEST (PA & LAT)
In comparison with the study of ___, the cardiac silhouette
remains
enlarged, though not as prominent as on the previous study.
Continued mild pulmonary vascular congestion with bibasilar
atelectatic changes and small pleural effusions. The right
subclavian PICC line extends to about the level of the
cavoatrial junction. If there is any concern for it being the
inciting factor for the arrhythmia, it could be pulled back
about 2 cm to definitely be above the cavoatrial junction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 37.5 mg PO Q6H
2. Isosorbide Mononitrate 15 mg PO BID
3. Melatin (melatonin) 6 mg oral QHS
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 17.2 mg PO DAILY
6. Calcium Carbonate 500 mg PO QID:PRN reflux
7. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
8. Chloraseptic Throat Spray 1 SPRY PO Q2H:PRN sore throat
9. OLANZapine 5 mg PO BID:PRN agitation
10. Ondansetron 4 mg IV Q8H:PRN nausea
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Warfarin 3 mg PO DAILY16
14. Docusate Sodium 100 mg PO BID
15. Furosemide 60 mg IV DAILY
16. GuaiFENesin ER 1200 mg PO Q12H
17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Pantoprazole 40 mg PO Q12H
20. QUEtiapine Fumarate 12.5 mg PO QHS
21. PARoxetine 20 mg PO DAILY
22. Simvastatin 20 mg PO QPM
23. Pulmicort (budesonide) 2.5/2 mcg/ml inhalation BID
24. Perforomist (formoterol fumarate) 20 mcg/2 mL inhalation BID
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. Lactulose 30 mL PO DAILY:PRN constipation
4. Metoprolol Succinate XL 150 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
Hold for K >4.0
6. Tiotropium Bromide 1 CAP IH DAILY
7. Torsemide 80 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Senna 17.2 mg PO BID
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
11. Calcium Carbonate 500 mg PO QID:PRN reflux
12. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
13. Chloraseptic Throat Spray 1 SPRY PO Q2H:PRN sore throat
14. Docusate Sodium 100 mg PO BID
15. GuaiFENesin ER 1200 mg PO Q12H
16. Melatin (melatonin) 6 mg oral QHS
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. PARoxetine 20 mg PO DAILY
20. Perforomist (formoterol fumarate) 20 mcg/2 mL inhalation
BID
21. Polyethylene Glycol 17 g PO DAILY
22. Pulmicort (budesonide) 2.5/2 mcg/ml inhalation BID
23. QUEtiapine Fumarate 12.5 mg PO QHS
24. Simvastatin 20 mg PO QPM
25. Warfarin 3 mg PO DAILY16
26.Outpatient Lab Work
Date: ___
Dx: Chronic diastolic heart failure (I50.23)
Labs: Na, Cl, K, HCO3, BUN, Cr, Mg
Please send results to on call doctor at ___
in ___ Fax: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- constipation
- Chronic diastolic heart failure
SECONDARY:
- Chronic renal failure
- atrial fibrillation on warfarin
- COPD
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: NO_PO contrast; History: ___ with obstipation x5 daysNO_PO
contrast// Eval for evidence of bowel obstruction, oglive's syndrome
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 4.8 s, 52.4 cm; CTDIvol = 15.6 mGy (Body) DLP = 819.1
mGy-cm.
Total DLP (Body) = 830 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: Partially imaged left lower lobe consolidation is seen which may
be due to atelectasis, but underlying infection is not excluded. There is
also right base atelectasis. Very trace right pleural effusion is seen. No
pericardial effusion is seen. Coronary calcification is seen. The heart is
enlarged.
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: Spleen is not enlarged. The spleen is homogeneous without focal
lesion seen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are relatively atrophic but demonstrate symmetric
nephrogram and excretion of contrast. There is no evidence of focal renal
lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Some is relatively collapsed. No bowel obstruction or bowel
wall thickening is seen. The hepatic flexure is interposed above the right
aspect of the liver. There is moderate colonic fecal loading. The appendix
is not definitely seen.
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 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. Extensive atherosclerotic
calcification is seen along the aorta and its branches..
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Multilevel degenerative changes are seen. There is severe narrowing of the
central canal, L2/L3 where prominent posterior osteophyte causes severe
narrowing of the central canal.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Partially imaged left lower lobe consolidation may be due to atelectasis,
but underlying pneumonia is not excluded. Right base atelectasis and very
trace right pleural effusion.
2. No evidence of bowel obstruction or bowel wall thickening. No free fluid.
3. Extensive atherosclerotic disease.
4. Severe narrowing of the central canal at L2/L3 with prominent posterior
osteophyte causes severe narrowing.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with diastolic CHF, atrial fibrillation and
recent admission for PNA with wheezing on exam// Please evaluate for pulm
edema, PNA? Also please evaluate location of PICC
IMPRESSION:
In comparison with the study of ___, the cardiac silhouette remains
enlarged, though not as prominent as on the previous study. Continued mild
pulmonary vascular congestion with bibasilar atelectatic changes and small
pleural effusions.
The right subclavian PICC line extends to about the level of the cavoatrial
junction. If there is any concern for it being the inciting factor for the
arythmia, it could be pulled back about 2 cm to definitely be above the
cavoatrial junction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Constipation
Diagnosed with Pneumonia, unspecified organism
temperature: 97.9
heartrate: 64.0
resprate: 16.0
o2sat: 98.0
sbp: 111.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | ___ female with COPD, diastolic CHF, atrial fibrillation
on warfarin recently admitted with respiratory failure who
presented to the ___ ED on ___ with constipation and
obstipation.
# Constipation:
CT A/P on ___ during last admission showed severe colonic
distention suggestive of primary ___ given absence of
abdominal pain and nausea. Had colonoscopic decompression with
colonic/rectal tube placement on ___ after there was no
improvement with aggressive enemas, reduction of anticholinergic
meds, lytes management, attempts to ambulate. Colonic tube was
in place for 24hrs with significant improvement. Antipsychotics
were also downtitrated and diliazem was transitioned to
metoprolol given concern for medication induced ileus. On this
admission, patient again reports having gone 5 days with
constipation/obstipation without abdominal pain or
nausea/vomiting. CT A/P now without ileus or obstruction/bowel
wall thickening and significantly improved from prior. Patient
received tap water enema this AM with large, well-formed BM
shortly thereafter and patient feels significantly better. Per
patient, she was not receiving enemas at the rehab, and does
have a tendency to get constipated with prolonged ___
facility stay. TSH 0.54. Continue standing docusate and miralax.
Change senna to standing. Added lactulose and tap water enemas
prn if no BM for>48hrs. Discontinued Zofran.
#Anemia
Hb 6.9 upon admission. D/c Hb of 7.1
Has chronic anemia as outpatient. During previous admission,
retic index high, hemolysis labs negative, iron studies showed
low iron level and very low iron saturation (6%) c/w iron
deficiency. She was started on PPI BID out of concern / high
risk for gastritis/PUD. However, concern for gastritis low at
this time. Heart burn likely secondary to deconditioning.
Received one unit prbc on ___ in ED. Reduced PPI to 40 daily
and added iron supplements daily to improve iron deficiency in
setting of poor PO intake. We discussed that iron may make her
stools dark and may make her constipated but that she should
continue to make sure she has a good BM every day.
#CT chest findings / Hypoxia
Of note, during last admission, pt's sputum cultures grew MRSA
and stenotrophonas. ID was consulted and patient completed a 7
day course of vancomycin (ended ___, 5 days azithro (ended
___, and bactrim (ended ___. CT chest on ___ did not show any
significant consolidation, but patient had persistent hypoxia
after completing abx course. Repeat CXR on ___ was suggestive of
new retrocardiac opacity, but pt did not have clinical signs of
infection and she did not receive further abx. On this
admission, she is requiring 2L NC O2. CT A/P showed LLL
consolidation and R basilar atelectasis but repeat CXR showed
continued mild pulmonary vascular congestion with bibasilar
atelectatic changes and small pleural effusions. Her symptoms
are likely secondary to volume overload and she is afebrile,
denies cough, congestion, or rhinorrhea. There is no
leukocytosis. She was discharged on an increased dose of
diuretic as below.
#Asymptomatic pyuria: U/A on admission with large leukocytes, 21
WBC, few bacteria. Pt denies urinary sx. Will follow up culture
and defer treatment of asymptomatic pyuria at this time.
#COPD: Patient with diagnosis of COPD as an outpatient. Was
recently treated for COPD exacerbation and s/p prednisone taper.
Exam today with mild wheezing but no recent cough or increased
sputum production. Her tioptropium was restarted and home advair
was continued. She can continue albuterol nebulizers PRN upon
discharge.
#Diastolic heart failure (LVEF 56% on TTE ___: Dry weight
is 185. Current weight is 183 lbs but given recent decrease in
apatite likely there is some weight loss and dry weight is not
accurate. Exam with wheezing and mild crackles. 2+ ___ edema
present. Was receiving 60 mg IV Lasix at rehab, this was changed
to torsemide 80mg daily and she should have repeat labs (Na, Cl,
K, HCO2, BUN, Cr, Mg) on ___ to assess her renal function
and potassium. Please adjust her diuretic and potassium
supplementation as needed. Also changed isosorbide to long
acting imdur once daily.
#CKD: B/l Cr 1.2-1.5, currently at 1.2.
#Atrial fibrillation. CHADS2-vasc 5. On warfarin 3mg daily at
home and metoprolol. INR 2.2 on admission. Changed metoprolol to
succinate once daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
doxycycline / Dilaudid
Attending: ___.
Chief Complaint:
vomiting, abd pain, diarrhea
Major Surgical or Invasive Procedure:
...
History of Present Illness:
HPI: Ms. ___ is a ___ year-old woman who began having loose
stools around ___, around the time that she was
started on new medications (lamotrigine, bupropion, and
clonazepam). She generally had one loose bowel movement per
day. In late ___ she had nausea, vomiting, abdominal cramps,
and diarrhea ___ times per day. Her sister had similar
symptoms at the time; the sister's symptoms improved, but the
patient's did not. She was admitted to another hospital: C diff
was negative, CT showed left-sided colitis. She was started on
ciprofloxacin and metronidazole. She was transferred to ___.
CRP, ESR, and TTG IgA were normal. CT showed mild improvement
in colitis. Her symptoms ultimately improved and she was
discharged to home on ___.
.
She was seen in GI clinic here on ___, and was doing better at
that time, with no nausea, vomiting, or abdominal pain. She was
still having ___ loose bowel movements per day. Differential
included postinfectious IBS, medication effect, microscopic
colitis, celiac disease, or IBD. Plan was made for colonoscopy.
.
On ___, she ate steamed vegetables and rice at a ___
restaurant and became ill 60-90 minutes thereafter. She had
severe abdominal cramping as well as sharp pains, diarrhea, and
vomiting (some blood in vomit). No one else who ate with her
became ill. These symptoms have persisted since then, including
at night, and regardless of whether she eats or not. ___ bowel
movements per day, some soft, some watery. No melena or dark
vomitus. No fever. She has lost about 15 pounds over the last
few weeks.
.
-In the ED, initial VS: 99.5 96 119/88 16 100% RA
-Exam notable for: diffusely tender abdomen, stool
guaiac-negative
-Labs notable for: leukocytosis
-The pt received: Dilaudid and Zofran (developed rash),
ketorolac
.
ROS: Denies fever, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, dysuria, hematuria. All other ROS negative.
Past Medical History:
Anorexia nervosa
Anxiety
Depression
Social History:
___
Family History:
No family history of IBD, celiac disease, or colon cancer.
Physical Exam:
VS: 98.9 51 116/74 16 100% RA
GENERAL: appears fatigued, a bit uncomfortable, no distress,
pleasant
HEENT: PERRL, OP clear
NECK: Supple, no LAD
HEART: RRR, no murmur
LUNGS: CTAB
ABDOMEN: +BS, soft, ND, mild diffuse tenderness
RECTAL: deferred (done in ED, stool guaiac-negative)
EXTREMITIES: warm, no edema
SKIN: rash on upper chest
NEURO: Awake, alert, appropriate, normal sensation to light
touch, ___ strength in bilateral UEs and ___
___ Results:
___ 03:05PM URINE UCG-NEGATIVE
___ 11:42AM GLUCOSE-95 UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-21* ANION GAP-20
___ 11:42AM ALT(SGPT)-68* AST(SGOT)-28 ALK PHOS-88 TOT
BILI-0.7
___ 11:42AM LIPASE-28
___ 11:42AM ALBUMIN-4.9
___ 11:42AM WBC-15.3*# RBC-5.20 HGB-15.3 HCT-44.6 MCV-86
MCH-29.4 MCHC-34.3 RDW-12.4
___ 11:42AM NEUTS-74.6* ___ MONOS-5.4 EOS-0.3
BASOS-0.4
___ 11:42AM PLT COUNT-323
KUB
IMPRESSION: No evidence of bowel obstruction or free air.
EGD:
Erythema in the gastroesophageal junction compatible with Mild
esophagitis (biopsy)
Normal mucosa in the stomach (biopsy)
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow-up biopsy results
Antireflux regimen: Avoid chocolate, peppermint, alcohol,
caffeine, onions, aspirin. Elevate the head of the bed 3 inches.
Go to bed with an empty stomach.
Prilosec 20mg BID
Will proceed with Colonoscopy.
Colonoscopy
Terminal ileum mucosa looked normal. Cold forceps biopsies were
performed for histology at the Terminal ileum.
Impression: Normal mucosa in the colon (biopsy)
Terminal ileum mucosa looked normal. (biopsy)
Otherwise normal colonoscopy to cecum
Recommendations: follow-up biopsy results
Further management per inpatient GI team.
Medications on Admission:
Wellbutrin 100 mg daily
Ativan prn anxiety
Discharge Medications:
1. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for Pain.
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for abdominal pain for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Nausea and vomiting
Diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Abdominal pain, nausea and vomiting. Evaluate for free air.
COMPARISON: Chest radiograph, ___.
FINDINGS: The lungs are clear without consolidation or edema. There is no
pleural effusion or pneumothorax. The cardiomediastinal silhouette is normal.
There is no free air below the hemidiaphragms.
IMPRESSION:
1. No acute cardiopulmonary process.
2. No evidence of free air below the hemidiaphragms.
Radiology Report
INDICATION: Nausea, vomiting and leukocytosis. Evaluate for free air or
small bowel obstruction.
COMPARISON: Abdominal radiograph ___.
FINDINGS: There is no free air below the hemidiaphragms. The bowel gas
pattern is normal without dilated loops of small bowel or air fluid levels.
There is no evidence of obstruction or ileus. Air is seen extending to the
rectum. The osseous structures are unremarkable.
IMPRESSION: No evidence of bowel obstruction or free air.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PIAN/DIARRHEA
Diagnosed with ABDOMINAL PAIN GENERALIZED, NAUSEA WITH VOMITING
temperature: 99.5
heartrate: 96.0
resprate: 16.0
o2sat: 100.0
sbp: 119.0
dbp: 88.0
level of pain: 7
level of acuity: 3.0 | ___ with anxiety, depression, several month history of diarrhea,
recent admission for diarrhea, abd pain, and nausea/vomiting
with evidence of colitis; improved and discharged on ___ now
p/w 5 days of diarrhea, abd pain, and nausea and vomiting. Ddx
includes gastroenteritis, infectious colitis, IBD, microscopic
colitis.
#Abdominal pain, Nausea and vomiting, Diarrhea
She was treated with IVF. GI was consulted. She underwent EGD
and colonoscopy on ___, which showed mild esophagitis but were
otherwise unremarkable. Biopsy results are currently pending at
time of discharge but there was no overt mucosal colitis on
colonoscopy. Infectious stool studies were negative. She was
advised to take PPI bid and to follow an anti-reflux regimen.
The most likley cause of her symptoms was felt to be ongoing
discomfort as a result of a viral gastroenteritis per the GI
team. Even though her anti-TTG ab was previously negative
biopsies should help further eliminate the possibility of
celiac's disease. If she has ongoing symptoms GI ___ want to
pursue a MRE to evaluate for small bowel inflammatory changes
that could exist in the setting of crohn's limited to that
region, however her inflammatory markers were normal this
admission.
#LEUKOCYTOSIS: WBC up to 15 on admission, improved without
therapy
.
#ANXIETY AND DEPRESSION: continued home Wellbutrin.
.
#POSSIBLE ALLERGY: In the ED, she received Zofran and Dilaudid
and subsequently developed a significant rash. She had received
these medications previously without incident.
exam on day of ___ 105 / 61 63
well appearing, but fatigued
soft, non-distended abdomen, +BS, no guarding or rebound
no peripheral edema |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
elevated d-dimer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with DM2, HTN, tobacco use, and h/o PNA ___ years ago who was
referred to the ED due to elevated D-dimer. She had a productive
cough and fever to 101 for >1 week. She was started on
Azithromycin 4 days prior to this presentation. Has been feeling
much better, in fact is back to baseline, but outpatient
provider called her at home due to elevated D-dimer (964) which
was checked as an outpatient.
.
In the ED, initial VS: 98.2 80 ___ 98% RA. labs notable
for WBC 3.2 (40% PMN, 47% lymphs). CTA did rule out PE but
showed nodular opacities that could represent infection,
malignancy, sarcoidosis. Patient felt fine but due to
"diagnostic uncertainty" she was admitted to Medicine. Got
levofloxacin prior to coming up.
.
Currently, she has no complaints except that she wants to go
home. Notes that she feels back to baseline. Quit smoking ~1
week ago and says this may be contributing to her cough.
Past Medical History:
Type 2 Diabetes mellitus
s/p C section (G2P2)
Depression
Asthma
Social History:
___
Family History:
-Diabetes in multiple members of family.
-MGM ?ovarian ca, MGF colon ca
-Mother died of ___ ca
-Maternal aunts (4): with ovarian, breast, colon? unclear who
has
what.
-Cousin with breast ca
Physical Exam:
ADMISSION EXAM
VS - Temp 97.5F, BP 131/86, HR 75, R 18, O2-sat 99% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
(discharged within 12h of admission, no change in exam)
Pertinent Results:
ED LABS
___ 01:13PM BLOOD WBC-3.5*# RBC-4.10* Hgb-12.8 Hct-37.6
MCV-92 MCH-31.2 MCHC-34.0 RDW-12.4 Plt ___
___ 01:13PM BLOOD Neuts-51.3 ___ Monos-7.4 Eos-1.6
Baso-0.4
___ 01:13PM BLOOD D-Dimer-964*
.
ADMISSION LABS
___ 11:00PM BLOOD WBC-3.2* RBC-3.77* Hgb-12.3 Hct-35.0*
MCV-93 MCH-32.7* MCHC-35.2* RDW-12.1 Plt ___
___ 11:00PM WBC-3.2* RBC-3.77* HGB-12.3 HCT-35.0* MCV-93
MCH-32.7* MCHC-35.2* RDW-12.1
___ 11:00PM NEUTS-39.9* LYMPHS-47.2* MONOS-5.8 EOS-4.2*
BASOS-2.8*
___ 11:00PM GLUCOSE-142* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
___ 11:00PM ___ PTT-30.7 ___
.
DISCHARGE LABS
none
.
PENDING LABS
___ 01:13PM BLOOD ___
.
MICRO
___ BLOOD CULTURES PENDING X2
.
IMAGING
___ CTA CHEST
FINDINGS: The pulmonary arterial tree is well opacified and no
filling defect to suggest pulmonary embolism is seen. There is
no evidence of acute aortic syndrome.
Within the lungs, there are multiple bilateral nodular
opacities,
predominantly peribronchovascular with predominance for the left
lower lobe
however also present in the lingula as well as the right middle
and lower
lobes. There is bilateral hilar adenopathy measuring up to 1 cm
in short
axis. Mediastinal lymph nodes do not meet CT criteria for
pathologic
enlargement. No axillary lymphadenopathy is seen.
No evidence of endobronchial lesion is seen. The heart and great
vessels
appear grossly unremarkable. No pleural or pericardial effusion
is seen. No
pneumothorax is identified.
No concerning osseous lesion is seen.
Limited views of the upper abdomen are grossly unremarkable.
IMPRESSION: Multiple bilateral, predominantly
peribronchovascular nodular
opacities greatest in the left lower lobe. The differential for
this
appearance is atypical infection, less commonly vasculitis such
Goodpasture's syndrome or sarcoidosis. No pulmonary embolism.
Radiology Report
INDICATION: Cough with hemoptysis.
TECHNIQUE: Multidetector helical CT scan of the chest was obtained after the
administration of 100 cc IV Omnipaque contrast. Coronal, sagittal and oblique
reformations were prepared.
FINDINGS: The pulmonary arterial tree is well opacified and no filling defect
to suggest pulmonary embolism is seen. There is no evidence of acute aortic
syndrome.
Within the lungs, there are multiple bilateral nodular opacities,
predominantly peribronchovascular with predominance for the left lower lobe
however also present in the lingula as well as the right middle and lower
lobes. There is bilateral hilar adenopathy measuring up to 1 cm in short
axis. Mediastinal lymph nodes do not meet CT criteria for pathologic
enlargement. No axillary lymphadenopathy is seen.
No evidence of endobronchial lesion is seen. The heart and great vessels
appear grossly unremarkable. No pleural or pericardial effusion is seen. No
pneumothorax is identified.
No concerning osseous lesion is seen.
Limited views of the upper abdomen are grossly unremarkable.
IMPRESSION: Multiple bilateral, predominantly peribronchovascular nodular
opacities greatest in the left lower lobe. The differential for this
appearance is atypical infection, less commonly vasculitis such Goodpasture's
syndrome or sarcoidosis. No pulmonary embolism.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ELEVATED D-DIMER
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT
temperature: 98.2
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 112.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | ___ with DM2, tobacco use, and recent PNA presented to the ED
due to elevated D-dimer at ___'s office, was ruled out for PE
and admitted for further evaluation of pulmonary nodules noted
on CTA.
.
#. Pulmonary nodular opacities
Differential included atypical infection, vaculitis, sarcoid,
lymphoma/mets. Given that she is a smoker who had recent PNA
(cough, fever) treated with Abx, noted CT abnormalities were
thought to represent a resolving pneumonia. She was
asymptomatic. She was discharged home with 4 days of
levofloxacin for a total 5 day course, to treat any residual
pulmonary infection. Recommended PCP ___ with ___
chest imaging.
.
#. DM2, Psych, Migraines
Home medications were continued. No apparent symptoms.
.
TRANSITIONAL ISSUES
1. ___ clinical exam, chest imaging
2. ___ pending ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
iron
Attending: ___
Chief Complaint:
PCP: ___. ___ - ___ -- ___
CC: weakness, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with no significant PMH who
is presenting with weakness, diarrhea, numbness, and palpations.
Patient reports multiple new symptoms over the past two weeks.
She has had generalized weakness for around two weeks. She then
reports that earlier today while walking home she suddenly
developed a racing heart, and then a cold sensation that spread
throughout her body - it first went down her legs, and then
spread to her upper body. After this she became weak all over
and was no longer able to walk. The weakness lasted around 2
hours and then has slowly gotten better, but has left behind
numbness, which she now notes mostly in her fingertips. She
currently reports no headache, though has stated that she has a
"head heaviness". She has also had ongoing dizziness, which was
not improved with meclizine. She has felt that her left eye has
some pressure.
She has also had some generalized abdominal pain and multiple
stools with mucous. However, this improved, and her last bowel
movement was dark "coffee-colored". She notes that she is being
workup up for celiac disease.
Regarding her palpitations, patient reports several episodes of
feeling like her heart was racing, including the one noted
above. She states that during one event she felt a tightness
that went through her left arm, and then left her throat sore.
Patient reports no chemical exposures, no sick contacts, and no
family members who have experienced similar symptoms. She has
not traveled recently, no recreational drugs. She reports a
mosquito bite but otherwise no insect bites.
In the ED:
Initial vital signs were notable for: T 98.1, HR 112, BP 139/33,
RR 20, 100% RA
Exam notable for:
CV: Tachy and rhythm, normal ___ and ___ heart sounds, no ___
heart sound, no JVD, no pedal edema, 2+ distal upper extremity
and lower extremity pulses. Capillary refill less than 2
seconds.
MSK: strength ___ in bilateral upper and lower extremities,
unable to make fist or move fingers. Able to mildly wiggle toes
on right, less on left,No cyanosis, clubbing or edema
Neuro: Alert and following commands, not moving all extremities
spontaneously, sensation intact to light touch in upper
extremities, decreased in lower extremities, speech fluent
Psych: Crying/AO X 3
Labs were notable for:
- CBC: 6.7, hgb 11.2, plt 317
- Lytes:
142 / 106 / 9 AGap=14
-------------- 89
4.2 \ 22 \ 0.6
- lactate 2.1
- u/a negative
- tox screen negative
- trop <0.01
- ddimer 308
- coags normal
Studies performed include:
- CXR with no acute process
Consults:
Neuro was consulted, and felt like there was no clear unifying
diagnosis. They have low suspicion for an infectious cause of
symptoms. Do recommend MRI brain and MRA head and neck, as well
and MRV to rule out sinus venous thrombosis
Patient was given:
___ 01:09 PO Ondansetron ODT 4 mg
___ 03:28 IVF NS 1000 mL ___
___ 07:31 PO Meclizine 25 mg
Vitals on transfer: T 98.2, HR 96, BP 117/73, RR 13, 97% RA
Upon arrival to the floor, patient recounts history as above.
She currently denies headache, chest pain, or shortness of
breath, though does note a new cough. States that she remains
weak on the left side.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- iron deficiency anemia
- history of panic
Social History:
___
Family History:
- mother - CHF
- maternal grandmother - CHF
- maternal aunt - diabetes
- paternal grandmother - hypertension
- sister - asthma
Physical ___:
VITALS: T 98.0, HR 89, BP 107/70, RR 18, 98% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: 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, Full str in all ext
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 06:35AM BLOOD WBC-4.1 RBC-3.84* Hgb-10.3* Hct-32.9*
MCV-86 MCH-26.8 MCHC-31.3* RDW-14.2 RDWSD-44.5 Plt ___
___ 06:35AM BLOOD Glucose-82 UreaN-13 Creat-0.7 Na-139
K-4.4 Cl-102 HCO3-24 AnGap-13
___ 04:20PM BLOOD LD(LDH)-168
___ 06:35AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.0
___ 07:00AM BLOOD Hapto-109
___ 06:40AM BLOOD T4-6.0 Free T4-1.2
___ 06:40AM BLOOD Cortsol-12.8
___ 06:40AM BLOOD ___ Titer-1:40*
___ 06:42AM BLOOD CRP-0.3
___ 06:40AM BLOOD Lyme Ab-NEG
___ 03:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
MRI cervical and thoracic spine w/wo contrast:
1. No evidence of spinal canal or neural foraminal narrowing.
No evidence of focal spinal cord lesion or abnormal enhancement.
CT neck with contrast:
Mildly prominent palatine tonsils and other lymphoid tissue in
the pharynx. Proliferation of cervical lymph nodes, likely
reactive although these could be followed by clinical
examination
or imaging if surveillance is felt necessary
clinically.
CT chest with contrast:
Unremarkable study.
# ___ CT a/p w/ contrast:
IMPRESSION:
1. 3.8 cm cyst within the left adnexa, presumably physiologic in
a patient of this age. In addition, there is small amount of
intra-abdominal and intrapelvic free fluid, also likely
physiologic.
2. No acute abnormality to account for the patient's left upper
quadrant symptoms. No splenomegaly or evidence of
diverticulitis.
# ___ NCHCT (Atrius): IMPRESSION: Normal CT of the head
without contrast
# ___ CXR (pa and lat): IMPRESSION: No acute
cardiopulmonary abnormality
# Brain MRI/MRA (___): Normal MRI of the brain. No venous
sinus
thrombosis. Normal MRA of the head.
# TTE (___): The left atrial volume index is normal. There is
normal left ventricular wall thickness with a normal cavity
size.
There is normal regional and global left ventricular systolic
function. The visually estimated left ventricular ejection
fraction is 70%. There is no left ventricular outflow tract
gradient at rest or with Valsalva. Tissue Doppler suggests a
normal left ventricular filling pressure (PCWP less than
12mmHg).
There is normal diastolic function. Normal right ventricular
cavity size with normal free wall motion. Tricuspid annular
plane
systolic excursion (TAPSE) is normal. The aortic sinus diameter
is normal for gender with a normal ascending aorta diameter for
gender. The aortic arch diameter is normal with a normal
descending aorta diameter. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal. There is mild [1+] mitral regurgitation.
The
pulmonic valve leaflets are normal. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Negative/normal labs:
- AM cortisol 12.8
- Lyme Ab
- Chromogranin A
- 24 hour metanepherines (creatinine ordered for other test
taken
from same sample and was adequate)
- 24 hour urine catecholamines
- Calcitonin
- ___ 1:40
- Urine Porphobilinogen Screen
- ESR, CRP
- Tryptase
- VIP
- Seratonin essentially normal
- 5-HIAA
- c diff negative
- H pylori negative
LP:
___ 05:50PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-2 Polys-0
___ ___ 05:50PM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-55
LD(LDH)-16
___ 05:50PM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-55
LD(LDH)-16
___ 05:50PM CEREBROSPINAL FLUID (CSF) VDRL-Test
___ 5:50 pm CSF;SPINAL FLUID Source: LP #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
RX *ibuprofen 200 mg 3 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*10 Tablet Refills:*0
4. Vitamin D 2000IU PO daily
Discharge Disposition:
Home
Discharge Diagnosis:
Tachycardia
Weakness
diarrhea
Anemia
Discharge Condition:
Stable
A/Ox3
self-ambulatory
No activity restrictions
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN
INDICATION: ___ year old woman with c/o generalized ascending weakness, left
upper motor neuron pattern weakness and sensory changes// Evaluate for VST,
pleast perform post-contrast MPRAGE sequence
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 with ADC map and axial gradient echo images.
Post-contrast axial T1 weighted images as well as sagittal MPRAGE with axial
and coronal reformats were performed. 3D time-of-flight MRA of the brain was
also performed with 3D reformatted images
COMPARISON: None.
FINDINGS:
MR:
There is no intracranial mass, mass effect, or midline shift. There is no
focal parenchymal signal abnormality. Ventricles and sulci are
age-appropriate. There is no restricted diffusion to suggest acute infarct. No
abnormal susceptibility artifact identified. Major intravascular flow voids
are preserved including within the major dural venous sinuses which also have
a normal postcontrast appearance.
Visualized paranasal sinuses and mastoid air cells demonstrate no abnormal
signal.
Post-contrast images demonstrate no abnormal parenchymal or meningeal
enhancement.
MRA: Intracranial vascular structures are unremarkable without evidence of
significant stenosis, aneurysm, or occlusion.
IMPRESSION:
Normal MRI of the brain. No venous sinus thrombosis.
Normal MRA of the head.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST Q412
INDICATION: ___ year old woman with 2 weeks of cough, intermittent
tachycardia, flushing, syncope. Concern for neuroendocrine tumor. Palpable
neck nodes. // Eval for lymphadenopathy or abnormal lung paranchyma
TECHNIQUE: Multidetector CT images of the chest were obtained with
intravenous contrast. Sagittal and coronal reformations were also performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.2 s, 40.4 cm; CTDIvol = 8.5 mGy (Body) DLP = 337.8
mGy-cm.
Total DLP (Body) = 338 mGy-cm.
COMPARISON: CT of the abdomen and pelvis is available from ___.
FINDINGS:
The heart is normal in size. Great vessels are unremarkable.
There is no pleural or pericardial effusion. No enlarged lymph nodes are
found in the chest. Residual anterior thymic tissue is within normal limits
for age.
The lungs appear clear.
Limited views of the upper abdomen are unremarkable.
There are no suspicious bone lesions. Vertebral body heights and interspaces
appear preserved in height.
IMPRESSION:
Unremarkable study.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22
INDICATION: ___ year old woman with 2 weeks of cough, intermittent
tachycardia, flushing, syncope. Concern for neuroendocrine tumor. Palpable
neck nodes. // Eval for lymphadenopathy
TECHNIQUE: Multidetector CT images of the neck were obtained with intravenous
contrast. Sagittal and coronal reformations were also performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 29.8 cm; CTDIvol = 10.7 mGy (Body) DLP = 312.4
mGy-cm.
Total DLP (Body) = 312 mGy-cm.
COMPARISON: No relevant prior study is available.
FINDINGS:
Visualized base of the brain is unremarkable. Partly visualized orbits also
appear normal. Salivary glands appear within normal limits. Thyroid appears
normal as well. There are a number of subcentimeter lymph nodes throughout
the neck, especially along posterior cervical triangles and at level 2, but
these do not appear enlarged by size criteria although somewhat striking by
number.Major vascular structures appear widely patent. Partly imaged thymic
tissue is probably normal for age. Visualized lung apices appear clear.
Major airways appear widely patent. There is no prevertebral soft tissue
thickening. Palatine tonsils are mildly enlarged with postinflammatory
calcifications. Nasopharyngeal lymphoid tissue and lingular tonsillar tissue
also are mildly prominent. Epiglottis is not thickened. Visualized paranasal
sinuses and mastoid air cells appear clear. Bony structures are unremarkable.
IMPRESSION:
Mildly prominent palatine tonsils and other lymphoid tissue in the pharynx.
Proliferation of cervical lymph nodes, likely reactive although these could be
followed by clinical examination or imaging if surveillance is felt necessary
clinically.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ year old woman with no PMH who has recurrent paralysis and
numbness in all extremities // Recurrent episodes of whole-body paralysis
Recurrent episodes of whole-body paralysis
Recurrent episodes of whole-body paralysis
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: None.
FINDINGS:
CERVICAL:
Minimal anterolisthesis of C3 on C4. Vertebral body and intervertebral disc
signal intensity appear normal. The spinal cord appears normal in caliber and
configuration. There is no evidence of spinal canal or neural foraminal
narrowing. There is no evidence of infection or neoplasm. There is no
abnormal enhancement after contrast administration.
THORACIC:
Alignment is normal. Vertebral body and intervertebral disc signal intensity
appear normal. The spinal cord appears normal in caliber and configuration.
There is no evidence of spinal canal or neural foraminal narrowing. There is
no evidence of infection or neoplasm. There is no abnormal enhancement after
contrast administration.
OTHER: Incidentally noted Thornwaldt cyst versus inflammatory retention cyst
within the nasopharynx (3:8). The partially visualized paraspinal muscles,
lung parenchyma and abdominal organs are unremarkable.
IMPRESSION:
1. No evidence of spinal canal or neural foraminal narrowing. No evidence of
focal spinal cord lesion or abnormal enhancement.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with c/o generalized progressive
ascendingweakness/paralysis// Chest pathology?
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
WALK IN
Chief complaint: Anxiety, Dizziness, Palpitations
Dizziness, Weakness
Diagnosed with Weakness
Dizziness and giddiness, Weakness
temperature: 98.1
97.7
heartrate: 112.0
83.0
resprate: 20.0
14.0
o2sat: 100.0
99.0
sbp: 139.0
114.0
dbp: 33.0
73.0
level of pain: 0
1
level of acuity: 3.0
3.0 | The pt was admitted for repeated episodes of weakness, flushing,
and tachycardia in the setting of other non-specific complains
including diarrhea. She continues to have these episodes
inpatient. During the episodes, she will suddenly become
tachycardic to 150s-170s with acute onset whole-body weakness
and
numbness. The symptoms last for about 2 hours as they slowly
self-resolve. Workup so far has been unrevealing (see below) and
the episodes continue to happen. The pt's syx seem to improve
and
be prevented by Ativan.
On ___, the pt had a prolonged episode a/w lateral
beating of the eyes. She reports that she was awake and aware
during the episode but unable to communicate. However she may be
remembering commotion right before the episode, as she cannot
give any details about what she heard that align with what
actually occurred. She received 0.5 mg IVP Ativan which was
already at bedside. The episode broke before further Ativan
could
be given. She had a depressed respiratory rate and erratic
breathing during the event, though her oxygen level stayed at
100% on RA and she protected her airway. She was loaded with
Keppra.
On ___, the pt had another episode while on EEG monitoring.
There was no sign of seizure on EEG. Potassium, sodium, and
magnesium were normal during the episode.
MR cervical and thoracic spine showed no abnormalities. LP was
unremarkable. Nephrology consulted for ?hypokalemic periodic
paralysis, but no evidence of it as her K has always been
normal.
She interestingly had 2 more episodes both related to IV LR
infusion, but quickly resolved after fluids were stopped. POTS
disease related to recent viral infection is a possibility. We
have recommended that she follows up with ___ neurology and
___ clinic for further testing. Functional
neurologic disorder is also a possibility.
Her Vit D is deficient and she will be placed on supplement.
She developed post LP headache, which was conservatively
managed. She is instructed to call pain clinic for blood patch
if the headache remains severe after discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ R craniotomy for tumor resection
History of Present Illness:
___ who had a miscarriage 10 week prior presents to ED as
transfer from OSH with c/o progressively worsening headaches
since her miscarriage. She states the headaches began increasing
in severity over the past month turning into migraines. She
states the headaches come on randomly and wake her at night.
Patient reports that on ___ the headaches became even
worse, and she developed new onset sensitivities to smells, with
nausea and two episodes of vomiting. She states that while
trying
to unbutton her pants her left hand went completely numb and she
was unable to complete the task. Patient also notes episodes of
left leg numbness and tingling and at one point that ___ her
left leg stopped working, with an associated tingling sensation
down the front of her leg and a "frozen foot". That ___ she
presented to ___, where they gave her pain control and
followed up with her PCP on ___. Upon review of systems
she reports blurred vision and spinning, and yesterday had a new
sensation of someone grabbing the back of her neck and sharp
"zings" down her back. She denies any fevers, chills or recent
illnesses. CT scan obtained at OSH which demonstrated a right
parietal/temporal ring enhancing lesion with vasogenic edema,
mass effect and MLS.
Past Medical History:
- Miscarriage 10 weeks prior to presentation
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION
============
Gen: WD/WN, comfortable, NAD.
HEENT:
Pupils: PERRL
EOMI(patient becomes dizzy & headache worsens with lateral gaze)
Neck: Supple.
Lungs: RR normal, equal lung expansion visualized
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, 3-2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact. Slight left facial
VIII: Hearing intact to voice.
IX, X: Not tested
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
ON DISCHARGE
============
Pertinent Results:
Please see OMR for pertinent imaging & labs
Medications on Admission:
- Loratidine
- Prilosec
- Amitriptyline
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Dexamethasone 4 mg PO Q12H
This is the maintenance dose to follow the last tapered dose
RX *dexamethasone 4 mg 1 tablet(s) by mouth every 12 hours Disp
#*45 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth every 12 hours Disp
#*45 Tablet Refills:*0
5. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth every 12 horus
Disp #*60 Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every 4 hours as
needed Disp #*30 Tablet Refills:*0
7. Senna 17.2 mg PO QHS
8.Outpatient Occupational Therapy
ICD 9 code: ___
Please preform for home safety evaluation. S/p Brain tumor
resection ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Brain lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman s/p crany and R sided tumor excision// please
perform 3 hrs post op at 6pm
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain
window.
DOSE: Total DLP (Head) = 934 mGy-cm.
COMPARISON: MRI head ___
CT CTA head ___
MRI head ___
FINDINGS:
Patient is status post right-sided craniotomy and excision of right
frontotemporal lesion, previously characterized on MRI head ___.
There is fluid density foci and foci of air within the resection bed. There
is also surrounding edema with mass effect and effacement of the right lateral
ventricle with 1 cm leftward midline shift (02:19), mildly increased in size
from MRI ___, previously measuring up to 7 mm. Pneumocephalus
and extra-axial fluid along the right frontotemporal convexity is within
normal limits given recent surgery. There are ill-defined irregular linear
hyperintense foci in the resection bed likely representing small foci of
intraparenchymal hemorrhage.
There is opacification of the left sphenoid sinus. Remaining paranasal
sinuses clear. Mastoid air cells and middle ear cavities are well aerated.
Right-sided post craniotomy changes are noted.
IMPRESSION:
1. Status post right sided craniotomy and resection of frontotemporal lesion
previously characterized on MRI ___.
2. Ill-defined irregular linear hyperintense foci in the resection bed could
represent small foci of intraparenchymal hemorrhage.
3. Postoperative changes including fluid and foci of air within the resection
bed with surrounding edema and 10 mm of rightward midline shift, previously 7
mm on MRI ___.
4. Right-sided pneumocephalus and right-sided extra-axial fluid are likely
postoperative.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with right parieto-temporal brain mass//
evaluate brain mass
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
COMPARISON: Outside hospital CT head ___
FINDINGS:
Centered within the right frontotemporal operculum, there is a T1 isointense,
T2 heterogeneously hyperintense, heterogeneously enhancing mass measuring
approximately 5.2 x 3.3 x 3.6 cm (AP by TV by SI). The mass contains numerous
small cystic components, areas of restricted diffusion, and areas of
intralesional hemorrhage.
There is extensive vasogenic edema seen within the surrounding white matter
with extension into the right insular cortex, right basal ganglia, and right
thalamus. There is resultant local mass effect, with effacement of the
adjacent sulci. Additionally, there is approximately 9 mm of leftward midline
shift. Uncal herniation is seen on the right, without evidence for downward
herniation at this time.
There is moderate effacement of the right lateral ventricle. The remainder of
the ventricular system appears unremarkable. The basal cisterns are patent.
The right M1/M2 segments appear pushed anteriorly from the resultant mass
effect, but appear patent on this non angiographic phase study. Otherwise,
there is gross preservation of the principal intracranial vascular flow voids.
The dural venous sinuses appear patent on MP-RAGE imagine sequences.
There is complete opacification of the left sphenoid sinus. The remainder of
the visualized paranasal sinuses, middle ear cavities, and mastoid air cells
are well aerated and clear. The orbits are within normal limits bilaterally.
IMPRESSION:
1. 5.2 x 3.3 x 3.6 cm heterogeneous, enhancing mass centered within the right
frontotemporal operculum containing areas of restricted diffusion, internal
hemorrhage, and numerous cystic components. Findings are suggestive of a
primary intra-axial neoplasm, such as a high-grade glioma. A lower grade
glioma would be unlikely given the extent of enhancement. Metastatic disease
along the differential is considered much less likely.
2. Associated mass effect, with 9 mm of leftward midline shift, moderate
effacement of the right lateral ventricle, and moderate right uncal
herniation.
3. Additional findings described above.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with right parieto-temporal brain mass //
evaluate for metastatic disease
TECHNIQUE: Abdomen and pelvis CT: Post-contrast images were acquired through
the abdomen and pelvis.
Oral contrast was not administered.
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 7.0 s, 1.0 cm; CTDIvol = 16.2 mGy (Body) DLP =
16.2 mGy-cm.
3) Spiral Acquisition 16.4 s, 63.1 cm; CTDIvol = 8.1 mGy (Body) DLP = 495.3
mGy-cm.
Total DLP (Body) = 533 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to the separate report of CT chest performed on the
same day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits.
Appendix contains air, has normal caliber without evidence of fat stranding.
There is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. Trace free fluid in pelvis is
physiologic.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No evidence of metastatic disease in the abdomen or pelvis.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ year old woman with new R parietal ring enhancing brain
lesion, with vasogenic edema, mass effect and MLS// Evaluate vascularity of R
parietal lesion
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7
mGy-cm.
3) Stationary Acquisition 3.5 s, 1.0 cm; CTDIvol = 26.1 mGy (Head) DLP =
26.1 mGy-cm.
4) Spiral Acquisition 5.1 s, 19.7 cm; CTDIvol = 25.4 mGy (Head) DLP = 459.8
mGy-cm.
Total DLP (Head) = 1,338 mGy-cm.
COMPARISON: CT head and MR head ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is a large heterogeneous 4.7 x 3 cm temporoparietal mass with associated
mass effect and surrounding vasogenic edema. There is moderate effacement of
the right lateral ventricle. There is 9 mm of midline shift to the left. There
is evidence of uncal herniation on the right. There is no evidence hemorrhage.
There is a moderate-sized mucosal cyst in the right maxillary sinus. The
visualized portion of the remaining paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The right M1 segment appears to be displaced anteriorly and superiorly. There
is displacement and narrowing of multiple sylvian branches of the right MCA.
There is a prominent vessel extending laterally within the area of the lesion
which likely represents early venous filling. The remaining vessels of the
circle of ___ and their principal intracranial branches appear normal with
no evidence of stenosis, occlusion, or aneurysm. The dural venous sinuses are
patent.
IMPRESSION:
1. Large heterogeneous temporoparietal mass with associated mass effect, 9 mm
of midline shift to the left, and surrounding vasogenic edema, unchanged
compared to prior study.
2. There is displacement of the right M1 segment and displacement and
narrowing of multiple right MCA sylvian branches.
3. Prominent ecstatic vessel extending laterally within the area lesion,
likely demonstrating early venous filling.
Radiology Report
EXAMINATION: Functional MRI
INDICATION: ___ year old woman with new R parietal ring enhancing brain
lesion, with vasogenic edema, mass effect and MLS // Pre-op evaluation,
please include DTI sequences
TECHNIQUE: The examination was performed using a 3.0T MRI scanner. After the
uneventful administration of 5 ml of Gadavist contrast agent, axial FSPGR,
axial Arterial Spin Labeled (ASL), diffusion tensor images (DTI) using 36
directions and task based functional imaging paradigms were obtained.
Functional imaging was performed using Echo Planar/BOLD (blood oxygen level
dependent) technique using block design functional paradigms.
The functional paradigms include analysis of the motor areas during the
alternating movement of the left hand (motion =3 mm), right hand and feet
(motion =less than 2 mm) and tongue (motion =less than 2 mm) and language
areas during the mental process of generating words with different letters
(motion =2.5 mm during native language, less than 2 mm during ___
language). Post processing of functional images, DTI fiber tractography and
reference image skull stripping was performed using a dedicated workstation.
All obtained and derived images were used to generate this report.
COMPARISON: ___ contrast brain MRI.
FINDINGS:
Motion during left hand and native word generation tasks did exceed 2 mm which
makes these images potentially nondiagnostic.
Again is demonstrated a stable peripherally enhancing, centrally
cystic/necrotic mass in the right frontotemporal operculum with surrounding
vasogenic edema. The mass demonstrates slow diffusion in its periphery with
surrounding vasogenic edema in the white matter, but no obvious restricted
diffusion in this white matter. Mass effect with leftward midline shift and
mild uncal herniation as previously described. The arterial spin labeled
sequence is notable for increased perfusion peripherally in this mass.
The tractography color maps demonstrate medial and anterior deviation of the
major corticospinal tracts. In the immediate vicinity of the tumor there are
multiple association and commissural tracks displaced inferiorly and medially.
The functional MRI demonstrates BOLD activation areas during the movement of
the hands, feet and tongue.
Bold activation during right toe movement is a the expected position of the
medial left motor cortex.
Bold activation during left toe movement is poor.
Bold activation during right hand movement is in the expected position of the
left motor cortex.
Bold activation during left hand movement is in the expected position of the
right motor cortex away from the tumor, but please note that these images are
potentially nondiagnostic due to motion.
Bold activation during tongue movement is poor which makes placement of its
bold topography difficult.
Bold activation during native word generation is poor, but is seen
predominantly in the left hemisphere, most likely related to dominance but
please note that the images are potentially nondiagnostic due to motion.
Bold activation during ___ language word generation is poor
IMPRESSION:
1. Stable right frontotemporal opercular mass as described above, with
increased peripheral perfusion, medial deviation of the major corticospinal
tracts.
2. Inferior and medial displacement of the immediately adjacent association
and commisural fibers suggest superolateral entry may be favorable.
3. Motion artifact degrades the diagnostic sensitivity of the left hand and
native word generation tasks. Poor BOLD signal on many of the fMRI tasks of
the left side of the body most likely secondary to impaired patient
cooperation due to right frontotemporal mass with associated cerebral edema.
4. Native language paradigm demonstrates the propagation of activation in the
convexity with the majority of the BOLD activity in the left cerebral
hemisphere, likely related with dominance. Please take note of the decreased
degree of certainty due to potential motion artifact.
RECOMMENDATION(S):
1.
Radiology Report
EXAMINATION: MR HEAD W/ CONTRAST T___ MR HEAD
INDICATION: ___ with new R parietal ring enhancing brain lesion, with
vasogenic edema, mass effect and MLS.// Pre-operative planning, please perform
prior to 6am ___
TECHNIQUE: After administration of 5 mL of Gadavist intravenous contrast,
axial imaging was performed with MPRAGE and T1 technique. Sagittal and coronal
orientation reformatted images of the MPRAGE acquisition was then produced.
COMPARISON: MR head ___.
FINDINGS:
The patient's previously noted right frontotemporal heterogeneously enhancing
lesion measuring 5 x 3 x 3.7 cm is again seen. There is a large area of ring
enhancement with central hypointensities, likely representing necrosis. There
is surrounding vasogenic edema with associated mass effect and moderate
effacement of the right lateral ventricle. There is 6 mm of midline shift to
the left. There is evidence of uncal herniation on the right.
IMPRESSION:
1. Stable right frontotemporal heterogeneously enhancing lesion with
associated mass effect, leftward midline shift, and uncal herniation on the
right.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ woman with brain mass. Evaluate for metastatic
disease.
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 7.0 s, 1.0 cm; CTDIvol = 16.2 mGy (Body) DLP =
16.2 mGy-cm.
3) Spiral Acquisition 16.4 s, 63.1 cm; CTDIvol = 8.1 mGy (Body) DLP = 495.3
mGy-cm.
Total DLP (Body) = 533 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Main pulmonary artery and thoracic aorta are normal in
caliber. Heart size is normal. No pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Central airways are patent. There is no pulmonary
consolidation. There is mild pleural/parenchymal scarring at bilateral
apices. There is a 2 mm nonspecific nodule, probably ground-glass in
attenuation, in the anterior basal right lower lobe on image 7:172. A tiny
linear pleural tag is incidentally noted in the left upper lobe on image 7:66.
BASE OF NECK: Visualized thyroid is unremarkable.
ABDOMEN: Concurrent abdominal/pelvic CT is reported separately.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
2 mm nonspecific, probably ground-glass nodule in the right lower lobe.
RECOMMENDATION(S): For an incidentally detected single ground-glass nodule
smaller than 6 mm, no CT follow-up is recommended.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman s/p crany and R tumor excision// POD 1
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 4.5 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT head without contrast ___, MR head with contrast
___
FINDINGS:
There is evidence of right-sided craniotomy. The previously seen right
frontotemporal lesion has been resected. There is evidence of pneumocephalus
and an overlying extra-axial collection, consistent with postsurgical changes.
On gradient and T1 precontrast images there is evidence of hemorrhage in the
surgical bed. Surrounding edema with 9 mm of midline shift, and evidence of
mass effect with partial effacement of the right lateral ventricle, is overall
similar to prior exam. T2/FLAIR hyperintensities in the subcortical and
periventricular white matter are nonspecific, but may represent sequela of
chronic migraine headache, prior trauma, infectious/inflammatory etiology or
small vessel ischemic disease in a patient of this age. There is
postoperative mild dural thickening and enhancement, subjacent to the
craniotomy site. There is no abnormal enhancement or definite nodular
masslike enhancement after contrast administration. No acute infarct is
identified. There is diffusion-weighted hyperintense signal along the margins
of the resection bed, compatible with a combination of operative changes and
hemorrhage product.
There is a mucous retention cyst seen within the right maxillary sinus. There
is opacification of the left sphenoid sinus. The remaining paranasal sinuses
and mastoid air cells appear clear. The orbits are unremarkable. There is
evidence of soft tissue swelling overlying the right frontal and temporal
lobes which extends down over the zygoma.
IMPRESSION:
1. Status post right-sided craniotomy and resection of previously seen
frontotemporal lesion, with expected postsurgical changes of right-sided
pneumocephalus and overlying extra-axial fluid collection. Mild expected
dural thickening and enhancement underlying the craniotomy site is noted.
2. There is evidence of hemorrhage within the surgical bed and edema
surrounding the surgical site with 9 mm of midline shift evidence of mass
effect, similar to prior CT, but improved from preoperative MRI.
3. No definite evidence of masslike or nodular enhancement within the
resection cavity. No acute infarct.
4. Additional findings as described above.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal CT, Headache
Diagnosed with Disorder of brain, unspecified
temperature: 99.5
heartrate: 64.0
resprate: 18.0
o2sat: 100.0
sbp: 112.0
dbp: 75.0
level of pain: 1
level of acuity: 2.0 | ___ presenting with headaches, found to have new R parietal ring
enhancing brain lesion with vasogenic edema, mass effect and
MLS.
#Neuro: Brain lesion
The patient was admitted on ___ after outpatient ___
revealed a right parietal brain lesion during evaluation of
headache. She underwent MRI which further demonstrated a right
parietal ring enhancing lesion with vasogenic edema and mass
effect. She was treated with dexamethasone for cerebral edema
and keppra for seizure prophylaxis. Functional MRI and CTA for
surgical planning were completed on ___. CT Torso was performed
to evaluate for primary malignancy, which was negative. Patient
underwent a right craniotomy for tumor resection with Dr. ___
on ___. Please see separately dictated operative report for
complete details of procedure. Patient was extubated in the OR
and transferred to the PACU for recovery. Post-op head CT showed
expected post-operative changes and continued vasogenic edema.
She was neurologically and hemodynamically stable and was
transferred to the floor. Post-op MRI showed expected
postsurgical changes and edema surrounding the surgical site
with 9 mm of midline shift evidence of mass effect, similar to
prior CT, but improved from preoperative MRI. Decadron was
tapered to 4 bid.
On POD#4 she remained neurologically intact, was tolerating PO
diet, ambulating independent and pain remained well controlled.
She was cleared for discharge home by OT with intermittent
family supervision. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___. is a ___ male who presents to ___ on ___ with a moderate TBI. The patient was originally
brought to ___ by a friend and HCP after he woke up
with
a frontal headache and noted that he had a bump on the back of
his head. The patient has no recollection of falling during the
night and he awoke in his own bed. He called his cardiologist
for
recommendations given his Coumadin use and he was instructed to
go to the ED. On arrival to ___, he had a NCHCT. After
discovery of a subarachnoid/subdural hemorrhage, his INR of 3.4
was treated with Kentra and Vit K and he was medflighted to
___.
Past Medical History:
Cardiac ablation for atrial flutter ___
multiple DVTs that were unprovoked requiring lifelong Coumadin
and IVC filter placement in ___.
Hyperlipidemia
Hypertension
Social History:
___
Family History:
Father: old age, early ___. Mother: pancreatic cancer age ___.
Physical Exam:
exam on admission and discharge:
GCS ___
Eye Opening:
[x]4 Opens eyes spontaneously
Verbal:
[x]5 Oriented
Motor:
[x]6 Obeys commands
Gen: WD/WN, comfortable, NAD.
Extrem: warm and well perfused
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Pertinent Results:
please see OMR for pertinent results
Medications on Admission:
ACYCLOVIR [ZOVIRAX] - Zovirax 5 % topical ointment. apply as
needed prm every 4 hours 60 grams
FINASTERIDE - finasteride 5 mg tablet. 1 tablet(s) by mouth
daily
LISINOPRIL - lisinopril 5 mg tablet. 1 Tablet(s) by mouth once a
day - (Prescribed by Other Provider)
METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth twice daily
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. one
capsule(s) by mouth twice daily
TAMSULOSIN - tamsulosin 0.4 mg capsule. 1 capsule(s) by mouth
once a day
WARFARIN - warfarin 4 mg tablet. 1 tablet(s) by mouth one daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
3. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth every 12 hours
Disp #*12 Tablet Refills:*0
4. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours as needed Disp #*20 Tablet Refills:*0
5. Finasteride 5 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10.Outpatient Physical Therapy
Evaluate and treat, s/p fall with subdural hematoma
Discharge Disposition:
Home
Discharge Diagnosis:
subdural hematoma
h/o DVTs
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with SAH, subdural eval for aneurismal bleed// SAH,
subdural eval for aneurismal bleed
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 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) Sequenced Acquisition 2.0 s, 4.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
200.7 mGy-cm.
3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 87.1 mGy (Head) DLP =
43.6 mGy-cm.
4) Spiral Acquisition 5.5 s, 43.5 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,351.0 mGy-cm.
Total DLP (Head) = 2,498 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is right hemispheric acute subdural hematoma overlying right frontal,
parietal, temporal occipital lobes, measuring 0.6 cm in maximum thickness.
Midline shift is 0.4 cm to the left. There is acute tentorial subdural
hemorrhage, measuring 1.2 cm maximum thickness focally, otherwise it is very
thin at other levels. There is acute small volume subarachnoid hemorrhage
overlying right temporal, parietal and occipital lobes.. Subarachnoid
hemorrhage does not extend into the sylvian fissure or basal cisterns.
Suggestion of trace intraventricular hemorrhage within left occipital horn.
There are mild to moderate chronic small vessel ischemic changes. There is no
evidence of acute infarct. Partial effacement right perimesencephalic
cistern. Patent pre pontine cistern, foramen magnum.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation.
Suboptimal filling of the abdominal right transverse and sigmoid sinuses, may
be related to mass effect from adjacent subdural hematoma. Recommend MR
venogram to exclude thrombosis. Filling of the medial, central portion of
jugular vein at the jugular foramen, suggesting of a filling defect more
laterally.. Remainder venous sinuses are patent.
CTA NECK:
There is probably metal related artifact projecting at the same level within
proximal subclavian arteries. Mild atherosclerotic narrowing of the proximal
left V2 segment vertebral artery. The carotid and vertebral arteries and
their major branches appear normal with no evidence of stenosis or occlusion.
There is no evidence of internal carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria. Bilateral submandibular glands are atrophic.
IMPRESSION:
1. No evidence of aneurysm.
2. Acute subdural hematoma overlying right cerebral hemisphere, and layering
along the tentorium. 0.4 cm midline shift to the left. Effaced right
perimesencephalic cistern.
3. Right convexal mild volume subarachnoid hemorrhage, without extension into
the basilar cisterns.
4. Suboptimal filling of a dominant right transverse, sigmoid sinus, may be
related to adjacent tentorial hemorrhage, suggestion of a filling defect at
the jugular foramen along the lateral wall, recommend MR ___ to exclude
dural venous sinus thrombosis.
RECOMMENDATION(S): MR ___
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:49 pm, 10 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with R SDH// Eval for interval change; pls do ___
before 8am
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
Small acute right subdural hemorrhage along the right convexity currently
measures 8.1 mm, previously 7 mm, although this is likely unchanged accounting
for differences in technique and slice selection. There is mild effacement of
the adjacent sulci along the right convexity. As before, hyperdensities in
the right parietal, temporal, and occipital sulci are compatible with
subarachnoid hemorrhage. Hyperdense hemorrhage layering along the tentorium
bilaterally, right greater than left, is unchanged. There is a small foci of
hemorrhage in the superior cerebellar cistern as before. There is
approximately 3.5 mm of midline shift, unchanged.
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 significant change from prior. Acute small right subdural hemorrhage,
diffuse subarachnoid hemorrhage in the right temporal, occipital and parietal
lobes, as well as hyperdense hemorrhage along the tentorium bilaterally, right
greater than left, are unchanged.
2. Approximately 3.5 mm of midline shift, unchanged.
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: s/p Fall, SAH, SDH, Transfer
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified, Personal history of other venous thrombosis and embolism, Long term (current) use of anticoagulants
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Mr. ___ is a ___ male on Coumadin for DVTs admitted
from the ED with TBI.
#Subdural hematoma
CT head showed right side SDH, SAH and SDH along the tentorium.
He was neurologically intact. INR at OSH was 3.4 and was
reversed with K centra and Vitamin K. Repeat INR on arrival was
1.5. Repeat CT on ___ was stable. He was given a second dose of
Vitamin K and INR was 1.3. He remained neurologically intact. He
was evaluated by Physical Therapy, who recommended cleared him
for discharge home with outpatient ___. He will follow up in 1
week with repeat head CT to discuss resuming Coumadin.
#H/o DVTs on Coumadin
Coumadin was held and reversed on admission. Patient has IVC
___ in place. There is still risk of stroke/DVT while holding
Coumadin, and this was discussed with patient, however, this
risk is outweighed by risk of bleeding with acute intracranial
hemorrhage. Plan to hold for at least 1 week, until follow up
with neurosurgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive / codeine / ketorolac
Attending: ___.
Chief Complaint:
Neck Abscess
Major Surgical or Invasive Procedure:
Intubation
Extubation
___ aspiration of neck abscess
History of Present Illness:
___ without significant past medical history who presented as a
transfer from ___ due to enlarging neck abscess. Patient
reported at presentation to the ___ ED that she had been
unable to swallow water or pills after 2 days of throat
swelling. Her pharyngitis had been previously felt to be viral
___ etiology. However, on presentation to the OSH, she was noted
to be visibly short of breath with stridor. While ___ the OSH ED,
she was found to have a WBC 15.4 with 88% PMNs. She was given a
dose of clindamycin there and intubated. CT of the Neck showed a
large rim-enhacing fluid collection that wrapped around the
posterior aspect of the larynx. She also received racemic
epinephrine, methylprednisolone, etomidate and succinylcholine
as well as propofol, midazolam and fentanyl. She was then
transferred to ___ ED for further management. ___ the ED,
initial VS were as follows: 81 122/70 24 100% Intubation.
Patient was then transferred to the MICU for further management.
While ___ the ED, she received Unasyn 3g IV X 1, Dexamethasone
8mg X 1, Vancomycin 1mg X 1 ___s acetaminophen 1000mg IV X
1, fentanyl and propofol and NS at 125cc/hr. Vital signs at
transfer were as follows: 59 117/61 15 98% Intubation.
Past Medical History:
Nephrolithiasis
Social History:
___
Family History:
None reported
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: intubated, sedated, ___ NAD
HEENT: sclera anicteric
LUNGS: clear to auscultation anteriorly, no wheezes
CV: regular, no murmurs
ABD: soft, non-tender, non-distended, no guarding or rebound
EXT: warm, well perfused, no pedal edema
SKIN: no rashes
NEURO: sleepy but awakes to voice
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 135/82 42 16 97 Ra
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 09:08AM WBC-14.8* RBC-4.02 HGB-12.1 HCT-37.2 MCV-93
MCH-30.1 MCHC-32.5 RDW-12.4 RDWSD-42.3
___ 09:08AM NEUTS-92.6* LYMPHS-2.5* MONOS-3.9* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-13.65* AbsLymp-0.37* AbsMono-0.58
AbsEos-0.00* AbsBaso-0.02
___ 09:08AM GLUCOSE-127* UREA N-11 CREAT-0.5 SODIUM-140
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-20* ANION GAP-16
___ 09:24AM LACTATE-1.5
___ 09:36AM ___ PO2-30* PCO2-41 PH-7.40 TOTAL CO2-26
BASE XS--1 INTUBATED-INTUBATED
___ 10:54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
___ 10:54AM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 10:54AM URINE COLOR-Yellow APPEAR-Clear SP
___
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-12.1* RBC-4.12 Hgb-12.2 Hct-40.1
MCV-97# MCH-29.6 MCHC-30.4* RDW-12.4 RDWSD-43.8 Plt ___
___ 07:20AM BLOOD Glucose-75 UreaN-23* Creat-0.6 Na-142
K-4.2 Cl-109* HCO3-18* AnGap-19
___ 07:20AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.3
MICRO:
___ 4:10 pm ABSCESS Source: neck abscess.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND ___ SHORT
CHAINS.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary): RESULTS PENDING.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
IMAGING/REPORTS
CT NECK ___
IMPRESSION:
Large irregular crescent shaped faintly rim-enhancing
intermediate density fluid collection immediately anterior to
the hyoid bone and wrapping around the posterior aspect of the
larynx on the left.
Posterior C-spine fusion at C4-C5. Degenerative changes and
facet hypertrophy seen at C5-C6 with slight grade 1
spondylolisthesis.
Complex hypodense thyroid lesions arising from both inferior
poles.
CT NECK ___
IMPRESSION:
1. No significant change ___ the fluid collection extending from
the left inferior margin of the hyoid bone inferiorly over
bilateral thyroid cartilages. Rim enhancement is most
pronounced along the left superior portion of the collection,
similar to the prior study, and less conspicuous than on the
prior study along the inferior bilateral portion of the
collection. This is overall compatible with an abscess
2. Left greater than right strap muscle edema has improved. New
trace fluid extending from the caudal portion of the
above-described fluid collection ___ the midline to the level of
the thyroid isthmus, without rim enhancement.
3. The above-described collection displaces the left thyrohyoid
membrane medially and displaces the airway to the right. The
patient is intubated.
4. Bilateral thyroid nodules measuring up to 1.6 cm.
Medications on Admission:
None
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every twelve (12) hours Disp #*13 Tablet
Refills:*0
2. Methylprednisolone 16 mg PO DAILY
On ___ take 16mg, on ___ take 12mg, on ___ take 8mg, on ___
take 4mg
Tapered dose - DOWN
RX *methylprednisolone 4 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
- neck phlegmon
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: History: ___ with abscess, intubated. ETT placement?
TECHNIQUE: Frontal chest radiograph
COMPARISON: None.
FINDINGS:
Patient is status post endotracheal tube placement with tip projecting over
the mid thoracic trachea. The enteric tube is seen below the diaphragm with
tip coiling and projecting over the expected location of the distal esophagus.
The lungs are well inflated and clear. There is no pleural effusion or
pneumothorax. The heart size is within normal limits. Mediastinal hilar
contours are unremarkable.
IMPRESSION:
-Endotracheal tube in appropriate location.
-Enteric tube tip coiling and projecting over the distal esophagus.
Repositioning is recommended.
-No acute intrathoracic abnormalities.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with neck abscess, intubated// confirm
placement of ET tube confirm placement of ET tube
IMPRESSION:
Comparison to 11. ___. The endotracheal tube and the feeding tube
remain in stable correct position. The feeding tube has been pulled back, the
side hole is now at the level of the gastroesophageal junction. Stable normal
size of the heart. No pulmonary edema, no pleural effusions. No pneumonia.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old woman with neck abscess. Please evaluate neck
abscess, extent and any improvement.
TECHNIQUE: Imaging was performed after administration of 70 ml 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 3.5 s, 27.7 cm; CTDIvol = 4.6 mGy (Body) DLP = 126.9
mGy-cm.
Total DLP (Body) = 127 mGy-cm.
COMPARISON: CT neck from ___
FINDINGS:
There is a fluid collection abutting the left inferior margin of the hyoid
bone of which crosses the midline inferior to the hyoid bone, extending over
or bilateral thyroid cartilages. While it is difficult to measure this
collection due to its complex geometry, it does not appear significantly
changed in size, for example measuring approximately 2.9 x 1.8 cm in the left
neck (02:49), previously 2.9 x 1.6 cm. The thickness of the hypodense fluid
anterior to the cricoid cartilage measures up to 8 mm, previously 9 mm
(02:54). There is partial rim enhancement along the left superior part of the
collection, similar to the prior study, with thinner and less avid rim
enhancement of the lower bilateral portion of the collection. Thickening of
left greater than right strap muscles caudal to the collection has decreased
since the prior study. However, there is new trace fluid without rim
enhancement tracking inferiorly in the midline to the level of the thyroid
isthmus, image 602:27.
The collection appears to displace the left thyrohyoid membrane medially, with
rightward shift of the airway. The patient is status post endotracheal
intubation and orogastric tube placement, with associated secretions along the
pharyngeal courses of the tubes. Evaluation of the mucosal surfaces is
limited.
The salivary glands appear unremarkable.
There are multiple bilateral thyroid nodules measuring up to 1.6 cm on the
left, image 602:35.
No pathologically enlarged cervical or supraclavicular lymph nodes are seen.
Cervical carotid and vertebral arteries appear patent. Allowing for mixing
artifact from the external circulation branches, internal jugular veins appear
patent.
There is mild pleural/parenchymal scarring at the included lung apices.
There are no suspicious osseous lesions concerning for infection or
malignancy. Patient is status post instrumented fusion of C4-5 spinous
processes with cerclage wires. There is partial fusion of C4 and C5 vertebral
bodies and facet joints, possibly congenital. 3 mm anterolisthesis of C5 on
C6 is unchanged.
Some of the bilateral anterior ethmoid air cells are opacified. There is
trace fluid in the right sphenoid sinus, image 2:9, likely secondary to
prolonged supine positioning and endotracheal intubation. Mastoid air cells
appear clear. This exam is not technically optimized for evaluation of the
included intracranial structures, but no concerning abnormalities are seen.
IMPRESSION:
1. No significant change in the fluid collection extending from the left
inferior margin of the hyoid bone inferiorly over bilateral thyroid
cartilages. Rim enhancement is most pronounced along the left superior
portion of the collection, similar to the prior study, and less conspicuous
than on the prior study along the inferior bilateral portion of the
collection. This is overall compatible with an abscess
2. Left greater than right strap muscle edema has improved. New trace fluid
extending from the caudal portion of the above-described fluid collection in
the midline to the level of the thyroid isthmus, without rim enhancement.
3. The above-described collection displaces the left thyrohyoid membrane
medially and displaces the airway to the right. The patient is intubated.
4. Bilateral thyroid nodules measuring up to 1.6 cm.
RECOMMENDATION(S): Outpatient thyroid ultrasound is recommended according to
the ACR guidelines for nodules exceeding 1.5 cm.
Radiology Report
INDICATION: ___ year old woman with neck abscess// Please perform
diagnostic/therapeutic drainage, would like cytology, gram stain and culture
of aspirate
COMPARISON: CT neck ___
PROCEDURE: Ultrasound-guided drainage of left neck collection.
OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the 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 16 gauge needle into the collection.
Approximately 1 cc of purulent fluid was drained with a sample sent for
microbiology evaluation. The needle was removed. Sterile dressing was
applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 20
minutes during which patient's hemodynamic parameters were continuously
monitored by the ICU nurse.
FINDINGS:
A small collection of fluid is seen measuring 2.6 x 1.7 x 1.1 cm. This was
aspirated to completion. After aspiration of the fluid, the phlegmonous
tissue is seen remaining in the neck but no remaining fluid.
IMPRESSION:
Successful US-guided complete aspiration of a left neck collection. Samples
was sent for microbiology evaluation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abscess, Transfer
Diagnosed with Cutaneous abscess of neck
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | ___ without significant past medical history who presented as a
transfer from ___ due to enlarging neck phlegmon requiring
intubation for airway protection
# NECK PHLEGMON: Patient presents with evidence on imaging of
large abscess ___ the neck. ENT consulted on patient ___ the ED
and attempted aspiration but was unsuccessful. Patient was
intubated due to respiratory distress/stridor. Follow up CT did
not show improvement ___ abscess so she had ___ aspiration
with only a small amount of fluid aspirated, consistent with
phlegmon, rather than abscess. She subsequently developed a cuff
leak and was able to be extubated. She was treated ___ the ICU
with vancomycin, unasyn and dexamethasone 8 mg q8h per ENT
recommendations. This was transitioned to Medrol Pak and
Augmentin after extubation. She will follow up with ENT ___
weeks after discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug) / morphine
Attending: ___.
Chief Complaint:
odynophagia
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a ___ year old female with multiple medical
problems including distant gastric bypass with multiple
complications and subsequent surgeries, chronic abdominal pain,
substance abuse, and pulmonary embolism currently on lovenox who
presents with 3 days of odynophagia and burning chest pain. She
has chronic epigastric abdominal discomfort and nausea related
to multiple surgeries. She was in her normal state of health
until three days ago when she developed substernal burning chest
discommfort and odynophagia. She states that these symkptoms are
identical to a prior episode of ___ esophagitis in ___. She describes the pain as sharp and burning with
swallowing - worse with solids than liquids. She can swallow
pills. There is no radiation, no change with position, no
shortness of breath. She also endorses low grade fever to 100.2
at home several days ago, as well as multiple episodes of
diarrhea on ___ and ___ which have since resolved. No
melana, BRBPR. She reports her weight has been stable at 138
pounds.
The patient was admitted in ___ for odynophagia. She had
an EGD on ___ that demonstrating esophageal candidiasis
and longitudinal ulcerations at the gastroesophageal junction
and the cardia. She was treated with a 3 week course of
fluconazole. She was also given carafate QID, PPI, BID, and
cholestyramine. An HIV test and H. pylori was negative. A
dobhoff tube was placed during this admission and tube feeds
were started for malnutrition. She was in rehab from ___ until
___. Per Dr. ___ G tube was attempted in ___ at
___ but she developed a hematoma so it was removed.
In the ED, initial vs were: T98.6 87 134/78 16 96%RA.
On exam patient was uncomfortable, complaining of ___
mid-sternal CP which she describes as "esophagus" pain. Exam is
notable for dry mucus membranes, no appreciable oral lesions or
evidence for candidiasis.
[ ] CBC with diff, lytes: no leukocytosis
[x] troponin: negative
[x] IVF bolus, 1L NS
[x] EKG: consistent with prior
[ ] CXR
[x] Nausea: IV zofran
[x] pain control: IV dilaudid PRN, pt is on chronic methadone
[x] GI: touched base with her GI Dr. ___ recs as he has
not seen her as a pt before --> GI consult, per GI admit to
medicine and they will see her as an inpatient
Review of sytems:
(+) Per HPI
(-) Ten point review of systems is otherwise negative.
Past Medical History:
-Morbid obesity (max 448lbs) s/p gastric bypass & CCY at
___ and complete reversal
-History of HTN, DM, asthma (prior to gastric bypass)
-Opiate addiction: prior intranasal herion, oral dilaudid abuse,
now on suboxone
-Depression/Anxiety
-Esophagitis: EGD ___ showed mild active esophagitis.
-DJD
-2 SBOs
-Menopause completed
Past Surgical History:
-___- gastric bypass & CCY and subsequent complete
reversal
-7 surgeries on the abdomen. "stomach leak" hernia, 2 SBOs,
attempted reverse of the gastric bypass, the most recent in ___
Social History:
___
Family History:
-Mother with diabetes
Physical Exam:
General: appears older than stated age, comfortable
HEENT: anicteric sclera, oropharynx clear
Lungs: CTA bilaterally, unlabored
CV: S1, S2 regular rhythm, normal rate
Abdomen: healed surgical scars, soft, non-tender, non-distended
Ext: warm, distal pulses intact
Skin: no obvious rash
Neuro: alert, speech fluent, tongue midline
Pertinent Results:
___ 10:00AM BLOOD WBC-4.2 RBC-4.10*# Hgb-12.2# Hct-39.2#
MCV-96 MCH-29.8 MCHC-31.2 RDW-14.0 Plt ___
___ 06:35AM BLOOD Plt ___
___ 10:00AM BLOOD Plt ___
___ 10:00AM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-141 K-3.5
Cl-97 HCO3-32 AnGap-16
___ 06:35AM BLOOD Glucose-81 UreaN-8 Creat-0.7 Na-142 K-3.5
Cl-105 HCO3-32 AnGap-9
___ 07:30AM BLOOD Glucose-72 UreaN-8 Creat-0.8 Na-139 K-3.5
Cl-101 HCO3-32 AnGap-10
___ 10:00AM BLOOD ALT-10 AST-19 LD(LDH)-219 AlkPhos-112*
TotBili-0.2
___ 10:00AM BLOOD Lipase-10
___ 10:00AM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:30AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
___ 07:30AM BLOOD HIV Ab-NEGATIVE
___ 06:35AM BLOOD COPPER (SERUM)-117
.
CXR:
FINDINGS: AP upright and lateral views of the chest were
provided. Lungs
appear clear bilaterally without focal consolidation, effusion
or
pneumothorax. There is no free air below the right
hemidiaphragm. The
cardiomediastinal silhouette is normal. The bony structures are
intact.
IMPRESSION: No acute findings.
.
SMALL BOWEL FOLLOW THROUGH
FINDINGS:
Upon review of prior CT abdomen/pelvis, it was determined that
the patient is
status post gastric bypass with complete reversal of the bypass.
The stomach
appears slightly deformed with thickened and edematous gastric
folds, likely
secondary to surgical changes. Thin barium passes appropriately
through the
distal antrum into the duodenum, and then into the jejunum.
There is no
contrast filling of the Roux limb, which presumably was closed
or excised.
There is no extravasation of contrast to suggest fistula or
leak. Small-bowel
follow-through was limited due to patient fatigue and inability
to tolerate
swallowing much barium. Considerable portions of the distal
small bowel are
only minimally opacified and contrast opacification was not
pursued to the
terminal ileum. There is dilation of small bowel loops at the
JJ anastomosis.
Mild reflux of contrast past the GE junction into the distal ___
of the
esophagus is noted.
IMPRESSION:
1. Status post gastric bypass, with complete reversal.
Contrast passes from
the stomach into the duodenum and then jejunum as intended,
without
extravasation of contrast to suggest fistula or leak.
2. Thickened and edematous gastric folds, likely secondary to
prior
surgeries.
3. Mild reflux at the GE junction into the distal ___ of the
esophagus.
.
.
EGD:
Findings:
Esophagus:
Mucosa:Erosive esophagitis with ulcerations and contact
bleeding was seen extending up to 28cm. Cold forceps biopsies
were performed for histology at the esophagus; biopsies were
also sent for viral culture.
Stomach:
OtherAn end-end gastrojejunal anastomosis was seen, with a
small remnant gastric pouch. There was also a suture with
granulomatous tissue around it in the proximal gastric pouch.
Bile was seen in the remnant gastric pouch as well.
Jejunum:Normal jejunum.
Impression:Esophagitis (biopsy)
An end-end gastrojejunal anastomosis was seen, with a small
remnant gastric pouch. There was also a suture with
granulomatous tissue around it in the proximal gastric pouch.
Bile was seen in the remnant gastric pouch as well.
Otherwise normal EGD to jejunum
Recommendations:F/u biopsies
Further management per inpatient team
.
GI BIOPSY:
PATHOLOGIC DIAGNOSIS:
Esophageal mucosal biopsy:
- Squamous mucosa, with rare eosinophils, spongiosis and
increased
basal zone regeneration, consistent with mildly active
esophagitis.
.
GI BIOPSY:
ime Taken Not Noted Log-In Date/Time: ___ 2:07 pm
VIRAL CULTURE: R/O CYTOMEGALOVIRUS Site: ESOPHAGUS
TEST VERIFIED BY ___ ___.
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.
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary):
No Herpes simplex (HSV) virus isolated.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. ClonazePAM 1 mg PO TID
3. copper gluconate 2 mg oral daily
4. Doxepin HCl 75 mg PO HS
5. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
6. Furosemide 40 mg PO BID
7. Methadone 10 mg PO Q6H
8. Mirtazapine 22.5 mg PO HS
9. Omeprazole 20 mg PO BID
10. QUEtiapine Fumarate 100 mg PO QAM
11. QUEtiapine Fumarate 300 mg PO QHS
12. Sucralfate 1 gm PO QID
13. Vitamin D 1000 UNIT PO DAILY
14. Cyanocobalamin Dose is Unknown PO DAILY
15. Magnesium Oxide Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. ClonazePAM 1 mg PO TID
3. copper gluconate 2 mg oral daily
4. Doxepin HCl 75 mg PO HS
5. Methadone 10 mg PO Q6H
6. Mirtazapine 22.5 mg PO HS
7. QUEtiapine Fumarate 100 mg PO QAM
8. QUEtiapine Fumarate 300 mg PO QHS
9. Sucralfate 1 gm PO QID
10. Cholestyramine 4 gm PO TID
RX *cholestyramine (with sugar) 4 gram 1 packet by mouth three
times a day Disp #*90 Not Specified Refills:*0
11. Lidocaine Viscous 2% 15 mL PO TID
RX ___ [FIRST-Mouthwash BLM] 400
mg-400 mg-40 mg-25 mg-200 mg/30 mL ___ teaspoons three times a
day Disp #*450 Milliliter Refills:*0
12. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*60 Capsule Refills:*0
13. Furosemide 40 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN
odynophagia
16. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q6 Disp
#*35 Tablet Refills:*0
17. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Esophagitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior chest CT from ___ as well as a chest radiograph from
___.
CLINICAL HISTORY: Past medical history of gastric bypass and multiple
abdominal surgeries with recent pneumonia, who presents with chest pain,
assess for pneumonia or free air.
FINDINGS: AP upright and lateral views of the chest were provided. Lungs
appear clear bilaterally without focal consolidation, effusion or
pneumothorax. There is no free air below the right hemidiaphragm. The
cardiomediastinal silhouette is normal. The bony structures are intact.
IMPRESSION: No acute findings.
Radiology Report
HISTORY: History of gastric bypass with a small remnant gastric pouch
admitted with esophagectomy. Evaluate for emptying and fistula.
COMPARISON: CT abdomen/pelvis from ___ and ___.
FINDINGS:
Upon review of prior CT abdomen/pelvis, it was determined that the patient is
status post gastric bypass with complete reversal of the bypass. The stomach
appears slightly deformed with thickened and edematous gastric folds, likely
secondary to surgical changes. Thin barium passes appropriately through the
distal antrum into the duodenum, and then into the jejunum. There is no
contrast filling of the Roux limb, which presumably was closed or excised.
There is no extravasation of contrast to suggest fistula or leak. Small-bowel
follow-through was limited due to patient fatigue and inability to tolerate
swallowing much barium. Considerable portions of the distal small bowel are
only minimally opacified and contrast opacification was not pursued to the
terminal ileum. There is dilation of small bowel loops at the JJ anastomosis.
Mild reflux of contrast past the GE junction into the distal ___ of the
esophagus is noted.
IMPRESSION:
1. Status post gastric bypass, with complete reversal. Contrast passes from
the stomach into the duodenum and then jejunum as intended, without
extravasation of contrast to suggest fistula or leak.
2. Thickened and edematous gastric folds, likely secondary to prior
surgeries.
3. Mild reflux at the GE junction into the distal ___ of the esophagus.
These findings were communicated via telephone by Dr. ___ to Dr.
___ at 1547 on ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: CHEST PAIN/WEAKNESS
Diagnosed with CHEST PAIN NOS, ESOPHAGITIS UNSPECIFIED
temperature: 98.6
heartrate: 87.0
resprate: 16.0
o2sat: 96.0
sbp: 134.0
dbp: 78.0
level of pain: 10
level of acuity: 3.0 | ASSESSMENT AND PLAN:
___ year old female with multiple medical problems including
distant gastric bypass with multiple complications and
subsequent surgeries, chronic abdominal pain on methadone, and
pulmonary embolism now on lovenox who presents with 3 days of
odynophagia and burning chest pain.
.
#ODYNOPHAGIA / ESOPHAGITIS: Her presentation was most consistent
with esophagitis due to GERD. She underwent EGD that confirmed
esophagitis (grossly and on biopsy). VIral culture was
negative. She has a history of ___ esophagitis (___) but
biopsy did not demonstrate fungus. HIV test was negative. She
was started on PPI BID and sucrulfate (slurry) 1gram QID. She
was given viscous lidocaine to take prior to meals and was able
to tolerate a regular diet. EGD noted bile in the stomach so
she was started on cholestyramine. Small bowel follow through
did not demonstrate fistula between remnant and gastric pouch
causing non acid bile reflux. She will continue PPI BID,
sucrulfate, and cholestyramine until she follows up with GI in
___ weeks (scheduled). She was given a prescription for GI
cocktail with lidocaine that she can take for one week. She was
given a small number of PO dilaudid for pain control.
CHRONIC:
#History of Copper deficiency: Followed by neurology and felt
that long standing weakness may be ___ copper deficiency so she
was started on supplemental copper. A copper level was checked
and was within normal limits. She was continued on copper
gluconate 2mg daily
#Hx of DVT: She was continued on lovenox 1mg BID for history of
venous thromboembolism.
#Chronic Pain: She was continued on her home of methadone
#Depression/anxiety: She was continued on home Doxepin,
clonazepam, Quetapin, and Mirtazapin
# CODE: DNR per patient |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
acute onset headache and R eye vision loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old left-handed man with history of HIV+
on HAART, former IVDU, who presents with acute onset ~1400 of R
facial HA, R eye twitching, R eye blurry vision, and "black
spot"
in R eye visual field(inferior temporal quadrant). The HA is R
temporal and periorbital, pain is nonspecific and improving.
There was no specific inciting event, and he has not had these
symptoms before. He has a history of sinus headaches which he
says are different from this. He said that he also seemed to
have
more difficulty walking and tripped but did not fall. He denied
any focal weakness or numbness.
He has no prior history of stroke or blood clots. He has been
having some R-sided neck pain in the last few weeks, but has not
had any recent trauma or manipulation of his neck.
Initial NIHSS at 1530 was 4 (R eye visual field cut, slight R
nasolabial fold decreased activation, RLE drift, RUE decr sharp
sensation), repeat NIHSS at 1545 by attending of 2 (R eye visual
field cut, RLE drift). HCT negative. CTA did not show any
evident
occlusions or stenoses.
On neuro ROS, the pt says that he has had poorer memory and
concentration for the last ___ months (e.g. forgetting details
about books he has read). He denies 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.
On general review of systems, the pt endorses ___ months of SOB
with exertion, intermittent central/left chest pain not
associated with exertion or SOB, intermittent R-sided abdominal
pain. He denies recent fever or chills. No night sweats or
recent weight loss, has had some weight gain. Denies cough.
Denies palpitations. Denies nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria, has had slow urine stream. Denies arthralgias or
myalgias. Has rash on back (?eczema).
Past Medical History:
HIV dx ___
History of IV drug use, crystal meth, now sober ___ years
Anal HPV, internal external condyloma s/p surgery ___
L hand 3rd degree burns
R hand cellulitis
Tonsillectomy
R knee surgery
Anxiety
Social History:
___
Family History:
Maternal GF died of cerebral aneurysm. Paternal grandmother and
grandfather had strokes in old age. Mother HTN,
HLD. Father died of lung cancer. Brother and sister healthy.
Depression runs on paternal side, anxiety on maternal side.
Physical Exam:
ADMISSION EXAM:
Vitals: per flowsheet
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, few white spots on
tongue, no thrush in oropharynx. No ocular bruits. Mild TTP R
temple.
Neck: Supple, no carotid/vertebral bruits appreciated. No nuchal
rigidity. Mild tenderness along R trapezius.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, ND, mild TTP RLQ, normoactive bowel sounds, no
masses or organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. 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. 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. Monocular R temporal inferior
quadrantanopia to finger counting and wiggling. Funduscopic exam
on R showed a possible tortuous or cut off vessel, no
papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, slightly less on R.
VII: Initially had slower activation of R lower face, now
appears
resolved, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. On holding up RLE, has some drift downward.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R 5- ___ ___ 5- 5 5- 5 5 5 5
-Sensory: Patchy decreased pinprick sensation all over body, not
in any specific distribution, no sensory level. Decreased cold
sensation RLE. Decreased vibration sense bilateral ___ R more
than
L at toe and metatarsal. Proprioception intact both toes. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 2 3 1
R 2 1 2 3 1
Crossed adductors bilaterally
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. R hand movements
slightly
slower than L.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem and on toes without difficulty.
Romberg absent.
DISCHARGE EXAM:
Physical exam notable for no visual field cuts, normal
fundoscopic exam, and patchy sensory deficits that may be
attributed to HAART/HIV neuropathy, and mild givaway weakness in
the right deltoid and right iliopsoa.
Pertinent Results:
___ 03:29PM BLOOD WBC-6.8# RBC-5.32 Hgb-17.4 Hct-50.6#
MCV-95# MCH-32.7* MCHC-34.4 RDW-13.1 Plt ___
___ 03:29PM BLOOD Neuts-57.3 ___ Monos-4.9 Eos-2.3
Baso-2.2*
___ 03:29PM BLOOD Plt ___
___ 03:29PM BLOOD ___ PTT-43.6* ___
___ 03:39PM BLOOD Creat-1.0
___ 03:29PM BLOOD UreaN-14
___ 03:29PM BLOOD ALT-148* AST-92* AlkPhos-61 TotBili-0.5
___ 03:29PM BLOOD Albumin-4.6
___ 03:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:32PM BLOOD Glucose-113* Na-141 K-4.2 Cl-102
calHCO3-26
CT head ___
No acute intracranial abnormality.
CTA head and neck ___ prelim
No aneurysm or arteriovenous malformation. Patent ICA, vertebral
arteries
and its major branches bilaterally without significant stenosis.
Pending
reformats.
ECHO ___
Patent foramen ovale. Mild symmetric LVH with normal global and
regional biventricular systolic function.
MRI/ MRA fat sat head and neck ___
1. No evidence of acute intracranial process.
2. 3 mm superiorly projecting outpouching in left supraclinoid
ICA, measuring approximately 3 mm, consistent with a small
aneurysm.
3. No evidence of focal stenosis, occlusion, dissection or
other aneurysm. There is no stenosis by NASCET criteria.
___ ___
No evidence of DVT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Raltegravir 800 mg PO DAILY
3. BuPROPion (Sustained Release) 300 mg PO QAM
4. ValACYclovir 500 mg PO Q24H
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal
congestion
6. Lorazepam 1 mg PO Q8H:PRN anxiety
7. Escitalopram Oxalate 20 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. ClonazePAM 0.5 mg PO BID
10. ZyrTEC (cetirizine) 10 mg oral daily:prn allergies
11. Multivitamins 1 TAB PO DAILY
12. Vitamin B Complex 1 CAP PO DAILY
13. TraZODone 25 mg PO HS:PRN insomnia
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash
15. ammonium lactate 12 % topical TID:PRN rash
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. ClonazePAM 0.5 mg PO BID
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal
congestion
6. Lorazepam 1 mg PO Q8H:PRN anxiety
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Raltegravir 800 mg PO DAILY
10. TraZODone 25 mg PO HS:PRN insomnia
11. Vitamin B Complex 1 CAP PO DAILY
12. ammonium lactate 12 % topical TID:PRN rash
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash
14. ValACYclovir 500 mg PO Q24H
15. ZyrTEC (cetirizine) 10 mg oral daily:prn allergies
16. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
transient ischemic attack (TIA)
Ocular migraine
PFO
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro exam: non-focal
Followup Instructions:
___
Radiology Report
INDICATION: Right-sided weakness. Evaluate for hemorrhage or stroke.
COMPARISONS: CT of the head from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin
section bone reformatted images were obtained and reviewed.
TOTAL DLP: 891.93 mGy-cm.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
large vascular territory infarction. The ventricles and sulci are normal in
size and configuration. The basal cisterns are patent. There is preservation
of gray-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses are clear. The
left mastoid air cells are underpneumatized. There is a small amount of
opacification in these left mastoid air cells and the left middle ear middle
ear. This is unchanged from the prior exam. The right mastoid air cells and
middle ear are clear. The soft tissues are unremarkable.
IMPRESSION: No acute intracranial abnormality. MRI is more sensitive for the
detection of acute infarction.
Radiology Report
HISTORY: ___ male with right-sided headache, right lower extremity
weakness. Evaluate for aneurysm.
TECHNIQUE: Using a multi detector CT scanner, volumetric data was acquired
after intravenous administration of contrast through the head and neck and
collimated at 1.25 mm slice thickness. Axial, sagittal and coronal multi
maximum intensity projections were generated. Additional multiplanar
reconstructions were performed on a separate workstation.
COMPARISON: CT head without contrast ___.
FINDINGS:
CTA Head: There is a 3 mm superiorly projecting outpouching in left
supraclinoid ICA, measuring approximately 3 mm (___). Otherwise, the
internal carotid, anterior cerebral and middle cerebral arteries demonstrated
normal opacification and branching pattern. The anterior communicating artery
complex is visualized.
The posterior circulation, including vertebral, basilar and posterior cerebral
arteries also demonstrate normal opacification and branching pattern. The
vertebral arteries are codominant. The posterior communicating arteries are
diminutive.
There is no evidence of significant stenosis, dissection or other aneurysm
greater than 3 mm.
CTA Neck: There is a left aortic arch with normal great vessel anatomy. There
is normal opacification of the bilateral common carotid, internal carotid and
vertebral arteries. There is mild atherosclerotic disease at the bilateral
carotid bulbs and origins of the internal carotid.
There is no evidence of stenosis at the origin or throughout the course of
these vessels. There is no dissection or aneurysm/pseudoaneurysm.
Right internal carotid artery (minimal diameter in mm):
Proximal: 4.0
Distal: 4.0
Left internal carotid artery (minimal diameter in mm):
Proximal: 5.0
Distal: 4.0
Additional findings: Note is made of hypoplasia of the left temporal bone
with underpneumatization of the mastoid air cells. The oropharynx,
nasopharynx, hypopharynx, larynx, oral and nasal cavities are otherwise
normal. There is no lymphadenopathy by CT criteria. The parotid and
submandibular glands and thyroid glands are normal. The soft tissues and
osseous structures are normal. The visualized lung apices are clear.
IMPRESSION:
1. 3 mm superiorly projecting outpouching in left supraclinoid ICA, measuring
approximately 3 mm, consistent with a small aneurysm.
2. No evidence of focal stenosis, occlusion, dissection or other aneurysm.
There is no stenosis by NASCET criteria.
Dr. ___ these findings by phone with Dr. ___
at 5:20 pm on ___.
Radiology Report
HISTORY: ___ man with acute onset of right eye outer inferior field
cut. Evaluate for infarct/dissection.
TECHNIQUE: Multiplanar, multi sequence MRI of the head was performed without
intravenous contrast administration. In addition, 3D time-of-flight MR
angiography was performed of the intracranial vessels. The 2D time-of-flight
angiography of the neck vasculature, as well as dynamic time resolved and 3D
high-resolution contrast-enhanced MR angiography of the neck vasculature was
also obtained after intravenous contrast administration. Maximum intensity
projections of the head and neck were generated.
COMPARISON: CTA head and neck ___,.
FINDINGS:
MRI Head: No evidence of acute infarct, hemorrhage, midline shift, mass
effect or extra-axial fluid collections. The ventricles, sulci and basilar
cisterns are within normal limits. The brain parenchyma demonstrates normal
signal intensity on all sequences. The paranasal sinuses are clear. Again
noted is underpneumatization of the left mastoid air cells. The right mastoid
air cells are clear. The orbits and soft tissues are grossly unremarkable.
MRA Head: There is a 3 mm superiorly projecting outpouching in left
supraclinoid ICA, measuring approximately 3 mm, consistent with a small
aneurysm. Otherwise, there is adequate flow related enhancement within the
bilateral internal carotid, anterior cerebral, middle cerebral, vertebral,
basilar and posterior cerebral arteries. From the anterior communicating
artery is visualized. The the vertebral arteries are codominant. The
posterior communicating arteries are diminutive and not clearly visualized.
There is no evidence of significant stenosis, occlusion, dissection or other
aneurysm.
MRA Neck: There is a left-sided aortic arch with normal great vessel anatomy.
There is normal flow related enhancement within the bilateral common carotid,
internal carotid and vertebral arteries. There is no evidence of stenosis at
the origin or throughout the course of these vessels. There is no evidence of
dissection, aneurysm /pseudoaneurysm, focal stenosis or occlusion. No
evidence of internal carotid artery stenosis by NASCET criteria.
IMPRESSION:
1. No evidence of acute intracranial process.
2. 3 mm superiorly projecting outpouching in left supraclinoid ICA, measuring
approximately 3 mm, consistent with a small aneurysm.
3. No evidence of focal stenosis, occlusion, dissection or other aneurysm.
There is no stenosis by NASCET criteria.
Dr. ___ these findings by phone with Dr. ___
at 5:20 pm on ___.
Radiology Report
HISTORY: Patent foramen ovale with transient vision loss.
TECHNIQUE: Grayscale, color, and spectral Doppler evaluation was performed of
the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation in the bilateral
common femoral, proximal femoral, mid femoral, distal femoral, and popliteal
veins. Normal color flow is also demonstrated in the posterior tibial and
peroneal veins. There is normal respiratory variation in the common femoral
veins bilaterally. There is a small left-sided popliteal cyst.
IMPRESSION:
No evidence of DVT.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Headache, R Facial numbness, Vision changes
Diagnosed with TRANS CEREB ISCHEMIA NOS
temperature: 97.4
heartrate: 115.0
resprate: 20.0
o2sat: 97.0
sbp: 132.0
dbp: 85.0
level of pain: 10
level of acuity: 1.0 | The pt is a ___ with history of HIV+ on HAART (CD4 456 and
viral load < 75 on ___ per ___ Health and the only
complication was oral thrush) who presents with acute onset R
facial HA, R eye twitching, R eye blurry vision, and "black
spot" in R eye visual field (inferior temporal quadrant).
Symptoms are resolved by HOD2. Exam on HOD2 notable for absence
of visual field cuts, normal fundoscopic exam. Diffuse patchy
sensory changes remain and may be attributed to HAART and HIVn
neuropathy. HCT was negative. CTA showed no evidence of
occlusions or stenoses. Differential remains branch retinal
artery occlusion either by vasospasm or embolus, with headache
favoring the first. Retinal migraine is another consideration.
CTA and MRA (fat sat) of the head and neck are unremarkable
except for incidental finding of 3mm aneurysm of the left ICA
Very unlikely termporal arteritis given his age but ESR/CRP
sent. Opportunistic infectious due to HIV are important to
consider although less likely given CD4 of 456 and viral load <
75. He was started on ASA 81mg to lower stroke risk. Risk
factors eval: a1c 5.6. ECHO revealed PFO. Lower extremites
doppler showed no DVT. D-dimer unremarkable. Ophthalmology also
evaluated patient and found no intraocular abnormalities that
would explain his clinical presentation.
# Transitional issues
[ ] follow up ESR/CRP
[ ] follow up pending fasting lipid panel
[ ] he was noted to have mild transaminitis (asymptomatic, ALT
127, AST75). Please recheck LFTs and consider further work up.
[ ] 3mm aneurysm of the left ICA. Please monitor and consider
___ clinic referral. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall from ladder
Major Surgical or Invasive Procedure:
___ Embolization
___ Pelvic fixation
History of Present Illness:
___ male presents with the above fracture s/p mechanical fall
of ___ feet. Patient was at work, climbing a ladder, when he
slipped and fell approximately 20 feet, landing on his buttocks.
He endorses severe buttock and right hip pain, as well as lesser
pain to injured hand and lower back. Otherwise no active
complaints
Past Medical History:
Appendectomy
Social History:
___
Family History:
NC
Physical Exam:
General: Well-appearing, breathing comfortably, sitting up-right
in the bed
MSK:
- Dressings c/d/I on abdomen and hip
- Soft, non-tender thigh and leg
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Intact rectal tone, with mildly diminished, but improving
___ sensation.
Hip Adduction, Knee extension, Knee Flexion are all with good
strength.
Pertinent Results:
See OMR
L Spine MRI
1. Status post interval placement of pelvic fixation hardware
including a
right sacroiliac screw. Although immediately adjacent
structures are somewhat
obscured by hardware artifact, within these confines there is no
new spinal
canal or neural foraminal narrowing or new cauda equina nerve
root
impingement.
2. Redemonstration of burst type fracture of L1 with moderate
overall height
loss and 4 mm posterior bony retropulsion without significant
spinal canal
narrowing or cauda equina impingement.
3. Redemonstration of disruption of the anterior longitudinal
ligament at the
site of the L1 fracture associated with prevertebral hematoma,
unchanged.
4. Marrow edema in the upper sacrum, compatible with known
sacral fractures.
5. Background moderate lumbar spondylosis, unchanged. Notably,
spinal
narrowing is worst (moderate) at L4-5, and multilevel neural
foramina
narrowing is worst (moderate to severe) on the left at L5-S1.
Further
details, as above.
Medications on Admission:
N/A
Discharge Medications:
1. Acetaminophen 975 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*25 Syringe
Refills:*0
4. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours as
needed Disp #*30 Tablet Refills:*0
6. Senna 17.2 mg PO BID
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pelvis fracture, L1 burst fracture, left hand laceration
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: Fall from 20 feet, pelvic injury
TECHNIQUE: Supine AP view of the chest and supine AP view of the pelvis
COMPARISON: None. Patient is currently listed as EU critical.
FINDINGS:
Within the chest, heart size is normal. Mediastinal and hilar contours are
normal. Lungs are clear. Pulmonary vasculature is not engorged. Lungs appear
clear of though the left costophrenic angle is excluded from the field of
view. No large pleural effusion or pneumothorax, but assessment on the left
is limited as the left costophrenic angle was excluded. No displaced
fractures.
In the pelvis, there is diastasis of the pubic symphysis. Mildly displaced
fractures of the sacrum bilaterally are noted. Femoroacetabular joints are
preserved without significant degenerative changes. No concerning lytic or
sclerotic osseous abnormalities. Rounded calcifications project over the
right superior pubic ramus, likely phleboliths.
IMPRESSION:
1. Left costophrenic angle is excluded from the field of view. Otherwise, no
acute cardiopulmonary abnormality within the chest.
2. Open book pelvic fracture with bilateral sacral fractures.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall ___ nfet, pelvis fr. on plain film,//
trauma, fall ___ feet
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 20.0 s, 20.4 cm; CTDIvol = 49.1 mGy (Head) DLP =
1,003.4 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is mild thickening of the right
anterior ethmoid air cells and mucous retention cysts in the right maxillary
sinus. Otherwise, the visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
No acute intracranial findings.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with, pelvis fr. on film// fall ___ feet fall
___ feet
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 6.4 s, 25.0 cm; CTDIvol = 22.8 mGy (Body) DLP = 571.7
mGy-cm.
Total DLP (Body) = 572 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified.Mild degenerative changes are
seen with multilevel intervertebral disc space narrowing and small disc
bulges, most pronounced C5-6 with mild flattening of the ventral thecal sac.
There is no evidence of high-grade spinal canal or neural foraminal stenosis.
There is no prevertebral soft tissue swelling. There is no evidence of
infection or neoplasm.
The visualized lung apices demonstrate mild centrilobular emphysema. The
thyroid is normal. There are aerosolized secretions within the esophagus.
IMPRESSION:
No acute fracture or traumatic subluxation.
Radiology Report
History: ___ with fall ___ nfet, pelvis fr. on plain film,// trauma, fall ___
feet
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. Physiologic trace pericardial fluid is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma. There are
calcified hilar and paratracheal lymph nodes.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. A millimetric left upper lobe calcified granuloma is present.
The airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion 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 lesion or laceration. There is a punctate splenic calcified
granuloma.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized. There is no
evidence of mesenteric injury.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is
extraperitoneal hematoma at the anterior and right posterolateral pelvis and
in the presacral region.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: No pathologically enlarged lymph nodes in the abdomen or pelvis.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is pubic symphysis diastasis by 1.8 cm (series 2, image 253). An
extraperitoneal hematoma tracks along the anterior pelvic brim, with two areas
of discrete contra extravasation, 1 near the superior pubic ramus (series 2,
image 246), and 1 more inferior near the inferior pubic ramus (series 2, image
260).
There is a comminuted right sacral ala fracture with multiple distracted
fragments including a laterally angulated fragment along the course of the
internal iliac artery (series 3 image 209). Multiple punctate areas of high
attenuation adjacent to the fragment may represent smaller bone fragments with
tiny foci of extravasation not excluded (series 2, image 208). The right
sacral ala fracture extends posteriorly into the sacral foramina (series 3,
image 209-241). There is a mildly displaced fracture of the S1 left lamina
which extends inferiorly through the sacral foramina (series 3, image
193-216).
The sacroiliac joints are intact bilaterally. Femoroacetabular joints appear
within normal limits with mild degenerative changes demonstrated.
Burst fracture of the L1 vertebral body with 2 mm of posterior translation
with surrounding hypodensity measuring up to 4 mm off of the posteriorly
distracted fragment is worrisome for hematoma (series 602, image 93). There
is approximately 30% height loss.
SOFT TISSUES: There is hematoma near the right inguinal canal.
IMPRESSION:
1. Open book pelvic fracture with diastasis of the pubic symphysis of 1.8 cm.
Extraperitoneal hematoma with active extravasation seen near the right
superior and inferior pubic rami (series 2 image 246; series 2, image 260).
Punctate foci hyperdensity posteriorly near the sacral ala (series 2, image
209) may represent additional sites of tiny active contrast extravasation
versus bone fracture fragments.
2. Burst fracture of the L1 vertebral body with 2 mm of posterior translation
and surrounding hypodensity measuring up to 4 mm off of the posteriorly
distracted fragment, for which hematoma may be present (series 602, image 93).
Correlate with neurological findings and consider MR for further evaluation.
3. Comminuted mildly distracted fracture of the right sacral ala with
extension posteriorly into the neural foramina.
4. Mildly displaced fracture of the S1 left lamina extending inferiorly
through the sacral foramina.
5. Calcified hilar and mediastinal lymph nodes with calcified left upper lobe
pulmonary nodule and punctate calcification in the spleen compatible with the
sequela of prior granulomatous disease.
RECOMMENDATION(S): Burst fracture of the L1 vertebral body with 2 mm of
posterior translation and surrounding hypodensity measuring up to 4 mm off of
the posteriorly distracted fragment, for which hematoma may be present.
Correlate with neurological findings and consider MR for further evaluation.
Radiology Report
INDICATION: History: ___ with finger laceration// eval fracture left ___
digit
TECHNIQUE: Three views of the left ring finger
COMPARISON: None.
FINDINGS:
Soft tissue swelling and laceration are seen involving the mid and distal
aspects of the ring finger with punctate radiopaque foreign bodies along the
radial aspect of the finger suggestive of foreign bodies. Additionally, mild
cortical irregularity is seen involving the base of the radial aspect of the
distal phalanx of the ring finger which may reflect a tiny fracture. No
dislocation. Joint spaces are preserved without significant degenerative
changes.
IMPRESSION:
1. Soft tissue swelling and laceration involving the mid and distal aspect of
the ring finger with radiopaque foreign bodies.
2. Mild cortical irregularity involving the base of the radial aspect of the
distal phalanx of the ring finger suggestive of a tiny fracture.
3. No dislocation.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with L1 compression fracture// evaluate fracture
evaluate fracture
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of Gadavist
contrast agent.
COMPARISON: CT torso with contrast dated ___
FINDINGS:
Alignment is normal, with the conus ending at the T12-L1 level.
STIR hyperintensity of the L1 vertebral body with a burst fracture morphology
in the upper vertebral body only. There is associated 4 mm retropulsion of
the superior fragment of the body (series 3, image 13). There is no
compression of the spinal cord or nerve roots. The spinal cord signal
intensity is normal.
The anterior longitudinal ligament overlying the T12 vertebral body is
disrupted with prevertebral hemorrhage (series 3, image 13). The posterior
longitudinal ligament is normal. There is STIR hyperintensity at the left
L1-L2 facet capsule (series 3, image 16), concerning for trauma.
Additionally, there is STIR hyperintensity at the S2 vertebral body, most
likely reflecting fracture. Again visualized is a comminuted fracture of the
right sacral ala (series 101, image 81).
T11-T12:
No neural foraminal narrowing. No spinal cord compression.
T12-L1:
No neural foraminal narrowing. No spinal cord compression.
L1-L2:
No neural foraminal narrowing. Mild anterior spinal canal narrowing from
retropulsion of the fractured L1 vertebral body without spinal cord
compression.
L2-L3:
Mild bilateral lateral recess and neural foraminal narrowing and mild anterior
spinal canal narrowing from intervertebral disc bulge.
L3-L4:
T2 hypodensity of the intervertebral disc, likely reflecting degenerative
disease. No neural foraminal narrowing. No spinal cord compression.
L4-L5:
There is a midline disc protrusion, migrating inferiorly, with midline annular
fissure (series 3, image 12). Along with thickened bilateral ligamentum
flavum, this has led to severe spinal canal narrowing without cord compression
(series 101, image 66).
L5-S1:
Minimal posterior disc bulge and bilateral facet osteophyte without spinal
canal or neural foraminal compromise.
Lastly, patchy multiple STIR hypodensity within the thecal sac dependent
portion of the visualized sacral level, which could represent debris or blood
products. There is narrowing of the thecal sac posterior due to the fractures
demonstrated on the CT, poorly documented on the MR exam
The spinal cord appears normal in caliber and configuration. There is no
evidence of infection or neoplasm.
IMPRESSION:
1. Burst fracture to the upper portion of the L1 vertebral body with 4 mm
retropulsion without spinal cord or nerve root compression.
2. Disruption of the anterior longitudinal ligament at L1, with associated
prevertebral hemorrhage.
3. STIR signal abnormality at the left L1-L2 facet capsule, concerning for
trauma.
4. Severe spinal canal narrowing at the L4-L5 intervertebral level from disc
protrusion and bilateral ligamentum flavum thickening.
5. STIR hyperintensity at S2 vertebral body, most likely reflecting fracture.
6. Comminuted fracture of the right sacral ala.
7. Multilevel degenerative disease, specified above.
Radiology Report
INDICATION: ___ y/o male s/p fall from ladder, pelvic fx with arterial extrav
on imaging and dropping H H.// assess for arterial bleed
COMPARISON: CT abdomen pelvis ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___
Interventional ___ and Dr. ___, interventional Radiology
fellow performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
175mcg of fentanyl and 3 mg of midazolam throughout the total intra-service
time of 3 hours 10 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:
CONTRAST: 170 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 36.5 minutes, 2299 mGy
PROCEDURE: 1. Left radial artery access
2. Right internal iliac arteriogram.
3. Right external iliac arteriogram.
4. Right pudendal arteriogram
5. Gel-Foam embolization of the anterior division of the right internal iliac
artery to near stasis.
6. Post embolization right internal iliac arteriogram.
7. Superior gluteal artery branch arteriogram.
8. Gel-Foam and coil embolization of a third order branch of the superior
gluteal artery.
9. Post embolization right internal iliac arteriogram.
10. Post embolization distal aortic/iliac arteriogram.
11. Abdominal aortogram.
PROCEDURE DETAILS:
Following a discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. Left arm was
prepped and draped in the usual sterile fashion.
Using palpation, the left radial artery was identified. After injection of 1%
subcutaneous lidocaine, a micropuncture needle was advanced into the radial
artery until brisk blood return was identified. An 018 Nitinol wire was easily
advanced into the radial artery. The micropuncture needle was exchanged for a
5 ___ Glide sheath. The sheath was flushed and 3000 units of intra-arterial
heparin, 200 mcg of nitroglycerin and 2.5 mg of verapamil were injected into
the radial artery. The sheath was connected to a pressurized bag of
heparinized saline.
A glidewire with ___ 125 cm ___ catheter was advanced easily under
fluoroscopy into the aorta and then used to select the right common iliac
artery and then internal iliac artery. Contrast injection was then performed
confirming position. A right internal iliac arteriogram was performed which
demonstrated irregularity of the pudendal artery though no active
extravasation. The catheter was then retracted and advanced into the right
external iliac artery. Contrast injection confirmed position. Right external
iliac arteriogram was performed which did not demonstrate any areas of active
extravasation. The catheter was retracted and the internal iliac artery was
selected. An ___ microcatheter and double angled glide microwire were used to
select the pudendal artery. Contrast injection confirmed position. A right
pudendal arteriogram was performed which did not demonstrate any areas of
active extravasation. The decision was made to Gel-Foam embolize the right
anterior division. The microcatheter and microwire were retracted into the
origin of the anterior division and Gel-Foam embolization was performed to
prune peripheral vessels. A post embolization right internal iliac
arteriogram was performed which demonstrated contrast pooling and possible
extravasation arising from a branch of the superior gluteal artery. The
superior gluteal artery was selected with the microcatheter and microwire.
Contrast injection confirmed position.
An exchange length Glidewire was introduced and the ___ catheter was
exchanged over the wire for ___ F 110 cm pigtail flush catheter. A distal
aortogram was performed to evaluate any additional areas of bleeding within
the pelvis. An abdominal aortogram was performed to evaluate for any
additional areas of bleeding arising from lumbar arteries. The Glidewire wire
was used to remove the pigtail flush catheter.
A TR band was placed over the patient's left wrist. After inflation of the
band with 18 cc of air, the sheath was removed. The band was slowly deflated
until bleeding was noted at the skin entry site. An additional 2 cc of air was
introduced into the band. The total volume of air in the band is 12 cc.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Initial right internal iliac arteriogram demonstrated irregularity of the
pudendal artery without definite active extravasation.
2. Selective pudendal arteriogram did not demonstrate active extravasation or
pseudoaneurysm.
3. Post Gel-Foam embolization anterior division right internal iliac
arteriogram demonstrated satisfactory pruning of the peripheral vasculature
and a small area of contrast pooling arising from a branch of the superior
gluteal artery.
4. Superior gluteal branch arteriogram confirmed active extravasation arising
from a third order arterial branch.
5. Post Gel-Foam and coil embolization arteriogram demonstrated resolution of
active bleeding without evidence of pseudoaneurysm.
6. Post embolization right internal iliac arteriogram not demonstrate any
additional suspicious areas of active bleeding or pseudoaneurysm.
7. Abdominal aortic arteriogram did not demonstrate any additional areas of
active extravasation or pseudoaneurysm arising from the lumbar arteries or
pelvis.
IMPRESSION:
Left radial artery access pelvic arteriogram with Gel-Foam embolization of the
anterior division of the right internal iliac artery and coil and Gel-Foam
embolization of a third order branch of the right superior gluteal artery
where active bleeding was noted.
Radiology Report
EXAMINATION: Intraoperative fluoroscopy of the pelvis.
INDICATION: ORIF of pelvic injuries.
TECHNIQUE: 14 intraoperative fluoroscopic spot views of the pelvis were
obtained without presence of radiologist.
DOSE: Fluoroscopy time 101.1 seconds, cumulative dose 4.33 rad.
COMPARISON: ___.
FINDINGS:
Patient is status post open reduction internal fixation of the pubic symphysis
and the right sacroiliac joint.
IMPRESSION:
ORIF of pelvic fractures. Please see the operative note for further details
of needed.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with known L1 burst fracture and s/p ORIF APCII
pelvis fx with new perianal numbness// assess for nerve compression
potentially resulting in perianal numbness assess for nerve compression
potentially resulting in perianal numbness
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON:
1. Pelvic radiographs ___.
2. MR lumbar spine ___.
3. CT torso ___.
FINDINGS:
New from prior studies hardware artifact in the upper sacrum from pelvic
fixation hardware including a right sacroiliac transit trans-syndesmotic
fixation screw. Artifact somewhat limits evaluation of immediately adjacent
structures; within these confines:
Again seen is an acute appearing compression fracture involving the full AP
depth of the L1 vertebral body, with buckling and slight posterior
retropulsion of the posterior cortex into the spinal canal, measuring
approximately 4-5 mm, unchanged (03:13). Diffuse marrow edema seen in the
vertebral body and extending into the pedicles bilaterally, unchanged. There
is overall unchanged mild to moderate vertebral body height loss. Trace STIR
hyperintense fluid, likely hematoma, is seen in the prevertebral space at this
level, along with associated disruption of the anterior longitudinal ligament,
as previously seen (see series 3, image 15).
STIR hyperintense signal within the sacrum inferior to the hardware artifact
is again noted, compatible with previously demonstrated sacral fracture.
Marrow signal is otherwise within normal limits.
Elsewhere, remaining vertebral body heights are preserved. Alignment is
within normal limits. The distal spinal cord and conus medullaris is
unremarkable and terminates at L1. The cauda equina nerve roots are normal.
Intervertebral disc hypointense signal at L3-4 and L4-5 likely reflects
degeneration. There is slight L1-L2 disc T2/STIR high signal, as seen
previously, likely edema in the setting of adjacent fracture.
T12-L1: Bony retropulsion of the buckled posterior L1 cortex at the level of
the pedicles slightly effaces the anterior CSF space at this level, without
overall spinal canal narrowing or cauda equina contact (2:46 and 101:4). No
neural foraminal narrowing.
L1-2: Unremarkable.
L2-3: Posterior disc bulge, ligamentum flavum thickening, and facet
osteophytes without significant spinal canal narrowing. There is very mild
bilateral neural foraminal narrowing due to the disc bulge.
L3-4: Broad-based posterior disc bulge is mild, along with ligamentum flavum
thickening and facet osteophytes causing mild spinal canal narrowing. There
is very mild bilateral neural foraminal narrowing.
L4-5: Central disc protrusion associated with an annular fissure, ligamentum
flavum thickening, and facet osteophytes cause moderate spinal canal narrowing
with narrowing of the subarticular zones but no definite descending S1 nerve
root impingement. There is mild bilateral neural foraminal narrowing.
L5-S1: Partially obscured due to hardware artifact from right sacroiliac
screw. No definite encroachment of the screw on the spinal canal or neural
foramina. No definite spinal canal narrowing. Moderate to severe left and
moderate right neural foraminal narrowing is unchanged.
The remaining visualized prevertebral paraspinal soft tissues are
unremarkable. Imaged portions of the abdomen retroperitoneum are without
acute focal abnormality on limited evaluation.
IMPRESSION:
1. Status post interval placement of pelvic fixation hardware including a
right sacroiliac screw. Although immediately adjacent structures are somewhat
obscured by hardware artifact, within these confines there is no new spinal
canal or neural foraminal narrowing or new cauda equina nerve root
impingement.
2. Redemonstration of burst type fracture of L1 with moderate overall height
loss and 4 mm posterior bony retropulsion without significant spinal canal
narrowing or cauda equina impingement.
3. Redemonstration of disruption of the anterior longitudinal ligament at the
site of the L1 fracture associated with prevertebral hematoma, unchanged.
4. Marrow edema in the upper sacrum, compatible with known sacral fractures.
5. Background moderate lumbar spondylosis, unchanged. Notably, spinal
narrowing is worst (moderate) at L4-5, and multilevel neural foramina
narrowing is worst (moderate to severe) on the left at L5-S1. Further
details, as above.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: s/p Fall
Diagnosed with Stable burst fracture of first lumbar vertebra, init, Fall on and from ladder, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 6
level of acuity: 1.0 | ___ M fall from ladder at work - 20 feet, no LOC, w/ L1
compression fx, b/l sacral fx. Mr. ___ had his left finger lac
repaired ___ Nylon. An MRI L-spine showed Burst fracture
L1. His HCT continued to drift so ___ was consulted for
embolization of the superior gluteal artery branch. The
following day, he went to the operating room on ___ for
surgical fixation of his pelvis, 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.
He was transfused 2 units of additional pRBCs for a low
hematocrit, after which he stabilized. On HD 10, that patient
noted some ___ numbness, but was without changing strength
in the lower extremities or numbness/tingling elsewhere. He did
not have any urinary or bowel incontinence or numbness/tingling
in the legs. Rectal tone was intact. Given his L1 burst fracture
and pelvic fixation, a repeat L Spine MRI was obtained to rule
out cauda equina. The MRI demonstrated that there was no
concerning neural compression. Repeat examination the following
day continued to demonstrate good strength in the lower
extremities distally and improving ___ sensation. The
patient was informed about symptoms to look out for with regard
to cauda equine syndrome and informed that he must emergently
seek care if he developed any of those danger signs. He
expressed full understanding and was in agreement. 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
partial weightbearing with bilateral upper extremity support in
the right lower extremity, and will be discharged on enoxaparin
40mg sc for DVT prophylaxis. He should take this for one month's
time since his operation - end date ___. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Primary PCI for STEMI of occluded RCA with DES ___
History of Present Illness:
Mr. ___ is a ___ y/o man with PMH notable for HTN and CAD (DES
x2 in RCA and POBA to LAD in ___, admitted after being found
down with chest pain.
Per information gathered from his son, the patient was in his
usual state of health on day of presentation. He is a regular
runner and went out for a run as per usual without any recent
complaints of chest pain/pressure, DOE, SOB. Some time later, he
was found down about a few blocks from his son's house (visiting
from ___ for ___) by a passerby, who happened
to be a ___. His son's neighbor was also around and
called his son. The pediatrician who found the patient stated
that he was able to endorse chest pain and remain conversant,
however had a very slow pulse and perhaps looked pale. It is
unclear how long the down time was and if there was any loss of
consciousness. The patient's son arrived at the scene around the
time EMS had come and the patient was brought to ___ for
further care.
Per patient's son, he does have a history of chest pain with
STEMI in ___, treated with what son thinks was DES x2 to RCA
and POBA of ?LAD. He was on aspirin 325mg PO daily and Plavix
for many years until about ___ years ago. The Plavix was
discontinued about ___ years ago as he was so many years removed
from the STEMI. He has been on a baby aspirin since. He also has
never had a history of GI bleed, intracranial bleed, or major
bleed of any sort. His only medications at this point apart from
baby aspirin include enalapril (2.5mg to 5mg daily - son is
unclear which dosing) and simvastatin 80mg PO daily. He used to
be on metoprolol, but this was recently discontinued because of
intolerance to beta blockade (especially with exercise and
running).
In the ED initial vitals were:
-P 40, 153/93 14, 100% RA
-Subsequent recorded vitals include P48, 72/52, 12, 100%
Non-Rebreather
ECG per my read: atrial rate of ~55bpm, ventricular rate of 39
bpm; rhythm consistent with complete heart block; normal axis;
probable left atrial abnormality, Q waves in inferior leads with
sub-mm ST-elevations; 4-5mm ST depressions across V1-V4; 1mm ST
elevations in V5-V6; no prior for comparison, consistent with
likely postero-lateral STEMI (?evolving inferior as well)
Labs/studies notable for:
-Chem10 with K 3.3, Cr 1.2 (unclear baseline)
-CBC with Hgb 13.3, Plt 147
Patient was given:
-Dopamine gtt
-Norepinephrine gtt
-PO Ticagrelor 180mg x1
Patient was taken urgently to the cath lab where he was
intubated on the table due to possible hypoxic respiratory
failure and need to maintain airway protection prior to
catheterization. He underwent successful aspiration thrombectomy
and DES x1 placement to mid-total RCA occlusion. Given lack of
enteral access, he received PR aspirin, IV heparin gtt (started
in ED until cath), tirofiban gtt post-cath. He also had a pacer
wire placed in the ED prior to transfer to cath lab, but quickly
resumed native sinus conduction post-stenting without further
need for pacing.
He was subsequently transferred to the CCU intubated and
sedated. At time of arrival he was agitated and initially not
following commands. He also had repetitive myoclonic movements,
concerning for seizure-like activity. However, these quickly
resided and the patient was following commands, endorsing
discomfort around the endotracheal tube. No future ROS could be
collected i/s/o intubated/sedated status.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
2. CARDIAC HISTORY
- CAD s/p STEMI in ___ (DES x2 to RCA and POBA of LAD per son's
report)
3. OTHER PAST MEDICAL HISTORY
- None
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: Well developed, well nourished in NAD. Intubated,
sedated, but able to respond to simple questions and follow
directions.
HEENT: hematoma as below; EOMI, able to track with eyes,
bilaterally; able to protrude tongue on command; ETT and OGT in
mouth
NECK: Supple. JVP unable to be assess with patient's temp wire
and bandaging in place
CARDIAC: RRR, normal S1, S2; no m/r/g
LUNGS: CTAB with mechanical breath sounds over bilateral
anterior and lateral lung fields
ABDOMEN: Soft, unable to assess for tenderness, non-distended.
No r/g, BS+
EXTREMITIES: Warm, well perfused. No pitting edema.
SKIN: 5.5 x 4cm raised, soft, hematoma over left forehead;
multiple abrasions over LLE
PULSES: Distal pulses palpable and symmetric.
NEURO: as above; moving all extremities spontaneously and
intermittently to command
DISCHARGE PHYSICAL EXAM:
VS: Reviewed in POE
GENERAL: Well developed, well nourished in NAD.
HEENT: hematoma as below; EOMI, PERRLA
CARDIAC: RRR, normal S1, S2; no m/r/g
LUNGS: CTAB
ABDOMEN: Soft, nontender, non-distended. No r/g, BS+
EXTREMITIES: Warm, well perfused. No pitting edema.
SKIN: 5.5 x 4cm raised, soft, hematoma over left forehead;
multiple abrasions over LLE
PULSES: Distal pulses palpable and symmetric.
NEURO: as above; moving all extremities spontaneously and
intermittently to command
Pertinent Results:
ADMISSION LABS:
___ 03:39PM BLOOD WBC-7.8 RBC-4.47* Hgb-13.3* Hct-41.9
MCV-94 MCH-29.8 MCHC-31.7* RDW-12.1 RDWSD-41.9 Plt ___
___ 03:39PM BLOOD Neuts-36.5 Lymphs-53.4* Monos-5.4 Eos-4.0
Baso-0.4 Im ___ AbsNeut-2.84 AbsLymp-4.15* AbsMono-0.42
AbsEos-0.31 AbsBaso-0.03
___ 03:39PM BLOOD ___ PTT-24.7* ___
___ 03:39PM BLOOD Glucose-150* UreaN-16 Creat-1.2 Na-144
K-3.3 Cl-102 HCO3-22 AnGap-20*
___ 06:55PM BLOOD ALT-222* AST-934* LD(LDH)-1271*
___ AlkPhos-87 TotBili-0.7
___ 06:55PM BLOOD Albumin-3.8 Calcium-7.3* Phos-3.3 Mg-1.8
Cholest-153
___ 06:56PM BLOOD ___ pO2-251* pCO2-44 pH-7.26*
calTCO2-21 Base XS--6
___ 06:56PM BLOOD Lactate-3.2*
MICRO:
No relevant results
IMAGING:
CATH REPORT:
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is normal
* Left Anterior Descending
The LAD has no significant disease
* Circumflex
The Circumflex is a very small short vessel with severe proximal
disease
* Right Coronary Artery
The RCA is a very large dominant vessel with mid total
occlusion.
Interventional Details
The RCA was engaged with a ___ Fr JR4 guide. The mid occlusion was
crossed with a Prowater wire restoring flow showing a severe
lesion at the site of mid occlusion and a more distal mid lesion
with the appearance of possible thrombus. The more proximal
lesion was dilated with a 2.5 balloon. An Export catheter was
then passed into the distal vesel with little change in the
appearance of the more distal lesion. Both lesions were then
covered with a 38 x 3.75 Onyx stent postdilated to 4.0 mm at 20
atm with
no residual normal flow Tirofiban started at the beginning of
the procedure to be continued until ticagrelor can be given.
Initial rhythm was paced and he was hypotensive on dopamine and
levophed. After opening of the RCA, rhythm was sinus and
pressors were discontinued.
A temporary pacemaker had been placed in the ED via the RIJ vein
prior to PCI
He was intubated on arrival to the room due to poor mental
status and hypoxia.
Impressions:
Successful primary PCI for STEMI of occluded RCA with DES
Normal LAD
Severe disease of very small LCX
Recommendations
Continue aspirin uninterrupted indefinitely
Continue ticagrelor minimal ___ year
Continue tirofiban until ticagrelor begun
Monitoring in CCU
Head CT in view of developing forehead hematoma during
procedure.
CT HEAD W/O CONTRAST ___:
1. High density opacification of the ethmoid air cells and
right maxillary
sinus without clear air-fluid levels may represent fungal or
atypical
sinusitis. However, given history of trauma, hemosinus cannot
be excluded.
No definitive evidence of acute skullbase fracture despite right
lamina
papyracea deformity.
2. Right frontal subgaleal hematoma.
3. Minimally displaced right nasal bone fracture.
CT C-SPINE W/O CONTRAST ___:
IMPRESSION:
No acute fracture or traumatic malalignment.
ECHO ___:
The left atrial volume index is normal. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with akinesis of
the inferolateral wall and hypokinesis of the inferior,
anterolateral and anterior walls. The remaining segments
contract normally (Biplane LVEF = 35 %). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction most c/w CAD. Mild mitral regurgitation.
Increased PCWP.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
RELEVANT LABS:
___ 06:55PM BLOOD CK-MB-GREATER TH cTropnT-10.84*
___ 11:13PM BLOOD CK-MB-575* MB Indx-6.2* cTropnT-14.20*
___ 04:15AM BLOOD CK-MB-327* MB Indx-4.4 cTropnT-18.54*
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-7.4 RBC-3.44* Hgb-10.3* Hct-31.9*
MCV-93 MCH-29.9 MCHC-32.3 RDW-12.9 RDWSD-43.9 Plt Ct-99*
___ 06:25AM BLOOD Neuts-77.3* Lymphs-14.0* Monos-7.6
Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.73# AbsLymp-1.04*
AbsMono-0.56 AbsEos-0.02* AbsBaso-0.02
___ 06:25AM BLOOD ___ PTT-32.4 ___
___ 06:25AM BLOOD Glucose-106* UreaN-15 Creat-0.8 Na-143
K-4.2 Cl-109* HCO3-24 AnGap-10
___ 03:54AM BLOOD ALT-117* AST-377* LD(LDH)-1172*
CK(CPK)-2467* AlkPhos-51 TotBili-1.0
___ 06:25AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Simvastatin 80 mg PO QPM
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
3. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
4. Enalapril Maleate 2.5 mg PO DAILY
RX *enalapril maleate 2.5 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
Right coronary artery ST elevation myocardial infarction
Newly reduced ejection fraction heart failure with reduced
ejection fraction 35%
Temporary complete heart block
Acute Kidney Injury
Right nasal bone fracture/subgaleal hematoma
SECONDARY DIAGNOSIS
===================
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man found down, with facial hematoma s/p intubation
and cath for RCA STEMI.// NCHCT, found down, facial hematoma
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 19.1 cm; CTDIvol = 47.3 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute infarction, intracranial hemorrhage, edema, or
mass. The ventricles and sulci are normal in size and configuration.
There is a moderate sized right frontal subgaleal hematoma (03:26). There is
deformity of the right lamina papyracea (301:66), however the adjacent
extraconal fat is preserved. The orbits are unremarkable. The orbital rim and
maxillary walls are intact. There is no definitive underlying skullbase
fracture within limitations of the study.
There is high density material in the ethmoidal air cells and right maxillary
sinus, without a clear air-fluid level, however given patient history
hemosinus cannot excluded. The left maxillary sinus is clear. The mastoid
air cells and middle ear cavities are clear.
IMPRESSION:
1. High density opacification of the ethmoid air cells and right maxillary
sinus without clear air-fluid levels may represent fungal or atypical
sinusitis. However, given history of trauma, hemosinus cannot be excluded.
No definitive evidence of acute skullbase fracture despite right lamina
papyracea deformity.
2. Right frontal subgaleal hematoma.
3. Minimally displaced right nasal bone fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ year old man found down, with facial hematoma s/p intubation
and cath for RCA STEMI.// found down, head hematoma; eval fro 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 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 469.3
mGy-cm.
Total DLP (Body) = 469 mGy-cm.
COMPARISON: None.
FINDINGS:
There is minimal retrolisthesis of C4 on C5. Otherwise, alignment is normal.
No acute fractures are identified.No severe spinal canal or neural foraminal
stenosis.There is no prevertebral edema.
The patient is intubated and an enteric tube partially imaged. The partially
imaged thyroid gland is unremarkable. Lung apices are not imaged. Incidental
note is made of partial nuchal ligament calcification.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
INDICATION: ___ year old man with RCA STEMI s/p intubation and cath.// eval
for ETT and NGT placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: None
IMPRESSION:
The tip of the endotracheal tube projects over the mid thoracic trachea and
the tip of an enteric tube courses below the level the diaphragm but beyond
the field of view of this radiograph. A single pacing lead projects over the
right ventricle.
Diffuse bilateral airspace opacities likely reflect moderate pulmonary edema.
No pleural effusion or pneumothorax is identified. The size of the cardiac
silhouette is within normal limits.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Chest pain
Diagnosed with ST elevation (STEMI) myocardial infarction of unsp site
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | Mr. ___ is a ___ y/o man with PMH notable for HTN and CAD (DES
x2 in RCA and POBA to LAD in ___, admitted after being found
down i/s/o IPL STEMI c/b transient CHB s/p DES x1 to RCA and
temp-wire placement and removal. Course complicated by
aspiration of thin liquids for which he was seen by speech and
swallow and put on nectar-thickened liquids.
# CORONARIES: DES x1 to RCA on ___
# PUMP: EF 35%
# RHYTHM: transient CHB; now sinus
# RCA STEMI:
# CAD
Patient with known prior coronary disease with mid-RCA occlusion
successfully treated with DES x1. Post-intervention TTE with EF
35% and akinesis of inferolateral wall and hypokinesis of the
inferior, anterolateral and anterior walls. s/p full dose ASA
load and tirofiban. Continued on aspirin daily, ticagrelor BID,
atorvastatin daily. Started on metoprolol 6.25mg q6, and
transitioned to metoprolol 25 XL. Reduced enalapril to 2.5 daily
based on soft pressures (was on 6.25 captopril q8h and with soft
pressures). Will not need life vest with EF 35%. Will need
cardiac rehab.
# CHB: patient presented with complete heart block in the
setting of RCA ischemia and transient nature of CHB, likely due
to heightened vagal tone. Temporary pacing wire initially placed
but pulled on ___. Received 1g Vanc for possible contamination
during placement. No further events on tele.
# Intubation/hypoxic respiratory failure
Patient was urgently intubated in the cath lab, in the setting
of urgent need to proceed with catheterization as well as
possible hypoxic event. He was on minimal vent settings ___ 50%
on PSV) post-op and extubated rapidly ___. Possible residual
edema with difficulty swallowing thin liquids. Speech and
swallow recommended continuing regular solids with nectar thick
liquids also recommend following up with PCP for further
evaluation with a speech pathologist, including a video swallow
study.
# Rhabdomyolysis:
# ___
Patient presented with Cr 1.2 from unclear but presumed normal
baseline. Cr downtrended to 0.9 after cath, suggesting ischemia
and transient hypotension to potentially be contributing.
Additionally, the patient had elevated CK to >10,000 concerning
for rhabdo and also received 110cc contrast intra-cath
increasing risk for progressive ___. CK downtrended and Cr
normalized.
# Subgaleal hematoma:
# Right nasal bone fracture:
# s/p Fall:
Patient collapsed without clear downtime. Appears to have
sustained head strike but imaging notable only for superficial
injuries (subgaleal hematoma) and minimally displaced right
nasal fracture. Seen by plastics who recommend outpt follow up
in one week.
# HTN: decreased home enalapril to 2.5 daily
TRANSITIONAL ISSUES
==================
DISCHARGE WEIGHT: 154 lb |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic appendectomy
History of Present Illness:
The patient is an otherwise healthy ___ y.o. man who presents
with 1 day of RLQ abdominal pain. The pain started on waking the
day prior to admission. It was focused in his RLQ and did not
move or radiate. He has nausea and 1 episode of emesis that AM.
He had subjective chills but no fever. He had no diarrhea. The
pain gradually increased over the next ___ hours, which brought
him to the ED.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
VS: 98.5 70 129/84 14 100%
Gen: NAD
CV: RRR S1 S2
Lungs: CTA B/L
Abd: soft, ND, TTP focally in RLQ with localized rebound, no
guarding, negative Rovsing and psoas signs.
Extr: WWP
On discharge:
VS 97.9, 92, 118/63, 14, 98% on room air
Pertinent Results:
___ 12:00PM BLOOD WBC-8.6 RBC-5.29 Hgb-16.6 Hct-48.7 MCV-92
MCH-31.5 MCHC-34.1 RDW-12.8 Plt ___
___ 12:00PM BLOOD Neuts-59.8 ___ Monos-5.9 Eos-6.7*
Baso-0.7
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD ___ PTT-33.2 ___
___ 12:00PM BLOOD Glucose-91 UreaN-15 Creat-1.1 Na-140
K-4.4 Cl-102 HCO3-28 AnGap-14
___ 12:00PM BLOOD ALT-15 AST-21 AlkPhos-85 TotBili-0.9
___ 12:00PM BLOOD Albumin-5.2
IMAGING:
___ RUQ U/S
Dilated hyperemic appendix with possible sliver of adjacent
fluid compatible with acute appendicitis.
___ Appendix: Tissue pathology (pending)
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right lower quadrant pain.
COMPARISON: None available.
FINDINGS: Grayscale and Doppler ultrasound images of the right lower quadrant
were obtained.
FINDINGS: The appendix is dilated and hyperemic measuring 1.0 cm in diameter
approximately and 0.5 cm in diameter distally. There is a possible sliver of
adjacnet free fluid. The appendix is able to be traced from the cecum and the
tip is blind ending and well visualized. The appendix is non-compressible,
particularly proximally.
IMPRESSION: Dilated hyperemic appendix with possible sliver of adjacent fluid
compatible with acute appendicitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 98.6
heartrate: 69.0
resprate: 16.0
o2sat: 97.0
sbp: 123.0
dbp: 71.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ was admitted on ___ under the acute care surgery
service for management of his acute appendicitis. He was taken
to the operating room and underwent a laparoscopic appendectomy.
Please see operative report for details of this procedure. He
tolerated the procedure well and was extubated upon completion.
He was subsequently taken to the PACU for recovery.
The patient was transferred to the surgical floor
hemodynamically stable. His vital signs were routinely monitored
and he remained afebrile and hemodynamically stable. He was
initially given IV fluids postoperatively, which were
discontinued when he was tolerating PO's. His diet was advanced
on the morning of ___ to regular, which he tolerated without
abdominal pain, nausea, or vomiting. He was voiding adequate
amounts of urine without difficulty. He was encouraged to
mobilize out of bed and ambulate as tolerated, which he was able
to do independently. His pain level was routinely assessed and
well controlled at discharge with an oral regimen as needed.
On the afternoon of ___, Mr. ___ was discharged home with
scheduled follow up in ___ clinic. He was hemodynamically
stable, afebrile and in no acute distress. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex / lactose
Attending: ___.
Chief Complaint:
R arm pain
Major Surgical or Invasive Procedure:
Double Lumen Chest Port Placement ___
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a history of HIV
(undetectable VL, CD4>1200 per pt), depression and hypertension
recently diagnosed with osteosarcoma of the right humerus with
concern for LN, lung metastases presenting for pain control and
initiation of chemotherapy.
On ___ he was seen by Orthopaedic Oncology, a biopsy was made on
___ which resulted as osteosarcoma. His case was reviewed today
in tumor board and he was asked to come to the ED.
ED initial vitals were 97.6 94 119/72 18 98% RA
Prior to transfer vitals were 98.5 77 107/67 18 99% RA
Exam in the ED showed : "Palpable radial pulse, right upper
extremity edema, paresthesias to digits 1 through 4 but
sensation
is intact. Very limited range of motion secondary to pain. "
ED work-up significant for:
-CBC: WBC: 16.2*. HGB: 13.7. Plt Count: 292. Neuts%: 63.4.
-Chemistry: Na: 132* . K: 4.3 . Cl: 94*. CO2: 23. BUN: 16.
Creat:
1.1.
-UENI: "No UE DVT"
ED management significant for:
-Medications: oxycodone 5mg x2, nicotine lozenge 2mg x2
On arrival to the floor, patient reports he has been having
progressively worse right upper extremity edema, pain and
paresthesia. The pain barely lets him sleep in spite of frequent
oxycodone 5mg. He has no other complaints. He has been
constipated since he started the oxycodone.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per ___, reviewed):
As per ortho-onc H&P ___: "He has been having some mild pain
for about 6 months. He initially thought it was related to his
work as a ___. Then in late ___, he was lifting
an
object and felt acutely worse pain. He was evaluated in the
emergency department and told that he may have cancer. He
subsequently had follow-up with his infectious disease doctor
___ at ___), who helped facilitate the workup. Most
recently he saw Dr. ___ oncologist down in ___.
Patient has also noticed a lump in his right armpit for the last
several months. Denies any recent weight loss. Denies fevers or
chills. He does feel a bit more tired in the last couple weeks.
Denies any other lumps or bumps."
Tumor board note ___ ___ has newly diagnosed right arm
osteosarcoma, very large lesion with bone destruction of
humerus.
CT chest showed about 4 lung nodules, very small, though
suspicious for metastatic disease. There are also adenopathy in
the right axillary area, supraclavicular and pectoralis
concerning for metastatic disease, though this degree of
adenopathy is unusual for osteosarcoma."
PAST MEDICAL HISTORY (Per ___, reviewed):
-HTN
-Asthma
-Depression
-Anxiety
-HIV
Social History:
___
Family History:
Paternal grandmother with cancer, father with
diabetes and heart disease, maternal grandfather with lung
disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: ___ Temp: 98.4 PO BP: 117/68 HR: 89 RR: 20 O2 sat:
97% O2 delivery: RA
GENERAL: Well-appearing gentleman lying on his back with pillow
over abdomen seeking anthalgic position.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear.
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: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. RUE with marked edema and erythema in
right arm, and pitting edema without erythema in right forearm
and hand. Limited right shoulder mobility ___ pain.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM
VS: 24 HR Data (last updated ___ @ 004)
Temp: 97.5 (Tm 97.7), BP: 100/60 (96-109/58-69), HR: 73
(73-82), RR: 16 (___), O2 sat: 93% (93-99), O2 delivery: RA,
Wt: 234.3 lb/106.28 kg
GENERAL: Well-appearing gentleman sitting in a chair, pleasant,
in no acute distress
HEENT: Anicteric, Mucous membranes moist, oropharynx clear.
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: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. RUE with 4+ pitting edema in right
arm,
and pitting edema in right forearm and hand. Weakness of right
shoulder (cannot lift to 90 degrees). Poor right hand mobility
___ swelling and possible weakness.
NEURO: Alert and oriented, good attention, linear thought
process. A&Ox3. Decreased sensation to light touch and
temperature in entire RUE.
SKIN: No significant rashes.
ACCESS: Port
Pertinent Results:
ADMISSION LABS
___ 09:19AM WBC-16.2* RBC-4.48* HGB-13.7 HCT-40.8 MCV-91
MCH-30.6 MCHC-33.6 RDW-13.5 RDWSD-45.1
___ 09:19AM NEUTS-63.4 ___ MONOS-13.9* EOS-0.2*
BASOS-0.4 IM ___ AbsNeut-10.26* AbsLymp-3.46 AbsMono-2.24*
AbsEos-0.04 AbsBaso-0.06
___ 09:19AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 09:19AM GLUCOSE-110* UREA N-16 CREAT-1.1 SODIUM-132*
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-23 ANION GAP-15
___ 09:19AM ALBUMIN-4.0
PERTINENT/DISCHARGE LABS
___ 05:15AM BLOOD WBC-11.0* RBC-3.17* Hgb-9.3* Hct-29.2*
MCV-92 MCH-29.3 MCHC-31.8* RDW-13.5 RDWSD-45.9 Plt ___
___ 05:15AM BLOOD Plt ___
___ 05:15AM BLOOD ___ PTT-27.0 ___
___ 05:15AM BLOOD Glucose-122* UreaN-20 Creat-0.7 Na-138
K-4.3 Cl-105 HCO3-22 AnGap-11
___ 05:15AM BLOOD ALT-11 AST-17 LD(LDH)-238 AlkPhos-401*
TotBili-0.3
___ 05:15AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.3
IMAGING/STUDIES
RUE U/S ___- 1. No evidence of deep venous thrombosis in the
right upper extremity, however
there is extremely slow venous flow along the brachial veins
which puts the
patient at risk for formation of deep venous thrombosis.
2. Right upper extremity subcutaneous edema.
3. Redemonstration of a node with calcification in the right
axillary region,
as demonstrated on prior CT.
TTE ___- The left atrial volume index is normal. The right
atrium is mildly enlarged. There is normal left ventricular wall
thickness with a normal cavity size. There is normal regional
left ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 60 %. There is no resting left
ventricular outflow tract gradient. No ventricular septal defect
is seen. Transmitral and tissue Doppler suggests normal
diastolic function, and a normal left ventricular filling
pressure (PCWP less than 12mmHg). 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 with a
normal descending aorta diameter. There is no evidence
for an aortic arch coarctation. The aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. There
is trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes, regional/global systolic function. No valvular
pathology or pathologic flow identified.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: History: ___ with RUE swelling hx of osteosarcoma// r/o DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: CT pre-procedure right upper extremity, ___
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible but show extremely slow flow with normal augmentation.
Marked subcutaneous edema is seen in the right upper extremity. Within the
anterior chest wall and right axillary region, there is an ill-defined
markedly anechoic structure with distal shadowing which correlates with the
abnormal lymph node in the right axillary region containing calcifications.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right upper extremity, however
there is extremely slow venous flow along the brachial veins which puts the
patient at risk for formation of deep venous thrombosis.
2. Right upper extremity subcutaneous edema.
3. Redemonstration of a node with calcification in the right axillary region,
as demonstrated on prior CT.
Radiology Report
INDICATION: ___ year old man with (likely metastatic) osteosarcoma. Plan for
urgent initiation of MAP regimen tomorrow.// Please place DOUBLE LUMEN chest
port leave both accessed. ___ aware.
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the
procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 20 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.4 min, 10.6 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.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a 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. 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.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Other specified soft tissue disorders
temperature: 97.6
heartrate: 94.0
resprate: 18.0
o2sat: 98.0
sbp: 119.0
dbp: 72.0
level of pain: 10
level of acuity: 3.0 | Outpatient Providers: ___ year-old gentleman with a history of
HIV on HAART (undetectable VL per pt and pending, CD4>1200),
depression, and hypertension, recently diagnosed with
osteosarcoma of the right humerus with concern for LN, lung
metastases presenting for pain control and initiation of
chemotherapy.
Started chemo regimen of MAP on ___ and completed day 2 on
___. Pain regimen titrated to 10mg oxycodone ER PO TID and
gabapentin 400mg PO TID. Lymph node biopsy and Neulasta shot
planned for outpatient on ___.
============== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Wound infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with longstanding history of IBD that required a colectomy
with colostomy for obstruction (and SBR of 55 cm) in ___ and
was restored to continuity in ___, then followed by an abscess
that found in ___ and underwent a repeat colectomy and small
bowel resection with end colostomy at ___. This was
complicated by a GI bleed (in the setting of a supratherapeutic
INR), holding her anticoagulation and insertion of a PICC line
which resulted in PEs and a PICC-associated DVT. Her
anticoagulation was resumed and she was discharged without
incident. She has since been hospitalized again for altered
mental status and an orthopedic procedure.
She presents today from rehab where she was noted to be
screaming
in pain and found to have 300 cc of purulent drainage from the
base of her midline incision. She was given a fluid bolus
through
her existing PICC line and sent here. In the ED, she notes
persistent pain in her lower abdomen.
Past Medical History:
PMH:
IBD (unclear UC vs. Crohns ___ years ago), DM2, Hypothyroid, HTN
DVT LLE ___
PSH:
___ (OSH) - ___ for large bowel obstruction due to IBD
___ (OSH) - Reanastamosis (ostomy takedown) (OSH)
___ (___) - Sigmoid perforation with abscess,
___
Social History:
___
Family History:
h/o colon ca
Physical Exam:
Admission Physical Exam:
97.8 129 148/67 18 94% RA
Pleasant but not oriented, but appropriate in conversation
relevance ("I do not want surgery")
Reg rhythm
Unlabored respirations
Abdomen soft, protuberant but non-distended, midline incision
healed (except see below), stoma to left abdomen with copious
brown stool output, small <1 cm hole at base of midline
incision
approximately 5 cm superior to the pubic symphysis with copious
purulent output on expression of lower abdomen, no erythema
Discharge Physical Exam:
GEN: alert, oriented
CV: RRR, no murmur
PULM: CTA bilat
ABD: soft, NT, ND, clean wound
EXT: warm, 2+ pulses
Pertinent Results:
IMAGING:
___: CXR:
Low lung volumes. No focal consolidation to suggest pneumonia.
___: CT Abdomen/Pelvis:
1. 2.3 x 4.5 x 1.8 cm air and fluid containing collection
compatible with and abscess in the lower anterior abdominal
wall, just to the right of midline. No fistulous communication
to bowel identified.
2. Status post partial colectomy with a colostomy in the left
lower quadrant.
No evidence of bowel obstruction.
3. Cholelithiasis.
LABS:
___ 03:26AM GLUCOSE-118* UREA N-99* CREAT-1.3* SODIUM-144
POTASSIUM-5.4* CHLORIDE-114* TOTAL CO2-14* ANION GAP-21*
___ 03:26AM CALCIUM-8.2* PHOSPHATE-3.2 MAGNESIUM-2.2
___ 03:26AM WBC-18.6* RBC-3.11* HGB-8.1* HCT-26.3* MCV-85
MCH-26.0 MCHC-30.8* RDW-18.4* RDWSD-55.9*
___ 03:26AM PLT COUNT-355
___ 03:26AM ___ PTT-58.2* ___
___ 07:03PM K+-5.7*
___ 06:56PM GLUCOSE-193* UREA N-122* CREAT-1.8*
SODIUM-135 POTASSIUM-5.9* CHLORIDE-104 TOTAL CO2-16* ANION
GAP-21*
___ 04:21PM LACTATE-2.6* K+-8.6*
___ 04:21PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 04:21PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 04:21PM URINE RBC-5* WBC-169* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
___ 04:21PM URINE HYALINE-5*
___ 04:21PM URINE WBCCLUMP-FEW MUCOUS-RARE
___ 04:00PM GLUCOSE-219* UREA N-133* CREAT-2.0*#
SODIUM-138 POTASSIUM-6.8* CHLORIDE-109* TOTAL CO2-13* ANION
GAP-22*
___ 04:00PM ALT(SGPT)-9 AST(SGOT)-25 ALK PHOS-105 TOT
BILI-0.2
___ 04:00PM LIPASE-67*
___ 04:00PM ALBUMIN-2.7*
___ 04:00PM WBC-22.9*# RBC-3.56* HGB-9.1* HCT-30.3*
MCV-85 MCH-25.6* MCHC-30.0* RDW-18.7* RDWSD-58.5*
___ 04:00PM NEUTS-84* BANDS-0 LYMPHS-12* MONOS-4* EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-19.24* AbsLymp-2.75
AbsMono-0.92* AbsEos-0.00* AbsBaso-0.00*
___ 04:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-3+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ BURR-2+
___ 04:00PM PLT SMR-HIGH PLT COUNT-409*
___ 04:00PM ___ PTT-58.9* ___
MICRO:
___ 11:12 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
___ 10:34 am SWAB Source: Abdominal wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
STAPH AUREUS COAG +. SPARSE GROWTH.
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.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Time Taken Not Noted Log-In Date/Time: ___ 12:51 am
BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) ON
___ @
11:09AM.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Furosemide 20 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Warfarin 3 mg PO DAILY16
7. CefePIME 2 g IV Q24H
8. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
9. GlipiZIDE 5 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Gabapentin 100 mg PO BID
12. Mirtazapine 15 mg PO QHS
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY Duration: 10 Days
RX *ascorbic acid (vitamin C) 500 mg 1 tablet(s) by mouth once a
day Disp #*6 Tablet Refills:*0
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp
#*44 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7
Days
5. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth at bedtime
Disp #*30 Capsule Refills:*0
8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
9. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth once
a day Disp #*6 Capsule Refills:*0
10. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
11. ___ MD to order daily dose PO DAILY16
12. Furosemide 20 mg PO DAILY
13. Gabapentin 100 mg PO BID
14. GlipiZIDE 5 mg PO DAILY
15. Levothyroxine Sodium 100 mcg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. Lisinopril 20 mg PO DAILY
18. Mirtazapine 15 mg PO QHS
19. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*5 Tablet Refills:*0
20. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Abdominal abscess
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: KNEE (2 VIEWS) RIGHT
INDICATION: ___ year old woman with right knee pain// acute trauma acute
trauma
TECHNIQUE: Frontal and cross-table lateral radiographs of right knee
COMPARISON: AP, cross-table lateral, and oblique views the left knee from ___
FINDINGS:
No fracture or dislocation is detected.
Tricompartmental degenerative changes with severe joint space loss of the
medial compartment. There is degenerative spurring involving all 3
compartments of the knee most advanced in the medial compartment. There is
subchondral sclerosis involving the medial femoral condyle and tibial plateau.
There is slight chondrocalcinosis noted in the lateral compartment.
No suspicious lytic or sclerotic lesion is identified.
There is a small amount of fluid within the joint without a large joint
effusion or fat fluid level identified.
No soft tissue calcification or radio-opaque foreign body is detected.
IMPRESSION:
No fractures or dislocation is identified.
Tricompartmental degenerative changes most advanced in the medial compartment.
The medial compartment of the knee demonstrates severe joint space narrowing
with subchondral sclerosis. There is degenerative spurring involving all 3
compartments of the knee, most advanced in the medial compartment.
Radiology Report
EXAMINATION: Pouchogram.
INDICATION: ___ year old woman s/p ___ procedure in ___, now with
wound infection. Note- only has rectal stump- please give gentle contrast
enema to evaluate for fistula tract// Please evaluate for rectal stump
collection or fistula
TECHNIQUE: Pouchogram.
DOSE: Acc air kerma: 0.9 mGy; Accum DAP: 33.7 uGym2; Fluoro time: 01:30
COMPARISON: CT abdomen and pelvis without contrast dated ___.
FINDINGS:
After scout images were obtained, a ___ Foley catheter was inserted into
the
rectum. 60 cc of water soluble contrast was gently hand injected.
Due to limitations with patient positioning secondary to discomfort, only
supine views were obtained. Contrast is seen filling the anus, though does
not reach the level of the rectum. No leak or fistulous tract identified.
IMPRESSION:
Limited examination, due to lack of patient compliance with positioning, with
only supine views obtained. Contrast with seen only to the level of the anus,
therefore rectal stump was not fully evaluated. No definite leak or fistulous
communication identified. MRI could be considered for better evaluation of
the area of interest.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Abnormal labs
Diagnosed with Severe sepsis with septic shock
temperature: 97.8
heartrate: 129.0
resprate: 18.0
o2sat: 94.0
sbp: 148.0
dbp: 67.0
level of pain: un
level of acuity: 2.0 | Ms. ___ is a ___ y/o F with history of ___ procedure in
___ who presented this admission with 300 cc of purulent
drainage from the
base of her midline incision. She was given a fluid bolus
through
her existing PICC line and was sent here. She underwent bedside
I&D of the wound with packing, she notes persistent pain in her
lower abdomen. The incision was packed with iodiform. Wound
cultures were sent. She was started on IV vancomycin and was
admitted to the Acute Care Surgery service for further medical
care.
The wound dressing was changed daily. WBC and fever curves were
watched for signs of infection. Oxacillin resistant Staph
resulted from the wound swab and nasal swab was positive for
MRSA. The patient was started on a course of Bactrim, that was
switched to Cephalexin few days before discharge and she would
need another 11 days of treatment.
Urine Cx grew yeast. the patient has a Foley cath. inserted for
urinary retention and at this point this need to be further
cultured and if persistent than can be treated as appropriate
depending on Cx results.
The remainder of the ___ hospital course is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with acetaminophen
and oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet and early ambulation were encouraged throughout
hospitalization.
GI/GU/FEN: The patient tolerated a regular diet, intake and
output were closely monitored. The patient was noted to have
urinary retention >600 ml. She was straight catheterized twice.
Flomax was started, but the patient still retained urine >600
ml, so a foley catheter was placed. On HD11, the patient was
ordered for a barium enema to assess for any e/o fistula r/o
leak or fistula
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received warfarin, INR was monitored.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet
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:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
EtOH abuse, EtOH hepatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of heavy etOH use but no prior history
of liver disease who presents as an admission from liver clinic.
Patient was followed by her PCP and was referred to hepatology
given abnl LFTs, jaundice, and significant etOH history. Patient
has had a long history of heavy alcohol consumption for approx.
___ years. Over the summer, she had yellowing of her eyes and
increasing abdominal girth. Also reports weight loss of 20 lbs.
Denies confusion, hematemesis, melena, hematochezia, no recent
illness including fevers and chills. Of note, last drink was
approx. 1 week ago when she went to ___ for detox
She was seen in hepatology for initial evaluation on ___. At
that time it was felt that her presentation was consistent with
a combination of alcoholic cirrhosis and alcoholic hepatitis.
There was also some concern for less likely autoimmune liver
disease or other infiltrative process given severe
hepatosplenomegaly and elevated protein-albumin gap. She was
also severely malnourished with sarcopenia.
Labs were concerning for hepatitis with ___ 42; plt 124,
Hgb 8.7, WBC 7.2.
Past Medical History:
H/o ?SBO: strangulated hernia vs strangulated bowel with sepsis
___
Sleeve gastrectomy ___ (BI-M)
CCY ___
Multiple abdominal hernia repairs
CSection x4
GERD
Obesity
Social History:
___
Family History:
No family members with liver disease
Sister has ___ lymphoma, autoimmune disease
Physical Exam:
ADMISSION:
Vitals: T 99.7 BP 119/71 HR ___ RA
General: Alert, oriented, mildly anxious appearing
HEENT: Sclera icteric, MMM, sublingual jaundice noted,
oropharynx clear, neck supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: significant hepatosplenomegaly noted on exam with liver
edge palpated approx. 11 cm from costal margin, mildly TTP;
spleen approx. 7 cm from costal margin, abdominal scars noted;
abdominal distension noted; unable to appreciate ascites.
Ext: Warm, well perfused, 2+ ___ edema, no palmar erythema,
+spider angiomas
Neuro: A&Ox3. + asterixis
DISCHARGE:
Vitals: 98.1 99/64 89 18 94% RA
General: Alert, oriented, NAD
HEENT: Sclera icteric, MMM, (+) sublingual jaundice, oropharynx
clear, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abd: (+) significant hepatosplenomegaly with mild TTP, abdominal
distension noted; unable to appreciate ascites.
Ext: Warm, well perfused, 2+ ___ edema, no palmar erythema,
+spider angiomas
Neuro: A&Ox3, no asterixis
Pertinent Results:
ADMISSION/PERTINENT:
___ 04:13PM WBC-7.2 RBC-2.50* HGB-8.7* HCT-26.3* MCV-105*
MCH-34.8* MCHC-33.1 RDW-17.3* RDWSD-66.2*
___ 04:13PM ___
___ 04:13PM UREA N-3* CREAT-0.5 SODIUM-134 POTASSIUM-3.1*
CHLORIDE-99 TOTAL CO2-26 ANION GAP-12
___ 04:13PM ALT(SGPT)-26 AST(SGOT)-115* ALK PHOS-93 TOT
BILI-5.2* DIR BILI-2.2* INDIR BIL-3.0
___ 04:13PM TOT PROT-7.9 ALBUMIN-2.7* GLOBULIN-5.2*
___ 04:13PM HBsAg-Negative HBs Ab-Negative HBc
Ab-Negative
___ 04:13PM AMA-NEGATIVE Smooth-NEGATIVE
___ 04:13PM ___
___ 04:13PM AFP-5.3
___ 04:13PM IgG-2900* IgA-973* IgM-826*
___ 04:13PM HIV Ab-Negative
___ 04:13PM tTG-IgA-6
___ 04:13PM HCV Ab-Negative
DISCHARGE:
___ 05:03AM BLOOD WBC-7.5 RBC-2.25* Hgb-7.7* Hct-24.4*
MCV-108* MCH-34.2* MCHC-31.6* RDW-17.7* RDWSD-69.8* Plt ___
___ 05:03AM BLOOD ___ PTT-43.6* ___
___ 05:03AM BLOOD Glucose-76 UreaN-6 Creat-0.4 Na-140 K-3.7
Cl-105 HCO3-25 AnGap-14
___ 05:03AM BLOOD ALT-29 AST-115* AlkPhos-88 TotBili-3.7*
IMAGING:
-CXR (___):
IMPRESSION:
There are no prior chest radiographs available for review. Aside
from linear atelectasis or scarring at one of the lung bases, as
seen on
the lateral view, lungs are clear. Nipple shadow should not be
mistaken for lung nodules. Heart size top-normal. No pleural
abnormality or evidence of central lymph node enlargement.
-RUQ U/S (___):
IMPRESSION:
1. Cirrhotic appearing liver without ascites.
2. Patent portal vein.
3. Massive splenomegaly, increased in size from ___.
MICRO:
___ 5:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:47 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:30 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Vitamin D ___ UNIT PO 1X/WEEK (___)
4. Cetirizine 10 mg PO DAILY
5. Cephalexin Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Potassium Chloride 20 mEq PO DAILY
Hold for K >4
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*6
2. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*42 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:*6
4. Cetirizine 10 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D ___ UNIT PO 1X/WEEK (___)
8.Outpatient Lab Work
Please check CBC with diff, Na, K, Cl, HCO3, BUN, Cr, AST, ALT,
Alk Phos, T Bili
Dx: Alcoholic cirrhosis ICD-10: K70.31
Please fax results to Dr. ___ at ___
9.Ensure
Please provide patient with 120 Ensures/month with goal of
having 4 Ensures/day
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Alcoholic hepatitis
-Alcoholic cirrhosis
-Malnutrition
SECONDARY
-Alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with alcoholic hepatitis, possible cirrhosis,
rule out PNA, pulmonary edema as etiology of decompensation // evidence of
PNA, pulmonary edema as etiology of decompensation evidence of PNA,
pulmonary edema as etiology of decompensation
IMPRESSION:
There are no prior chest radiographs available for review.
Aside from linear atelectasis or scarring at one of the lung bases, as seen on
the lateral view, lungs are clear. Nipple shadow should not be mistaken for
lung nodules.
Heart size top-normal. No pleural abnormality or evidence of central lymph
node enlargement.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with etOH abuse, suspected cirrhosis, admitted
for alc hepatitis // evidence of PVT, cirrhosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT of the abdomen pelvis from ___.
FINDINGS:
LIVER: The liver is heterogeneous in echotexture. The contour of the liver is
nodular, consistent with cirrhosis. There is no focal liver mass. The main
portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
GALLBLADDER: Not visualized.
SPLEEN: Normal echogenicity, measuring 20.8 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic appearing liver without ascites.
2. Patent portal vein.
3. Massive splenomegaly, increased in size from ___.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: UNKNOWN-CC
Diagnosed with Encounter for examination and observation for unsp reason
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ F PMHx alcohol abuse, s/p sleeve gastrectomy presenting
with alcoholic hepatitis/cirrhosis and malnutrition.
#EtOH hepatitis/cirrhosis: Ms. ___ has a long history of EtOH
abuse. Review of OMR was notable for hepatomegaly on CT A/P from
___, concerning for long-standing liver disease. She had been
evaluated by Hepatology as an outpatient, and due to concern for
EtOH hepatitis and malnutrition she was referred to ___ for
admission. On admission she had a discriminant function of 42
and her total bilirubin peaked at 6.3. Infectious work-up,
including CXR, urine culture, and blood cultures, was negative.
RUQ U/S showed nodular liver with splenomegaly, negative for
ascites. Her hepatitis serologies were negative. She was started
on prednisone 40mg and her lab work was reassuring for a
downtrend in her bilirubin; she was discharged on a course of x2
weeks of prednisone 30mg daily. She will need a screening EGD as
an outpatient which will be coordinated by her outpatient
Hepatologist's office.
#Malnutrition: patient reported poor po intake and poor
appetite, and her exam was concerning for temporal wasting. She
was evaluated by Nutrition, who recommended supplemental Ensure
QID. She was counseled extensively on keeping up with her
calorie intake and received a prescription for Ensures.
#EtOH abuse: Patient with longstanding EtOH history, with daily
drinking for years. She had recently been admitted to ___. ___
for detox, and was sober for approximately x1 week prior to
admission. She was monitored on CIWA with no signs of
withdrawal. She should continue on MVI, thiamine, folate. She
was seen by ___ and provided with resources regarding relapse
prevention and was encouraged to reach out to the recommended
services.
#Anemia: patient was noted to have a macrocytic anemia on
admission without evidence of active bleed. Etiology thought to
be most likely due to a combination of nutritional deficiency vs
ACD in setting of hepatitis vs marrow suppression with liver
disease. Lab work notable for low folate. She was started on
folate supplementation. She will get screening EGD for varices. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prozac
Attending: ___
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
Large Volume Paracentesis
History of Present Illness:
Ms. ___ is a ___ woman with a history of NASH/EtOH
cirrhosis who was referred in for worsening abdominal distention
and lab anormalities.
Patient is follwed by PCP ___ in ___ and
Hepatologist Dr. ___ with ___. She has
a history of cirrhosis (never biopsied, thought to be due to
NASH/EtOH, + HE, - EBV, - SBP) which has worsened rapidly over
past few months.
She reports she was hospitalized with confusion and poor PO
intake (per ED call in, hospitalized with HE, worsening edema,
ascites) in ___ at ___ x 2 weeks. She
reports taking an extended prednisone taper after her admission,
which she finished about 2 weeks ago, though she is unclear on
exact timeline. She says the prednisone was for her liver. She
reports drinking heavily before her hospitalization, saying "it
used to be just ___ glasses of wine per night but for those few
weeks it was more than that, more than 3, I wasn't taking in
anything else." It is difficult to elicit more specific
information on alcohol intake. She says many time that she has
always been "only a social drinker." When asked about most
recent drink, patient does not mention ___ episode and
says, ___, but I'm telling people ___
She has seen Dr. ___ in outpatient setting. She reports having
an extensive laboratory work-up and is awaiting results. She has
discussed that she might need liver transplant and was told she
needs 6 months of sobriety for eligibility.
Patient reports that her confusion has improved since her
hospitalization. She is taking lactulose and rifaximin and has
several loose stools per day. She still feels confused when
discussing health information and reports trouble keeping track
of details.
She has had abdominal pain for the past ___ months that is
currently at baseline; her peritoneal fluid has been tested many
times and she has never had SBP. She has had worsening abdominal
distention. Over the past few months, she has required q2 week
8L paracenteses; most recent para was 1 week ago ___ (only 4L)
but she reported full reaccumulation by the next day.
She denies recent fevers, chills, nausea, vomiting, congestion,
cough, sore throat. She has ___ loose, liquid stools per day,
which has been her baseline since she started taking lactulose.
No dysuria, frequency, urgency, hematuria, blood in stool, black
stools. No hematemesis. No recent travel, unusual foods, or sick
contacts. She is a ___ but had to take a leave
of absence earlier this year due to her illness.
In the ED initial vitals were: 2 97.8 113 108/67 20 100%. Labs
were significant for AP 303, Tbili 2.3, albumin 2.1, AST 109,
ALT 36. Serum tox (including EtOH) was negative. WBC 17.9 (83%
PMN), plt 270, INR 1.7, Na 127. CXR showed atalectasis at R base
but no evidence of pneumonia. A diagnostic paracentesis was
negative for SBP. Vitals prior to transfer were: 98.8 ___
100% RA
On the floor, patient provides above history.
Past Medical History:
- HTN
- Cirrhosis (thought to be due to NASH/EtOH)
- Anxiety
Social History:
___
Family History:
- Father has alcoholism (currently sober x ___ years) and liver
disease
- Mother had valvular heart disease
- No family history of cancer or MI
Physical Exam:
Admission physical exam:
Vitals 98.1 93/54 93 20 100 RA
GENERAL: Lying in bed, NAD
HEENT: Ruddy face, AT/NC, EOMI, PERRL, anicteric sclera, pink
conjunctiva, patent nares, MMM, nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: LCTAB, no w/r/r
ABDOMEN: Distended, lagre ascites, + fluid wave, significant
tenderness to palpation diffusely without r/g, NABS, cannot
assess for HSM due to ascites
EXTREMITIES: Moving all extremities, trace-1+ edema to knee
bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, mild tremor vs. asterixis, A+O x 3 but
tangential, unclear on on many details of history
SKIN: Warm and well perfused, petecchiae on bilateral arms,
anterior chest, no palmar erythema
DISCHARGE EXAM:
VS: 98.3, 101/68, 107, 18, 97%RA
GENERAL: Lying in bed, NAD
HEENT: Ruddy face, sclera anicteric, clear conjuctiva.
NECK: supple, no LAD or JVD
CARDIAC: regular rhythm, no murmurs
LUNG: clear bilaterally, no wheezes of crackles
ABDOMEN: Distended, tight ascites, RUQ mildly TTP.
EXTREMITIES: Moving all extremities, trace-1+ edema to distal
shins bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, mild asterixis, A+O x 3
SKIN: Warm and well perfused, spiders on chest
Pertinent Results:
Admission labs:
___ 12:10PM WBC-17.9* RBC-4.00* HGB-11.6* HCT-36.6 MCV-92
MCH-29.0 MCHC-31.7 RDW-14.7
___ 12:10PM NEUTS-83* BANDS-0 LYMPHS-12* MONOS-4 EOS-1
BASOS-0 ___ MYELOS-0
___ 12:10PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 12:10PM PLT SMR-NORMAL PLT COUNT-270
___ 12:10PM ___ PTT-38.2* ___
___ 12:10PM GLUCOSE-91 UREA N-9 CREAT-0.7 SODIUM-127*
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-20* ANION GAP-10
___ 12:10PM ALT(SGPT)-36 AST(SGOT)-109* ALK PHOS-303* TOT
BILI-2.3*
___ 12:10PM LIPASE-20
___ 12:10PM ALBUMIN-2.1*
___ 12:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 05:20PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 05:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 05:20PM URINE UCG-NEGATIVE
Discharge labs:
___ 07:00AM BLOOD WBC-17.2* RBC-4.02* Hgb-11.6* Hct-35.5*
MCV-88 MCH-28.9 MCHC-32.7 RDW-14.8 Plt ___
___ 07:00AM BLOOD ___
___ 07:00AM BLOOD UreaN-8 Creat-0.7 Na-130* K-4.0 Cl-101
HCO3-18* AnGap-15
___ 07:00AM BLOOD ALT-34 AST-107* AlkPhos-287* TotBili-2.5*
___ 07:00AM BLOOD Calcium-8.6 Phos-5.2* Mg-1.9
Micro:
Blood cx negative
Urine cx with 10,000-100,000 E coli
Imaging:
___ CXR
FINDINGS: The lungs are normally expanded. There are linear
areas of opacity in the right base likely reflecting
atelectasis. No focal airspace opacity is detected to suggest
pneumonia. The heart is not enlarged. The mediastinal and
hilar contours are normal. There is no pleural effusion or
pneumothorax.
IMPRESSION: Atelectasis at the right base but no evidence of
pneumonia.
___ RUQ U/S
1. Coarsened echotexture and nodular contour of the liver in
keeping with
cirrhosis. No focal hepatic mass identified.
2. Mild splenomegaly and moderate ascites.
3. No detectable color Doppler flow in the main portal vein and
right portal vein, which may relate to extremely slow flow,
although thrombosis cannot be excluded. Color Doppler flow is
identified in the left portal vein, however. Further evaluation
with CT scan of the abdomen could be obtained, but initially,
suggest repeat Doppler ultrasound with a radiology attending
scanning the patient (this can be performed at no additional
charge to the patient).
4. Normal directional flow and velocities of the main, right and
left hepatic arteries. Normal directional flow of right, main
and left hepatic veins.
5. Circumferential gallbladder wall thickening likely related to
third spacing from underlying liver disease.
___ CT A/P
1. Main portal vein and its branches are patent.
2. Cirrhosis with sequelae of portal hypertension including mild
splenomegaly, recanalized paraumbilical vein, esophageal
varices, and large intra-abdominal ascites.
3. Area of hypoenhancement within the pancreatic body. This may
be a
complication of prior pancreatitis, but neoplasm cannot be
excluded. Follow up with MRCP or short interval CT is
recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO DAILY
2. Klor-Con (potassium chloride) 40 mEq oral daily
3. FoLIC Acid 2 mg PO DAILY
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Magnesium Oxide 400 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs PRN sob
9. ZyrTEC (cetirizine) 10 mg oral daily as needed for allergy
10. flunisolide 25 mcg (0.025 %) nasal 1 whiff for allergies
11. Levothyroxine Sodium 25 mcg PO DAILY
12. Furosemide 20 mg PO DAILY
13. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 2 mg PO DAILY
2. Lactulose 30 mL PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Rifaximin 550 mg PO BID
5. flunisolide 25 mcg (0.025 %) nasal 1 whiff for allergies
6. Furosemide 20 mg PO DAILY
7. Klor-Con (potassium chloride) 40 mEq oral daily
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Magnesium Oxide 400 mg PO DAILY
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs PRN sob
11. Spironolactone 50 mg PO DAILY
12. ZyrTEC (cetirizine) 10 mg oral daily as needed for allergy
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis, likely related to alcohol use.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Leukocytosis. Evaluate for infection.
COMPARISON: None.
TECHNIQUE: Upright PA and lateral radiographs of the chest.
FINDINGS: The lungs are normally expanded. There are linear areas of opacity
in the right base likely reflecting atelectasis. No focal airspace opacity is
detected to suggest pneumonia. The heart is not enlarged. The mediastinal
and hilar contours are normal. There is no pleural effusion or pneumothorax.
IMPRESSION: Atelectasis at the right base but no evidence of pneumonia.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old woman with cirrhosis, abdominal pain. Please do
Doppler study to assess hepatic vasculature/rule out PVT.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver demonstrates a coarsened echotexture and nodular contour in
keeping with cirrhosis. There is no focal liver mass. Moderate amount of
ascites is noted.
VASCULATURE: The right, main and left hepatic vein demonstrate normal
directional flow and waveforms. IVC demonstrates normal directional flow.
No significant color Doppler flow is identified in the main portal vein and
right portal vein. Normal directional color Doppler flow is noted in the left
portal vein demonstrating velocities up to 10 cm/sec.
The main hepatic artery, right hepatic artery and left hepatic artery
demonstrate low resistance waveforms and normal directional flow. The peak
systolic velocity of the main hepatic artery, right hepatic artery and left
hepatic artery are 203, 127, and 110 cm/sec. The resistive indices of the main
hepatic artery, right hepatic artery and left hepatic artery are 0.61, 0.64
and 0.65 respectively.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: Gallbladder wall appears thickened, likely related to third
spacing from underlying liver disease. Minimal dependent sludge is seen within
the gallbladder.
PANCREAS: Pancreas is poorly visualized, with only pancreatic head identified
which demonstrates no focal masses or pancreatic ductal dilatation.
SPLEEN: Spleen is mildly enlarged measuring 14 cm.
IMPRESSION:
1. Coarsened echotexture and nodular contour of the liver in keeping with
cirrhosis. No focal hepatic mass identified.
2. Mild splenomegaly and moderate ascites.
3. No detectable color Doppler flow in the main portal vein and right portal
vein, which may relate to extremely slow flow, although thrombosis cannot be
excluded. Color Doppler flow is identified in the left portal vein, however.
Further evaluation with CT scan of the abdomen could be obtained, but
initially, suggest repeat Doppler ultrasound with a radiology attending
scanning the patient (this can be performed at no additional charge to the
patient).
4. Normal directional flow and velocities of the main, right and left hepatic
arteries. Normal directional flow of right, main and left hepatic veins.
5. Circumferential gallbladder wall thickening likely related to third spacing
from underlying liver disease.
NOTIFICATION: This consultation was reviewed with Dr ___ telephone at
09:30 on ___.
Radiology Report
INDICATION: Alcoholic cirrhosis with concern for portal vein thrombus on
ultrasound.
COMPARISON: Ultrasound ___.
TECHNIQUE: MDCT axial images from the lung bases to the iliac crest were
obtained before and after the uneventful administration of contrast in the
arterial, portal venous and three-minute delayed phases. Multiplanar
reformation images were provided for review.
DLP: 1244 mGy-cm.
CT ABDOMEN WITH AND WITHOUT CONTRAST: The visualized lung bases demonstrate
subsegmental linear atelectasis. There is no pleural or pericardial effusion.
The liver is nodular with heterogeneous enhancement, compatible with provided
history of cirrhosis. No suspicious liver lesion is identified. The
gallbladder is decompressed. Gallbladder wall edema is nonspecific in the
setting of ascites. The spleen is mildly enlarged measuring 13 cm. The
pancreas is somewhat atrophic. An area of hypoenhancement within the
pancreatic body (4:44), which persists on delayed images (8:45, 13:27) is
nonspecific and although it does not appear mass-like, a neoplasm cannot be
excluded. The bilateral adrenal glands are normal. The kidneys enhance
symmetrically and excrete contrast promptly without hydronephrosis.
The imaged portions of the small and large bowel are not obstructed. There is
large intra-abdominal ascites. No free air. The main portal vein, left portal
vein and the right anterior and right posterior portal veins are patent. The
paraumbilical vein is recanalized. Hepatic veins are patent. The splenic vein
and SMV are patent. Small esophageal varices are noted. There is a replaced
right hepatic artery, originating directly from the aorta. The abdominal aorta
is of normal caliber. Small porta hepatic lymph nodes may be related to
chronic liver disease. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are identified.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
IMPRESSION:
1. Main portal vein and its branches are patent.
2. Cirrhosis with sequelae of portal hypertension including mild
splenomegaly, recanalized paraumbilical vein, esophageal varices, and large
intra-abdominal ascites.
3. Area of hypoenhancement within the pancreatic body. This may be a
complication of prior pancreatitis, but neoplasm cannot be excluded. Follow up
with MRCP or short interval CT is recommended.
Findings and recommendations discussed with Dr. ___ by phone at 5:03pm
___.
Radiology Report
EXAMINATION: Abdominal MRI. MRCP.
INDICATION: ___ year old woman with cirrhosis and ascites, finding of
pancreatic hypodensity on CT // assess area of concern on abdominal CT
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 14 cc of Gadavist intravenous
contrast.
COMPARISON: CT and ultrasound available from ___.
FINDINGS:
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Lung bases are clear. There is no pericardial or pleural effusion. The heart
size is normal.
There is moderate perihepatic and perisplenic ascites (series 3, image 27).
The liver contour is nodular, compatible with cirrhosis. Reticular contrast
enhancement, particularly throughout the posterior aspect of the right hepatic
lobe on delayed sequences, denotes confluent fibrosis (series 15, image 25).
There is heterogeneous signal drop-off of the hepatic parenchyma on T1
weighted out of phase images in comparison to in phase sequences, denoting
steatosis (series 6, image 12). No focal hepatic mass is detected. There is
conventional hepatic arterial anatomy. The portal and hepatic veins are
patent.
The spleen is mildly enlarged (series 2, image 13), measuring 13 cm.
Perisplenic varices and a recannalized paraumbilical vein denotes chronic
portal hypertension (series 13, image 50). The adrenal glands, kidneys,
stomach, and intra-abdominal loops of small and large bowel are normal. There
is no mesenteric or retroperitoneal lymphadenopathy.
The pancreas demonstrates normal signal intensity on T1 and T2 weighted
sequences. The main pancreatic duct is normal. An ill-defined area of
hypoenhancement within the pancreatic tail seen on the ___ CT
examination is again demonstrated on MRI on both early and delayed
post-contrast dynamic series (series 12, image 51); however, no correlate is
seen on T1 weighted precontrast images were T2 and diffusion weighted
sequences. There is no atrophy.
The abdominal aorta, celiac trunk, SMA, and renal arteries are patent and
normal in caliber. A left accessory renal artery is present (series 12, image
46 52).
There are no bony lesions concerning for malignancy or infection.
IMPRESSION:
1. Ill-defined area of hypoenhancement within the pancreatic body has no DWI,
T1 precontrast, or T2 correlates, and may reflect the sequela of prior
pancreatits. No discrete mass. Normal-caliber pancreatic duct. This can be
followed for stability on future hepatic screening imaging.
2. Cirrhotic liver with confluent fibrosis. Splenomegaly, perisplenic
varices, recannalized paraumbilical vein, and moderate ascites reflecting
chronic portal hypertension. No suspicious lesion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN GENERALIZED, LEUKOCYTOSIS, UNSPECIFIED , CIRRHOSIS OF LIVER NOS
temperature: 97.8
heartrate: 113.0
resprate: 20.0
o2sat: 100.0
sbp: 108.0
dbp: 67.0
level of pain: 2
level of acuity: 3.0 | Ms. ___ is a ___ woman with a history of NASH/EtOH
cirrhosis who was referred to the ___ ED for worsening liver
function. Patient complains of subacute fatigue and poor
appetite.
ACUTE
# Decompensated Cirrhosis ___ ETOH abuse: MELD 16 (unknown
baseline). Currently decompensated with progressive ascites, ?
mild encephalopathy. Last hospitalization ___ for alcoholic
hepatitis s/p steroid tx, but currently transaminases low, bili
much improved and tox screen negative for EtOH. Concern for PV
thrombosis on RUQ u/s, but no e/o clot on CT A/P. Continued
lactulose and rifaximin. Performed large volume paracentesis
and restarted home diuretics on discharge. Will f/u with liver
clinic as outpatient for further management and transplant
evaluation.
# Leukocytosis: No clear localizing symptoms of infection.
Stable. Patient reports stool studies recently WNL at OSH. Could
be secondary to recent steroid use (though unknown when she
stopped), downtrended from high 30's last hospitalization.
# Alcohol Abuse: By history, it sounds like patient was drinking
as recently as ___ unclear last drink.
# ? Hx of hypertension: BPs in the ___ here. Likely secondary
to decompensated liver disease; however, patient's report that
she actually has HTN (and takes diltiazem) does raise concern
that hypotension is new and possibly due to another etiology
such as infection/sepsis. As above, there are no clear
localizing symptoms and patient is well-appearing, so will hold
off on empiric antibiotics. Further infectious w/u was
negative. Diltiazem was discontinued on discharge.
TRANSITIONAL
- liver f/u
- titration of diuretics
# Emergency Contact: Husband ___ ___
# ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ibuprofen / cefuroxime / ioversol
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ history of HFrEF (EF 20%), cardiac arrest
___ now with LifeVest, PAD s/p L AKA and R BKA, AF, HTN,
pancreatic ca s/p resection, without other records in ___
system, brought in with several day history of worsening
confusion, somnolence, and productive cough, initially admitted
to ___ transferred for further management.
___ records currently unavailable, following history
obtained from patient with ___ interpreter and collateral
from son. Per son, patient was in her usual state of health 3
days prior. For the last 3 days, he has noted she has had
worsening confusion, somnolence, and sleeping more at home. She
has also been having a productive cough with sputum with very
poor PO intake. Also with chills. Patient was also complaining
of
dysuria prior to presenting to ___. Of records currently
available, patient presented to her PCP ___
for current symptoms and was subsequently admitted to ___.
At ___, noted to be hyponatremic to 122, lactate 1.0, was
started on IV zosyn and vancomycin for UTI was >50WBCs in urine.
___ records unavailable however for my review. Per PCP
note,
was recently hospitalized at ___ however details
of
which are not documented, per son patient was hospitalized for
UTI 2 weeks prior.
In the ED here, initial VS were: T 97.5 HR 56, BP 126/71 RR 16,
O2 96%2L
Exam notable for:
Gen: Ill-appearing woman mildly uncomfortable
Pulm: Rhonchorous breath sounds heard throughout right greater
than left
CV: RRR
HEENT: Dry mucous membranes
Abdomen: Large epigastric ventral hernia, moderately distended
mild tenderness to palpation no rebound tenderness
Extremities: Right lower extremity with BKA left lower extremity
with AKA no obvious skin breakdown
Neuro: Patient awake and responsive however exam limited by
language barrier
Labs notable for:
- WBC 12.5, Hb 9.6, HCT 30.2, PLT 273
- Na 122, Cl 89, bicarb 15, BUN 66, Cr 2.2, glucose 211
- Ca 7.2, phos 6.2
- ALT 329, AST 208, ALP 183, T. bili 0.6, albumin 2.7, lipase
130
- ___ 14.5, PTT 25.9, INR 1.3
- UA large leukocytes, small blood, neg nitrites, 72 WBC,
moderate bactereia
- Lactate 1.0
- Troponin 0.02
Imaging:
CT Chest WO Contrast ___:
1. Mild-to-moderate centrilobular emphysema with mild
superimposed pulmonary edema.
2. Patchy opacities in the left lower lobe may represent
aspiration pneumonia in the setting of left main stem bronchus
secretions. No evidence of bronchial occlusion.
3. Multiple prominent and borderline enlarged supraclavicular
and
mediastinal lymph nodes are nonspecific, but may be reactive.
4. Nodules measuring up to 5 cm in the left lung, one of which
may be infectious or inflammatory, can be followed with optional
CT in 12 months if the patient is high risk.
CT A/P WO Contrast ___:
1. No clear acute findings to explain the patient's reported
symptoms within the abdomen or pelvis.
2. Two large ventral bowel containing hernias. The more central
hernia contains mildly distended loops of bowel without evidence
of obstruction. The more lateral hernia on the right abdomen
contains decompressed loops of bowel which enter and exit the
hernia and a small amount of nonspecific free fluid
which could be related to ascites, although ischemia cannot be
excluded. No definite transition point identified. If there is
clinical concern for obstruction, surgical consultation is
recommended.
3. Cholelithiasis with mildly distended gallbladder. Trace
pericholecystic fluid could be secondary to third spacing of
fluids. If indicated, ultrasound may be obtained for further
evaluation.
4. Small volume ascites.
5. Anasarca.
6. Nonvisualization of the pancreas and right kidney may be due
to technical factors or suggest history of prior surgery.
Clinical correlation recommended.
7. Compression deformity of the L1 vertebra is of indeterminate
chronicity without prior studies for comparison.
CXR ___: No definite acute cardiopulmonary process.
EKG: Sinus, irregular, HR 57, normal PR, QRS widened 159, no
acute ST changes, non-specific TWI II, III
Administered:
___ 23:16 IV Morphine Sulfate 1 mg
Subjective: On arrival to the floor, patient states that she is
currently complaining of a headache. Also has total body pain,
worse in her back. Currently without abdominal pain. Notably
with
significant cough, complaining she has copious sputum
production.
No nausea, vomiting, only with Foley in place, previously had
dysuria. No diarrhea.
Past Medical History:
- HFrEF (EF 20%)
- Cardiac arrest ___ and ___, now with LifeVest
- PAD s/p L AKA and R BKA
- AF
- HTN
- Pancreatic tumor s/p resection (~ ___ years ago per son)
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: ___ 0141 Temp: 98.3 PO BP: 144/81 R HR: 65 RR: 19 O2
sat: 100% O2 delivery: 3L
General: Uncomfortable appearing due to total body pain,
coughing
HEENT: NC/AT, PERRLA, EOMI
Lungs: Diffuse rhonchorous breath sounds throughout, no wheezes
or rales appreciated
CV: Rhythm, no murmurs, rubs, or gallops
Abdomen: 2 large ventral hernia both nontender to palpation, no
overlying erythema, reducible
Back: Superficial sacral decubitus ulcers with no visible
muscle/bone, no purulence
GU: Bilateral inguinal erythema difficult to visualize, already
with overlying lotion
Ext: S/p L AKA and R BKA
Neuro: CN II-XII intact. No focal neurological deficits. Moving
all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM
=========================
24 HR Data (last updated ___ @ 1116)
Temp: 97.3 (Tm 97.8), BP: 127/67 (96-127/59-80), HR: 60 (59-62),
RR: 20 (___), O2 sat: 100%, O2 delivery: 2L
Fluid Balance (last updated ___ @ 836)
Last 8 hours Total cumulative -70ml
IN: Total 580ml, PO Amt 580ml
OUT: Total 650ml, Urine Amt 650ml
Last 24 hours Total cumulative -575ml
IN: Total 1750ml, PO Amt 1750ml
OUT: Total 2325ml, Urine Amt 2325ml
GEN: Laying in bed, in NAD
HEENT: MMM, poor dentition
CV: RRR, ___ systolic murmur LLSB, no r/g, JVP is difficult to
appreciate but does not appear to be elevated on examation
PULM: Diffuse course breath sounds anteriorly, less rhoncherous
ABD: Large epigastric ventral hernieas, reducible, tender to
palpation, no guarding or rebound. 8 cm linear area of ___
crusted papules on an erythematous base, tender to palpation on
right side, ~T8
EXT: RLE BKA, LLE AKA, trace pitting edema right thigh
MSK: Superficial sacral decubitus ulcers not visualized today
GU: foley in place
Pertinent Results:
ADMISSION LABS:
=============
___ 09:51PM BLOOD WBC-12.5* RBC-3.50* Hgb-9.6* Hct-30.2*
MCV-86 MCH-27.4 MCHC-31.8* RDW-20.5* RDWSD-64.4* Plt ___
___ 09:51PM BLOOD Neuts-91.4* Lymphs-1.8* Monos-5.8
Eos-0.3* Baso-0.1 NRBC-0.4* Im ___ AbsNeut-11.44*
AbsLymp-0.23* AbsMono-0.73 AbsEos-0.04 AbsBaso-0.01
___ 09:13PM BLOOD ___ PTT-25.9 ___
___ 09:13PM BLOOD Glucose-211* UreaN-66* Creat-2.2* Na-122*
K-4.6 Cl-89* HCO3-15* AnGap-18
___ 09:13PM BLOOD ALT-329* AST-208* CK(CPK)-257*
AlkPhos-183* TotBili-0.6
___ 09:13PM BLOOD Lipase-130*
___ 09:13PM BLOOD cTropnT-0.02*
___ 09:13PM BLOOD CK-MB-3 ___
___ 09:13PM BLOOD Albumin-2.7* Calcium-7.2* Phos-6.2*
Mg-1.7
___ 09:18PM BLOOD Lactate-1.0
OTHER PERTINENT LABS:
==================
___ 06:19AM BLOOD calTIBC-307 ___ Folate->20
Ferritn-198* TRF-236
___ 03:45AM BLOOD Ret Aut-4.9* Abs Ret-0.16*
___ 09:13PM BLOOD CK-MB-3 ___
___ 09:13PM BLOOD cTropnT-0.02*
___ 05:26AM BLOOD CK-MB-3 cTropnT-0.03*
DISCHARGE LABS:
==============
___ 08:28AM BLOOD WBC-7.9 RBC-2.95* Hgb-8.4* Hct-27.0*
MCV-92 MCH-28.5 MCHC-31.1* RDW-22.7* RDWSD-75.7* Plt ___
___ 08:28AM BLOOD Plt ___
___ 08:28AM BLOOD Glucose-111* UreaN-101* Creat-2.2*
Na-128* K-4.1 Cl-84* HCO3-27 AnGap-17
___ 08:28AM BLOOD ALT-72* AST-68* AlkPhos-214* TotBili-0.3
___ 08:28AM BLOOD Albumin-2.9* Calcium-8.1* Phos-6.0*
Mg-3.1*
IMAGING/STUDIES:
==============
CT Chest WO Contrast ___:
1. Mild-to-moderate centrilobular emphysema with mild
superimposed pulmonary edema.
2. Patchy opacities in the left lower lobe may represent
aspiration pneumonia in the setting of left main stem bronchus
secretions. No evidence of bronchial occlusion.
3. Multiple prominent and borderline enlarged supraclavicular
and mediastinal lymph nodes are nonspecific, but may be
reactive.
4. Nodules measuring up to 5 cm in the left lung, one of which
may be infectious or inflammatory, can be followed with optional
CT in 12 months if the patient is high risk.
CT A/P WO Contrast ___:
1. No clear acute findings to explain the patient's reported
symptoms within the abdomen or pelvis.
2. Two large ventral bowel containing hernias. The more central
hernia contains mildly distended loops of bowel without evidence
of obstruction. The more lateral hernia on the right abdomen
contains decompressed loops of bowel which enter and exit the
hernia and a small amount of nonspecific free fluid which could
be related to ascites, although ischemia cannot be excluded. No
definite transition point identified. If there is clinical
concern for obstruction, surgical consultation is recommended.
3. Cholelithiasis with mildly distended gallbladder. Trace
pericholecystic fluid could be secondary to third spacing of
fluids. If indicated, ultrasound may be obtained for further
evaluation.
4. Small volume ascites.
5. Anasarca.
6. Nonvisualization of the pancreas and right kidney may be due
to technical factors or suggest history of prior surgery.
Clinical correlation recommended.
7. Compression deformity of the L1 vertebra is of indeterminate
chronicity without prior studies for comparison.
CXR ___: No definite acute cardiopulmonary process.
TTE ___
The left atrial volume index is moderately increased. The
estimated right atrial pressure is >15mmHg. There is normal left
ventricular wall thickness with a normal cavity size. There is a
large anteroapical aneurysm. No thrombus or mass is seen in the
left ventricle (on contrast-enhanced imaging) but cannot be
excluded with certainty due to the technically suboptimal
images. Overall left ventricular systolic function is severely
depressed secondary to extensive apical akinesis with focal
apical dyskinesis. The visually estimated left ventricular
ejection fraction is 20%. There is no resting left ventricular
outflow tract gradient. Normal right ventricular cavity size
with focal hypokinesis of the apical free wall. 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 (?#) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is moderate mitral annular calcification. The
transmitral E-wave deceleration time is short (<140ms). There is
mild to moderate [___] mitral regurgitation. There is
significant pulmonic regurgitation. The tricuspid valve leaflets
appear structurally normal. There is moderate [2+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
RUQUS ___
IMPRESSION: No biliary dilatation is identified. No
sonographic signs of cholecystitis are identified. A small
amount of sludge and stones identified, however the gallbladder
is not distended and there is no gallbladder wall thickening.
RECOMMENDATION(S): If cholecystitis remains a consideration,
liver MRI is more sensitive in the detection of acute on
chronic cholecystitis
RUQUS ___
IMPRESSION:
Cholelithiasis without evidence of cholecystitis. No biliary
duct dilatation is identified. There is trace ascites.
Medications on Admission:
1. Multivitamins 1 TAB PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. FoLIC Acid 1 mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 100 mg PO DAILY
7. HydrALAZINE 10 mg PO Q8H
8. Gabapentin 100 mg PO BID
9. Furosemide 40 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Carvedilol 6.25 mg PO BID
12. Amiodarone 200 mg PO DAILY
13. Atorvastatin 40 mg PO QPM
14. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN
BREAKTHROUGH PAIN
15. Aspirin 81 mg PO DAILY
16. Levothyroxine Sodium 50 mcg PO DAILY
17. ClonazePAM 0.5 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth Q8H PRN Disp #*60 Tablet Refills:*0
2. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Bisacodyl ___AILY:PRN Constipation - Second Line
If no bowel movement on oral medications, can use this
medication rectally
RX *bisacodyl 10 mg 1 suppository(s) rectally daily PRN Disp
#*30 Suppository Refills:*0
4. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
6. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour Apply to skin Every 72 hours Disp #*10
Patch Refills:*0
7. GuaiFENesin ___ mL PO Q6H:PRN Cough
RX *guaifenesin 100 mg/5 mL 5 mL by mouth Q6H prn Refills:*0
8. Isosorbide Dinitrate 10 mg PO TID
RX *isosorbide dinitrate 10 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*90 Tablet Refills:*0
9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN right leg pain
10. Miconazole 2% Cream 1 Appl TP BID
RX *miconazole nitrate 2 % Apply to red itchy areas of skin
daily PRN Refills:*0
11. Sarna Lotion 1 Appl TP TID:PRN Itchiness
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to itchy
skin daily PRN Refills:*0
12. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Torsemide 100 mg PO BID
RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
14. ValACYclovir 1000 mg PO DAILY Duration: 7 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth Daily Disp #*4
Tablet Refills:*0
15. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
16. Gabapentin 200 mg PO BID
RX *gabapentin 100 mg 2 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
17. HydrALAZINE 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
18. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus U-100 Insulin] 100 unit/mL 30 units
30 Units before BED; Disp #*1 Vial Refills:*0
19. Amiodarone 200 mg PO DAILY
20. Aspirin 81 mg PO DAILY
21. Atorvastatin 40 mg PO QPM
22. Carvedilol 6.25 mg PO BID
23. ClonazePAM 0.5 mg PO TID
24. FoLIC Acid 1 mg PO DAILY
25. Levothyroxine Sodium 50 mcg PO DAILY
26. Multivitamins 1 TAB PO DAILY
27. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN
BREAKTHROUGH PAIN
28. Pantoprazole 40 mg PO Q24H
29.___ LIFT
Z89.611, I50.84
___ LIFT
___: Lifetime, Ht: 48in Wt: 137lb
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute on chronic heart failure with reduced ejection fraction
Hypoxemic respiratory failure
Urinary tract infection
Acute on chronic kidney disease
SECONDARY DIAGNOSIS
Herpes zoster (shingles)
Chronic pain on opioids in setting of lower extremity
amputations
Coronary artery disease complicated by recent cardiac arrests
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: ___ with sepsis and rhonchorous breath sounds cough// Pneumonia?
TECHNIQUE: Frontal lateral views the chest.
COMPARISON: Chest x-ray from ___ performed at an outside
institution.
FINDINGS:
There is moderate enlargement of cardiac silhouette. Right chest wall port is
seen with tip in the right atrium. Electronic device with numerous component
seen overlying/obscuring the chest and cardiac silhouette as seen on prior.
Streaky right mid opacity is likely atelectasis. Opacity projecting over the
right upper lung is felt to be due to external tubing. No large confluent
consolidation or effusion. No overt edema. Orthopedic hardware projecting
over the lower thoracic upper lumbar spine.
IMPRESSION:
No definite acute cardiopulmonary process.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with transaminitis ventral hernia
confusionNO_PO contrast// Evidence of intra-abdominal process
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 2.6 s, 20.1 cm; CTDIvol = 26.7 mGy (Body) DLP = 534.8
mGy-cm.
2) Spiral Acquisition 4.1 s, 32.1 cm; CTDIvol = 23.3 mGy (Body) DLP = 746.6
mGy-cm.
Total DLP (Body) = 1,281 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: Evaluation of the liver is limited due to streak artifact from
overlying metallic device. 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 mildly distended and contains
gallstones. No definite wall thickening or pericholecystic fluid.
PANCREAS: The pancreas is not well seen due to anasarca and streak artifact.
No gross fluid collections within its expected region.
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 right kidney is not visualized. The left kidney is slightly
atrophic. 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. There are large ventral bowel
containing hernias in the midline and right abdomen. The more central hernia
contains mildly distended loops of bowel on entry and exit. The right
abdominal hernia contains decompressed loops of bowel and a small amount of
nonspecific free fluid. No transition point identified. Elsewhere, the colon
and rectum are unremarkable. There is small volume ascites. The appendix is
not visualized.
PELVIS: The urinary bladder is decompressed around a Foley catheter, limiting
evaluation of its wall. The distal left ureter is unremarkable. The distal
right ureter is not seen. There is small volume free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is a fibroid uterus. No adnexal abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted. There is a femorofemoral bypass graft of which the patency
cannot be assessed without contrast.
BONES: The bones are diffusely osteopenic. A compression deformity of the L1
vertebra is of indeterminate chronicity without prior studies for comparison.
There is no evidence of worrisome osseous lesions. Posterior spinal fusion
hardware extends from the T10-L3 level.
SOFT TISSUES: There is diffuse subcutaneous edema suggestive of anasarca.
IMPRESSION:
1. No acute findings to explain the patient's reported symptoms within the
abdomen or pelvis.
2. Two large ventral bowel containing hernias. No evidence of obstruction.
3. Anasarca.
4. Cholelithiasis with mildly distended gallbladder. Trace pericholecystic
fluid is likely secondary to anasarca.
5. Nonvisualization of the pancreas and right kidney may be due to technical
factors and anasarca or suggest history of prior surgery. Clinical
correlation recommended.
6. Compression deformity of the L1 vertebra is of indeterminate chronicity
without prior studies for comparison.
Radiology Report
INDICATION: ___ year old woman with hypoxia// PNA?
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. There are
extensive atherosclerotic calcifications about the aortic arch, proximal arch
vessels, and descending thoracic aorta. There are multiple coronary stents.
The heart is moderately enlarged. No pericardial effusion. Calcific
densities about the left ventricle are suggestive of prior infarct. No
pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy by CT size
criteria. There are innumerable prominent but subcentimeter supraclavicular
and anterior mediastinal lymph nodes measuring up to 0.8 cm. A borderline
enlarged 1.0 cm right lower paratracheal lymph node (4:80). No large
mediastinal mass or hematoma. There are multiple right axillary venous
varices.
PLEURAL SPACES: No significant pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Mild to moderate centrilobular emphysema. Diffuse interlobular
septal thickening and ground-glass opacification is suggestive of pulmonary
edema. A 0.5 cm left lower lobe nodule is nonspecific, possibly infectious or
inflammatory (4:135). There is a 0.5 cm nodule in the lingula (4:122). Few
patchy opacities in the left lower lobe may represent aspiration in the
setting of left main bronchus secretions. The airways are otherwise grossly
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: This mid esophagus is distended with debris.
ABDOMEN: Findings will be reported on the same day CT of the abdomen and
pelvis.
BONES: Posterior spinal fusion hardware projects over the lower thoracic
spine. No suspicious osseous abnormality is seen.? Apparent deformity of the
T9 vertebra is likely a degenerative Schmorl's node. There is no acute
fracture.
IMPRESSION:
1. Mild-to-moderate centrilobular emphysema with mild superimposed pulmonary
edema.
2. Patchy opacities in the left lower lobe may represent aspiration pneumonia
in the setting of left main stem bronchus secretions. No evidence of
bronchial occlusion.
3. Multiple prominent and borderline enlarged supraclavicular and mediastinal
lymph nodes are nonspecific, but may be reactive.
4. Nodules measuring up to 0.5 cm in the left lung, one of which may be
infectious or inflammatory, can be followed with optional CT in 12 months if
the patient is high risk.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with HFrEF (EF 20%), cardiac arrest ___ now
with LifeVest, PAD s/p L AKA and R BKA, AF, HTN, pancreatic ca s/p resection,
with abnormal LFTs, CT A/P GB distention and some pericholecystic fluid// Eval
for cholecystis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdomen CT ___
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: 0.5 cm
GALLBLADDER: At least 1 small stone is again seen in the neck of the
gallbladder. There is no gallbladder wall edema and no pericholecystic fluid
is seen.
PANCREAS: The pancreas is not visualized due to overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 10.9 cm
IMPRESSION:
Cholelithiasis. No sonographic signs of cholecystitis.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with transaminitis, abdominal pain// eval for
cholecystitis, biliary obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites. A small right pleural effusion is
incidentally noted.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 0.2 cm
GALLBLADDER: The gallbladder is not distended. A small amount of sludge and a
gallstone is visualized within the neck of the gallbladder.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 10.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
No biliary dilatation is identified. No sonographic signs of cholecystitis
are identified. A small amount of sludge and stones identified, however the
gallbladder is not distended and there is no gallbladder wall thickening.
RECOMMENDATION(S): If cholecystitis remains a consideration, liver MRI is
more sensitive in the detection of acute on chronic cholecystitis
NOTIFICATION: The suggestion of Liver MRI was discussed with ___,
M.D. by ___, M.D. on the telephone on ___ at 11:12 am,
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright
INDICATION: Heart failure with productive cough and leukocytosis. Aspiration
risk.
COMPARISON: Prior radiographs from ___ and CT from ___.
FINDINGS:
Port-A-Cath terminates in the right atrium, as before. ___ rod again
projects over the lower thoracic spine. Cardiac, mediastinal and hilar
contours appear stable including mild to moderate cardiomegaly. Left
ventricular apex is again calcified. Right hemidiaphragm is again mildly
elevated. There is slight blunting of each costophrenic sulcus, possibly due
to small pleural effusions. There is no pneumothorax. Decreased platelike
opacities in the right midlung suggest improving atelectasis. However,
persistent mild diffuse interstitial abnormality suggests mild pulmonary
edema, similar to prior study.
IMPRESSION:
Similar mild interstitial process suggesting pulmonary edema.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old ___ woman with transaminitis and
elevated WBC// ? signs of cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound of the abdomen from ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is trace ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 0.5 cm
GALLBLADDER: There is cholelithiasis without evidence of cholecystitis.
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: 10.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Cholelithiasis without evidence of cholecystitis. No biliary duct dilatation
is identified. There is trace ascites.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abnormal sodium level, UTI, Transfer
Diagnosed with Other fatigue
temperature: 97.5
heartrate: 56.0
resprate: 16.0
o2sat: 96.0
sbp: 126.0
dbp: 71.0
level of pain: 3
level of acuity: 3.0 | ==================
PATIENT SUMMARY
==================
Ms. ___ is a ___ year old woman with a history of HFrEF (EF
20%), cardiac arrest ___ now with LifeVest as outpatient, PAD
s/p L AKA and R BKA, AF on apixaban, HTN, pancreatic ca s/p
resection, brought in with several day history of worsening
confusion and productive cough found to have acute heart failure
exacerbation and UTI. During her hospital course, she was
diuresed with a Lasix drip then developed ___. She was
transitioned to oral diuretics. The palliative care team was
involved with her care and assisted with pain management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Gadolinium-Containing Agents / Percocet / Tegretol
/ Beta-Blockers (Beta-Adrenergic Blocking Agts) / Verapamil /
Shellfish Derived / Honey Bee Venom / gluten
Attending: ___.
Chief Complaint:
Abdominal pain and diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with a history of celiac
disease, developmental
delay, NAFLD & c.diff colitis (___) who presents with
abdominal pain, fever, and diarrhea. His symptoms began
yesterday
morning after eating ___. He had mild abdominal pain that
progressed throughout the day and into today. Additionally, he
had non-bloody, foul smelling and yellow diarrhea that stopped
at
around 2100 last night. This was all accompanied by poor oral
intake. This was accompanied by fever, so his mother brought him
to the hospital. After arrival to the ED he had improvement in
his abdominal pain, nausea, and diarrhea.
In the ED, initial VS were: T 101.4 HR 150 BP 104/60 RR 22 O2
98% RA
Lowest BP in the ED was 96/44. He was given 3L NS, cefepime,
vancomycin, and 40 mEq KCl
Exam notable for:
Gen: Feels somewhat pale, diaphoretic, awake and alert
___: NC/AT. EOMI.
Neck: No swelling.
Cor: Tachycardic. No m/r/g.
Pulm: CTAB, Nonlabored respirations but with mild tachypnea
Abd: Soft, mildly distended with mild tenderness to palpation in
the epigastrium
Ext: No edema, cyanosis, or clubbing.
Skin: No rash.
Neuro: AAOx3. Gross sensorimotor intact.
Psych: Normal mentation.
Heme: No petechial
Labs showed:
5.2> 13.2/39.1 <153
Na 140 K 3.4 BUN 14 Cr 1.1
Lactate 3.2 ---3L NS---> 0.9
CT A/P:
1. Prominent gas may simply be adherent to the dependent portion
of the
transverse colon, but there is suspicion of mild or early
pneumatosis coli.
Surgery was consulted due to hypotension and the CT findings.
They felt that history and exam were not concerning for
pneumatosis and recommended admission to medicine with surgery
consult.
Transfer VS were: T 99.2 HR 101 BP 100/52 RR 18 O2 98% RA
On arrival to the floor, patient reports that his abdominal pain
is mostly resolved. He is still having watery diarrhea. Mom is
at
bedside and states that he has not had any recent sick contacts,
not eating raw ___ lettuce, and he has not had any
reheated rice.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
NAFLD
- Hepatology: Dr. ___
___ DELAY
- Neurology: Dr. ___ - ___: insertional deletion of
5q: ___
SENSORINEURAL HEARING LOSS
- Intermittently uses amplification
HYPERTRIGLYCERIDEMIA
SEASONAL ALLERGIES
___ SYNDROME
- Cardiology: Dr. ___ - ___: EPS: could not ablate
secondary to anatomy
CELIAC DISEASE
- GI: Dr. ___
___
- Allergy: Dr. ___
H/O CLOSTRIDIUM DIFFICILE ENTEROCOLITIS
H/O HERNIA
H/O HELICOBACTER PYLORI
- S/P treatment ___
Past Surgical History:
s/p appendectomy ___
s/p hernia repair
Social History:
___
Family History:
The patient's mother provides history notable for mother with
history of hypertension and intracranial aneurysm, father with
history of CABG in his ___. Maternal grandparents with history
of hypertension and diabetes. Maternal grandfather with history
of Alzheimer's dementia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 99.4 BP 97/54 HR 94RR 18O2 94%Ra
GENERAL: NAD, mother at beside
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
mucous membranes dry
NECK: supple, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, very mildly tender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: T 98.0 BP 110/75 HR 94 RR20O2 sat 97 Ra
General: Awake and alert, no acute distress
___: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Less distended, hyperactive BS, no TTP
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Pertinent Results:
ADMISSION LABS:
___ 11:11PM BLOOD WBC-5.2 RBC-4.42* Hgb-13.2* Hct-39.1*
MCV-89 MCH-29.9 MCHC-33.8 RDW-15.2 RDWSD-49.7* Plt ___
___ 11:11PM BLOOD Neuts-77.1* Lymphs-18.4* Monos-3.3*
Eos-0.4* Baso-0.4 Im ___ AbsNeut-3.98 AbsLymp-0.95*
AbsMono-0.17* AbsEos-0.02* AbsBaso-0.02
___ 11:11PM BLOOD Glucose-115* UreaN-14 Creat-1.1 Na-140
K-3.4* Cl-108 HCO3-19* AnGap-13
___ 09:20AM BLOOD ALT-120* AST-129* LD(LDH)-202 AlkPhos-31*
TotBili-0.6
___ 09:20AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.8
___ 10:42AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS*
___ 10:42AM BLOOD HCV Ab-NEG
URINE:
___ 11:30PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 11:30PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 11:30PM URINE RBC-1 WBC-8* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 11:30PM URINE CastHy-1*
MICRO:
___ 4:30 am STOOL CONSISTENCY: WATERY
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Pending):
___ 04:30
VIRAL MOLECULAR
Norovirus Genogroup I NEGATIVE NEG
GENOGROUP I - TEST PERFORMED BY PCR
Norovirus Genogroup II POSITIVE* NEG
GENOGROUP II - TEST PERFORMED BY PCR
DISCHARGE LABS:
___ 05:55AM BLOOD WBC-10.5* RBC-4.42* Hgb-13.4* Hct-38.9*
MCV-88 MCH-30.3 MCHC-34.4 RDW-15.7* RDWSD-50.7* Plt ___
___ 05:55AM BLOOD Glucose-83 UreaN-7 Creat-0.8 Na-142 K-3.8
Cl-104 HCO3-19* AnGap-19*
___ 05:55AM BLOOD ALT-109* AST-70* AlkPhos-36* TotBili-0.6
___ 03:40PM BLOOD Phos-3.3
___ 05:55AM BLOOD Calcium-8.1* Phos-1.0* Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fenofibrate 200 mg PO DAILY
7. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild
8. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
4. Fenofibrate 200 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Norovirus
SECONDARY DIAGNOSES: Celiac disease and developmental delay
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: NO_PO contrast; History: ___ with abdominal pain, tachycardia,
hypotensionNO_PO contrast// Evaluate for evidence of appendicitis versus other
intra-abdominal infection
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 7.3 s, 57.6 cm; CTDIvol = 11.6 mGy (Body) DLP = 666.4
mGy-cm.
Total DLP (Body) = 674 mGy-cm.
COMPARISON: CT abdomen ___, CT pelvis ___
FINDINGS:
LOWER CHEST: There is mild scarring atelectasis at the lung bases,
bilaterally.
ABDOMEN:
HEPATOBILIARY: A 1.4 cm hepatic hypodensity in the left lobe (series 2, image
19) may represent a hemangioma and is unchanged from ___. A 9 mm enhancing
lesion at the dome of the liver (series 2, image 8) is also unchanged from
___ and compatible with a hemangioma.
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. Gas adherent to
the wall within the transverse colon is noted. 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: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra-abdominal abnormality. The appendix is surgically absent.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with sepsis, abdominal distention// eval free air,
pna
TECHNIQUE: Single AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are low, limiting assessment. The cardiomediastinal silhouette
is within normal limits. Patchy opacities at the right lung base appear to
represent prominent vessels, better seen on CT of the abdomen and pelvis from
the same date. No evidence of free air below the diaphragm.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Fever
Diagnosed with Sepsis, unspecified organism
temperature: 101.4
heartrate: 150.0
resprate: 22.0
o2sat: 98.0
sbp: 104.0
dbp: 60.0
level of pain: 0
level of acuity: 1.0 | SUMMARY:
========
___ with a history of celiac disease, developmental delay, NAFLD
& c.diff colitis (___) who presents with abdominal pain,
diarrhea, poor PO intake and fever found to have norovirus. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ibuprofen
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with PMH of HLD, diet-controlled DM2, and COPD who p/w
sudden onset cramping left-sided chest pain. Patient reports
that he woke up this morning feeling well. He exercised with
some light weight lifting without difficulty or pain. While
eating breakfast patient developed severe (___) left chest
cramping pain with some radiation to back and neck. He has never
had pain similar to this. There is no association with
lightheadedness, shortness of breath, or pleuritic component. He
denies fevers, chills, abdominal pain, nausea, vomiting, and
diarrhea. Reports recent 4 lb. weight loss. Notably, patient
smoked for ___ years before quitting ___ years ago.
In the ED, initial vital signs were 97.9, 56, 144/82, 18, 100%
RA. Patient was managed initially for ACS and given ASA and NTG.
However, two sets of cardiac enzymes were negative and multiple
EKGs were unremarkable. There was concern for aortic dissection
given severity of pain for which CTA chest was performed. This
revealed no evidence of dissection but did show a large LLL lung
mass. This was communicated to his PCP who requested an
admission for pain control and biopsy. On the floor, initial
vital signs were 97.9, 88, 151/94, 20, 95% RA. Patient reports
that chest pain has resolved. Does not believe this was due to
pain medications. He is without complaints at this time with the
exception of some bloating.
Past Medical History:
- Hyperlipidemia
- Type II diabetes, diet-controlled
- COPD
- Melanoma in ___
- H. pylori gastritis
- Osteoarthritis
- Allergic rhinitis
- Tobacco abuse
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM
Vitals: 97.9, 88, 151/94, 20, 95% RA
General: AAOx3, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: Limited exam, RRR, nl S1/S2, no MRG
Lungs: Decreased breath sounds and crackles at left base
Abdomen: Soft, NTND, positive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, no cyanosis/clubbing/edema
Neuro: CN II-XII grossly intact
DISCHARGE EXAM
Vitals: 97.8, 69, 114/80, 18, 96% RA
General: AAOx3, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: Limited exam, RRR, nl S1/S2, no MRG
Lungs: Decreased breath sounds and crackles at left base
Abdomen: Soft, NTND, positive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, no cyanosis/clubbing/edema
Neuro: CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS
___ 07:30AM BLOOD WBC-10.8 RBC-4.95 Hgb-15.5 Hct-46.2
MCV-93 MCH-31.3 MCHC-33.6 RDW-12.3 Plt ___
___ 07:30AM BLOOD Neuts-67.9 ___ Monos-7.4 Eos-1.5
Baso-0.5
___ 07:30AM BLOOD ___ PTT-28.5 ___
___ 07:30AM BLOOD Glucose-167* UreaN-18 Creat-1.3* Na-136
K-4.6 Cl-101 HCO3-27 AnGap-13
___ 07:30AM BLOOD ALT-19 AST-22 AlkPhos-80 TotBili-0.4
___ 07:30AM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD Albumin-4.4
DISCHARGE LABS
___ 07:50AM BLOOD WBC-12.5* RBC-4.29* Hgb-13.4* Hct-40.4
MCV-94 MCH-31.3 MCHC-33.2 RDW-12.3 Plt ___
___ 07:50AM BLOOD Glucose-103* UreaN-13 Creat-0.9 Na-137
K-3.9 Cl-103 HCO3-26 AnGap-12
___ 07:50AM BLOOD CK(CPK)-28*
___ 07:50AM BLOOD CK-MB-6 cTropnT-<0.01
___ 07:50AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0
IMAGING
CTA chest (___): No pulmonary embolism or acute aortic
syndrome. There is a large left lower lobe lung mass (?pleural
based) measuring 4.1 x 2.3 cm. In addition, there is a large
left adrenal mass of similar characteristics measuring 3.4 x 3.2
cm. These require outpatient oncologic workup and biopsy.
CXR (___): No acute cardiopulmonary process. See subsequent CT
for more complete evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Fexofenadine 180 mg PO DAILY:PRN allergy symptoms
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID:PRN SOB
4. Montelukast Sodium 10 mg PO DAILY:PRN SOB
5. Pravastatin 40 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID:PRN SOB
3. Montelukast Sodium 10 mg PO DAILY:PRN SOB
4. Pravastatin 40 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every
four (4) hours Disp #*24 Tablet Refills:*0
7. Lorazepam 0.5 mg PO ONCE Duration: 1 Dose
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth twice a day Disp
#*4 Tablet Refills:*0
8. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth DAILY Disp #*30
Tablet Refills:*0
9. Simethicone 80 mg PO QID:PRN bloating/gas pains
RX *simethicone 80 mg 1 tablet by mouth four times a day Disp
#*120 Tablet Refills:*0
10. Fexofenadine 180 mg PO DAILY:PRN allergy symptoms
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Lung mass, atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain.
COMPARISON: None available.
FINDINGS: A portable AP radiograph of the chest demonstrates clear lungs and
normal hilar and cardiomediastinal contours. There is no pneumothorax or
pleural effusion. Pulmonary vascularity is normal. Left lower lobe mass seen
on subsequent CT is not visible on this study.
IMPRESSION: No acute cardiopulmonary process. See subsequent CT for more
complete evaluation.
Radiology Report
HISTORY: Chest and back pain. Evaluate for aortic dissection.
COMPARISON: None available.
TECHNIQUE: MDCT acquired axial images of the chest were obtained during the
early arterial phase after the rapid administration of 100 cc Omnipaque
intravenous contrast material. Multiplanar reformations consist of coronal
and sagittal series. Additional pulmonary artery oblique maximal intensity
projection images were also constructed.
DLP: 692.55 mGy-cm.
FINDINGS:
CT ANGIOGRAM: There are no pulmonary arterial filling defects to suggest
presence of pulmonary embolism. The thoracic aorta is normal in caliber,
without dissection. The imaged portion of the aortic arch vessels is
unremarkable.
CHEST: The imaged portion of the thyroid gland is unremarkable. There is no
supraclavicular, mediastinal, hilar, or axillary lymphadenopathy. The heart
size is normal and there is no pericardial effusion. There are coronary
arterial calcifications. The airways are patent to the subsegmental level
bilaterally. Emphysema is noted. The lungs are clear. There is no
pneumothorax or pleural effusion.
Emphysema is noted with a 4.1 x 2.3 x 3.4 cm mass in the left lower lobe
(2:94), concerning for malignancy.
There is a 3.4 x 3.2 cm left adrenal mass (2:117), indeterminate though given
pulmonary mass, metastasis is a concern. There is focal hyperenhancement in
hepatic segment VII/VIII not fully characterized. A small hiatal hernia is
present.
BONES: There are no destructive osseous lesions concerning for malignancy or
infection.
IMPRESSION:
1. No pulmonary embolism or acute aortic syndrome.
2. Emphysema with a 4.1 x 2.3 x 3.4 cm left lower lobe lung mass, worrisome
for primary malignancy. Also noted is a 3.4 x 3.2 cm left adrenal mass,
concerning for metastasis. Oncologic workup and biopsy is recommended.
3. Foci of hyperenhancement in the dome of the liver, indeterminate, warrant
further evaluation during oncologic workup.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS
temperature: 98.3
heartrate: 62.0
resprate: 24.0
o2sat: 99.0
sbp: 129.0
dbp: 77.0
level of pain: 3
level of acuity: 2.0 | ___ yo M with PMH of HLD, diet-controlled DM2, and COPD who p/w
sudden onset cramping left-sided chest pain and found to have
large LLL lung mass on CTA chest.
ACTIVE ISSUES
# Chest pain: There was no evidence of ACS or PE per cardiac
enzymes, EKG, and a negative CTA chest. Pain was most likely
related to large LLL lung mass appreciated on CTA chest. Most
likely represents malignancy given patient's extensive smoking
history. Consulted Interventional Pulmonology for biopsy but
their impression was that mass was too peripheral to access via
bronchoscopy. Called Interventional Radiology who will biopsy as
an outpatient. Patient's pain had resolved by the time he was
admitted and he developed no subsequent chest pain. Because
biopsy in ___ could not be scheduled for several days patient was
discharged home with a prescriptions for Dilaudid and as needed
bowel regimen.
CHRONIC ISSUES
# Hyperlipidemia: Continued home pravastatin.
# Type II diabetes: Diet-controlled at home. Did not start
sliding scale.
# COPD: Stable. Continued home inhaler regimen.
TRANSITIONAL ISSUES
- Patient discharged with Rx for oral Dilaudid
- Biopsy of LLL lung and left adrenal mass to be scheduled
___
- Patient will follow-up with PCP early next week
- Holding off on knee replacement pending lung cancer workup |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness and lightheadedness with standing; transient loss of
vision in right eye
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old female with a past medical history
notable for T2DM (last HA1c = 13.9 on ___, HTN, atrial
fibrillation on Coumadin, severe three vessel CAD with ischemic
cardiomyopathy and heart failure with reduced ejection fraction
(EF25-30%), hypokinesis, thrombus in the left ventricle, and
pulmonary hypertension who presented for dizziness, temporary
loss of vision in her right eye, one episode of emesis, and
several days of increased confusion. Notably, the patient was
recently admitted 2 months prior for failure to thrive after
moving to the ___ from ___ and had not had medical
attention for the last ___ years. It was at this time that she
was found to have the abovementioned chronic diseases, and it
was decided to treat her CAD medically rather than surgically.
As per Ms. ___ daughter, her mother was working with home
physical therapy the morning of admission. During this session
she stood up and felt extremely lightheaded, los vision in her
right eye temporarily and had an episode of non-bloody,
non-bilious emesis. The symptoms quickly resolved when she sat
down; and she was referred to the ED by ___.
In the ED, initial vitals were: 98.1 69 112/64 16 97%RA. Labs
were significant for nitrite positive urinalysis. CTA head and
neck showed no flow limiting stenosis. EKG showed atrial
fibrillation with left axis deviation, left ventricular
hypertrophy but no worrisome ST changes and relatively unchanged
compared to prior. Neurology evaluated the patient and stated
that the symptoms were likely explained by her known orthostatic
hypotension and transient hypoperfusion through a stenosed right
ophthalmic artery. She was given 2g cefepime and 1L NS before
transfer to the floor. Upon arrival to the floor, Ms. ___
stated she was feeling better, and had no more nausea, vomiting,
or abdominal pain. She denied urinary frequency, dysuria, chest
pain, and shortness of breath. Further questioning of her
daughter revealed that her mother has had some cognitive
deterioration over the past few weeks/months; that she is more
forgetful, intermittently more or less confused, occasionally
incontinent, and incapable of performing activities of daily
living on her own. Dementia has not been formally diagnosed. Her
daughter stated that Ms. ___ had been acting more confused over
the last few days, and that the confusion was waxing and waning.
Past Medical History:
Ischemic cardiomyopathy
Heart failure with reduced ejection fraction (EF25-30%)
3 vessel CAD (medically managed)
Atrial fibrillation
T2DM (last HgbA1c of 13.9%)
Hypertension
Pulmonary Hypertension
Social History:
___
Family History:
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.6 134/74 64 18 96%RA
General: Alert, no acute 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, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE PHYSICAL EXAM:
Vitals: Temp 97.6-98.3 BP 110-136/48-78 HR ___ 96-99%RA
24H I/O: 880 PO 600 IV 700 GU BMx2
FSG ___, ___: 126,178,204,112
Current weight (bed scale): 54.5kg
Orthostatic Measurements (AM):
Supine: BP 130/60 HR 57
Sitting: 122/63 HR 61
Standing: BP 87/57 HR 90
General: Sitting up in chair. Had previously stood up with
assistance and had been walking steadily with her walker to the
bathroom. Alert; conversant in ___. No acute
distress.
HEENT: Anicteric sclerae; PERLL; MMM. JVP 8cm above the sternal
angle.
Lungs: Clear to auscultation bilaterally. No wheezes, rales,
rhonchi.
CV: Irregular rhythm, regular rate, normal S1, S2, soft II/VI
apical holosystolic murmur.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: nontender, nonedematous, unable to appreciate pedal pulses.
Neuro: Answering questions appropriately. No focal
abnormalities; moving all 4 extremities spontaneously.
Pertinent Results:
ADMISSION LABS:
___ 03:40PM BLOOD WBC-7.5# RBC-4.63 Hgb-13.5 Hct-40.7
MCV-88 MCH-29.2 MCHC-33.2 RDW-15.4 RDWSD-49.4* Plt ___
___ 03:40PM BLOOD Neuts-56.8 ___ Monos-7.1 Eos-1.3
Baso-0.4 Im ___ AbsNeut-4.27 AbsLymp-2.55 AbsMono-0.53
AbsEos-0.10 AbsBaso-0.03
___ 04:42PM BLOOD ___ PTT-40.4* ___
___ 03:40PM BLOOD Plt ___
___ 03:40PM BLOOD Glucose-168* UreaN-19 Creat-0.9 Na-135
K-5.5* Cl-99 HCO3-25 AnGap-17
___ 03:40PM BLOOD cTropnT-<0.01
___ 03:40PM BLOOD Calcium-9.7 Phos-3.6 Mg-1.8
___ 03:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:19PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:19PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:19PM URINE RBC-4* WBC-55* Bacteri-MOD Yeast-NONE
Epi-1
___ 05:19PM URINE CastHy-5*
___ 05:19PM URINE Mucous-RARE
___ 05:19PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS:
___ 08:20AM BLOOD WBC-6.0 RBC-4.13 Hgb-12.1 Hct-36.7 MCV-89
MCH-29.3 MCHC-33.0 RDW-15.5 RDWSD-49.7* Plt ___
___ 08:20AM BLOOD Plt ___
___ 08:20AM BLOOD ___ PTT-36.4 ___
___ 08:20AM BLOOD Glucose-219* UreaN-14 Creat-0.7 Na-137
K-4.2 Cl-103 HCO3-25 AnGap-13
___ 08:20AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2
___ 08:20AM BLOOD Digoxin-0.8*
PERTINENT LABS:
___ 07:32AM BLOOD WBC-5.9 RBC-4.30 Hgb-12.3 Hct-38.0 MCV-88
MCH-28.6 MCHC-32.4 RDW-15.4 RDWSD-49.6* Plt ___
___ 07:30AM BLOOD WBC-6.9 RBC-4.42 Hgb-12.8 Hct-39.2 MCV-89
MCH-29.0 MCHC-32.7 RDW-15.3 RDWSD-49.5* Plt ___
___ 07:32AM BLOOD Plt ___
___ 07:32AM BLOOD ___ PTT-34.5 ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-38.4* ___
___ 07:32AM BLOOD Glucose-138* UreaN-14 Creat-0.8 Na-139
K-4.3 Cl-102 HCO3-25 AnGap-16
___ 07:30AM BLOOD Glucose-128* UreaN-14 Creat-0.7 Na-138
K-4.6 Cl-102 HCO3-26 AnGap-15
___ 07:32AM BLOOD ALT-15 AST-24 AlkPhos-64 TotBili-0.8
___ 07:32AM BLOOD Lipase-26
___ 07:32AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.7
___ 07:30AM BLOOD Calcium-9.6 Phos-3.6 Mg-1.7
___ 07:32AM BLOOD VitB12-400
___ 07:30AM BLOOD Digoxin-1.0
MICROBIOLOGY:
___ 5:19 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:32 am SEROLOGY/BLOOD
RAPID PLASMA REAGIN TEST (Pending): IMAGING AND STUDIES:
IMAGING AND STUDIES:
EKG (___):
Atrial fibrillation with mean ventricular rate of 63. Compared
to the previous tracing of ___
ventricular rate is reduced. Otherwise, no diagnostic change.
CTA Head & CTA Neck (___):
IMPRESSION:
1. Senescent volume loss and probable small vessel ischemic
changes. Otherwise, no acute
intracranial abnormality.
2. Beaded appearance of the bilateral distal cervical internal
carotid arteries compatible with
fibromuscular dysplasia. In addition, there is superimposed
irregularity of the internal carotid artery
and intracranial vasculature, likely secondary to
atherosclerosis. No evidence of high-grade stenosis, occlusion
or aneurysm.
3. Mild mediastinal lymphadenopathy and patchy ground-glass
opacities which may be secondary to
early pulmonary edema.
4. Enlarged, nodular left thyroid gland, which may represent
multi nodular goiter. A thyroid
ultrasound can be performed if clinically indicated.
5. A 0.6 cm right nasal skin lesion. Correlate with physical
exam.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Digoxin 0.125 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Spironolactone 12.5 mg PO DAILY
8. Torsemide 10 mg PO 2X/WEEK (MO,TH)
9. Warfarin 4 mg PO 2X/WEEK (___)
10. Warfarin 3 mg PO 5X/WEEK (___)
11. MetFORMIN (Glucophage) 500 mg PO DAILY
12. GlipiZIDE 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Digoxin 0.125 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Warfarin 4 mg PO 2X/WEEK (___)
7. Warfarin 3 mg PO 5X/WEEK (___)
8. GlipiZIDE 5 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Spironolactone 12.5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Orthostatic hypotension
Urinary tract infection
Secondary Diagnosis:
Heart failure with reduced ejection fraction (HFrEF)
Atrial fibrillation
Type II Diabetes Mellitus
Coronary Artery Disease
Right amaurosis fugax
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ year old female with presyncope and unilateral visual changes.
Evaluate for stroke.
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: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 9.0 s, 0.5 cm; CTDIvol = 98.0 mGy (Head) DLP =
49.0 mGy-cm.
5) Spiral Acquisition 4.9 s, 38.8 cm; CTDIvol = 31.7 mGy (Head) DLP =
1,231.9 mGy-cm.
Total DLP (Head) = 2,178 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, ormass
effect. Prominent ventricles and sulci are compatible with age-related volume
loss. Periventricular white matter hypodensities are consistent with chronic
small vessel ischemic disease. There is a 9 mm calcification/ossification
along the inner table of the right middle temporal fossa (series 4, image 10)
which may represent dural calcification versus a calcified meningioma.
Right frontal sinus disease is seen. Mucosal thickening of the ethmoid
sinuses is noted. There is a retention cyst in the left maxillary sinus. The
visualized portion of the mastoid air cells and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is irregularity, with no high grade stenosis, of the basilar, vertebral,
internal carotid and middle cerebral arteries, likely secondary to
atherosclerosis. Otherwise, the vessels of the circle of ___ and their
principal intracranial branches appear normal without occlusion or aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
There is atherosclerotic calcification of the aortic arch. Atherosclerotic
calcification of bilateral carotid bulbs is also seen with no stenosis by
NASCET criteria. There is multifocal irregularity of the internal carotid and
vertebral arteries, likely secondary to atherosclerosis. In addition, there
are superimposed beaded appearance of the right and left cervical internal
carotid arteries, most prominently seen in the right just proximal to the
petrous segment (series ___, image 60).
Carotid artery just proximal to the horizontal Otherwise, the carotid and
vertebral arteries and their major branches are patent without evidence of
occlusion. There is no evidence of internal carotid stenosis by NASCET
criteria.
OTHER:
There are patchy regions of ground-glass opacity in the left upper lobe. The
left thyroid gland is enlarged and nodular, which may represent multinodular
goiter. There are multiple prominent AP window, prevascular and paratracheal
lymph nodes, measuring up to 1 cm. There is a 0.6 cm right nasal skin lesion.
Degenerative changes are noted throughout the cervical spine.
IMPRESSION:
1. Senescent volume loss and probable small vessel ischemic changes.
Otherwise, no acute intracranial abnormality.
2. Beaded appearance of the bilateral distal cervical internal carotid
arteries compatible with fibromuscular dysplasia. In addition, there is
superimposed irregularity of the internal carotid artery and intracranial
vasculature, likely secondary to atherosclerosis. No evidence of high-grade
stenosis, occlusion or aneurysm.
3. Mild mediastinal lymphadenopathy and patchy ground-glass opacities which
may be secondary to early pulmonary edema.
4. Enlarged, nodular left thyroid gland, which may represent multinodular
goiter. A thyroid ultrasound can be performed if clinically indicated.
5. A 0.6 cm right nasal skin lesion. Correlate with physical exam.
RECOMMENDATION(S): The left thyroid gland is enlarged and nodular, which may
represent multinodular goiter. Thyroid ultrasound if clinically indicated.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Vomiting
Diagnosed with SYNCOPE AND COLLAPSE, URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS , HYPERTENSION NOS
temperature: 98.1
heartrate: 69.0
resprate: 16.0
o2sat: 97.0
sbp: 112.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ year old woman with a past medical history of
T2DM, hypertension, atrial fibrillation on coumadin, three
vessel disease CAD (medically managed), heart failure with EF
___, and pulmonary hypertension who presented with
lightheadedness, right amarousis fugax, emesis and possible
worsening confusion who was acutely treated for orthostatic
hypotension and UTI.
#Lightheadedness/Orthostasis: Ms. ___ presented because of
dizziness, lightheadedness, and temporary loss of vision in her
right eye with standing during a ___ session the morning of
admission. Her symptoms were present upon sitting or standing,
and had been present for the last few days prior to admission,
but may have been going on more chronically, as her daughter
reported that when Ms. ___ came back from ___ to live
with her, she was already primarily wheel-chair bound because
she had been having difficulty standing in ___ secondary
to lightheadness. Differential included orthostasis, autonomic
dysfunction because of longstanding uncontrolled diabetes,
infection such as UTI causing systemic vasodilation, or basilar
insufficiency, the last of which is less likely because initial
evaluation in the ED with CTA head and neck imaging showed no
flow-limiting stenosis. The Neurology team was consulted in the
ED and concluded that her amaourosis fugax symptoms were likely
explained by her known orthostatic hypotension and transient
hypoperfusion through a stenosed right ophthalmic artery.
The diagnosis of orthostatic hypotension was supported
throughout her stay with positive orthostatic vital signs, which
were most likely worsened by vasodilation in the setting of UTI
(see below), CHF medications that she had been recently
prescribed that caused systemic vasodilation, as well as
decreased PO intake recently. She was treated conservatively at
first by decreasing the dose of her isosorbide mononitrate from
120 mg PO daily to 90 mg PO daily, but she remained symptomatic.
The medication was then stopped altogether, after which she was
no longer symptomatic with dizziness or lightheadedness upon
standing, but she remained positive on objective orthostatic
measurements. She did not experience any chest pain after
stopping the isosorbide mononitrate. She was also treated with
several 500mL NS boluses to support her blood pressures, which
the team felt comfortable proceeding with as Ms. ___ did not
appear volume up on examination (non elevated JVP; no crackles
on pulmonary examination; no lower extremity edema), and was
still symptomatically dizzy upon standing. On the day of
discharge, her torsemide was also discontinued given significant
orthostasis and reported poor PO intake. She remained
orthostatic by vital signs, but continued to have decreased
symptoms. Her orthostasis will likely persist as it has been
long standing, and there is likely a diabetic neuropathy
component to her symptoms. Goal was to decrease her risk of
falls, and that is why the above medications discontinued. Ms.
___ should continue to use her wheelchair at home as much as
possible to minimize fall risk. She should have 24 hour care and
should not ambulate without assistance.
#UTI: Prior to presentation Ms. ___ had been experiencing
worsening orthostasis, emesis 1x, and fluctuating changes in
mental status, with initial workup in the ED showing positive
urinalysis with nitrites. Urine culture showed mixed bacterial
flora consistent with skin or genital contamination. She was
given 1 dose of cefepime in the ED, then transitioned to 1 gm IV
ceftriaxone q24h while inpatient, for a total of 3 days for
uncomplicated UTI. As per her daughter, her mental status
returned to baseline at the time of discharge.
#HFrEF: Ms. ___ heart failure with reduced ejection fraction
(EF ___ is a result of ischemic cardiomyopathy. She remained
euvolemic throughout this admission, and did not acutely
decompensate. She was being treated with high doses of
vasodilatory agents, such as the isosorbide mononitrate, most
likely contributing to her symptomatic orthostasis (see above).
Her isosorbide mononitrate was first reduced in dosing, then
discontinued, without any development of anginal symptoms.
Torsemide was also discontinued on the day of discharge given
persistently positive orthostatic measurements and reportedly
decreased PO intake recently, with no evidence of volume
overloaded state on exam (see above). Aspirin, atorvastatin,
metoprolol, lisinopril and spironolactone were continued. Daily
electrolytes, ins/outs, and weights were monitored throughout
her admission. Given Ms. ___ multiple comorbidities and
increased risk of arrhythmias, she was also monitored on
telemetry throughout her admission with no worrisome changes or
decompensations.
#Atrial fibrillation: Ms. ___ has a history of atrial
fibrillation with LV thrombus and cardiac areas of hypokinesis
that is managed with digoxin and coumadin in the outpatient
setting. She remained in atrial fibrillation throughout her
hospitalization, as monitored both by telemetry and physical
exam. Her INR remained therapeutic between ___ throughout her
stay, and monitored daily. Her home dose digoxin was continued
at 0.125mg PO daily, as was her home dose metoprolol succinate
XL 25 mg PO daily. She was continued on her warfarin as
scheduled, 4 mg PO 2X/WEEK ___ 3 mg PO 5X/WEEK
___, and monitored on telemetry throughout her
admission with no worrisome changes or decompensations requiring
further therapeutic intervention.
#T2DM: Ms. ___ was only recently diagnosed with T2DM when she
saw a doctor for the first time after over ___ years of no
medical care in ___. Her T2DM is poorly controlled, with
her last HgbA1c of 13.9 on ___. She is on metformin and
glipizide at home, but was managed with insulin sliding scale,
diabetic diet, and daily blood glucose level monitoring
throughout her admission. She was restarted on her home
medications at discharge.
#CAD: Recent cardiac catheterization in ___ showed severe
three vessel CAD (EF25-30%). The patient and her family opted
for medical management of her severe coronary artery disease.
She takes aspirin 81 mg PO daily and atorvastatin 80mg PO daily
at home, and these medications were continued throughout her
hospitalization.
TRANSITIONAL ISSUES
#Imdur discontinued.
#Torsemide discontinued. No evidence of volume overload during
this admission. Monitor for pulmonary or peripheral edema
#Consider discontinuing spironolactone if orthostatic vital
signs or symptoms persist.
#F/u orthostasis, lightheadness and fall risk
#Continue home ___
#F/u with cardiology for medication management
#Consider outpatient neurocognitive work up for official
diagnosis of dementia and possible treatment/management
evaluation
#F/u INR
#Outpatient addressment of goals of care
#CODE: FULL
#CONTACT: Daughter (HCP); ___, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / ferrous sulfate
Attending: ___
Chief Complaint:
Feeling Unwell
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with sig CAD hx s/p recent MI this month, DM and ESRD s/p
DDRT ___ who presents with feeling unwell with profuse
diarrhea. He reports that has been doing well since discharge on
___ but developed general malaise and low grade fever with
N/V/D over the past 2 days though the profuse, watery, brown
diarrhea has been present for 5 days but he only started feeling
otherwise unwell 2 days ago. No sick contacts. He also has been
unable to tolerate PO intake since yesterday.
Renal ___ was consulted in the ED and advised sending stool
cultures, o/p, C. Diff, blood CMV and urine cx. Transplant
surgery was consulted and recommended sending a flu swab which
was negative.
In the ED, initial vitals T 99, HR 100, BP 122/58, RR 18,
96%RA. No exam documented on ED Dash. Labs notable for
leukocytosis to 21.2 with neutrophilic predominance, Hgb 8.2,
Plt 82. Chem 7 with bicarb 13, BUN/Cr 39/3.2 (most recently 2.4
i/s/o delayed graft function), AG 21, glucose 235. Lactate 1.7.
LFTs with AP elevation to 141. UA with 100 WBCs, + ___, +
Nitrites, + ketones. Blood Cx and urine Cx obtained. Renal Tx
US: Renal tx US with small amount of perinephric fluid and
normal wafeforms. CXR without acute process. Patient was given
1gm Tylenol, 2gm Cefepime, 1L NS, 500mg Flagyl and Vancomycin.
On arrival to the floor, pt reports that he feels better and
confirms the above story. He has not had any further diarrhea.
He tells me that he has not taking any of his short acting
insulin as he has not eaten for 2 days. He did take his 22U of
lantus yesterday evening.
Past Medical History:
1. CARDIAC RISK FACTORS: +diabetes, HLD, HTN
2. CARDIAC HISTORY:
- CABG: ___ - Urgent coronary artery bypass graft x3;
left internal mammary artery to left anterior descending artery,
saphenous vein graft to obtuse marginal and distal right
coronary arteries.
- PERCUTANEOUS CORONARY INTERVENTIONS: Hx of DES to LAD and LCx
prior to CABG ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Nephrolithiasis
- ESRD s/p DDRT on ___ c/b Delayed Graft Function
(previously on HD and PD)
- CAD s/p CABG in ___
- left radiocephalic AVF (___)
- laparoscopic cholecystectomy
- "surgery for renal stones" x 3
Social History:
___
Family History:
Father with CAD and CABG @ age ___. Mother with diabetes, died of
MI at age ___.
Physical Exam:
ADMISSION PHYSICAL:
Vitals: 98.8; 116/53; 88; 18; 99%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Incision
line from recent transplant healing well with one area of
ulceration but no erythema or concern for infection
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE PHYSICAL:
VS: 97.9 120-148/48-63 63-71 ___ RA
Weight: 102.9 kg > 102.1 > 102.7 > 104.0 > 103.7 > 103.4
I/O: 8H ___, 24H 1760/1320
GENERAL: Alert, oriented in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: CTAB
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 tenderness over graft site.
EXT: Warm, well perfused, 2+ pulses, 2+ ___ edema to knees
NEURO: AAOx3, grossly intact
ACCESS: PIVs , pulses, no edema
Neuro: grossly normal
Pertinent Results:
==================
ADMISSION LABS
==================
___ 07:28PM BLOOD WBC-21.2*# RBC-2.89* Hgb-8.5* Hct-27.4*
MCV-95 MCH-29.4 MCHC-31.0* RDW-15.2 RDWSD-52.7* Plt Ct-82*#
___ 07:28PM BLOOD Neuts-92.7* Lymphs-0.2* Monos-6.1
Eos-0.0* Baso-0.1 Im ___ AbsNeut-19.66*# AbsLymp-0.04*
AbsMono-1.30* AbsEos-0.00* AbsBaso-0.02
___ 07:28PM BLOOD ___ PTT-26.6 ___
___ 07:28PM BLOOD Plt Smr-LOW Plt Ct-82*#
___ 07:28PM BLOOD Glucose-235* UreaN-39* Creat-3.2* Na-142
K-4.2 Cl-108 HCO3-13* AnGap-25*
___ 07:28PM BLOOD ALT-14 AST-24 AlkPhos-141* TotBili-0.6
___ 07:28PM BLOOD Lipase-15
___ 07:28PM BLOOD Albumin-3.6
___ 07:35PM BLOOD tacroFK-12.2
___ 03:20AM BLOOD ___ pO2-47* pCO2-35 pH-7.24*
calTCO2-16* Base XS--11 Comment-GREEN
___ 07:34PM BLOOD Lactate-1.7
================
DISCHARGE LABS
================
================
MICRO
================
___ 7:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
450-5257D,
___.
ESCHERICHIA COLI. ___ MORPHOLOGY).
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
450-5257D,
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___, @08:40 ON
___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S)
___ 7:28 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
___ 2:50 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
___ Reported to and read back by ___ @11:45
AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ 8:41 am Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
___ 9:41 am 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.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
================
IMAGING
================
___ CXR:
FINDINGS:
Lung volumes are relatively low with bibasilar atelectasis,
similar compared to prior. There is no effusion or
consolidation worrisome for pneumonia. Probable calcified
granulomas identified at the right lung base. The
cardiomediastinal silhouette is within normal limits. Median
sternotomy wires are again notable for fracture of the superior
most wire. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
___ RENAL TRANSPLANT U.S.:
FINDINGS:
There is a right iliac fossa renal transplant. The cortex is of
normal
thickness, but appears somewhat echogenic. There is no
urothelial thickening and renal sinus fat is normal. There is
no hydronephrosis. There is a small amount of perinephric fluid
at the lower pole.
There has been interval improvement of diastolic flow when
compared to prior. The resistive index of intrarenal arteries no
ranges from 0.71 to 0.82, previously approaching 1. The main
renal artery shows a normal waveform, with prompt systolic
upstroke and continuous antegrade diastolic flow, with peak
systolic velocity of 133 cm/sec. Vascularity is symmetric
throughout transplant. The transplant renal vein is patent and
shows normal waveform.
IMPRESSION:
1. Somewhat echogenic transplant kidney and a small amount of
perinephric
fluid at the lower pole.
2. Improved diastolic flow since prior, with resistive indices
ranging from 0.71 to 0.82.
___ TTE:
Conclusions
The left atrium is elongated. The left ventricular cavity is
mildly dilated. There is mild regional left ventricular systolic
dysfunction with basal and mid-anterior septal hypokinesis, as
well as mild hypokinesis of the distal inferior wall (consistent
with post-CABG coronary anatomy). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Moderate mitral regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. Rosuvastatin Calcium 40 mg PO QPM
3. Acetaminophen 650 mg PO Q6H:PRN Pain
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. insulin lispro As directed unit/mL subcutaneous PER SLIDING
SCALE WITH MEALS
7. Tacrolimus 6 mg PO Q12H
8. ValGANCIclovir 450 mg PO Q24H
9. Vitamin D ___ UNIT PO DAILY
10. TiCAGRELOR 90 mg PO BID
11. Mycophenolate Sodium ___ 360 mg PO QID
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Calcium Carbonate 500 mg PO QID:PRN nausea/indigestion
16. Lantus (insulin glargine) 22 units subcutaneous QHS
17. Dapsone 100 mg PO DAILY
18. Cinacalcet 45 mg PO DAILY
19. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Mirtazapine 15 mg PO QHS
RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet
Refills:*0
3. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*56 Capsule Refills:*0
4. Calcium Carbonate 1000 mg PO NOON dyspepsia
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2
tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0
5. Glargine 28 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Mycophenolate Sodium ___ 720 mg PO BID
RX *mycophenolate sodium 360 mg 2 tablet(s) by mouth twice a day
Disp #*120 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q12H
8. Tacrolimus 2 mg PO Q12H
RX *tacrolimus 1 mg 2 capsule(s) by mouth twice a day Disp #*120
Capsule Refills:*0
9. ValGANCIclovir 450 mg PO 2X/WEEK (WE,SA)
10. Acetaminophen 650 mg PO Q6H:PRN Pain
11. Aspirin 81 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. PredniSONE 5 mg PO DAILY
16. Rosuvastatin Calcium 40 mg PO QPM
17. TiCAGRELOR 90 mg PO BID
18. Vitamin D ___ UNIT PO DAILY
19. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until you see your cardiologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Sepsis due to urinary tract infection
Acute c. diff colitis
Diabetic ketoacidosis
End stage renal disease
Non-ST-elevation myocardial infarction
SECONDARY DIAGNOSES:
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with DOE // r/o acute process
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are relatively low with bibasilar atelectasis, similar compared
to prior. There is no effusion or consolidation worrisome for pneumonia.
Probable calcified granulomas identified at the right lung base. The
cardiomediastinal silhouette is within normal limits. Median sternotomy wires
are again notable for fracture of the superior most wire. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ with s/p renal transplant // eval for renal transplant
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ultrasound ___
FINDINGS:
There is a right iliac fossa renal transplant. The cortex is of normal
thickness, but appears somewhat echogenic. There is no urothelial thickening
and renal sinus fat is normal. There is no hydronephrosis. There is a small
amount of perinephric fluid at the lower pole.
There has been interval improvement of diastolic flow when compared to prior.
The resistive index of intrarenal arteries no ranges from 0.71 to 0.82,
previously approaching 1. The main renal artery shows a normal waveform, with
prompt systolic upstroke and continuous antegrade diastolic flow, with peak
systolic velocity of 133 cm/sec. Vascularity is symmetric throughout
transplant. The transplant renal vein is patent and shows normal waveform.
IMPRESSION:
1. Somewhat echogenic transplant kidney and a small amount of perinephric
fluid at the lower pole.
2. Improved diastolic flow since prior, with resistive indices ranging from
0.71 to 0.82.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recent MI, and new orthopnea and dyspnea //
? Pulm edema ? Pulm edema
IMPRESSION:
In comparison with the study of ___, there are lower lung volumes with
bibasilar atelectasis most prominent on the left. No evidence of acute focal
pneumonia. cardiomediastinal silhouette is stable, though there is some
suggestion of increasing pulmonary vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with renal transplant, decompensated CHF //
interval change interval change
IMPRESSION:
Comparison to ___. Decrease in severity of the pre-existing
pulmonary edema. Elevation of the left hemidiaphragm and platelike
atelectasis at the left lung bases persists. No pneumonia, no pleural
effusions. Stable alignment of the sternal wires.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pulm edema // interval change interval
change
IMPRESSION:
In comparison with the study of ___, there is again increased
opacification at the left base silhouetting the hemidiaphragm. Although this
could merely represent atelectasis, in the appropriate clinical setting,
superimposed pneumonia should be considered. Mild indistinctness of pulmonary
vessels is consistent with the clinical diagnosis of elevated pulmonary venous
pressure.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness, Diarrhea
Diagnosed with Sepsis, unspecified organism, Diarrhea, unspecified, Acute kidney failure, unspecified
temperature: 99.0
heartrate: 100.0
resprate: 18.0
o2sat: 96.0
sbp: 122.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ yom with a hisory DM and ESRD s/p DDRT
___ c/b delayed graft function and CAD s/p recent NSTEMI in
early ___ treated medically, who presented with feeling
unwell with profuse diarrhea found to have GNR bacteremia and c.
diff colitis. He was also found to be in DKA ketones in his
urine and an elevated glucose in the 400s. He was transferred to
the MICU for insulin drip and started on PO vanc for his c. diff
infection and ceftriaxone for his UTI/sepsis due to urinary
tract infection. His DKA resolved, but he was then found to have
acute renal failure in his transplanted kidney. He was
eventually called out to the floor where he was stable but
required intermittent HD due to impaired kidney function and
poor UOP. He also was persistently anemic requiring several
blood transfusions. He was otherwise asymptomatic. His UOP
improved in the days prior to discharge with boluses of IV
Lasix, and he will be discharged with close renal transplant and
cardiac follow up.
# DIABETIC KETOACIDOSIS: Pt admitted to the hospital and found
to have DKA with glucose in 400s ketones in urine. First episode
of DKA. Likely in the setting of not getting insulin with
concomitant infection with c. diff, UTI, and E.coli bacteremia
as triggers. Patient maintained on insulin gtt until gap closed.
___ consulted and provided recs on ongoing insulin regimen.
# E. coli Bacteremia
# UTI:
GNR bacteremia with only clear source being urinary tract. Could
potentially be in the setting of GI translocation ___ colitis
and immunosuppression. Patient initially treated with cefepime,
narrowed to ceftriaxone based on sensitivities. Patient finished
14 day course while in the hospital, from last clear blood
culture (___).
# Anuric Acute Renal Failure:
#Acute Tubular Necrosis: Urine sediment confirmed muddy brown
casts likely ___ to hypovolemia from C diff, tacrolimus
toxicity. Should also consider rejection. Patient started on
renal replacement therapy in the MICU due to escalating oxygen
requirement and acidosis. Patient did have return of kidney
function and UOP to Lasix and metolazone dosing by time of
transfer back to the floor. His UOP was fairly poor for quite
some time while on the floor but was finally responsive to
boluses of IV lasix. UOP was > 1L in day prior to discharge. He
will be discharged to have renal function monitored by ___
transplant nephrology.
#C. diff colitis: Patient treated for severe C. diff colitis
given underlying immunosuppression with PO vancomycin and IV
metronidazole. Patient to continue PO vancomycin for 2 weeks
after last dose of ceftriaxone (end date ___.
# Anemia: Patient's Hb 7.5 on ___ (stable from ___ was in
the 7s over the last couple days without evidence of bleeding or
symtpoms. Anemia is likely ___ ACD, given recent ferritin >900.
He required several units of blood throughout the course of the
hospitalization.
# NSTEMI: Elevated trop with flat MB with worsening TWI and ST-D
on EKG., no clear trigger. Atrus cardiology consulted. Patient
placed on heparin gtt for 48 hours. Patient optimized medical
management (aspirin 81mg, ticagrelor 90mg BID, rosuvasatin,
metoprolol). Repeat TTE similar to prior. Unable to continue
lisinopril due to renal failure. Follow up with cardiology as
outpatient
#S/P Renal tx: Delayed graft function. Noted to have perinephric
fluid collection which may represent post operative changes.
# Supratherapeutic tacrolimus dosing: Patient noted to have high
tacrolimus levels, likely secondary to diarrhea from C. Diff.
Tacrolimus dosed daily, and decreased from 6mg to 1mg BID by
time of transfer.
- Immunosupression - patient continued on prednisone,
mycophenolate, and
- Proph: Valgancyclovir (q48 based on GFR), Dapsone 100mg qD
CHRONIC ISSUES:
#GERD - Patient on home dose pantroprazole 40mg q12H. Held in
setting of C. Diff
#Deficiency - Continued Vit. D, cinacalcet
TRANSITIONAL ISSUES
=====================
DISCHARGE WEIGHT: 103.4 kg
DISCHARGE DIURETIC: Torsemide 80 mg PO daily
DISCHARGE IMMUNOSUPPRESSION: Tacrolimus 2 mg PO BID, Pred 5mg
qD, MMF 720 mg bid
MEDICATIONS STARTED: Mirtazapine 15 mg PO/NG QHS, Vancomycin
Oral Liquid ___ mg PO/NG Q6H
MEDICATIONS CHANGED: Mycophenolate Sodium ___ 720 mg PO BID,
Calcium Carbonate 1000 mg PO/NG NOON dyspepsia, Tacrolimus 2 mg
PO Q12H ValGANCIclovir 450 mg PO 2X/WEEK (WE,SA)
- Patient to continue PO vancomycin for 2 weeks after last
dose of ceftriaxone (end date ___
- Patient to have repeat labs drawn on ___ in ___ and ___
have results faxed to ___ neprhology transplant ___.
They will be in touch with him for further follow up.
- Consider restarting isosorbide/hydral as tolerated
- Consider referral to psychiatrist as an outpatient. Patient
reported depressed mood and expressed desire to speak with a
psychiatrist but decided to try starting mirtazapine as an
inpatient first and potentially see psychiatry as an outpatient.
- Insulin dosing adjusted per ___ recs. Discharged on
Glargine 28 Units Breakfast and sliding scale which was provided
to patient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, confusion
Major Surgical or Invasive Procedure:
___: Left frontal craniotomy for tumor resection
History of Present Illness:
___ year old male who does not routinely seek preventative care
presents to OSH with headache, confusion, memory issues and word
finding difficulty x 2 weeks. History obtained by wife at
bedside due to patients altered mental status. She reports 2
weeks patient reported headache and she noticed progressively he
would be forgetful, confused on planned events, and over the
past week with word finding difficulty. She states he refused to
go to seek medical care until his confusion worsened and she
brought him to be evaluated. CT head showed left frontal brain
lesion with vasogenic edema with 1.4 mm MLS. He was transferred
to ___ ER for further evaluation. He is now s/p craniotomy for
tumor resection.
Past Medical History:
None
Social History:
___
Family History:
Father deceased pancreatic cancer
Physical Exam:
ON ADMISSION:
************
T:99 BP:112/76 HR:82 RR:17 O2Sats:98%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3mm bilaterally EOMs Full
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert , confused disoriented to
situation.
Orientation: Oriented to person, year with choices.
Language: Hypophonic, slow to respond to questions Speech
fluent,
with word finding difficulty
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to 2mm
bilaterally. Unable to test visual fields due to patients mental
status and unable to understand task
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. Right ptosis
V, VII: Right facial droop with normal sensation bilaterally.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius left stronger than RIGHT .
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
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ON DISCHARGE:
*************
___ ___ Temp: 97.9 PO BP: 102/73 HR: 63 RR: 18 O2 sat: 97%
O2 delivery: RA FSBG: 117
Exam:
Appears comfortable, eating breakfast in chair.
Opens eyes: [x] Spontaneous [ ] To voice [ ] To noxious
Orientation: [x] Person [x] Place [x] Time
Follows commands: [ ] Simple [x] Complex [ ] None
Pupils: PERRL 3-2mm bilaterally
EOM: [x] Full [ ] Restricted
Face Symmetric: [ ]Yes [x]No
Has mild right NL flattening, activates symmetrically
Tongue Midline: [x] Yes [ ] No
Pronator Drift [ ] Yes [x] No
Speech Fluent: [x] Yes [ ] No
Comprehension intact [x] Yes [ ] No
Motor: Moves all extremities symmetric, strength ___ throughout
Sensation: Intact to light touch
Wound:
[x] Healing incision, well approximated
[x] No drainage or signs of infection
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Medications on Admission:
Acetaminophen PRN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen 325 mg ___ tablet(s) by mouth Q6hr Disp #*90
Tablet Refills:*0
2. Dexamethasone 2 mg PO Q12H
RX *dexamethasone 2 mg 1 tablet(s) by mouth Q12hr Disp #*60
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *docusate sodium [Colace] 100 mg ___ capsule(s) by mouth
daily Disp #*60 Capsule Refills:*0
4. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 ___ daily; remove used patch prior
to new patch placement. Rotate sites. daily Disp #*28 Patch
Refills:*0
7. Senna 17.2 mg PO QHS:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *sennosides [senna] 8.6 mg ___ tablets by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left frontal brain metastasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with left brain lesion with vasogenic edema,
chest xray concern for mass// Metastatic workup
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen was done with IV
contrast. A single bolus of IV contrast was injected and the abdomen and
pelvis was scanned in the portal venous phase, followed by scan of the abdomen
in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.0 s, 26.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 201.3
mGy-cm.
2) Spiral Acquisition 4.9 s, 64.2 cm; CTDIvol = 8.4 mGy (Body) DLP = 536.9
mGy-cm.
3) Spiral Acquisition 2.0 s, 26.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 201.8
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.3 mGy (Body) DLP =
20.1 mGy-cm.
Total DLP (Body) = 962 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
No hydronephrosis in either kidney. There are bilateral hypoattenuating
lesions, some of which are cysts while the others are too small to
characterize. The largest cyst measures 4.2 cm (series 3, image 29). There
is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There are
scattered colonic diverticula, without findings of acute diverticulitis. The
colon and rectum are otherwise unremarkable. The appendix is unremarkable.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is not enlarged.
LYMPH NODES: No enlarged mesenteric, retroperitoneal, pelvic, or inguinal
lymph nodes.
VASCULAR: There is no abdominal aortic aneurysm. Ectasia of the bilateral
common iliac arteries are noted measuring up to 1.4 cm. Moderate
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is moderate loss of disc height with vacuum disc phenomenon at L4-5.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of malignancy within the abdomen and pelvis.
2. Please see separate report performed on the same day for detailed
evaluation of the chest.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with left frontal brain lesion with vasogenic
edema; can be completed with MRI WAND study, please include MPRage sequence//
Evaluate left frontal brain lesion; can be completed with MRI WAND study,
please include MPRage sequence
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: CT of the head dated ___.
FINDINGS:
There is a left frontal lobe mass measuring 2.2 x 2.4 x 2.3 cm (AP x TV x SI).
This demonstrates significant surrounding vasogenic edema, causing sulcal
effacement of the left frontal lobe, a 1.2 cm rightward midline shift with a
subfalcine herniation. The lesion enhances in homogeneously after contrast
administration with areas of limited enhancement that suggest necrosis. These
all only enhancing portion of the mass demonstrates slow diffusion, with fast
diffusion in the area that appears necrotic.
There is no evidence of hemorrhage or infarction. The intraorbital contents
are normal.
IMPRESSION:
1. In homogeneously enhancing left frontal lobe with extensive surrounding
edema and a suggestion of necrosis. Differential considerations include
metastatic disease or a primary neoplasm such as high-grade glioma.
2. Mass effect with 1.2 cm rightward midline shift.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with left brain lesion with vasogenic edema,
chest xray concern for mass// Metastatic workup
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 2.0 s, 26.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 201.3
mGy-cm.
2) Spiral Acquisition 4.9 s, 64.2 cm; CTDIvol = 8.4 mGy (Body) DLP = 536.9
mGy-cm.
3) Spiral Acquisition 2.0 s, 26.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 201.8
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.3 mGy (Body) DLP =
20.1 mGy-cm.
Total DLP (Body) = 962 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: None available.
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either axilla. No
lymphadenopathy in the right supraclavicular station, the largest measuring
approximately 2.0 x 2.5 cm. No abnormalities on the chest wall. Mild
atherosclerotic calcifications in the head and neck arteries.
HEART AND VASCULATURE:
The heart is normal in size and shape. No pericardial effusion. Mild
atherosclerotic calcifications in the coronary arteries and aorta, none in the
cardiac valves. The pulmonary arteries and aorta are normal in caliber
throughout.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Enlarged lymph nodes in the right paratracheal
station, the largest history necrotic center measuring 4.7 x 3.9 cm (302:67)
displaces and deforms the superior vena cava. Nodal tissue in the right hilum
measuring 1.3 x 1.2 cm (302:74) invades the anterior branch pulmonary artery.
No left hilar lymphadenopathy.
PLEURA:
No pleural effusions. No apical scarring bilaterally.
LUNGS:
Respiratory motion artifacts impair optimal parenchymal evaluation. The
airways are patent to subsegmental levels. No bronchial thickening,
bronchiectasis or mucus plugging. Lobulated mass in the posterior segment of
the right upper lobe (302:62) measuring approximately 2.9 x 2.2 x 1.4 cm.
CHEST CAGE:
No acute fractures. No suspicious lytic or sclerotic lesions.
UPPER ABDOMEN:
Please refer to same day abdominal CT report for subdiaphragmatic findings.
IMPRESSION:
Lobulated lung mass in the right upper lobe suspicious for primary lung
cancer. If clinically warranted, this lesion is assessable through CT-guided
percutaneous biopsy. Lymphadenopathy in the right hilum, right paratracheal
station and right supraclavicular station. No radiographically detected
osseous lesions.
Radiology Report
EXAMINATION:
Head CT.
INDICATION: ___ year old man with left frontal brain lesion s/p resection//
Evaluate for hemorrhage post craniotomy
TECHNIQUE: Multidetector CT images of the head were obtained without
intravenous contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.6 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: Recent MR from ___ and CT from ___.
FINDINGS:
Patient is status post interval resection of a ring-enhancing lesion in the
left frontal lobe. An air-fluid cavity at the site measures 22 mm in
diameter. More diffuse white matter abnormality in the left lobe frontal lobe
persists. The degree of rightward shift, previously measuring up to 14 mm on
CT, now measures 9 mm, so decreased. A more limited white matter abnormality
involving the medial right frontal lobe also persists. Left ventricular
system appears unchanged. There is no evidence of intracranial hemorrhage.
Anticipated pneumocephalus is found deep to left frontal craniotomy site. Air
is also expected in overlying soft tissues. Left frontal stable line is noted
superficially. Paranasal sinuses and mastoid air cells remain clear.
IMPRESSION:
Anticipated postoperative findings after resection of left frontal lobe mass.
Mild reduction in rightward mass effect.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with left frontal lesion s/p left craniotomy and
resection// Evaluate for residual tumor post resection
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: MRI head with and without contrast ___.
FINDINGS:
Postsurgical changes are seen secondary to a left frontal craniotomy for
resection of a left frontal lobe mass, including minimal scalp edema, a small
epidural collection, focal dural thickening and blood products within the
resection cavity. There is enhancement along the periphery of the resection
cavity. The degree of surrounding T2 signal abnormality, left frontal horn
effacement and midline shift are unchanged.
The ventricles and sulci are normal in caliber and configuration. The
paranasal sinuses, mastoid air cells and middle ear cavities are clear. The
intraorbital contents are normal.
IMPRESSION:
1. Postsurgical changes secondary to a left frontal craniotomy for resection
of a left frontal lobe mass.
2. Residual enhancement at the margin of surgical cavity identified
posteromedially.
3. Unchanged degree of surrounding T2 signal abnormality in midline shift.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with rising leukocytosis; POD#7 from brain tumor
resection// evaluate for infection
TECHNIQUE: Chest PA and lateral
COMPARISON: CT dated ___
FINDINGS:
There is a bilobed opacity projecting over the right upper lobe, likely not
significantly changed since the prior CT chest. No new focal consolidation is
seen. No pleural effusion or pneumothorax. Prominence of the right upper
mediastinum corresponds to known mediastinal lymphadenopathy. The size of the
cardiac silhouette is within normal limits.
IMPRESSION:
No focal consolidation. Known right upper lobe pulmonary mass and mediastinal
lymphadenopathy.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man POD# from craniotomy with rising leukocytosis.
Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Headache
Diagnosed with Altered mental status, unspecified
temperature: 99.0
heartrate: 82.0
resprate: 17.0
o2sat: 98.0
sbp: 112.0
dbp: 76.0
level of pain: 8
level of acuity: 2.0 | #Brain Lesion
Patient was found to have a left frontal brain lesion with
surrounding edema on NCHCT. He was admitted to the ___ for
close monitoring. MRI brain with and without contrast was
obtained which showed a homogeneously enhancing left frontal
lobe lesion with extensive surrounding edema, a suggestion of
necrosis and 1.2 cm rightward midline shift. CT torso was
obtained for malignancy workup which revealed a bilobed right
upper lobe pulmonary mass measuring up to 2.9 x 1.4 cm
concerning for primary lung cancer. Of note, CXR from OSH was
concerning for 2.7cm density in right upper lobe, suspicious for
mass. He went to the OR for left frontal craniotomy for
resection of the lesion in ___ - please see Dr. ___
___ operative report for further details. The resected tumor
was sent for pathology. He underwent a ___ in the PACU that
showed no significant hemorrhage. Following the procedure, he
was transferred back up to the ___ for close monitoring. He
underwent a post-operative MRI brain w/ and w/o that was
pertinent for expected post-operative changes. He was started on
decadron taper to 2 mg bid and keppra 1g bid. He was made floor
status on ___ and his neurologic checks were liberalized to
every 4 hours. Follow up was arranged with brain tumor clinic.
#Leukocytosis
WBC continued to rise. He remained afebrile and incision showed
no signs of infection. Infectious workup was ordered which was
unrevealing. Repeat CBC on ___ showed stable WBC at 20.1.
#Right upper lobe lung mass
Imaging revealed lung mass and thoracic oncology was consulted.
He will follow up in
thoracic ___ clinic. PET scan was scheduled as outpatient,
and PET scan instructions were provided to the patient.
#Speech, Language and Cognitive-linguistics evaluation
The patient was evaluated by SLP on ___ who recommended
services targeting language and cognitive-linguistic
intervention in order to maximize functional outcomes and
independence. Upon discharge, the patient was given outpatient
prescription for theses services.
At the time of discharge, the patient was tolerating a regular
diet, ambulating independently and following ___
recommendations, he was discharged home. His significant other
has agreed to assist the patient with minimal supervision and
help with IADLs. He will follow up in brain tumor clinic for
continued care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin / Neomycin / hydralazine / Statins-Hmg-Coa Reductase
Inhibitors
Attending: ___
Chief Complaint:
fall, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ yo M with h/o sCHF with EF ___ w/ICD, afib
on eliquis s/p AVJ ablation with RV pacing, DM, recent admission
to CCU for CHF now admitted with CHF exacerbation.
Mr. ___ recent medical history is notable a hosptilization
from ___ when he was admitted with GI bleed and
required ICU stay. that was complciated with difficult to
control afib with RVR preciptating cardiogenic shock and CCU
transfer. His TTE showed LVEF of ___ with mild MR. ___ mixed
venous was 27. He was diuresed with Lasix gtt 30 cc/hr and
dopanine 3 mcg/kg/min for a total of 20 L. His course has been
complicated by VT in the setting of hypokalemia requiring ICD
therapies, currently on digoxin, amiodarone and mexiletene. DCCV
was not performed given that it was thought it would be
unsuccesful given permanent AF. Not good location of CS lead and
CS thought not good candidate for epicardial lead at this time,
so CRT-D was not pursued. He underwent AVJ ablation. He was
discharged euvolemic on apixiban for stroke ppx and high risk of
GI bleed.
Discharged on ___, seen in ___ clinic on ___, at which time he
was felt to be volume overloaded, for which patient's metolazone
to 5 mg every other day. Then presented to the ED on ___ after
feeling weak and falling at home, with headstrike. Initially
seen in clinic, at which time he was noted to be hypotensive
(81/52) and ?EKG changes (per note, ST-T elevation in anterior
septal precordial leads V1), refered to the ED. Had trauma w/u
for head strike, which was negative. Repeat EKG unchanged from
prior, repeat SBP in ___, which was baseline during last
admission. Given pip-tazo. Labs notable for lactate 2.3, Cr 2.2
(baseline), trop 0.05, new mildly elevated transaminases, BNP
1700 and Na 121 (chronic). Seen in ED by cardiology who
recommended admission for decompensated heart failure, however
patient left AMA.
Today, ___ noted patient's systolics in ___. Patient's daughter
brought him back to the hospital.
In the ED intial vitals were: 97 90 108/69 18 99% RA
EKG: Vpaced at 90bpm cwp
CXR: some upper zone redistribution c/w volume overload
Labs/studies notable for: Na 126, Cr 2.1, BNP 1700, lactate 2.1.
Patient was given: nothing
Vitals on transfer: 97.4 91 90/56 16 100% RA
On the floor has no complaints, reports he feels fine, would
rather not be here. Patient denies fever, chills, any infectious
symptoms, SOB, ___ swelling (even though this is obvious on
exam), CP, palpitations, orthopnea or PND. He denies
lightheadedness
Of note, patient was hospitalized ___, initially
due to a GIB, followed by rapid atrial tachycardia,
decompensated heart failure, right sided failure and VT. He
ultimately failed rate control agents and underwent an AVJ
ablation with underlying RV pacing. His anatomy and epicardium
were unsuitable for BiV pacing.
REVIEW OF SYSTEMS: On review of systems, denies any prior
history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. Denies
recent fevers, chills or rigors. Denies exertional buttock or
calf pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-CAD: S/p CABG ___
-CHF: Most recent EF ___ s/p Implantable cardiac
defibrillator
-Atrial fibrillation, restarted on Coumadin recently (on hold
after ___)
-Diabetes II
-CKD, ~1.5-2.0
-HTN
-BPH
-SDH s/p left craniotomy for ___ evacuation on ___
Social History:
___
Family History:
Brother CAD/PVD - Early; Cancer - Prostate
Father ___ - Type II
Mother ___
Sister Cancer - Breast
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: 97.4 94/54 92 16 100RA
WT: 91.4kg
IO: 180/400
GENERAL: Tired appearing elderly gentlman, NAD, lying ___ in
bed. Delayed responses.
HEENT: NCAT. PERRL, EOMI. OP clear, MMM
NECK: Supple with JVP of at angle of jaw 30 degrees.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: unlabored. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ ___ edema with shins bandaged from water
blisters.
SKIN: Blistering of ___
___: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
=======================
VS: 98.2, 85-94/50-54, 87-91, 20, 98% RA
Ins/Outs: 660/100 (MN), 1476/1750+ (___)
Weights: 91.4kg -> 90.9 -> 91.8
GENERAL: Tired appearing elderly gentlman, NAD, lying ___ in
bed. Delayed responses.
HEENT: NCAT. PERRL, EOMI. OP clear, MMM
NECK: Supple with JVP of at angle of jaw 30 degrees.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: unlabored. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ ___ edema with shins bandaged from water
blisters.
SKIN: Blistering of ___
___: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS
==============
___ 01:30PM BLOOD WBC-8.0 RBC-3.71* Hgb-8.7* Hct-27.8*
MCV-75* MCH-23.5* MCHC-31.3 RDW-18.9* Plt ___
___ 01:30PM BLOOD Neuts-76.4* Lymphs-11.8* Monos-9.2
Eos-2.2 Baso-0.3
___ 01:30PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-1+ Burr-1+ Tear
Dr-1+ Acantho-OCCASIONAL
___ 01:30PM BLOOD ___ PTT-31.7 ___
___ 01:30PM BLOOD Glucose-143* UreaN-124* Creat-2.2*
Na-121* K-3.2* Cl-83* HCO3-25 AnGap-16
___ 01:30PM BLOOD ALT-49* AST-92* CK(CPK)-130 AlkPhos-52
TotBili-0.3
PERTINENT LABS
==============
___ 01:30PM BLOOD Lipase-49
___ 11:46AM BLOOD proBNP-1760*
___ 01:30PM BLOOD cTropnT-0.05*
___ 01:30PM BLOOD CK-MB-8
___ 01:30PM BLOOD Albumin-3.0*
___ 01:42PM BLOOD Lactate-2.3*
___ 11:37AM BLOOD Lactate-2.1* Na-123* K-4.4
___ 12:09AM BLOOD Lactate-1.9
DISCHARGE LABS
==============
___ 06:20AM BLOOD WBC-10.4 RBC-4.18* Hgb-9.6* Hct-32.5*
MCV-78* MCH-22.9* MCHC-29.4* RDW-20.4* Plt ___
___ 11:46AM BLOOD Neuts-75.6* Lymphs-12.4* Monos-9.4
Eos-2.4 Baso-0.2
___ 11:46AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-2+
___ 06:20AM BLOOD ___ PTT-31.0 ___
___ 06:20AM BLOOD Glucose-195* UreaN-106* Creat-2.4*
Na-121* K-4.9 Cl-88* HCO3-28 AnGap-10
___ 08:05AM BLOOD ALT-67* AST-72* AlkPhos-57 TotBili-0.6
___ 06:20AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.6
RELEVANT STUDIES
================
- CXR (___): Stable cardiomegaly with mild congestion and
probable tiny bilateral pleural effusions.
- CT HEAD W/O CONTRAST (___): Post-surgical changes with
dural thickening from prior left subdural hematoma evacuation.
No acute intracranial process.
- CT C-SPINE W/O CONTRAST (___):
1. No definite acute fracture of the cervical spine.
2. Subacute or chronic appearing fractures of the C7 and T1
spinous processes. Correlate clinically for tenderness over this
location.
3. Possible right thyroid nodule, nonemergent thyroid ultrasound
could be
performed if clinically indicated.
- CXR (___):
1. COPD and cardiomegaly, with AICD type device, similar to the
prior film.
2. There is upper zone redistribution, without other evidence of
CHF.
- CAROTID ULTRASOUND (___): Duplex evaluation was performed
of bilateral carotid arteries.
1. On the right there is Mild heterogeneous plaque in the ICA.
On the left there is mild heterogeneous plaque seen in the ICA.
2. On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 41/11, 62/18, 52/14
cm/sec. CCA peak systolic velocity is 50 cm/sec. ECA peak
systolic velocity is 31 cm/sec. The ICA/CCA ratio is 1.2. These
findings are consistent with <40% stenosis.
3. On the left systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 51/10, 45/11, 65/23
cm/sec. CCA peak systolic velocity 61 cm/sec. ECA peak systolic
velocity is 54 cm/sec. The ICA/CCA ratio is 1.1.These findings
are consistent with <40% stenosis.
4. Right antegrade vertebral artery flow.
5. Left antegrade vertebral artery flow.
Impression:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
- ARTERIAL DUPLEX UPPER EXTREMITIES (___): Widely patent
bilateral upper extremity subclavian, axillary and brachial
arteries without evidence of proximal or upper arm stenosis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO BID:PRN pain
2. Amiodarone 400 mg PO DAILY
3. Bisacodyl ___ mg PO DAILY:PRN if no bowel movements.
4. Docusate Sodium 100 mg PO BID
5. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN rash
6. Aspirin 81 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Apixaban 2.5 mg PO BID
11. Bumetanide 5 mg PO BID
12. Mexiletine 150 mg PO Q8H
13. Pantoprazole 40 mg PO Q24H
14. Sertraline 25 mg PO DAILY
15. Spironolactone 37.5 mg PO DAILY
16. TraZODone 25 mg PO QHS:PRN insomnia
17. Cetirizine 10 mg PO DAILY:PRN allergies
18. Ferrous Sulfate 325 mg PO QOD
19. Multivitamins 1 TAB PO DAILY
20. pitavastatin 4 mg oral DAILY
21. Potassium Chloride 60 mEq PO DAILY
22. Vitamin D 4000 UNIT PO DAILY
23. Zolpidem Tartrate 5 mg PO QHS
24. Metolazone 2.5 mg PO QOD:PRN weight gain >2 lbs in 24
hours
25. Glargine 45 Units Breakfast
Glargine 45 Units Bedtime
Discharge Medications:
1. Amiodarone 400 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___ mg PO DAILY:PRN if no bowel movements.
5. Bumetanide 5 mg PO BID
6. Cetirizine 10 mg PO DAILY:PRN allergies
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO QOD
9. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN rash
10. Glargine 45 Units Breakfast
Glargine 45 Units Bedtime
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Mexiletine 150 mg PO Q8H
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. pitavastatin 4 mg oral DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Sertraline 25 mg PO DAILY
18. Spironolactone 37.5 mg PO DAILY
19. TraZODone 25 mg PO QHS:PRN insomnia
20. Vitamin D 4000 UNIT PO DAILY
21. Zolpidem Tartrate 5 mg PO QHS
22. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
23. Metolazone 2.5 mg PO QOD:PRN weight gain >2 lbs in 24
hours
24. Metoprolol Succinate XL 25 mg PO DAILY
25. Potassium Chloride 60 mEq PO DAILY
Hold for K >
26. Acetaminophen 500 mg PO BID:PRN pain
27. Shower Chair
Shower Chair
ICD9: 428.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Heart failure with reduced ejection fraction
Asymptomatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chf // eval for chf
COMPARISON: ___ at 14 35
FINDINGS:
Probable background hyperinflation/COPD. The patient is status post
sternotomy. The cardiomediastinal silhouette is enlarged, but unchanged.
Left-sided pacemaker/AICD type device is present, with lead tip unchanged.
Multiple epicardial pacing wire is are present, similar to the prior film.
There is upper zone redistribution, but no overt CHF. No focal infiltrate or
effusion is identified. Minimal atelectasis versus slight thickening of the
minor fissure is noted. Slight pleural thickening along lower chest walls
bilaterally may relate to body habitus rather than frank pleural thickening.
.
IMPRESSION:
1. COPD and cardiomegaly, with AICD type device, similar to the prior film.
2. There is upper zone redistribution, without other evidence of CHF.
Radiology Report
EXAMINATION: ART DUP EXT UP BILAT COMP
CLINICAL HISTORY ___ year old man with discrepant blood pressures, systolics
with doppler 87 left upper extrem, 72 RUE, 135 right calf // please assess
bilateral carotid, subclavian, and axillary arteries for stenosis please
assess bilateral carotid, subclavian, and axillary ar
FINDINGS:
Bilateral upper extremity arterial duplex was performed from the subclavian
through the brachial arteries.
Right:
The right subclavian artery waveform is bi/triphasic with normal velocities
ranging from 88- 113 cm/ second. Similarly the axillary and brachial artery
waveforms are triphasic with velocities ranging from 87-97cm/second.
Left:
The left subclavian artery waveforms are triphasic with velocities ranging
from 60-85 cm/ second. The left axillary and brachial waveforms are also
triphasic with velocities ranging from 60-80 cm/second.
IMPRESSION:
Widely patent bilateral upper extremity subclavian, axillary and brachial
arteries without evidence of proximal or upper arm stenosis.
Radiology Report
FINDINGS:
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: CHF, Asx hyotension
Findings:
Duplex evaluation was performed of bilateral carotid arteries. On the right
there is Mild heterogeneous plaque in the ICA. On the left there is mild
heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 41/11, 62/18, 52/14 cm/sec. CCA peak systolic
velocity is 50 cm/sec. ECA peak systolic velocity is 31 cm/sec. The ICA/CCA
ratio is 1.2. These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 51/10, 45/11, 65/23 cm/sec. CCA peak systolic velocity
61 cm/sec. ECA peak systolic velocity is 54 cm/sec. The ICA/CCA ratio is 1.1.
These findings are consistent with <40% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Palpitations, Dizziness
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 97.0
heartrate: 90.0
resprate: 18.0
o2sat: 99.0
sbp: 108.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ yo M with h/o sCHF with EF ___ w/ICD, afib
on eliquis s/p AVJ ablation with RV pacing, DM, recent admission
to CCU for CHF. Last EF ___. BNP 1700 on admission (range
___. Recent admission complicated by patient's poor
adherecene to fluid restrictions leading to worsened heart
failure. Decompensated heart failure on last admission in
setting of uncontrolled atrial fibrillation. He underwent AVJ
ablation but was deemed not to be candidate for advanced
therapies. On this admission, pt was optimized and sent home, as
it appears he is compliant with regimen at home and had lost
___ since discharge on ___, and pt had attended clinic
appts. Diuresis and home treatment limited by low measurements
of SBP but pt has been asymptomatic. On reexamination, after
being on bumex gtt for several hours, pt appears to be stable at
SBP 85 in L arm, perfusing all organs and mentating well. Will
be new threshold for normotension, with no need to use
telemonitoring, and no need to check BPs or worry about measured
BPs if pt is asymptomatic and LUE cuff pressure is above 70.
Sent home with information for how to get shower chair and
LifeAlert home monitoring. Set up old ___ per
pt preference. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
stupor and involuntary movements
Major Surgical or Invasive Procedure:
spinal tap
History of Present Illness:
Mr. ___ is a ___ left-handed man presenting with
Stupor and involuntary movements on a background of no other
medical problems.
Per ___, his friend:
He has been doing well until this week. Since about ___ he
has not slept well and this may have happened two weeks ago
also.
On that prior occasion, he was awake for two days straight and
then slept for one whole day. He had been rejected two weeks
ago by one college and became scarred. Now he stays awake
waiting to hear about another school.
This time, he has not slept since ___. He went to the gym
last night and then took tablets of melatonin at 2 AM. He went
to his room, closed the door. This morning, his friend ___, his room mate that has known and lived with him for
one year, was going to go to class at 8:55 AM and ___ was
still not awake. He went into the room to find him in bed,
covered in blankets, breathing quickly and deep. ___ called
him, shook and nothing happened. He put water on his face, then
tickled his nose with a tissue and nothing happened. He called
___ and they instructed to turn him on his side. When he did
this, he noted that ___ breathed even more quickly and was
rigid with arms straight without any rhythmic movement.
The heating system is old and seems to have been central. He
usually closes his door. Nothing like this has happened before.
Per the patient when more conversant later:
He has lost 20 kg of weight in the last two months. He has been
coughing recently, but there was no blood in his sputum. He had
one episode of some bright red blood with stool a week or so
ago.
His vision and hearing have both been slightly worse over this
period also. He saw an optometrist who seems to have found one
eye myopic and the other presbiopic. Over the last two days he
has had nucal pain and posterior headache that has been
worsening. There have been no head injuries or other trauma,
but
he has been frequently going to the gym. He has been very
stressed waiting to hear about his college applications. He
also
states not taking any other medications, but he did take
melatonin twice yesterday. There is no double vision, but on
looking to the extreme left, objects fatten slightly and blur.
Further review of systems was negative except as above.
Past Medical History:
None
Social History:
___
Family History:
Older brother that "thinks like a ___ year old boy"
Younger brother with "breathing problems"
Physical Exam:
ADMISSION:
Vitals: 99.1 F, 90 BPM, 128/86 (180/94 on arrival) mmHg, 16
breaths, 100% RA
He is lying still on the bed with an obvious right ptosis and
irregular jerk of the right leg. He is slim, well groomed and
looks otherwise healthy. His head and neck are of normal
appearance. There is no meningismus and his neck is supple.
Mouth is moist. Normal ears and nose without rash. Lungs are
vescicular, heart sounds dual, near tachycardic. Abdomen is
mildly tender to palpation. Skin appears normal.
He is awake, but is mildly stuporous and complains that he feels
sleepy. He can state his name, but earlier, when still showing
irregular jerking of right leg, would sometimes show interuption
to his speech, pause briefly then resume where he left off. He
says that he has been recently forgetting things and feels that
his memory is not right, but was able to register and recall
three words. He is presently learning ___, but has
excellent
comprehension and spoken language and rarely does not know an
uncommon word, which seems to be that this was not previously
know - for example, he did not know the term for feces, but
described urine as normal.
Cranial Nerves:
I: Not tested.
II: Pupils symmetric, round and reactive to light, 5 to 3 mm
bilaterally. Visual fields are full to confrontation. Fundi are
normal. There is a right ptosis that is partial, but more than
typical with Horner's syndrome, perhaps 3-4 mm.
III, IV, VI: Extraocular movements full, conjugate and without
nystagmus.
V, VII: He has mild right facial weakness. Facial sensation
intact.
VIII: Hearing intact to voice, but dimished mildly on left
compared to the right.
IX, X: Palatal elevation symmetric.
XI: Sternocleidomastoid and trapezius are of normal bulk and
strength bilaterally.
XII: Tongue slightly weaker on protusion to left.
Tone and Bulk:
Tone is normal throughout (arms, legs, neck). Muscle bulk is
normal.
Power is reduced in an upper motor neuron pattern on the right
hemibody with slightly greater weakness in the right leg -
initially the IP was just antigravity, then later was ___, as
was
the hamstring 3 to ___ on the right. On the right there was a
no
less than ___ pattern of upper motor neuron weakness and on the
left there was very trace upper motor neuron weakness in the arm
only.
Reflexes were symmetrically brisk in the leg with bilateral
cross-adductor, but down-going toes.
Pinprick was diminished on the right hemibody, but not on the
face.
Coordination and Cerebellar Function:
RAM's were slowed bilaterally. There was bilateral overshoot on
finger-nose-finger, without intention tremor.
Gait:
Not tested.
DISCHARGE:
Fully oriented and able to converse.
Pertinent Results:
___ 10:25AM PLT COUNT-180
___ 10:25AM NEUTS-50.8 ___ MONOS-6.6 EOS-4.3*
BASOS-0.9
___ 10:25AM WBC-4.7 RBC-5.21 HGB-15.9 HCT-48.0 MCV-92
MCH-30.6 MCHC-33.2 RDW-12.8
___ 10:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:25AM TSH-2.4
___ 10:25AM GLUCOSE-107* UREA N-13 CREAT-1.0 SODIUM-143
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-28 ANION GAP-12
___ 10:26AM GLUCOSE-97 LACTATE-1.2
___ 12:18PM O2 SAT-77 CARBOXYHB-2
___ 12:18PM ___ PO2-46* PCO2-50* PH-7.35 TOTAL
CO2-29 BASE XS-0 COMMENTS-GREEN TOP
___ 01:15PM BLOOD ___ * Titer-1:80
___ 01:15PM BLOOD CRP-0.5
___ 01:15PM BLOOD HIV Ab-NEGATIVE, HIV RNA not detected
RPR non reactive
___ VIRUS VCA-IgG AB (Final ___: NEGATIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1:10
BY IFA.
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
50 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
___ 01:00PM CEREBROSPINAL FLUID (CSF) WBC-25 RBC-3225*
POLYS-49 ___ MONOS-11 EOS-1
___ 01:00PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-83*
POLYS-27 ___ ___ 01:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-24
GLUCOSE-73
___ 01:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:45PM URINE HOURS-RANDOM
CXR ___: No acute cardiopulmonary process.
NCHCT ___: No acute intracranial process.
EEG ___: This is a normal awake and sleep EEG. There are no
epileptiform discharges, seizures, or focal slowing recorded. No
note is made of abnormal movements during this study.
MR head w/wo contrast ___: No intracranial abnormalities.
MRA brain w/o contrast ___: No abnormalities.
MRA neck w/wo contrast ___: No abnormalities.
Medications on Admission:
None
Discharge Medications:
1. Lorazepam 1 mg IV Q6H:PRN anxiety
2. Acetaminophen 650 mg PO Q6H:PRN pain or fever
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aseptic meningitis
Depression with suicidal ideations
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with new onset dysmetria and dysarthria.
COMPARISON: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass
effect, or infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation.
No fracture is identified. There are mucous retention cysts in the left
maxillary maxillary and left sphenoid sinuses. Visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The globes are intact.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: New onset seizure disorder.
TECHNIQUE: AP upright portable view of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: ___ man, with seizure and cranial neuropathy. Assess for
basal meningitis, HSV encephalitis.
COMPARISON: CT head without contrast on ___.
TECHNIQUE:
MRI HEAD: Multiplanar, multisequence T1- and T2-weighted images were acquired
through the head before and after administration of IV gadolinium contrast.
Diffusion-weighted images and ADC maps were also obtained for evaluation.
MRA HEAD: Non-contrast 3D time-of-flight images were acquired through the
head per standard MRA head protocol. Dedicated 3D rendering was performed to
better visualize the underlying vessels.
MRA NECK: Coronal images were acquired through the neck before and after
administration of IV gadolinium contrast per standard MRA neck protocol.
Dedicated 3D rendering was performed to better assess the underlying vessels.
FINDINGS:
MRI HEAD: The image quality is mildly motion-degraded. Postcontrast MPRAGE
images are further limited by wrap-around and other artifacts, but
postcontrast axial T1 weighted images are diagnostic. There is no abnormal
enhancement in the brain parenchyma, along the cranial nerves or along the
meninges. There is no edema, mass effect, abnormal diffusion, or evidence of
blood products in the brain. The ventricles and sulci are normal in size and
symmetric in configuration. There are small mucus-retention cysts in the left
maxillary and sphenoid sinuses. The globes are unremarkable.
MRA HEAD: The image quality is motion-degraded. Major intracranial vessels
appear patent without evidence of hemodynamically significant stenoses. There
is no evidence of an aneurysm.
MRA NECK: There is a normal three-vessel aortic arch. The origin of the left
vertebral artery is excluded from the imaged volume. Other major cervical
vessels are patent without hemodynamically significant stenoses.
IMPRESSION:
1. Unremarkable MRI head, allowing for motion artifacts. No evidence of
abnormal enhancement to suggest basal meningitis. No evidence of HSV
encephalitis.
2. Normal MRA of the neck.
3. Unremarkable MRA of the head, allowing for motion artifacts.
Please note that the original report for this study was lost. This report is
issued on ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FOR EVAL
Diagnosed with OTHER CONVULSIONS
temperature: 98.0
heartrate: 97.0
resprate: 16.0
o2sat: 99.0
sbp: 180.0
dbp: 94.0
level of pain: 0
level of acuity: 3.0 | This is a ___ yo left-handed male presenting with three nights of
sleep deprivation found to be difficult to arouse, then with
involuntary bilateral semi-rhythmic movements in the setting of
multiple life stressors, 20 kg unintentional weight loss, and
mildly impaired hearing and vision.
# NEURO:
In the emergency room, the patient was started on phenytoin and
acyclovir for concern of meningitis. Lumbar puncture results
were consistent with an inflammatory process with mild
pleocytosis, though no clear lymphocytic or neutrophilic
predominance, and negative gram stain consistent for aseptic
meningitis. Preliminary infectious work-up was reassuring, with
negative HSV, CMV, and HIV studies (EBV/lyme serologies,
CSF/stool studies pending). Concern for systemtic
inflammatory/autoimmune processes was low given ESR and CRP were
both within normal limites. EEG results were also reassuring for
no epileptiform discharges, seizures, or focal discharges.
Acyclovir and phenytoin was discontinued on hospital day two.
Clinical symptoms were significantly improved at that time with
stable mental status, near full motor strength at the upper and
lower extremities, and increased sensation at the right lower
leg, which was initially absent on admission.
# PSYCH:
The patient endorsed depressive symptoms since childhood,
acutely worsening over the past month with active suicidal
ideations and plans. The psychiatry team evaluted the patient on
hospital day two and found that the patient met ___
criteria. Medical work-up from a neurologic perspective appeared
most consistent with clinically resolving aseptic meningitis.
Patient was transferred to an inpatient psychiatry unit on
___ given that he remained at high risk for self-harm with
concrete plans and no protective factors identified. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Triple Antibiotic
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an ___ with medical history of ESRD via LUE AVF
(___), DMII, HTN, Hx DVT, who presented to the ED with chest
pain occurring just PTA while at dialysis, got most of dialysis
but did not finish. She initially reported a ___ sub-sternal
chest pain that she described as pressure-like, no radiation,
+dyspnea with pain, denies vomiting or diaphoresis, and lasted
45 minutes. Not pleuritic or positional. Pain gradually improved
and was ___ in the ED but intermittently in the mild range.
Denies fever or chills. She notes that she is on antibiotics for
recent respiratory illness.
Of note, she has a well-documented history of similar symptoms
while getting dialysis with multiple ED visits. She does not
have these symptoms at rest or with walking; only with dialysis.
She had a normal myocardial perfusion study with preserved left
ventricular systolic function in ___. DSE in ___
that showed: "Resting images were acquired at a heart rate of 91
bpm and a blood pressure of 120/60 mmHg. These demonstrated
normal regional and global left ventricular systolic function.
Right ventricular free wall motion is normal. There is no
pericardial effusion. Doppler demonstrated no aortic stenosis,
aortic regurgitation or significant mitral regurgitation or
resting LVOT gradient."
She was also was seen in ___ ED ___ for chest pain; seen
by
Cardiology attg on call who noted that she had similar
presentations in the past, negative DSE as above. Per his note:
"Transient CP in setting dialysis, likely reflecting volume
shifts."
In the ED initial vitals were: 97.8 76 146/76 20 98% RA.
EKG: NSR, poor baseline, old inferior Q waves, similar
morphology to prior
Labs/studies notable for: Hgb 9.9, wbc 12.3, chemistries notable
for K 6.2 (hemolyzed), repeat K 5.1, and Cr 2.5 (on HD).
Troponin 0.03. MB 1. Coags WNL.
Vitals on transfer: T 97.7, HR 74, BP 134/65, O2 95% RA.
On the floor patient is a&ox3. She denies chest pain, chest
pressure, and shortness of breath. She endorses muscle pain in
both her arms as well as mild burning pain in her legs. She
feels tired but otherwise well.
Past Medical History:
END STAGE RENAL DISEASE
DIABETES, TYPE II
ATRIAL FIBRILLATION
LOW BACK PAIN
GOUT
HYPERTENSION
OSTEOARTHRITIS
SLEEP APNEA
HYPERLIPIDEMIA
ANEMIA
SHOULDER PAIN
SIALADENITIS
NARCOTICS AGREEMENT
Social History:
___
Family History:
-Mother died at ___ of stroke, hypertension, acute renal failure.
-Father died in his ___. She has no sisters.
-She has two brothers. One died at ___ of diabetes and coronary
artery disease. The other one is still alive and is in
reasonably good health.
-She has two daughters, ___ and ___, in good health.
-She has two sons, the eldest one the ___ has liver
cancer and the younger one, ___, is legally blind.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 97.7, HR 74, BP 134/65, O2 95% RA
GENERAL: Obese female, lying in bed. Oriented x3. Mood, affect
appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. No JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, obese, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. Slightly tender to palpation. Has LUE AVF
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
VS: T 98.7, HR 85, BP 108/51, O2 92% RA
GENERAL: Alert and oriented, NAD. Breathing comfortably.
HEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No
pallor or cyanosis of the oral mucosa.
NECK: Supple. No JVD
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, obese, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. Slightly tender to palpation. Has LUE AVF
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
LABS:
Basic labs:
___ 12:00PM BLOOD WBC-12.3* RBC-3.23* Hgb-10.4* Hct-32.6*
MCV-101* MCH-32.2* MCHC-31.9* RDW-17.0* RDWSD-61.2* Plt ___
___ 06:55AM BLOOD WBC-9.5 RBC-2.96* Hgb-9.2* Hct-30.0*
MCV-101* MCH-31.1 MCHC-30.7* RDW-17.3* RDWSD-61.5* Plt ___
___ 12:00PM BLOOD ___ PTT-26.0 ___
___ 12:00PM BLOOD Glucose-100 UreaN-12 Creat-2.5*# Na-137
K-6.2* Cl-95* HCO3-27 AnGap-21*
Cardiac enzyme trend:
___ 12:00PM BLOOD CK-MB-1
___ 12:00PM BLOOD cTropnT-0.03*
___ 11:38PM BLOOD CK-MB-<1 cTropnT-0.04*
___ 06:55AM BLOOD CK-MB-<1 cTropnT-0.04*
MICRO: None
STUDIES:
___ CXR:
IMPRESSION:
Heart size is prominent. There is tortuosity of the thoracic
aorta. There are low lung volumes. There is atelectasis at the
lung bases. No focal consolidation is seen. There is mild
pulmonary edema. There is a rounded 15 mm density at the right
base. This appears new since the previous study and may
represent a parenchymal lung nodule. Nonemergent chest CT could
be performed for further evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Midodrine 10 mg PO TID
6. Nephrocaps 1 CAP PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
8. Senna 8.6 mg PO BID:PRN constipation
9. Sertraline 50 mg PO DAILY
10. sevelamer CARBONATE 1600 mg PO TID W/MEALS
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. B complex with C#20-folic acid 1 mg oral DAILY
13. Levocarnitine 330 mg PO TID
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Atorvastatin 20 mg PO QPM
16. Lidocaine 5% Patch 1 PTCH TD QAM pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. B complex with C#20-folic acid 1 mg oral DAILY
6. Docusate Sodium 100 mg PO BID
7. Levocarnitine 330 mg PO TID
8. Lidocaine 5% Patch 1 PTCH TD QAM pain
9. Midodrine 10 mg PO TID
10. Nephrocaps 1 CAP PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 8.6 mg PO BID:PRN constipation
15. Sertraline 50 mg PO DAILY
16. sevelamer CARBONATE 1600 mg PO TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Chest 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: History: ___ with chest pain // Effusion, edema, infiltrate
COMPARISON: Radiographs from ___.
IMPRESSION:
Heart size is prominent. There is tortuosity of the thoracic aorta. There
are low lung volumes. There is atelectasis at the lung bases. No focal
consolidation is seen. There is mild pulmonary edema. There is a rounded 15
mm density at the right base. This appears new since the previous study and
may represent a parenchymal lung nodule. Nonemergent chest CT could be
performed for further evaluation.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified, Localized edema, End stage renal disease
temperature: 97.8
heartrate: 76.0
resprate: 20.0
o2sat: 98.0
sbp: 146.0
dbp: 76.0
level of pain: 4
level of acuity: 2.0 | Ms. ___ is an ___ with ESRD via LUE AVF (___), DMII,
HTN, Hx DVT and multiple ED visits and prior admission for chest
pain in the setting of hemodialysis, admitted for chest pain in
the setting of HD.
# Chest pain: Patient has had several prior episodes of chest
pain c/w typical angina i/s/o dialysis, likely caused by
intravascular fluid shifts. No CAD history, but risk factors
include ESRD, DM2, HTN, HLD, and age. Trop in ED to 0.03, and MB
1. Pharm MIBI in ___ was normal. Patient reports history of
similar recent episodes that only happen during dialysis. Plan
is for outpatient cardiac follow up with potential for
outpatient stress testing.
Chronic issues
# Atrial fibrillation: not on OAC- after discussion with her
nephrologist Dr. ___ year, the decision was made to
not continue warfarin given the unclear net clinical benefit in
the HD population with Afib. Continued home amiodarone and
aspirin 81mg.
# ESRD: Has LUE AVF for access, and gets HD ___. Completed
most of session on day of admission prior to developing chest
pain. She will continue to get
# Orthostatic hypotension:
- cont home midodrine
# OA on chronic narcotics
- Cont home oxycodone, acetaminophen, lidocaine and gabapentin
# Depression:
- cont home sertraline
# T2DM:
- qACHS fingersticks and ISS with Humalog while in house
# HLD:
- cont home atorvastatin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with CAD c/b
STEMI s/p DES x2 (___), DMII (diet-controlled), HLD, and recent
admission (___) at ___ for NSAID-induced ___
with nephrotic syndrome, as well as admission at ___
(___) for basal ganglia ischemic stroke s/p tPA
administration, with course c/b IPH secondary to right temporal
lobe mass, presenting with dizziness and nausea.
After his most recent admission he was discharged without
residual deficits and has been living at home, doing well.
The patient is an imperfect historian, but reports ___ days
prior
to this admission he began having intermittent dizziness,
tinnitus, as well as nausea, vomiting, periumbilical abdominal
pain, dyspnea, palpitations, and chills. The time course is
somewhat unclear as to which symptoms came first.
His symptoms have acutely worsened the morning of admission and
he has been persistently dizzy since waking up this morning,
unable to tolerate PO, and unable to walk secondary to
dizziness.
He denies fevers, chest pain, focal numbness/weakness/tingling
of
any extremity, or speech problems.
Neurology was consulted in the ED.
Impression: "Given positive orthostatics, positionally related
dizziness, and some improvement noted since fluids started, his
dizziness is most likely due to orthostasis. His exam appears
mostly unchanged compared to previous, with the exception of
bidirectional nonfatiguable nystagmus, which was not previously
noted in notes. He did have a small vermal bleed in his last
admission, which could potentially produce this finding. It
would
not be unreasonable to obtain a repeat MRI brain however, though
the suspicion is lower. He does not have any EOM abnormalities
however or other brainstem findings. His NCHCT does not show new
bleed, old blood has been reabsorbed, his mass appears stable.
The imaging being stable is reassuring that a new neurologic
process is less likely to be involved in regards to his symptoms
today.
- consider medicine admission for treatment/workup of ___,
elevated proBNP, abdominal pain
- will follow on consult service
- consider MRI head w/o contrast (preferably with contrast, but
Cr 5.5) once admitted"
In the ED, initial vitals: 99.6 74 182/104 20 99% RA
- Labs notable for:
BNP 37K (baseline unknown)
WBC 11.2
Hb 9.6
Cr 5.5 (at baseline)
Lactate 2.0
Trop 0.02
- Imaging notable for:
NCHCT
IMPRESSION:
1. There is known evolution of an approximately 3.3 x 1.7 cm
right temporal hematoma since ___.
2. The previously described midline cerebellar hematoma is not
well seen on today's exam, better seen on dedicated MR from
___. No new intracranial hemorrhage or large acute
infarct.
- Pt given:
___ 16:20 IV Ondansetron 4 mg
___ 16:20 IVF LR Started 150 mL/hr
___ 20:19 IV Ondansetron 4 mg
- Vitals prior to transfer: 77 179/99 16 95% RA
Upon arrival to the floor, the patient reports the story as
above. As he was moved from the stretcher to the bed he vomiting
some non-bloody vomitus and felt quite dizzy. States he feels
quite dehydrated, and he felt better when he got fluids in the
ED.
Past Medical History:
PMH/PSH:
CAD c/b STEMI s/p DES x2 (___)
DMII (diet-controlled)
HLD
Recent admission for NSAID-induced ___ with nephrotic syndrome
Social History:
___
Family History:
Notable for multiple family members with strokes on father's
side, as well as ?CRAO in mother apparently treated with
warfarin, c/b fatal ICH.
Physical Exam:
PHYSICAL EXAM:
VITALS: 98.3 ___ 98Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
GU: No Foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities
DISCHARGE EXAM
General: Alert, oriented, no acute distress
CV: Normal rate, regular rhythm, normal S1 + S2, no murmurs,
rubs, or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
GU: No Foley
Ext: Warm, well perfused, no ___ edema
Neuro: Alert and oriented x3. Right-beating end-gaze nystagmus
with rightward gaze that does not extinguish, no vertical skew,
positive head impulse test. No dysmetria with finger-nose or
heel-shin.
Pertinent Results:
ADMISSION
___ 02:55PM BLOOD WBC-11.2* RBC-3.50* Hgb-9.6* Hct-31.2*
MCV-89 MCH-27.4 MCHC-30.8* RDW-13.3 RDWSD-43.4 Plt ___
___ 02:55PM BLOOD Neuts-87.2* Lymphs-6.1* Monos-4.5*
Eos-0.5* Baso-0.6 Im ___ AbsNeut-9.78* AbsLymp-0.68*
AbsMono-0.51 AbsEos-0.06 AbsBaso-0.07
___ 03:36PM BLOOD ___ PTT-29.1 ___
___ 02:55PM BLOOD Glucose-131* UreaN-54* Creat-5.5* Na-147
K-5.1 Cl-108 HCO3-19* AnGap-20*
___ 02:55PM BLOOD ALT-15 AST-28 AlkPhos-165* TotBili-0.5
___ 02:55PM BLOOD cTropnT-0.02* ___
___ 02:55PM BLOOD Albumin-2.4*
___ 06:50AM BLOOD Calcium-7.7* Phos-6.8* Mg-2.4
___ 02:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:05PM BLOOD Lactate-2.0'
DISCHARGE
___ 05:50AM BLOOD WBC-7.2 RBC-2.89* Hgb-7.8* Hct-25.5*
MCV-88 MCH-27.0 MCHC-30.6* RDW-13.2 RDWSD-42.5 Plt ___
___ 05:50AM BLOOD Glucose-83 UreaN-49* Creat-5.6* Na-144
K-3.6 Cl-109* HCO3-21* AnGap-14
___ 05:50AM BLOOD Calcium-7.2* Phos-4.6* Mg-2.2
___ 07:05AM BLOOD calTIBC-113* ___ TRF-87*
___ 06:50AM BLOOD ALT-25 AST-16 AlkPhos-160* TotBili-0.3
IMAGING
___ MRI HEAD
1. Unchanged findings consistent with a right temporal lobe
subacute
intraparenchymal hematoma.
2. No evidence of increased blood flow
3. Spectroscopic analysis is nondiagnostic due to field
inhomogeneity caused by the hematoma.
4. No acute infarct.
___ RENAL ARTERY ULTRASOUND
Unremarkable renal ultrasound. No evidence of significant renal
artery
stenosis. Mild stenosis would be better evaluated on MRA or
CTA, if
clinically applicable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sodium Bicarbonate ___ mg PO TID
2. Calcium Acetate 667 mg PO TID W/MEALS
3. HydrALAZINE 25 mg PO TID
4. Labetalol 200 mg PO BID
5. Furosemide 80 mg PO QAM
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. CARVedilol 25 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Meclizine 12.5 mg PO TID
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Sodium Bicarbonate 1300 mg PO TID
9. Calcium Acetate 667 mg PO TID W/MEALS
10. HELD- Furosemide 80 mg PO QAM This medication was held. Do
not restart Furosemide until directed by nephrologist.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
- Intracerebral hemorrhage
- Vertigo
SECONDARY
=========
- Hypertension
- Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with dizziness s/p stroke// ? stroke
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: MR head from ___.
CT head without contrast from ___.
FINDINGS:
Hypodensity in the right temporal lobe at the site of prior hematoma likely
reflects developing encephalomalacia. Previously described midline cerebellar
hematoma is less conspicuous. There is no new intracranial hemorrhage or
large acute infarct. The ventricles and sulci are unchanged. There is stable
appearance of chronic infarcts in the right caudate head and putamen.
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. Developing encephalomalacia at the site of prior right temporal lobe
hemorrhage.
2. Previously noted midline cerebellar hematoma not well seen on current exam.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with dyspnea, dizziness, elevated BNP, ?
pneumonia, pulm edema// ___ year old man with dyspnea, dizziness, elevated BNP,
? pneumonia, pulm edema
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Outside reference chest radiograph ___.
IMPRESSION:
There is no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. There is no pulmonary
edema. No acute osseous abnormalities are identified.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with R subcortical infarct with tPA
administration c/b IPH in ___, now with vertigo and nausea, ? new
infarct/bleed// ___ year old man with R subcortical infarct with tPA
administration c/b IPH in ___, now with vertigo and nausea, ? new
infarct/bleed
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: MRI of ___ and CT of ___.
FINDINGS:
An area of restricted diffusion in the right temporal lobe indicate subacute
hematoma with peripheral rim of hemosiderin. No other areas of restricted
diffusion seen to indicate acute infarct. There is no mass effect midline
shift or hydrocephalus. Chronic infarct in right parietal lobe with changes
of small vessel disease are again seen. Vascular flow voids are maintained.
IMPRESSION:
1. No acute infarcts are identified.
2. Subacute intra-axial hematoma is seen in the right temporal lobe with
peripheral continuous rim of hemosiderin, evolved from the previous MRI and
unchanged in size compared to the CT..
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: ___ year old man with CAD c/b STEMI s/p DES x2 (___), DMII
(diet-controlled), HLD, basal ganglia stroke now with persistent hypertension.
Working up for secondary causes of hypertension.// evaluate for renal artery
stenosis
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: Noncontrast CT torso dated ___.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Right kidney: 10.9 cm
Left kidney: 11.7 cm
Renal Doppler: Intrarenal arteries show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive indices of the
right intra renal arteries range from 0.7-0.8. The resistive indices on the
left range from 0.73-0.85. Bilaterally, the main renal arteries are patent
with normal waveforms. The peak systolic velocity on the right is 48
centimeters/second. The peak systolic velocity on the left is 50.5
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Unremarkable renal ultrasound. No evidence of significant renal artery
stenosis. Mild stenosis would be better evaluated on MRA or CTA, if
clinically applicable.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with right temporal mass.// Eval right temporal
mass vs hematoma **ASL and multivoxel MR spectroscopy**
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained. Signal multi voxel spectroscopic analysis was also performed.
COMPARISON MRI head without contrast ___
CT head without contrast ___.
FINDINGS:
An area of T2/FLAIR hyperintense signal and slow diffusion is re-demonstrated
in the right temporal lobe with peripheral hemosiderin deposition, unchanged.
Spectroscopic analysis is nondiagnostic due to field inhomogeneity from the
hematoma.
Perfusion imaging demonstrates no evidence of elevated blood flow associated
with the hematoma.
The ventricles and sulci are prominent, consistent with global cerebral volume
loss. Old infarcts are seen in the right parietal lobe and right basal
ganglia. Patchy T2 hyperintensities are seen in the periventricular white
matter and bilateral dentate nuclei, right greater than left. These most
likely are sequela of chronic microvascular angiopathy.
IMPRESSION:
1. Unchanged findings consistent with a right temporal lobe subacute
intraparenchymal hematoma.
2. No evidence of increased blood flow
3. Spectroscopic analysis is nondiagnostic due to field inhomogeneity caused
by the hematoma.
4. No acute infarct.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: n/v/d, Weakness
Diagnosed with Dizziness and giddiness
temperature: 99.6
heartrate: 74.0
resprate: 20.0
o2sat: 99.0
sbp: 182.0
dbp: 104.0
level of pain: 0
level of acuity: 3.0 | SUMMARY
=======
Mr. ___ is a ___ with CAD c/b STEMI s/p DES x2 (___), DMII
(diet-controlled), HLD, and recent admission (___) at
___ for ___ with nephrotic syndrome, as well as
admission at ___ (___) for basal ganglia ischemic
stroke s/p tPA administration, with course c/b ICH secondary to
right temporal lobe mass. Currently presenting with dizziness
and nausea. Course complicated by hypernatremia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Pericardiocentesis (___)
Pericardial Window (___)
History of Present Illness:
PCP: ___ does not know name
CHIEF COMPLAINT: dyspnea
REASON FOR TRANSFER: pericardial effusion
___ ___ nonsmoker with hyperlipidemia presenting
from her PCPs office with 4 days of exertional dyspnea without
pain.
The ___ states that she first noticed her exertional dyspnea
climbing stairs but over the last couple of days she has noticed
it even walking on a flat surface even for short distances. She
denies any fevers/chills, night sweats, or weight loss, but
admits to a nonproductive cough one to 2 weeks ago which
resolved spontaneously. Endorses mild orthopnea. Endorses mild
bilateral peripheral edema, which is chronic.
VS at ___:
97.8 F (36.6 C). Pulse: 72. Respiratory Rate: 24.
Blood-pressure:
140/70. Oxygen Saturation: 98%.
OSH electrolyte panel, trop, coags, BNP unremarkable.
CBC with WBC 4.5, Hgb 11.0, plt 152.
OSH EKG ___ showed: Sinus rhythm with low precordial ___.
ESR: 30 Mm/Hr
Interpretation: sinus rhythm, heart rate 72, no acute ischemia
OSH CXR ___ showed:
Significant cardiomegaly.? Possible pericardial effusion.
Cardiac echo recommended. No significant CHF. No pleural fluid.
OSH CTA ___ showed:
No evidence of pulmonary embolus. Large pericardial effusion,
with
a 10.5 x 7.3 x 6 cm right superior mediastinal mass, presumed to
be invading the pericardium. Suspicion of malignant thymoma,
differential includes lymphoma, or teratoma.
Left superior mediastinal prevascular pathologically enlarged
1.3 cm lymph node. Small right pleural effusion, mild
cardiomegaly.
Flattened appearing trachea, mainstem bronchi possibly
incidental tracheobronchiomalacia, versus mechanical effect of
cardiac enlargement and of pericardial fluid.
Given ___ complexity she was transferred to ___ for
further evaluation.
In the ED, initial vitals were: 98.8 72 156/116 22 97%. She had
a pulsus of 8 then 10. Labs notable for anemia H/H 10.9/34.3,
thrombocytopenia 149, normal WBC of 4.3. UA/chem-7/lactate were
normal. EKG showed sinus rhythm @ vent rate of 73. Q wave in
lead III. Low voltages in precordial leads with T wave
flattening/inversion. Bedside TTE revealed large pericardial
effusion and possible diastolic collapse of RV suggestive of
tamponade, prompting admission to the CCU for close monitoring.
Vitals on transfer were 98.5 70 161/85 20 96% RA. In the ICU,
she reports that she currently does not have dyspnea or chest
pain.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
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:
HLD ___ refused to start statin)
Social History:
___
Family History:
Brother with MI @ age ___. Does not know about family history of
cancers.
Physical Exam:
ADMISSION PHYSICAL:
============================
VS: T=98.4 BP=123/72 HR=72 RR=30 O2 sat=94% RA Pulsus 6
Gen: Pleasant, obese
HEENT: PERRL.EOMI. No lid lag.
NECK: Soft, supple. JVP not elevated. No lymphadenopathy or
thryoid masses appreciated
CV: Muffled heart sounds. RRR. S1 and S2. No murmurs, rubs or
gallops.
LUNGS: Tachypneic but speaks in full sentences. Occasional
expiratory wheeze but clear to auscultation bilaterally.
ABD: + BS. Non-tender
EXT: Warm, well-perfused. Trace pedal edema bilaterally
PULSES: 2+ DP and ___ pulses bilat.
SKIN: Linear excoriations on bilateral upper extremities
NEURO: AAOx3. CN2-12 grossly intact. ___ upper and lower
extremity strength.
DISCHARGE PHYSICAL:
============================
VITALS: 98.4 119/57 ___ 18 99%
General: well appearing, NAD sitting in bed conversational
Neck: supple
CV: RRR
Lungs: CTAB.
Abdomen: non-tender, non-distended, +BS, no hepatosplenomegaly,
midline scar healing well, sight of chest tube removal with with
dressing c/d/i. non eythematous
Ext: trace ankle edema
Neuro: CN II-XII grossly intact, symmetrical facial features
Skin: WWP, no rashes apprecaited
Pertinent Results:
ADMISSION LABS:
=====================
___ 07:00PM BLOOD WBC-4.3 RBC-4.10* Hgb-10.6* Hct-34.3*
MCV-84 MCH-25.9* MCHC-31.0 RDW-13.6 Plt ___
___ 07:00PM BLOOD Neuts-60.2 ___ Monos-6.4 Eos-2.2
Baso-0.6
___ 03:37AM BLOOD ___ PTT-34.2 ___
___ 07:00PM BLOOD Ret Aut-1.7
___ 07:00PM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-139
K-3.7 Cl-104 HCO3-24 AnGap-15
___ 07:00PM BLOOD ALT-25 AST-24 LD(LDH)-181 AlkPhos-114*
TotBili-0.5
___ 07:00PM BLOOD UricAcd-3.8 Iron-21* Cholest-139
___ 07:00PM BLOOD calTIBC-404 Ferritn-35 TRF-311
___ 07:00PM BLOOD Triglyc-103 HDL-49 CHOL/HD-2.8 LDLcalc-69
___ 07:00PM BLOOD TSH-0.83
___ 07:00PM BLOOD ___
___ 07:11PM BLOOD Lactate-1.1
PERTINENT LABS:
=====================
ECG (___):
Sinus rhythm. There are non-diagnostic Q waves in the inferior
leads.
Non-specific ST-T wave changes. There is an early transition
that is
non-specific. Low voltage in the precordial leads. No previous
tracing
available for comparison.
Read by: ___.
___ Axes
Rate PR QRS QT/QTc P QRS T
73 158 96 ___ 32
ECHOCARDIOGRAM (___):
Estimated left ventricular systolic function is normal (LVEF
55%). There is a large pericardial effusion with evidence of
possbile mass adjacent to the pericardium in subxyphoid views.
There is brief right atrial diastolic collapse. There is
respiratory variation in mitral valve inflows, close to 30%
variation in peak E wave variation, consistent with impaired
ventricular filling. Findings may be consistent with early
cardiac tamponade physiology by echo.
CARDIAC CATHETERIZATION PROCEDURE (___):
Successful pericardiocentesis with removal of 770 cc bloody
fluid which is sent to Pathology for analysis.
ECHOCARDIOGRAM ___, post pericardiocentesis)
FOCUSED STUDY/LIMITED VIEWS: No atrial septal defect is seen by
2D or color Doppler. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is a very small pericardial effusion.
The effusion appears loculated. No right ventricular diastolic
collapse is seen.
Compared with the prior study (images reviewed) of ___,
the majority of the pericardial effusion has been drained. There
are no echocardiographic signs of tamponade.
ECHOCARDIOGRAM (___):
IMPRESSION: Some beats reveal evidence of brief diastolic right
ventricular inward motion not collapse. The mitral inflow
pattern shows respirophasic variation exceeding 25%. The RA and
IVC could not be visualized. Compared to yesterday the
pericardial effusion has increased and yesterday there was no
mitral inflow variation. Taken together, the change in mitral
inflow pattern together with the increase in pericardial
effusion size is concerning for early tamponade physiology.
MRI HEAD ___. Study is degraded by motion.
2. Within limits of study, no definite intracranial metastatic
disease
identified.
3. Probable small vessel ischemic changes.
CTA ABD/PELV ___
IMPRESSION:
1. No evidence for malignancy in the abdomen and pelvis.
2. Incompletely imaged 7.8 cm heterogeneously enhancing
mediastinal mass is better evaluated on recent chest CT.
Differential diagnosis includes thymoma or teratoma.
BONE SCAN ___
FINDINGS: The images show diffuse uptake in the paranasal
region which may represent sinusitis. Foci of increased uptake
around the knees and ankles bilaterally are most consistent with
degenerative changes. There is no focus of increased uptake
suspicious for malignancy.
The kidneys and urinary bladder are visualized, the normal route
of tracer excretion.
DISCHARGE LABS:
=====================
___ 06:03AM BLOOD WBC-4.1 RBC-3.90* Hgb-10.6* Hct-33.3*
MCV-85 MCH-27.2 MCHC-31.8 RDW-13.6 Plt ___
___ 06:03AM BLOOD Plt ___
___ 06:03AM BLOOD Glucose-94 UreaN-11 Creat-0.6 Na-139
K-4.1 Cl-106 HCO3-21* AnGap-16
___ 06:03AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4
PATHOLOGY:
======================
IMMUNOPHENOTYPING-MEDIASTINAL MASS
Non-diagnostic study. Clonality could not be assessed in this
case due to insufficient numbers of B cells. Cell marker
analysis was attempted, but was non-diagnostic in this case due
to insufficient numbers of cells. Correlation with clinical
findings and morphology is recommended. Cytospin preparations of
the flow sample reveals cell clusters suggestive of a
non-hematological neoplasm (see separate pathology report
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This ___ is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain
2. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Final diagnosis:
Pericardial effusion
Mediastinal Mass- Carcinoid tumor
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p pericardiocentesis ___ with new tachypnia,
RR 34 // ? pneumothorax? ? pneumothorax?
IMPRESSION:
In comparison with the study of ___, there is little change in the huge
enlargement of the cardiac silhouette, much of which could represent
pericardial effusion. No definite pneumothorax or pneumopericardium.
Pulmonary vascularity is essentially within normal limits.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pericardial effusion (suspected
malignant), acculumating pleural effusion, not stable to go off floor //
pre-op for pericardial window Surg: ___ (pericardial window)
COMPARISON: Chest radiograph ___ and outside CT ___.
IMPRESSION:
Large right anterior mediastinal mass has been more fully characterized on the
at outside CT and is associated with a known pericardial effusion resulting in
enlargement of the cardiac silhouette. Pulmonary vascularity is normal, and
lungs are grossly clear.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p pericardial window // ?PTX ?PTX
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
The change in right contour of the large cardiomediastinal silhouette has
changed to reflect some drainage of the large pericardial effusion. Today
there is no pneumothorax. Small left pleural effusion is presumed. Upper
lungs clear.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST
INDICATION: ___ female presenting with shortness of breath, found to
have a large hemorrhagic pericardial effusion and mediastinal mass, for
metastatic workup.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: DLP: 1218 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL Omnipaque
COMPARISON: Chest CT dated ___.
FINDINGS:
LOWER CHEST:
Limited images of the lower chest demonstrate interval decompression of
previously identified moderate pericardial effusion. A right pericardial drain
is in place with scattered adjacent gas locules. There is an incompletely
imaged 7.8 x 6.0 cm heterogeneous enhancing mediastinal mass resulting in mass
effect on the distal superior vena cava and proximal right atrium. Minimal
bibasilar atelectasis and trace effusions are present.
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. Incidental note is made of
cholelithiasis. No gallbladder wall thickening or pericholecystic fluid is
present.
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.
Two well-circumscribed hypodense foci in the upper and mid poles of the right
kidney measure water attenuation likely represent cysts. There is no evidence
for renal calculus, hydroureteronephrosis, or perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. Colon and rectum are within normal
limits. RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder is unremarkable. There is no evidence of pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits
BONES AND SOFT TISSUES:
Degenerative changes are seen in the lower thoracolumbar spine..
IMPRESSION:
1. No evidence for malignancy in the abdomen and pelvis.
2. Incompletely imaged 7.8 cm heterogeneously enhancing mediastinal mass is
better evaluated on recent chest CT. Differential diagnosis includes thymoma
or teratoma.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with evidence of thymoma. Evaluate for
intracranial metastatic disease.
TECHNIQUE: Sagittal T1, axial T1, GRE, FLAIR, and T2 imaging was performed.
Additional sagittal MPRAGE and axial T1 postcontrast imaging was obtained
after the uneventful intravenous administration of 7 ml of Gadavist contrast
agent. Multiplanar reformatted images of the MPRAGE acquisition was then
produced.
COMPARISON: None.
FINDINGS:
Please note the study is degraded by motion. There is no acute intracranial
hemorrhage, abnormal extra-axial fluid collection, midline shift, or acute
territorial infarction. The ventricles and sulci are preserved. The paranasal
sinuses and mastoid air cells are preserved. There is no abnormal enhancement
on post-contrast imaging. Periventricular and subcortical T2 and FLAIR
hyperintensities are noted, which may represent small vessel ischemic changes.
IMPRESSION:
1. Study is degraded by motion.
2. Within limits of study, no definite intracranial metastatic disease
identified.
3. Probable small vessel ischemic changes.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with mediastinal mass and pericardial effusion,
s/p pericardial window, chest tube pulled today. ***PLEASE DO AT 7:30PM*** //
eval after chest tube pulled- please check at 730pm eval after chest tube
pulled
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
Previous pulmonary vascular congestion has resolved. Large areas of lung are
obscured by the very large cardiac silhouette, and although the frontal view
suggests right infrahilar consolidation, there is no corresponding finding on
the lateral. Right pleural effusion is tiny.
The cardiac silhouette is comparable in its great size and shape to prior
images, indicating large pericardial effusion persists.
Deflection of the trachea the thoracic inlet is due to a large goiter.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with ACUTE PERICARDITIS NOS, CHEST SWELLING/MASS/LUMP
temperature: 98.8
heartrate: 72.0
resprate: 22.0
o2sat: 97.0
sbp: 156.0
dbp: 116.0
level of pain: 0
level of acuity: 2.0 | ___ non-smoker with past medical history of untreated
hyperlidiemia who presents with progressive dyspnea on exertion
and was found to have pericardial effusion and mediastinal mass.
#) PERICARDIAL EFFUSION/TAMPONADE: ___ initially had signs
of tamponade on informal TTE, however, was hemodynamically
stable with no pulsus. She had drainage of 770 cc of bloody
fluid in the cath lab on ___. Post procedure echo showed
normal cardiac function but on ___ had a repeat TTE that showed
interval reaccumulation of fluid and signs of early tamponade.
She went for a pericardial window on ___ by thoracic surgery
which was successful. ___ had chest tube removed 2 days
after procedure and remained symptom free. Pathology analanlysis
of perocardial fluid was pending at discharge.
#) MEDIASTINAL MASS - primary neuroendocrine carcinoma:
Suspicious for malignant thymoma per radiology read of CTA,
invading the pericardium. No weakness in history on exam to
suggest myasthenia ___ from thymoma. She had no B-symptoms
suggestive of lymphoma. Preliminary studies of the mediastinal
mass indicated that it was a primary neuroendocrine carcinoma.
Further workup including CT abdomen and pelvis, MRI head and a
bone scan did not reveal any evidence of metastasis.
#)ATRIAL FIBRILLATION: During placement of pericardial window
___ developed intraoperative atrial fibrillation. ___
was treated with metoprolol for rate controll and spontaneously
converted to sinus rhythm. She had no further episodes of atrial
fibrillation noted on telemetry during this hospitalization. She
was discharged on metoprolol succinate.
#) ANEMIA: Borderline normocytic. Unknown if acute or chronic.
No active signs of bleeding. Concerning for BM involvement in
setting of concurrent thrombocytopenia.
#) THROMBOCYTOPENIA: No AMS, renal dysfunction to suggest TTP.
She does not take any medications that could be contributing.
Concerning for BM involvement in setting of concurrent anemia.
No splenomegaly on exam.
#) HYPERLIPIDEMIA: ___ reports she has high cholesterol but
refused to start medicine.
# CODE: presumed Full
# CONTACT: ___ ___
___ Issues:
___ needs to follow up with oncology to better characterize
and evaluate the mediastinal mass
Metoprolol was started due to atrial fibrillation induced in the
perioperative setting. Please reconsider whether this is
necessary in the outpatient setting. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
sulfa
Attending: ___.
Chief Complaint:
Worsening headache, shuffling gait
Major Surgical or Invasive Procedure:
___ Left craniotomy for subdural hematoma evacuation
History of Present Illness:
___ yo M hx HTN followed by Dr. ___ small left SDH since
___ at ___ who developed worsening HA on ___. Family
noticed that his gait was off and he was shuffling and that he
was slow to respond. He went to OSH ED where head CT showed
progression to acute on chronic left SDH with midline shift and
entrapment of the right temporal horn. Pt was loaded with 1g
Keppra IV and transferred to ___ for definitive care. Pt
endorses HA and change in gait. Denies weakness, numbness,
tingling.
Past Medical History:
HTN, HLD, left TKR
Social History:
___
Family History:
___
Physical Exam:
O: T: 97.7 HR:81 BP:125/79 RR:17 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 slightly thick with good comprehension and
repetition.
Naming intact. No paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils anisocoria Right 4mm -3mm, left 3mm-2mm round and
reactive to light. 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: Subtle right pronator drift.
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: dysmetric on right finger-nose-finger
On Discharge:
AAO x 3, PERRL, EOMs intact
No facial droop, tongue midline
No pronator drift
Strength and sensation full throughout
Left surgical incision CDI, closed with staples and sutures.
Pertinent Results:
CT head ___:
1. Status post left frontal craniotomy with evacuation of
subdural hematoma with resultant pneumocephalus and mixed
density subdural fluid collection consistent with evolving blood
products.
2. Relative to prior study, degree of rightward shift and
effacement of the left lateral ventricle and adjacent sulci is
decreased.
3. No new hemorrhage is identified.
4. Moderate sinus disease as described above
___ 06:15AM BLOOD WBC-13.2* RBC-4.98 Hgb-14.2 Hct-41.4
MCV-83 MCH-28.5 MCHC-34.3 RDW-13.5 Plt ___
___ 03:17AM BLOOD WBC-13.3*# RBC-4.81 Hgb-13.5* Hct-39.5*
MCV-82 MCH-28.1 MCHC-34.2 RDW-13.4 Plt ___
___ 04:16AM BLOOD WBC-8.5 RBC-4.51* Hgb-13.0* Hct-37.7*
MCV-84 MCH-28.8 MCHC-34.5 RDW-13.6 Plt ___
___ 06:15AM BLOOD ___ PTT-27.2 ___
___ 06:15AM BLOOD Glucose-107* UreaN-18 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-23 AnGap-16
___ 03:17AM BLOOD Glucose-131* UreaN-20 Creat-0.8 Na-138
K-3.3 Cl-101 HCO3-24 AnGap-16
___ 04:16AM BLOOD Glucose-117* UreaN-27* Creat-1.0 Na-142
K-3.5 Cl-104 HCO3-24 AnGap-18
___ 06:15AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2
___ 03:17AM BLOOD Calcium-9.2 Phos-3.7# Mg-2.1
___ 04:16AM BLOOD Calcium-8.8 Phos-6.4* Mg-2.0
Medications on Admission:
Amlodipine, Losartan
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Amlodipine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Losartan Potassium 50 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ male status post left craniotomy for subdural
hemorrhage evacuation.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 892 mGy-cm
CTDI: 55 mGy
COMPARISON: ___ outside head CT.
FINDINGS:
Patient is status post left frontal craniotomy and evacuation of subdural
hematoma. There is resultant pneumocephalus. The remains extra-axial subdural
fluid of mixed density consistent with evolving blood products. This measures
9 mm in maximum dimension along the left frontal convexity. This is associated
with an 8 mm rightward shift of normally midline structures, previously 1.3
cm. There is effacement of adjacent sulci as well as effacement of the left
lateral ventricle. Basal cisterns are clear. Gray-white matter differentiation
appears preserved. No evidence a large territorial ischemia.
Orbits are unremarkable. Near-complete opacification of right frontal sinus,
anterior right ethmoidal air cells, and moderate mucosal thickening within the
right maxillary and sphenoid sinuses is noted. Bilateral mastoid air cells and
middle ear cavities are clear. Soft tissue postsurgical changes along the left
craniotomy site are expected.
IMPRESSION:
1. Status post left frontal craniotomy with evacuation of subdural hematoma
with resultant pneumocephalus and mixed density subdural fluid collection
consistent with evolving blood products.
2. Relative to prior study, degree of rightward shift and effacement of the
left lateral ventricle and adjacent sulci is decreased.
3. No new hemorrhage is identified.
4. Moderate sinus disease as described above.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Headache, Transfer
Diagnosed with SUBDURAL HEMORRHAGE, HYPERTENSION NOS
temperature: 97.8
heartrate: 80.0
resprate: 16.0
o2sat: 99.0
sbp: 140.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | Patient was admitted directly to the OR for evacuation of a left
sided SDH. He tolerated the procedure well, was extubated in the
operating room, and transferred to the ICU post-operatively for
further management and care. Post op imaging was done that
showed evacuation of the hematoma and expected post-op changes.
He remained stable into ___ and worked with ___ who felt he did
not require further ___ assessment and was safe to discharge home
once medically ready. He remained stable overnight into ___.
On ___ he was seen and evalauted and deemed fit for transfer to
the floor. Orders for transfer were written in the morning. Mr.
___ was seen and evaluated by Physical Therapy and Occupational
Therapy and it was decided that can be discharged home with
outpatient ___ services. Mr ___ is neurologically intact. He
will continue on Levetiracetam for anticonvulsant prophylaxis.
His pain is being controlled with Oxycodone ___. He has been
ambulating and taking a regular diet without any complications.
Mr. ___ was offered home ___ services at the time of discharge
but felt he didn't need them. He said he'd be staying with his
son and his daughter is a ___.
At the time of discharge, Mr. ___ was afebrile, hemodynamically
and neurologically stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fatigue
Shortness of breath
Major Surgical or Invasive Procedure:
left chest tube placement (___)
History of Present Illness:
Ms. ___ is a ___ female with history of
pulmonary embolism on xarelto, hypertension, hyperlipidemia,
type
II diabetes, and metastatic mucinous adenocarcinoma of unknown
primary with peritoneal carcinomatosis and malignant ascites
currently on palliative ___ who presents with shortness
of breath.
Patient reports shortness of breath for the past couple weeks.
This has worsened over the past three days and she notified her
daughter. She has been unable to catch her breath. She notices
the shortness of breath particularly with exertion. She also
notes tightness under her bilateral breasts. She notes decreased
appetite. She also reports nausea with vomiting related to
chemotherapy. She does note that her abdomen is more distended
recently, but denies abdominal pain. She notes her chemotherapy
was held ___ for generalized weakness.
She initially presented to ___ Urgent Care. Labs were
notable for WBC 7.1, H/H 8.2/25.3, Plt 345, INR 2.3, Na 132, K
4.3, BUN/Cr ___, LFTs wnl, BNP 349, trop < 0.01, and UA with
moderate leuks, pyuria, and bacteruria. She had a CTA chest
which
showed massive left pleural effusion and no PE. She was
transferred to ___ ED for further evaluation.
Past Medical History:
- ___: Port placed
- ___: C1 D1 ___ (AUC2) Taxol (60mg/m2)
- ___: C1 D8 "
- ___: C1 D15" "
- ___: C2 D1, ___ ___ 15% to AUC 1.7, Taxol 60mg/m2,
Procrit
- ___: C2 D8 - HOLD treatment for diarrhea, nausea/vomiting;
support with IVF
- ___: IVF
- ___: C2 D15
- ___: 1 unit of PRBC
- ___: US guided paracentesis, removed 3.6L
- ___: C3 D1
- ___: C3 D8
- ___: C3 D15 - treat as planned; tachycardic, defer to PCP
- ___: Imaging; improved carcinomatosis; decrease in size of
L
pleural effusion; incidental R LL PE --> continue treatment
- ___: C4 D1 ___, Dr15%; taxol, 60mg/m2
- ___ C4 D8 "
- ___: C4 D15 "
- ___: US guided paracentesis; removed 0.3L
- ___: C5 D1, ___ DR15%; taxol, 60mg/m2 - treat 1, 8,15
- ___: C6 D1 "
- ___: C7 Day 1 ___ and Taxol.
- ___: C8 D1 Carboplatin and Taxol.
PAST MEDICAL HISTORY:
- Pulmonary Embolism on Xarelto
- Hypertension
- Hyperlipidemia
- Type II Diabetes
- Stage III Chronic Kidney Disease
- Arthritis
- Glaucoma
- Gallstones
Social History:
___
Family History:
Father with alcohol abuse.
Physical Exam:
ADMISSION EXAM
=============================
VS: Temp 97.4, BP 105/72, HR 104, RR 18, O2 sat 97% RA.
GENERAL: Pleasant woman, slow to respond, in no distress,
sitting
in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: Tachycardic, regular rhythm, normal s1/s2, no m/r/g.
LUNG: Decreased breath sounds on left lung.
ABD: Soft, non-tender, mildly distended, positive bowel sounds.
EXT: Warm, well perfused, trace bilateral lower extremity edema.
NEURO: A&Ox2-3 (initially thought ___ and unknown month but was
able to answer correctly with prompting). CN II-XII intact.
Strength full throughout. Sensation to light touch intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE EXAM
=============================
VS: 97.9 103/62 112 18 94 RA
GENERAL: No acute distress
HEENT: Moist mucous membranes
CV: Regular rate & rhythm, no murmurs
LUNGS: Bilateral breath sounds at apex, R > L at bases.
ABD: Soft, non-tender, non-distended.
EXT: Warm, well perfused, no edema.
NEURO: AAOx3. Moving all four extremities with purpose.
Pertinent Results:
ADMISSION LABS
==============================
___ 02:10PM BLOOD WBC-7.1 RBC-2.60* Hgb-8.2* Hct-25.3*
MCV-97 MCH-31.5 MCHC-32.4 RDW-17.2* RDWSD-61.5* Plt ___
___ 02:10PM BLOOD Neuts-65.5 Lymphs-18.1* Monos-14.0*
Eos-1.3 Baso-0.4 Im ___ AbsNeut-4.65 AbsLymp-1.28
AbsMono-0.99* AbsEos-0.09 AbsBaso-0.03
___ 02:10PM BLOOD Plt ___
___ 02:23PM BLOOD ___ PTT-35.4 ___
___ 02:10PM BLOOD Glucose-117* UreaN-25* Creat-1.0 Na-132*
K-4.3 Cl-99 HCO3-23 AnGap-10
___ 02:10PM BLOOD ALT-7 AST-15 AlkPhos-73 TotBili-0.2
___ 02:10PM BLOOD Lipase-58
___ 02:10PM BLOOD cTropnT-<0.01 proBNP-349
___ 02:10PM BLOOD Albumin-2.6*
___ 09:29PM BLOOD ___ pO2-33* pCO2-41 pH-7.41
calTCO2-27 Base XS-0
___ 09:29PM BLOOD Lactate-1.0
___ 09:24PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:35PM URINE Type-RANDOM Color-Yellow Appear-Slcldy*
Sp ___
___ 09:24PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD*
___ 02:35PM URINE Blood-TR* Nitrite-POS* Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-MOD*
___ 09:24PM URINE RBC-6* WBC-17* Bacteri-FEW* Yeast-NONE
Epi-1
___ 02:35PM URINE ___ WBC->50 Bacteri-MANY* Yeast-NONE
___ 09:24PM URINE Mucous-OCC*
PERTINENT LABS
==============================
___ 04:53AM BLOOD WBC-7.5 RBC-3.38* Hgb-10.1* Hct-31.1*
MCV-92 MCH-29.9 MCHC-32.5 RDW-18.2* RDWSD-61.1* Plt ___
___ 04:53AM BLOOD ___ PTT-26.7 ___
___ 04:53AM BLOOD Glucose-128* UreaN-20 Creat-1.0 Na-132*
K-4.0 Cl-97 HCO3-22 AnGap-13
___ 10:39AM BLOOD Na-137
___ 04:53AM BLOOD ALT-10 AST-14 AlkPhos-83 TotBili-0.3
___ 02:10PM BLOOD cTropnT-<0.01 proBNP-349
___ 02:10PM BLOOD Lipase-58
___ 09:29PM BLOOD Lactate-1.0
PERTINENT STUDIES
==============================
CTA CHEST (___)
1. Massive left pleural effusion, grown since ___,
loculated and
heterogeneous which may suggest malignant involvement. Near
complete collapse
of the left lower lobe and substantial atelectasis in the left
upper lobe.
2. No evidence of pulmonary embolism or acute aortic
abnormality.
3. Small right pleural effusion and small volume loculated
ascites.
4. 2.4 x 1.6 cm hypodense structure in the medial border of the
inferior vena
cava may represent loculated fluid or otherwise be related to
the patients
underlying malignancy
5. 8 mm right thyroid nodule, could be assessed by dedicated
thyroid US if
clinically indicated.
6. Cholelithiasis.
PLEURAL FLUID (___)
DIAGNOSIS: PLEURAL FLUID:
POSITIVE FOR MALIGNANT CELLS.
Consistent with adenocarcinoma.
ECHO (___)
Suboptimal image quality. Normal biventricular cavity sizes with
preserved global systolic function. Due to suboptimal image
quality, a focal wall motion abnormality cannot be fully
excluded. No pathologic valvular flow identified.
CT CHEST (___)
Loculated left hydro pneumothorax. Left-sided chest tube in
place. Small right pleural effusion. Several scattered
pulmonary nodules ranging in size from 2-4 mm throughout the
right lung concerning for metastasis.
High-density ascites, consistent with known peritoneal
carcinomatosis.
Right-sided Port-A-Cath with its tip in the SVC. Gallstones
CXR (___)
Right Port-A-Cath catheter tip is at the level of lower SVC.
Left pleural
effusion is moderate. Minimal left basal pneumothorax is
unchanged. Interval slight increase in left pleural effusion is
suspected. Small right pleural effusion is unchanged.
MICRO
==============================
UCx (___)
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 8:00 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Radiology Report
INDICATION: ___ year old woman s/p chest tube w/ persistent tachycardia//
infection/ pleural effusion improvement?
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph ___
FINDINGS:
There is a stable moderate left loculated hydropneumothorax with adjacent
atelectasis. There is atelectasis at the right lung base and likely small
right pleural effusion. There is no acute focal consolidation. The
cardiomediastinal silhouette and pulmonary vascular congestion are stable. A
right Port-A-Cath terminates at the cavoatrial junction. Left chest tube in
unchanged position.
IMPRESSION:
There is a stable moderate left loculated hydropneumothorax with adjacent
atelectasis. There is atelectasis at the right lung base and likely small
right pleural effusion. There is no acute focal consolidation. The
cardiomediastinal silhouette and pulmonary vascular congestion are stable. A
right Port-A-Cath terminates at the cavoatrial junction. Left chest tube in
unchanged position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p chest tube placement// tube positioning,
interval improvement in effusion? tube positioning, interval improvement
in effusion?
IMPRESSION:
Comparison to ___. Stable position of the left chest tube.
Stable extent of the left fluid or pneumothorax. No change in appearance of
the heart and of the right lung.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman s/p chest tube// tube positioning/ interval
improvement in effusion? tube positioning/ interval improvement in
effusion?
IMPRESSION:
Compared to chest radiographs ___ through ___.
Persistent moderate left hydropneumothorax, with a relatively small fluid
component, not appreciably changed over the past several days, despite the
indwelling left pigtail pleural drainage catheter entering the lower chest
laterally and sitting in the posterior hemithorax.
Moderate right basal atelectasis and small right pleural effusion are
unchanged. Heart size top-normal. Pulmonary vasculature is engorged but
there is no pulmonary edema.
Right transjugular central venous infusion catheter ends close to the superior
cavoatrial junction.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ year old woman s/p chest tube with new dyspnea// chest tube
placement, effusion interval change?
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph ___
FINDINGS:
There is a stable loculated left hydropneumothorax with left lung base
atelectasis. Stable appearance of the right lung. The cardiomediastinal
silhouette is unchanged. A right Port-A-Cath terminates at the cavoatrial
junction. Left chest tube is in stable position.
IMPRESSION:
No significant interval change.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman h/o PE on xarelto and metastaticmucinous
adenocarcinoma of unknown primary with peritonealcarcinomatosis and malignant
ascites currently on palliativecarbo/taxol admitted for massive, loculated
left-sided pleural. s/p chest tubeeffusion.// please evaluate pleural
effusion, ?trapped lung
TECHNIQUE: multi detector CT of the chest was performed without the
administration of intravenous contrast. Axial, coronal, sagittal and maximum
intensity reconstructions were acquired.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 37.4 cm; CTDIvol = 12.5 mGy (Body) DLP = 459.0
mGy-cm.
Total DLP (Body) = 459 mGy-cm.
COMPARISON: no prior CT chest is available for comparisons.
FINDINGS:
The thyroid is unremarkable. There are no enlarged axillary lymph nodes.
Right-sided Port-A-Cath tip projects to the SVC. Heart size is normal. There
is no pericardial effusion. There is a small pericardial effusion.
There is a small to moderate loculated left pleural effusion with the larger
component loculated anteriorly of a from the tip of the pigtail catheter.
There is a small left-sided pneumothorax. There is also mild associated
pleural thickening and subsegmental atelectasis in the lingula and left lower
lobe. Pockets of air extend along the fissure.
There is also of small right pleural effusion with subsegmental atelectasis in
the right lung base.
There are several ___ concerning for metastasis. Mm scattered pulmonary
nodules throughout the right lung she
Review of bones shows degenerative changes involving the thoracic spine.
Limited sections through the upper abdomen shows gallstones. There is
high-density ascites.
IMPRESSION:
Loculated left hydro pneumothorax. Left-sided chest tube in place.
Small right pleural effusion. Several scattered pulmonary nodules ranging in
size from 2-4 mm throughout the right lung concerning for metastasis.
High-density ascites, consistent with known peritoneal carcinomatosis.
Right-sided Port-A-Cath with its tip in the SVC.
Gallstones
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with massive pleural effusion, now s/p chest
tube removal// effusion interval change effusion interval change
IMPRESSION:
Right Port-A-Cath catheter tip is at the level of lower SVC. Small bilateral
pleural effusions are unchanged. Left pigtail catheter has been removed.
Minimal 80 basal loculated most likely pneumothorax and small left apical
pneumothorax are unchanged as well as left basal opacification.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman w/malignant effusion s/p CT removal// please
eval interval change please eval interval change
IMPRESSION:
Right Port-A-Cath catheter tip is at the level of lower SVC. Left pleural
effusion is moderate. Minimal left basal pneumothorax is unchanged. Interval
slight increase in left pleural effusion is suspected. Small right pleural
effusion is unchanged.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with sob hx metastain malignany and PE// ? recurrent
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) = 409 mGy-cm.
COMPARISON: Chest CT from ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus
except in the right lung base where assessment of the subsegmental pulmonary
arteries is limited due to respiratory motion. The thoracic aorta is normal
in caliber without evidence of dissection or intramural hematoma.. No
pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass. The mediastinum is shifted
rightward by the large left pleural effusion.
PLEURAL SPACES: Small nonhemorrhagic right pleural effusion. Massive left
pleural effusion, grown from ___, is likely low-density in
nonhemorrhagic although somewhat heterogeneous and loculated.
LUNGS/AIRWAYS: There is near complete collapse of the left lower lobe
substantial atelectasis in the left upper lobe adjacent to the pleural
effusion. Mild atelectasis in the right lung base adjacent to the pleural
effusion. The airways are patent to the subsegmental level bilaterally.
BASE OF NECK: In the right lobe of the thyroid, an 8 mm hypodensities
compatible with a thyroid nodule.
ABDOMEN: A hiatal hernia is small. Cholelithiasis are present in the
gallbladder without evidence of cholecystitis. A 2.4 x 1.6 cm hypodense
structure along the medial border of the inferior vena cava may be related to
the patients underlying malignancy (2:96, 601:31). Small volume
nonhemorrhagic ascites is loculated. The remaining included portion of the
upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Degenerative changes are present in the spine.
IMPRESSION:
1. Massive left pleural effusion, grown since ___, loculated and
heterogeneous which may suggest malignant involvement. Near complete collapse
of the left lower lobe and substantial atelectasis in the left upper lobe.
2. No evidence of pulmonary embolism or acute aortic abnormality.
3. Small right pleural effusion and small volume loculated ascites.
4. 2.4 x 1.6 cm hypodense structure in the medial border of the inferior vena
cava may represent loculated fluid or otherwise be related to the patients
underlying malignancy
5. 8 mm right thyroid nodule, could be assessed by dedicated thyroid US if
clinically indicated.
6. Cholelithiasis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:42 pm, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with left pleueral effusion// s/p chest tube
placement
IMPRESSION:
In comparison with the study ___, there is a substantial increase in
the degree of left pleural effusion with a chest tube in place. Gas density
above the effusion laterally suggests that this may represent a loculated
hydropneumothorax. If clinically possible, a lateral view would be most
helpful for further evaluation.
Right IJ central catheter extends to about the cavoatrial junction. Continued
enlargement of the cardiac silhouette with mild vascular congestion and
possible small right effusion.
Radiology Report
EXAMINATION: Portable AP chest radiograph.
INDICATION: ___ year old woman w/ left pleural effusion s/p chest tube
placement on ___// chest tube positioning.
TECHNIQUE: AP chest x-ray
COMPARISON: Prior chest radiograph dated ___.
FINDINGS:
Right-sided Port-A-Cath remains in place in the cavoatrial junction. Left
chest tube remains position in the left lower lung. There has been a moderate
reduction in size of the left loculated hydro pneumothorax, with residual air
tracking to the left apex, which is improved from previous. The pulmonary
vascular congestion and cardiomediastinal silhouette appears mildly improved.
IMPRESSION:
Moderate reduction in the size of left loculated hydro pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 98.2
heartrate: 107.0
resprate: nan
o2sat: 95.0
sbp: 103.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | ___ woman with PMH of pulmonary embolism on rivaroxaban,
hypertension, hyperlipidemia, type II diabetes, and metastatic
mucinous adenocarcinoma of unknown primary with peritoneal
carcinomatosis and malignant ascites currently on palliative
___ who presented for worsening fatigue and dyspnea and
discovered to have massive left pleural effusion. Underwent
chest tube drainage with unsuccessful conversion to tunneled
catheter. Pathology consistent with known adenocarcinoma. Plan
for outpatient follow up with interventional pulmonary to
re-attempt PleurX in ___ weeks.
# MASSIVE LEFT PLEURAL EFFUSION
Presented for chief complaint of worsening fatigue and dyspnea.
Underwent CTA chest notable for massive left pleural effusion
with near collapse of the left lower lobe. No PE visualized.
Underwent chest tube placement ___ with bloody, exudative
effusion and cytology notable for malignant cells. Remained in
place for three days with interval improvement in pleural
effusion size. Chest tube later removed with intent for tunneled
catheter placement however this was unsuccessful due to
complexity of the space and concern for trapped lung. Underwent
repeat CT chest that demonstrated persistent loculated
hydropneumothorax, improved in size. Remained completely
asymptomatic from respiratory standpoint with good O2 saturation
over course of hospitalization. Discharged with plan for
interventional pulmonary outpatient follow up for consideration
of PleurX at that time.
# SINUS TACHYCARDIA:
Noted to have persistent sinus tachycardia to 100-130s, up to
150s on occasion with exertion. Review of records suggests this
has been ongoing issue. No response to fluid bolus, pRBC
transfusion (s/p 1U pRBCs ___. CXR stable. CT chest without
pericardial effusion and pulsus normal. Echo reassuring. Minimal
pain. Possibly rebound from holding home atenolol (in setting of
borderline hypotension) however this would likely have
dissipated over length of admission. Trialed low-dose
fractionated metoprolol however this caused worsening
orthostasis and was discontinued. Remained hemodynamically
stable other than persistent tachycardia. Did not resume
atenolol at discharge given SBP 100s. Overall possibly due to
widely metastatic disease though no clear diagnosis.
# METASTATIC MUCINOUS ADENOCARCINOMA OF UNKNOWN PRIMARY
History of peritoneal carcinomatosis and malignant ascites. On
palliative ___ (last dose C1, W3, ___.
# ASYMPTOMATIC BACTERURIA:
UA with bacteria but patient asymptomatic. Given CTX in the ED
but discontinued given absence of symptoms. Repeat UA negative.
# HX PULMONARY EMBOLISM:
History of multiple LLL PEs in ___. Rivaroxaban held for
chest tube procedure with heparin bridge. Resumed at discharge.
# ANEMIA:
Stable. On Procrit as outpatient. No evidence of active
bleeding. s/p 1U pRBCs on ___ for tachycardia in case this was
evidence of symptomatic anemia. Appropriate rise in Hgb.
# HYPERTENSION:
Held home atenolol and lisinopril given borderline hypotension
during admission.
# CKD STAGE 3:
Baseline Cr 0.9-1.1.
# HYPERLIPIDEMIA:
- simvastatin
# PSYCH:
- duloxetine
TRANSITIONAL ISSUES
===========================
[ ] Attempted PleurX catheter placement at bedside was
unsuccessful due to complex anatomy and concern for trapped
lung. Will follow up with interventional pulmonary in ___ weeks
to re-consider. IP office will contact patient.
[ ] Persistent sinus tachycardia to 100-130s. Extensive workup
(discussed above) was unremarkable. Most likely due to widely
metastatic disease; otherwise hemodynamically stable.
Discontinued atenolol given SBP 100-110s.
[ ] Consider discontinuing omeprazole unless strong patient
preference. Notable that patient is requiring magnesium
supplements.
[ ] Held lisinopril at discharge for SBPs in 100-110s.
[ ] CTA notable for incidental 8 mm right thyroid nodule, could
be assessed by dedicated thyroid US if clinically indicated.
#CODE: full (confirmed)
#CONTACT: ___ (daughter/HCP) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
latex / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
L pilon fracture
Major Surgical or Invasive Procedure:
___: ORIF L pilon fracture
History of Present Illness:
___ with PMH CAD, DM on insulin, who tripped over her dog
earlier this afternoon, sustaining a twisting moment to her left
ankle. Denies syncopal episode, LOC or headstrike. Was taken to
___ where she was found to have an ankle fracture and
was transferred here for further care.
Reports no pain anywhere other than left ankle. Otherwise has
been in her normal state of health, no active medical problems.
Past Medical History:
CABG (3-vessel) in ___, chronic back pain (occasional oxycodone
PRN), IDDM
Social History:
___
Family History:
Non-contributory
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Splint in place, clean, dry, and intact
Left lower extremity fires ___
Left lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Left lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
Xray ankle ___: Intraoperative fluoroscopic spot films are
submitted is documentation of procedure performed under imaging
guidance with our radiologist in attendance.
Xray ankle ___: Distal tibial and fibular fractures with
posterior subluxation of the talus.
CT ___ ___:
1. Comminuted distal fibular fragment with large butterfly
fragment displaced anteriorly.
2. Comminuted intraarticular fracture of the distal tibia and
tibial plafond with distraction of the posterior malleolus
creating a gap in the articular surface. There is severe
posterior subluxation of the talus in relation to the largest
tibial plafond fracture fragment.
3. There is a transverse component of the tibial fracture
through the medial malleolus with mild widening of the anterior
aspect of the medial ankle joint.
4. Equivocal small avulsion or impaction fracture of the
posterior lateral
body of the talus and lucency in the posterior medial aspect of
the talus may be artifact versus nondisplaced fracture.
5. Incidental small focus of chondroid matrix and distal medial
femur, likely enchondroma.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT
INDICATION: ___ with tib/fib pilon fracture.
TECHNIQUE: Frontal and lateral views of the tibia/fibula and frontal,
lateral, and oblique views of the ankle
COMPARISON: Outside ankle radiographs from earlier the same day
FINDINGS:
Overlying cast somewhat limits evaluation. Compared with earlier today, no
significant changes detected. Again seen are the intra-articular,
longitudinally oriented fracture of the distal tibia and the comminuted
fracture of the distal fibular diaphysis. The talus is posteriorly subluxed
with regards to the tibia.
IMPRESSION:
Distal tibial and fibular fractures with posterior subluxation of the talus.
Radiology Report
EXAMINATION: CT LOW EXT W/O C LEFT
INDICATION: ___ with tib/fib pilon fracture. Evaluate tibia, fibula, foot,
and ankle joint space. No need for femur evaluation. // ___ with tib/fib
pilon fracture. Evaluate tibia, fibula, foot, and ankle joint space. No need
for femur evaluation. ___ with tib/fib pilon fracture. Evaluate tibia,
fibula, foot, and ankle joint space. No need for femur evaluation.
TECHNIQUE: 2.5 mm axial images were obtained through the left lower extremity
without intravenous contrast. Coronal and sagittal reformats.
DOSE: DLP: 696.19mGy/cm
COMPARISON: Tibia and fibula radiograph ___ and left ankle and
foot radiograph from outside hospital ___
FINDINGS:
There is a comminuted fracture of the distal fibular diaphysis extending to
the anterior aspect of the lateral malleolus with a large butterfly fragment
seen displaced anteriorly and mildly angulated.
There is a comminuted predominantly vertically oriented fracture of the distal
tibia extending from the mid diaphysis to the tibial plafond with distraction
of the fracture fragments (posterior malleolus) at the articular surface.
There is a gap in the articular surface measuring up 9 mm in AP dimension
(series 2, and 0.60). In addition, there is a transverse fracture through the
medial malleolus. There is severe posterior subluxation of the talus in
relation to the larger fracture fragment of the tibial plafond. The lateral
and medial aspect of the ankle mortise remains in articulation with mild
widening of the anterior aspect of the medial ankle joint space (series 2,
image 173).
There is a predominantly vertically oriented lucency in the posterior medial
aspect of the talus which may represent artifact versus nondisplaced fracture
(series 400bH, image 25). In addition, there is minimal irregularity of the
posterior lateral talar cortex, may represent small impaction or avulsion
injury (series 400bH, series 32 and 401bG, series 38-39). The subtalar joints
are preserved.
Small osseous fragments along the medial aspect of the navicular bone, likely
small ossicles (series 2K, image 183).
There is a small foci of air in the syndesmosis interval (series 3, image
152). There is mild soft tissue edema most prominent along the lateral aspect
of the ankle.
The anterior extensor tendons, medial long flexor tendons, and peroneal
tendons are grossly intact without evidence of entrapment. The Achilles
tendon is intact.
Incidental note is made of a rounded area of chondroid matrix in the distal
medial femoral metaphysis, measuring 9 x 7 x 13 mm.
IMPRESSION:
1. Comminuted distal fibular fragment with large butterfly fragment displaced
anteriorly.
2. Comminuted intraarticular fracture of the distal tibia and tibial plafond
with distraction of the posterior malleolus creating a gap in the articular
surface. There is severe posterior subluxation of the talus in relation to
the largest tibial plafond fracture fragment.
3. There is a transverse component of the tibial fracture through the medial
malleolus with mild widening of the anterior aspect of the medial ankle joint.
4. Equivocal small avulsion or impaction fracture of the posterior lateral
body of the talus and lucency in the posterior medial aspect of the talus may
be artifact versus nondisplaced fracture.
5. Incidental small focus of chondroid matrix and distal medial femur, likely
enchondroma.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: Preop Surg: ___ (orif)
COMPARISON: None available
FINDINGS:
AP upright and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. Heart size is
top-normal. Imaged osseous structures are intact. No free air below the right
hemidiaphragm is seen. Sternal wires are intact.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
INDICATION: Intraoperative radiograph for surgical guidance.
COMPARISON: None relevant
FINDINGS:
60 Views of the left ankle obtained fluoroscopically. Fixation hardware is
seen placed about the left ankle. Please refer to full operative note for
further details.
IMPRESSION:
Intraoperative fluoroscopic spot films are submitted is documentation of
invasive procedure performed under imaging guidance with our radiologist in
attendance.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Tib/Fib Fracture
Diagnosed with Displaced pilon fracture of left tibia, init for clos fx, Fall same lev from slip/trip w/o strike against object, init
temperature: 98.1
heartrate: 77.0
resprate: 16.0
o2sat: 94.0
sbp: 166.0
dbp: 55.0
level of pain: 4
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 L pilon fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF L pilon fracture, 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 home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the left lower extremity, and will be discharged on
lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
wheat / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
post-operative chills, nausea, shortness of breath
Major Surgical or Invasive Procedure:
None this admission.
POD#3 ___ myotomy with partial fundoplication for type II
achalasia
History of Present Illness:
Mr. ___ is a ___, who presented to the ED for subjective
chills, nausea, and shortness of breath on POD#2 of ___
myotomy with partial fundoplication. He was discharged from
___ in stable condition the day prior, with adequate pain
control, independent ambulation, voiding well, and tolerating
regular diet with no nausea or vomiting. His discharge vitals
were within normal limits. He received anticipatory guidance to
return to the hospital if experiencing chills or nausea, and
came to the ED.
Past Medical History:
___ esophagus
Colonic adenoma
Sleep apnea w/home CPAP
HTN
Dysthymic disorder
Varicose veins
Obesity
Cancer of bladder wall s/p surgery+chemo
PSH:
Right shoulder surgery
Right axillary vein pseudoaneurysm repair
Umbillical hernia repair
Transurethral bladder tumor excision
Social History:
___
Family History:
Father - cancer
Mother - breast cancer, HTN, phlebitis
Sister - ___ esophagus
Maternal grandfather - cancer
Physical ___:
Gen: AAOx3, NAD, appears comfortable
HEENT: MMM, no scleral icterus
Resp: nl effort, CTABL, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops
Abd: +BS, soft, obese, ND, appropriately tender to palpation
Port site incisions C/D/I with steristrips
Ext: no edema, 2+ DP
Pertinent Results:
___ 10:43AM WBC-8.6 RBC-4.83 HGB-14.1 HCT-41.8 MCV-87
MCH-29.2 MCHC-33.7 RDW-12.5 RDWSD-39.7
___ 12:35AM GLUCOSE-109* UREA N-15 CREAT-0.9 SODIUM-136
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15
Medications on Admission:
Sucralfate 100 mg/mL - 1gm bid
Ranitidine 300 mg qhs
Triamterene-HCTZ 37.5 mg / 25 mg qd
Lisinopril 20 mg qd
pantoprazole 40 mg bid
escitalopram oxalate (LEXAPRO) 20 mg qd
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Docusate Sodium 100 mg PO BID
4. Escitalopram Oxalate 20 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Nicotine Patch 21 mg TD DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
8. Pantoprazole 40 mg PO Q24H
9. Ranitidine 300 mg PO QHS
10. Senna 8.6 mg PO BID
11. Sucralfate 1 gm PO DAILY
12. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Post-operative chills, nausea, shortness of breath
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with weakness s/p ___ // eval for acute
process
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Bilateral pleural effusion is small. There is no pneumothorax. Linear
opacity is identified in the left lower lobe. There is bilateral increased
perihilar interstitial markings. Cardiac silhouette is mildly enlarged.
IMPRESSION:
Linear opacity in the left lower lobe is probably atelectasis. Small
bilateral pleural effusions.
Radiology Report
INDICATION: ___ year old man with s/p lap ___ myotomy and Dor
fundoplication // please perform water-soluble swallow study to eval for leak
TECHNIQUE: Single contrast upper GI.
DOSE: Acc air kerma: 101 mGy; Accum DAP: 1446 uGym2; Fluoro time: 1 min 13
seconds
COMPARISON: Chest radiograph ___
FINDINGS:
Water-soluble contrast (Optiray) was administered.
No evidence of leak is identified. Small amount of contrast passed into the
stomach from the esophagus with the majority of contrast held up at the distal
esophagus.
IMPRESSION:
No evidence of leak .Small amount of contrast passed into the stomach from the
esophagus with the majority of contrast held up at the distal esophagus.
Radiology Report
INDICATION: ___ man status post esophagram. Evaluate for interval
passage of contrast.
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Esophagram from ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Radiodense
contrast is seen in the distal small bowel, ascending colon, and hepatic
flexure. There is no contrast in the distal colon or rectum.
There is no free intraperitoneal air.
Degenerative changes throughout the spine. Osseous structures are otherwise
unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Interval passage of contrast into the distal small bowel and proximal colon.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 98.3
heartrate: 65.0
resprate: 20.0
o2sat: 95.0
sbp: 132.0
dbp: 89.0
level of pain: 6
level of acuity: 2.0 | Mr. ___ was admitted to the General Surgical Service on
___ for evaluation and treatment of post-operative chills,
nausea, and shortness of breath. He is POD#2 of ___ myotomy
with partial fundoplication and was discharge from the hospital
in stable condition on POD#1. Testing in the ED with an UGI and
KUB revealed that he did not have a leak at the myotomy, and
that contrast was passing reasonably well into the small bowel
and proximal colon. He was afebrile, with a WBC wnl. His nausea
and shortness of breath resolved spontaneously, although he had
Zofran and albuterol ordered PRN for symptomatic relief.
Throughout his stay, Mr. ___ remained nutritionally
supported with regular diet without bread. He was able to
tolerate oral pain medication oxycodone. At the time of
discharge his diet included regular diet without bread. 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 during this stay.
At the time of discharge, Mr. ___ was doing well, afebrile
with stable vital signs. He was tolerating diet as above per
oral, ambulating, voiding without assistance, and pain was well
controlled. He 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: CARDIOTHORACIC
Allergies:
Tylenol / acetaminophen
Attending: ___.
Chief Complaint:
hemoptysis/right pneumothorax
Major Surgical or Invasive Procedure:
removal of chest tube
History of Present Illness:
This is a case of ___ year old male patient presenting to ___
as transfer from ___ Family with R pneumothorax s/p chest tube
placement at ___. Pt had CT guided right upper lobe biopsy 4
days
ago for lung nodules. Since then pt has been having intermittent
hemoptysis with cough (measuring as tea spoon) and SOB with DOE.
The blood has been increasing in amount over the last 2 days
until he went to OSH today where he was found to have 50% ptx
thus he got the chest tube placed. He denies any
nausea/vomiting,
chest pain, fever/chills, weight loss, and no other complaints.
Past Medical History:
BRAIN ANEURYSM
TOBACCO ABUSE
BACK PAIN
NECK PAIN
R HEAD PAIN
R FACIAL NUMBNES
FACIAL PAIN
FATIGUE
LUNG NODULES
PSH:
___: R Craniotomy for clipping of ACOMM aneurysm
___: Diagnostic cerebral angiogram
corrective foot surgery at ___ yrs old
Social History:
___
Family History:
NC
Physical Exam:
Admit PE:
Temp:98.4 HR:86 BP:120/76 RR:18 O2 Sat:96%RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[ ] Abnormal findings: Right Chest Tube in place
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
Discharge PE:
Vitals: Temp 99.2 PO, BP 109/46, HR 94, RR 20, O2sat 96% RA
Gen: A&O, NAD, resting comfortable in bed, ambulatory for
several days including previously with chest tube now removed
CV: RRR
Pulm: no increased WOB, CTAB, chest tube site on right upper
lateral chest is clean and dry, closed, no drainage, erythema,
or induration
Abd: soft, NT/ND
Ext: WWP, no CCE
Pertinent Results:
CHEST (PA & LAT) Study Date of ___ 9:22 AM:
The tiny right apical pneumothorax seen previously has resolved.
Cardiomediastinal silhouette is within normal limits. There has
been improved aeration at the left base however there remains
some atelectasis. No definite consolidation are seen.
Medications on Admission:
BACLOFEN - baclofen 10 mg tablet. 1 tablet(s) by mouth one in
the
am, one at 2P and 2 at bedtime - (Prescribed by Other Provider)
GABAPENTIN [NEURONTIN] - Neurontin 600 mg tablet. 1 tablet(s) by
mouth three times per day - (Prescribed by Other Provider)
OXYCODONE - oxycodone 10 mg tablet. 1 tablet(s) by mouth three
times a day as needed for pain - (Prescribed by Other Provider)
PREGABALIN [LYRICA] - Lyrica 150 mg capsule. capsule(s) by mouth
twice a day - (Prescribed by Other Provider) (Not Taking as
Prescribed: pt states no longer taking)
Discharge Medications:
1. Baclofen 10 mg PO TID
2. Docusate Sodium 100 mg PO TID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Gabapentin 600 mg PO TID
4. Pregabalin 150 mg PO BID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive or drink alcohol while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right pneumothorax
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 50% pneumothorax s/p lung biopsy, s/p CT placed at OSH
TECHNIQUE: AP upright view of the chest.
COMPARISON: Chest radiograph ___. PET-CT ___. CT
interventional procedure images ___.
FINDINGS:
The cardiomediastinal contours are normal. There is no large pleural
effusion. A right chest tube is present, terminating at the right lung apex.
There is no definite residual pneumothorax. The lungs are well-expanded.
Increased haziness at the right lower lobe and left hilum may represent
postprocedural changes and underlying nodule. There is no focal consolidation
concerning for pneumonia. Soft tissue gas along the right upper lateral chest
wall is second to chest tube placement.
IMPRESSION:
1. Right chest tube with tip terminating in the right apex. No definite
residual pneumothorax.
2. Haziness in the right lower lung and left hilum may be post procedural and
underlying nodule. Attention on follow-up is recommended.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with pnx // follow on right pnx, morning date of
___
IMPRESSION:
In comparison to prior radiograph of 1 day earlier, a right chest tube remains
in place, with a probable tiny right apical pneumothorax. Exam is otherwise
similar to the recent study except for worsening atelectasis the left lung
base and development of a small left pleural effusion.
Radiology Report
INDICATION: ___ M w/ hx of RLL/RML lung mass c/f lung cancer with 1 wk hx
dyspnea, hemoptysis after CT guided lung biopsy, 50% ptx s/p CT placement at
OSH ED. // Please eval for pneumothorax, Chest tube clamp trial
COMPARISON: Radiographs from ___ at 09:04.
IMPRESSION:
There is a right-sided chest tube with distal tip is at the apex. No definite
pneumothorax is seen. There is some atelectasis at the lung bases, unchanged.
Heart size is within normal limits.
Radiology Report
INDICATION: ___ M w/ hx of RLL/RML lung mass c/f lung cancer with 1 wk hx
dyspnea, hemoptysis after CT guided lung biopsy, 50% ptx s/p CT placement at
OSH ED // Please eval for interval change
COMPARISON: Radiographs from ___
IMPRESSION:
The tiny right apical pneumothorax seen previously has resolved.
Cardiomediastinal silhouette is within normal limits. There has been improved
aeration at the left base however there remains some atelectasis. No definite
consolidation are seen.
Radiology Report
INDICATION: ___ year old man with chest tube removal // ?pneumothorax
COMPARISON: Radiographs from ___ at 18:37.
IMPRESSION:
There has been removal of the right-sided chest tube. There is a very tiny
right apical pneumothorax. There has been improvement of the subcutaneous
emphysema along the right lateral chest wall. There is atelectasis at the left
base with elevation of left hemidiaphragm. Heart size is within normal
limits.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Pneumothorax
Diagnosed with Pneumothorax, unspecified
temperature: 99.0
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 76.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ is a ___ year-old male who underwent CT guided right
upper lobe biopsy on ___ for lung nodules (RUL, 18G core, per
procedural note - parenchymal bleeding noted). He subsequently
had persistent intermittent hemoptysis (non-massive - 35-50cc
per day) and gradual worsening of SOB and DOE. He initially
presented to OSH ED and was found to have a right pneumothorax.
A right chest tube was placed and the patient as transferred to
___ for further management ___. IP was consulted for
bronchoscopy given the patient's hemoptysis. However, flexible
bronchoscopy was deferred given rapid improvement/resolution of
hemoptysis without intervention. The patients chest tube was
initially kept to WS and chest films reveal interval resolution
of his small apical pneumothorax. His chest tube was clamped
for 6 hours without interval development of expanding
pneumothorax. His chest tube was removed ___ and post-up films
demonstrated tiny right apical pneumothorax with subsequent
resolution the morning of ___. The patient was discharged home
in stable condition with clinic follow-up and CXR scheduled for
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
V Tach arrest
Major Surgical or Invasive Procedure:
___: cardiac cath for ICD lead extraction
History of Present Illness:
Mr. ___ is a ___ male with cardiac history significant for CAD
(anteroseptal MI s/p LAD ___, s/p stent left posterior
descending and OM in ___, systolic heart failure (EF ___,
inducible sustained VT s/p ICD ___.
Today, patient was in his usual state of health until he was
shocked ten times by his device before becoming unresponsive.
EMS was called and found him in pulseless ventricular
tachcyardia. He was subsequently defibrillated into normal sinus
rhythm with normal mental status and brought to ___ ED
where he was given amiodarone 150mg IV x1 and then started on a
1mg/min amiodarone drip. He was then transferred to ___ for EP
evaluation. On arrival to ___ ED, he was in stable in sinus
rhythm.
In the ED, initial vitals were 97.8 68 106/57 18 98% 4LNC. He
was continued on amiodarone drip. Labs significant for K 4.5, Mg
2.2 and INR of 3.1 and trop 0.01. EP evaluation/interrogation of
device revealed lead fracture. Patient was not in VT and had
inappropriate shocks, which put him into VT, at which point he
was found pulseless by EMS and shocked externally. ICD was
turned off in the ED. EP team advised admission and stopping
coumadin.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
- CAD s/p anteroseptal MI ___
LAD stenting ___
LPDA/OM stenting ___
- PACING/ICD: DDD-ICD (placed ___, generator changed ___
- LV dysfunction: EF ___
- Apical aneurysm
- Paroxysmal atrial fibrillation, on coumadin
3. OTHER PAST MEDICAL HISTORY:
Right inguinal hernia repair
Left inguinal hernia repair
Tendon laceration-hand
GI bleed -in records, pt's wife denies
___ arthritis
Social History:
___
Family History:
Mother had cancer. Father died from ALS. Sister, brother and
nephew have all died from ALS.
Physical Exam:
ADMISSION EXAM:
===============
VS: T=97.8 BP=119/77 HR=60 RR=18 O2 sat= 98%RA
Weight: 71.4 kg
General: NAD, A&Ox3, comfortable
HEENT: NCAT, EOMi
Neck: Supple, no JVD
CV: RRR, normal S1 S2, no murmurs
Lungs: bibasilar crackles
Abdomen: soft, NTND
Ext: no lower extremity edema
Neuro: CN grossly intact. Moves all extremities
PULSES: 2+ DP bilaterally
DISCHARGE EXAM:
===============
VS: Temp=98 HR=110 (afib) BP=103/69 RR=22 O2 sat=96% RA
General: NAD, A&Ox3, comfortable
HEENT: NCAT, EOMI, pupils equal and reactive to light, no facial
droop
Neck: Supple, no JVD
CV: RRR, normal S1 S2, no murmurs
Lungs: faint bibasilar crackles
Abdomen: soft, NTND
Ext: no lower extremity edema
Neuro: CN II-12 intact. ___ strenght grossly in all extremeties
PULSES: 2+ DP bilaterally
Pertinent Results:
ADMISSION LABS:
================
___ 05:45PM BLOOD WBC-9.3 RBC-3.92* Hgb-12.5* Hct-38.1*
MCV-97 MCH-32.0 MCHC-32.9 RDW-11.7 Plt ___
___ 05:45PM BLOOD Neuts-87.0* Lymphs-6.9* Monos-5.3 Eos-0.3
Baso-0.5
___ 05:45PM BLOOD ___ PTT-32.7 ___
___ 05:45PM BLOOD Glucose-129* UreaN-18 Creat-0.9 Na-140
K-4.5 Cl-103 HCO3-25 AnGap-17
___ 05:45PM BLOOD Calcium-8.4 Phos-3.1 Mg-2.2
IMAGING AND STUDIES:
=====================
PPM Interrogation ___:
Elevated threshold for RV pacing at 3.0 V at 0.5 ms. ___
voltage lead impedance revealed recent jump from ~40 ohms to >
200 ohms since ___. RV pace impedance appears to have
also oscillated over the past 12 months. Interrogation episode
log reveals ___ frequency, non-physiology signals in the RV
lead
beginning on ___. On ___ the patient had a series
ofhigh frequency activity leading to triggering of ATP. On
___ the patient had numerous episodes of ___ frequency,
non physiologic activity in the RV lead. On one occasion
(presumably time of arrest) ___ frequency activity falling in
the VF zone resulted in triggering of ICD discharge. Following
this shock there appears to be induction of monomorphic VT or
VF,
however, subsequent shocks from the device fail to terminate
ventricular arrhythmia. Since ICD discharge there have been
further episodes of ___ frequency activity, though they have
not
resulted in tachy therapies.
TTE Echocardiogram ___:
Conclusions
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is moderate
regional left ventricular systolic dysfunction with akinesis of
the distal segments and an aneurysmal apex with mild dyskinesis.
There is mild hypokinesis of the remaining segments (LVEF = 25
%). [Intrinsice left ventricular systolic function may be more
depressed given the severity of mitral regurgitation.] No masses
or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. 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. Moderate (2+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Left ventricular cavity dilation with extensive
regional and global systolic dysfunction c/w multivessel CAD or
other diffuse process. Moderate mitral regurgitation. Pulmonary
artery hypertension. Right ventricular cavity dilation with free
wall hypokinesis. Increased PCWP.
CT head, CTA head and neck, CT perfusion ___:
IMPRESSION:
Noncontrast head CT demonstrates subtle hyperdensity in the left
parietal
region suggestive of an acute infarct. No intracranial
hemorrhage.
CT perfusion demonstrates increase in mean transit time and
decrease in
cerebral blood flow in the left parietal region without decrease
in cerebralblood volume. Findings are indicative of ischemia in
this region, butambiguous in regards to completed infarction.
However, given the hypodensityon the noncontrast head CT favor
infarction.
There is moderate stenosis at the origin of the left vertebral
artery. The
head and neck CTA is otherwise unremarkable without evidence of
significant
stenosis, aneurysm or dissection.
___ ECHO: Focused exam:
The left atrium is mildly dilated. Moderate to severe
spontaneous echo contrast is seen in the body of the left
atrium. The left atrial appendage emptying velocity is depressed
(<0.2m/s). A definite thrombus is seen in the left atrial
appendage. Left ventricular wall thicknesses are normal. Overall
left ventricular systolic function is moderately depressed. The
right ventricular cavity is mildly dilated with borderline
normal free wall function. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. 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
a very small pericardial effusion. Thrombus in RA from ICD lead
noted - not mobile, not indicative of vegetation
echocardiographically.
Post procedure:
left and right heart structure and function remain unchanged. No
tamponade or worsening of pericardial effusion seen. New leads
seen in situ. No rigth ventricular perforation noted.
___ CXR: In comparison with study of ___, the pacer leads
extend to the
region of the right atrium and apex of the right ventricle.
Continued
enlargement of the cardiac silhouette without definite vascular
congestion. Atelectatic changes are seen at the left base.
MICROBIOLOGY:
=============
Urine ___: mixed bacteria c/w skin flora
DISCHARGE LABS:
===============
___ 09:14AM BLOOD Hct-33.5*
___ 04:46AM BLOOD Hct-30.0*
___ 03:52AM BLOOD WBC-9.5 RBC-3.13* Hgb-9.5* Hct-30.8*
MCV-98 MCH-30.4 MCHC-31.0 RDW-12.4 Plt ___
___ 03:52AM BLOOD Plt ___
___ 03:52AM BLOOD Glucose-98 UreaN-20 Creat-0.8 Na-138
K-3.6 Cl-107 HCO3-24 AnGap-11
___ 03:52AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Amlodipine 2.5 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. Metoprolol Succinate XL 12.5 mg PO BID
9. Warfarin 2.5 mg PO 3X/WEEK (___)
10. Warfarin 1.25 mg PO 4X/WEEK (___)
11. Pravastatin 40 mg PO HS
12. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral daily
13. Amoxicillin 500 mg PO Q8H
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Hydroxychloroquine Sulfate 200 mg PO BID
3. Pravastatin 40 mg PO HS
4. PredniSONE 5 mg PO DAILY
5. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral daily
6. Furosemide 20 mg PO EVERY OTHER DAY
7. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg One tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [Xarelto] 20 mg One tablet(s) by mouth QHS with
dinner Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Primary: Ventricular tachycardia arrest, Stroke
# Secondary: Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Ventricular tachycardia, AICD defibrillation.
TECHNIQUE: Portable upright AP view of the chest.
COMPARISON: ___.
FINDINGS:
Left-sided AICD device is re- demonstrated with leads in the right atrium and
right ventricle, unchanged. Heart size is mildly enlarged. Mediastinal and
hilar contours are unremarkable. Lung volumes are low with minimal
retrocardiac atelectasis noted. No pleural effusion, pulmonary edema or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process. Unchanged position of the AICD leads.
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION
INDICATION: ___ year old man with sCHF and LV aneurysm now with word finding
difficultiesand right sided deficits // Code Stroke, please complete CT head
non-con, CTA head and CTA neck
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial images were obtained through the
head and neck using CTA protocol after the uneventful administration of 110 cc
of Omnipaque intravenous contrast. Curve reformats, volume rendered
reformations and maximum intensity projection images were generated on an
independent workstation. In addition, CT perfusion was performed with blood
flow, blood volume and mean transit time maps created on an independent
workstation.
DOSE: DLP: 3739.61 mGy-cm
COMPARISON: None.
FINDINGS:
CT HEAD: There is subtle hypodensity in the left parietal region suggestive
of an acute infarct. There is no hemorrhage or mass effect. The ventricles
and sulci are normal in caliber and configuration. There are nonspecific
periventricular and subcortical white matter hypodensities, likely sequela of
chronic small vessel ischemic disease.
The orbits, and paranasal sinuses are unremarkable. There is a small amount of
fluid within the left mastoid air cells.
CT PEFUSION: There is mild decrease in cerebral blood flow and increase in
mean transit time in the left parietal region. The cerebral blood volume is
preserved in this area.
HEAD AND NECK CTA: There is minimal calcified atherosclerotic disease of the
intracranial ICAs, but without significant stenosis. The anterior, and middle
cerebral arteries are unremarkable. The posterior communicating arteries are
not identified. The posterior circulation is otherwise unremarkable.
There is a normal 3 vessel left-sided aortic arch. The common carotid,
internal carotid and external carotid arteries are patent without evidence of
significant stenosis based on NASCET criteria. There is minimal calcified
atherosclerotic disease of the carotid bifurcations bilaterally.
There is moderate stenosis at the origin of of the left vertebral artery. The
right vertebral artery is unremarkable.
There is minimal bilateral dependent atelectasis.
IMPRESSION:
Noncontrast head CT demonstrates subtle hyperdensity in the left parietal
region suggestive of an acute infarct. No intracranial hemorrhage.
CT perfusion demonstrates increase in mean transit time and decrease in
cerebral blood flow in the left parietal region without decrease in cerebral
blood volume. Findings are indicative of ischemia in this region, but
ambiguous in regards to completed infarction. However, given the hypodensity
on the noncontrast head CT favor infarction.
There is moderate stenosis at the origin of the left vertebral artery. The
head and neck CTA is otherwise unremarkable without evidence of significant
stenosis, aneurysm or dissection.
Case discussed with Dr. ___ by Dr. ___ telephone at 14:19h, on ___, immediately after the findings were made.
Radiology Report
INDICATION: CHF, AFib, ICD, new stroke, increased white blood cell count,
evaluate for pneumonia.
COMPARISON: ___.
FINDINGS: AP and portable view of the chest. There is new diffuse hazy
opacities in lungs bilaterally and also increase in fullness of the hila
bilaterally, which may represent new pulmonary vascular congestion. No
pleural effusions. No pneumothorax. A small retrocardiac opacity appears to
be slightly increased in size, may represent atelectasis or pneumonia. A
left-sided ICD is in appropriate position.
IMPRESSION: Slight increase in mild pulmonary vascular congestion.
Retrocardiac opacity is slightly increased in size and may represent
atelectasis or possibly early pneumonia.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Status post right internal jugular vein placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, no relevant change is seen.
The patient has received a right internal jugular vein catheter. The course
of the catheter is unremarkable, the tip of the catheter projects over the
lower SVC. No evidence of complications, notably no pneumothorax. The
parenchymal changes and the borderline size of the cardiac silhouette are
constant in appearance.
Radiology Report
AP CHEST, 7:23 P.M., ___
HISTORY: A ___ man after lead extraction. Evaluate possible pneumo-
or hemothorax.
IMPRESSION: AP chest compared to ___:
No pneumothorax, hemothorax, mediastinal widening. Right jugular line ends in
the upper-to-mid SVC. Transvenous right atrial and right ventricular pacer
defibrillator lead are in standard placements. Mild-to-moderate cardiomegaly
stable. Pulmonary vasculature mildly engorged, no edema or appreciable
pleural effusion.
Radiology Report
HISTORY: Lead position.
FINDINGS: In comparison with study of ___, the pacer leads extend to the
region of the right atrium and apex of the right ventricle. Continued
enlargement of the cardiac silhouette without definite vascular congestion.
Atelectatic changes are seen at the left base.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Cardiac arrest
Diagnosed with SYNCOPE AND COLLAPSE
temperature: 97.8
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 106.0
dbp: 57.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ with PMHx of CAD (s/p PCI), sCHF (EF ___,
inducible sustained VT s/p ICD ___, PAF on coumadin, presents
after VT arrest due to ICD lead impedance complication.
ACUTE ISSUES:
=============
# Ventricular Tachycardia: Patient with lead malfunction which
incorrectly sensed VT, delivered inappropriate shocks which put
him into VT. There was not a lead fracture on CXR. The
malfunction was thought due to an issue with lead impedance. He
was temporarily on an amiodarone drip s/p VT, but was
discontinued. On ___, the patient underwent sucsessful lead
revision. Had small hematoma around ICD post-procedure; stable
on discharge. To have follow up with EP next week.
# Stroke: Found to have acute non-fluent aphasia and right
facial droop with mild right sided weakness around 12:30 on
routine nursing check. He could follow commands but speech was
dysarthric and nonsensical. He was last seen well by the same
nurse at 12:06. A CODE STROKE was called; Neurology evaluated
the patient, and he underwent NCHCT and CTA Head & Neck that
showed left MCA ischemia. Etiology of stroke thought most likely
embolic from left atrial appendage clot later identified on ECHO
in setting of paroxysmal atrial fibrillation. At time of CVA,
INR was still 2.0, so patient was transitioned from coumadin to
rivaroxaban. Had initial improvement in symptoms with supine
positioning and with-holding blood pressure medications.
However, later that evening the patient required dopamine to
elevate his blood pressures in setting of recrudescence of
symptoms with SBPs 90-100s. He was transfered to the CCU for
further pressor administration. A central line was placed and he
was transitioned from dopamine to norepinephrine, then to
phenylephrine due to ectopy. He was kept on pressors for 48
hours and then weaned off, without recurrence of symptoms.
Further blood pressure medications, other than metoprolol, were
held on discharge to allow for continued permissive
hypertension.
CHRONIC ISSUES:
===============
# Chronic systolic heart failure: Patient with ischemic
cardiomyopathy with EF 25% on ECHO this admission, showing
regional left ventricular systolic dysfunction with akinesis of
the distal segments and an aneurysmal apex with mild dyskinesis.
Continued home metoprolol, but held ___ in setting of permissive
hypertension. Sent home on furosemide 20mg every other day.
# Paroxysmal Atrial Fibrillation: Currently in sinus rhythm, but
atrial fibrillation recurred later in his hospital stay.
Admitted on warfarin, placed on heparin IV ___,
and transitioned to rivaroxaban post-lead revision in setting of
stroke and sub-therapeutic INR.
# CAD: History of anteroseptal MI s/p LAD ___, s/p stent left
posterior descending and OM in ___. Continued ASA and
metoprolol, but held other BP lowering meds (losartan, imdur) in
setting of recent stroke.
# H/o LV aneurysm: ECHO this admission showed aneurysmal apex
with mild dyskinesis. No thrombi in LV, but thrombus in RV and
left atrial apendage. Discharged on rivaroxaban.
# HLD: Continued home pravastatin.
# HTN: Held home amlodipine and losartan in setting of
permissive hypertension for recent stroke.
# Cough: Being treated for pneumonia as outpatient with
amoxicillin (started ___, finished seven days on ___.
# Rheumatoid Arthritis: Patient restarted on prednisone 10mg as
outpatient one month ago, tapered to 5mg one week ago. Continued
home hydroxychloroquine and home prednisone. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Claritin / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ Cardiac catheterization
History of Present Illness:
___ yo M with CAD with NSTEMI in ___ s/p DES to LAD who
presents with chest pain.
Patient reports that he developed right-sided chest pain while
shopping for groceries at 13:00. He denies radiation to jaw,
shoulder, or back and associated shortness of breath, nausea,
vomiting, diaphoresis, and pre-syncope. He describes the pain as
a "gripping" sensation that was ___ in severity. Chest pain
subsided without intervention after about 30 minutes. At 15:00,
patient reports that pain occured again. This episode was
entirely similar to initial chest pain. The patient called EMS.
Per EMS, patient seemed to be hiding in his apartment, which was
filthy.
Patient was transported to ___. En route to ___, patient was
given aspirin 324 mg and NTG which resulted in complete
resolution of his chest pain.
In the ED, initial vital signs were 98, 64, 163/85, 18, and 97%
RA.
Labs were remarkable for WBC 12.2, Cr 1.3, and troponin 0.05.
Immediately after having labs drawn and prior to their return,
patient left AMA. Patient was called back on discovery of the
elevated troponin. He returned to the ED, where CXR showed no
acute cardiopulmonary process. Patient was admitted to ___,
with plan to hold on heparin gtt pending next set of cardiac
biomarkers.
On transfer, vital signs were 97.9, 66, 149/78, 16, 99% RA.
On the floor, patient reports that he remains free of chest pain
and that he feels completely well at this time. He denies fever,
chills, shortness of breath, cough, abdominal pain, nausea,
vomiting, diarrhea, and urinary symptoms. He is not sure why he
has to be in the hospital.
Review of Systems: As per HPI
Past Medical History:
- Hypertension
- CAD with NSTEMI in ___ s/p DES to LAD
- COPD not on oxygen
- Chronic lymphocytic leukemia
- Prostate cancer
- DVT and PE in ___
- GERD
- Raynaud's syndrome
- Osteoarthritis of left knee
- Osteoporosis
- Spinal stenosis
- Attention deficit disorder
- Anxiety and depression
Social History:
___
Family History:
- Sister has a brain tumor.
- No family history of early MI, arrhythmia, cardiomyopathies,
or
sudden cardiac death; father had colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7, 60, 146/78, 18, 94% RA
GENERAL: Well appearing male in no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated
CARDIAC: RRR, nl S1/S2, no MRG
LUNG: CTAB, no wheezes/rales/rhonchi
ABDOMEN: Soft, NTND, normoactive bowel sounds
EXTREMITIES: Warm, well-perfused, no cyanosis/clubbing/edema
NEURO: AAOx3, CN II-XII grossly intact
SKIN: No concerning lesions
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.7, 133/67, 61, 20, 96%RA
GENERAL: Well appearing male in no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Supple, No JVD
CARDIAC: RRR, nl S1/S2, no MRG
LUNG: CTAB, no wheezes/rales/rhonchi
ABDOMEN: Soft, NTND, normoactive bowel sounds
EXTREMITIES: Right femoral cath site intact, no edema
NEURO: AAOx3, CN II-XII grossly intact
Pertinent Results:
=== ADMISSION LABS ====
___ 07:00PM BLOOD WBC-12.2* RBC-4.86 Hgb-14.4 Hct-43.8
MCV-90 MCH-29.7 MCHC-32.9 RDW-15.1 Plt ___
___:00PM BLOOD Neuts-50.5 Lymphs-42.5* Monos-5.6 Eos-1.1
Baso-0.4
___ 07:33PM BLOOD ___ PTT-29.5 ___
___ 07:00PM BLOOD Glucose-98 UreaN-39* Creat-1.3* Na-141
K-4.8 Cl-103 HCO3-28 AnGap-15
___ 11:00AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.6
=== PERTINENT LABS ===
___ 07:00PM BLOOD cTropnT-0.05*
___ 06:10AM BLOOD CK-MB-4 cTropnT-0.08*
___ 11:00AM BLOOD CK-MB-4 cTropnT-0.08*
___ 06:02AM BLOOD cTropnT-0.10*
=== DISCHARGE LABS ===
___ 06:02AM BLOOD WBC-12.9* RBC-4.65 Hgb-14.1 Hct-41.2
MCV-88 MCH-30.4 MCHC-34.4 RDW-14.8 Plt ___
___ 06:02AM BLOOD Glucose-88 UreaN-29* Creat-1.1 Na-138
K-4.6 Cl-100 HCO3-28 AnGap-15
=== STUDIES ===
CARDIAC CATH (___):
- LMCA: normal
- LAD: proximal 30% smooth disease. The prior stents are widely
patent.
- Circumflex: 80% eccentric hazy mid lesion
- RCA: normal
- Outcome: Successful placement of DES in left circumflex
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. BuPROPion (Sustained Release) 300 mg PO QAM
4. Lorazepam 1.5 mg PO QHS insomnia
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN
7. DiphenhydrAMINE 25 mg PO QHS insomnia
8. Multivitamins 1 TAB PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. modafinil 200 mg oral BID
13. lisinopril-hydrochlorothiazide ___ mg oral As directed
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. AndroGel (testosterone) 1.25 gram/ actuation (1 %)
transdermal 5 pumps daily
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 300 mg PO QAM
4. Clopidogrel 75 mg PO DAILY
5. DiphenhydrAMINE 25 mg PO QHS insomnia
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN
7. Lorazepam 1.5 mg PO QHS insomnia
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. AndroGel (testosterone) 1.25 gram/ actuation (1 %)
transdermal 5 pumps daily
12. lisinopril-hydrochlorothiazide ___ mg ORAL AS DIRECTED
13. modafinil 200 mg ORAL BID
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually Q5MIN Disp
#*30 Tablet Refills:*0
15. Atorvastatin 80 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
NSTEMI
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 chest pain.
TECHNIQUE: Frontal and lateral chest radiographs were obtained with the
patient in the upright position.
COMPARISON: CT from ___ and radiograph from ___.
FINDINGS:
The lungs are hyperinflated and clear of focal consolidation, pleural effusion
or pulmonary edema. There is atelectasis in the right lung base. The heart is
normal in size, and mediastinal contours are stable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
AMBULANCE
Chief complaint: Chest pain
Elevated troponin
Diagnosed with CHEST PAIN NOS, HYPERTENSION NOS, HX VENOUS THROMBOSIS/EMBOLISM
ABN CARDIOVASC STUDY NEC, HYPERTENSION NOS
temperature: 97.9
98.0
heartrate: 64.0
64.0
resprate: 16.0
18.0
o2sat: 98.0
97.0
sbp: 158.0
163.0
dbp: 80.0
85.0
level of pain: 4
0
level of acuity: 2.0
2.0 | ___ year old male with hx of CAD with NSTEMI in ___ (s/p 2x
DES to LAD) and ___ (s/p PTCA and balloon dilatation of 50%
in-stent restenosis) who presented with chest pain on exertion
and was found to have an NSTEMI.
# NSTEMI: Patient with two episodes of chest pain the day of
admission associated with exertion. Found to have elevated
troponin of 0.05 in the ED without ischemic changes on EKG. He
was subsequently diagnosed with an NSTEMI, started on a heparin
gtt and admitted to ___ for further management. His troponin
continued to trend upwards to 0.08. He underwent cardiac
catheterization on ___ which revealed 80% eccentric hazy
mid-lesion, LAD with proximal 30% smooth disease and widely
patent prior stents, normal LMCA and RCA. A DES was placed in
the left circumflex artery. Recommended continuation of aspirin
indefinately and Plavix for a minimum of ___ year. He was
continued on his home ASA 81mg and Plavix 75mg qday during his
hospital stay. He declined to stay for inpatient ECHO to assess
EF.
==== TRANSITIONAL ISSUES ====
# NSTEMI:
- Patient has cardiology followup with ___. ___ on ___.
- Will need outpatient ECHO (declined to remain in-house for
this)
# CODE STATUS: DNI/DNR (confirmed with patient on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cozaar / Ace Inhibitors / Morphine / IV Dye, Iodine Containing
Contrast Media
Attending: ___
___ Complaint:
no urine output
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ PMHx DM, CAD s/p CABG, CHF (EF ___, CKD
(Cr 2.0, recently in the 3s), recent admission for CHF
exacerbation (___) requiring milrinone + lasix drips
(discharge wt 81.6kg) presenting with decreased UOP. After
recent hospitalization was discharged to ___, and then
discharged home this past ___ no medication changes
since discharge (remains on diuretic regimen of torsemide
daily), but reports that on morning of presentation noticed
decreased UOP. He took his usual 80mg PO torsemide this morning.
He felt the need to urinate, but was unable to as he usually
does. He was concerned that is kidneys were worsening in
function and so he called the ED and was instructed to come into
the ED. Denies dysuria/hematuria, decreased PO intake, dietary
indiscretion (follows his fluid restriction diet, <1.5L/day); no
CP, SOB/DOE, PND. At baseline, patient can walk from one
telegraph pole to the next, but not further without feeling SOB.
.
In the ED, initial vitals were 98.2 67 149/57 16 100%. Exam
notable for trace edema to mid-shin, 8cm JVD, lungs CTA, no
abdominal/scrotal edema. Labs and imaging significant for Cr 2.4
(baseline reportedly ___, but has been low 3's most recently),
Hct 28 (at baseline), K of 3.4. UA with WBCs, large leuks, and
bacteria. CXR showed evidence of vascular engorgement. Patient
took his home torsemide 80mg and after foley placement, put out
300cc to that. ECG showed AV pacing without ST elevations or
depressions. ED discussed this pt with Dr. ___
recommended admission to ___. Vitals on transfer were T 97.1 °F
(Oral), Pulse: 70, RR: 16, BP: 127/77, O2Sat: 98RA.
.
On arrival to the floor, patient states he feels well and is
without any complaints.
Past Medical History:
CARDIAC HISTORY: Hyperlipidemia, Hypertension, Diabetes mellitus
CABG: ___ (SVG-distal LAD, distal LCx, distal RCA), re-do in
___
PERCUTANEOUS CORONARY INTERVENTIONS: None
PACING/ICD: ___ biventricular ICD (placed in ___
PAST MEDICAL & SURGICAL HISTORY
1. Paroxysmal atrial fibrillation
2. Infarct-related cardiomyopathy with significant coronary
disease, (EF ___, left ventricular systolic dysfunction with
akinesis of the inferior septum, inferior wall, and
inferolateral wall)
3. Coronary artery disease
4. Ventricular tachycardia storm status-post biventricular ICD
placement in ___ ___ ___ generator replacement
in ___ VT ablation ___. Atrial tachycardia
status-post ablation (___), atrial flutter status-post
ablation, and AVNRT status-post slow pathway modification
6. Prior history of stroke post-CABG in ___ another stroke
(___) - mild residual visual disturbance and unsteady gait
7. Prostate cancer s/p TURP
8. Insulin dependent diabetes mellitus
9. Chronic renal insufficiency (baseline 2.0-2.3, more recently
3s)
10. h/o nephrolithiasis
11. Intermittent vertigo history
12. Mild insomnia (sleeps ___ hours nightly)
13. s/p Tonsillectomy (at age ___
14. s/p Mastoidectomy
Social History:
___
Family History:
Patient is adopted. Unaware of biological family history.
Physical Exam:
Admission Exam:
VS: 97.5, 122/57, 73, 20, 96%RA
Wt 82.3kg (last discharge wt: 81.6kg)
GENERAL: ___ elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Very poor dentition.
NECK: Supple with JVP not elevated.
CARDIAC: PMI not felt. RRR, normal S1, S2. ___ systolic murmur
over the ___ and ___. No r/g. No thrills, lifts. No S3 or S4.
Left sided ICD.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, mild rales R>L
base, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. 3x4inch bruise over
abdomen lateral to umbilicus.
GU: foley inplace with dark yellow urine
EXTREMITIES: No c/c. Trace edema of feet to shins.
SKIN: No ulcers, scars, or xanthomas. Chronic ___ skin changes.
Old sternotomy scar healed.
PULSES: 1+ DP and ___ b/l
Discharge Exam:
VS: 97.7, 132/98, 71, 18, 96%RA
Wt 82.0kg
GENERAL: ___ elderly man with central obesity in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: PERRL, Very poor dentition.
NECK: Supple with JVP 6-7cm at 90 degrees.
CARDIAC: PMI not felt. RRR, normal S1, S2. ___ systolic murmur
over the ___ and ___. No r/g. No thrills, lifts. No S3 or S4.
Left sided ICD.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, with
only mild velcro rales at the right base, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
GU: no foley in place
EXTREMITIES: No c/c. Trace edema of feet and shins.
SKIN: Chronic ___ skin changes. Old sternotomy scar healed.
3x4inch bruise over abdomen lateral to umbilicus.
PULSES: 1+ DP and ___ b/l
Pertinent Results:
Admission Labs:
___ 01:20PM BLOOD WBC-8.6 RBC-3.34* Hgb-9.2* Hct-28.9*
MCV-87 MCH-27.6 MCHC-31.9 RDW-18.2* Plt ___
___ 01:20PM BLOOD Neuts-76.3* Lymphs-17.5* Monos-4.4
Eos-1.3 Baso-0.4
___ 01:20PM BLOOD Glucose-190* UreaN-53* Creat-2.4* Na-134
K-3.4 Cl-95* HCO3-27 AnGap-15
___ 01:20PM BLOOD Mg-2.2
___ 02:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 02:00PM URINE RBC-1 WBC-44* Bacteri-MANY Yeast-NONE
Epi-0
___ 02:00PM URINE CastHy-47*
Discharge Labs:
___ 07:45AM BLOOD WBC-8.4 RBC-3.55* Hgb-9.7* Hct-31.3*
MCV-88 MCH-27.4 MCHC-31.1 RDW-18.3* Plt ___
___ 07:45AM BLOOD ___ PTT-35.5 ___
___ 07:45AM BLOOD Glucose-132* UreaN-50* Creat-2.2* Na-138
K-4.0 Cl-98 HCO3-32 AnGap-12
___ 07:45AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.3
Imaging:
___ CXR: Frontal and lateral views of the chest were
compared to previous exam from ___. When compared to
prior, there is more prominent central pulmonary vascular
engorgement and indistinct pulmonary vasculature suggestive of
pulmonary edema. There is no large effusion. Cardiac silhouette
is enlarged but stable in configuration. Triple-lead pacing
device is seen in stable position. Median sternotomy wires and
mediastinal clips again noted. Osseous and soft tissue
structures are unremarkable. IMPRESSION: Findings suggestive of
mild failure, similar to previous exam.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 20 mg Tablet - one tablet by mouth once
a day
Quinidine ER 324mg TID
ISOSORBIDE DINITRATE - 20 mg Tablet - 1 Tablet(s) by mouth three
times a day
METOLAZONE - 2.5 mg Tablet - 1 (One) Tablet(s) by mouth Once a
week, as directed
METOPROLOL ?SUCCINATE - 200 daily
Mexilitine 150mg Q8h
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1
Tablet(s) sublingually every ___ minutes x 3 as needed for
chest pain call doctor if the chest pain does not go away after
second pill
TORSEMIDE [DEMADEX] - 20 mg Tablet - 4 tablets daily
ASCORBIC ACID - (Prescribed by Other Provider) - 1,000 mg
Tablet
- 1 Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet,
Chewable
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit Capsule - 2 Capsule(s)
Qday COD LIVER OIL - (OTC) - Oil - 1 TBS Oil(s) by mouth
Daily
FOLIC ACID - (OTC) - 0.4 mg Tablet - Tablet(s) by mouth
MINERAL OIL - (OTC) - Emulsion - 2 tablespoons by mouth daily
MULTIVITAMIN - (OTC) - Tablet - Tablet(s) by mouth
VITAMIN E - (OTC) - 400 unit Capsule once a day
B complex daily
Lantus 20units Qhs
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. quinidine gluconate 324 mg Tablet Extended Release Sig: One
(1) Tablet Extended Release PO Q8H (every 8 hours).
3. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day: every ___ minutes x 3 as needed for
chest pain call doctor if the chest pain does not go away after
second pill.
5. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. cod liver oil Oil Sig: One (1) TBS PO once a day.
9. folic acid ___ mcg Tablet Sig: One (1) Tablet PO once a day.
10. mineral oil Oil Sig: Two (2) tablespoons PO once a day.
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a
day.
13. B Complex Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
14. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
15. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
16. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
17. Outpatient Lab Work
___ Draw Basic Metabolic Panel and fax results to Dr.
___: ___, Fax: ___.
18. Lantus 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous at bedtime: Please check your finger sticks at
night and in the morning and record them for Dr. ___.
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary Diagnosis: Urinary Retention
Secondary Diagnosis:
Chronic Kidney Disease
Congestive Heart Failure
CAD s/p CABG
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ male with CHF, presents with decreased urine output.
FINDINGS: Frontal and lateral views of the chest were compared to previous
exam from ___. When compared to prior, there is more prominent
central pulmonary vascular engorgement and indistinct pulmonary vasculature
suggestive of pulmonary edema. There is no large effusion. Cardiac
silhouette is enlarged but stable in configuration. Triple-lead pacing device
is seen in stable position. Median sternotomy wires and mediastinal clips
again noted. Osseous and soft tissue structures are unremarkable.
IMPRESSION: Findings suggestive of mild failure, similar to previous exam.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NO URINE OUTPUT
Diagnosed with URIN TRACT INFECTION NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT, AORTOCORONARY BYPASS, DIABETES UNCOMPL ADULT, CONGESTIVE HEART FAILURE, UNSPEC
temperature: 98.2
heartrate: 67.0
resprate: 16.0
o2sat: 100.0
sbp: 149.0
dbp: 57.0
level of pain: 0
level of acuity: 3.0 | ___ yo M with h/o DM, CAD (s/p CABG in ___, infarct
related cardiomyopathy (EF ___, s/p BiV ICD, prostate cancer
s/p b/l orchiectomy and TURP, ___ of bladder stones and
radiotherapy ___, who p/w decreased UOP consistent with urinary
retention.
# Urinary retention: Patient is s/p TURP. Had urinary retention
last admission in the context of having a foley placed. He
presented to the ED with a complaint of anuria with a sensation
to urinate but inability to do so. Foley was placed and 300cc
urine evacuated, indicating that patient's anuria was likely due
to urinary retention. Patient made adequate urine during his
time in the hospital. Foley was removed the morning after
discharge and the patient voided twice without difficulty prior
to discharge. He has follow up with Dr. ___ 2 days after
discharge. BPH medications can be considered if voiding issues
persist.
.
# CHF: EF 25% on ___ echo. Patient appears close to euvolemic
(100% sat RA, clear lungs, no signs of right sided heart
failure, but mild pulm edema on CXR). Weight is close to
discharge weight on last admission. Torsemide was decreased to
60mg PO daily. Metolazone was discontinued. Patient has follow
up with Dr. ___ on ___ for further management.
.
# RHYTHM/ h/o afib: Pt is A/V paced, has BiV pacemaker for
chronic dCHF, not on coumadin at home. Aspirin 325mg,
mexilitine, quinidine, and metoprolol was continued.
.
# CAD s/p CABG: EKG showed no new ischemic changes. Denies any
symptoms of ACS. Continued home aspirin 325 mg, isordil,
metoprolol and atorvastatin.
.
# Chronic kidney failure: He presented with decreased UOP,
however once foley was placed in the ED, he put out 300cc and
continues to put out clear yellow urine. Cr improved from last
admission, 2.2 on discharge.
.
# Positive UA: Patient is asymptomatic with a positive UA. No
antibiotics were given.
.
# DM: A1C 7.7% on ___. Continued on home Lantus and sliding
scale. Patient was discharged from rehab on lantus 20units Qhs.
Patient was unclear what dose he was taking at home. This
admission, lantus was decreased to 16 units Qhs and patient was
requested to monitor finger sticks ___ daily and to record
them for his upcoming appointment with Dr. ___.
.
# HLD: Good lipid profile last admission ___ Tchol 109, HDL
40, LDL 54, ___ 69). Continued home atorvastatin.
.
# Anemia: Hct 28.9 on admission. Baseline appears to be in the
low ___, with occasional values in the high ___. Labs on
previous admission last month was suggestive anemia of chronic
disease with likely contribution from CKD. Hct on discharge
31.3. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
itching
Major Surgical or Invasive Procedure:
-___ Ophtho laser procedure for proliferative diabetic
retinopathy
-___ Colposcopy w/ biopsies
-___ Cervical suture, cautery and packing in OR for persistent
bleeding from cervical biopsy
History of Present Illness:
The patient is a ___ hx IDDM, idiopathic cirrhosis (thought to
be ___ NASH during previous admission), IDDM and asthma now
presenting with itching and jaundice. She was recently admitted
to ___ for decompensated cirrhosis, with worsening bilirubin
as well as headaches and cough. Infectious workup was negative.
Abdominal ultrasound demonstrated no ascites or portal vein
thrombosis. MRCP did not demonstrate any hepatobiliary
obstruction. The patient's TBili peaked at 13.4 and stabilized
to 12.2. She had a liver biopsy during this admission, which
showed stage IV cirrhosis and hepatocellular cholestasis. The
etiology of the patient's hyperbilirubinemia was unclear, but
may be in the setting of worsening liver disease. The patient
has consistently denied alcohol abuse (she says she does not
drink any alcohol). At time of discharge on ___, the patient
was asymptomatic and had no complaints.
On ___, the patient again presented to the ED with worsening
itching and jaundice. Per her sister (HCP), she has also seemed
somewhat confused. The patient states that since her discharge,
she adhered to her medication regimen (with no added
supplements) and abstained from alcohol as she always does. The
patient's sister confirmed that the patient does not drink
alcohol. The patient reports that she has been feeling well
overall, with no symptoms of infection--she denies fever,
chills, nausea, vomiting, SOB, CP, dysuria, abdominal pain. She
has a persistent headache similar to the one she had on her last
admission. She has been having approximately 5 BMs a day on
lactulose, and she has noticed that her stool has been lighter
in color. Her urine has also been darker but non-bloody. Of
note, the patient reports that she had an EGD done about one
year ago, which was negative. Admitted before could go to outpt
apt with Dr. ___ after last admission.
ED course:
T 96.8 HR 59 BP 127/58 RR 18 O2sat 100% RA
Labs showed hyperbilirubinemia (Tbili 21.2, Dbili 16.2) and
mildly elevated LFTs, with normal PTT (32.7) and mildly elevated
___ (15.5). No leukocytosis and normal electrolytes.
RUQUS showed cholelithiasis with no e/o cholecystitis or
obstructive process, cirrhotic appearing liver, splenomegaly,
and no e/o portal vein thrombosis or ascites.
Patient received IV Diphenhydramine 25 mg once.
Transfer VS were
T 97.8 HR 58 BP 137/66 RR 19 O2sat 99%RA
GI/Hepatology were consulted.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports that she is feeling
well except for her itchiness. She continues to deny fever,
chills, nausea, vomiting, SOB, CP, abdominal pain.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
- Cirrhosis
- Hypertension
- Diabetes
- Elevated cholesterol
- Asthma
Social History:
___
___ History:
HTN - mother and father
CAD - father
No significant family history of stomach, breast or colon
cancer.
Physical Exam:
Admission Physical Exam:
VS: T 97.8 HR 57 BP 151/73 RR 20 O2sat 98%RA
GENERAL: NAD, jaundiced
HEENT: AT/NC, EOMI, PERRL, scleral icterus, MMM
NECK: JVP ~9cm
HEART: RRR, S1/S2, soft systolic murmur loudest at USB
LUNGS: CTAB, breathing comfortably
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, + caput medusa, scattered bruises at insulin
injection sites
EXTREMITIES: 1+ pitting edema in ___ b/l, no cyanosis or
clubbing, no palmar erythema, moving all 4 extremities with
purpose, 2+ DP pulses bilaterally
NEURO: AOx3, CN II-XII intact, ___ strength throughout b/l
SKIN: jaundiced, warm and well perfused, no excoriations or
lesions, no rashes
Pertinent Results:
ADMISSION LABS:
===============
134 | 100 | 16
---------------< 254
4.7 | 24 | 0.8
Ca: 8.2 Mg: 1.6 P: 2.2
12.1
3.7 >------< 44 12.1 44
37.5
MCV 97
___: 15.5 PTT: 32.7 INR: 1.4
ALT: 36 AP: 176 Tbili: 21.2 Alb: 2.6
AST: 91 LDH: Dbili: 16.2 TProt:
___: Lip: 47
U/A
SpecGr 1.015 pH 6.5 Urobil 0.2 Bili Lg
Leuk Tr Bld Neg Nitr Neg Prot Neg
Glu 100 Ket Neg RBC 1 WBC 2 Bact Few
Yeast None Epi 2
IMAGING:
========
___ Liver Or Gallbladder Us (Single Organ)
1. No evidence of portal vein thrombosis.
2. Cirrhotic appearing liver with splenomegaly and recannulized
umbilical vein.
3. Cholelithiasis.
4. Mild gallbladder wall edema is unchanged from abdominal
ultrasound ___ and is likely secondary to third
spacing from cirrhosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 5 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH QDAILY
3. Furosemide 40 mg PO DAILY
4. Lactulose ___ mL PO TID
5. Meclizine 25 mg PO TID
6. Nadolol 20 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Rifaximin 550 mg PO BID
9. Spironolactone 100 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO DAILY
12. Ursodiol 300 mg PO BID
13. albuterol sulfate 90 mcg/actuation inhalation Q24H
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Artificial Tear Ointment 1 Appl BOTH EYES PRN open eyes
3. Aspirin 81 mg PO DAILY for aortic conduit-for life
4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
5. Fluconazole 400 mg PO Q24H
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. Glargine 16 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
NPH 38 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
10. Lidocaine 5% Patch 1 PTCH TD QPM
11. LOPERamide 2 mg PO BID
12. Metoprolol Tartrate 12.5 mg PO BID
Hold for sbp <110 or HR <60
13. Mycophenolate Mofetil 500 mg PO QID
14. PredniSONE 12.5 mg PO DAILY
follow printed taper
15. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN lowers
potassium
RX *sodium polystyrene sulfonate 15 grams by mouth once a day
Refills:*2
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Tacrolimus 5 mg PO Q12H
continue for 2 doses on ___ then decrease to 3mg twice
daily starting ___. Tacrolimus 3 mg PO Q12H
start ___
dose decrease due to Fluconazole increase on ___
19. ValGANCIclovir 450 mg PO Q24H
20. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
21. Escitalopram Oxalate 5 mg PO DAILY
22. Omeprazole 20 mg PO DAILY
23. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
=====================
- Acute on chronic liver failure
SECONDARY:
=====================
Non-alcoholic Fatty Liver disease
Malnutrition
DM
Pleural effusion
hypothyroid (sick thyroid)
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: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with RUQ abdominal pain // ?portal vein thrombosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. Th a large recannulized umbilical vein is again noted
unchanged from abdominal ultrasound ___.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is a conglomerate of gallbladder stones. There is mild
gallbladder wall edema, nonspecific and unchanged from ___. The
gallbladder is nondistended.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity and enlarged measuring 14.3 cm, previously
measuring 14.2 cm on ___.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No evidence of portal vein thrombosis.
2. Cirrhotic appearing liver with splenomegaly and recannulized umbilical
vein.
3. Cholelithiasis.
4. Mild gallbladder wall edema is unchanged from abdominal ultrasound ___ and is likely secondary to third spacing from cirrhosis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with decompensated cirrhosis. // ? evidence of
infection
TECHNIQUE: Chest two views
COMPARISON: ___
FINDINGS:
Shallow inspiration. Normal heart size, pulmonary vascularity. No edema.
Lungs are clear. No pneumothorax. No effusion.
IMPRESSION:
Normal chest
Radiology Report
EXAMINATION: MRCP
INDICATION: Ms. ___ is a ___ w/ hx IDDM, idiopathic cirrhosis (thought to
be NASH), IDDM, and asthma who was admitted less than 2 weeks ago for
decompensated cirrhosis unknown etiology who is again presenting with jaundice
and worsening direct hyperbilirubinemia. Evaluate for hepatobiliary
obstruction.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: MRCP from ___.
FINDINGS:
Lower Thorax: Within the limitations of MRI the lung bases are grossly clear.
The visualized heart and pericardium are unremarkable.
Liver: The liver is diffusely nodular in contour compatible with known
cirrhosis. No suspicious focal liver lesion is identified. There is a very
large recanalized paraumbilical vein with extensive varices within the midline
subcutaneous soft tissues shunting blood flow away from the main portal vein.
There are also esophageal varices.
Biliary: The gallbladder is very collapsed and not well evaluated on today's
exam. Punctate foci of low signal intensity in the gallbladder fossa could
represent known gallstones. There is no definite gallbladder wall thickening
or pericholecystic fluid. There is mild intrahepatic biliary ductal
dilatation in the left lobe of the liver, minimally changed since the prior
study from ___. No obstructing mass or stricture is identified,
although the central aspect of the left biliary ducts is obscured by a very
large recanalized paraumbilical vein.
Pancreas: The pancreas demonstrates normal signal intensity and enhancement.
Scattered cystic lesions are again seen in the pancreas measuring up to 9 mm
in the body, likely side branch IPMNs. There is no pancreatic ductal
dilatation.
Spleen: The spleen is markedly enlarged measuring 14.5 cm. It demonstrates
homogeneous enhancement. A splenule is incidentally noted.
Adrenal Glands: Bilateral adrenal glands are normal.
Kidneys: The kidneys demonstrate normal enhancement without hydronephrosis or
suspicious solid renal lesion. Punctate 3 mm cyst is present in the
interpolar region of the right kidney.
Gastrointestinal Tract: The stomach, included small and large bowel are
grossly unremarkable.
Lymph Nodes: There is no mesenteric or retroperitoneal lymphadenopathy.
Vasculature: The abdominal aorta is normal in caliber. Major branching
vessels are patent. Hepatic arterial anatomy is conventional. There is
persistent unchanged filling defect in the posterior aspect of the upper SMV
which is compatible with a chronic appearing thrombus (series 19, image 68).
Osseous and Soft Tissue Structures: Marrow signal is within normal limits.
Extensive varices in the anterior abdominal wall are noted.
IMPRESSION:
1. Mild left lobe intrahepatic biliary ductal dilatation is minimally changed
since the ___ study, with the central portions obscured by a large
recanalized paraumbilical vein. No obstructing mass or stone.
2. Cirrhosis with sequelae of portal hypertension including splenomegaly,
large recanalized paraumbilical vein, and extensive abdominal wall and
esophageal varices.
3. Unchanged chronic-appearing non-occlusive thrombus along the posterior
aspect of the upper SMV.
4. Collapsed gallbladder. Known gallstones are not clearly visualized on
today's exam.
5. Scattered pancreatic cystic lesions measuring up to 9 mm, likely side
branch IPMNs. ___ year follow-up MRCP is recommended as previously suggested.
RECOMMENDATION(S): Followup MRCP in ___ year.
Radiology Report
EXAMINATION: TEETH (PANOREX FOR DENTAL)
INDICATION: ___ w/ hx IDDM, idiopathic cirrhosis (thought to be NASH), IDDM,
and asthma who was admitted less than 2 weeks ago for decompensated cirrhosis
unknown etiology who is again presenting with jaundice and worsening direct
hyperbilirubinemia. Performing expedited transplant workup. // Dental eval
for liver transplant eval Dental eval for liver transplant eval
IMPRESSION:
No comparison. Multiple missing teeth. No evidence of chronic infectious
changes.
Radiology Report
EXAMINATION: BILATERAL DIGITAL DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD
INDICATION: Patient on transplant list. Decompensated cirrhosis and
worsening for expedited transplant workup.
COMPARISON: None. Baseline.
TECHNIQUE: Digital CC and MLO views were obtained. Computer aided detection
was utilized and assisted with interpretation.
FINDINGS:
Tissue density: B - There are scattered areas of fibroglandular density.
Benign calcifications noted in the right inferior medial breast.There is no
dominant mass, unexplained architectural distortion or suspicious grouped
microcalcifications in either breast.
IMPRESSION:
No specific evidence of malignancy.
RECOMMENDATION: Age and risk appropriate screening is recommended.
NOTIFICATION: A lay report will be sent to the patient with this result.
BI-RADS: 2 Benign.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ w/ hx IDDM, idiopathic cirrhosis (thought to be NASH), IDDM,
and asthma who was admitted less than 2 weeks ago for decompensated cirrhosis
unknown etiology who is again presenting with jaundice and worsening direct
hyperbilirubinemia of unclear etiology. W/ Fall this AM// r/o
hemorrhage/trauma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.5 cm; CTDIvol = 47.4 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 843 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass. There is
probable chronic lacunar infarct in the upper left thalamus. There is
probable chronic lacunar infarct versus prominent prevascular space in the
right centrum semiovale. 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:
There are no acute findings. There is no hemorrhage.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old woman with history of possible stroke, undergoing
liver transplant// stenosis
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
The right carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 83 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 41, 65, and 48 cm/sec, respectively.
The peak end diastolic velocity in the right internal carotid artery is 16
cm/sec.
The ICA/CCA ratio is 0.78.
The external carotid artery has peak systolic velocity of 79 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 75 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 29, 60, and 37 cm/sec, respectively.
The peak end diastolic velocity in the left internal carotid artery is 12
cm/sec.
The ICA/CCA ratio is 0.8.
The external carotid artery has peak systolic velocity of 76 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
No sonographic evidence of hemodynamically significant stenosis or plaques in
the carotid arteries.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with worsening encephalopathy// PNA PNA
IMPRESSION:
Comparison to ___. Low lung volumes. Borderline size of the
cardiac silhouette. Mild elongation of the descending aorta. Mild fluid
overload but no overt pulmonary edema.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: Ms. ___ is a ___ w/ hx IDDM, idiopathic cirrhosis (thought to
be NASH), IDDM, and asthma who was admitted less than 2 weeks ago for
decompensated cirrhosis (Childs B-C, MELD 26 on ___ unknown etiology who is
again presenting with jaundice and worsening direct hyperbilirubinemia,
transplant pending. Now w/ ___. Eval for ascites// eval for ascites
TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained.
COMPARISON: None.
FINDINGS:
Targeted ultrasound images were obtained of the abdominal cavity. No ascites
could be identified.
IMPRESSION:
No ascites was identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ hx IDDM, idiopathic cirrhosis (thought to be NASH), IDDM,
and asthma who was admitted less than 2 weeks ago for decompensated cirrhosis
(Childs B-C, MELD 26 on ___, worked up for liver transplant. Now w/ pleuritic
chest pain and crackles.// r/o pulm edema, PNA
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiographs from ___ and ___.
FINDINGS:
Compared to ___, lung volumes are improved. The heart is mildly
enlarged. The mediastinal contours are within normal limits. There is
increased pulmonary edema, right greater than left, with small bilateral
effusions. A possible superimposed pneumonia cannot be excluded in the
appropriate clinical setting. There is no pneumothorax.
IMPRESSION:
1. Compared to ___, mild cardiomegaly with increased asymmetric
pulmonary edema, right greater than left, and small bilateral effusions.
2. A possible superimposed pneumonia cannot be excluded in the proper clinical
setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p liver transplant// assess for interval
change assess for interval change
IMPRESSION:
The patient is of the liver transplantation, the examination is compared to ___. All monitoring and support devices, including the Swan-Ganz
catheter and the endotracheal tube are in correct expected position. Lung
volumes are low but there is no evidence of pulmonary edema or larger pleural
effusions. Mild retrocardiac atelectasis. No pneumothorax.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman POD0 liver transplant// assess vasculature,
ductal dilation, perihepatic collection
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: None.
FINDINGS:
Note is made that the ultrasound is severely technically limited due to
overlying bandages limiting the sonographic windows and inaccessible approach
to the midline and subcostal region. Within that limitation the liver
echotexture is normal. There is no evidence of focal liver lesions or biliary
dilatation. The common hepatic duct could not be visualized. There is trace
perihepatic ascites. There is a moderate right pleural effusion. A
___ fluid collection/hematomas is identified measuring 5 cm at the
dome of the right lobe.
The spleen measures 13.1 cm and has normal echotexture.
DOPPLER: Doppler evaluation of the hepatic vessels is technically limited due
to overlying bandages, as described above. The main hepatic cannot be
visualized. Appropriate arterial waveforms are seen in the right hepatic
artery and the left hepatic artery with resistive indices of 0.72. The main
portal vein could not be visualized. The right and left portal veins are
patent with hepatopetal flow and normal waveform. Appropriate flow is seen in
the hepatic veins and the IVC.
IMPRESSION:
1. Severely technically limited ultrasound due to overlying bandages and
limited sonographic windows.
2. Patent intrahepatic vasculature with appropriate waveforms. Note is made
that the main hepatic artery and main portal vein cannot be evaluated on
today's exam.
3. No evidence of intrahepatic ductal dilatation.
4. Trace perihepatic ascites with a fluid collection/hematoma measuring
approximately 5 cm at the posterior dome of the right lobe.
5. Moderate right pleural effusion.
6. Mild splenomegaly.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, on the telephone on ___ at 1:55pm, 30 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman POD0 liver transplant with increasing O2
requirement// interval change
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiographs from ___ through ___.
FINDINGS:
Compared to ___ at 04:28, lung volumes remain low. The right
Swan-Ganz catheter is now positioned in the descending portion of the right
pulmonary artery. Other tubes and lines are unchanged in position. There is
diffusely increased opacification over the right lung, which may be due to a
layering effusion or breast shadowing. There is mild vascular congestion. No
pneumothorax is seen. Retrocardiac atelectasis persists.
IMPRESSION:
1. Compared to ___ at 04:28, lung volumes remain low with diffusely
increased opacification over the right lung, which may be due to a layering
effusion breast shadowing.
2. Persistent retrocardiac atelectasis.
3. Right Swan-Ganz catheter position in the descending portion of the right
pulmonary artery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p liver transplant with open abdomen// please
evaluate endotracheal tube position please evaluate endotracheal tube
position
TECHNIQUE: Since ___, most recently ___.
IMPRESSION:
Compared to chest radiograph since ___, most recently ___.
Relatively uniform opacification of the right lower hemithorax persists. The
explanation is uncertain, either posteriorly layering pleural effusion or
severe consolidation or collapse of the lower lobe. Chest CT would be
definitive in distinguishing among these possibilities. Left lower lobe
consolidation and previous mild pulmonary edema have improved. Heart size is
normal.
Cardiopulmonary support devices are in standard placements unchanged.
RECOMMENDATION(S): Consider chest CT for explanation pleural pulmonary
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with s/p liver transplant// evaluate volume
status pt on CVVH Surg: ___ (abdominal closure)
COMPARISON: Chest x-ray from ___ at 13:21
FINDINGS:
The ET tube lies approximately 5.1 cm above the carina, at the upper edge of
the clavicular heads. NG tube extends beneath diaphragm, off film. Right IJ
sheath overlies the mid/distal SVC. Right IJ Swan-Ganz catheter probably lies
in the proximal right pulmonary artery--full characterization is somewhat
limited due to patient rotation.
Allowing for differences in position and technique, cardiomediastinal
silhouette is probably unchanged. It appears slightly prominent, but this is
likely accentuated by low lung volumes and lordotic positioning.
There is mild vascular plethora, also likely accentuated by low lung volumes.
Increased retrocardiac density is again seen, compatible left lower lobe
collapse and/or consolidation. No gross left effusion.
Hazy opacity at the right base likely reflects a layering small right pleural
effusion.
IMPRESSION:
Lines and tubes as described. The ET tube lies approximately 5.1 cm above the
carina. Clinical correlation regarding advancement is requested.
Allowing for low lung volumes, no definite change in cardiac silhouette.
Layering right pleural effusion. Increased retrocardiac density consistent
with left lower lobe collapse and/or consolidation. These findings are
similar to the prior study.
Apparent vascular plethora is likely accentuated by low lung volumes.
Radiology Report
EXAMINATION: ABD (SINGLE VIEW ONLY) IN O.R.
INDICATION: Rule out retained lap pad prior to closing during abdominal
surgery. Performed per protocol, though no clinical concern for retained
material.
TECHNIQUE: Intraoperative AP view of the chest and abdomen.
COMPARISON: None.
FINDINGS:
The patient is on a temperature control pad or other device that introduces
artifact throughout the images. No separate image of the item of interest
(lap pad) is available for review at this time. The extreme right and left
abdominal soft tissues are excluded from the film.
There is tubing overlying the lower abdomen and pelvis.. Apparent dual lumen
right femoral line versus 2 adjoining right femoral lines. ET tube with tip
approximately 4.4 cm above the carina. NG tube, with tip below diaphragm.
Right Swan-Ganz catheter tip proximal right pulmonary artery.
Metallic surgical instrument overlies the chest. There are scattered linear
densities that are thought to represent surgical clips and, also, skin staples
which may be either on or adjacent to the patient.
Inspiratory lung volumes are low with some increased retrocardiac density
consistent with left lower lobe collapse and/or consolidation.
Allowing for this, no focal radiopacity suggestive of a lap pad is identified.
IMPRESSION:
Limited exam due to considerable overlying artifact. However, no radiodensity
suggestive of a lap pad is detected. If clinical concern were high, then a
dedicated radiograph of the item of interest could be obtained to help for
further assessment.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p liver transplant// interval change
interval change
IMPRESSION:
In comparison with the study ___, the endotracheal tube appears to have
been removed. Other monitoring and support devices are stable.
Continued low lung volumes with enlargement of the cardiac silhouette and some
elevation of pulmonary venous pressure. No acute focal consolidation is
appreciated.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new central line.// appropriate line
placement? Central and NG tube Contact name: ___: ___
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiographs from ___, ___.
FINDINGS:
Compared to ___, there is a new right IJ central venous catheter with
its distal tip in the lower right atrium. Endotracheal and enteric tubes are
in appropriate and unchanged position. Lung volumes remain low. The
cardiomediastinal silhouette is unchanged. Vascular congestion is unchanged.
A right layering pleural effusions again noted. A left pleural effusion is
also seen, with volume loss in the left base.
IMPRESSION:
1. Compared to ___, new right IJ central venous catheter with distal
tip in the low right atrium. Recommend withdrawing approximately 7 cm for
positioning at the cavoatrial junction, if desired.
2. The heart lungs are not significantly changed in appearance with persistent
vascular congestion, layering right pleural effusion, a left pleural effusion
and volume loss at the left base.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:15 pm, 2 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new line placement// line positioning
Contact name: ___: ___ line positioning
IMPRESSION:
In Comparison with the earlier study of this date, the right IJ catheter has
been pulled back. The tip is still approximately 2 cm below the cavoatrial
junction.
Little overall change in the appearance of the heart and lungs.
Radiology Report
EXAMINATION: ___ intestinal tube advancement.
INDICATION: ___ w/ hx IDDM, idiopathic cirrhosis (likely NASH), and asthma
here for decompensated cirrhosis unknown etiology s/p deceased donor liver
transplant. ___ intestinal tube advancement.
DOSE: Acc air kerma: 4.6 mGy; Accum DAP: 123.28 uGym2; Fluoro time: 0.3
COMPARISON: ___ chest radiograph.
___ MRCP.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, the existing Dobhoff feeding tube was advanced
post-pylorically using a guidewire.
12 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the tip of the feeding tube in at the
duodenojejunal junction.
The feeding tube was affixed to the patient's nose using tape.
IMPRESSION:
Successful post-pyloric advancement of a Dobhoff feeding tube. The tube is
ready to use.
Radiology Report
INDICATION: ___ year old woman s/p liver transplant// interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ at 17:10
FINDINGS:
Right-sided IJV CVP in situ with the tip in the proximal right atrium. Two
nasogastric feeding tubes in situ. Elevation of the left hemidiaphragm.
Platelike atelectasis in the left lower lung zone.
Moderate right-sided pleural effusion appears slightly increased compared to
prior. Increased airspace density in the right mid and lower lung zones is
most likely secondary to the pleural effusion. Mild pulmonary vascular
congestion. Perihepatic abdominal drain in situ.
IMPRESSION:
Suspected mild increase in size of the right-sided pleural effusion. Mild
increase in pulmonary vascular congestion, but no overt pulmonary edema.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman s/p liver transplant with new dobhoff//
evaluate dobhoff position
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiographs from ___.
FINDINGS:
Compared to ___ at 04:19, there is a new Dobhoff tube with its tip in
the proximal stomach, near the gastroesophageal junction. Other lines and
tubes are unchanged in position. There is little change to the appearance of
the heart and lungs.
IMPRESSION:
1. Compared to ___ at 04:19, there is a new Dobhoff tube with tip in
the proximal stomach, near the gastroesophageal junction. Recommend advancing
8-10 cm for more optimal positioning.
2. There is little change in the appearance of heart lungs.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new trialysis line// line position
Contact name: ___: ___
TECHNIQUE: Chest single view
COMPARISON: ___ 13:52
FINDINGS:
Right IJ central line tip near cavoatrial junction. Very shallow inspiration.
2 enteric tubes tips well below diaphragm. More prominent left basilar
opacity, likely atelectasis. Right pleural effusion is more apparent,
adjacent mild atelectasis. Normal heart size, mildly prominent pulmonary
vascularity. No pneumothorax. Catheter projected over right upper quadrant,
upper abdomen. Surgical staples upper abdomen.
IMPRESSION:
New right IJ central line, no pneumothorax.
More prominent right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p liver transplant and known pleural
effusion// interval change interval change
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Lung volumes remain very low. Moderate right pleural effusion has not
improved. Left lower lobe atelectasis is mild to moderate, but improved over
the past several days. Pulmonary vasculature is engorged but there is no
edema. Heart size is normal. No pneumothorax.
Esophageal drainage tube ends in the upper stomach. Feeding tube passes out
of the field of view.
Right jugular dual channel catheter ends in the right atrium as before.
Radiology Report
INDICATION: ___ year old woman s/p liver transplant// interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Serial interval increase in size of the right-sided pleural effusion with
associated atelectasis. The left lung is clear. Mild left basal atelectasis
with elevation of the left hemidiaphragm. Tube positions unchanged.
IMPRESSION:
Serial interval progression of the right-sided pleural effusion with
associated atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p liver transplant, now with increased work
of breathing// Interval change
TECHNIQUE: Single AP radiograph of the chest.
COMPARISON: Chest radiograph with the same date.
FINDINGS:
Right jugular catheter terminates in the right atrium. Post pyloric Dobhoff
tube is appropriate. NGT with tip and side hole below the diaphragm.
Layering right pleural effusion is unchanged, moderate in size. No new focal
consolidations. No pulmonary edema. Stable appearance of the
cardiomediastinal silhouette. No pneumothorax.
IMPRESSION:
Unchanged examination with a moderate right pleural effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman s/p DDLT 1 week ago, now with acute blown left
pupil. Otherwise following commands. Please assess for hemorrhagic stroke.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: CTDIvol: 46.71 mGY
DLP: ___ Mgy-cm
COMPARISON: Head CT ___
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 stable in size and configuration. There
are periventricular and subcortical lucencies, which may represent small
vessel ischemic changes. Chronic left basal ganglia, left thalamic and right
corona radiata probable lacunar infarcts are again noted. The imaged
paranasal sinuses are clear. Mastoid air cells and middle ear cavities are
well aerated. The bony calvarium is intact. Endotracheal tube and nasogastric
tube are partially visualized.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or large territorial
infarction.
2. Please note that MRI is more sensitive for the detection of infarction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ? pulm edema// ? pulmonary edema
COMPARISON: None.
FINDINGS:
Low inspiratory volumes. 2 enteric type tubes both of which extend beneath
the diaphragm off the film. Additional tubing overlies the right upper
quadrant, source uncertain. Dual lumen right IJ catheter with both tips over
the right atrium.
Inspiratory volumes are quite low. No pneumothorax detected. Arts heart size
is borderline, probably not enlarged. No CHF, focal infiltrate or effusion is
identified. Minimal subsegmental atelectasis present. While tiny bilateral
effusions cannot be excluded, no gross effusion identified.
IMPRESSION:
Low inspiratory volumes. Doubt overt CHF. No pulmonary edema.
Radiology Report
INDICATION: ___ year old woman with right pleural eff, s/p ___// r/o ptx
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
Low bilateral lung volumes. The right pleural effusion has decreased in size,
now likely trace in extent. No pneumothorax. Minimal bibasilar atelectasis.
Unchanged 2 positions.
IMPRESSION:
Interval decrease in size of the right pleural effusion, now likely trace in
extent. No pneumothorax.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: r/o hepatic artery stenosis, rejection
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Ultrasound from ___.
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. No focal liver
lesions are identified. A perihepatic crescentic fluid collection/hematoma is
noted, decreased in size from prior exam.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct was not visualized.
Pancreas: Pancreas is not well seen to overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, measuring up to 13.5 cm
Kidneys: Limited views of the right kidney are unremarkable. No stones,
masses, or hydronephrosis are identified in either kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 81.6 cm/sec.
Right and left portal veins are patent, with antegrade flow.
Main hepatic artery is patent with brisk systolic upstroke in contiguous
antegrade flow. Peak systolic velocity is 62 cm/s.
Right hepatic artery is patent with the resistive index of 0.73. Left hepatic
artery is also patent with a resistive index of 0.83.
IMPRESSION:
1. Patent hepatic vasculature with appropriate waveforms. Resistive the
indices in the right and left hepatic arteries of 0.73 and 0.83.
2. No intrahepatic biliary ductal dilatation. The common hepatic duct was
not visualized.
3. Interval decrease in size of perihepatic fluid collection/hematoma.
4. Stable mild splenomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with liver transplant, now s/p drainage of
pleural effusion// interval change
COMPARISON: Chest x-ray from ___ at 04:54
FINDINGS:
Again seen are 2 enteric tubes, which both extend beneath diaphragm, off this
film. Also again seen is a dual lumen catheter from a right IJ approach,
unchanged. No pneumothorax detected.
As before, inspiratory volumes are low. Prominence of the cardiomediastinal
silhouette is likely accentuated by low inspiratory volumes and technical
factors. No gross effusion is identified, though minimal blunting of the
costophrenic angles is likely present. There is bibasilar atelectasis, but no
frank consolidation. Allowing for low lung volumes, no definite CHF.
Previously seen drain in the right upper quadrant is no longer visualized.
IMPRESSION:
Apparent interval removal of right upper quadrant abdominal drain.
No gross change compared 1 day earlier. Inspiratory volumes are lower. Small
tiny bilateral effusions are likely present.
Radiology Report
INDICATION: ___ year old woman with liver transplant, now with increased
shortness of breath// Interval change
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right internal jugular catheter projects over the right atrium.
Enteric tubes course below the level of the diaphragms but beyond the field of
view of this radiograph.
Low bilateral lung volumes with probable layering bilateral pleural effusions.
No large focal consolidation or pneumothorax. The appearance of the cardiac
silhouette is unchanged.
IMPRESSION:
No significant interval change since the prior chest radiograph.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p liver transplant// Interval change
Interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild edema is exaggerated by low lung volumes. Mild right basal atelectasis
has worsened. Small right pleural effusion is likely. No appreciable left
pleural effusion or pneumothorax.
Heart size top-normal exaggerated by low lung volumes.
Transesophageal feeding tube passes alongside a drainage tube ending in the
mid stomach, passing into the duodenum and out of view.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
Abdominal ultrasound with Doppler
INDICATION: Please assess by Doppler the hepatic vasculature. Also assess
for fluid collections
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Abdominal doppler ultrasound ___
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. There is a subcapsular
hematoma which is grossly unchanged as compared to abdominal ultrasound ___. There is no evidence of focal liver lesions or biliary
dilatation. There is a small right pleural effusion which is unchanged. There
is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 2 mm.
Pancreas: The imaged portion of the pancreas appears within normal limit,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal architecture but is enlarged measuring
13.9 cm across maximal diameter.
Kidneys: Survey images of the right kidney demonstrate no gross abnormality.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 84.6 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
IMPRESSION:
1. Patent hepatic vasculature.
2. Subcapsular hematoma is grossly unchanged as compared to abdominal
ultrasound with Doppler ___.
3. Stable small right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ idiopathic vs. NASH cirrhosis s/p DDLT w/ aortic conduit
c/b coagulopathy requiring intra-abdominal packing with open abdomen s/p
washout, CBD reconstruction, closure with feeding tube. Now with
nausea/vomiting// assess location of feeding tube tip
TECHNIQUE: Chest single
COMPARISON: ___
FINDINGS:
Feeding tube is not identified, it may be coiled in the oral cavity or
pharynx. Right central line tip in the right atrium. Mild right, small left
pleural effusions. Shallow inspiration accentuates heart size, pulmonary
vascularity which are prominent, similar to mildly worsened since prior.
Surgical staples in the abdomen wall. Right basilar opacity, likely
atelectasis.
IMPRESSION:
Feeding tube is not identified.
Radiology Report
INDICATION: ___ year old woman with DHT placed// Assess for placement of DHT
TECHNIQUE: Portable upright chest radiographs
COMPARISON: ___ at 16:43
IMPRESSION:
A right IJ approach dialysis catheter terminates in the right atrium. The
enteric tube terminates in the gastric antrum. Lung volumes are low with mild
interstitial edema and a moderate right pleural effusion. No significant left
pleural effusion. No pneumothorax. Heart size is stably enlarged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p dobhoff insertion// for placement of
tubethank you
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 (PORTABLE AP)
INDICATION: ___ year old woman with liver txp, now w/ subjective dyspnea//
Assess for thoracic pathology or gastric dilatation Assess for thoracic
pathology or gastric dilatation
IMPRESSION:
Comparison to ___. Minimal decrease in extent of the pre-existing
right pleural effusion. Mild cardiomegaly persists. No pulmonary edema, no
pneumonia. Stable monitoring and support devices. The radiograph provides no
evidence for gastric dilatation.
Radiology Report
EXAMINATION: Chest AP and lateral
INDICATION: ___ year old woman with SOb susp pleural eff on the Rt// status of
pleural eff on the Rt, other consolidation?
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest x-ray dated ___.
FINDINGS:
Since most recent prior dated ___, there has been no change in
loculated right-sided pleural effusion. No left-sided pleural effusion is
seen. Low lung volumes. No evidence of pneumonia. Mild cardiomegaly.
Mediastinal and hilar contours are unchanged. No pneumothorax. Monitoring and
support devices are stable.
IMPRESSION:
Unchanged right-sided pleural effusion. No evidence of pneumonia.
Radiology Report
EXAMINATION: Portable AP chest
INDICATION: ___ year old woman with dyspnea// assess for interval change
TECHNIQUE: Portable AP chest
COMPARISON: Chest x-ray dated ___.
FINDINGS:
Low lung volumes. There has been an increase in right-sided pleural effusion.
Cardiomediastinal and hilar silhouettes are unchanged. No pneumothorax.
There is been interval removal of the right-sided hemodialysis catheter.
IMPRESSION:
Increase in right-sided pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with recurrent pleural effusion s/p chest
tube// pneumothorax? tube placement?
TECHNIQUE: Chest single view
COMPARISON: ___ 06:14
FINDINGS:
Enteric tube tip is well below diaphragm, out of view. Very shallow
inspiration accentuates heart size, pulmonary vascularity. Right pleural
effusion has nearly resolved, there is new right pleural catheter. No
pneumothorax. Minimal right basilar atelectasis. Surgical staples abdomen.
IMPRESSION:
Improvement since prior.
No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with R pleural effusion s/p pigtail
placement.// Assess for interval change.
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 7 hours earlier
IMPRESSION:
Right lower lobe atelectasis has worsened. Right basal pigtail catheter
remains in place. There are low lung volumes. No other interval change from
prior study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with R pigtail chest tube// assess for interval
change. Please perform at 0500 ___
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 3 hours earlier
IMPRESSION:
Is aeration of the right lower lobe has minimally improved. No other interval
change from prior study.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman post procedure day 1 from thoracentesis with
drain placement, continued O2 requirement// Please assess chest without
contrast s/p thoracentesis ___ with drain in placew still having O2
requirement. ? reaccumulation of fluid
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
DOSE: DLP: 407 mGy-cm
COMPARISON: No previous CT examination available for comparison.
FINDINGS:
No incidental thyroid findings. No supraclavicular, infraclavicular or
axillary lymphadenopathy. Patient carries a feeding tube. No enlarged lymph
nodes in the mediastinum. Severe coronary calcifications, no pericardial
effusion. Punctate splenic calcification. No abnormalities are noted at the
level of the large mediastinal vessels. No osteolytic lesions at the level of
the ribs, the sternum, or the vertebral bodies. Mild degenerative vertebral
disease. No vertebral compression fractures. Mild right-sided pneumothorax.
A right pleural drain is in situ. The tip of the drain is located in the
posterior aspect of the right lung. The right lower lobe shows signs of
volume loss and a rather large masslike parenchymal consolidation (302, 91).
No larger fluid collections on either the left or the right side are noted.
Minimal atelectasis at the left lung basis. Non characteristic small
left-sided subpleural ground-glass nodule (302, 69).
IMPRESSION:
Right pleural chest drain in situ. Right pneumothorax of mild extent.
Masslike right lower lobe consolidation, likely of infectious origin. Non
characteristic nodule on the left. Otherwise unremarkable left hemithorax.
Radiology Report
INDICATION: ___ year old woman with pleural effusion, mild pneumothorax on CT
chest this morning. S/P chest tube removal this afternoon.// ?pneumothorax
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT chest from earlier today
FINDINGS:
Low bilateral lung volumes. Opacities at both lung bases may reflect
atelectasis and/or consolidation. No discrete pneumothorax is identified.
The size of the cardiac silhouette is within normal limits. An enteric tube
extends into the stomach.
IMPRESSION:
Low bilateral lung volumes. No discrete pneumothorax identified.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with R pigtail chest removed// Assess for
interval change. Please perform at 0500 ___ Assess for interval change.
Please perform at 0500 ___
IMPRESSION:
Type of tube tip is in the stomach. Heart size and mediastinum are stable.
Bibasal consolidations and bilateral pleural effusions are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with recurrent simple exudate after liver
transplant// ?recurrent exudate ?recurrent exudate
IMPRESSION:
Type of tube passes below the diaphragm. Heart size and mediastinum are
stable. Lung volumes are low. Bibasal areas of consolidations are unchanged.
There is no pneumothorax.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: 61 ___ w/ idiopathic vs. NASH cirrhosis s/p DDLT w/ aortic
conduit c/b coagulopathy requiring intra-abdominal packing with open abdomen
s/p washout, CBD reconstruction, closure// assistance w/ dobhoff tube
placement assistance w/ dobhoff tube placement
IMPRESSION:
In comparison with study of ___, the new Dobhoff tube extends to the mid
body of the stomach. Continued low lung volumes without acute pneumonia or
vascular congestion, blunting of both costophrenic angles is again seen.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Jaundice
Diagnosed with Unspecified jaundice, Right upper quadrant pain
temperature: 96.8
heartrate: 59.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 58.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ w/ hx IDDM, idiopathic cirrhosis (thought to
be NASH), IDDM, and asthma who was admitted for decompensated
cirrhosis. Given worsening liver function, encephalopathy, and
rising bilirubin with no clear source, expedited transplant
workup was performed and patient was offered a liver on ___
at which point she was transferred to the transplant surgery
service. Patient noted to have nonocclusive thrombus on MRCP.
Coumadin held prior to surgery. Of note, on ___ she
underwent Colposcopy w/ biopsies: LGSIL and on ___ required
cervical suture, cautery and packing in OR for persistent
bleeding from cervical biopsy. Bleeding resolved.
On ___, she underwent deceased donor liver transplant,
temporary portacaval shunt, arterial conduit (will need to be on
ASA for life), portal vein thrombectomy and staged transplant
with temporary abdominal closure and packing. Surgeons were Drs.
___ and ___. She had massive
hemorrhage (10 L) and received the following:PRBC 23, FFP 20,
Plt 7, Cryo 2, Factor VII x1, Cell saver 370, Crys 7L
Postop, she went to the SICU intubated where the a liver u/s
appeared wnl, but the main portal or main hepatic artery could
not be seen given Abthera dressing. She was given broad spectrum
antibiotics were given (Vanco, Aztreonam and Flagyl). A right
femoral dialysis catheter was placed and CRRT started. On
___, Dr. ___ took her back to the OR for removal of
the abdominal packing and wash out of hematoma,
choledochocholedochostomy and temporary abdominal closure.
Pressor support was weaned off and sedation lightened. LFTs
decreased after an initial expected increase. Mental status
improved and CRRT was stopped on ___. Medial JP output was
high. She required intermittent blood products, but was stable.
On ___, she went back to the OR for re-exploration of liver
transplant with abdominal washout and removal of retained packs
and abdominal closure. Surgeon was Dr. ___. Please
refer to operative notes for further intraop details. Broad
antibiotic coverage was given (Vanco, Postop, CRRT was resumed
via the femoral line that was later removed and a R IJ trialysis
line was placed. CVVHD continued until urine output improved and
overall volume status improved.
NG was removed and a post pyloric feeding tube placed. Tube
feeds were started using glucerna. Insulin drip was used for
hyperglycemia then this was switched to Lantus and sliding
scale. NPH was later added to cover steroid. She had bouts of
diarrhea with several stools sent and negative for c.diff.
Imodium was started on ___ with decreased stools the next day
on ___ ( 7 daily down to 2 daily).
LFTs continued to improve. Repeat liver duplex (___)
demonstrated patent vasculature and no biliary ductal
dilatation. LFTs decreased, but alk phos 300-240 range and alt
ranged in 60-70s.
On ___ while still in SICU, there was concern for pupillary
asymmetry in setting of slow mentation. A non-con head CT was
done that was negative for intracranial process. She continued
to be intermittently delirious. Seroquel was given. CRRT was
held on ___, but HD was resumed on ___ for rising BUN and
sedation. Urine culture was positive for yeast on ___ while on
Fluc. The foley was removed.
On ___, she was also dyspneic with decreased breath sounds on
right. CXR demonstrated pleural effusion. Intermittent doses of
Lasix were given. Thoracentesis was performed by IP for 650ml of
fluid on ___. Cell count showed PMNs and no organisms. Fluid
was exudative per Light's criteria. Blood cultures were
negative. Dyspnea resolved.
On ___, CT chest revealed a small pneumothorax, and RLL local
post expansion pneumonia or local consolidation. The pigtail
drain was removed by IP. She continued to improve.
Mental status improved. Speech and swallow continued to eval and
gradually diet was progressed to solid food and thin liquids.
The lateral JP was removed on ___ and the medial on ___.
Output was non-bilious. Incision staples were removed on ___.
Incision was intact without redness or drainage. Weight was down
to 77.6 kg on ___.
LFTs were stable normal. Immunosuppression consisted of cellcept
1 gram bid that was changed to 500mg 4 times daily for frequent
stools/gi complaints. Steroids were weaned to prednisone taper
which decreased to 12.5mg on ___. Tacrolimus was started and
adjusted per daily trough levels (trough goal 10). Dose was
increased to 5mg twice daily for trough of 6.0 on ___. Trough
increased to 8.3 on ___. Given that Fluconazole dose was
increased on ___, Tacrolimus dose will need to decrease to 3mg
twice daily starting ___. Fluconazole inhibits Tacrolimus.
She should have labs done on ___ with Tacrolimus lab couriered
to ___ lab control for stat processing.
___ Tacro 5mg/5mg
___ Tacro 5mg/5mg (6.0)
___ Tacro 4mg/4mg (5.7)
___ Tacro 3mg/3mg (6.6)
___ Tacro 2.5mg/2.5mg(6.2)
___ Tacro 2mg/2mg (-)
___ Tacro 2mg/2mg (10.9)
___ assessed and determined rehab needs. A bed was available at
___ and she was discharged in stable condition.
CHRONIC ISSUES:
# Diabetes Mellitus Type 2:
Most recent HbA1c 7.6.
- continue Glargine 58 Units Bedtime
- Insulin SC Sliding Scale using Humalog Insulin
- recheck HbA1c
# Depression:
- continue home Escitalopram Oxalate 5 mg PO DAILY
# Asthma
- continue Fluticasone Propionate 110mcg 2 PUFF IH QDAILY
- Albuterol Sulfate (Extended Release) 1 INH PO Q6H:PRN
wheezing
TRANSITIONAL ISSUES
===================
#CODE STATUS: full (confirmed)
#CONTACT: ___ (___)
Daughter: ___ (in ___: ___
(home-preferred#) ___ (cell) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Losartan
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC: ___, Failure To Thrive
HISTORY OF PRESENT ILLNESS: Ms ___ is a ___ with PMHx CKD,
afib, DM, no known psych hx who presents on ___ from her
PCPs office for AMS and agitation. Pt saw her PCP today and PCP
___ pt due to paranoid delusions and AMS. History is
obtained from notes as pt is unable to recount history and son
was not answering the phone when I called. Per ED notes, pt was
living with her son but there was some concern about her safety
there - apparently the house was very cluttered and she was
noted
being adequately cared for. She therefore moved in w/ family
friend 1 week ago and family friend noted change in her mental
status ever since, with decreased PO, wt loss, paranoid
delusions, pressured speech, agitation, and behavioral
disturbance. Pt was sent to ER by PCP due to concerns for her
safety at home and altered mental status. Pt denies any recent
falls.
In the ED, initial vitals were: 98.0 50 131/53 20 98% RA. Labs
were notable for trop 0.02, neg tox screen, creatinine 1.7. CT
showed no acute process. CXR showed congestion with mild
interstitial edema. Pt was given 5 mg olanzapine.
On the floor, pt is unable to recount her history and ___ is
difficult to understand. Attempted interview with interpreter
however patient remained difficult to understand and was
switching back and forth between speaking in creole and ___.
She is able to tell me that she is in the hospital but is unable
to tell me why she came into the hospital. She states that she
doesn't feel great, but also doesn't feel bad but is unable to
elaborate. She is cooperative and generally following commands.
Review of systems: unable to obtain due to altered mental status
Past Medical History:
PAST MEDICAL HISTORY (per chart, unable to confirm with pt):
CHRONIC KIDNEY DISEASE
? SLEEP APNEA
PULMONARY HYPERTENSION
? CORONARY ARTERY DISEASE
- Referenced in renal note, ___
SICKLE CELL TRAIT
OSTEOPOROSIS
HYPERLIPIDEMIA
HYPERTENSION
GASTROESOPHAGEAL REFLUX OSTEOARTHRITIS
HxBRADYCARDIA,ICD
H/O BREAST CANCER
- S/P lumpectomy, XRT - Patient has deferred mammographic
follow-up
H/O CONGESTIVE HEART FAILURE
- Per renal note, ___
H/O DIABETES MELLITUS
LUMPECTOMY ___
Social History:
___
Family History:
FAMILY HISTORY(per chart, unable to confirm with pt):Mother with
sickle cell
Physical Exam:
Admission Physical Exam:
========================
Constitutional: Thin, Alert, oriented to hospital not to date,
no
acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Irregular, normal S1 + S2, ___ SEM, rubs, gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, 1+ bilat pitting edema to mid shin
NEURO: aaox1, CNII-XII and strength grossly intact
SKIN: no rashes or lesions
Discharge Physical Exam:
========================
Gen: Lying in bed in no apparent distress
Vitals: Eflowsheets
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
Admission Labs
==============
___ 01:05PM BLOOD WBC-6.4 RBC-3.83* Hgb-11.8 Hct-36.3
MCV-95 MCH-30.8 MCHC-32.5 RDW-13.1 RDWSD-45.1 Plt ___
___ 01:05PM BLOOD Glucose-70 UreaN-23* Creat-1.7* Na-142
K-4.9 Cl-103 HCO3-24 AnGap-15
___ 01:05PM BLOOD ALT-10 AST-26 CK(CPK)-132 AlkPhos-90
TotBili-1.3
___ 01:05PM BLOOD CK-MB-6 cTropnT-0.02*
___ 07:50PM BLOOD cTropnT-0.02*
___ 01:05PM BLOOD Albumin-4.0 Calcium-10.1 Phos-3.1 Mg-2.0
___ 06:45AM BLOOD VitB12-371
___ 06:45AM BLOOD TSH-1.1
___ 01:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:21PM BLOOD Lactate-2.0
Imaging:
========
CT Head:
1. No acute intracranial hemorrhage or evidence of infarction.
2. Chronic involutional changes consistent with age as well as
evidence of
chronic microangiopathy
Discharge Labs:
===============
___ 06:55AM BLOOD WBC-5.3 RBC-3.70* Hgb-11.5 Hct-34.8
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.8 RDWSD-47.0* Plt ___
___ 06:35AM BLOOD Glucose-86 UreaN-52* Creat-1.7* Na-144
K-4.8 Cl-105 HCO3-29 AnGap-10
___ 06:35AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.7*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Apixaban 2.5 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. Furosemide 20 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
7. Calcium Carbonate 1500 mg PO DAILY
8. Vitamin D 200 UNIT PO DAILY
9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. OLANZapine 5 mg PO QHS
RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*30 Packet Refills:*0
3. Ramelteon 8 mg PO QHS
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
4. TraZODone 25 mg PO QHS
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*15 Tablet Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
7. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
9. Calcium Carbonate 1500 mg PO DAILY
RX *calcium carbonate 600 mg calcium (1,500 mg) 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
11. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Vitamin D 200 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 0.5 (One half)
tablet(s) by mouth daily Disp #*15 Tablet Refills:*0
14.Ensure
Ensure TID
ICD 10 E44
Dispense: 90
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Dementia
Fever
Secondary:
CKD
DM
HTN
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with AMS// eval for pna
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided. Right chest wall pacer
device is again seen with leads extending to the region the right atrium and
right ventricle. Pulmonary vascular congestion is noted with possible mild
interstitial pulmonary edema. No large effusion, pneumothorax or signs of
pneumonia. Cardiomediastinal silhouette appears unchanged. Imaged bony
structures are intact. High riding right humeral head suggests chronic
rotator cuff disease. Bilateral AC joint arthropathy is partially visualized.
Degenerative changes in the spine appear grossly unchanged with partially
visualized lumbar levoscoliosis.
IMPRESSION:
Congestion with mild interstitial edema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with AMS// eval for acute head bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major infarction,hemorrhage,edema,or discrete
mass. There is prominence of the ventricles and sulci suggestive of
involutional changes, consistent with age. Multiple subcortical and
periventricular white matter hypodensities are likely sequela of chronic
microangiopathy.
There is no acute fracture. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage or evidence of infarction.
2. Chronic involutional changes consistent with age as well as evidence of
chronic microangiopathy.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dementia, afib, now with fever// please
eval for evidence of aspiration or consolidation
IMPRESSION:
In comparison with the study of ___, there are lower lung volumes.
Cardiac silhouette is at the upper limits of normal in size without
appreciable vascular congestion, pleural effusion, or acute focal pneumonia.
Dual channel pacer leads again extend to the right atrium and right ventricle.
Otherwise, little change.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Agitation, Failure to thrive
Diagnosed with Restlessness and agitation
temperature: 98.0
heartrate: 50.0
resprate: 20.0
o2sat: 98.0
sbp: 131.0
dbp: 53.0
level of pain: 0
level of acuity: 2.0 | ___ with PMHx CKD, afib, DM, dementia who presented from her PCP
with acute encephalopathy.
# Acute encephalopathy
# FTT
# Moderate protein-calorie malnutrition
# Paranoid delusions
Presenting with agitation and aggression at home, and was
referred to the ED by her PCP on ___ due to paranoid and
agitated behavior. Head CT was negative for acute process.
Infectious workup including CXR, urinalysis, and blood cultures
were negative. Toxicology screen was negative. In terms of
reversible causes of dementia, TSH and RPR were normal and B12
was low normal (would consider methylmalonic acid testing as an
outpatient). She remained pleasant and interactive in the
morning and with sundowning starting around 5 ___ with severe
aggression and paranoid delusions. She was seen by psychiatry
who recommended titration of antipsychotic medications. She was
discharged on 5mg olanzapine at night and should follow up with
her primary care medication to discuss possibly downtitrating
this medication as an outpatient.
Overall her agitated and paranoid behavior was thought to be
secondary to progressive dementia. She was not deemed to be safe
to be alone and 24 hour care was recommended.
After several family meetings decision was made that patient
will go to stay with her niece ___ at her home where 24 hour
care can be provided. Her family will apply in the meantime for
expanded care coverage through ___. If this is eventually
arranged to cover 12 hour daytime care then she may eventually
be able to return home (son stays in apartment overnight).
# Fever: had single isolated fever to 100.6 during 11 day
hospital stay. She was asymptomatic without localizing symptoms.
Repeat CXR and urinalysis were negative for infection. Blood
cultures were sent and were pending at time of discharge.
# CKD: creatinine mostly at baseline. Did increase on several
days when PO intake was poor and home Lasix was held on those
days. Creatinine at discharge was 1.7 which was within range of
baseline
# DM: per chart however does not appear to be on meds. Monitored
on insulin sliding scale but did not require supplemental
insulin
# Afib: rate controlled, hx of bradycardia with pm in place.
Continued home apixaban and metoprolol
# HLD: continued home atorvastatin
# ___, chronic dCHF: seen by cardiology recently, thought to be
due to pulmonary hypertension/elevated filling pressures as well
as decreased physical activity/venous stasis. She was continued
on home Lasix at 20mg daily dose (had recently been increased to
BID) given at times poor PO intake secondary to agitation or
lethargy.
> 30 minutes spent on discharge coordination and planning |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transient word-finding difficulties
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ M w/ multiple vascular risk factors including
AFib/AFlutter on Coumadin s/p DC version ___, CAD s/p LAD
PCI ___ and CABG ___, CHF, CKD w/ b/l Cr 1.3-1.5, renal artery
stenosis s/p stents, bilateral carotid artery stenosis s/p L ICA
stent ?___, who presents with transient word-finding
difficulties resolved after 15mins.
History is obtained by patient and his daughter who witnessed
the
event. He was in his usual state of health until dinner today
around 5:45pm when he suddenly had difficulty speaking the word
"zinfadel". He states that he was able to think of the word but
he had trouble producing the word and it came out "scrambled".
He
denies slurred speech. He was able to speak other words and
understand his daughter, but he found trouble saying certain
other words as well such as "alphabet". Daughter called
ambulance
who brought him to ___ ED. At time of evaluation, patient
reports his symptoms are completely resolved and he is able to
say both "zinfadel" and "alphabet easily. He denies weakness,
sensory changes, visual changes, headache, dysarthria,
difficulty
comprehending speech, bowel or bladder incontinence.
ED course:
In ED, initial VS sig for BP 179/76, HR 76, 100% RA. Neurologic
examination was essentially wnl with normal language/speech and
memory, mild chronic sensory loss on LLE. EKG showed sinus
rhythm. He underwent CT noncontrast at 1840 which was negative
for acute bleed. Labs revealed INR 2.8, CBC wnl, BMP w/ Cr 1.3
(chronic).
Later at ___, patient had worsening of his symptoms with
inability to remember his daughter's and his roommates' names.
On
evaluation he was inattentive and had some difficulty naming
objects, mistaking watch for "telephone" and poor memory. CTA
head/neck around ___ reveal new left temporal hyperdensity c/w
hemorrhage; also revealed right-sided complete ICA occlusion as
well as mod stenosis of left ICA but patent stent. No large MCA
cutoff. Noncontrast head CT was performed and showed increased
size of hemorrhage with extension into the occipital horn of
left
lateral ventricle. Neurosurgery was consulted who initially
recommended continued monitoring and no indication for surgery
currently. He was subsequently given IV vitamin K and
prothrombin
complex to reverse his INR, and given 1u platelets given he was
on dual antiplatelet therapy. Admitted to Neuro ICU.
Past Medical History:
Coronary artery disease (s/p LAD stent in ___, ___, s/p 3-vessel CABG ___
Meningioma s/p resection
Adjustment disorder
Left posterior meningioma s/p resection
Sleep apnea
Obesity
Carotid stenosis s/p left ICA stent (___)
CHF (congestive heart failure), ___ class III
Chronic renal insufficiency
Bilateral renal artery stenosis s/p stents (___)
Hyperlipidemia
Hypertension
Left lumbar radiculopathy
Atrial flutter
Atrial fibrillation
Social History:
___
Family History:
Mother with TIAs in her ___, breast cancer, skin cancers
Father with MI at age ___
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
Vitals: BP 179/76, HR 76, RR 13, spO2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, R>L carotid bruits appreciated. No nuchal
rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x3. 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.
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 ___ objects and recall ___ at 10 minutes, remembered
___
with category cue. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 3 2+
R 2+ 2+ 2+ 3 2+
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred.
On repeat exam at ___:
-MS: Patient was oriented to ___ and hospital, but
could not name which hospital he was at, and perseverated on the
date. Able to name ___ but not backwards. Able to repeat simple
phrases, speech fluent but with paraphasic errors. Named thumb
and nail, but could not name cuticle, and stated "telephone" for
watch. Able to follow commands.
-CN, Motor, Sensory exams unchanged
=========================
DISCHARGE PHYSICAL EXAM
=========================
Tmax: 36.8°C (98.3°F)
T current: 36.6°C (97.9°F)
HR: 82 (80 - 120) bpm
BP: 117/87(91) {94/50(58) - 166/120(129)} mmHg
RR: 18 (16 - 31) insp/min
SPO2: 99%
Total In:1,865 mL
PO:1,865 mL
Total out:1,525 mL
Urine:1,525 mL
Balance:340 mL
General: Awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, R>L carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR
Abdomen: Soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: No rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented to person and time only. States
in ___ but unable to state the name of the hospital. Able to
name high frequency objects but not low frequency objects.
Semantic paraphasic errors (e.g. thermostat for stethoscope).
Repetition intact to simple phrases but impaired for complex
phrases. Able to follow 3-step commands. Perseverative.
Decreased
short term memory. Pt was able to register ___ words and recall
___ at 1 minute. Able to read a sonnet but skips words and
phrases. Names only 1 animal in 1 minute.
-Cranial Nerves: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to finger wiggling. Facial
sensation intact to light touch. Face symmetric. ___ strength in
trapezii bilaterally. Tongue midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L ___ 3 2
R ___ 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred.
Pertinent Results:
==========
LABS
==========
___ 06:30PM BLOOD ___ PTT-43.5* ___
___ 03:42AM BLOOD ___ PTT-34.3 ___
___ 06:30PM BLOOD ALT-42* AST-49* AlkPhos-82 TotBili-0.5
___ 06:30PM BLOOD Lipase-142*
___ 06:30PM BLOOD cTropnT-<0.01
___ 03:42AM BLOOD %HbA1c-5.9 eAG-123
___ 03:42AM BLOOD Triglyc-70 HDL-56 CHOL/HD-3.0 LDLcalc-99
___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:40AM BLOOD Glucose-100 UreaN-19 Creat-1.2 Na-139
K-4.3 Cl-101 HCO3-25 AnGap-17
==========
IMAGING
==========
CTA HEAD AND NECK (___):
1. In the interval between the initial head CT without contrast
and CTA
examination, development of a 4.6 left temporal lobe parenchymal
hemorrhage. No definite spot sign or aneurysm.
2. Multi segment high-grade stenosis of the left intracranial
ICA, complete occlusion of the right ICA from the carotid
bifurcation to the right carotid terminus. The remainder of the
intracranial circulation is patent, allowing for anatomic
variation. No aneurysm.
3. Metallic stent covers the proximal cervical left internal
carotid artery where there is multifocal luminal narrowing
resulting in approximately 75% stenosis by NASCET criteria.
Complete occlusion of the cervical right internal carotid
artery. Multifocal high-grade stenosis of the left V1 segment.
The right vertebral artery is grossly unremarkable.
4. Multiple left pulmonary nodules, unchanged in appearance from
CTA chest of ___.
NCHCT (___):
1. Left temporal intraparenchymal hemorrhage appears grossly
similar to prior CTA performed 4 hours prior.
2. Extension of hemorrhage into the left lateral ventricle and
third
ventricle.
3. Small amount of left parietal subarachnoid hemorrhage.
ECHO (___):
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. The right ventricular
cavity is mildly dilated with borderline normal free wall
function. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
no clear change.
NCHCT (___):
1. Slight interval increase the left temporal intraparenchymal
hemorrhage with mass effect and minimal uncal herniation.
2. Intraventricular extension of hemorrhage and less conspicuous
left parietal subarachnoid hemorrhage.
NCHCT (___):
1. Unchanged appearance of left temporal lobe parenchymal
hemorrhage with
minimal left uncal herniation.
2. No interval change in appearance of hemorrhage extension into
left
occipital horn of the lateral ventricle and third ventricle.
3. No hydrocephalus. No new hemorrhage or acute territorial
infarct.
MRI HEAD WITH AND WITHOUT CONTRAST (___):
1. Left temporal lobe hemorrhage with intraventricular extension
is not
significantly changed compared to prior CTs, allowing for
inter-modality
differences.
2. No evidence of acute infarction, underlying mass lesion or
new intracranial hemorrhage elsewhere in the brain.
3. Left occipital craniotomy changes and associated focal
encephalomalacia, unchanged.
4. Dural thickening versus a small sliver residual subdural
collection is
noted along the left frontotemporal convexity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Warfarin 7.5 mg PO DAILY16
4. Nasacort (triamcinolone acetonide) 55 mcg nasal Other
5. Atorvastatin 80 mg PO QPM
6. Sildenafil Dose is Unknown PO Frequency is Unknown
7. BuPROPion (Sustained Release) 150 mg PO QAM
8. Furosemide 20 mg PO BID
9. Lisinopril 5 mg PO DAILY
10. Sotalol 80 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Furosemide 20 mg PO BID
4. Acetaminophen ___ mg PO Q6H:PRN PAIN
5. Atorvastatin 80 mg PO QPM
6. Nasacort (triamcinolone acetonide) 55 mcg nasal Other
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
9. Outpatient Speech/Swallowing Therapy
Speech evaluation and treatment
Diagnosis: Left temporal lobe ischemic stroke with hemorrhagic
conversion
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Left temporal lobe ischemic stroke with hemorrhagic conversion
Secondary diagnosis:
AFib/AFlutter status post cardioversion ___
CAD status post LAD PCI ___ and CABG ___
CHF
CKD (baseline Cr 1.3-1.5)
Renal artery stenosis status post stents (___)
Bilateral carotid artery stenosis status post L ICA stent
(___)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with difficulty speaking // Eval for ICH
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.
Please note, noncontrast head CT was performed at 7 ___. The CTA portion of
the examination was performed at ___.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP =
35.4 mGy-cm.
4) Spiral Acquisition 5.2 s, 40.9 cm; CTDIvol = 32.1 mGy (Head) DLP =
1,313.8 mGy-cm.
Total DLP (Head) = 1,349 mGy-cm.
COMPARISON: CTA chest with without contrast of ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST: PERFORMED AT 7pm on ___
The patient is status post left occipital craniotomy with left occipital lobe
encephalomalacia. There is no intra or extra-axial mass effect, acute
hemorrhage or territorial infarct. Sulci, ventricles and cisterns are within
expected limits for the patient's age related global cerebral volume loss,
allowing for encephalomalacia. The paranasal sinuses are essentially clear.
The orbits are unremarkable. The mastoid air cells are clear.
ble.
CTA HEAD: PERFORMED at ___ on ___
Interval development of a 4.5 x 2.3 cm (AP, TRV) left temporal lobe
parenchymal hemorrhage with mild surrounding edema pattern, resulting in mild
left uncal herniation. Although there appears to be traversing vessels
through the hemorrhage, no clear spot sign is identified.
There is complete occlusion of the right internal carotid artery starting at
the carotid bifurcation extending into the cavernous portion with
reconstitution of the M1 segment, from collateral flow. The left internal
carotid artery contains a proximal cervical segment metallic stent, and is
patent but with multifocal narrowing throughout the stent. There is severe
narrowing of the proximal petrous portion of the left ICA as well as the
cavernous portion. Atherosclerotic calcification of the bilateral cavernous
segments are also noted. The bilateral M1 and M2 segments appear patent
without stenosis or occlusion. Bilateral ACAs are patent. There is fetal
type origin of the right PCA. The left posterior communicating artery is not
visualized. The posterior circulation is also patent. The left vertebral
artery ends in ___.
CTA NECK: In addition to the above,
There is a 3 vessel arch. As noted above, there is complete occlusion of the
right cervical internal carotid artery at the level of the bifurcation. A
metallic stent covers the proximal cervical internal carotid artery with
multifocal narrowing with approximately 75% stenosis by NASCET criteria.
Atherosclerotic calcification at the origin of the left vertebral artery
results in high-grade stenosis of the left V1 segment is also identified with
reconstitution at the V2 level at C6. The right vertebral artery is grossly
unremarkable from its origin to the skullbase.
The bilateral common carotid arteries are patent. There is narrowing at the
origin and proximal left vertebral artery which reconstitutes at the level of
C6.
OTHER:
There is a 4 mm ground-glass nodule in the left upper lobe (series 28, image
9), an additional scattered less than 2 mm nodules near the lung apices are
similar appearance to prior CTA chest of ___. No new pulmonary
nodules. There is no lymphadenopathy by size criteria. The thyroid gland is
unremarkable. The visualized aerodigestive tract is also unremarkable.
Median sternotomy wires are noted.
IMPRESSION:
1. In the interval between the initial head CT without contrast and CTA
examination, development of a 4.6 left temporal lobe parenchymal hemorrhage.
No definite spot sign or aneurysm.
2. Multi segment high-grade stenosis of the left intracranial ICA, complete
occlusion of the right ICA from the carotid bifurcation to the right carotid
terminus. The remainder of the intracranial circulation is patent, allowing
for anatomic variation. No aneurysm.
3. Metallic stent covers the proximal cervical left internal carotid artery
where there is multifocal luminal narrowing resulting in approximately 75%
stenosis by NASCET criteria. Complete occlusion of the cervical right
internal carotid artery. Multifocal high-grade stenosis of the left V1
segment. The right vertebral artery is grossly unremarkable.
4. Multiple left pulmonary nodules, unchanged in appearance from CTA chest of
___.
RECOMMENDATION(S): Follow-up of multiple left pulmonary nodules as suggested
on CTA chest of ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ male with new bleed on cta (since prior noncontrast
head CT). Evaluate for a bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 903 mGy-cm.
COMPARISON: CTA head neck from 21 Nvember ___ at 18:40.
FINDINGS:
There is a 3.8 x 2.5 cm left temporal lobe intraparenchymal hemorrhage,
grossly similar in size to the prior CTA from 4 hours prior. A small amount
of subarachnoid hemorrhage is noted along the right parietal lobe (series
2a:image 19). Extension of the hemorrhage into the left lateral ventricle
and third ventricle is noted. No hydrocephalus is seen. No shift of midline
structures is noted. Prior left occipital craniotomy is noted pulse well as
underlying encephalomalacia in the left occipital lobe.
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. Left temporal intraparenchymal hemorrhage appears grossly similar to prior
CTA performed 4 hours prior.
2. Extension of hemorrhage into the left lateral ventricle and third
ventricle.
3. Small amount of left parietal subarachnoid hemorrhage.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with left temporal intraparenchymal hemorrhage.
Assess for interval change in bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___ 22:10.
FINDINGS:
A left temporal intraparenchymal hemorrhage appears slightly increased in
size, currently measuring 4.5 x 2.8 cm compared to 3.6 x 2.3 cm (series 2:
Image 12). Associated mass-effect is seen causing minimal uncal herniation.
Extension of the hemorrhage into the left lateral ventricle and third
ventricle is seen. Ventricular configuration in size is unchanged from prior
exam. A small amount of right parietal subarachnoid hemorrhage is less
conspicuous on this exam. No new infarct, hemorrhage, edema or mass is seen.
Prior left suboccipital craniotomy is noted. There is no evidence of
fracture. The visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Slight interval increase the left temporal intraparenchymal hemorrhage with
mass effect and minimal uncal herniation.
2. Intraventricular extension of hemorrhage and less conspicuous left parietal
subarachnoid hemorrhage.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with L ischemic temporal stroke with hemorrhagic
conversion // ? interval 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 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 844 mGy-cm.
COMPARISON: CT head without contrast of ___ at 04:26 and ___.
FINDINGS:
Left 4.2 x 2.6 cm (AP, TRV) the temporal lobe parenchymal hemorrhage with
surrounding vasogenic edema pattern is essentially unchanged in size when
compared to the prior examination of ___ at 04:26. Associated
mass effect with minimal uncal herniation is unchanged. Ventricular extension
the hemorrhage into the occipital horn of the left lateral ventricle and
superior third ventricle is also stable. The configuration and size of the
ventricles are unchanged without evidence of developing ventriculomegaly. No
new hemorrhages. No acute territorial infarct. Suggestion of right parietal
subarachnoid hemorrhage is noted. There is essentially no midline shift.
Remote left occipital craniotomy and left occipital encephalomalacia are
stable. The visualized paranasal sinuses are essentially clear. The orbits
are unremarkable. The mastoid air cells and middle ear cavities are well
pneumatized and clear.
IMPRESSION:
1. Unchanged appearance of left temporal lobe parenchymal hemorrhage with
minimal left uncal herniation.
2. No interval change in appearance of hemorrhage extension into left
occipital horn of the lateral ventricle and third ventricle.
3. No hydrocephalus. No new hemorrhage or acute territorial infarct.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with L temporal bleed // ?ischemia,
?characterization
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 11 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CTA head and neck: ___.
CT head: ___ and ___.
FINDINGS:
A large left temporal lobe hematoma appears unchanged in size compared to
prior CTs, allowing for inter modality differences. There is a central T1
hyperintense component (2:6), representing acute/subacute blood products, with
large blooming artifact on gradient recalled echo images. There is
surrounding vasogenic edema, causing local mass effect with no significant
shift of the normally midline structures. Dural thickening versus a small
sliver residual subdural collection is noted along the left frontotemporal
convexity (11:16). Extension of hemorrhagic products into the occipital horn
of the left lateral ventricle is noted on axial FLAIR sequence images (11:12).
Prior left occipital craniotomy changes are again noted, with associated
encephalomalacia in the left occipital lobe (12:9). Postcontrast images
reveal no evidence of underlying enhancing mass in the region of the left
temporal hemorrhage or elsewhere within the brain. There is no acute
infarction. Ventricles and sulci are stable in size and configuration.
Intracranial vascular flow voids are preserved and dural venous sinuses are
patent.
IMPRESSION:
1. Left temporal lobe hemorrhage with intraventricular extension is not
significantly changed compared to prior CTs, allowing for inter-modality
differences.
2. No evidence of acute infarction, underlying mass lesion or new intracranial
hemorrhage elsewhere in the brain.
3. Left occipital craniotomy changes and associated focal encephalomalacia,
unchanged.
4. Dural thickening versus a small sliver residual subdural collection is
noted along the left frontotemporal convexity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Slurred speech
Diagnosed with Nontraumatic intcrbl hemorrhage in hemisphere, cortical, Aphasia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ yo man with a past medical history notable for
atrial fibrillation and atrial flutter on coumadin status post
cardioversion (___), CAD s/p LAD PCI ___ and CABG ___,
CHF, CKD (baseline Cr 1.3-1.5), renal artery stenosis s/p stents
(___), and bilateral carotid artery stenosis s/p L ICA stent
___ posterior meningioma s/p resection, who presented
___ with transient word-finding difficulties. During his ED
course, neurologic deficits recurred with NCHCT revealing a left
temporal intraparenchymal hemorrhage. CTA showed a likely
chronically occluded R ICA and high grade stenosis (~75%) of the
L ICA stent. Pt was admitted to the neurologic ICU for further
management.
Pt's bleed was presumed to be due to a hemorrhagic conversion of
an ischemic infarct. MRI did not reveal an underlying lesion or
microhemorrhages. The hemorrhagic conversion was likely related
to pt's use of ASA, Plavix and warfarin. These medications were
all held at admission. Pt's infarct was felt to be an embolic
infarct either due to a cardiac source (given his history of
atrial fibrillation and recent cardioversion) or atherosclerotic
source (given his severe atherosclerosis). TTE did not show an
intracardiac thrombus.
For management, systolic blood pressure goals were between 120
and 160 to maintain adequate cerebral perfusion given pt's
severe atherosclerotic disease while also preventing expansion
of the bleed. INR was reversed to a goal of <1.5. Neurosurgery
was consulted who deferred surgical management. Pt's statin was
initially held as there was concern this would worsen the
hemorrhage.
On hospital day #4, aspirin 81 mg daily was restarted. This was
started to prevent stent thrombosis and also for secondary
stroke prevention. Warfarin will be restarted on ___.
Pt's cardiologist was contacted who was in agreement that the
risk associated with starting dual anti-platelet in conjunction
with warfarin outweighed the benefits. Once INR is therapeutic
on warfarin, plans are to discontinue aspirin 81mg daily. Pt's
PCP and cardiologist have been contacted regarding this plan.
Otherwise, pt's renal function remained stable during
hospitalization.
=======================================================
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:
Iodine / Latex
Attending: ___.
Chief Complaint:
weakness, epigastric/left-sided chest pain, globus sensation
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. ___ is a ___ year old lady with history of HTN, HLD,
chronic HA, OA, aortic stenosis, frequent falls, questionable
___ disease vs. multiple system atrophy who presented to
our emergency department with reported R sided weakness and
epigastric pain since this morning.
Pt reports right sided and epigastric abdominal pain. She has
felt something "growing inside" of her for the last 1 month and
the pain worsened this morning. Lower back pain X 1 week.
Pt reports recent fall 2 weeks ago where she hit the left side
of her face with no LOC. Per grandson, he has noticed worsened
stability with leaning to the right side over the last week and
"not making sense" intermittently but denies confusion. She has
had increased difficulty picking up both feet.
Patient reports pleuritic right sided chest pain and tightness
in chest with associated shortness of breath. Tenderness to
palpation ~R 5th rib.
She also reports she has felt some discomfort/something stuck in
throat since this morning after eating banana. Denies dysphagia.
PE in the ___, significant for PERRL, nonfocal neurological exam,
CNII-XII grossly intact, sensation grossly intact b/l ___
no epigastric mass palpated, +Rovsings sign
The ___ felt that she may have appendicitis vs AAA, ?TIA, so she
had a CT head non-contrast which showed no acute ICP. Abd
ultrasound ruled out AAA. CT a/p with PO contrast initially
normal, but per further review by radiology, ascending ___ may
have some thickening vs artifact from mixing with PO contrast
and stool. No concern for inflammation or colitis. They
recommended follow up with colonoscopy to make sure there is no
underlying mass. No CXR done.
LFTs and lipase were normal. EKG was NSR. ___ MD attempted to
walk her, gait test patient unable to support herself even with
assistance. Noted leaning towards one side or the other.
Given that patient has little assistance at home, patient lives
with ___ young nephews, ___ to walk without stance.
Daughter is working on placement to nursing home but worries she
may be denied because of income level.
In the ___, initial vs were: ___ 73 124/71 18 97%. Patient
was given morphine, carbidopa-levidopa, and 1 liter of NS.
Past Medical History:
Obesity
Osteopenia
Osteoarthritis
Diverticulosis
Degenerative disk disease
Hypercholesterolemia
Hypertensive retinopathy
Benign Hypertension
Borderline diabetes
s/p cholecystectomy ___
s/p hysterectomy ___
s/p shoulder surgeries, most recently ___
s/p left total knee arthroplasty, ___
persistent epigastric pain, felt to be possible costochondritis
by GI
___ disease vs. multiple system atrophy
Hemorrhagic calluses and hyperkeratosis of bilateral feet
Chronic daily headache
Aortic stenosis
Social History:
___
Family History:
Positive for breast cancer in sisters. Her mother died of
congestive heart failure.
Physical Exam:
ADMISSION PHYSICAL EXAM:
.
Vitals: 97.5 - 152/68 - 57 - 18 - 100ra
General: pleasant obese interactive elderly lady
HEENT: nc/at sclera anicteric mucosa moist
Neck: supple
Lungs: clear to auscultation
CV: ___ systolic murmur reg rate and rhythm
Abdomen: soft, non tender
Ext: no edema. R hand chronically flexed, difficult to open
Skin: no rashes
Neuro: alert, oriented x3, moves all 4 extremities; no cogwheel
rigidity bilaterally, no ratchet like movements of arms, gait
not tested, speech fluent linear and appropriate. tongue seems
to deviate slightly ot the right. face asymmetric: keeps R eye
closed on purpose as has R eye lateral deviation chronically w/
double vision, but eyebrow lift symmetric
.
DISCHARGE PHYSICAL EXAM:
.
Vitals: T 98.2 BP 145/86 HR 62 RR 18 100% on RA
General: pleasant obese interactive elderly lady
HEENT: non-reactive dialated pupils, sclera anicteric, mucosa
moist, R eye exotropia
Neck: supple, no palpable thyroid masses/nodules
Lungs: clear to auscultation
CV: ___ systolic murmur reg rate and rhythm, chest pain
reproducable on palpation
Abdomen: soft, tenderness over epigastrum and ___ ribs, soft,
maleable masses palpated in epigastrum as well as in left
quadrant
Ext: no edema. R hand chronically flexed
Skin: no rashes
Neuro: alert, oriented x3, moves all 4 extremities; no cogwheel
rigidity bilaterally, no ratchet like movements of arms, speech
fluent w/hypophonia. tongue seems to deviate slightly ot the
right. face asymmetric: keeps R eye closed on purpose as has R
eye exotropia, but eyebrow lift symmetric.
Pertinent Results:
ADMISSION LABS:
___ 05:15PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
___ 05:15PM URINE RBC-<1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-2
___ 01:33PM LACTATE-2.3* K+-4.3
___ 01:00PM GLUCOSE-147* UREA N-16 CREAT-1.0 SODIUM-138
POTASSIUM-5.3* CHLORIDE-103 TOTAL CO2-20* ANION GAP-20
___ 01:00PM ALT(SGPT)-21 AST(SGOT)-57* ALK PHOS-96 TOT
BILI-0.3
___ 01:00PM LIPASE-46
___ 01:00PM CK-MB-6 cTropnT-<0.01
___ 01:00PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.0
MAGNESIUM-2.1
___ 01:00PM TSH-2.4
___ 01:00PM WBC-6.5 RBC-4.58 HGB-13.2 HCT-39.4 MCV-86
MCH-28.7 MCHC-33.5 RDW-14.2
___ 01:00PM NEUTS-59.1 ___ MONOS-5.4 EOS-1.4
BASOS-0.4
___ 01:00PM PLT COUNT-214
___ 01:00PM ___ PTT-23.9* ___
___ 01:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 01:00PM URINE RBC-0 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-12 TRANS EPI-<1
.
ADMISSION IMAGING:
.
___ CHEST XRAY: As compared to the previous radiograph, the
lung volumes are unchanged. Status post left shoulder surgery.
No evidence of pleural effusions or pneumothorax. The size of
the cardiac silhouette continues to be borderline, without
evidence of pulmonary edema.
In the interval, the tortuosity of the thoracic aorta has
increased and the diameter of the aortic arch and aortic knob
also appears increased. This effect could in large parts be due
to patient rotation. However, there also is the possibility of
an aortic disease at the level of the arch and proximal part of
the descending aorta. Therefore, if clinically possible, a CTA
of the aorta should be performed to rule out acute aortic
disease.
___ CT ABD & PELVIS W/O CON:IMPRESSION: Normal appendix. No
evidence of nephrolithiasis or hydronephrosis. Diverticulosis
without evidence of diverticulitis. Equivocal mild wall of the
ascending ___ vs artifact from oral contrast mixing with
stool. This may be artifactual. Findings could be confirmed
with outpatient colonoscopy.
___ CT HEAD W/O CONTRAST: No acute intracranial process.
___ ABD U/S: No evidence of abdominal aortic aneurysm.
.
INTERIM IMAGING:
.
___ CTA CHEST W/&W/O Contrast: No evidence of acute aortic
pathology or pulmonary embolus. Widened mediastinum on
radiograph is likely due to a combination of mild thoracic
aortic tortuosity as well as patient rotation. Dilated main PA
suggestive of chronic pulmonary hypertension. Thoracic aortic
atheromatous subtle ulcerative plaques at the level of the arch,
no thoracic aneurysm. Hiatal hernia.
.
DISCHARGE LABS:
.
___ 01:20PM BLOOD WBC-12.4* RBC-4.19* Hgb-12.0 Hct-35.5*
MCV-85 MCH-28.6 MCHC-33.7 RDW-14.2 Plt ___
___ 01:20PM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-94 UreaN-22* Creat-1.1 Na-141
K-5.0 Cl-103 HCO3-30 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID W/MEALS
3. Carbidopa-Levodopa (___) 1.5 TAB PO TID W/MEALS
4. Omeprazole 20 mg PO DAILY
5. traZODONE 50 mg PO HS:PRN insomnia
6. Vitamin D 800 UNIT PO DAILY
7. Acetaminophen 1000 mg PO Q8H:PRN pain, fever
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Senna 2 TAB PO BID:PRN constipation
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Vitamin D 800 UNIT PO DAILY
3. traZODONE 50 mg PO HS:PRN insomnia
4. Senna 2 TAB PO BID:PRN constipation
5. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*30 Capsule Refills:*1
6. Docusate Sodium 100 mg PO BID
7. Carbidopa-Levodopa (___) 1.5 TAB PO TID W/MEALS
8. Calcium Carbonate 500 mg PO TID W/MEALS
9. Aspirin 81 mg PO DAILY
10. Acetaminophen 650 mg PO Q6H pain, fever
for at least 2 weeks; if no improvement in pain may discontinue
after this time
RX *acetaminophen 325 mg 2 tablet(s) by mouth four times a day
Disp #*84 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Primary:
- musculoskeletal chest pain and possible GERD/gastritis
#Secondary:
- Parkinsons vs. multisystem atrophy
- Aortic Stenosis
- Osteopenia
- Osteoarthritis
- Insomnia
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Epigastric pain. Evaluate for abdominal aortic aneurysm.
COMPARISON: CT Torso from ___.
FINDINGS: The proximal aorta measures 2.4 cm in maximal diameter. The mid
aorta measures 2.3 cm in diameter. The distal aorta measures 1.9 cm in
diameter. The common iliac arteries measure 1.4 cm in diameter bilaterally.
There is normal color flow throughout the aorta. No significant
atherosclerotic disease is seen. The bilateral kidneys are without stones or
hydronephrosis. The right kidney measures 11.2 cm and the left kidney 10.6 cm
in length.
IMPRESSION: No evidence of abdominal aortic aneurysm.
Radiology Report
HISTORY: Right-sided weakness with nonfocal neurologic exam. Evaluate for
TIA or stroke.
TECHNIQUE: MDCT acquired contiguous axial images were obtained through the
head. No contrast was administered. Coronal and sagittal reformats reviewed.
COMPARISON: CT of the head from ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect, or
vascular territorial infarction. The ventricles and sulci are proportionally
prominent, consistent with age related involutional changes. Periventricular
and subcortical white matter hypodensities are suggestive of chronic small
vessel ischemic disease. No fracture is identified. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Right-sided abdominal pain. Evaluate for appendicitis.
TECHNIQUE: MDCT acquired axial images were obtained from the lung bases to
the pubic symphysis after enteric contrast only. Coronal and sagittal
reformats reviewed.
COMPARISON: CT from ___.
FINDINGS:
The lower chest is unremarkable.
ABDOMEN: Limited, noncontrast views of the liver, intrahepatic biliary tree,
the spleen, adrenal glands, and pancreas are unremarkable. Minimal dilation
of the CBD is stable and likely secondary to cholecystectomy. An extra renal
pelvis is noted on the right side, stable. The kidneys are symmetric in size,
without hydronephrosis, stone, or mass. There is no perinephric fluid
collection or stranding.
The stomach is collapsed. The small bowel, and large bowel are normal in
caliber. There is equivocal mild wall thickening at ascending, most likely
due to mixing of contrast and fecal material. There is colonic diverticulosis
without evidence of diverticulitis. The appendix is normal. There is no
ascites, fluid collection, pneumoperitoneum, or focal mesenteric fat
stranding. There is no lymphadenopathy. The abdominal aorta is normal in
caliber.
PELVIS: The urinary bladder and rectum are unremarkable. There are no stones
within either ureter or within the bladder. The there is no pelvic free
fluid, lymphadenopathy, or mass. The uterus and ovaries are not well-seen.
MUSCULOSKELETAL: There are no destructive osseous lesions concerning for
malignancy or infection. Stable compression fracture of L1.
IMPRESSION:
1. Normal appendix.
2. No evidence of nephrolithiasis or hydronephrosis.
3. Diverticulosis without evidence of diverticulitis.
4. Equivocal mild wall of the ascending colon vs artifact from oral contrast
mixing with stool. This may be artifactual. Findings could be confirmed with
outpatient colonoscopy.
NOTIFICATION: Impression #4 was communicated to Dr. ___ by Dr.
___ on ___ at 9:05 pm via telephone.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Epigastric pain, right-sided abdominal pain, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes are
unchanged. Status post left shoulder surgery. No evidence of pleural
effusions or pneumothorax. The size of the cardiac silhouette continues to be
borderline, without evidence of pulmonary edema.
In the interval, the tortuosity of the thoracic aorta has increased and the
diameter of the aortic arch and aortic knob also appears increased. This
effect could in large parts be due to patient rotation. However, there also
is the possibility of an aortic disease at the level of the arch and proximal
part of the descending aorta. Therefore, if clinically possible, a CTA of the
aorta should be performed to rule out acute aortic disease.
At the time of dictation and observation, 8:52 a.m., the referring physician,
___, was paged for notification. At 9:40 a.m. on the same day, findings
were discussed over the telephone with Dr. ___ the recommendation
for a CTA.
Radiology Report
HISTORY: Aortic stenosis and parkinsonism who presents with left-sided chest
pain and dysphagia. On chest radiograph found to have widened mediastinum.
Concern for enlarged thyroid.
COMPARISON: Chest radiograph ___, CT torso ___.
TECHNIQUE: Axial helical MDCT images were obtained of the chest after the
administration of IV contrast in the arterial phase. Multiplanar reformatted
images were generated in the coronal and sagittal planes as well as bilateral
oblique maximum intensity projection images.
DLP: 478.30 mGy-cm.
FINDINGS: The thyroid is not imaged. The trachea is midline and the airways
are patent to the subsegmental level. Minimal atelectasis is noted in
bilateral lung bases. The lung parenchyma is otherwise clear without nodule
or focal consolidation. The pleural surfaces are clear without focal
thickening, effusion, or pneumothorax.
Heart size is normal with minimal characterization of aortic valve and
coronary artery calcifications due to contrast administration. A mildly
tortuous thoracic aortic arch is normal in caliber, with note made of lumenal
ulcerative atheromatous plaques. There is no evidence of aneurysm or
dissection. The main pulmonary artery is dilated to a maximum diameter of 3.4
cm suggestive of chronic pulmonary hypertension. There is no pulmonary
embolus to the subsegmental level. There is no supraclavicular, axillary,
hilar or mediastinal lymphadenopathy by CT size criteria.
This study is not tailored for the evaluation of subdiaphragmatic structures;
however, within those limitations, the visualized portions of the upper
abdominal organs are grossly unremarkable. There is a small hiatal hernia.
OSSEOUS STRUCTURES: There are no focal blastic or lytic lesions in the
visualized osseous structures concerning for malignancy.
IMPRESSION:
1. No evidence of acute aortic pathology or pulmonary embolus. Widened
mediastinum on radiograph is likely due to a combination of mild thoracic
aortic tortuosity as well as patient rotation.
2. Dilated main PA suggestive of chronic pulmonary hypertension.
3. Thoracic aortic atheromatous subtle ulcerative plaques at the level of the
arch, no thoracic aneurysm.
4. Hiatal hernia.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: RIGHT SIDED WEAKNESS/ABD PAIN
Diagnosed with OTHER MALAISE AND FATIGUE, ABDOMINAL PAIN OTHER SPECIED
temperature: 98.8
heartrate: 73.0
resprate: 18.0
o2sat: 97.0
sbp: 124.0
dbp: 71.0
level of pain: 8
level of acuity: 2.0 | Ms ___ was admitted for chest pain and fatigue. She also
complained of a sensation of globus. She has is also very weak
and deconditioned and has had multiple falls recently.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: ___ days of L sided upper abdominal pain
Major Surgical or Invasive Procedure:
Left percutaneous nephrostomy tube
History of Present Illness:
___ year old M with PMH CAD (s/p 3 stents, last in ___,
atrial fibrillation on Coumadin, bladder CA x ___ years (s/p
tumor
resection) who presents with ___ days of constant, new upper L
abdominal pain.
Patient was diagnosed with bladder cancer ___ years ago and has
had intermittent local recurrences requiring tumor resections.
On
___, patient underwent an uneventful tumor resection
at
___. He had 2 episodes of passing which resolved
after irrigation with urology. Last ___, patient also started
passing clots and bleeding "profusely" in his urine associated
with penile pain and went to the hospital early ___
morning. These symptoms resolved again with irrigation. On
___ afternoon, he developed L upper abdominal pain he
associated with constipation. He was unable to eat secondary to
nausea and retching. No vomiting. His urologist recommended he
come into the hospital.
Patient denies having fevers/chills. Patient stopped taking his
Coumadin last ___ (last dose on ___. Last BM 3 days ago.
No headaches, dizziness, lightheadedness. No chest pain or
shortness of breath. Feels fatigued but no weakness, numbness or
tingling.
At ___, patient was HD stable. A foley was
inserted
and showed maroon, red urine. His creatinine was 1.75 (b/l 1.13)
and HB 10.8. CT showed a periureteral/RP fluid collection and
left sided hydronephrosis.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
CAD/MI s/p 3 stents (___) and angioplasty ___
DMII (FSBG 135-145)
Bladder cancer s/p TURBT (multiple)
R ear ___ surgery
Social History:
___
Family History:
FAMILY HISTORY:
Brother - CA *unknown origin
Sister - alive - breast cancer, in remission
Brothers - 1 w/DMII, kidney stone
Physical Exam:
VITALS: T 99.3 BP 120/65 RR 59 RR 18 O2: 95% on RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils constricted some reactivity with light,
symmetric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: RRR, no mrg
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, ttp of left upper abdomen.
Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation. Foley
draining yellow urine
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 Physical Exam:
T: 98.5, BP: 135 / 78, HR: 83 RR: 18, O2: 99% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, PERRL, symmetric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: NS1/S2, RRR, ___ systolic murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, TTP LLQ otherwise NT
Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation. Foley
draining yellow urine, left nephrostomy tube draining yellow
urine
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:
___ 06:30AM BLOOD WBC-6.0 RBC-3.08* Hgb-10.4* Hct-31.0*
MCV-101* MCH-33.8* MCHC-33.5 RDW-14.0 RDWSD-51.8* Plt ___
___ 06:30AM BLOOD WBC-5.2 RBC-2.91* Hgb-9.9* Hct-29.3*
MCV-101* MCH-34.0* MCHC-33.8 RDW-13.9 RDWSD-52.2* Plt ___
___ 06:40AM BLOOD WBC-6.2 RBC-2.83* Hgb-9.6* Hct-28.7*
MCV-101* MCH-33.9* MCHC-33.4 RDW-14.2 RDWSD-52.8* Plt ___
___ 07:14AM BLOOD WBC-8.2 RBC-3.25* Hgb-11.0* Hct-33.5*
MCV-103* MCH-33.8* MCHC-32.8 RDW-14.6 RDWSD-55.5* Plt ___
___ 06:40AM BLOOD Neuts-64.5 ___ Monos-10.6 Eos-2.3
Baso-0.5 Im ___ AbsNeut-3.97 AbsLymp-1.34 AbsMono-0.65
AbsEos-0.14 AbsBaso-0.03
___ 07:14AM BLOOD Neuts-69.6 ___ Monos-9.0 Eos-0.2*
Baso-0.2 Im ___ AbsNeut-5.73 AbsLymp-1.67 AbsMono-0.74
AbsEos-0.02* AbsBaso-0.02
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD ___
___ 07:14AM BLOOD Plt ___
___ 07:14AM BLOOD ___ PTT-24.1* ___
___ 06:30AM BLOOD Glucose-149* UreaN-16 Creat-1.0 Na-143
K-4.9 Cl-105 HCO3-28 AnGap-10
___ 06:40AM BLOOD Glucose-139* UreaN-23* Creat-1.2 Na-142
K-4.7 Cl-104 HCO3-27 AnGap-11
___ 07:14AM BLOOD Glucose-164* UreaN-32* Creat-1.7* Na-138
K-4.4 Cl-100 HCO3-25 AnGap-13
___ 06:30AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.8
___ 06:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9
___ 06:40AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1
___ 06:40AM BLOOD VitB12-403 Folate-13
___ 06:30AM BLOOD TSH-0.65
___ 07:28AM BLOOD Lactate-1.5
___ 07:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 07:00AM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5
Leuks-MOD*
___ 07:00AM URINE RBC-114* WBC-26* Bacteri-NONE Yeast-NONE
Epi-0
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Abd XR: no e/o intestinal obstruction or free intraperitoneal
air.
___ 7:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
UA: neg for infection
CT a/p with contrast: increased hydronephorosis on L side and
there is now retroperitoneal fluid extending from level of L
renal pelvis to just above the uretrerovesicular junction. High
grade obstruction or possibly ureteral leak. Undergone resection
of L sided bladder neoplasm.
Final Report
___
INDICATION: ___ year old man with left RP fluid, abdominal
pain// please perform nephrostogram and PCN placement
TECHNIQUE: OPERATORS: Dr. ___, interventional Radiology
Fellow and ___ radiologist performed the
procedure. Dr. ___ supervised the trainee during
the key components of the procedure and has reviewed and agrees
with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating
divided doses of 50 mcg of fentanyl and 0 mg of midazolam
throughout the total intra-service time of 30 minutes during
which the patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. 1%
lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: 1g of Cephazolin
CONTRAST: 15 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 4.6 min, 40 mGy
PROCEDURE: 1. Left ultrasound guided renal collecting system
access.
2. Left nephrostogram.
3. Left ___ nephrostomy 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
left flank was prepped and draped in the usual sterile fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous
soft tissues, the left renal collecting system was accessed
through a posterior lower pole calyx under ultrasound guidance
using a 21 gauge Cook needle. Ultrasound images of the access
were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast
outlined a dilated renal collecting system. Under fluoroscopic
guidance, a Headliner wire was advanced into the renal
collecting system. After a skin ___, the needle
was exchanged for an Accustick sheath. Once the tip of the
sheath was in the collecting system; the sheath was advanced
over the wire, inner dilator and metallic stiffener. The wire
and inner dilator were then removed and diluted contrast was
injected into the collecting system to confirm position. A ___
wire was advanced through the sheath and coiled in the
collecting system. The sheath was then removed and a 8 ___
nephrostomy tube was advanced into the
renal collecting system. The wire was then removed and the
pigtail was formed in the collecting system. Contrast injection
confirmed appropriate positioning. The catheter was then
flushed, 0 silk stay sutures applied and the catheter was
secured with a Stat Lock device and sterile dressings. The
catheter was attached to a bag.
FINDINGS:
Ureteral extravasation of contrast into retroperitoneum. No
passage of
contrast into the bladder.
IMPRESSION:
Successful placement of 8 ___ nephrostomy on the left.
RECOMMENDATION(S): 1. Follow up antegrade nephrostogram in 1
month.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Amiodarone 200 mg PO DAILY
3. Warfarin 4 mg PO DAILY16
4. Atorvastatin 20 mg PO QPM
5. Metoprolol Succinate XL 50 mg PO DAILY
6. GlipiZIDE 2.5 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Fenofibrate 54 mg PO DAILY
9. Tolterodine 4 mg PO DAILY
10. Maginex (magnesium aspartate HCl) 61 mg (615 mg) oral BID
11. Aspirin 81 mg PO Q48H
12. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice daily Disp #*8
Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY Constipation - Third Line
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily as needed for constipation Disp #*30 Packet
Refills:*0
3. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Take ___
tablet (25 mg) every 6 hours as needed for pain Disp #*20 Tablet
Refills:*0
4. Amiodarone 200 mg PO DAILY
5. Aspirin 81 mg PO Q48H
6. Atorvastatin 20 mg PO QPM
7. Fenofibrate 54 mg PO DAILY
8. GlipiZIDE 2.5 mg PO BID
9. Maginex (magnesium aspartate HCl) 61 mg (615 mg) oral BID
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL PRN chest pain
13. Warfarin 4 mg PO DAILY16
14. HELD- Tolterodine 4 mg PO DAILY This medication was held.
Do not restart Tolterodine until seen by urology or PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Left sided hydronephrosis
Acute kidney injury
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 left RP fluid, abdominal pain// please
perform nephrostogram and PCN placement
TECHNIQUE: OPERATORS: Dr. ___, interventional Radiology Fellow and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 0 mg of midazolam throughout the total intra-service
time of 30 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1g of Cephazolin
CONTRAST: 15 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 4.6 min, 40 mGy
PROCEDURE: 1. Left ultrasound guided renal collecting system access.
2. Left nephrostogram.
3. Left ___ nephrostomy 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 left flank was prepped and draped in the usual sterile fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the left renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast outlined a
dilated renal collecting system. Under fluoroscopic guidance, a Headliner wire
was advanced into the renal collecting system. After a skin ___, the needle
was exchanged for an Accustick sheath. Once the tip of the sheath was in the
collecting system; the sheath was advanced over the wire, inner dilator and
metallic stiffener. The wire and inner dilator were then removed and diluted
contrast was injected into the collecting system to confirm position. A ___
wire was advanced through the sheath and coiled in the collecting system. The
sheath was then removed and a 8 ___ nephrostomy tube was advanced into the
renal collecting system. The wire was then removed and the pigtail was formed
in the collecting system. Contrast injection confirmed appropriate
positioning. The catheter was then flushed, 0 silk stay sutures applied and
the catheter was secured with a Stat Lock device and sterile dressings. The
catheter was attached to a bag.
FINDINGS:
Ureteral extravasation of contrast into retroperitoneum. No passage of
contrast into the bladder.
IMPRESSION:
Successful placement of 8 ___ nephrostomy on the left.
RECOMMENDATION(S): 1. Follow up antegrade nephrostogram in 1 month.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 97.4
heartrate: 66.0
resprate: 14.0
o2sat: 97.0
sbp: 114.0
dbp: 68.0
level of pain: 6
level of acuity: 2.0 | ___ year old male with PMH CAD (s/p 3 stents, last in ___,
atrial fibrillation on Coumadin, bladder CA x ___ years (s/p
tumor resection) who presents with ___ days of constant, new
upper L abdominal pain. Concern for tumor
progression causing obstruction versus obstruction from clots
causing hydronephrosis. Also possible there was some ureter
injury causing leakage and an RP fluid collection now s/p left
perc nephrostomy tube on ___ by interventional radiology.
Urology also consulted while hospitalized. He was continued on
pain medications (Morphine IV and Morphine PO) while
hospitalized and transitioned to Tramadol PO on discharge for
LLQ pain at site of tube placement. ___ improved on discharge
with creatinine 1.1 on discharge.
He will need to follow-up with interventional radiology as an
outpatient.
He will need follow-up antegrade nephrostogram in 1 month.
Discussed with his urology team at ___,
has scheduled cystoscopy/TURBT on
___ with Dr. ___ at ___. He will
need preop appointment prior to this and they requested he stop
taking Coumadin on ___ and follow-up for pre-op appointment in
addition to obtaining stress ECHO as outpatient. Told patient to
discuss these directions with his cardiologist and to follow-up
with urology at ___ to discuss directly.
He will follow-up with his PCP ___ ___ to have repeat INR
drawn. Continue current dose of Coumadin on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
tramadol / ribavirin / Tylenol / Epclusa
Attending: ___.
Chief Complaint:
Acute on Chronic Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with history of CAD s/p DES
(___), HCV, CKD, charcot foot on chronic opioids who was
referred from ___ clinic for altered mental status, n/v, and
abdominal pain. He ran out of his pain meds early (took 7 days
worth in 5 days). History limited by altered mental status and
fixation on his pain medications. He reports abdominal pain
which he initially says is chronic ___ years but then says is
worse than usual and diffuse. He is not sure when he took his
last dose of opiates (told his NP it was the night before
admission). Denies taking any other meds, etoh, non rx drug use.
The ED resident spoke with the outpatient provider who knows
him well.
Of note:
- He is on a narcotics contract, now back to receiving
prescriptions for one week because he was not following
contract.
- He had a recent increase in pain meds ___ weeks ago, then
misused.
- Previously had someone else managing his meds, now he's doing
it himself and misuses them. Getting ___ day prescriptions at a
time.
- At his baseline, he is a/o x3
- Abdominal symptoms are atypical for him
- He has had diverticulitis a few times In the ED, initial
vital signs were: 98.0 84 130/70 16 97% RA
- Exam notable for: disheveled appearance, oriented to place,
person, does not know date/year, harsh breath sounds, abdomen
soft, diffusely reports tenderness, guards intermittently in
LLQ, no ___ edema
- Labs were notable for: Lactate 1.6 CBC hemoconcentrated,
leukocyotosis to 11.9 (baseline 4k, 80% PMNs) INR 1.2 Cr at
baseline (1.2), BUN elevated to 40
LFTS to 49/59 (similar to prior values--though normalized in
___ Lipase 23 Phos 1.9
UA w/ SG 1.039, TR protein & ketones,
Urine culture pending.
UTox with amphetamines and opiates
- Studies performed include
___ CT HEAD (prelim read):
IMPRESSION:
No acute intracranial abnormality.
___ CT A/P (prelim read):
1. Bibasilar bronchogenic ground glass opacities, left worse
than right, nonspecific, in the appropriate clinical setting
would reflect pneumonia.
2. Diverticular disease without evidence of diverticulitis.
3. Moderate fecal loading.
___ CXR (AP/Lateral):
IMPRESSION:
Lower lung opacities, left greater than right, worrisome for
pneumonia.
- Patient was given: ___ 17:35 IVF NS ( 1000 mL ordered)
___ 17:57 PO OxyCODONE (Immediate Release) 10 mg
___ 17:57 PO Azithromycin 500 mg ___ 17:57 IV
CeftriaXONE (1 g ordered) ___ 19:01 PO Morphine SR (MS
___ 30 mg ___ 19:01 PO Metoprolol Succinate XL 50 mg
___ 19:01 PO/NG Gabapentin 800 mg
- Vitals on transfer: T 98 HR 81 BP 144/91 RR16 SaO2 97% RA
Upon arrival to the floor, the patient states that he came in
because he has been in severe pain since last weekend and did
not want to be stuck at home during the snow storm. He states
that he has "pain everywhere". He also notes some loose stools
without vomiting. He endorses fevers and chills but did not take
his temperature. He endorses shortness of breath without cough
or wheeze. He endorses palpitations and dizziness. He endorses
pain of his head, chest/back, abdomen, both arms, both legs. He
endorses some hesitancy while urinating and burning. He endorses
weakness in both legs.
Review of Systems:
(+) per HPI
Past Medical History:
Per records:
-peripheral neuropathy (currently on gabapentin)
-Hepatitis C
--genotype 2b infection; intolerant of interferon/ribavirin in
1990s
--Fibroscan ___ consistent with Metavir stage ___ liver
scarring
--stage I fibrosis per last liver biopsy in ___
-Depression with prior suicide attempts
-Diverticulosis
-CAD; s/p 2 DES to RCA ___
-Hypertension
-Hyperlipidemia; total cholesterol 156, HDL 60 in ___.
-Polysubstance abuse: heroin, alcohol (last drink 1980s),
benzodiazepines
-Chronic foot pain due to Charcot deformity, s/p multiple
surgeries
-GERD
-BPH
-Erectile dysfunction
-Reiter's syndrome
-Bell's palsy
-history of mitral valve prolapse
-history of osteomyelitis
-history of chronic constipation.
Social History:
___
Family History:
Per records:
His mother is alive, she has dementia and history of alcoholism.
Mother had colon cancer in her ___. His father is deceased (age
___, had history of CAD and CHF.
Physical Exam:
Admission Physical Exam:
Vitals: 98.1PO 175 / 92 69 18 96 RA
GENERAL: Lying in bed. NAD
HEENT: EOMI. 4mm pupils b/l. OP clear
NECK: Supple, no LAD
CARDIAC: Distant heart sounds
LUNGS: CTAB
CHEST: Severe pain to sternal palpation radiating to L ribs
ABDOMEN: Diffusely tender, no rebound/guarding
EXTREMITIES: No edema
SKIN: Scratches on hand ("cat")
NEUROLOGIC: A&O x 2.5 (name, situation, month but not day or
year).
DISCHARGE PHYSICAL EXAM:
VS: T 98.2 BP 126/76 HR 53 RR 18 O2 ___ Ra
GENERAL: Lying in bed. NAD
HEENT: EOMI. Has lower dentures. MMM. PERRL
CARDIAC: Distant heart sounds
LUNGS: CTAB
CHEST: Severe pain to sternal palpation radiating to L ribs
ABDOMEN: Soft, non-distended, very mild TTP.
EXTREMITIES: No edema
SKIN: Scratches on hand ("cat")
NEUROLOGIC: A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 03:15PM BLOOD WBC-11.9*# RBC-4.16* Hgb-12.4* Hct-36.2*
MCV-87 MCH-29.8 MCHC-34.3 RDW-15.7* RDWSD-49.6* Plt ___
___ 03:15PM BLOOD Neuts-80.9* Lymphs-10.9* Monos-7.3
Eos-0.1* Baso-0.3 Im ___ AbsNeut-9.60*# AbsLymp-1.29
AbsMono-0.86* AbsEos-0.01* AbsBaso-0.03
___ 03:15PM BLOOD ___ PTT-26.8 ___
___ 03:15PM BLOOD Glucose-128* UreaN-39* Creat-1.2 Na-135
K-4.3 Cl-98 HCO3-22 AnGap-19
___ 03:15PM BLOOD ALT-49* AST-59* CK(CPK)-137 AlkPhos-70
TotBili-0.7
___ 03:15PM BLOOD Albumin-4.0 Calcium-9.5 Phos-1.9* Mg-1.8
___ 03:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:45PM URINE Color-Straw Appear-Clear Sp ___
___ 04:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:45PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 04:45PM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG
________________________
MICRO:
___ 4:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
________________________
IMAGING:
___ CHEST (PA & LAT):
Lower lung opacities, left greater than right, worrisome for
pneumonia.
___ CT ABD & PELVIS WITH CO:
1. Bibasilar bronchogenic ground glass opacities, left worse
than right, nonspecific, in the appropriate clinical setting
would reflect pneumonia.
2. Nodular contour of the liver with splenomegaly is consistent
with history of cirrhosis and suggestive of portal hypertension.
No ascites.
3. Moderate fecal loading throughout, worst in the rectum and
left hemicolon. No bowel obstruction.
___ CT HEAD W/O CONTRAST:
No acute intracranial abnormality.
________________________
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-6.7 RBC-4.11* Hgb-12.4* Hct-35.7*
MCV-87 MCH-30.2 MCHC-34.7 RDW-15.7* RDWSD-49.7* Plt ___
___ 07:40AM BLOOD Glucose-104* UreaN-25* Creat-1.0 Na-138
K-3.5 Cl-101 HCO3-24 AnGap-17
___ 07:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. BuPROPion 75 mg PO BID
4. Gabapentin 1200 mg PO TID
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Morphine SR (MS ___ 30 mg PO Q12H
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN constipation
12. TraZODone 300 mg PO QHS insomnia
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Lisinopril 40 mg PO DAILY
15. DULoxetine 30 mg PO DAILY
16. Chlorthalidone 25 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
3. Narcan (naloxone) 4 mg/actuation nasal ONCE
RX *naloxone [Narcan] 4 mg/actuation 1 spray nasally once Disp
#*1 Spray Refills:*0
4. Morphine SR (MS ___ 15 mg PO Q8H
RX *morphine 15 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. BuPROPion 75 mg PO BID
9. Chlorthalidone 25 mg PO DAILY
10. DULoxetine 30 mg PO DAILY
11. Gabapentin 1200 mg PO TID
RX *gabapentin 600 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
12. Lisinopril 40 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 40 mg PO BID
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Senna 8.6 mg PO BID:PRN constipation
19. TraZODone 300 mg PO QHS insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: Chronic pain (dorsalgia, peripheral
neuropathy), opiate withdrawal hyperesthesia, pneumonia
Secondary Diagnoses: Anxiety/depression, Charcot foot
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ with AMS, ?infection// any e/o pneumonia or aspiration?
TECHNIQUE: AP and lateral chest radiograph
COMPARISON: Chest radiograph dated ___
FINDINGS:
AP and lateral chest radiograph. There are ill-defined opacities in the lower
lungs, more prominent on the left, concerning for pneumonia.
Cardiomediastinal and hilar contours are stable relative to prior examination.
There is no evidence of pleural effusion, pneumothorax or pulmonary edema.
There is no air under the right hemidiaphragm.
IMPRESSION:
Bilateral lower lobe pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with multiple falls, AMS// any e/o subdural?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 903 mGy-cm.
COMPARISON: Unenhanced head CT dated ___
FINDINGS:
There is no hemorrhage, edema, or mass effect. Ventricles and sulci are age
appropriate in size and configuration. Very mild periventricular white matter
hypodensities are nonspecific, likely sequela of chronic small vessel
ischemia. There is no shift of normally midline structures. Basal cisterns
are patent. Gray-white matter differentiation is preserved.
The orbits are unremarkable. Imaged paranasal sinuses, bilateral mastoid air
cells, and middle ear cavities are clear. The bony calvarium is intact.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with abdominal painNO_PO contrast//
any e/o diverticulitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 5.2 s, 56.5 cm; CTDIvol = 16.2 mGy (Body) DLP = 916.8
mGy-cm.
Total DLP (Body) = 929 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
LOWER CHEST: Bronchocentric ground-glass opacities within the lower lungs,
left worse than right, are new relative to prior examinations dated ___. There is no pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout,
slightly nodular in contour. 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 appears atrophic without pancreatic duct dilation or a
focal lesion. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal attenuation throughout, without evidence of
focal lesions. The spleen is mildly enlarged.
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. Moderate fecal
loading is noted throughout the colon. There is mild diverticular disease
without inflammatory changes to suggest acute diverticulitis. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The 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.
Mild degenerative changes are present, worst at the L4-L5 level with
intervertebral disc space narrowing. Probable hemangioma involves the T11
vertebral body (02:17), stable.
SOFT TISSUES: A small umbilical fat containing hernia is noted.
IMPRESSION:
1. Bibasilar bronchogenic ground glass opacities, left worse than right,
nonspecific, in the appropriate clinical setting would reflect pneumonia.
2. Nodular contour of the liver with splenomegaly is consistent with history
of cirrhosis and suggestive of portal hypertension. No ascites.
3. Moderate fecal loading throughout, worst in the rectum and left hemicolon.
No bowel obstruction.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Altered mental status
Diagnosed with Pneumonia, unspecified organism
temperature: 98.0
heartrate: 84.0
resprate: 16.0
o2sat: 97.0
sbp: 130.0
dbp: 70.0
level of pain: 7
level of acuity: 2.0 | ___ is a ___ year old man with history of CAD s/p DES
(___), HCV, CKD, charcot foot on chronic opioids who was
referred from ___ clinic for altered mental status and abdominal
pain found to have pneumonia and concern for constipation on
imaging with diverticulosis without evidence of active
diverticulitis. The patient's primary concern was pain control.
He had taken all 7 days of his pain medications in 5 days and
ran out. Once we re-started his home pain medication, his pain
was under much better control, indicating that the issue was
withdrawal hyperesthesia. His abdominal pain resolved and he was
back to his baseline of leg pain and low back pain. He was also
AOx3 by discharge. He was discharged for close outpatient follow
up and with a course of antibiotics to finish treating his
pneumonia.
TRANSITIONAL ISSUES:
====================================
CODE STATUS: Full Code
CONTACT: Proxy name: ___
Relationship: friend Phone: ___
_________________________
FYI:
- The patient's pain resolved once he was back on his home pain
regimen. There were no studies, labs, or clinical signs that
were concerning for significant abdominal pathology.
_________________________
TO DO:
[ ] F/U pain regimen and tolerance: decreased MS contin back to
his prior outpatient dose
[ ] Patient may require a podiatry follow up for dry gangrene on
his foot
[ ] ___ consider a TCA for pain control. Patient had multiple
points of tenderness on exam here concerning for fibromyalgia.
_________________________
MEDICATIONS:
- Discharged with Narcan spray and ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Concern for EtOH Withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with past medical history significant for
alcohol abuse, alcohol withdrawal seizures, subdural hematoma
status post craniotomy presents with alcohol intoxication, acute
on chronic ___ transferred from ___
for further evaluation by ___, management of altered mental
status.
The patient reports that he fell 2 days ago, and has been having
headaches since that time as well as lower abdominal pain. He
reports abdominal pain today, which is what brought him to the
outside hospital. He has been intermittently taking insulin but
ran out supplies earlier this week. He last ___ at the start
of ___. He denies IV drug use, cocaine. Began drinking 1L
whiskey on ___,
At the outside hospital, work-up did not demonstrate a clear
etiology for his abdominal pain, however work-up redemonstrated
a subdural hematoma. He was however noted to have a bicarb level
of 17, anion gap of 28, glucose 385, concerning for DKA. The
patient was transferred for further evaluation and treatment.
In ED initial VS: T: 98.2 HR: 103 BP: 118/73 RR: 18 SO2: 95%
RA
Labs significant for:
WBC: 5.0 Hgb: 12.7 (MCV 77) Plt: 226
Na: 137 Cl: 92 BUN: 8
K: 4.4 HCO3: 19 Crt: 0.7 Glu: 337
pH 7.41 pCO2 24 pO2 85 HCO3 16 BaseXS -6
Lactate:4.6
Serum EtOH 350
UA notable for Glu 1000 Ket 150
___: 11.5 PTT: 29.8 INR: 1.1
Serum ASA, Acetmnphn, ___, Tricyc Negative
Patient was given:
___ 23:41 IVF NS
___ 01:31 PO/NG Diazepam 10 mg
___ 01:32 IVF NS 1000 mL
___ 01:32 IV Thiamine 500 mg
Imaging notable for: CT HEAD (OSH): Status post interval redo
left-sided craniotomy and frontoparietal region with decrease in
size of left sided subdural hematoma/collection with reduced
mass-effect. There is persistent subdural collection of
different densities with hyperdense component is particularly
along the left frontal region suggesting an acute on chronic
component. Persistent mass-effect with effacement of the sulci
on the left and mid bowing of the midline falx
Consults: Neurosurgery assessed patient as severely
intoxicated, PERRL, confused, following simple commands,
antigravity all 4 extremities. High lactate and BG, possible DKA
per ED. Interval improvement in previous L acute on chronic SDH
compared to last discharge scan. "Ok with Medicine admission if
needed for metabolic abnormalities, we will follow."
VS prior to transfer: T: 98.2 HR:99 BP: 112/64 RR: 22 SO2:
94% RA
On arrival to the MICU, patient is drowsy but confirms history
as above.
Past Medical History:
1. History of alcoholic pancreatitis.
2. Hypertension.
3. Hyperlipidemia.
4. Asthma.
5. Diabetes.
6. Assault ___ with facial and nasal fractures
7. Subdural hematoma s/p craniotomy for evacuation ___
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION EXAM
===============
VITALS: Reviewed in metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rhythm tacycardic, 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: bruising left ___ nail no obvious splinter hemorrhages,
no obvious needle track marks
NEURO: follows commands crossing midline, repetition intact,
language fluent, mild dysarthria, UE ___ ___ ___
DISCHARGE EXAM
================
VITALS: T 98.3 BP 108 / 68 HR 86 RR 18 SpO2 98 Ra
GENERAL: AAOx3, no apparent distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, 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: bruising left ___ nail no obvious splinter hemorrhages, no
obvious needle track marks
NEURO: CN intact. Strength UE ___, ___ ___.
Pertinent Results:
ADMISSION LABS
================
___ 11:50PM WBC-5.0 RBC-5.00# HGB-12.7* HCT-38.7*
MCV-77*# MCH-25.4* MCHC-32.8 RDW-15.4 RDWSD-42.0
___ 11:50PM NEUTS-50.8 ___ MONOS-8.0 EOS-0.2*
BASOS-1.0 IM ___ AbsNeut-2.56# AbsLymp-2.00 AbsMono-0.40
AbsEos-0.01* AbsBaso-0.05
___ 11:50PM PLT COUNT-226
___ 11:50PM ___ PTT-29.8 ___
___ 11:50PM ALBUMIN-4.8 CALCIUM-8.4 PHOSPHATE-3.3
MAGNESIUM-2.4
___ 11:50PM LIPASE-9
___ 11:50PM ALT(SGPT)-25 AST(SGOT)-29 ALK PHOS-197* TOT
BILI-0.9
___ 11:50PM GLUCOSE-337* UREA N-8 CREAT-0.7 SODIUM-137
POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-19* ANION GAP-26*
___ 11:53PM LACTATE-4.6*
___ 12:34AM ___ PO2-85 PCO2-24* PH-7.41 TOTAL
CO2-16* BASE XS--6
STUDIES/IMAGING
================
___ CXR
No acute intrathoracic abnormality.
___ CT Head (OSH)
Status post interval redo left-sided craniotomy and
frontoparietal region with decrease in size of left sided
subdural hematoma/collection with reduced mass-effect. There is
persistent subdural collection of different densities with
hyperdense component is particularly along the left frontal
region suggesting an acute on chronic component. Persistent
mass-effect with effacement of the sulci on the left and mid
bowing of the midline falx.
MICROBIOLOGY
============
Blood and urine cultures pending.
Discharge labs
===============
___ 07:20AM BLOOD WBC-3.2* RBC-4.05* Hgb-10.5* Hct-32.8*
MCV-81* MCH-25.9* MCHC-32.0 RDW-15.6* RDWSD-44.3 Plt ___
___ 06:22AM BLOOD Glucose-169* UreaN-17 Creat-0.7 Na-139
K-4.0 Cl-101 HCO3-24 AnGap-14
___ 06:22AM BLOOD Calcium-8.4 Phos-5.4* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Headache
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. LevETIRAcetam ___ mg PO Q12H
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: decreased dose
9. Thiamine 100 mg PO DAILY
10. Glargine 35 Units Bedtime
Novolog 13 Units Breakfast
Novolog 13 Units Lunch
Novolog 16 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. alcohol swabs 1 swab topical PRN
RX *alcohol swabs [BD Alcohol Swabs] 1 swab prn Disp #*100 Pad
Refills:*0
2. BD Ultra-Fine Nano Pen Needles (pen needle, diabetic) 32
gauge x ___ miscellaneous qACHS
RX *pen needle, diabetic [BD Ultra-Fine Nano Pen Needles] 32
gauge X ___ as directed qACHS Disp #*200 Box Refills:*0
3. Docusate Sodium 100 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. FreeStyle Lancets (lancets) 28 gauge miscellaneous PRN
RX *lancets [FreeStyle Lancets] 28 gauge one lancet fours times
daily Disp #*100 Each Refills:*0
6. FreeStyle Lite Strips (blood sugar diagnostic) 1 strip
miscellaneous PRN
RX *blood sugar diagnostic [FreeStyle Lite Strips] 1 strip four
times daily Disp #*100 Strip Refills:*0
7. Gabapentin 300 mg PO TID
8. HydrOXYzine 25 mg PO Q6H:PRN anixety
RX *hydroxyzine HCl 25 mg 1 by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
9. insulin syringe-needle U-100 0.3 mL 29 gauge x ___
miscellaneous PRN
RX *insulin syringe-needle U-100 [Lite Touch Insulin Syringe] 29
gauge x ___ 1 syringe PRN Disp #*100 Syringe Refills:*0
RX *insulin syringe-needle U-100 [FreeStyle Precision] 30 gauge
x ___ 1 syringe prn Disp #*100 Syringe Refills:*0
10. Multivitamins 1 TAB PO DAILY
11. Thiamine 100 mg PO DAILY
12. TraZODone 25 mg PO QHS:PRN anxiety, sleep
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
13. Glargine 30 Units Breakfast
Novolog 15 Units Breakfast
Novolog 15 Units Lunch
Novolog 15 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 30 Units before
BKFT; Disp #*5 Vial Refills:*3
RX *insulin aspart [Novolog] 100 unit/mL AS DIR 15 Units before
BKFT; 15 Units before LNCH; 15 Units before DINR; Disp #*5 Vial
Refills:*3
14. LevETIRAcetam ___ mg PO BID
15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: decreased dose
16. Acetaminophen 650 mg PO Q8H:PRN Headache
17. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Alcohol intoxication
Diabetic Ketoacidosis
Secondary Diagnosis:
Acute on Chronic Subdural Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LATERAL)
INDICATION: History: ___ with DKA, weakness// eval for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The cardiomediastinal silhouette and pulmonary vasculature are unremarkable.
There is no focal consolidation, pleural effusion, or pneumothorax. Streaky
bibasilar opacities are most consistent with atelectasis. No definite focal
consolidation is identified.
Left hilar lymph node calcifications are probably due to previous
granulomatous infection. There is no evidence of recurrent infection.
IMPRESSION:
No acute intrathoracic abnormality.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by AMBULANCE
Chief complaint: ETOH, Transfer
Diagnosed with Headache, Alcohol abuse with intoxication, unspecified
temperature: 98.2
heartrate: 103.0
resprate: 18.0
o2sat: 95.0
sbp: 118.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | This is a ___ old male with past medical history significant for
alcohol abuse, alcohol withdrawal seizures, insulin dependent
diabetes, subdural hematoma status post craniotomy ___,
admitted to the ICU for DKA and ETOH withdrawal on phenobarbital
taper, now called out to the floor for further DM management and
monitoring during alcohol detoxification.
============= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with history of diastolic CHF, prostate cancer s/p radiation
and
cyberknife, HCV cirrhosis c/b HCC s/p OLT ___ (mild
cellular rejection in ___, recent R brachiocephalic AVF
___ for CKD.
He presents for worsening shortness of breath and dyspnea on
exertion.
The patient's symptoms began 1 week prior to arrival when he
realized that he became short of breath while walking around the
block. He was still able to walk his normal distance, but felt
that he had to breath harder than usual. This progressed
throughout the week to the point that he became significantly
short of breath while walking his normal distances. Last night,
the patient awoke in bed at 1:30 AM with palpitations, which
subsequently resolved. The patient also notices that his legs
have been swelling equally for the past week. His appetite has
also been down. He reports gaining 10 lbs over the past week and
his dry weight is reportedly 164lbs. He was sent in by his PCP
this morning.
He denies fever, chills, cough, sputum production, rhinorrhea,
abdominal pain (besides incisional pain), diarrhea,
constipation, chest pain, or dysuria. No blood in stools.
Of note, the patient had a peritoneal dialysis catheter removed
___ and also had a right-sided AV fistula created for his
CKD. He has not yet had dialysis, but decided with his family
that HD would be better for him.
Also of note, the patient was recently seen in the clinic on ___
with Dr. ___ with plan to transition to Prograf plus
everolimus for renal protective effect.
Per office note:
- Starting prograf 2 mg BID with a goal of ___ and
will discontinue cyclosporine.
- He'll come back in 4 days to check prograf level and at that
point will start Everolimus at 1.5 mg BID with a goal of ___.
-Will also reduce MMF to 500 mg BID on ___. Our plan is to
eventually take him off cellecpt."
In the ED, initial VS were: 98.5 73 162/79 18 95% RA
Exam notable for crackles at the bases of his lungs. Has a
clean, dry, and intact surgical site on the abdomen to the left
of the umbilicus. He has tenderness over this area, with no
rebound or guarding. 2+ bilateral pitting edema in both legs.
Labs showed: tacroFK: 2.7, K:5.3, Lactate:0.9, Bicarb 15, Cr
3.1, Trop-T: 0.04, AST: 50, ___: ___, Hb 7.6
UA not suggestive of infection, but Protein 100
Imaging showed
CXR: Small right and trace left pleural effusions. Enlarged
cardiac silhouette. Mild to moderate interstitial edema. Right
base opacity may relate to fluid overload, however,
consolidation due to pneumonia may be present in the appropriate
clinical setting.
Liver US: Patent hepatic vasculature with appropriate waveforms.
Received 80mg IV Lasix per renal
Transfer VS were 98.5, 183/88, 82, 18, 99 RA
Hepatology, transplant surgery and renal services were
consulted.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports he is feeling baseline
at rest, no SOB, CP, lightheadedness or dizziness. Reports some
pain from foley insertion.
Past Medical History:
EtOH/HCV cirrhosis c/b portal hypertension, ascites, grade 3
esophageal varices ___, s/p 4 bands), encephalopathy, and
asymptomatic hepatopulmonary syndrome, HCC s/p OLT ___
Hypothyroidism
Surgery for exophthalmos ___
peripheral vascular disease in bilateral lower extremities
chronic venous stasis
Benign Hypertension
incision hernia repair ___
Social History:
___
Family History:
Mother with DM, HTN. Brother with DM. 2 uncles with prostate CA
as well as his brother with prostate cancer.
Physical Exam:
ADMISSION EXAM:
VS - 98.5, 183/88, 82, 18, 99%RA
GENERAL: Pt uncomfortable with foley, standing and pacing in
room
HEENT: AT/NC, EOMI, PERRL, sclera slightly pigmented, pink
conjunctiva, MMM
NECK: nontender supple neck, no LAD, JVP within normal limits
CARDIAC: RRR, S1/S2, ___ systolic murmur heard throughout the
precordium
LUNG: Crackles bilaterally in the lower lung fields, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, mild ___ tenderness, no
rebound/guarding, liver percussed just below the costal margin
EXTREMITIES: no cyanosis/clubbing, moving all 4 extremities with
purpose, 2+ pitting edema from the feet bilaterally to the
knees, no asterixis, no palmar erythema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in all extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. AV fistula site on right arm, non-erythematous and
clean.
DISCHARGE EXAM:
VS - 98.0 134/65 62 16 100 RA
GENERAL: NAD, resting comfortably
HEENT: Much improved bilateral mild R>L swelling of the lips,
cheeks, sublingual and submandibular areas without airway
compromise. No pain on palpation. No stridor. Able to visualize
malampati III view, No LAD, PERRL, sclera slightly pigmented,
MMM
NECK: nontender supple neck, no LAD, JVP wnl
CARDIAC: RRR, S1/S2, ___ systolic murmur heard throughout the
precordium
LUNG: Crackles bilaterally in the lower lung fields, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, mild ___ tenderness, no
rebound/guarding, liver percussed just below the costal margin
EXTREMITIES: no cyanosis/clubbing, moving all 4 extremities with
purpose, no ___ edema, no asterixis, no palmar erythema
PULSES: 2+ DP pulses bilaterally
NEURO: Grossly intact, alert and oriented
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. AV fistula site on right arm, non-erythematous and
clean, bruit present.
Pertinent Results:
ADMISSION LABS:
___ 11:53AM BLOOD WBC-5.5 RBC-2.80* Hgb-7.6* Hct-25.9*
MCV-93 MCH-27.1 MCHC-29.3* RDW-15.7* RDWSD-53.1* Plt ___
___ 11:53AM BLOOD Neuts-67.6 Lymphs-16.1* Monos-11.8
Eos-2.2 Baso-0.5 Im ___ AbsNeut-3.73 AbsLymp-0.89*
AbsMono-0.65 AbsEos-0.12 AbsBaso-0.03
___ 06:45AM BLOOD ___ PTT-29.8 ___
___ 11:53AM BLOOD Glucose-107* UreaN-58* Creat-3.1* Na-140
K-6.6* Cl-114* HCO3-15* AnGap-18
___ 11:53AM BLOOD ALT-11 AST-50* AlkPhos-107 TotBili-0.3
___ 11:53AM BLOOD cTropnT-0.04* ___
___ 11:53AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.5 Mg-2.6
___ 06:45AM BLOOD VitB12-1520* Folate-16.9
___ 11:53AM BLOOD tacroFK-2.7*
IMAGING:
___ CXR: Small right and trace left pleural effusions. Enlarged
cardiac silhouette. Mild to moderate interstitial edema. Right
base opacity may relate to fluid overload, however,
consolidation due to pneumonia may be present in the appropriate
clinical setting.
___ Liver US: Patent hepatic vasculature with appropriate
waveforms.
___ TTE:
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is mildly dilated. Overall left
ventricular systolic function is mildly depressed (LVEF = 45 %)
secondary to hypokinesis of the inferior and posterior walls.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The right ventricular free wall
thickness is normal. The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric, posteriorly
directed jet of Moderate (2+) mitral regurgitation is seen. Due
to the eccentric nature of the regurgitant jet, its severity may
be significantly underestimated (Coanda effect). There is
moderate pulmonary artery systolic hypertension. There is a very
small pericardial effusion. There are no echocardiographic signs
of tamponade. Compared with the prior study (images reviewed) of
___ the left ventricular ejection fraction is somewhat
reduced.
MICRO: ___ Blood cx NO GROWTH
Discharge Labs:
___ 06:25AM BLOOD WBC-2.8* RBC-2.82* Hgb-7.4* Hct-25.5*
MCV-90 MCH-26.2 MCHC-29.0* RDW-14.6 RDWSD-47.5* Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-93 UreaN-43* Creat-2.6* Na-141
K-4.2 Cl-110* HCO3-20* AnGap-15
___ 06:25AM BLOOD ALT-7 AST-17 AlkPhos-87 TotBili-0.2
___ 06:25AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.3 Mg-2.0
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with SOB on exertion, lower extremity edema // Eval
fluid overload
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is a small right pleural effusion and trace left pleural effusion. Mild
to moderate interstitial edema. Right lower lobe opacity is seen, which may
relate to fluid overload, however, pneumonia may be present in the appropriate
clinical setting. Peribronchial thickening is also seen. The mediastinal
contours unremarkable. The cardiac silhouette is mild to moderately enlarged.
IMPRESSION:
Small right and trace left pleural effusions. Enlarged cardiac silhouette.
Mild to moderate interstitial edema.
Right base opacity may relate to fluid overload, however, consolidation due to
pneumonia may be present in the appropriate clinical setting.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with fluid overload, dyspnea on exertion s/p liver
transplant ___ years ago // Eval with Doppler for patency of vessels for liver
transplant
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Abdominal ultrasound dated ___.
MR liver dated ___.
FINDINGS:
Liver echotexture is normal. There is no evidence of focal liver lesions or
biliary dilatation. The common hepatic duct measures 0.7 cm, unchanged
compared to prior. There is a small amount of perihepatic ascites, which is
unchanged compared to ultrasound dated ___.
The spleen measures 10.9 cm and has normal echotexture.
DOPPLER: The main hepatic arterial waveform is within normal limits, with
prompt systolic upstrokes and continuous antegrade diastolic flow. Peak
systolic velocity in the main hepatic artery is 47. Appropriate arterial
waveforms are seen in the right and left hepatic arteries. The main portal
vein and the right and left portal veins are patent with hepatopetal flow and
normal waveform. Appropriate flow is seen in the hepatic veins and the IVC.
IMPRESSION:
Patent hepatic vasculature with appropriate direction of flow.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF and now angioedema in the setting of
starting lisinopril // ?interval changed of pulmonary edema ?interval
changed of pulmonary edema
IMPRESSION:
In comparison with the study ___, there again is substantial
enlargement of the cardiac silhouette. However, the degree of pulmonary
vascular congestion has substantially decreased. No evidence of acute focal
pneumonia or definite effusion. Probable atelectatic changes at the left
base.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea on exertion
Diagnosed with Heart failure, unspecified
temperature: 98.5
heartrate: 73.0
resprate: 18.0
o2sat: 95.0
sbp: 162.0
dbp: 79.0
level of pain: 6
level of acuity: 2.0 | The patient is a ___ year-old male with a history of diastolic
congestive heart failure, prostate cancer status-post radiation
and cyberknife, hepatitis C virus cirrhosis complicated by
hepatocellular carcinoma status-post liver transplant ___
(mild cellular rejection in ___, recent right brachiocephalic
AV fistula ___ for chronic kidney disease. He presented for
worsening shortness of breath and dyspnea on exertion, found to
have decreased systolic function on echocardiogram, and improved
with diuresis. On the morning of ___, patient developed acute
facial swelling concerning for angioedema in the setting of
recent lisinopril. He was given methylprednisone, Benadryl and
transferred to the ICU for airway monitoring. In the ICU, he was
monitored for airway compromise and was transferred back to the
floor following improvement in his symptoms. He was discharged
at ___ without any diuretic. His immune suppression was
titrated and should be closely monitored outpatient.
#Angioedema, likely ACEi-associated:
On the morning of ___, patient developed acute facial swelling
concerning for angioedema in the setting of recent lisinopril.
He was given methylprednisone, Benadryl and transferred to the
ICU for airway monitoring. In the ICU, he was monitored for
airway compromise and was transferred back to the floor
following improvement in his symptoms. Allergy was consulted and
described a possibility of starting ___ at some point in the
future, although this does carry some risk for repeated
angioedema. He should not be started on ACE inhibitors in the
future, and this was added as an allergy to his list.
#Acute on chronic systolic congestive heart failure:
The patient was admitted with signs of volume overload on exam,
with elevated BNP and CXR with interstitial edema. He had a
transthoracic echocardiogram which showed mildly depressed
ayatolic dysfunction (EF = 45 %) secondary to hypokinesis of the
inferior and posterior walls. EKG was unchanged from prior and
his troponins remained flat at approximately 0.5. He had no
symptoms of acute coronary syndrome. He was given IV and
subsequently oral Lasix diuresis until he reached euvolemia. He
should follow up with his cardiologist as an outpatient for his
systolic congestive heart failure. His home pravastatin was
switched to atorvastatin 40mg daily and this was continued upon
discharge.
#Chronic Kidney Disease, stage V:
The patient has chronic kidney disease with unclear and
fluctuating baseline creatinine. He recently had placement of an
AV fistula. He presented with high creatinine that did not
appear to be acutely elevated over at least the last few weeks.
Nephrology was consulted and recommended diuresis as above and
oral bicarbonate for non-anion-gap acidosis. There was no
indication for urgent dialysis during this hospitalization. The
patient should follow up in the outpatient setting for his
chronic kidney disease. He should continue taking 650mg bicarb
twice daily.
#Non anion-gap metabolic acidosis:
The patient was found to have a non-anion-gap acidosis that was
attributed to his chronic kidney disease and decreased acid
clearance. This improved with diuresis and oral bicarbonate as
above.
#Hyperkalemia:
The patient presented with borderline hyperkalemia that was
attributed to his chronic kidney disease and decreased clearance
of potassium. This improved with diuresis and oral bicarbonate
as above.
#Normocytic Anemia (baseline Hb ___:
The patient presented with a normocytic anemia below baseline.
He has been worked up in the past and iron and ferritin were
normal in ___. EGD in ___ showed varices at the lower third of
the esophagus (ligation) and erosions and superficial ulcers in
the antrum. B12 was 1520 and folate was normal. There were no
signs of active bleeding. The patient should follow up in the
clinic with a repeat CBC and discussion of possible epogen
therapy as appropriate with his chronic kidney disease.
#Troponinemia:
The patient was found to have elevated but stable troponin of
approximately 0.5 in the absence of acute coronary symptoms.
This is likely in the setting of possible mild demand ischemia
and stage V chronic kidney disease. EKG was stable from prior.
He was continued on his home aspirin, statin, and carvedilol.
#Hepatitis C Virus status-post liver transplant:
The patient had a right upper quadrant ultrasound that was
normal without evidence of ascites. He had no signs of liver
failure on exam. Although his AST was very mildly elevated on
admission, his transaminases otherwise remained in normal range.
His home immunosuppression regimen was adjusted for discharge:
Everolimus 2mg BID and Tacrolimus 1mg BID, home Mycophenolate
Mofetil unchanged. He should follow up in the clinic with his
transplant hepatologist.
#Hypertension:
The patient remained hypertensive but stable. He was continued
on his home carvedilol, hydralazine, imdur, and Norvasc. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
===============
Admission labs
===============
___ 05:05PM BLOOD WBC-4.5 RBC-3.72* Hgb-11.3 Hct-37.2
MCV-100* MCH-30.4 MCHC-30.4* RDW-15.0 RDWSD-54.0* Plt Ct-45*
___ 05:05PM BLOOD Neuts-91.5* Lymphs-4.7* Monos-3.4*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-4.08 AbsLymp-0.21*
AbsMono-0.15* AbsEos-0.00* AbsBaso-0.00*
___ 05:05PM BLOOD ___ PTT-36.7* ___
___ 05:05PM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-144
K-4.0 Cl-100 HCO3-32 AnGap-12
___ 05:05PM BLOOD ALT-9 AST-20 AlkPhos-51 TotBili-1.4
___ 05:55AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7
___ 05:05PM BLOOD Albumin-4.2
===============
Pertinent labs
===============
___ 06:12AM BLOOD METHYLMALONIC ACID-###################
___ 03:20AM BLOOD HIV Ab-#####################
___ 06:12AM BLOOD HCV Ab-NEG
___ 06:12AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:55AM BLOOD VitB12-252 Hapto-109
___ 11:00AM BLOOD Ret Aut-1.9 Abs Ret-0.06
___ 11:00AM BLOOD Poiklo-1+* Macrocy-1+* Ovalocy-1+* Tear
Dr-1+*
===============
Discharge labs
===============
___ 04:08AM BLOOD WBC-4.3 RBC-3.25* Hgb-10.1* Hct-32.8*
MCV-101* MCH-31.1 MCHC-30.8* RDW-15.3 RDWSD-55.8* Plt Ct-51*
___ 04:08AM BLOOD Glucose-94 UreaN-20 Creat-0.9 Na-144
K-3.8 Cl-98 HCO3-34* AnGap-12
___ 04:08AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9
===============
Studies
===============
ECG ___: Sinus tachycardia Cannot rule out Inferior MI -
indeterminate age Otherwise normal ECG When compared with ECG of
___ 16:26, No significant change was found
UGI study ___: IMPRESSION: 1. No gross evidence of
esophageal stricture, web, or ring. 2. Diffuse tertiary
contractions through the mid through lower esophagus. 3. Small
hiatal hernia.
CXR ___: No acute cardiopulmonary abnormality. Emphysema
and bibasilar atelectasis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Azithromycin 250 mg PO ___
3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
4. Famotidine 20 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. LevoFLOXacin 500 mg PO Q24H
7. LORazepam 0.5 mg PO BID:PRN anxiety
8. Levothyroxine Sodium 100 mcg PO DAILY
9. PredniSONE 10 mg PO DAILY
10. roflumilast 500 mcg oral DAILY
11. sodium chloride 0.9 % inhalation Q8H:PRN
12. umeclidinium 62.5 mcg/actuation inhalation DAILY
13. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
14. Senna 17.2 mg PO QHS:PRN Constipation - First Line
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Azithromycin 250 mg PO ___
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. Famotidine 20 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. LORazepam 0.5 mg PO BID:PRN anxiety
8. PredniSONE 10 mg PO DAILY
9. roflumilast 500 mcg oral DAILY
10. Senna 17.2 mg PO QHS:PRN Constipation - First Line
11. sodium chloride 0.9 % inhalation Q8H:PRN
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
13. umeclidinium 62.5 mcg/actuation inhalation DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# GERD
# Possible peptic ulcer
# Severe COPD
# Otitis media
# Pancytopenia
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, abdomen and pelvis with contrast
INDICATION: History: ___ with hx small cell cancer s/p of chemo; gnawing abd
pain, productive cough for 1 week. // ?pna, ?metastasis
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 8.1 s, 64.1 cm; CTDIvol = 15.8 mGy (Body) DLP =
1,011.1 mGy-cm.
Total DLP (Body) = 1,023 mGy-cm.
COMPARISON: CT chest, abdomen, and pelvis ___
FINDINGS:
CHEST:
HEART AND VASCULATURE: Mild calcified atherosclerosis about the aortic arch is
again seen. The thoracic aorta is normal in caliber without evidence of acute
injury. Although not tailored for the evaluation of pulmonary emboli, no
central pulmonary emboli are seen. Stable mild cardiomegaly with mild aortic
valvular and mitral annular calcifications. Moderate coronary artery
calcifications. No pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Left upper lobe subpleural lesion measuring 1.2 x 0.4 cm is
unchanged (2:25), previously 0.5 x 1.1 cm. Multiple previously described
pulmonary nodules measuring up to 5 mm are unchanged. No new or growing
pulmonary nodules. Lungs are clear without masses or areas of parenchymal
opacification. Moderate narrowing of right bronchus intermedius with
secretions. Otherwise, the airways are patent to the level of the segmental
bronchi bilaterally.
BASE OF NECK: The thyroid is heterogeneous with multiple subcentimeter
hypoattenuating thyroid nodules.
ABDOMEN:
HEPATOBILIARY: The liver contour is nodular. Few subcentimeter
hypoattenuating lesions throughout are unchanged. No new focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder contains gallstones without wall thickening or surrounding
inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is mildly enlarged measuring 13.2 cm. There is normal
attenuation throughout, without evidence of focal lesion or laceration.
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.
Few subcentimeter hypodensities throughout the bilateral kidneys are too small
to characterize, statistically likely cysts. There is no hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. The small bowel is generally
decompressed throughout. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. Apparent mild mural thickening and
mucosal hyperenhancement throughout the colon is likely due to
underdistention, although subtle pericolonic fat stranding about the cecum may
suggest this finding is real. Mild pancolonic diverticulosis. The appendix
is not visualized.
There is no free fluid or free air in the abdomen.
PELVIS:
The urinary bladder is underdistended, limiting its evaluation. The distal
ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: A 1.2 cm retrocrural lymph node (2:46) is stable. Elsewhere,
there is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic
or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: There is no acute fracture. No focal suspicious osseous abnormality.
Unchanged mild anterolisthesis of L2 on L3.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No new findings to suggest metastatic disease within the abdomen or pelvis.
2. Suggestion of mural thickening and mucosal hyperenhancement throughout the
colon could suggest mild pancolitis, which if real, is likely infectious or
inflammatory.
3. Mildly enlarged retrocrural lymph node and indeterminate subcentimeter
hepatic lesions are stable.
4. Cholelithiasis without acute cholecystitis.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old woman with severe COPD on 3LNC and a history of lung
cancer presenting with severe epigastric pain // evaluate for esophageal
strictures
TECHNIQUE: Barium esophagram.
DOSE: Acc air kerma: 12 mGy; Accum DAP: 167.4 uGym2; Fluoro time: 1 minute 46
seconds
COMPARISON: CT chest abdomen pelvis ___
FINDINGS:
The esophagus was not dilated. There was no stricture within the esophagus.
There was no esophageal mass.
There are diffuse tertiary contractions were seen throughout the mid and lower
esophagus. The lower esophageal sphincter opened and closed normally.
There was no gastroesophageal reflux. There was a small hiatal hernia.
No overt abnormality in the stomach or duodenum on limited evaluation.
IMPRESSION:
1. No gross evidence of esophageal stricture, web, or ring.
2. Diffuse tertiary contractions through the mid through lower esophagus.
3. Small hiatal hernia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Ear pain
Diagnosed with Unspecified abdominal pain
temperature: 97.3
heartrate: 112.0
resprate: 20.0
o2sat: 95.0
sbp: 142.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | SUMMARY:
========
Ms. ___ is an ___ year old woman with a history of COPD (GOLD D
on 3L home O2), stage IIIb small cell lung cancer s/p chemo XRT
(completed ___, hx of perforated diverticuli s/p ___
procedure/colostomy now reversed, and multiple hospital
admissions for PNA and COPD who presents abdominal pain
concerning for PUD. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cold right foot
Major Surgical or Invasive Procedure:
Lysis catheter to R below-knee popliteal artery and ___
R Popliteal Artery Aneurysm resection
History of Present Illness:
___ PMH HTN, HLD, right popliteal artery aneurysm (since at
least ___ presents from OSH with cool right foot since earlier
today (10 am) and intramural thrombus of the right popliteal
artery aneurysm seen on US.
Patient reports he noticed bruising on his right leg on
___ upon awakening which turned to a scab and became
slightly erythematous around it. He can recall no injury to the
area. On ___, he experienced foot pain/numbness and
presented to ___ for evaluation. There he says
he had an ultrasound, but is unsure what it showed. He was given
a single dose of Lovenox, an antibiotic shot, and a prescription
for Keflex and Bactrim. The symptoms subsided and he was
discharged home. On ___, he had recurrent pain, numbness
and tingling and presented to ___ for evaluation. There
he was noted to have intramural thrombus within the popliteal
artery aneurysm. Symptoms again subsided within several hours
and he was discharged home with a prescription for Xarelto and a
follow-up appointment with Dr. ___. He tried to fill the
Xarelto, but could not afford the more than $400 co-pay. His
symptoms resumed this morning at 10am and have continued to
worsen. He again presented to ___ who started
him on a heparin drip and transferred him to ___ for further
management.
Past Medical History:
-HTN
-HLD
-right popliteal artery aneurysm
Social History:
___
Family History:
-no family history of vascular disease, aneurysms, connective
tissue disorder, or sudden death
Physical Exam:
ADMISSION PHYSICAL EXAM
Physical Exam:
Afebrile, vitals WNL
GEN: NAD
HEENT: EOMI, MMM
CV: RRR
PULM: non-labored breathing
ABD: soft, NT/ND
EXT: RLE with sharply demarcated area of pallor along base of
all
5 toes, cool to touch compared to right foot. Decreased
sensation
to light palpation over dorsal aspect of RLE and unable to
appreciate light palpation over distal most aspect of all 5
right
toes. Able to plantarflex/dorsiflex foot and move all toes of
RLE
with preservation of strength compared to LLE. Right anterior
midshin with area of ecchymosis and skin necrosis with some
draininage of serosanguinous fluid with palpation. No evidence
of
infection.
PULSES:
LLE-palp femoral, palp popliteal, palp DP, dop ___
RLE-palp femoral, large pulsatile mass in right popliteal
fossa, monophasic ___, no signal DP
NEURO: A&Ox3
PSYCH: appropriate mood, appropriate affect
DISCHARGE PHYSICAL EXAM
VS: 98.6 PO 122 / 67 94 18 98 Ra
General: oriented x 3, in nad
CV: regular rate and rhythm
Pulm: no respiratory distress or work of breathing, comfortable
on RA
Abdomen: soft, nontender, resolving maculopapular rash on back,
R groin with resolving hematoma, erythema without tenderness or
discharge
Extremities: RLE with superficial bullae at distal aspect that
have popped, diffuse petechiae, mild pitting edema, staples on
medial aspect of RLE, foot warm to touch
Pulses: Doppler signals at R ___
Pertinent Results:
ADMISSION LABS
___ 02:00PM GLUCOSE-97 UREA N-17 CREAT-1.3* SODIUM-143
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17*
___ 02:00PM estGFR-Using this
___ 02:00PM ALT(SGPT)-41* AST(SGOT)-61* ALK PHOS-90 TOT
BILI-0.3
___ 02:00PM LIPASE-27
___ 02:00PM cTropnT-<0.01
___ 02:00PM ALBUMIN-3.8
___ 02:00PM WBC-14.1* RBC-4.55* HGB-14.1 HCT-42.1 MCV-93
MCH-31.0 MCHC-33.5 RDW-13.0 RDWSD-43.8
___ 02:00PM NEUTS-64.7 ___ MONOS-7.5 EOS-2.6
BASOS-0.9 IM ___ AbsNeut-9.12* AbsLymp-3.33 AbsMono-1.06*
AbsEos-0.36 AbsBaso-0.12*
___ 02:00PM PLT COUNT-226
___ 02:00PM ___ PTT-150* ___
DISCHARGE LABS
___ 06:08AM BLOOD WBC-14.2* RBC-2.51* Hgb-7.8* Hct-23.4*
MCV-93 MCH-31.1 MCHC-33.3 RDW-12.7 RDWSD-43.8 Plt ___
___ 06:08AM BLOOD Plt ___
___ 06:08AM BLOOD Glucose-101* UreaN-20 Creat-0.9 Na-137
K-4.8 Cl-101 HCO3-24 AnGap-12
___ 06:08AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0
PERTINENT LABS
___ 05:42AM BLOOD CK(CPK)-1782*
___ 11:47PM BLOOD CK(CPK)-921*
___ 06:28AM BLOOD CK(CPK)-777*
Medications on Admission:
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Pravastatin 40 mg PO QPM
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 7 Days
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
2. Apixaban 5 mg PO BID Duration: 3 Months
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*168 Tablet Refills:*0
3. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth every 6 hours as needed
for pain Disp #*15 Capsule Refills:*0
5. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 100 mg 1.5 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
6. Allopurinol ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Pravastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Popliteal Aneurysm s/p ___
___ Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: VEIN MAPPING-Lower extremities
INDICATION: ___ year old man with R popliteal aneurysm scheduled for resection
today// vein mapping
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral
lower extremity veins.
COMPARISON: None.
FINDINGS:
RIGHT: The great saphenous vein is patent with diameters ranging from 0.39 to
0.5 cm. The right small saphenous vein is patent with diameters ranging from
0.22 to 0.33 cm.
LEFT: The great saphenous vein is patent with diameters ranging from 0.35 to
0.63 cm AK. BTK diameters are smaller 0.14-0.21cm The left small saphenous
vein is patent with diameters ranging from 0.26 to 0.6 cm.
IMPRESSION:
The great and small saphenous veins are patent bilaterally. Please see
digitized image on PACS for formal sequential measurements. The left GSV is
small below the level of the knee.
Radiology Report
INDICATION: ___ PMH HTN, HLD, and R popliteal artery aneurysm w/ acute onset
pain, pallor, and pulselessness to RLE now s/p RLE lysis catheter (removed)
and R SFA-BKpop bypass with pop aneurysm resection// ?pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: None available
FINDINGS:
There is a retrocardiac infiltrate which given the lack of prior imaging may
reflect a focus of consolidation/pneumonia. No focal consolidation is seen
within the right lung. There is no pleural effusion or pneumothorax.
IMPRESSION:
Possible left lower lobe pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg pain, R POPLITEAL ANEURYSM
Diagnosed with Pain in left leg
temperature: 98.8
heartrate: 86.0
resprate: 20.0
o2sat: 96.0
sbp: nan
dbp: nan
level of pain: 9
level of acuity: 2.0 | ___ y/o M with a PMH of HTN, HLD admitted as a transfer from an
outside hospital with acute limb ischemia of the right lower
limb found to have a right popliteal artery aneurysm with
intramural thrombus now s/p TPA lysis catheters and popliteal
aneurysm resection with return of signals.
#R Popliteal artery aneurysm s/p resection: Admitted with cool
right foot and US report from OSH ___ ___ noting
4.34 cm popliteal aneurysm with intramural thrombus. He was
transferred to ___ on heparin drip. Admission evaluation noted
bounding R popliteal artery aneurysm and monophasic ___, but no
signal at DP. He was taken to the OR ___ for RLE angio which
demonstrated patent tibial trifurcation with slow fill, but not
visualization of tibial vessels in distal extent or at level of
the foot. Thrombolysis catheter was placed in the right
below-knee popliteal artery. On ___ he was taken back for lysis
check with repeat angio that revealed sluggish filling of the
distal right anterior tibial and posterior tibial arteries
without patent anterior tibial or posterior tibial across the
right ankle. Subsequently had angiojet of ___ and AT with
placement of infusion catheters in ___ and AT and improvement in
signals. On ___ catheters were removed and patient underwent
Right SFA to below-knee popliteal bypass using non- reversed
greater saphenous vein and ligation and resection of the
popliteal artery aneurysm. Post-operatively patient was briefly
continued on heparin drip and then transitioned to xarelto. Due
to insurance issues patient was discharged on therapeutic
apixiban dose. Pulse exam on discharge with strong Doppler
signals in R DP and ___
#Pneumonia: Patient febrile on with leukocytosis and
tachycardia, found to have left lower lobe pneumonia on ___.
Started on levofloxacin x 7 days with improvement in symptoms
and downtrending leukocytosis.
TRANSITIONAL ISSUES
===================
[]Tachycardia: Home metoprolol xl uptitrated from 100 to 150mg
with appropriate HR control <110
[]s/p popliteal aneurysm resection and lysis catheters: Patient
to continue apixiban 10mg bid x 7 days, followed by 5mg BID for
a total of 3 months
[]Pneumonia: continue levofloxacin 750mg daily x 5 days (total 7
day course)
[]Follow-up with Dr. ___ ___ @ 10:00am in ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cortisone / Poison ___ / Aleve
Attending: ___.
Chief Complaint:
Weight gain, abdominal distention, hallucinations
Major Surgical or Invasive Procedure:
Diagnostic paracentesis ___
Therapeutic paracentesis ___ (5L removed)
History of Present Illness:
Mr. ___ is a ___ yo male with a PMHx significant for HCV/EtOH
cirrhosis, HCC s/p TACE x3, hepatic vein thrombus, radiotherapy
with CyberKnife, sorafenib ___, recently discharged on
___ after hospitalized for nausea/vomiting thought to be
secondary to sorafenib now transitioned to capecitabine,
presenting to the ED with abdominal distention, weight gain and
SOB for about 2 weeks. States that over the last 2 wks weight
has gone from 175lb to 198lb with increasing abdominal girth and
decreased UOP, progressive SOB with exertion. He also reports
swelling of his lower extremities L>R. He minimizes his report
of hallucinations, stating about once a month "when his blood
gets all messed up with medications" he will see something out
of the corner of his eye or see words or writing that isn't
really there.
In the ED, initial vitals were 98.4 61 114/67 20 99%. In triage,
he was noted to be a+ox2-3, but having hallucinations. On exam:
no asterixis, significant abdominal distension, guiaiac
negative. Labs significant for WBC 2.4 with 76.6% PMN, 4.4% eos,
12% lymphs, Hct 36.9 (at ___, Plats 62 (at ___ INR 1.7 (up from
1.4 as far back as ___, AST/ALT 51/21, AP 72, T bili 1.9,
alb 2.9, lipase 22. U/A pos for bili but no e/o infection.
CHEM-7 WNL with cr 0.8 (at ___. A paracentesis was performed and
did not show evidence of SBP.
On arrival to the floor, ___ is irritated with repetative
questioning and frustrated by his right knee pain which he has
not had pain meds for yet today and reports that he "shouldn't
have come to the hospital, should have put a bullet in my head
instead". Upon further questioning he states he was not serious,
has not thought seriously about hurting himself, does not have
and never has had a plan to hurt himself or anyone else, does
not own or have access to firearms.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, sore throat, cough, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- HCV diagnosed in ___.
- History of alcohol abuse/cirrhosis
- Hypercholesterolemia.
- Upper GI bleed in ___ due to a gastric ulcer.
- History of grade 1 to 2 varices.
- Status post bilateral knee surgery.
- Status post left inguinal and umbilical hernia repair
___.
- CAD: inferolateral wall MI ___. CK 844, MB 135, EF 40%-47%.
- h/o pAfib
- Multiple HCC s/p TACE ___ to segment VII/VIII, RFA
___, TACE ___, and TACE ___ to right
hepatic lobe and right hepatic vein segment thrombus. s/p
CyberKnife right liver and hepatic vein tumor thrombus ___.
Started sorafenib ___ but self-discontinued ___ due
to poor tolerance (N/V). Started capecitabine ___ at a
dose of 1000 mg/m2 b.i.d.
days 1 through 14 of a 21-day cycle.
Social History:
___
Family History:
The ___ father died of an MI at ___ years. He has two
brothers and three sisters. One brother had a stroke at ___
years.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9F, BP 113/71, HR 66, RR 17, 100%RA 87.6Kg
GENERAL: Ill appearing M in mild distress ___ knee pain
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple no ___ or JVD
CARDIAC: irregularly irregular, S1 S2 clear and of good quality
without murmurs, rubs or gallops.
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: Distended but soft, non-tender to palpation. Dullness
to percussion over dependent areas. Paracentesis site clean no
leakage. Blanchable erythema 10in dia paraumbilical
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
left leg edema, 1+ right leg edema; L
SKIN: dry flaking erythema over shoulders, chest, forearms,
peeling on feet.
DISCHARGE PHYSICAL EXAM:
VS: 98.1, BP 98/68, HR 91, RR 20, 100%RA
GENERAL: Ill appearing M in NAD
HEENT: Sclera anicteric. PERRL, EOMI.
CARDIAC: irregularly irregular, S1 S2 clear and of good quality
without murmurs, rubs or gallops.
LUNGS: CTAB
ABDOMEN: Distended but soft, non-tender to palpation. Dullness
to percussion over dependent areas. Paracentesis site clean no
leakage. Blanchable erythema 10in dia paraumbilical improving
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
left leg edema, 1+ right leg edema; L
SKIN: dry flaking erythema over shoulders, chest, forearms,
peeling on feet. scattered spider hemangiomas on back
Pertinent Results:
ADMISSION LABS:
___ 11:40AM BLOOD WBC-2.4* RBC-3.71* Hgb-12.4* Hct-36.9*
MCV-99* MCH-33.5* MCHC-33.7 RDW-24.3* Plt Ct-62*
___ 11:40AM BLOOD Neuts-76.6* Lymphs-12.1* Monos-6.3
Eos-4.4* Baso-0.6
___ 11:40AM BLOOD ___ PTT-36.8* ___
___ 11:40AM BLOOD Glucose-91 UreaN-18 Creat-0.8 Na-135
K-4.2 Cl-101 HCO3-28 AnGap-10
___ 11:40AM BLOOD ALT-21 AST-51* AlkPhos-72 TotBili-1.9*
___ 11:40AM BLOOD Lipase-22
___ 11:40AM BLOOD Albumin-2.9*
___ 12:15PM ASCITES WBC-250* RBC-420* Polys-19* Lymphs-14*
Monos-37* Mesothe-11* Macroph-19*
___ 12:15PM ASCITES TotPro-0.8 Glucose-113 Albumin-PND
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-1.5* RBC-3.20* Hgb-10.6* Hct-31.9*
MCV-100* MCH-33.1* MCHC-33.1 RDW-24.2* Plt Ct-63*
___ 06:00AM BLOOD Neuts-71.3* Lymphs-16.1* Monos-8.3
Eos-4.1* Baso-0.4
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD Glucose-137* UreaN-13 Creat-0.8 Na-139
K-3.8 Cl-104 HCO3-31 AnGap-8
___ 06:00AM BLOOD ALT-21 AST-36 AlkPhos-61 TotBili-1.7*
___ 06:00AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0
PERTINENT MICRO:
___ URINE CULTURE- NEG FINAL
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ PERITONEAL FLUID GRAM STAIN- NEG FINAL; FLUID
CULTURE-NEG FINAL; ANAEROBIC CULTURE-PRELIMINARY
PATH: cytology peritoneal fluid ___
Peritoneal fluid:
NEGATIVE FOR MALIGNANT CELLS.
PERTINENT IMAGING
___ Liver US with doppler
IMPRESSION:
1. Persistent thrombosis of the anterior right portal vein.
There is no there is no extension of thrombus into the other
central portal branches
2. Increasing ascites since ___. Splenomegaly.
4. Gallbladder wall thickening secondary to ascites.
___ 2-view CXR
FINDINGS: As compared to the previous radiograph, the lung
volumes have
decreased. No pleural effusions are seen on the frontal and the
lateral
radiographs. Plate-like areas of atelectasis at the left lung
base, better
appreciated on the frontal than on the lateral image. No
evidence of
pneumonia. Borderline size of the cardiac silhouette. Normal
hilar and
mediastinal structures.
___ non-con head CT
IMPRESSION: No acute intracranial process. Please note that
MRI is more
sensitive for the detection of subtle masses and early infarct
and may be
considered in the correct clinical setting if there are no
contraindications
to the use of MRI.
___ ___ left leg
IMPRESSION: No evidence of deep vein thrombosis in the left
leg.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Capecitabine 500 mg PO Q12H
2. Citalopram 20 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
5. Lisinopril 2.5 mg PO DAILY
___ unsure if still taking
6. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety/nausea/vomiting
7. Nadolol 20 mg PO DAILY
8. OLANZapine 2.5 mg PO DAILY nausea
9. Omeprazole 40 mg PO DAILY
10. Simvastatin 10 mg PO DAILY
11. Aspirin 325 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Outpatient Lab Work
CBC on ___.
Diagnosis: pancytopenia, cirrhosis, HCC on chemo
Please fax results to Dr. ___ (___)
2. Citalopram 20 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
5. Nadolol 20 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Simvastatin 10 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. OLANZapine 2.5 mg PO DAILY nausea
11. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety/nausea/vomiting
12. Amiloride HCl 10 mg PO DAILY
RX *amiloride 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
13. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
14. Lactulose 30 mL PO TID
titrate to 3 BM daily
RX *lactulose 10 gram/15 mL 30 mL by mouth three times a day
Disp #*3000 Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
hallucinations, possibly hepatic encephalopathy.
ascites
Secondary:
hepatocellular carcinoma
cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man with advanced hepatocellular carcinoma and known
right anterior portal vein from thrombus presenting with worsening ascites.
COMPARISON: Multiphasic abdominal CT ___, duplex ultrasound ___
, abdominal MRI ___.
FINDINGS:
The liver has a nodular contour. The extent of the known infiltrative
hepatocellular carcinoma is incompletely assessed on this limited ultrasound
which was tailored specifically towards patency of the hepatic vasculature.
The gallbladder wall is thickened up to 5 mm. There is no intra or
extrahepatic biliary dilatation. Common bile duct measures 5 mm. The spleen
is enlarged up to 20 cm. The left kidney measures 10.6 cm. The right kidney
measures 12.2 cm. There is no hydronephrosis in either kidney. Large volume
ascites has increased since ___.
Hepatic Doppler: The main portal vein is patent with hepatopetal flow. The
posterior right portal vein is patent on real-time visualization. The
anterior right portal vein branch is not well seen, compatible with previously
seen thrombosis. The left portal vein is patent with hepatopetal flow. The
hepatic veins are patent with patent appropriate hepatopetal flow. The IVC is
normal in caliber and appearance. The main hepatic artery is patent with
normal arterial waveforms.
IMPRESSION:
1. Persistent thrombosis of the anterior right portal vein. There is no there
is no extension of thrombus into the other central portal branches.
2. Increasing ascites since ___. Splenomegaly.
4. Gallbladder wall thickening secondary to ascites.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Hepatic encephalopathy, questionable infection.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes have
decreased. No pleural effusions are seen on the frontal and the lateral
radiographs. Plate-like areas of atelectasis at the left lung base, better
appreciated on the frontal than on the lateral image. No evidence of
pneumonia. Borderline size of the cardiac silhouette. Normal hilar and
mediastinal structures.
Radiology Report
INDICATION: ___ man with hepatitis C and alcoholic cirrhosis, now
with visual hallucinations.
COMPARISON: CT head with and without contrast ___.
TECHNIQUE: Contiguous axial images were obtained through the brain without
the administration of IV contrast. Multiplanar reformats were generated and
reviewed.
FINDINGS: There is no evidence of acute intracranial hemorrhage, discrete
masses, mass effect or shift of normally midline structures. The ventricles
and sulci are normal in size and configuration. Gray-white matter
differentiation is preserved with no evidence of acute major vascular
territory infarction.
Bilateral mastoid air cells and visualized paranasal sinuses are clear.
Orbits and conus are symmetric.
IMPRESSION: No acute intracranial process. Please note that MRI is more
sensitive for the detection of subtle masses and early infarct and may be
considered in the correct clinical setting if there are no contraindications
to the use of MRI.
Radiology Report
HISTORY: ___ man with left greater than right lower extremity edema,
evaluate for DVT.
COMPARISON: No previous exam for comparison.
FINDINGS: Grayscale, color, and Doppler images were obtained of the left
common femoral, femoral, popliteal and tibial veins. Normal flow, compression
and augmentation is seen in all of the vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left leg.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ACITIES,SOB,PAIN
Diagnosed with CHEST PAIN NEC, MAL NEO LIVER, PRIMARY
temperature: 98.4
heartrate: 61.0
resprate: 20.0
o2sat: 99.0
sbp: 114.0
dbp: 67.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ is a ___ yo male with a history of HCV/EtOH cirrhosis,
MELD 15 but 22 for ___, presenting with increasing abdominal
girth and visual hallucinations concerning for hepatic
encephalopathy.
# Encephalopathy: ___ presented with visual hallucinations,
reported seeing things out of the corner of his eyes and seeing
words that we not there. He was reportedly experiencing further
visual hallucinations in the ED though no further details of
this were documented and ___ denied that these visual
disturbances were significant or persistent. He was alert and
oriented x3, without asterixis. Work up for hepatic
encephalopathy was unrevealing, showed patent liver vessels,
diagnositic paracentesis negative for infection. Infectious work
up was negative though several cultures were pending at
discharge. Non-contrast head CT was negative for acute bleed. He
was started on rifaximin and lactulose was titrated to ___ bowel
movements per day and sedating medications were held. His
chemotherapy agent, capecitabine was also held per discussion
with Dr. ___.
- Discharged on lactulose, consider adding rifaximin if concern
for HE persists
- Blood and peritoneal fluid cultures pending at discharge
# Cirrhosis: HCV/EtOH related cirrhosis, complicated by ascites,
encephalopathy, HCC. MELD on admission was 15 (22 for HCC),
___ not on transplant list.
- SBP: total ascites protein 0.8, no known h/o SBP, Cipro ppx
started for low ascites protein
- Hepatic Encephalopathy: as above
- Varices: Continued nadolol
- Ascites: Continue lasix, 2g Na diet, SAAG consistent with
cirrhosis over malignant effusion, cytology negative for
malignant cells. Started on amiloride while admitted.
# HCC: On capecitabine C3D6 (___), followed by Dr. ___
___. ___ is s/p TACE x3, radiotherapy with CyberKnife,
sorafenib ___. Dr. ___ was notified of the admission and
capecitabine was held, to be restarted as directed by Dr.
___
- ___ follow up with Dr. ___ in clinic
#Asymmetric lower extremity edema: concerning for DVT in
chronically ill man with malignancy, but LENIs of the left leg
were negative for DVT.
#Atrial fibrillation: ___ reports known history of
paroxysmal AFib, not on anticoagulation. He was noted to be in
Afib with normal rate during this admission and hemodynamically
stable. ___ declined telemetry, was made aware of risks of
not using continuous monitoring.
-Continued nadolol for history of varices
#Pancytopenia: likely from cirrhosis and recent chemotherapy.
ANC was just above 1000 at time of discharge, ___ was
instructed to present to the emergency room immediately if he
developed fever.
- Continued iron supplementation
- Should have repeat labs ___
#GERD: continued omeprazole
#Chronic knee pain: continued dilaudid, lidocaine patch
#Anxiety/depression: continued citalopram, held ativan for AMS
- ___ may take ativan as needed, if AMS recurs, consider
holding again
#CAD: inferolateral wall MI ___. CK 844, MB 135, EF 40%-47%.
- Did
#Hyperlipidemia: continued simvastatin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with CAD, HTN, CKD, and DLBCL to CNS admitted from
clinic for relapsed CNS lymphoma and cycle #4 high-dose
methotrexate. Previous MTX was complicated by ___. He was then
changed to temazolamide and then to pemetrexed, but now he has
relapsed presenting to clinic with mild confusion and failure to
thrive. He was given high-dose MTX, dose reduced to 3.0g/m2 to
avoid worsening renal failure. Dexamethasone was increased from
4mg daily to 4mg BID. Pt cleared MTX and was discharged to a
rehab facility yesterday.
Upon arrival at rehab pt was agitated and wanted to leave, so
was sent back. Pt had been confused during admission, but never
agitated prior. Wife thinks the thought of rehab made him think
he would not return home.
Currently, pt denies any complains, has been explained and
understands the purpose of going to rehab and is willing to
return.
Full ten point ROS is negative except for fatigue.
Past Medical History:
PAST ONCOLOGIC HISTORY (per Dr/ ___ note ___ Developed renal failure
___ Abdominal LAD found, had biopsy
Pathology: B-cell lymphoma
___ BMBx negative
___ Left calf DVT
___ - ___ CHOP-R and CVP
___ Developed dizziness and falls
___ Brain MRI showed left temporal lesion
___ CT-guided biopsy of left temporal lesion by Dr. ___: Lymphoma
___ C1D1 HD-MTX 3.5 g/m2
___ C1D15 HD-MTX 3.5 g/m2
___ C2D1 HD-MTX 3.5 g/m2
___ C2D15 HD-MTX 3.5 g/m2
___ C1D1 Pemetrexed 600 mg/m2
___ C1D15 Pemetrexed 600 mg/m2
___ Developed rash
___ C1 Temodar
___ - ___ Admitted for fatigue
___ C2D1 Temozolomide
___ MRI brain shows new lesion
___ C2D1 Pemetrexed
___ C3D1 Pemetrexed
___ HD MTX
.
PAST MEDICAL HISTORY:
1. NHL, brain involvement as above
2. Hypertension
3. Peptic ulcer disease
4. Left lower extremity DVT ___
5. Abdominal aortic aneurysm repair ___
6. Renal failure when presented with NHL
7. Pulmonary interstitial fibrosis (does not require O2 at
baseline)
8. Cardiomegaly
9. Gout
Social History:
___
Family History:
Eldest child with ALS.
Son had ___, now resected.
Physical Exam:
Physical Examination:
VS: Tcurr 96.4, BP 132/78, HR 69, RR 18, O2 Sat 95% RA,
GEN: A,Ox2 (not year) NAD
HEENT: Sclerae non-icteric, EOM intact, CNs intact, no thrush,
MMM.
Neck: Supple, no LAD.
CV: S1S2, reg rate and rhythm, 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, + bowel sounds.
EXTR: No edema or calf tenderness. No finger clubbing.
NEURO: Strength ___, non-focal.
SKIN: No rash.
PSYCH: Occionally confused, but calm, appropriate.
Pertinent Results:
___ 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 01:30AM GLUCOSE-113* UREA N-28* CREAT-1.4* SODIUM-138
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-32 ANION GAP-11
___ 01:30AM CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 01:30AM CARBAMZPN-LESS THAN
___ 01:30AM WBC-6.9 RBC-3.02* HGB-10.3* HCT-31.7*
MCV-105* MCH-34.0* MCHC-32.5 RDW-16.7*
___ 01:30AM NEUTS-85.4* LYMPHS-11.6* MONOS-1.6* EOS-1.1
BASOS-0.4
___ 01:30AM PLT COUNT-___:
IMPRESSION:
1. No change from recent studies of ___ and ___,
with left
temporal and frontoparietal vasogenic edema related to the known
left temporal lobar intra-axial mass.
2. Impending left uncal herniation, unchanged in degree, with no
subfalcine herniation.
.
CXR ___:
FINDINGS:
No change from ___. No acute process.
Medications on Admission:
1. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO QID
(4 times a day): to start one day prior to next Methotrexate
admission.
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
10. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
11. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: ___
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
12. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
13. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 4 days.
Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
2. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 3 days.
3. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
4. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
12. nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four
times a day.
13. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: One
(1) Ophthalmic four times a day as needed for dry eyes.
14. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a
day.
15. Zyprexa 2.5 mg Tablet Sig: ___ Tablets PO once a day as
needed for agitation.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
DLBCL with CNS involvement
Pneumonia
Confusion
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
INDICATION: ___ with mental status change.
TECHNIQUE:
Frontal and lateral radiographs of the chest were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
There is mild cardiomegaly. The cardiomediastinal shilouette and hila are
normal. No effusion. The lungs are clear. A left Port-A-Cath ends at the
cavoatrial junction. No change from ___.
FINDINGS:
No change from ___. No acute process.
Radiology Report
INDICATION: ___ with mental status change.
TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal
reformats were acquired.
COMPARISON: NECT of the head from ___, and enhanced MRI of the
head from ___.
FINDINGS:
CT OF THE HEAD:
There is no hemorrhage. There is extensive vasogenic edema spreading
throughout the left temporal and frontoparietal lobe associated with
underlying left temporal lobe mass, better demonstrated on the recent MRI.
The degree of impending left uncal herniation is similar compared to that on
the MR study, with stable mild effacement of the left lateral ventricle, and
no significant shift of midline structures. There is moderate confluent
hypodensity in the centra semiovale and periventricular, as well as central
pontine, white matter, as before, consistent with sequelae of chronic small
vessel ischemic disease. Allowing for these abnormalities, there is no large
acute vascular territorial infarction.
A burr hole is seen in the left paramedian frontal bone. There is no
suspicious lytic or sclerotic bony lesion or fracture. The included paranasal
sinuses, middle ear cavities and mastoid air cells are clear.
IMPRESSION:
1. No change from recent studies of ___ and ___, with left
temporal and frontoparietal vasogenic edema related to the known left temporal
lobar intra-axial mass.
2. Impending left uncal herniation, unchanged in degree, with no subfalcine
herniation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: AGITATED
Diagnosed with ALTERED MENTAL STATUS , SPECIAL SYMPTOM NEC/NOS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, RENAL FAILURE, UNSPECIFIED
temperature: 96.8
heartrate: 67.0
resprate: 16.0
o2sat: 96.0
sbp: 157.0
dbp: 75.0
level of pain: 0
level of acuity: 3.0 | ___ man with CAD, HTN, CKD, and DLBCL to CNS admitted from
clinic for relapsed CNS lymphoma and cycle #4 high-dose
methotrexate. Previous MTX was complicated by ___. He was then
changed to temazolamide and then to pemetrexed, but now he has
relapsed presenting to clinic with mild confusion and failure to
thrive. He was given high-dose MTX, dose reduced to 3.0g/m2 to
avoid worsening renal failure. Dexamethasone was increased from
4mg daily to 4mg BID. Pt received MTX ___, was discharged
last night to rehab and was sent back due to agitation.
.
# Agitation: Likely delirium, with baseline confusion and
sundowning due to underlying CNS lymphoma.
-full infectious w/u done and negative so far, repeat HCT
negative
-pt will need re-direction and encouragement while he djusts to
rehab facility, wife will accompany him there (or meet him
there)
-will add prn Zyprexa for agitation if needed
.
# CNS lymphoma: s/p Cycle #4 high-dose MTX 3.0g/m2 given
worsening renal function with previous 3.5g/m2 dose ___.
- Continue levetiracetam.
- Increased dexamethasone from 4mg daily to 4mg BID.
- Plan for Rituxan next ___ in clinic followed by
admission for HD MTX
.
# Pneumonia: To complete treatment with Ceftriaxone/azithromycin
.
# CKD: MTX dose adjusted for creat clearance. However, poor
prognosis for malignancy now supersedes risk to kidneys. cont
to renally dose meds
.
# CAD/CHF:
- Cont ASA (Hold aspirin during MTX and restart after MTX
clears).
- Continue carvedilol and lisinopril.
- Follow Ins/Outs and daily weights.
.
# Thrush: on nystatin until clearance
.
# Hypertension: Continued carvedilol and lisinopril.
.
# Hyperlipidemia: Hold atorvastatin due to transaminitis and
MTX.
.
# FEN: Regular diet, Replete lytes PRN.
.
# DVT prophylaxis: Ambulation, pneumoboots.
.
# GI prophylaxis: H2 blocker (hold PPI until while getting
intermittent MTX). Bowel regimen.
.
# Lines: Port and peripheral IV.
.
# Precautions: None.
.
# CODE: FULL.
.
# Contact: Wife.
.
# Discussed with: Patient Nursing Houses___ PCP ___
___ Oncologist
.
# Dispo: Rehab
[x ] Discharge documentation reviewed, stable for discharge.
[x ] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
.
Active meds: See below.
.
.
.
_________________________________
___, MD, pager ___
. |
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:
___ is a ___ male patient with a history of COPD, CHF, Afib
on warfarin who presented with SOB. He states that he has SOB at
baseline over many months, but that it acutely worsened this
week. For the last 5 days or so, he felt as though he wasn't
able
to walk the same distances or do the same activities without
becoming increasingly SOB. During this time he also noticed that
he was having rhinorrhea, a worsening cough, and a sore throat.
He also noticed increased ___ swelling.
Was here in the ED yesterday ___ ___ut appears to have
been seen for hypoglycemia and UTI. Was sent home on cefpodoxime
for 10 days for UTI and no intervention was needed for
hypoglycemia.
Denied fever, chills, chest pain, but does endorse multiple
hospitalizations this year for COPD and HF.
In the ED:
=================================
- Initial vital signs were notable for:
Temp not taken, HR 88, BP 132/84, RR 30, SpO2 92%
- Exam notable for:
General: Accessory muscles to breath, uncomfortable appearing
CV: RRR w/o MRG
Pulm: Bilateral wheezes
- Labs were notable for:
BUN 72, Cr 2.9 (baseline difficult to assess ___, Glu 60
BNP 726
WBC 10.4 (80% Neut), Hgb 8.9, Hct 31.0, Plt 246
All others WNL
- Studies performed include:
Chest Xray ___:
1. Redemonstration of a right pleural effusion. A superimposed
pneumonia would be difficult to exclude.
2. Mild pulmonary vascular congestion edema, similar to slightly
improved compared to the most recent prior examination of ___.
EKG:
Sinus rhythm
Nonspecific intraventricular conduction delay
Probable anterior infarct, age indeterminate
QTc 550
- Patient was given:
Albuterol, Atrovent IH x2
Azithromycin 500mg PO at 10AM
Prednisone 40mg PO at 10AM
Furosemide 80mg IV at 10AM
Albuterol Neb at 2:30PM
- Consults:
None currently
Vitals on transfer:
HR 79, BP 129/69, RR 22, 96% on 3L NC
Upon arrival to the floor:
=================================
Confirms the above history and states that he does have SOB at
baseline, but the last couple days have been really bad for him.
He denies any increased sputum or change in sputum color (has
intermittent white colored sputum). Feels a little bit better
after getting the nebulizer treatments, but still not feeling
like he is at baseline.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD
- Pump: LVEF 67% ___
- SR, hx of paroxysmal AF
3. OTHER PAST MEDICAL HISTORY
HFpEF
GERD
Gout
GCA (___)
GI bleed
CAD
COPD
EOTH abuse
CVA
PVD
CKD Stage 3
Afib on warfarin
Social History:
___
Family History:
Uncles with alcoholism. Mother with a heart attack after ___
y/o. Daughter passed away of complications due to diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================================
Vitals: 24 HR Data (last updated ___ @ ___)
Temp: 97.7 (Tm 97.7), BP: 135/78, HR: 78, RR: 18, O2 sat:
93%, O2 delivery: 2L
GENERAL: Alert and interactive. Laying at 30 degree angle. Does
require some pauses between sentences to catch breath.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Decreased breath sounds bilaterally, most difficult to
appreciate over the right lower lung fields. Mild expiratory
wheezes bilaterally, basilar crackles appreciated over left
lower
lung fields, no rhonchi. Some increased work of breathing.
ABDOMEN: Normal bowels sounds, distended but not tense abdomen,
non-tender to deep palpation in all four quadrants. No
organomegaly. Umbilical hernia that is reducible and non-tender
is present.
EXTREMITIES: Amputation of the right leg at the level of the
thigh. Left leg has non-tense pitting edema to the thigh. Radial
pulses 2+, ___ and DP not appreciated in LLE. Decreased sensation
in foot/ankle. No tenderness to palpation, erythema, or warmth
in
the LLE.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. CN2-12 intact.
PSYCH: appropriate mood and affect
Discharge physical exam
=======================
24 HR Data (last updated ___ @ 1710)
Temp: 97.5 (Tm 98.6), BP: 134/73 (122-148/63-80), HR: 75
(65-75), RR: 18 (___), O2 sat: 95% (95-97), O2 delivery: RA,
Wt: 214.51 lb/97.3 kg
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Fine wheezes that clear with cough. No crackles. No
increased work of breathing.
ABDOMEN: Normal bowels sounds, distended but not tense abdomen,
non-tender to deep palpation in all four quadrants. No
organomegaly. Umbilical hernia that is reducible and non-tender
is present.
EXTREMITIES: Amputation of the right leg at the level of the
thigh. Left leg has tray edema to ankle.
Radial pulses 2+, ___ and DP not appreciated in LLE. Decreased
sensation in foot/ankle. No tenderness to palpation, erythema,
or
warmth in the LLE.
Pertinent Results:
Admisison labs
===============
___ 08:39AM PLT COUNT-246
___ 08:39AM BLOOD WBC-10.4* RBC-3.95* Hgb-8.9* Hct-31.0*
MCV-79* MCH-22.5* MCHC-28.7* RDW-18.1* RDWSD-51.8* Plt ___
___ 08:39AM BLOOD ___
___ 06:02AM BLOOD ___ PTT-46.4* ___
___ 08:39AM BLOOD Glucose-60* UreaN-72* Creat-2.9* Na-144
K-4.4 Cl-108 HCO3-24 AnGap-12
___ 08:39AM BLOOD proBNP-726
___ 08:39AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0
Discharge labs
===============
___ 06:21AM BLOOD WBC-10.9* RBC-4.29* Hgb-9.7* Hct-32.7*
MCV-76* MCH-22.6* MCHC-29.7* RDW-17.6* RDWSD-48.2* Plt ___
___ 06:21AM BLOOD ___ PTT-37.1* ___
___ 06:21AM BLOOD Glucose-207* UreaN-85* Creat-2.1* Na-139
K-5.1 Cl-94* HCO3-30 AnGap-15
___ 06:21AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
___ 06:04AM BLOOD calTI___ Ferritn-22* TRF-244
TTE ___
CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color
Doppler. The estimated right atrial pressure is ___ mmHg. There
is normal left ventricular wall thickness
with a normal cavity size. There is normal regional and global
left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 55 %
(normal 54-73%). There is no resting
left ventricular outflow tract gradient. Mildly dilated right
ventricular cavity with normal free wall
motion. The aortic sinus diameter is normal for gender. There is
a normal descending aorta diameter.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid regurgitation.
There is moderate pulmonary artery
systolic hypertension. There is systolic notching of the right
ventricular outflow tract/pulmonary artery
Doppler spectrum (Flying W sign) is present, suggesting a
significant precapillary component of right
ventricular outflow impedance.There is a trivial pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size, and
regional/global systolic function. Mild right ventricular cavity
dilation with normal systolic
function. Mild tricuspid regurgitation. Moderate pulmonary
artery systolic hypertension.
CXR ___
FINDINGS:
Lung volumes remain low. Cardiac, mediastinal and hilar
contours appear
stable. Very small pleural effusions are probably unchanged.
No visible
pneumothorax. Left perihilar opacity is mostly resolved. There
is still
slight asymmetry probably corresponding resolving infection, but
similar
bilateral opacities suggest mild pulmonary edema. Mild
atelectasis is similar
to somewhat increased in the lung bases.
IMPRESSION:
Findings suggest mild pulmonary edema. Mostly resolved
suspected left
perihilar pneumonia from the previous month. Findings CS mild
atelectasis
CXR ___
EXAMINATION: CHEST (PA AND LAT)
IMPRESSION:
Comparison to ___. Persistent small right pleural
effusion and
minimal left pleural effusion. Stable low lung volumes. On
today's
radiograph the patient shows signs of mild to moderate pulmonary
edema. Mild
cardiomegaly is present. Mild elongation of the descending
aorta.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
6. CARVedilol 25 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
9. Gabapentin 400 mg PO BID
10. Isosorbide Dinitrate 10 mg PO TID
11. Pantoprazole 40 mg PO Q24H
12. Tamsulosin 0.4 mg PO QHS
13. FoLIC Acid 1 mg PO DAILY
14. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
15. umeclidinium 62.5 mcg/actuation inhalation DAILY
16. Clopidogrel 75 mg PO DAILY
17. Senna 17.2 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
18. Warfarin 7.5 mg PO DAILY16
19. HydrALAZINE 100 mg PO TID
20. Torsemide 60 mg PO DAILY
21. linaGLIPtin 5 mg oral DAILY
22. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
23. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
24. Warfarin 10 mg PO 2X/WEEK ___ fib
25. Warfarin 7.5 mg PO 5X/WEEK ___ fib
26. Glargine 15 Units Dinner
Humalog 7 Units Dinner
Discharge Medications:
1. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
every other day Disp #*30 Tablet Refills:*0
2. HydrALAZINE 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
3. Glargine 18 Units Bedtime
Humalog 6 Units Dinner
4. Torsemide 100 mg PO DAILY
RX *torsemide 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
7. Allopurinol ___ mg PO DAILY
8. amLODIPine 10 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
11. CARVedilol 25 mg PO BID
12. Clopidogrel 75 mg PO DAILY
13. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
16. FoLIC Acid 1 mg PO DAILY
17. Gabapentin 400 mg PO BID
18. Isosorbide Dinitrate 10 mg PO TID
19. linaGLIPtin 5 mg oral DAILY
20. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
21. Pantoprazole 40 mg PO Q24H
22. Senna 17.2 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
23. Tamsulosin 0.4 mg PO QHS
24. umeclidinium 62.5 mcg/actuation inhalation DAILY
25. Warfarin 7.5 mg PO DAILY16
26. Warfarin 10 mg PO 2X/WEEK ___ fib
27. Warfarin 7.5 mg PO 5X/WEEK ___ fib
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Acute on Chronic HFpEF excerterbation
Chronic Obstructive Pulmonary Disease
Dysphagia
Chronic microcytic anemia
Asymptomatic bacteruria
Chronic Kidney Disease Stage IV
Paroxysmal Atrial fibrillation
Secondary diagnosis
===================
Diabetes Mellitus Type II
Peripheral Vascular Disease
Hyperlipidemia
Gastrointestinal Reflux Disease
Gout
Benign Prostatic Hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with SOB, tachypnea, hx CHF // ?acute
process,volume overload, consolidation
TECHNIQUE: Portable AP chest
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
Lung volumes are low. Small right pleural effusion remains. A superimposed
pneumonia would be difficult to exclude in the correct clinical context.
Bilateral interstitial opacities suggest mild pulmonary vascular congestion
and edema, similar to slightly improved compared to the prior examination.
The cardiomediastinal contours are unchanged.
IMPRESSION:
1. Redemonstration of a right pleural effusion. A superimposed pneumonia
would be difficult to exclude.
2. Mild pulmonary vascular congestion edema, similar to slightly improved
compared to the most recent prior examination of ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ male patient with a history of CHF, COPD, Afib onwarfarin,
CKD, and uncontrolled DM who presented with 1 weekhistory of acute on chronic
dyspnea that significantly worsened the last 2 days with concurrent URI
symptoms concerning for CHF exacerbation // rule out pneumonia rule out
pneumonia
IMPRESSION:
Comparison to ___. Persistent small right pleural effusion and
minimal left pleural effusion. Stable low lung volumes. On today's
radiograph the patient shows signs of mild to moderate pulmonary edema. Mild
cardiomegaly is present. Mild elongation of the descending aorta.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Wheezing
Diagnosed with Shortness of breath, Chronic obstructive pulmonary disease w (acute) exacerbation, Dyspnea, unspecified
temperature: nan
heartrate: 67.0
resprate: 26.0
o2sat: 100.0
sbp: 132.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | This is a ___ male patient with a history of CHF, COPD, Afib on
warfarin, CKD, and uncontrolled DM who presented with 1 week
history of acute on chronic dyspnea that significantly worsened
2 days prior to presentation with concurrent URI symptoms,
increased ___ edema and chest Xray notable for pulmonary edema
and pleural effusion concerning for Acute on chronic HFpEF
exacerbation.
===================
TRANSITIONAL ISSUES
====================
DISCHARGE WEIGHT: 97.3 kg (214.51 lb)
DISCHARGE Cr: 2.1
DISCHARGE DIURETIC: Torsemide 100mg daily
[] Patient's hydralazine was decreased from 100mg TID to 25mg
TID, please follow of blood pressure control in the outpatient
adjust dosage as needed.
[] Patient presented with elevated INR peaked to 4.3. His
warfarin was slowly restarted. Recommend close monitoring of his
INR and possible education on diet while on warfarin.
[] Due to elevated blood glucose levels, increased his glargine
to 18 units and added Humalog 6 units at lunch and dinner.
However discharged on only Humalog 6 units at dinner and
glargine 18 units due to concern for insulin administration.
Please follow-up outpatient and adjust insulin regiment as
needed.
[] Torsemide dose was changed to 100MG Daily. Of note patient
gets most of his home medications in blister packs from
pharmacy, but torsemide is not included in this. Please make
sure that he takes his torsemide daily and continue to monitor
volume status and adjust dose as needed.
ACUTE ISSUES
============
#Dyspnea on exertion
#Acute on chronic HFpEF exacerbation ( EF 55% ___
Patient presented with increasing dyspnea on exertion, exam
notable for lower extremity edema. Chest x-ray notable for
vascular congestion, history of HFpEF (last echo 63% in ___ managed primarily on carvedilol 25mg BID and torsemide
40mg daily increased from 20mg daily. Repeat echo ___,
noted EF 55%, Unclear trigger, likely due to medication changes
versus dietary indiscretions . Unclear baseline weight as
patient does not measure weight daily. His volume overload was
managed with IV Lasix 100mg BID and he was transitioned to
torsemide 100mg daily. After loaded reduction with reduced
hydralazine at 25MG TID and Isosorbide Dinitrate 10 mg PO/NG TID
and Neurohormonal blockage with carvedilol 25MG BID.
#Possible COPD Exacerbation
Noted to have URI symptoms of rhinorrhea, cough w/o change in
sputum, and sore throat prior. He had had some improvement with
nebulizer therapy since here, initially requiring 2L NC to
maintain
saturation 88-92%. Chest X-ray without pulmonary process;
however, there is a right sided pleural effusion. He was
initially started on prednisone 40mg and azithromycin.Given low
suspicion of COPD excertabtion azithromycin and prednisone were
stopped. He was quickly weaned to RA on the flow. He was managed
with DuoNebs Q6H PRN and Albuterol Neb Q4H:PRN. Continued home
fluticasone-salmeterol inhaler BID and fluticasone propionate
nasal spray daily. His Umeclidinium inhaler held due to
non-formulary and restarted on discharge.
#Dysphagia
States that he has a history of dysphagia and has been seen by
speech and swallow as an outpatient. Has an episode of choking
about once every three months, usually manages by chopping up
food small and eating slowly. Felt SOB with the event but
quickly back to baseline. No episodes of dysphasia today.
Consulted speak and swallow, recommended diet: Soft/thin
Medications: Whole as tolerated and Aspiration Precautions:1:1
supervision with all PO.
#Chronic microcytic anemia.
Patient could potentially have underlying iron deficiency.
Unclear if patient has received iron supplementation in the
past. Likely component of CKD also contributing. Repeat iron
studies notable for iron of 29, TIBC 217, Ferritin of 22 and
Transeferrin 244. He received IV Iron X1 prior to discharge and
discharged on oral iron supplements.
# DM II
Most recent documented prescription is 15U insulin glargine at
dinner or bedtime and 7U of Humalog at dinner, but the patient
is unsure if this is what he has been taking. It appears this
regimen was adjusted by ___ during his previous hospital stay
in ___. He also on linagliptin 5mg daily. Had elevated blood
sugars at lunch and dinner. Increased to 18U insulin glargine at
bedtime, Started 6 units Humalog at lunch and dinner, however we
stopped the lunch time insulin, we became aware that son, who
___ his insulin would be unable to give lunch dose. His
linagliptin was continued on discharge. Continue home gabapentin
400mg PO BID for peripheral neuropathy and phantom leg pain.
#Hypertension:
Home meds include: hydralazine 100 mg TID, Isosorbide dinitrate
10 mg TID, Carvedilol 25 BID, and amlodipine 10mg QD. His
hydralazine 100mg TID,was decreased to 25 mg TID, which was
sufficient to manage his blood pressures.
#Asymptomatic bacteruria.
Presented to ED 2 days prior to admission, UA notable for WBC
14, few bacteria, 30 protein, positive leukocyte Estrase but
negative nitrates. He was started on Cefpodoxime 200 ___ mg
for
10-day course. However patient denied any urinary symptoms,
except for polyuria which could be explained by his diuretics,
denies dysuria discharge or CVA tenderness. Antibiotics were
stopped and no new symptoms during the hospitalization.
#CKD stage IV (baseline Cr ___
Noted to gave elevated Cr of 2.9 on ___ felt likelya component
of cardio renal syndrome based his presenting volume overloaded
state. His creatine improved to baseline with diuretics. His
discharge creatine was 2.1
CHRONIC ISSUES
==============
#pAFib:(CHADS2VASc:5)
Previously on apixaban but switched to warfarin given renal
function. Sinus rhythm on admission. Presented with INR of 3.9,
which peaked to 4.3. His warfarin was initially held and slowly
restarted. Discharge INR at 3.3. He was given 4 mg of warfarin
prior to discharge.
# PVD:
S/P R right AKA (___) and left fem to ATA bypass with reversed
greater saphenous ___.
-Continued home clopidogrel 75 mg QDay
#Hyperlipidemia Continued home atorvastatin 80mg PO QPM
#GERD: Continued home pantoprazole 40 mg daily
#Gout: Continued home allopurinol ___ mg daily
#BPH: Continue home Tamsulosin 0.4 mg QD
Agree with hospital course as documented. 35 minutes spent on
discharge preparation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
"hopelessness and feeling sick"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with depression and
polysubstance use (IV meth) who presented to the ED with 1 day
of
fevers as well as increasing thoughts of suicidality.
History from patient is limited as he just got Benadryl in the
ED
for redman syndrome from vancomycin and is very drowsy.
He says he came to the ED because, "I was feeling hopeless and
feeling sick," he says.
He was feeling hopeless and wanted to kill himself. His plan was
to take a large amount of heroin. He has been feeling this way
for months. He has had 3 suicide attempts in the past, all by
overdose.
He also complained of generalized malaise and vomiting for about
a week. The emesis has been orange colored. The last episode was
about 24 hours ago. He says he is nauseated but is also asking
for food. He had subjective fevers for the past 1 day. He denies
diarrhea - he has not had a bowel movement for 1 week, which is
common for him because of the heroin and Suboxone he uses. No
dysuria. No unintentional weight loss.
He denies headache, visual changes. No chest pain, palpitations,
or shortness of breath. He denies back pain or joint
pain/swelling. His skin is "a mess," mostly from picking. He has
a lesion on his penis from "picking and having a lot of sex." He
only has female partners. He has had 2 partners in the last
month. He does not use protection.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
ED COURSE:
VS: Tmax 100, HR ___, BP 120s-150s/70s-80s, RR ___, SpO2
94-97% on RA
Exam: excoriations across bilateral lower extremities and penis,
lungs CTAB, no cardiac murmur, no stigmata of endocarditis, no
back tenderness
Labs: Normocyctic anemia, WBC wnl, plt wnl, CRP 77.1, Lactate
1.6, Utox positive for amphetamines, flu negative
Imaging: CXR clear
Interventions: acetaminophen 1000 mg PO, vancomycin 1500 mg IV
He developed Red Man syndrome to vanco and was given Benadryl
Past Medical History:
Major depressive disorder with prior suicide attempts
Polysubstance abuse
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION
VITALS: T 98.1, HR 73, BP 124/82, RR 14, SpO2 95% on RA
GENERAL: Drowsy but able to rouse, breathing room air
comfortably
EYES: Anicteric, PERRL
ENT: OP clear, mucous membranes slightly tacky
CV: NR/RR, no m/r/g. JVP not elevated.
RESP: CTAB, no wheezes or crackles.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: ~0.5 cm penile ulceration
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Scabs and excoriations over all limbs, no ___ lesions
___ nodes, no splinter hemorrhages
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: withdrawn
DISCHARGE
VS: 98.4 PO 118 / 71 52 18 95 RA
Gen - asleep, awakening to voice, then sitting up; comfortable
appearing
Eyes - EOMI, PERRL
ENT - OP clear, MMM
Ext - no edema
Skin - erythematous lesion on shaft of penis with clean borders;
now with overlying scab, improved in appearance; no exudate; no
other skin lesions
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate affect
Pertinent Results:
ADMISSION
___ 09:50AM BLOOD WBC-7.7 RBC-4.42* Hgb-12.9* Hct-38.3*
MCV-87 MCH-29.2 MCHC-33.7 RDW-13.2 RDWSD-41.0 Plt ___
___ 09:50AM BLOOD Glucose-102* UreaN-11 Creat-0.9 Na-135
K-3.7 Cl-95* HCO3-22 AnGap-18
___ 12:40PM BLOOD ALT-21 AST-32 AlkPhos-70 TotBili-0.4
CXR - ___
No evidence of acute cardiopulmonary process.
___ - BCx - WITHOUT GROWTH AT DISCHARGE
___ - Bcx - WITHOUT GROWTH AT DISCHARGE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DULoxetine 60 mg PO BID
Discharge Medications:
1. DULoxetine 60 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Nausea and vomiting secondary to viral enteritis
# Polysubstance abuse
# Major depressive disorder with suicidal ideation
# Penis rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fever, evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
There is no focal consolidation, pleural effusion, pulmonary edema, or
pneumothorax. The cardiomediastinal silhouette is within normal limits.
Platelike atelectasis is noted on the lateral viewed due to low lung volumes.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SI, Substance use
Diagnosed with Fever, unspecified
temperature: 100.0
heartrate: 103.0
resprate: 20.0
o2sat: 194.0
sbp: 153.0
dbp: 87.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ male past medical history of
majkor depressive disorder and polysubstance abuse admitted
___ with viral enteritis and suicidal ideation,
recommended for voluntary inpatient psychiatric admission,
course notable for patient expressing interest in suboxone
re-initiation, discharged to ___.
# Nausea and vomiting secondary to viral enteritis
Patient presented with several days of nausea and vomiting in
setting of malaise. Patient had a nonfocal abdominal exam and
labs were reassuring. He was felt to have viral enteritis and
was treated supportively with improvement in his symptoms over
___ days following admission. Blood cultures remained without
growth during his hospital course.
# Penis rash
Admitted with erythematous patch over shaft of penis. Patient
reported he thought it was related to friction from "too much
sex". He declined HIV testing. GC/chlamydia testing negative.
RPR negative. No vesicular component to suggest HSV. Patch
resolved without intervention--may have actually related to
friction. Counseled re: important of safe sex.
# Major depressive disorder with suicidal ideation
Patient reported worsening depression and suicidal ideation at
time of admission. He was seen by psychiatry service who
recommended voluntary inpatient psychiatric admission. Patient
was screened by BEST team and was subsequently discharged to
HRI. Continued home duloxetine.
# Polysubstance abuse
On admission patient reported recent use of multiple drugs,
including suboxone he had purchased illicitly. He had mild
opiate withdrawal symptoms including diaphoresis and anxiety,
treated symptomatically with clonidine. He reported previously
being prescribed suboxone, but not in recent years. He
expressed an interest in being initiated on this--before this
could be done, a psychiatric bed was identified. Would consider
suboxone initiation while at facility.
# Drug reaction
Developed "red man syndrome" in the ED while receiving IV
vancomycin. No respiratory issues. Resolved by the time
patient arrived on the floor. Antibiotics were not continued
given no indication.
Transitional issues
- Patient discharged to ___ for psychiatric treatment for
depression
- Patient previously on suboxone in the remote past; more
recently reported abusing opiates and buying suboxone illicitly;
this admission he expressed an interest in starting suboxone
treatment; please consider starting on suboxone with
coordination with his PCP's office
- Would consider HIV testing if patient will consent
> 30 minutes spent on this discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right foot and ankle infection
Major Surgical or Invasive Procedure:
___: Right Foot debridement with ___ metatarsal base
resection
History of Present Illness:
This is a ___ male who presents to the ED on ___
for a worsening infection of right foot. Patient is followed
closely by Dr. ___ for chronic ulcerations right foot.
Patient was last seen in clinic on ___ where it was noted
he has a right foot infection and was placed on PO Ciprofloxacin
and Bactrim. A culture was taken with preliminary cultures
growing GNR and GPC. Today, patient states there is an increased
redness to his wounds with overall malaise. Denies fever,
chills, nausea, vomiting, shortness of breath, chest pain.
Past Medical History:
- DM last HbA1c 6.7% ___
- HTN
- Basal Cell Skin CA
Social History:
___
Family History:
-Mother: DM, HTN
-Father: ___ CA
-___: MI
-MGF: Alzheimers
Physical Exam:
PHYSICAL EXAMINATION on admission:
VITAL SIGNS: T 98.5 HR 80 BP 148/77 RR 18 O2 100%RA
GENERAL: Well appearing, in no acute distress.
CARDIOVASCULAR: Well perfused lower extremities.
RESPIRATORY: No respiratory distress.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: Right lower extremity exam: DP and ___ pulses are
palpable. Capillary refill time is less than 3 seconds to all
digits. Erythema and edema noted to the right foot with minor
increased warmth. Protective sensation grossly diminished to
right foot, ulceration on the lateral aspect of the right fifth
metatarsal base with a deep central area probing. No fluctuance,
no purulence. Wound to lateral aspect right ankle with no
underlying fluctuance. Surrounding erythema and edema
surrounding both wounds.
PHYSICAL EXAMINATION on discharge:
VITAL SIGNS: AVSS
GENERAL: Well appearing, in no acute distress.
CARDIOVASCULAR: Well perfused lower extremities.
RESPIRATORY: No respiratory distress.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: Right lower extremity exam: DP and ___ pulses are
palpable. Capillary refill time is less than 3 seconds to all
digits. Surgical dressing in place. prior to surgical dressing
placement the incision to the lateral right foot was noted to
have intact sutures with no drainage or signs of infection.
Granular wound noted to the lateral aspect of the ankle with no
deep probing or signs of infection.
Pertinent Results:
___ 02:50PM GLUCOSE-153* UREA N-20 CREAT-1.3* SODIUM-130*
POTASSIUM-6.2* CHLORIDE-93* TOTAL CO2-19* ANION GAP-24*
___ 02:50PM estGFR-Using this
___ 02:50PM ALT(SGPT)-25 AST(SGOT)-47* ALK PHOS-115 TOT
BILI-0.2
___ 02:50PM ALBUMIN-4.7
___ 02:50PM CRP-9.9*
___ 02:50PM WBC-7.8 RBC-4.13* HGB-12.6* HCT-37.3* MCV-90
MCH-30.5 MCHC-33.8 RDW-12.2 RDWSD-40.4
___ 02:50PM NEUTS-78.0* LYMPHS-15.1* MONOS-5.9 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-6.05 AbsLymp-1.17* AbsMono-0.46
AbsEos-0.02* AbsBaso-0.02
___ 02:50PM PLT COUNT-283
Pertinent Imaging:
Right foot and ankle images: Ulcers along the lateral mid and
hindfoot are noted. There is bony destruction at the base of
the fifth metatarsal concerning for osteomyelitis. Also noted
is a fracture at the base of fifth metatarsal which appears
subacute. The lateral hindfoot is poorly visualized though no
definite signs of osteomyelitis seen.
Right ankle: Lateral soft tissue swelling with small ulceration
noted at the right ankle. No fracture, dislocation. Mortise is
symmetric. No convincing signs of osteomyelitis.
IMPRESSION:
Osseous destruction at the base of fifth metatarsal is
concerning for
osteomyelitis. No additional areas of osteomyelitis
definitively identified.
Medications on Admission:
1. amLODIPine 5 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Lisinopril 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
6. Aspirin 81 mg PO DAILY
7. Cal-Citrate (calcium citrate-vitamin D2) uncertain oral
DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Cal-Citrate (calcium citrate-vitamin D2) 1 tablet oral DAILY
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right foot infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with charcot of bilateral feet, now with R ankle and foot
ulcerations
COMPARISON: Prior right foot radiograph dated ___
FINDINGS:
Right foot: Ulcers along the lateral mid and hindfoot are noted. There is
bony destruction at the base of the fifth metatarsal concerning for
osteomyelitis. Also noted is a fracture at the base of fifth metatarsal which
appears subacute. The lateral hindfoot is poorly visualized though no
definite signs of osteomyelitis seen.
Right ankle: Lateral soft tissue swelling with small ulceration noted at the
right ankle. No fracture, dislocation. Mortise is symmetric. No convincing
signs of osteomyelitis.
IMPRESSION:
Osseous destruction at the base of fifth metatarsal is concerning for
osteomyelitis. No additional areas of osteomyelitis definitively identified.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old man s/p ___ met base resection // postop
COMPARISON: Right foot radiographs from ___.
FINDINGS:
Compared with ___ , the ossific fragment at the base of fifth
metatarsal as well as the proximal segment of the remaining portion of the
fifth metatarsal bone have been removed.
Otherwise, doubt significant interval change. Again seen is diffuse
osteopenia and varus angulation centered in the hindfoot, with deformity of a
distal talus and navicular bones, compatible or Charcot osteoarthropathy.
Scattered lucent foci are again noted in the second and third metatarsal
bones, possibly areas of more pronounced osteopenia. No cortical
transgression is identified in these areas.
Soft tissue swelling and subcutaneous emphysema is consistent with recent
surgery. A bandage is in place.
IMPRESSION:
Interval resection of the proximal portions of the fifth metatarsal bone. No
new fracture or dislocation detected.
Radiology Report
INDICATION: ___ year old man with known Charcot // surgical planning for
Charcot
TECHNIQUE: Contiguous helical MDCT images were obtained through the head
right foot and ankle without IV contrast. Multiplanar axial, coronal,
sagittal and thin section bone algorithm reconstructed images were generated.
Deformity of the midfoot limits optimal reconstruction in the coronal and
sagittal planes.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.8 s, 20.8 cm; CTDIvol = 14.1 mGy (Body) DLP = 293.3
mGy-cm.
Total DLP (Body) = 293 mGy-cm.
COMPARISON: Radiographs of the right foot ___.
FINDINGS:
The tibiotalar and subtalar joints are congruent with mild degenerative
change. There is severe degenerative change at the talonavicular joint with
bony fragmentation and flattening of the anterior talus (403b:64).
Nonweightbearing views are limited for assessment of the arch, however there
is apparent collapse of the transverse arch of the midfoot.
There is mild inferior subluxation of the cuboid in relation to the calcaneus
but no dislocation (403b:56). The fourth and fifth rays are inferiorly
subluxed relative to the first through third metatarsals but in line with the
cuboid. There is fragmentation of the anterior process of the calcaneus (403
b:63) but no evidence of acute fracture. The navicular-cuneiform
articulations are preserved, however the lateral cuneiform is inferiorly
subluxed relative to the navicular bone (401b:153).
There are postoperative changes surrounding the base of the fifth metatarsal
from previous resection. The margins of amputation are unremarkable. There
is expected postoperative edema and scattered locules of gas (403b:81). There
is mild degenerative change at the first metatarsophalangeal joint and an
incidentally noted bipartite tibial hallux sesamoid.
There is moderate subcutaneous edema about the ankle and foot. Vascular
calcifications are extensive. The distal Achilles tendon is intact with a
dorsal calcaneal enthesophyte. This study is limited for evaluation of the
tendons and ligaments about the ankle, however there is no tenosynovitis and
the imaged portions of the flexor, extensor and peroneal tendons are grossly
intact.
IMPRESSION:
1. Charcot foot with collapse of the transverse arch as detailed above.
2. Postoperative changes following resection of the base of the fifth
metatarsal.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval, R Foot pain
Diagnosed with Type 2 diabetes mellitus with foot ulcer, Cellulitis of right lower limb
temperature: 98.5
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 148.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | The patient was admitted to the podiatric surgery service after
presenting to the ED for a Right foot and ankle infection,
failing a course of PO antibiotics. On admission, he was started
on broad spectrum IV antibiotics.
Upon admission, the patient remained afebrile with stable vital
signs; pain was well controlled oral pain medication on a PRN
basis. The patient was taken to the operating room on ___
for right foot ___ met resection, 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 remained stable from both a cardiovascular and pulmonary
standpoint. He was placed on vancomycin, ciprofloxacin, and
flagyl while hospitalized and discharged with oral antibiotics.
His intake and output were closely monitored and noted to be
adequate. The patient received subcutaneous heparin throughout
admission; early and frequent ambulation were strongly
encouraged. the patient was seen by a member of the physical
therapy team who cleared the patient to return home non-weight
bearing to the right foot.
The patient was subsequently discharged to home on POD 1 with
oral antibiotics. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Prior to discharge the patient had a CT of the Right foot and
ankle for preoperative planning for reconstruction of the right
foot. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient with a h/o HLD presents with fevers and malaise after
recently returning from ___. She saw her PCP ___ ___ with
cough and fever to 102.6 x 1d. CXR at that time showed no acute
abnormality and rapid influenza was negative. At that time,
denied N/V or diarrhea. She returned to ___ ___ ___ for high
fevers (102.6 in PCP ___ and malaise. Of note, she went to
___ mid ___ returned to ___ ___. She started
feeling sick after one week in ___ with complaints of high
fevers, abdominal pain and diarrhea. Notes no sick contacts in
___. Diarrhea is improving, though patient attributed this to
decreased PO intake. She had a watery stool yesterday after
drinking apple juice. She has a productive cough. She also
endorses feeling dizzy when she stands up and intermittent
headache when she coughs. She has no neck pain or stiffness and
myalgias but no arthritis. No sob, chest pain or wheezing. No
nausea or vomiting. She was referred to ___ ED by her PCP.
In the ED, initial vitals were: 101.9 80 124/80 28 98% RA. Her
labs were significant for a white count of 2.4 (5.7 on ___,
H/H 13.2/40 (13.3/40.1) and a platelet count of 64 (268 on
___. She also had elevated ALT to 51 (15 in ___, AST to
125, and lipase to 95. Her PTT was 43.3, INR 1.1.
On the floor, she is resting comfortably and states that she is
feeling better now that her fever has come down. She states that
her abdominal pain is intermittent and is improved by ___.
Diarrhea is improving. No joint pain. +headache.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Obesity
Hyperlipidemia
___ Adenoma
Social History:
___
Family History:
Maternal Aunt - ___
Mother - ___ CVA
Sister - ___ Cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:99.6 BP:104/59 P:71 R:18 O2:98/RA
General: Alert, oriented, mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, +submandibular lymphadenopathy
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
Neuro: PEERL. AOx3
DISCHARGE PHYSICAL EXAM:
VS: 98.6 ___ 70 100% RA
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation, no w/r/r
HEART: RRR, no m/r/g
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP
NEURO: awake, A&Ox3
Pertinent Results:
-------------------
ADMISSION LABS ___:
-------------------
WBC-2.5* RBC-4.65 Hgb-12.1 Hct-36.9 MCV-79* MCH-26.1* MCHC-33.0
RDW-13.2 Plt Ct-64*
Neuts-26* Bands-9 Lymphs-50* Monos-7 Eos-1 Baso-0 Atyps-7*
___ Myelos-0
Hypochr-1+ Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL
Microcy-1+ Polychr-NORMAL
___ PTT-43.3* ___
Glucose-124* UreaN-7 Creat-0.7 Na-134 K-3.4 Cl-99 HCO3-24
AnGap-14
Albumin-3.0* Calcium-7.7* Phos-2.3* Mg-1.8
Lactate-1.1
-------------------
URINE ___:
-------------------
Color-Yellow Appear-Clear Sp ___
Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
RBC-<1 WBC-4 Bacteri-FEW Yeast-NONE Epi-1 CastHy-4*Mucous-RARE
-------------------
OTHER HEME LABS:
-------------------
___ ___
-------------------
HEPATITIS SEROLOGIES:
-------------------
___ IgM HAV-NEGATIVE
___ HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV
Ab-POSITIVE
___ HCV Ab-NEGATIVE
-------------------
CV LABS:
-------------------
___ 07:40AM BLOOD Triglyc-203*
LFT trend:
___ ALT-51* AST-125*
___ ALT-43* AST-81*
___ ALT-44* AST-83*
___ ALT-128* AST-277*
___ ALT-139* AST-178*
-------------------
MICRO:
-------------------
- Parasite smear negative x2
- Malaria Ag negative
- Hep A IgM-/IgG+
- HBsAg-/HBsAb+/HBcAb-
- HCV Ab negative
- HIV negative, VL undetectable
- EBV VCA-IgG Ab+ / EBNA IgG Ab + / VCA IgM negative / EBV PCR
___
- Monospot negative
- CMV IgM-/IgG+, VL undetectable
- Dengue Fever IgG 10.11 (positive) / Dengue Fever IgM 0.86
(negative)
- Chikungunya Ab IgM negative, IgG negative
- Blood Culture (___): negative
- Urine Culture (___): negative
- Stool Culture (___): negative
-------------------
Imaging:
-------------------
# US Liver & Gallbladder: Normal examination of the liver. The
liver does not appear enlarged on ultrasound.
-------------------
DISCHARGE LABS:
-------------------
___ WBC-5.5 RBC-4.48 Hgb-11.9* Hct-35.5* MCV-79* MCH-26.5*
MCHC-33.4 RDW-15.1 Plt ___
___ Glucose-97 UreaN-6 Creat-0.7 Na-139 K-4.8 Cl-102
HCO3-26 AnGap-16
___ ALT-139* AST-178* LD(LDH)-484* AlkPhos-56 TotBili-0.8
___ Calcium-9.1 Phos-4.0 Mg-2.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
Discharge Medications:
1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
2. Ciprofloxacin HCl 500 mg PO/NG Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*13 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: viral infection, neutropenia,
thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with fevers, thrombocytopenia, leukopenia, and
worsening transaminitis // ?hepatomegaly, infiltrate
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. Main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: The gallbladder is contracted without evidence of stones.
PANCREAS: Imaged portion of the pancreas appears heterogenous, but is within
normal limits, without masses or pancreatic ductal dilation, with portions of
the inferior head and distal pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.1 cm.
KIDNEYS: The right kidney measures 12.1 cm. The left kidney measures 10.4 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Normal examination of the liver. The liver does not appear enlarged on
ultrasound.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Fever, Cough
Diagnosed with FEVER, UNSPECIFIED, LEUKOCYTOPENIA, UNSPECIFIED
temperature: 101.9
heartrate: 80.0
resprate: 28.0
o2sat: 98.0
sbp: 124.0
dbp: 80.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ female with recent travel to
___ who presented with high fevers and diarrhea and was found
to have neutropenia and thrombocytopenia. Her fevers and
diarrhea resolved over the course of her hospitalization as did
her neutropenia and thrombocytopenia. Workup consistent with
viral syndrome. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Demerol / morphine / hydrocodone / erythromycin base /
Penicillins / nadolol / Iodinated Contrast Media - IV Dye /
Furadantin / radiopaque dye / Artificial Tears / latex / sodium
chloride / mependine / Macrobid
Attending: ___
Chief Complaint:
low back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ with h/o CAD, HTN, A. fib on Coumadin,
chronic back pain who presented to OSH for lower back pain and
was transferred for further evaluation of T12 compression
fracture. Pt is currently delirious and tells me
that she came into the hospital because "a horse knocked her
down," therefore history is obtained primarily from ___ and
___ records and from speaking with her daughter who is a ___
and also her HCP. The pts sxs started about 10 days ago when
she was seen at ___ for LBP. She was admitted there and
ultimately discharged on tramadol for pain. A few days later
she went for a steroid injection as an outpatient. Just prior
to this admission she stood up and had twisted her body and
developed severe ___ acute lower back pain, prompting her to
call an ambulance for evaluation at the ___. She denied
stool incontinence, numbness/weakness in lower extremities,
fever. Her daughter does not think that she fell prior to this
admission however she has had falls in the past. Her daughter
tells me that the patient attributed the pain to "downsizing".
She has no history of dementia/delerium/confusion. Of note,
records indicate that the pt has a chronic indwelling foley
however on talking with the pts daughter, she states that this
is not true. Pt did endorse 2 episodes of urinary incontinence
on arrival to the ED.
While at ___ a CT L-spine showed acute compression fracture
of T12 and L1 compression fracture deformity without significant
change. Severe spinal stenosis at L3-L4. She was transferred to
___ for neurosurgical eval.
In the ___ ED, initial vitals were: 98.4 90 156/74 16 96% RA.
Labs were notable for creatinine of 1.5, lactate of 1.8, INR
1.9.
Head CT showed no acute process. Pt was seen by psychiatry for
delirium and ultimately required multiple doses of Seroquel,
haldol and Lorazepam for agitation. She was also seen by spine
and ___ who recommended against surgery, TLSO brace for comfort,
rehab placement. She was given lidocaine patch,
cyclobenzaprine, Tylenol, ketorolac, home medications of
acyclovir, amlodipine,
amiodarone, losartan, pravastatin, gabapentin, furosemide.
On the floor, she states back pain is about ___. She has no
new complaints. She is able to recount some of her medications
however is hypervigilant and tangential, unable to recount
details of why she came to the hospital.
Past Medical History:
CAD, s/p CABG of LAD in ___
___
afib on Coumadin
HTN
Glaucoma
s/p cataract surgery
trigeminal neuralgia
HLD
myelodysplaia
essential thrombocytosis
schatzki ring
hysterectomy
GERD
ocular herpes c/b corneal abrasion
cataracts
Social History:
___
Family History:
HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.4 ___
Constitutional: Agitated, hypervigilant, confused
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, ___ SEM, no rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: Foley in place draining clear urine
EXT: Warm, well perfused, no CCE
NEURO: aao to person only. Unable to do full neuro exam due to
agitation although CNII-XII and strength grossly intact
SKIN: large bruise on R back, cluster of 4 crusted lesion on R
upper back, several crusted lesions on face
MSK: no pain on palpation of lumbar spine
DISCHARGE PHYSICAL EXAM:
========================
afebrile, 162/69 60 sat well on RA, BED WEIGHT (not standing) is
127.4 lbs
pleasant, NAD
MMM
JVP flat
RRR, II/VI SEM best at RUSB with radiation to R carotid,
preserved S2
CTAB
sntnd
wwp, neg edema
A&Ox3, DOWB intact, EOMI, slight R>L anisocoria, R pupil
reactive but sluggish (h/o B cataracts), L pupil normally
reactive, B consensual response, ___ BUE, 4+/5 R hip flexion (pt
reports ___ pain) otherwise ___ BLE, SILT BUE/BLE except chronic
R plantar numbness, downgoing toes bilaterally, 2+ patellar DTRs
___ Results:
ADMISSION LABS:
===============
___ 11:38AM BLOOD WBC-4.9 RBC-3.31* Hgb-12.2 Hct-34.9
MCV-105* MCH-36.9* MCHC-35.0 RDW-13.8 RDWSD-52.8* Plt ___
___ 11:38AM BLOOD ___ PTT-28.2 ___
___ 11:38AM BLOOD Glucose-111* UreaN-47* Creat-1.5* Na-142
K-4.9 Cl-99 HCO3-25 AnGap-18
___ 11:38AM BLOOD ALT-20 AST-39 AlkPhos-39 TotBili-0.5
___ 11:38AM BLOOD Albumin-4.2 Calcium-9.4 Phos-4.0 Mg-2.3
___ BLOOD CULTURE PENDING
___ URINE cx neg final
IMAGING:
========
___ CXR
No focal consolidation.
CT non con head
FINDINGS:
Some of the images were repeated due to motion artifact on the
initial scan. There is no evidence of acute hemorrhage, edema,
mass effect, or acute major vascular territorial infarction.
Periventricular, deep, and subcortical white matter
hypodensities are nonspecific, however likely due to chronic
small vessel ischemic disease in this age group. There is
moderate global parenchymal volume loss with prominent
ventricles and sulci, likely age-related.
No concerning bone lesion is seen. Aerosolized secretions are
seen in a right middle ethmoid air cell. There is trace
opacification of left mastoid tip air cells. There is evidence
of bilateral cataract surgery.
IMPRESSION:
No evidence acute intracranial abnormalities. MRI would be more
sensitive for an acute infarction, if clinically warranted.
DISCHARGE LABS:
===============
___ 09:40AM BLOOD WBC-4.7 RBC-3.13* Hgb-11.6 Hct-32.5*
MCV-104* MCH-37.1* MCHC-35.7 RDW-14.3 RDWSD-54.0* Plt ___
___ 06:34AM BLOOD ___ PTT-25.6 ___
___ 09:40AM BLOOD Glucose-183* UreaN-23* Creat-0.9 Na-144
K-4.6 Cl-109* HCO3-22 AnGap-13
___ 09:40AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Fenofibrate 54 mg mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU BID
5. Furosemide 20 mg PO DAILY
6. Gabapentin 100 mg PO TID
7. Hydroxyurea 500 mg PO DAILY
8. Losartan Potassium 50 mg PO BID
9. Nitroglycerin Patch 0.1 mg/hr TD Q24H
10. Pravastatin 20 mg PO QPM
11. timolol 0.5 % ophthalmic (eye) BID
12. Warfarin 1.25 mg PO 3X/WEEK (___)
13. Warfarin 2.5 mg PO 4X/WEEK (___)
14. Acyclovir 400 mg PO Q12H
15. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
16. Vitamin D 1000 UNIT PO DAILY
17. Metoprolol Succinate XL 25 mg PO DAILY
18. TraMADol 50 mg PO TID:PRN Pain - Moderate
19. Calcium Carbonate 500 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Lidocaine 5% Patch 1 PTCH TD QAM lbp
RX *lidocaine 5 % Apply 1 patch to painful area of back once
daily Disp #*30 Patch Refills:*0
4. Senna 8.6 mg PO BID
5. Losartan Potassium 25 mg PO BID
6. Acyclovir 400 mg PO Q12H
7. Amiodarone 200 mg PO DAILY
8. amLODIPine 10 mg PO DAILY
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
10. Calcium Carbonate 500 mg PO BID
11. Fenofibrate 54 mg mg PO DAILY
12. Fluticasone Propionate NASAL 2 SPRY NU BID
13. Gabapentin 300 mg PO QHS
14. Hydroxyurea 500 mg PO DAILY
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Nitroglycerin Patch 0.1 mg/hr TD Q24H
17. Pravastatin 20 mg PO QPM
18. timolol 0.5 % ophthalmic (eye) BID
19. TraMADol 50 mg PO TID:PRN Pain - Moderate
20. Vitamin D 1000 UNIT PO DAILY
21. Warfarin 1.25 mg PO 3X/WEEK (___)
22. Warfarin 2.5 mg PO 4X/WEEK (___)
23. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until instructed by your doctors
___:
Extended Care
Facility:
___
Discharge Diagnosis:
# T12 compression fracture
# Acute renal failure
# Urinary retention
# Agitated delirium
# Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with new confusion// pna?cva?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
Left chest wall dual-chamber cardiac pacer, multiple mediastinal cerclage
wires and mediastinal surgical clips are noted.The lungs are clear without
focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac
and mediastinal silhouettes are unremarkable. Sclerotic focus in the left
humeral head, partially imaged in obscured by the overlying marker likely
represents an enchondroma.
IMPRESSION:
No focal consolidation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with new confusion. Cerebrovascular accident?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Some of the images were repeated due to motion artifact on the
initial scan. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 1.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
2) Sequenced Acquisition 7.0 s, 14.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
702.4 mGy-cm.
3) Sequenced Acquisition 1.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
Some of the images were repeated due to motion artifact on the initial scan.
There is no evidence of acute hemorrhage, edema, mass effect, or acute major
vascular territorial infarction. Periventricular, deep, and subcortical white
matter hypodensities are nonspecific, however likely due to chronic small
vessel ischemic disease in this age group. There is moderate global
parenchymal volume loss with prominent ventricles and sulci, likely
age-related.
No concerning bone lesion is seen. Aerosolized secretions are seen in a right
middle ethmoid air cell. There is trace opacification of left mastoid tip air
cells. There is evidence of bilateral cataract surgery.
IMPRESSION:
No evidence acute intracranial abnormalities. MRI would be more sensitive for
an acute infarction, if clinically warranted.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lower back pain, Transfer
Diagnosed with Low back pain, Abnormal coagulation profile, Fall on same level, unspecified, initial encounter, Chest pain, unspecified
temperature: 98.4
heartrate: 90.0
resprate: 16.0
o2sat: 96.0
sbp: 156.0
dbp: 74.0
level of pain: 2
level of acuity: 3.0 | ___ is an ___ year old woman with no prior
neuropsychiatric history, with CAD, AF (on warfarin), AS and
hypertension, who presented with back pain secondary to a T12
compression fracture, found to have urinary retention, ___ as
well as agitated delirium.
ACTIVE ISSUES
# low back pain: due to compression fractures. Pt was evaluated
by neurosurgery in the ED who advised no acute surgical
intervention. Given the lack of any other spinal signs or
symptoms (despite urinary retention), as well as CT findings,
they recommended no indication for MRI (pt also has pacemaker).
She has minimal chronic R foot numbness which is unchanged and
minimal R hip weakness ___ pain otherwise no deficits. A TLSO
brace was offered for comfort. She will follow up with spine as
outpatient. Pain was reasonably controlled with home gabapentin
and standing acetaminophen and lidocaine patch. Tramadol was
held as below given delirium and because it could have caused
urinary retention as below. ___ saw and recommended rehab.
# ___: Last creatinine on record was 1.2 ___. Likely
combination of pre-renal and ___ urinary retention. Cr
downtrended with holding ___, gentle IVF, resolved to
0.9 on discharge and downtrending. Resumed lower dose losartan
as below. PVR not pathologically elevated thereafter.
# toxic metabolic encephalopathy
# delirium:
Multiple potential causes of delirium include pain, pain
medications, urinary retention, ___, medications (e.g.
tramadol), hyperNa. No s/s of infection currently. Pt received
several doses of Haldol and olanzapine in ED, as well as Ativan.
Per ED, Ativan worked well. LFTs/TSH/Ca/Mg/phos/UCx wnl.
Resolved with above mgmt.
# urinary retention: pt retaining >1 L on arrival to the floor,
___ placed as pt unlikely to tolerate straight cath in setting
of delirium. While this could be a sign of cord compression,
her exam is otherwise reassuring and it seems more likely that
this is related to medications (? tramadol given that she had a
single dose prior to admission). UA negative for infection.
Foley removed promptly and urinated well, PVR was minimal.
# AS: unclear severity per family, chronic. BP control as below,
held furosemide as above. Euvolemic on discharge.
# Afib: currently rate controlled, continued home amiodarone,
metoprolol. Continued home warfarin but gave a single extra dose
of 1mg warfarin on ___.
# ocular herpes: cont acyclovir
# mild hypernatremia: resolved with IVF
# CAD s/p CABG remotely: continued nitro patch, metop, BP mgmt.
# HTN: continued home amlodipine, initially held losartan in
setting ___ but now resolved and resumed and uptitrating.
Changed to 25mg po BID on ___ from QD with BP in low 160s
systolic, anticipate will require uptitration in coming days.
# HLD: cont statin, fenofibrate
# essential thrombocytosis: cont home hydroxyurea
# glaucoma: cont brimodine and timolol eye drops
> 30 minutes spent on patient care and coordination on day of
discharge
Anticipate <30 day stay at rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lipitor
Attending: ___.
Chief Complaint:
malaise
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ p/w ILI (fever, myalgia, cough, dyspnea, diarrhea) for the
past 5 days. She has had associated decreased PO. Multiple
family memebers living with her have had similar symptoms.
On arrival to the ED, T 100.2, HR 144 (afib), BP 103/70, 18, 97%
on RA. Influenza A positive. Labs notable for normal WBC, H/H
11.7/33.4. INR 2.9. Chem panel notable for K 3.1, BUN 9, Cr
0.5. Trop <0.01, lactate 1.6. CXR without evidence of
consolidation or pulmonary edema. UA benign.
While in the ED, BP dropped transiently to 80/42, though repeat
BP with cuff on the leg was 107/56. She received 2.5L NS,
oseltamivir, metoprolol 5mg IV x1, and potassium chloride. Her
vital signs did not change significantly, but she had
improvement in her symptoms. She then received home metoprolo
tartrate 50mg daily and was admitted to the ICU for further
manegemen given transient hypotension and continued tachycardia
On arrival to the MICU, pt. reports feeling significantly
better. HR 80 (sinus), BP 101/63, RR 18, SpO2 98% on RA.
Past Medical History:
1. Sick sinus syndrome, status post DDD pacemaker.
2. Paroxysmal atrial fibrillation.
3. Diabetes.
4. Hypertension.
5. Osteoporosis
6. Hypothyroidism
7. Diastolic heart failure
8. Aortic aneurysm
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Admission Exam:
Vitals- HR 80, BP 101/63, RR 18, SpO2 98% on RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Occasional expiratory wheeze throughout; no crackles
CV: Regular rate and rhythm,distant heart sounds
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ DP, no edema
Discharge Exam:
Vitals- 98.6 133/80(110-140/60-70) 69(60-70s) 18 97% on RA
Tele: HR ___
GENERAL: pleasant, ___ speaking elderly woman, obese,
comfortable, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: lungs now ctab, no wheezing, no crackles
CV: Regular rate and rhythm, distant heart sounds
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ DP, no edema
NEURO: AOx3. CN II-XII intact. Moving all extremities.
Pertinent Results:
LABS:
___ 04:30AM BLOOD WBC-8.8 RBC-4.19* Hgb-11.7* Hct-33.4*
MCV-80*# MCH-27.8 MCHC-34.9 RDW-14.5 Plt ___
___ 06:30AM BLOOD WBC-6.2 RBC-3.48* Hgb-9.4* Hct-28.8*
MCV-83 MCH-26.9* MCHC-32.6 RDW-14.8 Plt ___
___ 03:45PM BLOOD WBC-9.9# RBC-3.59* Hgb-10.0* Hct-29.6*
MCV-83 MCH-28.0 MCHC-33.9 RDW-14.5 Plt ___
___ 04:30AM BLOOD Neuts-65.0 ___ Monos-6.4 Eos-0.3
Baso-0.3
___ 04:30AM BLOOD ___ PTT-43.0* ___
___ 06:30AM BLOOD ___ PTT-43.0* ___
___ 04:30AM BLOOD Glucose-111* UreaN-9 Creat-0.5 Na-138
K-3.1* Cl-101 HCO3-23 AnGap-17
___ 11:25AM BLOOD Glucose-98 UreaN-6 Creat-0.4 Na-142 K-3.9
Cl-113* HCO3-20* AnGap-13
___ 06:30AM BLOOD Glucose-100 UreaN-6 Creat-0.5 Na-139
K-3.4 Cl-106 HCO3-23 AnGap-13
___ 04:30AM BLOOD ALT-13 AST-23 AlkPhos-52 TotBili-0.3
___ 04:30AM BLOOD cTropnT-<0.01
___ 04:30AM BLOOD proBNP-1323*
___ 06:30AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.7
___ 04:30AM BLOOD Albumin-3.5
___ 04:34AM BLOOD Lactate-1.6
___ 06:19AM URINE Color-Straw Appear-Hazy Sp ___
___ 06:19AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:40AM OTHER BODY FLUID FluAPCR-POSITIVE
FluBPCR-NEGATIVE
IMAGING:
CXR ___: Low lung volumes without pulmonary edema or focal
consolidation
EKG:
In ED: afib with RVR
On arrival to MICU: sinus rhythm, HR 70, left axis, AV
conduction delay
Discharge labs:
___ 04:56PM BLOOD WBC-8.8 RBC-3.67* Hgb-9.7* Hct-30.2*
MCV-82 MCH-26.4* MCHC-32.0 RDW-14.4 Plt ___
___ 06:00AM BLOOD Glucose-108* UreaN-12 Creat-0.5 Na-138
K-3.9 Cl-105 HCO3-26 AnGap-11
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dofetilide 250 mcg PO Q12H
2. Furosemide 40 mg PO QAM
3. Furosemide 20 mg PO QPM
4. Gabapentin 300 mg PO QPM
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO BID
8. Metoprolol Tartrate 50 mg PO BID
9. Oxybutynin 5 mg PO HS
10. Pravastatin 20 mg PO DAILY
11. Warfarin 5 mg PO 2X/WEEK (MO,FR)
12. Enablex (darifenacin) 15 mg Oral qPM
13. Warfarin 7.5 mg PO 5X/WEEK (___)
Discharge Medications:
1. Dofetilide 250 mcg PO Q12H
2. Furosemide 40 mg PO QAM
3. Gabapentin 300 mg PO QPM
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Oxybutynin 5 mg PO HS
6. Pravastatin 20 mg PO DAILY
7. Warfarin 5 mg PO 2X/WEEK (MO,FR)
8. Warfarin 7.5 mg PO 5X/WEEK (___)
9. Enablex (darifenacin) 15 mg Oral qPM
10. MetFORMIN XR (Glucophage XR) 500 mg PO BID
11. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
12. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
13. Docusate Sodium 100 mg PO BID
14. Ferrous Sulfate 325 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Acetaminophen 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis:
influenza
atrial fibrillation
secondary diagnosis:
Sick Sinus Syndrome s/p permanent pacemaker
diastolic CHF
diabetes mellitus, type 2
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 shortness of breath, evidence of
pneumonia.
TECHNIQUE: Frontal chest radiographs were obtained with the patient in the
upright position.
COMPARISON: Radiograph from ___.
FINDINGS:
There is bibasilar atelectasis with low lung volumes crowding the
bronchovascular markings. There is no focal consolidation or pulmonary edema.
The heart is enlarged, and a left cardiac device is in stable position with
its leads projecting over the right atrium and ventricle.
IMPRESSION:
Low lung volumes without pulmonary edema or focal consolidation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with influenza, dCHF, no consolidation on CXR.
now with afib w/ rvr to 120-130s. // eval for interval change, pulmonary
edema, new consolidation.
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Pacemaker leads terminate in the expected location of right atrium and right
ventricle. Cardiomegaly is substantial, unchanged. Interstitial opacities in
the perihilar and lower lobes are concerning for mild interstitial pulmonary
edema. Two-view right basal consolidation has slightly increased in the
interim most likely due to progression of the edema but underlying infection
is a possibility and assessment after diuresis is recommended
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: ILI
Diagnosed with FLU W RESP MANIFEST NEC, ATRIAL FIBRILLATION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, HYPOTHYROIDISM NOS, LONG TERM USE ANTIGOAGULANT
temperature: 100.2
heartrate: 144.0
resprate: 18.0
o2sat: 97.0
sbp: 103.0
dbp: 70.0
level of pain: 13
level of acuity: 1.0 | Ms. ___ is an ___ w/ history notable for SSS s/p PPM,
afib on coumadin, dCHF, and DM2 who presents with malaise and
fever found to be flu positive with ED course c/b afib with RVR
and intermittent hypotension. Continued to have several episodes
of afib with RVR which resolved prior to discharge. She
converted back to NSR and was on room air, and normotensive.
Treating with oseltamivir for a five day course.
# Afib with RVR: Noted in the ED but resolved on arrival to the
ICU. RVR likely in setting of flu and hypovolemia. On arriving
from the MICU to ___ 2, she was in afib with RVR, HR to 160s.
Chest pain free, no palpitations (had not received 8pm meds
prior to callout from MICU). Asymptomatic, not short of breath.
O2 sat stable. Continued to go in and out of afib with RVR and
HR ___. Repeat CXR showed mild increase in pulmonary edema.
Metoprolol increased to 37.5mg q6h. RVR resolved, HR ___ for
>24hours prior to discharge. Discharged on metoprolol succinate
150mg daily. CHADS2 of 4 so continued on anticoagulation. Held
warfarin for INR 4.1, restarted ___.
# Hypotension: Resolved. Baseline SBPs 120s-130s. In MICU and on
floor SBP 88-100s, likely secondary to infection as well as
increase in metoprol dose. Asymptomatic. Pt appeared hydrated on
exam and began taking PO. Held lisinopril 10mg daily for
hypotension, did not restart on discharge. Restarted morning
dose of home lasix 40mg PO prior to discharge. Was initially
held for hypotension. Did not restart 20mg lasix PO evening
dose. Should follow up outpatient for further heart rate and
blood pressure monitoring.
# Influenza A: Symptoms started 5 days ago, but given ICU
admission treated with oseltamivir nonetheless. No e/o bacterial
superinfection, no focal consolidation on CXR. Sputum culture
was contaminated. Oseltamivir was initiated on ___ with intent
to treat for 5 days. Although the patient has no documented
history of asthma/COPD, she was wheezy on exam and was given
nebulizers periodically. Improved respiratory status, afebrile.
Oseltamivir x5days (Day 1 = ___, Day 5 = ___.
# Hypothyroidism: Levothyroxine was continued.
# DM2: Metformin was held while inpatient and pt was placed on
an insulin sliding scale. Metformin restarted on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: assault to face
nasal bridge laceration - repaired
nasal septum fracture
Left superior orbit hematoma
Major Surgical or Invasive Procedure:
suturing of laceration left side of nose
History of Present Illness:
This patient is a ___ year old male who complains of
ASSAULT. Patient was brought in by EMS from scene after he
was assaulted in his driveway, reportedly was punched kicked
and struck with a bottle in the head. There was a reported 2
minutes loss of consciousness. He was then alert for her EMS
although somewhat combative, no concern for language
barrier. He denies any abdominal or chest pain.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 99.8 HR: 107 BP: 114/67 Resp: 20 O(2)Sat: 97 Normal
Constitutional: Constitutional: Comfortable, No acute
distress, A+O x 3
Head/Eyes: Significant left-sided facial swelling,
periorbital ecchymosis, 2 cm laceration over her medial
aspect of left thigh, actively bleeding, no loose teeth,
midface stable, no obvious ptosis, pupils reactive
bilaterally.
ENT/Neck: No midline tenderness
Chest/Resp: NO chest wall tenderness or crepitus, bilateral
breath sounds
Cardiovascular: Regular rate and rhythm
GI/Abdominal: Soft, nontender, nondistended
GU/Flank: No Costovertebral angle tenderness
Musculoskeletal: No deformity
Skin: No abrasions, lacerations, ecchymosis
Neuro: GCS 15, spontaneously moves all extremities to
command
Psych: Normal mood
Pertinent Results:
___ 12:43AM BLOOD WBC-6.3 RBC-5.07 Hgb-14.1 Hct-40.2
MCV-79* MCH-27.8 MCHC-35.1* RDW-14.1 Plt ___
___ 12:43AM BLOOD Plt ___
___ 12:43AM BLOOD ___ PTT-28.6 ___
___ 12:43AM BLOOD ___ 04:39AM BLOOD Glucose-88 UreaN-11 Creat-1.0 Na-138
K-3.8 Cl-101 HCO3-29 AnGap-12
___ 12:43AM BLOOD UreaN-17 Creat-1.0
___ 04:39AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0
___ 12:43AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:49AM BLOOD freeCa-1.14
___: chest x-ray:
IMPRESSION: Low lung volumes. Otherwise, unremarkable chest
radiographic examination. Of note, this study is suboptimal for
the assessment of rib fractures and if there is clinical
concern, dedicated rib views should be performed.
___: cat scan of the head:
1. No evidence of acute intracranial injury.
2. Partially visualized facial fractures and soft tissue
injuries. Please
refer to the concurrent facial bone CT report for further
detail.
___: cat scan of the c-spine:
No cervical spine fracture or malalignment.
___: cat scan of sinus and mandible:
1. Comminuted bilateral nasal bones and nasal septum fractures,
as well as nondisplaced fracture of the anterior nasal spine of
the maxilla.
2. Large left preseptal periorbital hematoma and a small
postseptal,
extraconal hematoma in the superomedial left orbit, with
involvement of the superior rectus and superior oblique muscles,
and inferolateral displacement of the left globe. No orbital
fracture. Ophtalmology consultation is recommended.
3. Comminuted fracture of the posterolateral left maxillary
sinus wall. This finding was not included in the preliminary
report; it was communicated by Dr. ___ to Dr. ___ from
surgery on ___ at 10:04 am over the telephone.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
7 day course, last dose ___
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every twelve (12) hours Disp #*13 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
avoid driving while on this medication, may cause drowsiness
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: hit in face
nasal bridge laceration - repaired
nasal septum fracture
Left superior orbit hematoma
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 assault with loss of consciousness.
Evaluate for pneumothorax or any other evidence of trauma in the chest.
COMPARISON: None available.
TECHNIQUE: Frontal supine chest radiograph.
FINDINGS: Assessment is limited due to artifact from trauma board. Allowing
for these limitations, the lung volumes are low, without focal opacities.
Cardiomediastinal and hilar contours are unremarkable. There is no pleural
effusion or pneumothorax. No rib fractures are identified. A normal bowel
gas pattern is seen.
IMPRESSION: Low lung volumes. Otherwise, unremarkable chest radiographic
examination. Of note, this study is suboptimal for the assessment of rib
fractures and if there is clinical concern, dedicated rib views should be
performed.
Radiology Report
HISTORY: Status post trauma after assault with loss of consciousness
COMPARISON: None available.
TECHNIQUE: Axial contiguous MDCT images were obtained through the head
without administration of IV contrast. Coronal, sagittal, and thin slice bone
reformations were generated. DLP: 1282.15 mGy-cm
FINDINGS: Some of the images were repeated due to motion on the initial scan.
There is no acute intracranial hemorrhage, edema, mass effect, or loss of
gray-white matter differentiation. The sulci, ventricles and basal cisterns
are normal in size and configuration.
There is no calvarial fracture. Left periorbital hematoma, bilateral nasal
bone fractures, nasal septum fracture, left maxillary sinus posterior wall
fracture, and fluid in the left maxillary sinus are partially visualized,
better seen on the concurrent facial bone CT. There is blood in the left
frontal sinus. There is mucosal thickening, and fluid or blood, in bilateral
ethmoidal air cells. There is a focus of secretions or globular mucosal
thickening in the anterior left sphenoid sinus. Mastoid air cells are clear.
IMPRESSION:
1. No evidence of acute intracranial injury.
2. Partially visualized facial fractures and soft tissue injuries. Please
refer to the concurrent facial bone CT report for further detail.
Radiology Report
HISTORY: ___ male with trauma after assault and loss of
consciousness.
TECHNIQUE: Axial helical MDCT images were obtained from the skull base to the
level of T1 without administration of IV or oral contrast. Coronal, sagittal
and thin slice bone reformations are generated. DLP: 693.23 mGy-cm
COMPARISON: None.
FINDINGS:
There is no acute fracture, malalignment or prevertebral soft tissue swelling.
Minimal depression of the superior anterior corner of the vertebral body of C5
has associated sclerosis and appears chronic. There are chronic non-united
fractures of the spinous processes of T1 and T2 with sclerotic margins. Disc
space heights are preserved, and the outline of the thecal sac is grossly
unremarkable, within the limitations of CT.
The imaged lung apices are clear. Left maxillary sinus posterolateral wall
fracture is partially visualized; concurrent head and facial bone CTs are
reported separately.
IMPRESSION:
No cervical spine fracture or malalignment.
Radiology Report
HISTORY: ___ male status post facial trauma with loss of
consciousness
COMPARISON: None available
TECHNIQUE: Axial helical MDCT images were obtained through the paranasal
sinuses and mandible and without administration of IV contrast. Coronal and
sagittal reformations were generated.
DLP: 779 mGy-cm.
FINDINGS:
There are bilateral, extensively comminuted nasal bone fractures with
rightward deviation of main distal fragments. There is a minimally displaced
fracture through the anterior nasal spine of the maxilla. There is a
comminuted nasal septum fracture. The nasal septum is deviated to the right
anteriorly and to the left posteriorly.
There is a communited fracture of the posterolateral wall of the left
maxillary sinus, with a free fragment displaced into the sinus. There is a
small amount of fluid in the left maxillary sinus, presumably blood, though
insufficient in amount for density measurements.
There is a large hematoma overlying the left orbit, maxilla and mandible. With
the regard to the orbit, there is a large preseptal hematoma and a small
postseptal, extraconal hematoma in the superomedial aspect of the orbit,
displacing the left globe inferolaterally. The globe is intact. The left
superior rectus and superior oblique muscles are thickened, suggesting edema
and/or hematoma. There is no orbital fracture or zygomatic arch fracture.
The mandible and the maxillary alveolar ridge appear intact.
There is blood in the left frontal sinus. There is mucosal thickening, and
fluid or blood, in bilateral ethmoidal air cells. There is a focus of
secretions or globular mucosal thickening in the anterior left sphenoid sinus.
Ostiomeatal units are narrowed by mucosal thickening but not occluded. There
are secretions in the nasopharynx. The imaged mastoid air cells are clear.
Concurrent head and cervical spine CTs are reported separately.
IMPRESSION:
1. Comminuted bilateral nasal bones and nasal septum fractures, as well as
nondisplaced fracture of the anterior nasal spine of the maxilla.
2. Large left preseptal periorbital hematoma and a small postseptal,
extraconal hematoma in the superomedial left orbit, with involvement of the
superior rectus and superior oblique muscles, and inferolateral displacement
of the left globe. No orbital fracture. Ophtalmology consultation is
recommended.
3. Comminuted fracture of the posterolateral left maxillary sinus wall. This
finding was not included in the preliminary report; it was communicated by Dr.
___ to Dr. ___ from surgery on ___ at 10:04 am over the telephone.
Radiology Report
FACIAL BONE CT WITHOUT CONTRAST, ___
INDICATION: Status post assault with left orbital septal injury. Please
perform thin cuts to assess for an orbital fracture.
COMPARISON: Facial bone CT performed earlier today on ___.
TECHNIQUE: Axial non-contrast multidetector CT images of the facial bones
were obtained and displayed with 1.25-mm slice thickness. Sagittal and
coronal reformatted images were generated with 1-mm slice thickness.
FINDINGS: Extensive left periorbital preseptal soft tissue swelling is again
noted. The previously noted small post-septal, extraconal hematoma in the
superomedial aspect of the left orbit has decreased in extent and conspicuity.
The superior rectus and superior oblique muscles no longer appear overtly
thickened. Previously noted inferolateral displacement of the left globe has
decreased in conspicuity. The left globe is intact. No orbital fracture is
seen. There is no zygomatic arch fracture. A comminuted fracture of the
posterolateral wall of the left maxillary sinus, with a free fracture fragment
mildly depressed into the sinus, is again seen. Small amount of blood in the
left maxillary sinus has decreased. Mild mucosal thickening now remains
present in the left maxillary sinus.
Bilateral comminuted nasal bone fractures are again seen, with rightward
angulation of distal fracture fragments. A comminuted fracture of the nasal
septum is also again seen. The nasal septum is deviated to the right
anteriorly and to the left posteriorly, as before. A non-displaced fracture
through the anterior nasal spine of the maxilla is also again seen.
Again seen is a large hematoma overlying the left maxilla and mandible. There
is no mandibular fracture and no fracture of the maxillary alveolar ridge.
Fluid and blood is again seen in the left frontal sinus. Mucosal thickening
is again seen in bilateral ethmoidal air cells. There is persistent mild
mucosal thickening in the left sphenoid sinus, but the previously noted focus
of secretions in its anterior aspect, has resolved. The imaged mastoid air
cells and middle ear cavities are well aerated.
IMPRESSION:
1. Large left preseptal periorbital hematoma is unchanged. Small
post-septal, extraconal hematoma in the superomedial left orbit has decreased,
and the superior rectus and superior oblique muscles no longer appear overtly
edematous/thickened. No orbital fracture is seen.
2. Unchanged appearance of comminuted bilateral nasal bone fractures,
comminuted nasal septum fracture, and nondisplaced fracture of the anterior
nasal spine of the maxilla.
3. Unchanged appearance of the comminuted fracture of the left posterolateral
maxillary sinus wall.
Gender: M
Race: OTHER
Arrive by UNKNOWN
Chief complaint: ASSAULT
Diagnosed with NASAL BONE FX-CLOSED, ASSAULT NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient was admitted to the hospital after he was assaulted.
The patient reportedly was punched, kicked and struck with a
bottle in the head. There was a reported 2 minutes loss of
consciousness. Upon admission to the hospital, the patient was
made NPO, given intravenous fluids, and underwent imaging. Cat
scan images of the head and neck were normal. The patient was
reported to have a bilateral nasal bone and nasal septum
fracture, as well as nondisplaced fracture of the anterior nasal
spine of the maxilla. He was also reported to have a left
preseptal periorbital hematoma and a postseptal, extraconal
hematoma in the superomedial left orbit, with involvement of the
superior rectus and superior oblique muscles, and inferolateral
displacement of the left globe. No orbital fracture was
identified. Because of his injuries, the ophthalmology was
consulted and after ocular examination of the patient
recommended orbital cat scan to assess the extension of the
postseptal hematoma. The postseptal hematoma remained unchanged
and there was no orbital fracture.
The patient was placed on sinus precautions because of his
injuries and had ice pack applied to the swellling on the left
side of his face. He was started on a 1 week course of augmentin
per recommendations of the Plastic surgery service. Since there
was no indication for surgery, the patient was started on clears
and advanced to a regular diet. His vital signs remained stable
and he was afebrile. He received oral analgesia for management
of his pain. He was placed on sinus precautions. He was seen by
the Social worker who provided support to both him and his
family. Because of his loss of consciousness, he was evaluated
by the occupational therapist who made recommendations for
outpatient cognitive evaulation. Patient was kept in the
hospital for ophthalmology re-evaluation, but left AMA, before
being re-evalated and before receiving discharge instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
BRBPR and abdominal pain for 1 day
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with no significant PMH who presents with
BRBPR and abdominal pain for 1 day. The only change in her
health that she noticed in the last few days was that she was
passing more gas than usual. Otherwise, she was in her usual
state of health until midnight when she woke up with cramping
hypogastric abdominal pain, nausea, cold sweats and had a normal
bowel movement. She then proceeded to have up to 10 bowel
movements throughout the night, and the stool transitioned from
solid to soft and then watery, and then around 3:30 AM she began
to have blood and pass blood clots. She had substantial blood in
the toilet (she had photo documentation). She had ___ total
bloody bowel movements, her last bloody bowel movement was at
9:30 AM, and she has not had any passing of gas or blood or
bowel movement since that time. She saw her PCP this morning,
who did a rectal exam which was positive for blood and then sent
her to the ED.
She has had no fevers, recent antibiotic use, sick contacts, new
food exposures, or recent travel. She has never had abnormal
bowel movements (consistently 1 BM every other day, normal size
and consistency), pain with defecation, or prior GI bleeding.
She has never had visual changes, joint pains or effusions, or
rashes.
In the ED, her vitals were T 97.2, HR 68, BP 135/72, RR 16 and
O2 sat 100% RA. Patient was given 1 L NS and IV morphine and
Zofran.
Her labs were notable for WBC of 12.7 with 85% PMN predominance,
Hg 12.6, Hct 39.7, Plt 259, normal ___ PTT and INR 1.0, lactate
of 1.0, and Chem 7 within normal limits. Pregnancy test was
negative. UA with + ketones, RBC 6, WBC 3. Urine and blood
culture sent and pending.
Her CT abd and pelvis with contrast showed significant wall
thickening and pericolonic stranding involving the left colon,
suggesting infectious or inflammatory colitis, and less likely
ischemic colitis given sparing of sigmoid and rectum.
Past Medical History:
-Hemorrhoids after pregnancies, protrudes when she strains.
Social History:
___
Family History:
Father has an ulcer, HTN and cholesterol in the family.
No bleeding disorders, UC/Crohn history, or autoimmune disorders
that she is aware of.
Physical Exam:
ADMISSION EXAM
Vitals: T 98.4 BP 146/74 HR 70 RR 18 O2 sat 100% RA Pain ___
General: Appears uncomfortable and dry heaving in bed
HEENT: Extraocular movements intact, pupils equal and reactive
to light, moist mucous membranes, throat without erythema or
lesions
Lymph: Shotty lymph nodes in anterior cervical chain and
supraclavicular chain
CV: Normal S1 and S2, RRR, no murmurs/rubs/gallops
Lungs: Equal chest rise bilaterally, CTAB, no wheezing/rhonchi
Abdomen: Bowel sounds present but diminished, abdomen
nondistended, tender to light palpation in the hypogastric
region, but nontender to light or deep palpation in other
regions. No rebound tenderness/guarding.
Ext: No edema or swelling, normal tone and range of movement of
lower extremity joints
Neuro: Alert and oriented x3
Skin: No rashes, bruises, or lesions
DISCHARGE EXAM
Vitals: T 98.8 BP 118/47 (SBP 95-120, DBP 35-60) HR 71 RR 16 O2
sat 100% RA
General: Appears comfortable, lying in bed
HEENT: Extraocular movements intact, moist mucous membranes
CV: Normal S1 and S2, RRR, no murmurs/rubs/gallops
Lungs: Equal chest rise bilaterally, CTAB, no
wheezing/rhonchi/crackles
Abdomen: Bowel sounds diminished, abdomen nondistended, no
tenderness to light palpation, tender to deep palpation in the
hypogastric region. No rebound tenderness/guarding.
Ext: No edema or swelling, normal tone and range of movement of
lower extremity joints
Neuro: Alert and oriented x3
Skin: No rashes, bruises, or lesions
Pertinent Results:
ADMISSION LABS ___
WBC 12.7 Hgb 12.6 Hct 39.7 Plt 259 MCV 90
Neutrophils 85.4% lymphs 10.0% monos 4.0% eosinophils 0.2%
Na 137 Cl 104 BUN 5 Glucose 95 AGap=17
K 4.6 HCO3- 21 Cr 0.7
___ 11.4 PTT 34.7 INR 1.0
Glucose 95 Urea 5 Cr 0.7 HCO3 21 Anion gap 17
Beta-hcg <5
Lactate 1.0
UA color yellow, clear, ___ >1.050, Ketone 10, pH 6.5 Leuks
neg Nitrite neg RBC 6 WBC 3 Bacteria none yeast none
DISCHARGE LABS ___
WBC-7.6 RBC-3.75* Hgb-10.9* Hct-35.3 MCV-94 MCH-29.1 MCHC-30.9*
RDW-12.8 RDWSD-44.2 Plt ___
___ PTT-33.8 ___
Glucose-79 UreaN-5* Creat-0.6 Na-139 K-3.5 Cl-105 HCO3-25
AnGap-13
ALT-8 AST-13 LD(LDH)-126 AlkPhos-43 TotBili-1.4
Albumin-4.0 Calcium-8.8 Phos-2.8 Mg-2.1
OTHER LABS
___ 07:05AM BLOOD CRP-13.9*
___ 07:05AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.0
MICROBIOLOGY
C dif DNA amplification assay negative
EHEC O157:H7 Vibrio Yersenia and Stool culture (Campylobacter,
Salmonella, shigella) pending
Urine culture: Mixed bacterial flora consistent with skin and/or
genital contamination
Blood culture pending
IMAGING
CT ABD & PELVIS WITH CONTRAST ___ impression (per
radiology):Acute colitis involving the descending colon.
Differential considerations
include infectious or inflammatory colitis.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
primary: colitis; likely infectious.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Followup Instructions:
___
Radiology Report
INDICATION: ___ with diffuse abd pain and BRBPR // eval ? colitis, enteritis
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: 100 mL Omnipaque. Coronal and
sagittal reformations were performed and reviewed on PACS. Oral contrast was
not administered.
DOSE: Total DLP (Body) = 550 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver enhances homogeneously. Punctate hypodensity in
segment 6 is too small to characterize (02:24). There is no intra or
extrahepatic biliary duct dilation. The gallbladder is normal.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is
circumferential wall thickening, hyperemia and pericolonic stranding involving
the left colon. No evidence of perforation or pneumatosis. The sigmoid and
rectum appear to be spared. 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 is unremarkable. There is a 1.9 cm right
corpus luteal cyst (2:63). The left ovary appears normal. There is small
amount of 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.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Acute colitis involving the descending colon. Differential considerations
include infectious or inflammatory colitis.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: BRBPR, Abd pain
Diagnosed with Noninfective gastroenteritis and colitis, unspecified
temperature: 97.2
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 135.0
dbp: 72.0
level of pain: 5
level of acuity: 2.0 | ___ year old lady with ?hx of hemorrhoids presents on ___
after one day of ___ episodes of BRBPR and abdominal pain in the
past day.
#COLITIS:
Her clinical presentation, physical exam, labs, and imaging were
consistent with both infectious and inflammatory colitis. Once
she arrived on the floor, she remained afebrile with normal and
stable vitals. She had 3 more episodes of diarrhea, and each
episode was less bloody, and stool was sent for cultures for
detection of possible C. Dif, Campylobacter, Salmonella,
Shigella, Vibrio, Yersenia, or E. Coli O157:H7. Stool cultures
were negative for C. dif, and other stool cultures are still
pending.
Gastroenterology was consulted in order to help differentiate
between infectious vs inflammatory colitis, and to determine
whether any further work-up or procedures like a colonoscopy was
needed. Gastroenterology felt that her presentation was most
consistent with an infectious process, and recommended following
up her H&H, which trended from 12.6 to 10.1 to 10.9 during her
course, following up on stool cultures, and scheduling an
outpatient appointment with them in ___ weeks to see if symptoms
have resolved.
Ms. ___ was hemodynamically stable and clinically improved by
the time of discharge. She was tolerating a normal diet, having
less bowel movements, exhibiting less tenderness to palpation,
and had a stabilized H&H and downtrending WBC by 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:
Seizures, coffee ground emesis
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with PMHx of ICH c/b seizures, depression/anxiety, early
onset dementia and ETOH abuse who lives ___ long term care
facility (___) transferred given seizure.
Per report patient had several seizures within a short period of
time at his ___ facility not responsive to IM benzos. EMS was
called. Upon arrival patient was still actively seizing (normal
FSBS) and had episode of vomiting coffee ground emesis. There
were no reports of medication non-adherence. He was taken to
___.
Upon arrival to ___ patient was non-verbal. Examination
was notable for tonic R eye deviation with blinking initially.
Labs were notable for Hgb 10.9, WBC 6.7, ABG 7.30/55/135, Cr
0.8, Negative UA, VPA level 39.8 uG/mL.
Patient was intubated for airway protection. Intubation was not
reported to be traumatic. While at ___, Hgb decreased to
9.1. OG tube returned about 200cc of coffee grounds so he was
transfused 1 unit pRBC and given IV PPI.Stool was guiac
negative. CT Head was negative for acute bleed or shift of
midline. For ongoing seizures, he was treated with propofol,
phenobarbital load, and AEDs. He was given an additional Keppra
load (60/kg). ___ total he received 4mg LZP, 1000mg Keppra, 500mg
Fosphenytoin, 500mg of Valproate, and1819.5mg of phenobarbital.
He was started on At this time he was transferred to ___.
___ ED initial VS: 33, 100/59, 13, 100% Intubation
Labs significant for: Cr 0.7, Hgb 10.6, Plt 253, INR 0.9, UTox
positive for benzos, barbs, and opiates and serum tox positive
for barbs, Lipase 22, VBG 7.41/36, Lactate 1.8
Patient was given: CTX, Propofol and Levophed
Imaging notable for: CXR showing ETT, NGT, Left subclavian and
mild bibasilar opacities most likely due to atelectasis, small
component of aspiration is not excluded.
Consults: Neurology and GI
- Neurology: Recommended cEEG, infectious work up, antibiotics,
continuation of AEDs and reloading with VPA.
VS prior to transfer: 97.8, 62, 144/79, 20, 100% intubated
On arrival to the MICU, patient is intubated and sedated.
Withdrawing lower extremities to painful stimuli.
Of note patient had a similar presentation ___ and ___
when he presented from ___ facility with multiple seizures
refractory to Ativan management, requiring re-loading of AEDs.
Trigger for each seizure event thought either due to medication
non-compliance, medication underdosing or reduced seizure
threshold ___ the setting of infection (PNAs).
REVIEW OF SYSTEMS: Per HPI
Past Medical History:
- Hypertension
- Asthma
- Epilepsy
- History of ICH, with residual left parietal infarct
- History of alcohol abuse
- Generalized anxiety disorder
- Dementia, early onset
- Thrombocytopenia
Social History:
___
Family History:
Not obtained.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, ETT ___
place
NECK: left subclavian central line ___ place
LUNGS: Mechanical breath sounds
CV: Bradycardic, regular
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
NEURO: Intubated, sedated, withdrawing lower extremities to pain
DISCHARGE PHYSICAL EXAM:
========================
General: alert, A+Ox2
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: Somewhat limited as patient not consistently following
commands. Face symmetric, EOMI. Moving all 4 extremities. Gait
not assessed.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:00PM BLOOD WBC-9.1 RBC-4.24* Hgb-10.6* Hct-32.8*
MCV-77* MCH-25.0* MCHC-32.3 RDW-17.4* RDWSD-48.4* Plt ___
___ 10:00PM BLOOD ___ PTT-26.4 ___
___ 04:02AM BLOOD Glucose-126* UreaN-9 Creat-0.7 Na-139
K-4.0 Cl-103 HCO3-24 AnGap-12
___ 04:02AM BLOOD ALT-14 AST-16 LD(LDH)-131 AlkPhos-54
TotBili-0.3
___ 02:54AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.7
___ 10:00PM BLOOD ASA-NEG Ethanol-NEG Carbamz-<2*
Acetmnp-NEG Bnzodzp-NEG Barbitr-POS* Tricycl-NEG
___ 10:32PM BLOOD pO2-85 pCO2-36 pH-7.41 calTCO2-24 Base
XS-0
___ 10:32PM BLOOD Glucose-133* Lactate-1.8 Na-136 K-4.3
Cl-104
___ 10:32PM BLOOD Hgb-11.4* calcHCT-34 O2 Sat-95 COHgb-2
MetHgb-0
PERTINENT INTERVAL LABS:
========================
___ 04:02AM BLOOD Phenyto-8.1* Valproa-47*
___ 02:54AM BLOOD Phenyto-8.4* Valproa-46*
___ 04:07AM BLOOD Phenyto-8.9* Valproa-40*
IMAGING/STUDIES:
================
## CXR ___
Endotracheal tube terminates 5.7 cm above the carina. Enteric
tube courses below the diaphragm, out of the field of view. Left
PICC terminates ___ the proximal SVC. Mild bibasilar opacities
most likely due to atelectasis, small component of aspiration is
not excluded.
## ___ EGD:
- Normal duodenum
- Grade C esophagitis ___ the distal esophagus
- Erosions ___ the stomach body
MICROBIOLOGY:
=============
___ 3:03 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
THIS IS A CORRECTED REPORT (___).
___ PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
PREVIOUSLY REPORTED AS (___).
___ PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by ___ 10:34 ON
___.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
ACINETOBACTER BAUMANNII. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
STAPH AUREUS COAG +. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
ASPERGILLUS FUMIGATUS COMPLEX. RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GuaiFENesin ER 600 mg PO BID:PRN cough
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
3. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
4. Lactulose 30 mL PO DAILY:PRN constipation
5. LORazepam 1 mg IM Q2HRS seizures
6. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First Line
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Ipratropium-Albuterol Neb 1 NEB NEB Q8H
9. LevETIRAcetam 1250 mg PO BID
10. Phenytoin Infatab 200 mg PO BID
11. amLODIPine 5 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Divalproex (DELayed Release) 1000 mg PO BID
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days
Through ___
2. Pantoprazole 40 mg PO BID
3. Valproic Acid ___ mg PO Q6H
4. GuaiFENesin ___ mL PO Q6H:PRN cough
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. amLODIPine 5 mg PO DAILY
8. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Lactulose 30 mL PO DAILY:PRN constipation
11. LevETIRAcetam 1250 mg PO BID
12. LORazepam 1 mg IM Q2HRS seizures
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Phenytoin Infatab 200 mg PO BID
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis
- Seizure
Secondary Diagnosis
- Epilespy
- Aspiration pneumonia
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 (PORTABLE AP)
INDICATION: History: ___ with intubated*** WARNING *** Multiple patients with
same last name!// eval tube
TECHNIQUE: Single frontal view of the chest
COMPARISON: Earlier today, ___ at 20:46
FINDINGS:
Endotracheal tube terminates 5.7 cm above the carina. Enteric tube courses
below the diaphragm, out of the field of view. Left-sided PICC terminates in
the proximal SVC. Mild bibasilar opacities are most likely due to
atelectasis, small component of aspiration is not excluded. No focal
consolidation seen elsewhere. There is no pleural effusion or pneumothorax.
The cardiac mediastinal silhouettes are unremarkable.
IMPRESSION:
Endotracheal tube terminates 5.7 cm above the carina.
Enteric tube courses below the diaphragm, out of the field of view.
Left PICC terminates in the proximal SVC.
Mild bibasilar opacities most likely due to atelectasis, small component of
aspiration is not excluded.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with seizures, intaubted for airway protection//
ETT placement ETT placement
IMPRESSION:
Compared to chest radiographs ___.
ET tube in standard placement. Esophageal drainage tube passes into the
stomach and out of view. Left central venous catheter ends at the origin of
the SVC.
Previous pulmonary vascular congestion has improved. There is no pulmonary
edema. Moderate bibasilar peribronchial opacification has improved on the
right, stable on the left. This could be due to recent aspiration. No
pneumonia in the upper lungs. No appreciable pleural effusion or evidence of
pneumothorax.
Radiology Report
EXAMINATION: AP portable chest radiograph.
INDICATION: ___ year old man with ICH and seizures s/p intubation// r/o PNA,
lines/tubes
TECHNIQUE: AP portable chest radiograph
COMPARISON: Reference made to the prior portable chest radiograph dated ___ at 13:50 as well as multiple priors dating back to ___.
FINDINGS:
In comparison to the prior radiograph dated ___ at 13:50, the lungs
remain clear without focal consolidation. Trace right basilar opacities
likely represent atelectasis. The pulmonary vasculature is within normal
limits. There is no large pleural effusion. There is no pneumothorax.
Endotracheal tube terminates 4.1 cm above the carina. A left central venous
catheter ends in the proximal SVC. An enteric tube courses below the level of
the diaphragm before disappearing from view.
IMPRESSION:
1. In comparison to the prior radiograph dated ___, the lungs remain
clear without focal consolidation or large pleural effusion.
2. Monitoring and support devices are in unchanged in appropriate position.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with ICH and seizures admitted with coffee ground
emesis and seizure; now with new OGT placement// please eval placement of OGT
IMPRESSION:
In comparison with the earlier study of this date, the there has been
placement of a new orogastric tube with the tip extending to the antrum.
Otherwise, little overall change.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with encephalopathy, seizures. Concern for
structural lesion.// Structural lesions to explain encephalopathy
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.
FINDINGS:
There is no evidence of acute hemorrhage, edema, masses, mass effect, midline
shift or acute infarction. Encephalomalacia and chronic blood products in the
left posterior parietal lobe is compatible with chronic infarct or prior
parenchymal hemorrhage. There is no abnormal enhancement after contrast
administration. The ventricles, cerebral sulci, and basal cisterns are normal
in size for age. There are small foci of high T2 signal in the subcortical,
deep, and periventricular white matter of the cerebral hemispheres, which are
nonspecific but may be related to sequela of chronic small vessel ischemic
disease in a patient of this age.
Major arterial flow voids are grossly preserved. Mucosal thickening and near
complete opacification of the bilateral maxillary sinuses is visualized as
well as mild mucosal thickening of the left ethmoidal air cells. Otherwise
the visualized paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormalities or acute infarcts.
2. Changes of encephalomalacia and chronic blood products in the left parietal
lobe could be related to prior infarcts or previa parenchymal hemorrhage.
3. No abnormal enhancement is seen.
4. Sequelae of probable chronic small vessel ischemic disease.
Radiology Report
EXAMINATION: SKULL APANDLAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING
INDICATION: ___ year old man with MR SCREENING// MR SCREENING MR
SCREENING
TECHNIQUE: Lateral view of the skull, frontal view of the neck, frontal view
of the chest, abdomen and pelvis were obtained
COMPARISON: None
FINDINGS:
No radio-opaque foreign body is detected over the orbits. The skull and
paranasal sinuses are unremarkable. The upper cervical spine is well aligned.
There are no radiodense foreign bodies projecting over the soft tissues of the
neck. The lungs are clear with no focal consolidation, pleural effusion or
pneumothorax. The size of the cardiac silhouette is within normal limits.
There are no abnormally dilated loops of bowel within the abdomen or pelvis.
IMPRESSION:
No radio-opaque foreign body is detected over the skull, neck, chest, abdomen
or pelvis.
Radiology Report
EXAMINATION: Video oropharyngeal swallow
INDICATION: ___ year old man with swallowing difficulty// swallow
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: Less than 5 minutes.
COMPARISON: None
FINDINGS:
There was no gross aspiration or penetration.
IMPRESSION:
Normal oropharyngeal swallowing videofluoroscopy.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Seizure, Transfer
Diagnosed with Epilepsy, unsp, not intractable, with status epilepticus, Urinary tract infection, site not specified, Gastrointestinal hemorrhage, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | ___ with PMHx of ICH c/b seizures, depression/anxiety, early
onset dementia and ETOH abuse who lives ___ long term care
facility (___) transferred intubated given
breakthrough seizures.
# ICH C/B RECURRENT SEIZURES
# BREAKTHROUGH SEIZURE
Reported breakthrough seizures again at ___, not responsive to
IV Ativan, eventually responsive after phenobarb load,
intubation/sedation with propofol and re-loading of AEDs.
Etiology of breakthrough seizures suspected to be lowering of
threshold due to infection (PNA) vs. GI bleed. No acute process
on ___. Pt was loaded with VPA x2. Levels of VPA noted to be
slightly low - per neurology, this is expected as phenytoin
inhibits VPA. Also loaded with phenytoin x2 with improvement of
levels. Discharged on valproic acid ___ q6H as well as home
Keppra and Phenytoin. MRI head showed old blood and chronic
small vessel changes, no acute infarcts. Recommend follow-up
with outpatient neurology to discuss regimen further.
# COFFEE GROUND EMESIS
# UGIB
Coffee grounds noted on OGT at ___. Hgb 10 stable from
past admission value from ___ without further evidence of
active GIB. Evaluated with EGD which showed gastritis,
esophagitis for which he was treated with PPI. Will need repeat
EGD ___ 8 weeks.
# HYPOTENSION
Admitted requiring low dose levophed, likely sedation related
given no need prior to intubation. Unlikely hemorrhagic given
stable Hgb. Unlikely distributive/septic given afebrile, normal
WBC and no reported infectious symptoms. Lactate normal. Pressor
requirement resolved after extubation/stopping sedation.
# ACUTE HYPOXIC RESPIRATORY FAILURE
# VAP/ASPIRATION PNA
Intubated ___ the setting of breakthrough seizures, inability to
protect airway, with CXR unable to r/o aspiration. High risk for
aspiration based on past admissions. Noted to have acinetobacter
___ sputum. Hypoxia resolved with treatment. Continue Augmentin
875mg q12H for 7 days for PNA (through ___.
TRANSITIONAL ISSUES:
======================
- Discharged on valproic acid ___ q6H as well as home Keppra
and Phenytoin.
- Recommend follow-up with outpatient neurology to discuss
regimen further.
- MRI final read was pending on discharge and should be
followed-up as outpatient.
- Discharged on PPI. Should have repeat EGD ___ 8 weeks (GI will
schedule)
- Continue Augmentin 875mg q12H for 7 days for PNA (through
___.
- Should f/u with outpatient epileptologist as phenytoin and VPA
inhibit each other so difficult to get levels therapeutic.
- Recommend chest XR 4 weeks after antibiotic course to assure
resolution given acinetobacter
# Communication: HCP is his brother, ___, ___.
# Code: Full, presumed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Acetaminophen / aspirin
Attending: ___.
Chief Complaint:
Diarrhea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with a history of celiac sprue, and T1DM c/b
retinopathy and R eye blindness, neuropathy, and ESRD s/p LRRT
from her brother (___) on MMF and tacro who presents with 2
days
of diarrhea and vomiting.
She had acute onset of vomiting and diarrhea waking her from
sleep early in the morning the day prior to admission. She has
also had watery diarrhea which has been decreasing in frequency.
No blood that she has noticed although she has poor color
vision.
No fevers, chills, or rigors. No sick contacts. She has not
eaten
anything unusual or eaten out recently. She did have a cup of
coffee the day prior to onset of her symptoms that tasted
strange
and later learned that the milk was expired so is not sure if
that is the cause of her symptoms.
She also has dyspnea which she has had since starting
immunosuppression. No cough or chest pain.
Past Medical History:
- CKD stage IV, possibly ___ DM1, s/p living donor related
transplant in ___
- recurrent UTIs
- DM1 (dg ___ with nephropathy, neuropathy, retinopathy
- Legally blind ___ diabetic retinopathy and lost right eye ___
- glaucoma
- DLD
- HTN
- Depression
- Bulimia
- celiac
- genital herpes
Social History:
___
FAMILY HISTORY:
- Both parents with type 1 diabetes mellitus
Family History:
Her mother has anxiety.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.1PO 121/73L Lying 79 18 99 RA
GENERAL: NAD
HEENT: MMM, sclerae anicteric, conjunctivae noninjected
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: warm, no edema
NEURO: Alert and interactive, moving all 4 extremities with
purpose
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 1203)
Temp: 98.1 (Tm 98.4), BP: 112/68 (111-132/66-77), HR: 71
(70-77), RR: 18 (___), O2 sat: 100% (96-100), O2 delivery: RA,
Wt: 135.7 lb/61.55 kg
PHYSICAL EXAMINATION:
GENERAL: NAD
HEENT: MMM, sclerae anicteric, conjunctivae noninjected
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no tenderness over renal allograft
EXTREMITIES: warm, no edema
NEURO: AAOx3, moving all 4 extremities with purpose
SKIN: no rashes
Pertinent Results:
ADMISSION LABS
=============
___ 04:35PM BLOOD WBC-7.6 RBC-4.08 Hgb-12.5 Hct-37.4 MCV-92
MCH-30.6 MCHC-33.4 RDW-12.2 RDWSD-40.7 Plt ___
___ 04:35PM BLOOD Neuts-74.7* Lymphs-15.7* Monos-6.9
Eos-1.6 Baso-0.7 Im ___ AbsNeut-5.66 AbsLymp-1.19*
AbsMono-0.52 AbsEos-0.12 AbsBaso-0.05
___ 04:35PM BLOOD Glucose-243* UreaN-27* Creat-1.4* Na-136
K-6.0* Cl-98 HCO3-22 AnGap-16
___ 04:35PM BLOOD ALT-26 AST-30 AlkPhos-109* TotBili-1.1
___ 04:35PM BLOOD Lipase-14
___ 04:35PM BLOOD cTropnT-<0.01
___ 04:35PM BLOOD Albumin-4.3
___ 04:43PM BLOOD tacroFK-18.7
___ 04:43PM BLOOD ___ pO2-86 pCO2-35 pH-7.41
calTCO2-23 Base XS--1 Intubat-NOT INTUBA Comment-GREEN TOP
___ 04:43PM BLOOD K-4.4
INTERVAL LABS:
===============
___ 05:40AM BLOOD tacroFK-20.5*
MICRO
========
URINE CULTURE: PENDING
BLOOD CULTURES: PENDING
IMAGING
=========
___ CXR
(READ PENDING)
___ RENAL US
FINDINGS:
The left iliac fossa transplant renal morphology is normal. The
transplant kidney measures 12.8 cm, previously 12.5 cm. The
cortex is of normal thickness and echogenicity, pyramids are
normal, there is no urothelial thickening, and renal sinus fat
is normal. There is no hydronephrosis and no perinephric fluid
collection.
The resistive index of intrarenal arteries ranges from 0.72 to
0.76,
borderline elevated, previously 0.61-0.71. The main renal
artery shows a
normal waveform, with prompt systolic upstroke and continuous
antegrade
diastolic flow, with peak systolic velocity of 76.8 cm/sec near
the hilum and increasing to 160 cm/sec closer to the
anastomosis, increased from previous value of 84.3 cm/sec.
Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform.
The urinary bladder is underdistended, limiting evaluation.
DISCHARGE LABS:
===============
___ 06:00AM BLOOD WBC-3.8* RBC-3.59* Hgb-11.3 Hct-32.5*
MCV-91 MCH-31.5 MCHC-34.8 RDW-12.1 RDWSD-39.4 Plt ___
___ 06:00AM BLOOD Glucose-238* UreaN-14 Creat-1.2* Na-143
K-4.1 Cl-105 HCO3-27 AnGap-11
___ 05:40AM BLOOD ALT-20 AST-14 AlkPhos-102 TotBili-0.9
___ 06:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.8
___ 06:00AM BLOOD tacroFK-8.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mycophenolate Mofetil 500 mg PO BID
2. Tacrolimus 2.5 mg PO Q12H
3. Vitamin D ___ UNIT PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. BuPROPion XL (Once Daily) 150 mg PO BID
7. Citalopram 20 mg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia
Discharge Medications:
1. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
2. Tacrolimus 2 mg PO Q12H
RX *tacrolimus 1 mg 2 capsule(s) by mouth twice a day Disp #*120
Capsule Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. BuPROPion XL (Once Daily) 150 mg PO BID
6. Citalopram 20 mg PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia
9. Mycophenolate Mofetil 500 mg PO BID
10. Vitamin D ___ UNIT PO DAILY
11.Outpatient Lab Work
Renal transplant T86.1
Please check Chem10 and tacrolimus level on ___ and fax
results to ___ in attn. of Dr ___
___ Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Viral gastroenteritis
SECONDARY DIAGNOSES
===================
Supratherapeutic Tacrolimus
Acute Kidney Injury
Type I DM s/p Liver Donor Renal Transplant
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: ___ woman with shortness of breath, cough, vomiting and
diarrhea. Evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Lungs are well expanded and clear. No focal consolidation, edema, effusion,
or pneumothorax. The heart is normal in size. The mediastinum is not
widened. Vertebral body heights are preserved.
IMPRESSION:
No focal pneumonia.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ woman with kidney transplant, vomiting and diarrhea;
evaluate patency of transplant.
Transplant ___
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: The renal transplant ultrasound dated ___.
FINDINGS:
The left iliac fossa transplant renal morphology is normal. The transplant
kidney measures 12.8 cm, previously 12.5 cm. The cortex is of normal
thickness and echogenicity, pyramids are normal, there is no urothelial
thickening, and renal sinus fat is normal. There is no hydronephrosis and no
perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.72 to 0.76,
borderline elevated, previously 0.61-0.71. The main renal artery shows a
normal waveform, with prompt systolic upstroke and continuous antegrade
diastolic flow, with peak systolic velocity of 76.8 cm/sec near the hilum and
increasing to 160 cm/sec closer to the anastomosis, increased from previous
value of 84.3 cm/sec. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
The urinary bladder is underdistended, limiting evaluation.
IMPRESSION:
Patent renal vasculature and similar waveforms to prior, but now borderline
elevated intrarenal artery resistive index, now 0.72 to 0.76, previously 0.61
to 0.71, and MRA peak systolic velocity now up to 160 cm/sec, previously 84.3
cm/sec.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea, Vomiting
Diagnosed with Shortness of breath
temperature: 97.7
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 105.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ with a history of celiac sprue, HTN, and
T1DM c/b retinopathy and R eye blindness, neuropathy, and ESRD
s/p LRRT from her brother (___) on MMF and tacro who presents
with 2 days of diarrhea and vomiting found to have ___ in the
setting of elevated tacrolimus level. Patient was given fluid
resuscitation, supportive care with improvement on Tacrolimus
level and Cr. Tacrolimus was held temporarily, and it was
restarted at a lower dose of 2mg BID at discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tequin / Hydrocodone
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of metastatic breast cancer to
liver, ?left adrenal, L4 presents with fever, nausea, vomiting,
diarrhea, and weakness.
Patient reports that over the last month she has felt
progressively more weak. The night prior to presentation she was
reportedly found slumped in a chair. Reports feeling so weak
that
she could not walk to the bathroom. Denied fall. Also reports
intermittent nausea but worse in the last few weeks with
vomiting. Has had some diarrhea over the last few weeks but no
BMs today after taking Imodium yesterday. Reports chills x 1
day.
Denies headaches, chest pain, shortness of breath, cough,
abdominal pain, urinary symptoms. Of note, blood pressure has
been low recently and pcp has discontinued some meds.
In the ED, initial vitals were 97.8 111 105/63 16 94% RA. Labs
significant for mild hyponatremia. CXR showed effusion,
atelectasis and could not exclude underlying infiltrate. She was
given cefepime, vanco, and zofran and admitted to OMED. Vitals
on
transfer 97.8 100 112/53 21 96% RA.
REVIEW OF SYSTEMS: A 10 point review of systems was performed in
detail and is negative except as noted in the HPI.
PAST ONCOLOGIC HISTORY (per OMR):
- In ___, Mrs. ___ underwent regular mammography and
was found to have a left breast nodule. Same day core needle
biopsy showed infiltrating ductal carcinoma that was hormonal
receptor positive. She was found to have positive FNA on the
left axilla. She opted for a left mastectomy, which revealed two
foci of cancer 1.8 and 1.2 cm each, accompanied by extensive
intermediate grade DCIS and focal lymphatic invasion. Her
margins were clear, ___ lymph nodes were positive, the largest
being 1.2 cm. Following mastectomy, she received radiation
therapy. She underwent adjuvant chemotherapy with
cyclophosphamide, doxorubicin and a taxane.
- She received endocrine therapy from ___ to ___ with
anastrozole daily. Her HER2 status was unclear for initial
tumor. There is some description of it being 0, likely
reflecting immunohistochemistry to be negative.
- She did not experience any side effects from chemotherapy or
hormonal therapy. She subsequently received active surveillance
of right breast.
- In ___, her mammogram showed an inferior lateral mass on
the right breast. She received a same-day ultrasound, which
detected a 1.8-cm hypoechoic mass. A biopsy was performed.
There
are no detectable lymph nodes in the right axillary area.
Pathology revealed grade 3 infiltrating ductal carcinoma, ER/PR
positive, HER-2/neu is 3+ by immunohistochemistry.
- On ___, she received lumpectomy with sentinel lymph node
evaluation. The final pathology showed pT1c, pN0, pMX (stage I)
- ___ paclitaxel with trastuzumab weekly (total of 8 doses
received)
- ___ starting trastuzumab Q3wk
- ___ radiation
- ___ starting anastrozole
- ___ completed one year of trastuzumab
She had a colonoscopy in ___ which showed an ulcerated
lesion in her cecum. Dr. ___ at ___ then scheduled her for a CT scan of the
abdomen
and pelvis with contrast. scan showed in the lower chest a
right
pleural effusion which was partially loculated. In the liver,
low-attenuation lesions were noted throughout the liver
compatible with metastases. In addition to the liver finding
with
multiple lesions, there was a 1.2 x 1.3 cm mass in the medial
limb of the left adrenal gland. Her kidneys showed very small
lesions which were likely cysts. There was nodularity of the
greater omentum and transverse mesocolon in keeping with a
diagnosis of peritoneal carcinomatosis. There was a 2.2 cm
lesion seen in the left ovary. She also has calcified fibroids.
Paraesophageal, porta hepatis and portacaval lymph nodes were
noted. On bone windows, there was a 1.7 cm blastic focus in the
L4 vertebral body. There are multilevel degenerative changes in
the spine as well as an old left ninth rib fracture. The
impression from the scan primarily was that of metastases in the
liver, left adrenal gland and peritoneal cavity as well as
probably in the body of L4 and possibly in her ovary.
She had a liver biopsy in ___ which showed this tumor is
estrogen and progesterone receptor positive and non-amplified
for
HER-2. This is therefore more compatible with her ___ left
breast malignancy than it is with the more recent right breast
cancer which was amplified for HER-2.
___ was initiated on Xeloda on ___.
Past Medical History:
1. Diabetes.
2. Hypertension.
3. Hypothyroidism.
4. Obesity.
5. Metastatic breast CA see above
1. Mastectomy ___ years ago.
2. C-section above ___ years ago.
Social History:
___
Family History:
maternal cousin with breast cancer and there is one additional
relative with a cancer of unspecified primary site
Physical Exam:
VS: T T 97.5, HR 79, BP 124/52, RR 18, O2 sat 99% RA
Gen: NAD, resting
Eyes: EOMI, no scleral icterus
HENT: NCAT, trachea midline
CV: RRR, S1-S2, ___ holosystolic murmur, no edema, 2+ ___ BLE
Lungs: CTA B, decreased lung sounds in RLL and RML are improved
today and still did not appreciate crackles or wheezes
GI: +BS, soft, NTTP, NDGU: No foley
MSK: ___ strength bilaterally,now able to transfer on own
Neuro: Moving all extremities, no focal deficits, A+Ox3
Skin: No rash or ecchymosis
Psych: Congruent affect, good judgment
Pertinent Results:
___ CT head
1. No acute intracranial abnormality.
___ CXR
Large right pleural effusion with overlying atelectasis,
underlying consolidation not excluded.
___ CT chest
No obvious explanation for the persistent moderate to large
nonhemorrhagic
right pleural effusion or large areas of atelectasis in the
right lung, all
stable since ___.
Previously questioned right adenopathy has either resolved or
was miss
identified. There is no supraclavicular or axillary adenopathy
today.
Moderate emphysema.
Moderately severe coronary atherosclerotic calcification. .
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Capecitabine 1500 mg PO BID
2. Gabapentin 800 mg PO BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. LOPERamide 2 mg PO Frequency is Unknown
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Janumet (SITagliptin-metformin) 50-1,000 mg oral daily
8. Ascorbic Acid Dose is Unknown PO DAILY
9. Aspirin 81 mg PO DAILY
10. Vitamin D Dose is Unknown PO DAILY
11. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
12. ginkgo biloba unknown oral Other
13. Glucosamine (glucosamine sulfate) unknown oral unknown
14. Ibuprofen Dose is Unknown PO Frequency is Unknown
15. Fish Oil (Omega 3) 1000 mg PO Frequency is Unknown
16. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Cyanocobalamin 100 mcg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. ginkgo biloba unk tab ORAL DAILY
5. Glucosamine (glucosamine sulfate) 1 tab ORAL DAILY
6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
7. LOPERamide 2 mg PO TID:PRN diarrhea
8. Vitamin D 1000 UNIT PO DAILY
9. Aspirin 81 mg PO DAILY
10. Capecitabine 1500 mg PO BID
11. Gabapentin 800 mg PO BID
12. Janumet (SITagliptin-metformin) 50-1,000 mg oral daily
13. Levothyroxine Sodium 75 mcg PO DAILY
14. Lisinopril 40 mg PO DAILY
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. R Pleural Effusion
2. Deconditioning/General Malaise
3. Metastatic Breast CA
4. Protein Calorie Malnutrition
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with fever, weakness, cough // infiltrate
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Moderate to large right pleural effusion with overlying atelectasis is seen,
underlying consolidation not excluded. The left lung is grossly clear. No
left pleural effusion is seen. There is no pneumothorax. Cardiac mediastinal
silhouettes are grossly stable given partially obscured by the right sided
opacity.
IMPRESSION:
Large right pleural effusion with overlying atelectasis, underlying
consolidation not excluded.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall yesterday // eval acute intracranial injury
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or large mass. Deep
white matter periventricular hypodensities are nonspecific but likely
represent sequela of chronic small vessel ischemic disease. The ventricles
and sulci are normal in size and configuration.
There is no acute fracture. Air-fluid levels are noted in the sphenoid
sinuses. The paranasal sinuses are otherwise clear.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with metastatic breast cancer with pleural
effusion and fevers with concern for pneumonia.
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.3 s, 33.4 cm; CTDIvol = 13.5 mGy (Body) DLP = 455.4
mGy-cm.
Total DLP (Body) = 455 mGy-cm.
COMPARISON: CHEST CT SCAN ___.
FINDINGS:
11 mm right supraclavicular lymph node, poorly defined in the absence of
intravenous contrast agent, is stable or slightly smaller compared ___.
There is no left supraclavicular or left axillary lymph node enlargement.
Previously questioned right axillary lymph node is either a miss identified
muscle, or it has resolved. Patient has had left mastectomy. Evaluation of
the breasts would require mammography, for example, a spiculated 16 x 18 mm
nodular collection of tissue in the right breast, 5:172. Marked enlargement
of the right thyroid lobe is homogeneous, unlikely to represent a mass, and
unchanged since ___.
Atherosclerotic calcification is not apparent in head neck vessels, but is
substantial in the coronary arteries. Had aorta is normal size. Main
pulmonary arteries are mildly enlarged. Pericardial effusion is small,
unchanged, with no calcification or evidence of cardiac tamponade. There is
no left pleural effusion. Moderate, nonhemorrhagic right pleural effusion is
nearly all dependent, in the right posterior chest, but there is small volume
that is probably loculated anterior to the middle lobe, 5:131. Pleural
surfaces are not distinguishable from the effusion in the absence of
intravenous contrast agent.
Lungs:
Emphysema is widespread, moderately severe. A large region of peripheral
consolidation in the right middle lobe is probably atelectasis, unchanged
since ___. Smaller amount of atelectasis is also present at the base of
the right lung. There is no bronchial obstruction to explain either.
Subpleural scarring in the left lung anteriorly reflects previous radiation.
New atelectasis at the left base is mild.
Bronchi are patent to subsegmental levels and there is no bronchiectasis.
A sharply defined round sclerotic lesion in the midportion of a mid thoracic
vertebral body has any central dense calcification. This could be an osteoma.
There are no bone lesions in the chest cage suspicious for malignancy and no
compression or pathologic fractures.
IMPRESSION:
No obvious explanation for the persistent moderate to large nonhemorrhagic
right pleural effusion or large areas of atelectasis in the right lung, all
stable since ___.
Previously questioned right adenopathy has either resolved or was miss
identified. There is no supraclavicular or axillary adenopathy today.
Moderate emphysema.
Moderately severe coronary atherosclerotic calcification. .
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, s/p Fall, Fever
Diagnosed with Pneumonia, unspecified organism
temperature: 97.8
heartrate: 111.0
resprate: 16.0
o2sat: 94.0
sbp: 105.0
dbp: 63.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ yo CF with PMH recurrent metastatic
breast CA ER/PR+/HER2+ and h/o ER/PR+/HER2Neg, hypothyroidism,
htn, T2DM presented on ___ with cough and subjective fever.
# Cough/ R pleural effusion - likely malignant but cannot rule
out underlying infection. However afebrile, no WBC, and cough
can
be attributed to effusion.
--D/C abx and no fever, cough improved. Likely all due to
pleural effusion. CT showed similar size of pleural effusion. No
O2 requirements and no dyspnea
# Deconditioning - s/p chemotherapy with severe decline in
functional status
--___ eval today with daily work, pt has stairs at home
--Nutrition for help with po intake
# Diarrhea - resolved by time of admission, soft abd/+BS.
Patient had improvement with food as well.
# Dehydration/Malnutrition - dry mucous membranes. Improved with
fluids and able to tolerate a full diet and finish 100% meal at
time of discharge
# T2DM - held janumet on admission for contrasted CT, restarted
when goes home. SSI in hospital controlled.
# Functional status: Evaluated by ___, independent but set up ___
for next week
# Consults: Nutrition, ___
# Diet: Regular
# GI Prophy: None Indicated
# Precautions: None
# Code status: DNR per patient request. Updated primary
oncologist as well.
# Contact: ___ son ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Crestor
Attending: ___.
Chief Complaint:
Tumor lysis syndrome
Major Surgical or Invasive Procedure:
___: bone marrow biopsy
History of Present Illness:
___ yo female with PMHx JAK2+ myeloproliferative disorder
previously on hydroxyurea stopped ___ pancytopenia, COPD, aortic
stenosis, HTN, HLD, DM who presented to ___ with
several days of confusion and lethargy.
On arrival to the OSH ED, the patient was noted to be confused
and unable to give the ED team information on her care. She
explained that she had recently stopped hydroxyurea ___
pancytopenia. She notes recent history of lethargy and
difficulty walking over the past several days. Also complains of
abdominal pain, back pain and lightheadedness. Denies CP, SOB.
She follows with oncologist ___. Per his colleague,
the patient had been on hydroxyurea for myeloproliferative
disorder since ___, but it was stopped around ___ due
to pancytopenia.
At ___, labs were notable for:
WBC: 26.8
Hb: 4.4
Na: 134
K: 6.5
Cr: 2.35
BUN: 56
Calcium: 7.1
Alk phos: 198
AST: 98
ALT: 46
CT the abdomen pelvis was notable for: Mild mural prominence of
the splenic flexure with mild pericolic fat stranding, likely
accentuated by underdistention. Findings suggest mild infectious
or inflamed or colitis.
She received IVF, allopurinol, morphine, Zofran, calcium
gluconate, insulin, D50. Due to finding of 11% blasts and labs
consistent with TLS, she was transferred to ___ for further
management.
On arrival to ___, physical exam was notable for: patient
confused and unable to explain presentation, cardiac murmur, LUQ
and RLQ tenderness to palpation. Labs were notable for: WBC 90,
15% "other", uric acid 17.2, K 6.0, Cr 2.7, lactate 3.7, Ca 8.1,
Phos 6.8. EKG was within normal limits. BMT and Renal were
consulted. She receive IVF, allopurinol, rasburicase.
Hyperkalemia was managed with insulin/dextrose, calcium
gluconate. She was admitted to ___ for TLS management and
concern for acute transformation of AML.
On arrival to the FICU, patient complains of confusion,
weakness, dizziness of several weeks duration. She says she has
felt generally unwell, very fatigued and not like herself. She
complains of ongoing diarrhea that is unchanged from chronic.
Also complains of worsening shortness of breath of several weeks
duration.
Past Medical History:
COPD
aortic stenosis (mild to moderate)
HTN
HLD
DM
s/p partial ___ mastectomy
?CML
Hx of myeloproliferative disorder (Jak 2 +) on hydroxyurea since
___.
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: temp 97.8, HR 98, BP 98/67, RR 18, O2 sat 97% on 2L
GEN: AAOx2, confused, tearful
EYES: PERRLA
HENNT: MMM, anicteric sclera, no mucosal lesions, dentures in
place
CV: RRR, ___ systolic murmur
RESP: bibasilar crackles, normal inspiratory effort
GI: soft, nondistended. + mild tenderness to palpation in LUQ,
RLQ
MSK: moving all extremities
SKIN: no skin lesions
NEURO: CNs intact, sensation intact in upper and lower
extremities, strength intact in ___ upper and lower extremities
PSYCH: normal affect, depressed mood
DISCHARGE PHYSICAL EXAM
=======================
___.___
Gen: no acute distress, lying on bed
HEENT: dentures in, clear OP, MMM. PERRLA
CARDIAC: RRR, III/VI systolic murmur best heard at ___
LUNGS: CTAB, no R/R/W, breathing comfortably on RA
ABD: S/NT/ND
DERM: purpura in RLQ abd c/w SQH
EXT: WWP, 1+ BLE pitting edema
NEURO: alert, oriented. PERRLA
LINES: R chest port without access; RIJ C/D/I
Pertinent Results:
ADMISSION LABS:
========================
___ 12:15AM BLOOD WBC-89.8* RBC-3.50* Hgb-11.3 Hct-38.5
MCV-110* MCH-32.3* MCHC-29.4* RDW-23.2* RDWSD-90.0* Plt ___
___ 12:15AM BLOOD Neuts-50 Bands-7* Lymphs-6* Monos-17*
Eos-1 Baso-1 Atyps-2* Metas-1* Myelos-0 Blasts-15* NRBC-11*
Other-0 AbsNeut-51.19* AbsLymp-7.18* AbsMono-15.27* AbsEos-0.90*
AbsBaso-0.90*
___ 12:15AM BLOOD Hypochr-NORMAL Anisocy-2+* Poiklo-2+*
Macrocy-2+* Microcy-OCCASIONAL Polychr-1+* Ovalocy-1+* Burr-2+*
Tear Dr-OCCASIONAL
___ 12:15AM BLOOD ___ PTT-36.8* ___
___ 04:58AM BLOOD ___
___ 12:15AM BLOOD Ret Man-12.5* Abs Ret-0.44*
___ 12:15AM BLOOD Glucose-147* UreaN-57* Creat-2.7* Na-135
K-6.0* Cl-98 HCO3-15* AnGap-22*
___ 04:58AM BLOOD ALT-44* AST-94* LD(___)-2500*
AlkPhos-191* TotBili-1.7* DirBili-1.1* IndBili-0.6
___ 12:15AM BLOOD Albumin-2.6* Calcium-8.1* Phos-6.8*
Mg-2.9* UricAcd-17.2*
___ 04:58AM BLOOD Hapto-<10*
___ 12:49AM BLOOD ___ pO2-60* pCO2-40 pH-7.25*
calTCO2-18* Base XS--9 Comment-GREEN TOP
___ 12:49AM BLOOD Lactate-3.7* Creat-2.7* K-5.7*
___ 04:19PM BLOOD freeCa-2.87*
___ 06:29PM BLOOD freeCa-1.14
RELEVANT LABS:
========================
___ 04:58AM BLOOD WBC-96.3* RBC-3.26* Hgb-10.5* Hct-35.4
MCV-109* MCH-32.2* MCHC-29.7* RDW-23.0* RDWSD-87.4* Plt ___
___ 03:50AM BLOOD WBC-68.4* RBC-3.02* Hgb-9.7* Hct-32.9*
MCV-109* MCH-32.1* MCHC-29.5* RDW-23.5* RDWSD-88.8* Plt ___
___ 03:50AM BLOOD WBC-45.0* RBC-2.98* Hgb-9.7* Hct-31.8*
MCV-107* MCH-32.6* MCHC-30.5* RDW-22.5* RDWSD-86.2* Plt ___
___ 04:00AM BLOOD WBC-28.9* RBC-3.00* Hgb-9.6* Hct-32.2*
MCV-107* MCH-32.0 MCHC-29.8* RDW-21.8* RDWSD-84.9* Plt ___
___ 03:33AM BLOOD WBC-16.4* RBC-2.59* Hgb-8.3* Hct-27.7*
MCV-107* MCH-32.0 MCHC-30.0* RDW-21.7* RDWSD-83.0* Plt Ct-90*
___ 03:14AM BLOOD WBC-11.9* RBC-2.67* Hgb-8.8* Hct-28.5*
MCV-107* MCH-33.0* MCHC-30.9* RDW-21.7* RDWSD-83.2* Plt Ct-72*
___ 03:19AM BLOOD WBC-6.0 RBC-2.65* Hgb-8.6* Hct-28.0*
MCV-106* MCH-32.5* MCHC-30.7* RDW-22.0* RDWSD-81.5* Plt Ct-59*
___ 02:27AM BLOOD WBC-4.1 RBC-2.50* Hgb-7.9* Hct-25.9*
MCV-104* MCH-31.6 MCHC-30.5* RDW-21.9* RDWSD-80.4* Plt Ct-50*
___ 04:18AM BLOOD WBC-2.3* RBC-2.07* Hgb-6.7* Hct-21.7*
MCV-105* MCH-32.4* MCHC-30.9* RDW-21.8* RDWSD-80.3* Plt Ct-31*
___ 01:39AM BLOOD WBC-2.4* RBC-2.39* Hgb-7.6* Hct-24.3*
MCV-102* MCH-31.8 MCHC-31.3* RDW-21.4* RDWSD-75.0* Plt Ct-22*
___ 05:04AM BLOOD WBC-2.3* RBC-2.20* Hgb-7.1* Hct-22.6*
MCV-103* MCH-32.3* MCHC-31.4* RDW-20.7* RDWSD-73.3* Plt Ct-13*
___ 12:00AM BLOOD WBC-2.0* RBC-2.19* Hgb-6.9* Hct-22.6*
MCV-103* MCH-31.5 MCHC-30.5* RDW-20.4* RDWSD-73.0* Plt Ct-14*
___ 12:00AM BLOOD WBC-1.0* RBC-2.46* Hgb-7.7* Hct-24.3*
MCV-99* MCH-31.3 MCHC-31.7* RDW-20.5* RDWSD-70.3* Plt Ct-26*
___ 12:00AM BLOOD WBC-0.7* RBC-2.30* Hgb-7.3* Hct-22.7*
MCV-99* MCH-31.7 MCHC-32.2 RDW-19.9* RDWSD-68.3* Plt Ct-20*
___ 12:00AM BLOOD WBC-0.5* RBC-2.19* Hgb-6.7* Hct-21.3*
MCV-97 MCH-30.6 MCHC-31.5* RDW-19.3* RDWSD-64.3* Plt Ct-18*
___ 12:00AM BLOOD WBC-0.6* RBC-2.39* Hgb-7.3* Hct-23.1*
MCV-97 MCH-30.5 MCHC-31.6* RDW-18.7* RDWSD-62.5* Plt Ct-19*
___ 12:00AM BLOOD WBC-0.7* RBC-2.25* Hgb-6.8* Hct-21.6*
MCV-96 MCH-30.2 MCHC-31.5* RDW-18.6* RDWSD-61.8* Plt Ct-13*
___ 12:00AM BLOOD WBC-0.8* RBC-2.63* Hgb-8.1* Hct-24.4*
MCV-93 MCH-30.8 MCHC-33.2 RDW-19.6* RDWSD-61.4* Plt Ct-11*
___ 12:00AM BLOOD WBC-0.6* RBC-2.48* Hgb-7.4* Hct-23.4*
MCV-94 MCH-29.8 MCHC-31.6* RDW-19.1* RDWSD-61.8* Plt Ct-7*
___ 12:00AM BLOOD WBC-0.8* RBC-2.57* Hgb-7.9* Hct-24.4*
MCV-95 MCH-30.7 MCHC-32.4 RDW-19.1* RDWSD-61.3* Plt Ct-13*
___ 12:00AM BLOOD WBC-0.9* RBC-2.44* Hgb-7.5* Hct-23.3*
MCV-96 MCH-30.7 MCHC-32.2 RDW-19.9* RDWSD-61.0* Plt Ct-15*
RELEVANT MICRO
========================
___ BLOOD CULTURE: NO GROWTH
___ URINANALYSIS: Negative leuks, negative nitrites, 10 WBCs
___ URINE CULTURE: STAPHYLOCOCCUS, COAGULASE NEGATIVE.
>100,000 CFU/mL.
RELEVANT IMAGING
========================
___ CXR AP
No prior chest radiographs available.
Heart size top-normal. Lungs grossly clear. No pleural
abnormality. Right jugular central venous infusion catheter
ends at the origin of the SVC.
___ TTE
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global biventricular systolic function. Mild
aortic stenosis. Moderate tricuspid regurgitation.
___ RIGHT UPPER QUADRANT ULTRASOUND
1. Splenomegaly, measuring up to 18.0 cm. The previously seen
peripheral mass was not demonstrated on the current study.
2. Trace perihepatic ascites.
3. Post cholecystectomy without intrahepatic or extrahepatic
biliary ductal
dilation.
___. No acute intracranial process.
2. Suggestion of mild acute sphenoid sinusitis.
___ CT ABDOMEN WITHOUT CONTRAST (___)
1. Moderate hepatosplenomegaly consistent with
myeloproliferative neoplasm.
2. Small amount of ascites.
3. Small bilateral pleural effusions with adjacent compressive
atelectasis.
4. Minimal colonic thickening at the splenic flexure with mild
fat stranding may be related to hypoalbuminemia. A delayed
follow-up CT abdominopelvic scan with oral contrast demonstrated
in the sigmoid colon may help to further characterize the
colonic wall.
5. A 32 x 32 mm soft tissue density is demonstrated in the
lateral left
breast.
6. Diffusely heterogenous osseous structures is consistent with
known
myelodysplastic neoplasia.
___ CT ABDOMEN WITHOUT CONTRAST (___)
1. Moderate hepatosplenomegaly consistent with the
myeloproliferative
neoplasm.
2. Unfortunately, the contrast in the small bowel did not reach
the sigmoid.
3. Small amount of ascites.
4. Left lateral breast mass partially covered.
___ VENTILATION/PERFUSION SCAN
Low likelihood ratio for recent pulmonary embolism.
___ CT CHEST WITHOUT CONTRAST
1. Partially visualized left lateral breast mass for which
dedicated mammogram
is recommended for further evaluation.
2. Aortic valve calcifications for which referral to the Aortic
Center is
recommended.
___ CXR AP
Mild interstitial pulmonary edema with small bilateral pleural
effusions.
RELEVANT PATHOLOGY
========================
___ BONE MARROW BIOPSY
FLOW CYTOMETRY
Immunophenotypic findings consistent with involvement by an
abnormal CD34 positive myeloid blasts comprising 8% of the total
analyzed events. Correlation with clinical, morphologic (see
separate pathology/cytogenetics report ___ and
other ancillary findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
PATHOLOGY
INVOLVEMENT BY PATIENT'S KNOWN MYELOPROLIFERATIVE NEOPLASM WITH
SIGNIFICANT MYELOFIBROSIS AND INCREASED BLASTS, SEE NOTE.
Note: The marrow biopsy is hypercellular with myeloid dominant
Hematopoieis, dysplastic megakrayocytes, and increased blasts
(___) which together with an absolute monocytosis, raise the
possibility of involvement by chronic myelomonocytic leukemia
further subclassified as CMML-2. However, myeloproliferative
neoplasm (MPN) can also be associated with monocytosis or can
develop it during the course of the disease; these cases may
mimic CMML. The patient's previously reported JAK2 mutation
along with the significant marrow fibrosis (MF-3) and the lack
of significant dysgranulopoiesis in the peripheral blood tend to
support the diagnosis of a myeloproliferative neoplasm (MPN)
with monocytosis rather than CMML. Nevertheless, both increased
fibrosis and increasing blasts are signs of disease progression.
Correlation with clinical, cytogenetic studies and laboratory
findings is recommended.
MYELOID NGS
JAK2 V617F mutation was detected by targeted next generation
sequencing.
FLT3-ITD by PCR was NOT DETECTED
FLT3-TKD by PCR was NOT DETECTED
CALR insertion/deletion by PCR was NOT DETECTED
DISCHARGE LABS
========================
WBC 1.4, Hgb 7.9, Hct 25.4, Platelets 27
Diff: Neutrophils 47%, ANC 660
Glucose 113, BUN 18, Cr 1.2, Na 140, K 3.3, Cl 99, Bicarb 27
proBNP 3695
Calcium 8.2, Phos 2.8, Mg 1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 80 mg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. ALPRAZolam 0.5 mg PO BID:PRN anxiety
6. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - First Line
7. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea
8. Aspirin 81 mg PO DAILY
9. hyoscyamine sulfate 0.125 mg oral Q6H:PRN
10. Nystatin Cream 1 Appl TP BID under breasts
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
12. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
13. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % 15 mL oral rinse twice a day
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 100 mg PO DAILY
RX *furosemide 20 mg 5 tablet(s) by mouth Daily Disp #*150
Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
Reason for PRN duplicate override: Alternating agents for
similar severity
7. Posaconazole Delayed Release Tablet 300 mg PO DAILY
RX *posaconazole [Noxafil] 100 mg 3 tablet(s) by mouth daily
Disp #*90 Tablet Refills:*0
8. Potassium Chloride 40 mEq PO DAILY
RX *potassium chloride 10 mEq 4 capsule(s) by mouth Daily Disp
#*120 Capsule Refills:*0
9. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
10. Lisinopril 20 mg PO DAILY
11. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
12. ALPRAZolam 0.5 mg PO BID:PRN anxiety
13. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea
14. FLUoxetine 80 mg PO DAILY
15. hyoscyamine sulfate 0.125 mg oral Q6H:PRN
16. Metoprolol Succinate XL 12.5 mg PO DAILY
17. Omeprazole 20 mg PO BID
18. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - First
Line
19.commode
commode for home use
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
#Myeloproliferative neoplasm with monocytosis
#Tumor lysis syndrome
#Disseminated intravascuar coagulation
#Depression
#Goals of care
#Left breast mass
#Vision changes
SECONDARY DIAGNOSES
#T2DM
#COPD
#HTN
#Mild aortic stenosis
#Chronic 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
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ w/o h/o JAK2+ MPN with monocytosis who initially p/w TLS c/b
___ s/p CRRT. Recent V/Q scan shows underlying pulmonary abnormalities.
Patient notes intermittent dyspnea.// please characterize lungs and examine
for etiology of dyspnea
TECHNIQUE: Axial images of the chest were obtained without IV contrast.
Coronal and sagittal reformats were obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.2 s, 33.9 cm; CTDIvol = 11.4 mGy (Body) DLP = 377.7
mGy-cm.
Total DLP (Body) = 378 mGy-cm.
COMPARISON: No prior chest CT for comparison
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The distal tip of right chest wall
port terminates within the cavoatrial junction. The visualized thyroid gland
is unremarkable. No axillary adenopathy.
UPPER ABDOMEN: Except for small hiatal hernia and splenomegaly, the visualized
upper abdominal structures are unremarkable.
MEDIASTINUM: Few scattered prominent but non pathologically enlarged
mediastinal lymph nodes. No abnormal mediastinal masses.
HILA: No abnormal hilar masses or hilar adenopathy.
HEART and PERICARDIUM: The heart is enlarged. Coronary atherosclerotic
vascular calcifications and aortic valve calcifications are noted. There is
no pericardial effusion.
PLEURA: No fusion
LUNG:
1. PARENCHYMA: Rounded atelectasis is noted in the right middle lobe and right
lower lobe. There are diffuse ground-glass opacities in the left upper lobe
which are nonspecific and may represent infection or drug toxicity.
2. AIRWAYS: Diffuse bilateral minimal bronchial wall thickening of the small
airways suggests infectious or inflammatory/drug reactive process.
3. VESSELS: Mild aortic atherosclerotic the calcified and noncalcified plaque.
CHEST CAGE: There is a partially visualized left lateral breast mass for which
dedicated mammogram is recommended for further evaluation. Bones have a
diffusely sclerotic appearance which can be seen in matter dysplastic
syndrome. There is no aggressive osseous lesion within the imaged chest.
IMPRESSION:
1. Diffuse nonspecific ground-glass opacities in the left upper lobe, in the
setting of minimal bronchial wall thickening of the small airways, suggests an
infectious or inflammatory process versus changes related to drug toxicity.
2. Partially visualized left lateral breast mass for which dedicated mammogram
is recommended for further evaluation.
3. Aortic valve calcifications for which referral to the Aortic Center is
recommended.
RECOMMENDATION(S):
1. Partially visualized left lateral breast mass for which dedicated mammogram
is recommended for further evaluation.
2. Aortic valve calcifications for which referral to the Aortic Center is
recommended.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 15:31 into the Department of Radiology
critical communications system for direct communication to the referring
provider.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with wheezing and volume overload// evaluate
for pulmonary edema, effusion
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___
FINDINGS:
Distal tip of the right chest wall port overlies the mid SVC.
Cardiomediastinal silhouette is unchanged. There are small bilateral pleural
effusions with mild interstitial pulmonary edema.
IMPRESSION:
Mild interstitial pulmonary edema with small bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo female with PMHx CML previously on hydroxyurea stopped ___
pancytopenia presented to St. ___ hospital w/confusion, diarrhea, found to
have 11% blasts and labs c/w TLS.// infiltrate infiltrate
IMPRESSION:
No prior chest radiographs available.
Heart size top-normal. Lungs grossly clear. No pleural abnormality. Right
jugular central venous infusion catheter ends at the origin of the SVC.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with CML// Placement of new RIJ dialysis
catheter Contact name: ___: ___
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Right-sided central line is unchanged. A right IJ line has been placed with
its tip in the SVC. The right hilar looks more prominent than on the prior
study, could be related to vascular structures. Cardiomediastinal silhouette
is stable. Lungs are low volume with bibasilar atelectasis. No pneumothorax
is seen.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with transformation of CML to AML with
bilirubinemia// ?cholethiasis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen dated ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is trace perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 mm
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 18.0 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Splenomegaly, measuring up to 18.0 cm. The previously seen peripheral mass
was not demonstrated on the current study.
2. Trace perihepatic ascites.
3. Post cholecystectomy without intrahepatic or extrahepatic biliary ductal
dilation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ w/ CMML-2 and thrombocytopenia (most recently 14) ___ chemo
now c/o light sensitivity.// ?ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 45.3 mGy (Head) DLP =
684.4 mGy-cm.
Total DLP (Head) = 684 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect. There
is prominence of the ventricles and sulci suggestive of involutional changes.
Periventricular and subcortical white matter hypodensities are nonspecific but
suggest chronic small vessel ischemic changes.
There is no evidence of fracture. Trace fluid in the sphenoid sinus.
Paranasal sinuses, mastoids otherwise clear.
IMPRESSION:
1. No acute intracranial process.
2. Suggestion of mild acute sphenoid sinusitis.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 11:25 am, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with CMML-2 on chemotherapy w/ new dyspnea.// ?hypervolemia
vs. consolidation
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tips of a right chest wall Port-A-Cath in right internal jugular central
line project over the upper SVC and right atrium respectively. There is no
focal consolidation or pneumothorax. Small bilateral pleural effusions are
suspected.
IMPRESSION:
Suspected small bilateral and subjacent atelectasis..
Radiology Report
EXAMINATION: CT abdomen and pelvis without intravenous contrast
INDICATION: ___ w/ myeloproliferative neoplasm who p/w TLS, s/p CRRT and back
to the floor, now on chemo and neutropenic. Now w/ abdominal pain. CT A/P 2
weeks ago at OSH noted ?mild mural prominence ofthe splenic flexure with mild
pericolic fat stranding.// please e/o evidence of inflammation and/or
infection
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 7.4 s, 47.9 cm; CTDIvol = 25.4 mGy (Body) DLP =
1,199.8 mGy-cm.
Total DLP (Body) = 1,200 mGy-cm.
COMPARISON: CT abdomen pelvis from outside hospital dated ___.
FINDINGS:
LOWER CHEST: Small bilateral pleural effusions, right greater than left with
adjacent atelectasis. There is diffuse interlobular septal thickening likely
secondary to fluid overload. Cardiac size is within normal limits. No
evidence of pericardial effusion. Moderate calcified atherosclerosis is
demonstrated in the coronary arteries and aortic valve.
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 surgically absent.
PANCREAS: Moderately, atrophic 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: A well-circumscribed hypodensity within the spleen measures 36 x 33 mm
demonstrate attenuation of 13 Hounsfield units consistent with a splenic cyst.
Splenomegaly up to 15.2 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. In the interpolar
region of the left kidney is a 23 mm well-circumscribed pedunculated lesion
with the tenuous shin of 11.8 ___ units consistent with a simple renal
cyst a 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. Diverticulosis of the sigmoid
colon is noted, without evidence of wall thickening and fat stranding.
Unchanged colonic wall thickening at the splenic flexure with mild fat
stranding may be related to hypoalbuminemia. The appendix is not visualized.
A small amount ascitic fluid is demonstrated.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
trace amount of simple free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are 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 atherosclerotic disease
is noted.
BONES: Visualized bones are diffusely heterogenous which is suggestive of an
infiltrative osseous process. A small hyperdense lesion is demonstrated in
the vertebral body at L2 likely a bone island.
SOFT TISSUES: Diffuse soft tissue stranding is consistent with anasarca. A 32
x 32 mm soft tissue density is demonstrated in the lateral left breast,
(series 3, image 8).
IMPRESSION:
1. Moderate hepatosplenomegaly consistent with myeloproliferative neoplasm.
2. Small amount of ascites.
3. Small bilateral pleural effusions with adjacent compressive atelectasis.
4. Minimal colonic thickening at the splenic flexure with mild fat stranding
may be related to hypoalbuminemia. A delayed follow-up CT abdominopelvic scan
with oral contrast demonstrated in the sigmoid colon may help to further
characterize the colonic wall.
5. A 32 x 32 mm soft tissue density is demonstrated in the lateral left
breast.
6. Diffusely heterogenous osseous structures is consistent with known
myelodysplastic neoplasia.
RECOMMENDATION(S):
1. A delayed follow-up CT abdominopelvic scan with oral contrast demonstrated
in the sigmoid colon may help to further characterize the colonic wall.
2. Mammography is recommended to further characterize the soft tissue mass in
the left breast.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:05 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ CMML-2 who p/w TLS s/p CRRT, now off it. Again w/
recurrent dyspnea and O2 in mid ___ on RA.// please e/o consolidation, fluid
overload please e/o consolidation, fluid overload
IMPRESSION:
Compared to chest radiographs ___ and ___ one.
Small left pleural effusion is new. Lungs grossly clear. Heart size normal.
Dual channel right supraclavicular central venous line ends in the right
atrium. Jugular line ends in the upper SVC.
Radiology Report
EXAMINATION: Abdominal pelvis CT
INDICATION: ___ h/o MPN w/ p/w TLS. Now w/ abdominal pain, prior OSH CT ___
w/ ?splenic flexure bowel inflammation. Follow up CT.// please examine for e/o
bowel inflammation
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 7.2 s, 46.9 cm; CTDIvol = 24.7 mGy (Body) DLP =
1,140.8 mGy-cm.
Total DLP (Body) = 1,141 mGy-cm.
COMPARISON: Abdominal pelvis CT from ___ at 15:44
FINDINGS:
LOWER CHEST: Small bilateral pleural effusion with the right greater than left
adjacent atelectasis is again seen.
Partially seen is a left breast Mass measuring 2.6 cm. There is a right
posterior chest wall lipoma measuring 2.3 x 3.1 cm.
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: Moderate atrophy of the pancreatitis again seen. No main duct
dilatation.
SPLEEN: Splenomegaly measuring 15.8 cm. Again seen is a 3.8 x 3.3 hypodense
lesion consistent with a splenic cyst.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. Again seen is a 2.3 cm
pedunculated cyst in the interpolar of the left kidney. 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. Uncomplicated colonic
diverticulosis. Unfortunately, the contrast in the small bowel did not reach
the sigmoid.
PELVIS: The urinary bladder and distal ureters are unremarkable. Small amount
of ascites in the abdomen and 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: Diffuse patchy sclerotic appearance of the bones in keeping with the
myelodysplastic syndrome.
SOFT TISSUES: Diffuse soft tissue stranding suggestive of anasarca.
IMPRESSION:
1. Moderate hepatosplenomegaly consistent with the myeloproliferative
neoplasm.
2. Unfortunately, the contrast in the small bowel did not reach the sigmoid.
3. Small amount of ascites.
4. Left lateral breast mass partially covered.
RECOMMENDATION(S): Mammography is recommended to further characterize the
left breast Mass.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea, Weakness
Diagnosed with Tumor lysis syndrome
temperature: 97.8
heartrate: 98.0
resprate: 18.0
o2sat: 96.0
sbp: 98.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | ======================
SUMMARY
======================
___ with PMHx MPN previously on hydroxyurea stopped ___
pancytopenia presented to ___ w/confusion,
diarrhea, found to have 11% blasts and labs c/w TLS, with BMB
showing high risk CMML. She was initially restarted on
hydroxyurea and then started on 20mg/m2 IV decitabine (___) for 5 days. She was temporarily on CRRT for urate
nephropathy causing renal failure. She was pancytopenic
initially due to restarting hydroxyurea and later due to the
effects of decitabine. She was followed by psychiatry and
palliative care and remained full code with the goal to treat
her malignancy.
======================
ACUTE ISSUES
======================
#MPN with monocytosis
#TLS
#DIC
Patient follows with oncologist ___. She had
recently been taken off of hydroxyurea ___ pancytopenia. On
arrival, labs were consistent with TLS and DIC. Patient had not
received any recent treatment so this was felt to be due to
likely transformation of CML to AML. ___ was consulted. They
recommended acutely treating TLS with allopurinol and the
patient ended up requiring two doses of rasburicase. She was
placed back on hydroxyurea. Once she was stabilized, bone marrow
biopsy was performed which showed hypercellular marrow c/w
MDS/MPN disorder w/ ___ blasts so did not quite meet
threshold for acute leukemia diagnosis though was felt to be
progressing towards AML. Due to worsening pancytopenia,
hydroxyurea was discontinued. Following ___ conversations, she
was started on chemotherapy with decitabine at 20mg/m2 for 5
days. She tolerated the chemotherapy without significant issue.
Labs are notable for persistent pancytopenia requiring
transfusion support about every other day. For prophylaxis, she
is on acyclovir, and posaconazole. Levofloxacin was discontinued
as ANC >500 upon d/c. She was also recommended to start
ruxolitinib given her JAK2+ status under her outpatient
oncologist's guidance.
___
#Hypervolemia
Patient was noted to have ___ on admission felt to be secondary
to uric acid nephropathy. She was rapidly placed on CRRT due to
electrolyte abnormalities and rapidly changing renal function.
This was continued until ___ when TLS had resolved and she was
taken off. Following this, her creatinine remained stable and
she did not have any further need for dialysis. She initially
received aggressive fluid resuscitation for her ___ causing her
to be volume overloaded. She then received Lasix with/without
diuril as needed for diuresis.
#HFpEF
#Moderate tricuspid regurgitation
#Mild aortic stenosis:
After receiving aggressive fluid resuscitation for TLS and ___,
clinically appeared volume overloaded with edematous legs B/L
and elevated JVP. TTE with HF with preserved EF, mild AS, and
moderate TR. Initially cardiac meds (lisinopril/metoprolol) were
held, but metoprolol succinate was re-started at home dose of
12.5mg daily and lisinopril was halved to 20mg daily given
softer BPs and recovering ___. Likely can go back on full dose
lisinopril as outpatient if BPs and kidneys tolerate. For
diuresis she was given IV Lasix +/- diuril and transitioned to
Lasix 100mg PO daily.
#___
#Depression
Patient initially have very depressed mood and was confused
regarding ongoing treatment. As she improved clinically, she
became much more aware of her medical status and the
interventions that were being done. Following ___ conversations,
she decided she wanted to move forward with treatment.
Psychiatry and Palliative care both were consulted. She was
continued on fluoxetine, alprazolam. Also received QHS
ramelteon.
#Left breast mass
Incidentally noted on imaging. Patient has a history of
right-sided breast cancer s/p lumpectomy without radiation and 2
months of aromatase inhibitor. Has h/o known left-sided atypical
ductal hyperplasia s/p incisional biopsy ___ years prior.
Outpatient oncology Dr. ___ was made aware of this
incidental finding.
#Vision changes, light sensitivity
Patient intermittently c/o blurry vision and light sensitivity.
Notes it as a chronic issue since having a fall and injuring her
neck ___ years prior. CT head without issue.
======================
CHRONIC/RESOLVED ISSUES
======================
#T2DM
Patient was on insulin at home, which was changed while
inpatient. She was discharged on home regimen.
#COPD
Patient initially required oxygen supplementation but was weaned
off. She received albuterol PRN.
#HTN
Patient was not on any anti-hypertensive medications while in
the hospital. Lisinopril and metoprolol were held. BP was
well-controlled off antihypertensives.
#Chronic back pain
Was on tramadol at home. Given small doses of oxycodone here and
sent home with 30 5mg tablets.
#Urinary frequency/dysuria: Resolved without treatment. UCx with
coag negative staph. Did not treat as symptoms resolved.
# Code Status: Full Code
# Emergency Contact: Husband ___
====================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / lisinopril / bee stings / shellfish derived
Attending: ___
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Time (and date) the patient was last known well: ___ unknown
time (24h clock)
___ Stroke Scale Score: 2
The NIHSS was performed:
Date: ___
Time: 1215
(within 6 hours of patient presentation or neurology consult)
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: 1 (chronic)
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 1
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
t-PA given:
-No Reason t-PA was not given or considered: outside of time
window
Thrombectomy performed: [] Yes [x] No
-If no, reason thrombectomy was not performed or considered:
outside of time window
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
Pre-mRs:3
REASON FOR CONSULTATION: Code stroke/or stroke
HPI:
Ms. ___ is a ___ female with medical history notable for
asthma complicated by recurrent exacerbations, obesity, chronic
pain/fibromyalgia syndrome, history of CVA, hypertension,
hypothyroidism who presents with dizziness.
Briefly, patient reports that 3 days ago she suddenly developed
sudden onset vertigo, room spinning to the right while walking
to
her kitchen. This is been persistent. Is worse with certain
movements, and is resolves when laying still. Patient has fallen
multiple times over the last 2 days, soft falls with abrasions
to
her left elbow, no head strike. Denies associated neurological
symptoms such as new focal weakness (has chronic left weakness
from previous stroke), no numbness or difficulty with language,
no dysarthria. Denied any diplopia, however on formal testing
found to have diplopia when looking to the right. headaches. No
headache, but does report nausea. Patient also reports mild leg
swelling over the past 1 week, no chest pain or shortness of
breath.
Regarding her past stroke:
___, CVA, it was apparently an atypical
presentation secondary to a right leg DVT and pulmonary embolus
in the setting of right foot surgery. This is the same foot that
in ___ had to be reconstructed and revascularized from a
traumatic motorcycle accident. The CVA apparently occurred
through a small patent foramen ovale that was not suspected. She
was worked up at ___. Again, it did not present as an acute
stroke, it was more of a slow developing weakness of the upper
and lower extremities, which persists and diminished left-sided
hearing. The patent foramen ovale was, therefore, determined
relatively late and they did not recommend closure at that time.
She remains aware of upper and lower extremity weakness on the
left and reduced hearing."
Of note patient has been seen in the ED two times last week for
back and neck pain. This has much improved and does not
currently
bother her. Also upon chart review it appears that she is coming
to the ED at least ___ times per months for years for various
problems.
Also per chart review was seen for vertigo once in ___
ROS: 10 point ROS reviewed as in HPI
Past Medical History:
___: ___, CVA (residual L side weakness) ___ RLE DVT/PE, PFO,
OSA, hx PNA, Lumbar DJD w/spinal stenosis, HTN, asthma,
hypothyroid, neuropathy, obesity (BMI 38.8), fibromyalgia,
migraines, GERD, Raynaud syndrome, OSA(on 2 liters O2 qhs) L
knee OA, and diverticulosis, herniated cervical discs, fatty
liver.
Social History:
___
Family History:
Pancreatic cancer, GERD, stomach ulcers, COPD and asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: trace edema in BLE, pulses palpated
- 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.
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. Diplopia on
right lateral gaze resolved when covering right eye. However not
resolved when covering left eye. She was unable to tell me which
image disappeared.
III, IV, VI: EOMI with nystagmus on lateral gaze
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. LUE drift (chronic)
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4 5- ___ 5 5 5 5 5 5
R 5 ___ 5 5 5 5 5 5 5
-DTRs:
[Bic] [Tri] [___] [Quad]
L 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+
Plantar response flexor bilaterally.
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-Coordination: No intention tremor. Dysmetria on FNF
bilaterally.
-Gait: Able to get of bed by herself and walk a few steps,
appears unsteady and somewhat broad based.
*HIT w/o correction
*Subtle skew deviation noted
*No nystagmus with ___ hall pike
DISCHARGE PHYSICAL EXAM
========================
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: obese, soft, nontender, nondistended
- Extremities: trace edema in BLE, no cyanosis or clubbing
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. 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. No diplopia.
III, IV, VI: EOMI with bilateral nystagmus without fatigue.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger snapping bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. LUE drift (chronic)
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ 5 5 5 5 5 5 5
-DTRs:
[Bic] [Tri] [___] [Quad]
L 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+
Plantar response flexor bilaterally.
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-Coordination: No intention tremor. Dysmetria on FNF
bilaterally
(L>R)
-Gait: Able to get of bed by herself and walk a few steps,
unsteady, veered to left side when standing with eyes closed.
Broad based.
Pertinent Results:
ADMISSION LABS
================
___ 11:55AM BLOOD WBC-10.2* RBC-4.11 Hgb-12.6 Hct-36.4
MCV-89 MCH-30.7 MCHC-34.6 RDW-14.2 RDWSD-45.5 Plt ___
___ 11:55AM BLOOD Neuts-72.4* Lymphs-16.9* Monos-7.4
Eos-2.3 Baso-0.6 Im ___ AbsNeut-7.36* AbsLymp-1.72
AbsMono-0.75 AbsEos-0.23 AbsBaso-0.06
___ 11:55AM BLOOD Plt ___
___ 11:05AM BLOOD Glucose-153* UreaN-13 Creat-0.9 Na-146
K-2.9* Cl-101 HCO3-29 AnGap-16
___ 11:05AM BLOOD ALT-37 AST-39 AlkPhos-100 TotBili-0.3
___ 11:05AM BLOOD Lipase-24
___ 11:05AM BLOOD cTropnT-<0.01
___ 11:05AM BLOOD proBNP-41
___ 11:05AM BLOOD Albumin-3.8 Calcium-9.6 Phos-2.7 Mg-1.8
___ 11:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
================
___ 08:13AM BLOOD WBC-6.7 RBC-3.98 Hgb-12.1 Hct-35.6 MCV-89
MCH-30.4 MCHC-34.0 RDW-14.1 RDWSD-45.7 Plt ___
___ 08:13AM BLOOD Plt ___
___ 08:13AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-146
K-3.5 Cl-103 HCO3-32 AnGap-11
___ 08:13AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7
IMAGING
========
FINDINGS:
CTA HEAD W&W/O C & RECONS Study Date of ___
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute large territorial infarction,
hemorrhage, edema, or mass effect. The ventricles and sulci are
within expected limits in size and configuration.
There is trace mucosal thickening of the right sphenoid sinus
and left
maxillary sinus. The remaining visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion,
or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
Mild motion artifact, photon starvation and timing of bolus
results in
slightly suboptimal evaluation of the carotid and vertebral
vessels within the neck. Within this confines, the carotid and
vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of
internal carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the thyroid gland is within normal limits. There is
no lymphadenopathy by CT size criteria.
IMPRESSION:
1. Unremarkable CTA head and neck. No evidence of high-grade
stenosis,
occlusion or aneurysm. No stenosis of the cervical internal
carotid arteries
by NASCET criteria.
2. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial
hemorrhage.
3. Additional findings as described above.
MR HEAD W/O CONTRAST Study Date of ___
FINDINGS:
Evaluation is suboptimal due to motion artifact. There is no
evidence of hemorrhage, edema, masses, mass effect, midline
shift or infarction. The ventricles and sulci are prominent,
consistent with global cerebral volume loss. Minimal patchy
periventricular T2 hyperintensities are most consistent with
chronic small vessel ischemic disease.
The visualized paranasal sinuses are clear. The mastoid air
cells are clear. The intraorbital contents are normal.
IMPRESSION:
1. No acute intracranial abnormalities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO BID
2. Chlorthalidone 25 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Aspirin 162 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN SOB
8. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection BID:PRN
9. Esomeprazole 20 mg Other BID
10. Ranitidine 300 mg PO QHS
11. Baclofen 10 mg PO TID
12. BuPROPion 100 mg PO BID
13. Citalopram 40 mg PO QHS
14. Gabapentin 600 mg PO TID
15. Promethazine 25 mg PO Q6H:PRN allergies
16. lutein 20 mg oral unknown
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth DAILY Disp #*90
Tablet Refills:*3
2. LORazepam 0.5 mg PO DAILY:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet(s) by mouth DAILY Disp #*6 Tablet
Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
4. amLODIPine 5 mg PO BID
5. Aspirin 162 mg PO DAILY
6. Baclofen 10 mg PO TID
7. BuPROPion 100 mg PO BID
8. Chlorthalidone 25 mg PO DAILY
9. Citalopram 40 mg PO QHS
10. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection BID:PRN
11. Esomeprazole 20 mg Other BID
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Gabapentin 600 mg PO TID
14. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN SOB
15. Levothyroxine Sodium 125 mcg PO DAILY
16. lutein 20 mg oral unknown
17. Promethazine 25 mg PO Q6H:PRN allergies
18. Ranitidine 300 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
#Vertigo
#HLD
#HTN
#Asthma
#Hypothyroid
#Chronic pain
#Fibromyalgia
#Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with leg swelling, abrasions on elbow; +vertigo, +HINTS,
concern for vertebral infarct// eval PNA, pulm edema; eval fracture; eval
stenosis
TECHNIQUE: Frontal lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with leg swelling, abrasions on elbow; +vertigo, +HINTS,
concern for vertebral infarct// eval PNA, pulm edema; eval fracture; eval
stenosis
TECHNIQUE: Three views of the left elbow.
COMPARISON: None.
FINDINGS:
There is no acute fracture. Well corticated ossific density adjacent to the
trochlea appears chronic, potentially degenerative. There is no elbow joint
effusion. Soft tissues are unremarkable.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with leg swelling, abrasions on elbow; +vertigo,
+HINTS, concern for vertebral infarct// eval PNA, pulm edema; eval fracture;
eval 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 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 3.0 s, 0.5 cm; CTDIvol = 15.0 mGy (Body) DLP =
7.5 mGy-cm.
3) Spiral Acquisition 4.7 s, 36.9 cm; CTDIvol = 15.2 mGy (Body) DLP = 560.3
mGy-cm.
Total DLP (Body) = 568 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: No relevant priors on PACS.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute large territorial infarction, hemorrhage, edema,
or mass effect. The ventricles and sulci are within expected limits in size
and configuration.
There is trace mucosal thickening of the right sphenoid sinus and left
maxillary sinus. The remaining visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
Mild motion artifact, photon starvation and timing of bolus results in
slightly suboptimal evaluation of the carotid and vertebral vessels within the
neck. Within this confines, the carotid and vertebral arteries and their major
branches appear normal with no evidence of stenosis or occlusion. There is no
evidence of internal carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Unremarkable CTA head and neck. No evidence of high-grade stenosis,
occlusion or aneurysm. No stenosis of the cervical internal carotid arteries
by NASCET criteria.
2. No acute intracranial abnormality on noncontrast head CT. Specifically no
large territory infarct or intracranial hemorrhage.
3. Additional findings as described above.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old woman with vertigo// eval stroke
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 head and neck dated ___
FINDINGS:
Evaluation is suboptimal due to motion artifact.
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are prominent, consistent with global
cerebral volume loss. Minimal patchy periventricular T2 hyperintensities are
most consistent with chronic small vessel ischemic disease.
The visualized paranasal sinuses are clear. The mastoid air cells are clear.
The intraorbital contents are normal.
IMPRESSION:
1. No acute intracranial abnormalities.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, s/p Fall
Diagnosed with Dizziness and giddiness
temperature: 97.8
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 145.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with medical history notable
for asthma complicated by recurrent exacerbations, obesity,
chronic pain/fibromyalgia syndrome, history of CVA with residual
left sided weakness, hypertension and hypothyroidism who
presented with 3 days of vertigo. She had an MRI of her brain
which was negative for any acute stroke.
#Vertigo ___ to peripheral vestibulopathy
Presented with several days of vertigo and sensation of room
spinning, associated with headache. Her dizziness resulted in a
fall in which she hit her left elbow and knee. Initial exam
notable or bilateral nystagmus on lateral gaze, monocular
diplopia, and bilateral dysmetria. ___ hall pike negative. CT
head with no acute process. CTA head and neck with patent
vessels. She had a prior CVA in ___, presented as slow
left-sided weakness of upper and lower extremities, may have
been in setting of R leg DVT and PE following foot surgery,
found to have PFO which was not closed. She was admitted to the
stroke service for MRI. Throughout her admission, her repeat
neurologic exams were notable for persistent gait unsteadiness
(swayed to left with eyes closed) and bilateral nystagmus. She
continued to have positional vertigo and intermittent headaches.
Her MRI demonstrated NO STROKE. Her symptoms drastically
improved and she was able to ambulate independently at the time
of discharge.
Her stroke risk factors were assessed and notable for LDL: 139,
A1C 4.8. She was initiated on atorvastatin 40 mg daily, she was
continued on her home aspirin 162 mg daily.
#Asthma:
Chronic, complicated by multiple exacerbations. On 3L oxygen in
evening. No evidence of exacerbation on admission. Continued
home duonebs, Fluticasone-Salmeterol in-house. Other home
medications non formulary.
#HTN:
Continued home amlodipine, chlorthalidone.
#Hypothyroidism:
TSH 0.93. Continued home levothyroxine.
#Chronic pain
#Fibromyalgia:
Peripheral inflammatory markers elevated. No evidence of acute
flare. Continued home gabapentin.
#Depression:
Continued home citalopram, wellbutrin. She expressed significant
anxiety, she was given 3 days of Ativan until she sees her PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
L ankle pain
Major Surgical or Invasive Procedure:
Ex-fix left tibia
History of Present Illness:
___ with left pilon fracture. Patient fell off a ladder.
Originally presented to ___. X-rays showed a
distal communinuted fracture of the left distal tibia and
fibula. At the time he was noted to have a cold foot and pulses
were unable to be found by doppler. He was then transferred.
Past Medical History:
HTN, HLD
Social History:
___
Family History:
nc
Physical Exam:
Admission PE:
In general, the patient is a well-appearing man
Vitals: 98.7 96 154/88 14 98% RA
Left lower extremity:
Skin intact
Soft, non-tender thigh
Patient with mild deformity of left ankel with intact skin
Non-palpable DP or ___ pulses but strong signal found by doppler
Full, painless AROM/PROM of hip, knee,
Difficulty with ROM of left ankle due to pain
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
Discharge PE:
AVSS
NAD
LLE: Dressing c/d/i. nvid.
Pertinent Results:
___ 04:25AM BLOOD WBC-15.9* (improving) RBC-4.82 Hgb-15.0
Hct-42.6 MCV-89 MCH-31.1 MCHC-35.2* RDW-13.6 Plt ___
Medications on Admission:
Lisinopril 20 mg qdaily
Simvastatin 40 mg qdaily
ASA 81 mg
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc qpm Disp #*14 Syringe
Refills:*0
5. Lisinopril 20 mg PO DAILY
6. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth q8h prn Disp #*30
Tablet Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
hold for sedation. decrease dosage as soon as possible.
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*50
Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
L tibia/fibula fracture
Discharge Condition:
Improved. AO3. NWB LLE in ex-fix.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with tib fib fracture s/p reduction // eval for post
reduction
TECHNIQUE: AP and lateral views of the proximal and distal left tibia and
fibula.
COMPARISON: None.
FINDINGS:
Overlying cast obscures fine bony detail. There is a comminuted
intra-articular distal left tibia fracture. There is approximately 7 mm of
medial displacement of the largest medial fracture fragment. Similar degree of
posterior displacement seen of the posterior malleolus. Distal left fibular
fracture at the level of the syndesmosis is noted. There is medial angulation
of the distal fracture fragment. Proximally, there is no tibia or fibular
fracture.
Radiology Report
INDICATION: ___ with 8 foot fall // eval for rib fracture, ptx
TECHNIQUE: Single supine view of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear of focal consolidation, effusion, or evidence of
pneumothorax on this supine film. The cardiomediastinal silhouette is within
normal limits. No displaced rib fracture identified.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: A ___ man with a fall and headache, concern for
intracranial hemorrhage or fracture.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: ___ MGy-cm.
CTDI: ___ MGy.
COMPARISON: None.
FINDINGS:
There is no hemorrhage, acute large vascular territorial infarct, or brain
edema. The basal cisterns are patent. There is no shift of normally midline
structures. There is no ventriculomegaly. There is preservation of
gray-white matter differentiation. The visualized paranasal sinuses and
mastoid air cells are clear. The globes and bony orbits are unremarkable.
There is no fracture.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: A ___ man with a fall and headache, evaluate for C-spine
injury.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
DLP: 975.27 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no fracture or traumatic subluxation. There is no prevertebral soft
tissue swelling or hematoma. There are mild degenerative joint changes of the
cervical spine. Uncovertebral osteophytes result in mild neural foraminal
narrowing, worst at C5-6. There is no critical central spinal canal narrowing.
IMPRESSION:
No fracture or traumatic subluxation.
NOTIFICATION: The above findings were communicated over telephone to Dr.
___ by Dr. ___ on ___ at 15:15.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT IN O.R.
INDICATION: Left ankle external fixator placement.
TECHNIQUE: 17 spot fluoroscopic images obtained in the OR without radiologist
present.
Fluoroscopy time: 23.2 seconds
COMPARISON: Left tibia and fibula radiographs ___
FINDINGS:
The available images show placement of external fixator device with proximal
transfixing through screws through the tibia and a distal screw than appears
to pass through the calcaneus. There is again visualized a comminuted fracture
of the distal tibia and fibula with talar tilt and intra-articular extension.
The subsequent images show distraction of the tibiotalar joint with improved
alignment. There is diffuse soft tissue swelling. Please see the operative
report for further details.
IMPRESSION:
Intraoperative images from external fixation of a distal tibia and fibula
fracture.
Radiology Report
INDICATION: ___ year old man s/p fall now s/p L tib ex-fix application. Eval
in traction for ORIF planning. // post op eval; ex-fix L tibia
COMPARISON: Left ankle radiographs dated ___. Intraoperative
spot fluoroscopic views from ___
FINDINGS:
External fixation devices are present, secured in the posterior calcaneus and
tibial midshaft.
There are markedly comminuted fractures of the distal tibia and fibula.
The tibial fracture extends to the articular surface of the tibial plafond.
There are components of the fracture which exit at the distal tibial
metadiaphysis and an additional vertical fracture line subtending the medial
malleolus. There is marked comminution and morselization of bone in the region
of the tibial metaphysis. Along the tibial plafond, there is a punch-die type
defect that measures approximately 12.3 mm (anteroposterior), with depression
of approximally 13.1 mm(400 b: 38 -40). In addition, there is a large
posterior tibial fragment, which is depressed relative to its usual position,
resulting in marked widening of the tibiotalar joint posteriorly. This
involves approximately 10.1 mm of the posterior tibial articular surface
(anteroposterior), with depression of approximately 23.8 mm. More anteriorly,
the tibial articular surface is located in its usual position (400 b: 46).
Multiple punctate ossific fragments lie within the mortise joint itself (400
b: 43-44).
The distal fibular diaphyseal fracture is in overall anatomic alignment, with
very slight (cortical width) anterior displacement of the distal fragment and
very slight anterior and lateral apex angulation.
No other fractures are identified. The subtalar, talonavicular,
calcaneocuboid, and remaining tibiotalar joints remain congruent on this
nonstress exam. The talar dome is intact, without evidence of talar dome OCD.
Incidental note is made of an os trigonum ossicle. Tiny ossific densities
adjacent to the medial talus (2:121), likely represent a small bipartite
accessory navicular ossicle. Rounded lucency with surrounding sclerosis in the
distal medial navicular abutting the navicular cuneiform joint space is not
fully characterized, but likely represents a degenerative cyst with reactive
sclerosis. Scattered foci of subcutaneous emphysema are present.
Assessment of the surrounding soft tissues is limited, but there is prominent
soft tissue swelling. As noted on the wet reading, the tibialis posterior and
flexor digitorum longus tendons lie in close proximity to a posteromedial
fracture line, with the PTT interposed within both fracture fragments,
concerning for possible entrapment (3:99). Vascular calcification noted.
IMPRESSION:
1. Comminuted fracture of the distal tibia with components involving the
distal meta diaphysis, medial malleolus, and tibial plafond.
2. The tibial plafond component is compatible with a severely comminuted pilon
type fracture. There is considerable distraction and depression of the
fracture fragments, with respect to the usual tibial plafond articular
surface, detailed above. Punctate fracture fragments noted within the mortise
joint.
3. Comminuted fracture of the distal fibular diaphysis, in overall anatomic
alignment, with only minimal offset and angulation.
4. No other fractures detected about the ankle/hindfoot.
5. Tibialis posterior tendon interposed between 2 tibial fracture fragments
along the posterior tibia, with the FDL tendon immediately adjacent to it
(3:99). This finding raises concern for tendon entrapment.
6. External fixation device in place.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: TRAUMA TRANSFER
Diagnosed with FX ANKLE NOS-CLOSED, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, HYPERTENSION NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ex-fix L ankle, which the patient tolerated well
(for full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
w/services was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the LLE, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cyclobenzaprine / Humira
Attending: ___.
Chief Complaint:
Left hip pain and erythema
Major Surgical or Invasive Procedure:
Left hip washout ___
PICC line insertion ___
TEE cardioversion ___
History of Present Illness:
___ with multiple medical problems, including atrial
fibrillation on warfarin, presenting from ___ ___
___ with left hip erythema and pain. The patient recently
completed a course of vancomycin on ___ for left hip
osteomyelitis vs. septic hip. Since discontinuation of
antibiotic therapy the patient has experienced increased left
hip symptoms.
___ the ED initial vitals signs were: 98.9 80 105/62 97% 3L NC.
He spiked a fever to 100.3 while ___ the emergency deparmtne. A
CT scan of the left hip showed extensive fragmentation and
osteolysis of the left femoral head likely osteomyelitis with
concern for phlegmon/abscess. The CT scan also noted bibasilar
lung consolidations potentially representing aspiration/PNA.
Orthopedics was consulted ___ the ED and recommended IV
antibiotics, ___ aspiration, and consideration of washout after
___ drainage. The patient was given vancomycin and Zosyn ___ the
ED. While ___ the ED, the patient was transiently hypotensive to
systolic blood pressures of 60-80. His blood pressure was
responsive to two 500cc boluses.
His EKG was significant for STE ___ AVR and ST depressions ___
v3-v6. Troponin was elevated at 0.14 -> 0.14 with normal CK MB.
His BNP was noted to be 7700. His INR was theraputic at 2.4. His
white blood cell count was 10 at rehab, increasing to 16.9 on
admission.
On arrival to the MICU, the patient is complaining of right
wrist pain, chronic low back pain and left hip pain. He is vague
with regards to the onset and timing of his symptoms. He denies
fevers, chills, dysuria, N/V/D, CP, SOB, HA, and abd pain.
Review of systems:
Per HPI
Past Medical History:
MRSA bacteremia
Left hip septic arthritis treated with vancomycin for 6 weeks
Hypercholesterolemia
Chronic venous insufficency
Rheumatoid arthritis,
Coronary artery disease s/p CABG
Osteoarthritis
OS blindness
Adrenal insufficiency
Hiatal hernia
Chronic tinnitus
Fatty liver
Substernal thyroid
OSA
Restless legs syndrome
Pulmonary hypertension
Gout
Neuropathy peripheral
Vitamin D deficiency
Osteopenia
Iron deficiency anemia
Monoclonal gammopathy
Keratosis
Diabetes mellitus with neurological manifestation
Systolic HF
AL amyloidosis
Diverticulitis of large intestine with perforation s/p colostomy
Asbetosis on home oxygen (3L)
Atrial fibrillation/atrial flutter
Social History:
___
Family History:
Father: renal failure, heart failure
Mother: myocardial infarction
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 99.8 BP: 108/55 P: 113 R: 24 O2: 95% on 4 L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx with copius discharge,
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,
ronchi
Abdomen: soft, non-tender, non-distended, right sided colostomy
bag, mid abdominal wound healing by secondary intention.
BACK: Stage 3 sacral decub per nursing.
GU: no foley
Ext: Left hip is erythematous, warm, tender, decreased ROM ___
pain. warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moving all extremities. Sensation intact. Pt awake,
alert.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.4 125/88 64 16 100% on 3L
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx w/o mucosal lesions,
EOMI, right pupil RRL, left pupil s/p cataract surgery
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur, no rubs or gallops
Lungs: Fine crackles at bases bilaterally
Abdomen: soft, non-tender, non-distended, right sided colostomy
bag, mid abdominal wound healing by secondary intention.
BACK: Stage 3 sacral decub per nursing.
GU: no foley
Ext: Upper extremity rheumatoid deformities. Left hip dressing
C/D/I with surrounding edema w/o erythema. Extremities warm,
well perfused, 2+ pulses, no clubbing/cyanosis.
Neuro: Moving all extremities. Sensation intact.
Pertinent Results:
ADMISSION LABS:
___ 09:30PM BLOOD WBC-16.9* RBC-3.69* Hgb-11.9* Hct-36.6*
MCV-99* MCH-32.2* MCHC-32.5 RDW-16.6* Plt ___
___ 09:30PM BLOOD Neuts-89.2* Lymphs-4.4* Monos-3.1 Eos-3.0
Baso-0.2
___ 03:45AM BLOOD ___
___ 06:23AM BLOOD ESR-120*
___ 09:30PM BLOOD Glucose-83 UreaN-34* Creat-1.0 Na-139
K-4.8 Cl-96 HCO3-29 AnGap-19
___ 09:30PM BLOOD CK(CPK)-35*
___ 06:23AM BLOOD Albumin-2.7* Calcium-8.7 Phos-4.2 Mg-1.6
___ 04:15AM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:15AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 04:15AM URINE RBC-6* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
DISCHARGE LABS:
___ 05:58AM BLOOD WBC-13.0* RBC-2.81* Hgb-8.8* Hct-27.8*
MCV-99* MCH-31.5 MCHC-31.8 RDW-16.8* Plt ___
___ 05:58AM BLOOD Neuts-81.6* Lymphs-9.4* Monos-7.7 Eos-0.9
Baso-0.4
___ 05:58AM BLOOD ___ PTT-38.1* ___
___ 05:58AM BLOOD Glucose-79 UreaN-26* Creat-0.7 Na-139
K-5.5* Cl-100 HCO3-28 AnGap-17
___ 01:05PM BLOOD Na-140 K-5.2* Cl-100
___ 05:58AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8
PERTINENT LABS:
___ 06:23AM BLOOD ESR-120*
___ 02:41AM BLOOD Hapto-410*
___ 06:23AM BLOOD CRP->300
___ 09:30PM BLOOD CK-MB-3 cTropnT-0.14* proBNP-7705*
___ 05:10AM BLOOD CK-MB-4 cTropnT-0.14*
___ 09:40AM BLOOD CK-MB-5 cTropnT-0.14*
___ 11:07PM BLOOD CK-MB-4 cTropnT-0.09*
___ 04:05AM BLOOD CK-MB-4 cTropnT-0.07*
___ 02:41AM BLOOD CK-MB-3 cTropnT-0.05*
___ 06:40AM BLOOD Vanco-16.2
___ 06:20AM BLOOD Vanco-18.6
___ 06:54AM BLOOD Vanco-17.5
___ 05:58AM BLOOD Vanco-18.3
CT Abdomen/Pelvis ___
IMPRESSION:
1. Extensive fragmentation and osteolysis involving the left
femoral head, which may represent osteomyelitis ___ the
appropriate clinical settings. There is extensive mildly
enhancing soft tissue surrounding the left hip joint. Anterior
to the left hip joint, there is a 2.6 x 3.6cm hypodense
collection with hyper-enhancing rim, which likely represents an
abscess.
2. Small bibasilar consolidations, right greater than left,
concerning for infection or aspiration ___ the appropriate
clinical setting.
3. Extensive calcified atherosclerotic disease without
associated aneurysmal changes.
4. Bilateral renal cysts.
5. Colonic diverticula without evidence of acute diverticulitis.
6. Small hiatal hernia.
7. Small ventral hernias, containing decompressed small bowel
loops. No
evidence of bowel obstruction.
Joint Aspiration ___
IMPRESSION:
1. Uneventful left hip joint aspiration of approximately 3 mL of
sanguinous nonpurulent left hip joint fluid. Specimens were
obtained and carried directly to the pathology laboratory for
microbiologic and fluid analysis.
2. Imaging demonstrates advanced joint space loss ___ the left
hip joint, with destruction of the femoral head and remodeling
of the left acetabulum.
L Leg ___ Doppler
IMPRESSION:
No evidence of DVT ___ the left lower extremity.
CT Abdomen/Pelvis ___
IMPRESSION:
1. Interval development of a large right rectus abdominis
hematoma measuring approximately 9.7 x 7.3 x 13.3 cm with
intrapelvic extension. Tiny hyperdense focus within hematoma
may represent punctate pseudoaneurysm. Close monitoring of
hematocrit advised.
2. Interval improvement of bibasilar clung onsolidations.
3. Interval increased fragmentation and osteolysis of the left
femoral head consistent and placement of drain consistent with
interval debridement of known septic hip. Interval resolution
of rim-enhancing adjacent collection evident on prior study.
4. Additional stable (nonemergent) findings as ___ the body of
this report.
TTE ___
The left atrium is elongated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. LV systolic function appears depressed probably
moderately to severely but views are technically suboptimal.
Estimated left ventricular ejection fraction is uncertain,
possibly 25%. The right ventricular cavity is mildly dilated
with depressed free wall contractility. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets are
mildly thickened (?#). The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is no pericardial
effusion.
TEE ___
No spontaneous echo contrast or thrombus is seen ___ the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect is seen by
2D or color Doppler. There are simple atheroma ___ the descending
thoracic aorta. The aortic valve leaflets are mildly thickened
(?3). The left and noncoronary cusp appear partially fused as a
result of degenerative change. No masses or vegetations are seen
on the aortic valve. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The tricuspid valve leaflets are
mildly thickened. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. Moderate [2+] tricuspid regurgitation is seen. No
masses or vegetations are seen on the pulmonic valve, but cannot
be fully excluded due to suboptimal image quality. IMPRESSION:
No intra-atrial SEC or clot. At least moderate mitral
regurgitation and moderate tricuspid regurgitation with no
vegetations or abcesses seen.
CT ABD/PELVIS
FINDINGS:
Note is again made of calcified pleural plaques bilaterally.
Again also seen is a chronic appearing small subdiaphragmatic
fluid collection. Extensive coronary calcifications are present
within a mildly enlarged heart. Within the limits of this
unenhanced study, the liver, spleen, and pancreas appear
unremarkable. The adrenal glands are unremarkable. Multiple
kidney cysts bilaterally are again noted. There is no
pelvicaliceal dilatation or perinephric abnormality present.
Again seen is a mixed type hiatal hernia. The stomach and small
bowel are unremarkable. The patient is status post partial
colectomy with colostomy seen ___ the right lower quadrant,
unremarkable. Again seen is a anterior midline small bowel
hernia. Again also seen is a rectus sheath hematoma appearing
largely stable compared to the prior study. It currently
measures 8.7 x 7.7 cm. The mild surrounding inflammatory change
is less prominent on the current study. There is no new area of
fluid collection concerning for hematoma. Again seen is stable
appearance of the left femoral head with removal of the catheter
which resided ___ the joint space. There is no focal fluid
collection ___ this area. Again noted is a right total hip
replacement. Stable degenerative changes of the spine are again
seen. Asymmetrical muscle bulk ___ the left hip is again noted.
IMPRESSION: 1. No new source of bleeding identified. 2. Stable
appearance of rectus sheath hematoma.
CULTURE DATA
___ 9:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___ FROM
___.
STAPH AUREUS COAG +. ___ MORPHOLOGY.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
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.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ 615PM
___.
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
Time Taken Not Noted ___ Date/Time: ___ 6:51 am
URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA OXYTOCA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA OXYTOCA
| |
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S 4 S
CEFAZOLIN------------- <=4 S 8 R
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
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 ___
/___ 11:00 am TISSUE FEMORAL HEAD + NECK BONE.
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 NURSE ___ (___)
ON ___
AT 3:00PM.
TISSUE (Final ___:
___. ___ ___ REQUESTED SENSITIVITIES TO BE
PERFORMED
SEPARATELY ___.
STAPH AUREUS COAG +. SPARSE GROWTH.
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.
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.
STAPH AUREUS COAG +. SPARSE GROWTH. SECOND MORPHOLOGY.
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.
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 +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S 0.25 S
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ 1 S 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 11:00 am SWAB SUPERFICIAL LEFT HIP.
SWAB FROM AN ABSCESS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___,
___.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Medications on Admission:
1. Morphine SR (MS ___ 90 mg PO Q8H
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
4. Furosemide 20 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Metoprolol Tartrate 50 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Warfarin 8 mg PO DAILY16
9. traZODONE 50 mg PO HS:PRN insomnia
10. Senna 2 TAB PO HS
11. Bisacodyl 10 mg PO DAILY:PRN constipation
12. Ondansetron 4 mg PO Q6H:PRN nausea
13. Sorbitol 30 mL PO QPM:PRN constipation
14. Colchicine 0.6 mg PO BID
15. Milk of Magnesia 30 mL PO QHS:PRN constipation *AST Approval
Required*
16. Fleet Enema ___AILY:PRN constipation
17. Magnesium Citrate 10 ounces PO DAILY:PRN constipation
18. PredniSONE 30 mg PO DAILY
19. Ascorbic Acid ___ mg PO DAILY
20. Allopurinol ___ mg PO DAILY
21. Glargine 20 Units Breakfast
22. Simvastatin 40 mg PO QHS
23. Gabapentin 300 mg PO BID
patient states still taking this
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. Allopurinol ___ mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Furosemide 20 mg PO DAILY
7. Gabapentin 300 mg PO Q8H
8. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
10. Metoprolol Tartrate 50 mg PO QID
11. Morphine SR (MS ___ 60 mg PO Q8H
12. PredniSONE 20 mg PO DAILY
13. Warfarin 7.5 mg PO DAILY16
14. Aspirin 81 mg PO DAILY
15. Atorvastatin 80 mg PO DAILY
16. Digoxin 0.125 mg PO DAILY
17. Famotidine 20 mg PO Q12H
18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
19. Lisinopril 10 mg PO DAILY
20. Miconazole Powder 2% 1 Appl TP QID:PRN rash
21. Miconazole Powder 2% 1 Appl TP BID:PRN rash
22. Sarna Lotion 1 Appl TP QID:PRN itch
23. Sulfameth/Trimethoprim DS 1 TAB PO MWF
24. Thiamine 100 mg PO DAILY
25. Vancomycin 1500 mg IV Q 24H
continue until ___
26. Acetaminophen 650 mg PO Q6H:PRN pain
27. Lidocaine 5% Patch 1 PTCH TD DAILY
28. Magnesium Citrate 10 ounces PO DAILY:PRN constipation
29. Milk of Magnesia 30 mL PO QHS:PRN constipation
30. Senna 2 TAB PO HS
31. Ondansetron 4 mg PO Q6H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MRSA bacteremia
Left septic hip
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).
Followup Instructions:
___
Radiology Report
HISTORY: Residual bone cleanup.
FINDINGS: Images from the operating suite are presented. Further information
can be gathered from the operative report.
Radiology Report
PORTABLE AP SEMI-ERECT CHEST FILM, ___ AT 22:03
CLINICAL INDICATION: ___ with septic hip. Evaluate for pulmonary
edema.
___ at 6:44.
A portable semi-erect chest film, ___ at 22:03 is submitted.
IMPRESSION:
1. Overall stable cardiac and mediastinal contours in this patient status
post median sternotomy for CABG. Interval improvement in pulmonary edema
since the previous study, although there is still residual mild edema on the
current examination. There is a large hiatal hernia. Calcified diaphragmatic
pleural plaques are again seen consistent with prior asbestos exposure.
Interval removal of the right PICC line. Probable small left effusion. No
evidence of pneumothorax.
Radiology Report
INDICATION: History of diverticulitis and perforation, status post ostomy
with abdominal hernia with increasing right lower quadrant abdominal pain,
area feels firm on examination. Please evaluate for incarcerated hernia or
abdominal wall hematoma.
COMPARISON: Comparison is made to CT abdomen and pelvis performed ___.
TECHNIQUE: Contrast-enhanced axial images obtained from the lung bases to the
pelvic outlet. Coronal and sagittal reformations were provided.
FINDINGS: There is redemonstration of an incompletely visualized mixed-type
hiatal hernia. The stomach is otherwise unremarkable. The patient is status
post a partial colectomy with colostomy evident in the right lower quadrant.
There is diastasis of the rectus abdominis muscles progressing to an anterior
midline small bowel containing hernia more inferiorly. There has been
interval development of a large 9.7 x 7.3 x 13.3 cm (TRV x AP x CC) right
rectus sheath hematoma with break through into the intraperitoneal space. A
tiny hyperdense focus is identified in the inferomedial aspect of the hematoma
(2:68) which may represent a punctate pseudoaneurysm. Attention on follow-up.
The right inferior epigastric artery is remote from hyperdense focus. The new
right rectus sheath hematoma is causing some narrowing of neck of lower
midline hernia though there is no evidence of associated small bowel
obsruction or strangulation. There is a mild amount of surrounding
inflammatory change in both overlying superficial soft tissues and adjacent
intrabdominal fat.
Majority of visualized muscle bulk is severly atrophic likely related to
longterm immobility associated with known left septic hip. Asymmetric muscle
bulk in the right piriformis and proximal aspect of the right gluteus maximus
(2:70, 2:75)is unchanged compared to prior study and likely due to assymetric
atrophy than another area of intramuscular hematoma.
There is increased fragmentation and osteolysis of the left femoral head
consistent with continued debridement of known septic joint. A catheter now
terminates in the joint space and the previously noted adjacent rim enhancing
collection has resolved. There are significant surrounding inflammatory
changes and soft tissue edema without focal fluid collection. Specifically, a
fluid collection noted on the ___ study is no longer evident.
Right total hip hardware appears intact. Stable degenerative changes noted in
the lumbar spine including bialteral L5 pars defects and associated grade 1
anterolisthesis of L5 on S1 .
Calcified pleural plaques are identified bilaterally. There is
chronic-appearing small subdiaphragmatic fluid collection on the left
measuring 1.3 cm, unchanged from prior. In addition, there are multiple areas
of partially calcified complex fluid density collections the abdomen (2:66,
2:55) which may relate to resolving collections from prior operative
intervention.
The liver is homogeneous in attenuation without discrete masses or lesions.
There is no intra- or extra-hepatic biliary ductal dilatation. The
gallbladder is unremarkable. The pancreas is atrophic. The spleen is normal.
The bilateral adrenal glands are unremarkable. Multiple cysts are identified
in the bilateral kidneys, unchanged compared to prior study. There is no
hydronephrosis or hydroureter evident.
Coronary artery calcifications are identified. Heart size is mildly enlarged.
Extensive atherosclerotic changes are noted throughout the abdominal aorta
without aneurysm or dissection. Calcified plaques were noted at the ostia of
the celiac and superior mesenteric artery. Within the proximal superior
mesenteric artery, there is a large noncalcified plaque causing significant
narrowing of the vessel and post-stenotic dilatation (2:26, 603B:44). The
distal superior mesenteric artery is well perfused.
IMPRESSION:
1. Interval development of a large right rectus abdominis hematoma measuring
approximately 9.7 x 7.3 x 13.3 cm with intrapelvic extension. Tiny hyperdense
focus within hematoma may represent punctate pseudoaneurysm. Close monitoring
of hematocrit advised.
2. Interval improvement of bibasilar clung onsolidations.
3. Interval increased fragmentation and osteolysis of the left femoral head
consistent and placement of drain consistent with interval debridement of
known septic hip. Interval resolution of rim-enhancing adjacent collection
evident on prior study.
4. Additional stable (nonemergent) findings as in the body of this report..
Radiology Report
HISTORY: ___ male patient with left PICC line placement.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: Portable AP chest radiograph.
FINDINGS:
The left PICC line tip is seen at the level of the mid to lower SVC. There are
stable mediastinal and cardiac contours. There is residual pulmonary edema.
Again seen are calcified diaphragmatic pleural plaques consistent with prior
asbestos exposure. There is no pneumothorax. Sternotomy wires are intact.
IMPRESSION: Left PICC line tip at level of mid to lower SVC.
These findings were discussed with ___, venous access nurse, by
Dr. ___ telephone on ___ at 11:00 AM, time of
discovery.
Radiology Report
HISTORY: Rectus sheath hematoma with dropping hematocrit.
TECHNIQUE: Contiguous axial CT images were obtained through the abdomen and
pelvis without the administration of contrast. Coronal sagittal reformats
were also examined.
DLP: 846.65 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
Note is again made of calcified pleural plaques bilaterally. Again also seen
is a chronic appearing small subdiaphragmatic fluid collection. Extensive
coronary calcifications are present within a mildly enlarged heart.
Within the limits of this unenhanced study, the liver, spleen, and pancreas
appear unremarkable. The adrenal glands are unremarkable. Multiple kidney
cysts bilaterally are again noted. There is no pelvicaliceal dilatation or
perinephric abnormality present.
Again seen is a mixed type hiatal hernia. The stomach and small bowel are
unremarkable. The patient is status post partial colectomy with colostomy seen
in the right lower quadrant, unremarkable. Again seen is a anterior midline
small bowel hernia. Again also seen is a rectus sheath hematoma appearing
largely stable compared to the prior study. It currently measures 8.7 x 7.7
cm. The mild surrounding inflammatory change is less prominent on the current
study. There is no new area of fluid collection concerning for hematoma.
Again seen is stable appearance of the left femoral head with removal of the
catheter which resided in the joint space. There is no focal fluid collection
in this area. Again noted is a right total hip replacement. Stable
degenerative changes of the spine are again seen. Asymmetrical muscle bulk in
the left hip is again noted.
IMPRESSION:
1. No new source of bleeding identified.
2. Stable appearance of rectus sheath hematoma.
Radiology Report
AP CHEST, 9:07 A.M., ___
HISTORY: ___ man with episode of hypoxia and rising white count.
Suspect pneumonia.
IMPRESSION: AP chest compared to ___:
I would be tempted to call the increased peribronchovascular opacification in
the right mid lung recent aspiration, however on ___, when the patient
was resolving pulmonary edema, the right lung had the same appearance.
Therefore, I prefer vascular dilatation and early edema. Nevertheless, I
would continue close radiographic surveillance if pneumonia is suspected.
Linear calcifications in the right lung and nodular opacities in the left lung
could all be due to prior asbestos exposure.
Moderate cardiomegaly is stable, less pronounced today than it was on ___. There is probably a good-sized hiatus hernia. Because of the complexity
of multiple intrathoracic findings, if the clinical situation is equally
unclear, I would strongly recommend CT scanning for assessment.
Left PIC line ends in the upper SVC. Pleural effusion is small if any. No
pneumothorax.
Radiology Report
REASON FOR EXAMINATION: Picc line placement.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The right PICC line tip is at the level of cavoatrial junction. Heart size
and mediastinum are unchanged including cardiomegaly. There is slight
interval improvement of pulmonary edema, but still present substantial
vascular engorgement and nodular opacities in the lower lungs, partially
assessed on the current study as well as right lower lobe consolidation
worrisome for infectious process.
Radiology Report
FLUOROSCOPIC-GUIDED LEFT HIP ASPIRATION DATED ___.
CLINICAL INDICATION: Left hip erythema and extreme pain. ?septic arthritis.
COMPARISON: CT dated ___.
PROCEDURE:
Written informed consent was obtained after explaining the procedure to be
performed, risks, and alternatives. A preprocedure timeout confirmed the
procedure to be performed and the identity of the patient using three patient
identifiers.
The skin entry site at the left anterolateral hip was chosen and the skin was
prepped in standard sterile fashion. Approximately 2 mL of 1% lidocaine was
infiltrated into the subcutaneous soft tissues overlying region of interest.
Under intermittent fluoroscopic guidance, an 18 gauge spinal needle was
advanced into the left hip joint space. Approximately 3 mL of red nonpurulent
left hip joint space fluid was aspirated.
The needle was removed, pressure applied to needle entry site, and hemostasis
achieved. Patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
There is advanced joint space loss in the left hip joint with destruction of
the left femoral head, which is displaced superiorly. There is remodeling of
the left acetabulum.
IMPRESSION:
1. Uneventful left hip joint aspiration of approximately 3 mL of sanguinous
nonpurulent left hip joint fluid. Specimens were obtained and carried directly
to the pathology laboratory for microbiologic and fluid analysis.
2. Imaging demonstrates advanced joint space loss in the left hip joint, with
destruction of the femoral head and remodeling of the left acetabulum.
Dr. ___, the attending radiologist, was present and supervising throughout
the procedure.
Radiology Report
HISTORY: Persistent cellulitis in the left leg. Evaluate for DVT.
TECHNIQUE: Grayscale, color and spectral Doppler ultrasound images of the
left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins.
Normal color flow and compressibility is demonstrated in the right posterior
tibial and peroneal veins. There is normal respiratory variation of the
common femoral veins bilaterally.
IMPRESSION:
No evidence of DVT in the left lower extremity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HIP PAIN
Diagnosed with CELLULITIS OF LEG, SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.96
heartrate: 80.0
resprate: nan
o2sat: 97.0
sbp: 105.0
dbp: 62.0
level of pain: 8
level of acuity: 3.0 | ___ with a past medical history of CAD s/p CABG, atrial
fibrillation/flutter on warfarin, diverticulitis s/p colostomy,
and recurrent left hip osteomyelitis/septic arthritis who
presented with weakness and hypotension, found to have septic
arthritis and MRSA bacteremia.
#Septic arthritis
The patient presented with weakness and pain ___ his left hip. He
had a history of recurrent septic arthritis ___ his left hip and
was s/p multiple courses of IV vancomycin and aspiration
procedures ___ the previous ___ months at ___.
The last course of antibiotics was completed 2 weeks before
admission. Interestingly, the patient has a history of R hip
replacement ___ years prior, but this joint has never been
involved. CT abdomen/pelvis on arrival demonstrated signs of
osteomyelitis of the L hip. The patient was started on IV
vancomycin ___ house. Initially, interventional radiology
performed aspiration of the joint that was not convincing for
septic arthritis. Infectious Disease was consulted who
encouraged the Orthopedics service to perform a washout of the
joint. The patient underwent two separate washout procedures
___ and ___, during which large abscesses were found,
and necrotic bone, including the entire femoral head, was
removed. Cultures from the washouts grew MRSA. The patient was
afebrile with sterile cultures after these washouts. The
incisions and covering dressings remained C/D/I. He continues to
have mild left hip edema w/o erythema or warmth. He will
complete a six week course vancomycin, last dose ___. He
will be followed at ___ for this and lab work should be
faxed to them on a weekly basis to ___. He will also
follow up ___ ___ clinic.
#MRSA bacteremia
The patient was treated with IV vancomycin as above. The patient
had a PICC on arrival to ___ which was removed. One blood
culture grew out VRE, but the ID service felt this to be a
contaminant, especially since the patient was improving
clinically while on vancomycin only. The patient had a TEE
performed that ruled out endocarditis as a source of his
bacteremia. No vegetations were seen on the TEE.
#Atrial flutter/fibrillation with RVR
After his second washout procedure, the patient developed atrial
flutter/fibrillation with RVR. While at home, he takes
metoprolol for rate control and warfarin for anticoagulation.
Warfarin was held on admission due to the impending surgical
procedures. The patient's rates were inadequately controlled on
nodal agents. He underwent a TEE that showed no ___. He
was then given heparin and a successful cardioversion was
performed. He was discharged to the medical floor ___ normal
sinus rhythm on digoxin and metoprolol with plan to consider
outpt coumadin. INRs should be monitored on a daily basis to
start given need for close titration. He will follow up with
Atrius cardiology.
#NSTEMI
The patient presented with a troponin of .17, which eventually
down-trended. At___ Cardiology was consulted who uptitrated his
beta blocker therapy and recommended atorvastatin 80mg. The
patient again had a troponin bump during his initial run of
atrial flutter with RVR after the second washout procedure. This
episode was also associated with ST depressions on ECG. The
patient never complained of any chest discomfort or shortness of
breath during these episodes. ST depressions resolved with rate
control. Subsequent ECHO did show significant decrease ___ EF
from prior study. The patient should have a repeat echo should
he develop signs/symptoms of heart failure.
#RLQ Hematoma/Blood loss anemia
The patient complained of RLQ pain also after his second washout
procedure. General Surgery was consulted who recommended a CT
Abdomen which showed a rectus sheath hematoma. This was likely
from a poorly positioned heparin SQ injection. After
consultation with surgery and cardiology, the decision was made
to move forward with IV heparin and the TEE/cardioversion. The
patient was discharged to the medical floor hemodynamically
stable with a stable hct while on a heparin gtt. His hematocrit
was trended and he received 2 units of pRBCs on the general
medicine floor.
#Delirium
The patient developed marked delirium while ___ the ICU. He often
imagined his son ___ the room while he was not there. On the
general medicine floor the patient continued to be delirius. ___
talking with the family it appeared the patient has been
delirous before while on cholchine. Cholchine was discontinued.
The patient's delirium was also significantly improved with
blood transfusions.
#Pain Control
The patient's pain was difficult to control. He would often
refuse PO pain medication. A dilaudid PCA was tried, but the
patient reported he would forget to use the button. The patient
was transferred to the medical floor on an aggressive PO
regimen. He was continued on chronic prednisone along with
ranitidine and TMP-SMX prophylaxis.
# Systolic heart failure: LVEF uncertain, potentially 25% on
ECHO ___ setting of NSTEMI and SVT. BNP of 7700 this admission.
Breathing comfortable. He was treated with and discharged on
BB, ACEi, digoxin, and furosemide 20mg PO daily
# Rheumatoid Arthritis: On daily prednisone 30mg daily as outpt,
decreased to 20mg daily ___ house with GI and bactrim ppx. ___
consider further outpt taper after discussion with his
rheumatologist given his wound healing difficulties.
# Wound dehiscence Inspection of prior abdominal surgical
incision was suspicious for possible dehiscence. The patient was
seen by the general surgery service for this issue who
recommended close monitoring. Wound care followed ___ and
he should have continued wound care to the area. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old gentleman, with recent admission
for relapsed hairy cell leukemia, now D24 of cladribine (___), who was transferred from ___ with fevers and
abdominal pain.
.
In brief, hairy cell leukemia was diagnosed in ___, initially
treated with cladribine (___). Disease relapsed in ___.
Patient began treatment with second course of cladribine on
___, with course complicated by neuotropenic fevers that were
attributed to chemotherapy (infectious work-up was unrevealing),
as well as left basilic non-occlusive thrombus (previous ___
site) demonstrated on U/S ___, profound hypophosphatemia, and
bilateral lower extremity discomfort. He was discharged on
___.
.
Since then, patient began experiencing low grade fevers on
___. He was evaluated by Dr. ___ in clinic that day, found
to have temp of 100.3, with complaint of a cough. Chest x-ray at
that time was unremarkable. Labs were notable for Hct 22.8, from
26.6 at the time of discharge on ___ he received one unit
PRBCs, with resultant Hct ___ of 23.2. He continued to
experience low-grade fevers. At 5 am on ___, he awoke with
sharp, epigrastric pain and presented to ___, where he
was found to have Hct 19, ANC 900, lipase 900, and CT torso with
very mild jejunal fluid vs. inflammation, no evidence of
pancreatic or biliary abnormalities. He receieved cefepime and
vancomycin, as well as 1 unit PRBCs. He was given food there as
well. En route to ___, the ride was "bumpy," and patient
vomited pink-tinged vomit (from Gatorade at ___. On
arrival to ___ ED, he finished vancomycin and PRBCs. GI
cocktail (Maalox/lidocaine) helped abdominal pain, but
morphine/Dilaudid did not. No vomiting. No rectal exam was done,
given neutropenia. Labs notable for WBC 1.8 with 67.5%N, Hct
20.8. He had no vomiting in the ED.
.
On arrival to the floor, the patient was comfortable, but
complaining of continued abdominal discomforts. Notes that he
ate lettuce, potato salad in oil dressing, chicken salad, and
lactaid chocolate milk the night before presentation. No know
sick contacts, no melena or hematochezia, no vomiting at home.
States that his diffuse abdominal pain has been unchanged for
the past three weeks. Wonders whether he has chest wall
tenderness from coughing.
.
Review of symptoms:
Positive as noted in the HPI. +cough recently, with frequent
colds over the past year. Frequent headaches (chronic),
+continued calf discomfort relieved by stretching
Negative: chills or night sweats. He denies any ,
lightheadedness, shortness of breath, or chest pain. He has no
further pain on his right side. No melena or hematochezia. No
dysuria or hematuria. No diarrhea or constipation. No GERD. All
other ROS negative.
Past Medical History:
Oncologic history: First presented with hairy cell leukemia when
he was admitted to ___ on ___ after noting
shortness
of breath particularly on exertion as well as increased fatigue.
He was found to be anemic with a hematocrit of 13% and
thrombocytopenic with a platelet count of 37,000, his white
count was 11.9 with decreased neutrophils. Bone marrow aspirate
and biopsy was concerning for hairy cell leukemia, and he was
transferred to ___ on ___ for further treatment
and evaluation. He received treatment with 2-CdA therapy for
seven days with day one on ___. During his admission, he
was noted for neutropenic fevers, although no infection source
was found. He also developed a PICC-associated cephalic vein
thrombosis. He was treated prophylactically for a period of time
with acyclovir and Bactrim. Following this, ___ had done very
well with recovery of his counts. He was noted for mild
elevation of his liver function tests, but these eventually
normalized. Because of proximity to his home, he transferred his
care to Dr. ___ at ___ in ___ and is now
being followed by Dr. ___.
In ___, ___ was noted for dropping counts,
particularly in his platelets and also noted increasing fatigue.
He had previously noted a viral illness, and it was felt that
possibly his counts were low because of this, but he recovered
from this illness, and his counts remained low; he subsequently
underwent bone marrow aspirate and biopsy on ___,
which showed evidence for recurrent hairy cell leukemia. Given
that it has been over ___ years since his last treatment, the
plan is to move forward with a second cycle of 2-CdA. ___ was
seen on ___ for this admission but was noted for an upper
respiratory infection. He underwent a chest xray which did not
show any evidence for pneumonia and was treated with a Z-pak.
___ presents today for admission for this treatment.
.
OTHER PAST MEDICAL HISTORY:
1. Status post hernia operation as a child.
2. History of a broken wrist.
3. Hypothyroidism.
4. Hypercholesterolemia; no treatment at this time.
5. Hairy cell leukemia as noted above.
6. Chronic headaches.
Social History:
___
Family History:
Grandmother died from possible cancer. His mother is alive with
skin cancers. Father is alive in his ___. ___ has a twin
brother and another brother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.5 125/63 20 85 99%RA
Gen: Well-appearing, overweight, NAD
HEENT: NCAT, PERRL, EOMI, anicteric sclerae, clear oropharynx
Neck: Supple, no cervical supraclavicular LAD.
Lungs: CTAB, good air movement, no wheezes/crackles
Heart: RRR, Nl S1/S2, No MRG
Chest: No costochondral tenderness
Abd: Normoactive bowel sounds, soft, nondistended, slight
non-localized tenderness
Extr: WWP, no edema, 2+ distal pulses
Skin: Without rashes.
Access: 2 PIVs
.
DISCHARGE PHYSICAL EXAM:
VS: 98.0 (98.2) 138/58 (102-138/58-70)
76 (75-82) 20 96%RA (96-100%RA)
I/O 8h ___ | 2742/3650 + 2 large formed G-neg stool
Gen: Well-appearing, overweight, NAD
HEENT: NCAT, PERRL, EOMI, anicteric sclerae, clear oropharynx
Neck: Supple, no cervical supraclavicular LAD.
Lungs: CTAB, good air movement, no wheezes/crackles
Heart: RRR, Nl S1/S2, No MRG
Chest: No costochondral tenderness
Abd: Normoactive bowel sounds, soft, nondistended, slight
non-localized tenderness
Extr: WWP, no edema, 2+ distal pulses
Skin: Without rashes.
Access: 2 PIVs
Pertinent Results:
ADMISSION LABS:
___ 10:50AM BLOOD WBC-1.8* RBC-2.35* Hgb-7.3* Hct-20.8*
MCV-89 MCH-31.1 MCHC-35.0 RDW-15.5 Plt ___
___ 10:50AM BLOOD Neuts-67.5 ___ Monos-2.7 Eos-5.8*
Baso-0.4
___ 10:50AM BLOOD ___ PTT-18.4* ___
___ 10:50AM BLOOD Glucose-141* UreaN-9 Creat-0.6 Na-136
K-4.2 Cl-103 HCO3-26 AnGap-11
___ 10:50AM BLOOD ALT-61* AST-72* AlkPhos-117 TotBili-0.8
___ 10:50AM BLOOD Lipase-66*
___ 10:50AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.1
___ 09:31PM BLOOD Triglyc-102
___ 09:31PM BLOOD TSH-6.8*
___ 09:31PM BLOOD Free T4-1.1
___ 11:01AM BLOOD Glucose-138* Lactate-1.7 Na-136 K-4.2
Cl-102 calHCO3-25
___ 11:01AM BLOOD freeCa-1.03*
___ 11:01AM BLOOD ___ pH-7.41
___ 01:00PM URINE Color-Straw Appear-Clear Sp ___
___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
.
RELEVANT LABS:
___ 06:00AM BLOOD Lipase-26
.
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-2.9* RBC-2.70* Hgb-8.6* Hct-24.1*
MCV-89 MCH-31.7 MCHC-35.5* RDW-16.3* Plt ___
___ 06:05AM BLOOD Neuts-46* Bands-4 ___ Monos-2
Eos-14* Baso-0 ___ Myelos-0
___ 06:05AM BLOOD ___ PTT-27.5 ___
___ 06:05AM BLOOD Glucose-120* UreaN-9 Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-25 AnGap-14
___ 06:05AM BLOOD ALT-43* AST-21 LD(LDH)-190 AlkPhos-84
Amylase-59 TotBili-0.6
___ 06:05AM BLOOD Lipase-43
___ 06:05AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.2
.
MICROBIOLOGY:
___ BLOOD CULTURES X2: no growth to date
___ BLOOD CULTURE: no growth to date
___ URINE CULTURE: no growth
.
IMAGING:
___ CHEST X-RAY (PA/LAT): The lungs are clear with no
evidence of consolidation, effusion, or pneumothorax.
Cardiomediastinal silhouette remains top normal but stable.
Visualized osseous structures are normal.
IMPRESSION: No acute cardiopulmonary process.
.
___ NON-CONTRAST CT CHEST: The lungs are clear bilaterally.
No pulmonary nodules or areas concerning for infection are
noted. The airways are clear. There is no mediastinal, hilar, or
axillary lymphadenopathy. The heart size is normal without
pericardial effusion. The myocardium is slightly denser than the
intraventricular blood, suggesting anemia. There is minimal
coronary calcification of the left coronary artery. There is no
pleural effusion.
This examination is not tailored for subdiaphragmatic
evaluation. However, the non-contrast appearance of the
visualized upper abdomen is within normal limits.
BONE WINDOWS: No concerning osseous lesions are identified.
IMPRESSION: No findings to explain patient's continued cough. No
evidence of infection.
.
___ EKG: NSR @ 80 bpm, NA/NI, no change from prior.
.
___ RUQ U/S: The liver appears diffusely echogenic. The
gallbladder demonstrates sludge. The wall is within normal
limits in thickness at 3 mm and is not striated in echogenicity;
that it appears hypoechoic is because of the hyperechogenicity
of the adjacent liver. No sonographic ___ sign was elicited.
The common bile duct measures 0.5 cm.
The spleen measures 13.6 cm, mildly enlarged. There is no free
fluid. The
main portal vein is patent. The pancreatic neck and body and
superior
portions of the head and medial portions of the tailwere
visualized and
without abnormality; however, the remainder of the pancreas was
not clearly
visualized on this study.
IMPRESSION:
1. Gallbladder with sludge. Gallbladder wall is not thickened
and there are
no secondary signs of acute cholecystitis.
2. Highly echogenic liver consistent with fatty deposition.
However, as the
density of the liver on ___ Chest CT was only suggestive of
slight fatty
Medications on Admission:
1. levothyroxine 25 mcg Tablet PO daily
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H
3. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every ___
hours as needed for pain: Do not take more than 4g per day.
4. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (SA).
5. potassium & sodium phosphates ___ mg Powder in Packet
Sig: Two (2) Powder in Packet PO BID (2 times a day).
Disp:*60 Powder in Packet(s)* Refills:*0*
6. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. acetaminophen 500 mg Tablet Sig: ___ Tablets PO q6h prn as
needed for fever or pain: Do not exceed 4g per day.
4. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week: on ___.
5. potassium & sodium phosphates ___ mg Powder in Packet
Sig: Two (2) packet PO twice a day.
6. pentamidine 300 mg Recon Soln Sig: Three Hundred (300) mg
Inhalation once a month: first dose ___.
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO QID (4 times a day) as needed for heartburn. ML(s)
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Gastroesophageal reflux disease
.
Secondary diagnoses:
Hypothyroidism
Hairy cell leukemia
Eosiniophilia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ gentleman with recent admission for relapsed hairy
cell leukemia with fevers and abdominal pain. Lipase at ___ was
939, however in-house is presently 66.
COMPARISON: Abdominal ultrasound from ___, CT of the chest ___, CT of the abdomen and pelvis ___ at 6:28 at ___
___.
LIVER AND GALLBLADDER ULTRASOUND: The liver appears diffusely echogenic. The
gallbladder demonstrates sludge. The wall is within normal limits in
thickness at 3 mm and is not striated in echogenicity; that it appears
hypoechoic is because of the hyperechogenicity of the adjacent liver. No
sonographic ___ sign was elicited. The common bile duct measures 0.5 cm.
The spleen measures 13.6 cm, mildly enlarged. There is no free fluid. The
main portal vein is patent. The pancreatic neck and body and superior
portions of the head and medial portions of the tailwere visualized and
without abnormality; however, the remainder of the pancreas was not clearly
visualized on this study.
IMPRESSION:
1. Gallbladder with sludge. Gallbladder wall is not thickened and there are
no secondary signs of acute cholecystitis.
2. Highly echogenic liver consistent with fatty deposition. However, as the
density of the liver on ___ Chest CT was only suggestive of slight fatty
deposition, other forms of diffuse liver disease should be considered.
3. Pancreas incompletely visualized on today's study but without duct
dilation or abnormality seen.
4. Mild splenomegaly.
Initial interpretation was discussed with Dr. ___ at 7:40 p.m. on
___ via telephone by Dr. ___. The final interpretation was
discussed by ___ by Telephone with Dr. ___ at 935 am on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: CP/ HEMATEMESIS
Diagnosed with ACUTE PANCREATITIS, NEUTROPENIA, UNSPECIFIED , ANEMIA NOS
temperature: 97.6
heartrate: 78.0
resprate: 20.0
o2sat: 98.0
sbp: 140.0
dbp: 79.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman, with recent admission
for relapsed hairy cell leukemia, now s/p 7-day course of
cladribine (___), who was transferred from ___
with fever at OSH and abdominal pain, initially concerning for
pancreatitis; labs prior to admission were also concerning for
acute bleed. Admission was complicated by development of
eosinophilia.
.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
gastric outlet obstruction
Major Surgical or Invasive Procedure:
___
1. Laparoscopic reduction of hiatal hernia.
2. Closure of diaphragmatic hiatus.
3. ___ fundoplication.
History of Present Illness:
___ M h/o chronic thromboembolic pulmonary HTN on ___,
___ esophagus presents as transfer from OSH with
paraesophageal hernia resulting in gastric outlet obstruction.
Patient reports being in his usual state of health until 3 days
ago when he had epigastric pain and intolerance to PO. He had
several episodes of NB/NB emesis (whatever he ate). He has
never had these symptoms before. Per patient and wife, he was
admitted to ___ on ___ where CT scan
demonstrated an paraesophageal hernia resulting in GOO. He had
immediate relief of symptoms with NGT decompression. Patient
reports that during his hospital course he had an EGD with
"attempted decompression of his hernia". It was thought to be
successful initially and his NGT was removed yesterday. After
attempted PO, he had recurrent symptoms. The NGT was replaced
and the patient was transferred to ___ for further management.
Patient denies fevers, chills, diarrhea, palpitations,
dysphagia, dyspnea.
Past Medical History:
PMH: HLD, diverticulosis, asthma, ___ esophagus (followed
at ___ (last EGD ~ ___ yr ago), colonic adenoma,
chronic thromboembolic pulm HTN on ___ (unclear
etiology)
PSH: b/l inguinal hernia repair at age ___, R shoulder surgery, R
wrist surgery
Social History:
___
Family History:
NC; Denies family history of GI cancer, IBD
Physical Exam:
VS: 99.1 75 157/96 16 96%
Gen: NAD, AOx3
Neck: Trachea midline, supple, no cervical, no supraclavicular
lymphadenopathy
___: reg
Pulm: CTA-B
Abd: Soft, min distended, NT
___: No LLE
Pertinent Results:
___ 03:26PM WBC-10.2 RBC-5.11 HGB-14.9 HCT-44.7 MCV-87
MCH-29.2 MCHC-33.5 RDW-14.6
___ 03:26PM ___ PTT-27.1 ___
___ 03:26PM GLUCOSE-104* UREA N-21* CREAT-0.9 SODIUM-142
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-29 ANION GAP-14
___ Ba swallow :
No evidence of obstruction or leakage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ___ 20 mg PO DAILY
2. Sucralfate 1 gm PO QHS
3. Omeprazole 20 mg PO DAILY
4. Sildenafil 20 mg PO ASDIR
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Sildenafil 20 mg PO ASDIR
3. Sucralfate 1 gm PO QHS
4. ___ 20 mg PO DAILY
5. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
8. Milk of Magnesia 30 mL PO Q12H:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated diaphragmatic hernia with obstruction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with OSH CT with no report // please eval for obstruction
hernia
TECHNIQUE: MDCT axial images of abdomen and pelvis with intravenous and oral
contrast as well as coronal and sagittal reformations were available for
review. were .
DOSE: DLP: 603 mGy-cm .
COMPARISON: None.
FINDINGS:
LOWER CHEST:
Mild bibasilar atelectasis is noted. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
GENERAL: There is no intra-abdominal free air or free fluid.
HEPATOBILIARY: 1 cm hypodensity in the liver segment 4B is likely a simple
cyst or biliary hamartoma.
The gallbladder is unremarkable.
PANCREAS: Unremarkable.
SPLEEN: Unremarkable.
ADRENALS: Unremarkable.
URINARY: There are multiple simple renal cysts bilaterally. Other several
hypodensities in bilateral kidneys are too small to be characterized.
GASTROINTESTINAL: There is gastric antrum herniating paraesophageally above
the diaphragm. The antral wall appears mildly thickened. Only trace amount
of oral contrast passes from fundus to antrum at the site of hernia. There is
narrowing as the distal part of the stomach passes superiorly into the
mediastinum, which may be due to crural mass effect, not necessarily twisted;
however, the possibility of obstruction and/or incomplete organoaxial volvulus
is not excluded.
Colon and small bowel loops demonstrate normal caliber.Appendix is
unremarkable.
LYMPH NODES: Prominent mesenteric lymph nodes are likely lymph nodes.
VASCULAR: Abdominal aorta is normal in caliber.
PELVIS:
The bladder and prostate are unremarkable.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions.
IMPRESSION:
There is gastric antrum, which appears mildly thickened, herniating
paraesophageally above the diaphragm. Enteric contrast in the gastric fundus
without significant progression into the antrum. Possibility of obstruction
and/or incomplete organoaxial volvulus is not excluded.
Radiology Report
INDICATION: ___ M h/o chronic thromboembolic pulmonary HTN on ___,
___ OSH txfr w/ paraesophageal hernia w/GOO // pre-op cxr Surg:
___
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Enteric tube terminates in the stomach. The lungs are well inflated. Linear
left lower zone opacity likely linear atelectasis. No lobar consolidation
present. No pleural effusion or pneumothorax. Bony thorax is unremarkable.
IMPRESSION:
No lobar consolidation. Likely left lower lobe linear atelectasis.
Radiology Report
INDICATION: ___ M s/p paraesophageal hernia repair // please r/o PTX
COMPARISON: Radiographs from ___
IMPRESSION:
There is subcutaneous emphysema at the base of neck and along the right
lateral chest wall. Rounded air-filled structure projects over the left
retrocardiac area possibly within a hiatal hernia. Lungs are grossly clear.
There is a small left-sided pleural effusion. No pneumothoraces are
pneumomediastinum is seen.
Radiology Report
INDICATION: ___ year old man s/p lap esophageal hernia // interval assesment
of PTX
COMPARISON: Radiographs from ___
IMPRESSION:
There is mild improvement of the subcutaneous emphysema. Heart size is upper
limits of normal but stable. There is a left retrocardiac opacity, consistent
with prior surgery. Small bilateral effusions are seen. There is no overt
pulmonary edema or pneumothoraces. Small amount of free air underneath the
right hemidiaphragm is seen.
Radiology Report
INDICATION: ___ M s/p paraesophageal hernia repair // Interval assesment
COMPARISON: Radiographs from ___
IMPRESSION:
There is again seen subcutaneous emphysema at the base of the neck. The
subcutaneous emphysema along the right lateral chest wall has improved. There
is unchanged cardiomegaly. There is a left retrocardiac opacity which likely
represents fluid filling the hiatal hernia. Small left-sided pleural effusion
is stable. There is no overt pulmonary edema or pneumothoraces.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old man s/p paraesophageal hernia repair, in need of
barium swallow study // barium swallow study please
TECHNIQUE: Multiple images of the esophagus and stomach were obtained after
the administration of water soluble iodinated contrast, followed by thin
barium.
COMPARISON: None
FINDINGS:
Barium flows through the esophagus and into the stomach without evidence of
obstruction or leakage. Mild slow transit time through the gastroesophageal
junction is likely due to postop inflammation. Contrast is seen passing from
the stomach into the proximal small bowel.
IMPRESSION:
No evidence of obstruction or leakage.
Radiology Report
INDICATION: Evaluate for interval change in a patient with oxygen
desaturation after hernia repair.
COMPARISON: Chest radiographs from ___.
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal
silhouette and well-aerated lungs. Retrocardiac opacity is unchanged. There
is no new focal consolidation, pleural effusion, or pneumothorax. The
visualized upper abdomen demonstrates air distended bowel loops with layering
radiodense contrast. Free air under the right hemidiaphragm is decreased.
Subcutaneous emphysema is increased.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 99.1
heartrate: 75.0
resprate: 16.0
o2sat: 96.0
sbp: 157.0
dbp: 96.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ presented to the ___ on ___ with paraesophageal
hernia resulting in gastric outlet obstruction. He was admitted
to the thoracic surgery service. A nasogastric tube was placed
for decompression initially. Heparin gtt was started for history
of chronic thromboembolic pulmonary HTN. He was taken to the
Operating Room on ___ and underwent a laparoscopic reduction
of hiatal hernia, closure of diaphragmatic hiatus and a Nissen
fundoplication. He tolerated the procedure well and returned to
the PACU in stable condition. He maintained stable hemodynamics
and his pain was controlled with IV Dilaudid.
Following transfer to the Surgical floor he continued to
progress well. A barium swallow was done on ___ which
showed no leak and he was placed on a liquid diet which he
tolerated well. He was up and walking independently and his
port sites were dry. His oxygen saturations were only 94% on 4L
on post day #1, possibly due to pain inhibiting his deep
breathing. He was switched to oral Dilaudid and was better. He
was able to be weaned off of oxygen and his ambulatory room air
saturations were 95%. His pre op ___ was resumed on
post op day #1. After an uncomplicated recovery he was
discharged to home on ___ and will follow up in the
Thoracic Clinic in 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Ceclor / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
nausea, vomiting/malaise
Major Surgical or Invasive Procedure:
___:
___ ___ drain to bulb drainage for collection
left thorocentesis
History of Present Illness:
___ y/o F with a h/o hypothyroidism presents to the ED as a
transfer from ___ with L pleural effusion. Patient
was a pedestrian struck by a car in ___ with a
splenic embolization, L rib fracture, and L femur fracture.
She was discharged from rehab 1 week ago and was seen at her
PCP on ___. At her PCP's, she was found to have Afib
(previously had in the past but was corrected) and new
diabetes so she was started on Coumadin and Metformin.
She was also placed on antibiotics for a UTI and possible
sinus infection. She presented today to ___ with
palpitations, nausea, vomiting and diarrhea.
Per EMS, patient was found to have left pleural effusion
with a large splenic air and fluid collection. She was
brought here for further evaluation and treatment. She is
followed by Dr. ___. She currently denies any pain or
discomfort.
Past Medical History:
HTN, Afib not on anticoagulation, Burn to torso as child,
Nonegastric bypass, B/L knee replacement surgery,
cholecystectomy, hand surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION upon admission: ___
Temp: 99.4 HR: 107 BP: 123/79 Resp: 18 O(2)Sat: 98 Normal
Constitutional: Constitutional: comfortable
Head
/ Eyes: NC/AT
ENT: OP WNL
Resp: CTAB
Cards: RRR. s1,s2. no MRG. chest wall tendenress
Abd: S/NT/ND
Flank: no CVAT
Skin: no rash
Ext: No c/c/e; L leg in CAM device
Neuro: speech fluent
Psych: normal mood
Physical examination: upon discharge:
vital signs: 99.7, hr=69, 148/77, rr=18, 96% room air
GENERAL: NAD
CV: Ns1, s2, no murmurs
LUNGS: clear left side, diminished right lateral
ABDOMEN: soft, non-tender, DSD left abdominal drain site
EXT: Bledoe brace left leg, no pedal edema bil, no calf
tenderness
NERURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 05:00AM BLOOD WBC-6.4 RBC-3.64* Hgb-9.1* Hct-30.6*
MCV-84 MCH-25.0* MCHC-29.7* RDW-18.3* RDWSD-56.2* Plt ___
___ 09:53AM BLOOD WBC-7.0 RBC-3.87* Hgb-9.6* Hct-32.4*
MCV-84 MCH-24.8* MCHC-29.6* RDW-18.3* RDWSD-53.9* Plt ___
___ 01:06PM BLOOD WBC-10.0 RBC-4.04 Hgb-10.0* Hct-33.3*
MCV-82 MCH-24.8* MCHC-30.0* RDW-17.9* RDWSD-52.9* Plt ___
___ 10:43PM BLOOD WBC-7.9 RBC-4.02# Hgb-10.0* Hct-33.1*#
MCV-82 MCH-24.9* MCHC-30.2* RDW-17.7* RDWSD-50.1* Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD ___
___ 05:00AM BLOOD Glucose-196* UreaN-12 Creat-0.3* Na-137
K-4.2 Cl-99 HCO3-25 AnGap-17
___ 09:53AM BLOOD Glucose-312* ___-9 Creat-0.4 Na-137
K-3.8 Cl-98 HCO3-22 AnGap-20
___ 06:28AM BLOOD Glucose-133* UreaN-8 Creat-0.2* Na-137
K-3.8 Cl-100 HCO3-24 AnGap-17
___ 05:00AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
___ 09:53AM BLOOD Free T4-1.4
___: ___ drain:
FINDINGS:
1. Limited grayscale ultrasound imaging of the left upper
abdomen demonstrated
a mildly complex ___ collection.
2. Successful placement of ___ all-purpose drain within the
collection. A
very small volume was able to be aspirated with appearance of
hematoma.
3. A small volume of aspirate was sent to the laboratory for
analysis.
IMPRESSION:
Successful placement of ___ F all-purpose drain with in the
___
collection.
___: pleural aspirant:
IMPRESSION:
Successful ultrasound-guided thoracentesis on the left.
___: ct abd. /pelvis:
1. Patent portal veins.
2. Moderate ___ collection measures 9.3 x 8.4 x 7.6 cm.
3. Known hepatic segment VIII/VII infarction.
4. Heterogeneous area of enhancement at the junction of the
right and left
hepatic lobes likely represent vascular shunting but correlate
with LFTs.
5. Persistent large pleural effusion at the left lung base.
___ 6:43 pm ABSCESS Source: Splenic Abscess.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Calcium Carbonate 500 mg PO BID:PRN Heartburn
4. Docusate Sodium 100 mg PO BID
5. Coumadin
6. Lidocaine 5% Patch 1 PTCH TD QAM pain
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN
9. Senna 8.6 mg PO BID:PRN constipation
10. Amphetamine-Dextroamphetamine 30 mg PO BID
11. Citalopram 20 mg PO DAILY
12. estradiol 0.01 % (0.1 mg/gram) vaginal DAILY
13. Metoprolol Succinate XL 100 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
last dose ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*15 Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. ___ MD to order daily dose PO DAILY16
daily ___ dosing as per PCP
9. Citalopram 20 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO QHS
11. Omeprazole 20 mg PO DAILY
12. Zolpidem Tartrate 2.5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___:
left pleural effusion
___ collection
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: ___ h/o Afib newly on Coumadin ped vs veh s/p ___ embo splenic
aa. L ___ rib, humerus, femur fx managed nonop p/w dyspnea/malaise, N/V CT
w/ L pleural effusion splenic abscess // evaluate extent of splenic
collection, evaluate portal vein latency
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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 7.5 s, 1.0 cm; CTDIvol = 17.4 mGy (Body) DLP =
17.4 mGy-cm.
3) Spiral Acquisition 13.9 s, 47.8 cm; CTDIvol = 11.1 mGy (Body) DLP =
513.5 mGy-cm.
Total DLP (Body) = 545 mGy-cm.
COMPARISON: Outside facility chest CT ___
FINDINGS:
LOWER CHEST: There is a large non-hemorrhagic pleural effusion on the left,
partially imaged. No pleural effusion on the right.
ABDOMEN:
HEPATOBILIARY: There is a wedge shaped hypodensity involving hepatic segment
VIII/VII, which appears similar to ___, and consistent with a
hepatic infarction. Heterogeneous enhancement is noted at the junction of the
right and left hepatic lobes, with suggestion of tiny nodular foci; this is a
non-specific finding, and may be perfusional. Minimal intrahepatic and
extrahepatic biliary dilation are likely within normal limits
post-cholecystectomy. The gallbladder is surgically absent. 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: There is a perisplenic collection containing air that measures 9.3 x
8.4 x 7.6 cm AP x TV x CC (5:23). Interval placement of a pigtail catheter
within this collection.
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. Subcentimeter hypodensities in the right kidney
are too small to characterize, but statistically likely represent cysts.
There is no perinephric abnormality.
GASTROINTESTINAL: Patient is status post prior gastric bypass surgery. Small
bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. Normal appendix.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is lobular in appearance with hypodense
lesions, likely representing necrotic fibroids.
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. Patient is status post distal splenic artery coil embolization.
BONES: There are chronic left-sided rib fractures.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Patent portal veins.
2. Moderate perisplenic collection measures 9.3 x 8.4 x 7.6 cm.
3. Known hepatic segment VIII/VII infarction.
4. Heterogeneous area of enhancement at the junction of the right and left
hepatic lobes likely represent vascular shunting but correlate with LFTs.
5. Persistent large pleural effusion at the left lung base.
Radiology Report
EXAMINATION: Ultrasound-guided thoracentesis
INDICATION: ___ year old woman with left pleural effusion.
TECHNIQUE: Ultrasound guided therapeutic thoracentesis on the left.
COMPARISON: Outside hospital CT chest dated ___
FINDINGS:
Limited grayscale ultrasound imaging of the left hemithorax demonstrated a
moderate volume of simple appearing pleural fluid. A suitable target in the
deepest pocket in the left mid axillary line was selected for thoracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A ___ catheter was advanced into the largest fluid pocket in the left
mid-axillary line and 500 mL of clear straw-colored fluid was removed.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
Successful ultrasound-guided thoracentesis on the left.
Radiology Report
INDICATION: ___ year old woman with splenic abscess.
COMPARISON: Outside hospital CT chest dated ___
TECHNIQUE: OPERATORS: Dr. ___ fellow and Dr. ___
radiologist performed the procedure. Dr. ___ supervised the
trainee during the key components of the procedure and has reviewed and agrees
with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
200 mcg of fentanyl and 4 mg of midazolam throughout the total intra-service
time of 50 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1%
lidocaine was injected subcutaneously at the access site.
MEDICATIONS: As above.
CONTRAST: 5 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.5 min, 6.4 mGy
PROCEDURE:
1. Limited left upper quadrant abdominal ultrasound
2. Placement of perisplenic ___ all-purpose drain
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 left
intercostal mid axillary line. 1% lidocaine was instilled for local
anesthesia. Under direct ultrasound guidance, an 18 gauge needle was advanced
into the perisplenic collection. Aspiration was unsuccessful. A small volume
of contrast was injected to confirm location. A ___ wire was advanced
through the needle. After a skin ___ was made over the needle, the needle
was removed. An ___ dilator was advanced over the wire to dilate the entrance
site. The dilator was removed and a ___ all-purpose drain was advanced over
the wire into the perisplenic collection. The drain was advanced over its
metal stiffener. The metal stiffener was removed and the pigtail was formed.
A small hand contrast injection confirmed placement. A small volume of
perisplenic hematoma was aspirated and sent to the laboratory. The catheter
was secured with 0 silk suture and attached to a JP bulb. Sterile dressings
were applied. The patient tolerated the procedure well and there no immediate
postprocedure complications.
FINDINGS:
1. Limited grayscale ultrasound imaging of the left upper abdomen demonstrated
a mildly complex perisplenic collection.
2. Successful placement of ___ all-purpose drain within the collection. A
very small volume was able to be aspirated with appearance of hematoma.
3. A small volume of aspirate was sent to the laboratory for analysis.
IMPRESSION:
Successful placement of ___ F all-purpose drain with in the perisplenic
collection.
RECOMMENDATION: Please keep the drain to JP bulb drainage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Palpitations
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 99.4
heartrate: 107.0
resprate: 18.0
o2sat: 98.0
sbp: 123.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | ___ year old female who was admitted to the hospital on ___
after being a struck by a car. As a result of the accident, she
sustained a splenic laceration, left sided ___ rib fractures,
and a left humerus and femur fracture. Her fractures were
managed non-operatively by the Orthopedic surgery service. She
underwent a splenic arteriogram and was reported to have active
extravasation from a splenic arterial branch and underwent ___
embolization.
She was discharged to a rehabilitation facility of ___ and
discharged home 1 week ago. Since that time she noted malaise,
dyspnea, nausea, vomiting and diarrhea. She also reported a
decreased appetite. During a ___ visit, she was found to be in
atrial fibrillation with a heart rate of 130. She was started on
anti-coagulation. She presented to the emergency room on
___ for further evaluation.
Upon admission, the patient was made NPO, given intravenous
fluids, and underwent imaging. Imaging studies showed a left
pleural effusion and ___ collection. The patient was
taken to ___ where a drain was placed into the ___
collection. Fluid was aspirated and a culture was sent. The
patient was started on a course of Zosyn. Results of the
culture showed no micro-organisms. During the patient's
hospitalization, she had bouts of rapid atrial fibrillation
which was controlled with intravenous metoprolol along with her
home dose. Electrolytes were monitored and repleted. She was
noted to have a decreased TSH and instructed to follow-up with
her Endocrinologist. The patient continued on Coumadin with
daily dosing and monitoring of ___.
The ___ drain was removed by radiology on ___ after it was
reported to have minimal output despite normal saline flushes
and instillation of TPA. The patient prepared for discharge home
on ___. Her vital signs were stable and she was afebrile. Her
white blood cell count normalized. She was tolerating a regular
diet and voiding without difficulty. Her heart rate normalized
and intravenous metoprolol was discontinued. An appointment for
follow-up was made with the Acute care service with a scheduled
abdominal cat scan prior to the visit. The patient was
instructed to follow-up with her primary care provider,
___, and Endocrinologist. ___ services were arranged to
monitor the patient's cardiovascular status and ___ for
Coumadin dosing. The patient was instructed to complete a week
course of amoxicillin. Her daughter was present when the
discharge instructions were reviewed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Coughing up blood and right leg pain
Major Surgical or Invasive Procedure:
___ -- Bronchoscopy
History of Present Illness:
Mr. ___ is a ___ man with no past medical
history and low utilization of medical care who presented to ___ with one week of hemoptysis, chest pain, and right leg
pain and weakness, found to have a new lung mass consistent with
malignancy, and transferred to ___ out of concern for
metastasis to the spine. ___ was in his normal state of health
until five days ago, when he developing a deep pain on the right
side of his back that radiated down to his knee. Prior to this,
he was able to walk easily, including climbing stairs, but now
he
noted that walking was much more difficult, and he walked with a
limp. He stated this was due to both pain and weakness. He also
complained of a deep chest pain "like my chest was caved in"
that
was associated with coughing up a mixture of bright red blood,
clots, and sputum. This happened several times a day, and was
never of large volume. He denied fevers, but has had chills over
the past several weeks, and night sweats several times a week,
requiring him to change clothes. He also has had new onset of
migraines in the last two months -- severe bilateral headaches.
No stool incontinence, no saddle anesthesia. No weakness in his
upper extremities. No changes in vision or hearing. Numbness in
his RLE, but nowhere else. No mouth abscesses. No swollen lymph
nodes. No abdominal pain.
At ___, vitals notable for temp 98.3, BP 179/85.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative. He had an initial
chest x-ray which showed:
Left lower lobe pneumonia. Focal hemorrhage is in the
differential.
Follow-up chest x-rays in 6 weeks is recommended to ensure
resolution.
Because of his leg weakness, a head CT was obtained, which
showed:
No acute intracranial process by CT. Mild age-related atrophy
with chronic small vessel ischemic change of the periventricular
white matter.
Finally, a CTA abd/pelvis was obtained which showed:
No CT evidence for thoracoabdominal aortic dissection.
Large medial left lower lobe lung mass measuring up to 8.9 cm in
sagittal dimension of concern for carcinoma abuts the medial
pleura. Small subcarinal lymph node.
Because of his leg weakness/pain, and new diagnosis of presumed
metastatic lung cancer, he was transferred to ___. In the
___
ED, a code cord was called and an MRI of his spine was obtained,
which showed:
Cord or cauda equina compression: yes, posterior disc bulge and
ligamentum flavum hypertrophy at C3-4 causes cord compression
with abnormal cord signal at this level (7; 18). Posterior disc
bulge, facet arthropathy, ligamentum flavum hypertrophy cause
cauda equina compression at L5-S1. There is severe spinal canal
stenosis at C5-6, C6-7, T2-3, and L4-5 with cord/cauda equina
deformation, however a posterior rim of CSF remains visible.
Neurosurgery evaluated, and their preliminary recommendations
are
that this is degenerative changes, not requiring an acute
intervention.
With this, he was admitted to the medicine service for expedited
work up of his presumed lung malignancy.
Past Medical History:
1. HTN
2. HLD
3. Chronic back pain
Social History:
___
Family History:
No family history of malignancy.
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Poor dentition, no dental abscesses note.
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: No wheezes, normal I:E ratio. Normal breath sounds, in
left
midlung, dullness to percussion. No dullness at the bases.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: CN II-XII tested, and are intact. UE ___, RLE hip
flexion,
fleg flexion, extension, plantar/dorsiflexion of foot all ___.
Patellar reflexes are brisk bilaterally. Decreased sensation to
light touch over the left shin and foot.
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: ___ 0752 Temp: 98.1 PO BP: 148/62 HR: 60 RR: 18 O2
sat: 93% O2 delivery: RA
___ ___ Dyspnea: 9 RASS: 0 Pain Score: ___
___ 0920 Dyspnea: 0 RASS: 0 Pain Score: ___
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, sclerae anicteric, OP clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. No
pain to palpation of chest.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema
DERM: No active rash.
Neuro: moves all four extremities, non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 07:26AM BLOOD WBC-7.1 RBC-4.91 Hgb-14.3 Hct-43.9 MCV-89
MCH-29.1 MCHC-32.6 RDW-13.1 RDWSD-42.5 Plt ___
___ 11:30PM BLOOD Neuts-71.8* Lymphs-18.0* Monos-6.8
Eos-2.5 Baso-0.7 Im ___ AbsNeut-7.07* AbsLymp-1.77
AbsMono-0.67 AbsEos-0.25 AbsBaso-0.07
___ 07:26AM BLOOD Glucose-85 UreaN-16 Creat-1.0 Na-144
K-4.4 Cl-105 HCO3-26 AnGap-13
___ 11:30PM BLOOD ALT-17 AST-16 AlkPhos-82 TotBili-0.4
___ 11:30PM BLOOD Lipase-14
___ 11:30PM BLOOD cTropnT-<0.01
___ 11:30PM BLOOD Albumin-4.1
___ 11:42PM BLOOD Lactate-1.2
IMAGING
-------
CXR ___:
1. No pneumothorax.
2. Redemonstration of the left lower lobe lobulated mass.
Bronchoscopy cytology brushing ___:
Positive for squamous cell carcinoma
MICROBIOLOGY
------------
Urine culture ___: negative
DISCHARGE LABS
--------------
___ 07:10AM BLOOD WBC-9.5 RBC-4.73 Hgb-13.7 Hct-42.1 MCV-89
MCH-29.0 MCHC-32.5 RDW-12.9 RDWSD-42.3 Plt ___
___ 07:10AM BLOOD Glucose-93 UreaN-16 Creat-0.9 Na-141
K-4.4 Cl-104 HCO3-26 AnGap-11
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
3. Gabapentin 200 mg PO BID
RX *gabapentin 100 mg 2 capsule(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
4. Lidocaine 5% Patch 2 PTCH TD QAM
RX *lidocaine 5 % 1 patch daily Disp #*10 Patch Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN moderate to
severe
RX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Lung cancer
Cervical stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: History: ___ with new cancer diagnosis, leg weaknessIV contrast
to be given at radiologist discretion as clinically needed// eval compression;
new diagnosis likely lung cancer with new leg numbness. Please prioritize
lumbar, then thoracic, then cervical. eval compression; new diagnosis
likely lung cancer with new leg numbness. Please prioritize lumbar, then
thoracic, then cervical., eval compression; new diagnosis likely lung cancer
with new leg numbness. Please prioritize lumbar, then thoracic, then
cervical., eval compression; new diagnosis likely
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed.
COMPARISON: CT of the chest, abdomen and pelvis dated ___.
FINDINGS:
Large 5.6 cm mass left lower lobe, better seen on CT chest ___.
Exam is moderately motion degraded.
CERVICAL:
There is straightening of the normal cervical lordosis.There is mild
multilevel loss of vertebral body height. Disc osteophyte complexes with
hypertrophy of the ligamentum flavum are seen at C2-3, C3-4, C4-5, C5-6 and
C6-7. Posterior element hypertrophic changes. Congenital narrowing spinal
canal.
C2-C3: Moderate central canal narrowing, mild cord flattening, preserved CSF,
moderate to severe bilateral foraminal narrowing.
At C3-C4 level there is severe central canal narrowing, central bright T2
signal within both hemi cords, most consistent with spondylotic myelomalacia.
Cord flattening. Moderate severe bilateral foraminal narrowing.
At C4-C5 level there is moderate central canal narrowing, mild cord
flattening. Moderate to severe bilateral foraminal narrowing.
At C5-6 level there is severe central canal narrowing, cord flattening,
equivocal cord edema. Moderate to severe bilateral foraminal narrowing.
At C6-C7 level there is moderate to severe central canal narrowing, no
definite cord edema. Moderate bilateral foraminal narrowing.
At C7-T1 level, mild central canal narrowing. Mild-to-moderate bilateral
foraminal narrowing.
THORACIC:
Alignment is normal.Mild multilevel loss of vertebral body height and
intervertebral disc signal intensity is seen.No cord T2 signal abnormality.
Disc bulges with hypertrophy ligamentum flavum are seen at T2-3, T3-4, T4-5,
T10-11 and T11-12.
T1-T2 level: Mild central canal narrowing, severe bilateral foraminal
narrowing.
T2-T3: Moderate central canal narrowing. Severe bilateral foraminal
narrowing..
T3-T4: Mild-to-moderate central canal narrowing. Moderate left, mild right
foraminal narrowing..
T4-T5: Mild central canal narrowing. Moderate bilateral foraminal narrowing..
Mild central canal narrowing T10-T11, T11-T12, mild-to-moderate central canal
narrowing T12-L1 level
LUMBAR:
Transitional anatomy is seen with partial lumbarization of L5. There is mild
levoconvex curvature of the lumbar spine with the apex at L3. There is mild
multilevel loss of vertebral height. Mild endplate edema L 2, L3, L4, L5
levels, likely reactive. No worrisome osseous lesions. The spinal cord
appears normal in caliber and configuration and terminates at L1.Disc bulges
with hypertrophy of the ligamentum flavum and facets are seen at T12-L1, L1-L
2, L2-L3, L3-L4 and L4-L5. Postoperative changes lower lumbar spine.
Advanced facet arthritis.
T12-L1: Mild central canal narrowing. Mild bilateral foraminal narrowing.
L1-L2: Small right paramedian, inferior disc protrusion, measures 5 mm in AP
diameter, narrowed lateral recess, mild mass effect on traversing right L2
nerve, mild-to-moderate central canal narrowing. Mild-to-moderate bilateral
foraminal narrowing.
L2-L3: Moderate spinal canal. Mild left, moderate right foraminal narrowing.
L3-L4: Severe spinal canal narrowing with clumping of the nerve roots.
Moderate to severe bilateral foraminal narrowing.
L4-L5: Mild facet arthropathy. Severe spinal canal narrowing with clumping of
the nerve roots. Severe right, moderate to severe left foraminal narrowing.
L5-S1: No spinal canal or foraminal narrowing.
OTHER: Subcentimeter benign simple cyst left kidney. Prominent extrarenal
pelvis bilaterally. Mild thickening left adrenal gland.
IMPRESSION:
1. Large mass left lower lobe, consistent with malignancy.
2. Advanced degenerative changes cervical spine, with areas of moderate, and
severe central canal narrowing, cord flattening, worse at C3-C4 level.
Findings most consistent with spondylotic myelomalacia at C3-C4 level.
Multilevel significant foraminal narrowing cervical spine.
3. Partial lumbarization L5 level, for counting purposes.
4. Severe central canal narrowing L3-L4, L4-5 level.
5. Multilevel significant foraminal narrowing lumbar spine, as above.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:08 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MRI of the brain with and without contrast.
INDICATION: ___ year old man with new diagnosis of metastatic lung cancer,
with left lower leg weakness. Spine with chronic changes. MRI for staging and
diagnostic purposes.// Please evaluate for brain metastasis.
TECHNIQUE: Planned protocol was for multisequence, multiplanar MR images of
the head both prior to and following the weight based intravenous
administration of gadolinium-based contrast, per departmental protocol.
Following acquisition of 3-plane localizer images and sagittal T1 weighted
images, the patient endorsed significant claustrophobia and declined further
imaging. The following report is based on the provided images.
COMPARISON: Unenhanced head CT ___.
FINDINGS:
3-plane localizer images and sagittal T1 weighted images were obtained.
Available images are markedly motion-degraded. Grossly, sagittal T1 images
demonstrate normal midline structures including a fully formed corpus callosum
and normal appearance of the sella turcica. No definite evidence of
intracranial mass-effect. Further assessment is precluded.
IMPRESSION:
Nondiagnostic study, with only limited MR scout and sagittal T1-weighted
images obtained, as the patient endorsed claustrophobia, and declined further
imaging.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: Post bronchoscopy. Rule out pneumothorax.
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Outside reference chest radiograph ___. Outside
reference CT torso ___.
FINDINGS:
There is redemonstration of the lobulated mass in the left lower lobe. There
is no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. There are no acute
osseous abnormalities.
IMPRESSION:
1. No pneumothorax.
2. Redemonstration of the left lower lobe lobulated mass.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with hemoptysis s/p bronchoscopy// Hemorrhage?
Pneumothorax?
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 15:55
FINDINGS:
There is redemonstration of the lobular mass in the left lower lobe. There is
no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities are identified.
IMPRESSION:
Redemonstration of the lobular mass in the left lower lobe. No pneumothorax.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with new diagnosis of metastatic lung cancer,
with left lower leg weakness. Spine with chronic changes. MRI for staging and
diagnostic purposes. Eval for brain metastases.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 11 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT head without contrast dated ___ from outside
facility.
FINDINGS:
Examination is mildly degraded by motion.
There is no evidence of acute intracranial hemorrhage, edema, masses, or acute
infarction. Tiny focus of susceptibility artifact in the left cerebellum on
gradient recalled echo images likely represents microhemorrhage.
The ventricles and sulci are age-appropriate in size and configuration with no
mass effect or midline shift. Patchy to confluent areas of T2 and FLAIR
hyperintense signal abnormalities in the periventricular and subcortical white
matter are nonspecific, but likely reflect chronic small vessel ischemic
changes.
No abnormally enhancing lesions or masses are seen. No leptomeningeal
enhancement is definitively visualized. The major intracranial arterial flow
voids are preserved. The dural venous sinuses are patent.
There is mild mucosal thickening of the ethmoid sinuses. The mastoid air
cells are clear. Unremarkable intraorbital contents.
IMPRESSION:
1. No convincing evidence of metastatic disease. No evidence of abnormal
enhancing lesions are left meningeal enhancement normal exam is limited due to
artifact.
2. No evidence of acute infarction or intracranial hemorrhage.
3. Moderate chronic small vessel ischemic disease.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old man with worsening of long standing cervical and back
pain. Stenosis of cervical spine seen on earlier MRI a few day ago but Ortho
spine is recommending dedicated cervical MRI for better evaluation. Cervical
pain.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: MRI cervical spine dated ___.
FINDINGS:
Examination is mildly degraded by motion.
There is unchanged straightening of the normal cervical lordosis which may
relate to patient positioning or muscle spasm. There is mild multilevel loss
of vertebral body height. There is a 6 mm cystic lesion in the tip of the
dens. There is multilevel disc desiccation.
There is multilevel ligamentum flavum thickening, uncovertebral joint
hypertrophy, and facet joint hypertrophy.
The spinal cord appears normal in caliber and configuration without evidence
of edema.
C2-C3: Disc bulge with effacement of the ventral and dorsal CSF spaces and
flattening along the ventral aspect of the cord. Mild to moderate spinal
canal and moderate to severe bilateral neural foraminal narrowing.
C3-C4: Disc bulge with effacement of the ventral and dorsal CSF spaces and
flattening along the ventral aspect of the cord. Signal abnormalities within
the spinal cord are consistent with spondylotic myelomalacia (image 16 of
series 14). Severe spinal canal and moderate to severe bilateral neural
foraminal narrowing.
C4-C5: Disc bulge with superimposed disc protrusion and mild flattening of the
ventral aspect of the cord. Moderate spinal canal narrowing and moderate to
severe bilateral neural foraminal narrowing.
C5-C6: Disc bulge with effacement of the ventral and dorsal CSF spaces and
deformation of the spinal cord. Mild-to-moderate spinal canal narrowing and
moderate to severe bilateral neural foraminal narrowing.
C6-C7: Disc bulge with effacement of the ventral and dorsal CSF spaces and
flattening along the ventral aspect of the cord. Moderate spinal canal
narrowing and moderate to severe bilateral neural foraminal narrowing.
C7-T1: Mild spinal canal narrowing and moderate bilateral neural foraminal
narrowing.
The paraspinal muscles are unremarkable.
IMPRESSION:
1. Severe multilevel multifactorial degenerative disc disease of the cervical
spine as described above.
2. Spondylotic myelomalacia of the spinal cord seen at C3-C4.
3. Severe spinal canal stenosis at C3-4 level and moderate spinal canal
narrowing at C4-5 and C6-7 levels.
4. Multilevel moderate-to-severe foraminal changes as described above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hemoptysis, L Leg weakness
Diagnosed with Hemoptysis
temperature: 97.9
heartrate: 58.0
resprate: 18.0
o2sat: 93.0
sbp: 179.0
dbp: 76.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ year-old man who presented with acute
onset of chest pain and hemoptysis and was found to have newly
diagnosed likely metastatic lung cancer. He receieved a
bronchoscopy and biopsy on ___, which showed squamous cell
carcinoma. MRI of his head was obtained for staging, which
showed no malignancy. He will receive a PET scan as an
outpatient. He will follow up with Oncology soon after
discharge.
# New presumed metastatic lung CA: Bronchoscopy done by IP,
biopsy back with moderately differentiated squamous cell
carcinoma. MRI brain did not show any evidence of metastases.
He will follow up with Oncology soon after discharge, and PET
scan will be performed as an outpatient. He had chest and back
pain treated with oxycodone and acetaminophen.
# Concer for cauda equina compression and left lower leg
weakness. A code cord was obtained in the emergency room, but
the MRI of his spine showed only degenerative changes. He will
need to follow up with Dr. ___ in the ___. A
cervical MRI is being repeated for better images as per Dr.
___ and was negative for compression.
# Hypertension: continued amlodipine 10 mg.
# Social: patient is not happy with the place where he currently
lives. Social Work saw the patient and was given information
about Rest Homes, a possible supportive housing option available
through ___. An advocacy letter can also be provided by
Oncology team once he has a clear diagnosis to give him extra
help for housing and transportation.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with Oncology following
discharge, and will need to get a PET scan. He should also
follow up with the Spine team within one week, as well as his
PCP.
# Code Status/ACP: full code (please also see current POE order) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
nausea/vomiting/epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of HLD and anxiety who presents
for nausea, vomiting, and bradycardia. She says that a few days
ago she was removing a tightly-fitted bra and immediately felt
nauseated afterwards. Her nausea has continued since. This has
caused her to vomit ___ times the past few days. Nausea is
constant and she has been unable to tolerate much oral intake.
She denies abdominal pain, constipation, diarrhea, or dysuria.
She was evaluated by her PCP who obtained an EKG and noted that
her heart rate was sinus in the ___ (she has no history of
bradycardia). CXR obtained showed increased interstitial
markings from prior study in ___ concerning for CHF. She was
referred to ED for possible CHF exacerbation and further
investigation into possible pacemaker for new bradycardia.
In the ED, initial vitals were: T 98.4, P 40, BP 134/56, RR 16,
O2sat 98% Nasal Cannula
Labs notable for:
UA with few bacteria and small leukocytes
Normal CBC and chem-7
Negative trop
Imaging notable for:
RUQ US @ ___ ___. Unremarkable appearance of the gallbladder and biliary tree.
2. Unchanged heterogenous appearance of the liver parenchyma.
CXR @ ___ ___. Increased interstitial markings compared to ___
suggest pulmonary edema.
2. New, somewhat linear small opacity at the left base could
represent atelectasis, aspiration, pneumonia, or projectional
artifact.
Patient was given IV Lorazepam .25 mg
Cardiology was consulted and recommended admission for possible
pacemaker placement.
Vitals prior to transfer were T 98.1, P 40, BP 129/78, RR 18,
O2sat 95% on RA
On the floor, patient endorsed some continued nausea but denied
abdominal pain. She denied chest pain, orthopnea, and lower
extremity swelling. She endorsed exertional dyspnea but stated
that this has been stable for the past ___ years.
Past Medical History:
Anxiety controlled on medication
History of painful neuropathy of her feet
History of hypercholesterolemia
Urinary frequency
Social History:
___
Family History:
No family history of heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
====================
Vital Signs: T 97.7, BP 156/57, P 38, RR 18, O2sat 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: bradycardic, normal rhythm, no murmurs
Lungs: slight crackles on LLL
Abdomen: slightly TTP in epigastric region, otherwise benign
abdomen
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength in upper and lower
extremities, grossly normal sensation
DISCHARGE PHYSICAL EXAM:
====================
VS - T 98.2-98.5, BP 102-134/59-60, P ___ , RR ___, O2sat
96-97% on RA
General: no acute distress, appears comfortable
HEENT: Sclera anicteric, JVP not elevated
CV: RRR, no murmurs, rubs, or gallops
Lungs: CTA anteriorly
Abdomen: nontender, nondistended, normoactive bowel sounds
GU: No foley
Ext: Warm, well perfused, +reticulated and varicose veins, 2+
pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact
Pertinent Results:
ADMISSION LABS:
===============
___ 06:15PM BLOOD WBC-9.2 RBC-4.43# Hgb-13.3# Hct-40.7#
MCV-92# MCH-30.0 MCHC-32.7 RDW-13.3 RDWSD-45.0 Plt ___
___ 06:15PM BLOOD Neuts-78.7* Lymphs-13.8* Monos-7.0
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.24* AbsLymp-1.27
AbsMono-0.64 AbsEos-0.00* AbsBaso-0.01
___ 06:15PM BLOOD ___ PTT-26.8 ___
___ 06:15PM BLOOD Glucose-106* UreaN-21* Creat-0.7 Na-139
K-4.1 Cl-107 HCO3-22 AnGap-14
___ 06:15PM BLOOD CK(CPK)-194
___ 06:15PM BLOOD Lipase-20
___ 06:15PM BLOOD CK-MB-6 cTropnT-<0.01
___ 06:54PM URINE Color-Straw Appear-Clear Sp ___
___ 06:54PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 06:54PM URINE RBC-0 WBC-6* Bacteri-FEW Yeast-NONE Epi-0
OTHER RELEVANT LABS:
==================
___ 06:15AM BLOOD ALT-16 AST-25 LD(LDH)-208 AlkPhos-57
TotBili-0.4
___ 06:15AM BLOOD TSH-5.7*
___ 06:15AM BLOOD Free T4-1.5
DISCHARGE LABS:
=================
___ 07:00AM BLOOD WBC-7.6 RBC-5.10 Hgb-15.1 Hct-46.6*
MCV-91 MCH-29.6 MCHC-32.4 RDW-13.4 RDWSD-44.6 Plt ___
___ 07:00AM BLOOD Glucose-92 UreaN-23* Creat-1.0 Na-139
K-4.5 Cl-101 HCO3-27 AnGap-16
___ 07:00AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2
IMAGING:
=================
CT Abdomen and Pelvis with Contrast (___)
IMPRESSION:
1. No small bowel obstruction
2. Extensive colonic diverticulosis without evidence of
diverticulitis
3. 2.5 cm aneurysm of the left internal iliac artery with mural
thrombus. Ectasia of the infrarenal abdominal aorta.
ECHO (___): The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The 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. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation.
Medications on Admission:
1. Simvastatin 20 mg PO QPM
2. Multivitamins 1 TAB PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Citalopram 20 mg PO DAILY
5. TraZODone 100 mg PO QHS
6. Oxybutynin 5 mg PO DAILY
7. LORazepam 0.5 mg PO DAILY:PRN anxiety
8. Gabapentin 300 mg PO QAM
9. Gabapentin 600 mg PO QPM
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Ranitidine 300 mg PO QHS
4. Senna 8.6 mg PO BID
5. Citalopram 20 mg PO DAILY
6. Gabapentin 300 mg PO QAM
7. Gabapentin 600 mg PO QPM
8. LORazepam 0.5 mg PO DAILY:PRN anxiety
9. Multivitamins 1 TAB PO DAILY
10. Simvastatin 20 mg PO QPM
11. TraZODone 100 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Nausea
Sinus bradycardia
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 the abdomen and pelvis
INDICATION: NO_PO contrast; History: ___ with vomiting, nauseaNO_PO contrast
// 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 administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 886 mGy-cm.
COMPARISON: CT abdomen pelvis from ___ and ultrasound of the
abdomen from ___
FINDINGS:
LOWER CHEST: Visualized lung fields show bibasilar 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. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of hydronephrosis. There is no perinephric abnormality.
Bilateral kidney interpolar region and left upper pole subcentimeter
hypodensities which are too small to characterize but may be cysts. Ultrasound
could be considered for further evaluation
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon shows
extensive diverticulosis without diverticulitis. The appendix is not seen.
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 ectasia of the infrarenal aorta, measuring up to 2.5 cm.
Mild aortic atherosclerotic disease is noted. Aneurysm of the left internal
iliac artery with mural thrombus, measuring up to 2.5 cm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Evidence of prior right-sided healed rib fractures. Degenerative changes.
Left screw fixation across the femoral neck with surrounding heterotopic
ossification.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No small bowel obstruction
2. Extensive colonic diverticulosis without evidence diverticulitis
3. 2.5 cm aneurysm of the left internal iliac artery with mural thrombus.
Ectasia of the infrarenal abdominal aorta.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Bradycardia
Diagnosed with Bradycardia, unspecified
temperature: 98.4
heartrate: 40.0
resprate: 16.0
o2sat: 98.0
sbp: 134.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ female with a history of HLD and
anxiety who presents with nausea, vomiting, and bradycardia.
#Sinus bradycardia: Patient presented with sinus bradycardia,
intermittently with HRs in the ___. This was thought to be
secondary to increased vagal tone from her nausea/vomiting. She
experienced no syncope or lightheadedness. This improved with
management of her GI symptoms (see below). At time of discharge,
her heart rate was in the ___ in normal sinus rhythm. Of
note, citalopram has occasionally been associated with sinus
bradycardia so patient was discontinued from this medication.
However, after the development of her GI symptoms concerning for
citalopram withdrawal and due to the fact that the patient but
has been on this medication for years, she was restarted on
citalopram. Her heart rate improved again while on citalopram.
She has no history concerning for CHF or MI and no current
symptoms/EKG findings for current MI. She was evaluated by
electrophysiology who recommended no pacemaker placement
emergently at this time. ECHO was notable for normal global and
regional biventricular systolic function and mild aortic
regurgitation. TSH was mildly elevated at 5.7, but free T4 was
wnl at 1.5. She was monitored on telemetry without incident.
#Nausea, dyspepsia: These symptoms were thought to be secondary
to GERD. She received symptomatic management for nausea with
Compazine and Zofran, and her symptoms then improved greatly on
ranitidine.
#Anxiety: Ativan was continued. Citalopram was initially held
and then restarted during this hospitalization.
#Neuropathy: Gabapentin was continued during this
hospitalization.
#HLD: Simvastatin was continued during this admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Wasp Venom
Attending: ___.
Chief Complaint:
Epigastric Pain
Major Surgical or Invasive Procedure:
ERCP with sphincteroplasty
History of Present Illness:
___ with h/o appy, chole, p/w epigastric pain, started last
night 30 mins after dinner, achy, ___, no radiation, no f/c,
n/v/d. Passing flatus, last BM in AM. Pt notes a similar pain
started ___ years ago, recently much worse, more frequent, several
times a week and usually postprandial. On ___ was seen in
clinic and LFTs were 90/235 with alk phos 78 TB 0.1. Very
functional at baseline, no CAD, PVD, HLD, HTN, DM.
.
In the ED, initial vitals: 97.6 88 158/72 16 99% RA. Labs
notable for WBC 8.9, AST 1300, AST ___, Alk Phos, 156 TB 1.7.
RUQ with dilated CBD. She received a dose of Unasyn. ERCP team
was consulted.
.
Currently, patient feeling well on the floor and on ROS she
denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria. A complete 10 point ROS otherwise stable.
Past Medical History:
# Depressive disorder
# Diverticulosis
# Pulmonary nodule/lesion, solitary
# Macular drusen
# Ocular hypertension
# Vitamin D deficiency
# Mild stage glaucoma
# Primary open angle glaucoma
Social History:
___
Family History:
Extensive family history of gallstones. No autoimmune diseases
Physical Exam:
VS: 99.8 150/71 84 18 95RA
GENERAL: NAD, comfortable, appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no thyromegaly, no JVD
HEART: PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN: no rashes or lesions
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
Discharge Exam:
AVSS
No icterus
Abdomen benign
Pertinent Results:
Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 07:15 4.31 3.97* 12.5 38.5 97 31.4 32.4 14.5 138*
___ 05:04 8.9 4.71 15.2 45.2 96 32.3* 33.6 12.8 215
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 07:15 ___ 3.6 ___
___ 05:04 ___ 143 3.7 ___
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 07:15 1267* 691* 152* 2.5*
___ 05:04 1387* 2154* 156* 1.7*
INR 1.2
MRCP
IMPRESSION:
1. Choledocholithiasis and stones within the remnant cystic
duct; ductal wall
hyperenhancement indicates cholangitis. Largest stone within
the common bile
duct measures up to 6 mm. Mild intrahepatic biliary ductal
dilation.
2. Mild periportal edema, hepatic enlargement and heterogeneous
arterial
enhancement suggest hepatitis; a chronic hepatic abnormality is
possible.
2. Normal homogeneous-appearing pancreas without evidence of
gallstone
pancreatitis.
.
U/S:
IMPRESSION: Common bile duct dilation up to 16 mm with
associated mild
intrahepatic biliary duct dilation. No stone is identified
within the ducts, although it is not traced completely to the
pancreatic head. There is no evidence of pancreatic duct
dilation. Given these findings, further evaluation with an MRCP
is recommended to exclude a distal stone or obstructing mass.
.
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: Normal major papilla
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.
Biliary Tree Fluoroscopic Interpretation: The common bile duct
was found to be dilated to 13mm. Given the clinical
presentation, elevated liver enzymes and dilated common bile
duct, a sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire.
Procedures: A balloon sweep was performed with extraction of
sludge.
I supervised the acquisition and interpretation of the
fluoroscopic images. The quality of the fluoroscopic images was
good. Total fluoro time: 3.1min.
Impression: Normal major papilla
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
The common bile duct was found to be dilated to 13mm.
Given the clinical presentation, elevated liver enzymes and
dilated common bile duct, a sphincterotomy was performed in the
12 o'clock position using a sphincterotome over an existing
guidewire.
A balloon sweep was performed with extraction of sludge.
Otherwise normal ercp to third part of the duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Psyllium Wafer 1 WAF PO DAILY
Discharge Medications:
1. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Psyllium Wafer 1 WAF PO DAILY
4. Outpatient Lab Work
Please have CBC, Chem 7, AST, ALT, Alk Phos, T. Bili, D. Bili
and Lipase checked on ___. Please call Dr. ___ with the
results at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Choledocolithiasis with obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Presenting with right upper quadrant pain. Has a history of a
prior cholecystectomy. Evaluate for retained stone.
COMPARISONS: None.
TECHNIQUE: Grayscale and Doppler ultrasound images were acquired through the
right upper quadrant.
FINDINGS: The liver is normal in shape and contour. There is normal
echogenicity. No focal hepatic lesions are identified. The main portal vein
is patent with normal hepatopetal flow.
The patient is status post cholecystectomy. There appears to be mild
intrahepatic biliary duct dilation. The common bile duct is very dilated
measuring up to 16 mm. No stone is visualized within the ducts. The duct
cannot be completely followed to the pancreatic head, although the majority of
its course is visualized. The pancreas appears normal. The pancreatic duct
is within normal limits measuring 2 mm. The pancreatic tail is somewhat
obscured by overlying bowel gas.
There is no evidence of ascites in this limited right upper quadrant
ultrasound. Limited views of the right kidney demonstrate an extrarenal
pelvis.
IMPRESSION: Common bile duct dilation up to 16 mm with associated mild
intrahepatic biliary duct dilation. No stone is identified within the ducts,
although it is not traced completely to the pancreatic head. There is no
evidence of pancreatic duct dilation. Given these findings, further
evaluation with an MRCP is recommended to exclude a distal stone or
obstructing mass.
Radiology Report
MRCP
INDICATION: ___ woman status post cholecystectomy with abdominal
pain, LFTs in the ___ and ___, evaluate for CBD stone.
TECHNIQUE: Multiplanar and multisequence MR imaging was obtained before and
after the administration of IV contrast. 7 cc of Gadavist IV contrast was
administered. 2.5 cc of Gadavist mixed with 75 cc of water was administered
orally.
FINDINGS:
Lung bases demonstrate minimal bibasilar subsegmental atelectasis. The
visualized heart is prominent without pericardial effusion. The liver appears
enlarged with very heterogeneous arterial phase enhancement which normalizes
on subsequent post-contrast images. There is a mild amount of intrahepatic
biliary ductal dilatation and mild periportal edema noted.
Remnant cystic duct is dilated with a few large filling defects noted
measuring up to 6 mm. These demonstrate mild susceptibility artifact on the
corresponding in-phase images. Significant dilation of the common
hepatic/common bile duct is again seen measuring up to 13 mm at the level of
the extrapancreatic common bile duct. Distally, the common bile duct measures
up to 8 mm, with intraluminal stones measuring up to 6 mm. No definitive
cholecystectomy clips are appreciated. Additionally, the common hepatic,
common bile and cystic duct walls have slight hyperenhancement consistent with
cholangitis.
The pancreas, however, is homogeneous with top normal pancreatic ductal
caliber. No evidence of gallstone pancreatitis is seen. No significant
peripancreatic fluid collection or significant lymphadenopathy is appreciated.
Incidental note of bilateral extrarenal pelves, without evidence of
hydronephrosis. Renal cyst is noted within the right upper kidney.
The visualized skeletal structures demonstrate no significant abnormality.
IMPRESSION:
1. Choledocholithiasis and stones within the remnant cystic duct; ductal wall
hyperenhancement indicates cholangitis. Largest stone within the common bile
duct measures up to 6 mm. Mild intrahepatic biliary ductal dilation.
2. Mild periportal edema, hepatic enlargement and heterogeneous arterial
enhancement suggest hepatitis; a chronic hepatic abnormality is possible.
2. Normal homogeneous-appearing pancreas without evidence of gallstone
pancreatitis.
CRITICAL FINDINGS COMMUNICATION:
PRELIMINARY FINDINGS SIMILAR TO ABOVE FINAL FINDINGS WERE VERBALLY
COMMUNICATED BY PHONE TO ___. ___ FELLOW) IN THE AFTERNOON ON ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 97.6
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 158.0
dbp: 72.0
level of pain: 8
level of acuity: 3.0 | ___ with hx of CCY, presenting with acute on chronic sharp,
crampy epigastric pain post-prandially found to have a dilated
CBD and transaminases >1000.
.
# Choledocolithiasis: Pt presented with transaminases >1000. DDx
includesd choledocolithiasis with obstruction, acute
cholangitis, acute viral hepatitis, shock liver, autoimmune
hepatitis. MRCP and subsequent ERCP confirmed dx of biliary
sludge and the patient AST/ALT downtrended the following day
(see above). The pt was without fever or leukocytosis, thus abx
were discontinued. The pt was instructed to have her labs
checked on ___ and have the results called to the ERCP
fellow, Dr. ___ at ___.
.
# Glaucoma: Continued Home timolol dosing |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
aspirin / Penicillins / bee sting / epinephrine
Attending: ___.
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Intubation, mechanical ventilation
History of Present Illness:
EU Critical ___ ___ is a ___ M
with h/o primary generalized epilepsy (GTCs and myoclonic
seizures, h/o AED noncompliance, on VPA) and EtOH abuse (h/o
multiple admissions for withdrawal seizures) who is transferred
to ___ from ___ for status epilepticus, which has
resolved s/p PHT 1.5g load, intubation and sedation with
fent/midaz.
IN ___: p/w status. Loaded with fosphenytoin about 1500 PE
equivalents. BP at time of intubation in the 110's systolic
increasing to 230/100 following intubation. Propofol drip
started
with stable BP x 20 minutes then decreasing to 80's. Propofol
discontinued and patient switched to Versed gtt with bolused
Fentanyl
with improved stability and sedation however low MAP's so on
small
dose neo gtt to maintain MAP's > 90. Given persistent
hypotension
despite 3L of NS and no propofol, central access obtained in
right
groin. Labs in ___ only remarkable for ETOH level of 160.
Transferring given no EEG available at ___ overnight.
In our ___, vitals 97 57 148/107 22 100% intubated. Patient
sedated with midazolam and fentanyl, but responsive to
questions, follows commands. NCHCT remarkable only for sinus
disease, no intercranial process. Neurology consulted. Per their
exam in ___, sensorimotor exam and reflexes are intact, tone is
normal, and toes are downgoing. There is no meningismus. Patient
no longer in status.
Past Medical History:
-Epilepsy:
Diagnosed at the age of ___, described above. States that his
baseline for seizures is approximately 1-2/year.
-___ Disease:
Diagnosed in ___ with tremor, problems writing (Dr.
___
- CAD s/p ___ MIs: ___ and 8 stents
-Hypercholesterolemia-familial
-Restless leg syndrome
-GERD
-Sciatica
-Anxiety
-Depression
Social History:
___
Family History:
Family history of DM, HTN, MI, strokes and EtOH abuse on both
maternal and paternal sides. Sister with epilepsy.
Physical Exam:
Vitals: see metavision
General- intubated, minimally responsive
HEENT- Sclera anicteric, MMM
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- foley in place
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 05:53PM VALPROATE-65
___ 03:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 03:00PM URINE RBC-24* WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0
___ 08:18AM TYPE-CENTRAL VE TEMP-37.2 PO2-61* PCO2-47*
PH-7.30* TOTAL CO2-24 BASE XS--3 INTUBATED-INTUBATED
___ 08:18AM LACTATE-1.5
___ 07:29AM ALT(SGPT)-47* AST(SGOT)-33 ALK PHOS-38* TOT
BILI-0.2
___ 07:29AM PHENYTOIN-2.5*
___ 04:35AM ASA-NEG ETHANOL-57* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 04:35AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 03:12AM TYPE-ART RATES-15/ TIDAL VOL-500 PEEP-5
O2-100 PO2-490* PCO2-56* PH-7.19* TOTAL CO2-22 BASE XS--7
AADO2-170 REQ O2-38 -ASSIST/CON INTUBATED-INTUBATED
___ 04:35AM WBC-10.3 RBC-4.89 HGB-15.3 HCT-44.8 MCV-92
MCH-31.3 MCHC-34.2 RDW-14.1
IMAGING:
head CT ___: 1. No acute intracranial abnormality. 2.
Paranasal sinus disease, including aerosolized secretions in the
sphenoid sinus. Recommend clinical correlation for acute
sinusitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO DAILY:PRN constipation
2. Diltiazem Extended-Release 120 mg PO DAILY
3. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily
4. Diazepam 10 mg PO TID
5. Divalproex (DELayed Release) 500 mg PO BID
6. Ezetimibe 10 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO DAILY
8. Ropinirole 1 mg PO BID
Discharge Medications:
1. Diazepam 10 mg PO TID
2. Ropinirole 1 mg PO BID
3. Rosuvastatin Calcium 40 mg PO DAILY
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Divalproex (DELayed Release) 500 mg PO TID
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Ezetimibe 10 mg PO DAILY
8. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Discharge condition: fair
Mental status: awake, alert and oriented
Ambulatory status: ambulates independently
Followup Instructions:
___
Radiology Report
INDICATION: Found down with status epilepticus.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin
section bone reformatted images were obtained and reviewed.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
large vascular territory infarction. The ventricles and sulci are normal in
size and configuration. The basal cisterns are patent.
No fracture is identified. There is a mucus retention cyst in the right
maxillary sinus, mucosal thickening throughout the paranasal sinuses, and
aerosolized secretions in the sphenoid sinus. Mastoid air cells and middle
ear cavities are clear. Soft tissues are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Paranasal sinus disease, including aerosolized secretions in the sphenoid
sinus. Recommend clinical correlation for acute sinusitis.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Seizure, intubation. Evaluation.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The patient is intubated. The tip of the endotracheal tube
projects 6 cm above the carina. The tube should be advanced by 1-2 cm. The
technical quality of the image is limited. A part of the left costophrenic
sinus is missing. Lung volumes are low. There is a calcified granuloma in
the right upper lobe. Borderline size of the cardiac silhouette without
pulmonary edema. Minimal atelectasis in the retrocardiac lung areas. No
pneumothorax. A minimal right pleural effusion might be present.
Radiology Report
HISTORY: Fever and seizures
COMPARISON: Same day earlier in the morning.
FINDINGS:
There is mild cardiomegaly. Widened upper mediastinum is new. Bilateral
basal atelectasis greater in the left have minimally increased. There is mild
vascular congestion. There is a small left effusion. ET tube is in standard
position. NG tube tip is below the diaphragm, out of view.
IMPRESSION:
New mild vascular congestion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ETOH;SZ
Diagnosed with GRAND MAL STATUS, ALCOH DEP NEC/NOS-CONTIN
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ with h/o seizure d/o and EtOH abuse transferred from OSH
with status epileptic in the form of multiple GTCs. Was
intubated and sedated prior to admission to MICU. Extubated on
___.
# Status Epilepticus (RESOLVED): Etiology was thought to be ___
AED noncompliance vs EtOH withdrawal. Given concern over EtOH
withdrawal he was admitted to the MICU. Prior to transfer to
the MICU he was loaded with fosphenytoin at OSH, but this was
subseqently discontinued. In the ___ at ___, valproate level
was checked, which was subtherapeutic. Per admission records,
pt was on valproate 500mg BID recently but was noncompliant with
meds. Of note he was previously on up to 4g of valproate daily
in the past. In the MICU he was restarted on his valproate at
500mg TID. He was also started on midazolam drip for first day
in ICU. In the ICU he had two episodes of GTC seizures both of
which were aborted with midazolam boluses. Seizures occured
before EEG monitoring was set up. On HD1 he was extubated and
did not have any more seizure activity in the ICU. His
midazolam was stopped prior to extubation and his home diazepam
was restarted. Patient was on EEG monitoring but that was
discontinued on ___ given that there is no EEG findings
suggestive of seizures. Patient has no clinical seizures after
the discontinuation of his EEG. ___ seizures are thought to be
a combination or medication non-compliance and withdrawal from
ETOH and intermittent use of valium. Patient is counseled on
limiting ETOH use and the importance of taking medications as
directed. Patient will be followed up at Dr. ___
after discharge with the plan to transition his care to a
provider that is closer to his home.
# Alcohol Abuse/Withdrawal: Pt presented with etoh level in ___,
so less likely that he was actually withdrawing, although he
does have a reported hx of DTs, so could potentially be
withdrawing from etoh even with an serum etoh level. After
extubation pt was asked about his etoh use and he reports that
he only drinks once a week. Regardless, he was started on CIWA
scale after extubation. He was given 3 doses of PO valium for a
total of 30mg. On HD2 pt was not scoring on CIWA scale, so it
was discontinued. His home diazepam dose was restarted. Pt was
also given IV thiamine, MVI and folate while in the MICU.
Inactive issues:
# CAD s/p ___ MIs: ___ and 8 stents. Pt was
continued on home dose of plavix. He is not on ASA because of
reported allergy. He was also continued on home dose
rosuvastatin and zetia.
# Parkinsonism: continued on home ropinerole dose.
# GERD: continued on home dose of nexium. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Invega / Klonopin / Detrol / Compazine
Attending: ___
Chief Complaint:
Confusion, Worsening ___ Symptoms
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with PMHx of early-onset ___ disease as well as
? sleep disorder, who was sent in from clinic yesterday when she
was noted to be altered. Pt reports that she initially felt off
from baseline earlier this week, with increased rigidity. She
also noted worsening of her tremors as well as myocolonic
movements of the LEs. She notes dysuria, abnormal smell to her
urine, as well as dark matter (?clots) in her urine. She denies
any fevers or chills, but does endorse hot flashes. Symptoms are
consistent with recent UTI's per patient.
Of note, she also have a fall earlier this week, which she
attributes to increased rigidity and gait instability. No LOC /
head strike. No prodromal s/s prior to fall.
ED Course:
Initial VS: 98.8 115 131/81 20 99% RA Pain ___
Labs significant for + UA.
Imaging: CXR without acute process. Hand films with nondisplaced
fracture through the shaft of the fifth metacarpal.
Meds given:
___ 20:43 IVF 1000 mL NS 1000 mL
___ 21:51 PO Acetaminophen 650 mg
___ 00:01 IVF 1000 mL NS 1000 mL
___ 00:33 PO/NG Carbidopa-Levodopa (___) 1 TAB
___ 00:33 IV Meropenem 500 mg
VS prior to transfer: 98.2 96 108/60 18 100% RA Pain ___
On arrival to the floor, the patient reports that she feels
better after getting abx in the ED. She does endorse being tired
after being awake all night. She reports that her right hand ___
been "stiff" but is starting to feel better. she reports some
lightheadedness earlier, now resolve.
ROS: As above. Denies headache, lightheadedness, dizziness, sore
throat, sinus congestion, chest pain, heart palpitations,
shortness of breath, cough, nausea, vomiting, diarrhea, focal
numbness or tingling, skin rash. The remainder of the ROS was
negative.
Past Medical History:
GAIT DISTURBANCE
BACK PAIN
LUMBAR RADICULOPATHY
___ DISEASE
DEPRESSION
DELIRIUM
NEUROGENIC BLADDER
C.DIFF
Social History:
___
Family History:
2 maternal aunts with MS and grandfather with dementia. Also
history of hypertension, diabetes mellitus, and CAD. No FH of
PD.
Physical Exam:
ADMISSION EXAM:
VS - 97.9 118/61 95 18 100 RA
GEN - Alert, NAD
HEENT - Atraumatic, masked facies, symmetric, tongue midline,
MMM
NECK - Supple
CV - RRR, no m/r/g appreciated
RESP - CTA B
BACK - no CVAT
ABD - S/NT, BS present
GU - Foley catheter in place
EXT - splint in place on right hand
SKIN - No apparent rashes
NEURO - Alert, able to recount history easily, face symmetric,
___ strength in all 4 extremities, significant rigidity noted in
the LEs, + cogwheeling in the LUE, ___ patellar DTRs
bilaterally
PSYCH - ___, appropriate
DISCHARGE EXAM:
VSS, AF
GEN: Alert, NAD
HEENT: NC/AT, masked facies
CV: RRR, no m/r/g
PULM: CTA B
GI: S/NT/ND, BS present
NEURO: Alert, Still with rigidity noted in the LUE with some
cogwheeling
EXT: right hand splinted
Pertinent Results:
___ 08:45PM BLOOD WBC-8.5 RBC-4.13 Hgb-12.1 Hct-34.5 MCV-84
MCH-29.3 MCHC-35.1 RDW-12.9 RDWSD-38.7 Plt ___
___ 08:45PM BLOOD Neuts-60.5 ___ Monos-5.7 Eos-0.4*
Baso-0.2 Im ___ AbsNeut-5.12 AbsLymp-2.79 AbsMono-0.48
AbsEos-0.03* AbsBaso-0.02
___ 08:45PM BLOOD Glucose-83 UreaN-10 Creat-0.6 Na-137
K-4.1 Cl-103 HCO3-21* AnGap-17
___ 08:56PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:56PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 08:56PM URINE RBC-2 WBC-32* Bacteri-FEW Yeast-NONE
Epi-2
___ 07:20AM BLOOD WBC-7.6 RBC-4.33 Hgb-12.3 Hct-36.5 MCV-84
MCH-28.4 MCHC-33.7 RDW-12.9 RDWSD-39.5 Plt ___
___ 07:20AM BLOOD Glucose-83 UreaN-9 Creat-0.6 Na-139 K-4.2
Cl-106 HCO3-25 AnGap-12
___ 07:20AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1
Hand Films - IMPRESSION:
Oblique nondisplaced fracture through the shaft of the fifth
metacarpal,
without intra-articular extension.
CXR - IMPRESSION:
No acute cardiopulmonary process.
Renal U/S - IMPRESSION:
Normal renal ultrasound. No sonographic evidence of perinephric
fluid
collection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. carbidopa-levodopa-entacapone ___ mg oral QID
2. Amantadine 100 mg PO TID
3. Carbidopa-Levodopa (___) 2 TAB PO QHS
4. Pramipexole 1 mg PO TID
5. Sertraline 200 mg PO QHS
6. Nitrofurantoin (Macrodantin) 100 mg PO DAILY
7. Ascorbic Acid ___ mg PO BID
8. Myrbetriq (___) 50 mg oral QHS
9. LORazepam 0.75 mg PO QHS
10. Necon 0.5/35 (28) (norethindrone-ethin estradiol) 0.5-35
mg-mcg oral DAILY
Discharge Medications:
1. amantadine HCl 100 mg oral TID
2. ascorbic acid (vitamin C) 500 mg oral BID
3. ascorbic acid (vitamin C) 500 mg oral BID
4. Ascorbic Acid ___ mg PO BID
5. Carbidopa-Levodopa (___) 2 TAB PO QHS
6. carbidopa-levodopa-entacapone ___ mg oral QID
7. LORazepam 0.75 mg PO QHS
8. Myrbetriq (mirabegron) 50 mg oral QHS
9. Necon 0.5/35 (28) (norethindrone-ethin estradiol) 0.5-35
mg-mcg oral DAILY
10. pramipexole 1 mg oral TID
11. Sertraline 200 mg PO QHS
12. sennosides-docusate sodium 8.6-50 mg oral DAILY:PRN
constipation
13. melatonin 12 mg oral QHS
14. Sulfameth/Trimethoprim DS 1 TAB PO BID
Last dose of this medication is the evening of ___
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Urinary Tract Infection
Early-onset ___
Right ___ metacarpal shaft 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
EXAMINATION: RENAL U.S.
INDICATION: ___ woman with UTI, back pain; assess for evidence of
perinephric abscess.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound dated ___.
FINDINGS:
The exam is slightly limited secondary to overlying bowel gas. The right
kidney measures 9.8 cm. The left kidney measures 9.6 cm. There is no
hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally. No evidence of
perinephric fluid collections.
The bladder is partially distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No sonographic evidence of perinephric fluid
collection.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion, Dysuria
Diagnosed with Dysuria
temperature: 98.8
heartrate: 115.0
resprate: 20.0
o2sat: 99.0
sbp: 131.0
dbp: 81.0
level of pain: 5
level of acuity: 2.0 | ___ y/o F with PMHx of early-onset ___ disease as well as
? sleep disorder, here with confusion and worsening ___
s/s, found to have UTI.
# Urinary Tract Infection: Pt presented with dysuria, worsening
___ symptoms, as well as confusion. She reported that
presentation was consistent with prior episodes of UTI's. She
was treated with meropenem, given h/o ESBL E.coli. ID was
consulted. Ultimately, she grew proteus that was pan-sensitive
to antibiotics, so was switched to Bactrim DS on ___ to
complete a total of 10 days of antibiotics (end date = ___.
She should be RESTARTED on Nitrofurantoin for suppressive
therapy after she completes the course of Bactrim as per
outpatient ID.
# ___ Metacarpal Fracture: In splint and is non-weight bearing
for now. She needs a repeat xray by ___ or ___ to assess
healing and will need follow-up with Plastic Surgery at ___
(number on discharge worksheet).
# ___ Disease: Recent worsening symptoms likely related
to acute infection. Maintained on home regimen of
carbidopa-levodopa-entacapone ___ mg oral QID,
Amantadine 100 mg PO TID, Carbidopa-Levodopa (___) 2 TAB PO
QHS, Pramipexole 1 mg PO TID, and Myrbetriq (mirabegron) 50 mg
oral QHS. Neurology was involved during admission and
recommended continuation of home regimen. Her outpatient sleep
medications were also continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
Weakness, Lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with a history of metastatic
prostate cancer on cabazitaxel, afib (not on anticoagulation),
HFpEF, orthostatic hypotension (on midodrine), CKD, and
hydroureteronephrosis s/p percutaneous nephrostomy tube
placement who presents with disorientation.
The patient was admitted to ___ two weeks ago with a dislodged
percutaneous nephrostomy tube. This was replaced, but his urine
grew E. coli resistant to most agents but susceptible to
pip/tazo and meropenem. He completed meropenem through his
midline on ___.
For the past few days, however, the patient has been acting
confused. At baseline he has some forgetfulness, but recently he
has been saying strange things, has been disoriented, and at
times has been slightly agitated. His wife is unaware of any
fevers, reports of pain, difficulty breathing, or diarrhea. His
percutaneous nephrostomy has been functioning as expected, and
there were no problems with the midline. His wife gave him
oxycodone a couple nights ago. Besides this and the meropenem he
has not had any new medications.
Regarding his prostate cancer, his last cabazitaxel was on
___. His PSA has been rising lately.
In the ED he was tachycardic and had a leukocytosis to 12.3.
Lactate was 1.2. Urine obtained from the percutaneous
nephrostomy tube showed WBCs and bacteria. He otherwise does not
usually pass urine on his own. Pip/tazo was started.
ROS: Unable to obtain secondary to encephalopathy.
Past Medical History:
1. Metastatic prostate cancer
2. Atrial fibrillation on Coumadin
3. Orthostatic hypotension
4. CKD III
5. HFpEF
6. Anemia
7. Malnutrition
8. Hydronephrosis
9. Perc neph placement
Social History:
___
Family History:
No family history of prostate cancer
Physical Exam:
ADMISSION EXAM
GENERAL: Elderly thin gentleman, hard of hearing, lying in bed,
awake
NECK: Normal ROM, JVD not elevated
HEART: Regular at time of exam, no murmurs
LUNGS: CTAB, good air movement
ABDOMEN: Soft, non tender, non distended, +BS
BACK: L nephrostomy tube insertion site, dressed and clean, no
surrounding erythema or induration, yellow urine in bag
EXTREMITIES: Left midline with dried blood under bandage but no
purulent drainage
NEURO: Oriented to person only. Conversant but talking about
unrelated topics
SKIN: Sacral erythema but no ulcer, present prior to admission
98.1
PO 143 / 77 67 18 99 RA
tired and lying down in AM but asking for food, then more alert
and interactive sitting up
L nephrostomy draining yellow urine, site not painful
no peripheral edema or labored breathing
Pertinent Results:
ADMISSION LABS:
___ 11:24AM BLOOD WBC-12.3*# RBC-3.11* Hgb-9.5* Hct-30.5*
MCV-98 MCH-30.5 MCHC-31.1* RDW-16.9* RDWSD-60.3* Plt ___
___ 11:24AM BLOOD Neuts-75.4* Lymphs-13.0* Monos-9.8
Eos-0.5* Baso-0.4 Im ___ AbsNeut-9.28*# AbsLymp-1.60
AbsMono-1.20* AbsEos-0.06 AbsBaso-0.05
___ 11:24AM BLOOD Glucose-90 UreaN-23* Creat-1.2 Na-139
K-4.0 Cl-99 HCO3-26 AnGap-14
___ 11:24AM BLOOD ALT-23 AST-31 AlkPhos-75 TotBili-1.1
___ 11:24AM BLOOD Lipase-12
___ 11:24AM BLOOD Albumin-3.5 Calcium-9.4 Phos-3.9 Mg-2.2
___ 05:47AM BLOOD PSA-42.6*
___ 11:31AM BLOOD Lactate-1.2
___ 01:40PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
URINE STUDIES
___ 01:00PM URINE Color-Straw Appear-Clear Sp ___
___ 01:00PM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 01:00PM URINE RBC-4* WBC-61* Bacteri-FEW* Yeast-NONE
Epi-0
URINE CULTURE (Final ___: NO GROWTH.
CT HEAD - IMPRESSION:
Within limitations caused by severe motion artifact, no acute
intracranial
process. No evidence of intracranial hemorrhage.
CXR - IMPRESSION:
Comparison to ___. Stable normal lung volumes.
Borderline size of the cardiac silhouette. No pulmonary edema.
No pneumonia, no pleural effusion. Stable rounded radiodensity
in the left lung apex, very likely caused by a calcified
costosternal junction, and not visualized on the lateral image.
RENAL U/S - IMPRESSION:
Limited examination demonstrating moderate right renal atrophy
and mild fullness of the bilateral renal collecting systems
without frank hydronephrosis. Left percutaneous nephrostomy
tube is partially visualized, though the distal pigtail location
is not well seen.
___ 06:24AM BLOOD WBC-8.5 RBC-3.10* Hgb-9.4* Hct-30.5*
MCV-98 MCH-30.3 MCHC-30.8* RDW-17.0* RDWSD-60.0* Plt ___
___ 06:24AM BLOOD Glucose-134* UreaN-26* Creat-1.2 Na-141
K-4.7 Cl-104 HCO3-24 AnGap-13
___ 05:47AM BLOOD PSA-42.6*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Midodrine 5 mg PO TID
3. Mirtazapine 15 mg PO QHS
4. Multivitamins W/minerals Liquid 15 mL PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
7. zoledronic acid 4 mg injection Q3MONTHS
8. PredniSONE 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Toxic Metabolic Encephalopathy
Prostate Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with altered mental status// Eval for pneumoniaEval
for subdural Eval for pneumoniaEval for subdural
IMPRESSION:
Comparison to ___. Stable normal lung volumes. Borderline size of
the cardiac silhouette. No pulmonary edema. No pneumonia, no pleural
effusion. Stable rounded radiodensity in the left lung apex, very likely
caused by a calcified costosternal junction, and not visualized on the lateral
image.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with altered mental status// Eval for pneumoniaEval for
subdural
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 20.0 s, 20.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
1,003.4 mGy-cm.
2) Sequenced Acquisition 20.0 s, 20.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
1,003.4 mGy-cm.
Total DLP (Head) = 2,007 mGy-cm.
COMPARISON: None.
FINDINGS:
The study is severely limited due to motion artifact, despite repeat scan.
Within these limitations:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of age-related cerebral
volume loss. Periventricular and subcortical white matter hypodensities are
nonspecific, though likely sequelae of chronic small vessel ischemic disease.
Atherosclerotic vascular calcifications are noted of bilateral vertebral and
cavernous portions of internal carotid arteries.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
Within limitations caused by severe motion artifact, no acute intracranial
process. No evidence of intracranial hemorrhage.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with met prost cancer, perc neph// Assess for fat
stranding suggestive of pyelo, dislodgement of perc neph, hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdominal ultrasound ___.
FINDINGS:
Examination is limited due to available acoustic window and inability of
patient to fully cooperate with the examination.
The right kidney measures 7.6 cm. The left kidney measures 10.6 cm. There is
mild fullness of the bilateral renal collecting systems without frank
hydronephrosis. There is no obvious stone or focal renal mass. A left
percutaneous nephrostomy tube is partially visualized, though the distal
position is not visualized.
The bladder is nearly completely collapsed and not fully evaluated.
IMPRESSION:
Limited examination demonstrating moderate right renal atrophy and mild
fullness of the bilateral renal collecting systems without frank
hydronephrosis. Left percutaneous nephrostomy tube is partially visualized,
though the distal pigtail location is not well seen..
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 97.9
heartrate: 115.0
resprate: 18.0
o2sat: 97.0
sbp: 133.0
dbp: 61.0
level of pain: Unable
level of acuity: 2.0 | ___ male w/ hx of metastatic prostate cancer on
cabazitaxel, afib (not on anticoagulation), HFpEF, orthostatic
hypotension (on midodrine), CKD, and hydroureteronephrosis s/p
percutaneous nephrostomy tube placement who presents with
encephalopathy / weakness / FTT.
# Toxic Metabolic Encephalopathy / Weakness / Failure to Thrive:
Head CT unremarkable. CXR without clear evidence of PNA. Given
WBC's and few bacteria on UA, there was concern for UTI, for
which patient was started on zosyn. However, urine culture
returned negative, making UTI unlikely. Given reports of sleep
disruption at home, the patient's initial altered mental status
could be explained by delirium superimposed on a background of
failure to thrive in the setting of progression of his prostate
CA. Furthermore, his initial somnolence could have been
medication effect from the olanzapine and haloperidol he
received on the evening of admission. ___ consulted.
# Orthostatic Hypotension: The patient has known orthostatic
hypotension and chronically low BPs. During a previous
admission, he was noted to have orthostatic hypotension that
persisted despite IV fluids, blood transfusion, and
discontinuing beta blocker. He is on midodrine at home. He is
also on steroids for suspected adrenal insufficiency. Steroid
dose was briefly increased in the setting of concern for acute
infection.
# Metastatic Prostate Cancer: Patient with known metastatic
prostate cancer since ___. Is currently on cabazitaxel. Follows
with Dr. ___. Missed his most recent administration due
to this presentation. PSA noted to be higher than recent values.
Oncology was consulted and recommended follow up next week on
___ to discuss declining performance status and progressive
cancer and discussion of goals of care.
# CKD: Review of ___ records shows recent baseline Cr
1.1-1.3. More recent values in OMR closer to 1.4. Cr improved .
# Anemia: H/H largely consistent with recent baseline. No
evidence of bleeding on exam. H/H stable today.
- continue iron supplementation
# Paroxysmal Afib: Rates well controlled. Not currently on
anticoagulation ___ fall risk. Will need to continue discussions
re: a/c with PCP.
# HFpEF: Appears euvolemic-to-hypovolemic on exam. Not on home
diuretics. Continue to monitor volume status closely.
>30min on discharge activities
medically stable for discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Shellfish Derived
Attending: ___
Chief Complaint:
Pelvic pain
Major Surgical or Invasive Procedure:
Abscess drainage under imaging guidance
Depo Provera injection ___
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, minimally TTP in midline pelvis, no rebound/guarding,
incision c/d/i
Ext: no TTP
Pertinent Results:
LABS
===================
___ 06:00AM BLOOD WBC-11.3* RBC-4.04 Hgb-10.5* Hct-32.9*
MCV-81* MCH-26.0 MCHC-31.9* RDW-13.4 RDWSD-40.0 Plt ___
___ 12:50PM BLOOD WBC-13.4* RBC-4.27 Hgb-11.1* Hct-34.8
MCV-82 MCH-26.0 MCHC-31.9* RDW-13.4 RDWSD-39.6 Plt ___
___ 06:15AM BLOOD WBC-11.9* RBC-3.94 Hgb-10.3* Hct-32.4*
MCV-82 MCH-26.1 MCHC-31.8* RDW-13.5 RDWSD-40.2 Plt ___
___ 06:51AM BLOOD WBC-10.1* RBC-3.73* Hgb-9.8* Hct-30.5*
MCV-82 MCH-26.3 MCHC-32.1 RDW-13.5 RDWSD-40.3 Plt ___
___ 06:06AM BLOOD WBC-11.4* RBC-3.41* Hgb-8.9* Hct-27.5*
MCV-81* MCH-26.1 MCHC-32.4 RDW-13.6 RDWSD-39.6 Plt ___
___ 07:05AM BLOOD WBC-12.6* RBC-3.30* Hgb-8.7* Hct-26.3*
MCV-80* MCH-26.4 MCHC-33.1 RDW-13.4 RDWSD-39.5 Plt ___
___ 06:45AM BLOOD WBC-13.4* RBC-3.18* Hgb-8.4* Hct-25.4*
MCV-80* MCH-26.4 MCHC-33.1 RDW-13.4 RDWSD-38.8 Plt ___
___ 06:40AM BLOOD WBC-14.3* RBC-3.24* Hgb-8.5* Hct-26.2*
MCV-81* MCH-26.2 MCHC-32.4 RDW-13.4 RDWSD-39.7 Plt ___
___ 02:20PM BLOOD WBC-14.5* RBC-3.44* Hgb-9.0* Hct-28.3*
MCV-82 MCH-26.2 MCHC-31.8* RDW-13.5 RDWSD-40.1 Plt ___
___ 06:30PM BLOOD WBC-14.2* RBC-3.64* Hgb-9.6* Hct-29.7*
MCV-82 MCH-26.4 MCHC-32.3 RDW-13.3 RDWSD-39.8 Plt ___
___ 06:00AM BLOOD Neuts-67.1 ___ Monos-6.3 Eos-1.8
Baso-0.4 Im ___ AbsNeut-7.57* AbsLymp-2.56 AbsMono-0.71
AbsEos-0.20 AbsBaso-0.04
___ 12:50PM BLOOD Neuts-75.0* Lymphs-18.5* Monos-4.1*
Eos-0.6* Baso-0.4 Im ___ AbsNeut-10.01* AbsLymp-2.47
AbsMono-0.55 AbsEos-0.08 AbsBaso-0.05
___ 06:15AM BLOOD Neuts-67.1 ___ Monos-5.1 Eos-1.9
Baso-0.4 Im ___ AbsNeut-7.98* AbsLymp-2.84 AbsMono-0.61
AbsEos-0.23 AbsBaso-0.05
___ 06:51AM BLOOD Neuts-70.2 ___ Monos-4.8* Eos-2.5
Baso-0.4 Im ___ AbsNeut-7.09* AbsLymp-2.05 AbsMono-0.48
AbsEos-0.25 AbsBaso-0.04
___ 06:06AM BLOOD Neuts-73.9* Lymphs-17.4* Monos-5.9
Eos-1.0 Baso-0.3 Im ___ AbsNeut-8.44* AbsLymp-1.99
AbsMono-0.67 AbsEos-0.11 AbsBaso-0.03
___ 07:05AM BLOOD Neuts-78.6* Lymphs-12.7* Monos-6.1
Eos-0.9* Baso-0.4 Im ___ AbsNeut-9.95* AbsLymp-1.60
AbsMono-0.77 AbsEos-0.11 AbsBaso-0.05
___ 06:45AM BLOOD Neuts-79.6* Lymphs-12.5* Monos-5.7
Eos-1.0 Baso-0.2 Im ___ AbsNeut-10.70* AbsLymp-1.68
AbsMono-0.76 AbsEos-0.13 AbsBaso-0.03
___ 06:40AM BLOOD Neuts-79.6* Lymphs-12.7* Monos-6.0
Eos-0.7* Baso-0.2 Im ___ AbsNeut-11.33* AbsLymp-1.81
AbsMono-0.86* AbsEos-0.10 AbsBaso-0.03
___ 02:20PM BLOOD Neuts-77.8* Lymphs-13.6* Monos-7.3
Eos-0.3* Baso-0.3 Im ___ AbsNeut-11.29* AbsLymp-1.97
AbsMono-1.06* AbsEos-0.04 AbsBaso-0.04
___ 06:30PM BLOOD Neuts-79.8* Lymphs-12.4* Monos-6.7
Eos-0.3* Baso-0.2 Im ___ AbsNeut-11.35* AbsLymp-1.76
AbsMono-0.96* AbsEos-0.04 AbsBaso-0.03
___ 06:00AM BLOOD Plt ___
___ 12:50PM BLOOD Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:51AM BLOOD Plt ___
___ 10:40AM BLOOD ___ PTT-31.7 ___
___ 06:06AM BLOOD Plt ___
___ 07:05AM BLOOD Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:40AM BLOOD Plt ___
___ 02:20PM BLOOD Plt ___
___ 02:20PM BLOOD ___ PTT-27.3 ___
___ 06:30PM BLOOD Plt ___
___ 06:06AM BLOOD Creat-0.7
___ 02:20PM BLOOD Glucose-72 UreaN-8 Creat-0.7 Na-137 K-4.1
Cl-100 HCO3-22 AnGap-19
___ 06:30PM BLOOD Glucose-91 UreaN-7 Creat-0.6 Na-135 K-3.8
Cl-96 HCO3-23 AnGap-20
___ 08:50AM BLOOD HIV Ab-Negative
___ 03:40PM BLOOD HIV Ab-Negative
___ 06:35PM BLOOD Lactate-0.8
___ 02:10PM URINE Color-Straw Appear-Clear Sp ___
___ 07:59PM URINE Color-Straw Appear-Clear Sp ___
___ 02:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 07:59PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 07:59PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 07:59PM URINE UCG-NEGATIVE
MICROBIOLOGY
===================
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
Reported to and read back by ___ ___ ___ AT
11:04A.
FUSOBACTERIUM NUCLEATUM. SPARSE GROWTH. BETA LACTAMASE
NEGATIVE.
___ 3:40 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ 2:54 pm SWAB Source: Vaginal.
**FINAL REPORT ___
SMEAR FOR BACTERIAL VAGINOSIS (Final ___:
GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS.
YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR
YEAST.
___ 2:30 pm URINE
**FINAL REPORT ___
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___:
Negative for Chlamydia trachomatis by ___ 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.
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.
___ 2:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 7:59 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
===================
___ CT
Final Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: NO_PO contrast; History: ___ with LLQ, L flank
pain, partially
treated UTI. NO_PO contrast// eval for intraabdominal infection
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 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy
(Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 4.5 s, 49.4 cm; CTDIvol = 9.9 mGy
(Body) DLP = 491.3
mGy-cm.
Total DLP (Body) = 500 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is a subcentimeter hypodensity seen in the right hepatic
lobe, too small
to fully characterize but likely representing hepatic cyst or
biliary
hamartoma. There is no evidence of focal lesions. There is no
evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
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: There is a fibroid uterus with an IUD
appearing
appropriately placed. There is a 3.9 x 3.8 cm left adnexal
cystic structure
with demonstrates rim enhancement, concerning for tubo-ovarian
abscess (series
2: Image 58). Smaller rim enhancing fluid collections seen
lateral to the
dominant collection likely represents additional abscesses.
There is
associated peritoneal thickening (series 601b: Image 19) with
reactive wall
thickening of the adjacent sigmoid colon. There is associated
stranding and
inflammatory changes seen along the gonadal vein. A hypodense
focus seen
within the gonadal vein (series 2: Image 43), is concerning for
a tiny clot.
The right adnexa appears unremarkable.
LYMPH NODES: There is no retroperitoneal lymphadenopathy.
Multiple small
mesenteric lymph nodes appear prominent, particularly in the
left lower
quadrant, without meeting CT size criteria for lymphadenopathy..
There is no
pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. 3.9 cm dominant left adnexal rim enhancing cystic collection
concerning for
tubo-ovarian abscess with smaller adjacent collections likely
also
representing abscesses. There is associated inflammatory
changes seen along
the gonadal vein with a hypodense focus seen within the vein
concerning for
tiny clot. Additionally, there is peritoneal thickening and
reactive sigmoid
colonic wall thickening.
2. Fibroid uterus with an IUD seen appropriately placed.
NOTIFICATION: The findings were discussed with ___,
M.D. by ___, M.D. on the telephone on ___ at 8:52 am, 5 minutes
after discussion
of findings with attending radiologist. Patient had been
discharged home with
Ob-gyn follow up visit scheduled, and upon discussion with ED
following the
updated read, the decision was made to contact the patient for
return to the
hospital for further treatment.
___ PELVIC US
Final Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman admitted with ___ and gonadal
vein
thrombosis// Please evaluate for interval changes in ___
TECHNIQUE: Grayscale ultrasound images of the pelvis were
obtained with
transabdominal approach followed by transvaginal approach for
further
delineation of uterine and ovarian anatomy.
COMPARISON: CT ___ ultrasound ___
FINDINGS:
The uterus is anteverted. The uterus is enlarged and measures
11.5 x 5.0 x
6.1 cm. Uterine fibroids are present. The largest fibroid is
exophytic
located on the right measuring 5.3 x 4.1 x 4.3 cm. The
endometrium is
distorted due to fibroids however, where seen appears homogenous
and measures
4 mm.
There is a complex left adnexal lesion/collection with central
complex cystic
component and thick-walled rim measuring overall 7.7 x 4.8 x 6.6
cm,
previously 5.8 cm by ultrasound. The largest cystic component
measures 5.2
cm, previously 3.2 cm by ultrasound. There is no vascularity
demonstrated
with color flow Doppler. The right ovary is not visualized.
There is a trace
amount of free fluid.
IMPRESSION:
1. Complex left adnexal lesion/collection which was
characterized as a left
tubo-ovarian abscess on most recent CT. When compared to the
most recent CT,
there has been no significant change in the overall size of this
structure
however, with slightly larger cystic component. Overall no
significant change
when compared to most recent CT. When compared to most recent
ultrasound,
this has increased in size overall.
2. Stable fibroid uterus.
3. Nonvisualization of the right ovary.
___ CT-GUIDED DRAINAGE
EXAMINATION: CT-GUIDED DRAINAGE
INDICATION: ___ year old woman with left ___, on IV abx x 72h,
with enlarging
___// please drain as much as ___ as possible, and send for
microbiology.
COMPARISON: CT abdomen and pelvis dated ___
PROCEDURE: CT-guided drainage of a left pelvic collection.
OPERATORS: Dr. ___, radiology fellow and Dr. ___
___,
attending radiologist. Dr. ___ supervised
the trainee
during the key components of the procedure and reviewed and
agrees with the
trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the
procedure were
explained to the patient. After a detailed discussion, informed
written
consent was obtained. A pre-procedure timeout using three
patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan
table. Limited
preprocedure CT scan was performed with a grid to localize the
collection.
Based on the CT findings an appropriate skin entry site for the
drain
placement was chosen. The site was marked. Local anesthesia
was administered
with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___
needle was
inserted into the collection. A sample of fluid was aspirated,
confirming
needle position within the collection. 0.038 ___ wire was
placed through
the needle and needle was removed, and the tract was
progressively dilated
using 6 ___ and 8 ___ dilators. This was followed by
placement of
___ Exodus pigtail catheter into the collection. The
plastic stiffener
and the wire were removed. The pigtail was deployed. The
position of the
pigtail was confirmed within the collection via CT fluoroscopy.
Approximately 42 cc of purulent fluid was aspirated with a
sample sent for
microbiology evaluation. The catheter was secured by a StatLock.
The catheter
was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate
post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 23.7 cm; CTDIvol = 7.0 mGy
(Body) DLP = 168.8
mGy-cm.
2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body)
DLP = 5.1
mGy-cm.
13) Spiral Acquisition 4.5 s, 23.7 cm; CTDIvol = 7.0 mGy
(Body) DLP = 168.8
mGy-cm.
Total DLP (Body) = 394 mGy-cm.
SEDATION: Moderate sedation was provided by administering
divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total
intra-service time of 17
minutes during which patient's hemodynamic parameters were
continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited preprocedural planning CT of the pelvis demonstrates a
heterogeneous
left adnexal collection, in keeping with the previously
characterized tubo-
ovarian abscess. Intra procedural fluoroscopic CT demonstrates
appropriate
positioning of the ___ needle within this collection. A
limited
postprocedural CT demonstrates the pigtail catheter in
appropriate position
within this collection, which has decreased in size after
drainage.
IMPRESSION:
1. Successful CT-guided placement of an ___ pigtail
catheter into the
left hemi- pelvic collection, presumed to be a tubo-ovarian
abscess. Samples
were sent for microbiology evaluation.
2. 40 mL of pus was aspirated and a sample was sent for
microbiology and
cultures.
RECOMMENDATION(S): 1. Monitor output.
2. Flush catheter with 10 mL of normal saline Q 8 hours.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman admitted with ___ and gonadal vein
thrombosis// Please evaluate for interval changes in ___
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: CT ___ ultrasound ___
FINDINGS:
The uterus is anteverted. The uterus is enlarged and measures 11.5 x 5.0 x
6.1 cm. Uterine fibroids are present. The largest fibroid is exophytic
located on the right measuring 5.3 x 4.1 x 4.3 cm. The endometrium is
distorted due to fibroids however, where seen appears homogenous and measures
4 mm.
There is a complex left adnexal lesion/collection with central complex cystic
component and thick-walled rim measuring overall 7.7 x 4.8 x 6.6 cm,
previously 5.8 cm by ultrasound. The largest cystic component measures 5.2
cm, previously 3.2 cm by ultrasound. There is no vascularity demonstrated
with color flow Doppler. The right ovary is not visualized. There is a trace
amount of free fluid.
IMPRESSION:
1. Complex left adnexal lesion/collection which was characterized as a left
tubo-ovarian abscess on most recent CT. When compared to the most recent CT,
there has been no significant change in the overall size of this structure
however, with slightly larger cystic component. Overall no significant change
when compared to most recent CT. When compared to most recent ultrasound,
this has increased in size overall.
2. Stable fibroid uterus.
3. Nonvisualization of the right ovary.
Radiology Report
EXAMINATION: CT-GUIDED DRAINAGE
INDICATION: ___ year old woman with left ___, on IV abx x 72h, with enlarging
___// please drain as much as ___ as possible, and send for microbiology.
COMPARISON: CT abdomen and pelvis dated ___
PROCEDURE: CT-guided drainage of a left pelvic collection.
OPERATORS: Dr. ___, radiology fellow and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee
during the key components of the procedure and reviewed and agrees with the
trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan was performed with a grid to localize the collection.
Based on the CT findings an appropriate skin entry site for the drain
placement was chosen. The site was marked. Local anesthesia was administered
with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed, and the tract was progressively dilated
using 6 ___ and 8 ___ dilators. This was followed by placement of
___ Exodus pigtail catheter into the collection. The plastic stiffener
and the wire were removed. The pigtail was deployed. The position of the
pigtail was confirmed within the collection via CT fluoroscopy.
Approximately 42 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 23.7 cm; CTDIvol = 7.0 mGy (Body) DLP = 168.8
mGy-cm.
2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1
mGy-cm.
13) Spiral Acquisition 4.5 s, 23.7 cm; CTDIvol = 7.0 mGy (Body) DLP = 168.8
mGy-cm.
Total DLP (Body) = 394 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 17
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited preprocedural planning CT of the pelvis demonstrates a heterogeneous
left adnexal collection, in keeping with the previously characterized tubo-
ovarian abscess. Intra procedural fluoroscopic CT demonstrates appropriate
positioning of the ___ needle within this collection. A limited
postprocedural CT demonstrates the pigtail catheter in appropriate position
within this collection, which has decreased in size after drainage.
IMPRESSION:
1. Successful CT-guided placement of an ___ pigtail catheter into the
left hemi- pelvic collection, presumed to be a tubo-ovarian abscess. Samples
were sent for microbiology evaluation.
2. 40 mL of pus was aspirated and a sample was sent for microbiology and
cultures.
RECOMMENDATION(S): 1. Monitor output.
2. Flush catheter with 10 mL of normal saline Q 8 hours.
Gender: F
Race: WHITE
Arrive by WALK IN
WALK IN
Chief complaint: Pelvic pain
Abd pain
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
Salpingitis and oophoritis, unspecified
temperature: 99.2
97.4
heartrate: 96.0
79.0
resprate: 18.0
16.0
o2sat: 99.0
96.0
sbp: 129.0
110.0
dbp: 78.0
67.0
level of pain: 9
3
level of acuity: 3.0
3.0 | On ___ Ms. ___ was admitted to the Gynecology service
for management of a left tubo-ovarian abscess and gonadal vein
thrombosis.
*) Tubo-ovarian abscess: CT scan on the day of admission
demonstrated a 3.9 cm left tubo-ovarian abscess with smaller
adjacent cysts. Pt had a Tmax of 101.2 on ___. She remained
afebrile from ___ @ 20:15 throughout the remainder of her
hospital stay. She also had a downtrending leukocytosis: 14.5
(___) -> 11.4 ___ 10.1 (___) -> 11.9 (___) -> 13.4 (___) ->
11.3 (___). She was started on IV
Ampicillin/Gentamicin/Clindamycin (___). On ___ she
continued to have pelvic pain, thus repeat imaging was
performed. Pelvic ultrasound on ___ revealed a complex left
adnexal lesion measuring 7.7 x 4.8 x 6.6 cm (When compared to
the most recent CT, there has been no significant change in the
overall size of this structure however, with slightly larger
cystic component. Overall no significant change when compared
to most recent CT.). On ___ she underwent CT-guided drainage of
42cc of purulent fluid. The drain culture grew prelim 2+ OMNs
and anaerobic GNR. She was transitioned to PO Doxycline/Flagyl
(___). On ___ her regimen was changed to
Levofloxacin/Flagyl. She was discharged on this regimen.
*) Left gonadal vein thrombosis: Pt received lovenox 70mg BID
throughout this admission.
*) Contraception: Pt underwent bedside removal of her Mirena
IUD. Pt elected for Depo Provera, and she received an IM dose on
___.
By ___, pt's abdomianl pain was minimal, she was afebrile,
and her leukocytosis had improved. She was tolerating a regular
diet and ambulating without issues. She was then discharged to
home in good condition with outpatient follow-up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Actos / omeprazole / Fosamax
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with diabetes, hypertension, alcoholism (alcoholic
cerebellar degeneration--ataxia), osteoporosis presenting with
gradual onset of hip pain, beginning 10 hours prior to
presentation to ED. It is a sharp pain that became progressively
worse with ambulation. She usually ambulates with a walker and
was stil able to bear weight on the left hip, but with
increasing pain. This is the second admission to the ED in 2
days, she was discharged yesterday for back pain, now presenting
with L-hip pain, tender to touch on presentation to ED, but on
the floor patient reports now non-tender to palpation after
tylenol. It does not hurt when she tries to move it now. Denies
recent illness, fevers/chills, N/V. She had one episode of
non-bloody diarrhea on ___, which resolved. This was the
last BM. She does not feel constipated now. She notes decreased
appetite for ___ weeks, but no weight loss.
In the ED, initial VS were T99, HR 107, BP 153/82, RR 16,
100%RA. Labs showed WBC 11.3 (81%pmn), normal lytes and INR.
Received 1000mg PO acetaminophen. Transfer VS were HR101, BP
148/62, RR 16, 98% RA.
Past Medical History:
*Alcohol abuse, c/b ataxia ___ alcoholic cerebellar degeneration
and peripheral neuropathy
*T2DM, insulin-dependent
*Osteoporosis
*Osteoarthritis, needs bilateral TKR
___ esophagus
*Chronic abdominal pain s/p H. pylori treatment
*Obesity
*Hypercholesterolemia
*Hypertension
*Depression
*Chronic anemia
*PVD, chronic peripheral edema
*recurrent cellulitis
*ovarian cyst
*total abdominal hysterectomy
*c sections X 4
*cholecystectomy
*appendectomy
*ventral hernia
Social History:
___
Family History:
The patient reports a mother with reported history of breast
cancer in the ___, now deceased. She denies a family history of
ovarian, uterine, cervical, vaginal, colon, or any other
cancers. She reports a family history significant for diabetes,
hypertension, hypercholesterolemia, and heart disease.
Physical Exam:
Admission exam:
VS - HR101, BP 148/62, RR 16, 98% RA.
General: obese woman, in no distress lying comfortably in bed
HEENT: normocephalic
Neck:
CV: regular rate, rhythm. normal S2, S2.
Lungs: clear bilaterally, breath sounds distant.
Abdomen: soft, nontender. +BS x4 quadrants
Ext: pedal pulses 2+, pitting edema 2+ to knees.
Neuro: moving all extremities freely, no gross neuro
abnormalities, sensation intact
Skin: erythematous patches on bilateral lower extremities to
mid-shin with overlying white-yellow hypertrophic scale. pt
reports this is chronic. not warm to touch or tender to
palpation.
Discharge exam:
VS - Tc 99.2 HR 79 BP 138-185/74-80, RR 18, 97% RA.
General: obese woman, in no distress lying comfortably in bed
HEENT: normocephalic
CV: regular rate, rhythm. normal S2, S2.
Lungs: clear bilaterally, breath sounds distant.
Abdomen: soft, nontender. +BS x4 quadrants
Ext: pedal pulses 2+, pitting edema 2+ to knees. left hip not
tender to palpation, not warm to touch. no pain with active or
passive ROM.
Neuro: moving all extremities freely, no gross neuro
abnormalities, sensation intact
Skin: erythematous patches on bilateral lower extremities to
mid-shin with overlying white-yellow hypertrophic scale. pt
reports this is chronic. not warm to touch or tender to
palpation.
Pertinent Results:
IMAGING:
====================
CT ABD/PEL ___
IMPRESSION:
1. New compression deformity of L3.
2. Multiple chronic findings including small hiatal hernia,
complex cystic lesion in the upper pole of the right kidney,
ventral abdominal wall hernia, left adrenal adenoma, and right
adnexal cyst are unchanged.
====================
MRI HIP ___
READ PENDING as of ___
======================
PLAIN FILMS OF HIPS ___
FINDINGS: Apparent shortening of the right femoral neck is
likely positional. No fracture of the right hip on CT performed
two days prior. There is joint space loss of the right hip.
There is more severe joint space loss in the left hip. However,
there is no fracture or dislocation. The remainder of the left
femur is also intact.
The partially visualized left knee shows severe degenerative
changes with near complete tricompartmental joint space loss,
subchondral sclerosis and spurring.
IMPRESSION: Degenerative changes in both hips and partially
visualized left knee as detailed above but no evidence of
fracture or dislocation.
Admission labs:
___ 04:56AM BLOOD WBC-11.3* RBC-4.88 Hgb-13.1 Hct-42.1
MCV-86 MCH-26.9* MCHC-31.2 RDW-13.8 Plt ___
___ 04:56AM BLOOD Neuts-81.5* Lymphs-12.5* Monos-5.2
Eos-0.5 Baso-0.2
___ 04:56AM BLOOD ___ PTT-30.0 ___
___ 04:56AM BLOOD Plt ___
___ 04:56AM BLOOD ESR-37*
___ 04:56AM BLOOD Glucose-176* UreaN-20 Creat-0.8 Na-142
K-4.4 Cl-102 HCO3-23 AnGap-21*
___:56AM BLOOD CRP-69.8*
Discharge labs:
___ 06:10AM BLOOD WBC-7.6 RBC-4.39 Hgb-11.8* Hct-37.0
MCV-84 MCH-26.8* MCHC-31.8 RDW-13.6 Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-127* UreaN-17 Creat-0.8 Na-143
K-3.9 Cl-105 HCO3-28 AnGap-14
___ 06:10AM BLOOD Calcium-9.6 Phos-2.3* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Levemir 16 Units Lunch
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Tartrate 100 mg PO BID
5. Ranitidine 150 mg PO BID
6. Simvastatin 40 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
BID
9. Docusate Sodium 100 mg PO BID
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Levemir 16 Units Lunch
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Tartrate 100 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Ranitidine 150 mg PO BID
9. Simvastatin 40 mg PO DAILY
10. Acetaminophen 1000 mg PO Q6H pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*80 Tablet Refills:*0
11. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
BID
12. Miconazole Powder 2% 1 Appl TP TID:PRN fold mycosis
13. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
Duration: 3 Doses
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth q4 Disp
#*15 Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis:
hip pain, osteoarthritis
secondary diagnoses:
diabetes, hypertension, alcoholism, osteoporosis
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: Left hip pain. Evaluate for fracture.
COMPARISON: CTA of the abdomen and pelvis ___.
TECHNIQUE: AP view of the pelvis with additional AP and lateral views of the
left femur.
FINDINGS: Apparent shortening of the right femoral neck is likely positional.
No fracture of the right hip on CT performed two days prior. There is joint
space loss of the right hip. There is more severe joint space loss in the
left hip. However, there is no fracture or dislocation. The remainder of the
left femur is also intact.
The partially visualized left knee shows severe degenerative changes with near
complete tricompartmental joint space loss, subchondral sclerosis and
spurring.
IMPRESSION: Degenerative changes in both hips and partially visualized left
knee as detailed above but no evidence of fracture or dislocation.
Radiology Report
EXAMINATION: MR HIP ___ CONRAST LEFT
INDICATION: ___ year old woman with left hip pain // fx?
TECHNIQUE: Imaging performed at 1.5 TESLA, sequences acquired include coronal
T1 and STIR, axial T1, axial T2 fat sat, sagittal oblique axial coronal proton
density fat sat weighted sequences.
COMPARISON: CT abdomen and pelvis ___, left hip radiographs ___.
FINDINGS:
Imaging is directed towards evaluation of the left hip joint. Mild
degenerative changes seen in the left hip joint (10:11). No marrow edema
identified about the hip. There is minimal fluid in both hips, within
physiologic limits and without frank joint effusion. There is moderate fatty
atrophy of the pelvic girdle muscles. There is mild edema as the origin of the
left hamstrings (07:34) which may reflect tendinosis. No edema is identified
about the greater trochanter to suggest trochanteric bursitis. The piriformis
muscles are symmetric. Degenerative disk disease noted at L5-S1 (04:14).
Assessment of the pelvic parenchymal structures is limited, nonetheless a
large right anterior abdominal wall hernia is seen (06:18) containing loops of
small bowel. There is a 5.6 x 5.2 x 4 cm cystic structure in the right adnexal
region (4:8), unchanged compared to multiple prior studies dating back to
___.
IMPRESSION:
1. No evidence of a left hip fracture.
2. Possible tendinosis of the left hamstring origin.
3. 5.6 cm cystic structure in the right adnexa region, stable to mildly
decreased when compared to prior studies.
4. Mild degenerative change at L5-S1
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: L Hip pain
Diagnosed with JOINT PAIN-PELVIS
temperature: 99.0
heartrate: 107.0
resprate: 16.0
o2sat: 100.0
sbp: 153.0
dbp: 82.0
level of pain: 10
level of acuity: 3.0 | HOSPITAL COURSE: ___ woman with diabetes, hypertension,
alcoholism (alcoholic cerebellar degeneration--ataxia), PVD,
osteoporosis, presenting with 1 day of gradual onset of hip
pain. Had MRI which showed only osteoarthritis and possible
trochanteric bursitis. Stable on oral pain regimen. ___ saw her
and recommended rehab.
ACUTE ISSUES
===============
#Left hip pain
No evidence of fracture on plain films. Low suspicion for septic
joint (no fever, normal WBC count, able to bear weight, move
joint) though ESR, CRP elevated. She was evaluated by
orthopedics who recommended ___ aspiration if high
suspicion for infection. Ortho considered likely progression of
severe osteoarthritis and low back pain. Also thought she may
have trochanteric bursitis. Pain is actually more localized to
lower back, not localized to left hip joint. Pain well
controlled with acetaminophen 1000mg q6h standing dose. Physical
therapy evaluation recommended ___ rehab with ___ to improve
strength, weight-bearing status, and mobility.
#Medicaion list
Medications reconciled from OMR. Family/patient do not know most
recent meds/doses. Because admitted over the weekend, unable to
contact adult daily center who adminsters medication (center is
closed ___.
CHRONIC ISSUES
===============
#Diabetes mellitus, type 2
-Sliding scale insulin, fingerstick qid.
#Hypertension
-monitor BP
-continued home meds, BP stable in systolic 120s-140s
TRANSITIONAL ISSUES
=====================
___ benefit from steroid injections given severity of
osteoarthritis and chronic pain. Low suspicion for septic
hip--"hip" pain described actually localizing to left lower
back.
ANTICIPATED LENGTH OF STAY AT REHAB IS LESS THAN 30 DAYS |
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, positive stress test
Major Surgical or Invasive Procedure:
None
History of Present Illness:
============================================
___ CARDIOLOGY ADMISSION NOTE
============================================
OUTPATIENT CARDIOLOGIST: Dr. ___: ___.
CHIEF COMPLAINT: Chest pain, ? Syncope
HISTORY OF PRESENTING ILLNESS:
___ w/___ CAD, CKD and hx of MI ___ years ago treated with
Coumadin who is presenting with chest tightness, lightheadedness
and syncope after walking up the stairs to her apartment today.
Patient has recurrent epistaxis and was seen in the ED this
morning for epistaxis and was discharged after her right nares
were packed and she had stable labs. She did not had any p.o.
intake today. On arrival to her home with her daughter, patient
began to have chest tightness and increased lightheadedness
while walking up the stairs. At the top of the stairs she
slipped down to the floor with her daughter assisting to lower
her with questionable loss of consciousness for less than one
minute. No head strike. She reports this feels similar to her
previous heart attack where she was catheterized but did not
receive any stenting or bypass procedures due to "too many
blockages." 911 was called and she was brought to the ED by
ambulance. On arrival, she was no longer having chest tightness
or pain, but endorsed persistent lightheadedness that improved
with lying on the stretcher. She denied shortness of breath,
nausea, vomiting, diarrhea, persistent bleeding from the nares
or elsewhere, vision changes, numbness or blood in the urine or
stool.
In the ED initial vitals were: 98.6 87 106/70 19 97% RA
EKG: NSR, no STE, QTc 516
Labs/studies notable for: Neg troponin, Cr 1.9, positive nuclear
stress test
Vitals on transfer: Afebrile 74 112/48 18 98% RA
On the floor patient reports feeling better. She denies losing
consciousness at home. She states she had just felt very weak.
She did not notice chest pain or shortness of breath at that
time. Currently denies fever, chills, dysuria.
Past Medical History:
PAST MEDICAL HISTORY:
Cataract, nuclear sclerotic senile
Positive ___ (antinuclear antibody)
Chronic kidney disease, stage IV (severe)
Atrial fibrillation
CAD (coronary artery disease) s/p MI
Hypertension, essential
Hypercholesterolemia
Macular degeneration
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission Physical Exam:
PHYSICAL EXAMINATION:
VS: Afebrile 137/92 66 20 100% on RA
___: Elderly female in NAD
HEENT: NCAT. MMM
CARDIAC: RRR without MRG, normal S1 and S2
LUNGS: CTAB without increased WOB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: WWP without edema
Neuro: AAOx3, moving all ext, CN II-XII intact
Discharge Physical Exam:
VS: orthostatics: Lying down 109/65 pulse 60 sitting 114/64,
pulse 64 Standing up 97/62 63 bpm
___: Elderly female in NAD
HEENT: NCAT. MMM Nasal packing in place
CARDIAC: RRR without MRG, normal S1 and S2
LUNGS: CTAB without increased WOB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: WWP without edema
Neuro: AAOx3, moving all ext, CN II-XII intact
Pertinent Results:
Admission Labs:
___ 07:15AM BLOOD WBC-11.2* RBC-3.50* Hgb-10.2* Hct-34.2
MCV-98 MCH-29.1 MCHC-29.8* RDW-15.9* RDWSD-55.8* Plt ___
___ 06:49PM BLOOD Neuts-70.4 ___ Monos-6.6 Eos-0.2*
Baso-0.2 Im ___ AbsNeut-8.18* AbsLymp-2.57 AbsMono-0.76
AbsEos-0.02* AbsBaso-0.02
___ 07:15AM BLOOD ___ PTT-37.0* ___
___ 07:15AM BLOOD Glucose-134* UreaN-25* Creat-1.8* Na-145
K-4.6 Cl-110* HCO3-25 AnGap-15
___ 06:49PM BLOOD cTropnT-<0.01
___ 06:49PM BLOOD Calcium-8.9 Phos-2.8 Mg-2.0
Discharge Labs:
___ 07:15AM BLOOD WBC-9.1 RBC-2.71* Hgb-7.9* Hct-26.4*
MCV-97 MCH-29.2 MCHC-29.9* RDW-16.1* RDWSD-57.6* Plt ___
___ 06:49PM BLOOD Neuts-70.4 ___ Monos-6.6 Eos-0.2*
Baso-0.2 Im ___ AbsNeut-8.18* AbsLymp-2.57 AbsMono-0.76
AbsEos-0.02* AbsBaso-0.02
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-95 UreaN-21* Creat-1.5* Na-143
K-4.5 Cl-108 HCO3-23 AnGap-17
___ 07:15AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0
___ 07:45AM BLOOD VitB12-273
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Amiodarone 100 mg PO DAILY
3. Cyanocobalamin 1000 mcg IM/SC MONTHLY
4. Aspirin 81 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Warfarin 1 mg PO 3X/WEEK (___)
9. Warfarin 1.5 mg PO 4X/WEEK (___)
10. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
11. Torsemide 5 mg PO 5X/WEEK (___)
Discharge Medications:
1. Isosorbide Dinitrate 10 mg PO BID
2. Oxymetazoline 1 SPRY NU BID Duration: 3 Days
3. Amiodarone 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
7. Cyanocobalamin 1000 mcg IM/SC MONTHLY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 1 mg PO 3X/WEEK (___)
12. Warfarin 1.5 mg PO 4X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Orthostasis, coronary artery disease
Secondary: Anemia, CKD, epistaxis, Afib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with syncope and chest tightness// ? pneumonia
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Moderate to severe cardiac enlargement is unchanged. Mediastinal and hilar
contours are similar. Mild atherosclerotic calcifications are seen at the
aortic knob. Pulmonary vasculature is normal. Linear opacities in the lung
bases likely reflect areas of atelectasis, without focal consolidation. No
pleural effusion or pneumothorax is seen. Mild multilevel degenerative
changes are noted in the thoracic spine with mild anterior compression
deformity of a mid thoracic vertebral body, unchanged.
IMPRESSION:
Mild bibasilar atelectasis without focal consolidation to suggest pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
AMBULANCE
Chief complaint: Epistaxis
Dizziness, Presyncope
Diagnosed with Epistaxis, Unspecified atrial fibrillation
Dizziness and giddiness, Essential (primary) hypertension
temperature: 98.4
98.6
heartrate: 72.0
87.0
resprate: 18.0
19.0
o2sat: 100.0
97.0
sbp: 184.0
106.0
dbp: 89.0
70.0
level of pain: 4
0
level of acuity: 3.0
2.0 | Summary
___ w/pmh CAD, CKD and hx of MI ___ years ago treated with
Coumadin who is presenting with chest tightness, lightheadedness
and weakness after walking up the stairs to her apartment. She
was found to have positive stress test in the ED. On floor she
was found to be orthostatic and she improved with IVF. She was
also treated for possible UTI. She was discharged home in good
condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
fish products
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with s past medical history
of HTN, MR, and ciguatera poisoning who presented with melena.
He reports that one week ago he felt the need to have a bowel
movement and proceeded to have a large amount of bright red
blood
per rectum. He is a naturopathic doctor and took something
called
Soldier Pills to help stop the bleeding. For the following two
days he did not have any further bleeding. Then on the third day
he had a large amount of black stools along with bright red
liquid. He also felt that his stomach was very bloated. He had
an
additional episode of bleeding after that, he is unsure of when,
but decided to go to ___ to seek further medical care. He has
not been taking his aspirin and blood pressure medications since
he began having bleeding.
He reports prior colonoscopy in ___ with adenomas, negative for
malignancy.
He has a history of mitral regurgitation and is scheduled for
upcoming surgery at ___. He has never had symptomatic heart
failure and denies shortness of breath.
In the ED, he was found to have copious melanotic stool in the
rectal vault. Hg remained stable at 12.2. CTA did not reveal
source of bleed. He was seen by GI who recommended IV PPI BID,
NPO, and possible EGD/colonoscopy in the AM. In the ED he
received esomeprazole and IV fluids.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
-s/p cervical and lumbar spinal fusions in last ___ years
-s/p ciquatera ingestion ___
-HTN
-depression
-HFrEF with LVEF 40-45%
Social History:
___
___:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION 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
CV: Heart regular, systolic murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation
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
CV: Heart regular, systolic murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
===============
___ 01:50PM BLOOD WBC-5.3 RBC-3.88* Hgb-12.2* Hct-37.0*
MCV-95 MCH-31.4 MCHC-33.0 RDW-13.1 RDWSD-45.3 Plt ___
___ 02:19PM BLOOD ___ PTT-24.9* ___
___ 01:50PM BLOOD Glucose-113* UreaN-10 Creat-0.8 Na-143
K-4.1 Cl-105 HCO3-26 AnGap-12
___ 01:50PM BLOOD ALT-20 AST-28 AlkPhos-84 TotBili-0.6
___ 05:30AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.1
___ 04:56PM BLOOD Lactate-1.0
DISCHARGE LABS:
===============
___ 05:21AM BLOOD WBC-6.3 RBC-3.73* Hgb-11.8* Hct-36.0*
MCV-97 MCH-31.6 MCHC-32.8 RDW-13.2 RDWSD-46.6* Plt ___
___ 06:05AM BLOOD ___
___ 06:05AM BLOOD Glucose-102* UreaN-6 Creat-0.9 Na-147
K-4.0 Cl-109* HCO3-27 AnGap-11
___ 06:05AM BLOOD Calcium-8.4 Mg-2.0
IMAGING:
========
___ CTA Abd/Pelvis:
1. No active extravasation to localize bleeding in the bowel.
2. No retroperitoneal hematoma or evidence abdominopelvic
hemorrhage.
3. Colonic diverticulosis without diverticulitis.
4. Severe stenosis of the celiac origin.
5. Severe hepatic steatosis.
6. Prostatomegaly.
PROCEDURES:
==========
EGD ___:
Impression: Esophagitis in the lower third of the esophagus
Scattered erosions in the antrum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: GI consult service to discuss with inpatient
primary team.
Follow-up biopsy results
Proceed to colonoscopy
COLONOSCOPY ___:
Impression: Diverticulosis of the primarily in sigmoid colon but
also scattered throughout whole colon
Grade 1 internal hemorrhoids
Two tattoos seen in the sigmoid colon. The area was carefully
examined and no residual polypoid tissue was found.
No fresh blood, old blood or potential bleeding sources were
seen. Most likely source of bleeding is diverticular.
Otherwise normal colonoscopy to cecum
Recommendations: Repeat colonoscopy in ___ years.
GI consult service to discuss with primary team
Follow-up CBC with PCP within one week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Diverticulosis
Esophagitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: History: ___ with bright red blood per rectum and melena for 1
week with Hgb drop of 1 point.//eval for intraluminal extravasation
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 14.0 s, 48.2 cm; CTDIvol = 6.4 mGy (Body) DLP = 297.6
mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 5.0 s, 1.0 cm; CTDIvol = 11.6 mGy (Body) DLP =
11.6 mGy-cm.
4) Spiral Acquisition 12.6 s, 48.5 cm; CTDIvol = 15.1 mGy (Body) DLP =
707.4 mGy-cm.
5) Spiral Acquisition 12.6 s, 48.5 cm; CTDIvol = 15.0 mGy (Body) DLP =
703.9 mGy-cm.
Total DLP (Body) = 1,735 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is moderate calcium burden in
the abdominal aorta and great abdominal arteries. There is a replaced right
hepatic artery off SMA. Severe narrowing of the celiac origin with post
stenotic dilatation is noted (06:37, 12:79).
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous low attenuation throughout
compatible with steatosis. 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 with normal nephrogram.
There is no evidence of stones or hydronephrosis. Bilateral hypodensities
measure up to 2.8 cm in the lower pole of the left kidney and 2.4 cm in the
interpolar region of the right kidney measuring 7 and 2 Hounsfield units,
compatible with simple cysts. There are no urothelial lesions in the kidneys
or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Enteric tube terminates in the stomach. Small bowel loops
demonstrate normal caliber, wall thickness and enhancement throughout. There
is prominent diverticulosis of the sigmoid colon without wall thickening or
surrounding fat stranding to suggest diverticulitis. The rectum is
unremarkable. Appendix contains air, has normal caliber without evidence of
fat stranding. There is no evidence of mesenteric lymphadenopathy.
No contrast extravasation intraluminally to suggest active site of bleeding.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. No
retroperitoneal hematoma.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged measuring up to 6.7 cm in
transverse dimension. The seminal vesicles are unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Bilateral small to moderate size inguinal hernias containing fat
are noted.
IMPRESSION:
1. No active extravasation to localize bleeding in the bowel.
2. No retroperitoneal hematoma or evidence abdominopelvic hemorrhage.
3. Colonic diverticulosis without diverticulitis.
4. Severe stenosis of the celiac origin.
5. Severe hepatic steatosis.
6. Prostatomegaly.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.0
heartrate: 90.0
resprate: 18.0
o2sat: 97.0
sbp: 163.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | # GI bleed:
# Divertciulosis
# Esophagitis/antral erosions
Pt presented with alternating melena and BRBPR. Hg was found to
be relatively stable, in the ___ range and pt was otherwise
hemodynamically stable. He underwent EGD/colonoscopy which
showed some esophagitis and antral erosions and severe
diverticulosis that were felt to be the most likely source of
bleeding (though no active bleeding seen on scopes). Pt was
started on a PPI for esophagitis/antral erosions (biopsy
pending), counseled on lifestyle modifications for
diverticulosis and started on docusate/senna for constipation.
He had no further reported melena post-procedure.
# Hypertension:
Held home lisinopril and metoprolol in the setting of bleed,
restarted on discharge
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ breast cancer admitted from clinic after had chest pain
and diuresis after getting unit of pRBC in clinic. On arrival to
ED, patient's VS were stable, CXR -ve, trops normal, and no
further symptoms. However was admitted due to some questionable
t wave changes on EKG.
Past Medical History:
- Coronary artery disease: s/p BMS to proximal ramus (___)
- Mitral regurgitation: moderate-severe with MVP/partial flail
(___)
- Aortic regurgitation: Moderate (TTE ___
- Heart failure: Diastolic. (EF 55% ___
- Hypertension
- Dyslipidemia
- Permanent atrial fibrillation - CHADS2=3 (age, CHF, HTN).
- Pulmonary artery HTN - (PASP of ___+ RA, TTE ___.
- Invasive breast cancer T2N3 ER+, HER-2/neu -, s/p left
mastectomy on tamoxifen (___)
- Chronic kidney disease, stage III: Baseline cr 1.6
- Obstructive sleep apnea, on CPAP
Social History:
___
Family History:
- Father: Died at age ___ from MI, stroke
- Mother: Died at age ___ from bowel cancer
- Siblings: Brother with bowel cancer, sister died at ___
- Children: Son, daughter, 5 grandchildren are healthy
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: 98.8 140/66 94 18 100 RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: IRREGULARLY IRREGULAR, LOUD ___ SYSTOLIC MURMUR LOUDEST IN
APEX
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits, neuro
exam grossly normal, mentating fine, gait normal
Pertinent Results:
ADMISSION:
___ 10:35AM BLOOD WBC-1.9* RBC-2.79* Hgb-8.0* Hct-25.1*
MCV-90 MCH-28.5 MCHC-31.6 RDW-23.1* Plt ___
___ 10:35AM BLOOD Neuts-64.5 ___ Monos-5.1 Eos-3.3
Baso-1.2
___ 10:35AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-3+
Macrocy-1+ Microcy-2+ Polychr-NORMAL Ovalocy-2+
Schisto-OCCASIONAL Burr-1+ Pencil-1+ Tear Dr-2+ Bite-OCCASIONAL
Fragmen-OCCASIONAL
___ 02:45PM BLOOD Glucose-120* UreaN-29* Creat-1.3* Na-134
K-3.5 Cl-101 HCO3-25 AnGap-12
___ 02:45PM BLOOD ALT-28 AST-41* AlkPhos-131* TotBili-1.4
___ 02:45PM BLOOD Lipase-76*
___ 09:33AM BLOOD CK-MB-4 cTropnT-<0.01
___ 02:45PM BLOOD cTropnT-<0.01 proBNP-1428*
___ 02:45PM BLOOD Albumin-3.4* Calcium-9.5 Phos-2.5* Mg-2.0
___ 05:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
DISCHARGE:
___ 01:05PM BLOOD WBC-2.0* RBC-2.96* Hgb-8.7* Hct-26.4*
MCV-89 MCH-29.3 MCHC-32.8 RDW-22.0* Plt ___
CXR ___: Cardiomegaly and interstitial prominence, right
greater than left concerning for asymmetric edema versus
lymphangitic tumor spread. Diffuse bony metastatic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Potassium Chloride 10 mEq PO BID
4. Tamoxifen Citrate 20 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Apixaban 2.5 mg PO BID
7. Sodium Chloride Nasal ___ SPRY NU QID
8. Neilmed Sinus Rinse Complete (sodium bicarb-sodium chloride)
1 rinse nasal DAILY:PRN nasal congestion
9. Torsemide 20 mg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO DAILY
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Potassium Chloride 10 mEq PO BID
7. Sodium Chloride Nasal ___ SPRY NU QID
8. Tamoxifen Citrate 20 mg PO DAILY
9. Torsemide 20 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Neilmed Sinus Rinse Complete (sodium bicarb-sodium chloride)
1 rinse nasal DAILY:PRN nasal congestion
Discharge Disposition:
Home
Discharge Diagnosis:
Tranfusion Reaction
Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with CP s/p blood transfusion, history of breast cancer.
COMPARISON: Chest x-ray dated ___.
FINDINGS:
AP upright and lateral chest radiograph. Cardiomegaly is again noted with
asymmetric prominence of the interstitial pulmonary markings which raises
concern for edema though lymphangitic tumor spread is difficult to exclude. No
large effusion is seen. No pneumothorax. Diffuse osseous metastatic disease is
re- demonstrated.
IMPRESSION:
Cardiomegaly and interstitial prominence, right greater than left concerning
for asymmetric edema versus lymphangitic tumor spread. Diffuse bony metastatic
disease.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, ANEMIA NOS, NEUTROPENIA, UNSPECIFIED , MAL NEO MALE BREAST NEC
temperature: 98.3
heartrate: 89.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 65.0
level of pain: nan
level of acuity: 2.0 | HOSPITAL COURSE: Admitted after transfusion reaction to getting
one unit of blood in clinic. Hct stable however, outpatient
oncologist wanted additional unit of blood given which was then
given as inpatient. Given concurrent lasix.
# AFIB; continued apixaban, aspirin, metop
# CHF; assymetric edma from MR. ___ torsemide and gave
additinoal lasix with pRBC
# HTN: continued lisinopril
# Breast Cancer; continue tamoxifen, will get Bm biospy on next
clinic visit
# HLD: continued atorva |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Confusion and agitation
Major Surgical or Invasive Procedure:
___ Placement
History of Present Illness:
___ year old female with ___, CAD s/p CABG, ischemic sCHF
(EF 40%), atrial fibrillation on warfarin, T2DM (on insulin),
and recent admission for decompression and laminectomy for T9
fracture with cord compression presents with several days of
increased confusion and agitation. Her son ___ raised concerns
yesterday with PCP that ___ has been ___, calling
out names of deceased family members in the middle of the night
since she was discharged home from ___. He also
reports she had been calling out at night while in rehab during
the preceding three weeks. A ___ obtained a UA last week that
cultured positive today for two bacteria, per son's report. PCP
subsequently sent ___ to ED for further evaluation. She
was unable to give a full history in the ED, with significant
confusion. Her son endorses that she was taking 1 mg lorazepam
at night to help with sleep and has had significant pain around
her lower flanks/abdomen requiring up to 200 mg tramadol at
night. He denies she had taken any trazodone or oxycodone, or
other sleep aids/neuroleptics since coming home. An infectious
workup including a head CT, given that she is on Coumadin, was
pursued. EKG was notable for afib with no changes from prior
result (___.) She is admitted to SIRS with Dr. ___,
___, for ___, UTI, and PNA on CXR.
In the ED, initial vitals:
- Exam notable for: AOx2, normocephalic/atraumatic head, normal
mentation, fluent speech, no CVA tenderness, healed spinal scar
with no tenderness/erythema
- Labs notable for: UA with 47 WBCs, 5 RBC, 1 epi and 13 hyaline
casts, BUN 86, cr up to 1.6 (from 1.1 on ___, eGFR 31, WBC
8.4, Hbg 11/Hct 33.3 (baseline ___, ___ 20.3, INR 1.8.
Blood culture x 2 and urine culture pending
- Imaging: CT head negative, AP/lat CXR with mild congestion and
mild edema with left basal opacity concerning for atelectasis
versus pneumonia and possible effusion.
- Consultants: Dr. ___ (endocrine)- *be sure* to
involve him in any endocrinology-related issues.
- Patient was given: 1 L NS, cefepime 2 g IV, vanc 1 g IV,
carbidopa-levodopa ___ x 2, Tramadol 50 mg, acetaminophen 1 g
- Vitals prior to transfer: ___, 97.4, 56, 130/56, 21, 97% on
RA
On arrival to the floor, pt is conversant with logical thought
process and reports her side pain (along upper pelvic rim) is
well controlled. She endorses she has been confused, calling out
at night for just the last 2 days, which she attributes to sleep
medications (per son, only sleep aid is lorazepam, taking 0.5 mg
x2 at night.) She also endorses mild cough, denies SOB, fever,
chest pain. Denies dysuria, hematuria, flank pain. Her son
reports she had been fecally continent. However, patient was
incontinent of urine and feces during interview.
Past Medical History:
PMH
-sCHF with EF 40%
-CAD s/p 2 stents, CABG
-DIABETES MELLITUS on 10 units lantus QAM and sliding scale 3
units for FSG >150 before meals
-HYPERCALCEMIA
-HYPERCHOLESTEROLEMIA
-HYPERTENSION
-HYPOTHYROIDISM
-OBESITY
-___ DISEASE
-MACULAR DEGENERATION
-RETINOPATHY
-EPIDURAL HEMATOMA
PSH
-CABG as above
-Laminectomy with T6-T11 Instrumentation
Social History:
___
Family History:
Several family members with MI at early age - mother in ___,
brother in ___, and sister in ___.
Physical Exam:
PHYSICAL EXAM on admission:
Vitals: 97.5 58 132/44 20 measured by ___, Sub-I, 93% on RA
General: AOx2 (person, place), comfortable appearing
HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink.
tachy mucus membranes. OP clear.
Neck: supple, no LAD, no JVP elevation
Lungs: diffuse bilateral crackles lower ___, more dense R>L, no
w/r/r
CV: irregular, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender. No HSM.
Skin: 1x.05 cm stage 2 ulcer on upper sacrum
GU: foley to gravity, urine clear yellow
Ext: WWP. 2+ peripheral pulses. No edema. No nail on L ___ toe
(secondary to fungus per pt)
Neuro: CNs II-XII intact. Grossly normal sensation bilagteral UE
and ___. Rest tremor RUE. Grossly normal strength bilateral UE,
___ quads, ___ plantarflexion, ___ dorsiflexion bilaterally
PHYSICAL EXAM on discharge:
VS: 98.1; ___ 60-70; 20; 97RA
Wt: Innacurate Bed Weights, 91kg on transfer to cardiology
service but 100kg on day of discharge desite significant
diuresis on heart failure service, I/Os: 570/___ 24H
GENERAL: obese female, fatigued, opens eyes to voice, answering
questions appropriately
HEENT: NCAT, MMM, no LAD
NECK: JVP 8-10cm
Lungs: Upper airway transmitted sounds throughout, no
crackles/wheezes
CV: irregular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: non-tender, non-distended, bowel sounds present
GU: foley
Ext: warm, pulses not palpable, 1+ pitting edema to knees
Pertinent Results:
ADMISSION LABS:
___ 12:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 12:00PM URINE HYALINE-13*
___ 10:18AM GLUCOSE-122* UREA N-86* CREAT-1.6* SODIUM-136
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
___ 10:18AM ALT(SGPT)-10 AST(SGOT)-45* LD(LDH)-460* ALK
PHOS-99 TOT BILI-0.7
___ 10:18AM ALBUMIN-3.0* CALCIUM-9.1 PHOSPHATE-4.2#
MAGNESIUM-2.0
___ 10:18AM WBC-8.4 RBC-3.78*# HGB-11.0*# HCT-33.3*#
MCV-88 MCH-29.2 MCHC-33.2 RDW-18.3*
___ 10:18AM ___ PTT-34.7 ___
DISCHARGE LABS:
___ 05:12AM BLOOD WBC-4.4 RBC-3.13* Hgb-9.3* Hct-28.2*
MCV-90 MCH-29.7 MCHC-33.1 RDW-18.1* Plt ___
___ 05:12AM BLOOD ___ PTT-39.8* ___
___ 05:12AM BLOOD Glucose-148* UreaN-64* Creat-1.6* Na-136
K-3.8 Cl-106 HCO3-22 AnGap-12
___ 05:12AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9
MICRO:
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___ 9AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
Blood Cx: No growth
Urine Cx: No growth
STUDIES/IMAGING:
CT Chest: Increased left lower lobe opacity may be due to
atelectasis or pneumonia. Increased small bilateral pleural
effusions. Stable mild pulmonary edema.
TTE: The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is mild-moderate global left ventricular
hypokinesis (LVEF = 40 %). The right ventricular cavity is
dilated with mild global free wall hypokinesis. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild global biventricular systolic
dysfunction. Moderate pulmonary artery hypertension. Moderate
mitral regurgitation.
Compared with the prior study (images reviewed) of ___, the
findings are similar. The higher PA systolic pressure on current
study was found post-Optison, while the non-Optison estimated PA
systolic pressure was similar to the prior study.
CXR ___: In comparison with the study of ___, the right
subclavian catheter has been replaced with one that extends to
the mid to lower portion of the SVC. There are extremely low
lung volumes with opacification at the left base consistent with
volume loss in the lower lobe and pleural effusion. Posterior
fusion device in the thoracic spine is again seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Carbidopa-Levodopa (___) 1 TAB PO TID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Lorazepam 0.5 mg PO ___ TABS QPM PRN insomnia
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Omeprazole 20 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Torsemide 20 mg PO BID
11. TraMADOL (Ultram) 50 mg PO ___ TABS BID
12. Glargine 10 Units Breakfast
13. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Carbidopa-Levodopa (___) 1 TAB PO TID
5. Insulin SC
Sliding Scale
Fingerstick TID with meals
Insulin SC Sliding Scale using HUM Insulin
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Ranitidine 150 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Torsemide 40 mg PO DAILY
12. Warfarin 0.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Acute on chronic systolic heart failure with reduced ejection
fraction
- C. Difficile Infection
SECONDARY DIAGNOSIS:
- Acute Kidney Injury
- IDDM
- ___ disease
- Atrial Fibrillation
- Hypothyroidism
- Gastroesophageal Reflux Disease
- Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with AMS delirum
COMPARISON: ___.
FINDINGS:
AP upright and lateral views of the chest provided. Midline sternotomy wires
again noted. Spinal hardware again noted. Previously seen right adjacent
venous catheter, skin staples, endotracheal tube and orogastric tubes have
been removed. Lung volumes are markedly low. There is consolidation in the
left lower lung which was seen on prior exam in may represent effusion,
atelectasis versus pneumonia. There is right basal atelectasis also noted.
Mild edema and congestion is likely present. No large pneumothorax. Heart size
grossly stable.
IMPRESSION:
Mild congestion and mild edema with left basal opacity concerning for
atelectasis versus pneumonia and possible effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ woman with altered mental status and delirium;
evaluate for intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 1226 mGy-cm
CTDI: 112 mGy
COMPARISON: Head CT dated ___.
FINDINGS:
There is no evidence of acute infarction, hemorrhage, edema, or mass effect.
Periventricular and subcortical white matter hypodensities are nonspecific but
may represent sequelae of chronic small vessel ischemic disease and are
minimally progressed to unchanged compared to the prior exam. Bilateral,
symmetric prominence of the ventricles and sulci is also nonspecific, but
likely age-related, and is overall stable. No shift of normally midline
structures. The perimesencephalic cisterns are patent. Intracranial vascular
calcifications are again seen. Bilateral basal ganglia calcifications are
unchanged.
No fracture. The soft tissues of the calvarium are unremarkable. There is
partial opacification of the left ethmoidal air cells. There is mild mucosal
thickening of the left maxillary and sphenoid sinuses. The remaining
incompletely visualized paranasal sinuses as well as mastoid air cells are
clear. Debris in the right external ear canal is probably cerumen. The lens
have been replaced; otherwise, the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality, including no intracranial hemorrhage.
2. Overall no change from the prior head CT in ___.
Radiology Report
EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL)
INDICATION: ___ year old woman with hematuria, left flank pain, and elevated
creatinine.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdominal ultrasound from ___.
FINDINGS:
The right kidney measures 10.0 cm. The left kidney measures 12.1 cm. There is
no hydronephrosis, stones, or suspicious masses bilaterally. A 6 x 8 x 7 mm
simple exophytic cyst is seen in the midpole of the left kidney. Normal
cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
The bladder is decompressed with a Foley catheter.
Limited views of the spleen demonstrate a 1.4 x 1.4 x 1.3 cm simple cyst.
IMPRESSION:
Essentially normal renal ultrasound with a 8 mm simple cysts in left kidney.
No evidence of hydronephrosis or stones bilaterally.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with ?PNA // f/u CXR for pneumonia vs
atelectasis. Please evaluate for edema
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Plain chest radiograph dated ___. Correlation made to
thoracic spine CT dated ___.
FINDINGS:
Lung volumes are low. Chronic small bilateral pleural effusions have
increased. Despite vascular crowding, mild pulmonary edema likely persists.
The left lower lobe airspace opacity has increased, and is worrisome for
pneumonia or atelectasis. The heart and mediastinum are magnified by the
projection. Sternotomy wires and spinal fixation hardware are again noted.
IMPRESSION:
Increased left lower lobe opacity may be due to atelectasis or pneumonia.
Increased small bilateral pleural effusions.
Stable mild pulmonary edema.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with AMS and questionable PNA seen on CXR //
Please evaluate for pneumonia vs pulmonary edema
TECHNIQUE: Non-contrast chest CT was performed acquiring sequential axial
images from the thoracic inlet through the adrenal glands. Thin section axial,
coronal, sagittal and axial MIP's were also obtained.
DOSE: Total DLP = 823.23mGy-cm
COMPARISON: ___.
FINDINGS:
The thyroid gland is unremarkable. Several small mediastinal lymph nodes
measuring up to 8 mm in short axis in the right lower paratracheal location
are stable (2, 17). There are no pathologically enlarged supraclavicular,
axillary, or mediastinal lymph nodes. Hilar lymphadenopathy is difficult to
exclude in the absence of intravenous contrast.
The patient has had prior CABG. Moderate cardiomegaly with multichamber
enlargement is unchanged. Moderate aortic annular calcifications are
unchanged. Extensive coronary artery calcifications and mitral
annular/valvular are also all unchanged. Mild dilatation of the main pulmonary
artery to 3.4 cm is also unchanged.
Multiple images of the lungs are substantially degraded by respiratory motion
artifact, which may limit detection of small nodules and subtle parenchymal
lesions. Images were also inadvertently acquired in expiration. Geographic
areas of heterogeneous attenuation in the right lung are due to air trapping
or mild pulmonary edema. Bilateral bandlike areas of linear and subsegmental
atelectasis are present.
New moderate right and small left nonhemorrhagic pleural effusions contribute
to bilateral subpleural atelectasis. The left pleural effusion is associated
with visceral and parietal pleural thickening suggesting chronicity. The large
area of dependent left lower lobe consolidation containing aspirated barium
is progressive and associated with swirling of the bronchovascular structures,
a feature of rounded atelectasis (4, 126). A similar opacity in the lingula
is also larger (602, 104). A 2 mm left apical nodule is stable (4, 32). A
calcified left upper lobe granuloma is incidentally noted. There is no
endobronchial lesion.
The patient has had prior cholecystectomy. Extensive vascular calcifications
diffusely involve the descending aorta and its tributaries, particularly the
splenic artery.
There is mild anasarca at both partially imaged flanks.
Generalized osteopenia and extensive multilevel spinal degenerative changes
are present. The patient has had prior spinal fusion. There are old
compression fractures at T8, T9 and L1, as well as old healed bilateral rib
and sternal fractures.
IMPRESSION:
Motion limited exam.
No evidence of pneumonia. The increasing opacity left lower lobe opacity seen
on recent chest radiograph likely corresponds to progressive left lower lobe
rounded atelectasis in the setting of chronic pleural thickening and chronic
effusion. T here is also progressive rounded atelectasis in the lingula, and
atelectasis in the right lower lobe. These opacities may be followed by chest
radiography.
Mild pulmonary edema and/or airtrapping.
Chronic left pleural thickening. New moderate right and stable small left
nonhemorrhagic pleural effusions.
Extensive coronary artery calcifications.
Stable mild dilatation of the main pulmonary artery suggests pulmonary
arterial hypertension.
Mild anasarca and small ascites.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF, now hypoxia and crackles // Please
eval for edema
COMPARISON: ___.
IMPRESSION:
Low lung volumes persist. Unchanged sternal wires and vertebral fixation
devices. Moderate cardiomegaly. Small bilateral pleural effusions and mild
pulmonary edema are unchanged.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with picc // r dl picc 42cm iv ping ___
Contact name: ping, ___: ___
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient has received the new right
PICC line. The line is coiled in the subclavian vein and needs to be
repositioned. No pneumothorax or other complication. Otherwise unchanged
radiograph.
Radiology Report
INDICATION: ___ year old woman with CHF, ___, and C diff. Bedside PICC
malpositioned // Please place PICC
COMPARISON: Same day chest radiograph.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and
Dr. ___ radiology attending) performed the procedure.
The attending, Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings
ANESTHESIA: None.
MEDICATIONS: None.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.1 min, 3 mGy
PROCEDURE: 1. Repositioning of right PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed and a Nitinol guidewire was introduced
into the superior vena cava (SVC). A peel-away sheath was then placed over a
guidewire. The guidewire was then advanced into the superior vena cava. A
double lumen PIC line measuring 43 cm in length was then placed through the
peel-away sheath with its tip positioned in the distal SVC under fluoroscopic
guidance. Position of the catheter was confirmed by a fluoroscopic spot film
of the chest. The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing right arm approach PICC coiled in the right axillary vein,
replaced with a new double lumen PIC line with tip in the distal SVC.
IMPRESSION:
Successful placement of a 43 cm right arm approach double lumen PowerPICC with
tip in the distal SVC. The line is ready to use.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Evaluate for hemorrhage in a ___ woman status post fall
and head strike, with an elevated INR.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 897.1 mGy-cm
CTDI: 55.5 mGy
COMPARISON: Noncontrast CT head from ___.
FINDINGS:
There is no evidence of acute large territory infarction, hemorrhage, edema,
or mass effect. Prominent ventricles and sulci are suggestive of age-related
involutional changes. Periventricular, subcortical, and deep 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:
1. No acute intracranial abnormality. Specifically, no evidence of acute
hemorrhage.
2. Age-related involutional changes and likely sequela of chronic small vessel
ischemic disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new o2 requirement // eval for
infiltrate, pulmonary edema eval for infiltrate, pulmonary edema
IMPRESSION:
In comparison with the study of ___, the right subclavian catheter has been
replaced with one that extends to the mid to lower portion of the SVC. There
are extremely low lung volumes with opacification at the left base consistent
with volume loss in the lower lobe and pleural effusion. Posterior fusion
device in the thoracic spine is again seen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with URIN TRACT INFECTION NOS, PNEUMONIA,ORGANISM UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.0
heartrate: 60.0
resprate: 18.0
o2sat: 97.0
sbp: 121.0
dbp: 63.0
level of pain: 0
level of acuity: 3.0 | ___ year old female with ___, CAD s/p CABG, ischemic sCHF
(EF 40%), atrial fibrillation on warfarin, T2DM (on insulin),
and recent admission for spinal surgery c/b delirium presents
with increased confusion and agitation found to have prerenal
___ and pulmonary edema/effusion c/w CHF exacerbation as well as
a C. Diff infection.
ACTIVE PROBLEMS:
#Acute decompensated sCHF (EF 40%): The patient has been
followed in ___ clinic by Dr. ___ visit ___, with
an EF of 40% per last echo in ___. On admission, the
patient had 2+ pitting edema to her calves and diffuse bibasilar
crackles, indicating volume overload. Patient with ___ initially
on admission so home diuretic held, however volume status
worsened. Therefore, patient was transferred to the CHF service
for aggressive IV diuresis with lasix gtt with intermittined
large dose IV lasix boluses. The patient diuresed well on lasix
gtt, however when transitioned to lasix IV boluses alone, had
minimal output, though volume status felt to remain stable with
only mild pitting edema of lower extremities. At discharge, plan
for diuretic regimen of 40mg torsemide daily.
#Altered mental status: The patient was oriented to name and
place on admission, inattentive, intermittently somnolent and
hallucinating conversations with deceased relatives, consist
with delirium. Her delirium was initially thought to be a new
onset due to pneumonia based on initial CXR with LLL opacity,
which was treated with 5 days of antibiotics, but was ultimately
determined be an ongoing delirium that had begun in ___ when the patient suffered a T9 compression injury and
spinal hematoma requiring complex spinal surgery. Also felt that
delerium was acutely worsened ___ CHF exacerbation and C. Diff
infection and improved with treatment of each respectively. Pain
was controlled with standing tylenol and lidocaine patch to her
lower spine. Lantus was discontinued and sliding scale with
insulin was administered only for FSG>200. Her Parkinsonism and
hallucinations were also concerning for ___ Body dementia, so
Haldol was listed as an allergy. Non-pharmacologic measures
included having the patient out of bed for meals, avoidance of
constraints, bed by window, discouragement of naps, avoidance of
overnight vitals/labs/medications, and frequent reorientation.
Also discontinued patient's home benadryl and Lorazepam as
concern that these medications may be contributing to her
delirium/AMS.
# C Diff: The patient had ___ large BM on ___, prompting stool
culture that was positive for C diff. Given her AMS, she was
treated with flagyl 500mg TID. Plan for ___ompleted
___.
# ___: The patient had a creatinine of 1.1 in ___ and 1.6 on
admission. Given exam consistent with volume overload, low
effective circulating volume was likely due to CHF exacerbation.
She was initially given IVF, however with worsening volume
overload, started on diuresis. Renal function remained stable at
1.3-1.6 which likely represents new patient baseline.
___: The patient was continued carbidopa/levodopa
___ TID during her admission.
#Insomnia: The patient has had difficulty sleeping for years,
which has acutely worsened since her spine surgery. Trazodone
has caused substantial paranoia per her family and seroquel
caused profound somnolence during the day, so all sleep aids
were stopped.
#Atrial fibrillation: The patient was taking 2 mg warfarin at
home and has a CHADS2 risk score of 3 for age, DM, and CHF,
indicating anticoagulation should be continued. Warfarin given
this admission to maintain INR goal of ___. Was discharged on
0.5mg daily due to INR of 3.2 though levels and warfarin
requirement fluctated this admission. During week prior to
discharge required 8mg total warfarin.
#IDDM, type 2: The patient was taking 10 units glargine in the
morning with sliding scale of 3 units humalog for glucose levels
>150 before meals. However, the majority of her FSGs were in the
___ during her admission with ___ daily measurements <70
that prompted discontinuation of glargine. To avoid
hypoglycemia, humalog sliding scale was adjusted to 2 units if
glucose >200 before meals.
#Instability: the patient has been unable to move her legs
against resistance since her spinal compression injury. ___ and
OT consults were conducted, which recommended keeping the
patient in a rehab facility after discharge.
#Anemia: The patient has chronic anemia wit hemoglobin ___. Hbg
remained stable this admission.
#Hypothyroidism: The patient was continued home levothyroxine
50mcg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
AMS, abd pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ invasive bladder carcinoma s/p b/l PCN, AF on Coumadin,
dementia, CHF, HTN, HLD who presents with 1 day of worsening abd
pain and fatigue. Patient has dementia and most history gathered
from son who was at the bedside.
She has bilateral PCNs placed in ___ and changed q3
months, last change one week PTA. Her left PCN was capped one
week ago with plans for internalization, per the son. Minimal
Foley output for the past few days. This morning he uncapped the
L neph tube and noted drainage of 400cc (over the next few
hours). No fever, although patient feels more weak and lethargic
and complains of lower abdominal pain that improved with
uncapping of left nephrostomy tube. No cough, headache, LOC,
recent trauma, chest pain, shortness of breath, diarrhea.
In the ED, initial vitals were: 99.1 51 142/68 18 99% RA
Exam notable for: nephrostomy tubes in place, Foley in place
lower abdominal tenderness
lungs clear
Labs notable for: Chem panel with Cr at 1.8 (less than recent
baseline of 2), bicarb 21. CBC with WBC to 11.1, h.h stable with
prior. thrombocytosis to 523, above baseline. Lactate 1.4.
Grossly positive US from bilateral nephrostomy tubes with
pyuria.
Imaging notable for:
CT abd pelvis w/ contrast:
1. No acute intra-abdominal process.
2. Well-positioned bilateral PCNU stents. No evidence of
hydronephrosis.
CXR: No report on transfer
Patient was given:
___ 14:51 IV CefePIME 2 g ___
___ 15:30 PO Acetaminophen 1000 mg ___
___ 15:30 IVF 1000 mL NS 1000 mL ___
___ consulted and recommended: Patient with bilateral PCNUs,
concern for changing status / ?infection. CT obtained and
reviewed: both PCNUs in good position, no perinephric,
periureteral or intra-abdominal fluid collections, no evidence
of hydro (both tubes functioning). No manipulation or
intervention for PCNUs required at this time.
Vitals prior to transfer: 97.9 50 153/43 16 97% RA
On the floor, son reports that patient looks improved but not
at her baseline. She seems more tired and weak than she is
usually. Patient reports no complaints. Denies any current pain,
n/v, SOB, chills, sweats or fever.
Past Medical History:
high grade sarcomatoid carcinoma of the bladder c/b ureteral
obstruction requiring bl PCN s/p TURBT and radiation
dementia
afib
gait instability
hypothyroidism
hx CVA
CHF
HLD
HTN
Family History:
Mother had breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
Vital Signs: 97.6 PO 137 / 39 50 18 98 RA
General: Alert, oriented to self, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM
VS - 98.6, 150/58, 48, 16, 99% r.a.
General: AAO x 1 (self)
HEENT: EOMI, no JVD, no LAD
Neck: supple
CV: irregularly irregular, normal S1/S2, no m/r/g
Lungs: CTA b/l=
Abdomen: sntnd, + bs
GU: nephrostomy tubes in place, no foley
Ext: wwp, 2+
Neuro: grossly in tact
Pertinent Results:
PERTINENT LABS
===============
___ 01:10PM WBC-11.1* RBC-3.07* HGB-8.5* HCT-27.9* MCV-91
MCH-27.7 MCHC-30.5* RDW-17.0* RDWSD-55.9*
___ 01:10PM NEUTS-72.7* LYMPHS-12.9* MONOS-9.5 EOS-3.6
BASOS-0.6 IM ___ AbsNeut-8.09*# AbsLymp-1.44 AbsMono-1.06*
AbsEos-0.40 AbsBaso-0.07
___ 01:10PM proBNP-___*
___ 01:10PM ALBUMIN-3.2*
___ 01:10PM ALT(SGPT)-9 AST(SGOT)-17 ALK PHOS-104 TOT
BILI-0.2
___ 01:10PM LIPASE-41
___ 01:10PM GLUCOSE-73 UREA N-28* CREAT-1.8* SODIUM-137
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17
___ 01:25PM URINE RBC-95* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-<1
___ 01:25PM URINE RBC-125* WBC-127* BACTERIA-FEW
YEAST-NONE EPI-0
___ 1:25 pm URINE LEFT NEPHRO.
URINE CULTURE (Preliminary):
CITROBACTER FREUNDII COMPLEX. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFTAZIDIME----------- =>___ R
CEFTRIAXONE----------- =>___ R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. melatonin 1 mg oral QHS:PRN insomnia
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Amiodarone 100 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Nystatin Cream 1 Appl TP BID
7. Vitamin D 1000 UNIT PO DAILY
8. Sarna Lotion 1 Appl TP QID:PRN itching
9. Lidocaine 5% Patch 1 PTCH TD QAM left shoulder pain
10. TraZODone 25 mg PO QHS:PRN insomnia
11. FLUoxetine 10 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO BID:PRN constipation
14. Warfarin 2 mg PO DAILY16
15. amLODIPine 2.5 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*24 Tablet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Amiodarone 100 mg PO DAILY
5. amLODIPine 2.5 mg PO DAILY
6. FLUoxetine 10 mg PO DAILY
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM left shoulder pain
9. melatonin 1 mg oral QHS:PRN insomnia
10. Metoprolol Tartrate 25 mg PO BID
11. Nystatin Cream 1 Appl TP BID
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Sarna Lotion 1 Appl TP QID:PRN itching
14. TraZODone 25 mg PO QHS:PRN insomnia
15. Vitamin D 1000 UNIT PO DAILY
16. Warfarin 2 mg PO DAILY16
17.hospital bed
18.Outpatient Lab Work
On ___
___ clinic
ICD-9: 427.31
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ with increasing weakness. // ___ with increasing weakness.
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
This study was made available for my interpretation, today, ___.
There may be trace pleural fluid. No definite focal consolidation is seen.
Slight increase in interstitial markings bilaterally may be due to mild
interstitial edema. No pneumothorax is seen. The cardiac silhouette remains
enlarged. The aorta is calcified and tortuous. Old left-sided posterior
sixth rib fracture/ deformity is noted. The bones are diffusely osteopenic.
IMPRESSION:
Possible trace pleural fluid. Cardiomegaly. Interstitial edema.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST.
INDICATION: ___ woman with lower abdominal pain and tenderness as
well as increased lethargy, history of invasive bladder carcinoma with
bilateral PCNU/
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: DLP: 611 mGy-cm.
COMPARISON: Abdominal and pelvic CT ___
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis. There are severe coronary artery
and aortic valvular calcifications. There is no pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
segment ___ liver hypodensity measuring 9 mm is unchanged and most consistent
with a simple cyst. There is mild intrahepatic biliary duct dilation,
unchanged. The gallbladder mildly distended without surrounding stranding.
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: There are bilateral PCNU stents which appear well-positioned. There
is no hydronephrosis. Atrophic right kidney unchanged in appearance. There
is a 1.8 x 1.3 cm simple cyst in the left lower pole. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Stomach is decompressed.
Small and large bowel are normal in caliber without focal wall thickening.
Not visualized but no secondary signs of appendicitis in the right lower
quadrant. There is diverticulosis of the sigmoid colon.
PELVIS: Streak artifact from right total hip arthroplasty limits evaluation of
deep pelvic structures. Within these limitations, a Foley catheter is seen
within a decompressed bladder. No large pelvic mass or free fluid is seen.
REPRODUCTIVE ORGANS: The reproductive organs are not well seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are multilevel degenerative changes of the lumbar spine including mild
anterolisthesis of L4-5, also seen previously. In addition there is disc
space narrowing at L4-5 and L5-S1.
SOFT TISSUES: There is a small umbilical hernia.
IMPRESSION:
1. No acute intra-abdominal process.
2. Well-positioned bilateral PCNU stents. No evidence of current
hydronephrosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Lethargy
Diagnosed with Urinary tract infection, site not specified
temperature: 99.1
heartrate: 51.0
resprate: 18.0
o2sat: 99.0
sbp: 142.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | ___ yo female with w/ invasive bladder carcinoma s/p b/l PCN, AF
on Coumadin, dementia presents with 2 days of worsening abd pain
and fatigue with pyuria from bilateral nephrostomy tubes.
# UTI: Likely explains suprapubic pain and UA notable for
significant pyuria. Patient placed on amp/sulbactam (covers both
recent e.coli and enterococcus species and she tolerated it
during her last admission). Patient transitioned to oral
augmentin and stable/improving. Citrobacter sensitive to
augmentin came back day of discharge. Pt is to continue
augmentin bid x 12 more days (end ___. Pt to continue
followup with interventional radiology on ___ regarding her
nephrostomy tube care.
# AMS: Patient initially more fatigued than baseline likely in
the setting of UTI. Suspicion that her left nephrostomy tube
which was capped was not draining leading to retained urine and
nidus of infection. Patient is HD stable. Now that tube is
draining she has source control. Patient placed on amp/sulbactam
(covers both recent e.coli and enterococcus species and she
tolerated it during her last admission) but transitioned to
augmentin as above. Citrobacter sensitive to Bactrim came back
day of discharge. Pt is to continue Bactrim DS bid x 12 more
days (end ___. Pt at baseline per son at time of
discharge.
# afib: Pt continued on home Coumadin, metoprolol, amiodarone
# HTN: Pt continued on home amlodipine
# hypothyroidism: Pt continued on home levothyroxine
# Depression: Pt continued on fluoxetine
TRANSITIONAL
=============
- Pending blood culture x 2 and urine culture x 1 from ___.
- Pt to follow-up with radiology on ___ regarding her
nephrostomy tube care |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Bactrim
Attending: ___
Chief Complaint:
cord compression
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ man with hx of bladder CA being treated w
radiation who presented to ___ today with
quadriplegia. Per patient, he walked towards his front door this
morning to open the door for the visiting nurse. Unfortunately,
he did not make it to the door. Next thing he remember is that
he woke up from the floor. Before he regained conciousness, the
visiting nurse had already got a spare key from his neighbor,
opened the door, found him down on the floor and called ___. At
OSH, He was AAOx3. He was unable to move any limbs and had
sensory level at T5 at OSH. MD at ___ pt regained
sensation and was able to moves LEs, but Mr ___ says he cannot
move legs on command. CT head, neck, T, L, S spine was negative
for acute injury. He was transferred to ___ for further
evaluation.
Of note, he was discharged from ___ yesterday after admission for
UTI. At ___, his UA was dirty and he was treated with Vanc
and ceftriaxone. Also at ___, he was hypotensive even after
IVF bolus and he was started on levophed before he was
transferred to ___.
ROS is positive for severe neck pain and inability to move all
four of his limbs. Pt A&Ox3 and complained of neck pain. MD at
___ pt regained sensation and was able to moves LEs,
but
stated that he was not in control of them. Cannot move legs on
command.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention that he knows of. (He is quite
distracted at this point so ROS is not entirely reliable.)
On general review of systems, the pt denies recent fever or
chills. Denies cough. Denies chest pain.
Past Medical History:
Glaucoma
Gastritis
Vertigo
Cholecystectomy
GERD
Bladder cancer, status post TURBT in ___ followed Dr.
___
___ History:
___
Family History:
No family history of bladder, prostate, testicle, kidney cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
Physical Exam:
Vitals: T:96.7 P:72 R: 16 BP:97/42--->138/75 (s/p IVF bolus
and placed on levophed at OSH) SaO2: 97%RA
General: Awake, alert, easily distractable. Very hard of hearing
In moderate distress.
HEENT: NC/AT
Neck: in C-collar
Pulmonary: Lungs CTA anteriorly
Cardiac: RRR
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Neurologic:
-Mental Status: Alert, oriented to self, ___, month
and
year. Date was off by one day. Able to relate history but quite
distractable. Language is fluent grossly with normal prosody.
There were no paraphasic errors. 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.
III, IV, VI: ?Skew deviation. (left eye slightly elevated
compared to right eye.) Otherwise, EOMI without nystagmus.
Normal
saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, decreased tone throughout. He has
spontaneous movements in the legs (sliding on the bed) but he is
not aware of the movements and insists that he cannot move the
legs. No spontaneous movement in the arms. There is no
withdrawal in all four extremities to noxious stimuli.
-Sensory: (Patient was very inattentive and hard of hearing so
exam was difficult)
Decreased light touch throughout UE and ___ bilaterally.
PP decreased throughout UE and ___ bilaterally as well as chest
wall except for L shoulder (~C4) and L chest wall ~T3-5 area.
Vibration decreased throughout UE and ___ bilaterally except on L
shoulder
Loss of proprioception in biilateral fingers, wrists, toes and
ankles.
-DTRs: ___ diminished ___ bilateral UE and ___.
Unable
to do augmentation.
Plantar response was flexor on the right and mute on the left.
-Coordination: Unable to perform
-Gait: Unable to perform
DISCHARGE PHYSICAL EXAM
deceased
Pertinent Results:
ADMISSION LABS
___ 04:52AM GLUCOSE-139* UREA N-31* CREAT-1.7* SODIUM-140
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
___ 04:52AM estGFR-Using this
___ 04:52AM ALT(SGPT)-17 AST(SGOT)-23
___ 04:52AM CALCIUM-8.2* PHOSPHATE-3.2 MAGNESIUM-2.2
___ 04:52AM TSH-1.2
___ 04:52AM WBC-10.9 RBC-3.46* HGB-9.8* HCT-30.6* MCV-88
MCH-28.3 MCHC-32.0 RDW-14.5
___ 04:52AM PLT COUNT-254
___ 06:13PM GLUCOSE-209* UREA N-31* CREAT-1.9* SODIUM-135
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-15
___ 06:13PM ALT(SGPT)-20 AST(SGOT)-27 ALK PHOS-82 TOT
BILI-0.3
___ 06:13PM LIPASE-17
___ 06:13PM cTropnT-<0.01
___ 06:13PM ALBUMIN-3.3*
___ 06:13PM WBC-12.2* RBC-3.51* HGB-10.0* HCT-30.7*
MCV-87 MCH-28.6 MCHC-32.7 RDW-14.5
___ 06:13PM NEUTS-92.4* LYMPHS-3.8* MONOS-3.3 EOS-0.2
BASOS-0.3
___ 06:13PM PLT COUNT-318
___ 06:13PM ___ PTT-27.7 ___
___ 06:13PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:13PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG
___ 06:13PM URINE RBC->182* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 06:13PM URINE WBCCLUMP-FEW MUCOUS-RARE
MRI + MRA ___
No evidence for acute ischemia.
No vascular cutoff in the neck or intracranially.
MRI C spine
Findings concerning for ALL injury at C6-C7 as well as posterior
interspinous ligament injury at the same level. Severe cord
compression at C2-C3 and C3-C4 relating to underlying
degenerative disc and spondylotic changes. Cord signal
increased at C4 likely represents myelomalacia, acute on
chronic. No acute post-traumatic changes in the thoracic or
lumbar spine.
KUB ___
Massively dilated loops of small and large bowel, findings favor
ileus over obstruction.
Renal US ___
Stable mild right-sided hydronephrosis. Poorly visualized 2.5
cm complex cystic lesion in the left renal upper pole. Recent
CT demonstarted a calcified cyst. Urinary bladder could not be
assessed.
DISCHARGE LABS
___ 03:44AM BLOOD WBC-8.3 RBC-3.31* Hgb-9.4* Hct-30.3*
MCV-92 MCH-28.4 MCHC-31.0 RDW-16.3* Plt ___
___ 03:44AM BLOOD Glucose-146* UreaN-28* Creat-1.9* Na-142
K-3.5 Cl-114* HCO3-20* AnGap-12
___ 03:44AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.0
___ 04:52AM BLOOD TSH-1.2
___ 06:13PM BLOOD Albumin-3.3*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
Discharge Medications:
N/a DECEASED
Discharge Disposition:
Expired
Facility:
___
___ Diagnosis:
Primary diagnosis
1. acute cord compression
2. spinal shock
3. ileus
4. hypotension
5. klebsiella urinary tract infection,
Discharge Condition:
N/a DECEASED
Followup Instructions:
___
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: New-onset paraplegia. Assess line.
Comparison is made with prior study ___.
Left subclavian catheter tip is in the mid SVC. There is no pneumothorax.
Cardiac size is normal. The aorta is tortuous. Minimal increased opacities
in the left lower lobe are worrisome for aspiration. There is no pleural
effusion.
Radiology Report
HISTORY: ___ male with quadraparesis and a distended abdomen, assess
for obstruction or ileus.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
One frontal view of the abdomen shows multiple air-filled dilated loops of
small and large bowel. The cecum measures up to 1.2 cm. There is a paucity
of gas in the rectum. There is no pneumatosis or secondary evidence of free
air. There are surgical clips noted in the right upper abdomen. In addition,
there are degenerative changes of the visualized osseous structures.
IMPRESSION:
Massively dilated loops of small and large bowel, findings favor ileus over
obstruction.
Critical findings were communicated to Dr. ___ by Dr. ___ the
telephone on ___ at 10:15, 15 min after findings were made.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with SPINAL CORD INJURY NOS, UNSPECIFIED FALL
temperature: 96.7
heartrate: 72.0
resprate: 18.0
o2sat: 97.0
sbp: 138.0
dbp: 75.0
level of pain: 0
level of acuity: 1.0 | Mr ___ is a ___ man with hx of bladder CA being treated w
radiation who was found down in the setting of sudden onset
inability to move all four extremities. Neuro exam is remarkable
for quadraparesis, decreased PP in all fours. MR of the whole
spine was remarkable for cord compression at C2-C3 and C3-C4
spinal stenosis with cord flattening and acute on chronic
myelomalacia. Mr ___ presentation is likely ___ to
compression of the cervical cord s/p fall. Spine surgery was
consulted. There is no need for steroid at this time. Surgical
decompression was considered but was not thought to be
appropriate given his age and likely a small chance of benefit
for recovery of his function. Also, patient himself is not sure
about whether he wanted to undergo the surgery. He was kept in
the ICU on pressors due to hypotension from spinal shock. He
also developed an ileus requiring flexiseal placement. He also
developed a UTI which was treated with CTX.
With continued hypotension requiring pressors, a meeting was
held with the patient (who remained lucid with capacity per
psych eval) and family, in which the patient clearly stated he
wished to be made DNR/DNI as well as CMO and Do Not Hospitalize.
He felt he would have poor quality of life as a quadraparetic.
Per the patient's wishes he was taken off pressors and
transfered to the floor. He remained hypotensive but was
intermittently awake. He required pain control for severe neck
pain, and sometimes got delerious or sleepy with the pain
medication. On the afternoon of ___, he expired.
The family was notified and autopsy was declined. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / narcotics
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of lung cancer and a LLL lobectomy presents
with 1day cough, shortness of breath. Ms. ___ states that
on ___ she felt completely well with no symptoms. Waking up on
___ she felt that her asthma symptoms were worsening due to
ragweed, but albuterol provided no relief. She had persistent
cough productive of non-bloody phlegm that is mostly clear. She
also felt short of breath and was experiencing wheezing.
Fever of 104 at ___. CTA negative for PE but showed
parenchymal necrosis of RLL. Given Vanc/CTX, Zosyn, levaquin as
well as 125mg solumedrol. Transferred to ___.
Rec'd ceftriaxone 1g at 1525. Rec'd levaquin 750mg at 1624.
Rec'd Venco 1750mg at 1723. Also rec'd solumedrol 125mg at 1456
and IV Tylenol and 2L NS at OSH. Received 2L NS at outside
hospital.
In our ED initial vitals T97.5, HR 81, BP 124/59, RR20, 93% on
nasal cannula. Labs notable for WBC 19.5 (90% PMN), Blood
Glucose 225, Lactate 3.4, 7.47/32.
On arrival to the MICU, she was saturating >95% on 2L n/c.
ROS as above, but somewhat limited on admission given acute
respiratory illness.
Past Medical History:
- Congestive heart failure - Not on Lasix due to hx
hypotension/hypokalemia
- R eye shingles - on daily prednisone drops
- Mechanical fall and found to have sustained a T8 compression
fracture Underwent kyphoplasty by neurosurgery ___
- Asthma
- Hypothyoridism
- Anxiety
- Transient ischemic attacks
- Degenerative joint disease
- Lung cancer, status post left lower lobe lobectomy in ___, no chemo or radiation
- COPD
- Glaucoma
- Peripheral neuropathy
- osteoporosis
- Asthma
- Bone scan on ___ which showed an abnormal intake in the
region of medial left clavicle the chest CT a on admission
showed old healing fracture of the left clavicular head
Surgical History
Appendectomy, hysterectomy, sinus surgery and tonsillectomy.
Social History:
___
Family History:
Mother: ___ ___ from MI
Father: ___ ___ from emphysema
Sister: ___ ___ from heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VITALS: T98.4, HR 76, BP104/84, RR19, SaO2 97%2LN/c
GENERAL: Tired, well appearing woman sitting in bed speaking to
me comfortably
HEENT: Pupils equal and reactive, no scleral icterus, moist
mucous membranes
NECK: No JVD
LUNGS: Loud wheezes in R lung base, otherwise no wheezing or
rhonchi, intermittently coughing during exam but no respiratory
distress
CV: S1/S2 regular with no murmurs, rubs or S3/S4
ABD: Soft, non-tender, nondistended
EXT: No lower extremity edema, warm extremities
NEURO: A+Ox3, no gross abnormalities
DISCHARGE PHYSICAL EXAM
========================
VS: 97.6 112/59 hr92 rr18 93%2l
GENERAL: Elderly woman in NAD
HEENT: Moist mucus membranes. Conjunctival erythema on right eye
HEART: Regular rhythm this morning, no murmur rubs or gallops
LUNGS: Crackles at right mid to lower lung field, a few crackles
at left lower base. Otherwise clear to auscultation without
wheeze. No use of accessory muscles.
ABDOMEN: Soft, nondistended, nontender
EXTREMITIES: warm, no edema
NEURO: Face grossly symmetric, alert, oriented to date,
location,
medical situation
SKIN: Erythematous macular rash present on right buttocks.
Pertinent Results:
ADMISSION LABS:
==============
___ 09:10PM WBC-19.5* RBC-3.93 HGB-13.1 HCT-37.8 MCV-96
MCH-33.3* MCHC-34.7 RDW-12.0 RDWSD-42.0
___ 09:10PM NEUTS-90.0* LYMPHS-3.0* MONOS-5.5 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-17.56* AbsLymp-0.58*
AbsMono-1.08* AbsEos-0.00* AbsBaso-0.03
___ 09:16PM LACTATE-3.4*
___ 09:16PM O2 SAT-89
___ 09:16PM ___ PO2-56* PCO2-32* PH-7.47* TOTAL
CO2-24 BASE XS-0
___ 03:45AM GLUCOSE-211* UREA N-15 CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
INTERVAL LABS/MICROBIOLOGY
===========================
Sputum, induced:
NEGATIVE FOR MALIGNANT CELLS.
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.
MRSA SCREEN (Final ___: No MRSA isolated.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
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 in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Blood cultures: NGTD
___ 04:55AM BLOOD %HbA1c-6.1* eAG-128*
___ 06:24AM BLOOD TSH-3.3
___ 06:45PM BLOOD Vanco-20.5*
___ 07:55PM BLOOD Vanco-13.5
___ 06:15AM BLOOD Vanco-11.9
IMAGING
===================
___ CXR
A roughly 4 cm wide thick walled ring shadow projects lateral to
the right
descending pulmonary artery. Perhaps this is the referenced
necrotizing
pneumonia. It looks more like a mass or abscess, but should be
reviewed on the chest CT scan when that becomes available. A d
3 cm wide oval radiopacity also projecting over the right hilus
is presumably cement in the mid thoracic vertebral body but that
2 would need to be confirmed. Lungs are otherwise clear. Heart
size is normal and pleural effusions small if any. No
pneumothorax.
DISCHARGE LABS
===================
___ 05:55AM BLOOD WBC-6.1 RBC-3.03* Hgb-10.3* Hct-30.0*
MCV-99* MCH-34.0* MCHC-34.3 RDW-12.2 RDWSD-42.9 Plt ___
___ 05:55AM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-138
K-4.2 Cl-100 HCO3-27 AnGap-11
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Gabapentin 200 mg PO TID
3. ALPRAZolam 0.5 mg PO QHS
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Tiotropium Bromide 1 CAP IH DAILY
6. Montelukast 10 mg PO QHS
7. Calcitonin Salmon 200 UNIT NAS DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
10. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
11. azelastine 2 spray nasal BID
12. Atorvastatin 20 mg PO QPM
13. Senna 17.2 mg PO QHS
14. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Benzonatate 100 mg PO TID:PRN cough
3. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN Cough
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H wheezing
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth twice a day Disp #*1 Dose Pack Refills:*0
7. Vancomycin 1250 mg IV Q 12H
8. ALPRAZolam 0.5 mg PO QHS
RX *alprazolam 0.5 mg 1 tablet(s) by mouth at night Disp #*2
Tablet Refills:*0
9. Atorvastatin 20 mg PO QPM
10. azelastine 2 spray nasal BID
11. Calcitonin Salmon 200 UNIT NAS DAILY
12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
13. Gabapentin 200 mg PO TID
14. Levothyroxine Sodium 88 mcg PO DAILY
15. Montelukast 10 mg PO QHS
16. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
17. Senna 17.2 mg PO QHS
18. Tiotropium Bromide 1 CAP IH DAILY
19. Vitamin D ___ UNIT PO DAILY
20. HELD- Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze This
medication was held. Do not restart Albuterol Inhaler until you
are off the nebulizer version
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
================
MRSA necrotizing pneumonia
Atrial fibrillation
Secondary diagnosis
================
Osteoporosis
Hypothyroidism
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CT findings consistent with necrotizing
PNA// Eval for PNA Eval for PNA
IMPRESSION:
No prior chest images available for review.
A roughly 4 cm wide thick walled ring shadow projects lateral to the right
descending pulmonary artery. Perhaps this is the referenced necrotizing
pneumonia. It looks more like a mass or abscess, but should be reviewed on
the chest CT scan when that becomes available. A d 3 cm wide oval radiopacity
also projecting over the right hilus is presumably cement in the mid thoracic
vertebral body but that 2 would need to be confirmed. Lungs are otherwise
clear. Heart size is normal and pleural effusions small if any. No
pneumothorax.
Radiology Report
EXAMINATION: Chest radiograph PA and lateral
INDICATION: ___ year old woman with necrotizing MRSA pneumonia not improving,
with ongoing new AF and wheezing// evaluate for evidence of heart failure,
interval changes in pna
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Lung volumes are low. There is a perihilar right lower lobe opacification
concerning for pneumonia. There are bilateral pleural effusions. Heart size
is top-normal. Evidence of thoracic vertebral kyphoplasty.
IMPRESSION:
Right lower lobe pneumonia.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with picc// s/p r 47cm picc ___ ___
Contact name: ___: ___
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___ 15:36
IMPRESSION:
Compared to the earlier same day examination, there has been placement of a
right-sided PICC which is malpositioned coursing in the right internal jugular
vein with the tip outside of field-of-view. There is no other interval change
with persistent low lung volumes and right perihilar and lower lobar
consolidation unchanged. There may be tiny bilateral pleural effusions.
There is no new consolidation. There is no pneumothorax. Mid thoracic
vertebroplasty changes are seen.
NOTIFICATION: The findings were discussed with ___ of the venous
access team by ___, M.D. on the telephone on ___ at 5:48 pm, 5
minutes after discovery of the findings.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with malplaced picc, repositioned// confirm
positioning
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___ 17:30
IMPRESSION:
Compared to the examination from roughly 1 hour prior, the right PICC remains
malpositioned coursing through the right internal jugular vein and requires
repositioning. No interval changes seen.
Radiology Report
INDICATION: ___ year old woman with malpositioned picc// reposition picc.
thank you!
COMPARISON: Chest x-ray from ___
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure.
Dr. ___ supervised during the key components of the procedure and
has reviewed and agrees with the findings.
ANESTHESIA: None.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.9 min, 6 mGy
PROCEDURE: 1. Repositioning of right PICC.
PROCEDURE DETAILS: Under real-time fluoroscopic guidance, the existing PICC
line was flushed multiple times and successfully repositioned from the right
internal jugular vein into the right atrium. Due to distal positioning within
the lower right atrium, the existing PICC line was retracted with tip at the
cavoatrial junction. The catheter was secured to the skin, flushed, and a
sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing right arm approach PICC with tip in the right internal jugular
vein repositioned with tip in the cavoatrial junction.
IMPRESSION:
Successful repositioning right arm approach single lumen PowerPICC with tip in
the cavoatrial junction. The line is ready to use.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Fever, Transfer
Diagnosed with Pneumonia, unspecified organism
temperature: 97.5
heartrate: 81.0
resprate: 20.0
o2sat: 93.0
sbp: 124.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with a history of LLL lung
cancer s/p resection in ___ (no chemo/radiation) who presents
with hypoxia and a necrotizing MRSA pneumonia of the RLL. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
right L4-5 microdiscectomy
History of Present Illness:
___ yo M s/p L4-5 right microdiscectomy on ___ with Dr.
___ presents with progression of radicular symptoms. Pt
was
seen and evaluated in the ED on ___. In brief the patient
developed worsening low back pain ___ weeks ago. He saw his
chiropractor for manipulation, underwent massage therapy and
cupping therapy but the pain worsened and he developed right leg
radicular pain approximately 1 week ago, similar to his
preoperative pain. Subsequently he started ___ on ___. On the
morning of ___ he had significant pain and presented to the
ED.
An MRI was recommended at that time however pt elected not to
wait for the MRI and wanted to follow up outpatient.
Today he developed worsening back pain and new left leg
radicular
pain into buttock and posterior thigh. He feels the right leg
is
"going dead" with tingling and pins and needles in the thigh.
Denies Saddle anesthesia, denies numbness in his groin or
perianal region, denies bowel or bladder incontinence, denies
new
weakness but has increasing difficulty walking due to pain.
Past Medical History:
depression, hyperlipidemia
Right hand and knee surgery and lithotripsy.
Social History:
___
Family History:
Cancer, diabetes.
Physical Exam:
Physical exam on admission:
O: T:97.3 HR 88 BP 112/80 RR 16 98% RA
Gen: WD/WN, significanat discomfort
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
R 5 5 5 5 5 5
L 5 5 5 5 5 5
Sensation: Intact to light touch bilaterally.
Reflexes: Pa Ac
Right 1+ 1+
Left 1+ 1+
Toes downgoing bilaterally
Physical exam on discharge:
Gen: WD/WN, significanat discomfort
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
R 5 5 5 5 5 5
L 5 5 5 5 5 5
Sensation: Intact to light touch bilaterally.
Reflexes: Pa Ac
Right 1+ 1+
Left 1+ 1+
Toes downgoing bilaterally
Dressing over his midline back is clean, dry and intact without
surrounding erythema, induration, or palpable fluctuance.
Pertinent Results:
unremarkable.
Medications on Admission:
Klonopin 0.5 mg tablet 1 tablet(s) by mouth twice daily as
needed
___ Multivitamin For Men 200 mcg-175 mcg-250 mcg 1 tablet daily
Vicodin 5 mg-300 mg tablet 2 tablet(s) by mouth every 6 hours
PRN
atorvastatin 20 mg tablet 1 tablet(s) by mouth once a day
ibuprofen 100 mg tablet (dose uncertain)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Atorvastatin 20 mg PO QPM
3. Methylprednisolone 8 mg PO DAILY Duration: 24 Hours
This is dose # 5 of 7 tapered doses
RX *methylprednisolone [Medrol] 2 mg 1 tablet(s) by mouth four
times a day Disp #*4 Tablet Refills:*0
4. Methylprednisolone 4 mg PO DAILY Duration: 24 Hours
This is dose # 6 of 7 tapered doses
RX *methylprednisolone [Medrol] 2 mg 1 tablet(s) by mouth twice
a day Disp #*2 Tablet Refills:*0
5. Methylprednisolone 2 mg PO DAILY Duration: 24 Hours
This is dose # 7 of 7 tapered doses
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 6
hours Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L4-L5 radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: ___ year old man with recurrent radiculopathic pain.// ? etiology
of radiculopathy ? etiology of radiculopathy
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 4.2 s, 33.6 cm; CTDIvol = 27.2 mGy (Body) DLP = 913.9
mGy-cm.
Total DLP (Body) = 914 mGy-cm.
COMPARISON: Lumbar spine MRI from an outside facility of ___
MRI total spine of ___
FINDINGS:
There is no evidence of fracture or subluxation. The patient is status post
right L4 hemilaminectomy with a small amount of postoperative fluid at the
surgical site. Multilevel degenerative changes are better assessed on lumbar
spine MRI of ___. These changes are most severe at L4-5 where a
central disc protrusion causes severe canal narrowing and moderate to severe
bilateral neural foraminal narrowing. A disc bulge at L3-4 in combination
with ligamentum flavum hypertrophy causes moderate canal narrowing. Neural
foraminal narrowing is also mild bilaterally at L3-4 and moderate on the left
and mild on the right at L5-S1.
Bilateral nonobstructing calculi are demonstrated in the kidneys, measuring up
to 5 mm in the right upper pole collecting system. Moderate atherosclerotic
calcifications of the abdominal aorta and iliac vessels are present.
IMPRESSION:
1. No evidence of fracture or malalignment.
2. Central disc protrusion at L4-5 causes severe canal narrowing and moderate
to severe bilateral neural foraminal narrowing, better assessed on MRI of the
lumbar spine from the day prior.
3. Additional mild-to-moderate degenerative changes as described above.
4. Status post right L4 hemilaminectomy with a small amount of postoperative
fluid at the surgical site.
Radiology Report
EXAMINATION: L-SPINE FLEX AND EXT (2 VIEWS)
INDICATION: ___ year old man with radicular pain// stability?
TECHNIQUE: 2 lateral views of the lumbar spine, 1 labeled flexion the other
labeled flexion.
COMPARISON: L targeted review of L-spine CT from ___. L-spine
radiographs from ___ at
FINDINGS:
There is limited range of motion on the flexion view, where there are 5
non-rib-bearing vertebral bodies. No vertebral body compression. Mild
degenerative spurring at multiple levels, with slight disc space narrowing at
L4/5 and L5/S1 and trace retrolisthesis at L5/S1. Moderate to moderately
severe facet arthrosis, worst from L3 through S1. Scattered aortic
calcification.
On the extension view, no gross change in alignment.
IMPRESSION:
Mild multilevel discogenic degenerative changes, most pronounced at L4-S1 and
moderate to moderately severe facet degenerative changes worst from L3-L1.
Trace retrolisthesis at L4/5.
No gross change in alignment detected on flexion/extension views. Limited
range of motion in flexion.
Radiology Report
EXAMINATION: LUMBAR SINGLE VIEW IN OR
INDICATION: Posterior L4-L5 microdiskectomy
TECHNIQUE: Single lateral view of the lumbar spine obtained in the OR without
radiologist present
COMPARISON: Lumbar spine radiographs ___ and CT lumbar spine ___
FINDINGS:
The single available image shows surgical equipment positioned at the
posterior elements of L4. Please see the operative report for further
details.
Radiology Report
EXAMINATION: MRI OF THE THORACIC SPINE WITHOUT CONTRAST
INDICATION: *** CODE CORD *** History: ___ with microdiscectomy L5 5w/a. Saw
___, unilat R radiculopathy and benign exam. Now bilateral pain and BLE
weakness on examIV contrast to be given at radiologist discretion as
clinically needed// eval for central cord compression, post op complication,
infection
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the
thoracic and the lumbar spine were acquired. T1 sagittal and axial images
obtained following the administration gadolinium.
COMPARISON: ___.
FINDINGS:
Thoracic spine:
Mild multilevel degenerative changes seen. There is no spinal stenosis or
cord compression. No abnormal signal seen within the spinal cord. Incidental
hemangiomas are seen in the thoracic vertebral bodies.
Lumbar spine:
Since the previous study, the patient has undergone right-sided
hemilaminectomy. There is a central disc herniation seen which compresses the
thecal sac and demonstrates marginal enhancement indicative of epidural
scarring. Findings are consistent with a recurrent disc herniation with a
moderate-to-severe spinal stenosis. Small amount of fluid the laminectomy
sites at appear postoperative in nature. There is no evidence of enhancement
of the vertebral margins or indistinct vertebral margins or enhancement within
the disc to indicate discitis or osteomyelitis. Mild degenerative changes in
the lumbar region again seen.
IMPRESSION:
1. Recurrent disc herniation at L4-5 level with compression of the thecal sac
and resulting in moderate-to-severe spinal stenosis at this level.
2. Mild degenerative changes at other levels in the lumbar region unchanged
from the previous MRI.
3. No evidence of cord compression in the thoracic region. No abnormal signal
within the thoracic spinal cord up to conus level.
4. Small amount of fluid the laminectomy site appears postoperative in nature.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, Weakness, Transfer
Diagnosed with Other dorsalgia
temperature: 97.3
heartrate: 88.0
resprate: 16.0
o2sat: 98.0
sbp: 112.0
dbp: 80.0
level of pain: 3
level of acuity: 2.0 | ___ with a history of anxiety presents with radiculopathy and is
now status post right L4-L5 microdisectomy.
#radiculopathy:
Patient presented with back pain 6 weeks L5-S1 microdisectomy
for radiculopathy. His neurological exam was intact. He was
admitted for pain control and right L4-L5 microdisectomy. His
procedure was complicated by CSF leak and he was kept flat on
bedrest for 48 hours post-operatively. After 48 hours the head
of his bed was advanced and he ambulated easily around the unit
without difficulty. He was tolerating a diet and voiding
appropriately. He was discharged home in stable condition.
#Anxiety:
His Klonipin for anxiety was continued while he was inpatient.
#hyperlipidemia:
his atorvastatin for hyperlipidemia was continued while he was
inpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
shellfish derived / peanut
Attending: ___.
Chief Complaint:
Right lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
___: Open appendectomy, small bowel resection
History of Present Illness:
Mr ___ is a ___ yo M s/p laparascopic drainage for an
appendiceal abscess on ___ now presenting with recurrent
right lower quadrant pain. He states the pain began last
evening. It began with a crampy quality. It has become
progressively more severe. It is worst in the right lower
quadrant though does extend across his lower abdomen. He has
relief when he lies still with his back slightly elevated. He
tried some tylenol for pain relief without effect. He did note
that on the ride to the hospital he had sharp abdominal pain
with bumps in the road.
He denies fevers, chills, or night sweats. Denies nausea or
vomiting. Denies anorexia though the last time he had anything
to eat was 3PM yesterday. He has had two episodes of diarrhea
over the past 24 hours.
Review of systems: negative for chest pain, shortness of breath,
new bleeding or bruising problems, dysuria, frequency, urgency,
lower extremity swelling, blood per rectum, vision changes or
hearing changes.
Past Medical History:
Asthma
Hypercholesterolemia
Social History:
___
Family History:
Father deceased age ___ from complications of "lung and prostate
cancer"
Mother deceased age ___ from lung CA
7 brothers, 2 sisters in reported ___
Physical Exam:
VS: Temp 98.7, HR 81, BP 153/82, RR 18, SpO2 98%RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: Soft, mildly tender to palpation incisionally,
non-distended. Incisions: clean, dry and intact, with staples on
top half of wound. Wound vac in place on lower half of wound. No
erythema or fluctuance noted.
EXTREMITIES: Warm, well perfused, pulses palpable, (+/-) edema.
Pertinent Results:
CT Abdomen/Pelvis (___):
Findings suggest recurrent acute appendicitis with severe
inflammatory changes in the right lower quadrant with tethering
of adjacent small bowel. No macro perforation or discrete
abscess though small phlegmon difficult to exclude.
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with lower abd pain. Pt had appendiceal abscess in ___. Now
with one day of lower abd pain, max tender RLQ.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
No oral contrast was administered.
DOSE: DLP: 883 mGy-cm (abdomen and pelvis.
COMPARISON: CT abdomen pelvis on ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: A subcentimeter hypodensity in the right lobe is too small to
characterize but unchanged, otherwise the liver demonstrates homogenous
attenuation throughout with no evidence of other 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 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 appendix is hyperemic and dilated up to 13 mm in
diameter. There is small bowel tethered to the inflamed appendix with adjacent
fat stranding and small amount of free fluid. No discrete abscess is seen
though early phlegmonous changes difficult to exclude. No free air is present.
Sigmoid colon is partially tethered as well with minimal reactive thickening
is noted.
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.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits
BONES AND SOFT TISSUES: Unremarkable.
IMPRESSION:
Findings suggest recurrent acute appendicitis with severe inflammatory changes
in the right lower quadrant with tethering of adjacent small bowel. No macro
perforation or discrete abscess though small phlegmon difficult to exclude.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr.
___ at 14:15 on ___ in person at time of discovery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 98.0
heartrate: 102.0
resprate: 16.0
o2sat: 98.0
sbp: 129.0
dbp: 84.0
level of pain: 5
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of right lower quadrant
abdominal pain. Admission abdominal/pelvic CT revealed
recurrent acute appendicitis with severe inflammatory changes in
the right lower quadrant with tethering of adjacent small bowel.
No macroperforation or discrete abscess though small phlegmon
was difficult to exclude. WBC was elevated at 16.3. The patient
underwent open appendectomy with small bowel resection on
___, which went well without complication (reader referred
to the Operative Note for details). His PACU stay was uneventful
and the patient was transferred to the floor.
A wound vac was placed on the lower half of his midline
abdominal incision on ___. This vac was changed on the day
of discharge (___).
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient had slow return of bowel function, and did not pass
flatus until hospital day 6. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. Home ___ services were set up to assist the
patient with wound care. |
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:
Right lower quadrant pain
Major Surgical or Invasive Procedure:
IV antibiotics
History of Present Illness:
___ yo G0 transferred from ___ ED with RLQ and 17 cm
right adnexal mass. RLQ pain suddenly developed ___ morning.
Since then the pain has been constant. She was initially able to
carry on with her usual activities, but it has become
progressively worse since then. Yesterday she began to feel
dizzy
and lightheaded and by ___ afternoon she was no longer
able to ambulate and carry on with daily activities and as a
result presented to ___ ED. While there a transabdominal
ultrasound (TAUS) revealed a "uterus measuring 6 x 3.4 x 4.2 cm.
The endometrial echocomplex measured 6 mm. A distinct right
ovary
not delineated. Tubular cystic areas in the right adnexa noted,
one measuring 10.9 x 11.4 x 12.9 cm and the other measuring 6.5
x 4.7 x 7.6 cm. There is some flow in the septation between
these cysts. Left ovary measures 6 x 1.7 x 2.1 cm and
demonstrates no definite abnormality. No free fluid." She
subsequently had a
pelvic/abdominal CT that showed "mild to moderate right-sided
hydronephrosis with mild to moderate right hydroureter. A
transition is in the pelvis at the site of a large pelvic mass.
No stones are seen. Left kidney ureter demonstrates normal
caliber. The appendix is visualized and is unremarkable. The
visualized colon is unremarkable. No adenopathy is seen. No free
fluid or free air. A large septated cystic structure is
identified, extending from the right adnexa into the abdomen,
measuring 16.9 x 10.0 x 13.0 cm. No uterine abnormality is seen.
Left ovary is not well delineated. No free fluid is seen." At
the OSH she was febrile to a tmax of 100.7 and tachycardic to
133. While at the OSH she received one dose of 2 g IV
ceftriaxone given concern for pyelonephritis. She was then
transferred to ___ ED for further management.
Her pain was ___. She reported resolution of pain at the OSH
after receiving 4 mg IV morphine. Denies n/v. Last ate ___
morning. Reported dysuria and hematuria since ___. Denied
fevers. Reported palpitations. Last bowel movement was
yesterday. She also developed light vaginal bleeding which is
abnormal for her given she is in the middle of her cycle and her
bleeding is usually very regular.
Past Medical History:
OB: G0, virginal
GYN:
- LMP: ___, menses once a month, last 7 days, denies
dysmenorrhea, heavy menses
- Sexually active: virginal, denies any form of sexual activity
- STIs: denies
- Contraception: denies
- Pap: ? ___ years ago
- h/o endometriosis, fibroids, cysts: denies
PMH: denies
PSH: denies
Social History:
___
Family History:
___:
- Paternal aunt cervical cancer
- ___ great grandmother with cervical cancer
- Denies breast, ovarian and colon cancer
Physical Exam:
TMax 100.2 TCurr 98.3PO BP 103 / 65 HR 100 RR 18 SpO2 99 ra
General: NAD, comfortable
CV: RRR
Lungs: CTAB
Abdomen: softly distended, +TTP and fullness RLQ without rebound
or guarding, +CVAT slightly improved from yesterday
Extremities: no edema, no TTP, pneumoboots in place bilaterally
Pertinent Results:
___ 07:25AM BLOOD WBC-9.2# RBC-3.97 Hgb-9.8* Hct-32.1*
MCV-81* MCH-24.7* MCHC-30.5* RDW-14.3 RDWSD-42.3 Plt ___
___ 07:25AM BLOOD Neuts-70.8 Lymphs-16.0* Monos-11.0
Eos-1.7 Baso-0.1 Im ___ AbsNeut-6.47*# AbsLymp-1.46
AbsMono-1.01* AbsEos-0.16 AbsBaso-0.01
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-87 UreaN-11 Creat-0.9 Na-140
K-3.9 Cl-106 HCO3-23 AnGap-11
___ 07:25AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.0
___ 07:25AM BLOOD CEA-0.2 CA125-126*
___ 07:25AM BLOOD Estradl-56
___ 05:34AM BLOOD Lactate-0.9
Pelvic US ___:
IMPRESSION:
1. Large right adnexal cyst measuring at least 14.7 cm a
sonographic
appearance most consistent with endometrioma. However, in the
setting of
fever leukocytosis, tubo-ovarian abscess cannot be excluded
possibility.
2. A heterogeneously echogenic 6.4 x 2.1 cm structure abutting
the large right adnexal cyst may represent the right ovary.
Given size and grayscale appearance, right ovarian torsion
cannot be excluded.
3. Fibroid uterus with normal left ovary.
Chest Xray ___:
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
MRI ___:
IMPRESSION:
1. 21.2 cm right hematosalpinx. No enhancing components
suspicious for
malignancy.
2. Moderate right hydroureteronephrosis extending to the point
where the
right ureter crosses the iliac vessels, with delayed nephrogram
likely related to mass effect from the right hematosalpinx.
3. Endometriosis and endometriomas, largest measuring 3.8 cm,
adjacent to the right ovary. Findings equivocal for deep pelvic
endometriosis.
4. Fibroid uterus.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*40 Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice daily Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pyelonephritis
right hydronephrosis
endometriosis with hydrosalpinx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: History: ___ with rt LQ pain// pelvic mass?
TECHNIQUE: Grayscale and Doppler ultrasound images of the pelvis were
obtained with transabdominal approach. Patient declined transvaginal
evaluation.
COMPARISON: Outside reference CT abdomen and pelvic ultrasound from ___.
FINDINGS:
The uterus is anteverted. The uterus is enlarged measuring 9.0 x 3.5 x 4.2 cm.
Two uterine fibroids are seen in the anterior wall measuring 3.1 x 2.1 cm and
2.4 x 2.5 cm. The endometrium is homogenous and measures 7 mm.
The left ovary is normal. A large, septated, predominantly homogeneously
echogenic right adnexal cyst is seen and measures at least 14.7 cm. An
adjacent tubular, fluid-filled structure may represent hydrosalpinx. Abutting
this is a heterogeneously echogenic structure measuring approximately 6.4 x
2.1 cm, which demonstrates some internal vascularity, and may represent the
right ovary.
IMPRESSION:
1. Large right adnexal cyst measuring at least 14.7 cm a sonographic
appearance most consistent with endometrioma. However, in the setting of
fever leukocytosis, tubo-ovarian abscess cannot be excluded possibility.
2. A heterogeneously echogenic 6.4 x 2.1 cm structure abutting the large right
adnexal cyst may represent the right ovary. Given size and grayscale
appearance, right ovarian torsion cannot be excluded.
3. Fibroid uterus with normal left ovary.
NOTIFICATION: The updated findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:35 am.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with fever. infectious work up// PNA
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: MR abdomen/pelvis.
INDICATION: ___ year old woman with large adnexal mass extending into abdomen
and ureteral obstruction causing pyelonephritis, concern for endometriosis.
Assess for endometriosis burden, ?infiltrative endometriosis in area of
ureteral obstructions
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis
were acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
COMPARISON: Outside CT pelvis ___.
FINDINGS:
Lower thorax: Limited evaluation of the lung bases are clear. No pleural
effusion.
Liver: Liver is homogeneous in signal intensity without focal lesion. No
ascites.
Biliary: No intrahepatic or extrahepatic biliary duct dilatation. The
gallbladder is unremarkable.
Pancreas: Pancreas is homogeneous signal intensity without focal lesion. No
pancreatic divisum. No peripancreatic fat stranding.
Spleen: Normal in size without focal lesion.
Adrenal Glands: Unremarkable.
Kidneys: Again seen is moderate right hydronephrosis, unchanged since prior CT
with mildly delayed nephrogram. Left kidney is unremarkable. No left
hydronephrosis. No perinephric fat stranding.
Gastrointestinal Tract: Distal esophagus, stomach, small and large bowel are
unremarkable. Trace free fluid against the ascending colon noted. No
obstruction.
Pelvis: Small amount of pelvic free fluid noted. Fibroid uterus measures 6.8
x 3.9 x 6.5 cm with a dominant 3.2 x 2.5 cm left exophytic fibroid. (16:21).
Endometrium and junctional zone are within normal limits.
There is a large T1 hyperintense, mildly T2 hypointense, nonenhancing lesion
within the pelvis adjacent to the right ovary which demonstrates few linear
intraluminal incomplete septae, consistent with a hematosalpinx. Overall this
area measures 8.0 cm AP x 13.4 cm TV x 21.2 cm SI. No enhancing nodular
components. Adjacent to the right ovary is a 3.8 x 1.4 cm mildly T2
hyperintense, T1 hyperintense, nonenhancing cystic lesion consistent with an
endometrioma which is in close approximation with the right-sided
hematosalpinx. (16:27).
Within the left ovary is a 1.4 cm T1 hyperintense lesion (17:89), consistent
with an endometrioma. Left ovary is otherwise within normal limits. Few
punctate T1 hyperintense foci as well as T2 hypointense foci along the
posterior uterine wall are consistent with endometriomas with endometriosis.
(3: 10; 17: 89). Uterosacral ligament is within normal limits.
Lymph Nodes: Inguinal, pelvic sidewall, retroperitoneal, mesenteric lymph
nodes nonenlarged.
Vasculature: No abdominal aortic aneurysm; patent vasculature. Celiac axis,
SMA, bilateral renal arteries, ___ are patent. Hepatic anatomy is
conventional. Hepatic veins, main portal vein, SMV, and splenic vein are
patent.
Osseous and Soft Tissue Structures: Notable for a 0.6 cm bone island along the
left femoral head. Otherwise osseous structures and soft tissues are
unremarkable.
IMPRESSION:
1. 21.2 cm right hematosalpinx. No enhancing components suspicious for
malignancy.
2. Moderate right hydroureteronephrosis extending to the point where the
right ureter crosses the iliac vessels, with delayed nephrogram likely related
to mass effect from the right hematosalpinx.
3. Endometriosis and endometriomas, largest measuring 3.8 cm, adjacent to the
right ovary. Findings equivocal for deep pelvic endometriosis.
4. Fibroid uterus.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 11:30 am, 5 minutes after discovery of
the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever, RLQ abdominal pain, Transfer
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 100.9
heartrate: 113.0
resprate: 16.0
o2sat: 100.0
sbp: 115.0
dbp: 98.0
level of pain: 4
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the gynecology service
for pain management and evaluation eight pyelonephritis and
hydronephrosis concerning for obstruction
likely from newly diagnosed 17 cm right adnexal mass consistent
with large endometrioma.
Regarding her pyelonephritis, she was febrile to 100.9 on
arrival and was continued on IV ceftriaxone. Her pain was
controlled with IV dilaudid and Tylenol. Urology was consulted,
but percutaneous nephrostomy tube(s) were not indicated at that
time.
At time of admission, based on ultrasound findings, there was
concern that the mass could represent a malignancy, and Gyn
Oncology was consulted. However, final MRI was more consistent
with a large hematosalpinx and endometriosis. Thus she was not
seen by the Oncology team.
By hospital day 1, she was afebrile, tolerating a regular diet,
ambulating, voiding, and her pain was well controlled on oral
medications. She was discharged home with follow up with the
Minimally Invasive GTN team. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Cephalexin / Lipitor
Attending: ___.
Chief Complaint:
L ankle infection
Major Surgical or Invasive Procedure:
Ankle aspiration, superficial fluid collection growing coag+
staph aureus
History of Present Illness:
___ year old female with PMH of psoriatic arthritis (not on
immunosuppression), right ankle replacement at ___ in ___,
presenting with concern for Right ankle infection. She has a
history of a right ankle replacement as well as hammertoe
correction on the right foot. She has been wearing an ___
brace to the area for the past 2 weeks, as Dr. ___
orthopedics felt that she would eventually need an amputation
but that she could try bracing for the time being. She reports 2
weeks of progressively worsening Right ankle pain with weight
bearing, and for the past 2 days she has noted a painful
swelling to the lateral aspect of her Right ankle. She has no
pain while at rest. Last night and today she noted serous
drainage from the site. She denies fevers.
Past Medical History:
Psoriatic Arthritis
HTN
History of Breast Cancer s/p chemo, radiation, lumpectomy. In
remission.
HLD
HYPOTHYROIDISM
DEPRESSION
ANXIETY
OBESITY
INACTIVE TUBERCULOSIS
S/P GASTRECTOMY LAP SLEVE
S/P BILATERAL OOPHORECTOMY
S/P APPENDECTOMY
Social History:
___
Family History:
NC
Physical Exam:
AVSS
NAD, A&Ox3
RLE
mild erythema. Incision well approximated. Fires
___. SITLT s/s/dp/sp/tibial
distributions. 1+ DP pulse, wwp distally.
Pertinent Results:
___ 05:00PM JOINT FLUID WBC-156* HCT-3.0* POLYS-77*
___ MONOS-2 EOS-1*
___ 03:20PM WBC-9.6 RBC-4.19 HGB-12.6 HCT-38.8 MCV-93
MCH-30.1 MCHC-32.5 RDW-14.5 RDWSD-49.5*
Medications on Admission:
- aspirin (ASPIR-81) 81 mg tablet,delayed release (___) Take
81 mg by mouth daily
- multivitamin capsule Take by mouth OTC
- CALCIUM CARBONATE/VITAMIN D3 (CALCIUM 500 + D, D3, ORAL) Take
by mouth OTC
- Ferrous Sulfate 324 mg (65 mg iron) tablet,delayed release
(___) Take by mouth OTC
- lorazepam 1 mg tablet Take 1 mg by mouth at bedtime
- omeprazole 20 mg capsule,delayed ___ TAKE ONE
CAPSULE BY MOUTH EVERY DAY
- pravastatin 40 mg tablet Take 40 mg by mouth daily
- traMADol 50 mg tablet TAKE 2 TABLETS BY MOUTH EVERY EVENING
- triamcinolone 0.1 % Cream Apply to the affected area twice
daily
- diclofenac potassium 50 mg tablet TAKE 2 TABLET(S) BY MOUTH
ONCE A DAY as needed
- Clobetasol 0.05 % Ointment USE TO RASH ON ARMS, BACK, CHEST,
ABDOMEN TWICE A DAY AS NEEDED
- sertraline 100 mg tablet Take 100 mg by mouth 2 tablets daily
- levothyroxine 150 mcg tablet Take 1 tablet by mouth daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV every
four hours Disp #*252 Intravenous Bag Refills:*0
4. Rifampin 300 mg PO Q12H
RX *rifampin 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*1
5. Senna 17.2 mg PO HS
6. TraMADol 25 mg PO QHS:PRN pain
7. Aspirin 81 mg PO DAILY
8. Calcium Carbonate 500 mg PO QID
9. Ferrous Sulfate 325 mg PO DAILY
10. Levothyroxine Sodium 150 mcg PO DAILY
11. LORazepam 1 mg PO QHS:PRN insomnia/anxiety
12. Omeprazole 20 mg PO DAILY
13. Pravastatin 40 mg PO QPM
14. Sertraline 200 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R ankle hardware infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with hx of psoriatic arthritis and the right ankle
replacement presenting with right lateral malleolus ulceration and cellulitis
with swelling. //
COMPARISON: Prior dated ___
FINDINGS:
AP, lateral, oblique views of the right ankle provided. An ankle prosthesis
is again noted. A long lag screw is again noted traversing the mid and
hindfoot through the calcaneocuboid joint. Marked deformity of the midfoot
and hindfoot is again noted similar in overall appearance with prior exam. No
soft tissue gas or definite radiopaque foreign body. The talus is not
visualized and may be surgically absent. In this patient with right lateral
malleolar soft tissue ulceration, there is no definite underlying signs for
osteomyelitis. Given extensive deformity, is difficult to exclude a subtle
osteomyelitis.
IMPRESSION:
As above.
Radiology Report
INDICATION: ___ year old woman with 46cm left arm SL power PICC. ___ ___
// Left arm 46cm SL power PICC. ___ ___ Contact name: ___:
___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the left PICC line projects over the mid SVC.
There is no focal consolidation, pleural effusion or pneumothorax identified.
Unchanged atelectasis/ scarring at the left lung base. The size of the
cardiomediastinal silhouette is within normal limits.
Bilateral shoulder arthroplasties.
IMPRESSION:
The tip of the left PICC line projects over the mid SVC. No pneumothorax is
identified.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Cellulitis of right lower limb
temperature: 97.9
heartrate: 95.0
resprate: 18.0
o2sat: 97.0
sbp: nan
dbp: nan
level of pain: 7
level of acuity: 3.0 | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L ankle erythema and was admitted to the orthopedic
surgery service. The patient had superficial fluid collection
aspiration and was found to have coag+ staph, close to her L
ankle arthroplasty site. Infectious disease was consulted and
recommended long term IV abx. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home with services was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the Right extremity. 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: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall with difficulty walking, weakness and difficulty eating
Major Surgical or Invasive Procedure:
___ Diagnostic Angiogram
History of Present Illness:
The patient recently came back from ___ (___) where he
went for a week to visit his family. He was in his usual state
of health until ___ when while laying at the edge of the bed
he was turning and fell out of the bed. He said that was pretty
high. When he fell he hit his head, there was no loss
of consciousness. He said he had trouble getting up and his
family had to help him. He has had this bilateral legs felt
weak, but he denies any focal weakness. He said while in
___ his family had to help him get around. He also endorsed
a mild headache since the fall. He denies any other focal
neurological symptoms at this time. He flew back to ___ on
___. On arrival he had an episode of nausea and emesis and
his wife noticed that he had difficulty with coordination while
eating.
He was brought to be ___ or CT head was obtained and showed
left perimesencephalic hemorrhage. His INR was 2.56 and his
platelets were 159. He was given 2 mg of IM vitamin K and
transferred to ___ for further
evaluation. He was seen by neurosurgery who recommended CTA
head and neck which did not show any aneurysm or AVM. Patient
denies any vertigo, visual deficits, trouble producing or
comprehending speech, difficulty swallowing.
He does endorse bilateral lower extremity numbness, and
difficulty walking. Denies recent fevers, illness, weight loss
or night sweats.
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. No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-Coronary artery disease status post coronary artery bypass
grafting x3
-Atrial fibrillation status post pulmonary vein isolation with
Maze procedure
-Mitral regurgitation s/p mechanical mitral valve replacement
-Chronic systolic heart failure, last dry weight 52.2kg
-Rate controlled atrial flutter
-Parkinsons disease
-Hypertension
-Hyperlipidemia
-Hemorrhoidal lower gastrointestinal bleed
-Erectile dysfunction
-Hypoprolactinemia
-Essential tremor
-Subdural hematoma s/p fall ___, readmitted ___ for
craniotomy and ___ evacuation
-Permanent Pacemaker / ICD placement (___)
Social History:
___
Family History:
No family history of premature coronary artery disease or sudden
death.
Physical Exam:
ON ADMISSION:
VSS. Awake & alert. ___ -- intact. CN: II-XII
intact, except for anisocria (R 3mm; L 2mm). +ve drift R UE;
strength ___ proximally. Sensations intact. Toes down. +
laceration over R vertex. + bruise over R knee.
ON DISCHARGE:
Vitals: 98.0 119/70 62 16 98% Ra
General: chronically ill, no acute distress
HEENT: Eyes open, neck is mobile
Lungs: breathing comfortably on room air
Abd: soft, nontender
___: No foley. No blood at meatus
Ext: non-edematous
Neuro:
MS: Oriented to self, BI, city, month, date. Eyes open, fluent
speech output. Hypophonic voice, moderate dysarthria, follows
simple commands.
CN: Eyes open, PERRL R 2>1; L 3>2; tracks, no facial asymmetry,
tongue midline
Motor: Increased tone right > left UE and ___, +spasticity,
strength full in all muscles groups bilaterally.
Reflexes: deferred
Coord: deferred
Pertinent Results:
___ 04:28AM BLOOD WBC-7.6# RBC-3.92* Hgb-12.1* Hct-37.8*
MCV-96 MCH-30.9 MCHC-32.0 RDW-15.0 RDWSD-53.0* Plt ___
___ 05:57AM BLOOD ALT-14 AST-21
___ 04:28AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.8
___ 02:36AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
___ 04:30AM BLOOD %HbA1c-5.8 eAG-120
___ 04:30AM BLOOD Triglyc-61 HDL-50 CHOL/HD-2.4 LDLcalc-58
___ 03:26AM BLOOD TSH-0.12*
___ 04:30AM BLOOD TSH-0.33
___ 03:26AM BLOOD Free T4-1.7
___ 08:06AM BLOOD Cortsol-13.8
___ 12:50PM BLOOD ___ Titer-1:160* CRP-63.0*
___ 02:17PM BLOOD Lactate-0.9
___ 12:50PM BLOOD NEURONAL NUCLEAR (___) ANTIBODIES-Negative
___ 12:50PM BLOOD ___ ANTIBODY-Negative
___ 12:50PM BLOOD QUANTIFERON-TB GOLD-Indeterminate
___ 12:50PM BLOOD DNA AUTOANTIBODIES, SS-Negative
___ 12:50PM BLOOD RO & LA-Negative
___ 12:50PM BLOOD GQ1B IGG ANTIBODIES-Negative
___ 12:50PM BLOOD GLUTAMIC ACID DECARBOXYLASE-Negative
___ 12:50PM BLOOD ANGIOTENSIN 1 - CONVERTING ___
Test Result Reference
Range/Units
LISTERIA AB, CF <1:8
IMAGING:
CTA HEAD/NECK ___
IMPRESSION:
1. Hemorrhage centered within the left superior cerebellar
peduncle with
extension into the left ambient cistern and quadrigeminal plate
cistern. No underlying PCA aneurysm identified. Narrowing of
the basilar and proximal PCA vessels is likely secondary to
atherosclerotic disease, or potentially vasospasm if the on set
of hemorrhage was greater than 3 days prior. No ischemic
infarct in the PCA distributions.
2. No obvious underlying mass. There is an increased number of
enhancing
veins in this area which may be reactive in nature or may
represent an
underlying vascular anomaly. Follow-up imaging after resolution
of the
hemorrhage advised to further evaluate this.
3. Generalized atherosclerotic changes of the neck and
intracranial arteries, with less than 50% stenosis of the right
cervical internal carotid artery by NASCET criteria and no
stenosis on the left.
4. Chronic right temporal parietal infarct appear similar
compared to prior.
5. Marked degenerative changes of the cervical spine.
MR HEAD W AND W/O CONTRAST ___:
1. Acute to subacute punctate infarcts are present in the body
of the right
caudate nucleus and left occipital lobe.
2. Unchanged amount of subarachnoid hemorrhage is present within
the left
ambient and quadrigeminal plate cisterns with vasogenic edema in
the adjacent parenchyma. There is also evidence of hemosiderin
deposition in the same region. No discrete underlying lesion is
demonstrated, however repeat imaging should be obtained upon
resolution of the acute hemorrhage.
3. Postcontrast images are limited by patient motion, however no
enhancing
mass is identified.
CT HEAD W/O CONTRAST ___:
1. Overall stable appearance of hemorrhage centered within the
left superior cerebellar peduncle, extending into the left
ambient cistern and quadrigeminal plate cistern.
2. No evidence of new or enlarging hemorrhage or large territory
infarct.
More conspicuous subarachnoid hemorrhage in the posterior fossa
is likely due to interval redistribution of blood products
rather than new hemorrhage.
DIAGNOSTIC ANGIOGRAM ___:
Right common carotid artery: Carotid bifurcations
well-visualized. There is no significant atherosclerosis or
carotid stenosis.
Right internal carotid artery: The distal right ICA, proximal
and distal MCA and ACA branches are well-visualized. Vessel
caliber smooth and tapering. Normal arterial, capillary, and
venous phase . No vascular abnormalities identified.
Left common carotid artery: Carotid bifurcations
well-visualized. There is no significant atherosclerosis or
carotid stenosis.
Left internal carotid artery: Distal left ICA, proximal and
distal MCA and
ACA branches are well-visualized. Vessel caliber smooth and
tapering. Normal arterial, capillary, and venous phase . No
vascular abnormalities identified.
Left vertebral artery , left ___, basilar artery, bilateral
AICA, bilateral SCA and bilateral PCAs are well-visualized. The
right ___ is not well visualized as there was no cross-filling
to the right vertebral artery. No vascular abnormalities
identified, vessel caliber smooth and tapering. Arterial,
capillary, venous phases were normal .
Right common femoral artery: Well-visualized with a good caliber
size for
closure device.
CTA HEAD W AND W/O C AND RECONS ___
1. No evidence of aneurysm, or AVM.
2. Intracranial extracranial atherosclerotic disease
3. Stable parenchymal hematoma centered at left superior, middle
cerebellar
peduncles and posterior left brainstem.
MR HEAD W/O CONTRAST ___:
Confluent subarachnoid hemorrhage with involvement of the left
dorsal mid
brain, pons, superior and middle cerebellar peduncles, left
dentate nucleus, and subarachnoid spaces appears unchanged from
___. Signal abnormality within the left dorsal
midbrain on T2 weighted images may be slightly worse, however
this is likely equivocal. No definite interval infarction or
intracranial hemorrhage. Etiology of hemorrhage is
indeterminate, consider cavernoma. This would be atypical
location for
sequela of amyloid angiopathy. Vasculopathy or vasculitis is
very unlikely.
Follow-up to resolution is recommended to exclude underlying
neoplasm.
The previously identified tiny infarct within the body of the
right caudate
nucleus is not seen on this exam, possibly secondary to slice
selection. No findings to suggest interval infarction from ___.
Old infarct within the left inferior parietal lobule and lateral
occipital
temporal gyrus with associated hemosiderin staining. Chronic
lacunar
infarcts. Parenchymal atrophy, right greater than left likely a
sequela of
prior infarct.
EEGStudy Date ___
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of frequent epileptiform discharges in the right
frontocentral region, suggesting an area of increased
epileptogenicity. Continuous slowing over the left hemisphere
with background attenuation suggests a structural lesion and/or
cortical dysfunction in this region. Overall background slowing
suggests a nonspecific encephalopathy. No electrographic
seizures are present. Compared to the day prior's recording,
there is no significant change.
CT HEAD W/O CONTRAST ___
IMPRESSION:
Interval evolution of blood products centered at left brainstem,
cerebellar
peduncle. Follow-up MRI in 3 months suggested.
Stable chronic infarcts.
RECOMMENDATION(S): Follow-up MRI in 3 months.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carbidopa-Levodopa ___ TAB PO TID
4. Losartan Potassium 12.5 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pramipexole 1 mg PO TID
7. Ranitidine 150 mg PO BID
8. Torsemide 10 mg PO 5X/WEEK (___)
9. Warfarin 2 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. Torsemide 20 mg PO 2X/WEEK (MO,FR)
13. Hyoscyamine 0.125 mg PO QID:PRN Cramping
14. Cyanocobalamin 500 mcg PO DAILY
15. Calcitriol 0.25 mcg PO EVERY OTHER DAY
Discharge Medications:
1. Amantadine 100 MG PO DAILY
2. LevETIRAcetam 750 mg PO Q12H
3. ___ ___ UNIT PO Q8H
4. Ramelteon 8 mg PO QHS insomnia
DISCONTINUE PRN RESOLUTION OF DELIRIUM OR AS OUTPATIENT
5. Tamsulosin 0.4 mg PO QHS
6. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY
7. Warfarin 2 mg PO DAILY16
8. Amiodarone 100 mg PO DAILY
9. Atorvastatin 80 mg PO DAILY
10. Calcitriol 0.25 mcg PO EVERY OTHER DAY
11. Cyanocobalamin 500 mcg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. Hyoscyamine 0.125 mg PO QID:PRN Cramping
14. Losartan Potassium 12.5 mg PO DAILY
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Pramipexole 1 mg PO TID
17. Ranitidine 150 mg PO BID
18. Torsemide 10 mg PO 5X/WEEK (___)
19. Torsemide 20 mg PO 2X/WEEK (MO,FR)
20. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Perimesencephalic hemorrhage
___ disease
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD.
INDICATION: ___ with head bleed; traumatic vs atraumatic. Evaluate for
source of bleed.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 5 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CTA head from ___.
FINDINGS:
The study is moderately limited by patient motion, particularly the MPRAGE
acquisitions.
Several foci of slow diffusion are demonstrated in the body of the right
caudate nucleus (302:20) and left occipital lobe (320:13, 22). Subarachnoid
hemorrhage within the left ambient and quadrigeminal plate cisterns causing
mass effect upon the adjacent midbrain and aqueduct without occlusion is
unchanged in comparison with the day prior. There is also susceptibility in
this region suggestive of hemosiderin deposition. There is edema within the
adjacent midbrain, left cerebellar hemisphere and left thalamus. There is no
significant midline shift. An additional focus of susceptibility overlying
the left parietal lobe probably reflects old blood products (12:17).
The ventricles and sulci are prominent, compatible with involutional changes.
T2 and FLAIR hyperintensity in the right parietal lobe is consistent with a
chronic infarct. Additional periventricular and subcortical T2 and FLAIR
hyperintensities most likely reflect chronic small vessel ischemic disease.
Postoperative changes from a right frontotemporal craniotomy are noted.
Postcontrast images are significantly limited due to patient motion, within
this limitation no enhancing masses identified. The dural venous sinuses are
grossly patent on MP-RAGE images.
There is mild mucosal thickening in the bilateral maxillary sinuses and
anterior ethmoid air cells. The orbits are unremarkable portion of bilateral
lens replacements.
IMPRESSION:
1. Acute to subacute punctate infarcts are present in the body of the right
caudate nucleus and left occipital lobe.
2. Unchanged amount of subarachnoid hemorrhage is present within the left
ambient and quadrigeminal plate cisterns with vasogenic edema in the adjacent
parenchyma. There is also evidence of hemosiderin deposition in the same
region. No discrete underlying lesion is demonstrated, however repeat imaging
should be obtained upon resolution of the acute hemorrhage.
3. Postcontrast images are limited by patient motion, however no enhancing
mass is identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with permesenphalic bleed.// worsening hemorrhage
or infarct
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 =
747.4 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Head CTs from ___ and MRI from ___.
FINDINGS:
Again seen is hemorrhage centered within the left superior cerebellar
peduncle, extending into the left ambient cistern and quadrigeminal plate
cistern, not significantly changed in size and extent compared to ___. The fourth ventricle is stably narrowed due to vasogenic edema of the
left cerebellum, pons and midbrain, though remains patent. More conspicuous
is hyperdense thickening of the tentorium and the posterior falx as well as
bilateral parieto-occipital gyri and the cerebellar folia, likely representing
redistribution of prior hemorrhage.
There is stable appearance of prior right frontoparietal craniotomy and right
temporal parietal encephalomalacia from chronic infarct. There is no evidence
of enlarging hemorrhage or large territory infarct.
The ventricles and sulci are unchanged in size and configuration.
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. Overall stable appearance of hemorrhage centered within the left superior
cerebellar peduncle, extending into the left ambient cistern and quadrigeminal
plate cistern.
2. No evidence of new or enlarging hemorrhage or large territory infarct.
More conspicuous subarachnoid hemorrhage in the posterior fossa is likely due
to interval redistribution of blood products rather than new hemorrhage.
Radiology Report
INDICATION: ___ year old man with perimesencephalic hemorrhage, angiogram
___// cardiopulmonary process Surg: ___ (angiogram)
TECHNIQUE: PA portable chest radiograph
COMPARISON: ___
FINDINGS:
A left chest wall dual lead AICD is present. There is no focal consolidation,
pleural effusion or pneumothorax identified. Linear opacities in the left
lower lung are unchanged likely reflective of atelectasis. There is mild
pulmonary vascular congestion. The size the cardiac silhouette is unchanged.
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: Right common carotid artery angiogram.
Left common carotid artery angiogram.
Left vertebral artery angiogram.
Right common femoral artery angiogram.
INDICATION: ___ year old man s/p fall ___ who presented with difficulty
walking, generalized weakness, and uncoordinated eating since ___. CT with
left perimesencephalic bleed.// Evaluate for vascular malformation
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
Versed and fentanyl throughout the total intra service time of 56 minutes
during which the patient's hemodynamic parameters were continuously monitored.
TECHNIQUE: Patient was brought into the angio suite, ID was confirmed via
wrist band.The patient was placed supine on fluoroscopy table and bilateral
groins were prepped and draped in the usual sterile manner. Time-out procedure
was performed per institutional guidelines. The location of the right mid
femoral head was located using anatomic and radiographic landmarks. 10 +10 cc
of subcutaneous lidocaine was infused into the tissue. Micropuncture kit was
used to gain access to the right femoral artery, serial dilation was
undertaken until a long 5 ___ groin sheath connected to a continuous
heparinized saline flush could be inserted. ___ catheter was
connected to the power injector and also to a continuous heparinized saline
flush. This was advanced over the 0.038 glidewire brought up the aorta used to
select the right common carotid artery. AP, oblique and lateral views of the
anterior cerebral circulation were obtained .
Catheter was then pulled back in the aorta and used to select the left common
carotid artery. AP, oblique and lateral views of the anterior cerebral
circulation were obtained. The catheter was then pulled back in the aorta and
the left subclavian artery was selected. AP and lateral road map imaging was
undertaken. Next, the left vertebral artery was selected. AP and lateral
views were taken from this vessel for the posterior cerebral circulation. The
catheter was then pulled back in the aorta fully removed from the body. A
common femoral arteriogram was performed prior to use of a closure device,
subsequently 6 ___ Angio-Seal was put in. At the conclusion of the
procedure, there is no evidence of thromboembolic complication and the patient
was at his neurologic baseline.
COMPARISON: None.
PROCEDURE: Diagnostic cerebral angiogram.
FINDINGS:
Right common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis.
Right internal carotid artery: The distal right ICA, proximal and distal MCA
and ACA branches are well-visualized. Vessel caliber smooth and tapering.
Normal arterial, capillary, and venous phase . No vascular abnormalities
identified .
Left common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis.
Left internal carotid artery: Distal left ICA, proximal and distal MCA and
ACA branches are well-visualized. Vessel caliber smooth and tapering. Normal
arterial, capillary, and venous phase . No vascular abnormalities identified .
Left vertebral artery , left ___, basilar artery, bilateral AICA, bilateral
SCA and bilateral PCAs are well-visualized. The right ___ is not well
visualized as there was no cross-filling to the right vertebral artery. No
vascular abnormalities identified, vessel caliber smooth and tapering.
Arterial, capillary, venous phases were normal .
Right common femoral artery: Well-visualized with a good caliber size for
closure device.
I, ___, participated in the procedure. I, ___,
was present for the entirety of the procedure and supervised all critical
steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
IMPRESSION:
Diagnostic cerebral angiogram within normal limits.
RECOMMENDATION(S):
1. Management of perimesencephalic none aneurysmal subarachnoid hemorrhage as
per usual protocol.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with IPH started on hep for mechanical MVR as
bridge to coumadin// eval IPH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total exam DLP: 936.91
COMPARISON: Head CT of ___
FINDINGS:
Again demonstrated is an evolving intraparenchymal hemorrhage centered in the
left superior cerebellar peduncle extending into the left ambient and
quadrigeminal plate cisterns, and interdigitating within the cerebellar sulci.
There remains a similar degree of adjacent vasogenic edema and effacement of
the fourth ventricle and aqueduct. The ventricles are unchanged in size. No
new or increasing hemorrhage or large acute infarction is demonstrated. Right
temporal parietal encephalomalacia is unchanged.
Right fronto temporal craniotomy changes are stable. 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 with the exception of bilateral lens replacements.
IMPRESSION:
Evolving intraparenchymal hemorrhage centered in the left superior cerebellar
peduncle with extension into the subarachnoid space is essentially unchanged.
There is a similar degree of effacement of the fourth ventricle without change
in the size of the third or lateral ventricles. No evidence of new or
increasing hemorrhage, or acute infarct.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with IPH, on heparin gtt. Delirium overnight,
headache worse.// eval for change in IPH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 23.4 mGy (Body) DLP =
421.9 mGy-cm.
Total DLP (Body) = 422 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
Again demonstrated, is a similar volume evolving intraparenchymal hemorrhage
centered in the left superior cerebellar peduncle extending into the left
ambient and quadrigeminal cisterns. There is similar extension into the
subarachnoid space adjacently. There is similar degree of vasogenic edema and
effacement of the fourth ventricle. No evidence of new areas of hemorrhage or
acute territorial infarct. Right temporoparietal encephalomalacia is
unchanged. The ventricles are unchanged in size. There is similar degree of
mild rightward midline shift of approximately 4 mm.
Right frontal temporal calvarial changes secondary to craniotomy are stable.
Otherwise, 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 volume, evolving intraparenchymal hemorrhage centered in left
superior cerebellar peduncle with extensions of subarachnoid space.
2. Similar mild rightward midline shift and fourth ventricle effacement.
3. No new areas of hemorrhage or acute territorial infarcts.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ year old man with IPH s/p fall on heparin gtt for mechanical
MV// evaluate evolution of IPH on heparin gtt
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.3 mGy-cm.
2) Spiral Acquisition 3.0 s, 23.2 cm; CTDIvol = 27.6 mGy (Head) DLP = 641.9
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 73.8 mGy (Head) DLP =
36.9 mGy-cm.
Total DLP (Head) = 1,613 mGy-cm.
COMPARISON: CT head ___ 06:31
FINDINGS:
CT HEAD WITHOUT CONTRAST: Intraparenchymal hemorrhage centered in the left
superior cerebellar peduncle, posterior midbrain, pons, extending into the
left middle cerebellar peduncle is stable. Interval evolution of blood
products when compared to the ___ study. This hemorrhage is again
seen extending into the left ambient and quadrigeminal cisterns. Stable
adjacent subarachnoid hemorrhage. Unchanged in appearance mild mass effect on
the fourth ventricle. No hydrocephalus.
There is no evidence of new hemorrhage or acute large territorial infarction.
There is a similar degree of rightward midline shift. The ventricles are
unchanged in size. Right temporoparietal encephalomalacia from chronic infarct
is unchanged. Moderate chronic small vessel ischemic changes.
Postsurgical changes are again identified at the right frontotemporal
calvarial region. There is no evidence of acute fracture. The visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD: There is no evidence of arterial venous malformation, aneurysm, or
feeding vessels in region of the intraparenchymal hemorrhage.
Mild narrowing right M1 segment. Moderate narrowing left M 2 segment. There
is mild narrowing of the basilar artery which may represent atherosclerotic
disease. Again seen is atherosclerotic disease within the V3 and V4 segments
of the bilateral vertebral arteries. There is moderate to severe narrowing of
the right vertebral artery V4 segment. Mild-to-moderate narrowing of the left
V4 segment.
There is moderate atherosclerotic disease of the bilateral cavernous segments
internal carotid arteries, with mild-to-moderate narrowing bilaterally.
Significant atherosclerotic calcifications are seen at the bilateral proximal
ICA near origin, partially imaged on this scan.
No evidence of aneurysm. Irregularity of bilateral PCAs is partially from
motion, there may be mild atherosclerotic disease. Other vessels are patent.
No early shunting vein.
IMPRESSION:
1. No evidence of aneurysm, or AVM.
2. Intracranial extracranial atherosclerotic disease
3. Stable parenchymal hematoma centered at left superior, middle cerebellar
peduncles and posterior left brainstem.
RECOMMENDATION(S): Follow-up MRI brain without and with contrast in 3 months.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with acute unresponsiveness// Rule out infarct,
no contrast necessary
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
___ MR head with without contrast
___ CTA head neck
___ CT head without contrast
___ CT head without contrast
FINDINGS:
There is expected interval evolution of blood products within the left dorsal
mid brain, left superior and middle cerebellar peduncle, left dorsal pons,
left dentate nucleus, and within the subarachnoid space of the surrounding
quadrigeminal plate and ambient cisterns. There the degree of signal
abnormality within the left midbrain on T2 weighted images may be slightly
worse (series 10, image 14), however this is uncertain.
The cerebral aqueduct is narrowed, however appears similar in caliber. The
ventricular configuration appears stable, with dilation of the lateral
ventricles and third ventricle likely secondary to parenchymal volume loss.
There are chronic lacunar infarcts to the level of the bilateral basal
ganglia. There is moderate brain parenchymal atrophy, with atrophy in the
right temporal and parietal lobes greater than on the left, likely sequela of
chronic right-sided infarct. Significant atrophy of the right hippocampus.
The previously identified tiny acute infarct within the body of the right
caudate nucleus is not seen on this exam, possibly due to slice selection. No
findings to suggest an interval infarction from the ___ MRI.
The volume of subarachnoid blood products within the bilateral parietal and
occipital sulci appears unchanged.
The encephalomalacia within the right inferior parietal lobule and lateral
occipital temporal gyrus likely reflects a sequela of an old infarct, with
residual hemosiderin staining. Additionally, there is an old infarct within
the right inferior cerebellar hemisphere. Areas of hyperintense signal within
the subcortical and periventricular white matter the, but likely reflect the
sequela of moderate chronic small vessel disease. The major vascular flow
voids are preserved.
Small foci of susceptibility artifact within the left superior parietal lobule
and right superior cerebellar hemisphere likely reflect chronic
microhemorrhage and appear unchanged.
There are bilateral lens implants. The orbits are otherwise unremarkable.
IMPRESSION:
Confluent subarachnoid hemorrhage with involvement of the left dorsal mid
brain, pons, superior and middle cerebellar peduncles, left dentate nucleus,
and subarachnoid spaces appears unchanged from ___. Signal
abnormality within the left dorsal midbrain on T2 weighted images may be
slightly worse, however this is likely equivocal. No definite interval
infarction or intracranial hemorrhage. Etiology of hemorrhage is
indeterminate, consider cavernoma. This would be atypical location for
sequela of amyloid angiopathy. Vasculopathy or vasculitis is very unlikely.
Follow-up to resolution is recommended to exclude underlying neoplasm.
The previously identified tiny infarct within the body of the right caudate
nucleus is not seen on this exam, possibly secondary to slice selection. No
findings to suggest interval infarction from ___.
Old infarct within the left inferior parietal lobule and lateral occipital
temporal gyrus with associated hemosiderin staining. Chronic lacunar
infarcts. Parenchymal atrophy, right greater than left likely a sequela of
prior infarct.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with NG tube// eval placement
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___.
IMPRESSION:
Upper enteric tube tip terminates in the proximal stomach with the side port
is in the distal esophagus and should be advanced by roughly 7 cm for ideal
placement. Aeration of the left lower lung has improved. Otherwise no
interval change is seen. Postsurgical changes from CABG and moderate
cardiomegaly are unchanged. There remains minimal left base atelectasis.
Lungs are otherwise clear. There is no large effusion or pneumothorax. Left
anterior chest wall AICD is unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ng tube check placement s/p advancing// ng
tube eval placement ng tube eval placement
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Nasogastric drainage tube passes below the diaphragm and out of view.
Transvenous right atrial and right ventricular pacer defibrillator leads in
standard placements continuous from the left pectoral generator.
Moderate cardiomegaly is stable but pulmonary vascular congestion has
increased. Pleural effusions are small if any. No pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with perimesencephalic lesion// Eval resorption
of blood
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.3 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: MRI brain ___, head CT ___.
FINDINGS:
There has been interval evolution of blood products within parenchymal
hematoma involving left superior and middle cerebellar peduncles and adjacent
brainstem, and adjacent extra-axial blood products. 0.9 cm focus of
parenchymal hemorrhage is seen today, compared with 1.5 cm on prior, with
surrounding mild edema. Chronic basal ganglia and parenchymal infarcts are
again seen, better seen on MRI ___. No new hemorrhage. Stable
ventricular size. Punctate focus of hemorrhage versus calcification within
posterior right temporal lobe chronic infarct, similar to prior.
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. NG tube in place. Right parietal
craniotomy.
IMPRESSION:
Interval evolution of blood products centered at left brainstem, cerebellar
peduncle. Follow-up MRI in 3 months suggested.
Stable chronic infarcts.
RECOMMENDATION(S): Follow-up MRI in 3 months.
Radiology Report
INDICATION: ___ year old man with ng tube// ng tube
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a nasogastric tube projects over the distal stomach. A left chest
wall dual lead AICD is present. The patient is post median sternotomy and
cardiac valve replacement.
Patchy opacities in both lungs may reflect pulmonary edema with atelectasis.
Superimposed pneumonia/aspiration cannot be excluded in the proper clinical
context. There is no large pleural effusion or pneumothorax identified. The
size of the cardiac silhouette is enlarged but unchanged. The thoracic aorta
is again noted to be unfolded.
IMPRESSION:
The tip of the nasogastric tube projects over the distal stomach.
Pulmonary edema and atelectasis. Superimposed infection/aspiration cannot be
excluded in the proper clinical context PA
Radiology Report
INDICATION: ___ year old man with NG// confirm NG placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from 3 hours prior
IMPRESSION:
The tip of the nasogastric tube projects over the stomach, unchanged. Overall,
there is no significant interval change since the prior chest radiograph
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with Right PICC // Right Power PICC DL 44cm
___ ___ Contact name: ___: ___ Right Power PICC DL 44cm
___ ___
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Severe cardiomegaly worsened between ___ and ___, subsequently
unchanged. Pulmonary vasculature and hilar pulmonary arteries are also
enlarged. There is probably no pulmonary edema or focal pulmonary
abnormality. Small left pleural effusion unchanged.
Right PIC line ends close to the superior cavoatrial junction. Nasogastric
drainage tube passes below the diaphragm and out of view. Transvenous right
atrial and pacer and right ventricular pacer defibrillator leads are
continuous from the left pectoral generator.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with NGT placement // NGT placement Contact
name: ___: ___ NGT placement
IMPRESSION:
Pacemaker defibrillator leads terminate in the right ventricle. Heart size
and mediastinum are unchanged including moderate cardiomegaly. Replaced most
likely mitral valve is in expected location.
Right PICC line tip is at the cavoatrial junction. There is mild vascular
congestion but no overt pulmonary edema
NG tube tip is in the distal stomach.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old man with NGT placement
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray ___ approximately 18 hours previous
FINDINGS:
The tip of the NG tube is in the distal stomach. The right PICC tip is in the
region of the cavoatrial junction, similar to previous. There is a left
pacemaker in situ. The patient is status post valve replacement. There are
low lung volumes which compromises evaluation. There may be a small left
effusion. The heart is enlarged. There is pulmonary venous congestion.
IMPRESSION:
Cardiomegaly with pulmonary venous congestion. Possible small left effusion.
NG tube tip in the distal stomach.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with Contus/lac/hem crblm w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: 98.3
heartrate: 57.0
resprate: 15.0
o2sat: 99.0
sbp: 131.0
dbp: 85.0
level of pain: uta
level of acuity: 2.0 | The patient is a ___ w mechanical MV and atrial fibrillation on
Coumadin who p/w intraparenchymal and perimesencephalic
hemorrhage after mechanical fall. Upon multiple discussions with
Neuroradiology, the etiology of the hemorrhage remains
ultimately unclear, but the leading diagnosis is underlying
cavernous
malformation.
At the OSH, his INR was 2.56 and his platelets were 159. He was
given 2 mg of IM vitamin K for reversal prior to transfer.
Anti-coagulation was held for 5 days in the setting of his
intraparenchymal and perimesencephalic hemorrhage. In
discussions with cardiology, given his high risk for further
embolization in the setting of a mechanical MV and atrial
fibrillation, we resumed anti-coagulation with heparin on ___.
He continued to complain of a severe headache, which was
treated with a trial of acetazolamide. Clinically, the patient
had initially been very alert and stable upon resumption of
heparin. However, he experienced an acute change in mental
status/neuro exam on morning of ___, becoming acutely
somnolent, rigid, with right hemiplegia and right gaze
deviation. The etiology is still unclear regarding acute change.
His exam at the time included right-sided hemiplegia and right
gaze-deviation, which could be from hemorrhagic or ischemic
involvement in his already affected left dorsal mid brain, pons,
superior and cerebellar peduncles, and left dentate nucleus.
Repeat imaging with non-con head CT and MRI w and w/o contrast
showed relative stability of the IPH and was not conclusive for
additional hemorrhage or infarct, although the sensitivity of
imaging was confounded by the pre-existing blood.
Anti-coagulation with heparin was continued in the absence of
hemorrhagic evolution. Acetazolamide was discontinued given his
acute change in mental status.
The simplest explanation may be that the blood from his
perimesencephalic hemorrhage may have resulted in mechanical
pressure leading to compression of his paramedian arteries
resulting in a localized infarct, vs. re-bleeding from the same
focus. The old blood surrounding this area may compound our
ability to detect a new infarct on MRI. Alternatively, since he
has been off anticoagulation for several days, he may have also
had an ischemic infarct from a seeded embolus from his
mechanical mitral valve. We evaluated his mechanical valve via
ECHO and did not detect signs of thrombus formation. A similar
lesion in the midbrain reticular formation may also explain his
somnolence and acute change in consciousness.
As there was no clear difference on imaging for his acute change
in mental status, we pursued an empiric diagnostic approach,
including a trial of 2mg IV ativan out of concern for seizure,
which had no clinical effect. Although continuous video EEG was
negative for seizures, he did have frequent sharp wave
discharges in the right frontal central region across F4-C4. We
continued him on keppra 750 mg BID out of concern for a lower
seizure threshold and a prior CVA representing a possible
seizure focus.
Alternative explanations for his altered mental status were also
discussed and included metabolic derangements vs infectious
etiologies, although the sudden change would be atypical. We
discussed the possibility that his hemorrhage may have resulted
from a possible infectious etiology, such as listeria, which
sometimes presents with rhomboencephalitis. Although he was not
reported to be clinically sick prior to his fall, out of concern
for a possible infectious etiology with an atypical clinical
presentation, we also started him on empiric antibiotic
treatment with vancomycin (which was discontinued within 4
days), ampicillin, and ceftriaxone (2g BID). Although unlikely
to be infectious, his clinical exam began to improve, while he
has been on antibiotic therapy, the possibility of
rhomboencephalitis (such as caused by listeria or mycobacteria)
cannot be ignored. He was treated empirically with Ampicillin
for 3 weeks. This was subsequently discontinued and he remained
stable without infectious sign/symptoms.
He has also developed what appears to be dystonic posturing on
the right hemibody as well as worsening dysarthria and rigidity
that could be reflectively of worsening parkinsonism in the
setting of an acute injury affecting extrapyramidal pathways in
the brainstem. This resolved with a trial of amantadine.
His mental status began to improve with return to baseline
within 4 days of his acute change. He was initially NG-tube
dependent in the setting of his acute change but has improved
and began to tolerate adequate PO intake. Coumadin was
initiated on ___ with continued heparin bridge until his INR
reached 2.0 on ___. Heparin was discontinued and coumadin was
continued for goal INR 2.5-3.5.
His hospital course was further complicated by delirium
resulting in ongoing attempts to pull out his NG tube as well as
his foley. Urology was consulted out of concern for ongoing
hematuria. They recommended to keep his foley in place for at
least ___ days to tamponade a possible abrasion site. He also
developed a transient pre-renal ___ secondary to contrast and
decreased PO intake which resolved with gentle IV hydration.
# Perimesencephalic and intraparenchymal hemorrhage, later
complicated by acute change in mental status
- continue warfarin for goal INR 2.5-3.5
- repeat MRI with and without gadolinium by ___ (he has a
pacemaker that is MR-compatible but this may require
cardiology's involvement during MR scan pending
hospital/radiology protocol)
- monitor for adequate PO intake
- continue ___, OT, speech therapy
# Concern for infectious/auto-immune etiology for
perimesencaphilc/intraparenchymal hemorrhage
- blood cultures, urine cultures negative
- Serum Listeria antibodies negative
- autoimmune workup negative
# ___ disease
- continue amantadine
- titrate dose of carvidopa/levidopa as needed
# ___ - resolved, likely pre-renal in setting of poor PO and IV
contrast
# Hematuria - secondary to self-removal of foley in setting of
anti-coagulation. Improved
# Delirium - resolving
- maximize delirium precautions, day-night reaffirmation
- continue remelteon/melatonin qhs
# ? Seizures, low seizure threshold at baseline
- continue empiric keppra 750 mg PO BID. Plan to treat for 3
months empirically
- wean keppra in outpatient setting (likely in ___
# Dysphagia, improving
- Should have ongoing evaluation with speech/language
pathologist for assessment and management of dysphagia
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================================================================
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: M
Service: MEDICINE
Allergies:
Erythromycin Base / Trazodone / morphine / Codeine
Attending: ___.
Chief Complaint:
Abd pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with HCV genotype 3 and alcohol-mediated liver cirrhosis
with course complicated by variceal bleeds status post banding
and TIPS ___ ___, multiple admissions for hepatic
encephalopathy, DM2, history of polysubstance abuse, multiple
psychiatric diagnoses who presents with worsening abdominal pain
and hyperglycemia.
.
Of note, he was recently admitted from ___ for
hematemesis and abdominal pain and he left AMA. He was also seen
in the ED on ___ for non-bloody emesisx2. He is now
complaining of upper abdominal pain has been going on for 2
weeks. He states he lives with ___ abdominal pain but that it
has been increased to ___. Today patient developed lower
abdominal pain and nonbloody diarrhea he believes is from a UC
flare. He reports approx 10 episodes of diarrhea today and
reports nausea and chills but no vomiting, fevers, ___ swelling,
confusion.
.
In the ED, initial VS were 97.5 80 112/66 18 96%. Rectal exam
was guaic negative. LFTs at baseline. CXR clear. CT abdomen
showed no acute process. He was given dilaudid 1 mg iv x 2.
Admission Vitals were 120/74, hr 81, sao2 99, temp 98.1, rr 17
.
On the floor the patient has not had any bowel movements and is
AVSS. He is walking around frequently but still reports ___ abd
pain and asking for pain meds.
Past Medical History:
- cirrhosis due to hepatitis C (genotype 3) and prior alcohol
abuse; course complicated by esophageal variceal bleeds treated
with banding at ___ and TIPS in ___ recent EGD ___ with
only one cord of grade 1 varices; multiple prior episodes of
hepatic encephalopathy; denied liver transplant at ___ because
of history of relapse, was also turned down by ___ for
same reason
- hepatitis B
- prior polysubstance abuse including clonazepam, alcohol and
daily IV heroin
- diabete mellitus on insulin; diagnosed over ___ yrs ago
following an episode of severe pancreatitis; complicated by
diabetic neuropathy
- ulcerative colitis
- hypertension
- cocaine-induced MI in ___
- prior hernia repair
- prior unilateral orchiectomy
- anxiety
- post-traumatic stress disorder
- benign prostatic hyperplasia
- s/p cholecystectomy
Social History:
___
Family History:
Father: ___ disease.
Brother: ___ MJ Abuse.
Physical Exam:
VS - wt 88.2 kg Temp 97.4 F, BP 115-138/67-73, HR 70-80, R
___, O2-sat 98-100% RA
GENERAL - well-appearing male in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, sl dry MM, OP
clear
NECK - supple, no JVD
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 - scar present over RUQ, BS+, soft, diffuse mild TTP
greatest in RUQ, no rebound or guarding, no HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, steady
gait. no asterixis
Pertinent Results:
___ 06:50PM GLUCOSE-284* UREA N-13 CREAT-0.6 SODIUM-134
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-8
___ 06:50PM estGFR-Using this
___ 06:50PM ALT(SGPT)-261* AST(SGOT)-239* ALK PHOS-203*
TOT BILI-1.1
___ 06:50PM CRP-11.0*
___ 06:50PM WBC-4.0 RBC-3.66* HGB-12.6* HCT-35.3* MCV-97
MCH-34.5* MCHC-35.8* RDW-13.7
___ 06:50PM NEUTS-74.7* LYMPHS-15.2* MONOS-7.3 EOS-2.3
BASOS-0.4
___ 06:50PM PLT COUNT-63*
___ 06:50PM SED RATE-35*
.
ABD CT ___
FINDINGS: The imaged lung bases are clear. No pulmonary nodules.
No pleural
effusions. The imaged portion of the heart and pericardium are
normal.
The liver is shrunken and nodular in contour, consistent with
known history of
cirrhosis. A TIPS shunt is patent and is in optimal position. A
stable 14-mm
hypodense lesion within the left lobe, likely represents a
simple hepatic
cyst. The main portal vein is patent. The patient is status post
cholecystectomy. Prominent mesenteric adenopathy at the level of
the celiac
axis, porta-hepatis and gastrohepatic ligament are unchanged.
The adrenal glands and pancreas are normal. The spleen is
enlarged, measuring
17.1 cm. Both kidneys enhance and excrete contrast
symmetrically, without
evidence of hydroureteronephrosis or concerning renal masses.
The stomach, small and large bowel loops are normal, without
evidence of bowel
wall thickening, obstruction or active inflammation. The
appendix is normal.
Apparent wall thickening of the terminal ileum is likely due to
peristalsis.
The abdominal aorta has minimal atherosclerotic calcification
without
aneurysmal dilation. Prominent retroperitoneal lymph nodes do
not meet CT
criteria for significant adenopathy. There is no intra-abdominal
free fluid
or air.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder,
prostate,
rectum and sigmoid colon are normal. No pelvic free fluid or
adenopathy is
seen.
BONES AND SOFT TISSUES: No bone lesions suspicious for infection
or
malignancy are detected. Degenerative changes are seen in the
lumbar spine.
IMPRESSION:
1. No acute abdominal or pelvic pathology.
2. Cirrhotic liver, with a patent TIPS shunt. Splenomegaly. No
ascites.
Medications on Admission:
1. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. lactulose 10 gram/15 mL Syrup Sig: ___ (45) ML PO TID
6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ferrous sulfate Oral
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
11. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO once
14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: ___ (28) units Subcutaneous once a day: Please
take 28 units at breakfast.
16. Humalog 100 unit/mL Solution Sig: qs units Subcutaneous four
times a day: Breakfast Lunch Dinner At Bedtime
___ mg/dL Proceed with hypoglycemia Protocol
71-150 mg/dL Units 4 Units 4 Units 4 Units 0
151-200 mg/dL Units 10 Units 10 Units 10 Units 0
201-250 mg/dL Units 14 Units 14 Units 14 Units 2
251-300 mg/dL Units 18 Units 18 Units 18 Units 4
301-350 mg/dL Units 22 Units 22 Units 22 Units 6
351-400 mg/dL Units 24 Units 24 Units 24 Units 8
.
PER ___ REPORT ONLY
Dilaudid 2 mg po BID (pt reports script from Health & Wellness
pain clinic in ___
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. lactulose 10 gram/15 mL (15 mL) Solution Sig: ___ (45)
mL PO three times a day.
6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO twice a day.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
13. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for pain: As prescribed from pain clinic in ___
(not confirmed).
16. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: ___ (28) Units Subcutaneous once a day: At
breakfast.
17. Humalog 100 unit/mL Cartridge Sig: Per sliding scale
Subcutaneous four times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest, frontal and lateral views.
CLINICAL INFORMATION: ___ male with history of shortness of breath,
chills.
COMPARISON: ___.
FINDINGS: Frontal and lateral views of the chest are obtained. No focal
consolidation, pleural effusion, or evidence of pneumothorax is seen. The
cardiac and mediastinal silhouettes are stable and unremarkable, as are the
hilar contours. Minimal degenerative changes are seen along the spine.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ man with ulcerative colitis, abdominal pain and
diarrhea, to evaluate for acute intra-abdominal pathology.
COMPARISON: CT of the abdomen with contrast ___.
TECHNIQUE: MDCT helical images were acquired through the abdomen and pelvis
after administration of 130 cc of Omnipaque intravenous contrast. Sagittal
and coronal reformats were generated and reviewed.
FINDINGS: The imaged lung bases are clear. No pulmonary nodules. No pleural
effusions. The imaged portion of the heart and pericardium are normal.
The liver is shrunken and nodular in contour, consistent with known history of
cirrhosis. A TIPS shunt is patent and is in optimal position. A stable 14-mm
hypodense lesion within the left lobe, likely represents a simple hepatic
cyst. The main portal vein is patent. The patient is status post
cholecystectomy. Prominent mesenteric adenopathy at the level of the celiac
axis, porta-hepatis and gastrohepatic ligament are unchanged.
The adrenal glands and pancreas are normal. The spleen is enlarged, measuring
17.1 cm. Both kidneys enhance and excrete contrast symmetrically, without
evidence of hydroureteronephrosis or concerning renal masses.
The stomach, small and large bowel loops are normal, without evidence of bowel
wall thickening, obstruction or active inflammation. The appendix is normal.
Apparent wall thickening of the terminal ileum is likely due to peristalsis.
The abdominal aorta has minimal atherosclerotic calcification without
aneurysmal dilation. Prominent retroperitoneal lymph nodes do not meet CT
criteria for significant adenopathy. There is no intra-abdominal free fluid
or air.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder, prostate,
rectum and sigmoid colon are normal. No pelvic free fluid or adenopathy is
seen.
BONES AND SOFT TISSUES: No bone lesions suspicious for infection or
malignancy are detected. Degenerative changes are seen in the lumbar spine.
IMPRESSION:
1. No acute abdominal or pelvic pathology.
2. Cirrhotic liver, with a patent TIPS shunt. Splenomegaly. No ascites.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN, HYPERGLYCEMIA
Diagnosed with ABDOMINAL PAIN RLQ, CIRRHOSIS OF LIVER NOS, DIABETES UNCOMPL JUVEN
temperature: 97.5
heartrate: 80.0
resprate: 18.0
o2sat: 96.0
sbp: 112.0
dbp: 66.0
level of pain: 10
level of acuity: 3.0 | ___ with HCV and alcohol-mediated liver cirrhosis with course
complicated by variceal bleeds status post banding and TIPS ___
___, multiple admissions for hepatic encephalopathy, not on
transplant list at ___ because of history of relapse, DM2,
history of polysubstance abuse, multiple psychiatric diagnoses
who presents with abdominal pain and profuse diarrhea admitted
for ? UC flare.
.
# Ulcerative colitis: Presented with report of profuse diarrhea
but has not had any here. CT did not show any evidence of an
ulcerative colitis flare. He toleratee PO diet well. we planned
to discharge him without any changes to his medications.
However, when he heard he would be discharged he took his own IV
out and left prior to receiving discharge paperwork.
.
#Abdominal pain: CT did not show any acute cause of his
abdominal pain. He did not appear in significant pain on exam
but continued to report ___ pain. He reported having received
dilaudid from a pain clinic but could not recall the name only
that it was in ___. This was never confirmed and he was not
given any dilaudid at discharge. When told he would be
discharged he took his own IV out and left prior to receiving
discharge paperwork.
.
# Cirrhosis: From hepatitis C and prior alcohol abuse
complicated by esophageal varices s/p banding and TIPS. EGD
performed ___ revealed no sign of active bleeding, showed 2
cords of grade I varices. There was no significant interval
change since ___.
.
# Diabetes mellitus: Continued home insulin regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
unknown antibiotic
Attending: ___.
Chief Complaint:
episode of left lip numbness/swelling and difficulty walking
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ man with a PMHx signifcant only for
osteoarthritis s/p left hip replacement who presents today with
acute onset left lip numbness and difficulty ambulating. He had
been in his USOH until approximately 90 - 120 minutes or so
prior to presentation when he was sitting in ___ and noted
that his left lip suddenly felt "numb". He describes the feeling
as like a "swelling" of his lip. Denies any weakness of his
face, any difficulty speaking or extremity weakness. He then
tried to get up and go to the bathroom and noted that he had
some significant difficulty ambulating, stating that his left
side felt like it didn't want to "support itself". When he got
up, he
also experienced some dizziness, stating that he felt
lightheaded, but denies a sensation that the room was spinning
or that the floor was moving. He was assisted to the bathroom
by one of the baristas. In the bathroom, he had to lean against
the wall in order to support himself. He then returned to his
seat
and his dizziness gradually resolved. Denies HA, visual
changes, difficulty speaking. He has had two similar events
___ years ago that involved him becoming standing with
dizziness. One caused him to lose his "balance" and fall down
the stairs and fracture his C2. He is s/p five months in a
c-collar. He was able to order a coffee and shortbread, but
became concerned as his symptoms in his face persisted. He then
called his brother, who came to ___ to pick him up 45
minutes later. In the interim, his facial symptoms resolved
(lasted approximately one hour in duration). His gait was
improved and
he was able to ambulate with his cane to his brother's car.
However, given his symptoms, he opted to come to the ___ ED
for urgent evaluation. Given his acute onset, a code stroke was
called.
Past Medical History:
1. Osteoarthritis s/p left hip replacement back in ___.
2. GERD
3. Retinal detachment s/p repair a few months ago
4. Hemorroids
Social History:
___
Family History:
Father-MI ~___.
Mother passed away from an MI at the age of ___.
GF had diabetes requiring amputation of distal leg.
Brother had an aortic dissection.
Physical Exam:
Initial Physical Exam:
VS: T: 99.8 HR: 67 BP: 139/76 RR: 16 O2: 100%
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: soft, NTND, NABS
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, able to
follow simple and multi-step commands. Speech is fluent with
normal comprehension and repetition; naming intact. No
dysarthria. Reading intact. No right-left confusion. No
evidence
of apraxia or neglect.
Cranial Nerves: +anisocoria: +surgical pupil on right side
(3mm),
reactive on left (2->1mm). Visual fields are full to
confrontation. Extraocular movements intact bilaterally without
nystagmus. Sensation intact V1-V3. +mild L NL fold flattening,
but facial movement symmetric with activation. Palate elevation
symmetric. Sternocleidomastoid and trapezius full strength
bilaterally. Tongue midline, movements intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. No pronator drift. **left ___ somewhat
limited by pain
Del Tri Bi WE FE FF IP H Q DF PF TE
R ___ ___ ___ ___
L ___ ___ ___ ___
Sensation: Intact to light touch, pinprick, vibration, position
sense, and cold sensation throughout. No extinction to DSS.
Reflexes: 2+ and symmetric throughout. Toes downgoing
bilaterally.
Coordination: finger-nose-finger and RAM normal.
Gait: Narrow based, but antalgic.
Discharge Physical Exam:
Essentially unchanged from admission. Alert, oriented, nl mental
status. No motor, sensory, coordination changes. Gait is
antalgic due to hip pain.
Pertinent Results:
Admission Labs:
___ 04:02PM GLUCOSE-118* NA+-138 K+-4.0 CL--101 TCO2-26
___ 03:59PM WBC-12.6* RBC-3.26* HGB-10.4* HCT-31.2*
MCV-96 MCH-32.0 MCHC-33.5 RDW-14.2
___ 03:59PM PLT COUNT-316
___ 03:59PM ___ PTT-24.6 ___
___ 04:00PM CREAT-1.1
___ 03:59PM UREA N-38*
Other Pertinent Labs:
___ 04:25AM BLOOD Triglyc-92 HDL-56 CHOL/HD-2.7 LDLcalc-76
___ 04:25AM BLOOD ESR-87*
___ 04:25AM BLOOD CRP-0.6
___ 04:25AM BLOOD CK-MB-7 cTropnT-0
___ 04:25AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0 Cholest-150
Pertient Radiology Studies:
___ CT HEAD W/O CONTRAST
There is no acute intracranial hemorrhage, edema, masses, mass
effect, or
acute territorial infarction. The ventricles and sulci are
prominent,
compatible with age-appropriate atrophy. A hypodensity in the
left cerebellum is similar to the CT of the C-spine from
___, likely representing a chronic infarct. Stable
subcortical chronic infarct in the left parietal lobe (series 2,
image 23) is redemonstrated.
BONES: There are no suspicious lytic or sclerotic bony lesions.
There is
minimal mucosal thickening of the maxillary sinuses. Remaining
paranasal
sinuses and mastoid air cells are clear.
IMPRESSION:
1. No acute process in the head.
2. Stable subcortical chronic infarct in the left parietal lobe
and in the
left cerebellum.
___ CHEST (PA & LAT)
FINDINGS: In comparison with the study of ___, there is again
biapical
thickening and adjacent pulmonary parenchymal scarring with
tortuosity of the aorta. Mild elevation of the right
hemidiaphragm is again seen.
No evidence of pulmonary vascular congestion or acute focal
pneumonia.
___ ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The abdominal aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
findings are similar. Trace aortic regurgitation is now
detected.
ECG:
Baseline artifact. Sinus bradycardia. Short P-R interval. Since
the previous tracing of ___ there is possibly no significant
change but there is considerable artifact on both tracings.
Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
59 ___ -31 38 50
Medications on Admission:
Tylenol and Tums prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Dizziness
Old cerebral infarcts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: Right pupil is surgical 3mm; left pupil is reactive,
2-->1 with light. Left facial droop; Left IP strength ___
(chronic, prior hip replacement). Gait has slightly wide stance,
limping left leg but relatively steady with cane.
Followup Instructions:
___
Radiology Report
INDICATION: ___ yo with TIA symptoms.
TECHNIQUE:
Axial images of the head were obtained. Coronal and sagittal reformats were
acquired.
COMPARISON: CT of the head from ___.
FINDINGS:
CT OF THE HEAD:
There is no acute intracranial hemorrhage, edema, masses, mass effect, or
acute territorial infarction. The ventricles and sulci are prominent,
compatible with age-appropriate atrophy.
A hypodensity in the left cerebellum is similar to the CT of the C-spine from
___, likely representing a chronic infarct.
Stable subcortical chronic infarct in the left parietal lobe (series 2, image
23) is redemonstrated.
BONES: There are no suspicious lytic or sclerotic bony lesions. There is
minimal mucosal thickening of the maxillary sinuses. Remaining paranasal
sinuses and mastoid air cells are clear.
IMPRESSION:
1. No acute process in the head.
2. Stable subcortical chronic infarct in the left parietal lobe and in the
left cerebellum.
Radiology Report
HISTORY: Leukocytosis and dizziness.
FINDINGS: In comparison with the study of ___, there is again biapical
thickening and adjacent pulmonary parenchymal scarring with tortuosity of the
aorta. Mild elevation of the right hemidiaphragm is again seen.
No evidence of pulmonary vascular congestion or acute focal pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DIZZY
Diagnosed with TRANS CEREB ISCHEMIA NOS, JOINT REPLACEMENT-HIP
temperature: 99.8
heartrate: 67.0
resprate: 16.0
o2sat: 100.0
sbp: 139.0
dbp: 76.0
level of pain: 0
level of acuity: 1.0 | The cause of Mr. ___ transient lip numbness and
lightheadedness was unclear. We doubted a TIA or vascular event.
His head CT in the ED showed old infarcts, and he was slightly
dehydrated. Therefore, we admitted him for observation,
hydration, and to investigate the cause(s) of his prior
infarcts. He was started on 325 ASA and stroke risk factors were
assessed: his lipids were total cholesterol 150, LDL 76, HDL 56,
HbA1C 5.9%. Repeat exam the following morning was nonfocal and
stable. He had a TTE, which was unrevealing. Telemetry showed no
evidence of atrial fibrillation. We planned to obtain a MRI/MRA
head without contrast and MRA neck with contrast during his
admission. Mr. ___ initially refused to undergo the MRI,
unless his brother was present. We attempted to obtain it the
following day, but this could not be done due to scheduling
conflicts. Therefore, we elected to obtain his MRI as an
outpatient within 1 week of discharge.
Mr. ___ was in good condition upon discharge, with clear
understanding of the reasons and need for undergoing MRI. He
will follow up in the stroke clinic with Dr. ___, his
Neurologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Protonix / iv contrast / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Hallucinations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ female with history of dCHF,
T2DM, HTN, and Stage V CKD who presents with reports of visual
hallucinations.
Per patient's ___, he reports visual and auditory
hallucinations for about 1 month. It is unclear how long this
has been going on as ___ has only been here for a week. The
patient has been seeing male images and children running around.
Her ___ has been visiting from ___ for the last week, but
his sister noticed this for the last two weeks. She other
appears well per her family. Her ___ is concerned about her
safety living alone. He is interested in long term care options
at this time.
The patient reports that she currently feels well. She reports
that she does sometimes see children on the wall but this does
not bother her. She does note a headache yesterday and the day
before, but none today. She denies fever/chills, shortness of
breath, chest pain, cough, abdominal pain, and dysuria.
In the ED, initial vital signs were: 99.5 70 164/70 16 94% RA.
Labs were notable for WBC 3.4, H/H 8.6/27.0, plt 189, Na 140, K
4.7, BUN/Cr 64/6.8, INR 1.0, ammonia 11, BNP 10212, and UA
bland. Imaging with CXR with mild pulmonary vascular congestion
with small bilateral pleural effusions and Head CT with no acute
intracranial process. The patient was given nothing. Orthostatic
vital signs positive for >20mmHg drop in blood pressure standing
(177->153). Vitals prior to transfer were: 73 182/69 18 95% RA.
Upon arrival to the floor, patient is feeling well and has no
complaints.
Past Medical History:
- Stage V Chronic Kidney Disease
- Diastolic Congestive Heart Failure
- Type II Diabetes
- Hypertension
- Orthostasis
- Ductal Carcinoma in Situ s/p incision in ___
- Anemia
- Sickle Cell Trait
- Gallstone Pancreatitis s/p cholecystectomy
Social History:
___
Family History:
Father had history of DM, HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Temp 97.8, BP 144/65, HR 79, RR 18, O2 sat 92% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: Normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP less than 10.
CARDIAC: RRR, systolic murmur at ___.
PULMONARY: Coarse breath sounds bilaterally.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, bilateral pedal edema.
Maturing fistula on left arm.
NEUROLOGIC - A&Ox2 ___, ___, CN
II-XII grossly normal, gross strength and sensation intact,
knows president, can state days of week forward but not
backwards, unable to do simple arithmetic.
DISCHARGE PHYSICAL EXAM:
VITALS: 98.6 71 ___ 18 95% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: Normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP less than 10.
CARDIAC: RRR, systolic murmur at ___.
PULMONARY: Coarse breath sounds bilaterally.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, bilateral pedal edema.
Maturing fistula on left arm.
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, gross strength and
sensation intact, knows president, can state days of week
forward but not backwards, unable to do simple arithmetic.
Pertinent Results:
ADMISSION LABS:
=================
___ 11:18AM BLOOD WBC-3.4* RBC-2.96* Hgb-8.6* Hct-27.0*
MCV-91 MCH-29.1 MCHC-31.9* RDW-14.8 RDWSD-48.9* Plt ___
___ 11:18AM BLOOD Neuts-57.4 ___ Monos-11.3 Eos-3.6
Baso-0.9 Im ___ AbsNeut-1.93 AbsLymp-0.89* AbsMono-0.38
AbsEos-0.12 AbsBaso-0.03
___ 11:18AM BLOOD Glucose-114* UreaN-64* Creat-6.8* Na-140
K-4.7 Cl-106 HCO3-21* AnGap-18
___ 11:18AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.1
___ 11:18AM BLOOD TSH-1.7
___ 11:18AM BLOOD Ammonia-11
___ 07:45AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.1
DISCHARGE LABS:
=================
___ 07:45AM BLOOD Glucose-101* UreaN-60* Creat-6.7* Na-141
K-4.3 Cl-107 HCO3-23 AnGap-15
___ 07:45AM BLOOD WBC-3.6* RBC-2.85* Hgb-8.4* Hct-25.9*
MCV-91 MCH-29.5 MCHC-32.4 RDW-14.5 RDWSD-48.6* Plt ___
PERTINENT FINDINGS:
====================
MICRO:
-------
Time Taken Not Noted Log-In Date/Time: ___ 6:42 am
SEROLOGY/BLOOD ADDED TO SPEC ___ ___.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
Imaging:
--------
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. Prominence of ventricles and
sulci are compatible with age related global atrophy.
Ill-defined periventricular and subcortical white matter
hypodensities are nonspecific but likely due to a sequela of
chronic small vessel ischemic changes. There is stable
appearance of the known aneurysm clip in the right supraclinoid
region. The imaged paranasal sinuses are clear. Mastoid air
cells and middle ear cavities are well aerated. Prior right
temporal craniotomy is re-demonstrated.
IMPRESSION:
No acute intracranial process.
CXR ___:
FINDINGS:
The heart is severely enlarged. There is mild pulmonary
vascular congestion and small bilateral pleural effusions.
Mediastinal silhouette is unchanged.
No focal consolidation is identified. No pneumothorax.
IMPRESSION:
Mild pulmonary vascular congestion with small bilateral pleural
effusions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Omeprazole 40 mg PO BID
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. Sodium Bicarbonate 1300 mg PO BID
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. Vitamin D ___ UNIT PO 1X/WEEK (MO)
10. Labetalol 200 mg PO TID
11. Amlodipine 10 mg PO HS
12. Torsemide 20 mg PO EVERY OTHER DAY
13. Acetaminophen 1000 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO HS
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Labetalol 200 mg PO TID
7. Omeprazole 40 mg PO BID
8. sevelamer CARBONATE 1600 mg PO TID W/MEALS
9. Sodium Bicarbonate 1300 mg PO BID
10. Torsemide 20 mg PO EVERY OTHER DAY
RX *torsemide 20 mg 1 tablet(s) by mouth every other day Disp
#*30 Tablet Refills:*0
11. Vitamin D ___ UNIT PO 1X/WEEK (MO)
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary:
- Hallucinations, likely ___ Dementia NOS
Secondary:
- Diastolic Congestive Heart Failure
- Hypertension
- CKD Stage V
- Anemia
- GERD
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 hallucinations/delirium // acute process
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm. mGy-cm
COMPARISON: CTA Head from ___
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Prominence of ventricles and sulci are compatible with age
related global atrophy. Ill-defined periventricular and subcortical white
matter hypodensities are nonspecific but likely due to a sequela of chronic
small vessel ischemic changes. There is stable appearance of the known
aneurysm clip in the right supraclinoid region. The imaged paranasal sinuses
are clear. Mastoid air cells and middle ear cavities are well aerated. Prior
right temporal craniotomy is re-demonstrated.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with cough // acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest radiographs from ___,
___
FINDINGS:
The heart is severely enlarged. There is mild pulmonary vascular congestion
and small bilateral pleural effusions. Mediastinal silhouette is unchanged.
No focal consolidation is identified. No pneumothorax.
IMPRESSION:
Mild pulmonary vascular congestion with small bilateral pleural effusions.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hallucinations
Diagnosed with Altered mental status, unspecified
temperature: 99.5
heartrate: 70.0
resprate: 16.0
o2sat: 94.0
sbp: 164.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ female with history of dCHF,
T2DM, HTN, and Stage V CKD who presented with reports of visual
hallucinations.
# Hallucinations: The patient as brought in by family after
admitting to seeing
seeing small children "playing and dancing around on the wall
and on my floor" The patient denied having hallucinations this
admission and notes that they did not interfere with her daily
activities. Per family, patient with visual and auditory
hallucinations for at least the past month. During interview
with psychology, the patient was found to have suggestive of
major neurocognitve
decline/dementia, however exact etiology unclear, exam
suggestive perhaps of combination of AD and vascular pathology.
No obvious infectious cause (CXR, cultures negative, no
leukocytosis, fevers, or changes in vitals, RPR negative).
Electrolytes and TSH normal, no physical exam signs were
consistent with uremia, and Nephrology did not believe it was
related to her renal failure. Toxicology screen was negative and
there were no recent medication changes. While the etiology
remains unclear, thought most likely secondary to dementia. The
patient was evaluated by ___ and OT and cleared for return to
home with ongoing services. The family indicated they would be
able to provide 24 hour supervision and patient was discharged
home with plans for close follow up with her PCP, ___.
# Diastolic Congestive Heart Failure: Patient was noted to be
euvolemic on exam and satting well on RA. However, CXR showed
pulmonary vascular congestion, so she was given 80 IV lasix,
with moderate urine output. She was then restarted on her home
torsemide.
# Hypertension: Patient was normotensive with mild hypertension
on the floor, likely due to volume status during hospital stay.
She was continued on home labetalol and amlodipine.
# Stage V Chronic Kidney Disease: Cr 6.8 on admission with
baseline Cr from 6.2-7. Her electrolytes were stable and no
signs of severe volume overload. No indication for hemodialysis,
though has L AVF fistula, apparently mature. She was continued
on home sevalamer, sodium bicarbonate, and calcitriol. She is
scheduled for follow up with her Nephrologist, Dr. ___. Cr.
60/6.7, K+ 4.3, Phos 4.8
# Anemia: At baseline. Likely secondary to renal insufficiency
and sickle trait. Patient on aransep as an outpatient.
# GERD: Stable, continued home omeprazole |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ___
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
-percutaneous jejunostomy tube placement by ___ on ___
History of Present Illness:
Mr. ___ is a very pleasant ___ year old gentleman with a
history of PE on Coumadin, dysphagia/dysphonia followed by ENT
who presents with progressively worsening dysphagia and
inability to take PO.
He states that his symptoms have been progressively worsening
over the past week. He has recently completed a course of
doxycycline for pneumonia. For the past few days he has been
unable to tolerate eating or drinking due to aspiration. Patient
states that "after I eat or drink its hard to clear my throat
and then I cough." Cough is productive, clear sputum. Of note,
he has lost approximately 8 pounds over the past week due to
inability to keep PO intake down. He denies odynophagia and has
been able to tolerate pills without difficulty.
In the ED, initial vitals were: 97.8 HR 92 122/85 16 97% RA
Labs were notable for WBC 9.9, Hgb 11.7 Plt 305. Chemistry with
Cr 1.3 (baseline 0.9-1.0).
Imaging was notable for: CXR with retrocardiac opacity is
potentially atelectasis though infection or aspiration would be
possible.
He received 500cc NS. On call physician for Dr. ___ was
reached by ED who agreed with plan for admission.
On the floor, he appears comfortable though coughs and clears
his throat throughout the interview and exam. He states that his
voice has been more hoarse in recent days.
He denies headache, vision changes, chest pain, dyspnea,
abdominal pain, nausea, vomiting, diarrhea, constipation,
melena/hematochezia, myalgias, arthralgias.
Past Medical History:
- Esophageal adenocarcinoma s/p esophageal resection and
chemoradiation
- Supraglottic soft tissue mass (sp bx ___ and ___
and resection ___
- Paroxysmal atrial fibrillation on warfarin
- Renal cell carinoma s/p right partial nephrectomy
- PUD (sp UGIB at BIN)
- GERD
- Thrush
- Anemia
- Thyroid nodules - multinodular w sick euthyroid
- Osteopenia
- H/o pulmonary embolism
- H/o babesiosis in ___
- sessile colonic polyp noted on CS in ___
- ___ esophagus vs. squamous papilloma
- Remote suspected tick-borne illness without serology approved
for possible Babesia at ___ complicated by
atrial fibrillation which resolved with treatment in ___
- Duodenitis
- AR/MR
Social History:
___
Family History:
Mother had pancreatic cancer
Father had stomach cancer
Physical Exam:
ADMISSION EXAM:
Vital Signs: 98.2 88 16 95 RA
General: Alert, oriented, no acute distress, clears throat
throughout interview and exam
HEENT: Sclerae anicteric, dry mucous membranes, oropharynx
clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD, uvula
deviates to left
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert and oriented x3, moving about the room without
difficulty
DISCHARGE EXAM:
VS: 98.0
PO 104 / 56
R Lying 62 16 95 RA
Gen: comfortably sitting in bed, no respiratory distress,
clearing his throat frequently
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, clear OP, MMM,
tongue & palate midline
Neck: +Goiter, no bruit or stridor, no LAD
Cardiac: Irregularly irregular, no r/g/m
Chest: CTAB
Abd: Soft NT ND +BS, newly placed J tube in L abdomen c/d/i
Ext: WWP, no edema, L great toe is ever so slightly warmer than
R (although had his sock partially off of the R so hard to tell.
no redness or swelling seen.
Neuro: AAOx3, moving all four extremities
Psych: Normal affect
Pertinent Results:
ADMISSION LABS:
___ 06:00PM BLOOD WBC-9.9 RBC-3.88* Hgb-11.7* Hct-37.3*
MCV-96 MCH-30.2 MCHC-31.4* RDW-13.2 RDWSD-46.8* Plt ___
___ 06:00PM BLOOD Neuts-73* Bands-3 Lymphs-13* Monos-9
Eos-2 Baso-0 ___ Myelos-0 AbsNeut-7.52* AbsLymp-1.29
AbsMono-0.89* AbsEos-0.20 AbsBaso-0.00*
___ 06:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Acantho-OCCASIONAL
___ 06:00PM BLOOD Glucose-129* UreaN-36* Creat-1.3* Na-142
K-4.5 Cl-104 HCO3-20* AnGap-23*
IMAGING & STUDIES:
___ CT Neck:
IMPRESSION:
No definite tracheoesophageal fistula identified, however cannot
be excluded on the basis of this examination. Direct
visualization is again recommended.
Secretions are noted within the vallecula and hypopharynx.
Correlation for aspiration is recommended.
___ Video S&S:
SUMMARY:
Today's assessment was most notable for leak at approximately
the
level of the PES which nectar thick liquid barium was noted to
then spill into the trachea. This is likely cause of current
pneumonia and patient report of notable coughing with liquids.
___ CXR
Retrocardiac opacity is potentially atelectasis though infection
or aspiration would be possible.
___
PROCEDURE: Flexible videostroboscopy.
INDICATIONS: Dysphonia that would not clearly be evaluated by
indirect laryngoscopy.
PREOPERATIVE DIAGNOSIS: Dysphonia.
POSTOPERATIVE DIAGNOSES: Bilateral vocal fold hypomobility,
bilateral vocal fold scar, primary muscle tension dysphonia,
dysphagia with cricopharyngeal dysfunction, Zenker's
diverticulum.
FINDINGS:
1. Supraglottic hyperfunction: Moderate false vocal fold
compression.
2. Right vocal fold movement: Abduction, adduction,
longitudinal tension decreased.
3. Left vocal fold movement: Abduction, adduction,
longitudinal
tension decreased.
4. Arytenoid joint movement: Could not assess.
5. True vocal fold characteristics: Bilateral scar.
6. Masses or vibratory margin irregularities: Absent.
7. Other structural lesions: Pooled secretions.
8. Glottic Closure: Complete.
9. Vocal process height: Uneven, high on the left.
10. Vibration: Phase: Asymmetric mild.
11. Periodicity: Irregular.
12. Amplitude: Decreased left and right.
13. Waveform: Right and left decreased moderate.
___ EGD
Previous esophago-gastric anastomosis of the esophagus
At 20 cm just below the upper esophageal sphincter there was a
1.5 cm nodule and below the nodule there was an area likely
where biopsy was done with an adherent clot and no visible
bleeding. Otherwise normal EGD to third part of the duodenum
=========================================================
MRI SOFT TISSUE NECK, W/O AND W/CONTRAST T925 MR NECK ___
1. Homogeneous enhancement of the posterior supraglottic
laryngeal soft tissue which is favored to represent
posttreatment
changes given the homogeneous nature of enhancement, however
recurrent disease cannot be excluded. Short-term follow-up MRI
is recommended for further evaluation. Comparison with prior
studies would also be helpful. 2. Thyroid nodule as seen on the
prior CT.
Flexible and rigid esophagoscopy and microlaryngoscopy
___
Findings: Macule type area just underneath the cricopharyngeus
that was consistent with the
previous location and morphology of the lesion. This did not
appear suspicious, the previous white fleshy coloration had
resolved. A small Zenker diverticulum was found posteriorly and
there was a small outpouching anteriorly (biopsy) with food
contents. a balloon was used to dilate from 10-15 mm without
undue resistance.
Pathology:
1. "Diverticulum, contents": Fragments of food matter and
fibrinopurulent exudate.
2. Diverticulum mucosa, excision: Squamous mucosa with focal
acute esophagitis, detached fragments of fibrinopurulent exudate
and food matter.
3. Anterior esophageal mass, excision: Squamous mucosa with
focal
acute esophagitis. Unremarkable submucosa.
4. Crico-pharyngeus mass, excision: Squamous mucosa with
hyperplasia and focal acute esophagitis. Fragments of
fibrinopurulent exudate.
Note: No malignancy identified. Multiple levels are examined.
EGD ___
Impression: Previous esophago-gastric of the esophagus. At 20 cm
just below the upper esophageal sphincter there was a 1.5 cm
nodule and below the nodule there was an area likely where
biopsy
was done with an adherent clot and no visible bleeding. I
decided
not to remove the clot. Otherwise normal EGD to third part of
the
duodenum (No biopsy). No pathology report available.
Oropharyngeal swallowing videofluoroscopy ___
Impression: Penetration aspiration of thin liquid and nectar
thick liquid.
CXR ___
Impression: Compared to chest radiographs since ___, most
recently ___. Hyperinflation indicates emphysema.
Patient has had esophagectomy and gastric pull-up. Moderate
amount of retained barium indicates right lower lobe aspiration.
There may be a small region of new consolidation but the lungs
are clear elsewhere.
Oropharyngeal swallowing videofluoroscopy ___
Impression: Tracheoesophageal fistula at the level of the
cricopharyngeus muscle / cricoid cartilage. Given history of
esophagectomy, this may represent anastomotic dehiscence. Direct
visualization with endoscopy is recommended.
CT neck ___
Impression:
No definite tracheoesophageal fistula identified, however cannot
be excluded on the basis of this examination. Direct
visualization is again recommended. Secretions are noted within
the vallecula and hypopharynx. Correlation for aspiration is
recommended.
Bronchoscopy ___
Tracheo esophageal fistula just below vocal cords on the
posterior trachea (almost 1 cm from vocal cords)
========================================================
J Tube Placement by ___ ___:
PROCEDURE: 1. Placement of a 12 ___ Wills ___ jejunostomy
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. Utilizing real-time
ultrasound
guidance, a 21 gauge x 15 cm percutaneous needle was advanced
into a fluid
filled loop of bowel which had been tacked up at the previous
access site.
Intraluminal positioning was confirmed with aspiration of air
and injection of
contrast. Next, a Nitinol micro wire was advanced into the lumen
of the small
bowel loop. The percutaneous needle was then removed and
exchanged for the
inner portion of a Accustick set.
Next, the Nitinol micro wire and inner dilator were removed and
a 0.035
glidewire was introduced into the bowel. Subsequently the micro
sheath was
removed and exchanged for a 5 ___ MPA catheter. The Glidewire
was then
removed and exchanged for an Amplatz wire.
Next, serial dilatations from 6 ___, 8 ___, 10 ___ and
12 ___ were
then performed. Finally, under fluoroscopic guidance, a 12
___ Wills
___ jejunostomy tube is was advanced into the jejunum loops
over the wire.
The Amplatz wire was removed and injection of contrast confirmed
intraluminal
positioning. The catheter was secured by forming the retaining
loop in the
small bowel loop after confirming the positioning of the
catheter with a
contrast injection. The catheter was then flushed, capped and
secured to the
skin with 0-silk sutures. Sterile dressings were applied.
The patient tolerated the procedure well and there were no
immediate
complications.
FINDINGS:
1. Successful placement of a ___ F Wils Ogelsby jejunostomy tube
IMPRESSION:
Successful placement of a ___ F Wils ___ jejunostomy tube.
The catheter
should not be used for 24 hours for enteral feeding.
============================================================
MRI Neck ___:
IMPRESSION:
1. Subtle defect of the posterior left paramedian trachea,
roughly 1 cm
inferior to the glottis, corresponding to a defect to better
seen on the prior
CT examination, which corresponds to the tracheoesophageal
fistula on barium
swallow examination.
2. Partial visualization of changes from esophagectomy and
gastric pull-up.
3. 11 mm left thyroid lobe nodule. The ___ College of
Radiology
guidelines suggest that in the absence of risk factors for
thyroid cancer, no
further evaluation is recommended.
4. No neck mass identified.
=
================================================================
Discharge Labs:
___ 10:20PM BLOOD WBC-8.9 RBC-3.33* Hgb-10.1* Hct-31.5*
MCV-95 MCH-30.3 MCHC-32.1 RDW-12.9 RDWSD-44.5 Plt ___
___ 06:30AM BLOOD WBC-7.1 RBC-3.03* Hgb-9.2* Hct-28.6*
MCV-94 MCH-30.4 MCHC-32.2 RDW-13.1 RDWSD-45.1 Plt ___
___ 07:05AM BLOOD WBC-9.0 RBC-3.10* Hgb-9.3* Hct-29.2*
MCV-94 MCH-30.0 MCHC-31.8* RDW-13.1 RDWSD-44.6 Plt ___
___ 10:20PM BLOOD ___
___ 07:10AM BLOOD Glucose-168* UreaN-20 Creat-0.9 Na-134
K-4.2 Cl-98 HCO3-27 AnGap-13
___ 10:20PM BLOOD Glucose-156* UreaN-16 Creat-1.0 Na-136
K-4.5 Cl-99 HCO3-28 AnGap-14
___ 06:30AM BLOOD Glucose-122* UreaN-15 Creat-0.9 Na-136
K-3.7 Cl-102 HCO3-27 AnGap-11
___ 07:10AM BLOOD Calcium-7.7* Phos-3.2 Mg-2.8*
___ 10:20PM BLOOD Calcium-8.0* Phos-2.6* Mg-1.7
___ 06:30AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methimazole 2.5 mg PO EVERY OTHER DAY
2. Warfarin 5 mg PO 3X/WEEK (___)
3. Ferrous GLUCONATE 324 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
6. calcium citrate-vitamin D3 315-250 mg-unit oral daily
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 2.5 mg PO 4X/WEEK (___)
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg one half tablet(s) by mouth two
times a day Disp #*30 Tablet Refills:*0
2. Neutra-Phos 1 PKT PO DAILY
RX *potassium, sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg
1 powder(s) per J tube daily Disp #*14 Packet Refills:*0
3. Warfarin 2 mg PO DAILY16
4. Ascorbic Acid ___ mg PO DAILY
5. calcium citrate-vitamin D3 315-250 mg-unit oral daily
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Methimazole 2.5 mg PO EVERY OTHER DAY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11.suction machine
One suction machine and supplies
12.Tube Feeding Order
Tubefeeding: Jevity 1.5 Full strength (or equivalent);
Starting rate: 20 ml/hr; Advance rate by 10 ml q4h Goal rate:
55 ml/hr
Flush w/ 150 ml water q4h (can space out to q8h)
Other instructions: cycle goal 95mL/h over 14h
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Tracheoesophageal Fistula. Hx Cricopharyngeal Mass (Benign
Biopsies in the Past) with Hx Cricopharyngeal
Dysfunction/Zenker's Diverticulum. Hx Bilateral Vocal Fold
Hypomobility and Scar. Hx Lower Esophageal Ca s/p chemoXRT. Hx
Atrial Fibrillation.
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 worsening dysphagia/dysphonia, history
multiple chronic pharyngeal issues and Zenker's diverticulum. // pls eval
swallow function
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 12 seconds
COMPARISON: Oropharyngeal video swallow from ___
Esophogram from ___.
CT Neck from ___.
FINDINGS:
On limited views, bolus initiation and epiglottic closure are normal without
penetration or passage of barium into the trachea under the epiglottis.
At the level of the cricopharyngeus muscle, a communication between the
esophagus and trachea results and barium passing into the airway. Given
history of esophagectomy with unclear level of anastomosis (at the level of
the azygous vein per operative report, but suture material visualized to the
level of the cricoid cartilage on CT neck from ___ this could be at the
level of the anastomosis.
IMPRESSION:
Tracheoesophageal fistula at the level of the cricopharyngeus muscle / cricoid
cartilage. Given history of esophagectomy, this may represent anastomotic
dehiscence. Direct visualization with endoscopy is recommended.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
RECOMMENDATION(S): Direct visualization with endoscopy is recommended.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 15:48 ___, 5 minutes after
discovery of the findings.
The updated findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 4:57 ___, 5 minutes after discovery of
the updated findings.
Radiology Report
EXAMINATION: CT NECK W/O CONTRAST (EG: PAROTIDS)
INDICATION: ___ year old man with concern for trachea-esophageal fistula on
video swallow // rule out fistula
TECHNIQUE: MDCT acquired helical axial images were obtained from the thoracic
inlet through the skull base without IV contrast.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Total DLP (Body) = 221 mGy-cm.
COMPARISON: Barium swallow on ___, CT neck on ___,
MR neck on ___, thyroid ultrasound on ___
FINDINGS:
Patient is status post esophagectomy and gastric pull-through, with stable
appearance of the partially visualized proximal neo esophagus. There is no
definite tracheoesophageal fistula identified. A small amount of
secretions/debris is present in the esophagus. Initially secretions are noted
layering within the vallecular on and hypopharynx (series 7 images 39-44).
Previously seen isodense area posterior to the supraglottic larynx is less
prominent compared with CT neck ___, and likely represented
postsurgical change.
The salivary glands enhance normally and are without mass or adjacent fat
stranding. A 1.4 cm hypodense thyroid nodule is stable, and was previously
evaluated by ultrasound. There is no lymphadenopathy by CT criteria.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. A small amount of debris is noted in the proximal left
mainstem bronchus (4:90). Multilevel degenerative changes are similar to
prior. There are no osseous lesions. Chronic appearing rim displaced right
posterior sixth rib fracture.
IMPRESSION:
No definite tracheoesophageal fistula identified, however cannot be excluded
on the basis of this examination. Direct visualization is again recommended.
Secretions are noted within the vallecula and hypopharynx. Correlation for
aspiration is recommended.
RECOMMENDATION(S): Recommend direct visualization.
Radiology Report
INDICATION: ___ year old man with hx of esophageal ca s/p ___ surgery
(___) now presenting with TE fistula // need for percutaneous feeding tube
access
COMPARISON: CT abdomen and pelvis ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
25 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 45 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: 5 cc 1% buffered lidocaine subcutaneous injection at the access
site
CONTRAST: 25 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 5.5 min, 14 mGy
PROCEDURE: 1. Placement of a 12 ___ Wills ___ jejunostomy 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. Utilizing real-time ultrasound
guidance, a 21 gauge x 15 cm percutaneous needle was advanced into a fluid
filled loop of bowel which had been tacked up at the previous access site.
Intraluminal positioning was confirmed with aspiration of air and injection of
contrast. Next, a Nitinol micro wire was advanced into the lumen of the small
bowel loop. The percutaneous needle was then removed and exchanged for the
inner portion of a Accustick set.
Next, the Nitinol micro wire and inner dilator were removed and a 0.035
glidewire was introduced into the bowel. Subsequently the micro sheath was
removed and exchanged for a 5 ___ MPA catheter. The Glidewire was then
removed and exchanged for an Amplatz wire.
Next, serial dilatations with 6 ___, 8 ___, 10 ___ and 12 ___ were
then performed. Finally, under fluoroscopic guidance, a 12 ___ Wills
___ jejunostomy tube is was advanced into the jejunum loops over the wire.
The Amplatz wire was removed and injection of contrast confirmed intraluminal
positioning. The catheter was secured by forming the retaining loop in the
small bowel loop after confirming the positioning of the catheter with a
contrast injection. The catheter was then flushed, capped and secured to the
skin with 0-silk sutures. Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful placement of a ___ F Wils Ogelsby jejunostomy tube
IMPRESSION:
Successful placement of a ___ F Wils Ogelsby jejunostomy tube. The catheter
should not be used for 24 hours for enteral feeding.
Radiology Report
EXAMINATION: MRI SOFT TISSUE NECK, W/O AND W/CONTRAST T925 MR NECK
INDICATION: History of esophageal adenocarcinoma post resection and radiation
with gastric pull-up as well as RCC post partial nephrectomy in remission
presenting with tracheoesophageal fistula described on prior barium swallow
and direct visualization 1 cm below the glottis.
TECHNIQUE: Sagittal and axial T1 weighted imaging was performed along with
axial fat-suppressed T2 weighted imaging. After administration of 8 mL of
Gadavist intravenous contrast, axial and coronal T1 weighted imaging were
performed with fat suppression.
COMPARISON: Video or pharyngeal swallow examination ___. CT neck
examinations from ___ and ___. MR soft tissue neck
___.
FINDINGS:
On prior CT examination from ___, there is a subtle, rounded
defect within the posterior airway, roughly 1 cm inferior to the glottis,
slightly to the left of midline (5:562 on the ___ examination),
corresponding to the level of tracheoesophageal communication seen on prior
barium swallow examination. A similar subtle abnormality is seen within the
subglottic airway on the axial T1 post sequences (08:19).
There is no exophytic mucosal mass. There is no lymphadenopathy by imaging
criteria. The principal cervical vascular flow voids are preserved. The
salivary glands are unremarkable without focal lesion. There is an 11 mm,
loculated cystic appearing left lobe thyroid nodule.
There is partial visualization of postsurgical changes from esophagectomy with
gastric pull-up.
IMPRESSION:
1. Subtle defect of the posterior left paramedian trachea, roughly 1 cm
inferior to the glottis, corresponding to a defect to better seen on the prior
CT examination, which corresponds to the tracheoesophageal fistula on barium
swallow examination.
2. Partial visualization of changes from esophagectomy and gastric pull-up.
3. 11 mm left thyroid lobe nodule. The ___ College of Radiology
guidelines suggest that in the absence of risk factors for thyroid cancer, no
further evaluation is recommended.
4. No neck mass identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Decreased PO intake
Diagnosed with Acute kidney failure, unspecified
temperature: 97.8
heartrate: 92.0
resprate: 16.0
o2sat: 97.0
sbp: 122.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | Summary: Mr. ___ is a ___ M with hx of pAF, PE on Coumadin,
hx esophageal Ca s/p chemoXRT and esophageal cancer s/p
esophagogastrectomy in ___ complicated by cricopharyngeal
dysfunction/Zenker's diverticulum, hx vocal fold hypomobility,
hx post-infectious muscle tension dysphonia, recent dx
pneumonia, admitted for progressive dysphonia & dysphagia, found
to have new trachea-esophageal fistula on video
speech-and-swallow ___. Thoracics was consulted who rec IP c/s
for direct visualization via bronch. Hospital course notable
for development of hypoglycemia on ___ in the setting of poor
PO intake for which he was started D5W w/hypoglycemia protocol.
His hospital course was complicated by rapid afib while walking
(for which he triggered rates 130s, asymptomatic) after his
metop had been held for two days (to minimize pills) which
resolved after resuming metoprolol. He underwent a bronch on
___ by IP which confirmed a TE fistula was present.
S/p ___ J tube placement on ___. Tube feeding began 24h later
on the evening of ___ but was to be held now in preparation
for MRI requested by ENT for planning purposes. He tolerated the
MRI well on ___ and tube feeds were resumed and cycled
overnight into ___, which he tolerated well. On further
discussions with ENT, it was decided that, given his nutritional
status, he would certainly not be having his surgery done this
hospitalization and thus will follow up with ENT surgery as
outpatient for surgical planning.
Interval Events/ROS: Feeling well this morning. No nausea or
vomting or ab pain after cycling tube feeds last night. His MRI
went well. He is excited to go home. He mentioned a "twinge" in
his L toe but was able to move it well and stand on his foot
this morning. I could find little e/o gout on my exam. He
thought he might have stubbed his toe on his bed last night
while he was sleeping.
Rest of hospital course/plan are outlined below by issue:
# Progressive Dysphagia/Dysphonia
# Known Cricopharyngeal Dysfunction/Zenker's Diverticulum
# New Dx Tracheo-esophageal Fistula
Patient thought to have multifactorial dysphonia/dysphagia for
the many chronic reasons listed above, but found to have new TEF
on video S&S exam ___. Seen by Thoracics, CT non-con did not
find definite TEF, so direct visualization recommended. s/p
bronch by IP on ___ which did confirm the TEF. On further
discussion with thoracics and based on the anatomical location
of the fistula, thoracics recommended ENT was more appropriate
for the surgery so thoracics has signed off.
-script for suction machine was written for the patient to have
at home
# ? Aspiration Pneumonia:
# Leukocytosis
Completed 5d Levaquin for retrocardiac opacity/bandemia on
admission, presumed PNA.
# Severe Malnutrition: albumin 2.8. Prealbumin 9. Prolonged
period inpatient without PO intake due to multiple procedures
and issues obtaining enteric access.
# H/O PE
# Atrial fibrillation
# Supratherapeutic INR:
- INR peaked at 10, s/p PO Vit K 2.5mg x3 on ___ & ___ &
___ with improvement of INR to 2.2 on ___ in prep for
bronch. INR was finally 1.4 on ___. Warfarin was resumed on
___ after no further procedures were planned. He was restarted
on 2mg daily (previous outpatient dose had been 2.5mg
alternating with 5mg but reduced due to supratherapeutic INR
recently). No anticoagulant bridge was used due to recent ___
procedure.
- was on metop 12.5 q6h but was briefly held to minimize pills
however developed rapid afib to 130s on ___ while walking
(asymptomatic) so metop 12.5 mg q6h was resumed. he was also
mildly hypomagnesemic at the time which was repleted.
# Grave's Disease:
- Continue home methimazole
# Osteopenia:
- Hold calcium and Vitamin D
# GERD:
- Converted to IV PPI to PO PPI
# Transitional Issues:
-new meds: metop 12.5 BID, daily phos-NaK (to continue while
starting tube feeding, can be d/c'd by PCP based on
electrolytes)
-IP bronch biopsies will need to be followed up as outpatient by
his oncologist
-outpatient onc follow up (___), thoracic surgery, ENT
follow up
-Will need BMP with magnesium and phosphorous levels daily for
at least the first two days of tube feeding, then twice weekly
thereafter, these labs are to be followed up by PCP ___.
___ at Phone: ___.
-He will also need INR monitoring for his Coumadin therapy and
Coumadin dose adjusted (he is currently subtherapeutic but not
on a anticoagulant bridge due to his recent ___ procedure). INR
monitoring to be followed by his PCP ___ as above.
First INR to be checked ideally within ___ after discharge.
# CONTACTS: health care proxy: ___
Relationship: Son
Phone number: ___
Cell phone: ___
-updated son ___ in person or over the phone daily while I was
taking care of the patient.
-I Called the ___ office and I spoke with Dr. ___
relayed the plan going forward and we discussed his hospital
course. I specifically informed him of the follow up
electrolytes and INR monitoring.
#Nutrition: tube feeds ___ tarted per nutrition recs: jevity
goal 55mL/h, Patient will remain NPO (except for pills in jello)
for tracheoesophageal fistula - will likely need tube feeds for
3 months, replete electrolytes including phos, ongoing
aspiration precautions,
Consults: Thoracics (signed off), General Surgery (Dr.
___, IP, Nutrition, ENT
Dispo: dc home with services today. Pt has been ambulating well
without assistance.
Spent > 30 minutes seeing the patient and organizing discharge.
_________________________________
___, MD
___
Pager ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
pcn
Attending: ___.
Chief Complaint:
Diarrhea, nausea, chest discomfort
Major Surgical or Invasive Procedure:
___ Placement
History of Present Illness:
___ female with stage IV endometrial cancer on
anastrazole, DM2, CAD, CKD, chronic respiratory failure with
hypoxemia on home oxygen, and morbid obesity presents from her
PCP's office with gastrointestinal illness and chest discomfort.
She was in her usual state of health until ___, when she
experienced the onset of fever, headache, diarrhea, heaving
(mostly dry), and malaise. She noted some chest discomfort
accompanying the dry heaves that felt "like someone punching
her" in the chest (not like the pressure she felt with her prior
MI). Her PCP was concerned about EKG changes, and sent her to
the hospital.
She has a history of cardiac disease, including an MI in ___.
At that time, she was cathed and found to have significant
disease but due to intolerance of the procedure no intervention
was carried out. She has been medically managed in the interim.
In the ED, initial vitals were T 99.4 HR 72 BP 102/45 RR 18 SpO2
98%2L. CT head w/o contrast was unremarkable. CXR showed mild
cardiomegaly with central vascular congestion. Labs were
remarkable for K of 3.0 for which she was given 40meq potassium.
Vitals prior to transfer were T 100.4 HR 66 BP 129/69 RR 18
SpO296%2L.
On the floor, vitals are stable and she feels better. She denies
heaves, chest pain, difficulty breathing, nausea, or abdominal
pain. She does endorse ongoing diarrhea.
Past Medical History:
Endometrial cancer: Diagnosed ___, Stage IV, s/p hysterectomy
and radiation, on anastrazole
DM2: Latest HbA1C 4.5 (___)
CAD: ___ ___, underwent cardiac catheterization
without intervention
Chronic respiratory failure: 2L home oxygen
CKD stage 3
HTN
hypothyroidism
thrombocytopenia
anemia
depression
Social History:
___
Family History:
Father died at ___ after ___ MIs
Mother died at ___, had CHF
Sister died of breast cancer
Physical Exam:
Admission:
VS: T 98.4 BP 105/52 HR 64 RR 20 SpO2 98%2L
General: Obese woman sleeping in hospital bed, easily arousable.
HEENT: NCAT, MMM, no teeth
Neck: Supple, no LAD, no JVD
CV: Distant heart sounds. Regular rate and rhythm, no M/R/G
appreciated.
Lungs: Clear to auscultation bilaterally.
Abdomen: Obese, soft, non-distended, non-tender. Bowel sounds
present.
GU: Deferred
Ext: Warm, 2+ distal pulses bilaterally, darkened skin around
ankles (?stasis dermatitis), no edema
Neuro: Alert, oriented, moving all extremities
Discharge:
VS: T 97.8 BP 104/52 HR (not recorded) RR 18 SpO2 94%RA
General: Obese woman in hospital bed, no distress.
HEENT: NCAT, mucous membranes moist
Neck: Supple, no LAD
CV: Regular rate and rhythm, distant heart sounds, no
appreciable murmurs/rubs/gallops
Lungs: Poor aeration throughout, otherwise clear to auscultation
Abdomen: Obese, soft, non-distended. Bowel sounds present.
Ext: Warm, 2+ distal pulses bilaterally, darkened skin around
ankles (?stasis dermatitis), 2+ pitting edema
Neuro: Alert, oriented, moving all extremities
Pertinent Results:
___ 01:50PM BLOOD WBC-6.8 RBC-3.51* Hgb-9.5* Hct-29.2*
MCV-83 MCH-27.1 MCHC-32.5 RDW-15.7* Plt Ct-62*
___ 08:25AM BLOOD WBC-5.2 RBC-3.67* Hgb-10.0* Hct-30.8*
MCV-84 MCH-27.2 MCHC-32.5 RDW-15.8* Plt Ct-59*
___ 07:15AM BLOOD WBC-3.7* RBC-3.13* Hgb-8.4* Hct-26.3*
MCV-84 MCH-26.9* MCHC-32.1 RDW-15.2 Plt Ct-46*
___ 01:30PM BLOOD WBC-3.4* RBC-3.12* Hgb-8.4* Hct-26.4*
MCV-85 MCH-27.0 MCHC-31.9 RDW-15.3 Plt Ct-51*
___ 05:40AM BLOOD WBC-3.0* RBC-3.23* Hgb-8.9* Hct-27.3*
MCV-84 MCH-27.6 MCHC-32.7 RDW-15.4 Plt Ct-53*
___ 05:36AM BLOOD WBC-1.9* RBC-3.08* Hgb-8.2* Hct-25.6*
MCV-83 MCH-26.6* MCHC-31.9 RDW-15.2 Plt Ct-54*
___ 07:15AM BLOOD WBC-1.5* RBC-2.89* Hgb-7.7* Hct-24.0*
MCV-83 MCH-26.6* MCHC-32.0 RDW-15.2 Plt Ct-71*
___ 03:40PM BLOOD WBC-2.2* RBC-3.07* Hgb-8.2* Hct-26.0*
MCV-85 MCH-26.8* MCHC-31.6 RDW-15.3 Plt Ct-88*
___ 07:00AM BLOOD WBC-1.5* RBC-2.79* Hgb-7.6* Hct-23.6*
MCV-85 MCH-27.4 MCHC-32.4 RDW-15.2 Plt Ct-81*
___ 01:20PM BLOOD WBC-1.9* RBC-3.24* Hgb-8.6* Hct-27.4*
MCV-85 MCH-26.6* MCHC-31.5 RDW-15.1 Plt Ct-93*
___ 06:35AM BLOOD WBC-1.9* RBC-2.88* Hgb-7.9* Hct-24.2*
MCV-84 MCH-27.5 MCHC-32.6 RDW-15.2 Plt Ct-90*
___ 01:50PM BLOOD Neuts-87.6* Lymphs-6.4* Monos-5.7 Eos-0.1
Baso-0.1
___ 05:36AM BLOOD Neuts-73.4* Lymphs-17.0* Monos-7.0
Eos-2.3 Baso-0.3
___ 07:15AM BLOOD Neuts-65 Bands-0 ___ Monos-5 Eos-5*
Baso-0 ___ Myelos-0
___ 06:35AM BLOOD Neuts-61.4 ___ Monos-12.3*
Eos-1.5 Baso-0.9
___ 01:50PM BLOOD Glucose-165* UreaN-19 Creat-1.0 Na-140
K-3.0* Cl-98 HCO3-33* AnGap-12
___ 05:40AM BLOOD Glucose-103* UreaN-23* Creat-1.1 Na-135
K-3.8 Cl-101 HCO3-30 AnGap-8
___ 06:35AM BLOOD Glucose-101* UreaN-16 Creat-0.7 Na-139
K-4.1 Cl-103 HCO3-31 AnGap-9
___ 01:50PM BLOOD CK(CPK)-26*
___ 08:35PM BLOOD ALT-23 AST-28 CK(CPK)-20* AlkPhos-158*
TotBili-1.8*
___ 05:36AM BLOOD CK(CPK)-11*
___ 07:00AM BLOOD ALT-24 AST-35 LD(LDH)-165 AlkPhos-288*
TotBili-0.3
___ 06:35AM BLOOD ALT-31 AST-48* AlkPhos-297* TotBili-0.3
___ 01:50PM BLOOD CK-MB-1 cTropnT-0.21*
___ 08:35PM BLOOD CK-MB-1 cTropnT-0.17*
___ 03:15AM BLOOD CK-MB-1 cTropnT-0.16*
___ 08:25AM BLOOD CK-MB-1 cTropnT-0.19*
___ 07:15AM BLOOD CK-MB-1 cTropnT-0.14*
___ 01:50PM BLOOD Calcium-8.0* Phos-1.2* Mg-1.3*
___ 05:40AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.0
___ 06:35AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.6
Imaging
___ CHEST (PA & LAT): IMPRESSION: Mild cardiomegaly with
central vascular congestion, but without frank edema.
___ CT HEAD W/O CONTRAST: IMPRESSION: No acute
intracranial process. Small hypodensity in the left centrum
semiovale may relate to small vessel ischemic change, however,
given assymetric with the right side, nonurgent brain MRI would
further evaluate.
___ Cardiovascular ECHO: Poor echo windows. The left
atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
___ RENAL U.S.: IMPRESSION: 1. No definite ultrasound
findings to suggest pyelonephritis, although this diagnosis
cannot be excluded sonographically. 2.1 cm hypoechoic lesion in
the
right upper renal pole, poorly visualized and indeterminate;
this could represent a cyst but in the current clinical setting,
focal infection or abscess cannot be excluded. Per the
patient's report, there has been a recent abdominal CT performed
at ___ comparison to this study is recommended. Of
note, if this study is uploaded into PACS, an addendum could be
issued at that time. If this study cannot be obtained, further
evaluation could be performed with CT. 3. Right lower pole 15
mm cyst or calyceal diverticulum. 4. Possible duplex right
kidney.
___ CT ABD & PELVIS WITH CO: IMPRESSION: 1. Large
rim-enhancing fluid collection along the lower abdominal
incision site, likely a seroma, is stable to slightly smaller
since ___.
Recommended clinical correlation to assess for possible
superinfection. 2. No intra-abdominal pathology identified to
explain the patient's symptoms. 3. Unexplained massive
splenomegaly.
4. Cholelithiasis.
___ CHEST PORT. LINE PLACEM: IMPRESSION: 1. Right PICC at
the cavoatrial junction. 2. Stable cardiomegaly.
MICROBIOLOGY
___ 3:15 am BLOOD CULTURE RIGHT ARM.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
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-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. anastrozole *NF* 1 mg Oral daily
3. Omeprazole 40 mg PO DAILY
4. Fluoxetine 40 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO BID
9. Aspirin 81 mg PO DAILY
10. TraZODone 25 mg PO HS
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
13. Naproxen 220 mg PO Q8H:PRN pain
14. Humulin N 15 Units Breakfast
Humulin N 15 Units Bedtime
Discharge Medications:
1. anastrozole *NF* 1 mg Oral daily
2. Aspirin 81 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Humulin N 15 Units Breakfast
Humulin N 15 Units Bedtime
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO BID
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Omeprazole 40 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Simvastatin 20 mg PO DAILY
13. TraZODone 25 mg PO HS
14. Naproxen 220 mg PO Q8H:PRN pain
15. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 g IV once daily Disp #*7 Syringe
Refills:*0
16. Outpatient Lab Work
Please check CBC with differential on ___ and fax results to
PCP ___ MD Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Diarrhea
2. Urinary tract infection
3. GNR bacteremia
4. Pancytopenia
5. Demand ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Headache and vomiting.
COMPARISON: None available.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformation images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 1025.72 mGy-cm.
FINDINGS: There is no hemorrhage, edema, mass effect or acute vascular
territorial infarct. There is a small hypodensity in the left centrum
semiovale. Mild prominence of the ventricles and sulci suggestive of
age-related involutional change. Minimal periventricular white matter
hypodensity is compatible with chronic small vessel ischemic disease. The
basal cisterns are patent and there is preservation of the gray-white matter
differentiation. Dense atherosclerotic vascular calcifications are noted
within the vertebral arteries and carotid siphons. The visualized paranasal
sinuses and middle ear cavities are clear. Bilateral mastoids are under
pneumatized. The globes are intact.
IMPRESSION: No acute intracranial process. Small hypodensity in the left
centrum semiovale may relate to small vessel ischemic change, however, given
assymetric with the right side, nonurgent brain MRI would further evaluate.
Findings discussed with Dr. ___ at 11:30AM on ___ via
telephone.
Radiology Report
HISTORY: Gram negative bacteremia and positive urinalysis. Assess
pyelonephritis.
COMPARISON: None at this institution.
FINDINGS:
The study is slightly limited due to suboptimal acoustic penetration. The
kidneys are normal in size, with the right kidney measuring 12.4 cm and the
left kidney measuring 11.8 cm. A band of renal parenchyma is seen extending
across the right interpolar region, suggestive of a duplicated collecting
system. Within the right lower renal pole, there is a 10 x 15 x 8 mm cyst or
calyceal diverticulum. Within the right upper pole, there is a 2.1 x 1.7 x
2.3 cm hypoechoic structure, incompletely evaluated on the present study.
There is no hydronephrosis or evidence of nephrolithiasis. The bladder is
unremarkable.
IMPRESSION:
1. No definite ultrasound findings to suggest pyelonephritis, although this
diagnosis cannot be excluded sonographically. 2.1 cm hypoechoic lesion in the
right upper renal pole, poorly visualized and indeterminate; this could
represent a cyst but in the current clinical setting, focal infection or
abscess cannot be excluded. Per the patient's report, there has been a recent
abdominal CT performed at ___ comparison to this study is
recommended. Of note, if this study is uploaded into PACS, an addendum could
be issued at that time. If this study cannot be obtained, further evaluation
could be performed with CT.
3. Right lower pole 15 mm cyst or calyceal diverticulum.
4. Possible duplex right kidney.
Radiology Report
INDICATION: ___ woman with stage IV endometrial cancer, post TAH-BSO
in ___, radiation treatment in ___ now presents with hypoxemia, E.
coli bacteremia, nausea, vomiting and diarrhea.
COMPARISON: None.
TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained
after the uneventful intravenous administration of 150 cc of Omnipaque
intravenous contrast. Sagittal and coronal reformations were performed and
reviewed.
TOTAL DLP: 888.98 mGy-cm.
FINDINGS: The imaged portion of the lung bases and heart are normal. A small
hiatal hernia is present. The liver enhances homogeneously, without focal
lesions or biliary dilation. Multiple gallstones are seen, without evidence
of acute cholecystitis. The spleen is enlarged measuring 19.7 cm. There is
nodular thickening of the left adrenal gland without a focal mass. The right
adrenal gland and pancreas are normal. Multiple subcentimeter hypodense
lesions seen in both kidneys are not characterized in this single-phase
contrast-enhanced study. There is no hydronephrosis. The abdominal aorta is
normal in course and caliber. No significant retroperitoneal or mesenteric
lymphadenopathy is seen. The stomach, small bowel and large bowel loops are
unremarkable, without evidence of obstruction or inflammation. There is no
intra-abdominal free fluid or air.
CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is partially filled
and appears unremarkable. The patient is status post total abdominal
hysterectomy and bilateral salpingo-oophorectomy with expected post-surgical
changes. The rectum and sigmoid colon are normal. Small external iliac lymph
nodes do not meet CT criteria for significant adenopathy.
BONES AND SOFT TISSUES: Bilateral sacroiliac joint degenerative changes are
seen. No lytic or sclerotic bone lesion is is seen.
A 14 x 6.2 x 3.0 cm rim-enhancing fluid collection seen along the ventral
abdominal incision site in the lower abdomen/pelvis (2:70) with extensive
surrounding fat stranding, is stable to slightly smaller compared to the prior
outside hospital study of ___.
IMPRESSION:
1. Large rim-enhancing fluid collection along the lower abdominal incision
site, likely a seroma, is stable to slightly smaller since ___.
Recommended clinical correlation to assess for possible superinfection.
2. No intra-abdominal pathology identified to explain the patient's symptoms.
3. Unexplained massive splenomegaly.
4. Cholelithiasis.
Radiology Report
INDICATION: ___ woman with new line placement.
COMPARISONS: Chest radiograph from ___.
FINDINGS: Single portable supine chest radiograph was provided. A new right
PICC terminates at the cavoatrial junction. Again seen is cardiomegaly.
There is no focal consolidation, pleural effusion or pneumothorax. The bones
are intact.
IMPRESSION:
1. Right PICC at the cavoatrial junction.
2. Stable cardiomegaly.
Radiology Report
HISTORY: Chest pain.
COMPARISON: None available.
TECHNIQUE: PA and lateral chest radiograph, two views.
FINDINGS: Cardiac silhouette is mildly enlarged. Mild tortuosity of the
thoracic aorta. There is mild central vascular congestion with cephalization.
Streaky bibasilar atelectasis is noted. There is no focal consolidation
worrisome for pneumonia. There is no pleural effusion or pneumothorax.
IMPRESSION: Mild cardiomegaly with central vascular congestion, but without
frank edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V/D
Diagnosed with DEHYDRATION
temperature: 99.4
heartrate: 72.0
resprate: 18.0
o2sat: 98.0
sbp: 102.0
dbp: 45.0
level of pain: 4
level of acuity: 2.0 | ___ female with stage IV endometrial cancer on
anastrazole, DM2, CAD, CKD, chronic respiratory failure with
hypoxemia on home oxygen, and morbid obesity presents from her
PCP's office with chest discomfort and possible EKG changes in
the context of a gastrointestinal illness.
.
# Nausea/vomiting/diarrhea
Patient presented following three days of diarrhea, nausea, and
dry heaving. This was more severe than her chronic diarrhea from
radiation, and was likely the result of a viral or bacterial
gastroenteritis. Stool studies and C. diff testing were
negative, and according to the patient's oncologist, Arimidex
was not likely causative. Ondansetron was originally given for
nausea but this was changed to compazine given concern about QTc
prolongation. The nausea and vomiting resolved over the course
of the hospital stay, and the diarrhea improved significantly.
.
# Chest pain
Patient presented with chest discomfort that occurred in the
context of dry heaving. Her PCP was concerned about EKG changes
(septal Q waves and T wave inversions), especially concerning
given the patient's significant history of CAD, including an MI
that led to a cardiac catheterization in ___ (occlusion of the
cardiac vessels was found at that time but patient did not
tolerate the procedure and no intervention was done). However,
following admission the patient noted that the discomfort was
different from the pressure she had felt during her prior MI,
and repeat EKG was similar to prior baseline (___). Troponins
were elevated to 0.21 but downtrended. The overall presentation
was not considered highly concerning for acute coronary
syndrome, so anticoagulation was avoided given baseline
thrombocytopenia. Cardiology (Atrius) was consulted and agreed
that this was likely demand ischemia in the context of
hypovolemia rather than ACS.
.
# Fever/GNR bacteremia (E.Coli)
Febrile to 100.4 at ED, and had several further low-grade fevers
on the floor. UA was positive for nitrites, and given diarrhea,
GI was considered another possible source of infection. She was
started on Bactrim on ___, but this was changed to meropenem on
___ when blood cultures grew gram negative rods. This was
continued despite final culture results showing pan-sensitive E.
coli due to concern about cross-reactivity of cephalosporins
with a penicillin allergy and fluoroquinolones in the context of
prolonged QTc. ID consulted and determined that it was likely
safe for her to try ceftriaxone, which she did on ___, and she
was discharged on this after PICC placement. Surveillance blood
cultures were negative. Renal U/S and CT scan of abd/pelvis
were obtained, which did not show evidence of abscess. She did
have a fluid collection in the abdomen, but this is known from
prior imaging approximately 1 month ago, and has improved in
size. The collection is most likely a seroma.
.
#Pancytopenia
Downtrending WBCs (to 1.5), hematocrit, and platelets; she was
placed on neutropenic precautions. Possibly secondary to
infection, antibiotics (Bactrim or meropenem), or other
medication effect. OSH records showed baseline WBCs over past
few months in 3s following radiation treatment. Although the
levels did not return to baseline, they stabilized prior to
discharge, and she will follow up with her outpatient providers.
.
# Elevated bicarb
Bicarb elevated to 33 on admission, likely representing a
metabolic alkalosis due to GI losses from diarrhea. Metabolic
compensation for a chronic respiratory acidosis may also have
contributed. Trended down shortly after admission.
.
# Diabetes
Patient's home NPH was continued, and she was placed on an
insulin sliding scale.
.
# Endometrial cancer
Completed radiation therapy; not a candidate for chemo. Arimidex
was continued.
.
TRANSITIONAL ISSUES
1. complete course of IV antibiotics for E. coli bacteremia
2. repeat CBC in 2 days to monitor leukopenia, anemia,
thrombocytopenia
3. repeat LFT's at PCP ___
4. non-emergent MRI head to evaluate small hypodensity seen on
CT head from ___ (see below for report)
5. consider serial imaging of abdomen to monitor lesions in
right kidney and fluid collection in abdomen.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary angiography
Percutaneous Coronary Intervention
History of Present Illness:
___ M w/ family history heart disease (father w/ CABG x4 in ___
who presents with around 8 weeks of progressive chest tightness
over left breast. Mostly would occur when cycling to work, and
occasionally radiating to left arm. Pain does not occur at rest.
Pain dissipates approximately ___ minutes after stopping
exercising. The discomfort is associated with SOB and
breathlessness. No syncope or associated diaphoresis.
In the ED, initial vitals were: 97.8 76 161/104 20 98% RA
- Labs notable for troponin 0.02. CBC and chem panel
unremarkable. BNP 183
- Imaging notable for CXR with no lung volumes, no infection or
pulmonary edema. EKG with new Q waves and biphasic T waves
anteriorly
- Atrius cardiology was consulted and recommended: heparin drip
and admission to cardiology
- Patient was started on a heparin drip with bolus, also given
atorvastatin 80mg. Received ASA 325mg in the ambulance.
Decision was made to admit for unstable angina/NSTEMI.
Vitals prior to transfer: 98.1 76 127/76 16 94% RA
On the floor, the patient tells me that he is chest pain free.
He has no complaints.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Past Medical History:
- Stickler syndrome c/b torn retina in R eye (s/p surgery at age
___: no vision in R eye, relatively preserved vision in L eye.
- Hyperlipidemia
- Osteopenia
- Sensorineural hearing loss
Social History:
___
Family History:
Father with CABG X 4 in his ___. No other family history of
heart disease. Grandfather committed suicide. No history of
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vital Signs: T 98.2, 151/94, 74, 18, 94%RA
General: Alert, oriented, no acute distress
HEENT: R eye s/p surgical changes, L eye with reactive pupil and
preserved EOM. Oropharynx wnl.
NECK: No JVP elevation.
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.
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Access: PIV
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: T 98.2, 151/94, 74, 18, 94%RA
General: Alert, oriented, no acute distress
HEENT: R eye s/p surgical changes, L eye with reactive pupil and
preserved EOM. Oropharynx wnl.
NECK: No JVP elevation.
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.
Ext: Warm, well perfused, no clubbing, cyanosis or edema. Right
radial ecchymosis w/ intact distal pulses and sensation.
Pertinent Results:
___ 08:23PM ___ PTT-31.7 ___
___ 08:23PM ___ PTT-31.7 ___
___ 06:40PM GLUCOSE-80 UREA N-14 CREAT-1.0 SODIUM-137
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19
___ 06:40PM estGFR-Using this
___ 06:40PM cTropnT-0.02*
___ 06:40PM proBNP-183*
___ 06:40PM WBC-7.3 RBC-4.69 HGB-14.7 HCT-43.1 MCV-92
MCH-31.3 MCHC-34.1 RDW-11.6 RDWSD-38.7
___ 06:40PM NEUTS-52.7 ___ MONOS-8.0 EOS-4.3
BASOS-1.0 IM ___ AbsNeut-3.85 AbsLymp-2.44 AbsMono-0.58
AbsEos-0.31 AbsBaso-0.07
___ 06:40PM PLT COUNT-278
INTERVAL/DC LABS:
=================
___ 06:45AM BLOOD WBC-6.6 RBC-4.46* Hgb-13.8 Hct-41.5
MCV-93 MCH-30.9 MCHC-33.3 RDW-11.6 RDWSD-39.7 Plt ___
___ 06:45AM BLOOD Glucose-83 UreaN-13 Creat-1.0 Na-140
K-4.1 Cl-105 HCO3-20* AnGap-19
___ 09:43PM BLOOD cTropnT-0.01
___ 06:45AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3
IMAGING:
=======
# CXR ___
No cardiopulmonary process.
# CATH ___
Dominance: Right
* Left Main Coronary Artery
The LMCA is normal.
* Left Anterior Descending
The LAD has a discrete 99% mid stenosis, with a separate 50%
stenosis more distally in the mid segment. There is TIMI 2
distal flow.
* Circumflex
The Circumflex has minimal luminal irregularities.
* Right Coronary Artery
The RCA is a small, non-dominant vessel and is normal.
Impressions:
1 vessel CAD.
Successful PTCA/stent of mid LAD using drug-eluting stent.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
2. Simvastatin 10 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Non ST elevation myocardial infarction
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with progressive chest pain with exertion.
Please evaluate for cardiomegaly, congestive heart failure, pleural effusion
or wedge defect.
TECHNIQUE: PA and lateral chest radiographs were obtained.
COMPARISON: None.
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
The aorta is tortuous. The cardiac silhouette is top-normal. No pulmonary
edema is seen.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion
Diagnosed with Cardiomyopathy, unspecified
temperature: 97.8
heartrate: 76.0
resprate: 20.0
o2sat: 98.0
sbp: 161.0
dbp: 104.0
level of pain: 0
level of acuity: 2.0 | ___ gentleman with a family history of coronary disease
(father had CABG), who presented to ___
___ with 8 weeks of progressive exertional chest
tightness.
# NSTEMI
Patient pressented with subacute yypical anginal sx. EKG showed
new Q waves and biphasic T waves anteriology. Initial trp .02.
He was given ASA, atorva, metop, hep ggt. Patient underwent
catheterization on ___, which showed the following: He
had a right dominant system with a normal left main coronary,
his LAD had a discrete 99% mid stenosis with a separate 50%
stenosis more distally in the mid segment. The circumflex had
minimal irregularities and the right coronary was a small vessel
and there was an additional branch of the right coronary and all
of that was patent. He underwent a successful stenting procedure
to the 99% LAD lesion with a 3.0 mm x 12 mm Promus PREMIER
drug-eluting stent. He was continued on medical management with
Plavix 75 mg a day, atorvastatin 80 mg a day, metoprolol
tartrate 12.5 mg twice a day, aspirin 81 mg a day. Of note,
patient did have ecchymosis/hematoma at right radial access
site. Distal sensation and pulse intact.
# Hypertension
He also had elevated blood pressure throughout his
hospitalization (SBP 150-170) and was started on lisinopril 5 mg
daily.
TRANSITIONAL ISSUES:
====================
[] Patient will need echo as an outpatient
[] Optimization of blood pressure medication
[] Physical therapy recommends referral to cardiac rehab as an
outpatient
[] f/u with cardiology 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:
Neck swelling, Deep Venous Thrombosis
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old Male who presents afer recent parathyroidectomy on
___ who presented 1 day prior to admission with neck
swelling. He initially presented with neck swelling on ___ to
the ED and was thought to simply have marked post-operative
swelling. He subsequently returned on the day of admission with
additional concerns about his swelling. He denies any difficulty
breathing, stridor or change in his voice.
An ultrasound of the swelling noted a large non-occlusive
thrombus in the internal jugular on the ipsilateral side from
the surgery. Dr. ___ contacted the vascular
surgery team for consultation inthe ED, who felt that he should
be managed with lovenox and coumadin, however with his ESRD, he
is admitted to the medical service for unfractionated heparin
bridging to coumadin.
He did not undergo hemodialysis while in the ED, despite it
being his scheduled day, as the vascular issue was being
clarified. The renal-HD consult team is aware of the patient. In
the ED, initial vitals 96.8 76 190/92 18 100% RA.
ROS:
per HPI
(-) Denies pain, fevers, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, nausea,
dysphagia,
vomiting, hematemesis, bloating, cramping, melena, BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency, tingling/weakness
Past Medical History:
-HIV on tenofovir, abacavir and lopinavir/ritonavir (CD4:385 and
undetectable viral load on ___
-HIV associated nephropathy s/p cadaveric renal transplant
(___) which has been complicated by chronic allograft
nephropathy and BK nephropathy, currently on hemodialysis MWF
through Right AVF
-subtotal parathyroidectomy secondary to his renal disease
-HTN
-neuropathy from HIV
PSH:
-Subtotal parathyroidectomy with 0.5 glands remaining (___),
-Modified uvulopalatopharyngoplasty (___)
-Superficialization right upper arm AV fistula (___)
-Right brachiocephalic atrioventricular fistula (___)
-Anterior cervical corpectomy, C4 and C5, arthrodesis, C3
through C6, Structural allograft, and plating plating, C3 to C6
-Right radiocephalic arteriovenous fistula (___)
-Ligation left upper arm AV fistula (___),
-Deceased donor kidney transplant, right iliac fossa over a
___ double-J stent ___ ___
-Transanal microscopically-assisted biopsy and laser destruction
of anal condylomata ___ ___
Social History:
___
Family History:
Father: DM
Mother: healthy
No history of renal disorders or coagulopathy in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 97.6, 145/90, 85, 20, 99%
GEN: A&O, NAD
HEENT: EOMI, PERRL, sclera anicteric, MMM, no oral lesions,
negative stridor/hoarseness
NECK: parathyroidectomy incision well healed, no erythema or
tenderness along site. Soft tissue swelling along anterior neck,
on superior aspect of incision without erythema, warmth,
induration, or drainage. Soft and nontender. Enlarged posterior
lymph nodes b/l, mobile
LUNGS: ctab, no crackles, wheezes, rhonchi
CV: RRR, no m/g/r
ABDOMEN: +BS, no guarding/rebound, soft, NT, ND, no
organomegaly, surgical incision site well-healed
Ext: R AVF with palpable thrill, no c/e
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM
Vitals: Temp 98.6, BP 140/71, HR 82, RR 20, O2 sat 96% RA
GEN: A&O, NAD
NECK: Soft tissue swelling along anterior neck much improved
from prior, almost completely resolved, neck remains free of
erythema, warmth, induration, or drainage. Soft and nontender.
Enlarged posterior lymph nodes b/l, mobile
LUNGS: ctab, no crackles, wheezes, rhonchi
CV: RRR, no m/g/r
ABDOMEN: +BS, no guarding/rebound, soft, NT, ND, no
organomegaly, surgical incision site well-healed
Ext: R AVF with palpable thrill, +bruit
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS
___ 05:40AM BLOOD WBC-3.9* RBC-3.83* Hgb-12.1* Hct-38.7*
MCV-101* MCH-31.6 MCHC-31.3 RDW-15.6* Plt ___
___ 05:40AM BLOOD Neuts-53.6 ___ Monos-7.1 Eos-2.5
Baso-0.5
___ 05:40AM BLOOD Glucose-107* UreaN-51* Creat-13.1* Na-140
K-4.4 Cl-98 HCO3-27 AnGap-19
DISCHARGE LABS
___ 06:12AM BLOOD WBC-3.5* RBC-3.87* Hgb-12.4* Hct-38.6*
MCV-100* MCH-32.0 MCHC-32.1 RDW-16.3* Plt ___
___ 07:25AM BLOOD ___ PTT-119.4* ___
___ 06:12AM BLOOD Glucose-81 UreaN-46* Creat-13.8*# Na-135
K-4.4 Cl-95* HCO3-25 AnGap-19
___ 06:12AM BLOOD Calcium-6.2* Phos-4.5 Mg-2.1
RELEVANT LABS
___ 05:45AM BLOOD PTH-23
___ 05:45AM BLOOD 25VitD-16*
___ 07:35AM BLOOD tacroFK-6.6
US NECK, SOFT TISSUE Study Date of ___ 8:00 AM
IMPRESSION:
1. Partially occlusive clot with some retraction in the right
internal
jugular vein.
2. Complex collection superficial to the isthmus. This is
potentially postop changes, but should be followed with repeat
ultrasound.
3. Multiple enlarged lymph nodes bilaterally. Again these are
likely
reactive nodes secondary to postop changes; however, these could
also be
followed on the repeat ultrasound.
ARTERIAL DUPLEX EXT U/S ___
IMPRESSION:
1. Patent brachial to basilic AV fistula with no evidence of
intraluminal
thrombus.
2. Elevated peak systolic velocities at the level of the
arterial
anastomosis.
3. Elevated access volume flow (mean 1618 ml/min).
Medications on Admission:
-abacavir 300 mg tablet BID
-tenofovir 300mg ___
-labetalol 600 mg tablet TID
-lopinavir-ritonavir [Kaletra] 50 mg-200 mg tablet 2 Tablets
BID
-methocarbamol 750 mg tablet 1 Tablet TID prn muscle spasm
-omeprazole 40 mg once a day
-prednisone 5 mg tablet once a day
-Bactrim SS 1 Tablet by mouth daily
-tacrolimus 0.5 mg capsule q ___
-tenofovir disoproxil fumarate [Viread] 300 mg tablet once a
week
-furosemide 40mg po daily
Discharge Medications:
1. Abacavir Sulfate 300 mg PO BID
2. Calcitriol 2 mcg PO BID
3. Calcium Carbonate 500 mg PO QID
4. Furosemide 40 mg PO DAILY
5. Labetalol 600 mg PO TID
please hold for SBP <100, HR <60
6. Lopinavir-Ritonavir 2 TAB PO BID
7. Omeprazole 40 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 0.25 mg PO 1X/WEEK (MO)
11. Tenofovir Disoproxil (Viread) 300 mg PO 1X/WEEK (MO)
12. Nephrocaps 1 CAP PO DAILY
RX *Nephrocaps 1 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
13. Warfarin 7.5 mg PO DAILY
please adjust dose as instructed by your doctor
RX *Coumadin 2.5 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
14. Methocarbamol 750 mg PO TID:PRN muscle spasm
15. Outpatient Lab Work
Please check INR at hemodialysis on ___ and fax results to
Dr. ___ at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: right internal jugular vein thrombosis,
post-parathyroidectomy neck edema
Secondary diagnosis: HIV on HAART, end-stage renal disease on
hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man status post parathyroidectomy, now with swelling.
COMPARISON: None.
TECHNIQUE: Neck ultrasound.
FINDINGS: The left internal jugular is patent and compressible; however, the
right internal jugular shows non-compressibility with thrombus within it.
This thrombus shows some retraction and is partially occlusive in several
areas with peripheral flow, but in other areas it appears to fill the entire
vessel. The clot extends from the superior aspect of the posterior triangle
of the neck down to the confluence of the internal jugular and subclavian,
however, does not appear to extend into the superior vena cava or the
subclavian.
There are several enlarged lymph nodes on the left (up to 1.5 cm in the long
axis) labeled as levels 2, 3 and 4. On the right side, a node at labeled level
3 measures up to 2 cm.
Images of the thyroid show normal echotexture with no evidence of masses or
lesions. Right thyroid measures 2.6 x 2.5 x 4.2 cm and the left thyroid
measures 1.9 x 1.9 x 4.1 cm. Superficial to the isthmus, there is a complex
area of cystic-appearing structure with linear internal echoes measuring 2.0 x
4.4 x 0.9 cm.
IMPRESSION:
1. Partially occlusive clot with some retraction in the right internal
jugular vein.
2. Complex collection superficial to the isthmus. This is potentially postop
changes, but should be followed with repeat ultrasound.
3. Multiple enlarged lymph nodes bilaterally. Again these are likely
reactive nodes secondary to postop changes; however, these could also be
followed on the repeat ultrasound.
Radiology Report
INDICATION: ___ male with right upper extremity AV fistula,
presenting with clot in the right internal jugular vein.
TECHNIQUE AND FINDINGS: Ultrasound evaluation of the right upper extremity AV
fistula was performed with B mode, color and spectral Doppler ultrasound.
The native brachial artery proximal to the AV fistula is patent with peak
systolic velocities ranging between 249 cm/sec and 299 cm/sec. At the level
of the brachial artery to basilic vein anastomosis, the peak systolic velocity
is 675 cm/sec.
Peak systolic velocities in the venous outflow of the fistula ranged between
66 cm/sec and 165 cm/sec.
Access volume flow measurements were obtained, demonstrating 1422 ml/min, 1403
ml/min and 2030 ml/min, with a mean of 1618 ml/min.
IMPRESSION:
1. Patent brachial to basilic AV fistula with no evidence of intraluminal
thrombus.
2. Elevated peak systolic velocities at the level of the arterial
anastomosis.
3. Elevated access volume flow (mean 1618 ml/min).
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
WALK IN
Chief complaint: NECK SWELLING
NECK SWELLING
Diagnosed with OTHER SPEC COMPL S/P SURGERY, SWELLING OF LIMB, ABN REACT-PROCEDURE NOS
SWELLING OF LIMB, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE
temperature: 99.0
96.8
heartrate: 81.0
76.0
resprate: 16.0
18.0
o2sat: 100.0
100.0
sbp: 139.0
190.0
dbp: 87.0
92.0
level of pain: 0
0
level of acuity: 3.0
3.0 | ___ gentlemen with h/o HIV (CD4>300, VL: undetectable) on
HAART, ESRD ___ HIVAN s/p kidney transplant c/b chronic
allograft and BK nephropathy now on HD presents for neck
swelling post elective parathyroidectomy and clot in RIJ on
ultrasound.
# Deep Venous Thrombosis of the Right Internal Jugular Vein
- Given the centrality of the vessel this is obviously a
concerning DVT
- As he has ESRD, he underwent heparin to coumadin bridging, and
cannot take low molecular weight heparin
- Given all the interactions below, started at a lower dose of
coumadin and INR was closely monitored. Started on 3mg and
increased to 7.5mg. His INR at discharge is 2.3
- Vascular surgery and primary surgical team was consulted, and
did not feel a surgical intervention is required.
- No airway compromise was noted
# Neck Swelling: had parathyroidectomy on ___ due to
secondary hyperparathyroidism. No complications post surgery. On
___ began to notice the swelling. He denied any dysphagia,
difficulty breathing, or change in voice. The swelling
progressively improved each day of hospitalization. At time of
discharge, it was almost completely resolved. TSH in ___ was
normal.
-likely a secondary to post-surgical edema. No sign of infection
(no erythema, warmth, fevers).
-calcium levels were monitored carefully given recent
parathyroidectomy and risk for "hungry bone syndrome." Patient
denied any oral paresthesias, numbness, tingling. Ca at 6.2-6.6
range. He was continued on calcitriol and calcium supplements
# ESRD on HD, Renal Transplant
- Renal Consulted
- HD MWF (although missed ___, underwent HD during his
hospitalization without any problems
- U/s to evaluate the patency of the fistula was obtained and it
was normal
- Continued on tacrolimus, prednisone, omeprazole and Bactrim
for chronic prophylaxis
- tacrolimus level obtained and it was 6.6 (___). Interaction
was discussed with pharmacy team --> no interaction with
warfarin. There is interaction with bactrim (increases INR) and
Kaletra (decreases INR). PCP aware and ___ monitor closely.
# HIV Asymptomatic and responding well to HAART, CD4>300, VL:
undetectable
- Continued on HAART medications: abacavir, tenofovir, and
kaletra
# CHRONIC ISSUES
-HTN: continue home labetalol and furosemide
-Anemia: ___ renal disease: Hct remained stable, receives EPO q
___
-OSA: s/p soft palatoplasty with uvulectomy for redundant tissue
and obstructive sleep apnea. Significant improvement in sleep
pattern post surgery.
# TRANSITIONAL ISSUES
-Arranged to obtain INR on ___ after HD and fax results to
PCP (Dr. ___. Dr. ___ will call patient and adjust coumadin
dose as appropriate. Dr. ___ will also arrange for setting up
follow up with ___ clinic at ___
-Neck ultrasound showed fluid collection near thyroid gland and
enlarged lymph nodes secondary to post-op changes. Please follow
up with these changes with a repeat ultrasound |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Sulfa(Sulfonamide Antibiotics) / codiene / tamazepam /
Plavix
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with past medical history significant for Afib, TIAs and
recent admission for fall with left hip fracture and right
subdural hematoma with subsequent seizures who presents from ___
with acute onset of agitation and altered mental status.
Per the patient's daughter she has been slightly more irritable
for the past few days, but she became acutely agitated this
morning and bit her caregiver at her ___ causing bleeding. Per
the daughter, this is the first time that she has been acting
"this crazy."
In the ED, initial vitals were 99.8 80 134/70 18 96% ra.
Initial CBC, chemistry, urinalysis unremarkable. CT head did
not show extension right posterior subdural hematoma without
evidence of new intracranial hemorrhage. She received Zyprexa
5mg and Ativan 1mg.
On arrival to the floor, initial vitals were 98.4 80 168/80 18
98%RA. She is loud and perseverating on getting a commode and
drinking water. She is also saying that her daughter is lying
and she does not want to be left alone. On questioning however,
she is oriented to person, place ___, ___ and
minimally to time (___. She complains of dull headache
on the left frontotemporal side for the past day. No change in
vision or speech. No muscle weakness. No chest pain, SOB, n/v,
or abdominal pain.
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:
- Right subdural hemorrhage (___)
- left hip fracture s/p fixation (___)
- Atrial fibrillation on coumadin
- prior stroke 9 months ago with residual left hemianopsia
- HLD
- Depression
- peripheral neuropathy
- hypothyroidism
- IBS
- insomnia
Social History:
___
Family History:
Brother died due to cardiac disease. Mother with multiple
strokes. Father died of bowel obstruction.
Physical Exam:
Admission Physical Exam:
Vitals- 98.4 80 168/80 18 98%RA
General- Alert, oriented to person, place ___, ___ and minimally to time (___. Shouting in the room
HEENT- PERRL, EOMI MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- orientation described above. speech fluent. attention
intact. Left field of vision compromised. CNs2-12 intact, motor
function grossly normal, however she will not allow fully
strength testing. Unable to test DTRs. ___ unsteady.
Discharge Physical Exam:
Vitals- 97.3 116/68 (100-149/50-70s) 91 20 98%RA
General- Cachectic appearing, alert, calling for "help" upon
entering the room, wants me to bring her a sweater, having
trouble finding words
HEENT- PERRL, EOMI MM dry, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi, cachectic with protruding spinous processes
CV- regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, NT ND +BS, no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- orientation described above. speech fluent but not
always coherent.
Pertinent Results:
ADMISSION LABS:
___ 11:54AM BLOOD WBC-6.6 RBC-3.87* Hgb-12.1 Hct-36.7
MCV-95 MCH-31.2 MCHC-32.9 RDW-15.0 Plt ___
___ 11:54AM BLOOD Neuts-73.6* Lymphs-17.4* Monos-6.3
Eos-1.9 Baso-0.7
___ 12:51PM BLOOD ___ PTT-25.8 ___
___ 11:54AM BLOOD Glucose-98 UreaN-5* Creat-0.6 Na-140
K-3.9 Cl-103 HCO3-23 AnGap-18
___ 11:54AM BLOOD TSH-2.7
___ 06:30AM BLOOD Phenyto-22.3*
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-6.4 RBC-3.89* Hgb-11.8* Hct-36.7
MCV-95 MCH-30.5 MCHC-32.2 RDW-15.5 Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-141
K-4.2 Cl-102 HCO3-30 AnGap-13
___ 07:50AM BLOOD Phos-3.9 Mg-2.2
URINE:
___ 12:00PM URINE Color-Straw Appear-Clear Sp ___
___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
MICROBIOLOGY:
___ 5:44 URINE CULTURE : negative
IMAGING:
CT HEAD NON-CONTRAST ___
Hypodense material layering along the posterior right cerebral
convexity and posterior aspect of the falx is consistent with
expected evolution of previous subdural hematoma without
interval increase in quantity of fluid. There is no acute
intracranial hemorrhage, edema, mass effect or major vascular
territory
infarction. There is no shift of normally midline structures.
Left temporal encephalomalacia is unchanged. Periventricular
and subcortical white matter hypodensities suggest chronic small
vessel ischemic disease. There is no fracture. Imaged
paranasal sinuses and mastoid air cells reveal mild left
maxillary mucosal thickening.
IMPRESSION: Expected evolution of the right posterior subdural
hematoma without evidence of new intracranial hemorrhage.
EEG ___: Showed no evidence of epileptiform activity, but
dud show nonspecific left and right temporal slowing.
Radiology Report
HISTORY: Recent subdural hemorrhage and prior stroke with altered mental
status.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformations were prepared.
COMPARISON: ___.
FINDINGS:
Hypodense material layering along the posterior right cerebral convexity and
posterior aspect of the falx is consistent with expected evolution of previous
subdural hematoma without interval increase in quantity of fluid. There is no
acute intracranial hemorrhage, edema, mass effect or major vascular territory
infarction. There is no shift of normally midline structures. Left temporal
encephalomalacia is unchanged. Periventricular and subcortical white matter
hypodensities suggest chronic small vessel ischemic disease. There is no
fracture. Imaged paranasal sinuses and mastoid air cells reveal mild left
maxillary mucosal thickening.
IMPRESSION:
Expected evolution of the right posterior subdural hematoma without evidence
of new intracranial hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ___ /BIT STAFF
Diagnosed with SEMICOMA/STUPOR
temperature: 99.8
heartrate: 80.0
resprate: 18.0
o2sat: 96.0
sbp: 134.0
dbp: 70.0
level of pain: 13
level of acuity: 2.0 | ___ with PMH of Afib, and recent admission for fall with left
hip fracture and right subdural hematoma with subsequent
seizures who presents from ___ with acute onset of agitation and
altered mental status. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zithromax / levofloxacin / vancomycin / Bactrim
Attending: ___.
Chief Complaint:
dyspnea, cough
Major Surgical or Invasive Procedure:
No procedures performed ___ the hospital
History of Present Illness:
Ms. ___ is a ___ year old female with a PMHx of ectodermal
dysplasia, hypogammaglobulinemia on IVIG, asthma, s/p flex
bronch ___ with balloon dilation for bronchiectasis, prior
PNA presenting with dyspnea, productive cough.
Pt reports symptoms started last ___ developed increasing
dyspnea, wheezing, and productive cough w/yellow sputum. She had
fever and chills which "broke" on ___ currently no
subjective fevers. She denies sick contacts. She has required
increased use of duonebs (normally does x1/day, now increased)
and has been compliant w/ other inhalers and meds.
She was last on abx (Bactrim) approx. x6 weeks ago - she
received cyclical abx per her Pulmonologist. She has not been on
steroids since her last admission.
She denies lightheadedness/dizziness, CP/palp, abd pain/N/V,
dysuria, ___ edema. She reports constipation.
Of note, she is due for IVIG on ___.
___ the ED, initial VS were 98.2 119 ___ 97% RA.
Exam notable for accessory muscle use and diffuse wheezing
throughout.
Labs showed:
Normal Chem 7, WBC 9.9 with 75% PMNs, Hgb 10.6 (MCV 72) with
baseline ___, Plt 426 (baseline 300s).
Lactate:1.3
UCG: Negative
Unremarkable UA
CXR showed: Subtle bibasilar opacities worrisome for multifocal
infection. Known bronchiectasis was better seen on prior CT
scan.
Patient received:
___ 17:19 IH Albuterol 0.083% Neb Soln 1 NEB
___ 17:19 IH Ipratropium Bromide Neb 1 NEB
___ 18:40 IH Albuterol 0.083% Neb Soln 1 NEB
___ 18:40 IH Ipratropium Bromide Neb 1 NEB
___ 18:51 IV CefePIME 2 g
___ 18:51 PO PredniSONE 60 mg
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports fatigue and productive
cough that is blood tinged ___ AM. She has been self-medicating
at home with Robitussin DM and ibuprofen PRN for lung pain. She
states this feels like her prior episodes of pneumonia, which
she states she had >30 ___ the past. She endorses worsened
dyspnea on exertion and orthopnea.
Past Medical History:
-asthma
-bronchiectasis
-humoral immunity deficiency, NOS on IVIG trial
-ectodermal dysplasia
-GERD
-airway stenosis, thought due to chronic GERD
-obesity
-insomnia
Social History:
___
Family History:
cardiac disease ___ mom's side, dads father with stroke, aunt
with brain ___, T2DM moms side
Physical ___:
ON ADMISSION
============
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: diffuse expiratory and inspiratory wheezing, no rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender ___ 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
ON DISCHARGE
=============
Vitals: 98.6 | 127/61 | 86 | 18 | 98 RA
General: Well-appearing, alert, oriented, breathing with mild
discomfort
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Fair air movement bilaterally, expiratory wheezing. No
rhonchi or crackles.
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, no cyanosis or edema
Neuro: nonfocal
Pertinent Results:
ON ADMISSION
=============
___ 05:15PM BLOOD WBC-9.9 RBC-4.95 Hgb-10.6* Hct-35.7
MCV-72*# MCH-21.4*# MCHC-29.7* RDW-16.4* RDWSD-41.8 Plt ___
___ 05:15PM BLOOD Neuts-75.1* Lymphs-13.8* Monos-8.0
Eos-2.3 Baso-0.3 Im ___ AbsNeut-7.40*# AbsLymp-1.36
AbsMono-0.79 AbsEos-0.23 AbsBaso-0.03
___ 05:15PM BLOOD Glucose-101* UreaN-7 Creat-0.6 Na-141
K-4.0 Cl-103 HCO3-28 AnGap-14
___ 01:28PM BLOOD ALT-36 AST-24 LD(LDH)-143 AlkPhos-110*
TotBili-0.1
___ 05:15PM BLOOD Iron-25*
___ 05:15PM BLOOD calTIBC-433 Hapto-326* Ferritn-22 TRF-333
___ 07:53AM BLOOD ___ pO2-138* pCO2-48* pH-7.38
calTCO2-29 Base XS-2 Comment-GREEN TOP
MICRO
======
__________________________________________________________
___ 2:15 am SPUTUM Source: Induced.
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Preliminary):
ACID FAST CULTURE (Preliminary):
__________________________________________________________
___ 6:45 pm SPUTUM Site: INDUCED Source: Induced.
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.
ACID FAST SMEAR (Preliminary):
ACID FAST CULTURE (Preliminary):
__________________________________________________________
___ 1:28 pm SEROLOGY/BLOOD CRY ADDED TO ___.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
A negative serum does not rule out localized or
disseminated
cryptococcal infection.
Appropriate specimens should be sent for culture.
__________________________________________________________
___ 11:58 am SPUTUM Source: Induced.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Preliminary):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
This is only a PRELIMINARY result. If ruling out
tuberculosis, you
must wait for confirmation by concentrated smear.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
___ 7:45 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
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
__________________________________________________________
___ 6:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
=========
CHEST (PA & LAT)Study Date of ___ 4:53 ___
Linear opacity extending laterally from the left hilum is likely
atelectasis versus scarring. New compared to most recent exam
are subtle areas opacity at the lung bases, likely ___ part
within the right middle lobe. Bibasilar regions of
bronchiectasis were better seen on prior CT scan.
Cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities.
IMPRESSION: Subtle bibasilar opacities worrisome for multifocal
infection. Known bronchiectasis was better seen on prior CT
scan.
CT CHEST W/O CONTRASTStudy Date of ___ 2:47 ___
Interval substantial progression of infectious process seen as
worsening bronchiectasis, endobronchial secretions, extensive
___ opacities, narrowing of the airway origin with
subsequent atelectasis as well as substantial lymphadenopathy
that has progressed since the prior study. Findings might
represent progression of known CV ID with superimposed diffuse
bronchogenic infection.
Malignancy is less likely although cannot be entirely excluded
and short-term followup ___ ___ weeks after aggressive
antibiotic treatment is recommended.
DISCHARGE LABS:
=================
___ 07:50AM BLOOD WBC-7.9 RBC-4.52 Hgb-9.6* Hct-32.6*
MCV-72* MCH-21.2* MCHC-29.4* RDW-16.4* RDWSD-41.9 Plt ___
___ 07:50AM BLOOD Neuts-57.9 ___ Monos-6.6 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-4.56 AbsLymp-2.65 AbsMono-0.52
AbsEos-0.07 AbsBaso-0.03
___ 07:50AM BLOOD Glucose-86 UreaN-13 Creat-0.5 Na-141
K-3.5 Cl-102 HCO3-30 AnGap-13
___ 07:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
Radiology Report
INDICATION: ___ with recurrent pneumonia, dyspnea // pneumonia?
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___ chest x-ray and chest CT from ___.
FINDINGS:
Linear opacity extending laterally from the left hilum is likely atelectasis
versus scarring. New compared to most recent exam are subtle areas opacity at
the lung bases, likely in part within the right middle lobe. Bibasilar
regions of bronchiectasis were better seen on prior CT scan.
Cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
Subtle bibasilar opacities worrisome for multifocal infection. Known
bronchiectasis was better seen on prior CT scan.
Radiology Report
EXAMINATION: Chest CT
INDICATION: ___ year old woman with bronchiectasis, epidermal dysplasia and
CVID presenting with fevers 4 days ago and acute on chronic respiratory
distress // Evaluate to confirm pneumonia as CXR not fully conclusive in
patient with chronic lung fidings. PLEASE DO LOW DOSE STUDY.
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: Several chest radiographs dating back to ___ and
chest CT from ___
FINDINGS:
Right thyroid calcified nodule is unchanged with overall diffuse thyroid
enlargement ranging up to 12 mm, series 3, image 2. Several mediastinal lymph
nodes are enlarged and appear to be substantially increased as compared to
previous study for example in the right mid paratracheal area 15 x 12.5 mm as
compared to 8.5 x 7 mm, in right lower paratracheal area, 11 mm as compared to
4 mm, in paraesophageal location, 17 mm as compared to 8 mm. Hilar
lymphadenopathy is difficult to determine in the absence of IV contrast but at
least 1 cm lymph nodes are present.
Heart size is normal. There is no pericardial pleural effusion. Aorta and
pulmonary arteries are normal in diameter.
Anemia is demonstrated he as increased density of the left ventricle.
Trachea and main bronchi are patent. Substantial interval progression in
bronchiectasis, extensive endobronchial secretions, the cystic component of
bronchiectasis in particular in the lower lobes as well as the extent of
bronchial narrowing in particular at the level of the right middle lobe
bronchus and origin and right lower lobe bronchus origin, series 5 images 144
and 133 is demonstrated. Extensive ___ opacity, ground-glass
opacities a new nodular opacities are also old in favor of active infection
currently. New atelectasis, substantial of the left upper lobe is present,
series 5, image 106, most likely related to segmental obstruction, series 5,
image 115.
Image portion of the upper abdomen reveals no appreciable abnormality.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
IMPRESSION:
Interval substantial progression of infectious process seen as worsening
bronchiectasis, endobronchial secretions, extensive ___ opacities,
narrowing of the airway origin with subsequent atelectasis as well as
substantial lymphadenopathy that has progressed since the prior study.
Findings might represent progression of known CV ID with superimposed diffuse
bronchogenic infection.
Malignancy is less likely although cannot be entirely excluded and short-term
followup in ___ weeks after aggressive antibiotic treatment is recommended.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Cough
Diagnosed with Pneumonia, unspecified organism
temperature: 98.2
heartrate: 119.0
resprate: 24.0
o2sat: 97.0
sbp: 112.0
dbp: 97.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ is a ___ year old female with asthma,
bronchiectasis, ectodermal dysplasia, humoral immunity
deficiency NOS on IVIG trial presenting with worsening dyspnea
and productive cough.
# Bronchiectasis exacerbation: Her presentation was more
consistent with subacute to worsening chronic infectious process
___ setting of bronchiestasis and humoral deficiency NOS. CT
Chest significant for interval worsening of bronchiectatic
process, sputum cultures growing MSSA. Initially started on
empiric broad coverage with Vancomycin, Cefepime and Doxycycline
then based on IDs recommendations narrowed to ceftriaxone and
doxycycline. Of note had allergic reaction to vancomycin, see
details below. Was continued on ceftriaxone and doxycycline
until discharge with clinical improvement, she was discharged on
cefpodoxime and doxycycline to complete a 10-day course of
antibiotics. Negative broad work-up including PJP smear,
Cryptococcal serum Ag, Histoplasma Urine Ag, Aspergillus GM and
Ab. Beta-D-glucan was positive which was thought to be related
to her receiving IVIG.
Had 3x induced sputum for AFB smears which were negative and
culture which were pending at the time of discharge.
#Iron deficiency anemia: MCV 73, ferritin 22, TRF 333, serum
iron
25, TIBC 433, %Sat 5.4%. Started Ferrous sulfate 325mg PO BID
w/ondansetron 4mg PO q8hr:PRN for nausea with iron. Nutrition
saw the patient as an inpatient as well.
#Humoral immunodeficiency: previously followed as an outpatient
by Dr. ___ at ___. Received IVIG on ___, will have
outpatient f/u.
# Asthma exacerbation: Given significant wheezing and dyspnea
she received prednisone 50mg ___ the hospital with a taper
(decrease by 10mg each week) as well as albuterol/ipratropium
nebs q4-6h and prn. Tiotropium, montelukast and ceterizine were
continued. As symbicort was NF, she was bridged with Advair
while ___ house. She was discharged on albuterol nebulizers and
with a new nebulizer machine.
# GERD: Continued on home omeprazole
TRANSITIONAL ISSUES
==================
- patient has switched insurance and is no longer eligible for
___ outpatient primary care
- Her new PCP is ___ at ___ -> she needs a
referral to see a new pulmonologist within ___ weeks of
discharge from ___
- she received her dose of IVIG ___ house on ___
- she received pneumococcal vaccine on ___
- she received home nebulizer machine and was discharged w/nebs
- pending infectious studies should be followed up by PCP and
pulmonologist
FULL CODE
Fiance, ___ ___
HCP is sister, ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vertigo, nausea, vomiting, right facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a h/o prior stroke, HTN and
HLD, who presents with acute onset of vertigo, unsteadiness, and
slurred speech today.
Mr. ___ was in his USOH this morning and went out doing his
normal errands until 330PM today when he had sudden onset of
vertigo. He also felt like his right face was numb. He sat down
since he felt unsteady. His wife found him sitting down,
speaking
with notably slurred speech, and unable to stand. She called ___
and he was taken to an OSH, where he was noted to have marked
ataxia, a right facial droop, and nystagmus. Assessment for tPA
was performed through telemedicine neurology consult, and
although a cerebellar infarct was suspected, given location, it
was recommended no tPA be given and he be transferred to ___
for further care.
At the OSH, he had emesis intermittently for 3 hours. During my
evaluation, he had another episode of emesis, although he
continues to deny nausea. He does report feeling unsteady and
clumsy. He feels there has been no improvement and his vertigo
persists.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, 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 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 diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria.
Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
Stroke ___ years ago- ?R.MCA, pt reports left hemiparesis, wife
and ___ feel that he had a right facial droop and weakness.
T2DM
HTN
HLD
s/p CABG ___
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION EXAM
Vitals: T: 98.8 HR 65 BP 145/54 RR 18 O2 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Speech
is mildly dysarthric. Able to follow both midline and
appendicular commands. 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 confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: Nystagmus at rest with rotatory component. With
EOMI, horizontal and vertical nystagmus seen. Denies diplopia.
Normal saccades.
V: Facial sensation intact to light touch.
VII: Right NLF flattening and decreased activation of right side
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.
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 5 5
*unable to test R. WE as he has baseline pain from fusion in
that
wrist
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense throughout. No extinction to DSS. JPS ___
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: Notable ataxia and slowness on right FNF,
slightly
slower on right RAM. Left FNF is mildly unsteady, RAM fluent.
HKS
normal bilaterally. Notable truncal ataxia with consistent
falling toward right.
-Gait: deferred
DISCHARGE EXAM
Vitals: T: 98.8 HR 60-80s BP 130-150/60s RR 18 O2 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM,
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Speech fluent but slowed. No evidence of
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 1mm on Right and 2 on left but reactive; VFF to
confrontation.
Nystagmus at endgaze with rotatory component but improved. Full
EOMI. Endorses occasional diplopia. Normal saccades.
V: Facial sensation intact to light touch.
VII: Right NLF flattening and decreased activation of right side
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. Slight right pronator
drift.
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: Today no deficits to pinprick though during admission
had decreased pinprick on left arm/leg and right face. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: Mild ataxia and slowness on right FNF and less
coordinated in right RAM. Left FNF is also unsteady. Minimal
right tilt when sitting.
-Gait: Wide-based gait and leans to right; very unstable.
Pertinent Results:
ADMISSION DATA:
CBC: 13.5/___/170 N90L6M3
Coags: ___
Chem: ___ Ca 9.7 Mg 2.1 P3.4
Lactate 1.9
Serum tox and Utox neg
UA +prt, +glucose, +ketones.
Radiologic Data:
___: Reported negative
MRI/MRA Head/Neck (___): Focal area of slow diffusion
identified on the right medulla oblongata as described in detail
above, visible only on the DWI sequence, suggesting a hyperacute
ischemic change, please correlate clinically. Scattered foci of
high signal intensity are identified in the subcortical white
matter on FLAIR and T2, which are nonspecific and may reflect
areas of small vessel disease.
Essentially normal MRA of the head, with no evidence of flow
stenotic lesions. The right vertebral artery is dominant.
Tortuosity of both internal carotid arteries, with no evidence
of flow stenotic lesions. Dominance of the right vertebral
artery is present as a vascular anatomical variation.
ECHO (___): 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.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No ASD or PFO. Normal global and regional
biventricular systolic function. Mild mitral regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Rosuvastatin Calcium 20 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Amlodipine 20 mg PO DAILY
5. GlipiZIDE Dose is Unknown PO BID
6. MetFORMIN (Glucophage) Dose is Unknown PO BID
7. Lantus *NF* (insulin glargine) 100 unit/mL Subcutaneous daily
Patient on sliding scale based on morning fasting BG. If <100,
no Lantus; If BG 150-200 then 14u; if BG>200, give 18u.
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Amlodipine 20 mg PO DAILY
4. Rosuvastatin Calcium 20 mg PO DAILY
5. GlipiZIDE 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Lantus *NF* (insulin glargine) 100 unit/mL Subcutaneous daily
Patient on sliding scale based on morning fasting BG. If <100,
no Lantus; If BG 150-200 then 14u; if BG>200, give 18u.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1) Right medullary infarct
2) Hypertension
3) Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Can walk while monitored but has significant lean to
right when upright.
Followup Instructions:
___
Radiology Report
STUDY: MRI and MRA of the brain and MRA of the neck.
CLINICAL INDICATION: History of ataxia, dizziness, possible cerebellar
stroke, clots, occlusion.
COMPARISON: Prior head CT dated ___.
TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic susceptibility,
and axial diffusion-weighted sequences were obtained through the brain.
MRA OF THE HEAD: 3D time-of-flight arteriography of the head was obtained,
axial source images and multiplanar reformations were reviewed.
MRA OF THE NECK:
After the administration of intravenous gadolinium contrast, bolus tracking
technique sequences were obtained throughout the neck vessels, coronal source
images and multiplanar reformations were reviewed.
FINDINGS: On the diffusion-weighted sequence, there is a focus of wall
diffusion on the right at the level of the medulla oblongata, visible on the
image #4, series #6, which is not clearly evident in the corresponding ADC.
No FLAIR or T2 abnormalities are seen in this area, the possibility of
hyperacute ischemic event is a consideration. A perivascular space is
identified on the right side of the pons, the cerebellopontine cisterns and
fourth ventricle are unremarkable. Supratentorially, the ventricles and sulci
are slightly prominent, likely indicating cortical volume loss, and possibly
age related and involutional in nature. Few scattered foci of high signal
intensity are identified in the subcortical white matter, which are
nonspecific and may reflect areas of small vessel disease. The major vascular
flow voids are present and demonstrate normal distribution. The orbits are
unremarkable. The paranasal sinuses demonstrate mild mucosal thickening at
the ethmoidal air cells bilaterally, the mastoid air cells are clear.
IMPRESSION: Focal area of slow diffusion identified on the right medulla
oblongata as described in detail above, visible only on the DWI sequence,
suggesting a hyperacute ischemic change, please correlate clinically.
Scattered foci of high signal intensity are identified in the subcortical
white matter on FLAIR and T2, which are nonspecific and may reflect areas of
small vessel disease.
Mild mucosal thickening noted at the ethmoidal air cells.
MRA OF THE HEAD:
There is evidence of vascular flow in both internal carotid arteries as well
as the vertebrobasilar system, the right vertebral artery is dominant. The
anterior and middle cerebral arteries are patent as well as the posterior
cerebral arteries, with no evidence of flow stenotic lesions or aneurysms
larger than 2 mm in size.
IMPRESSION: Essentially normal MRA of the head, with no evidence of flow
stenotic lesions. The right vertebral artery is dominant.
MRA OF THE NECK:
The origin of the supra-aortic vessels appears normal, both common carotid
arteries are patent with no evidence of flow stenotic lesions, there is
significant tortuosity along the left internal carotid artery and also
significant tortuosity on the right internal carotid artery below the P2
segment with no evidence of flow stenotic lesions. The right vertebral artery
is dominant.
IMPRESSION: Tortuosity of both internal carotid arteries, with no evidence of
flow stenotic lesions. Dominance of the right vertebral artery is present as
a vascular anatomical variation.
These findings were communicated to Dr. ___ at 13:05 hours on
___, via phone call by Dr. ___.
Gender: M
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by WALK IN
Chief complaint: R SIDED WEAKNESS/DROOP
Diagnosed with LACK OF COORDINATION, MUSCSKEL SYMPT LIMB NEC, FACIAL WEAKNESS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: nan
heartrate: 65.0
resprate: 16.0
o2sat: 100.0
sbp: 126.0
dbp: 75.0
level of pain: 0
level of acuity: 1.0 | NEURO: Mr. ___ was admitted for further imaging and ECHO. His
exam on admission was notable for right sided dysmetria with
significant ataxia (fell to right on standing), nystagmus that
changed direction with gaze, blurry vision/ghosting but no frank
diplopia, mild right facial droop, and decreased sensation on
the right face and left arm and leg. This picture of right
sided ataxia and facial sensation changes and left body
sensation changes was concerning for a lateral medullary
(___) syndrome though it was unusual that there was no
Horner's Syndrome.
MRI/MRA did show a small right medullary infarct but no problems
with the vasculature. Stroke work-up included an ECHO that
showed normal systolic function and no ASD/PFO and labs, which
showed an adequately controlled cholesterol (LDL 54, HDL 38, ___
129) but a slightly elevated HgbA1c of 6.9%. Telemetry revealed
sinus arrhythmia but no atrial fibrillation.
Mr. ___ was switched from Aspirin to Plavix in hopes of
secondary stroke prevention but no other medication changes were
made. Physical therapy felt that he would need ___
rehabilitation. Nutrition recommended a diet of moist ground
solids and nectar thick liquids due to aspiration risk.
ENDO: Mr. ___ metformin and glipizide were held due to
contrast CT. We spoke to his outpatient endocrinologist who
reported that normally Mr. ___ uses Lantus on a sliding scale
basis based on fasting AM blood glucose (0 if BG<150; 14u if
150-200; 18u if >200). We gave him 20units QHS of Lantus and an
insulin sliding scale because he had BG 200-300s frequently
through admission. Before discharge, we restarted Glipizide and
Metformin and we restarted his home Lantus plan; this may have
to be adjusted at rehab, especially given he had HgbA1c of 6.9%. |
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
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o F with PMH of COPD (FEV1 66%, GOLD II)
on home O2 when SOB who presented to the ED overnight on ___
with dyspnea.
The patient reports worsening of her chronic dyspnea at ~10pm on
the night of admission. Came to the ED where her initial RA sat
was 77%. CXR notable for hyperexapnded lungs but no
consolidations. No other infectious symptoms. ECG without
ischemic changes. Thought to be having a COPD exacerbation and
given duonebs x2 and methylpred. Her respiratory status improved
with sats rising to the ___, however the patient began to become
tired. Decision made to place the patient on BiPAP. Patient did
well on BiPAP and was admitted to the MICU for further
management.
Of note, the patient was recently admitted here ___ with
similar symptoms. Treated for a COPD exacerbation and improved.
Also admitted to ___ in ___ for COPD exacerbation. Followed
with Dr. ___ in clinic. There is some suggestion of medication
non-adherance due to cost issues. States that she has been
taking all medications as prescribed.
On arrival to the MICU the patient is on BiPAP and appears
comfortable. Still with audible wheezing.
Past Medical History:
1. MVP history
2. Crohn's/uveitis c.o Dr. ___
3. Postmenopausal
4. Hiatal hernia/GERD
5. Dyslipidemia
.
Surg:
1. s/p rectal fistula repair
2. bladder sling procedure in recent months
Social History:
___
Family History:
Mother (___): CAD, DM & ?ovarian cancer
Father (___): died of lung cancer (heavy smoker)
Denies premature MI, stroke, aneurysm, cholesterol problems,
HTN,
asthma, thyroid problems, bleeding tendencies, anemia,
skin/breast/colon cancer
Physical Exam:
ADMISSION EXAM:
T 98.9 HR 94 BP 111/65 RR 20 94% 4L
GENERAL: Seated in bed, no accessory muscle use, speaking full
sentences, NAD
HEENT: No LAD, JVD < 10cm
CV: normal S1 S2, no M/R/G
PULM: Scattered bilateral expiratory wheezes, moderate air
movement
ABD: Soft, NT/ND, + BS
GU: no foley
NEURO: AAOx3
EXT: no edema, WWP, +pneumoboots
DISCHARGE EXAM:
97.9, 117/70 (100-110s/60-70s), 88 (80-90s), 18, >91% RA
GENERAL: Seated in chair, no accessory muscle use, speaking full
sentences, NAD
HEENT: No LAD, JVD < 10cm
CV: normal S1 S2, no M/R/G
PULM: Scattered bilateral expiratory wheezes, good air movement
ABD: Soft, NT/ND, + BS
GU: deferred
NEURO: AAOx3, CN II-XII intact
EXT: no edema, WWP
Pertinent Results:
ADMISSION:
___ 02:41PM TYPE-ART PO2-199* PCO2-34* PH-7.47* TOTAL
CO2-25 BASE XS-2 INTUBATED-NOT INTUBA
___ 01:55PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:55PM URINE RBC-4* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-1
___ 01:55PM URINE HYALINE-1*
___ 01:55PM URINE MUCOUS-RARE
___ 08:44AM TYPE-ART RATES-/20 PO2-75* PCO2-53* PH-7.34*
TOTAL CO2-30 BASE XS-0 INTUBATED-NOT INTUBA VENT-SPONTANEOU
___ 05:05AM ___ COMMENTS-GREEN TOP
___ 05:05AM LACTATE-1.4
___ 04:30AM GLUCOSE-154* UREA N-10 CREAT-0.7 SODIUM-136
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-29 ANION GAP-16
___ 04:30AM estGFR-Using this
___ 04:30AM cTropnT-0.02*
___ 04:30AM WBC-9.0 RBC-5.20 HGB-16.3* HCT-47.3 MCV-91
MCH-31.4 MCHC-34.5 RDW-14.4
___ 04:30AM NEUTS-67.4 ___ MONOS-5.5 EOS-4.0
BASOS-1.2
___ 04:30AM PLT COUNT-306
DISCHARGE:
___ 07:00AM BLOOD WBC-9.8 RBC-4.61 Hgb-14.7 Hct-42.4 MCV-92
MCH-31.9 MCHC-34.7 RDW-14.8 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD
___ 07:00AM BLOOD Glucose-77 UreaN-19 Creat-0.6 Na-139
K-3.9 Cl-96 HCO3-32 AnGap-15
___ 07:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
IMAGING:
___ CXR: mild hyperinflation, no acute process. Hiatal
hernia.
___ CXR: No acute process. Stable hiatal hernia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. ClonazePAM 0.5 mg PO TID:PRN anxiety
3. Omeprazole 40 mg PO DAILY
4. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN SOB
5. Simvastatin 80 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. Azithromycin 250 mg PO Q24H
8. Pulmicort Flexhaler (budesonide) 180 mcg/actuation Inhalation
BID
Discharge Medications:
1. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN SOB
2. Azithromycin 250 mg PO Q24H Duration: 1 Dose
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
3. ClonazePAM 0.5 mg PO TID:PRN anxiety
4. Omeprazole 40 mg PO DAILY
5. Simvastatin 80 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. Citalopram 20 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
RX *albuterol sulfate 0.63 mg/3 mL 1 nebulizer inhaled q4hr Disp
#*60 Unit Refills:*0
9. PredniSONE 60 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
Inhalation BID
11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, shortness
of breath
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 nebulizer solution
inhaled every 6 hours Disp #*30 Not Specified Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Obstructive Pulmonary Disease Exacerbation (COPD)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath in a patient with a history of COPD.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Chest, portable upright. The lungs are hyperinflated but clear. The hilar
and cardiomediastinal contours are normal. There is no pneumothorax or
pleural effusion. Pulmonary vascularity is normal.
IMPRESSION:
No acute cardiopulmonary process. Hyperinflated lungs, consistent with the
stated history of COPD.
Radiology Report
AP CHEST, 5:39 A.M., ___
HISTORY: ___ woman with COPD.
IMPRESSION: AP chest compared to ___:
Lungs clear. Heart size normal. Hiatus hernia noted. No pleural
abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | ___ yo F w/ h/o COPD (FEV1) and Crohn's (on remicade) presenting
for increasing shortness of breath.
ACUTE
# COPD exacerbation: Pt with hx of mild COPD. On arrival to the
ED on ___, she had O2 sats of 77%, and continued to require O2
throughout the admission until the day of discharge. She was
given IV methylpred, azithromycin, and nebs with initial
improvement in her symptoms, but was transferred to the MICU for
bipap given concerns of respiratory fatigue. She was transferred
to the floor on ___ w/ 4L O2 requirement, and ambulatory sats of
77%. ABG showed hypoxemia at 7.46/42/56 (pH/pCO2/pO2). Her nebs
were spaced to q6h, with good air movement on exam and O2 sats
of >91% on RA by ___. She should f/u with her outpt
pulmonologist with repeat PFTs at that time. She did very well
at rest but may benefit from O2 with activity - she refused
this. She was discharged with prolonged steroid taper and
sufficient azithromycin to complete a ___HRONIC
#. Crohn's: She receives remicade as an outpatient, and her
disease was stable this admission. She is followed by GI
outpatient.
#. HLD: She was continued on simvastatin.
#. Depression/anxiety: She was continued on citalopram/klonipin.
TRANSITION
# COPD: plan for outpatient f/u with pulmonologist with repeat
PFTs at that time. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Tetracycline / Hibiclens / Dilaudid / tramadol / oxycodone /
morphine
Attending: ___
___ Complaint:
Abdominal pain and emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman ___ UC s/p lap proctocolectomy
w/ end ileostomy ___ with revision later that month, s/p repair
of parastomal hernia on ___, recently admitted with SBO
___. An ileostomy was performed during that admission,
which identified no frank obstruction. Biopsies taken at 70cm
were read as 'mild ileitis'. Since her discharge, she has
continued to have intermittent abdominal pain. This became much
worse yesterday night. The pain occurs across the middle of her
abdomen, behind her ostomy. The pain comes in waves, in crampy
in
nature, and does not radiate. She and her husband report that
she
has had impressive borborigmi during this time. She had an
episode of small volume emesis early this morning around 3am,
which produced only a few table spoons. This prompted her to
seek
care at the ___ ED. Of note, she reports continued flatus
during this time as well as production of liquid stool, albeit
at
lower volumes than usual.
Past Medical History:
1. Hyperlipidemia
2. Ulcerative proctitis.
3. Hypothyroidism.
3. Migraines.
4. Recurrent nephrolithiasis.
5. History of multiple skin cancers including basal cell,
squamous cell, and melanoma in situ (___).
6. Genital herpes, with recent flare while on steroids
7. Oral thrush ___ on steroids
Past Surgical History:
1. ___ Ileostomy revision
2. ___ Lap TPC with end ileostomy
3. ___ Left ureteroureterostomy with stent
4. ___ breast excision
Social History:
___
Family History:
Her brother has ulcerative colitis, he has never had surgery. A
first cousin also has ulcerative colitis. Her father had an MI
at age ___. Her mother had breast cancer. Many family members
have hypertension.
Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Soft, mildly tender to palpation in the mid abdomen and in
the ___ area, well healed surgical scars, ostomy in
place with liquid stool and some gas in bag wih red rubber in
place.
Ileostomy appears pink.
EXT: No ___ edema, warm and well perfused
Pertinent Results:
___ 06:00AM BLOOD WBC-4.0 RBC-2.62* Hgb-7.2* Hct-22.6*
MCV-86 MCH-27.5 MCHC-31.9* RDW-13.2 RDWSD-41.5 Plt ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Simvastatin 10 mg PO QPM
3. Phenazopyridine 200 mg PO TID
4. Acyclovir 400 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Simvastatin 10 mg PO QPM
3. Phenazopyridine 200 mg PO TID
4. Acyclovir 400 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 800 UNIT PO DAILY
8. rifaximin 550 mg TID for 14 days
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 ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with PMH of ulcerative colitis s/p laparoscopic
proctocolectomy with end ileostomy (___), c/b parastomal hernia now s/p
hernia repair on ___, and recent admission for symptoms of obstruction,
who presents now with abdominal discomfort and nausea.// Recurrent
obstruction? Ileitis?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP =
6.0 mGy-cm.
2) Spiral Acquisition 5.3 s, 41.6 cm; CTDIvol = 8.5 mGy (Body) DLP = 355.1
mGy-cm.
Total DLP (Body) = 361 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: There is minimal bibasilar atelectasis. Visualized lung fields
are otherwise within normal limits. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. The previously seen 8 mm cyst
in the body the pancreas is stable. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral subcentimeter hypodensities are unchanged, too small to
characterize. A 1.0 cm calculus in the lower pole of the right kidney is
unchanged. There is no hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia, with a small amount of oral
contrast noted within the hernia. The patient is status post proctocolectomy
with right lower quadrant ileostomy and mesh placement at the ostomy site.
There is focal narrowing at the ostomy site, with multiple upstream loops of
dilated, fluid-filled small bowel measuring up to 3.7 cm. Appearance of
possibly diluted contrast material within the jejunum..
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 atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Multilevel degenerative changes of the spine are re-demonstrated, most
pronounced at L4-5.
SOFT TISSUES: Aside from the right lower quadrant ileostomy, the abdominal and
pelvic wall is within normal limits.
IMPRESSION:
1. Focal narrowing at the right lower quadrant ostomy site, with multiple
upstream loops of dilated, fluid-filled small bowel, consistent with partial
versus early complete obstruction.
2. The previously noted possible cystic lesion of the pancreas for which MRCP
was recommended is likely stable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V
Diagnosed with Other intestnl obst unsp as to partial versus complete obst, Unspecified abdominal pain, Nausea with vomiting, unspecified
temperature: 98.5
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 115.0
dbp: 70.0
level of pain: 10
level of acuity: 3.0 | Following her admission, Mrs ___ underwent a CT scan that
failed to show a transition point. Because of this fact and how
her ostomy continued to produce liquid stool and flatus, it was
determined that there was no surgical pathology causing her
symptoms at this time. Her stoma was also intubated with a red
rubber catheter, which facilitated the passage of stool. Her
nausea and vomiting decreased and she continued to progress over
the next two days to the point where she was tolerating a
regular diet well. Her pain and other symptoms were well
controlled and she was able to ambulate independently.
The catheter fell out of the stoma numerous times. We then
decided to place a nasal trumpet into the stoma and stitch it in
place. Stomal output was good and the patient was discharged
home with stomal care instructions.
She will also receive a course of rifaximin 550 mg TID for 14
days, per GI recommendations. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall with abdominal pain
Major Surgical or Invasive Procedure:
___ embolization of splenic artery
___- ___ coil embolization of proximal splenic artery
History of Present Illness:
___ s/p fall ___, now tx from OSH after syncopal event, found
to have grade III splenic laceration, active extravasation; s/p
proximal ___ embolization x2
Past Medical History:
PMH: HTN, HLD, h/o colon ca s/p R colectomy, gout
PSH: Extended right colectomy approx ___ years ago, incisional
hernia repair with mesh approx ___ years ago (in ___
Social History:
___
Family History:
non-contributory
Physical Exam:
Exam on discharge:
T 99 HR 69 BP 136/53 RR 19 96RA
NAD
RRR
CTAB
abd protuberant but soft and near baseline per patient
no edema
Pertinent Results:
___ 03:15PM BLOOD WBC-8.1 RBC-3.87* Hgb-11.7* Hct-34.0*
MCV-88 MCH-30.3 MCHC-34.4 RDW-13.2 Plt ___
___ 01:52AM BLOOD WBC-7.9 RBC-2.83* Hgb-8.7* Hct-25.3*
MCV-89 MCH-30.7 MCHC-34.4 RDW-13.2 Plt ___
___ 02:54PM BLOOD Hct-25.8*
___ 10:00PM BLOOD Hct-22.6*
___ 02:12AM BLOOD WBC-5.5 RBC-2.41* Hgb-7.4* Hct-21.1*
MCV-88 MCH-30.8 MCHC-35.2* RDW-13.9 Plt ___
___ 07:33AM BLOOD Hct-24.6*
___ 01:43PM BLOOD Hct-25.0*
___ 07:30PM BLOOD Hct-24.7*
___ 12:20AM BLOOD Hct-24.4*
___ 04:00AM BLOOD WBC-5.4 RBC-2.74* Hgb-8.6* Hct-24.2*
MCV-88 MCH-31.2 MCHC-35.4* RDW-13.9 Plt ___
___ 12:37PM BLOOD Hct-25.2*
___ 08:44PM BLOOD Hct-26.2*
___ 04:35AM BLOOD WBC-5.5 RBC-2.87* Hgb-8.9* Hct-25.4*
MCV-88 MCH-30.9 MCHC-35.0 RDW-14.3 Plt ___
___ 03:15PM BLOOD ___ PTT-28.9 ___
___ 04:35AM BLOOD ___ PTT-30.1 ___
___ 08:30PM BLOOD Glucose-164* UreaN-21* Creat-1.0 Na-140
K-4.9 Cl-104 HCO3-25 AnGap-16
___ 04:35AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-135
K-3.9 Cl-99 HCO3-30 AnGap-10
___ 01:59AM BLOOD Lactate-1.5
___ Angio: Multiple areas of active extravasation involving the
lower pole of the spleen, all of which supplied by a single
lower pole artery.
Selective coil embolization of supplying low pole artery.
Medications on Admission:
Lipitor 20'; Aspirin 81'; Nadolol 20'; Hydrochlorothiazide 25';
Indomethacin 50'
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Nadolol 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth
every ___ hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
splenic laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man status post fall one day ago with weakness and
dizziness today. CTA demonstrating splenic laceration with active
extravasation. Angiographic assessment with potential splenic artery
embolization is requested in the setting of hemodynamic stability.
OPERATORS: Dr. ___ (fellow) and Dr. ___ (attending)
performed the procedure.
PROCEDURE PERFORMED:
1. Celiac axis and selective splenic artery arteriograms.
2. Selective lower pole branch arteriogram.
3. Embolization of lower pole splenic artery branch.
ANALGESIA: Moderate sedation was achieved by providing divided doses of 300
mcg of fentanyl and 4 mg of midazolam during the total intraservice time of 1
hour and 25 minutes.
PROCEDURE DETAILS:
Written informed consent was obtained outlining the risks, benefits, and
potential complications of the procedure. The patient was brought to the
angiography suite and placed supine on the imaging table. A preprocedure
timeout was performed as per ___ protocol.
Using a combined palpatory and fluoroscopic guidance approach and following
administration of local anesthetic, the right common femoral artery was
accessed with a 19 gauge single wall puncture needle. A 0.035 ___ wire
was easily advanced into the lower thoracic aorta. The needle was removed and
following a 2-mm incision, a 5 ___ vascular sheath was advanced over the
___ wire and into the common femoral artery. The inner dilator was
removed and a sheath was attached to a continuous heparinized saline sidearm
flush. A 5 ___ C2 glide catheter was then used to selectively cannulate
the celiac axis. Run performed from this position demonstrated a large celiac
trunk towards the right with relatively elongated splenic artery. Three areas
of active extravasation were identified involving the lower pole of the
spleen.
Subsequently, a Glidewire was used to gain further purchase of the C2 glide
catheter into the splenic artery. DSA run was performed from that position.
The latter redemonstrated multiple active bleeding sources involving the lower
pole of the spleen, all of them supplied by a lower pole splenic artery
branch.
Accordingly, a decision was made against proximal splenic artery embolization
and selective embolization of the supplying lower pole splenic branch.
Hence the combination of Renegade ___ and a double-angled Glidewire was used
to select the lower pole branch. Another DSA run performed with the
microcatheter confirmed the previous findings and was used to fine tune the
position of the microcatheter for subsequent coiling. Subsequently, 5 and
6-mm Hilal Cook embolization coils were deployed in the lower pole splenic
artery branch. A control run performed over the 5 ___ C2 glide catheter
demonstrated satisfactory result with cessation of previously identified
active extravasation and markedly reduced parenchymal blush involving the
lower pole of the spleen.
The catheter and the sheath were removed and hemostasis achieved by holding
pressure for about 20 minutes.
IMPRESSION:
1. Multiple areas of active extravasation involving the lower pole of the
spleen, all of which supplied by a single lower pole artery.
2. Selective coil embolization of supplying low pole artery.
Radiology Report
HISTORY: Recent splenic artery embolization, new abdominal distention and
tympany.
FINDINGS: Single portable supine view of the abdomen is submitted. The bowel
gas pattern is unremarkable without evidence of ileus or obstruction. The
left upper quadrant embolization coil is appreciated. Bony structures and
remaining soft tissues are grossly unremarkable, some vascular calcification.
IMPRESSION: No ileus or obstruction.
Radiology Report
INDICATION: ___ man with splenic laceration following selective
splenic artery embolization with continuous oozing down-trend of hematocrit.
OPERATORS: Dr. ___ (fellow), Dr. ___, Dr. ___
___ and Dr. ___.
PROCEDURES PERFORMED:
1. Selective splenic artery arteriogram.
2. Reinforcement of selective lower pole splenic artery embolization by use
of additional coils, Gelfoam and glue.
3. Proximal splenic artery embolization between the dorsal pancreatic and
pancreatic magna.
MEDICATION: Moderate sedation was achieved by providing divided doses of 6 mg
of midazolam and 275 mcg of fentanyl during the entire procedure time of 280
minutes.
RADIATION DOSE: 4867 mGy.
PROCEDURE DETAILS: Written informed consent was obtained from the patient.
The patient was brought to the angio suite and placed supine on the imaging
table. A preprocedure timeout was performed as per ___ protocol.
Using a combined palpatory and fluoroscopic guidance and following
administration of local anesthetic, the right common femoral artery was
accessed with a 19-gauge single wall puncture needle. A 0.035 ___ wire
was easily advanced into the lower aorta and the needle then exchanged for a 5
___ vascular sheath. The latter was attached to a continuous heparinized
saline sidearm flush. A combination of Glidewire and 5 ___ C2 Glide
catheter was then used to access the celiac trunk and advance the Glide
catheter into the splenic artery. A DSA run performed from that position
demonstrated persistent flow through the recently coiled lower pole splenic
artery with signs of partial recanalization and identification of one active
bleeding source. Once again no active extravasation was seen involving the
remainder of the spleen.
In an attempt to reinforce the lower pole artery embolization, four additional
5 mm Cook Hilal embolization coils were placed in the existing coil pack. This
was performed after introducing a Renegade ___ microcatheter and advancing it
by help of a 0.018 double J glidewire. In addition, about 2 cc of Gelfoam was
deployed in the coil pack. Subsequently, Dermabond glue was mixed with
lipiodol (1:4), the microcatheter in the coil pack primed with D5 solution and
a small amount of glue injected in the area of the coil pack. However, as
visualistion of the glue was suboptimal, we refrained from a more aggressive
approach or occlusion of the entire feeding vessel.
The microcatheter was then removed and an additional run performed over the
main 5 ___ catheter. The latter demonstrated significant reduction of flow
in the lobe artery, however, with residual flow and mild active extravasation
despite all previous treatment attempts.
Accordingly, a decision was made to at add a proximal splenic artery
embolization between the dorsal pancreatic and pancreatic magna arteries. To
this end, Renegade ___ catheter was advanced with a Transcend wire and
adequately positioned. As 10 mm Hilal embolization coils would not form in
the splenic artery, four 22 mm GDC coils were eventually deployed proximal to
the pancreatic magna, resulting in subtotal occlusion of the splenic artery
with cessation of active extravasation and significant reduction of
parenchymal blush involving the lower splenic pole. At this point, note was
also made of a new perfusion deficit involving the upper pole of the spleen,
likely related to some degree of non-targeted embolization by previous Gelfoam
injection.
Given the satisfactory result, all catheters and the sheath were withdrawn and
manual pressure was applied for 20 minutes. The patient withstood the
procedure well and there were no immediate complications.
IMPRESSION:
1. Reinforcement of selective lower pole splenic artery embolization by means
of additional coils, Gelfoam and glue.
2. Performance of proximal splenic artery embolization.
Gender: M
Race: OTHER
Arrive by UNKNOWN
Chief complaint: SPLENIC INJURY
Diagnosed with SPLEEN PARENCHYMA LACER, UNSPECIFIED FALL
temperature: 98.0
heartrate: 82.0
resprate: 18.0
o2sat: 97.0
sbp: 118.0
dbp: 72.0
level of pain: 10
level of acuity: 2.0 | Patient was found to have a Grade III splenic laceration and was
initially taken by ___ where he had embolization of the lower
pole. He was brought to the ICU for close monitoring afterwards
and on serial Hcts he was noted to be drifting. He was
normotensive and his Urine output was adequate. His abdomen was
large but patient stated that this was near his baseline. He was
transfused 2u RBC on ___ and then again on ___. He was not
bumping appropraitely with the transfusions and after
considering taking him to the operating room for a splenectomy
___ believed they could stop the slow drift and on repeat angio
he was found to have a low extravasation and had proximal
embolization of the splenic artery. After that point all was
stable including his urine output, abd girth, hematocrit, and
symptoms. He was discharged to home tolerating a regular diet,
voiding, and with good pain control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Metoclopramide
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation ___ - ___
History of Present Illness:
___ with hx of dementia (non-verbal at baseline), HTN, DM2,
schizophrenia who presents from her nursing facility with AMS.
Per report, patient has possible unwitnessed seizure as drooling
when found and reported bleeding from her tongue. Per report
obtained from brother in ___ and nursing home sign out, patient
is non-verbal at baseline.
On initial presentation to the ___ patient was unresponsive,
drooling at mouth. Withdrawing to pain. GCS 6. Pupils equal,
reactive to light. Vitals 100, 67, 144/79, 16, 89% on 2L.
Patient was rapidly intubated for airway protection. Initial
labs notable for white count 7.4, Hgb 12.8, Chem 7 with Cr of
1.8 (appears to be close to prior baseline) with AG of 18.
Lactate elevated at 6.4. UA frankly positive. Trop 0.02. UTox
negative. Patient given ~2L NS and 1gm IV Ceftriaxone. CT head
without evidence of acute intracranial pathology. Neurology
consulted and after obtaining collateral from nursing home, did
not feel that patient had true seizure and was only noted to
have occasional myoclonic jerks in the ___ for with Ativan was
administered without effect. In the setting of toxic-metabolic
encephaolopathy "Myoclonic jerks ... are not unexpected. As
there is no clear semiology concerning for seizure, no personal
or family history of seizure, would not obtain EEG at this time.
No AED needed." Patient was then admitted to MICU.
Of note, patient developed sinus bradycardia just prior to
transfer to the MICU. HR dropped to 38 but then quickly came up
to high ___. BP stable. EKG notable only for sinus bradycardia.
On arrival to the MICU, patient intubated, sedated and HD
stable.
ROS: unable to obtain due to intubation and baseline non-verbal
status.
Past Medical History:
Past Medical History:
Schizophrenia-like disorder
HTN
h/o PNA
chronic pulmonary disease
DM
___ edema
Lichen Planus
Past Surgical History:
Hysterectomy
BSO
Ventral hernia repair (?mesh)
"Cyst excision" (after her ovarian resection)
Social History:
___
Family History:
mother w/ DM. No h/o cancer or significant CAD
Physical Exam:
ADMISSION PE:
Vitals: T: 98.2 BP: 159/60 P: 60 R: 18 O2: 100% on ___
GENERAL: Intubated and sedated
HEENT: Sclera anicteric, MMM, pinpoint pupils
NECK: supple, JVP not apprecated ___ body habitus
LUNGS: Ventilated breathsounds apprecaited anteriorly without
rales, ronchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: obese. soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
appreciated
EXT: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes/lesions noted
NEURO: Intubated, sedated, not following commands.
DISCHARGE PE:
Vitals: Temp 98.9 HR ___ BP 130s-160s/60s-70s RR ___ SpO2
96-100% on 2L NC
GENERAL: Babbling. Laying comfortably in bed.
HEENT: Sclera anicteric, MMM
NECK: supple, JVP not appreciated ___ body habitus
LUNGS: clear to auscultation in all fields, no wheezes, ronchi,
or increased WOB
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: obese. soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
appreciated
EXT: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes/lesions noted
NEURO: not following commands. wiggles toes spontaneously
bilaterally. strength and sensation unable to be tested
Pertinent Results:
ADMISSION LABS:
___ 04:10PM BLOOD WBC-7.4 RBC-4.61 Hgb-12.8 Hct-42.2 MCV-92
MCH-27.8 MCHC-30.3* RDW-13.1 RDWSD-43.1 Plt ___
___ 04:10PM BLOOD Neuts-67.6 ___ Monos-6.3 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-5.00 AbsLymp-1.81 AbsMono-0.47
AbsEos-0.07 AbsBaso-0.03
___ 04:10PM BLOOD Plt ___
___ 04:10PM BLOOD Glucose-220* UreaN-34* Creat-1.8* Na-144
K-4.5 Cl-105 HCO3-21* AnGap-23*
___ 04:10PM BLOOD ALT-9 AST-13 AlkPhos-84 TotBili-0.3
___ 04:10PM BLOOD Lipase-31
___ 04:10PM BLOOD cTropnT-0.02*
___ 04:10PM BLOOD Albumin-4.4 Calcium-10.3 Phos-3.9 Mg-1.9
___ 05:52PM BLOOD Type-ART pO2-348* pCO2-37 pH-7.42
calTCO2-25 Base XS-0
___ 04:29PM BLOOD Lactate-6.4*
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-5.8 RBC-3.95 Hgb-11.0* Hct-36.7
MCV-93 MCH-27.8 MCHC-30.0* RDW-13.1 RDWSD-44.2 Plt ___
___ 07:35AM BLOOD Glucose-169* UreaN-20 Creat-1.4* Na-147*
K-3.5 Cl-111* HCO3-23 AnGap-17
___ 07:35AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0
___ 08:32AM BLOOD ___ pO2-138* pCO2-42 pH-7.40
calTCO2-27 Base XS-1
MICRO:
Blood Cx: NGTD
Urine Cx: contaminated
STUDIES/IMAGING:
CXR: Low lung volumes with bibasilar opacities, likely
atelectasis. Infection cannot be excluded.
CT Head:
1. No acute intracranial process.
2. Age advanced atrophy
3. Chronic small vessel disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Senna 17.2 mg PO BID
2. Simvastatin 20 mg PO QPM
3. Vitamin D 400 UNIT PO DAILY
4. Acetaminophen 650 mg PO Q4H:PRN fever
5. Bisacodyl 10 mg PR QHS:PRN constipation
6. Amlodipine 10 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. GlipiZIDE 5 mg PO BID
9. MetFORMIN (Glucophage) 750 mg PO QHS
10. Metoprolol Tartrate 75 mg PO BID
11. Mirtazapine 30 mg PO QHS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 75 mg PO BID
4. Senna 17.2 mg PO BID
5. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q4H:PRN fever
7. Bisacodyl 10 mg PR QHS:PRN constipation
8. GlipiZIDE 5 mg PO BID
9. Mirtazapine 30 mg PO QHS
10. Simvastatin 20 mg PO QPM
11. Vitamin D 400 UNIT PO DAILY
12. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
complicated urinary tract infection
seizures
Secondary diagnosis:
schizophrenia
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
INDICATION: ___ with AMS, ?seizure. intubated // eval for tube placement,
eval for bleed
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
Low lung volumes are noted. Endotracheal tube tip is approximately 5.5 cm
from the carina. There are bibasilar opacities, likely atelectasis.
Superiorly the lungs are clear. Cardiac silhouette is likely accentuated by
AP technique with low lung volumes. No acute osseous abnormalities.
IMPRESSION:
Low lung volumes with bibasilar opacities, likely atelectasis. Infection
cannot be excluded.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with AMS, ?seizure. intubated
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformats were obtained.
DOSE: Total DLP (Head) = 892 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major, hemorrhage, edema, or large mass. There
are extensive bilateral periventricular and subcortical white matter
hypodensities, which are nonspecific but may represent a sequela of chronic
small vessel ischemic changes. There is prominence of the ventricles and
sulci suggestive involutional changes, age advanced.
Atherosclerotic calcifications are seen within the bilateral carotid siphons.
There is no fracture. Mild mucosal thickening is noted within the bilateral
ethmoid air cells. Remainder of 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 acute intracranial process.
2. Age advanced atrophy
3. Chronic small vessel disease.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: Tube placement
COMPARISON: ___
IMPRESSION:
Newly placed nasogastric tube. The tip projects over the gastroesophageal
junction. No evidence of complications.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with question seizures intubated for airway
protection // interval change
TECHNIQUE: Portable semi-upright chest radiograph.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The ETT terminates 5 cm above the carina. The NG tube curls in the stomach.
Low lung volumes. There is bibasilar atelectasis, left worse than right. The
lungs are otherwise clear. Heart size is stable. The mediastinal and hilar
contours are stable. The pulmonary vasculature is normal. No pleural effusion
or pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
1. Appropriate positioning of the ETT and NG tube.
2. Bibasilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with altered mental status // Evaluate for
infiltrates
IMPRESSION:
As compared to ___ radiograph, bibasilar atelectasis has slightly
worsened. No other relevant changes.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, Hypoxia
Diagnosed with URIN TRACT INFECTION NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, SENILE DEMENTIA UNCOMP, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: nan
heartrate: 80.0
resprate: 16.0
o2sat: 89.0
sbp: 132.0
dbp: 68.0
level of pain: 13
level of acuity: 1.0 | ___ with hx of demenatia (non-verbal at baseline), HTN, DM2,
schizophrenia who presents from her nursing facility with AMS
likely ___ to urosepsis with concern for seizure.
# Encephalopathy
# Seizure disorder
Most likely due to complicated UTI and seizure activity.
Unfortunately, unclear mental baseline on admission and patient
reportedly unable to follow commands or speak clearly at
baseline. Patient intubated in ___ for airway protection and
admitted to MICU. Patient given course of IV Ceftriaxone for
presumed Urosepsis. Patient also with question of myoclonic
jerks initally. Neurology intitially felt that unlikely sizure,
however performed EEG which was felt to be consistent with
seizure activity. Patient loaded and started on daily Keppra.
She will need 1 month of Keppra and follow-up in Neurology
clinic. Blood cultures obtained and were negative. Patient
gradually returned to her baseline mental status.
# Complicated UTI: Patient treated with ceftriaxone initially
and transitioned to cefpodoxime at discharge. She should
complete a 7 day course (___).
# Respiratory Failure - intubated for airway protection in ___
with only minimal vent settings. Patient easily extubated on HD
2. Continued on famotidine while intubated.
# Lactic Acidosis - DDx included urosepsis vs seizure vs
metformin induced lactic acidosis. Lactate improved with IVF and
seizure treatment as above. |