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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / ibuprofen
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ERCP
___: laparoscopic cholecystectomy
History of Present Illness:
___ yo F with history of biliary colic, who presents with
epigastric pain and nausea. Pt developed nausea and epigastric
pain radiating to the back last ___ after eating a
bacon cheeseburger for dinner. Pt initially thought it was GERD
but symptoms did not improve with ranitidine and OTC antacids.
The following day she felt a little better but in the subsequent
days she had recurrence of symptoms. She was seen in primary
care clinic on ___ where she had LFT's drawn which were
elevated. RUQ u/s done as an outpatient showoed no
choledocholithiasis or cholecystitis but did show
cholelithiasis. Pt had persistent elevation in her LFT's on
follow up labs so she was urged to come to the ED for evaluation
today. Notably, pt reports that her pain improved today, no
longer has abdominal pain and is just nauseous. Denies any
fevers or chills during this entire period of time.
In the ED, vitals were stable. No leukocytosis. Transaminases
and Tbili elevated but downtrending on serial checks in the ED.
Lipase elevated at 700. Pt admitted for further management.
Past Medical History:
PMH:
1. History of sigmoid colon adenomatous polyp, ___.
2. Mild mitral regurgitation on stress echocardiogram, ___.
3. History of hypothyroidism.
4. History of hypercholesterolemia treated in the past with a
statin, which she stopped.
5. History of lower GI bleed which she thinks might have been
related to naproxen.
6. History of frozen shoulder.
PSH:
1. Status post vaginal hysterectomy, ovaries remain, for
uterine
prolapse, in ___ by Dr. ___.
2. Status post kidney stones removed in approximately ___.
3. Status post basal cell carcinoma excised from her nose x 2.
She had it done in ___.
4. Status post left wrist surgery about ___ years ago after a
fracture with plate and screws placed.
Social History:
___
Family History:
Mother had ___.
Physical Exam:
Vitals: T 98.1 146/80 95 18 97%RA
Gen: NAD
HEENT: no jaundice
CV: rrr, no rmg
Pulm: clear b/l
Abd: soft, no tenderness, normal bowel sounds
Ext: no edema
Neuro: alert and oriented x 3, no focal deficits
Pertinent Results:
___ 08:17PM WBC-8.9 RBC-4.03* HGB-13.0 HCT-36.9 MCV-92
MCH-32.3* MCHC-35.3* RDW-13.4
___ 08:17PM PLT COUNT-173
___ 08:17PM GLUCOSE-111* UREA N-13 CREAT-1.0 SODIUM-138
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
___ 03:00PM ALT(SGPT)-394* AST(SGOT)-219* ALK PHOS-350*
AMYLASE-388* TOT BILI-5.0*
___ 08:17PM ALT(SGPT)-367* AST(SGOT)-193* ALK PHOS-316*
TOT BILI-4.1* DIR BILI-2.6* INDIR BIL-1.5
___ 08:17PM LIPASE-368*
___ 03:00PM LIPASE-701*
___ 10:11PM URINE RBC-0 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1 RENAL EPI-<1
RUQ u/s ___:
1. Diffusely increased hepatic echogenicity suggestive of
hepatic steatosis.
Underlying fibrosis, cirrhosis, or steatohepatitis cannot be
excluded by
ultrasound.
2. Gallstones measuring up to 2.6 cm without evidence of acute
cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Ranitidine 150 mg prn
3. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
Discharge Medications:
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth Q4 hours Disp #*30
Tablet Refills:*0
5. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
6. Ranitidine 150 mg PO DAILY:PRN heartburn
7. Senna 8.6 mg PO BID:PRN cosntipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___ pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with cholelithiasis // pre-op eval Surg:
___ (CCY)
COMPARISON: Compared to prior radiographs from ___.
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. Lungs are slightly
hyperexpanded. There are no focal consolidations, pleural effusion, or
pulmonary edema. There are no pneumothoraces.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Jaundice, Abnormal labs
Diagnosed with ACUTE PANCREATITIS, CHOLELITHIASIS NOS
temperature: 98.9
heartrate: 92.0
resprate: 18.0
o2sat: 99.0
sbp: 132.0
dbp: 99.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is an ___ presenting with likely choledocholithiasis
with passed stone with associated gallstone pancreatitis. She
was started on ciprofloxacin. She underwent ERCP on ___ where a
sphincterotomy was done and the biliary tree was swept. One
large stone was seen in the gallbladder. She was transfered to
the ACS surgery for a laparoscopic cholecystectomy which was
completed on ___ withut any complications. Please see operative
note for further details. She recovered well post-operatively.
Pain was initially not very well controlled and she had to be
encouraged to take the narcotics as needed. SHe worked with
physical therapy who recommended that she could be discharged
home. By POD1 she was tolerating a regular diet and by POD3 was
ambualating without issues, tolerating a regular diet, pain well
controlled and stable for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Amlodipine / omeprezole / lansoprazole / ACE
Inhibitors
Attending: ___
Chief Complaint:
Fall at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH afib on ASA, CAD, HTN, and etoh abuse who presents
following s/p unwitnessed fall in his bedroom. Known AFib, used
to take Coumadin but was d/c'd by PCP due to recurrent falls.
Yesterday evening, pt arose from bed to go to the bathroom.
While walking to bathroom, he fell and struck his head. He
states his R knee gave out, which has happened previously. He
normally walks with cane but does not know if he was using it at
the time. Denies N/V or lightheadedness at the time, though he
sometimes feels a little lightheaded when he gets up from lying
or seated position. He is unsure if he lost consciouness. Wife
heard a crash and found him down. She is unsure if he lost
consciousness but states he initially did not respond to her
questions. She believes a hole in the wall was from his elbow,
and that he hit his head on a closet door; pt sustained head
abrasion. Pt reports somewhat poor po, but consistent with
baseline. No recent med changes, other than starting on
colchicine for gout (was recently seen by PCP for gout in R
great toe).
Pt drinks 10 beers per day at baseline, with last drink
yesterday at 5pm. Wife states he was not intoxicated yedsterday
evening. He denies prior history of seizure or withdrawal.
Denies incontinence or tongue biting with fall.
Pt underwent cath in ___ which showed LAD disease (stent placed
at that time), mild mitral stenosis, and 60% EF at that time. Pt
underwent 24 hr Holter monitoring in ___ which showed afib with
slow response and low grade ventricular ectopy, without
symptoms.
In the ED, initial vital signs were: 97.8 90 170/100 18 99% ra.
Labs were notable for glucose 143, WBC 5.0, hct 38.4, INR 1.0,
Trop-T: <0.01, serum tox negative for ethanol. EKG showed A fib
@66, nonspecific inferior/lateral St-T changes. CT head without
acute intracranial process. CT C-spine without acute fracture.
CXR with mild pumonary edema without consolidation. Pt was
placed in c-collar which was removed. Pt was not treated with
antihypertensives.
On Transfer Vitals were: 97.5 57 177/69 22 98% RA. Upon arrival
to the floor, pt SBP 230s; pt triggered. EKG showed afib with
small ST depression (1mm) in lateral leads, consistent with
prior. Pt reports sore ribs. Denies f/c, N/V, feeling
lightheaded, SOB.
Past Medical History:
CAD, s/p cath ___ with LAD stent
Cardiomyopathy ?EtOH related
Afib
HTN
TIA ___
Lacunar infarct (left external capsule)
Mucus retention cyst in right maxillary sinus
Arachnoid cysts in left temporal fossa
Rhinitis
?COPD
Pulmonary hypertension
Peripheral neuropathy
Prostate cancer s/p radiation
Shingles ___
Morbid obesity
GERD
EOSINOPHILIC ESOPHAGITIS
Schatzki's ring (ESOPHAGEAL STRICTURE)
FOREIGN BODY ESOPHAGUS
Macular degeneration
Glaucoma
Retinal artery occlusion in left eye
DIVERTICULOSIS
___ (1:1280)
Past surgical history:
s/p carotid endarterectomy
Social History:
___
Family History:
2 daughters and son healthy. Father died of CVA at ___.
Mother had dementia and expired at age ___. No known history of
sudden cardiac death.
Physical Exam:
On admission:
Vitals- 97.8 BP R arm 234/107, L arm 197/94, 59 20 98%RA
General- Elderly man lying in bed, alert, NAD
HEENT- Abrasions on anterior head, sclera anicteric, dry MM,
oropharynx clear
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: tenderness to palpation over R lateral chest
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- oriented x 3, CNs2-12 intact, strength ___ throughout, no
tremor or asterixis
On discharge:
Vitals- 99.2 150/80 62 18 96%RA
General- Elderly man lying in bed, alert, oriented, NAD
HEENT- Abrasions on anterior head, sclera anicteric, MMM,
oropharynx clear
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- regular rate, irregular rhythm, + systolic murmur
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- no hand tremor or asterixis
Pertinent Results:
==================
Labs:
==================
___ 04:45AM BLOOD WBC-5.0 RBC-3.70*# Hgb-12.6*# Hct-38.4*#
MCV-104* MCH-33.9* MCHC-32.7 RDW-12.0 Plt ___
___ 06:20AM BLOOD WBC-5.9 RBC-3.47* Hgb-12.1* Hct-35.6*
MCV-102* MCH-34.9* MCHC-34.1 RDW-12.7 Plt ___
___ 04:45AM BLOOD Neuts-75.5* Lymphs-16.5* Monos-6.7
Eos-0.9 Baso-0.3
___:45AM BLOOD ___ PTT-26.4 ___
___ 04:45AM BLOOD Glucose-129* UreaN-17 Creat-0.9 Na-135
K-3.5 Cl-98 HCO3-24 AnGap-17
___ 05:56AM BLOOD Glucose-101* UreaN-16 Creat-0.8 Na-133
K-3.5 Cl-101 HCO3-25 AnGap-11
___ 04:45AM BLOOD ALT-40 AST-54* AlkPhos-87 TotBili-0.8
___ 06:20AM BLOOD CK(CPK)-139
___ 04:45AM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD CK-MB-7 cTropnT-<0.01
___ 04:45AM BLOOD Albumin-4.2 Calcium-8.7 Phos-3.4 Mg-1.9
___ 05:56AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8
___ 04:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
==================
Micro:
==================
None
==================
Imaging:
==================
Portable TTE (Complete) Done ___ at 3:29:10 ___ FINAL
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (valve area 1.0-1.2cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Moderate calcific aortic
stenosis. Mild mitral regurgitation. Moderate pulmonary
hypertension.
CT HEAD W/O CONTRAST Study Date of ___ 4:49 AM
IMPRESSION:
1. No acute intracranial abnormality.
2. Low-attenuation regions in the right frontal and occipital
lobes, likely from prior infarctions.
3. Large arachnoid cyst in the left middle cranial fossa,
unchanged.
CT C-SPINE W/O CONTRAST Study Date of ___ 4:50 AM
IMPRESSION: No acute fracture. Minimal anterolisthesis of C3
on C4, likely chronic and related to degenerative disc and facet
joint disease at this level.
CHEST (SINGLE VIEW) Study Date of ___ 6:16 AM
IMPRESSION: No focal consolidation. Mild pulmonary edema from
congestive heart failure.
EKG ___: Atrial fibrillation with a mean ventricular rate of
66. Non-specific repolarization abnormalities. Compared to the
previous tracing of ___ there is no significant change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 80 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Thiamine 100 mg PO DAILY
4. Valsartan 80 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Colchicine 0.6 mg PO DAILY
9. Alphagan P (brimonidine) 0.1 % ophthalmic 1 drop each eye TID
10. Azopt (brinzolamide) 1 % ophthalmic 1 drop each eye TID
11. Lumigan (bimatoprost) 0.01 % ophthalmic 1 drop each eye qhs
Discharge Medications:
1. Alphagan P (brimonidine) 0.1 % ophthalmic 1 drop each eye TID
2. Aspirin 325 mg PO DAILY
3. Azopt (brinzolamide) 1 % ophthalmic 1 drop each eye TID
4. Colchicine 0.6 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Lumigan (bimatoprost) 0.01 % ophthalmic 1 drop each eye qhs
9. Simvastatin 40 mg PO DAILY
RX *simvastatin 40 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
10. Thiamine 100 mg PO DAILY
11. Valsartan 160 mg PO DAILY
RX *valsartan [Diovan] 160 mg 1 tablet(s) by mouth once daily
Disp #*30 Tablet Refills:*0
12. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once daily Disp #*30
Capsule Refills:*0
13. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*0
14. Rolling Walker
Diagnosis: Probable syncope
Prognosis: Good
Length of need: Lifetime
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Probable syncope in setting etoh use
Secondary:
-EtOH abuse
-HTN, uncontrolled
-___
-CAD
-Afib
-Macrocytic anemia
-Gout
-Glaucoma
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: Fall, evaluate for bleeding or fracture.
COMPARISON: ___.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered. Coronal and sagittal reformations were performed.
Bone algorithm was obtained.
Total DLP is 1003 mGy-cm. CTDIvol is 50 mGy.
FINDINGS: There is no evidence of acute hemorrhage, edema, mass, mass effect,
or acute territorial infarction. There are periventricular white matter
hypodensities most consistent with chronic small vessel ischemic disease,
slightly progressed from prior study. There is an area of encephalomalacia in
the right frontal lobe which may represent prior infarction. In the right
occipital lobe, there is an area of encephalomalacia which is new from prior
study but appears chronic likely from prior infarction or injury. The large
area of low attenuation in the left temporal fossa is unchanged most
consistent with an arachnoid cyst. Mild mucosal thickening in the maxillary
sinuses bilaterally and sphenoid sinus. The mastoid air cells are well
aerated. No fracture is identified.
IMPRESSION:
1. No acute intracranial abnormality.
2. Low-attenuation regions in the right frontal and occipital lobes, likely
from prior infarctions.
3. Large arachnoid cyst in the left middle cranial fossa, unchanged.
Radiology Report
INDICATION: Fall, evaluate for bleeding or fracture.
COMPARISON: None available.
TECHNIQUE: MDCT images were obtained through the cervical spine without
contrast. Coronal and sagittal reformations were performed. Bone algorithm
was obtained.
Total DLP is 856 mGy-cm. CTDIvol is 37 mGy.
FINDINGS: There is no acute fracture. There is minimal anterolisthesis of C3
on C4. There are mild degenerative changes of the cervical spine, most
prominent from C3-4 to C5-6. There is no prevertebral soft tissue
abnormality. There is no aerodigestive tract abnormality. The visualized
lung apices are grossly clear.
Noted is medialization of the right common carotid artery, with extensive
calcification of the carotid bulb and proximal ICA.
IMPRESSION: No acute fracture. Minimal anterolisthesis of C3 on C4, likely
chronic and related to degenerative disc and facet joint disease at this
level.
Radiology Report
INDICATION: Altered mental status.
COMPARISON: Chest radiograph on ___.
FINDINGS: AP view of the chest. There are diffuse hazy opacities in the lung
bilaterally, with cephalization of the vessels and engorgment of the
mediastinal vessels. There is no pleural effusion or pneumothorax. No focal
consolidation. Cardiomediastinal and hilar contours are normal. There is
prominence of the central vasculature.
IMPRESSION: No focal consolidation. Mild pulmonary edema from congestive
heart failure.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with SYNCOPE AND COLLAPSE
temperature: 97.8
heartrate: 90.0
resprate: 18.0
o2sat: 99.0
sbp: 170.0
dbp: 100.0
level of pain: 13
level of acuity: 2.0 | ___ w/ PMH afib on ASA, CAD, HTN, and etoh abuse who presents
following s/p unwitnessed fall at home.
# Probable syncope, vs mechanical fall: It is unclear if pt lost
consciousness, though wife reports not initially responsive to
questioning. Per wife report pt was not intoxicated, and serum
etoh was negative, though pt had been drinking during the day
before the fall. Syncope workup did not reveal etiology. Pt did
not report history consistent with vasovagal. Pt was not
orthostatic. EKG and troponins not consistent with ACS. Echo
shows preserved EF with mild mitral stenosis. No significant
events on tele. CT head negative. Pt to have home ___ and OT
following discharge.
# Etoh abuse: Pt drinks ~10 beers per day at baseline. Pt denies
history of seizures or withdrawal symptoms. Given extensive
drinking history and negative serum etoh, was placed on CIWA,
and received 2 doses of diazepam. Did not score >10 on CIWA
during the day prior to discharge. Was treated with folated,
thiamine, and multivitamin. Pt has no intention to stop
drinking.
# HTN: SBP elevated to 230s on arrival to floor. Possibly
secondary to pain following fall, though pt did not report
severe pain. Was at risk for EtOH withdrawal but was treated as
per CIWA protocol. Recieved prn doses of hydralazine. Home
valsartan was increased from 80mg to 160mg daily, and was
started on spironolactone 25mg daily. His primary cardiologist
was made aware. Has allergy to amlodipine.
# dCHF: Continued on home lasix.
# CAD, history of TIA: continued on home aspirin. Simvastatin
dose was reduced from 80mg to 40mg daily, given increased risk
of myopathy as pt had recently started on colchicine for gout.
# Afib: Not on coumadin at home due to history of falls. Was
continued on home aspirin.
# Macrocytic anemia, thrombocytopenia, possibly secondary to
etoh abuse: Continued on B12 supplementation.
# ?COPD: Was treated with albuterol and ipratropium nebs prn.
# Gout: Continued on home colchicine.
# Glaucoma: Continued on home eye drops. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Isopropyl alcohol ingestion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx significant for major depressive disorder & PTSD,
alcohol abuse without any history of withdrawal seizures, who
presented with ingestion of hand sanitizer. The patient lives in
a group home for patients with substance abuse, and reported
that he drank 2 bottles of hand sanitizer earlier on the day of
admission. He denied any other alcohol or drug use and denies
IVDU.
In the ED, initial vital signs were: T 97.7, HR 75, BP 125/81,
RR 18, 95% RA. Exam in the ED was unremarkable. Labs were
notable for Na 146, mildly elevated; lactate 3.0; EtOH 148; osms
339; normal osmolar gap at 7, and normal anion gap of 16. Tox
screen was positive for ethanol (___) and benzodiazepines. EKG
showed NSR with QRS of 113 that decreased to 96 on repeat.
Non-contract head CT showed no evidence of acute intracranial
hemorrhage or mass, but evidence of acute/chronic sinus disease.
Patient was given 2L of NS, IV Thiamine 300mg, followed by 200mg
PO, Diazepam 20 mg IV, then 10mg IV x2, Haloperidol 2.5 mg IV,
Ibuprofen 800 mg PO ONCE, Folic Acid 1 mg PO ONCE. Vitals on
transfer were T 97.6, P ___, BP 131/76, RR 22, 97% RA.
Upon arrival to the floor, the patient reports that he's feeling
better. He explains that he relapsed at his group home and drank
2 bottles of hand sanitizer. He shows no signs of regret. He
reports some fevers and chills initially, followed by diarrhea,
and visual and auditory hallucinations. Upon further
questioning, patient reports that he has had some significant
family troubles in the past few years and has been having
trouble coping with everything that has happened in his life. He
wants to get into a dual diagnosis program such as the on at
___ so that he can be properly treated.
Review of Systems:
per HPI
Past Medical History:
Alcohol abuse
Depression
PTSD
Social History:
___
Family History:
Depression in aunts and uncles.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.1, 143/88, 108, 20, 99%RA
GENERAL: AOx3, NAD
HEENT: NCAT. PERRL. Oropharynx clear.
NECK: No cervical LAD.
CARDIAC: RRR, no murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales.
BACK: No CVA tenderness.
ABDOMEN: Obese, mildly distended, non-tender to deep palpation
in all four quadrants. Normal bowels sounds.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses 2+
bilaterally.
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 99.1, 118-147/63-80, 85-105, ___, 94-97RA
GENERAL: AOx3, NAD, sad and anxious
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Deaf in L ear. Moist mucous membranes, poor
dentition. Oropharynx is clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Minimal left basilar crackles.
ABDOMEN: Normal bowels sounds, distended and tender to deep
palpation in lower right and lower left quadrants. Negative
peritoneal signs or ___ sign. Tympanic to percussion. Liver
and spleen margins not appreciated.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Mild ataxia and dysmetria (finger to nose test),
dysdiadochokinesia (pronation/supination test)consistent with
yesterday. Gait is wide based. Cannot perform heel-toe walking.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:15AM PLT COUNT-100*
___ 12:15AM NEUTS-41.1 ___ MONOS-10.9 EOS-4.0
BASOS-1.3* IM ___ AbsNeut-1.97 AbsLymp-2.03 AbsMono-0.52
AbsEos-0.19 AbsBaso-0.06
___ 12:15AM WBC-4.8 RBC-4.17* HGB-12.2* HCT-36.2* MCV-87
MCH-29.3 MCHC-33.7 RDW-15.3 RDWSD-47.9*
___ 12:15AM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-POS* barbitrt-NEG tricyclic-NEG
___ 12:15AM OSMOLAL-339*
___ 12:15AM ALBUMIN-3.6 CALCIUM-7.8* PHOSPHATE-3.9
MAGNESIUM-1.8
___ 12:15AM LIPASE-19
___ 12:15AM ALT(SGPT)-24 AST(SGOT)-44* ALK PHOS-93 TOT
BILI-0.5
___ 12:15AM estGFR-Using this
___ 12:15AM GLUCOSE-90 UREA N-9 CREAT-0.6 SODIUM-146*
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-26 ANION GAP-16
___ 12:31AM LACTATE-3.0*
___ 12:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 12:40AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:40AM URINE bnzodzpn-POS* barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 12:40AM URINE HOURS-RANDOM
___ 10:45AM GLUCOSE-93 UREA N-8 CREAT-0.8 SODIUM-141
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-20* ANION GAP-19
___ 01:28PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS* barbitrt-NEG tricyclic-NEG
___ 01:28PM ACETONE-SMALL OSMOLAL-320*
___ 01:28PM GLUCOSE-151* UREA N-7 CREAT-0.8 SODIUM-143
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-24 ANION GAP-17
DISCHARGE/PERTINENT LABS:
=========================
___ 08:28AM BLOOD WBC-8.3 RBC-4.37* Hgb-12.8* Hct-38.3*
MCV-88 MCH-29.3 MCHC-33.4 RDW-15.7* RDWSD-49.3* Plt ___
___ 08:28AM BLOOD Glucose-109* UreaN-8 Creat-1.0 Na-136
K-3.3 Cl-98 HCO3-24 AnGap-17
___ 08:28AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.7
___ 08:31AM BLOOD VitB___-___ Folate-9.3
___ 09:45AM BLOOD HIV Ab-Negative
___ 04:02PM BLOOD Lactate-1.7
MICROBIOLOGY:
=============
___ 12:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 2:35 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
IMAGING:
========
HEAD CT W/O CONTRAST (___):
1. Study is mildly degraded by motion.
2. Within limits of study, no evidence of acute intracranial
hemorrhage.
3. Within limits of this motion degraded, noncontrast
examination, no definite evidence of intracranial mass.
4. Interval progression of paranasal sinus disease concerning
for acute and chronic sinusitis, as described.
CXR (___):
1. Left mid lung pneumonia.
2. Right lateral pleural thickening versus a trace right pleural
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 30 mg PO DAILY
2. TraZODone 150 mg PO QHS
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*2
2. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*7
Tablet Refills:*0
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*2
4. Thiamine 500 mg IV Q8H Duration: 3 Days
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth Daily
Disp #*60 Tablet Refills:*2
5. Citalopram 30 mg PO DAILY
6. TraZODone 150 mg PO QHS
7.Outpatient Lab Work
Blood for: CBC/diff, CHEM10
Please fax to Dr. ___ at ___.
ICD10 Codes: D69.6, N17.9
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Isopropyl Alcohol Ingestion
Suicidal Ideation
Community Acquired Pneumonia
SECONDARY DIAGNOSES:
====================
Major Depressive Disorder
Anxiety
Traumatic epistaxis
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 with altered mental status. Evaluate for acute
intracranial hemorrhage or intracranial mass.
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, 18.9 cm; CTDIvol = 47.9 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 9.0 s, 18.9 cm; CTDIvol = 47.9 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 1,806 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
Study is mildly degraded by motion. 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. Evolving right parietal scalp soft tissue
swelling is again noted (see 02:15 on current study and 02:13 on prior exam).
There is mucosal thickening in the bilateral maxillary sinuses. Bony
sclerosis adjacent to the right maxillary sinus is again noted. New left
frontal and bilateral ethmoid air cell mucosal thickening is present. The
visualized portion of the mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Within limits of study, no evidence of acute intracranial hemorrhage.
3. Within limits of this motion degraded, noncontrast examination, no definite
evidence of intracranial mass.
4. Interval progression of paranasal sinus disease concerning for acute and
chronic sinusitis, as described.
Radiology Report
INDICATION: ___ man with cough, evaluate for pneumonia.
TECHNIQUE: PA and lateral chest radiograph.
COMPARISON:
1. CT abdomen and pelvis ___.
2. Chest x-ray ___.
FINDINGS:
The cardiomediastinal silhouette is stable allowing for improved lung volumes
on the current study compared with prior, within normal limits. The hila are
unremarkable. New since the prior exam has a left mid lung hazy opacity which
is concerning for developing infection. Equivocal linear opacity in the right
mid lung may reflect platelike atelectasis. There is no pulmonary vascular
congestion or pulmonary edema. There is no pneumothorax. There is a left
pleural effusion. Suggestion of right mid and lower lung lateral pleural
thickening was not clearly seen on the prior, however this may be due to
inter-examination differences in technique, possibly focal pleural thickening
or trace pleural fluid.
IMPRESSION:
1. Left mid lung pneumonia.
2. Right lateral pleural thickening versus a trace right pleural effusion.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 1:36 ___, 10 minutes
after discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ETOH
Diagnosed with Poisoning by local antifung/infect/inflamm drugs, acc, init, Oth places as the place of occurrence of the external cause, Alcohol abuse with intoxication, unspecified, Blood alcohol level of 120-199 mg/100 ml
temperature: 97.7
heartrate: 75.0
resprate: 18.0
o2sat: 95.0
sbp: 125.0
dbp: 81.0
level of pain: 0
level of acuity: 3.0 | ___ with PMHx significant for major depressive disorder, PTSD,
and alcohol abuse, presenting for ingestion of hand sanitizer at
his group home.
# Isopropyl alcohol ingestion/Alcohol abuse/Suicidal Ideations:
Patient reports drinking 3x20oz hand sanitizer (isopropyl
alcohol) over the course of 3 days PTA. On admission, he was
hemodynamically stable. Patient was difficult to arouse with
significantly unintelligible, slurred speech, but was endorsing
suicidal ideations. Patient had no electrolyte abnormalities on
admission, and anion and osmolar gap were within normal limits
and remained so throughout his stay. EKG remained unchanged.
Patient recovered from his intoxication and was admitted under
___ with a 1:1 sitter. There was some concern for
continued altered mental status, and Wernicke's encephalopathy,
so the patient was started on high-dose thiamine 500mg IV TID,
and ultimately there was lesser suspicion for ___'s
encephalopathy in discussion with psychiatry such that he was
felt to be safe for transition to oral thiamine at discharge.
His mental status improved shortly after being transferred to
the floor and subsequently returned to normal. He remained
severely depressed. He was placed on a CIWA scale, but was not
scoring. He was connected with social work, who met with him and
provided him with resources to participate in the PAATHS program
at ___ (___), which is a walking clinic that
can provide him with resources for treatment of alcohol abuse
and help him find a shelter. He was provided with a cab voucher
to go to ___ following discharge. Social work also gave him the
contact information of the intake coordinator at "___ for
Promise", a residential treatment program, who is awaiting his
call for an informal assessment over the phone and possible
placement. At discharge, the patient was not endorsing SI or HI,
and was cleared by psychiatry and toxicology. He reports wanting
to join a treatment program to help him with his recovery.
# Pneumonia:
Patient complained of a new cough on ___, with exam notable
for minimal left basilar crackles. Patient afebrile, with normal
oxygen saturation on room air. CXR was done and showed evidence
of a left lower lobe infiltrate highly suggestive of pneumonia.
Patient was started on a 7-day course of levofloxacin for
treatment of pneumonia (7 days chosen versus 5 days, given
possible sinusitis, see below). QTc was stable at discharge.
# Acute on Chronic Sinusitis:
On admission, head CT showed evidence of interval progression of
paranasal sinus disease concerning for acute and chronic
sinusitis. Patient also reports several episodes of epistaxis on
___ and ___, likely in the setting of thrombocytopenia.
Reports no recent trauma or rhinotillexis. Given concomitant
pneumonia, plan was to extend course from 5 days to 7 days to
cover possible bacterial sinusitis.
# Thrombocytopenia:
Patient found to have a platelet count of ~ 100k. Possibly
related to marrow suppression due to alcohol abuse. No evidence
of significant liver disease on recent CT abdomen/pelvis to
explain thrombocytopenia. Basic work-up, including HCV Ab and
HIV Ab, unrevealing. Platelet count remained stable. Plan to
follow-up with repeat CBC as outpatient and evaluation by PCP.
# Depression:
Patient with a known history of anxiety and MDD currently on
treatment with citalopram and trazodone. Medications initially
held at the time of admission given toxic ingestion, but
subsequently restarted following clearance from toxicology and
psychiatry.
# Pain management:
Patient previously evaluated in the ED for left-sided rib
fracture and was reporting severe pain. Pain was adequately
managed with standing acetaminophen (<2g/day) and lidocaine
patch.
# Elevated Creatinine:
Patient had an elevation in creatinine to 1.2, up form his
baseline of 0.6-0.9. FENa of 2.7%, however, no evidence
supporting ATN, AIN, or an underlying glomerulonephritis. Plan
is for outpatient follow-up with PCP.
# Concern for STIs:
Patient is not currently sexually active, but requested STI
testing. He does not report any genital rashes, ulcers, or
discharge. HIV and HCV serologies done and were negative. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left tibia pain, warmth, and swelling
Major Surgical or Invasive Procedure:
___ Left tibia - I+D, Wound vac application
___ Left tibia - I+D, Wound vac application
___ Left tibia - I+D, Wounc vac application
History of Present Illness:
___ from ___ with history of L tib/fib fractures in ___ s/p
external fixation complicated by osteomyelitis s/p multiple skin
and bone graft procedures, presenting with 3 days fever and
warmth, redness, and pain over old surgical site distal to L
knee. On ___, patient reports developing fevers to 101. She
noticed an erythematous area distal to L knee has progressively
spread since ___, now with area of visible pus that has not yet
drained. Patient endorses pain distal to the L knee when
weightbearing, denies reduced range of motion or pain with
movement. Denies new trauma to the leg. Patient was in usual
state of health until late ___, when she developed 'tight'
left leg pain from the thigh to the ankle, with moderate
increase in baseline swelling. She was evaluated at that time
and had lower extremity US without evidence of clot and XR L
left leg without evidence of new fracture, but with marked varus
deformity. She was given flexeril and pain medicationn, and told
to follow up ___ Dr. ___ at ___ for eval for possible
surgical revision.
She returned to ___ ED for her new symptoms (fever and
swelling/redness), was found to have a ESR of 114 and CRP 385,
and was transferred to ___ with initial vitals: 100.0 111
123/83 18 100%. Labs remarkbale for wbc 12.2 (80% neutrophils).
She had XR of Tib/fib and received IV vanc and morphine.
Currently, patient is in NAD in bed.
ROS: per HPI, denies 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:
L tib/fib fracture ___ s/p ext fixation, c/b osteomyelitis and
s/p multiple skin and bone grafting procedures
Social History:
___
Family History:
HTN
Physical Exam:
ADMISSION EXAM ___:
VS - Temp 98.5F, BP 116/73, HR 108, R 16, O2-sat 98% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
HEART - Rapid rate, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, non-pitting edema in L leg from ankles to
just below L knee. More tense in the upper calf.
MSK: Full ROM in hips. ___ plantarflexion bilaterally, somewhat
reduced dorsiflexion on L>R.
SKIN - Numerous surgical scars on L lower extermity. Thin
membrane of skin overlying visible fluid collection with
purulent fluid inside. Tense and indurated surrounding skin
approximately 5cmX7cm.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout.
DISCHARGE EXAM ___
AFVSS
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
HEART - Rapid rate, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES
- Left leg: wound vac in place with good seal at -125 mm Hg of
suction. Numerous surgical scars
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout.
Pertinent Results:
ADMISSION LABS:
___ 12:55PM GLUCOSE-85 UREA N-9 CREAT-0.5 SODIUM-140
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-31 ANION GAP-12
___ 12:55PM CK(CPK)-37
___ 12:55PM CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-2.1
___ 12:55PM WBC-12.5* RBC-3.73* HGB-11.1* HCT-34.2*
MCV-92 MCH-29.6 MCHC-32.3 RDW-11.7
___ 12:55PM NEUTS-75.6* LYMPHS-15.1* MONOS-5.8 EOS-3.1
BASOS-0.4
___ 12:55PM PLT COUNT-404
___ 09:20PM URINE HOURS-RANDOM
___ 09:20PM URINE UCG-NEGATIVE
___ 09:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 08:17PM LACTATE-0.9
___ 10:00AM GLUCOSE-90 UREA N-11 CREAT-0.6 SODIUM-138
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14
___ 10:00AM estGFR-Using this
___ 10:00AM WBC-12.2* RBC-4.16* HGB-12.3 HCT-38.2 MCV-92
MCH-29.5 MCHC-32.1 RDW-11.6
___ 10:00AM NEUTS-80.8* LYMPHS-12.1* MONOS-5.0 EOS-1.7
BASOS-0.3
___ 10:00AM PLT COUNT-446*
IMAGING:
XR L leg ___ IMPRESSION:
1. Posttraumatic of the tibia and fibula as above.
2. Cortical thickening and sclerosis of the tibia at the
fracture site, which may represent chronic osteomyelitis.
3. No radiographic evidence for acute or active osteomyelitis.
If there is continued concern, recommend further evaluation with
MRI.
XR L knee AP/LAT/OB ___: 1. Posttraumatic of the tibia
and fibula as above. 2. Cortical thickening and sclerosis of
the tibia at the fracture site, which may represent chronic
osteomyelitis.
MRI L leg ___: 1. Posttraumatic of the tibia and fibula
as above.
2. Cortical thickening and sclerosis of the tibia at the
fracture site, which may represent chronic osteomyelitis. 3. No
radiographic evidence for acute or active osteomyelitis. If
there is continued concern, recommend further evaluation with
MRI.
CTA L lower extremity ___: 1. Interval debridement of the
anterior soft tissues overlying the proximal left tibia and
fibula and placement of a vacuum sponge device. 2.Smaller
residual abscess collection between the left proximal tibia and
fibula measuring 3.1 x 9.2 x 1.8 cm. 3. Small locules of air
within the posteromedial soft tissues near the left proximal
femur, likely related to recent intervention, though infection
with gas-producing organisms is within the differential. 4. 4.5
cm segment of the proximal left peroneal artery not opacified
with distal reconstitution. 5. Remainder of the left lower
extremity vasculature is widely patent including the anterior
and posterior tibial arteries to the level of the foot. 6. Varus
deformity of the left proximal tibia and fibula with diffuse
cortical thickening related to patient's known history of acute
on chronic osteomyelitis, better characterized on recent MRI of
the calf.
MICROBIOLOGY
___ Tissue Culture: STAPH AUREUS COAG +. SPARSE GROWTH OF
TWO COLONIAL MORPHOLOGIES.
___ Tissue Culture: ___ PARAPSILOSIS. STAPH AUREUS
COAG +.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Cyclobenzaprine 10 mg PO TID:PRN pain
2. oxyCODONE-acetaminophen *NF* ___ mg Oral q6hours PRN pain
3. Diazepam Dose is Unknown mg PO Frequency is Unknown anxiety
4. Ibuprofen Dose is Unknown mg PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
reflux
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Cepacol (Menthol) 1 LOZ PO PRN sore throat
5. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN pain
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC QPM
8. Ferrous Sulfate 325 mg PO DAILY
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
10. Milk of Magnesia 30 ml PO BID:PRN Constipation
11. Multivitamins 1 TAB PO DAILY
12. Nafcillin 2 g IV Q6H Duration: 5 Weeks
13. Omeprazole 20 mg PO DAILY
14. Vitamin D 400 UNIT PO DAILY
15. Cyclobenzaprine 10 mg PO TID:PRN pain
16. Diazepam ___ mg PO Q6H:PRN anxiety
17. Ibuprofen 600 mg PO Q6H:PRN pain or swelling
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute on chronic osteomyelitis
Secondary Diagnosis: Remote L Tib/Fib fracture with varus
deformity
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
MR EXAMINATION OF LEFT CALF WITH AND WITHOUT CONTRAST.
HISTORY: ___ woman with history of tibia and fibula fractures in
___, status post external fixation. History of known osteomyelitis with
multiple skin and bone grafts in this region. Evaluation for osteomyelitis /
drainable fluid collections.
TECHNIQUE: Multisequence, multiplanar MR examination of the left calf is
performed following departmental infection protocol. Axial T1, coronal STIR,
axial T2, coronal T1, axial STIR, sagittal T1, sagittal STIR, coronal STIR,
coronal T1, axial 3D T1 SPGR pre- and post-, axial T1 fat sat post, coronal T1
fat sat post, sagittal T1 fat sat, and axial subtraction sequences were
performed of the left calf.
COMPARISON: Radiographs of the left foot performed ___.
FINDINGS:
Prominent multiloculated peripherally enhancing collection is present within
the proximal left lower extremity on axial series 101, image 34 and sagittal
series 16, image 11. Collection is also visualized on coronal series 15,
image 11 and measures approximately 6.6 cm AP x 1.5 cm TRV x 4.1 cm SI.
Collection is positioned between the proximal tibia and fibula and extends in
an anterolateral axis from the posterior tibialis to the anterior tibialis and
subsequently communicates with the skin. Skin defect measures approximately
4.2 cm along the anterolateral aspect of the left lower extremity.
Prominent cortical thickening is present within the tibia as well as the
fibula in this region consistent with posttraumatic / postoperative changes.
No evidence for subperiosteal abscess.
Heterogeneous edema and minimal enhancement is present within the medullary
cavity of the proximal left tibia with concomitant heterogeneous T1
hypointense signal of indeterminant chronicity.
Foci of susceptibility artifact are present adjacent to the proximal third of
the left fibula consistent with postoperative changes.
Prominent enhancing subcutaneous edema is present within the left lower
extremity, centered within the anterolateral aspect of the leg. Heterogeneous
muscular enhancement is present centered within the anterior and posterior
tibialis muscles. Tendons and musculature of the left calf are otherwise
normal in appearance.
No left knee effusion. Imaged portions of the left femur are normal in
appearance. Distal left lower extremity is normal in appearance. Imaged
portions of the right leg are normal in appearance.
IMPRESSION:
1. Large peripherally enhancing multiloculated fluid collection (likely
abscess) extending anterolaterally from the posterior tibialis to the anterior
tibialis between the proximal left tibia and fibula communicates with a skin
defect.
2. Prominent enhancement centered within the anterior and posterior tibialis
indicative for myositis.
3. Prominent cortical thickening with minimal heterogeneous signal within the
proximal left tibia of indeterminate etiology and chronicity. Findings may be
postoperative / post traumatic in etiology, however acute on chronic or
chronic residual osteomyelitis cannot be entirely excluded within the proximal
tibia, although felt less likely.
4. Posttraumatic changes within the proximal left tibia and fibula, better
appreciated on the radiographs of the left lower extremity performed today.
Preliminary findings were discussed on the phone by Dr ___ with Dr ___
___ on ___ at 19.00.
Radiology Report
HISTORY: ___ with history of tibia/fibula fracture and osteomyelitis,
now erythema, swelling, and purulent drainage.
AP and lateral views of the leg, show prominent post-fracture deformities and
angulation of the proximal tibial and fibular diaphysis with lateral
subluxation of the proximal fibular head. However, no demonstrable bone
destruction and there is complete healing of the fractures. There is
prominent associated soft tissue abnormality and defects. The suboptimally
visualized ankle shows joint space narrowing along its horizontal portion with
slight widening of the joint space medially & associated generalized soft
tissue swelling. No comparison exams at this facility.
IMPRESSION: Healed tibial and fibular fractures with marked osseous and soft
tissue residual deformities. No bone destruction to suggest osteomyelitis.
Associated abnormality left ankle
Radiology Report
Portable AP radiograph of the chest was reviewed with no prior studies
available for comparison.
REASON FOR EXAMINATION: New central line placement.
AP radiograph of the chest shows the right PICC line tip being in the right
atrium. Pulling back of the PICC line for approximately 3.0 cm is suggested.
Heart size and mediastinum are unremarkable. Lungs are essentially clear.
Radiology Report
REASON FOR EXAMINATION: PICC line placement assessment.
AP radiograph of the chest was reviewed in comparison to prior study.
Currently the PICC line tip is at the level of low SVC, appropriate position.
Heart size and mediastinum are unremarkable. Lungs are clear.
Radiology Report
HISTORY: ___ female status post prior fracture of the proximal tibia
and fibula complicated by acute on chronic osteomyelitis. The patient is POD
#1 status post debridement of the anterior soft tissues surrounding the
proximal left tibia. CTA for evaluation of recipient vessels prior to free
flap reconstruction.
COMPARISON: MRI of the left calf with and without gadolinium contrast from
___.
TECHNIQUE: ___ MDCT-acquired axial images from the left iliac crest to the
left toes were displayed with 2.5 mm slice thickness. Initial axial images
were acquired in a non-contrast phase followed by arterial and delayed phase
imaging. Coronal and sagittal reformations were prepared. Additionally, 3D
maximum intensity projection and volume-rendered images were created on a
separate workstation and reviewed on the PACS.
CT OF THE LEFT LOWER EXTREMITY WITH AND WITHOUT INTRAVENOUS CONTRAST:
SOFT TISSUES: There is circumferential soft tissue edema and skin thickening
surrounding the left ankle joint, which extends superiorly to the level of the
mid calf. The patient is status post surgical debridement of the soft tissues
anterior to the left proximal tibia. A vacuum sponge device is in place at
the site of debridement. There is a full-thickness defect of the anterior
soft tissues with exposure of the bone to the surface. The remaining left
lower extremity musculature surrounding the proximal tibia and fibula appears
macerated and atrophic. Additionally, there is a residual fluid collection in
the interosseous space between the left proximal tibia and fibula measuring
3.1 x 9.2 x 1.8 cm (3b:576 and 400a:46), findings concerning for residual
abscess cavity as seen on prior MRI of the calf. Within the interosseous
space, there are multiple focal hyperdensities that likely represent small
bone fragments from prior surgeries (3b:513 and 3b:569). Above the left knee
joint, the musculature appears normal. Small locules of gas are seen in the
posterior medial soft tissues near the left proximal femur, likely related to
recent surgical intervention (3a:78 and 81), though gas producing organisms
are within the differential.
BONES: There is a severe varus deformity of the distal tibia and fibula
beyond the site of prior healed fracture. Multiple screw tracks are seen
through the proximal tibia related to prior fixation hardware. The bones
overall demonstrate circumferential cortical thickening and appear dysmorphic,
findings consistent with the history of chronic osteomyelitis at the site of
prior fracture. No acute fracture or bone destructive lesion is identified.
CTA: The left external iliac artery is widely patent without flow-limiting
stenosis. The left superficial and deep femoral arteries are fully opacified.
The popliteal artery is widely patent. Within the lower extremity, the
anterior tibial artery is widely patent at its origin and remains patent as it
courses past the known abscess to the level of the foot. No disruption or
focal stenosis is identified. The common tibioperoneal trunk is also widely
patent. The posterior tibial artery demonstrates no flow-limiting stenosis
throughout its course to the level of the foot. The peroneal artery is not
opacified at its mid portion. Approximately 5 cm from its origin at the
tibioperoneal trunk, opacification of the vessel is not seen. However, flow
within the distal peroneal artery reconstitutes, likely due to collateral
vasculature from the adjacent tibial arteries. The peroneal artery is not
opacified for a 4.5 cm craniocaudal segment.
CT LEFT PELVIS WITH INTRAVENOUS CONTRAST: Imaged loops of small and large
bowel appear normal. The uterus and adnexa appear within normal limits. The
bladder is moderately distended and appears normal. No pathologically
enlarged pelvic or inguinal lymph nodes are identified.
IMPRESSION:
1. Interval debridement of the anterior soft tissues overlying the proximal
left tibia and fibula and placement of a vacuum sponge device.
2. Smaller residual abscess collection between the left proximal tibia and
fibula measuring 3.1 x 9.2 x 1.8 cm.
3. Small locules of air within the posteromedial soft tissues near the left
proximal femur, likely related to recent intervention, though infection with
gas-producing organisms is within the differential.
4. 4.5 cm segment of the proximal left peroneal artery not opacified with
distal reconstitution.
5. Remainder of the left lower extremity vasculature is widely patent
including the anterior and posterior tibial arteries to the level of the foot.
6. Varus deformity of the left proximal tibia and fibula with diffuse
cortical thickening related to patient's known history of acute on chronic
osteomyelitis, better characterized on recent MRI of the calf.
Preliminary findings were communicated to Dr. ___ at 10:52 p.m. and
again at 11:55 p.m. on ___ at the time of initial review of the study by
Dr. ___.
Radiology Report
STUDY: Three views of the left tibia and fibula ___.
COMPARISON: None.
INDICATION: Three days of redness and swelling and erythema distal to the
knee. Question osteomyelitis.
FINDINGS: Significant subcutaneous edema. Posttraumatic deformity of the
proximal tibia and fibula diaphysis. There is cortical thickening of the tibia
at the region of the old trauma and there is sclerosis. While this may be all
due to the prior fracture, this may represent chronic osteomyelitis. No areas
of cortical destruction or periostitis. The visualized tibiotalar joint is
unremarkable. Calcific densities are seen within the intraosseous membrane,
which may be from the prior injury or vascular in nature.
IMPRESSION:
1. Posttraumatic of the tibia and fibula as above.
2. Cortical thickening and sclerosis of the tibia at the fracture site, which
may represent chronic osteomyelitis.
3. No radiographic evidence for acute or active osteomyelitis. If there is
continued concern, recommend further evaluation with MRI.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: LEFT LEG REDNESS
Diagnosed with CELLULITIS OF LEG
temperature: 100.0
heartrate: 111.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 83.0
level of pain: 5
level of acuity: 3.0 | The patient was initially admitted to the internal medicine
service on ___ with pain, swelling, and infectious signs of
her left tibia after remote fracture in ___. Patient was taken
to the ___ on ___ for I&D of left tibia with wound vac
application. Subsequently, the patient was transferred to the
orthopaedic surgery service. Patient subsequently underwent two
additional I&D with wound vac changes on ___ and ___.
The plastic surgery service was consulted during the admission
for wound coverage, they evaluated the wound intra-operatively
on ___ and ___. Patient tolerated all procedures well
and was transferred to the to PACU, then floor in stable
condition after each operation. Please see operative reports for
full details.
Musculoskeletal: Throughout hospitalization, patient remained
weight-bearing as tolerated on her left lower extremity. She
worked with physical therapy regularly.
Neuro: Post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone.
Patient complained of nausea with oxycodone and was subsequently
transitioned to Dilaudid po with iv Dilaudid for breakthrough.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient suffered from acute blood loss anemia.
The nadir of her HCT was 23.1. Patient refused blood
transfusion and requested iron supplementation, which was
administered. Her HCT increased to 24.9 on discharge, down from
her initial HCT of 38.2.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started on
a bowel regimen to encourage bowel movement. Intake and output
were closely monitored.
ID: The patient was closely followed by the infectious disease
service for her osteomyelitis throughout the course of her
hospitalization. She received pathogen directed therapy of
nafcillin 2 mg q6h. A PICC line was placed as ID service
recommended antibiotic therapy for ___ weeks.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #8 from initial I&D,
the patient was doing well, afebrile with stable vital signs,
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The wound vac was
changed on day of discharge, and patient tolerated this well.
The wound vac remained on suction at -125 mm Hg with good seal.
The left lower extremity was NVI distally throughout. The
patient was given written instructions concerning precautionary
instructions and the appropriate follow-up care. The patient
will be continued on chemical DVT prophylaxis for 2 weeks
post-operatively and IV antibiotics for an additional 5 weeks.
All questions were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
adhesive tape
Attending: ___
Chief Complaint:
worsening shortness of breath with exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y.o. M w/ h/o non-ischemic cardiomyopathy, HTN, OSA on CPAP,
atrial fibrillation who presents w/ ___ weeks of worsening
shortness of breath with exertion. He noticed it at work that he
used to be able to go up 4 sets of stairs and then get short of
breath now it is down to 1 set. At first he thought it was a
URI,
but then realized he felt like he did with his prior CHF
exacerbation. He is not short of breath at rest. He is able to
lay flat without difficulty. He does not wake up short of
breath.
He has had no chest pain, palpitations, nausea, vomiting. He
also notes leg swelling. He says this is intermittent for him,
comes and goes, currently it is up.
Last seen ___ cardiology clinic ___ has been maintained
on medical therapy and Lasix 60 3 times/week, 40 2 times/week.
Initially he presented to urgent care however reportedly
hypotensive to SBPs ___ and noted to be lightheaded thus he was
referred to ___. While at urgent care he received 1x cefazolin
for cellulitis, calcium for low calcium.
In the BI ED he initially had pressures in the low ___, but
they improved to 100-110s SBP by time of transfer to the floor.
His exam was notable for a JVP to slightly above mandible at 45
degrees, lungs with crackles bilateral bases, extremities with
2++++ edema bilateral lower extremities to slightly above knees,
bilateral upper and lower extremities warm and well perfused
Labs
Hgb 10.3, Plt 154
BMP Cr 3.4 (prior 1.2 ___, BUN 54
Trop 0.04, pro-bNP ___
Lactate 1.5
EKG
heart rates ___s PVcs, noted QRS 140s IVCD,
similar to prior;
He was given 160 mg Lasix around 2 am and he urinated out over
1.5 L by 5 am.
On the floor he endorses the above history. He also states that
he often gets cellulitis in his legs. He says his wounds do not
heal well and he has learned to manage that better. He says his
left leg has been more red about the last ___ days.
REVIEW OF SYSTEMS:
On further review of systems, denies fevers or chills. Denies
any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains,
cough, black stools or red stools.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes w/ neuropathy of legs
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronaries RCA and LAD disease
- Pump: dilated cardiomyopathy, sCHF. ___ EF
- Rhythm sinus, prior cardioversion for atrial fibrillation
3. OTHER PAST MEDICAL HISTORY
Obesity
ADHD
Sleep apnea (CPAP)
MVA about ___ years ago
T&A
Surgery for an undescended testicle
Lap band surgery
Social History:
___
Family History:
Father - lung cancer, HTN
Mother - brain tumor
Sister - colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=======================
VS: 24 HR Data (last updated ___ @ 421)
Wt: 284.39 lb/129 kg
97.5 PO 99 / 63 R Lying 69 RR18 97 RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP at the mandible.
CARDIAC: midclavicular line. Regular rate and rhythm. Normal S1,
S2. No murmurs, rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. crackles in the bases
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. RT leg w/ hemosiderin
staining,
left as well, but left is warmer than RT. ___ pitting edema to
the
knees 3+ bilaterally. Scattered scabs on legs bilaterally,
several covered with band aids.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
=======================
24 HR Data (last updated ___ @ 827)
Temp: 97.8 (Tm 98.4), BP: 98/59 (95-136/58-82), HR: 60
(52-75), RR: 18 (___), O2 sat: 95% (91-98)
Fluid Balance (last updated ___ @ 959)
Last 8 hours Total cumulative -100ml
IN: Total 650ml, PO Amt 600ml, IV Amt Infused 50ml
OUT: Total 750ml, Urine Amt 750ml
Last 24 hours Total cumulative 435ml
IN: Total 1485ml, PO Amt 1380ml, IV Amt Infused 105ml
OUT: Total 1050ml, Urine Amt 1050ml
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP low neck.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: CTAB. Respiration is unlabored with no accessory muscle
use.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. chronic venous stasis changes,
but L LLE more erythema than R, nontender. Dependent pitting
edema b/l to the knee. Scattered scabs on legs bilaterally
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
___ 11:40PM BLOOD WBC-9.2 RBC-3.96* Hgb-10.3* Hct-33.0*
MCV-83 MCH-26.0 MCHC-31.2* RDW-15.0 RDWSD-45.1 Plt ___
___ 11:40PM BLOOD Neuts-76.9* Lymphs-13.0* Monos-8.7
Eos-0.8* Baso-0.1 Im ___ AbsNeut-7.10* AbsLymp-1.20
AbsMono-0.80 AbsEos-0.07 AbsBaso-0.01
___ 12:46AM BLOOD ___ PTT-30.8 ___
___ 11:40PM BLOOD Glucose-120* UreaN-51* Creat-3.4*#
Na-133* K-3.8 Cl-96 HCO3-19* AnGap-18
___ 07:12AM BLOOD ALT-14 AST-26 AlkPhos-71 TotBili-0.7
___ 11:40PM BLOOD cTropnT-0.04* ___ 11:40PM BLOOD Calcium-8.0* Phos-5.0* Mg-1.8
___ 11:49PM BLOOD Lactate-1.5
INTERVAL/DISCHARGE LABS & STUDIES:
CHEST (PORTABLE AP) Study Date of ___ 12:01 AM
IMPRESSION:
Interstitial prominence most likely is technical due to low lung
volumes
although it is difficult to exclude pulmonary vascular
congestion. Mild
cardiomegaly. Repeat PA and lateral at full inspiration could
clarify.
Transthoracic Echocardiogram Report
Name: ___ MRN: ___ Date: ___ 24:00
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. There is
no evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___
mmHg. There is normal left ventricular wall thickness with a
moderately increased/dilated cavity. There
is mild-moderate left ventricular regional systolic dysfunction
with severe hypokinesis of the basal half
of the inferior and inferolateral walls (see schematic) and mild
global hypokinesis of the remaining
segments. The visually estimated left ventricular ejection
fraction is 40%. There is no resting left
ventricular outflow tract gradient. Mildly dilated right
ventricular cavity with low 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. 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 not well seen. The tricuspid valve leaflets appear
structurally normal. There is physiologic
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial
effusion.
IMPRESSION: Poor image quality. Left ventricular cavity dilation
with regional and global
systolic dysfunction.Right ventricular cavity dilation with mild
global free wall hypokinesis. Mild
pulmonary artery systolic hypertension. Mild mitral
regurgitation with normal valve morphology.
___ 06:41AM BLOOD WBC-9.9 RBC-4.74 Hgb-12.3* Hct-39.9*
MCV-84 MCH-25.9* MCHC-30.8* RDW-14.7 RDWSD-44.9 Plt ___
___ 06:41AM BLOOD Glucose-78 UreaN-36* Creat-1.6* Na-142
K-4.0 Cl-100 HCO3-28 AnGap-14
___ 06:41AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Lisinopril 5 mg PO DAILY
3. Glargine 60 Units Breakfast
Glargine 60 Units Bedtime
Humalog Unknown Dose
4. CARVedilol 25 mg PO QPM
5. Amphetamine-Dextroamphetamine XR 60 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
7. Spironolactone 12.5 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Furosemide 60 mg PO 3X/WEEK (___)
10. Furosemide 40 mg PO 4X/WEEK (___)
11. Cyanocobalamin 1000 mcg PO DAILY
12. Gabapentin 300 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO QHS
15. HydrOXYzine 50 mg PO QHS
16. Multivitamins 1 TAB PO DAILY
17. CARVedilol 50 mg PO QAM
Discharge Medications:
1. Cephalexin 500 mg PO BID Duration: 9 Days
2. Torsemide 60 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. CARVedilol 25 mg PO BID
5. Glargine 40 Units Breakfast
Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Amphetamine-Dextroamphetamine XR 60 mg PO DAILY
7. Apixaban 5 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Gabapentin 300 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO QHS
13. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until told by Dr. ___
14. HELD- MetFORMIN XR (Glucophage XR) 1000 mg PO BID This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until the kidney function recovers completely
15. HELD- Spironolactone 12.5 mg PO DAILY This medication was
held. Do not restart Spironolactone until told by Dr. ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic heart failure with reduced ejection fraction
Left leg cellulitis
Acute kidney injury on chronic kidney disease
Secondary diagnosis:
Type 2 diabetes
Obstructive sleep apnea
Atrial fibrillation
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with dyspnea// eval for pulmonary edema
TECHNIQUE: Chest AP
COMPARISON: None
FINDINGS:
Lung volumes are slightly low. Technical factors accentuate the heart size
although even accounting for these it is likely enlarged. Interstitial
prominence is likely due to technical factors although pulmonary vascular
congestion is difficult to exclude. No focal opacity concerning for pneumonia
although assessment is limited.
IMPRESSION:
Interstitial prominence most likely is technical due to low lung volumes
although it is difficult to exclude pulmonary vascular congestion. Mild
cardiomegaly. Repeat PA and lateral at full inspiration could clarify.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion, Presyncope, Weakness, Transfer
Diagnosed with Hypotension, unspecified
temperature: 97.8
heartrate: 67.0
resprate: 20.0
o2sat: 95.0
sbp: 92.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | ======================
BRIEF SUMMARY
======================
___ year old man with non-ischemic cardiomyopathy with reduced
EF, HTN, DM, OSA on CPAP, atrial fibrillation who presents with
around ___ months of worsening shortness of breath with
exertion, a diabetic lower extremity cellulitis, and
hypotension.
The patient received IV diuresis during his hospital stay. He
was also noted to have acute kidney injury on presentation with
creatinine on admission of 3.4 from a baseline of 1.2 in
___. This was thought to be cardiorenal (resolved with IV
diuresis) vs recovering ATN (given report of hypoTN in the
community with SBP ___. The patient was also noted to have
cellulitis on his left lower extremity in the setting of
worsening peripheral edema, which was treated with antibiotics
(cefazolin -> Keflex). His blood pressures during his hospital
stay were soft with systolics in the ___, but remained stable.
Spironolactone, lisinopril were held in the setting of
hypotension and ___ and his home Coreg was continued at a
reduced dose. He was eventually transitioned to an oral diuretic
regimen with torsemide and an oral Keflex (dose adjusted for his
renal function) to complete a course for the cellulitits.
Physical therapy noted that the patient was ambulating well and
did not need further evaluation. Ultimately, he was discharged
home with a wound care nurse.
We discussed with the patient that he will be discharged on
lower doses of heart failure medications, that can be
uptitirated as an outpatient with Dr. ___. We also discussed
that he may benefit from a BiV device given his wide QRS,
reduced EF, and on as much ___ medical therapy
that he can tolerate.
=========================
TRANSITIONAL ISSUES
=========================
#MEDICATION CHANGES:
[]New medications: Keflex ___ BID x 9 days (total 14 days)
[]Changed medications: Atorvastatin increased to 80mg,
Carvedilol decreased to 25BID from 50AM 25PM.
[]Held medications: spironolactone, lisinopril
#AT DISCHARGE:
[]Weight: 125.6 kg (276.9 lb)
[]Cr: 1.6
#PCP:
[]Please check weight, electrolytes, and renal function at next
visit and titrate diuresis accordingly
[]Continue to monitor LLE for resolution of cellulitis
[]Continue to encourage CPAP for OSA
#CARDIOLOGY:
[]Consider whether patient would be candidate for biventricular
pacing given slightly widened QRS and EF 40% and symptoms
[]Consider restarting and titrating guideline directed medical
therapy based on blood pressures and renal function (lisinopril,
coreg, and spironolactone)
#WOUND CARE INSTRUCTIONS:
-Elevate ___ while sitting.
-Moisturize B/L ___ and feet, intact skin only BID with Sooth
And Cool Ointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Scrotal swelling and ___ edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ yo man with history of hypertension, GERD, and
recently diagnosed CHF in ___ (EF 54%), afib on apixaban,
who
presents with ___ weeks of worsening edema of his scrotum and
penis.
He was recently hospitalized in ___ for 6 months of
intermittend testicular and lower extremity swelling that was
refractory to oral diuretics at home, though there was some
concern for intermittent compliance. He was noted to have BNP of
19,574 on admission with JVP elevated to the mandible at 90
degrees. He also had scrotal edema, with ultrasound showing
diffuse edema of the skin and no e/o hernia. CXR showed mild
pulmonary edema and small pleural effusions bilaterally. He had
a
TTE that demonstrated LVH with an EF of 54%, as well as severe
pulmonary HTN, mildly dilated RV with hypertrophied and
hypokinetic RV free wall. He improved significantly during
admission with IV Lasix, and was discharged on Lasix 40 mg po
daily.
Since being discharged in late ___, Mr. ___ endorses
intermittent dyspnea on exertion that is unchanged from his
baseline prior to his prior hospitalization. He denies any chest
pain, fevers, chills, nausea, vomiting. Denies any scrotal pain.
Denies any dysuria. He is urinating frequently since his Lasix
was increased to 60 mg (unclear exactly when this was increased
-
either several weeks ago or immediately following last
admission). He denies swelling of his abdomen other than the
area
directly superior to the base of his penis. He states that the
swelling in his legs is better than during the last
hospitalization and has not noticed any worsening of this along
with his scrotal/penile swelling. He also notes occasional
dysphagia, feeling as though food gets momentarily stuck in his
chest.
In the ED: Noted that patient was intermittently hypoxic to the
low ___ on RA.
- Initial vital signs were notable for:
T 97.8, HR 74, BP 132/80, RR 18, O2sat 98% on RA
- Exam notable for:
- A&Ox3
- CV and Pulm exams normal
- 2+ lower extremity edema bilaterally
- Significant edema of the scrotum and penis, without any
erythema or signs of infection
- Labs were notable for:
- Trop 0.03, ___ 15647
- WBC 5.3, Hgb 14.0, Glucose 142
- BUN 34, Cr 1.2
- ___ 17.6, PTT 33.6, INR 1.6
- Studies performed include:
- CXR: No pulmonary edema. Decreased size of small
bilateral
pleural effusions. Mild bibasilar atelectasis.
- Patient was given:
- IV furosemide 60 mg
- Consults: None
Vitals on transfer:
T 97.7, HR 77, BP 133/92, RR 18, O2sat 94% on RA
Upon arrival to the floor, the patient was feeling well with no
shortness of breath or chest pain. He does endorse increased
swelling primarily of his scrotum and penis. Notes that he feels
that he needs to urinate after taking the Lasix.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
HFpEF
AF
HTN
GERD
Social History:
___
Family History:
Mother lived to be ___ years old with no significant medical
history. Father died aged ___ secondary to emphysema. Son had a
heart attack in his ___. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITALS: T97.6, BP 158/97, HR 110, RR 20, O2sat 97% on RA
GENERAL: Alert and interactive. In no acute distress.
EYES: PERRL though L pupil shows decreased constriction compared
to R, EOMI. Sclera anicteric and without injection.
ENT: MMM. No cervical lymphadenopathy. JVD to ear lobe at 30
degrees and to mandible at 90 degrees.
CARDIAC: Regular rhythm with occasional irregular beats, S3
heart
sound audible. Audible S1 and S2. No murmurs.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Some muscular guarding
diffusely.
GU: Significant edema in penis and scrotum diffusely, overlying
skin somewhat firm to palpation.
MSK: 1+ edema in bilateral lower extremities
SKIN: Warm. Widespread actinic keratosis and pigmented macular
spots. Nose deep red-purple color and cool to touch.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. AOx3.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM
==========================
Temp: 97.9 PO BP: 124/80, 72, RR 20 92 O2 on RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic and atraumatic, sclera anicteric and
without
injection
CARDIAC: Regular rate, irregularly irregular rhythm, normal S1
and S2. No murmurs, rubs, or gallops. JVP elevated ~11 cm
RESP: Breathing comfortably on room air, CTAB
ABDOMEN: NTND
Extremities: Warm and well-perfused, 1+ pitting edema to just
below b/l knees
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS
=====================
___ 09:10PM cTropnT-0.03*
___ 02:51PM GLUCOSE-100 UREA N-34* CREAT-1.2 SODIUM-144
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
___ 02:51PM estGFR-Using this
___ 02:51PM cTropnT-0.03*
___ 02:51PM ___
___ 02:51PM WBC-5.3 RBC-4.01* HGB-14.0 HCT-43.8 MCV-109*
MCH-34.9* MCHC-32.0 RDW-14.6 RDWSD-59.5*
___ 02:51PM NEUTS-77.2* LYMPHS-11.0* MONOS-9.5 EOS-0.4*
BASOS-1.1* IM ___ AbsNeut-4.09 AbsLymp-0.58* AbsMono-0.50
AbsEos-0.02* AbsBaso-0.06
___ 02:51PM ___ PTT-33.6 ___
___ 02:51PM PLT COUNT-142*
==================
DISCHARGE LABS
===================
___ 07:56AM BLOOD WBC-4.2 RBC-3.91* Hgb-13.6* Hct-42.4
MCV-108* MCH-34.8* MCHC-32.1 RDW-14.5 RDWSD-57.9* Plt ___
___ 07:56AM BLOOD Plt ___
___ 07:56AM BLOOD Glucose-99 UreaN-41* Creat-1.5* Na-146
K-3.9 Cl-105 HCO3-26 AnGap-15
___ 07:56AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
2. Furosemide 60 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Tamsulosin 0.4 mg PO QHS
5. Apixaban 5 mg PO BID
6. Atorvastatin 40 mg PO QPM
7. LORazepam 1 mg PO QHS:PRN Insomnia
8. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth once a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute Heart Failure with Preserved Ejection Fraction,
exacerbation
Pulmonary hypertension
Hypertension
Atrial fibrillation
SECONDARY DIAGNOSES
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with 3 of CHF presenting with dyspnea.// Pulmonary
edema signs of heart failure.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is moderate enlarged, unchanged. The mediastinal and hilar
contours are similar with tortuosity of the thoracic aorta again noted. The
pulmonary vasculature is not engorged. Lungs are hyperinflated with patchy
atelectasis visualized in the lung bases. Probable trace bilateral pleural
effusions are decreased in size from the prior exam. No pneumothorax is seen.
There are no acute osseous abnormalities.
IMPRESSION:
No pulmonary edema. Decreased size of small bilateral pleural effusions.
Mild bibasilar atelectasis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: B Leg swelling, Dyspnea on exertion
Diagnosed with Other specified soft tissue disorders
temperature: 97.8
heartrate: 74.0
resprate: 18.0
o2sat: 98.0
sbp: 132.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ====================
PATIENT SUMMARY:
====================
Mr. ___ is a ___ year old former ___ with history of
hypertension, GERD, a fib on apixaban (no rate control), and
recently diagnosed HFpEF in ___, who presented with lower
extrmity and scrotal edema, concerning for significant right
heart failure and acute HFpEF exacerbation. Etiology of
exacerbation likely secondary to medication non-adherence as he
states he wasn't taking his Lasix daily because it makes him
urinate often. He was treated with IV diuresis with good
response and had a repeat TTE ___ that showed severe right
ventricular contractile dysfunction; moderate-to-severe
tricuspid regurgitation; at least mild pulmonary hypertension,
and EF of 68%. He was transitioned to PO diuretics however
developed ___ with creatinine rising to 1.5 from 1.2.
We would have strongly preferred that patient stay for ongoing
monitoring of renal function and titration of diuretics, but he
opted to leave against medical advice, and he was able to state
the risks/benefits/alternatives to this decision.
====================
TRANSITIONAL ISSUES:
====================
[ ] Patient left AMA, understood risks of leaving at discharge
[ ] Held diuretic medication at discharge given ___ (Cr 1.5
from baseline ~1.1)
[ ] Scheduled follow up appointment with primary care 1 day
after discharge (___)
[ ] Consider starting Lasix 40 PO daily if kidney function
stable on ___
[ ] Please recheck kidney function on ___ if
restarting diuretic on ___
[ ] Heart failure exacerbation likely secondary to medication
non-adherence in setting of worsening pulmonary HTN
[ ] Discontinued Losartan 25 given low blood pressures, SBP
100-120 off this medication
[ ] ___ require dose adjustment of apixaban if Cr >= 1.5 on
recheck given age
[ ] Please consider referring patient to local cardiologist
[ ] If patient amenable, please consider discussing goals of
care including what is important to patient in life
Discharge weight: 73.3 kg
Discharge creatinine: 1.5 (baseline 1.1)
Discharge diuretic: Held, given ___. Please consider starting
Lasix 40 if Cr stable.
====================
ACUTE ISSUES:
====================
#HFpEF Exacerbation
#Edema of scrotum and penis
Weight at last discharge was 162. Weight on admission 175 lbs.
On admission he had an elevated JVP and significant
penile/scrotal swelling with ongoing lower extremity edema
suggestive of right-sided heart failure. CXR showed no pulmonary
edema and improvement in his pleural effusions, so less likely
that L-sided dysfunction was driving this exacerbation. Repeat
TTE ___ that showed severe right ventricular contractile
dysfunction; moderate-to-severe tricuspid regurgitation; at
least mild pulmonary hypertension, and EF of 68%. Etiology of
exacerbation likely secondary to medication non-adherence as he
states he wasn't always taking his Lasix daily because it makes
him urinate often. He was transitioned to PO diuretics
(Torsemide 20) however developed ___ with creatinine rising
to 1.5.
On day of discharge, we discussed with patient extensively
regarding his hospital course and ongoing diuretic titration,
and that we would prefer that he stay for (1) monitoring of
renal function and (2) to determine dose of diuretic that would
keep him euvolemic.
He stated that he would like to go home to be with his wife, and
that he had lived for ___ years already, and did not want to
stay in the hospital for any longer. We discussed that the risks
of leaving included worsening renal function, which could result
in renal failure, worsening volume overload and cardiac
decompensation, which could cause significant injury and
potentially death. He shared that he understood the risks of
leaving the hospital, and he understood the benefits of staying.
He was agreeable to getting labs drawn as an outpatient, and he
agreed to follow up with his primary care physician. After
repeated questioning, he did state that should he feel
physically ill, he would present to a hospital.
I note that while his logic/ reasoning is entirely
understandable, it is regretfully, strictly speaking, against
medical advice, given unclear goals of care as he did not wish
to engage in conversation- hence the default is to presume
full/aggressive medical care. Hence, in general, I would
consider it ___ medical practice to discharge a
patient admitted for management of heart failure from the
hospital with rising creatinine and uncertain diuretic plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
H/A, R-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female on ASA and Plavix for a coronary stent who woke up
this morning complaining of headache and then developed right
sided weakness. Patient was taken to an outside hospital, CT
scan of the head revelaled a 2.5 X5 cm left temporal ICH and
diffuse SAH around the circle of ___ and contralateral
sylvian fissure. Pt was intubated, and transferred to ___,
where she was admitted to the ICU. Her family gathered, and
decided that the pt should be CMO (based on her previously
voiced wishes if this situation were to ever arise). She was
terminally extubated with her family at the bedside and was
pronounced dead at 7:40pm on ___.
Past Medical History:
HTN,Hyperlipidemia, CAD
Social History:
___
Family History:
There is no family history of stroke, exessive
bleeding, or unexplained death.
Physical Exam:
EXAM AT THE TIME OF ADMISSION:
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT
Lungs: CTA bilaterally.
Cardiac: RRR.
Abd: Soft
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Intubated, unresponsive
Cranial Nerves:
I: Not tested
II:Pupils 3mm and non reactive, No corneals
Weak cough.
Motor: Extensor posturing with bilateral lower extremities
spontaneously,decorticate
EXAM AT THE TIME OF DEATH:
GEN: pale woman lying in bed not moving
HEENT: pupils fixed and dilated, no carotid pulse felt
CV: no heartbeat auscultated
PULM: no breaths auscultated
EXT: cool, no radial pulse felt
Pertinent Results:
LABS (admission labs and labs at the time of expiration are the
same time):
___ 11:00AM BLOOD WBC-17.6* RBC-4.02* Hgb-13.3 Hct-37.4
MCV-93 MCH-33.1* MCHC-35.6* RDW-12.1 Plt ___
___ 11:00AM BLOOD Neuts-70 Bands-12* Lymphs-10* Monos-8
Eos-0 Baso-0 ___ Myelos-0
___ 11:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 11:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 11:00AM BLOOD Glucose-271* UreaN-18 Creat-0.6 Na-134
K-4.8 Cl-106 HCO3-19* AnGap-14
___ 11:00AM BLOOD cTropnT-0.07*
___ 11:00AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.1
___ 11:59AM BLOOD pO2-385* pCO2-39 pH-7.36 calTCO2-23 Base
XS--2 -ASSIST/CON Intubat-INTUBATED
REPORTS:
CTA HEAD ___: IMPRESSION:
1. Larger left frontotemporal intraparenchymal hemorrhage with
associated
vasogenic edema and increased midline shifting deviation towards
the right, now measuring up to 12 mm.
2. Narrowing of the left perimesencephalic cistern as described
above.
3. Diffuse subarachnoid hemorrhage overlying the cerebral
hemispheres and
intraventricular system.
4. Lobulated saccular formation identified in the bifurcation of
the left
middle cerebral artery at the M1-M2 segment, measuring
approximately 6 x 9 mm in size.
5. There is an infundibulum the right PCOM insertion in the
right internal
carotid artery.
6. There is a small outpouching at the left extracranial
internal carotid
artery at the level of C2 superior endplate, possibly
representing a small
aneurysm versus possible vascular tortuosity. No flow-stenotic
lesions are
identified.
Medications on Admission:
Lisinopril 5mg QD
Metoprolol 50 mg TID
Plavix 5mg QD
Discharge Medications:
N/A pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Discharge Condition:
Please see discharge summary for full exam at time of death. Pt
pronounced dead at 7:40pm on ___. Family at the bedside.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ woman with intracranial hemorrhage. Evaluate
ETT placement.
COMPARISON: Chest radiograph ___ at 8:22 a.m. from ___
Hospital.
FINDINGS: A frontal supine view of the chest was obtained portably. The
endotracheal tube is low, ending 1.1 cm above the carina. A nasogastric tube
follows the expected course ending below the diaphragm, although the tip is
not visualized. There is bibasilar atelectasis, more significant on the
right. No pleural effusion or pneumothorax. Cardiac and mediastinal
silhouettes are stable.
IMPRESSION: Endotracheal tube ends 1.1 cm above the carina and could be
pulled back 2-3 cm to avoid bronchial intubation.
Discussed with Dr. ___ by phone at 11:05 a.m. ___.
Radiology Report
STUDY: CTA of the head with and without contrast.
CLINICAL INDICATION: Acute intraparenchymal hemorrhage demonstrated on a
prior CT from an outside hospital, rule out worsening bleed, aneurysm.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without contrast material. Subsequently, rapid axial imaging was performed
through the brain during the injection of Omnipaque intravenous contrast
material. Images were then processed on a separate workstation with display
of curved reformats, 3D volume-rendered images, and maximum intensity
projection images.
COMPARISON: Prior head CT from an outside institution ___
___ dated ___ at 0819 hours).
FINDINGS: There is increased size of the left frontotemporal intraparenchymal
hemorrhage and also increase in the surrounding vasogenic edema, associated
rightward midline shifting, now measuring approximately 12 mm, compared to 9
mm on the outside hospital CT from earlier today. There is also narrowing of
the left perimesencephalic cisterns with mild uncal herniation. Diffuse
subarachnoid hemorrhage overlying both cerebral hemispheres and
intraventricular system, extending into the foramen magnum, is not
significantly changed. The soft tissues and bony structures are grossly
unremarkable.
CTA OF THE HEAD.
A saccular irregular lobulated outpouching is demonstrated on the bifurcation
of the M1-M2 segment on the left middle cerebral artery, measuring
approximately 6 x 9 mm in size, likely consistent with the lobulated saccular
aneurysm. There is an infundibulum in the right PCOM insertion in the right
internal carotid artery. There is slight outpouching of the left extracranial
internal carotid at the level of C2 superior endplate (image #11, series #3
and image #17, series #401B). This finding may represent possible vascular
tortuosity, however, a small aneurysm cannot be completely excluded. There is
no evidence of flow-stenotic lesions.
IMPRESSION:
1. Larger left frontotemporal intraparenchymal hemorrhage with associated
vasogenic edema and increased midline shifting deviation towards the right,
now measuring up to 12 mm.
2. Narrowing of the left perimesencephalic cistern as described above.
3. Diffuse subarachnoid hemorrhage overlying the cerebral hemispheres and
intraventricular system.
4. Lobulated saccular formation identified in the bifurcation of the left
middle cerebral artery at the M1-M2 segment, measuring approximately 6 x 9 mm
in size.
5. There is an infundibulum the right PCOM insertion in the right internal
carotid artery.
6. There is a small outpouching at the left extracranial internal carotid
artery at the level of C2 superior endplate, possibly representing a small
aneurysm versus possible vascular tortuosity. No flow-stenotic lesions are
identified.
A preliminary report was provided by Dr. ___ communicated to Dr.
___ at 1:20 p.m. via telephone on ___.
Gender: F
Race: MULTIPLE RACE/ETHNICITY
Arrive by AMBULANCE
Chief complaint: HEAD BLEED
Diagnosed with SUBARACHNOID HEMORRHAGE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ was admitted to the hospital at 5:12pm on
___ to the ICU for her IPH. Given her poor prognosis, her
family gathered and decided to make her CMO. She was terminally
extubated and died with her family at the bedside at 7:40pm on
___. Her family declined an autopsy, as did the medical
examiner. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
atorvastatin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
exploratory laparotomy, repair of colonic perforation, small
bowel resection and diverting loop ileostomy
History of Present Illness:
Mr. ___ is a ___ with a PMH pertinent for HIV, ITP, NSTEMI
s/p
DES and an episode of rectosigmoid perforation ___ insertion of
a
foreign body into his rectum in ___, who presents with
worsening
abdominal pain and free air on AXR 8 hours s/p insertion of a
foreign body into his rectum. He was reportedly using an
approximately 12 inch phallic sex toy around 1200, when he
developed severe ___ abdominal pain radiating to his L
shoulder. This progressed throughout the day, leading him to
present to the ED where an upright plain film showed free air
below the diaphragm. He endorses chills and hematochezia since
the event. He denies fever, chest pain, SOB, dyspnea, nausea,
vomiting, diarrhea and dizziness. He states he had a "stomach
bug" 4 weeks ago that gave him diarrhea and nausea with emesis,
that was followed by a "flu" 2 weeks ago that gave him full body
aches. He did not present to a hospital for either event, and
states he feels he has recovered from those illnesses.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
1) Closed Fracture of Shaft of Clavicle (ICD-810.02)
2) Hand Pain, Bilateral (ICD-729.5) (ICD10-M79.641)
3) HIV Infection (ICD-042) (ICD10-B20)
4) Hx of Immune Thrombocytopenic Purpura (ICD-287.31)
(ICD10-D69.3)
5) Dermatophytosis of Nail (ICD-110.1) (ICD10-B35.1)
6) H/F Peritonitis (ICD-567.9) (ICD10-K65.9)
7) Hx of Colostomy Status - Reversed (ICD-V44.3)
Social History:
___
Family History:
Non-contributory
Physical Exam:
P/E:
VS: Please see flowsheets in POE
GEN: NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, No JVD
PULM: normal excursion, no respiratory distress
ABD: soft, TTP, ND, no mass, no hernia
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
WOUND: c/d/i
[x] ostomy : bilious stool
[x] drain: serous
Pertinent Results:
___ 07:02AM BLOOD WBC-12.0* RBC-4.04* Hgb-11.6* Hct-35.5*
MCV-88 MCH-28.7 MCHC-32.7 RDW-12.9 RDWSD-41.6 Plt ___
___ 09:15AM BLOOD WBC-7.2 RBC-4.34* Hgb-12.2* Hct-37.5*
MCV-86 MCH-28.1 MCHC-32.5 RDW-12.5 RDWSD-39.8 Plt ___
___ 07:10AM BLOOD WBC-12.7* RBC-4.35* Hgb-12.5* Hct-38.3*
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.2 RDWSD-42.7 Plt ___
___ 06:55AM BLOOD WBC-12.9* RBC-4.47* Hgb-12.9* Hct-39.2*
MCV-88 MCH-28.9 MCHC-32.9 RDW-13.1 RDWSD-42.1 Plt ___
___ 06:15PM BLOOD WBC-14.6* RBC-5.32 Hgb-15.1 Hct-47.5
MCV-89 MCH-28.4 MCHC-31.8* RDW-13.1 RDWSD-42.5 Plt ___
___ 06:15PM BLOOD Neuts-86.4* Lymphs-7.6* Monos-5.5
Eos-0.1* Baso-0.1 Im ___ AbsNeut-12.64* AbsLymp-1.11*
AbsMono-0.80 AbsEos-0.02* AbsBaso-0.02
___ 07:02AM BLOOD Plt ___
___ 09:15AM BLOOD Plt ___
___ 07:10AM BLOOD Plt ___
___ 06:55AM BLOOD Plt ___
___ 06:15PM BLOOD ___ PTT-22.7* ___
___ 06:15PM BLOOD Plt ___
___ 07:53AM BLOOD Glucose-83 UreaN-13 Creat-0.7 Na-140
K-3.8 Cl-99 HCO3-28 AnGap-13
___ 07:49AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-143
K-3.5 Cl-103 HCO3-29 AnGap-11
___ 07:02AM BLOOD Glucose-124* UreaN-10 Creat-0.7 Na-139
K-3.7 Cl-103 HCO3-29 AnGap-7*
___ 06:43AM BLOOD Glucose-148* UreaN-15 Creat-0.8 Na-136
K-4.0 Cl-95* HCO3-27 AnGap-14
___ 07:10AM BLOOD Glucose-130* UreaN-14 Creat-0.9 Na-136
K-4.0 Cl-99 HCO3-29 AnGap-8*
___ 06:55AM BLOOD Glucose-124* UreaN-17 Creat-0.8 Na-139
K-4.3 Cl-103 HCO3-27 AnGap-9*
___ 06:15PM BLOOD Glucose-139* UreaN-21* Creat-0.8 Na-140
K-4.1 Cl-102 HCO3-25 AnGap-13
___ 06:15PM BLOOD ALT-25 AST-27 AlkPhos-82 TotBili-0.7
___ 06:15PM BLOOD Lipase-23
___ 06:15PM BLOOD cTropnT-<0.01
___ 07:53AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0
___ 07:49AM BLOOD Albumin-3.0* Iron-13*
___ 07:49AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.8
___ 07:02AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
___ 06:43AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.8
___ 07:10AM BLOOD Calcium-8.6 Phos-2.0* Mg-2.1
___ 06:55AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.7
___ 07:49AM BLOOD calTIBC-147* Ferritn-1057* TRF-113*
___ 06:55AM BLOOD CRP-152.9*
___ 06:15PM BLOOD Lactate-1.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. emtricita-rilpivirine-tenof DF 200-25-300 mg oral DAILY
3. Rosuvastatin Calcium 5 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Complera (emtricita-rilpivirine-tenof DF) 200-25-300 mg oral
QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Aspirin 81 mg PO DAILY
4. Complera (emtricita-rilpivirine-tenof DF) 200-25-300 mg oral
QPM
5. emtricita-rilpivirine-tenof DF 200-25-300 mg oral DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Rosuvastatin Calcium 5 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
colonic perforation due to recreational insertion of a rectal
foreign body
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with HIV, CAD s/p ___ free air after recreational
insertion of a rectal foreign body s/p ex-lap, repair of colonic perforation,
SBR, diverting loop ileostomy// NGT placed correctly in stomach?
TECHNIQUE: Portable chest AP upright.
COMPARISON: Chest radiograph from ___
FINDINGS:
Nasogastric tube terminates in the stomach. Free air under the diaphragm has
resolved. New consolidation at the right base consistent with pleural
effusion and atelectasis. No evidence of other focal consolidation or
pneumothorax. Cardiac silhouette is top-normal.
IMPRESSION:
Interval placement nasogastric tube terminates in the stomach. Resolution of
free air. Developing right pleural effusion with atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with HIV, CAD s/p ___ free air after recreational
insertion of a rectal foreign body s/p ex-lap, repair of colonic perforation,
SBR, diverting loop ileostomy// NGT fell out and was replaced. NG in stomach?
IMPRESSION:
In comparison with the study of earlier in this date, the nasogastric tube has
been pulled back somewhat and devices coiled within the fundus of the stomach
with the tip pointing laterally.
Otherwise little change.
Gender: M
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Laceration of sigmoid colon, initial encounter, Exposure to other specified factors, initial encounter, Unspecified abdominal pain
temperature: 98.1
heartrate: 87.0
resprate: 18.0
o2sat: 99.0
sbp: 117.0
dbp: 63.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ presented to the ED at ___ on ___ for an
emergency exploratory laparotomy, repair of colonic perforation,
small bowel resection and diverting loop ileostomy. He tolerated
the procedure well without complications (Please see operative
note for further details). After a brief and uneventful stay in
the PACU, the patient was transferred to the floor for further
post-operative management.
Neuro: Pain was well controlled on Tylenol and tramadol for
breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. He had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: The patient was initially kept NPO after the procedure. The
patient was advanced to and tolerated a regular diet. Patient's
intake and output were closely monitored, due to increase in
ostomy output patient was placed in 2mg of daily Imodium and
psyllium wafers 3 times a day. Gave him strict parameters of
drinking at least 72oz a day of liquids at home to prevent
dehydration and strict monitoring of his ostomy output. His
surgical JP drain was removed before discharge.
GU: The patient had a Foley catheter that was removed prior to
discharge. At time of discharge, the patient was voiding without
difficulty. Urine output was monitored as indicated.
ID: The patient was closely monitored for signs and symptoms of
infection and fever, of which there was none.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. He/she was encouraged to get up and
ambulate as early as possible. The patient is being discharged
on prophylactic Lovenox.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. He will follow-up in the clinic in ___
weeks. This information was communicated to the patient directly
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female w/ history of anxiety presents as transfer from
___ with pneumomediastinum. She describes acute onset of sharp,
non-radiating sub sternal and right anterior chest pain
beginning at 7pm on ___ while sitting at her computer writing
an email. She ___ vomiting, wretching or any strenous
manuvers. She also denies associated SOB or dyspnea. She had
never experienced this before.
She went to the ___ ED and had a CT scan which showed
pneumomediastinum and she was transfered to ___. She was
afebrile with benign labs and stable vitle signs at ___.
Past Medical History:
Anxiety
Social History:
___
Family History:
Non contributory
Physical Exam:
Discharge Exam:
V: 98.6, 78, 102/54, 18, 97%RA
Gen: NAD, A and OX3
CV: RRR, no murmur, no TTP to anterior chest, no subcutaneous
emphysema
Pulm: CTAB, no wheeze
Abd: Soft, NT/ND, no rebound/guarding
Ext: WWP, no cyanosis.
Medications on Admission:
MethylPHENIDATE (Ritalin) 20 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. MethylPHENIDATE (Ritalin) 20 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumomediastinum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old woman with pneumomediastinum. // eval for esophageal
perf with barium esophagogram
TECHNIQUE: Barium esophagram.
COMPARISON: Outside CT of the chest ___
FINDINGS:
The esophagus was evaluated with the patient upright using water-soluble
contrast initially followed by thin consistency barium. The esophagus was not
dilated. There was no stricture within the esophagus. There was no esophageal
mass. The esophageal mucosa appeared normal.
The primary peristaltic wave was normal, with contrast passing readily into
the stomach. The lower esophageal sphincter opened and closed normally. There
is no hiatal hernia.
Limited views of the stomach revealed no gross abnormality.
IMPRESSION:
Normal esophagram. No evidence of perforation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PNEUMOMEDIASTINUM
Diagnosed with INTERSTITIAL EMPHYSEMA
temperature: 98.5
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 102.0
dbp: 64.0
level of pain: 5
level of acuity: 1.0 | ___ y/o female who was sent as a transfer from ___ with
pneumomediastinum with no preceeding event. After reviewing OSH
imaging a barium swallow was ordered. It showed no esophageal
perforation and she was clinically stable. However, due to
continued pain and significant pneumomediastinum on CT scan she
was admitted overnight for observation and was held NPO
overnight.
On HD#2 her pain had improved and she continued to have stable
vitals. Her diet was advanced from clears to regular diet and
she was discharged home. She should follow up with GI to work
up potential eosinophillic esophagitis as possible cause of
pneumomediastinum. At the time of discharge her pain was
controlled with tylenol, she was tolerating a regular diet and
was ambulatory. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / clindamycin / Nortriptyline / surgical tape /
strwberries / pineapple / milk
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F PMH dystonia and chronic back pain p/w back pain and
weakness and numbness to both legs since this am. Patient states
she slipped off her toilet and fell on to her buttocks early
this morning. Patient states she felt fine and walked
immediately afterward, but states that later in the day both of
her legs went out from under her and became numb. This has been
an issue every since ___ when she got a spinal injection
for chronic low back pain from her pain specialist. She states
this feels exactly like previous times that this has happened.
She states that when this has happened previously, she was given
medications and the symptoms quickly resolved. As per OSH
records, pt was very difficult to examine and had typical
dystonic reaction. There patient was reportedly given 2mg
dilaudid, 60mg IM toradol. A plain film showed no evidence of
fracture or dislocation. Per notes, patient was to be admitted
for pain control, but as per patient she was sent here due to
"medical complexity"
OSH Labs (___) - ___
8.8 > 3.2/40.1 < 215
143 | 106 | 7
--------------< 161
3.9 | 22 | 0.8
UA- neg bil, neg ketones, large BLDR, trace protein, neg
nitrites, small leuks
___ WBC, 50-100 RBC, trace bact, no casts, ___ squam
HCGU negative
OSH Imaging:
XR Lumbar Spine:
FINDINGS: There is a sacral stimulator device on the left. There
is
mild disc space narrowing at L4-5 and L5-S1. There is slight
scoliosis convex to the right. Vertebral body heights are
maintained. There is no evidence of fracture or subluxation.
There
is mild sclerosis at the lower lumbar facets.
There are surgical clips in the right upper quadrant.
IMPRESSION: No evidence of fracture or subluxation. Mild
scoliosis
and degenerative facet disease. Mild disc space narrowing in the
lower lumbar spine.=
In the ED, initial vitals: 98.6 68 101/64 14 99% RA
Pt triggered for seizure. Frothing at mouth with generalized
tonic/clonic activity. Unresponsive. Responded to Ativan. Admit
to medicine for possible withdrawal seizure. Patient usually
takes Ativan daily but has not had any yet today.
Labs at ___ were unremarkable.
CT L spine unremarkable.
In the ED, she received
___ 02:36 IV Lorazepam 2 mg
___ 02:36 IV Ketorolac 30 mg
___ 08:15 PO/NG Pregabalin 150 mg
___ 08:15 PO/NG LamoTRIgine 100 mg
___ 08:15 PO/NG Tizanidine 4 mg
___ 08:15 PO TraMADol 50 mg
___ 08:15 PO/NG Sertraline 200 mg
___ 08:15 PO/NG Diltiazem 120 mg
___ 08:24 PO LORazepam 1 mg
___ 14:44 PO DiphenhydrAMINE 25 mg
___ 14:44 PO TraMADol 100 mg
___ 14:44 PO Lorazepam 1 mg
___ 14:54 PO/NG Pregabalin 150 mg
___ 14:54 PO/NG Tizanidine 4 mg
___ 20:00 PO/NG Pregabalin
___ 20:00 PO/NG Tizanidine
___ 20:00 PO/NG Mirtazapine
___ 22:21 IV Lorazepam 2 mg
___ 03:19 PO/NG Tizanidine 4 mg
___ 03:21 PO LORazepam 1 mg
___ 08:00 PO/NG Pregabalin
___ 08:00 PO/NG LamoTRIgine
___ 08:00 PO/NG Sertraline
___ 09:01 IV Sodium Chloride 0.9% Flush 3 mL
___ 09:01 PO/NG Pregabalin 150 mg
___ 09:01 PO/NG LamoTRIgine 100 mg
___ 09:01 PO/NG Sertraline 200 mg
___ 10:17 IV Lorazepam 2 mg
___ 12:18 PO/NG Tizanidine 4 mg
___ 12:18 PO Pantoprazole 40 mg
Vitals prior to transfer: 98.5 89 127/106 22 99% RA
Currently, pt reports she feels better after having something to
eat and getting her medications. She reports she has had
previous episodes of her dystonic convulsions after which she
has no memory of the events. She usually has one episode per
day of her dystonic convulsions and they are brought on by
stress, pain, and missing her medications.
Past Medical History:
fibromyalgia diagnosed in ___ at ___
gastric bypass ___
DM II, resolved after gastric bypass
asthma
migraine headaches
restless legs syndrome
irritable bowel syndrome
osteoporosis
trigeminal neuralgia
status post ACL repair
vitamin D deficiency
regional pain disorder
functional movement disorder
GERD
dystonia
Social History:
___
Family History:
Not significant for any pain disorders, muscle or joint
disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98 132/77 96 18 98% on RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: Difficult to examine given dystonia. RLE ___ strength,
sensation intact to light touch, LLE ___ strength with decreased
sensation to light touch, R lumbar paravertebral ttp without
stepoffs. Positive left leg raise.
DISCHARGE PHYSICAL EXAM:
VS: 98 129/83 56 16 98% on RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: Difficult to examine given dystonia. RLE ___ strength,
sensation intact to light touch, LLE ___ strength with decreased
sensation to light touch, R lumbar paravertebral ttp without
stepoffs. Positive left leg raise.
Pertinent Results:
RELEVANT LABS:
___ 06:22AM BLOOD Calcium-9.4 Phos-4.1# Mg-1.9
___ 06:22AM BLOOD Glucose-87 UreaN-10 Creat-0.6 Na-141
K-4.0 Cl-105 HCO3-22 AnGap-18
___ 06:22AM BLOOD WBC-7.1 RBC-4.43 Hgb-13.5 Hct-41.4 MCV-94
MCH-30.5 MCHC-32.6 RDW-13.1 RDWSD-44.5 Plt ___
IMAGING:
CT L-spine without contrast ___
IMPRESSION:
1. Streak artifact from nerve stimulator limits examination.
2. No evidence of fracture.
3. No definite evidence of epidural hematoma or osteomyelitis.
4. New mild bilateral L4-5 and stable mild bilateral L5-S1 facet
joint
arthropathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN breathing
2. LaMOTrigine 100 mg PO DAILY
3. Lorazepam ___ mg PO Q8H:PRN anxiety
4. Mirtazapine 7.5 mg PO QHS
5. Pramipexole 0.375 mg PO QHS:PRN restles leg
6. Pregabalin 150 mg PO TID
7. Sertraline 200 mg PO DAILY
8. Sucralfate 1 gm PO TID
9. Tizanidine ___ mg PO Q4H:PRN pain
10. TraMADOL (Ultram) 50-100 mg PO Q6H:PRN pain
11. EpiPen 2-Pak (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection
ONCE per allergic reaction
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. Pantoprazole 40 mg PO Q12H
14. rizatriptan 10 mg oral ONCE MR1
15. Fluticasone Propionate 110mcg 2 PUFF IH BID
16. ALPRAZolam 1 mg PO ONCE for severe dystonia
17. melatonin 5 mg/15 mL oral QHS
18. DiphenhydrAMINE 25 mg PO ONCE dystonic episodes
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN breathing
2. LaMOTrigine 100 mg PO DAILY
3. Lorazepam ___ mg PO Q8H:PRN anxiety
RX *lorazepam 1 mg ___ tab by mouth every eight (8) hours Disp
#*18 Tablet Refills:*0
4. Mirtazapine 7.5 mg PO QHS
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Pramipexole 0.375 mg PO QHS:PRN restles leg
7. Pregabalin 150 mg PO TID
8. Sertraline 200 mg PO DAILY
9. Sucralfate 1 gm PO TID
10. Tizanidine ___ mg PO Q4H:PRN pain
11. TraMADOL (Ultram) 50-100 mg PO Q6H:PRN pain
12. Bisacodyl 10 mg PO DAILY:PRN constipation
13. Docusate Sodium 100 mg PO BID
14. Lactulose 30 mL PO DAILY:PRN constipation
15. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
16. OxycoDONE Liquid 2.5-5 mg PO Q6H:PRN pain,convulsions
RX *oxycodone 5 mg/5 mL 5 mL by mouth every eight (8) hours Disp
___ Milliliter Refills:*0
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 8.6 mg PO BID constipation
19. ALPRAZolam 1 mg PO ONCE for severe dystonia
20. DiphenhydrAMINE 25 mg PO ONCE dystonic episodes
21. EpiPen 2-Pak (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection
ONCE per allergic reaction
22. Fluticasone Propionate 110mcg 2 PUFF IH BID
23. melatonin 5 mg/15 mL oral QHS
24. rizatriptan 10 mg oral ONCE MR1
25. Maalox/Diphenhydramine/Lidocaine 30 mL PO TID:PRN dystonic
episodes
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Low back pain
Psychogenic non-epileptic convulsions
Functional movement disorder/dystonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: ___ female functional movement disorder and
neurostimulator now with back pain and bilateral lower extremity weakness and
numbness similar to prior episodes. Evaluate for lumbar spine fracture,,
epidural hemorrhage or evidence of osteomyelitis.
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, 25.1 cm; CTDIvol = 31.9 mGy (Body) DLP = 801.2
mGy-cm.
Total DLP (Body) = 801 mGy-cm.
COMPARISON: ___ noncontrast lumbar spine CT.
FINDINGS:
Streak artifact from nerve stimulator limits examination. Alignment is
normal. No fractures are identified. There is no evidence of bony spinal canal
stenosis. Mild bilateral L4-5 facet joint arthropathy not definitely seen on
prior examination is noted. Stable mild bilateral L5-S1 facet arthropathy is
seen. There is no prevertebral soft tissue swelling. Within the limits of
this noncontrast study, there is no evidence of infection or neoplasm.
A neurostimulator sits in the superficial soft tissues overlying the left
iliac bone, with leads which extend inferiorly beyond the field of view of
imaging.
IMPRESSION:
1. Streak artifact from nerve stimulator limits examination.
2. No evidence of fracture.
3. No definite evidence of epidural hematoma or osteomyelitis.
4. New mild bilateral L4-5 and stable mild bilateral L5-S1 facet joint
arthropathy.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Body pain
Diagnosed with Other dystonia, Low back pain
temperature: 98.6
heartrate: 68.0
resprate: 14.0
o2sat: 99.0
sbp: 101.0
dbp: 64.0
level of pain: 8
level of acuity: 3.0 | ___ with history of pseudoseizures/psychogenic dystonia who
presents with back pain and left leg numbness.
# Back pain/left leg numbness - this improved without
intervention. History and exam c/w radiculopathy. Possibly due
to recent back injection. She denies bladder or bowel
incontinence. She was continued on her home medications and
liquid oxycodone as needed for dystonic episodes.
# Psychogenic dystonic reactions - She has one episode per day
at home, and she denies these being actual seizures. During
these episodes, she is able to make volitional movements, follow
commands at times, and answer questions with sign language at
times. They last 20min to 3 hours at a time. She takes crushed
lorazepam, tramadol, and diphenhydramine at home (delivered into
her mouth through a syringe) to stop these psychogenic
convulsions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ who presents after a fall from her garage
roof while laying down squirrel traps. She landed her left leg.
She notes left foot pain. She denies headstrike or LOC. No other
injuries in the leg. She denies any numbness or tingling.
Past Medical History:
None
Social History:
___
Family History:
___
Physical Exam:
NAD
Breathing comfortably
Left lower extremity:
- Splint intact
- Full, painless AROM/PROM of hip, knee
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Calcaneus 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: Chest radiograph
INDICATION: ___ with calcaneal fx s/p fall. evaluation for pre-op.// ?
pneumonia
TECHNIQUE: AP upright and lateral chest radiographs
COMPARISON: None.
FINDINGS:
The lungs are well expanded and clear. The cardiomediastinal silhouette is
within normal limits. There is no pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CALCANEAL FX, s/p Fall
Diagnosed with Unsp fracture of left calcaneus, init for clos fx, Other fall from one level to another, initial encounter
temperature: 99.0
heartrate: 77.0
resprate: 16.0
o2sat: 97.0
sbp: 163.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | Patient was admitted to the orthopaedic trauma service for her
calcanceus fracture. She was placed into a bulky ___ splint.
She was evaluated by ___ who deemed discharge to home
appropriate. She will be discharged on aspirin for DVT
prophylaxis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Cephalosporins
Attending: ___.
Chief Complaint:
SOB, tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of COPD on home O2, chronic dCHF, AFib, DM who
presents with reported shortness of breath and tachycardia.
Patient says he has intermittent SOB. Today felt SOB so called
___ who saw patient and noted tachycardia though the
documentation is unclear how tachycardic. Patient denies chest
pain, cough, fevers, chills, lightheadedness.
Of note he has had multiple recent admissions including
___ for MRSA pneumonia, Cdiff colitis and acute
interstitial nephritis. He was also admitted ___ for acute
diastolic CHF exacerbation. He was mostly recently admitted four
days ago, ___ with with fever, cough, and increased work of
breathing for one day. Prior to that he had been in good health.
He was also noted to have gained approximately 2kg. He was given
antibiotics in the hospital and ultimately discharged with a
course of levofloxacin for pneumonia with plan to finish on
___. Patient was also noted to have a five pound weight gain on
___ from the ___ team.
In the ED, initial vital signs were: 98 100 108/57 20 99% RA
- Exam was notable for: not documented
- Labs were notable for: WBC 10.4, H/H 6.5/20.5, Plts 394, INR
2.2, BNP 11,862, BUN/CRT 56/3.1, lactate 1.6
- Imaging: Chest xray showed worsening airspace opacities in
the mid and left lower lung that was concerning for pneumonia
- The patient was given: vanc, zosyn
- Consults: None
- Vitals prior to transfer were: 98.1 91 134/73 16 100% RA
Upon arrival to the floor, patient said he was feeling well. He
was receiving blood. Lasix 40IV was given to prevent worsening
shortness of breath with transfusion.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, dyspnea, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, hematochezia,
dysuria, rash, paresthesias, and weakness.
Past Medical History:
-Moderate-severe obstructive pulmonary disease: Last PFTs
___, FEV1 40% predicted, uses 2.5L O2 at home
-? Coronary artery disease: ___ Stress test negative, but
frequent atrial irritability. -- MIBI revealed normal myocardial
perfusion.
-Diastolic congestive heart failure
-Recurrent aspiration
-CKD
-Diabetes mellitus, type 2
-GERD w/ h/o H. pylori gastritis
-Gynecomastia
-Hypertension
-Dysphagia
-Peripheral neuropathy
-Dyslipidemia
-Right eye blindness ___ eye injury in childhood)
-Atrial fibrillation
Social History:
___
Family History:
Patient denies pulmonary disease, heart diseases/conditions,
diabetes, cancers (though daughter with lung cancer noted in
records). His oldest son died at age ___ from lung cancer. He was
a smoker.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.7 145/64 99 18 100% on 2L
WEIGHT: 76.5kg (dry weight appears 67-69kg)
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 flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: +crackles, +rhonchi, +intermittent wheeze
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: 2+ pitting edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, moving all extremities
Discharge exam:
VS - Tmax 99.4 Tc 98 HR 60-90s BP 90-130/40-70 RR ___ 02 100
2L
sat on RA
I/O --/--?
Weight: ? <- 62 kg
General: NAD, A&Ox3, responding appropriately
HEENT: atrumatic, normocephalic, blind in right eye,
Neck: No JVD
CV: tachycardic, regular, no murmurs, rubs or gallops
Lungs: Expiratory rhonchi, no crackles appreciated, on going
cough
Abdomen: soft, NT/ND, BS+
GU: no foley
Ext: 1+ bilateral leg edema L>R
Neuro: grossly intact
Skin: Warm Well Perfused
Pertinent Results:
Admission and notable labs:
___ 12:42PM BLOOD WBC-10.4* RBC-2.60* Hgb-6.5* Hct-20.5*
MCV-79* MCH-25.0* MCHC-31.7* RDW-19.3* RDWSD-53.5* Plt ___
___ 12:42PM BLOOD ___ PTT-45.7* ___
___ 12:42PM BLOOD Glucose-155* UreaN-56* Creat-3.1* Na-133
K-5.6* Cl-95* HCO3-25 AnGap-19
___ 12:42PM BLOOD LD(LDH)-468*
___ 12:42PM BLOOD ___
___ 12:42PM BLOOD Iron-35*
___ 03:37PM BLOOD Calcium-8.7 Phos-4.2 Mg-1.7
___ 12:42PM BLOOD calTIBC-276 Hapto-387* Ferritn-207
TRF-212
___ 12:53PM BLOOD Lactate-1.6
Discharge labs (patient refused labs after this date; no labs
available on day of discharge)
___ 03:37PM BLOOD WBC-11.1* RBC-2.90* Hgb-7.4* Hct-22.9*
MCV-79* MCH-25.5* MCHC-32.3 RDW-17.5* RDWSD-50.6* Plt ___
___ 03:37PM BLOOD Glucose-185* UreaN-54* Creat-3.2* Na-134
K-4.3 Cl-94* HCO3-31 AnGap-13
Imaging:
CXR ___:
FINDINGS: Re demonstrated are massive bilateral parenchymal
opacities, demonstrating overall interval worsening in the mid
and lower left lung and slight interval improvement in the right
lung base. There may be a small left pleural effusion. There
is no evidence of a pneumothorax. Mild cardiomegaly, has been
stable compared to prior exams dated back tumor ___.
The hilar and mediastinal contours, are otherwise unremarkable.
IMPRESSION: Slight interval worsening of airspace opacity
overlying the mid and lower left lung, concerning for pneumonia.
EKG ___
Atrial fibrillation with a controlled ventricular response.
Baseline artifact makes ST-T wave interpretation difficult.
Compared to the previous tracing of ___ artifact is new.
Micro: Blood cultures pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
2. Ferrous GLUCONATE 324 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Ranitidine 150 mg PO DAILY
6. sevelamer CARBONATE 2400 mg PO TID W/MEALS
7. Tiotropium Bromide 1 CAP IH DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Warfarin 8 mg PO 2X/WEEK (MO,FR)
10. Warfarin 6 mg PO 5X/WEEK (___)
11. Lovastatin 10 mg ORAL DAILY
12. Torsemide 20 mg PO DAILY
13. Levofloxacin 500 mg PO Q48H
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
2. Ferrous GLUCONATE 324 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Ranitidine 150 mg PO DAILY
6. sevelamer CARBONATE 2400 mg PO TID W/MEALS
7. Tiotropium Bromide 1 CAP IH DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Warfarin 8 mg PO 2X/WEEK (MO,FR)
10. Warfarin 6 mg PO 5X/WEEK (___)
11. Lovastatin 10 mg ORAL DAILY
12. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute decompensated systolic heart failure
Hospital acquired pneumonia
Secondary:
Atrial fibrillation
Chronic kidney disease
Anemia
Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Walker.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough // eval infiltrate
TECHNIQUE: Chest AP and lateral
COMPARISON: CT of the chest from ___. Chest radiograph from ___.
FINDINGS:
Re demonstrated are massive bilateral parenchymal opacities, demonstrating
overall interval worsening in the mid and lower left lung and slight interval
improvement in the right lung base. There may be a small left pleural
effusion. There is no evidence of a pneumothorax. Mild cardiomegaly, has
been stable compared to prior exams dated back tumor ___. The hilar
and mediastinal contours, are otherwise unremarkable.
IMPRESSION:
Slight interval worsening of airspace opacity overlying the mid and lower left
lung, concerning for pneumonia.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with Other fatigue
temperature: 98.0
heartrate: 100.0
resprate: 20.0
o2sat: 99.0
sbp: 108.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with history of COPD on home 2.5L
NC, chronic dCHF, AFib, DM who presents with SOB and
tachycardia.
#ACUTE DECOMPENSATED DIASTOLIC HEART FAILURE: Patient has had
several recent admissions, most recently ___ for CHF
exacerbation and again ___ for HCAP. After discharge on
___, pt was in his USOH at home when he complained of SOB to his
___ and so presented to ED. Admission labs were notable for BNP
12K from 9K on ___ and exam was consistent with volume
overload. Given this, he underwent diuresis with Lasix 40 mg IV
for HF exacerbation x2 and his home torsemide was increased to
20 mg daily (this was discussed via telephone on the day prior
to admission due to weight increase noted in outpatient
setting). He was continued on metoprolol as below. Of note,
patient not on ___ given CKD.
#H/O HOSPITAL ACQUIRED PNA: Patient was recently admitted
___ for HCAP. During that admission, he was placed on
levofloxacin for a planned 7 day course, which was ongoing
during this admission, ending on ___. CXR on ___ showed
persistent PNA. This admission he had continued cough which was
improving. He had a 1x temp of 100.8 but was otherwise afebrile
and not meeting SIRS criteria.
#Afib: patient noted to be tachycardic by ___ and so presented
to ED. EKG consistent with Afib with HR in 100s, which persisted
on telemetry. Patient's home metoprolol XL was increased to 25
mg daily from 12.5 daily. He was continued on Coumadin for goal
INR ___.
#CKD: Creatinine of 3.1 on admission, which increased to 3.2
with diuresis. This is consistent with prior discharge
Creatinine 2.9. He was continued on home sevelamer this
admission. Of note, prior discharge paperwork documents that
family and patient would not want HD if kidney function were to
worsen per GOC.
#Anemia: HCT on admission was similar to recent baseline, but
slightly below 7 and so was given 1U pRBCs with appropriate
increase. He was continued on home ferrous sulfate.
#COPD: on home 2.5L NC. Continued Spiriva, Advair, albuterol PRN
#DM2: diabetic diet, continued sliding scale insulin
#HLD: continued statin
#GERD: continued ranitidine 150 mg PO DAILY |
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: fall:
Mildly depressed Right zygomatic arch fracture
Right lateral orbital wall fracture
? left max sinus injury
Nondisplaced fracture C4 SP
Left post calc fx (likely old)
C4/5 longit. lig inj ___. prevert hematoma
IS lig injury spanning C2-6
Major Surgical or Invasive Procedure:
repair of head laceraton
History of Present Illness:
This patient is a ___ year old male who complains of s/p
Fall. The patient with a history of alcohol abuse, who
presents via EMS living on with this fall down 5 to 7
stairs. His ___ son reportedly heard a crash coming
called ___. He was noted to be extremely combative with
obvious facial and head trauma
Past Medical History:
spine cyst - bilateral lower extremity numbness - contributes to
repeated falls, L ankle fx - supposed to wear a boot, h/o heroin
abuse
Social History:
___
Family History:
unknown
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
HR: 125 BP: 143/97 Resp: 20 O(2)Sat: 100
Constitutional: Constitutional: agitated , yelling and
attempting to strike staff then intermittently calm
Head/Eyes: Normocephalic, laceration x 2 to R forehead,
Pupils equal, round, reactive to light
ENT/Neck: c-collar in place 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 14, spontaneously moves all extremities to
command.
Psych: agitated
Physical examination at discharge: ___:
vital signs: 98.2, hr=69, bp=113/82 18,
GENERAL: NAD, patient sitting in chair, very protective of left
leg
CV: ns1, s2, -s3 -s4
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: no calf tenderness bil. air boot left foot ( very
protective and limited examination)
NEURO; alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 01:00PM BLOOD WBC-6.3 RBC-2.86* Hgb-10.1* Hct-27.4*
MCV-96 MCH-35.3* MCHC-36.8* RDW-15.0 Plt ___
___ 06:00AM BLOOD WBC-4.3 RBC-2.32* Hgb-8.1* Hct-22.8*
MCV-98 MCH-35.0* MCHC-35.7* RDW-14.3 Plt Ct-91*
___ 01:00PM BLOOD Plt ___
___ 01:54AM BLOOD ___ PTT-32.0 ___
___ 05:13AM BLOOD ___ 06:55PM BLOOD Glucose-107* UreaN-9 Creat-0.5 Na-134
K-3.9 Cl-96 HCO3-22 AnGap-20
___ 05:32AM BLOOD ALT-34 AST-91* AlkPhos-51 TotBili-0.9
___ 06:00AM BLOOD Lipase-797*
___ 06:55PM BLOOD Calcium-8.8 Phos-3.8 Mg-1.6
___ 05:13AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___: cat scan of the c-spine:
1. Prevertebral soft tissue edema and hematoma spanning C2-C5,
raising
concern for ligamentous injury. MRI is recommended.
There is also a lucency through the uncinate process of C4 on
the right
(4:140) concerning for nondisplaced fracture.
2. Nondisplaced fracture of the C4 posterior process.
___: cat scan of the head:
1. No intracranial hemorrhage. Large right frontal scalp
hematoma.
2. Mildly depressed right zygomatic arch fracture. Probable
nondisplaced
fracture of the right lateral orbital wall.
3. High density material within the left maxillary sinus,
potentially
hemorrhage. Although no fracture is identified, given trauma
history, occult fracture is possible.
4. Prominent ventricles and sulci, disproportionate to age.
___: chest x-ray:
No pneumothorax or displaced rib fracture
___: MRI cervical spine:
Limited exam due to motion and only sagittal images were
acquired as this
patient could not tolerate completing the exam.
Disruption of the anterior longitudinal ligament at C4-C5 with
prevertebral hematoma.
Interspinous ligamentous injury spanning C2-3 through C5-6.
Fluid within the C1-C2 articulations. While this could be
degenerative,
ligamentous injury involving this joint is not entirely
excluded.
___: left ankle injury:
Posterior calcaneal defect with associated fracture of
indeterminate age.
Soft tissue thickening along the posterior calcaneus at the
Achilles tendon insertion
___: chest x-ray:
Cardiomediastinal silhouette is within normal limits. There is
a linear
density at the right base which may represent atelectasis or
developing
infiltrate. This is more apparent than on the prior study.
There are no
pneumothoraces
___: cat scan ___:
1. Moderate posterior calcaneal avulsion fracture with
questionable extension to the articular surface at the mid
subtalar facet. Mild superomedial displacement of the proximal
fracture fragment attached to the distal Achilles tendon which
demonstrates moderate tendinosis. In addition, there is
suggestion of slight medial displacement of the plantar portion
of the calcaneus.
2. Generalized osteopenia. Given the degree of diffuse
osteopenia, subtle nondisplaced fractures might not be apparent
.
3. Loss of normal subcutaneous fat over the heel. The patient's
known skin ulceration within this region is not definitely seen
on the current exam.
Limited evaluation for osteomyelitis in the context of severe
osteopenia and enthesopathy at the posterior calcaneus.
4. Thickening of the Achilles and peroneus longus tendons is
suggestive of tendinopathy. No obvious tendon tear is detected,
though a subtle tendon tear might not be apparent on this
examination. No tendon entrapment identified .
___: Gallbladder US;
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including hepatic fibrosis or cirrhosis or
steatohepatitis cannot be excluded on the basis of this
examination.
2. Irregular, slightly echogenic nonmobile material along the
gallbladder wall could represent adherent sludge or stones,
versus small polyps.
Medications on Admission:
suboxone (dose unknown)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO BID
4. Heparin 5000 UNIT SC TID
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3
hours Disp #*25 Tablet Refills:*0
6. Nicotine Patch 21 mg TD DAILY
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: fall
Mildly depressed right zygomatic arch fracture
Right lateral orbital wall fracture
? left maxillary sinus injury
Nondisplaced fracture C4 SP
Left post calc fracture (likely old)
C4/5 longit. ligamentous injury with prevert hematoma
IS ligamentous injury spanning C2-6
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 fall, head injury, unequal pupils, head lacerations //
r/o ICH
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast. Coronal and sagittal reformations, and
thin slice bone algorithm reconstructions were reviewed.
CTDIvol: 53 mGy.
DLP: 1003 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large territorial
infarction. No pneumocephalus. Prominence of the ventricles and sulci are
disproportionate to age. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
Large right frontal scalp hematoma. No underlying osseous injury. Mildly
depressed right zygomatic arch fracture. The lateral wall of the right orbit
is irregular, likely representing fracture. Moderate left maxillary sinus
mucosal thickening. In addition, there is high density material layering in
the left maxillary sinus, potentially hemorrhage. Although no acute fractures
definitely the visualized, occult fracture is possible. The bilateral
pterygoid plates are intact. Mucous retention cyst within the right maxillary
sinus. Partial opacification of ethmoid air cells. Mastoid air cells are
clear.
IMPRESSION:
1. No intracranial hemorrhage. Large right frontal scalp hematoma.
2. Mildly depressed right zygomatic arch fracture. Probable nondisplaced
fracture of the right lateral orbital wall.
3. High density material within the left maxillary sinus, potentially
hemorrhage. Although no fracture is identified, given trauma history, occult
fracture is possible.
4. Prominent ventricles and sulci, disproportionate to age.
Radiology Report
INDICATION: ___ with fall, head injury, unequal pupils, head lacerations //
r/o ICH
TECHNIQUE: 2.5 mm helical axial MDCT sections were obtained from the skull
base through the superior endplate of T3. Axial images were interpreted in
conjunction with coronal and sagittal reformats.
DLP: 827 mGy-cm
CTDIvol: 37 mGy
COMPARISON: None.
FINDINGS:
Vertebral body heights are maintained without evidence of compression. A
nondisplaced fracture is seen of the posterior process of C4 (2:41, 603b:39).
Intervertebral disc heights are maintained. No acute alignment abnormality is
identified. Lucency through the right uncinate process of C4 (4:140) is
suggestive of a nondisplaced fracture.
Moderate prevertebral soft tissue edema/hematoma spans C2 through C5, raising
concern for ligamentous injury. No lymphadenopathy is present by CT size
criteria. The thyroid is unremarkable. Moderate paraseptal emphysema seen in
the upper lobes.
IMPRESSION:
1. Prevertebral soft tissue edema and hematoma spanning C2-C5, raising
concern for ligamentous injury. MRI is recommended.
There is also a lucency through the uncinate process of C4 on the right
(4:140) concerning for nondisplaced fracture.
2. Nondisplaced fracture of the C4 posterior process.
NOTIFICATION: Additional finding discussed with Dr. ___ by Dr. ___ at
10:45 on ___.
Radiology Report
INDICATION: History: ___ with fall, head injury, unequal pupils, head
lacerations // r/o ICH
COMPARISON: None.
TECHNIQUE: Single frontal view of the chest.
FINDINGS:
Heart size and cardiomediastinal contours are normal. Lungs are clear without
focal consolidation, pleural effusion, or pneumothorax. No displaced rib
fracture.
IMPRESSION:
No pneumothorax or displaced rib fracture.
Radiology Report
INDICATION: History: ___ with fall stairs // bleed?
TECHNIQUE: TECHNIQUE: MDCT images were obtained from the thoracic inlet to
the pubic symphysis. IV Omnipaque contrast was administered. Oral contrast
was not administered. Axial images were interpreted in conjunction with
sagittal and coronal reformats.
DLP: 1028 mGy-cm
COMPARISON: None.
FINDINGS:
CHEST:
The thyroid is normal. Axillary, supraclavicular, mediastinal, and hilar
lymph nodes are not pathologically enlarged. The great vessels are
unremarkable. The heart and mediastinum are normal. No pericardial effusion.
The airways are patent to the subsegmental levels.
Moderate biapical paraseptal emphysema. No focal consolidation, pleural
effusion, or pneumothorax. The esophagus is unremarkable.
ABDOMEN:
Diffuse hepatic steatosis without concerning focal lesion. The gallbladder,
intra and extrahepatic bile ducts, spleen, adrenal glands, kidneys, and
ureters are normal. Subcentimeter left lower pole renal hypodensity is too
small to characterize. There is moderate peripancreatic fat stranding without
areas of pancreatic hypoenhancement to suggest necrosis. No peripancreatic
fluid collection.
The stomach is decompressed and there is moderate hyperenhancement of the
gastric and duodenal mucosa, which may be related to pancreatic findings. Mild
right colonic edema is nonspecific and may be related to underlying liver
disease or reactive to pancreatitis. The small and large bowel otherwise
enhance homogeneously and have a normal course and caliber. The appendix is
normal.
No retroperitoneal or mesenteric lymphadenopathy. The portal and
intra-abdominal systemic vasculature are normal without evidence of
psuedoaneurysm or thrombosis. No abdominal wall hernia, pneumoperitoneum, or
free abdominal fluid.
PELVIS:
The bladder and terminal ureters are normal. Prostate contains dystrophic
calcifications. No pelvic side-wall or inguinal lymphadenopathy. No inguinal
hernia. Trace free pelvic fluid.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy. Grade 2 anterolisthesis of L5 on S1 with bilateral L5
spondylolysis. 2.6 cm lucent lesion in the left ilium adjacent to the
sacroiliac joint is nonaggressive appearing.
IMPRESSION:
1. No evidence of acute traumatic injury in the torso. Anterolisthesis of L5
on S1 with bilateral L5 spondylolysis is likely chronic, please correlate with
symptoms.
2. Peripancreatic stranding consistent with acute pancreatitis. No evidence
of pancreatic necrosis or peripancreatic fluid collection. Hyperenhancement of
the gastric and duodenal musoca is likely secondary to pancreatitis.
3. Nonaggressive appearing 2.6 cm left iliac lucent lesion, possibly a benign
bone cyst.
4. Hepatic steatosis.
5. Nonspecific mild right colonic edema, likely either related to underlying
liver disease or reactive from pancreatitis.
6. Biapical paraseptal emphysema.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST
INDICATION: ___ with fall down stairs with ? C2-C5 ligamentous injuryIV
contrast to be given at radiologist discretion as clinically needed // r/o
ligamentous injury
TECHNIQUE: MRI of the cervical spine was performed using sagittal T1, T2, and
stir sequences. Examination was then terminated as patient became combative.
COMPARISON: Correlation made to same day CT of the cervical spine.
FINDINGS:
Exam is somewhat motion limited, particularly on the sagittal T1 weighted
images, and only contains sagittal images. Following observations are noted:
Extensive prevertebral hematoma seen spanning from essentially the skullbase
to C5. There is disruption of the anterior longitudinal ligament at the C3-C4
level (6:8).
There is T2/ STIR hyperintensity in the region of the interspinous ligaments
spanning C2-3 through C5-6 worrisome for ligamentous injury. Swelling seen in
the adjacent paraspinal musculature at these levels as well.
There is fluid within the bilateral C1-C2 joints (06:15 and 2). While this
could be degenerative, ligamentous injury at this level cannot be entirely
excluded.
Based on sagittal images, there is no cord signal abnormality. Included
portion of the posterior fossa is unremarkable.
Mucosal thickening is noted in the right maxillary sinus. .
IMPRESSION:
Limited exam due to motion and only sagittal images were acquired as this
patient could not tolerate completing the exam.
Disruption of the anterior longitudinal ligament at C4-C5 with prevertebral
hematoma.
Interspinous ligamentous injury spanning C2-3 through C5-6.
Fluid within the C1-C2 articulations. While this could be degenerative,
ligamentous injury involving this joint is not entirely excluded.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: History: ___ with left ankle swelling, pain // Fx?
TECHNIQUE: 3 views of the left ankle
COMPARISON: None
FINDINGS:
There is diffuse osteopenia. Defect of the posterior calcaneus with fracture
is seen. Findings are of indeterminate age. There is diffuse osteopenia. No
dislocation is seen. There appears to be soft tissue thickening at the
insertion of the Achilles tendon on the posterior calcaneus.
IMPRESSION:
Posterior calcaneal defect with associated fracture of indeterminate age.
Soft tissue thickening along the posterior calcaneus at the Achilles tendon
insertion.
Radiology Report
INDICATION: ___ year old man with fever // ? cause of fever
COMPARISON: Radiographs from ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There is a linear
density at the right base which may represent atelectasis or developing
infiltrate. This is more apparent than on the prior study. There are no
pneumothoraces.
Radiology Report
EXAMINATION: NONCONTRAST CT SCAN OF THE LEFT ANKLE AND FOOT
INDICATION: ___ male with left posterior calcaneal defect.
TECHNIQUE: A noncontrast CT scan of the left ankle and foot was performed
with 1.25 mm thin contiguous axial sections from the distal tibia through the
toes. Subsequent coronal and sagittal reconstructed images were obtained in
bone algorithm.
Total exam DLP is 544.13 mGy-cm.
COMPARISON: LEFT ANKLE RADIOGRAPHS DATED ___.
FINDINGS:
There is a generalized disuse osteopenia, limiting evaluation for nondisplaced
fracture.
There is tongue-type obliquely oriented avulsion fracture of the posterior
superior calcaneus with slight distraction of the fragment, which includes the
attachment site of the distal Achilles tendon a which measures approximately
6.0 x 2.9 x 3.4 cm. There is questionable intra-articular extension of the
fracture into the mid subtalar facet at the sustentacular tali (series 402b
image 75) with limited assessment secondary to osteopenia. The posterior and
anterior subtalar facets appear uninvolved. Faint fracture margin sclerosis
is noted along the medial aspect of the fracture line (series 2 image 96).
There is no anterior calcaneal process fracture. The coronal index views
suggest some medial displacement of the inferior portion of the calcaneus with
respect to the superior portion of the calcaneus (401b: 224). No additional
fracture is seen.
There is no dislocation. The joint spaces appear grossly congruent. No row
joint effusion is seen.
Assessment of soft tissues is limited. Allowing for this, no gross joint
effusion is seen . There is mild to moderate thickening of the distal Achilles
tendon in the AP dimension (10.7 mm), consistent with tendinopathy. No
obvious tear is detected, though a subtle partial tear might not be apparent
by CT . Slight large 1of the peroneus longus tendon could also reflect some
degree of tendinopathy (2:70) The remainder of the visualized tendons appear
grossly unremarkable without evidence of tendinous entrapment by a fracture
fragment.
The visualized muscles appear grossly unremarkable.
There is replacement of the normal subcutaneous fat over the heel with soft
tissue density and skin thinning. The patient's known skin ulceration with
this region is not definitely seen on the current exam. There is an overlying
bandage. There is limited evaluation for osteomyelitis given the degree of
osteopenia and posterior calcaneal enthesopathy.
IMPRESSION:
1. Moderate posterior calcaneal avulsion fracture with questionable extension
to the articular surface at the mid subtalar facet. Mild superomedial
displacement of the proximal fracture fragment attached to the distal Achilles
tendon which demonstrates moderate tendinosis. In addition, there is
suggestion of slight medial displacement of the plantar portion of the
calcaneus.
2. Generalized osteopenia. Given the degree of diffuse osteopenia, subtle
nondisplaced fractures might not be apparent .
3. Loss of normal subcutaneous fat over the heel. The patient's known skin
ulceration within this region is not definitely seen on the current exam.
Limited evaluation for osteomyelitis in the context of severe osteopenia and
enthesopathy at the posterior calcaneus.
4. Thickening of the Achilles and peroneus longus tendons is suggestive of
tendinopathy. No obvious tendon tear is detected, though a subtle tendon tear
might not be apparent on this examination. No tendon entrapment identified .
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: Evaluate for chololithiasis, in a patient with pancreatitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: Irregular, slightly echogenic material along the gallbladder wall
is nonmobile, and could represent adherent sludge versus stones, or small
polyps.
PANCREAS: The pancreas is largely obscured by overlying bowel gas, without
obvious focal mass or ductal dilation.
SPLEEN: Normal echogenicity, measuring 11.6 cm.
KIDNEYS: Limited views of the bilateral kidneys demonstrate no hydronephrosis,
focal mass, or stone.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including hepatic fibrosis or cirrhosis or steatohepatitis cannot be excluded
on the basis of this examination.
2. Irregular, slightly echogenic nonmobile material along the gallbladder
wall could represent adherent sludge or stones, versus small polyps.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX FACIAL BONE NEC-CLOSE, FX MALAR/MAXILLARY-CLOSE, FX C4 VERTEBRA-CLOSED, OPEN WOUND OF FOREHEAD, AC ALCOHOL INTOX-UNSPEC, FALL ON STAIR/STEP NEC, ACUTE PANCREATITIS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | ___ year old male who has been admitted to the trauma service
after he sustained a fall down stairs. At the time of the
incident, he was reportedly under the influence of alcohol. He
sustained a cervical spine fracture and multiple facial
fractures. Upon admission to the intensive care unit, he was
made NPO and given intravenous fluids. Because of his agitation
there was a concern for alcohol withdrawal and the patient was
started on the phenobarbital protocol. His head laceration was
sutured. The patient was evaluated by the Plastic surgery
service who determined that there was no indication for surgical
repair of the facial fractures. The patient was placed on sinus
precautions, given a week course of augmentin and started on a
nasal spray. There was no evidence of eye entrapment after an
examination by Opthamology.
The Spine service evaluated the patient for his cervical injury.
After review of the imaging, they determined that there was no
acute cervical fracture and the patient was placed in a cervical
collar for neck stablization. Cat scan imaging showed edema of
C2-C5 with a nondisplaced fracture of the C4 spinous process An
MRI was done which showed interspinous ligamentous injury
spanning C2-3 through C5-6. Importance of wearing the cervical
collar was addressed with the patient. Recommendations were made
for follow-up in the spine clinic in 3 weeks. The patient did
not exhibit any weakness of his upper and lower extremities
throughout his hospitalizaton.
During the hospital course, the patient reported left ankle pain
upon tertiary survey and the Orthopedic service was consulted.
It was determined that he sustained a known left calcaneous
fracture in the beginnning of the year. He was evaluated at an
outside hospital where he was referred to Orthopaedics. He
reports that the skin was white over the back of his heel at the
time of innjury. He was subsequently treated non-operatively
with NWB and an air-cast boot. He has gone on to develop an
ulceration over the posterior heel and reported pain and
swelling. Local wound care of the heel was advised with
continuation of NWB and follow up with his orthopaedic surgeon.
The patient was transferred to the surgical floor on HD #2. He
received 1 unit of packed red blood cells for a hematocrit of
19. He was weaned off his phenobarbital taper on ___ and
completed his course of augmentin. There were no signs of
alcohol withdrawal. His vital signs remained stable and he was
afebrile. His hematocrit stabilzed at 27. His sutures were
removed from his head and steri-strips applied. The patient
reportedly had episodes of hallucinations and confusion during
his hospital stay and at one point was found "scooting" on the
floor to avoid falling. Psychiatry was consulted and
recommended ongoing treatment of substance abuse disorder and
out-patient psychiatry for consideration of mood disorder,
bipolar type. There was no indication for acute intervention.
The patient was evaluated by physical therapy and
recommendations were made for discharge to a rehabilitation
facility where the patient could regain his strength and
mobility.
The patient was discharged on HD #8 in stable conditon.
Appointments for follow-up were made with the Plastic, Spine,
and acute care surgery.
Rehabilitation stay <30 days |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left side weakness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo RH woman with PMH of HTN, pANCA vasculitis (renal/lung
involvement) on chronic steroids, CKD and HLD who present with
worsening L weakness.
She noted new left leg weakness ___ weeks ago and was seen in
emergency room at that time, head CT was read as normal and she
was discharged home. Since then, she has developed new left arm
weakness as well x1 week and worsening left leg weakness. She
also complains of decreased sensation in left side.
Daughter brought her to the ED because patient had fallen
yesterday morning (2 times more earlier in the week) and her
husband had hurt himself trying to help her up. Daughter spent
the night with them last night and noticed that she was dragging
her left leg much more than before.
In addition, she complains of headache for last 3 months
relieved
with tylenol, posterior neck pain and numbness in feet. She
complained of blurry vision and got a new prescription for
glasses but has not changed them. Denies diplopia. Also has had
this "dizziness" and problem in left year since ___, which
she feels is getting worse. She cannot describe dizziness much
more, saying that it's sometimes vertiginous and sometimes
lightheadedness. Has new left arm rash, x1 week.
On neuro ROS, the pt denies loss of vision, diplopia,
dysarthria,
dysphagia, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
p ANCA vasculitis with involvement of lung/kidneys
renal insufficiency secondary to vasculitis
insulin dependent DM, partially related to steroids
HLD
HTN
normocytic anemia
pulmonary nodule - wegener's granulomatosis improved with
pred/mtx
GERD
Vertigo/tinnitis
Social History:
___
Family History:
DM, HTN
Physical Exam:
Vitals: 97.8 66 148/78 12 100% RA
General: Obese AA woman with moon facies, awake, cooperative,
NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL anteriorly
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: nonpitting edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
- Mental Status: Alert, oriented to place and time; able to
relate history but has difficulty describing her symptoms.
Attentive, able to name ___ backward without difficulty.
Language is fluent without paraphasic errors. Pt. was able to
name both high and low frequency objects. 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 2.5 to 2mm. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Unable to test pronator
drift due to LUE weakness. No adventitious movements, such as
tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L * 4+ 4+ 4+ ___ 3 3 3+ 4 4
R 5 ___ ___ 5 5 5 5 4
*give away weakness in L deltoid, required multiple prompting
throughout examination.
-Sensory: Decreased PP in feet bilaterally, patchy decreased PP
in left arm. No deficits to light touch.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally.
-Coordination: No intention tremor. Unable to test on LUE as pt
was unable to lift her arm, but FTN without dysmetria on RUE.
-Gait: deferred.
Pertinent Results:
___ 01:41PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:41PM URINE BLOOD-TR NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 01:41PM URINE RBC-1 WBC-9* BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-1
___ 01:41PM URINE MUCOUS-RARE
___ 12:25PM GLUCOSE-193* UREA N-52* CREAT-2.7* SODIUM-140
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
___ 12:25PM estGFR-Using this
___ 12:25PM CK(CPK)-79
___ 12:25PM CALCIUM-9.1 PHOSPHATE-4.0 MAGNESIUM-1.7
___ 12:25PM WBC-8.4 RBC-2.94* HGB-9.2* HCT-28.7* MCV-98
MCH-31.2 MCHC-32.0 RDW-14.7
___ 12:25PM NEUTS-88.8* LYMPHS-6.7* MONOS-3.7 EOS-0.6
BASOS-0.3
___ 12:25PM PLT COUNT-288
___ 12:25PM ___ PTT-32.0 ___
___ 12:25PM SED RATE-50*
CT head ___:
New hypodensities in the right lentiform nucleus, caudate head,
and anterior thalamus, consistent with a subacute infarction.
No intracranial hemorrhage or mass effect.
CT spine ___: No acute fracture or prevertebral soft tissue
swelling.
Mild symmetric left ventricular hypertrophy with preserved
regional and global biventricular systolic function. No definite
structural cardiac source of embolism identified.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
MRI/MRA ___:
1. Multifocal subacute infarcts involving the right basal
ganglia and
anterior right temporal lobe. No evidence of hemorrhagic
conversion. No
midline shift.
2. Normal MRA head, without intracranial aneurysm,
arteriovenous
malformation, or occlusion. No specific MR evidence of
vasculitis.
Carotid US:
Echo ___:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Azathioprine 100 mg PO DAILY
4. CloniDINE 0.1 mg PO BID
5. Furosemide 240 mg PO DAILY
in AM
6. Furosemide 80 mg PO HS
in evening
7. Glargine 5 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
8. Labetalol 600 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. PredniSONE 10 mg PO DAILY
11. traZODONE 50 mg PO HS:PRN insomnia
12. Vitamin D 800 UNIT PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. CloniDINE 0.1 mg PO BID
4. Azathioprine 100 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Furosemide 240 mg PO DAILY
in AM
7. Furosemide 80 mg PO HS
5pm
8. Glargine 5 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
9. Labetalol 600 mg PO TID
10. PredniSONE 10 mg PO DAILY
11. traZODONE 50 mg PO HS:PRN insomnia
12. Vitamin D 800 UNIT PO DAILY
13. Clopidogrel 75 mg PO DAILY
14. Ranitidine 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Ischemic infarcts
acute on chronic kidney disease
Discharge Condition:
alert and oriented x3, no facial asymmetry. Left UE: DElt 4 Bic
4+ Tri 4 ECR 3+ Fex 4+ FFL 5. RIGHT UE: delt 4+ bic 5 tri 5- ECR
5 Fex5 FFL 5. Right/Left ___- full strength with giveway.
Followup Instructions:
___
Radiology Report
INDICATION: Left arm weakness.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, and thin section bone reconstruction algorithm
images were acquired.
COMPARISON: CT of the head ___.
FINDINGS: There are new hypodensities in the right lentiform nucleus, caudate
head, and anterior thalamus concerning for subacute infarction. There is no
hemorrhage, mass effect, or shift of normally midline structures. Mild
subcortical white matter hypodensities likely reflect sequela of chronic
microvascular infarction. The ventricles and sulci are prominent in size but
normal in configuration, compatible with age-related involutional changes.
The basal cisterns are patent. Mild calcification of the distal vertebral
arteries and cavernous carotid arteries is noted. There is no fracture. The
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear.
IMPRESSION: New hypodensities in the right lentiform nucleus, caudate head,
and anterior thalamus, consistent with a subacute infarction. No intracranial
hemorrhage or mass effect.
Radiology Report
HISTORY: Fall, left arm weakness, on chronic steroids.
TECHNIQUE: MDCT acquired axial images were obtained through the cervical
spine without intravenous contrast. Multiplanar reformatted images were
prepared and reviewed.
COMPARISON: None available.
FINDINGS:
Mild multilevel degenerative changes are visualized with disc space narrowing,
small posterior disc bulges, and anterior osteophytes. No critical central
canal stenosis is present. There is no evidence of acute fracture or
prevertebral soft tissue swelling. Normal cervical spine alignment is
maintained. CT is not sensitive evaluation of the thecal sac but the
visualized outline of the thecal sac appears unremarkable. Vascular
calcifications are noted within the distal vertebral arteries. The visualized
portions of the thyroid glands are normal. The visualized lung apices
demonstrate minor atelectatic changes.
IMPRESSION:
No acute fracture or prevertebral soft tissue swelling.
Radiology Report
HISTORY: ___ woman, with p-ANCA with renal and lung involvement and
other multiple medical problems. Now presenting with left-sided weakness one
to three weeks. Found to have right thalamic lesions on head CT. Evaluate
for right thalamic lesion.
COMPARISON: Non-contrast CT head on ___.
TECHNIQUE:
MRA HEAD: Non-contrast 3D time-of-flight images were acquired through the
head per standard MRA brain protocol. Dedicated 3D rendering was performed on
the underlying vessels.
MRI HEAD: Non-contrast multiplanar, multisequence MRI images were acquired
through the head. Diffusion-weighted images and ADC maps were also obtained
for evaluation.
FINDINGS:
MRA HEAD: Major intracranial vessels are patent. There is no aneurysm
greater than 3 mm, arteriovenous malformation or occlusion. There is no
abnormal "beading" or narrowing of the vessels to suggest vasculitis.
MRI HEAD: There are multiple foci of DWI-bright and ADC-dark signal
abnormality in the right basal ganglia, predominately involving the head of
the right caudate and right putamen, and also involving the anterior right
temporal lobe, representing multifocal subacute infarctions. There is no
evidence of hemorrhagic conversion. The ventricles and sulci remain normal in
size and symmetric in configuration. There is no shift of normally midline
structures.
There are superimposed scattered T2/FLAIR hyperintensities in the
periventricular and subcortical white matter, compatible with superimposed
chronic microvascular ischemic changes. Major vascular flow voids are
present.
The visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Multifocal subacute infarcts involving the right basal ganglia and
anterior right temporal lobe. No evidence of hemorrhagic conversion. No
midline shift.
2. Normal MRA head, without intracranial aneurysm, arteriovenous
malformation, or occlusion. No specific MR evidence of vasculitis.
These findings were discovered by Dr. ___ at 10:40 hrs, and communicted via
phone call to Dr. ___, at 14:45 by Dr. ___ on ___.
Radiology Report
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: ___ y/o women with vasculitis presents with left sided weakness found
to have right thalamic lesions.
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is mild heterogenous plaque in the ICA. On the left there is
no plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 75/17, 62/17, 77,/27 cm/sec. CCA peak systolic
velocity is 82/14 cm/sec. ECA peak systolic velocity is 113 cm/sec. The
ICA/CCA ratio is 0.9. These findings are consistent with <40 stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 59/13, 80/17, 82/24 cm/sec. CCA peak systolic velocity
is 84/20 cm/sec. ECA peak systolic velocity is 95 cm/sec. The ICA/CCA ratio is
0.9. These findings are consistent with 0% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA <40 stenosis.
Left ICA 0% stenosis.
Radiology Report
INDICATION: P-ANCA vasculitis, right-sided thalamic lesions, new right-sided
weakness looking for new lesions.
COMPARISON: MRA done on ___.
TECHNIQUE: MR head without IV contrast.
FINDINGS:
The axial FLAIR sequence is somewhat limited due to motion. The previously
noted areas of increased signal intensity in the right caudate, the right
lentiform nucleus and the anterior right temporal lobe are again seen. These
demonstrate increased signal intensity on the DWI sequence and decreased ADC
signal, as on the recent study done two days ago. A small focus noted along
the right cerebral peduncle/substantia nigra medially series 702, image 12 is
more conspicuous on the present study. There is moderate mass effect on the
right lateral ventricle, predominantly the right frontal horn increased since
the prior study. However, there is no significant change in the shift of
midline structures to the left side, which is likely very minimal. This is
likely due to the adjacent surrounding edema.
There is no new focus of increased DWI signal intensity in the left cerebral
hemisphere.
There are several small scattered nonspecific FLAIR hyperintense foci as seen
on the prior study.
Prominent extra-axial CSF spaces in the frontal regions on both sides are
unchanged. The major intracranial arterial flow voids are noted. The
paranasal sinuses and the mastoid air cells are clear.
IMPRESSION:
Redemonstration of the multiple acute-subacute infarcts involving the right
basal ganglia and the right anterior temporal lobe with mild surrounding edema
and slightly increased mass effect on the frontal horn of the right lateral
ventricle, with minimal leftward shift of midline structures. Increased
conspicuity of the focus of slow diffusion, in the right side of the midbrain.
No new lesions noted on the left side.
Radiology Report
INDICATION: Right MCA territory infarcts, question vasculitis versus embolic
strokes.
COMPARISON: Recent MR head done on ___.
TECHNIQUE: MR angiogram of the neck without IV contrast -- axial 2D TOF and
3D TOF at the bifurcation.
FINDINGS:
The origins of the arch vessels are grossly patent. The imaged portions of
the proximal subclavian arteries appear patent.
The common carotid arteries and the cervical internal carotid arteries are
patent without focal flow-limiting stenosis or occlusion. Contour irregularity
noted at the common carotid bifurcations and the proximal cervical internal
carotid artery with some degree of narrowing of the proximal cervical internal
carotid artery on both sides. The cervical vertebral arteries are patent,
without flow-limiting stenosis. The origin of the left vertebral artery is
tortuous in course. Left very distal vertebral artery is diminutive in size
beyond the origin of the posterior inferior cerebellar artery.
IMPRESSION:
1. Patent common carotid, cervical internal carotid and the vertebral
arteries as described above, without flow-limiting stenosis or occlusion.
Assessment for subtle details is limited given the low resolution of the
study. Correlation with color Doppler ultrasound can be considered if needed.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: DECREASED SENSATION
Diagnosed with OTHER MALAISE AND FATIGUE
temperature: 98.4
heartrate: 69.0
resprate: 18.0
o2sat: 100.0
sbp: 141.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | Transition of Care Issues: Check Cr on ___ to ensure
stabilization (last 3.3). Follow up appointments as below.
This is ___ yo RH woman with pANCA vasculitis (lung/kidney) and
other multiple medical problems who presents with progressive
left leg and arm weakness and found to have multiple right
thalamic and temporal lobe lesions involving multiple vascular
territories. Concerning for CNS vasculitis vs ischemic stroke
from atherosclerosis/cardioembolic source also possible given
patient's risk factors.
NEURO: The patient was admitted to the Neurology service. She
was evaluated for both atherosclerotic/embolic as well as
vasculitic causes of infarct. She had an echocardiogram which
was unchanged from priors. Carotid ultrasound showed less than
40% stenosis. Her glycohemoglobin and LDL was checked and both
were elevated at 6.9% and 177 respectively. She was continued on
her prescribed dose of atorvastatin (she was not taking it at
home). She had an MRI as noted above and MRA which did not show
any signs of overt vasculitis. She was started on plavix for
stroke prevention as the patient had hemoptysis in the past with
aspirin. On ___ the patient developed new right arm and leg
weakness. Repeat MRI at that time showed no new stroke and the
weakness actually resolved. This may have been somewhat due to
effort on the part of the patient. The patient also had an MRA
of the neck which showed no stenosed vessels. As the strokes
appeared embolic (if not related to vasculitis), a TEE was
arranged to better evaluate the heart for embolic source.
Unfortunately the patient on first attempt was too somnolent and
could not consent and on second attempt could not tolerate the
procedure. At this time it is unclear if the cause of the
strokes is vasculitis vs embolic and rheumatology felt that
empiric treatment for CNS vasculitis would be overly aggressive
given toxicities. The option of brain biopsy was discussed with
the patient and her daughter in order to provide a definative
diagnosis but this was declined. If the patient continues to
have future infarcts brain biopsy should be strongly encouraged.
RHEUM: The patient was continued on her home medications.
Rheumatology was consulted regarding the possibility of CNS
vasculitis. They requested a ANCA be checked and this was
negative. They also requested skin biopsy of new arm lesions.
Dermatology performed this but the sample was negative for
vasculitis. They felt that the likelihood of Vasculitis as a
cause was low as her ANCA was negative and vasculitis was not
active in the lungs and kidneys at the moment.
RENAL: The patient has a history of CKD stage V. Her creatinine
remained around her baseline while admitted though it did begin
to trend up on ___. Renal was curbsided and they recommended
trending. On discharge the Cr had trended down to 3.3 which is
about baseline.
CARDIAC: The patient has a history of diastolic heart failure
with pulmonary edema. She was continued on her home lasix dose
and did not require any oxygen. Her Labetolol dose was increased
to TID due to hypertension. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Protonix / Soy Protein / adhesive tape / Metallic
Poisoning, Agents To Treat / NSAIDS / CITRIC ACID / Effexor /
PROTONIX / PAPER TAPE / METALS / Bactrim / diazepam /
Pravastatin / clonidine / metoprolol / hydrochlorothiazide /
PLASTICS / red dye / WELLBURTIN / amlodipine / lorazepam
Attending: ___.
Chief Complaint:
ruptured abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
___
1. Endovascular repair of ruptured abdominal aortic
aneurysm with Endurant main body delivered to the right,
28 x ___ x 16 and left contralateral limb 16 x 90 mm.
2. Left groin exploration and primary repair of aortotomy.
3. Re-exploration of left groin with thrombectomy and patch
angioplasty.
___
1. Abdominal aortogram.
2. Exploratory laparotomy with packing and open abdomen.
3. Exploration of left groin.
___
1. washout and closure of open abdomen
History of Present Illness:
This is an ___ with known 6cm infrarenal AAA p/w abdominal pain,
nausea,
diarrhea and vomiting that started 2 prior to presentation. She
had known about
the aneurysm but previously did not want to consider repair. She
now is being taken to the operating room urgently after workup
in the emergency department has revealed rupture of her AAA.
Past Medical History:
Left adrenal adenoma
Primary hyperparathyroidism s/p parathyroidectomy ___
Multinodular goiter s/p lobectomy ___
Hypertension
Abdominal aortic aneurysm (infra-renal)
Fibromyalgia
TIAs, cerebrovascular disease
DM2 -- diet controlled
Osteopenia
Neuropathy
Depression
spinal stenosis
claudication
vitamin D deficiency
diverticulosis
hemorrhoids
prior adenomatous polyps in colon
Has fracture on her right foot ___ metatarsal)
Past Surgical History:
1) Parathyroidectomy with re-implantation of one parathyroid
gland
2) Left lower thyroid lobectomy
3) Right carotid endarterectomy ___
4) Tonsillectomy
5) Rectal prolapse reconstruction
6) Oophorectomy
7) Cholecystectomy
8) Rectal prolapse reconstruction ___
Social History:
___
Family History:
Her father died of lung cancer. Her mother died of tuberculosis.
Her fraternal twin sister recently died of lung cancer. Her
paternal grandfather died of cancer.
Physical Exam:
on admission
Vitals: 98 92 106/62 24 ___ Facemask
GEN: Agitated, anxious
HEENT: No scleral icterus, mucus membranes moist
CV: Tachycardic
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, tender diffusely, guarding,
+peritoneal signs
DRE: deferred
Ext: Femoral pulses palpable bilateraly. non-palpable distal
pulses bilaterally.
On discharge:
AFVSS
Gen: NAD, AAOx3, pleasant and positive attitude
CV: RRR, soft holosystolic murmur heard best at left sternal
border
Pulm: CTAB
Abd: Soft, NT/ND, incision healing well, staples removed
R groin puncture site c/d/i, no drainage, gauze in place
L groin incision with staples draining serous fluid,
non-malodorous, no evidence of infection.
Bilateral groins: no evidence of infection/hematoma
Lower extremities:
Warm and well perfused, no lesions noted on exam
Pulses:
Fem Pop DP ___
Left P P D D
Right P P D D
Pertinent Results:
Radiology Report CTA PELVIS W&W/O C & RECONS Study Date of
___ 7:59 AM
___ ___ 7:59 AM
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip #
___
Reason: ?rupture
Contrast: OMNIPAQUE Amt: 90
Final Report
HISTORY: AAA and abdominal pain and hypotension, question
rupture
TECHNIQUE: Axial helical MDCT images were obtained through the
abdomen and
pelvis before and after administration of Omnipaque intravenous
contrast in
the arterial phase. Multiplanar reformatted images in coronal
and sagittal
axes were generated.
DLP: 1150 mGy-cm
COMPARISON: ___
FINDINGS:
The bases of the lungs are clear. The visualized heart and
pericardium are unremarkable.
CT abdomen: The liver enhances homogeneously without focal
lesions or
intrahepatic biliary dilatation. The patient is status post
cholecystectomy. The pancreas, spleen and adrenal glands are
unremarkable. There are numerous bilateral renal cysts some of
which are hemorrhagic. A 2 cm lesion in the interpolar region
of the right kidney is intermediate density.
The small and large bowel are normal in caliber with no evidence
of
obstruction. There is diverticulosis without evidence of
diverticulitis. There is a large fat containing umbilical
hernia.
CT pelvis: The urinary bladder is unremarkable. There is no
pelvic free
fluid. There is no inguinal or pelvic wall lymphadenopathy.
CTA: There is a large infrarenal AAA measuring up to 8.8 cm
with high density material in the left retroperitoneum on the
non contrast which expands dramatically on the postcontrast
phase with a large amount of active arterial extravasation.
Osseous structures: No lytic or sclerotic lesions suspicious
for malignancy is present.
IMPRESSION:
1. Large ruptured infrarenal AAA measuring up to 8.8 cm with a
large amount of active arterial extravasation into the
retroperitoneum
2. Intermediate density right renal lesion, recommend further
evaluation with nonemergent ultrasound if clinically indicated.
Discussed # 1 with Dr. ___ Dr. ___ by Dr ___
in person at 8:10 ___ 1 min after exam.
------------
Radiology Report PELVIS (AP ONLY) PORT Study Date of ___
10:55 AM
___ ___ 10:55 AM
PELVIS (AP ONLY) PORT Clip # ___
Reason: NO COUNT IN OR
Final Report
PLAIN FILM, PELVIS
HISTORY: Endovascular repair. No count in OR.
FINDINGS: Single surgical clip overlying the right iliac bone.
Aortic stent graft noted. Staples noted in the left groin.
Otherwise, no radiopaque intra-abdominal foreign body is
identified.
-------------
Radiology Report PELVIS (AP ONLY) PORT Study Date of ___
12:37 ___
___. ___ ___ 12:37 ___
PELVIS (AP ONLY) PORT Clip # ___
Reason: NO COUNT IN OR
Final Report
PLAIN FILM, PELVIS
HISTORY: Endovascular stent graft. No count in OR.
FINDINGS: Single surgical clip noted overlying the right iliac
bone. Lower
end of the aortic stent graft is noted. Staples are noted in
the left groin.
Otherwise, no radiopaque intra-abdominal foreign body
identified. Results
were called to Dr. ___ by me at 1305 hours over the telephone.
------------
Radiology Report CHEST (PORTABLE AP) Study Date of ___
1:45 ___
___. ___ ___ 1:45 ___
CHEST (PORTABLE AP) Clip # ___
Reason: PLACEMENT OF LINES AND TUBES
UNDERLYING MEDICAL CONDITION:
___ year old woman with RUPTURED AAA S/P REPAIR
REASON FOR THIS EXAMINATION:
PLACEMENT OF LINES AND TUBES
Final Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with RUPTURED AAA S/P REPAIR //
PLACEMENT OF
LINES AND TUBES
COMPARISON: CHEST RADIOGRAPHS ___ THROUGH ___
IMPRESSION:
MILD INTERSTITIAL PULMONARY ABNORMALITY IS PROBABLY EDEMA, SMALL
LEFT PLEURAL
EFFUSION IS NEW. HEART SIZE IS NORMAL. ET TUBE AND RIGHT
INTERNAL JUGULAR LINE
ARE IN STANDARD PLACEMENTS RESPECTIVELY. NO PNEUMOTHORAX.
-------------
Radiology Report CHEST (PORTABLE AP) Study Date of ___
10:07 ___
___. ___ ___ 10:07 ___
CHEST (PORTABLE AP) Clip # ___
Reason: SP OPEN ABDOMEN
Final Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Followup
COMPARISON: ___, 13:56
IMPRESSION:
As compared to the previous radiograph, the lung volumes have
decreased and
the signs indicative of pulmonary edema have slightly increased.
In addition,
the pre-existing small left pleural effusion has also slightly
increased. The
monitoring and support devices are in unchanged position,
moderate
cardiomegaly is present.
-----------
Radiology Report PORTABLE ABDOMEN IN O.R. Study Date of
___ 3:28 ___
___ ___ ___ 3:28 ___
PORTABLE ABDOMEN IN O.R. Clip # ___
Reason: ABD CLOSURE
Final Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: Sponge count.
TECHNIQUE: Supine portable radiograph of the abdomen.
COMPARISON: ___
FINDINGS:
There is a nasogastric tube with the tip in the stomach and the
proximal side
hole past the gastroesophageal junction. Cholecystectomy clips
are seen in the
right upper quadrant. Surgical clips are also noted in the
pelvis bilaterally.
Endovascular stent is seen in the aorta. No radiopaque sponge is
seen.
IMPRESSION:
No radiopaque sponge seen.
These findings were relayed to Dr. ___ by Dr. ___
at 16:15, via
telephone.
The study and the report were reviewed by the staff radiologist.
---------------
Radiology Report CHEST (PORTABLE AP) Study Date of ___
4:40 ___
___. ___ ___ 4:40 ___
CHEST (PORTABLE AP) Clip # ___
Reason: assess tubes & lines
UNDERLYING MEDICAL CONDITION:
___ year old woman s/p closure of open abdomen
REASON FOR THIS EXAMINATION:
assess tubes & lines
Final Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p closure of open abdomen //
assess tubes
lines
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is
seen in position
of the endotracheal tube, the nasogastric tube and a right
internal jugular
vein catheter. The lung volumes remain low. Moderate pulmonary
edema and areas
of atelectasis at the left and the right lung base is still
present. In
addition, there is again visualization of a small left pleural
effusion. No
pneumothorax.
-----------------
Medications on Admission:
oxycodone 10 mg TID PRN, acetaminophen 500 mg q4h PRN, Aspirin
81 mg daily, cholecalciferol (vitamin D3) 1,000 unit daily,
LIDOCAINE - Dosage uncertain, MILK OF MAGNESIA
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin EC 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Milk of Magnesia 30 mL PO DAILY:PRN constipation
5. Metoprolol Tartrate 12.5 mg PO BID
6. Mirtazapine 15 mg PO HS
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*120 Tablet Refills:*0
8. Albuterol Inhaler 4 PUFF IH Q4H:PRN wheeze
9. Ipratropium Bromide MDI 2 PUFF IH QID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ruptured abdominal aortic aneurysm
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
HISTORY: AAA and abdominal pain and hypotension, question rupture
TECHNIQUE: Axial helical MDCT images were obtained through the abdomen and
pelvis before and after administration of Omnipaque intravenous contrast in
the arterial phase. Multiplanar reformatted images in coronal and sagittal
axes were generated.
DLP: 1150 mGy-cm
COMPARISON: ___
FINDINGS:
The bases of the lungs are clear. The visualized heart and pericardium are
unremarkable.
CT abdomen: The liver enhances homogeneously without focal lesions or
intrahepatic biliary dilatation. The patient is status post cholecystectomy.
The pancreas, spleen and adrenal glands are unremarkable. There are numerous
bilateral renal cysts some of which are hemorrhagic. A 2 cm lesion in the
interpolar region of the right kidney is intermediate density.
The small and large bowel are normal in caliber with no evidence of
obstruction. There is diverticulosis without evidence of diverticulitis.
There is a large fat containing umbilical hernia.
CT pelvis: The urinary bladder is unremarkable. There is no pelvic free
fluid. There is no inguinal or pelvic wall lymphadenopathy.
CTA: There is a large infrarenal AAA measuring up to 8.8 cm with high density
material in the left retroperitoneum on the non contrast which expands
dramatically on the postcontrast phase with a large amount of active arterial
extravasation.
Osseous structures: No lytic or sclerotic lesions suspicious for malignancy
is present.
IMPRESSION:
1. Large ruptured infrarenal AAA measuring up to 8.8 cm with a large amount
of active arterial extravasation into the retroperitoneum
2. Intermediate density right renal lesion, recommend further evaluation with
nonemergent ultrasound if clinically indicated.
Discussed # 1 with Dr. ___ Dr. ___ by Dr ___ in person at
8:10 ___ 1 min after exam.
Radiology Report
PLAIN FILM, PELVIS
HISTORY: Endovascular repair. No count in OR.
FINDINGS: Single surgical clip overlying the right iliac bone. Aortic stent
graft noted. Staples noted in the left groin. Otherwise, no radiopaque
intra-abdominal foreign body is identified.
Results were called by me to Dr. ___ the phone at 11:20 hours on day
of the examination ___.
Radiology Report
PLAIN FILM, PELVIS
HISTORY: Endovascular stent graft. No count in OR.
FINDINGS: Single surgical clip noted overlying the right iliac bone. Lower
end of the aortic stent graft is noted. Staples are noted in the left groin.
Otherwise, no radiopaque intra-abdominal foreign body identified. Results
were called to Dr. ___ by me at 1305 hours over the telephone.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with RUPTURED AAA S/P REPAIR // PLACEMENT OF
LINES AND TUBES
COMPARISON: CHEST RADIOGRAPHS ___ THROUGH ___
IMPRESSION:
MILD INTERSTITIAL PULMONARY ABNORMALITY IS PROBABLY EDEMA, SMALL LEFT PLEURAL
EFFUSION IS NEW. HEART SIZE IS NORMAL. ET TUBE AND RIGHT INTERNAL JUGULAR LINE
ARE IN STANDARD PLACEMENTS RESPECTIVELY. NO PNEUMOTHORAX.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Followup
COMPARISON: ___, 13:56
IMPRESSION:
As compared to the previous radiograph, the lung volumes have decreased and
the signs indicative of pulmonary edema have slightly increased. In addition,
the pre-existing small left pleural effusion has also slightly increased. The
monitoring and support devices are in unchanged position, moderate
cardiomegaly is present.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: Sponge count.
TECHNIQUE: Supine portable radiograph of the abdomen.
COMPARISON: ___
FINDINGS:
There is a nasogastric tube with the tip in the stomach and the proximal side
hole past the gastroesophageal junction. Cholecystectomy clips are seen in the
right upper quadrant. Surgical clips are also noted in the pelvis bilaterally.
Endovascular stent is seen in the aorta. No radiopaque sponge is seen.
IMPRESSION:
No radiopaque sponge seen.
These findings were relayed to Dr. ___ by Dr. ___ at 16:15, via
telephone.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p closure of open abdomen // assess tubes
lines
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen in position
of the endotracheal tube, the nasogastric tube and a right internal jugular
vein catheter. The lung volumes remain low. Moderate pulmonary edema and areas
of atelectasis at the left and the right lung base is still present. In
addition, there is again visualization of a small left pleural effusion. No
pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman // eval effusion
COMPARISON: Chest radiographs ___.
IMPRESSION:
Moderate asymmetric pulmonary edema has worsened in the right lung, improved
on the left, perhaps due to patient positioning. Severe left lower lobe
collapse atelectasis is unchanged. ET tube and right internal jugular line are
in standard placements and a a nasogastric tube ends in the nondistended
stomach. Small to moderate left pleural effusion stable. No pneumothorax.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Followup pulmonary edema after diuresis.
COMPARISON: ___.
Mild pulmonary edema has improved. Cardiomegaly is stable. Left lower lobe
opacity is a combination of moderate effusion and adjacent atelectasis,
minimally increased. There is no pneumothorax. Right effusion has decreased.
ET tube is in standard position. Right IJ catheter tip is in the lower SVC
and the tube tip is in the stomach.
Radiology Report
EXAMINATION: Portable abdominal radiograph.
INDICATION: ___ female status post ex lap. Evaluate for ileus.
TECHNIQUE: Abdominal radiograph.
COMPARISON: Radiograph dated ___.
FINDINGS:
Portable radiograph of the abdomen demonstrates several loops of dilated small
bowel measuring up to 4.7 cm. In addition, there is mildly prominent air
filled loop of colon measuring 9 cm. Air is seen within the distal rectum.
Several surgical clips are identified projecting over the mid abdomen. An
endovascular stent is seen within the aorta. There is been interval removal of
a nasogastric tube. No evidence to suggest free intraperitoneal air. There
is no pneumatosis.
IMPRESSION:
Dilated loops of small and large bowel most consistent with ileus.
Radiology Report
INDICATION: Status post ex lap and T bar now with white blood cell count,
assess for infiltrates.
COMPARISON: ___.
FINDINGS:
Frontal radiograph of the chest demonstrates the right internal jugular
central venous catheter in unchanged position in the low SVC. The patient has
been extubated and the NG tube has been removed. Lung volumes are lower with
stable cardiomegaly. Mild pulmonary edema is worsened. A retrocardiac
opacity likely reflects a combination of atelectasis and effusion; although,
an underlying infection or aspiration is possible. Right basilar atelectasis
is present. No pneumothorax.
Radiology Report
EXAMINATION: CT abdomen/ pelvis with contrast.
INDICATION: ___ year old woman s/p ex lap/retroperitoneal bleed after TEVAR.
Assess for source of elevated WBC.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous administration of 100cc of Omnipaque. Coronal and
sagittal reformations were performed. Oral contrast was administered.
DOSE: DLP: 815 mGy-cm.
COMPARISON: CT abdomen/ pelvis ___. Chest radiograph ___. CT abdomen ___.
FINDINGS:
CHEST: Limited assessment lung bases demonstrates bilateral right greater
than left nonhemorrhagic pleural effusions, new since CTA abdomen/pelvis from
___. Bilateral lower lobe atelectasis noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. Patient is status post cholecystectomy.
No fluid within the gallbladder fossa. The hepatic veins, main portal vein,
splenic vein, and SMV are patent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. Punctate pancreatic
calcifications within the pancreatic body are consistent with chronic
pancreatitis.
SPLEEN: The spleen is unchanged in size with normal attenuation throughout.
No focal lesions.
ADRENALS: The right adrenal gland is unremarkable. A 3.1 x 2.5 cm left
adrenal lesion is unchanged from ___ (previously 3.0 x 2.1
cm) and reportedly has been previously characterized as an adenoma.
KIDNEYS: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of obstructing stones, or hydronephrosis. Multiple
bilateral hypodense renal lesions, largest measuring 2.3 x 1.8 cm (05:42)
(previously 2.2 x 1.8 cm) within the lower pole of the right kidney is
unchanged and likely represents a hemorrhagic cyst given its intermediate
attenuation.
GI: A small hiatal hernia is noted. The stomach, small bowel, colon are within
normal limits without mucosal hyper enhancement, fat stranding, focal mass
lesion, or obstruction. Multiple sigmoid and descending colonic diverticula
seen without evidence of acute diverticulitis. The appendix is normal without
evidence of acute appendicitis. No free intraperitoneal air. Small fat
containing umbilical hernia noted. No ascites.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymph
node enlargement.
VASCULAR: Patient is status post endovascular repair with a suprarenal
biiliac stent graft placement with superior aspect beginning approximately 7
mm above the right renal artery. No evidence of active extravasation or
endoleak, although limited due to absence of arterial phase. Excluded aortic
sac is similar in size measuring 8.3 x 6.6 cm (05:40) (previously 8.2 x 7.3
cm). Large left retroperitoneal hematoma with extension into the iliopsoas
muscle with maximal diameter of 6.5 cm (5:62) (previously 6.7 cm). No
peripherally enhancing fluid collection to suggest abscess. The celiac axis,
and SMA are patent.
PELVIS:
The urinary bladder is collapsed with a Foley. The distal ureters are
unremarkable. There is no evidence of pelvic or inguinal lymph node
enlargement. Small amount of nonhemorrhagic free fluid within the pelvis.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions.
IMPRESSION:
1. Status post endovascular repair of a ruptured abdominal aortic aneurysm.
Stable excluded aneurysm sac size.
2. Large retroperitoneal hematoma with extension into the left iliopsoas
muscle is similar in size to ___ study. No evidence of active
extravasation.
3. No peripherally enhancing focal fluid collection to suggest abscess.
4. Diverticulosis without evidence of acute diverticulitis.
Radiology Report
INDICATION: Left PICC placement.
COMPARISON: ___ at 9:02.
FINDINGS:
A new left PICC extends superiorly into the neck and out of view at the
superior edge of the image and should be repositioned. The right internal
jugular catheter has been removed. A nasogastric tube extends below the
diaphragm and out of view at the inferior edge of the image. A right-sided
peripheral line is seen ending in the axilla. There is stable appearance of
mild pulmonary edema and cardiomegaly.
IMPRESSION:
Left PICC extending into the neck and out of view superiorly, should be
repositioned.
NOTIFICATION: The findings were discussed by Dr. ___ with Ping of IV
nursing on the telephone on ___ at 5:16 ___, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with AAA rupture, s/p EVAR ex-la for RP
hematoma evac, s/p closure. Now w/pulm edema. // Interval imaging of pulm
edema
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the nasogastric tube has been removed.
The lung parenchyma is slightly increased in transparency, reflecting a
decreasing pulmonary edema and and improvement in ventilation. However, mild
to moderate pulmonary edema is still present. In addition, a left pleural
effusion is shown. The effusion causes atelectasis at the left lateral lung
bases. The stomach is moderately overinflated. Unchanged appearance of the
cardiac silhouette.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with increased O2 requirements, previous fluid
overload // Please rule out pleural effusion
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the signs indicative of pulmonary
edema have substantially decreased in severity. No new focal parenchymal
opacities. Also decreased is the extent of a small left pleural effusion and
of the subsequent left basal atelectasis.
Radiology Report
EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) LEFT
INDICATION: ___ year old woman with new onset LLE pain.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
Examination is limited due to bandage material in the groin. In the left
groin, an ill-defined area of fluid is seen in the subcutaneous tissues,
superficial to the vessels, measures 2.3 x 3.6 cm, with an irregular tract
extending towards the skin surface. No color flow is demonstrated within this
collection. There is normal compressibility, flow and augmentation of the left
common femoral, superficial 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:
1. No evidence of deep venous thrombosis in the left lower extremity veins.
2. Ill-defined fluid in the subcutaneous tissues in the left groin, at site
of recent surgery, most likely representing seroma.
Radiology Report
INDICATION: ___ year old woman with COPD s/p AAA rupture, ex-lap for hematoma
evac, now closed w/O2 requirement and pulm edema. // Eval pulm edema
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
Compared to the prior study the pulmonary edema continues to improve. However
there is persistent increased opacity in the right upper lung which could
reflect residual asymmetric pulmonary edema but an underlying infectious
process is possible. Stable top-normal heart size. The small left pleural
effusion persists with associated atelectasis. No pneumothorax.
IMPRESSION:
Improvement in pulmonary edema now with asymmetric opacification of the right
upper lung which could reflect asymmetric residual pulmonary edema; however,
underlying infectious process is possible.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3:45 ___, 10 minutes after discovery of the
findings.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Vomiting
Diagnosed with RUPT ABD AORTIC ANEURYSM
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | The patient was admitted to the Vascular Surgery Service for
evaluation and treatment. On ___, the patient underwent
Endovascular repair of ruptured abdominal aortic aneurysm with
Endurant main body delivered to the right, 28 x ___ x 16 and
left contralateral limb 16 x 90 mm Left groin exploration and
primary repair of aortotomy, Re-exploration of left groin with
thrombectomy and patch angioplasty. (reader referred to the
Operative Note for details). Patient received 4 units of PRBC
intraoperatively and IVF for ongoing resuscitation.
The patient was taken to the CV-ICU postoperatively for ongoing
critical care intubated and sedated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
Replaced nephrostomy tube ___
History of Present Illness:
___ PMH T1DM, diabetic nephropathy s/p SPK in ___, with
subsequent failure of pancreas allograft ___, recent
cellular (and possible humoral) rejection ___ (received ATG
x
7 days, pulse steroids, IVIg x 4), HTN, HLD, urinary obstruction
with PCNU, presenting to the ED with symptomatic anemia.
Patient had admission ___ for enterobacter cloacae UTI,
anemia, and ___. UTI treated with meropenem, course finished on
___. Anemia has been previously worked up with negative parvo /
CMV / EBV testing, iron studies, B12/folate, and hemolysis
studies; thought to be due to CKD, has been having issues with
getting outpatient aranesp. Had multiple admissions in ___ for
___ in setting of allograft hydronephrosis s/p PCN and likely
Bactrim induced granulomatous interstitial nephritis with UTI.
Patient endorses lightheadedness. She also states that she has
been having daily diarrhea for the past three months. She states
that it occurs on average ___ times per day. She says that it is
watery at times. It was black a few days ago (rectal exam in ED
significant for external hemorrhoids, guaiac negative). She
endorses decrease appetite and mild nausea but denies vomiting.
She also endorses foul smelling urine. Denies dysuria. She
passes
urine mostly into the PCNU bag but occasionally passes urine
through her urethra.
Past Medical History:
Type I diabetes ___ complicated by retinopathy and ESRD
requiring HD now s/p simultaneous pancreas and kidney transplant
in ___
Cellular (and possible humoral) rejection of renal allograft
Retinopathy s/p at least six laser treatments
Hypertension
Hyperlipidemia
Osteoporosis
Remote history of tuberculosis s/p 6 month treatment
C section ___
Social History:
___
Family History:
Mother with diabetes ___ type 2
Mother with "kidney problems"
Father with diabetes ___ type 2
Brother ___ years old and healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ Temp: 98.4 PO BP: 129/79 HR: 90 RR: 18 O2
sat: 99% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NC/AT, sclera anicteric and without injection
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normoactive BS, soft, non-distended, non-tender, PCNU
in
place in LLQ, dressing c/d/i
EXTREMITIES: WWP. No ___ edema.
NEUROLOGIC: AOx3.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: ___ Temp: 98.5 PO BP: 145/80 HR: 88 RR: 18 O2
sat: 98% O2 delivery: RA
General: Alert, oriented, no acute distress.
HEENT: Pallor+, no icterus, conjunctiva and sclera clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, nontender BS+; pcnu draining clear yellow urine,
no drainage, warmth, or erythema
Ext: No clubbing, cyanosis or edema
Neuro: No focal deficits, normal speech.
Pertinent Results:
ADMISSION LABS:
================
___ 11:38AM BLOOD WBC-3.9* RBC-2.23* Hgb-6.7* Hct-20.8*
MCV-93 MCH-30.0 MCHC-32.2 RDW-14.5 RDWSD-48.8* Plt ___
___ 02:25PM BLOOD Neuts-88.3* Lymphs-3.5* Monos-4.7*
Eos-0.2* Baso-0.0 Im ___ AbsNeut-4.29 AbsLymp-0.17*
AbsMono-0.23 AbsEos-0.01* AbsBaso-0.00*
___ 11:38AM BLOOD Plt ___
___ 02:25PM BLOOD ___ PTT-34.9 ___
___ 02:25PM BLOOD Glucose-213* UreaN-36* Creat-3.4* Na-137
K-4.7 Cl-107 HCO3-18* AnGap-12
___ 02:25PM BLOOD ALT-11 AST-14 AlkPhos-71 TotBili-0.3
___ 02:25PM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.2 Mg-1.8
___ 11:38AM BLOOD tacroFK-4.8*
___ 02:43PM BLOOD Lactate-0.7
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-3.3* RBC-3.17* Hgb-9.3* Hct-28.7*
MCV-91 MCH-29.3 MCHC-32.4 RDW-13.9 RDWSD-45.8 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-84 UreaN-26* Creat-3.0* Na-144
K-5.0 Cl-112* HCO3-22 AnGap-10
___ 07:00AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.1
MICROBIOLOGY:
==============
__________________________________________________________
___ 5:36 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.
__________________________________________________________
___ 5:36 am URINE Source: ___.
URINE CULTURE (Preliminary):
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
__________________________________________________________
___ 12:36 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
CYCLOSPORA STAIN (Pending):
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
__________________________________________________________
___ 12:36 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
Reported to and read back by ___. ___ @
___ ON
___.
POSITIVE. (Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of
C. difficile and detects both C. difficile infection
(CDI) and
asymptomatic carriage. Therefore, positive C. diff PCR
tests
trigger reflex C. difficile toxin testing, which is
highly
specific for CDI.
C. difficile Toxin antigen assay (Final ___:
POSITIVE. (Reference Range-Negative).
PERFORMED BY ___.
This result indicates a high likelihood of C. difficile
infection
(CDI).
__________________________________________________________
___ 3:54 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
Identification and susceptibility testing performed on
culture #
___- ___.
__________________________________________________________
___ 2:34 pm URINE
URINE CULTURE (Preliminary):
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
KLEBSIELLA PNEUMONIAE. 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
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- =>64 R <=1 S
CEFTAZIDIME----------- =>64 R <=1 S
CEFTRIAXONE----------- =>64 R <=1 S
CIPROFLOXACIN--------- =>4 R <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- <=0.25 S
NITROFURANTOIN-------- 128 R 128 R
PIPERACILLIN/TAZO----- =>128 R <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
IMAGING:
========
___ Imaging RENAL TRANSPLANT U.S.
IMPRESSION:
1. Normal renal transplant ultrasound. No hydronephrosis.
2. Partially imaged nephroureterostomy tube.
3. Incidental right 3.6 cm hemorrhagic ovarian cyst
___ Imaging CHEST (PA & LAT)
IMPRESSION:
No acute cardiopulmonary abnormality.
___ Imaging URIN CATH REPLC
FINDINGS:
1. Left transplant antegrade nephrostogram shows persistent mid
ureteral
stricture.
2. Ureteroplasty performed again up to 6 and 8 mm.
3. Appropriate final position of left transplant nephroureteral
tube.
IMPRESSION:
Technically successful left transplant 10 ___ nephroureteral
tube exchange. Repeat ureteroplasty. This represents the third
ureter ureteroplasty performed (#1: ___, #2: ___.
RECOMMENDATION(S): The patient should return in ___ weeks to ___
for repeat nephrostogram and ureteroplasty. Of note, the
patient has returned at some points prior to the designated
follow-up time frame. However, adherence to the ___ week
duration should be maintained as much as possible for
ureteroplasty specifically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atova___ Suspension 1500 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Mycophenolate Sodium ___ 720 mg PO BID
4. PredniSONE 5 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Simvastatin 10 mg PO QPM
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
8. Sodium Bicarbonate 650 mg PO BID
9. Tacrolimus 3 mg PO Q12H
10. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO)
RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by
mouth Every ___. Once a week. Disp #*8 Packet Refills:*0
2. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth QID (four times a
day) Disp #*56 Capsule Refills:*0
3. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Mycophenolate Sodium ___ 360 mg PO BID
RX *mycophenolate sodium [Myfortic] 360 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
5. Atovaquone Suspension 1500 mg PO DAILY
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Ranitidine 150 mg PO BID
10. Simvastatin 10 mg PO QPM
11. Sodium Bicarbonate 650 mg PO BID
12. Tacrolimus 3 mg PO Q12H
13.Outpatient Lab Work
Z___.899: Checking Tacrolimus blood levels.
Please fax results to:
___, MD
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=========
UTI
C. difficile
Anemia
SECONDARY:
===========
CKD
Kidney transplant
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: cough, hx TB// cough, hx TB
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Streaky linear opacity in the left upper
lobe is unchanged, likely scarring. Remainder of the lungs are clear. No
pleural effusion or pneumothorax is seen. There are no acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: History: ___ with renal transplant, kidney failing// renal
transplant, kidney failing
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ultrasound from ___
FINDINGS:
The left iliac fossa transplant renal morphology is normal. Specifically, the
cortex is of normal thickness and echogenicity, pyramids are normal, there is
no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection. A nephroureterostomy
stent is partially imaged. The bladder appears decompressed
The resistive index of intrarenal arteries ranges from 0.64 to 0.70, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 73.4 centimeters/second. Vascularity is symmetric throughout
transplant. The transplant renal vein is patent and shows normal waveform.
Incidental note is made of a heterogeneous right adnexal lesion, measuring 2.9
x 3.3 x 3.6 cm, which is predominantly hypoechoic and contains hyperechoic
avascular debris, some of which appear layering, compatible with a hemorrhagic
ovarian cyst. The uterus is partially seen. Small amount pelvic free fluid
is noted.
IMPRESSION:
1. Normal renal transplant ultrasound. No hydronephrosis.
2. Partially imaged nephroureterostomy tube.
3. Incidental right 3.6 cm hemorrhagic ovarian cyst.
Radiology Report
INDICATION: ___ year old woman with SPK transplant c/b allograft and humoral
rejection and obstruction s/p perc nephrostomy c/b recurrent UTI.Here again
with c/f recurrent Enterobacter UTI, would like perc neph tube exchange//
exchange of percutaneous nephrotomy tube placement
COMPARISON: Prior studies from ___, and ___
TECHNIQUE: OPERATOR: Dr. ___ radiology attending)
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
1 mg of midazolam throughout the total intra-service time of 18 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: As above
CONTRAST: 20 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 4.5 minutes, 18 mGy
PROCEDURE:
1. Left transplant kidney diagnostic antegrade nephrostogram.
2. Ureteroplasty with 6 mm and 8 mm Conquest balloons
3. Left transplant kidney 10 ___ nephroureterial tube exchange (modified
APDL as a PCNU).
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 prone
on the exam table. A pre-procedure time-out was performed per ___ protocol.
The left lower quadrant was prepped and draped in the usual sterile fashion.
Diluted contrast was injected into the left nephroureteral tube to confirm
catheter position. The image was stored on PACS. Local anesthesia was
administered with instillation of lidocaine jelly. The catheter was cut. A
___ wire was advanced into the left nephroureteral tube and advanced into
the bladder. The stay sutures were cut and the catheter was removed over the
wire. A 6 ___ bright tip sheath was placed over the wire, a pull-back
nephrostogram was performed. This again demonstrated persistent mid ureteral
stricture. Therefore, as the patient last had their ureteroplasty performed 6
weeks ago, decision was made to perform ureteroplasty. First, a 6 mm x 4 cm
Conquest balloon catheter was advanced, and the midportion of the ureter was
dilated. Following this, repeat nephrostogram demonstrated persistent
stricture. Therefore gentle ureteroplasty performed using 8 mm x 4 cm
Conquest balloon catheter, which demonstrated effacement of a mid ureteral
stricture. Following this, an antegrade nephrostogram was performed. The 10
___ nephroureteral tube was then replaced, using a modified APDL tube, with
additional sideholes cut matched to the prior tube. The wire and stiffener
were removed and the pigtail was formed. Contrast injection confirmed
appropriate positioning. The final image was saved. The catheter was then
flushed, stay sutures applied and the catheter was secured with a Stat Lock
device and sterile dressings. The catheter was attached to a bag for
drainage.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Left transplant antegrade nephrostogram shows persistent mid ureteral
stricture.
2. Ureteroplasty performed again up to 6 and 8 mm.
3. Appropriate final position of left transplant nephroureteral tube.
IMPRESSION:
Technically successful left transplant 10 ___ nephroureteral tube exchange.
Repeat ureteroplasty. This represents the third ureter ureteroplasty
performed (#1: ___, #2: ___.
RECOMMENDATION(S): The patient should return in ___ weeks to ___ for repeat
nephrostogram and ureteroplasty. Of note, the patient has returned at some
points prior to the designated follow-up time frame. However, adherence to
the ___ week duration should be maintained as much as possible for
ureteroplasty specifically.
Gender: F
Race: ASIAN - KOREAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Anemia
Diagnosed with Anemia, unspecified
temperature: 97.3
heartrate: 103.0
resprate: 18.0
o2sat: 98.0
sbp: 126.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | ___ PMH T1DM, diabetic nephropathy s/p SPK in ___, with
subsequent failure of pancreas allograft ___, recent
cellular (and possible humoral) rejection ___ (received ATG
x 7 days, pulse steroids, IVIg x 4), HTN, HLD, urinary
obstruction with PCNU, presenting with symptomatic anemia and
likely UTI, found to also have C. diff colitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Confusion, left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ yo M with PMHx IDDM (HbA1c 9.3 in ___,
HTN, HLD, nicotine dependence and possible TIA who presents to
___ ED ___ after an episode of confusion accompanied by left
sided weakness lasting 1 hour.
Pt states that he was in his usual state of health when he left
work ~14:30 on ___. He arrived home at 15:30 and checked his
glucose, per his usual routine. The glucometer read as "high" so
he took 15 units of his sliding scale insulin. He then took a
nap. Around 22:00, he woke up and noted that he felt off balance
when standing and walking. He also felt like his left side was
weak. He lives in the attic of his parent's home and he needed
to use the bathroom so he then went down two flights of stairs
to the basement in order to use the bathroom. He felt unstable
but did not fall while going down the stairs. His parents heard
him "stumbling around" and went to find him in the basement.
When they found him in the basement, he urinated on himself (he
states this was because he could not make it to the bathroom in
time) and his parents called EMS. He states he was confused at
the time, especially because there is a closer basement on the
first floor. He denies feeling numb anywhere, having a facial
droop, or having difficulty understanding what people were
saying to him at the time. He states his parents commented that
his speech was a little slurred.
When EMS arrived, accucheck was 126. Pt states he was given an
orange but pt does not recall if this was before or after the
accucheck and the EMS report does not clarify this. Pt denies
have any other drinks or food prior. En route to the hospital,
pt's confusion and left sided weakness resolved. Symptoms lasted
about a hour.
At time of assessment, pt was feeling well and back to his
normal self. He had no further complaints.
Of note, pt reports having similar symptoms of confusion,
numbness or unilateral weakness related to low blood sugar. Pt
was hospitalized at ___ in ___ with a similar presentation
(episode of right sided numbness and weakness and confusion) and
at that presentation he was noted to have a blood glucose of 65.
Symptoms resolved with D5. MRI did not show any stroke at that
time and aspirin was increased to 325 at discharge as TIA could
not be ruled out.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
INSULIN DEPENDENT DIABETES ___ (HbA1c 9.3 in ___
GASTROESOPHAGEAL REFLUX
HYPERCHOLESTEROLEMIA
HYPERTENSION
COLONIC ADENOMA
SENSORINEURAL HEARING LOSS
?TIA
Social History:
___
Family History:
Mother Living DIABETES ___
Father Living DIABETES ___
Sister Living DIABETES ___
CARDIOMYOPATHY
Physical Exam:
# Admission Physical Exam #
Vitals: 97.2 68 141/84 16 100%
General: NAD, comfortable, smells like urine
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily maintained. Recalls a coherent history. Able to
recite months of year backwards. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Content of speech demonstrates intact naming (high and low
frequency) and no paraphasias. Normal prosody. No dysarthria. No
apraxia. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response withdrawal bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and arm swing. Stable without sway. Negative Romberg.
# Discharge Exam #
unchanged from above
Pertinent Results:
LABS:
___ 11:19PM BLOOD WBC-8.6 RBC-4.22* Hgb-12.6* Hct-36.9*
MCV-87 MCH-29.9 MCHC-34.2 RDW-14.4 Plt ___
___ 11:19PM BLOOD Neuts-78.9* Lymphs-13.2* Monos-7.0
Eos-0.6 Baso-0.3
___ 11:19PM BLOOD Glucose-100 UreaN-17 Creat-0.9 Na-141
K-4.1 Cl-105 HCO3-24 AnGap-16
___ 11:19PM BLOOD ALT-32 AST-44* AlkPhos-98 TotBili-0.3
___ 11:19PM BLOOD Albumin-4.1 Calcium-9.4 Phos-5.1* Mg-2.0
Cholest-222*
___ 11:19PM BLOOD %HbA1c-10.3* eAG-249*
___ 11:19PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:19PM BLOOD Triglyc-49 HDL-115 CHOL/HD-1.9 LDLcalc-97
___ 04:48AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:48AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
IMAGING:
- CHEST (PA & LAT)
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal
cardiomediastinal
silhouette and well-aerated lungs which are clear. There is no
focal
consolidation, pleural effusion, or pneumothorax. The visualized
upper abdomen
is unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
- CT HEAD W/O CONTRAST
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles
and sulci are normal in size and configuration.
No osseous abnormalities seen. The paranasal sinuses, mastoid
air cells, and
middle ear cavities are clear. The orbits are unremarkable.
There is mild
right frontal scalp swelling.
IMPRESSION:
Mild right frontal scalp swelling. Otherwise normal CT head.
MRI Head ___:
1. There is no evidence of acute or subacute intracranial
process, essentially
normal MRI of the brain with no evidence of intracranial
hemorrhage or
diffusion abnormalities to suggest acute or subacute ischemic
changes.
2. Unchanged T2 and FLAIR high signal within the pons, which is
nonspecific
and may reflect changes due to small vessel disease.
3. Unchanged fusiform appearance of the mid segment of the
basilar artery. No
flow stenotic lesions are seen.
4. Essentially normal MRA of the neck with dominance of the
right vertebral
artery as described above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 2.5 mg PO DAILY
3. Testim (testosterone) 50 mg/5 gram (1 %) transdermal Unknown
4. Aspirin 325 mg PO DAILY
5. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
6. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using UNK Insulin
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Lisinopril 2.5 mg PO DAILY
3. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
4. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
5. Testim (testosterone) 50 mg/5 gram (1 %) transdermal Unknown
6. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoglycemia
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: Confusion.
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: 881.9 mGy-cm
CTDI: 54.6 mGy
COMPARISON: Noncontrast CT head from ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable. There is mild
right frontal scalp swelling.
IMPRESSION:
Mild right frontal scalp swelling. Otherwise normal CT head.
Radiology Report
EXAMINATION: MRI and MRA Head, MRA of the neck.
INDICATION: ___ year old man with episode of left sided weakness// ?stroke>
TECHNIQUE: Multi planar multi sequence MR images of the brain were obtained
without contrast, including sagittal T1, axial T2, axial FLAIR, axial magnetic
susceptibility and axial diffusion-weighted images
MRA of the head, non contrast 3D time-of-flight MRA of the brain was
performed, axial source images and multiplanar reformations were reviewed. .
MRA of the neck, noncontrast 2D time-of-flight MRA arteriography of the neck
vessels was obtained, axial source images and multiplanar reformations were
reviewed.
COMPARISON: MRI and MRA of the head and neck dated ___. Head CT
without contrast dated ___.
FINDINGS:
MR Head: No significant changes are identified since the prior examination
performed in ___. There is no intracranial hemorrhage, mass, mass
effect or shifting of the normally midline structures. Diffusion weighting
imaging does not demonstrate evidence of acute infarct. Gray white matter
differentiation is maintained. Ventricles and extra axial spaces are normal.
There is a persistent area of T2 and FLAIR high signal intensity within the
pons, which is nonspecific and may represent chronic microvascular ischemic
disease The orbits are unremarkable, the paranasal sinuses and mastoid air
cells are clear.
MRA Head: Again there is fusiform appearance of the mid segment of the
basilar artery, the right vertebral artery is dominant, unchanged hypoplasia
of the left vertebral artery is seen, with patency of the posterior
communicating arteries and hypoplastic P1 segments bilaterally, consistent
with fetal type posterior communicating arteries.
MRA of the neck: Both common carotid arteries are patent with no evidence of
stenosis at the carotid cervical bifurcations. The vertebral arteries are
patent with dominance of the right vertebral artery.
IMPRESSION:
1. There is no evidence of acute or subacute intracranial process, essentially
normal MRI of the brain with no evidence of intracranial hemorrhage or
diffusion abnormalities to suggest acute or subacute ischemic changes.
2. Unchanged T2 and FLAIR high signal within the pons, which is nonspecific
and may reflect changes due to small vessel disease.
3. Unchanged fusiform appearance of the mid segment of the basilar artery. No
flow stenotic lesions are seen.
4. Essentially normal MRA of the neck with dominance of the right vertebral
artery as described above.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Confusion
Diagnosed with ALTERED MENTAL STATUS , DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.2
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 84.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ yo M with PMHx IDDM (HbA1c 9.3 in ___, HTN,
HLD, nicotine dependence and possible TIA who was admitted to
stroke service after a 1 hour of transient confusion, unsteady
gait and possible subjective left sided weakness that resolved
completely. He reported that he took 15 units of Humalog earlier
in the afternoon for FSBS>600, then fell asleep instead of
eating something as he had intended. FSBS was 126 when checked
by EMS, but likely this was after he had eaten an orange. His
presenting story was concerning for possible TIA vs.
hypoglycemic episode however the symptoms were quite
non-localizing. He was seen by ___ who noted that the amount
of insulin he took was enough to drop his blood glucose by 600
points. Etiology of the event was likely symptomatic
hypoglycemia, but an will MRI was obtained to rule out stroke
given his multiple risk factors. ___ has recommended decrease
in his insulin sliding scale while inpatient and close
outpatient follow-up for hopeful placement of continuous glucose
monitor. Stroke risk factors showed LDL 97 and A1C 10%. We have
strongly encouraged smoking cessation as well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HMED ATTENDING INITIAL NOTE
DATE SEEN: ___
TIME SEEN 935 ___
.
___ yo F s/p remote CCY, h/o Sjrogen's, with chronic abdominal
pain s/p GI w/u consisting of ERCPs, EGD/EUS, secretin secretion
test presents d/t worsening RUQ pain. Pt has had similar pain in
past, has some RUQ pain at baseline, however pain now much worse
over past 5 days- it feels like someone or something is
pinching. + nausea, no vomiting. Chronic constipation but she
has been moving her bowels every day with formed stools. No
alternating with diarrhea. Eating does make it worse. Pain
worsens with inspiration and has been very debilitation. No
cough. + chills but no cough. + weight gain of 40 lbs over the
past year. She used to exercise 6x per week and now she is not
able to sleep because of pain and is thus too tired to exercise.
She used to to hike up mountains with her children up to ___ years
ago but she doesn't do that anymore because of exhaustion from
dealing with the pain. Exercising per se does not make the pain
worse. Pain is worsened by eating. She will go a whole day
without eating and then eat a big meal at the end of the day
trying to decrease the amount of pain she has. She take dilaudid
overnight to help with the pain to avoid taking it while at
work. This worsening in her pain 5 days ago does not appear to
be worsended by a particular trigger. She has not been having a
low fat diet necessarily but is not sure is fatty foods make her
sx worse. Pt had labs at OSH with WBC 11.6 and AP sl elevated
around 130. Pt w/o other complaints.
.
In ED VS: 8 97.8 98 146/88 18 100% RA
Given 1L NS, dilaudid 1 mg IV x 3, zofran 4 mg x 2.
Labs unremarkable except for leukocytosis to 10K and elevated
ALP- 137- highest on record.
.
Review of ___ demonstrates that she receives 75 tablets of 4
mg dilaudid every month. She has had 16 presciptions and 7
prescribers.
.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
BILIARY PMH
-cholecystectomy in ___
-s/p several ERCPs with ___ at ___
-ERCP with biliary balloon sphincteroplasty in ___ ___ a trial of a PD stent in ___
-ERCP with a CBD stent ___
-CBD stent ___
- EGD ___ - Antral mucosa with focal changes of reactive
gastropathy which was described a superficial in letter to
patient
- EGD/EUS ___ Overall there are only two features of chronic
pancreatitis (hyperechoic strands and hyperechoic walls of the
PD) which is insufficient for a diagnosis of chronic
pancreatitis. Her secritin level was 74 which is just below the
cutoff of 75. Test repeated in ___ and peak bicarbonate was
83 which is WNL. Per Dr. ___ " Thus, in conjunction with
Dr. ___ normal EUS as well as normal MRCP, this
would make chronic pancreatitis less likely."
___: Presented to ED and found to have large fecal loading
KUB thus d/c'ed home with agressive bowel regimen.
-Pancreatitis -___
-left ___
-breast biopsy in ___ and ___
-tubal ligation and myomectomy in ___.
-Hypertension.
-Hypothyroidism.
-Scoliosis.
-Vitamin Deficiency
-Sjogren's.
Social History:
___
Family History:
Mother and Aunt s/p cholecystectomy for gallstone dz
Physical Exam:
Vitals: T 98.1 P 84 BP 138/91 RR 18 SaO2 98% on RA
GEN: NAD, slightly uncomfortable appearing
HEENT: ncat anicteric MMM
NECK: supple
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
ABD: +bs, soft,distended, epigastric and RUQ pain, negative
rebound
EXTR:no c/c/e 2+pulses
DERM: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
Pertinent Results:
___ 06:15PM URINE HOURS-RANDOM
___ 06:15PM URINE HOURS-RANDOM
___ 06:15PM URINE UHOLD-HOLD
___ 06:15PM URINE GR HOLD-HOLD
___ 06:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 12:00PM GLUCOSE-91 UREA N-12 CREAT-0.6 SODIUM-136
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-25 ANION GAP-17
___ 12:00PM estGFR-Using this
___ 12:00PM ALT(SGPT)-21 AST(SGOT)-17 ALK PHOS-137* TOT
BILI-0.2
___ 12:00PM LIPASE-25
___ 12:00PM ALBUMIN-4.4
___ 12:00PM WBC-10.2*# RBC-4.43 HGB-12.6 HCT-39.1 MCV-88
MCH-28.4 MCHC-32.2 RDW-13.7 RDWSD-44.3
___ 12:00PM NEUTS-70.0 ___ MONOS-7.7 EOS-1.0
BASOS-0.5 IM ___ AbsNeut-7.14* AbsLymp-2.06 AbsMono-0.79
AbsEos-0.10 AbsBaso-0.05
___ 12:00PM PLT COUNT-299
====================
MRCP
IMPRESSION:
1. Mild stable dilation of CBD and central intrahepatic bile
ducts without
obstructing lesion is likely within normal limits in the setting
of prior
cholecystectomy.
2. Mild narrowing and downward deflection at the origin of the
celiac trunk
appears to be secondary to mass effect from the median arcuate
ligament.
Although this can be seen in asymptomatic patients it is also
found in
symptomatic patients (median arcuate ligament syndrome).
3. Trace bilateral pleural effusions and mild bibasilar
atalectasis.
4. Steatohepatosis
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 50 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Duloxetine 20 mg PO BID
4. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Lisinopril 10 mg PO QHS
7. NexIUM (esomeprazole magnesium) 20 mg oral DAILY - pt not
sure of dose
8. Ranitidine Dose is Unknown PO QHS
9. Pravastatin 40 mg PO QPM
10. Viokace (lipase-protease-amylase) 20,880-78,300- 78,300 unit
oral TID W/MEALS
11. HYDROmorphone (Dilaudid) 4 mg PO TID:PRN pain
Discharge Medications:
1. Amitriptyline 50 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Duloxetine 20 mg PO BID
4. HYDROmorphone (Dilaudid) 4 mg PO TID:PRN pain
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Lisinopril 10 mg PO QHS
7. Pravastatin 40 mg PO QPM
8. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
9. NexIUM (esomeprazole magnesium) 20 mg oral DAILY
10. Ranitidine 150 mg PO QHS
11. Viokace (lipase-protease-amylase) 20,880-78,300- 78,300 unit
oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with h/o cholecystectomy w/ worsening RUQ pain // ?
biliary dilitation/abnormalities
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis dated ___, right upper quadrant
ultrasound dated ___ and MRCP dated ___
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation with unchanged
pneumobilia. The CBD measures 4 mm.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 11.5 cm.
KIDNEYS: The right kidney measures 10.5 cm. The left kidney measures 10.9 cm.
Limited views of the right and left kidney demonstrate no stones or
hydronephrosis.
IMPRESSION:
1. Again seen pneumobilia likely related to prior sphincterotomy
2. No evidence of intra or extrahepatic biliary dilatation
3. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
Radiology Report
INDICATION: ___ year old woman with constipation and abdominal pain. //
Please assess for degree of fecal loading.
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal CT from ___ and right upper quadrant
ultrasound from ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is a moderate amount of fecal loading throughout the length of the
colon.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Moderate fecal loading.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with acute on chronic RUQ pain, CCY, s/p
multiple ERCPs in past // eval for evidence of biliary obstruction,
dilatation, stone, sludge
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet. Intravenous contrast: 9 mL Gadavist
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: MRCP ___. Abdominal ultrasound ___.
FINDINGS:
Lower Thorax: Aside from mild atelectasis the included lung fields are grossly
clear. There are trace pleural effusions bilaterally.
Liver: Multiple sub cm T2 bright foci similar to prior likely reflect benign
biliary hamartomas (5: 5, 6, 23). Diffuse drop in signal of the liver on out
of phase sequences is compatible with fatty deposition. Unchanged 7 mm focus
of arterial hyperenhancement in segment 8 at the dome of the liver (___:35)
is unchanged and normalizes on delayed phase sequences most likely reflecting
transient hepatic intensity difference.
Biliary: Mild dilation of the central intrahepatic bile ducts and CBD to 10 mm
is unchanged and likely normal in the setting of prior cholecystectomy. No
obstructing lesion is seen.
Pancreas: Normal in size and signal intensity without focal lesions. The
pancreatic duct is normal in caliber.
Spleen: Normal in size and signal intensity.
Adrenal Glands: Normal.
Kidneys: No hydronephrosis or focal lesions. The proximal ureters are normal
in caliber.
Gastrointestinal Tract: The stomach and included loops of small and large
bowel are grossly normal without obstruction.
Lymph Nodes: There is no mesenteric retroperitoneal lymphadenopathy.
Vasculature: The abdominal aorta is normal in caliber. Mild narrowing at the
origin of the celiac trunk with post-stenotic dilation. There is mild
narrowing and downward deflection at the origin of the celiac trunk which
appears to be secondary to mass effect from the median arcuate ligament
(___:11). The portal vein is patent.
Osseous and Soft Tissue Structures: Bone marrow signal is normal. The
abdominal wall is unremarkable.
IMPRESSION:
1. Mild stable dilation of CBD and central intrahepatic bile ducts without
obstructing lesion is likely within normal limits in the setting of prior
cholecystectomy.
2. Mild narrowing and downward deflection at the origin of the celiac trunk
appears to be secondary to mass effect from the median arcuate ligament.
Although this can be seen in asymptomatic patients it is also sometimes found
in symptomatic patients ("median arcuate ligament syndrome").
3. Trace bilateral pleural effusions and mild bibasilar atalectasis.
4. Hepatic steatosis.
NOTIFICATION: The findings were telephoned to ___, MD by ___
at 15:38, ___, 20 min after discovery.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RUQ abdominal pain
Diagnosed with Epigastric pain
temperature: 97.8
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 146.0
dbp: 88.0
level of pain: 8
level of acuity: 3.0 | The patient is a ___ year old female with Sjrojen's syndrome with
h/o chronic RUQ pain of unclear etiology who presents with
worsening of her RUQ pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___ Ventricular Mass with Hydrocephalus
Major Surgical or Invasive Procedure:
___ - Right frontal craniotomy with transcortial resection
of third ventricular cyst
History of Present Illness:
Ms. ___ is a ___ year-old female with HTN, NIDDM, HC presenting
to ___ ED on transfer from OSH with new diagnosis of ___
ventricular mass with hydrocephalus. Her husband brought her to
the hospital for 10 days of progressive cognative concerns. He
reports that she has been more forgetful, less interactive, and
increasingly fatigued. Two days ago she was at Church and called
her husband very confused, unable to recall where she parked the
car. He notes that her gait has been "more deliberate", with
slowed, focused steps. No significant instablity, dizziness, or
falls. The patient reports that this has been a concern for the
past ___ months, but that she has continued to participate in
her weekly walking group without significant difficulty. Denies
headache, visual concerns, speech difficulties, new
numbness/tingling/weakness in extremities. No urinary
incontinence.
Past Medical History:
HTN
NIDDM
Hypercholesterol
Arthritis
Diverticulitis
Social History:
___
Family History:
Father deceased from MI vs. aneurysm. Mother deceased, ___
bladder cancer & dementia at advanced age. No family history of
early onset dementia.
Physical Exam:
PHYSICAL EXAM:
O: T: 98.4 BP: 105/75 HR: 80 RR: 18 O2Sat: 97% RA
Gen: Well-appearing, no acute distress.
HEENT: No external signs of trauma.
Extremities: 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 & repetition intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not assessed
II: Pupils equally round and reactive to light, 2mm to 1mm
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 pronator drift. No
abnormal movements, tremors. Strength full power ___ throughout.
Sensation: Grossly intact to LT throughout.
Coordination: No dysmetria as assessed by finger-nose-finger,
rapid alternating movements.
___________________________
PHYSICAL EXAM AT DISCHARGE:
Awake, alert, oriented x 3. Speech fluent.
Follows commands briskly. Sitting in chair.
PERRL, EOM-I. Face symmetric. Tongue midline.
Moves all extremities with full strength throughout.
Wound clean, dry, intact, closed with staples.
Pertinent Results:
___ MRI Brain:
1. Findings compatible with a hemorrhagic 1.3 cm colloid cyst
centered at the foramen of ___.
2. There is ventriculomegaly of the third and lateral ventricles
with
transependymal CSF flow, compatible with obstructive
hydrocephalus.
___ CXR:
Mild left subsegmental atelectasis. Otherwise normal chest
radiograph.
___ Head CT:
Status post right frontal craniotomy and placement of a catheter
ending in the third ventricle. A few areas of subtle
hyperdensity in the right frontal lobe may represent minimal
parenchymal blood products or artifact.
___ MRI Brain:
1. Expected postsurgical changes from resection of the third
ventricular mass with enhancing choroid plexus in the third
ventricle and no definite evidence of residual mass.
2. Unchanged position of the right frontal ventriculostomy
catheter with
decreased size of the ventricles and no evidence of
transependymal CSF flow.
3. No acute infarct.
___ CXR:
As compared to ___, lower lung volumes accentuate
the
cardiomediastinal contours and result in crowding of
bronchovascular
structures. Interval worsening of multifocal the linear and
patchy opacities in the mid and lower lungs, most likely due to
atelectasis although coexisting infection is possible in the
appropriate clinical setting. Probable small bilateral pleural
effusions are also noted.
___. Evolving postoperative changes related to patient's right
frontal
craniotomy and third ventricular mass resection as described.
2. Stable right frontal approach ventriculostomy catheter with
tip within the super sellar cistern, unchanged.
3. Allowing for difference in technique, grossly stable
ventricles.
4. Grossly stable intraventricular hemorrhage and subdural
collections.
Medications on Admission:
1. Diovan HCT (valsartan-hydrochlorothiazide) 320-12.5 mg oral
DAILY
2. Multivitamins 1 TAB PO DAILY
3. Simvastatin 40 mg PO QPM
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Medications:
1. Simvastatin 40 mg PO QPM
2. Acetaminophen 650 mg PO Q6H:PRN pain/fever
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. Diovan HCT (valsartan-hydrochlorothiazide) 320-12.5 mg oral
DAILY
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*1
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
9. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 4 tablet(s) by mouth TAPER Disp #*22 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___ Ventricular Mass
Hydrocephalus
Gout
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: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: History: ___ with hydrocephalus, AMS< gait instability, ?colloid
cyst on CT // evaluate for colloid cyst vs. NPH vs. other acute process, +/-
contrast per neurosurgery
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: Outside hospital CT head of ___.
FINDINGS:
Centered in the roof of the third ventricle at the level of the foramen ___
is a 1.0 x 1.3 x 1.1 cm (AP, TRV, SI) cystic lesion demonstrating a internal
focus of rounded gradient echo susceptibility and T1 hyperintense signal most
compatible with hemorrhage. The lesion demonstrates mild peripheral
enhancement without definitive internal enhancement. There is resultant
ventriculomegaly involving the third and lateral ventricles. FLAIR
hyperintense signal capping the frontal and occipital horns of the lateral
ventricles suggests transependymal CSF flow. Incidental note is made of a 1.3
x 1.8 cm (AP, TRV) left anterior middle cranial fossa arachnoid cyst.
There is a single punctate FLAIR hyperintense focus of the right
periventricular white matter. There is no acute infarct. The major
intracranial flow voids are preserved. The dural venous sinuses are patent.
The basilar cisterns are patent. The sulci are within expected limits.
The paranasal sinuses are clear. The orbits are unremarkable. The mastoid
air cells are clear.
IMPRESSION:
1. Findings compatible with a hemorrhagic 1.3 cm colloid cyst centered at the
foramen of ___.
2. There is ventriculomegaly of the third and lateral ventricles with
transependymal CSF flow, compatible with obstructive hydrocephalus.
NOTIFICATION: At the time of this dictation, the neurosurgery staff was aware
of these findings based on admission notes.
Radiology Report
INDICATION: ___ year old woman with hydrocephalus // pre op Surg: ___
(vpshunt)
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Mild left subsegmental atelectasis. The lung volumes are normal. Normal size
of the cardiac silhouette. Normal hilar and mediastinal structures. Unchanged
appearance of the spine on the lateral chest radiograph. No pneumonia, no
pulmonary edema. No pleural effusions.
IMPRESSION:
Mild left subsegmental atelectasis. Otherwise normal chest radiograph.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old female with ___ ventricle mass status post craniotomy
and mass resection.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7 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: MRI from ___ and CT from ___.
FINDINGS:
Surgical changes are noted post right frontal craniotomy. A small amount of
hemorrhage is noted layering in the bilateral occipital horns. Expected
postoperative hemorrhage is noted around the surgical site and ventriculostomy
catheter. Postoperative pneumocephalus is seen. Trace bilateral subdural
hematomas are seen with no mass effect or midline shift. FLAIR hyperintense
signal is noted in the right frontal lobe, along the margin of the surgical
tract. A right frontal ventriculostomy catheter is seen which terminates in
the third ventricle. Diffuse pachymeningeal enhancement is seen, likely
postoperative in etiology. The ventricles have decreased in size in
comparison to the prior MRI with no evidence of transependymal CSF flow.
Enhancing cord plexus is seen in the third ventricle with no definite evidence
of residual mass.
There is no evidence of an acute infarct. Periventricular and subcortical T2
and FLAIR hyperintensities are noted.
The orbits are normal. There is mild mucosal thickening in the ethmoid
sinuses. The vascular flow voids are normal. Degenerative changes are noted
at the bilateral temporomandibular joints, worse on the right.
IMPRESSION:
1. Expected postsurgical changes from resection of the third ventricular mass
with enhancing choroid plexus in the third ventricle and no definite evidence
of residual mass.
2. Unchanged position of the right frontal ventriculostomy catheter with
decreased size of the ventricles and no evidence of transependymal CSF flow.
3. No acute infarct.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman with third ventricle mass. Now status post
craniotomy and removal of a mass. Evaluate for postoperative bleeding.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 18.0 cm; CTDIvol = 44.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Nonenhanced CT head ___.
FINDINGS:
The patient is status post right frontal craniotomy. A right frontal approach
catheter ends in the third ventricle. Pneumocephalus is expected
postoperatively. The ventricles are stable in size and appearance. A few
areas of subtle hyperdensity in the right frontal lobe may represent minimal
parenchymal contusions or artifact (series 2, images 12 and 13). Extra-axial
intermediate density adjacent to the right frontal and parietal lobes measures
5 mm in maximum depth and is presumably related to the recent surgery.
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:
Status post right frontal craniotomy and placement of a catheter ending in the
third ventricle. A few areas of subtle hyperdensity in the right frontal lobe
may represent minimal parenchymal blood products or artifact.
RECOMMENDATION(S): NOTIFICATION:
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with SpO2 87% on 3L. // ?reason for desats
IMPRESSION:
As compared to ___, lower lung volumes accentuate the
cardiomediastinal contours and result in crowding of bronchovascular
structures. Interval worsening of multifocal the linear and patchy opacities
in the mid and lower lungs, most likely due to atelectasis although coexisting
infection is possible in the appropriate clinical setting. Probable small
bilateral pleural effusions are also noted.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ female with history of third ventricular mass, status
post resection, and EVD placement. Evaluate ventricular size.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 7.2 s, 19.5 cm; CTDIvol = 51.8 mGy (Head) DLP =
1,009.3 mGy-cm.
Total DLP (Head) = 1,009 mGy-cm.
COMPARISON: ___ contrast brain MRI.
___ noncontrast head CT.
FINDINGS:
Evolving postoperative changes related to the patient's right frontal
craniotomy and periventricular mass resection are again seen, including
pneumocephalus, bifrontal subdural collection and blood products adjacent to
the craniotomy site.
A right frontal approach ventriculostomy catheter is again noted, with its tip
in the region of the suprasellar cistern, unchanged.
Allowing for difference in technique, grossly stable layering intraventricular
hemorrhage is again seen.
The ventricles and sulci are stable in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Evolving postoperative changes related to patient's right frontal
craniotomy and third ventricular mass resection as described.
2. Stable right frontal approach ventriculostomy catheter with tip within the
super sellar cistern, unchanged.
3. Allowing for difference in technique, grossly stable ventricles.
4. Grossly stable intraventricular hemorrhage and subdural collections.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status, Transfer
Diagnosed with ALTERED MENTAL STATUS
temperature: 98.4
heartrate: 80.0
resprate: 18.0
o2sat: 97.0
sbp: 105.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was admitted to ___ on ___ for close neurological
monitoring in the setting of newly diagnosed ___ ventricular
mass and resulting hydrocephalus. She remained neurologically
intact throughout ICU admission, and was transferred to the
inpatient floor on ___. MRI confirmed the presence of a
hemorrhagic cystic lesion obstructing the ___ ventricle.
Ventricle size was stable. Neuro-oncology was consulted, and
recommended serial imaging as an outpatient to evaluate for
interval mass enlargement. Risks and benefits of operative
intervention were discussed with the patient who wished to
proceed with surgical management.
She proceeded to the OR on ___ for craniotomy with excision
of lesion and EVD placement. The procedure was uncomplicated and
well-tolerated by the patient. She was extubated in the OR and
transferred to the ICU overnight for close neurological
monitoring. EVD was clamped on POD#1 and she wad transferred to
the Step-Down Unit. It was noted that there was some CSF
drainage around the evd catheter and so an extra suture was
added. On POD#2, Her EVD was clamped. Head CT on POD#3 showed
stable ventricle size, and her EVD was removed. She remained
inpatient for neurological monitoring without acute events. She
was evaluated by ___ who recommended discharge home with
family support and home ___ services. At time of discharge, she
was ambulating with assistance, voiding, and tolerating a full
diet. Pain was well-controlled on oral medication. She was
discharged home on POD#5 (___) in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
Chief Complaint: Abd pain and fever
Reason for MICU transfer: A. fib with
Major Surgical or Invasive Procedure:
PEG tube placement ___
History of Present Illness:
Ms. ___ is a ___ y/o F with a h/o frontal dementia,
hypothyroidism, and hypertension who was admitted from ___
___ (lives there as long term care) on ___ with abdominal
pain and fever. CT of her abdomen/pelvis in the ER were notable
for an SBO and a LLL PNA, she was admitted to ___ for
conservative management of a SBO. Her abdominal pain improved,
she had a BM and ACS said her SBO resolved, they then
transferred her to ___ on ___ for management of her pna and
and delirium. She is currently on vanc/cefepime/flagyl for abx
coverage. She is afebrile, only oriented to herself, she is
pulling out her IV's, etc. Her O2 requirement and CXR was
worseing during her ward course. On ___ she triggered at
8:55 for difficulty breathing and HR to 140s in a fib with BPs
of 170s to ___. Pt noted at that time to be positive 4Ls with
UOP of about 20/Hr of fluid and requiring 2L NC for 88%. 20mg of
IV lasix was given and 5mg of metoprolol iv which she diuressed.
Throughout the day she had occasional a fib with SBPs in the
160-170s and triggered an additional two times. She was given
20+20+40 IV lasix, 5+5 of metoprolol and 25 of PO metoprolol
Q8Hr. Then she continued to be in A. fib with RVR to the
150-160s and was transferred to the MICU.
Past Medical History:
- Dementia, Hypertension, Hypothryroid, Latent syphilis,
depression, Osteoarthritis
- Bilateral knee replacement in ___
Social History:
___
Family History:
Two brothers and two sisters, one of which died of old age. The
living siblings have dementia, hypertension, diabetes mellitus
and a stroke. Five children, one with asthma, three with
hypertension.
Physical Exam:
ADMISSION EXAM PER ACS:
Vitals: 98.6 99 137/69 16 96%RA
GEN: sleeping but intermittently responsive, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear on right, mildly coarse BS on left
ABD: Soft, +distension, mildly tender L abd, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
TRANSFER EXAM:
GEN: eyes closed, NG tube in place, arms restrained, NAD
HEENT: sclera anicteric, no nuchal rigidity
CV: RRR, no m/r/g
PULM: CTA anteriorly
EXT: no edema
NEURO:
MSE: Eyes open with light sternal rub, grimaces, and makes sound
but not discernable words. Does not follow commands or answer
what her name is. Fixes on examiner intermittently when eyes
open and awake, but then closes eyes and has roving eye
movements apparent under closed lids. When eyes are forced open
she does resist, with positive Bells phenomenon. No clear
neglect, as she
attends to her daughter on either side.
CN: PERRL 4 to 2mm, no hippus. EOMI. R lower facial droop.
MOTOR: paratonia more on the left side. Bilateral hand tremor
while at rest, R>L that is not suppressible.
LUE spontaneous antigravity and purposeful (tries to grab my
hand while pinching her).
RUE not moving as much as left and not as purposeful, withdraws
very briskly and antigravity to pinch.
LLE is externally rotated and paratonic. Both ___ withdraw
briskly to Babinski testing.
Sensation intact to pinch throughout.
DTR: 2+ UEs, 0 patellars (s/p TKR), no clonus, L toe upgoing at
baseline with positive Babinski response, R toe equivocal.
DISCHARGE EXAM:
GENERAL EXAM: mildly tenderness to palpation on abdominal exam,
otherwise comfortable, NAD.
NEURO:
MSE: opens eyes briefly to voice, and the keeps it closed for
the rest of the exam. does not follow commands.
CN: PERRL 4->2mm bilaterally, right nasolabial flattening
MOTOR: paratonia on L side, also increased tone on right side.
LUE spontaneous antigravity and purposeful movements. RUE
withdraws with antigravity strength in elbow, some spontaneous
movements but less than left side. Both ___ to noxious
stimuli.
Reflexes: hyperreflexic in RUE, positive babinski bilaterally.
Pertinent Results:
Admission Lab:
___ 11:45PM GLUCOSE-180* UREA N-26* CREAT-1.7* SODIUM-137
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-23 ANION GAP-19
___ 11:45PM WBC-20.4*# RBC-3.88* HGB-10.3* HCT-32.6*
MCV-84 MCH-26.7* MCHC-31.7 RDW-14.8
___ 11:45PM NEUTS-95.7* LYMPHS-2.4* MONOS-1.4* EOS-0.5
BASOS-0
___ 11:45PM PLT COUNT-236
___ 11:45PM ALT(SGPT)-17 AST(SGOT)-37 ALK PHOS-66 TOT
BILI-0.7
___ 11:45PM LIPASE-11
___ 11:45PM ALBUMIN-3.8
EKG: A fib, rate 94, rr 635m pr 130, qrs 106, qtc 459, nl axis
DISCHARGE LABS:
___ 04:30AM BLOOD WBC-7.7 RBC-3.18* Hgb-8.3* Hct-27.6*
MCV-87 MCH-26.2* MCHC-30.2* RDW-17.6* Plt ___
___ 04:30AM BLOOD Glucose-129* UreaN-11 Creat-0.6 Na-137
K-3.7 Cl-100 HCO3-31 AnGap-10
___ 04:30AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.7
COAGS:
___ 04:30AM BLOOD ___ PTT-31.2 ___
___ 07:10PM BLOOD ___ PTT-30.6 ___
___ 01:35PM BLOOD ___ PTT-66.4* ___
___ 04:35AM BLOOD ___ PTT-49.6* ___
___ 07:35PM BLOOD ___ PTT-71.9* ___
MICROBIOLOGY:
___ STOOL C. difficile DNA amplification assay NEGATIVE
___ BLOOD CULTURE NEGATIVE
___ BLOOD CULTURE NEGATIVE
___ URINE CULTURE- YEAST ___ MRSA SCREEN NEGATIVE
___ URINE CULTURE- YEAST ___ BLOOD CULTURE NEGATIVE
___ BLOOD CULTURE NEGATIVE
___ BLOOD CULTURE NEGATIVE
___ BLOOD CULTURE NEGATIVE
IMAGING:
___ CT ABD/PELVIS:
IMPRESSION:
1. Findings consistent with small-bowel obstruction with a
transition point in the left lower quadrant of the abdomen.
2. Left lower lobe pneumonia.
3. Extensive lumbar spine degenerative changes with compression
of L1
vertebral body, acuity unknown.
4. Healing right-sided rib fractures.
___ ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 65%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
___. No evidence of acute vascular territorial infarction. In
the setting of high clinical suspicion for acute ischemia, MRI
with diffusion sequences can be considered for further
assessment.
___. Low-attenuating region within the left corona radiata
extending into the left caudate head and possibly the left
putamen appears better evolved than ___ and is concerning
for subacute infarction.
2. Lacunes in the left striatocapsular region are unchanged
since the prior examination.
3. Left maxillary sinus disease.
___ MRI HEAD:
IMPRESSION:
1. Extensive relatively acute infarction involving the left
deep gray matter structures, including the caudate and lentiform
nuclei, likely accounting for the acute presentation.
2. Numerous additional more punctate infarcts scattered
throughout both cerebral hemispheres, including in the posterior
circulation territory. The overall appearance is suggestive of
"embolic shower" from a central source, with which should be
correlated with clinical information.
3. No evidence of hemorrhage.
4. No space-occupying lesion or pathologic enhancement.
5. Disproportionate medial temporal atrophy, compared to the
degree of global volume loss, raising the possibility of
underlying Alzheimer disease, which should also be correlated
with clinical information.
___ EEG:
This is an abnormal continuous video EEG monitoring study
because of abundant generalized and multifocal epileptiform
discharges, seen in the
left central temporal region, right frontal temporal region, or
isolated to either the left central or right central regions. At
times, these discharges occurred in a periodic fashion at ___
Hz, but there was no clinical change noted on video during these
bursts. These findings indicate generalized and multifocal
epileptogenic cortex but the discharges did not evolve into
electrographic seizures. There was a single pushbutton
activation for limb shaking, but the EEG demonstrated no
evidence of electrographic seizures and this could not be
visualized on video. Otherwise, the background was slow and
disorganized indicative of a diffuse encephalopathy with further
slowing noted at times over the left hemisphere indicative of
focal hemispheric dysfunction. Compared to the previous day's
recording, there was no significant change.
___ CXR:
The NG tube is in good position in the distal stomach.
Stability of the surelevation of the right hemidiaphragm with
small pleural effusion. Stable left lower lobe atelectasis.
Stability of the proeminence of the
vessels that could be compatible with light volume overload.
Mediastinal and cardiac contours normal.
___ abdominal XRAY:
Nonspecific bowel gas pattern with no evidence of bowel
obstruction.
Radiology Report
INDICATION: ___ woman with abdominal pain, fever and dementia.
COMPARISON: Chest radiograph ___.
PA AND LATERAL CHEST RADIOGRAPHS: Dense consolidation in the retrocardiac
left lung base, is concerning for an acute infectious process. There is a
small left pleural effusion. The cardiomediastinal and hilar contours are
stable, with heart in the upper limits of normal. There is no intra-abdominal
free air.
IMPRESSION: Left lower lobe pneumonia. Recommended follow-up chest
radiographs in ___ weeks to document resolution.
Radiology Report
INDICATION: ___ woman with abdominal pain, fever and dementia, to
rule out acute abdominal pathology.
COMPARISON: None.
TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained
after the administration of 130 cc of Omnipaque intravenous contrast.
Sagittal and coronal reformations were performed and reviewed.
FINDINGS: Dense consolidation in the left lower lobe and lingula, is
concerning for pneumonia. There is no pleural or pericardial effusion.
Moderate to severe coronary arterial calcifications are seen.
The liver enhances homogeneously, without focal lesions. There is no intra-
or extra-hepatic biliary dilatation. The gallbladder contains a small amount
of echogenic material, likely sludge. The adrenal glands, spleen, and
pancreas are normal. Both kidneys enhance and excrete contrast symmetrically,
without hydronephrosis. A 2.3 cm exophytic simple renal cortical cyst is seen
in the upper pole of the left kidney. Subcentimeter hypodensities in the left
renal lower pole are too small to characterize.
The stomach is mildly distended. There is moderate dilation of the mid and
distal small bowel loops measuring up to 3.9 cm, with a fecalized loop of
small bowel seen in the left lower quadrant of abdomen/pelvis and an adjacent
focal transition point (2:56), consistent with acute small-bowel obstruction.
The distal small bowel loops are relatively collapsed. The cecum is fluid
filled; however, the descending colon is relatively decompressed. Scattered
colonic diverticulosis is seen, without evidence of acute diverticulitis.The
appendix is normal. The abdominal aorta has moderate atherosclerotic
calcification without aneurysmal dilation. No significant retroperitoneal or
mesenteric lymphadenopathy is seen. Few calcified nodules in the right
lower quadrant of the abdomen represent calcified lymph nodes. There is no
intra-abdominal free fluid or air.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder and uterus
and adnexa are unremarkable. The rectum is impacted with stool. No pelvic
lymphadenopathy or free fluid is seen.
BONES AND SOFT TISSUES: No bone lesions suspicious for infection or
malignancy are detected. Healing right tenth and eleventh rib fractures are
noted. There is grade 1 anterolisthesis of L4 on L5. There are extensive
degenerative changes at the facet joints of the lumbar spine. There is mild
anterior wedge compression of L1 vertebral body.
IMPRESSION:
1. Findings consistent with small-bowel obstruction with a transition point
in the left lower quadrant of the abdomen.
2. Left lower lobe pneumonia.
3. Extensive lumbar spine degenerative changes with compression of L1
vertebral body, acuity unknown.
4. Healing right-sided rib fractures.
The findings were discussed with Dr. ___ at 3.00 a.m. on ___ via
telephone.
Radiology Report
ABDOMEN FILM ON ___
HISTORY: Intermittent abdominal pain, question free air or obstruction.
There are multiple dilated loops of small bowel measuring up to 41 mm;
however, gas is also seen in the ascending colon and stool is seen in the
splenic flexure and in the rectum. On the decubitus film there are multiple
air-fluid levels, some of which are in colon, but many of which are in small
bowel. This could either be an ileus or an early/partial SBO.
Radiology Report
INDICATION: ___ woman with past medical history of dementia,
presenting with abdominal pain, elevated lactate and fever, evaluate for
interval change of ischemic bowel versus possible bowel obstruction.
COMPARISONS: CT abdomen and pelvis with contrast from ___. Abdomen
supine and erect radiographs from ___.
TECHNIQUE: Portable supine and upright radiographs were obtained.
FINDINGS: There is a nonspecific bowel gas pattern with some air within both
the small and large bowel. Previously seen dilated loops of small bowel have
improved. There is stool within the rectum. There is no evidence of free
air. There are degenerative changes and scoliosis of the spine.
IMPRESSION: No definite ileus or obstruction, findings likely chronic.
Radiology Report
INDICATION: ___ woman with pneumonia with increased bibasilar rales.
Assess for worsening pneumonia or fluid overload.
COMPARISONS: ___.
FINDINGS: Left basal opacity compatible with known pneumonia is increased
extending into the left midlung. Accompanying increase in vascular congestion
is without overt edema. Cardiac size is stable, though silhouette is obscured
by this process.
IMPRESSION: Increase in left-sided opacities, into the left mid lung,
concerning for worsening pneumonia.
Finings were discussed by phone with ___, NP, by Dr. ___ at 1025 on
___.
Radiology Report
INDICATION: ___ woman with shortness of breath, assess for CHF.
COMPARISONS: ___.
FINDINGS: Decreased vascular congestion is accompanied by slightly decreased
left mid lung and unchanged left lower lung opacities. Lungs remain very low
in volume with small to moderate bilateral pleural effusions. Heart is poorly
assessed but appears mild to moderately enlarged with calcified aortic arch.
IMPRESSION: Decreased mild pulmonary vascular congestion with decrease in
left mid lung and unchanged left lower lung opacities compatible with known
pneumonia. Given the interval improvement, the left midlung opacity may
reflect the result of an aspiration event.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Hypoxia, AFib.
Comparison is made with prior study performed a day earlier.
There are lower lung volumes. Mild to moderate pulmonary edema has increased.
Mild lower lobe atelectasis has increased. Left perihilar and left lower lobe
opacities are grossly unchanged consistent with known pneumonia. If any there
are small bilateral pleural effusions.
Radiology Report
INDICATION: Patient with leftward gaze and altered mental status. Assess for
stroke.
COMPARISONS: None available.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images were displayed.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect, or shift
of normally midline structures. Linear area of hyperattenuation overlying the
right frontal region is likely artifactual (2A:13). There is no cerebral
edema or loss of gray-white matter differentiation to suggest an acute
ischemic event. The sulci and ventricles are prominent, likely age-related
involutional changes. Confluent hypodensities in periventricular and
subcortical white matter distribution likely reflect small vessel ischemic
disease. Focal hypodensity in left basal ganglia, represents small remote
lacunar infarct (2A:11). Basal cisterns are patent. Mild mucosal thickening
of the right anterior frontal sinuses is seen. Otherwise, imaged paranasal
sinuses and mastoid air cells are well aerated. No acute fracture is seen.
IMPRESSION:
1. No evidence of acute vascular territorial infarction. In the setting of
high clinical suspicion for acute ischemia, MRI with diffusion sequences can
be considered for further assessment.
2. Prominent sulci and ventricles, likely age-related involutional changes.
3. Small vessel ischemic disease.
Radiology Report
MR EXAMINATION OF BRAIN WITHOUT AND WITH CONTRAST, ___.
HISTORY: ___ female with frontal dementia, hypertension, and
hypothyroidism; now with new leftward gaze deviation, stroke versus seizure.
TECHNIQUE: Routine ___ enhanced MR examination, according to the "acute
seizure" protocol, comprising oblique-coronal thin-section 3D heavily
T2-weighted and dual-echo fast STIR FSE sequences, obtained orthogonal to the
long-axis of the temporal lobes, prior to contrast administration, as well as
T1-weighted axial SE and oblique-coronal MP-RAGE sequences, post-contrast
administration, the latter with sagittal and axial reformations.
FINDINGS: The study is compared with the NECT obtained roughly 16 hours
earlier.
There are scattered foci of slow diffusion in both cerebral hemispheres. This
process most markedly involves the left caudate nucleus, as well as that
putamen, with corresponding hypointensity on the ADC map and relatively faint
FLAIR-hyperintensity (___), and represents relatively acute left
basal ganglionic infarction. Also noted are scattered more punctiform foci of
slow diffusion in superficial left frontal and temporal lobar cortex, as well
as both occipital lobes, the right lateral aspect of the splenium of corpus
callosum, and the right posterior sylvian region. The widespread nature of
these abnormalities is highly suggestive of embolic infarction from a central
source.
These infarcts occur on the background of chronic small vessel ischemic
disease. There is no evidence of hemorrhagic transformation, and no intra- or
extra-axial hemorrhage, elsewhere. There is moderate prominence of the
cortical sulci and fissures, representing generalized cortical atrophy.
However, there is disproportionate ventriculomegaly; in particular, there is
relatively symmetric dilatation of the lateral ventricular temporal horns,
likely ex vacuo, with marked atrophy of the medial temporal lobes and their
hippocampal formations (best demonstrated on the dedicated oblique-coronal
sequences), in a pattern suggestive of underlying Alzheimer disease.
Incidentally noted is likely "coarctation" of the frontal horn of the right
lateral ventricle, a congenital variant. There is no pathologic parenchymal,
leptomeningeal or dural focus of enhancement. The principal intracranial
vascular flow-voids, including those of the dural venous sinuses, are
preserved and these structures enhance normally.
IMPRESSION:
1. Extensive relatively acute infarction involving the left deep gray matter
structures, including the caudate and lentiform nuclei, likely accounting for
the acute presentation.
2. Numerous additional more punctate infarcts scattered throughout both
cerebral hemispheres, including in the posterior circulation territory. The
overall appearance is suggestive of "embolic shower" from a central source,
with which should be correlated with clinical information.
3. No evidence of hemorrhage.
4. No space-occupying lesion or pathologic enhancement.
5. Disproportionate medial temporal atrophy, compared to the degree of global
volume loss, raising the possibility of underlying Alzheimer disease, which
should also be correlated with clinical information.
Radiology Report
PORTABLE AP CHEST FILM, ___ AT 1:45 A.M.
CLINICAL INDICATION: ___ with question CVA and atrial fibrillation.
Recent Dobbhoff placement.
Comparison is made to the patient's previous studies dated ___ at 23:27.
Portable semi-erect chest film, ___ at 1:45 a.m. is submitted.
IMPRESSION:
1. Interval placement of a Dobbhoff feeding tube which courses below the
diaphragm and the tip projects over the expected location of the stomach.
Lung volumes remain low and there is bilateral airspace process, most likely
representing worsening pulmonary edema. In addition, bibasilar opacities
likely reflect compressive atelectasis in the setting of layering effusions,
although bibasilar pneumonia cannot be entirely excluded. Mediastinal
contours are likely unchanged given differences in patient positioning and
technique between studies. No pneumothorax.
Radiology Report
INDICATION: ___ woman initially admitted with small-bowel obstruction
complicated by AFib and stroke, now with leukocytosis, assess for interval
change.
COMPARISONS: ___.
Dobbhoff tube courses into the stomach and out of view. Moderate pulmonary
edema and right greater than left basal pleural effusions and atelectasis
persist. These could easily hide a developing pneumonia. Cardiomediastinum
is not well assessed.
Radiology Report
INDICATION: Evaluate for interval change in pulmonary edema and pleural
effusion in a patient with embolic CVA.
TECHNIQUE: Series of radiographs dating back to ___, most recently
from ___.
FINDINGS: A portable AP radiograph of the chest demonstrates persistent mild
pulmonary edema, moderate right pleural effusion, and small left pleural
effusion. There is no significant change from yesterday. Atelectasis of the
left lower lobe persists. Heart size is difficult to assess, but the hilar
and mediastinal contours are unchanged. Tortuosity of the aorta as well as
atherosclerotic calcifications in the aortic arch are unchanged. A Dobbhoff
feeding tube seen coursing into the stomach, terminating at or just beyond the
pylorus. There is no pneumothorax.
IMPRESSION: Persistent decompensated congestive heart failure with mild
pulmonary edema, moderate right and small left pleural effusions.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Dobbhoff placement, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, tip of the Dobbhoff
catheter projects over the middle parts of the stomach. The catheter could be
advanced by approximately 5-7 cm.
Otherwise, taking into account different projection, the radiographic
appearance is unchanged. No evidence of complications, notably no
pneumothorax.
Radiology Report
INDICATION: Persistent encephalopathy, with as yet negative workup.
PROCEDURE: Attempted fluoroscopically-guided lumbar puncture.
PHYSICIANS: Dr. ___ Dr. ___
___: 1% lidocaine.
PROCEDURAL DETAILS AND FINDINGS: Prior to the procedure, informed consent was
obtained via telephone from the patient's daughter who demonstrated good
understanding of the indication, risks, benefits and alternatives. A
preprocedural timeout was performed in the fluoroscopy suite per standard
___ protocol. The patient was placed in the prone position on the
fluoroscopy table. After selecting an appropriate interspinous level, using
fluoroscopy, the patient was anesthetized using 1% lidocaine. Thereafter,
numerous attempts were made at multiple levels to advance a 22-gauge spinal
needle, all of which were unsuccessful related to extensive degenerative
change at the level of the spinous processes (and a morphology consistent with
Baastrup). Attempts at oblique needle orientation were also unsuccessful.
The spinal needles were removed, and good hemostasis was achieved. The
patient was transferred in stable condition from the fluoroscopy suite.
IMPRESSION:
1. Unsuccessful fluoroscopically-guided lumbar puncture attempts, likely
related to extensive degenerative changes in the lumbar spine as above.
2. Recommend further evaluation of the lumbar spine via a non-contrast spine
CT, in order to assess for any possible access route for a lumbar puncture.
These results and recommendations were discussed via telephone by Dr. ___
with Dr. ___ from the neurology service at 3:15 p.m. on ___.
Radiology Report
INDICATION: ___ woman with dementia and multiple medical problems
with recent embolic strokes from atrial fibrillation and new sluggish pupil on
the left, evaluate for new stroke.
COMPARISON: ___.
TECHNIQUE: Contiguous axial images were obtained through the brain without
the administration of IV contrast.
FINDINGS: There is no evidence of acute intracranial hemorrhage, discrete
masses, mass effect or shift of normally midline structures. Hypoattenuation
within the left corona radiata extending into the left caudate head and
possibly the left putamen appears more evolved since the most recent prior
examination ___ and likely represents a subacute infarct.
Lacunes are noted within the left lenticulostriate region.
The ventricles and sulci appear prominent consistent with age-related
involutional changes. Periventricular and subcortical low-attenuating regions
appear consistent with sequelae of chronic small vessel ischemic disease.
Mucosal thickening is noted within the left maxillary sinus. The orbits and
conus are symmetric.
IMPRESSION:
1. Low-attenuating region within the left corona radiata extending into the
left caudate head and possibly the left putamen appears better evolved than
___ and is concerning for subacute infarction.
2. Lacunes in the left striatocapsular region are unchanged since the prior
examination.
3. Left maxillary sinus disease.
Please note MRI is more sensitive for the detection of acute infarction and
should be considered in the correct clinical setting if there is no
contraindication to the use of MRI. Dr. ___ was paged at 11:15 a.m. at the
time of discovery of critical findings on ___. Contact was made with
Dr. ___ at 11:54am on ___ and findings were communicated by Dr.
___ telephone.
Radiology Report
AP CHEST X-RAY
INDICATION: Recent stroke, NG tube placement.
COMPARISON: ___.
FINDINGS: The NG tube is in good position in the distal stomach. Stability
of the surelevation of the right hemidiaphragm with small pleural effusion.
Stable left lower lobe atelectasis. Stability of the proeminence of the
vessels that could be compatible with light volume overload. Mediastinal and
cardiac contours normal.
CONCLUSION: The NG tube is in good position.
Radiology Report
INDICATION: ___ woman with recent CVAs and PEG placement, now with
abdominal pain.
COMPARISON: Comparison is made with abdominal radiograph from ___
and CT abdomen and pelvis from ___.
FINDINGS: Two supine images of the abdomen show a nonspecific bowel gas
pattern. Recently placed PEG tube is visualized. There are several round and
oval calcifications visualized in the right lower quadrant. These were
previously identified on CT scan and likely represent calcified lymph nodes.
Visualized osseous structures are unremarkable.
IMPRESSION: Nonspecific bowel gas pattern with no evidence of bowel
obstruction.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: FEVERS
Diagnosed with INTESTINAL OBSTRUCT NOS, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 98.6
heartrate: 99.0
resprate: 16.0
o2sat: 96.0
sbp: 137.0
dbp: 69.0
level of pain: 13
level of acuity: 3.0 | TRANSITIONAL ISSUE:
[ ] Monitor INR and adjust coumadin dosing as needed
[ ] Post stroke rehab
====================
Mrs. ___ is a ___ y/o F with PMH of dementia, hypothyroidism,
and hypertension who was admitted from ___ (lives
there as long term care) with abdominal pain and fever. She was
found to have an SBO and LLL infiltrate concerning for pneumonia
on CT of her abdomen/pelvis in the ER so she was initially
admitted to ___. She was conservatively managed with improvement
in her abdominal pain. As her SBO resolved, she was transferred
to medicine service for management of her pneumonia and
delirium. She developed afib with RVR and hypertension and was
transferred to MICU for diltiazem gtt for her rate control and
was converted back to sinus rhythm. In MICU, she was noted to
have persistent left gaze and somnolence, so neurology was
consulted. Her CT did not show an acute process but her MRI did
show L sided acute infarcts, which was thought to be from
thromboembolic source associated with her paroxysmal afib and
conversion to sinus. Her TTE did not show an atrial thrombus.
She was started on anticoagulation with heparin gtt and bridged
to coumadin. She was called out to the neurology floor and was
monitored. Keppra was initially started given concern for
seizures, but as her long term EEG monitoring only epileptiform
discharges and no electrographic seizures, it was discontinued.
Unfortunately, her neurologic status did not improve much after
her stroke and as she was unable to pass speech/swallow
evaluation, PEG tube was placed. Coumadin was restarted after
PEG tube placement.
# NEURO: Patient with baseline dementia and living at dementia
unit, but during this hospitalization developed small embolic
infarcts L>R, likely from paroxysmal atrial fibrillation.
Embolic infarcts were found when patient developed persistent
left gaze and R sided weakness, CT head did not show an acute
stroke but her MRI did show multiple small embolic infarcts,
L>R. She was started on heparin gtt and bridged to coumadin.
Patient had residual right sided spastic hemiparesis, no speech
output and could not follow commands. Given these neurologic
deficits, she failed speech and swallow evaluation multiple
times. Given the poor mental status and leukocytosis during this
hospitalization, lumbar puncture was considered and her
anticoagulation was reversed and patient started on heparin gtt
for LP. Both the attempt on the floor and ___ guided LP were
unsuccessful, and as leukocytosis resolved without any
antibiotics, no further attempt at LP were made. While she was
on heparin gtt, PEG tube was placed and patient was restarted on
coumadin. As she had been in sinus rhythm since transfer from
the ICU with heparin gtt on board, heparin was discontinued and
only coumadin was continued. Patient will require INR follow up
and ___ rehabilitation in hopes of improving her
functional status.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) No
-> patient developed stroke more than 2 days into the
hospitalization, but heparin started within 2 days of diagnosis
of new stroke.
4. LDL documented? (x) Yes (LDL = 75) - () No
5. Intensive statin therapy administered? Not applicable, LDL =
75 (for LDL > 100) () Yes - (x) No (if LDL >100, Reason Not
Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - (x) unable to participate)
7. Stroke education given? () Yes (to family) - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No (LDL <100)
10. Discharged on antithrombotic therapy? (x) Yes (Type: ()
Antiplatelet - (x) Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
# CV: Patient developed atrial fibrillation with RVR on the
medicine service and was transferred to MICU for diltiazem gtt.
Her heart rhythm converted to sinus after diltiazem gtt was
started and remained in sinus. Her blood pressure initially
remained elevated but came down. Patient appeared volume
overloaded so she was diuresed with IV and then PO furosemide.
Her anticoagulation was managed as above.
# Pulm: Prior to transfer to the ICU, patient became hypoxic,
requiring supplemental O2. Thought to be due to acute pulmonary
congestion from volume overload. Respiratory status improved
with diuresis and she remained 93-96% on RA.
# ID: Patient with ? of LLL pneumonia on abdomen/pelvis CT on
admission. However, patient did not have leukocytosis or fevers
at that time. She was empirically treated with vanc/cefepime and
flagyl for healthcare associated pneumonia with possible
component of aspiration pneumonia. However, the antibiotics were
stopped as her respiratory status improved with diuresis. Later
during the hospitalization, patient did develop leukocytosis to
22, and another infectious work up was done with UA/UCx (yeast),
CXR (largely unchanged, still with bilateral pleural fluids and
atelectasis), c diff toxin and blood cultures, which were
otherwise negative. Patient's zoster was treated with 5 day
course of PO acyclovir. LP was also attempted without success
both by the floor team and also by ___. As patient's leukocytosis
resolved on its own without antibiotics and remained normal, no
further infectious work up was undertaken.
# GI: After her PEG placement, patient would wince with
abdominal exam, but otherwise comfortable. No peritoneal signs
and soft abdomen. This was thought to be due to recent procedure
and patient was given tylenol with improvement.
# Endo: Continued on levothyroxine for hypothyroidism.
# FEN: Patient unable to pass speech and swallow test after her
stroke, and underwent PEG placement on ___. Tube feed
started through PEG with residuals ranging from ___ cc, but
now tube feed at goal without issues.
# Contact: daughter ___ is HCP, cell ___
# Code status: DNR/DNI, confirmed with daughter |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceclor / Codeine / Sulfa (Sulfonamide Antibiotics)
/ Vicodin / Tape ___ / aspartame / red wine vinigar
Attending: ___
Chief Complaint:
neck pain, fever
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
HISTORY OF PRESENT ILLNESS ___, 4 HPI or status of 3
chronic)
Mrs ___ is a pleasant ___ with who presented to ___ ED
earlier today with neck pain, headache and fever to 101.3.
Patient states that the neck pain started 2 days ago and she
attributed it to sleeping on it the wrong way. Initially it was
on the L side of her neck, but then moved to the middle of her
neck. Then, this morning, she woke up with horrible HA, chills
and fever. No other localizing symptoms of infection including
cough, worsening abd pain, diarrhea, dysuria frequency. She was
initially seen at ___ where an LP was attempted multiple
times without success, therefore she was transferred here for ___
guided LP. Prior to transfer she was given vancomycin and
tylenol, which improved her HA. Has history of allergy to pcn
and cephalosporins.
In the ED, initial vs were pain score 3 99.2 72 143/75 14 97%
ra. Patient was given morphine, ketorolac, ID was consulted and
recommended vancomycin, meropenem and acyclovir. Vitals on
transfer were pain score 7 99.8 80 141/54 16 100%.
On the floor, neck pain currently ___, also back pain at LP
site is ___. Pt c/o diffuse, mild abd pain which is at ___ and
also states that she hasn't eaten all day which may be
contributing to her sxs. She had one episode of vomiting on
arrival to 12 R, however she states that this has been occuring
every other day since ___ and has been attributed to her
esophageal hernia. She denies vision changes or focal
neurologic symptoms.
Review of sytems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies diarrhea, constipation. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
ANGIOEDEMA ARTHRITIS
BREAST CANCER
HYPERLIPIDEMIA
HYPOTHYROIDISM
SMALL BOWEL OBSTRUCTION
LEFT MASTECTOMY
BREAST REDUCTION
FIBROMYALGIA
URINARY INCONTINENCE
ESOPHAGEAL HERNIA
h/o crypptococcal pneumonia ___ years ago
Social History:
___
Family History:
Mother with Lung CA, Father with bladder CA, CV disease, sister
with breast and thyroid CA. Denies tobacco, illicits.
Physical Exam:
Vitals: T:98.9 BP:138/70 P:75 R:18 O2:95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: pain with movement, stiffness with chin to chest
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild, diffuse tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Skin: no lesions or ecchymoses
Neuro: aaox3. CNs ___ intact. Strength and sensation grossly
intact
Psych: pleasant, appropriate
Pertinent Results:
BIN labs reviewed and were unremarkable.
MICRO (___): Blood cxs x2 NGTD
STUDIES:
___LINICAL HISTORY: ___ female with headache and neck
pain.
TECHNIQUE: Contiguous axial MDCT images were obtained
through the
brain without administration of IV contrast. Reformatted
coronal and
sagittal images were acquired.
COMPARISON: None.
FINDINGS:
There is no evidence of 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. The visualized paranasal
sinuses, mastoid
air cells, and middle ear cavities are clear. The globes
are intact.
IMPRESSION:
NO EVIDENCE OF ACUTE INTRACRANIAL PROCESS.
___
CHEST:
CLINICAL HISTORY: Fever, headache, pain.
Two views. Comparison with ___. The lungs remain
clear. There
is a rounded density projected behind the heart consistent
with a
moderate hiatal hernia. Surgical clips are projected in
the
mediastinum. The aorta is mildly tortuous. Mediastinal
structures
are otherwise unremarkable. The heart is normal in size.
The bony
thorax is grossly intact. Compared with the previous study,
the hiatal
hernia is newly apparent.
IMPRESSION:
HIATAL HERNIA. SURGICAL CLIPS PROJECTED IN THE MEDIASTINUM.
___ 10:56 am CSF;SPINAL FLUID Source: LP.
ADD-ON REQUEST FOR CRYTOCOCCAL ANTIGEN AND FUNGAL FROM
___
ON ___ @1356.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
Results should be evaluated in light of culture results
and clinical
presentation.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
HSV PCR negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamoxifen Citrate 20 mg PO DAILY
2. Albuterol Inhaler 1 PUFF IH BID:PRN sob
3. Atenolol 50 mg PO DAILY
4. estradiol *NF* 10 mcg Vaginal q week
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Rosuvastatin Calcium 5 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. ZYRtec *NF* 10 mg Oral daily
10. Omeprazole 20 mg PO DAILY
11. ClonazePAM 0.5 mg PO QHS
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. ClonazePAM 0.5 mg PO QHS
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Rosuvastatin Calcium 5 mg PO DAILY
7. Tamoxifen Citrate 20 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. ZYRtec *NF* 10 mg Oral daily
10. Albuterol Inhaler 1 PUFF IH BID:PRN sob
11. estradiol *NF* 10 mcg Vaginal q week
12. lactobacillus combination no.4 *NF* 0 dose ORAL DAILY
13. Prochlorperazine ___ mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg ___ tablet(s) by mouth
every six (6) hours Disp #*15 Tablet Refills:*0
14. Acetaminophen 500 mg PO Q6H:PRN pain/headache
Up to a maximum of 3 grams a day (6 extra-strength 500 mg
tablets from over the counter)
Discharge Disposition:
Home
Discharge Diagnosis:
Aseptic meningitis
Secondary:
hiatal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ year old woman with multiple failed bedside LP attempts, headache
and fever, rule out meningitis.
COMPARISON: None.
PROCEDURE:
Clinical assessment was performed. Informed consent was obtained from the
patient. The patient was brought to the angiography suite and positioned
prone on the table. The lower back was prepped and draped in the usual
sterile fashion. Under fluoroscopic guidance, the L3-L4 level was initially
selected for lumbar puncture, but attempts to access teh thecal space at this
level were unsuccessful. Therefore, the L2-L3 level was then selected under
fluoroscopy. 1% lidocaine was administered at the L2-L3 level for local
anesthesia. A 22 gauge spinal needle was advanced into the thecal sac under
fluoroscopic guidance at L2-L3. Fluoroscopic images were acquired confirming
the needle position. Approximately 12 mL of clear colorless CSF was collected
and sent to the laboratory for analysis as requested by the referring clinical
team. The needle was removed. Sterile dressing was applied. The patient
tolerated the procedure well and there was no immediate complication.
FINDINGS:
Uncomplicated lumbar puncture at L2-L3, with 12 mL of CSF collected.
IMPRESSION:
Uncomplicated lumbar puncture at L2-L3, with 12 mL of CSF collected and sent
to the laboratory for analysis as requested by the referring clinical team.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: TRANSFER R/O MENINGITIS
Diagnosed with HEADACHE, CERVICALGIA
temperature: 99.2
heartrate: 72.0
resprate: 14.0
o2sat: 97.0
sbp: 143.0
dbp: 75.0
level of pain: 3
level of acuity: 3.0 | ___ yo F transferred from ___ for ___ guided LP given concern for
meningitis and inability to perform bedside LP.
# Aseptic meningitis: There was initial concern for bacterial
meningitis given fever, neck stiffness and headache. Lumbar
puncture was attempted in the ER of ___. This was
unsuccessful, so the patient was started on vancomycin and
meropenem and acyclovir and transferred for ___ LP. LP
here was unremarkable, and antibiotics were stopped. As the
patient had a distant history of cryptococcal pneumonia,
cryptococcal ag was checked in CSF and was negative. Acyclovir
was continued until HSV PCR returned negative. Symptoms
improved with tylenol and brief ketorolac, though she feels that
her headache character has changed and may be post-LP headache.
#Nausea: Unclear if this is related to her hiatal hernia (she
reported some intermittent nausea in the past ___ months) or
meningitis presentation. Her abdominal exam was benign. She
had some relief with ondansetron prn here and requested short
outpt Rx, but due to difficulty with insurance coverage she was
given a Rx for compazine po prn instead.
# Hiatal hernia: Motility study was rescheduled in preparation
for anticipated hiatal surgery next month.
# Hypothyroidism: Continued levothyroxine
# Hx breast CA: Continued tamoxifen
# asthma: Continued albuterol PRN
# HTN: Continued atenolol
# HLD: Continued rosuvastatin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with angioplasty
History of Present Illness:
___ history of hypertension, hyperlipidemia, recent
hospitalization for NSTEMI with acute systolic CHF that is
transferred to ___ for c. cath.
Patient was recently admitted from ___ to ___ at
___ for acute on chronic systolic congestive heart
failure, acute coronary syndrome s/p NSTEMI with intermittent
short runs of atrial fibrillation.
Per ___ discharge summaries, the patient was complaining of
mid-upper back pain for 6 months on admission most recently
complicated by shortness of breath and diaphoresis. She was
found to have acute pulmonary edema as well as acute coronary
syndrome. She was admitted to the ICU for further treatment.
In the ICU, she was treated for acute on chronic decompensated
systolic congestive heart failure with pulmonary edema. She was
diuresed with lasix approximately 4 L net negative. Her pOx was
90 % on 2 L NC, and weaning of O2 failed. She would drop to pOx
87 % at rest. She was continued on lasix in addition to
spironolactone on discharge.
Patient also experienced NSTEMI with maximum troponin of 0.176.
She was started on a heparin infusion. The family decided
against intervention and favored medical management at the time.
She was also noted to have anemia with a Hct drop by 9 points
with discontinuation of heparin. She was also treated with a
nitroglycerin infusion to treat recurrent chest pain. Stool
guiaics were negative. She was given one unit of pRBC with
discharge Hct of 36.7.
She was placed on aspirin, plavix, and a statin. She was also
discharged on lisionpril as well and a small dose of
beta-blocker.
The patient was evaluated by Cardiology, Dr. ___ on
___ for
intermittent and atrial fibrillation. No need for treatment was
recommended. Heart rate is well controlled. The patient will
follow up as an outpatient with both primary care physician and
___.
Echocardiogram showed hypokinesis in the mid anterolateral wall,
the distal lateral wall and the apex. Ejection fraction was
approximately 45%.
The patient weight on discharge was 112 pounds (___), which
seems to be her baseline.
Patient was brought in by ambulance to ___ today for chest
pain. Initial VS were 97.0 HR: 90 BP: 145/85 Resp: 17 O(2)Sat:
94 Low. She reported intermittent chest pain for the last week
and was discharged from ___ as above. Yesterday, her pain
returned with ___ episodes of chest pain occuring at rest. This
morning while she was walking back from the bathroom very
slowly, the pain returned and it had been persistent since that
time. Initial troponin was 0.046.
Impression was that patient was presenting with her typical
anginal symptoms but that they were not occurring at rest and
with minimal exertion. ECG (not available for review, per
reports ST-depressions primarily in V3-V6 that resolved. )
showed ST depressions while having pain (distribution unknown).
She was given aspirin, NTG, heparin. It was discussed that
intervention was advisable, and patient was transferred to
___.
Initial VS on arrival were HR 67 RR 14 BP 127/62 pOx 94 on 3 L.
Pain was ___. She arrived on heparin insuion at 700 units and
nitroglycerin infusion at 20 mcgs down to 14 mcgs at admission.
Per reports, there were new ST depressions in I, aVL, and V3-V6.
Patient was pain free. CXR was performed showing moderate
pulmonary edema.
She was taken to the ___. cath lab on arrival.
C. cath with left radial approach showed 99 % distal left main
into the proximal LAD. LAD was 99 % at origin followed by
proximal 60 % involving D1. LCx had ostial occlusion.
Collaterals fill a diseased OM1 and OM2 from RCA. RCA had mild
luminal irregularties. Left subclavian was ___ % at origin.
BMS x 2 was performed to left main/proximal LAD.
During the procedure, she had transient hypotension while
catheter was in the RCA, which could have represented ?
dampening on the catheter while in RCA - which resolved within
30 seconds. She also had bradycardia while in RCA, which
resolved within 30 seconds. It was favored that this was
probably catheter induced.
After procedure, patient had a small amount of chest pain that
was improved from pre-procedure chest pain. She was sent to the
CCU with nitroglycerin infusion. She was given ASA 325 mg PO x 1
and plavix 75 mg PO x 1. Heparin infusion was discontinued at 1
___.
On arrival to CCU, CCU team met with patient and family. Per
family, patient not complaining of any chest discomfort but does
feel slightly "faint."
.
On review of systems, patient unable to provide comprehensive
review of systems. She denies any chest pain.
.
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:
- Acute-on-chronic systolic congestive heart failure.
- Recent Acute coronary syndrome, status post non-ST elevation
myocardial infarction.
- History of paroxysmal atrial fibrillation.
- Anemia.
- Poor functional status.
- Hypertension
- Arthritis
- Hypothyroidism
- Hyperlipidemia
- Fasting glucose intolerance based on A1c 6.2 on ___
PAST SURGICAL HISTORY:
- Hysterectomy
Social History:
___
Family History:
Mother: Unknown history
Father: Unknown history
___: She has one sister who died at age ___
Children: Three children, two sons and one daughter. Her
daughter developed arthritis in her mid ___
Physical Exam:
General: No acute distress,
HEENT: PERRL, MMM, OP clear, sclera anicteric
Cardio: RRR, nl s1s2, no m/r/g
Resp: Clear b/l.
Abdominal: soft, non-tender
Extremities: WWP, no edema
Pertinent Results:
___ ECHO
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with severe hypokinesis of the basal half
of the inferolateral wall and mild dyskinesis of the distal
inferior wall. The remaining segments contract normally (LVEF =
45-50 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). 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. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild to moderate (___) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation. Pulmonary artery
hypertension. Increased PCWP.
___ CARDIAC CATH
Patient brought urgently to the cath lab given rest angina in
the
holding area despite maximal medical therapy. She had chest
pain
ongoing at the time of arrival to the catheterization
laboratory.
Subclavian angiography performed during entry due to difficulty
advancing the guide wire to the ascending aorta. This revealed
an origin 70-80% stenosis. An angled glide wire was advanced
past the blockage and into the ascending aorta easily. A 6
___ JL3.5 guide provided good support. A ChoICE ___ XS wire
was advanced into the diagonal and the lesion was predilated
with
a 2.0 balloon which improved chest pain symptoms. The ChoICE ___
XS Wire was redirected into the distal LAD. A 3.5 x 12 mm
Integriti stent was deployed and a more distal overlapping 2.5 x
18 mm Integriti stent. The Proximal portion of the distal stent
and the 3.5 mm stent were postdilated with a 3.5 mm balloon.
The
distal portion of the proximal stent was postdilated with a 4.0
mm balloon. Final angiography revealed normal flow, no
dissection and 0% residual stenosis in the stent. The patient
tolerated the procedure well and left the laboratory in stable
condition with almost complete relief of her chest pain.
___ 07:10AM BLOOD WBC-9.0 RBC-3.91* Hgb-10.8* Hct-34.5*
MCV-88 MCH-27.7 MCHC-31.4 RDW-14.6 Plt ___
___ 06:31AM BLOOD ___ PTT-27.1 ___
___ 07:10AM BLOOD Glucose-100 UreaN-9 Creat-0.7 Na-125*
K-4.6 Cl-93* HCO3-24 AnGap-13
___ 06:31AM BLOOD CK-MB-4 cTropnT-0.07*
___ 09:50PM BLOOD CK-MB-3 cTropnT-0.07*
___ 11:10AM BLOOD cTropnT-0.04*
Medications on Admission:
- Spironolactone 12.5 mg p.o. daily.
- Lasix 20 mg p.o. daily.
- Tylenol ___ mg p.o. 3 times daily.
- Metoprolol 12.5 mg p.o. twice daily.
- Plavix 75 mg p.o. daily.
- Aspirin 325 mg p.o. daily.
- Zocor 20 mg p.o. daily.
- Lisinopril 10 mg p.o. daily.
- Tramadol p.r.n.
- Calcium with vitamin D, one combo tab p.o. twice daily.
- Multivitamin 1 tablet p.o. daily.
- Conjugated Premarin cream twice daily.
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*0*
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. lisinopril 10 mg Tablet Sig: 0.5 Tablet PO once a day: until
you follow-up with your primary doctor.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months: with meals.
Disp:*60 Tablet(s)* Refills:*0*
7. calcium carbonate-vitamin D3 Oral
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Outpatient Lab Work
Please obtain chemistry panel including BUN/Cr on ___
___ and have the results sent to ___, MD
___
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
TO START 1 MONTH AFTER 200mg BID.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Myocardial infarction
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with CHF on nitro, question of abnormality.
COMPARISON: None available.
FINDINGS: One AP portable view of the chest. There is evidence of
mild-to-moderate pulmonary edema. There is moderate cardiomegaly. No focal
consolidation concerning for pneumonia. No pneumothorax. No large pleural
effusions. The cardiac, mediastinal and hilar contours are normal. There is
diffuse osteopenia in the bones.
IMPRESSION: Mild-to-moderate pulmonary edema. Moderate cardiomegaly.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: USA
Diagnosed with INTERMED CORONARY SYND, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: nan
heartrate: 70.0
resprate: 10.0
o2sat: 96.0
sbp: 120.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | ___ female with h/o HTN, HLD, recent NSTEMI, and sCHF (45-50%)
presented to ___ with UA, transferred for c. cath
showing significant left main and LAD disease s/p BMSx2 with
transient hypotension/bradycardia during procedure attributed to
catheter placement.
.
# CAD
Patient had NSTEMI that was medically managed a week prior to
admission. She presented again with chest pain consistent with
unstable angina, associated with ECG changes and borderline
cardiac biomarkers. She was started on heparin and
nitroglycerin infusion and transferred to ___. After
discussions with her family, a cardiac catheterization was
performed revealing significant left main and LAD disease. Two
BMS were placed in the left circumflex ostial occlusion with
collaterals. The patient had transient hypotension/bradycardiac
during her procedure attributed to catheter placement. She was
monitored in the CCU after and her vital signs remained stable.
She is to continue ASA 325 mg indefinitely and will require
plavix 75 mg daily for at least 1 month, but preferably for 12
months. She was continued on metoprolol with a goal heart rate
of 60-70. She was also continued on lisinopril and started on
atorvastatin for optimal medical management. She remained chest
pain free during her stay.
.
# Acute on chronic systolic heart failure (Most recent EF
45-50%)
Pt was recently discharged from ___ with a documented
weight of 112 lbs (50.9 kg). She had recently been started on
lasix, lisinopril and spironolactone. She did not appear
overtly fluid overloaded on admission, and her admission weight
was 107.8 lbs (49 kgs). Her admission CXR revealed some
evidence of mild-moderate pulmonary edema, which may reflect
diastolic dysfunction from demand ischemia. Her I/O were
monitoered and she was weighed daily. Lasix and spironoloactone
were held. A repeat TTE revealed Normal left ventricular cavity
size with mild regional systolic dysfunction c/w CAD (PDA
distribution).
.
# RHYTHM:
The patient has known paroxysmal AF, but was in NSR upon
admission. The morning of ___, she was noted to be in atrial
fibrillation with rapid ventricular response. She was
hemodynamically stable. She was given metoprolol 5 mg IV x2
with out a significant drop in her heart rate. She was then
loaded with amiodarone (initially IV, later transitioned to po
when she converted back to sinus). She remained in NSR
throughout the rest of her hospital course and is to continue on
amiodarone upon discharge.
.
# Hyponatremia
The patient's admission Na was 127, and initially thought to be
secondary to intravascular volume depletion with non-osmotic
release of ADH given active usage of diuretic regimen.
Her sodium continued to trend down. Urine electrolytes were
consistent with diuresis leading to hyponatremia.
Her fluids were restricted and she was given small boluses of
IVF given likely hypovolemia. Her sodium stabilized to 125.
.
# HTN
The patient was continued on her home metoprolol and lisinopril.
As above, her furosemide and spironolactone here held. She
remained normotensive throughout her CCU and floor stay.
.
# HLD
Her most recent lipid panel (___) revealed good lipid
control (chol 134, ___ 57, HDL 71, LDL 43). She was continued on
atorvastatin 80 mg given her ACS.
.
# Left subclavian stenosis
Her BP was monitored on her right arm. This should be monitored
as an outpatient.
.
# History of fasting glucose intolerance
Her most recent HbA1c was 6.2 on ___. Her morning glucose
ranged from 100-140s on average. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Ceftin / Erythromycin Base / Levaquin / Famvir /
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Weight loss and odonyphagia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ female with history of hypothyroidism, fibromyalgia,
depression, admitted with ongoing weight loss, malaise and
odynophagia.
.
Pt is somewhat tangential so story is difficult to piece
together, but she reports that from ___, pt lost
about 40 pounds, which she attributed initially to intentional
weight loss but then to poorly controlled depression and
decreased appetite. Her mood improved and she had been doing
well until ___, when she began losing weight again. Her
odynophagia is worse with solids than with liquids, and the
patient describes a feeling of 'thick mucous' and 'things
catching' in the back of her throat. Recently, she reports
weight loss of 5 pounds between ___ and today, which
prompted her presentation to the ED this evening. Currently, she
weighs around 100 pounds, baseline weight is 160. Pt also
reports multiple other symptoms, including shingles outbreak in
___ involving nose, right forehead and ear, with ongoing
right ear pain for which she saw an ENT physician on ___.
She had been taking prednisone for post herpetic neuralgia and
valtrex ___ mg TID until ___, when it was discontinued by
ENT. She reports that ENT recommended Famvir, but she reports an
allergy to Famvir and has not started taking this yet. She
describes some pain radiating from her right ear along her jaw
in the V3 distribution.
.
She also has recurrent HSV lesions in her mouth, which has been
causing her increasing tongue pain and pain with swallowing. She
has been using Benadryl and Kaopectate mouth wash with some
improvement in her pain. She also reports difficulty swallowing,
which has been progressive over the past several weeks, now with
difficulty swallowing pills and frequent choking when trying to
swallow water.
.
The patient's depression has been worsening over the ___ due
to many losses in her family and her partner's family. She
reports significant stressors in her life including her
partner's mother's illness and a neice with a high risk
pregnancy. She has been unable to work for several years and
feels that since leaving her job her healthcare providers have
been taking her concerns less seriously. Her appetite has been
poor but she has been trying to increase her PO intake and has
been taking Carnation Instant Breakfast supplementation with
ongoing weight loss.
.
She reports many ongoing symptoms including chronic fatigue and
weakness, sore throat, cervical lymphadenopathy and cough
productive of clear sputum, no blood. Cough is associated with
some shortness of breath. She has not had any known fevers but
has been having night sweats (previously had intermittent night
sweats from menopause but these recent night sweats are
significantly different). She denies any abdominal pain,
occasional nausea but no vomiting, constipation or diarrhea, no
melena or BRBPR, no pedal edema. She does have chronic headaches
located over her right eye, also intermittent palpitations. She
also reports chest discomfort consistent with her fibromyalgia,
no recent changes. She reports some lightheadedness and a
history of POTS.
.
In the ED, initial VS were: 99.2 78 126/106 15 99%. Pt had CXR
with no acute process per my read. Labs were mainly
unremarkable. HIV and TSH sent, blood cultures and throat swab
pending. VS on transfer:98.6 67 111/57 20 95%.
.
On the floor, pt reports feeling very tired. She is tearful and
blames herself for not seeking care sooner. She is requesting
frequent reassurance that she is going to be ok.
Past Medical History:
# depression
# recurrent HSV with herpetic neuropathy
# fibromyalgia
# hypothyroidism
# chronic fatigue syndrome
# headaches
# vit D deficiency
Social History:
___
Family History:
M: died at ___ from breast cancer
uncle: ___ with leukemia in ___, still living
MGF: died of leukemia at ___
F: died at ___, unknown cause
PGF: died of brain cancer
Sister: died at ___ from drug overdose, hx IVDU
no family history of colon cancer
Physical Exam:
Exam on Admission:
VS: 98 109/65 81 16 98% RA
GENERAL: chronically ill appearing, extremely cachectic with
temporal wasting
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, no sinus
tenderness, no zoster lesions, no lesions in nose, TM clear,
ulcerated lesion under tongue on left, no other oropharyngeal
lesions, no tonsillar erythema or exudates
NECK: supple, tender anterior cervical lymphadenopathy on left
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses, no hepatosplenomegaly
EXTREMITIES: trace edema to ankles, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Exam on Discharge:
VS T98.1 BP 101-109/60s HR 71 RR 16 SpO2 99% on RA
GEN Alert, oriented, no acute distress, teary multiple times
HEENT tongue coated with whitish/yellow, no oral lesions
visible, sclerae anicteric, moist mucous membranes, no rash or
elsions apparent on face; payient able to swallow pill and water
with difficulty but without aspiration
NECK supple, no JVD, tender bilateral cervical lymphadenopathy,
no suprclavicular nodes, no thyromegaly or thyroid lesions
BREAST no masses or visible lesions
PULM Good aeration, CTAB, no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, non-tender, non-distended
EXT warm and well-perfused, 2+ pulses palpable bilaterally
radial and DP, no edema, BLE tender to palpation
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Labs:
___ 08:25PM BLOOD WBC-4.1 RBC-3.64* Hgb-12.7 Hct-38.3
MCV-105* MCH-34.9* MCHC-33.1 RDW-14.6 Plt ___
___ 07:52AM BLOOD WBC-3.5* RBC-3.68* Hgb-13.3 Hct-39.3
MCV-107* MCH-36.2* MCHC-33.9 RDW-15.2 Plt ___
___ 08:05AM BLOOD WBC-3.0* RBC-3.91* Hgb-13.4 Hct-41.2
MCV-105* MCH-34.3* MCHC-32.6 RDW-14.2 Plt ___
___ 08:25PM BLOOD ___ PTT-29.3 ___
___ 07:52AM BLOOD ESR-7
___ 07:52AM BLOOD CRP-0.5
___ 08:25PM BLOOD Glucose-103* UreaN-21* Creat-0.7 Na-143
K-3.9 Cl-105 HCO3-31 AnGap-11
___ 07:52AM BLOOD Glucose-96 UreaN-15 Creat-0.6 Na-144
K-4.0 Cl-106 HCO3-29 AnGap-13
___ 08:05AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-144
K-4.1 Cl-106 HCO3-30 AnGap-12
___ 08:25PM BLOOD ALT-15 AST-17 LD(LDH)-151 AlkPhos-46
TotBili-0.2
___ 08:25PM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.9*# Mg-2.2
___ 07:52AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1
___ 08:05AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
___ 08:25PM BLOOD TSH-1.2
___ 08:25PM BLOOD HIV Ab-NEGATIVE
___ 08:25PM BLOOD tTG-IgA-3
___ 08:41PM BLOOD Lactate-0.7
___ 06:14PM BLOOD METHYLMALONIC ACID-PND
.
Studies:
Barium Swallow ___:
DOUBLE CONTRAST ESOPHAGRAM: Barium passes freely through the
esophagus and into the stomach with primary peristaltic
contractions. Mild dysmotility is noted with premature
termination of the primary peristaltic wave in mid esophagus and
proximal escape. No hiatal hernia or free reflux, however, is
appreciated. The esophagus does not demonstrate any abnormal
dilatation, narrowing, or stricture. Barium passes freely from
the stomach into the small bowel. Limited views of the stomach
appear normal. Several diverticuli are noted in the duodenum.
A 13 mm barium tablet was given which readily passed
into the stomach.
.
IMPRESSION:
1. No evidence of abnormal dilatation, narrowing, or stricture
in the
esophagus.
2. Multiple duodenal diverticuli.
.
Videoscopic Swallow Evaluation ___:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There was no gross aspiration
or penetration. For details, please refer to speech and swallow
note in ___.
.
IMPRESSION:
No evidence of gross penetration or aspiration.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clonazepam 0.5 mg PO BID
hold for sedation or RR <10
2. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO BID:PRN pain
hold for sedation or RR <10
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Sertraline 200 mg PO DAILY
5. traZODONE 100 mg PO HS
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Clonazepam 0.5 mg PO BID
2. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO BID:PRN pain
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Sertraline 200 mg PO DAILY
5. traZODONE 100 mg PO HS
6. Vitamin D 1000 UNIT PO DAILY
7. Lidocaine Viscous 2% 20 mL PO TID:PRN mouth pain
RX *lidocaine HCl 20 mg/mL swish and spit 20mL three times a
day Disp #*1 Bottle Refills:*1
8. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Failure to Thrive
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with weight loss and dysphagia, evaluate for
mass or dysmotility.
COMPARISON: None available.
DOUBLE CONTRAST ESOPHAGRAM: Barium passes freely through the esophagus and
into the stomach with primary peristaltic contractions. Mild dysmotility is
noted with premature termination of the primary peristaltic wave in mid
esophagus and proximal escape. No hiatal hernia or free reflux, however, is
appreciated. The esophagus does not demonstrate any abnormal dilatation,
narrowing, or stricture. Barium passes freely from the stomach into the small
bowel. Limited views of the stomach appear normal. Several diverticuli are
noted in the duodenum. A 13 mm barium tablet was given which readily passed
into the stomach.
IMPRESSION:
1. No evidence of abnormal dilatation, narrowing, or stricture in the
esophagus.
2. Multiple duodenal diverticuli.
Radiology Report
HISTORY: B symptoms and weight loss.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac, mediastinal, and hilar contours are
unremarkable. No pulmonary edema is seen.
IMPRESSION:
No acute cardiopulmonary process. Normal chest radiographs.
Radiology Report
HISTORY: Dysphagia and weight loss.
TECHNIQUE: Oropharyngeal swallowing video-fluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
COMPARISON: None available.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was no gross aspiration or penetration. For details, please
refer to speech and swallow note in OMR.
IMPRESSION:
No evidence of gross penetration or aspiration.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: WEAKNESS
Diagnosed with OTHER SPEECH DISTURBANCE
temperature: 99.2
heartrate: 78.0
resprate: 15.0
o2sat: 99.0
sbp: 126.0
dbp: 106.0
level of pain: 3
level of acuity: 3.0 | Primary Reason for Admission: ___ female with a history of
hypothyroidism, chronic fatigue syndrome, fibromyalgia and
depression admitted with ___ chronic weight loss and
odonyphagia.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Bupropion
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___ Pharmacologic Stress Test
History of Present Illness:
Mr. ___ is a ___ with h/o recent anterior STEMI (s/p DES to
mid LAD ___ w/residual RCA disease, c/b LV aneurysm), who
presents with chest pain.
He presented to ___ on ___ for substernal chest pain, many
hours after the initial pain. This was found to be an anterior
STEMI. He was cathed with DES to LAD and found to have moderate
LV dysfunction and anterior apical LV aneurysm. He was d/c'ed on
___ on Plavix/ASA, Coumadin, Metoprolol and Lisinopril.
Since discharge, he has felt well, with no chest pain or
shortness of breath, although he notes that he has realized he
has less energy than before. Yesterday, ___ at 6PM, he lifted a
40 pound box with the help of his daughter and carried it
upstairs. 10 minutes later, he felt "very different" from
before.
He reports a minor chest tightness, although it was "nothing at
all" like the pain he had prior to his STEMI. He waited 20
minutes without the symptoms resolving and then came in to the
ED. He noted that the chest tightness had resolved by the time
he
arrived. He denied any fevers, chills, cough, nausea, vomiting,
diaphoresis.
In the ED...
-Initial vitals were: T97.2 57 137/78 20 100% RA
-EKG: sinus 55, left deviation, no ST ischemic changes, deep TWI
in V2-V6, deep in V3,4,5
-Labs/studies notable for:
-Trop 0.16 --> 0.17 --> 0.14
-BUN/Cr ___, WBC 7.2 --> 10.1, INR 2.0
-CXR w/no acute intrathoracic process
-Patient was given: PO Ativan 1mg, ASA 243mg, Plavix 75mg,
Lisinopril 2.5mg, Metop XL 25mg
-Cardiology was consulted:
- Initially recommended obs overnight and MIBI, however on
further discussion planned to admit to ___
-Vitals on transfer: T 98, BP 92/64, HR 57, O2 98
On the floor, he denies any current complaints. He reports he
has
taken all his medications as prescribed since discharge. He
denies any chest pain, shortness of breath.
Past Medical History:
1. Cardiac Risk Factors
- None
2. Cardiac History
- STEMI s/p DES to mid-LAD, w/unresolved mod RCA Dz &
Anteroapical LV aneurysm (___)
3. Other PMHx
- Insomnia
- Depression
- OSA non complaint on CPAP
- CKD
Social History:
___
Family History:
Father - MI (___)
Mother - healthy
No family history of cancer, stroke.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
VITALS: ___ 1048 Temp: 98.0 PO BP: 92/64 HR: 57 O2 sat: 98%
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. JVP not visible at 45 degrees.
CARDIAC: NR, RR. Nl S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAMINATION
VS: 24 HR Data (last updated ___ @ 439)
Temp: 98.0 (Tm 98.3), BP: 95/63 (92-96/57-64), HR: 55
(51-66), RR: 20 (___), O2 sat: 97% (94-98), O2 delivery: RA,
Wt: 169.3 lb/76.79 kg (169.3-173.28)
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. JVP not visible at 45 degrees.
CARDIAC: NR, RR. Nl S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS
==============
___ 09:45PM BLOOD WBC-7.2 RBC-5.10 Hgb-14.4 Hct-42.3 MCV-83
MCH-28.2 MCHC-34.0 RDW-12.9 RDWSD-38.8 Plt ___
___ 09:45PM BLOOD Neuts-58.3 ___ Monos-7.6 Eos-2.8
Baso-0.6 Im ___ AbsNeut-4.19 AbsLymp-2.16 AbsMono-0.55
AbsEos-0.20 AbsBaso-0.04
___ 10:25PM BLOOD ___ PTT-31.8 ___
___ 09:45PM BLOOD Glucose-96 UreaN-27* Creat-1.5* Na-141
K-4.1 Cl-100 HCO3-21* AnGap-20*
___ 10:25PM BLOOD cTropnT-0.16*
TROPONIN TREND
==============
___ 10:25PM BLOOD cTropnT-0.16*
___ 03:50AM BLOOD cTropnT-0.17*
___ 09:50AM BLOOD cTropnT-0.14*
___ 09:50AM BLOOD CK-MB-2
STUDIES
=======
TTE with Lumason ___
Focused (contrast-enhanced) study There is an apical left
ventricular aneurysm. No masses or thrombi are seen in the left
ventricle. The right ventricular free wall thickness is normal.
Right ventricular chamber size is normal with focal hypokinesis
of the apical free wall. Compared with the prior study (images
reviewed) of ___, no major change.
STESS ___
IMPRESSION: No anginal type symptoms with no significant ST
segment
changes during the infusion or recovery. Appropriate hemodynamic
response. Nuclear report sent separately.
CARDIAC PERFUSION ___
Severe, predominantly fixed defect in the apical, anterior,
anteroseptal and inferoseptal walls. Moderate systolic
dysfunction with EF of 31% which might be slightly
underestimated due to inaccurate identification of
the inferior wall.
DISCHARGE LABS
==============
___ 07:50AM BLOOD WBC-10.8* RBC-5.23 Hgb-14.8 Hct-44.4
MCV-85 MCH-28.3 MCHC-33.3 RDW-13.3 RDWSD-41.0 Plt ___
___ 07:50AM BLOOD ___ PTT-33.7 ___
___ 07:50AM BLOOD Glucose-85 UreaN-24* Creat-1.5* Na-142
K-4.9 Cl-98 HC___ AnGap-18
___ 07:50AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Warfarin 5 mg PO DAILY16
8. LORazepam 0.5 mg PO QHS:PRN insomnia
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. LORazepam 0.5 mg PO QHS:PRN insomnia
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Sertraline 200 mg PO DAILY
7. Warfarin 5 mg PO DAILY16
please discuss your Coumadin dose with the ___
clinic going forward
8. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until you talk with your PCP or
___
9. HELD- Metoprolol Succinate XL 25 mg PO DAILY This medication
was held. Do not restart Metoprolol Succinate XL until you talk
with your PCP or ___
___ Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Coronary Artery Disease
Apical Akinesis
SECONDARY DIAGNOSES
===================
Depression
Obstructive Sleep Apnea
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with chest pain// eval PNA
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 97.2
heartrate: 57.0
resprate: 20.0
o2sat: 100.0
sbp: 137.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY
===============
Mr. ___ is a ___ with h/o recent anterior STEMI (s/p DES to
mid LAD ___ w/residual RCA disease, c/b LV aneurysm), who
re-presented with chest pain, s/p negative stress test.
#CORONARIES: mid LAD total occlusion s/p DES. Moderate residual
RCA distal disease.
#PUMP: ___
#RHYTHM: NSR
ACUTE ISSUES
============
# Chest Pain
# CAD s/p acute STEMI with DES to LAD
# Residual RCA disease, asymptomatic
Presented with short period of chest pain after exertion,
although quickly relieved and different from prior STEMI pain.
Troponins slightly elevated, peaked at 0.17, MB flat. No further
angina symptoms while inpatient. No events on telemetry. Stress
test performed which showed no anginal symptoms or ST changes.
Cardiac perfusion showed fixed, irreversible defect in LAD
territory with no reversible defects. Pt will f/u as scheduled
with outpatient Cardiology within one week.
# HFrEF
# Apical Aneurysm
Anticoagulated for apical aneurysm. INR 2.0 on admission on
Warfarin. TTE with Lumison performed which showed no thrombus in
the LV and no change from prior TTE.
# CKD
Baseline Cr 1.3-1.4, Cr 1.5 on admission.
CHRONIC ISSUES
==============
# Depression
Continued home lorazepam, sertraline.
# OSA
Continued home CPAP.
TRANSITIONAL ISSUES
===================
[ ] Holding prior home low dose Metop XL and Lisinopril as BPs
and HRs both low and pt with mild Sx related to soft BPs
[ ] Please check electrolytes at f/u within one week, mild Cr
increase of 1.5 on DC, prior baseline 1.2-1.4
[ ] Stop ASA in one month from STEMI (___).
[ ] Needs to continue anticoagulation for apical aneurysm for 6
months (through ___. Discharged on Warfarin. Could discuss
Warfarin v. DoAC with o/p Cardiologist on ___ (per telephone
note prior to admission). Follows at ___
clinic. Should discuss with outpt Cardiologist any further
potential cardiac imaging required
[ ] After discontinuation of Warfarin on ___, should
transition back to DAPT with Plavix/Aspirin.
[ ] Encourage home CPAP use
[ ] Consider referral to cardiac rehab
[ ] Encourage further diet modification
#Discharge Weight: 169.3 lb
#CODE: Full code
#CONTACT/HCP: ___ (___) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
Joint aspiration of right hip ___
Ultrasound guided aspiration of abscess in right thigh ___
History of Present Illness:
___ h/o migraines presents with 2 weeks R groin/inguinal pain.
About ___ developed sudden onset pain in the right inguinal
area. The pain then radiated to her anterior right leg and to
her knee, which she reported as swollen on and off. She
developed a low grade fever and was evaluated in the office. She
was sent to the ER for evaluation. Testing there on ___
showed a normal CT, normal pelvic ultrasound, normal ultrasound
of the appendix. HCG negative, labs reassuring. She was
discharged home with uncertain diagnosis.
Represented to PCP ___ with pain, given naproxen and ultram and
sent for MRI of pelvis/hip (no effusion but with R inguinal
LAD), also gyn workup advised. Was using implanon for
contraception and condoms, has h/o ovarian cysts. Ongoing low
grade fevers to 100, and severe pain with ambulation. Lyme
antibody positive, pending western blot. CRP/ESR elevated in
atrius records. Referred to ED. On exam in ED had pain w/
passive ROM of R hip and logrool, mild swelling in inguinaal
crease. No h/o rash. Seen by ortho in ED, recommended admit to
medicine for ___ guided hip aspiration and additional work-up.
Rec'd holding antibiotics until aspiration if patient otherwise
stable and NPO after midnight in case aspiration positive.
Vitals in the ED: Triage 14:28 10 100.0 108 107/61 18 99% RA
Labs notable for WBC 13.7. Hip/pelvis plain films in ED
unremarkable.
Patient given percocet.
Vitals prior to transfer: Today ___ 67 95/50 19 100%
RA
On the floor continues to have R hip pain. Reports that she has
pain walking or with any movement of her R hip, also notes
swelling in R groin, intermittent swelling of R knee,
parasthesias of R foot. Has h/o sciatica, but this is different.
Also notes intermittent chills, subjective fevers.
Past Medical History:
Migraine headache
Ovarian cyst ___
Sciatica
Back pain
Pneumonia ___
Childhood asthma
Social History:
___
Family History:
Parents: mother with migraines
___: grandmother with ___
Uncle with epilepsy
Physical Exam:
Admission physical exam:
Vitals - T: 98.3, 100/57, 90, 18, 100%RA pain ___
GENERAL: NAD, laying in bed. Father at bedside.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
MSK: R hip painful with any passive ROM. Some swelling and
erythema of R inguinal crease with palpable tender LAD in R
groin
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Parasthesia of R foot, but sensation
intact.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. Piercing over manubrium and on chin. Tattoo on back.
Discharge physical exam:
Vitals: Pain ___ Tm 100.0 Tc 98.1 BP 101/66 (97-106/68-69) HR
89 RR 18 O2 99 RA
General: NAD
HEENT: AT/AC, anicteric sclera, dry tongue, peeling lips, good
dentition, oropharynx clear
Lymph: nontender, supple, no LAD, no JVD
CV: RRR, no murmur
Lungs: CTAB, no wheezes
Abdomen: nondistended, nontender, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
MSK: Minor tenderness in R inguinal node. Able to passively and
actively move extremities with minimal tenderness
Pulses: 2+ DP bilaterally
Neuro: sensation intact in ___ bilaterally
Skin: no rash
Pertinent Results:
Admission labs:
___ 04:13PM BLOOD WBC-13.7*# RBC-4.25 Hgb-12.0 Hct-36.4
MCV-86 MCH-28.3 MCHC-33.0 RDW-12.7 Plt ___
___ 04:13PM BLOOD Plt ___
___ 04:13PM BLOOD Glucose-96 UreaN-6 Creat-0.6 Na-133 K-4.2
Cl-98 HCO3-25 AnGap-14
___ 07:15AM BLOOD Calcium-9.9 Phos-4.1 Mg-2.2
___ 07:15AM BLOOD CRP-246.8*
___ 01:00PM BLOOD HIV Ab-NEGATIVE
Discharge labs
___ 06:18AM BLOOD WBC-7.8 RBC-3.84* Hgb-11.1* Hct-33.3*
MCV-87 MCH-28.8 MCHC-33.2 RDW-12.8 Plt ___
___ 06:18AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-37.3* ___
___ 06:18AM BLOOD Glucose-95 UreaN-9 Creat-0.5 Na-140 K-4.0
Cl-104 HCO3-25 AnGap-15
___ 07:00AM BLOOD ALT-37 AST-28 AlkPhos-128* TotBili-0.4
___ 06:18AM BLOOD Calcium-9.5 Phos-4.5 Mg-2.2
Micro:
GRAM STAIN (Final ___: 4+ POLYMORPHONUCLEAR LEUKOCYTES. 2+
GRAM POSITIVE COCCI IN PAIRS AND CHAINS. BETA STREPTOCOCCUS
GROUP A. MODERATE GROWTH. ANAEROBIC CULTURE: NO ANAEROBES
ISOLATED.
Imaging:
CXR ___: A left PICC terminates at the lower SVC. There is
no pneumothorax, focal consolidation, or pleural effusion. The
heart size is normal. The hilar and mediastinal contours are
within normal limits.
CT ABD/PELV WITH CON ___: 1. 3.0 x 1.7 x 4.3 cm fluid
collection in the right groin anteriorly, which is likely an
abscess. 2. Borderline splenomegaly. 3. Intraabdominal findings
are unremarkable.
HIP PLAIN FILM ___: No fracture. No focal osseous
abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN severe
headache
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Penicillin G Potassium 4 Million Units IV Q4H
End date ___
RX *penicillin G pot in dextrose 2 million unit/50 mL 4 million
units IV Every 4 hours Disp #*240 Intravenous Bag Refills:*0
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN severe
headache
4. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % ___ ml
IV Daily and PRN Disp #*30 Syringe Refills:*0
5. Outpatient Lab Work
Check CBC with diff and Chem 7 weekly. Starting on ___.
Send to ___ ID OPAT at ___. ICD-9 Code: 682.9
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Group A strep abscess in pectineus muscle of right thigh
Secondary diagnosis:
Sepsis
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with atraumatic R hip pain // R/O fx
TECHNIQUE: AP view of the pelvis. AP and frogleg lateral views of the right
hip.
COMPARISON: None.
FINDINGS:
There is no fracture or focal osseous abnormality. Pubic symphysis and SI
joints are preserved. No significant degenerative changes identified. Soft
tissues are unremarkable. Unfused posterior elements of S1 incidentally
noted.
IMPRESSION:
No fracture. No focal osseous abnormality.
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ year old woman with concern for R hip septic arthritis // R
hip aspiration, please send for gram stain, culture, and send fluid for Lyme
PCR
TECHNIQUE: The risks, benefits and alternatives were explained to the patient
and written informed consent was obtained.
A pre-procedure timeout confirmed three patient identifiers.
Under fluoroscopic guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
4 cc 1% Lidocaine was used to achieve local anesthesia.
Under intermittent fluoroscopic guidance, an 18-gauge spinal needle was
advanced into the right hip joint. Attempted aspiration yielded no significant
quantity of fluid. Appropriate intra-articular position was confirmed by the
injection of a small amount of Optiray water-soluble contrast. Approximately
8 cc of 0.9% sterile saline was then instilled into the joint space.
Subsequent re-aspiration yielded 3 cc of serosanguineous fluid. Samples were
sent to the laboratory for Gram stain/culture, cell count/differential, and
lyme PCR.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in stable
condition. There were no immediate complications.
COMPARISON: Pelvis/hip radiographs from ___.
FINDINGS:
Fluoroscopic images demonstrated injected water-soluble contrast material in
the right hip joint.
IMPRESSION:
1. Findings - injected water-soluble contrast material in the right hip
joint.
2. Procedure - successful fluoroscopic guided right hip joint aspiration
yielding 3 cc of serosanguineous re-aspirate.
NOTIFICATION: The procedure was supervised by Dr. ___ attending
radiologist, who was present for the critical portions of the procedure. Dr.
___ and agrees with the above report.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with R groin pain. Concern for infection // R
Groin pain and inflammation. Concern for abscess
TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed with oral
and IV contrast. Multiplanar reformations were provided.
IV contrast: Omnipaque 130mL
DOSE: DLP: 674 mGy cm
COMPARISON: None.
FINDINGS:
Lung Bases: The imaged lung bases are clear.
Abdomen: Spleen is borderline enlarged, measuring 13.4 cm. The liver,
gallbladder, adrenal glands, and pancreas are unremarkable. Kidneys are
unremarkable. The abdominal aorta is normal in caliber. No lymphadenopathy,
free air or free fluid is seen. The stomach and duodenum are unremarkable.
Loops of small and large bowel demonstrate no signs of ileus or obstruction.
Pelvis: Bladder, uterus and ovaries are unremarkable.
Bones/ soft tissue: There is 3.0 x 1.7 x 4.3 cm fluid collection in the right
groin anteriorly with surrounding inflammatory changes. Right common femoral
vein is slightly compressed by the fluid collection without evidence of
thrombosis. Prominent right groin lymph nodes are likely reactive. No
worrisome lytic or blastic osseous lesion is seen.
IMPRESSION:
1. 3.0 x 1.7 x 4.3 cm fluid collection in the right groin anteriorly, which is
likely an abscess.
2. Borderline splenomegaly.
3. Intraabdominal findings are unremarkable.
Radiology Report
INDICATION: ___ year old woman with concern for abscess in thigh // Drainage
of abscess in thigh area seen on CT.
COMPARISON: CT performed on ___.
PROCEDURE: Ultrasound-guided drainage of right groin collection.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on the
ultrasound findings an appropriate skin entry site for the aspiration was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, an 18 gauge spinal needle was advanced
into the) collection. 5 cc of pus was aspirated. Subsequently, a 5 ___ ___
catheter was advanced into the collection and an additional 10 cc of pus was
aspirated. Specimen was sent for C&S.
Sterile dressing was applied. There were no immediate post-procedural
complications.
FINDINGS:
Limited ultrasound evaluation of the right groin demonstrates multiple
prominent reactive lymph nodes. An echogenic 3.5 x 2.1 cm collection was
identified and targeted for aspiration as described above.
IMPRESSION:
Successful ultrasound-guided aspiration of right groin abscess.
Radiology Report
INDICATION: PICC placement.
COMPARISON: None.
TECHNIQUE: Frontal chest radiograph.
IMPRESSION:
A left PICC terminates at the lower SVC. There is no pneumothorax, focal
consolidation, or pleural effusion. The heart size is normal. The hilar and
mediastinal contours are within normal limits.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: R Hip pain
Diagnosed with JOINT PAIN-PELVIS
temperature: 100.0
heartrate: 108.0
resprate: 18.0
o2sat: 99.0
sbp: 107.0
dbp: 61.0
level of pain: 10
level of acuity: 3.0 | Ms ___ is a ___ y/o F with two weeks of progressive Rt hip
pain and erythema, tender Rt inguinal lymphadenopathy, an
elevated WBC, and elevated ESR and CRP who was ill-appearing and
diaphoretic this morning.
#Right hip pain: Ms ___ presented with ___ right hip pain
that radiated to her groin and down her thigh. On exam she had
erythema, tender,palpable lymphadenopathy, and pain on passive
and active movement. There was concern for septic arthritis due
to the hip pain, fever, and elevated ESR/CRP so the joint was
aspirated, but there were no signs of infection. At this point
she was spiking regular fevers, had a WBC count >12, was
tachycardic to 110 meeting ___ SIRS criteria. Blood cultures
were drawn and she was started on IV Vancomycin and cefepime
with resolution of her fevers. A CT showed an abscess in her
right pectineus muscle. This was aspirated by ___ and grew Group
A strep. Her antibiotics were narrowed to IV Penicillin. A PICC
was placed for continued outpatient therapy.
## TRANSITIONAL ISSUES:
================================
- Monitor BPs. Patient had BPs in ___ SBP while inpatient
- On penicillin IV for abscess in right thigh. End date ___
- OPAT labs for Beta lactam antibiotics weekly |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Enalapril / Pollen Extracts / clindamycin /
Cephalexin
Attending: ___.
Chief Complaint:
Fatigue, abdominal pain, chest pain
Major Surgical or Invasive Procedure:
Colonoscopy and EGD ___
History of Present Illness:
Ms. ___ is a ___ ___ woman with
history of atrial fibrillation on warfarin, SSS ___ PPM upgraded
to CRT-P, sCHF, MR ___ MitraClip, CAD, PAD, HTN, OSA not on
CPAP,
recent admission for chest pain, abdominal pain, and weakness
now
presenting with same.
The patient is known to me from prior admission. She was
recently
admitted from ___ for chest pain, abdominal pain, and
weakness and found to have acute on chronic anemia. She
underwent
EGD during last admission that showed a non-bleeding AVM, and a
colonoscopy that did not reveal a bleeding source. Warfarin was
initially held, and then she was transitioned to apixaban.
Regarding her chest pain, this was thought to be due to valvular
disease.
The patient saw her cardiologist on ___, who believes that her
chest pain is secondary to coronary steal phenomenon related to
her aortic regurgitation. Her aortic root has in the past been
deemed to be too large for transcatheter aortic valve
replacement. Although a surgical aortic valve replacement could
be done, she has been deemed to be a high risk surgical
candidate, and therefore has declined aortic valve replacement.
It was recommended that she follow up with Dr. ___ to revisit
whether she would be a TAVR candidate.
Per history taken from the patient's daughter by ___ providers,
the patient has been having worsening chest and abdominal pain
for the last month. This is corroborated from her recent
cardiology note. In the ___, the patient reported worse when
laying down. Patient also complaining of generalized diffuse
abdominal pain. Per report, the patient was admitted to ___ with
anemia with a hemoglobin in the 6s; she was transfused and it
was
recommended that she undergo a capsule endoscopy.
In the ___, vitals: 98.8 70 124/73 16 97% RA
On exam:
- Resp: Clear to auscultation
- CV: Regular rate and rhythm, normal ___ and ___ heart sounds,
no ___ heart sound, no JVD, mild bilateral pedal edema
- Abd: Soft, tenderness to palpation in periumbilical, left,
suprapubic region, no rebound no guarding, nondistended
Labs notable for: WBC 8, Hb 7.2, INR 1.4; BUN/Cr ___ proBNP
4593, trop<0.01
Imaging: CXR, CT A/P
Consults: GI
Patient given: Morphine 2 mg IVx3, pantoprazole 40 mg, LR 200cc
On arrival to the floor, additional history is taken from the
patient via a ___ phone translator. The patient is unable to
relate what brought her to the hospital, but she denies any
chest
pain, palpitations, shortness of breath, abdominal pain, nausea,
vomiting, or blood in the stool. She states that she feels tired
and would like to sleep. She otherwise denies any other
complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Atrial fibrillation on apixaban
- AV block ___ VVI PPM ___
- Heart failure, mixed systolic/diastolic (EF 50-55% in ___,
37% ___
- Possible prior rheumatic heart disease: echocardiogram in ___
showed moderate aortic and moderate mitral regurgitation
- H/o chronic atypical chest pain: pMIBI in ___ showed fixed
infero-apical perfusion defect. Clean coronaries.
- Hypertension
- Carotid stenosis
- CKD (b/l 1.5)
- Depression
- Sleep apnea
- Left inguinal hernia ___ repair
- Nephrolithiasis
- PSHx: Cholecystectomy, hernia repair, pacemaker, basal cell
cancer removed from face
Social History:
___
Family History:
Mother with Lung CA. No family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VITALS: 99.1 161/73 71 18 97 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, systolic murmur at LLSB, neck veins flat
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.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, no peripheral edema
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.
MMMs
CV: irregular
RESP: Lungs clear to auscultation with good air movement, mild R
basilar crackles. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
MSK: No erythema or swelling of joints
SKIN: No rashes or ulcerations noted
EXTR: wwp minimal edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 08:26PM WBC-8.2 RBC-2.91* HGB-7.2* HCT-24.0* MCV-83
MCH-24.7* MCHC-30.0* RDW-18.5* RDWSD-53.9*
___ 08:26PM NEUTS-59.8 ___ MONOS-9.6 EOS-2.1
BASOS-0.4 IM ___ AbsNeut-4.90 AbsLymp-2.26 AbsMono-0.79
AbsEos-0.17 AbsBaso-0.03
___ 08:26PM PLT COUNT-219
___ 08:26PM GLUCOSE-121* UREA N-24* CREAT-1.5* SODIUM-143
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-27 ANION GAP-18
___ 08:26PM ALT(SGPT)-7 AST(SGOT)-20 ALK PHOS-100 TOT
BILI-0.4
___ 08:26PM ALBUMIN-3.7
___ 08:26PM cTropnT-<0.01 proBNP-4593*
___ 08:26PM LIPASE-33
___ 08:33PM ___ PTT-32.7 ___
___ 10:59PM LACTATE-2.3*
___ 03:50PM HAPTOGLOB-109
___ 03:50PM LD(LDH)-254* TOT BILI-0.7
INTERVAL DATA:
WBC wnl
Hgb 7.2-9.2 (9.2 on last check ___
Cre 1.5--->1.9 ---> 1.3 (___)
trops neg x5
Iron 181 TIBC 299 B12 348 FOlate ___ Ferritin 37
Micro:
- Urine culture (___): no growth
Imaging:
- EGD (___) - normal
- Colonoscopy (___) - mild diverticulosis, single diverticular
bleed with adherent clot, endoclip placed with resolution
- CT A/P (___):
IMPRESSION:
1. No bowel obstruction. No finding to suggest bowel ischemia.
2. Fluid-filled colon. Please correlate with clinical history
for
diarrhea.
3. Cardiac hepatopathy.
- CXR (___):
IMPRESSION: Right basilar opacity, potentially atelectasis
though
infection is not entirely excluded. Overall findings similar
compared to multiple priors dating back to ___. Vascular
congestion without overt edema.
- EGD (___): normal esophagus, granularity and erythema in
the stomach body, angioectasia int eh stomach body (thermal
therapy), normal mucosa in the duodenum (biopsy)
- Colonoscopy (___): High residual material was noted
throughout. Multiple attempts were made to irrigate the colon
but
the mucosa could not be visualized adequately. Unable to
intubate
terminal ileum due to significant looping. No red blood, old
blood, or likely sources of bleeding were seen. Diverticulosis
of
the descending colon and sigmoid colon.
- TTE (___):
IMPRESSION: Well seated mitraclip with likely moderate to severe
residual mitral regurgitation accounting for shadowing and
eccentric nature of the jet (could be better defined by TEE).
Mean transmitral gradient of 5mmHg at HR 70/min. Valve area
severely reduced by PHT however at 1.3cm2. Moderate eccentric
aortic regurgitation. Mild left ventricular systolic dysfunction
c/w CAD in the Lcx territory. Mildly dilated thoracic aorta.
Mild
aortic stenosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Atorvastatin 40 mg PO QPM
3. Gabapentin 200 mg PO QHS
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Apixaban 2.5 mg PO BID
7. Torsemide 80 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Potassium Chloride 20 mEq PO BID
12. Loratadine 10 mg PO DAILY:PRN allergy symptoms
13. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN SOB
14. albuterol sulfate 0.63 mg/3 mL inhalation Q6H:PRN SOB
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Omeprazole 20 mg PO BID
17. Lidocaine Viscous 2% 15 mL PO TID:PRN chest pain
Discharge Medications:
1. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth nightly as
needed Disp #*7 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN SOB
4. albuterol sulfate 0.63 mg/3 mL inhalation Q6H:PRN SOB
5. Apixaban 2.5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Gabapentin 300 mg PO QHS
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Lidocaine Viscous 2% 15 mL PO TID:PRN chest pain
11. Loratadine 10 mg PO DAILY:PRN allergy symptoms
12. Metoprolol Succinate XL 12.5 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Omeprazole 20 mg PO BID
16. Potassium Chloride 20 mEq PO BID
17. Torsemide 80 mg PO BID
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diverticular bleeding
Anemia
Chest pain related to aortic insufficiency
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: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with history of A. fib, CHF, bowel
obstruction, presented with chief complaint of diffuse abdominal pain
worsening x1 monthNO_PO contrast// Bowel obstruction? Ischemic colitis?
Abdominal pathology?
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 9.0 s, 0.5 cm; CTDIvol = 43.3 mGy (Body) DLP =
21.7 mGy-cm.
2) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 19.6 mGy (Body) DLP =
1,040.6 mGy-cm.
Total DLP (Body) = 1,062 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: There is mild atelectasis in the imaged lung bases. No pleural
or pericardial effusion is seen. The heart is severely enlarged. Aortic
valvular calcifications are severe.
ABDOMEN:
HEPATOBILIARY: The liver is diffusely hypoenhancing, with a heterogeneous,
mottled pattern. There is no evidence of focal lesions. There is no evidence
of intrahepatic or extrahepatic biliary dilatation. The gallbladder is not
visualized.
The portal veins are patent. Poor contrast enhancement in the hepatic veins
and IVC suggest venous congestion, likely secondary to cardiac dysfunction.
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 mildly atrophic. Bilateral simple cysts are again
seen. Additional subcentimeter hypodensities are too small to characterize.
There is no hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the colon is noted, without evidence of wall thickening and fat stranding. The
colon is fluid-filled. No pneumatosis or free air.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: A small, partly calcified exophytic fibroid is seen at
the right uterine fundus. No adnexal mass.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Redemonstration of mild S-shaped curvature of the thoracolumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No bowel obstruction. No finding to suggest bowel ischemia.
2. Fluid-filled colon. Please correlate with clinical history for diarrhea.
3. Cardiac hepatopathy.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Dyspnea, unspecified
temperature: 98.8
heartrate: 70.0
resprate: 16.0
o2sat: 100.0
sbp: 124.0
dbp: 73.0
level of pain: 5
level of acuity: 2.0 | ___ yo ___ F PMHx atrial fibrillation on eliquis, SSS
___ PPM upgraded to CRT-P, sCHF (EF 45%), MR ___ MitraClip, CAD,
PAD, HTN, OSA not on CPAP, recent admission for chest pain,
abdominal pain, and weakness, now presenting with the same,
found to have diverticular bleed on colonoscopy.
# Acute on chronic anemia:
# Diverticular bleed:
Given her symptoms of chest pain and fatigue, transfused 1 unit
pRBCs after admission. Symptoms improved after transfusion.
Colonoscopy on ___ with active diverticular bleed ___ clip
placement. Received additional unit RBCs on ___ after
colonoscopy and bumped appropriately. She was restarted on home
apixaban. Her counts remained stable so she was discharged to
home.
# Chest pain due to suspected coronary steal phenomenon related
to aortic regurgitation:
Intermittent chest pain is thought to be due to coronary steal
phenomenon due to eccentric aortic regurgitation jet with
Venturi effect. This effect has likely been exacerbated in the
setting of acute on chronic anemia. Her symptoms improved after
blood transfusion on ___. Of note, she had clean coronaries on
cardiac cath from ___. She was evaluated by CT Surgery for
valve replacement during a previous admission though she was
determined not to be a TAVR candidate (due to aortic annulus
size) and family declined SAVR at that time due to high surgical
risk. She continued to have chest pain intermittently throughout
the admission, at times associated with weakness or dyspnea.
Nitroglycein and tylenol intermittently helped, but not
consistently. Discussed with cardiologist Dr. ___
requested ___ for TAVR in case newer devices could
accommodate her aortic annulus size, but the TAVR team stated
that they did not have such devices. The patient and her family
do not wish to pursue high risk SAVR at this point. She will
continue use of PRN NTG and tylenol for her pain and follow-up
closely with cardiology. Morphine was avoided given its
deliriogenic for this patient.
# Atrial fibrillation:
# SSS ___ PPM upgrade to CRT-P
CHADs2Vasc=5. Continued home metoprolol and aspirin. Eliquis
was initially held in the setting of GI bleeding and then
restarted, without evidence of further bleeding.
# Mitral stenosis ___ mitraclip
# Aortic regurgitation
# Chronic systolic congestive heart failure: LVEF 45%.
Patient appeared euvolemic on exam. Home torsemide was initially
held in the setting of GIB, and then subsequently restarted.
She continued home Imdur, and low-dose metoprolol
# HTN:
Continued metoprolol, Imdur
# HLD:
Continued statin, aspirin
# OSA:
Patient does not tolerate CPAP mask
# GERD:
Continued home PPI
# Neuropathy:
Continued gabapentin
======================================
====================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pain, sob
Major Surgical or Invasive Procedure:
Biopsy, mass adjacent to right acetabulum ___
History of Present Illness:
This is a ___ year old man with newly diagnosed sebaceous
carcinoma of the scalp and RUL mass with bilateral pulmonary
nodules and mediastinal and hilar LAD. Two weeks prior to
___, he developed right flank pain that persistent,
prompting presentation to ___ ED where eventual
CT Chest showed 6 x 5 x 6.8 cm lobulated RUL mass, bilateral
round pulmonary nodules up to 2.5cm in diameter and mediastinal
and hilar lymphadenopathy. He was given pain control and sent
home. On follow-up with his PCP ___ ___, he was found to have
enlarging R scalp lesion. A biopsy of this revealed sebaceous
carcinoma, and he underwent a wide excision (Dr. ___ in
___, ___.
Since that time, he has continued to have positional right flank
pain. It is described as burning, pressure like that crescendos
to a throbbing pain. He also has some right hip pain that
radiates to the back of the calf. Family has tried vicodin,
Percocet, ibuprofen and Tylenol without much relief. He also
endorses nausea, constipation, leg swelling, chills and night
sweats. He has had some low grade temps in the ___ range while
being on anti-pyretics. He last lost 7 lbs since ___. He
denies recent travel or sick contacts. There is no dysuria,
abdominal pain or headaches.
He recently established care with IP at ___ with plan for
flexible bronchoscopy, EBUS/TBNA, TBBX, Brushings and BAL for
tissue diagnosis. Labs at that appointment were notable for WBC
20, Hgb 9.5 and plt 506.
Today, his family found that he was objectively dyspneic, new
bilateral leg swelling, and pain was not controlled. His son,
who is a RN, checked his O2 sat and found it to be 89% on room
air. They brought him to the ED for further evaluation. He has
no cough, wheezing or dyspnea.
In the ED
- initial VS: T98.3, HR96, RR 24, Spo2 95% RA.
- labs: WBC 19 (87% PMNs), Hgb 8.6 (down from 9.5 two days
prior), plt 428. INR 1.4 Chem panel essentially normal. Mild
transaminitis. Elevated alk phos. Albumin 2.8.
CT Chest showed:
1. Compared to ___, no significant change in a
large
multilobulated right upper lobe mass. No significant change in
diffuse metastases throughout the lungs.
2. The airways are patent to the level of the segmental bronchi
bilaterally. No evidence of obstruction by the known
multilobulated right upper lobe mass.
3. Interval increase in a moderate right non - hemorrhagic
pleural effusion.
4. There is new ground-glass opacity in the bilateral upper
lobes, concerning for inflammation or infection.
- ECG: sinus, rate 95, normal axis, normal intervals (QTc 421),
Q waves in III.
- CTA Chest showed no PE.
- He was given morphine IV x2, azithromycin and ceftriaxone.
On arrival to the floor, he states that the morphine has helped
his pain. He is accompanied by his daughter, ___, and her
boyfriend.
Past Medical History:
HTN
Hypercholesterolemia
BPH
Nephrolithiasis s/p lithotripsy
Hernia repair ___
Sebaceous Carcinoma- scalp (___) s/p wide excision (___)
R lung mass ___
Social History:
___
Family History:
Father: ___
Mother: CAD/MI, lung cancer
Paternal Uncle: breast
Son: ___ Lymphoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: 98.6, BP 135/73, HR 99, SpO2 18, SpO2 96% 2L.
___: alert, oriented, intermittently closes eyes, but awakens
easily and is not acute distress
HEENT: head wrapped in gauze, adentulous (does not wear
dentures), MMM, oropharynx is clear, EOMI, PERRL
Neck: supple, no JVP elevation
Cor: regular rate, normal rhythm, III/VI systolic murmur best
heard in the tricuspid position with radiation into the carotids
Pulm: bibasilar crackles, no increased work of breathing, no
wheezes or rhonchi
Abd: soft, non-tender, non-distended, no HSM, NABS
Neuro: CN II-XII intact, strength is ___ in all extremities
except at the right hip which is 4+/5 and limited by pain,
straight leg testing is negative bilaterally
Skin: warm, well-perfused; 1+ pitting edema at the ankles R > L
Access: PIVs
DISCHARGE PHYSICAL EXAM:
=======================
VS: 97.9 PO 139 / 57 90 24 87 50% ___
___: alert, oriented, nad
HEENT: head wrapped in gauze MMM, oropharynx is clear, EOMI,
PERRL
neck supple, no JVP elevation
Cor: regular rate, normal rhythm, III/VI systolic murmur best
heard in the tricuspid position with radiation into the carotids
Pulm: bibasilar crackles, no increased work of breathing, no
wheezes or rhonchi
Abd: soft, distended, no HSM, NABS, mild ttp in RUQ
Neuro: CN II-XII intact, strength is ___ in all extremities
except at the right hip which is 4+/5 and limited by pain,
straight leg testing is negative bilaterally
Skin: warm, well-perfused; trace pedal edema at the ankles R > L
Access: PIV
Pertinent Results:
ADMISSION LABS:
===============
___ 09:15AM GLUCOSE-100 UREA N-21* CREAT-0.7 SODIUM-135
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-28 ANION GAP-16
___ 09:15AM ALT(SGPT)-56* AST(SGOT)-67* LD(LDH)-697* ALK
PHOS-395* TOT BILI-0.5
___ 09:15AM CALCIUM-8.0* PHOSPHATE-3.4 MAGNESIUM-1.9
___ 09:15AM WBC-19.2* RBC-3.02* HGB-8.0* HCT-25.7* MCV-85
MCH-26.5 MCHC-31.1* RDW-13.7 RDWSD-42.5
___ 09:15AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-OCCASIONAL BURR-1+
___ 09:15AM PLT COUNT-449*
___ 09:15AM ___ PTT-28.6 ___
___ 06:45AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 11:30PM GLUCOSE-134* UREA N-26* CREAT-0.9 SODIUM-135
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18
___ 11:30PM ALT(SGPT)-66* AST(SGOT)-89* LD(___)-792* ALK
PHOS-445* TOT BILI-0.4
___ 11:30PM cTropnT-<0.01
___ 11:30PM ALBUMIN-2.8* URIC ACID-4.5 IRON-19*
___ 11:30PM calTIBC-191* HAPTOGLOB-246* FERRITIN-806*
TRF-147*
___ 11:30PM ACETMNPHN-NEG
___ 11:30PM WBC-19.0* RBC-3.12* HGB-8.6* HCT-26.2* MCV-84
MCH-27.6 MCHC-32.8 RDW-13.6 RDWSD-41.6
___ 11:30PM NEUTS-87.6* LYMPHS-4.4* MONOS-5.8 EOS-0.5*
BASOS-0.3 IM ___ AbsNeut-16.67* AbsLymp-0.83* AbsMono-1.10*
AbsEos-0.10 AbsBaso-0.05
___ 11:30PM PLT COUNT-428*
___ 11:30PM RET AUT-2.6* ABS RET-0.08
DISCHARGE LABS:
===============
___ 06:35AM BLOOD WBC-23.1* RBC-3.15* Hgb-8.3* Hct-27.3*
MCV-87 MCH-26.3 MCHC-30.4* RDW-14.4 RDWSD-45.3 Plt ___
___ 06:35AM BLOOD Glucose-104* UreaN-23* Creat-0.8 Na-132*
K-4.4 Cl-96 HCO3-25 AnGap-15
___ 06:28AM BLOOD ALT-54* AST-105* AlkPhos-201*
TotBili-2.1* DirBili-1.6* IndBili-0.5
MICRO:
======
[] Pending at time of DC
IMAGING:
========
CT chest w/o contrast ___
1
.
C
o
mpared to ___, interval increase in size of a large
m
u
l
tilobulated right upper lobe mass. Interval increase in size of
innumerable metastases throughout the lungs.
2
.
T
h
e
a
i
r
w
a
y
s
a
r
e
p
a
t
e
n
t
t
o
t
h
e
l
e
v
e
l
o
f
t
h
e
s
e
g
m
e
n
t
a
l
b
r
o
n
c
h
i
b
i
l
a
t
e
r
a
l
l
y
.
No evidence of obstruction by the known multilobulated RUL mass.
3
.
I
n
t
e
r
v
a
l
increase in a moderate right non - hemorrhagic pleural effusion
4. There is new ground
glass opacity in the bilateral upper lobes, concerning
for inflammation or infection.
5
.
I
n
t
e
r
___ increase in size of multiple hepatic metastases and a single
splenic metastasis.
CTA ___:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Please see same-day CT chest without contrast for description
of an
enlarging large right apical multilobulated mass and interval
increase in size of innumerable pulmonary metastases, among
other findings.
PATH:
====
Poorly differentiated carcinoma (see note).
Note: Most of the core biopsy is necrotic; several small sheets
and nests of tumor cells with pleomorphic nuclei, prominent
nucleoli, and moderate amount of cytoplasm are present. By
immunohistochemistry, tumor cells show the following staining
profile:
- Positive: cytokeratin cocktail (AE1/3, Cam5.2), GATA3, p40,
CK7 (focal).
- Negative: CK20, TTF1, PAX8, CDX2, S100, CD45, synaptophysin.
Based on the co-expression of GATA3 and p40, the differential
diagnosis includes metastasis from the patient's known sebaceous
carcinoma or a urothelial carcinoma. Spread from a pulmonary
squamous cell carcinoma is less likely, given the strong and
diffuse GATA3 expression. Correlation with clinical and imaging
findings is advised.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. amLODIPine 10 mg PO DAILY
5. Lovastatin 10 mg oral DAILY
6. HYDROcodone-acetaminophen ___ mg oral Q6H:PRN
7. Aspirin 325 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild
10. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob, wheezing
2. Aquaphor Ointment 1 Appl TP TID:PRN skin lesion
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. CefePIME 2 g IV Q12H
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID:PRN
oral care
6. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
7. Heparin 5000 UNIT SC BID
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
9. Lactulose 30 mL PO DAILY
10. Levofloxacin 750 mg PO DAILY
11. LORazepam 0.5 mg PO QHS:PRN insomnia
RX *lorazepam 1 mg ___ tab by mouth qhs anxiety Disp #*10
Tablet Refills:*0
12. Morphine SR (MS ___ 30 mg PO QAM
RX *morphine [MS ___ 30 mg 1 tablet(s) by mouth QAM Disp #*5
Tablet Refills:*0
13. Morphine SR (MS ___ 45 mg PO QHS
RX *morphine [MS ___ 30 mg 1.5 tablet(s) by mouth QPM Disp
#*5 Tablet Refills:*0
14. Morphine SR (MS ___ 30 mg PO Q2PM
RX *morphine [MS ___ 30 mg 1 tablet(s) by mouth Q2PM Disp
#*5 Tablet Refills:*0
15. Morphine Sulfate ___ 7.5-15 mg PO Q4H:PRN Pain - Moderate
RX *morphine 15 mg 1 tablet(s) by mouth Q4H:PRN Disp #*40 Tablet
Refills:*0
16. Morphine Sulfate ___ mg IV Q3H:PRN BREAKTHROUGH PAIN
RX *morphine (PF) in dextrose 5 % 100 mg/100 mL (1 mg/mL) ___ mg
IV q3h prn Disp #*3 Bag Refills:*0
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
18. Polyethylene Glycol 17 g PO DAILY
19. Senna 17.2 mg PO HS
20. Vancomycin 1000 mg IV Q 12H
21. Acetaminophen 650 mg PO Q8H
22. Ibuprofen 400 mg PO Q8H
23. Docusate Sodium 100 mg PO BID
24. Finasteride 5 mg PO DAILY
25. Metoprolol Tartrate 50 mg PO BID
26. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until told to resume by your doctor.
27. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until told to
resume by your PCP.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Community Acquired Pneumonia
Metastatic Cancer, Presumed Urothelial vs. Sebaceous Primary
SECONDARY DIAGNOSIS:
Normocytic Anemia
Hepatitis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT chest without contrast
INDICATION: History: ___ with PET scan on ___ c/f metastatic lung ca p/w
worsening dyspnea. // ?airway compression or evolution of R effusion
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Outside CT chest ___
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. There
calcifications of the thoracic aorta and its branches. There are
calcifications of the coronary arteries and aortic valve. The heart,
pericardium, and great vessels are otherwise within normal limits based on an
unenhanced scan. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There multiple enlarged mediastinal and
bilateral hilar lymph nodes. There are a few calcified pretracheal lymph
nodes, as before. No mediastinal mass or hematoma.
PLEURAL SPACES: Interval increase in a moderate right non - hemorrhagic
pleural effusion. No pneumothorax.
LUNGS/AIRWAYS: Compared to ___, interval increase in size of a
large multilobulated right upper lobe mass, measuring approximately 5.9 x 5.1
x 7.5 cm (___) without a definite fat plane between the esophagus and
trachea. Interval increase in size of innumerable metastases throughout the
lungs. Index nodules: Left lower lobe, measuring 2.7 cm (___), previously
1.8 cm and right middle lobe, measuring 2.8 cm (___), previously 2.0 cm.
There is new ground-glass opacity in the bilateral upper lobes, concerning for
inflammation or infection. The airways are patent to the level of the
segmental bronchi bilaterally.
BASE OF NECK: There is a punctate calcification in the left hemi thyroid, of
indeterminate clinical significance. Otherwise, the portions of the base of
the neck show no abnormality.
ABDOMEN: Limited evaluation of the abdomen demonstrates an interval increase
in size of multiple large hypodense lesions in the liver and a single
metastasis in the spleen, concerning for metastases.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
There is DISH, as before.
IMPRESSION:
1. Compared to ___, interval increase in size of a large
multilobulated right upper lobe mass. Interval increase in size of
innumerable metastases throughout the lungs.
2. The airways are patent to the level of the segmental bronchi bilaterally.
No evidence of obstruction by the known multilobulated right upper lobe mass.
3. Interval increase in a moderate right non - hemorrhagic pleural effusion.
4. There is new ground-glass opacity in the bilateral upper lobes, concerning
for inflammation or infection.
5. Interval increase in size of multiple hepatic metastases and a single
splenic metastasis.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with lung cancer // ?PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE:
Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
2) Spiral Acquisition 3.9 s, 30.4 cm; CTDIvol = 13.5 mGy (Body) DLP = 410.8
mGy-cm.
Total DLP (Body) = 415 mGy-cm.
COMPARISON: Same-day CT chest without contrast.
FINDINGS:
The pulmonary vasculature is well opacified to the subsegmental level without
filling defect to indicate a pulmonary embolus. The thoracic aorta is normal
in caliber without evidence of dissection or intramural hematoma.
Please see same-day CT chest without contrast for description of an enlarging
large right apical multilobulated mass and interval increase in size of
innumerable pulmonary metastases, among other findings.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Please see same-day CT chest without contrast for description of an
enlarging large right apical multilobulated mass and interval increase in size
of innumerable pulmonary metastases, among other findings.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ male with newly diagnosed metastatic cancer of
unknown primary.
TECHNIQUE: Incomplete study as patient was unable to complete the exam to
entirety due to pain and refusal to continue. Only diffusion, axial T1,
sagittal T1 images were obtained. No contrast was administered.
COMPARISON None
FINDINGS:
Incomplete study as above, with the provided images demonstrating 2 small foci
of slow diffusion within the left parietal lobe (06:22) and additional focus
of slow diffusion within the right parietal lobe. There is diffuse
parenchymal volume loss with commensurate prominence of the ventricles, sulci,
and cisterns. There is no midline shift. The paranasal sinuses and bilateral
mastoid air cells appear clear.
IMPRESSION:
1. Incomplete study due to patient's refusal to continue the exam and reported
pain.
2. Small foci of slow diffusion within bilateral parietal lobes, which is felt
to most likely represent acute to subacute infarction. However, on this
noncontrast study without FLAIR images, it is difficult to entirely exclude
the possibility of small metastatic foci demonstrating slow diffusion,
although felt less likely.
NOTIFICATION: The findings were discussed with ___. ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:10 AM, 3 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with newly diagnosed sebaceous carcinoma of the
scapula and RUL mass with bilateral pulmonary nodules and mediastinal and
hilar LAD concerning for metastatic disease, with worsened hypoxia //
?pulmonary edema ?pulmonary edema
IMPRESSION:
Compared to chest radiographs ___ read in conjunction with
subsequent chest CTA ___.
Multiple peripheral lung nodules as well as the paramediastinal right upper
lobe mass invading the mediastinum and pleura are all substantially larger.
Small right pleural effusion is new. Pulmonary edema is minimal if any.
Heart size is normal.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: This is a ___ year old man with newly diagnosed sebaceous
carcinoma of the scalp and widely metastatic malignancy of unknown primary.
// ? pulmonary edema or other intrapulm process ? pulmonary edema or other
intrapulm process
IMPRESSION:
Comparison to ___. No relevant change is seen. Massive likely
metastatic nodularities throughout the entire lung parenchyma. Metastatic
paramediastinal right apical lesion. No new parenchymal opacities. No cardiac
enlargement. No pleural effusions. No pulmonary edema.
Radiology Report
EXAMINATION: CT-guided right pelvic mass biopsy
INDICATION: ___ year old man with newly dx metastatic malignancy, unknown
primary. // right gluteal mass biopsy via U/S?
COMPARISON: Outside CT abdomen ___
PROCEDURE: CT-guided right pelvic mass biopsy.
OPERATORS: Dr. ___ trainee and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a right lateral decubitus position on the CT scan
table. Limited preprocedure CTscan of the intended biopsy area was performed.
Based on the CT findings an appropriate position for the biopsy was chosen.
The site was marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the
lesion. An 18 gauge core biopsy device with a 22 mm throw was used to obtain
3 core biopsy specimens, which were sent for pathology.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Total DLP (Body) = 276 mGy-cm.
SEDATION: 25 mcg fentanyl was provided in addition to local anesthesia for
pain.
FINDINGS:
1. Pre procedural CT re- demonstrates the patient's right pelvic sidewall
mass.
2. Intraprocedural CT demonstrates appropriate positioning of the biopsy
device.
3.
IMPRESSION:
Successful CT-guided biopsy of a right pelvic mass.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Dyspnea, Pain
Diagnosed with Shortness of breath, Pleural effusion, not elsewhere classified
temperature: 98.3
heartrate: 96.0
resprate: 24.0
o2sat: 95.0
sbp: 140.0
dbp: 81.0
level of pain: 9
level of acuity: 2.0 | ___ yo male with a history of smoking who was recently found to
have a right upper lobe mass with extensive metastatic lesions
throughout the lung and significant hilar and mediastinal
lymphadenopathy:
# Widely Metastatic Cancer, Poorly differentiated carcinoma, to
liver, lung, bone
Chest imaging revealed a new right pleural effusion and interval
increase in the size of known RUL mass, the multiple metastatic
lung lesions and the hepatic and splenic lesions.
Patient was seen by interventional pulm, heme-onc and
interventional radiology to coordinate biopsy site. Biopsy of
mass adjacent to right acetabulum was done. Path showed poorly
differentiated carcinoma with possible urothelial primary vs
sebaceous carcinoma.
Given the poor prognosis, the family and patient decided to
focus on comfort and pain control rather than pursue further
treatment of malignancy. Palliative care was consulted for
assistance with Sx management. He was DC'd to ___ facility.
# Acute cancer Pain
Patient presented with significant pain. He was seen by
palliative care, who helped uptitrate pain control w/ ibuprofen,
acetaminophen, MS ___, morphine ___ and IV morphine. Please
see transitional issues for current regimen. Patient's pain well
controlled during daytime ___, but did tend to increase to
___ at night.
# Sebaceous carcinoma of the scalp: Sebaceous caricinoma is a
very rare tumor, and most common sites of metastasis are local
lymph nodes. Distant metastasis may involve the parotid gland,
liver, lung, and bone, which are sites of this patient's
disease. However, none the lymph nodes that drain the scalp
(parotid, submandibular, deep cervical, posterior auricular and
occipital lymph nodes) were positive on recent PET scan,
suggesting against sebaceous carcinoma as the primary tumor for
his metastatic disease. While he has had an excisional biopsy,
the PET scan suggested two areas on the scalp (vertex and left
frontoparietal portion) that were positive, and it is unknown
how many lesions were excised. Biopsy of pelvic mass could have
represented met from sebaceous carcinoma vs. urothelial
carcinoma. Wound care per surgeon: aquaphore x once per day
# Presumed atypical/bacterial pneumonia
# Hypoxemia
Patient with increasing SOB, significantly elevated WBC ct to 20
with neurotrphilic predominance and Chest CT w/ new groundglass
opacity in the bilateral upper lobes concerning for infection
vs. inflammation. No PE seen on imaging. Leukocytosis may also
be related to underlying inflammation from multiple necrotic
masses (lungs, liver). Hypoxemia may also be related to pleural
effusion v. splinting from pain. IP eval of pleural effusion and
felt to be too small to intervene upon. Patient initially
treated w/ CTX, azithromycin (___) and then broadened to
vanc/cefepime (___) due to worsening respiratory status
requiring 6L o2 and then 50% ___ mask. Patient discharged on
levaquin to end ___.
# Normocytic Anemia: No obvious signs of blood loss. Pleural
effusion noted to be non-hemorrhagic on imaging. ___ be related
to malignancy, anemia of chronic disease (esp. given
thrombocytosis), bone marrow failure from infiltrative disease.
Hemolysis less likely w/ elevated haptoglobin. Patient was
ultimately transfused 1 pRBC ___ for worsening respiratory
status. Hgb stable post transfusion.
# Hepatitis: likely related to large hepatic metastases seen on
imaging. Other causes include possible drug induced, viral or
underlying liver disease. Daughter says he has been getting
Percocet, vicodin and also up to 4g Tylenol per day, so this
does put him at risk for Tylenol overdose; however, Tylenol
level was normal. He is also on a statin which could contribute.
Viral and underlying liver disease less likely currently iso
mets. Statin was held during hospitalization.
# Hypoalbuminemia
# Leg swelling
Prior h/o left ankle injury with venous stasis. Known
hypoalbuminea. CT negative for PE. Leg edema improved w/ TEDs.
TRANSITIONAL ISSUES:
====================
# NEW MEDICATIONS:
--patient's pain control regimen, in cooperation with palliative
care:
MS-Contin 30mg TID, Morphine ___ PO 7.5-15mg q4h severe pain,
Morphine IV ___ q3h prn breakthrough pain, Ibuprofen 400mg TID
(per pt family request, gabapentin was DC'd), Tylenol ___ TID
--other palliative meds: 0.5-1mg Lorazeparm qhs prn: anxiety,
Zofran ODT 4mg q8h prn: nausea, 30ml Lactulose qd
--started on Abx for potential ___ finish 8d course of
Levaquin 750mg qd on ___
[] Please continue biopsy wound care site of scalp and right
pelvic mass. See page 1 for details.
# CONTACT: son ___ ___ (Health Care Proxy)
# CODE: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / adhesive tape / bee venom (honey bee) / Iodine
Attending: ___.
Chief Complaint:
Events concerning for seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ right-handed WF, who presents with a chief
complaint of a cluster of generalized seizures. Pt carries a
diagnosis of TLE since ___, but has not had any proven
seizures based on previous evaluations here, including during
LTM w/ cvEEG ___, which occurred after another cluster of
generalized convulsions, but during which she had normal EEGs
and none of her typical events despite weaning off of VPA and
TPM (was maintained on GBP). She follows with Dr. ___ has
kept pt on GBP 900 mg TID only, and has been urging the pt to
get an ambulatory EEG to capture the events that happen in the
outpt setting. Based on his notes and the family's report today,
pt has been free of any convulsive seizures since ___, and has
had a decrease in her other seizure type (brief episodes of
unresponsiveness or staring) since uptitration of her
gabapentin.
Pt now presents with a cluster of ___ seizures starting at
around 3pm yesterday, when her boyfriend noticed her to have one
of her typical staring episodes, followed by an episode of her
shaking her head left and right, with subsequent bilateral arm
shaking.
He saw two further episodes before transfer to OSH ED, wher the
ED physician ___ 2 more generalized convulsions. Daughter
then arrived, and witnessed another 2 convulsions, which she
describes as eyes rolling back during one seizure, with eyes
closed during the other, both with head shaking left and right,
accompanied by arm shaking (one arm going up as the other goes
down). At a couple points during these episodes, pt appeared to
try to open her eyes but said to the daughter "I see four of
you". No incontinence during any of these episodes but pt claims
that she bit her tongue during one of them (although I can see
no mark on the ___ exam). Pt claims complete amnesion for the
episodes in question.
.
SEIZURE TYPES:
1) In ___, had one episode of numbness in the right arm that
spread to the leg. Initially underwent TIA evaluation for this
2) Staring episodes with decreased responsiveness, sometimes
with word-finding difficulties, lasting few seconds to about 1
minute; these had been occurring several times per day, but more
recently has only been having one or two per week
3) In ___, had cluster of generalized convulsions, with
prodrome of dizziness and "not feeling well", complaining that
"it is too loud here", then appearing disoriented before having
a generalized convulsion. Per ___ discharge summary, daughter
observed her to have dilated pupils, eyes rolling back,
unresponsiveness, generalized convulsions lasting for about 1
minute, followed by some postictal disorientation. No tongue
biting or incontinence.
4) Similar to third type, generalized convulsion but was
witnessed by daughter to have had some right hand shaking
preceding this.
.
PREVIOUS EVALUATIONS:
Previous EEGs showed:
1) One EEG from OSH reportedly showed frequent b/l temporal
spikes
2) OSH EEG ___, per Dr. ___ shows rare R temporal
sharp waves & rare theta
3) ___ OSH EEG, per Dr. ___ w/occasional L central
theta slowing
4) cvEEG in EMU here ___: no electrographic or clinical
events, no epileptiform abnormalities. Previous MRIs showed in
___ slightly prominent sulci for age, no diffusion abnormality
or other focal finding, no mesial temporal sclerosis
.
RISK FACTORS FOR SEIZURES:
1. Head Trauma: endorses distant domestic head trauma leading to
shattered jaw and broken ear drum
2. CNS Infections: none
3. Family History of Seizures: father with generalizes seizures,
details unknown; one brother with 2 generalized seizures.
Daughter ___ was recently diagnosed with epilepsy after
suffering 2 generalized tonic-clonic seizures preceded by
premonitory aura, with LOC, incontinence and biting of the side
of the tongue; EEG apparently showed some L temporal focality.
Has been seizure free seince being started on levetiracetam.
4. Developmental Delay: none
5. Febrile Seizures: none
6. CNS Tumors: none
7. CNS Vascular Disease: has vague history of stroke or TIA in
___, although pt does not recall the details, and there was no
corresponding abnormality on MRI in ___.
8. Significant Medical History: anxiety, depression, migraines
.
CURRENT MEDICATIONS:
Gabapentin 900 mg TID
Other meds: ASA 81 mg daily, simvastatin 10 mg daily, trazodone
100 mg qhs PRN, Percocet PRN, APAP PRN, fish oil 1000 mg daily,
Ca + D
The patient's side effects to the current medications are none.
.
PRIOR ANTICONVULSANT HISTORY:
Previous anticonvulsant medications included: VPA (ineffective,
caused alopecia), OXC (hyponatremia, questionable efficacy), LEV
(forgetfulness, dangerous behaviors such as leaning on hot stove
or opening car door in traffic)
.
On neurologic ROS, no
headache/lightheadedness/confusion/syncope/difficulty with
producing or comprehending speech/amnesia/concentration
problems; no loss of vision/blurred
vision/amaurosis/diplopia/vertigo, tinnitus, hearing difficulty,
dysarthria, or dysphagia. No muscle weakness. No loss of
sensation/numbness/tingling. No difficulty with gait/balance
problems/falls.
On general ROS, no fevers/chills/rigors/night
sweats/anorexia/weight loss. No chest
pain/palpitations/dyspnea/exercise intolerance/cough. No
nausea/vomiting/diarrhea/constipation/abdominal pain. No
dysuria/hematuria, and no bowel or bladder
incontinence/retention/hesitancy. No myalgias/arthralgias/rash.
Past Medical History:
- TLE vs non-epileptic seizures
- Hep C
- Latent TB s/p Rx
- ? TIA/stroke as above
- Anxiety
- Depression
- Migraines
- Neuropathy
- Scoliosis
- Vertigo
- Fibromyalgia, s/p trigger-point injections in pain clinic
- T12 compression fx
Social History:
___
Family History:
Her father had generalized seizures, but she does not know
further details about this. No other known seizures in family.
She does not know any other family medical history.
Physical Exam:
Admission exam:
Physical Examination:
VS T97 HR 72 BP 114/75 RR 18 SpO2 98%
I did see several of pt's "staring spells" during this
evaluation. These were not stereotyped events, variably
characterized by looking in one direction without answering,
head dropping to left with eyes closing. These were brief
events, lasting < 10 seconds. No automatisms noted.
General: NAD, lying in bed comfortably. No obvious
dysmorphology.
- Head: NC/AT, no conjunctival pallor or icterus, no
oropharyngeal lesions
- Neck: Supple, no nuchal rigidity. No lymphadenopathy or
thyromegaly.
- Cardiovascular: carotids with normal volume & upstroke; RRR,
no M/R/G
- Respiratory: Nonlabored, clear to auscultaton with good air
movement bilaterally
- Abdomen: nondistended, normal bowel sounds, no
tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edema
.
Neurological Exam:
-Mental Status: Awake, alert, oriented x 3. Recalls a coherent
history. Concentration maintained when recalling months
backwards, with 2 self-corrected mistakes. Language fluent
without dysarthria and with intact repetition and verbal
comprehension. No paraphasic errors. Follows two-step commands,
midline and appendicular. High- and low-frequency naming intact.
Normal reading. Normal prosody. No dysarthria. Registration ___
and recall ___. No ideomotor apraxia or neglect. Normal
performance on Luria hand sequencing.
.
-Cranial Nerves: [II] PERRL 3->2 brisk. VF full to number
counting. [III, IV, VI] EOM intact, no nystagmus. [V] V1-V3
without deficits to light touch bilaterally. Pterygoids contract
normally. [VII] No facial asymmetry. [VIII] Hearing grossly
intact. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius
strength ___ bilaterally. [XII] Tongue midline and moves
facilely.
.
-Motor: Normal bulk and tone. No pronation or drift. No tremor
or asterixis.
[Delt] [Bic] [Tri] [ECR] [FF] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___] [EDB]
L 5 5 5 5 5 5 5 5 5 5 5
5 5
R 5 5 5 5 5 5 5 5 5 5 5
5 5
.
-Sensory: No deficits to proprioception bilaterally. Intact
warm/cold temperature discrimination.
.
-Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response flexor bilaterally.
.
-Coordination: No dysmetria on finger-to-nose and heel-knee-shin
testing. No dysdiadochokinesia
.
-Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable stance without sway. No Romberg. Intact heel,
toe gait. Unable to tandem
.
Discharge exam:
Unchanged
Pertinent Results:
Lab:
___ 03:30PM BLOOD WBC-6.0 RBC-4.16* Hgb-13.5 Hct-40.3
MCV-97 MCH-32.4* MCHC-33.4 RDW-13.6 Plt ___
___ 05:50AM BLOOD WBC-5.3 RBC-3.76* Hgb-12.1 Hct-36.4
MCV-97 MCH-32.1* MCHC-33.2 RDW-13.7 Plt ___
___ 03:30PM BLOOD Neuts-56.6 ___ Monos-7.9 Eos-1.7
Baso-1.1
___ 05:50AM BLOOD Neuts-38.8* Lymphs-51.6* Monos-6.4
Eos-1.6 Baso-1.6
___ 03:30PM BLOOD Plt Smr-NORMAL Plt ___
___ 05:50AM BLOOD Plt ___
___ 03:30PM BLOOD Glucose-85 UreaN-8 Creat-0.7 Na-142 K-4.7
Cl-107 HCO3-27 AnGap-13
___ 05:50AM BLOOD Glucose-76 UreaN-15 Creat-0.8 Na-140
K-4.3 Cl-105 HCO3-27 AnGap-12
___ 03:30PM BLOOD estGFR-Using this
___ 05:50AM BLOOD ALT-9 AST-17 AlkPhos-83 TotBili-0.2
___ 05:50AM BLOOD TotProt-5.6* Albumin-3.9 Globuln-1.7*
Calcium-8.9 Phos-4.7* Mg-2.0
___ 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:30PM BLOOD HoldBLu-HOLD
___ 03:30PM BLOOD LtGrnHD-HOLD
___ 03:30PM BLOOD GreenHd-HOLD
___ 02:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:00AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 02:00AM URINE RBC-7* WBC-106* Bacteri-FEW Yeast-NONE
Epi-4
___ 02:00AM URINE Mucous-FEW
___ 02:55PM URINE Hours-RANDOM
___ 02:55PM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
ECG:
___ ECG
Sinus rhythm. Non-diagnostic Q waves inferiorly. Early R wave
transition.
Non-specific ST segment flattening. No previous tracing
available for comparison.
.
Imaging:
___ CHEST (PORTABLE AP)
FINDINGS: In comparison with study of ___, the atelectatic
changes at the left base have cleared. Now there is no evidence
of pneumonia, vascular congestion, or pleural effusion.
.
EEG: No epileptiform activity captured over course of admission
Medications on Admission:
Gabapentin 900 mg TID
ASA 81 mg daily
simvastatin 10 mg daily
trazodone 100 mg qhs PRN
Percocet PRN
APAP PRN
fish oil 1000 mg daily
Ca + D
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Gabapentin 900 mg PO Q8H
4. Vitamin D 400 UNIT PO DAILY
5. Simvastatin 10 mg PO DAILY
6. traZODONE 100 mg PO HS:PRN insomnia, anxiety
7. Aspirin 81 mg PO DAILY
8. Ibuprofen 800 mg PO Q8H:PRN Pain
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Doses
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Non-electrical epileptic events
Secondary:
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Epilepsy with seizure cluster, to assess for pneumonia.
FINDINGS: In comparison with study of ___, the atelectatic changes at the
left base have cleared. Now there is no evidence of pneumonia, vascular
congestion, or pleural effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
WALK IN
Chief complaint: UNSTEADY GAIT/UNCOOPERATIVE
SEIZURES
Diagnosed with OTHER CONVULSIONS, URIN TRACT INFECTION NOS
EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY
temperature: 98.8
97.0
heartrate: 77.0
72.0
resprate: 18.0
18.0
o2sat: 94.0
98.0
sbp: 114.0
114.0
dbp: 66.0
75.0
level of pain: 13
9
level of acuity: 2.0
3.0 | ___ y/o woman who has a history of epilepsy who presented on ___
for reported seizure cluster. She was going to be admitted but
had left against medical advice only to return again on ___ by her primary care provider after she was found to be
agitated and unsteady. Here she was somewhat uncooperative, the
history was gathered by her daughter, who said that the patient
was not telling the truth.
At admission, she reported headache, back pain, and anger at
watched by the sitter. A general review of systems revealed a
mild expiratory wheeze but was otherwise unremarkable. Her
neurologic examination was normal except for minor swaying on
Romberg and a little difficulty in performing tandem gait. On
laboratory investigations, she was found to have anaemia, an
evelated white count and a UTI.
# SEIZURE:
- Monitored on video EEG for 5 days with no pushbutton events
captured as seizure, was weaned on ___ off gabapentin from 900mg
to 450mg x3 doses then off, which did not trigger any seizure
events. Restarted gabapentin 900mg TID with plans to follow up
with Dr. ___.
# HEADACHE:
Given Trazadone qhs PRN pain, Tramadol, Ibuprofen, and Ketorolac
which did not help pain. Fiorcet given PRN x2 for better
control.
# HYPERLIPIDEMIA:
Continued home Simvasatin
# UTI:
Found UA was positive for UTI, continued Bactrim x7 days ___
first dose, will be d/c'ed with 2 additional days).
# TRANSITIONS OF CARE:
- No EEG correlate to any activity even under taper off of
gabapentin
- Continued Gabapentin as outpatient
- Will f/u with ___ in clinic
- Bactrim x7d, will complete 2 additional days |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
transfer from OSH with acute stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old man who presents as a transfer from
___. The history is obtained from the OSH and the
patient's wife as the patient is not able to provide a history
at this time. Per his wife, the patient awoke at 7am and went
down stairs to watch television. His wife did not speak to him
or see him from 7am until she went into the kitchen at 8:30am
and found him slumped on the counter with coffee spilled all
over the floor. She tried speaking to him, but he did not
respond. She called EMS who arrived within a few minutes. At
___, they performed a NCHCT and CTA head and neck. He
was noted to be globally aphasic with mild right-hemibody
weakness. They bolused IV TPA at 9:45am. A laceration was noted
on the patient's right cheek, it was unclear what this was due
to, but suspected it may have occurred while slumped on the
counter at home. This laceration started to bleed and swell to
the extent that the TPA infusion was stopped early, at about
10:35am (50 minutes into the hour-long infusion). The patient
was then transferred here for post-TPA care and consideration of
neurointervention.
ROS: Unable to obtain due to aphasia. Per patient's wife, no
recent symptoms or complaints.
Past Medical History:
none
Social History:
___
Family History:
Younger brother had a stroke about ___ years ago, still
recovering. His parents lived to their ___ and both had heart
disease. No other strokes in the family.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.5 P: 101 -->93 BP: 144/79 (133-144/78-79) RR: 18
SaO2: 98-99% RA
___: Awake, cooperative, appears frustrated.
HEENT: Right cheek swollen with laceration near corner of mouth
that is oozing. Crusted blood on right side of lip. No scleral
icterus, MMM
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irreg irreg, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: large patches ___ red areas over bilateral calves.
___ Stroke Scale score was: 10
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 2
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 1
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 2
10. Dysarthria: 0
11. Extinction and Neglect: 0
Neurologic:
-Mental Status: Alert. Attentive, in that he mimics movements
and
attempts to participate in exam. Speaks in short, common catch
phrases with no actual content. Nonfluent. Unable to follow
simple commands. Can not repeat or name. Able to read one letter
correctly, unable to read any words. Attempts to write, but
stops
in frustration after writing no decipherable letters. Speech was
not dysarthric. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Blinks to threat in bilateral
visual fields. Funduscopic exam revealed no papilledema.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Reacts to light touch on face bilaterally
VII: Appears to have flattening of righ N-L fold, although
difficult to visualize due to swelling from laceration.
VIII: Reacts to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: Turns head symmetrically.
XII: Tongue protrudes in midline and moves without clumsiness.
-Motor: Normal bulk, tone throughout. Very slight drift of right
upper and lower extremities. Able to hold all extremities
antigravity for 10 seconds in UEs and 5 in lowers. No
adventitious movements. Does not cooperate with formal strength
testing.
-Sensory: Reacts to light touch and pinch in all extremities.
-DTRs:
___ Pat Ach
L 2+ ___ 2+
R 2+ ___ 2+
Plantar response was extensor bilaterally.
-Coordination: No dysmetria on FNF, although difficult to coach
patient on how to participate. UE RAMs symmetric.
-Gait: deferred
==========================================================
Discharge Physical Exam:
___: Awake and alert, NAD. Large area of ecchymosis and
swelling over R face, with ecchymosis tracking down into his R
neck and supraclavicular area.
Mental status: Alert and oriented x3. Language is fluent but
with frequent phoenemic paraphasic errors (jock for job, adviror
for advisor, treble for travel). Naming is intact for high but
not low frequency objects. Repetition is intact for simple but
not complex phrases. He is able to follow commands with
repetition and encouragement. He is able to read but with
paraphasic errors
and word substitutions. He is able to write his name and ___ short
sentence.
Cranial nerves: Pupils equal and reactive, EOMI. +R lower facial
droop.
Motor: Normal bulk and tone. Very slight R pronator drift.
Strength is ___ throughout in all muscle groups of the upper and
lower extremities.
Sensation: Intact to light touch throughout.
Reflexes: 2+ and symmetric, toes downgoing.
Coordination: FNF without dysmetria.
Gait: Normal steady casual.
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-18.2* RBC-5.19 Hgb-16.8 Hct-48.1
MCV-93 ___-32.3* MCHC-34.8 RDW-13.2 Plt ___
___ 01:20PM BLOOD Neuts-84.5* Lymphs-10.7* Monos-3.4
Eos-0.8 Baso-0.6
___ 01:20PM BLOOD ___ PTT-29.6 ___
___ 12:16PM BLOOD Glucose-115* UreaN-12 Creat-0.8 Na-141
K-4.0 Cl-105 HCO3-26 AnGap-14
___ 12:16PM BLOOD Calcium-8.6 Phos-2.0* Mg-2.1 Cholest-167
___ 03:15PM BLOOD %HbA1c-5.6 eAG-114
___ 12:16PM BLOOD Triglyc-84 HDL-65 CHOL/HD-2.6 LDLcalc-85
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-10.8 RBC-5.05 Hgb-16.1 Hct-47.4
MCV-94 MCH-31.9 MCHC-34.0 RDW-12.6 Plt ___
___ 07:35AM BLOOD Glucose-108* UreaN-13 Creat-0.9 Na-139
K-4.4 Cl-103 HCO3-25 AnGap-15
___ 07:35AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.1
URINE:
___ 01:37PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:37PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:37PM URINE RBC-1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-<1
URINE CULTURE ___ BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
IMAGING:
ECG ___:
Atrial fibrillation. Leftward axis. Possible septal myocardial
infarction of indeterminate age. Non-specific repolarization
abnormalities. No previous tracing available for comparison.
CT head:
There is hypodensity with loss of gray-white matter
differentiation
in the posterior insular region on the left extending to the
left
frontoparietal region and the left medial temporal lobe,
consistent with
ischemic stroke. A hyperdensity is seen within a left MCA
branch overlying
the left insula, consistent with thrombus. There is no evidence
of acute
hemorrhage. There is no midline shift.
There is a 9 x 13 mm hypodensity in the right side of the
cerebellum, which may represent a recent infarct given its
rounded configuration. There is a hypodensity in left side of
the cerebellum, likely reflecting an old infarct. Prominent
ventricles and sulci suggest age related involutional changes.
Scattered white matter hypodensities are suggestive of chronic
small vessel ischemic disease. The basal cisterns appear
patent.
No fracture is identified. Mucosal thickening is seen in the
ethmoid air
cells. The right maxillary sinus is opacified and there is
mucosal thickening left maxillary sinus. The other visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
1. Recent infarct in left MCA territory as detailed above.
2. Hypodensity is cerebellum on the right, which may represent
infarct, age indeterminate. This would be better evaluated on
MR.
___ brain:
Subacute ischemic changes identified in the posterior fossa
involving both cerebellar hemispheres, left superior colliculus
and left insular and parietal regions as described in detail
above, there is no evidence of hemorrhagic transformation,
hydrocephalus or significant mass effect.
Opacity of the right maxillary sinus appears unchanged and also
mild mucosal thickening in the ethmoidal air cells.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
2. Rivaroxaban 15 mg PO DAILY
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
3. Outpatient Speech/Swallowing Therapy
Speech and language evaluation and treatment.
Discharge Disposition:
Home
Discharge Diagnosis:
Left Middle Cerebral Artery Stroke
Atrial fibrillation
Aphasia
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic exam on discharge: fluent aphasia with frequent
paraphasic errors. Right sided lower facial droop. Right arm
and leg strength are back to normal.
Followup Instructions:
___
Radiology Report
HISTORY: Embolic stroke today, status post t-PA.
COMPARISON: Comparison is made with head CT from outside hospital from
earlier the same day, ___.
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 hypodensity with loss of gray-white matter differentiation
in the posterior insular region on the left extending to the left
frontoparietal region and the left medial temporal lobe, consistent with
ischemic stroke. A hyperdensity is seen within a left MCA branch overlying
the left insula, consistent with thrombus. There is no evidence of acute
hemorrhage. There is no midline shift.
There is a 9 x 13 mm hypodensity in the right side of the cerebellum, which
may represent a recent infarct given its rounded configuration. There is a
hypodensity in left side of the cerebellum, likely reflecting an old infarct.
Prominent ventricles and sulci suggest age related involutional changes.
Scattered white matter hypodensities are suggestive of chronic small vessel
ischemic disease. The basal cisterns appear patent.
No fracture is identified. Mucosal thickening is seen in the ethmoid air
cells. The right maxillary sinus is opacified and there is mucosal thickening
left maxillary sinus. The other visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
1. Recent infarct in left MCA territory as detailed above.
2. Hypodensity is cerebellum on the right, which may represent infarct, age
indeterminate. This would be better evaluated on MR.
Radiology Report
STUDY: MRI of the head.
CLINICAL INDICATION: ___ man with global aphasia and mild right arm
and leg weakness, status post TPA at 9 a.m. on ___, evaluate for
hemorrhagic transformation post TPA and evaluate stroke.
COMPARISON: Prior CTA from an outside institution dated ___ and
prior head CT performed at ___ on ___ at 13:48 hours.
TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic susceptibility
and axial diffusion-weighted images were obtained through the brain.
FINDINGS: Areas of restricted diffusion are identified in both cerebellar
hemispheres, slightly more prominent on the right, measuring approximately 16
x 10 mm in transverse dimension and on the left 12 x 3 mm in transverse
dimension. There is no evidence of mass effect in the IV ventricle.
Supratentorially, extensive area of subacute ischemia and slow diffusion is
identified, vascular territory of the left middle cerebral artery, involving
the posterior insular region and left parietal lobe, there is no evidence of
mass effect or shifting of the normally midline structures. There is no
evidence of hemorrhagic transformation or susceptibility changes. Scattered
foci of high signal intensity are identified in the subcortical white matter
bilaterally, which are nonspecific and may reflect changes due to small vessel
disease. A small focus of slow diffusion is identified in the left superior
colliculus (image #9, series #8), consistent with focal area of subacute
ischemia. The major vascular flow voids in the skull base are present. The
orbits are unremarkable, mucosal thickening is noted in the ethmoidal air
cells and complete opacity of the right maxillary sinus appears unchanged
since the prior CT.
IMPRESSION: Subacute ischemic changes identified in the posterior fossa
involving both cerebellar hemispheres, left superior colliculus and left
insular and parietal regions as described in detail above, there is no
evidence of hemorrhagic transformation, hydrocephalus or significant mass
effect. Opacity of the right maxillary sinus appears unchanged and also mild
mucosal thickening in the ethmoidal air cells.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: New Afib stroke and leukocytosis.
There is moderate cardiomegaly. Right lower lobe opacities could be due to
atelectasis but aspiration should be considered. There is no pneumothorax or
pleural effusion.
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: CVA, Transfer
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, ATRIAL FIBRILLATION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a previously healthy ___ man with no
known past medical history who presented with acute onset
difficulty speaking and right sided weakness in the setting of
undiagnosed atrial fibrillation.
# Acute inferior division left MCA ischemic stroke: He presented
with aphasia and mild right-sided weakness to an outside
hospital where he was administered tpa prior to transfer to
___. At ___, MRI showed large infarct in the inferior left
MCA distribution, in addition to two smaller infarcts in the
cerebellum and one in the left midbrain. This was most
consistent with a shower of emboli that resulted from his newly
diagnosed atrial fibrillation. He was initiated on rivaroxaban
for anticoagulation. Also started on a statin. Other stroke
risk factors were evaluated and were within normal limits. On
discharge, his primary deficit remained his fluent aphasia (see
discharge exam for further details). He was given a script for
speech and language therapy as he wished to pursue this close to
home. He was also told about ___ related aphasia research and
given contact numbers regarding this. He will follow-up at
___ stroke clinic.
# Atrial fibrillation: New diagnosis this admission. This is
the likely trigger for the embolic shower described above. TTE
did not show cardiac thrombus. He was started on rivaroxaban
for anticoagulation. There was no need for rate control
medication. His primary care physician was made aware of this
and was asked to arrange follow-up with a cardiologist near the
patient's home.
TRANSITIONAL ISSUES:
1) Speech and language evaluation: family preferred to set this
up in ___ rather than at ___
2) New cardiology follow-up will be arranged by PCP
3) Patient interested in aphasia research projects at ___. We
provided him information. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Augmentin
Attending: ___.
Chief Complaint:
vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old left-handed female with
relapsing-remitting multiple sclerosis (currently not on disease
modifying therapy; followed by Dr. ___ who presents with
acute-onset persistent vertigo since awakening this morning.
Patient was feeling well until this morning. She went to bed at
9:45pm and awoke at 6AM. Upon awakening she was profoundly
vertiginous (described as room spinning around her). Vertigo is
exacerbated by any kind of movement of her body or head. Her
gait
is very unsteady. She needs to hold onto furniture/walls to
ambulate. She denies headache, new sensory or motor symptoms,
vision changes. She had chills yesterday, but denies specific
infectious symptoms. She has no ear fullness or change in
hearing.
She reports having vertigo once before (years ago). She was
prescribed meclizine, which helped. Her symptoms resolved in a
few days.
She most recently saw Dr. ___ in clinic on ___. At
that
time, he had planned to start Ms. ___ on teriflunomide;
however, she has not yet started taking this medication.
On neurologic ROS, the pt denies headache, loss of vision,
blurred vision, diplopia, dysarthria, 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. 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:
Asthma
Lactose intolerance
Ovarian cyst s/p removal ___
Back Pain
Dysmenorrhea
Lymphocytic colitis, controlled
constipation
IBS (irritable bowel syndrome)
Postpartum hemorrhage
Social History:
___
Family History:
Mother: ___
Paternal Grandmother, great ___, 3 aunts with
lupus
___ uncle: DVT at age ___
Maternal grandmother: "epileptic"
Physical Exam:
Admission Physical Exam
Vitals: T36, HR 96, BP 122/80, 99% RA
General: Awake, cooperative, NAD.
HEENT: No scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Non-labored breathing on ambient air
Cardiac: RRR, no MRG.
Abdomen: Soft, NT/ND, no masses or organomegaly noted.
Extremities: Warm, well-perfused, no cyanosis, clubbing or edema
bilaterally
Skin: no rashes or lesions noted.
NEUROLOGIC:
-----------
-Mental Status:
Oriented to date and location. Able to ___ backwards. Recalls
___ objects at 3 minutes. Speech is articulate, fluent, and no
errors.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic
exam deferred due to severe discomfort.
III, IV, VI: Full range, conjugate gaze. Left-beating nystagmus
on left gaze. No nystagmus in primary position. No vertical
nystagmus. No skew deviation. Cannot tolerate head impulse test.
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
R 5 ___ 5 ___- 5 5 5 5 5
Of note, patient was quite uncomfortable, so the motor exam was
not reliable. Given these limitations, I could not appreciate
significant focal weakness.
-Sensory:
No deficits to light touch, pinprick.
-Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Patellar reflexes slightly brisk bilaterally, with
+suprapatellar
but no crossed adductors.
Plantar response was flexor bilaterally.
-Coordination:
Mild intention tremor bilaterally. No dysmetria. There is slight
dysdiadochokinesia of the RUE.
-Gait:
Very unsteady. Falls to the right when standing or attempting
stride. Vomits several times after standing up.
Discharge Physical Exam
___ 1111 Temp: 98.2 PO BP: 117/76 HR: 77 RR: 14 O2 sat: 96%
O2 delivery: Ra FSBG: 106
General: Awake, cooperative, NAD.
HEENT: No scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Non-labored breathing on ambient air
Cardiac: RRR, no MRG.
Abdomen: Soft, ND
Extremities: Warm, well-perfused, no cyanosis, clubbing or edema
bilaterally
Skin: no rashes or lesions noted.
NEUROLOGIC:
-----------
-Mental Status: Alert & oriented. Speech is articulate, fluent,
and no errors.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV, VI: Full range, conjugate gaze. No nystagmus on primary
gaze or on lateral/vertical gaze testing. No skew deviation.
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
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory:
No deficits to light touch.
-Reflexes:
Bi Tri ___ Pat Ach
L 1 1 1 2 1
R 1 1 1 2 1
Patellar reflexes slightly brisk bilaterally.
Plantar response was flexor bilaterally.
-Coordination:
No dysmetria. There is no dysdiadochokinesia.
Mild veering towards right side while standing upright, no
ataxia with sitting upright in bed
-Gait:
mildly unsteady. veers to the right when walking
Pertinent Results:
___ 11:52AM %HbA1c-5.3 eAG-105
___ 11:52AM WBC-11.1* RBC-4.63 HGB-12.2 HCT-39.3 MCV-85
MCH-26.3 MCHC-31.0* RDW-15.4 RDWSD-46.9*
___ 11:52AM NEUTS-88.8* LYMPHS-7.8* MONOS-2.5* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-9.86* AbsLymp-0.86* AbsMono-0.28
AbsEos-0.01* AbsBaso-0.03
___ 11:52AM PLT COUNT-213
___ 10:30AM GLUCOSE-108* UREA N-9 CREAT-0.6 SODIUM-138
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-20* ANION GAP-14
___ 10:30AM estGFR-Using this
___ 10:30AM ALT(SGPT)-20 AST(SGOT)-20 ALK PHOS-99 TOT
BILI-0.2
___ 10:30AM LIPASE-23
___ 10:30AM cTropnT-<0.01
___ 10:30AM ALBUMIN-4.6 CALCIUM-9.3 PHOSPHATE-2.1*
MAGNESIUM-1.6
___ 10:30AM HCG-<5
___ 10:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 10:30AM ___ PTT-26.2 ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
2. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
2. Vitamin D ___ UNIT PO 1X/WEEK (___)
3.Rolling Walker
To be obtained by ___ dept
Diagnosis: Multiple Sclerosis
Prognosis: good
Length of Need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MS ___
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 T___ MR HEAD
INDICATION: History: ___ with presumed MS flare // Multiple sclerosis
protocol
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: Brain MRI dated ___.
FINDINGS:
There are numerous new white matter lesions demonstrating increased
diffusion-weighted signal. These include lesions in the left corona radiata
with associated enhancement (7:21, 14:123), right frontal lobe (7:23), left
splenium of the corpus callosum with mild rim enhancement (7:18, 14:110), and
right middle cerebellar peduncle (7:8). Overall, in comparison to the study
of ___, the extent of T2 and FLAIR hyperintense white matter
abnormality has significantly progressed.
There is no intracranial hemorrhage or mass. Prominence of the ventricles and
sulci are likely related to parenchymal volume loss in the setting of
demyelinating disease. Optic nerve signal intensity is normal. The imaged
upper cervical cord does not demonstrate any signal abnormality.
There is mild mucosal thickening in the anterior ethmoid air cells. Mastoid
air cells and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Numerous white matter lesions many of which demonstrate high signal on the
diffusion weighted images and a couple with abnormal postcontrast enhancement
consistent with acute demyelinating lesions given the history of multiple
sclerosis. Locations include both frontal lobes, the left splenium of the
corpus callosum, and right middle cerebellar peduncle.
2. Overall, significant increase in white matter disease compared to ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, N/V
Diagnosed with Dizziness and giddiness
temperature: 96.8
heartrate: 96.0
resprate: 16.0
o2sat: 100.0
sbp: 122.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old left handed woman who
presented with hyperacute onset of severe persistent vertigo and
truncal as well as right sided ataxia. She was found on imaging
to have progression of her MS with ___ new midline
cerebellar/inferior peduncle lesion which is consistent with her
clinical findings. She was treated with Methylprednisolone 1g IV
q24h x 4 days while in hospital, and one day after discharge for
a total of 5 days of therapy. Of note ___ recommended acute
rehabilitation, but after understanding the risks and benefits
of being discharged to home ___ rehab, the patient elected to be
discharged directly home.
TRANSITIONAL ISSUES
Follow up disease modifying therapy regimen aubagio vs
tysabri/ocrevus/tecfidera. Pt was scheduled for aubagio but
never took it bc of prohibitively high co-pay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD ___
Bilateral thoracentesis ___
History of Present Illness:
The patients is a ___ with a history of alcoholic cirrhosis,
afib presenting for an acute UGIB concerning for a varicele
bleed. We do not have any history from this patient in our
system, so this history is all gathered from the patient and we
will work toward finding outside hospital records to confirm.
The patient reports that he has had varicele bleeds in the past,
most recently in ___ when he was seen at ___ and had
what sounds like a banding procedure of 5 bleeding varices. PTA
of OSH he had ___ large hematemesis events with lightheadedness
and vision changes.On arrival to OSH, he is reported to have had
SBPs in the ___. At that time he was given 4 liters of
crystalloid, and two units of PRBCs. He was started on
Octreotide and pantoprazole. We do not have any labs from that
time. The patient was then urgently transferred to the ___ ED.
During transport, the patient's SBPs remained stable in the ___,
and continued to mentate well. On arrival to the ED, he was
continued on Octreotide and pantoprazole, and CTX was added.
Upon arrival, he was mentating and answering questions
appropriately. He states he has minimal abdominal pain and has
had no fevers or chills. He denies any chest pain, palpitations,
dyspnea, urinary symptoms, rashes, or paresthesias.
Last drink ___
In the ED, initial vitals were:
98.4 ___ 15 100% Nasal Cannula
- Exam notable for:
Con: alert, oriented and in no acute distress
HEENT: NCAT. PERRLA, no icterus or injection but pallor
bilaterally. EOMI. No erythema or exudate in posterior pharynx;
uvula midline; MMM.
Neck: neck veins flat with full ROM
LAD: no cervical LAD
Resp: Breathing comfortably on RA. No incr WOB, CTAB with no
crackles or wheezes.
CV: irregularly irregular and tachycardic. Normal S1/S2. NMRG.
2+ radial and DP pulses bilateral.
Abd: Soft, mild tenderness diffusely, Nondistended with no
organomegaly; no rebound tenderness or guarding. Reducible
umbilical hernia
MSK: ___ without edema bilaterally
Skin: No rash, Warm and dry, No petechiae
Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
Psych: Normal mentation
- Labs notable for:
17.5>8.4/27.1 <166
___: 21.9 PTT: 36.9 INR: 2.0
ALT: 39AP: 131Tbili: 5.6Alb: 2.7
AST: ___
___
5.1201.2
Lactate:2.6
- Imaging was notable for: None
- Patient was given: CTX, Zofran, Octreotide
Consults:
___ M with etoh cirrhosis and portal hypertension with prior
history of EV bleed requiring banding in ___, ascites,
no reported HE. Presenting from home for large volume
hematemesis this morning, light headedness and some mild
dyspnea. Last drink ___.
HH stable but after 2 units of blood at OSH this morning.
Unclear baseline. Tachycardic to 120s. Map 62.
Past Medical History:
Alcoholic cirrhosis
AF not on AC
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
===========================
VITALS: Reviewed in MetaVision.
HEENT: NCAT. PERRLA, no icterus or injection. Intubated and
sedated
Neck: neck veins flat
Resp: CTAB with no crackles or wheezes.
CV: irregularly irregular and tachycardic. Normal S1/S2. NMRG.
2+ radial and DP pulses bilateral.
Abd: Soft, Nondistended with no organomegaly; no rebound
tenderness or guarding. Reducible umbilical hernia
MSK: ___ without edema bilaterally
Skin: No rash, Warm and dry, No petechiae
Neuro: Sedated to a RAS -2 to 3
Psych: Normal mentation
DISCHARGE PHYSICAL EXAM:
============================
VS: 24 HR Data (last updated ___ @ 822)
Temp: 97.9 (Tm 99.3), BP: 107/67 (88-107/47-69), HR: 99
(95-122), RR: 16 (___), O2 sat: 98% (94-100), O2 delivery: Ra,
Wt: 224.3 lb/101.74 kg
GEN: in no acute distress
HEENT: anicteric sclerae, MMM
CARDIAC: Irregularly irregular, nl S1/S2, no mgr
LUNGS: normal WOB, speaking full sentences, CTAB, good
inspiratory effort, no wheezing or crackles
ABDOMEN: NABS, soft, moderately distended, nontender, no
rebound/guarding
NEUROLOGIC: A/Ox3, moves all extremities, no asterixis
Pertinent Results:
ADMISSION LABS
=================================
___ 09:05AM BLOOD WBC-17.5* RBC-2.95* Hgb-8.4* Hct-27.1*
MCV-92 MCH-28.5 MCHC-31.0* RDW-16.5* RDWSD-54.7* Plt ___
___ 09:05AM BLOOD Neuts-79.8* Lymphs-6.0* Monos-11.0
Eos-1.7 Baso-0.5 Im ___ AbsNeut-13.93* AbsLymp-1.04*
AbsMono-1.92* AbsEos-0.30 AbsBaso-0.09*
___ 09:05AM BLOOD ___ PTT-36.9* ___
___ 09:05AM BLOOD Glucose-111* UreaN-21* Creat-1.2 Na-137
K-5.1 Cl-106 HCO3-20* AnGap-11
___ 09:05AM BLOOD ALT-39 AST-54* AlkPhos-131* TotBili-5.6*
___ 09:05AM BLOOD Lipase-41
___ 09:05AM BLOOD Albumin-2.7*
___ 12:09PM BLOOD Calcium-7.5* Phos-5.5* Mg-1.7
___ 09:27AM BLOOD Lactate-2.6*
___ 05:09PM BLOOD Hgb-10.8* calcHCT-32
___ 05:09PM BLOOD freeCa-1.04*
DISCHARGE LABS:
======================================
___ 06:55AM BLOOD WBC-10.0 RBC-3.18* Hgb-9.3* Hct-29.2*
MCV-92 MCH-29.2 MCHC-31.8* RDW-17.8* RDWSD-59.0* Plt ___
___ 06:55AM BLOOD ___ PTT-43.0* ___
___ 06:55AM BLOOD Glucose-99 UreaN-13 Creat-0.7 Na-138
K-4.3 Cl-105 HCO3-23 AnGap-10
___ 06:55AM BLOOD ALT-32 AST-48* AlkPhos-167* TotBili-3.3*
___ 06:55AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.7
OTHER PERTINENT LABS:
======================================
___:16AM BLOOD Ret Aut-2.2* Abs Ret-0.07
___ 03:16AM BLOOD ___
___ 09:05AM BLOOD Lipase-41
___ 05:29AM BLOOD 25VitD-6*
___ 09:59AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
___ 09:59AM BLOOD HCV Ab-NEG
___ pleural fluid:
left: TNC 185, RBC 1485, poly 13%, total prot 3.4, gluc 118, LDH
115, alb 2.3, cholesterol 53
right: TNC 258, RBC 369, poly 5%, total prot 1.9, gluc 125, LDH
75, alb 1.5, cholesterol 26
___ 05:40AM BLOOD ALT-38 AST-54* LD(LDH)-203 AlkPhos-111
TotBili-3.4*
___ 07:02AM BLOOD TotProt-5.9* Calcium-8.8 Phos-2.9 Mg-1.5*
IMAGING:
======================================
___ Abdominal Ultrasound
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The
contour of the liver is nodular, consistent with cirrhosis.
There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 6 mm.
GALLBLADDER: The gallbladder is distended though there is no
evidence of
stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic tail obscured by overlying bowel gas.
SPLEEN: The spleen measures up to 12 cm and demonstrates normal
echogenicity throughout.
KIDNEYS: The right kidney measures 10.8 cm. The left kidney
measures 11.6cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of masses, stones, or hydronephrosis in the kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
OTHER: A right pleural effusion is demonstrated.
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion,
splenomegaly or ascites.
2. Patent hepatic vasculature.
3. Right pleural effusion, incompletely assessed.
___ Imaging CHEST (PORTABLE AP)
Comparison to ___. The patient has been extubated.
The moderate right and small left pleural effusion persist. No
change in appearance of the cardiac silhouette. Stable mild
pulmonary edema. No new abnormalities in the ventilated
portions of the lung parenchyma.
___ Imaging CHEST (PORTABLE AP)
Compared to chest radiographs ___ and ___.
Since midnight, bilateral pleural effusions have been aspirated.
Right is
small. Left may have been entirely cleared. No pneumothorax.
Mild
atelectasis crosses the left lower lung. A larger region of
atelectasis or consolidation effects the right lung base
medially. Follow-up advised. Heart mildly enlarged. No
pulmonary edema or other evidence of cardiac
decompensation.
MICROBIOLOGY:
=============================================
___ blood, urine, sputum cx negative
___ blood cx negative
___ pleural fluid cultures negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO BID
2. Furosemide 40 mg PO BID
3. Spironolactone 100 mg PO BID
4. Propranolol 40 mg PO BID
5. Mesalamine 1000 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Midodrine 5 mg PO TID
8. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Sucralfate 1 gm PO TID
RX *sucralfate 1 gram 1 tablet(s) by mouth three times daily
Disp #*22 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 40 mg PO BID
5. Lactulose 30 mL PO BID
6. Mesalamine 1000 mg PO BID
7. Midodrine 5 mg PO TID
8. Propranolol 40 mg PO BID
9. Spironolactone 100 mg PO BID
10. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Hematemesis, upper GIB
Hemorrhagic shock, resolved
Acute kidney injury
Bilateral pleural effusion
SECONDARY DIAGNOSIS:
ETOH cirrhosis
A fib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: History: ___ with post-intubation// ETT placement ETT
placement
IMPRESSION:
No comparison. The patient is intubated. The tip of the endotracheal tube
projects approximately 25 mm above the carinal. No pneumothorax or other
complication. Mild cardiomegaly. No pulmonary edema. Moderate right pleural
effusion.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with cirrhosis and new bleeding// question of
portal venous thrombosis (please use Doppler)
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 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. The CBD measures 6 mm.
GALLBLADDER: The gallbladder is distended though there is no evidence of
stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: The spleen measures up to 12 cm and demonstrates normal echogenicity
throughout.
KIDNEYS: The right kidney measures 10.8 cm. The left kidney measures 11.6 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
OTHER: A right pleural effusion is demonstrated.
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion, splenomegaly or ascites.
2. Patent hepatic vasculature.
3. Right pleural effusion, incompletely assessed.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with right sided pleuritic chest pain and
cirrhosis// eval for change in pleural effusions eval for change in
pleural effusions
IMPRESSION:
Comparison to ___. The patient has been extubated. The moderate
right and small left pleural effusion persist. No change in appearance of the
cardiac silhouette. Stable mild pulmonary edema. No new abnormalities in the
ventilated portions of the lung parenchyma.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with bilateral pleural effusion s/p bilateral
thoracentesis// eval for pneumothorax eval for pneumothorax
IMPRESSION:
Compared to chest radiographs ___ and ___.
Since midnight, bilateral pleural effusions have been aspirated. Right is
small. Left may have been entirely cleared. No pneumothorax. Mild
atelectasis crosses the left lower lung. A larger region of atelectasis or
consolidation effects the right lung base medially. Follow-up advised.
Heart mildly enlarged. No pulmonary edema or other evidence of cardiac
decompensation.
Gender: M
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by AMBULANCE
Chief complaint: GI bleed, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: 77.0
dbp: 53.0
level of pain: uta
level of acuity: 1.0 | ===================
SUMMARY
===================
___ year old man with a history of ETOH cirrhosis decompensated
by ascites, and esophageal varices (prior bleed), atrial
fibrillation, who presented with large volume hematemesis and
hypotension. He underwent EGD that showed no evidence of active
bleeding. He also developed ___, likely pre-renal, which
resolved. He had worsening pleural effusions during admission
that were drained and showed transudative fluid.
===================
ACTIVE ISSUES
===================
# Hematemesis, upper GIB
# Hemorrhagic shock, resolved
Upper GI bleed with hematemesis. He was initially admitted to
the MICU and received total of 5 units PRBC and 4L crystalloid
due to shock prior to transfer to floor. EGD showed linear
erosions oozing around previous band with no evidence of active
bleed. Given IV PPI, octreotide, sucralfate x2 wks, CTX for SBP
ppx x7 days. While on the floor he had no further evidence of
bleeding.
# ETOH cirrhosis:
MELD-Na on admission of 24. Decompensated by varices, ascites.
No known history of SBP, HE or diuretic refractory ascites. MELD
21 prior to bleed, may be TIPS candidate in future. He is on
home diuretics and propranolol which were initially held in the
setting of GI bleed but resumed post-EGD. The patient was also
noted to have mild HE despite lactulose, thus rifaximin 550mg
BID was started as well with good effect. This was discontinued
on discharge as HE had resolved and patient had previously been
well-controlled with lactulose alone.
Discharge Na: 138.
Discharge weight: 101.7kg.
# ___
Cr on admission of 1.2, elevated to 1.7 on HD#2. Suspected
prerenal in setting of bleed and improvement to baseline after
resuscitation. Was briefly on midodrine for possible HRS however
this was discontinued. Discharge Cr was 0.7.
#AFib
#Prolonged QTc (resolved)
On propranolol at home but not anticoagulation due to previous
variceal bleeds. Pt remained in afib throughout admission.
Initially propranolol was held in the setting of bleed and was
intermittently tachycardic to the 120s but did not require RVR
treatment. His propranolol was re-started on the floor with
improvement in HRs. Pt was also found to have prolonged QTc to
580 on admission after receiving Zofran in the ED, improved once
Zofran was discontinued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
chest pain (transfer for STEMI)
Major Surgical or Invasive Procedure:
cardiac catheterization with drug eluting stent to the left
circumflex artery
History of Present Illness:
Ms. ___ is a ___ lady with DM2, CAD s/p inferoposterior MI
in ___ s/p tPA and RCA stent, COPD who presented to an OSH
yesterday evening with chest pain and is admitted due to
inferior STEMI. She has angina at baseline which is controlled
with a nitro patch. She also has dyspnea on exertion at baseline
for which she uses her albuterol inhaler. She endorses
occasional palpitations that are not associated with syncope.
Last week, she had an episode where she felt dizzy and numbness
in her left face and arm. Her symptoms resolved after 1 day.
Last night she developed acute onset substernal chest pressure
that was associated with left sided arm/ jaw and face numbness.
Her symptoms were similar to her prior MI in ___. The pain
worsened to ___ and was associated with shortness of breath.
She then went to ___.
At ___, initial VS were T 97, P 74, BP 136/76, RR:
18, 100% on RA. She had new ST depressions noted in V2-4, AVF.
Posterior EKG was reportedly unremarkable. Troponin was
negative. She received ASA, Heparin gtt, Fentanyl, and NTG gtt
due to refractory pain and was transferred to ___.
In the ___ ED, initial VS were pain ___, T 98.3, HR 82, BP
129/94, RR 16, POx 97%RA. She complained of substernal chest
discomfort radiating to the jaw; denied significant shortness of
breath. Labs were notable for normal CBC and CHEM7 (Cr 0.5).
Troponin <0.01. EKG with STE in III, V6, ST depressions in V1-4
(Worse compared to ECGs from OSH). She received Morphine for
pain as well as Methylprednisolone/ Benadryl/ Famotidine due to
h/o contrast allergy and went to cath lab where she was found to
have an occluded Cx, as well as RCA with occlusion of prior
stent and LAD lesions. She underwent DES to LCx. She was placed
on integrillin drip. She was loaded with prasugel.
On arrival to the floor, patient denied chest pain but felt
somewhat short of breath, which she related to her chronic
bronchitis.
REVIEW OF SYSTEMS
(+) recent URI, chronic right leg pain and intermittent
swelling, BLE neuropathy
(-) she denies any prior history of pulmonary embolism, bleeding
at the time of surgery, myalgias, joint pains, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: prior RCA stent
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- h/o TIA
- neuropathy
- DM2
- COPD
Social History:
___
Family History:
No coronary artery disease. Mother and father with DM. Father w
several CVAs. Mother died of 'stomach cancer'
Physical Exam:
ADMISSION EXAM
VS: AF, BP=124/88 HR=87 RR=16 O2 sat= 99% on 2L NC
GENERAL: obese female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, unable to assess JVP ___ habitus
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: good air movement, no respiratory distress. diffuse
expiratory wheezes, crackles
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: right radial with TR band in place; DP/ ___ dopplerable
bilaterally
DISCHARGE EXAM
VS 98.0 103/60 73 18 97%RA
Gen: awake, alert, NAD
CV: RRR, no m/r/g
Lungs: CTAB
Abd: +BS, soft, NT/ND
Ext: WWP, no edema
Pertinent Results:
ADMISSION LABS
___ 04:40AM BLOOD WBC-9.3 RBC-4.64 Hgb-12.3 Hct-38.6
MCV-83# MCH-26.5*# MCHC-31.8# RDW-16.0* Plt ___
___ 04:40AM BLOOD Neuts-62.8 ___ Monos-3.8 Eos-1.6
Baso-0.6
___ 04:40AM BLOOD ___ PTT-65.7* ___
___ 04:40AM BLOOD Glucose-268* UreaN-8 Creat-0.5 Na-134
K-4.4 Cl-98 HCO3-25 AnGap-15
___ 04:40AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.7 Cholest-179
CARDIAC ENZYME TREND
___ 04:40AM BLOOD CK(CPK)-62
___ 04:40AM BLOOD CK-MB-5
___ 04:40AM BLOOD cTropnT-<0.01
___ 11:48AM BLOOD CK(CPK)-2986*
___ 11:48AM BLOOD CK-MB-131* MB Indx-4.4 cTropnT-6.68*
___ 09:50PM BLOOD CK(CPK)-1673*
___ 09:50PM BLOOD CK-MB-64* MB Indx-3.8 cTropnT-4.78*
___ 04:50AM BLOOD CK-MB-44* cTropnT-3.27*
OTHER PERTINENT LABS
___ 04:40AM BLOOD %HbA1c-9.0* eAG-212*
___ 04:40AM BLOOD Triglyc-182* HDL-46 CHOL/HD-3.9
LDLcalc-97
___ 11:48AM BLOOD TSH-0.59
DISCHARGE LABS
___ 07:20AM BLOOD WBC-10.0 RBC-3.89* Hgb-10.2* Hct-32.0*
MCV-82 MCH-26.2* MCHC-31.9 RDW-16.2* Plt ___
___ 07:20AM BLOOD ___ PTT-26.5 ___
___ 07:20AM BLOOD Glucose-89 UreaN-22* Creat-0.6 Na-137
K-3.9 Cl-99 HCO3-28 AnGap-14
URINALYSIS
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 05:00PM URINE Hours-RANDOM Creat-36 Na-63 K-28 Cl-41
___ 05:00PM URINE Osmolal-727
CARDIAC CATHETERIZATION ___
1. Three vessel CAD with acute occlusion of the large OM at its
proximal segment.
2. Successful PTCA and stenting of the proximal OM with 2.75x12
mm Resolute drug-eluting stent with excellent result
3. Residual disease (severe mid LAD lesion and occluded RCA
stent) needs further evaluation and management: CABG would be
appropriate given diabetes. The LAD is amenable to PCI (focal
lesion). The distal RCA is collateralrized.
4. ASA 325 mg daily x minimum of 3 months then 162 mg daily
lifelong
5. Prasugrel 60 mg today (loading dose given in cath lab) then
10 mg daily for a minimum of 12 months. Note this event occurred
despite ongoing Clopidogrel therapy
6. Integrilin gtt x 8 hours
7. Post MI care including echocardiogram and global CV risk
reduction strategies
TRANSTHORACIC ECHOCARDIOGRAM ___
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is mildly depressed (LVEF= 40%)
secondary to severe hypokinesis of the basal-mid inferior and
infero-lateral walls. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
very small pericardial effusion. There are no echocardiographic
signs of tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional and global systolic dysfunction c/w CAD. Mild
mitral regurgitation.
ECG Study Date of ___ 4:34:58 AM
Sinus rhythm. Inferior ST segment elevation combined with
anterior ST segment depression and T wave inversion raises
concern for inferoposterior myocardial infarction or aneurysm
formation. Compared to the previous tracing of ___ the
previously seen T wave inversions in the inferior leads have
resolved. There are now ST segment depressions and T wave
inversions in leads V1-V3 along with slight ST segment elevation
and QRS complex notching in lead V6. Clinical correlation is
suggested.
ECG Study Date of ___ 3:23:04 ___
Sinus rhythm. Partial intraventricular conduction defect with
borderline left axis deviation. Inferior wall myocardial
infarction. Compared to tracing ___ segment
depression is improved.
CHEST (PORTABLE AP) Study Date of ___ 11:04 AM
No previous images. There are relatively low lung volumes that
enhance the prominence of the transverse diameter of the heart.
No definite pulmonary vascular congestion, acute pneumonia or
pleural effusion on this technically limited study with
scattered radiation related to the size of the patient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Gabapentin 300 mg PO HS
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Metoprolol Tartrate 50 mg PO TID
5. Omeprazole 20 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO QHS
9. 70/30 60 Units Breakfast
70/30 60 Units Dinner
Glargine 50 Units Bedtime
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Nitroglycerin Patch 0.4 mg/hr TD Q24H
12 h on, 12 h off
13. Amitriptyline 25 mg PO HS
14. Acetaminophen 500 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Amitriptyline 25 mg PO HS
3. Aspirin 325 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Gabapentin 600 mg PO HS
RX *gabapentin 300 mg two capsule(s) by mouth at bedtime Disp
#*60 Capsule Refills:*2
6. Omeprazole 20 mg PO DAILY
7. TraMADOL (Ultram) 50 mg PO QHS
8. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
9. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
10. Metoprolol Succinate XL 300 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 200 mg 1.5 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
11. Nicotine Patch 14 mg TD DAILY
RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour
(14) one patch daily Disp #*1 Kit Refills:*0
12. Prasugrel 10 mg PO DAILY
RX *prasugrel [Effient] 10 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Outpatient Lab Work
Please check Chem-7 on ___ with results to Dr.
___ at Phone: ___
Fax: ___
ICD-9: 428
16. Humalog ___ 54 Units Breakfast
Humalog ___ 48 Units Dinner
RX *insulin lispro protam & lispro [Humalog Mix 75-25] 100
unit/mL (75-25) 54 Units before BKFT; 48 Units before DINR;
(twice a day) Disp #*3060 Unit Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation myocardial infarction
Acute Systolic dysfunction
Diabetes, poorly controlled
Dyslipidemia
COPD
Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: MI, to assess for edema.
FINDINGS: No previous images. There are relatively low lung volumes that
enhance the prominence of the transverse diameter of the heart. No definite
pulmonary vascular congestion, acute pneumonia or pleural effusion on this
technically limited study with scattered radiation related to the size of the
patient.
Gender: F
Race: WHITE
Arrive by HELICOPTER
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with INTERMED CORONARY SYND
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 2.0 | Ms. ___ is a ___ y/o female with DM2, CAD s/p (DES to RCA) who
presented with chest pain and inferior STEMI found to have 3VD
and now s/p DES to LCx.
Active issues:
# CAD: Patient has 3VD on cardiac cath but LCx occlusion was
thought to be lesion responsible for inferior STEMI. Now s/p DES
to LCx. No intervention to occlusion of RCA stent as appeared to
be chronic. She also had lesion in LAD. Given 3VD, may benefit
from CABG. Patient accessed via right radial artery. She was
maintained on integrillin drip for 18 hours and was loaded with
prasugrel. She continued on prasugrel 10mg daily and ASA 81mg
daily. She was also continued on a statin. Patient will require
outpatient work-up/discussion for CABG vs PCI for remaining CAD.
# STEMI: See CAD above for additional details. Patient was taken
to cath lab and LCx was stented with DES as it was thought to be
cause of STEMI. Her cardiac enzymes were trended and peaked at
6.68. She was on an integrillin drip for 18 hours, loaded with
prasugrel and maintained on prasugrel 10mg PO daily and ASA 81mg
daily. She had no adverse events.
# COPD: Hx of reduced RV function on echo in ___. No known CHF
but with significant dyspnea which was thought to be related
COPD. Repeat ECHO showed mildly depressed LV function with EF
40%. Dyspnea attributed to COPD. Continued home flovent and
ipratropium nebs PRN. Continued to encourage/educate regarding
smoking cessation. Patient initially reported smoking only 1
cigarette/day, then 3 cigs/day then admitted to continuing to
smoke 2 ppd. Patient given nicotine patch Rx to facilitate
quitting.
# DM2: Patient was on significant amount of insulin at home.
HgbA1C was 9.0 on admission. As patient was on an unusual
regimen, ___ was consulted to facilitate appropriate
adjustment and transition to improved regimen as an outpatient.
We held home regimen and metformin and maintained patient on
standing and ISS. In conjunction with ___, this was
transitioned to a standing regimen for outpatient use (not
sliding scale). Patient was restarted on home metformin at
discharge.
Chronic issues:
# Hyperlipidemia: On simvastatin at home. Started on
atorvastatin 80 mg po daily during this admission.
# Hypertension: Normotensive. Patient initially on nitro drip.
Restarted home metoprolol and added ACEi to regimen.
# Neuropathy: Stable, but with significant symptoms. Nerontin
increased from 300mg qhs to 600mg qhs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right arm and leg numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year-old man with a past medical history
of HTN and paroxsymal atrial fibrillation not on
anti-coagulation
who presents with acute onset right sided arm and leg numbness.
Patient reports he was lying in bed talking with his girlfriend
when he noticed a buzzing in his left ear like a "static radio."
This last about 20 seconds then disappeared. This sensation was
also accompanied by a feeling of lightheadedness which lasted
about a minute. He said to his girlfriend, "I think I'm going to
pass out." He then noticed sudden onset right arm and leg
numbness. The intensity of the numbness was more noticable in
the
right leg than the right arm. He was able to move his right side
but there was a funny sensation that the muscles were "discreet"
and "asynchronous." His girlfriend said he was speaking normally
during this time. He stood up to try to walk but his right leg
felt "sleepy." He was able to put weight on his leg but it was
difficult to walk because of the numbness. He denied
parasthesiae.
He presented to ___ ED and a code stroke was called. NIHSS was
0. He denied any symptoms except minor sensory changes around
the
base of his right big toe. CT head did no show any evidence of
bleed. He was given aspirin 325. His exam was normal but reports
he feels a sesation around the base of his right foot like "just
after a cramp; like the muscle is twitching."
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, vertigo. Denies
difficulties producing or comprehending speech. Denies focal
weakness, 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 nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
HTN
Afib not on anticoagulation
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.9 P: 104 R: 16 BP: 166/85 SaO2: 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Irregular rate and rhythm, 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. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. 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. Right visual field cut, mostly
superior quadrant.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
==========================
DISCHARGE PHYSICAL EXAM:
T 97.7 BP 138-162/89-103, HR 53-106, RR 20, O2 99%RA
Continues to have RUQ field cut on visual field confrontation,
face symmetric, EOMI, sensation intact to light touch
throughout, has difficulty tapping fingers quickly and very mild
overshoot when mirroring examiner. Motor exam ___ throughout.
Pertinent Results:
ADMISSION LABS:
___ 02:28AM BLOOD WBC-8.3 RBC-5.01 Hgb-15.5 Hct-43.8 MCV-87
MCH-30.9 MCHC-35.4 RDW-13.5 RDWSD-42.0 Plt ___
___ 02:28AM BLOOD ___ PTT-31.1 ___
___ 10:05AM BLOOD Glucose-286* UreaN-22* Creat-1.0 Na-138
K-4.6 Cl-103 HCO3-18* AnGap-22*
___ 10:05AM BLOOD ALT-31 AST-22 LD(LDH)-303* AlkPhos-73
TotBili-0.3
___ 02:28AM BLOOD cTropnT-<0.01
___ 10:05AM BLOOD CK-MB-1 cTropnT-<0.01
___ 10:05AM BLOOD Calcium-10.0 Phos-3.5 Mg-1.9 Cholest-202*
___ 10:05AM BLOOD Triglyc-190* HDL-45 CHOL/HD-4.5
LDLcalc-119
___ 10:05AM BLOOD TSH-1.9
___ 02:28AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CT HEAD ___:
1. No evidence for acute intracranial process.
CXR ___:
Low lung volumes, mild cardiomegaly, and bibasilar atelectasis.
CTA HEAD AND NECK ___:
____________________________________
MRI BRAIN ___:
1. Acute infarctions of the left occipital lobe, left thalamus,
and right cerebellar tonsil.
2. Occlusion of the right intradural vertebral artery.
DISCHARGE LABS:
Stroke workup:
- Risk factors: HgbA1c 10.2, TSH 1.9, lipid panel: chol 202/LDL
119/HDL ___ 190.
- Echo: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved global systolic function.
No PFO/ASD identified.
- CTA neck: occlusion of R V4 segment of vertebral artery with
distal retrograde filling. Occlusion of the right V4 segment
vertebral artery with distal retrograde filling. Infarct of L
occipital cortex. Patent neck vasculature without carotid
stenosis.
- MRI head: Acute infarctions of the left occipital lobe, left
thalamus, and right cerebellar tonsil. Occlusion of the right
intradural vertebral artery.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
2. Atenolol 50 mg PO DAILY
3. Glargine 18 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 18 Units before
BED; Disp #*1 Vial Refills:*3
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
18 Units before BED; Disp #*30 Syringe Refills:*3
RX *blood-glucose meter Please check your blood sugar when you
wake up and before each meal and before bed for a total of 5
times per day five times daily Disp #*1 Kit Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL AS DIR 6 units three
times per day with meals Disp #*1 Vial Refills:*3
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 6 units
three times per day with meals Disp #*90 Syringe Refills:*3
4. Amlodipine 10 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*3
7. insulin syringe-needle U-100 0.3 mL 30 x ___ miscellaneous
QIDWMHS
RX *insulin syringe-needle U-100 30 gauge X ___ Please use
this to draw up your insulin. One time use only four times per
day Disp #*120 Syringe Refills:*3
8. Glucosource (lancets) miscellaneous QIDWMHS
RX *lancets [OneTouch UltraSoft Lancets] four times a day Disp
#*100 Each Refills:*5
9. Gluco Navii Glucose Monitor (blood-glucose meter)
miscellaneous QIDWMHS
RX *blood-glucose meter [OneTouch Verio Sync] Disp #*1 Kit
Refills:*0
10. Gluco Navii Test Strip (blood sugar diagnostic)
miscellaneous QIDWMHS
RX *blood sugar diagnostic [OneTouch Ultra Test] four times a
day Disp #*100 Strip Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Dancing at bedside.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with 1:55am difficulty walking, R sided weakness //
rule out ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 18.0 s, 19.2 cm; CTDIvol = 52.4 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 preservation of
gray-white matter differentiation. The basal cisterns remain patent.
There is no evidence of fracture. A large mucous retention cyst is noted
within left maxillary sinus. The remainder of the paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. No evidence for acute intracranial process.
Radiology Report
EXAMINATION: Chest radiographs.
INDICATION: History: ___ with stroke // Eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
Lung volumes are low leading to crowding of the bronchovascular structures.
Mild bibasilar atelectasis is noted. There is no lobar consolidation, pleural
effusion, pneumothorax, or pulmonary edema identified. Mild cardiomegaly is
noted.
IMPRESSION:
Low lung volumes, mild cardiomegaly, and bibasilar atelectasis.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ male experiencing right-sided numbness and weakness.
Evaluate for aneurysm.
TECHNIQUE: 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 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 98.0 mGy (Head) DLP =
49.0 mGy-cm.
4) Spiral Acquisition 5.3 s, 41.7 cm; CTDIvol = 35.3 mGy (Head) DLP =
1,473.0 mGy-cm.
Total DLP (Head) = 1,522 mGy-cm.
COMPARISON: ___ noncontrast head MRI.
___ noncontrast head CT.
FINDINGS:
CTA HEAD:
There is occlusion of the right V4 segment vertebral artery with
reconstitution of the short segment prior to its anastomosis with the basilar
artery via retrograde flow. There is diminished flow within the more proximal
second and third segments of the right vertebral artery.
There is calcific and noncalcified atherosclerosis with segmental luminal
narrowing at the mid left V4 segment vertebral artery (2:216).
Lack of vascular enhancement in the distal left posterior cerebral artery,
suggestive of partial occlusion or severe narrowing, otherwise, the anterior
circulation and the remainder of the posterior circulation are patent without
aneurysm dissection or occlusion. The sinuses and major cerebral veins are
patent.
There is loss of the gray-white matter differentiation within the left
occipital lobe consistent with infarction. The ventricles and extra-axial
spaces are unremarkable. The orbits, calvarium, and soft tissues are
unremarkable. There are left maxillary sinus mucous retention cysts.
CTA NECK:
There is occlusion of the right V4 segment vertebral artery with
reconstitution of the short segment prior to its anastomosis with the basilar
artery via retrograde flow. There is diminished flow within the more proximal
second and third segments of the right vertebral artery. There is streak
artifact from periarterial veins which obscures the lumen of the right first
and proximal second segment vertebral arteries.
There is calcific and noncalcified atherosclerosis with segmental luminal
narrowing at the mid left V4 segment vertebral artery (2:216).
The carotid 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:
There are calcified granulomas within the visualized lung apices. The
visualized portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria.
IMPRESSION:
1. Occlusion of the right V4 segment vertebral artery with distal retrograde
filling. Diminished contrast filling proximal to the occlusion. Obscured
first and proximal second segments of the right vertebral artery due to
periarterial venous contrast.
2. Atherosclerosis with segmental luminal narrowing at the left V4 segment
vertebral artery.
3. Infarction of the left occipital cortex. This is better characterized on
dedicated head MRI performed subsequent to this study.
4. Patent neck vasculature without carotid stenosis by NASCET criteria.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with transient right sided numbness // eval for
stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head and neck ___
CT head ___
FINDINGS:
There is restricted diffusion in the left occipital lobe, left thalamus, and
right cerebellar tonsil associated with T2/FLAIR hyperintense signal. There
is no evidence of hemorrhage, edema, masses, mass effect, midline shift.
Scattered foci of T2/FLAIR hyperintensities in the supratentorial white matter
are nonspecific, but may represent the sequela of chronic small vessel
ischemic disease. The ventricles and sulci are normal in caliber and
configuration.
Loss of the flow void in the right intradural vertebral artery corresponds to
the occlusion seen on recent prior CTA.
The left maxillary sinus contains a large mucous retention cyst. The mastoid
air cells are clear. The visualized orbits are unremarkable.
IMPRESSION:
1. Acute infarctions of the left occipital lobe, left thalamus, and right
cerebellar tonsil.
2. Occlusion of the right intradural vertebral artery.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 10:20 AM.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Numbness
Diagnosed with TRANS CEREB ISCHEMIA NOS, OTHER ABNORMAL GLUCOSE, ATRIAL FIBRILLATION
temperature: 97.9
heartrate: 104.0
resprate: 20.0
o2sat: 99.0
sbp: 166.0
dbp: 85.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ ___ year-old man with a past medical history of
HTN and paroxsymal atrial fibrillation not on anti-coagulation
who presents with acute onset right sided arm and leg numbness.
NIHSS 0. Exam notable for R upper quadrant visual field cut
bilaterally. MRI showed L PCA and small ___ infarcts. Has
newly diagnosed diabetes. Likely embolic source given afib not
on anticoagulation. On discharge, he was counseled on stroke
prevention and diabetes and blood pressure management. On exam,
he had a R upper quadrant visual field cut and was dancing
without losing his balance. He is stable to go home with close
PCP follow up and follow up with Dr. ___.
Stroke workup:
- Risk factors: HgbA1c 10.2, TSH 1.9, lipid panel: chol 202/LDL
119/HDL ___ 190.
- Echo: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved global systolic function.
No PFO/ASD identified.
- CTA neck: occlusion of R V4 segment of vertebral artery with
distal retrograde filling. Occlusion of the right V4 segment
vertebral artery with distal retrograde filling. Infarct of L
occipital cortex. Patent neck vasculature without carotid
stenosis.
- MRI head: Acute infarctions of the left occipital lobe, left
thalamus, and right cerebellar tonsil. Occlusion of the right
intradural vertebral artery.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - (X) Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 119) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - () No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: ()
Antiplatelet - (X) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X) Yes - () No - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperglycemia, coffee-ground emesis
Major Surgical or Invasive Procedure:
EGD ___
Peritoneal drainage catheter ___
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
===========================
Mr. ___ is a ___ male with history of pancreatic
cancer, recently discontinued chemotherapy who presents with
coffee-ground emesis and hyperglycemia.
Patient arrived from ___ on ___. He felt weak and
lightheaded after disembarking the plane. Has been having ___
days of coffee-ground emesis. No dark stool, diarrhea or
abdominal pain. Last bowel movement was 2 days ago, states he is
still passing gas. Denies any known liver disease. No fever,
chest pain, SOB, HA, urinary symptoms, ___ edema/pain.
Past Medical History:
GERD
Hyperlipidemia
Type II diabetes without complications- Last A1c 11.6% Diagnosed
___
History of 2 seizures, one at age ___ and another ___ years ago.
not on AED. Work up negative
Social History:
___
Family History:
Father- ___ and pre-diabetes. Grandfather- MI
in
___ or ___.
No history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.7, HR 98, BP 114/66, RR 16, O2 sat 98% RA
GEN: tired, in no acute distress
HEENT: EOMI, PERRLA, NGT with coffee ground-colored output
NECK: supple
CV: Tachycardic, regular rhythm. No murmurs/rubs/gallops
RESP: Clear to auscultation bilaterally
GI: Soft, distended, non-tender to palpation
MSK: No ___ edema
SKIN: No rash
NEURO: AAOx3, full strength and sensation
PSYCH: Linear thought process
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: T:98.8 PO BP:101/65 L Lying HR:90 RR:18 O2:97 Ra
GEN: in no acute distress
HEENT: EOMI
NECK: supple, no JVD, supraclavicular wasting noted
CV: RRR, no m/r/g
RESP: CTAB. no wheezes or rhonchi
GI: tense, distended, non-tender to palpation
MSK: No ___ edema, WWP
SKIN: No rash, warm
NEURO: AAOx3, full strength and sensation
Pertinent Results:
ADMISSION LABS
==============
___ 02:40PM BLOOD WBC-12.8* RBC-2.77* Hgb-8.6* Hct-26.9*
MCV-97 MCH-31.0 MCHC-32.0 RDW-13.6 RDWSD-48.3* Plt ___
___ 02:40PM BLOOD Neuts-89.1* Lymphs-2.4* Monos-7.6
Eos-0.0* Baso-0.1 Im ___ AbsNeut-11.39* AbsLymp-0.31*
AbsMono-0.97* AbsEos-0.00* AbsBaso-0.01
___ 02:40PM BLOOD ___ PTT-30.7 ___
___ 02:40PM BLOOD Glucose-840* UreaN-42* Creat-2.3*#
Na-127* K-7.1* Cl-81* HCO3-11* AnGap-35*
___ 07:41PM BLOOD Calcium-9.4 Phos-2.6* Mg-2.0
___ 02:40PM BLOOD Albumin-3.3*
___ 02:40PM BLOOD ALT-64* AST-51* AlkPhos-391* TotBili-1.0
___ 02:48PM BLOOD ___ pO2-41* pCO2-19* pH-7.45
calTCO2-14* Base XS--7
___ 02:48PM BLOOD Glucose-794* Lactate-19.0* Creat-2.1*
Na-126* K-6.5* Cl-88*
INTERVAL LABS
==============
___ 05:11PM BLOOD WBC-9.1 RBC-2.79* Hgb-8.7* Hct-26.8*
MCV-96 MCH-31.2 MCHC-32.5 RDW-13.9 RDWSD-48.8* Plt ___
___ 03:04AM BLOOD ___ PTT-26.9 ___
___ 03:04AM BLOOD Glucose-198* UreaN-36* Creat-1.2 Na-136
K-4.5 Cl-97 HCO3-28 AnGap-11
___ 03:04AM BLOOD ALT-187* AST-126* AlkPhos-350*
TotBili-0.8
___ 03:04AM BLOOD Calcium-8.7 Phos-2.4* Mg-2.0
___ 03:35AM BLOOD ___ Temp-36.9 pO2-38* pCO2-43
pH-7.44 calTCO2-30 Base XS-4
DISCHARGE LABS
==============
___ 06:10AM BLOOD WBC-7.1 RBC-2.95* Hgb-9.2* Hct-27.4*
MCV-93 MCH-31.2 MCHC-33.6 RDW-14.0 RDWSD-46.8* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-28.5 ___
___ 06:10AM BLOOD Glucose-70 UreaN-29* Creat-1.0 Na-134*
K-4.2 Cl-96 HCO3-27 AnGap-11
___ 06:10AM BLOOD ALT-231* AST-87* LD(LDH)-189 AlkPhos-375*
TotBili-0.7
___ 06:10AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1
IMAGING STUDIES
===============
CXR ___
IMPRESSION:
1. The tip of the enteric tube projects over the upper stomach.
2. No acute cardiopulmonary process.
CT Abdomen/Pelvis w/o contrast ___
IMPRESSION:
1. The study is extremely limited due to lack of intravenous
contrast. Within the limitation of the study, no evidence of
bowel obstruction.
2. Small-bowel loops in the left abdomen are collapsed and wall
thickening is not excluded and may be present. Additionally the
ascending colon is mostly decompressed and wall thickening
cannot be excluded.
3. The known pancreatic cancer or possible intra-abdominal
intrapelvic
metastasis are not as well-demonstrated on noncontrast study as
on prior
study.
4. Large volume ascites.
5. Again seen pneumobilia most pronounced at the left hepatic
lobe secondary to common bile duct stent placement
EGD ___
===========
- Varices in the distal esophagus
- Erosions in the distal esophagus
- Grade C esophagitis in the distal esophagus
- Ulcers in the antrum, fundus and stomach body
- Normal mucosa in the whole examined duodenum
- Anatomic distortion of the pylorus
- A possible healing ___ tear was noted in the gastric
fundus on retroflexion
- A nasogastric tube was places with endoscopic confirmation
during the procedure
Peritoneal drainage catheter placement ___
IMPRESSION:
Successful peritoneal PleurX catheter placement
MICROBIOLOGY
============
Urine culture ___
< 10,000 CFU/mL
Blood culture ___
No growth to date (prelim result on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Gabapentin 300 mg PO QHS
4. Methadone 10 mg PO TID
5. Glargine 20 Units Bedtime
6. Polyethylene Glycol 17 g PO DAILY
7. naloxegol 25 mg oral DAILY:PRN
8. Omeprazole 20 mg PO DAILY
9. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
10. Venlafaxine 300 mg PO DAILY
11. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
12. Senna 17.2 mg PO QAM
13. Senna 8.6 mg PO QPM
Discharge Medications:
1. Baclofen 10 mg PO TID:PRN Hiccups
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
2. FreeStyle ___ 14 Day Reader (flash glucose scanning
reader) miscellaneous ASDIR
RX *flash glucose scanning reader [FreeStyle ___ 14 Day
Reader] As directed Disp #*1 Each Refills:*0
3. FreeStyle ___ 14 Day Sensor (flash glucose sensor)
miscellaneous ASDIR
RX *flash glucose sensor [FreeStyle ___ 14 Day Sensor] As
directed Disp #*1 Kit Refills:*0
4. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro 100 unit/mL AS DIR Up to 10 Units TID per
sliding scale Disp #*3 Syringe Refills:*2
5. Bisacodyl 10 mg PR QHS:PRN Constipation
6. Gabapentin 300 mg PO QHS
7. Methadone 10 mg PO TID
8. naloxegol 25 mg oral DAILY:PRN
9. Omeprazole 20 mg PO DAILY
10. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 17.2 mg PO QAM
13. Senna 8.6 mg PO QPM
14. Venlafaxine XR 300 mg PO DAILY
15. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until instructed by your oncologist.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=======================
Hyperglycemic emergency
SECONDARY DIAGNOSIS
=======================
Upper gastrointestinal bleed
Pancreatic adenocarcinoma
Superior mesenteric vein thrombus
Acute kidney injury
Chronic cancer-related pain
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with pancreatic cancer// Infection, aspiration,
fluid
TECHNIQUE: Chest AP radiograph.
COMPARISON: Chest CT dated ___.
FINDINGS:
The tip of a right-sided Port-A-Cath projects over the cavoatrial junction.
Low lung volumes with increased conspicuity of the bronchovascular markings at
the lower lung zones. Cardiomediastinal and hilar contours are unremarkable.
No focal consolidation or pulmonary edema. No pleural effusion or
pneumothorax. The visualized osseous structures are grossly unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) IN O.R.
INDICATION: History: ___ with NGT// NGT placement
TECHNIQUE: Chest AP radiograph.
COMPARISON: Same day chest radiograph. CT chest dated ___.
FINDINGS:
The tip of a right-sided Port-A-Cath projects over cavoatrial junction. The
tip of the enteric tube projects over the upper stomach.
No change of cardiopulmonary findings when compared to same day chest
radiograph. Visualized osseous structures are also unchanged in comparison to
same day chest radiograph.
IMPRESSION:
1. The tip of the enteric tube projects over the upper stomach.
2. No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: NO_PO contrast; History: ___ with metastatic pancreatic cancer on
chemotherapy presents with emesisNO_PO contrast// Obstruction, 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 6.0 s, 47.6 cm; CTDIvol = 18.6 mGy (Body) DLP = 883.0
mGy-cm.
Total DLP (Body) = 883 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is pneumobilia, unchanged since ___ and likely secondary
to common bile duct stent placement the gallbladder is within normal limits.
There is large volume ascites in the abdomen.
PANCREAS: Evaluation of the pancreas is extremely limited by large volume
ascites and lack of intravenous contrast. The known pancreatic cancer is not
as well demonstrated on current study as on prior contrast enhanced study.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no suspicious
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 distended with ingested material and contains
an enteric tube terminating within the proximal stomach. The small-bowel
loops in the left abdomen are collapsed and wall thickening cannot be
excluded. Additionally the ascending colon is mostly decompressed and wall
thickening cannot be excluded. No bowel obstruction is seen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: The mesentery and peritoneum demonstrate a heterogenous
appearance which is concerning for peritoneal nodularity. Given the lack of
intravenous contrast peritoneal nodularity cannot be confirmed or excluded on
current examination.
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. The study is extremely limited due to lack of intravenous contrast. Within
the limitation of the study, no evidence of bowel obstruction.
2. Small-bowel loops in the left abdomen are collapsed and wall thickening is
not excluded and may be present. Additionally the ascending colon is mostly
decompressed and wall thickening cannot be excluded.
3. The known pancreatic cancer or possible intra-abdominal intrapelvic
metastasis are not as well-demonstrated on noncontrast study as on prior
study.
4. Large volume ascites.
5. Again seen pneumobilia most pronounced at the left hepatic lobe secondary
to common bile duct stent placement
Radiology Report
INDICATION: ___ year old man with metastatic pancreatic cancer and recurrent
ascites// Onc requesting pleurex drain for draining ascites from metastatic
pancreatic cancer
COMPARISON: CT scan of the abdomen and pelvis on ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___ fellow performed the procedure. Dr. ___
___ supervised the trainee during any key components of the procedure
where applicable and reviewed and agrees with the findings as reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1.5 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: 1 g of Ancef, 20 cc of 1% lidocaine.
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 1.2 min, 17 mGy
PROCEDURE:
1. Limited abdominal ultrasound
2. Peritoneal PleurX catheter placement
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained. The abdomen was cleaned
and draped in standard sterile fashion. A pre-procedure time-out was performed
as per ___ protocol.
Under ultrasound guidance, an entrance site was selected in the right lower
quadrant. 1% lidocaine was instilled for local anesthesia. Under direct
ultrasound guidance, a A single wall 19 G needle was advanced into the ascitic
fluid. A ___ wire was passed through the needle and crossed to the left
side of the abdominal cavity. A location for the subcutaneous tunnel was
chosen and 1% lidocaine was administered at the skin entry site and along the
tunnel tract. A skin incision was made and the catheter was tunneled to the
peritonotomy site. The access site was dilated and a peel-away sheath was
inserted. The PleurX catheter was passed through the peel-away sheath. Final
position of the catheter was confirmed with fluoroscopy. The access site was
closed by Steri-Strips. The patient tolerated the procedure well without any
immediate postprocedure complications.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated
moderateascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for PleurX catheter placement.
IMPRESSION:
Successful peritoneal PleurX catheter placement
RECOMMENDATION: PleurX catheter is ready for use.
Gender: M
Race: WHITE - EASTERN EUROPEAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Hyperglycemia
Diagnosed with Unspecified abdominal pain
temperature: 98.1
heartrate: 126.0
resprate: 22.0
o2sat: 100.0
sbp: 94.0
dbp: 44.0
level of pain: 0
level of acuity: 2.0 | SUMMARY:
=====================
Mr. ___ is a ___ male with history of pancreatic
cancer, recently discontinued chemotherapy who presents with
coffee-ground emesis and hyperglycemia, admitted for probable
DKA and upper GI bleed. A palliative peritoneal PleurX catheter
was placed and he was discharged to home hospice.
TRANSITIONAL ISSUES:
======================
[]Note apixaban (SMV thrombus) held indefinitely for hemorrhagic
shock and ultimate hospice disposition.
[]Lantus increased to 25 units nightly and Humalog corrective
scale added. If patient has a constitutional decline, and his
appetite lessens, adjust insulin needs accordingly.
[]For palliative peritoneal PleurX, recommend draining one liter
of ascites every other day. Adjust drainage frequency and/or
amount to achieve comfort.
# Hemorrhagic shock secondary to UGIB
Mr. ___ had ___ days of coffee-ground emesis and presented
with hypotension and tachycardia. His Hgb dropped from baseline
of 10.7 to 8.6. He received 1u pRBC in ED and his Hgb improved
appropriately. An NGT was placed. He was also given 1 unit FFP
and 3 days of vitamin K 5mg IV. His apixaban was held. EGD was
performed on ___ which showed non-bleeding varices,
esophagitis, multiple gastric ulcers, and a possibly resolving
___ tear. His home omeprazole was increased from 20mg
daily to BID. His Hgb was stabilized at 9.2 at time of
discharge.
# Hyperglycemic emergency
Upon admission he had diffuse abdominal pain and an elevated
glucose of 840, anion gap metabolic acidosis, lactate, and
ketonuria suggestive for DKA. Insulin gtt was started. His
acidosis corrected and his lactate normalized. The DKA was
likely iso non-compliance as patient had reported not taking
insulin for few days. ___ diabetes team was consulted for
management of diabetes. Once blood glucose was stable, the
insulin gtt was transitioned to subq insulin. The
recommendations for insulin regimen on discharge is 20 units
lantus in morning with fasting blood glucose 140-180.
# Malignant ascites
He had abdominal distention likely in setting of malignant
ascites. Most recent diagnostic and therapeutic paracentesis was
on ___. A PleurX catheter was placed on ___. He had
relief after two liters were drained prior to discharge.
# Acute kidney injury
On presentation, Cr 2.3 from 0.9 10 days prior. This was likely
pre-renal in setting of DKA and GI Bleed. Patient received IV
fluids and Cr continues to improve. Cr on discharge is 1.0.
# Hiccups
Per palliative care, this was due to phrenic nerve irritation
with ascites and GI bleeding. Patient received IV PPI for GI
bleed and pleurX catheter was placed on ___.
# GOC
Palliative was consulted and he is already followed as an
outpatient. He was discharged to home with hospice. He is
DNR/DNI but would like to return to the hospital at his
discretion.
# Locally advanced pancreatic adenocarcinoma grade III
Mr. ___ oncologist is Dr. ___ at
___. Per oncology note in ___, he had disease
progression and was counseled about resuming treatment. He was
eligible for a clinical trial, however the trial will have both
immunotherapy and chemotherapy as treatments. He did not want
the treatment if chemotherapy is part of his treatment. ___ had
clear understanding of his disease and prognosis. He was
discharged home with hospice.
# Pain, chronic
Likely related to cancer. Denied new or worsening pain. Home
pain
medications are methadone 10mg PO TID, oxycodone ___ ___ mg
every ___ hours PRN, and gabapentin 300 mg at night. Home
medications were continued during hospitalization.
# Non-occlusive thrombus within the SMV
Found on CT from ___. Since ___, patient had been on
apixaban 5mg BID. The apixaban was held in setting of GI bleed.
# Opioid induced constipation.
Home meds included Miralax, Senna, naloxegol and Bisacodyl prn.
Patient received miralax and senna. He was discharged on home
medications.
# Depression
Home venlafaxine 300 mg daily was resumed when patient was able
to take PO.
CORE MEASURES
===============
#CODE STATUS: DNR/DNI
#EMERGENCY CONTACT:
Name of health care proxy: ___
Relationship: sister
Cell phone: ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ / ___
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ PMHx HOCM dx ___ BWH, DM, peripheral neuropathy, suspicion
of autonomic insuffiency, Stage III CKD, GERD, presents with
SOB. Per Atrius Cardiology note from today, BNP 260 and nl CXR
in ___. Diuresis at that time was deferred. Since, she has
had worsening of her breathing, with SOB over any distance.
Quoting the note, "she has been sleeping with an adjustable bed
with the head end elevated upto 45 degrees. She does get short
of breath when she slips down to a lower angle." 6lb subjective
weight gain was reported, as well as cough with clear phlegm in
the last ___ months. Endorsed whole-day wheezing, night and day.
On physical exam, JVP could not be appreciated due to body
habits. Lung exam was remarkable for reduced breath sounds and
few basal rales. Cardiac exam with ___ systolic ejection murmur.
She had trace edema. For O2Sat 90%, she was sent to ___ ED.
In the ED, her initial vitals were: 97.6 70 124/55 18 98%. She
was later 97% on nasal cannula. ED physical exam with clear
lungs, 2+ edema to the shins, JVP could not be assessed. Notable
labs:
- CBC: WBC 7.2, H/H ___, PLT 227
- Chem7: Na 141, K 5.6, Cr 1.3 (baseline 1.3-1.4)
- proBNP 1416
- Trop <0.01
- UA: 30 Protein, Few Bacteria, 1 WBC, 3 Epi
EKG with NSR HR 66, nl axis, nl intervals, ~1mm STE V3, >1mm STE
V1-V3, TWI I and aVL, poor R-wave progression. All changes
previous seen on Atrius EKG from ___. CXR limited study, but
mild interstitial edema was commented on. She received 20mg IV
lasix and was admitted to the floor for CHF exacerbation.
On the floor, the patient again confirms the history above. She
is not in distress here, and is surprised to be in the hospital.
She denies HA, f/c, n/v, CP/SOB, abdominal pain, bowel or
urinary sx, muscle or joint pains. Her exercise tolerance was
minimal >1mth ago (she states, "I don't exercise."), but now is
worse with DOE with minimal exertion (she uses the distance from
her room to the front desk as an example). She has not had an
episode like this previously.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes Type 2 with complications,
Dyslipidemia, Hypertension
2. CARDIAC HISTORY: HOCM dx ___ BWH. No CABG, PCI, Pacer/ICD.
3. OTHER PAST MEDICAL HISTORY:
CKD stage 3, GFR ___ ml/min 585.3
PVD
GERD
DM Neuropathy
DM Retinopathy
Colon adenomas
Hydradenitis
B12 deficiency
Vertigo
Migraine
Social History:
___
Family History:
Family history of colon cancer.
Father with mild heart attack, in his ___.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: Wt= 219lbs (Atrius) T= 98.2 BP= 124/57 HR= 73 RR= 14 O2 sat=
93%NC2L
General: Calm, conversant, sitting in bedside chair, completing
full sentences, NAD
HEENT: NCAT, EOMI, no sinus tenderness, clear OP, MMM
Neck: supple, unable to appreciate JVP d/t body habitus (also
sitting), no LAD or thyroid abN
CV: III/VI SEM LLSB, nl S1 S2, no r/g/m
Lungs: CTA b/l, no w/r/r
Abdomen: Central obesity, Soft, NT, ND, +BS, no HSM
GU: no Foley
Ext: WWP, Trace edema past the ankles b/l
Neuro: CN II-XII grossly intact, ___ strength ___ b/l
Skin: No rashes, bruises
Pulses: 2+ DP, ___ & Radial pulses b/l
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS: 97.9 113/61 76 18 99% 2L, 91-92% on RA
Wt= 85kg (down from 95.2Kg yesterday, questionable reliability)
I/O: 800cc/2300cc
General: found awake, speaking full sentences, NAD
HEENT: NCAT, clear OP, MMM
Neck: cannot appreciate JVP given body habitus
CV: III/VI SEM LLSB, nl S1 S2, no r/g/m
Lungs: CTA b/l, no w/r/r
Abdomen: Central obesity, Soft, NT, ND, +BS, no HSM
GU: no foley
Ext: WWP, 1+ edema past the ankles b/l
Neuro: face symmetric, moving all four limbs appropriately
Pertinent Results:
ADMISSION LABS:
===============
___ 12:45PM BLOOD WBC-7.2 RBC-3.45* Hgb-10.0* Hct-32.0*
MCV-93 MCH-28.9 MCHC-31.2 RDW-14.7 Plt ___
___ 12:45PM BLOOD Neuts-66.1 ___ Monos-7.0 Eos-1.5
Baso-0.6
___ 12:45PM BLOOD ___ PTT-27.1 ___
___ 12:45PM BLOOD Glucose-82 UreaN-19 Creat-1.3* Na-141
K-5.6* Cl-103 HCO3-26 AnGap-18
___:45PM BLOOD cTropnT-<0.01 proBNP-1416*
DISCHARGE LABS:
===============
___ 06:05AM BLOOD WBC-7.0 RBC-3.58* Hgb-10.4* Hct-33.2*
MCV-93 MCH-29.1 MCHC-31.4 RDW-14.6 Plt ___
___ 06:05AM BLOOD Glucose-162* UreaN-21* Creat-1.3* Na-144
K-4.7 Cl-102 HCO3-30 AnGap-17
___ 06:05AM BLOOD Calcium-8.8 Phos-5.2* Mg-1.9
STUDIES:
========
___ EKG with NSR HR 66, nl axis, nl intervals, ~1mm STE V3,
>1mm STE V1-V3, TWI I and aVL, poor R-wave progression. All
changes previous seen on Atrius EKG from ___.
___ CXR: IMPRESSION: Possible mild interstitial edema.
Otherwise, unremarkable. Limited exam.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Metoprolol Tartrate 100 mg PO BID
4. Omeprazole 20 mg PO BID
5. MetFORMIN (Glucophage) 500 mg PO BID
6. 70/30 42 Units Breakfast
70/30 52 Units Bedtime
Insulin SC Sliding Scale using 70 / 30 Insulin
7. Gabapentin 900 mg PO TID
8. Vitamin D ___ UNIT PO DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO TID
11. Multivitamins 1 TAB PO DAILY
12. Duloxetine 60 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 500 mcg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. Gabapentin 900 mg PO TID
5. 70/30 42 Units Breakfast
70/30 52 Units Bedtime
Insulin SC Sliding Scale using 70 / 30 Insulin
6. Metoprolol Tartrate 100 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO BID
9. Simvastatin 40 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO TID
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Furosemide 20 mg PO ONCE Duration: 1 Dose
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
14. Outpatient Lab Work
Chem6 (Na, K, Cl, HCO3, BUN, Cr) to be checked by ___, with
results faxed to Dr. ___ at ___ (or have them
checked on visit to Atrius provider).
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs orally q6hrs
Disp #*1 Inhaler Refills:*0
16. Ipratropium Bromide MDI 2 PUFF IH QID
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 1 puff
by mouth four times a day Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: CHF Exacerbation
Secondary: 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
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Dyspnea, assess for pneumonia.
FINDINGS: PA and lateral views of the chest are provided. Large body habitus
and underpenetrated technique somewhat limits evaluation for subtle edema.
There is no large consolidation to raise concern for pneumonia. Mild edema
may be present. No large effusion or pneumothorax is seen. The heart and
mediastinal contours appear normal. Bony structures are intact.
IMPRESSION: Possible mild interstitial edema. Otherwise, unremarkable.
Limited exam.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 97.6
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 124.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | ___ PMHx hypertrophic cardiomyopathy diagnosed in ___, diabetes
on metformin and insulin, peripheral neuropathy, suspicion of
autonomic insufficiency, Stage III chronic kidney disease, GERD,
admitted for presumed CHF exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness/confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ ___ male with a past medical history
of
hypertension, AVR, A. fib not on AC since ___, diabetes who
presented originally to ___ for 1.5 weeks of weakness and
progressive confusion - transferred to ___ for concern of
multiorgan failure.
Patient is a poor historian. He reports starting to feel unwell
with progressive weakness as well as intermittent confusion for
about the past 2 weeks. On ___ night he had a fall that was
audibly witnessed by his wife with head strike. He was
transported to ___ where he was evaluated with head
CT scan (chronic changes) and lumbar spine films (DJD). He
apparently did not have any lab testing during that assessment
and was discharged home. He was also diagnosed with cellulitis
of
the right third toe and started on Keflex for this.
After getting out of the hospital on ___, he was getting out
of the car and was unable to support his weight and fell a
second
time. Did not have a head strike. He was helped back home but
for
the past 3 days he has been feeling very weak - lying on couch
without moving much, eating or drinking and continuing to be
intermittently confused. He denies have any chest pain or
pressure. Denies any dyspnea. Denies any headache, abdominal
pain, nausea/vomiting/diarrhea, melena or hematochezia. Does
report some urinary incontinence starting about 2 weeks ago,
though the chronicity of this is unclear. Denies bowel
incontinence. Since his fall earlier, he has had worsening or
pre-existing back pain. Also reports having a cold 2 weeks ago,
though no fever or cough with no recent travel or sick contacts.
Patient denies over taking Tylenol for pain.
Given his persistent weakness, patient was brought to ___
___ today. At ___, he had blood work concerning for ALT
and AST in the thousands, CK of 37,000, troponin of 0.12,
elevated creatinine. Also found to be in A. fib with RVR for
which he was started on diltiazem drip. He received 1.5 L of
fluid. Given 1 g of ceftriaxone and started on vancomycin 1 g.
Transfered here for further eval. Also had a CT head that was
negative. He was also noticed to have a necrotic third toe
(unclear chronicity). Presentation concerning for a septic
emboli.
In the ED,
Initial Vitals: T98.1, HR 130, BP 120/60, RR 20, 96% on 6L
Exam:
Con: Chronic ill-appearing, sitting up in bed
HEENT: NCAT. PERRLA, no icterus. EOMI
Neck: +JVD
Resp: Tachypneic, faint bibasilar crackles. No increased work of
breathing.
CV: Irregularly irregular
Abd: Soft, Nontender
MSK: Right third toe is necrotic. Palpable DP and ___ pulses
bilaterally.
Skin: No rash, Warm and dry, No petechiae
Neuro: AOx3, intermittently confused, able to follow commands,
speech fluent, no obvious facial asymmetry, moves all 4 ext to
command.
Labs:
CBC: 8.6 > ___ < 101
BMP: Na 130, K 4.4, Cl 96, HCO3 15, BUN 84, Cr 5.8
LFTs: AST 2314, ALT 1730, AP 57, Tbili 0.9, Albuin 3.2, Lipase 9
CK ___
Lactate 1.4
VBG ___
INR 1.4
___ 13276
UA large blood, 6 RBC, 13 WBC, mod bacteria, >300 protein,
glucose 100, trace ketone, negative ___
Trop 0.10
Serum tox negative, Urine tox + oxycodone, otherwise negative
Imaging:
Renal ultrasound with no evidence of hydronephrosis
CXR: Mild cardiomegaly with pulmonary vascular congestion and
mild left basal atelectasis.
Consults: cardiology
Interventions: vanc/zosyn, diltiazem gtt @7.5mg/hr, 1L NS
While in the ED was put on BiPAP pre-emptively while fluid
resuscitating given tachypnea and signs of increased work of
breathing. His lowest O2 sat was 91% on RA.
VS Prior to Transfer:
T97, HR 112-122, BP 115/71, RR 21 on 98% BiPAP
On arrival to the ICU, patient reports feeling "better" though
unable to clearly state what feels improved.
Past Medical History:
Afib (previously on warfarin, stopped in ___ - likely in
setting
of falls)
Aortic valve replacement
DM
HTN
Arthritis
Bilateral knee replacement
L femur fracture - surgical repair
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION EXAM
=====================
VS: T97.6, HR 106, BP 121/80, RR 24, 95% on 3L NC
GEN: lying in bed, in no acute distress
EYES: PERRLA, EOMI
HENNT: NC/AT, dry mucous membranes
CV: irreg irreg, no m/r/g
RESP: unable to sit patient up, CTAB anteriorly, no
wheezes/rales/rhonchi
GI: TTP in RUQ
EXT: WWP, no ___ edema, R foot with necrotic appearing third toe
with mild surrounding erythema, ulcer on dorsal R ___ toe
NEURO: A&Ox2-3 (person, BID in ___, ___
having clonic jerking of bilateral upper>lower extremities
CN II-XII intact
Strength:
UE - ___ deltoid, tricep, bicep, hand grip strength ___ on R,
___ on L
___ - ___ bilateral hip flexion and extension, ___nd flexion, ___ foot dorsiflexion and plantar flexion
Sensation: intact throughout
Reflexes: difficult to illicit
DRE: good rectal tone
DISCHARGE EXAM
======================
24 HR Data (last updated ___ @ 740)
Temp: 97.7 (Tm 98.5), BP: 101/69 (91-116/56-76), HR: 96
(77-106), RR: 18 (___), O2 sat: 94% (90-100), O2 delivery: 1L,
Wt: 311.07 lb/141.1 kg
GEN: A&Ox3,
HEENT/Neck: JVP not elevated
CV: mildly tachycardic, irregular, systolic murmur over upper
sternal borders
PULM: decreased breath sounds and poor air movement bilaterally,
minimal crackles. No increased work of breathing
GI: nontender, mildly distended, no rebound or guarding
EXT: warm well perfused. ___ edema significantly improved
SKIN: no rashes
NEURO: A&Ox3, moving all extremities
Pertinent Results:
ADMISSION LABS
=====================
___ 09:02PM BLOOD WBC-8.6 RBC-4.39* Hgb-12.0* Hct-36.8*
MCV-84 MCH-27.3 MCHC-32.6 RDW-13.8 RDWSD-42.4 Plt ___
___ 09:02PM BLOOD ___ PTT-29.9 ___
___ 09:02PM BLOOD Glucose-130* UreaN-84* Creat-5.8* Na-130*
K-4.4 Cl-96 HCO3-15* AnGap-19*
___ 09:02PM BLOOD ALT-1730* AST-2314* ___
AlkPhos-57 TotBili-0.9
___ 09:02PM BLOOD cTropnT-0.10* ___
___ 09:02PM BLOOD Albumin-3.2* Calcium-7.5* Phos-4.0 Mg-2.1
___ 09:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
RELEVANT STUDIES
=====================
___ Cardiovascular Transthoracic Echo Report
CONCLUSION:
The left atrial volume index is normal. There is no evidence for
a right-to-left shunt with agitated saline at
rest. There is mild symmetric left ventricular hypertrophy with
a normal cavity size. There is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
basal inferolateral walls (see schematic) and
preserved/normal contractility of the remaining segments. No
thrombus or mass is seen in the left ventricle.
Quantitative biplane left ventricular ejection fraction is 63 %.
There is no resting left ventricular
outflow tract gradient. Normal right ventricular cavity size
with normal free wall motion. The aortic sinus
diameter is normal for gender with mildly dilated ascending
aorta. The aortic arch diameter is normal with a
normal descending aorta diameter. An aortic valve bioprosthesis
is present. The prosthesis is well seated with
normal leflet motion but high gradient. The effective orifice
area index is moderately reduced (0.65-0.85 cm2/
m2) suggesting patient/prosthesis mismatch. There is no aortic
regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
moderate mitral annular calcification. There is
trivial mitral regurgitation. Due to acoustic shadowing, the
severity of mitral regurgitation could be
UNDERestimated. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid regurgitation. The
estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic
___ Cardiovascular STRESS
___ Imaging CARDIAC PERFUSION PHARM
IMPRESSION:
1. Partially reversible, medium sized, severe perfusion defect
involving the RCA
territory.
2. Normal left ventricular cavity size. Mild systolic
dysfunction with
hypokinesis of the basal inferior and inferolateral walls.
___ Cardiovascular Transthoracic Echo Report
CONCLUSION:
The estimated right atrial pressure is ___ mmHg. There is
moderate symmetric left ventricular hypertrophy.
There is mild regional left ventricular systolic dysfunction
with basal inferior hypokinesis (see schematic). The
visually estimated left ventricular ejection fraction is 45-50%.
An aortic valve bioprosthesis is present.
The prosthesis is well seated with HIGH gradient. The mitral
valve leaflets are mildly thickened with no mitral
valve prolapse. There is moderate mitral annular calcification.
There is moderate [2+] mitral regurgitation.
Due to acoustic shadowing, the severity of mitral regurgitation
could be UNDERestimated.
IMPRESSION: 1) Mild regional/global systolic dysfunction c/w
mixed ischemic (prior MI in PDA
territory) and non-ischemic cardiomyopath. 2) Moderate mitral
regurgitation of unclear
mechanism. 3) Well seated aortic valve bioprosthesis with high
transvalvular gradients.
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION:
1. New punctate hypodensity within the right frontal parietal
white matter,
which may represent a new embolic infarct, and can be confirmed
with MRI, if
clinically necessary. No evidence of hemorrhage.
2. Other known punctate embolic infarcts are better seen on the
prior MR dated
___.
___ Cardiovascular Transesophageal Echo Final Report
CONCLUSION:
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium/right atrial appendage. There is
no evidence for an atrial septal defect by 2D/color Doppler.
Overall left ventricular systolic function is normal.
There are no aortic arch atheroma. There is a complex (>4mm,
non-mobile) atheroma in the descending
aorta. An aortic valve bioprosthesis is present. The prosthesis
is well seated with normal leaflet motion. No
masses or vegetations are seen on the aortic valve. No abscess
is seen. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. No masses or vegetations are seen on
the mitral valve. No abscess is seen. There is moderate [2+]
mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. No mass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is
mild [1+] tricuspid regurgitation.
IMPRESSION: No discrete vegetation or abscess seen. There is a
complex (>4mm, non-mobile)
atheroma in the descending aorta. Moderate mitral regurgitation.
Mild tricuspid regurgitation.
___ Imaging CTA HEAD AND CTA NECK
IMPRESSION:
1. Redemonstration of the known subacute infarcts in the high
right frontal
and parietal lobes. Other known infarcts are not seen given
their size. No
hemorrhage.
2. Moderate focal narrowing of the right P2 segment with patent
distal
run-off.
3. Retropharyngeal course of the right distal common and
proximal internal
carotid arteries.
4. Calcification and narrowing of the right V4 segment,
secondary to
atheromatous change, with patent distal run-off.
5. Moderate-size right pleural effusion.
___ Imaging MR HEAD W/O CONTRAST
IMPRESSION:
1. Multiple acute likely embolic infarcts in the setting of AFib
involving
bilateral cerebral hemispheres and the right cerebellum. Some
of the lesions
do appear to be possibly in the watershed distribution however.
2. Additional findings as described above.
OTHER PERTINENT LABS
=====================
___ 09:02PM BLOOD cTropnT-0.10* ___
___ 02:28AM BLOOD cTropnT-1.11* ___
___ 01:55PM BLOOD CK-MB-24* cTropnT-1.20*
___ 07:15PM BLOOD CK-MB-21* MB Indx-7.9* cTropnT-1.03*
___ 05:38AM BLOOD CK-MB-43* MB Indx-16.9* cTropnT-2.55*
___ 11:18AM BLOOD cTropnT-2.62*
___ 11:11PM BLOOD cTropnT-2.84*
___ 07:55AM BLOOD CK-MB-60* MB Indx-12.8* cTropnT-2.86*
___ 03:30PM BLOOD CK-MB-70* MB Indx-12.3* cTropnT-2.84*
___ 09:10PM BLOOD cTropnT-2.56*
___ CT HEAD W/O CONTRAST:
1. No acute intracranial findings.
2. Bilateral frontal lobe, perisylvian atrophy.
MICROBIOLOGY
=====================
___ 9:46 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___
___ - ___.
GRAM POSITIVE COCCI IN CLUSTERS.
___ 8:56 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS HOMINIS. FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS HOMINIS
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___ @1706 ON
___.
DISCHARGE LABS
=====================
___ 07:25AM BLOOD WBC-7.3 RBC-2.90* Hgb-8.3* Hct-27.1*
MCV-93 MCH-28.6 MCHC-30.6* RDW-17.8* RDWSD-61.1* Plt ___
___ 07:25AM BLOOD ___ PTT-44.2* ___
___ 07:25AM BLOOD Glucose-135* UreaN-32* Creat-1.7* Na-140
K-3.9 Cl-97 HCO3-32 AnGap-11
___ 07:25AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. Cephalexin 500 mg PO QID
3. Dextroamphetamine 30 mg PO BID
4. OxyCODONE (Immediate Release) 20 mg PO Q8H:PRN Pain -
Moderate
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Gabapentin 400 mg PO TID
7. Glargine 80 Units Bedtime
Humalog 30 Units Breakfast
Humalog 30 Units Lunch
Humalog 30 Units Dinner
8. QUEtiapine Fumarate 300 mg PO QHS
9. Mirtazapine 45 mg PO QHS
10. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PO/PR DAILY
6. Metoprolol Succinate XL 200 mg PO BID
7. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
8. Polyethylene Glycol 17 g PO DAILY
9. Ramelteon 8 mg PO QHS:PRN sleep
Should be given 30 minutes before bedtime
10. Senna 8.6 mg PO BID
11. sevelamer CARBONATE 800 mg PO TID
12. ___ MD to order daily dose PO DAILY16
pending daily INR. goal ___. Gabapentin 100 mg PO QHS
14. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. OxyCODONE (Immediate Release) 5 mg PO TID:PRN Pain - Severe
RX *oxycodone 5 mg 1 capsule(s) by mouth three times a day Disp
#*9 Capsule Refills:*0
16. QUEtiapine Fumarate 50 mg PO QHS
17. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Omeprazole 20 mg PO DAILY
20. HELD- Mirtazapine 45 mg PO QHS This medication was held. Do
not restart Mirtazapine until consider resuming at ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Aortic arch atheroma
Acute embolic infarct
Acute tubular necrosis
Non-ST elevation myocardial infarction
SECONDARY DIAGNOSES:
=====================
Rhabdomyolysis
Acute toxic metabolic encephalopathy
Chronic right third toe
Bloodstream infection due to methicillin sensitive staph aureus
Atrial fibrillation with rapid ventricular response
Type 2 diabetes
Dysphasia
Severe protein calorie malnutrition
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with urinary incontinence, frequent falls,
confusion, c/f normal pressure hydrocephalus but unable to obtain collateral
about baseline mental status// stroke, ventricular enlargement
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territory infarction,hemorrhage,edema, or
mass. Brain parenchymal atrophy, most prominent at the frontal lobes and
sylvian fissures. Mild chronic small vessel ischemic change.
There is no evidence of fracture. There is mild leftward deviation of the
bony nasal septum. 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 findings.
2. Bilateral frontal lobe, perisylvian atrophy.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old man with hx afib, prior AVR, T2DM presenting with ___
weakness and falls, e/o rhabdo, transaminitis (seems too high to be c/w
rhabdo)// pneumonia, intraabdominal infection, liver pathology
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 5.7 s, 75.7 cm; CTDIvol =
24.5 mGy (Body) DLP = 1,851.6 mGy-cm. Total DLP (Body) = 1,852 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: Liver is diffusely hypoattenuating, consistent with hepatic
steatosis. There is no evidence of focal lesions within the limitations of an
unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: Spleen is mildly enlarged measuring up to 13.8 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. There is no pneumoperitoneum or ascites.
PELVIS: Urinary bladder is collapsed around a Foley catheter. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: Surgical hardware is partially imaged in the left proximal femur.
SOFT TISSUES: Evaluation of the soft tissues is notable for nonspecific
subcutaneous stranding about the bilateral hip soft tissues (2:129).
IMPRESSION:
1. No definite infectious source identified within the abdomen or pelvis.
2. Hepatic steatosis. Please note that assessment for hepatic parenchymal
pathology is somewhat limited in the absence of intravenous contrast.
3. Mild splenomegaly.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with hx afib, prior AVR, T2DM presenting with ___
weakness and falls, e/o rhabdo, transaminitis (seems too high to be c/w
rhabdo)// pneumonia, intraabdominal infection, liver pathology
TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with
intravenous infusion of nonionic, iodinated contrast agent, following oral
administration of contrast agent for selected abdominal studies, and/or
followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0
or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm
MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck
will be reported separately. All images of the chest were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.7 s, 75.7 cm; CTDIvol = 24.5 mGy (Body) DLP =
1,851.6 mGy-cm.
Total DLP (Body) = 1,852 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: None available.
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either axilla or
thoracic inlet. No abnormalities in 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. Status post
aortic valve replacement. Moderate atherosclerotic calcifications in the
coronary arteries and aorta. The pulmonary arteries and aorta are normal in
caliber throughout.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Small mediastinal lymph nodes, none
pathologically enlarged by CT size criteria. No hilar lymphadenopathy.
PLEURA:
Small bilateral pleural effusions. No apical scarring bilaterally.
LUNGS:
The airways are patent to the subsegmental levels. Mild centrilobular
emphysema. Mild diffuse bronchial wall thickening. No bronchiectasis or
mucus plugging. Secretions are noted in the right and left main bronchi.
Partial compressive atelectasis noted in both lower lobes.
CHEST CAGE:
Moderate dorsal spondylosis. Status post midline sternotomy with unremarkable
wires. No acute fractures. No suspicious lytic or sclerotic lesions.
UPPER ABDOMEN:
Please refer to same day abdominal CT report for subdiaphragmatic findings.
IMPRESSION:
Stable postoperative appearance of aortic valve replacement.
No evidence of pulmonary infection or edema.
Trace bilateral pleural effusions with subsequent compressive atelectasis.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ hx afib, AVR, HTN, DM2 presenting with weakness, falls and
confusion, found to have rhabdo, transaminitis, and acute renal failure.// ?
bleed, mass, atrophy
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Head CT dated ___.
FINDINGS:
The study is mildly degraded by motion artifact. There are multiple foci of
restricted diffusion involving, but not limited to the right cerebellum, left
uncus, left middle frontal gyrus, right precentral gyrus, and right post
central gyrus. There is no evidence of hemorrhage, edema, masses, mass
effect, midline shift. There is redemonstration of brain parenchymal atrophy,
most prominent at the frontal lobes and sylvian fissures bilaterally.
Periventricular and subcortical white matter FLAIR hyperintensities are
compatible with sequelae chronic small vessel ischemic disease.
Major intracranial flow voids are preserved. The visualized paranasal sinuses
are essentially clear allowing for mild mucosal thickening of the ethmoid air
cells. The orbits are unremarkable. Fluid opacification of the mastoid air
cells noted. No suspicious marrow signal.
IMPRESSION:
1. Multiple acute likely embolic infarcts in the setting of AFib involving
bilateral cerebral hemispheres and the right cerebellum. Some of the lesions
do appear to be possibly in the watershed distribution however.
2. Additional findings as described above.
RECOMMENDATION(S): The findings were discussed with Dr. ___, M.D. by
Dr. ___. on the telephone on ___ at 2:23 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with new trialysis line placement.// location and
?PTX Contact name: ___: ___
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There are postsurgical changes from aortic valve replacement. There has been
interval placement of a right internal jugular central venous catheter which
terminates in the upper superior vena cava.
Low lung volumes are noted. Blunting of the left costophrenic angle and a
retrocardiac opacity most likely represent a small pleural effusion and
subsegmental atelectasis. The cardiomediastinal silhouette is stable in
appearance with central pulmonary vascular congestion but no overt pulmonary
edema. There is no pneumothorax. The osseous structures are unchanged.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old man with necrotic third right toe// Right third toe
osteomyelitis? Fracture?
IMPRESSION:
No previous images. In there is a thin metallic opacification in the soft
tissues lateral to the distal phalanx of the third digit, which could well
represent a foreign body. The cortical integrity of the distal tuft is
questionable, which could reflect a region of osteomyelitis.
Several other similar linear opacification is are seen over the first
metatarsal and proximal phalanx, adjacent to the tarsal navicular, and
projected over the fifth metatarsal.
The bony structures and joint spaces are quite well maintained except for a
small to moderate inferior calcaneal spur and a tiny posterior calcaneal spur.
Radiology Report
INDICATION: ___ year old man with necrotic right third toe, concern for
occlusion vs septic emboli. Please eval arterial flows in right lower
extremity.// Arterial flows in right foot? Necrotic third toe
TECHNIQUE: Non-invasive evaluation of the arterial system in the lower
extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the common femoral
and popliteal arteries but monophasic waveforms are noted at the posterior
tibial and dorsalis pedis arteries.
The right ABI was 0.97. The toe pressure is 41 mm Hg yielding a TBI of 0.36..
On the left side, biphasic doppler waveforms are seen at the common femoral
and popliteal levels but monophasic at the posterior tibial and dorsalis pedis
arteries.
The left ABI was 0.95. The toe pressure is 36 mm Hg yielding a TBI of 0.31..
Pulse volume recordings showed symmetric amplitudes bilaterally, at all
levels.
IMPRESSION:
Moderate right lower extremity ischemia based on toe pressure likely related
to popliteal tibial occlusive disease.
Moderate left lower extremity ischemia based on toe pressure likely related to
multilevel occlusive disease.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: Mr. ___ ___ male with a past medical history
ofhypertension, AVR, A. fib not on AC since ___, diabetes whopresented
originally to ___ for 1.5 weeks of weakness and progressive confusion found
to have acute stroke ? ___ cardioembolic vs watershed? etiology of acute
embolic infarct
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 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
2) Spiral Acquisition 5.2 s, 40.5 cm; CTDIvol = 13.3 mGy (Body) DLP = 538.5
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 23.7 mGy (Body) DLP =
11.9 mGy-cm.
Total DLP (Body) = 552 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: MRI head with and without contrast ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Punctate hypodense foci are seen in the high right parietal and frontal lobes
(2: 25, 28), correlating with the subacute infarcts seen on the prior MRI.
The other infarcts are not seen given their size.
There is no evidence of hemorrhage,edema,ormass. The ventricles and sulci are
prominent, consistent global cerebral volume loss.
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:
Atherosclerotic changes of the cavernous and supraclinoid segments of the
bilateral internal carotid arteries are seen mild stenosis.
There is moderate focal narrowing of the right P2 segment with patent distal
run-off.
A fenestrated proximal left M1 segment is seen with patent distal run-off.
Otherwise, the vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion, or aneurysm
formation. There is fetal origin of the left posterior cerebral artery. The
dural venous sinuses are patent.
CTA NECK:
The right distal common and proximal internal carotid arteries demonstrated
retropharyngeal course.
Atherosclerotic changes of the carotid bifurcations are seen without
narrowing of the internal carotid arteries, by NASCET criteria.
There is calcification and narrowing of the right V4 segment (3:219) due to
atherosclerotic change with patent distal run-off. Otherwise, the vertebral
arteries appear normal with no evidence of stenosis or occlusion.
OTHER:
A moderate-sized right pleural effusion is seen with atelectatic changes.
Mild biapical emphysematous changes are seen. Sternotomy wires are seen. A
nasoenteric tube is partially visualized. A right internal jugular central
venous catheter is seen terminating within the SVC. The visualized portion of
the thyroid gland is within normal limits. There is no lymphadenopathy by CT
size criteria. Degenerative changes of the cervical spine are seen.
IMPRESSION:
1. Redemonstration of the known subacute infarcts in the high right frontal
and parietal lobes. Other known infarcts are not seen given their size. No
hemorrhage.
2. Moderate focal narrowing of the right P2 segment with patent distal
run-off.
3. Retropharyngeal course of the right distal common and proximal internal
carotid arteries.
4. Calcification and narrowing of the right V4 segment, secondary to
atheromatous change, with patent distal run-off.
5. Moderate-size right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with rhabody- NPO. dobhoff placement// dobhoff
placement dobhoff placement
IMPRESSION:
Comparison to ___. The newly inserted feeding tube projects over
the proximal parts of the stomach. No complications, notably no pneumothorax.
Improved lung volumes with improved ventilation of the left lower lobe.
Borderline size of the cardiac silhouette.
Radiology Report
EXAMINATION: VEIN MAPPING-Lower extremities
INDICATION: ___ year old man with T2DM, with R third toe gangrene// b/l ___
vein mapping for evaluation of bypass
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral
lower extremity veins.
COMPARISON: None.
FINDINGS:
The study is limited due to the patient not being able to move his legs.
RIGHT: The proximal great saphenous vein is patent and measures 0.38 cm in
diameter. The more distal great saphenous vein is not visualized which may be
a partially on account of the patient not being able to move his leg.
LEFT: The great saphenous vein is patent measuring 0.5 cm proximally, 0.2 cm
in its midportion and 0.2 cm distally. The greater saphenous vein measures
0.2 cm at the knee, 0.14 cm in the proximal calf, 0.19 cm in the mid calf and
0.15 cm in the distal calf. The left greater saphenous vein is also noted to
be thick walled which may be related to scarring from chronic thrombus.
IMPRESSION:
The left great saphenous is patent however the technologist notes the walls
are slightly thickened which may be from chronic scarring. The right great
saphenous vein is not well visualized due to patient immobility.
Radiology Report
INDICATION: ___ year old man with new onset renal failure, will need tunneled
HD line// placement of tunneled HD line
COMPARISON: Chest radiograph dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
and Dr. ___, Interventional Radiology fellow performed the procedure.
Dr. ___ supervised the trainee during any key components of
the procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: 100 mg Fentanyl was administered for pain control. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 2.5 min, 12 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right 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 tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 19cm tip-to-cuff length catheter was selected. The
catheter was tunneled from the entry site towards the venotomy site from where
it was brought out using a tunneling device. The venotomy tract was dilated
using the introducer of the peel-away sheath supplied. Following this, the
peel-away sheath was placed over the ___ wire through which the catheter was
threaded into the right side of the heart with the tip in the right atrium.
The sheath was then peeled away. The catheter was sutured in place with 0 silk
sutures. Steri-strips were also used to close the venotomy incision site.
Final spot fluoroscopic image demonstrating good alignment of the catheter and
no kinking. The tip is in the right atrium. The catheter was flushed and both
lumens were capped. Sterile dressings were applied. The patient tolerated the
procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing
catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 19cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with a past medical history ofhypertension, AVR,
A. fib not on AC since ___, and diabetes whopresented originally to ___
for 1.5 weeks of weakness andprogressive confusion, transferred to ___ with
acuteencephalopathy, embolic CVA, bloodstream infection, andhypotension.
Peripherally overloaded, on HD for acute renal failure// eval for pulm edema,
source of SOB
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The NG tube projects below the left hemidiaphragm and out of field-of-view.
Right IJ line is unchanged. Cardiomediastinal silhouette is stable. Small
bilateral effusions left greater than right are unchanged. No pneumothorax
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypertension, AVR, A. fib not on AC since
___, and diabetes who presented originally to ___ for 1.5 weeks of
weakness and progressive confusion, transferred to ___ with acute
encephalopathy, embolic CVA, bloodstream infection, and hypotension, now with
increased dyspnea// evidence of volume overload or infection?
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are stable, as is the enlargement of the cardiac silhouette. There is further
engorgement of ill defined pulmonary vessels, consistent with worsening
pulmonary edema. In retrocardiac opacification is concerning for volume loss
in the left lower lobe and there are small bilateral pleural effusions.
Although no definite acute focal consolidation is appreciated, in the
appropriate clinical setting would be impossible to exclude superimposed
aspiration/pneumonia, especially in the absence of a lateral view.
Radiology Report
INDICATION: ___ year old man with a past medical history of hypertension, AVR,
A. fib not on AC since ___, and diabetes who presented originally to ___
for 1.5 weeks of weakness and progressive confusion, transferred to ___ with
acute encephalopathy, embolic CVA, bloodstream infection, and hypotension. Now
w abdominal pain, no BM in 3+ days. Evaluation for SBO, ileus.
TECHNIQUE: Portable supine and left lateral decubitus radiographs of the
abdomen were obtained.
COMPARISON: Comparison to CT abdomen/pelvis from ___.
FINDINGS:
Enteric tube courses below the level of the diaphragm and into the expected
location of the stomach. Gaseous distention of multiple large bowel loops
measures up to 9.4 cm in diameter, with gas extending to the level of the
rectum, findings most consistent with ileus.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Median sternotomy wires appear intact and
well aligned.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Gaseous distention of multiple large bowel loops extending to the level of the
rectum, findings most consistent with ileus.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: Mr. ___ is a ___ year old man with a past medical history of
hypertension, AVR, A. fib not on AC since ___, and diabetes who presented
originally to ___ for 1.5 weeks of weakness and progressive confusion,
transferred to ___ with acute encephalopathy, embolic CVA, bloodstream
infection, and hypotension. Acutely encephalopathic this am, concerned for
bleed given embolic CVA and on warfarin// eval for bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 1,495 mGy-cm.
COMPARISON: CTA head and neck dated ___.
MR brain dated ___.
FINDINGS:
Known punctate embolic infarcts are better seen on the prior MR. ___
hypodensity within the right frontoparietal white matter was not definitively
seen on prior examinations, and may represent a new punctate infarct (series
3, image 20). There is no evidence of hemorrhage,edema,or mass. Mild
periventricular white matter hypodensities are nonspecific, but likely
represent the sequela of chronic microvascular ischemia. There is prominence
of the ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. New punctate hypodensity within the right frontal parietal white matter,
which may represent a new embolic infarct, and can be confirmed with MRI, if
clinically necessary. No evidence of hemorrhage.
2. Other known punctate embolic infarcts are better seen on the prior MR dated
___.
Radiology Report
INDICATION: ___ PMHx hypertension, AVR, A. fib not on AC since ___, ___
transferred from ___ after weakness/confusion found to have embolic CVA due
to aortic atheroma, MSSA bloodstream infection. Course recently complicated by
SOB/volume overload/hypercarbia s/p urgent HD ___, found to have troponin
elevation to 1.1, ECG unchanged, and TTE findings c/f inferior WMA c/f NSTEMI.
Now with renal recovery no longer requiring HD// please remove HD line
COMPARISON: none
TECHNIQUE: OPERATORS: Dr. ___ (radiology resident) and Dr. ___
___ radiology attending) performed the procedure. The attending,
Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: None
MEDICATIONS: None
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: None
PROCEDURE: 1. Right chest tunneled central catheter removal.
PROCEDURE DETAILS: The patient was brought to the angiography holding area
and positioned with his head upright on a stretcher. The Right chest tunneled
line site was cleaned and draped in standard sterile fashion. 1% lidocaine was
administered around the tube track. The cuff was loosened with a bent forceps.
The catheter was removed with gentle traction while manual pressure was held
at the venotomy site. Hemostasis was achieved after 5 min of manual pressure.
A clean sterile dressing was applied. The patient tolerated the procedure
well. There were no immediate postprocedural complications.
FINDINGS:
Expected appearance after tunneled line removal.
IMPRESSION:
Successful removal of a right chest tunneled line.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ PMHx hypertension, AVR, A. fib, transferred from ___ after
weakness/confusion found to have embolic CVA due to aortic atheroma, MSSA
bloodstream infection. Course recently complicated by SOB/volume
overload/hypercarbia s/p urgent HD ___// evaluate for volume overload
evaluate for volume overload
IMPRESSION:
Compared to chest radiographs, ___ through ___.
Mild pulmonary edema has improved substantially. Moderate cardiomegaly and
mediastinal venous engorgement have probably improved as well. Aeration is
compromised in the left lower lobe, explained by dependent edema and
atelectasis, but pneumonia is not excluded. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with dyspnea// eval for fluid overload
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. Midline sternotomy wires are noted.
There is linear retrocardiac opacity which is most suggestive of atelectasis.
Pulmonary vascular congestion is noted without frank edema. No pneumothorax
or large effusion. The heart is mildly enlarged. Mediastinal contour is
grossly unremarkable. Bony structures are intact.
IMPRESSION:
Mild cardiomegaly with pulmonary vascular congestion and mild left basal
atelectasis.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with multi-organ failure, elevated Cr// eval for
hydronephrosis, kidney stone
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys and
bladder were obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 13.5 cm. The left kidney measures 12.7 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally.
The bladder is collapsed with a Foley and cannot be evaluated.
IMPRESSION:
No hydronephrosis.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with new urinary incontinence and acute on
chronic weakness// spinal cord pathology spinal cord pathology
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: CT abdomen pelvis of ___.
FINDINGS:
Alignment is anatomic. Superior endplate deformity of T12 is associated with
linear STIR hyperintense signal and T1 hypointense signal, likely representing
a subacute, fracture (series 2, image 45; series 3, image 14; series 4, image
14). The remainder of the vertebral body heights are preserved. No other
focal suspicious marrow lesion. Disc heights are maintained. The conus
medullaris terminates at the L1-L2 level, within expected limits. There is no
signal abnormality of the terminal cord.
T11-T12 through L3-L4: No significant spinal canal or neural foraminal
narrowing.
L4-L5: A small disc bulge does not narrow the spinal canal. In conjunction
with facet arthropathy there is mild bilateral neural foraminal narrowing.
L5-S1: No significant spinal canal or neural foraminal narrowing.
There is T2 hyperintense signal diffusely of the paraspinal muscles and of the
iliopsoas muscles, which is nonspecific, but likely reflects patient's given
history of rhabdomyolysis. Remainder the visualized prevertebral paraspinal
soft tissues are grossly unremarkable.
IMPRESSION:
1. Minimal degenerative changes without spinal canal or neural foraminal
narrowing. No evidence for cord compression or cauda equina compression.
2. Diffuse T2 hyperintense signal of the paraspinal muscles and iliopsoas
muscles. Findings are nonspecific, but likely reflects given history of
rhabdomyolysis.
3. Additional findings described above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypotension, Transfer
Diagnosed with Sepsis, unspecified organism, Nonspec elev of levels of transamns & lactic acid dehydrgnse, Acute kidney failure, unspecified
temperature: 98.1
heartrate: 130.0
resprate: 20.0
o2sat: 96.0
sbp: 102.0
dbp: 60.0
level of pain: uta
level of acuity: 2.0 | Mr. ___ ___ male with a past medical history
of
hypertension, AVR, A. fib not on AC since ___, DM2 who
presented originally to ___ for 1.5 weeks of weakness and
progressive confusion. Transferred to ___ for concern of
multiorgan failure, course c/b multiple brain emboli thought to
be from aortic atheroma. Course complicated by MSSA bloodstream
infection, Afib with RVR, rhabdomyolysis leading to acute renal
failure requiring HD, and later NSTEMI. Transferred from MICU to
floor on ___ after able to transition from CRRT to iHD.
ACUTE ISSUES
===============
# Aortic arch atheroma
# Acute embolic CVA
Patient the patient's initial presentation was thought to be
secondary to severe PVD with showering of cholesterol emboli.
___ demonstrated an aortic arch atheroma which was thought to be
the source of emboli as there was no evidence endocarditis or
intracardiac thrombus due to AFib. This would explain his livedo
reticularis, necrotic/gangrenous toe, and brain emboli. Lipid
panel wnl. Vascular surgery consulted about utility of
endovascular graft, with no plans for intervention on the
atheroma but future plans for ___ angiogram when stable and
renal function improved.
# Acute Kidney Injury
# Acute Tubular Necrosis
# Rhabdomyolysis
Acute renal failure likely secondary to ATN from rhabdomyolysis
given muddy
brown casts in sediment, though may have had cholesterol emboli
to renal vasculature given overall presentation. On CRRT in
MICU, transitioned to HD until renal function improved and
diuresed with Lasix 160mg IV prn. Renal function improved with
no further need for HD per renal. After improvement in renal
function he began to void well and maintain even I/O without
diuresis. Continued on Sevelamer for ongoing hyperphosphatemia.
Discharge Cr 1.7.
#NSTEMI
#Volume Overload
On ___, the patient developed SOB/volume overload/hypercarbia
requiring urgent hemodialysis. Likely due to NSTEMI given
troponin elevation to 1.1, ECG
unchanged, and subsequent TTE findings concerning for inferior
WMA. The patient was heparin and ASA loaded, and was started on
atorvastatin 80 mg nightly. There was a partially reversible
defect in RCA territory on pMIBI possibly concerning for
saphenous vein graft failure. Given improved clinical status and
wall motion abnormality on repeat echocardiogram, coronary
angiogram was deferred per cardiology team. Another episode of
hypoxia/SOB occurred ___ and trops were found to peak at 2.86,
which was thought to represent demand ischemia. Coronary
angiogram was again deferred.
# Acute metabolic encephalopathy
Likely multifactorial related to his multiple embolic CVA,
hypercarbia, infection,
___. Discontinued Seroquel and dose reduced gabapentin with some
improvement. Developed intermittent worsening in MS due to
volume overload/hypercarbia, hyponatremia. He was maintained on
delirium precautions and OT was consulted
# Necrotic R third toe
# MSSA and S. hominuns blood stream infection
Etiology of bacteremia was unclear, possibly secondary to
necrotic toe though toes did not look actively infected. S.
hominus common skin flora, so could represent contaminant. There
was no evidence of endocarditis on TTE/TEE, and the patient was
treated with a 2 week total course of Vancomycin completed ___
with no further positive blood cultures.
# Rhabdomyolysis
# Generalized ___ weakness
___ weakness likely secondary to rhabdomyolysis in the setting of
immobility for several days prior to presentation. MRI L-spine
with no e/o cord compression. Resolved with peak CK of 35k.
Rheumatologic workup and paraneoplastic eval was negative except
positive aldolase which is nonspecific.
# Afib with RVR
Hx of Afib, presenting in RVR to 130s with SBPs in 100s at
___ and started on dilt gtt that was transitioned to
metoprolol tartrate with uptitration. He was previously on
coumadin, stopped in ___ likely in setting of falls. CHADS2VASC
6 (HTN, age, DM, stroke x2, vascular disease) so bridged with
heparin gtt for anticoagulation. Before discharge, warfarin and
heparin had to be discontinued as patient's INR became
supratherapeutic in the setting of worsened PO intake after tube
feeds were stopped. Discharge INR 5.5, currently holding
warfarin
# T2DM
Blood sugars were labile during admission. He became hypoglyemic
after removing NGT and stopping TF, requiring discontinuation of
lantus and liberalization of diet. Since liberalizing the
patient's diet, he was found to be eating foods with very high
glycemic index including candy
# Dysphagia
# Severe Protein Calorie Malnutrition
Dobhoff removed ___ per patient request. Since had been taking
in soft solids
and thin liquids, ensure enlive. Nutrition and SLP consulted.
Diet was liberalized given hypoglycemia
TRANSITIONAL ISSUES
===================
Discharge weight 144.5 kg (318.56 lb)
Discharge Cr 1.7
Discharge INR 5.5
# Afib
[] Please obtain INR daily until warfarin dose determined. Was
taking 6 mg warfarin daily while on tube feeds. dosing
requirement on current diet is unknown.
[] Warfarin being held iso supratherapeutic INR, but warfarin
dose will need to be titrated with potential need for heparin
bridge if INR drops. would recommend bridge given presentation
with atheroembolic strokes
[] Metoprolol succinate increased to 200mg bid for rate control
# Embolic CVA
[] Consider follow up MRI as found to have new hypodensity
concerning for a new embolus on CT head ___
# PVD # Toe Ischemia
[] Right lower extremity CTA, angiogram with vascular pending
renal recovery
[] f/u podiatry re need for toe amputation
[] should get HBV vaccination
[] Gabapentin decreased in the setting of ___, and Adderall held
during admission. Consider reinitiation of outpatient if needed
# NSTEMI # HFpEF
[] Discharged without PO diuretic, which should be titrated as
outpatient (possibly torsemide 40mg). Weight patient daily and
if regains 5 lbs or more consider restarting torsemide.
[] Based on the echocardiographic findings and ___ ACC/AHA
recommendations,
antibiotic prophylaxis IS recommended prior to dental cleanings
and other non-sterile procedures.
#Acute renal failure
[] Discharged on sevelamer for hyperphosphatemia, however may be
able to stop as outpatient
# Acute metabolic encephalopathy
[] Discontinued Seroquel and dose reduced gabapentin with some
improvement.
# DM2 # Dysphagia
[] Blood sugars labile after NGT removed. Uptitrating lantus as
needed after discontinuing in the setting of hypoglycemia. prior
to admission had been on Lantus 80U QHS and Humalog 30U TIDAC
[] Diet was liberalized given hypoglycemia but SLP recs were for
soft solids, thin liquids. Encourage healthy and stable diet
# Suspected history of mood disorder
[] titrate quetiapine as need. had been on 300 mg QHS at home,
was held in setting of encephalopathy then resumed at 50 qhs
[] consider resuming home mirtazapine at low dose
#CODE STATUS: FULL CODE
#EMERGENCY CONTACT: ___ (Wife, HCP): ___
>30 min spent on discharge planning including face to face time. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pradaxa / Hydroxychloroquine
Attending: ___.
Chief Complaint:
B/L lower extremity pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HMED ATTENDING INITIAL NOTE
DATE: ___
TIME: 1050 ___
.
HPI:
___ with history of seronegative arthritis, afib on AC and
tikosyn presents with worsening bilateral lower extremity pain
and L ankle pain. He fell and twisted his ankle on ___. He then
saw ortho on ___ where he received vicoden. His L leg was
placed in a boot. He rested it, iced it, put heat on it, wrapped
it and the pain continued to worsen. His right foot then started
hurting and he was unable to walk to the BR. He thought that he
might have injured his R foot. He then developed L knee pain, R
thumb pain.
X-rays which showed increased swelling about the L lateral
malleoulus but no obvious evidence of fracture. Reports poor
control of pain despite this.
+ Shortness of breath when he arrived to ___. +
lethargy. He has been on FMLA since ___ and he has been in
bed for the past week. No chest pressure or tightness. Does
report worsening shortness of breath/orthopnea.
+ nausea and vomiting secondary to percocet.
.
At ___ BP = 135/82, P = 94, O2 sat = 99% on
RA, T = 97.3. WBC = 9.7 with 79.1 PMNs. CRP = 110, Cr = 1.33, K
= 3.3, Troponin < 0.04, BNP = 63 (WNL) CXR clear. B/L ___ US:
negativ for DVT. He received KCL 40 meq, Percocet ___ x
2T,solumedrol 80 mg IV x T
.
Upon arrival to ___ ED VS:
He recieved lipitor 10 mg , celexa 10 mg, toprol25 mg, morphine
4 mg IV,
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [?] weight loss, + night sweats
HEENT: [X] All normal
RESPIRATORY: [+] shortness of breath, no cough
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [+] Ecchymosis/abrasion of R medial malleolus
MUSCULOSKELETAL: [+] Per HPI
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [+] stressed about risk of losing his job.
All other systems negative except as noted above
Past Medical History:
1. H/o RA with mildly positive anti-CCP antibody with a negative
rheumatoid factor in ___ previously on MTX which he self
d/c'ed. He was supposed to start leflunomide but never kept his
f/u appointment.
2. Status post lap band removal recently in ___,
which was placed in ___.
3.Gastroesophageal reflux disease, question ___
esophagus.
4. Atrial fibrillation
5. Hypertension.
6. Hypercholesterolemia, of note, the patient has no history of
7. DVT.
8. History of gout.
9. History of trigger finger, his third middle finger in
___.
10. History of cardioversion for atrial fibrillation.
11. History of right knee arthroscopic surgery in high school.
12. History of left eye strabismus surgery.
Social History:
___
Family History:
Sister with PMR died one year ago from ? intestinal hemorrhage.
Mother is alive and blind. Father died of an MI at age ___.
Brother with carotid artery stenosis s/p stent placement.
Another brother with schizophrenia died in his ___.
Physical Exam:
Vitals: T = 97.8 P 95 BP 142/83 RR 20 SaO2 97% on RA
GEN: NAD, obese, comfortable appearing, NAD
HEENT: ncat anicteric MMM
NECK: obese and supple
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
ABD: +bs, soft, NT, ND, no guarding or rebound
EXTR:2+pulses
LLE with increased swelling and edema compared to R
Chronic venostsis changes
DERM: no rash
NEURO: face symmetric speech fluent with exception of R blind
eye which wanders
PSYCH: calm, cooperative. At first a little flat then later
appropriate affect with occasional brightening.
Pertinent Results:
___ 08:36PM LACTATE-2.2*
___ 08:15PM GLUCOSE-151* UREA N-25* CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-22 ANION GAP-19
___ 08:15PM estGFR-Using this
___ 08:15PM proBNP-249*
___ 08:15PM CRP-89.7*
___ 08:15PM WBC-9.2 RBC-4.90 HGB-14.7 HCT-43.4 MCV-89
MCH-30.0 MCHC-33.9 RDW-13.9 RDWSD-44.9
___ 08:15PM NEUTS-93.7* LYMPHS-4.3* MONOS-0.9* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-8.66* AbsLymp-0.40* AbsMono-0.08*
AbsEos-0.00* AbsBaso-0.01
___ 08:15PM PLT COUNT-208
___ 07:45PM URINE HOURS-RANDOM
___ 07:45PM URINE HOURS-RANDOM
___ 07:45PM URINE UHOLD-HOLD
___ 07:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:45PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:45PM URINE HYALINE-15*
Test Result Reference
Range/Units
CYCLIC CITRULLINATED PEPTIDE 20 H UNITS
(CCP) AB (IGG)
Reference Range
Negative: <20
Weak Positive: ___
Moderate Positive: 40-59
Strong Positive: >59
___ 05:15AM BLOOD RheuFac-6
___ 06:18AM BLOOD WBC-9.2 RBC-4.15* Hgb-12.5* Hct-37.9*
MCV-91 MCH-30.1 MCHC-33.0 RDW-14.1 RDWSD-47.4* Plt ___
___ 05:15AM BLOOD Glucose-100 UreaN-31* Creat-1.1 Na-136
K-4.3 Cl-104 HCO3-26 AnGap-10
___ 05:40AM BLOOD CRP-60.2*
==================
ECG: afib at 90 bpm, no acute changes, Q in III and avF
Left: No acute fracture or dislocation. Joint spaces are
present. History intoeing osseous spurring undersurface of
calcaneus. There are minimal enthesopathic changes at the
insertion Achilles tendon. Minimal degenerative chagnes at the
first MTP joint. Soft tissues are unremarkable.
Right foot: No acute fracture or dislocation. Joint spaces are
present mild enthesopathic changes are seen at the insertion of
the Achilles tendon. Minimal degenerative chagnes at the first
MTP joint.Soft tissues are unremarkable.
IMPRESSION:
No acute fracture or dislocation. No erosions to suggest an
inflammatory
arthropathy such as rheumatoid arthritis.
COMPARISON: Compared to radiographs from ___
IMPRESSION:
There is mild medial greater than lateral malleolar soft tissue
swelling. No acute fractures or dislocations are seen. Ankle
mortise is preserved. There are no osteochondral lesions.
Joint spaces are preserved without significant degenerative
changes. There is normal osseous mineralization.There is a small
plantar spur. There are no bony erosions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Terazosin 5 mg PO QHS
2. Rivaroxaban 20 mg PO QHS
3. Potassium Chloride ___ mEq PO DAILY
4. Atorvastatin 10 mg PO QPM
5. HydrALAzine 20 mg PO Q6H
6. Valsartan 320 mg PO DAILY
7. Dofetilide 500 mcg PO Q12H
8. Citalopram 10 mg PO DAILY
9. Metoprolol Succinate XL 37.5 mg PO DAILY
10. Furosemide 40 mg PO DAILY:PRN when he feels like he has too
much salt
11. Amlodipine 10 mg PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
13. Multivitamins 1 TAB PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Citalopram 10 mg PO DAILY
4. Dofetilide 500 mcg PO Q12H
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Furosemide 40 mg PO DAILY:PRN when he feels like he has too
much salt
7. HydrALAzine 20 mg PO Q6H
8. Metoprolol Succinate XL 37.5 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Rivaroxaban 20 mg PO QHS
11. Terazosin 5 mg PO QHS
12. Valsartan 320 mg PO DAILY
13. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
14. Cyanocobalamin 100 mcg PO DAILY
15. Potassium Chloride ___ mEq PO DAILY
Hold for K >
16. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four
hours Disp #*25 Tablet Refills:*0
17. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
18. Acetaminophen 1000 mg PO Q8H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Polyarthritis
atrial fibrillation
OSA
Rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with RA, poor compliance with RA therapy s/p fall
with L ankle swelling and pain now with R thumb pain. // Please evaluate R
thumb and also evaluate for RA changes.
COMPARISON: Compared to radiographs from ___
IMPRESSION:
No acute fractures or dislocations are seen. There are mild degenerative
changes with some joint space narrowing at the first MCP and first CMC joints.
No bony erosions are seen to indicate an inflammatory arthropathy such as
rheumatoid arthritis. There is normal osseous mineralization.No radiopaque
foreign bodies are seen.
Radiology Report
INDICATION: ___ year old man with RA s/p fall with L ankle swelling and pain.
// R/o fracture
COMPARISON: Compared to radiographs from ___
IMPRESSION:
There is mild medial greater than lateral malleolar soft tissue swelling. No
acute fractures or dislocations are seen. Ankle mortise is preserved. There
are no osteochondral lesions. Joint spaces are preserved without significant
degenerative changes. There is normal osseous mineralization.There is a small
plantar spur. There are no bony erosions.
Radiology Report
EXAMINATION: Bilateral foot radiographs
INDICATION: ___ year old man with RA and bilateral foot pain // assess for
active arthritis, fx
TECHNIQUE: THREE VIEWS OF THE LEFT FOOT AND THREE VIEWS OF THE RIGHT FOOT
COMPARISON: No prior foot radiograph for comparison.
FINDINGS:
Left: No acute fracture or dislocation. Joint spaces are present. History
intoeing osseous spurring undersurface of calcaneus. There are minimal
enthesopathic changes at the insertion Achilles tendon. Minimal degenerative
chagnes at the first MTP joint. Soft tissues are unremarkable.
Right foot: No acute fracture or dislocation. Joint spaces are present mild
enthesopathic changes are seen at the insertion of the Achilles tendon.
Minimal degenerative chagnes at the first MTP joint.Soft tissues are
unremarkable.
IMPRESSION:
No acute fracture or dislocation. No erosions to suggest an inflammatory
arthropathy such as rheumatoid arthritis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: B Leg pain
Diagnosed with JOINT PAIN-MULT JTS
temperature: 98.2
heartrate: 95.0
resprate: 18.0
o2sat: 97.0
sbp: 121.0
dbp: 85.0
level of pain: 7
level of acuity: 3.0 | The patient is a ___ year old male with h/o obesity, HTN, afib on
xarelto, seronegative arthitis off therapy presenting with L
ankle, b/l foot pain, L knee pain and R thumb pain along with
elevated inflammatory markers concerning for an RA flare.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ - Urgent coronary artery bypass graft x5; left internal
mammary artery to left anterior descending artery, and saphenous
vein graft to diagonal, saphenous vein graft to obtuse marginal,
and saphenous vein sequential graft to distal circumflex and
ramus arteries.
___ - Cardiac catheterization
History of Present Illness:
___ year-old man without known cardiac disease presents with a
week of chest pain with worsening symptoms over the past 24
hours accompanied by diaphoresis and shortness of breath. He
presented to ___ where he had EKG changes with ST
elevation in aVR and VI and depressions in II, V3-V6 and a
troponin I of 0.9. He was given ASA325, IV lasix bolus,
metoprolol, started on a heparin drip, and transferred to ___
for further management.
Upon arrival in our ED, the patient's vitals were T 98.2 HR 108
BP 120/77. He was satting 83% on RA which increased to 88% on
6LNC and 98% NRB. He was noted to have increased work of
breathing and was placed on BiPAP. The patient was unable to
tolerate BiPAP and was transitioned back to a NRB. CXR showed
moderate pulmonary edema. He was evaluated by the cardiology
fellow who performed a bedside TTE showing estimated EF 25% with
lateral wall-motion abnormalities. The patient was rebolused
with 40mg of lasix and started on a lasix drip at 5mg/h and
admitted to the CCU.
Past Medical History:
HTN
HL
GERD
?Depression
Social History:
___
Family History:
Unable to confirm, patient intubated and sedated
Physical Exam:
ADMISSION EXAM:
VS: T=98.3 BP=120/83 HR=112 ___ O2 sat=90% NRB
Gen: Tachypnic in respiratory distress
NECK: Supple, JVP elevated.
CV: tachycardic. normal S1,S2. No murmurs, rubs, clicks, or
gallops
LUNGS: Diffuse crackles throughout, tachypnic with increased
work of breathing
ABD: NABS. Soft, NT, ND. No HSM.
EXT: slightly cool, NO CCE. Palpable distal pulses bilaterally.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout. ___ strength throughout.
Discahrge Exam:
VS T 98 HR 75 SR BP 128/72 RR 18 O2sat 95%-RA
Gen NAD
Neuro Alert and oriented x2, easily reoriented-
CV RRR, sternum stable. Incision CDI
Pulm Diminished in bases, scattered rhonchi
Abdm soft, NT/ND/+BS
Ext warm, well perfused. trace edema bilat
Pertinent Results:
ADMISSION LABS:
___ 04:00AM BLOOD WBC-17.9* RBC-5.36 Hgb-16.3 Hct-47.1
MCV-88 MCH-30.4 MCHC-34.7 RDW-14.6 Plt ___
___ 04:00AM BLOOD Neuts-87.6* Lymphs-7.3* Monos-4.5 Eos-0.2
Baso-0.4
___ 04:00AM BLOOD ___ PTT-106.3* ___
___ 04:00AM BLOOD Glucose-159* UreaN-18 Creat-1.2 Na-142
K-4.1 Cl-101 HCO3-27 AnGap-18
___ 04:00AM BLOOD CK(CPK)-615*
___ 04:00AM BLOOD CK-MB-68* MB Indx-11.1* cTropnT-0.62*
___ 09:00AM BLOOD ALT-97* AST-214* LD(LDH)-667* AlkPhos-85
Amylase-47 TotBili-0.3 DirBili-0.1 IndBili-0.2
___ 12:25PM BLOOD %HbA1c-6.1* eAG-128*
___ 07:15AM BLOOD Type-ART pO2-78* pCO2-49* pH-7.31*
calTCO2-26 Base XS--2
DISCHARGE LABS:
___ 08:45AM BLOOD WBC-18.6* RBC-3.70* Hgb-11.1* Hct-34.1*
MCV-92 MCH-30.0 MCHC-32.5 RDW-15.4 Plt ___
___ 08:45AM BLOOD ___
___ 08:45AM BLOOD UreaN-22* Creat-0.9 Na-141 K-3.9 Cl-105
___ 01:58AM BLOOD ALT-73* AST-73* AlkPhos-92 Amylase-195*
TotBili-0.7
___ 08:45AM BLOOD Mg-2.4
MICROBIOLOGY:
___ 9:25 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ @ 3:16
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ 4:30 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of 2g every 8h.
HAFNIA ALVEI. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| HAFNIA ALVEI
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
IMAGING:
___ Portable TTE (Focused views)
Conclusions
The left atrium is normal in cavity size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. There is moderate regional left
ventricular systolic dysfunction with severe hypokinesis of the
distal septum, anterior, and lateral walls. The apex is mildly
aneurysmal and akinetic. The remaining segments contract well
(LVEF 35%). Images are suboptimal to assess for an
intraventricular thrombus. Right ventricular chamber size and
free wall motion are grossly normal. The free wall was not well
seen. The aortic valve leaflets are mildly thickened (?#). No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
IMPRESSION: Technically suboptimal study. Borderline left
ventricular cavity dilation with regional systolic dysfunction
c/w multivessel CAD (distal LAD and LCX distribution).
___ CHEST (PORTABLE AP)
FINDINGS: Mild cardiomegaly is seen. There is mild to moderate
pulmonary edema. Note is made of mild bibasilar atelectasis.
Aside from vascular congestion, the hilar and mediastinal
contours are normal. There is no large pleural effusion or
pneumothorax. The visualized osseous structures are
unremarkable.
IMPRESSION: Moderate pulmonary edema.
___ Cardiovascular ECHO (TEE)
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 20% to 25% >= 55%
Aortic Valve - LVOT diam: 2.0 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: No spontaneous echo contrast in the body of the LA.
No spontaneous echo contrast or thrombus in the ___ or the
RA/RAA. No spontaneous echo contrast is seen in the ___. Good
(>20 cm/s) ___ ejection velocity. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Normal LV wall thickness. Severe regional LV
systolic dysfunction. Severely depressed LVEF. [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate (___) MR.
___ VALVE: Normal tricuspid valve leaflets. Mild to
moderate [___] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
Prebypass
No spontaneous echo contrast is seen in the left atrial
appendage. Left ventricular wall thicknesses are normal. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %). [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. IABP is
seen in correct position below subclavian take off.
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 to moderate
(___) mitral regurgitation is seen.
Mild to Moderate [2+] tricuspid regurgitation is seen.
There is no pericardial effusion.
Dr. ___ was notified in person of the results in the OR
during the procedure.
Postbypass
The patient separated from bypass with IABP, Phenylephrine and
an Epinephrine infusion.
LVEF 35% with improvement in the anterior walls. There is no
sign of aortic injury or dissection.
The Mitral Regurgitation is unchanged from prior
Intact thoracic aorta.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Since the prior radiograph of a few hours earlier, and
intra-aortic balloon pump has been placed, terminating 2.8 cm
below the superior aspect of the aortic knob. Endotracheal tube
has been placed, terminating 6.9 cm above the Carina, and a
nasogastric tube courses below the diaphragm outside of the
field of view of the radiograph. Interval worsening of
asymmetrical pulmonary edema pattern accompanied by moderate
left and small right pleural effusions.
___ Imaging CHEST PORT. LINE PLACEM
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Felodipine 5 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. Ibuprofen 800 mg PO Q8H:PRN pain
4. Metoclopramide 5 mg PO TID
5. Paroxetine 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
2. Albuterol 0.083% Neb Soln ___ NEB IH Q6H:PRN sob/wheezing
3. Amiodarone 400 mg PO DAILY
400 mg daily x1 week then 200mg daily
4. Aspirin EC 81 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Carvedilol 25 mg PO BID
7. Heparin 5000 UNIT SC TID
8. Lisinopril 5 mg PO DAILY
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 5 Days
10. Sarna Lotion 1 Appl TP QID:PRN itching
11. Gabapentin 300 mg PO TID
12. Paroxetine 20 mg PO DAILY
13. Simvastatin 20 mg PO QPM
14. Pantoprazole 40 mg PO Q24H
15. Metoclopramide 5 mg PO TID
16. Felodipine 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Coronary artery disease s/p Cabg
post-op atrial fibrillation
post-op delerium
VAP w/Klebsiella
Cdiff positive
Secondary:
GERD
Ventral Hernia
Discharge Condition:
Alert and oriented x2 nonfocal
Ambulating with assistance
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg - healing well, no erythema or drainage.
Edema-trace
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with chest pain, shortness of breath, hypoxia.
Please evaluate for CHF.
TECHNIQUE: Supine portable radiograph of the chest.
COMPARISON: Radiograph from ___ at 1:50 a.m.
FINDINGS:
Mild cardiomegaly is seen. There is mild to moderate pulmonary edema. Note is
made of mild bibasilar atelectasis. Aside from vascular congestion, the hilar
and mediastinal contours are normal. There is no large pleural effusion or
pneumothorax. The visualized osseous structures are unremarkable.
IMPRESSION:
Moderate pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with STEMI. S/p balloon pump placement. //
Assess IABP placement.
IMPRESSION:
Since the prior radiograph of a few hours earlier, and intra-aortic balloon
pump has been placed, terminating 2.8 cm below the superior aspect of the
aortic knob. Endotracheal tube has been placed, terminating 6.9 cm above the
Carina, and a nasogastric tube courses below the diaphragm outside of the
field of view of the radiograph. Interval worsening of asymmetrical pulmonary
edema pattern accompanied by moderate left and small right pleural effusions.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p CABG // FAST TRACK EARLY EXTUBATION CARDIAC
SURGERY Contact name: ___, Phone: 1 FAST TRACK EARLY
EXTUBATION CARDIAC SURGERY
IMPRESSION:
IN COMPARISON WITH THE EARLIER STUDY OF THIS DATE, THERE IS A PLACEMENT OF A
SWAN-GANZ CATHETER WITH ITS TIP IN THE RIGHT PULMONARY ARTERY. THE REMAINDER
OF THE MONITOR AND SUPPORT DEVICES ARE UNCHANGED. THERE IS SOME IMPROVEMENT
IN AERATION IN THE LEFT LUNG WITH SOME AREAS OF OPACIFICATION ADJACENT TO THE
LEFT CHEST TUBE. CONTINUED ASYMMETRIC PULMONARY EDEMA MORE PROMINENT ON THE
RIGHT. THERE MAY WELL BE SMALL PLEURAL EFFUSIONS BILATERALLY.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p CABG // eval lines/effusions eval
lines/effusions
IMPRESSION:
In comparison with the study of ___, the IABP is been removed. The
other monitoring and support devices are essentially unchanged.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Status post CABG. Evaluate for CVA.
TECHNIQUE: Contiguous axial images MDCT images of the brain were obtained
without intravenous contrast. Coronal and sagittal as well as thin
bone-algorithm reconstructed images were obtained.
DLP: 891 mGy-cm
COMPARISON: None
FINDINGS:
There is no hemorrhage, edema, mass effect, midline shift, or mass. Prominence
of the ventricles and sulci is indicative of volume loss. Periventricular and
subcortical white matter hypodensities are nonspecific, but likely a sequela
of chronic small vessel ischemia. A focal hypodense area in the right parietal
region (02:24) may be sequela of prior infarct. The basal cisterns are patent
and there is normal gray-white matter differentiation.
No bony abnormalities seen. There is partial opacification of the mastoid air
cells bilaterally. The maxillary, sphenoid, and ethmoid sinuses are clear.
There is mild atherosclerotic calcification of the cavernous carotids
bilaterally.
IMPRESSION:
No acute infarction or hemorrhage.
Sequela of chronic small vessel ischemic disease and likely prior infarct in
the right parietal region.
Radiology Report
FINDINGS:
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: ___ year old man with unresponsiveness following CABG.
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 40/11, 47/12, 64/21, cm/sec. CCA peak systolic
velocity is 63 cm/sec. ECA peak systolic velocity is 110 cm/sec. The ICA/CCA
ratio is 1.0 . These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 45/19, 61/20, 48/18, cm/sec. CCA peak systolic
velocity 63 cm/sec. ECA peak systolic velocity is 51 cm/sec. The ICA/CCA ratio
is 1.3. 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.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p CABG, post pull // eval ptx eval
ptx
IMPRESSION:
In comparison with the study of ___, the monitoring and support
devices are unchanged, as is the appearance of the heart and lungs. No
evidence of pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p cardiac surgery- CT d/c'd, NG d/c'd, dob hoff
placed // evaluate for pneumothorax and new dob hoff tube evaluate for
pneumothorax and new dob hoff tube
COMPARISON: Chest radiographs ___ through ___ one.
IMPRESSION:
Patient is still intubated, ET tube in standard placement. Right jugular
introducer ends at the thoracic inlet. Feeding tube with the wire stylet in
place is crural than the nondistended stomach.
Mild left basal atelectasis and small left pleural effusion persist following
removal of the left basal pleural tube. No appreciable pneumothorax. Right
lung clear.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with re-position of NGT // tip of dobhoff
tip of dobhoff
COMPARISON: Chest radiographs most recently ___ one and ___ at
3:46 p.m.
IMPRESSION:
Nasogastric feeding tube with the wire stylet in place, is not obviously
changed in position, curled in a nondistended stomach. ET tube in standard
placement. Right lung clear. Normal cardiomediastinal silhouette. Small
left pleural effusion and persistent elevation of the left lung base. No
pneumothorax. Right jugular sheath ends at the thoracic inlet.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p CABG // eval for line position s/p line
change over a wire Contact name: ___: ___
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the right venous introduction sheet
has been exchanged against the right internal jugular vein catheter. The
course of the catheter is unremarkable, the tip of the catheter projects over
the cavoatrial junction. No complications, notably no pneumothorax. The
other monitoring and support devices are in constant position. Minimally
increasing left basal and retrocardiac atelectasis, potentially combines to a
minimal left pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p CABG with elevated WBC // eval for
infiltrate
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, a pre-existing left pleural effusion
has almost completely resolved. There is a mild retrocardiac atelectasis
persisting. The patient has been extubated and the nasogastric tube was
removed but the right internal jugular vein catheter remains in place. The
lung volumes have, as expected, slightly decreased. As a consequence, the
platelike atelectasis has newly developed at the right lung base. Moderate
cardiomegaly persists. No pulmonary edema. No new focal parenchymal
opacities. No pneumothorax. The alignment of the sternal wires is normal and
constant.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC
temperature: 98.2
heartrate: 108.0
resprate: 16.0
o2sat: 97.0
sbp: 120.0
dbp: 77.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ was admitted to the ___ on ___ for management
of his myocardial infarction and acute heart failure. He was
diuresed amnd intubated for hypoxia. Heparin was started and
aspirin was given. He was taken urgently to the cardiac
catheterization lab where he was found to have left main and
three vessel disease. An intraaortic balloon pump was placed.
The cardiac surgery service was consulted and he was evaluated
for emergent surgery. He was then taken to the operating room
where he underwent five vessel coronary artery bypass grafting.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit. His intra-aortic balloon pump
was clotted and thus removed. Milrinone and levophed were added
for hemodynamic instability. Over the next few days pressors
were slowly weaned and lasix was continued for volume overload.
He was slow to wake neurologically and had some extremity
weakness, a head ct was done, also narcotics were discontinued.
The head CT showed evidence of an old infract but no new
changes. A sputum culture revealed klebsiella and Cefepime was
started for presumed VAP pneumonia. On ___ Mr. ___ was
successfully extubated. He was given free water boluses for
hypernatremia which resolved. He slowly improved neurologically
with movement and level of alertness, he was also noted to have
episodes of delerium. Cefepime was switched to ciprofloxacin and
stopped on ___. A stool sample showed him to have CDiff and he
was started on flagyl this should continue thru ___ Days)
On ___ he was transferred to the step down unit for further
recovery. He worked with physical therapy and occupational
therapy for improvement in his strength and mobility. He
continued to make slow progress and on ___ he was transferred
to rehabilitation at ___ in ___. He is to
follow up with Dr ___ in 1 month |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / lisinopril
Attending: ___.
Chief Complaint:
Shortness of breath, leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of hypertension, tobacco use, HCV s/p treatment
and COPD/chronic bronchitis who presents with lower extremity
edema and shortness of breath. He reports that for the past 6
months he has noted progressive swelling of his lower
extremities. He also has developed 3 pillow orthopnea and
paroxysmal nocturnal dyspnea. On further clarification, however,
he actually uses the extra pillows for back pain and not for
shortness of breath. In fact, he says he does not feel short of
breath at all lying down. He also says that he wakes up at night
because he has a dry throat and not short of breath. He also
reports that his feet hurt after walking about 2 blocks and that
he is slightly short of breath. He has an occasional
non-productive cough that is no worse than usual. He denies any
chest pain. He also reports a chronic nonproductive cough.
Past Medical History:
Chronic low back pain
COPD
HCV s/p treatment with Harvoni
PTSD - agoraphobia from when he was in jail, death of son
___ R eye
Alcohol use disorder
Tobacco use
Colonic polyps
Gastric polyps
H. pylori gastritis
Social History:
___
Family History:
Brother - colon cancer
Son - murdered at age ___
Multiple family members with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS:
___ 0448 Temp: 97.4 PO BP: 133/74 HR: 88 RR: 18 O2 sat: 98%
O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress. Hoarse
voice.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Scant scattered wheezes. No rhonchi or rales. No
increased
work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Bilateral lower extremities painful with tense
non-pitting edema.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
======================
VITALS:
24 HR Data (last updated ___ @ 1559)
Temp: 97.7 (Tm 98.0), BP: 134/77 (120-134/70-77), HR: 88
(83-89), RR: 18 (___), O2 sat: 96% (96-98), O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, sclera anicteric and without injection. MMM.
CV: RRR, normal S1 and S2, no S3 or S4 appreciated; no murmurs,
gallops or rubs
LUNGS: No wheeze. No rhonchi or rales; CTAB. No increased work
of
breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
palpation in all four quadrants.
EXTREMITIES: Bilateral lower extremities painful with 1+
non-pitting edema
NEUROLOGIC: AOx3.
Pertinent Results:
INITIAL LAB RESULTS:
================
___ 08:38PM PLT COUNT-278
___ 08:38PM NEUTS-62.2 ___ MONOS-6.7 EOS-2.8
BASOS-0.4 IM ___ AbsNeut-4.70 AbsLymp-2.09 AbsMono-0.51
AbsEos-0.21 AbsBaso-0.03
___ 08:38PM WBC-7.6 RBC-4.46* HGB-13.3* HCT-40.5 MCV-91
MCH-29.8 MCHC-32.8 RDW-15.1 RDWSD-50.0*
___ 08:38PM ALBUMIN-4.1
___ 08:38PM proBNP-184
___ 08:38PM cTropnT-<0.01
___ 08:38PM ALT(SGPT)-19 AST(SGOT)-28 ALK PHOS-82 TOT
BILI-0.3
___ 08:38PM estGFR-Using this
___ 08:38PM GLUCOSE-84 UREA N-8 CREAT-0.9 SODIUM-141
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
___ 10:39PM URINE MUCOUS-RARE*
___ 10:39PM URINE RBC-1 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:39PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:39PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:39PM URINE UHOLD-HOLD
___ 10:39PM URINE HOURS-RANDOM
___ 11:08PM D-DIMER-1213*
PERTINENT LAB RESULTS:
====================
___ 01:50AM BLOOD cTropnT-<0.01
___ 06:07AM BLOOD %HbA1c-5.2 eAG-103
___ 01:50AM BLOOD TSH-1.8
___ 12:16AM BLOOD ___ pO2-32* pCO2-46* pH-7.40
calTCO2-30 Base XS-2
MICRO:
=====
___ 12:13 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:39 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 10:39 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
=======
CHEST (PA & LAT) ___:
IMPRESSION:
No acute findings.
UNILAT LOWER EXT VEINS LEFT ___:
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
CTA CHEST ___:
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
TRANSTHORACIC ECHO ___:
IMPRESSION: Normal biventricular cavity sizes and
regional/global biventricular systolic
function. No valvular pathology or pathologic flow identified.
Mildly dilated descending thoracic
aorta. Normal estimated pulmonary artery systolic pressure.
DISCHARGE LABS:
==============
___ 06:56AM BLOOD WBC-7.6 RBC-4.29* Hgb-13.1* Hct-38.2*
MCV-89 MCH-30.5 MCHC-34.3 RDW-15.3 RDWSD-49.6* Plt ___
___ 06:56AM BLOOD Glucose-94 UreaN-15 Creat-0.9 Na-142
K-4.2 Cl-107 HCO3-23 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO QHS
2. Diazepam 10 mg PO Q12H:PRN anxiety
3. Naltrexone 50 mg PO DAILY
4. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
Discharge Medications:
1. Chlorthalidone 12.5 mg PO DAILY HTN
RX *chlorthalidone 25 mg 0.5 (One half) tablet(s) by mouth once
a day Disp #*30 Tablet Refills:*0
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone propion-salmeterol [Advair Diskus] 250 mcg-50
mcg/dose 1 puff inh morning and night Disp #*1 Disk Refills:*0
3. Diazepam 5 mg PO Q12H:PRN anxiety
4. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*45 Capsule Refills:*0
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
6. HELD- Naltrexone 50 mg PO DAILY This medication was held. Do
not restart Naltrexone until talking to your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Lower Extremity Edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with lower extremity, shortness of breath. D-dimer
elevated to 1216.// PE? Pulmonary findings to suggest cause of shortness of
breath (PNA, edema)?
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 3.5 s, 0.5 cm; CTDIvol = 21.3 mGy (Body) DLP =
10.6 mGy-cm.
2) Spiral Acquisition 4.0 s, 31.3 cm; CTDIvol = 16.9 mGy (Body) DLP = 528.2
mGy-cm.
Total DLP (Body) = 539 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: There is respiratory artifact limiting evaluation of
the subsegmental branches in the lung bases. Otherwise, pulmonary vasculature
is well opacified to the subsegmental level without filling defect to indicate
a pulmonary embolus. the thoracic aorta is normal in caliber without evidence
of dissection or intramural hematoma. The heart, pericardium, and great
vessels are within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: B Leg pain, B Leg swelling
Diagnosed with Shortness of breath
temperature: 97.7
heartrate: 97.0
resprate: 18.0
o2sat: 94.0
sbp: 123.0
dbp: 110.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ with history of hypertension,
tobacco use, HCV s/p treatment and likely COPD/chronic
bronchitis who presents with six months of progressive bilateral
lower extremity swelling and dyspnea with exertion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
fever, sepsis
Major Surgical or Invasive Procedure:
Intubation ___ (extubated ___
History of Present Illness:
___ y/o M with prior CVA and resulting right hemiparesis and
aphasia, diabetes, dysphagia with g-tube dependence and multiple
admissions for sepsis and pneumonia over the past few months who
is presenting with fever, lethargy and increased pulmonary
congestion over the past day. Tmax ___ at facility. He was
transferred here and is unable to provide further history.
His recent admissions include ___ and ___ for
pneumonia, requiring intubation ___ ___. He was most recently
admitted on ___ when he presented for congestion, cough and
low grade fevers and was found to be hypernatremic to 156 after
recent discharge on diuretics. CXR was negative for pneumonia
and respiratory symptoms presumed to be aspiration pneumonitis.
He was discharged on ___ with Na 142.
He is now presenting again from his facility with a fever to 102
and was found ___ the ED to have a +UA with fever to 104. CXR
negative for consolidation however he required intubation for
worsening respiratory failure. He received vancomycin and
cefepime for coverage of UTI and empiric respiratory infection.
Plan:
[/]EKG
[x]PR Tylenol
[/]CXR- possible small ptx on the left apices
[x]IVF
[/]labs, VBG
[x]IV Vanc, Cefepime
[x]UA- UTI
Dispo: Admission to ICU for urosepsis
- ___ ED initial VS: 101.6 (Tm 104.8) 118 ___ 93% RA
- Exam: R>L rhonchi, +tachypnea, using accessory muscles, +G
tube, minimally responsive
- Patient was given:
___ 13:00 IVF NS ___ Started
___ 13:39 PR Acetaminophen 650 mg ___
___ 13:39 IV CefePIME 2 g ___
___ 14:00 IVF NS ( 1000 mL ordered) ___
Started Stop
___ 14:03 IV Vancomycin ___ Started
___ 14:30 IV Etomidate 20 mg ___
___ 14:30 IV Rocuronium 80 mg ___
___ 14:36 IV DRIP Fentanyl Citrate ___ mcg/hr
ordered) ___ Started 100
___ 14:36 IV DRIP Midazolam (0.5-2 mg/hr ordered)
___ Started 2
___ 15:00 IVF NS 1 mL ___ Stopped (2h ___
___ 15:12 IV Vancomycin 1 mg ___ Stopped (1h
___
- Imaging notable for: CXR with no definite consolidation or
effusion.
- VS prior to transfer: T 100.8 HR 116 BP 107/74 RR 18 99%,
intubated
On arrival to the MICU, patient is sedated and intubated. He is
unresponsive to voice.
Past Medical History:
- Type II Diabetes Mellitus
- Recurrent CVAs (3) with Right sided hemiparesis and aphasia
- Hypertension
- Depression
- GERD
- Dysphagia requiring G tube
- Hyperlipidemia
- recent admissions for PNA ___ ___
Social History:
___
Family History:
No family history of sudden cardiac death, stroke or clotting
disorders.
Physical Exam:
Admission:
VITALS: Per metavision
GENERAL: Sedated and intubated. Does not respond to voice or
sternal rub.
HEENT: R pupil larger than left, minimally responsive. L pupil
briskly responsive. Sclera anicteric. No conjunctival injection.
ET tube ___ place.
NECK: Supple
LUNGS: Coarse breath sounds
CV: Tachycardiac, regular, normal S1/S2, no m/r/g
ABD: Soft, non-tender, non-distended, +BS
EXT: 2+ radial pulses, unable to feel DP pulses bilaterally.
No edema
SKIN: No breaks ___ skin
Discharge:
GEN: NAD, follows commands, mouths responses
HEENT: EOMI, R pupil 4mm and fixed, L pupil 2mm and reactive to
light. MMM, anicteric. Symmetric eyebrow raise with symmetric
creases above eyebrows bilaterally. R sided facial droop.
Unable
to assess sensation of face or hearing. Tongue deviated to L
with
fasciculations. Significant pooling of saliva ___ mouth on
dependent side. Unable to assess pharyngeal muscles.
NECK: Symmetric, strong head turn.
CV: RRR without m/r/g.
LUNG: Expiratory rhonchi ___ anterior lung fields. stable from
previous exams.
ABD: Soft, +BS, non-tender, non-distended. G-J tube ___ place,
dressing is clean, dry and intact.
EXT: Warm and well perfused without e/c/c.
NEURO: ___ strength L handgrip, hip flexion, knee flexion,
dorsiflexion, plantar flexion. ___nd RLE. CN
II, V, VIII-X unable to be assessed. Deficits ___ CN III, VII,
XII. CN XI intact, possibly IV, VI possibly intact.
Pertinent Results:
ADMISSION LABS
===============
___ 01:14PM
WBC-12.2*# RBC-4.74# HGB-11.2*# HCT-38.4*# MCV-81* MCH-23.6*
MCHC-29.2* RDW-22.5* RDWSD-64.3*
___ 05:17PM GLUCOSE-297* UREA N-75* CREAT-1.3*
SODIUM-153* POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-23 ANION
GAP-17*
___ 05:48PM TEMP-38.5 PO2-163* PCO2-32* PH-7.38 TOTAL
CO2-20* BASE XS--4
MICROBIOLOGY
============
___ 1:14 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM------------- 8 R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
___ 1:14 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:56 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 9:03 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, ___
infected patients the excretion of antigen ___ urine ___
vary.
___ 8:56 pm MRSA SCREEN Source: Nasopharyngeal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 8:44 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
HEAVY GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
IMAGING
============
___ CXR
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There are
low lung
volumes with crowding of the pulmonary vascular markings at the
lung bases.
No definite consolidation or pleural effusion or pulmonary edema
seen. There
are no pneumothoraces.
___ b/l ___ Duplex
IMPRESSION:
No evidence of deep venous thrombosis ___ the right or left lower
extremity
veins.
___ Echo
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No pathology valvular flow identified.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
___ Abdominal XRay for Perc G/J Tube Check
IMPRESSION:
Successful exchange of a gastrostomy tube for a new 18 ___
MIC
gastrojejunostomy tube. The tube is ready to use.
DISCHARGE LABS
==============
___ 05:59AM BLOOD WBC-5.1 RBC-3.20* Hgb-8.0* Hct-26.6*
MCV-83 MCH-25.0* MCHC-30.1* RDW-20.5* RDWSD-61.4* Plt ___
___ 05:59AM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-141
K-4.0 Cl-108 HCO3-23 AnGap-10
___ 05:59AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9
Radiology Report
INDICATION: History: ___ with sob fever*** WARNING *** Multiple patients with
same last name!// pna?
COMPARISON: Radiographs from ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There are low lung
volumes with crowding of the pulmonary vascular markings at the lung bases.
No definite consolidation or pleural effusion or pulmonary edema seen. There
are no pneumothoraces.
Radiology Report
INDICATION: History: ___ with tachypnea *** WARNING *** Multiple patients
with same last name!// ETT placement
COMPARISON: Compared to prior radiographs from ___ and from 1 hour
earlier
IMPRESSION:
There has been interval placement of an endotracheal tube whose distal tip is
4 cm above the carina. There is a nasogastric tube whose side port is at the
GE junction. This could be advanced several cm for more optimal placement.
There are low lung volumes. There has been development of opacities at the
lung bases. They may represent aspiration or developing pneumonia. There are
no pneumothoraces.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old man with h/o CVA, dysphagia, intubated for
respiratory distress.// Evaluate OG tube placement
TECHNIQUE: Portable chest x-ray semi-erect
COMPARISON: Previous portable supine chest x-ray from ___
approximately 3 hours prior
FINDINGS:
The endotracheal tube is unchanged imposition. The NG tube has been advanced
several cm. There is low lung volume. There is interval decrease in
opacities at the lung bases when compared to the prior study. The aorta is
atherosclerotic and tortuous.
IMPRESSION:
The NG tube has been advanced several cm, the tip is within the stomach.
Improved aeration lung bases.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with history of PE, requiring intubation.// ?DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with urosepsis, intubated// Interval changes
IMPRESSION:
In comparison with the study ___, the monitoring and support devices are
unchanged. Continued low lung volumes. Increasing opacification at the
bases, especially in the right cardiophrenic angle. Although this could
merely reflect atelectasis, in the appropriate clinical setting
aspiration/pneumonia would have to be seriously considered.
Radiology Report
INDICATION: ___ year old man with split G-tube// Please replace existing tube
with post-pyloric tube. Thanks.
COMPARISON:
Prior G-tube replacement procedure.
TECHNIQUE: OPERATORS: Dr. ___, interventional Radiology Fellow
and Dr. ___, attending radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: 1% Lidocaine subcutaneously.
MEDICATIONS: None.
CONTRAST: 15 ml of Optiray
FLUOROSCOPY TIME AND DOSE: 1.6 min, 7 mGy
PROCEDURE: 1. Gastrostomy tube exchange ___ MIC).
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
The existing tube was injected with contrast and showed opacification of the
gastric rugae. The stay sutures were cut and ___ wire was introduced
into the stomach. The existing feeding tube was then removed. A ___ MIC
gastrostomy catheter was advanced over the wire into position. The sheath was
then peeled away. The balloon was inflated and the disc cinched down followed
by confirming the position of the catheter with a contrast injection.
Dressings were applied. The patient tolerated the procedure well and there
were no immediate complications.
FINDINGS:
1. Appropriately positioned but cracked existing gastrostomy tube. Successful
replacement.
IMPRESSION:
Successful exchange of a gastrostomy tube for a new ___ MIC tube. The tube is
ready to use.
Radiology Report
INDICATION: ___ year old man with G-tube, high residuals, aspiration risk//
replace with GJ tube
___
TECHNIQUE: OPERATORS: Dr. ___ radiology attending)
performed the procedure.
ANESTHESIA: Lidocaine jelly
MEDICATIONS:
CONTRAST: 40 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 19.5, 218 mGy
PROCEDURE: MIC gastrostomy exchange for gastrojejunostomy.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
The gastric lumen was injected with contrast and showed opacification of the
gastric rugae.
The tube was removed over ___ wire and ___ sheath was advanced into the
stomach. The pylorus was crossed with ___ wire and Kumpe catheter. A
stiff glidewire was advanced into the jejunum. A new ___ Fr MIC G-J tube was
advanced into the Jejunum.
A new 18 ___ MIC gastrojejunostomy catheter was advanced over the wire
into position. The balloon was inflated and retention disk pulled to the skin
and tied with 0-silk suture. The position of the catheter was confirmed with
a contrast injection. The catheter was then flushed, capped and secured to the
skin with 0-silk sutures. Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Appropriately positioned new 18 ___ MIC gastrojejunostomy tube.
IMPRESSION:
Successful exchange of a gastrostomy tube for a new 18 ___ MIC
gastrojejunostomy tube. The tube is ready to use.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever, Lethargy
Diagnosed with Sepsis, unspecified organism
temperature: 101.6
heartrate: 118.0
resprate: 20.0
o2sat: 93.0
sbp: 111.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a pleasant ___ year old male with Type II Diabetes
Mellitus and prior stroke with lasting right hemiparesis and
aphasia, dysphagia with g-tube dependence, and chronic foley
catheter who presented with pseudomonas urosepsis, requiring
intubation for increased respiratory effort.
# Urosepsis
Mr. ___ presented from ___ with fever (Tm 104) and
lethargy, and was found to have
lactate 5.5, tachycardia, leukocytosis w/ left shift and
urinalysis concerning for urinary tract infection. Subsequent
urine cultures grew pseudomonas susceptible to Cefepime. The
patient was initially started on vancomycin and Cefepime ___ the
intensive care unit, however vancomycin was discontinued
following a negative MRSA screen. His foley catheter was
exchanged. The patient will continue cefepime (___) for a
total of 2 weeks. He had a midline placed for antibiotic
delivery, which should be removed after the course is complete.
Upon discharge, the patient was afebrile, hemodynamically
stable, and leukocytosis was resolved.
#Acute Anemia:
Mr. ___ had slowly ___ blood counts during his
admission, however, on ___, following his G-J tube procedure,
he was noted to have an acute hemoglobin drop to 6.7. The
patient's sister/healthcare proxy was called and consented for
transfusion, and he was transfused 1 U PRBC with appropriate
response. The acute anemia was most likely secondary to GI
bleeding due to the patient's recent G-tube procedures and acute
illness stress vs. iron deficiency anemia ___ the setting of
malnutrition. The patient had guaiac positive residuals on ___,
however no clinical evidence of bleeding. Stools were guaiac
negative. He remained hemodynamically stable. ___ the setting of
suspected GI bleed, the patient was started on Esomeprazole
sodium 40 mg IV Q12H, and heparin and aspirin were discontinued.
Hemoglobin stable at 8.0 on day of discharge.
# Respiratory Distress s/p Extubation on ___
# Multiple admissions for pneumonia
The patient presented with worsening pulmonary congestion with
multiple recent admissions for pneumonia, requiring intubation
___ ___. He was intubated on admission, and then extubated
on ___. Chest xray on ___ not concerning for pneumonia.
Sputum culture showed commensal flora. Respiratory status
returned to clinical baseline. MRSA Swab was negative.
# H/o CVA
# H/o subsegmental PE
# Subtherapeutic INR
# New onset Afib w/ RVR
# Supraventricular tachycardia
The patient has a history of multiple CVAs (per the patient's
sister, initial 3 CVAs were ___ the frontal part of the brain
beginning at age ___ ___ the setting of alcoholism, uncontrolled
diabetes and hypertension. The most recent CVA ___ be
hemorrhagic ___ the back of the brain; no concern for genetic
hypercoagulable predisposition), subsegmental PE (___)
who stopped warfarin after 3-month therapy was completed. A
lower extremity ultrasound was negative for DVTs. The patient's
CHADS-VASc score is 5. Although the patient did not have a
history of atrial fibrillation, he developed Afib with RVR while
___ ICU during this admission. A subsequent transthoracic
echocardiogram showed normal biventricular function and no
valvular abnormalities. He was started on a heparin drip and
metoprolol for rate control. Heparin was ultimately discontinued
given suspicion for GI bleed as above. Further anticoagulation
was deferred because of bleeding risk. On discharge, the patient
was ___ sinus rhythm and no longer requiring metoprolol for rate
control (and was ___ fact intermittently bradycardic). Plan to
restart ASA on discharge.
# Tube Feeds/ G- Tube
# Malnutrition
Mr. ___ had a history of large residuals at ___, as well as
aspiration pnuemonitis. The patient underwent G-tube exchange on
___, which revealed dark brown residuals with black flecks,
which were guiac negative. The patient continued to have high
residuals on ___, which were guiac positive. Interventional
radiology was consulted performed ___ G-J tube to reduce
residuals and evaluate stigmata of bleeding. No bleeding was
identified. Upon proper functioning of his feeding tube, Mr.
___ resumed tube feeds with advancing feeds q4hrs to goal of
75cc/hour.
# Hypernatremia
The patient's sodium was 152 on presentation. He had recent
admissions with Na 156 thought to be secondary to volume
depletion after recent discharge on diuretics. Pt's. Na improved
to 144 on transfer w/ increased free water flushes. The
patient's electrolytes were checked daily and repeated as
needed.
- Free water flushes: Free water amount: 250 mL; Free water
frequency: Q3H with tube feeds.
# Chronic systolic heart failure
# NSTEMI
Mr. ___ has a history of LV wall hypokinesis and reduced EF ___
setting of acute
illness. Had troponin elevation on admission and elevated BNP on
admission concerning for heart failure, which could have caused
afib. BNP: 1616, trops: 0.06, 0.05. CK-MB: negative. Elevated
troponin likely due to demand ischemia ___ setting of septic
shock. Repeat Echocardiogram during this admission showed normal
biventricular function and no valvular abnormalities.
# Hyperglycemia
The patient's glucose was 348 on admission. Likely hyperglycemic
on admission ___ setting of sepsis. After the patient was no
longer acutely ill, his sugars normalized. He had some episodes
of low blood sugar, and thus his insulin regimen was
down-titrated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with a history of prior TB (unclear treatment)
___ years prior in ___, hx of HBV (dx in ___, not
treated), HTN, presenting with shortness of breath, shoulder
pain, chest pain that has been present for the past few months.
The patient notes that the dyspnea and chest discomfort is not
exertional or pleuritic, located in the middle of chest,
constant in nature. Worse dyspnea at night. Also endorses a
cough that has lasted months, productive of white sputum, no
hemoptysis. Shoulder discomfort is over bilateral shoulders.
Notes subjective fevers, no chills, denies night sweats or
weight loss. Decreased PO intake secondary to decreased
appetite, and the patient endorses fatigue. Patient was seen at
PCP last week at ___ visit and reportedly had a "blood test
that was positive for TB", but no CXR. The patient noted that he
had TB at a concentration camp in ___ ___ years prior, and
per daughter at bedside unclear treatment at that time but that
his "mother brought antibiotics." The patient has had no issues
in the interim. Has been living in the ___ for the past ___ years,
working in a ___. Remote smoking history for ___ years, ___
years prior, now quit.
Past Medical History:
TB
HBV
HTN
Social History:
___
Family History:
No history of TB. No other known family history.
Physical Exam:
ADMISSION EXAM
=====================
VS - 98.3, 70, 137/73, 14, 96% RA
GENERAL: NAD, pleasant
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: Diminished sounds at left base, otherwise clear
bilaterally
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact x4 extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
=====================
VITALS: temp 98.2, HR 63, BP 120/75, RR 18, 98% RA
GENERAL: NAD, pleasant, resting comfortably in bed
HEENT: AT/NC, PERRL, anicteric sclera, MMM
NECK: nontender supple neck, no adenopathy
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Clear bilaterally without wheezes, rhonchi, or rales
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact x4 extremities, A+Ox3
SKIN: warm and well perfused, no excoriations or lesions
Pertinent Results:
ADMISSION LABS
=======================
___ 12:05PM BLOOD WBC-7.3 RBC-4.80 Hgb-15.0 Hct-45.0 MCV-94
MCH-31.3 MCHC-33.3 RDW-12.2 RDWSD-42.3 Plt ___
___ 12:05PM BLOOD Neuts-69.9 Lymphs-18.5* Monos-8.5 Eos-2.3
Baso-0.4 Im ___ AbsNeut-5.09 AbsLymp-1.35 AbsMono-0.62
AbsEos-0.17 AbsBaso-0.03
___ 12:05PM BLOOD Glucose-145* UreaN-23* Creat-0.8 Na-140
K-3.9 Cl-101 HCO3-26 AnGap-17
___ 12:05PM BLOOD cTropnT-<0.01
___ 06:08PM BLOOD cTropnT-<0.01
___ 12:05PM BLOOD ALT-26 AST-26 AlkPhos-47 TotBili-0.4
___ 12:05PM BLOOD Albumin-4.5 Calcium-9.6 Phos-3.1 Mg-2.0
___ 12:08PM URINE Color-Straw Appear-Clear Sp ___
___ 12:08PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
DISCHARGE LABS
=======================
___ 08:20AM BLOOD WBC-8.0 RBC-5.17 Hgb-16.2 Hct-48.6 MCV-94
MCH-31.3 MCHC-33.3 RDW-12.6 RDWSD-43.5 Plt ___
___ 08:20AM BLOOD Glucose-116* UreaN-18 Creat-0.8 Na-137
K-3.7 Cl-96 HCO3-30 AnGap-15
___ 08:20AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.3
PERTINENT LABS
========================
___ 08:20AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Positive* HAV Ab-Positive*
___ 08:20AM BLOOD HIV Ab-Negative
___ 08:20AM BLOOD HCV Ab-Negative
REPORTS
========================
CXR ___
Small left lung base pleural scarring and/or pleural effusion of
unknown chronicity. Lungs are clear.
CXR ___
1. Pleural thickening in the left lower lobe at the costophrenic
angle with associated calcification. Correlation is suggested.
2. Left apical pleural thickening. If available, comparison to
prior studies and correlation with clinical history is suggested
3. No acute pulmonary process.
MICROBIOLOGY
========================
Acid fast smear x3: NO ACID FAST BACILLI SEEN ON CONCENTRATED
SMEAR
Urine culture: negative
AFB culture: Pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Vitamin D 400 UNIT PO DAILY
3. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Dyspnea
History of tuberculosis
Secondary:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with h/o remote TB presenting with ___ weeks of
shortness of breath and subjective fevers // eval for infiltrate, evidence of
TB, acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: None available
FINDINGS:
Small left pleural effusion and/or pleural scarring is noted. There appears
to be pleural calcification. There is biapical pleural thickening. There is
no consolidation or pneumothorax. Cardiomediastinal silhouette is normal
size.
IMPRESSION:
Small left lung base pleural scarring and/or pleural effusion of unknown
chronicity. Lungs are clear.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Cough
Diagnosed with Cough
temperature: 97.9
heartrate: 80.0
resprate: 20.0
o2sat: 98.0
sbp: nan
dbp: nan
level of pain: 6
level of acuity: 3.0 | ___ year old man with a history of prior TB (unclear treatment)
___ years prior in ___, history of cleared HBV, HTN,
presenting with subacute shortness of breath and chest pain.
Admitted for a TB rule out.
ACTIVE PROBLEMS
======================
# Dyspnea, Chest pain, TB rule out: Presents with several months
of central chest pain and SOB. Troponin x2 negative, EKG with
sinus rhythm, LVH, and no ischemic changes. Influenza negative.
CXR showing left lung base pleural scarring, with similar
findings noted on an outside CXR in ___, no e/o PNA or other
acute process. He reports a history of TB while living in
___, possibly treated, but regimen not certain. No night
sweats, weight change, or hemoptysis. Reports to have had a
positive Quantiferon before, though given history of prior TB
this cannot delineate between active and latent disease. He was
admitted for TB rule out, and 3 acid fast smears with negative
for acid fast bacilli. The acid fast cultures and MTB testing
will be followed up on as an outpatient, as these take longer to
result. As an outpatient, should work up his symptoms further
with an exercise stress test. Long term, could consider getting
a pleural biopsy, but suspicion for active TB is low.
CHRONIC PROBLEMS
=========================
# HTN: BP's currently within normal limits on home regimen of
Losartan 50mg and HCTZ 12.5mg.
# Hepatitis B: LFT's normal. Per ___
records, in ___ he had positive Hep B core antibody, positive
surface antibody, negative surface antigen, negative viral load.
These labs, from ___, are consistent with cleared Hepatitis B
infection, and have been confirmed with the labwork this
admission. He is Hep C negative, and Hep A positive, but this is
unlikely acute Hep A given lack of symptoms consistent with
this. Hep B viral load pending on discharge.
# Vitamins - continue home vitamin D, multivitamin
TRANSITIONAL ISSUES
=========================
- Acid fast smears were negative, but cultures still pending on
discharge, and typically take weeks to grow
- Hepatitis B viral load pending on discharge
- Given subacute, intermittent dyspnea and chest pain over the
last few months, would recommend an outpatient exercise stress
test to evaluate for cardiac etiology. Of note, EKG and cardiac
enzymes were normal here.
- Patient had 3 negative AFB stains but does have evidence of
pleural scarring on CXR. This could be from past TB infection,
and is unlikely to be a sequelae of acute TB. Could pursue
biopsy of this in the future, if symptoms are persistent. |
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, cough, and fever with temp 103 at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with recently diagnosed multiple myeloma on velcade and
Revlimid initiated ___ with last velcade ___ and next planned
for ___, followed at ___ though saw Dr. ___ at ___ on
___ w/ plan to transfer care to ___ now presenting with
dyspnea, cough, and fever with temp 103 at home. He is taking
ASA ppx with revlimid
REVIEW OF SYSTEMS:
GENERAL: + fever/ night sweats, no recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, but + rhinorrhea and
congestion
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: + cough but no, shortness of breath, hemoptysis, or
wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel habits, hematochezia, or melena.
GU: No dysuria or change in bladder habits.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
PSYCH: No feelings of depression or anxiety. All other review of
systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
multiple myeloma with M spike, see ___ records
/___ labs and diagnostic studies at time of initial
diagnosis:
Serum protein electrophoresis: M spike 4.9 grams per
deciliter-IgG kappa light chain specificity
Beta-2 microglobulin 2.5
Albumin 2.3, total protein 11.8, calcium 8.1, creatinine 1.2
with GFR greater than 60
WBC 10.4, hemoglobin 9.6, hematocrit 29, platelets 212-41% PMN,
3% bands, 45% lymphocytes, 7% monocytes, 2% eosinophils, 1%
basophils, 1% metamyelocytes
Skeletal survey without any evidence of well-defined punched
out
lytic lesions
BONE MARROW CORE BIOPSY, ASPIRATE SMEARS, TOUCH PREPARATION AND
PERIPHERAL BLOOD SMEAR:
PLASMA CELL MYELOMA, SEE NOTE, COMMENTS AND SUMMARY.
Erythrocytes:
Red blood cells are present in decreased number, with moderate
anisopoikilocytosis. There is significant rouleaux formation on
scan. Abnormal forms include: Microcytic forms and rare target
cells. Occasional nucleated red blood cells are also seen.
White blood cells:
White blood cells are present in normal numbers, and are
comprised predominantly of neutrophils. Granulocytes demonstrate
intact cytoplasm granularity. Lymphocytes are present with small
mature as well as large/activated forms seen including large
granular lymphocytes and plasmacytoid forms. Monocytes are
present, and are unremarkable morphologically.
Bone marrow aspirate smears:
Bone marrow smears are suboptimal for evaluation due to a
paucispicular specimen, and hemodilution.
A 500 cell count reveals 1% blasts, 1% promyelocytes, 2%
myelocytes, 8% metamyelocytes, 15% bands/neutrophils, 7%
lymphocytes, 55% plasma cells and 10% erythroid precursors.
KAPPA AND LAMBDA IN SITU HYBRIDIZATION STUDIES, PLASMA CELLS ARE
KAPPA RESTRICTED. MYELOMA CELLS EXPRESS CD56 AND CYCLIN-D1
Plasma cells are numerous, with atypical features, including
enlargement and having prominent nucleoli. Myeloid precursors
show normal and complete maturation. Erythroid precursors show
normal and complete maturation. Megakaryocytes are present in
normal numbers, with normal morphology. The myeloid to erythroid
ratio is 2.7:1.
Iron stain is adequate for evaluation and shows increased
storage
iron.
Rare to absent sideroblasts are present, with no ring
sideroblasts identified.
Bone marrow core biopsy:
The bone marrow core biopsy specimen measures 1.2 cm, and has a
cellularity ranging from 80-100%, with an overall cellularity of
85%. The myeloid to erythroid ratio is normal. The myeloid
maturation is complete. Erythroid maturation is complete.
Megakaryocytes are present in normal numbers. Numerous/sheets of
plasma cells are identified throughout the core, that are
enlarged and demonstrate prominent nucleoli. Reticulin stain
shows no significant increase in reticulin fiber deposition (0
1+).
By immunohistochemistry, CD138 immunostain highlights plasma
cells, that comprise 90% of the bone marrow cellularity.
(Immunostains for CD56, bcl-1 and in situ hybridization studies
for kappa and lambda are in process, and the interpretive
results
will be issued in an addendum.)
Comment#1: Immunostain controls show appropriate reactivity.
Flow Cytometry
Flow cytometry, performed at ___,
under ___ specimen number: ___, with a viability
of 70% demonstrated a monotypic plasma cell population. An
abnormal, monotypic cytoplasmic Kappa-restricted plasma cell
population is noted, representing approximately 24% of the total
cells. No monoclonal B-cell population was detected. Kappa:
Lambda ratio is 1.5. There is no loss of, or aberrant expression
of the pan T-cell antigens to suggest a neoplastic T-cell
process. CD4:CD8 ratio is 1.3. Myeloblasts with normal-appearing
phenotype represent 0.3% of the total cells analyzed. There is
no
immunophenotypic evidence of abnormal myeloid maturation. Mature
monocyte show aberrant expression of CD56, a finding that can be
seen in association with both reactive/activated processes as
well as neoplastic processes.
PAST MEDICAL HISTORY:
Astigmatism
Presbyopia
Dry eye syndrome
CRVO (central retinal vein occlusion)
HTN (hypertension)
Neck mass
Aortic regurgitation
Aortic insufficiency
Nonrheumatic aortic valve insufficiency
h/o appendectomy in ___
Social History:
___
Family History:
sister has a history of breast cancer status post surgery, now
doing well
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 97.9 125/73 86 20 97% RA
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly. Conjunctival erythema and
some clear mucous drainage from eyes bilaterally, but
PERRLA/EOMI
CV: crackles at bases, coughing during the interview no wheezing
PULM: CTAB
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: macular/flat somewhat petechial appearing rash on left
lower foreleg. Similar appearance of rash over his back but much
more faded/subtle in appearance. NO mucosal lesiosn/breakdown.
No
blisters or other skin erythema/breakdown
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities; reflexes are 2+ of the biceps, triceps,
patellar, and Achilles tendons, toes are down bilaterally; gait
is normal, coordination is intact
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: 98.6 100/55 84 19 99% RA
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly. Conjunctival erythema
improved and some clear mucous drainage from eyes bilaterally,
but PERRLA/EOMI
CV: crackles at bases, no wheezing
PULM: CTAB
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: macular/flat somewhat petechial appearing rash on left
lower foreleg. Similar appearance of rash over his back but much
more faded/subtle in appearance. NO mucosal lesiosn/breakdown.
No
blisters or other skin erythema/breakdown
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities; reflexes are 2+ of the biceps, triceps,
patellar, and Achilles tendons, toes are down bilaterally; gait
is normal, coordination is intact.
Pertinent Results:
LABS:
___ 05:55AM BLOOD WBC-6.4 RBC-2.85* Hgb-9.2* Hct-28.1*
MCV-99* MCH-32.3* MCHC-32.7 RDW-15.4 RDWSD-56.1* Plt ___
___ 07:35AM BLOOD WBC-5.9 RBC-2.85* Hgb-9.3* Hct-27.7*
MCV-97 MCH-32.6* MCHC-33.6 RDW-15.4 RDWSD-54.9* Plt ___
___ 06:45AM BLOOD WBC-5.4 RBC-3.11* Hgb-10.1* Hct-29.6*
MCV-95 MCH-32.5* MCHC-34.1 RDW-14.9 RDWSD-51.8* Plt ___
___ 10:19PM BLOOD WBC-7.7 RBC-3.32* Hgb-10.8* Hct-31.3*
MCV-94 MCH-32.5* MCHC-34.5 RDW-15.0 RDWSD-51.7* Plt ___
___ 05:55AM BLOOD Neuts-51 Bands-0 ___ Monos-15*
Eos-7 Baso-0 ___ Myelos-0 AbsNeut-3.26 AbsLymp-1.73
AbsMono-0.96* AbsEos-0.45 AbsBaso-0.00*
___ 07:35AM BLOOD Neuts-53 Bands-2 ___ Monos-8 Eos-3
Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-3.25 AbsLymp-2.01
AbsMono-0.47 AbsEos-0.18 AbsBaso-0.00*
___ 06:45AM BLOOD Neuts-44 Bands-7* ___ Monos-18*
Eos-7 Baso-1 ___ Metas-1* Myelos-0 AbsNeut-2.75
AbsLymp-1.19* AbsMono-0.97* AbsEos-0.38 AbsBaso-0.05
___ 10:19PM BLOOD Neuts-53 Bands-8* ___ Monos-12
Eos-0 Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-4.70 AbsLymp-2.08
AbsMono-0.92* AbsEos-0.00* AbsBaso-0.00*
___ 05:55AM BLOOD Plt Smr-NORMAL Plt ___
___ 07:35AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:45AM BLOOD Plt Smr-LOW Plt ___
___ 10:19PM BLOOD Plt Smr-LOW Plt ___
___ 05:55AM BLOOD Glucose-88 UreaN-14 Creat-1.0 Na-138
K-3.5 Cl-106 HCO3-24 AnGap-12
___ 07:35AM BLOOD Glucose-94 UreaN-16 Creat-0.9 Na-139
K-3.5 Cl-109* HCO3-20* AnGap-14
___ 06:45AM BLOOD Glucose-122* UreaN-15 Creat-1.1 Na-135
K-3.6 Cl-105 HCO3-24 AnGap-10
___ 10:19PM BLOOD Glucose-129* UreaN-15 Creat-1.3* Na-132*
K-3.2* Cl-97 HCO3-27 AnGap-11
___ 05:55AM BLOOD ALT-55* AST-59* LD(LDH)-238 AlkPhos-99
TotBili-0.3
___ 07:35AM BLOOD ALT-57* AST-58* LD(LDH)-182 AlkPhos-103
TotBili-0.5
___ 06:45AM BLOOD ALT-69* AST-74* LD(LDH)-222 AlkPhos-102
TotBili-2.1* DirBili-1.0* IndBili-1.1
___ 05:55AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.8 Mg-1.9
UricAcd-3.7
___ 07:35AM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.5*
Mg-1.9 UricAcd-3.7
___ 06:45AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.7
___ 10:19PM BLOOD Calcium-7.9*
___ 11:55AM BLOOD Vanco-5.9*
___ 10:30PM BLOOD Lactate-1.7
___ 02:50PM BLOOD QUANTIFERON-TB GOLD-PND
IMAGING:
CXR (PA/LATERAL) ___
FINDINGS:
Cardiac, mediastinal and hilar contours are normal. The
pulmonary vasculature is not engorged. Ring-like opacities are
noted diffusely within the right upper and mid lung fields as
well as within the left lung base likely reflective of diffuse
bronchiectasis with airway wall thickening. Adjacent patchy
opacities may reflect regions of infection. No pleural effusion
or pneumothorax is present. There are no acute osseous
abnormalities.
IMPRESSION:
Diffuse bronchiectasis, most pronounced in the right upper and
mid lung fields in left lung base, with airway inflammation and
adjacent patchy opacities suggestive of infection
CT CHEST ___
FINDINGS:
Diffuse bronchial dilation is present throughout all lobes of
both lungs with a cylindrical configuration accompanied by mild
diffuse bronchial wall thickening. Widespread small airways
disease is present throughout both lungs, manifested by
branching and nodular centrilobular opacities consistent with a
___ pattern. This involves the right upper and both
lower lobes to the greatest degree with lesser involvement of
the middle lobe, lingula and left upper lobe.
Enlarged sub- carinal and borderline bilateral paratracheal and
hilar lymph nodes are likely reactive in the setting of diffuse
airways disease. Heart size is normal, and no pericardial or
substantial pleural effusion is identified.
Exam was not tailored to evaluate the subdiaphragmatic region,
but note is
made of a its tiny nonobstructing calculus in the right kidney
as well as an incompletely evaluated low-density 2.6 cm upper
pole lesion potentially due to a cyst. Remaining imaged upper
abdomen is unremarkable on this limited assessment.
Skeletal structures of the thorax demonstrate multilevel
degenerative changes in the spine.
IMPRESSION:
1. The multilobar bronchial dilation, wall thickening and
extensive small
airways disease with ___ pattern. In the setting of
acute fever and respiratory symptoms, this is most likely due to
an acute viral or mycoplasma infection.
2. Enlarged sub- carinal and borderline paratracheal and hilar
nodes are
likely reactive in the setting of acute airway infection.
3. Incompletely evaluated 2.6 cm right renal lesion, potentially
a cyst.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Acyclovir 400 mg PO Q12H
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Allopurinol ___ mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Aspirin 81 mg PO DAILY
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Levofloxacin 750 mg PO DAILY Duration: 7 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
6. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 5 ml by mouth every 6hrs Refills:*0
7. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID Duration: 2
Days
RX *erythromycin 5 mg/gram (0.5 %) 1 application in each eye
three times a day Refills:*0
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled
every 4hrs Disp #*1 Inhaler Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple Myeloma
Community Acquired Pneumonia
Conjunctivitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with fever PNA // evaluate for infection
TECHNIQUE: MULTI DETECTOR HELICAL SCANNING OF THE CHEST WAS PERFORMED WITHOUT
INTRAVENOUS CONTRAST AGENT, RECONSTRUCTED AS CONTIGUOUS 5 AND 1.25 MM THICK
AXIAL, 5 MM THICK CORONAL AND PARASAGITTAL, AND 8 MM MIP AXIAL IMAGES.
SUBSEQUENT SCANNING OF THE ABDOMEN AND PELVIS WILL BE REPORTED SEPARATELY, AND
WILL PROVIDE THE TOTAL DOSAGE OF SCANNING THE ENTIRE TORSO.
DOSAGE: TOTAL DLP 293mGy-cm
COMPARISON: Chest radiograph ___
FINDINGS:
Diffuse bronchial dilation is present throughout all lobes of both lungs with
a cylindrical configuration accompanied by mild diffuse bronchial wall
thickening. Widespread small airways disease is present throughout both
lungs, manifested by branching and nodular centrilobular opacities consistent
with a ___ pattern. This involves the right upper and both lower
lobes to the greatest degree with lesser involvement of the middle lobe,
lingula and left upper lobe.
Enlarged sub- carinal and borderline bilateral paratracheal and hilar lymph
nodes are likely reactive in the setting of diffuse airways disease. Heart
size is normal, and no pericardial or substantial pleural effusion is
identified.
Exam was not tailored to evaluate the subdiaphragmatic region, but note is
made of a its tiny nonobstructing calculus in the right kidney as well as an
incompletely evaluated low-density 2.6 cm upper pole lesion potentially due to
a cyst. Remaining imaged upper abdomen is unremarkable on this limited
assessment.
Skeletal structures of the thorax demonstrate multilevel degenerative changes
in the spine.
IMPRESSION:
1. The multilobar bronchial dilation, wall thickening and extensive small
airways disease with ___ pattern. In the setting of acute fever and
respiratory symptoms, this is most likely due to an acute viral or mycoplasma
infection.
2. Enlarged sub- carinal and borderline paratracheal and hilar nodes are
likely reactive in the setting of acute airway infection.
3. Incompletely evaluated 2.6 cm right renal lesion, potentially a cyst.
RECOMMENDATION(S): 1. Followup chest CT is recommended in 3 months in order
to assess for potential reversibility of airway dilation in order to
differentiate transient bronchial dilation associated with an acute
respiratory infection from chronic forms of bronchiectasis. At the same time,
the intrathoracic lymph nodes can be reassessed for resolution.
2. Consider renal ultrasound to more fully characterize a upper pole right
renal cystic lesion.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: Dyspnea, Fever
Diagnosed with Pneumonia, unspecified organism
temperature: 104.0
heartrate: 116.0
resprate: 20.0
o2sat: 96.0
sbp: nan
dbp: nan
level of pain: 10
level of acuity: 2.0 | ASSESSMENT AND PLAN:
___ M with recently diagnosed multiple myeloma on velcade and
Revlimid initiated ___ with last velcade ___ and next planned
for ___, followed at ___ though saw Dr. ___ at ___ on
___ w/ plan to transfer care to ___ now presenting with
dyspnea, cough, rhinorrhea, sore throat, and fever to 104, found
to have pulmonary infiltrates suggestive of infection, and ___.
#Community Acquired Pneumonia
Clinically the constellation of symptoms (very high fever,
bilateral conjunctivitis, bilateral infiltrates on CXR,
cough/sore throat, with rapid onset in last 102 days, along with
petechial rash over some areas of the body) seem most consistent
with viral syndrome. Highest on ddx given the conjunctivitis
would be adenovirus or influenza (but flu pcr negative) among
others. At this point, also concerning that he has possibly
developed superimposed bacterial pneumonia given cough and
findings on CXR. Normal PMN count also points away to bacterial
illness (though bandemia is suspicious). His rash is not
consistent with vesicular disseminated zoster but would also be
something to consider given conjunctivitis and pneumonia, along
with CMV or EBV though these seem less likely. Pt is not
neutropenic but has been getting weekly high dose dex and on
RVD.
He has no recent travel exposures, in fact has quit his job as
he
has been receiving therapy, and no sick contacts though has ___
year old child at home. No tick bites, no ventures out into the
woods recently, and no travel in the past year around or outside
the country at all. No pets at home or pet exposure.
Reassuring that pt has deverfesced and hemodynamics are stable.
Degree of fever and symptomatology on exam however is
concerning.
No headaches, no myalgias. Certainly velcade can also be
associated w/ pneumonitis and respiratory distress but doubt
that
the conjunctivitis and sore throat would be seen with that.
-treat for possible bacterial PNA/superinfection will cont
vanc/cefepime (discontinued ___ as non-neutrapenic) and added
levoflox for possible CAP/atypical - will continue levo for 10D
course
organisms.
-Unclear why read as bronchiectasis as pt has no known
h/o recurrent pulm infections, though he does note a subacute
cough the past 2 months preceeding current illness
-will obtain CT chest for further evaluation-consistent with
viral vs mycoplasma infection
-added on urine mycoplasma Ag for evaluation PND at discharge
-for conjunctivitis: likely viral but for now will cont
erythromycin ointment, to complete ___
-send sputum-PND at discharge
-hold off on Tamiflu for now as flu pcr negative though not
impossible to have
positive flu on culture, resp cx pending at discharge
-send sputum, urine legionella (neg) and S pneumo PND
-continue acyclovir ppx
#conjunctivitis: seems c/w viral process. cont erythro ointment
as above
#Fever: Resolved, very high temp of 104 in ED on arrival on ___.
Due to viral vs bacterial pulm process. NO other localizing
symptoms. Treating for HCAP as above w/ antibiotics. No dysuria,
diarrhea, other localizing symptoms
#Petechial Rash: pt noted in the ED. Present largely on right
inner foreleg. No vesicular nature, not pruritic. No
desquamation or mucosal lesions. Likely ___ viral process. Could
be due to allopurinol but given timing suspect related to
infectious
process. Will hold allopurinol for now pending clinical
trajectory
#Transaminitis: Improving. noted for elevated AST/ALT and t
bili, likely medication induced due to revlimid and/or velcade.
only other new medication on differential includes allopurinol
which is being held as above due to rash
-fractionate bili and will f/u-bili WNL
-consider RUQ u/s if continues
#Tachycardia: Resolved. was likely due to high temp, infection.
Resolved w/ fever resolution and IVF in ED
#Hyponatremia: Resolved, suspect due to hypovolemia. Urine lytes
sent given pulm process to r/o SIADH-most consistent with
hypovolemia.
___: Improved. Cr 1.0 today. pt with creatinine up to 1.3
suspect due to hypovolemia from infection, insensible losses as
reflected by fever/tachycardia.
#Hypokalemia: Normalized at discharge. Repleted cautiously given
renal impairment
#Multiple Myeloma - initiated RVD ___. IgG, symptomatic anemia,
no renal impairment/bone lesions/hypercalcemia to date. Started
RVD as outpt, with last velcade ___ next planned for ___. He
states he had 1 more day of revlimid tomorrow then was planned
for week off. Was transitioning care to Dr. ___ at ___
___ of therapy: Lenalidomide 25 milligrams per day orally
on days ___ hold
with active infection Bortezomib 1.3 milligrams per meter
squared subcutaneously on
days 1, 4, 8 and 11 Dexamethasone 40 milligrams weekly Cycle
length every 21 days.
-cont ASA ppx, acyclovir
-holding home revlimid for now
CODE STATUS: Full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with DM2 on insulin, HOCM, CKD stage 5 awaiting dialysis,
presents with hypoglycemia. He was recently admitted here
several weeks ago for community-acquired pneumonia and volume
overload. He was discharged to Epoch of ___ rehab. He
progressed well there and was discharged home this afternoon.
Within an hour of arriving home, he felt unwell and confused.
EMS arrived and found BS 33. He was given glucagon 1mg IM with
glucose, and OJ with resultant BS 56 and transferred to ___.
In the ED initial vitals were: 96.7 60 126/64 18 100% room BS
56. He responded to 25 grams of D50 with BS 135. Labs with
stable anemia and renal function, Cr 6.9. UA with glucose and no
bacteria. CXR clear. ECG with V pacing, unchanged from prior.
On the floor, he reports complete resolution of symptoms. His
family notes that he is back to his baseline. He is alert and
oriented. He reports no increased activity today. He thinks he
was given his usual insulin dosing. He ate a full meal at lunch.
He reports no changes to his medication list from last admission
except for reduced furosemide from BID to daily.
ROS: Resolution of prior symptoms which included confusion,
dizziness, shaking, diaphoresis. No fever, chills, nausea,
vomiting, chest pain, dyspnea, abdominal pain, diarrhea,
constipation, dysuria, frequency, headache, cough.
Past Medical History:
- CKD, stage V with mature R fistula, awaiting HD initiation
soon
- Hypertrophic cardiomyopathy with two septal ablations in ___
and ___, s/p pacemaker, c/b line infection and endocarditis
- Enterococcal bacteremia with L psoas abscess s/p drainage,
spinal osteomyelitis, and pacer lead vegetation (___) -
treated with ampicillin / gentamicin, then transitioned to
chronic amoxicillin
- h/o Pseudomonas bacteremia due to cholecystitis ___
- ___ disease
- DM2 c/b peripheral neuropathy on insulin
- Hypertension
- Hyperlipidemia
- GERD
- Hyperparathyroidism
- Osteoporosis
- Thyroid nodule
- Osteoporosis s/p bisphosphonate therapy
- BPH
- Actinic keratoses, seborrheic keratoses, and lentigines
- H/o nephrolithiasis
PAST SURGICAL HISTORY
- R radiocephalic AVF
- Ligation of L forearm AV fistula
- L radiocephalic AVF
- Cataract surgery
- Septal ablation
Social History:
___
Family History:
Father with DM2 died from MI in ___. Son and daughter both with
HOCM.
Physical Exam:
ADMISSION, ___:
VS: T98.3 161/68 76 18 100RA
GENERAL: Well appearing elderly man in no acute distress
HEENT: MMM, OP clear
NECK: JVP not elevated
HEART: RRR, holosystolic ___ murmur throughout precordium
LUNGS: Clear, no wheezes, rales, or rhonchi
ABD: Soft, nontender, BS+, nondistended
EXT: no ___ edema, 2+ DP and ___ pulses
NEURO: Alert and oriented, no confusion
SKIN: No rashes. Right forearm AV fistula with palpapble thrill
DISCHARGE, ___:
VS - 98.3; 140-161/60s; HR 69-72; 100% on RA
___: 120-268
Gen: well-appearing elderly M in no distress; very pleasant;
reduced facial expression
HEENT: MMM no OP lesions
Cor: systolic murmur, regular
Pulm: clear throughout
Abd: soft, non-tender
Extrem: lower extremity much reduced from prior admission on
___ now w/ only 1+ asymmetric (L>R) ankle edema
Neuro:
Motor- strength reduced throuhgout (___) in UE; intact in ___. No
rigidity, no resting remor.
Pertinent Results:
LABS
====================================
7.4 > 8.7 / 25.9 < 205 (___)
136 95 87 Ca 9.3
--------------< 92 Mg 2.1 (___)
4.2 23 6.5 Phos 5.3
HbA1c: 6.2% ___ eAG: 131
UA: 1.010 / Prot 100/ Mod blood / 35 RBCs / 6 WBCs (___)
MICRO
====================================
BCx: ___ - NGTD
UCx: ___ - NGTD (accompanying UA neg for infection)
STUDIES
====================================
*CXR (PA/Lat) (___):
Prior small bilateral pleural effusions have since
resolved. The lungs are clear of consolidation or
pulmonary vascular congestion. The cardiomediastinal
silhouette is stable. Left chest wall dual lead pacing
device is unchanged. Degenerative changes seen at the
shoulders bilaterally.
*ECG (___):- V paced at 71 bpm, unchanged from prior ECG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin 500 mg PO Q24H
2. Ascorbic Acid ___ mg PO BID
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Carbidopa-Levodopa (___) 2.5 TAB PO TID
5. Carbidopa-Levodopa (___) 1 TAB PO QHS
6. Cyanocobalamin 50 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Finasteride 5 mg PO DAILY
10. Metoprolol Tartrate 50 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. rotigotine 2 mg/24 hour transdermal QHS
13. Simvastatin 10 mg PO DAILY
14. Sodium Bicarbonate 650 mg PO BID
15. Acetaminophen 650 mg PO Q8H:PRN pain, fever
16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheeze
17. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheeze
18. Senna 8.6 mg PO BID:PRN constipation
19. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
20. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral daily
21. Metolazone 2.5 mg PO 3X/WEEK (___)
22. Furosemide 80 mg PO DAILY
23. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain, fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheeze
3. Amoxicillin 500 mg PO Q24H
4. Ascorbic Acid ___ mg PO BID
5. Calcium Acetate 667 mg PO TID W/MEALS
6. Carbidopa-Levodopa (___) 2.5 TAB PO TID
7. Carbidopa-Levodopa (___) 1 TAB PO QHS
8. Cyanocobalamin 50 mcg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Finasteride 5 mg PO DAILY
12. Furosemide 80 mg PO DAILY
13. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Glucose Gel 15 g PO PRN hypoglycemia protocol
RX *dextrose 15 gram/59 mL 1 liquid(s) by mouth as needed for
hypoglycemia Refills:*0
15. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral daily
16. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
17. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheeze
18. Metolazone 2.5 mg PO 3X/WEEK (___)
19. Metoprolol Tartrate 50 mg PO BID
20. Omeprazole 20 mg PO DAILY
21. rotigotine 2 mg/24 hour transdermal QHS
22. Senna 8.6 mg PO BID:PRN constipation
23. Simvastatin 10 mg PO DAILY
24. Sodium Bicarbonate 650 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypoglycemia
Discharge Condition:
Appropriate mental status.
Ambulatory with walker.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with confusion // eval infiltrate
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Prior small bilateral pleural effusions have since resolved. The lungs are
clear of consolidation or pulmonary vascular congestion. The cardiomediastinal
silhouette is stable. Left chest wall dual lead pacing device is unchanged.
Degenerative changes seen at the shoulders bilaterally.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Hypoglycemia, Altered mental status
Diagnosed with DIAB W MANIF NEC ADULT, LONG-TERM (CURRENT) USE OF INSULIN, PARKINSON'S DISEASE, HYPERTENSION NOS
temperature: 96.7
heartrate: 60.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 64.0
level of pain: 13
level of acuity: 1.0 | ___ with CKD stage V with mature fistula (plan to initiate HD
week of ___, HOCM s/p septal ablation s/p PPM complicated by
endocarditis / bacteremia on chronic amoxicillin, ___,
DM2 on insulin admitted from home with symptomatic hypoglycemia
mere hours after discharge from a 2.5 week rehab stay.
Hypoglycemia secondary to excessive insulin dosing in the
setting of reduced insulin requirements from reduced renal
clearance. Discharged on a much reduced sliding scale, although
this ___ need to be reconsidered when he starts HD next week
(___).
# HYPOGLYCEMIA:
- On review of rehab records, he had been on a sliding scale
which began with 4 units at a ___ of 100, and increased by 1 unit
thereafter. On the rehab regimen, am fasting ___ averaged
100-200, noon ___ averaged 100-225, dinner ___ averaged 100-300
and HS ___ averaged 150-350. He was recieving a total of at
least 16 units of short acting insulin with sliding scale daily
in addition to his home regimen of 7 units of glargine qHS and
did not have any lows until discharge.
- Given the symptomatic low he presented with and A1c of 6.1%
(___) his sliding scale was down-titrated as follows:
---Humalog (Lispro): 2 units starting at a fingerstick of 200,
and increasing by 1unit for every 50 above 200. No sliding
scale at bedtime.
- Glargine was continued at 7units nightly
- Given his age and comorbidies, more lenient glucose control is
appropriate (<8% per ___ ___ guideliens and ACCORD trial ___
and will protect him against future episodes of hypoglycemia.
- Insulin requirements may change when he initiates HD (which is
planned for next week, ___. As he will be monitored for
inpatient for HD initiation, this provides an opportunity to
further titrate his insulin regimen.
# CKD, stage V with mature fistula.
- Euvolemic this admission at a weight of 68kg/150lbs
- Plan to initiate HD next week (week of ___ per Dr. ___
- Cont furosemide 80 daily and metolazone MWF
CHRONIC ISSUES:
# H/o endocarditis in ___: cont chronic amoxicillin.
# ___ disease: cont carbidopa/levodopa and rotigotine
# HTN: cont home metoprolol, not on other antihypertensives
# HLD: cont home simvastatin
# Supplementation: cont home vitamins
# BPH: cont finasteride
# FEN: cardiac diabetic diet
# Prophylaxis: SC heparin, bowel regimen |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EUS
History of Present Illness:
Ms. ___ is an ___ PMHx ESRD s/p living-related renal
transplant in ___ maintained on tacrolimus, MMF, prednisone
(baseline Cr 1.2-1.4), CAD s/p CABG and bioprosthetic AVR, HLD,
HTN and prior episode of gallstone pancreatitis at ___ in ___
(treated conservatively) who is transferred from ___
___ for abdominal pain, n/v concerning for pancreatitis.
She presented to ___ with sudden onset abdominal
pain associated with nausea and frequent NBNB emesis. Her
initial labs there showed Cr 1.34, AST 470, ALT was not
quantifiable, Alk phos 59, lipase was 131, Tbili 0.7, WBC 14.7
with 24% bands and lactate 2.4. CT abdomen there showed
peripancreatic fat stranding concerning for primary pancreatitis
vs duodenal inflammatory process as well as ectasia of her CBD.
Upon arrival to ___, her initial VS were 101.3, 82, 123/51,
20, 92% on RA. Her abdominal exam was concerning for diffuse
tenderness. Her Renal graft was minimally tender. Labs showed
Na 147, Cr 1.4, Trop-T 0.08. ALT 285, AST 323, AP 55, Tbili
0.5, lipase 8300. WBC 23.8 with 88% PMNs and 6% bands. Lactate
was initially elevated to 2.8, improved to 1.8 upon re-check.
EKG showed NSR, nml axis, pathologic Q waves in the inferior
leads as well as poor R wave progression (no priors for
comparison). RUQ US showed mild intrahepatic and moderate
extrahepatic biliary ductal dilatation with mild CBD dilatation
to 12 mm without any obvious choledocholithiasis; however, this
study was limited. The patient was placed on vanc/zosyn for
empiric treatment of cholangitis. She was given 3L NS as well
prior to transfer to the floor. The ERCP and Renal Transplant
teams were consulted in the ED.
Upon arrival to the floor, the patient reports having diffuse
abdominal pain, worse in the epigastric and RUQ region. She
continue to have some nausea, but overall feels improved from
prior. She reports having some dark urine and having had
decreased PO intake. She denies any changes in her bowel
habits.
REVIEW OF SYSTEMS: All other 10-system review negative in
detail.
(-) 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:
- ESRD s/p LRRT in ___ on Tacro/MMF/prednisone, baseline Cr
1.2-1.3. No transplant complications of h/o rejection.
- CAD s/p CABG and bioprosthetic AVR
- HLD
- s/p L4-L5 lumbar fusion in ___
- R chronic hip stiffness requiring cane
- h/o gallstone pancreatitis in ___
- HTN
- Chronic leg edema, reportedly ___ CHF (no prior ECHOs here and
not currently on Lasix)
Social History:
___
Family History:
Both parents deceased, no known medical history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2, 146/63, 71, 18, 100% on 3L NC
GENERAL: very pleasant elderly female in mild distress
HEENT: MMM, NCAT, EOMI, anicteric sclera
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, ___ systolic murmur best heard at ___
radiating to carotids
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
lying flat in bed without use of accessory muscles
ABDOMEN: soft, nondistended, +TTP of epigastrium and RUQ, no TTP
over RLQ at site of renal transplant, + bowel sounds, no rebound
or guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: AOX3, moving all extremities spontaneously, speech fluent
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Exam on discharge:
VS: T:98.1 BP: 142/62 HR:76 R:18 O2:96 RA
GENERAL: elderly female laying in bed in NAD
HEENT: MMM, NCAT, anicteric sclera
NECK: nontender supple neck
HEART: RRR, S1/S2, ___ systolic murmur best heard at LUSB
radiating to carotids
LUNGS: decreased air entry throughout
ABDOMEN: soft,non-tender, no rebound or guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: AOX3, speech fluent
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 05:22PM BLOOD WBC-23.8* RBC-3.77* Hgb-11.2 Hct-36.3
MCV-96 MCH-29.7 MCHC-30.9* RDW-14.8 RDWSD-51.8* Plt ___
___ 05:22PM BLOOD Glucose-70 UreaN-44* Creat-1.4* Na-147*
K-4.3 Cl-109* HCO3-23 AnGap-19
___ 05:22PM BLOOD ALT-285* AST-323* CK(CPK)-69 AlkPhos-55
TotBili-0.5
___ 05:22PM BLOOD Albumin-3.6 Calcium-8.8 Phos-3.8 Mg-1.7
OTHER RELEVANT LABS
___ 05:22PM BLOOD CK-MB-3 cTropnT-0.08*
___ 09:10AM BLOOD CK-MB-5 cTropnT-0.16*
___ 05:22PM BLOOD Lipase-8300*
Discharge Labs:
___ 07:30AM BLOOD WBC-8.4 RBC-3.86* Hgb-11.5 Hct-36.3
MCV-94 MCH-29.8 MCHC-31.7* RDW-13.9 RDWSD-47.4* Plt ___
___ 07:30AM BLOOD Glucose-85 UreaN-18 Creat-1.1 Na-143
K-3.7 Cl-109* HCO3-23 AnGap-15
___ 07:30AM BLOOD ALT-40 AST-21 LD(LDH)-250 AlkPhos-49
TotBili-0.2
___ 09:31AM BLOOD CK-MB-3 cTropnT-0.15*
___ 07:30AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.6
___ 09:15AM BLOOD tacroFK-7.5
MICRO:
___ 6:10 pm BLOOD CULTURE #2.
**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------------ 16 I
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___, ___ @
09:07AM
(___).
STUDIES
___BDOMEN
Impression:
1. There is fat stranding surrounding the pancreas as well as
mild thickening of the duodenum. The findings may represent
primary pancreatitis with associated secondary inflammation of
the duodenum. Alternatively the findings could represent a
primary duodenal inflammatory of infectious process with
secondary inflammation of the pancreas. Additionally, the
increased ectasia of the CBD may represent an element of
obstruction at the distal CBD due to this inflammatory process
however the possibility of a pancreatic head malignancy
producing obstruction is not excluded. Correlate with clinical
and laboratory assessment. If indicated, further evaluation by
MRCP may be helpful.
2. Polycystic appearance of the kidneys with a right lower
quadrant renal transplant showing no evidence of complication.
3. Diverticulosis coli.
4. Fusiform ectasia of the infrarenal abdominal aorta, similar
to prior.
5. L1 vertebral compression deformity, similar to prior.
___ RUQ US
1. Mild intrahepatic and moderate extrahepatic biliary ductal
dilatation with the common bile duct measuring up to 12 mm. No
choledocholithiasis identified, although evaluation of the
distal CBD is limited by patient's inability to hold breath and
significant midline bowel gas.
2. Trace perihepatic ascites.
EKG: NSR, nml axis, pathologic Q waves in the inferior leads as
well as poor R wave progression (no priors for comparison).
Also non-specific ST flattening of the lateral leads
___
IMPRESSION:
1. Exam is markedly limited due to non breath hold technique and
marked
breathing motion artifact.
2. There is dilation of the intrahepatic and extrahepatic bile
ducts as well as the pancreatic duct at the duct of Wirsung. No
mass is seen at the ampulla however this exam is limited. A
small obstructing mass or stricture may be causing the dilation.
3. Limited evaluation of the pancreas shows abnormal low T1
signal and mild high T1 signal throughout consistent with
pancreatitis. There is no evidence of large collection.
Postcontrast imaging is nondiagnostic so enhancement
characteristics cannot be determined.
4. Bibasilar consolidations are likely from atelectasis,
clinically correlate to exclude pneumonia or aspiration.
___
IMPRESSION: Mild symmetric left ventricular hypertrophy.
Increased left ventricular filling pressure. Bioprosthetic
aortic valve with higher than expected gradients. Mild to
moderate mitral and tricuspid regurgitation. Moderate pulmonary
artery systolic pressure.
EUS: ___
EUS was performed using a linear echoendoscope at ___ MHz
frequency:
The head and uncinate pancreas were imaged from the duodenal
bulb and the second / third duodenum.
The body and tail [partially] were imaged from the gastric body
and fundus.
Linear EUS evaluation of the pancreas revealed heterogeneous
changes throughout, suggestive of pancreatic inflammation and
some trace free fluid.
No mass is seen, although ongoing pancreatitis can limit
ability to exclude small mass.
Focused examination of the bile duct did not reveal any
filling defects. The CBD was mildly dilated to approximately
12mm.
There is a periampullary diverticulum noted.
The PD was prominent in the head of the pancreas, measuring
approximately 4mm.
Recommendations: Follow-up LFTs
If an additional episode occurs, ERCP sphincterotomy can be
considered on a preventive basis (although data supporting this
approach is limited)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carvedilol 6.25 mg PO BID
3. Lisinopril 5 mg PO DAILY
4. Lovastatin 40 mg oral DAILY
5. Mycophenolate Mofetil 250 mg PO BID
6. PredniSONE 5 mg PO DAILY
7. Tacrolimus 1 mg PO Q12H
8. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral DAILY
9. amLODIPine 10 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D 5000 UNIT PO DAILY
12. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth Q12hrs
Disp #*18 Tablet Refills:*0
2. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Lovastatin 40 mg oral DAILY
9. Multivitamins 1 TAB PO DAILY
10. Mycophenolate Mofetil 250 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Tacrolimus 1 mg PO Q12H
13. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis
Acute cholangitis
Sepsis due to gram negative rod bacteremia
NSTEMI
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with abdominal pain and pancreatitis, evaluate for CBD
obstruction.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside hospital CT of the abdomen dated ___.
FINDINGS:
Of note, study is moderately limited by patient's inability to hold breath and
significant midline gas limiting the acoustic windows.
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 mild intrahepatic biliary dilation. The proximal CBD
measures 12 mm. Midline gas precludes evaluation of the distal CBD.
GALLBLADDER: The gallbladder surgically absent.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 9.5 cm. Trace free fluid seen
adjacent to the spleen.
KIDNEYS: Limited views of the right lower quadrant transplant kidney show no
hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Mild intrahepatic and moderate extrahepatic biliary ductal dilatation with
the common bile duct measuring up to 12 mm. No choledocholithiasis
identified, although evaluation of the distal CBD is limited by patient's
inability to hold breath and significant midline bowel gas.
2. Trace perihepatic ascites.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:36 ___, 1 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with ESRD s/p renal transplant, CAD s/p CABG
and bioprosthetic AVR, HLD, HTN, and prior episode of gallstone pancreatitis
re-presenting with likely pancreatitis and evidence of intra/extrahepatic
ductal dilatation. // ?pancreatitis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 6 mL Gadavist.
Oral contrast: Not administered due to patient's inability to take oral
contrast
Exam is limited by non breath hold technique and motion artifact
COMPARISON: CT of the abdomen from ___
FINDINGS:
Lower Thorax: Visualized lung bases show a trace left effusion and a small
right effusion with associated right basilar atelectasis. There is a small
amount of linear subsegmental atelectasis of the left lung base. Findings
have worsened since ___. Heart is enlarged.
Liver: The left lateral lobe and to a lesser extent the left medial lobe of
the liver is markedly atrophic. There are several scattered small T2
hyperintense foci consistent with cysts vs hamartomas.
No solid enhancing mass is seen noting that this exam is limited due to non
breath hold technique and marked breathing motion artifact. No evidence of
hepatic steatosis on the dual-echo GRE images.
There is a small amount of ascites
Biliary: There is marked intrahepatic and extrahepatic biliary dilation. The
CBD measures up to 17 mm. The intrahepatic ducts are dilated. There are no
definite stones within biliary system, however evaluation is limited due to
marked motion artifact
Gallbladder is absent. The cystic duct remnant is dilated.
Pancreas: Limited exam shows likely abnormal low T1 signal and high T2 signal
throughout the pancreas consistent with changes of pancreatitis. No evidence
of large collection. Postcontrast images are nearly nondiagnostic due to
breathing motion artifact and enhancement characteristics cannot be determined
The duct of Santorini as well as the majority of the main pancreatic duct are
not dilated. The duct of Wirsung is dilated measuring up to 8 mm. There are
a few sub 6 mm cystic lesions within the pancreas which are most consistent
with side-branch IPMNs. In addition there is a 1.3 x 0.6 cm cystic lesion at
the pancreatic body which is also most consistent with a side-branch IPMN.
These are not completely evaluated due to non breath hold technique and marked
motion artifact.
Spleen: Normal in size, signal, and enhancement.
Adrenal Glands: Normal in size, signal, and enhancement. No nodularity.
Kidneys: The native kidneys are entirely replaced by cysts. There is a right
iliac fossa transplant kidney which shows no hydronephrosis. There are a few
punctate simple cyst within the transplant kidney.
Gastrointestinal Tract: No evidence of obstruction. No mass. There is a
duodenal diverticulum noted
Lymph Nodes: No enlarged mesenteric or retroperitoneal lymph node.
Vasculature: Aorta is of normal caliber. .
Osseous and Soft Tissue Structures: No soft tissue mass. There is diastases
of the upper rectus muscles. Normal bone marrow signal. There is diffuse mild
anasarca. Sternotomy wires are noted. Right mastectomy is noted.
IMPRESSION:
1. Exam is markedly limited due to non breath hold technique and marked
breathing motion artifact.
2. There is dilation of the intrahepatic and extrahepatic bile ducts as well
as the pancreatic duct at the duct of Wirsung. No mass is seen at the ampulla
however this exam is limited. A small obstructing mass or stricture may be
causing the dilation.
3. Limited evaluation of the pancreas shows abnormal low T1 signal and mild
high T1 signal throughout consistent with pancreatitis. There is no evidence
of large collection. Postcontrast imaging is nondiagnostic so enhancement
characteristics cannot be determined.
4. Bibasilar consolidations are likely from atelectasis, clinically correlate
to exclude pneumonia or aspiration.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Abd pain
Diagnosed with Cholangitis
temperature: 101.3
heartrate: 82.0
resprate: 20.0
o2sat: 92.0
sbp: 123.0
dbp: 51.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is an ___ PMHx ESRD s/p living-related renal
transplant in ___ maintained on tacrolimus, MMF, prednisone
(baseline Cr 1.2-1.4), CAD s/p CABG and bioprosthetic AVR, HLD,
HTN and prior episode of gallstone pancreatitis at ___ in ___
(treated conservatively) who is transferred from ___
___ for suspected biliary pancreatitis with sepsis due to
gram negative rod bacteremia
# Acute pancreatitis
# Acute cholangitis
Overall presentation is most suggestive of biliary pancreatitis,
acute cholangitis with resultant gram negative rod bacteremia.
No gallstones were noted on limited ultrasound, but given high
suspicion for biliary pancreatitis, an MRCP (poor quality due to
patient participation) showed dilated bile ducts. The patient
subsequently underwent an EUS which did not show
choledocolithasis. She was initially kept NPO with IVF for
pancreatitis. Her abdominal pain improved, and her diet was
advanced. She was tolerating a regular diet without abdominal
pain prior to discharge. If the patient has a subsequent episode
of pancreatitis, could consider a repeat ERCP with
sphincterotomy per ERCP note, although data supporting this
approach is limited.
# Sepsis present on admission
# Gram negative rod bacteremia
Most likely due to acute pancreatitis / cholangitis. She was
initially treated broadly with vancomycin and
piperacillin/tazobactam, and ultimately narrowed to Zosyn and
then Ceftriaxone. ID was consulted and recommended Cipro to
complete a 14 day course- last day of antibiotics is ___.
Given the possible interaction of Cipro with tacrolimus would
check an EKG at PCP follow up.
# NSTEMI, type II demand type
# CAD s/p CABG and bioprosthetic AVR.
# Diastolic CHF exacerbation.
EKG shows changes likely related to old prior infarcts. Patient
was asymptomatic and lower suspicion of ACS at this time. TTE
was obtained, which showed normal EF with increased filling
pressure and increased gradient across the valve. The patient
was give one dose of IV Lasix with improvement in her
oxygenation. Continued home carvedilol but initially held home
lovastatin due to abnormal liver function tests.
- Consider outpatient cardiology evaluation if within goals of
care, otherwise, can optimize medically.
#Hypertension
The patient had significantly elevated blood pressures during
her hospitalization. Her Carvediolol was increased to 12.5mg BID
and Lisinopril to 10mg daily with improvement in her blood
pressure.
# ESRD s/p LRRT: Baseline creatinine 1.2-1.4. Continued home
prednisone, MMF, and tacrolimus. Renal Transplant team was
involved throughout hospitalization. The patient should have
follow up labs the week of ___ with results sent to the
transplant team.
# HLD: Home lovastatin was held in the setting of transaminitis
but resumed on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough, fever
Major Surgical or Invasive Procedure:
Ultrasound-guided Thoracentesis on ___
VATS with washout and Chest Tube Placement (Temporary) on ___
History of Present Illness:
Mr. ___ is a ___ M with IDDM, sarcoidosis, HTN, and 10 days of
dry cough.
His cough started at least 2 weeks ago, around ___ or earlier.
He describes the cough as forceful and occasionally productive.
He was seen by his PCP ___ ___ for cough. Clinic vital signs at
that visit were BP 120/78, Pulse 95, T 99.6, SpO2 94%. At that
time he was given symptomatic treatment for bronchitis
(guaifenesin-codeine), but his cough did not improve. In fact
for the last ___ days he has noted significant worsening in his
cough, and also has had shortness of breath. Also endorses
fatigue and fevers, and both anterior and lateral chest wall
pain that he associates with cough.
Notably he describes reflux which has worsened over the last
week. This does happen at night and he is unsure whether he
might have had reflux of stomach contents into his airway. He
has also had some occasional vomiting with forceful cough in
last 5 days.
He reports BRBPR with blood streaked stool, but describes this
as the same kind of bleeding he has had in the past associated
with known history of internal hemorrhoids, seen on colonoscopy
in ___. No diarrhea or constipation. No recent travel, no sick
contacts. No recent homelessness or prison exposures.
He presented to ___ office again today where vitals were notable
for BP 138/78, Pulse 114, T 103.0, SpO2 89%. CXR showed LLL
consolidation. He was sent to ___ ED for further evaluation.
In the ED, initial VS were 99.1 112 141/89 20 96% 2L. Imaging
was notable for left lower lobe pneumonia with small left
pleural effusion. He received Flagyl 500mg IV, Azithromycin 500
mg IV, CeftriaXONE 1 g IV, and Aspirin 325 mg. Also received 3L
IVF. He was transferred to the floor for further management.
On arrival to the floor, patient endorses subjective dyspnea as
well as pain with cough.
REVIEW OF SYSTEMS:
Denies headache, vision changes, rhinorrhea, congestion, sore
throat, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
- Sarcoidosis
- Type 2 diabetes mellitus, last A1C 6.9
- Hypertension, essential
- Hyperlipemia
- Diabetic macular edema
- Strabismic amblyopia of right eye
Social History:
___
Family History:
Mother has sarcoidosis and DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
98.8 141/81 103 28 96RA
GENERAL: Lying in bed, obese, breathing rapidly and appears
uncomfortable
HEENT: R strabismus noted. AT/NC, EOMI, PERRL, anicteric sclera,
pink conjunctiva, patent nares, MMM.
Poor dentition, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Decreased lung sounds at left base, also dull to
percussion compared to right. Lying in bed and breathing well
but appears to have mildly increased effort.
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly detected though exam
limited by habitus.
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, excoriations on bilateral shins
which patients says are chronic
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS:
===============
___ 11:51AM BLOOD WBC-19.4* RBC-3.99* Hgb-10.1* Hct-31.9*
MCV-80* MCH-25.3* MCHC-31.7 RDW-13.1 Plt ___
___ 11:51AM BLOOD Neuts-85.8* Lymphs-8.2* Monos-5.5 Eos-0.1
Baso-0.3
___ 12:10PM BLOOD ___ PTT-32.0 ___
___ 11:51AM BLOOD Glucose-167* UreaN-63* Creat-2.4* Na-134
K-5.2* Cl-99 HCO3-23 AnGap-17
___ 05:30AM BLOOD ALT-53* AST-44* AlkPhos-295* TotBili-0.7
___ 07:00AM BLOOD LD(___)-179
___ 05:30AM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.0 Mg-2.5
___ 09:24PM BLOOD HIV Ab-NEGATIVE
___ 06:43AM BLOOD ___ pO2-124* pCO2-36 pH-7.38
calTCO2-22 Base XS--2 Comment-GREEN TOP
IMPORTANT LABS:
===============
___ 04:00PM PLEURAL ___ Polys-0 Lymphs-0
___ 04:00PM PLEURAL TotProt-4.5 Glucose-0 LD(LDH)-7850
IMPORTANT IMAGING:
===================
CT CHEST W/O CONTRAST ___:
Large multiloculated, nonhemorrhagic left pleural effusion, more
likely
empyema than malignant. There is no obvious source of infection
so pre CT pneumonia is presumed. If thoracentesis is not
diagnostic, I would recommend repeat chest CT scanning only if
drainage achieves substantial re-expansion of the now largely
atelectatic left lower lobe.
CXR ___:
Left lower lobe pneumonia with small left pleural effusion.
Lateral left-sided pleural based lesion may represent a
loculated pleural effusion. Recommend CT for further evaluation.
ULTRASOUND GUIDED THORACENTESIS ___:
Ultrasound-guided diagnostic and therapeutic thoracentesis of
largest locule of left pleural fluid, with aspiration of 375 cc
of brown turbid fluid.
CT CHEST W/CONTRAST ___:
SLIGHT DECREASE IN SIZE OF MULTILOCULATED LEFT PLEURAL EFFUSION
FOLLOWING
THORACENTESIS, WITH DEVELOPMENT OF SMALL LOCULATED
HYDROPNEUMOTHORACES WHICH ARE LIKELY POST PROCEDURAL IN
ETIOLOGY.
ALL BORDERLINE MEDIASTINAL LYMPH NODES AND ENLARGED LEFT HILAR
LYMPH NODES ARE LIKELY REACTIVE.
3.5 CM LOW DENSITY SPLENIC LESION IS NOT FULLY CHARACTERIZE BY
CT. CONSIDER ULTRASOUND FOR MORE COMPLETE CHARACTERIZATION.
MICROBIOLOGY:
=============
DISCHARGE LABS:
===============
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 25 Units Bedtime
Humalog 7 Units Lunch
Humalog 7 Units Dinner
2. Chlorthalidone 50 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. tadalafil 10 mg oral PRN sexual intercourse
5. Atenolol 75 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Lisinopril 40 mg PO DAILY
8. vacuum erection device system As directed miscellaneous PRN
erectile dysfunction
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Amlodipine 10 mg PO DAILY
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Glargine 25 Units Bedtime
Humalog 7 Units Lunch
Humalog 7 Units Dinner
2. vacuum erection device system 1 Device MISCELLANEOUS PRN
erectile dysfunction
3. tadalafil 10 mg oral PRN sexual intercourse
4. Omeprazole 20 mg PO BID
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*80 Tablet Refills:*0
9. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 1 vial IV Q24H Disp #*14 Vial Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*80 Capsule Refills:*0
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Take PO for 2 weeks
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*40 Tablet Refills:*0
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*80 Tablet Refills:*0
13. Amlodipine 10 mg PO DAILY
14. Atenolol 75 mg PO DAILY
15. Lisinopril 40 mg PO DAILY
16. Chlorthalidone 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Multiloculated effusion/Empyema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fever and cough // pneumonia?
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. There is a retrocardiac opacity which
obscures the left hemidiaphragm concerning for pneumonia. There is no evidence
of pneumothorax. Small left pleural effusion is noted. Large 14.8-cm
(craniocaudal) left-sided pleural based lateral opacity may represent a
loculated pleural effusion.
IMPRESSION:
Left lower lobe pneumonia with small left pleural effusion.
Lateral left-sided pleural based lesion may represent a loculated pleural
effusion. Recommend CT for further evaluation.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with fever, cough and left-sided pleural based
lesion on CXR. // Please characterize pleural effusion
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.
DOSAGE: TOTAL DLP 725.0mGy-cm
COMPARISON: Read in conjunction with conventional chest radiograph on ___.
FINDINGS:
A large volume of multi loculated pleural effusion is found along virtually
all the left pleural surfaces--costal, fissural, paraspinal, juxta
mediastinal, and diaphragmatic. Its attenuation values range from ___ ___,
consistent with non-serous, nonhemorrhagic fluid. The costal component is
contiguous at the apex with higher attenuation thickening of the pleural
surface, 32 ___, 2:9, but the higher value could be due to artifact from the
bony chest cage and shoulders, so there is no good evidence for any pleural
mass. The components in the lower chest are probably responsible for
substantial atelectasis in the lower lobe since there is no bronchial
compromise. Despite contiguity with the mediastinum along the left ventricle
and obliteration of mediastinal and epicardial fat layers at that level,
4:154, pericardial effusion is only small.
Other contiguous structures are also unremarkable as a source of or
compromised by pleural effusion, specifically the mediastinum, thoracic spine,
and upper abdomen. This study is not designed for subdiaphragmatic diagnosis
but shows abundant tortuous vasculature in the region of the splenic artery,
despite any atherosclerotic calcification or, alternatively findings of
cirrhosis or portal hypertension that would lead to venous varices.
Thyroid is unremarkable. Supraclavicular and axillary lymph nodes are not
pathologically enlarged and there are no soft tissue findings in the wall of
the chest or imaged upper abdomen suspicious for malignancy or infection.
Gynecomastia is mild.
Top-normal size lymph nodes are numerous in the mediastinum, in the thoracic
inlet, upper and lower paratracheal, and paraesophageal stations. Left upper
internal mammary a lymph nodes are probably enlarged, but difficult to
separate from the adjacent pleural effusion, and presumably reactive. More
difficult to assess is the extent of left hilar adenopathy, but even if
present it further displaces but does not occlude the bronchial tree already
deviated anteriorly by the large pleural loculation posterior to it. The
aerated portions of the left lung are free of consolidation or nodules. The
largely collapsed left lower lobe could ___ either.
Large disc intrusions, disk space narrowing, and large bridging osteophytes
are present at multiple levels in the thoracic spine. There are no bone
findings of malignancy or infection in the chest cage.
IMPRESSION:
Large multiloculated, nonhemorrhagic left pleural effusion, more likely
empyema than malignant. There is no obvious source of infection so pre CT
pneumonia is presumed. If thoracentesis is not diagnostic, I would recommend
repeat chest CT scanning only if drainage achieves substantial re-expansion of
the now largely atelectatic left lower lobe.
NOTIFICATION: Dr. ___ reported the findings to Dr.
___ by telephone on ___ at 9:21 AM, 15 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with PNA and L loculated effusion s/p
thoracentesis. **please perform at 0600 on ___ // Change in left pleural
effusion?
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the known pleural lesion appears
slightly smaller, given a different patient position. As second left lateral
pleural lesion, likely reflecting in capsulated pleural fluid, appears to be
new. The atelectasis at the left lung bases is slightly increased. Unchanged
normal appearance of the heart and of the right lung.
Radiology Report
EXAMINATION: US THORACENTESIS NEEDLE/CATHETER ASP W IMAGING
INDICATION: ___ year old man with symptomatic L loculated effusions on CXR and
CT, s/p attempted IP drainaged today at bedside without success, per IP needs
image-guided drainage (CT) // please drain L loculated effusions under
image-guidance per IP
TECHNIQUE: Ultrasound guided diagnostic and therapeutic thoracentesis
COMPARISON: Chest CT ___
FINDINGS:
Limited grayscale ultrasound imaging of the left hemithorax demonstrated
loculated pleural fluid. A suitable target in the deepest pocket in the left
posterior mid scapular 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 5 ___ catheter was advanced into the largest fluid pocket in the left
posterior mid scapular line and 375 mL of brown turbid fluid was removed.
Specimens were sent for requested lab studies.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ attending radiologist, was present throughout the critical
portions of the procedure.
IMPRESSION:
Ultrasound-guided diagnostic and therapeutic thoracentesis of largest locule
of left pleural fluid, with aspiration of 375 cc of brown turbid fluid.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with PNA and multiloculated effusion s/p
thoracentesis // Please characterize remaining effusion
TECHNIQUE: Multidetector helical scanning of the chest was reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images compared to chest CT scanning since and a
chest CT .
DOSE: DLP: 978.___
COMPARISON: ___
FINDINGS:
A LARGE MULTILOCULATED LEFT PLEURAL EFFUSION SHOWS SLIGHT INTERVAL DECREASE IN
THE BASILAR COMPONENT CONSISTENT WITH RECENT THORACENTESIS. 2 NEW AIR-FLUID
LEVELS WITHIN 2 LOCULATED COMPONENTS POSTERIORLY IN THE LEFT HEMI THORAX AND
ANTERIORLY ADJACENT TO THE LEFT VENTRICLE (IMAGE 44, SERIES 2) ARE LIKELY
LIKELY RELATED TO RECENT INTERVENTION. Note is also made of a split pleura
sign. Adjacent areas of atelectasis near the effusions in the left hemi
thorax are largely similar to the prior study except for slight improved
aeration in the left lower lobe adjacent to the decreasing loculated
components. 2 mm left perifissural nodule is unchanged and may reflect an
intrapulmonary lymph node (30;2).
The thyroid is MILDLY ENLARGED AND HETEROGENEOUS WITHOUT CHANGE AND NOT FULLY
CHARACTERIZED BY CT. BORDERLINE MEDIASTINAL LYMPH NODES and enlarged left
hilar nodes ARE STABLE TO SLIGHTLY DECREASED IN SIZE FROM PRIOR STUDY.
Supraclavicular AND axillary lymph nodes are not enlarged. Mildly enlarged
right pericardial node is unchanged. Aorta and pulmonary arteries are normal
size. Cardiac configuration is normal and there is no appreciable coronary
calcification.
The exam was not tailored to evaluate the subdiaphragmatic region, but note is
made of a 3.5 cm diameter low-density lesion within the spleen, not fully
characterized.
IMPRESSION:
SLIGHT DECREASE IN SIZE OF MULTILOCULATED LEFT PLEURAL EFFUSION FOLLOWING
THORACENTESIS, WITH DEVELOPMENT OF SMALL LOCULATED HYDROPNEUMOTHORACES WHICH
ARE LIKELY POST PROCEDURAL IN ETIOLOGY.
ALL BORDERLINE MEDIASTINAL LYMPH NODES AND ENLARGED LEFT HILAR LYMPH NODES ARE
LIKELY REACTIVE.
3.5 CM LOW DENSITY SPLENIC LESION IS NOT FULLY CHARACTERIZE BY CT. CONSIDER
ULTRASOUND FOR MORE COMPLETE CHARACTERIZATION.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with left empyema sp decort // ptx
COMPARISON: Chest CT from ___.
FINDINGS:
AP portable upright view of the chest.
A tiny left apical pneumothorax is present. Two thoracostomy tubes are
present. The heart size is top normal. There is central pulmonary vascular
congestion, with no appreciable edema. A left basilar opacity likely reflects
a combination of atelectasis and a small left pleural effusion.
IMPRESSION:
1. Tiny left apical pneumothorax.
2. Mild pulmonary vascular congestion. No overt edema.
3. Small left pleural effusion with adjacent atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with left empyema sp decort // ptx
COMPARISON: Chest radiograph from ___.
FINDINGS:
AP portable upright view of the chest.
Two left thoracostomy tubes are unchanged in position. There is no
pneumothorax. The lung volumes are lower in comparison to the ___
study. Mild central pulmonary vascular congestion is unchanged. A small left
pleural effusion remains stable.
IMPRESSION:
Left pneumothorax no longer detected. Unchanged left pleural effusion. Stable
central pulmonary vascular congestion.
Radiology Report
EXAMINATION: Chest radiographs PA and lateral
INDICATION: ___ year old man with pneumonia s/p VATS decortication // f/u
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
Since the prior CXR, there has been interval resolution of right-sided
pulmonary edema. The right lung is otherwise free of focal consolidations,
large pleural effusions or pneumothorax. Within the left lung, there is
extensive atelectasis at the lung base. The two chest tubes are unchanged in
position. The moderate/large left loculated pleural effusion is not
significantly changed compared to ___. Tiny hydropneumothoraces
noticed in the left lung apex. No acute osseous abnormalities.
IMPRESSION:
Unchanged moderate to large left loculated pleural effusion, with small
loculated apicolateral hydropneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with emphysema // pneumothorax
COMPARISON: ___
IMPRESSION:
Status post removal of 1 of 2 left-sided chest tubes, with no substantial
interval change in moderate to large loculated left pleural effusion with
small loculated hydro pneumothorax apicolaterally.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with pneumonia // f/u
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen in severity
and extent of the known left parenchymal opacities, combines to areas of
lateral pleural thickening. The position of the left chest tube is constant
and unchanged. Blunting of the left costophrenic sinus is likely caused by a
combination of pleural effusion and pleural thickening. The right lung is
unremarkable. Moderate cardiomegaly.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with pneumonia // post-pull evaluation
post-pull evaluation
IMPRESSION:
In comparison with the earlier study of this date, the left chest tube has
been removed. No evidence of acute pneumothorax. Otherwise little change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ male for pneumonia followup.
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: ___ and dating back to ___.
FINDINGS:
There has been no significant interval change and the loculated moderate left
hydropneumothorax. The left costophrenic angle has been excluded from the
field of view. The right lung remains clear. The cardiomediastinal contour is
stable.
IMPRESSION:
No significant interval change in moderate loculated left hydropneumothorax.
Clear right lung.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ year old man with new line // new left basilic POWER PICC 54
cm ___ ___ name: ___: ___
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest x-ray ___
FINDINGS:
Since the prior radiograph, there has been interval placement of a left-sided
PICC line that terminates in the cavoatrial junction. The known loculated
left sided pleural effusion is not significantly changed from the prior
radiograph. The right lung remains essentially clear. There is no
pneumothorax. Cardiomediastinal silhouette is stable.
IMPRESSION:
1. The new left sided PICC line terminates at the cavoatrial junction.
2. Unchanged loculated left pleural effusion.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever, Dyspnea
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, PLEURAL EFFUSION NOS, HYPERTENSION NOS, DIABETES UNCOMPL ADULT
temperature: 99.1
heartrate: 112.0
resprate: 20.0
o2sat: 96.0
sbp: 141.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | ___ with IDDM, distant history of sarcoidosis, HTN, presenting
with 10 days of cough, fevers, found to be hypoxemic and with
new CXR infiltrates at PCP office, determined to have L-sided
multiloculated empyema here, requiring surgical intervention. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Azithromycin / Bactrim / Avelox / Flexeril / IV Morphine / Latex
/ Latuda / Geodon / Tizanidine / Transderm-Scop / ferumoxytol /
Dilaudid / Feraheme / Feraheme / aloe / chicken derived / egg /
Fish Containing Products / soy / wheat / chickpea / banana / red
meat / cantalope / milk / shellfish derived
Attending: ___.
Chief Complaint:
positive blood culture
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram ___
___ PICC placement ___
Percutaneous gastrostomy jejunostomy tube placement ___
History of Present Illness:
___ woman with a complex past medical history including
___ vs ___ Syndrome, dysautonomia/POTS,
regional complex pain syndrome, partial stump of epiglottis and
absent uvula, bronchiectasis, anxiety, depression, PTSD, eating
disorder presenting with positive blood cultures.
She had blood cx drawn at her PCP for workup of
hypergammaglobulinemia which resulted positive for GNRs and
budding yeast. She complains that everything is terrible for the
last year and can't say if anything is different recently.
___ the ED was received Zosyn. After starting vancomycin she
developed a mild rash. Received Benadryl and restarted
vancomycin.
___ the ED, vitals were:
T 98.1, HR 66, BP 124/59, RR 18, 95% RA
Exam:
General: thin pale woman wearing sunglasses
She allows cardiac exam which is normal, declines lung exam.
Labs:
WBC 3.0
Hgb 7.5
Plt 108
Lactate 1.0
UA: few bacteria, trace Leuks, neg nitrite
They were given:
Zosyn 4.5 g IV
Vancomycin 1.5 g IV
Benadryl 50 mg IV
1L NS
On arrival to the floor, the patient confirms the above history.
Was instructed to present to the ___ ED by her PCP for
positive
blood culture. Denies new symptoms acutely. Says her diffuse
chronic pain is worse and her joints are popping out more.
Denies
fevers, CP, SOB, abdominal pain, dysuria. Patient also says that
she would prefer to have female providers.
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
-Anorexia Nervosa/Bulemia
-Hx of Gastroparesis with frequent nausea/vomiting (notably
mostecent GES normal)
-___ Syndrome
-Leukopenia (followed by Dr. ___
-Anemia ___, ? other contributors)
-MGUS (bi-clonality)
-Migraines
-Eosinophelia esophagitis
-Recurrent thrush
-Bronchiectasis
-Dysautonomia with POTS
-Dysthymia
-PTSD
-Depression/anxiety with h/o multiple suicide attempts
-Dissociative disorder
-Congenital Palate malformations (no uvula, soft palate is
almost
completely missing)
-Recurrent Vaginitis-denies recent problems
-Hx MRSA UTIs-denies recent problems.
-Hx MRSA skin infections
-Reflex sympathetic dystrophy (B/L ___ DX age ___, uses cane
since
age ___.
-GERD
Social History:
___
Family History:
Sister - unknown cancer
Aunt - depression
___ cousins x2 - breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ Temp: 97.6 PO BP: 157/89 HR: 79 RR: 16 O2
sat: 100% O2 delivery: ra
GENERAL: Very thin, chronically ill-appearing woman.. Alert and
interactive. ___ no acute distress.
HEENT: EOMI. Sclera anicteric and without injection. MMM.
Posterior oropharynx with dried reddish residue.
NECK: Supple
CARDIAC: RRR, S1 and S2
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
EXTREMITIES: LUE PICC without erythema, purulence, or
tenderness.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. Unsteady
gait.
DISCHARGE PHYSICAL EXAM
=======================
VS: 24 HR Data (last updated ___ @ 1157)
Temp: 98.5 (Tm 98.9), BP: 130/71 (116-132/68-73), HR: 79
(73-86), RR: 18, O2 sat: 100% (98-100), O2 delivery: Ra
GENERAL: Very thin, chronically ill-appearing woman. ___ no acute
distress.
HEENT: NC/AT, mouth dry
CARDIAC: RRR, S1 and S2 present
LUNGS: Clear to auscultation bilaterally
ABDOMEN: Nontender to palpation, dressing C/D/I
EXTREMITIES: RUE midline without erythema, purulence, or
tenderness.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
Pertinent Results:
ADMISSION LABS
====================
___ 04:00PM BLOOD WBC-2.0* RBC-2.59* Hgb-6.8* Hct-22.3*
MCV-86 MCH-26.3 MCHC-30.5* RDW-15.9* RDWSD-49.8* Plt ___
___ 04:00PM BLOOD Neuts-57.0 ___ Monos-9.5
Eos-10.0* Baso-1.5* AbsNeut-1.14* AbsLymp-0.44* AbsMono-0.19*
AbsEos-0.20 AbsBaso-0.03
___ 01:35PM BLOOD Glucose-103* UreaN-6 Creat-0.5 Na-134*
K-3.5 Cl-102 HCO3-22 AnGap-10
___ 04:00PM BLOOD Albumin-2.4* Phos-2.9 Mg-1.7 Iron-14*
___ 04:07AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.6
___ 04:00PM BLOOD ALT-6 AST-13 AlkPhos-89 TotBili-0.2
___ 04:00PM BLOOD LD(LDH)-123
___ 04:00PM BLOOD calTIBC-121* Ferritn-73 TRF-93*
___ 04:00PM BLOOD Hapto-170
___ 04:00PM BLOOD TSH-5.8*
___ 04:00PM BLOOD Free T4-1.0
___ 04:00PM BLOOD CRP-52.1*
___ 04:00PM BLOOD FreeKap-98.8* FreeLam-95.9* Fr K/L-1.0
___ 04:00PM BLOOD IgG-2197* IgA-1087* IgM-417*
___ 04:34PM URINE Color-Straw Appear-Clear Sp ___
___ 04:34PM URINE Blood-MOD* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR*
___ 04:34PM URINE RBC-14* WBC-4 Bacteri-FEW* Yeast-NONE
Epi-1
MICRO
=========
___ 4:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
PSEUDOMONAS PUTIDA . FINAL SENSITIVITIES.
___.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Yeast Susceptibility:.
Fluconazole MIC OF 0.25 MCG/ML.
Antifungal agents reported without interpretation lack
established
CLSI guidelines.
Results were read after 24 hours of incubation.
test result performed by Sensititre.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS PUTIDA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM------------- 2 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 8 R
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
BUDDING YEAST.
Reported to and read back by ___ (___) @09:17
(___).
___ 7:00 pm ASPIRATE Source: Sinus.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___:
PRESUMPTIVE VEILLONELLA SPECIES. SPARSE GROWTH.
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
FUNGAL CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
YEAST.
IMAGING
==========
CT ABDOMEN W/ CONTRAST ___
FINDINGS:
Lung bases: Please refer to same-day chest CT for findings above
the
diaphragm.
Abdomen: Several tiny hypodensities within the liver are too
small to
characterize. Main portal vein is patent. There is no biliary
ductal
dilation. The gallbladder is not fully distended. The spleen
is prominent
and measures 13 cm ___ length. There are multiple hypodensities
within the
spleen which are not fully characterize, possibly hemangiomas.
Both right and
left adrenal glands appear normal. The kidneys enhance
symmetrically. No
worrisome renal lesion. Several tiny cortical hypodensities are
noted on the
right which are too small to characterize. The abdominal aorta
is normal ___
course and caliber without appreciable atherosclerotic
calcification. No
adenopathy, free air or free fluid. The stomach and duodenum
appear normal.
Pelvis: Small bowel loops demonstrate no signs of ileus or
obstruction. The
appendix is normal. The colon contains a large fecal load. No
signs of
colonic wall thickening. The uterus is retroverted and
retroflexed. There is
no adnexal mass. Trace free fluid is likely physiologic. The
urinary bladder
is decompressed. There is no pelvic sidewall or inguinal
adenopathy.
Bones: No worrisome lytic or blastic osseous lesion is seen.
There is mild to
moderate osteoarthritis at the hips.
IMPRESSION:
Large fecal loading of the colon. Several small hypodensities
involving the
liver and spleen are not fully characterized, possibly cysts
and/or
hemangiomas. Mild splenomegaly measuring 13 cm.
___ CT CHEST WITH CONTRAST
FINDINGS:
THORACIC INLET: Thyroid is unremarkable. There is a left-sided
PICC line with
its tip ___ the SVC.
BREAST AND AXILLA : No enlarged axillary lymph nodes.
MEDIASTINUM: There are no enlarged mediastinal hilar lymph
nodes. Heart size
is normal. There is no pericardial effusion.
PLEURA: There is no pleural effusion
LUNG: There are multiple tiny bilateral pulmonary nodules
ranging ___ size from
2-4 mm, are indeterminate (6, 77, 83, 85, 102, 134, 164, 197,
___.
BONES AND CHEST WALL : Review of bones shows no lytic or
sclerotic lesions.
No acute fractures are seen.
UPPER ABDOMEN: Limited sections through the upper abdomen shows
multiple
hypodense liver lesions.
IMPRESSION:
Multiple bilateral pulmonary nodules ranging ___ size from 2-4
mm.
RECOMMENDATION(S): For incidentally detected multiple solid
pulmonary nodules
smaller than 6mm, no CT follow-up is recommended ___ a low-risk
patient, and an
optional CT follow-up ___ 12 months is recommended ___ a high-risk
patient.
___ CT SINUS/MANDIBLE/MAXILLA
FINDINGS:
Postsurgical changes after partial ethmoidectomy and
turbinectomy of the
superior and middle right turbinates processes as well as
bilateral
antrostomies with likely uncinectomies are again noted.
There is partially frothy mucous ___ the bilateral frontal
sinuses with
obliteration of the bilateral frontoethmoidal junctions. There
is near
complete opacification of the right ethmoid air cells and
anterior left
ethmoid air cells. There is mild mucosal thickening along the
posterior left
ethmoid air cells.
Questionable focal dehiscence versus very thin bone along the
right cribriform
plate (series 5, image 42 and series 6, image 55). The lamina
papyracea are
intact.
There is mild mucosal thickening ___ the maxillary sinuses. The
left maxillary
sinus is nearly completely obliterated with complete
opacification of the neo
ostium. There is moderate to severe mucosal thickening ___ the
right maxillary
sinus with partial obliteration of the neo ostium. Frothy
mucous with few
septations is seen ___ the right nasal cavity.
The mucous ___ the sinuses is partially hyperdense which could
reflect
inspissated secretions or fungal colonization.
The nasal septum is dehiscent and demonstrates mild bowing
towards the left,
unchanged. The carotid canals and optic nerve canals are
covered by bone.
There is bony resorption/dehiscence of the nasal bones, right
greater than
left, acuity uncertain, which may be sequela of prior trauma
surgery or
trauma. There is mild soft tissue prominence overlying the
nasal bones
without definitive inflammatory stranding. Clinical correlation
is
recommended.
There is a near midline cystic lesion of the hard palate
measuring 7 mm
(series 9, image 32) not seen on prior examination without
aggressive borders
which may represent a non odontogenic fissural cyst.
Incidental note is made of 3 stones ___ the right submandibular
duct which is
dilated (series 3, image 54). The right submandibular gland
appears
unremarkable without evidence of inflammatory changes. The
remainder of the
visualized salivary glands appears normal.
Note is made of a circumscribed hypodense, oval midline
structure at the base
of the tongue (series 3, image 42 and series 9, image 36) which
measures 2.0 x
1.5 x 1.5 cm (AP X TR X SI) and abuts the hyoid bone inferiorly.
There is
minimal surrounding enhancement but no enhancement within the
lesion. The
central contents of the lesion measure up to 65 Hounsfield
units, suggestive
of a complicated cyst with possibly hemorrhagic and
proteinaceous contents.
___ retrospect, the lesion can be identified on the MRI from ___ where
demonstrated intrinsic T1 hyperintense signal, suggestive of
hemorrhagic or
highly proteinaceous contents. At that time, the lesion measure
approximately
1.4 x 1.7 x 0.9 cm (AP X TR X SI).
The mastoid air cells are clear. The external auditory canals
and visualized
middle ear structures appear unremarkable.
Visualized structures of the brain and soft tissues appear
unremarkable. The
orbits are normal.
There are periapical lucencies involving the roots of the right
second
bicuspid maxillary and mandibular teeth (series 2, image 86 and
51). The
temporomandibular joints appear unremarkable.
IMPRESSION:
1. Stable postsurgical changes after partial ethmoidectomy and
turbinectomy as
well as bilateral antrostomies with likely uncinectomies.
2. Diffuse partially severe paranasal sinus disease with near
complete
obliteration of the left maxillary sinus and aeration of the
bilateral
frontoethmoidal junctions and ostiomeatal neo ostia.
3. Partially hyperdense mucous ___ the paranasal sinuses could
reflect
inspissated secretions or fungal colonization.
4. Questionable small focal dehiscence versus very thin bone
along the right
cribriform plate as described above.
5. Right submandibular sialoliths with ductal dilation but no
evidence of
inflammatory changes of the right submandibular gland.
6. Increase ___ size of a circumscribed hypodense, oval midline
structures at
the base of the tongue extending to the hyoid bone which, ___
retrospect, has
been present ___ ___ and likely represents a complicated
vallecular or
thyroglossal duct cyst. However, a soft tissue mass is not
entirely excluded
and further evaluation with a dedicated neck MRI with and
without contrast is
recommended.
7. Periapical lucencies involving the right second bicuspid
maxillary and
mandibular teeth. Clinical correlation for odontogenic
sinusitis is
recommended.
8. Unchanged dehiscence of the nasal septum with mild leftward
bowing. New
midline 7 mm hard palate cyst, which may represent a non
odontogenic visual
cyst.
9. Bony resorption dehiscence of the nasal bones, right greater
than left,
acuity uncertain, which may be sequela of prior trauma or
surgery. Clinical
correlation is recommended.
___ CHEST XRAY
FINDINGS:
The distal tip of the left PICC line projects over the superior
vena cava. No
focal consolidation. The costophrenic angles are sharp. There
is mild
pulmonary vascular congestion. Cardiomediastinal silhouette is
normal ___ size
and contour.
IMPRESSION:
Mild pulmonary vascular congestion.
___ LEFT UPPER EXTREMITY ULTRASOUND
FINDINGS:
There is normal flow with respiratory variation ___ the bilateral
subclavian
veins.
PICC line is demonstrated ___ the brachial vein. The left
internal jugular,
and brachial veins are patent, show normal color flow, spectral
doppler, and
compressibility. There is limited compression of the low left
axillary vein
due to technical difficulties, but there is normal color flow
and Doppler of
the left axillary vein. The left basilic, and cephalic veins
are patent,
compressible and show normal color flow.
IMPRESSION:
No evidence of deep vein thrombosis ___ the left upper extremity.
___ CT CHEST WITH CONTRAST
FINDINGS:
CHEST: Thyroid is unremarkable. Supraclavicular, axillary,
mediastinal, and
hilar lymph nodes are not pathologically enlarged. Thoracic
aorta and main
pulmonary artery are normal caliber. There is no pericardial
effusion.
There is no pleural effusion. Numerous micronodules and
ground-glass
opacities are demonstrated ___ bilateral lungs. Bronchiectasis
is present ___
bilateral lower lobes and right middle lobe. 1.8 cm area of
atelectasis is
noted ___ the right middle lobe.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
Multiple subcentimeter hypodense lesions are identified ___ the
liver, similar
to ___. 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: Numerous hypodense lesions ___ the spleen are similar to
before.
ADRENALS: The right and left adrenal glands are normal ___ 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.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is
small free fluid ___ the pelvis.
REPRODUCTIVE ORGANS: Uterus and bilateral adnexa are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: No suspicious soft tissue lesions identified.
IMPRESSION:
1. Numerous micronodules and ground-glass opacities ___ bilateral
lungs with
bibasal bronchiectasis are consistent with suspected fungal
infection.
2. Numerous hypodense lesions ___ the liver and spleen are
nonspecific but may
related to fungal septicemia given that there were not present
on the MR
enterography dated ___. Cysts and/or hemangiomas
are thought to
be less likely.
___ CT ABDOMEN/PELVIS WITH CONTRAST
FINDINGS:
CHEST: Thyroid is unremarkable. Supraclavicular, axillary,
mediastinal, and
hilar lymph nodes are not pathologically enlarged. Thoracic
aorta and main
pulmonary artery are normal caliber. There is no pericardial
effusion.
There is no pleural effusion. Numerous micronodules and
ground-glass
opacities are demonstrated ___ bilateral lungs. Bronchiectasis
is present ___
bilateral lower lobes and right middle lobe. 1.8 cm area of
atelectasis is
noted ___ the right middle lobe.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
Multiple subcentimeter hypodense lesions are identified ___ the
liver, similar
to ___. 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: Numerous hypodense lesions ___ the spleen are similar to
before.
ADRENALS: The right and left adrenal glands are normal ___ 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.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is
small free fluid ___ the pelvis.
REPRODUCTIVE ORGANS: Uterus and bilateral adnexa are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: No suspicious soft tissue lesions identified.
IMPRESSION:
1. Numerous micronodules and ground-glass opacities ___ bilateral
lungs with bibasal bronchiectasis are consistent with suspected
fungal infection.
2. Numerous hypodense lesions ___ the liver and spleen are
nonspecific but may related to fungal septicemia given that
there were not present on the MR enterography dated ___. Cysts and/or hemangiomas are thought to be less likely.
TRANSTHORACIC ECHO ___
CONCLUSION: The left atrial volume index is normal. 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. The
visually estimated left ventricular ejection
fraction is 60%. There is no resting left ventricular outflow
tract gradient. Tissue Doppler suggests a
normal left ventricular filling pressure (PCWP less than
12mmHg). There is normal diastolic function.
Mildly dilated right ventricular cavity with normal free wall
motion. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a
normal descending aorta diameter. The aortic valve leaflets (3)
are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with leaflet straightening, but no frank
systolic prolapse. No masses or vegetations are seen on the
mitral valve. There is trivial mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally
normal. No mass/vegetation are seen on the tricuspid valve.
There is physiologic tricuspid regurgitation.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: No 2D echocardiographic evidence for endocarditis.
If clinically suggested, the
absence of a discrete vegetation on echocardiography does not
exclude the diagnosis of
endocarditis.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
TRANSESOPHAGEAL ECHO ___
Conclusion:
There is no spontaneous echo contrast or thrombus ___ the body of
the left atrium/left atrial appendage.
No spontaneous echo contrast or thrombus is seen ___ the body of
the right atrium/right atrial appendage.
There is no evidence for an atrial septal defect by 2D/color
Doppler. Overall left ventricular systolic
function is normal. The right ventricle has normal free wall
motion. There are no aortic arch atheroma
with no atheroma ___ the descending aorta to 38 cm from the
incisors. The aortic valve leaflets (3) appear
structurally normal. No masses or vegetations are seen on the
aortic valve. No abscess is seen. There is
trace aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
No abscess is seen. There is mild [1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen
on the tricuspid valve. No abscess is seen. There is trivial
tricuspid regurgitation.
IMPRESSION: No discrete vegetation or abscess seen. If
clinically suggested, the absence of a
discrete vegetation on echocardiography does not exclude the
diagnosis of endocarditis. Mild
mitral regurgitation.
GJ PLACEMENT ___
FINDINGS:
1. Successful placement of a 16 ___ MIC gastrojejunostomy
tube with its tip
___ the proximal jejunum.
IMPRESSION:
Successful placement of a 16 ___ MIC gastrojejunostomy tube
with its tip ___
the proximal jejunum. The gastric port should not be used for 24
hours.
DISCHARGE LABS
==============
___ 06:13AM BLOOD WBC-2.7* RBC-2.41* Hgb-6.8* Hct-22.6*
MCV-94 MCH-28.2 MCHC-30.1* RDW-19.3* RDWSD-64.7* Plt Ct-UNABLE
TO
___ 06:13AM BLOOD Glucose-101* UreaN-10 Creat-0.4 Na-139
K-3.6 Cl-102 HCO3-26 AnGap-11
___ 06:30AM BLOOD ALT-7 AST-18 AlkPhos-91 TotBili-<0.2
___ 06:13AM BLOOD Calcium-8.5 Phos-4.6* Mg-1.7
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Potassium Chloride 20 mEq IV TWICE A WEEK
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheezing
3. Cathflo Activase (alteplase) 2 mg Other ONCE MR1
4. amoxicillin-pot clavulanate 250-125 mg oral BID for the first
10 days of every month
5. azelastine 137 mcg (0.1 %) nasal BID
6. betamethasone, augmented 0.05 % topical DAILY
7. budesonide 1 mg/2 mL inhalation DAILY
8. Belbuca (buprenorphine HCl) 600 mcg buccal BID
9. ClonazePAM 1 mg PO TID
10. Clotrimazole Cream 1 Appl TP BID:PRN rash
11. DICYCLOMine 40 mg PO QID
12. Dupixent (dupilumab) 300 mg/2 mL subcutaneous every 2 weeks
13. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection 1 dose IM prn
14. Fludrocortisone Acetate 0.1 mg PO 2 TABLETS BY MOUTH ___ AM
AND 1 ___ ___
15. FoLIC Acid 1 mg PO DAILY
16. heparin lock flush (porcine) (heparin, porcine (PF)) 100
unit/mL injection daily flush 5 days a week (days not receiving
IVF)
17. Hydrocortisone Cream 2.5% 1 Appl TP BID UP TO 2 WEEKS PER
MONTH
18. Ketoconazole 2% 1 Appl TP DAILY AS NEEDED
19. Lidocaine 5% Ointment 1 Appl TP APPLY TO LEFT SHOULDER DAILY
20. Lidocaine Viscous (lidocaine HCl) 2 % mucous membrane apply
to upper left palate up to TID
21. Modafinil 200 mg PO QAM
22. Nasonex (mometasone) 50 mcg/actuation nasal DAILY
23. Montelukast 10 mg PO DAILY
24. Mupirocin Ointment 2% 1 Appl TP TID
25. Naloxone Nasal Spray 4 mg IH DAILY:PRN overdose
26. nystatin 100,000 unit/mL oral 4 mL by mouth 4x/day
27. Omeprazole 40 mg PO BID
28. orphenadrine citrate 100 mg oral Q12H:PRN muscle spasm
29. Elidel (pimecrolimus) 1 % topical DAILY
30. Klor-Con (potassium chloride) 20 mEq oral 1 packet by mouth
daily up to three per ___ instructions, based on potassium
levels
31. sodium chloride 0.9 % inhalation three to four times a day
as needed for SOB, wheeze to be mixed with albuterol neb
32. Sodium Chloride 0.9% Flush 20 mL IV 5 DAYS A WEEK (WHEN NOT
RECEIVING IVF)
33. Topiramate (Topamax) 75 mg PO BID
34. Triamcinolone Acetonide 0.1% Cream 1 Appl TP APPLY TO ECZEMA
AS NEEDED
35. Venlafaxine XR 75 mg PO ___ CAPSULES BY MOUTH ONCE DAILY
36. Cetirizine 10 mg PO BID
37. Vitamin D ___ UNIT PO DAILY
38. DiphenhydrAMINE 50 mg PO BID:PRN insomnia, itching
39. Magnesium Oxide 500 mg PO DAILY
40. melatonin 2 mg oral QHS
41. Vivonex T.E.N. (nut.tx.impaired digest fxn) 11.5 gram-300
kcal/80.4 gram oral TID
42. Polyethylene Glycol 17 g PO TID:PRN Constipation - Third
Line
43. Senna 8.6 mg PO BID:PRN Constipation - First Line
44. Saline Nasal (sodium chloride) 0.65 % nasal 1 vial inhaled
mixed with the albuterol nebs
45. Pediatric Electrolyte
(electrolytes-dextrose;<br>sodium-potas-chloride-dextrose) 17 g
oral QID
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tab-cap by mouth once a day Disp
#*30 Tablet Refills:*2
3. Sodium Chloride Nasal ___ SPRY NU BID
RX *sodium chloride [Nasal Spray (sodium chloride)] 0.65 % ___
sprays intranasal twice a day Disp #*1 Ampule Refills:*2
4. Thiamine 200 mg PO DAILY
RX *thiamine HCl (vitamin B1) 250 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*2
5. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
RX *zinc sulfate [Orazinc] 220 mg (50 mg zinc) 1 capsule(s) by
mouth once a day Disp #*30 Capsule Refills:*2
6. Fludrocortisone Acetate 0.1 mg PO QPM
7. Fludrocortisone Acetate 0.1 mg PO QAM
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheezing
9. amoxicillin-pot clavulanate 250-125 mg oral BID for the
first 10 days of every month
10. Belbuca (buprenorphine HCl) 600 mcg buccal BID
11. budesonide 1 mg/2 mL inhalation DAILY
12. Cetirizine 10 mg PO BID
13. ClonazePAM 1 mg PO TID
14. DICYCLOMine 40 mg PO QID
15. DiphenhydrAMINE 50 mg PO BID:PRN insomnia, itching
16. Elidel (pimecrolimus) 1 % topical DAILY
17. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection 1 dose IM prn
18. FoLIC Acid 1 mg PO DAILY
19. Hydrocortisone Cream 2.5% 1 Appl TP BID UP TO 2 WEEKS PER
MONTH
20. Ketoconazole 2% 1 Appl TP DAILY AS NEEDED
21. Lidocaine 5% Ointment 1 Appl TP APPLY TO LEFT SHOULDER
DAILY
22. Lidocaine Viscous (lidocaine HCl) 2 % mucous membrane apply
to upper left palate up to TID
23. Magnesium Oxide 500 mg PO DAILY
24. melatonin 2 mg oral QHS
25. Modafinil 200 mg PO QAM
26. Montelukast 10 mg PO DAILY
27. Mupirocin Ointment 2% 1 Appl TP TID
28. Naloxone Nasal Spray 4 mg IH DAILY:PRN overdose
29. orphenadrine citrate 100 mg oral Q12H:PRN muscle spasm
30. Pediatric Electrolyte
(electrolytes-dextrose;<br>sodium-potas-chloride-dextrose) 17 g
oral QID
31. Polyethylene Glycol 17 g PO TID:PRN Constipation - Third
Line
32. Senna 8.6 mg PO BID:PRN Constipation - First Line
33. Sodium Chloride 0.9 % inhalation THREE TO FOUR TIMES A DAY
AS NEEDED FOR SOB, WHEEZE TO BE MIXED WITH ALBUTEROL NEB
34. Topiramate (Topamax) 75 mg PO BID
35. Triamcinolone Acetonide 0.1% Cream 1 Appl TP APPLY TO
ECZEMA AS NEEDED
36. Venlafaxine XR 75 mg PO ___ CAPSULES BY MOUTH ONCE DAILY
37. Vitamin D ___ UNIT PO DAILY
38. HELD- Dupixent (dupilumab) 300 mg/2 mL subcutaneous every 2
weeks This medication was held. Do not restart Dupixent until
you see Dr. ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Line associated ___ bloodstream infection
Line associated pseudomonal bloodstream infection
Severe Protein Calorie Malnutrition
SECONDARY DIAGNOSES:
1) Bronchiectasis
2) Chronic rhinosinusitis
3) Dermatitis
4) Dysautonomia/POTS
5) ___ Syndrome
6) Chronic pain
7) Anxiety/Depression
8) Chronic migraine
9) IBS-C: Continued miralax
10) Eosinophilic esophagitis.
11) GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with bacteremia and left PICC// evaluate PICC
position. evaluate for PNA. evaluate PICC position. evaluate for PNA.
COMPARISON: Chest x-ray ___
FINDINGS:
The distal tip of the left PICC line projects over the superior vena cava. No
focal consolidation. The costophrenic angles are sharp. There is mild
pulmonary vascular congestion. Cardiomediastinal silhouette is normal in size
and contour.
IMPRESSION:
Mild pulmonary vascular congestion.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with fungemia, GNR bacteremia. Patient can be
challenging, often requests female providers. Can be more agreeable if you let
her know that her PCP ___ is requesting this evaluation// Any
evidence DVT, assess picc line (if still in) for vegetation/sign of infxn,
Left
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 bilateral subclavian
veins.
PICC line is demonstrated in the brachial vein. The left internal jugular,
and brachial veins are patent, show normal color flow, spectral doppler, and
compressibility. There is limited compression of the low left axillary vein
due to technical difficulties, but there is normal color flow and Doppler of
the left axillary vein. The left basilic, and cephalic veins are patent,
compressible and show normal color flow.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST; CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with fungemia and gram negative bacteremia of
unclear etiology// Sight of infection
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) Spiral Acquisition 5.9 s, 77.7 cm; CTDIvol = 5.6 mGy (Body) DLP = 436.8
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 18.3 mGy (Body) DLP =
9.1 mGy-cm.
Total DLP (Body) = 447 mGy-cm.
COMPARISON: CT torso with contrast ___, CT abdomen and pelvis
with contrast ___
FINDINGS:
CHEST: Thyroid is unremarkable. Supraclavicular, axillary, mediastinal, and
hilar lymph nodes are not pathologically enlarged. Thoracic aorta and main
pulmonary artery are normal caliber. There is no pericardial effusion.
There is no pleural effusion. Numerous micronodules and ground-glass
opacities are demonstrated in bilateral lungs. Bronchiectasis is present in
bilateral lower lobes and right middle lobe. 1.8 cm area of atelectasis is
noted in the right middle lobe.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Multiple subcentimeter hypodense lesions are identified in the liver, similar
to ___. 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: Numerous hypodense lesions in the spleen are similar to before.
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.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus and bilateral adnexa are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: No suspicious soft tissue lesions identified.
IMPRESSION:
1. Numerous micronodules and ground-glass opacities in bilateral lungs with
bibasal bronchiectasis are consistent with suspected fungal infection.
2. Numerous hypodense lesions in the liver and spleen are nonspecific but may
related to fungal septicemia given that there were not present on the MR
enterography dated ___. Cysts and/or hemangiomas are thought to
be less likely.
Radiology Report
INDICATION: ___ year old woman who requires chronic IV KCl, admitted for
candidemia/pseudomonas putida bacteremia likely from prior l ___ site.
Requires antibiotics so could not have line holiday but had midline placed 1
week ago. BCx cleared, now needs ongoing IV access// please place L picc- pt
prefers to be seen by female provider or male provider w/ female chaperone
COMPARISON: No relevant comparisons available.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 2, 5 mGy
PROCEDURE:
1. Double lumen PICC placement through the left brachial vein.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the left
brachial vein was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A double lumen PIC line measuring 40 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Brachialvein approach double lumen left PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a left 40 cm brachial approach double lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Radiology Report
INDICATION: ___ year old woman with complicated ENT history, extreme
malnutrition.// G-J placement
COMPARISON: CT of the abdomen/pelvis from ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: General anesthesia administered by the anesthesia department.
MEDICATIONS: None
CONTRAST: 40 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 14.3 minute, 35 mGy
PROCEDURE: 1. Placement of a MIC gastrojejunostomy tube.
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. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilutecontrast. The needle trajectory
was directed towards the pylorus. A ___ wire was introduced and coiled
within the stomach. A small skin incision was made along the needle and the
needle was removed.
A 6 ___ sheath was placed. A Kumpe catheter was then introduced over the
wire and the ___ was exchanged for a Glidewire. The Glidewire and a Kumpe
cathter was used to advance the wire into the ___ part of the duodenum. The
Glidewire was then exchanged for an stiff Glidewire wire. The sheath was then
removed and after serial fascial dilation a 20 ___ peel-away sheath was
placed over the wire. A 16 ___ MIC gastrojejunostomy catheter was advanced
over the wire into position. The sheath was then peeled away.
The wire and sheath were removed. The catheter was locked by instilling 7 ml
of dilute contrast into the balloon in the stomach after confirming the
position of the catheter with a contrast injection. The catheter was then
flushed, capped and secured to the skin with 0-silk sutures. Sterile dressings
were applied. The patient tolerated the procedure well and there were
noimmediate complications.
FINDINGS:
1. Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip
in the proximal jejunum.
IMPRESSION:
Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in
the proximal jejunum. The gastric port should not be used for 24 hours.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Positive blood cultures
Diagnosed with Bacteremia
temperature: 98.1
heartrate: 66.0
resprate: 18.0
o2sat: 95.0
sbp: 124.0
dbp: 59.0
level of pain: 10
level of acuity: 3.0 | SUSUMMARY STATEMENT:
====================
___ woman with a complex past medical history including
___ vs ___ Syndrome, dysautonomia/POTS,
regional complex pain syndrome, partial stump of epiglottis and
absent uvula, bronchiectasis, anxiety, depression, PTSD, eating
disorder presenting with positive blood cultures which were
collected by her outpatient hematologist ___ the workup of
chronic hypergammaglobulinemia. She was treated with antibiotics
and antifungals for her ___ fungemia and Pseudomonas
bacteremia for line associated bacteremia (negative TEE). She
also underwent a 10d course of vancomycin for a nasal aspirate
growing MRSA. Due to ongoing issues with nutrition and poor p.o.
intake, GJ tube was placed on ___ and tube feeds were
initiated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Neurontin / Elavil
Attending: ___.
Chief Complaint:
Chief Complaint: abdominal pain
Reason for MICU transfer: HTN, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y F with PMH significant for DCIS s/p lumpectomy, right
carotid artery stenosis s/p CEA ___, anemia, and significant
chronic abdominal pain s/p cholecystectomy in ___. She was in
her usual state of health until the day prior to her chornic
pain appointment on ___, when she had severe abdominal pain
which was different from her typical abdominal pain, as well as
a headache. During that visit she had elevated SBP in the 190s,
but declined to go to the ED at that time. Over the past few
days she has also noticed difficulty fully voiding. On ___ her
abdominal pain remained severe and she presented to the ED. Per
report, she was rigoring at presentation with SBP up to 220 and
severe abdominal pain. A foley catheter was placed for distended
bladder seen on U/S, which drained 500 cc urine. She was given
Lorazepam, Acetaminophen and a single dose of 1mg Hydromorphone
for her severe pain, and metoprolol for continued tachycardia.
She has not had fevers/chills, diarrhea, N/V, or dysuria leading
up to this presentation, and denies taking her medications other
than as directed or ingesting any other substances.
In terms of her chronic abdominal pain, it began in ___ after
an open chole. She had previously been on oxycodone/oxycontin
until an inpatient detox program at ___ and since then
has been off opiates including suboxone. She currently takes
amitiza, laxatives, duloxetine, and donnatal for her pain. In
reading through OMR, multiple physicians as well as her partner
have been concerned about her lethary/slow speech on these
medications.
In the ED, initial vitals: 98.5 98 192/113 20 100% RA
Labs notable for: lactate 1.8, normal LFTs, tox positive for
barbituates. Phenoba: 5.5.
Imaging:
CT head: no acute process
Chest xray: no evidence of infection
CT abdomen: pending
EKG: sinus tach, normal intervals, no ST changes
Consults called: Toxicology
Recommendations: " Her physical exam findings do not fit with an
anticholinergic or serotonergic toxidrome. Per OMR, patient uses
barbituates and benzos for chronic pain and we suspect she may
be withdrawing. Please check a phenobarb level. Recommend
benzodiazepine administration for agitation and tachycardia. If
patient does not improve, recommend barbituate administration."
She received: 11 mg lorazepam, 1 L LR, and metoprolol for
continued tachycardia.
On arrival to the FICU, she is somnulent and lethargic but
following commands and answering questions appropriately. She
complains of exhaustion, but no pain, chest pain, or SOB.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
-left-sided DCIS
-history of SVT
-osteopenia
-migraine headaches
-hypertension
-colonic adenoma
-tobacco use for many years (now discontinued)
-admission in ___ for acute cholangitis complicated by SIADH
and narcotics withdrawal, status post open cholecystectomy and
since then, chronic abdominal pain for which she has undergone
multiple
extensive evaluations.
Ampullary stenosis, increased LFTs, EUS ___ stable mild
PD/CBD dilation, ampulla biopsy normal.
Iron deficiency anemia-avms/duod/jejunum-IV iron ___
Social History:
___
Family History:
Family hx of CAD in mother/father, and hx of stroke in the
family.
She has eight sisters and four brothers. She has a brother with
a history of a stroke and CABG, one sister had a stroke and a
CABG. Another sister died of HIV from drugs, her grandmother
may have had colon cancer, she died with a bowel obstruction.
Her mother had diabetes. Her father had constipation and died.
Mother died from cardiac disease at ___, grandmother bowel
obstruction.
Physical Exam:
ADMISSION:
Vitals: T: afebrile BP: 100/62 P: 74 R: 18 O2: 100% RA
GENERAL: somnulent, arousable, A+O x 3, NAD, very slow speech
HEENT: pupils equal and reactive, mildly dilated, no nsystagmus
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB
CV: RRR, no murmurs
ABD: normoactive BS, soft, non-distended, mildly tender to
palpation in epigastric region
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: no hyperreflexia, no muscle rigidity, no clonus, Toes
down going on Babinski exam. Frequent twitching of facial
muscles (mentioned in prior outpatient notes as well).
Pertinent Results:
Admission Labs:
___ 12:00PM BLOOD WBC-9.0 RBC-4.27# Hgb-12.4# Hct-35.6*#
MCV-83 MCH-29.0 MCHC-34.8 RDW-18.0* Plt ___
___ 12:00PM BLOOD Neuts-68.9 ___ Monos-7.1 Eos-0.5
Baso-0.2
___ 12:00PM BLOOD ___ PTT-27.2 ___
___ 12:00PM BLOOD Glucose-111* UreaN-10 Creat-0.9 Na-132*
K-3.9 Cl-94* HCO3-21* AnGap-21*
___ 12:00PM BLOOD ALT-33 AST-33 LD(LDH)-183 CK(CPK)-63
AlkPhos-73 TotBili-0.3
___ 12:00PM BLOOD Lipase-31
___ 12:00PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD Albumin-4.8
___ 12:00PM BLOOD Phenoba-5.5*
___ 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:54PM BLOOD ___ pO2-33* pCO2-51* pH-7.36
calTCO2-30 Base XS-1
___ 12:23PM BLOOD Lactate-1.8
___ 05:54PM BLOOD Lactate-1.1
___ 10:30AM URINE Color-Straw Appear-Clear Sp ___
___ 10:30AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 10:30AM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 10:30AM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Pertinent Labs:
___ 01:18AM BLOOD ALT-40 AST-77* AlkPhos-77 TotBili-0.3
___ 02:19AM BLOOD TSH-1.4
___ 02:19AM BLOOD Cortsol-32.9*
___ 12:00PM BLOOD Phenoba-5.5*
Discharge Labs:
Imaging/Reports:
CHEST X-RAY ___: FINDINGS:
The cardiac hand mediastinal silhouettes are stable. Lungs are
relatively hyperinflated. No focal consolidation is seen.
There is no pleural effusion or pneumothorax.
HEAD CT ___:
There is no evidence of hemorrhage, acute major infarction,
large mass, edema, or shift of normally midline structures.
Mild prominence of the ventricles and sulci is compatible with
age related involutional change. Subtle periventricular white
matter hypodensity is compatible with the sequelae of chronic
small vessel ischemia. The visualized paranasal sinuses and
mastoid air cells are clear. The globes and bony orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. White matter small vessel ischemic change and age-appropriate
involutional change.
ABDOMINAL CT ___:
LUNG BASES:
Streaky opacities at the dependent portions of the lung bases
are most
compatible with subsegmental atelectasis. Otherwise, the
partially imaged lung bases are clear. There is no pleural or
pericardial effusion.
CT ABDOMEN: The liver enhances homogeneously without evidence of
focal lesion. The portal vein is patent. There is diffuse
intrahepatic biliary ductal dilation. The gallbladder is
surgically absent. An additional, there is marked common duct
dilation to 10 mm, increased from most recent CT from ___. The common duct ends abruptly at the sphincter
of Oddi. There is no demonstrable periampullary mass on the
current examination.
The gallbladder surgically absent. The pancreas enhances
homogeneously
without evidence of peripancreatic stranding. There is a
mildlyprominent
main pancreatic duct measuring up to 3 mm in the pancreatic
body/tail. The spleen and adrenal glands are unremarkable.
There is normal symmetric renal enhancement. There is no
evidence of hydronephrosis.
Nondilated small bowel loops are normal in course caliber
without evidence of wall thickening or obstruction. The colon
is unremarkable. The appendix is not directly seen, however
there are no secondary signs of appendicitis. There is no free
intraperitoneal air or fluid.
The abdominal aorta is normal in caliber without evidence of
aneurysm or
dilation. Major proximal tributaries appear patent. Mixed
atherosclerotic disease is most prominent infrarenal abdominal
aorta. There appears to be compression of the left renal vein
in between the abdominal aorta and the SMA ; additionally, there
are dilated left perirenal varices as well as a dilated left
gonadal vein and which is continuous inferiorly with multiple
dilated left-sided pelvic veins. These findings are consistent
with ___ syndrome.
There is no retroperitoneal or mesenteric lymphadenopathy by CT
size criteria.
CT PELVIS:
The uterus is either atrophic, or surgically absent. A Foley
catheter balloon is inflated in the bladder lumen. Otherwise,
the imaged pelvic organs including the bladder and terminal
ureters are unremarkable. Pelvic floor descent it also noted.
As above, multiple dilated enhancing left pelvic veins are
noted. There is no pelvic sidewall or inguinal lymphadenopathy
by CT size criteria. There is a trace amount of free pelvic
fluid.
MUSCULOSKELETAL:
There is mild multilevel thoracolumbar spine degenerative
change, with disc height loss, endplate sclerosis, and anterior
osteophytes. Alignment is normal. No focal lytic or sclerotic
osseous lesions are seen.
IMPRESSION:
1. Interval increase in diffuse marked intrahepatic biliary
ductal dilation, as well as interval increase in CBD dilation,
currently 10 mm. Mildly prominent main pancreatic duct. There
is no evidence of periampullary mass though MRCP may be
performed to further assess.
2. Compression of the left renal vein with dilated left
perirenal varices, a dilated left gonadal vein, and dilated left
pelvic veins, compatible with nutcracker syndrome. Please
correlate for pelvic congestion syndrome.
3. No evidence of obstruction or incarceration.
4. Status post cholecystectomy.
5. Pelvic floor descent.
abdominal u/s:
IMPRESSION:
Normal renal ultrasound with Doppler spectral analysis.
No ultrasound evidence of renal artery stenosis.
.
MRI brain:
IMPRESSION:
1. No acute infarction.
2. Two tiny chronic infarcts in the left cerebellar hemisphere.
Extensive supratentorial white matter and pontine signal
abnormalities are nonspecific but likely sequela of chronic
small vessel ischemic disease in a patient of this age.
prior CT chest ___:
IMPRESSION:
1. ___ year stability of biapical pleural nodularity and small
pulmonary nodules can be attributed to benign pleural
parenchymal scarring. No evidence of intra thoracic malignancy.
2. Worsened ___ nodularity with mucous plugging and
areas of scarring in the left lower lobe likely related to
aspiration.
3. Small pericardial effusion increased from ___.
.
___:19
Metanephrines (Plasma)
Test Name Flag Results Units
Reference Value
--------- ---- ------- -----
---------------
Metanephrines, Fract., Free
Normetanephrine, Free H 3.5 nmol/L <
0.90
Metanephrine, Free 0.47 nmol/L <
0.50
METANEPHRINES, FRACTIONATED, 24HR URINE
Test Result Reference
Range/Units
24 HR URINE VOLUME 550 mL
METANEPHRINE 166 90-315 mcg/24
h
This specimen was submitted with a pH greater
than 5.0. Optimum pH for this assay is 1.0-5.0.
Improper preservation may compromise the validity
of the assay.
Test Result Reference
Range/Units
NORMETANEPHRINE ___ mcg/24
h
METANEPHRINES, TOTAL ___ mcg/24
h
CATECHOLAMINES
Test Result Reference
Range/Units
24 HR URINE VOLUME 550 mL
EPINEPHRINE, 24 HR URINE 32 H ___ mcg/24 h
NOREPINEPHRINE, 24 ___ 89 ___ mcg/24
h
CALCULATED TOTAL (E+NE) 121 ___ mcg/24
h
DOPAMINE, 24 HR URINE 1133 H 52-480 mcg/24
h
CREATININE, 24 HOUR URINE 0.55 L 0.63-2.50 g/24
h
___ 02:19
Metanephrines (Plasma)
Test Name Flag Results Units
Reference Value
--------- ---- ------- -----
---------------
Metanephrines, Fract., Free
Normetanephrine, Free H 3.5 nmol/L <
0.90
Metanephrine, Free 0.47 nmol/L <
0.50
Performing Site:
___
___
Lab Director: ___, M.D., Ph.D.
Comment: HEM # 138T ___
___ 05:45AM BLOOD WBC-7.5 RBC-3.28* Hgb-9.4* Hct-30.0*
MCV-92 MCH-28.7 MCHC-31.3* RDW-18.5* RDWSD-61.7* Plt ___
___ 05:45AM BLOOD Glucose-89 UreaN-15 Creat-0.7 Na-136
K-4.0 Cl-98 HCO3-29 AnGap-13
___ 01:18AM BLOOD ALT-40 AST-77* AlkPhos-77 TotBili-0.3
___ 12:00PM BLOOD Lipase-31
___ 12:00PM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD calTIBC-242* Ferritn-360* TRF-186*
___ 02:19AM BLOOD TSH-1.4
___ 02:19AM BLOOD Cortsol-32.9*
___ 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:53PM BLOOD Lactate-1.4
___ 02:19AM BLOOD Metanephrines (Plasma)-Test Name
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Duloxetine 40 mg PO DAILY
3. esomeprazole magnesium 40 mg oral BID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Lorazepam 1 mg PO Q8H:PRN anxiety
6. Lorazepam 2 mg PO QHS
7. Lubiprostone 24 mcg PO BID
8. Metoprolol Tartrate 25 mg PO BID
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Donnatal (phenobarb-hyoscy-atropine-scop) 16.2 mg-0.1037
mg/5 mL (5 mL) oral TID
11. Polyethylene Glycol 34 g PO DAILY
12. RISperidone 1 mg PO BID
13. TraZODone 50 mg PO QHS
14. Aspirin 81 mg PO DAILY
15. Calcium Carbonate 1000 mg PO QID
16. Vitamin D ___ UNIT PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Senna 8.6 mg PO BID
19. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 1000 mg PO QID
3. Duloxetine 20 mg PO DAILY
continue at 20mg x2 weeks. Then, increase by 20mg every 2 weeks
to 60mg
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Metoprolol Tartrate 25 mg PO BID
6. Senna 8.6 mg PO BID
7. TraZODone 50 mg PO QHS
8. Simethicone 40-80 mg PO QID:PRN bloating, gas
9. QUEtiapine Fumarate 12.5 mg PO QHS
10. QUEtiapine Fumarate 12.5 mg PO BID:PRN anxiety
continue to monitor QTC interval on this medication
11. Acetaminophen 650 mg PO Q6H
12. Docusate Sodium 100 mg PO BID
13. Atorvastatin 20 mg PO QPM
14. esomeprazole magnesium 40 mg oral BID
15. Lubiprostone 24 mcg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Polyethylene Glycol 34 g PO DAILY
18. Vitamin B Complex 1 CAP PO DAILY
19. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
anxiety
drug withdrawal
chronic abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with abdominal pain and rigors, please r/o PNA
or infectious process. // r/o infection
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
The cardiac hand mediastinal silhouettes are stable. Lungs are relatively
hyperinflated. No focal consolidation is seen. There is no pleural effusion
or pneumothorax.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: Abdominal pain. Evaluate for colitis.
TECHNIQUE: Contiguous axial multidetector CT images through the abdomen and
pelvis with intravenous contrast. Multiplanar reformations were generated and
reviewed.
Total DLP (Body) = 305 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LUNG BASES:
Streaky opacities at the dependent portions of the lung bases are most
compatible with subsegmental atelectasis. Otherwise, the partially imaged
lung bases are clear. There is no pleural or pericardial effusion.
CT ABDOMEN:
The liver enhances homogeneously without evidence of focal lesion. The portal
vein is patent. There is diffuse intrahepatic biliary ductal dilation. The
gallbladder is surgically absent. An additional, there is marked common duct
dilation to 10 mm, increased from most recent CT from ___. The
common duct ends abruptly at the sphincter of Oddi. There is no demonstrable
periampullary mass on the current examination.
The gallbladder surgically absent. The pancreas enhances homogeneously
without evidence of peripancreatic stranding. There is a mildly prominent
main pancreatic duct measuring up to 3 mm in the pancreatic body/tail. The
spleen and adrenal glands are unremarkable. There is normal symmetric renal
enhancement. There is no evidence of hydronephrosis.
Nondilated small bowel loops are normal in course caliber without evidence of
wall thickening or obstruction. The colon is unremarkable. The appendix is
not directly seen, however there are no secondary signs of appendicitis.
There is no free intraperitoneal air or fluid.
The abdominal aorta is normal in caliber without evidence of aneurysm or
dilation. Major proximal tributaries appear patent. Mixed atherosclerotic
disease is most prominent infrarenal abdominal aorta. There appears to be
compression of the left renal vein in between the abdominal aorta and the SMA
; additionally, there are dilated left perirenal varices as well as a dilated
left gonadal vein and which is continuous inferiorly with multiple dilated
left-sided pelvic veins. These findings are consistent with nutcracker
syndrome.
There is no retroperitoneal or mesenteric lymphadenopathy by CT size criteria.
CT PELVIS:
The uterus is either atrophic, or surgically absent. A Foley catheter balloon
is inflated in the bladder lumen. Otherwise, the imaged pelvic organs
including the bladder and terminal ureters are unremarkable. Pelvic floor
descent it also noted. As above, multiple dilated enhancing left pelvic veins
are noted. There is no pelvic sidewall or inguinal lymphadenopathy by CT size
criteria. There is a trace amount of free pelvic fluid.
MUSCULOSKELETAL:
There is mild multilevel thoracolumbar spine degenerative change, with disc
height loss, endplate sclerosis, and anterior osteophytes. Alignment is
normal. No focal lytic or sclerotic osseous lesions are seen.
IMPRESSION:
1. Interval increase in diffuse marked intrahepatic biliary ductal dilation,
as well as interval increase in CBD dilation, currently 10 mm. Mildly
prominent main pancreatic duct. There is no evidence of periampullary mass
though MRCP may be performed to further assess.
2. Compression of the left renal vein with dilated left perirenal varices, a
dilated left gonadal vein, and dilated left pelvic veins, compatible with
nutcracker syndrome. Please correlate for pelvic congestion syndrome.
3. No evidence of obstruction or incarceration.
4. Status post cholecystectomy.
5. Pelvic floor descent.
RECOMMENDATION(S): Recommend MRCP for further evaluation of etiology of
diffuse intra- and extra-hepatic biliary ductal dilation, increased from prior
exams.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with altered mental status, unclear cause.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 897 mGy-cm.
COMPARISON: Head CT without contrast ___..
FINDINGS:
There is no evidence of hemorrhage, acute major infarction, large mass, edema,
or shift of normally midline structures. Mild prominence of the ventricles
and sulci is compatible with age related involutional change. Subtle
periventricular white matter hypodensity is compatible with the sequelae of
chronic small vessel ischemia. The visualized paranasal sinuses and mastoid
air cells are clear. The globes and bony orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. White matter small vessel ischemic change and age-appropriate involutional
change.
Radiology Report
EXAMINATION: RENAL DOPPLER ULTRASOUND.
INDICATION: ___ woman with hypertension and tachycardia, evaluate
for renal artery stenosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Comparison is made to abdominal and pelvic CT from ___.
FINDINGS:
The right kidney measures 11.3 cm. The left kidney measures 11.1 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is decompressed.
DOPPLER: The main renal veins are patent bilaterally. The intrarenal
arteries demonstrate normal waveforms with resistive indices of 0.62, 0.61,
and 0.73 and 0.61, 0.68, and 0.71 in the upper, mid, and lower pole intrarenal
arteries in the right and left kidney, respectively. The main renal arteries
are patent bilaterally with peak systolic velocities of 89.8 cm/second on the
right and 47.9 cm/second on the left.
IMPRESSION:
Normal renal ultrasound with Doppler spectral analysis.
No ultrasound evidence of renal artery stenosis.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with cognitive decline after recent right
carotid endarterectomy. Evaluate for ischemia.
TECHNIQUE: Sagittal T1 weighted, and axial T1 weighted, T2 weighted, FLAIR,
gradient echo, and diffusion-weighted images of the brain were obtained.
Following intravenous gadolinium administration, axial T1 weighted images of
the brain and sagittal MPRAGE images of the brain with multiplanar
reformations were obtained.
COMPARISON: Noncontrast head CTs from ___, ___.
FINDINGS:
There is no acute infarction, edema, mass effect, or evidence for blood
products. There is no evidence for an intracranial mass, and no pathologic
pachymeningeal or leptomeningeal contrast enhancement. There are 2 tiny
chronic infarcts in the left cerebellar hemisphere, image 8:6. There are
numerous foci of high T2 signal in the subcortical, deep, and periventricular
white matter of the cerebral hemispheres, as well as in the pons, which are
nonspecific but likely sequela of chronic small vessel ischemic disease in a
patient of this age. Ventricles, sylvian fissures, and cerebral sulci are
prominent due to cerebral atrophy, similar to prior CTs.
Major arterial flow voids are grossly preserved. Major dural venous sinuses
are patent on postcontrast MP RAGE images.
Right mastoid air cells are partially opacified. There is a small mucous
retention cyst in the right maxillary sinus. Left sphenoid sinus is small due
to asymmetric insertion of the sphenoid septum and partially opacified.
IMPRESSION:
1. No acute infarction.
2. Two tiny chronic infarcts in the left cerebellar hemisphere. Extensive
supratentorial white matter and pontine signal abnormalities are nonspecific
but likely sequela of chronic small vessel ischemic disease in a patient of
this age.
Radiology Report
INDICATION: History of biliary dilation abdominal pain. Evaluate for mass or
cause of biliary dilation.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: Gadavist 4 cc.
COMPARISON: CT of the abdomen and pelvis from ___. CT of the
abdomen from ___.
FINDINGS:
Liver: The liver is normal in shape and contour. The liver parenchyma has low
signal on the T2 weighted images. Additionally, there is lower signal in the
liver on the in phase images when compared to the out of phase images. This
is consistent with iron deposition. Similar findings are noted in the spleen
and bone marrow, though not in the pancreas. This is consistent with
hemosiderosis. There are no morphologic changes in the liver to suggest
cirrhosis or fibrosis. No focal lesions are identified. Evaluation for the
presence of fat is limited. The portal veins are patent.
Biliary: There is prominence of the intra and extrahepatic biliary duct
dilation. The common bile duct measures up to 8 mm. It appears slightly less
marked that on the prior CT. There is no evidence of a stricture or beading
of the bile ducts. There is no wall thickening or surrounding inflammation.
There is no choledocholithiasis. The distal CBD tapers appropriately, without
evidence of an ampullary mass. The patient is status post a cholecystectomy.
Pancreas: The pancreatic parenchyma enhances homogeneously. There are no
pancreatic masses or duct dilation.
Spleen: The spleen is normal in size, measuring 10.3 cm. Like in the liver,
there is low signal on the T2 weighted images and drop of signal on the in
phase imaging, compatible with iron deposition. No focal lesions are
identified.
Adrenal Glands: The bilateral adrenal glands are normal.
Kidneys: In the left kidney, there are several sub-5-mm T2 hyperintense
lesions, compatible with simple cysts. No worrisome renal lesions are
identified. There is no hydronephrosis. The kidneys enhance symmetrically.
Gastrointestinal Tract: The imaged portions of the large and small bowel are
within normal limits. There is no ascites.
Lymph Nodes: There is no periportal, mesenteric, or retroperitoneal
lymphadenopathy.
Vasculature: The abdominal aorta is normal in caliber without evidence of an
aneurysm.
Osseous and Soft Tissue Structures: No worrisome osseous lesions are
identified. The soft tissues are unremarkable.
IMPRESSION:
1. Hemosiderosis. No morphologic abnormalities in the liver to suggest
cirrhosis or fibrosis. No focal liver lesions.
2. Prominent intra and extrahepatic bile ducts, though within the range of
the upper limits of normal after cholecystectomy. No choledocholithiasis or
evidence of an ampullary mass.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 3:20 ___, 5 minutes after discovery of the findings.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Hypertension, Abd pain
Diagnosed with ALTERED MENTAL STATUS , HYPOTENSION NOS
temperature: 98.5
heartrate: 98.0
resprate: 20.0
o2sat: 100.0
sbp: 192.0
dbp: 113.0
level of pain: 0
level of acuity: 2.0 | ___ y F with PMH significant for chronic abdominal pain who
presented to the ED with severe abdominal pain as well as
hypertension with SBPs in the 200s, concerning for
barbituate/benzo withdrawal vs serotonin syndrome.
# AMS/Toxidrome concerning for barbituate/benzodiazepine
withdrawl: Patient presented with slow speech, agitation and
severe fidgiting on arrival to the ED, most concerning for
barbibuate/benzo withdrawl secondary to inconisitent medication
use and possible overuse. She was treated with ativan in the ED.
She was also notably hypertensive (systolic 190-200s) and
tachycardic (130-150s) with concerns of serotonin syndrome
secondary to either cymbalta, trazadone, and recent restart of
risperidone. However the rest of her exam was inconsistent with
this, she was not flushed/diaphoretic/hyperthermic. There were
also features consistent with anticholinergic toxidrome given
her urinary retension. Her u-tox was positive for barbituates,
and she has long hx of barbituate/benzo use. Toxicology was
consulted and recommended phenobarb protocol. She was initially
treated with ativan PRN. Patient continued to be agitated,
tachycardic and hypertensive. She was started on a phenobarbital
protocol. After receiving first dose of phenobarb she became
unresponsive briefly and bp drop to ___. placed in tberg. back
to baseline mentation and up to 120s systolics. She did require
a rescue dose for continued tachycardia, tremors and
hypertension. Metoprolol was restarted for possible beta-blocker
withdrawl however patient became hypotensive and it was
discontinued. Toxicology recommended precedex and the patients
tachycardia improved to the 100s. Patient continued to have
intermittent insomnia and agitation that was contolled with
trazadone x1, hydroxyzine and haldol PRN. Toxicology did not
thing she fit into any diagnostic category and felt that she may
still be withdrawing from benzodiazepines. They recommended
quick taper of phenobarbital. Pt's symptoms improved with
completion of phenobarbitol taper.
# Labile blood pressures- hypertension and hypotension: patient
had presented with blood pressure acutely elevated in the
setting of either withdrawal or serotonin sydrome. She had SBPs
in the 190s at outpatient visit on ___, but declined ED workup
at that time and was asymptomatic, and she had SBPs in the 200s
on arrival to the ED. She takes metoprolol at home and had been
normotensive on prior outpt visits. In the ED on ___ she had a
headache, no focal neuro findings on exam and no acute process
seen on ED head CT. EKG without ST changes, creatinine normal.
Patient was treated with ativan, phenobarbital, precedex and
metoprolol as per above. She intermittently became hypotensive
to the ___ notably while sleeping. She did have one brief
episode of being unresponsive. Episodes impoved with fluid
boluses. Work up was started for possible endocrine issues. TSH
was normal. Cortisol was elevated. Likely to be normal stress
response however there were concerns about pheochromocytoma.
Plasma metanephrines elevated but, 24h urine metanephrines and
catecholamines were ordered and were unrevealing. Renal artery
ultrasound: no evidence of stenosis. Can consider endocrine
consultation and further work up prn. Blood pressure and heart
rate remained stable and consistent while on the medical floor.
#?Concern for possible pheochromocytoma-See above. Pt with
labile blood pressures. AFter much thought and discussion, this
was felt to be more likely related to stress response, anxiety,
and withdrawal. She did have plasma metanephrines tested that
showed one small elevation. 24hr urine for normetanephrines and
metanephrines was within normal limits. She had a fractionated
urine analysis that revealed elevated dopamine. Her testing is
hard to interpret in the setting of drug withdrawal, anxiety,
and being on psychactive drugs/TCAs including risperidol,
trazodone, and duloxetine. In addition, she had a CT scan of the
abdomen/pelvis that showed unremarkable adrenal glands. She
was/is also on betablockers. Ideally, this study should be
repeated when off psychoactive medications for 2 weeks. However,
this may not be feasible or possible. Therefore, would recommend
repeating these studies and consideration of endocrinology
referral and/or further work up. BP/HR stable while on the
medical floor after treatment for withdrawal.
# Acute on chronic abdominal pain: patient had some crampy
abdominal pain which was epigastric in nature, different from
her chronic abdominal pain. ___ be secondary to urinary
retention, as she has had several days of difficulty voiding and
a distended bladder on u/s. However her abdominal imaging showed
dilated biliary tree which was new. Outpatient GI doctor recs
___ consult for recent changes in biliary tree. ERCP was
consulted and recommended follow up once patient stabilized from
possible withdrawl. Patients chronic abdominal pain has been
treated with a varitey of medications in the past. She was
started on tylenol and lidocaine patch. Given maalox and
simethicone PRN. Acute pain services was consulted would not
recommend ketamine given AMS as sympathetic stimulant, would not
recommend nerve block as pain is not consistent with this, could
try lidocaine ointment. Recommended further workup of abdominal
pain. MRCP and/or ERCP to be considered after treatment of acute
issues. MRCP was done prior to discharge but final results were
PENDING.
# Urinary retention: several days of difficulty voiding prior to
admission, bladder distended on arrival to the ED, foley was
placed thought to be due to anticholindergic side effect.
Patient had foley pulled and tolerated well. Cultures were
negative.
# Anxiety/insomnia/Psych/?somatoform disorder: on ativan,
trazadone, and recently restarted risperidone. Medications were
held. Ativan was given PRN. Psych was consulted and recommended
holding off medications till phenobarbital taper completed.
Outpatient psychiatrist Dr. ___ ___
___ rehab. He sees her weekly and she is always very
distressed, very anxious, and taking meds erraticaly. Psychiatry
recommended reiki, prn seroquel for anxiety/insomnia, cymbalta
20mg daily x2 weeks with plan to uptitrate 20mg q2weeks as pt
tolerates to treat for depression, anxiety, pain. Consideration
of accupuncture vs. biofeedback. Pt was also recommended to f/u
at advanced pain management care at ___.
.
#?cognitive deficits-suggest formal neurocognitive testing.
Brain MRI revealed concern for possible small vessel disease and
old infarcts.
.
#HTN-controlled with home metoprolol.
TRANSITIONAL ISSUES:
# f/u final MRCP report and continue GI f/u and work up for
abdominal pain. Pt has GI f/u arranged.
#pt was worked up for possible pheochromocytoma. Please see labs
above. Please consider need for endocrine referral. Would repeat
this evaluation after pt has been stabilized and/or if HTN/HR
issues arise again. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Nsaids / Sulfa (Sulfonamide Antibiotics) / Ranitidine / Adhesive
Attending: ___.
Chief Complaint:
SBO I/s/o past Roux-en-Y gastric bypass
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F w/ hx of roux-en-y gastric bypass in ___ by Dr. ___ SBO. Patient she ate a meal of filet mignon and asparagus
and
shortly therafter developed obstructive symptoms. She reports 2
episodes of emesis, but has passed gas and had 2 bowel movements
in the past 48 hours. She presented to ___ ED intitially
because of her significant abdominal pain. The patient at the
outside hospital received pain medication and then had a CT scan
performed which shows that there is a small bowel obstruction
proximal to the J-J anastomosis, with no free fluid noted. She
denies fevers, chills, SOB, or other systemic symptoms.
Past Medical History:
PMH: DM1 (insulin pump), HTN, retinopathy, HLD, Graves (s/p
radioactive iodine, now hypothyroid), OSA (no CPAP), gastritis,
GERD, iron-deficiency anemia, stress urinary incontinence, PCOS
PSH: lap CCY ___, rotator cuff ___, b/l CTR ___, b/l knee
arthroscopy ___, R knee surgery ___, wisdom teeth ___, b/l
myringotomies ___, T+A ___, umbilical hernia repair with mesh
Social History:
___
Family History:
She has no family history as she is adopted.
Physical Exam:
DISCHARGE EXAM:
GEN: A&Ox3, NAD, resting comfortably
HEENT: NCAT, EOMI, sclera anicteric.
PULM: no respiratory distress
ABD: soft, nontender, ND, no rebound or guarding
EXT: warm, well-perfused, no edema
PSYCH: normal insight, memory, and mood
Pertinent Results:
Please see OMR for pertinent results.
Medications on Admission:
___:
Humalog 100 unit/mL subcutaneous (self regulate)
Prevacid SoluTab 30', Levoxyl 88 mcg', oxycodone 5 mg/5 mL,
Pepcid AC 10', spironolactone 25', Biotin 1', CaCO3, Cetirizine
10',
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
2. OxycoDONE Liquid ___ mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg/5 mL ___ ml by mouth q6h prn Refills:*0
3. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: ___
Fingersticks: Q6H, if NPO
MD acknowledges patient competent
MD has ordered ___ consult
MD has completed competency
4. Pantoprazole 40 mg PO Q24H
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: CHEST (SINGLE VIEW)
INDICATION: Tube placement
TECHNIQUE: 2 frontal views of the chest
COMPARISON: None.
FINDINGS:
The lungs are clear.
The cardio-mediastinal silhouette is unremarkable.
No significant pleural effusion or pneumothorax.
NG tube tip is at least in the distal stomach, but the tip is not visualized
as it extends outside the film.
IMPRESSION:
No acute pulmonary disease. The NG tube tip is off the film, but at least in
the distal stomach.
Radiology Report
EXAMINATION: CT-SECOND OPINION CT TORSO
INDICATION: ___ Roux-en-Y gastric bypass p/w bd pain with no written report
from OSH c/w SBO, unclear location.// SBO with R-en-Y gastric bypass, unclear
location. CT ___ opinion ED read was placed 3AM (5 hours ago)
TECHNIQUE: Contrast enhanced images of the abdomen and pelvis were obtained.
Coronal and sagittal reformats were performed.
Oral contrast was not administered.
DOSE: Acquisiton at outside hospital.
COMPARISON: ___, MR enterography dated ___
FINDINGS:
LOWER CHEST: The lung bases are clear aside from bibasilar dependent
atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is mild intrahepatic biliary
ductal dilatation as well as prominence of the common bile duct, which
measures up to 1.1 cm, which may be related to prior cholecystectomy.
Findings are essentially similar to the prior MR enterography. The
gallbladder is absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: There is mild nodular thickening of the left adrenal gland,
unchanged since prior MR enterography. The right adrenal gland is
unremarkable.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A subcentimeter hypodensity in the interpolar region of the left kidney is too
small to characterize, but may represent a cyst. There is no perinephric
abnormality.
GASTROINTESTINAL: The patient is status post Roux-en-Y gastric bypass. The
biliary limb of the bypass is decompressed. The jejunal limb of the gastric
bypass is dilated to up to 4 cm, presumed to be a chronic process. Fecalized
intraluminal contents noted at the mid portion of this bowel segment
(602:41-50) as it approaches the J-J anastomosis, and given an abrupt superior
turn of the this limb at the point where the fecalized contents end
(approximately 18 cm proximal to the J-J anastomosis) and there is dilated but
nondistended, thick-walled small bowel leading to the jejunojejunal
anastomosis in the left mid abdomen (for example 3:282) distal to which the
small bowel is entirely decompressed. The J-J anastomosis itself does not
appear strictured. The colon is unremarkable. Cecal diverticulum is noted.
The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. Small pelvic
free fluid is noted.
REPRODUCTIVE ORGANS: The uterus is unremarkable. A Nuvaring is in place.
There are no adnexal masses.
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: Mild multilevel degenerative changes are seen in the lower thoracic and
lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Status post Roux-en-Y gastric bypass.
2. There is dilation of the jejunal (Roux) limb to up to 4 cm, with region of
focal fecalization suggesting obstruction; transitioning approximately 18 cm
proximal to the J-J anastomosis to non-fecalized but somewhat patulous bowel.
This might be secondary to adhesion at the transition. Beyond this
anastomosis, the small bowel is not abnormally distended.
3. Stable central intrahepatic biliary ductal dilatation as well as prominence
of the common bile duct, likely postsurgical.
Radiology Report
EXAMINATION: UPPER GI WITH SMALL-BOWEL FOLLOW-THROUGH
INDICATION: ___ year old woman s/p RnY w/ SBO.// obstruction status vs
resolution. Please use gastrograffin contrast.
TECHNIQUE: Initial scout radiographs of the abdomen were obtained. Following
ingestion of Gastrografin, radiographs and spot fluoroscopic images were
obtained during the transit of barium through the esophagus, remnant stomach
and small-bowel.
DOSE: Acc air kerma: 14.0 mGy; Accum DAP: 309.7 uGym2; Fluoro time: 01:05
COMPARISON: Second opinion CT torso from ___.
FINDINGS:
PO Gastrografin passed readily through the esophagus, remnant stomach and into
the small bowel.
Additional Gastrografin contrast was administered through the patient's nasal
jejunal tube. Contrast quickly advanced into distal small bowel loops,
without evidence of obstruction. No focal strictures were seen.
The nasojejunal tube was partly withdrawn by Dr. ___ of the
surgical team, under fluoroscopic guidance, with the final tube position
demonstrated to be in the proximal jejunal portion of the Roux limb.
IMPRESSION:
1. No evidence of gastrointestinal obstruction or focal stricture.
2. Final position of the nasojejunal tube is in the proximal jejunal portion
of the Roux limb.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SBO, Transfer
Diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst
temperature: 96.9
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 138.0
dbp: 70.0
level of pain: 5/8
level of acuity: 3.0 | Ms. ___ is a ___ female with a history of a
Roux-en-Y gastric bypass (Dr. ___ ___ who presents the
emergency department on ___ with abdominal pain concerning
for small bowel obstruction (alimentary limb proximal to the JJ
anastomosis).
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of nausea and vomiting.
Admission CT revealed a small bowel obstruction in the
alimentary limb proximal to the JJ anastomosis. The patient was
admitted to the ___ bariatric surgery service, was made
n.p.o., was given IV fluids, and NG tube was placed in the ED.
overnight, the patient had mild episode of hypoglycemia to the
___, and the ___ diabetes service was consulted to help with
management of patient's insulin pump. Insulin dosage was
subsequently decreased by 20%.
On hospital day 2, the patient underwent a upper GI series which
was negative for obstruction. The patient was advanced to
bariatric 3 diet, NG tube was discontinued, and the patient's IV
was hep-locked.
Throughout her stay, Ms. ___ nausea medications via
her IV, and was given IV pain medications that were subsequently
converted to oral. Pain was well-controlled throughout her
hospitalization.
At the time of discharge on hospital day 3, the patient was
doing well, afebrile with stable vital signs. The patient was
tolerating her stage III diet, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
___: L2-L3 Level Interlaminar Epidural Steroid Injection
History of Present Illness:
Mr. ___ is a ___ gentleman with a history of
chronic lumbosacral radiculopathy s/p laminectomy x2 and R L4
tranforaminal epidural steroid injection ___ who presents
with acute on chronic right lower back pain radiating down the
leg after twisting to the right yesterday. He underwent an
injection 2 days ago with some relief, then yesterday when
bending down and reaching for a towel he twisted to the right
and developed acute worsening of pain. He denies fall. The
pain worsened throughout the day and worsens with
movement/walking. He reports subjective weakness of his leg and
pain with bearing weight. He also reports numbness/tingling
along his right hip/thigh. Patient denies urinary retention or
incontinence or saddle anesthesia. He has tried Percocet with
no relief.
Patient takes Percocet for pain at home and is on a narcotics
agreement. He has required multimodal analgesia (gabapentin,
oxycodone, trazadone, and anti-inflammatories) and has been
diagnosed with "failed back surgery syndrome." He underwent
spinal cord stimulator phase 1 implant in ___ with no
improvement after 1 week (the implant was later removed). His
next pain clinic injection is scheduled for ___.
- In the ED, initial vitals were: Pain 10 T 96.9 HR 67 BP 140/71
RR 20 95% RA.
- Exam was notable for absence of saddle anesthesia and normal
rectal tone.
- He received: Dilaudid 1 mg x2, Morphine 5 mg x2, ketorolac 30
mg x1, Zofran 4 mg z1, and Diazepam 5 mg x1.
- Vitals on transfer: Pain 8 HR 68 BP 135/77 RR 14 99% RA
On the floor, patient reports ___ right low back pain
radiating down the side and front of his leg.
Past Medical History:
Chronic low back pain on a narcotics contract
ETOH dependence
Hypertension
Hyperlipidemia
___ Esophagus
Left L5 Hemilaminectomy and L4/L5, L5S1 foraminotomies on
___: L3-L4 radiculopathy secondary to right-sided disc
extrusion
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: Afebrile, non-tachycardic, not hypoxic
General: Alert, oriented, curled on left side, appears
uncomfortable but in 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
Back: Tenderness to palpation along right lumbar spinous
processes and right lumbar paraspinal muscles. R SLR reproduced
right low back pain but no radiation of pain. L SLR negative.
Neuro: CNIII-XII intact, sensation intact and symmetric
bilaterally, ___ strength lower extremities though limited by
pain, gait deferred.
DISCHARGE EXAM
==============
Tm 98.1, 133/68, 59-73, 16, 98% on RA.
General: A&O x3, lying in bed on left side, pleasant affect.
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, no rebound or
guarding.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Back: Tenderness to palpation superior to right buttock. No
spinous process tenderness.
Neuro: ___ strength lower extremities though limited by pain of
the right leg. ___ strength to plantar flexion and dorsiflexion.
Positive straight leg raise on right. Sensation decreased on the
lateral aspect of the right thigh which has been stable.
Sensation intact in bilateal lower extremities otherwise.
Pertinent Results:
ADMISSION LABS:
================
___ 08:45PM BLOOD WBC-9.6 RBC-4.88 Hgb-15.4 Hct-43.0
MCV-88# MCH-31.6 MCHC-35.9*# RDW-13.0 Plt ___
___ 08:45PM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-141
K-4.0 Cl-103 HCO3-22 AnGap-20
___ 08:45PM BLOOD Calcium-9.3 Phos-3.4 Mg-1.7
DISCHARGE LABS
===============
___ 04:00AM BLOOD WBC-7.2 RBC-4.68 Hgb-15.0 Hct-41.9 MCV-90
MCH-32.0 MCHC-35.7* RDW-13.0 Plt ___
___ 05:10AM BLOOD ___ PTT-27.7 ___
___ 04:00AM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-139
K-3.9 Cl-100 HCO3-28 AnGap-15
___ 04:00AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0
IMAGING/STUDIES:
=================
___: MR ___ WITHOUT CONTRAST
IMPRESSION:
1. New L3-L4 disc extrusion superimposed on disc bulge with
bilateral facet arthropathy and ligamentum flavum thickening
also noted at this level. Findings result in moderate spinal
canal narrowing, bilateral neural foraminal narrowing right
greater than left, and mass effect on the bilateral traversing
nerve roots and right exiting L3 nerve root.
2. Disc herniations at L4-L5 and L5-S1 slightly more pronounced
than on prior study without significant spinal canal stenosis.
Left greater than right neural foraminal narrowing is noted at
these levels.
3. Nonspecific T2/STIR signal in the facet joints at L3-L4
which is likely related to degenerative changes at this same
level although inflammation or infection cannot be entirely
excluded given the history of prior surgery/procedures.
Correlate clinically and followup as needed.
Limited assessment on the noncontrast study. No obvious large
fluid
collections.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST
INDICATION: ___ year old man with chronic lumbosacral radiculopathy s/p
laminectomy x2 and R L4 tranforaminal epidural steroid injection ___ who
presents with acute on chronic right lower back pain radiating down the leg
// Any evidence of disk herniation? Any evidence of disk herniation?
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed.
COMPARISON: Most recent prior MRI of the lumbar spine dated ___.
FINDINGS:
Numbering used a shown on series 2, image 10.
Patient is status post laminectomy from L3-L4 through L5-S1.
There is unchanged grade 1 retrolisthesis of L5 on S1. There is a small amount
of bone marrow edema involving the posterior inferior endplate of the L3
vertebral body. There are mixed ___ type 1 and 2 degenerative endplate
changes at L5-S1.
There is loss of normal intervertebral disc signal and height from L3-L4
through L5-S1 most pronounced at L5-S1.
Vacuum disc phenomenon is also noted at L5-S1.
The conus is normal in configuration and signal in terminates at the L1 level.
At T11-T12: Mild diffuse disc bulge, with anterior component causing mild
displacement of the anterior longitudinal ligament.
No significant canal or foraminal narrowing.
At L1-L2, there is no disc herniation, spinal canal stenosis, or neural
foraminal narrowing.
At L2-L3, there is mild diffuse disc bulge with bilateral facet arthropathy
and fluid in the facet joints.
There is no significant spinal canal stenosis or neural foraminal narrowing.
At L3-L4, there is a disc bulge with a superimposed new central disc extrusion
which migrates superiorly posterior to the inferior endplate of the L3
vertebral body. There is resultant moderate spinal canal narrowing with mass
effect on the bilateral traversing nerve roots. Disc material extends into
the right greater than left neural foramen resulting in severe right and
moderate left neural foraminal narrowing and mass effect on the exiting right
L3 nerve root. There is also bilateral facet arthropathy with small amount of
fluid in the facet joints and small synovial cysts and ligamentum flavum
thickening at this level. There is abnormal nonspecific elevated signal seen
involving the bilateral facet joints.
Status post bilateral laminectomy.
At L4-L5, there is diffuse disc bulge with a small superimposed central disc
protrusion which appears slightly more pronounced than on prior study. There
is no significant spinal canal stenosis. There is bilateral facet arthropathy
with fluid in the facet joints and resultant mild right and moderate left
neural foraminal narrowing.
At L5-S1, there is diffuse disc bulge asymmetric to the left with a
superimposed central disc extrusion which migrates inferiorly posterior to the
S1 vertebral body. This finding appears slightly more pronounced than on prior
study.
There is no significant spinal canal stenosis at this level. There is
bilateral facet arthropathy with fluid in the facet joints and resultant mild
-moderate bilateral neural foraminal narrowing.
There are expected postsurgical changes in the posterior soft tissues most
notable at L4-L5 and L5-S1 from prior surgery and also recent facet injection.
Limited assessment on the noncontrast study.
Fatty infiltration of the posterior paraspinous muscles, with marked atrophy,
in the lower lumbar region, similar to the prior study.
Paraspinal soft tissues are otherwise unremarkable. No obvious large fluid
collections.
IMPRESSION:
1. New L3-L4 disc extrusion superimposed on disc bulge with bilateral facet
arthropathy and ligamentum flavum thickening also noted at this level.
Findings result in moderate spinal canal narrowing, bilateral neural foraminal
narrowing right greater than left, and mass effect on the bilateral traversing
nerve roots and right exiting L3 nerve root.
2. Disc herniations at L4-L5 and L5-S1 slightly more pronounced than on prior
study without significant spinal canal stenosis. Left greater than right
neural foraminal narrowing is noted at these levels.
3. Nonspecific T2/STIR signal in the facet joints at L3-L4 which is likely
related to degenerative changes at this same level although inflammation or
infection cannot be entirely excluded given the history of prior surgery
/procedures.
Correlate clinically and followup as needed.
Limited assessment on the noncontrast study. No obvious large fluid
collections.
Spine consult can be considered
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R Hip pain
Diagnosed with BACKACHE NOS
temperature: 96.9
heartrate: 67.0
resprate: 20.0
o2sat: 95.0
sbp: 140.0
dbp: 71.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ gentleman with a history of
chronic lumbosacral radiculopathy s/p laminectomy x2 and R L4
tranforaminal epidural steroid injection ___, on a
narcotics contract, who presents with acute on chronic right low
back pain radiating down the leg after twisting to the right,
admitted for pain control, who underwent MRI L ___ without
Contrast which showed "new L3-L4 disc extrusion superimposed on
disc bulge."
# Radiculopathy Secondary New L3-L4 Disc Extrusion: Patient
presented with acute onset right back with radiation down the
leg after twisting to the right. Initial examination showed
rectal tone was normal, no saddle anesthesia, no bladder/bowel
incontinence. He did, however, have paresthesias on thee lateral
aspect of the right thigh. Given history of degenerative disc
disease, there was concern for progression of the disc disease.
Patient underwent an MRI of the Lumbar ___ on ___ per
recommendation of his outpatient providers which showed "new
L3-L4 disc extrusion superimposed on disc bulge with bialteral
facet arthropathy and ligamentum flavum thickening also noted at
this level. Findings result in moderate spinal canal narrowing,
bilateral nueral foraminal narrowing right greater than left,
and mass effect on the bilateral traversing nerve roots and
right exiting L3 nerve root." Given these findings, patient was
seen by chronic pain management as well as ___ Surgery. ___
Surgery did not believe there was need for surgical intervention
given these findings. They plan to follow-up with him with Dr.
___ in approximately two weeks following discharge from the
hospital. Chronic Pain Management evaluated patient and started
a pain regimen of acetaminophen 1000 mg PO Q8H, diazepam 5 mg PO
TID, hydromorphone ___ mg PO Q4H:PRN, lidocaine patch, ibuprofen
400 mg q8 hours prn pain. This helped improve his pain
moderately and he was able to walk with a walker, although
limited by pain. For further pain management, he underwent an
L2-L3 interlaminar epidural steroid injection by Chronic Pain
Services on ___. Although he did not have "weakness"
(walking limited by pain), he was evaluated by Physical Therapy
who recommended rehabilitation given pain he was experiencing.
#Depression: Stable. Continued on fluoxetine 20 mg PO daily.
#Gastroesophageal Reflux Disease: Continued omeprazole 20 mg PO
BID.
#Hypertension: Stable. Continued atenolol 25 mg PO daily.
TRANSITIONAL ISSUES
===================
#Will require outpatient follow-up with Dr. ___ of
___ Surgery within the next two weeks. phone ___
#Adjustments to pain medication regimen: These adjustement were
made per Chronic Pain Service Recommendations: Tylenol ___ mg
PO Q8H, Diazepam 5 mg PO TID, Gabapentin 600 mg PO TID,
Hydromorphone ___ mg PO Q4H:PRN pain, Lidocaine patch, ibuprofen
400 mg q8 hours prn pain.
#CODE: Full code
#CONTACT: Wife (___): ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fluid overload
Major Surgical or Invasive Procedure:
PICC Line Placement
Temporary HD line placement
Tunnelled HD Line Placement
Peritoneal Dialysis Catheter Placement
History of Present Illness:
Mr. ___ is a ___ year old man with DM1 on insulin pump, CAD
s/p CABG, sCHF (EF 20%) s/p ICD, CKD (baseline Cr ~ 2.5)
presented to the ED on ___ with 26lb weight gain, leg
swelling, decreased urine output despite taking his usual dose
of diuretic. He denies dyspnea, but he notes worsening
orthopnea. Denies chest pain.
Baseline weight is 188 lbs post diuresis after hospitalization
in ___ for CHF exacerbation. Discharge weight of 208 lbs from
most recent discharge on ___, and patient was instructed to
increase torsemide to 60 mg daily for continued outpatient
diuresis, but he failed this regimen as an outpatient with
weight gain and decreased urine output. At baseline he can clime
13 stairs without dyspnea, now he must stop half way to catch
his breath. He has worsening swelling, and claims he can lay
flat, but prefers to sleep in a recliner. Dr. ___
cardiologist) requested admission to ___ for inpatient
monitoring and diuresis.
In the ED, initial vitals were 97.6 66 103/55 18 100% RA. Exam
was notable for JVP elevated to ear, faint bibasilar crackles,
3+ ___ edema. CXR with mild pulmonary edema. BNP was elevated to
___. He was given lasix 40 mg IV x 1 with good response and
sent to the cardiology service for further management.
On arrival to the floor, vital signs were 97.7 118/92 -> 92/66
72 18 92-98%RA. On review of systems, he denies history of
stroke, TIA, deep venous thrombosis, pulmonary embolism, fevers,
chills or rigors. 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 (___): LIMA to LAD, SVG to OM and PDA
- Systolic heart failure, LVEF 30%, s/p ICD/BiV pacer (___)
- Hypertension
- Hyperlipidemia
- Diabetes mellitus, type 1 (on insulin pump). Complicated by
peripheral neuropathy, cataracts.
- CKD, baseline creatinine 2.4
- Anemia of chronic disease
- Bursitis
- Gout
- GERD
- C. diff ___ treated with metronidazole
Social History:
___
Family History:
- Father: Died from CAD/CHF at age ___.
- Mother: Died of MI at age ___.
- Brother: Died of renal failure, had diabetes.
- No history of cancer
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS:.7 118/92 -> 92/66 72 18 92-98%RA
General: Well apparing sitting comfortably in bed
HEENT: No jaundice, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP to ear at 90 degrees
CV: RRR nl S1/S2, no murmurs appreciated, no rubs
Lungs: Faint bibasilar rales, good air movement, unlabored
breathing
Abdomen: Soft, NT, NT
Ext: 2+ pitting edema bilaterally up to knees, sacral edema
Neuro: AAO x3,
Pulses: 2+ DP
DISCHARGE PHYSICAL EXAM:
VS: 97.6, 103/60, 79, 18, 100%RA
IO 24h: 550/650
IO 8h: 400/475
Weight: 97.1 kg (admit) -> 96.9 -> 96.8 -> 95.9 --> 95.8 -->
95.1 --> 94.8 --> 94.1 --> 92.4kg --> 94.7kg ----> 91.4kg -->
92.1kg -> 93.3kg -> 92.4kg -> 92.9kg -> 93.5kg --> 93.8kg [dry
wt 85.3kg)
General: NAD
HEENT: MMM, OP clear
Neck: supple, JVP at mid neck with pt upright
CV: RRR normal S1 and S2, no MRG
Lungs: LCTA-bl, no w/r/r
Abdomen: Soft, nontender, nondistended
Ext: 3+ edema to knees. ___ waxy appearance with chronic venous
stasis changes/erythema.
Pertinent Results:
Admission labs:
___ 01:20PM BLOOD WBC-6.2 RBC-3.61* Hgb-9.3* Hct-30.8*
MCV-85 MCH-25.8* MCHC-30.2* RDW-18.4* Plt ___
___ 01:20PM BLOOD Neuts-80* Bands-0 Lymphs-6* Monos-7
Eos-7* Baso-0 ___ Myelos-0
___ 01:20PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
Acantho-OCCASIONAL
___ 01:20PM BLOOD Glucose-121* UreaN-85* Creat-2.8* Na-130*
K-5.1 Cl-90* HCO3-28 AnGap-17
___ 01:20PM BLOOD ___
___ 07:20AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.7*
Other Relevant Labs:
___ 01:20PM BLOOD ___
___ 05:02PM BLOOD ___
___ 05:23PM BLOOD ___ pO2-31* pCO2-51* pH-7.47*
calTCO2-38* Base XS-11
___ 03:35PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 03:35PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
Discharge labs:
___ 04:30AM BLOOD WBC-5.1 RBC-3.17* Hgb-7.7* Hct-25.6*
MCV-81* MCH-24.4* MCHC-30.2* RDW-18.6* Plt ___
___ 05:18AM BLOOD ___ PTT-33.8 ___
___ 04:30AM BLOOD Glucose-133* UreaN-67* Creat-3.2* Na-131*
K-4.6 Cl-93* HCO3-22 AnGap-21*
___ 04:30AM BLOOD Calcium-8.4 Phos-5.5* Mg-2.6
Studies:
___ CXR:
Left-sided pacemaker device is noted with leads terminating in
the right atrium, right ventricle, and coronary sinus. The
patient is status post median sternotomy and CABG. The cardiac
silhouette size is moderately enlarged. The mediastinal and
hilar contours are within normal limits and unchanged. There is
minimal pulmonary vascular congestion. Blunting of the
costophrenic angles posteriorly on the lateral view is chronic
and compatible with small effusions. There is no pneumothorax.
There are mild degenerative changes in the thoracic spine.
IMPRESSION:
Mild pulmonary vascular congestion and trace bilateral pleural
effusions.
___ CXR:
The right PICC line tip is at the level of mid SVC.
Biventricular pacer leads are in appropriate position. Heart
size and mediastinum are unchanged. There is slight interval
progression of interstitial pulmonary edema, in particular
toward the lower lobes. Pleural effusion is not evident,
although right costophrenic angle was not included in the field
of view. There is no pneumothorax. The study and the report
were reviewed by the staff radiologist.
___ RENAL US:
FINDINGS: The right kidney measures 10.9 cm and the left kidney
measures 10.3cm. Both kidneys are echogenic. There is no
evidence of hydronephrosis, stones or concerning masses. The
bladder is well distended and trabeculated in appearance.
IMPRESSION:
1. Echogenic kidneys compatible with medical renal disease.
2. Trabeculated bladder suggests chronic outflow tract
obstruction.
Prior studies:
___ TTE:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is moderately dilated. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated with severe global
hypokinesis/near akinesis. The basal inferolateral and basal
anterior walls contract best (LVEF = 20 %). 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 moderate
global free wall hypokinesis. 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 aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen.
IMPRESSION: Biventrcular cavity enlargement with severe
biventricular systolic dysfunction c/w multivessel CAD or other
diffuse process. Mild moderate mitral regurgitation. Pulmonary
artery hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Docusate Sodium 200 mg PO BID
4. Finasteride 5 mg PO DAILY
5. FoLIC Acid ___ mcg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Polyethylene Glycol 17 g PO BID
8. Pravastatin 40 mg PO HS
9. Torsemide 60 mg PO DAILY
10. Fluocinonide 0.05% Cream 1 Appl TP TID:PRN puritis
11. Vitamin D 1000 UNIT PO DAILY
12. Bisacodyl 10 mg PO DAILY:PRN Constipation
13. Carvedilol 3.125 mg PO BID
14. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal rate minimum: 0.7 units/hr
Basal rate maximum: 1.5 units/hr
Bolus minimum: 1U:18g units
Bolus maximum: 1U:15g units
Target glucose: 80-180
15. Ferrous Sulfate 325 mg PO DAILY
16. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN Constipation
4. Docusate Sodium 200 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fluocinonide 0.05% Cream 1 Appl TP TID:PRN puritis
8. FoLIC Acid ___ mcg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO BID
11. Pravastatin 40 mg PO HS
12. Tamsulosin 0.4 mg PO HS
13. Vitamin D 1000 UNIT PO DAILY
14. ___ hospital bed
Patient has a medical condition which requires positioning of
the body not feasible in an ordinary bed to allieviate pain:
systolic CHF, CKD with severe volume overload
15. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal Rates:
Midnight - 4AM: .9 Units/Hr
4AM - 8AM: .9 Units/Hr
8AM - 12PM: .7 Units/Hr
12PM - 12AM: 1 Units/Hr
Meal Bolus Rates:
Breakfast = 1:15
Lunch = 1:18
Dinner = 1:18
Snacks = 1:18
High Bolus:
Correction Factor = 1:50
Correct To ___ mg/dL
16. Torsemide 100 mg PO BID
RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
17. Lactulose 15 mL PO DAILY
RX *lactulose 10 gram/15 mL (15 mL) 10 gram by mouth twice a day
Disp #*500 Milliliter Refills:*0
18. Metolazone 5 mg PO BID
RX *metolazone 5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
19. Senna 1 TAB PO BID
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
20. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
- Acute on chronic systolic heart failure (EF 20%)
- Acute on chronic kidney injury
Secondary diagnoses:
- CAD, s/p CABG (___): LIMA to LAD, SVG to OM and PDA
- Systolic heart failure, LVEF 30%, s/p ICD/BiV pacer (___)
- Hypertension
- Hyperlipidemia
- Diabetes mellitus, type 1 (on insulin pump). Complicated by
peripheral neuropathy, cataracts.
- CKD, baseline creatinine 2.4
- Anemia of chronic disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Worsening shortness of breath.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Left-sided pacemaker device is noted with leads terminating in the right
atrium, right ventricle, and coronary sinus. The patient is status post
median sternotomy and CABG. The cardiac silhouette size is moderately
enlarged. The mediastinal and hilar contours are within normal limits and
unchanged. There is minimal pulmonary vascular congestion. Blunting of the
costophrenic angles posteriorly on the lateral view is chronic and compatible
with small effusions. There is no pneumothorax. There are mild degenerative
changes in the thoracic spine.
IMPRESSION:
Mild pulmonary vascular congestion and trace bilateral pleural effusions.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with new PICC line
placement.
AP radiograph of the chest was reviewed in comparison to ___.
The right PICC line tip is at the level of mid SVC. Biventricular pacer leads
are in appropriate position. Heart size and mediastinum are unchanged. There
is slight interval progression of interstitial pulmonary edema, in particular
toward the lower lobes. Pleural effusion is not evident, although right
costophrenic angle was not included in the field of view. There is no
pneumothorax.
Radiology Report
HISTORY: History of CKD and decompensated CHF. Question structural
abnormality.
COMPARISON: Renal ultrasound from ___.
TECHNIQUE: Renal Ultrasound.
FINDINGS: The right kidney measures 10.9 cm and the left kidney measures 10.3
cm. Both kidneys are echogenic. There is no evidence of hydronephrosis,
stones or concerning masses. The bladder is well distended and trabeculated
in appearance.
IMPRESSION:
1. Echogenic kidneys compatible with medical renal disease.
2. Trabeculated bladder suggests chronic outflow tract obstruction.
Radiology Report
PROCEDURE: Placement of right-sided temporary hemodialysis catheter via the
right internal jugular vein.
HISTORY: ___ male with history of coronary artery disease and
congestive cardiac failure, requires CVVH.
COMPARISON: Reference is made to a recent chest x-ray of ___.
OPERATORS: Dr. ___ (attending) performed the procedure.
MEDICATION: Patient received 1 mg of Versed. 5 cc of 1% buffered lidocaine
to the skin overlying the right internal jugular vein.
PROCEDURE NOTE IN DETAIL: Informed consent was obtained outlining the risks
and benefits of the proposed procedure. The patient was then brought to the
angiography suite and placed supine on the imaging table. The right side of
neck was prepped and draped in the usual sterile fashion. A preprocedure
timeout was performed as per ___ protocol.
Under real-time ultrasound guidance, using a freehand technique, the patent
and compressible right internal jugular vein was accessed using a
micropuncture needle. An 0.018 wire was easily advanced into the right side
of the heart under fluoroscopic guidance. The needle was removed and
exchanged for a 4.5 ___ micropuncture sheath. The 0.018 wire was exchanged
via the micropuncture sheath for an 0.035 ___ wire, which was advanced into
the IVC for stability. A 2-mm incision was made using an 11 blade. Under
fluoroscopic guidance, the venotomy tract was dilated using 12 and 14 ___
dilators. Following dilatation, a 14 ___ x 15 cm temporary hemodialysis
catheter was advanced with the tip positioned at the cavoatrial junction. The
catheter was secured to the patient's skin using 0 silk sutures and a sterile
dressing was applied. Both ports flushed and aspirated normally and the line
was primed as per protocol.
Overall, the patient tolerated the procedure well and there were no early
complications.
IMPRESSION: Uncomplicated placement of a 14 ___ x 15 cm right-sided
temporary hemodialysis catheter via the right internal jugular vein. The tip
lies at the cavoatrial junction and the catheter may be used for therapy
immediately.
Radiology Report
HISTORY: Fluid overload, renal failure.
COMPARISON: ___.
TECHNIQUE: Portable frontal chest radiograph, single view.
FINDINGS: Moderate cardiomegaly is unchanged from prior examination. The
mediastinal contour is unremarkable. A new consolidation at the right lung
base may represent asymmetric pulmonary edema, although it appears out of
proportion to only mild central pulmonary vascular congestion with relative
lack of interstitial edema elsewhere. A right internal jugular wide-bore
catheter terminates at the level of the mid SVC. A left anterior chest wall
ICD remains in position with unchanged position of the intracardiac as well as
a single extracardiac lead. This extracardiac lead follows a somewhat
tortuous path but is unchanged since at least ___. There is no
pleural effusion or pneumothorax.
IMPRESSION: New focal consolidation at the right lung base which may
represent asymmetric edema, although it appears out of proportion to mild
central vascular congestion and lack of interstitial edema favoring a
diagnosis of pneumonia.
Results were discussed over the telephone with Dr. ___ by Dr.
___ at 11:40AM on ___ at time of initial review.
Radiology Report
HISTORY: ___ male with CHF and plan for peritoneal dialysis catheter.
Evaluate for ascites.
COMPARISON: ___ abdominal ultrasound.
FINDINGS:
Limited 4 quadrant ultrasound examination was performed to evaluate for
ascites. There is trace ascites in the left upper quadrant adjacent to the
spleen ending in the right upper quadrant adjacent to the liver. No ascites
is appreciated in the lower quadrants.
IMPRESSION:
Trace ascites, not sufficient for drainage, in the upper quadrants.
Radiology Report
INDICATION: ___ man with CHF, awaiting placement of PD catheter.
CLINICIANS: Dr. ___ and Dr. ___ performed the
procedure.
ANESTHESIA: Sedation was provided by administrating divided doses of 0.5 mg
of Versed, 50 mcg of fentanyl throughout the total intraservice time of 40
minutes during which patient's hemodynamic parameters were continuously
monitored.
Local anesthesia was provided by using 5 cc of 1% lidocaine to the dermis and
5 cc of 1% lidocaine with epinephrine into the subcutaneous tissues.
PROCEDURE: Written informed consent was obtained. The patient was witnessed
by one additional physician. This was performed after explaining the risk,
benefits, alternatives and indications of the procedure.
The patient was transported to the angiography suite and placed supine on the
imaging table. The right neck and existing catheter was prepped and draped in
usual sterile fashion. A preprocedural huddle and timeout was performed per
___ protocol.
An 035 ___ wire was advanced into the superior vena cava via the existing
temporary hemodialysis catheter via the right internal jugular vein. The
measurements were made for skin incision four fingerbreadths below the
venotomy site. The wire was then advanced into the RA.
Attention was now turned to creation of a subcutaneous tunnel. After
additional local anesthesia, 1 cm skin incision was made. A 15.5F ___
tunneled catheter was passed from the incision to the venotomy site with the
aid of a metal tunneling device. A ___ Peel-away sheath was passed over the
wire. The wire and inner cannula were removed and the catheter was passed
through the peel-away sheath. The peel-away sheath was removed while the
catheter was pushed into the right atrium. This was confirmed with
fluoroscopy, demonstrating the catheter tip in the right atrium. Both lumens
withdrew blood and flushed easily. Catheter was secured with 0 silk sutures.
The dermatatomy over the IJ access was closed with two Vicryl subcuticular
stitch. Dry sterile dressings were applied. No immediate post-procedure
complications were noted. The line was primed as per protocol.
Overall, the patient tolerated the procedure well and there were no early
complications.
IMPRESSION: Uncomplicated placement of a 15.5 ___ x 27 cm right-sided
hemodialysis catheter via existing catheter access in the right internal
jugular vein. The tip lies at the right atrium and the catheter may be used
for therapy immediately.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WEIGHT GAIN
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, RENAL & URETERAL DIS NOS
temperature: 97.6
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 103.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with DM1 on insulin pump, CAD
s/p CABG, sCHF (EF 20%; s/p ICD), CKD (baseline Cr ~ 2.5), who
presented ___ with 26 lb weight gain, leg swelling,
decreased urine output despite taking his usual dose of
diuretic, admitted to cardiology for diuresis and inpatient
monitoring.
# Acute on chronic systolic heart failure (EF 30%):
Baseline weight was reported to be 188lbs [85.3kg] post diuresis
after hospitalization in ___ for CHF exacerbation, and
discharge weight was 208 lbs from most recent admission ___.
Patient was instructed to increase torsemide to 60 mg daily for
continued diuresis as an outpatient and to follow up with Dr.
___ continued to gain weight and was 97.1kg on this
admission. During admission, he was started on a lasix drip
(titrated up to 40mg/hr), in addition to metolazone 10mg po
dailt and spironolactone 12.5mg po daily without adequate
diuresis. Dopamine was then started at 2.5mcg/kg/hr. Pt
continued to have limited progress with diuresis and actually
began to gain weight. He underwent placement of a temporary HD
line and underwent CVVH starting on ___. This was complicated
by episodes of hypotension (systolic BP ~80s). Subsequently, a
tunnelled RIJ HD catheter was placed (___) and pt underwent
several sessions of HD. He developed severe leg cramping which
limited diuresis. To decrease fluid/electrolyte shifts, it was
decided that peritoneal dialysis was likely to be the best
option. Pt underwent placement of peritoneal dialysis catheter
on ___. Plan was to wait several days for catheter to become
more ingrained in the tissue and to initiate PD on an outpatient
basis on ___. In the interim, goal was for patient to have
stable weight and, to facilitate this, he was given high doses
of fiuretic (torsemide 100mg po bid and metolazone 5mg po bid).
In addition, he continued to receive Aspirin EC 81 mg PO DAILY.
Carvedilol 3.125 mg PO BID, imdur 60mg po daily, and hydralazine
10 po q8h were held, given episodes of hypotension. He was
discharged on low-dose metoprolol. Tunnelled HD catheter
remained in place in case pt were to require urgent HD while
awaiting maturation of PD catheter.
# Acute on chronic kidney injury:
Patient's baseline Cr is 2.5. Patient's Cr on admission was 2.8.
Most likely secondary to CHF, as above.
# Hyponatremia: Sodium of 130 on admission in the setting of
volume overload from heart failure, above. Na remained stably
low in the 129-130 range during diuresis.
# DM1: Patient's last A1c of 6.2 % two months prior to
admission. He was continued on his insulin pump with assistance
___ consultants.
# Anemia: Baseline HCT approximately 30. Most likely secondary
to CKD. Patient also found to be iron deficiency with Iron
studies at OSH howed iron of 23, TIBC 385, and IBC of 408, with
% saturation of 5, c/w iron deficiency anemia. Guaiac negative.
Normal colonoscopy in ___. He was continued on ferrous sulfate
325 mg daily.
# Hyperlipidemia: Continued pravastatin.
# Subclinical Hypothyroidism: Patient had TSH of 12.7, but free
T4 of 1.26.
# BPH: Previously on finasteride. He had improvement in
symptoms after additional of tamsulosin at OSH on previous
admission. Continued finasteride and tamsulosin.
# Gout: Continued allopurinol.
# GERD: Continued pantoprazole.
# Transitional issues:
- Code: Full (confirmed ___
- Contact: Wife ___ (h) ___ (c)
- Discharge weight: 93.8kg [dry wt reported 85.3kg)
- Follow up with urology for his BPH (may be a candidate for
TURP) and nephrologist for his CKD.
- Please consider further investiagation of cause of
Fe-deficiency anemia
- Please note, Carvedilol 3.125 mg PO BID, imdur 60mg po daily,
and hydralazine 10 po q8h were held due to hypotension; pt was
discharged on Metoprolol XL 25mg po daily; please consider
starting spironolactone and re-starting anti-HTN medications as
necessary.
- Please repeat TFTs on follow-up
- Please continue to address pt's anxiety and emotional
exhaustion in setting of severe CHF requiring PD
- Please note, pt believes that BPH and constipation contribute
to his hypervolemia; bladder scan was consistently negative
post-void; please reassure pt with regard to BPH and continue
aggressive bowel regimen
- Please repeat Chem10 at follow-up given active attempt at
diuresis
- Please ensure removal of tunneled RIJ HD catheter if PD is
successful |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracycline / Ativan
Attending: ___.
Chief Complaint:
abdominal pain, nausea, emesis
Major Surgical or Invasive Procedure:
___ - Endoscopic retrograde cholangiopancreatography
History of Present Illness:
This is a ___ year-old Male with a PMH significant for chronic
lower extremity pain syndrome (on narcotics), HTN, OSA (not on
CPAP), chronic constipation and undefined asymptomatic cardiac
septal defect who presented with acute onset abdominal pain,
nausea and emesis for 1-day who was found to have evidence of
gallstone pancreatitis and transferred from ___ for
further management.
.
The patient notes that he awoke feeling well on ___ and ate
a hotdog for lunch without issues; however, within an hour of
consumption he felt nausea and generalized malaise with chills.
Following these symptoms, he developed epigastric abdominal pain
that was ___ in intensity, that was intermittent and achy-dull
in character radiating through to his back. He notes that he had
a similar pain after breakfast a week prior to this episode; but
never before that. The patient also notes associated
non-bilious, non-bloody emesis surrounding his nausea. He denies
fevers. No unintentional weight loss. He notes yellowing of the
skin. He denies headache or vision changes. No loose or bloody
stools, notes recent constipation issues (last BM morning of
admission to OSH was dark, formed and non-bloody). Around 7PM,
his pain worsened and he presented to ___. Of note,
he has had on-going, bilateral proximal lower extremity pain
issues that has been managed for several months with Percocet
(previously with Celecoxib) and recent he started Prednisone 15
mg PO daily with some improvement.
.
At ___, the patient arrived with VS 98.2 75 169/83
22 94% RA. Exam was notable for epigastric abdominal pain and
yellowing of the skin. Laboratory studies notable for WBC 12.6
(86.9% neutrophilia, no bandemia), HCT 47.5%, PLT 161.
Creatinine 0.87. LFTs: AST 446, ALT 413, AP 59, T-bili 3.8 with
lipase 639. Troponin 0.01. U/A negative. A CT abdomen and pelvis
demonstrated multiple gallstones, a prominent gallbladder
measured to 9-cm with mild stranding. There was also mild
pancreas stranding without evidence of small bowel obstruction.
He received 1L NS x 3, Zosyn 3.375 g IV x 1, Morphine 8 mg IV x
1 and Fentanyl 100 mcg IV x 1 for pain control; he received
Zofran 4 mg IV x 2, Protonix 80 mg IV x 1 with infusion
following. He also received Benadryl 25 mg IV x 1,
Metoclopramide 10 mg IV x 1 and given his recent steroid use,
Hydrocortisone 100 mg IV x 1. He was transferred to ___ for
further management and ERCP team evaluation.
.
In the ___ ED, initial VS 100.5 82 182/84 18 98%RA. Exam
notable for improved abdominal pain. Laboratory data notable for
WBC 9.6 (neutrophilia 89%), HCT 45.7, PLT 173. Creatinine 0.8.
INR 1.2. LFTs: AST 452, ALT 512, AP 73, T-bili 4.1, Albumin 0.8,
lipase 645. Lactate 2.1. An EKG demonstrated NSR @ 85, NA/NI,
IVCD, no ST-changes. ERCP fellow evaluated patient and agreed
with transfer for urgent ERCP needs. He received Dilaudid 2 mg
IV x 1, Zofran 4 mg IV x 1 and a Foley catheter was placed prior
to transfer. He received 1L NS x 2. Vitals prior to transfer,
97.9 149/79 81 15 95%RA.
.
On arrival to ___, he appears non-toxic and stable. He has some
epigastric abdominal complaints with mild nausea.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Chronic proximal lower extremity pain (on chronic narcotic
therapy, has trialed Celecoxib and recently started Prednisone
treatment)
2. Hypertension
3. Chronic constipation (given narcotic use)
4. Septal defect in myocardium (stable since childhood, serially
monitored with 2D-Echo)
5. Obstructive sleep apnea (does not tolerate CPAP use)
6. Hypogonadism
7. s/p appendectomy (years prior)
Social History:
___
Family History:
Mother had lung cancer; father with gallstones and aggressive
thyroid carcinoma. No strong cardiovascular history or history
of other malignancies.
Physical Exam:
ADMISSION EXAM:
.
VITALS: 97.9 149/79 81 15 96% RA
GENERAL: Appears in no acute distress. Alert and interactive.
Non-toxic appearing with notable jaundice.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes dry. Scleral icterus noted.
NECK: supple without lymphadenopathy. JVD difficult to assess
given body habitus.
___: Regular rate and rhythm, II/VII mid-systolic murmur heard
at ___ without radiation, no rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sounds at bases bilaterally without
adventitious sounds. No wheezing, rhonchi or crackles. Stable
inspiratory effort.
ABD: soft, diffusely tender to deep palpation, non-distended,
with normoactive bowel sounds. No palpable masses or peritoneal
signs. Negative ___ sign.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength ___ bilaterally, sensation grossly intact. Gait
deferred.
.
Pertinent Results:
.
IMAGING:
___ CT ABDOMEN & PELVIS (from ___ - multiple
gallstones, a prominent gallbladder measured to 9-cm with mild
stranding. There was also mild pancreas stranding without
evidence of small bowel obstruction (per Radiology report).
.
___ 05:50AM BLOOD WBC-10.5 RBC-4.50* Hgb-12.6* Hct-38.5*
MCV-86 MCH-28.0 MCHC-32.7 RDW-15.7* Plt ___
___ 05:00PM BLOOD Hct-37.2*
___ 10:53AM BLOOD WBC-11.3* RBC-4.41* Hgb-12.5* Hct-38.2*
MCV-87 MCH-28.4 MCHC-32.8 RDW-15.7* Plt ___
___ 05:00AM BLOOD WBC-18.1* RBC-4.97 Hgb-14.0 Hct-43.5
MCV-88 MCH-28.2 MCHC-32.2 RDW-15.4 Plt ___
___ 03:35PM BLOOD Hct-43.8
___ 04:17AM BLOOD WBC-18.4* RBC-4.78 Hgb-13.1* Hct-41.4
MCV-87 MCH-27.4 MCHC-31.7 RDW-15.9* Plt ___
___ 09:05PM BLOOD WBC-11.8* RBC-5.05 Hgb-13.6* Hct-44.5
MCV-88 MCH-26.8* MCHC-30.5* RDW-15.9* Plt ___
___ 09:05PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL
___ 11:35PM BLOOD Neuts-85.6* Lymphs-5.7* Monos-8.2 Eos-0.4
Baso-0
___ 04:17AM BLOOD ___ PTT-34.6 ___
___ 06:09AM BLOOD ___ PTT-28.2 ___
___ 05:50AM BLOOD Glucose-98 UreaN-11 Creat-0.6 Na-142
K-2.8* Cl-101 HCO3-30 AnGap-14
___ 07:20PM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-143
K-2.7* Cl-103 HCO3-28 AnGap-15
___ 10:53AM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-146*
K-3.2* Cl-104 HCO3-28 AnGap-17
___ 11:35PM BLOOD Glucose-88 UreaN-9 Creat-0.6 Na-135
K-3.1* Cl-93* HCO3-27 AnGap-18
___ 05:00AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-132*
K-3.4 Cl-93* HCO3-26 AnGap-16
___ 07:30AM BLOOD Glucose-88 UreaN-9 Creat-0.7 Na-130*
K-3.3 Cl-94* HCO3-26 AnGap-13
___ 04:17AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-132*
K-3.5 Cl-98 HCO3-25 AnGap-13
___ 06:45AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-138
K-3.7 Cl-106 HCO3-22 AnGap-14
___ 09:05PM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-140
K-3.9 Cl-109* HCO3-22 AnGap-13
___ 06:09AM BLOOD Glucose-119* UreaN-16 Creat-0.8 Na-138
K-4.1 Cl-105 HCO3-22 AnGap-15
___ 05:50AM BLOOD ALT-71* AST-18 AlkPhos-54 TotBili-2.5*
___:53AM BLOOD ALT-83* AST-22 CK(CPK)-180 AlkPhos-52
TotBili-2.9* DirBili-1.4* IndBili-1.5
___ 11:35PM BLOOD ALT-99* AST-25 CK(CPK)-60 AlkPhos-56
TotBili-2.6*
___ 11:55AM BLOOD CK(CPK)-83
___ 05:00AM BLOOD ALT-148* AST-23 CK(CPK)-86 AlkPhos-57
TotBili-2.6* DirBili-0.8* IndBili-1.8
___ 07:30AM BLOOD ALT-225* AST-32 CK(CPK)-109 AlkPhos-65
Amylase-78 TotBili-3.0*
___ 04:17AM BLOOD ALT-222* AST-32 AlkPhos-59 Amylase-88
TotBili-2.5*
___ 06:45AM BLOOD ALT-332* AST-83* LD(LDH)-291* AlkPhos-71
TotBili-2.4*
___ 09:05PM BLOOD ALT-393* AST-139* LD(LDH)-205 AlkPhos-72
TotBili-2.9*
___ 06:09AM BLOOD ALT-512* AST-452* AlkPhos-73 TotBili-4.1*
___ 05:50AM BLOOD Lipase-37
___ 05:00AM BLOOD Lipase-22
___ 06:45AM BLOOD Lipase-545*
___ 09:05PM BLOOD Lipase-1345*
___ 06:09AM BLOOD Lipase-645*
___ 10:53AM BLOOD CK-MB-6 cTropnT-<0.01
___ 11:35PM BLOOD CK-MB-3 cTropnT-<0.01
___ 11:55AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:00AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-3649*
___ 07:30AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:50AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.2
___ 07:20PM BLOOD Calcium-8.3* Phos-2.2* Mg-2.2
___ 10:53AM BLOOD Calcium-8.4 Phos-1.4* Mg-2.2
___ 11:35PM BLOOD Calcium-8.6 Phos-1.6* Mg-1.7
___ 12:03AM BLOOD ___ pO2-140* pCO2-37 pH-7.50*
calTCO2-30 Base ___ ERCP
Impression: Cannulation of the biliary duct was successful and
deep with a sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
The common bile duct was dilated to 12 mm.
There were several filling defects in the mid-CBD consistent
with stones and/or sludge.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Balloon sweep x 3 was performed with successful extraction of
copious amounts of sludge and debris.
Final cholangiogram was normal without filling defects.
.
Recommendations: NPO overnight with aggressive IV hydration with
LR at 200 cc/hr.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call (___)
Continue aggressive management of pancreatitis.
Continue antibiotics x 7 days.
Consider cholecystectomy.
.
___ CT abdomen/pelvis:
IMPRESSION:
1. Findings consistent with reported diagnosis of pancreatitis
with minimally increased peripancreatic and periduodenal fat
stranding as well as interval development of notable
pancreatico-duodenal groove bowel wall thickening likely related
to either groove pancreatitis or duodenal hematoma given recent
ERCP. No complications of pancreatitis such as : splenic venous
thrombosis, splenic artery pseudoaneurysm, focal abscess, or
phlegmon formation.
2. New bilateral pleural effusions, both small in size, right
greater than
left.
3. Bilateral hyperdense renal cystic lesions likely represent
hemorrhagic
cysts, could be further evaluated with renal ultrasound.
.
___ ___:
IMPRESSION: No DVT in the left upper extremity.
.
CXR ___:
Left PICC line tip is at the mid SVC. NG tube passes below the
diaphragm
terminating most likely in the stomach. There is interval
development of
pulmonary edema on the top of preexisting consolidations in the
lung bases.
Pulmonary hypertension is most likely present given the
prominence of
pulmonary arteries.
.
___ Head CT:
IMPRESSION: No CT evidence for acute intracranial process.
___ CT ABD PELVIS: IMPRESSION:
1. Interval increase in peripancreatic stranding and duodenal
wall
thickening. No pseudocyst or other complication identified.
2. Hypodensities within the portal vein adjacent to the
pancreatic head may
represent flow artifact or less possibly thrombus. Attn on
followup.
3. Poor opacification of SMV does not allow for adequate
assessment.
.
___ CXR: FINDINGS: In comparison with the study of ___,
there is continued
enlargement of the cardiac silhouette with mild improvement in
pulmonary
venous pressure. Prominent pulmonary arteries are again seen
bilaterally.
Little change in the appearance of the nasogastric tube
.
___ Video Fluoroscopy:
SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing
videofluoroscopy was
performed in conjunction with the speech and swallow division.
Multiple
consistencies of barium were administered. Barium passed freely
through the
oropharynx without evidence of obstruction. There is penetration
with thin
liquids. There was no gross aspiration. The barium tablet is
held up at the
vallecula but clears with multiple swallows of barium.
Degenerative change is
seen in the cervical spine.
IMPRESSION: Penetration with thin liquids. For details, please
refer to
speech and swallow note in OMR.
___ KUB:
FINDINGS: Two upright and two supine frontal views of the
abdomen show
gaseous distention of several loops of small bowel, increased
from ___.
There is gas in non-dilated loops of large bowel as well as the
rectum. No
air-fluid level or evidence of pneumoperitoneum is detected.
Multiple
calcific densities are noted in the pelvis which may represent
vascular
calcifications seen on recent CT of ___. The visualized lung
bases
demonstrate mild atelectasis. The osseous structures are within
normal
limits.
IMPRESSION: Gaseous distention of the small bowel increased from
___ most
likely represents ileus; partial small bowel obstruction cannot
be entirely
excluded. No free air.
___ KUB
In comparison with the study of ___, there is gas within mildly
dilated
transverse colon. Remainder of the bowel gas is essentially
within normal
limits, so that the overall pattern most likely reflects
adynamic ileus.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient's Pharmacy)
1. Percocet ___ mg ___ tabs) PO Q6H PRN pain
2. Aspirin 81 mg PO daily
3. Atenolol 50 mg PO daily
4. Prednisone 15 mg PO daily (started ___
5. Sennosides 2 tabs PO daily
6. Testosterone (Androgel) 1 application topically daily
7. Citalopram 20 mg PO daily
8. Ergocalciferol 50,000 units PO weekly
9. Lactulose 30 mL ___ teaspoons) PO daily
Discharge Medications:
1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID
(2 times a day).
Disp:*1 BOTTLE* Refills:*0*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute gallstone pancreatitis
choledocholithiasis
delirium
fever
pulmonary edema
ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with pancreatitis, now with left arm edema, to
rule out DVT.
COMPARISON: None.
FINDINGS: Grayscale and Doppler sonograms of left internal jugular,
subclavian, axillary, brachial, and superficial veins were performed. There
is normal compressibility, flow and augmentation throughout.
IMPRESSION: No DVT in the left upper extremity.
Radiology Report
INDICATION: Chest pain status post ERCP for pancreatitis and ileus, shortness
of breath, please evaluate for etiology of chest pain and shortness of breath.
COMPARISON: Comparison is made to chest radiograph performed ___
and CT abdomen and pelvis performed ___.
FINDINGS: Portable chest radiograph demonstrates interval placement of a
nasogastric tube, although the tip is not well seen. The side port appears to
be located approximately 2.5 cm below the carina and with tip likely at the GE
junction. Mediastinal contour is unremarkable. Bilateral hila are engorged.
Heart size is top normal. Faint right lower lung opacification is relatively
unchanged compared to ___, and likely reflects atelectasis, exaggerated
by bilateral low lung volumes. No focal opacifications evident. No overt
pulmonary edema.
IMPRESSION: Nasogastric tube tip not well seen, but presumed to be at the GE
junction as side port is evident in the mid-to-distal esophagus. Minimal
pulmonary edema.
Radiology Report
INDICATION: Please evaluate for NG tube placement.
COMPARISON: Comparison is made to chest performed half and hour earlier.
FINDINGS: Interval advancement of nasogastric tube with tip in the fundus of
stomach. Side port is well beyond GE junction. Otherwise, unchanged exam.
IMPRESSION: NG tube with tip in stomach.
Radiology Report
REASON FOR EXAMINATION: NG tube pulled out, reassessment of placement.
AP radiograph of the chest was reviewed with comparison to ___
obtained at 06:33 a.m.
The NG tube tip cannot be clearly seen beyond mid low esophagus and most
likely should be readvanced. The rest of the imaging findings are unchanged.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess NG tube.
Comparison is made with prior study performed two hours earlier.
NG tube is coiled in the mid-esophagus with tip goes back to the upper
esophagus. There are no other interval changes.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess line.
Left PICC tip is in the lower SVC. NG tube tip has been repositioned and now
is in the stomach. Cardiomediastinal contours are normal. Bibasilar
opacities larger on the right side and in the left perihilar region are
unchanged. There is no pneumothorax or enlarging pleural effusions.
Findings were discussed with IV nurse, ___ by phone on ___ at
1:30 p.m.
Radiology Report
REASON FOR EXAMINATION: Wheezing, fever.
Portable AP radiograph of the chest was reviewed in comparison to ___.
Left PICC line tip is at the mid SVC. NG tube passes below the diaphragm
terminating most likely in the stomach. There is interval development of
pulmonary edema on the top of preexisting consolidations in the lung bases.
Pulmonary hypertension is most likely present given the prominence of
pulmonary arteries.
Radiology Report
INDICATION: ___ male with a history of gallstone pancreatitis, now
presents with fever.
COMPARISON: Comparison is made to CT abdomen and pelvis performed ___.
TECHNIQUE: Multidetector CT-acquired axial images from the base of the lungs
to the pelvic outlet were obtained after administration of IV and oral
contrast. Coronal and sagittal reformats were produced.
FINDINGS:
LUNG BASES: Mild interval increase in bilateral pleural effusion and
associated atelectasis.
CT ABDOMEN WITH CONTRAST: Liver, spleen, adrenal glands, and kidneys are
unremarkable. Left kidney remains somewhat atrophic with irregular cortical
contour, possibly related to prior infection. Simple renal cyst in the lower
pole of the left kidney is unchanged. No free fluid or air seen within the
abdomen. Pneumobilia previously seen has resolved; however, a small amount of
gas remains within the gallbladder.
There has been moderate interval increase in the amount of peripancreatic
stranding. There is decreased enhancement of the pancreas around the uncinate
process. There has been increase in amount of bowel wall thickening seen
within the adjacent duodenum.
There is a hypodensity seen within the portal vein adjacent to the pancreatic
head which may represent a thrombus or a beam hardening artifact. Close
followup on following exam is recommended. There is poor opacification of the
SMV which does not allow for adequate assessment; ultrasound evaluation might
be more sensitive. No pseudocyst formation is yet seen. There is no free
fluid. The remainder of the stomach, small bowel, and colon are normal in
course and caliber. There is no retroperitoneal or mesenteric
lymphadenopathy.
CT PELVIS WITH CONTRAST: The rectum, prostate, and bladder are unremarkable.
A Foley catheter is seen in place. There is no free fluid or air found within
the pelvis.
BONE WINDOW: There are no blastic or lytic lesions suspicious for malignancy.
There are moderate multilevel degenerative changes seen along the spine.
IMPRESSION:
1. Interval increase in peripancreatic stranding and duodenal wall
thickening. No pseudocyst or other complication identified.
2. Hypodensities within the portal vein adjacent to the pancreatic head may
represent flow artifact or less possibly thrombus. Attn on followup.
3. Poor opacification of SMV does not allow for adequate assessment.
Radiology Report
INDICATION: ___ male with altered mental status.
COMPARISON: None available.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast.
FINDINGS: The study is slightly degraded by motion artifact. Within this
limitation, there is no evidence of hemorrhage, large mass, mass effect,
edema, hydrocephalus, or recent infarction. The basal cisterns appear patent.
There is preservation of gray-white matter differentiation. A lacune or
prominent perivascular space is seen in the left basal ganglia. White matter
hypodensity is likely secondary to sequela of chronic small vessel ischemic
disease. Prominent ventricles and sulci suggest age-related involutional
changes.
Mucosal thickening is seen in the right maxillary sinus; the remainder of the
visualized portions of the paranasal sinuses and mastoid air cells appear well
aerated. No acute bony abnormality is detected.
IMPRESSION: No CT evidence for acute intracranial process.
Radiology Report
HISTORY: Gallstone pancreatitis with fever.
FINDINGS: In comparison with the study of ___, there is continued
enlargement of the cardiac silhouette with mild improvement in pulmonary
venous pressure. Prominent pulmonary arteries are again seen bilaterally.
Little change in the appearance of the nasogastric tube.
Radiology Report
INDICATION: ___ male status post PICC placement.
COMPARISON: ___.
TECHNIQUE: Single frontal chest radiograph was obtained portably with the
patient in an upright position.
FINDINGS: There has been interval placement of a right-sided PICC with tip
projecting at the level of the high-mid superior vena cava. No pneumothorax
is detected. The right costophrenic angle is not included on this view. Hazy
opacification of the left lower lung field likely represents known pleural
effusion and atelectasis. There is mild interstitial pulmonary edema. There
has been interval removal of the esophageal catheter. Heart and mediastinal
contours appear stable with cardiomegaly and pulmonary arterial enlargement.
IMPRESSION: Right PICC tip in the high-mid superior vena cava.
This finding was discussed with ___ by Dr. ___ by phone at 9:58
a.m. on ___.
Radiology Report
CLINICAL HISTORY: ___ man with pancreatitis and delirium. Evaluate
for etiology of difficulty swallowing.
SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing videofluoroscopy was
performed in conjunction with the speech and swallow division. Multiple
consistencies of barium were administered. Barium passed freely through the
oropharynx without evidence of obstruction. There is penetration with thin
liquids. There was no gross aspiration. The barium tablet is held up at the
vallecula but clears with multiple swallows of barium. Degenerative change is
seen in the cervical spine.
IMPRESSION: Penetration with thin liquids. For details, please refer to
speech and swallow note in OMR.
Radiology Report
INDICATION: ___ male with history of pancreatitis and recent ileus,
now with recurrent nausea and vomiting, here to evaluate for bowel obstruction
or ileus.
COMPARISON: CT of the abdomen and pelvis performed on ___.
FINDINGS: Two upright and two supine frontal views of the abdomen show
gaseous distention of several loops of small bowel, increased from ___.
There is gas in non-dilated loops of large bowel as well as the rectum. No
air-fluid level or evidence of pneumoperitoneum is detected. Multiple
calcific densities are noted in the pelvis which may represent vascular
calcifications seen on recent CT of ___. The visualized lung bases
demonstrate mild atelectasis. The osseous structures are within normal
limits.
IMPRESSION: Gaseous distention of the small bowel increased from ___ most
likely represents ileus; partial small bowel obstruction cannot be entirely
excluded. No free air.
Radiology Report
HISTORY: Pancreatitis with ileus.
FINDINGS:
In comparison with the study of ___, there is gas within mildly dilated
transverse colon. Remainder of the bowel gas is essentially within normal
limits, so that the overall pattern most likely reflects adynamic ileus.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pancreatitis and increased abdominal pain, questionable free air.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are low. Borderline size of the cardiac
silhouette. No pleural effusions. No other parenchymal opacities. No
evidence of free air.
Radiology Report
INDICATION: Pancreatitis and likely ileus now s/p NGT placement
FINDINGS: Portable chest radiographs demonstrate interval placement of a
nasogastric tube with tip in the fundus of the stomach and sideport at the
level of the GE junction, and which could be advanced several centimeters.
Mediastinal and hilar contours are unremarkable. Heart size is top normal.
Lungs are clear. No pleural effusion or pneumothorax.
IMPRESSION:
Nasogastric tube with tip in fundus of stomach, could be advanced several
centimeters.
Radiology Report
INDICATION: Gallstone pancreatitis, status post ERCP, now with presumed
ileus, status post NG tube and worsening abdominal distention. Evaluate for
small bowel obstruction.
COMPARISON: Comparison is made to CT abdomen performed ___ and
abdominal x-ray performed ___.
TECHNIQUE: Intravenous and oral contrast axial images obtained from the lung
bases to pelvic outlet. Coronal and sagittal reformations were provided.
FINDINGS:
CT ABDOMEN WITH CONTRAST: Though this exam is not tailored for
supradiaphragmatic evaluation, note is made of new bilateral pleural
effusions, right greater than left, with adjacent compressive atelectasis.
Heart size is mildly enlarged without pericardial effusion.
The liver is homogenous in attenuation without discrete masses or lesions.
Interval development of pneumobilia, likely related to recent ERCP. There is
no intrahepatic biliary ductal dilatation. The gallbladder is minimally
distended and contains air. The common bile duct is prominent but tapers
smoothly to the level of the pancreatic head.
The pancreas, particularly the pancreatic head, is edematous with
peripancreatic fat stranding minimally increased compared to next preceding
study with minimal fluid tracking down the bialteral paracolic grooves. No
phlegmonous change identified. No pancreatic duct dilatation evident. No
pancreatic parenchymal heterogeneity to suggest necrosis. No portal venous
system thrombosis or splenic artery pseudoaneurysm.
There has been interval development of significant hypodense duodenal groove
wall thickening which does not appear to be extending beyond the region of the
pancreatic head. There is also minimally increased fat stranding surrounding
the second and third portions of the duodenum. Findings may represent groove
pancreatitis versus duodenal hematoma related to recent ERCP.
There is no free air. No evidence of upstream bowel dilatation with NG tube
tip terminating in the fundus of the stomach. The remainder of the small and
large bowel are unremarkable.
The left kidney is somewhat atrophic with an irregular cortical contour,
possibly related to prior infectious insult. Bilateral hyperdense cystic
lesions are evident, possibly related to hemorrhagic contents.
CT PELVIS WITH CONTRAST: The bladder and seminal vesicles are unremarkable.
TURP-like defect is noted within the prostate. No pelvic lymphadenopathy or
free fluid.
The abdominal aorta is calcified throughout without evidence of aneurysmal
dilatation. The ostia of the celiac and superior mesenteric arteries appear
widely patent. The main portal vein and its major tributaries are patent. No
evidence of splenic artery pseudoaneurysm.
No suspicious lytic or blastic lesions evident.
IMPRESSION:
1. Findings consistent with reported diagnosis of pancreatitis with minimally
increased peripancreatic and periduodenal fat stranding as well as interval
development of notable pancreatico-duodenal groove bowel wall thickening
likely related to either groove pancreatitis or duodenal hematoma given recent
ERCP. No complications of pancreatitis such as : splenic venous thrombosis,
splenic artery pseudoaneurysm, focal abscess, or phlegmon formation.
2. New bilateral pleural effusions, both small in size, right greater than
left.
3. Bilateral hyperdense renal cystic lesions likely represent hemorrhagic
cysts, could be further evaluated with renal ultrasound.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ACUTE PANCREATITIS, CHOLELITHIASIS NOS
temperature: 100.5
heartrate: 82.0
resprate: 18.0
o2sat: 98.0
sbp: 182.0
dbp: 84.0
level of pain: 8
level of acuity: 3.0 | ___ with a PMH significant for chronic lower extremity pain
syndrome (on narcotics and steroids), HTN, OSA (not on CPAP),
chronic constipation and undefined asymptomatic cardiac septal
defect who presented with acute onset abdominal pain, nausea,
emesis and jaundice for 1-day with CT evidence of obstructing
common biliary duct stone; mild-moderate transaminitis,
hyperbilirubinemia with lipasemia consistent with acute
gallstone pancreatitis now s/p ERCP with successful sludge
extraction. Hospital course was complicated by delirium,
hypertensive urgency with CP but no evidence of ACS. He also
developed pulmonary edema from aggressive hydration for his
pancreatitis, ileus, and required nutritional supplement with
TPN.
.
#Moderate-severe PANCREATITIS, ACUTE/GALLSTONE
PANCREATITIS/CHOLEDOCHOLITHIASIS W/ OBSTRUCTION: Patient
presented with abdominal, nausea, emesis and jaundice for 1-day
with CT imaging evidence of obstructing common biliary duct
stone; mild-moderate transaminitis, hyperbilirubinemia with
lipasemia consistent with gallstone pancreatitis. No prior
history of biliary colic or prior episodes of pancreatitis,
despite significant alcohol history. ERCP evaluated the patient
and felt urgent ERCP was necessary, this was performed with
stone and sludge extraction. Pt was felt to have had a moderate
pancreatitis and the general surgery and ERCP teams followed the
patient. Pt was given aggressive IV fluids and zosyn for concern
of possible early cholangitis at OSH prior to admission. Zosyn
was continued for 10 days. Pt was given IV narcotics and
antiemetics for pain control. Given continued pain on the
medical floor, pt had a CT scan of the abdomen performed on ___
showing concern for possible duodenal hematoma vs. edema from
pancreatitis. Both the ERCP and Surgery teams felt this to be
consistent with edema from pancreatitis given stability of Hct.
NG tube was placed given ileus. Given prolonged, NPO status PPN
was initiated as there was no central access. Repeat CT scan
showed interval increase in peripancreatic stranding and
duodenal wall thickening. No pseudocyst or other complication
identified. His abdominal pain gradually improved. He had a
PICC line placed for TPN which he pulled out while delirious so
it was replaced and he continued on TPN as his diet was
gradually advanced. He failed a bedside speech and swallow and
underwent video swallow study. Speech and swallow recommended
ground solids and thin liquids. This should also be low fat and
low residue. Unfortunately he re-developed nausea and vomiting
and KUB showed increased gaseous distention. He was made NPO
again. Repeat KUB showed ileus. His diet was slowly advanced,
and he tolerated it well, without nausea or increase in
abdominal pain. At the time of discharge, his diet was low-fat,
no dairy, no coffee (as recommended by GI).
.
#Fever/Leukocytosis-likely due to above. CT scanning showed
acute pancreatitis. No dysuria, diarrhea, or cough to suggest
additional causes. lactate normal. Pt developed fever to 102 on
___. Vancomycin was added to the zosyn regimen. Serial BCX, UCX
were drawn which remained negative. Repeat CXR and CT
Abd/Pelvis did not show any new signs of infection. Vanco was
d/ced on ___ and the pt was monitored without any further fever
or leukocytosis. Zosyn was d/ced on ___ after 10 days
(including OSH coverage).
.
#Metabolic encephalopathy-Initially the patient was A&O x 3 but
with developed sundowning and delirium. He denied headache or
signs of meningitis. No evidence for seizures. Etiology was
likely multifactoral related to polypharmacy from opioids,
anti-emetics, age, acute illness, hospitalization. Infectious
work up was unrevealing EKG was not suggestive of ischemia. Pt
was given a 1:1 sitter to prevent pulling out of lines. Zyprexa
5mg BID was administered. Head CT showed no acute intracranial
abnormalities. His mental status gradually improved and at
discharge he is alert and oriented x3, reading newspapers.
.
#Chest pain/Hypertensive urgency-Pt developed CP and SOB ___
overnight in setting of SBP 180-200. EKG unchanged from prior.
Serial cardiac biomarkers negative. He was given aspirin and SL
nitro in that setting. No events were recorded on telemetry.
This was likely due to pain, pulmonary edema and hypertensive
urgency. Pt was placed on standing IV hydralazine and metoprolol
which was later transitioned to PO metoprolol. Lisinopril was
also added later in his hospitalization.
.
#Pulmonary edema/volume overload-Thhis was related to aggressive
fluid resuscitation as recommended for gallstone pancreatitis.
IV fluids were decreased and pt was given lasix. He required 2L
of NC but this was weaned off.
.
# POLYMYALGIA RHEUMATICA on SYSTEMIC STEROID THERAPY
CHRONIC LOWER EXTREMITY PAIN - Patient presented with
long-standing history of chronic lower extremity edema which has
been managed with chronic narcotics (Percocet), trial of
Celecoxib and now Prednisone dosing (since ___ with
improvement. Pain symmetric and isolated to the proximal lower
extremities concerning for polymylagia rheumatica. His EMG was
reassuring. The differential also includes rheumatoid arhtirits
vs. hypothyroidism vs. spondyloarthropathy vs. fibromyalgia vs.
myopathy. Pt was continued on prednisone 15mg daily which was
converted to hydrocortisone when the pt was NPO. He received
Dilaudid for pain but when his mental status improved, he was
transitioned to oxycodone. He did not have any signs of vascular
compromise. He should follow up with his PCP for further
management.
.
# HYPERTENSION - History of hypertension that has been managed
on ACEI previously, but now only beta-blockers (Atenolol daily).
See above, pt was given standing IV hydralazine and metoprolol
but was later restarted on an ACEI. Hydralazine was not
continued.
.
#Duodenal hematoma?-There was concern raised on CT imaging. Hct
remained stable. Other differential included edema related to
acute pancreatitis. Surgery and ERCP teams monitored the
patient.
.
#Acute on chronic CONSTIPATION with ileus - This has been an
on-going issue since his narcotic use for his lower extremity
pain. CT without evidence of bowel obstruction and his last
bowel movement was formed, hard and non-bloody the morning prior
to admission. Aggressive bowel regimen attempted, but pt was
found to have an ileus. NGT was placed and the patient remained
NPO especially as he was also delirious. When his mental status
improved, NGT was d/ced and he was restarted on a PO bowel
regimen. He later developed diarrhea but KUB showed increased
gaseous distention suggestive of an ileus.
.
# Diarrhea - Later in his hospitalization, the pt developed
diarrhea. Cdiff test was negative. Diarrhea improved.
.
#Hyponatremia/hypernatremia - This was managed with IVF
intermittently during his hospitalization.
.
#OSA-does not tolerate CPAP. Outpt f/u.
.
#Thrombocytopenia-could be due to acute illness, vs. medication
effect. Improved.
TRANSITIONAL ISSUES
1. Follow a low-fat diet, avoiding dairy and coffee.
2. Antihypertensives changed to metoprolol 25 mg bid and
lisinopril 20 mg daily.
3. Check K and Cr next week (on ___ here, K was 3.6 and Cr 0.7).
4. Follow-up with Surgery for elective cholecystectomy
5. Other notable labs on last check: Hct 39.4 (borderline low),
ALT 101, AST 41, AlkPhos 65, Total Bili 0.7. Would repeat LFTs
in the outpatient setting.
6. Abd CT on ___ showed: "Bilateral hyperdense renal cystic
lesions likely represent hemorrhagic cysts, could be further
evaluated with renal ultrasound." Can consider renal ultrasound
in outpatient setting, if clinically indicated.
7. Abd CT on ___ showed: "Hypodensities within the portal vein
adjacent to the pancreatic head may represent flow artifact or
less possibly thrombus. Attn on followup." Would consider
repeat imaging in follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base / Stinoprate / Amoxicillin
Attending: ___
Chief Complaint:
left arm weakness and facial asymmetry
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ yo R-handed ___ woman with a
history of chronic renal insufficiency, hypertension,
hyperlipidemia, and breast cancer who presents with sudden-onset
weakness of the L arm accompanied by facial asymmetry.
She was in her normal state of health until roughly 9:30am when
she experienced a sudden onset "numbness" on her left arm. She
describes the feeling as a "numbness" or "not feeling right",
but
on further questioning she identified the feeling mostly as one
of not being able to move her fingers and arm. She added that
the
feeling was ascending - traveling from the finger tips up to the
top of her left arm. It traveled all the way up in a matter of
a
second. Her fingers felt "stiff" and her left hand felt clumsy.
She walked to the mirror noticed facial asymmetry - though she
cannot clearly describe which side was weak. She says she was
frightened and immediately walked to the phone to call her
daughter. She reports no difficulty walking and neither she nor
her daughter noticed any dysarthria or language disturbance. By
the time her daughter, who lives 10 minutes away, arrived
roughly
15 minutes later (~20 minutes after onset of symptoms), the
paresis and tingling had resolved, and there was no marked
facial
droop at rest.
Ms. ___ reports continuing to feel "out of it," though links
this in part to feeling scared. She notes that she has felt mild
chest discomfort and feelings of shortness of breath and
lightheadedness since this morning. She had experienced no
weakness, paresis, paresthesias, incoordination, or other
unusual
symptoms in her R arm, R hand, trunk, or legs. At the time of
arrival to the emergency room, she continued to feel weak in her
L arm with loss of coordination in the L fingers, but she had
regained motion. She has no history of similar events.
On neuro ROS, she also denies ataxia, headache, vision changes,
diplopia, dysarthria, dysphagia or other swallowing
difficulties,
tinnitus or hearing difficulty. She experienced no difficulties
with gait, no difficulties producing or comprehending speech,
and
no cognitive changes or altered level of consciousness. No bowel
or bladder incontinence or retention.
On general review of systems, the she denies recent
fever/chills,
weight change, night sweats, cough, shortness of breath, chest
tightness/pain/palpitations. She denies nausea, vomiting,
diarrhea, constipation or abdominal pain. She denies dysuria
but
does note some recent increase in urinary frequency. She
endorses
arthritis in her knees, worse in her L knee, causing pain and
some limitation of mobility, sometimes necessitating the use of
a
cane.
Past Medical History:
- Breast cancer diagnosed ___, treated with lumpectomy,
radiation (in ___ presently treated with Tamoxifen.
- Gastric ulcers (seen on endoscopy late last year). ASA was
discontinued in ___ due to these ulcers
- Osteoarthritis of knees bilaterally, worst in L knee
- Chronic renal insufficiency, unclear etiology
- Hypertension
- Hyperlipidemia
Social History:
___
Family History:
Unknown
Physical Exam:
Physical Exam:
Vitals:
Initial vitals in ED (11:26am):
T: 98.1 HR: 55 BP: 181/61 RR: 18 O2 sat: 100% RA
Current vitals (2:12pm):
T: 97.6 HR: 55 BP: 159/53 RR: 16 O2 sat: 99% RA
General: Awake, alert, friendly, and cooperative. NAD. Appears
stated age.
HEENT: NC/AT with no scleral icterus. Moist mucous membranes and
no obvious lesions noted in oropharynx
Neck: Supple with no nuchal rigidity
Extremities: Extremities are warm and well-perfused with no
cyanosis, clubbing, or edema bilaterally, 2+ radial.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert and oriented x 3. Though ___ is not
her
first language and her daughters translated/explained some
questions to her in ___, she is able to relate a history
with
no difficulties aside from slight language barrier. She is
attentive and able to name ___ backward without difficulty from
___ to ___, at which point she stopped. Language is
fluent
(again, except for occasional word-finding difficulty related to
language barrier) with intact comprehension, normal prosody. No
paraphasic errors. She was able to name both high and low
frequency objects. No evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3--->2mm.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: There is initial hemiparesis of R lip while smiling, though
this lessens markedly over the course of the interview such that
there is only mild flattening of R nasolabial fold without
asymmetry of smile by the end of the exam.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically, midline uvula.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone throughout. No pronator drift
bilaterally. Slight postural and action tremors.
Her strength exam is partly limited by arthritic pain. She has
giveaway weakness, bilateral proximal muscle weakness. She has
UMN weakness in left arm and leg. She has subtle weakness in
the
left arm on orbiting exam. Slightly slower finger and toe
tapping
on the left.
Delt Bic Tri WrE FFl FE Quad Ham TA ___ ___
L 4+ 5 5- 4 5- 4+ 5- 3 5 5- 4+
R 4+ 5 5 5 5 5 5- 3 5 5- 5-
-Sensory: No deficits to light touch, pinprick, cold sensation,
or vibratory sense. Slight decrease in joint position sense in
toes bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was flexor bilaterally.
-Coordination: Slowing of fine finger movements on L; FNF
testing
normal on R but L side was limited by weakness though there is
no
evidence of dysmetria. Some clumsiness and slowing when tapping
L
foot.
Discharge Exam:
She does have a grossly normal motor exam, allowing for some
limitations in the language/cognitive part of the exam, given
that her mother language is ___. She does have some give-way
weakness on the proximal left arm and leg
that seems to be related to shoulder and hip pain.
Pertinent Results:
___ 07:20AM BLOOD WBC-5.8 RBC-4.17*# Hgb-12.0 Hct-39.7
MCV-95 MCH-28.7 MCHC-30.2* RDW-12.2 Plt ___
___ 07:00AM BLOOD WBC-5.9 RBC-3.30* Hgb-9.7* Hct-31.8*
MCV-96 MCH-29.5 MCHC-30.7* RDW-12.3 Plt ___
___ 11:40AM BLOOD WBC-5.4 RBC-4.26 Hgb-12.4 Hct-40.2 MCV-95
MCH-29.0 MCHC-30.7* RDW-12.3 Plt ___
___ 11:40AM BLOOD ___ PTT-34.7 ___
___ 07:20AM BLOOD Glucose-108* UreaN-16 Creat-1.2* Na-148*
K-4.6 Cl-112* HCO3-26 AnGap-15
___ 05:20PM BLOOD Glucose-107* UreaN-19 Creat-1.1 Na-141
K-4.7 Cl-110* HCO3-24 AnGap-12
___ 07:00AM BLOOD Glucose-61* UreaN-15 Creat-0.8 Na-144
K-2.8* Cl-121* HCO3-21* AnGap-5*
___ 11:40AM BLOOD ALT-8 AST-18 AlkPhos-100 TotBili-0.3
___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:38PM BLOOD D-Dimer-511*
___ 07:00AM BLOOD %HbA1c-5.8 eAG-120
___ 07:00AM BLOOD Triglyc-73 HDL-32 CHOL/HD-3.4 LDLcalc-61
___ 07:00AM BLOOD TSH-0.98
EEG: This is a normal awake and sleep EEG. No focal
abnormalities or
epileptiform discharges are present.
CT and MRI brain: normal
Echo: Mild symmetric left ventricular hypertrophy with preserved
regional and global biventricular systolic function. Trace
aortic regurgitation. Mild mitral regurgitation. Increased PCWP.
Dilated ascending aorta. No definite structural cardiac source
of embolism identified.
CTA chest done in the ED: normal
Lipids were normal
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 20 mg PO DAILY
2. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Enalapril Maleate 20 mg PO DAILY
5. Atenolol 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
TIA vs complex migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with mild chest pain and shortness of breath, history
of breast cancer.
COMPARISON: None.
TECHNIQUE: PA and lateral views of the chest were obtained.
FINDINGS: There is mild-to-moderate cardiomegaly. Calcification in the
aortic knob is noted. Otherwise, the mediastinal and hilar contours are
unremarkable. There is no pleural effusion or pneumothorax. The lungs are
well expanded without focal consolidation concerning for pneumonia. A 1.0 cm
round opacity projects at the lung base posteriorly, best seen on the lateral
view. This is not definitively identified on the frontal view but may be
present at the left lung base. The upper abdomen is unremarkable. Surgical
clips are noted projecting over the breast tissue on the lateral view.
IMPRESSION:
1. No evidence of acute cardiopulmonary process.
2. Apparent round opacity projecting over the posterior lung bases on the
lateral view. Chest CT is recommended when clinically appropriate.
Radiology Report
CHEST CT
HISTORY: Chest pain and shortness of breath with elevated d-dimer.
COMPARISONS: Chest radiographs from earlier on the same day; no prior imaging
available.
TECHNIQUE: Multidetector CT images of the chest were obtained with
intravenous contrast in the pulmonary arterial phase. Sagittal and coronal
reformations were also performed.
FINDINGS:
There is a small rim-enhancing collection in the left breast with surrounding
surgical clips. The collection measures 33 x 22 mm in axial ___ and is
typical for a small remaining seroma after prior lumpectomy.
No filling defects are visualized among pulmonary arteries. There are no
substantial pleural or pericardial effusions.
There is mild central airway thickening bilaterally as well as small bilateral
hilar lymph nodes, not enlarged by size criteria and probably reactive. Lung
attenuation is mosaic which is sometimes due to fluid overload, although more
often due to air trapping which is suspected here.
Two patchy consolidations in the right lower lobe suggests bronchopneumonia.
The x-ray finding corresponds to a somewhat nodular appearing consolidative
opacity in the left lower lobe (2:82) that is one of two small areas of
pneumonia suspected in the lower lobe.
Peripheral reticulation in the lingula suggests radiation change in a typical
pattern following prior breast surgery and possibly even some degree of active
radiation pneumonitis depending on the timing and/or superimposed infection.
Streaky opacity in the lingula suggests minor atelectasis.
A small hypodense lesion in segment VII of the liver measuring 12 x 8 mm in
axial ___ (2:78) is bounded anteriorly by early arterial enhancement
and overall suggests a hemangioma.
The bones are probably demineralized. There are no suspicious lytic or
blastic bone lesions.
IMPRESSION:
1. Small multifocal areas of suspected bronchopneumonia in the lower lungs.
2. No evidence of pulmonary embolism.
3. Small probably benign liver lesion in the right lobe, hemangioma most
likely. Confirmation with ultrasound is recommended when clinically
appropriate or possibly MR if desired.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old woman with left arm/leg weakness and right face droop
// stroke eval
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. 3D
time-of-flight MRA of the circle of ___ was obtained. Gadolinium enhanced
MRA of the neck was acquired.
COMPARISON: CT of the head of ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, or infarction.
Mild to moderate brain atrophy and mild changes of small vessel disease.
MRA of the neck shows normal flow in the carotid and vertebral arteries
without stenosis or occlusion.
MRA of the head shows normal signal in the arteries of the anterior and
posterior circulation. No evidence of vascular occlusion stenosis or an
aneurysm greater than 3 mm in size seen.
IMPRESSION:
No significant abnormalities are seen on MRI of the brain without gadolinium.
No significant abnormalities are seen on MRA of the head and neck.
Radiology Report
HISTORY: ___ female with left facial and left upper extremity
numbness, which began two hours ago, now resolved.
COMPARISON: None available.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of intravenous contrast. Reformatted coronal,
sagittal and thin slice bone images were reviewed.
DLP: 891.9 mGy-cm.
CTDIvol: 55.8 mGy.
FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or acute
vascular territorial infarction. The ventricles and sulci are prominent, due
to age-related atrophy. Mild periventricular and subcortical white matter
hypodensities are likely related to the sequelae of chronic small vessel
ischemic disease, and are mild. There is no shift of the normally midline
structures. The basal cisterns appear patent and the gray-white matter
differentiation is preserved. Calcifications are noted in the intracranial
portions of the internal carotid arteries. There is no cranial or facial soft
tissue abnormality. The visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION: No acute intracranial abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Arm numbness, L Facial numbness
Diagnosed with FACIAL WEAKNESS, SKIN SENSATION DISTURB, HYPERTENSION NOS
temperature: 98.1
heartrate: 55.0
resprate: 18.0
o2sat: 100.0
sbp: 181.0
dbp: 61.0
level of pain: 3
level of acuity: 1.0 | Ms. ___ was admitted to ___ Stroke Service due to left arm
sensory changes. Brain imaging revealed that she did not have a
stroke but possibly a transient ischemic attach (TIA). An EEG
was also normal, suggesting that it was unlikely a seizure.
Given her history of complex migraines, this is the most likely
explanation of her symptoms. Regardless to prevent future
strokes, we suggest that she take a coated aspirin a day. We
have started her on a medication to prevent stomach ulcers as
well. Our physical therapists have worked with her and suggested
that she have someone work with her as an outpatient with outpt
___.
Her final diagnosis is either TIA or a migraine accompaniment,
which is a benign condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
acyclovir / Amoxicillin
Attending: ___
Chief Complaint:
oral ulcers, rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo ___ man with a history of CAD
and left partial nephrectomy for ___ in ___ who presents
with painful oral ulcers, rash, and swollen red right eye. Four
weeks PTA he developed painful oral ulcers, which prompted him
to visit his PCP, who diagnosed him with HSV and strep throat.
He was given a mouthwash, which did not help, prompting him to
visit his PCP ___ 2 weeks PTA. He was given
amoxicillin/valcyclovir, which also resulted in no improvement.
Seven days PTA he developed periorbital redness and swelling of
his right eye, pain in his Achilles' tendons b/l, a white
coating on his tongue, and rash on his trunk, back, and legs
b/l. The rash began as red papules that appeared one after
another over a few days (beginning on face and spreading to
trunk and then legs). The papules became pseudovesicular and
then more indurated with a central area of crusting. He
describes his right eye swelling as non-painful, non-pruritic,
and not affecting his vision. The pain in his Achilles tendons
is worsened by flexing/extending his ankles, and he describes
his ankles as swollen and warm b/l. He denies any additional
joint involvement. Three days PTA he returned to his PCP with ___
100.6 (he reports similar temperatures at home for the past
several days) and was referred to the ___ ED. His sx were
attributed to the amoxicillin/acyclovir, and he was discharged
on Benadryl. On the day of admission he presented to the ED
again with no improvement in his sx and inability to eat due to
his oral ulcers.
In the ED, VS on admission were 100.2, HR 100, BP 131/84, RR 16,
98% on RA. Exam was significant for erythema and edema of the
right periorbital region without pain or pruritis. There was no
conjunctival injection noted, flourescin exam was negative for
dendritic ulcers, and visual acuity was normal. Several
erythematous nonpruritic papules were noted on the head, trunk,
arms, and legs without palmar or solar involvement. The rash on
the legs was described as palpable purpura. Erythematous tongue
lesions, which were present on prior ED presentation, were
noted. There was tenderness to palpation of the Achilles'
tendons b/l. Labs showed normal UA, CBC, and Chem7 except Hgb
13.9 (baseline) and lactate 1.3. He was given 150 mg PO
clindamycin out of concern for preseptal cellulitis. VS on
transfer were 98.9, HR 83, BP 127/83, RR 14, 99% on RA.
On the floor, VS were 99.2, BP 135/74, HR 81, RR 18, 99% on RA.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Impaired glucose tolerance
- History of clear cell RCC (3.8cm) s/p L partial nephrectomy;
no chemoradiation
- Probable CAD (positive ETT, normal ECHO)
Social History:
___
Family History:
- No family hx of autoimmune or rheumatologic diseases
- Father: passed away from cancer (unsure which type but not
renal)
Physical Exam:
ADMISSION PHYSICAL EXAM:
- VS: T 99.6, BP 127/71, HR 82, RR 18, 94% on RA
- General: no acute distress; laying quietly in bed
- Neuro: alert; oriented; CN II-XII intact; intact UE and ___
sensation to light touch; ___ ankle flexion/extension b/l
- HEENT: periorbital erythema and swelling of the right palpebra
without conjunctival injection; intact visual acuity; anicteric
sclera; PERRL; EOMI without pain; no proptosis; white, slightly
scrapable plaque over the tongue with scattered white vesicles;
white-based aphthous ulcers on the inner lower lip and hard
palate; erythematous hard palate; erythema around nares with
some scale
- Neck: supple
- CV: RRR; normal S1 & S2; no m/r/g; 2+ pulses b/l
- Lungs: CTAB; no adventitious breath sounds
- Abdomen: +BS; soft; nontender; nondistended; no HSM; several
hyper and hypopigmented macules on the lower abdomen (scars from
nephrectomy)
- GU: no Foley; no genital ulcers
= Skin: - Skin phototype III
- Erythematous edematous plaques with ill-defined borders
involving R periorbital region, L cheek, and nasal and
infranasal
region
- Multiple 1-2 cm erythematous, edematous, bosselated,
well-demarcated plaques, some with pseudovesiculation, central
pustule or ulcerations on the scalp, bilateral arms, right
shoulder, and lower extremities
- Multiple oral aphthous ulcers on lateral aspects of tongue
- White ulcerated plaques on the L lower lip
- Thick, white plaques on the tongue suggestive of oral thrush
= Extremities: WWP; no cyanosis or clubbing; b/l posterior ankle
erythema, edema, and warmth to touch; pain on ankle
flexion/extension and tenderness to palpation of posterior
ankles b/l
- Lymph: no axillary, inguinal, preauricular, postauricular,
occiptal, submandibular, cervical, or supraclavicular LAD
DISCHARGE PHYSICAL EXAM:
- VS: Tmax/Tcurrent 98.1/101.0, BP 110/69 (110-116/69-72), HR 88
(86-88), RR 20, 95% on RA (95-98)
- General: no acute distress; lying in bed
- HEENT: decreased periorbital erythema and swelling of the
right eye without conjunctival injection; intact visual acuity;
anicteric sclera; PERRL; EOMI without pain; no proptosis; white,
scrapable coating over the tongue; increased number of white
vesicles on the hard palate; erythematous hard palate;
white-based aphthous ulcers on the inner lower lip
- Neck: supple
- CV: RRR; normal S1 & S2; no m/r/g
- Lungs: CTAB; no adventitious breath sounds
- Abdomen: +BS; soft; nontender; nondistended; no HSM; several
hyper and hypopigmented macules on the lower abdomen (scars from
nephrectomy)
- GU: no Foley
= Skin
- Resolving erythematous plaque involving R periorbital region,
significantly less edematous and red compared to four days ago.
- Resolving plaques on L cheek, nasal and infranasal regions
- Multiple 1-2 cm flat plaques with brown pigmentation and some
with ulcerations on the scalp, bilateral arms, right shoulder,
and lower extremities
- Few new 0.5 cm erythematous papules on the arms and lower
extremities
- Multiple aphthous ulcers on lateral aspects of tongue and hard
palate
- Crusted erosions on the L lower lip, resolving
- Thick, white plaque on the tongue suggestive of oral thrush
= Extremities: WWP; no cyanosis or clubbing; b/l posterior ankle
erythema, edema, and warmth to touch (improved from yesterday);
pain on R ankle flexion/extension and tenderness to palpation of
R ankle
- Neuro: alert; ___ ankle flexion/extension b/l
Pertinent Results:
ADMISSION LABS
___ 06:07PM BLOOD WBC-7.3 RBC-4.36* Hgb-13.9* Hct-40.3
MCV-93 MCH-31.9 MCHC-34.5 RDW-12.3 Plt ___
___ 06:07PM BLOOD Neuts-67.7 ___ Monos-10.0 Eos-0.5
Baso-0.7
___ 06:07PM BLOOD Plt ___
___ 01:30PM BLOOD ___ PTT-41.2* ___
___ 01:30PM BLOOD Neuts-76.4* Lymphs-13.5* Monos-9.7
Eos-0.1 Baso-0.3
___ 06:07PM BLOOD Glucose-106* UreaN-9 Creat-1.1 Na-137
K-4.7 Cl-102 HCO3-26 AnGap-14
___ 06:35AM BLOOD ALT-18 AST-21 AlkPhos-61 TotBili-0.7
___ 06:35AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.1
___ 06:16PM BLOOD Lactate-1.3
___ 06:47PM URINE Color-Straw Appear-Clear Sp ___
___ 06:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 06:47PM URINE
___ 11:37 AM CHEST X-RAY (PA & LAT)
There is mild streaky atelectasis at the left lung base. No
focal consolidation, pleural effusion, pneumothorax, or
pulmonary edema is seen. The cardiomediastinal silhouette, hilar
contours, and pleural surfaces are normal.
IMPRESSION: No central adenopathy or other lung findings to
suggest sarcoidosis.
DISCHARGE LABS
___ 06:30AM BLOOD WBC-5.8 RBC-4.45* Hgb-13.7* Hct-41.1
MCV-92 MCH-30.8 MCHC-33.4 RDW-12.0 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-37.1* ___
___ 10:45AM BLOOD ESR-52*
___ 06:30AM BLOOD Glucose-133* UreaN-11 Creat-0.9 Na-140
K-4.8 Cl-100 HCO3-27 AnGap-18
___ 06:30AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.3
___ 10:45AM BLOOD Ferritn-354
___ 01:30PM BLOOD CRP-83.0*
___ 10:45AM BLOOD HIV Ab-NEGATIVE
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
55 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
If current infection is suspected, submit follow-up serum
in ___
weeks.
___ 10:45AM BLOOD HCV Ab-NEGATIVE
___ 06:35AM BLOOD ___
___ 06:35AM BLOOD RheuFac-11 CRP-71.9*
___ 06:35AM BLOOD ANCA-NEGATIVE B
___ 10:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___ 2:53 pm TISSUE Source: Skin biopsy.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
___ 3:00 pm SWAB Site: ARM Source: left arm.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): NO GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
FUNGAL CULTURE (HAIR/SKIN/NAILS) (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
___ 6:35 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
URINE CULTURE (Final ___: NO GROWTH.
___ 6:07 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
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 25 mg PO DAILY
4. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN pain
5. Atorvastatin 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 8 hours
Disp #*9 Capsule Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN pain
7. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
8. Lidocaine Viscous 2% 10 mL PO TID:PRN mouth pain
please take prior to food, only as needed for mouth pain, for
maximum 3 times a day
RX ___ [FIRST-Mouthwash ___] 400
mg-400 mg-40 mg-25 mg-200 mg/30 mL 10 ml three times a day Disp
#*1 Bottle Refills:*0
9. Fluconazole 200 mg PO Q24H Duration: 14 Days
RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Sweet's syndrome
Secondary diagnosis: thrush
Tertiary diagnoses: coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Patient with RCC status post nephrectomy, now with ankle swelling
and rash, rule out sarcoid.
COMPARISON: ___.
FINDINGS: Frontal and lateral chest radiographs were obtained.
There is mild streaky atelectasis at the left lung base. No focal
consolidation, pleural effusion, pneumothorax, or pulmonary edema is seen.
The cardiomediastinal silhouette, hilar contours, and pleural surfaces are
normal.
IMPRESSION: No central adenopathy or other lung findings to suggest
sarcoidosis.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: R Eye pain, Rash
Diagnosed with ORAL APHTHAE, CELLULITIS OF FACE
temperature: 100.2
heartrate: 100.0
resprate: 16.0
o2sat: 98.0
sbp: 131.0
dbp: 84.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year-old ___ man with a history of left
partial nephrectomy for renal cell carcinoma who presents with
painful oral ulcers, rash, and right periorbital swelling. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Shortness of Breath, Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with h/o COPD on home O2, HCV cirrhosis (Child's
class A, genotype 1A on 24 week course of sofosbuvir and
daclatasvir) c/b portal hypertension, splenomegaly, abdominal
varices, morbid obesity, CAD, HTN and opioid use disorder on
methadone who presents with shortness of breath and hemoptysis.
Of note, the patient was recently admitted to ICU ___ with
respiratory failure requiring intubation and was diagnosed with
pneumococcal pneumonia.
She presents today with worsening shortness of breath and
lightheadedness. She states that she was seen by her physician
___ 10 days ago and was diagnosed with a pneumonia
after chest x-ray revealed bilateral patchy infiltrates and
prescribed doxycycline and augmentin for 5 days. She states that
she finished the course 3 days ago but continues to have
subjective fevers, chills, bilateral back pain, lightheadedness,
dyspnea and some chest pain. She has also had some scant
epistaxis. She does not have hemoptysis as stated in the ED
dashboard. She does not know of any prior history of DVT or PE,
she does not have any leg swelling or pain.
In the ED, initial VS were:
98.6 68 112/58 16 96% 2L NC
Exam notable for:
Patient alert and oriented to conversation
anicteric
No respiratory distress, lungs CTA b/l
Exam with some mild abdominal tenderness without clear
localization.
Labs showed:
Troponin <0.01
Platelet count of 67
WBC of 5.5
INR 1.4
Imaging showed:
CTA:
1. No evidence of pulmonary embolism or aortic dissection.
2. Parenchymal opacification in the bilateral lung bases, right
greater than
left, likely reflect atelectasis. However, in the appropriate
clinical
setting, superimposed infection cannot be excluded.
3. Peripheral peribronchovascular opacification the left upper
and lower lobes
may represent small airways inflammation.
4. Mildly enlarged mediastinal and right hilar lymph nodes are
similar to
mildly bigger compared to ___ and may be reactive.
5. Moderate coronary artery calcifications
Patient received:
___ 21:01 PO Ibuprofen 600 mg
___ 23:51 IV CefePIME
___ 23:51 PO/NG Gabapentin 300 mg
___ 00:05 IV Azithromycin
___ 00:38 IV CefePIME 2 g
___ 02:29 IV Azithromycin 500 mg
Hepatology was consulted and had no other recommendations.
Transfer VS were:
98.5 63 97/56 15 95% 2L NC
On arrival to the floor, patient reports feeling somewhat better
and reports continued SOB that comes and goes in episodes.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
HEPATITIS C
CIRRHOSIS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
CHRONIC METHADONE
Daily dosing from Habit ___
CORONARY ARTERY DISEASE
HYPERTENSION
LOW BACK PAIN
CVA ___, no significant residuals
Social History:
___
Family History:
HLD, COPD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 PO 128 / 68 R Sitting 63 20 97 3l
Weight: 209.9 lb. Discharge weight in ___ was 203 lbs.
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Diminished breath sounds at the bases. bilateral crackles
heard up to mid lungs. anterior wheezing.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vital Signs: T:98.2 BP:101 / 64 P:70 RR:18 POx:95% on 2L NC
GENERAL: Obese woman in no acute distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, oropharynx clear
NECK: supple, no LAD, no JVD, Posterior neck with 3cm soft,
mobile, rubbery skin-colored, mildly tender nodule.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Improved air movement. Inspiratory and expiratory
rhonchi. Breathing comfortably on 2 L of oxygen without the use
of accessory muscles.
ABDOMEN: Obese, soft, + bowel sounds non-distended, non-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
Pertinent Results:
ADMISSION LABS: ___ 02:40PM
================
WBC-5.5 RBC-3.54* Hgb-11.3 Hct-34.9 MCV-99* MCH-31.9 MCHC-32.4
RDW-14.3 RDWSD-51.8* Plt Ct-67*
___ PTT-31.5 ___
Glucose-102* UreaN-12 Creat-0.6 Na-140 K-4.9 Cl-106 HCO3-27
AnGap-7*
ALT-24 AST-54* AlkPhos-165* TotBili-0.6
Lipase-44
cTropnT-<0.01
Albumin-2.9* Calcium-8.3* Phos-3.5 Mg-1.9
BLOOD TOX: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Lactate-1.2
DISCHARGE ___ 05:34AM
===============
WBC-4.9 RBC-3.52* Hgb-11.2 Hct-34.6 MCV-98 MCH-31.8 MCHC-32.4
RDW-14.3 RDWSD-51.3* Plt Ct-60*
___ PTT-31.8 ___
Glucose-82 UreaN-15 Creat-0.7 Na-141 K-4.6 Cl-101 HCO3-31
AnGap-9*
ALT-21 AST-33 AlkPhos-150* TotBili-0.7
Albumin-3.0* Calcium-8.9 Phos-4.2 Mg-1.9
MICROBIOLOGY
============
URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA.
>100,000 CFU/mL. Alpha hemolytic colonies consistent with alpha
streptococcus or Lactobacillus sp.
IMAGING:
========
Chest XRAY ___:
COMPARISON: Chest radiographs from ___ and ___.
CT of the
chest dated ___
IMPRESSION: Similar overall pattern of mid to lower lung
ground-glass opacities which may represent an atypical pneumonia
and/or scarring. Please correlate clinically.
LIVER ULTRASOUND ___:
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion or ascites.
2. Patent portal and hepatic veins.
3. Splenomegaly of 17.0 cm is similar to ___.
4. Cholelithiasis without evidence of cholecystitis.
CT ANGIOGRAM ___:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Parenchymal opacification in the bilateral lung bases, right
greater than left, likely reflect atelectasis. However, in the
appropriate clinical setting, superimposed infection cannot be
excluded.
3. Peripheral peribronchovascular opacification in the the left
upper and
lower lobes may represent small airways inflammation or
infection.
4. Mildly enlarged mediastinal and right hilar lymph nodes are
similar to
mildly bigger compared to ___, nonspecific but may
be reactive.
5. Moderate coronary artery calcifications.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with worsening abdominal distension, history of ascites//
assess for pna, assess for pvt
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___ and ___. CT of the
chest dated ___
FINDINGS:
PA and lateral views the chest were provided. Nonspecific ground-glass
opacities within the mid and lower lungs bilaterally again noted which may
represent pneumonia versus scarring. A component of atelectasis is suspected
at the right lung base. No large effusion or pneumothorax. No convincing
evidence for edema. Cardiomediastinal silhouette appears normal. Imaged bony
structures are intact.
IMPRESSION:
Similar overall pattern of mid to lower lung ground-glass opacities which may
represent an atypical pneumonia and/or scarring. Please correlate clinically.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with worsening abdominal distension, history of ascites//
assess for pna, assess for pvt
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___.
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 and right
portal veins are patent with hepatopetal flow. The hepatic veins are patent.
There is no ascites. A small right pleural effusion is noted.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm.
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, enlarged measuring 17.0 cm, previously 17.8 cm.
A 0.9 cm echogenic focus in the spleen is incompletely characterized, but
likely represents a hemangioma.
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 liver, without evidence of focal lesion or ascites.
2. Patent portal and hepatic veins.
3. Splenomegaly of 17.0 cm is similar to ___.
4. Cholelithiasis without evidence of cholecystitis.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with dyspnea, hemoptysis*** WARNING *** Multiple
patients with same last name!// assess for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 3.3 s, 25.8 cm; CTDIvol = 19.6 mGy (Body) DLP = 506.1
mGy-cm.
Total DLP (Body) = 516 mGy-cm.
COMPARISON: CTA chest from ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart size is normal. Coronary artery
calcifications are moderate. There is no pericardial effusion. Main
pulmonary artery diameter is within normal limits.
AXILLA, HILA, AND MEDIASTINUM: Several mildly enlarged mediastinal and right
hilar lymph nodes measuring up to 1.4 cm (2:31, 34, 35) are similar to prior
or mildly bigger. No axillary lymphadenopathy is present. No mediastinal
mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Respiratory motion limits detailed evaluation. Moderate upper
lobe predominant centrilobular and paraseptal emphysema is similar to prior.
Areas of parenchymal opacification in the bilateral lung bases, right greater
than left, are noted. Peripheral peribronchovascular opacifications in the
left upper and lower lobes (3:90) may represent small airways inflammation.
The central airways are patent.
ABDOMEN: A subcentimeter hypodensity in the posterior right lobe (2:82) is too
small to characterize. Otherwise, the imaged portions of the upper abdomen
are unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Parenchymal opacification in the bilateral lung bases, right greater than
left, likely reflect atelectasis. However, in the appropriate clinical
setting, superimposed infection cannot be excluded.
3. Peripheral peribronchovascular opacification in the the left upper and
lower lobes may represent small airways inflammation or infection.
4. Mildly enlarged mediastinal and right hilar lymph nodes are similar to
mildly bigger compared to ___, nonspecific but may be reactive.
5. Moderate coronary artery calcifications.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Sore throat, Weakness
Diagnosed with Pneumonia, unspecified organism
temperature: nan
heartrate: 64.0
resprate: nan
o2sat: 100.0
sbp: 114.0
dbp: 53.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ female ___ yo female with h/o COPD
on home O2, HCV cirrhosis (Child's class A, genotype 1A on 24
week course of sofosbuvir and daclatasvir) c/b portal
hypertension, splenomegaly, abdominal varices, morbid obesity,
CAD, HTN and opioid use disorder on methadone who presented with
shortness of breath and hemoptysis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
___ - Pigtail chest catheter placement
History of Present Illness:
___ h/o MVC at the end of ___, restrained, didn't go to
hospital. Has been having ___ weeks of increasing exertional
dyspnea, which he attributed increasing SOB to seasonal
allergies. On seeing his PCP, O2 sat was noted to be 91% with
decreased BS on the L chest, so he was referred to the ED for
further evaluation. Having a mild cough, no pain.
Past Medical History:
PMH: HTN, cardiac disease, h/o TIA, DJD/back pain/spinal
stenosis, h/o prior falls multiple times last year, had syncope
work-up that was normal. Pain clinic patient
PSH: Cysto and open kidney stone removal
Social History:
___
Family History:
Brother: CAD. Mother: DM
Physical ___:
ON DISCHARGE:
VS: T98.1, HR 62, BP 116/58, RR 16, SaO2 94-100% RA
GEN: NO acute distress, alert and cooperative
HEENT: NCAT, EOMI, MMM
CV: RRR
PULM: Easy work of breathing, clear to auscultation
ABD: Soft, nontender, nondistended
EXT: Warm, well perfused
Pertinent Results:
CBC
___ 03:42PM BLOOD WBC-10.1 RBC-4.38* Hgb-15.3 Hct-42.5
MCV-97 MCH-34.9* MCHC-35.9* RDW-16.0* Plt ___
___ 06:05AM BLOOD WBC-10.2 RBC-4.15* Hgb-14.3 Hct-41.2
MCV-99* MCH-34.4* MCHC-34.6 RDW-15.9* Plt ___
___ 05:42AM BLOOD WBC-8.8 RBC-4.09* Hgb-14.2 Hct-38.9*
MCV-95 MCH-34.7* MCHC-36.5* RDW-15.2 Plt ___
CHEMISTRY
___ 03:42PM BLOOD Glucose-99 UreaN-21* Creat-1.3* Na-143
K-4.0 Cl-105 HCO3-25 AnGap-17
___ 06:05AM BLOOD Glucose-111* UreaN-19 Creat-1.3* Na-141
K-3.6 Cl-102 HCO3-32 AnGap-11
___ 05:42AM BLOOD Glucose-144* UreaN-23* Creat-1.4* Na-141
K-3.9 Cl-102 HCO3-30 AnGap-13
___ 06:05AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.7
___ 05:42AM BLOOD Calcium-9.2 Phos-2.7 Mg-1.6
___ CXR
Moderate to large left pneumothorax with concern for underlying
tension, as above. Possible small left pleural effusion.
Pneumomediastinum.
___ CXR
AP portable upright view of the chest. There has been interval
placement of a pigtail left chest tube with interval
re-expansion of the left lung. The tip of the chest tube abuts
the lateral pleura of the left mid lung. There is now a small
amount of subcutaneous emphysema in the left chest wall at the
chest tube insertion site. Mild left basal atelectasis
persists. There is otherwise no change.
___ CXR
As compared to ___ chest radiograph, left pigtail
pleural catheter has slightly changed in position, and a tiny
left apical pneumothorax is visualized with apparent resolution
of the basilar component of the pneumothorax. Exam is otherwise
remarkable for coarse reticularinterstitial opacities at both
lung bases with appearance favoring chronic interstitial lung
disease although coexisting acute interstitial abnormality is
also possible.
___ CXR
As compared to previous radiograph of several hr earlier, left
pleural
catheter remains in place, with a tiny left apical pneumothorax.
Slight
worsening of left basilar opacity, likely due to atelectasis
superimposed upon chronic fibrosis although aspiration is an
additional consideration for the acute component.
___ CXR
Interval removal of left pleural catheter. No pneumothorax.
Medications on Admission:
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Dipyridamole-Aspirin 1 CAP PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 20 mg PO QPM
8. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Spironolactone 25 mg PO DAILY
8. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 tablets by mouth at bedtime Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
spontaneous pneumothorax, resolved s/p pigtail placement (and
subsequent removal)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with DOE // SOB
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is a moderate left-sided pneumothorax. There is flattening of the left
hemidiaphragm, bb possible subtle widening of the left rib interspaces and
slight mediastinal shift to the right, raising concern for tension. There may
be small amount of left pleural fluid. Evidence of pneumomediastinum as also
seen. Subtle patchy right base opacity may be due to atelectasis. The aorta
is calcified and tortuous. The cardiac silhouette is top-normal.
IMPRESSION:
Moderate to large left pneumothorax with concern for underlying tension, as
above. Possible small left pleural effusion. Pneumomediastinum.
NOTIFICATION: Findings discussed with Dr. ___ at 15:33 on ___ 1 minute after discovery, via telephone.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with spontaneous pneumo s/p chest tube placement // eval for
chest tube placement
COMPARISON: Prior exam performed earlier today.
FINDINGS:
AP portable upright view of the chest. There has been interval placement of
a pigtail left chest tube with interval re-expansion of the left lung. The
tip of the chest tube abuts the lateral pleura of the left mid lung. There is
now a small amount of subcutaneous emphysema in the left chest wall at the
chest tube insertion site. Mild left basal atelectasis persists. There is
otherwise no change.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with spotaneous PTX s/p CT to water seal // post
water-seal film
IMPRESSION:
As compared to ___ chest radiograph, left pigtail pleural catheter has
slightly changed in position, and a tiny left apical pneumothorax is
visualized with apparent resolution of the basilar component of the
pneumothorax. Exam is otherwise remarkable for coarse reticular interstitial
opacities at both lung bases with appearance favoring chronic interstitial
lung disease although coexisting acute interstitial abnormality is also
possible.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with spontaneous PTX, now s/p chest tube clamp 1
hr trial // chest tube clamp 1 hr trial, post-clamp film
IMPRESSION:
As compared to previous radiograph of several hr earlier, left pleural
catheter remains in place, with a tiny left apical pneumothorax. Slight
worsening of left basilar opacity, likely due to atelectasis superimposed upon
chronic fibrosis although aspiration is an additional consideration for the
acute component.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with spontaneous PTX, now s/p chest tube pull //
s/p chest tube pull (L pigtail), interval change
TECHNIQUE: PA and lateral chest are submitted.
COMPARISON: Chest x-ray from 13 19 same day.
FINDINGS:
The left pleural catheter has be removed. There is expected subcutaneous
emphysema. There is no pneumothorax. There is patchy opacity in the left
lung base which could represent atelectasis as seen previously. The remainder
of the lungs and mediastinal structures are unchanged.
IMPRESSION:
Interval removal of left pleural catheter. No pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Unsteady gait
Diagnosed with OTHER PNEUMOTHORAX, HYPERTENSION NOS
temperature: 97.8
heartrate: 63.0
resprate: 18.0
o2sat: 93.0
sbp: 135.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman with history of MVC at
the end of ___, restrained, but didn't go to hospital. He has
been having increasing shortness of breath, and was referred to
the ED after seeing his PCP who noted O2 saturation to 91% on
RA. He was found to have a moderate sized pneumothorax on chest
x-ray. A pigtail catheter was put in, which successfully
evacuated the air and was placed on water seal without a leak.
He was subsequently admitted to the Thoracic Surgery service for
observation and monitoring of the pneumothorax. On hospital day
2, the chest tube was removed with no residual pneumothorax.
Given his age and recent trauma, he was evaluated by physical
therapy who ultimately recommended discharge to home. On
hospital day 3, he was discharged. At the time of discharge, he
was oxygenating well, tolerating a regular diet, and pain was
controlled with oral medications alone. He was given the
appropriate discharge and follow-up instructions, specifically
to follow-up with his PCP for restarting his home Aggrenox. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
___
Attending: ___
Chief Complaint:
Neck pain s/p mechanical fall down stairs
Major Surgical or Invasive Procedure:
___: Fusion occiput to C3
___: Emergent cricothyrotomy
___: Conversion of cricothyrotomy to formal tracheotomy
History of Present Illness:
___ w ___ Disease presenting from Neurologist office
___ (___) after suffering a fall down stairs 5 days
prior
with worsening neck pain. Pain markedly increased in the day
prior to presentation. The patient presented to the ED with his
wife and son
(physician by training) who provide most of the patients history
of present
illness.
On ___ the patient was ascending the stairs carrying some
items
when he has a presumed mechanical trip and then fall down 5
stairs with +HS, -LOC. There were no associated prodromal
symptoms of LH, palpitations, aura, CP, SOB, vision changes. Of
note, the patient's family reports he has had new onset of
dysarthria and dysphagia with R sided facial droop since his
fall.
C-spine XR and Head CT at his Neurologist office was revealing
for fracture of the base of the odontoid with posterior
displacement of the dens, anterior soft tissue swelling, as well
as fracture of A-P C1 arch. No acute intracranial findings,
mild-to-moderate chronic small vessel ischemic changes were also
noted.
Both Neurology and Neurosurgery were consulted for further
evaluation of possible stroke and for known c-spine fracture.
Upon presentation to the ED the patient denied F/C/N/V/D
CP/SOB/palp/LH/vision changes/HA.
Endorsed dysarthria, dysphagia, neck pain, though denied new
numbness, paresthesias, weakness. Per pt and family he was
displaying his baseline parkinsonian symptoms, notabley LUE>RUE
resting tremor. Denied urinary or rectal incontience
Past Medical History:
___ Disease
Social History:
___
Family History:
No neurologic issues except a grandfather or great-grandfather
may have had PD.
Physical Exam:
ON ADMISSION
============
Afebrile VSS
Gen: WD/WN, comfortable, NAD. C-collar in place.
HEENT: ERRL bilaterally. Face symmetric, tongue symmetric with
normal palatal elevation.
Neck: point tenderness along the cervical spinous processes,
cephalad more tender than caudad processes.
Lungs: unlabored breathing, regular rate
Cardiac: RRR
Abd: Soft, NT, ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: somnolent, cooperative with exam, following
commands, normal affect. Reads fluently though with mild
dysarthria. Able to repeat back repetitive consonants.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 4+ 4+ 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Resting tremor noted bilaterally, LUE>RUE
Reflexes: B T Br Pa Ac
Right ___
Left ___
Propioception intact
Toes downgoing bilaterally
Rectal - deferred
ON DISCHARGE
============
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place (with options) hypophonic,
trached
Follows commands: [x]Simple [ ]Complex [ ]None
Pupils: Right 3mm Left 3mm
EOM: Tracks
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Speech Fluent: [ ]Yes [x]No - tracheostomy, hypophonic
Comprehension intact [x]Yes [ ]No
Motor: BUE's significant tremor/rigidity. Grips full.
antigravity
BUE's. Wiggles toes to command. Unable to follow formal motor
exam.
Wound: [x]Clean, dry, intact
Pertinent Results:
Please see OMR for pertinent imaging & labs
Medications on Admission:
Sinemet ___ BID, Donepezil 5mg qHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Heparin 2500 UNIT SC BID
8. Insulin SC
Sliding Scale
Fingerstick Q8
Insulin SC Sliding Scale using REG Insulin
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN constipation
12. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H:PRN
secretion
13. Carbidopa-Levodopa (___) 1 TAB PO BID
___ be increased to TID at rehab per neurology.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Unstable displaced C1 arch and type 2 dens fractures with
posterior displacement of the dens and subluxation of C1 on C2
-Complete disruption of the anterior longitudinal ligament
-Respiratory arrest
-Cardiac arrest
-___ Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ man with neck pain status post fall with a possible
dens fx on radiograph presenting for further evaluation.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 427 mGy-cm.
COMPARISON: Cervical spine radiograph dated ___, earlier on the
same day at 10:57.
Reference is made with the CT cervical spine dated ___.
FINDINGS:
There is a horizontal type 2 dens fracture with approximately 1 cm posterior
translation of the odontoid. The posterior aspect of the odontoid is
angulated inferiorly. There is also mildly displaced acute fractures of the
right aspect of the anterior arch of C1 (series 2, image 15) and posterior
arches of C1, consistent with ___ fracture (series 2, image 16).
There is associated posterior translation of C1 on C2. There is mild
prevertebral soft tissue swelling at this level. There is narrowing of the
anterior spinal canal at this level.
Mild anterolisthesis of C5 on C6, C6 on C7 and C7 on T1 are similar the prior
exam and likely degenerative. Background multilevel degenerative changes in
the cervical spine are mild-to-moderate.
IMPRESSION:
Unstable displaced acute C1 arch (___) and type 2 dens fractures with
asoociated posterior translation.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old man with fall and unstable C1 fracture. Evaluation of
ligaments surrounding// ligment injury ligment injury
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: CT cervical spine performed ___, and ___
FINDINGS:
Seen again is a known horizontally oriented type 2 odontoid fracture with
posterior subluxation of the dominant fracture fragment by 9 mm. There is
subluxation of C2 relative to C1, and multiple additional known C1 fractures
are better delineated on the prior CT examination.
There is associated prevertebral soft tissue edema. Anterior longitudinal
ligament is disrupted. Disruption of anterior atlantoaxial ligament. Sprain
of the anterior atlantooccipital membrane without complete disruption. Intact
apical ligament of dense and tectorial membrane.. Suggestion of sprain of the
posterior longitudinal ligament along the right paramedian level sagittal
image 5, without complete disruption. The ligamentum flavum is intact.
Suggestion of interspinous ligament injury at C2-C3. Transverse ligament
appears intact. Mild edema in the posterior paraspinal fat pad at C2-C3
level..
No definite epidural component is identified.
The posterior subluxation of the dominant C2 fracture fragment are results in
moderate to severe canal stenosis, marginating the cervical spinal cord. No
definite cord signal abnormality is seen. No cord flattening.
Subtle mild fracture of the superior ___ T2 endplate.
The remainder of the vertebral body heights are maintained. There is 2 mm of
anterolisthesis of C5 on C6, C6 on C7, and C7 on T1. Within the remainder of
the cervical spinal cord, there is multilevel spondylosis without significant
canal stenosis. Mild right C2-C3, mild bilateral C3-C4, mild-to-moderate
bilateral C4-C5, mild bilateral C5-C6 foraminal narrowing.
The lung apices demonstrate scarring. Small left-sided perineural cyst is
seen at C6-C7. The remainder of the paraspinal soft tissues are grossly
unremarkable.
IMPRESSION:
1. Known 0.9 cm posterior displaced type 2 odontoid fracture,. Moderate
central canal narrowing, minimal cord flattening. No cord edema or
hemorrhage. Complete disruption of the anterior longitudinal ligament,
additional ligamentous injuries as above.
2. No epidural hematoma.
3. Subtle fractures superior T2 endplate, no retrolisthesis.
4. Multiple additional sites of fracture involving C1, better assessed on
recent CT.
5. Degenerative changes, as above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with C1 and C2 displaced fractures//
cardiopulmonary processes cardiopulmonary processes
IMPRESSION:
Compared to chest radiographs ___ and ___.
No pneumonia or evidence of cardiac decompensation. No pneumothorax or
pleural effusion. Heart size normal.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ h/o Parkinsons s/p fall 5 days ago w worsening neck pain
x1day found to have unstable C1 arch C2 dens fx w subluxation of C1 on C2.//
please obtain CTA head/neck to r/out dissection
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 4.3 s, 33.9 cm; CTDIvol = 13.3 mGy (Body) DLP = 450.9
mGy-cm.
3) Stationary Acquisition 5.7 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP =
16.7 mGy-cm.
Total DLP (Body) = 468 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Noncontrast CT C-spine ___.
FINDINGS:
Dental amalgam streak artifact limits study.
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute infarction, hemorrhage, edema, or mass.
Subcortical and periventricular white matter hypodensities are nonspecific,
likely the sequela of small-vessel ischemic disease. The ventricles and sulci
are prominent, suggestive of involutional changes.
There is mild mucosal thickening of the ethmoid air cells with opacification
of several right ethmoid air cells. 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:
Occlusive narrowing right P1 2 junction is noted (see 315:2). Otherwise, 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. Calcification is seen along bilateral carotid
siphons without significant stenosis.
CTA NECK:
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 show apical scarring and dependent
atelectasis. The visualized portion of the thyroid gland is preserved. There
is no lymphadenopathy by CT size criteria. Cervical spine fractures are again
seen including a fracture of the right anterior arch of C1 and bilateral
posterior arches of C1, and a type 2 dens fracture with subluxation of C1 on
C2.
IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. Within limits of study, no evidence of significant stenosis, occlusion or
dissection of the vessels of the head or neck.
3. Nonocclusive narrowing of right posterior cerebral artery and P1-2
junction.
4. C1 and odontoid fractures are again seen with subluxation of C1 on C2.
Radiology Report
EXAMINATION: C-SPINE (PORTABLE)
INDICATION: ___ h/o Parkinsons s/p fall w/ C1 arch C2 dens fx w subluxation
of C1 on C2; now s/p traction with 20 pounds// LATERAL VIEW. please evaluate
for reduction with 20-pound traction. please obtain at 3pm
TECHNIQUE: Single cross-table lateral view of the cervical spine obtained
portably.
COMPARISON: C-spine radiograph from ___ at 10:59, targeted
review of C-spine CT from ___
FINDINGS:
Compared with lateral view of the cervical spine obtained at 10:59 on ___, there has been marked improvement in alignment of the dens
fracture fragment with respect to the base of C2. Overall alignment appears
anatomic on this view. However, possible minimal posterior displacement of
the dens fragment cannot be entirely excluded as there is obscuration of the
posterior surface of the bones by the mandible. Craniocaudal distraction of
the dens fragment from the body of C2 measures approximately 1.6 mm. No
widening of the atlantodental interval.
Elsewhere, cervical lordosis grossly preserved. Trace retrolisthesis at C3/4
is unchanged. Trace retrolisthesis of C4-5 is new or better seen. Trace
anterolisthesis at C5/6 and C6/7 are no longer visualized. The C7/T1 level is
not well visualized on this examination.
Vertebral body heights are preserved.Background facet arthrosis again noted.
Aside from the dens fracture, no displaced fractures identified on this view.
Artifact related to the bed and/or sheets overlies posterior elements of the
lower cervical spine
IMPRESSION:
Considerable interval improvement in alignment of the dens fracture with
respect to the body of C2. Possible minimal posterior displacement of the
dens fragment cannot be entirely excluded.
Minimal multilevel spondylolistheses, with slight changes of some levels
compared with ___, detailed above.
Radiology Report
EXAMINATION: C-SPINE (PORTABLE)
INDICATION: ___ h/o Parkinsons s/p fall with unstable C1/C2 fx s/p reduction
with cervical traction, now with traction removed// LATERAL VIEW. please
obtain at 6pm. please evaluate stability of reduction with traction removed
LATERAL VIEW. please obtain at 6pm. please evaluate stability of reduction
with traction removed
TECHNIQUE: Single portable lateral view of the cervical spine.
COMPARISON: ___ 15:12.
IMPRESSION:
With traction removed, malalignment of the dens fracture has reappeared, with
re-demonstration of roughly 10-11 mm posterior displacement of the superior
fracture fragment. No other changes seen.
Radiology Report
EXAMINATION: C-SPINE (PORTABLE)
INDICATION: ___ h/o Parkinsons s/p fall 5 days ago w worsening neck pain
x1day found to have unstable C1 arch C2 dens fx w subluxation of C1 on C2;
placed back in traction// please obtain LATERAL view at 9pm thanks. eval for
reduction now back in traction please obtain LATERAL view at 9pm thanks.
eval for reduction now back in traction
TECHNIQUE: Single portable cross-table lateral view of the cervical spine.
COMPARISON: ___ 18:04.
IMPRESSION:
Compared to the earlier same day examination, alignment of the dens fracture
has improved, and appears now near anatomic after the patient was placed back
and traction. No other interval changes seen.
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
IMPRESSION:
Fluoroscopic images show steps in a posterior occiput-C4 fusion. Further
information can be gathered from the operative report.
Radiology Report
EXAMINATION: C-SPINE (PORTABLE)
IMPRESSION:
Image from the operating suite shows posterior fusion from the occiput to C3.
Further information can be gathered from the operative report.
Radiology Report
INDICATION: ___ year old man with ___, cspine fracture// L subclavian
line placement Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of the left central venous catheter projects over the cavoatrial
junction. A feeding tube extends to the stomach. There are low bilateral lung
volumes and patchy diffuse opacities which may reflect an element of pulmonary
edema and atelectasis. No pneumothorax. The size of the cardiac silhouette is
within normal limits.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man, intubated// assess for atelectasis, pulmonary
edema assess for atelectasis, pulmonary edema
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderately severe pulmonary edema which developed between ___ and
___ has improved. Lung volumes have increased. No pleural effusion
or pneumothorax. Heart size top-normal.
Tracheostomy tube is off center and approximately one/3 the diameter of the
trachea as inflated by the trach cuff. Clinical inspection of tracheostomy
tube is recommended.
Left subclavian line ends in the low SVC. Nasogastric drainage tube ends in
the upper stomach.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man s/p arrest, ROSC on cooling protocol.// assess
for acute process
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CTA head and neck from ___. head CT ___
FINDINGS:
There is no evidence of acute major vascular territory
infarction,hemorrhage,edema, or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes. Few asymmetric left hemispheric
frontal lobe, subinsular subcortical and deep white matter low densities,
stable since ___, may represent sequela of chronic small vessel
ischemic changes, late subacute ischemia cannot be excluded. Mild
atherosclerotic calcifications are seen in the carotid siphons.
Again partially seen is C1 fracture. Instrumentation is partially seen in the
cervical spine, occiput. There is partial opacification of the ethmoid air
cells. Mild mucosal thickening is seen in the right maxillary sinus.
Moderate mucosal thickening is seen in the sphenoid sinuses. The mastoid air
cells and middle ear cavities appear clear. Po the visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. No new findings. Small left hemispheric subcortical deep white matter
low-attenuation changes, may represent sequela of chronic small vessel
ischemic changes, subacute ischemia cannot be excluded.
2. Moderate paranasal sinus opacification.
3. C1 fracture, instrumentation in place.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with PD and post-op arrest after C1-C3 fusion.
Currently undergoing targeted temperature management and on dexamethasone.//
?Evidence of infection. ?Evidence of infection.
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Widespread pulmonary opacification which developed on ___ continues to
improve. Presumably this was either asymmetric edema or severe aspiration.
Heart size normal. No pleural abnormality. Tracheostomy tube midline. Left
subclavian line ends in the mid SVC. Nasogastric drainage tube ends in the
stomach but would need to be advanced four cm to move all the side ports below
the diaphragm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p Cervical fusion// Remains trached, please
evaluate lung fields Remains trached, please evaluate lung fields
IMPRESSION:
Compared to chest radiographs since ___. Lung volumes are lower and
widespread consolidation has worsened dramatically, with a basal predominance.
The rapid progression since ___ favors pulmonary edema over bilateral
aspiration pneumonia. Pleural effusions are likely but not large. Heart size
top-normal. Mediastinal veins slightly engorged. No pneumothorax.
Tracheostomy tube midline. Upper enteric drainage tube ends in the upper
stomach. Left subclavian line ends in the mid SVC.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ s/p occiput-C3 fusion, post-procedure arrest, poor exam.//
?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 head ___, MR cervical spine ___
FINDINGS:
The patient is status post posterior spinal fusion extending from the occiput
through C3, incompletely imaged on this brain MRI examination. Susceptibility
artifact from the orthopedic hardware limits evaluation of adjacent
structures, particularly within the posterior fossa.
Within these confines, there is no evidence for acute infarction or acute
intracranial hemorrhage. There is no mass, mass effect, edema, or midline
shift. Postsurgical changes are seen along the posterior elements of the
upper cervical spine and occiput, better characterized on subsequent MR
cervical spine examination.
Generalized parenchymal atrophy. Findings consistent with moderate chronic
small vessel ischemic changes. There is gross preservation of the principal
intracranial vascular flow voids.
Mucosal thickening and secretions are seen throughout scattered ethmoid air
cells with partial opacification and air-fluid level seen in the bilateral
sphenoid sinuses and left maxillary 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. No acute intracranial hemorrhage or infarction.
2. Parenchyma volume loss and moderate chronic small vessel ischemic disease.
3. Paranasal sinus opacification, suggestion of acute paranasal sinusitis or
sequela of recent intubation.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ s/p occiput-C3 fusion, post-procedure arrest, poor exam.//
Evaluate hardware
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: CT cervical spine ___, MR cervical spine ___.
FINDINGS:
Patient is status post interval posterior spinal fusion extending from the
occiput through C3. Susceptibility artifact from the orthopedic
instrumentation limits evaluation of the adjacent structures.
Extensive postsurgical changes are noted. The patient's known C1 and
displaced C2 fractures are noted, but better characterized on prior CT
examination. Alignment of the odontoid fracture has significantly improved
since prior. Posterior spinal laminal line alignment is now anatomic.
Central canal narrowing at C1 level secondary to fracture has resolved.
Within the posterior soft tissues overlying the upper cervical spine occiput,
there is a T2 hyperintense, T1 hypointense irregular fluid collection which
measures up to 5.7 x 1.7 cm (SI by AP) and maximum diameter, likely
representing a postoperative seroma. There is minimal mass effect from this
fluid collection on the posterior epidural surface (for example, 07:19).
Normal cord. No evidence of hardware violation of the foramina. Vascular
flow voids are preserved. Postsurgical spinal alignment is anatomic. The
cervical vertebral body heights are grossly maintained. There are no
suspicious osseous lesions identified.
C1-C2, C2-C3, C3-4: There is no definite spinal canal stenosis or neural
foraminal narrowing.
C4-C5: Mild central canal narrowing, more prominent. Mild bilateral foraminal
narrowing. Trace posterior epidural fluid at this level.
C5-C6: Minimal posterior disc bulging is seen without significant canal
narrowing. Uncovertebral and facet joint hypertrophy result in mild bilateral
foraminal narrowing.
C6-C7: A posterior disc bulge flattens the ventral thecal sac with minimal
canal stenosis. There is no significant neural foraminal narrowing at this
level.
C7-T1: There is no definite spinal canal stenosis or neural foraminal
narrowing.
Small volume fluid sphenoid sinus. Prevertebral edema of the level of the
skull base, C1, C2.
IMPRESSION:
1. Status post posterior spinal fusion from the occiput-C3, re-established
anatomic alignment since prior. Resolved canal stenosis at fracture level.
2. 5.7 x 1.7 cm T2 hyperintense postsurgical seroma with minimal mass effect
along the posterior epidural space at the level of C4.
3. C1 and C2 fractures are better visualized on prior CT examination.
4. Mild multilevel spondylosis of the cervical spine, as detailed above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Cervical fusion// Remains trached. Please
evaluate lungs Remains trached. Please evaluate lungs
IMPRESSION:
Compared to chest radiographs ___ through ___.
Patient was in moderate pulmonary edema on ___ when lung volumes
decreased substantially. There is transient improvement, but the edema
recurred on ___, with even lower lung volumes.
Now lung volumes have partially recovered and pulmonary abnormality is largely
restricted to the lower lobes attributable to the combination of edema and
atelectasis, until subsequent developments suggests pneumonia instead.
Tracheostomy tube is midline but caliber of the tube is about ___ the trachea.
Left subclavian line ends in the mid SVC. Upper enteric drainage tube ends in
the mid stomach.
Radiology Report
INDICATION: ___ year old man with Cervical fusion// Possible Ilues, please
evaluate
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None available
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p cardiac arrest with tracheostomy in place//
Eval for consolidation/edema
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged, as is the overall appearance of the heart and lungs.
Heterogeneous areas of opacification are again seen primarily at the right
base and in the left mid zone. In the appropriate clinical setting, this
would be worrisome for aspiration/pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p cardiac arrest, intubated// Eval for
consolidation/edema
IMPRESSION:
In comparison with study of ___, the monitoring and support devices are
stable. There are lower lung volumes. Heterogeneous opacification ends are
again seen primarily at the right base and left mid to upper zone. In the
appropriate clinical setting, this would be worrisome for multifocal
pneumonia. Indistinctness of pulmonary vessels is consistent with some
elevation in pulmonary venous pressure.
Radiology Report
INDICATION: ___ year old man with unstable fx C1 arch C2 dens w
subluxation//resolution versus worsening of previous opacities
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___
FINDINGS:
In comparison to the previous study, the monitoring and supporting devices
appear stable. Patchy opacifications at the right lung base and left mid lung
appear unchanged. This may represent pneumonia. There is improved aeration
in the left upper lobe. There are somewhat low lung volumes. Degenerative
changes are seen in the spine. There is no large pleural effusion. There is
stable left apical pleural thickening.
IMPRESSION:
Improved aeration left lung apex when compared to the previous study.
Otherwise stable.
Radiology Report
INDICATION: ___ year old man with cervical fxs, s/p occiput to C3 fusion,
emergent cricothyrotomy, OR tomorrow for formalization of trach// Pre-op
evaluation Surg: ___ (formalization of trach)
TECHNIQUE: Chest x-ray ___. Chest x-ray ___.
COMPARISON: Chest x-ray ___
FINDINGS:
There is a tracheostomy tube in situ. Increased interstitial markings are
seen at the lung bases, possibly pneumonia. There are low lung volumes. The
heart is normal in size. Degenerative changes are seen in the spine. There
is no large pleural effusion. Stable left apical pleural thickening.
IMPRESSION:
Low lung volumes. Increased interstitial markings at the lung bases similar
to previous.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p trach, febrile// Confirm NG tube placement
and rule out pneumonia
IMPRESSION:
In comparison with the study of ___, there are improved lung volumes.
Tracheostomy tube remains in place and the mask obscures much of the superior
mediastinum. Cardiac silhouette is unchanged with mild elevation of pulmonary
venous pressure. No definite consolidation.
Specifically, the tip of the nasogastric tube is below the hemidiaphragm and
the side-port is in the region of the normal position of the esophagogastric
junction.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abnormal CT, s/p Fall
Diagnosed with Unsp disp fx of first cervical vertebra, init for clos fx, Unspecified fall, initial encounter
temperature: 98.1
heartrate: 74.0
resprate: 14.0
o2sat: 100.0
sbp: 163.0
dbp: 78.0
level of pain: 8
level of acuity: 2.0 | #Unstable displaced C1 arch and type 2 dens fractures with
posterior displacement of the dens and subluxation of C1 on C2 +
Complete disruption of the anterior longitudinal ligament
Upon presentation to the ___ ED, CT C-spine and MRI C-spine
were promptly obtained. These studies were revealing for
unstable displaced C1 arch and type 2 dens fractures with
posterior displacement of the dens and subluxation of C1 on C2,
as well as complete disruption of the anterior longitudinal
ligament at these levels. The patient was admitted to the
neurosurgical service and his neurological status was monitored
frequently on the ward. On the morning of HD1, the patient was
transferred to the ___ for hourly neurologic examinations and
for placement of axial traction. A ___ traction tong
was applied with 20lbs of traction. After approximately 2 hours
of traction, portable lateral XR of the C spine were obtained
and demonstrated considerable interval improvement in alignment
of the dens fracture with respect to the body of C2. Traction
weight was then removed and a repeat lateral XR of the C spine
was taken after reduction without traction in place and was
revealing for loss of reduction of fracture, so traction was
replaced. On the evening of HD 1, the patient and his family
arrived at the decision to proceed with occiput to C4 fusion.
On HD 2 the patient was taken to the OR with Dr. ___
___ occiput to C3 fusion. His operative course was
uncomplicated, however upon extubation the patient displayed
signs of airway obstruction and suffered an episode of
respiratory arrest requiring a brief course of CPR and
administration of epiniephrine. An airway was established via
cricothrotomy after attempts at fiberoptic intubation were
unsuccessful. Please see operative note and anesthesia event
note for full details. Postoperatively, the patient was
transferred to the Neurosurgical Intensive Care Unit for
neurologic monitoring. paralytics were reversed in the ICU.
Cervical collar was continued postoperatively. His motor exam
improved during his ICU stay. EEG showed abnormal discharges,
but no generalization so no AED was started. He was continued on
his home Sinemet. Patient was transferred to the ___ as his
neurological exam began to improve and remained neurologically
stable during his hospitalization.
#Dysarthria/dysphagia
Patient was evaluated in the ED by Neurology service upon
presentation. Per their initial evaluation, the suspicion for
stroke was low, and it was felt that his dysarthria could be a
sequelae of his ___ disease and worsened in the context
of pain from neck fracture. Advanced additional imaging (i.e.
MRI Brain) was not deferred at the time with plans to obtain a
brain MRI if his neurologic status/exam demonstrated an acute
change or persistence of symptoms. Given the possibility of a
vertebral artery dissection leading to small brainstem infarct
in the setting of C1-C2 fracture, CTA head and neck were
obtained early on HD1. CTA head and neck were negative for an
acute intracranial or vertebral process, vessel stenosis,
occlusion, aneurysm, or dissection. The neurology service
continued to follow the patient during his inpatient admission.
SLP was consulted to evaluate the patient's swallowing. SLP
evaluation was deferred until s/p tracheostomy reconstruction.
Post-reconstruction, SLP evaluation was deferred until the cuff
could be deflated and will be performed at rehab.
#Respiratory/Cardiac Arrest
Postoperatively, the patient was slow to awaken. He was
ultimately extubated and was breathing spontaneously. Shortly
after, he developed upper airway obstruction, respiratory
arrested and lost pulse. ROSC was achieved with spontaneous
breathing after CPR and epinephrine. His airway remained labile
and was unable to be secured via fiberoptic intubation.
Cricothyrotomy was created to establish airway. Postcardiac
cooling was initiated on POD#0 and completed POD#1. he underwent
bronchoscopy and BAL in the ICU which grew GNR's. ENT was
consulted for decannulation of cricothyrotomy and vocal cord
assessment. Tracheostomy was formalized with ENT on ___.
Tracheostomy cuff was deflated on ___ with a plan to return
as an outpatient follow up for trach change. ENT discussed the
plan for tracheostomy change with the family, who agreed with
the plan.
#GU
KUB on ___ was concerning for possible SBO vs ileus, bowel
regimen was adjusted.
#Fever
The patient was on post-arrest cooling protocol on POD#0 and
rewarmed on POD#1. he was febrile during his ICU stay and
placed on arctic sun POD#1. He was pancultured and started on
cefepime/vancomycin for leukocytosis. BAL grew GNR's and MRSA
swab was negative for vancomycin was discontinued on ___.
Antibiotics were narrowed to ceftriaxone on ___, to complete
___.
Patient had axillary temp up to 101.0 on ___, UA/UC and BC were
ordered. Initially, the family declined BC, but later agreed.
The family declined condom catheter, so collection of UA was
deferred until a sample could be collected. A CXR was also
ordered, which the family refused. WBC downtrended. The patient
was afebrile in the afternoon but spiked again overnight; CXR
was completed which showed no definite consolidation. Sputum
culture was sent and is pending; this may be followed up at
rehab. He remained afebrile at the time of discharge.
#Anticoagulation
The patient had elevated PTT and INR; heparin was held
postoperatively and he received vitamin K to maintain INR goal
of <1.4. Heparin was started, but at a lower dose of 2500 units.
#Discharge Planning
After discussion with ENT and at request of the family, the
patient was discharged to rehab on ___ with tracheostomy cuff
deflated with agreed-upon plan to return through the ED in 1
week for tracheostomy change. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with a history of recently diagnosed
neuroendocrine gastric tumor on cisplatin/etoposide (last dose
___ fibrillation on apixaban, peptic ulcer
disease, CAD s/p inferior STEMI (___) s/p multiple PCI, HRpEF
(EF 60%) and hypertension who was admitted to the FICU for
management of tachycardia.
Patient reports on ___ he developed worsening shortness of
breath and dizziness when ambulating to the bathroom. He denied
any chest pain, diaphoresis, or nausea at this time. He checked
his BPs, which were elevated in the 140/80 and HRs 103-130. He
took a dose of
enalapril and had some improvement in his shortness of breath,
but continued to have palpitations without chest pain. Due to
the persistence of symptoms, he presented this AM to his PCP, at
which time an EKG was done showing ectopic atrial tachycardia
vs. atrial flutter and a ventricular rate of 134. He was sent to
the ER for further evaluation
In the ED, initial vitals:
T 96.6, HR 133, RR 16, BP 142/95, O2 98% on RA
Exam notable for a clear lung exam and tachycardia. Overall
appeared euvolemic and stable
Labs notable for chem 7 WNL, Trop 0.03, lactate 1.7, and
negative UA.
Imaging:
CXR ___
AP portable upright view of the chest. Overlying EKG leads are
present. Left CP angle is partially excluded. The lungs appear
clear. No focal consolidation, large effusion or pneumothorax.
The heart appears top-normal in size. Mediastinal contour
appears normal. Bony structures are intact. AC joint
arthropathy noted bilaterally.
CTA ___
No evidence of pulmonary embolism or aortic dissection.
Scattered apparent ground-glass opacity/mosaic attenuation of
the lungs, may relate to combination of expiration and areas of
air trapping. There may also be a component of pulmonary edema.
Cholelithiasis.
Patient received:
1325 Metoprolol IV 5mg
1350 Metoprolol IV 5mg
1401 metoprolol 50mg PO
1533 esmolol drip at 50mcg/kg/min
1539 esmolol drip at 100mcg/kg/min
1618 esmolol drip at 200mcg/kg/min, 1L NS
___ esmolol drip at 150mcg/kg/min
Consults: None
Vitals on transfer:
T 97.9 HR123 RR 17 Bp 110/76 O2 98% on room air
Upon arrival to ___, Mr. ___ was stable, with HRs in the
110-124 on esmolol drip. Denied any CP, SOB, or abdominal pain.
He states he may have missed his metoprolol dose on ___, but
he is unsure. He has not had any recent URI symptoms, fevers,
chills, nausea, vomiting, or diarrhea. Has been tolerating
chemotherapy well.
Past Medical History:
A-fib on apixaban (held ___
CAD s/p STEMI (___) s/p multiple
iHFrEF (LVEF 45%)
HTN
COPD
Peptic ulcer disease
Arthritis (ankles, knees, spine, hands)
Gout
Social History:
___
Family History:
Father died at ___ from stroke. No family history of tumors,
aneurysms, brain hemorrhage, or neuro degenerative disease.
Physical Exam:
ADMISSION EXAM:
VITALS: T 97.9 HR123 RR 17 Bp 110/76 O2 98% on room air
GENERAL: Lying in bed in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rhythm,tachycardic, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: wide- spread seborrheic keratoses
NEURO: CN II-XII intact, strength ___ UE and ___, AAOx3, no focal
deficits
ACCESS: 2 peripheral
Discharge physical exam:
VITALS: 98.0 PO 110 / 65 112 24 99% Ra
GENERAL: Lying in bed in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rhythm, tachycardic, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: wide- spread seborrheic keratoses
NEURO: CN II-XII intact, strength ___ UE and ___, AAOx3, no focal
deficits
ACCESS: 2 peripheral
Pertinent Results:
___ 05:38AM BLOOD UreaN-20 Creat-1.3* Na-139 K-4.1 Cl-100
HCO3-24 AnGap-15
___ 05:38AM BLOOD WBC-6.6 RBC-2.79* Hgb-8.4* Hct-26.9*
MCV-96 MCH-30.1 MCHC-31.2* RDW-27.0* RDWSD-94.8* Plt Ct-81*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO BID
2. Amiodarone 100 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Colchicine 0.6 mg PO PRN gout
5. Docusate Sodium 100 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. Ranitidine 150 mg PO DAILY
8. Apixaban 5 mg PO BID
9. Aspirin 81 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Diltiazem 60 mg PO TID
RX *diltiazem HCl [Cardizem] 60 mg 1 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*3
2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0
3. Amiodarone 200 mg PO TID Duration: 3 Days
RX *amiodarone 100 mg 2 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*1
4. Metoprolol Succinate XL 150 mg PO BID
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*3
5. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN
6. Allopurinol ___ mg PO BID
7. Apixaban 5 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Colchicine 0.6 mg PO PRN gout
11. Docusate Sodium 100 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. Ranitidine 150 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
AFib/Flutter with rapid ventricular response
Dyspnea on exertion
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: ___ with chest pain and shortness of breath// ?pna, edema
COMPARISON: Prior study from ___ and CT from ___
FINDINGS:
AP portable upright view of the chest. Overlying EKG leads are present. Left
CP angle is partially excluded. The lungs appear clear. No focal
consolidation, large effusion or pneumothorax. The heart appears top-normal
in size. Mediastinal contour appears normal. Bony structures are intact. AC
joint arthropathy noted bilaterally.
IMPRESSION:
Mild cardiomegaly, no signs of edema or pneumonia.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with cancer, tachycardia// assess for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 4.4 s, 34.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 785.2
mGy-cm.
Total DLP (Body) = 796 mGy-cm.
COMPARISON: CT chest from ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level without filling defect to indicate a pulmonary embolus. The
aorta is normal in course and caliber. Coronary artery calcifications are
seen. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. Punctate left hilar calcifications may relate to
prior granulomatous disease. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Respiratory motion limits detailed evaluation. Examination was
obtained in relative expiration. Scattered apparent ground-glass
opacity/mosaic attenuation of the lungs, may relate to combination of
expiration and areas of air trapping. There may also be a component of
underlying pulmonary edema. A 2 mm nodule at the left lung apex (___) is
unchanged. The central airways are patent.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen demonstrates cholelithiasis.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Ossification of the anterior longitudinal ligament is noted in the imaged
thoracic spine. A large anterior bridging osteophyte spans T1 to T3.
IMPRESSION:
No evidence of pulmonary embolism or aortic dissection.
Scattered apparent ground-glass opacity/mosaic attenuation of the lungs, may
relate to combination of expiration and areas of air trapping. There may also
be a component of pulmonary edema
Cholelithiasis.
Radiology Report
INDICATION: ___ year old man with new L PICC//.
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Radiograph from ___.
FINDINGS:
Mild cardiomegaly is unchanged compared to the prior exam. Left-sided PICC
line terminates within the mid to low SVC. There is no large pleural effusion
or pneumothorax. Visualized osseous structures are unremarkable.
IMPRESSION:
Left-sided PICC line terminates within the mid to low SVC.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Tachycardia, Weakness
Diagnosed with Unspecified atrial fibrillation
temperature: 96.6
heartrate: 133.0
resprate: 16.0
o2sat: nan
sbp: 142.0
dbp: 95.0
level of pain: 0
level of acuity: 1.0 | ___ hx recently diagnosed neuroendocrine gastric tumor (on
cisplatin/etoposide, last dose ___, stroke ___, AFib on
apixaban, PUD, CAD s/p inferior stemi ___ and s/p stents, HF
with EF 60% in ___ and 43% in ___, Htn p/w dizziness,
tachycardia, admitted to the ICU for uncontrolled HR.
#Tachycardia (atrial flutter, some afib overnight)
-at home metoprolol XL 100mg daily is home dose, was previously
on 100mg XL BID which was changed by o/p cardiologist per
patient
___ normal blood pressure, about a month ago. Also takes
amiodarone 100mg po daily. In the ICU required esmolol and
Cardizem drips,
- upon arrival to telemetry floor HR still in the 120-130's. Not
clearly related to infection but seems more likely related to
medication dose change. Has had cardioversion
- after transfer to floor we attempted a number of changes to
reduce his HR:
1. amiodarone 200mg TID x 3 days (started ___ in ___
2. metoprolol increased 150mg XL po BID
3. dilt 30 tid
-cardiology following, decision was that cardioversion was need
to control rate better, however given concerns about platelet
count and how long eliquis was being taken consistently decision
to pursue as outpatient. Though his HR continued to be elevated
(low 110's) he was asymptomatic and able to ambulate halls
without an issue.
- discharge plan as outlined in discharge orders. f/u in ___
hrs
- chose to increase dilt at discharge with hope that this can
further drop his HR or possibly he might convert to sinus on his
own |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
CC: ___ Pain
HPI: Mrs. ___ is ___ yo woman with well controlled asthma,
prior treated h pylori and anxiety who presents with one week of
worsening abdominal pain.
She states about one week ago started to feel sharp LUQ and
midepigastric abdominal pain. The pain was ___ and worse with
eating. It got better when she didn't eat or when she was
sleeping. Due to increasing pain she went to see her PCP who did
___ rectal exam which was positive for gross blood prompting her
to
send the patient to the ED.
On arrival to the ED vitals were T 98.3, HR 82, Bp 131/88, RR16,
O2Sat 98% RA. She had a CT abdomen which showed an area of the
duodenum which was read as either duodenal diverticulum vs
duodenal ulcer. She was given GI cocktail, donnatal, lidocaine,
and Tylenol. Surgery was consulted and recommended full GI
workup
with EGD.
On arrival to the floor she is very tearful and continues to be
in pain. She feels dehydrated and has a headache. She is missing
many jobs this weekend and is worried what that means for her
family. She denies any weight loss, diarrhea, melena, BRBPR.
14 point ROS reviewed with patient and negative except per HPI
Past Medical History:
headache
Asthma
Anxiety
H Pylori treated ___ years ago
.
Medications on admission:
Albuterol
Zoloft
Allergies: Compazine
.
Social History: ___
Family History: M: very healthy, vision issues
F; Died recently of lung cancer
.
Past Medical History:
Past Medical History:
headache
Asthma
Anxiety
H Pylori treated ___ years ago
.
Social History:
___
Family History:
Family History: M: very healthy, vision issues
F; Died recently of lung cancer
Physical Exam:
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, minimally tender to palpation in
midepigastric area,
mildly distended
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
___ 06:23PM BLOOD WBC-6.2 RBC-4.23 Hgb-12.9 Hct-39.7 MCV-94
MCH-30.5 MCHC-32.5 RDW-12.0 RDWSD-41.5 Plt ___
___ 06:23PM BLOOD Plt ___
___ 06:23PM BLOOD Glucose-93 UreaN-12 Creat-0.8 Na-138
K-4.2 Cl-103 HCO3-25 AnGap-10
___ 06:23PM BLOOD ALT-15 AST-23 AlkPhos-69 Amylase-52
TotBili-0.7
___ 06:23PM BLOOD Lipase-35
___ 06:23PM BLOOD cTropnT-<0.01
___ 06:23PM BLOOD Albumin-4.6
___ 05:20PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.0 Mg-2.2
___ 06:53AM BLOOD Ferritn-71
CT Scan
1. Subcentimeter hypodense region within the pancreatic head
with surrounding
hyperemia, which appears contiguous with the adjacent duodenum,
either a
mildly inflamed duodenal diverticula or a duodenal ulcer with a
contained
perforation given history of peptic ulcer disease. Small
hemorrhage cannot be
excluded given the blush of contrast. Recommend
gastrointestinal consult for
possible endoscopy.
2. No other acute findings within the abdomen or pelvis.
CT Scan with oral contrast
COMPARISON: Prior day.
FINDINGS:
Visualized lung bases appear clear.
There is no biliary dilatation. No focal liver lesions are
identified. There
is layering material in the gall bladder which is suspected to
be due to
vicarious excretion of contrast from recent prior administration
of
intravenous contrast. The pancreas appears normal. Spleen is
normal in size
and appearance. Adrenals appear normal. There is no evidence
for stones,
solid masses or hydro nephrosis involving either kidney.
There is a very small axial hiatal hernia. Small bowel appears
normal. No
definite duodenal abnormality found although it is possible that
there may be
a small collapsed diverticulum along the second portion. No
evidence for
inflammatory change on this follow-up scan. Appendix appears
normal. Large
bowel is unremarkable.
Intrauterine device is appropriately seated in the endometrium.
Adnexa appear
normal. Bladder is unremarkable. There is no lymphadenopathy,
free air, or
free fluid. Major vascular structures appear widely patent.
There are no suspicious bone lesions.
IMPRESSION:
No evidence of acute abnormality involving the abdomen or
pelvis.
EGD
gastritis
Test Result Reference
Range/Units
HELICOBACTER PYLORI AG, EIA, SEE NOTE
STOOL
HELICOBACTER PYLORI AG, EIA, STOOL
MICRO NUMBER: ___
TEST STATUS: FINAL
SPECIMEN SOURCE: STOOL
SPECIMEN QUALITY: ADEQUATE
RESULT: Not Detected
Antimicrobials, proton pump inhibitors, and
bismuth preparations inhibit H. pylori and
ingestion up to two weeks prior to testing
may
cause false negative results. If clinically
indicated the test should be repeated on a
new
specimen obtained two weeks after
discontinuing
treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
2. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN pain
RX *alum-mag hydroxide-simeth [Maalox Maximum Strength] 400
mg-400 mg-40 mg/5 mL 5 ml by mouth four times a day Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Sucralfate 1 gm PO QID
RX *sucralfate [Carafate] 1 gram 1 tablet(s) by mouth four times
a day Disp #*56 Tablet Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
5. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#Abdominal Pain
#Gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT of the abdomen and pelvis.
INDICATION: ___ year old woman with CT scan concerning for perforated duodenal
ulcer now need repeat scan with oral contrast to decide if truly perforated
and contained// ?is there a perforated ulcer
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
with oral and intravenous contrast. Sagittal and coronal reformations were
also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 19.4 s, 0.2 cm; CTDIvol = 331.5 mGy (Body) DLP =
66.3 mGy-cm.
3) Spiral Acquisition 7.5 s, 48.9 cm; CTDIvol = 11.0 mGy (Body) DLP = 529.4
mGy-cm.
Total DLP (Body) = 598 mGy-cm.
COMPARISON: Prior day.
FINDINGS:
Visualized lung bases appear clear.
There is no biliary dilatation. No focal liver lesions are identified. There
is layering material in the gall bladder which is suspected to be due to
vicarious excretion of contrast from recent prior administration of
intravenous contrast. The pancreas appears normal. Spleen is normal in size
and appearance. Adrenals appear normal. There is no evidence for stones,
solid masses or hydro nephrosis involving either kidney.
There is a very small axial hiatal hernia. Small bowel appears normal. No
definite duodenal abnormality found although it is possible that there may be
a small collapsed diverticulum along the second portion. No evidence for
inflammatory change on this follow-up scan. Appendix appears normal. Large
bowel is unremarkable.
Intrauterine device is appropriately seated in the endometrium. Adnexa appear
normal. Bladder is unremarkable. There is no lymphadenopathy, free air, or
free fluid. Major vascular structures appear widely patent.
There are no suspicious bone lesions.
IMPRESSION:
No evidence of acute abnormality involving the abdomen or pelvis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Epigastric pain
temperature: 98.3
heartrate: 82.0
resprate: 16.0
o2sat: 98.0
sbp: 131.0
dbp: 88.0
level of pain: 5
level of acuity: 3.0 | Mrs. ___ is ___ yo woman with well controlled asthma, prior
treated h pylori and anxiety who presents with one week of
worsening abdominal pain found to have mildly inflamed duodenal
diverticula vs duodenal ulcer with a contained perforation on CT
scan but subsequent CT scan 12 hours later was completely
negative for acute abnormality.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
peanuts
Attending: ___.
Chief Complaint:
left knee dislocation and pain
Major Surgical or Invasive Procedure:
Closed reduction of dislocated left knee
History of Present Illness:
___ otherwise healthy transferred from OSH follow closed
reduction of a knee dislocation. He was playing softball earlier
today, hit the ball, threw the bat and it somehow became caught
between his legs while he wa running, causing him to fall and
dislocating his left knee. He was taken by ambulance to an OSH
where closed reduction was performed. Per report, he always had
good distal pulses. He now complains of inability to dorsiflex
or evert his foot. He has a burning pain over the dorsum of his
foot.
Past Medical History:
GERD
Social History:
___
Family History:
noncontributory
Physical Exam:
Vitals - 99.1 99 124/105 16 97% RA
Extremities - LLE in knee immbolizer. Skin intact with no open
wounds. TTP around knee. No pain with ROM of ankle. Unable to
evert or dorsiflex ankle.
Neurologic - ___ FHL/GSC, ___ ___. Decreased sensation to
light touch in SPN/DPN distribution.
Vascular - 2+ ___ pulses bilaterally. ABI 1.04.
Pertinent Results:
IMAGING:
Left knee x rays from OSH show posterior dislocation.
Post reduction films obtained here show adqueate reduction, no
evidence of fracture or continued dislocation.
Arterial study with normal blood flow bilaterally.
Medications on Admission:
omeprazole
Discharge Medications:
1. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth every 8 hours Disp
#*50 Capsule Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*80 Tablet Refills:*0
3. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left knee dislocation and subsequent ligamentous injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
RADIOGRAPHS OF THE LEFT KNEE
HISTORY: Recent left knee dislocation status post reduction.
COMPARISONS: Radiographs from earlier on the same day.
FINDINGS: There is a small-to-moderate joint effusion. Previously seen
dislocation was reduced. There is no evidence of fracture. The joint spaces
appear preserved.
IMPRESSION: Small-to-moderate effusion. Status post reduction.
Radiology Report
EXAMINATION: MR KNEE W/O CONTRAST LEFT
INDICATION: ___ year old man with left knee dislocation (now reduced) //
ligamentous damage following knee dislocation
TECHNIQUE: Imaging performed at 3.0 using the quad knee coil. Sequences
include axial proton density fat saturation, sagittal proton density, sagittal
T2 fat saturation and coronal proton density fat saturation..
COMPARISON: Knee radiographs from ___.
FINDINGS:
There is a moderate effusion with fluid fluid levels and a small amount of fat
consistent with a Lipo hemarthrosis.
In the medial compartment, the meniscus is intact. Hyaline cartilage is
preserved. No subchondral marrow edema.
In the lateral compartment, globular increased signal is noted within the
anterior horn of the lateral meniscus which is likely secondary to
intra-articular fluid interposing between fibers of the meniscus. Otherwise,
there is no evidence of a lateral meniscal tear. Hyaline cartilage is
preserved. No subchondral marrow edema.
In the patellofemoral compartment, cartilage is preserved. No subchondral
marrow edema.
There are high-grade tears of the proximal fibers of the anterior and
posterior cruciate ligaments. There is complete rupture of the distal lateral
collateral ligament with proximal retraction. The medial collateral ligament
is intact and normal in signal. Increased signal is noted at the interface
between the proximal medial collateral ligament and medial retinaculum.
The quadriceps and patellar tendons are intact.
There is complete disruption of the distal biceps femoris tendon. There is
moderate intramuscular edema within the biceps femoris and both the medial and
lateral heads of the gastrocnemius.
Bone marrow edema is noted over the medial femoral condyle without
demonstration of a discrete fracture line. No osseous avulsion is seen.
Marked subcutaneous soft tissue edema is noted over the lateral aspect of the
knee.
Limited evaluation of the popliteal vessels demonstrate normal flow voids
without evidence of vascular compromise. Please note that this does not
represent a dedicated vascular examination .
IMPRESSION:
High-grade tears of the proximal fibers of both the anterior and posterior
cruciate ligaments.
Complete disruption with retraction of the distal lateral collateral ligament
and biceps femoris tendon.
Increased signal noted at the interface between the proximal medial
collateral ligament and the medial retinaculum consistent with sprain.
Moderate intramuscular edema within the biceps femoris and both the medial
lateral head of the gastrocnemius consistent with moderate strains.
Moderate marrow edema over the medial femoral condyle without demonstration of
a discrete fracture line in the presence of a small Lipo hemarthrosis. A small
nondisplaced fracture is not entirely excluded, and further characterization
with CT can be obtained if clinically indicated.
Radiology Report
INDICATION: ___ man who suffered left knee dislocation, evaluate
ankle-brachial indices.
TECHNIQUE: Bilateral arterial Doppler and pulse volume recordings were
obtained with measurement of ankle pressures and calculation of the ABI.
FINDINGS: Arterial Doppler demonstrates triphasic waveforms at the femoral,
popliteal and tibial vessels on the right and normal triphasic waveforms at
the posterior tibial and dorsalis pedis on the left. Ankle-brachial indices
at rest were (R/L) 1.36/1.31. Pulse volume recordings demonstrated normal
phasic flow with normal amplitude at all levels including the ankle and
metatarsal level.
IMPRESSION: Normal arterial Doppler and pulse volume recording study without
evidence of ischemia.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: L Knee pain
Diagnosed with JOINT PAIN-L/LEG, LOWER LEG INJURY NOS, STRUCK IN SPORTS WITHOUT FALL
temperature: 99.1
heartrate: 99.0
resprate: 16.0
o2sat: 97.0
sbp: 124.0
dbp: 105.0
level of pain: 10
level of acuity: 3.0 | Admitted to orthopaedics for pain control and physical therapy.
By HD 1, he was weight bearing as tolerated, knee in brace in
extension and AFO in place.
Pain was well-controlled on oral pain medications, he was
voiding spontaneously in good amounts, and medically clear for
discharge home. |
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, sustained Vtach
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ YO F w/ PMH of congestive heart failure,
nonsustained ventricular tachycardia, moderate mitral
regurgitation, pulmonary hypertension, dilated cardiomyopathy,
hyperlipidemia presented to ___ with CC of shortness of
breath. Patient says this shortness of breath started at 4 AM in
the morning and woke her up. She denies having any symptoms
before going to the bed. She called her nephew and drove to ___
ED. She describes the complaint as gasping for breath, without
any aggrevating/alleviating factors. She didn't take her usual
medications today as she rushed to the hospital in the morning,
however, she states she is very compliant to her medication
usually.
She says she had similar episodes before and these symptoms
started ___ years ago, she was hospitalized in ___ due to
similar symptoms in ___. She gets short of breath with
going 3 steps up, can't walk 1 block (she repots walking 1.5
miles daily before the symptoms started). She sleeps with 2
pillows but denies getting short of breath laying flat. She
feels palpitations when she gets short of breath, however, she
doesn't get light-headed or dizzy w/ the palpitations. She
doesn't have h/o syncope. Per ___ records she first heard of
nonsustained ventricular tachycardia ___ years ago, had been on
atenolol for that, until it has been switched to metoprolol.
Per ___ records she had transient hypotension with BP of
80 systolic, her EKG showed nonsustained ventricular
tachycardia.
At the outside hospital she had transient hypotension with a
blood pressure of 80 systolic but was found to have 130/100 on
left arm. She was initiated on an amiodarone drip (200mg) and IV
lasix and was transfered to ___.
In the ED, initial vitals were 97.5 125 113/81 18 96%
Labs and imaging significant for Troponin <0.01
Patient given
Today 08:53 Amiodarone 150mg/3mL
Today 09:03 Amiodarone 150mg/3mL
Today 09:39 Amiodarone 600 mg in 5% Dextrose (EXCEL BAG) 1 from
Pharmacy
Today 10:38 Nitroglycerin SL 0.4mg SL Tablet Bottle 1
Today 10:40 Amiodarone 150mg/3mL
On arrival to the floor, patient T=97.8BP=120/67HR=110RR=24 O2
sat=85%
Past Medical History:
. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Corneal implants ___ years ago
-Appendix removal ___ yrs ago
Social History:
___
Family History:
One of her sisters had valve replacement, other sister died of
heart problems. Her family history is significant with diabetes,
otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=97.8 BP=111/79 HR=110 RR=24 O2 sat=98%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink. Had oxygen
mask on.
NECK: Supple with JVP of 2 cm above the clavicle.
CARDIAC: Irregular heart rhythm, S1 and S2 could not be
differenciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Fast
breath sounds, diffuse crackles. Decreased
ABDOMEN: Soft, NTND. Active bowel sounds
EXTREMITIES: No c/c/e.
PULSES: 2+ throughout
DISCHARGE PHYSICAL EXAM
Vitals - Tm/Tc:97.___,4 ___ BP: 105-111/52-67
sat: 100% RA
In/Out:
Last 24H: 770/395 ++
Last 8H: ___
Weight:71.9(70.9)
.
GENERAL: Pleasant in NAD. Alert and interactive.
NECK: supple without lymphadenopathy, JVD at clavicle.
___: regular irregular. ___ systolic murmur at ___.
RESP: No accessory muscle use. Lungs with crackles right base.
ABD: soft, NT/ND, normoactive bowel sounds.
EXTR: no edema. Feet warm
NEURO: Alert and oriented x 3. Denies pain. MAE.
.
Pertinent Results:
ADMISSION LABS
___ 12:52PM BLOOD WBC-9.2 RBC-4.32 Hgb-12.4 Hct-39.8 MCV-92
MCH-28.8 MCHC-31.3 RDW-15.3 Plt ___
___ 12:52PM BLOOD ___ PTT-34.1 ___
___ 09:05AM BLOOD Glucose-121* UreaN-20 Creat-1.2* Na-146*
K-4.3 Cl-108 HCO3-24 AnGap-18
___ 09:05AM BLOOD Calcium-10.1 Phos-3.7 Mg-2.4
DISCHARGE LABS
___ 07:20AM BLOOD WBC-7.4 RBC-4.03* Hgb-11.4* Hct-35.8*
MCV-89 MCH-28.3 MCHC-31.9 RDW-15.3 Plt ___
___ 07:20AM BLOOD Glucose-81 UreaN-30* Creat-1.3* Na-141
K-3.8 Cl-100 HCO3-25 AnGap-20
___ 08:12PM BLOOD Calcium-9.4 Phos-4.3 Mg-2.1
CTA chest ___
IMPRESSION:
1. No evidence of acute aortic syndrome or pulmonary embolism.
2. Pulmonary and cardiac findings compatible with acute
pulmonary edema in the setting of dilated cardiomyopathy.
However given patchy scattered nodular consolidations an
underlying infectious process cannot be excluded.
CXR ___
There is moderate cardiomegaly. There is pulmonary vascular
congestion and cephalization of the hilar vessels with
peribronchial cuffing, this likely represents pulmonary edema in
the setting of congestive heart failure. There are diffuse
patchy opacities, some of which appear nodular. These are
better seen on concurrent chest CT. These may relate to
pulmonary edema, but superimposed infection is not excluded.
Bilateral pleural effusions. No pneumothorax.
The study and the report were reviewed by the staff
radiologist.
Portable TTE (Complete) Done ___ at 9:42:12 AM FINAL
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is moderately
depressed (LVEF= ___ %). The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate to severe
(3+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Moderately dilated left ventricle with moderate
global hypokinesis. The interventricular septum has relatively
worse function. Mildly dilated right ventricle with borderline
systolic function. Moderate to severe, posteriorly directed,
mitral regurgitation likely due to leaflet tethering. Moderate
elevation of pulmonary artery systolic pressure. Biatrial
dilation.
Radiology Report
INDICATION: ___ female with shortness of breath and hypoxia.
Evaluate for PE.
COMPARISON: Chest radiograph performed two hours prior to this exam as well
as chest radiograph on ___.
TECHNIQUE: Axial helical MDCT images were obtained through the chest after
the administration of 100 cc Omnipaque at an early arterial phase following a
PE protocol. Coronal and sagittal reformations were generated. Oblique MIP
reformats were generated on an independent workstation.
DLP: 459.45 mGy-cm.
CTDI: 13.66 mGy.
FINDINGS: There is no supraclavicular lymphadenopathy. The airways are
patent to the subsegmental level. There are some scattered mediastinal lymph
nodes ranging up to 1 cm in the anterior low paratracheal station (2:44).
There is no hilar or axillary lymphadenopathy. A hyperdensity adjacent to the
left pulmonary artery (2:51) is a calcified lymph node. The heart is enlarged,
and there is severe thinning of the left ventricular wall suggesting dilated
cardiomyopathy. There is also reflux of contrast within the IVC and hepatic
veins. There is no hiatal hernia or esophageal wall thickening.
Lung windows show diffuse bilateral ground-glass opacities with areas of
scattered nodular consolidations more prominent in the apices but seen
throughout both lungs. A dominant 9-mm nodule in the left apex (2:29) is
present. There is also moderate bilateral moderate pleural effusions, right
worse than left, with associated compressive atelectasis. There is no
evidence of pneumothorax.
CHEST CTA: The aorta is well opacified, and there is no aneurysmal
dilatation, dissection, or intramural hematoma. Minimal atherosclerotic
calcifications of the aortic arch are present. The pulmonary arteries are well
opacified to the segmental level. There is mild ectasia of the right
pulmonary artery, but there are no filling defects to suggest pulmonary
embolism or edema. There is no evidence of AV malformation.
Although this study is not tailored for the assessment of subdiaphragmatic
structures, the visualized liver, spleen, and pancreas are unremarkable.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions concerning for
malignancy.
IMPRESSION:
1. No evidence of acute aortic syndrome or pulmonary embolism.
2. Pulmonary and cardiac findings compatible with acute pulmonary edema in
the setting of dilated cardiomyopathy. However given patchy scattered nodular
consolidations an underlying infectious process cannot be excluded.
These findings were communicated to Dr. ___ on ___ at 10:40 a.m. by
Dr. ___ telephone immediately after discovery of the findings.
Radiology Report
INDICATION: ACUTE ONSET SHORTNESS OF BREATH, question CHF.
COMPARISON: Chest radiograph on ___.
There is moderate cardiomegaly. There is pulmonary vascular congestion and
cephalization of the hilar vessels with peribronchial cuffing, this likely
represents pulmonary edema in the setting of congestive heart failure. There
are diffuse patchy opacities, some of which appear nodular. These are better
seen on concurrent chest CT. These may relate to pulmonary edema, but
superimposed infection is not excluded. Bilateral pleural effusions. No
pneumothorax.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: Patient with congestive heart failure, nonsustained ventricular
tachycardia, moderate mitral regurgitation, pulmonary hypertension, dilated
cardiomyopathy, hyperlipidemia, presented with dyspnea due to CHF
exacerbation.
COMPARISON: ___.
FINDINGS:
Moderate-to-severe pulmonary edema has significantly improved and is now mild.
Left lower lobe atelectatic bands are minimal. There are also bilateral small
layering pleural effusions without pneumothorax. Mediastinal and cardiac
contours are normal.
CONCLUSION:
Significant improvement of pulmonary edema, which is now mild.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: VTACH
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PAROX VENTRIC TACHYCARD
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ YO F w/ PMH of congestive heart failure,
nonsustained ventricular tachycardia, moderate mitral
regurgitation, pulmonary hypertension, dilated cardiomyopathy,
hyperlipidemia presented with dyspnea due to CHF exacerbation.
# Non-sustained ventricular tachycardia- The patient has known
NSVT diagnosed about ___ years ago. She refused EP studies in
the past and wanted to continue medical management with
amiodarone. She has had previous CHF exacerbations in the past
when amiodarone has been decreased. She self discontinued her
amiodarone. Per her pharmacy last re-fill of amiodarone was in
___. She was loaded with 3gm amiodarone IV and
transitioned to PO amiodarone which she will take 200mg BID for
1 week and 200 mg daily. She continued to have frequent runs of
NSVT during her admission but remained asymptomatic and
hemodynamically stable. Her home metoprolol was switched from
tartrate 25mg BID to 50mg XL BID. Further up titration of beta
blocker was limited by blood pressure. EP recommended medical
management of her arrythmia given that the location of the
ectopic foci was likely epicardial in location. She will have a
Holter monitoring and follow up with Dr. ___ at discharge.
# Acute systolic heart failure exacerbation- the patient
presented to the ED with dyspnea and evidence of volume overload
on CXR, briefly requiring BIPAP in the ED. Her exacerbation was
likely precipitated by her tachyarrhythmia as above and
exacerbated by her moderate to severe MR as seen on ___. She
was diuresed with IV lasix boluses with good effect and
supplemental O2 was able to be weaned. Her metoprolol was up
titrated as above. Her home losartan was discontinued on
admission give her borderline blood pressures, and she was
started on low dose lisinopril. Repeat Echo this admission
showed EF of ___ % ( was 40-50% on Echo from ___
# CHRONIC KIDNEY DISEASE- The patient has a baseline Cr. of
1.1-1.2 per ___ records. She was admitted with a Cr. of 1.2
which peaked to 1.5 with diuresis. Her Cr improved to 1.3 at
discharge
# HYPERTENSION: The patient has a history of hypertension,
however her BPs were borderline with SBPs in the ___. Her
home losartan and amlodipine were stopped during this admission.
She was started on lisinopril 2.5mg at discharge. Her home
metoprolol tartrate was discontinued and was discharged home on
metoprolol succinate 50mg BID.
Transitional Issues
# Holter monitoring and follow up with Dr. ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cymbalta
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with HepC/EtOH cirrhosis and HCC s/p TACE presents after
a recent fall with abdominal pain and mild confusion. He has
also recently lost his home, where his meds were, and he has not
taken any of his meds in about 2 weeks. The fall was mechanical,
tripping over a piece of wood while walking up a set of stairs;
he describes hitting his head and endorses LOC although timing
of such is unclear. Since that time, he's had a headache and
right-sided neck pain. In regards to his abdominal pain, he's
had RUQ pain since he had his RFA in ___, but it is worse
since 3 days ago, and associated with dry heaves, no actual N/V.
He has not had a bowel movement for several days. No fevers, but
does endorse chills and cough previously with sputum. At OSH,
negative head neck CT.
In the ED, initial vitals were: 9 99.2 82 136/72 18 97%
- Labs were significant for tbili 5.0, plt 69, H/H at baseline,
Cr at baseline ALT 50, AST 141 at recent baseline
- Imaging revealed CXR w/no acute process, no consolidation. RUQ
w/patent portal vein, two hypoechoic lesions in right liver
lobe, splenomegaly, no ascites
- The patient was given 5mg oxycodone
Vitals prior to transfer were: 9 98.0 84 131/83 19 98% RA
Upon arrival to the floor, the patient appears comfortable.
Past Medical History:
HEPATITIS C
HEPATOCELLULAR CARCINOMA
CIRRHOSIS
NARCOTICS AGREEMENT
ACHALASIA
PEPTIC ULCER DISEASE
DYSPHAGIA
HYPERTENSION
TOBACCO ABUSE
H/O ALCOHOL ABUSE; Last drank etoh ___.
ANXIETY/DEPRESSION
Social History:
___
Family History:
Mother DIVERTICULITIS
Father MYOCARDIAL INFARCTION
STROKE
Sister SPECIAL NEEDS
Physical Exam:
ADMISSION EXAM:
================
Vitals: 98.2 133/82 93 18 99% RA
General: Alert, oriented to self, date, details of personal
history, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Mild tachycardia, regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, TTP in RUQ without rebound, partially
distractible, non-distended, bowel sounds present, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, no asterixis, gait deferred. Some mild
slurring of speech but pt able to recount details of medical
history clearly, date/name/place, months backwards
DISCHARGE EXAM:
================
Vitals: 98.5/98.4; 126-155/52-67; 90-108; 20; 94-97%RA
I/O: 240/BR, 1200/1040+, 3xBM
General: AAOx3, responds appropriately. However, gets
intermittently confused.
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: RRR, normal S1 + S2, no MRG
Lungs: Breathing comfortably, no accessory muscle use. Diffuse
exp wheezing.
Abdomen: +BS, soft, nondistended, no rebound. TTP along R
abdomen.
+extensive echymoses extending from incision site to Right
posterior flank, slightly retracted from previous line that was
drawn.
Neuro: Alert, oriented x3, significant asterixis, stbale from
prior.
Pertinent Results:
ADMISSION LABS:
================
___ 09:35PM BLOOD WBC-5.9 RBC-3.57* Hgb-11.8* Hct-34.0*
MCV-95 MCH-33.0* MCHC-34.6 RDW-16.4* Plt Ct-69*
___ 09:35PM BLOOD Neuts-55.4 ___ Monos-7.9 Eos-3.1
Baso-0.7
___ 12:06AM BLOOD ___ PTT-41.2* ___
___ 09:35PM BLOOD Glucose-71 UreaN-10 Creat-0.8 Na-135
K-3.5 Cl-105 HCO3-22 AnGap-12
___ 09:35PM BLOOD ALT-50* AST-141* AlkPhos-276*
TotBili-5.0* DirBili-2.0* IndBili-3.0
___ 09:35PM BLOOD Lipase-52
___ 09:35PM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.0 Mg-1.5*
___ 05:10AM BLOOD TSH-1.0
___ 09:35PM BLOOD ASA-NEG Ethanol-INTERPRET Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:50PM BLOOD Lactate-2.6*
DISCHARGE LABS:
================
___ 08:05AM BLOOD WBC-12.8* RBC-2.38* Hgb-8.4* Hct-23.9*
MCV-101* MCH-35.2* MCHC-35.0 RDW-18.6* Plt ___
___ 08:05AM BLOOD ___ PTT-42.3* ___
___ 08:05AM BLOOD Glucose-86 UreaN-11 Creat-0.7 Na-132*
K-4.1 Cl-102 HCO3-23 AnGap-11
___ 08:05AM BLOOD ALT-54* AST-127* AlkPhos-226*
TotBili-17.2* DirBili-11.2* IndBili-6.0
___ 08:05AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.2
MICROBIOLOGY:
==============
___ Blood cultures x 2 Negative
___ Urine culture negative
___ Bcx x2: Negative
___ Ucx: Negative
___ Bcx x2: Negative
___ Ucx: Negative
___ C. difficile negative
STUDIES/IMAGING:
=================
CXR (___):
In comparison with the study of ___, there are lower lung
volumes with dense atelectatic streaks at both bases. This
could be related to splinting. No definite evidence of rib
fracture, though specific views could be obtained if this is a
serious clinical concern. No pneumothorax is identified.
Chest CTA (___):
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental pulmonary
arteries. Limited evaluation of the subsegmental pulmonary
arteries due to motion artifact.
2. Cirrhotic liver with known hepatic masses, more fully
characterized on the MRI from ___.
RUQ US (___):
IMPRESSION:
1. No evidence of portal vein thrombosis of the main portal
vein.
2. Cirrhotic liver with at least two hypoechoic lesions in the
right lobe. These and other known lesions were better assessed
on prior MRI from ___.
3. Splenomegaly.
CXR (___):
FINDINGS:
The lungs are well inflated and clear. The cardiomediastinal
silhouette,
hilar contours, and pleural surfaces are normal. There is no
pleural effusion or pneumothorax. Old healed left rib fractures
are noted.
RFA (___):
IMPRESSION:
1. Radiofrequency ablation of lesions in segment VI/VII and
segment IV/VIII as detailed above.
2. Paracentesis with removal of 500 cc mildly blood-tinged
ascitic fluid.
3. Small residual hemorrhagic ascites after the procedure,
within the expected range. No hepatic subcapsular hematoma or
pneumothorax.
4. Hepatic infarction in segment VI/VIII, contiguous with the
radiofrequency ablation zone, likely due to occlusion of a
branch of the right hepatic artery adjacent to the lesion
targeted for ablation.
RECOMMENDATION: 1. Intravenous hydration if the patient's
clinical status allows, as the patient received 250 cc of IV
contrast for this procedure.
2. Follow-up MRI in ___ months to assess ablation zones, per
hepatology
service protocol.
CT A/P with Contrast (___):
IMPRESSION:
1. Small contained hemorrhage in regions of recent
radiofrequency ablation in the segment IV/VIII and VI/VII. No
evidence of active extravasation.
2. Other arterial enhancing lesions better evaluated on recent
MRI. A tiny arterial enhancing focus in the post superior right
lobe of the liver demonstrates no washout.
3. Cirrhotic liver with mild splenomegaly.
4. Stranding and asymmetry of the right lateral wall
musculature, likely
representing a combination of edema and blood products.
5. Increased nonhemorrhagic right pleural effusion, now
moderate.
US Guided Thoracentesis (___):
IMPRESSION:
Technically successful ultrasound-guided right thoracentesis.
200 mL of
serous fluid was aspirated with samples sent for microbiology
and chemistry analysis per referring service orders.
CXR: ___
IMPRESSION:
In comparison with the study ___, the there has been
substantial
decrease in the opacification in the right hemithorax related to
thoracentesis. No evidence of pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheeze
2. Amitriptyline 50 mg PO QHS:PRN neuropathic pain
3. Baclofen 10 mg PO BID
4. BuPROPion 150 mg PO BID
5. Fluoxetine 60 mg PO DAILY
6. Isosorbide Dinitrate 5 mg PO Q8H
7. Lactulose 30 mL PO TID
8. Mirtazapine 15 mg PO QHS
9. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
10. Pantoprazole 40 mg PO Q24H
11. Sucralfate 1 gm PO QACHS
12. TraZODone 100 mg PO QHS
13. Vitamin D 1000 UNIT PO DAILY
14. Docusate Sodium 100 mg PO DAILY:PRN constipatoin
15. Multivitamins 1 TAB PO DAILY
16. Senna 8.6 mg PO QHS:PRN constipation
17. Simethicone 80 mg PO DAILY: PRN gas
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheeze
2. Baclofen 10 mg PO BID
3. Docusate Sodium 100 mg PO DAILY:PRN constipatoin
4. Fluoxetine 60 mg PO DAILY
5. Isosorbide Dinitrate 5 mg PO Q8H
6. Lactulose 30 mL PO TID
7. Mirtazapine 15 mg PO QHS
8. Multivitamins 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
RX *oxycodone 15 mg 1 tablet(s) by mouth every four (4) hours
Disp #*48 Tablet Refills:*0
10. Pantoprazole 40 mg PO Q24H
11. Senna 8.6 mg PO QHS:PRN constipation
12. Sucralfate 1 gm PO QACHS
13. Vitamin D 1000 UNIT PO DAILY
14. Levofloxacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
15. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
16. TraZODone 100 mg PO QHS
17. Simethicone 80 mg PO DAILY: PRN gas
18. Amitriptyline 50 mg PO QHS:PRN neuropathic pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hepatocellular carcinoma
Alcoholic cirrhosis c/b hepatic encephalopathy
Pleural effusion
Health care associated pneumonia
Bronchitis
Secondary:
Anxiety
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with sharp L-sided pleuritic lateral chest wall
pain and cough // PNA? Rib fracture? PNA? Rib fracture?
IMPRESSION:
In comparison with the study of ___, there are lower lung volumes with
dense atelectatic streaks at both bases. This could be related to splinting.
No definite evidence of rib fracture, though specific views could be obtained
if this is a serious clinical concern. No pneumothorax is identified.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ year old man with pleuritic chest pain and tachycardia. //
Evaluate for PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 384 mGy-cm
COMPARISON: MRI abdomen ___
FINDINGS:
The study is slightly limited by motion artifact.
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence
of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the segmental level, with no
evidence of filling defect within the main, right, left, lobar, or segmental
pulmonary arteries. Evaluation of the subsegmental pulmonary arteries is
limited by motion artifact. The main and right pulmonary arteries are normal
in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is mild bibasilar dependent atelectasis. The pulmonary parenchyma is
otherwise unremarkable The airways are patent to the subsegmental level.
Limited images of the upper abdomen demonstrate a view nodular liver contour,
compatible with known cirrhosis. There are also several hepatic lesions that
are partially visualized and better characterized on the recent dedicated MRI
from ___.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Old posterior rib fractures are noted on the left (2:74, 87).
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental pulmonary arteries.
Limited evaluation of the subsegmental pulmonary arteries due to motion
artifact.
2. Cirrhotic liver with known hepatic masses, more fully characterized on the
MRI from ___.
Radiology Report
INDICATION: ___ year old man with chest congestion // PNA? effusion
COMPARISON: Compared to prior study from ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There is improved
aeration. Atelectasis at the lung bases has improved. No focal consolidation,
pleural effusions, or pneumothoraces are seen.
Radiology Report
INDICATION: Multifocal ___ status post RFA and TACE in the past. Most recent
MRI reviewed in ___ with 2 lesions meeting OPTN criteria in segment VI/VII and
segment IV. RFA advised. RFA is requested for 2 HCC lesions meeting OPTN
criteria.
COMPARISON: MRI ___
TECHNIQUE: OPERATORS: Dr. ___ (radiology fellow) and Dr. ___
___ (interventional radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
Dr. ___ radiologist, personally supervised the trainee during
the entire procedure and reviewed and agreed with the trainee's findings.
ANESTHESIA: General anesthesia was provided by the anesthesia service.
MEDICATIONS: Please see anesthesia records.
CONTRAST: 250 ml of Optiray contrast.
PROCEDURE: Radiofrequency ablation of 2.6 x 2.2 cm segment VI/VII lesion and
a 1.7 cm segment IV/VIII lesion
PROCEDURE DETAILS:
Following 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 computed tomography suite and placed supine on the
imaging table. General anesthesia was induced by the anesthesiologist.
Attention was first turned to the lesion in segment VI/VII. The lesion was
found with ultrasound and an appropriate approach identified. The skin was
marked. The skin was prepped and draped in the usual sterile fashion. Under
continuous ultrasound guidance, a COOL-TIP cluster radiofrequency ablation
probe ___ cm) was advanced through the intercostal space until the tip of
the probe was just beyond the lesion in segment VI/VII. The position of the
probe was confirmed with a non-enhanced CT scan (series 3). A small amount of
nonhemorrhagic ascites was noted on the CT. Thus, a 5 ___ ___ catheter was
advanced adjacent to the ablation probe and 500 mL of mildly blood-tinged
ascitic fluid was removed for better apposition of the liver against the body
wall with the ablation. The ___ catheter was left in place during the
ablation.
Radiofrequency ablation was performed with two overlapping ablations (12
minutes each) for a total of 24 minutes, achieving a peak current of ___
mAmps and a temperature 60 degrees Celsius with the first ablation and a peak
current of 1840 mAmps and a temperature of 66 degrees Celsius with the second
ablation. The probe was withdrawn under low energy to ablate the access
tract. The ___ catheter was removed. Manual hemostasis was achieved.
Attention was then turned to the lesion in segment IV/VIII, identified on the
non-enhanced CT scan. Based on the CT findings, an appropriate skin entry
site within the already sterile field was chosen. The site was marked. Under
CT fluoroscopy, a cool tip cluster radiofrequency ablation probe ___ cm)
was advanced through the intercostal space until the tip of the probe was at
expected location of the liver lesion. Non-enhanced CT scan followed by
contrast enhanced CT scan were performed to confirm placement of the
radiofrequency ablation probe (series 8 and 9). As the lesion was just beyond
the tip of the radiofrequency ablation probe on the CT, the probe was advanced
by an additional 1.5 cm. Radiofrequency ablation was performed with a single
ablation for 12 minutes, achieving a peak current of ___ mAmps and a maximum
temperature of 71 degrees C. The probe was then withdrawn under low energy to
ablate the access tract.
Multiphasic CT scan was performed (series 10, 11, 12) demonstrating the
segment IV/VIII ablation zone immediately lateral to an enhancing lesion with
washout (11:37, 12:34) and it was felt that the segment IV/VIII lesion was not
adequately ablated. Thus, a new entrance site for ablation was chosen and the
skin was marked. Under CT fluoroscopy, an a cluster radiofrequency ablation
probe ___ cm) was advanced through the intercostal space until the tip of
the probe was within the expected location of the segment IV/VIII liver
lesion. Radiofrequency ablation was performed with a single ablation for 12
minutes, achieving a peak current of 1850 mAmps and a temperature of 84
degrees Celsius.
A final non-enhanced CT scan was performed (series 15).
The skin was then cleaned and a dry sterile dressing was applied. The patient
was awakened from general anesthesia without incident and there were no
immediate post-procedure complications. The patient was transferred to the
post-anesthesia care unit for further monitoring.
FINDINGS:
1. Ultrasound: Pre-procedure ultrasound of segment VI/VII was performed
identifying a 2.8 x 2.1 cm hypoechoic lesion adjacent to a portal venous
branch and hepatic arterial branch as noted on the prior MRI. This was
targeted for the first RFA. The tip of the probe is seen just beyond the
lesion, confirmed on subsequent non-enhanced CT.
2. Non-enhanced CT (series 3, 4, 5): The ablation probe is seen in segment
VI/VII with the tip beyond the expected location of the targeted lesion. There
is a small amount of perihepatic ascites. Bibasilar atelectasis is noted.
Bilateral gynecomastia. The patient is status post cholecystectomy. The spleen
is enlarged to 14 cm. Enlarged porta hepatic lymph nodes are similar to ___.
3. Non-enhanced CT and contrast-enhanced CT with 100cc Omnipaque (series 8,
9): Non-enhanced CT demonstrates hyperdensity within the RFA zone in segment
VI/VII, compatible with coagulation necrosis, expected after ablation. The
amount of ascites has decreased after paracentesis, but is now hemorrhagic,
indicating blood products within the trace remaining perihepatic ascites,
within the expected range after ablation. The ablation probe is seen with the
tip just lateral to the lesion in segment IV/VIII. Contrast-enhanced CT
demonstrates peripheral wedge-shaped hypodensity in segment VI/VII, contiguous
with the ablation zone, compatible with hepatic infarction, likely related to
occlusion of the hepatic arterial branch seen adjacent to the segment VI/VII
lesion. A patent portal venous branch courses through the infarcted liver.
Old ablation zones are seen in segment VII (09:37, 09:27). A hypodense lesion
in segment II is better evaluated on MRI ___. Perigastric varices
are noted. A trace right pleural effusion has developed since the prior CT.
4. Triphasic CT with 150cc Omnipaque (series 10, 11, 12): Following initial
ablation of the segment IV/VIII lesion, hyperdensity is seen immediately
lateral to the lesion (10:23), compatible with coagulation necrosis. Slightly
hemorrhagic perihepatic ascites has not increased. Contrast is seen within the
renal collecting systems from the prior CT scan. Contrast-enhanced study in
the arterial and portal venous phases demonstrates a 2.5 x 2.8 cm ablation
zone in segment IV/VIII, but it is immediately lateral to a 1.8 cm enhancing
lesion with washout, which was targeted for ablation (11:37, 12:35). Thus, it
was felt that the segment IV/VIII lesion was not adequately ablated and a
second ablation of the area was performed as detailed above. Again noted is
the wedge-shaped hepatic infarction in segment VI/VII with patent hepatic
venous and portal venous branches coursing through it. A trace right pleural
effusion is slightly larger. Bibasilar atelectasis is stable. Small
perihepatic ascites with blood products is stable.
5. Post-procedure non-enhanced CT scan (series 15): Hyperdensity indicating
coagulation necrosis is identified in segment VI/VII (15:24) as well as
segment IV/VIII (15:18) at sites of radiofrequency ablation. A trace right
pleural effusion and bibasilar atelectasis are stable. There is no increase in
slightly hemorrhagic perihepatic ascites. No subcapsular hematoma is
identified. No pneumothorax.
IMPRESSION:
1. Radiofrequency ablation of lesions in segment VI/VII and segment IV/VIII as
detailed above.
2. Paracentesis with removal of 500 cc mildly blood-tinged ascitic fluid.
3. Small residual hemorrhagic ascites after the procedure, within the expected
range. No hepatic subcapsular hematoma or pneumothorax.
4. Hepatic infarction in segment VI/VIII, contiguous with the radiofrequency
ablation zone, likely due to occlusion of a branch of the right hepatic artery
adjacent to the lesion targeted for ablation.
RECOMMENDATION: 1. Intravenous hydration if the patient's clinical status
allows, as the patient received 250 cc of IV contrast for this procedure.
2. Follow-up MRI in ___ months to assess ablation zones, per hepatology
service protocol.
The findings and recommendations were discussed by Dr. ___ with Dr.
___ (hepatology service) on the telephone on ___ at 16:53, upon
procedure completion.
Radiology Report
INDICATION: Evaluate for pneumonia in a patient with cirrhosis, undergoing
RFA today.
COMPARISON: Chest radiographs from ___, ___.
FINDINGS:
A portable frontal chest radiograph demonstrates a normal cardiomediastinal
silhouette and fairly well-aerated lungs without focal consolidation, pleural
effusion, or pneumothorax. The visualized upper abdomen is unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo M with HepC/EtOH cirrhosis and HCC s/p TACE presents after
a recent fall with abdominal pain and mild confusion. S/p RFA of HCC, with new
fevers. Please assess for evidence of PNA. // r/o PNA
IMPRESSION:
As compared to recent radiograph of 1 day earlier, pulmonary vascular
congestion and interstitial edema are new. Patchy and linear right lower lobe
opacities are also new and favor atelectasis considering the presence of mild
volume loss. Coexisting aspiration or an early focus of infectious pneumonia
is also possible. Note is also made of air-filled distension of the thoracic
esophagus suggesting esophageal dysmotility.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with cirrhosis and ___ s/p paracentesis and RFA
now with severe echmymoses, please assess for any additional causes of abd
pain as well as ?bleeding
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, portal venous and
delayed phase images were acquired through abdomen and pelvis
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DLP: 2803 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL of Omnipaque
COMPARISON: Comparison is made to interventional procedure from ___.
Comparison is also made to right upper quadrant ultrasound from ___
and MR liver ___.
FINDINGS:
VASCULAR:
There is no evidence of active extravasation of IV contrast. The abdominal
aorta and its major branches are patent. There is no abdominal aortic
aneurysm. There is a single renal artery bilaterally. The portal vein is
patent. A branch of the right posterior portal vein traverses the RFA site an
segment VII, but appears patent.
LOWER CHEST: There is a moderate nonhemorrhagic right pleural effusion with
associated atelectasis. The left lung base is clear.
ABDOMEN:
HEPATOBILIARY: The liver is shrunken and nodular compatible with cirrhosis.
Changes from radiofrequency ablation present in segment VI/VII and segment
IV/VIII, with high density centrally, compatible with blood products.
Previously described arterial enhancing lesions better seen on MRI. A tiny
arterial enhancing focus in the posterior right lobe of the liver (series 3A,
image 53), demonstrates no washout correlate. 1.6 x 1.4 cm hypodensity in
segment II, 1.9 x 1.9 cm hypodensity in segment V, and 1.1 x 2.3 cm
hypodensity in segment VI, representing postprocedural changes (Series 3a, and
image 23, 36, 47). Arterial enhancement seen in these regions not appreciated
on the current CT. The gallbladder is surgically absent. There is no intra
or extrahepatic biliary duct dilation. There is trace intra-abdominal
ascites, decreased from prior.
PANCREAS: The pancreas enhances homogeneously and is without focal lesions.
There is no pancreatic duct dilation.
SPLEEN: The spleen is mildly enlarged measuring 13.2 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys enhance symmetrically. There are no focal renal lesions.
There are no perinephric abnormalities. There is no hydronephrosis. The
ureters are normal in caliber along their course to the bladder.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Mild wall thickening of the sigmoid colon and
rectum, nonspecific likely secondary to third spacing of fluid. Appendix
contains air, has normal caliber without evidence of fat stranding. There are
numerous mesenteric lymph nodes, none of which are pathologically enlarged.
Enlarged portacaval lymph node has not significantly changed from prior MRI
measuring 15 x 33 mm (series 3B, image 237).
RETROPERITONEUM: There is no retroperitoneal adenopathy by CT size criteria.
PELVIS: The bladder is partially distended with a thickened wall. 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:
There is no evidence of worrisome lesions. The patient is status post L1
vertebroplasty. There are no concerning lytic or sclerotic bony lesions.
Stranding and asymmetry of the right lateral abdominal wall musculature,
compatible with a combination of postoperative edema and blood.
IMPRESSION:
1. Small contained hemorrhage in regions of recent radiofrequency ablation in
the segment IV/VIII and VI/VII. No evidence of active extravasation.
2. Other arterial enhancing lesions better evaluated on recent MRI. A tiny
arterial enhancing focus in the post superior right lobe of the liver
demonstrates no washout.
3. Cirrhotic liver with mild splenomegaly.
4. Stranding and asymmetry of the right lateral wall musculature, likely
representing a combination of edema and blood products.
5. Increased nonhemorrhagic right pleural effusion, now moderate.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cirrhosis, hematoma now w/SOB // Is there
an acute pulmonary process to explain SOB/desat? Is there an acute
pulmonary process to explain SOB/desat?
IMPRESSION:
In comparison with the study of ___, there is substantial increased
opacification at the right base with continued pulmonary vascular congestion.
The right hemidiaphragm is not well seen, consistent with fluid in the pleural
space. The more coalescent opacification on the right could reflect
superimposed pneumonia or, in view of the recent ablation procedure, pulmonary
hemorrhage.
NOTIFICATION: This information was discussed with Dr. ___.
Radiology Report
EXAMINATION: Ultrasound-guided thoracentesis
INDICATION: ___ year old man with new pleural effusion following RFA and large
ecchymoses -febrile w/ WBC, and cough // please perform therapeutic/diagnostic
___ (send for micro), aspirate as completely as possible. Given ecchymoses
and leaking, is fluid bloody, serosanguinous?
TECHNIQUE: Ultrasound guided diagnostic and therapeutic thoracentesis
COMPARISON: Chest radiograph ___. CT abdomen pelvis ___.
FINDINGS:
Limited grayscale ultrasound imaging of the right hemithorax demonstrated
small volume pleural fluid. A suitable target in the deepest pocket in the
right posterior mid scapular 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.
Under continuous ultrasound visualization, a 5 ___ catheter was advanced
into the largest fluid pocket in the right posterior mid scapular line and 200
mL of serous 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:
Technically successful ultrasound-guided right thoracentesis. 200 mL of
serous fluid was aspirated with samples sent for microbiology and chemistry
analysis per referring service orders.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with effusion and ?PNA sp ___ // PNA?
effusion? PNA? effusion?
IMPRESSION:
In comparison with the study ___, the there has been substantial
decrease in the opacification in the right hemithorax related to
thoracentesis. No evidence of pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Confusion, Transfer, N/V
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, ALCOHOL CIRRHOSIS LIVER
temperature: 99.2
heartrate: 82.0
resprate: 18.0
o2sat: 97.0
sbp: 136.0
dbp: 72.0
level of pain: 9
level of acuity: 2.0 | Mr. ___ is a ___ gentleman with HCV/alcoholic
cirrhosis and ___ s/p TACE and RFA who presented after a recent
fall with abdominal pain and mild confusion in setting of social
situation which created lack of access to medications.
# HCC: MRI in ___ revealed two new tumors. Pt underwent RFA
on ___ for 2x HCCs seen on previous imaging.
Post-procedure course was complicated by large ecchymoses and
transudative pleural effusion for which pt underwent ___
thoracentesis on ___. H/H was stable at discharge. Pt was
notably seen by primary oncologist during this hospitalization,
who considered the possibility of sorafenib in the future if
patient was able to become more compliant with follow up.
# Abdominal pain: Dates back to RFA in ___ though worsened
after a fall prior to admission. TBili elevated though RUQ
appeared unchanged. Pain may be secondary to known HCC lesions
vs. musculoskeletal s/p fall. Likely exacerbated by lack of
access to narcotics. Oxycodone was continued but increased to
15 mg q4h prn given ongoing pain.
# Pneumonia: Pt also developed pneumonia, and was initially
treated with vanc/cefepime starting on ___. He was narrowed
to levofloxacin on discharge. He was discharged with a plan to
complete an 8-day course of antibiotics (d1 = ___.
# Bronchitis: Pt completed a 5-day course of azithromycin for
bronchitis during this hospitalization.
# Chest pain: Patient developed left sided chest pain that was
reproducible on exam, felt to be musculoskeletal. CXR showed
atelectasis but no focal infiltrates. CTA negative for PE. EKG
with no ischemic changes and troponins negative. Chest pain
improved over the course of the hospitalization as his cough
improved.
# Hepatic encephalopathy: Mild encehalopathy on admission
likely due to lack of access to lactulose. Lactulose was
uptitrated and rifaximin was added. Infectious work-up was
negative. Mental status improved over the course of the
hospitalization.
# Hyperbilirubinemia: TBili elevated to 5.7 on admission, up
from 3 in ___. No evidence of ductal dilation on RUQ
ultrasound. No fever or leukocytosis to suggest cholangitis.
Likely related to new HCC lesions (evident on MRI in ___.
EtOH level negative on admission (albeit after several hours
added-on). Tbili downtrended intiially. However, TBili began to
rise after RCC, and was felt to be secondary to his hematoma.
# Fall: Low suspicion for syncope, appeared mechanical in
nature. EKG without arrhythmias. Patient was monitored on
telemetry with no events.
# Anxiety/depression: Continued home venlafaxine and
mirtazapine. Bupropion was held (it was for smoking cessation
and patient had not started it yet).
# Elevated PTT: Likely ___ liver disease. SCH may be
contributing (PTT decreased with holding heparin, particularly
since patient is also on fluoxetine). Hemolysis less likely.
# HCV/EtOH cirrhosis: MELD at discharge was 24. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
adhesive tape / Tetracycline
Attending: ___.
Chief Complaint:
Abdominal wall cellulitis and pain
Major Surgical or Invasive Procedure:
CT-guided drainage of abdominal wall collection, catheter
placement
History of Present Illness:
___ with significant surgical history including TAH and
radiation
for uterine cancer in ___ and multiple ventral hernia repairs
subsequently. She was last admitted from ___ to ___ for
chronic wound drainage from her abdominal wound at which time a
1x4cm segment of mesh was removed from the actively draining
wound. This was not sent for pathology, however wound swabs at
the time grew out pan susceptible staph. She now returns as a
transfer from an outside hospital with abdominal pain and an
enlargind abdominal wall mass. She has had increasing abdominal
pain over the past week accompanied by fevers, chills, and
sweats. She underwent an CT scan at the OSH which reportedly
demonstrated an abscess versus an infected hematoma in
association with her ventral hernia. She is passing gas and
having bowel movements.
Past Medical History:
Past Medical History:
HTN, sleep apnea, chronic low back pain, DM, arthritis, afib,
narcolepsy, uterine CA
Past Surgical History:
TAH and radiation, ___, multiple ventral hernia repairs, R TKA,
BIH repair, B THA, cataracts, bladder sling
Social History:
___
Family History:
Family history is notable for mother with diabetes, otherwise
negative.
Physical Exam:
PE on discharge:
AFVSS
NAD, A+OX3
no scleral icterus
RRR
Irregular irregular
Abd obese,Large ventral hernia (not incarcerated), some pain
over drain site which is c/d/i. No cellulitis seen. Drain is
drain serosanginous fluid.
Mild pitting edema b/l
Pertinent Results:
WBC: 11.3->10.6->8.6
HCt: 40.1->36.1->34.3
Plt: 399->314->322
Chemistry WNL
INR: 1.9 (on arrival)-> 1.3-> 1.2->1.3->1.4
CT Abd/Pelvis (OSH): 9x11x5.5 cm collection in the anterior
abdominal wall, in association with bowel loops in the ventral
hernia but likely
percutaneously accessible from the patient's left side.
CT Drainage ___: Under CT 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 short trocar needle was advanced into the abscess
under CT guidance, and a wire was inserted through the trocar
and a Bard ___ 8 ___ catheter was advanced over the wire
and into the fluid collection. Initial aspiration demonstrated
pus. Thus it was decided a drainage catheter would be left in
place. About 200 cc of pus in total was aspirated into a
connected bag.
After demonstrating near complete collapse of the fluid
collection. A sinogram was then performed with 60 cc of dilute
contrast demonstrating no obvious communication with bowel.
Micro: Drain culture:
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Medications on Admission:
1. Acetaminophen 325-650 mg PO Q8H:PRN pain
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Warfarin 2 mg PO DAILY16
4. Valsartan 160 mg PO DAILY
5. Provigil *NF* (modafinil) 200 mg Oral daily
6. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN headache
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. modafinil *NF* 200 mg Oral daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
4. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
5. Valsartan 160 mg PO DAILY
6. Warfarin 2 mg PO DAILY16
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Ibuprofen 400-600 mg PO Q6H:PRN pain
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
10. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*33 Tablet Refills:*0
11. MetFORMIN XR (Glucophage XR) 500 mg PO ASDIR
Do Not Crush
___: take 1 tablet (500 mg) before dinner
___ and ___: take 2 tabs (1000 mg) before dinner
___ - onward: take 4 tabs ___ mg) before dinner
***if you start to have diarrhea related to this medication,
decrease dosage back to previous dose and remain on it for 2
days before increasing again***
RX *metformin [Glucophage XR] 500 mg 1 tablet(s) by mouth as
instructed below Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal wall fluid collection, likely infected hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CT INTERVENTIONAL PROCEDURE
INDICATION: ___ woman with fever/chills/abdominal pain, formerly on
Coumadin, last CT showed large abdominal wall fluid collection, attempt to
drain.
COMPARISON: Outside CTs from ___.
PHYSICIANS: Dr. ___, abdominal imaging fellow and Dr. ___,
___ radiologist.
PROCEDURE:
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained. A preprocedure timeout was
performed discussing the planned procedure, confirming the patient's identity
with three identifiers, and reviewing a checklist per ___ protocol.
Under CT 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 short trocar needle was advanced into the abscess under CT
guidance, and a wire was inserted through the trocar and a ___ ___ 8
___ catheter was advanced over the wire and into the fluid collection.
Initial aspiration demonstrated pus. Thus it was decided a drainage catheter
would be left in place. About 200 cc of pus in total was aspirated into a
connected bag.
After demonstrating near complete collapse of the fluid collection. A sinogram
was then performed with 60 cc of dilute contrast demonstrating no obvious
communication with bowel.
75 micrograms of fentanyl was administered without complication. Ten minutes
of intraservice time was utilized during which the patient's hemodynamic
parameters were continuously monitored by radiology nursing personnel. Fluid
was sent for microbiology.
The patient tolerated the procedure well with no immediate complications.
Dr. ___ attending radiologist, was present throughout the entire
procedure.
Pre and post procedure imaging demonstrated a large ventral abdominal wall
hernia defect containing bowel and fat without evidence of underlying bowel
obstruction. Degenerative changes in the visualized skeletal structures.
Bilateral hip prostheses are also noted. Post-sinogram images demonstrate no
evidence of communication with bowel and contrast remained within the pocket
of previously aspirated fluid collection. The contrast was also subsequently
aspirated to resolution.
IMPRESSION:
CT-guided abscess drainage in the left abdominal wall. Microbiology is
pending.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOM/PELVIC SWELL/MASS LLQ
temperature: 98.1
heartrate: 88.0
resprate: 16.0
o2sat: 97.0
sbp: 126.0
dbp: 72.0
level of pain: 0
level of acuity: 3.0 | The patient was seen in the ED by the surgical service. Imaging
from the OSH demonstrated a left sided hematoma vs. abscess over
the rectus muscle. She was afebrile but had a slight
leukocytosis. Her INR was therapeutic at 1.9. Given the
cellulitis and pain and an increased WBC, she was admitted to
the surgical service and started on broad spectrum antibiotics
(vancomycin, ciprofloxacin, flagyl).
The next day she underwent a CT guided drainage procedure.
Approximately 200 cc of purulent fluid was aspirated and a drain
was placed for further drainage on the floor. She tolerated the
procedure well. Her diet was advanced.
Drain cultures speciated out MSSA. Her antibiotics were switched
over to oral Keflex. She has a h/o diabetes, however is not on
any anti hyperglycemic medications. Given her persistent high
blood sugars (200-300's), ___ Diabetes was consulted for
further management and recommended starting Metformin.
On discharge, the patient is stable. She is tolerating a
diabetic diet. Her drain continues to drain serosanginous fluid.
She will be discharged on 11 days of Keflex (overall total
antibiotic use 14 days). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / lisinopril
Attending: ___.
Chief Complaint:
Obstruction, vomiting, unable to take PO
Major Surgical or Invasive Procedure:
Lap band removal
History of Present Illness:
___ woman with locally advanced left breast cancer,
status post chemotherapy, last dose ___, who is
currently awaiting mastectomy tomorrow. For the past few months
she has been complaining of severe symptoms of acid reflux and
vomiting and unable to keep anything down. She had a lap band in
___ in ___, lost 55 lbs. She also had a recent admission to
___ last week for hematemesis. ___,
which revealed a single nonbleeding erosion at the
gastroesophageal junction, and intact impression of the lap
band.
At this time the patient had assumed that the band had been
completely empty. She has been having many side effects from her
chemotx including neuropathy, but have improved since chemo
complete, but dysphagia still there.
Past Medical History:
Breast Cancer, as above
Hypertension
Migraine headaches
Panic disorder
S/p kidney donor, ___
S/p lap band
HSV, genital
Social History:
___
Family History:
Heavy family history of breast cancer. No family history of GI
disease.
Physical Exam:
Physical Exam:
Vitals: WNL
GEN: A&O, seems uncomfortable, somewhat malnourished
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, port in place, incisions well healed
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 07:40AM BLOOD WBC-5.6# RBC-3.75* Hgb-10.5* Hct-32.5*
MCV-87 MCH-28.1 MCHC-32.5 RDW-13.6 Plt ___
___ 11:15AM BLOOD Glucose-70 UreaN-6 Creat-1.0 Na-140 K-3.5
Cl-103 HCO3-25 AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. butalbital-acetaminophen-caff (codeine-butalbital-ASA-caff)
50-325-40 mg oral daily:prn migraines
2. Gabapentin 300 mg PO BID
3. Tamoxifen Citrate 20 mg PO DAILY
4. ClonazePAM 1 mg PO QHS:PRN anxiety, nausea, vomiting
5. Atenolol 25 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Senna 1 TAB PO BID:PRN constipation
8. Amlodipine 10 mg PO DAILY
9. Sucralfate 1 gm PO QID
10. Omeprazole 40 mg PO BID
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Venlafaxine 112.5 mg PO DAILY
13. Ranitidine 150 mg PO HS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. ClonazePAM 1 mg PO QHS:PRN anxiety, nausea, vomiting
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 300 mg PO BID
6. Ranitidine 150 mg PO HS
7. Senna 1 TAB PO BID:PRN constipation
8. Sucralfate 1 gm PO QID
9. Venlafaxine 112.5 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
11. butalbital-acetaminophen-caff (codeine-butalbital-ASA-caff)
50-325-40 mg oral daily:prn migraines
12. Omeprazole 40 mg PO BID
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Tamoxifen Citrate 20 mg PO DAILY
15. All medications
All prior medications as per PCP and ___
___ Disposition:
Home
Discharge Diagnosis:
Lap Band prolapse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Lap band years ago. Presents with months of emesis and unfill
earlier today. Assess for prolapse.
COMPARISON: Chest radiograph ___.
FINDINGS:
Single-contrast upper GI: The lap band has slipped distally and is over the
pylorus. There is complete obstruction at this site with no passage of
contrast distally. Debris is noted in the distended stomach. There is likely
associated edema in the antrum. No leak.
IMPRESSION:
Slippage of the lap band distally over the pylorus with a distended stomach
without passage of contrast distally consistent with gastric outlet
obstruction from the lap band.
Results were conveyed to Dr. ___ on ___ at 15:15
within 10 min of observation of findings.
Radiology Report
HISTORY: Lap band prolapse. Assess NG tube placement.
COMPARISON: Upper GI ___.
FINDINGS: Supine abdominal radiograph demonstrates NG tube with tip in the
distal stomach. Contrast is seen pooling in the distal stomach with no
passage into the duodenum. Air and stool is seen in the distal bowel.
Phleboliths and right lower quadrant clips are noted. Visualized osseous
structures are unremarkable.
IMPRESSION:
1. No passage of contrast from the stomach into the duodenum.
2. NG tube with tip in the distal stomach.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Vomiting
Diagnosed with NAUSEA WITH VOMITING
temperature: nan
heartrate: 55.0
resprate: 16.0
o2sat: 100.0
sbp: 151.0
dbp: 92.0
level of pain: 4
level of acuity: 2.0 | Pt was seen by the Bariatric team for symptoms of obstruction.
She had a known lap band from prior hospital that she thought
was empty. But when we evaluted her lap band had 8cc of fluid in
it which we removed. With a completely empty band we did an UGI
that showed a complete obstruction. She was scheduled for
mastectomy the next day which was canceled and we took her to OR
emergently for lap band removal. Refer to operative note for
details. The next day we took out NGT and foley and advanced her
diet to clears. The following day we advanced her to
regulardiet. She is tolerating diet, no N/V/D/C. Pain is
controlled, she is clear from Bariatric standpoint to be sent
home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lidocaine
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
___ - 1) irrigation and debridement of left shoulder to
include the subacromial bursa and the glenohumeral joint; 2)
left biceps tenotomy; 3) arthrotomy with irrigation and
debridement of septic right wrist
History of Present Illness:
___, previously active and healthy, who presents with cyclical
fevers and migratory polyarthritis. Her symptoms started 1 week
ago at home when she had a fever up to ___ with severe chills.
She also reported some GI symptoms of nausea, vomitting, and
diarrhea at that time. Her fever resolved within 12 hours
without medications, but she reported continued low grade fever
and occassional spikes throughout the week.
At around the same time of fever onset, she also experienced
severe acute onset joint pain in her L shoulder, lower back,
lateral aspect of her R knee, and R wrist and MCP joints, in
succession of onset over the past week. These joint pains last
___ days, with rapid onset, and slow gradual improvement. There
is associated erythema and swelling locally at the joint. She
has never had a history of joint pain before, no h/o gout,
rheumatoid arthritis, or other joint conditions.
She also reported feeling confused during her initial episode of
fever, describing the feeling as "haziness" and altered mental
abilities. She reports feeling "odd" the morning of admission,
but no headache, dizziness, black outs, seizure activity, or
chorea.
She denies trauma, abdominal pain, headche, unusual exposures,
tick bites, neck pain, rashes, nodules, palpitations, shortness
of breath, chest pain. She also denies dysuria, burning
sensation, suprapubic pain, gross hematuria.
She reports having dental work done 1 month ago for her palate.
She has a history of oromaxillofacial problems (patient was not
specific) which has required multiple surgeries over the past
___ years. She reportedly did not receive antibiosis during or
after her recent oral surgery and does not remember the last
time she has received antibioitics. She is followed by ___
___, MD an ___ surgeon at ___.
She was seen at ___ initially and given pain medication
for suspected bursitis which offered mild symptomatic
improvement. She then developed worsening joint pain, saw her
PCP at ___ yesterday, and sent to ___ for
additional evaluation. On presentation, her vitals were: Temp:
100 HR: 92 BP: 130/70 Resp: 16 O(2)Sat: 98. Her ESR was 110, CRP
> 300, and blood cultures x2 are pending.
She was given Dilaudid 1mg IV x3 and sent to the floor.
Past Medical History:
- s/p oral mass, benign replaced with bone from R hip
- s/p custom oral implant in hard palate, repeated oral
surgeries over the past ___ years (patient not very specific)
- osteoarthritis ___ runner
- L knee meniscal repair
- R knee meniscal tear with corticosteroid injections
- recent dental work 1 month ago, reportedly no antibiotic
coverage was given
Social History:
___
Family History:
- two daughters, both healthy, one expecting in ___
- ___ are both runners with osteoarthritis and "joint
problems"
- father died at ___ of an MI
- mother died at ___ of "old age," with osteoporosis and a
pacemaker
- strong family history of breast cancer
Physical Exam:
ADMISSION EXAM
VS - Temp 100.0, BP 130/79, HR 102, O2-sat 97% RA
GENERAL - NAD, uncomfortable because of pain
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
custom fit implant in hard palate
NECK - supple, no JVD
HEART - RRR, nl S1-S2, split S2 in LLSB, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - normal BS, soft/NT/ND, no masses or HSM, no
rebound/guarding; no rash
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
- R wrist: extreme tenderness to palpation, swelling, erythema,
severely restricted passive and active ROM
- L shoulder: tenderness to palpation in L AC joint, restricted
passive/active shoulder abduction, swelling, mild erythema
- R knee: tenderness in the lateral part of R knee, mild
swelling, not much erythema
- other joints are otherwise painless
- no nodules noted on any joints (fingers or toes)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, slow speech, CNs II-XII intact, mild
weakness on left hand grip, mild hypotonia, sensation grossly
intact throughout
DISCHARGE EXAM:
98.7, 139/73, 80, 18, 95%ra
Gen: nad, comfortable
Cardiac: rrr, no murmurs
Pulm: clear to auscultation
Ext: no pedal edema
MSK: left shoulder in bandage. Right wrist with bandage, some
swelling of fingers
Pertinent Results:
___ joint fluid of shoulder:
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___. ___ @ 11:53 AM ON
___.
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
___ joint fluid of shoulder:
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ TTE:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal. Left ventricular
systolic function is hyperdynamic (EF>75%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. There is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Borderline pulmonary
hypertension.
___ TEE Echo
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). There
are minimal simple atheroma in the descending thoracic aorta and
aortic arch. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. 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. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. No vegetation/mass is seen on the pulmonic valve.
IMPRESSION: No vegetation or abcess seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Calcium Carbonate 500 mg PO BID
3. Naproxen 500 mg PO Q12H
4. Penicillin G Potassium 4 Million Units IV Q4H
RX *penicillin G pot in dextrose 2 million unit/50 mL 4 million
units IV q 4 hours Disp #*28 Bag Refills:*0
5. Vitamin D 400 UNIT PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Septic left shoulder
Septic right wrist
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left shoulder pain and decreased range of motion.
COMPARISONS: None available.
FINDINGS:
Three views of the left shoulder demonstrate no evidence of acute fracture or
dislocation. Glenohumeral articulation is preserved. Mild-to-moderate
degenerative changes of the glenohumeral and AC joints are seen with
osteophyte formation and joint space narrowing. Bones are diffusely
demineralized. No suspicious lytic or sclerotic bony lesion is seen.
Imaged left lung demonstrates decreased lung volumes with perihilar vascular
congestion and no pneumothorax.
Three views of the left humerus demonstrates no evidence of acute fracture or
dislocation. No suspicious lytic or sclerotic bony lesions noted. Soft
tissues are unremarkable.
IMPRESSION:
No evidence of acute fracture or dislocation.
Radiology Report
HISTORY: ___ female patient with right PICC placement.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: Portable AP view of the chest.
FINDINGS:
The right PICC line tip is at the level of the lower SVC. The heart is
normal. The hilar and mediastinal contours are normal. The lungs are
well-expanded and clear. There are no pleural effusions or pneumothorax.
IMPRESSION: Right PICC line tip at the lower SVC.
These findings were discussed with ___ by Dr. ___ via
telephone on ___ at 12:15, time of discovery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: UPPER EXTREMITY PAIN
Diagnosed with FEVER, UNSPECIFIED
temperature: 100.0
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 130.0
dbp: 70.0
level of pain: 10
level of acuity: 3.0 | ___ yo previously healthy and active female with a h/o oral
surgery (recent surgery 1 mo) presents with 1 week of cyclical
fevers up to ___ and chills, associated migratory polyarthritis
of the R wrist/MCP joints, L shoulder, and R knee, found to have
elevated ESR 110 and CRP > 300. Joint fluid grew group B strep,
consistent with a septic polyarthritis.
# Septic Polyarthritis: Left shoulder and right wrist grew out
Group B strep. S/p washout from ortho and found an
empyema/abscess in L glenohumoral joint. Unclear primary source.
TTE and TEE negative for vegetations. ASO negative, so unlikely
rheumatic fever. Possibly seeding from recent dental/maxillary
work. ___ placed in RUE. Started on penicillin G 4million U
every 4 hours for total 4 week course. Start Date: ___, Stop
Date: ___.
# Anemia: Mild Anemia likely from acute infection. HCT 35 on
admission and trended down to 28 at discharge and stable. Retic
count low. Neg hemolysis labs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS / lisinopril
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HTN, HLD, DMII, hx of CVA ___ ICH (___)
s/p craniectomy/evacuation (initially with some cognitive
impairment, much improved), hyperparathyroidism, GERD, gout,
OSA, CKD, who presents with headache with associated nausea and
mild shortness of breath for past three days.
Patient reports that he developed a headache 3 days ago,
somehwat suddenly although cannot remember what time of day,
which has not been improving since then. He also reports nausea,
decreased PO intake, but no vomiting. No focal
numbness/weakness, facial droop/slurred speech. Wife reports his
prior ICH presented similar with headache and nausea. No falls,
trauma. Has not taken any medications for pain. No chest
pain/pressure. SOB started around same time as headache, worse
with exertion. Also reporting some nasal congestion.
He didn't take normal medications morning of day of
presentation, but has been taking medications as usual until day
of presentation.
In the ED intial vitals were: 7 97.8 64 151/79 18 100%. SBP was
up to 190/88 and received IV hydral 10 mg x1 with improvement of
SBP to 150's. Labs were notable for K 4, Cr 2.7 (baseline 2.8
per Atrius records), Tpn 0.02 and < 0.01 and BNP 860 (prior
5000). Mg 1.6. EKG showed sinus at 55 bpm, LVH, TWIs are
unchanged from priors. CT head without contrast was obtained
which showed craniotomy changes along the occiput with
encephalomalacia in the medial posterior right cerebellar
hemisphere. Cerebral white matter disease most often due to
chronic small vessel ischemic disease. No findings suggest an
acute process. CXR did not show acute process.
Initial plan was to check ___ set of enzymes and do stress ECHO
in AM of ___ however at 6:30, patient had several runs of
non-sustained runs vtach that were asymtomatic. Given this,
patient is being admitted for further care. Case was discussed
with Dr. ___ ___ ___ in the ED. Patient was
given morphine/zofran/reglan for headache and nausea, 1 L NS.
Hydral x1 as above for SBP 190. Home medications were given
while patient was in the ED.
On the floor, initial vital signs were 98.6 164/100 56 20 96RA.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes (IFG), +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY: (per At___ records)
- Obesity
- Incidental adenoma on imaging ___, unchnaged on CT scan ___
- EtOH abuse
- Hemorrhoids
- Diffuse fatty liver infiltration on CT
- Polycythemia
- First metacarpal bone fracture
- Impaired fasting glucose
- Anemia
- H/o GIB
- H/o colonic polyps
- GERD
- Gout
- Thumb spica cast for fractures at the base of the R1st
metacarpal and triquetral fracture.
Social History:
___
Family History:
M and F both with HTN, CAD, DM. No family history of early
MI,arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 98.6 164/100 56 20 96RA
GENERAL: well-appearing male, NAD
HEENT: NCAT, MMM, OP clear, anicteric sclerae
NECK: Supple with JVD just above the clavicle at 90 degrees
CARDIAC: RRR (+)S1/S2 with SEM at LUSB
LUNGS: Generally CTA b/l without crackles, rales, or wheeze
ABDOMEN: Soft, non-distended, mild periumbilical tenderness,
NABS
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, or xanthomas. Scar overlying
cervical spine and head.
PULSES: Palpable
DISCHARGE PHYSICAL EXAM:
=========================
VS: 99 98.9 140-170/80-100 (143/87) 50-60 (62) 20 97/RA
GENERAL: Well-appearing male in NAD
HEENT: NCAT, MMM, OP clear, anicteric sclerae, sounds congested
NECK: Supple with JVD just above the clavicle at 90 degrees
CARDIAC: RRR (+)S1/S2 with SEM at LUSB
LUNGS: CBAT crackles, rales, or wheeze
ABDOMEN: Soft, NT/ND, NABS
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, or xanthomas. Scar overlying
cervical spine and head.
PULSES: 1+ ___ pulses
Pertinent Results:
LABS:
=====
___ 05:55AM BLOOD WBC-5.7 RBC-3.44* Hgb-10.5* Hct-32.3*
MCV-94 MCH-30.7 MCHC-32.6 RDW-13.1 Plt ___
___ 12:40PM BLOOD WBC-6.1 RBC-3.79* Hgb-11.0* Hct-36.5*
MCV-96# MCH-29.0# MCHC-30.1*# RDW-13.4 Plt ___
___ 05:55AM BLOOD ___ PTT-33.0 ___
___ 12:40PM BLOOD ___ PTT-32.5 ___
___ 05:55AM BLOOD Glucose-118* UreaN-27* Creat-2.9* Na-142
K-4.2 Cl-104 HCO3-29 AnGap-13
___ 07:00PM BLOOD Glucose-156* UreaN-27* Creat-2.7* Na-139
K-4.0 Cl-103 HCO3-25 AnGap-15
___ 12:40PM BLOOD Glucose-129* UreaN-28* Creat-2.8* Na-139
K-4.4 Cl-102 HCO3-26 AnGap-15
___ 05:55AM BLOOD cTropnT-0.02*
___ 07:00PM BLOOD cTropnT-<0.01
___ 12:40PM BLOOD cTropnT-0.02* proBNP-860*
IMAGING:
========
CT HEAD (___):
IMPRESSION: No evidence of acute intracranial process.
Craniotomy changes
along the occiput with encephalomalacia in the medial posterior
right
cerebellar hemisphere. Particularly if the craniotomy was
performed for any history of neoplasm, it should be noted that
persistent or recurrent
neoplastic disease cannot be excluded by this examination.
Correlation with prior outside imaging, if available, would be
helpful to evaluate further.
CXR (___):
IMPRESSION: No evidence of acute disease.
STRESS (___):
NTERPRETATION: This ___ year old NIDDM man with a history of HTN,
HL, CKD and ICH-CVA was referred to the lab for evaluation of
shortness
of breath. The patient exercised for 7.25 minutes of a modified
___
protocol and asked the test be stopped for fatigue. The
estimated peak
MET capacity was 5.2 which represents a poor functional capacity
for his
age. No arm, neck, back or chest discomfort was reported by the
patient
throughout the study. There were no significant ST segment
changes
during exercise or in recovery. The rhythm was sinus with no
ectopy.
Blunted HR and low normal BP response to exercise on beta
blocker
therapy.
IMPRESSION: Poor functional exercise capacity. No anginal type
symptoms
or ischemic EKG changes to achieved low workload. Blunted heart
rate
response to exercise. Echo report sent separately.
ECHO (___):
The patient exercised for 7 minutes and 25 seconds according to
a Modified ___ protocol ___ METS) reaching a peak
heart rate of 84 bpm and a peak blood pressure of 134/70 mmHg.
The test was stopped because of fatigue and at the patient's
request. This level of exercise represents a poor exercise
tolerance for age. In response to stress, the ECG showed no ST-T
wave changes (see exercise report for details). The blood
pressure response to exercise was normal. There was a blunted
heart rate response to stress [beta blockade].
Resting images were acquired at a heart rate of 60 bpm and a
blood pressure of 104/70 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Right
ventricular free wall motion is normal. There is no pericardial
effusion. Resting E/e' is >=13 suggesting PCWP>18 mmHg. Doppler
demonstrated trace aortic regurgitation with no aortic stenosis
or significant mitral regurgitation or resting LVOT gradient. A
left-to-right shunt across the interatrial septum is seen at
rest c/w a small secundum atrial septal defect is present.
Echo images were acquired within 36 seconds after peak stress at
heart rates of 81 - 74 bpm. These demonstrated appropriate
augmentation of all left ventricular segments. There was
augmentation of right ventricular free wall motion. Post
exercise E/e' increased to 20 (from resting 16).
IMPRESSION: Poor functional exercise capacity. No ECG or 2D
echocardiographic evidence of inducible ischemia to achieved low
workload. Blunted heart rate response to physiologic stress.
Small secundum type atrial septal defect. Increased resting and
post-exercise PCWP.
Suboptimal study: Target heart rate not achieved.
Medications on Admission:
The Preadmission Medication list ___ be inaccurate and requires
futher investigation.
1. Gabapentin 300-600 mg PO HS
2. Calcitriol 0.25 mcg PO DAILY
3. Hydrocortisone Acetate Suppository ___ID
4. Torsemide 20 mg PO DAILY
5. HydrALAzine 75 mg PO QID
6. Spironolactone 12.5 mg PO DAYS (___)
7. Amlodipine 10 mg PO DAILY
8. Allopurinol ___ mg PO DAILY
9. Doxazosin 2 mg PO HS
10. Omeprazole 20 mg PO DAILY
11. Atorvastatin 20 mg PO DAILY
12. Finasteride 5 mg PO DAILY
13. Labetalol 900 mg PO BID
14. CloniDINE 0.4 mg PO BID
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Multivitamins 1 TAB PO DAILY
17. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. CloniDINE 0.4 mg PO BID
6. Doxazosin 2 mg PO HS
7. Finasteride 5 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Gabapentin 300-600 mg PO HS
10. HydrALAzine 75 mg PO QID
11. Hydrocortisone Acetate Suppository ___ID
12. Labetalol 900 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Spironolactone 12.5 mg PO DAYS (___)
16. Torsemide 20 mg PO DAILY
17. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
18. Acetaminophen 500 mg PO Q4H:PRN Headache
Do NOT take more than 4 grams per day.
RX *acetaminophen 500 mg 1 tablet(s) by mouth Every 4 hours as
needed Disp #*90 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Shortness of Breath
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HEAD CT
HISTORY: Prior craniotomy in ___ and intracranial hemorrhage with three days
of headache.
COMPARISONS: None available.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is an occipital craniotomy site overlying a region of
hypodensity in the medial right cerebellar hemisphere. Attenuation is mixed,
however, and it is not possible to exclude the potential for any residual
tumor at this site if neoplasm was in fact the reason why the patient had had
a craniotomy in the past.
There is no hydrocephalus, mass effect, or shift of the normally midline
structures. There is no evidence for acute intracranial hemorrhage. The
gray-white matter distinction appears preserved, but there are areas of vague
geographic subcortical white matter hypodensity in parietal and frontal lobes,
most often due to chronic small vessel ischemic disease. A subcortical
hypodensity of 3 mm in the right frontal lobe suggests a prior small lacunar
infarct.
Vascular calcifications are widespread. Surrounding soft tissue structures
are unremarkable. Mild mucosal thickening is noted along ethmoid air cells
bilaterally. The mastoid air cells appear clear. Moderate degenerative
changes involve each temporomandibular joint. There is a right frontal burr
hole in addition to craniotomy changes along the occiput.
IMPRESSION: No evidence of acute intracranial process. Craniotomy changes
along the occiput with encephalomalacia in the medial posterior right
cerebellar hemisphere. Particularly if the craniotomy was performed for any
history of neoplasm, it should be noted that persistent or recurrent
neoplastic disease cannot be excluded by this examination. Correlation with
prior outside imaging, if available, would be helpful to evaluate further.
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Nausea and shortness of breath.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The cardiac, mediastinal and hilar contours appear unchanged. The
heart is borderline enlarged. There is no pleural effusion or pneumothorax.
The lungs appear clear. There is some chronic-appearing bony fragmentation
along the distal right clavicle.
IMPRESSION: No evidence of acute disease.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with HYPERTENSION NOS
temperature: 97.8
heartrate: 64.0
resprate: 18.0
o2sat: 100.0
sbp: 151.0
dbp: 79.0
level of pain: 7
level of acuity: 3.0 | ___ with multiple medical problems including diabetes,
hypertension, chronic kidney disease, and past history of
intracranial hemorrhage presenting with headache, nausea, and
shortness of breath for three days. He had no focal neuro sx and
a CT scan of his head was performed that was otherwise
unremarkable for bleed. Changes consistent with prior history of
craniotomy. His headache that was anterior with some nasal
congestion could have been a minor head cold with no e/o acute
sinusitis. For his reported SOB, on further inquiry appears to
be stable with no DOE. CXR unremarkable with stable EKG. He also
had trops that were negative x3. He had plans for stress echo
from the ED but had reported episodes of NSVT that prompted
admission, but, on further review, were c/w artificact. No other
events otherwise on tele. Stress echo was performed with pt
without arrhythmia or ischemic changes. Other structural changes
such as LVH c/w prior and otherwise normal EF. He was otherwise
hemodynamically stable and once his home BP medications were
resumed, was back to his baseline BP control. Recommened
continued f/u PCP for HA and HTN control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
R flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M w/ h/o VRE, recurrent pyelonephritis, bladder & renal
cell
carcinoma s/p left nephrectomy, recent admission for
pyelonephritis in early ___ p/w several hours of worsening
right sided flank pain, dysuria, urinary frequency, and now RLQ
pain. ___ reports that about 10 days ago his foley was bother
him,
so ___ removed it and has been voiding on his own since. ___ was
doing fine until today, when ___ developed sharp R flank pain on
day of presentation. Felt different to prior episodes of pyelo.
Getting worse, now ___. No fevers, chills, nausea, vomiting, or
hematuria. No history of stones.
In the ED, initial vitals were:
On arrival, his vitals were 96.3 ___ 18 100% RA
Prior to transfer his vitals were 98.7 77 128/78 16 99% RA
His exam was notable for nontoxic appearance, severe R CVAT,
mild
suprapubic pain R>L, no rebound or guarding.
His labs were notable for WBC 13.6, Cr 1.7 (baseline 1.3), UA
with Lg Leuks, Mod Blood, 20 RBC, >182 WBC.
___ received:
___ 17:10 PO Acetaminophen 1000 mg ___
___ 18:01 IV CefePIME 2 g ___
___ 18:47 IV Linezolid ___ mg ___
On the floor, patient was well-appearing and able to fully
endorse history. ___ notes that ___ has been intermittently
cathing
himself for a number of years due to bladder cancer. However,
recently had TURP with Dr. ___ not needed to self-cath
for 2 months.
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:
COPD
Type 2 Diabetes
Recurrent UTI's
Papillary RCC s/p L nephrectomy
BPH
Bladder cancer s/p several resections, seen by Dr. ___ s/p MI
A-Fib not on anticoagulation
Likely primary hyperparathyroidism
Social History:
___
Family History:
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased
Multiple family members with bladder cancer.
Physical Exam:
Physical Exam on Admission:
Vital Signs: T98, BP 120s-140s/60s-70s, HR ___, RR14, O2 98%
General: AAOx3, no acute distress , relatively well-appearing
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly. +R flank pain.
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, 2+ reflexes bilaterally, gait
deferred.
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
Physical Exam on Discharge:
Vital Signs: T 98.1 BP 120s-130s/60s-70s, HR ___, RR14, O2
98%
General: AAOx3, no acute distress , relatively well-appearing
HEENT: Sclerae anicteric, MMM, oropharynx clear, poor dentition
and many teeth not present, EOMI, PERRL,
neck supple, flat JVP.
CV: RRR, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly. +R flank pain, much improved.
GU: No foley
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, narrow based
gait.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Pertinent Results:
Labs on Admission:
___ 04:16PM BLOOD WBC-13.6* RBC-4.22* Hgb-12.9* Hct-39.6*
MCV-94 MCH-30.6 MCHC-32.6 RDW-16.2* RDWSD-55.3* Plt ___
___ 04:16PM BLOOD Neuts-63.6 ___ Monos-9.3 Eos-2.6
Baso-1.0 NRBC-0.1* Im ___ AbsNeut-8.66* AbsLymp-3.07
AbsMono-1.26* AbsEos-0.35 AbsBaso-0.14*
___ 04:16PM BLOOD Plt ___
___ 04:16PM BLOOD Glucose-130* UreaN-23* Creat-1.7* Na-140
K-4.4 Cl-104 HCO3-26 AnGap-14
___ 04:16PM BLOOD Albumin-4.4
=
=
=
=
=
=
=
================================================================
Labs on Discharge:
___ 05:00AM BLOOD WBC-9.7 RBC-3.73* Hgb-11.2* Hct-34.3*
MCV-92 MCH-30.0 MCHC-32.7 RDW-15.6* RDWSD-51.9* Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-127* UreaN-21* Creat-1.4* Na-138
K-4.4 Cl-105 HCO3-26 AnGap-11
___ 05:00AM BLOOD Calcium-10.0 Phos-2.6* Mg-1.8
=
=
=
=
=
=
=
================================================================
MICRO:
___ 05:11PM URINE RBC-20* WBC->182* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
___ 05:11PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:11PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:11PM URINE
___ 05:11PM URINE Mucous-RARE
___ 5:11 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
=
=
=
=
=
=
================================================================
Radiology:
___ RUS
IMPRESSION:
No hydronephrosis, nephrolithiasis, or suspicious focal renal
lesion within the right kidney.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Omeprazole 40 mg PO BID
8. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 40 mg PO QPM
11. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN chets
congestion
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN chets congestion
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
10. Senna 8.6 mg PO BID:PRN constipation
11. Simvastatin 40 mg PO QPM
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Fosfomycin Tromethamine 3 g PO EVERY 3 DAYS
Dissolve in ___ oz (90-120 mL) water and take immediately. Take
every 3 days until ___.
RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by
mouth every 3 days (___) Disp #*3 Packet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Pyelonephritis
2. Urinary retention
3. Acute kidney injury
Secondary Diagnoses:
1. COPD
2. Type 2 diabetes
3. CAD
4. A Fib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ with h/o recurrent VRE pyelonephritis, LEFT nephrectomy p/w 1
day of R flank pain, dysuria, RLQ pain, evaluate for kidney stones or
obstruction.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Prior renal ultrasound dated ___.
FINDINGS:
The right kidney measures 11.5 cm. The left kidney is surgically absent.
There is no hydronephrosis, stone, or mass within the right kidney. Multiple
simple cysts are unchanged from the prior study.
The bladder is moderately well distended. Mild bladder and prostate
irregularity is consistent with history of multiple prior surgeries.
IMPRESSION:
No hydronephrosis, nephrolithiasis, or suspicious focal renal lesion within
the right kidney.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Right sided abdominal pain
Diagnosed with Acute pyelonephritis, Acute kidney failure, unspecified
temperature: 96.3
heartrate: 107.0
resprate: 18.0
o2sat: 100.0
sbp: 138.0
dbp: 104.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ with h/o COPD, T2DM, CAD s/p MI (___), Afib
not on anticoagulation, h/o RCC s/p left nephrectomy,
non-invasive low grade papillary urothelial cancer s/p multiple
TURBTs, and MDR UTIs, who presented with severe right flank pain
and positive UA, likely from recurrent pyelonephritis in the
setting of chronic urinary retention.
#R Pyelonephritis: Patient was initially admitted to the
hospital with leukocytosis, positive UA and R severe flank pain,
consistent with pyelonephritis. Urine culture without any
notable growth. Blood cultures remain no growth to date. R flank
pain steadily improved from ___ to ___ with treatment, and the
leukocytosis resolved shortly. Patient has a history of growing
MDR organisms and VRE, hence was started on linezolid and
cefepime (___). The chronic urinary retention is likely
contributing to patient's recurrent pyelonephritis admissions.
Per discussion with inpatient ID, it was recommended that
patient be discharged on fosfomycin 3g q3 days to complete a 14
day course (___). Patient will ___ with Dr. ___
on ___. ID also recommended that patient be considered for
qweekly fosfomycin prophylaxis in an attempt to decrease the
frequency of UTIs. Patient was counseled extensively about the
need to present to the hospital should ___ develop any new
fevers, urinary symptoms or flank pain again.
#Urinary Retention: Patient has a history of urothelial cancer
and is s/p TURBT 2 months ago with Dr. ___ was
recently hospitalized for R pyelonephritis and was discharged
with a foley. ___ removed his foley 1 week ago and has been
voiding ok. However, ___ does endorse having delayed stream
initiation and early termination, with residual urge to void
afterward. During this admission, we monitored his PVR and they
ranged between 230s-270s. Urology recommended that patient
straight cath himself after every void to ensure that ___ is not
having significant urinary retention and risk of reflux
contributing to recurrent pyelonephritis. Patient endorsed that
___ has all of the cath materials at home and is fully educated
on how to self-cath. Please follow up with the patient as to
whether ___ is following this recommendation.
#Acute Renal Failure: Patient initially presented with ___ to
1.7, likely in the setting of pre-renal azotemia. ___ was given
IVF with improvement in his Cr. Given that patient was able to
have good PO intake, we did not give him any additional IVF.
Patient has been able to void adequately, although with some
mildly elevated PVR numbers (200s). However, this was unlikely
to be an obstructive process as the PVRs were not impressive
enough to cause persistent obstruction. Patient's Cr was 1.4 on
discharge. Please continue to ___ on patient's renal
function in the outpatient setting, and check a chemistry panel
during the next PCP ___ appointment on ___.
# Urothelial cancer: Patient has a history of urothelial cancer
and had TURBT 2 months ago with Dr. ___ has not needed to
self-cath since. Patient will ___ with outpatient urology
after discharge. Per patient's preference, ___ would like to have
a new provider, and Dr. ___ Dr. ___
___ with.
#Normocytic anemia: Patient was admitted with a hgb of 12.9. His
hgb decreased to 11.2 but patient was well-appearing without any
evidence of active bleeding. ___ denied any hematuria and UA was
only notable for microscopic hematuria. Patient will ___
with outpatient PCP ___ ___, where a repeat CBC will be checked.
# CAD: We continued patient on home aspirin, metop, simvastatin.
# COPD: Patient denied any recent COPD exacerbations x years. ___
is not on home O2. We continued his home COPD meds and his
respiratory status was stable on discharge.
# AFib: We continued patient on home metop. ___ is not on
anticoagulation.
# GERD: We continued patient on home omeprazole.
# DMII: We continued patient on ISS while ___ was in-house, and
resumed his metformin on discharge.
# Hx of RCC: Patient has a history of RCC s/p L nephrectomy,
currently has been stable. ___ follows with Dr. ___ at ___.
=
================================================================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, Pneumonia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo f with a h/o severe AS, COPD, HTN, HLD, who has had
multiple falls over the last 3 months, who presents after fall
at ___ ~20:00. She was trying to change her pajamas. Landed on
her backside, couldn't get up, and called ___. She was brought
to ___. Denies head strike, denies LOC. No chest pain,
dizziness, nausea, vomiting, LH, or hemoptysis. She does c/o
heartburn and asks for Zantac. Some SOB and cough but she says
they are chronic.
In the ED, initial vitals were: 99.2, HR 115, BP 116/77, RR 18,
98% RA
Labs notable for:
WBC 19.3 with neutrophilia
Na 129
Glu 51
K>10?, on recheck 4.5
Imaging notable for:
CT HEAD ___
No fracture or intracranial hemorrhage.
Patient was given:
___ 00:55 PO/NG Acetaminophen 650 mg
___ 00:55 PO/NG OxyCODONE (Immediate Release) 5 mg
___ 02:02 IVF 1000 mL NS 500 mL
___ 02:49 IV Levofloxacin 500 mg
Vitals on transfer: 99 112 111/68 16 99% RA
On the floor, pt is very adamant about receiving a menu to
order food
ROS: negative in detail other than stated in HPI
Past Medical History:
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hearing loss.
3. History of mild aortic stenosis.
4. Ventricular hypertrophy.
5. ___ esophagus.
6. History of rectal prolapse, fecal incontinence.
7. Chronic obstructive pulmonary disease.
8. Osteopenia.
9. Low back pain secondary to lumbar spinal stenosis with
radiculopathy. Followed in pain clinic.
10. Osteoarthritis.
11. Obesity.
PAST SURGICAL HISTORY:
1. Left tympanic membrane repair.
2. Surgical repair of rectal prolapse.
3. Bilateral cataract surgery ___.
4. TAH/BSO.
5. Gastric bypass surgery in ___.
6. Lumbar decompression for management of stenosis, L4/L5 and
L5/S1 in ___.
7. L3/L4 laminectomy with revision decompression and L3/S1
revision instrumentation ___.
Social History:
___
Family History:
Father had colon cancer. Mother had a myocardial infarction as
well as maternal aunt. Two aunts had postmenopausal breast
cancer.
Physical Exam:
>> ADMISSION PHYSICAL EXAM:
Vital Signs: 98.5, 130 / 47, HR 104, RR 18, 100% RA
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, ___ mid-peaking systolic murmur
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, no edema
Neuro: grossly intact
.
>> DISCHARGE PHYSICAL EXAM
Vital Signs: 98.0 PO 124 / 57 108 19 97 RA
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, ___ mid-peaking, harsh systolic
murmur
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, no edema. right malleolus 2 cm
circular well-healing ulceration.
Neuro: grossly intact
Pertinent Results:
>> ADMISSION LABS:
___ 12:00AM BLOOD WBC-19.3*# RBC-3.76* Hgb-11.1* Hct-35.4
MCV-94 MCH-29.5 MCHC-31.4* RDW-22.9* RDWSD-78.0* Plt ___
___ 09:06AM BLOOD Glucose-71 UreaN-12 Creat-0.8 Na-134
K-4.3 Cl-98 HCO3-24 AnGap-16
___ 09:06AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.7
___ 09:06AM BLOOD ___ 09:06AM BLOOD Osmolal-278
___ 01:30AM BLOOD Glucose-51* Na-129* K-GREATER TH Cl-102
calHCO3-19*
.
>> DISCHARGE LABS
___ 05:48AM BLOOD WBC-10.4* RBC-3.11* Hgb-9.1* Hct-30.4*
MCV-98 MCH-29.3 MCHC-29.9* RDW-21.9* RDWSD-77.7* Plt ___
___ 05:48AM BLOOD Glucose-66* UreaN-12 Creat-0.7 Na-136
K-4.0 Cl-102 HCO3-25 AnGap-13
.
>> PERTINENT REPORTS :
___ HEAD W/O CONTRAST: No fracture or
intracranial hemorrhage.
___ (AP, LAT & OBLIQUE: 1. No fracture or
joint effusion.
2. There are increased degenerative changes from ___.
___ (AP, MORTISE & LA : No fracture
identified.
___ (PA & LAT):
1. Left lower lobe pneumonia.
2. No evidence of fracture within the limits of plain
radiography.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ with fall and ankle and knee pain // fracture?
TECHNIQUE: Three views of the left knee
COMPARISON: Knee radiographs from ___
FINDINGS:
There is moderate to severe degenerative change at the medial femorotibial
compartment, progressed from previous. Less marked degenerative changes seen
in the lateral and patellofemoral compartments. No large effusion. No acute
fracture. No concerning bone lesion. There is vascular calcification.
IMPRESSION:
1. No fracture or joint effusion.
2. There are increased degenerative changes from ___.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ with fall and ankle and knee pain // fracture?
TECHNIQUE: Three views of the right ankle.
COMPARISON: Right knee radiographs from ___.
FINDINGS:
The ankle mortise is congruent. The talar dome is intact. No acute fracture
is seen. There is some soft tissue swelling. Plantar and posterior calcaneal
spurs are seen. There is vascular calcification.
IMPRESSION:
No fracture identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST.
INDICATION: ___ with fall // multiple falls, bleed?.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Noncontrast head CT from ___.
FINDINGS:
There is no evidence of large vascular territory infarction, hemorrhage,
edema, or mass. The ventricles and sulci are prominent consistent with
involutional changes. Periventricular white matter hypodensities may
represent microvascular angiopathy changes.
No fracture. Ossification of the left mastoid air cells is unchanged from
___. Opacification of the right mastoid air cells is new since then. The
paranasal sinuses and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
No fracture or intracranial hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Pneumonia, unspecified organism, Urinary tract infection, site not specified
temperature: 99.2
heartrate: 115.0
resprate: 18.0
o2sat: 98.0
sbp: 116.0
dbp: 77.0
level of pain: 3
level of acuity: 3.0 | ___ yo F with history of severe aortic Stenosis, COPD, chronic
back pain, and HTN, who presents after a fall at home and is
found to have tachycardia, leukocytosis, ?pna on imaging, and
?UTI.
.
>> ACTIVE ISSUES:
# Fall: Patient was found after a traumatic fall and after
reviewing the medical record, there have been several instances
of falls over this past year. the etiology of her fall seemed to
be multifactorial, in the setting most likely of polympharmacy
as patient is on TCA and opiates and methadone for chronic pain.
However, other etiologies that were considered included low PO
intake in the setting of an incidental pneumonia seen on chest
x-ray, as well as her underlying severe aortic stenosis. Upon
history review, no current indication for syncope as her severe
aortic stenosis may make her more pre-load dependent and thus
volume changes could lead to syncopal episode. Patient had
trauma evaluation with CT head, ankle, knee only significant for
worsening degenerative changes, and no fall during hospital
stay. Patient worked with physical therapy, instructed on walker
use (which she has at home), and was cleared for home safety.
Services were then set up to ensure home safety evaluations and
further safety measures at home.
.
# Community Acquired Pneumonia: Patient was incidentally found
on trauma imaging to have a left lower lobe pneumonia. Patient
initially treated with IV Ceftriaxone+Azithromycin, and then
de-escalated to oral regimen of cefpodoxime and azithromycin for
7 days. She was pulmonary asymptomatic during hospital stay
without sputum production. Repeat chest radiograph to ensure
resolution of infiltrate recommended in ___ weeks.
.
# Pre-Existing Lateral Malleolus Pressure Ulcer: Patient had
wound care and off-loading recommendations with cleaning.
.
# Leukocytosis: Likely ___ to infection, stress from trauma.
Improved during hospital stay.
.
# Severe Aortic Stenosis: Valve area 0.5 cm, currently being
worked up for potential TAVR candidate. Patient's fall was not
thought to be related to underlying cardiac condition, and
therefore no further echocardiogram to trend valve changes were
performed. Patient to follow up with outpatient cardiologist.
.
# Hypertension: Patient currently not on agents as thought to
contribute to falls, monitored and no signs of hypertensive
urgency during hospital stay.
.
# Hyperlipidemia: Patient continued on home pravastatin
.
# COPD: Continued on home tiotropium and albuterol
.
# GERD: Continued on home raniditine
.
# Chronic Pain: Continued on home methadone (5mg QAM, 10mg QPM),
nortryptiline, oxycodone PRN, gabapentin
.
>> TRANSITIONAL ISSUES
===================
# POLYPHARMACY: As patient has had increasing number of falls,
please look over medications for risk reduction.
# COMMUNITY ACQUIRED PNEUMONIA/URINARY TRACT INFECTION: She will
need to finish her course of azithromycin for five days (Day 5=
___ and your cefpodoxime for seven days (Day 7= ___. Please obtain a repeat chest x-ray in ___ weeks to ensure
resolution of infiltirate.
# Normocytic Anemia: Please continue to trend and workup as
outpatient.
# Physical Therapy: Please continue to monitor patient for need
while using walker at home.
# CODE: full presumed
# CONTACT: sister ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a ___ year old right-handed woman with a history
of HTN and dyslipidemia presenting after two discreet episodes
of dizziness. Several hours into the morning on ___ she had
acute onset head-spinning vertigo that occurred a few moments
after standing (though not immediately). She describes the
dizziness as a sensation of movement in her head. She denies
that the surroundings were moving. She went outside for a walk
and the sensation went away in less than one minute. She
continued to have a normal day with no recurrence of symptoms.
The next day she woke and felt fine, sent a few emails and ran a
few errands. She was getting the dogs ready to go for a walk
when immediately she had sudden onset dizziness again, similar
to the prior day but much more severe. She starting walking to
the right, feeling as if something was pulling her in that
direction, and needed to brace against a wall for stability. She
made it back inside and sat down. Her dizziness became more
severe, and she called her PCP, her son and 911.Again, she
describes the dizziness as a sensation of movement in her head.
She started vomiting and retched a few times. She was taken to
the ___ where she thought for a moment she had quadruple
vision that was not horizontal or vertical, but "distorted and
swirled." A head CT was negative for hemorrhage or stroke. She
received meclizine and Zofran and was transferred to our ___. She
is convinced that the Meclizine helped her with the dizziness.
She denies ever having these symptoms before. No hearing loss or
tinnitus. She has had no new medications, no recent infections
and no trauma.
She is under a lot of stress, since she is awaiting results of a
biopsy on a breast calcification from last ___. The recent
deaths in her family have also been difficult and reminded her
of her husband's death ___ years ago. Loosing her husband has been
particularly difficult. In the 6 months after his death, she
lost 100 pounds.
Past Medical History:
Obesity
Hypertension
Hyperlipidemia
Asthma
Hx of atypia on breast biopsy
Social History:
___
Family History:
Sister, heart attack.
Mother, hypertension.
Sister, stroke.
Sister, history of phlebitis.
Paternal aunt, breast cancer.
There is also lupus and pulmonary fibrosis that runs in the
family.
Physical Exam:
Upon discharge:
Tmax/Tcurrent: 98.9/98.4 BP: 96-144/56-92 HR: 53-61 RR: 18
O2:94-96%
General: NAD
HEENT: NCAT, no oropharyngeal lesions
Neurologic Examination:
-Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive. Speech is fluent with
full sentences, intact repetition, and intact verbal
comprehension. Naming intact. No paraphasias. No dysarthria.
Normal prosody. No evidence of hemineglect. No left-right
confusion. Able to follow both midline and appendicular
commands.
-Cranial Nerves: PERRL. EOMI, no direct, end-gaze or vertical
nystagmus. Smooth pursuit b/l. Visual fields intact. Symmetric
smile. No facial movement asymmetry. Hearing grossly intact.
SCM/Trapezius strength ___ bilaterally.
-Motor: Normal bulk and tone. No drift. No tremor or asterixis.
-Sensory: No deficits to light touch or temperature bilaterally.
-Coordination: No dysmetria with finger to nose or heel knee
shin. Good speed and intact cadence with rapid alternating
movements. No truncal ataxia.
-Gait: ___ up slowly, but had no symptoms. Normal initiation.
Narrow base, but hesitant. Normal stride length and arm swing.
Stable without sway. Able to tandem without difficulty. Negative
Romberg.
-Head impulse testing: Negative
-Unterberger test: Negative
Pertinent Results:
___ 09:50PM BLOOD WBC-11.3* RBC-4.36 Hgb-12.7 Hct-39.0
MCV-89 MCH-29.1 MCHC-32.6 RDW-12.5 RDWSD-41.2 Plt ___
___ 09:50PM BLOOD Neuts-77.7* Lymphs-16.0* Monos-5.1
Eos-0.4* Baso-0.4 Im ___ AbsNeut-8.77* AbsLymp-1.80
AbsMono-0.57 AbsEos-0.04 AbsBaso-0.05
___ 09:50PM BLOOD Glucose-103* UreaN-16 Creat-0.7 Na-140
K-4.4 Cl-106 HCO3-22 AnGap-16
___ 09:50PM BLOOD ALT-37 AST-32 AlkPhos-77 TotBili-0.9
___ 09:50PM BLOOD Lipase-36
___ 09:50PM BLOOD Albumin-4.2 Calcium-9.8 Phos-3.7 Mg-2.1
Cholest-167
___ 09:50PM BLOOD %HbA1c-5.5 eAG-111
___ 09:50PM BLOOD Triglyc-95 HDL-55 CHOL/HD-3.0 LDLcalc-93
___ 09:50PM BLOOD TSH-1.8
___ ___ (done at ___: no evidence of stroke,
hemorrhage, or mass.
___ MRI/MRA BRAIN: Dominant left vertebral artery is noted,
a congenital variant. In addition, there is aberrant right
subclavian artery. No stroke, no hemorrhage or mass.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cetirizine 10 mg PO DAILY
4. Montelukast 10 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Docusate Sodium 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Montelukast 10 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Rosuvastatin Calcium 5 mg PO DAILY
6. Meclizine 12.5 mg PO Q8H:PRN dizziness
RX *meclizine 12.5 mg 1 tablet(s) by mouth every 6 hours Disp
#*20 Tablet Refills:*0
7. Cetirizine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Dizziness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI BRAIN WITH AND WITHOUT CONTRAST.
MRA BRAIN WITHOUT CONTRAST.
WITHOUT AND WITH CONTRAST.
INDICATION: ___ with dizziness, balance issues, emesis this AM // eval for
cerebellar infarct, tentorial mass
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 19 mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique. Post-contrast T1 and sagittal MPRAGE with
coronal and axial reformats were performed.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: None.
FINDINGS:
MRI Brain:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration.
Post-contrast images demonstrate no abnormal parenchymal or meningeal
enhancement.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation. Noted is a fetal type right PCA with a prominent right
posterior communicating artery.
MRA neck: The common, internal and external carotid arteries appear normal.
There is no evidence of internal carotid artery stenosis by NASCET criteria.
The origins of the great vessels, subclavian and vertebral arteries appear
normal bilaterally. Dominant left vertebral artery is noted, a congenital
variant. In addition, there is aberrant right subclavian artery.
IMPRESSION:
1. No stroke, no hemorrhage or mass.
2. Unremarkable MRA of the head and neck.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Transfer
Diagnosed with Other abnormalities of gait and mobility
temperature: 97.9
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 150.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | Upon arrival to our ___, Ms. ___ symptoms had largely
resolved, though she still had mild dizziness. Her vital signs
were T 97.9, HR 62, BP 150/92, RR 18, 100% on RA. On exam she
had a normal mental status, cranial nerve, motor, sensory, and
coordination exam. Hearing was intact. Though she was hesitant,
her gait was normal. She had a negative Romberg test, negative
head impulse test, negative ___, and she had a normal
___ test. She had an MRI/MRA head which showed no
evidence of stroke or mass. The patient's dizziness largely
subsided, and repeat exams continued to show no focal findings.
Her labs were unremarkable. The cause of her episodes of
dizziness was not determined, though possibly functional in
etiology ___ increased worry and poor sleep with waiting for
results of a recent breast biopsy 1 week prior to admission and
becoming increasingly anxious. Her description of the dizziness
was not typical for a vertiginous dizziness. Imaging ruled out
intracranial abnormalities, and her history and physical were
inconsistent with peripheral or central vestibular abnormality.
She was discharged home with a short course of Meclizine PRN
given symptomatic improvement at the outside ___.
No follow-up with Neurology required, only on an as needed
basis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p mechanical fall
Major Surgical or Invasive Procedure:
___ reduction and internal fixation of right olecranon
fracture
History of Present Illness:
___ female who is presenting after a
mechanical fall down approximately 10 stairs landing on
concrete. She reports that her heel got stuck as she was
midway down the staircase and went head first. Denies any
loss of consciousness and ambulated to the ED. Is
complaining of right elbow pain and pain of her right eye
area. Also notes some pain in her upper back. No blood
thinning medications.
Past Medical History:
ALLERGIC RHINITIS
HYPERLIPIDEMIA
HYPOTHYROIDISM
MENOPAUSE
OSTEOARTHRITIS
TINNITUS
OSTEOPOROSIS
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Temp: 98.1 HR: 82 BP: 135/87 Resp: 20 O(2)Sat: 100 Normal
Constitutional: Awake
HEENT: Ecchymotic and tender right orbit, extraocular
motions are intact-small amount of blood in the nares
without any bony deformity of the nasal bone and no septal
hematoma
Chest: No chest wall crepitus or tenderness, Clear to
auscultation
Cardiovascular: Normal
Abdominal: Normal
Extr/Back: Gross deformity of the right elbow without any
skin tear-left lower leg with diffuse ecchymosis and
swelling of the anterior shin relative to the right-no bony
point tenderness to palpation-mild ecchymosis of the right
anterior ankle without any underlying bony tenderness
Pelvis is stable x3, back with some paraspinous right-sided
tenderness in the thoracic area
Neuro: Normal
Psych: Normal mentation
Discharge Physical Exam:
VS: 98.1, 109/66, 88, 18, 96 Ra
Gen: A&O x3, sitting up in chair in brace
HEENT: right sided periorbital ecchymosis and swelling
CV: HRR
Pulm: LS ctab
Abd: soft, NT/ND
Ext: RUE:
Clean, dry, and intact Ace wrapped splint
Fires EPL, FPL, and DIO
Sensation is intact to light touch in the axillary, radial,
median, and ulnar nerve distributions
Fingers are warm and well-perfused
Neuro: intact, no neurological deficits
Pertinent Results:
___ 10:35AM BLOOD WBC-6.3 RBC-2.49* Hgb-8.1* Hct-25.4*
MCV-102* MCH-32.5* MCHC-31.9* RDW-14.3 RDWSD-53.1* Plt ___
___ 07:20AM BLOOD WBC-6.8 RBC-2.89* Hgb-9.3* Hct-27.9*
MCV-97 MCH-32.2* MCHC-33.3 RDW-13.7 RDWSD-49.1* Plt ___
___ 02:05PM BLOOD WBC-9.2 RBC-3.58* Hgb-11.9 Hct-35.7
MCV-100* MCH-33.2* MCHC-33.3 RDW-13.6 RDWSD-50.2* Plt ___
___ 10:35AM BLOOD Glucose-139* UreaN-6 Creat-0.7 Na-137
K-3.9 Cl-101 HCO3-25 AnGap-11
___ 07:20AM BLOOD Glucose-117* UreaN-6 Creat-0.6 Na-130*
K-4.2 Cl-92* HCO3-23 AnGap-15
___ 02:05PM BLOOD Glucose-162* UreaN-10 Creat-0.8 Na-132*
K-4.0 Cl-93* HCO3-22 AnGap-17
___ 10:35AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.9
___ 07:20AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0
___ 02:55PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
IgM HBc-NEG IgM HAV-NEG
Radiology:
___: CXR
No evidence of traumatic injury in the chest.
___: CT Head
1. No acute intracranial process.
2. Acute fracture and 5 mm depression of the right orbital floor
(involving the infraorbital canal). The right inferior rectus
closely abuts the fracture site and there is retro-orbital air
with right-sided proptosis. Recommend clinical correlation for
possible entrapment and compartment syndrome.
3. Dependent hemorrhagic fluid in the right maxillary and
sphenoid sinuses.
___: CT C Spine
No acute fracture or traumatic malalignment.
___: CT Chest
1. Acute moderate compression fracture of T5 and a minimally
distracted fracture of the T5 spinous process. No malalignment
or retropulsion.
2. A punctate lucency at the distal tip of the T4 spinous
process
is nonspecific, but may reflect a subtle nondisplaced fracture
in
the setting of acute trauma to this region.
3. No other acute injuries in the torso.
___: L Tib/fib XR
Anterolateral soft tissue contusion along the left shin without
underlying fracture, foreign body or soft tissue gas.
___: L ankle XR
No acute fracture or dislocation involving the left ankle.
___: R elbow XR
Acute fracture of the olecranon, with 1.0 cm proximal
retraction.
___: CT Sinus/mandible/maxilla
1. Redemonstration of a comminuted, inferiorly displaced right
inferior orbital wall fracture involving the infraorbital
foramen
with fragments displaced into the right maxillary sinus by 5 mm.
The right lamina papyracea is intact.
2. There is mild inferior herniation of the right inferior
rectus
muscle into the right maxillary sinus, with mild impingement
along the medial aspect of the muscle secondary to a fracture
fragment. Small hematoma within the inferior orbit adjacent to
the fracture fragments. Retro-bulbar gas and right-sided
proptosis is unchanged.
3. Right nasal bone fracture, minimally displaced.
4. Air-fluid level with hemorrhagic products within the right
maxillary sinus as on prior.
___: R elbow intraop
The available images show steps related to open reduction
internal fixation of an olecranon fracture with placement of a
dorsal post plate and screw fixation device. Alignment is
improved when compared to the preoperative study with near
anatomic alignment. Please see the operative report for further
details.
___: MRI T Spine
1. Acute severe compression fracture of T5 with 4 mm bony
retropulsion into the spinal canal of the buckled posterior
cortex, causing mild spinal canal narrowing however without cord
contact.
2. Known T5 spinous process fracture is not well seen by MRI,
better assessed on prior CT.
3. No other thoracic spine fracture identified.
4. Mild thoracic degenerative changes without additional area of
spinal canal or neural foraminal narrowing at any level.
5. Incidentally noted trace bilateral layering pleural
effusions.
Other incidental findings, as above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Alendronate Sodium 70 mg PO QMON
4. Patanol (olopatadine) 0.1 % ophthalmic (eye) DAILY
5. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Spectravite Senior (geriatric
multivit-iron-mins;<br>multivit-min-FA-lycopen-lutein)
___ mcg oral DAILY
8. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Artificial Tears ___ DROP BOTH EYES PRN irritation
3. Bacitracin Ointment 1 Appl TP BID
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
5. Cyclobenzaprine 5 mg PO Q8H:PRN muscle spasm
6. Docusate Sodium 100 mg PO BID
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID
10. Alendronate Sodium 70 mg PO QMON
11. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
12. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
13. Levothyroxine Sodium 75 mcg PO DAILY
14. Patanol (olopatadine) 0.1 % ophthalmic (eye) DAILY
15. Spectravite Senior (geriatric
multivit-iron-mins;<br>multivit-min-FA-lycopen-lutein)
___ mcg oral DAILY
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right orbital floor fracture with orbital emphysema
Right olecranon fracture
T5 compression fracture and T5 posterior spinous process
fracture
nasal bone fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Followup Instructions:
___
Radiology Report
EXAMINATION: TRAUMA #3 (PORT CHEST ONLY)
INDICATION: Trauma
TECHNIQUE: Portable AP supine chest
COMPARISON: None
FINDINGS:
Lungs are hyperexpanded are clear. Cardiomediastinal silhouette and hila are
unremarkable. No pneumothorax or pleural effusion. Visualized osseous
structures appear intact within the limits of plain radiography.
IMPRESSION:
No evidence of traumatic injury in the chest.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall down stairs// trauma
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 500 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
Trace anterolisthesis of C2 on C3 and C3 on C4 is unchanged from ___.
No acute fractures are identified.Mild multilevel degenerative changes are
seen, most extensive at C3-4 and C5-6 and notable for loss of intervertebral
disc space.There is no prevertebral edema.
The thyroid is unremarkable. Mild scarring is noted in the imaged lung
apices.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall down stairs// trauma
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 ___.
FINDINGS:
There is no evidence of large territorial infarction,hemorrhage,edema,or
mass-effect. There is prominence of the ventricles and sulci suggestive of
age-related atrophy.
There are acute fractures of the right orbital floor, involving the right
infraorbital canal, and inferior aspect of the right lamina papyracea
(601:29). This is associated with approximately 5 mm depression of the right
orbital floor. The right inferior rectus muscle closely abuts the fracture
area. There is dependent hemorrhagic fluid in the right maxillary sinus and
air in the right retro-orbital fat, associated with right sided proptosis.
Small volume dependent fluid in the right sphenoid sinus is also likely
hemorrhagic.
There is also an acute, minimally displaced, fracture of the nasal bone on the
right side (03:13). There is extensive soft tissue edema and small foci of
subcutaneous air surrounding the right orbit.
The visualized portion of the mastoid air cells, and middle ear cavities are
clear. The left orbit is unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Acute fracture and 5 mm depression of the right orbital floor (involving
the infraorbital canal). The right inferior rectus closely abuts the fracture
site and there is retro-orbital air with right-sided proptosis. Recommend
clinical correlation for possible entrapment and compartment syndrome.
3. Dependent hemorrhagic fluid in the right maxillary and sphenoid sinuses.
RECOMMENDATION(S): Clinical correlation for possible right orbit entrapment
and compartment syndrome, for impression point 2.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. in person on ___ at 3:08 pm, 2 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: TRAUMA TORSO WITH CONTRAST
INDICATION: ___ with fall down stairs// trauma
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 658 mGy-cm.
COMPARISON: None.
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. No pericardial effusion is seen.
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: No focal consolidations or suspicious nodules. No pulmonary
contusion. 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.
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 and large bowel loops
are normal in caliber. The appendix is normal (2:200). No pneumoperitoneum.
PELVIS: The urinary bladder is unremarkable. There is trace simple free fluid
in the pelvis (2:212), nonspecific.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: There is an acute moderate compression fracture of T5, associated with
mild surrounding soft tissue edema. There is also a minimally distracted
fracture of the T5 spinous process (605:64). There is no retropulsion or
associated malalignment. A punctate lucency in the distal tip of the T4
spinous process is nonspecific.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Acute moderate compression fracture of T5 and a minimally distracted
fracture of the T5 spinous process. No malalignment or retropulsion.
2. A punctate lucency at the distal tip of the T4 spinous process is
nonspecific, but may reflect a subtle nondisplaced fracture in the setting of
acute trauma to this region.
3. No other acute injuries in the torso.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. in person on ___ at 3:05pm, 1 minute after discovery of the
findings.
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ with fall down stairs// trauma
TECHNIQUE: Three views right elbow.
COMPARISON: None.
FINDINGS:
There is an acute fracture of the olecranon, with 1.0 cm retraction. No
suspicious osseous lesions or radiopaque foreign objects.
IMPRESSION:
Acute fracture of the olecranon, with 1.0 cm proximal retraction.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. in person on ___ upon completion of the study.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: ___ with fall down stairs// trauma
TECHNIQUE: AP, lateral, oblique views of the left ankle
COMPARISON: No left foot radiographs from ___ ne
FINDINGS:
No fracture or dislocations are seen. There are no significant degenerative
changes. The mortise is congruent. The tibial talar joint space is preserved
and no talar dome osteochondral lesion is identified. No suspicious lytic or
sclerotic lesion is identified. No soft tissue calcification or radiopaque
foreign body is identified.
IMPRESSION:
No acute fracture or dislocation involving the left ankle.
Radiology Report
INDICATION: ___ with fall down stairs// trauma
COMPARISON: None
FINDINGS:
AP and lateral views of the left tibia fibula and AP, lateral, oblique views
of the left knee were provided. There is soft tissue contusion along the left
anterolateral calf, without signs of underlying fracture. There is no
radiopaque foreign body or soft tissue gas. The left ankle appears to align
normally. Dedicated views of the left knee demonstrate no fracture,
dislocation or joint effusion. No significant DJD.
IMPRESSION:
Anterolateral soft tissue contusion along the left shin without underlying
fracture, foreign body or soft tissue gas.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: History: ___ with fall, facial fx// eval facial fracture.
requested by plastics
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were also obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.9 s, 22.5 cm; CTDIvol = 25.9 mGy (Head) DLP = 584.3
mGy-cm.
Total DLP (Head) = 584 mGy-cm.
COMPARISON: CT head 8 hours prior ___
FINDINGS:
Comminuted fracture of the inferior right orbital wall with displacement
inferiorly of the fracture fragment into the right maxillary sinus is again
demonstrated, with similar extent of displacement to 5 mm. Infraorbital
foraminal involvement is again demonstrated (series 2, image 68). There is a
small amount of hematoma in the inferior orbit which overlies the fracture
fragments. The inferior rectus muscle mildly herniates inferiorly into the
maxillary sinus with mild impingement of the medial aspect of the muscle
secondary to an overlying fracture fragment (series 601, image 69).
Retrobulbar air and right-sided proptosis appear similar extent. The wall the
right lamina papyracea appears intact. There is a right nasal bone fracture,
minimally displaced (series 2, image 61).
The pterygoid plates are intact. There is no mandibular fracture and the
temporomandibular joints are anatomically aligned. The left orbit is intact.
The left globe and extra-ocular muscles are unremarkable.
There is an air-fluid level again demonstrated within the right maxillary
sinus with hyperdense material consistent with blood products. The remainder
of the paranasal sinuses are clear. The visualized mastoid air cells and
inner ear cavities are clear. Included extracranial soft tissues are
unremarkable.
IMPRESSION:
1. Redemonstration of a comminuted, inferiorly displaced right inferior
orbital wall fracture involving the infraorbital foramen with fragments
displaced into the right maxillary sinus by 5 mm. The right lamina papyracea
is intact.
2. There is mild inferior herniation of the right inferior rectus muscle into
the right maxillary sinus, with mild impingement along the medial aspect of
the muscle secondary to a fracture fragment. Small hematoma within the
inferior orbit adjacent to the fracture fragments. Retro-bulbar gas and
right-sided proptosis is unchanged.
3. Right nasal bone fracture, minimally displaced.
4. Air-fluid level with hemorrhagic products within the right maxillary sinus
as on prior.
Radiology Report
EXAMINATION: MR THORACIC SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old woman with T5 SP and compression fx. please evaluate
fractures// ___ year old woman with T5 SP and compression fx. please evaluate
fractures ___ year old woman with T5 SP and compression fx. please
evaluate fractures
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: CT Torso ___.
FINDINGS:
There is a severe anterior compression deformity of the T5 vertebral body with
diffuse T2/STIR hyperintense marrow signal, compatible with a likely acute
compression fracture with marrow edema. The posterior cortex is slightly
buckled, worst along the inferior margin, with slight posterior bony
retropulsion into the spinal canal measuring up to 4 mm (series 4, image 8),
unchanged from recent CT. There is mild spinal canal narrowing due to the
bony retropulsion without cord contact or cord signal abnormality. The T5
spinous process fractures not well assessed by MRI, better seen on prior CT.
Elsewhere, vertebral body heights are preserved. There is mild (2-3 mm) T2-3
anterolisthesis. Alignment is normal elsewhere. Probable intraosseous
hemangioma is seen in T11. Focal fat is seen in the T12 vertebral body.
The thoracic spinal cord is normal in caliber and signal intensity. Multiple
bilateral thoracic neural foraminal perineural cysts are noted. Mild signal
and height loss of thoracic spine intervertebral discs is consistent with
degenerative change, worst at T8-9 and T9-10. Aside from mild narrowing due
to bony retropulsion at T5-6, as above, there is no thoracic spinal canal
narrowing. There is no neural foraminal narrowing in the thoracic spine.
There are trace bilateral layering pleural effusions. The imaged prevertebral
and paraspinal soft tissues are otherwise unremarkable
IMPRESSION:
1. Acute severe compression fracture of T5 with 4 mm bony retropulsion into
the spinal canal of the buckled posterior cortex, causing mild spinal canal
narrowing however without cord contact.
2. Known T5 spinous process fracture is not well seen by MRI, better assessed
on prior CT.
3. No other thoracic spine fracture identified.
4. Mild thoracic degenerative changes without additional area of spinal canal
or neural foraminal narrowing at any level.
5. Incidentally noted trace bilateral layering pleural effusions. Other
incidental findings, as above.
Radiology Report
EXAMINATION: ELBOW, AP AND LAT VIEWS IN O.R. IN O.R. RIGHT
INDICATION: Right olecranon fracture ORIF
TECHNIQUE: 6 spot fluoroscopic images obtained in the OR without radiologist
present
Fluoroscopy time: 21.5 seconds
COMPARISON: Right elbow radiographs ___
FINDINGS:
The available images show steps related to open reduction internal fixation of
an olecranon fracture with placement of a dorsal post plate and screw fixation
device. Alignment is improved when compared to the preoperative study with
near anatomic alignment. Please see the operative report for further details.
Radiology Report
EXAMINATION: Thoracic spine radiographs, stand AP and lateral views.
INDICATION: T5 fracture in brace.
COMPARISON: MR from ___.
FINDINGS:
Compression deformity of the T5 vertebral body is difficult to visualized due
to overlapping structures but appears probably unchanged.
IMPRESSION:
Probably unchanged degree of volume loss and stable alignment at L5 fracture
site, although not well visualized on radiography due to overlapping
structures.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall
Diagnosed with Fracture of oth skull and facial bones, right side, init, Fall (on) (from) other stairs and steps, initial encounter
temperature: 98.1
heartrate: 82.0
resprate: 20.0
o2sat: 100.0
sbp: 135.0
dbp: 87.0
level of pain: 6
level of acuity: 2.0 | ___ y/o female with a history of hypothyroidism and osteoporosis
presenting to ___ s/p fall down approximately 10 steps w/ a
loss of balance. Pt admits to head strike but denies loss of
consciousness. The patient was hemodynamically stable. Imaging
revealed displaced right olecranon fracture, right comminuted
inferiorly displaced orbital wall fracture with orbital
emphysema, and T5 compression fracture that extends to the
posterior sinus with concern for bony Chance fracture. The
patient was admitted to the Trauma service for management of her
polytrauma.
Ortho Spine was consulted and recommended nonoperative
management w/ CTO brace for ___ weeks. Plastics consulted re:
orbital fracture, recommending
sinus precautions and outpatient follow up. Ophthalmology
consulted given
her CT findings of orbital emphysema and the patient was
complaining of diplopia. They recommended eye patch and
outpatient follow-up. Orthopedic surgery was consulted for the
right olecranon fracture. The patient was taken to the operating
room and underwent open reduction internal fixation of right
olecranon on ___ which went well without complication
(reader referred to the Operative Note for details). After a
brief, uneventful stay in the PACU, the patient arrived on the
floor tolerating sips, on IV fluids, and oral analgesia for pain
control. The patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
was out of bed with Physical Therapy once her brace had been
fitted. They were recommending the patient be discharged to
rehab once medically cleared. The patient was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous lovenox and venodyne boots were used during this
stay. At discharge, the patient was converted to full strength
aspirin per Orthopedic recommendations for one month for DVT
prophylaxis.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged to rehab to continue her
recovery. The patient received discharge teaching and follow-up
instructions with the multiple involved services, with
understanding verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxacillin / Penicillins / CellCept / Percocet
Attending: ___.
Chief Complaint:
Right knee pain
Right knee infection
Major Surgical or Invasive Procedure:
___: Right knee I&D
History of Present Illness:
Mrs. ___ is a ___ who is 2 months s/p right arthroscopic
synovectomy and lateral retinacular release for patellofemoral
syndrome by Dr. ___. She presents to the ED today for
progressive knee pain, swelling and new-onset erythema over the
arthroscopic sites. She complains that her right knee has been
progressively painful since the surgery, and the swelling has
increased significantly, causing her a great amount of pain with
ambulation and limiting her activities of daily living. She
states she has an appointment with Dr. ___ upcoming
___ but decided to visit the ED given progressive signs and
symptoms. She denies fever, chills or night sweats.
Past Medical History:
- AML in remission, s/p allogeneic BMT
- UTI: klebsiella
- Hepatic GVHD, on liver transplant list
- Kidney stones
- Paroxysmal atrial fibrillation
- Photopheresis
Social History:
___
Family History:
Her mother has a history of chronic stress headaches and
hypertension. She has no family history of migraines. Her father
has ___ lymphoma. Past history of 2 siblings
non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: AVSS
GEN: WDWN woman in NAD, AOx3
RLE:
- Inspection: prominent effusion & erythema over anterolateral
knee, incision c/d/i
- Palpation: slightly warm to touch, mildly TTP
- ROM: pain w/ a/pROM, ___ flexion-extension
- Strength: ___
- Sensory: SILT ___
DISCHARGE PHYSICAL EXAM
========================
Tmax 98.1 BP 124/70 P 60 R 18 SaO2 100%
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: Irregularly irregular 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, 1+ pitting edema at ankles,
R knee with vertical line of staples extending over kneecap, no
surrounding erythema, mild oozing
Neuro: A&Ox 3 (knew name, time, place), mild flap on left
Pertinent Results:
ADMISSION LABS
==============
___ 06:45PM BLOOD WBC-9.8 RBC-3.17* Hgb-11.8* Hct-36.7
MCV-116* MCH-37.2* MCHC-32.0 RDW-15.8* Plt ___
___ 06:45PM BLOOD Neuts-66 Bands-0 ___ Monos-12*
Eos-3 Baso-1 ___ Myelos-0
___ 06:45PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Target-1+
___ 06:45PM BLOOD Glucose-108* UreaN-28* Creat-1.4* Na-132*
K-5.3* Cl-95* HCO3-31 AnGap-11
___ 06:20AM BLOOD ALT-54* AST-143* AlkPhos-167*
TotBili-5.8*
___ 06:20AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.0
___ 06:45PM BLOOD CRP-61.4*
___ 06:45PM BLOOD ESR-76*
___ 06:50PM BLOOD Lactate-2.4*
RELEVANT LABS
==============
___ 06:15AM BLOOD WBC-16.7*# RBC-2.65* Hgb-10.3* Hct-30.6*
MCV-115* MCH-38.6* MCHC-33.5 RDW-15.2 Plt ___
___ 06:15PM BLOOD WBC-10.8 RBC-2.66* Hgb-9.8* Hct-31.0*
MCV-116* MCH-36.7* MCHC-31.6 RDW-15.5 Plt ___
___ 06:15PM BLOOD Neuts-76.0* Lymphs-14.3* Monos-9.0
Eos-0.4 Baso-0.3
___ 06:15PM BLOOD ___ PTT-32.7 ___
___ 04:40PM BLOOD Glucose-140* UreaN-48* Creat-2.4*# Na-137
K-4.5 Cl-98 HCO3-27 AnGap-17
___ 06:15PM BLOOD Glucose-123* UreaN-49* Creat-2.3* Na-136
K-3.9 Cl-99 HCO3-27 AnGap-14
___ 06:10AM BLOOD Glucose-76 UreaN-50* Creat-2.2* Na-137
K-4.0 Cl-98 HCO3-31 AnGap-12
___ 06:40AM BLOOD ALT-67* AST-156* AlkPhos-167*
TotBili-6.5*
___ 06:10AM BLOOD ALT-62* AST-147* AlkPhos-154*
TotBili-6.6*
___ 06:30AM BLOOD Vanco-32.0*
___ 05:50AM BLOOD Vanco-24.8*
___ 06:10AM BLOOD Vanco-23.6*
___ 06:40AM BLOOD Vanco-12.8
DISCHARGE LABS
==============
___ 06:04AM BLOOD WBC-10.8 RBC-2.40* Hgb-8.7* Hct-27.8*
MCV-116* MCH-36.1* MCHC-31.1 RDW-15.5 Plt ___
___ 06:04AM BLOOD ___ PTT-35.1 ___
___ 06:04AM BLOOD Glucose-99 UreaN-48* Creat-2.2* Na-138
K-3.6 Cl-100 HCO3-32 AnGap-10
___ 06:04AM BLOOD ALT-51* AST-133* AlkPhos-159*
TotBili-6.0*
PERTINENT MICRO
===============
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ ___ 8:55AM.
STAPHYLOCOCCUS EPIDERMIDIS. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS.
Isolated from only one set in the previous five days.
Susceptibility testing requested by ___
(___) ON
___. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
Blood Culture, Routine (Final ___: NO GROWTH.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. RARE GROWTH.
IDENTIFICATION AND Sensitivity testing per ___
___ ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Blood Culture, Routine (Final ___: NO GROWTH
___ 8:46 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
PERTINENT IMAGING
=================
KNEE (AP, LAT & OBLIQUE) ___:
No evidence of acute fracture or dislocation is seen. There is
a small
suprapatellar joint effusion. Soft tissue swelling is noted.
TTE ___:
IMPRESSION: Moderate tricuspid regurgitation with normal leaflet
morphology. Very mild mitral regurgitation with normal leaflet
morphology. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Compared
with the prior study (images reviewed) of ___, the severity
of tricuspid regurgitation is increased with similar valve
morphology. If clinically indicated, a TEE is suggested to
better define tricuspid valve morphology.
Renal US ___: No stones or hydronephrosis. Large ___
varices noted.
Abd US ___: No ascites is present.
TEE ___:
IMPRESSION: Moderate tricuspid regurgitation with normal leaflet
morphology. Very mild mitral regurgitation with normal leaflet
morphology. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Compared
with the prior study (images reviewed) of ___, the severity
of tricuspid regurgitation is increased with similar valve
morphology. If clinically indicated, a TEE is suggested to
better define tricuspid valve morphology.
CXR ___:
In comparison with the study of ___, there has been
placement of a right subclavian PICC line that extends to the
lower portion of the SVC. This information was telephoned to
___, a venous access nurse. Otherwise little change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
3. Flecainide Acetate 150 mg PO Q12H
4. Furosemide 40 mg PO BID
5. Levothyroxine Sodium 50 mcg PO 6X/WEEK (___)
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. PredniSONE 15 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Magnesium Oxide 400 mg PO 1X/WEEK (FR)
12. potassium gluconate 595 mg (99 mg) oral daily
13. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Levothyroxine Sodium 50 mcg PO 6X/WEEK (___)
3. Pantoprazole 40 mg PO Q24H
4. PredniSONE 15 mg PO DAILY
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
6. Vancomycin 1000 mg IV Q 24H Duration: 5 Weeks
last dose ___
RX *vancomycin 1 gram 1 gram IV Q24h Disp #*15 Vial Refills:*0
7. Magnesium Oxide 400 mg PO 1X/WEEK (FR)
8. Multivitamins 1 TAB PO DAILY
9. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
10. Outpatient Lab Work
ICD-9 code: 711.0
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Please obtain weekly CBC with differential, Bun, Cr, vancomycin
trough, ESR, CRP.
11. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
last dose ___
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*13 Syringe
Refills:*0
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Flecainide Acetate 75 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
# Septic arthritis
# Acute kidney injury
SECONDARY DIAGNOSES
===================
# Acute myelogenous leukemia
# Graft versus host disease of liver
# Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with knee pain/swelling // r/o fx/effusion
TECHNIQUE: RIGHT Knee, 4 views
COMPARISON: None.
FINDINGS:
No evidence of acute fracture or dislocation is seen. There is a small
suprapatellar joint effusion. Soft tissue swelling is noted.
IMPRESSION:
No evidence of acute fracture or dislocation.
Radiology Report
INDICATION: ___ year old woman with history of kidney stones, recent spike in
creatinine from 1.1 to 2.4. Evaluation for kidney stones/renal obstruction.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: MRI abdomen from ___.
FINDINGS:
The right kidney measures 11.3 cm. The left kidney measures 11.3 cm. There is
no hydronephrosis, stones, or masses bilaterally. There is a 9 x 10 x 7 mm
simple cyst in the mid right kidney, unchanged. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well seen and normal in appearance.
Large varices are incidentally noted in the left upper quadrant of the
abdomen.
IMPRESSION:
No stones or hydronephrosis. Large ___ varices noted.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old woman with GVHD of liver, known cirrhosis. Evaluate
for ascites.
TECHNIQUE: Limited grayscale ultrasound examination of the 4 abdominal
quadrants was performed.
COMPARISON: Ultrasound from ___.
FINDINGS:
Four-quadrant ultrasound did not demonstrate any ascites.
IMPRESSION:
No ascites is present.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with chronic hip pain // 43cm picc placed, ?
tip position. ___ IV nurse ___ name: ___: ___
picc placed, ? tip position. ___ IV nurse
IMPRESSION:
In comparison with the study of ___, there has been placement of a
right subclavian PICC line that extends to the lower portion of the SVC. This
information was telephoned to ___, a venous access nurse. Otherwise little
change.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Knee pain
Diagnosed with JOINT EFFUSION-L/LEG, ABN REACT-PROCEDURE NOS
temperature: 99.2
heartrate: 90.0
resprate: 16.0
o2sat: 96.0
sbp: 138.0
dbp: 80.0
level of pain: 8
level of acuity: 3.0 | BRIEF SUMMARY
=============
___ y/o with AML s/p allogenic BMT in remission c/b GVHD of liver
(on transplant list) on immunosuppression, who is s/p recent
right arthroscopy in ___, presented to the orthopedic service
with increasing R knee pain increased effusion, consistent with
septic arthritis, s/p I&D ___ with cultures from
arthrocentesis, tissue, and blood growing Staph epidermidis. Was
transferred to the general medicine service for worsening acute
kidney injury.
ACUTE ISSUES
==============
# Septic arthritis - The patient presented to the emergency
department and was evaluated by the orthopedic surgery team. The
patient was found to have right knee infection (2 months s/p
arthroscopic surgery of right knee) and was admitted to the
orthopedic surgery service. Admitting labs were significant for
ESR 76 CRP 61.4, WBC 9.8 with 66% neutrophils. She was taken to
the operating room on ___ for right knee I&D, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was given perioperative
antibiotics and anticoagulation per routine. 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.
Joint fluid from ___ grew staph epidermidis and blood cx from
___ were growing coagulase-negative staph, so infectious
disease was consulted for further infectious work-up and
antibiotic management in the setting of the patient's
immunosuppression. She was started on vancomycin on ___ for
empiric MRSA coverage. It was however noted that the patient had
supratherapeutic levels ___ and worsening renal function
(see below), so vancomycin was held on ___ upon transfer to the
general medicine service and resumed on ___ in the setting of
AM vancomycin trough of 12.8 (goal ___. Due to presence of
coagulase-negative staph, the patient underwent TTE on ___ to
evaluate for endocarditis. The study was inconclusive so TEE was
performed on ___, which was negative. On ___, the patient's
joint fluid from ___ and tissue culture from ___ were found to
be growing staph epidermidis, as well as blood culture from ___
x 1 also growing staph epidermidis (though with different
sensitivities). All subsequent surveillance blood cultures had
shown no growth to date. Infectious disease felt that this was
the infectious pathogen and recommended a total of 6-week
antibiotic therapy with vancomycin 1 g q24h with her last dose
___. The patient was consented for and successfully underwent
PICC placement on the afternoon of ___. She will follow-up with
infectious disease as an outpatient on ___. She will receive
weekly CBC with differential, CRP, ESR, BUN, Cr, and vancomycin
trough monitoring, with lab results faxed to Outpatient
Parenteral Antibiotic Therapy (OPAT).
# Acute kidney injury - The patient on admission had an elevated
creatinine of 1.4, which decreased to 1.1 on ___. However, she
developed acute kidney injury to creatinine of 2.4, which
prompted transfer from the orthopedic service to general
medicine on ___. Renal was consulted on ___ for assistance
with management. Renal US performed showed no evidence of
obstruction. Though vancomycin was supratherapeutic, they did
not believe the levels were high enough to cause vancomycin
toxicity. Exact etiology of acute kidney injury was not clear,
though likely a combination of neomycin toxicity versus mild
ischemic injury (lowest intra-operative blood pressure was
approx 90/40, single granular cast seen on microscopy). In the
setting of acute kidney injury, the patient was placed on renal
dosing of her medications. Home flecainide was decreased by 50%
to 75 mg q12h and her home diuretics were held. The patient
remained non-oliguric and her creatinine improved to 2.2 on ___
and was 2.2 on discharge. She will follow-up in ___ clinic on
___.
CHRONIC ISSUES
================
# Acute myelogenous leukemia - Patient had allogenic stem cell
transplantation for AML in ___ and is now in remission. She was
continued on her home immunosuppression with cyclosporine 25 mg
and prednisone 15 mg. She was continued on acyclovir 400 mg q12h
for herpes prophylaxis.
# Graft versus host disease of liver - The patient is on the
transplantation list. Last seen by GI ___, where MELD score was
calculated at 20. MRI ___ showed ascites with no focal liver
lesion. Last EGD ___ showed no esophageal varices but mild
portal hypertensive gastropathy. Patient was not encephalopathic
throughout her hospitalization. Repeat abd US ___ showed no
evidence of ascites. Her home Lasix and spironolactone were held
in the setting of her acute kidney injury and can be restarted
once her renal function improves. She will follow-up with
transplant on ___. Labs on discharge were ALT 51 AST 133 AP
159 Tbili 6.0 INR 1.5.
# Paroxysmal atrial fibrillation - Stable during
hospitalization. The patient was decreased to flecainide 75 mg
q12h in the setting of acute kidney injury. She was discharged
on this dose and can be uptitrated as her renal function
improves. She was placed on metoprolol tartrate 12.5 mg BID in
the setting of sepsis and was discharged on a decreased dose of
metoprolol succinate 25 mg daily.
TRANSITIONAL ISSUES
===================
# Patient will be receiving vancomycin through ___ for 5
additional weeks, last dose ___. She will require weekly labs:
CBC with differential, CRP, ESR, BUN, Cr, vanc trough with
results faxed to ___ clinic FAX: ___.
# Her home metoprolol was decreased to 25 mg daily in the
setting of sepsis. If her blood pressure is elevated on
follow-up with PCP, can ___ to 50 mg daily.
# In the setting of acute kidney injury, patient's flecainide
was decreased to 75 mg q12h. As her renal function improves at
follow-up, her dose can be uptritrated back to 150 mg q12h.
# In the setting of acute kidney injury, the patient's
spironolactone, Lasix, and potassium supplementation were held.
As her renal function improves at follow-up, she can be resumed
on these medications.
# Of note, patient has several follow-up appointment scheduled:
- PCP ___ ___ for medication review.
- Liver transplant ___.
- Infectious disease ___.
- Orthopedics ___, where staples will be removed.
- Renal appointment ___.
# CONTACT: Mother (lives in ___, ___). Home: ___,
Cell: ___
# Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Dilaudid / Darvocet-N / Motrin / erythromycin base
/ aspirin
Attending: ___.
Chief Complaint:
Abdominal pain with emesis after laparoscopic cholecystectomy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ female POD ___ s/p laparoscopic
cholecystectomy for chronic cholecystitis. Patient was
discharged home from ___ in satisfactory condition. Last night
she developed severed abdominal pain, which did not responded to
oral pain medication. Patient reported busy night as she had to
take her some in ED with asthma attack around midnight. She
developed nausea with emesis in ___ ED, and
vomited 4 times total prior her return in ___ ED this AM.
Patient denies fever, chill, flatus, bowel movements, burping or
hiccups. Patient reported episodes of diaphoresis and
difficulties with urination.
Past Medical History:
- Asthma
- Gastritis
- Bipolar manic depression with schizoaffective attributes
- Anxiety
- PTSD
Social History:
___
Family History:
Mother - MI at ___. HTN
Father - HTN
Physical ___:
Prior to Discharge:
Pertinent Results:
RECENT LABS:
___ 08:50AM BLOOD WBC-9.3 RBC-3.57* Hgb-11.6 Hct-33.7*
MCV-94 MCH-32.5* MCHC-34.4 RDW-13.7 RDWSD-47.8* Plt ___
___ 08:50AM BLOOD Neuts-67.2 ___ Monos-11.7
Eos-0.2* Baso-0.2 Im ___ AbsNeut-6.24*# AbsLymp-1.90
AbsMono-1.09* AbsEos-0.02* AbsBaso-0.02
___ 05:24AM BLOOD Glucose-88 UreaN-3* Creat-0.6 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-10
___ 05:24AM BLOOD ALT-100* AST-138* AlkPhos-69 TotBili-0.8
___ 05:24AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.9
___ 12:15PM URINE Color-Straw Appear-Clear Sp ___
___ 12:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 12:15PM URINE Hours-RANDOM
___ 12:15PM URINE Uhold-HOLD
RADIOLOGY:
___ LIVER US:
IMPRESSION:
The CBD measures similar to prior ultrasound. No new biliary
ductal
dilatation. The explanation for pain is not elucidated.
___ KUB:
IMPRESSION:
Prominent mildly dilated loop of small bowel in the mid abdomen
could
represent focal ileus or findings of early obstruction. There
is gas
throughout the colon.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Sertraline 50 mg PO DAILY
3. QUEtiapine Fumarate 100 mg PO QHS
4. Pantoprazole 40 mg PO Q24H
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Divalproex (EXTended Release) 1000 mg PO QHS
7. Nicotine Patch 14 mg TD DAILY
8. Nicotine Polacrilex 2 mg PO Q1H:PRN cravings
9. LORazepam 1 mg PO TID
10. LORazepam 1 mg PO Q8H:PRN chest pain
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
3. Senna 8.6 mg PO BID
4. LORazepam 1 mg PO Q8H:PRN anxiety
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. Divalproex (EXTended Release) 1000 mg PO QHS
7. LORazepam 1 mg PO Q8H:PRN chest pain
8. Nicotine Patch 14 mg TD DAILY
9. Nicotine Polacrilex 2 mg PO Q1H:PRN cravings
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Pantoprazole 40 mg PO Q24H
12. QUEtiapine Fumarate 100 mg PO QHS
13. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Post operative ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with lap chole ___ here w severe RUQ pain// eval
for RUQ pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 6 mm,
similar to prior ultrasound (5 mm).
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 6.8 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis. The right
kidney measures 11.3 cm. The left kidney measures 10.7 cm.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
The CBD measures similar to prior ultrasound. No new biliary ductal
dilatation. The explanation for pain is not elucidated.
Radiology Report
INDICATION: ___ year old woman with abd pain after lap chole ___// pls eval
for SBO/ileus
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT from ___
FINDINGS:
There is gas throughout the colon. A prominent air-filled loop of small bowel
in the mid abdomen may represent focal ileus versus a finding of early bowel
obstruction. Cholecystectomy clips are again noted. No free air
demonstrated. The visualized lung bases are clear.
IMPRESSION:
Prominent mildly dilated loop of small bowel in the mid abdomen could
represent focal ileus or findings of early obstruction. There is gas
throughout the colon.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Other acute postprocedural pain
temperature: 98.2
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 152.0
dbp: 100.0
level of pain: 10
level of acuity: 3.0 | The patient s/p laparoscopic cholecystectomy was re-admitted to
the General Surgical Service for evaluation of increased
abdominal pain and emesis. In ED patient underwent liver US and
KUB, which was concerning for post operative ileus. Patient was
afebrile with normal WBC, her labs were noticeable for elevated
ALT/AST. Patient was started on IV fluid, made NPO and admitted
for observation. She received IV Morphine for pain control. On
HD 2 patient's pain improved, she remained afebrile with normal
WBC, her LFTs still slightly elevated but down-trending. She
started to pass gas and her diet was advanced. On HD 3 patient
was discharged home in stable condition.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. LFTs were decreasing. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cefepime
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with AML (diagnosed in
___ status post induction and cycle 3 of decitabine, legal
blindness due to congenital cataracts, and chronic pancytopenia
requiring frequent transfusions of red cells and platelets, who
presents after syncope.
The patient has chronic pancytopenia and is maintained on
frequent transfusions. In the past month, he received 1 unit of
RBC on ___, and ___, and platelets on ___, and ___. Based on prior documented
notes
from his oncology appointments, it appears that the patient is
not interested in further aggressive therapy such as a bone
marrow transplant. He is happy with blood product support.
This morning he woke up and felt recently well in his usual
state
of health. He went to ___ to shop. While on his way to the
checkout area, he has sudden loss of consciousness and fell,
hitting his face. He reports having no prodromal symptoms aside
from possibly lightheadedness in the few seconds right before he
lost consciousness. He denies having any chest pain, difficulty
breathing, or palpitations prior. Upon awakening after a short
period of time, he noticed a nosebleed. He was brought by
ambulance to the ___ ED subsequently.
In the ___ ED he was noted to have orthostatic hypotension
with
BP 121/50 and heart rate 72 while supine and BP 106/54 and heart
rate 95 while standing. He was also found to have a hemoglobin
of 5.3. He received vancomycin 1500 mg IV, piperacillin
tazobactam 4.5 g IV, 2 units of red cells, and 500 mL of normal
saline.
Past Medical History:
- AML
- Legally blind
- History of retinal detachment
- Congenital cataracts
- Bilateral ocular hypertension
- Nystagmus
- Hypertension
- Hyperlipidemia
- Impaired fasting glucose
- Obesity
- Psoriasis
- Colonic adenoma
Social History:
___
Family History:
Paternal grandfather had CML. Father had AML.
Brother had multiple myeloma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: Temperature 97.3, BP 131/73, heart rate 86, respiratory
rate 20, O2 saturation 100% on room air
Gen: Pleasant, calm, in no acute distress
HEENT: No conjunctival pallor. Disconjugate gaze. Right eye with
irregularly shaped ___ without pupillary response to light.
Left
eye with opaque cornea. No icterus. MMM. OP clear.
NECK: JVP 5 cm. Normal carotid upstroke without bruits.
LYMPH: No cervical or supraclav LAD.
CV: Regular rate and rhythm. Soft heart sounds. Normal S1, S2.
No
murmur.
LUNGS: No increased WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema. No calf tenderness.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
DISCHARGE PHYSICAL EXAM:
===========================
VS: T max 97.5-98.1, BP 117/67, P 74, RR 19, O2sat 99% on RA
Gen: Pleasant, calm, in no acute distress
HEENT: No conjunctival pallor. Dysconjugate gaze. Right eye with
irregularly shaped ___ without pupillary response to light.
Left
eye with opaque cornea. No icterus. MMM. OP clear
CV: Regular rate and rhythm. Soft heart sounds. Normal S1, S2.
No
murmur.
LUNGS: No increased WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
Pertinent Results:
ADMISSION LABS:
====================
___ 11:44AM BLOOD WBC-0.7* RBC-1.61*# Hgb-5.3*# Hct-15.4*#
MCV-96 MCH-32.9* MCHC-34.4 RDW-16.6* RDWSD-49.9* Plt Ct-59*
___ 11:44AM BLOOD Neuts-10* Bands-0 Lymphs-88* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-0.07*
AbsLymp-0.62* AbsMono-0.01* AbsEos-0.00* AbsBaso-0.00*
___ 11:44AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-1+ Polychr-NORMAL Tear Dr-OCCASIONAL
___ 11:44AM BLOOD ___ PTT-26.8 ___
___ 11:44AM BLOOD Ret Aut-0.8 Abs Ret-0.01*
___ 11:44AM BLOOD Glucose-108* UreaN-28* Creat-1.6* Na-140
K-3.9 Cl-104 HCO3-23 AnGap-17
___ 11:44AM BLOOD ALT-17 AST-15 LD(LDH)-168 AlkPhos-123
TotBili-0.5
___ 11:44AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0 Iron-162*
___ 11:44AM BLOOD calTIBC-186* Hapto-343* Ferritn-3767*
TRF-143*
___ 04:05PM URINE Color-Straw Appear-Clear Sp ___
___ 04:05PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:05PM URINE RBC-1 WBC-14* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
___ 04:05PM URINE CastHy-1*
___ 09:27PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
OTHER RELEVANT LABS:
===========================
___ 05:18AM BLOOD ___
___ 07:56PM BLOOD Vanco-20.7*
___ 05:29AM BLOOD Lactate-0.8
DISCHARGE LABS:
===========================
___ 12:00AM BLOOD WBC-1.2* RBC-2.50* Hgb-7.5* Hct-22.6*
MCV-90 MCH-30.0 MCHC-33.2 RDW-16.5* RDWSD-47.6* Plt Ct-40*
___ 12:00AM BLOOD Neuts-14* Bands-0 Lymphs-83* Monos-2*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-0.14*
AbsLymp-0.83* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 01:29PM BLOOD Plt Ct-88*#
___ 12:00AM BLOOD Glucose-98 UreaN-23* Creat-1.4* Na-142
K-4.2 Cl-104 HCO3-26 AnGap-16
___ 12:00AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.0
MICRO:
============================
URINE CULTURE (Final ___: ENTEROCOCCUS SP..
10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
IMAGING:
=============================
CT Head (___): No acute intracranial abnormality.
CXR (___): No pneumonia.
TTE (___):
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 with normal cavity size and regional/global systolic
function (LVEF>55%). There is mild (non-obstructive) focal
hypertrophy of the basal septum. There is no left ventricular
outflow obstruction at rest or with Valsalva. Right ventricular
chamber size and free wall motion are normal. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. An eccentric, posteriorly
directed jet of mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: No intracardiac source of syncope identified. Mild
symmetric left ventricular hypertrophy with preserved
biventricular systolic function. Mild mitral and tricuspid
regurgitation. Normal pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of ___,
the severity of mitral and tricuspid regurgitation has minimally
increased.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. amLODIPine 5 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Atovaquone Suspension 1500 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q12H
6. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
7. Famotidine 20 mg PO DAILY
8. Fluconazole 200 mg PO Q24H
9. FoLIC Acid 1 mg PO DAILY
10. Prochlorperazine 10 mg PO Q8H:PRN nausea
11. Zinc Sulfate 220 mg PO DAILY
12. Cyanocobalamin ___ mcg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Atovaquone Suspension 1500 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
5. Cyanocobalamin ___ mcg PO DAILY
6. Famotidine 20 mg PO DAILY
7. Fluconazole 200 mg PO Q24H
8. FoLIC Acid 1 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Prochlorperazine 10 mg PO Q8H:PRN nausea
11. Vitamin D ___ UNIT PO DAILY
12. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Complicated urinary tract infection
Febrile neutropenia
Acute myeloid leukemia
Syncope
Orthostatic hypotension
Acute on chronic renal failure
Secondary:
Anemia
Chronic kidney disease stage 3A
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 AML, syncope and fall with head strike// eval for ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 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.
There is no evidence of fracture. There is mild mucosal thickening in the
ethmoid air cells. The visualized portion of the mastoid air cells and middle
ear cavities are clear. A hyperdense focus is seen in the left lens. A right
scleral buckle is noted. The right lens is not visualized.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with neutropenia, please eval for occult PNA
COMPARISON: Prior from ___ and ___
FINDINGS:
PA and lateral views of the chest provided. Right chest wall Port-A-Cath is
again noted with catheter tip in the region of the cavoatrial junction as on
prior. Lung volumes are low though the lungs appear clear bilaterally. No
focal consolidation, large effusion or pneumothorax. The heart size and
mediastinal contour appears normal. Bony structures are intact. No free air
below the right hemidiaphragm.
IMPRESSION:
No pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Epistaxis, Syncope
Diagnosed with Other pancytopenia, Epistaxis
temperature: 96.9
heartrate: 80.0
resprate: 22.0
o2sat: 100.0
sbp: 110.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ gentleman with AML (diagnosed in
___ status post induction and cycle 3 of decitabine, legal
blindness due to congenital cataracts, and chronic pancytopenia
requiring frequent transfusions of red cells and platelets, who
presented after a pre-syncopal event and was found to be febrile
to 102.6 on ___ and found to have ampicillin-resistant
Enterococcus UTI s/p 7 days antibiotics
#Febrile Neutropenia
#Enterococcus UTI
Febrile to 102.6 on ___. Given ANC of 70 on admission and
fever, he was empirically started on vancomycin and zosyn (given
cefepime allergy). His chest x-ray showed no e/o pneumonia and
patient had no localizing signs or symptoms on initial
presentation. Patient's urine culture was positive for
Enterococcus sp that was sensitive to vancomycin (___)
followed by dose of fosfomycin. He was continued on acyclovir,
atovaquone, and fluconazole for prophylaxis.
#Syncope
Most likely caused by hypovolemia, a result of a combination of
anemia, as he presented with a Hgb 5.3 and possibly dehydration
vs underlying infection as above. EKG was wnl. He had a
structurally normal TTE from ___. TTE showed no structural
abnormalities. Received 2 units pRBCs. BP improved with
antibiotics and fluids and he had no further events during this
admission.
# AML- He is s/p 3 cycles of decitabine as an outpatient. He
previously did not want to pursue bone marrow transplant.
Continued Acyclovir 400 mg every 12 hours, atovaquone 1500 mg
daily, and fluconazole 200 mg daily for prophylaxis. Repeat bone
marrow biopsy performed during hospitalization
# Anemia- Patient presented with Hgb 5.3 on admission, requiring
2 units pRBCs. Hemolysis labs were wnl and patient was continued
on B12 and folic acid supplementation.
# Hypertension- Home amlodipine and atenolol were held and not
resumed as BP well controlled without them
# CKD
Presented with Cr 1.6, slightly above baseline 1.3-1.4. Most
likely from hypovolemia and improved with IVF resuscitation and
adequate PO intake. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lomotil / Cephalosporins / vancomycin /
Erythromycin Base / narcotics / Feraheme / atropine
Attending: ___.
Chief Complaint:
Abdominal pain, emesis x1 day
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with complex GI hx including Oglivies syndrome ___ opioids
administered perioperatively), s/p end ileostomy and recurrent
stomal prolapse requiring re-siting, multiple admissions for abd
pain/N/V/SBO requiring ketamine gtt, most recently hospitalized
___ with suspected viral gastroenteritis, now
presenting with 24 hours of emesis, ?decreased ostomy output,
and decreased urination.
Pt describes onset of emesis since midnight on day of
presentation, was initially green, nonbloody before he had
contrast, then the color of contrast. He describes spasms of
pain, started in his feet, then eventually spread to his whole
body. Abdominal pain was stabbing, LUQ, deep to ostomy site,
initially ___, then progressed to ___. There has been no
significant change in his ostomy output, although he notes that
it is chronically highly irregular. He believes that the output
may have been decreased prior to administration of PO contrast.
He denies fevers, chills. He denies chest pain, although the
abdominal pain does sometimes radiate upwards towards the chest.
He lives at a ___, and is not aware of others having been ill
with GI symptoms recently. He urinates twice daily x ___ year,
requires "forcing" himself to urinate. He has noted decrease in
urination over the preceding 24 hours, last at 10 am on day of
presentation. He describes the quality of this pain as somewhat
different compared to prior presentations, less localized to
abdomen, but otherwise similar in intensity.
In the ___ ED:
VSS
Received IV dilaudid, 2L IVF, with improvement in lactate from
4.4 to 2.1
CT abd/pelvis without evidence of acute obstruction
On arrival to the floor, he endorses ___ pain. He reports that
he got no relief from IV dilaudid in the ED, and endorses
persistent nausea. He describes last episode of emesis as in the
ED, immediately prior to transfer to the floor.
ROS: all else negative
Past Medical History:
Per discharge summary, confirmed with pt:
1) Sinus bradycardia s/p pacemaker placement (___)
2) CAD s/p stent to RCA (___)
3) HTN
4) Hyperlipidemia
5) PE (___), x2 in total
6) Trigeminal neuralgia s/p two neurosurgeries at ___ in
the mid ___, now with left hemifacial anesthesia, but
continued pain which has been refractory to many different
medications including alprazolam, nortriptyline, amitriptyline,
gabapentin, methadone, fentanyl, and trazodone.
7) Prolonged hospitalization ___ at ___
___ in ___ after he was found down at home in the setting of
multiple narcotic use and observed hallucinations in the weeks
prior, ?seizure disorder
8) GERD - h/o GIB vs. gastritis (___)
9) Possible seizure disorder, where patient describes going
into a black hole. Did have reported seizure activity in EEG
monitoring at OSH (previous treatments include lamotragine,
gabapentin, Dilantin, Keppra, Depakote)
10) Chronic insomnia, refractory in the past to nortriptyline,
amitriptyline, trazadone, methadone, Ativan, Xanax, Ambien,
Lunesta
11) Restless legs syndrome, previously on ropinirole (stopped in
___ due to lack of efficacy)
12) Mood disorder NOS, treated previously with various
TCA/SSRI/SNRI/pain medications.
13) Conversion Disorder: resulting in ___ paralysis, slurred
speech and facial droop (resolved)
14) prolonged hospitalized at ___ ___:
# Acute Protein Calorie Malnutrition / Malfunctioning Jtube -
# Recurrent stoma prolapse on ___
# Rectus abdominis abscess / Enterococcus Infection
# readmission ___ for weakness, facial droop, thought to
be conversion disorder
Social History:
___
Family History:
No known. Mother and father both died in an accident. Brother
and maternal aunt live in ___. Brother is healthy, Aunt has
"chronic illnesses" but unknown
Physical Exam:
Admission Exam:
VS 98.4 PO 135 / 55 R Lying 68 16 93 RA
Gen: Very pleasant middle-aged male, lying in bed, alert,
interactive, NAD
HEENT: PERRL, EOMI, L ptosis, dry MM, anicteric sclera
Neck: supple, no cervical or supraclavicular adenopathy
CV: RRR, no m/r/g
Lungs: CTAB, no wheeze or rhonchi
Abd: soft, ostomy in place draining white contrast mixed with
green stool, nonbloody, multiple well-healed incisions,
+guarding, no rebound tenderness, hyperactive bowel sounds
GU: No foley
Ext: WWP, no clubbing, cyanosis, or edema
Neuro: L ptosis, CN II-XII intact, moving all extremities, alert
and interactive
Discharge Exam:
Vitals: 98.5 PO 128 / 74 77 16 100 ra
Pain Scale: ___ OFF Ketamine infusion
General: Patient appears overall well. He is in great spirits,
with a big smile on his face and relief that his symptoms
resolved.
Abdomen: Ileostomy with green watery liquid stool, no blood or
melena. Non-tender to palpation, no rebound or guarding.
Hyperactive bowel sounds
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly
intact in bilateral UE and ___, symmetric
Pertinent Results:
Admission Labs
___ 08:21PM LACTATE-2.1*
___ 02:44PM LACTATE-4.4*
___ 02:35PM GLUCOSE-131* UREA N-50* CREAT-3.0*#
SODIUM-135 POTASSIUM-5.8* CHLORIDE-93* TOTAL CO2-13* ANION
GAP-35*
___ 02:35PM estGFR-Using this
___ 02:35PM ALT(SGPT)-37 AST(SGOT)-28 ALK PHOS-120 TOT
BILI-1.4
___ 02:35PM LIPASE-57
___ 02:35PM ALBUMIN-5.8*
___ 02:35PM WBC-12.1*# RBC-5.98 HGB-18.4*# HCT-52.3*
MCV-88 MCH-30.8# MCHC-35.2# RDW-15.9* RDWSD-47.2*
___ 02:35PM NEUTS-85.6* LYMPHS-7.5* MONOS-5.2 EOS-0.5*
BASOS-0.5 IM ___ AbsNeut-10.33*# AbsLymp-0.91* AbsMono-0.63
AbsEos-0.06 AbsBaso-0.06
___ 02:35PM PLT COUNT-288
___ 02:35PM ___ PTT-35.8 ___
Discharge Labs:
___ 03:38AM BLOOD WBC-5.9# RBC-4.98 Hgb-14.5# Hct-44.5
MCV-89 MCH-29.1 MCHC-32.6 RDW-14.9 RDWSD-48.6* Plt ___
___ 06:18AM BLOOD UreaN-29* Creat-1.2# Na-137 K-4.5 Cl-106
HCO3-22 AnGap-14
___ 03:38AM BLOOD ALT-22 AST-20 AlkPhos-79 TotBili-1.1
___ 03:38AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.6
Reports:
CT abd/pelvis without contrast, ___:
1. No evidence of high-grade small-bowel obstruction. Status
post total colectomy with left lower quadrant ileostomy.
2. Cholelithiasis.
3. Nonobstructive right renal calculus.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 100 mg PO QHS
2. ClonazePAM 1 mg PO BID
3. Duloxetine 30 mg PO DAILY
4. Rivaroxaban 10 mg PO DAILY with food
5. Zolpidem Tartrate ___ mg PO QHS:PRN insomnia
6. Cyanocobalamin ___ mcg PO DAILY
Discharge Medications:
1. Amitriptyline 100 mg PO QHS
2. ClonazePAM 1 mg PO BID
3. Cyanocobalamin ___ mcg PO DAILY
4. DULoxetine 30 mg PO DAILY
5. Rivaroxaban 10 mg PO DAILY with food
6. Zolpidem Tartrate ___ mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Active:
- Viral gastroenteritis
- Nausea with vomiting
Chronic:
- Ogilve s/p colectomy
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 W/O CONTRAST
INDICATION: +PO contrast; History: ___ with abdominal pain+PO contrast //
abdominal pain
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 50.0 cm; CTDIvol = 13.2 mGy (Body) DLP = 660.5
mGy-cm.
Total DLP (Body) = 661 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis. An AICD is partially
visualized. There is no pericardial or pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains gallstones without wall thickening or
evidence of inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. A 2 mm nonobstructive right renal calculus is noted.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. The patient is status post
total colectomy with left lower quadrant ileostomy. While several prominent
loops of small bowel are seen in the pelvis, measuring up to 2.9 cm, oral
contrast material flows freely through the loops of small bowel through the
ileostomy. There is no evidence of high-grade bowel obstruction.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged. The seminal vesicles are
unremarkable
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Severe atherosclerotic
disease is noted.
BONES: There is levoscoliosis of the lumbar spine, with the apex at L3-4.
Fixation hardware is seen at L5-S1.
SOFT TISSUES: A right-sided fat containing inguinal hernias identified.
IMPRESSION:
1. No evidence of high-grade small-bowel obstruction. Status post total
colectomy with left lower quadrant ileostomy.
2. Cholelithiasis.
3. Nonobstructive right renal calculus.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 97.4
heartrate: 100.0
resprate: 18.0
o2sat: 98.0
sbp: 122.0
dbp: 96.0
level of pain: 10
level of acuity: 3.0 | ___ with complex GI hx including Oglivies syndrome ___ opioids
administered perioperatively), s/p end ileostomy and recurrent
stomal prolapse requiring re-siting, multiple admissions for abd
pain/N/V/SBO requiring ketamine gtt, most recently hospitalized
___ with suspected viral gastroenteritis, who presented
with nausea, vomiting and abdominal pain consistent with viral
gastroenteritis.
# Abdominal pain:
# Nausea with vomiting:
# Viral Gastroenteritis:
Hx of recurrent SBOs - both functional and mechanical -
requiring ketamine gtt. CT on admission noted some small bowel
dilation without evidence of mechanical obstruction and he had
continued ostomy output consistent with normal output suggesting
less likely SBO. Given acute onset of nausea with vomiting and
prompt resolution in symptoms viral gastroenteritis, including
norovirus considered most likely. He was treated conservatively
with IVFs, antiemetics which he did not require and NPO. Within
24 hours of admission his symptoms completely resolved, with no
abdominal pain, nausea or vomiting and tolerating a regular
diet. He was briefly treated with IV Ketamine infusion
consistent with many prior admissions and managed with help of
chronic pain service consultation to assist with dosing,
titration and weaning. There were no complications related to
Ketamine while inpatient. Stool studies were negative for CDiff
and Norovirus PCR. Given prompt resolution considered viral
gastroenteritis as most likely etiology and he was discharged
after tolerating a regular diet.
# Acute renal failure:
Admitted with Cr of 3.0 from baseline around 1.4, noted to be
rising in ___, for which pt was referred to urgent
care but does not appear to have gone. Cr rapidly improved to
baseline of 1.2 with IVFs consistent with pre-renal etiology.
# L ptosis:
Noted on admission. Pt believes that is new but had no other
focal neurologic deficits, and prior notes do make mention of
mild L facial droop. He has had fairly extensive neurologic
evaluation in the past, including CTA head and neck ___
which was unrevealing. Neuro exam was normal throughout
hospitalization without additional facial findings. This was
thought to be baseline and low likelihood of acute neurologic
event. In the absence of additional sxs and given stability, no
further imaging thought warranted. Neuro consultation thought
not needed given low suspicion for acute neurologic event.
# Mood disorder:
Chronic, stable. Continued home
amitriptyline/clonazepam/duloxetine
# Hx of PE:
Prior PEs x2, mostly recently in ___. Rivaroxaban dose
recently reduced to 10 mg daily in outpatient setting given easy
bruising/bleeding. Continued rivaroxaban during admission.
# CAD:
Chronic, stable though he reports no longer takes ASA, BB or
statin. Unclear if he truly has CAD or if these indications are
even warranted.
Plan of care during hospitalization and transition to the
outpatient setting was communicated to outpatient providers via
email prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Dilantin Kapseal / Latex / Mysoline / Nsaids / prednisone
Attending: ___.
Chief Complaint:
MEDICINE ATTENDING ADMISSION NOTE
Time of Initial Eval: ___ 04:35
CC: ___ Pain, N/V
Major Surgical or Invasive Procedure:
ERCP with stent placement
History of Present Illness:
Note: Pt is a very poor historian.
Pt is a ___ y/o F with PMHx of chronic angina on NTG patch, HTN,
HLD, CKD, hypothyroidism, h/o benign papillary stenosis s/p ERCP
in ___ w/ sphx (brushings negative), and ? recurrent CBD
stones, who presented with abdominal pain and nausea/vomiting
that began on the day of presentation. Pt reports that she
initially woke up on the day of presentation with nausea, which
is not unusual for her (she frequently takes Zofran at home for
nausea). However, she then developed emesis followed by upper
abdominal "squeezing" and associated "aching" in the right
shoulder. These symptoms were similar to her prior episodes of
CBD stones. She went to ___, labs: Tbili 1.6, Lipase 483,
ast 228, alt 109, wbc 7.8, Temp 99.9. Received Unasyn,
transferred to ___ ___ for ERCP evaluation.
___ Course:
Initial VS: 98.6 73 131/66 17 100% ra Pain ___
Labs significant for ALT 292 AST 508 ALP 126 TB 1.5 Lipase 199.
UA with >182 WBCs, many bacteria.
Imaging: RUQ u/s with intrahepatic and extrahepatic biliary duct
dilation. CBD 2.0 cm.
Meds given: zofran, nitrofurantoin; unasyn given at OSH
VS prior to transfer: 99.7 69 128/90 16 99% RA
Tm in the ___ 100.0.
On arrival to the floor, the patient endorsed the above
symptoms. She also endorses diarrhea (non-bloody, watery) which
started yesterday. On further questioning, she reports urinary
frequency, nocturia, and dysuria.
On ROS, she reports chronic exertional angina for which she is
on NTG patch as well as PRN SL NTG. She also reports exertional
dyspnea. She reports chronic nausea in the morning, for which
she takes zofran. She has had a 20 lb weight loss over the past
6 months. She reports chronic weakness in her legs. She also
reports sharp headaches that have been intermittently occuring
for the past several months.
ROS: As above. Denies cough, constipation, muscle or joint
pains, focal numbness or tingling, skin rash. The remainder of
the ROS was negative.
Past Medical History:
Angina on plavix, NTG
Hypertension
Hyperlipidemia
Diverticulosis
Chronic Kidney Disease, Stage III
Raynaud's disease
Hypothyroidism
Recurrent UTI's
Pyelonephritis
s/p appy
s/p hysterectomy
s/p CCY
Social History:
___
Family History:
Does not know her family history, as she is adopted.
Physical Exam:
VS - 100.2 164/80 68 18 97%RA
GEN - Alert, NAD
HEENT - NC/AT, OP clear
NECK - Supple, no JVD
CV - RRR, ___ systolic murmur loudest at the apex
RESP - CTA B
ABD - S/NT/ND, BS present, no CVAT
EXT - No ___ edema, LLE is diffusely tender (chronic)
SKIN - No apparent rashes
NEURO - Alert, oriented x 3, non-focal
PSYCH - Calm, appropriate
Pertinent Results:
___ 01:20AM BLOOD WBC-5.5 RBC-3.61* Hgb-11.6* Hct-35.4*
MCV-98 MCH-32.2* MCHC-32.9 RDW-12.9 Plt ___
___ 01:20AM BLOOD Neuts-74.2* ___ Monos-5.9 Eos-0.5
Baso-0.7
___ 03:01AM BLOOD ___ PTT-28.1 ___
___ 01:20AM BLOOD Glucose-113* UreaN-21* Creat-1.1 Na-140
K-3.8 Cl-105 HCO3-25 AnGap-14
___ 01:20AM BLOOD ALT-292* AST-508* AlkPhos-126*
TotBili-1.5
___ 01:20AM BLOOD Lipase-199*
___ 01:20AM BLOOD Albumin-4.0 Calcium-8.8 Phos-2.5* Mg-2.0
___ 01:28AM BLOOD Lactate-1.1
___ 01:45AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 01:45AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-LG
___ 01:45AM URINE RBC-24* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
Discharge Labs:
___ 06:30AM BLOOD WBC-7.2 RBC-3.36* Hgb-10.9* Hct-33.8*
MCV-101* MCH-32.5* MCHC-32.3 RDW-13.3 Plt ___
___ 06:30AM BLOOD Glucose-103* UreaN-13 Creat-0.9 Na-138
K-3.4 Cl-108 HCO3-24 AnGap-9
___ 06:30AM BLOOD ALT-228* AST-181* TotBili-0.7
Microbiology:
Blood culture PENDING x 2
**FINAL REPORT ___ URINE CULTURE (Final ___: NO
GROWTH.
RUQ U/S - Moderate intrahepatic and extrahepatic biliary duct
dilitation. CBD is dilated measuring 2.0 cm. Distal CBD not well
seen. No stone identified in the visualized bile ducts.
OSH Labs:
TBili 1.6
Lipase 483
AST 228
ALT 109
ECG: SR, left axis, no concerning signs of ischemia
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: S/P sphincterotomy - stenosis of the
sphincterotomy at major papilla was noted. No mass lesion was
noted. No spontaneous flow of contrast was noted.
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in partial opacification.
Biliary Tree: A severe dilation was seen at the main duct with
the CBD measuring 18 mm. No obvious stricture was noted. Given
suspicion for cholangitis, high pressure cholangiogram was not
obtained.
Procedures: A 5cm by ___ Double pig-tail biliary stent was
placed successfully in the main duct.
Impression: Stenosis of the major papilla
A severe dilation was seen at the main duct with the CBD
measuring 18 mm. No obvious stricture was noted. Given suspicion
for cholangitis, high pressure cholangiogram was not obtained.
A 5cm by ___ Double pig-tail biliary stent was placed
successfully in the main duct. (stent placement)
Otherwise normal ercp to third part of the duodenum
Recommendations: Return patient to hospital ward for ongoing
care
Repeat ERCP in 2 - 4 weeks for treatment of sphincter stenosis -
patient will need to be off Plavix for 5 days if possible/safe.
Please address with cardiologist.
Additional notes: Patient was given a copy of the report. The
patient's reconciled home medication list is appended to this
report. The procedure was done by Dr. ___ the GI Fellow.
Estimate blood loss = 0 cc. No specimens were obtained. See
impression for final diagnosis. I supervised the acquisition and
interpretation of the fluoroscopic images. The quality of the
fluoroscopic images was good.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Multivitamins 1 TAB PO DAILY
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Isosorbide Dinitrate Dose is Unknown PO Frequency is Unknown
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Ondansetron Dose is Unknown PO Frequency is Unknown
8. Nitroglycerin Patch Dose is Unknown TD Frequency is Unknown
9. Nitroglycerin SL Dose is Unknown SL Frequency is Unknown
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Isosorbide Dinitrate 5 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nitroglycerin Patch 0.4 mg/hr TD Q24H
7. TraZODone 50 mg PO HS:PRN insomnia
8. Atorvastatin 10 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Ondansetron 4 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary obstruction
Cholangitis
Stable angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Abdominal pain and elevated LFTs.
COMPARISON: ERCP on ___.
FINDINGS: The liver is normal in echogenicity. There is moderate
intrahepatic biliary duct dilatation and extrahepatic biliary duct dilatation
with the common bile duct measuring 2.0 cm and this is similar to the results
of ERCP from ___. The distal CBD is not well seen. The
pancreas is not well seen due to overlying bowel gas. The evaluation of the
aorta is limited, but is grossly unremarkable. The visualized portions of the
IVC are normal. Limited exam of the right kidney is unremarkable. Patient is
status post cholecystectomy.
IMPRESSION: Moderate intrahepatic and extrahepatic biliary duct dilatation
with CBD measuring 2.0 cm, similar to ERCP in ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, URIN TRACT INFECTION NOS, HYPERTENSION NOS
temperature: 98.6
heartrate: 73.0
resprate: 17.0
o2sat: 100.0
sbp: 131.0
dbp: 66.0
level of pain: 2
level of acuity: 3.0 | ___ y/o F with PMHx of chronic angina on NTG patch, HTN, HLD,
CKD, hypothyroidism, h/o benign papillary stenosis s/p ERCP in
___ w/ sphx (brushings negative), and ? recurrent CBD stones,
here with N/V and abdominal pain, imaging/labs concerning for
bile duct obstruction.
# Bile Duct Obstruction: RUQ u/s showed biliary ductal dilation
without clear evidence of stone. Labs showed elevated
transaminases and lipase with normal t.bili. Her CBD was dilated
to 2.0cm on imaging. She was taken for ERCP. Due to her being on
plavix a stent was placed, but no sphincterotomy was made. Her
LFTs improved and she was tolerating a diet at discharge. She
will need a repeat ERCP in ___ weeks, and if safe to do so, off
of plavix 5 days prior to procedure. She was treated with Unasyn
initially for presumed cholangitis, and was discharged on a two
week course of Augmentin.
# Pancreatitis: Labs with elevated lipase, consistent with mild
pancreatitis. Likely related to bile duct obstruction as
described above. Abdominal exam benign throughout admission. She
had a decreased appetite, but was tolerating a regular diet on
discharge without pain. As she stated, the hospital food did not
appeal to her.
# Urinary Tract Infection: UA grossly positive in the ___. No
culture was initially sent, and repeat UA showed improving WBCs
on Augmentin. Culture (while on antibiotics) was no growth.
# Chronic Angina: On plavix, NTG patch, SL NTG and isosorbide.
She had no events of CP during admission. She was maintained on
her home regimen.
# Hyperlipidemia: Continued lipitor.
# Hypothyroidism: Continued levothyroxine.
# MEDICATION RECONCILIATION: Ms. ___ was forthcoming and
stated that she has been non-compliant with medications and
appointments. She stated that she knows "its only hurting
myself." This was confirmed with her pharmacy as several of her
home medications hadn't been filled in months (Levothyroxine
last filled in ___, Plavix last filled in ___ - though she
says she was on plavix just prior to admission). We discussed at
length the improtance of keeping her appointments. She assured
me that she will keep the appointments scheduled for follow-up
of this hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Cipro
Attending: ___.
Chief Complaint:
shortness of breath, palpitations, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo woman w/ intermittent atrial fibrillation, on Eliquis,
HFpEF, hypothyroidism, asthma, HTN, hyperlipidemia, IDDM who
presents to the ED with dyspnea and chest pain.
Per the ED dash, patient describes that she started to
experience
shortness of breath yesterday that occurred both at rest and
with
minimal exertion. She also describes that last night around 2:30
AM, she had an episode of left-sided nonradiating chest pressure
that was associated with diaphoresis and dyspnea and lasted for
about an hour. Around the same time, she also experienced
palpitations that also lasted for about an hour. Pain went away
on its own, but throughout the day she continued to experience
intermittent chest pressure lasting anywhere from ___ minutes.
Otherwise, she has not experienced any cough, fever, chills,
nausea, vomiting, abdominal pain or any other recent illness.
Past Medical History:
Ischemic colitis ___ (conservative treatment)
Afib
Hypertension
Hyperlipidemia
Diabetes Type II
Hypothyroid
Asthma
Multiple nephrolithiasis
Pneumonia
Appendectomy
Cholecystectomy
Left knee surgery
Social History:
___
Family History:
No heart problems in family
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.4 PO 159 / 69 79 18 99 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 97.4 PO BP: 147 / 67 HR: 67 RR: 20 O2: 98 Ra
GENERAL: elderly woman, sitting up, NAD
HEENT: AT/NC
NECK: supple, no JVD appreciated
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: no cyanosis, clubbing, or edema
NEURO: A&O, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 06:30PM BLOOD WBC-7.7 RBC-3.27* Hgb-7.5* Hct-26.2*
MCV-80*# MCH-22.9*# MCHC-28.6* RDW-18.1* RDWSD-53.0* Plt ___
___ 06:30PM BLOOD Glucose-57* UreaN-29* Creat-1.5* Na-141
K-4.2 Cl-102 HCO3-22 AnGap-17
___ 06:30PM BLOOD CK-MB-2 proBNP-3122*
___ 06:30PM BLOOD Iron-301*
RELEVANT LABS:
___ 12:50PM BLOOD ___ PTT-32.1 ___
___ 06:30PM BLOOD CK-MB-2 proBNP-3122*
___ 07:05AM BLOOD TotProt-5.9* Calcium-9.6 Phos-3.9 Mg-2.0
Iron-18*
___ 07:05AM BLOOD calTIBC-407 VitB12-127* Ferritn-28
TRF-313
___ 07:05AM BLOOD PEP-PND FreeKap-33.4* FreeLam-27.4* Fr
K/L-1.2
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-6.2 RBC-3.52* Hgb-8.4* Hct-28.4*
MCV-81* MCH-23.9* MCHC-29.6* RDW-18.0* RDWSD-51.9* Plt ___
___ 06:45AM BLOOD Glucose-106* UreaN-37* Creat-1.4* Na-140
K-4.6 Cl-102 HCO3-26 AnGap-12
IMAGING:
___ CXR
1. Mild bibasilar opacities may represent atelectasis.
2. Blunting of the posterior costophrenic angles are likely due
to small
bilateral pleural effusions.
Medications on Admission:
1. Apixaban 5 mg PO BID
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Sucralfate 1 gm PO TID
7. GlipiZIDE XL 5 mg PO DAILY
8. Allopurinol ___ mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN
11. Glargine 10 Units Bedtime
12. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY Duration: 2 Weeks
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*14 Tablet Refills:*0
2. FoLIC Acid 5 mg PO DAILY Duration: 2 Weeks
RX *folic acid 1 mg 5 tablet(s) by mouth daily Disp #*70 Tablet
Refills:*0
3. Allopurinol ___ mg PO DAILY
4. Apixaban 5 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. GlipiZIDE XL 5 mg PO DAILY
8. Glargine 10 Units Bedtime
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN
13. Simvastatin 20 mg PO QPM
14. Sucralfate 1 gm PO TID
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary:
Anemia
Dypsnea on exertion
heart failure with preserved ejection fraction
Secondary:
intermittent atrial fibrillation
hypothyroidism
diabetes type II
asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with SOB + Chest pain, please r/o cardiopulmonary process//
SOB + Chest pain, please r/o cardiopulmonary process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
No focal consolidation is identified. Mild bibasilar opacities may represent
atelectasis. There is no pulmonary edema or pneumothorax. Mild blunting of
the posterior costophrenic angles may be due to small bilateral pleural
effusions. Degenerative changes are seen along the thoracic spine with
anterior bridging osteophytes. The cardiomediastinal silhouette and hilar
contours are unchanged.
IMPRESSION:
1. Mild bibasilar opacities may represent atelectasis.
2. Blunting of the posterior costophrenic angles are likely due to small
bilateral pleural effusions.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Hypoxemia
temperature: 98.9
heartrate: 90.0
resprate: 18.0
o2sat: 99.0
sbp: 110.0
dbp: 65.0
level of pain: 3
level of acuity: 2.0 | ___ yo woman w/ intermittent atrial fibrillation, on Eliquis,
HFpEF, hypothyroidism, asthma, HTN, hyperlipidemia, IDDM who
presents with intermittent dyspnea, palpitations, and chest pain
likely due to combination atrial fibrillation with RVR and
anemia.
#Dyspnea and palpitations
#Intermittent atrial fibrillation
These have been ongoing since she was discharged from the
hospital in ___. Palpitations and SOB have been intermittent
and slowly getting worse since discharge. There is no evidence
of pneumonia on chest x-ray. She is not wheezing on exam. Her
home metop was recently decreased from 200 daily to 50 daily and
dilt was stopped. It's possible that she's going into runs of
afib with RVR more frequently since her nodal agents were
decreased and that this causes her shortness of breath since she
typically gets palpitations and lightheadedness followed by
chest pain. We fractionated metoprolol to 12.5 q6h and continued
her home Apixaban 5 mg BID. Also monitored patient on telemetry
with no significant events while in hospital. Could consider
longer term monitoring on outpatient basis.
#Chest pain
No ischemic changes on EKG. Initial troponins were undetectable.
f/u trops negative. We continued her home simvastatin.
#Anemia
Patient states she has chronic anemia. She had a colonoscopy in
___ at ___ which found a sessile adenoma on bx, ___ gastric
bx showed gastritis and sigmoidoscopy showed colitis. Denies
hematochezia, melena. Her hemoglobin dropped below 7 during this
hospitalization and she received 1 unit of RBCs. Rectal exam and
stool guaic were negative for blood. Iron level was low at 18
during this hospital stay; VitB12 also low at 127. She was given
IV iron and PO vitamin B12 repletion.
#HFpEF
She has no signs or symptoms of heart failure. BNP on ___
was 4155, 3122 during this hospital admission.
#Headache
She had a fleeting headache on day of admission lasting only 1
minute. No neurological deficits appreciated. She mentated well
during her stay.
#Hypothyroidism
We continued her home levothyroxine.
#Asthma
We continued her home Fluticasone-Salmeterol Diskus (250/50).
#Insulin-dependent diabetes
ISS while inpatient; held home meds. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy ___
Lumbar Puncture ___
Hemodialysis (most recent session ___
History of Present Illness:
Mr. ___ is a ___ yo man with a PMHx of EBV associated
T-Cell lymphoma and ESRD on dialysis (___) completed C6 of
CHOEP (___) and recently hospitalized at ___ ___ -
___ w/ fever, headache, and thrombocytopenia. He was treated w/
broad spectrum abx for sinusitis w/ preseptal cellulitis, on CT
sinus/orbit ___ sinusitis had worsened since ___ but no
evidence of bony erosion or septal involvement. He was
discharged on ___ w/ course of levaquin and vanco w/ HD.
Yesterday he started to feel poorly with body aches like when he
takes neupogen and had fever to 100.7 in afternoon. He took a
dose of acetaminophen. Fever improved but aches persisted and he
also had some chills. He has been c/o nausea and has had minimal
po intake. He is starting to feel chilled. Also c/o congestion.
Denies sinus pain or drainage. But has feeling of fullness
behind eyes and under the jaws, no LN enlargement. Currently no
HA, no change in vision, no red eyes. No sore throat, dysuria,
abdominal pain, vomiting, diarrhea, or cough. BM regular. Was
eating up until lunch yesterday then felt malaised.
Initial VS in ED 23:18 6 102.4 112 130/95 24 100%, prior to
admit 03:52 0 99.1 111 131/71 20 99% RA.
WBC 1.2 w/ ANC ~400, CXR- mild cardiomegaly and central vascular
congestion. Left lower lobe and retrocardiac airspace opacities
likely reflect atelectasis, although underlying infection is
difficult to exclude.
He was given vanco, cefepime, tylenol and 1L NS in ED
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Mr. ___ was diagnosed with infectious mononucleosis in
the ___ in the setting of flu-like symptoms,
adenitis, positive Monospot and mild splenomegaly. In the
ensuing months, the patient continued to have waxing and waning
constitutional symptoms and in ___ he was hospitalized for
progressive impaired renal function secondary to
glomerulonephritis. At the same time he was found to have
persistently elevated EBV viral loads, consistent with chronic
EBV infection. Further immunologic work up was notable for a
profound NK cell deficiency, but he tested negative for XLP1 and
ALPS syndromes. Although he did have a population of DN T cells
by FC in the peripheral blood and BM at that time, the PCR for
TCR rearrangement was negative and there was no definitive
evidence of lymphoma. Subsequently, Mr ___ received a
course of steroids for his glomerulonephritis with initial
improvement of his kidney function, but this was complicated by
bilateral serous retinal detachments and the prednisone was
gradually tapered over a period of 4 months, with subsequent
deterioration of his renal function. A repeat kidney biopsy in
___ showed progressive glomerulonephritis and he was started
on hemodialysis on ___. With regards to his EBV viremia, he has
been on Valgancyclovir since ___ with inadequate response.
It was subsequently discontinued.
Mr. ___ was again hospitalized in ___ with malaise,
night sweats and cough. CT torso was notable for a new LUL
nodule. He underwent wedge resection and the pathology was
consistent with an EBV-associated cytotoxic gamma-delta T cell
lymphoma. Staging BM biopsy showed no definitive evidence of
lymphoma involvement, but FC was positive for a population of DN
T cells. PCR for TRC rearrangement was negative in the marrow.
The patient also had an LP that did not show elevated lymphocyte
counts, but PCR on CSF was positive for EBV DNA. Finally,
staging PET/CT on ___ showed scattered bilateral FDG-avid
nodules in the lungs, single FDG-avid lesion in the R lobe of
the liver, and moderate non-avid splenomegaly.
Mr. ___ commenced cycle 1 of R-CHOEP on ___ and he
as also been evaluated at ___ for consideration of combined
kidney/bone marrow transplant, assuming that he achieves a
durable remission with chemotherapy.
TREATMENT HISTORY:
- ___ C1D1 R-CHOEP (Cyclophosphamide and Etoposide 50%
dose reduced). Patient remained hospitalized till ___ for
febrile neutropenia, abdominal pain, otalgia and mucositis.
- ___ C2D1 R-CHOEP (Cyclophosphamide and Etoposide dose
reduced 58% and 55% respectively)
- ___ Hospitalization for fever and abdominal pain.
Patient empiriaclly covered with cipro/flagyl for possible
abdominal source, however his ID work-up was negative, he
remained afebrile and antibiotics were discontinued once
neutropenia recovered. Fever could have been due to Neupogen
injections. For his chornic abdominal discomfort, the patient
underwent EGD on ___ that was concerning for esophageal
candidiasis, although stains were negative. Patient received
brief course of fluconazole. Patient also received one dose of
ivermectin on ___ for his history of strongyloides. For his
cytopenias, he required 2 units of pRBCs and 3 units of PLTs.
- ___: C3 Rituximab. PET/CT with marked response.
- ___: PET/CT with no evidence of FDG avid disease.
- ___: Started on Rituximab post-HD ___.
- ___: Rituximab #5
- ___: CHOEP (full dose vincristine, 20% dose reduction of
doxorubicin, 66% dose reduction of cyclophosphamide, 68% dose
reduction of etoposide)
- ___: Rituximab #6
- ___: Rituximab #___
- ___ CHOEP # 4 Modified: Cyclophosphamide 300 mg/m2,
DOXOrubicin 50 mg/m2, VinCRIStine 2 mg IV, Etoposide IV Days 1,
2 and 3. 20 mg/m2
- ___ NCSE: antiepileptics initiated
- ___ IT Cytarabine
- ___ CHOEP #5 Modified: Cyclophosphamide 300 mg/m2,
DOXOrubicin 50 mg/m2, VinCRIStine 2 mg IV, Etoposide IV Days 1,
2 and 3. 20 mg/m2
- ___ CHOEP #6 Cyclophosphamide 750 mg/m2 - dose reduced by
50% to 375 mg/m2, DOXOrubicin 50 mg/m2 - dose reduced by 50% to
25 mg/m2, VinCRIStine 2 mg - dose reduced by 50% to 1 mg,
Etoposide 100 mg/m2 - dose reduced by 50% to 50 mg/m2
PAST MEDICAL/SURGICAL HISTORY:
- Infectious mononucleosis in ___
- NK cell deficiency
- High grade chronic EBV viremia
- Strongyloiadiasis-treated with 3 doses ivermectin ___
- Latent TB infection treated with 9 months INH, finished ___
- ESRD secondary to glomerulonephritis (FSGS from EBV viremia)
- Mild gastritis
- Cervical LAD s/p non-diagnostic biopsy ___ years ago
- Sinusitis and multifocal PNA (___)
Social History:
___
Family History:
His parents are alive, father is ___ and mother is ___ years old.
They do not have any major health issues. His grandmother died
from lung cancer. One brother died in his sleep at the age of
___, possibly due to seizure disorder. The patient also states
that his brother had a swollen leg right before the event,
raising the possibility of VTE as the cause of death. There is
no history of frequent infections in any family members. No
family history of hematologic disorders or malignancies.
Physical Exam:
ADMISSION PHYSICAL:
===============================
Vitals: T 98.6, BP 138/76, HR 103, RR 20, O2 99/RA
Gen: Pleasant, calm, NAD
HEENT: Right perioribital edema, mild swelling of the cheek, no
conjunctival injection, EOMI. No icterus. MMM. OP clear. nasal
mucosa erythematous bilateral w/out ulceration or discharge, no
maxillary tenderness
Neck: supple, no LAD
CV: RRR. Normal S1, S2. No M/R/G
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema. LUE AVF with palpable thrill
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: Alert and oriented, EOMI, face symmetric, gait normal
LINES: PIV
DISCHARGE PHYSICAL:
===============================
Vitals: T 97.4 (Tm 98.2), BP 130/88, HR 79, RR 18, O2 100/RA
Gen: Pleasant, calm, NAD
HEENT: Right perioribital edema, mild swelling of the cheek, no
conjunctival injection, EOMI. No icterus. MMM. OP clear.
CV: RRR. Normal S1, S2. No M/R/G
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema. LUE AVF with palpable thrill
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: Alert and oriented, non-focal
LINES: PIV
Pertinent Results:
ADMISSION LABS:
============================
___ 01:00AM BLOOD WBC-1.2*# RBC-2.71* Hgb-9.2* Hct-25.8*
MCV-95 MCH-33.8* MCHC-35.6* RDW-16.3* Plt Ct-77*
___ 01:00AM BLOOD Neuts-32* Bands-1 ___ Monos-30*
Eos-0 Baso-3* Atyps-3* ___ Myelos-0
___ 09:25AM BLOOD ___ PTT-37.5* ___
___ 01:00AM BLOOD Glucose-95 UreaN-44* Creat-8.6*# Na-132*
K-5.0 Cl-92* HCO3-22 AnGap-23*
___ 01:00AM BLOOD ALT-241* AST-315* LD(LDH)-501*
AlkPhos-307* TotBili-0.5
___ 01:00AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.8
___ 01:04AM BLOOD Lactate-1.3
DISCHARGE LABS:
============================
___ 06:00AM BLOOD WBC-2.8*# RBC-2.54* Hgb-8.2* Hct-24.0*
MCV-95 MCH-32.5* MCHC-34.3 RDW-15.9* Plt Ct-76*
___ 06:00AM BLOOD Neuts-38* Bands-0 ___ Monos-29*
Eos-0 Baso-0 Atyps-1* ___ Myelos-0
___ 06:00AM BLOOD ___ PTT-34.1 ___
___ 06:00AM BLOOD Glucose-96 UreaN-23* Creat-4.3* Na-136
K-4.3 Cl-97 HCO3-32 AnGap-11
___ 06:00AM BLOOD ALT-393* AST-394* LD(LDH)-449*
AlkPhos-472* TotBili-0.7
___ 06:00AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.8
PERTINENT LABS:
============================
___ 05:45AM BLOOD GGT-399*
___ 05:45AM BLOOD calTIBC-248* Ferritn-8457* TRF-191*
___ 05:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 05:45AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 05:45AM BLOOD ___
___ 05:45AM BLOOD IgG-1099 IgA-140 IgM-66
___ 05:45AM BLOOD HCV Ab-NEGATIVE
MICROBIOLOGY:
============================
All Blood and Urine Cultures Negative.
See BRIEF HOSPITAL COURSE for details on other microbiology.
STUDIES:
============================
___ CHEST X-RAY:
IMPRESSION:
Mild cardiomegaly and central vascular congestion. Left lower
lobe and
retrocardiac airspace opacities likely reflects atelectasis,
although
underlying infection is difficult to exclude.
___ MRI HEAD W/OUT CONTRAST:
IMPRESSION:
1. New T2 hyperintensity in bilateral cerebellum. The lytic
considerations include lymphomatous infiltration, viral or other
infectious cerebellitis, and paraneoplastic cerebellitis.
2. Near complete opacification of the right maxillary sinus
with fluid
mucosal thickening, slightly progressed since ___.
Presence of active infection cannot be determined by MRI.
___ CT CHEST/ABDOMEN/PELVIS W/OUT CONTRAST:
IMPRESSION (CHEST):
Improvement as compared to the previous scan, knee complete
resolution of the nodular opacities. Resolution of the bilateral
pleural effusions. No
adenopathy.
IMPRESSION (ABDOMEN/PELVIS):
1. No abdominal or pelvic source for patient's symptoms.
2. Splenomegaly with spleen measuring 15.8 cm in length.
3. Unchanged nonenlarged retroperitoneal lymph nodes and mild
stranding of the para-aortic and mesenteric fat.
4. Please see separate CT chest dictation for thoracic findings.
___ MRI HEAD W/ AND W/OUT CONTRAST:
IMPRESSION:
Areas of high T2/FLAIR signal in the cerebellum are
nonenhancing. However, lymphomatous infiltration remains in the
differential. Infectious cerebellitis is also a possibility.
___ RUQ US
IMPRESSION:
1. Heterogeneous liver without focal mass. This appearance is
nonspecific but could be effect of ___ viremia or drug
toxity. Lymphoproliferative involvement is not excluded.
2. Small, echogenic kidneys consistent with known chronic kidney
disease.
3. Splenomegaly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO DAILY
2. Atovaquone Suspension 1500 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Gabapentin 100 mg PO DAILY
7. Labetalol 100 mg PO BID
8. Lactulose 30 mL PO BID:PRN constipation
9. LeVETiracetam 500 mg PO DAILY
10. LeVETiracetam 250 mg PO 3X/WEEK (___)
11. Lorazepam 0.5-1 mg PO Q4H:PRN nausea
12. Nephrocaps 1 CAP PO DAILY
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Pantoprazole 40 mg PO Q12H
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Ranitidine 300 mg PO DAILY
17. Senna 8.6 mg PO BID
18. Sertraline 25 mg PO DAILY
19. Vitamin D ___ UNIT PO DAILY
20. Levofloxacin 250 mg PO 3X/WEEK (___)
21. Guaifenesin ___ mL PO Q6H:PRN throat irritation
22. Vancomycin 1000 mg IV HD PROTOCOL
Discharge Medications:
1. Acyclovir 400 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Gabapentin 100 mg PO DAILY
6. Guaifenesin ___ mL PO Q6H:PRN throat irritation
7. Labetalol 100 mg PO BID
8. Lactulose 30 mL PO BID:PRN constipation
9. LeVETiracetam 500 mg PO DAILY
10. LeVETiracetam 250 mg PO 3X/WEEK (___)
11. Lorazepam 0.5-1 mg PO Q4H:PRN nausea
12. Nephrocaps 1 CAP PO DAILY
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Pantoprazole 40 mg PO Q12H
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Ranitidine 300 mg PO DAILY
17. Senna 8.6 mg PO BID
18. Sertraline 25 mg PO DAILY
19. Vitamin D ___ UNIT PO DAILY
20. Atovaquone Suspension 1500 mg PO DAILY
21. Dexamethasone 6 mg PO DAILY Duration: 6 Days
Take 6 mg daily for 3 days (___) then 4 mg daily for 3
days (___)
Tapered dose - DOWN
RX *dexamethasone 2 mg 3 tablet(s) by mouth daily Disp #*15
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: ___ viremia, ___ virus associated T
cell lymphoma
SECONDARY: headache, fever, end-stage renal disease on
hemodialysis, transaminitis
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 without intravenous contrast.
INDICATION: ___ year old man with EBV-associated T cell lymphoma, fevers on
vanc/cef, transaminitis // eval for site of 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.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: DLP: 755.40 mGy-cm (abdomen and pelvis).
COMPARISON: CT abdomen and pelvis ___.
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 lesion. Metallic artifact within the liver parenchyma
is unchanged. 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 is enlarged measuring 15.8 cm in length. There is no
evidence of splenic lesion.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence of
focal renal lesion or hydronephrosis. There is no nephrolithiasis. There is no
perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber and wall
thickness throughout. Colon and rectum are within normal limits. Appendix
contains air, has normal caliber without evidence of fat stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal or mesenteric
lymphadenopathy. There are few scattered para-aortic lymph nodes and mild
haziness of the para-aortic and mesenteric fat, similar to prior CT
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:
There is no evidence of worrisome lesions. Abdominal and pelvic wall are
within normal limits.
IMPRESSION:
1. No abdominal or pelvic source for patient's symptoms.
2. Splenomegaly with spleen measuring 15.8 cm in length.
3. Unchanged nonenlarged retroperitoneal lymph nodes and mild stranding of the
para-aortic and mesenteric fat.
4. Please see separate CT chest dictation for thoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: T-cell lymphoma
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: Given in abdominal CT report
COMPARISON: ___.
FINDINGS:
Unchanged hypertrophy of the thyroid gland. Borderline lymph nodes in the
axillary region. Normal size lymph nodes in the mediastinum and the hilar
region. 1 calcified subpleural lymph node. Unchanged appearance of the heart.
Minimal pericardial effusion. Normal appearance of the posterior mediastinum.
Known embolization material in the liver. No abnormalities at the level of
the ribs, the sternum and the vertebral bodies.
Left-sided status post wedge resection. The pre-existing pleural effusion has
completely resolved. The pre-existing millimetric subpleural pulmonary nodule
in the right lower lobe (5, 166) has slightly decreased in size. The second
pulmonary nodule in the middle lobe (5, 216) is barely visible on today's
examination. No new pulmonary nodules. No pleural thickening. No diffuse
lung disease.
IMPRESSION:
Improvement as compared to the previous scan, knee complete resolution of the
nodular opacities. Resolution of the bilateral pleural effusions. No
adenopathy.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with EBV associated T cell lymphoma, cerebellar
lesions, ESRD on MWF HD // evaluate for cerebellar lymphomatous infiltration
(concern based on non-contrasted study) -- will need to be timed with HD for
patient
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 12cc of Gadoteridol 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: MR head from ___
FINDINGS:
Areas of high T2/FLAIR signal intensity in the cerebellar hemispheres and
vermis are not significantly changed and show no evidence of enhancement. Few,
subtle scattered foci of T2/FLAIR signal hyperintensity in the
periventricular, deep, and subcortical white matter which are nonspecific, are
again seen. There is no evidence of hemorrhage, masses, mass effect, or
infarction.
Prominent ventricles and sulci are again seen. There is no abnormal
enhancement after contrast administration. Near-complete opacification of the
right maxillary sinus with fluid in mucosal thickening is again seen and may
suggest an inflammatory process or possible fungal colonization.
IMPRESSION:
Areas of high T2/FLAIR signal in the cerebellum are nonenhancing. However,
lymphomatous infiltration remains in the differential. Infectious
cerebellitis is also a possibility.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with EBV associate T cell lymphoma, persistent
EBV viremia, worsening transaminitis // eval for cause of transaminitis (___
patient will be off the floor from ___
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___ non contrasted CT of the abdomen and pelvis; ___ abdominal ultrasound.
FINDINGS:
LIVER: The hepatic parenchyma is diffusely heterogeneous. The contour of the
liver is smooth. An approximately 2 cm echogenic, shadowing focus in the
right lobe of the liver correlates with embolization coils on comparison CT.
No focal liver mass is identified. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: The gallbladder is contracted and not well evaluated.
PANCREAS: Imaged portions of the pancreas are normal in echogenicity without
focal abnormality or pancreatic duct dilatation.
SPLEEN: The spleen is enlarged, measuring 16 cm in length, with homogeneous
echotexture.
KIDNEYS: The kidneys are echogenic and small with loss of normal
corticomedullary differentiation. There is no hydronephrosis. The right kidney
measures 6.2 cm and the left kidney measures 7.4 cm. No stone, cyst, or solid
mass is seen in either kidney.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Heterogeneous liver without focal mass. This appearance is nonspecific but
could be effect of ___ viremia or drug toxity. Lymphoproliferative
involvement is not excluded.
2. Small, echogenic kidneys consistent with known chronic kidney disease.
3. Splenomegaly.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ c hx lymphoma, on chemo, renal failure, p/w fever.
// infiltrate
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___, CT chest dated ___.
FINDINGS:
Unchanged mild cardiomegaly with mild central vascular congestion and
pulmonary edema, slightly improved since the prior study. Linear left lower
lobe atelectasis. A subtle, left retrocardiac airspace opacity may represent
atelectasis versus pneumonia. No large pleural effusion or pneumothorax.
Metallic embolization coils are noted overlying the right upper quadrant.
IMPRESSION:
Mild cardiomegaly and central vascular congestion. Left lower lobe and
retrocardiac airspace opacities likely reflects atelectasis, although
underlying infection is difficult to exclude.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with EBV associated T cell lymphoma with low
grade fevers, head/neck/jaw pain, sinusitis. Evaluate for CNS lymphoma and for
possible sinus infection/process.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique. Intravenous
contrast was withheld on this time due to the patient's chronic renal failure.
COMPARISON: Prior MRI of the head dated ___.
FINDINGS:
There is new T2/FLAIR signal hyperintensity in bilateral cerebellar
hemispheres and small portions of the vermis. There is no associated diffusion
abnormality or blood products. There is no associated mass effect, including
no effacement of the fourth ventricle. Third and lateral ventricles are also
normal in size.
There are also unchanged scattered foci of T2/FLAIR signal hyperintensity in
the periventricular, deep, and subcortical white matter which are nonspecific
but could be post inflammatory or secondary to mild chronic small vessel
ischemic disease if this young patient has chronic cardiovascular risk
factors. Major vascular flow voids are preserved.
There is mild mucosal thickening within the ethmoid air cells. There is
near-complete opacification of the right maxillary sinus with fluid in mucosal
thickeningThe mastoid air cells are clear.
IMPRESSION:
1. New T2 hyperintensity in bilateral cerebellum. The lytic considerations
include lymphomatous infiltration, viral or other infectious cerebellitis, and
paraneoplastic cerebellitis.
2. Near complete opacification of the right maxillary sinus with fluid
mucosal thickening, slightly progressed since ___. Presence of
active infection cannot be determined by MRI.
RECOMMENDATION(S): Further evaluation of the cerebellar abnormality with
gadolinium enhanced MRI would be helpful, if dialysis may be arranged to
follow MRI.
Gender: M
Race: HISPANIC/LATINO - HONDURAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with NEUTROPENIA, UNSPECIFIED , FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE, OTHER PANCYTOPENIA, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 102.4
heartrate: 112.0
resprate: 24.0
o2sat: 100.0
sbp: 130.0
dbp: 95.0
level of pain: 6
level of acuity: 3.0 | ___ yo man with a PMHx of EBV associated T-Cell lymphoma and ESRD
on dialysis (___) with recent admission for fevers and
thrombocytopenias, discharged 2 days prior to this admission,
presenting again with fever and malaise.
# Fever/Malaise: Recent EBV viral load uptrended to 117,000.
Possibly this is all related to EBV. No obvious alternative
etiology.
- Given fever on vanc/levofloxacin, started Cefepime 1g Q24H but
switched to Ceftazidime 1g post-HD given prior encephalopathy
with cefepime, then to Zosyn given rising LFTs. Continued
vancomycin. Stopped levofloxacin.
- Flu negative, blood and urine cultures NGTD
- EBV VL 110,000 (___)
- Parvo, CMV, HHV6, adeno viral loads negative. HBV, HCV
pending.
- Consulted ophtho for fundoscopic evaluation of possible CNS
lymphoma disease -- normal exam on ___.
- CT torso ___ to look for other possible infectious etiologies
-- generally unremarkable.
- beta-glucan 52, galactomannan pending
- LP on ___ with 0 WBCs (N:1, L:82, M:15, Atyp:1), 1 RBCs, TProt
55, Gluc 48, other studies pending.
- Started on dexamethasone 10 mg IV daily with significant
symptom improvement and discharged on dexamethasone taper.
# EBV ssociated gamma-delta T cell lymphoma: Patient recently
s/p cycle 6 of R-CHOEP. Patient Patient will f/u with Dr.
___ further management.
- continued Acyclovir 400 mg PO/NG Q24H ppx
- continued At___ 1500 mg daily
- MR brain showed cerebellar lesion of unclear significance.
Neuro-onc was consulted. Will need ongoing f/u.
- Repeat bone marrow bx on ___, results pending. Prelim showed
hypocellular marrow, erythroid hyperplasia, otherwise
unremarkable, no signs of HLH.
- LP on ___, cytology/flow cytometry pending
- Neupogen x 2 days for neutropenia (unclear etiology)
# Transaminitis: Patient with elevated transaminases, alk phos;
may be medication related.
- Liver consulted, appreciate recs
- Stopped cephalosporins
- Iron studies consistent with anemia of chronic inflammation
- Autoimmune studies (AMA, smooth, ___ negative
- Hepatitis serologies negative for acute infection
- RUQ U/S on ___ with normal dopplers
# Thrombocytopenia: Likely secondary to bone marrow suppression
from recent chemotherapy versus viral infection versus drug
effect (vancomycin). Platelets stable above 30.
# ESRD on HD (MWF): This is likely secondary to FSGS from
chronic EBV viremia. Has been on dialysis since ___. Patient
was recently set up with new dialysis unit and had first session
on ___.
- continued on HD while in house, dose adjust medications
- continued on nephrocaps
- continued on Low K/Phos diet
# Seizure disorder: continued on LeVETiracetam 500 mg PO DAILY,
LeVETiracetam 250 mg PO 3X/WEEK (___)
# HTN: continued on home labetolol
# Depression: continued on home sertraline
# GERD: continued on home ranitidine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
trazodone / Lyrica
Attending: ___.
Chief Complaint:
dyspnea, abdominal distension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/pmh bicuspid aortic valve, s/p AVR with CABG ___, HFpEF,
stage IV CKD, DM, HTN, AF on warfarin who presented to ___
clinic today for worsening SOB, abdominal distention, and lower
extremity edema consistent with CHF exacerbation.
Patient also reports 2 pillow orthopnea, nighttime cough, and
PND. He says he becomes short of breath with chest tightness
after walking to the bathroom. He was treated with 160MG IV
Lasix. Refused hospital admission and was sent home. Labs back
later with creatinine of 4.3, and patient was called to report
to
the ED. Per ___ clinic, patient has had increasing weight
gain of about ___ pounds over last couple of months. Dry
weight
~185 pounds.
In the ED, initial VS were: 98.2 75 119/71 12 98% RA
Exam notable for:
Conjunctiva pale, JVD elevated to level of the ear, significant
abdominal distention with tenderness throughout, pitting lower
extremity edema 2+
Labs showed:
proBNP: 9534
Cr: 4.3, BUN 78
Anion Gap: 19
HgB: 9.0
INR: 2.6, on warfarin
Imaging showed:
CXR with Unchanged cardiomegaly with minimal pulmonary vascular
congestion, without frank pulmonary edema.
Patient received: none
Transfer VS were: 97.9 79 155/91 22 97% RA
On arrival to the floor, patient reports shortness of breath and
chest discomfort with lying flat. Otherwise feels well and has
been taking his medications consistently.
Past Medical History:
Aortic Insufficiency
Atrial Fibrillation
Benign Prostatic Hyperplasia
Bicuspid Aortic Valve
Congestive Heart Failure, diastolic
coronary Artery Disease status post PTCA to LAD
Depression
Diabetes Mellitus, Insulin Dependent
Gastroesophageal Reflux Disease
Glaucoma
Gout
Hyperlipidemia
Hypertension
Hypothyroid
Neuropathy
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 97.7 181/87 82 96% on RA
GENERAL: Adult male in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: JVP elevated 10-12cm
HEART: irregular rate, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: WWP with ___ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM:
===========================
VS: 98.0 157/81 51 18 95% RA
Weights: Admit weight 87.7 kg, Dry Weight 85.8kg Trend: 87.7kg
->
86.2kg -> 86kg-> 85.1kg->85.28kg
GENERAL: Adult male in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera,
NECK: JVP elevated to clavicle
HEART: irregular rate, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: warm and well perfused. Minimal edema on exam. Non
pitting.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
=================
___ 11:20AM BLOOD WBC-8.6 RBC-3.20* Hgb-9.0* Hct-28.8*
MCV-90 MCH-28.1 MCHC-31.3* RDW-15.1 RDWSD-49.6* Plt ___
___ 03:40AM BLOOD WBC-11.5* RBC-3.62* Hgb-10.1* Hct-31.6*
MCV-87 MCH-27.9 MCHC-32.0 RDW-15.0 RDWSD-47.8* Plt ___
___ 11:20AM BLOOD ___
___ 11:20AM BLOOD UreaN-78* Creat-4.3* Na-144 K-4.8 Cl-99
HCO3-26 AnGap-19*
___ 07:20PM BLOOD Glucose-153* UreaN-82* Creat-4.3* Na-140
K-5.0 Cl-98 HCO3-28 AnGap-14
___ 11:20AM BLOOD proBNP-9534*
___ 07:20PM BLOOD cTropnT-0.09*
___ 07:20PM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1
___ 03:40AM BLOOD calTIBC-270 Ferritn-53 TRF-208
IMAGING:
==========
CXR ___:
Unchanged cardiomegaly with minimal pulmonary vascular
congestion, without frank pulmonary edema.
RENAL US ___:
No hydronephrosis. Echogenic appearance of the kidney suggests
chronic
medical renal disease.
ECHO ___:
The left atrial volume index is moderately increased. The
estimated right atrial pressure is ___ mmHg. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function (biplane LVEF = 67 %). Right ventricular
chamber size and free wall motion are normal. The right
ventricular free wall is hypertrophied. A bioprosthetic aortic
valve prosthesis is present. The transaortic gradient is normal
for this prosthesis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a prominent fat pad.
MICRO:
===========
___ 7:48 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
================
___ 08:05AM BLOOD WBC-8.6 RBC-3.71* Hgb-10.4* Hct-32.2*
MCV-87 MCH-28.0 MCHC-32.3 RDW-14.7 RDWSD-46.8* Plt ___
___ 08:05AM BLOOD Plt ___
___ 08:05AM BLOOD Glucose-161* UreaN-81* Creat-4.3* Na-138
K-4.7 Cl-91* HCO3-29 AnGap-18
___ 08:05AM BLOOD Calcium-9.1 Phos-5.5* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
4. Calcitriol 0.5 mcg PO DAILY
5. Carvedilol 25 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO BID
12. TraZODone 100 mg PO QHS:PRN insomnia
13. Venlafaxine 75 mg PO BID
14. Torsemide 100 mg PO DAILY
15. Allopurinol ___ mg PO DAILY
16. Colchicine 0.6 mg PO 2X/WEEK (___)
17. HydrALAZINE 75 mg PO TID
18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
19. Gabapentin 300 mg PO QHS
20. Warfarin 7.5 mg PO 6X/WEEK (___)
21. Warfarin 5 mg PO 1X/WEEK (MO)
22. Glargine 20 Units Breakfast
Glargine 16 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Dinner
Discharge Medications:
1. Gabapentin 200 mg PO QHS
RX *gabapentin 100 mg 2 capsule(s) by mouth at bedtime Disp #*60
Capsule Refills:*0
2. Torsemide 100 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
7. Calcitriol 0.5 mcg PO DAILY
8. Carvedilol 25 mg PO BID
9. Finasteride 5 mg PO DAILY
10. HydrALAZINE 75 mg PO TID
11. Glargine 20 Units Breakfast
Glargine 16 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Dinner
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 75 mcg PO DAILY
15. Losartan Potassium 100 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 20 mg PO BID
18. TraZODone 100 mg PO QHS:PRN insomnia
19. Venlafaxine 75 mg PO BID
20. Warfarin 7.5 mg PO 6X/WEEK (___)
21. Warfarin 5 mg PO 1X/WEEK (MO)
22. HELD- Colchicine 0.6 mg PO 2X/WEEK (___) This medication
was held. Do not restart Colchicine until instructed to start by
PCP
___:
Home
Discharge Diagnosis:
Primary Diagnosis:
================
Acute exacerbation of Chronic Diastolic Heart Failure
Stage IV Chronic Kidney Disease
Secondary Diagnosis:
=================
Atrial Fibrillation on Warfarin
Depression
GERD
Hypothyroidism
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with worsening dyspnea on exertion.// Dyspnea on
exertion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Patient is status post median sternotomy, aortic valve replacement, and CABG.
Fracture of the superior mediastinal wire is unchanged. Cardiac silhouette
size remains moderately enlarged. The mediastinal and hilar contours are
unchanged. There is minimal pulmonary vascular congestion, but no frank
pulmonary edema is present. No focal consolidation, pleural effusion, or
pneumothorax is present. Mild degenerative changes are seen in the thoracic
spine.
IMPRESSION:
Unchanged cardiomegaly with minimal pulmonary vascular congestion, without
frank pulmonary edema.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with CKD, CHF, admitted with volume overload and
___ on CKD with worsening renal function despite diuresis// evaluate cause of
renal failure
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
The right kidney measures 10.2 cm. The left kidney measures 12.0 cm. There is
no hydronephrosis, stones, or masses bilaterally. Simple cysts are seen in
both kidneys measuring up to 1.8 cm in the right interpolar region and 1.7 cm
in the upper pole the left kidney. Echogenic appearance of the kidneys
suggests chronic medical renal disease.
The bladder is moderately well distended and normal in appearance. Oblong
cystic structure adjacent to the bladder measuring approximately 6 cm
corresponds to penile prosthesis reservoir seen on prior CT in ___.
IMPRESSION:
No hydronephrosis. Echogenic appearance of the kidney suggests chronic
medical renal disease.
Gender: M
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Dizziness
Diagnosed with Acute kidney failure, unspecified, Heart failure, unspecified, Dyspnea, unspecified
temperature: 98.2
heartrate: 75.0
resprate: 12.0
o2sat: 98.0
sbp: 119.0
dbp: 71.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ is a ___ year old male with a history of
chronic diastolic heart failure, atrial fibrillation, Stage IV
CKD, hypothyroidism, GERD who presented from heart failure
clinic with worsening dyspnea, abdominal distension and concern
for acute on chronic kidney injury. Patient notably was 2kg
above his presumed dry weight at time of admission with Sr Cr
elevated to 4.3 compared to a previous baseline of approximately
3.0. While inpatient, he received IV 120mg Lasix daily which
resulted in diuresis and subsequent improvement in his symptoms.
Once euvolemic patient was transitioned to home PO Torsemide
100mg. Regarding his renal function. Patient was evaluated with
a renal ultrasound which did not demonstrate acute changes. He
was also evaluated by the Nephrology team who suggested this
likely represented a progression of his known chronic kidney
disease. Patient was discharged once stable on an oral diuretic
regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
sepsis, bacteremia
Major Surgical or Invasive Procedure:
___ US-guided placement of ___ pigtail catheter into
the
collection. 95ml of purulent fluid drained
___ Successful percutaneous embolization of perisplenic
pseudoaneurysm using thrombin and histoacryl glue.
___ exchange and downsize of a percutaneous left hepatic
lobe abscess drainage catheter
___ right picc line insertion
___ and ___ paracentesis
___ CT-guided aspiration of a perisplenic and pelvic
hemorrhagic
collections. Samples were sent for microbiology evaluation.
___ exchange of distally occluded right 10 ___ internal
external biliary drain for a new drain.
___ exchange of splenic drain for a new perisplenic fluid
collection drain. Exchange and downsize of left hepatic lobe
collection drain.
History of Present Illness:
___ with HCV cirrhosis and HCC, s/p DDLT w/roux-en-Y
hepaticojejunostomy (___) c/b hepatic artery thrombosis,
sepsis, persistent VRE bacteremia, malnutrition, s/p stenting of
his hepatic artery, coiling the splenic artery and drainage of
biloma. He was most recently discharged on ___, and was
seen
in the ___ clinic yesterday for a planned
cholangiogram, drain exchange, and debridement of left lobe.
However, at that time he was noted to have a low-grade
temperature to 99.7 and his ___ procedure was postponed. He was
evaluated by transplant surgery at that time, blood cultures
were
drawn and he was discharged home. His blood cultures came back
positive for gram-negative rods and he was called back into the
emergency department for further evaluation and management.
Upon evaluation in the emergency department Mr. ___ notes that
he was feeling increasingly nauseated this morning and had had
one episode of emesis while eating breakfast. He denied further
sweats or chills, denies changes in drainage from his abdominal
drains, abdominal pain, changes in bowel habits, or dysuria.
Past Medical History:
___ deceased donor livertransplant with Roux-en-Y
hepaticojejunostomy
___ to ___ hepatic artery thrombosis
-Insulin dependent DM
-HCV Cirrhosis c/b portal HTN with grade II/III varices
-Hepatocellular carcinoma
-___ s/p RFA ___
-Esophageal variceal bleed
-S/p TIPS procedure ___, extention ___, revision ___
-Pancreatitis
-Non-occlusive splenic vein thrombosis
-Thrombocytopenia
-Colonic polyps
-Diverticulitis
-Hypersplenism
-Embolization of coronary vein supplying esophageal and gastric
varices
___ deceased donor livertransplant with Roux-en-Y
hepaticojejunostomy
___ to ___ hepatic artery thrombosis
-Insulin dependent DM
-HCV Cirrhosis c/b portal HTN with grade II/III varices
-Hepatocellular carcinoma
-HCC s/p RFA ___
-Esophageal variceal bleed
-S/p TIPS procedure ___, extention ___, revision ___
-Pancreatitis
-Non-occlusive splenic vein thrombosis
-Thrombocytopenia
-Colonic polyps
-Diverticulitis
-Hypersplenism
-Embolization of coronary vein supplying esophageal and gastric
varices
Social History:
___
Family History:
Mother died of breast cancer. Father died at age ___. He has a
healthy daughter and healthy siblings.
Physical Exam:
Admission PE:
Vitals: 98.1 79 99/57 21 99% RA
GEN: no acute distress, A&Ox3
Resp: unlabored breathing, easy work of breathing on RA
CV: RRR
ABD: soft, nontender, nondistended, well healed prior incision,
PTBD scant bilious output, pigtail with bilious output
Ext: warm and well perfused
___ 06:30AM BLOOD WBC: 3.8* RBC: 3.57* Hgb: 9.8* Hct: 32.8*
MCV: 92 MCH: 27.5 MCHC: 29.9* RDW: 17.4* RDWSD: 58.2* Plt Ct:
129*
___ 08:00AM BLOOD ___: 14.2* PTT: 33.9 ___: 1.3*
___ 06:30AM BLOOD Glucose: 242* UreaN: 32* Creat: 1.0 Na:
130* K: 4.9 Cl: 97 HCO3: 18* AnGap: 15
___ 08:00AM BLOOD ALT: 84* AST: 72* AlkPhos: 889* TotBili:
0.8
CT A/P:
IMPRESSION:
1. Status post liver transplant with interval decrease in size
of
the necrotic left lobe infarction. A percutaneous drain is in
unchanged position.
2. Mild right intrahepatic biliary ductal dilatation, with
stable
positioning of an internal external right hepatic biliary drain.
3. Grossly stable 3.8 cm fluid collection in hepatic segment 6.
4. New subcentimeter hypodensities in hepatic segment ___ are
too
small to characterize and while there is no surrounding
enhancement or edema developing abscesses cannot be excluded.
5. Splenomegaly with stable splenic infarcts status post splenic
artery embolization.
6. Trace perihepatic ascites.
Discharge PE:
-Underwent ___ PTBD exchange
-CT A/P revealed unchanged splenic collection, ___ without intent
to manipulate drain given ongoing drainage
-ID recs dapto/cefe for discharge and f/u in OPAT
-Pain well controlled, tolerating regular diet, would like to be
discharged home
PHYSICAL EXAMINATION:
24 HR Data (last updated ___ @ 2337)
Temp: 98.2 (Tm 98.2), BP: 134/77 (123-135/75-83), HR: 82
(74-86), RR: 18 (___), O2 sat: 98% (98-99), O2 delivery: Ra,
Wt: 177.9 lb/80.7 kg
Fluid Balance (last updated ___ @ 2302)
Last 8 hours Total cumulative -748ml
IN: Total 232ml, PO Amt 120ml, IV Amt Infused 112ml
OUT: Total 980ml, Urine Amt 900ml, Abscess 10ml, PTBD 65ml,
splenic drain 5ml
Last 24 hours Total cumulative -1039ml
IN: Total 1448ml, PO Amt 1160ml, IV Amt Infused 288ml
OUT: Total 2487ml, Urine Amt ___, Abscess 35ml, PTBD
365ml, splenic drain 12ml
GENERAL: [x ]NAD [ x]A/O x 3 [ ]intubated/sedated [ ]abnormal
CARDIAC: [x ]RRR [ ]no MRG [ ]Nl S1S2 [ ]abnormal
LUNGS: [ ]CTA b/l [x ]no respiratory distress [ ]abnormal
ABDOMEN: [ ]NBS [x ]soft [x ]Nontender [ ]appropriately
tender
[ x]nondistended [ ]no rebound/guarding [ ]abnormal
WOUND: [ x]CD&I [ ]no erythema/induration [x ]JP with dark
bilious drainage, PTBD with bilious drainage, splenic drain with
serosanguineous drainge [ ]abnormal
EXTREMITIES: [ x]no CCE [ ]Pulse [ ]abnormal
LABS
___ 05:39AM BLOOD WBC: 3.5* RBC: 3.18* Hgb: 8.6* Hct: 28.4*
MCV: 89 MCH: 27.0 MCHC: 30.3* RDW: 16.5* RDWSD: 53.6* Plt Ct:
158
___ 05:39AM BLOOD ___: 15.4* PTT: 43.0* ___: 1.4*
___ 05:39AM BLOOD Glucose: 95 UreaN: 6 Creat: 0.5 Na: 131*
K: 4.7 Cl: 98 HCO3: 21* AnGap: 12
___ 05:39AM BLOOD ALT: 7 AST: 16 AlkPhos: 1162* TotBili:
0.9
___ 05:39AM BLOOD Calcium: 8.0* Phos: 2.9 Mg: 1.8
___ 05:39AM BLOOD tacroFK: 5.4
Pertinent Results:
___ CTA Abd and Pelvis
1. Interval placement of percutaneous drain within the
collection in the
posterior spleen. Probable 4.1 cm laceration at the inferior
tip of the
spleen with associated foci of active contrast consolidation,
and large
subcapsular hematoma tracking inferiorly to the pelvis. The
drained
collection appears slightly smaller.
2. Increased size of A heterogeneous rim enhancing lesion in the
right liver segment ___, concerning for developing hepatic
abscess. Mildly increased prominence of small hypoattenuating
lesions in segment 7. Otherwise decreased size of collections
within the liver.
3. Status post hepatic transplant with multiple drains and
interventions as described above.
___ CT AP
1. Slight decrease in the size of the left lobe of liver
collection with a
drain in situ.
2. Similar appearance of the segment VII/VIII and segment VI
liver
collections.
3. Similar size of the splenic collection with slight reduction
in the size of the overlying hematoma.
4. Unchanged moderate volume ascites but with overall decrease
in the
hyperdense blood products.
5. Unchanged nonocclusive eccentric thrombus in the distal
splenic vein.
___ paracentesis
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 0.52 L of fluid were removed and sent for analysis.
___ paracentesis
1. Multiloculated ascites fluid.
2. Total of 1.5 L aspirated from multiple loculations in the
right lower
quadrant and midline.
3. Specimen sent for microbiology and hematology.
___ 03:55PM BLOOD WBC-2.4* RBC-3.34* Hgb-9.2* Hct-30.3*
MCV-91 MCH-27.5 MCHC-30.4* RDW-17.2* RDWSD-57.1* Plt ___
___ 06:34AM BLOOD WBC-1.3* RBC-3.06* Hgb-8.5* Hct-27.3*
MCV-89 MCH-27.8 MCHC-31.1* RDW-17.1* RDWSD-55.4* Plt Ct-48*
___ 01:42AM BLOOD WBC-10.1* RBC-2.49* Hgb-6.8* Hct-22.2*
MCV-89 MCH-27.3 MCHC-30.6* RDW-17.2* RDWSD-56.1* Plt ___
___ 05:12AM BLOOD WBC-13.9* RBC-3.45* Hgb-9.6* Hct-30.6*
MCV-89 MCH-27.8 MCHC-31.4* RDW-15.5 RDWSD-50.5* Plt ___
___ 04:58AM BLOOD WBC-5.5 RBC-3.70* Hgb-9.8* Hct-33.0*
MCV-89 MCH-26.5 MCHC-29.7* RDW-16.6* RDWSD-54.0* Plt ___
___ 06:45AM BLOOD ___ PTT-34.4 ___
___ 05:03AM BLOOD ___ PTT-36.9* ___
___ 04:20PM BLOOD ___ PTT-52.0* ___
___ 04:58AM BLOOD ___ PTT-29.7 ___
___ 03:55PM BLOOD Glucose-248* UreaN-33* Creat-1.1 Na-130*
K-6.0* Cl-98 HCO3-20* AnGap-12
___ 04:58AM BLOOD Glucose-134* UreaN-6 Creat-0.6 Na-129*
K-5.1 Cl-95* HCO3-21* AnGap-13
___ 03:55PM BLOOD ALT-80* AST-65* AlkPhos-935* TotBili-1.0
___ 05:03AM BLOOD ALT-126* AST-161* AlkPhos-307*
TotBili-0.7
___ 04:27AM BLOOD ALT-122* AST-73* CK(CPK)-25* AlkPhos-935*
TotBili-1.4
___ 05:50AM BLOOD ALT-11 AST-11 CK(CPK)-12* AlkPhos-360*
TotBili-1.0
___ 05:57AM BLOOD ALT-5 AST-10 AlkPhos-733* TotBili-0.8
___ 04:58AM BLOOD ALT-7 AST-14 AlkPhos-1051* TotBili-0.9
___ 5:14 pm PERITONEAL FLUID
SPLENIC COLLECTION PERITONEAL FLUID SPLONIC COLLECTION #1.
ADDON FUNGAL CULTURE PER ___ ___.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ MD (___)
___ @ 13:12.
ENTEROCOCCUS SP.. SPARSE GROWTH.
Daptomycin AND Tigecycline Susceptibility testing
requested per
___ (___) ___.
LINEZOLID test result performed by ___.
Daptomycin MIC = 4 MCG/ML, test result performed by
Etest.
Tigecycline MIC OF 0.06 MCG/ML SUSCEPTIBILITY RESULTS
WERE
OBTAINED BY A PROCEDURE THAT HAS NOT BEEN STANDARDIZED
FOR THIS
ORGANISM. RESULTS MAY NOT BE RELIABLE AND MUST BE
INTERPRETED WITH
CAUTION.. Tigecycline test result performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- R
PENICILLIN G---------- 32 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 4:00 pm BLOOD CULTURE
**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-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON
___ -
___.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Gabapentin 100 mg PO QHS
5. Pantoprazole 40 mg PO Q12H
6. PredniSONE 5 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. ValGANCIclovir 900 mg PO Q24H
9. Ciprofloxacin HCl 500 mg PO Q12H
10. Multivitamins W/minerals Chewable 1 TAB PO DAILY
11. OLANZapine 2.5 mg PO QHS
12. Thiamine 200 mg PO DAILY
13. Ursodiol 300 mg PO BID
14. HydrOXYzine 25 mg PO Q8H:PRN pruritus
15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
16. tedizolid ___ mg oral DAILY
17. Fluconazole 400 mg PO Q24H
18. Psyllium Powder 1 PKT PO BID
19. Benzonatate 100 mg PO TID
20. Tacrolimus 2.5 mg PO Q12H
21. Detemir 75 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
22. Enoxaparin Sodium 100 mg SC BID
Discharge Medications:
1. CefePIME 2 g IV Q12H
give via PICC line
2. Daptomycin 900 mg IV Q24H
3. Docusate Sodium 100 mg PO BID
4. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third
Line
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Acetaminophen 500 mg PO Q6H
7. Benzonatate 100 mg PO BID:PRN cough
8. Levemir 27 Units Bedtime
Novolog 7 Units Breakfast
Novolog 7 Units Lunch
Novolog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Psyllium Powder 1 PKT PO BID:PRN constipation
10. Tacrolimus 4 mg PO Q12H
next Lab draw ___. ValGANCIclovir 900 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Clopidogrel 75 mg PO DAILY
14. Enoxaparin Sodium 100 mg SC BID
15. Fluconazole 400 mg PO Q24H
16. Gabapentin 100 mg PO QHS
17. OLANZapine 2.5 mg PO QHS
18. Pantoprazole 40 mg PO Q12H
19. PredniSONE 5 mg PO DAILY
20. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
21. Ursodiol 300 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
h/o liver transplant c/b HAT
splenic abscess
bacteremia/sepsis (Ecoli and VRE)
___ pseudoaneurysm
hepatic abscess growing VRE
peritoneal collection, VRE
malnutrition
DM
anemia
insomnia
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 s/p DDLT w/roux-en-Y hepaticojejunostomy (___) c/b
hepatic artery thrombosis, sepsisNO_PO contrast// Abscess, colitis, other
intraabdominal pathology
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 6.9 s, 54.1 cm; CTDIvol = 18.1 mGy (Body) DLP = 977.6
mGy-cm.
Total DLP (Body) = 993 mGy-cm.
COMPARISON: CT from ___ and ___ and MR from ___
FINDINGS:
LOWER CHEST: There is minimal atelectasis at the right lung base. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The patient is status post hepatic transplant. Compared to the
prior study there has been interval decrease in size of the area of necrosis
in the left hepatic lobe which measures 9.4 x 7.4, previously 10.4 x 8.4 cm
(2; 18). A percutaneous drain is seen within the necrotic collection. A
hypoattenuating area is again seen in hepatic segment 6 which measures 3.8 x 3
cm, previously 4.1 x 2.8 cm (2; 31). A second peripheral area of infarction
in hepatic segment 6 has improved compared to the prior exam from ___
(2; 29).
There is mild right intrahepatic biliary dilation, similar to prior. 2
subcentimeter hypodensities are seen in hepatic segment ___, new compared to
prior and in close association with a dilated intrahepatic biliary duct ___
39, 40). There is no surrounding edema or enhancement.
An internal external biliary drain extends through the right hepatic lobe
terminating in the hepaticojejunostomy. A small catheter is seen coursing
beneath the right hepatic lobe and coiling within the hepaticojejunostomy.
Multiple surgical clips are seen at the porta hepatis. The gallbladder is
surgically absent.
Common hepatic artery and left hepatic artery stents are again seen. Numerous
embolization coils are seen in the upper abdomen consistent with prior splenic
artery embolization.
The left portal vein is not visualized consistent with thrombosis. The main
portal vein and SMV are patent though with areas of chronic nonocclusive
thrombus in the main portal vein, unchanged. Again seen is partial thrombosis
of the splenic vein (2; 32).
There is trace perihepatic ascites surrounding the subdiaphragmatic IVC.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring 20.5 cm. Again seen are multiple
peripheral areas of hypoenhancement consistent with infarction, the largest
measures 9.2 x 8 cm, previously 9.6 x 7.2 cm (2; 31).
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. A 3.8 cm cyst
arises from the lower pole of the left kidney. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. The patient is status post
hepaticojejunostomy. The small bowel small bowel anastomosis is unremarkable.
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. Diverticulosis of the sigmoid colon is noted, without evidence of
wall thickening or fat stranding. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: Multiple small retroperitoneal lymph nodes are noted which do not
meet the CT size criteria for lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is a L1 superior endplate deformity, similar to prior.
SOFT TISSUES: Foci of subcutaneous soft tissue stranding are likely the
sequelae of prior injections.
IMPRESSION:
1. Status post liver transplant with interval decrease in size of the necrotic
left lobe infarction. A percutaneous drain is in unchanged position.
2. Mild right intrahepatic biliary ductal dilatation, with stable positioning
of an internal external right hepatic biliary drain.
3. Grossly stable 3.8 cm fluid collection in hepatic segment 6.
4. New subcentimeter hypodensities in hepatic segment ___ are too small to
characterize and while there is no surrounding enhancement or edema developing
abscesses cannot be excluded.
5. Splenomegaly with stable splenic infarcts status post splenic artery
embolization.
6. Trace perihepatic ascites.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with cough, immunosuppressed// Pneumonia?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
Lungs are clear without focal consolidation, pleural effusion, or
pneumothorax. Mediastinal and hilar contours within normal limits. Heart
size is normal. No acute osseous abnormality is seen.
Embolization coils overlie the left upper quadrant. A percutaneous drain is
seen projecting over the right upper quadrant. A second more inferior
catheter is partially visualized projecting over the right upper quadrant.
Compared to the prior chest radiograph there has been interval removal of a
left PICC line and an enteric tube.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p DDLT c/b HAT, infected biloma, VRE bacteremia recently
discharged presenting with nausea/vomiting x1, low grade temps and new GNR
bacteremia// new onset SOB, chills, rigors, please eval for pulmonary etiology
of chills and SOB
TECHNIQUE: Portable frontal chest radiograph.
COMPARISON: Multiple prior chest radiographs, most recent dated ___.
FINDINGS:
Compared to the prior study from ___, the lungs are similarly well
inflated. There is no change to the cardiomediastinal silhouette. There is
no new focal opacity, pleural effusion or pneumothorax.
IMPRESSION:
No radiographic evidence of pneumonia.
Radiology Report
EXAMINATION: Ultrasound-guided splenic collection drainage.
INDICATION: ___ year old man with ___ s/p DDLT c/b HAT, infected biloma, VRE
bacteremia recently discharged presenting with nausea/vomiting x1, low grade
temps and new GNR bacteremia// PLEASE ASPIRATE SPLEEN Abscess and send for
gram stain and culture
COMPARISON: CT abdomen from ___.
PROCEDURE: Ultrasound-guided drainage of splenic collection.
OPERATORS: Dr. ___, radiology trainee and Dr. ___,
___, attending radiologist. Dr. ___ personally
supervised the trainee during the key components of the procedure and reviewed
and agree with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on the
ultrasound findings an appropriate skin entry site for the drain placement was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the collection. A sample of fluid was
aspirated, confirming catheter position within the collection. The pigtail was
deployed. The position of the pigtail was confirmed within the collection via
ultrasound.
Approximately 95 cc of purulent fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to suction bulb. 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 37
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited left upper quadrant ultrasound demonstrated an anechoic splenic
collection measuring 5.6 x 6.7 x 5.1 cm, targeted for ultrasound-guided
drainage as detailed above.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the
collection. 95ml of purulent fluid drained. Sample was sent for microbiology
evaluation.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ s/p DDLT c/b HAT, infected biloma, VRE bacteremia recently
discharged presenting with nausea/vomiting x1, low grade temps and persistent
GNR bacteremia s/p rij cvl placement// Eval RIJ placement Contact name:
___: ___
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Lungs are low volume. Right IJ line projects over the right atrium.
Cardiomediastinal silhouette is stable. No pneumothorax
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ s/p DDLT c/b HAT, infected biloma, VRE bacteremia septic
shock s/p ___ drainage of splenic collection now with 10pt hct drop, on
pressors// active bleeding, possible source spleen after ___ drainage yesterday
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 7.3 s, 57.6 cm; CTDIvol = 7.6 mGy (Body) DLP = 438.6
mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP =
9.1 mGy-cm.
3) Spiral Acquisition 7.3 s, 57.7 cm; CTDIvol = 17.5 mGy (Body) DLP =
1,009.5 mGy-cm.
4) Spiral Acquisition 7.3 s, 57.8 cm; CTDIvol = 17.5 mGy (Body) DLP =
1,012.6 mGy-cm.
Total DLP (Body) = 2,470 mGy-cm.
COMPARISON: ___.
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions with adjacent
compressive atelectasis. There is minimal pericardial fluid. Probable central
line terminating in the right atrium.
ABDOMEN:
HEPATOBILIARY: Redemonstrated are postsurgical changes of hepatic transplant.
Again seen is A percutaneous external internal biliary drain terminating in
the hepaticojejunostomy. Again seen are hepatic artery and Left hepatic
artery vascular stents. There are multiple metallic radiodensities again seen
in the gastrohepatic region consistent with embolization with associated
metallic artifact which obscures the adjacent structures. Small percutaneous
catheter again seen curling within the hepaticojejunostomy.
Similar mild right hepatic biliary ductal dilatation. Increasing prominence
of heterogeneous rim enhancing lesion in the segment ___, now measuring 3.1
cm, series 5 image 23. Small hypoattenuating lesions in segment 7, series 5,
image 43 may be slightly more prominent on prior. The rim enhancing
collection in segment 6 has decreased in size to 2.6 cm, previously 3.8 cm.
Percutaneous drain terminating in Left hepatic heterogeneous necrotic
collection is again seen, with mildly decreased size of the collection,
measuring 8.1 cm, previously 9.4 cm. Gallbladder is absent.
PANCREAS: Suboptimally evaluated due to metallic artifact. No large Mass or
area of hypoenhancement..
SPLEEN: There is a percutaneous drain within the collection in the posterior
spleen which now measures 8.7 x 7.2 cm, previously 9.2 x 8.0 cm. However
there is now large hyper dense subcapsular hematoma, with small foci of
arterial extravasation, series 5, image 83, concerning for active bleed.
There appears to be 4.0 cm area of hypoattenuation at the inferior splenic tip
concerning for laceration, series 601, image 78. The hematoma tracks
inferiorly along the pericolic gutter to the pelvis. Again is seen
splenomegaly with multiple splenic infarcts.
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, solid renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. Again seen is an
exophytic cyst off the inferior pole of the Left Kidney. There is no
perinephric abnormality.
GASTROINTESTINAL: Stomach is largely obscured by metallic artifact. Small
bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. Diverticulosis of the sigmoid colon is noted, without evidence of
wall thickening or fat stranding. The appendix is surgically absent.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is moderate size
hemoperitoneum.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Unchanged compression deformity of L1.
SOFT TISSUES: Multiple hyperdense foci in the subcutaneous tissues of the
abdominal wall, likely injection sites. There is anasarca.
IMPRESSION:
1. Interval placement of percutaneous drain within the collection in the
posterior spleen. Probable 4.1 cm laceration at the inferior tip of the
spleen with associated foci of active contrast consolidation, and large
subcapsular hematoma tracking inferiorly to the pelvis. The drained
collection appears slightly smaller.
2. Increased size of A heterogeneous rim enhancing lesion in the right liver
segment ___, concerning for developing hepatic abscess. Mildly increased
prominence of small hypoattenuating lesions in segment 7. Otherwise decreased
size of collections within the liver.
3. Status post hepatic transplant with multiple drains and interventions as
described above.
Radiology Report
INDICATION: ___ s/p DDLT c/b HAT, infected biloma, VRE bacteremia septic
shock s/p ___ drainage of splenic collection now with 10pt hct drop, on
pressors with CTA showing active extravasation from spleen// active
extravasation from spleen, please consult for embolization
COMPARISON: CTA abdomen and pelvis ___.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___ fellow performed the procedure. Dr. ___
___ supervised the trainee during any key components of the procedure
where applicable and reviewed and agrees with the findings as reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 1 hour and 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: 4000 units thrombin. 0.5 mL histoacryl
CONTRAST: 40 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 5.7, 172 mGy
PROCEDURE:
1. Ultrasound-guided right common femoral artery access.
2. Catheterization of the celiac trunk with arteriogram.
3. Ultrasound-guided percutaneous needle access into perisplenic
pseudoaneurysm.
4. Repeat celiac trunk arteriogram demonstrating percutaneous needle access
within splenic pseudoaneurysm.
5. Embolization splenic pseudoaneurysm using 4000 units thrombin and 0.5 mL
Histoacryl glue from the percutaneous needle access under direct ultrasound
visualization.
6. Post embolization celiac arteriogram demonstrating occlusion of
pseudoaneurysm.
7. Right groin arteriotomy closure using Mynx device.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right groin and left abdomen were prepped and draped in the
usual sterile fashion.
Using ultrasound and fluoroscopic guidance, the right common femoral artery
was punctured using a micropuncture needle at the mid femoral head. A 0.018
wire was passed easily into the vessel lumen. A small skin ___ was made over
the needle. The needle was then removed and the micropuncture sheath was
inserted. The inner dilator and wire were removed and ___ wire was
placed into the abdominal aorta. The micropuncture sheath was removed and a 5
___ sheath was placed into the right common femoral artery. At that timed,
a ___ catheter was advanced over the wire into the abdominal aorta. The
___ wire was removed and the catheter was formed. The celiac trunk was
catheterized and a celiac arteriogram was performed.
Celiac arteriogram demonstrated perisplenic pseudoaneurysm that was previously
visualized on same-day CTA.
At that time, ultrasound of the left upper quadrant was performed and the
perisplenic pseudoaneurysm was identified under ultrasound. A 22 gauge spinal
needle was advanced under direct ultrasound visualization into the perisplenic
pseudoaneurysm. Small amount of blood return was noted. A repeat celiac
arteriogram from the ___ catheter was performed which demonstrated
position of the percutaneous spinal needle inferior to the perisplenic
pseudoaneurysm.
Next a second 22 gauge spinal needle was advanced into the perisplenic
pseudoaneurysm slightly superior to the previously inserted spinal needle.
Embolization was performed with a percutaneous injection of 4000 units of
thrombin into the pseudoaneurysm under direct ultrasound visualization (3000
units in the superior needle and 1000 units in the inferior needle).
A post embolization celiac arteriogram was performed. No evidence of
pseudoaneurysm or extravasation.
An ultrasound of the pseudoaneurysm demonstrated near complete occlusion of
the pseudoaneurysm after thrombin injection. Final embolization of the
pseudoaneurysm was performed with an injection of 0.5 mL Histoacryl glue
directly into the pseudoaneurysm. After injection of glue, no blood return
was noted from the pseudoaneurysm.
The percutaneous needles were removed and sterile dressings were applied.
The ___ catheter was disengaged from the celiac trunk and removed. A
Mynx closure device was used for right groin sheath removal and hemostasis
from the arteriotomy. Postprocedure, the patient had 2+ right femoral, DP,
and ___ pulses. No evidence of hematoma in the right groin. A sterile
dressing was applied. The patient was transferred back to the floor in stable
condition.
For reporting clarification, diagnostic arteriograms were medically necessary
to evaluate for anatomy, abnormal vasculature, and the presence or absence of
active bleeding, pseudoaneurysms, and or arteriovenous fistula.
FINDINGS:
1. Initial celiac arteriogram demonstrating arterial flow in the small
perisplenic pseudoaneurysm. Celiac arteriogram also demonstrated flow through
the hepatic stents. Formal angiography and investigation of the a patent
stents was not performed.
2. Ultrasound of the left upper quadrant demonstrating an approximately 1 cm
perisplenic pseudoaneurysm. Significant perisplenic hematoma.
3. Satisfactory placement of 4000 units thrombin within the perisplenic
pseudoaneurysm under direct ultrasound visualization.
4. Post thrombin injection celiac arteriogram demonstrating no evidence of
perisplenic pseudoaneurysm by angiography.
5. Post thrombin injection ultrasound of the pseudoaneurysm demonstrates a
questionable area of recurrent bleeding. 0.5 mL of Histoacryl glue was
injected into the remaining pseudoaneurysm.
IMPRESSION:
Successful percutaneous embolization of perisplenic pseudoaneurysm using
thrombin and histoacryl glue.
Radiology Report
INDICATION: ___ year old man with bloating abdomen s/p spleen pseudoaneurysm
embolization by ___ this am// ___ year old man with bloating abdomen s/p spleen
pseudoaneurysm embolization by ___ this am
TECHNIQUE: Single-view portable AP abdominal radiograph
COMPARISON: Most recent CT abdomen pelvis dated ___
FINDINGS:
Multiple surgical clips are seen in the right upper abdomen in keeping with
known history of liver transplantation with Roux-en-Y hepaticojejunostomy.
Air-filled nondilated small bowel loops throughout. A Foley catheter balloon
is seen within the lower pelvis. No pneumoperitoneum.
There is a percutaneous transhepatic biliary drain which presumably terminates
within the Roux limb of the duodenum. A second larger percutaneous drain
terminates within the region of the left lobe of the liver. There is a
non-kinked stent within the hepatic artery. There is evidence of coil
embolization of the known splenic artery pseudoaneurysm. Additionally there
is a percutaneously placed drain within the abdomen in the region of the
spleen.
On this non-dedicated exam, no acute osseous injury. Moderate degenerative
disease of bilateral hip joints.
IMPRESSION:
Status post liver transplantation with Roux-en-Y hepaticojejunostomy with
evidence of prior splenic pseudoaneurysm embolization, hepatic artery
stenting, PTBD placement, liver and splenic drainage.
No abnormal bowel distension or discrete evidence of bowel obstruction.
Air-filled small and large bowel loops may represent ileus.
Radiology Report
INDICATION: ___ year old man ___ s/p DDLT s/p (roux-en-Y HJ and surgical PV
thrombectomy, subsequent HAT and stents, left lobe biloma s/p drain placement,
R biliary drain, s/p debridement and left ___ multi-sidehole drain, Rt ___
right PTBD// cholangiogram, debridement
COMPARISON: Biliary drain check change ___
TECHNIQUE: OPERATORS: Dr. ___, attending Interventional
Radiologist performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 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: None
CONTRAST: 10 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 2.3 minutes, 40 mGy
PROCEDURE:
1. Exchange of the existing 16 ___ percutaneous hepatic abscess drainage
catheter for a 14 ___ APDL.
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.
A scout image of the abdomen was obtained. Contrast was injected through the
existing 16 ___ biliary drain within the left hepatic lobe abscess. The
hub was cut. A ___ wire was advanced through the drain and coiled within
the collection. The drain was removed over the wire. A new 14 ___
modified APDL (2 additional side holes were placed) was advanced over the
wire. The pigtail was formed within the cavity. Suture and a StatLock were
used to secure the catheter. Sterile dressings were applied.
FINDINGS:
Initial radiograph demonstrated proper positioning of the existing 16 ___
catheter. The catheter was patent upon injection with dilute contrast.
Successful exchange for a new 14 ___ modified APDL catheter with additional
sideholes.
IMPRESSION:
Successful exchange and downsize of a percutaneous left hepatic lobe abscess
drainage catheter.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R IJ TLC, nurse pulled 2 inch out
accidentally comment on position// central line position
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The central line has been withdrawn, the tip projecting over the upper SVC.
The proximal portion of the line is looped overlying the right neck.
There are low bilateral lung volumes. Left basilar atelectasis is present.
No pleural effusion or pneumothorax. The size of the cardiac silhouette is
mildly enlarged but unchanged. Multiple drains and embolization coils project
over the upper abdomen.
IMPRESSION:
The right central line has been withdrawn, the tip now projecting over the
upper SVC.
Radiology Report
INDICATION: ___ year old man with new R PICC// 49 cm (out 2 cm) SL R basilic
PICC- ___ ___ Contact name: ___: ___
COMPARISON: Radiographs from ___
IMPRESSION:
The looped central line within the right IJ has been removed. There has been
placement of a new right-sided PICC line whose distal tip projects over the
mid right atrium. This could be pulled back 3-4 cm to be at the cavoatrial
junction. There are low lung volumes. Pigtail catheter and embolization
coils project over the upper abdomen. There are no pneumothoraces.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia
recently discharged presenting with nausea/vomiting x1, low grade temps and
persistent GNR bacteremia, splenic bleed s/p percutaneous embolization of
splenic PSA// please assess intraabdominal collection compared to prior
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 58.2 cm; CTDIvol = 17.6 mGy (Body) DLP =
1,023.8 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 8.4 s, 0.5 cm; CTDIvol = 47.0 mGy (Body) DLP =
23.5 mGy-cm.
Total DLP (Body) = 1,049 mGy-cm.
COMPARISON: CT abdomen and pelvis from ___
FINDINGS:
LOWER CHEST: Small left pleural effusion with mild adjacent atelectasis.
ABDOMEN:
HEPATOBILIARY: There are postsurgical changes from liver transplant. Large
percutaneous drainage catheter within the left lobe of the liver with slight
decrease in size of the gas and fluid collection compared to prior imaging,
now measuring 7.6 cm maximally, previously 8.1 cm. Further small
hypoenhancing lesion in the superior aspect of the right lobe of the liver
measuring 3.2 x 2.5 cm which is not significantly changed when compared to the
prior study and likely represents small fluid collection. No significant
change in the peripheral segment VI fluid collection measuring approximately
2.8 cm. Right-sided external internal biliary drainage catheter in situ.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation.
SPLEEN: Unchanged splenomegaly. Percutaneous drainage catheter within a
hypodense region within the spleen which appears similar in size when compared
to the prior study. There is hematoma overlying the lateral aspect of the
splenic extending inferiorly. This is slightly decreased when compared to the
prior study. No evidence of active bleeding on the current study. Extensive
splenic artery coiling noted.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Unchanged left lower pole renal cyst. There is no evidence of solid 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. Sigmoid
diverticulosis with no evidence of diverticulitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. Moderate
volume ascites in the abdomen or pelvis is similar in size compared to the
prior study with overall decreased hyperdense blood products.
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. Stents noted within the common and proper hepatic arteries.
Eccentric thrombus in the distal splenic vein is slightly decreased.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Unchanged mild superior endplate compression deformity of L1.
SOFT TISSUES: There are postsurgical changes in the anterior abdominal wall.
There are subcutaneous injections in the anterior abdominal wall. Mild
anasarca in the subcutaneous soft tissues is noted.
IMPRESSION:
1. Slight decrease in the size of the left lobe of liver collection with a
drain in situ.
2. Similar appearance of the segment VII/VIII and segment VI liver
collections.
3. Similar size of the splenic collection with slight reduction in the size of
the overlying hematoma.
4. Unchanged moderate volume ascites but with overall decrease in the
hyperdense blood products.
5. Unchanged nonocclusive eccentric thrombus in the distal splenic vein.
Radiology Report
EXAMINATION: Ultrasound-guided diagnostic and therapeutic paracentesis.
INDICATION: ___ s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia
recently discharged presenting with nausea/vomiting x1, low grade temps and
persistent GNR bacteremia, splenic bleed s/p percutaneous embolization of
splenic PSA// Please obtain an US guided paracentesis.
TECHNIQUE: Ultrasound-guided diagnostic and therapeutic paracentesis.
COMPARISON: CT of the abdomen pelvis from ___.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic and therapeutic paracentesis
Location: right lower quadrant
Fluid: 0.52 L of grossly bloody fluid
Samples: Fluid samples were submitted to the laboratory for the requested
analysis (chemistry, hematology).
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 0.52 L of fluid were removed and sent for analysis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia
recently discharged presenting with nausea/vomiting x1, low grade temps and
persistent GNR bacteremia, splenic bleed s/p percutaneous embolization of
splenic PSA W sob// assess for pulmonary edema, effusion
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes
that accentuate the prominence of the transverse diameter heart. No pneumonia
or vascular congestion. Opacification in the retrocardiac region is
consistent with volume loss in left lobe probable small effusion.
Radiology Report
INDICATION: ___ year old man with evaluate splenic drain// please evaluate
splenic drain
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis ___. Abdominal radiographs ___.
IMPRESSION:
There are two pigtail catheters and a percutaneous drain in the right upper
quadrant of the abdomen and a pigtail catheter in the left upper quadrant/mid
abdomen. Multiple surgical clips, stents and embolization coils are seen in
the upper abdomen. There are no abnormally dilated loops of large or small
bowel. There is no free intraperitoneal air. Osseous structures are
unremarkable.
Radiology Report
INDICATION: ___ s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia
recently discharged presenting with nausea/vomiting x1, low grade temps and
persistent GNR bacteremia, splenic bleed s/p percutaneous embolization of
splenic PSA// paracentesis for ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic and therapeutic paracentesis
Location: right lower quadrant
Fluid: 1.5 L of serosanguinous fluid
Samples: Hematology and microbiology
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket. The needle and catheter was redirected under continuous
guidance multiple times over a course of approximately 30 minutes to break
through and attempt aspiration of multiple loculations. At the completion of
the procedure there was no significant fluid pockets in the right lower
quadrant or midline.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
IMPRESSION:
1. Multiloculated ascites fluid.
2. Total of 1.5 L aspirated from multiple loculations in the right lower
quadrant and midline.
3. Specimen sent for microbiology and hematology.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST ___
INDICATION: ___ year old man with DDLT w RNY HJ c/b HAT, infected biloma, VRE
bacteremia recently discharged presenting with nausea/vomiting x1, low grade
temps and persistent GNR bacteremia, splenic bleed following drain placement
and s/p percutaneous embolization of splenic PSA// Please evaluate splenic
abscess for size (? decrease/increase/has stayed the same) in setting of drain
in place and continued antibiotics and also abdominal hematoma
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
with intravenous contrast and oral contrast. Sagittal and coronal
reformations were also performed.
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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 7.0 s, 1.0 cm; CTDIvol = 16.2 mGy (Body) DLP =
16.2 mGy-cm.
4) Stationary Acquisition 7.0 s, 1.0 cm; CTDIvol = 16.2 mGy (Body) DLP =
16.2 mGy-cm.
5) Spiral Acquisition 16.5 s, 56.8 cm; CTDIvol = 15.2 mGy (Body) DLP =
839.8 mGy-cm.
6) Spiral Acquisition 16.5 s, 56.8 cm; CTDIvol = 15.2 mGy (Body) DLP = 839.8
mGy-cm.
Total DLP (Body) = 1,742 mGy-cm.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
Left-sided pleural effusion has increased. It is incompletely imaged but now
appears approximately moderate in size. Visualized portion is probably
free-flowing and low in attenuation with increased associated atelectasis of
the basilar left lower lobe. Minor atelectasis at the right lung base.
Central venous catheter terminates at the cavoatrial junction.
Patient is status post liver transplant. Collection in segment VI (05:35)
with the thick wall measures 35 x 30 mm in axial ___, not significantly
changed, making a direct comparison. Small cluster of collections in the
eighth segment also shows no definite change. The whole left lobe is again
occupied by collection of air and fluid with marked volume loss. A pigtail
catheter terminating in the collection appears unchanged. This latter area of
abnormality again measures 75 mm. A right internal external biliary drain
appears unchanged. A very small percutaneous catheter has been removed.
Although not optimally depicted on this study, there again seems to be
narrowing of the hepatic artery to a substantial degree between two
preexisting hepatic arterial stents (05:35).
The pancreas is unremarkable though partly obscured by many embolization coils
in the upper abdomen, as seen previously. Each adrenal also appears normal.
Medium-size simple cyst found along the lower pole of the left kidney.
Kidney's are otherwise unremarkable.
A pigtail catheter again terminates in a posterior splenic collection with
persistent fluid as well as a few air bubbles in the vicinity of the catheter.
As measured on ___:31, the size of the splenic collection now measures up to 80
x 50 mm in axial ___, compared to 83 x 58 mm before, so there has been
a continued slight decrease.
However, areas of hemorrhagic ascites throughout the abdomen have now
organized into fairly extensive rim enhancing collections. The splenic drain
passes through a developing collection at the site of recent hemorrhage. At
the level where the drain crosses it, the collection previously was more
hyperdense and had measured 109 x 53 mm in axial ___, it now measures
up to 147 x 50 mm, although the more inferior component has decreased
somewhat.
Hematoma adjacent to the spleen and more generally hemorrhagic ascites fluid
shows evolution with decreased density and some shifting in location. The
overall quantity of fluid has mildly increased. However, even more striking
is the increasing organization into extensive rim enhancing collections in the
abdomen and pelvis. The largest discrete one is located in the upper pelvis
with extension along the right lower quadrant (5:81 and 07:27). This
component for example shows septations and hyperdense components measuring 145
x ___ x 66 mm in height with extension into the right lower quadrant. An area
in the left mid abdomen an earlier stage of organization (5:58 and 7:25)
measures up to 138 x 80 x ___ mm in height. These likely intercommunicate
with a number of smaller collections.
\\Medium to large simple cyst along the lower pole of the left kidney.
Kidney's otherwise appear normal.
Stomach is nondistended. Parts of the small and large bowel show mild wall
thickening which is probably secondary to peritoneal inflammation. Peritoneal
inflammation or edema is also likely to explain some increase in infiltrative
appearance of the omental fat. There is no free air. No bowel dilatation.
Prostate is borderline in size with central hypertrophy. Seminal vesicles and
bladder appear normal. Atherosclerotic change is mild. Aorta is normal in
caliber. No discrete lymphadenopathy.
There are no suspicious bone lesions.
IMPRESSION:
1. Minimal decrease in splenic abscess. Unchanged percutaneous drain.
2. Unchanged hepatic collections.
3. Persistent and even to some extent increased multifocal collections in the
abdomen and pelvis developing into widespread organized collections. These
could be seen with evolving hematomas. Possibility of superinfection is not
excluded. Correlation with clinical circumstances is recommended.
4. Narrowing of the hepatic artery between two existing stents.
5. Increased left pleural effusion, medium in size.
Radiology Report
EXAMINATION: CT-guided Procedure
INDICATION: ___ year old man with rim enhancing and loculated collections seen
on CT// Please drain ___ splenic and pelvic collections seen on CT from ___
COMPARISON: Prior abdominal CT from ___.
PROCEDURE: CT-guided drainage of perisplenic and pelvic collection.
OPERATORS: Dr. ___, radiology trainee 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 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. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. A maximum of 20 cc of sanguinous fluid was aspirated after
which the pigtail catheter was removed. Samples were sent for microbiology
evaluation.
Using intermittent CT fluoroscopic guidance, a 5 ___ ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. Unsuccessful attempt was made to
aspirate the Fluid through this Needle. After which, a 0.038 ___ wire was
placed through the needle and needle was removed. 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.
A maximum of 50 cc of serosanguineous fluid was aspirated with a sample sent
for microbiology evaluation. The pigtail catheter was removed.
Dressings were applied to both the incision sites.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 14.0 s, 42.7 cm; CTDIvol = 16.5 mGy (Body) DLP =
681.3 mGy-cm.
2) Stationary Acquisition 11.9 s, 1.4 cm; CTDIvol = 123.3 mGy (Body) DLP =
177.5 mGy-cm.
Total DLP (Body) = 875 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 4
mg Versed and 200 mcg fentanyl throughout the total intra-service time of 48
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Redemonstration of complex hemorrhagic collections surrounding the spleen and
within the pelvis.
These were aspirated to their greater extent and due to a sanguinous
appearance of the aspirated Fluid as opposed to frankly purulent, decision was
made not to the leave drains in place.
IMPRESSION:
Successful CT-guided aspiration of a perisplenic and pelvic hemorrhagic
collections. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia
recently discharged pw N/V x1, low grade temps persistent GNR bacteremia,
splenic abscess s/p ___ drain, splenic bleed s/p perc embo of PSA.// Assess
left leg for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Bilateral lower extremity Doppler ultrasound dated ___
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the left
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST ___
INDICATION: ___ s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia
recently discharged pw N/V x1, low grade temps persistent GNR bacteremia,
splenic abscess s/p ___ drain, splenic bleed s/p perc embo of PSA.// assess
splenic drain and collection. **note, patient is added on for ___ PTBD
interrogation- would be good to coordinate so patient does not miss call time
for ___ procedure ** IV contrast only
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
with intravenous contrast. Sagittal and coronal reformations were also
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 57.7 cm; CTDIvol = 16.9 mGy (Body) DLP = 974.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 8.4 s, 0.5 cm; CTDIvol = 47.0 mGy (Body) DLP =
23.5 mGy-cm.
Total DLP (Body) = 1,000 mGy-cm.
COMPARISON: Prior study from ___.
FINDINGS:
A small left-sided pleural effusion has decreased. This is again associated
with mild to moderate left basilar atelectasis. Trace barely detectable
pleural effusion on the right.
A rim enhancing collection in the sixth segment of the liver measures up to 29
x 30 mm in axial ___, compared to 35 x 30 mm before. A cluster of very
small collections in the eighth segment has also decreased slightly. Mild
intrahepatic biliary dilatation in the eighth segment appears unchanged.
Patient is status post liver transplant with hepaticojejunostomy. Right-sided
internal external biliary drain appears unchanged in position. Percutaneous
drain again terminates in a retracted liquified left lobe of the liver.
Associated heterogeneous collection containing ill-defined gas and fluid again
measures about 80 x 60 mm in axial ___ (as measured on 02:20), not
substantially changed. Hepatic artery stents are unchanged in position.
Despite lack of angiographic technique on this study there again seems to be
narrowing of the arterial flow immediately before entry into the more distal
stent.
Spleen is again enlarged. Pigtail catheter again terminates within liquified
collection associated with prior infarct. Due to irregular shape it is
difficult to measure but appears unchanged in size measuring up to 75 x 47 mm
in axial ___ (as measured on 02:34). This again seems to into freely
communicate with the collection along lateral to the inferior margin of the
spleen which can now be measured as up to 122 x 53 mm (02:46), compared to 150
x 56 mm before at a comparable location, somewhat decreased. Although not
well demonstrated this collection probably still intercommunicates with a
network of collections centered in the upper to mid pelvis and extending into
the right upper quadrant. This is again heterogeneous with septations and rim
enhancement. At the upper level of the upper pelvis this has decreased. For
example (as measured on 2:80), this part measures up to 122 x ___ mm, compared
to 133 x ___ mm before at a comparable location. Mid abdominal component to
the left of midline measures up to 139 x 85 mm (02:59), compared to 144 x 85
mm before, slightly decreased. Smaller components along the right-side of the
abdomen appear very similar. These include components associated with prior
hemorrhage in addition to small quantities of air that can probably be
explained by the presence of the drain.
Nonocclusive focal eccentric thrombus along the enlarged splenic vein shows no
change, partly obscured by streak artifact from numerous coils.
The pancreas appears normal. The adrenals appear normal. Medium-size simple
cyst again noted along the lower pole of the kidney.
Stomach is non-distended. Small bowel is unremarkable. Sigmoid
diverticulosis is moderate.
Prostate is borderline in size with central hypertrophy. Seminal vesicles and
latter appear normal. Atherosclerotic change is mild. There is no
lymphadenopathy.
There are no suspicious bone lesions. Mild superior endplate defect along the
superior margin of L1 is unchanged.
IMPRESSION:
Similar to decreased multifocal collections in the abdomen associated with
evolving hemorrhagic products. Similar to slightly decreased small
collections in the right lobe of the liver. Stable left lobe collection.
Unchanged drains. Concern for hepatic artery stenosis.
Radiology Report
INDICATION: ___ s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia
recently discharged pw N/V x1, low grade temps persistent GNR bacteremia,
splenic abscess s/p ___ drain, splenic bleed s/p perc embo of PSA.// PTBD
interrogation/exchange
COMPARISON: Images from prior procedure ___ and recent CT from ___
TECHNIQUE: OPERATORS: Dr. ___ attending, performed the procedure.
ANESTHESIA: Analgesia was provided by administrating divided doses of 50mcg of
fentanyl 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: As above
CONTRAST: 35 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 6.3 minutes, 107 mGy
PROCEDURE:
1. Cholangiogram through existing right percutaneous transhepatic biliary
drainage access.
2. Over-the-wire cholangiogram
3. Exchange of the existing right percutaneous transhepatic biliary drainage
catheter with a new 10 ___ PTBD catheter.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol.
The right 10 ___ internal-external biliary drain was prepped and draped.
Patient has multiple other drains, which were not evaluated on this study. An
initial spot fluoroscopic image was obtained demonstrating the drain in
appropriate position. Contrast injection through the drain demonstrated
filling of intrahepatic biliary ducts, and slow passage around the distal end
of the drain in pigtail into the Roux limb. The distal third of the drain
does not opacify with contrast, and appeared to be occluded.
Next, the drain was cut and a stiff Glidewire was advanced through the tube,
and with some difficulty through the pigtail. This was then coiled within the
Roux limb, and the drain was removed over the wire. A 6 ___ bright tip
sheath was placed, and an over-the-wire cholangiogram was performed. This
demonstrated free passage of contrast through the anastomosis.
Therefore, decision was made to replace the drain. A new 10 ___
internal-external biliary drain was advanced over the wire, and the pigtail
was formed within the Roux limb once the wire and inner catheter were removed.
Contrast injection confirmed good position of the intrahepatic portion of the
drain. Catheter was secured to the skin with suture and a StatLock device,
and attached to a bag for external drainage. Patient tolerated procedure
well, and was returned to the floor in stable condition.
FINDINGS:
1. Initial tube cholangiogram demonstrated occlusion of the distal third of
the internal-external drain, with slower contrast flow around the tube into
the Roux limb.
2. Over-the-wire cholangiogram demonstrated brisk antegrade flow through the
anastomosis. Limited evaluation of the intrahepatic ducts separate from the
anastomosis.
IMPRESSION:
Technically successful exchange of distally occluded right 10 ___ internal
external biliary drain for a new drain.
Radiology Report
INDICATION: ___ year old man with hepatic pigtail and splenic pigtail// Please
downsize hepatic pigtail and reposition splenic drain.
COMPARISON: CT abdomen and pelvis ___. Biliary catheter check
___. Biliary catheter check ___.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___ fellow performed the procedure. The
attending(s) personally supervised the trainee during any key components of
the procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Pain control using 100mcg of fentanyl 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: 100 mcg Fentanyl.
CONTRAST: 40 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 19.4 minutes, 132 mGy
PROCEDURE:
1. Sinogram of splenic abscess through old 8 ___ pigtail drain.
2. Removal of splenic abscess drain.
3. Fluoroscopic placement of a new 10 ___ multi side-hole biliary drain
into the perisplenic collection.
4. Sinogram left hepatic lobe collection through existing 14 ___ pigtail
drain.
5. Exchange of old 14 ___ pigtail drain in left hepatic lobe collection for
a new 10 ___ pigtail drain.
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.
A scout radiograph of the abdomen was performed.
A sinogram was performed through the existing 8 ___ pigtail drain in the
splenic collection. The end of the drain was cut and ___ wire was
advanced into the splenic collection. The drain was removed and a Kumpe
catheter was used in an attempt to access the known large perisplenic fluid
collection. Kumpe catheter was exchanged for a rim catheter and the ___
wire was exchanged for a Glidewire. There was difficulty accessing the
perisplenic collection so at that point under continuous ultrasound guidance
an 18 gauge needle was advanced into the perisplenic collection and a stiff
Amplatz wire was advanced into the collection. The needle was removed and the
track was dilated with a 10 ___ dilator. The dilator was removed and a 10
___ multi side-hole biliary catheter was advanced into the perisplenic
collection under fluoroscopic visualization. The inner dilator and wire were
removed and the drainage catheter pigtail was formed in the perisplenic
collection. The drain was attached to bulb suction drainage. The drain was
secured to the skin with 0 silk suture. A sterile dressing was applied. Old
blood from hematoma was drained.
At that time, we turned our attention to the left hepatic lobe collection
drain. A scout radiograph was performed. A sinogram of the left hepatic lobe
collection was performed with a hand injection of contrast. This was repeated
in multiple projections. It was determined that the size of the left hepatic
lobe collection has decreased so the end of the existing drain was cut and a
Amplatz wire was placed into the small left hepatic lobe collection. The
drain was removed. A new and down sized 10 ___ AP dL was advanced over the
wire into the left hepatic lobe collection. The wire and inner dilator were
removed and the catheter pigtail was formed in the collection. Final sinogram
through new drain was performed. Bulb drainage was attached. The drain was
secured to the skin with 0 silk suture.
Sterile dressings were applied. The patient tolerated the procedure well and
there were no immediate complications.
FINDINGS:
1. sinogram through the existing splenic drain demonstrates small residual
splenic cavity. This appears to communicate to a larger perisplenic fluid
collection. The old splenic drain was removed and a new drain was placed in
the larger perisplenic collection in satisfactory positioning.
2. Sinogram through existing left hepatic lobe collection drain demonstrates
decreased size of left hepatic lobe collection. There is also noted to be
small tract communications between the left hepatic lobe collection and the
biliary tree. Contrast injected into the left hepatic lobe collection was
seen draining through the existing right-sided PTB D into the bowel.
3. Based on the decreased size of the left hepatic lobe collection, the
existing 14 ___ pigtail drain was exchanged for a smaller 10 ___ pigtail
drain to promote continued size decrease of the collection.
IMPRESSION:
-Successful exchange of splenic drain for a new perisplenic fluid collection
drain.
-Successful exchange and downsize of left hepatic lobe collection drain.
Gender: M
Race: WHITE - BRAZILIAN
Arrive by WALK IN
Chief complaint: Hyperkalemia, Positive blood cultures
Diagnosed with Bacteremia, Altered mental status, unspecified, Unspecified abdominal pain
temperature: 99.1
heartrate: 105.0
resprate: 20.0
o2sat: 99.0
sbp: 117.0
dbp: 71.0
level of pain: 4
level of acuity: 2.0 | ___ male with HCV cirrhosis and HCC, s/p DDLT
w/roux-en-Y hepaticojejunostomy (___) c/b hepatic artery
thrombosis, sepsis, persistent VRE bacteremia, malnutrition, s/p
stenting of hepatic artery, coiling the splenic artery and
drainage of biloma. He was admitted to the hospital for
bacteremia and started on broad spectrum antibiotics. He was
persistently bacteremic despite his antibiotics.
On ___ ___ drained his splenic collection, with purulent
output, and placed a drain. After the procedure he was
hypotensive to systolic pressure of ___, resuscitated, and
transferred to the SICU for closer monitoring. In the SICU he
required transfusions for persistently dropping hematocrit and
was intermittently on low dose pressers. CTA showed active
splenic arterial bleed with new perisplenic hematoma, and he
underwent ___ embolization of his splenic pseudoaneurysm on ___.
Since the embolization he maintained hemodynamics without
further transfusion requirements and was transferred to the
floor in stable condition.
Transplant infectious disease continued to follow his course,
cultures, and microbiology and adjusted his antibiotics as
necessary. He was transitioned to Daptomycin, ceftaroline,
cipro, and flagyl. His last positive blood culture was on
___. He had a PICC placed on ___ in preparation for
discharge on IV antibiotics. He underwent CT scan on ___ to
assess his collections - left hepatic lobe collection and
perisplenic collections were decreased in size, other
collections stable. He had since underwent two diagnostic
paracentesis ___ and ___ without any growth. On ___ underwent
CT-guided drainage of his perisplenic and pelvic collection. His
perisplenic cultures grew Enterococcus resistant to vancomycin,
ampicillin, or penicillin, sensitive to daptomycin, but pelvic
collection did not grow anything. Infectious disease narrowed
his antibiotic regimen to daptomycin and cefepime, which he will
be discharged on. Repeat CT scan on ___ showed similar to
decreased multifocal collections in the abdomen associated
withevolving hemorrhagic products. Similar to slightly
decreased small collections in the right lobe of the liver.
Stable left lobe collection.
Unchanged drains. Concern for hepatic artery stenosis. He then
had the PTBD exchanged for decreased output. LFTs were notable
for rising alk phos up to 1162 that decreased to 1061 the next
day. On ___, ___ exchanged the left hepatic drain for a smaller
drain (___) and exchanged the splenic drain for lack of output
for 3 days. Postop procedure, vital signs were stable. The
splenic drainage was increased and appeared dark with a old
blood color.
Due to history of malnutrition, he was evaluated by nutrition
who reported he meets about 80% of his nutritional goals, with
low threshold of tube feeds. He was encouraged to take in more
supplements.
The patient requested to be discharged to home on ___ in order
to be present at a meeting at home on ___. Arrangements were
made with ___ and ___ Infusion met with him and planned
for antibiotic supplies to be delivered to his home in pm of
___ with a ___ visit on ___ for teaching review. The plan
was to continue on Cefepime and Dapto IV with oral Fluconazole
for an indefinite course while drains in place. He will f/u with
Dr. ___ to be scheduled ___ and Dr. ___ on ___. Of
note, in addition to twice weekly labs, he will need twice
weekly CK checks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Frank hematuria due to renal cell carcinoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old Male patient with HIV (last CD4 in OMR ~600 in
___, with metastatic renal cell carcinoma with metastesis to
the lung awaiting debulking surgery in ___ with urology,
known right inguinal hernia who presents with acute onset right
inguinal pain and frank hematuria. There was initial concern
that the patient had an incarceration of his hernia, but surgery
was consulted and felt this was not the case. Of note the
patient was discharged in ___ from the ___
service on the ___ after presenting with similar
complaints when he was diagnosed with renal cell carcinoma. He
was seen by urology and medical oncology at the time, and he has
a planned nephrectomy and cytoreductive surgery planned in
___ prior to chemotherapy initiation. The pathology
showed stage IV renal cell carcinoma (clear cell type). During
this admission staging evaluation with CT chest on ___
showed 3.4 cm right middle lobe lung lesion and left 0.8 cm
perifissural nodule. He
underwent biopsy of lung nodule on ___ which showed
metastatic clear cell renal cell carcinoma.
He presented to the ___ ED with similar complaints as the last
time with abdominal pain and frank hematuria. His initial vitals
in the ___ ED were 97.5, 88, 141/95, 26, 100% RA. In the ED he
receieved ondansetron, IV fluids, morphine and 2 doses of
ceftriaxone. ACS and GU were consulted and a 3-way irrigation
foley catheter was placed.
Past Medical History:
HIV infection
H/o treated H. pylori
GERD
Mood Disorder
Testicular hypofunction
Social History:
___
Family History:
Negative for urothelial malignancy or kidney stones.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 99.0, 141/77, 68, 18, 100\%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
GU: Large bulging right inguinal hernia, easily reducible, 3-way
foley with pink urine
NEURO: CAOx3, Motor ___ ___ Ext/Flex
DISCHARGE EXAM
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: RRR no m/r/g
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 tenderness
MSK: No erythema or swelling of joints
SKIN: No rashes or ulcerations noted
EXTR: wwp no edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
PERTINENT DATA
Creatinine 1.9-2.1, stable
Urine and blood cultures negative
Bladder US ___
No intrabladder clot or mass detected. Scattered, nonspecific
intraluminal echogenic debris. Foley catheter visualized.
CT ABD & PELVIS WITH CONTRAST
Study Date of ___ 10:46 ___
IMPRESSION:
1. Large right renal mass with adjacent right retroperitoneal
adenopathy is
consistent with patient's known renal cell carcinoma.
2. Within the dependent aspect of the urinary bladder is an
intermediate
density area which may represent intraluminal hematoma,
correlate with
urinalysis.
3. Small mesenteric fat and fluid containing right inguinal
hernia is
unchanged from prior
4. Small mesenteric fat containing umbilical hernia.
5. 18.3 cm splenomegaly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Testosterone Cypionate 100 mg IM QWEEK
2. LamoTRIgine 100 mg PO BID
3. Senna 8.6 mg PO BID:PRN Constipation - Second Line
4. abacavir-dolutegravir-lamivud 600-50-300 mg oral DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Third Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *bisacodyl [Biscolax] 10 mg 1 suppository(s) rectally daily
as needed Disp #*60 Suppository Refills:*0
2. Polyethylene Glycol 17 g PO TID
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 Gram by
mouth up to 3 times daily Refills:*0
3. Senna 17.2 mg PO BID:PRN Constipation - Second Line
RX *sennosides [senna] 8.6 mg ___ tablets by mouth up to twice
daily as needed Disp #*120 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth up to three times daily
Disp #*20 Tablet Refills:*0
6. abacavir-dolutegravir-lamivud 600-50-300 mg oral DAILY
7. LamoTRIgine 100 mg PO BID
8. Senna 8.6 mg PO BID:PRN Constipation - Second Line
9. Testosterone Cypionate 100 mg IM QWEEK
Discharge Disposition:
Home
Discharge Diagnosis:
Hematuria
Renal cell carcinoma
Constipation
Anxiety
Chronic kidney disease
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BLADDER US
INDICATION: ___ year old man with hematuria on continuous bladder irrigation
with continued intermittent obstruction// please assess for clots in bladder
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the bladder.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
bladder demonstrated a Foley catheter. No evidence of blood clots or masses.
There is scattered intraluminal echogenic debris which is nonspecific.
IMPRESSION:
No intrabladder clot or mass detected. Scattered, nonspecific intraluminal
echogenic debris. Foley catheter visualized.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Hematuria
Diagnosed with Right lower quadrant pain, Hematuria, unspecified
temperature: 97.5
heartrate: 88.0
resprate: 26.0
o2sat: 100.0
sbp: 141.0
dbp: 95.0
level of pain: 10
level of acuity: 2.0 | ___ year old Male patient with HIV (last CD4 in OMR ~600 in
___, with metastatic renal cell carcinoma with metastesis to
the lung awaiting debulking surgery in ___ with urology,
known right inguinal hernia who presents with acute onset right
inguinal pain and frank hematuria
# Frank hematuria due to renal cell carcinoma with metastesis to
lung and pelvis
Cause is presumed bleeding from the very large tumor. Awaiting
debulking/nephrectomy on ___ with Dr ___. This will
also involve lymph node dissection and the case will take at
least 6 hours. Patient has had catheter discontinued and then
replaced multiple times, during the admission with multiple
failed attempts to wean off CBI. Eventually his hematuria
slowed/stopped and catheter was able to be discontinued. There
is a reasonable possibility it will recur, however, which will
require a return to care. Started on flomax. Held meds that
could worsen retention.
# Inguinal Hernia
Discussed at length with ACS; they do not believe his pain and
symptomatology is from his hernia. Will NOT have hernia repair
performed with nephrectomy as nephrectomy is a six hour surgery
(discussed with Dr ___. Nonetheless, patient is worried that
his hernia will limit his return to work after nephrectomy. He
will have outpatient ACS f/u to discuss optimal timing of hernia
repair.
# Pain control: Has RLQ pain, presumably referred from
malignancy, abdominal distension. Continued treatment with
tramadol, which helped.
# Anxiety: Appreciate SW input, PCP ___, ___ to
also discuss need for ongoing outpatient support during this
period.
# CKD Stage III: Creatinine 2.0, stable.
# HIV
Continued HAART
#Constipation
Uptitrated bowel regime
============================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bee venom (honey bee)
Attending: ___.
Chief Complaint:
=============================================================
OMED ADMISSION NOTE
Admitted: ___
=============================================================
PCP: ___
PRIMARY ONCOLOGIST: ___, MPH, ___
PRIMARY DIAGNOSIS: Metastatic neuroendocrine tumor
TREATMENT REGIMEN: cisplain, etoposide
CC: biliary drain fell out
Major Surgical or Invasive Procedure:
___ Packed Red Blood Cells 1 unit transfusion
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ man
with poorly differentiated high-grade neuroendocrine tumor
metastatic to liver, currently treated w/ cisplatin and
etoposide
(C10D14) who presented after his biliary drain fell out.
The patient had his biliary drain replaced in ___ after
developing biliary obstruction; his prior drain had become
dislodged. Since that time, the drain has remained mostly capped
without output. The day of admission the patient awoke to find
his drain on the floor. He is not sure how it came out. There
was
no leaking fluid. The patient felt well without fever or chills.
Has chronic abdominal pain but none new. Decided to go to the
ED.
In the ED, pt noted to be tachycardic, also lactate elevated to
3, alk P elevated to 500s and Plt decreased to ___. Was given 1L
NS and admitted to oncology for further evaluation of
cholangitis.
On arrival to the floor, the patient's VS were 98 120/80 99 16
98%RA. He has no new complaints.
REVIEW OF SYSTEMS: (+) as per HPI. A 12-point pulmonary focused
ROS was otherwise unremarkable.
Past Medical History:
PAST ONCOLOGIC HISTORY
Poorly differentiated neuroendocrine tumor (onc history reviewed
in OMR)
PAST MEDICAL HISTORY:
BPH
Social History:
___
Family History:
Three cousins died in their ___ of unknown causes. No known
family history of liver, biliary, or gallbladder disease. No
known family history of malignancy, including GI malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98 120/80 99 16 98%RA
GENERAL: Lying in bed, NAD
HEENT: MMM, OP clear
CARDIAC: RRR, S1 and S2, no m/r/g
LUNG: CTAB, no w/r/r
ABD: Large liver, mild TTP over RUQ which patient reports as
chronic. Old biliary drain site without leaking fluid or
erythema. GJ tube.
EXT: No c/c/e
NEURO: Nystagmus which patient reports as chronic
.
.
DISCHARGE PHYSICAL EXAM
VS: 98.0 97.8 135/82 90 18 95% on RA
Gen: very thin elderly man who appears comfortable, sitting up
in a chair
HEENT: EOMI, pale conjunctiva
Chest: CTAB
CV: RR, mildly tachycardic (90s-100s), no murmurs, rubs, or
gallops
Abd: distended, firm, not tender to light or firm palpation,
BS+, +GJ tube
Ext: no peripheral edema, 2+ distal pulses
MSK: stable gait, stands from a seated position easily without
assistance
Neuro: AAOx3, clear speech
Psych: calm, cooperative, normal affect
Pertinent Results:
ADMISSION LABS:
Lactate:3.2
134 99 19 93 AGap=16
4.7 24 1.0
Ca: 9.5 Mg: 1.3 P: 3.2
ALT: 20 AP: 585 Tbili: 0.4 Alb: 3.7
AST: 49 LDH: 257
Lip: 12
___: 11.4 PTT: 28.2 INR: 1.0
.
MICROBIOLOGY:
___ BCx x 1 set - pending, NGTD
.
IMAGING:
___ RUQ US
IMPRESSION:
Large mass replacing nearly the entire left lobe of the liver
and a large amount of the right lobe of the liver.
Mild-to-moderate intrahepatic biliary dilatation, not
significantly changed from prior.
.
DISCHARGE LABS:
.
___:
WBC-5.8 Hgb-7.7* Hct-24.0* Plt Ct-52*
Glucose-78 UreaN-22* Creat-1.0 Na-138 K-5.0 Cl-104 HCO3-22
ALT-17 AST-55* LD(LDH)-277* AlkPhos-509* TotBili-0.4
Calcium-8.9 Phos-2.1* Mg-1.5* UricAcd-7.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dronabinol 2.5 mg PO BID
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
4. Mirtazapine 15 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. Tamsulosin 0.8 mg PO QHS
7. Allopurinol ___ mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Sodium Bicarbonate 650 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Dronabinol 2.5 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
4. Lorazepam 0.5 mg PO Q6H:PRN anxiety
5. Mirtazapine 15 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Sodium Bicarbonate 650 mg PO BID
9. Tamsulosin 0.8 mg PO QHS
Discharge Disposition:
Home with Service
Discharge Diagnosis:
biliary obstruction
tumor lysis syndrome
anemia
thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Gen: very thin elderly man who appears comfortable, sitting up
in a chair
HEENT: EOMI, pale conjunctiva
Chest: CTAB
CV: RR, mildly tachycardic (90s-100s), no murmurs, rubs, or
gallops
Abd: distended, firm, not tender to light or firm palpation,
BS+, +GJ tube
Ext: no peripheral edema, 2+ distal pulses
MSK: stable gait, stands from a seated position easily without
assistance
Neuro: AAOx3, clear speech
Psych: calm, cooperative, normal affect
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with hx liver tumor, biliary obstruction s/p R
PTBD, drain fell out, has alkP elevation // eval for biliary obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
LIVER: A large heterogeneous predominantly hyperechoic mass is again seen
replacing the nearly the entire left lobe and a large portion of the right
lobe of the liver. Within the non involved hepatic parenchyma there is
mild-to-moderate biliary dilatation which appears similar to the prior
studies. The common bile duct was unable to be visualized. There is trace
perihepatic ascites.
Limited views of the right kidney demonstrate mild fullness of the collecting
system, unchanged from prior.
IMPRESSION:
Large mass replacing nearly the entire left lobe of the liver and a large
amount of the right lobe of the liver. Mild-to-moderate intrahepatic biliary
dilatation, not significantly changed from prior.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Dehydration, Tachycardia, unspecified, Displacement of internal prosth dev/grft, init, Oth medical procedures cause abn react/compl, w/o misadvnt
temperature: 97.8
heartrate: 115.0
resprate: 18.0
o2sat: 99.0
sbp: 110.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ man with poorly differentiated
high-grade neuroendocrine tumor metastatic to liver, currently
treated w/ cisplatin and etoposide (C10D14) who presented after
his biliary drain fell out.
# Billiary obstruction/drain - The patient had his drain placed
in ___ i/s/o biliary obstruction. His tumor has since
responded somewhat to chemotherapy and he has had minimal drain
output recently. His drain has been capped most of the time.
Certainly his tachycardia and elevated lactate are c/f brewing
cholangitis, however we were reassured by absent fevers/chills,
hyperbilirubinemia, or new abdominal pain. Given his
immunocompromosed state, however, we felt it was reasonable to
monitor overnight and re-check labs in AM. No concerning labs
or clinical changes following AM. LFTs stable. No fever or
abd pain. ___ was consulted and we discussed with patient's
primary Oncology team, no need to replace biliary drain at
present time. ___ team feels like patient is likely draining
bile internally at ths point. Will hold off on replacing
biliary drain and allow for "drain holiday" at this time.
Patient was advised to seek immediate medical attention if he
develops increasing abdominal pain or distention,
nausea/vomiting, or jaundice. He will follow-up with his
primary Oncology team.
# Tumor lysis syndrome - hx persistently elevated uric acid
throughout recent treatment, on allopurinol, receives
intermittent IVF infusions as outpatient. Continue allopurinol
and NaHCO3. Encouraged PO fluid intake. Uric acid was checked
and was within the range he had been in recently at 7.2 on the
day of discharge.
# Pancytopenia - Likely chemo and malignancy related. Patient
completed filgastrim course this past ___. Was transfused 1
unit pRBCs while inpatient. Hgb had good response and was
subsequently stable. No chemical DVT ppx given thrombocytopenia.
Trended plt#, no need for transfusion at this time. Should
continue to have CBC's checked and transfusion PRN as outpatient
per primary Oncology team.
# Neuroendocrine tumor - continued symptom management with home
med regimen. Chemo plan per oncology.
Time spent: 35 minutes spent on discharge-related activities on
day of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Influenza Virus Vaccine / flowers,cologne,grass / cats /
lisinopril / dogs / oxycodone
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old gentleman with past medical history
of ESRD (dialysis MWF), DMT2 w/ peripheral neuropathy, HTN and
HLD who presents to the emergency room with dizziness.
Yesterday, he was walking to the bus stop and suddenly fell to
his R side and hit his R knee. He had no head strike or LOC. He
denies experiencing any chest pain, palpitations, vertigo,
lightheadedness or sudden weakness before his fall. He says he
"just fell". He felt fine while on the bus. On his walk home
(after the bus ride), he found himself leaning on his R side. He
continued to feel that he was unsteady on his feet, and that he
had to "really concentrate" to avoid falling. Again, he denies
vertigo or lightheadedness. He went to bed last night and when
he
woke up felt "dizzy" again. He describes his feeling of
dizziness
as "unsteadiness" and not as lightheadedness or feeling of room
spinning. He states these are the same symptoms he had the day
before. He was concerned for the persistence of his unsteadiness
and decided to visit the ED here at ___.
In the ED, he still feels unsteady, especially when he gets up.
He feels essentially normal while lying down or sitting. He was
given 500 mL of NS and 4 mg of Zofran.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness or sensory changes.
He has no recent injury/trauma to his neck, he does not go to a
chi___.
On general review of systems, the pt denies recent fever or
chills. Denies cough. Denies chest pain or tightness,
palpitations. Denies vomiting.
Past Medical History:
Likely TIA, ___
Seizures, 2 generalized tonic-clonic events in ___. Saw Dr.
___ was ultimately made not to start AEDs.
HLD
HTN
ESRD on dialysis
DMT2 with peripheral neuropathy
Social History:
___
Family History:
Mom - DM, HTN, kidney disease
Brother - DM, HTN
Grandmother - DM
Physical ___:
EXAM ON ADMISSION:
==================
Vitals: 97.9 ___ 20 100% RA
General: Tired appearing man in no acute distress
HEENT: NC/AT, no scleral icterus noted
Pulmonary: Normal work of breathing
Extremities: No ___ edema.
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 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:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Hypometric saccades when looking to L more than R.
There is a subtle horizontal skew deviation on alternate cover
test.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact.
IX, X: soft palate elevates symmetrically.
XI: Shoulder shrug ___ bilaterally.
XII: Tongue midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was mute bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally. Dysdiadochokinesia on L hand. No over or undershoot
with mirror testing.
-Gait: Good initiation. Narrow-based, with cane. Walks in a
straight line. Unsteady and stumbled minimally once but not
appreciably to one side. "Gait different than before", per niece
who was in the ED.
Pertinent Results:
Laboratory Data:
H/H: 10.5/32.7
K: 5.2
Cr: 8.3 (baseline 6.0)
HbA1C: 6.8%
EKG:
NSR. Bradycardic at rate of 55. No axis deviation. Minor STE in
V2-V3.
Rate PR QRS QT QTc (___) P QRS T
55 ___ 470/459 44 26 67
NCHCT:
"Impression:
1. No acute intracranial abnormalities.
2. Interval progression mild hydrocephalus "
Medications on Admission:
ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation
aerosol inhaler. 1 to 2 puffs(s) inhaled up to four times a day
as needed for cough or wheeze
AMLODIPINE - amlodipine 10 mg tablet. 1 tablet(s) by mouth once
a
day to control blood pressure
ATORVASTATIN - atorvastatin 40 mg tablet. 1 tablet(s) by mouth
once a day to lower cholesterol
AZELASTINE [ASTEPRO] - Astepro 0.15 % (205.5 mcg) nasal spray. 2
sprays nasally QPM
CALCITRIOL - calcitriol 0.25 mcg capsule. one capsule(s) by
mouth
every other day to maintain level of vitamin D DX: N18.5
CINACALCET [SENSIPAR] - Sensipar 30 mg tablet. 1 tablet(s) by
mouth daily - (Not Taking as Prescribed: it's $700 so he can't
affford it)
FLUTICASONE - fluticasone 50 mcg/actuation nasal
spray,suspension. 2 sprays both nostrils every day
LABETALOL - labetalol 200 mg tablet. 2 tablet(s) by mouth twice
a
day
OCCUPATIONAL THERAPY FOR WHEELCHAIR SEATING EVALUATION -
Occupational therapy for wheelchair seating evaluation . use as
directed Dx: multifactorial gait disorder. Hx of stroke, hx of
falls
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 2 (Two)
capsule(s) by mouth once a day
PHYSICAL THERAPY FOR WHEELCHAIR SEATING EVALUATION - Physical
therapy for wheelchair seating evaluation . use as directed Dx:
multifactorial gait disorder, hx of stroke, hx of falls
SEVELAMER CARBONATE [RENVELA] - Renvela 800 mg tablet. 1
tablet(s) by mouth three times a day with each meal
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 (One)
Tablet(s)
by mouth once a day to reduce risk of heart disease - (OTC)
B COMPLEX-VITAMIN C-FOLIC ACID [___] - ___ 0.8 mg
tablet. 1 tablet(s) by mouth daily
BLOOD SUGAR DIAGNOSTIC ___ AVIVA PLUS TEST STRP] -
___ Aviva Plus test strips. use as directed to check blood
sugars
CALCIUM CARBONATE-VITAMIN D3 - calcium carbonate 600 mg (1,500
mg)-vitamin D3 400 unit tablet. 1 (One) Tablet(s) by mouth twice
a day
CETIRIZINE - cetirizine 10 mg tablet. one tablet(s) by mouth
once
a day as needed for allergy
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000
unit capsule. one capsule(s) by mouth once a day
LANCETS [FREESTYLE LANCETS] - FreeStyle Lancets 28 gauge. use to
check blood sugars BID E11.65
VITAMIN E - Dosage uncertain - (Prescribed by Other Provider)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
peripheral neuropathy
peripheral vestibulopathy
small vessel disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, dizziness.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.1 cm; CTDIvol = 46.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT from ___, MRI from ___.
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass effect, or acute major
vascular territorial infarction. There is moderate global parenchymal volume
loss with prominent ventricles and sulci, progressed since ___.
Periventricular and deep white matter hypodensities have also progressed,
nonspecific but likely sequela of chronic small vessel ischemic disease in
this age group.
There are mucous retention cysts in the partially visualized maxillary
sinuses, larger on the left than right, similar to the prior MRI. There is
also mild mucosal thickening in the maxillary sinuses, ethmoid air cells, and
frontoethmoidal recesses. There is partial bilateral mastoid air cell
opacification.
IMPRESSION:
1. No evidence for acute intracranial abnormalities.
2. Supratentorial white matter hypodensities, progressed since ___,
nonspecific but likely secondary to chronic small vessel ischemic disease in
this age group.
3. Moderate global parenchymal volume loss, progressed since ___.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old man with ?cerebellar stroke// Eval for infarct
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of Multihance
intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: CT head ___, MR head ___.
FINDINGS:
MRI BRAIN:
There is no evidence of acute infarction. No intracranial hemorrhage. No
mass, mass effect, edema or midline shift.
The ventricles and sulci are prominent. Periventricular and subcortical white
matter FLAIR hyperintensities are noted, a nonspecific finding that most
likely represents the sequelae of chronic small vessel ischemic disease.
There is gross preservation of the principal intracranial vascular flow voids.
Mastoid fluid is seen bilaterally. Mucous retention cysts and mucosal
thickening is seen involving the bilateral maxillary sinuses. Mucosal
thickening is also noted throughout scattered ethmoid air cells. The orbits
are within normal limits bilaterally.
MRA BRAIN AND NECK:
There is a normal 3 vessel aortic arch identified. Bilateral common carotid
arteries are patent.
However, the proximal right internal carotid artery demonstrates areas of
focal severe narrowing (11:34), with minimal narrowing of the contralateral
side. These findings are most likely secondary to atherosclerotic disease.
However, exact assessment of stenosis is difficult on this noncontrast 2D
time-of-flight study.
The bilateral vertebral arteries appear hypoplastic, right greater than left,
with areas of minimal flow related signal seen within the right V 2 segment
(11:33) and within the bilateral V4 segments. Similarly, the basilar artery
is diffusely narrowed with minimal residual flow signal.
Mild-to-moderate right and moderate to severe left irregular narrowing of the
bilateral cavernous internal carotid arteries likely reflects underlying
atherosclerotic disease.
Otherwise, the intracranial vasculature appears grossly patent without
evidence of high-grade stenosis, occlusion, or aneurysm formation.
The right A1 segment is hypoplastic. There are dominant bilateral posterior
communicating arteries with diminutive P1 segments, a normal variant.
IMPRESSION:
1. No evidence for acute intracranial hemorrhage or infarction.
2. Moderate global parenchymal volume loss and evidence of chronic small
vessel ischemic disease. Medial temporal atrophy with prominence of temporal
horns.
3. Bilateral mastoid fluid and paranasal sinus disease, as above.
4. Focal, moderate narrowing of the proximal right ICA. Exact narrowing and
degree of percent stenosis is difficult to assess on this 2D time-of-flight
study.
5. Multifocal intracranial atherosclerotic disease, most notably causing
moderate to severe irregular narrowing of the left cavernous internal carotid
artery.
6. Diffusely hypoplastic bilateral vertebral and basilar arteries. This may
be in large part due to the prominent bilateral posterior communicating
arteries, as the extent and bilateral nature of these findings would make
dissection unlikely. If clinically indicated, a follow-up CTA of the neck
could be considered for further evaluation.
RECOMMENDATION(S): Small basilar artery could be further evaluated with CT
angiography if clinically indicated.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with Orthostatic hypotension, Dizziness and giddiness
temperature: 97.9
heartrate: 60.0
resprate: 20.0
o2sat: 100.0
sbp: 139.0
dbp: 56.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old man with a longstanding h/o DM, with
polyneuropathy and chronic gait impairment who presents with
worsening gait imbalance, fall,
and temporary episode of vertigo. His exam on admission was
significant for a
moderately advanced polyneuropathy with significant impairment
of
proprioception in his feet and toes and gait ataxia. He was
admitted for workup of a cerebellar or subcortical infarct given
his presenting symptoms and vascular risk factors. He was
continued on aspirin. MRI/MRA brain was without evidence of
acute infarct. ECHO demonstrated mildly increased left atrial
volume with dilated right atrium without evidence of PFO or ASD. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
aspirin / Brilinta / Plavix / diclofenac / ibuprofen /
lisinopril / naproxen
Attending: ___
Chief Complaint:
abdominal pain, hypertensive
Major Surgical or Invasive Procedure:
___: SMA/celiac angiogram
___: SMA angiogram and embolization of branch supplying
large
actively bleeding PSA. Sheath left in place and will be pulled
on
History of Present Illness:
___ h/o RNYGB, afib on xarelto, ___ transferred from
___ for hypotension ___ intra-abdominal hemorrhage,
with non-con CT showing large hemoperitoneum & with unclear
source.
She was recently observed at ___ for 24hrs where she was treated
for hypertensive urgency (SBP>200). Yesterday around 7 pm
(within
24hrs of discharge), she felt acute abdominal pain radiating to
the back. She had an episode of emesis as well. Her daughter was
present and called EMS, who took her to ___
___
she was found to be hypotensive to ___, brady 58. She received
1uprbc, 1 k-centra and was transferred to ___ urgently.
In our ED, a STAT surgery consult was called for hypotension to
___. Massive transfusion protocol was started and she received
5uprbc, 1plts, ___.
Last dose of xarelto was day of presentation
Past Medical History:
PMH: Afib on xarelto (last dose ___, HTN (recently discharged
for hypertensive urgency)
PSH: Gastric bypass ___, ___
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals:97.8 65 101/52 15 992L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, peritoneal signs
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical:
VS: 98.9, 132/73, 81, 20, 97 RA
CV: HRR NSR
Pulm: LS ctab
Abd: soft, NT/ND
Ext: No edema. WWP.
Pertinent Results:
___ 06:32AM BLOOD WBC-10.8* RBC-2.85* Hgb-9.0* Hct-27.1*
MCV-95 MCH-31.6 MCHC-33.2 RDW-13.9 RDWSD-47.0* Plt ___
___ 07:00AM BLOOD WBC-9.2 RBC-2.51* Hgb-8.2* Hct-24.1*
MCV-96 MCH-32.7* MCHC-34.0 RDW-14.0 RDWSD-47.5* Plt ___
___ 04:20AM BLOOD WBC-9.2 RBC-2.26* Hgb-7.5* Hct-21.2*
MCV-94 MCH-33.2* MCHC-35.4 RDW-13.5 RDWSD-46.2 Plt ___
___ 03:57PM BLOOD WBC-9.8 RBC-2.42* Hgb-7.9* Hct-22.3*
MCV-92 MCH-32.6* MCHC-35.4 RDW-13.6 RDWSD-46.0 Plt ___
___ 09:59AM BLOOD WBC-9.5 RBC-2.41* Hgb-7.8* Hct-22.3*
MCV-93 MCH-32.4* MCHC-35.0 RDW-13.4 RDWSD-45.1 Plt ___
___ 03:19AM BLOOD WBC-10.3* RBC-2.46* Hgb-8.1* Hct-22.9*
MCV-93 MCH-32.9* MCHC-35.4 RDW-13.6 RDWSD-45.5 Plt ___
___ 11:11PM BLOOD WBC-11.9* RBC-2.67* Hgb-8.6* Hct-24.2*
MCV-91 MCH-32.2* MCHC-35.5 RDW-13.7 RDWSD-45.3 Plt ___
Imaging:
CT A/P:
1. Active arterial hemorrhage in the region of the
gastroduodenal/right
gastroepiploic with large intraperitoneal hematoma and right
retroperitoneal hemorrhage and marked attenuation of the portal
splenic confluence. The distal portal vasculature appears
patent.
2. Hypoenhancement of the bilateral kidneys suggests
hypoperfusion
Mesenteric Arteriogram:
1. Superior mesenteric arteriogram demonstrated no evidence of
active bleed and successful thrombosis of the previously seen
pseudoaneurysm.
2. Celiac arteriogram with celiac stenosis, no active
extravasation.
IMPRESSION:
No evidence bleed. Successful thrombosis of previously seen
superior
mesenteric artery branch pseudoaneurysm.
TEE:
No valvular pathology or pathologic flow identified. Mild
symmetric
left ventricular hypertrophy with normal cavity size and
regional/global biventricular systolic function. Mild
pulmonary artery systolic hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 320 mg PO DAILY
2. Sotalol 120 mg PO BID
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. amLODIPine 2.5 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. Doxazosin 2 mg PO HS
7. Rivaroxaban 20 mg PO DAILY
8. NIFEdipine (Extended Release) 30 mg PO BID
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Enoxaparin Sodium 30 mg SC Q12H
RX *enoxaparin 30 mg/0.3 mL 30 mg subcutaneous every twelve (12)
hours Disp #*60 Syringe Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*20 Packet Refills:*0
4. amLODIPine 2.5 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. Doxazosin 2 mg PO HS
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Sotalol 120 mg PO BID
9. Valsartan 320 mg PO DAILY
10. HELD- NIFEdipine (Extended Release) 30 mg PO BID This
medication was held. Do not restart NIFEdipine (Extended
Release) until you see your PCP
___:
Home
Discharge Diagnosis:
Actively bleeding pseudoaneurysm arising from a third order
branch of the superior mesenteric artery
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 hemoperitoneum and hypotensive// For active
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 6.1 s, 48.1 cm; CTDIvol = 7.7 mGy (Body) DLP = 372.0
mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 24.3 mGy (Body) DLP =
12.1 mGy-cm.
3) Spiral Acquisition 6.4 s, 50.4 cm; CTDIvol = 17.4 mGy (Body) DLP = 877.6
mGy-cm.
4) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 17.4 mGy (Body) DLP = 879.6
mGy-cm.
Total DLP (Body) = 2,141 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR:
Active arterial extravasation is seen originating from a branch of the right
gastroepiploic artery as it comes off the gastroduodenal artery (04:53), with
contrast pooling noted posterior and inferior to the pancreas neck (05:47).
This is associated with marked attenuation of the portal splenic confluence
and main portal vein, likely secondary to local mass effect. The distal left
and right portal veins are patent.
A large hematoma is seen in the mesocolon and displaces the greater omentum
(05:58). Moderate volume hemoperitoneum is noted. Hemorrhage is also seen in
the right retroperitoneal region, tracking along the right anterior renal
space posterior to the ascending colon. Small volume hemorrhage also extends
into the subcutaneous fat of the midline anterior abdominal wall likely
through a small hernia (5:64).
LOWER CHEST: There is mild bibasilar atelectasis. No pleural or pericardial
effusion is seen.
ABDOMEN:
HEPATOBILIARY: The liver and gallbladder are unremarkable.
PANCREAS: The pancreas is unremarkable.
SPLEEN: The spleen is unremarkable.
ADRENALS: The adrenal glands are unremarkable.
URINARY: Relative ___ of the bilateral kidneys suggest
hypoperfusion. Subcentimeter hypoattenuating lesions in the right kidney are
too small to characterize. No hydronephrosis.
GASTROINTESTINAL: Patient is post gastric bypass. Small and large bowel loops
are normal in caliber.
PELVIS: The urinary bladder is unremarkable. Enlarged fibroid uterus.
LYMPH NODES: No enlarged abdominal or pelvic lymph nodes are seen.
BONES: There are no aggressive appearing osseous lesions.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Active arterial hemorrhage in the region of the gastroduodenal/right
gastroepiploic with large intraperitoneal hematoma and right retroperitoneal
hemorrhage and marked attenuation of the portal splenic confluence. The
distal portal vasculature appears patent.
2. ___ of the bilateral kidneys suggests hypoperfusion.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 3:58 am, 15 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman on Xarelto for a fib, active extrav into
mesentery. Hx of gastric bypass// mesenteric bleed
COMPARISON: CTA abdomen and pelvis dated ___
TECHNIQUE: OPERATORS: Drs. ___ Dr. ___ Interventional
___ and Dr. ___, Interventional Radiology fellow performed the
procedure. Dr. ___ supervised the trainee during any key
components of the procedure where applicable and reviewed and agrees with the
findings as reported below.
ANESTHESIA: The anesthesia team was present for the entirety of the case given
the hemodynamic instability.
MEDICATIONS: 100 mcg nitroglycerin
CONTRAST: 195 Ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 29 minutes, 1116 mGy
PROCEDURE:
1. Emergent right CFV central line placement under ultrasound guidance.
2. Right common femoral artery access under ultrasound guidance.
3. Right common femoral artery arteriogram
4. Superior mesenteric arteriogram in ___, ___ and AP projections.
5. IPDA artery branch angiogram.
6. Cone beam CT superior mesenteric arteriogram.
7. Two additional second order SMA branch arteriograms.
8. Arteriogram of ___ order ___ branch supplying PSA
9. Coil embolization across pseudoaneurysm.
10. Repeat arteriogram of superior mesenteric artery branch.
11. Repeat superior mesenteric arteriogram.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The right groin
was prepped and draped in the usual sterile fashion.
Using ultrasound guidance the right common femoral vein was punctured using a
19 gauge 1 wall needle. 0.038 wire was advanced through the needle. Needle
was removed and access site was dilated over the wire. Dilator was removed
and triple lumen central venous catheter was advanced over the wire.
Fluoroscopic image to confirm position demonstrated tip in the IVC. The
triple lumen central venous catheter was sutured in place.
Using palpatory and ultrasound guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A C2 catheter was advanced over ___ wire into the aorta. The wire was
removed and the superior mesenteric artery was selectively cannulated and a
small contrast injection was made to confirm position. AP, ___ and ___
superior mesenteric arteriograms were performed which demonstrated
pseudoaneurysm arising from a third order branch of the superior mesenteric
artery.
Rotational cone-beam CT angiography was performed to help delineate the
anatomy. Multiplanar CT images were reconstructed and 3D volume-rendered
images of the arterial anatomy required post-processing on an independent
workstation under direct physician ___. These images were used in the
interpretation, decision making for intervention and reporting of this
procedure.
All arteriograms were is central in the treatment of this patient given
failure of localization of CTA and need for identification of supplying
vessels to the pseudoaneurysm.
At this point, double angled Glidewire and STC microcatheter were utilized to
select a third order superior mesenteric artery branch. An arteriogram was
performed, which failed to demonstrate filling of the pseudoaneurysm. The
microcathter was retracted and with the aide of the double angle glidewire
advanced into two additional second order branches sequentially where
arteriograms were performed. The catheter was retracted another angiogram
performed which demonstrated slight spasm there for 100 mcg of nitroglycerin
were given into the artery. The microcatheter was retracted again and the
Glidewire was advanced into another third order superior mesenteric artery
branch. A repeat angiogram was performed, this time demonstrating the
pseudoaneurysm. At this point, a GT glidewire was utilized to navigate past
the neck of the pseudoaneurysm. Then, the decision was made to coil embolize
across the pseudoaneurysm. This was performed with 2 4 mm x 10 cm Concerto
coils and 1 4 mm x 8 cm Concerto coil. After embolization, repeat third order
superior mesenteric artery branch arteriograms performed demonstrating no
forward flow. The microcatheter was removed and a repeat SMA angiogram was
performed demonstrating successful cessation of flow to the branch supplying
the bleeding pseudoaneurysm as well as continued collateral flow to the liver
and splenic artery through various branches.
The decision was made to leave the sheath in place given the Xarelto
anticoagulation dose. The sheath was placed to side arm heparinized saline
flush. It was secured to the skin utilizing 0 silk sutures.
FINDINGS:
1. Celiac stenosis with retrograde filling of the hepatic vessels as well as
the splenic artery from various collateral branches
2. Actively bleeding pseudoaneurysm arising from a third order branch of the
superior mesenteric artery, successfully coil embolized
IMPRESSION:
Successful arteriogram and embolization of actively bleeding pseudoaneurysm
arising from a third order branch of the superior mesenteric artery.
RECOMMENDATION(S): The right common femoral artery sheath will be removed in
approximately 24 hours given the anticoagulation status. This should be
attached to heparinized side arm flush.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with retroperitoneal bleed. VM,ett.//
Tubes/lines.
IMPRESSION:
No previous images. There are very low lung volumes without definite vascular
congestion or acute focal pneumonia. Atelectatic changes are seen at the
bases.
Endotracheal tube tip lies approximately 3 cm above the carina.
Radiology Report
INDICATION: ___ year old woman with SMA bleed pod ___ s/p coil embo// continued
Hct drop
COMPARISON: CTA dated ___ and mesenteric angiogram dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___, Interventional Radiology fellow performed the procedure. Dr. ___
___ supervised the trainee during any key components of the procedure
where applicable and reviewed and agrees with the findings as reported below.
ANESTHESIA: The ICU nurse was present for integrity of the case.
MEDICATIONS: None
CONTRAST: 35 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 7.9 min, 219 mGy
PROCEDURE:
1. Superior mesenteric arteriogram.
2. Celiac arteriogram.
3. Right common femoral artery arteriogram
4. Angioseal closure of right CFA
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the health care proxy.
The patient was then brought to the angiography suite and placed supine on the
exam table. A pre-procedure time-out was performed per ___ protocol. Both
groins were prepped and draped in the usual sterile fashion.
Using the patient's indwelling right common femoral 5 ___ vascular sheath,
placed during the previous arteriogram, a C2 Cobra catheter was advanced over
___ wire into the aorta. The wire was removed and the superior
mesenteric artery was selectively cannulated and a small contrast injection
was made to confirm position. An angled Glidewire was advanced through the
catheter, and the catheter was further advanced into the superior mesenteric
artery, to gain better purchase within the artery. A superior mesenteric
arteriogram was performed, which demonstrated no evidence of active bleed and
successful thrombosis of the previously seen pseudoaneurysm.
The C2 catheter was then used to cannulate the celiac artery. A celiac
arteriogram was performed. Celiac arteriogram demonstrated sluggish flow,
compatible with retrograde filling from the superior mesenteric artery and no
evidence of bleed.
The catheter was then removed over the wire and the sheath was removed. An
Angioseal closure device was deployed and manual pressure was held until
hemostasis was achieved. Sterile dressings were applied. The patient
tolerated the procedure well.
FINDINGS:
1. Superior mesenteric arteriogram demonstrated no evidence of active bleed
and successful thrombosis of the previously seen pseudoaneurysm.
2. Celiac arteriogram with celiac stenosis, no active extravasation.
IMPRESSION:
No evidence bleed. Successful thrombosis of previously seen superior
mesenteric artery branch pseudoaneurysm.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Abdominal distention, Transfer
Diagnosed with Aneurysm of other specified arteries, Unspecified atrial fibrillation, Long term (current) use of anticoagulants, Hypotension, unspecified
temperature: 97.8
heartrate: 87.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 107.0
level of pain: 10
level of acuity: 2.0 | ICU Course:
The patient presented to Emergency Department on ___ for
sudden onset of abdominal pain. Upon arrival to ED, she was
evaluated by the ___ team. Her Hct from OSH was 37.1 and at
___ ED 25. She was found to have hemoperitoneum with active
extravasation from a branch off of celiac/SMA. 8 units of pRBC,
2 unit of plasma, and 1 unit of plalelet were given. Given
findings, the patient was taken to the interventional radiology
suite for ___ embolization of pseudoaneurysm in a branch off of
SMA. There were no adverse events in the operating room; please
see the operative note for details. Patient was taken to the
PACU until stable, then transferred to SICU for monitoring. On
POD1 her hct was 25.5 from 35.9 the day prior. Therefore, she
was given 1 unit of blood and went back to the ___ suite. No
active bleeding was found by ___, and thus a femoral sheath was
removed. Her hypertension was managed with home carvedilol and
valsartan while HCTZ was held. She required intermittent
labetalol while in the ICU, average IV 30mg per day. On ___
procedure day 2, her home antihypertensive medications were
restarted when she was tolerated clears, which was advanced to
regular on the same day. Her xarelto was held since she
presented to the ED. From a pulmonary standpoint, She initially
required nasal cannula, which she has weaned off of by POD2. Her
hemoglobin remained stable in high 7s and low 8s for 24 hours,
with hemodynamic stability and thus she was transferred to the
floor for further care.
Once out of the ICU and on the floor the patient remained
hemodynamically stable and hematocrit trended up from 22 to 24
on day of discharge. The Patient declined restarting xarelto
because she felt adamant that it was the cause of her bleeding.
Therefore she was started on lovenox and would follow-up with
her cardiologist to discuss a long term anticoagulation plan.
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. Vital signs were stable and hematocrit was 24. 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.
She was taught about lovenox injections and was able to
demonstrate proper technique. She had follow-up appointments
with her PCP and cardiologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / Percocet / calcium carbonate / tramadol
Attending: ___.
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yoF hx ___, LV aneurysm, CKD, DVT on warfarin, RA on
prednisone, methotrexate and Rituximab, admitted to the FICU for
anemia, intermittent hypotension and ?UGI bleed. Patient was
sent into ED by rheumatologist after routine labs revealed Hb
6.8. In ED patient reported she has felt more fatigued for past
week, and black stools for past ___ days. No history of GI
bleeds. Does have history of hemorrhoids, but no brbpr. No
NSAIDS, alcohol, abdominal pain. Never had colonoscopy or EGD
(declined). Of note, patient had recent admission in ___,
during which she was also anemic requiring transfusion, but was
felt to be acute on chronic ___. On ROS denied fever,
dizziness, lightheadedness, vomiting/hematemesis, chest pain,
SOB, abdominal pain, diarrhea, constipation, dysuria, urinary
frequency.
In the ED, initial vitals: T 98.3 P 68 BP 119/46 Rr 18 O2 100%
RA
Exam notable for ___ systolic murmur, benign abdomen. Refused
rectal.
Labs notable for: Hb 6.8, WBC 13.6 (neutrophil predominance, no
bands), ___ 21.7, INR 2.0, BUN 110, Cr 2.1 (baseline 1.6). CRP
44.8. LFTs wnl.
Patient received: IV pantoprazole, FFP to reverse INR, 1u
PRBCs. Hb improved to 7.4 post transfusion. Had episode of
hypotension to 80's (asymptomatic, rebounded without
intervention) and was given 1L NS.
Consults: GI consulted, who could not scope because patient had
recently eaten, but wil consider scope in AM, depending on
clinical status.
Vitals on transfer: P 91, 129/64, 19, 95% RA
Upon arrival to ___, patient is feeling well, just hungry. She
clarifies that she has actually been having black stools since
___. Denies dizziness, lightheadedness, chest pain, SOB,
blood in her stool. Confirms never had colonoscopy but had stool
guaiac cards last year which were negative. Per HCP ___, she
has been taking her iron supplementation daily.
Past Medical History:
- Cataracts s/p OS surgery in ___
- CVA ___, R frontal and R medial cerebellar embolic
infarcts, on warfarin
- L ventricular aneurysm
- CAD (chronic atypical chest pain w/ old inferior wall MI)
- Glucose intolerance
- HLD
- HTN
- Hypokalemia
- Peripheral edema, likely chronic venous insufficiency
- PVD (Common Iliac Artery Thrombus, aorto-biiliac disease, left
SFA disease, carotid artery stenosis)
- RA (on MTX, prednisone)
- osteoporosis
- s/p cholecystectomy
- DVT ___, on warfarin for chronic DVTs as well as left
ventricular aneurysm and poor ventricular function as per review
of the hematology notes in ___.
Social History:
___
Family History:
Daughter with ___ syndrome.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp 97.6 BP 136/94 HR 91 RR 19 97% on RA
GENERAL: well appearing, no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, ___ systolic murmur
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: no rashes
NEURO: no focal deficits
ACCESS: 2 PIV
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: ___ 0704 Temp: 98.0 PO BP: 124/67 R Lying HR: 89
RR: 18 O2 sat: 97% O2 delivery: 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: NR/RR, ___ systolic murmur, JVP not elevated
RESP: CTAB, no wheezes, crackles, or rhonchi
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, R ankle TTP over medial
malleoulus, pain with passive ROM, lidocaine patch in place
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 11:25AM BLOOD WBC-13.6* RBC-2.27* Hgb-6.8* Hct-22.5*
MCV-99* MCH-30.0 MCHC-30.2* RDW-14.5 RDWSD-51.4* Plt ___
___ 11:25AM BLOOD ___
___ 02:40PM BLOOD Glucose-188* UreaN-110* Creat-2.1* Na-146
K-5.1 Cl-105 HCO3-19* AnGap-22*
___ 02:40PM BLOOD Calcium-9.1 Phos-5.0* Mg-2.4 Iron-54
___ 02:40PM BLOOD calTIBC-308 Hapto-263* Ferritn-93 TRF-237
___ 11:25AM BLOOD CRP-44.8*
DISCHARGE LABS:
___ 01:00PM BLOOD WBC-12.8* RBC-2.58* Hgb-7.7* Hct-25.2*
MCV-98 MCH-29.8 MCHC-30.6* RDW-15.5 RDWSD-54.8* Plt ___
___ 05:28AM BLOOD Glucose-78 UreaN-51* Creat-1.4* Na-147
K-4.5 Cl-108 HCO3-25 AnGap-14
___ 05:32AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.6
MICRO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
XR ankle (___):
IMPRESSION:
Osteopenia is moderate. There is no fracture or dislocation.
Pes planus is noted. No destructive bone lesions are present.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Lisinopril 20 mg PO DAILY
4. metHOTREXate sodium 12.5 mg oral 1X/WEEK
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Alendronate Sodium 70 mg PO QFRI
7. Atorvastatin 40 mg PO QPM
8. Ferrous Sulfate (Liquid) 220 mg PO DAILY
9. Torsemide 40 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Warfarin Dose is Unknown PO DAILY16
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QPM for leg pain
RX *lidocaine HCl 4 % Apply to ankle or knee daily Refills:*0
2. Torsemide 20 mg PO DAILY
Take a lower dose of your torsemide until you can follow up with
your primary care doctor
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Alendronate Sodium 70 mg PO QFRI
5. Atorvastatin 40 mg PO QPM
6. Ferrous Sulfate (Liquid) 220 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. metHOTREXate sodium 12.5 mg oral 1X/WEEK (FR)
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. PredniSONE 5 mg PO DAILY
12. HELD- Warfarin Dose is Unknown PO DAILY16 This medication
was held. Do not restart Warfarin until you follow up with your
primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute blood loss anemia
Melena
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: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ year old woman with RA, ankle pain// acute ankle pain, assess
for fracture acute ankle pain, assess for fracture
IMPRESSION:
Osteopenia is moderate. There is no fracture or dislocation. Pes planus is
noted. No destructive bone lesions are present.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Anemia, Fatigue
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.3
heartrate: 69.0
resprate: 18.0
o2sat: 100.0
sbp: 119.0
dbp: 46.0
level of pain: 0
level of acuity: 3.0 | SUMMARY/ASSESSMENT: Ms. ___ is an ___ female with a
PMH notable for RA, stroke, LV aneurysm, DVT, chronic
anticoagulation, and anemia who presents with worsening anemia
and dark stools, concerning for active GI bleeding. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Simvastatin / Tape ___ / Hydrochlorothiazide /
Eptifibatide / CellCept / Integrilin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of CAD s/p CABG x5 and
multiple PCIs (last in ___ s/p DES to RCA), ischemic
cardiomyopathy (EF ___, atrial fibrillation s/p left MCA CVA
on warfarin, granulomatosis with polyangiitis c/b ESRD s/p LRD
renal transplant who presents with shortness of breath and
increased fatigue. The patient reports that ___ has had shortness
of breath since his last admission, possibly gradually increased
the past few days. The patient has stable orthopnea (uses
hospital bed), but reports episodes of Cheynes-Stokes-like
breathing. ___ denies any recent fevers, chills, new cough,
diarrhea, nausea/vomiting, or other infectious symptoms. ___
reports that ___ remains diligent about his diet and denies
recent soups, chips, prepared food, or added salt. The patient
has been taking torsemide 40mg BID consistently. ___ reports a
dry weight of 164, reports that ___ most recently was 168. With
regard to fatigue, the patient reports that this is unchanged
from prior, though it remains of concern to him.
In the ED intial vitals were pain 7, T 97.8, HR 70, BP 139/85,
RR 16, O2 97%). Initial labs demonstrated HCT 28.7% (baseline
~27%), platelets 108 (near baseline), creatinine 2.9 (baseline
~3.2), pro-BNP of 38000 (previously ___, troponin 0.02, and
an unremarkable UA. A CXR demonstrated slightly increased
pulmonary edema. The patient was given furosemide 60mg IV and
admitted for further evaluation.
Upon arrival to the floor, initial vital signs were 98.5 136/85
69 22 99%/2L. The patient corroborated the above history. ___ was
without current complaint.
ROS: 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,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: LIMA-LAD, SVG-D, SVG-OM, SVG-RCA in ___
- PERCUTANEOUS CORONARY INTERVENTIONS: occluded OM and RCA
grafts s/p multiple PCIs (including three-stent sandwich to
RCA), last ___
- PACING/ICD: BiV ICV ___
3. OTHER PAST MEDICAL HISTORY:
-Systolic heart failure (EF ___ on ___
-Paroxysmal atrial fibrillation
-ESRD s/p living donor (sister) renal transplant in ___
-Mitral regurgitation, improved with biventricular pacing
-granulomatosis with polyangiitis (renal/pulmonary involvement)
diagnosed ___ s/p cytoxan/prednisone x ___ initially, ANCA neg.
since (chronic proteinuria); now s/p renal transplant in ___
-GERD
-Gout
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: 98.5 136/85 69 22 99%/2L
General: well-appearing male, visibly dyspneic
HEENT: NCAT, tacky MMM, anicteric sclera
Neck: Supple, JVD 6cm above clavicle at 90 degrees
CV: RRR (+)S1/S2 Systolic murmur at apex
Lungs: Few bibasilar crackles, coarse breath sounds at bases,
clears in higher lung fields
Abdomen: Soft, NT/ND, NABS
GU: deferred
Ext: warm, well-perfused, good pulses, 1+ ___ edema b/l
Neuro: Non-focal, CN II-XII grossly intact, ambulating freely
Skin: No obvious rashes
DISCHARGE EXAM:
VS: 98.2 ___ 69-70 18 90-93%RA 100% CPAP
Weight 75.6 -> 75.3 (dry weight 166 pounds)
I/O 24h 1600/2250 AM ___
General: Appears older than stated age, fatigued. Appears
comfortable. No acute distress.
HEENT: NCAT, dry MM, anicteric sclera
Neck: Supple, JVP flat at 45 degrees
CV: RRR (+)S1/S2sSystolic murmur at apex
Lungs: CTAB
Abdomen: Soft, NT/ND, NABS
Ext: Warm, well-perfused, good pulses, no edema
Neuro: Non-focal, CN II-XII grossly intact
Skin: No obvious rashes
Pertinent Results:
ADMISSION LABS:
___ 03:50PM BLOOD WBC-5.9 RBC-3.28* Hgb-8.6* Hct-28.7*
MCV-88 MCH-26.3* MCHC-30.0* RDW-24.0* Plt ___
___ 03:50PM BLOOD Neuts-84* Bands-0 Lymphs-8* Monos-7 Eos-0
Baso-0 Atyps-1* ___ Myelos-0
___ 03:50PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL
Schisto-OCCASIONAL Burr-1+ Ellipto-1+
___ 03:50PM BLOOD ___ PTT-41.1* ___
___ 03:50PM BLOOD Glucose-111* UreaN-43* Creat-2.9* Na-134
K-3.3 Cl-95* HCO3-25 AnGap-17
___ 11:30PM BLOOD CK(CPK)-35*
___ 03:50PM BLOOD ___
___ 03:50PM BLOOD cTropnT-0.02*
___ 03:50PM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8
OTHER RELEVANT:
___ 11:30PM BLOOD Glucose-176* UreaN-44* Creat-3.0* Na-137
K-2.9* Cl-95* HCO3-28 AnGap-17
___ 06:30AM BLOOD Glucose-126* UreaN-43* Creat-2.9* Na-138
K-3.5 Cl-98 HCO3-26 AnGap-18
___ 09:10AM BLOOD Glucose-121* UreaN-44* Creat-3.2* Na-138
K-3.3 Cl-98 HCO3-28 AnGap-15
___ 05:15AM BLOOD Glucose-131* UreaN-44* Creat-3.1* Na-138
K-3.7 Cl-100 HCO3-25 AnGap-17
___ 07:36AM BLOOD Glucose-112* UreaN-40* Creat-3.2* Na-137
K-3.8 Cl-99 HCO3-29 AnGap-13
___ 03:50PM BLOOD cTropnT-0.02*
___ 11:30PM BLOOD CK-MB-2 cTropnT-0.02*
___ 06:30AM BLOOD CK-MB-2 cTropnT-0.02*
___ 04:40AM BLOOD Calcium-8.1* Phos-4.7* Mg-1.9
___ 06:30AM BLOOD tacroFK-5.2
___ 09:10AM BLOOD tacroFK-4.9*
___ 05:15AM BLOOD tacroFK-4.9*
___ 07:59AM BLOOD tacroFK-4.4*
___ 07:36AM BLOOD tacroFK-5.1
DISCHARGE:
___ 07:36AM BLOOD WBC-5.1 RBC-3.24* Hgb-8.9* Hct-29.1*
MCV-90 MCH-27.5 MCHC-30.6* RDW-23.4* Plt Ct-96*
___ 04:40AM BLOOD ___
___ 04:40AM BLOOD Glucose-110* UreaN-43* Creat-2.9* Na-137
K-3.0* Cl-96 HCO3-27 AnGap-17
___ 04:40AM BLOOD Calcium-8.1* Phos-4.7* Mg-1.9
___ EKG:
Atrial fibrillation with biventricular pacing. No significant
change compared to previous tracing of ___.
___ CXR:
IMPRESSION: Slight increase in degree of pulmonary edema.
___ ECHO:
The right atrium is markedly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is moderate to severe regional left ventricular systolic
dysfunction with inferior and infero-lateral akinesis. The
distal LV and apex are hypokinetic. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is dilated with moderate
global free wall hypokinesis. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Severe (___) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the overall LVEF has further decreased.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol 50 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Calcium Acetate 1334 mg PO BID
4. Carvedilol 25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion
7. Isosorbide Mononitrate 20 mg PO BID
8. Omeprazole 40 mg PO DAILY
9. Sertraline 150 mg PO DAILY
10. Sodium Bicarbonate 1300 mg PO BID
11. Tacrolimus 0.5 mg PO Q12H
12. Warfarin 3.75 mg PO DAILY16
13. Atorvastatin 10 mg PO DAILY
14. Lantus (insulin glargine) 5 units SUBCUTANEOUS HS
15. Magnesium Oxide 400 mg PO DAILY
16. HydrALAzine 50 mg PO TID
17. Lorazepam 0.5 mg PO HS
18. Myfortic (mycophenolate sodium) 720 mg ORAL BID
19. Torsemide 40 mg PO BID
20. Vitamin D ___ UNIT PO DAILY
21. Senna 1 TAB PO BID constipation
22. TraMADOL (Ultram) 50 mg PO BID:PRN pain
23. Docusate Sodium 100 mg PO BID
24. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN congestion
Discharge Medications:
1. Allopurinol 50 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Calcium Acetate 1334 mg PO BID
5. Carvedilol 25 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion
9. HydrALAzine 75 mg PO TID
RX *hydralazine 50 mg 1.5 tablet(s) by mouth three times a day
Disp #*135 Tablet Refills:*0
10. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1.5 tablet extended release 24
hr(s) by mouth daily Disp #*45 Tablet Refills:*0
11. Lorazepam 0.5 mg PO HS
12. Magnesium Oxide 400 mg PO DAILY
13. Myfortic (mycophenolate sodium) 720 mg ORAL BID
14. Omeprazole 40 mg PO DAILY
15. Senna 1 TAB PO BID constipation
16. Sertraline 150 mg PO DAILY
17. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
18. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN congestion
19. Tacrolimus 0.5 mg PO Q12H
20. Torsemide 60 mg PO BID
RX *torsemide 20 mg 3 tablet(s) by mouth twice a day Disp #*180
Tablet Refills:*0
21. Vitamin D ___ UNIT PO DAILY
22. Warfarin 2.5 mg PO DAILY16
RX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
23. Lantus (insulin glargine) 5 units SUBCUTANEOUS HS
24. TraMADOL (Ultram) 50 mg PO BID:PRN pain
25. Outpatient Lab Work
Please check Chem10 level along with INR on ___.
Indication: Hypokalemia and atrial fibrillation (276.8 and
427.31)
Please fax results to Dr. ___ (fax# ___
26. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, SOB
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute on chronic systolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS, ___.
HISTORY: ___ male with shortness of breath.
COMPARISON: ___ and ___.
FINDINGS: Frontal and lateral views of the chest. There is increased
pulmonary edema when compared to prior. Blunting of the posterior
costophrenic angle is compatible with small effusions. There is no confluent
consolidation. Moderate cardiomegaly again noted. Single-lead pacing device
is identified. Median sternotomy wires are identified as well as coronary
stents. No acute osseous abnormalities.
IMPRESSION: Slight increase in degree of pulmonary edema.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 97.8
heartrate: 70.0
resprate: 16.0
o2sat: 97.0
sbp: 139.0
dbp: 85.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ is a ___ with history of CAD s/p CABG and multiple
PCIs, post-infarct cardiomyopathy with depressed EF ___,
severe mitral regurgitation, and GPA s/p kidney transplant
presenting with worsening shortness of breath and elevated
weight due to heart failure exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Keflex /
Naprosyn
Attending: ___.
Chief Complaint:
S/P Fall
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ is a ___ female with PMH significant for
MDS, RA, PMR, HTN, hypothyroidism, and dementia who presents via
EMS for altered mental status. Per EMS, the patient was noted to
be wandering down the street in ___ (around .3 miles
from her residence). EMS witnessed the patient trip, fall, and
strike her head. There was no loss of consciousness. She was
able to ambulate after her fall. Cervical collar was placed and
she
was brought to the ED.
In the ED, the patient was only able to relate that her name is
___. She was unable to say anything else (later confirmed to
be just under her baseline). Per her last admission note in
___ (___), she was noted to have limited verbal
communication at baseline with increasing inability to
communicate over the last several years. She has had progressive
dementia for several years with her last MOCA of 5 in ___. She
did not complain of any pain at that time. The patient was
agitated in the ED and, at one point, tried to leave the
department during an ultrasound. She was brought back to her
room
and given Olanzapine x2. The CT did reveal a large non-occlusive
DVT.
The patient's two sons (one of which is the HCP) arrived bedside
and were able to provide more information about her living
situation and identify her. She has exhibited signs of dementia
in a gradual manner over the past several years. Her sons note
that she only speaks when spoken to and speaks in ___ word
sentences. She is able to perform her most of her ADLs without
much assistance (except for bathing and dressing). Her family
helps with all IADLs. A ___ service called ETHOS comes by her
home for four hours/day to help her with bathing, dressing,
medications, etc. She currently lives with only her ___ old
husband who they report is exhibiting signs of deteriorating
health. This is her second attempt to wander from her home
unsupervised in the past two weeks, the first time she was seen
by her neighbor trying to enter a vehicle before being brought
back into the house.
- In the ED, initial vitals were:
Temp: 97.2 HR: 80bpm BP: 115/50 RR: 18 SpO2: 98% RA
- Exam was notable for: Negative FAST, Abdomen soft and NTND.
Complete trauma survey notable only for abdominal tenderness to
palpation and a scalp abrasion.
- Labs were notable for: Hgb 11, Plt 134, PTT 23.6, BUN 26, Cr
0.8, negative tox, negative UA
- Studies were notable for:
* CT CHEST Portable: IMPRESSION: No acute findings.
* CT C-SPINE W/O CONTRAST: IMPRESSION: 1. No acute fracture or
traumatic dislocation. 2. Degenerative changes as described
above.
*CT HEAD W/O CONTRAST: IMPRESSION: No acute intracranial
hemorrhage. Acute nasal septal and left nasal bone fracture with
mild impaction. Frontal subgaleal hematoma.
*CT CHEST/ABD/PELVIS W/: IMPRESSION: No acute sequelae of
trauma. Incidental note of partially occlusive DVT within the
right common femoral vein extending into the deep and
superficial branches. Consider right lower extremity DVT exam
to assess the inferior extent. 2 small cystic lesions within the
pancreas which can be further evaluated with non-emergent MRCP.
Additional non-emergent findings as above.
*ECG: Sinus rhythm Borderline prolonged PR interval Probable
left atrial enlargement
* UNILAT LOWER EXT VEINS: Deep vein thrombosis within the right
common femoral and proximal right femoral veins extending to the
greater saphenous vein. Nonvisualization of the right posterior
tibial and peroneal veins.
- The patient was given:
*IM OLANZapine 2.5 mg x2
*Enoxaparin Sodium 60 mg,
NON-ABSORBABLE sutures were placed in the forehead wound.
Social work was consulted in the ED.
On arrival to the floor, the patient is agitated and anxious.
She was given an ice pack for her head wound and her heat pack
for her lower extremities. Her sons were present at bedside and
identified her and elaborated on her HPI.
Past Medical History:
HCC
Myelodysplastic syndrome
FTT (failure to thrive) in adult
Severe dementia
Frailty
Corns and callus
Hypertensive disorder
Rheumatoid arthritis
Osteoporosis
S/P cataract extraction and insertion of intraocular lens
bilaterally
Impaired glucose tolerance
Polymyalgia rheumatica
Nerve root disorder
Urinary incontinence
History of colon polyps
Hypercholesterolemia
Peripheral venous insufficiency
Anemia
Gastroesophageal reflux disease
Basal cell carcinoma of skin - ___
Malignant melanoma - ___
Cesarean section
Cholecystectomy
Social History:
___
Family History:
Patient's daughter passed away in ___ from an 'aggressive bone
cancer'. Family history difficult to attain prior to her
immigration to the ___ from ___.
Physical Exam:
ADMISSION
=========
VITALS: 97.5 Axillary 129/ 51 HR: 68 RR: 18 SPO2: 98 RA
GENERAL: disheveled, anxious, mildly agitated
HEENT: PERRL. Sclera anicteric and without injection. MM dry.
ecchymosis and abrasions over left side of face, eye and
forehead.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. II/VI
systolic murmur LLSB. No rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis. Pitting edema and erythema
on left lower extremity nearly circumferential around the shin
and calf. Chronic skin changes due to venous stasis (e.g
ichthyosis) Pulses DP/Radial 2+ bilaterally.
SKIN: Warm.
NEUROLOGIC: AOx1. Unintelligible speech. Moving all 4 limbs
spontaneously. Face symmetric
DISCHARGE
=========
VITALS:
24 HR Data (last updated ___ @ 738)
Temp: 97.6 (Tm 99.4), BP: 137/71 (110-137/64-74), HR: 88
(85-104), RR: 20 (___), O2 sat: 98% (93-98), O2 delivery: RA
GENERAL: Alert, no acute distress
HEENT: Bilateral periorbital ecchymosis, L sided abrasions and
hematoma lateral to the nose, poor dentition, MMM
RESP: Normal work of breathing
Pertinent Results:
ADMISSION
=========
___ 10:23AM PLT COUNT-134*
___ 10:23AM ___ PTT-23.6* ___
___ 10:23AM NEUTS-76.2* LYMPHS-12.6* MONOS-9.5 EOS-0.9*
BASOS-0.3 IM ___ AbsNeut-5.08 AbsLymp-0.84* AbsMono-0.63
AbsEos-0.06 AbsBaso-0.02
___ 10:23AM WBC-6.7 RBC-3.73* HGB-11.0* HCT-35.3 MCV-95
MCH-29.5 MCHC-31.2* RDW-13.8 RDWSD-47.8*
___ 10:23AM LACTATE-1.9
___ 10:23AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 10:23AM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-3.5
MAGNESIUM-1.9
___ 10:23AM cTropnT-<0.01
___ 10:23AM LIPASE-19
___ 10:23AM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-86 TOT
BILI-0.5
___ 10:23AM estGFR-Using this
___ 10:23AM GLUCOSE-128* UREA N-26* CREAT-0.8 SODIUM-142
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
___ 10:32AM URINE MUCOUS-MOD*
___ 10:32AM URINE HYALINE-1*
___ 10:32AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:32AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:32AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:32AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 10:32AM URINE HOURS-RANDOM
IMAGING
=======
___ CXR: No acute findings.
___ CT C/A/P w/Contrast
1. No acute sequelae of trauma.
2. Incidental note of partially occlusive DVT within the right
common femoral vein extending into the deep and superficial
branches. Consider right lower extremity DVT exam to assess the
inferior extent.
3. 2 small cystic lesions within the pancreas which can be
further evaluated with nonemergent MRCP.
4. Additional nonemergent findings as above.
___ CT Head and Neck w/o Contrast
1. No acute intracranial hemorrhage.
2. Acute nasal septal and left nasal bone fracture with mild
impaction.
3. Frontal subgaleal hematoma.
___ Lower Extremities Venous Doppler US
1. Deep vein thrombosis within the right common femoral and
proximal right
femoral veins extending to the greater saphenous vein.
2. Nonvisualization of the right posterior tibial and peroneal
veins.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever
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
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Fall
Deep venous thrombus
Secondary:
Advanced Dementia
Sinus Tachycardia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with AMS, s/p fall, eval for acute pathology
TECHNIQUE: Portable AP upright chest radiograph
COMPARISON: None available.
FINDINGS:
AP portable upright view the chest provided. Overlying EKG leads are present.
No large effusion or pneumothorax. The heart appears top-normal in size. No
signs of edema or pneumonia. Mediastinal contour is normal. Imaged bony
structures are intact.
IMPRESSION:
No acute findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with s/p fall, altered mental status// eval for acute
trauma, bleeding, acute abdominal pathology=
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.=
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territory infarction,intracranial
hemorrhage,edema,or discrete mass. There is prominence of the ventricles and
sulci suggestive of involutional changes.
There is an impacted nasal septal fracture as well as a mildly displaced left
nasal bone fracture. Overlying soft tissue swelling is noted as well as a
large forehead hematoma with a subgaleal component. Minimal mucosal
thickening of the ethmoid sinuses. Otherwise, the sinuses are clear. The
mastoid air cells and middle ear cavities are clear. Patient is status post
bilateral lens replacements.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Acute nasal septal and left nasal bone fracture with mild impaction.
3. Frontal subgaleal hematoma.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 1409, less than 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with s/p fall, altered mental status
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 469 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is anatomic.No acute fractures.Disc spaces appear largely preserved.
There is left-sided facet arthropathy and apparent fusion spanning C4-5. No
critical spinal canal or neural foraminal narrowing. There is no prevertebral
soft tissue swelling. Thyroid is enlarged with multiple nodules, likely
representing goiter.
IMPRESSION:
1. No acute fracture or traumatic dislocation.
2. Mild degenerative changes as described above.
3. Thyroid goiter.
Radiology Report
EXAMINATION: CT CHEST, ABDOMEN, AND PELVIS
INDICATION: ___ female status post fall.
TECHNIQUE: Multidetector CT through the chest, abdomen, and pelvis was
performed following IV contrast administration with multiplanar reformations
provided. Dose: Total DLP (Body) = 1,021 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST: Partially visualized thyroid is enlarged with innumerable nodules,
likely representing a goiter. The thoracic aorta is mildly calcified though
normal in caliber and course. The main pulmonary artery is mildly enlarged
measuring 3.4 cm in diameter, please correlate for pulmonary arterial
hypertension. There is no filling defect seen within the central branches of
the pulmonary arterial tree to suggest the presence of a pulmonary embolism.
There is mild aortic valvular calcification and mitral annular calcification
as well as mild calcification along the LAD. No pleural or pericardial
effusion. Slight right atrial enlargement is noted. There is no mediastinal
mass or adenopathy. The airways centrally patent. The esophagus is somewhat
patulous proximally.
The lungs are grossly clear though there is biapical pleuroparenchymal
scarring. No worrisome nodule, mass, or consolidation is seen within the
lungs. No pneumothorax. No hemothorax.
ABDOMEN: The liver enhances normally and appears intact. There is prominence
of the intrahepatic and extrahepatic biliary tree which likely reflect age as
well as prior cholecystectomy. The main portal vein is patent. No
perihepatic fluid. The spleen is intact and normal in size. Adrenals are
normal bilaterally. Th several small cystic lesions are seen within the
pancreas, for example on series 2, image 117 measuring 8 mm in maximal
dimension, series 2, image 123 in the midbody measuring 5 mm in maximal
dimension. The kidneys enhance symmetrically without signs of focal injury.
Several renal cortical hypodensities are likely simple cysts. No
hydronephrosis or hydroureter. No retroperitoneal hematoma. The abdominal
aorta is moderately calcified though normal in caliber. Stomach and duodenum
appear normal.
PELVIS: Loops of small and large bowel demonstrate no signs of ileus or
obstruction. No signs of bowel or mesenteric injury. The appendix is not
clearly visualized though there are no secondary signs of appendicitis.
Colonic diverticulosis is noted without evidence of acute diverticulitis. No
free air or free fluid. The uterus is somewhat atrophic. No adnexal mass.
Urinary bladder is only partially distended though appears normal. No pelvic
sidewall or inguinal adenopathy.
BONES: No osseous injury. No worrisome bony lesions.
SOFT TISSUES: Partially visualized in the right groin, is partially occlusive
thrombus within the right common femoral vein extending into the superficial
and deep femoral vein. Correlation with DVT exam may be helpful to assess the
inferior extent. There is no central extension into the pelvic veins or IVC.
IMPRESSION:
1. No acute sequelae of trauma.
2. Incidental note of partially occlusive DVT within the right common femoral
vein extending into the deep and superficial branches. Consider right lower
extremity DVT exam to assess the inferior extent.
3. 2 small cystic lesions within the pancreas which can be further evaluated
with nonemergent MRCP.
4. Additional nonemergent findings as above.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with AMS, DVT on CT*** WARNING *** Multiple patients
with same last name!// evaluate extent of DVT noted on CT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Same day CT torso.
FINDINGS:
There is echogenic material within the right common femoral vein extending to
the proximal right femoral vein and greater saphenous vein. Additionally, the
right common femoral and proximal right femoral and greater saphenous veins
are noncompressible.
There is normal compressibility, color flow, and spectral doppler of the mid
and distal right femoral, and popliteal veins. The posterior tibial and
peroneal veins are not demonstrated.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Deep vein thrombosis within the right common femoral and proximal right
femoral veins extending to the greater saphenous vein.
2. Nonvisualization of the right posterior tibial and peroneal veins.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Confusion, s/p Fall
Diagnosed with Altered mental status, unspecified
temperature: 97.2
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 115.0
dbp: 50.0
level of pain: UTA
level of acuity: 2.0 | TRANSITIONAL ISSUES
===================
[ ] Two small cystic lesions within the pancreas were found on
CT Pelvis in the ED. MRCP as outpatient for further
characterization if becomes within GOC.
[ ] Her metoprolol was held due to difficulty swallowing pills.
Should she develop tachycardia causing discomfort, this could be
restarted in the outpatient setting for her comfort.
[ ] She is being discharged on apixaban for treatment of DVT as
below.
SUMMARY
=======
___ w/PMH significant for MDS, RA, PMR, HTN, hypothyroidism, and
dementia who presented via EMS for altered mental status after
wandering unsupervised from her home. She was found to have a
small nasal bone fracture with no surgical indication and
incidental non-occlusive DVT and pancreatic cysts and toxic
metabolic workup was negative. She was discharged home with
hospice.
#Altered Mental Status
#Dementia
She has a history of progressive dementia that has limited her
ability to communicate, with a MOCA of 5 in ___. Since ___,
her living situation has changed from living with her son and
granddaughter (who have since moved out) to living with her
husband (also in his ___, who also exhibits signs of
deteriorating health. She has been found wandering away the her
home unsupervised twice in the past two weeks. Her living
situation likely puts her at risk for repeat incidents like
this. She was treated with IV acetaminophen for pain and speech
and swallow was consulted who stated that she was at high risk
for aspiration and she was started on pureed solids and
thickened liquids for comfort feeds per family preference,
although she continued to not take in much PO. After further
goals of care conversations, the decision was made to transition
to more comfort-focused care and she was discharged home with
hospice services. Given her home situation, the decision was
made to attempt to remain at home with 24-hour care with the
understanding that she may need a higher level of care.
#DVT
DVT found on Doppler ultrasound and CT within the right common
femoral and proximal right femoral veins extending to the
greater saphenous vein. Patient has frontal subgaleal hematoma
with low suspicion for intracalvarial bleed. She was treated
with subcutaneous enoxaparin 60mg. This was transitioned to
apixaban 2.5mg BID at discharge.
#Trauma/Fall
#Abrasions
#Nasal Fractures
Patient had an acute nasal septal and left nasal bone fracture
with mild impaction with frontal subgaleal hematoma and minor
abrasions on her forehead and lower extremities s/p fall.
Treated with IV acetaminophen and later PO pain medications.
CHRONIC/STABLE ISSUES
=====================
#Incidental Pancreatic Cysts
Two small cystic lesions within the pancreas were found on CT
Pelvis in the ED. MRCP as outpatient for further
characterization if becomes within ___.
#Sinus Tachycardic
Held home metoprolol given inability to take metoprolol. Was not
discharged on metoprolol.
#Venous Stasis Ulcer LLE
Low clinical suspicion for cellulitis. Has been treated for
cellulitis in the past with doxycycline in ___. Family
reports that the leg has been stable for an extended period of
time. Wrapped with ACE bandage.
#Onychomycosis
Outpatient follow-up with Podiatry. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levaquin / cortisone
Attending: ___.
Chief Complaint:
Fall, CHF
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with Hx of AVR and MVR due to rheumatic heart
disease ___, CHF with LVEF 30% ___ --> 65% in ___, afib on
warfarin, DMT2, who presented to ___ after
fall
at home, now felt to have volume overload.
According to her daughter she had been more fatigued than usual
for a few weeks before the fall. She did not have any DOE, ___
edema, CP, or orthopnea/PND at that time. She was outside her
home picking up a flower and felt dizzy when she stood back up.
She lost her balance and hit her head, likely against the wall
of
the house. She fell and was able to press her life alert button
but unable to stand up. She reported that she did not lose
consciousness. EMS arrived and she was taken to ___.
Per
report from ___ neuro exam was wnl and CT Head showed
no
bleed but did show "nondisplaced fracture of L occipital
condyle." She was given morphine and transferred to ___ for
further evaluation. Per her daughter, the morphine did cause her
to become confused and have some hallucinations.
At ___ initial eval revealed forehead laceration, normal
neurologic exam. She underwent MRI C and T spine which showed
chronic multilevel degenerative changes without acute injury.
Neurosurgery evaluated her for the occipital condyl fracture and
felt no intervention, no C collar needed, and no neurosurgical
follow up needed.
In the ED initial vitals were stable with patient arriving on 2L
NC but weaned to room air. Over the course of ED stay she was
resuscitated with approx. 2L of NS and developed desaturations
and crackles on exam. She required 2L NC and received 40 IV
Lasix. She is admitted now for IV diuresis. Her EKG showed a RBB
which is new from last prior in our system in ___. She had trop
negative x2. K was originally elevated to 6.0 but downtrended to
4.1 with fluids.
Patient was given:
___ 02:42 IV Morphine Sulfate 2 mg
___ 02:42 IV Acetaminophen IV 1000 mg
___ 02:42 IVF NS
___ 03:51 IV Morphine Sulfate 2 mg
___ 07:04 IVF NS ___
___ 07:38 IV Morphine Sulfate 2 mg
___ 07:46 PO/NG Fosfomycin Tromethamine 3 g
___ 09:20 PO/NG Sertraline 150 mg
___ 09:20 PO/NG Lisinopril 5 mg
___ 09:20 PO Metoprolol Succinate XL 75 mg
___ 09:20 PO/NG Levothyroxine Sodium 50 mcg
___ 09:20 PO BuPROPion XL (Once Daily) 150 mg
___ 11:20 IV Ondansetron 4 mg
___ 11:20 PO/NG OxyCODONE (Immediate Release) 20 mg
___ 11:21 IVF NS 100 mL/hr x2 hour then discontinued
___ 14:22 PO/NG Furosemide 40 mg
___ 14:27 IV Acetaminophen IV 1000 mg
On the floor she denies any chest pain, palpitations,
lightheadedness, leg swelling. She has pain in her neck. Per her
daughter she appears to be back at her mental status baseline.
Past Medical History:
Diabetes Type 2
HTN
2. CARDIAC HISTORY
Atrial fibrillation.
MVR in ___
AVR/MVR with #21 and #25 pericardial tissue valves ___
Systolic Hear Failure with LVEF 30% in periop period ___,
subsequently improved to 65% on ___ echo
3. OTHER PAST MEDICAL HISTORY
Pneumonia.
Osteomyelitis.
Right lower leg osteomyelitis.
Osteoporosis.
Vertebroplasty in ___.
History of rib fracture.
Dementia (baseline oriented to self and year, not president)
Hypothyroidism
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=======================
afebrile 123 / 82 99 20 88 RA
GENERAL: Well developed, well nourished and in NAD. Oriented x3
at present. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink.
NECK: Supple. JVP of 9 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregular rate and rhythm. Normal S1, S2. No murmurs,
rubs,
or gallops. No thrills or lifts.
LUNGS: Mild bibasilar crackles, otherwise CTAB with normal resp
effort.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: chronic venous stasis changes of the distal ___.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
===========================
VS: 24 HR Data (last updated ___ @ 843)
Temp: 98.9 (Tm 98.9), BP: 159/99 (92-159/60-99), HR: 107
(73-107), RR: 18 (___), O2 sat: 96% (86-96), O2 delivery: RA,
Wt: 118.39 lb/53.7 kg
GENERAL: Well developed, well nourished and in NAD. Oriented x3
at present. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink.
NECK: Supple. No JVP elevation.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregular rate and rhythm. Normal S1, S2. No murmurs,
rubs,
or gallops. No thrills or lifts.
LUNGS: Bibasilar crackles L>R, otherwise CTAB with normal resp
effort.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: chronic venous stasis changes of the distal ___.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS
==============
___ 02:33AM BLOOD WBC-10.8* RBC-3.96 Hgb-12.6 Hct-37.2
MCV-94 MCH-31.8 MCHC-33.9 RDW-13.2 RDWSD-45.8 Plt ___
___ 02:33AM BLOOD Neuts-76.8* Lymphs-13.4* Monos-8.5
Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.29* AbsLymp-1.45
AbsMono-0.92* AbsEos-0.05 AbsBaso-0.03
___ 02:33AM BLOOD ___ PTT-29.2 ___
___ 02:33AM BLOOD Glucose-157* UreaN-17 Creat-0.8 Na-133*
K-8.8* Cl-96 HCO3-23 AnGap-14
___ 02:33AM BLOOD CK(CPK)-176
___ 07:07AM BLOOD CK(CPK)-54
___ 02:33AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:07AM BLOOD CK-MB-2 proBNP-2440*
___ 07:07AM BLOOD cTropnT-<0.01
___ 02:33AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0
DISCHARGE LABS
==============
___ 06:40AM BLOOD WBC-7.9 RBC-3.86* Hgb-12.5 Hct-36.7
MCV-95 MCH-32.4* MCHC-34.1 RDW-13.5 RDWSD-47.0* Plt ___
___ 06:40AM BLOOD ___
___ 06:40AM BLOOD Glucose-139* UreaN-12 Creat-0.7 Na-138
K-4.1 Cl-99 HCO3-28 AnGap-11
MICROBIOLOGY
============
___ 2:34 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
=======
MRI C and T spine ___. Study is moderately degraded by motion.
2. T2, T7 and T12 chronic anterior compression deformities.
3. Within limits of study, no definite evidence of acute
cervical or thoracic
fracture or ligamentous injury.
4. Within limits of study, no definite evidence of cervical or
thoracic spinal
cord lesion or abnormal enhancement.
5. Multilevel cervical and thoracic spondylosis as described,
without definite
evidence of moderate or severe vertebral canal narrowing.
6. Question history of vertebroplasty of T10 through L3
vertebral bodies.
7. Incomplete evaluation of left renal lesions suggestive of
cysts. If
concern for renal masses, consider contrast renal MRI for
further evaluation.
Chest PA and Lat ___. Increased interstitial lung markings in both lungs which
could represent
progressed chronic interstitial lung disease and/or mild
pulmonary edema
superimposed on chronic interstitial lung disease.
2. Irregular linear opacities in both lower lobes which could
represent
atelectasis, scarring, or pneumonia.
TTE ___
IMPRESSION: Biatrial enlargement. Mild regional systolic
dysfunction (see schematic) in the setting
of globally preserved left ventricular systolic function.
Moderate to severe tricuspid regurgitation with
mild pulmonary hypertension and low normal right ventricular
function. Normally functioning
bioprosthetic aortic and mitral valves.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ with fall with head strike, CT at other hospital read as
showing occipital condyle fracture. Per neurosurgery evaluation, no occipital
condyle fracture, but some upper extremity weakness appreciated by
neurosurgery on exam. Evaluate for cord injury.
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: ___ abdomen and pelvis CT.
FINDINGS:
Study is moderately degraded by motion. Within these confines:
Cervical spine vertebral body alignment is grossly preserved.
Dextroscoliosis of the thoracic spine is noted. T2, T7 and T12 chronic
anterior compression deformity is present, with the T12 demonstrated on ___
prior exam. Otherwise, vertebral body heights are grossly preserved. C5
superior, C6-7, T3-4 and T6-7 endplates probable type ___ ___ changes without
definite epidural collection noted. Question history of vertebroplasty of T10
through L3 vertebral bodies.
The visualized portion of the spinal cord is grossly preserved in signal and
caliber.
There is loss of intervertebral disc height and signal throughout the cervical
and thoracic spine.
There is no prevertebral soft tissue swelling.
At C2-3 there is no vertebral canal or neural foraminal narrowing.
At C3-4 there is disc bulge, uncovertebral hypertrophy, facet joint
hypertrophy, mildvertebral canaland severe rightneural foraminal narrowing.
At C4-5 there is disc bulge, uncovertebral hypertrophy, facet joint
hypertrophy, and flavum hypertrophy, mildvertebral canal and mild bilateral
neural foraminal narrowing.
At C5-6 there is disc bulge, uncovertebral hypertrophy, facet joint
hypertrophy, hypertrophy, mildvertebral canal, severe left and mild
rightneural foraminal narrowing.
At C6-7 there is disc bulge, uncovertebral hypertrophy, facet joint
hypertrophy, mildvertebral canal, moderate right and severe leftneural
foraminal narrowing.
At C7-T1 there is disc bulge, facet joint hypertrophy, ligamentum flavum
hypertrophy, mildvertebral canal and no neural foraminal narrowing. Bilateral
probable perineural cysts are noted.
At T1-2 there is disc bulge, novertebral canal and no neural foraminal
narrowing. Bilateral probable perineural cysts are noted.
At T2-3 there is disc bulge, novertebral canal and no neural foraminal
narrowing.
At T3-4 there is no vertebral canal or neural foraminal narrowing.
At T4-5 there is no vertebral canal or neural foraminal narrowing.
At T5-6 there is no vertebral canal or neural foraminal narrowing.
At T6-7 there is no vertebral canal or neural foraminal narrowing.
At T7-8 there is no vertebral canal or neural foraminal narrowing.
At T8-9 there is no vertebral canal or neural foraminal narrowing.
At T9-10 there is no vertebral canal or neural foraminal narrowing.
At T10-___ there is disc bulge, mildvertebral canal and no neural foraminal
narrowing.
At T11-12 there is disc bulge, novertebral canal and no neural foraminal
narrowing.
At T12-L1 there is disc bulge, facet joint hypertrophy, novertebral canal or
neural foraminal narrowing.
At T12-L1 there is disc bulge facet joint hypertrophy, ligamentum flavum
hypertrophy, mild vertebral canal and no neural foraminal narrowing.
OTHER:
There is no paravertebral or paraspinal mass identified. Left renal probable
cysts are noted, incompletely evaluated on examination. Limited imaging lungs
suggest bilateral dependent atelectasis.
IMPRESSION:
1. Study is moderately degraded by motion.
2. T2, T7 and T12 chronic anterior compression deformities.
3. Within limits of study, no definite evidence of acute cervical or thoracic
fracture or ligamentous injury.
4. Within limits of study, no definite evidence of cervical or thoracic spinal
cord lesion or abnormal enhancement.
5. Multilevel cervical and thoracic spondylosis as described, without definite
evidence of moderate or severe vertebral canal narrowing.
6. Question history of vertebroplasty of T10 through L3 vertebral bodies.
7. Incomplete evaluation of left renal lesions suggestive of cysts. If
concern for renal masses, consider contrast renal MRI for further evaluation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ female with desatting, crackles and rhonchi on exam//
pulm edema and/or PNA?
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
There are increased interstitial lung markings in both lungs. There are
irregular opacities in the bilateral lower lobes. Heart is borderline
enlarged. Median sternotomy wires and mitral and aortic valve prostheses are
noted. Moderate to severe degenerative changes are noted in the bilateral
shoulders.
IMPRESSION:
1. Increased interstitial lung markings in both lungs which could represent
progressed chronic interstitial lung disease and/or mild pulmonary edema
superimposed on chronic interstitial lung disease.
2. Irregular linear opacities in both lower lobes which could represent
atelectasis, scarring, or pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Other specified injuries of head, initial encounter, Fall on same level, unspecified, initial encounter, Heart failure, unspecified, Shortness of breath, Hypoxemia
temperature: 98.2
heartrate: 98.0
resprate: 16.0
o2sat: 92.0
sbp: 158.0
dbp: 79.0
level of pain: 10
level of acuity: 2.0 | ___ with history of rheumatic heart disease s/p AVR/MVR
bioproesthetic valves ___, MVR in ___, afib on warfarin, HTN,
DM2 presented with after falling at home. In the ED, she was
also noted to have acute heart failure exacerbation requiring
admission and IV diuresis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Cipro
Attending: ___
Chief Complaint:
abdominal pain,
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o HTN & CKD (baseline Cr 2.5) who presents w/ acute
onset of abdominal pain. The pain started after eating lunch and
radiated to the back, she denies chest pain, shortness of
breath, lightheadedness, dizziness. She went to ___, where
non-contrast CT chest/abd/pelvis was concerning for descending
aortic anuerysm, and she was transferred to ___ for further
management. She received dilaudid for pain control and was
started on labetalol gtt for BP control (SBP 110s). In ED, she
is not complaining of any abdominal pain or back pain. WBC 6.5,
lactate 1.5 (OSH), and repeat Cr 2.1. She has h/o thoracic
outlet syndrome on R side and BP asymmetry, and follows her BP
on her left arm. Of note, she has had recent changes to her BP
medications (discontinued atenolol in ___ and started on
hydralazine), with recent BPs between 140-180s.
Past Medical History:
HTN
hypercholesterolemia
CKD stage III (Cr 2.5)
thoracic outlet syndrome (R arm SBP90s, L arm SBP 140s)
hypothyroidism
autoimmune leukoencephalopathy
L humerus fracture ___ years ago
L hip replacement following fall ___ years ago
Social History:
___
Family History:
CAD in the family, brother died of MI in ___ and mother also
died of MI. Father also with CAD. Denies history of DM, cancers.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: Tm 98.7, Tc 97.8, HR 75 (75-87), BP 123/70
(110-143/59-83), RR ___, O2 Sat 90-98%RA
Weight: 53kg today, 54.7kg yesterday
General: NAD, lying in bed, pleasant and conversant, in no
respiratory distress.
HEENT: NC/AT, MMM, tongue midline, symmetric palate elevation,
clear posterior OP, no lesions/erythema, EOMI, PERRL.
Lymph: No LAD in neck.
CV: RRR, soft heart sounds, ___ systolic murmur heard best in
LUSB.
Lungs: CTAB with tight air movement throughout, no
wheezes/rales.
Abdomen: soft, nontender to palpation, nondistended, no
organomegaly, +BS
GU: No foley
Ext: warm and well perfused, 2+ DP pulses, trace pitting edema
on the R, 1+ edema on the left, worse this morning on the L
compared to R. No calf tenderness.
Pertinent Results:
==== ADMISSION LABS ====
___ 05:35PM BLOOD WBC-6.5 RBC-3.32* Hgb-10.2* Hct-30.4*
MCV-92 MCH-30.6 MCHC-33.4 RDW-15.2 Plt ___
___ 05:35PM BLOOD Neuts-89.3* Lymphs-6.3* Monos-3.4 Eos-0.9
Baso-0.2
___ 05:35PM BLOOD ___ PTT-27.5 ___
___ 05:35PM BLOOD Glucose-270* UreaN-35* Creat-2.1* Na-139
K-4.1 Cl-107 HCO3-19* AnGap-17
___ 05:35PM BLOOD cTropnT-<0.01
___ 11:51PM BLOOD CK-MB-3 cTropnT-<0.01
___ 11:51PM BLOOD CK(CPK)-94
___ 04:03AM BLOOD Calcium-8.1* Phos-3.9 Mg-1.7
==== DISCHARGE LABS ====
___ 07:36AM BLOOD WBC-6.0 RBC-3.13* Hgb-9.9* Hct-28.2*
MCV-90 MCH-31.5 MCHC-35.1* RDW-15.4 Plt ___
___ 07:36AM BLOOD Glucose-76 UreaN-31* Creat-2.7* Na-140
K-3.7 Cl-104 HCO3-23 AnGap-17
___ 07:36AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
==== MICROBIOLOGY ====
NONE
==== IMAGING ====
___
___ CT A/P without IV but with oral contrast
1. Findings concerning for descending thoracic aortic dissection
without extension into or involvement of the abdominal aorta.
2. Diffuse abdominal aortic ectasia.
3. No evidence for bowel ischemia or obstruction, urinary tract
obstruction, or acute abdominal or pelvic process.
4. Recommend consideration for noncontrast chest CT for further
assessment of the thoracic aorta.
___
___ ECG:
Sinus rhythm. Prolonged Q-T interval. No previous tracing
available for
comparison.
___ ECG:
Sinus rhythm. There is a late transition which is probably
normal. Compared to the previous tracing of ___ the Q-T
interval is shorter.
___ CXR (PORTABLE):
Bilateral pleural effusions appear to be increased since the
prior study. Bibasal atelectasis has developed most likely
secondary but infectious process is a possibility. Upper lungs
are essentially clear. There is no evidence of pulmonary edema.
There is no evidence of pneumothorax.
___ TTE:
Left ventricular cavity size and global systolic function are
normal (LVEF >55%). Right ventricular cavity size and free wall
motion are grossly normal. The ascending aorta is mildly
dilated. No discrete dissection flap is seen on 2D imaging, or
suggested by color flow Doppler (does NOT exclude dissection if
clinically indicated). The aortic valve leaflets are moderately
thickened. Significant aortic stenosis cannot be excluded.
Aortic stenosis cannot be excluded. Mild (1+) aortic
regurgitation is seen. There is a prominent anterior fat pad.
IMPRESSION: Suboptimal image quality. Mildly dilated asending
aorta without definite 2D/color flow Doppler evidence for
dissection. Thickened aortic valve with mild aortic
regurgitation. Preserved global biventricular cavity size and
systolic function.
If clinically indicated, a TEE or MRI would be better able to
assess for an aortic dissection. TTE provides both false
positive and false negative results.
___ CXR (PA AND LATERAL):
Heart size is enlarged, unchanged. Bilateral pleural effusions
are unchanged. The size is moderate to large. There is no
pneumothorax. Bibasal atelectasis is present.
___ TTE:
IMPRESSION: Mild aortic stenosis with moderate aortic
regurgitation. Type Ia left ventricular diastolic dysfunction
with elevated left ventricular enddiastolic pressure. Mild
dilation of the thoracic and abdominal aorta.
Compared with the prior study (images not available) of
___, now the degree of aortic stenosis could be determined
as mild. The pressure half time was determined in the current
study and consistently around 300 ms making the aortic
regurgitation moderate in severity with similar left ventricular
afterload compared to the prior study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Famotidine 20 mg PO BID
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Pyridoxine 100 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Acetaminophen 650 mg PO ASDIR
9. HydrALAzine 25 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
Please continue with current dose until your next appointment
with your PCP
___ *amlodipine 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
2. Famotidine 20 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Pyridoxine 100 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
If you have persistent abdominal pain please come to the ED
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours as needed Disp #*15 Tablet Refills:*0
7. Acetaminophen 650 mg PO ASDIR
8. Multivitamins 1 TAB PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Labetalol 100 mg PO TID
RX *labetalol 100 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
11. Outpatient Lab Work
PLEASE CHECK CHEM-10 ___ AND FAX TO PCP: ___, MD
Phone: ___ Fax: ___ ICD___: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Type B Aortic dissection
Hypertension, uncontrolled
Acute diastolic congestive heart failure
Secondary Diagnoses:
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new O2 req // ? pulm edema
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Bilateral pleural effusions appear to be increased since the prior study.
Bibasal atelectasis has developed most likely secondary but infectious process
is a possibility. Upper lungs are essentially clear. There is no evidence of
pulmonary edema. There is no evidence of pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with aortic dissection, SOB with pleural
effusions seen on ___. // evaluate pleural effusion, pulm edema
TECHNIQUE: CHEST (PA AND LAT)
COMPARISON: ___
IMPRESSION:
Heart size is enlarged, unchanged. Bilateral pleural effusions are unchanged.
The size is moderate to large. There is no pneumothorax. Bibasal atelectasis
is present
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: THORACIC ANEURYSM, Transfer
Diagnosed with DISS THORACIC AORTIC ANEURYSM, HYPERTENSION NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | Ms. ___ is an ___ yo woman with h/o HTN, HLD, CKD (baseline
creatinine 2.5), thoracic outlet syndrome, and hypothyroidism
who presents with likely Type B aortic dissection and
hypertension, originally admitted to the Vascular Surgery
Service in the ___. Medicine Consult service was called
regarding optimal BP mgmt, and she was found to be in acute CHF.
Transferred to medical service for further mgmt.
ACTIVE ISSUES
==================
# Type B aortic dissection:
Patient presented to ___ with epigastric pain,
hypertensive to SBP 160s, non contrast CT chest/abd/pelvis was
concerning for descending thoracic aortic aneurysm likely just
descending thoracic, though limited resolution due to lack of
contrast. Patient was transferred to SICU at ___ for further
management. In SICU in stable condition, weaned off labetalol
gtt for SBP <140 in setting of dissection. TTE done to evaluate
ascending aorta given limited resolution on non contrast CT,
linear hyperdense flappy structure by the ascending aorta
consistent with artifact vs thrombus/atheroma vs dissection
flap. Patient and patient's family agreed that extreme
measures/surgery for intervention not within patient's goals of
care, thus no further imaging with contrast was pursued. Patient
transferred off unit to vascular surgery step down unit for
conservative management with blood pressure control per below.
Given prescription for short course of oxycodone for abdominal
pain control thought to be related to known dissection.
# Hypertension:
Patient was monitored initially in the surgical intensive care
unit, and then went to the step down unit for continued blood
pressure monitoring, with antihypertensive medication titration
with goal SBP <140 in setting of aortic dissection. Ultimately
this was achieved with 10mg daily amlodipine, 100mg BID of
labetolol, and 50mg hydralazine q8. Of note, she has had recent
changes to her BP medications (discontinued atenolol in ___
and started on hydralazine), with recent outpatient SBPs between
140-180s per PCP. On day of discharge, hydralazine was stopped
and labetalol was increased to 100mg TID. Amlodipine continued
at 10mg daily.
# Acute Diastolic CHF:
Patient noted to have volume overload this hospitalization, with
SOB with pleural effusions seen on CXR ___, with worsening dry
cough, new ___ edema, 7lbs weight gain over hospitalization, and
desaturations to high ___. No history of CHF. ECHO this
admission with very mild diastolic heart failure, Type 1a left
ventricular diastolic dysfunction, clinically with diastolic
heart failure. Treated with IV lasix, and breathing improved and
ambulatory O2 sats >90% without symptoms, weight downtrending.
Continued with ___ edema, may also be a component of fluid
overload from CKD. Continued on sodium restricted diet
throughout hospitalization. Will need CXR as outpatient to
monitor pleural effusions noted on CXR this admission. Discharge
weight 53 kg.
CHRONIC ISSUES
====================
# CKD: From HTN, with baseline Cr around 2.5, increased this
admission in setting of lasix. Will need continued monitoring of
Cr/labs as outpatient.
# Hypothyroidism: Stable, continued home levothyroxine.
# HL: Stable, continued home simvastatin.
TRANSITIONAL ISSUES
=======================
-BP medications change: stopped hydralazine at discharge,
increased labetalol to 100 mg TID and continued amlodipine 10 mg
daily. Simvastatin dose increased.
-Please monitor blood pressure and HR on ___.
-Chem10 check on ___ as Cr rising on day of discharge to 2.7,
in setting of IV lasix diuresis.
-Discharge weight = 53.0-kg. If weight increases by more than
3-lb, please call PCP.
-Please order 1 week f/u CXR to monitor pleural effusions.
# Code: ___/DNI
# Emergency Contact: HCP Son ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
EGD on ___
History of Present Illness:
___ with PMH of CAD, HTN, HL, DMII, CKD IV, and anemia of CKD on
iron and Epo, now sent in from the ___ Hgb=6.5.
___ reports he felt in his usual state of health on the
day of admission when he presented for his regularly scheduled
Epo injection. Labs at that time were notable for Hgb=6.5 and he
was referred in the ED. He reports generalized fatigue and
shortness of breath on exertion over the past year or so, with
no recent changes over the past several weeks. He also denies
recent change in the color of his stools, which he states have
been dark ever since starting iron ___ years ago. Of note,
colonoscopy ___ was notable only for 3 colonic polyps, which
were removed and found to be benign. EGD was notable for gastric
polyps with stigmata of recent bleeding which were also benign;
H.pylori was negative.
In the emergency room the patient remained hemodynamically
stable but was found to have guaiac positive stools. He was
transfused 1u pRBC and admitted for further evaluation of a GI
bleed.
ROS: As noted above, otherwise reviewed in detail and negative
Past Medical History:
CHRONIC KIDNEY DISEASE
CORONARY ARTERY DISEASE
DIABETES MELLITUS
HYPERLIPIDEMIA
HYPERTENSION
EOSINOPHILIA
ANEMIA OF CHRONIC DISEASE
ABDOMINAL PAIN
CONSTIPATION
Social History:
___
Family History:
Per OMR, confirmed with patient: Negative for DM, HTN, cancer or
heart disease.
Physical Exam:
VS: T=98.4 BP=152/83 HR=67 RR=18 O2 Sat=100% on RA
Gen: Awake, alert, NAD, comfortable appearing
HEENT: NCAT, EOMI, anicteric
CV: RR
Pulm: CTA B
Abd: Soft, NTND, positive bowel sounds
Ext: No edema or calf tenderness
Psych: Affect appropriate, good insight into own health
Neuro: Speech fluent
Pertinent Results:
Labs on Admission: ___ 01:50PM
WBC-7.7 RBC-2.09* Hgb-6.6* Hct-22.6* MCV-108* Plt ___
UreaN-24* Creat-1.4* Na-140 K-4.5 Cl-112* HCO3-20* AnGap-13
.
Imaging:
.
___ RUQ ultrasound:
IMPRESSION:
1. Coarsened liver echotexture, nonspecific but raises concern
for cirrhosis.
2. Patent portal vein.
3. Trace perihepatic and perisplenic ascites.
4. Cholelithiasis.
5. No splenomegaly.
Endoscopy ___
Impression:Varices at the gastroesophageal junction
Polyps in the antrum, stomach body and fundus (biopsy)
Normal mucosa in the duodenum
Oozing at the biopsy site which appeared to resolve without
intervention.
Otherwise normal EGD to third part of the duodenum
Recommendations:The likely source of bleeding is occult blood
loss from his gastsric polyps.
Protonix 40 mg BID.
Please consult hepatology given large varices and ultrasound
suggestive of cirrhosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Betamethasone Valerate 0.1% Cream 1 Appl TP BID
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. sitaGLIPtin 50 mg oral DAILY
6. Simvastatin 80 mg PO QPM
7. Ferrous Sulfate 325 mg PO BID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Omeprazole 20 mg PO Q12H
10. Aspirin 325 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Toujeo SoloStar (insulin glargine) 60 units subcutaneous
DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. sitaGLIPtin 50 mg oral DAILY
3. Toujeo SoloStar (insulin glargine) 60 units subcutaneous
DAILY
4. NovoLOG FLEXPEN (insulin aspart) sliding scale per scale
SUBCUTANEOUS TID
5. Nadolol 60 mg PO DAILY
RX *nadolol 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
6. Vitamin D ___ UNIT PO DAILY
7. Betamethasone Valerate 0.1% Cream 1 Appl TP BID
8. Bisacodyl 5 mg PO DAILY:PRN constipation
9. Ferrous Sulfate 325 mg PO BID
10. Losartan Potassium 25 mg PO DAILY
11. Simvastatin 80 mg PO QPM
12. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
gastrointestinal bleeding
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with upper GI bleeding and ? of distal esophageal
varix on prior EGD, evaluate for underlying liver disease, portal
hypertension, portal vein thrombosis,
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None available.
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is
slightly nodular. There are echogenic foci at the right dome of the liver
which may represent calcified granulomas. The main portal vein is patent with
hepatopetal flow. There is trace perihepatic and perisplenic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 8
mm.
GALLBLADDER: There are shadowing stones and sludge within the gallbladder.
There is no evidence of acute cholecystitis.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.7 cm.
IMPRESSION:
1. Coarsened liver echotexture, nonspecific but raises concern for cirrhosis.
2. Patent portal vein.
3. Trace perihepatic and perisplenic ascites.
4. Cholelithiasis.
5. No splenomegaly.
Gender: M
Race: HISPANIC/LATINO - CENTRAL AMERICAN
Arrive by WALK IN
Chief complaint: Anemia, Weakness
Diagnosed with Acute posthemorrhagic anemia
temperature: 97.0
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 161.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ y/o M w/ CAD, HTN, CKD stage III-IV, and
DM w/ hx of GI bleeding and recent endoscopy 5 months ago who
presents with anemia worse than baseline and black, guaiac
positive stool without other associated symptoms.
.
# Anemia - acute on chronic, likely due to blood loss anemia,
new cirrhosis, varices
- He received 2 units pRBCs during this hospitalization with
appropriate increase in Hgb following transfusion of the second
unit. Abdominal ultrasound on ___ showed likely cirrhosis.
Treated with PPI IV BID. EGD on ___ showed bleeding gastric
polyps and non-bleeding varicose. Hepatology was consulted and
recommended changed metoprolol to nadolol for variceal bleeding
prophylaxis.
.
# CAD; HTN, essential; HL: Given stable hemodynamics on
admission, he was continued on his home regimen ___ and
beta-blocker. His home statin was continued. Home ASA was held
in the setting of GI bleeding and planned endoscopy. Aspirin
was restarted at 81mg daily on discharge
.
# CKD, stage III-IV: Lytes stable on admission, and patient
appeared euvolemic on exam. Cr stable. Will continue ___ as
above.
.
# DM type II, insulin-dependent, controlled, with complications:
Home lantus recently changed to ___, which is non-formulary.
Continued Lantus 60u here and resumed ___ on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending: ___.
Chief Complaint:
Acute mental status changes, COPD exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ ___ white male with
past medical history significant for COPD, diabetes (w/
neuropathy), renal insufficiency, hypertension,
hypercholesterolemia, bipolar disorder, depression, mild aortic
stenosis, and gout, here for 3 days of disorientation. The
history was provided by his son ___.
The details of the HPI are not entirely clear, as Mr.
___ were not complete historians. At baseline,
patient takes care of all ADLs expecting bathing, and
administers his own medications and checks his own blood
glucose.
As per history, patient has a baseline COPD cough, but it has
worsened over the past month. During this time, he has been
staying up all night and sleeping during the day.
Over the past three days, his cough acutely worsened w/
increased sputum. Several times he fell asleep half-dressed,
and while sitting in a chair. He also neglected to take his
medications and check his blood glucose. As per his son, his
thinking is not clear, and "he is not himself." He has been
taking insulin and not eating, and eating without taking
insulin. On the night prior to admission, he had taken insulin
without eating, and was found to have a blood glucose of 22. At
other times over the weekend, his glucose was 200-300s.
Patient is was unable to provide history on his own, as he was
sleeping during exam. Patient only takes albuterol for COPD.
Son said was hesitant to approve steroids, given diabetes and
c/f worsening blood sugars.
As per son, patient has not had any trauma, head strike,
vomiting, fever, chest pain, shortness of breath. Patient has
diarrhea at baseline which is not worse than usual.
Pt has had ___ & ___ home services, ___ house call services.
Otherwise, ROS (as per son) was negative.
Past Medical History:
# Mild aortic stenosis
# HLD
# Non-insulin dependent type 2 diabetes
# Dementia
# CKD
# History of gout
# History of alcohol abuse
# Parkinsonism
# Schizophrenia
# Bipolar d/o
# Major depression s/p ECT
# ETOH abuse
# s/p cataract repair
Social History:
___
Family History:
Father: deceased, Mother: deceased, 2 living sons. Some family
history of hypertension and diabetes, but unable to specify.
Physical Exam:
ADMISSION EXAM:
==================
Vitals: 99.2PO 167/69 L Lying 98 20 94 2L
General: sleeping, coughing
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at R base; audible wheezing bilaterally
CV: holosystolic murmur at RUSB (known AS)
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: 1+ edema bilaterally
Neuro: CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
==================
PHYSICAL EXAM:
Vitals: 98.2PO 148/72 R Lying 72 22 93 Ra
General: awake, coughing
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles bilaterally; no audible wheezing
CV: holosystolic murmur at RUSB (known AS)
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: trace edema bilaterally
Neuro: Knows name, location, and date. Can only name days of
week forward. Can only name months forward. CNs2-12 intact,
motor function grossly normal
Pertinent Results:
ADMISSION LABS:
=================
___ 09:10PM BLOOD WBC-10.8* RBC-3.37* Hgb-11.6* Hct-37.5*
MCV-111* MCH-34.4* MCHC-30.9* RDW-15.3 RDWSD-62.8* Plt ___
___ 09:10PM BLOOD Plt ___
___ 09:10PM BLOOD Glucose-303* UreaN-79* Creat-1.8* Na-135
K-5.2* Cl-98 HCO3-22 AnGap-15
___ 09:10PM BLOOD ALT-24 AST-29 CK(CPK)-143 AlkPhos-68
TotBili-0.3 DirBili-<0.2 IndBili-0.3
___ 09:10PM BLOOD CK-MB-5
___ 09:10PM BLOOD Albumin-4.0 Calcium-8.8 Phos-3.8 Mg-2.0
___ 09:32PM BLOOD Lactate-3.5*
DISCHARGE LABS:
=================
___ 05:49AM BLOOD WBC-12.1* RBC-3.40* Hgb-11.2* Hct-36.3*
MCV-107* MCH-32.9* MCHC-30.9* RDW-14.6 RDWSD-56.4* Plt ___
___ 05:49AM BLOOD Plt ___
___ 06:47AM BLOOD Glucose-93 UreaN-67* Creat-1.6* Na-150*
K-4.9 Cl-105 HCO3-28 AnGap-17*
___ 05:49AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.3
IMAGING:
=================
___ . CHEST (PA & LAT)
There is subtle mild left base atelectasis without definite
focal
consolidation. No pleural effusion or pneumothorax is seen. The
cardiac and
mediastinal silhouettes are stable. No pulmonary edema is seen.
___ . CT HEAD W/O CONTRAST
There is no evidence of acute infarction,hemorrhage,edema, or
mass. There is
generalized brain parenchymal atrophy, similar to prior. Mild
chronic small
vessel ischemic changes. 0.9 cm x 0.3 cm extra-axial calcific
density
overlying the right frontal lobe is stable from prior exam and
likely
represents dural thickening or calcified meningioma (03:31).
Tiny lipoma as
are noted along the falx, unchanged.
There is no evidence of acute fracture. There is mild mucosal
thickening of
the bilateral ethmoid sinuses. 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. Dense
calcifications of
the bilateral carotid siphons are noted.
MICROBIOLOGY:
=================
___ . URINE CULTURE
< 10,000 CFU/mL.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. ARIPiprazole 2.5 mg PO DAILY
3. Divalproex (DELayed Release) 500 mg PO BID
4. Gabapentin 400 mg PO TID
5. Furosemide 40 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
8. 70/30 22 Units Breakfast
70/30 13 Units Dinner
Discharge Medications:
1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
2. Tiotropium Bromide 1 CAP IH DAILY
3. Glargine 15 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
5. Allopurinol ___ mg PO DAILY
6. ARIPiprazole 2.5 mg PO DAILY
7. Colchicine 0.6 mg PO EVERY OTHER DAY
8. Divalproex (DELayed Release) 500 mg PO BID
9. Furosemide 40 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. HELD- Gabapentin 400 mg PO TID This medication was held. Do
not restart Gabapentin until patient requires it once more. If
so, please re-dose.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute mental status changes, COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with altered mental status, weakness// Subdural, hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.4 cm; CTDIvol = 46.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass. There is
generalized brain parenchymal atrophy, similar to prior. Mild chronic small
vessel ischemic changes. 0.9 cm x 0.3 cm extra-axial calcific density
overlying the right frontal lobe is stable from prior exam and likely
represents dural thickening or calcified meningioma (03:31). Tiny lipoma as
are noted along the falx, unchanged.
There is no evidence of acute fracture. There is mild mucosal thickening of
the bilateral ethmoid sinuses. 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. Dense calcifications of
the bilateral carotid siphons are noted.
IMPRESSION:
No acute intracranial abnormalities.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old man with ?COPD here with SOB now with asymmetric
swelling in RLE.// please eval for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypoglycemia
Diagnosed with Altered mental status, unspecified
temperature: 98.9
heartrate: 92.0
resprate: 16.0
o2sat: 95.0
sbp: 156.0
dbp: 45.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old ___ man with a PMh of
COPD, diabetes (w/ neuropathy), renal insufficiency,
hypertension, hypercholesterolemia, bipolar disorder,
depression, mild aortic stenosis, and gout who was brought to
the ED by his son for evaluation of altered mental status.
History was notable for a uncontrolled diabetes for 3 days
leading up to admission, including FSBP as low as 22, and as
high as 300. Patient was also found half-dressed and sleeping
at inappropriate times/locations. Physical exam was significant
for bilateral wheezing in all fields, crackles present
bilaterally, and a productive, loud non-abating cough. Patient
also had 1+ pitting edema in the lower extremities. He was very
somnolent. Labs were notable for Hgb 3.07, glucose 289, Cr 1.6,
proBNP 544, HbA1c 7.5%, venous blood gas (pO2 24, pCO2 57, pH
7.34, calTCO2 32), negative UA. Imaging was notable for a
negative CT head w/o contrast, and an unremarkable CXR. The
patient began treatment with duonebs, prednisone, and
azithromycin. The following day, the patient's wheezing was
nearly completely resolved, and his breathing/cough was much
improved. His mental status returned back to baseline (as per
his son). His bilaterally lower extremity edema also resolved
w/ home furosemide and compression stockings. Of note, the
prednisone required some adjustments in his usual insulin
resume, and his blood glucose was closely monitored. The
patient was deemed medically stable, seen by Physical Therapy,
and discharged to rehabilitation.
# Altered mental status:
In the ED on ___, head CT w/o was negative for acute bleed, and
EKG was negative for signs of ischemia. Neurologic exam was
unremarkable. AMS changes were likely a combination of COPD
exacerbation, coupled with his already fatigued state from sleep
issues over the past month and functional malnutrition from
improper insulin dosing. Polypharmacy was also of particular
concern, given his high dose of gabapentin in the setting of
CKD. Gabapentin was held and patient was monitored for
symptoms. Attempts were made to maintain appropriate sleep-wake
cycle. Deliriogenic medications were avoided. With rest,
proper glucose control, treatment for COPD exacerbation, the
patient returned back to normal mental baseline by the second
day of admission, ___.
# COPD exacerbation:
On ___, patient was noted to have difficulty breathing with a
loud, non-abating productive cough and bilaterally crackles and
wheezing bilaterally. Patient also had oxygen requirement of 2L
NC to maintain oxygen saturation >90%. Despite these symptoms,
CXR in ED was negative for signs of infection. Patient was
transferred to Medicine and started on course of prednisone,
azithromycin, and duonebs. By ___, the patient breathing was
much improved, with markedly diminished wheezing and no further
oxygen requirement. However, cough persistent (though patient
says is at baseline). Spiriva was added to patient's home
medications, for COPD maintenance therapy.
# Diabetes, type 2:
The patient's diabetes management was adjusted during his
admission, due to treatment with prednisone. However, he
finished the prednisone course before discharge, so no discharge
adjustments are required for his diabetes management. He will
resume pre-admission insulin course at rehab/home.
# Gout
- Allopurinol continued daily.
- Colchicine continued biweekly.
# Aortic stenosis: slightly volume overloaded on today's exam.
CXR without pulm edema.
- Home lasix was continued
- Daily weights were trended.
# Bipolar Disorder
- Home abilify and valproex were continued. |
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 off bike
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male presents with the above weakness s/p
mechanical fall. Patient was riding his bicycle in a charity
cycling event, when he collided with something on the past. He
flipped over his handlebars, and landed on his head. Unclear
LOC. He had initial bilateral lower extremity weakness,
characterized at the outside hospital as lower extremity
paralysis. This however improved with time, and as the patient
was transferred to ___, he felt his arms becoming weak
instead.
Patient is complaining of neck and upper back pain, but
otherwise
no complaints. No loss of bowel or bladder continence. Patient
does have burning paresthesias, weakness in bilateral upper
extremities. No IVDU, no history of malignancy, no fevers or
chills.
Past Medical History:
SHOULDER PAIN
HTN
Social History:
___
Family History:
NC
Physical Exam:
Vitals: AVSS, afebrile
General: NAD, A&Ox3
nl resp effort
RRR
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R DIMM DIMM DIMM DIMM DIMM
L DIMM DIMM DIMM DIMM DIMM
T2-L1 (Trunk)
SILT
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)
R 4- 4- 4- 4- 4- 4- 4-
L 4- 4- 4- 4- 4- 4- 4-
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Reflexes
Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1)
R 2 2 2 2 2
L 2 2 2 2 2
___: Negative
Babinski: Downgoing
Clonus: No beats
Perianal sensation: Normal
Rectal tone: Intact
Pertinent Results:
IMAGING:
MR ___ (___):
CERVICAL SPINE:
Cord or cauda equina compression: None. There is mild canal
narrowing without evidence of current compression.
Cord signal abnormality: There is increased T2/STIR signal
within
the proximal cervical cord at the level of C3-C4 C4-C5.
Epidural collection: None.
Other: There is mild increased T2 signal at the
anterior-inferior
corner of C2 at the anterior aspect of C3. There is a T2/STIR
bright fluid anterior to the vertebral bodies at C2 through C5.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Hydrochlorothiazide 12.5 mg PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*100 Tablet Refills:*0
2. Dexamethasone 8 mg PO Q8H Duration: 3 Doses
This is dose # 1 of 3 tapered doses
RX *dexamethasone 2 mg ___ tablet(s) by mouth asidr Disp #*30
Tablet Refills:*0
3. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
4. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
SCI
central cord syndrome
C4-5 cervical spondylosis
c4-5 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 SPINE
INDICATION: *** CODE CORD *** History: ___ with bike accident, arm weaknessIV
contrast to be given at radiologist discretion as clinically needed// eval
central cord syndrome
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the
cervical, thoracic and lumbar spine were obtained. Diffusion sagittal images
of the cervical spine were obtained.
COMPARISON: Outside cervical spine CT of the same day.
FINDINGS:
CERVICAL SPINE: There is increased signal anterior to the C3-C4 and C5
vertebral bodies without abnormal signal within the ligamentous structures or
evidence of ligamentous disruption. This indicates small prevertebral
hematoma/fluid collection. There is congenital narrowing of the spinal canal
with superimposed mild disc bulging from C3-4 to C5-6 level. There is
increased signal within the spinal cord at C3 C4 and possibly at upper C5
level visualized both on T2 sagittal and axial and sagittal diffusion images.
The findings indicate cord contusion. There is no epidural or subdural
hematoma seen.
THORACIC SPINE: There is no compression fracture or marrow edema. No spinal
stenosis or cord compression seen. No abnormal signal seen within the spinal
cord in the thoracic region.
LUMBAR SPINE: Diffuse disc bulging is identified at L5 level without spinal
stenosis. No evidence of thecal sac compression or intraspinal hematoma seen.
IMPRESSION:
1. Findings suggestive of injury to the cervical spine without ligamentous
disruption and a small prevertebral fluid collection/hematoma. No intraspinal
hematoma or fluid collection.
2. Findings indicative of cord contusion.
3. Congenital narrowing of the cervical spinal canal with mild disc bulging
from C3-4 to C5-6 levels.
4. No evidence of cord compression in the thoracic region or thecal sac
compression in the lumbar region. Mild degenerative changes.
Radiology Report
EXAMINATION: DX BILATERAL SHOULDERS
INDICATION: History: ___ with pain in shoulders s/p fall// eval fractures
eval fractures
TECHNIQUE: Bilateral shoulders, three views each
COMPARISON: Right shoulder radiographs ___, bilateral shoulder
radiographs ___ at 12:34
FINDINGS:
RIGHT SHOULDER: There is no fracture or dislocation involving the glenohumeral
or AC joint. Mild degenerative spurring is seen involving the
acromioclavicular joint. Glenohumeral joint is preserved. No suspicious
lytic or sclerotic lesions are identified. No periarticular calcification or
radio-opaque foreign body is seen. Imaged right lung is clear.
LEFT SHOULDER: There is no fracture or dislocation involving the glenohumeral
or AC joint. Mild degenerative changes are seen involving the
acromioclavicular joint. Glenohumeral joint is preserved. No suspicious
lytic or sclerotic lesions are identified. No periarticular calcification or
radio-opaque foreign body is seen.
IMPRESSION:
No acute fracture or dislocation in either shoulder.
Radiology Report
INDICATION: History: ___ with numbness in the hands//eval fracture
TECHNIQUE: Right hand, three views
COMPARISON: None.
FINDINGS:
Assessment of the fingers is slightly limited due to positioning. No definite
acute fracture or dislocation. Minimal degenerative spurring at the first CMC
joint. No concerning lytic or sclerotic osseous abnormalities. No radiopaque
foreign bodies or soft tissue calcifications.
IMPRESSION:
Evaluation of the fingers is limited by positioning. Within this limitation,
no acute fracture or dislocation.
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Arm numbness, Bicycle accident, Transfer
Diagnosed with Unsp superficial injury of unsp part of head, init encntr, Pedl cyclst (driver) (passenger) injured in unsp traf, init
temperature: 98.9
heartrate: 67.0
resprate: 19.0
o2sat: 100.0
sbp: 104.0
dbp: 59.0
level of pain: 3
level of acuity: 2.0 | Patient was admitted to Orthopedic Spine Service on non ___
for further management. He was place in a hard collar at all
times. He was started on a course of dexamthesone with good
response.
Now, Day of Discharge, patient is afebrile, VSS, and neuro
intact with improvement of radiculopathy. Patient tolerated a
good oral diet and pain was controlled on oral pain medications.
Patient ambulated independently. Patient was seen by OT and was
cleared for home with services. Patient noted improvement in
radicular pain. Patient is set for discharge to home in stable
condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Naprosyn / metformin / ibuprofen / levetiracetam
Attending: ___.
Chief Complaint:
Called into ED for Epilepsy admission
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman with a history of
seizure disorder (both epileptic and non-epileptic seizures)
followed by Dr. ___ recently reestablished care with
neurology after insurance issues and poor follow-up and was
recently admitted to neurology in ___ for presumed
non-epileptic event and right weakness/numbness without
structural lesion on MRI started on Keppra as well a history of
depression. She was sent in for admission by Dr. ___ with
symptoms of vertigo, lightheadedness, and gait instability for
two weeks as well as worsening depressed mood and possibly
contemplating violence against her children (denied to me but
endorsed at clinic visit today).
Please see below for details of prior semiologies and seizure
work-up. She was recently admitted to the General Neurology
service (___) with right-sided weakness and numbness
after a seizure-like event (fall to ground and "floppy
movements" of all limbs) on ___ that was thought to be
consistent with non-epileptic seizure in the setting of multiple
stressors including move from ___ in ___, child with autism,
and a new baby. Examination showed significant give-way
weakness, but was full strength with best effort. She underwent
MRI brain and C-spine which did not show any acute pathology.
There were disc protrusions at C4-5 and C5-6 encroaching on the
spinal cord, slightly more prominent than previously imaged in
___, and a soft cervical collar was recommended. She was
started on Keppra 1g BID. Her prior medications, including
atorvastatin, fluoxetine, omeprazole, and metformin were
restarted (previously lost to follow-up). Transitional issues
included anemia. She was sent home with home ___ and a walker.
(Final Discharge summary for this admission is currently
pending).
She presented to epilepsy clinic today (___) to meet with
epilepsy nursing. She reported, "dizziness/spins, increased
fatigue, disorientation, b/l hand tremors, increased depression
(denies SI now), worsening irritability." Furthermore, "Today
she described increased irritability when parenting her
children to the point that fears she will not be able to control
herself and possibly harm them. Due to this, her family never
leaves her alone with the children. In addition, she feels
unsafe caring for them (one boy with autism and the other is a
newborn) considering the sedating medication side effects and
uncontrolled seizure activity. She is currently on an
antidepressant but has psychiatrist or counselor." (Note: I
think this should say but does not have a psychiatrist or
counselor). This was discussed with Dr. ___ the patient
was sent to the ED for admission "based on the need to adjust
AED therapy and the mood disturbance with patient-expressed
potential for physical aggression toward her children."
Today, she tells me that she has been having "dizziness,"
nausea, and tremors for the last two weeks, which she attributes
to Keppra. When asked if any of her symptoms worsen after her
Keppra dose, she says they all do; when asked how long after the
dose does she notice a change, she answered approximately 30
minutes. She clarified that the dizziness refers to vertigo,
lightheadedness, and disequilibrium that are constant; she
denies any clear triggers including changes with head/body
position. She ambulates with a walker, and she may be veering to
the right. She denies dysarthria, dysphagia, or problems with
hand-eye coordination. She has not had any episodes of loss of
consciousness or events concerning for seizure (including falls,
limb shaking of "floppy movements" that are part of her
non-epileptic semiology, arm stiffening, face twitching, or lost
time) since her admission in ___. She denies any recent
illnesses including fevers, although she does report chills. She
has been sleeping 6 hours per night. No recent traumas.
Additionally, she has had depressed mood, which she feels is
getting worse. She denies new stressors or clear trigger for
depressed mood. She also noes that she is staying in her
brother's home and is getting help with her kids. She denies
SI/HI. She denies fears about harming her children, which she
mentioned during her clinic visit earlier today.
Semiologies (quoted from ___):
1) "Floppy movements" of all four limbs, during which she may
fall to the ground and strike her head, intermittently with
right
facial twitching, right head jerking. Followed by confusion.
Duration was ___ minutes initially but has been ___ minutes over
the last few years. Initially, these seemed to occur during
sleep
but per husband can occur at any time. She had numerous of these
events captured during an EMU admission in ___, which did not
have a clear epileptic correlate. She has had ___ episodes per
month, which has been unchanged for many years, regardless of
whether she is on medication or not. She has no recollection of
these events.
2) Bilateral arm stiffening, at times associated with right face
grimacing/twitching, occurring during sleep. These last for
several seconds. She has no recollection of these events. It
appears similar events were captured in ___ that were non
epileptic.
3) Subclinical seizures arising from left fronto-temporal
region,
often with focal slowing arising from left temporal region,
without clinical correlate. These were noted during EMU
admission
in ___, and had been improved on oxcarbazepine.
Current AED:
LEV 1g BID per discharge medications on ___ but logged as 2g
BID under Medications tab on ___ (1g BID per Medication History
section)
Other AEDs trialed:
Previously on OXC but lost to follow-up; per patient, this did
not work
Per OMR, "For workup of her seizure disorder she has had an MRI
brain in ___ which revealed nonspecific white matter
hyperintensities, without any abnormal enhancement or cortical
lesions. She had an admission to the EMU in
___ which captured clinical events that were not electrographic
seizures as well as subclinical events that were electrographic
seizures. She had been maintained on oxcarbazepine 600mg BID
from
___- approximately ___, when she ran out of medication and had
insurance issues. To further complicate matters, she moved from
___ to ___ in ___ and has not followed up with
neurology since then."
ROS positive: blurry vision, vertical diplopia lasting seconds
to minutes ___ times per day (has not tried closing either eye),
right arm/leg weakness (slightly improved compared with recent
admission), chronic headache (unchanged from prior) (she denies
facial droop), leg>arm numbness and paresthesias radiating from
shoulder to hand in RUE and involving the entire limb in RLE
(unchanged from recent admission).
On neuro ROS, the pt denies loss of vision, dysarthria,
dysphagia, tinnitus, and 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. No
night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies vomiting, diarrhea, constipation, or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
DIABETES TYPE II
since ___
HYPERLIPIDEMIA
BACK PAIN
s/p work injury ___. Followed by Ortho. MRI with L5-S1 disc
herniation, no significant nerve compression. Referred to ___ at
___.
DEPRESSION
and anxiety
SEIZURES as per HPI
PNES as per HPI
G3P2
1) C-section in ___ for macrosomia/diabetes, 39w5d, healthy
son, no complications per patient 2) SAB x 2 (first was ___ years
ago, then in ___ 3) C-section in ___
CERVICAL RADICULITIS
RUE weakness, numbness of ___ digits
SEASONAL ALLERGIES
VITAMIN D DEFICIENCY
HEPATIC STEATOSIS
incidental finding on CT ___
OBESITY
ANAL FISSURE
H/O FINGER SPRAIN
___ right ___ digit DIP dislocation after getting finger
stuck in a door
Social History:
___
Family History:
Mother: DM.
MGM: DM.
MGF: Brain tumor.
Father: Healthy.
Sis: Thyroidectomy for possible cancer.
___: X2 with DM.
Children: Healthy son.
Physical Exam:
EXAM ON ADMISSION:
=================
Physical Exam:
Vitals: T: 98.2F P: 94 R: 16 BP: 136/73 SaO2: 100%RA, ___ 107
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, no tongue lacerations noted
Neck: Supple. No nuchal rigidity
Pulmonary: no work of breathing
Cardiac: warm and well-perfused
Abdomen: non-distended
Extremities: No C/C/E bilaterally. Right calf TTP.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, place, month, year,
day of week, and situation (did no recall date in ___. Able to
relate history without difficulty. Skips ___ on DOWB.
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 2
objects (2 objects on ___ attempts) and recall ___ at 5 minutes
___ with categorical prompts, ___ with MC prompts). 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. No skew. No
ptosis. No saccade with HI testing.
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 and tone. No pronation, no drift. No
adventitious movements, such as tremor, noted. No asterixis
noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
*Giveway in multiple muscle groups but ultimately full strength
-Sensory: No deficits to light touch. Decreased pinprick 50% of
normal in RUE/RLE (previously noted). Proprioceptive errors to
large and small movements at right hallux (previously noted), no
errors on left.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was withdrawal on left, mute on right.
-Coordination: +RUE intention tremor, no dysdiadochokinesia
noted (but slow on right). No dysmetria on FNF or HKS
bilaterally. Finger tap slow on right but cadence/aim normal,
normal on left.
-Gait: Deferred, RW not at bedside.
EXAM ON DISCHARGE:
==================
Exam:
VSS
Resting comfortably in bed, appears cachexic and older than
stated age
HEENT: no sclera icterus
Lungs: breathing comfortably in bedh
CV: well-perfumed
Ext: non-edematous
Neuro Exam:
MS: oriented to self and situation, attentive to conversation,
follows simple and complex commands
CN: PERRL face symmetric, eye movements intact, tongue midline
Motor: No PD, full strength and symmetric in UE; 4+ in Ham on
Right, 5 in Left
___: FNF intact
Pertinent Results:
___ 08:18AM BLOOD WBC-8.3 RBC-4.61 Hgb-9.4* Hct-32.2*
MCV-70* MCH-20.4* MCHC-29.2* RDW-17.3* RDWSD-43.0 Plt ___
___ 07:15AM BLOOD WBC-7.5 RBC-4.36 Hgb-8.9* Hct-29.9*
MCV-69* MCH-20.4* MCHC-29.8* RDW-17.2* RDWSD-41.8 Plt ___
___ 08:18AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-119* UreaN-10 Creat-0.6 Na-140
K-4.6 Cl-102 HCO3-24 AnGap-14
___ 02:44PM BLOOD Glucose-100 UreaN-10 Creat-0.6 Na-141
K-4.8 Cl-102 HCO3-21* AnGap-18
___ 02:44PM BLOOD ALT-12 AST-31 AlkPhos-98 TotBili-0.2
___ 02:44PM BLOOD Lipase-44
___ 07:15AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.1
___ 02:44PM BLOOD cTropnT-<0.01
___ 02:44PM BLOOD Albumin-4.0 Calcium-9.1 Phos-4.1 Mg-2.1
IMAGING:
========
NCHCT: No evidence of acute intracranial process.
EEG: no focal electrographic events, official read pending. 2
episodes of full-body shaking, head deviation that did not have
electrographic correlate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. FLUoxetine 10 mg PO DAILY
3. LevETIRAcetam 1000 mg PO BID
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Omeprazole 20 mg PO DAILY:PRN acid reflux
6. Vitamin D 3000 UNIT PO DAILY
7. Vitamin E 400 UNIT PO DAILY
8. Cyanocobalamin 100 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
Discharge Medications:
1. LamoTRIgine 25 mg PO DAILY
wk1:25mgqd wk2:25mgBID
wk3:50mgqAM 25mgqPM; wk4:50mgBID wk5:75mgqAM
50mgqPM...qwk8:100mgBID
RX *lamotrigine 25 mg 1 tablet(s) by mouth daily Disp #*240
Tablet Refills:*0
2. OXcarbazepine 300 mg PO BID
RX *oxcarbazepine 300 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
3. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
4. FLUoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
5. Omeprazole 20 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Cyanocobalamin 100 mcg PO DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 3000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
non-epileptic seizures
depression
seizures
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, difficulty ambulating, increase in seizures,
evaluate for intracranial mass or hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.7 cm; CTDIvol = 48.0 mGy (Head) DLP =
802.7 mGy-cm.
2) 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: Brain MRI dated ___ and CT of the head dated ___.
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. Mucous retention cysts are noted in both
maxillary sinuses. The visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavitiesare otherwise clear. The visualized portion
of the orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with dizziness// Evaluate for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
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. Increased
density overlying bilateral mid to distal clavicles may represent heterotopic
calcification or artifact, and was not seen on the prior radiograph from ___,
potentially external.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) RIGHT
INDICATION: ___ year old woman with recent admission and now using a walker.
Reports right calf pain.// Evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: F
Race: HISPANIC/LATINO - CENTRAL AMERICAN
Arrive by AMBULANCE
Chief complaint: Depression, Dizziness
Diagnosed with Dizziness and giddiness
temperature: 98.2
heartrate: 94.0
resprate: 16.0
o2sat: 100.0
sbp: 136.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | This is a ___ ___ woman with a history of
seizure disorder (both epileptic and non-epileptic seizures)
followed by Dr. ___ was admitted for a subacute history
of vertigo, lightheadedness, and gait instability, shaking
episodes, and severe depression with thoughts (but no intent or
action) to harm her children.
During her admission, we discontinued LevETIRAcetam and
monitored her on cvEEG. We captured 2 events of full body
shaking with head deviation that had no electrographic
correlate. We also had social work and psychiatry evaluate her
and she was deemed safe to go home to her children. We started
her on lamotrigine for mood and seizure disorder with plan to
uptitrate in outpatient setting, using oxcarbazepine as a
therapeutic bridge. We also increased her fluoxetine to 20mg
(10mg on admission). She will follow-up with ___ and Dr.
___ 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:
R groin pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, this patient is a ___ year old man with history of
coronary artery disease, atrial fibrillation on coumadin, COPD,
systolic and diastolic heart failure (LVEF 40%), hypertension,
recurrent pneumonias, recurrent CHF exacerbations who presents
with R groin pain. The patient developed groin pain gradually 2
days ago. He is unable to describe the pain but reports he has
never had these symptoms before. He does have a long history of
an inguinal hernia. The patient was recently admitted
___ for CHF and HCAP, discharged to ___ -
___ with ___. He reports shortness of breath and cough
for ___. He feels like he is "dying". The patient denies any
chest pain, diarrhea, abdominal pain, fever/chills and dysuria
currently. He has not had a BM for 3 days but is currently
passing gas.
Past Medical History:
1. Severe systolic and diastolic heart failure with LVEF of
40%.
2. Atrial fibrillation, status post ablation and pacemaker
placement in ___.
3. Multiple bouts of decompensated heart failure.
4. COPD.
5. Right ventricular dilatation and tricuspid regurgitation.
6. Diabetes not on medications
7. Past hypertension.
8. Hyperlipidemia
9. Chronic kidney disease.
10. History of left popliteal DVT
11. Sleep apnea.
12. Hypothyroidism.
13. Hypokalemia and hyponatremia.
14. Pseudogout, ?gout
Social History:
___
Family History:
Father died of massive MI at ___. Mother had MI in her ___, CHF,
HTN, and DM2.
Physical Exam:
Vitals - Temp:97.4, BP:123/73 HR:78 RR:22 O2sat:96% RA
GENERAL: Elderly genetleman, NAD, slightly agitated at times and
sleepy, alert and oriented x 3.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. dry mucos membranes.
CARDIAC: RRR. II/VI systeolic murmur at RUSB, no gallops/rubs,
no JVD or hepatojugular reflux
LUNGS: Poor inspiratory effort with diffuse upper airway sound.
No obvious crackles wheezing or rhonchi.
ABDOMEN: Soft, minimally tender, distended. Active bowel sounds.
GU: Palpable right inguinal hernia the size of a baseball,
partially reducible, tenderness to palpation
EXTREMITIES: No edema, no cyanosis, ecchymosis on arms
bilaterally. Hands cool with good pulses.
SKIN: ecchymoses present.
NEURO: CNII-XII intact, strength ___ throughout
PSYCH: Noncooperative, oriented but at times appears confused
about his current symptoms. He is easily distractable and falls
alseep if not continually spoken to.
Pertinent Results:
___ 08:02PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 08:02PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:00PM LACTATE-1.6
___ 07:54PM GLUCOSE-144* UREA N-61* CREAT-1.8* SODIUM-137
POTASSIUM-5.8* CHLORIDE-91* TOTAL CO2-38* ANION GAP-14
___ 07:54PM ALT(SGPT)-16 AST(SGOT)-22 ALK PHOS-70 TOT
BILI-0.3
___ 07:54PM ALBUMIN-4.0
___ 07:54PM WBC-11.5*# RBC-3.83* HGB-12.9* HCT-39.9*
MCV-104* MCH-33.7* MCHC-32.4 RDW-15.7*
___ 07:54PM NEUTS-78.3* LYMPHS-11.1* MONOS-6.6 EOS-3.7
BASOS-0.3
___ 07:54PM PLT COUNT-223
___ 07:00PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from AtriuswebOMR.
1. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Torsemide 160 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Senna 1 TAB PO HS:PRN constipation
8. melatonin *NF* 3 mg Oral QHS
9. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
10. Ferrous Sulfate 325 mg PO DAILY
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
12. Ipratropium Bromide MDI 2 PUFF IH BID:PRN SOB
13. Polyethylene Glycol 17 g PO DAILY Constipation
14. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q8H:PRN Pain
15. Allopurinol ___ mg PO DAILY
16. Potassium Chloride 60 mEq PO DAILY Duration: 24 Hours
Hold for K > 5.0
17. Levothyroxine Sodium 125 mcg PO DAILY
18. Levothyroxine Sodium 125 mcg PO QWED
19. Cetirizine *NF* 10 mg Oral Daily
20. Metolazone 2.5 mg PO MWF
21. Guaifenesin ___ mL PO Q6H:PRN Cough
22. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250
mcg Oral Daily
23. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral Daily
24. Warfarin 3 mg PO DAYS (___)
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Cetirizine *NF* 10 mg Oral Daily
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Guaifenesin ___ mL PO Q6H:PRN Cough
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Levothyroxine Sodium 125 mcg PO QWED
9. Metolazone 2.5 mg PO MWF
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY Constipation
13. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K > 5.0
14. Senna 1 TAB PO HS:PRN constipation
15. Warfarin 3 mg PO DAYS (___)
16. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
17. Aspirin 81 mg PO DAILY
18. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral Daily
19. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250
mcg Oral Daily
20. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q8H:PRN Pain
21. Ipratropium Bromide MDI 2 PUFF IH BID:PRN SOB
22. melatonin *NF* 3 mg Oral QHS
23. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
24. Torsemide 120 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Inguinal Hernia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___.
___.
CLINICAL HISTORY: Abdominal pain, evaluate right PICC line placement.
FINDINGS: Portable AP upright chest radiograph is obtained. There is a right
arm PICC line with tip in the region of the superior vena cava. Please note a
line was seen in the same position on prior exam. A dual-lead right chest
wall pacer is unchanged with proximal lead in the right atrium and distal lead
in the expected location of the right ventricle. The heart is mildly
enlarged. Mild vascular engorgement is seen without frank pulmonary edema.
An area of scarring is again noted at the left lower lobe. No large pleural
effusions are seen. No pneumothorax. An azygos fissure is noted.
Mediastinal contour appears stable. Bony structures are intact.
IMPRESSION: Mild vascular engorgement. Appropriately positioned right arm
PICC line.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with UNILAT INGUINAL HERNIA, HYPERKALEMIA
temperature: 98.3
heartrate: 73.0
resprate: 18.0
o2sat: 95.0
sbp: 104.0
dbp: 48.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ was admitted the night of ___ with 2 days of
intense R groin pain. In the ED, he was found the have ___ R
groin pain originating from the area of a R inguinal hernia. The
hernia was able to be reduced and the pain resolved. Surgery
evaluated the patient and felt surgery was not indicated. His
hernia remained reducible and mildly tender with no skin
changes. He was discharged on ___ with a reduced dose of
torsemide (160mg --> 120mg) after repeated elevated Bicarbs of
40 concerning for over-diuresis. He was sent home with hospice
and 24hr nursing care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydralazine / metal / Iodinated Contrast Media - IV Dye
Attending: ___
Chief Complaint:
Lethargy, Vomiting
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ PMH ESRD ___ DM2 and HTN s/p DDRT ___ c/b RCC in kidney
graft s/p cyberknife, IDDM, PVD, COPD, CAD s/p BMS to distal RCA
___, who presents with vomiting/diarrhea that started ___
and inability to tolerate PO medications including
immunosuppressants.
Per OMR, she's suffered some epigastric pain with associated low
grade fevers. No pain over graft, no dysuria or change in amount
of urine. No SOB or chest pain.
In the ED:
Initial vital signs were notable for: Pain ___, T96.9, HR89, BP
176/65, RR17, 98% RA Glucose 441
Exam notable for:
-Mucous membranes are dry
-Patient appears unwell but not in acute distress
-Mild tenderness over the graft site
-Fistula in the left arm
Labs were notable for:
6.5 > 13.2/39.3 < 237
Lactate:1.9
BMP: Crt 1.4, Glucose 458
UA: Glucose 1000, Ket 10, Prot 30, Neg bact/WBC/RBC
Studies performed include: Renal transplant ultrasound,
Blood/Urine Cx, Tacro level
Renal transplant US:
1. Loss of diastolic flow in the main renal artery. Resistive
indices elevated to 0.97, previously 0.93.
2. Mild increase in size of a heterogeneous, exophytic mass at
the upper pole of the right kidney, concerning for renal cell
carcinoma.
3. No evidence of a perinephric collection.
Consults: Renal-Transplant
Patient was given: IVF, Tacro sublingual, MMF, Fentanyl, ISS,
Zofran
On arrival to the floor, patient minimally cooperative to
interview secondary to nausea, lethargy and abdominal pain. She
did endorse ___ pain. She said she had only vomited
mucous recently and was able to tolerate "two medications" in
the
E.D., which were her first in days.
REVIEW OF SYSTEMS: Unable to fully complete secondary as patient
unwilling
Past Medical History:
PAST MEDICAL HISTORY:
Insulin-dependent diabetes ___
CAD s/p BMS to distal RCA in ___
End-stage renal disease s/p deceased donor renal transplant
___
- c/b Renal cell cancer in the kidney graft s/p cyberknife w/
subsequent CKD (Cr 1.5)
Peripheral vascular disease with venous ulcer
Left internal carotid artery stenosis status post stenting
COPD - no PFTs but chart diagnosis
Hypertension
Dyslipidemia
Peptic ulcer disease
Chronic anemia
First-degree AV block
PAST SURGICAL HISTORY:
1) Cholecystectomy
2) Cesarean section
3) urgery for retinopathy and cataracts
4) h/o MSSA bacteremia from an infected AV graft s/p revision
5) Angioplasty thrombectomy and subseqent stenting of AV graft
Social History:
___
Family History:
Her father died at ___ years old of lung cancer. Her mother died
at ___ years old of possible complications of diabetes ___.
She has 3 brothers and 3 sisters. 1 sister has hypertension. All
3 sisters have diabetes ___. She has 1 daughter who is
healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 98.3 192 / 73 HR 81 RR18 91% on Ra
GENERAL: Appears uncomfortable. Constantly changing positions.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: No increased work of breathing.
ABDOMEN: Hypoactive bowels sounds, mildly distended, tender to
light ___. No organomegaly.
EXTREMITIES: No clubbing, cyanosis. Minimal edema. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3.
DISCHARGE PHYSICAL EXAM:
======================
VITALS: 24 HR Data (last updated ___ @ 359)
Temp: 97.4 (Tm 97.5), BP: 121/54 (121-143/54-72), HR: 62
(62-71), RR: 18, O2 sat: 96% (95-100), O2 delivery: Ra, Wt: 179
lb/81.19 kg
GENERAL: AOx3. Seemingly tired, slow. But alert and interactive.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTAB. No increased work of breathing.
ABDOMEN: BS+, mildly distended, non-ttp
EXTREMITIES: L AV graft with no bruit or thrill. No clubbing,
cyanosis. Minimal edema. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap ref
Pertinent Results:
ADMISSION LABS:
==============
___ 01:55PM BLOOD WBC-6.5 RBC-5.32* Hgb-13.2 Hct-39.3
MCV-74* MCH-24.8* MCHC-33.6 RDW-15.7* RDWSD-40.9 Plt ___
___ 01:55PM BLOOD Neuts-58 Bands-1 Lymphs-15* Monos-19*
Eos-2 Baso-1 ___ Metas-4* Myelos-0 AbsNeut-3.84
AbsLymp-0.98* AbsMono-1.24* AbsEos-0.13 AbsBaso-0.07
___ 01:55PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-OCCASIONAL
Polychr-NORMAL Schisto-OCCASIONAL
___ 01:55PM BLOOD ___ PTT-34.7 ___
___ 01:55PM BLOOD Glucose-458* UreaN-27* Creat-1.4* Na-141
K-4.8 Cl-95* HCO3-28 AnGap-18
___ 01:55PM BLOOD ALT-18 AST-31 AlkPhos-90 TotBili-0.5
___ 01:55PM BLOOD Lipase-19
___ 01:55PM BLOOD Calcium-9.5 Phos-3.7 Mg-1.9
___ 03:24PM BLOOD tacroFK-<2.0*
___ 11:02PM BLOOD ___ pO2-53* pCO2-42 pH-7.41
calTCO2-28 Base XS-1
___ 02:10PM BLOOD Lactate-1.9
PERTINENT INTERMITTENT LABS:
=========================
___ 08:20AM BLOOD ALT-193* AST-151* LD(LDH)-489* AlkPhos-60
TotBili-0.3
___ 05:05AM BLOOD tacroFK-5.7
___ 05:03AM BLOOD tacroFK-5.2
IMAGING:
=======
___ CT A/P w/o CO:
No acute findings related to the right lower quadrant renal
transplant to account for the patient's pain. Known mass is not
well evaluated in absence of IV contrast but appears grossly
stable.
___ Renal Transplant U/S:
1. Absent diastolic flow within the main renal artery and
intrarenal arteries.
2. Patent renal vasculature.
3. Redemonstration of upper pole renal mass, minimally increased
in size now measuring up to 3.1 cm, which has previously
undergone CyberKnife therapy.
4. No perinephric abscess or fluid. No hydronephrosis.
___ RUQ U/S: Unremarkable liver parenchyma. Patent portal vein.
___ EGD: c/w esophagitis and gastritis.
___ CT Chest:
New ___ and ground-glass opacities involving the lingula
and Left lower lobe compatible with pneumonitis which could be
secondary to infectious or inflammatory processes including
aspiration given patient's clinical history.
No CT evidence of extrinsic compression on the esophagus as
clinically questioned however barium swallow is the preferential
study to evaluate for dysphagia.
___ AVF/DUPLEX HEMO/D:
Complete occlusion of the left upper extremity AV graft.
Patent brachial artery at arterial anastomotic end.
Occluded basilic vein.
PATHOLOGY:
==========
___ Tissue: GASTROINTESTINAL MUCOSAL BIOPSY:
1. Proximal esophagus, biopsy:
-Active, neutrophilic esophagitis. Stain for fungal organisms
(GMS) is negative.
2. Mid esophagus, biopsy:
-Active, neutrophilic esophagitis. Stains for fungal organisms
(GMS and PAS) are negative. 3. Gastroesophageal junction,
biopsy:
-Squamous epithelium within normal limits.
-No glandular mucosa identified.
4. Randomstomach,biopsy:
-Corpus/antral type mucosa within normal limits.
5. Duodenum, biopsy:
-Duodenal mucosa with regenerative epithelial changes and
Brunner's gland hyperplasia. Dr. ___ reviewed parts 1, 2
and 5 and concurs.
MICROBIOLOGY:
=============
___ 09:00AM BLOOD CMV VL-NOT DETECT
___ 03:20PM BLOOD HERPES SIMPLEX VIRUS, TYPE 1 & 2 DNA,
QUANTITATIVE REAL TIME PCR-Test : NEGATIVE
___ 03:20PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test:
NEGATIVE
___ 03:20PM BLOOD VARICELLA ZOSTER VIRUS DNA, PCR-Test:
NEGATIVE
DISCHARGE LABS:
==============
___ 06:56AM BLOOD WBC-4.2 RBC-3.68* Hgb-9.1* Hct-27.5*
MCV-75* MCH-24.7* MCHC-33.1 RDW-16.2* RDWSD-43.7 Plt ___
___ 06:56AM BLOOD Glucose-116* UreaN-13 Creat-1.6* Na-143
K-4.4 Cl-105 HCO3-23 AnGap-15
___ 06:56AM BLOOD ALT-65* AST-20 AlkPhos-57 TotBili-0.2
___ 06:56AM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.1 Mg-1.9
___ 06:56AM BLOOD tacroFK-8.7
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Carvedilol 50 mg PO BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Mycophenolate Sodium ___ 360 mg PO BID
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 2 mg PO Q12H
11. Vitamin D ___ UNIT PO DAILY
12. Famotidine 20 mg PO DAILY
13. CloNIDine 0.1 mg PO BID
14. Clopidogrel 75 mg PO DAILY
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral QHS
17. Polyethylene Glycol 17 g PO TID:PRN constipation
18. ProAir HFA (albuterol sulfate) 1 puff inhalation Q4H:PRN
shortness of breath
19. Senna 8.6 mg PO BID:PRN constipation
20. amLODIPine 10 mg PO DAILY
21. Furosemide 40 mg PO DAILY
22. Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*21
Tablet Refills:*0
2. Acetaminophen 500 mg PO QPM
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Bisacodyl 5 mg PO DAILY:PRN constipation
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral QHS
8. Carvedilol 50 mg PO BID
9. CloNIDine 0.1 mg PO BID
10. Clopidogrel 75 mg PO DAILY
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Famotidine 20 mg PO DAILY
13. Furosemide 40 mg PO DAILY
14. Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. Mycophenolate Sodium ___ 360 mg PO BID
17. Polyethylene Glycol 17 g PO TID:PRN constipation
18. ProAir HFA (albuterol sulfate) 1 puff inhalation Q4H:PRN
shortness of breath
19. Senna 8.6 mg PO BID:PRN constipation
20. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
21. Tacrolimus 2 mg PO Q12H
22. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Viral Gastroenteritis
SECONDARY DIAGNOSIS:
- Gastritis
- Esophagitis
- Elevated liver function tests
- ESRD s/p DDRT c/b RCC now s/p cyberknife on immunosuppression
- Anemia
- Diabetes ___ II
- Chronic obstructive pulmonary disease
- Peripheral vascular disease
- Coronary artery disease
- History of renal cell carcinoma s/p cyber knife
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: History: ___ with pain at graft site// perinephric abscess?
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ultrasound ___, MRI abdomen ___
FINDINGS:
Again noted within the right iliac fossa transplant kidney is a heterogeneous,
exophytic mass at the upper pole of the transplant kidney, measuring 3.1 x 2.5
x 2.8 cm, minimally changed in size when it previously measured 2.7 x 2.6 x
2.9 cm. No hydronephrosis or perinephric fluid.
The main renal artery now demonstrates lack of diastolic flow. Main renal
artery has a peak systolic velocity of 96 centimeters/second. All intrarenal
arteries demonstrate a lack of diastolic flow with the resistive index
measuring 1. Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform.
IMPRESSION:
1. Absent diastolic flow within the main renal artery and intrarenal arteries.
2. Patent renal vasculature.
3. Redemonstration of upper pole renal mass, minimally increased in size now
measuring up to 3.1 cm, which has previously undergone CyberKnife therapy.
4. No perinephric abscess or fluid. No hydronephrosis.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old woman with ESRD s/p transplant and RCCC with
significant abdominal pain// ?obstruction? signs of infection, inflammation?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis without intravenous contrast.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 25.7 mGy (Body) DLP =
1,260.7 mGy-cm.
Total DLP (Body) = 1,261 mGy-cm.
COMPARISON: ___. Correlation also with MRI from ___.
FINDINGS:
LOWER CHEST: Mild bibasal atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver is unremarkable within the limits of the unenhanced
study. There is no evident biliary dilation. The gall bladder is not
visualized.
PANCREAS: Unremarkable. There is no peripancreatic stranding.
SPLEEN: Unremarkable.
ADRENALS: Both adrenals are diffusely bulky. There are stable calcifications
on the right.
URINARY:
There is stable mild atrophy of the bilateral native kidneys.
The right lower quadrant transplant kidney appears overall similar to the
previous study and there is no hydronephrosis. The known interpolar cortical
mass is not well-defined without IV contrast but appears grossly similar in
size to the previous MRI, estimated at 3.7 cm. There are mild postsurgical
changes in the right lower quadrant, unchanged from prior.
GASTROINTESTINAL: Prominent lipomatous tissue around the ileocecal valve.
Otherwise unremarkable.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: There are multiple small calcified uterine fibroids.
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.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits aside from
a tiny fat containing periumbilical hernia.
IMPRESSION:
No acute findings related to the right lower quadrant renal transplant to
account for the patient's pain. Known mass is not well evaluated in absence
of IV contrast but appears grossly stable.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with h/o ESRD s/p transplant, now with N/V and
LFT abnormalities including rise in alk phos// Dopplers to assess for PVTe/o
inflammation, PVT?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___ CT abdomen and pelvis
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: 0.6 cm
GALLBLADDER: The patient is status post cholecystectomy.
SPLEEN: Normal echogenicity.
Spleen length: 9.2 cm
IMPRESSION:
Unremarkable liver parenchyma. Patent portal vein.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old woman with dysphagia s/p EGD on ___ with esophageal
stricture// esophageal evaluation
TECHNIQUE: Barium esophagram.
DOSE: Acc air kerma: 45 mGy; Accum DAP: 758.4 uGym2; Fluoro time: 02:01
COMPARISON: Chest CT dated ___
FINDINGS:
The study is limited due to patient's limited mobility. The esophagus was not
dilated. In the distal esophagus just above the GE junction there is short
segment that does not fully open, consistent with a stricture. No large
esophageal mass identified. The esophageal mucosa appears grossly
unremarkable.
The primary peristaltic wave was normal, with contrast passing readily into
the stomach. There is mild tertiary contraction.
There was no hiatal hernia.
IMPRESSION:
Short-segment stricture in the distal esophagus just above the GE junction.
No large esophageal mass identified.
Radiology Report
INDICATION: ___ year old woman with continued dysphagia. ___ PMH ESRD ___ DM2
and HTN s/p DDRT ___ c/b RCC in kidney graft s/p cyberknife, IDDM, PVD,
COPD, CAD s/p BMS to distal RCA ___, who presents with vomiting/diarrhea
that started ___ and inability to tolerate PO medications including
immunosuppressants.// evaluation of extrinsic compression of esophagus seen on
EGD ___
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is stable in size and contour.
Heart size is stable. Atherosclerotic calcifications including dense coronary
artery calcifications. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is stable dependent subsegmental atelectasis and/or
scarring involving right-greater-than-left lower lobe. There are new
ground-glass and ___ opacities involving the lingula and left lower
lobe compatible with pneumonitis. No larger of consolidation. The airways
are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the unenhanced upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
New ___ and ground-glass opacities involving the lingula and Left
lower lobe compatible with pneumonitis which could be secondary to infectious
or inflammatory processes including aspiration given patient's clinical
history.
No CT evidence of extrinsic compression on the esophagus as clinically
questioned however barium swallow is the preferential study to evaluate for
dysphagia.
Additional chronic changes as above not significantly changed from prior
study.
Radiology Report
EXAMINATION: Duplex and color Doppler imaging of the lower extremities
INDICATION: ___ year old woman with L. AV graft, no thrill// clot?
TECHNIQUE: Grayscale and color Doppler sonogram with waveform analysis and
velocity calculations performed of the left upper extremity AV graft .
COMPARISON: none
FINDINGS:
Patent left brachial artery with arterial waveform and velocity of 104
centimeters/second at the antecubital fossa. There arterial anastomosis
appears patent with a velocity of approximately 80 centimeters/second. There
is no visualized flow through the the remaining portion of the graft including
the the select anastomotic end.
IMPRESSION:
Complete occlusion of the left upper extremity AV graft.
Patent brachial artery at arterial anastomotic end.
Occluded basilic vein.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:56 pm, 5 minutes after
discovery of the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Lethargy, Vomiting
Diagnosed with Dehydration
temperature: 96.9
heartrate: 89.0
resprate: 17.0
o2sat: 98.0
sbp: 176.0
dbp: 65.0
level of pain: 5
level of acuity: 2.0 | SUMMARY FOR ADMISSION:
======================
___ PMH ESRD ___ DM2 and HTN s/p DDRT ___ c/b RCC in kidney
graft s/p cyberknife, IDDM, PVD, COPD, CAD s/p BMS to distal RCA
___, who presents with vomiting/diarrhea that started ___
and inability to tolerate PO medications including
immunosuppressants. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Cucumber (Cucumis Sativus) / Morphine / Phenytoin
Attending: ___
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH significant for Type A and Type B
aortic dissection (from carotids to iliac), vascular dementia,
stroke resulting in L side hemiparesis and Afib on coumadin who
presents with a 3 week history of L hip pain. She sustained a
mechanical fall in the bathroom of her rehab facility three
weeks
ago. Immediately following the fall, she had some L hip
discomfort that gradually worsened over the next few weeks. She
was initially managed conservatively, and XRays were obtained
that were apparantly negative for fracture (not available to
view). As she continued to complain of L hip discomfort, a CT
was
obtained to rule out occult fracture- this CT scan demonstrated
a
L acetabular fracture. She denies any history of previous
trauma,
but does endorse another fall within the past few days.
Furthermore, given her previous stroke, she has only mild motor
function in her LLE and spends most of the day wheelchair bound.
She only uses her LLE for transfers and is essentially
nonambulatory on this leg.
Past Medical History:
Limited due to poor patient recall.
-Dislipidemia, Hypertension, S/p aortic dissection repair, s/p
Stroke, s/p seizure, GERD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
-LLE tender to palpation in groin region
-Skin clean and intact, no open wounds, abrasions or lacerations
-No significant swelling, ecchymosis or edema notes
-Thighs and leg compartments soft
-Does endorse pain with logroll of L hip. Hip in neutral
alignment, with no shortening or internal/external rotation
-Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
-___ ___ TA Peroneals Fire
-1+ ___ and DP pulses
Pertinent Results:
___ 10:30PM ___ PTT-48.5* ___
___ 10:29PM GLUCOSE-100 UREA N-9 CREAT-0.6 SODIUM-141
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
___ 10:29PM estGFR-Using this
___ 10:29PM WBC-5.4 RBC-3.87* HGB-11.2* HCT-35.2* MCV-91
MCH-28.9 MCHC-31.8 RDW-13.8
___ 10:29PM NEUTS-72.6* ___ MONOS-7.4 EOS-1.1
BASOS-0.4
___ 10:29PM PLT COUNT-243
___ 09:20PM URINE HOURS-RANDOM
___ 09:20PM URINE UHOLD-HOLD
___ 09:20PM URINE MUCOUS-RARE
Radiology Report
HISTORY: Status post fall, on Coumadin. Rule out bleed.
COMPARISON: Prior head CT from ___.
TECHNIQUE: Contiguous axial MDCT images are obtained through the brain
without IV contrast. Sagittal, coronal reformations and bone algorithm
reconstructions were generated.
Total exam DLP: 1282 mGy-cm.
CTDI: 120 mGY.
FINDINGS:
Evaluation is somewhat limited by motion artifact.
There is no hemorrhage, acute vascular territory infarction, edema, mass or
shift of normally midline structures. There is again seen encephalomalacia in
the right MCA territory with associated wallerian degeneration of the right
cerebral peduncle. Periventricular white matter hypodensities are likely the
sequelae of chronic small vessel ischemic disease. Prominence of cortical
sulci, fissures, ventricles and extra-axial CSF spaces representing atrophy is
likely age-related. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
No definite fracture is identified. There is moderate mucosal thickening of
the left sphenoid sinus and mild mucosal thickening of the right sphenoid
sinus. Mild mucosal thickening is also seen in the anterior ethmoidal air
cells, with an osteoma in the right fronto-ethmoidal recess. The mastoid air
cells and middle ear cavities are clear.
IMPRESSION:
1. No acute intracranial process.
2. Old right MCA territory infarct.
3. Acute-on-chronic inflammatory disease in the left sphenoid air cell, with
sinoliths; correlate clinically.
Radiology Report
HISTORY: Rule out fracture.
COMPARISON: NECT cervical spine, ___.
TECHNIQUE: Axial MDCT images were obtained through the cervical spine without
IV contrast. Sagittal and coronal reformations were generated.
Total exam DLP: 732 mGy-cm.
CTDI: 32 mGy.
FINDINGS:
There is no prevertebral soft tissue swelling. There is no acute cervical
fracture or alignment abnormality. There is multilevel degenerative disc
disease and facet hypertrophy. Posterior disc osteophyte complexes are noted
at C4 C5-6 and C5-C6. CT is not able to provide intrathecal detail comparable
to MRI, however the visualized outline of the thecal sac appears unremarkable.
The thyroid gland is within normal limits. There is redemonstration of the
prominent lymph node inferior to the right parotid gland. No additional
cervical lymphadenopathy is noted. Lung apices are clear.
IMPRESSION: No evidence of acute cervical fracture or subluxation.
NOTE ADDED IN ATTENDING REVIEW: The "lymph node" above measures 15 (AP) x 11
(TRV) x 15 mm (CC) and may have a minute marginal calcification (2:36,
603b:4). It may lie within the tail of the parotid gland and is equivocally
larger since the ___ study. The differential diagnosis includes intraparotid
lymph node, though there are no definite others, as well as Warthin tumor.
Depending on clinical context, this may warrant further characterization,
including enhanced MR study of the neck soft tissues.
Radiology Report
PELVIS
REASON FOR EXAM: AP and Judet views to evaluate acetabular fracture.
There is a comminuted displaced fracture of the left acetabulum with impaction
of the left femoral head.
Phleboliths are seen in the pelvis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PELVIC FX
Diagnosed with FRACTURE ACETABULUM-CLOS, UNSPECIFIED FALL, ABNORMAL COAGULATION PROFILE, ADV EFF ANTICOAGULANTS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.5
heartrate: 101.0
resprate: 18.0
o2sat: 96.0
sbp: 117.0
dbp: 73.0
level of pain: 8
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 acetabular fracture and was admitted to the orthopedic
surgery service. The fracture pattern did not require any
surgical fixation. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to her rehab facility 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 and the patient was
voiding/moving bowels spontaneously. The patient is TDWB in the
LLE extremity, and will be discharged on her regimen of Warfarin
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: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
non-healing left hallux wound
Major Surgical or Invasive Procedure:
Left lower extremity angiogram and peroneal angioplasty
History of Present Illness:
___ with PAD, DMII, s/p RLE angio w/ AT PTA, R hallux amp
w/ pods in ___ now presents with left hallux non-healing wound.
The patient underwent local debridement of an ingrown toenail as
an outpatient two weeks ago. Following the debridement he was
noted to develop an infection at the site and was started on
doxycycline. The toe also had decreased sensation and the
patient
felt had become cooler. These symptoms have lasted one week. He
denies progressive sensory or motor loss of the foot. He has
claudication at baseline but is able to ambulate >1 block
without
rest. He has no pain at rest.
He overall feels well and denies fevers/chills, chest pain,
shortness of breath, cough, nausea/emesis, change in bowel or
bladder habits. Review of systems otherwise negative.
Past Medical History:
Tyep II diabetes
Peripheral vascular disease
- ___ anterior tibial artery angioplasty for hallux
gangrene
- ___ repeat right anterior tibial artery angioplasty for
nonhealing toe amputation site
- ___ R first ray amputation
Hypertension
Hyperlipidemia
Asthma
Hypogonadism
erectile dysfunction, with Penile prosthesis placed in ___
Cervical radiculopathy
Reactive airway disease
s/p bilateral hernia repairs, inguinal with mesh - ___
s/p right hand surgery
History of depression in ___, resolved
with psychotherapy, no medications. No psychiatric admission,
no
history of suicide attempts or self-harm.
Social History:
Per psych consult note this admission, verified with patient:
The patient had a history of significant alcohol use disorder
(drank heavily for ___ years). Has been sober since ___. Was
very involved with AA at the time.
The patient has a history significant for a ___ year incarceration
between ___ and ___. This was followed by ___ year probation.
No legal problems since. He has to register as a sex offender.
The patient was born and raised in ___ and is 1
of 12 children. He came to the ___ in ___ with his
entire family. He finished high school in ___, started
working as a ___ at the ___. Has 6 "recognized"
children, his first child was born when he was still in high
school. He spent ___ years in ___, describes this as a
violent time in his life where he witnessed violence and violent
himself. He came back to ___ in ___, says that he was
working as a ___, was selling drugs. ___ he was accused of
molesting a stepson. He currently is living in the house he
rents, has roommates. Takes care of himself.
Family History:
Father died of ___. He has a brother with alcohol use
disorder. 2 brothers with DM2
Physical Exam:
Admission:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: left hallux with erythema and swelling, decreased sensation
over lateral aspect of toe; no motor or sensory loss extending
into forefoot, no crepitus; right foot with hallux amputation
well-healed
L:p//d/d R:p//d/d
Discharge:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: left hallux with erythema and swelling, decreased sensation
over lateral aspect of toe; no motor or sensory loss extending
into forefoot, no crepitus; right foot with hallux amputation
well-healed
L:p//d/d R:p//d/d
dopplerable signals distally
groin cdi
Pertinent Results:
___ 05:26AM BLOOD WBC-8.5 RBC-3.60* Hgb-10.9* Hct-31.9*
MCV-89 MCH-30.3 MCHC-34.2 RDW-12.6 RDWSD-40.9 Plt ___
___ 10:50AM BLOOD WBC-9.2 RBC-3.61* Hgb-10.5* Hct-31.7*
MCV-88 MCH-29.1 MCHC-33.1 RDW-12.5 RDWSD-40.2 Plt ___
___ 04:13PM BLOOD WBC-12.2* RBC-3.89* Hgb-11.6* Hct-34.5*
MCV-89 MCH-29.8 MCHC-33.6 RDW-12.8 RDWSD-41.6 Plt ___
___ 04:13PM BLOOD Neuts-75.0* Lymphs-15.5* Monos-7.5
Eos-1.3 Baso-0.3 Im ___ AbsNeut-9.13* AbsLymp-1.89
AbsMono-0.91* AbsEos-0.16 AbsBaso-0.04
___ 05:26AM BLOOD Plt ___
___ 10:50AM BLOOD Plt ___
___ 10:50AM BLOOD ___ PTT-26.1 ___
___ 05:00PM BLOOD ___ PTT-26.0 ___
___ 04:13PM BLOOD Plt ___
___ 05:26AM BLOOD Glucose-110* UreaN-17 Creat-1.1 Na-142
K-5.6* Cl-107 HCO3-24 AnGap-11
___ 10:50AM BLOOD Glucose-139* UreaN-15 Creat-0.9 Na-143
K-4.8 Cl-105 HCO3-25 AnGap-13
___ 04:13PM BLOOD Glucose-172* UreaN-19 Creat-1.1 Na-141
K-4.8 Cl-104 HCO3-23 AnGap-14
___ 05:26AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.8
___ 10:50AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.6
___ 04:17PM BLOOD Lactate-1.7
___ DUP EXTEXT BIL (MAP/DVT) Clip # ___
Reason: eval for bypass
UNDERLYING MEDICAL CONDITION:
___ year old man with LLE non-healing hallux ulcer
REASON FOR THIS EXAMINATION:
eval for bypass
Final Report
EXAMINATION: VEIN MAPPING-Lower extremities
INDICATION: ___ year old man with LLE non-healing hallux ulcer//
eval for
bypass
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 0.3 to
0.5 cm. The right small saphenous vein is patent with diameters
ranging from
0.2 to 0.3 cm.
LEFT: The great saphenous vein is patent with diameters ranging
from 0.3 to
0.4 cm. The left small saphenous vein is patent with diameters
ranging from
0.2 to 0.3 cm.
IMPRESSION:
The great and small saphenous veins are patent bilaterally and
appear usable
for conduit. Please see digitized image on PACS for formal
sequential
measurements.
FOOT AP,LAT & OBL LEFT Clip # ___
Reason: please evaluate for gas or bony erosion
UNDERLYING MEDICAL CONDITION:
History: ___ with left first digit infection of left foot
REASON FOR THIS EXAMINATION:
please evaluate for gas or bony erosion
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read by ___. on FRI ___ 6:52 AM
Re-demonstrated along the lateral aspect of the distal tip of
the first toe is
a subtle lucency which appears similar to the ___
foot
radiograph. There is no soft tissue gas. These findings are
overall
indeterminate for osteomyelitis, MRI would be most sensitive for
detection of
osteomyelitis.
Final Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: History: ___ with left first digit infection of
left foot//
please evaluate for gas or bony erosion
TECHNIQUE: Three views of the left foot
COMPARISON: ___ left toe radiograph
FINDINGS:
Re-demonstrated along the lateral aspect of the distal tip of
the first toe is
a subtle lucency appearing similar to the ___ foot
radiograph.
There is mild swelling of the adjacent soft tissues. There is
no soft tissue
gas. No acute fractures or dislocation are seen. There are no
significant
degenerative changes. Mineralization is normal. Vascular
calcifications are
again noted.
IMPRESSION:
Re-demonstrated along the lateral aspect of the distal tip of
the first toe is
a subtle lucency which appears similar to the ___
foot
radiograph. There is no soft tissue gas. These findings are
overall
indeterminate for osteomyelitis, MRI would be most sensitive for
detection of
osteomyelitis.
Medications on Admission:
Insulin SC (per Insulin Flowsheet)
Quinapril 40 mg PO/NG DAILY
Atorvastatin 80 mg PO/NG QPM
Aspirin 81 mg PO/NG DAILY
Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
Clopidogrel 75 mg PO/NG DAILY
MetroNIDAZOLE 500 mg PO/NG Q8H
Ciprofloxacin HCl 500 mg PO/NG Q12H
Vancomycin 1000 mg IV Q 12H
Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 800 mg PO BID
7. Insulin SC
Sliding Scale
Fingerstick q6
Insulin SC Sliding Scale using HUM Insulin
8. Quinapril 40 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower extremity non-healing hallux wound
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: History: ___ with left first digit infection of left foot//
please evaluate for gas or bony erosion
TECHNIQUE: Three views of the left foot
COMPARISON: ___ left toe radiograph
FINDINGS:
Re-demonstrated along the lateral aspect of the distal tip of the first toe is
a subtle lucency appearing similar to the ___ foot radiograph.
There is mild swelling of the adjacent soft tissues. There is no soft tissue
gas. No acute fractures or dislocation are seen. There are no significant
degenerative changes. Mineralization is normal. Vascular calcifications are
again noted.
IMPRESSION:
Re-demonstrated along the lateral aspect of the distal tip of the first toe is
a subtle lucency which appears similar to the ___ foot
radiograph. There is no soft tissue gas. These findings are overall
indeterminate for osteomyelitis, MRI would be most sensitive for detection of
osteomyelitis.
Radiology Report
EXAMINATION: VEIN MAPPING-Lower extremities
INDICATION: ___ year old man with LLE non-healing hallux ulcer// eval for
bypass
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 0.3 to
0.5 cm. The right small saphenous vein is patent with diameters ranging from
0.2 to 0.3 cm.
LEFT: The great saphenous vein is patent with diameters ranging from 0.3 to
0.4 cm. The left small saphenous vein is patent with diameters ranging from
0.2 to 0.3 cm.
IMPRESSION:
The great and small saphenous veins are patent bilaterally and appear usable
for conduit. Please see digitized image on PACS for formal sequential
measurements.
Gender: M
Race: HISPANIC/LATINO - CUBAN
Arrive by WALK IN
Chief complaint: L Toe redness, Wound eval
Diagnosed with Cellulitis of left toe, Type 2 diabetes mellitus without complications
temperature: 98.4
heartrate: 80.0
resprate: 18.0
o2sat: 99.0
sbp: 153.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ presented to ___ on ___ with a non-healing
left hallux wound. He underwent a left lower extremity angiogram
and peroneal angioplasty. There was no named vessel in foot pre
or post. Perclosed. The procedure was uncomplicated. He had
bilateral ___ signals afterwards. On ___ he was given a
surgical boot then discharged home on 1 month Plavix and 2 weeks
oral Bactrim. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / Lithium
Attending: ___.
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
Inititation of straight catheterization
History of Present Illness:
___ pmh HTN, HLD, CKD V thought to be 2/t ___ and ___ recently
due to episodes of urinary retention, currently w/ indwelling
foley on linezolid (for unclear reasons) p/w weakness,
lightheadedness, and hypotension.
Transferred to ED from ___ clinic after being found to have
dizziness, lightheadedness w/ hypotension (76/53) / tachycardia
suggestive of dehydration. EMS was called at clinic and pt was
taken to ___. Pt reports about 1 week of lightheadedness
associated with L sided upset stomach-like pain, nausea (no
vomiting), and back pain. He currently has a catheter for
urinary retention and is being treated with IV Linezolid per
notes (has midline) but for unclear reasons, plan for 4 weeks
(last dose ___. Does not urinate, no f/c, no CP, no SOB, no
cough, no HA/neck pain, no diarrhea, no hematuria. This is
associated with poor PO intake, weakness, and ?confusion for a
week as well. No sxs of pain or nausea with eating. Also reports
he has had a upper extremity tremor during this time as well.
Recently admitted from ___ with falls, ___ weakness, and
foot pain found to have UTI, urinary retention, and ___ on CKD.
During the admission he had foley placed and was discharged with
it in place with f/up to see Renal and Urology. Discharged to
complete a course of Cipro. Seen by Neurology afterwards, where
his Parkinsonian movements was thought to be related to recent
escalation of Abilify to 20mg, advised to downtitrate. Renal has
been starting the process of renal replacement as well. Seen by
Transplant Surgery for graft consideration when they noted that
the pt was started on Linezolid IV after a ___ was placed to
complete a 28d course (unclear why), this visit was on ___.
During this visit, pt was also found to be hypotensive, they
contacted the NH who stopped Lasix and referred pt to Cards (Dr.
___ a referral given hypotension, risk fo clotting
graft). Urodynamic studies recently showed a weak bladder, and
plan was to continue with the foley, and consideration for
intermitent caths.
According a recent renal visit on ___: "Medicine admission
to ___ from ___ to ___ for acute on chronic renal
failure, altered mental status, paranoid delusions, and urinary
retention. Admission creatinine 5.4 with hyperkalemia; Renal
function improved with IVF and Foley insertion and urinary
decompression. Sodium on discharge 147, creatinine 3.6. He was
transferred to inpatient psychiatry at ___ for his paranoid
delusions from where he was discharged on ___. Of note he has
had numerous inpatient psychiatric stays in the past. He had
displayed violent behavior in the past toward caregivers at
group home. His potassium and sodium remained elevated. He has
refused kayexalate."
Vitals in the ED: 7 97.4 110 123/97 20 97%
-Labs notable for: WBC 12, lactate 3.8, cr 5.3/K 5.3, +UA from
his chronic suprapubic tube, plts of 123.
-Patient given: Zosyn, 2L IVF, Zofran.
-CT A/P: Acute interstitial pancreatitis, trace pelvic free
fluid, sequela ___ toxicity in kidney.
-CXR wnl.
-Urine and blood cx.
Vitals prior to transfer: 5 98.1 87 124/86 19 96% RA
Review of Systems:
Per HPI
Past Medical History:
-CKD Stage V thought to be from Lithium toxicity c/b
hyperkalemia (has refused keyexelate per last d/c summary), also
recently worsened by obstructive uropathy, currently with foley
-Nephrogenic DI
-Schizophrenia w/ paranoid psychosis requiring psychiatric
admission at ___, discharged ___ and numerous other inpatient
psychiatric admissions
-HTN
-HLD
-RBBB
-Hypothyroidism
-Venous insufficiency
-Urinary retention
-Secondary hyperparathyroidism
-Anemia of chronic disease
-COPD
Social History:
___
Family History:
Family psychiatric history:
sister with bipolar d/o and polysubstance abuse; mother with
dementia
Physical Exam:
ADMISSION PHYSICAL EXAM
==================================
Vitals: 98.3 ___ 20 96%RA
GENERAL: NAD, comfortable aaox3, cachetic appearing, foley in
place and also with midline
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
dry MMembranes
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Bibasilar crackles, no wheezes
ABDOMEN: very mildly distended, +BS, reports TTP throughout, 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, aaox3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
BACK: No CVA tenderness and no spinous process tenderness
DISCHARGE PHYSICAL EXAM
====================================
Vitals: 97.4 124/87 63 20 97%RA
GENERAL: NAD, comfortable aaox3, cachetic appearing, masked
facies
HEENT: EOMI, PERRLA, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Trace bibasilar crackles, no wheezes
ABDOMEN: nondistended, +BS, nontender to palpation, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or edema, moving all 4 extremities with
purpose. Lead pipe rigidity noted in upper extremities.
PULSES: 2+ DP pulses bilaterally
NEURO: aaox3, masked facies and lead pipe rigidity. Moves all
extremities, face symmetric, tongue midline, EOMI.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
BACK: No CVA tenderness and no spinous process tenderness
Pertinent Results:
ADMISSION LABS
==========================
___ 05:00PM BLOOD WBC-12.1* RBC-4.24* Hgb-14.4 Hct-39.3*
MCV-93 MCH-33.9* MCHC-36.6* RDW-14.4 Plt ___
___ 05:00PM BLOOD Neuts-79.3* Lymphs-12.7* Monos-7.2
Eos-0.7 Baso-0.1
___ 05:36AM BLOOD ___ PTT-29.2 ___
___ 05:00PM BLOOD Glucose-77 UreaN-99* Creat-5.3* Na-141
K-4.9 Cl-100 HCO3-22 AnGap-24*
___ 05:00PM BLOOD ALT-32 AST-55* AlkPhos-84 TotBili-0.8
___ 05:00PM BLOOD Lipase-4260*
___ 05:00PM BLOOD Albumin-3.5 Calcium-10.2 Phos-5.3* Mg-2.3
___ 05:36AM BLOOD Triglyc-126
___ 05:36AM BLOOD TSH-2.7
___ 05:36AM BLOOD Valproa-29*
___ 02:10AM BLOOD pH-7.29* Comment-GREEN TOP
___ 05:30PM BLOOD Lactate-3.8*
___ 02:10AM BLOOD freeCa-1.15
PERTINENT/DISCHARGE LABS
==========================
___ 12:59PM BLOOD Hgb-10.8* Hct-32.5*
___ 05:19AM BLOOD WBC-9.2 RBC-3.19* Hgb-10.7* Hct-30.5*
MCV-96 MCH-33.7* MCHC-35.2* RDW-14.3 Plt ___
___ 05:22AM BLOOD WBC-8.0 RBC-3.03* Hgb-10.0* Hct-29.5*
MCV-97 MCH-32.9* MCHC-33.9 RDW-14.4 Plt ___
___ 05:40AM BLOOD ___ PTT-35.0 ___
___ 05:22AM BLOOD Glucose-84 UreaN-49* Creat-3.1* Na-141
K-4.8 Cl-111* HCO3-22 AnGap-13
___ 05:40AM BLOOD ALT-20 AST-24 AlkPhos-80 TotBili-0.3
___ 05:22AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.0
___ 05:36AM BLOOD Albumin-2.7* Calcium-8.8 Phos-5.3* Mg-2.1
___ 05:22AM BLOOD Valproa-61
___ 05:53AM BLOOD Lactate-1.1
MICROBIOLOGY
==========================
___ 5:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
_____________________________________________________________
___ 5:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
_____________________________________________________________
___ 8:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
___ ALBICANS.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0610.
BUDDING YEAST.
_____________________________________________________________
___ 10:25 am BLOOD CULTURE Source: Line-MIdline.
Blood Culture, Routine (Pending):
_____________________________________________________________
___ 11:02 am CATHETER TIP-IV Source: Right midline.
**FINAL REPORT ___
WOUND CULTURE (Final ___: No significant growth.
FUNGAL CULTURE (Final ___:
SPECIMEN NOT PROCESSED DUE TO: TEST NOT PERFORMED ON
CATHETER TIP.
TEST CANCELLED, PATIENT CREDITED.
Reported to and read back by ___ ___.
_____________________________________________________________
___ 1:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
_____________________________________________________________
___ 3:38 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
_____________________________________________________________
___ 8:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
_____________________________________________________________
RADIOLOGY
=========================
CXR
FINDINGS:
AP upright and lateral views of the chest provided. The lungs
appear lucent
suggesting emphysema. There is mild elevation of the left
hemidiaphragm which
is unchanged. No convincing signs of pneumonia, edema. No
pleural effusion or
pneumothorax. The aorta is unfolded. Heart size appears normal.
Bony
structures are intact.
IMPRESSION:
No acute findings.
ABDOMINAL CT
FINDINGS:
CT ABDOMEN: Evaluation of the lung bases is limited by
respiratory motion. The
visualized portions of the heart pericardium are normal.
Evaluation of the
liver is limited in the absence of intravenous contrast, but
there is no gross
abnormality. The gallbladder, spleen, and left adrenal are
normal. There is a
1.4 x 0.8 cm nodule in the right adrenal with the typical
features of an
adenoma (2:20). There is no nephrolithiasis or hydronephrosis.
Numerous tiny
cysts and punctate calcifications throughout the renal cortices
correspond to
abnormalities on prior ultrasound and are compatible with prior
lithium
induced toxicity.
The pancreas is enlarged with surrounding fat stranding and
thickening of the
splenorenal ligament. There is no fluid collection. The stomach
contains oral
contrast in the fundus. The small bowel is unremarkable. There
is no
portocaval, mesenteric, or retroperitoneal lymphadenopathy.
Ectasia of the
infrarenal abdominal aorta to a 2.4 cm is noted (602b:41). An
IVC filter is
noted in place. There is no free air.
CT PELVIS: The appendix is not visualized, but there are no
secondary signs of
inflammation. Diverticulosis is noted without evidence of
diverticulitis.
Anastomotic sutures are noted in the rectosigmoid. The urinary
bladder is
decompressed and contains a Foley catheter, but there is
significant wall
thickening. The rectum,, seminal vesicles, and prostate are
unremarkable.
Trace free fluid is noted in the rectovesicular space (2:68).
There is no
pelvic lymphadenopathy.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion
worrisome for
malignancy. Sclerotic appearance of the bones is suggestive of
renal
osteodystrophy.
IMPRESSION:
1. Acute interstitial pancreatitis.
2. Moderate bladder thickening, consistent with urinary tract
infection shown on urinalysis. This was discussed with Dr.
___ at 11:14 p.m..
3. Trace pelvic free fluid.
4. Sequela of lithium induced toxicity in the kidneys.
5. Infrarenal abdominal aortic ectasia.
LIVER/GALLBLADDER US
IMPRESSION:
No evidence of gallstones. Normal right upper quadrant
ultrasound.
Inflammation surrounding the pancreas better seen on abdominal
and pelvic CT
from ___.
CARDIOLOGY
=========================
Cardiovascular Report ECG Study Date of ___ 4:47:44 ___
Significant artifact but probable sinus tachycardia. Incomplete
right
bundle-branch block. Compared to the previous tracing of ___
minor diffuse
ST-T wave abnormalities are now seen.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
___ 344/414 45 85 33
Cardiovascular Report ECG Study Date of ___ 8:24:02 AM
Sinus rhythm. Incomplete right bundle-branch block. Compared to
tracing #1
no significant change, much better quality tracing.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 ___ 56 85 53
Cardiovascular Report ECG Study Date of ___ 8:33:56 AM
Sinus rhythm. Right bundle-branch block. Non-specific ST-T wave
changes.
Compared to the previous tracing of ___ ST-T wave changes
are new and
right bundle-branch block is now complete.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
86 ___ 58 82 -12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath or
wheeze
2. ARIPiprazole 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Divalproex (EXTended Release) 750 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Finasteride 5 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Lorazepam 1.5 mg PO TID anxiety
11. Nicotine Patch 21 mg TD DAILY
12. Nicotine Polacrilex 2 mg PO Q1H:PRN Cravings
13. Omeprazole 40 mg PO DAILY
14. Senna 17.2 mg PO BID:PRN constipation
15. Tamsulosin 0.4 mg PO QHS
16. Tiotropium Bromide 1 CAP IH DAILY
17. ARIPiprazole 10 mg PO BID:PRN agitation
18. Furosemide 20 mg PO DAILY
19. Sodium Polystyrene Sulfonate 30 gm PO 3X/WEEK (___)
20. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Divalproex (EXTended Release) 750 mg PO BID
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. ARIPiprazole 10 mg PO DAILY
Increase back to 20mg dsay(with 10mg BID:PRN) after fluconazole
course finished ___
6. Docusate Sodium 100 mg PO BID
7. Finasteride 5 mg PO DAILY
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Senna 17.2 mg PO BID:PRN constipation
11. Tamsulosin 0.4 mg PO QHS
12. Tiotropium Bromide 1 CAP IH DAILY
13. Ciprofloxacin HCl 250 mg PO Q24H
Take through ___, then stop.
14. Fluconazole 200 mg PO Q24H
Take through ___ then stop.
15. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
16. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath or
wheeze
17. Lorazepam 1.5 mg PO Q8H:PRN anxiety
18. Nicotine Patch 21 mg TD DAILY
19. Nicotine Polacrilex 2 mg PO Q1H:PRN Cravings
20. Sodium Polystyrene Sulfonate 30 gm PO 3X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
================
Pseudomonas UTI
___ Fungemia
Acute Pancreatitis
Secondary
===================
Schizophrenia
Urinary Obstruction
CKD
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 (AP AND LAT)
INDICATION: ___ with dizziness // eval infiltrate
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided. The lungs appear lucent
suggesting emphysema. There is mild elevation of the left hemidiaphragm which
is unchanged. No convincing signs of pneumonia, edema. No pleural effusion or
pneumothorax. The aorta is unfolded. Heart size appears normal. Bony
structures are intact.
IMPRESSION:
No acute findings.
Radiology Report
INDICATION: ___ with abd pain, VOMITTING // eval obstruction, fluid
collection .
TECHNIQUE: MDCT images were obtained from the lung bases to the lesser
trochanters after the administration of oral contrast. IV contrast was not
administered. Coronal and sagittal reformations were prepared. DLP: 900.62
mGy-cm.
COMPARISON: Renal ultrasound, ___ and ___.
FINDINGS:
CT ABDOMEN: Evaluation of the lung bases is limited by respiratory motion. The
visualized portions of the heart pericardium are normal. Evaluation of the
liver is limited in the absence of intravenous contrast, but there is no gross
abnormality. The gallbladder, spleen, and left adrenal are normal. There is a
1.4 x 0.8 cm nodule in the right adrenal with the typical features of an
adenoma (2:20). There is no nephrolithiasis or hydronephrosis. Numerous tiny
cysts and punctate calcifications throughout the renal cortices correspond to
abnormalities on prior ultrasound and are compatible with prior lithium
induced toxicity.
The pancreas is enlarged with surrounding fat stranding and thickening of the
splenorenal ligament. There is no fluid collection. The stomach contains oral
contrast in the fundus. The small bowel is unremarkable. There is no
portocaval, mesenteric, or retroperitoneal lymphadenopathy. Ectasia of the
infrarenal abdominal aorta to a 2.4 cm is noted (602b:41). An IVC filter is
noted in place. There is no free air.
CT PELVIS: The appendix is not visualized, but there are no secondary signs of
inflammation. Diverticulosis is noted without evidence of diverticulitis.
Anastomotic sutures are noted in the rectosigmoid. The urinary bladder is
decompressed and contains a Foley catheter, but there is significant wall
thickening. The rectum,, seminal vesicles, and prostate are unremarkable.
Trace free fluid is noted in the rectovesicular space (2:68). There is no
pelvic lymphadenopathy.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for
malignancy. Sclerotic appearance of the bones is suggestive of renal
osteodystrophy.
IMPRESSION:
1. Acute interstitial pancreatitis.
2. Moderate bladder thickening, consistent with urinary tract infection shown
on urinalysis. This was discussed with Dr. ___ at 11:14 p.m..
3. Trace pelvic free fluid.
4. Sequela of lithium induced toxicity in the kidneys.
5. Infrarenal abdominal aortic ectasia.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with pancreatitis, evaluate for gallstones.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Comparison is made to CT abdomen and pelvis from ___.
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 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas. Fat stranding seen surrounding the pancreas
is better imaged on prior CT.
SPLEEN: Normal echogenicity, measuring 9.7 cm.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
No evidence of gallstones. Normal right upper quadrant ultrasound.
Inflammation surrounding the pancreas better seen on abdominal and pelvic CT
from ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lightheaded
Diagnosed with ACUTE PANCREATITIS, URIN TRACT INFECTION NOS
temperature: 97.4
heartrate: 110.0
resprate: 20.0
o2sat: 97.0
sbp: 123.0
dbp: 97.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ is a ___ pmh HTN, HLD, CKD V thought to be secondary
to lithium and more recently due to episodes of urinary
retention w/ indwelling foley p/w weakness, lightheadedness,
hypotension and weeks of abdominal pain found to have acute
pancreatitis, pan-sensitive pseudomonas UTI, and ___
albicans fungemia.
# Acute Pancreatitis: Diagnosis made with elevated lipase to
4260, WBCs to 12.1, abd pain/back pain/nauseaand abdominal CT
with evidence of acute pancreatitis. Etiology was unable to be
established. LFTs do not suggest biliary etiology unless it is
a passed stone and RUQ without obstructing stones (bili was
alwasy WNL but did downtrend during this stay). He is on
multiple meds labeled as class I agents that can cause
pancreatitis including Valproex and Lasix - appears to not be
associated with Linezolid. His Valproex was continued, his lasix
was held given hypovolemia. He denies EtOH. His
triglicerides/Calcium were WNL. Symptoms improved with IVF and
bowel rest. He tolerated a regular diet prior to discharge.
# UTI:
Acute complicated catheter associated UTI, present prior to
arrival. UA with >182 WBC, culture grew pan-sensitive
pseudomonas. Foley was changed ___, then D/C'd in favor of
intermittent catheterization. Will need to continue cipro 250mg
daily through ___ to complete ___cute blood stream infection with ___ fungemia:
He had a chronic indwelling midline catheter on admission (for
recent IV linezolid course for VRE UTI). In the setting of a
chronic midline in right arm and GI inflammation from
pancreatitis (risk for translocation), the ___ cultures that
grew candica were concerning for true fungemia. Infectious
diseases was consulted and recommended treatment. He will need
fluconazole 200mg after discharge to complete a total of 2 weeks
of treatment (last day ___. Opthalmology was consulted and
his eyes were not involved. He should have a repeat Opthalmology
exam in ___ weeks or immediately if he experiences floaters,
flashes, VF cuts or eye pain.
# Hypotension:
Hypotensive in ___ clinic and on presentation. Likely
related to the above processes, in particular acute
pancreatitis. Initially his tamsulosin was held, then restarted
this admission. His lasix was held and not restarted on
discharge. He had no edema during this stay. He was orthostatic
by diastolic pressure and HR, and we encourage increased PO
water in take given his nephrogenic DI.
# CKD Stage V
# Hyperkalemia:
Has a history of lithium toxicity and obstructive nephropathy.
Admit Cr of 5.3 was near baseline on review of previous Cr (high
4's low 5's recently). This downtrended during admission to 3.1
on discharge. His furosemide 10mg daily was held given
hypovolemia from pacnreatitis. Appears to be on kayexelate
after last admission but not on subsequent renal notes. This
was not continued in house, and his potassium was WNL in high
4's. Calcitriol 0.25mg was continued.
# Urinary Retention:
Seems to be related to poor bladder contraction and urinary
obstruction. Indwelling foley was discontinued per outpatient
urology and nephrology recommendations, and intermittent
catheterization (4 to 5 times a day) was initiated. Tamsulosin
was initially held due to hypotension (likely due to hypovolemia
from pancreatitis + diuretics), but restarted prior to
discharge. Finasteride was continued. Goal is to retrain bladder
and gradually taper straight catheterization.
CHRONIC ISSUES
# Hypothyrodisim: Continued Levothyroxine. TSH normal
# GERD: Continued omeprazole.
# COPD: Continued Tiotropium.
# Schizophrenia: Psychiatry followed, and he appears to be at
baseline. His abilify 20mg daily was decreased to to 10mg daily
while on fluconazole due to drug-drug interactions. His
additional 10mg BID:PRN was held. These can be returned to
their previous dosing after fluconazole course completed (last
day ___. Continued Divalproex ___ BID, with AM level of
61.
# HLD: Atorvastatin was initially continued, however it was put
on hold during the duration of the fluconazole course. Will need
to be restarted at 40mg q day after ___ (last day of
fluconazole).
===============================
TRANSITIONAL ISSUES
===============================
- Needs follow up for incidentally noticed adrenal adenoma (>1
cm), patient resides in ___ so no PCP to follow up. ___ primary
physician should repeat imaging for follow up.
- Clarification of indication for IVC filter and evaluation as
to whether removal is appropriate
- HCP was changed to Dr. ___, updated in ___ OMR
- After fluconazole course has been completed (on ___
Aripiprazole needs to be returned to usual 20mg daily dose, and
Atorvastatin 40mg should be restarted.
- Fluconazole 200mg PO daily until ___
- Cipro 250mg q 24 hr until ___
- Please perform an EKG on ___ to follow QTc on fluc + cipro
(was 409 on discharge)
- Please continue 5x/day straight cath as part of bladder
training, Please increase frequency if PVR are >600
- Stopped furosemide 10mg daily
- Avoid long-term indwelling catheters (urinary, midlines,
PICCs)
- Needs outpatient psychiatric follow up
- consider midodrine if continues to be orthostatic.
- Repeat Opthalmology exam in ___ weeks or immediately if he
experiences floaters, flashes, VF cuts or eye pain.
- Recommend repeat cross sectional imaging of pancreas in ___
weeks to evaluate for masses given unknown etiology of his
pancreatitis and long smoking history |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / pantoprazole
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ w/ newly dx metastatic pancreatic
cancer (pancreatic uncinate process mass extends into mesenteric
root with complete encasement of the SMA and obliteration of
portal vein/SMV confluence) s/p biliary stent ___, now C1D1
gemcitabine/abraxane on ___, who p/w generalized abdominal
pain.
Yesterday evening, developed diffuse abdominal pain. It was mild
to moderate in severity. This morning, she woke up with
significantly increased abdominal pain and temp 100.6 F. Pain
improved after taking 10 mg oxycodone. She denies any nausea,
vomiting, diarrhea, cough, headache. (Intermittent loose stools
present for weeks.) Of note, the patient has a generalized full
body pruritic rash. It began roughly 2 weeks ago.
In ED, tmax 100.3, HR 121, 113/69, 100% RA. Found to have
diffuse
abdominal TTP and generalized erythematous maculopapular
eruption. CT revealed increased obliteration of the main portal
vein since ___ CT. She received benadryl, hydroxyzine,
morphine, and heparin gtt. She was seen by ___. Heparin gtt was
started when the prelim read was c/f PVT but then when it was
felt this was not thrombus but obstruction, heparin gtt was
discontinued. She noted no effective relief from morphine.
REVIEW OF SYSTEMS:
12 point ROS reviewed in detail and negative except for what is
mentioned above in HPI. + ___
___ Medical History:
PAST MEDICAL HISTORY:
Pancreatic adenocarcinoma
left ear surgery
Social History:
___
Family History:
Family history is negative for GI diseases or pancreatitis.
Physical Exam:
ADMISSION
VITAL SIGNS: 98.6 PO 105 / 70 108 18 99 RA
General: NAD, Resting in bed appears uncomfortable from pain
HEENT: MMM
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, + diffuse TTP, L>R
LIMBS: WWP, trace non-pitting b/l ___, no tremors
SKIN: No notable rashes on extremities
NEURO: Strength b/l ___ intact, speech clear fluent
PSYCH: Thought process logical, linear, future oriented
ACCESS: R Chest port site intact w/o overlying erythema,
accessed
and dressing C/D/I
DISCHARGE
24 HR Data (last updated ___ @ 750)
Temp: 98.3 (Tm 98.3), BP: 100/63 (97-107/61-70), HR: 95
(95-108), RR: 18 (___), O2 sat: 98% (97-99), O2 delivery: RA
GEN: NAD
HEENT: MMM, OP clear. JVD not elevated.
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: Nondistended with normal BS. Soft. Diffuse moderate
tenderness, most pronounced in RLQ. No guarding, but has mild
rebound tendeerness, as well.
LIMBS: WWP, trace non-pitting edema LLE, no tremors
SKIN: Mild, erythematous, ___ rash on drunk with
hyperpigmented areas near prior excoriation. Blanchable.
NEURO: Strength b/l ___ intact, speech clear fluent
PSYCH: Thought process logical, linear, future oriented
ACCESS: R Chest port site intact w/o overlying erythema,
accessed
and dressing C/D/I
Pertinent Results:
ADMISSION
___ 12:51PM BLOOD WBC-7.8 RBC-3.23* Hgb-9.7* Hct-28.9*
MCV-90 MCH-30.0 MCHC-33.6 RDW-13.6 RDWSD-44.3 Plt ___
___ 12:51PM BLOOD Neuts-94.6* Lymphs-3.1* Monos-1.3*
Eos-0.4* Baso-0.1 Im ___ AbsNeut-7.26* AbsLymp-0.24*
AbsMono-0.10* AbsEos-0.03* AbsBaso-0.01
___ 07:46PM BLOOD ___ PTT-32.3 ___
___ 12:51PM BLOOD Glucose-104* UreaN-7 Creat-0.4 Na-138
K-4.1 Cl-102 HCO3-25 AnGap-11
___ 12:51PM BLOOD ALT-87* AST-70* LD(LDH)-291* AlkPhos-81
TotBili-1.7*
___ 06:25AM BLOOD Albumin-3.1* Calcium-7.8* Phos-2.3*
Mg-1.8
___ 01:11PM BLOOD Lactate-1.2
DISCHARGE
___ 06:56AM BLOOD WBC-17.8* RBC-2.99* Hgb-9.0* Hct-27.1*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.1 RDWSD-45.7 Plt Ct-96*
___ 06:56AM BLOOD Neuts-74* Bands-0 Lymphs-9* Monos-11
Eos-3 Baso-0 Atyps-1* ___ Myelos-2* AbsNeut-13.17*
AbsLymp-1.78 AbsMono-1.96* AbsEos-0.53 AbsBaso-0.00*
PERTINENT
MICRO
___ 3:34 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
IMAGING
___BD & PELVIS WITH CO
IMPRESSION:
1. Redemonstrated uncinate process pancreatic mass compatible
with pancreatic adenocarcinoma with increased involvement of
adjacent structures and extent into the porta hepatis.
2. Increased obliteration of the main portal vein and branches
of the SMV
since prior CT exam on ___ with edematous appearing small
and large bowel and ascites, which may suggest venous
congestion. No obstruction,
pneumoperitoneum, portal venous gas, or pneumatosis.
3. Hepatic lesions and mesenteric lymphadenopathy concerning for
metastatic disease.
4. No definite new mass lesions. Common bile duct stent in situ
without
intrahepatic biliary dilation.
___ Imaging BILAT LOWER EXT VEINS
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH
PAIN
2. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
3. Creon 12 2 CAP PO TID W/MEALS
4. Docusate Sodium 200 mg PO BID:PRN Constipation - First Line
5. Senna 17.2 mg PO BID:PRN Constipation - First Line
6. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Fexofenadine 120 mg PO BID
RX *fexofenadine 180 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
2. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN itch
RX *triamcinolone acetonide 0.1 % apply to affected areas twice
a day Refills:*1
3. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
4. Creon 12 2 CAP PO TID W/MEALS
5. Docusate Sodium 200 mg PO BID:PRN Constipation - First Line
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH
PAIN
8. Senna 17.2 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Abdominal Pain
Metastatic Pancreatic Cancer
Urinary Tract Infection
Diarrhea
Pancytopenia
Drug Eruption
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with pancreatic CA, now with worsening pain,
peritoneal findings.// r/o free air
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest ___
FINDINGS:
Right-sided Port-A-Cath tip terminates in the proximal right atrium. Heart
size is normal. Mediastinal and hilar contours are unremarkable. Lungs are
clear. Pulmonary vasculature is normal. No pleural effusion or pneumothorax.
A metallic common bile duct stent is noted along with pneumobilia in the right
upper quadrant of the abdomen. No acute osseous abnormalities. No
subdiaphragmatic free air.
IMPRESSION:
No acute cardiopulmonary abnormality. No subdiaphragmatic free air.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with ab'l pain, panc caNO_PO
contrast// ?masses ?incarceration
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 253 mGy-cm.
COMPARISON: CT of the abdomen and pelvis with contrast from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates heterogeneous attenuation throughout.
There are multiple hepatic lesions for example measuring 9 mm in the right
hepatic lobe (02:19), 26 mm hepatic segment 4 (02:19), as well as 8 mm in the
hepatic dome (2:7), which appear similar to prior examination on CT in ___. There is no evidence of intrahepatic or extrahepatic biliary dilatation
with common bile duct stent in situ and pneumobilia implying patency. The
gallbladder is within normal limits.
PANCREAS: As seen on prior CT exam, a 3-4 cm hypodense uncinate process masse
is compatible with pancreatic adenocarcinoma with increased surrounding
stranding and extent into the portahepatis since prior exam. The pancreatic
duct is prominent although not dilated, measuring 3 mm.
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. The small bowel appears
diffusely edematous involving a long segment jejunal loops, and the colon at
the splenic and hepatic flexures which may suggest venous congestion in the
setting of worsening vascular compromise (601:10, 02:14). There is new
adjacent ascites in the right lower quadrant pelvis. The rectum is within
normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small volume free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is an enlarged, fibroid uterus. No adnexal
abnormality is seen.
LYMPH NODES: The enlarged mesenteric lymph nodes measuring up to 11 mm in
short axis are again noted (02:40). There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: The main portal vein is obliterated by the stranding adjacent to the
mass, not well seen after the right and left bifurcation more extensive than
on prior CT (2:20, 2:21). Branches of the superior mesenteric vein also
appear obliterated by the mass, worse since prior examination (02:30). 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 previously described soft tissue nodule in the pelvis is not
well-visualized..
IMPRESSION:
1. Redemonstrated uncinate process pancreatic mass compatible with pancreatic
adenocarcinoma with increased involvement of adjacent structures and extent
into the porta hepatis.
2. Increased obliteration of the main portal vein and branches of the SMV
since prior CT exam on ___ with edematous appearing small and large bowel
and ascites, which may suggest venous congestion. No obstruction,
pneumoperitoneum, portal venous gas, or pneumatosis.
3. Hepatic lesions and mesenteric lymphadenopathy concerning for metastatic
disease.
4. No definite new mass lesions. Common bile duct stent in situ without
intrahepatic biliary dilation.
NOTIFICATION: The updated findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:20 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with pancreatic ca w/ ___// rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Right upper quadrant pain, Malignant neoplasm of pancreas, unspecified, Rash and other nonspecific skin eruption
temperature: 100.3
heartrate: 121.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 69.0
level of pain: 4
level of acuity: 3.0 | Ms. ___ is a pleasant ___ w/ newly dx metastatic pancreatic
cancer (pancreatic uncinate process mass extends into mesenteric
root with complete encasement of the SMA and obliteration of
portal vein/SMV confluence) s/p biliary stent ___, now C1D1
gemcitabine/abraxane on ___, who p/w rather acute onset
generalized abdominal pain.
# Abdominal Pain
# Ascites
# Acute on chronic cancer associated pain:
Improving from admission with PO opiate regimen. Likely due to
progression of known pancreatic mass with portal venous
obstruction. Initial CT in ED was concerning for new
PVT/mesenteric thrombosis with edematous appearing small and
large bowel and ascites suggestive of venous congestion and the
likely source of her pain. She was initially started on a
heparin gtt but this was discontinued after further evaluation
by GI revealed that this
PV obliteration was more likely due to tumor invasion. In
addition, this increased portal pressure was the likely cause of
her new ascites.
Her home opiate regimen was increased to oxycontin 20mg Q12 with
oxycodone ___ q4h PRN for break through. Her abdominal pain
was much improved with soft abd exams and normal lactates. Her
diet was advanced and she was tolerating a full diet by the time
of discharge.
Discussion with outpatient oncologist and advanced endoscopy
endorsed trial of PO pain control prior to pursuing celiac
plexus neurolysis. She will be seen by outpatient oncology on
___.
# Pancreatic Cancer:
Metastatic w/ peritoneal nodule and small lesion in liver. Now
has ascites. Plan to have ___ cycles of chemo.
- Cont home oxycodone and oxycontin w/ bowel regimen
- Cont home creon when taking meals
- Cont zofran prn
#Urinary Tract infection: Patient presented with fever from
home.
CT imaging did not demonstrate obvious source of infection.
Urine
Cx growing alpha hemolytic strep. No signs of dysuria, however,
given underlying malignancy, she is immunocompromised. She was
treated initially with zosyn given her fevers and this was
transitioned to augmentin for a total of 5 days of antibiotics.
#Pancytopenia: Likely due to nadir from chemotherapy. She was
started on neupogen on ___. Last dose ___.
# Rash: Started on buttocks 3 weeks ago, around the time she
initiated opiates. Has spread to anterior chest and back. No
dysuria or mucous membrane involvement to suggest DRESS/SJS.
Rash
predates chemotherapy. Has been improving with fexofenadine.
Seen by dermatology who thought the timing coincided better with
the Rx for pantoprazole which was already discontinued. She was
started on Triamcinolone ointment as well. Instructed per
dermatology to not use on groin, axilla or face (except for
forehead).
#Diarrhea: Stable, ___ watery BMs per day. C. diff negative.
Trialed loepramide x1 that caused increased bloating.
# Anemia in malignancy
- Haptoglobin not c/w gemcitabine hemolysis
# Elevated INR
- SP 10mg IV vitamin K ___
#Billing: 39 minutes were spent on coordingating with outpatient
providers, preparing paperwork and counseling patient
TRANSITIONAL ISSUES
[]Please ensure improvement of itching from rash
[]Please assess diarrhea, patient felt uncomfortable on
loperamide, consider Cholestyramine if continuing |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lithium / Haldol / Stelazine / Depakote
Attending: ___.
Chief Complaint:
acute mental status changes
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ year old female with hx signficant for developmental delay,
schizoaffective disorder (on clozaril), frequent urinary tract
infections, who was discharged from ___ to ___ on
___ after a workup for altered mental status. Had presented
during that admission with altered mental status, thought to be
due to behavioral catatonic spells and abdominal pain thought to
be secondary to urinary retention. Treated for dehydration and
urinary retention. Usually talkative, walking around, this am
noted to have stiff upper extremities, could not sit upright,
and yelled verbal responses, ich were appropriate. Pt was noted
to have BP 80/50, HR 91, no temp taken, also complaining of
abdominal pain, straight cath'd for 700cc at nursing home with
some improvement and sent to ED for evaluation.
.
Blood cultures from ___ NGTD, several recent urine cx
negative, most recent positive UCx from ___, growning
proteus sensitive to everything except ciprofloxacin and
tmp/smx. EEG final read pending but no epileptiform activity on
prelim.
.
Initial vitals in the ED: 97.4 82 ___ 100% 2L. In the ED,
Pt received 1 dose of ceftriaxone for presumed UTI due to pyuria
on UA, serum and urine tox were negative, and Pt was found to
have acute renal insufficiency w/ Cr 1.3 from baseline 0.9-1.0.
CXR w/out acute process. Pt was given 1L NS and admitted for
further workup.
.
Vitals on transfer: 97.8 99% RA 73 14 107/77
On arrival to the floor, vitals were 97.8F, 114/75, 76, 17, 98%
RA. Pt was mostly catatonic, only occasionally saying "what" but
not answering questions and not moving. Called ___
and spoke with Pt's nurse to get more collateral information.
Nurse states that Pt has been at ___ for several
weeks and that she was walking around, talking, and answering
questions. This morning, her "color looked terrible" and she was
not moving much. Nurse apparently checked BP and reported 80/50.
When asked if she rechecked BP, nurse replied that all
measurements were < 100/60. Nurse also bladder scanned ___ and
found 700mL, so she placed a foley and sent the Pt to the ED for
evaluation. Apparently, pt was only at ___ due to
incontinence. By the nurses' report, Pt's group home would not
take her back if she remained incontinent. Pt had vague
complaints of abdominal pain but no other complaints. Nurse
states that she was mostly worried about Pt's BP.
Review of systems: unable to obtain. Afebrile, apparently not
moving arms previously. Report of incontinence, but now urinary
retention. Vague abdominal pain, chronic.
Past Medical History:
SCHIZOAFFECTIVE DISORDER
IMPULSE CONTROL DISORDER
MENTAL RETARDATION
GASTRIC MOTILITY DISORDER
PARKINSONIAN DISORDER
GERD
CHRONIC ANEMIA
AMENORRHEA
HYPERLIPIDEMIA
RECURRENT UTI (PRESENTED WITH UNSTABLE GAIT, FALLS)
Social History:
___
Family History:
Father died of cancer (primary unknown). No family history of
seizures.
Physical Exam:
ADMISSION EXAM:
.
Vitals: 97.8F, 114/75, 76, 17, 98% RA.
GENERAL - woman lying awake with eyes open
HEENT - MMM, OP clear, pupils briskly reactive to light, but
reaction extinguishes quickly. Eyes w/ bilateral rightward gaze.
Blink reflex intact. No lymphadenopathy
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB anteriorly
ABDOMEN - normal bowel sounds, no masses, soft, ? mild
tenderness to palpation of LUQ
GU: Foley placed by ___ ___, wearing diaper
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
NEURO - awake, eyes open, not responsive to questions.
Occasionally states "what", stiffens limbs when they are moved
passively. 2+ bilateral biceps and patellar reflexes. Downgoing
babinski bilaterally.
Labs: see below
.
DISCHARGE EXAM:
.
VITALS: 98.1 98.1 106/68 76 18 96% RA
I/Os: 820 / NR | Inc ___: 103 mg/dL (on admission)
GENERAL: Appears in no acute distress. Alert and responding to
all questions this AM, in full sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD not elevated.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Decreased breath sounds at bases bilaterally; without
wheezing, rhonchi or rales. Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: awake, eyes open, fully responsive to questions. 2+
bilateral biceps and patellar reflexes. Downgoing babinski
bilaterally.
Pertinent Results:
ADMISSION LABS:
.
___ 07:05AM BLOOD WBC-5.4 RBC-3.44* Hgb-9.6* Hct-30.7*
MCV-89 MCH-27.8 MCHC-31.2 RDW-15.9* Plt ___
___ 07:05AM BLOOD Neuts-52.4 Lymphs-42.4* Monos-4.6 Eos-0.2
Baso-0.3
___ 07:20AM BLOOD ___ PTT-31.8 ___
___ 07:05AM BLOOD Glucose-92 UreaN-15 Creat-1.1 Na-148*
K-4.3 Cl-113* HCO3-26 AnGap-13
___ 07:05AM BLOOD Calcium-9.5 Phos-5.1* Mg-2.3
___ 07:05AM BLOOD VitB12-295 Folate-GREATER TH
___ 07:05AM BLOOD TSH-1.3
___ 10:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:08PM BLOOD Lactate-1.0
.
DISCHARGE LABS:
.
___ 07:25AM BLOOD Glucose-95 UreaN-24* Creat-1.3* Na-144
K-3.9 Cl-105 HCO3-30 AnGap-13
___ 07:25AM BLOOD Calcium-9.6 Phos-4.6* Mg-2.3
.
MICROBIOLOGIC DATA:
___ 10:25 am URINE Site: NOT SPECIFIED CHEM#
___ ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
MICROBIOLOGY DATA:
___ Blood cultures (x 2) - pending
___ Urine culture - < 10K organisms
___ Blood culture - pending
.
IMAGING:
___ CT HEAD W/O CONTRAST - No evidence of acute intracranial
hemrorhage or mass effect. Mild-moderate dilation of lateral and
third ventricles disproportionate from sulcal enlargement, which
may reflect central atrophy with/without a component of
communicating hydrocephalus -normal pressure hydrocephalus or
related to a component of narrowing of cerebral
aqueduct/developmental.
Correlate clinically and if necessary with LP/MRI if not CI
after neurology consult.
.
___ CXR - Bibasilar atelectasis, greater on the right than
the left. Pneumonia must be excluded in the proper clinical
setting.
.
___ AXR - Again seen is a nonspecific bowel gas pattern with
gasseous distention of the stomach as seen previously on ___ with a large amount of air and feces noted in the
colon. Clinical correlation recommended.
.
___ EEG - abnormal EEG because of a few bursts of generalized
slowing indicative of a subcortical or deep midline dysfunction
projecting bilaterally which is etiologically non-specific. The
background rhythm achieved normal frequencies with excess
diffuse
beta activity seen.
.
___ CXR (PORTABLE) - Frontal and lateral views of the chest
were obtained. No focal consolidation, pleural effusion, or
evidence of pneumothorax is seen. Cardiac and mediastinal
silhouettes are unremarkable.
Medications on Admission:
1. benztropine 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. clozapine 100 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
3. clozapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
5. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day).
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO twice a day.
9. propranolol 40 mg Tablet Sig: One (1) Tablet PO twice a day.
10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime.
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Medications:
1. clozapine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day).
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO BID (2 times a day).
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. propranolol 40 mg Tablet Sig: One (1) Tablet PO twice a day.
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. clozapine 150 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO at bedtime.
12. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 7 days: started ___, ending ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
1. Enterococcus urinary tract infection
2. Acute delirium with encephalopathy
.
Secondary Diagnoses:
1. Schizoaffective disorder
2. Impulse control disorder
3. Mental retardation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive at times only.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of altered mental
status.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. No focal
consolidation, pleural effusion, or evidence of pneumothorax is seen. Cardiac
and mediastinal silhouettes are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MS CHANGE
Diagnosed with URIN TRACT INFECTION NOS, DEHYDRATION
temperature: 97.4
heartrate: 82.0
resprate: 18.0
o2sat: 100.0
sbp: 101.0
dbp: 74.0
level of pain: 10
level of acuity: 3.0 | IMPRESSION: ___ with PMH significant for marked developemental
delay and schizoaffective disorder, urinary incontinence, who
was recently admitted for altered mental status and abdominal
pain secondary to behavioral catatonic spells and urinary
retention respectively who is now readmitted from facility with
continued mental status concerns and acute renal insufficiency
found to have Enterococcus UTI.
# ENCELPHALOPATHY, ACUTE DELIRIUM CONCERNS - Per nursing home,
patient is usually alert and oriented to self and nursing home
staff, able to ambulated independently. She has a history of
developemental delay as well as schizoaffective disorder.
Currently patient is somewhat distant with odd affect, but her
thought processes appear linear and appropriate. CXR with
bibasilar atelectasis, but no consolidation. Also has history of
constipation in the past. TSH, B12 and folate reassuring on last
admission. EEG reassuring. There is some concern that this
reflects behavioral issues. On prior admission, Psych felt her
home regimen was adequate - however, on this admission they
opted to decrease her Clozaril and discontinue Benztropine. This
did result in some improvement in her mood and behavior. These
changes were made in discussion with her outpatient
psychiatrist, Dr. ___. The only other reversible issue of note
was an Enterococcus UTI treated with Ampicillin. We noted minor
improvements in her mental status with UTI treatment and
adjustment of her Clozapine medication. At discharge, she was
mentating well, verbally interactive and cooperating with
nursing staff.
# ABDOMINAL PAIN - Patient describes diffuse midline crampy
abdominal pain which was associated with one episode of vomiting
several days prior to admission. Her abdomen is midly tender to
palpation without rebound or guarding. Her lipase was elevated
but her pain didn't correlate clinically; suspicion for
pancreatitis is low. Her pain is relieved with eating but she
mentions no reflux like symptoms. Patient reports regular bowel
movements however, on previous admissions she has been extremely
constipated. Acute urinary retention could haved play a role as
when she had her Foley placed she put out 1.5 liters of urine.
Following admission her abdominal pain resolved. We continued
her PPI dosing and maintained an aggressive bowel regimen.
# ENTEROCOCCUS UTI - Presenting with positive U/A. Difficult to
obtain symptom history. Urine culture from ___ demonstrated
moderately-sensitive Proteus. Recent Foley catheterization.
Received Ceftriaxone in the ED. Urine culture speciating
Enterococcus UTI, which was Ampicillin sensitive. We continued
Ceftriaxone until speciation and changes her to Ampicillin PO.
Her WBC remained reassuring and she remained afebrile.
# HYPERNATREMIA, ACUTE RENAL INSUFFICIENCY - Patient presents
with chronic renal insufficiency to 1.3 (baseline 0.9 to 1.3).
Evidence of poor PO intake previously; not hypernatremia on
admission. She required intermittent free water for
hypernatremia and poor PO intake, but overall had improved PO
intake prior to discharge given improvement in her mental
status. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / revlamid / Bactrim
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female past medical history multiple myeloma on
dexamethasone, diabetes, hypertension, history of DVT/PE not on
anticoagulation presenting with one day of left-sided pleuritic
chest pain. She reports non productive cough and nasal
conggestion for 4 days, with one day of left shoulder and rib
pain. This morning she was woken from sleep with left-sided
chest pain starting in her shoulder and now below her diaphragm,
and is worse with taking a deep breath or coughing. She has no
leg pain or leg swelling. She was previously on lovenox which
was stopped after 3 months for a retinal bleed.
With regard to her previous dvt/pe hx she was dx with DVT/ PE in
___ and was on lovenox for anticoagulation. Per her
heme-onc notes, revlemid was thought to be the cause of her
thrombosis, and was treating this as a provoked DVT with plan
for 6 month course. She was seen by optho on ___ after having 1
week of blurry vision, and was found to have massive subretinal
hemorrhage c/b increased IOP pressures. A lovenox level was
checked by her outpatient oncologist was elevated at 2, and in
the setting of the bleed lovenox was discontinued on ___. Per
discussion with her outpatient opthomologist and oncolgoist pt
was told that her vision would likely not return if the left
eye. Her IOP eventually improved on Diamox. Per last optho note
goal for her ___ eye visular acutity was comfort, given poor
prognosis and limited options.
In the ED initial vitals were: 8 98.8 98 139/62 17 99%
- Labs were significant for wbc of 11.3, normal chem, trop neg x
1 , normal lactate UA notable for ketones. blood cx time x 2
were sent
-Imaging: CTA showed ___ upper and ___ lower lobe PEs as
well as left lower lobe lobar pulmoary artery clots. cxr also
showed a suspected left basilar opacity concernign for
atelectais vs infection if there is clinical concern
- Patient was given morphine 2 mg IV x 1, levofloxaicn 500mg PO,
and 1L NS
Past Medical History:
HYPERTENSION
Osteoarthritis
DM (diabetes mellitus)
DIVERTICULOSIS
Hypercholesteremia
S/P total knee replacement ___ ___
DCIS (ductal carcinoma in situ)
Pulmonary embolus
Deep vein thrombosis (DVT)
Multiple Myeloma
diabetic retinopathy
Macular degeneration
R retinal hemorrhage c/b blindness
Social History:
___
Family History:
sister with diabetes
no clotting disorders
Physical Exam:
Admission exam:
Vitals - T 99.7 BP 157/65 P 97 RR 18 99% RA
GENERAL: elderly female in NAD
HEENT: AT/NC, EOMI,
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: crackles at left lung base, otherwise clear, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants,\
EXTREMITIES: no cyanosis, clubbing or edema, no calf pain with
palpation
NEURO: AOX 3
Discharge exam:
Unchanged.
Pertinent Results:
Admission labs:
___ 05:03PM BLOOD WBC-11.3* RBC-3.33* Hgb-9.8* Hct-30.2*
MCV-91 MCH-29.3 MCHC-32.3 RDW-15.0 Plt ___
___ 05:03PM BLOOD ___ PTT-25.7 ___
___ 05:03PM BLOOD Glucose-133* UreaN-19 Creat-0.9 Na-136
K-4.0 Cl-101 HCO3-24 AnGap-15
___ 07:30AM BLOOD LD(___)-189 TotBili-0.6 DirBili-0.3
IndBili-0.3
___ 08:33AM BLOOD CK(CPK)-28*
___ 05:03PM BLOOD cTropnT-<0.01
___ 08:33AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:03PM BLOOD Calcium-10.1 Phos-3.4 Mg-1.8
___ 08:33AM BLOOD PEP-ABNORMAL B FreeKap-19.9* FreeLam-3.2*
Fr K/L-6.21* IgG-2592* IgA-12* IgM-16*
___ 05:43PM BLOOD Lactate-1.8
Discharge labs:
___ 07:40AM BLOOD WBC-10.1 RBC-2.81* Hgb-8.1* Hct-26.3*
MCV-94 MCH-29.0 MCHC-30.9* RDW-16.1* Plt ___
___ 07:40AM BLOOD ___ PTT-71.2* ___
Pertinent micro:
Blood cultures negative x2
Pertinent imaging:
___ CXR
Suspected left basilar opacity, with a pattern commonly
associated with
atelectasis. If developing infection is a clinical concern then
short-term
follow-up radiographs may be helpful, preferably with PA and
lateral technique
if feasible.
___ CTA chest
1. Acute bilateral pulmonary emboli in the ___ upper lobe,
___ lower
lobe, and left lower lobe lobar pulmonary arteries as well as
several
segmental pulmonary arteries.
2. Heterogeneous thyroid with multiple hypodense nodules, which
can be
followed on a nonemergent basis with ultrasound if not already
performed.
3. Small left pleural effusion and trace ___ pleural effusion.
4. Stable 3 mm nodule in the lateral ___ upper lobe. Continued
followup
based on patient's risk factors is recommended, as per prior CT
report.
___ ___ Venous US
Persistent nonocclusive thrombus in the left mid and distal
superficial
femoral vein and popliteal vein similar to the study of ___.
___ ECHO
The left atrium and ___ atrium are normal in cavity size.
Normal left ventricular wall thickness, cavity size, and
regional/global systolic function (biplane LVEF = 64 %). There
is no left ventricular outflow obstruction at rest or with
Valsalva. ___ ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is hign normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mildly dilated ascending aorta. Normal biventricular
cavity sizes with preserved regional and global biventricular
systolic function. No valvular pathology or pathologic flow
identified. No structural cardiac cause of syncope identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Vitamin D 400 UNIT PO DAILY
3. Simvastatin 10 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Calcium Carbonate 650 mg PO DAILY
7. losartan-hydrochlorothiazide 50-12.5 mg oral daily
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Atropine Sulfate Ophth 1% 1 DROP ___ EYE BID
10. Dexamethasone 20 mg PO 1X/WEEK (___)
11. Dapsone 100 mg PO DAILY
12. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP ___ EYE BID
14. Timolol Maleate 0.5% 1 DROP ___ EYE Frequency is Unknown
Discharge Medications:
1. Atropine Sulfate Ophth 1% 1 DROP ___ EYE BID
2. Calcium Carbonate 650 mg PO DAILY
3. Dapsone 100 mg PO DAILY
4. Dexamethasone 20 mg PO 1X/WEEK (___)
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP ___ EYE BID
10. Simvastatin 10 mg PO DAILY
11. Timolol Maleate 0.5% 1 DROP ___ EYE BID
12. Vitamin D 400 UNIT PO DAILY
13. Acetaminophen 1000 mg PO Q6H:PRN pain or fever
Do not exceed 3gm/day.
14. Argatroban 0.5-2.2 mcg/kg/min IV DRIP INFUSION
15. Docusate Sodium 100 mg PO BID
16. Lidocaine 5% Patch 1 PTCH TD QAM
12 hrs on, 12 hrs off.
17. Senna 8.6 mg PO BID:PRN Constipation.
18. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
19. Warfarin 8 mg PO DAILY16
20. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
21. losartan-hydrochlorothiazide 50-12.5 mg oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pulmonary embolism
Deep vein thrombosis
Multiple myeloma
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: Chest pain and dyspnea.
COMPARISON: ___.
TECHNIQUE: Chest, portable AP upright.
FINDINGS:
The lung volumes are low. Allowing for that, there is no definite change in
cardiac, mediastinal or hilar contours. A right basilar opacity has probably
cleared. However, mild new opacification is present at the left lung base
partly obscuring the left hemidiaphragm. Small pleural effusions are
difficult to exclude.
IMPRESSION:
Suspected left basilar opacity, with a pattern commonly associated with
atelectasis. If developing infection is a clinical concern then short-term
follow-up radiographs may be helpful, preferably with PA and lateral technique
if feasible.
Radiology Report
INDICATION: History: ___ with MM, hx of DVT/PE, pleuritic CP, cough // PE?
rib fx?
TECHNIQUE: CTA imaging of the chest was performed after administration of
intravenous contrast. Multiplanar reformats were prepared and reviewed. MIP
images were generated and reviewed
DOSE: DLP: 513.43 mGy-cm
COMPARISON: Comparison is made with CTA chest from ___.
FINDINGS:
CHEST CTA:
Pulmonary emboli are visualized in the right upper lobe, right lower lobe, and
left lower lobe lobar pulmonary arteries and several segmental pulmonary
arteries. The right heart chambers are enlarged although this feature seems
unchanged. The heart is overall mildly enlarged. Coronary arteries are
calcified. Central pulmonary arteries are enlarged to a similar degree.
The thyroid is heterogeneous with multiple hypodense nodules.
CHEST:
Areas of unchanged round atelectasis are seen at the lung bases. There is a
stable 3 mm nodule in the right upper lobe laterally. There is also an
unchanged cluster of nodules in the anterior right upper lobe (02:20),
probably reflecting prior infectious or granulomatous disease. The airways
are patent to the subsegmental levels bilaterally.
No pathologically enlarged axillary, mediastinal, or hilar lymph nodes are
identified. There is a small left pleural effusion and trace right pleural
effusion.
The study is not tailored for subdiaphragmatic evaluation, but the visualized
intra-abdominal organs are unremarkable.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen. Prominent osteophytes are noted along the
thoracic spine. The bones appear demineralized.
IMPRESSION:
1. Acute bilateral pulmonary emboli in the right upper lobe, right lower
lobe, and left lower lobe lobar pulmonary arteries as well as several
segmental pulmonary arteries.
2. Heterogeneous thyroid with multiple hypodense nodules, which can be
followed on a nonemergent basis with ultrasound if not already performed.
3. Small left pleural effusion and trace right pleural effusion.
4. Stable 3 mm nodule in the lateral right upper lobe. Continued followup
based on patient's risk factors is recommended, as per prior CT report.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with hx of DVT/PE coming in with new PE // eval
for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Bilateral lower extremity ultrasound ___.
FINDINGS:
Nonocclusive thrombus persists in the left mid and distal superficial femoral
vein and popliteal vein. There is normal compressibility, flow and
augmentation in the right common femoral, superficial femoral, and popliteal
veins. Normal color flow and compression is demonstrated in the posterior
tibial and peroneal veins on the right. There is normal color flow in the left
posterior tibial veins, however the peroneal veins cannot be visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
Persistent nonocclusive thrombus in the left mid and distal superficial
femoral vein and popliteal vein similar to the study of ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with PULM EMBOLISM/INFARCT, MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.8
heartrate: 98.0
resprate: 17.0
o2sat: 99.0
sbp: 139.0
dbp: 62.0
level of pain: 8
level of acuity: 2.0 | ___ year old female hx of MM, DVT/PE, ___ retinal hemorrhage in
the setting of supratherapeutic lovenox level with subsequent
stopping of lovenox, R eye blindness, now presenting with
recurrent bilateral PE/DVT.
# PE and LLE DVT:
Pt was admitted to ___ ___ with newly diagnosed LLE DVT
and RLL PE, discharged on coumadin. Her clot was thought to be
provoked by Revlimid, so it was stopped. She was then readmitted
in ___ with worsening LLE pain and edema, found to have
expansion of clot despite adequate INR, and was changed to
lovenox at that time. Later, pt was hospitalized at ___
___ on ___ for R retinal hemorrhage, and lovenox level was
found to be 2. She was 3 months out from her "provoked" VTE, so
lovenox was stopped. Now, off revlimid, her PE has progressed to
the RUL and LLL, and the LLE DVT is persistent. Per discussion
with the patient and her family on admission, it was decided to
pursue anticoagulation for these clots despite recent bleed. Of
note, her outpatient ophthalmologist was contacted, who relayed
that her risk to bleed in the left eye was low. Heparin drip was
started on admission, but was then stopped when her platelets
appeared to be dropping. She was changed to an argatroban drip.
Platelets stabilized and HIT antibiotidies came back negative.
Coumadin was started at 4mg and uptitrated until discharge at
8mg daily. Pt. was discharged to ___ on argatroban drip
as bridge to therapeutic coumadin.
#Syncope:
Pt reported syncope the day of presentation. Troponins were
negative x2 and EKG unchanged. Telemetry revealed blocked PACs
which were asymptomatic. But otherwise, no events or abnormal
rhythms. Echo showed normal EF and no significant lab
abnormalities. Orthostatics were negative, although pt did have
intermittently low blood pressures. Likely etiology is PE. Her
home HCTZ was stopped and her home losartan was down titrated to
improve this. They can be uptitrated as needed as an outpatient.
#Cough:
Pt presented with productive cough, no fevers, +URI symptoms.
She had no pneumonia on Xray. This was felt to be a viral
bronchitis and was treated supportively. Symptoms resolved
midway into her admission.
#Pancytopenia:
Pt was noted to have an initial platelet and hematocrit drop
concerning for HIT or bleed. ___ HIT antibodies were negative,
and numbers stabilized. No evidence of blood loss. Could have
been suppression from her acute viral infection or inflammatory
response. Could also be related to her multiple myeloma. Atrius
oncology will trend as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
levofloxacin
Attending: ___
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
___ EGD with endoscopic guided NJ tube placement
___ Jtube placement
History of Present Illness:
Mr. ___ is a ___ year old male esophageal adenocarcinoma
currently being treated with ___ who presents with
progressive dysphagia to solids, liquids and medicine.
Of note, the patient was discharged from ___ yesterday
after presenting on ___ with hypotension and tachycardia after
checking his vital signs at home (BP 90/60, HR 160s) and was
found to be in AFib with RVR. This occurred in the setting of
progressive dysphagia due to his esophageal cancer leading to
poor PO intake and inability to take his medications.
Upon presentation to the outside hospital, he was found to be in
atrial fibrillation with RVR with a ventricular rate of 160. He
received IV metoprolol x2 with improvement of his HRs to 100s.
He
was subsequently admitted to the medical service for management
of his new AFib. While on the floor, he spontaneously converted
to sinus rhythym. He was started on apixaban, and his metoprolol
was increased to 100mg daily from 50mg daily.
TTE demonstrated an LVEF of 61% with no significant valvular
disease.
His laboratory work up was unremarkable. Notably, trop T <0.01,
pro-BNP 966, TSH 1.5.
The patient was discharged home but called his oncologist today
stating that he continued to be unable to eat, drink or take his
medications, he was subsequently referred to the ED for
admission
and J-Tube placement.
In the ED, the initial vital signs were:
T 98.6 HR 85 BP 145/96 R 16 SpO2 99% RA
Laboratory data was notable for:
Na 132,
WBC 1.4 ANC 1320 Hgb 8.1 Plt 70
INR 1.6
The patient received:
___ 17:45 IVF LR ( 1000 mL ordered)
Imaging demonstrated:
ECG: NSR rate 69, normal intervals with RBBB
Upon arrival to ___ the patient states that he feels well. He
has
no headache or vision changes. He has had chronic sinusitis and
post nasal drip leading to increased coughing up of phlegm.
However, over the last ___ days, when he noticed his dysphagia
increasing, he has had difficulty swallowing his secretions, in
addition to food, liquid and medications. He has no nausea. No
chest pain or dyspnea. No abd pain. No diarrhea, constipation or
dysuria.
ROS: 10 point review of systems discussed with patient and
negative unless noted above
Past Medical History:
In ___ he
developed intermittent dysphagia to solids, as well as
hoarseness
and hiccups. The symptoms improved but then recurred and on
___ Dr. ___ EGD which showed a 5 cm mass
of malignant appearance in the esophagus from 35-40 cm. Biopsy
of
the gastroesophageal junction and lower one third of the
esophagus was positive for mucinous adenocarcinoma, poorly
differentiated, with LVI.
EGD/EUS on ___ showed an ulcerated and friable 7 cm mass
extending from the distal esophagus with the bulk of the mass in
the gastric cardia involving the gastroesophageal junction;
there
was a single 1.0 cm nodule of benign appearance in the gastric
antrum and biopsy of this nodule showed fundic mucosa with
reactive/hyperplastic change. EUS showed an exophytic esophageal
mass at the lower one third, gastroesophageal junction, and
gastric cardia 7 cm in length and 1.5 cm maximum depth which
invaded beyond the muscularis propria compatible with a T3
lesion. There were no enlarged lymph nodes in the periesophageal
mediastinum, N0.
Mr. ___ saw Dr. ___ on ___ who recommended a
laparoscopy for diagnostic purposes.
On ___ CT of the chest with contrast showed no mediastinal
or hilar adenopathy. There was circumferential wall thickening
of
the distal esophagus from the level of the inferior pulmonary
veins to the gastroesophageal junction and proximal stomach, and
small gastrohepatic ligament lymph nodes. CT of the abdomen and
pelvis with contrast on ___ showed a 6.7 cm mass extending
from the distal esophagus to the gastroesophageal junction.
There
were no focal enlarged gastrohepatic ligament lymph nodes.
There
was a 0.6 cm hypodensity in segment VI of the liver and a 0.4 cm
hypodensity in segment II of the liver both felt likely biliary
hamartomas.
On ___ we met with Mr. ___ and discussed trimodality
therapy with curative intent. We discussed treatment according
to
the CROSS regimen with radiation therapy in combination with
carboplatin and paclitaxel.
PET/CT was completed on ___ which showed no evidence of
metastatic disease.
On ___ Dr. ___ a diagnostic laparoscopy and
placed a port. The three biopsies collected further ruled out
metastatic disease.
He initiated radiation therapy on ___ at ___ and
chemotherapy on ___.
PAST MEDICAL HISTORY:
Esophageal cancer, as above
GERD
HTN
HLD
AFib
Tachycardia
Depression
Sinusitis on augmentin ppx
Repair of ruptured disc in L5/L1 in ___
Repair of ruptured disc at C5-6 and C6-7 in ___
Social History:
___
Family History:
Unknown. The patient is adopted.
Physical Exam:
GENERAL: anxious, NAD
HEENT: MMM, noted post nasal drip, no erythema
EYES: PERRL, anicteric
NECK: supple
RESP: No increased WOB, no wheezing, rhonchi or crackles
___: RRR no MRG
GI: soft, NTND no HSM, J tube in place dressing c/d/I, mild
distention but normal bowel sounds
EXT: warm, no edema
SKIN: warm and well-perfused
NEURO: CN II-XII intact
ACCESS: R POC c/d/i
Pertinent Results:
Labs on discharge
EKG:
Afib RBBB, normal rate
EGD ___
-Grade A esophagitis in the distal esophagus consistent with
radiation induced injury
-Distal esophageal narrowing was noted but easily traversable
with therapeutic endoscope
-Nodule in the antrum
-A single 5mm non-bleeding nodule of benign appearance was seen
in the antrum. This finding was suggestive of a submucosal
lesion
-Otherwise, the reminder of the stomach appeared normal
-Normal mucosa in the whole examined duodenum
-An NJ tube was placed past the third portion of the duodenum.
The tube was moved from the mouth into the nose and bridled at
105cm. The tube flushed without difficulty.
___ 05:23AM BLOOD WBC-3.2* RBC-2.76* Hgb-7.7* Hct-23.7*
MCV-86 MCH-27.9 MCHC-32.5 RDW-20.1* RDWSD-56.7* Plt ___
___ 05:52AM BLOOD Glucose-159* UreaN-11 Creat-0.7 Na-135
K-4.1 Cl-97 HCO3-28 AnGap-10
___ 05:52AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Verapamil SR 240 mg PO Q24H
4. Atorvastatin 20 mg PO QPM
5. Lisinopril 40 mg PO DAILY
6. Chlorthalidone 12.5 mg PO DAILY
7. Apixaban 5 mg PO BID
Discharge Medications:
1. Acetaminophen (Liquid) 975 mg PO TID
RX *acetaminophen 325 mg/10.15 mL 30 ml by mouth every six (6)
hours Disp #*1 Bottle Refills:*0
2. Baclofen 10 mg PO TID:PRN hiccups
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
3. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *lansoprazole 30 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. LORazepam 0.5 mg PO Q8H:PRN anxiety or nausea
RX *lorazepam 0.5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. Maalox/Diphenhydramine/Lidocaine ___ mL PO Q4H:PRN for
"reflux pain" (esophageal mucositis)
RX *alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20
mg/5 mL ___ ml by mouth every four (4) hours Refills:*0
7. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Verapamil 80 mg PO Q8H
RX *verapamil 80 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
9. Apixaban 5 mg PO BID
10. Atorvastatin 20 mg PO QPM
11. Chlorthalidone 12.5 mg PO DAILY
12. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dysphagia
Radiation esophagitis
Esophageal cancer
AFib
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)
CLINICAL HISTORY History: ___ with neutropenia// neutropenic w/u
neutropenic w/u
COMPARISON: ___
FINDINGS:
The lungs remain clear. The heart is within normal limits in size. The aorta
is mildly tortuous. Mediastinal structures are stable. A MediPort catheter
remains in place. There is mild compression deformity of several midthoracic
vertebral bodies as demonstrated earlier. The bony thorax is grossly intact
IMPRESSION:
No evidence of pneumonia or acute cardiopulmonary disease.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with NGT and J tube. Need to confirm NGT position
after large vomiting episode// NGT position
IMPRESSION:
In comparison with the study of ___, the the long intestinal tube extends
to the upper duodenum. Mild dilatation of the visualized large and small
bowel.
Cardiomediastinal silhouette is stable without evidence of vascular congestion
or acute focal pneumonia. There is a streak of atelectasis at the left base
as well as bilateral subcutaneous gas along the lower chest and upper
abdominal wall, more prominent on the left.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Difficulty swallowing
Diagnosed with Dehydration, Dysphagia, unspecified, Other decreased white blood cell count, Bandemia, Palpitations
temperature: 98.6
heartrate: 85.0
resprate: 16.0
o2sat: 99.0
sbp: 145.0
dbp: 96.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ year old man with esophageal cancer and
a recent admission at ___ with new AFib/RVR in the
setting of poor PO intake due to progressive dysphagia, who
presented with persistent progressive dysphagia due to malignant
obstruction and esophagitis in the setting of neoadjuvant
chemo/XRT. Now s/p jtube placement on tube feeds
#Esophagitis and dysphagia due to malignancy/chemo-radiation
#Malnutrition (moderate)
#Bothersome esophageal symptoms (heartburn, regurgitation,
hiccups)
#QTc prolongation
Patient with dysphagia to both liquids and solids in the setting
of known esophageal malignancy, worsened in setting of
post-radiation edema and inflammation. Underwent endoscopic NJ
tube placement on ___, started on tube feeds. Continued to feel
bothersome heartburn and at times persistent hiccups, belching,
and regurgitation of phlegm. He felt that the NJ tube was too
bothersome and preferred to pursue a surgical jtube with the
___ service prior to discharge, which was placed ___.
Tube feeds were uptitrated to goal and well-tolerated. Home
infusion set up
Treated for esophagitis with PPI, H2 blocker, and GI cocktail.
Baclofen given PRN for hiccups since QTc elevated and thorazine
therefore felt to be less safe.
Patient and wife very anxious about managing tube at home so
provided maximal support and counseling. All meds are PO and not
through J tube given propensity to clog.
#Esophageal cancer (T3N0M0)
#Pancytopenia due to chemotherapy - iresolved
Underwent neoadjuvant chemo/XRT with plan for surgery
withcurative intent. Last session of radiation ___,
chemotherapycompleted. Surgery planned in ___ weeks. Patient
will follow-up closely with oncology as outpatient,
likely will undergo PET prior to surgery
#Sinusitis
Patient had been taking augmentin for sinusitis but this was
discontinued given his inability to tolerate PO (and had nearly
completed course). Symptoms exacerbated by ___ tube and patient
unable to have bridle placed due to nasal inflammation. However
this improved somewhat prior to discharge. Spoke with his
outpatient ENT Dr. ___. patient can continue his home
budesonide rinses. As inpatient he used nasal saline spray
#AFib/HTN
Diagnosed at BID-N recently, chads2vasc of 2. Started on
apixaban and continued on metoprolol and verapamil, as well as
lisinopril and chlorthalidone.
#HLD - restarted atorvastatin
======================
TRANSITIONAL ISSUES
- close oncology follow-up as outpatient
====================== |