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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cough, Sputum Production
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with COPD, tobacco abuse, DM2, HTN presnting
to the ED SOB, cough productive of yellow sputum, and subjective
fevers x 3 days. She has continued to smoke about 1 ppd. No
recent travel or sick contacts.
In the ED, initial VS were: 97.6 91 91/68 24 83% RA. She was
given nebs, sats increased to mid to high ___ on 3L. Peak flow
remained at 240 before and after. CXR showed multilobar
pneumonia on the right. She was given IV ceftriaxone and IV
azithro, 1 L NS with increase in BPs, and 125 methypred. ECG
normal. Labs normal. Vitals on transfer were 98.6 77 110/71 17
95%.
Of note, per clinic notes, baseline BPs in 100s-110s.
On arrival to the floor, patient comfortable, sating 100% RA.
Past Medical History:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DIABETES MELLITUS - Diet controlled, last A1c 6.2
GASTRITIS
GASTROESOPHAGEAL REFLUX
GOITER
HELICOBACTER PYLORI
HYPERCHOLESTEROLEMIA
HYPERTENSION
HYPERTHYROIDISM (Graves)
HYPOTHYROIDISM
POLYNEUROPATHY IN DIABETES
SCHATZKIS RING
SCIATICA
TOBACCO
Social History:
___
Family History:
- Multiple family members with DM and CAD
Physical Exam:
Admission Exam:
VS - 98.1 100/76 81 24 100% 2L
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Soft rhonchi over right lower/middle lobes, no egophony
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3
Discharge Exam:
VS - 98.1 128/81, 79, 20 98% RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - clear throughout without rhonchi or wheezes
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3
Pertinent Results:
CBC:
___ 09:00PM BLOOD WBC-6.4 RBC-4.18* Hgb-12.8 Hct-39.3
MCV-94 MCH-30.6 MCHC-32.5 RDW-15.3 Plt ___
___ 03:40PM BLOOD WBC-4.6 RBC-4.19* Hgb-12.6 Hct-39.4
MCV-94 MCH-30.1 MCHC-32.0 RDW-15.0 Plt ___
CMP:
___ 09:00PM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-139
K-3.7 Cl-102 HCO3-26 AnGap-15
___ 03:40PM BLOOD Glucose-124* UreaN-13 Creat-0.7 Na-137
K-4.5 Cl-98 HCO3-27 AnGap-17
___ 06:05AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.1
___ 03:40PM BLOOD Calcium-9.6 Phos-3.5 Mg-2.2
.
IMAGING:
CXR: ___
IMPRESSION:
Findings concerning for pneumonia within the right lung base and
right mid
lung field.
CT SCAN CHEST W/ CONTRAST: ___:
IMPRESSION:
1. Markedly peripheral airspace consolidation in the right
upper, middle and lower lobes with areas of air bronchograms are
consistent with pneumonia, however, suspect eosinophilic
pneumonia given recurrence and peripheral location. Consider
correlation with laboratory tests and/or bronchoscopy as
clinically warranted.
2. 3-mm left subpleural nodule vs. focal area of consolidation.
Depending on patient's risk factors, recommend 12-month
followup or no followup needed if low risk.
3. Mild background centrilobular emphysematous pattern.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. carisoprodol *NF* 350 mg Oral TID:PRN neck pain
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Gabapentin 600 mg PO HS
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Lorazepam 2 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO 5X/DAY
9. Potassium Chloride 20 mEq PO DAILY
10. Rosuvastatin Calcium 5 mg PO QHS
11. TraMADOL (Ultram) 100 mg PO TID:PRN pain
12. Valsartan 160 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. carisoprodol *NF* 350 mg Oral TID:PRN neck pain
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Gabapentin 600 mg PO HS
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Lorazepam 2 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO 5X/DAY
9. Potassium Chloride 20 mEq PO DAILY
10. Rosuvastatin Calcium 5 mg PO QHS
11. TraMADOL (Ultram) 100 mg PO TID:PRN pain
12. Valsartan 160 mg PO DAILY
13. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*6 Tablet
Refills:*0
14. Levofloxacin 750 mg PO Q24H Duration: 3 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth Daily
Disp #*3 Tablet Refills:*0
15. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 PUFF
INH Daily Disp #*30 Capsule Refills:*0
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/WHEEZING
RX *albuterol sulfate 90 mcg 2 PUFF INH every four (4) hours
Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diangosis:
COPD exacerbation
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: CT chest with contrast.
CLINICAL INDICATION: ___ woman with right middle lobe infiltrates
that need further evaluation. Rule out pneumonia vs. malignancy.
COMPARISON: Chest radiograph ___.
TECHNIQUE: Axial series through the chest with coronal and sagittal reformats
provided by technologist. Uneventful administration of 75 cc Omnipaque IV
contrast.
FINDINGS:
No lower cervical adenopathy. No significant thyroid tissue is seen. Heart
size within normal limits. Atherosclerotic coronary calcifications are noted.
Three-vessel aortic arch. No pericardial effusion. Normal appearance of the
gastroesophageal junction. Limited evaluation of the upper abdomen
demonstrates no gross abnormality.
Lungs demonstrate a mild centrilobular emphysematous pattern with a markedly
peripheral area of consolidation involving the right upper, right middle and
slightly involving the right lower lobe. The largest area of consolidation
demonstrates air bronchograms. There is mild peripheral ground glass opacity
seen on the left. Bilateral dependent atelectasis is noted. There is a 3-mm
nodule on the left fissure (2:25) which may represent a tiny consolidative
area vs. true nodule. No typical, suspicious nodules are seen.
No significant osseous abnormality.
IMPRESSION:
1. Markedly peripheral airspace consolidation in the right upper, middle and
lower lobes with areas of air bronchograms are consistent with pneumonia,
however, suspect eosinophilic pneumonia given recurrence and peripheral
location. Consider correlation with laboratory tests and/or bronchoscopy as
clinically warranted.
2. 3-mm left subpleural nodule vs. focal area of consolidation. Depending on
patient's risk factors, recommend 12-month followup or no followup needed if
low risk.
3. Mild background centrilobular emphysematous pattern.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: COUGH/CONGESTION
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOXEMIA, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.6
heartrate: 91.0
resprate: 24.0
o2sat: 83.0
sbp: 91.0
dbp: 68.0
level of pain: 10
level of acuity: 1.0 | ASSESSMENT & PLAN:
___ year old female with COPD, tobacco abuse presented with
several days of SOB and productive cough, multilobar pneumonia
on CXR.
# Hypoxia: The patient presented with cough, sputum production,
hypoxia and CXR concerning for pneumonia. SHe was given IV
solumedrol in the ED and antibiotics, but overnight the steroids
were stopped given the CXR findings and continued on
levofloxacin for pneumonia. She did not have a leukocytosis and
her HPI was more concerning for possible COPD exacerbation.
Steroids and nebulizers were restarted. It was noted that she
had PNA in a similar distribution previously and so we ordered a
CT scan to evaluate further. The CT scan showed peripheral
consolidation in the RML and upper segment of RLL. There was
concern for possible eosinophilic pneumonia and pulmonary was
consulted for possible bronchoscopy. Pulm did not think bronch
was indicated, but recommended completion of her course for COPD
exacerbation, outpatient PFTs and repeat imaging in 8 weeks. On
HD 2 the patient was breathing well on room air and was
discharged home with the appropriate follow up.
# Pain: Continue home pain regimen. Gabapentin 600 mg PO/NG HS,
Lorazepam 2 mg PO/NG HS, TraMADOL (Ultram) 100 mg PO TID:PRN
pain, carisoprodol *NF* 350 mg Oral TID:PRN,
Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO/NG 5X/DAY
# DVT Prophylaxis: Patient is ambulating well. Risks and
benefits of not using heparin prophylaxis was discussed at
length and the patient was adamant that she would walk around
multiple times a day. No heparin or Pneumoboots were ordered
and the patient ambulated.
# HTN: Continued valsartan 160mg PO Daily and amlodipine 5mg PO
daily
# HL: Continued crestor 5mg PO QHS
# DM: Diet controlled, Wrote for diabetic diet.
# Hypothyroidism: Continued levothyroxine 75mg PO daily
# GERD: Continued Omeprazole 20mg PO Daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Left hemiparesis, decreased level of consciousness
Major Surgical or Invasive Procedure:
EVD placement/removal
Ventriculoperitoneal shunt placement
History of Present Illness:
___ is a ___ M w/ hx AVR on Coumadin, HTN, HLD,
Hypothyroidism, NIDDM, who presents with acute right thalamic
intraparenchymal hemorrhage.
He was in his usual state of health until 12:30am this evening.
He told his face he had numbness and tingling in his face. EMS
was called; by their arrival, he was hemiparetic on the left
side. He was brought to ___, where his initial
BP was systolic 220, and he was started on nicardipine gtt. He
underwent noncontrast head CT which showed right sided thalamic
bleed with interventricular extension, 2-3mm MLS. Upon exiting
CT scanner he was obtunded and subsequently intubated for airway
protection. Unknown what his labs were, but given history of
anticoagulation he was given 1u FFP and 10 vitamin K. On
transfer here to ___, he was given 2nd unit FFP as well as
500cc of 3% saline.
Past Medical History:
PMH:
Hypertension
Hyperlipidemia
Diabetes
Hypothyroidism
PSH:
Aortic valve replacement
L3-L5 fusion
Left TKR ___
ORIF L distal femur fx ___
Social History:
___
Family History:
___ disease (daughter)
Physical Exam:
ADMISSION EXAM
General: Intubated
HEENT: NC/AT, ETT in place
Neck: Supple, no nuchal rigidity
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic (off sedation):
-Mental Status: eyes closed, grimaces to noxious stimuli.
-Cranial Nerves: R pupil 5mm and nonreactive. L pupil 3mm,
sluggish. Oculocephalic response absent. Corneal response absent
on R, present on L. Cough response is strong.
-Sensorimotor: extension response BUE, triple flexion response
BLE to noxious stimuli.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was extensor on L and flexor on R.
DISCHARGE EXAM
General: NAD, eyes open and tracks examiner
HEENT: NC/AT, tracheostomy tube in place, appears clean, dry,
and intact, no erythema, fluctuance, or drainage
Neck: Supple, no nuchal rigidity
Extremities: No C/C/E bilaterally
Neurologic:
-Mental Status: eyes open, follows axial and appendicular
commands (sticks tongue out, thumb/2 fingers on right, points to
left arm), no speech output, unable to write on pad
-Cranial Nerves: pupils 3->2 bilaterally, eyes with right
beating nystagmus when looking to the right, eyes midline,
limited ability to look to left but crosses midline. left facial
droop.
-Sensorimotor: right upper extremity moves spontaneously
antigravity, localizes. Left upper extremity is flaccid,
extension on noxious. Right lower extremity able to toe wriggle
on command. Left lower extremity with flexion of the foot on
noxious, no spontaneous movement.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was extensor on L and flexor on R.
Pertinent Results:
___ NCHCT
1. Interval enlargement of the right frontotemporal
intraparenchymal
hemorrhage with mass effect and effacement of the third
ventricle.
2. Intraventricular extension of the hemorrhage with large
amount of blood in the lateral, third and fourth ventricles.
3. Interval mild enlargement of the ventricles and
periventricular hypodensities concerning for hydrocephalus and
transependymal CSF migration.
___ CXR
1. High position of the endotracheal tube. Recommend
advancement.
2. Bibasilar opacities, left greater than right, concerning for
possible
aspiration or developing pneumonia. Recommend follow-up
radiographs.
___ NCHCT
1. Stable intraparenchymal hemorrhage centered around the right
thalamus with large amount of hemorrhage extending into the
lateral, third and fourth ventricles. No new hemorrhage.
2. Interval placement of a left frontal ventricular drain with
its tip
terminating near the left foramen of ___. Interval mild
decrease in
ventricle size and expected small amount of pneumocephalus.
___ CXR
ET tube in standard placement. Sharp definition of the upper
margin of the cuff reflects secretions that are allowed to pool
above that.
Nasogastric drainage tube ends above the gastroesophageal
junction.
Mild cardiomegaly stable. Right lung grossly clear.
Heterogeneous
opacification of the base the left lung is improving, but mild
edema may be developing. Mediastinal widening reflects venous
engorgement, DA increased intravascular venous pressure or
volume.
___ NCHCT
Right thalamic hemorrhage extending to the ventricle is
unchanged.
Ventricular prominence including temporal horn prominence is
unchanged. A
left frontal ventricular drain tip is in the third ventricle,
unchanged.
___ NCHCT
1. Interval decrease in size of hyperdense right thalamic
intraparenchymal
hemorrhage extending into the ventricles without definite new
focal
hemorrhage.
2. No change in the position of the left EVD.
3. New left paranasal sinus opacification may be related to
recent intubation.
___ EEG
IMPRESSION: This continuous video-EEG monitoring study captured
no pushbutton activations, electrographic seizures, or
epileptiform discharges. The background suggested a
mild-moderate diffuse encephalopathy, which implies widespread
cerebral dysfunction but is nonspecific as to etiology. Note is
made of a regular bradycardia on the cardiac rhythm strip.
___ NCHCT
1. Overall similar extent of intraparenchymal and
intraventricular hemorrhage in comparison to the most recent
examination. EVD in stable position.
___ TTE
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (biplane LVEF
72%). The right ventricular cavity is mildly dilated with normal
free wall contractility. He aortic root and ascending aorta are
mildly dilated. A well seated mechanical aortic valve prosthesis
is present. The transaortic gradient is higher than expected for
this type of prosthesis. Trace aortic regurgitation is seen.
[The amount of regurgitation present is normal for this
prosthetic aortic valve.] The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Well seated mechanical aortic valve prosthesis with
high gradient. Normal left ventricular cavity size with
preserved regional and global systolic function. Dilated
ascending aorta. Mild pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the aortic valve gradient has increased.
___ PORTABLE NCHCT
1. Overlying hardware streak artifact and moderate motion limits
examination.
2. Grossly stable left frontal approach ventriculostomy catheter
as described.
3. Grossly stable right thalamic and intraventricular hemorrhage
as described.
___ BILATERAL LOWER EXTREMITY ULTRASOUND
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ PORTABLC NCHCT
1. Overlying hardware streak artifact and motion artifacts limit
this study.
2. The right thalamic intraparenchymal hemorrhage and
surrounding rim of
vasogenic edema are stable in size and appearance.
3. There is mild interval improvement of the intraventricular
hemorrhage
within the occipital horns of the bilateral lateral ventricles
and the
temporal horn of the right lateral ventricle. There is no
evidence of new
hemorrhagic foci nor new acute large territorial infarction.
___ NCHCT
1. Slight decrease in prominence of the right thalamic and
intraventricular hemorrhage and decreased midline shift.
2. Slight decrease in mass-effect on the anterior horn of the
right lateral ventricle. The left lateral ventricle is
unchanged in size and configuration.
___ NCHCT
1. Left thalamic hemorrhage appears stable to minimally smaller
compared to ___.
2. Hemorrhage in the occipital horns of lateral ventricles has
decreased, and hemorrhage in the frontal horn and body of the
right lateral ventricle is essentially stable with interim clot
retraction.
3. Stable position of left frontal approach ventriculostomy
catheter. Interim enlargement of the lateral and third
ventricles.
4. Stable mild left parietal and occipital subarachnoid
hemorrhage with slight redistribution.
5. Stable mild leftward shift of midline structures.
___ NCHCT
1. Overall stable right thalamic intraparenchymal hemorrhage,
bilateral
interventricular hemorrhage, left parietal subarachnoid
hemorrhage as well as associated edema and mass effect since
___.
2. No new areas hemorrhage.
3. Unchanged left frontal approach ventriculostomy catheter
position as well as size and configuration of the ventricular
system since ___.
___ NCHCT
1. Interval removal of the left ventriculostomy catheter and
placement of a right frontal approach ventriculostomy catheter
resulting in decreased size of the ventricular system since
___.
2. Stable right thalamic intraparenchymal hematoma, surrounding
edema, and
mass effect since ___.
3. No evidence of infarction or new hemorrhage.
___ EEG
IMPRESSION: This is an abnormal continuous EEG monitoring study
because of
(1) frequent left frontal sharp wave discharges, occasionally
occurring in
brief ___ bursts at ___ Hz, consistent with focal cortical
irritability.
(2) Mild generalized background slowing and bursts of
intermittent rhythmic delta activity, consistent with a mild
encephalopathy. (3) Increased slowing and a relative attenuation
of faster frequencies on the right, consistent with focal
dysfunction. There are no electrographic seizures.
___ NCHCT
1. Stable to minimally decreased right thalamic hemorrhage.
Stable
intraventricular hemorrhage. No new hemorrhage.
2. Stable effacement of the right lateral ventricle body and of
the third
ventricle. Decreased size of the frontal and temporal horns of
the lateral ventricles. Stable VP shunt catheter position.
___ TTE
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>60-65%). The right
ventricle is not well seen but there appears to be grossly
normal free wall contractility. The ascending aorta is mildly
dilated. A mechanical aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. [The amount of
regurgitation present is normal for this prosthetic aortic
valve.] The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of ___ global left ventricular systolic
function, while still normal, is slightly less vigorous with a
decrease in transaortic valve gradients, now in the normal
range.
___ CXR
1. Persistent mild pulmonary edema and pulmonary venous
congestion.
2. Persistent left pleural effusion with underlying volume
loss.
___ MRI BRAIN
1. 4.6 x 3.8 x 5.5 cm hematoma in the right thalamus with
extension to the
midbrain is grossly unchanged in size given difference of
modality. The
surrounding edema and mass effect with 4 mm of leftward midline
shift appears similar to the prior examination. Given location,
this likely represents hypertensive hemorrhage.
2. Minimal peripheral contrast enhancement surrounding the
hemorrhage is
likely reactive to the hemorrhage itself. No definite
underlying mass.
3. Stable intraventricular hemorrhage. No new focus of
hemorrhage.
4. Unchanged position of a right frontal approach VP shunt
catheter with
stable ventricular size and configuration.
5. Left frontal enhancement along the path of the prior
ventricular catheter. This is probably post surgical, but
recommend follow-up evaluation of this area to ensure there is
not evidence of neoplastic extension along the tract.
___ CXR
Moderate to severe cardiomegaly is stable. There are low lung
volumes. Mild pulmonary edema is stable. Retrocardiac
atelectasis have improved.
Tracheostomy tube is in standard position. No other interval
change from
prior study.
LAB RESULTS
___ 06:00AM BLOOD WBC-5.5 RBC-3.71* Hgb-10.9* Hct-36.8*
MCV-99* MCH-29.4 MCHC-29.6* RDW-15.1 RDWSD-53.5* Plt ___
___ 05:50AM BLOOD WBC-4.8 RBC-3.67* Hgb-11.1* Hct-35.2*
MCV-96 MCH-30.2 MCHC-31.5* RDW-15.2 RDWSD-52.7* Plt ___
___ 07:19AM BLOOD WBC-6.3 RBC-3.46* Hgb-10.1* Hct-33.5*
MCV-97 MCH-29.2 MCHC-30.1* RDW-15.1 RDWSD-52.6* Plt ___
___ 06:28AM BLOOD WBC-11.5*# RBC-3.53* Hgb-10.7* Hct-34.5*
MCV-98 MCH-30.3 MCHC-31.0* RDW-15.1 RDWSD-53.2* Plt ___
___ 06:05AM BLOOD WBC-7.6 RBC-3.66* Hgb-10.8* Hct-35.3*
MCV-96 MCH-29.5 MCHC-30.6* RDW-14.9 RDWSD-52.0* Plt ___
___ 02:00AM BLOOD WBC-8.7 RBC-3.84* Hgb-11.2* Hct-37.1*
MCV-97 MCH-29.2 MCHC-30.2* RDW-14.6 RDWSD-51.5* Plt ___
___ 06:03AM BLOOD WBC-7.4 RBC-3.79* Hgb-11.2* Hct-36.8*
MCV-97 MCH-29.6 MCHC-30.4* RDW-15.3 RDWSD-53.1* Plt ___
___ 04:24AM BLOOD WBC-8.0 RBC-3.41* Hgb-10.0* Hct-33.4*
MCV-98 MCH-29.3 MCHC-29.9* RDW-14.6 RDWSD-52.3* Plt ___
___ 05:09AM BLOOD WBC-8.0 RBC-3.41* Hgb-10.0* Hct-33.2*
MCV-97 MCH-29.3 MCHC-30.1* RDW-14.7 RDWSD-52.6* Plt ___
___ 07:07AM BLOOD WBC-8.9 RBC-3.35* Hgb-9.8* Hct-32.0*
MCV-96 MCH-29.3 MCHC-30.6* RDW-14.6 RDWSD-50.6* Plt ___
___ 11:10AM BLOOD WBC-10.1* RBC-3.60* Hgb-10.7* Hct-34.5*
MCV-96 MCH-29.7 MCHC-31.0* RDW-14.5 RDWSD-50.1* Plt ___
___ 12:43PM BLOOD WBC-11.5* RBC-3.68* Hgb-10.7* Hct-35.4*
MCV-96 MCH-29.1 MCHC-30.2* RDW-14.4 RDWSD-49.9* Plt ___
___ 05:41AM BLOOD WBC-9.1 RBC-3.34* Hgb-9.9* Hct-32.2*
MCV-96 MCH-29.6 MCHC-30.7* RDW-14.2 RDWSD-49.7* Plt ___
___ 01:40AM BLOOD WBC-10.6* RBC-3.64* Hgb-10.7* Hct-34.1*
MCV-94 MCH-29.4 MCHC-31.4* RDW-14.0 RDWSD-47.6* Plt ___
___ 02:41AM BLOOD WBC-10.0 RBC-3.60* Hgb-10.6* Hct-33.7*
MCV-94 MCH-29.4 MCHC-31.5* RDW-13.7 RDWSD-46.5* Plt ___
___ 02:42AM BLOOD WBC-9.2 RBC-3.75* Hgb-11.0* Hct-35.0*
MCV-93 MCH-29.3 MCHC-31.4* RDW-13.5 RDWSD-46.4* Plt ___
___ 02:09AM BLOOD WBC-8.3 RBC-3.55* Hgb-10.5* Hct-33.1*
MCV-93 MCH-29.6 MCHC-31.7* RDW-13.4 RDWSD-46.3 Plt ___
___ 02:00AM BLOOD WBC-9.5 RBC-3.35* Hgb-9.8* Hct-31.9*
MCV-95 MCH-29.3 MCHC-30.7* RDW-13.3 RDWSD-45.4 Plt ___
___ 01:52AM BLOOD WBC-9.3 RBC-3.41* Hgb-10.0* Hct-32.4*
MCV-95 MCH-29.3 MCHC-30.9* RDW-13.5 RDWSD-47.3* Plt ___
___ 01:06AM BLOOD WBC-10.8* RBC-3.39* Hgb-10.0* Hct-32.6*
MCV-96 MCH-29.5 MCHC-30.7* RDW-13.7 RDWSD-48.8* Plt ___
___ 01:51AM BLOOD WBC-9.4 RBC-3.84* Hgb-11.3* Hct-36.1*
MCV-94 MCH-29.4 MCHC-31.3* RDW-13.9 RDWSD-47.4* Plt ___
___ 02:00AM BLOOD WBC-11.1* RBC-3.74* Hgb-11.0* Hct-35.1*
MCV-94 MCH-29.4 MCHC-31.3* RDW-13.9 RDWSD-47.5* Plt ___
___ 02:16AM BLOOD WBC-10.1* RBC-3.56* Hgb-10.7* Hct-33.3*
MCV-94 MCH-30.1 MCHC-32.1 RDW-13.9 RDWSD-47.3* Plt ___
___ 11:29PM BLOOD WBC-11.8* RBC-3.86* Hgb-11.4* Hct-35.8*
MCV-93 MCH-29.5 MCHC-31.8* RDW-13.3 RDWSD-44.8 Plt ___
___ 02:23AM BLOOD WBC-13.5* RBC-3.81* Hgb-11.4* Hct-35.1*
MCV-92 MCH-29.9 MCHC-32.5 RDW-13.5 RDWSD-45.7 Plt ___
___ 02:16AM BLOOD WBC-11.2* RBC-3.61* Hgb-10.9* Hct-33.8*
MCV-94 MCH-30.2 MCHC-32.2 RDW-13.7 RDWSD-46.7* Plt ___
___ 06:42AM BLOOD WBC-9.7 RBC-3.65* Hgb-11.0* Hct-34.6*
MCV-95 MCH-30.1 MCHC-31.8* RDW-13.4 RDWSD-46.5* Plt ___
___ 03:14AM BLOOD WBC-8.5 RBC-2.92* Hgb-8.8* Hct-28.3*
MCV-97 MCH-30.1 MCHC-31.1* RDW-13.3 RDWSD-47.5* Plt ___
___ 06:05AM BLOOD ___ PTT-49.6* ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-45.9* ___
___ 01:20PM BLOOD ___ PTT-45.4* ___
___ 01:20PM BLOOD ___ PTT-45.4* ___
___ 05:50AM BLOOD Plt ___
___ 07:19AM BLOOD Plt ___
___ 06:28AM BLOOD Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Plt ___
___ 02:00AM BLOOD Plt ___
___ 02:00AM BLOOD ___ PTT-49.3* ___
___ 06:03AM BLOOD Plt ___
___ 04:24AM BLOOD Plt ___
___ 04:24AM BLOOD ___ PTT-44.7* ___
___ 05:09AM BLOOD Plt ___
___ 07:07AM BLOOD Plt ___
___ 11:10AM BLOOD Plt ___
___ 12:43PM BLOOD Plt ___
___ 12:43PM BLOOD ___ PTT-42.7* ___
___ 05:41AM BLOOD Plt ___
___ 05:41AM BLOOD ___ PTT-39.7* ___
___ 01:40AM BLOOD Plt ___
___ 01:40AM BLOOD PTT-40.7*
___ 02:41AM BLOOD Plt ___
___ 02:41AM BLOOD ___ PTT-38.0* ___
___ 02:42AM BLOOD Plt ___
___ 02:42AM BLOOD ___ PTT-45.6* ___
___ 02:09AM BLOOD Plt ___
___ 02:09AM BLOOD ___ PTT-45.5* ___
___ 02:00AM BLOOD Plt ___
___ 02:00AM BLOOD ___ PTT-46.7* ___
___ 01:52AM BLOOD Plt ___
___ 01:52AM BLOOD ___ PTT-43.4* ___
___ 01:06AM BLOOD Plt ___
___ 01:51AM BLOOD Plt ___
___ 02:00AM BLOOD Plt ___
___ 02:00AM BLOOD ___ PTT-49.1* ___
___ 02:16AM BLOOD Plt ___
___ 02:16AM BLOOD ___ PTT-41.6* ___
___ 11:29PM BLOOD Plt ___
___ 02:23AM BLOOD Plt ___
___ 02:23AM BLOOD ___ PTT-40.4* ___
___ 02:16AM BLOOD Plt ___
___ 02:16AM BLOOD ___ PTT-42.7* ___
___ 06:42AM BLOOD ___ PTT-50.9* ___
___ 03:14AM BLOOD ___ PTT-45.1* ___
___ 05:10PM BLOOD FacVIII-221*
___ 05:10PM BLOOD VWF AG-219* VWF ___
___ 01:20PM BLOOD Inh Scr-POS Lupus-PND
___ 06:05AM BLOOD Na-140 K-4.4
___ 06:00AM BLOOD Glucose-154* UreaN-22* Creat-0.7 Na-140
K-4.3 Cl-99 HCO3-32 AnGap-13
___ 11:52PM BLOOD Glucose-174* UreaN-23* Creat-0.7 Na-140
K-4.3 Cl-100 HCO3-30 AnGap-14
___ 05:50AM BLOOD Glucose-148* UreaN-22* Creat-0.7 Na-140
K-4.0 Cl-99 HCO3-30 AnGap-15
___ 02:50PM BLOOD Glucose-162* UreaN-24* Creat-0.7 Na-140
K-4.0 Cl-99 HCO3-31 AnGap-14
___ 03:00PM BLOOD Glucose-158* UreaN-26* Creat-0.7 Na-139
K-3.6 Cl-98 HCO3-32 AnGap-13
___ 06:28AM BLOOD Glucose-178* UreaN-27* Creat-0.9 Na-140
K-4.1 Cl-97 HCO3-30 AnGap-17
___ 06:05AM BLOOD Glucose-165* UreaN-27* Creat-0.8 Na-142
K-4.3 Cl-98 HCO3-30 AnGap-18
___ 02:00AM BLOOD Glucose-180* UreaN-26* Creat-0.7 Na-138
K-4.2 Cl-97 HCO3-29 AnGap-16
___ 09:54AM BLOOD Glucose-162* UreaN-24* Creat-0.7 Na-139
K-4.2 Cl-98 HCO3-30 AnGap-15
___ 04:24AM BLOOD Glucose-131* UreaN-20 Creat-0.6 Na-141
K-4.5 Cl-101 HCO3-33* AnGap-12
___ 05:09AM BLOOD Glucose-160* UreaN-18 Creat-0.7 Na-139
K-4.5 Cl-100 HCO3-28 AnGap-16
___ 07:07AM BLOOD Glucose-160* UreaN-17 Creat-0.7 Na-138
K-4.2 Cl-98 HCO3-29 AnGap-15
___ 11:10AM BLOOD Glucose-162* UreaN-17 Creat-0.7 Na-138
K-4.3 Cl-98 HCO3-30 AnGap-14
___ 12:43PM BLOOD Glucose-158* UreaN-18 Creat-0.7 Na-136
K-4.1 Cl-98 HCO3-28 AnGap-14
___ 01:40AM BLOOD Glucose-185* UreaN-18 Creat-0.7 Na-135
K-4.7 Cl-98 HCO3-29 AnGap-13
___ 02:41AM BLOOD Glucose-177* UreaN-16 Creat-0.6 Na-135
K-4.8 Cl-98 HCO3-28 AnGap-14
___ 02:42AM BLOOD Glucose-169* UreaN-15 Creat-0.7 Na-135
K-4.7 Cl-97 HCO3-28 AnGap-15
___ 02:09AM BLOOD Glucose-176* UreaN-13 Creat-0.7 Na-135
K-4.3 Cl-99 HCO3-26 AnGap-14
___ 01:52AM BLOOD Glucose-137* UreaN-10 Creat-0.7 Na-136
K-3.3 Cl-105 HCO3-22 AnGap-12
___ 01:06AM BLOOD Glucose-169* UreaN-11 Creat-0.7 Na-138
K-3.8 Cl-105 HCO3-23 AnGap-14
___ 01:51AM BLOOD Glucose-177* UreaN-11 Creat-0.8 Na-138
K-4.2 Cl-104 HCO3-24 AnGap-14
___ 10:47AM BLOOD Na-136
___ 02:00AM BLOOD Glucose-184* UreaN-12 Creat-0.8 Na-135
K-3.8 Cl-102 HCO3-22 AnGap-15
___ 04:09PM BLOOD K-3.8
___ 02:16AM BLOOD Glucose-123* UreaN-11 Creat-0.8 Na-139
K-3.8 Cl-107 HCO3-23 AnGap-13
___ 11:29PM BLOOD Glucose-168* UreaN-12 Creat-0.7 Na-138
K-3.1* Cl-107 HCO3-21* AnGap-13
___ 02:23AM BLOOD Glucose-146* UreaN-11 Creat-0.6 Na-136
K-3.4 Cl-104 HCO3-21* AnGap-14
___ 02:16AM BLOOD Glucose-152* UreaN-12 Creat-0.7 Na-136
K-3.7 Cl-105 HCO3-21* AnGap-14
___ 06:42AM BLOOD Glucose-195* UreaN-10 Creat-0.7 Na-137
K-3.6 Cl-103 HCO3-23 AnGap-15
___ 06:05AM BLOOD ALT-24 AST-24
___ 02:42AM BLOOD ALT-24 AST-19
___ 02:00AM BLOOD ALT-26 AST-14 AlkPhos-54 TotBili-0.9
___ 02:16AM BLOOD ALT-32 AST-17
___ 06:42AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:14AM BLOOD Lipase-22
___ 06:00AM BLOOD Calcium-9.5 Mg-2.4
___ 11:52PM BLOOD Calcium-9.1 Phos-4.3 Mg-2.3
___ 05:50AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.4
___ 07:19AM BLOOD Mg-2.4
___ 06:28AM BLOOD Mg-2.3
___ 06:05AM BLOOD Phos-4.3 Mg-2.5
___ 02:00AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.3
___ 09:54AM BLOOD Calcium-9.7 Phos-5.2* Mg-2.2
___ 04:24AM BLOOD Calcium-9.3 Mg-2.2
___ 05:09AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2
___ 07:07AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2
___ 11:10AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.1
___ 12:43PM BLOOD Calcium-9.3 Phos-4.2 Mg-2.1
___ 11:29PM BLOOD Calcium-8.6 Phos-2.7 Mg-2.0
___ 02:23AM BLOOD Calcium-8.9 Phos-2.2* Mg-2.0
___ 02:16AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.9
___ 03:14AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:14AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 1:43 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 10:43 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 2:10 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 6:06 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Warfarin 7.5 mg PO DAILY16
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN Pain - Mild
2. Amantadine Syrup 100 MG PO BID
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Desonide 0.05% Cream 1 Appl TP DAILY
5. Docusate Sodium 100 mg PO BID
6. Furosemide 20 mg PO DAILY
7. Heparin 5000 UNIT SC BID
8. Insulin SC
Sliding Scale
Fingerstick q6
Insulin SC Sliding Scale using REG Insulin
9. Ketoconazole Shampoo 1 Appl TP ASDIR
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. ___ ___ UNIT PO Q8H swish and spit
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO BID
14. Sulfameth/Trimethoprim Suspension 20 mL PO BID
15. Warfarin 4 mg PO DAILY16
16. Aspirin 81 mg PO DAILY
17. Atorvastatin 10 mg PO QPM
18. Levothyroxine Sodium 175 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraparenchymal hemorrhage in the thalamus with ventricular
extension
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke s/p trach // interval change, pt
desatting
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Moderate to severe cardiomegaly is stable. There are low lung volumes. Mild
pulmonary edema is stable. Retrocardiac atelectasis have improved.
Tracheostomy tube is in standard position. No other interval change from
prior study.
Radiology Report
INDICATION: ___ male with head bleed. Evaluate for endotracheal tube
placement.
TECHNIQUE: AP frontal chest radiograph was obtained.
COMPARISON: Reference chest radiograph from ___.
FINDINGS:
There has been interval placement of a endotracheal tube which terminates 7.3
cm above the level the carina. An enteric tube terminates in the proximal
stomach. The patient is status post median sternotomy and aortic valve
replacement. There are bibasilar opacities, larger on the right, concerning
for aspiration or developing pneumonia.
IMPRESSION:
1. High position of the endotracheal tube. Recommend advancement.
2. Bibasilar opacities, left greater than right, concerning for possible
aspiration or developing pneumonia. Recommend follow-up radiographs.
NOTIFICATION: The findings were discussed with ___ by ___
___, M.D. on the telephone on ___ at 8:19 AM, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ male with head bleed. Evaluate for shift and
intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: Reference CT from ___.
FINDINGS:
Comparison to prior CT is limited due to motion artifact on the prior. There
is a 5.0 x 2.4 cm right frontotemporal intraparenchymal hemorrhage with
surrounding edema. This is increased in size from prior exam when it measured
2.5 x 3.7 cm. There is mass effect and effacement of the third ventricle
(series 2a:image 17). There is also intraventricular extension of the
hemorrhage with blood seen in the bilateral lateral ventricles, third
ventricle and fourth ventricle. There appears to be interval increase in size
of the ventricles with periventricular hypodensities concerning for
hydrocephalus and transependymal CSF migration.
No new intracranial hemorrhage is seen. There is no large vascular
territorial infarction. There is prominence of the ventricles and sulci
suggestive of involutional changes.
There is no evidence of fracture. There is mild mucosal thickening of the
bilateral ethmoid air cells. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Interval enlargement of the right frontotemporal intraparenchymal
hemorrhage with mass effect and effacement of the third ventricle.
2. Intraventricular extension of the hemorrhage with large amount of blood in
the lateral, third and fourth ventricles.
3. Interval mild enlargement of the ventricles and periventricular
hypodensities concerning for hydrocephalus and transependymal CSF migration.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with right thalamic intraparenchymal hemorrhage
and external ventricular drain placed. Evaluate placement.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Multiple head CTs from ___.
FINDINGS:
There is a 4.8 x 2.6 cm hemorrhage centered around the right thalamus, not
significant changed from prior exam when it measured 5.0 x 2.4 cm. There is
associated mass effect on the third ventricle. There is surrounding vasogenic
edema, and a large amount of hemorrhage extending into the left ventricles,
third ventricle and fourth ventricle are again noted.
There has been interval placement of a left frontal ventricular drain which
terminates near the left foramen of ___. Small amount of pneumocephalus is
noted along the left frontal convexity and adjacent to the frontal horn of the
lateral ventricle. There has been mild interval decrease in size of the
ventricles following drain placement. There is a slight bend to the distal
aspect of the drain.
No new intracranial hemorrhage is noted. No large vascular territorial
infarction is noted.
There is mucosal thickening of the bilateral ethmoid air cells. The mastoid
air cells and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Stable intraparenchymal hemorrhage centered around the right thalamus with
large amount of hemorrhage extending into the lateral, third and fourth
ventricles. No new hemorrhage.
2. Interval placement of a left frontal ventricular drain with its tip
terminating near the left foramen of ___. Interval mild decrease in
ventricle size and expected small amount of pneumocephalus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with thalamic hemorrhage // intubated
intubated
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
ET tube in standard placement. Sharp definition of the upper margin of the
cuff reflects secretions that are allowed to pool above that.
Nasogastric drainage tube ends above the gastroesophageal junction.
Mild cardiomegaly stable. Right lung grossly clear. Heterogeneous
opacification of the base the left lung is improving, but mild edema may be
developing. Mediastinal widening reflects venous engorgement, DA increased
intravascular venous pressure or volume.
No pneumothorax.
Radiology Report
EXAMINATION: CT HEAD WITHOUT CONTRAST
INDICATION: ___ year old man with right thalamic IPH, s/p intraventricular tPA
// hemorrhage extension, ok for portable
TECHNIQUE: Axial images of the head were obtained without contrast .
DOSE: DLP: 1273mGy-cm
COMPARISON: ___.
FINDINGS:
Right thalamic hemorrhage extending to the ventricle is unchanged.
Ventricular prominence including temporal horn prominence is unchanged. A
left frontal ventricular drain tip is in the third ventricle, unchanged.
IMPRESSION:
Unchanged appearance compared to the prior CT in thalamic hemorrhage with
intraventricular extension. Ventricular size is unchanged.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with IPH // OGT placement Contact name: ___,
___: ___ OGT placement
IMPRESSION:
Compared to the prior chest radiographs since ___, most recently ___.
ET tube in standard placement. Esophageal drainage tube ends in the upper
stomach.
Moderate cardiomegaly mild pulmonary vascular congestion persist. No
pneumothorax or appreciable pleural effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ man with a right thalamic intraparenchymal
hemorrhage. Evaluate for extension of stroke/edema.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.7 cm; CTDIvol = 50.8 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
A left frontal approach extraventricular drain ends in the area of the third
ventricle, unchanged. Multicompartmental hyperdense hemorrhage persists but
is overall similar compared to ___. Specifically, the right thalamic
intraparenchymal hemorrhage now measures up to 4.6 x 2.6 cm on axial images,
previously up to 4.4 x 3.2 cm (series 4, image 15). Intraventricular
extension of the hemorrhage filling most of the right lateral ventricle and
predominantly the occipital horn of the left lateral ventricle persists and is
slightly smaller. Hyperdense hemorrhage in the fourth ventricle has also
decreased (Series 4, image 8). Surrounding white matter hypodensity is likely
vasogenic edema, also unchanged. No shift of normally midline structures. No
definite new focal hemorrhage.
Air-fluid level in the left maxillary sinus is new (series 4, image 4). Some
of the left ethmoidal air cells are now partially or completely opacified.
The left nasal cavity is fluid filled. A right nasogastric tube is in
completely imaged in the right nasal cavity. The remaining partially imaged
paranasal sinuses, mastoid air cells, middle ear cavities are clear.
IMPRESSION:
1. Interval decrease in size of hyperdense right thalamic intraparenchymal
hemorrhage extending into the ventricles without definite new focal
hemorrhage.
2. No change in the position of the left EVD.
3. New left paranasal sinus opacification may be related to recent intubation.
Radiology Report
EXAMINATION: Chest single view
INDICATION: ___ year old man with SOB // assess for interval change
TECHNIQUE: Portable AP
COMPARISON: ___.
FINDINGS:
ET tube has been removed. NG tube in the stomach. Prostatic mitral valve
annulus again seen. Mild cardiomegaly. Increased right lower lobe opacity
noted. No pleural effusion or pneumothorax.
IMPRESSION:
New right lower lobe opacity. In the removal of ET tube. Sign rib
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ivh // interval change interval change
IMPRESSION:
In comparison with the study of ___, the left hemidiaphragm is slightly
better seen, which could reflect improving effusion or merely a more upright
position of the patient. Otherwise, slightly lower lung volumes with
prominence of the cardiac silhouette and possible mild elevation of pulmonary
venous pressure
Radiology Report
EXAMINATION: Chest single frontal view.
INDICATION: ___ year old man with ivh // interval change
TECHNIQUE: Portable AP.
COMPARISON: 05:18 the same day.
FINDINGS:
As on the previous right ago there is a new right lower lobe opacity. There
may be a small left effusion. The heart is enlarged as previously with mitral
valve replacement. Sternal wires. NG tube in the stomach.
IMPRESSION:
Persistent right lower lobe opacity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ M w/ hx AVR on Coumadin, HTN, HLD,
NIDDM, who presents with acute right thalamic IPH with IVH, intubated, EVD
placed. // e/p intubation
TECHNIQUE: Chest single view.
COMPARISON: ___ 09:28
FINDINGS:
Endotracheal tube tip in good position. Enteric tube tip in the mid stomach.
Sternotomy, valve prosthesis. Increased heart size, pulmonary vascularity,
similar. Left basilar consolidation, worsened. Small left pleural effusion,
worsened. Mildly improved right basilar opacity.
IMPRESSION:
Worsened left basilar consolidation.
Worsened left pleural effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with IPH, change in neuro status. s/p intrathecal
tPA // Interval changes, IPH with intraventricular extension
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 7.2 s, 19.7 cm; CTDIvol = 51.2 mGy (Head) DLP =
1,009.3 mGy-cm.
Total DLP (Head) = 1,009 mGy-cm.
COMPARISON: CT head without contrast dated ___
FINDINGS:
Again seen is a left frontal extraventricular catheter, with the tip
terminating in the region of the third ventricle, unchanged since the prior
examination. Again seen is extensive hemorrhage, involving the right thalamus
as well as the bilateral lateral ventricles and fourth ventricle. Hemorrhage
in the left lateral ventricle is slightly less prominent on the current
examination than on the prior. Surrounding edema is present, and unchanged.
There is no new midline shift.
There is no evidence of fracture. Again seen is partial opacification of the
left maxillary sinus and the left ethmoid air cells. The mastoid air cells
and middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Overall similar extent of intraparenchymal and intraventricular hemorrhage
in comparison to the most recent examination. EVD in stable position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yoM with intracranial bleed, pna, intubated // r/o pna, pulm
edema/chf r/o pna, pulm edema/chf
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild interstitial pulmonary edema has improved since ___, now largely at
the lung bases. Previous severe left lower lobe atelectasis has improved.
Pleural effusions are small if any, left-greater-than-right. No pneumothorax.
ET tube and nasogastric tube in standard placements.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old man with intracranial bleed. Evaluate for
intracranial hemorrhage stability.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CTDIvol = 70.7 mGy (Phantom type N/A) DLP = 1,273.1 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
Overlying hardware streak artifact and moderate motion limits examination.
Grossly stable left frontal approach ventriculostomy catheter with its tip
In the region of the foramen ___ within the left lateral ventricle
frontal horn is again noted (see 02:18). Ventricles and sulci are grossly
stable in size and configuration.
Grossly stable right thalamic hemorrhage with adjacent edema, and
intraventricular hemorrhage are again noted. Nonspecific paranasal sinus
opacification is noted, which may be related to intubation status.
IMPRESSION:
1. Overlying hardware streak artifact and moderate motion limits examination.
2. Grossly stable left frontal approach ventriculostomy catheter as described.
3. Grossly stable right thalamic and intraventricular hemorrhage as described.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ yoM with intracranial bleed // fevers, r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins on the right. Normal
color flow and compressibility is demonstrated in the posterior tibial and
peroneal veins on the left.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new PICC // right PICC 47 cm ___ ___
Contact name: ___: ___ right PICC 47 cm ___ ___
IMPRESSION:
Comparison to ___. The patient has received the new right-sided
PICC line. The course of the line is unremarkable, the tip of the line
projects over the cavoatrial junction. No complications, notably no
pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ventilator dependence // interval change
interval change
IMPRESSION:
Comparison to ___. No relevant change. Moderate cardiomegaly.
Monitoring and support devices are stable. Stable alignment of the sternal
wires. No pulmonary edema. No pneumonia. No larger pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with iph // interval changes interval
changes
IMPRESSION:
Compared to prior chest radiographs ___ through ___.
New PIC line is now looped in the right jugular vein before passing to the
upper SVC, partially withdrawn relative to ___. New tracheostomy tube
is midline. The symmetric degree of increase in mediastinal widening is
consistent with vascular engorgement from volume overload and/or biventricular
heart failure since there is new mild pulmonary edema and greater pulmonary
vascular engorgement. Moderate to severe cardiomegaly has increased slightly.
Pleural effusion is presumed, but not substantial. No pneumothorax.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old man with IPH // EVD clamped, evaluate for
hydrocephalus.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CTDIvol = 70.7 mGy (Phantom type N/A) DLP = 1,343.8 mGy-cm.
COMPARISON: ___ portable CT head without contrast
___ CT head without contrast
___ CT head without contrast
___ CT head without contrast
___ CT head without contrast
FINDINGS:
Overlying hardware streak artifact and motion artifacts limit this study.
The left frontal approach ventriculostomy tube remains in stable position.
The previously described right thalamic intraparenchymal hyperdense hemorrhage
and surrounding rim of hypodense vasogenic edema is stable in size and
appearance. The hyperdense intraventricular hemorrhage within the central
region of the right lateral ventricle is also stable in size. However, there
has been mild interval improvement of the intraventricular hemorrhage within
the bilateral occipital horns of the lateral ventricles and the temporal horn
of the right lateral ventricle. There is stable right hemispheric sulci
effacement and ventriculomegaly. There is no evidence of new hemorrhagic
foci nor new acute large territorial infarction.
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. Overlying hardware streak artifact and motion artifacts limit this study.
2. The right thalamic intraparenchymal hemorrhage and surrounding rim of
vasogenic edema are stable in size and appearance.
3. There is mild interval improvement of the intraventricular hemorrhage
within the occipital horns of the bilateral lateral ventricles and the
temporal horn of the right lateral ventricle. There is no evidence of new
hemorrhagic foci nor new acute large territorial infarction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with thalamic IPH // trach collar, pna, interval
exam trach collar, pna, interval exam
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previous mild pulmonary edema has resolved. Moderate cardiomegaly and
mediastinal vascular engorgement are stable. Pleural effusions are presumed,
but not large. No pneumothorax. Tracheostomy tube tip abuts the left wall of
the trachea. Right PIC line loops in the jugular vein ending in the upper
SVC.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST.
INDICATION: ___ year old man with left thalamic hemorrhage, EVD clamped //
change in size of ventricles, s/p EVD clamping. PLEASE OBTAIN at 5AM.
TECHNIQUE: Contiguous axial images from the 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, 18.5 cm; CTDIvol = 43.5 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 14.0 s, 16.2 cm; CTDIvol = 43.5 mGy (Head) DLP =
702.4 mGy-cm.
3) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: CT of the head ___. .
FINDINGS:
Examination mildly limited by motion. Stable appearance the left frontal
approach ventriculostomy catheter tip terminating in the region of the third
ventricle. Slight decrease in size of right thalamic and intraventricular
hemorrhage with unchanged surrounding edema. No areas of new hemorrhage
identified. Mass-effect on the right lateral ventricle ___ slowly decreased
in the left lateral ventricle is unchanged size configuration. Focal leftward
shift of midline structures measures 5 mm, decreased from ___. Basal
cisterns are patent.
IMPRESSION:
1. Slight decrease in prominence of the right thalamic and intraventricular
hemorrhage and decreased midline shift.
2. Slight decrease in mass-effect on the anterior horn of the right lateral
ventricle. The left lateral ventricle is unchanged in size and configuration.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with ___ man with history of aortic valve
replacement, on Coumadin, with hypertension, hyperlipidemia,
non-insulin-dependent diabetes mellitus, who presents with acute right
thalamic parenchymal hemorrhage and intraventricular hemorrhage, intubated,
EVD placed. Assess for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: CT head dated ___ and ___
FINDINGS:
Study is slightly degraded by patient motion artifact.
The right thalamic hemorrhage measures 3.5 x 2.0 cm compared to 3.4 x 2.3 cm
on ___. Any apparent difference could be related to differences in
patient head position and slice selection. Surrounding edema, which extends
into frontal and temporal white matter, is stable in extent.
Blood layering in the occipital horns of the lateral ventricles has decreased
in extent. The amount of blood in the body and frontal horn of the right
lateral ventricle has not changed significantly, but it demonstrates interim
clot retraction, with interim enlargement of both lateral ventricles. No
blood is seen in the third and fourth ventricles. The third ventricle has
also increased in size but remains shifted to the left. The fourth ventricle
is stable in size.
A left frontal approach ventriculostomy catheter enters the frontal horn of
the left lateral ventricle and terminates in the region of the foramen of
___, unchanged.
Mild leftward shift of midline structures is overall unchanged.
Mild left parietal and occipital subarachnoid hemorrhage remains present with
slight redistribution into more dependent position.
No new hemorrhage is seen. There is no evidence for an acute major vascular
territorial infarction.
Partial mastoid air cell opacification, left greater than right, is likely
secondary to prolonged supine positioning in the inpatient setting.
IMPRESSION:
1. Left thalamic hemorrhage appears stable to minimally smaller compared to ___.
2. Hemorrhage in the occipital horns of lateral ventricles has decreased, and
hemorrhage in the frontal horn and body of the right lateral ventricle is
essentially stable with interim clot retraction.
3. Stable position of left frontal approach ventriculostomy catheter. Interim
enlargement of the lateral and third ventricles.
4. Stable mild left parietal and occipital subarachnoid hemorrhage with slight
redistribution.
5. Stable mild leftward shift of midline structures.
NOTIFICATION: The findings were discussed with ___, N.P. by
___, M.D. on the telephone on ___ at 6 AM, 15 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with intracranial bleed, trached, desatting //
r/o pna, pulm edema r/o pna, pulm edema
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lungs are low in volume, but aside from a band of subsegmental atelectasis at
the left base, clear of any focal abnormality. Pleural effusions are small if
any. Heart size top- normal. Patient has had median sternotomy and MVR.
Right PIC line is still looped in the right internal jugular vein and the tip
as migrated superiorly into the brachiocephalic vein. Tracheostomy tube
midline. No pneumothorax.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old man with R. thalamic IPH and IVH with EVD in place
// Interval CT please use portable CT
TECHNIQUE: Portable contiguous axial images of the brain were obtained
without contrast.
DOSE: Acquisition sequence:
1) CTDIvol = 70.7 mGy (Phantom type N/A) DLP = 1,273.1 mGy-cm.
COMPARISON: Noncontrast CT of the head from ___.
FINDINGS:
Left frontal approach ventriculostomy catheter terminates in the anterior horn
of the left lateral ventricle near the foramen of ___, unchanged from ___. Right basal ganglia intraparenchymal hemorrhage centered in the thalamus
with surrounding edema measures approximately 34 x 23 mm, previously 35 x 20
mm, likely stable given differences in head positioning and slice thickness.
Associated mass-effect on anterior horn of the right lateral ventricle and
focal left for shift of midline structures portable are unchanged from ___. A the basal cisterns are patent.
Interventricular hemorrhage in the bilateral occipital horns of lateral
ventricles and anterior and posterior horns of the right lateral ventricle is
stable from ___. Left parietal subarachnoid hemorrhage appears
unchanged from ___. No new areas hemorrhage are identified. Fluid in
the left mastoid tip pan is similar to prior examination.
IMPRESSION:
1. Overall stable right thalamic intraparenchymal hemorrhage, bilateral
interventricular hemorrhage, left parietal subarachnoid hemorrhage as well as
associated edema and mass effect since ___.
2. No new areas hemorrhage.
3. Unchanged left frontal approach ventriculostomy catheter position as well
as size and configuration of the ventricular system since ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with trach, s/p VP shunt with postop hypoxia. //
postop hypoxia postop hypoxia
IMPRESSION:
In comparison with study of ___, the right PICC line again is looped in
the right internal jugular vein. The tip again line is in the brachiocephalic
vein.
Slightly improved lung volumes with some basilar atelectasis and probable mild
elevation of pulmonary venous pressure. Tracheostomy tube remains in place.
VP shunt is again seen and there is a gastrostomy tube in place.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with history of mechanical AVR presented with
acute right thalamic IPH with IVH due to htn vs. anticoagulation // S/p EVD
removal and VPS placement, evaluate 2 hours after placement.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.4 s, 18.7 cm; CTDIvol = 51.1 mGy (Head) DLP =
954.0 mGy-cm.
Total DLP (Head) = 954 mGy-cm.
COMPARISON: Noncontrast CT of the head from ___.
FINDINGS:
There has been removal of the left frontal approach ventriculostomy catheter
and placement of a right frontal approach ventriculostomy catheter which
terminates in the anterior horn of the right lateral ventricle near the
foramen of ___. Expected postsurgical changes including pneumocephalus
present. The ventricles have decreased in size since ___.
Intraparenchymal hemorrhage in the right thalamus with surrounding edema and
mass effect on the third ventricle measures 3.5 x 2.1 cm is stable from ___. There is no significant midline shift. There is no evidence of new
hemorrhage and no evidence of infarction. The basal cisterns are patent. The
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
orbits are unremarkable.
IMPRESSION:
1. Interval removal of the left ventriculostomy catheter and placement of a
right frontal approach ventriculostomy catheter resulting in decreased size of
the ventricular system since ___.
2. Stable right thalamic intraparenchymal hematoma, surrounding edema, and
mass effect since ___.
3. No evidence of infarction or new hemorrhage.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with somnolence s/p VP shunt. Assess for
interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.4 s, 18.5 cm; CTDIvol = 51.6 mGy (Head) DLP =
954.0 mGy-cm.
Total DLP (Head) = 954 mGy-cm.
COMPARISON: ___
FINDINGS:
Again seen is right thalamic hemorrhage with surrounding edema. The
hyperdense component measures 2.4 cm in maximal dimension compared to 2.5 cm
on ___. A right frontal approach ventriculostomy catheter terminates
near the foramen of ___. This is in unchanged position since the prior
examination. Small intraventricular hemorrhage is stable. No new hemorrhage
is identified. There is stable mild leftward shift of midline structures with
stable effacement of the right lateral ventricle body and of the third
ventricle. However, frontal and temporal horns of the lateral ventricles have
decreased in size. The basilar cisterns are not compressed. Pneumocephalus
has improved.
Scalp soft tissues are slightly more edematous than prior with small amount of
fluid along the VP shunt catheter in the right scalp. There is partial left
mastoid air cell opacification, likely secondary to prolonged supine
positioning in the inpatient setting. There is a mucous retention cyst in the
right maxillary sinus.
IMPRESSION:
1. Stable to minimally decreased right thalamic hemorrhage. Stable
intraventricular hemorrhage. No new hemorrhage.
2. Stable effacement of the right lateral ventricle body and of the third
ventricle. Decreased size of the frontal and temporal horns of the lateral
ventricles. Stable VP shunt catheter position.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with thalamic hemorrhage // interval change of
hemorrhage
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, 16.8 cm; CTDIvol = 47.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
3.0 cm x 1.9 cm parenchymal hematoma centered on right thalamus, minimally
decreased compared with 3.0 cm x 2.1 cm on ___. Stable surrounding
edema. Intraventricular hemorrhage within bilateral occipital horns, similar.
Stable right to left midline shift, approximately 0.6 cm. Slightly decreased
ventricular size, best seen at the level of temporal horns. Few subtle areas
of subarachnoid hemorrhage, less apparent compared with ___. No
new hemorrhage.
Stable 2 small areas of chronic encephalomalacia anterior basal frontal lobes,
along the floor of the anterior cranial fossa, consistent with distant trauma.
Right VP shunt catheter via a frontal burr hole, tip in the right frontal
horn. Left frontal burr hole, small zone of encephalomalacia left frontal
lobe from prior ventriculostomy tract.
No fractures are seen. Partial opacification left mastoid air cells, similar.
Patent left middle ear, right mastoid air cells, right middle ear. The
paranasal sinuses, are clear. The orbits are unremarkable.
IMPRESSION:
1. Parenchymal hematoma right thalamus, minimally decreased.
2. Stable intraventricular hemorrhage.
3. Minimally decreased ventricular size.
4. No new hemorrhage
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: Right thalamic intraparenchymal hemorrhage. Evaluate for
etiology of hemorrhage.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 10 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: Several head CT examinations dating from ___ through
___.
FINDINGS:
4.6 x 3.8 x 5.5 cm intraparenchymal hemorrhage centered in the right thalamus
with extension to the mid brain appears slightly larger than the dense portion
on prior CT examinations, though this is likely secondary to difference of
modality and overall degree of space-occupying pathology is grossly unchanged.
Again, there is intraventricular extension of hemorrhage into the occipital
horn of the right lateral ventricle, with a volume of intraventricular
hemorrhage layering within the occipital horns of the lateral ventricles
appearing similar to prior examination. Rim of surrounding vasogenic edema is
unchanged. There is unchanged mass effect with effacement of the right
lateral ventricle and 4 mm leftward midline shift. Minimal peripheral
enhancement is seen, likely secondary to the hemorrhage itself. There is no
new hemorrhage. There is no definite underlying mass.
There is no evidence of infarction. A right frontal approach VP shunt
catheter is unchanged in position terminating in the frontal horn of the right
lateral ventricle. A tract is seen from prior left frontal approach
ventriculostomy catheter. Enhancement along this tract is likely a
consequence of surgery. The ventricles and sulci are unchanged in caliber and
configuration. Areas of background periventricular, subcortical and deep
white matter T2/FLAIR hyperintensity are in a configuration most suggestive of
chronic small vessel ischemic disease. The principal intracranial vascular
flow voids are preserved.
There is a small mucous retention cyst in the right maxillary sinus. The
remainder of the visualized paranasal sinuses are grossly clear. The orbits
are grossly unremarkable. Again, there is partial bilateral mastoid air cell
opacification
IMPRESSION:
1. 4.6 x 3.8 x 5.5 cm hematoma in the right thalamus with extension to the
midbrain is grossly unchanged in size given difference of modality. The
surrounding edema and mass effect with 4 mm of leftward midline shift appears
similar to the prior examination. Given location, this likely represents
hypertensive hemorrhage.
2. Minimal peripheral contrast enhancement surrounding the hemorrhage is
likely reactive to the hemorrhage itself. No definite underlying mass.
3. Stable intraventricular hemorrhage. No new focus of hemorrhage.
4. Unchanged position of a right frontal approach VP shunt catheter with
stable ventricular size and configuration.
5. Left frontal enhancement along the path of the prior ventricular catheter.
This is probably post surgical, but recommend follow-up evaluation of this
area to ensure there is not evidence of neoplastic extension along the tract.
RECOMMENDATION(S): Recommend serial follow-up examination to resolution of
hemorrhage in order to exclude an underlying mass.
Radiology Report
EXAMINATION: Portable AP chest radiograph
INDICATION: ___ year old man with increasing O2 requirements, here with
stroke.
TECHNIQUE: Portable AP chest
COMPARISON: ___ portable AP chest radiograph
FINDINGS:
Lung volumes are low, likely resulting in crowding of the bronchovascular
structures an accentuation of heart size. Despite this, there appears to be
new, mild pulmonary edema and increased, moderate cardiomegaly. There is no
definite focal consolidation, but bibasilar atelectasis is possible. Pleural
effusions are small, if any.
A right-sided PICC remains coiled in the right internal jugular vein, but the
tip has retracted somewhat and terminates within the internal jugular vein
itself. A a presumed VP shunt is overall unchanged in position. A
tracheostomy, median sternotomy wires, and valve replacement are again noted.
IMPRESSION:
1. New, mild pulmonary edema.
2. A right-sided PICC is coiled and terminates within the right internal
jugular vein.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:01 AM, less than 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with R thalamic stroke with IVH s/p VPS now with
nystagmus and skew deviation on exam.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: ___ noncontrast head CT
FINDINGS:
The previously identified parenchymal hemorrhage centered at the right
thalamus is minimally decreased in size, measuring approximately 2.6 x 1.9 cm
(2a:14). Adjacent hypodensity likely reflecting edema is unchanged.
Approximately 3 mm of midline shift is unchanged. A right frontal approach
ventriculostomy catheter terminates in the lateral right ventricle near the
foramen of ___. Hemorrhage layering in the occipital ventricles is
essentially unchanged. Small foci of subarachnoid blood are unchanged, for
example overlying the left parietal lobe (2a:18). Foci of anterior basal
frontal lobe encephalomalacia are unchanged. There is no evidence of new
hemorrhage, new edema, infarction, or mass effect.
There is no evidence of acute fracture. Patchy left mastoid air cell
opacification is unchanged. There is a right maxillary sinus mucous retention
cyst. The visualized portion of the remaining paranasal sinuses and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Minimal interval decrease in size of the known parenchymal hemorrhage
centered on the right thalamus. Overall edema and midline shift are
unchanged.
2. Unchanged intraventricular hemorrhage.
3. No new hemorrhage.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ year old man with R DL PICC Line // R DL PICC Line Placement
___ Contact name: ___: ___
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph obtained 2 hours prior
FINDINGS:
Compared to the prior examination, no significant changes are noted. The
right sided PICC remains coiled in the internal jugular vein.
IMPRESSION:
Compared to the prior examination, no significant changes are noted. The
right sided PICC remains coiled in the internal jugular vein.
Radiology Report
INDICATION: ___ year old man with ivh, trach, pulmonary edema. Interval
changes.
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Tracheostomy tube and sternotomy wires are all unchanged. The lung volume is
small, exaggerating the pulmonary vascular markings. Mild pulmonary edema and
pulmonary vascular congestion is are unchanged. Left pleural effusion with
underlying volume loss is stable. No new consolidation. No pneumothorax.
Cardiomediastinal silhouette is unchanged.
IMPRESSION:
1. Persistent mild pulmonary edema and pulmonary venous congestion.
2. Persistent left pleural effusion with underlying volume loss.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified, Essential (primary) hypertension
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ is a ___ year old man with past medical history
significant for aortic valve replacement on Coumadin,
hypertension, hyperlipidemia, non-insulin dependent diabetes
mellitus who presents with acute right thalamic intraparenchymal
hemorrhage with intraventricular extension, likely due to
hypertension and/or anticoagulation.
#Thalamic intraparenchymal hemorrhage
Patient was admitted to Neuro ICU on ___, intubated at outside
hospital. An EVD was placed by Neurosurgery in the ICU. Exam was
initially very poor with fixed and dilated pupil on the right,
and no following of commands. In addition to FFP and vitamin K
he received prior to transfer, he was given PCC for an INR of
1.7 on transfer. Blood pressure goal maintained at <150,
initially controlled with nicardipine drip. Given extensive
nature of the bleed, he was treated with intraventricular tPA,
which was administered until resolution of clot in the ___
ventricle was observed on subsequent CTs. Repeat scans showed no
significant changes. He was monitored on cvEEG which did not
show epileptiform activity. Patient improved from a mental
status perspective and was noted to be following commands on the
right. He also had minimal ventilator requirement. Therefore, he
was initially extubated on ___ to face mask; however,
subsequently he was re-intubated on ___ for acute respiratory
distress. Given likely prolonged course of recovery, he
underwent uncomplicated tracheostomy and a PEG placement on
___. He was transitioned to trach collar on ___. In addition,
he was noted to have a normal amount of drainage out of his
ventricular drain, and a clamp trial was performed on ___ which
failed due to increasing intracranial pressures as well as
worsening exam. A repeat attempt on ___ also led to increased
intracranial pressure. After a third attempt, a
ventriculoperitoneal shunt was placed on ___. MRI of the brain
later in the course revealed no definite underlying mass lesion.
In discussion with Neurosurgery, we resumed aspirin 5 days after
the shunt was placed. We resumed anticoagulation with warfarin
in 10 days after the shunt. Notably, patient was found to have
very slow recovery of his alertness, likely due to the location
of his stroke involving the thalamus. He was trialed on
modafinil and amantadine to some effect.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
#Respiratory distress
Patient was intubated, as above, prior to admission. He
subsequently failed extubation and underwent uncomplicated
tracheostomy, and was transitioned to trach collar. Subsequently
transferred to the floor. On ___, however, patient experienced
acute decompensation of respiratory status requiring transfer
back to the Neurosciences-ICU, thought to be multifactorial due
to trach leak, alveolar derecruitment, and volume overload. No
overt evidence of infection was shown. He was treated with PEEP
as well as diuresis, which he tolerated well and was
subsequently re-transferred back to the floor, with continued
diuresis, chest physical therapy, and mobilization.
#Fevers
On admission to the Neuro-ICU, patient began to have
intermittent fevers. He was pan-cultured, which revealed a
klebsiella UTI. There was also concern for aspiration pneumonia
given copious vomiting on admission, as well as worsening
respiratory status while briefly extubated. He was initially
treated with broad spectrum antibiotics. Despite this, however,
he continued to have discrete episodes of fevers which were
associated with relative tachycardia, hypertension, and
adventitious movements resembling myoclonus. EEG was negative,
and no clear improvement on levetiracetam. No evidence of DVT.
Multiple cultures were obtained including blood, urine, and CSF,
which did not yield clear source of infection. Given that he was
being treated broad spectrum antibiotics, his episodes were felt
to be due to paroxysmal sympathetic hyperactivity, and he was
treated with low dose clonidine. Over his prolonged hospital
stay, he was found to have recurrent klebsiella UTI on ___, for
which he underwent another course of ceftriaxone and was
transitioned to Bactrim prior to discharge to rehab.
#History of aortic valve replacement
INR was reversed on admission. A transthoracic echocardiogram
showed well seated mechanical aortic valve prosthesis with
higher than previous gradient, normal left ventricular cavity
size with preserved regional and global systolic function. Per
discussion with Neurology, restarted anticoagulation with
warfarin on ___, target INR ___ per Hematology.
#Elevated PTT
Found to have persistently elevated PTT, despite holding HSQ.
Family reported history of ___ disease in the
family. Hematology/Oncology was consulted for optimal
management, including risk of bleeding. He underwent a series of
tests including causes of isolated PTT elevation, and ___
___ disease panel, which revealed no evidence of ___
___ disease. Mixing studies showed positive lupus
inhibitor, for which the treatment would be therapeutic
anticoagulation.
Transitional Issues
#Neurology
[ ] Strict BP management, goal less than 130/80
[ ] Continue Coumadin until therapeutic, goal ___
[ ] Please call Neurosurgery for post-discharge follow up in ___
weeks, ___
[ ] STOP ASPIRIN WHEN THERAPEUTIC ON COUMADIN
#Cardiology
[ ] Continue diuresis with 20mg Lasix daily. Titrate to goal net
even to -500cc daily (at max was receiving 20mg IV Lasix twice
daily). No issues with potassium while on diuretics.
[ ] Daily weights. If more than 3 pound gain in 1 day or 5
pounds in 1 week, consider contacting cardiologist or PCP for
diuretic management.
[ ] Please check creatinine in 1 week following discharge to
rehab.
[ ] Follow up with outpatient cardiologist ___
MD ___ in ___ weeks after discharged from ___
#Infectious Disease
[ ] Continue Bactrim for Klebsiella UTI until ___
#Hematology
[ ] On half-dose Coumadin (4, instead of home 7.5), while on
Bactrim. Please titrate Coumadin as needed to therapeutic INR.
INR on discharge was 1.1 on ___
[ ] No Hematology follow up is necessary at this time. |
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
Major Surgical or Invasive Procedure:
Endoscopy ___
History of Present Illness:
Patient is a ___ yo male with PMH of CAD s/p CABG ___, CHF w/ EF
55%, AFib (off coumadin for ___ yr), CKD, and long-standing iron
deficiency anemia, gastritis and chronic GI bleed presented to
his PCP's office today after he was seen in the at___ infusion
unit for iron infusion. When he presented to the infusion unit,
he was pale and short of breath with minimal ambulation. Of
note, he was recently hospitalized at ___ for 1
week in early ___ with CHF exacerbation where he was
diuresed down to a weight of 232 pounds. He was discharged on
lasix 40 mg po qAM, 20 mg po qPM. In the infusion unit, he was
noted to have a weight gain of ~25 pounds (232->258). He reports
shortness of breath and dyspnea on exertion x 1 month. He denies
PND but occasionally has difficulty using his CPAP unit. He
denies chest pain. He has occasioanal palpitations with climbing
stairs. He has been trying to diet recently and was drinking
more water and diet sodas to curb his appetite. He does not
follow a fluid restriction and has not been weighing himself at
home. He says a nurse prepares his medications and he does not
know how much lasix he has been taking.
Yesterday he also began to have abdominal cramping pains with
black diarrhea over past 3 days. He had ___ bowel movements per
day. He reports this is now resolved. He denies nausea,
vomiting, chest pain, BRBPR. His hgb was found to be 6.2 at the
___ clinic and he was referred to the ED for further
evaluation.
In the ED, initial VS were: 98.0 82 99/54 20 90% 12L. EKG showed
afib @ 76, new TWI v2-v5. Labs were significant for hct 23.3
(baseline ~28), creat 1.7 (at baseline), trop 0.02. Rectal exam
showed black-green heme positive stool. NG lavage showed clear
return, no blood. He was given pantoprazole 80 mg iv x 1. CXR
showed pulmonary edema. He was given 1 u blood + 20mg Lasix IV.
VS on transfer were: 80 104/42 18 94% RA
Past Medical History:
atrial fibrillation on coumadin, highest INR recently 3 in
___
T2DM A1c 5.5 ___
CRI, baseline ___
CAD s/p CABG ___, LIMA to LAD, vein graft to PDA, sequential
vein graft to D1 and OM
MI ___
___: cath with patent grafts and high grade OM1 treated with
stent
___: EF50%, cath with patent grafts except PDA which was
angioplasted
___: cardioversion for afib
___: EF unchanged
.
OA s/p THR
obesity
chronic pain
AVN femoral head and neck
PMR
colonic polyps
insomnia
gastritis/duodenitis
HLD
HTN
Social History:
___
Family History:
sister had breast cancer. No family hx of other cancers,
specifically GI malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.1, P: 69, BP: 154/75, RR: 18, 98% on 2l NC, Weight =
117.0KG
GENERAL: chronically ill-appearing male in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese, unable to assess JVP
LUNGS: mild crackles at bases, otherwise CTA bilat, no r/rh/wh,
good air movement, resp unlabored, no accessory muscle use
HEART: irreg rhythm, no MRG, nl S1-S2
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, 1+ pitting edema over shins b/l, 1+ ___
pulses
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
and sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
VS: 97.9, 145/100, 65, 18, 98%RA, Weight = 107.8kg
GENERAL: chronically ill-appearing male in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese, unable to assess JVP
LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
HEART: irreg rhythm, no MRG, nl S1-S2
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, mild edema over shins b/l, 1+ ___ pulses
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
and sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS:
___ 06:15PM BLOOD WBC-5.3 RBC-2.82* Hgb-6.8*# Hct-23.3*#
MCV-83# MCH-24.1*# MCHC-29.2* RDW-21.1* Plt ___
___ 06:15PM BLOOD Neuts-66 Bands-2 Lymphs-14* Monos-13*
Eos-3 Baso-0 Atyps-2* ___ Myelos-0
___ 06:15PM BLOOD ___ PTT-33.3 ___
___ 06:15PM BLOOD Glucose-103* UreaN-43* Creat-1.7* Na-137
K-4.6 Cl-99 HCO3-24 AnGap-19
___ 06:15PM BLOOD CK(CPK)-131
___ 06:15PM BLOOD CK-MB-3 cTropnT-0.02*
___ 06:00AM BLOOD Albumin-3.7 Calcium-9.2 Phos-4.6* Mg-2.2
___ 06:00AM BLOOD %HbA1c-5.7 eAG-117
___ 06:42PM BLOOD Lactate-2.2*
___ 06:42PM BLOOD Hgb-7.1* calcHCT-21
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-6.4 RBC-3.47* Hgb-9.2* Hct-31.0*
MCV-89 MCH-26.6* MCHC-29.8*# RDW-22.6* Plt ___
___ 06:45AM BLOOD Glucose-130* UreaN-31* Creat-1.7* Na-137
K-3.9 Cl-96 HCO3-30 AnGap-15
___ 06:00AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
MICROBIOLOGY:
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
IMAGING:
CXR - ___
FINDINGS: PA and lateral views of the chest were provided.
Midline
sternotomy wires are noted. There is a nasogastric tube
terminating in the
left upper quadrant. The heart is mildly enlarged. The lungs
appear clear.
Bony structures are intact.
IMPRESSION: Appropriately positioned nasogastric tube. Mild
cardiomegaly.
Otherwise, normal.
ECHO ___
Conclusions
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is moderately
dilated with mild global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal systolic
septal motion/position consistent with right ventricular
pressure overload. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate (___) mitral regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis. Severe pulmonary artery hypertension. Mild-moderate
mitral regurgitation. Mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function. Dilated ascending aorta.
Compared with the prior study (images reviewed) of ___,
the estimated PA systolic pressure is higher and mild right
ventricular systolic dysfunction is now seen.. These findings
are suggestive of a chronic or acute on chronic pulmonary
process. Is there a history of sleep apnea, bronchospasm or
chronic pulmonary embolism, etc.?
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Feraheme *NF* (ferumoxytol) 510 mg/17 mL (30 mg/mL) Injection
every 2 weeks
2. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral at
night
3. Tamsulosin 0.4 mg PO HS
4. Mirtazapine 7.5 mg PO HS:PRN insomnia
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Furosemide Dose is Unknown PO BID
8. Omeprazole 40 mg PO DAILY
9. Pravastatin 80 mg PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Colchicine 0.6 mg PO DAILY
12. Digoxin 0.125 mg PO DAILY
13. Citalopram 20 mg PO DAILY
14. Gabapentin 300 mg PO BID
15. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Mirtazapine 7.5 mg PO HS:PRN insomnia
3. Aspirin 81 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. Tamsulosin 0.4 mg PO HS
9. Colchicine 0.6 mg PO DAILY
10. Feraheme *NF* (ferumoxytol) 510 mg/17 mL (30 mg/mL)
Injection every 2 weeks
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Pravastatin 80 mg PO DAILY
14. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral at
night
15. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
16. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Anemia secondary to upper gastrointestinal bleed (GAVE
disease)
- Acute on chronic diastolic congestive heart failure
exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Chest radiograph from ___.
CLINICAL HISTORY: Shortness of breath.
FINDINGS: PA and lateral views of the chest were provided. Midline
sternotomy wires are noted. There is a nasogastric tube terminating in the
left upper quadrant. The heart is mildly enlarged. The lungs appear clear.
Bony structures are intact.
IMPRESSION: Appropriately positioned nasogastric tube. Mild cardiomegaly.
Otherwise, normal.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI BLEED
Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS
temperature: 98.0
heartrate: 82.0
resprate: 20.0
o2sat: 90.0
sbp: 99.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | Patient is a ___ year old male with a history of coronary artery
disease with a CABG in ___, congestive heart failure with a
ejection fraction of 55%, atrial fibrillation (off coumadin for
___ yr), chronic kidney disease, and long-standing iron deficiency
anemia, gastritis and chronic gastrointestinal bleed who
presented with weakness, shortness of breath, 25 pound weight
gain, diarrhea with guaic positive stools found to have
hemaglobin 6.
# Acute on chronic anemia: Multifactorial from acute blood loss
and iron deficiency. He also has chronic iron deficiency anemia
and receives iron infusions. He received 2 units of blood along
with lasix. Gastroenterolgy perfromed a endoscopy and found
gastroanteral vascular ectasia (GAVE) which was treated with
thermal cauterization. He will need a repeat endoscopy in ___
weeks. His hematocrit remained stabe as did his vital signs. He
was treated with pantoprazole.
# Acute on chronic diastolic congestive heart failure
exacerbation: Findings of pulmonary edema on chest xray. Patient
was treated with lasix diueresis. On admission he was 25 pounds
up in weight. His weight trended down ward through his admission
with diuresis.
# Atrial fibrillation: Rate controlled with metoprolol. Was on
coumadin in the past (~ ___ year ag) but this has been
discontinued given gastric bleeding. He was continued on 81mg
asprin.
# Coronary artery diseas: Chronic stable issue. He was continued
on asprin, metoprolol, simvastatin.
# Diabetes ___ 2: stable chronic issue. He was placed on a
insulin sliding scale while inpatient.
# Chronic pain: Chronic stable issue. We continued his home
oxycodone.
# Gout: Chronic stable issue. We continued his home allopurinol.
# Neuropathy: Chronic stable issue. We continued his home
gabapentin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ F h/o PE in ___ on apixaban presented with 3 episodes of
sharp, substernal chest pain over the course of the day. She has
been consistent with apixaban but found on CT to have linear
filling defects with morphology consistent with chronic PE, with
negative cardiac work-up, admitted for work-up and treatment of
PE and possible apixaban failure.
Patient was in usual state of health working on ___
when
she developed substernal chest pain at rest, requiring first
response. She had 3 separate episodes of chest pain, each
lasting
15min with ___ intervals, and each spontaneously resolving.
Chest pain was non-radiating, sharp, and focused at single point
in the ___ the chest. Patient reports that this pain is
different than what she experienced when she presented with PE
in
___ where it was more pressure and hypoxia. She endorses
nausea, mild dyspnea, chills, and LH. Denies fevers.
Patient had a cold ~2 weeks ago. She denies apixaban
non-compliance, leg swelling, recent surgery or trauma, recent
prolonged periods of immobility.
Regarding her prior PE in ___: It was diagnosed and treated at
___ from ___ with acute PE. She states that
she had been traveling to ___ and ___ in ___.
Approximately 3 weeks later, she began to feel chest pain and
SOB. She presented to the ER. CT scan showed bilateral pulmonary
emboli with a large clot burden and CT evidence of right
ventricular strain. ___ U/S were reportedly negative. She was
started on apixaban 10 mg BID and transitioned to 5 mg BID. She
was also found to have a new secundum ASD. She had negative
factor V leiden, anticardiolipin, eta2glycoprotein. She was seen
by outpatient heme/onc at ___ who recommended lifelong AC due
to ASD.
In the ED, initial vital signs were notable for: 98.4 82 133/82
16 100% RA
Exam notable for:
- No lower extremity swelling
- Decreased breath sounds bilaterally, no wheezes or rhonchi
- Regular HR
Labs were notable for: normal CBC, negative pregnancy test,
normal UA, normal chem 7, negative trops x2
Studies performed include:
CTA
1. Linear filling defects within the lobar, segmental and
subsegmental pulmonary arteries in both lower lobes as well as
within the right interlobar artery are compatible with
bilateral pulmonary emboli, most likely chronic given their
linear morphology. No evidence for right heart strain.
2. Hepatic steatosis.
Patient was given:
___ 22:50 PO/NG Atorvastatin 80 mg
___ 22:50 PO/NG Apixaban 5 mg
Vitals on transfer:85 99/69 17 97% RA
Upon arrival to the floor, the patient endorses history above.
She is chest pain free at the moment.
Past Medical History:
Pulmonary Embolism
Depression
Anxiety
Hyperlipidemia
CIN3 requiring LEEP (___), colposcopy in ___ with
metaplasia
Cholecystectomy
OSA
Atrial Septal Defect
Social History:
___
Family History:
unknown history of parents, died early (apparently by suicide),
Grandmother with history of DVT. She has a brother and sister
who
have had no blood clots.
Physical Exam:
ADMISSION EXAM
================
VITALS:98.0 PO 116 / 82 74 18 94 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes.
Oropharynx is clear.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. Mild reproducible chest pain just below
angle ___
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally. No erythema, ___ sign negative.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
DISCHARGE EXAM
===============
VITAL SIGNS:
___ 1108 Temp: 97.7PO BP111/77 HR88 RR18 O296 Ra
GENERAL: comfortable, in NAD
CARDIAC: Regular rate and rhythm, normal s1 s2
LUNGS: Breathing comfortably. Clear to auscultation bilaterally
with appropriate breath sounds appreciated in all fields.
ABDOMEN: NT ND no tenderness to palpation
EXTREMITIES: No edema. No calf tenderness. Distal pulses intact
bilaterally.
NEUROLOGIC: Alert and oriented x3. CN2-12 intact.
Pertinent Results:
LABS
=====
___ 04:25PM BLOOD WBC-9.2 RBC-4.52 Hgb-13.9 Hct-39.2 MCV-87
MCH-30.8 MCHC-35.5 RDW-12.5 RDWSD-38.8 Plt ___
___ 04:25PM BLOOD Neuts-69.7 ___ Monos-5.0 Eos-0.8*
Baso-0.5 Im ___ AbsNeut-6.37* AbsLymp-2.18 AbsMono-0.46
AbsEos-0.07 AbsBaso-0.05
___ 06:40AM BLOOD ___ PTT-27.7 ___
___ 08:00PM BLOOD cTropnT-<0.01
___ 04:25PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD Calcium-9.8 Phos-4.8* Mg-2.1
STUDIES
========
___ CTA Chest
1. Linear filling defects within the lobar, segmental and
subsegmental
pulmonary arteries in both lower lobes as well as within the
right interlobar
artery are compatible with bilateral pulmonary emboli, most
likely chronic
given their linear morphology. No evidence for right heart
strain.
2. Hepatic steatosis.
___ Bilat Venous US
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. Apixaban 5 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Loratadine 10 mg PO DAILY
4. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Loratadine 10 mg PO DAILY
4. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
========
Chest pain
SECDONDARY
============
History of PE
ASD
Hyperlipidemia
Depression
Anxiety
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 history of PE now with new onset of chest
pain// Rule out new episode of 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 2.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 3.2 s, 25.1 cm; CTDIvol = 24.8 mGy (Body) DLP = 622.5
mGy-cm.
Total DLP (Body) = 632 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level. Linear appearing filling defects are seen within the
bilateral lower lobe lobar, segmental and subsegmental pulmonary arteries,
potentially chronic pulmonary emboli (3:74, 80, 67). Additionally, a linear
filling defect within the right intralobar pulmonary artery is noted. Main
pulmonary artery is normal in caliber measuring up to 2.9 cm. 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 demonstrates diffuse hepatic
steatosis..
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Linear filling defects within the lobar, segmental and subsegmental
pulmonary arteries in both lower lobes as well as within the right interlobar
artery are compatible with bilateral pulmonary emboli, most likely chronic
given their linear morphology. No evidence for right heart strain.
2. Hepatic steatosis.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with hx of PE, here with chest pain// eval for
DVTs
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the 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: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.4
heartrate: 82.0
resprate: 16.0
o2sat: 100.0
sbp: 133.0
dbp: 82.0
level of pain: 4
level of acuity: 3.0 | ___ female with a history of PE in ___ on apixaban who
presented with substernal chest pain, CT demonstrating chronic
emboli without evidence for acute PE.
ACTIVE ISSUES
==============
# Chest Pain
The patient presented with acute onset chest pain described as
sharp, localized, substernal, without radiation. Her pain was
episodic, lasting on the order of seconds and resolved without
intervention and with SLNTG. Based on her imaging findings on
CTA, this was felt to not be c/f acute PE, her ACS work up was
negative. Other etiologies such as pericarditis or pleuritis
seemed less likely given her clinical course, imaging results
and EKGs. The patient will be recommended for an outpatient
exercise treadmill test and continue apixaban for her known
PE's. It is thought that her episodes of pain were more likely
musculoskeletal and related to her anxiety.
# Pulmonary Embolism:
Her intermittent sharp chest pain was different in character
than prior PE pain, which was characterized by pressure and
dyspnea. Although her CT shows PE, these appear more chronic
than acute. She had no signs of hemodynamic instability or right
heart
strain. Patient is not on OCPs nor is she pregnant. Had partial
work-up previously which included negative factor V leiden,
negative beta2glycoprotein, negative antiocardiolipin at ___.
Previously seen by heme/onc at ___ who recommended lifelong AC
due to secundum ASD. Based on her imaging findings of chronic
appearing PE's, it was decided to continue with current AC plan
with close follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / lisinopril
Attending: ___
Chief Complaint:
cough, SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with pAF on Coumadin, CAD s/p CABG, prior AVR, diastolic CHF
(prior systolic but resolved), T2DM, HTN, CKD with Cr 2.2,
morbid obesity, OSA, chronic osteoarthritis-related pain,
depression and gastritis who presents with SOB, new anemia and
cough. Patient reports cough X ___s generalized
fatigue. She reports cough is productive, whitish, denies
hemoptysis, fevers, chest pain. Also denies N/V/D or lower
extremity swelling. She says that one of her family member's
also had a cough last week. Reports dark stool ever since taking
iron supplement but no BRBPR.
In the ED, initial vitals: 98.1 77 132/76 18 98NC
- Labs notable for: trop .02, WBC 10.2, Hgb 7.8(10.4, ___, Cr
2.8(baseline 2.1-2.2), BNP 9786(4600 ___, UA negative
- Imaging notable for: CXR: Marked cardiomegaly with diffuse
pulmonary edema.
- Patient given: PO torsemide 60mg, pantoprazole 40mg PO
- Vitals prior to transfer: 98.0 69 152/65 20 97% RA
On arrival to the floor, pt reports mild SOB, minimal cough. No
fever, chills. No CP. No abdominal fullness, pain.
Past Medical History:
pAF on Coumadin
CHF, preserved EF
CAD s/p CABG x3 with AV replacement
DM
HTN
HL
CKD
Morbid obesity with OSA
Gastritis
Chronic low back pain and hip pain from osteoarthritis
Bilateral rotator cuff impingmenet
Chronic gait unsteadiness
Depression
Ovarian cyst
Colon polyps
Bilateral TKR
Diverticulitis s/p partial colectomy with primary anastomosis
Social History:
___
Family History:
None
Physical Exam:
ADMISSION:
Vitals: 98.1 PO 147 / 89 80 20 92 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVD
10
Lungs: decreased breath sounds, no absent breath sounds,
scattered faint crackles
CV: irregular irregular, normal S1 + S2, murmurs @ RUSB
Abdomen: obese, soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
GU: no bright blood on rectal exam
DISCHARGE:
VS: 98.1 97.8 ___ 20 94%RA
Weight: 110.5
GENERAL: Obese woman, lying in bed, appears comfortable
HEENT: MMM
NECK: Supple with JVP difficult to assess
CARDIAC: Irregular, soft systolic murmur LUSB
LUNGS: CTA b/l
ABDOMEN: soft, nontender throughout, NABS
EXTREMITIES: WWP, no peripheral edema
SKIN: No rashes appreciated.
LABS: Reviewed in OMR. Most notable for Cr decreasing
___
FeUrea 34.9%.
Pertinent Results:
ADMISSION:
___ 08:04PM BLOOD WBC-10.1* RBC-2.72* Hgb-7.8* Hct-25.8*
MCV-95 MCH-28.7 MCHC-30.2* RDW-15.0 RDWSD-51.2* Plt ___
___ 08:04PM BLOOD Neuts-63.9 ___ Monos-12.9 Eos-1.6
Baso-0.3 NRBC-0.4* Im ___ AbsNeut-6.45* AbsLymp-2.01
AbsMono-1.30* AbsEos-0.16 AbsBaso-0.03
___ 08:04PM BLOOD ___ PTT-43.7* ___
___ 08:04PM BLOOD Glucose-139* UreaN-73* Creat-2.8* Na-139
K-4.5 Cl-97 HCO3-31 AnGap-16
___ 08:04PM BLOOD ALT-13 AST-18 LD(LDH)-286* AlkPhos-95
TotBili-0.2
___ 08:04PM BLOOD proBNP-9786*
___ 08:04PM BLOOD CK-MB-3 cTropnT-0.02*
___ 06:10AM BLOOD CK-MB-3 cTropnT-0.02*
___ 06:20AM BLOOD CK-MB-2 cTropnT-0.02*
___ 10:15AM BLOOD CK-MB-2 cTropnT-0.02*
___ 12:40PM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:04PM BLOOD Calcium-8.4 Phos-4.1 Mg-2.5 Iron-39
___ 08:04PM BLOOD calTIBC-247* Hapto-367* Ferritn-167*
TRF-190*
___ 04:30AM BLOOD TSH-2.9
___ 08:20PM BLOOD Lactate-1.2
DISCHARGE:
___ 06:05AM BLOOD WBC-8.1 RBC-3.31* Hgb-9.6* Hct-32.5*
MCV-98 MCH-29.0 MCHC-29.5* RDW-16.0* RDWSD-55.7* Plt ___
___ 06:05AM BLOOD ___ PTT-28.0 ___
___ 06:05AM BLOOD Glucose-119* UreaN-78* Creat-3.1* Na-141
K-3.9 Cl-98 HCO3-34* AnGap-13
___ 06:05AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.5
==============================================================
STUDIES:
TTE ___:
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is at
least 15 mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF = 65%). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Doppler parameters are most consistent with Grade III/IV
(severe) left ventricular diastolic dysfunction. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is moderately dilated with severe global free wall
hypokinesis. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
severe right ventricular systolic dysfunction, severe tricuspid
regurgitation, and moderate-to-severe pulmonary hypertension are
now evident. The technically suboptimal nature of both studies
precludes definitive comparison.
CT CHEST ___:
1. Pulmonary vascular congestion without overt pulmonary edema.
2. No focal consolidation or pleural effusion.
3. Edematous left chest wall musculature with surrounding fat
stranding,
predominantly centered around the left ___ and ___
costochondral junctions. This may reflect underlying
nondisplaced fractures and clinical correlation with any history
of trauma or pain is recommended.
LUNG SCAN ___:
IMPRESSION: 1. Of note, this is a suboptimal study as the
ventilation images were not able to be obtained due to lack of
patient cooperation. However, there is no particular finding on
the perfusion images to suggest pulmonary embolus.
2. Decreased perfusion in the lingula and mildly decrease
perfusion in left lower lobe may be due to patient's known
cardiomegaly.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with CHF with recovered EF, new hypoxemia, does
not appear volume overloaded // interval change interval change
IMPRESSION:
In comparison with the study of ___, there is again huge enlargement
of the cardiac silhouette. Fracture of the most superior sternal wire is
again seen. There again is pulmonary edema that is difficult to assess due to
scatter radiation related to the size of the patient that limits the quality
of the image.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with effusion on CXR and R heart failure //
effusion
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
without intravenous contrast. Reformatted coronal, sagittal, thin slice axial
images images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 32.5 cm; CTDIvol = 23.5 mGy (Body) DLP = 762.3
mGy-cm.
Total DLP (Body) = 762 mGy-cm.
COMPARISON: None available
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: No supraclavicular or axillary
lymphadenopathy. The visualized thyroid gland is unremarkable. The left
chest wall musculature including the left pectoralis muscles and lattismus
dorsi are edematous with adjacent inflammatory changes.
UPPER ABDOMEN: The upper abdomen is notable for a small hiatal hernia.
Scattered hepatic calcifications are noted, likely reflective of prior
granulomatous infection. The limbs of the left adrenal gland are thickened
however no focal nodularity appreciated. The pancreatic tail appears
atrophic.
MEDIASTINUM: No size significant mediastinal lymph nodes.
HILA: No evidence of gross hilar adenopathy given the limitations of this
nonenhanced study.
HEART and PERICARDIUM: There is marked global enlargement of the heart. The
patient is status post aortic valve replacement. Calcification of the
coronary arteries, thoracic aorta and aortic arch are present.
PLEURA: No pleural effusion.
LUNG:
1. PARENCHYMA: No focal consolidation. Scattered calcified nodules measuring
up to 5 mm likely reflect sequela from prior granulomatous infection. No
pneumothorax.
2. AIRWAYS: The airways are patent through the segmental levels.
3. VESSELS: There is dilatation of the main pulmonary artery up to 3.7 cm.
There is tortuosity and prominence of the parenchymal arteries suggesting
pulmonary vascular congestion.
CHEST CAGE: Incompletely evaluated irregularity of the left ___ and ___
costochondral junctions with surrounding soft tissue density may reflect
nondisplaced fractures. DISH of the thoracic spine.
IMPRESSION:
1. Pulmonary vascular congestion without overt pulmonary edema.
2. No focal consolidation or pleural effusion.
3. Edematous left chest wall musculature with surrounding fat stranding,
predominantly centered around the left ___ and ___ costochondral junctions.
This may reflect underlying nondisplaced fractures and clinical correlation
with any history of trauma or pain is recommended.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with worsening somnolence over 2 days, but
arousable and protecting airway. // ?bleed, signs of incr. ICP
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.5 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: None.
FINDINGS:
Mild prominence of extra-axial space overlying very vertex of bilateral
parietal lobes, without high attenuation component, suggestive of late
subacute or chronic subdural hematoma. There is no evidence of
infarction,acute hemorrhage, edema, or mass. The ventricles and sulci are
normal in size and configuration. There is mild cerebellar atrophy. There
are mild chronic small vessel ischemic changes.
There is no evidence of fracture. There is moderate, greater than 50%
opacification of left mastoid air cells, middle ear cavity. There is
submucosal retention cyst of the left maxillary sinus. The remaining
visualized portion of the paranasal sinuses, right mastoid air cells, and
right middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Suggestion of small, late subacute or chronic subdural hematomas at
bilateral vertex. There is no acute hemorrhage.
2. Moderate opacification of left mastoid air cells, middle ear, consider
mastoiditis.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with ___ on CKD // r/o obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
Limited examination due to patient's body habitus. The right kidney measures
10.5 cm. The left kidney measures 9.8 cm. There is no hydronephrosis, stones,
or masses bilaterally. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Limited examination due to patient's habitus. Within these limitations,
normal renal ultrasound. No evidence of hydronephrosis.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Cough
Diagnosed with Cough
temperature: 98.1
heartrate: 77.0
resprate: 18.0
o2sat: 98.0
sbp: 132.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | ___ with pAF on Coumadin, CAD s/p CABG, prior AVR, diastolic CHF
(prior systolic but resolved), T2DM, HTN, CKD with Cr 2.2,
morbid obesity, OSA, chronic osteoarthritis-related pain,
depression and gastritis who presents with SOB, and acute on
chronic anemia. She had EKG with no significant changes and
troponin stable and 0.02. The patient had a TTE which showed new
severe right ventricular systolic dysfunction, severe tricuspid
regurgitation, and moderate-to-severe pulmonary hypertension.
She did not appear volume-overloaded and she had a chest CT
without edema, consolidation, or effusions. She had a V/Q scan
not suggestive of pulmonary embolism. On HD1, the patient became
hypotensive in the setting of melenotic stools and received 2
units of pRBCs and one FFP. She subsequently remained
hemodynamically stable with stable Hb/Hct. There was concern for
upper GI bleed, and plan for EGD, however anesthesia repeatedly
refused given concern for her mental status. Her dyspnea
ultimately improved with diuresis and she did not require any
oxygen on discharge.
# Hypoxemia/Dyspnea:
The patient presented with dyspnea and new oxygen requirement.
She had EKG with no significant changes and troponin stable at
0.02. The patient had a TTE which showed new severe right
ventricular systolic dysfunction, severe tricuspid
regurgitation, and moderate-to-severe pulmonary hypertension.
Volume status was very difficult to assess, but she had a chest
CT without edema, consolidation, or effusions. She had a V/Q
scan not suggestive of pulmonary embolism. Her symptoms were
attributed to worsening right-sided heart failure, OSA, and
obesity hypoventilation syndrome. She completed 5 day course of
treatment for presumed COPD exacerbation and was started on
night time CPAP.
She was successfully diuresed (given ___ on CKD thought
secondary to cardiorenal syndrome as below) with furosemide 160
mg IV x 1 followed by furosemide gtt 10 mg/hr x 3 days, then
transitioned to bumetanide 3 mg BID + acetazolamide 125 mg BID
on ___, and ultimately bumetanide 3 mg bid on discharge. After
diuresis she no longer required any oxygen.
# ___ on CKD: Patient's baseline Cr is 2.5-2.6 per Atrius
records. Initially concern for cardiorenal versus prerenal
etiology in setting of GIB. Exam was very difficult to follow
given body habitus, and I/O difficult to assess given
incontinence. We had planned for RHC, but she was declined due
to concerns over mental status. Hence we decided to volume
challenge on ___, and Cr rose to 3.8 (peak) from 3.2 on the
previous day. Hence, we opted to diurese with 160 mg furosemide
IV x 1 followed by furosemide gtt at 10 mg/hr x 3 days. With
diuresis, her Cr downtrended. She was switched to bumetanide 3
mg BID + acetazolamide 125 mg BID on ___, and will be
discharged on bumex 3 mg bid. Her discharge weight is 110.5 kg,
discharge Cr 3.1. Home valsartan was held at discharge.
# Question of altered mental status/ vertigo:
The patient over the course of her hospitalization became
slightly confused and intermittently sleepier than usual. This
was particularly noted during the night time by the RN, never
noticed during the day by MD ___ was hard of hearing and we had
to speak very loudly, but engaged in conversation and AOx4). Per
patient, she was never confused, but during the night she would
notice the ceiling spinning and her vision completely "turning
dark". Initially we were concerned whether this could be related
to cardiogenic cerebral hypoperfusion, as she was noticed to
become bradycardic to ___ hence decreased her metoprolol to 25
mg daily and her amiodarone to 400 mg daily. However, given
description of vertigo, neurology consult was obtained.
Differential diagnosis included seizures, a posterior
circulation vascular event, vertebrobasilar insufficiency, and
cardiogenic cerebral hypoperfusion. 20 minute EEG was negative
for seizure, and it was thought that MRI of the brain may be
warranted if continued episodes. Vessel imaging unfortunately
difficult given renal dysfunction. We reviewed ___ records which
included non-con MRI of brain that demonstrated only empty
sella. No vessel imaging was available; please consider as
outpatient.
# GI Bleed:
The patient became hypotensive with worsening anemia on HD1 and
received 2 units pRBCs as well as one of FFP. She was put on a
BID PPI and her warfarin and ASA were held. She continued to
have occasional small volume melenotic stools, though we note
that she was also on an iron supplement. GI was consulted and
EGD was not performed due to anesthesia's concern over her
mental status. The patient remained hemodynamically stable with
stable Hb/Hct for the remainder of her hospitalization. Her
warfarin and ASA were restarted on ___. Discharge Hgb 9.6 and
stable. Please consider outpatient EGD.
#Paroxysmal AF:
The patient presented in atrial fibrillation. She was rate
controlled appropriately with metoprolol. Her home metoprolol
100 mg was decreased to 25 mg daily due to concern for
bradycardia worsening vertigo and mental status as above. Her
coumadin was initially held due to GI bleed, but restarted on
___. Discharge INR 1.3 on warfarin 5 mg daily. She should
follow up for routine INR checks and adjustment of coumadin as
appropriate.
# Non-sustained Ventricular Tachycardia:
The patient has one run of 28 beats NSVT during hospitalization.
Her ICD had been removed due to a previous infection. She was
started on amiodarone, and will be discharged on amiodarone 400
mg daily
# Hypertension:
The patient's Imdur and Valsartan were initially held due to GI
bleed but gradually restarted. She was discharged on imdur and
hydralazine; valsartan was held in setting ___ as above but
can consider restarting as outpatient.
# Diabetes mellitus:
Reportedly diet-controlled as outpatient but required insulin on
sliding scale here. Consider initiating treatment as outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Hypaque-76
Attending: ___.
Chief Complaint:
right arm weakness/numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. ___ is an ___ RH man with a PMHx significant for
CKD stage five (not on dialysis) and HTN who presents today
after
two hours of right arm numbness and weakness concerning for
stroke. He had been in his USOH until 3:15pm today, when he
suddenly had numbness and weakness of his right forearm and
hand.
The symptoms appeared suddenly while he was watching a
television
program on his computer. He denies difficulty speaking or with
comprehension. He also denies difficulty walking, HA, neck or
back pain or incontinence. He describes difficulty with manual
tasks requiring dexterity, such as buttoning his shirt. He
states that he had to use his left hand in order to do most
tasks
that he would be normally quite adept at with his right.
Concerned, he took two ASAs (~700mg) and then called his son to
bring him to the ED for evaluation.
Upon arrival, his VS were significant for HTN with a SBP of
190. Neurology was then invited to consult regarding the
possibility of a stroke.
Past Medical History:
CKD Stage 5 - was recently taken off of lisinopril 10 days ago
by
his nephrologist. not on dialysis; manages his CKD with diet.
HTN
s/p b/l knee replacement
hard of hearing
s/p CABG several decades ago
Social History:
___
Family History:
His grandfather had a stroke at the age of ___
Physical Exam:
VS: T: 97.5 HR: 69 BP: 190/86 RR: 17 O2: 100%
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: NABS, soft, NTND abdomen
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says ___
backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. Reading intact. No
right-left confusion. No evidence of apraxia or neglect.
Cranial Nerves: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally without nystagmus.
Sensation intact V1-V3. Facial movement symmetric. Hearing
intact
to finger rub bilaterally. Palate elevation symmetric.
Sternocleidomastoid and trapezius full strength bilaterally.
Tongue midline, movements intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. No pronator drift. Slower finger tapping
on right.
Del Tri Bi WE FE FF IP H Q DF PF TE
R ___ ___ ___ ___
L ___ ___ ___ ___
Sensation: +hyperestesia to pinprick on right lateral forearm
and
dorsum or right hand (20% higher than left per patient).
However, light touch, position sense, and cold sensation
throughout. vibration normal in b/l UE, but decreased in b/l ___
___ secs b/l). No extinction to DSS.
Reflexes: 2+ on left, but 3+ on right (all reflexes). Toes
downgoing bilaterally.
Coordination: finger-nose-finger normal. Finger tapping slower
on right side.
Gait: Narrow based, steady. Able to tandem. Romberg negative.
.
Discharge Physical Examination:
Mental status is A+Ox3. The patient has normal recall and is
able to converse normally. His muscle strength is strong and
equal bilaterally - although, his grip strength in his right
hand may be slightly less than in his left hand. His lower
extremities are completely equal and strong. Sensation is equal
bilaterally. There may be slight decrease in right hand
repetitive movements, but he attributes this to arthritis. If
there is a deficit in right hand repetitive movements, it is
very slight. Cranial nerves are intact. Toes are downgoing
bilaterally.
Pertinent Results:
Admission labs:
___ 08:12PM URINE HOURS-RANDOM
___ 08:12PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 08:12PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:12PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 08:12PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-1
___ 08:12PM URINE GRANULAR-3*
___ 08:12PM URINE MUCOUS-RARE
___ 05:39PM COMMENTS-GREEN TOP
___ 05:37PM CREAT-5.3*#
___ 05:37PM CREAT-5.3*#
___ 05:37PM estGFR-Using this
___ 05:35PM WBC-7.0 RBC-3.42* HGB-10.8* HCT-33.5* MCV-98
MCH-31.6 MCHC-32.3 RDW-14.7
___ 05:35PM PLT COUNT-260
___ 05:35PM ___ PTT-29.4 ___
.
Discharge labs:
None.
.
Imaging:
.
ECHO IMPRESSION: Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation with normal valve morphology. Aortic
valve sclerosis. Dilated ascending aorta. No definite cardiac
source of embolism identified.
Compared with the report of the prior study (images unavailable
for review) of ___, the findings are similar.
.
MRI HEAD, MRA HEAD AND NECK
MRI HEAD: There are multiple tiny subacute infarcts seen within
bilateral frontal, left parietal lobes and left caudate nucleus.
There is no acute intracranial hemorrhage. There are extensive
T2/FLAIR hyperintensities in bilateral periventricular white
matter and centrum semiovale likely representing small vessel
ischemic disease. Chronic infarcts are seen in left perirolandic
and left parietal region. There is generalized prominence of
sulci, ventricles, and extra-axial CSF spaces. Visualized
orbits, paranasal sinuses and mastoid air cells are
unremarkable. The right vertebral artery flow void is not well
seen. The intracranial flow voids are otherwise preserved.
MRA HEAD: There is no flow signal seen in the right vertebral
artery.
Bilateral intracranial internal carotid arteries, left vertebral
artery,
basilar artery show no flow-limiting stenosis, occlusion,
dissection or
aneurysm formation.
MRA NECK: There is narrowing of the proximal left internal
carotid artery just beyond the bifurcation without flow limiting
stenosis or occlusion. Bilateral common carotid arteries,
internal carotid arteries are otherwise patent without
flow-limiting stenosis or occlusion or pseudoaneurysm formation.
The left vertebral artery shows normal flow signal without
flow-limiting stenosis or occlusion. There is no flow signal
seen in the right vertebral artery in the neck.
IMPRESSION:
1. Scattered subacute infarcts in bilateral frontal, parietal
lobes, left caudate, likely embolic.
2. Chronic infarcts in left perirolandic and left parietal
region.
3. Non-visualized flow signal in the right vertebral artery in
the head and neck concerning for right vertebral artery
occlusion.
4. Small vessel ischemic disease.
.
CT head w/out contrast
No evidence of acute intracranial hemorrhage. No acute major
vascular
territory infarction. MRI is more sensitive for the detection of
subtle
ischemia and early infarct and should be considered if there are
no
contraindications to the use of MRI and if clinically warranted.
Other details as above.
.
EKG
Baseline artifact. Sinus rhythm with occasiona ventricular
ectopy, otherwise, probably, no significant abnormalities.
Interpretation of the ST segment and T waves in some of the
leads is obscurred by the artifact. Repeat tracing is suggested.
Medications on Admission:
Renvela 800 mg Tab 2 (Two) Tablet(s) by mouth three times a day
with meals
Aspirin 81 mg Tab, Delayed Release Tablet(s) by mouth
Allopurinol ___ mg Tab 1 Tablet(s) by mouth once a day
Furosemide 20 mg Tab 2 Tablet(s) by mouth daily
Metoprolol SR 50 mg 24 hr Tab 1 Tablet(s) by mouth twice a day
magnesium Tab Oral 1 Tablet(s) , as needed for muscle cramps
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Two (2) Tablet Extended Release 24 hr PO twice a day.
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebral embolism with infarctions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with transient ischemic attack, right hand
weakness, evaluate for PE.
COMPARISON: None.
TECHNIQUE: Contiguous axial images were obtained through the brain without
the administration of IV contrast. Multiplanar reformats were generated and
reviewed.
FINDINGS: There is no evidence of acute intracranial hemorrhage, discrete
masses, mass effect, or shift of normally midline structures. The ventricles
and sulci are prominent consistent with age-related involutional changes.
Periventricular and subcortical white matter low attenuating regions appear
consistent with sequelae of chronic small vessel ischemic disease. Two small
foci of encephalomalacia in the left frontal lobe (series 2, image 23) and
left parietal lobe (series 2, image 24) are likely sequelae of old infarct. A
tiny lacune is noted within the right caudate head(series 2, image 12). No
acute major vascular territory infarction.
Bilateral mastoid air cells and visualized paranasal sinuses are clear.
Globes are intact.
IMPRESSION:
No evidence of acute intracranial hemorrhage. No acute major vascular
territory infarction. MRI is more sensitive for the detection of subtle
ischemia and early infarct and should be considered if there are no
contraindications to the use of MRI and if clinically warranted.
Other details as above.
Radiology Report
INDICATION: Right hand and forearm weakness and numbness.
COMPARISON: Same day head CT.
TECHNIQUE: MRI and MRA of the head and neck were obtained without contrast
per department protocol.
FINDINGS:
MRI HEAD: There are multiple tiny subacute infarcts seen within bilateral
frontal, left parietal lobes and left caudate nucleus. There is no acute
intracranial hemorrhage. There are extensive T2/FLAIR hyperintensities in
bilateral periventricular white matter and centrum semiovale likely
representing small vessel ischemic disease. Chronic infarcts are seen in left
perirolandic and left parietal region.
There is generalized prominence of sulci, ventricles, and extra-axial CSF
spaces. Visualized orbits, paranasal sinuses and mastoid air cells are
unremarkable. The right vertebral artery flow void is not well seen. The
intracranial flow voids are otherwise preserved.
MRA HEAD: There is no flow signal seen in the right vertebral artery.
Bilateral intracranial internal carotid arteries, left vertebral artery,
basilar artery show no flow-limiting stenosis, occlusion, dissection or
aneurysm formation.
MRA NECK: There is narrowing of the proximal left internal carotid artery
just beyond the bifurcation without flow limiting stenosis or occlusion.
Bilateral common carotid arteries, internal carotid arteries are otherwise
patent without flow-limiting stenosis or occlusion or pseudoaneurysm
formation. The left vertebral artery shows normal flow signal without
flow-limiting stenosis or occlusion. There is no flow signal seen in the
right vertebral artery in the neck.
IMPRESSION:
1. Scattered subacute infarcts in bilateral frontal, parietal lobes, left
caudate, likely embolic.
2. Chronic infarcts in left perirolandic and left parietal region.
3. Non-visualized flow signal in the right vertebral artery in the head and
neck concerning for right vertebral artery occlusion.
4. Small vessel ischemic disease.
Radiology Report
HEAD CT WITHOUT CONTRAST: ___.
HISTORY: ___ male with recent stroke, now with mechanical fall.
Question bleed or fracture.
TECHNIQUE: Contiguous axial images were obtained from skull base to the
vertex without intravenous contrast. Coronal and sagittal reformats were
reviewed.
COMPARISON: Head CT from ___ and brain MR from ___.
FINDINGS: When compared to prior, there has been no significant interval
change. Again seen is prominence of ventricles and sulci not out of
proportion to patient's age. Scattered periventricular and subcortical white
matter hypodensities are again seen suggestive of chronic small vessel
ischemic changes. Small focal regions of encephalomalacia seen in the left
frontal and left parietal lobes similar to prior. There is no acute
intra-axial or extra-axial hemorrhage, mass, midline shift, or vascular
territorial infarct.
Included paranasal sinuses and mastoids are clear. Soft tissue swelling seen
overlying the left forehead and periorbital region without underlying
fracture.
IMPRESSION: Soft tissue swelling in the left forehead and periorbital region
without underlying fracture. No acute intracranial abnormality.
Radiology Report
CERVICAL SPINE CT WITHOUT CONTRAST: ___.
HISTORY: ___ male with recent stroke, now with mechanical fall.
Question fracture.
TECHNIQUE: Contiguous axial images were obtained from skull base through
T3-T4 without intravenous contrast. Coronal and sagittal reformats were
reviewed. No previous exam was listed for comparison. Correlation is made to
scout films from head CT from ___ and localizer images from MRI dated
___.
FINDINGS: There is no visualized acute fracture. There is mild
anterolisthesis of C5 on C6 and C7 on T1, similar to localizer image from MRI
from ___. These can be attributed to extensive facet joint
hypertrophic changes at these levels. Multilevel degenerative changes are
notable for posterior disc bulges, worst at C3-4 which results in at least
mild to moderate canal narrowing. Extensive multilevel facet joint and
uncovertebral joint hypertrophy results in multilevel bilateral foraminal
narrowing worst at C4-5 where it is moderate to severe.
There is no prevertebral soft tissue swelling. Atherosclerotic calcifications
noted in the carotid bulbs and proximal internal carotid arteries bilaterally.
Additional images of the lower face are notable for soft tissue swelling with
subcutaneous gas in the infraorbital region on the left.
The thyroid and lung apices are unremarkable.
IMPRESSION:
No acute fracture.
Mild anterolisthesis of C5 on C6 and C7 on T1, likely due to facet joint
hypertrophy and unchanged from localizer image from MRI from two days prior.
Multilevel degenerative changes as above.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R ARM WEAKNESS
Diagnosed with TRANS CEREB ISCHEMIA NOS
temperature: 97.5
heartrate: 69.0
resprate: 17.0
o2sat: 100.0
sbp: 190.0
dbp: 86.0
level of pain: 0
level of acuity: 1.0 | Assessment: The patient was admitted after experiencing sudden
onset right arm numbness and weakness. In the emergency room,
exam was concerning for stroke, so the patient was admitted for
workup. The patient had an MRI of his brain that showed
scattered subacute infarcts in bilateral frontal, parietal
lobes, left caudate, likely embolic, chronic infarcts in left
perirolandic and left parietal region, small vessel ischemic
disease. The thought at this time was that the embolic sources
was likely either heart or aortic arch. A TTE was conducted
which was essentially unchanged from his prior ECHO in ___.
The patient was offered a TEE to evaluate for the extent of this
problem, but the patient refused this study. He also did not
want to pursue outpatient prolonged cardiac monitoring to r/o
paroxysmal AFib because he did not want to be on warfarin or
anticoagulation. The patient's symptoms had resolved by the time
of discharge. The patient was started on plavix (in place of
aspirin), and simvastatin (10mg). The patient's records
indicated that he had previously been on a atorvastatin, but
developed myalgias. Therefore, small dose simvastatin was
started. The patient recalls the symptoms of myalgias and will
be observant of such symptoms. THe patient was discharged in
stable condition.
.
Neurology: The patient was admitted and had MRI/MRA studies
performed (see pertinent results section for read). The patient
had an TTE done to look for the source of the emboli. No changes
were seen on echo (from ___, but there were atherosclerotic
changes on aortic arch. Patient refused to have a TEE done.
Patient had A1C and lipids checked (see results). Serum and
urine tox screen, along with metabolic evaluation for infection
were negative. Patient was started on plavix (stopped ASA).
Patient was started on low dose simvastatin (had history of
myalgias with atorvastatin).
.
CV: Patient's MI workup was negative. Patient was monitored on
telemetry with no findings. Patient's BP was allowed to
autoregular with goal SBP < 180. Patient's metoprolol was halved
while inpatient, but back to regular dose on discharge.
Patient's TTE results can be found in pertinent results. Patient
going home on plavix and simvastatin and stopping aspirin.
.
Code Status: FULL (confirmed with patient)
.
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?
(x) Yes - () No
4. LDL documented? (x) Yes () No
5. Intensive statin therapy administered? (for LDL > 100) (x)
Yes - () No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (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: (x)
Antiplatelet - () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea, NSTEMI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx CAD s/p CABG many years ago (1990s), NIDDM, afib on
coumadin, and a recent diagnosis of CHF who presented to ___
___ with confusion, lethargy, and decreased exercise
tolerance. The patient has had progressive dyspnea on exertion x
___ months. Along with this, he developed ___ edema, weight gain,
early satiety, orthopnea, and PND. Based on his report, his MD
diagnosed him with CHF and started him on a water pill which did
improve his symptoms. For the last ___ weeks, the patient has
noted "indigestion" mainly after meals and not always associated
with exertion. The patient described this as substernal
discomfort without radiation. Two days prior to admission, the
patient awoke with confusion. He was brought to ___
and diagnosed with hypoglycemia and discharged. On the morning
of admission, the patient again woke up confused and altered. At
___, he had a fever to 101 and positive cardiac
enzymes without EKG changes concerning for an NSTEMI. Also, his
Cr was found to be elevated from a baseline of 1.5 to 2.6. The
patient was transfered here for further workup.
.
In the ED, the patient was slightly hypoxic and was placed
briefly on NRB. A CXR showed a left lower lobe opacity c/w
atelectasis v PNA v effusion. The CXR did not suggest left sided
heart failure.
.
On arrival to the floor, the patient looked comfortable. He did
not endorse cough, fevers, chills, recent illnesses or other
infectious signs. He does say that he has had slightly low UOP,
but denies dysuria. He does wake up multiple times at night to
urinate. He does not have any chest pain.
.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: 1990s, unknown records
-PERCUTANEOUS CORONARY INTERVENTIONS: Unknown
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Afib with slow ventricular rate
BPH
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Family history
of non-specific cancers.
Physical Exam:
ADMISSION EXAM
VS: T= 97.2 BP= 110/47 HR= 43 RR= 19 O2 sat= 91% 4L NC
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
NECK: elevated JVP to ear.
CARDIAC: Distant heart sounds. Irregularly irregular and
bradycardic. Unable to elicit any murmurs or extra heart sounds.
LUNGS: CTAB, no wheezes, crackles, rhonchi, breathing
non-labored
ABDOMEN: Soft, NTND. No HSM or tenderness. No palpable bladder
EXTREMITIES: 3+ ___ edema to knee bilaterally
NEURO: strength ___ throughout, sensation grossly normal. Gait
not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE EXAM
T98, BP 113/47, HR 48, RR 18, 94% RA
Gen: AOx3, NAD
CV: Irregular irregular, ___ diastolic murmur at RUSB, ___ early
systolic murmur at ___
Lungs: CTAB, no wheezes, crackles, consolidations
Abd: soft, NT, ND, no rebound/guarding
Ext: 1+ edema R>L (due to old injury)
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-8.8 RBC-3.72* Hgb-10.3* Hct-35.1*
MCV-94 MCH-27.6 MCHC-29.2* RDW-15.5 Plt ___
___ 01:20PM BLOOD Neuts-80.0* Lymphs-12.0* Monos-7.3
Eos-0.2 Baso-0.6
___ 01:20PM BLOOD ___ PTT-39.8* ___
___ 01:20PM BLOOD Glucose-124* UreaN-51* Creat-2.6* Na-139
K-5.0 Cl-104 HCO3-26 AnGap-14
___ 07:30AM BLOOD ALT-299* AST-416* LD(LDH)-399*
CK(CPK)-268 AlkPhos-113 TotBili-1.2
___ 07:30AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.1
___ 01:43PM BLOOD Lactate-1.3
Cardiac Enzymes:
___ 01:20PM BLOOD CK-MB-20* MB Indx-7.9*
___ 01:20PM BLOOD cTropnT-0.66*
___ 05:37PM BLOOD cTropnT-0.97*
___ 07:30AM BLOOD CK-MB-19* MB Indx-7.1* cTropnT-1.15*
___ 06:56AM BLOOD CK-MB-10 MB Indx-7.6* cTropnT-1.10*
EKG:
Atrial fibrillation with slow ventricular response. Loss of R
waves across the precordium suggestive of anteroseptal
myocardial infarction of
indeterminage age. Left axis deviation. Low voltage across the
limb and
precordial leads. No previous tracing available for comparison.
==============
CXR:
IMPRESSION:
1. Worsening congestive heart failure with small right effusion.
2. Moderate left pleural effusions with adjacent left lower lobe
opacity. This may reflect atelectasis and dependent edema, but
coexisting infection should be considered in the appropriate
clinical setting.
===============
TTE:
LEFT ATRIUM: Moderate ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC
diameter (>2.1cm) with <50% decrease with sniff (estimated RA
pressure (>=15 mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Mildly depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No
resting LVOT gradient.
RIGHT VENTRICLE: Indeterminate RV wall thickness. Dilated RV
cavity. RV function depressed. Abnormal septal motion/position
consistent with RV pressure/volume overload.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
___ MR. [Due to acoustic shadowing, the severity of MR may
be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve supporting structures. No TS. Mild to moderate
[___] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Left pleural effusion.
Conclusions
The left atrium is moderately dilated. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 45 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular cavity is dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Systolic and diastolic motion and conformation of the
interventricular septum suggest that both the estimated
pulmonary artery pressure and tricuspid regurgitation severity
may be grossly underestimated by the Doppler findings in this
examination.
==============
Stress:Perfusion:
IMPRESSION: No anginal symptoms or ischemic ST segment changes
to
Persantine. Baseline systolic hypertension with an appropriate
blood
pressure response to the Persantine infusion. Nuclear report
sent
separately.
IMPRESSION: Moderate fixed apical perfusion defect.
================
Discharge Labs:
___ 07:30AM BLOOD WBC-6.2 RBC-3.42* Hgb-9.7* Hct-30.7*
MCV-90 MCH-28.4 MCHC-31.7 RDW-15.5 Plt ___
___ 07:30AM BLOOD ___ PTT-42.2* ___
___ 07:30AM BLOOD Glucose-111* UreaN-53* Creat-1.6* Na-147*
K-4.0 Cl-100 HCO3-35* AnGap-16
___ 07:30AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.3
Medications on Admission:
Amlodipine 10mg Qday
Enalapril 10mg Qday
Lisinopril 5mg Qday
Furosemide 80mg QAM, 40mg QPM
Glyburide 2.5mg Qday
Pravastatin 80mg Qday
Spironolactone 25mg Qday
Warfarin 3mg Qday
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
4. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
8. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
NSTEMI
Acute Systolic Heart Failure Exacerbation
Acute Kidney Innjury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Elevated troponin. Prior history of CABG. Concern for pneumonia as
well.
TECHNIQUE: Chest, AP upright portable.
FINDINGS: The patient is status post coronary artery bypass graft surgery.
The heart is mildly enlarged. There is patchy left basilar opacity which may
represent pneumonia, but atelectasis and pleural effusion could also be
considered. A pleural effusion is suspected but not well demonstrated.
Elsewhere, the lungs appear clear. There is no pneumothorax or evidence for
pleural effusion on the right.
IMPRESSION: Mild cardiomegaly. No evidence of congestive heart failure.
Left basilar opacification, not specific but which could be seen with
atelectasis or pneumonia and probably with a pleural effusion.
Radiology Report
PA AND LATERAL CHEST OF ___
COMPARISON: Radiograph of earlier the same date.
FINDINGS: Cardiac silhouette is enlarged, and accompanied by worsening
vascular engorgement and mild-to-moderate edema. Small right and moderate
left pleural effusion are again demonstrated as well as a confluent left lower
lobe opacity which may relate to atelectasis and dependent edema.
IMPRESSION:
1. Worsening congestive heart failure with small right effusion.
2. Moderate left pleural effusions with adjacent left lower lobe opacity.
This may reflect atelectasis and dependent edema, but coexisting infection
should be considered in the appropriate clinical setting.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ACUTE MI
Diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE, PNEUMONIA,ORGANISM UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.5
heartrate: 56.0
resprate: 16.0
o2sat: 96.0
sbp: 123.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | This is an ___ yo M with h/o CABG in ___ (unknown anatomy),
atrial fibrillation on coumadin, NIDDM, HTN, Hyperlipidemia, and
a recent diagnosis of CHF (unknown etiology) who was admitted
with acute systolic heart failure exacerbation, NSTEMI, and ___.
.
1. Acute Systolic Heart Failure Exacerbation: TTE here showed
LVEF 45%, depressed RV free wall contractility, signs of fluid
overload, and pulmonary hypertension. On exam, the patient
initially had elevated JVD, hepatic congestion, a pulsatile
liver, and massive lower extremity edema. The etiology of his
CHF is unclear, however, ischemia is possible given his
significant CAD. It is unlikely, however, that an ischemic event
caused this exacerbation. The patient was diuresed with a lasix
gtt. His weight on admission was 84kg. On discharge, the
patient's weight was 73kg. The patient was discharged on
torsemide 60mg Qday, lisinopril 5mg Qday, Metoprolol XL 25mg
Qday, and isosorbide XR 30mg. The patient had adequate HR
control with his afib and he will remain on Coumadin. The
patient's medications should be uptitrated as an outpatient. If
needed, the patient can have a R heart cath to determine PCWP
and pulmonary pressures. The patient was kept on 1500cc fluid
restriction while he was here.
.
2. NSTEMI: The patient presented to ___ with
confusion and signs of fluid overload, but he was without chest
pain. At OSH, he had positive troponins, but no signs of active
ischemia on EKG. Here, the patient was kept on coumadin and full
dose aspirin. He was placed on high dose atorvastatin. He was
not initialy placed on a beta blocker due to his slow heart
rate. The patient underwent a pharmacological stress:perfusion
that showed a moderate, fixed apical defect. No intervention was
undertaken. The patient will continue his aspirin, coumadin,
atorvastatin, and metoprolol as tolerated.
.
3. ___: The patient's Cr on admission was 2.8. Baseline Cr 1.5.
This was most consistent with ATN. The patient was diuresed with
improvement of his Cr to 1.6. The patient will continue a
Lisinopril 5mg, with careful monitoring of his Cr.
.
4. Afib with slow ventricular rate: Chronic, on coumadin. Goal
___.
.
5 Diabetes 2: The patient will be switched off of Glyburide to
Glipizide due to his slightly worse GFR. The patient should take
5mg Glipizide once a day. If warranted, the patient can have
Metformin added to his regimen by his PCP.
.
6. Hyperlipidemia: On atorvastatin 80mg
.
7. HTN: On meds as above. With multiple BP meds, the patient
should be monitored for hypotension/orthostasis.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
loperamide / mold
Attending: ___
___ Complaint:
Right flank pain
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ man with past mental history of spina
bifida with multiple orthopedic surgeries since birth, urostomy
age ___, cholecystectomy, appendectomy, and multiple chronic
urinary tract infections presenting with right flank pain and
transferred for left-sided obstructive renal calculus.
Patient reports that 2 nights prior to admission he developed
pain over his right back "over my right kidney." He states that
this pain was waxing and waning, at times severe. He went to
sleep, when he woke up on ___ his pain continued. He then
developed nausea and low-grade fevers, as well as feeling "a
little cold." He therefore presented to the emergency room. He
reports no abdominal pain. No pain on his left side.
Per review of ___ records, on presentation to the ED,
patient had a renal ultrasound showing new moderate right
hydronephrosis and hydroureter. He then had a CTU showing a 2.5
x 0.9 cm obstructive renal calculus in the left ureter. This
was discussed with urology, who felt the patient would likely
need
PCN placement. Therefore he was referred to ___ in
___. He was also given ceftriaxone for possible UTI.
In the ED:
Initial vital signs were notable for: T 97.9, HR 106, BP 100/70,
RR 18, 95% RA
Exam was notable for: Soft, Nontender, Nondistended with no
organomegaly; no rebound tenderness or guarding; urostomy in LLQ
w/ mild surrounding erythema but no TTP.
Labs were notable for:
- CBC: WBC 19.0, hgb 11.5, plt 463
- Lytes:
141 / 108 / 28
------------- 113
4.3 \ 20 \ 0.9
Patient was given:
___ 00:20 IVF NS ( 1000 mL ordered)
___ 01:28 PO/NG Acetaminophen 1000 mg
___ 03:05 IV Vancomycin (1500 mg ordered)
Urology and ___ reviewed the case. Initially plan for distal
cannulation by urology, with backup plan for bilateral PCN by
___. However, while in ED patient passed stone, and therefore no
intervention necessary. Urology recommended admission with plan
for repeat ultrasound in ___ hours to ensure resolution of
hydronephrosis.
Vitals on transfer: T 98.4, HR 86, BP 110/58, RR 16, 99% RA
Upon arrival to the floor, patient recounts history as above.
He notes that there is a large stone in his urostomy bag. He
continues to have some right-sided back pain. He has an
occasional cough, which he states is from his allergies and
post-nasal drip.
Past Medical History:
- spina bifida
- nephrolithiasis
- s/p ileal conduit urinary diversion
- History of syrinx status post ventricular shunt.
- Recurrent pyelonephritis.
- History of ESBL.
- Allergic rhinitis/cough.
- Chronic lower extremity edema.
- History of urosepsis in ___ with a gram-negative bacteremia,
including Klebsiella pneumoniae and ESBL.
Social History:
___
Family History:
- mother - hypertension and high cholesterol
- father - passed away in his ___ from melanoma. Also with h/o
prostate cancer and kidney cancer (s/p nephrectomy)
- ___ sisters with kidney stones
Physical Exam:
ON ADMISSION:
VITALS: T 99.8, HR 85, BP 109/54, RR 18, 98% Ra
GENERAL: Alert and in no apparent distress. Occasional cough
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen moderately distended though soft, non-tender to
palpation. Bowel sounds present. No HSM
GU: Urostomy bag in place with several small stones and one
fairly large irregular stone
MSK: Bilateral lower extremities without movement. Minimal
feeling below knees. Right lower extremity with moderate
swelling, erythema around calf, mildly warmer than left.
Nontender to palpation, though sensation overall diminished.
Left upper hand with some medial deviation
SKIN: Posterior right thigh with large shallow ulcer with
serosanguinous drainage. Skin crack on palm of right hand. A few
superficial tears and abrasions noted, with areas of dry skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, does not move lower extremities, minimal
sensation of lower extremities at baseline
PSYCH: pleasant, appropriate affect
========================================
ON DISCHARGE:
VITALS: ___ 0747 Temp: 97.5 PO BP: 113/77 HR: 76 RR: 18 O2
sat: 97% O2 delivery: RA
GENERAL: Alert and in no apparent distress, laying in bed, looks
comfortable, conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Moist
mucus membranes.
CV: RRR, no murmur, no S3, no S4. 2+ radial pulses bilaterally.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air.
GI: Abdomen soft, non-distended, non-tender, obese. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation. Urostomy
bag with clear, yellow, non-bloody urine.
MSK: Trace RLE edema, moves upper extremities, slightly moves
lower extremities. Both wrists with slight contracture.
SKIN: Posterior right thigh with large superficial ulcer with
flaking of skin, no drainage or bleeding. Right lower leg with
very faint erythema not approaching borders drawn in marker,
without warmth. Left heel wrapped in clean gauze. Callous on
right palm.
NEURO: Alert, oriented x3, face symmetric, speech fluent,
decreased sensation in both lower legs
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS ON ADMISSION:
___ 10:10PM BLOOD WBC-19.0* RBC-4.05* Hgb-11.5* Hct-35.9*
MCV-89 MCH-28.4 MCHC-32.0 RDW-16.3* RDWSD-52.6* Plt ___
___ 10:10PM BLOOD Neuts-83.4* Lymphs-7.0* Monos-8.8
Eos-0.0* Baso-0.3 Im ___ AbsNeut-15.87* AbsLymp-1.34
AbsMono-1.68* AbsEos-0.00* AbsBaso-0.06
___ 10:10PM BLOOD ___ PTT-28.3 ___
___ 10:10PM BLOOD Glucose-113* UreaN-28* Creat-0.9 Na-141
K-4.3 Cl-108 HCO3-20* AnGap-13
___ 08:42AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.2
___ 10:16PM BLOOD Lactate-1.0
==================================
LABS ON DISCHARGE:
___ 05:07AM BLOOD WBC-11.2* RBC-3.56* Hgb-10.0* Hct-31.9*
MCV-90 MCH-28.1 MCHC-31.3* RDW-15.9* RDWSD-52.6* Plt ___
___ 05:07AM BLOOD Glucose-89 UreaN-15 Creat-0.8 Na-138
K-4.1 Cl-102 HCO3-24 AnGap-12
___ 05:07AM BLOOD Mg-1.9
==================================
MICROBIOLOGY:
Blood culture ___: No growth (final)
Blood culture ___: No growth (final)
Blood culture x2 ___: PENDING - no growth to date
C. difficile PCR ___: Negative
MRSA screen ___: Negative
Urine culture ___ from ___: 50-100K CFU/mL
pan-sensitive Pseudomonas, <10K CFU/mL pan-sensitive
Pseudomonas, ___ CFU/mL MRSA (final)
==================================
IMAGING:
Renal ultrasound ___: (___)
IMPRESSION: 1. New moderate right hydronephrosis and
hydroureter.
2. No definite urinary stones are visualized.
3. Postsurgical changes from cystectomy and ileal conduit
creation, which are incompletely evaluated on ultrasound.
CT abdomen/pelvis without contrast ___: (___)
IMPRESSION:
1. A dominant 2.5 x 0.9 cm obstructive renal calculus is seen in
the left ureter with proximal bilateral mild-to-moderate
hydronephrosis, left greater than right. Additional smaller
stones are noted along the course of the ileal conduit,
including a 1.1 cm stone at the level of the left lower quadrant
ostomy opening.
2. Multiple nonobstructive renal stones are noted in bilateral
renal calices including a large staghorn calculus in the left
upper renal pole.
3. Decubitus ulcers seen extending to the rectum with concern
for rectocutaneous fistula, similar to the prior study in ___. No evidence of abscess.
4. 4 mm pulmonary nodule incidentally seen in the right lung
base, unchanged since at least ___.
5. Asymmetric right gynecomastia, unchanged since ___
CXR ___: (___)
IMPRESSION: The new right PICC extends into the ___ and makes a
turn at the level of the azygos vein. In the absence of a
lateral view, it is not clear whether the catheter terminates in
the SVC or azygos vein. According to ___ Nurse ___,
after this radiograph was obtained, the catheter was pulled back
by 2 cm. Therefore, it likely currently terminates in the
proximal SVC.
RLE ultrasound ___:
No definite evidence of deep venous thrombosis in the right
lower extremity veins. Limited visualization of the posterior
tibial and peroneal veins.
Renal ultrasound ___:
1. The scan is highly limited by patient body habitus, within
this limitation there is persistent unchanged moderate
hydronephrosis on the left.
2. 8 mm nonobstructing renal stone within the left kidney.
Additional
bilateral nonobstructing renal calculi were better evaluated on
the CT, and not seen well by ultrasound, due to technical
limitations related to patient body habitus.
RECOMMENDATION(S): Follow-up of passage of the known left-sided
ureteral
calculi should be performed by noncontrast CT, given the lack of
adequate
visualization of both kidneys due to patient body habitus.
CXR ___:
Right-sided PICC line terminates in the proximal SVC. No
pneumothorax or
other procedural complication.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO BID
2. Vitamin D ___ UNIT PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Lactobacillus acidophilus 1 capsule oral DAILY
5. Multivitamins 1 TAB PO DAILY
6. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP BID
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*6 Tablet Refills:*0
3. Linezolid ___ mg PO Q12H
RX *linezolid ___ mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*10 Tablet Refills:*0
4. Ascorbic Acid ___ mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Lactobacillus acidophilus 1 capsule oral DAILY
7. Multivitamins 1 TAB PO DAILY
8. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP BID
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fever
Pseudomonas and MRSA complicated urinary tract infection
Right lower leg cellulitis
Bilateral hydronephrosis
Obstructive left renal calculus
Diarrhea
Left heel pressure ulcer
Right posterior thigh/gluteal pressure ulcer
Hypokalemia
Anemia
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: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old man with spina bifida, R leg swelling and erythema//
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, color flow, and spectral doppler of the right
common femoral, femoral, and popliteal veins. Visualization of the posterior
tibial and peroneal veins are limited.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No definite evidence of deep venous thrombosis in the right lower extremity
veins. Limited visualization of the posterior tibial and peroneal veins.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with ileal conduit, urostomy, here with left
sided obstructive renal calculus with bilateral hydronephrosis, with passed
stone. Evaluate hydronephrosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
NOTE: Study is highly limited by patient body habitus.
RIGHT KIDNEY: The right kidney measures 10.8 cm. The known right renal
nonobstructing calculi are not well demonstrated on the renal ultrasound
LEFT KIDNEY: The left kidney measures 12.2 cm. Within the lower pole of the
left kidney is an approximately 3.6 cm simple appearing cyst. A
nonobstructing 8 mm renal stone is seen within the left upper pole. There is
increased echogenicity within the medullary sinus fat of the left kidney,
however there is likely persistent moderate hydronephrosis, not evaluated
completely due to patient body habitus and suboptimal scan.
The patient is status post ileal conduit, with absence of the native urinary
bladder.
IMPRESSION:
1. The scan is highly limited by patient body habitus, within this limitation
there is persistent unchanged moderate hydronephrosis on the left.
2. 8 mm nonobstructing renal stone within the left kidney. Additional
bilateral nonobstructing renal calculi were better evaluated on the CT, and
not seen well by ultrasound, due to technical limitations related to patient
body habitus.
RECOMMENDATION(S): Follow-up of passage of the known left-sided ureteral
calculi should be performed by noncontrast CT, given the lack of adequate
visualization of both kidneys due to patient body habitus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with spina bifida and ileal conduit here with UTI
and cellulitis.// Confirm correct position of previously placed PICC.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
Lung volumes are low. No focal consolidation, pleural effusion or
pneumothorax. A right-sided PICC line terminates in the proximal SVC. No
evidence of pneumothorax or other procedural complication. Cardiomediastinal
silhouette is unremarkable. Extensive degenerative changes are seen at the
bilateral shoulder joints.
IMPRESSION:
Right-sided PICC line terminates in the proximal SVC. No pneumothorax or
other procedural complication.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Flank pain
Diagnosed with Hydronephrosis with renal and ureteral calculous obstruction
temperature: 97.9
heartrate: 106.0
resprate: 18.0
o2sat: 95.0
sbp: 100.0
dbp: 70.0
level of pain: 5
level of acuity: 3.0 | Mr ___ is a ___ man with spina bifida with multiple
orthopedic surgeries since birth, urostomy at age ___,
cholecystectomy, appendectomy, and multiple chronic urinary
tract infections who presented with several days with right
flank pain. Renal ultrasound at ___ showed obstructive
renal calculus in left ureter with
bilateral mid-moderate hydronephrosis, small stones in ileal
conduit, and bilateral non-obstructing stones in renal calices.
He passed a large stone in the ED, with notable improvement in
pain. Imaging was not revealing for a right sided cause for
pain and repeat ultrasound showed persistent left
hydronephrosis. He had several fevers, which seems likely due
to Pseudomonas and MRSA UTI, but also could be due to right
lower leg cellulitis. His right flank pain has resolved and he
has been afebrile since ___. He developed abdominal pain
and diarrhea, likely side effects from antibiotics, as he has
negative C. difficile. He had a PICC placed for IV access and
this was removed prior to discharge. He was discharged to
___ short term rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension, Hyponatremia, Viral URI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old Male with hepatitis C with cirrhosis and grade 3
varices status-post variceal banding procedure 3 days prior to
admission, who presents with shaking chills, cough and myalgias.
He called his PCP's office from work, and was sent to urgent
care given his complex medical history, who felt this most
likely represented ILI (Influenza Like Illness) and he underwent
a influenza DFA.
The patient reported in addition to rigors, and chills he notes
headache, non-productive cough, nausea and myalgias. He did not
take his temperature but felt warm. He reports that he also has
a decreased appetite.
On presentation he was noted with initial vital signs of 101.7,
82, 118/50, 20, 98%RA. Given an elevated lactate, and mild
leukocytosis the patient had a chest x-ray to rule out
pneumonia. He subsequently had an episode of hypotension 92/52
which improved after 2L IV Fluids. He was started on Tamiflu
empirically, and Tylenol. He is admitted for both the
hypotension and hyponatremia noted on labs.
Past Medical History:
Hep C cirrhosis: treated in ___ with interferon c/b grade III
varices. No hx of encephalopathy, or ascites
COPD
DVT/PE
SMA thrombosis s/p small bowel resection on coumadin,
CAD s/p 2 BMS in ___ to LAD: LAST CARDIAC CATH ___ with
Moderate 2-vessel CAD, moderate pHTN and mild LV diastolic
dysfunction
Type 2 DM on oral agents
Chronic Stable Asthma
Hemochromatosis:homozygosity HFE ___ mutation-last phlebotomy
___
Systolic CHF: Last Echo ___ with EF 45-50%
___: GI bleed from portal hypertensive gastropathy/varices
s/p variceal banding.
Social History:
___
Family History:
Mother: cancer (type unknown)
Father: "old age"
Older brother: CHF
Physical ___:
ADMISSION EXAM
ROS:
GEN: + fevers, + Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, - Vomiting, - Diarrhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, + Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: + Myalgia, + Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 97.5, 105/64, 61, 18, 98%RA
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
DISCHARGE EXAM:
Vitals: 98.1 106/59 65 18 96%RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
sub-umbilical scar well healed
GU: no foley
Ext: warm, well perfused, tenderness, erythema with warmth over
L ankles, no peripheral edema
Neuro: non-focal
Pertinent Results:
ADMISSION LABS:
___ 04:25AM BLOOD WBC-11.8*# RBC-3.71* Hgb-11.9* Hct-35.5*
MCV-96 MCH-32.1* MCHC-33.5 RDW-14.0 RDWSD-48.3* Plt ___
___ 04:25AM BLOOD Neuts-86.1* Lymphs-7.0* Monos-4.8*
Eos-0.7* Baso-0.6 Im ___ AbsNeut-10.13*# AbsLymp-0.83*
AbsMono-0.57 AbsEos-0.08 AbsBaso-0.07
___ 04:25AM BLOOD ___ PTT-30.6 ___
___ 04:25AM BLOOD Glucose-99 UreaN-15 Creat-1.2 Na-130*
K-4.2 Cl-94* HCO3-19* AnGap-21*
___ 04:25AM BLOOD ALT-37 AST-51* AlkPhos-66 TotBili-0.7
___ 04:25AM BLOOD Albumin-4.0 Calcium-9.2 Phos-2.6* Mg-1.6
___ 06:40AM BLOOD Lactate-2.0
___ 04:31AM BLOOD Lactate-2.8* K-4.2
___ 11:55AM URINE Color-Straw Appear-Clear Sp ___
___ 11:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:39AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
DISCHARGE LABS:
___ 07:12AM BLOOD WBC-7.0 RBC-3.76* Hgb-11.8* Hct-36.8*
MCV-98 MCH-31.4 MCHC-32.1 RDW-14.5 RDWSD-51.8* Plt ___
___ 07:12AM BLOOD ___
MICRO:
___ URINE CULTURE (Pending):
___ 7:12 am BLOOD CULTURE pending
IMAGING:
CXR (___)
Subtle interstitial nodular opacities, most conspicuous in the
right upper and lower lung are unchanged and correlate with
previously demonstrated peribronchial nodules seen on prior
exams. No evidence of new focal consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Nadolol 20 mg PO DAILY
7. Simvastatin 20 mg PO QPM
8. Tiotropium Bromide 1 CAP IH DAILY
9. Diazepam 5 mg PO DAILY:PRN anxiety
10. Gabapentin 300 mg PO TID
11. glimepiride 2 mg ORAL DAILY
12. Hydrocortisone Cream 2.5% 1 Appl TP DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Omeprazole 20 mg PO BID
16. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
17. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
18. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
19. Warfarin 7.5 mg PO 2X/WEEK (WE,SA)
20. Warfarin 5 mg PO 5X/WEEK (___)
21. Furosemide 40 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Omeprazole 20 mg PO BID
5. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
6. Simvastatin 20 mg PO QPM
7. Tiotropium Bromide 1 CAP IH DAILY
8. Warfarin 7.5 mg PO 2X/WEEK (WE,SA)
9. Warfarin 5 mg PO 5X/WEEK (___)
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
11. Diazepam 5 mg PO DAILY:PRN anxiety
12. glimepiride 2 mg ORAL DAILY
13. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
14. Hydrocortisone Cream 2.5% 1 Appl TP DAILY
15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Nadolol 20 mg PO DAILY
19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
20. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: First Routine Administration Time
Get INR checked on the morning of ___. Take Lovenox on AM of
___ and then defer to ___ clinic
RX *enoxaparin 80 mg/0.8 mL 80 mg SC every 12 hours Disp #*10
Syringe Refills:*0
21. Furosemide 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Viral respiratory infection
Secondary Diagnosis: Hypotension, hyponatremia, subtherapeutic
INR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with cough, fever, evaluate for infiltrate.
TECHNIQUE: Chest PA and lateral
COMPARISON:
1. CT chest without contrast ___.
2. Chest x-ray ___.
FINDINGS:
Subtle interstitial opacities in the right upper and right lower lung
correlate with the locations of peribronchial nodules seen on prior CT chests,
most recently ___. Otherwise, there is no evidence of new focal
consolidation. The cardiomediastinal silhouettes are stable, within normal
limits. The bilateral hila are unremarkable. There is no pulmonary vascular
congestion or pulmonary edema. There is no pneumothorax or pleural effusion.
IMPRESSION:
Subtle interstitial nodular opacities, most conspicuous in the right upper and
lower lung are unchanged and correlate with previously demonstrated
peribronchial nodules seen on prior exams. No evidence of new focal
consolidation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ILI
Diagnosed with Cellulitis of left lower limb
temperature: 107.7
heartrate: 82.0
resprate: 20.0
o2sat: 98.0
sbp: 118.0
dbp: 50.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ male with history of CAD s/p MI
and PCI, DVT/PE on Coumadin, atrial fibrillation, hepatitis C
cirrhosis complicated by esophageal varices s/p endoscopy 2 days
ago, and systolic heart failure (EF 45-50%) who presents with
one day of chills, dry cough, and myalgias concerning for a
viral respiratory infection. |
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date:(...TRUNCATED) | "This is a ___ male w hx of AIDS, currently on 3TC, \nabacavir, and boosted atazanavir; poorly contr(...TRUNCATED) |
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