input
stringlengths 2.25k
112k
| label
stringlengths 60
11.2k
|
|---|---|
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. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pain at site of port
Major Surgical or Invasive Procedure:
None; continued drainage of chronic pleural effusion from
existing pleurex catheter
History of Present Illness:
___ male w hx of AIDS, currently on 3TC, abacavir, and
boosted atazanavir; poorly controlled type 2
DM complicated by nephropathy, neuropathy, and retinopathy, and
not currently on insulin therapy; Hodgkin's disease and
Burkitt's lymphoma, which are both currently in remission;
cardiomyopathy with congestive heart failure and recurrent right
pleural effusion, requiring a PleurX catheter drainage 3x weekly
who presents with irritation around the port site and admitted
for renal failure.
Was told that his port to be removed 3 months ago but has not
been removed. Over the last month has noted worsening pain
around the port site. No fevers or chills. No chest pain or
shortness of breath. Patient reportedly told nursing triage that
he had been feeling weak over the last few days and was not
answering the door at home. He lives with his brother, though
used to live with his mother who is now in a nursing home.
In the ED, initial vital signs were 98.8 101 ___ 96% RA.
Patient was given 1L NS. Labs notable for Na 125, Creat 2.1, WBC
10.6. Chest xray showed persistent R pleural effusion.
On the floor, vitals were: T 97.7, BP 117/84, P 96, RR 16, 95%
RA
Review of Systems:
(+) Per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- NSTEMI ___ medically managed
- HIV (CD4 198 ___,000 ___
- HIV cholangiopathy
- DM, type II, uncontrolled (most recent HA1c 9.0 on ___
- CKD
- Cardiomyopathy with EF 20% on ___ likely secondary to
doxorubicin, although HIV and/or ischemia may have contributed
- Pleural effusions
- Burkitt's lymphoma (___)
- Hodgkins lymphoma (last cycle ___, stable disease)
Social History:
___
Family History:
Mother alive with gastric cancer. Father died of ___ and
?cancer.
Physical Exam:
Admission Physical Exam:
Vitals- 97.7 117/84 96 16 95%RA
General- Alert, oriented, cachectic man in no acute distress,
soft spoken
HEENT- Sclera anicteric, MMM, oropharynx clear without thrush,
PERRL
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation on the left, poor breath sounds
right lung ___ to persistent pleural effusion
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Skin/lines: R portocatch site nonerythematous, nontender,
without drainage, no fulctuance or crepitus. Skin is excessively
dry throughout upper and lower extremities
Discharge Physical Exam:
Vitals- 99.6 ___ ___ 18 92-100%RA 142(4H),
159(6H), 184(96H), 160(12L)
General- Sleeping but easily arousable.
HEENT- Sclera anicteric, MMM, oropharynx clear without thrush,
PERRL, few teeth.
Neck- supple, JVD present, no LAD.
Lungs- CTA with bilateral crackles throughout.
CV- Regular rate and rhythm, normal S1 and widened S2 split,
II/VI systolic murmur best heard at the ___. No rubs or
gallops.
Abdomen- soft, mild tenderness to deep palpation, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly.
Ext- warm, well perfused, 2+ pulses, trace edema bilaterally. No
clubbing or cyanosis.
Neuro- A&O x3. CNs2-12 intact, motor function grossly normal.
Skin/lines: R portocatch site nonerythematous, nontender,
without drainage, no fluctuance or crepitus. Skin is excessively
dry throughout upper and lower extremities.
Pertinent Results:
Admission Labs:
___ 12:35PM BLOOD WBC-10.6# RBC-3.64* Hgb-11.6* Hct-35.6*
MCV-98 MCH-31.9 MCHC-32.7 RDW-14.7 Plt ___
___ 12:35PM BLOOD Neuts-84.1* Lymphs-11.0* Monos-3.4
Eos-0.7 Baso-0.8
___ 12:35PM BLOOD Plt ___
___ 12:35PM BLOOD Glucose-389* UreaN-76* Creat-2.1* Na-125*
K-4.8 Cl-90* HCO3-21* AnGap-19
___ 05:40AM BLOOD LD(LDH)-354*
___ 12:35PM BLOOD Calcium-8.7 Phos-4.5 Mg-2.7*
Pertinent Results:
___ 07:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 07:30PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 07:30PM URINE CastHy-3*
___ 07:30PM URINE Hours-RANDOM UreaN-552 Creat-59 Na-19
K-29 Cl-33
___ 07:30PM URINE Osmolal-344
___ ASPERGILLUS AG,EIA,SERUM Not Detected
___ HHV-8 DNA, QL PCR Not Detected
___ B-GLUCAN 355 pg/mL
___ B-GLUCAN Results Pending
___ Histoplasma Antigen <0.5 (neg)
___ CRYPTOCOCCAL ANTIGEN-FINAL Neg
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY INPATIENT
___ URINE Legionella Urinary Antigen Neg
___ URINE Legionella Urinary Antigen Neg
___ ACID FAST SMEAR-FINAL Neg; ACID FAST
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY;
___ RESPIRATORY CULTURE-FINAL; ACID FAST
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; FUNGAL
CULTURE-PRELIMINARY;
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT ALL
NEGATIVE
___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE-FINAL
INPATIENT
___ STOOL C. difficile DNA amplification assay-FINAL Neg
Cryptosporidium/Giardia (DFA)-FINAL; OVA + PARASITES-FINAL;
FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; CYCLOSPORA
STAIN-FINAL; MICROSPORIDIA STAIN-FINAL; VIRAL
CULTURE-PRELIMINARY INPATIENT ALL NEGATIVE
___ SPUTUM- CANCELLED
CXR ___: FINDINGS: Opacity over the right mid-to-lower
lateral lung appears similar, likely corresponding to known
loculated pleural effusion; catheter within the effusion appears
similarly positioned. Right Port-A-Cath terminates in the low
SVC, similar to prior. No new consolidation, left effusion,
pneumothorax, or pulmonary edema is detected. Heart size is
persistently enlarged, likely exaggerated by low lung volumes.
IMPRESSION: Stable-appearing loculated right pleural effusion
with
corresponding catheter.
CXR ___: IMPRESSION: AP chest compared to ___ through
___: The largely fissural right pleural effusion
has increased minimally since ___. Accompanying
increase in moderate cardiomegaly and mediastinal vascular
caliber suggests a component of early cardiac decompensation may
be present. There is no pneumothorax. Right subclavian
infusion port ends in the mid SVC. There is no appreciable left
pleural effusion. The right pleural drainage catheter has not
migrated since a PET/CT on ___ shows it cannulates the
right interlobar fissures from which the loculated pleural
effusion should be accessible.
___
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23 and 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast/lymphocyte yield. B cells comprise 24% of
lymphoid-gated events, do not express aberrant antigens, and
display cytophilic antibody staining (precluding evaluation of
clonality). T cells comprise 74% of lymphoid gated events. A
subset appear to express dim/equivocal CD19, favor technical
artifact.
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by lymphoma are not
seen in specimen. However, due to the presence of cytophilic
antibody B cell clonality could not be determined. Correlation
with clinical findings is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.
1127/12 Cell block pleural fluid: DIAGNOSIS:
Pleural fluid, cell block:
Negative for malignant cells.
Paucicellular specimen: few lymphocytes.
GMS and AFB stains are negative for microorganisms.
___ Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Scattered
lymphocytes.
___ CT CHEST W/O CONTRAST: FINDINGS: CHEST: The visualized
portion of the thyroid appears unremarkable. There is no
axillary or hilar lymphadenopathy; numerous small mediastinal
lymph nodes are present, but none meet pathologic size criteria.
The aorta is of normal caliber along its course as is the
pulmonary arterial trunk. The heart size
is large with calcified atherosclerotic disease but there is no
pericardial effusion. Moderate pleural effusion on the right
tracks along the posterolateral aspect of the pleural space as
well as into the major fissure. A drain has been placed and
courses into the major fissure. There is diffuse bronchial wall
thickening with scattered areas of mucus plugging, primarily in
the lower lungs.
Multiple pulmonary nodules are present as follows: A 4-mm
nodule at the
anterior aspect of the right upper lobe (4:41), new from prior
exam. A 5-mm nodule further down in the right upper lobe
(4:54), also new from prior exam. A 3-mm subpleural nodule in
the right upper lobe (4:62), which has progressed since prior
exam. A 5-mm subpleural nodule along the posteromedial aspect
of the right upper lobe (4:66), progressed from prior exam. A
5-mm nodule in the right lower lobe in the subpleural position
(4:137), similar to prior exam. A 3-mm subpleural nodule in the
left upper lobe (4:43), new from prior exam. A 4-mm nodule in
the left upper lobe (4:53), new from prior exam. A 4-mm nodule
just anterior to the major fissure in the left upper lobe, new
from prior exam
(4:60). A 3-mm nodule just posterior to the major fissure in
the left lower lobe, new from prior exam (4:96).
The visualized portion of the upper abdomen shows no overt
abnormality. The visualized bones demonstrate no
aggressive-appearing lytic or sclerotic lesions. IMPRESSION:
1. Multiple pulmonary nodules, new within the last month, as
well as
bronchial wall thickening and scattered areas of mucus plugging,
as described above; despite the patient's immune status and lab
results, these findings are not typical for fungal pneumonia;
findings are more consistent with viral or early bacterial
pneumonia.
2. Right pleural effusion tracking into the major and minor
fissures with drain in place.
___ CT ABDOMEN/PELVIS W/O CONTRAST: CT abdomen: Again, the
imaged lung bases demonstrate a moderate right loculated pleural
effusion. A Pleurx catheter is in place and courses along the
major fissure. Hyperdensity seen outlining the pleura likely
relates to prior pleurodesis. The previously described multiple
pulmonary nodules and
bronchial wall thickening or not fully imaged on this study but
are seen at the left lung base. A small amount of unchanged
atelectasis is seen at the right lung base. The imaged portion
the heart is top-normal in size. Coronary calcifications are
noted.
There are no focal liver lesions identified. The gallbladder is
decompressed and there is no intrahepatic biliary ductal
dilation. The spleen is normal in size. The pancreas and
adrenal glands are unremarkable. The kidneys enhance
symmetrically history contrast without hydronephrosis. A 3.6 x
2.8 cm cyst in the upper pole of the right kidney is unchanged.
The stomach, large and small bowel are normal. There is no
retroperitoneal or mesenteric lymphadenopathy. A small amount of
calcifications are seen in otherwise normal-appearing aorta. The
portal vein appears patent. There is a small amount of
subpulmonic and
perihepatic ascites.
CT pelvis: The bladder, rectum and prostate are normal. There
is a small amount of free pelvic fluid. The appendix is normal.
There is no inguinal or pelvic sidewall lymphadenopathy.
Pelvis: There are no suspicious osseous lesions.
IMPRESSION:
1. No change from most recent comparison studies.
2. Unchanged loculated right lung pleural effusion with
evidence of a prior pleurodesis and Pleurx catheter placement.
The known and bronchial wall thickening and pulmonary nodules
were not fully imaged but appear similar at the left lung base.
3. Unchanged amount of subpulmonic, perihepatic and pelvic free
fluid.
Discharge Labs:
___ 07:15AM BLOOD WBC-7.2 RBC-3.97* Hgb-12.8* Hct-37.8*
MCV-95 MCH-32.1* MCHC-33.7 RDW-15.2 Plt ___
___ 07:15AM BLOOD Glucose-86 UreaN-51* Creat-1.9* Na-132*
K-5.0 Cl-95* HCO3-28 AnGap-14
___ 07:15AM BLOOD ALT-28 AST-39 LD(LDH)-217 AlkPhos-441*
TotBili-1.4
___ 07:15AM BLOOD ALT-28 AST-39 LD(LDH)-217 AlkPhos-441*
TotBili-1.4
___ 07:15AM BLOOD Albumin-2.5* Calcium-8.4 Phos-4.3 Mg-2.3
___ 03:16PM PLEURAL WBC-530* RBC-970* Polys-6* Lymphs-80*
Monos-7* Other-7*
___ 03:16PM PLEURAL TotProt-3.5 Glucose-202 LD(LDH)-119
Albumin-1.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Atazanavir 300 mg PO DAILY
3. Atovaquone Suspension 1500 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Gabapentin 300 mg PO BID
6. LaMIVudine 300 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Nystatin Oral Suspension 10 mL PO Q8H
9. Ritonavir (Oral Solution) 80 mg/ml 1.25 ml (100ml) PO DAILY
take with atazanavir
10. Acetaminophen 325-650 mg PO Q4H:PRN pain, fever
11. Aspirin EC 81 mg PO DAILY
12. Bisacodyl ___AILY:PRN constipation
13. Milk of Magnesia 30 mL PO DAILY:PRN constipation
14. Fleet Enema ___AILY:PRN constipation
15. Hydrocerin 1 Appl TP DAILY
apply to dry skin and feet
16. Torsemide 20 mg 2 tabs PO DAILY
17. GlipiZIDE XL 15 mg PO DAILY
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q4H:PRN pain, fever
3. Atazanavir 300 mg PO DAILY
4. Atovaquone Suspension 1500 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Citalopram 20 mg PO DAILY
7. Gabapentin 300 mg PO BID
8. Hydrocerin 1 Appl TP DAILY
apply to dry skin and feet
9. LaMIVudine 300 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Milk of Magnesia 30 mL PO DAILY:PRN constipation
12. Nystatin Oral Suspension 10 mL PO Q8H
13. Ritonavir (Oral Solution) 80 mg PO DAILY
take with atazanavir
14. Torsemide 20 mg PO DAILY
15. GlipiZIDE XL 15 mg PO DAILY
16. Fleet Enema ___AILY:PRN constipation
17. Aspirin EC 81 mg PO DAILY
***NOTE: On discharge planning sheet error identified: written
to take 20mg torsemide instead of 2tabs 20mg torsemide for total
of 40mg; AND ritonavir 80mg written-correct dose 80mg/ml- 1.25
ml daily for total 100mg ritonavir. Patient was contacted to
correct this error, PACT team aware. ***
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: AIDS, acute kidney injury, diabetes mellitus
Secondary diagnosis: CHF, CKD, HTN, cardiomyopathy, persistent
pleural effusion
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with Burkitt's lymphoma, now with pain around
the right port site.
COMPARISON: ___.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
FINDINGS: Opacity over the right mid-to-lower lateral lung appears similar,
likely corresponding to known loculated pleural effusion; catheter within the
effusion appears similarly positioned. Right Port-A-Cath terminates in the
low SVC, similar to prior. No new consolidation, left effusion, pneumothorax,
or pulmonary edema is detected. Heart size is persistently enlarged, likely
exaggerated by low lung volumes.
IMPRESSION: Stable-appearing loculated right pleural effusion with
corresponding catheter.
Radiology Report
PA AND LATERAL CHEST, ___.
HISTORY: Asymptomatic desaturation, question worsening pleural effusion.
IMPRESSION: AP chest compared to ___ through ___:
The largely fissural right pleural effusion has increased minimally since
___. Accompanying increase in moderate cardiomegaly and mediastinal
vascular caliber suggests a component of early cardiac decompensation may be
present. There is no pneumothorax. Right subclavian infusion port ends in
the mid SVC. There is no appreciable left pleural effusion. The right
pleural drainage catheter has not migrated since a PET/CT on ___ shows
it cannulates the right interlobar fissures from which the loculated pleural
effusion should be accessible.
Radiology Report
HISTORY: ___ male with AIDS and recurrent right pleural effusion as
well as a history of Burkitt's and Hodgkin's lymphoma, now in remission, now
with relative hypoxia and elevated beta-glucan.
STUDY: CT of the chest without contrast; images were acquired in the soft
tissue and lung algorithms. Coronal and sagittal reformatted images were
generated as well as axial maximum intensity projection images.
COMPARISON: CT of the chest, abdomen, and pelvis from ___. PET-CT
from ___.
FINDINGS:
CHEST: The visualized portion of the thyroid appears unremarkable. There is
no axillary or hilar lymphadenopathy; numerous small mediastinal lymph nodes
are present, but none meet pathologic size criteria. The aorta is of normal
caliber along its course as is the pulmonary arterial trunk. The heart size
is large with calcified atherosclerotic disease but there is no pericardial
effusion.
Moderate pleural effusion on the right tracks along the posterolateral aspect
of the pleural space as well as into the major fissure. A drain has been
placed and courses into the major fissure. There is diffuse bronchial wall
thickening with scattered areas of mucus plugging, primarily in the lower
lungs.
Multiple pulmonary nodules are present as follows: A 4-mm nodule at the
anterior aspect of the right upper lobe (4:41), new from prior exam. A 5-mm
nodule further down in the right upper lobe (4:54), also new from prior exam.
A 3-mm subpleural nodule in the right upper lobe (4:62), which has progressed
since prior exam. A 5-mm subpleural nodule along the posteromedial aspect of
the right upper lobe (4:66), progressed from prior exam. A 5-mm nodule in the
right lower lobe in the subpleural position (4:137), similar to prior exam. A
3-mm subpleural nodule in the left upper lobe (4:43), new from prior exam. A
4-mm nodule in the left upper lobe (4:53), new from prior exam. A 4-mm nodule
just anterior to the major fissure in the left upper lobe, new from prior exam
(4:60). A 3-mm nodule just posterior to the major fissure in the left lower
lobe, new from prior exam (4:96).
The visualized portion of the upper abdomen shows no overt abnormality. The
visualized bones demonstrate no aggressive-appearing lytic or sclerotic
lesions.
IMPRESSION:
1. Multiple pulmonary nodules, new within the last month, as well as
bronchial wall thickening and scattered areas of mucus plugging, as described
above; despite the patient's immune status and lab results, these findings are
not typical for fungal pneumonia; findings are more consistent with viral or
early bacterial pneumonia.
2. Right pleural effusion tracking into the major and minor fissures with
drain in place.
Radiology Report
HISTORY: AIDS with recurrent right pleural effusion of unknown etiology and
history of Burkitt's and Hodgkin lymphoma in remission. Now with relative
hypoxia and elevated beta glycan.
TECHNIQUE: MDCT axial images were obtained from the dome liver to the pubic
symphysis after the uneventful administration of 100 mL of Omnipaque and oral
contrast. Coronal and sagittal reformations are provided and reviewed.
DLP: 383.30 mGy/cm.
COMPARISON: CT abdomen without contrast ___, PET CT ___
and chest CT ___.
FINDINGS:
CT abdomen: Again, the imaged lung bases demonstrate a moderate right
loculated pleural effusion. A Pleurx catheter is in place and courses along
the major fissure. Hyperdensity seen outlining the pleura likely relates to
prior pleurodesis. The previously described multiple pulmonary nodules and
bronchial wall thickening or not fully imaged on this study but are seen at
the left lung base. A small amount of unchanged atelectasis is seen at the
right lung base. The imaged portion the heart is top-normal in size.
Coronary calcifications are noted.
There are no focal liver lesions identified. The gallbladder is decompressed
and there is no intrahepatic biliary ductal dilation. The spleen is normal in
size. The pancreas and adrenal glands are unremarkable. The kidneys enhance
symmetrically history contrast without hydronephrosis. A 3.6 x 2.8 cm cyst in
the upper pole of the right kidney is unchanged. The stomach, large and small
bowel are normal. There is no retroperitoneal or mesenteric lymphadenopathy.
A small amount of calcifications are seen in otherwise normal-appearing aorta.
The portal vein appears patent. There is a small amount of subpulmonic and
perihepatic ascites.
CT pelvis: The bladder, rectum and prostate are normal. There is a small
amount of free pelvic fluid. The appendix is normal. There is no inguinal or
pelvic sidewall lymphadenopathy.
Pelvis: There are no suspicious osseous lesions.
IMPRESSION:
1. No change from most recent comparison studies.
2. Unchanged loculated right lung pleural effusion with evidence of a prior
pleurodesis and Pleurx catheter placement. The known and bronchial wall
thickening and pulmonary nodules were not fully imaged but appear similar at
the left lung base.
3. Unchanged amount of subpulmonic, perihepatic and pelvic free fluid.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: UPPER EXTREMITY PAIN
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.8
heartrate: 101.0
resprate: 16.0
o2sat: 96.0
sbp: 107.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | This is a ___ male w hx of AIDS, currently on 3TC,
abacavir, and boosted atazanavir; poorly controlled type 2 DM
complicated by nephropathy, neuropathy, and retinopathy, and not
currently on insulin therapy; Hodgkin's disease and Burkitt's
lymphoma, which are both currently in remission; cardiomyopathy
with congestive heart failure and recurrent right pleural
effusion, requiring a PleurX catheter drainage 3x weekly who
presents with irritation around the port site and admitted for
acute kidney injury, later developing hypoxia, cough and watery
diarrhea.
# ___: Resolved. Creatinine of 2.1 on admission which trend down
to baseline of 1.3 on torsemide. Most likely due to decreased
effective circulating volume in the setting of volume overload,
diffuse crackles, and trace edema bilaterally on admission.
Clinical exam improved upon discharge.
# Hypoxia: Patient found sating to 78% while sleeping after
receiving IVF for ___ and torsemide was held. Patient reported
non-adherence with atovaquone which raised the concern for a
possible Pneumocystis pneumonia. Patient re-started of
atovaquone prophylaxis, IVF discontinued, and torsemide
reinstated. Induced sputum sent out for PJP staining, bacterial
cultures, viral cultures, AFB culture, and fungal cultures.
Serum beta-glucan also sent. Patient saturation began to improve
once diuretic reinstated. Patient weaned off of O2 sating
92-94%RA with ambulation and 95-98%RA at rest. PJP staining and
all sputum cultures returned negative. Beta-glucan elevated to
355. ID consulted which recommended CT chest due to elevated
beta-glucan and possibility of indolent PJP infection. CT chest
did not show any acute process concerning for pneumonia. Repeat
beta-glucan pending.
# Persistent R pleural effusion: Persistent bloody pleural
effusion with 970RBC, 530WBC, 80%lymphs, 6%PMNs, 7%monos,
7%other. Protein 3.5, glucose 202, LDH 119, albumin 1.4. Patient
with pleurx catheter in place with 3x/week drainage. Concern was
for recurrence of heme malignancies vs HHV-8 infection causing
the persistent pleural effusion. Pleural studies sent including
fluid cx, anaerobic cx, fungal cx, AFB cx, viral cx for HHV-8,
immunophenotyping, cell block, and serum HHV-8. HHV8 from
pleural fluid could not be done. HHV8 serum pending. Atypical
lymphocytes in pleural fluid. Cell block and immunophenotyping
negative for malignant cells.
# AIDS: Last CD4 count 135 on ___. Last viral load
undetected on ___. Patient continued on home regimen:
lamivudine, ritonavir, abacavir, atazanavir. Atovaquone
restarted.
# Diarrhea: Resolved. Patient developed diarrhea during hospital
stay concerning for C. diff due to past history of C. diff
colitis. C. diff PCR negative. Stool cultures for included
cyclospora, microsporidia, cryptosporidium, giardia, ova,
parasites, Salmonella, Shigella, Campylobacter, and viral all
negative. Diarrhea resolved.
#Leukocytosis: Resolved. Patient developed leukocytosis of 11.3
on ___ and ___. UA, urine Legionella, urine histo, serum
crypto, galactomannam sent. Infectious workup of stool and urine
was unrevealing. Leukocytosis resolved, no source identified.
Repeat CBC recommended with PCP.
# Thrombocytosis: Resolving. Platelets elevated on admission and
continued to trend upward throughout admission, downtrending
upon discharge. Most likely an acute phase reactant in the
setting of infection of unknown etiology at this point. Repeat
CBC recommended with PCP.
# DM2: Patient on home glipzyde alone. Per PCP ___,
___ unwilling to self-administer insulin. Patient was
managed with 12L QHS and 4H with meals with ISS while in house.
Discharged home on glipizide. Follow up with PCP recommended for
monitoring.
# Hyponatremia: Resolved. Likely occurred in the setting of
volume overload, resolved with correction of volume status.
#CHF/cardiomyopathy: Chronic, stable during admission on
Torsemide 40mg PO daily.
#Portocath: Clinically does not appear infected, patient is
afebrile without systemic signs of infection. No flunctuance or
erythema. Per Heme/Onc, plan to remove portocath as outpatient.
# Hodgkin's/ Burkitt's lymphoma: currently in remission.
# Depression: continued on home citalopram and gabapentin.
Transitional Issues:
- follow up beta glucan
- repeat CBC
- monitor A1c, volume status
- monitor for home safety and need for additional assistance |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx HCV/EtOH cirrhosis, EtOH abuse, pancreatitis presenting
with abdominal pain, EtOH intoxication s/p assault presenting
with a chief complaint of epigastric abdominal pain and vomiting
ongoing for several months. He states his abdominal pain got
worse after his fight last night (hit in chest, face, abdomen).
The pain is described as "dull," constant, in the epigastrium,
nonradiating, and ranked a ___ in severity. He states alcohol
makes the pain worse; stopping drinking alcohol makes it better.
He has not tried any OTC's for pain relief. He denies
fevers/chills, hematemesis, coffee-ground emesis, dysuria,
hematuria, and new leg swelling.
In the ED, initial vitals were: T 98.9 P 85 BP 118/79 RR 17
SpO2 97% on RA
Exam notable for: dilated pupils, minimally reactive;
ecchymoses/edema of R eye; ecchymoses over R shoulder, with
limited mobility in all directions; large scrape over R ant shin
Labs showed: Thrombocytopenia to 73, leukopenia at 3.4, lipase
82, AST 113, ALT 47, and serum EtOH of 341.
Imaging showed:
CT torso (___):
1. No evidence of visceral organ injury. No acute fractures
identified. Compression deformity of T12 is unchanged from the
prior examination.
2. Cirrhotic liver with splenomegaly measuring up to 13 cm. No
free fluid
3. Moderately distended bladder.
CT spine (___):
No acute fracture or traumatic malalignment.
CT head (___):
No acute intracranial process. Mild soft tissue swelling
overlying the right parietal bone.
He was give thiamine, folate, and diazepam 10 mg x1.
Transfer VS were 98.5 135/87 64 18 97% on RA.
Based on review of lab data demonstrating thrombocytopenia,
decision was made to admit to medicine for further management.
On arrival to the floor, patient reports he has had some easy
bruising and bleeding (bleeds when he brushes his teeth
occasionally). He has not had any difficult-to-control
nosebleeds. His last drink of EtOH was yesterday evening; he
has had withdrawals from alcohol in the past, but never had a
seizure. He does not feel lightheaded or presyncopal. He does
not have any chest pain, SOB, or hallucinations
Past Medical History:
HCV
Cirrhosis
EtOH abuse
Aniridia
Social History:
___
Family History:
Aniridia. No early cardiac death.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.5 135/87 64 18 97%/RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD; ecchymosis & edema
surrounding OD
CARDIAC: Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
spleen tip palpable, liver edge not palpable.
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema; multiple abrasions across shins
SKIN: multiple ecchymoses scattered across body; no palmar
erythema, spider angiomata or caput medusa
NEUROLOGIC: face symmetric, gait not assessed, slight fine
tremor but no asterixis, slow horizontal nystagmus with minimal
pupillary reaction to light secondary to history of aniridia,
moves all extremities well, without difficulties; no slurring of
speech, fluent & logical speech
DISCHARGE EXAM:
Vitals: 98.0 141/89 59 20 100% RA
General: Alert and oriented to person, time, place. No acute
distress
HEENT: Sclera anicteric, minimal pupillary reaction to light
with history of aniridia, EOM intact with bilateral nystagmus.
Neck supple.
CV: Regular rate and rhythm, normal S1 + S2 with no murmurs,
rubs, or gallops.
Lungs: Clear to auscultation bilaterally with no wheezes, rales,
or rhonchi.
Abdomen: Soft, non-distended. Bowel sounds present. Subjective
diffuse tenderness to palpation. No rebound or guarding.
Tympanic to percussion in all four quadrants. No
hepatosplenomegaly appreciated.
GU: No foley
Ext: Warm, well perfused. R shoulder with limited active flexion
above 90 degrees and limited extension to ___ degrees.
Skin: No evidence of jaundice, palmar erythema, spider
angiomata, or caput medusa. No track marks observed. R frontal
abrasion, L occiput abrasion. Ecchymosis and edema over the R
eye. Ecchymosis over the R shoulder, eagle tattoo over R arm,
abrasions extending down R and L anterior shins. Scattered
ecchymoses in different stages of healing evident over all four
extremities.
Neuro: Speech fluent and logical with no slurring. No tremor or
asterixis. No protonator drift. Moves all extremities
purposefully without difficulty.
Pertinent Results:
ADMISSION LABS:
=================
___ 11:30PM BLOOD WBC-3.4*# RBC-3.57* Hgb-12.0* Hct-36.0*
MCV-101* MCH-33.6* MCHC-33.3 RDW-15.2 RDWSD-57.1* Plt Ct-73*#
___ 11:30PM BLOOD Neuts-33.7* Lymphs-53.1* Monos-11.1
Eos-0.9* Baso-0.9 Im ___ AbsNeut-1.15*# AbsLymp-1.81
AbsMono-0.38 AbsEos-0.03* AbsBaso-0.03
___ 06:52AM BLOOD ___ 11:30PM BLOOD Glucose-87 UreaN-8 Creat-0.8 Na-142 K-3.8
Cl-105 HCO3-28 AnGap-13
___ 11:30PM BLOOD ALT-47* AST-113* AlkPhos-113 TotBili-0.7
___ 11:30PM BLOOD Lipase-82*
___ 11:30PM BLOOD Albumin-4.0
___ 11:30PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
RELEVANT INPATIENT LABS:
========================
___ 11:30PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Negative
___ 11:30PM BLOOD HCV Ab-Positive*
___ 06:52AM BLOOD HIV Ab-Negative
___ 11:30PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Negative
___ 11:30PM BLOOD TSH-0.95
___ 06:52AM BLOOD ALT-40 AST-81* LD(LDH)-234 AlkPhos-115
TotBili-1.9*
IMAGING STUDIES:
================
___ CT HEAD W/O CONTRAST
1. Mild soft tissue swelling overlying the right parietal bone.
2. No acute intracranial process.
___ CT C-SPINE W/O CONTRAST
No acute fracture or traumatic malalignment.
___ GLENO-HUMERAL/SHOULDER XR
No acute fracture or dislocation.
___ CT CHEST/ABDOMEN/PELVIS W/ CONTRAST
1. No evidence of visceral organ injury. No acute fractures
identified.
Compression deformity of T12 is unchanged from the prior
examination.
2. Cirrhotic liver with splenomegaly measuring up to 13 cm. No
free fluid.
3. Moderately distended bladder.
DISCHARGE LABS:
===============
___ 06:52AM BLOOD WBC-3.0* RBC-3.76* Hgb-12.7* Hct-38.1*
MCV-101* MCH-33.8* MCHC-33.3 RDW-14.7 RDWSD-54.9* Plt Ct-48*
___ 06:52AM BLOOD Neuts-52.9 ___ Monos-14.0*
Eos-3.7 Baso-1.0 Im ___ AbsNeut-1.58*# AbsLymp-0.84*
AbsMono-0.42 AbsEos-0.11 AbsBaso-0.03
___ 06:52AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-135
K-4.2 Cl-100 HCO3-26 AnGap-13
___ 06:52AM BLOOD ALT-39 AST-74* AlkPhos-112 TotBili-1.6*
DirBili-0.5* IndBili-1.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Thrombocytopenia
Alcohol Withdrawal
Alcoholic Gastritis
Secondary:
Cirrhosis
Hepatitis C
Macrocytic Anemia
Leukopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT torso
INDICATION: ___ with ETOH and reports assault with chest and abdom pain //
ETOH and reports assault with chest and abdom pain
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.8 s, 68.9 cm; CTDIvol = 9.7 mGy (Body) DLP = 668.9
mGy-cm.
Total DLP (Body) = 669 mGy-cm.
COMPARISON:
CT on ___
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver shows a nodular contour consistent with cirrhosis.
No focal hepatic lesions are seen. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder shows cholelithiasis without
evidence of cholecystitis.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring up to 13 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. There is no
evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder is moderately distended. There is no free fluid
in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted. Note is made of paraesophageal
varices.
BONES: There is no acute fracture. T12 compression deformity is stable from
___. No focal suspicious osseous abnormality. A bone island in the right
sacrum is stable.
SOFT TISSUES: There is a small fat containing inguinal hernia
IMPRESSION:
1. No evidence of visceral organ injury. No acute fractures identified.
Compression deformity of T12 is unchanged from the prior examination.
2. Cirrhotic liver with splenomegaly measuring up to 13 cm. No free fluid.
3. Moderately distended bladder.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, ETOH
Diagnosed with Alcohol abuse with intoxication, unspecified
temperature: 98.9
heartrate: 85.0
resprate: 17.0
o2sat: 97.0
sbp: 118.0
dbp: 79.0
level of pain: 8
level of acuity: 3.0 | This is a ___ year old man with alcohol abuse & etOH/HCV
cirrhosis who presented post-assault, complaining of abdominal
pain, consistent with alcoholic gastritis. He was also found to
have thrombocytopenia without bleeding.
ACTIVE ISSUES
==========================
# ALCOHOL WITHDRAWAL: Pt requested detoxification while
inpatient. He received a total of two doses of diazepam. He
had an uncomplicated withdrawal. He was given IV thiamine,
folate and multivitamin while in house. He was discharged with
oral thiamine, folate, and multivitamin supplements. He was
referred to the ___ Clinic for further substance abuse
counseling.
# ALCOHOLIC GASTRITIS: improved with etOH abstinence and
pantoprazole.
# CIRRHOSIS: secondary to etOH and HCV. New diagnosis for
patient. No prior hepatologist. HCV VL pending. HBV non-immune
(given vaccine #1 while in house). He had no ascites or hepatic
encephalopathy.
# THROMBOCYTOPENIA: likely secondary to cirrhosis, given EtOH
use and HCV. No active bleeding while inpatient.
# MACROCYTIC ANEMIA: B12 & folate deficiencies likely given EtOH
intake, though cirrhosis and direct marrow toxicity of EtOH also
possible. Negative hemolytic workup. Discharged with B12 and
folate supplements.
# TRAUMA: patient in fight prior to arrival & sustained multiple
soft tissue injuries & ecchymoses. Full body scan without
evidence of severe injury. Given low dose APAP & oxycodone while
in house.
# LEUKOPENIA: predominantly neutropenia, with ANC 1150. Suspect
related to cirrhosis & etOH. No evidence of lymphopenia. HCV
infection also possible contributor. HCV VL pending.
# HEPATITIS C: no history of treatment. HCV VL pending. Will
need outpatient hepatology follow up.
=======================================
TRANSITIONAL ISSUES
=======================================
# ETOH USE DISORDER: to follow up at ___ for
abstinence counseling
# CIRRHOSIS: no hepatology follow up. Will need hepatology
follow up as well as EGD to evaluate for varices.
# HEPATITIS B IMMUNIZATIONS: series begun ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
ERCP with stone extraction ___: Laparoscopic Cholecystectomy
History of Present Illness:
This patient is a ___ year old female who complains of N/V.
She has prior episode x2 of choledocholithiasis, status post
ERCP with sphincterotomy 1021. She was supposed to followup
with surgery to schedule elective cholecystectomy, but did
not make the appointment. She has had an episode of right
upper quadrant abdominal pain associated with nausea and one
episode of nonbloody nonbilious emesis this afternoon,
reminiscent of prior biliary pain. No fevers or chills. No
other complaint
Past Medical History:
choledocholithiasis
Social History:
___
Family History:
mom w/DM
Physical Exam:
ADMISSION EXAM:
Vitals: T P BP RR SaO2
GEN: NAD, comfortable appearing
HEENT: ncat anicteric MMM
NECK:
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
ABD: +bs, soft, NT, ND, no guarding or rebound
back:
GU:
EXTR:no c/c/e 2+pulses
DERM: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
DISCHARGE EXAM:
VS: 98.2, 54, 113/54, 20, 97%ra
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended. Incisions: clean, dry and intact,
dressed and closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
ADMISSION LABS:
___ 04:35PM URINE HOURS-RANDOM
___ 04:35PM URINE HOURS-RANDOM
___ 04:35PM URINE UCG-NEGATIVE
___ 04:35PM URINE GR HOLD-HOLD
___ 04:35PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-2* PH-7.0 LEUK-NEG
___ 04:19PM LACTATE-1.7
___ 04:00PM GLUCOSE-116* UREA N-6 CREAT-0.9 SODIUM-136
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
___ 04:00PM estGFR-Using this
___ 04:00PM ALT(SGPT)-91* AST(SGOT)-71* ALK PHOS-116* TOT
BILI-3.2*
___ 04:00PM LIPASE-40
___ 04:00PM ALBUMIN-4.1
___ 04:00PM WBC-6.0# RBC-4.72 HGB-14.6 HCT-42.6 MCV-90
MCH-30.9 MCHC-34.3 RDW-12.8 RDWSD-42.3
___ 04:00PM NEUTS-90.4* LYMPHS-5.1* MONOS-4.0* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-5.44# AbsLymp-0.31* AbsMono-0.24
AbsEos-0.00* AbsBaso-0.01
___ 04:00PM PLT COUNT-194
===================
ADMISSION
RUQ US:
IMPRESSION:
1. Cholelithiasis without evidence of acute cholecystitis.
2. Pneumobilia, as expected post sphincterotomy.
3. No biliary duct dilation.
==========================
MRCP ___
IMPRESSION:
1. 4 mm stone in the common bile duct just superior to the
ampulla with
associated mild biliary duct dilation.
2. Cholelithiasis, including a small cluster the stone is in
the cystic duct.
No MRI evidence of cholecystitis.
___ ERCP
Evidence of a previous sphincterotomy that is stenosed was noted
in the major papilla.
Many stones ranging in size from 5 mm to 8 mm were seen at the
lower third and middle third of the common bile duct.
Otherwise normal biliary tree,
No filling of the gallbladder was noted.
A 8mm balloon was introduced for dilation and the diameter was
progressively increased to 10 mm successfully in the major
papilla .
Multiple stones (7 - 8) extracted successfully using a balloon.
No filling defects on occlusion cholangiogram.
Given plan for CCY tomorrow, stent was not placed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholelithiasis
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ woman with RUQ pain, history of choledocholithiasis
s/p sphincterotomy 1 month ago
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
There is pneumobilia in the intrahepatic and common bile duct, as expected
post sphincterotomy.
GALLBLADDER: There are small shadowing gallstones. There is no gallbladder
distention, wall thickening, or pericholecystic fluid.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
IMPRESSION:
1. Cholelithiasis without evidence of acute cholecystitis.
2. Pneumobilia, as expected post sphincterotomy.
3. No biliary duct dilation.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with Calculus of bile duct w/o cholangitis or cholecyst w/o obst
temperature: 98.0
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 71.0
level of pain: 7
level of acuity: 3.0 | ___ y/o female with recurrent choledocholithiasis admitted for
cholelithiasis and cholangitis. She was started on IV unasyn
and underwent an ERCP on ___ with removal of several stones.
The patient was then transferred to the Acute Care Surgery
service for definitive management of her symptomatic
cholelithiasis. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating sips, on IV fluids, and PO pain meds for pain
control. The patient was hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
.. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Neurontin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy
___ EGD
___ EGD nasojejeunal placed and bridled (removed ___ CT-guided placement of an ___ pigtail catheter into
the lesser sac collection. (removed ___
PICC placement.
History of Present Illness:
___ man with multiple recent admissions for waxing
and waning abdominal pain, history of EtOH/hep C cirrhosis, now
presents with 24 hours of acutely worsening epigastric pain
associated with multiple episodes of emesis and dark stools.
Patient states that his abdominal pain was at its baseline
yesterday at which point he noticed an acute worsening of his
pain that he describes as sharp and in his upper abdomen. He
also had several episodes of emesis, reporting his vomit as
being
dark brown in character. Decided to re-present to ED for
reevaluation of abdominal pain given acute worsening status.
Most recently presented to the ED over the weekend where he got
a
CT abdomen pelvis that did not show any acute interval changes
compared to prior scans. Was discharged home with expectant
management, transplant surgery was not consulted at that time.
Now, underwent repeat CT scan showing free air and fluid in the
lesser sac concerning for gastric perforation. Transplant
surgery is consulted for surgical management of this disease.
ROS:
(+) per HPI
Past Medical History:
- Hepatitis C (genotype 3)
- Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic
encephalopathy, portal hypertension with ascites and esophageal
varices, portal hypertensive gastropathy
- Gastric & Duodenal ulcers
- Insomnia
- Umbilical hernia
- Sacral osteoarthritis
Past Surgical History:
- Umbilical hernia repair (___)
-SBO requiring Ex lap & repair of ruptured umbilical hernia
with lysis of adhesions (___)
- Abdominal Hematoma evacuation (___)
- Abdominal incision opened, wound vac placed (___)
Social History:
___
Family History:
Sister and brother both with "collapsed lungs." No family
history of liver disease.
Physical Exam:
Admission Physical Exam:
=========================
Vitals: T 97.8 HR 96 BP 145/79 RR 20 100 RA
GEN: A&O, uncomfortable appearing
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Firm, tender to percussion in the epigastric region,
guarding present, moderately distended, no fluid wave
DRE: Deferred
Neuro: CSM grossly intact x 4
Ext: No ___ edema, UE and ___ warm and well perfused bilat
Discharge Physical Exam:
=========================
VS:97.5 95/56 65 18 99 Ra
GENERAL: cachectic appearing older male, sitting up in bed, more
conversant and interactive today.
HEENT: anicteric sclera, temporal muscle wasting
Neck: supple
HEART: irregular rhythm, no m/r/g
LUNGS: CTAB on anterior exam
ABDOMEN: protuberant but soft, +BS, tenderness to palpation
in right upper quadrant, midline surgical incision with staples
removed, well healed, dressing over RLQ with drain place
draining
dark brown serosanguineous fluid
EXTREMITIES: no lower extremity edema, no clubbing or cyanosis
SKIN: no jaundice, warm and dry
NEURO: alert, oriented, no asterixis, moving all extremities
Pertinent Results:
Admission Labs: ___ 02:35AM
================
WBC-15.9*# RBC-3.39* Hgb-11.7* Hct-35.5* MCV-105* MCH-34.5*
MCHC-33.0 RDW-14.7 RDWSD-56.3* Plt ___ PTT-29.5 ___
Glucose-122* UreaN-15 Creat-0.5 Na-134* K-4.3 Cl-97 HCO3-22
AnGap-15
ALT-24 AST-63* AlkPhos-92 TotBili-2.5*
Lipase-24
Calcium-6.8* Phos-3.7 Mg-1.7
Triglyc-36
Microbiology
============
Blood Culture, Routine (Final ___: NO GROWTH.
HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY
EIA.(Reference Range-Negative).
___ 7:44 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Imaging:
=========
CT Abdomen Pelvis ___
IMPRESSION:
1. Free air and increased fluid within the lesser sac concerning
for
perforated viscus, which could be from the stomach based on
location.
2. Mildly dilated small bowel bowel a transition point. This
could represent ileus versus partial small bowel obstruction.
No initial in of the bowel or pneumatosis.
3. Cirrhotic liver with findings of portal hypertension
including varices and ascites.
Upper GI Contrast Study: ___
IMPRESSION: Leak of contrast from the posterior antrum of the
stomach.
CXR: ___
COMPARISON: ___
IMPRESSION: Pulmonary edema has slightly worsened.
Cardiomediastinal silhouette is stable. Left-sided PICC line is
unchanged the NG tube projects below the left hemidiaphragm.
Small bilateral effusions left greater than right are
unchanged. No pneumothorax is seen
CT Abdomen Pelvis ___
IMPRESSION:
1. A 8.5 x 5.9 cm loculated fluid collection with rim
enhancement in the
lesser sac is identified. Compared to ___, the fluid
collection
demonstrates thicker and more discrete wall.
2. Small ascites and peritonitis is similar to before.
3. Liver cirrhosis with mild splenomegaly and portosystemic
shunt.
4. Small bilateral pleural effusions.
CT Abdomen for Interventional Procedure: ___
IMPRESSION: Successful CT-guided placement of an ___
pigtail catheter into the lesser sac collection. Samples were
sent for microbiology evaluation.
Abdominal Ultrasound ___:
IMPRESSION: No fluid pocket amenable to percutaneous sampling.
A diagnostic paracentesis was not performed.
Transfer Labs: ___ 06:32AM
===============
WBC-5.0 RBC-2.99* Hgb-9.7* Hct-31.0* MCV-104* MCH-32.4*
MCHC-31.3* RDW-17.1* RDWSD-64.6* Plt ___ PTT-28.8 ___
Glucose-108* UreaN-15 Creat-0.5 Na-137 K-4.5 Cl-106 HCO3-24
AnGap-7*
ALT-18 AST-58* AlkPhos-194* TotBili-1.2
Albumin-2.2* Calcium-7.3* Phos-2.6* Mg-1.8
Discharge Labs: ___ 05:55AM
===============
WBC-4.2 RBC-2.72* Hgb-9.0* Hct-28.7* MCV-106* MCH-33.1*
MCHC-31.4* RDW-16.6* RDWSD-65.1* Plt ___
Glucose-97 UreaN-14 Creat-0.5 Na-136 K-4.8 Cl-105 HCO3-21*
AnGap-10
ALT-19 AST-59* AlkPhos-198* TotBili-1.2
Albumin-2.1* Calcium-7.3* Phos-2.6* Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Lactulose 30 mL PO QID
4. Spironolactone 50 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis
6. Polyethylene Glycol 17 g PO DAILY
7. Bisacodyl ___AILY:PRN constipation
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
9. Multivitamins 1 TAB PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. Simethicone 40-80 mg PO TID:PRN gas pain
12. Thiamine 100 mg PO DAILY
13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
Discharge Medications:
1. Acetaminophen 500 mg NG Q6H
2. Lidocaine 5% Patch 1 PTCH TD QAM
apply to abdomen
remove in pm
3. OxyCODONE SR (OxyconTIN) 20 mg PO TID abdominal pain
RX *oxycodone 5 mg/5 mL 20 mL by mouth three times a day
Refills:*0
4. Simethicone 40-80 mg PO TID:PRN gas pain
5. Sucralfate 1 gm PO QID
6. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
7. OxyCODONE (Immediate Release) 10 mg PO Q2H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg/5 mL 10 mL by mouth every 2 hours Refills:*0
8. Bisacodyl ___AILY:PRN constipation
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
10. Lactulose 30 mL PO TID
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Gastric perforation, frozen abdomen.
Duodenal ulcer
Esophagitis
SECONDARY DIAGNOSES:
portal hypertensive gastropathy
anemia
malnutrition
Cirrhosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with abd pain and chest pain// ?infection ?edema
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___ and ___.
FINDINGS:
No focal consolidation to suggest pneumonia. There is an 8 mm right lower
lung opacity which is not definitively seen on lateral view. The pulmonary
vasculature is unremarkable. Small right pleural effusion is again noted. No
pneumothorax. Mediastinal silhouette is unchanged. No acute osseous
abnormalities.
IMPRESSION:
1. Unchanged small right pleural effusion. No additional acute
cardiopulmonary process.
2. 8 mm right lower lung opacity is not definitively seen on lateral view.
This could represent a nipple shadow. Rib view radiograph performed for
further evaluation of the location the opacity.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with abd pain and chest painNO_PO
contrast// ?infection ?edema
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 5.0 s, 54.4 cm; CTDIvol = 6.2 mGy (Body) DLP = 334.4
mGy-cm.
Total DLP (Body) = 349 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrate cirrhotic morphology. There is no
evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent. Again
seen is moderate amount of ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. There is a 1.3 cm accessory spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis in either kidney. Multiple hypoattenuating lesion
measuring up to 3.6 cm in the interpolar region of the right kidney and 2.1 cm
in the interpolar region of the left kidney consistent with cysts are
unchanged. There is no perinephric abnormality.
GASTROINTESTINAL: The gastric wall along lesser curvature is thinned. The
small bowel appears mildly dilated without a transition point this could
represent ileus or partial small bowel obstruction. There are foci free air
adjacent to the liver (series 2, image 21). Free air is also seen in the
lesser sac (series 2, image 31) with increased fluid compared to ___. Constellation of findings is concerning for perforated viscus which
could be from the stomach based on location. The colon and rectum are
unremarkable. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: Unchanged prominent retroperitoneal lymph nodes, measuring up to
10 mm (series 2, image 34). No mesenteric lymphadenopathy. There is no
pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted. There are esophageal varices and splenorenal shunts.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are multilevel degenerative changes of the lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Free air and increased fluid within the lesser sac concerning for
perforated viscus, which could be from the stomach based on location.
2. Mildly dilated small bowel bowel a transition point. This could represent
ileus versus partial small bowel obstruction. No initial in of the bowel or
pneumatosis.
3. Cirrhotic liver with findings of portal hypertension including varices and
ascites.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 5:38 am, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ with ? perforated viscus, s/p NGT placement// Please assess
NGT position
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___ at 03:01.
FINDINGS:
Since prior, there has been interval placement of an enteric tube with tip in
the left upper quadrant, side-port past the GE junction. There is new
retrocardiac atelectasis, otherwise, no change. Small right pleural effusion.
IMPRESSION:
Enteric tube in appropriate position.
Radiology Report
INDICATION: ___ year old man with upper GI series with small bowel follow
through to evaluate for SBO// upper GI series with small bowel follow through
to evaluate for SBO
TECHNIQUE: Single contrast upper GI.
DOSE: Acc air kerma: 46 mGy; Accum DAP: 919.4 uGym2; Fluoro time: 02:03
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
50 cc Water-soluble contrast (Optiray) was administered with the patient semi
upright.
Contrast passed freely through the esophagus into the stomach. In left
lateral decubitus positioning, contrast pooled within the body and fundus, but
with progressive repositioning to supine and right lateral positions, a focal
collection of contrast was seen in the posterior antrum which leaked out of
the stomach into the likely lesser sac.
IMPRESSION:
Leak of contrast from the posterior antrum of the stomach.
NOTIFICATION: The findings were discussed with ___, NP by ___
___, M.D. In person on ___ at 2:30 pm, 2 minutes after discovery of
the findings.
Radiology Report
INDICATION: ___ year old man with new NGT post op// confirm NGT
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
The tip of the nasogastric tube projects over the stomach. Skin staples are
seen over the upper abdomen at midline.
There is no focal consolidation, pleural effusion or pneumothorax identified.
The size of the cardiomediastinal silhouette is within normal limits.
IMPRESSION:
The tip of the nasogastric tube projects over the stomach.
Radiology Report
EXAMINATION: Portable AP chest radiograph.
INDICATION: ___ year old man with left PICC// left 41cm PICC ___ ___
Contact name: ___: ___
TECHNIQUE: AP chest x-ray
COMPARISON: ___
FINDINGS:
A left PICC is seen terminating in the level of the mid SVC. A nasogastric
tube is seen with the proximal port within the body of the stomach. An
intra-abdominal drain is unchanged in position from previous. Midline
abdominal surgical staples are stable.
There is no pneumothorax. Small right pleural effusion is mildly improved.
There is bibasilar atelectasis. No pulmonary edema.
Heart size and mediastinal contour are unchanged.
IMPRESSION:
1. Left PICC terminating in the mid SVC.
2. Small right pleural effusion with bibasilar atelectasis.
Radiology Report
INDICATION: ___ year old man w/ cirrhosis, contained duodenal perf, p/w poor
oxygenation// ? pulmonary pathology such as worsening pleural effusions, PNA,
aspiration
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Pulmonary edema has slightly worsened. Cardiomediastinal silhouette is
stable. Left-sided PICC line is unchanged the NG tube projects below the left
hemidiaphragm. Small bilateral effusions left greater than right are
unchanged. No pneumothorax is seen
Radiology Report
EXAMINATION: Chest single view
INDICATION: ___ year old man with NGT now putting out blood// depth of NGT?
TECHNIQUE: Chest portable AP
COMPARISON: ___
FINDINGS:
The distal portion of the NG tube appears in the body of the stomach with the
side hole just past the EG junction.
There has been increased the pulmonary vascular congestion compared to the
previous exam and the pulmonary edema. Left effusion unchanged. Left-sided
PICC line is unchanged with its tip in the upper SVC.
IMPRESSION:
NG tube in stomach. Increased pulmonary edema.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with stomach ulcer perforation now had PICC
repositioned.// PICC placement
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___.
IMPRESSION:
Compared to the examination from 1 day prior, the left-sided PICC has been
advanced and now terminates in the upper SVC, satisfactory. Mild cardiomegaly
is unchanged. There remains central pulmonary vascular congestion with
moderate asymmetric pulmonary edema, more severe on the right, though this
appears slightly improved as compared to the prior examination. The upper
enteric tube has been intervally removed. There remain tiny right greater
than left pleural effusions. No new dense consolidation is seen. There is no
pneumothorax.
Radiology Report
INDICATION: ___ year old man w/a frozen abd ___ multiple abd surgeries, p/w
abd pain c/w perforated duodenal ulcer.// 1. re-eval new onset of pain after
1wk of NPO 2. ?window to his stomach for possible transgastric GJ tube.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.9 s, 51.2 cm; CTDIvol = 9.6 mGy (Body) DLP = 491.7
mGy-cm.
2) Stationary Acquisition 6.1 s, 0.5 cm; CTDIvol = 30.5 mGy (Body) DLP =
15.2 mGy-cm.
Total DLP (Body) = 507 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: Bilateral pleural effusions are small, right larger than left.
Adjacent atelectases of bilateral lower lobes are. Right pleural thickening
is noted.
ABDOMEN:
Right upper abdominal drain terminates underneath the anterior abdominal wall.
Small ascites and peritoneal thickening is similar to before.
A 8.5 x 5.9 cm loculated fluid collection with multiple air-fluid levels and
rim enhancement is identified in the lesser sac, posterior to the stomach.
Small portion of the fluid collection extends superiorly along the medial
surface of the caudate lobe. Previously, the fluid collection measured 10.1 x
3.2 cm with the wall appearing less conspicuous.
HEPATOBILIARY: Heterogeneous attenuation of liver segment 7 and 8 are
unchanged. Liver demonstrates cirrhotic morphology. There is no evidence of
focal lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Mild splenomegaly measures 13.6 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral hypodense lesions measuring up to 3.8 cm are consistent with simple
renal cysts. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized.
PELVIS: Bladder is unremarkable.
REPRODUCTIVE ORGANS: Prostate is unremarkable.
LYMPH NODES: Mildly enlarged mesenteric lymph nodes measuring up to 1.1 cm
(02:27) are likely reactive.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted. Splenorenal and esophageal varices are again noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Anterior abdominal midline skin staples are noted.
IMPRESSION:
1. A 8.5 x 5.9 cm loculated fluid collection with rim enhancement in the
lesser sac is identified. Compared to ___, the fluid collection
demonstrates thicker and more discrete wall.
2. Small ascites and peritonitis is similar to before.
3. Liver cirrhosis with mild splenomegaly and portosystemic shunt.
4. Small bilateral pleural effusions.
NOTIFICATION: Impression 1. was discussed with ___, M.D. by ___
___, M.D. in person on ___ at 12:30pm, at the time of discovery of the
findings.
Radiology Report
INDICATION: ___ year old man with cirrhosis and a frozen abdomen, now with
perforated stomach ulcer leading to a fluid collection.// Abdomen, posterior
to stomach, 8cm fluid collection. Spoke with Dr. ___.
COMPARISON: CT from ___
PROCEDURE: CT-guided drainage of lesser sac collection.
OPERATORS: Dr. ___ radiologist.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The metal stiffener and the wire
were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 30 cc of hemorrhagic fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.2 s, 19.1 cm; CTDIvol = 10.1 mGy (Body) DLP = 187.1
mGy-cm.
2) Stationary Acquisition 4.0 s, 1.4 cm; CTDIvol = 41.4 mGy (Body) DLP =
59.6 mGy-cm.
Total DLP (Body) = 256 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
0.75 mg Versed and 37.5 mcg fentanyl throughout the total intra-service time
of 15 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Bilateral moderate pleural effusions. Moderate amount of ascites. Cirrhotic
liver.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the lesser
sac collection. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old man with worsening abdominal pain, fluid collection
post-ulcer rupture.// Please evaluate for spontaneous bacterial peritonitis
with diagnostic.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT scan of the abdomen and pelvis dated ___.
FINDINGS:
Focused ultrasound of the abdomen demonstrated trace ascites interspersed
between loops of bowel with no fluid pocket amenable to percutaneous sampling,
therefore a diagnostic paracentesis was not performed.
IMPRESSION:
No fluid pocket amenable to percutaneous sampling. A diagnostic paracentesis
was not performed.
NOTIFICATION: Findings were conveyed to the clinical team by telephone at
13:40, ___.
Gender: M
Race: PORTUGUESE
Arrive by AMBULANCE
Chief complaint: Chest pain, N/V
Diagnosed with Epigastric pain, Chest pain, unspecified
temperature: 98.8
heartrate: 106.0
resprate: 20.0
o2sat: 100.0
sbp: 163.0
dbp: 103.0
level of pain: 8
level of acuity: 2.0 | Summary:
---------
Mr ___ is a ___ man with alcoholic and hepatitis C
cirrhosis who presented with abdominal pain, and was found to
have a perforated inoperable duodenal and stomach ulcer. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left lower quadrant pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo G7P2 with +HCG (LMP ___ and LLQ pain presented to ED
from the office for r/o ectopic evaluation. Patient presented to
___ ED night prior where she was found to have unplanned
pregnancy with +HCG. She was managed with percocet and sent for
f/u in the office. On the day of admission she reports that she
had ___ lower abd pain while in the office and +nausea. She has
also had spotting.
Per Dr. ___ "US at ___ showed a ~11 x 6 x 8 cm uterus
without any IUP. Both ovaries contained 'normal-appearing
follicles'. 'A tubular structure near the left ovary is likely
an adjacent fallopian tube or a loop of small bowel'. " HCG 963
at ___ per atrius note
Past Medical History:
ObHx: ___
- G1: TAb
- G2: TAb
- G3: IOL PEC, 5#14, late preterm
- G4: SAb
- G5: SVD, full term, 7#12
- G6: SAb
GynHx:
- h/o abn pap in ___ adn ___, s/p colpo
- h/o CT in ___, s/p tx
- qmonthly cycles
- not using any contraception
PMH:
- Bipolar disorder: recent suicide attempt, OD in ___ not
on
meds
- ___ disease: now resolved
- Obesity BMI=36
PSHx: tonsillectomy, LSC cholecystectomy ___
Social History:
___
Family History:
Non contributory
Physical Exam:
PE on admission
T-98.4 HR-89 BP-107/63 RR-15 O2-99% RA
Gen: NAD
CV: RRR
Pulm: CTAB
Abd: soft, minimal LLQ tenderness, no rebound or guarding,
nondistended, obese
Pelvic: normal appearing external genitalia, inner labial folds.
Bimanual exam revealed small, mobile anteverted uterus. No CMT.
Minimal left adnexal tenderness. No masses appreciated. Scant
light brown blood on glove.
Ext: nontender
On day of discharge
GEN: NAD
CV: RRR
PULM: CTABL
ABD: soft, obese, ND, mildly tender in LLQ, no rebound, no
gaurding
EXT: wnl
Pertinent Results:
___ 07:50PM HCG-979
___ 07:18PM WBC-6.7 RBC-4.31 HGB-12.0 HCT-35.3* MCV-82
MCH-27.7 MCHC-33.9 RDW-13.3
___ 07:50PM GLUCOSE-78 UREA N-7 CREAT-0.6 SODIUM-141
POTASSIUM-3.3 CHLORIDE-108 TOTAL CO2-25 ANION GAP-11
___ 07:18PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:18PM URINE RBC-2 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-7
___ 07:18PM URINE MUCOUS-MOD
___ 10:57AM BLOOD WBC-6.3# RBC-3.79* Hgb-10.8* Hct-31.0*
MCV-82 MCH-28.5 MCHC-34.8 RDW-12.8 Plt ___
___ 07:00AM BLOOD HCG-1471
PELVIC ULTRASOUNDS:
___
FINDINGS: The uterus measures 4.3 x 6.8 x 7.1 cm. No focal
lesions are
identified. The endometrial thickness is 1.3 cm. No
gestational sac is seen
within the endometrial canal. The right and left ovaries are
unremarkable. A
corpus luteum is seen in the right ovary. There is trace simple
appearing
pelvic free fluid, within physiologic range.
IMPRESSION: No evidence of IUP. The differential diagnosis is
early
pregnancy, too early to visualize, miscarriage, cannot rule out
ectopic.
___
COMPARISON: ___.
FINDINGS:
LMP: ___
There is no visualized intrauterine pregnancy. The ovaries are
normal. There
is a corpus luteum noted on the right. There is trace free
fluid.
IMPRESSION:
No definite IUP. The differential diagnosis is early pregnancy,
too early to
visualize, miscarriage, cannot rule out ectopic. Requires
follow up with
serial bHCG levels.
Results were called to Dr. ___ at the time of the
scan at 9:40
am by telephone by ___, ___. The patient was an
inpatient at ___.
Medications on Admission:
none
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not drive or take with alcohol
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*12 Tablet
Refills:*0
2. Acetaminophen ___ mg PO Q6H:PRN pain
do not take over 4000mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth Q6H:PRN Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cannot rule out ectopic pregnancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with left lower quadrant pain and bleeding
since this afternoon, with an approximately six weeks of pregnancy.
COMPARISON: None available.
TECHNIQUE: Grayscale and color Doppler images of the pelvic organs were
obtained with a transabdominal approach followed by transvaginal approach for
better assessment of the uterus and adnexa.
LMP: ___
FINDINGS: The uterus measures 4.3 x 6.8 x 7.1 cm. No focal lesions are
identified. The endometrial thickness is 1.3 cm. No gestational sac is seen
within the endometrial canal. The right and left ovaries are unremarkable. A
corpus luteum is seen in the right ovary. There is trace simple appearing
pelvic free fluid, within physiologic range.
IMPRESSION: No evidence of IUP. The differential diagnosis is early
pregnancy, too early to visualize, miscarriage, cannot rule out ectopic.
These findings were communicated immediately after discovery by Dr ___ to Dr
___ on ___ at 9:30 pm via phone.
Radiology Report
HISTORY: Left lower quadrant pain ; positive HCG
HCG level of 979 on ___ ; HCG level pending drawn today.
TECHNIQUE: Transabdominal and transvaginal scans of the pelvis were obtained.
The transvaginal scan is performed to better assess the endometrial contents
and the adnexae.
COMPARISON: ___.
FINDINGS:
LMP: ___
There is no visualized intrauterine pregnancy. The ovaries are normal. There
is a corpus luteum noted on the right. There is trace free fluid.
IMPRESSION:
No definite IUP. The differential diagnosis is early pregnancy, too early to
visualize, miscarriage, cannot rule out ectopic. Requires follow up with
serial bHCG levels.
Results were called to Dr. ___ at the time of the scan at 9:40
am by telephone by ___, RDMS. The patient was an inpatient at 12
Reismann.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: LLQPAIN,R/O ECTOPIC
Diagnosed with HEM EARLY PREG-ANTEPART, OTH CURR COND-ANTEPARTUM, ABDOMINAL PAIN OTHER SPECIED
temperature: 98.8
heartrate: 82.0
resprate: 16.0
o2sat: 98.0
sbp: 117.0
dbp: 63.0
level of pain: 9
level of acuity: 2.0 | On ___, Ms. ___ was admitted to the gynecology
service after for management of a possible ectopic pregnancy.
She remained stable during her stay and her pain was well
controlled with oral medications. Two hCG levels were drawn (see
labs section) and two ultrasounds were performed that could not
identify the location of the pregnancy. Since she was stable and
without acute or severe pain she was counseled to follow up as
an outpatient 2 days after discharge or sooner if she developed
severe pain, bleeding, or feeling faint. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / aspirin / Bactrim / vancomycin / chocolate flavor
Attending: ___.
Chief Complaint:
Nausea
Vomiting
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o stage 4 pancreatic cancer, last chemotherapy last week,
now presents with abdominal pain, nausea and vomiting with
dehydration and diarrhea since chemo treatment. No BRBRP or
melena. No fevers or chills. No chest pain or
cough. Has chronic abdominal pain with no significant acute
changes. No flank pain or UTI symptoms. No CP/SOB, HA, stiff
neck, rash or focal weakness, numbness or tingling. No syncope.
c/o fatigue and generalized weakness.
In the ED, hemodynamically stable, s/p 3L NS, morphine 4mg IV x2
and Zofran. Pain improved on serial exams in the ER after
treatment. No evidence of acute abdomen or obstruction. ED spoke
with primary oncologist who recommended holding off on CT (had
recent imaging within several weeks) and holding off on
antibiotics at this point.
Of note, she was hospitalized in ___ for diarrhea. CT
showed small intesintal edema concerning for ischemia in the SMV
distribution. She was started on enoxaparin, which was stopped
in ___ as patient stated she couldn't continue
self-administering. During that admission she was treated
presumptively for SBP with 14-day course of cipro/flagyl. She
started FOLFOX ___, oxaliplatin held for the first dose but
added after her first infusion. S/p C3D14 of Folfox on ___.
On arrival to the floor, patient complains of mild abdominal
pain which improved with Morphine, continues to have diarrhea.
No fevers, chills, CP, difficulty breathing
REVIEW OF SYSTEMS: Per HPI
Past Medical History:
1. Extensive peripheral vascular disease status post multiple
stents and bypass graft.
2. Hypertension.
3. Hyperlipidemia.
4. Discoid lupus.
5. History of AVMs.
6. Homocysteinemia.
Social History:
___
Family History:
The patient's mother was diagnosed with breast cancer at ___
years and died at ___ years. Her father died at ___ years with
peripheral vascular disease and cardiovascular disease. She has
four sisters and two brothers, many of whom have diabetes
mellitus, one sister also has lupus. She has no children.
Physical Exam:
ON ADMISSION:
VITAL SIGNS: 97.7 122/78 110 18 99
HEENT: PERRL, dry mucous membranes, no cervical LAD
CV: Tachycardic but regular rhythm, no m/r/g
PULM: CTAB without crackles/wheezing/rhonchi
ABD: Diffuse tenderness to palpation, nondistended, bowel
sounds
present
Ext: WWP, no edema, distal pulses palpable
SKIN: No rashes or skin breakdown, no spider angiomas or
jaundice
NEURO: AAOx3, strength/sensation equally intact in all
extremities, no asterixis
ON DISCHARGE:
GEN: NAD
VS: 97.8 PO 120 / 82 102 20 100 RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary LAD
CV: Regular, normal S1 and S2 no S3, S4, or murmurs
PULM: Clear to auscultation bilaterally
ABD: BS+, soft, non-tender, slightly distended, no masses, no
hepatosplenomegaly, gas in all quadrants
LIMBS: No edema
SKIN: No rashes or skin breakdown
NEURO: Grossly nonfocal, alert and oriented
Pertinent Results:
ON ADMISSION:
___ 12:15PM BLOOD WBC-2.5*# RBC-4.33# Hgb-12.3# Hct-36.7#
MCV-85 MCH-28.4 MCHC-33.5 RDW-14.3 RDWSD-43.4 Plt ___
___ 12:15PM BLOOD Neuts-64 Bands-15* Lymphs-8* Monos-11
Eos-0 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-1.98
AbsLymp-0.20* AbsMono-0.28 AbsEos-0.00* AbsBaso-0.00*
___ 12:15PM BLOOD Glucose-101* UreaN-21* Creat-0.9 Na-131*
K-3.3 Cl-93* HCO3-20* AnGap-21*
___ 12:15PM BLOOD ALT-13 AST-16 AlkPhos-87 TotBili-0.5
___ 12:15PM BLOOD Lipase-11
___ 12:15PM BLOOD Albumin-3.7 Calcium-8.4 Phos-4.7* Mg-2.2
___ 12:26PM BLOOD Lactate-1.8
ON DISCHARGE:
MICROBIOLOGY:
___ 1:34 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___ @13:27.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
Blood cultures from ___ and ___ NGTD
IMAGING:
___ CTA A/P:
1. Minimal progression of previously demonstrated extensive
small
bowel wall thickening, along the SMV territory, likely secondary
to venous congestion.
2. Unchanged severe stenosis of the celiac axis and the SMA at
the origin, without evidence of thrombosis.
3. Stable pancreatic head hypodensity, unchanged compared to ___.
4. Persistent SMV occlusion. Patent main portal vein and its
branches.
5. Patent bi-iliac graft.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old woman with stage 4 pancreatic cancer on FOLFOX p/w
n/v and abd pain // e/o ischemia/thrombus, colitis, progressive cancer or
other acute process
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 5.2 s, 49.7 cm; CTDIvol =
1.5 mGy (Body) DLP = 76.3 mGy-cm. 2) Spiral Acquisition 9.1 s, 48.3 cm;
CTDIvol = 6.8 mGy (Body) DLP = 330.8 mGy-cm. Total DLP (Body) = 407 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is moderate calcium burden in
the abdominal aorta and great abdominal arteries. The there is severe
stenosis of the celiac artery at the origin. There is moderate to severe
stenosis of the SMA at the origin. However, distal to the origin, there is
wall to wall flow in the visualized portion of the arterial tributaries.
Patient is status post in bilateral external iliac stents to the profunda
femoris bilaterally, which are patent with wall to wall flow. The native
common femoral artery and SFA are occluded bilaterally, unchanged from prior.
The femoral to femoral graft is occluded, unchanged from prior. The
left-sided axillary femoral graft is also occluded, unchanged from prior. SMV
occlusion is unchanged compared to prior. The portal vein is patent in from
the confluence to the distal branches.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is heterogeneous in enhancement. 1.2 cm hypodensity
the segment 4A may represent a new area of metastatic focus. Previously
described multiple hepatic metastases with associated hyperemia are grossly
unchanged compared to prior. For example, index lesion in segment VIII
measures 7 mm (04:11), segment 2 lesion measures 4 mm (04:13), segment V
measures 4 mm (04:26), segment VI measures 4 mm (04:26), unchanged compared to
prior exam. There is stable mild dilation of the intrahepatic biliary ducts.
The common hepatic duct is stably dilated, measuring up to 1 point cm (04:32).
The gallbladder is within normal limits, without stones or gallbladder wall
thickening.
PANCREAS: Again seen is a hypo enhancing pancreatic head mass, measuring
approximately 2.1 x 2.1 cm, difficult to measure, though mildly decreased in
size compared to prior exam (04:42). Multiple mildly enlarged peripancreatic
lymph nodes are similar in size and distribution. Peritoneal fascial wall
enhancement and the retroperitoneal fat stranding appear similar in extent.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Compared to prior, the there is diffuse abnormal wall
thickening of the small bowel, minimally progressed in extent and distribution
compared to prior. The descending and transverse colon are mildly dilated.
However, there is normal mucosal enhancement throughout the small bowel in the
large bowel. Appendix is not visualized. Scattered mildly prominent lymph
adenopathy is not pathologic by CT size criteria.
RETROPERITONEUM: Retroperitoneum around the known pancreatic mass demonstrate
increased fat stranding and numerous lymphadenopathy, measuring up to 7 mm.
The fat stranding extending from the pancreatic mass surrounds the celiac axis
and the IVC without definite soft tissue component.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Hyperdensity in the right anterior abdominal wall is unchanged
compared to prior.
IMPRESSION:
1. Minimal progression of previously demonstrated extensive small bowel wall
thickening, along the SMV territory, likely secondary to venous congestion.
2. Unchanged severe stenosis of the celiac axis and the SMA at the origin,
without evidence of thrombosis.
3. Stable pancreatic head hypodensity, unchanged compared to ___.
4. Persistent SMV occlusion. Patent main portal vein and its branches.
5. Patent bi-iliac graft.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 14:20 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 97.9
heartrate: 90.0
resprate: 12.0
o2sat: 98.0
sbp: 118.0
dbp: 82.0
level of pain: 7
level of acuity: 3.0 | ___ stage IV pancreatic adenocarcinoma metastatic to the liver,
s/p C3D14 of FOLFIRINOX, with treatment complicated by
mucositis, nausea, and diarrhea, presenting with
nausea/diarrhea/dehydration.
# C.DIFF GASTROENTERITIS: Patient has prior history of possible
ischemia vs. colitis and was treated with enoxaparin, which
patient self-discontinued a couple weeks ago. Repeat CTA showed
mild increase in chronic venous changes but otherwise no new
changes, no e/o thrombus. Stool returned positive for c.diff.
She was started on Vancomycin 125mg po q6h for 14d course, day 1
= ___. Her diarrhea and abdominal pain improved
substantially by time of discharge, and she was able to tolerate
a regular diet. She was continued on her home Zofran for nausea.
# HYPOKALEMIA: K was as low as 2.2, likely from GI losses given
persistent diarrhea. She was repleted with stabilization in K.
She was monitored on telemetry without events. She was
discharged on PO potassium 20 mEq daily and a high K diet.
# TACHYCARDIA: Likely in the setting hypovolemia and pain. Pain
control and fluid management as above.
# METASTATIC PANCREATIC CANCER: Now s/p C3 of Folfox. Further
treatment as per outpatient oncologist. Continued pain control
with oxycontin + oxycodone
# Homocysteinemia: Continued home Plavix and atorvastatin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Dilaudid
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic Cholecystectomy ___
History of Present Illness:
Patient is a ___ with a history of symptomatic cholelithiasis
p/w RUQ pain radiating to her back x4 days. She was last seen
___ with RUQ pain, U/S and
HIDA were negative for acute cholecystitis and her pain
resolved.
She was discharged home with outpatient follow up. She came back
to the hospital on ___ with RUQ pain similar to her previous
episode but without
resolution. She endorsed nausea, vomiting, fevers and chills.
Past Medical History:
1. Diabetus mellitus
2. Hypertension
3. Hypercholesterolemia
4. Concern for coronary artery disease - last catheterization
___ with R dominant system, no significant CAD
5. Asthma
6. S/p two C-sections
7. Abdominal cellulitis (over ___ years ago) s/p pannilectomy
8. Pulmonary infection (?PCP) at ___ (___)
9. Hematuria of unclear etiology
Social History:
___
Family History:
Mother - CAD, ESRD on HD. Maternal aunt - breast ca. Maternal
uncle - prostate ca. Breast and ovarian cancer, mother had
diabetes
Physical Exam:
Physical Exam:Upin admission ___
Vitals:97.6 90 139/67 20 99 RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, RUQ tenderness, + murphys.
Ext: No ___ edema, ___ warm and well perfused
Physical Exam:Upon discharge
Vitals:98.4 / 98.0 / 80 / 151/67 /___ RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, RUQ tenderness, + murphys.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:04PM BLOOD WBC-7.0 RBC-4.19* Hgb-12.2 Hct-38.8
MCV-93 MCH-29.2 MCHC-31.6 RDW-12.5 Plt ___
___ 09:44AM BLOOD WBC-9.7 RBC-4.73 Hgb-13.8 Hct-44.1 MCV-93
MCH-29.2 MCHC-31.4 RDW-12.8 Plt ___
___ 09:10PM BLOOD WBC-12.4*# RBC-5.25 Hgb-15.3 Hct-47.7
MCV-91 MCH-29.2 MCHC-32.1 RDW-12.3 Plt ___
___ 09:10PM BLOOD Neuts-63.0 ___ Monos-5.3 Eos-2.7
Baso-0.5
___ 06:04PM BLOOD Plt ___
___ 06:04PM BLOOD Glucose-243* UreaN-14 Creat-1.0 Na-136
K-3.7 Cl-105 HCO3-26 AnGap-9
___ 09:44AM BLOOD Glucose-266* UreaN-14 Creat-0.9 Na-139
K-4.6 Cl-103 HCO3-30 AnGap-11
___ 09:10PM BLOOD Glucose-121* UreaN-16 Creat-0.9 Na-144
K-3.9 Cl-106 HCO3-25 AnGap-17
___ 09:10PM BLOOD ALT-27 AST-21 AlkPhos-80 TotBili-0.3
___ 09:10PM BLOOD Lipase-41
___ 11:14PM BLOOD CK-MB-4 cTropnT-<0.01
___ 02:50PM BLOOD CK-MB-4 cTropnT-<0.01
___ 09:44AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:04PM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9
\
___: liver/gallbladder US:
IMPRESSION:
1. Gallstones without evidence of acute cholecystitis.
2. Echogenic liver consistent with hepatic steatosis. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis and cirrhosis cannot be excluded on
the basis of this study.
___ ___ ___ ___
Pathology Report Tissue: GALLBLADDER Procedure Date of
___
Report not finalized.
Logged in only.
PATHOLOGY # ___
GALLBLADDER
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO TID
4. Glargine 50 Units Bedtime
Humalog 30 Units Breakfast
Humalog 30 Units Lunch
Humalog 30 Units Dinner
5. QUEtiapine Fumarate 25 mg PO DAILY
6. Zolpidem Tartrate 10 mg PO HS
7. Atorvastatin 20 mg PO DAILY
8. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO TID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Glargine 50 Units Bedtime
Humalog 30 Units Breakfast
Humalog 30 Units Lunch
Humalog 30 Units Dinner
6. Lisinopril 40 mg PO DAILY
7. QUEtiapine Fumarate 25 mg PO DAILY
8. Zolpidem Tartrate 10 mg PO HS
9. Acetaminophen 1000 mg PO Q8H
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN PAIN
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*30 Tablet
Refills:*0
11. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 cap by mouth twice a day Disp
#*20 Capsule Refills:*1
12. Aspirin 81 mg PO DAILY
13. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL INDICATION: Right upper quadrant abdominal pain and nausea. History
of gallstones. Evaluate for cholecystitis.
TECHNIQUE: Grayscale, color and spectral Doppler ultrasound evaluation of the
abdomen.
COMPARISON: CT abdomen and pelvis ___. Liver and gallbladder
ultrasound ___.
FINDINGS: The study is slightly limited due to poor acoustic penetration.
The liver is diffusely echogenic consistent with fatty infiltration. This
limits evaluation for focal liver lesions. The portal vein is patent and
demonstrates normal hepatopetal flow. There is no intrahepatic biliary duct
dilation. The gallbladder is collapsed and contains shadowing stones. There
is no pericholecystic fluid. The common bile duct measures 3 mm.
IMPRESSION:
1. Gallstones without evidence of acute cholecystitis.
2. Echogenic liver consistent with hepatic steatosis. Other forms of liver
disease and more advanced liver disease including significant hepatic fibrosis
and cirrhosis cannot be excluded on the basis of this study.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by UNKNOWN
Chief complaint: Abd pain
Diagnosed with CHOLELITHIASIS NOS
temperature: 97.6
heartrate: 90.0
resprate: 20.0
o2sat: 99.0
sbp: 139.0
dbp: 67.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain. Upon
admission, the patient was made NPO, given intravenous fluids
and underwent imaging. On cat scan of the abdomen she was
reported to have gallstones without evidence of acute
cholecystitis. Her liver function tests were normal. The
patient was taken to the operating room on HD #1 for a
cholecystectomy. During induction, the patient was noted to
have EKG changes demonstrated by ST depressions. The operative
case was aborted and the Cardiology service was consulted.
Troponins were cycled which were negative. After review of the
patient's history and diagnostic tests, she was deemed by
Cardiology to be at a low cardiovascular risk for a moderate
risk surgery. Recommendations for pre-op beta-blockers were
advised.
The patient was taken to the operating room on HD #2 where she
underwent a laparoscopic cholecystectomy. The operative course
was stable with minimal blood loss. The patient was extubated
after the procedure and monitored in the recovery room. Her
post-operative course was noted for decreased urine output for
which the patient received additional intravenous fluids.
Because the urine output failed to respond to the fluids, the
patient had a foley catheter replaced. After additional
intravenous fluids, her urine output improved and the the foley
catheter was removed. The patient was started on clears and
advanced to a diabetic diet. Her blood sugars were difficult to
control during the post-operative period and ___ was
consulted. Adjustments were made in her insulin regimen and her
blood sugars began to normalize. The patient's surgical pain
was controlled with oral analgesia.
The patient was prepared for discharge on POD # 3. Her vital
signs remained stable and she was afebile. She was ambulating
and voiding without difficulty. Her appetite was somewhat
diminished, but she was able to maintain her blood sugars. The
patient was discharged home in stable condition. Appointments
for follow-up were made with the Acute care service and with her
primary care provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R foot ulcer
Major Surgical or Invasive Procedure:
Bedside debridement of right heel ulcer by podiatry ___
Debridement of right heel ulcer ulcer on ___
PICC line placement on ___
___ RIGHT LOWER EXTREMITY ANGIOGRAPHY
1. ___ access to the left common femoral
artery and placement of a ___ sheath.
2. Selective catheterization of the right superficial
femoral artery, ___ vessel.
3. Right lower extremity angiogram.
4. Stent placement in the right SFA using a 6 x 60 mm
Complete stent.
History of Present Illness:
Mr. ___ is a ___ year old patient with history of DM, HTN,
CAD, CVA who presents with a left heel ulcer that started as a
blood blister on ___. Patient denies pain in his foot,
fevers, chills, nausea, vomiting, but does reports the ulcer has
been intermittently foul smelling. Home nursing has been going
to the patient's house to change the dressing. Patient was
started on ceflexin on ___ by his PCP and was scheduled to
have the ulcer debrided today; however, a podiatrist was not
available, so the patient presented to the ED at ___.
In the ED, initial vs were: T97.8; P65; BP142/60; R16; O2 sat
95% on RA. Labs were remarkable for leukocytosis of 11.9 with
72% PMNs, h&h of 10.7 and 34.1. Patient received dopplers which
showed monophasic DP and ___ pulses. Patient was given one dose
of vancomycin.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
Hypertension
Hypercholesterolemia (LDL 63 ___
DM type 2, uncontrolled, with neuropathy (HbA1c 8.6 ___
Coronary Artery Disease
Spinal stenosis, lumbar
Osteoarthritis s/p bilateral hip replacement
Carpal tunnel syndrome
BPH (benign prostatic hyperplasia)
Helicobacter positive gastritis
GERD (gastroesophageal reflux disease)
Bilateral cataract surgery
Social History:
___
Family History:
Mother: ___
___ Grandmother:
Sister: ___
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T: 98; 142/60; 77; 20; 99/RA
General: Pleasant, cooperative, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. L facial droop
and mild L eye ptosis
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Distant heart sounds, RRR,, no murmurs, rubs, gallops
Abdomen: soft, ___, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: DP and ___ pulses non palpable. Ulceration to right heel
with eschar and small amount of purulence on top. Foul smelling
with surrounding erythema. Ulcer is unstageable. +2 pitting
edema noted to b/l knees.
Neuro: A+Ox3, Unable to move R arm. Sensation intact in all
extremities. ___ strength in bilateral LEs. Mild dysarthria.
PHYSICAL EXAM ON DISCHARGE:
Vitals: 97.7; 71; 140/56; 18; 98/RA
General: Pleasant, cooperative, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. L facial droop
and mild L eye ptosis
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Distant heart sounds, RRR, no murmurs, rubs, gallops
Abdomen: soft, ___, bowel sounds present
Ext: Warm, well perfused, no clubbing, cyanosis or edema.
Skin: Ulceration to right heel s/p debridement by podiatry ___
and ___. Wound vac in place showing small amt of bloody
drainage. Waffle boots in place bilaterally
Neuro: A+Ox3, Unable to move R arm. Sensation intact in all
extremities. Moving lower extremities. Moderate dysarthria.
Pertinent Results:
LABS ON ADMISSION:
==============================
___ 01:44PM BLOOD ___
___ Plt ___
___ 01:44PM BLOOD ___
___
___ 01:44PM BLOOD Plt ___
___ 01:44PM BLOOD ___
___
LABS ON DISCHARGE:
==============================
___ 06:45AM BLOOD ___
___ Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD ___
___
OTHER PERTINENT LABS:
==============================
___ 01:44PM BLOOD ___
___ 01:44PM BLOOD ___
MICRO:
==============================
Blood cultures ___ (2 sets) NO GROWTH - final
___ 9:01 am SWAB Source: R foot deep.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ AND IN PAIRS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in
this culture..
___. ___ REQUESTED WORK UP OF ALL ORGANISMS
___.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
PROTEUS MIRABILIS. MODERATE GROWTH.
ESCHERICHIA COLI. MODERATE GROWTH.
___. MODERATE GROWTH.
ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE.
ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE. STRAIN
2.
BETA STREPTOCOCCUS GROUP G. QUANTITATION NOT AVAILABLE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PROTEUS MIRABILIS
| | ESCHERICHIA
COLI
| | |
MORGANELLA ___
| | | |
ENTER
| | | |
| E
| | | |
| |
AMPICILLIN------------ <=2 S =>32 R
<=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S 4 S <=1 S
CEFTRIAXONE----------- <=1 S =>64 R <=1 S
CIPROFLOXACIN--------- <=0.25 S =>4 R <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S <=1 S <=1 S <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM------------- <=0.25 S <=0.25 S <=0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G----------
2 S 2 S
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S =>16 R <=1 S
VANCOMYCIN------------
1 S <=0.5 S
___ 8:06 pm TISSUE R CALCANEUOS BONE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in
this culture..
FURTHER WORK UP REQUESTED PER ___. ___ ___
___.
ENTEROCOCCUS SP.. SPARSE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
PENICILLIN G---------- 4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
IMAGING:
==============================
ABI/PVR ___
Bilateral uncompressible arteries. Severe right leg
femoral/tibial disease. Left leg wave forms WNL.
RIGHT FOOT XRAY ___
IMPRESSION:
No definite cortical destruction is seen to suggest acute
osteomyelitis radiographically. Reported heel ulcer is not well
apparent radiographically. Soft tissue swelling is noted about
the mid and distal foot.
MRI RIGHT FOOT ___
IMPRESSION:
Soft tissue ulcer over the lateral heel with underlying
cellulitis and focal osteomyelitis at the posterolateral aspect
of the calcaneus. No drainable fluid collection is seen.
First metatarsophalangeal joint degenerative change.
Heterogeneity and thickening at the origin of the plantar fascia
consistent with background and incidental plantar fasciitis.
R LEG ANGIOGRARPHY ___
PROCEDURES PERFORMED:
1. ___ access to the left common femoral
artery and placement of a ___ sheath.
2. Selective catheterization of the right superficial
femoral artery, ___ vessel.
3. Right lower extremity angiogram.
4. Stent placement in the right SFA using a 6 x 60 mm
Complete stent.
5. Groin closure using a ___ Perclose device.
FINDINGS:
1. A ___ occlusion of the right superficial femoral
artery.
2. Patent popliteal artery.
3. The anterior tibial artery is patent proximally but
tapers down to a small collateral branch that is in
communication with the peroneal artery.
4. The posterior tibial artery has heavy disease in its
proximal course, but is getting retrograde perfusion via
collaterals at the level of the ankle, beyond which it
is
patent into the foot and formed the plantar arch.
5. The peroneal artery has diffuse disease.
R FOOT XRAY ___
FINDINGS:
There is mild diffuse osteopenia. There is no acute fracture,
dislocation, osseous erosion, or sclerotic or lytic osseous
lesion. There is moderate soft tissue swelling along the plantar
aspect of the foot. Severe degenerative changes are again seen
at the first MTP joint. No embedded radiopaque foreign bodies
detected.
IMPRESSION:
No osseous erosions. No embedded radiopaque foreign body.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PNEUMOcoccal ___ polysaccharide vaccine 0.5 ml IM NOW
X1
Start: ___, First Dose: Next Routine Administration Time
2. ___ 40 Units Breakfast
___ 30 Units Dinner
3. Polyethylene Glycol 17 g PO DAILY
4. TraZODone 100 mg PO HS
5. Furosemide 20 mg PO DAILY
6. Atorvastatin 40 mg PO DAILY
7. trospium 20 mg oral qd
8. Omeprazole 20 mg PO QAM
9. Atenolol 25 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO QAM
Discharge Medications:
1. trospium 20 mg oral qd
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. NPH 40 Units Breakfast
NPH 12 Units Dinner
Insulin SC Sliding Scale using REG Insulin
7. Isosorbide Mononitrate (Extended Release) 30 mg PO QAM
8. Omeprazole 20 mg PO QAM
9. Polyethylene Glycol 17 g PO DAILY
10. TraZODone 100 mg PO HS
11. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth q6h prn Disp #*30 Tablet Refills:*0
12. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
13. ertapenem 1 gram intravenous qd Duration: 33 Days
Please continue antibiotic until ___
RX *ertapenem [Invanz] 1 gram 1 g IV once a day Disp #*33 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Stage II pressure ulcer of R foot
Secondary diagnoses:
Diabetes
Peripheral artery disease
GERD
CAD
Hypertension
Chronic Diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with right heel ulcer // Assess for osteo of the
calcaneus
TECHNIQUE: Three views of the right foot
COMPARISON: None.
FINDINGS:
AP, oblique, and lateral views of the right foot were obtained. The osseous
structures are relatively osteopenic. There are severe degenerative changes at
the first MTP joint with joint space narrowing, marginal sclerosis, and
proliferative change. Reported history is heel ulcer, not clearly depicted on
radiograph. No cortical destruction is seen along the calcaneus to suggest
acute osteomyelitis radiographically. Soft tissue swelling is seen hot,
however, about the mid and distal foot. No definite cortical destruction seen
to suggest acute osteomyelitis. No soft tissue gas seen.
IMPRESSION:
No definite cortical destruction is seen to suggest acute osteomyelitis
radiographically. Reported heel ulcer is not well apparent radiographically.
Soft tissue swelling is noted about the mid and distal foot.
Radiology Report
STUDY: Lower extremity arterial noninvasives at rest.
REASON: Right heel ulcer.
FINDINGS: Doppler waveform analysis reveals bi/triphasic waveforms at the
right common femoral and superficial femoral arteries with monophasic
waveforms at the popliteal, DP and ___ and ABI could not be obtained due to
non-compressible vessels. On the left, there are triphasic waveforms at the
common femoral, superficial femoral and popliteal arteries with mono/biphasic
waveforms at the DP and ___. ABIs again could not be obtained due to
non-compressible vessels.
Pulse volume recordings demonstrate normal waveforms in the thigh bilaterally.
There is dampening at the level of the calf bilaterally, more so on the right
than the left, and there is further dampening at the ankle on the right only.
IMPRESSION: Right SFA and tibial disease, left SFA disease.
Radiology Report
EXAMINATION: MR FOOT ___ CONTRAST RIGHT
INDICATION: ___ year old man with foul-smelling stage 2 pressure ulcer s/p
debridement, ESR 72, CRP 42 // Evaluate for osteomyelitis
TECHNIQUE: Imaging performed at 1.5 using the quadfoot coil. Sequences
include axial and sagittal T1, axial and sagittal STIR axial T1 fat saturated
precontrast and axial and sagittal fat saturated T1 post contrast images after
the uneventful administration of 10 mL of Gadavist. Subsequent subtracted
images were obtained in the axial plane.
COMPARISON: Radiographs of the right foot ___.
FINDINGS:
There is significant motion artifact limiting the exam.
There is a soft tissue defect at the lateral aspect of the heel with
underlying T1 hypointense/ STIR hyperintense, enhancing focal marrow signal
abnormality at the posterior lateral aspect of the calcaneus measuring 2.1 cm
in anterior-posterior dimension by 7 mm in transverse dimension. No drainable
fluid collection is seen. Soft tissue edema and reticular enhancement is noted
over the heel, most pronounced within the region of the soft tissue
ulceration.
The remainder of the marrow signal is within normal limits. Subchondral
cystic change is noted at the head of the first metatarsal.
The Achilles, peroneus, flexor and extensor compartment tendons of the ankle
are grossly intact.
There is a plantar calcaneal spur with heterogeneous signal and thickening at
the origin of the plantar fascia. Soft tissue edema and enhancement is noted
surrounding and tracking towards the the edge of the plantar fascia.
The normal fatty signal is maintained within the sinus tarsi. There is no
significant joint effusion.
IMPRESSION:
Soft tissue ulcer over the lateral heel with underlying cellulitis and focal
osteomyelitis at the posterolateral aspect of the calcaneus. No drainable
fluid collection is seen.
First metatarsophalangeal joint degenerative change.
Heterogeneity and thickening at the origin of the plantar fascia consistent
with background and incidental plantar fasciitis.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with non healing right foot ulcer // pre op
chest x ray Surg: ___ (Right angiogram/ agioplasty )
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. Moderate
cardiomegaly with elongation of the descending aorta. No pulmonary edema. No
pneumonia, no pleural effusions.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new L PICC // L new single-lumen Power PICC
46cm ___ ___ Surg: ___ (Debridement) Contact name: ___:
___
COMPARISON: ___
IMPRESSION:
No change as compared to the previous examination. Moderate cardiomegaly
without pulmonary edema. No pleural effusions. No pneumonia.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ year old man with L new PICC // L new single-lumen PICC 50cm
___ ___ Surg: ___ (Debridement) Contact name: ___:
___
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph ___ at 10:28am
FINDINGS:
The left PICC line terminates in the mid SVC. Otherwise, no significant
changes since the prior radiograph. There are no focal consolidations, pleural
effusions or pneumothorax. Stable moderate cardiomegaly.
IMPRESSION:
Left PICC line terminates in the mid SVC. No pneumothorax.
Radiology Report
EXAMINATION: 3 radiographic views of the right foot.
INDICATION: ___ year old man s/p calcaneal debridement // post op
COMPARISON: Foot radiographs from ___.
FINDINGS:
There is mild diffuse osteopenia. There is no acute fracture, dislocation,
osseous erosion, or sclerotic or lytic osseous lesion. There is moderate soft
tissue swelling along the plantar aspect of the foot. Severe degenerative
changes are again seen at the first MTP joint. No embedded radiopaque foreign
bodies detected.
IMPRESSION:
No osseous erosions. No embedded radiopaque foreign body.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with PRESSURE ULCER, HEEL, PRESSURE ULCER, UNSPECIFIED STAGE
temperature: 97.8
heartrate: 65.0
resprate: 16.0
o2sat: 95.0
sbp: 142.0
dbp: 60.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old patient with history of DM, HTN,
CAD, and stroke who presents with a right heel stage III
pressure ulcer for 2 weeks, found to have focal osteomyelitis
s/p debridement by podiatry twice during admission.
Acute issues
================================
# Osteomyelitis secondary to stage III right heel pressure ulcer
- Patient was afebrile with no symptoms or foot pain, though the
wound was purulent, foul smelling, with surrounding erythema.
Patient was started on empiric IV ciprofloxacin, flagyl, and
vancomycin per podiatry recommendations. Podiatry performed
bedside debridement on ___ and sent deep wound cultures.
Given ESR 72 and CRP 42, a MRI was obtained to evaluate for
osteomyelitis, which showed focal osteomyelitis. Podiatry
performed a second debridement in the OR on ___ including
removal of calcaneus bone, which was sent for tissue culture.
Based on the growth sensitivity results from the deep wound
culture (MSSA, Proteus, E. coli, and Morganella), Infectious
Disease recommended changing antibiotic coverage to IV
___. Patient remained afebrile throughout
his hospital course. Patient received a PICC line on ___ and
was transitioned to IV ertapenem prior to discharge in order to
avoid multiple daily doses of zosyn.
- Patient should continue to wear waffle boots to prevent
pressure ulcers in the future
- Continue ertapenem 1g daily until ___
- Patient to go home with wound vac in R heel.
- Followup appointment with ID scheduled for ___
# Left heel pressure ulcer - Patient developed a 1x1 cm ulcer on
the left heel during his admission, with no signs of infection.
Unstageable due to overlying eschar. Podiatry recommended
against debridement. Patient should continue to wear waffle
boots.
# Peripheral Vascular Disease - On admission, patient had
diminished peripheral pulses in his extremities bilaterally, and
ABI on ___ found ___ vessels and right SFA and
tibial disease as well as left SFA disease. ___ right
angiogram was performed by vascular surgery on ___, during
which a stent was placed for an occlusion in the SFA. Patient
was started on aspirin following the procedure, and the femoral
artery entry site
# Diabetes - Patient's home insulin regimen was 40 NPH in the
morning and 30 before dinner. Blood glucose inpatient started
running low in the mornings, with lowest of 36. Unclear whether
this was due to him not eating an evening snack in the hospital
as he does at home or if hyperglycemia resolving with treatment
of his infection. Patient remained asymptomatic during
hypoglycemic episodes. ___ was consulted and recommended
decreasing the pm dose to 12 with adjustment of his sliding
scale insulin, with improvement of his blood glucose. His
evening dose of NPH may need to be readjusted after discharge if
his hypoglycemic episodes were due to him not eating as much in
the hospital.
Chronic issues
================================
# Diabetes - SSI in house. Discharged on home insulin
# GERD - continued omeprazole
# CAD - continued atorvastatin, plavix. Aspirin started due to
stenting.
# HTN- continued atenolol, isosorbide mononitrate
# CHF - continued furosemide
Transitional issues
================================
- Patient should continue to wear waffle boots to prevent
pressure ulcers in the future
- Continue ertapenem 1g daily until ___
- Patient to go home with wound vac in right heel.
- Patient's blood glucose in the morning were running low.
___ Diabetes consulted, adjusted evening dose of NPH to 12
and adjusted sliding scale. Continue to monitor blood glucose
and adjust insulin regimen as needed.
- F/u appointments with infectious disease, podiatry, vascular,
and PCP
- ___ appointments with weekly CBC with
differential, BUN, Cr, AST, ALT, TB, ALK PHOS, ESR/CRP |
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 and syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with peripheral vascular
disease s/p aortic stent, iron deficiency anemia and
hypothyroidism who presents with syncope and chest pain x 12
hours. Ms. ___ was in her usual state of health visiting from
___ on a bus tour of the ___ when she awoke
this morning and had 3 back to back urination episodes around
2am associated with non-radiating substernal chest
heaviness/aching. After urinating 3 times, she defecated and at
that time arose from sitting on the toilet and passed out,
hitting her right elbow/face along the way. She arose from the
ground and again passed out, this time hitting her left hip.
Over the last 12 hours, she also notes diarrhea. When she awoke,
then she called for her friend to assist her in getting to bed.
Of note, Ms. ___ is away from home. She is on a trip from
___. She is going through the ___ of
___ and ___. She has been eating a lot of seafood but
no raw seafood. Over the past several days she has been eating
chicken that was "a little too well done".
She also states that over the last several days, she has been
quite sessile sitting down for prolonged periods of time while
they moved from place to place along the tour, and complains of
RLE "claudication" which she hasn't felt in ___ years since her
aortic stenting.
In the ED, initial vitals 97.2 84 161/56 22 100%, and Vitals
prior to transfer: ___-143/59-98%ra
Past Medical History:
PVD, s/p dacron stent placed in Aorta ___ yrs ago
Hypothyroidism on levothyroxine
Glaucoma
Dry Eyes
Social History:
___
Family History:
Father died of heart attack in his ___. Mother Died of ALS at
age ___.
Physical Exam:
Admission:
VS - Temp 98.1 F, 112-135/44-66 BP , 65-76 HR , 18 R , ___
O2-sat % RA
GENERAL - well-appearing woman in NAD at rest, comfortable,
appropriate, talkative
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no apparent c/c/e, 2+ peripheral pulses
(radials, DPs), LLE appears larger than RLE
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Discharge:
VS - Temp 98.1 F, 112-135/44-66 BP , 65-76 HR , 18 R , ___
O2-sat % RA
GENERAL - well-appearing woman in NAD at rest, comfortable,
appropriate, talkative
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no apparent c/c/e, 2+ peripheral pulses
(radials, DPs), LLE appears larger than RLE
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
Admission:
___ 07:30AM BLOOD WBC-18.3* RBC-4.18* Hgb-13.7 Hct-41.2
MCV-99* MCH-32.8* MCHC-33.2 RDW-13.0 Plt ___
___ 07:30AM BLOOD Neuts-90.3* Lymphs-5.9* Monos-3.2 Eos-0.3
Baso-0.2
___ 07:30AM BLOOD Glucose-161* UreaN-22* Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-23 AnGap-15
___ 06:45PM BLOOD ___
Discharge:
___ 07:40AM BLOOD WBC-8.4 RBC-3.70* Hgb-11.9* Hct-37.4
MCV-101* MCH-32.1* MCHC-31.8 RDW-12.6 Plt ___
___ 07:40AM BLOOD Neuts-71.8* Lymphs-17.0* Monos-6.8
Eos-3.7 Baso-0.8
___ 07:40AM BLOOD ___ PTT-32.2 ___
___ 07:40AM BLOOD Glucose-118* UreaN-19 Creat-0.9 Na-138
K-4.6 Cl-103 HCO3-26 AnGap-14
___ 07:40AM BLOOD ALT-27 AST-29 LD(LDH)-305* AlkPhos-50
TotBili-0.5
___ 07:40AM BLOOD Albumin-3.8 Calcium-9.9 Phos-4.6* Mg-2.1
Pertinent:
Stress Test:
EXERCISE RESULTS
RESTING DATA
EKG: SINUS ___., 6 BEAT NARROW PSVT
HEART RATE: ___ PRESSURE: 118/78
PROTOCOL /
STAGETIMESPEEDELEVATIONWATTSHEARTBLOODRPP
(MIN)(MPH)(%) RATEPRESSURE
___ ___
TOTAL EXERCISE TIME: 4% MAX HRT RATE ACHIEVED: 51
SYMPTOMS:NONE
ST DEPRESSION:NONE
INTERPRETATION: This ___ year old woman with a PMH of PVD was
referred to the lab for evaluation of syncope and chest
discomfort. The
patient was infused with 0.142 mg/kg/min of dipyridamole over 4
minutes.
No arm, neck, back or chest discomfort was reported by the
patient
throughout the study. There were no significant ST segment
changes
during the infusion or in recovery. The rhythm was sinus with a
6 beat
run of a narrow complex PSVT prior to start of test. Appropriate
hemodynamic response to the infusion. The dipyridamole was
reversed
with 125 mg of aminophylline IV.
IMPRESSION: No anginal symptoms, ischemic EKG changes or
sustained
ectopy. Nuclear report sent separately.
SIGNED: ___
Stress:
Final Report
RADIOPHARMACEUTICAL DATA:
11.0 mCi Tc-99m Sestamibi Rest ___
33.0 mCi Tc-99m Sestamibi Stress ___
HISTORY: ___ year old woman with a PMH of PVD was referred to the
lab for
evaluation of syncope and chest discomfort.
SUMMARY FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
mg/kg/min.
IMAGING METHOD:
Resting perfusion images were obtained with Tc-99m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
Following resting images and two minutes following intravenous
dipyridamole,
approximately three times the resting dose of Tc-99m sestamibi
was administered
intravenously. Stress images were obtained approximately 30
minutes following
tracer injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is slightly affected by motion despite motion
correction.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 61%.
IMPRESSION:
Normal myocardial perfusion. LVEF 61%.
___, M.D.
Lower Extremity Doppler:
___ ___ ___
Radiology ReportUNILAT LOWER EXT VEINSStudy Date of ___
2:05 ___
___ 2:05 ___
UNILAT LOWER EXT VEINS Clip # ___
Reason: ?DVT
UNDERLYING MEDICAL CONDITION:
___ year old woman with elevated D dimer, L leg swelling, and
___ pain.
REASON FOR THIS EXAMINATION:
?DVT
Final Report
CLINICAL HISTORY: ___ woman with elevated D-dimer and
left leg
swelling.
FINDINGS: Gray-scale and color Doppler sonograms with spectral
analysis of
the bilateral common femoral veins and the left superficial
femoral,
popliteal, posterior tibial and peroneal veins were performed.
There is
normal compressibility, flow and augmentation. Normal phasicity
is seen in
the common femoral veins bilaterally.
IMPRESSION: No left lower extremity deep venous thrombosis.
The study and the report were reviewed by the staff radiologist
CTA Torso:
Final Report
INDICATION: ___ woman with syncope, chest pain and
unilateral
swelling of right lower extremity status post long bus ride with
elevated
D-dimer and history of aortic stent placement. Assess for PE or
change in
aortic aneurysm.
TECHNIQUE: CT images were obtained through the chest prior to
administration
of contrast. Subsequently images were obtained through the torso
in an
arterial phase after administering Omnipaque contrast.
Multiplanar
reformations were obtained.
COMPARISONS: None
DLP: ___.86 mGy-cm
CT OF THE CHEST WITH AND WITHOUT CONTRAST: Thyroid gland is
normal and
symmetric in appearance. The aorta and major branches in the
chest are patent
with normal three-vessel branching arch. A moderate degree of
atherosclerotic
calcification is seen in the aorta as well as the coronary
vessels. The heart
and pericardium are otherwise unremarkable without pericardial
effusion. The
pulmonary arteries are well opacified without evidence of
filling defect to
suggest pulmonary embolus. The lungs are clear with the
exception of mild
bibasilar atelectasis. No pleural effusion is seen. There is
no axillary,
hilar, mediastinal or supraclavicular pathologic adenopathy.
The esophagus is
somewhat patulous with a small amount of dense material within
the lumen of
the esophagus reflecting ingested material. The trachea and
central airways
are patent to the segmental level.
CT OF THE ABDOMEN WITH CONTRAST: The liver is normal in
attenuation without
focal lesion or intra- or extra-hepatic biliary ductal
dilatation. The
gallbladder appears normal without gallstones. The pancreas,
spleen and
bilateral adrenal glands appear unremarkable with the exception
of a 1 cm
right adrenal adenoma given Hounsfield units measurement of 9 on
the
pre-contrast imaging. The kidneys enhance symmetrically without
hydronephrosis, though excretory phase is not imaged. The
stomach, small and
large bowel appear grossly unremarkable with a moderate amount
of colonic
stool. There is no mesenteric or retroperitoneal adenopathy.
The patient
appears to be status post open fixation of abdominal aortic
aneurysm along
with aorto-bi-external-iliac grafts, all of which appear patent
and normal in
caliber with dense calcification of the distal native aorta.
These vessels
all appear normal in caliber without flow-limiting stenosis, but
there is
mild-to-moderate stenosis of the left common femoral artery
(3b:153). It is
not clear whether the inferior mesenteric artery fills by
anterograde or
retrograde flow. An accessory left renal artery is noted.
Conventional
hepatic arterial anatomy is seen.
CT OF THE PELVIS WITH CONTRAST: Assessment of pelvic organs is
limited due to
streak artifact from the left hip prosthesis. The bladder and
rectum appear
unremarkable. The uterus appears unremarkable, although the
ovaries are not
well assessed due to obscuration by bowel loops. There is no
free pelvic
fluid. There is no pelvic or inguinal pathologic adenopathy.
OSSEOUS STRUCTURES: Patient is status post left total hip
arthroplasty which
is incompletely imaged, but the portion that is seen appears
well seated.
There is irregular buckling of the left sacral ala which may
reflect a subtle
non-displaced fracture of uncertain chronicity. No other
fractures are seen,
though old posterior left rib fractures are identified in the
upper chest.
Very mild height loss in the T12 vertebral body of uncertain
chronicity.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic pathology
with patent
appearance to abdominal aorta and aortobiiliac graft.
2. Slight irregularity in the left sacrum could reflect a
subtle
non-displaced vs insufficiency fracture of uncertain chronicity.
No other
fractures are seen with slight height loss in the T12 vertebral
body of
uncertain chronicity and for which correlation to physical exam
findings is
recommended.
3. 1 cm right adrenal adenoma.
4. Stenosis of left common femoral artery.
Changes from the preliminary interpretation were discussed with
Dr. ___ by
Dr. ___ at 1535 on ___.
The study and the report were reviewed by the staff radiologist.
Hip Films:
Final Report
INDICATION: Pain after falling, evaluate for fracture.
COMPARISONS: None.
TWO VIEWS OF THE LUMBAR SPINE: There are five non-rib-bearing
lumbar-like
vertebrae. There is no fracture or malalignment of the lumbar
spine.
Extensive aortic calcifications are noted. Surgical clips are
seen overlying
the lower lumbar spine and sacrum. There are degenerative
changes of the
sacroiliac joints and lower lumber spine.
THREE VIEWS OF THE LEFT HIP: Left hip total prosthesis appears
to be in
satisfactory position without evidence of loosening.
Calcifications are seen
within the iliac arteries. There is no fracture or dislocation.
There are
mild degenerative changes of the right hip, marked by joint
space narrowing
and subchondral sclerosis.
The study and the report were reviewed by the staff radiologist.
___. ___
___:
Final Report
INDICATION: Pain after falling, evaluate for fracture.
COMPARISONS: None.
THREE VIEWS OF THE RIGHT ELBOW: There is no fracture or
dislocation. The
bones are poorly mineralized. There is no soft tissue swelling
or radiopaque
foreign object identified.
The study and the report were reviewed by the staff radiologist.
EKG:
Cardiovascular ReportECGStudy Date of ___ 7:19:34 AM
Probable ectopic atrial rhythm. Frequent premature atrial
contractions and
ventricular premature contractions. Modest inferolateral ST-T
wave changes
that are non-specific. No previous tracing available for
comparison.
Medications on Admission:
ASA 81mg
Cilostazol 100mg daily
Zolpidem 10mg qhs
Formula 303 muscle relaxant (hasn't taken in 3 weeks)
Calcium/Vitamin D
levothyroxine 75mcg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
3. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: Two (2)
Tablet PO once a day.
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic daily at
bedtime ().
8. cyclosporine 0.05 % Dropperette Sig: One (1) Drop Ophthalmic
BID (2 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for dyspepsia. Tablet, Chewable(s)
11. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily) for 12 days.
Disp:*12 40 mg syringes* Refills:*0*
13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*90 Tablet(s)* Refills:*0*
14. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope
Peripheral Vascular Disease
Supraventricular Tachycardia
Pelvic Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with syncope, chest pain and unilateral
swelling of right lower extremity status post long bus ride with elevated
D-dimer and history of aortic stent placement. Assess for PE or change in
aortic aneurysm.
TECHNIQUE: CT images were obtained through the chest prior to administration
of contrast. Subsequently images were obtained through the torso in an
arterial phase after administering Omnipaque contrast. Multiplanar
reformations were obtained.
COMPARISONS: None
DLP: 1035.86 mGy-cm
CT OF THE CHEST WITH AND WITHOUT CONTRAST: Thyroid gland is normal and
symmetric in appearance. The aorta and major branches in the chest are patent
with normal three-vessel branching arch. A moderate degree of atherosclerotic
calcification is seen in the aorta as well as the coronary vessels. The heart
and pericardium are otherwise unremarkable without pericardial effusion. The
pulmonary arteries are well opacified without evidence of filling defect to
suggest pulmonary embolus. The lungs are clear with the exception of mild
bibasilar atelectasis. No pleural effusion is seen. There is no axillary,
hilar, mediastinal or supraclavicular pathologic adenopathy. The esophagus is
somewhat patulous with a small amount of dense material within the lumen of
the esophagus reflecting ingested material. The trachea and central airways
are patent to the segmental level.
CT OF THE ABDOMEN WITH CONTRAST: The liver is normal in attenuation without
focal lesion or intra- or extra-hepatic biliary ductal dilatation. The
gallbladder appears normal without gallstones. The pancreas, spleen and
bilateral adrenal glands appear unremarkable with the exception of a 1 cm
right adrenal adenoma given Hounsfield units measurement of 9 on the
pre-contrast imaging. The kidneys enhance symmetrically without
hydronephrosis, though excretory phase is not imaged. The stomach, small and
large bowel appear grossly unremarkable with a moderate amount of colonic
stool. There is no mesenteric or retroperitoneal adenopathy. The patient
appears to be status post open fixation of abdominal aortic aneurysm along
with aorto-bi-external-iliac grafts, all of which appear patent and normal in
caliber with dense calcification of the distal native aorta. These vessels
all appear normal in caliber without flow-limiting stenosis, but there is
mild-to-moderate stenosis of the left common femoral artery (3b:153). It is
not clear whether the inferior mesenteric artery fills by anterograde or
retrograde flow. An accessory left renal artery is noted. Conventional
hepatic arterial anatomy is seen.
CT OF THE PELVIS WITH CONTRAST: Assessment of pelvic organs is limited due to
streak artifact from the left hip prosthesis. The bladder and rectum appear
unremarkable. The uterus appears unremarkable, although the ovaries are not
well assessed due to obscuration by bowel loops. There is no free pelvic
fluid. There is no pelvic or inguinal pathologic adenopathy.
OSSEOUS STRUCTURES: Patient is status post left total hip arthroplasty which
is incompletely imaged, but the portion that is seen appears well seated.
There is irregular buckling of the left sacral ala which may reflect a subtle
non-displaced fracture of uncertain chronicity. No other fractures are seen,
though old posterior left rib fractures are identified in the upper chest.
Very mild height loss in the T12 vertebral body of uncertain chronicity.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic pathology with patent
appearance to abdominal aorta and aortobiiliac graft.
2. Slight irregularity in the left sacrum could reflect a subtle
non-displaced vs insufficiency fracture of uncertain chronicity. No other
fractures are seen with slight height loss in the T12 vertebral body of
uncertain chronicity and for which correlation to physical exam findings is
recommended.
3. 1 cm right adrenal adenoma.
4. Stenosis of left common femoral artery.
Changes from the preliminary interpretation were discussed with Dr. ___ by
Dr. ___ at 1535 on ___.
Radiology Report
CLINICAL HISTORY: ___ woman with elevated D-dimer and left leg
swelling.
FINDINGS: Gray-scale and color Doppler sonograms with spectral analysis of
the bilateral common femoral veins and the left superficial femoral,
popliteal, posterior tibial and peroneal veins were performed. There is
normal compressibility, flow and augmentation. Normal phasicity is seen in
the common femoral veins bilaterally.
IMPRESSION: No left lower extremity deep venous thrombosis.
Radiology Report
INDICATION: Pain after falling, evaluate for fracture.
COMPARISONS: None.
TWO VIEWS OF THE LUMBAR SPINE: There are five non-rib-bearing lumbar-like
vertebrae. There is no fracture or malalignment of the lumbar spine.
Extensive aortic calcifications are noted. Surgical clips are seen overlying
the lower lumbar spine and sacrum. There are degenerative changes of the
sacroiliac joints and lower lumber spine.
THREE VIEWS OF THE LEFT HIP: Left hip total prosthesis appears to be in
satisfactory position without evidence of loosening. Calcifications are seen
within the iliac arteries. There is no fracture or dislocation. There are
mild degenerative changes of the right hip, marked by joint space narrowing
and subchondral sclerosis.
Radiology Report
INDICATION: Pain after falling, evaluate for fracture.
COMPARISONS: None.
THREE VIEWS OF THE RIGHT ELBOW: There is no fracture or dislocation. The
bones are poorly mineralized. There is no soft tissue swelling or radiopaque
foreign object identified.
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Pain after fall and syncope.
COMPARISONS: None.
TECHNIQUE: Chest, supine AP and lateral views.
FINDINGS: The heart is at the upper limits of normal size. The mediastinal
and hilar contours are unremarkable. There is coarsened appearance of lung
markings bilaterally with cuffed airways, probably due to airway inflammation
and likely chronic, but there is no focal opacification aside from streaky
lingular opacity which suggests minor atelectasis. There is no pleural
effusion or pneumothorax. A mild superior endplate compression deformity of
mid-to-upper thoracic vertebral body is likely chronic.
IMPRESSION: No evidence of recent injury or acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PRESSURE
Diagnosed with SYNCOPE AND COLLAPSE, CHEST PAIN NOS, HYPOTHYROIDISM NOS
temperature: 97.2
heartrate: 84.0
resprate: 22.0
o2sat: 100.0
sbp: 161.0
dbp: 56.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is an ___ year old woman with a PMHx of peripheral
vascular disease who presented with syncope x 2 while on
vacation associated with leukocytosis, new onset loose stools,
and chest pain. She sustained a hairline fracture to the sacrum
with the fall. She was been ruled out for MI.
# Syncope: Given new onset chest pressure and dynamic lateral ST
changes, concern was given to ACS resulting in arrythmia, but
patient ruled out for MI, echo demonstrated structurally normal
heart, and stress test was normal. Ms. ___ had a run of SVT
on telemetry (rate 140, 10 seconds) and this may have been the
cause of her fall--especially given the wandering pacemaker seen
on EKG. Also of concern was infection causing relative
hypotension in light of elevated white count. A unifying
diagnosis would have been UTI in light of increased urinary
frequency, but urine collected in the ED is less than convincing
for a UTI. Gastroentiritis was not outside of the realm of
possibility given new onset diarrhea, but abdominal exam is
benign and diarrhea resolved in less than 12 hours. In light of
prolonged immobility and ___ pain, DVT/PE were also
considerations but CTA/doppler were negative for PE/DVT. Of
note, she was not orthostatic.
In order to treat for potential that SVT resulted in syncope
episode, low dose metoprolol was initiated. Although Ms. ___
ruled out for MI, and stress test was normal, there did occur
dynamic non-specific ST changed during Ms. ___ chest pain.
Given this relatively low concern for ACS and Ms. ___ known
PVD, we recommended starting a low dose statin. We also
recommended continuing ASA 81mg. Would consider a cardiac
event monitor and carotid ultrasound as an outpatient; will
defer to PCP.
# L Hip pain, R Elbow pain: Non-displaced sacral fracture was
found on CT. Per ortho no need for brace, Ms. ___ could be
weight bearing as tolerated, and did not need inpatient physical
therapy. Oxycodone was given for severe pain, as well as
standing tylenol. Ms. ___ will also require lovenox
prophylaxis for 2 weeks.
# Hypothyroidism: Levothyroxine was continued.
# Glaucoma: Eye drops were continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Coumadin / morphine
Attending: ___.
Chief Complaint:
Chronic PE's not taking lovenox as prescribed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ past medical history of Crohn's disease, adenoma of colon,
Hodgkin's disease never treated from age ___, nephrolithiasis,
migraines, iron deficiency, and unprovoked pulmonary emboli on
lifetime a/c in ___ who was sent in after being sent
in by his hematologist for recurrent pulmonary embolism.
.
Unfortunately the patient is allergic to coumadin and requires
Lovenox. In ___, he lost access to a program which had given
him free Lovenox for several months. It is currently costing him
$600/mo. which is ___ of his income.
.
He has not been noticing any increasing symptoms from his
pulmonary embolism, but was complaining to his hematologist
about the cost of the Lovenox, so the hematologist got a
screening CT scan? to see if they could discontinue the
anticoagulation entirely. A CT scan which was done this morning
at ___ apparently showed multiple small
pulmonary emboli on both sides, and so the patient was called
into the emergency department for admission.
In the ED intial vitals were recorded as 99.2 85 141/75 16 98%
ra. EKG was unconcering. The patient admited to the ED team that
he had been trying to "space out" the Lovenox by taking it one
out of every ___ days to reduce the cost. Heparin drip was
started and vitals prior to transfer were 98.7, 86, 12, 132/69,
98% RA.
.
Currently, he is asymptomatic.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Chronic back pain ___ multiple spinal fusions starting in ___
requiring steroid injections q10 weeks
Recent admission to ___ with a "viral illness"
Migraines no ppx, imitrex prn
Hodgkins dx at ___, no tx
Crohn's in remission
GERD
Social History:
___
Family History:
NO FH of PE.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.9 F, 140/2 BP , 84 HR , 16 R , O2-sat 96% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
DISCHARGE PHYSICAL EXAM:
VS - 98, 130/78, 70, 15, 96% on RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD, no carotid bruits
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/e, Toes are cool to touch and had mild
delay in capillary refil. 2+ pulses ___
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, intact,
steady gait
Pertinent Results:
ADMITTING LABS:
___ 06:34PM BLOOD WBC-6.3 RBC-4.39* Hgb-11.8* Hct-38.3*
MCV-87 MCH-26.9* MCHC-30.9* RDW-15.6* Plt ___
___ 06:34PM BLOOD Neuts-53.4 ___ Monos-4.1 Eos-2.2
Baso-0.7
___ 06:34PM BLOOD ___ PTT-41.3* ___
___ 06:34PM BLOOD Glucose-106* UreaN-11 Creat-0.9 Na-143
K-3.8 Cl-108 HCO3-27 AnGap-12
___ 06:15AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.9
DISCHARGE LABS:
___ 06:32AM BLOOD WBC-5.7 RBC-4.56* Hgb-11.9* Hct-40.3
MCV-88 MCH-26.0* MCHC-29.5* RDW-15.4 Plt ___
___ 06:32AM BLOOD ___ PTT-39.6* ___
___ 06:32AM BLOOD Glucose-96 UreaN-9 Creat-0.8 Na-144 K-4.0
Cl-109* HCO3-30 AnGap-9
___ 06:32AM BLOOD Phos-3.0 Mg-1.8
EKG ON ___:
Artifact is present. Sinus rhythm. Probably normal tracing. No
previous
tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 198 ___ 50 -24 34
CXRAY PA & LAT ON ___:
FINDINGS: The heart is normal in size. The aortic arch is
partly calcified. The mediastinal and hilar contours are
otherwise unremarkable. The lungs appear clear. There are no
pleural effusions or pneumothorax. There is slight loss in a
lower thoracic vertebral body height, possibly T9 and likely
chronic. Small osteophytes are noted along the thoracic spine.
IMPRESSION: No evidence of acute disease. Mild loss in
vertebral body height along a lower thoracic vertebral body.
Medications on Admission:
Immitrex PRN migraine
Lovenox BID
Nexium daily
Extra Strength vicodin prn back pain
Discharge Medications:
1. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous once a day: Daily .
Disp:*30 injections* Refills:*1*
2. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO
ONCE MR1 (Once and may repeat 1 time) for 1 doses.
3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
every six (6) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Recurrent Pulmonary embolism
Secondary:
Migraine Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Bilateral pulmonary emboli.
COMPARISONS: None.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is normal in size. The aortic arch is partly calcified.
The mediastinal and hilar contours are otherwise unremarkable. The lungs
appear clear. There are no pleural effusions or pneumothorax. There is
slight loss in a lower thoracic vertebral body height, possibly T9 and likely
chronic. Small osteophytes are noted along the thoracic spine.
IMPRESSION: No evidence of acute disease. Mild loss in vertebral body height
along a lower thoracic vertebral body.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: PE
Diagnosed with PULM EMBOLISM/INFARCT, LONG TERM USE ANTIGOAGULANT
temperature: 99.2
heartrate: 85.0
resprate: 16.0
o2sat: 98.0
sbp: 141.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a history of untreated
Hodgkins disease since age of ___, migraines, Crohn's disease,
colonic adenoma, Fe deficiency anemia, nephrolithiasis, and
degenerative disc disease who presented with evidence of
chronic/recurrent PEs on outpatient CT scan in the context of a
lapse in lovenox administration due to inability to pay for his
Lovenox prescription.
# PEs: Pt has recurrent PE in the setting of only taking his
lovenox intermittently due to cost. He is currently symptoms
free, HD stable and sating in the upper ___. Treatment will
likely be difficult since ? if patient makes too much to qualify
to have free-care/mass health; however paying for his lovenox is
a financial burden to him ___ of his monthly income). We
discussed possible IVC filter, although this is not a current
indication for IVC filter since he did not fail therapy. In
addition, he would like benefit from anticoagulation in addition
to having IVC filter. However, this should be further discussed
with his hematologist given his financial difficulties and very
high risk for developing PEs which could be fatal. I called the
insurance company today asked for appeal of his coverage which
was denied. He will need to have a letter of necessity sent from
his PCP/hematologist for review and possible decreasing his
insurance copay. Currently he has a insurance gap of $4,700 so
he would have to cover his first $4,700 prior to the insurance
taking over his coverage. His lovenox for the ___ month would
cost $792 and the following month $1,600 which is more than his
monthly income. We also discussed other treatment options such
as fundapurinox which would have an even higher co-pay of $1489.
We also discussed other medications such as Rivaroxaban which
was just approved for the use of PE, but it not available in the
pharmacies. It will cost ~$300/ month (Oral Rivaroxaban for the
Treatment of Symptomatic Pulmonary Embolism, The ___
Investigators ___. Dabigatran is not approved for
the tx of PE. Another option would be heparin SQ (2.5mg/Kg) BID,
however he would need close PTT monitoring. For now we were able
to get him 2 weeks supply via free-care pharmacy, and he has
another 2 week supply at home. I also spoke to the nurse from
his Hematologist office who wil be able to supply another month.
So he will have the total of 2months supply of lovenox while he
discuss his options with his hematologist.
- lovenox in house, treatment dose of 1mg/kg BID (80mg).Once d/c
he was given a prescription for 1.5mg/Kg 120mg daily
.
# Migraine HA: pt states that this is a going problem and he is
now having then with more frequency. He was previously on
Topamax which was prescribed by his neurologist and had
significantly decresed the frequency of his migraine HA. He then
stopped taking this med since someone told him it could cause
kidney stones and he had 2 stones in ___ years. He had 2 doses of
Imitrex while inpatient which helped. He is now headache free.
- Will discuss possibly restarting on Topamax 50mg Qhs with his
neurologist
- Cont on Imitrex PRN
.
# Back pain: Currently back pain free, continue vicodin prn
.
# GERD: continue nexium
.
# FEN: No IVFs / replete lytes prn / regular diet
# PPX: on thereapeutic lovenox
# ACCESS: PIV
# CODE: confirmed full
# CONTACT: wife ___ ___
# DISPO: HOME
. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt reports that in the last ___ weeks, he has sustained 4 falls.
He reports that his legs feel weak and give in on him. He denies
head strike or LOC on all occasions. He also denies
lightheadness, dizziness, palpitations or any prodromal
symptoms.
The last fall was on ___ and he presents today due to worsening
leg pain that is affecting his ambulation.
Upon arrival to the floor, patient reports that he is still
having pain worst in his left buttock. Pain has been limiting
his
ability to ambulate around his home and has prevented him from
being able to perform all his ADLs including consistently taking
his medications. Pain is new after his repeated falls at home.
He
describes sensation of weakness when standing or ambulating for
extended periods where he knows he's going to fall and his legs
just give out under him. He has never felt lightheaded, dizzy,
or
had palpitations surrounding these events. Denies recent illness
including fever, chills, nausea, vomiting, diarrhea, dysuria,
increased confusion.
Past Medical History:
EtOH Cirrhosis
-Portal HTN
-Refractory Ascites s/p TIPS in ___
-Hepatic Encephalopathy
-HCC s/p RFA in ___ without recurrence
T2DBM
Iron Deficiency Anemia
B12 Deficiency
Osteoporosis
Hypothyroidism
Splenectomy
Appendectomy
Shoulder Surgery
Hernia Repair with mesh
Social History:
___
Family History:
Father - Lung Cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
GENERAL: Alert and interactive. In no acute distress. Resting
tremor in upper extremities
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. OP Clear.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. +2
systolic murmur loudest over RUSB
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, tender to
palpation
suprapubic
EXTREMITIES: WWP No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Face symmetric. LLE strength exam limited by pain w/
active ROM at hip otherwise strength ___. AOx3. No asterixis.
DISCHARGE PHYSICAL EXAM:
===========================
GENERAL: Thin appearance with temporal wasting, resting
comfortably in bed. Mild gynecomastia.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. OP Clear.
CARDIAC: RRR, normal S1/S2. II/VI systolic murmur loudest at
RUSB.
LUNGS: CTAB, no increased work of breathing
ABDOMEN: Soft, non-tender, non-distended, normoactive BS. No
flank dullness or bulging flanks.
EXTREMITIES: Warm, DP pulses 2+ bilaterally, no edema. ___
nails on hands.
NEUROLOGIC: AOx3. Able to state ___ backward. No asterixis, mild
resting tremor.
Pertinent Results:
ADMISSION LABS
===============
___ 02:10PM BLOOD WBC-5.8 RBC-4.09* Hgb-13.1* Hct-38.0*
MCV-93 MCH-32.0 MCHC-34.5 RDW-17.0* RDWSD-56.8* Plt ___
___ 02:10PM BLOOD ___ PTT-30.5 ___
___ 02:10PM BLOOD Plt ___
___ 02:10PM BLOOD Glucose-81 UreaN-14 Creat-0.9 Na-140
K-4.9 Cl-113* HCO3-17* AnGap-10
___ 02:10PM BLOOD ALT-23 AST-38 AlkPhos-217* TotBili-2.2*
___ 02:10PM BLOOD cTropnT-<0.01
___ 02:10PM BLOOD Albumin-2.6*
___ 08:52PM BLOOD Lactate-2.8*
PERTINENT LABS
===============
___ 05:41AM BLOOD VitB12-847
___ 05:41AM BLOOD 25VitD-23*
___ 08:52PM BLOOD Lactate-2.8*
___ 01:11PM BLOOD Lactate-1.9
___ 12:04AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:04AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 12:04AM URINE RBC-5* WBC-5 Bacteri-FEW* Yeast-NONE
Epi-0
___ 12:04AM URINE CastHy-1*
DISCHARGE LABS
===============
___ 05:16AM BLOOD WBC-7.7 RBC-3.86* Hgb-12.2* Hct-36.4*
MCV-94 MCH-31.6 MCHC-33.5 RDW-16.9* RDWSD-57.7* Plt ___
___ 05:16AM BLOOD Plt ___
___ 05:16AM BLOOD ___ PTT-41.7* ___
___ 05:16AM BLOOD Glucose-96 UreaN-11 Creat-0.8 Na-141
K-4.2 Cl-109* HCO3-24 AnGap-8*
___ 05:16AM BLOOD ALT-23 AST-29 LD(___)-258* AlkPhos-211*
TotBili-0.9
___ 05:16AM BLOOD Albumin-2.4* Calcium-9.6 Phos-2.7 Mg-2.0
MICROBIOLOGY
===============
None
IMAGING
===============
HIP X RAY (___)
IMPRESSION:
No acute fracture.
CT HEAD NON-CONTRAST (___)
IMPRESSION:
Bilateral subdural fluid collections, likely due to a chronic
subdural
hematoma measuring up to 1 cm on the left and a subacute to
chronic subdural hematoma on the right measuring 0.7 cm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO TID
2. Magnesium Oxide 400 mg PO BID
3. Furosemide 80 mg PO DAILY
4. Spironolactone 100 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sulfameth/Trimethoprim DS 1 TAB PO 5X/WEEK (___)
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Cyanocobalamin 200 mcg PO DAILY
9. Thiamine 50 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth Twice daily Disp #*60 Tablet Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth Twice daily
Disp #*60 Tablet Refills:*0
4. Lactulose 30 mL PO QID
5. Cyanocobalamin 200 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 80 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Magnesium Oxide 400 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. Spironolactone 100 mg PO DAILY
12. Sulfameth/Trimethoprim DS 1 TAB PO 5X/WEEK (___)
13. Thiamine 50 mg PO DAILY
14. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
====================
Falls
Chronic Subdural Hematomas
Hepatic Encephalopathy
SECONDARY DIAGNOSES
====================
Alcoholic Cirrhosis
Tremor
Diabetes Mellitus Type 2
Anemia
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT
INDICATION: ___ with multiple falls// ? acute bleed
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
cross-table lateral views of the left hip.
COMPARISON: CT ___
FINDINGS:
There is no fracture or dislocation. There are mild degenerative changes of
bilateral hip joints. There is no suspicious lytic or sclerotic lesion.
There is no soft tissue calcification or radio-opaque foreign body.
IMPRESSION:
No acute fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with multiple falls// ? acute bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
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 3.0 s, 6.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
New compared to prior exam is a low-density subdural fluid collection
overlying the left frontoparietal region measuring up to a maximum of 1.0 cm.
This likely represents interval, chronic subdural hematoma. There is also a
iso/hypodense right-sided subdural fluid collection measuring 7 mm in
thickness, likely subacute to chronic subdural hematoma overlying the frontal
lobe. Prominence of the ventricles and sulci is compatible with volume loss.
There is no midline shift. No significant mass effect. No additional
hemorrhage. Periventricular and subcortical white matter hypodensities are
likely sequela of chronic small vessel disease.
Included paranasal sinuses and mastoids are essential clear. Skull and
extracranial soft tissues are unremarkable.
IMPRESSION:
Bilateral subdural fluid collections, likely due to a chronic subdural
hematoma measuring up to 1 cm on the left and a subacute to chronic subdural
hematoma on the right measuring 0.7 cm.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Buttock pain
Diagnosed with Low back pain, Pain in left hip, Fall on same level, unspecified, initial encounter
temperature: 98.4
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 163.0
dbp: 86.0
level of pain: 8
level of acuity: 3.0 | ASSESSMENT AND PLAN:
====================
___ w/ PMHx EtOH cirrhosis c/b refractory ascites s/p TIPS/___
s/p RFA/HE/Portal HTN, T2DM, Hypothyroidism, Anemia,
osteoporosis who presented with 4 mechanical falls over last
month with worsening leg pain and one chronic, one subacute
subdural hematoma on imaging. He was found to have hepatic
encephalopathy with rapid improvement. Evaluated by ___ who felt
patient unsafe for discharge home and would need rehab.
ACUTE ISSUES:
=============
#Chronic subdural hemorrhages
#Deconditioning/Falls
Four falls at home appear mechanical in nature, with
descriptions of hitting hip on edge of chair and legs giving out
from under him. No fracture on X ray. No associated
lightheadedness, dyspnea, chest pain, palpitations. Hepatic
encephalopathy and SDH likely contributory though appear to be
primarily due to weakness, deconditioning. Orthostatics WNL.
Hip/buttock pain present with weight-bearing, although gradually
improving, likely muscular in nature. Recommended for rehab by
___.
#Mild hepatic encephalopathy
Noted to have asterixis, mild confusion on admission. Lactulose
increased and started on rifaximin with resolution of symptoms.
Discharged on lactulose QID and rifaximin.
#Nutrition
Albumin 2.6 on admission, likely component of poor nutrition.
Evaluated by nutrition, with dietary supplementation as per
nutrition. Started multivitamin and calcium carbonate. Continued
home folate, thiamine, B12, and vitamin D. B12 WNL. Vitamin D
23.
#Bloody stool
Noted to have streaking of blood with stool and on toilet paper
while inpatient. Patient has history of internal hemorrhoids and
says he has had this previously. Hgb stable, hemodynamically
stable. Last colonoscopy ___ with no overt bleeding sources,
although limited by poor prep. Likely secondary to hemorrhoids;
howoever, given cirrhosis with rectal varix seen on ___
colonoscopy, and poor prep on last colonoscopy in ___,
reasonable to consider repeat scope as outpatient if bloody BM
persistent.
CHRONIC ISSUES:
===============
#EtOH Cirrhosis
Follows with Dr. ___ as outpatient. MELD-Na 13 on admission.
Cirrhosis complicated in past by refractory ascites s/p TIPS,
___ s/p RFA, HE, Portal HTN. Mild HE on admission as noted
above, otherwise no evidence of decompensation.
-HE: managed per above
-Ascites: Continued home Lasix, spironolactone. No ascites
noted.
-Varices: EGD ___ without varices, not on nadolol
-SBP: Continued prophylaxis w/ Bactrim DS 5x/week
-HCC: CT ___ without evidence of recurrence
-Nutrition: Per above
-Coagulopathy: Received PO vitamin K x1 without improvement in
INR.
#Tremor
Bilateral hand tremor with action/posturing which has been
present for years, at baseline. Previously seen by neurology
outpatient. Patient scheduled for follow-up neurology
appointment on discharge.
#T2DM
Diet-controlled, glucose well-controlled in hospital.
#Chronic normocytic anemia
Known chronic anemia due to iron and B12 deficiency. Hgb 13.1 on
admission. Not on iron at home as last ferritin 88 and causing
GI upset. Continued home B12, folate as above.
#Osteoporosis
Increased vitamin D to 800 BID based on vitamin D level of 23.
Started on calcium carbonate.
#Hx of B12 deficiency
On home cyanocobalamin 200mcg daily. Level WNL at 847 this
admission. Per neurology note from ___, "continue Nascobal
indefinitely. ___ NOT be on po treatment only." Patient no
longer on home intranasal B12, did not start at this time given
normal B12 level, but plan for outpatient neurology follow-up
after discharge.
TRANSITIONAL ISSUES
====================
[ ] Titrate lactulose to at least 3BM per day
[ ] Neurology follow-up for tremor, falls, subdural hematomas
[ ] Consider starting intranasal B12 (see above)
[ ] If continuing to have hip pain, consider non-contrast MRI to
evaluate for occult fracture
[ ] Consider repeat colonoscopy if having persistent bloody BM
or worsening anemia
[ ] Patient wants to change PCPs. Please ensure patient is set
up with a new PCP on discharge from rehab. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa(Sulfonamide Antibiotics) / Ambien
Attending: ___.
Chief Complaint:
fever, abnormal labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of bicuspid
aortic valve s/p mechanical valve replacement on Coumadin,
ascending aortic aneurysm s/p graft placement, and BRCA+ breast
CA s/p chemo and double mastectomy who presents with fevers and
rash x 3 days.
Patient states that she was in her usual state of health until 3
days prior to admission (___) when she developed chills. On
___, she noted fevers between 101 - 102 and a new asymptomatic
erythematous truncal rash. She also had 2 episodes of loose (but
not watery) stool without blood or melena. She presented to her
PCP ___, the day prior to admission, who drew labs notable for
CRP of 159. She was told to present to the emergency room.
In terms of other symptoms, she reports pain in R hip ongoing
for
___ weeks, being treated as hip flexor tendonitis. The pain has
been less diffuse and slightly more severe over past week. She
can bear weight on her leg but has been limping. She does have
h/o R hip replacement. She denies chest pain, palpitations,
shortness of breath, recent breaks in skin, recent dental
procedures, IVDU, tattoos. She has mild non-productive cough
which she attributes to indigestion. She denies abdominal pain,
nausea, vomiting; had two episodes of loose stool as above but
bowel movements have been normal since then. No dysuria. No
headache, vision changes, odynophagia, dysphagia, eye
pain/dryness. Very poor appetite for past 3 days.
She lives near wooded area, and her family members have had tick
bites and lyme disease though she has no personal history of
Lyme
or known tick bites. No sick contacts, but has been taking care
of her young grandchildren. No new medications. No travel apart
from trip to ___ in ___ (stayed at ___ and went to
___) and ___ in ___. She does have bird feeders
which she tends to daily, but no direct contact with birds. No
recent weight loss. Endorses significant night sweats ongoing
for
___ years and unchanged.
In the ED, initial vitals were:
- Exam notable for: Systolic murmur, blanching pink patchy rash
over anterior chest. R hip without any pain with active or
passive ROM; tender to palpation (point tenderness) over point
where R flexor tendon crosses pelvic brim
- Labs notable for: WBC 7.7, INR 6.6, ALT 109, AST 61, CRP 240,
CK 95, Lactate 1.6. Flu negative. UA negative.
- Imaging was notable for: CXR - No acute cardiopulmonary
process.
- Patient was given: Vanc/zosyn, 1L NS, APAP 650mg
Upon arrival to the floor, patient reports very sore and dry
mouth which has been getting worse. She otherwise feels ok.
Denies chest pain, sob, abdominal pain, n/v.
Past Medical History:
- Bicuspid aortic valve s/p mechanical valve replacement on
Coumadin
- Ascending aortic aneurysm s/p graft placement
- R hip replacement
- BRCA+ breast CA s/p chemo and double mastectomy
- GERD
Social History:
___
Family History:
Father with prostate cancer
Mother with renal cancer, diabetes, HTN
Paternal grandmother with breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 98.4PO 111 / 61 86 18 93 Ra
GENERAL: Non-toxic appearing, sitting up in bed in NAD
HEENT: Erythema of tongue and lip mucosa but no discrete
lesions.
Petichiae on hard palate. No ocular or oropharyngeal
ulcers/blisters.
NECK: No cervical or supraclavicular LAD.
CARDIAC: RRR, + systolic murmur and mitral click best heard at
___.
LUNGS: CTAB, no wheezes/crackles
ABDOMEN: Soft, NTND, normal bowel sounds
EXTREMITIES: R hip without marked erythema or ttp, pain with
active and passive ROM; tender to palpation (point tenderness)
over point where R flexor tendon crosses pelvic brim
NEUROLOGIC: CN III-XII intact, strength ___ throughout other
than
R hip flexion which is ___ limited by pain, sensation intact
throughout. Awake, alert, answering questions appropriately.
SKIN: Blanching, pink, patchy macular rash over truck and upper
legs. No blisters/bullae. No ___ lesions, ___ nodes,
splinter hemorrhages in feet or hands
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: Temp: 98.4 (Tm 100.6), BP: 112/66 (92-118/54-66),
HR: 89 (88-97), RR: 18, O2 sat: 93% (93-97), O2 delivery: RA
GENERAL: Appears younger than stated age, sitting up in bed in
no
acute distress
HEENT: erythema of tongue and lip mucosa but no discrete
lesions.
Petichiae on hard palate. No ocular or oropharyngeal
ulcers/blisters.
CARDIAC: RRR, + systolic murmur and mitral click best heard at
LUSB.
LUNGS: CTAB, no wheezes/crackles
ABDOMEN: Soft, NTND, normal bowel sounds
EXTREMITIES: R hip without marked erythema, pain with active and
passive ROM; tender to palpation (point tenderness) over point
where R flexor tendon crosses pelvic brim
NEUROLOGIC: CN III-XII grossly intact, strength in R hip flexor
___ limited by pain. Awake, alert, answering questions
appropriately.
SKIN: Blanching, diffuse, pink, patchy macular rash covering
much
of her body and sparing face, palms, soles, and feet. No
blisters/bullae. No ___ lesions, ___ nodes, splinter
hemorrhages in feet or hands. Mild bilateral hand swelling.
Pertinent Results:
ADMISSION LABS:
=================
___ 01:05PM BLOOD WBC-7.7 RBC-3.72* Hgb-11.2 Hct-33.4*
MCV-90 MCH-30.1 MCHC-33.5 RDW-13.1 RDWSD-43.3 Plt ___
___ 01:05PM BLOOD Neuts-88.7* Lymphs-4.7* Monos-5.2
Eos-0.6* Baso-0.3 Im ___ AbsNeut-6.84* AbsLymp-0.36*
AbsMono-0.40 AbsEos-0.05 AbsBaso-0.02
___ 01:05PM BLOOD ___ PTT-56.3* ___
___ 01:05PM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-135
K-3.8 Cl-94* HCO3-26 AnGap-15
___ 01:05PM BLOOD ALT-109* AST-61* CK(CPK)-95 AlkPhos-93
TotBili-0.8
___ 01:05PM BLOOD Lipase-25
___ 01:05PM BLOOD cTropnT-<0.01
___ 01:05PM BLOOD Albumin-4.0
___ 01:05PM BLOOD CRP-240.2*
___ 02:30PM URINE Color-Straw Appear-Clear Sp ___
___ 02:30PM URINE Blood-MOD* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 02:30PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1
___ 02:30PM URINE Mucous-RARE*
___ 02:35PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
NOTABLE LABS:
=================
___ 06:25AM BLOOD Ret Aut-0.6 Abs Ret-0.02
___ 06:25AM BLOOD calTIBC-209* ___ Ferritn-328*
TRF-161*
___ 04:50PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 04:50PM BLOOD HCV Ab-NEG
___ 06:25AM BLOOD RheuFac-15* ___ CRP-234.2*
___ 11:07AM BLOOD HIV Ab-NEG
___ 06:55AM BLOOD 25VitD-18*
NOTABLE IMAGING:
=================
___ TTE
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional left ventricular systolic function. Global left
ventricular systolic function is normal. Quantitative biplane
left ventricular ejection fraction is 51 %. Left ventricular
cardiac index is normal (>2.5L/min/m2) No ventricular septal
defect is seen. There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus diameter is normal with
normal ascending aorta diameter. The aortic arch diameter is
normal. There is no evidence for an aortic arch coarctation. A
mechanical aortic valve prosthesis is present. The prosthesis is
well seated with normal disc motion and transvalvular gradient.
No masses or vegetations are seen on the aortic valve. No
abscess is seen. There is no aortic valve stenosis. There is a
paravalvular jet of mild [1+] aortic regurgitation. The mitral
leaflets are mildly thickened with no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve. No abscess
is seen. There is trivial mitral regurgitation. There is mild
pulmonic regurgitation. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is mild [1+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Good image quality. Mechanical aortic prosthesis
with normal gradients and mild paravalvular regurgitation. No
echocardiographic evidence of endocarditis.
___ CT PELVIS
FINDINGS:
BONES: The patient is status post right total hip arthroplasty
with long
femoral stem component. No evidence of hardware complication.
Beam hardening artifact from the hardware limits evaluation of
the surrounding soft tissues. Within this limitation, no large
right hip effusion is seen. No adjacent drainable fluid
collection. No acute fracture or dislocation.
Evaluation of the left hip demonstrates mild-to-moderate
degenerative changes. Mild degenerative changes at the pubic
symphysis and bilateral sacroiliac joints. Degenerative changes
of the visualized lower lumbar spine.
SOFT TISSUES: The overlying musculature of both hips are
symmetric. Surgical clips/suture material is noted in the lower
anterior abdominal wall.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis. Limited evaluation of
the bowel demonstrates no distended bowel loops or bowel wall
thickening. A normal appendix is
visualized. Trace pelvic ascites.
REPRODUCTIVE ORGANS: Surgical clips/suture material is noted in
bilateral
adnexa. Heterogeneous fluid is noted within the endometrial
cavity measuring up to 0.7 cm in thickness.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
IMPRESSION:
Right hip arthroplasty without evidence of hardware
complication. No large
right hip effusion. No abscess is identified.
Trace pelvic ascites of uncertain etiology.
Heterogeneous fluid noted within the endometrial cavity.
Correlate with prior imaging. If none are available, nonurgent
pelvic ultrasound is recommended for further evaluation.
DISCHARGE LABS:
=================
___ 06:55AM BLOOD WBC-6.3 RBC-3.48* Hgb-10.3* Hct-31.2*
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.2 RDWSD-43.7 Plt ___
___ 06:55AM BLOOD ___ PTT-48.7* ___
___ 06:55AM BLOOD Glucose-111* UreaN-6 Creat-0.6 Na-142
K-3.5 Cl-104 HCO3-27 AnGap-11
___ 06:55AM BLOOD ALT-60* AST-25 LD(LDH)-239 AlkPhos-71
TotBili-0.4
___ 06:55AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 37.5 mg PO DAILY
2. Pantoprazole 40 mg PO 2X/WEEK (MO,TH)
3. Warfarin 6 mg PO 5X/WEEK (___)
4. Aspirin 81 mg PO DAILY
5. Warfarin 7 mg PO 2X/WEEK (___)
6. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Vitamin D 1000 UNIT PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. Metoprolol Succinate XL 37.5 mg PO DAILY
6. HELD- Warfarin 7 mg PO 2X/WEEK (___) This medication was
held. Do not restart Warfarin until your INR is checked and your
doctor says it is OK.
7. HELD- Warfarin 7 mg PO 2X/WEEK (___) This medication was
held. Do not restart Warfarin until INR is checked and the
doctor tells you to take coumadin
8.Outpatient Lab Work
Please check INR on ___ and fax results to ___
___.
Diagnosis: Unspecified atrial fibrillation ICD10 I48.91.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Fevers
- Rash
- Glossitis
SECONDARY DIAGNOSIS:
- Coagulopathy
- Iron deficiency anemia
- Anemia of chronic inflammation
- Transaminitis
- GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with eval for pna, fever cough// eval for pna, fever cough
TECHNIQUE: Frontal and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear without consolidation, effusion, or edema.
Cardiomediastinal silhouette is within normal limits noting a prosthetic
aortic valve. Surgical clips project over the right anterior chest wall soft
tissues. Median sternotomy wires are intact.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT of the pelvis with contrast
INDICATION: ___ year old woman with h/o breast CA s/p chemo and bilateral
mastectomy, biscuspid AV with prior AVR and aortic aneurysm repair, admitted
with several days of high grade fever, unclear source does have ongoing r hip
pain and tenderness.// CT torso and hips with and without contrast to assess
for possible abscess. Also specifically to assess for possible signs of right
hip septic arthritis.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the pelvis following intravenous contrast administration with
split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 42.6 cm; CTDIvol = 14.7 mGy (Body) DLP = 628.4
mGy-cm.
Total DLP (Body) = 628 mGy-cm.
COMPARISON: None.
FINDINGS:
BONES: The patient is status post right total hip arthroplasty with long
femoral stem component. No evidence of hardware complication. Beam hardening
artifact from the hardware limits evaluation of the surrounding soft tissues.
Within this limitation, no large right hip effusion is seen. No adjacent
drainable fluid collection. No acute fracture or dislocation.
Evaluation of the left hip demonstrates mild-to-moderate degenerative changes.
Mild degenerative changes at the pubic symphysis and bilateral sacroiliac
joints. Degenerative changes of the visualized lower lumbar spine.
SOFT TISSUES: The overlying musculature of both hips are symmetric. Surgical
clips/suture material is noted in the lower anterior abdominal wall.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis. Limited evaluation of the bowel demonstrates no
distended bowel loops or bowel wall thickening. A normal appendix is
visualized. Trace pelvic ascites
REPRODUCTIVE ORGANS: Surgical clips/suture material is noted in bilateral
adnexa. Heterogeneous fluid is noted within the endometrial cavity measuring
up to 0.7 cm in thickness.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
IMPRESSION:
Right hip arthroplasty without evidence of hardware complication. No large
right hip effusion. No abscess is identified.
Trace pelvic ascites of uncertain etiology.
Heterogeneous fluid noted within the endometrial cavity. Correlate with prior
imaging. If none are available, nonurgent pelvic ultrasound is recommended
for further evaluation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs, Fever, Rash
Diagnosed with Fever, unspecified, Chest pain, unspecified
temperature: 100.6
heartrate: 103.0
resprate: 19.0
o2sat: 100.0
sbp: 120.0
dbp: 98.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with a history of bicuspid
aortic valve s/p mechanical valve replacement on Coumadin,
ascending aortic aneurysm s/p graft placement, and right hip
replacement, who presented with three days of fevers, chills,
and a diffuse, pink macular rash. The patient noted to have
fever to 100.6 on ___ while off of antibiotics, but did not
have another fever prior to discharge. CXR, UA/UCx, BCx
unrevealing. CT Pelvis was unrevealing. TTE without evidence of
endocarditis. Hepatitis serologies, HIV were negative. Further
workup for EBV, CMV, mycoplasma, ___ virus, parvovirus,
GAS, syphilis, and RVP were pending at time of discharge. ___
was negative and RF very mildly elevated. Patient's fevers and
rash were thought likely due to a viral illness. Given patient
was hemodynamically stable and afebrile x 24hrs off of
antibiotics, the patient was discharged home. The patient was
told to return to the hospital if she had persistent/worsening
fevers or if she was not tolerating PO intake. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Hyponatremia, Chronic Ventilator Dependence
Major Surgical or Invasive Procedure:
___ Placement ___
History of Present Illness:
___ with PMH of AF on apixaban, CVA several months ago, s/p
PEG tube, h/o nonbleeding gastric ulcer (asymptomatic), presents
from ___ with hyponatremia and chronic vent dependence.
Patient suffered embolic CVA in ___ in the setting of new
onset atrial fibrillation. She is now s/p tracheostomy and s/p
PEG tube placement. Her neurologic deficit has been slowly
improving (has some residual L sided weakness), but has had
ongoing difficulty weaning from ventilator. She was evaluated
initially at ___ for her respiratory
failure after CVA with LP which was unrevealing and MRI which
was difficult to interpret due to artifact. She was also
evaluated for neuromuscular disease at her LTAC with Achr Ab and
MUSK, both of which were negative. Repeat MRI at ___ on ___
showed mild small vessel disease, no acute or chronic infarcts,
no brainstem infarcts and no enhancing lesions. The etiology of
the patient's weakness remains unclear. There is some
discussion, per notes about possible occult malignancy causing
paraneoplastic syndrome.
___ rehab course has been complicated by intermittent
episodes of hyponatremia, last occurring ___ while trialing
vent wean. She was found at that time to have UNa 63, Uosm 518,
TSH 2.5. The patient's Na per recent lab work shows ___,
___. The patient has been getting NaCl flushes with her
TF and salt tabs with persistent low Na. Patient was transferred
to ___ for further management.
In terms of other medical history, patient seems to have been
recently treated for a urinary tract infection - with cultures
growning pseudomonas (sensitive to ceftaz, cefepime, gent,
imipenem, tobra, zosyn) and enterococcus faecium (sensitive to
vanc only). CXR on ___ showed unchanged left basilar opacity.
In ED initial VS: 99.5 ___ 18 100%
- Exam: alert and oriented.
- Labs: Na 117, Cl 79, Phos 2.2, Osm 252, UA w/large leuks,
moderate blood, > 182 WBCs, many bacteria, lactate 2.4, UNa <
20, UOsm 500, WBC 12.8, Hgb 11.1
- Imaging notable for: CXR with bilateral basal linear
atelectasis.
- Patient was given: 1gm ceftriaxone IV, IV NS
- Consults: Renal (see A+P below)
VS prior to transfer: 98.4 99 113/50 20 100% Trach
On arrival to the MICU, patient requesting TF. Endorses thirst.
Denies pain.
REVIEW OF SYSTEMS: (+) per HPI, all other ROS otherwise negative
Past Medical History:
- CVA unknown location
- Migraine Headaches
- Rheumatic Fever w/ normal TTE
- DJD
- Hypertension
- Left axillary Pain
- s/p cholecystectomy
- s/p appendectomy
- s/p BTL
- s/p temporal artery biopsy
- Breast Cancer s/p R breast biopsy s/p XRT
Social History:
___
Family History:
- Mom deceased of leukemia
- Father w/prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98, HR 77, BP 122/66, RR 16, O2 100%
GENERAL: well appearing, NAD
HEENT: Sclera anicteric
NECK: no JVD
LUNGS:RRR, normal S1 + S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: WWP, no edema
NEURO: grip strength ___ on L < R ___, weakness with abduction
of LUE
SKIN: no rash
DISCHARGE PHYSICAL EXAM:
VS: 97.4, HR 117, BP 126/61, RR 17, O2 100% on trach amsk
GENERAL: well appearing, NAD
HEENT: Sclera anicteric
NECK: no JVD
LUNGS:RRR, normal S1 + S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: WWP, no edema
NEURO: grip strength ___ on L < R ___, weakness with abduction
of LUE
SKIN: no rash
Pertinent Results:
ADMISSION LABS:
___ 02:02PM BLOOD WBC-12.8* RBC-3.76* Hgb-11.1* Hct-32.1*
MCV-85 MCH-29.5 MCHC-34.6 RDW-16.6* RDWSD-51.4* Plt ___
___ 02:02PM BLOOD Neuts-76.9* Lymphs-14.4* Monos-8.0
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.85* AbsLymp-1.85
AbsMono-1.03* AbsEos-0.00* AbsBaso-0.01
___ 02:02PM BLOOD ___ PTT-26.8 ___
___ 12:54PM BLOOD Glucose-90 UreaN-25* Creat-0.5 Na-117*
K-4.9 Cl-79* HCO3-29 AnGap-14
___ 12:54PM BLOOD Calcium-9.4 Phos-2.2* Mg-1.8
___ 12:54PM BLOOD Osmolal-252*
___ 11:06PM BLOOD ___ Temp-36.6 Tidal V-20 pO2-120*
pCO2-50* pH-7.40 calTCO2-32* Base XS-5 Intubat-NOT INTUBA
Comment-TRACH MASK
PERTINENT INTERVAL LABS:
___ 07:44PM BLOOD Glucose-81 UreaN-21* Creat-0.3* Na-121*
K-3.8 Cl-85* HCO3-28 AnGap-12
___ 09:04AM BLOOD Glucose-126* UreaN-27* Creat-0.3* Na-123*
K-4.3 Cl-84* HCO3-31 AnGap-12
___ 08:36PM BLOOD Glucose-126* UreaN-16 Creat-0.4 Na-132*
K-4.1 Cl-92* HCO3-27 AnGap-17
___ 06:02AM BLOOD Free T4-1.6
___ 06:02AM BLOOD TSH-1.6
___ 06:02AM BLOOD Cortsol-13.4
___ 05:53PM BLOOD Glucose-133* Lactate-1.7 Na-119* K-4.3
Cl-82*
MICROBIOLOGY:
- UCx ___ 12:54 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING/STUDIES:
CXR ___: Bilateral basal linear atelectasis.
CT CHEST ___:
Bibasal atelectasis versus pneumonia. No masses. Left upper lobe
potential infectious process as well. Substantial kyphosis.
TTE ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. Left ventricular
systolic function is hyperdynamic (EF>75%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. There is no aortic valve stenosis.
No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade.
EMG ___:
Abnormal study. There is electrophysiologic evidence for a
chronic,
generalized, sensorimotor polyneuropathy, of moderate severity
and primarily axonal in nature. There is also evidence for a
generalized myopathic disorder with denervating features, of
moderate severity. In this clinical setting, the overall
electrophysiologic picture is suggestive of critical illness
neuromyopathy; however, an inflammatory myositis cannot be
excluded. There is no evidence for a pre or post-synaptic
disorder of neuromuscular transmission. Of note, these studies
did not explore the significant asymmetry in the patient's
weakness, which is suggestive of a superimposed central lesion;
clinical correlation is advised.
MRI C-spine ___:
Study is moderately degraded by motion, especially on axial
imaging.
Vertebral body alignment is preserved. Vertebral body heights
are preserved. There is no marrow signal abnormality.
The C2-C5 spinal cord demonstrates long segment of T2/STIR
hyperintensity
without evidence of cord expansion or abnormal enhancement. At
C2-C3, there a focus of associated slow diffusion (10:5). There
is hypointensity on T1 weighted images. The signal abnormality
appears to be centrally located with areas extending to the
anterior column of the spinal cord.
Intervertebral disc signal and heights are preserved. There is
no prevertebral soft tissue swelling.. The visualized portion of
the posterior fossa, cervicomedullary junction, paranasal
sinuses and lung apicesare preserved.
At C2-3 there is no spinal canal stenosis, mild left and no
right neural
foraminal narrowing secondary to facet and uncovertebral joint
osteophytes..
At C3-4 there is moderate spinal canal stenosis with moderate
bilateral neural foraminal narrowing secondary to disc bulge,
ligamentum flavum thickening, bilateral facet and uncovertebral
joint osteophytes.
At C4-5 there is mild spinal canal stenosis with severe left and
moderate
right neural foraminal narrowing secondary to disc bulge,
ligamentum flavum thickening, bilateral facet and uncovertebral
joint osteophytes.
At C5-6 there is moderate spinal canal stenosis with severe
bilateral neural foraminal narrowing secondary to disc bulge,
ligamentum flavum thickening, bilateral facet and uncovertebral
joint osteophytes causing remodeling of the spinal cord.
At C6-7 there is mild spinal canal stenosis with mild bilateral
neural
foraminal narrowing secondary to disc bulge, ligamentum flavum
thickening, and bilateral facet and uncovertebral joint
osteophytes.
At C7-T1 there is no spinal canal or neural foraminal stenosis.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Nonenhancing long segment C2-C5 spinal cord signal
abnormality as
described, concerning for cord ischemia, with differential
considerations of demyelinating process, transverse myelitis,
neuromyelitis optica and
posttraumatic myelomalacia.
3. Moderate cervical spondylosis, most pronounced at C3-C4 and
C5-C6 levels with multilevel moderate to severe neural foraminal
narrowing, as described.
DISCHARGE LABS:
___ 04:00AM BLOOD WBC-7.7 RBC-3.48* Hgb-10.1* Hct-31.5*
MCV-91 MCH-29.0 MCHC-32.1 RDW-16.4* RDWSD-54.4* Plt ___
___ 04:00AM BLOOD Glucose-138* UreaN-12 Creat-0.3* Na-131*
K-3.6 Cl-90* HCO3-33* AnGap-12
___ 04:00AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.8
___ 09:38PM BLOOD Type-ART pO2-117* pCO2-59* pH-7.38
calTCO2-36* Base XS-8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
3. Omeprazole 20 mg PO BID
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
5. Albuterol Inhaler 2 PUFF IH Q6H
6. Bisacodyl ___AILY:PRN constipation
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. LORazepam 0.25 mg PO TID
9. Apixaban 5 mg PO BID
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. melatonin 2 mg oral QHS
12. Acetaminophen 975 mg PO Q8H:PRN Pain - Mild
13. Miconazole Powder 2% 1 Appl TP BID
14. melatonin 1 mg oral QPM:PRN
15. Polyethylene Glycol 17 g PO BID:PRN constipation
16. Metoprolol Tartrate 50 mg PO TID
17. LORazepam 0.5 mg PO Q3H:PRN anxiety
18. amLODIPine 10 mg PO DAILY
19. Sodium Chloride 1 gm PO BID
20. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
21. Simethicone 80 mg PO TID:PRN gas pain
22. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 1 gm IV Q24H Duration: 7 Days
2. Acetaminophen 975 mg PO Q8H:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q6H
4. Apixaban 5 mg PO BID
5. Atorvastatin 40 mg PO QPM
6. Bisacodyl ___AILY:PRN constipation
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
8. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
9. LORazepam 0.5 mg PO Q3H:PRN anxiety
10. LORazepam 0.25 mg PO TID
11. melatonin 1 mg oral QPM:PRN
12. melatonin 2 mg oral QHS
13. Metoprolol Tartrate 50 mg PO TID
14. Miconazole Powder 2% 1 Appl TP BID
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Omeprazole 20 mg PO BID
17. Ondansetron 4 mg PO Q8H:PRN nausea
18. Polyethylene Glycol 17 g PO BID:PRN constipation
19. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
20. Simethicone 80 mg PO TID:PRN gas pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Hyponatremia ___ SIADH, Complicated Urinary
Tract Infection, Chronic Hypoxemic Respiratory Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with resp failure// ? infectious process
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph ___.
FINDINGS:
Linear atelectasis of the right lung base and the right midlung as well as
left lower lobe. Tracheostomy noted. Cardiac size is normal. There is no
pneumothorax. Left costophrenic angle appears excluded from the edges of the
film. No large pleural effusions.
IMPRESSION:
Bilateral basal linear atelectasis.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with SIADH, evaluating for pulmonary pathology
leading to this syndrome. Please administer contrast at your discretion.
Patient is fluid restricted.// Malignancy, Mass, Pneumonia leading to SIADH-
Please use contrast at your discretion. Patient is fluid restricted.
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: CHEST RADIOGRAPH FROM ___
FINDINGS:
Left thyroid nodules are present. Aorta and pulmonary arteries are tortuous.
Heart size is enlarged. No pericardial effusion is present. Bibasal
consolidation most likely represent atelectasis although infectious process is
a possibility. R left upper lobe opacity, series 5 image 94 might potentially
represent additional focus of infectious process.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
Substantial kyphosis is present.
Airways are patent to the subsegmental level bilaterally. No pulmonary
nodules masses or consolidations demonstrated.
IMPRESSION:
Bibasal atelectasis versus pneumonia
No masses
Left upper lobe potential infectious process as well
Substantial kyphosis.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with PICC// Pt had a L PICC,44.5cm ___ ___
Contact name: ___: ___
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Left PICC line tip is in the mid neck in internal jugular vein, should be
pulled back and repositioned. Consider pulled back 13 cm, and advancing 16
cm. Tracheostomy. Shallow inspiration accentuates heart size. Small left
pleural effusion, left basilar consolidation, mildly more prominent. Minimal
right basilar opacity, likely atelectasis. Trace right pleural effusion is
likely. No edema. Strand of fibrosis or atelectasis left mid lung laterally,
stable. No pneumothorax.
IMPRESSION:
Left PICC line tip is in the neck, it should be repositioned, see above.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old woman with atrial fibrillation, stroke, progressive
weakness, respiratory failure. Evaluate for lesion, cord impingement.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed. Sagittal diffusion
weighted imaging was then performed. After administration of 6 mL of Gadavist
intravenous contrast, sagittal and axial T1 weighted imaging was performed.
COMPARISON: None.
FINDINGS:
Study is moderately degraded by motion, especially on axial imaging.
Vertebral body alignment is preserved. Vertebral body heights are preserved.
There is no marrow signal abnormality.
The C2-C5 spinal cord demonstrates long segment of T2/STIR hyperintensity
without evidence of cord expansion or abnormal enhancement. At C2-C3, there a
focus of associated slow diffusion (10:5). There is hypointensity on T1
weighted images. The signal abnormality appears to be centrally located with
areas extending to the anterior column of the spinal cord.
Intervertebral disc signal and heights are preserved. There is no prevertebral
soft tissue swelling.. The visualized portion of the posterior fossa,
cervicomedullary junction, paranasal sinuses and lung apicesare preserved.
At C2-3 there is no spinal canal stenosis, mild left and no right neural
foraminal narrowing secondary to facet and uncovertebral joint osteophytes..
At C3-4 there is moderate spinal canal stenosis with moderate bilateral neural
foraminal narrowing secondary to disc bulge, ligamentum flavum thickening,
bilateral facet and uncovertebral joint osteophytes.
At C4-5 there is mild spinal canal stenosis with severe left and moderate
right neural foraminal narrowing secondary to disc bulge, ligamentum flavum
thickening, bilateral facet and uncovertebral joint osteophytes.
At C5-6 there is moderate spinal canal stenosis with severe bilateral neural
foraminal narrowing secondary to disc bulge, ligamentum flavum thickening,
bilateral facet and uncovertebral joint osteophytes causing remodeling of the
spinal cord.
At C6-7 there is mild spinal canal stenosis with mild bilateral neural
foraminal narrowing secondary to disc bulge, ligamentum flavum thickening, and
bilateral facet and uncovertebral joint osteophytes.
At C7-T1 there is no spinal canal or neural foraminal stenosis.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Nonenhancing long segment C2-C5 spinal cord signal abnormality as
described, concerning for cord ischemia, with differential considerations of
demyelinating process, transverse myelitis, neuromyelitis optica and
posttraumatic myelomalacia.
3. Moderate cervical spondylosis, most pronounced at C3-C4 and C5-C6 levels
with multilevel moderate to severe neural foraminal narrowing, as described.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:30 am, 2
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with PICC// malpostioned L ___
___ ___ Contact name: ___: ___
TECHNIQUE: Chest single view
COMPARISON: ___ 18:45
FINDINGS:
Since prior, there has been no significant change, left PICC line tip is again
seen in the left neck, should be pulled back and repositioned.
IMPRESSION:
Left PICC line is in the left neck.
Radiology Report
INDICATION: ___ year old woman with PICC line coiled into the neck// PICC
replacement
COMPARISON: Chest radiograph ___
TECHNIQUE: OPERATORS: Dr. ___ radiology attending)
performed the procedure.
ANESTHESIA: Local
MEDICATIONS: Lidocaine
CONTRAST: None ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.6, 1 mGy
PROCEDURE: 1. Repositioning of left PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed and a Nitinol guidewire was introduced
into the superior vena cava (SVC). A peel-away sheath was then placed over a
guidewire. The guidewire was then advanced into the superior vena cava. A
double lumen PIC line measuring 46 cm in length was then placed through the
peel-away sheath with its tip positioned in the distal SVC under fluoroscopic
guidance. Position of the catheter was confirmed by a fluoroscopic spot film
of the chest. The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing left arm approach PICC with tip in the subclavian vein replaced
with a new double lumen PIC line with tip in the low SVC.
IMPRESSION:
Successful placement of a 46 cm left arm approach double lumen PowerPICC with
tip in the low SVC. The line is ready to use.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal sodium level
Diagnosed with Abn lev hormones in specimens from female genital organs
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ with PMH of AF on apixaban, CVA several
months ago, s/p PEG tube, h/o nonbleeding gastric ulcer
(asymptomatic), presents from LTAC with hyponatremia and chronic
vent dependence. Hyponatremia was thought to be secondary to
SIADH and improved with free water restriction. The patient was
able to be weaned from her ventilator and tolerated trach mask
at the time of discharge. Neurology was consulted for weakness
and recommended EMG and imaging of cervical spine to complete
work-up already in progress
# HYPONATREMIA: Patient presented with Na to 117. The etiology
of her hyponatremia was thought to underlying SIADH with some
component of hypovolemia. Na improved to 120s with 1L NS fluid
resuscitation initially on presentation. She was maintained on
fluid restriction thereafter with repeat urine lytes consistent
with SIADH. The patient did receive desmopressin x1 due to
concern for rapidly increased UOP, however this stabilized. The
patient's NaCl tabs were held as her Na improved without
additional supplementation. TSH and cortisol were WNL. CT Chest
showed no obvious lung pathology. Responded to stopping free
water boluses in tube feeds. Discharge Na 131.
# WEAKNESS
# CHRONIC RESPIRATORY FAILURE: Patient with undifferentiated
neurological disease and chronic vent dependence (since ___. She was evaluated with an LP (given unusual presentation)
which was unrevealing, and MRI which was difficult to interpret
due to artifact on her initial hospitalization. Her neurologic
deficit had slowly improved at rehab, though it was suspected
that ongoing weakness was contributing to her inability to wean
from vent. Work-up at her LTAC including Achr Ab and MUSK
antibody were negative. Repeat MRI at ___ on ___ showed mild
small vessel disease, no acute or chronic infarcts, no brainstem
infarcts and no enhancing lesions. Neuro consulted and
recommended further workup of primary motor weakness with MRI
spine and EMG. EMG suggestive of critical illness myopathy, but
could not exclude inflammatory myositis. MRI spine showed
Nonenhancing long segment C2-C5 spinal cord signal abnormality
as described, concerning for cord ischemia.Patient was able to
be weaned from ventilator support while hospitalized and
tolerated trach mask well. There was felt to also be some
anxiety component to her prior difficulty with weaning. She was
treated with lorazepam 1mg daily PRN with improvement. Patient
was continued on her home albuterol.
# URINARY TRACT INFECTION: UCx on admission with kleb pneumonia
sensitive to ceftriaxone, plan to treat with 7 day course from
day foley switched out ___. Last day ___.
# H/O CVA, Cervical spine ischemia: patient with reportedly MCA
CVA in ___ with residual left sided weakness, which was
improving at rehab. As above, MRI on ___ at ___ without
evidence of acute or chronic infarct. The patient was evaluated
for other causes of weakness with MRI C-spine and EMG. The
patient was continued on her home atorvastatin 40mg daily.
# H/O PEPTIC ULCER: reportedly asymptomatic, per OSH records
unknown if tested for H pylori. Continued PPI and simethicone
while hospitalized.
# H/O ATRIAL FIBRILLATION: continued home apixaban 5mg BID for
anticoagulation and metoprolol 50mg PO TID.
# ANXIETY/INSOMNIA: continued lorazepam PRN and trazodone.
Restarted home diphenhydramine and melatonin at discharge.
# HYPERTENSION: held home amlodipine and lisinopril during
hospitalization with good BP control.
TRANSITIONAL ISSUES:
- Continue ceftriaxone for treatment of complicated UTI through
___
- Hold anti-hypertensive regimen held while hospitalized with
good BP control. Consider restarting if needed after discharge.
- Continue voiding trial after discharge, resume straight
catheterization PRN. Consider urology follow up if persistent
urinary retention.
- Access: PICC placed during hospitalization given need for
frequent lab draws and IV antibiotics. Consider removal of PICC
pending stabilization of Na levels and pending treatment of
infection ___.
- Continue to monitor Na every other day until stabilization.
Continue to hold free water flushes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Imdur / metoprolol
Attending: ___.
Chief Complaint:
asymptomatic bradycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ speaking M with history of CAD, CHF, COPD, HTN,
and likely ectopic atrial rhythm with bradycardia refered from
PCP for symptomatic bradycardia. Patient's baseline sinus brady
to the ___. In adult daycare his HR was 38 and was in the ___ in
the PCP ___. PCP note describes SOB and dizziness. Patient
describes his SOB as baseline along with his dizziness. He took
some meclazine and the dizziness resolved. He also had some left
temporal headache that is similar to his normal headaches that
resolved with tylenol.
There was a question of medication error. He lives in an
apartment with a visiting nursing who helps him with his meds.
He only has meclazine and ambien that he takes himeself. He only
took the metoprolol that is in the pill box. He thinks he may
have taken 2 ambien last night. Depressed mood since his wife's
passing, no suicidial ideation.
In the ED, initial VS were:
98.3 40 167/74 18 99% RA
He denies f/c, chest discomfort, palpitations, abdominal pain,
worsening edema. Pt's ECG showed sinus brady with 1st degree AV
block. No evdience of acute ischemia. Pt's labs were at
baseline. Troponins were sent, first was 0.03. No evidence of
infection or acute process on CXR, no fever, no leukocytosis,
bland UA. Pt was given atropine 1 mg IV x 1 w/ no response in HR
(still in mid ___. Pt's beta blockers were held and pacer pads
were placed.
On arrival to the floor, VS:
97.4, 180/92, 51, 18, 96% RA
Via ___ interpreter:
Pt reports that he is feeling fine. States that he was feeling
well and was serendipitously found to have low HR. He has no
chest pain, no fevers, no chills. No lightheadedness, no feeling
faint. Reports intermittent dizziness, which has been a chronic
problem for him, which resolves with meclizine. Reports
unchanged chronic dry cough for decades. No nausea or vomiting.
Reports constipation. Reports difficulty initiating a stream of
urine.
Past Medical History:
1. Coronary artery disease
- Myocardial infarction (___)
- Cardiac cath
-->LMCA normal
-->LAD 90% lesion (STENTED with rescue PTCA of the patient's
second diagonal)
-->Diagonal 50% lesion
-->OM1 40% lesion
-->RCA 20% lesion.
-->Probable coronary distal perforation and a secondary coronary
AV fistula complicated the procedure
2. Hyperlipidemia
3. Peptic ulcer disease
4. Chronic obstructive pulmonary disease
5. Back pain (as per HPI)
6. Insomnia
7. Degenerative joint disease
8. History of colonic polyps
9. Hearing loss
Social History:
___
Family History:
Mother died at age ___ of breast cancer, and his father died at
___
in World War II. He does not have any siblings.
Physical Exam:
Admission exam:
97.4, 180/92, 51, 18, 96% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - inspiratory crackles in R base, otherwise clear.
HEART - PMI non-displaced, regular rhythm, slow rate, no MRG, nl
S1-S2
ABDOMEN - obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema bilaterally, slightly greater on R,
2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge exam:
afebrile SBP 150s heart rates consistently in ___ mid-high ___
on RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - inspiratory crackles in R base, otherwise clear.
HEART - PMI non-displaced, regular rhythm, slow rate, no MRG, nl
S1-S2
ABDOMEN - obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema bilaterally, slightly greater on R,
2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
General labs:
___ 04:50PM BLOOD WBC-8.4 RBC-4.40* Hgb-13.1* Hct-41.2
MCV-94 MCH-29.8 MCHC-31.7 RDW-13.1 Plt ___
___ 06:20AM BLOOD WBC-9.6 RBC-4.43* Hgb-13.4* Hct-41.3
MCV-93 MCH-30.3 MCHC-32.6 RDW-13.0 Plt ___
___ 04:50PM BLOOD Neuts-61.3 ___ Monos-7.5 Eos-3.0
Baso-0.5
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-30.5 ___
___ 04:50PM BLOOD Plt ___
___ 06:20AM BLOOD ALT-18 AST-23 LD(LDH)-291* CK(CPK)-202
AlkPhos-41 TotBili-0.5
___ 06:20AM BLOOD Albumin-3.6 Calcium-9.2 Phos-3.2 Mg-1.8
___ 04:50PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0
___ 11:18PM BLOOD TSH-3.3
Cardiac labs:
___ 11:18PM BLOOD CK(CPK)-222
___ 04:50PM BLOOD CK(CPK)-255
___ 06:20AM BLOOD CK-MB-5 cTropnT-0.03*
___ 11:18PM BLOOD cTropnT-0.03*
___ 11:18PM BLOOD CK-MB-6
___ 04:50PM BLOOD cTropnT-0.03*
___ 04:50PM BLOOD CK-MB-7
CXR ___:
EXAM: AP and lateral views of the chest.
CLINICAL INFORMATION: Coronary artery disease, CHF, COPD,
hypertension,
bradycardia with worsening sinus bradycardia.
COMPARISON: ___.
FINDINGS: AP upright frontal and lateral views of the chest
were obtained. There are low lung volumes, which accentuate the
bronchovascular markings. Given this, no focal consolidation,
pleural effusion, or evidence of pneumothorax is seen. There is
minimal interstitial edema. The cardiac and mediastinal
silhouettes are unremarkable. There is persistent elevation of
the right hemidiaphragm.
IMPRESSION: Low lung volumes, which accentuate the
bronchovascular markings. Given this, there is minimal
interstitial pulmonary edema.
EKG ___ (team read): sinus bradycardia with PACs
(telemetry showed likely Mobitz I on occasion)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. traZODONE 50 mg PO HS:PRN insomnia
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, sob
3. Desonide 0.05% Cream 1 Appl TP BID itchiness behind ear,
chest
no more than 2 wks / month
4. diclofenac epolamine *NF* 1.3 % Topical qhs
apply to affected area
5. diclofenac sodium *NF* 1 % Topical tid back pain
6. Furosemide 10 mg PO QAM
hold for sbp < 90
7. Hydrocortisone Acetate Suppository 1 SUPP PR QHS
8. Lidocaine 5% Patch 1 PTCH TD DAILY
9. Losartan Potassium 25 mg PO DAILY
hold for sbp < 90
10. Meclizine 12.5 mg PO Q8H:PRN dizziness
11. Metoprolol Tartrate 25 mg PO DAILY
hold for sbp < 90
12. Nitroglycerin SL 0.3 mg SL PRN chest pain
13. Omeprazole 20 mg PO DAILY Start: In am
14. Pravastatin 40 mg PO DAILY Start: In am
15. Spiriva with HandiHaler *NF* (tiotropium bromide) 18 mcg
Inhalation daily
16. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
17. Triamcinolone Acetonide 0.025% Cream 1 Appl TP QHS
18. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
19. Aspirin 81 mg PO DAILY Start: In am
20. Docusate Sodium 100 mg PO BID
21. Senna 1 TAB PO BID:PRN constipation
22. fluorouracil *NF* 5 % Topical BID Duration: 1 Months
to/around scar on left upper chest only for one month
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 10 mg PO QAM
hold for sbp < 90
5. Losartan Potassium 50 mg PO DAILY
6. Meclizine 12.5 mg PO Q8H:PRN dizziness
7. Desonide 0.05% Cream 1 Appl TP BID itchiness behind ear,
chest
no more than 2 wks / month
8. diclofenac epolamine *NF* 1.3 % Topical qhs
apply to affected area
9. diclofenac sodium *NF* 1 % TOPICAL TID back pain
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 40 mg PO DAILY
12. Senna 1 TAB PO BID:PRN constipation
13. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
14. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
15. fluorouracil *NF* 5 % Topical BID Duration: 1 Months
to/around scar on left upper chest only for one month
16. Hydrocortisone Acetate Suppository 1 SUPP PR QHS
17. Lidocaine 5% Patch 1 PTCH TD DAILY
18. Nitroglycerin SL 0.3 mg SL PRN chest pain
19. Spiriva with HandiHaler *NF* (tiotropium bromide) 18 mcg
Inhalation daily
20. traZODONE 50 mg PO HS:PRN insomnia
21. Triamcinolone Acetonide 0.025% Cream 1 Appl TP QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses: sinus bradycardia, intermittent Mobitz I
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: AP and lateral views of the chest.
CLINICAL INFORMATION: Coronary artery disease, CHF, COPD, hypertension,
bradycardia with worsening sinus bradycardia.
___.
FINDINGS: AP upright frontal and lateral views of the chest were obtained.
There are low lung volumes, which accentuate the bronchovascular markings.
Given this, no focal consolidation, pleural effusion, or evidence of
pneumothorax is seen. There is minimal interstitial edema. The cardiac and
mediastinal silhouettes are unremarkable. There is persistent elevation of
the right hemidiaphragm.
IMPRESSION: Low lung volumes, which accentuate the bronchovascular markings.
Given this, there is minimal interstitial pulmonary edema.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: BRADYCARDIA
Diagnosed with CARDIAC DYSRHYTHMIAS NEC, SHORTNESS OF BREATH, VERTIGO/DIZZINESS
temperature: 98.3
heartrate: 40.0
resprate: 18.0
o2sat: 99.0
sbp: 167.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ yo ___ speaking M with history of CAD, CHF, COPD, HTN,
and likely ectopic atrial rhythm with bradycardia refered from
PCP for symptomatic bradycardia.
ACTIVE ISSUES
# Sinus bradycardia, occasional Mobitz I: Patient seems to have
been bradycardic in a similar rhythm since at least ___. At
some point over the past several years he developed a right
bundle branch block. However, his current EKGs do not show any
significant difference from prior and after discontinuation of
his metoprolol his heart rate rose to the ___, where it remained
for the day. He was discharged without metoprolol. To compensate
for any potential increase in blood pressure after
discontinuation of metoprolol, his losartan was increased from
25 to 50 (further, he was hypertensive to the 180s on admission
and asymptomatic). He was discharged with a systolic pressure in
the 150s.
INACTIVE ISSUES
# Coronary artery disease: h/o single vessle disease s/p LAD
stent in ___. Most recent ETT in ___ shows no evidence of any
additional perfusion limitations.
The patient was continued on his home asa 81, pravastatin.
# COPD: home albuterol, tiotropium
# hypertension: home furosemide, losartan
# GERD: home omeprazole
# chronic pain: home tramadol, holding various creams and
patches for now
TRANSITIONAL ISSUES
# Sinus bradycardia: The patient was sent out without metoprolol
and on an increased dose of losartan. His symptoms of cough and
occasional vertigo have been long-standing (20+ years) but he
should be followed for development of new symptoms which might
indicate placement of a permanent pacemaker. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen / Levsin / chlorhexadine / Sulfa
(Sulfonamide Antibiotics) / heparin / levofloxacin / rifaximin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of secondary sclerosing
cholangitis,
recurrent bouts of cholangitis, with recent admission in
___, presenting with worsening abdominal pain.
Of note, she was recently admitted from ___ to ___
with abdominal pain. MRCP during that admission was significant
for worsening cholangitis. She was treated with ceftazidime and
flagyl, with a plan to complete a two week course, and
subsequently start doxycycline and metronidazole for longterm
suppression. She is followed in ___ clinic by ___. On
___, she was seen by Dr. ___ due to
escalating cholangitis symptoms, she was switched from
suppressive doxycycline and metronidazole to augmentin. She
tried this for a few days, but due to increasing abdominal pain,
switched back to doxycycline and metronidazole. She was again
seen by Dr. ___ ID on ___, where she was found
to have persistent and escalating abdominal pain. Due to
concerns regarding increasing abdominal pain and concern for
cholangitis, she underwent an outpatient MRCP at an OSH,
unfortunately the study was incomplete and cholangitis could not
be excluded. She was continued on doxycycline and metronidazole,
however, given lack of her symptoms to improve, she presented to
___ for further evaluation.
In the ED, initial vitals were: 97.4 104 139/73 18 100% RA.
Exam notable for teary patient, did not allow physician to
palpate ___ due to pain.
Labs showed WBC of 7.7, H/H of 14.1/43.3, Plt 156. BMP not
obtained. LFTS WNL with ALT/AST 33/40, t. bili of 0.3, lipase
20.
Of note, she had an MRCP done at an OSH and brought the disc in
with her. Per the ED, they requested a reread of her MRCP, but
it was a poor study and unable to be read. Repeat MR of the
abdomen was performed.
Received 15 mg oxycodone x2 , 5 mg diazepam, 500 mg IV flagyl,
2 g ceftrazidime.
Transfer VS were 98.7 72 ___ 99% RA .
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports that initially after
discharge she felt her symptoms improved. She felt that she was
getting better on the IV antibiotics. Once she switched to the
oral antibiotics and her PICC line was discontinued, she felt
that she started to decline. She reported feeling generally
unwell and ___ pain radiating to the back. Over the past week,
she reports that her abdominal pain has gotten significantly
worse. She endorses nausea and occasional vomiting. She also
endorses epigastric pain that radiates up her sternum and is
causing substernal pressure. She reports that when she pushes on
her abdomen, the pain in her chest worsens. She endorses
unchanged diarrhea. She reports that she has not eaten in the
past two days. She also reports that she has begun to experience
heart palpitations, a pound headache, ringing in her right ear,
a frontal headache and twitching pain in her head. She endorses
fevers at home to 100.7 this morning. She endorses some weight
loss.
She does not want to take flagyl because she feels that it is
bad for her. She reports that she takes diazepam every 8 hours,
but her current prescription is for 5 mg BID.
Past Medical History:
Past Medical History:
Recurrent cholangitis, Arthritis, headaches, reflux, gallstones,
chronic liver disease, pancreatic divisum
Past Surgical History:
c section, lap chole, paraspinal mass excision, benign breast
mass, multiple ERCPs, percutaneous cholangiogram, bile duct
exploration/RNY hepaticojejunostomy as above ___ by Dr
___
___ History:
___
Family History:
Mother- ___, Early onset Alzheimer's disease
Dad- healthy, hx of Meniere's
Paternal gma- SLE
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 97.9 PO 130 / 80 70 18 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, +mild thrush on tongue, EOMI,
PERRL, neck supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, ___ tenderness to palpation with
guarding of that area, rest of the abdomen is soft with minimal
tenderness and no guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: alert, oriented, moves all extremities
DISCHARGE EXAM
==============
Vital Signs: Tmax 98.8 BP 110-120/70-80s HR 60-90s RR 18 ___ on RA
General: Alert, oriented, in no acute distress, tearful
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert, oriented, moves all extremities
Pertinent Results:
ADMISSION LABS
==============
___ 01:20PM BLOOD WBC-7.7 RBC-4.90 Hgb-14.1 Hct-43.3 MCV-88
MCH-28.8 MCHC-32.6 RDW-13.5 RDWSD-43.8 Plt ___
___ 01:20PM BLOOD ___ PTT-40.5* ___
___ 01:20PM BLOOD Plt ___
___ 01:20PM BLOOD ALT-33 AST-40 TotBili-0.3
___ 01:20PM BLOOD Lipase-20
___ 01:20PM BLOOD Albumin-4.7
___ 01:20PM BLOOD HCG-<5
MICRO
=====
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-FINALEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-FINALEMERGENCY WARD
NOTABLE LABS
============
___ SED RATE 2
IMAGING
=======
___ SECOND READ MR ABDOMEN
IMPRESSION:
1. No significant change in mild intrahepatic biliary duct
dilatation within
segments V and II compatible with patient's known sclerosing
cholangitis. No
new focal areas of biliary ductal irregularity or dilatation.
2. Minimal peripheral wedge-shaped T2 hyperintensity within
segment V
suggestive of mild active cholangitis. No intrahepatic
abscesses.
3. Stable 3 mm cystic lesion in the uncinate process likely
representing
side-branch IPMN.
___ BILAT UPPER EXT US
IMPRESSION:
No evidence of deep vein thrombosis in the bilateral upper
extremity veins.
___ CXR
IMPRESSION:
In comparison with the study of ___, there is little
change and no
evidence of acute cardiopulmonary disease. No pneumonia,
vascular congestion,
or
DISCHARGE LABS
==============
___ 05:04AM BLOOD WBC-6.2 RBC-4.46 Hgb-12.9 Hct-39.2 MCV-88
MCH-28.9 MCHC-32.9 RDW-13.3 RDWSD-42.9 Plt ___
___ 05:04AM BLOOD Plt ___
___ 05:04AM BLOOD ___ PTT-32.9 ___
___ 05:04AM BLOOD Glucose-105* UreaN-3* Creat-0.6 Na-138
K-3.7 Cl-98 HCO3-26 AnGap-18
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 5 mg PO Q12H:PRN anxiety
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE:PRN anaphylaxis
4. FoLIC Acid 1 mg PO DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain - Mild
7. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
8. Pantoprazole 40 mg PO Q24H
9. Vitamin D 1000 UNIT PO DAILY
10. MetroNIDAZOLE 500 mg PO Q8H
11. Cholestyramine 4 gm PO DAILY:PRN itching
12. Lactobacillus acidophilus 2 capsules oral BID
13. Ursodiol 600 mg PO BID
14. LOPERamide 2 mg PO DAILY:PRN diarrhea
15. Senna 8.6 mg PO BID constipation
16. Doxycycline Hyclate 100 mg PO Q12H
17. Metoclopramide 10 mg PO BID:PRN nausea
18. Enoxaparin Sodium 60 mg SC Q12H
Discharge Medications:
1. Simethicone 40-80 mg PO QID:PRN epigastric pain
RX *simethicone 80 mg 1 tab by mouth four times a day Disp #*120
Tablet Refills:*0
2. Cholestyramine 4 gm PO DAILY:PRN itching
3. Diazepam 5 mg PO Q12H:PRN anxiety
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
6. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE:PRN anaphylaxis
7. FoLIC Acid 1 mg PO DAILY
8. Lactobacillus acidophilus 2 capsules oral BID
9. LOPERamide 2 mg PO DAILY:PRN diarrhea
10. Metoclopramide 10 mg PO BID:PRN nausea
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain - Mild
13. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
14. Pantoprazole 40 mg PO Q24H
15. Senna 8.6 mg PO BID constipation
16. Ursodiol 600 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Inflammatory Cholangitis
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Second opinion read on an MRCP
INDICATION: History: ___ with sclerosing cholangitis (presumably related to
complicated biliary stone disease) s/p cholecystectomy and hx of multiple
episodes of choledocholithiasis here w/abdominal pain c/f recurrent
cholangitis. Had MRCP at OSH recently // Evidence of cholangitis?
TECHNIQUE: Second opinion read on an MRCP performed at outside hospital dated
___ without the administration of intravenous contrast.
COMPARISON: Compared to prior MRI dated ___.
FINDINGS:
Lower Thorax: Lung bases are clear. No pleural or pericardial effusion.
Liver: Liver demonstrates normal contours without morphological signs of liver
cirrhosis. No worrisome hepatic mass lesions within limitations of a
noncontrast study.
Biliary: Patient status post cholecystectomy and hepaticojejunostomy. The
hepaticojejunostomy anastomosis site is patent (series 501, image 45). Stable
mild intrahepatic biliary duct dilatation and irregularity involving the
intrahepatic biliary ducts within segment V and II (series 301, image 13 and 5
and series 501, image 73) in keeping with known sclerosing cholangitis. There
is peripheral wedge-shaped T2 hyperintensity within segment V suggestive of
mild cholangitis. No findings to suggest intrahepatic abscess collections.
Pancreas: Pancreas demonstrates normal morphology and signal characteristics.
There is a stable 3 mm cystic lesion in the uncinate process (series 501,
image 55), likely representing a side-branch IPMN. There is pancreas divisum.
The main pancreatic duct is not dilated. No worrisome pancreatic lesions.
Spleen: Spleen is normal in size and signal characteristics.
Adrenal Glands: Adrenal glands are normal bilaterally without focal nodules.
Kidneys: Kidneys are symmetric in size bilaterally and demonstrate good
corticomedullary differentiation. No suspicious renal masses or
hydronephrosis.
Gastrointestinal Tract: The stomach, visualized small bowel and colon in the
upper abdomen are normal in caliber. No ascites.
Lymph Nodes: No suspicious mesenteric or retroperitoneal lymphadenopathy by
size criteria. Slightly prominent periportal lymph nodes, stable in size from
prior, likely reactive to underlying chronic liver disease.
Vasculature: Abdominal aorta is normal in caliber.
Osseous and Soft Tissue Structures: No suspicious osseous or soft tissue mass
lesions.
IMPRESSION:
1. No significant change in mild intrahepatic biliary duct dilatation within
segments V and II compatible with patient's known sclerosing cholangitis. No
new focal areas of biliary ductal irregularity or dilatation.
2. Minimal peripheral wedge-shaped T2 hyperintensity within segment V
suggestive of mild active cholangitis. No intrahepatic abscesses.
3. Stable 3 mm cystic lesion in the uncinate process likely representing
side-branch IPMN.
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ year old F w/recurrent cholangitis and reported DVTs in both
UE // Please evaluate for DVT in the UE
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The bilateral internal jugular and axillary veins are patent, show normal
color flow and compressibility.
The bilateral brachial, basilic, and cephalic veins are patent, compressible
and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the bilateral upper extremity veins.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with recurrent cholangitis now with chest pain,
pain with palpation, concern for superficial or mediastinal lesion // ___ year
old woman with recurrent cholangitis now with chest pain, pain with palpation,
concern for superficial or mediastinal lesion ___ year old woman with
recurrent cholangitis now with chest pain, pain with palpation, concern for
superficial or mediastinal lesion
IMPRESSION:
In comparison with the study of ___, there is little change and no
evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion,
or
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abd pain, Body pain
Diagnosed with Right upper quadrant pain
temperature: 97.4
heartrate: 104.0
resprate: 18.0
o2sat: 100.0
sbp: 139.0
dbp: 73.0
level of pain: 10
level of acuity: 3.0 | HOSPITAL COURSE
===============
Ms ___ is a ___ yo F with sclerosing cholangitis
(presumably related to complicated biliary stone disease) s/p
cholecystectomy in ___ and hx of multiple episodes of
choledocholithiasis with abdominal pain, poor PO intake and
recent admission for cholangitis which was treated with IV
antibiotics, who presented with recurrent abdominal pain.
# Abdominal Pain: Secondary to chronic inflammation of biliary
tree. MRCP stable from previous in ___, no worsening signs
of inflammation. Additionally ESR <2. LFTs normal. No
leukocytosis. Patient was watched closely off antibiotics for 72
hours with no fevers or leukocytosis. Blood cultures with no
growth. Given these findings infectious etiology highly
unlikely. Discussed with outpatient GI, surgical, and ID
providers who agreed to discontinue antibiotics and avoid future
antibiotics unless laboratory abnormalities, fever, or
significant changes on imaging. Also suspect patient's symptoms
related to chronic medical conditions and her expressed fear of
getting sick or dying and recommended patient follow up with out
patient mental health for coping with her chronic pain and
illness. Patient will need close follow up with PCP, pain
clinic, as well as mental health provider. Additionally as
patient complained of intermittent pain with swallowing would be
reasonable to consider EGD to evaluate for eosinophillic
esophagitis, though defer to outpatient hepatologist.
# Left breast pain: Patient concern for swelling. Normal breast
exam x 2 providers with no lymphadenopathy. Normal mammogram
___. Re-evaluate with PCP but do not feel further imaging
warranted at this time based on physical exam.
# Concern for Blood clot: On going concern for blood clots on
arms, neck. No evidence of swelling on exam. Mental health
provider as above for assistance with coping with chronic
medical conditions.
ACTIVE ISSUES
=============
# Chronic abdominal pain
# Recurrent Cholangitis: Patient with a history of sclerosing
cholangitis s/p cholecystectomy with history of recurrent
cholangitis, most recently in ___, on suppressive
antibiotics as an outpatient, most recently on
doxycycline/flagyl due to increasing abdominal pain. MRCP was
obtained at ___, stable from previous. After family
meeting on ___, decision made to d/c all antibiotics and
monitor, as does not seem to be infectious cause of pain.
Patient with acute pain attack on ___, drew CBC and lipase, all
within normal limits, and pain waned on ___. Repeat family
meeting on ___, with emphasis on avoiding over-testing and
iatrogenic risks.
Antibiotics: IV ceftazidine and flagyl (d1 ___ d/ced on
___, monitored off antibiotics and patient did not spike
fever, discharged home with no antibiotics.
Continued home regimen of oxycodone SR 60 mg q12 hr, oxycodone
15 mg PO q4 hr prn, ursodiol 600 mg PO BID, cholestyramine 4 gm
PO daily. Recommended on discharge that patient follow up with
mental health expert for management of stress associated with
chronic illness.
# Poor PO intake: Continue folic acid 1 mg PO daily, vitamin D
1000 unit daily, metoclopramide 10 mg BID prn nausea, Zofran 4
mg q8 hr prn nausea.
# Anxiety: She was continued on home diazepam as needed.
Recommended on discharge that patient follow up with mental
health expert for management of stress associated with chronic
illness.
# History of PICC associated thrombosis: Patient has a history
of superificial thrombophlebitis of the left basilic vein in the
setting of a midline and PICC in the past. She has a listed
allergy to heparin. Was taking treatment dose Lovenex on
admission. Recieved Lovenox 30 mg subQ q12 hr for DVT
prevention while inpatient. Discharged on her prior treatment
dose of Lovenox, to be adjusted by PCP with recommendation to
either continue anticoagulation for total 3 month course from
thrombosis diagnosis ___ vs discontinue anticoagulation as
clot of superficial vein and no evidence in the literature of
increased risk of vascular complications without treatment.
# Palpitations: Patient with palpitations on admission.
Telemetry overnight with no abnormalities, discontinued next
day, palpitations resolved.
# Multiple Somatic Complaints: During this admission patient
complained of abdominal pain as above, head and neck pain, left
breast pain and left arm swelling, and palpitations. Physical
exam and laboratory testing within normal limits. In reviewing
patient's chart she has had concerns of left breast swelling
related to family history of breast cancer, arm swelling related
to history of blood clots. Patient's behavior and complaints
concerning for a somatoform disorder. Given her underlying
medical conditions, concern was raised during this admission
that patient is at risk for iatrogenic harm due to unnecessary
CT scans with radiation exposure, antibiotics with risk of
developing resistance bacterial infections. Patient refuses to
have psychiatric evaluation at ___ for fear of being labeled
as "crazy" and that her medical complaints will be ignored.
Discussed with patient importance of following up with
outpatient mental health providers for treatment of her likely
underlying condition.
TRANSITIONAL ISSUES
===================
[] Multidisciplinary approach to ongoing abdominal pain: PCP,
___, mental health follow ups. Would avoid further abdominal
imaging unless fever, lab abnormality to avoid unnecessary
radiation exposure.
[] hx PICC associated DVT: appears patient no longer needs
lovenox for DVT ppx with no PICC line in place. Per NP ___
note ___ continue treatment dose though would strongly
consider discontinuing at PCP follow up visit
[] f/u breast pain, mammogram nl ___, consider further imaging
based on physical exam findings
[] consider EGD as outpatient with Dr. ___ evaluation
of ?eosinophilic esophagitis
# CONTACT: ___, sister, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Bactrim / Hydrochlorothiazide / Aricept
Attending: ___
Chief Complaint:
urinary frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ female with history of afib currently on
apixaban, non-progessive/non-vascular diffuse
leukoencephalopathy
, L fronto-parietal punctate stroke ___, living in nursing home
who p/w increased urinary frequency x 48hrs, lethargy,
intermittent fevers, nausea/vomiting ×1 episode. Last weekend
had
voluminous diarrhea which has resolved. She called her PCP ___ urinary frequency yesterday, had dirty catch urine
with increased WBC, Cx pending. Started on nitrofurantoin x 1day
without improvement in sx. Denies dysuria, flank pain, and
hematuria. She is a poor historian due to white matter dementia,
able to answer questions but not able to provide context. Most
of
the information is obtained via text with daughter who is MD,
and
non--MD daughter at bedside. Daughter at bedside states she is
at
cognitive baseline however appears very lethargic.
Past Medical History:
Afib off anticoagulation, prev on warfarin.
h/o C. difficile colitis
remote prior episode of dysarthria and hemianopia with migraine
migraine with aura
Non-progessive, non-vascular diffuse leukoencephalopathy (see
___
HTN, off antihypertensives and BP in low 100s since losing 20 lb
during hospitalization ___.
HLD
peripheral neuropathy
gait instability
CABG in ___
Social History:
___
Family History:
Father with glaucoma, HTN and glomerulonephritis, passed away
from ___
Mother with ___ dementia, rheumatic heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS:97.7PO 145 / 67 73 18 96 Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
CV: Irregular rhythm, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
SKIN: No erythema or breakdown
NEURO: Face symmetric, some irregular movements of tongue to
right side of cheek. Strength ___ throughout all 4 extremities,
sensation to light touch intact over all 4 extremities.
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 755)
Temp: 98.2 (Tm 98.2), BP: 129/81 (129-148/60-81), HR: 61
(61-79), RR: 18 (___), O2 sat: 97% (95-99), O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
CV: Irregularly irregular rhythm, S1/S2, no murmurs, gallops, or
rubs
PULM: CTAB, decreased BS bilateral bases no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants or
over bladder, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
SKIN: No erythema or breakdown
NEURO: Face symmetric, some irregular movements of tongue to
right side of cheek. Strength ___ throughout all 4 extremities,
sensation to light touch intact over all 4 extremities.
PSYCH: ___ woman speaking eloquently with enthusiasm,
mildly dysarthric, borderline socially inappropriate comments,
good attention, goal-oriented thought process, occasional
stereotyped movements of right arm and hand
Pertinent Results:
ADMISSION LABS:
===============
___ 05:07PM BLOOD WBC-22.9* RBC-5.06 Hgb-15.7 Hct-45.3*
MCV-90 MCH-31.0 MCHC-34.7 RDW-13.8 RDWSD-44.0 Plt ___
___ 05:07PM BLOOD Neuts-91.4* Lymphs-3.1* Monos-3.5*
Eos-0.6* Baso-0.2 Im ___ AbsNeut-20.92* AbsLymp-0.70*
AbsMono-0.81* AbsEos-0.14 AbsBaso-0.05
___ 05:07PM BLOOD Glucose-104* UreaN-26* Creat-1.4* Na-139
K-6.8* Cl-100 HCO3-25 AnGap-14
___ 06:05AM BLOOD ALT-23 AST-29 AlkPhos-61 TotBili-3.9*
DirBili-0.2 IndBili-3.7
___ 06:05AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
MICRO:
======
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
==============
___ 05:55AM BLOOD WBC-8.8 RBC-4.60 Hgb-13.8 Hct-41.7 MCV-91
MCH-30.0 MCHC-33.1 RDW-13.6 RDWSD-45.1 Plt ___
___ 05:55AM BLOOD Glucose-94 UreaN-21* Creat-1.2* Na-143
K-3.9 Cl-105 HCO3-24 AnGap-14
___ 05:55AM BLOOD TotBili-2.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LOPERamide 2 mg PO QID:PRN diarrhea
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
7. Apixaban 2.5 mg PO BID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
oral DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 3 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*6 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Apixaban 2.5 mg PO BID
4. Atorvastatin 10 mg PO QPM
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI
Elevated unconjugated bilirubin
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with elevated wbc, no good source of infection.// PNA?
COMPARISON: Prior chest radiographs dated ___ and CT of the chest
from ___
FINDINGS:
AP upright and lateral views of the chest provided. Midline sternotomy wires
and mediastinal clips are again noted. The heart remains mildly enlarged.
There is no signs of edema or congestion. A subtle opacity projecting over
the right lung base corresponds with a perifissural right lower lobe nodule on
prior CT dated ___. No focal consolidation concerning for pneumonia.
No large effusion, pneumothorax. The sign a contour is stable. Imaged
osseous structures are intact. No free air below the right hemidiaphragm.
IMPRESSION:
1. No signs of pneumonia.
2. Mild cardiomegaly.
3. Vague nodular opacity projecting over the right lung base corresponds with
a right lower lobe nodule on prior CT chest from ___. CT report for
further details.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V, Urinary frequency
Diagnosed with Other fatigue, Frequency of micturition, Nausea
temperature: 98.4
heartrate: 72.0
resprate: 18.0
o2sat: 96.0
sbp: 126.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | ___ female with history of afib currently on apixaban,
non-progessive non-vascular diffuse leukoencephalopathy, L
fronto-parietal punctate stroke ___, living in nursing home who
p/w increased urinary frequency, lethargy, intermittent fevers,
nausea/vomiting concerning for UTI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of chronic pancreatitis, migraines, and
recent admission to ___ for pancreatitis, who is
transferred from ___ w/ abd pain. Pt was discharged from
___ after hospitalization from ___ and represented
today with recurrent epigastric pain and vomiting. She was
managed conservatively during that hospitalization w/ a morphine
PCA and was symptom free on discharge, but woke up morning of
admission with nausea, vomiting and abdominal pain. Notes the
only thing she ate was chicken noodle soup the night of
discharge and mashed potatoes at ___ prior to discharge which
she tolerated w/o difficulty. She went to the ___ where
she was treated with dilaudid 1mg x 3, 0.5mg x1 and reglan with
only some relief of her pain. A CT scan of the abdomen was
performed that showed pancreatic duct dilatation. She is
followed by Dr. ___ so was transferred to ___ for
further management.
Of note, pt has had multiple episodes of pancreatitis w/
multiple ERCPs and sphincterotomies ___ w/ papillary
stenosis s/p biliary sphincterotomy, ___ w/ diffuse dilation
at CBD (12 mm) and sphincter restenosis s/p extension of
sphincterotomy, hosp ___, managed conservatively). She
underwent MRCP with secretin on ___ which was concerning
for recurrence of ampullary stenosis w/ moderate upstream
biliary and pancreatic ductal dilation. She was most recently
hospitalized at ___ for a flare from ___ to ___ when
she underwent ERCP which revealed a patent biliary area and
ampulla, but a possible pancreatic ductal stricture. She was
treated conservatively at that time.
In the ___, initial VS were: 99.5 66 114/71 16 98%. Patient
received dilaudid 1 mg IV and 1L NS bolus. Labs were notable for
hct of 28.7, lipase 24, normal chemistries and LFTs. CT
Abd/Pelvis was reviewed by radiology who felt there was no acute
process and that CBD and pancreatic ductal dilation persisted
similar to that seen on prior MRCP. VS on transfer were: 98.7 64
118/61 16 98%.
On arrival to the floor, pt reports ___ epigastric pain, but
appears in NAD. She describes the pain as "a hot poker from
inside to out, burning" w/ radiation to her back. She denies
current nausea.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-pancreatitis ___, s/p ERCP with sphincterotomy
-laparoscopic cholecystectomy ___
-pancreatitis ___, s/p ERCP with extension of sphincterotomy
-migraines
-seasonal allergies
Social History:
___
Family History:
Father with a history of pancreatitis, mother with heart
disease, grandmother with history of stomach cancer, died at age
___.
Physical Exam:
ADMISSION EXAM
VS: Temp 97.9F BP 117/68, HR 68, R 20, O2-sat 100% RA
GENERAL - tired appearing woman in NAD, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no JVD, no cervical LAD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, TTP in epigastrium, no r/g; NABS, non distended,
no masses or HSM,
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and
sensation grossly intact
DISCHARGE EXAM
VS: Tc 98.4 99/60 73 18 100% RA
GENERAL - well appearing woman in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no JVD, no cervical LAD
LUNGS - CTA bilat, no r/rh/wh
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, mild tenderness in epigastrum, no r/g; NABS, non
distended, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and
sensation grossly intact
Pertinent Results:
ADMISSION LABS
___ 08:50PM GLUCOSE-100 UREA N-7 CREAT-0.6 SODIUM-142
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-24 ANION GAP-12
___ 08:50PM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-31* TOT
BILI-0.3
___ 08:50PM LIPASE-24
___ 08:50PM ALBUMIN-3.4* IRON-17*
___ 08:50PM calTIBC-380 FERRITIN-6.0* TRF-292
___ 08:50PM WBC-5.0 RBC-3.22* HGB-9.3* HCT-28.7* MCV-89
MCH-29.1 MCHC-32.5 RDW-15.7*
___ 08:50PM NEUTS-55.7 ___ MONOS-6.2 EOS-0.2
BASOS-0.3
___ 08:50PM PLT COUNT-245
DISCHARGE LABS
___ 07:10AM BLOOD WBC-4.3 RBC-3.44* Hgb-10.4* Hct-31.2*
MCV-91 MCH-30.3 MCHC-33.4 RDW-15.8* Plt ___
___ 07:10AM BLOOD Glucose-92 UreaN-5* Creat-0.5 Na-142
K-3.3 Cl-106 HCO3-29 AnGap-10
___ 07:10AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.2
MICRO
none
IMAGING
CT ABD & PELVIS WITH CONTRAST; OUTSIDE FILMS READ ONLY ___
8:10 ___
FINDINGS:
Lung bases are clear.
Focal fat is seen adjacent to the falciform ligament. The liver
is otherwise unremarkable as are the kidneys, spleen, and
adrenal glands. Patient is status post cholecystectomy. There
is diffuse dilatation of common bile duct up to 9 mm. The
pancreatic duct is also dilated measuring up to 6 mm in
diameter. This is similar to prior MRCP from ___. The
pancreas is otherwise unremarkable.
The stomach and small bowel are normal in caliber. Colon
appears normal. The appendix is not visualized. There are no
inflammatory changes in the right lower quadrant. The bladder,
uterus and adnexa are unremarkable.
There is no free intraperitoneal fluid, free air, nor
intra-abdominal
adenopathy. Vascular structures are unremarkable.
No suspicious osseous lesions identified. There is enlargement
of several
sacral neural foramina which may be due to Tarlov cysts which
are better seen, partially visualized on MR.
___:
No acute intra-abdominal process to explain patient's symptoms.
Persistent dilatation of the common bile duct and pancreatic
duct as seen on prior MRCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sumatriptan Succinate 6 mg SC X1:PRN migraine
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
4. Promethazine 12.5 mg PR Q8H migraine, nausea
Discharge Medications:
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY
2. Promethazine 12.5 mg PR Q8H migraine, nausea
RX *promethazine [Phenadoz] 12.5 mg 1 Suppository(s) rectally
every eight (8) hours Disp #*15 Suppository Refills:*0
3. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
4. Sumatriptan Succinate 6 mg SC X1:PRN migraine
5. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
six (6) hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with history of chronic pancreatitis with
abdominal pain. Question pseudocyst or pancreatic ductal dilatation.
TECHNIQUE: Contiguous axial images were obtained from the diaphragm to the
pubic symphysis after the administration of intravenous contrast. Coronal and
sagittal reformats were reviewed.
COMPARISON: CT abdomen pelvis from ___ and MRCP from ___.
FINDINGS:
Lung bases are clear.
Focal fat is seen adjacent to the falciform ligament. The liver is otherwise
unremarkable as are the kidneys, spleen, and adrenal glands. Patient is
status post cholecystectomy. There is diffuse dilatation of common bile duct
up to 9 mm. The pancreatic duct is also dilated measuring up to 6 mm in
diameter. This is similar to prior MRCP from ___. The pancreas is
otherwise unremarkable.
The stomach and small bowel are normal in caliber. Colon appears normal. The
appendix is not visualized. There are no inflammatory changes in the right
lower quadrant. The bladder, uterus and adnexa are unremarkable.
There is no free intraperitoneal fluid, free air, nor intra-abdominal
adenopathy. Vascular structures are unremarkable.
No suspicious osseous lesions identified. There is enlargement of several
sacral neural foramina which may be due to Tarlov cysts which are better seen,
partially visualized on MR.
___:
No acute intra-abdominal process to explain patient's symptoms. Persistent
dilatation of the common bile duct and pancreatic duct as seen on prior MRCP.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ACUTE PANCREATITIS, CHRONIC PANCREATITIS
temperature: 99.5
heartrate: 66.0
resprate: 16.0
o2sat: 98.0
sbp: 114.0
dbp: 71.0
level of pain: nan
level of acuity: 3.0 | ___ with h/o chronic pancreatitis who presents from OSH w/
recurrent abdominal pain and vomiting.
# Chronic pancretitis: patient presented from OSH after three
day treatment for acute on chronic pancreatitis. Symptoms of
nausea/vomiting and periumbilical pain consistent with prior
pancreatitis flares although lipase was not elevated on
admission. CT abdomen from outside hospital showed relatively
unremarkable pancreas, unchanged from prior imaging.
Presentation likely due to patient advancing her diet too
quickly. Patient was put on bowel rest, given IV fluids, as
well as IV pain control and anti-nausea medicine. Abdominal
exam remained benign. Patient was tolerating clears within 24
hours of hospitalization and tolerated a full diet by day of
discharge. She is being discharged with a short supply of pain
medicine as well as antinausea medicine as her symptoms should
resolve over the next few days. Patient was advised to avoid
foods high in fat content. She has close follow-up with her
gastroenterologists.
CHRONIC ISSUES
# Migraines: patient has chronic migraines, on sumatriptan PRN.
Remained stable.
# Anemia: patient presented with baseline hematocrit in high
___. She did note that she has heavy muenstral periods.
Iron studies were ordered, which showed an iron deficiency.
MCV and B12 were in normal range. Hematocrit remained stable
throughout admission. Further workup advised as per primary
care physician.
TRANSITIONAL ISSUES
Patient needs follow-up for resolution of her current symptoms
as well as treatment for her chronic pancreatitis. She also
needs further evaluation for causes of persistent anemia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Nut Flavor
Attending: ___.
Chief Complaint:
Chest pain, positive stress test
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
___ presenting with chest pain. He reports that he has had three
episodes of substernal chest pain since ___. One was
yesterday and two today when exerting himself. The pain radiated
into his neck and left ring finger. Lasted about 30 seconds and
relieved while he was still walking. Pt states that this sort of
pain has occurred intermittently for the past several years.
Denies any chest pain at rest.
Last ETT was ___ with non-specific ST changes.
Today, had ischemic EKG changes on ETT, 1-1.5mm of ST segment
depression in inferior leadsd adn V2-V4, resolved within 1
minute of stopping exercise. No angina at high cardiac demand,
(completed ___ METS), stopped for fatigue.
In the ED, initial vitals were 98.8 98 127/75 18 100% RA
Labs and imaging significant for: negative CXR, cardiac enzymes
negative x2
Vitals on transfer were 98 76 129/88 16 99%
On arrival to the floor, patient pain free and feels well,
anxious about cath.
REVIEW OF SYSTEMS
Denies stroke, TIA, fevers, chills, cough, exertional
buttock/calf pain, PND, orthopnea, edema, syncope. Has had
similar chest pain on/off for the past several years.
Past Medical History:
# Hypertension
# Hyperlipidemia
# GERD
# Asthma
# Diverticulitis s/p partial bowel resection
Social History:
___
Family History:
Brother - died from ___ at age ___
Father - bypass at age ___
Mother - CAD recent stents in her ___
Physical Exam:
ADMISSION PHYSICAL EXAM
VS- 98.9 137/89 104 18 96RA Wt 84.9kg
GENERAL- WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. MMM.
NECK- Supple with JVP of 8-10 cm.
CARDIAC- Normal S1, S2, RRR. no m/r/g, no s3 or s4
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ ___ 2+
Left: Carotid 2+ ___ 2+
DISCHARGE PHYSICAL EXAM
PHYSICAL EXAMINATION:
VS- Tm 98.9 Tc 97.5 BP 126/64 (92-126/58-64) P 90 (66-90) R 18
O2sat 96%RA
Wt 83.5kg
GENERAL- WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. MMM.
NECK- Supple with JVP of 8-10 cm.
CARDIAC- Normal S1, S2, RRR. no m/r/g, no s3 or s4
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits. Left wrist cath site-
no hematoma, radial pulse intact.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ ___ 2+
Left: Carotid 2+ ___ 2+
Pertinent Results:
ADMISSION LABS:
___ 02:30PM BLOOD Glucose-98 UreaN-18 Creat-1.1 Na-141
K-4.0 Cl-101 HCO3-30 AnGap-14
___ 02:30PM BLOOD WBC-8.2 RBC-4.67 Hgb-15.9 Hct-43.5 MCV-93
MCH-34.0* MCHC-36.5* RDW-13.7 Plt ___
___ 02:30PM BLOOD ___ PTT-30.7 ___
DISCHARGE LABS:
___ 06:59AM BLOOD WBC-9.0 RBC-4.55* Hgb-15.0 Hct-42.3
MCV-93 MCH-32.9* MCHC-35.5* RDW-13.7 Plt ___
___ 06:59AM BLOOD Glucose-97 UreaN-18 Creat-1.1 Na-138
K-4.1 Cl-100 HCO3-30 AnGap-12
CARDIAC ENZYMES:
___ 02:30PM BLOOD cTropnT-<0.01
___ 08:52PM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD CK-MB-3 cTropnT-<0.01
EKG: TWI in III, avR, V1, stable from prior
___ 2D-ECHOCARDIOGRAM:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
___ CHEST X-RAY
IMPRESSION: No acute cardiopulmonary process.
___ STRESS TEST
- Exercised for 6 minutes ___ protocol, stopped for fatigue
(MET was 7). No chest discomfort. At peak exercise, there was
1-1.5 mm of horizontal/downsloping ST segment depression in the
inferior leads and V2-4. These ST segment changes resolved
within 1 minute of stopping exercise and are in the setting of a
baseline RBBB with no secondary ST segment abnormalities at
rest. The rhythm was sinus with rare isolated apbs and vpbs.
Appropriate increase in systolic BP with a rapid increase in HR
at low level of exercise.
IMPRESSSION: Ischemic EKG changes in the absence of angina at a
high
cardiac demand and average functional capacity.
CARDIAC CATH (remote > ___ years ago): no significant
obstruction
___ CARDIAC CATHETERIZATION
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
diffuse 3-vessel non-obstructive coronary artery disease. The
LMCA was
short, and had no significant angiographically apparent coronary
artery
disease. The LAD had diffuse irregularities up to 30% stenosis
proximally, with some ectasia noted. The LCx had a 30% proximal
lesion.
The RCA had two 30% discrete stenotic lesions in both the
proximal and
mid segments.
2. Limited resting hemodynamics revealed normal systolic blood
pressure.
3. Successful application of TR band to left radial artery.
FINAL DIAGNOSIS:
1. Non-obstructive three vessel coronary artery disease.
2. Normal systolic blood pressure.
3. Continue risk factor modification and management.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 10 mg PO DAILY
hold for SBP < 100
2. nizatidine *NF* 150 mg/10 mL Oral DAILY
3. Simvastatin 20 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
5. Aspirin EC 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
2. Aspirin EC 81 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
hold for SBP < 100
4. Simvastatin 20 mg PO DAILY
5. nizatidine *NF* 150 mg/10 mL Oral DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth DAILY Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Unstable angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with chest pain radiating to the neck. Evaluate
for widening of the mediastinum.
COMPARISON: ___.
TECHNIQUE: PA and lateral chest radiograph.
FINDINGS: The lungs are well expanded and clear. Cardiomediastinal and hilar
contours are unremarkable. Specifically, there is no evidence of mediastinal
widening. There is no pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS
temperature: 98.8
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 75.0
level of pain: 2
level of acuity: 2.0 | ASSESSMENT AND PLAN
___ with history of HTN, HLD presents with exertional chest
pain, stress test positive for ischemic changes on EKG, no
reproduction of chest pain.
# CORONARIES: Unstable angina - Positive stress test in patient
with multiple risk factors. ___ score: 42%
probability of significant CHD, probability of severe CHD is
32%, overall moderate risk.
- Acute coronary syndrome ruled out with 3 sets of negative
cardiac enzymes, no EKG changes.
- Diagnostic cardiac catheterization performed, showing no
obstructing lesions
- Medically manage anginal symptoms
- STARTED metoprolol XL 25 MG DAILY for angina
RISK FACTOR MODIFICATION
- Cont ASA 81mg
- LDL 95 on ___, no acute coronary syndrome, cont simvastatin
# PUMP: No s/sx of heart failure. Recent echo ___ shows
preserved systolic function.
# RHYTHM: Sinus rhythm on EKG
# HYPERTENSION: Normotensive.
- Cont lisinopril
# HYPERLIPIDEMIA:
- LDL 95 on ___, cont simvastatin
# GERD:
- H2 blocker
# ASTHMA:
- prn albuterol
# CODE- full confirmed
# EMERGENCY CONTACT- ___ (daughter) ___ |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / latex / adhesive / Augmentin / Cipro / ceftriaxone
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
PICC line insertion
Therapeutic and diagnositic thoracentesis
History of Present Illness:
___ history of hepatitis C cirrhosis decompensated with
recurrent HE, ___ s/p RFA and sorafenib in ___ c/b L hep art
bleed and then Cyberknife x5 in ___, presenting with altered
mental status since last night. Has had increasing cough with
sputum since ___. Denies fevers, chills and dysuria. ___
evaluated and felt her lung exam had crackles. The patient was
scheduled to be evaluated in the liver clinic today, but acutely
decompensated. At baseline is AAOx2.5 (often confused about
time). Does not do ADLs but is able to feed self.
At baseline able to ambulate with assistance. Does not use a
walker. Lives in single floor home. Chronic leg swelling since
___. Daughter has been giving her spironolactone 25mg daily
for last 5 days.
In the ED, initial vital signs were 97.2 64 119/58 26 90% on
unknown amount of O2. Noted to be somnolent but easily
arousable. UA signifcant for trace leuk esterase and 3 WBCs. Pt
given Vanc/Azithro/CTX and Tamiflu. Pt developed rash with
itching after administration likely to CTX and was treated with
famotidine and benadryl.
Review of Systems:
(+)
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- HCV presumed ___ blood transfusions in the early ___ in the
context of TTP requiring an ICU admission and plasmapheresis.
- Cirrhosis c/b hepatic encephalopathy and grade I esophageal
varices and fundal varices (last EGD in ___
- ___ treated with 9 days of Sorafenib/Placebo from ___
and RFA procedure on ___, with post-procedure course c/b L
hepatic artery bleed s/p embolization, now with completion of
cyberknife on ___
- Portal vein thrombus in ___ (on CT scan- affecting the
left but also the distal main; non-occlusive)
- Chronic ___ edema, pruritis and skin pealing. Followed by derm
in ___. Treated for ___ cellulitis ___.
- GERD
- Graves disease, diagnosed ___. Treated with radioactive
thyroid ablation and methimazole. Started synthroid ___
- Hypodense lesion in body of the pancreas possibly representing
an IPMN or focal fat (imaging ___.
- TTP in ___, requiring ICU stay, blood products and
plasmapharesis. Treated with monthly vincristine x 6, with the
last treatment delivered in ___
- Vitamin B12 deficiency.
- DJD.
- Gout of the toe.
- History of left breast cyst.
- A cholecystectomy in ___.
- Bacterial meningitis in ___ required ICU hospitalization
- Osteoporosis
Social History:
___
Family History:
Mother had goiter and died of complications of emphysema at ___.
Father deceased from lung cancer (smoker) at age ___.
Physical Exam:
ON ADMISSION:
Vitals- 96.4 110/70 64 20 94 on 4L
General- AOx2 (does not know date or president but knows she's
in ___ building), slow to respond, unable to assess asterixis
HEENT- No scleral icterus, oropharynx clear, scattered spider
angiomata on neck
Neck- supple, JVP not elevated, no LAD
Lungs- Decreased basilar breath sounds b/l. Crackles on right.
Dullness to percussion b/l.
Abdomen- soft, non-tender, distended but not tense, tympanic to
percussion, hyperactive bowel sounds, no rebound tenderness or
guarding
Ext- warm, well perfused, 2+ edema in ___ b/l (per daughter
stable since ___
ON DISCHARGE:
Vitals- 97 97/47 96 18 92% on 2L
I/O: ___ BM yesterday
General- AOx2 (self and place) Spontaneously open eyes, follows
commands, No jaundice. Inattentive. +asterixis
HEENT- No scleral icterus, EOMI, oropharynx clear, scattered
spider angiomata on neck and back
Neck- supple, JVP not elevated, no LAD
Lungs- Decreased breath sounds on left. Crackles on right.
Abdomen- Thin, soft, non-tender, distended but not tense,
tympanic to percussion, hyperactive bowel sounds, no rebound
tenderness or guarding
Ext- warm, well perfused, 2+ edema in ___ b/l
Pertinent Results:
ON ADMISSION:
___ 06:25AM BLOOD WBC-8.4# RBC-3.14* Hgb-11.6* Hct-35.4*
MCV-113* MCH-36.8* MCHC-32.6 RDW-17.1* Plt Ct-80*
___ 06:25AM BLOOD Neuts-56 Bands-1 Lymphs-17* Monos-10
Eos-14* Baso-1 Atyps-1* ___ Myelos-0
___ 06:25AM BLOOD ___ PTT-41.3* ___
___ 06:25AM BLOOD Glucose-83 UreaN-45* Creat-0.8 Na-133
K-5.7* Cl-109* HCO3-19* AnGap-11
___ 06:25AM BLOOD ALT-69* AST-132* AlkPhos-160*
TotBili-2.2*
___ 03:50PM BLOOD Calcium-9.3 Phos-3.9 Mg-1.7
___ 06:25AM BLOOD Albumin-2.4*
___ 06:05AM BLOOD TSH-1.4
___ 07:56AM BLOOD Type-ART Temp-37.2 pO2-94 pCO2-34*
pH-7.31* calTCO2-18* Base XS--8 Intubat-NOT INTUBA
___ 07:56AM BLOOD O2 Sat-96
ON DISCHARGE:
___ 04:53AM BLOOD WBC-3.6* RBC-2.28* Hgb-8.3* Hct-25.9*
MCV-114* MCH-36.4* MCHC-32.1 RDW-16.9* Plt Ct-32*
___ 04:53AM BLOOD ___ PTT-56.2* ___
___ 06:05AM BLOOD UreaN-48* Creat-0.9 Na-130* K-5.6* Cl-105
HCO3-21* AnGap-10
___ 04:53AM BLOOD ALT-47* AST-93* AlkPhos-133* TotBili-1.3
___ 06:05AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.9
Echocardiogram ___
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%) secondary to hypokinesis of the inferior and
posterior walls. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
CTA ___
FINDINGS:
There is no filling defect within the main, left, right, lobar,
segmental or subsegmental pulmonary arteries to suggest
pulmonary embolism. The heart and great vessels are essentially
unremarkable noting atherosclerotic calcifications at the arch
and within the coronary arteries. Mitral annular calcifications
are noted. There is mild cardiomegaly. There is a new moderate
to large left and small right pleural effusion which were not
present on most recent exam from ___. There is
atelectasis of a large portion of the left lower lobe and
subsegmental atelectasis in the medial segment of the right
lower lobe. Subpleural regions of scarring seen at the lung
apices bilaterally, not significantly changed. Motion degrades
evaluation for subtle are small pulmonary nodules. Central
airways are patent. Regions of mucous plugging seen within
distal airways including at the apices.
The liver is nodular in contour compatible cirrhosis. Again seen
is a
partially necrotic left liver mass with evidence of prior RFA,
without
significant interval change in appearance since most recent exam
especially given motion artifact which limits exact measurements
on the current exam. No definite new lesion is identified. The
portal vein appears patent. The patient is status post
cholecystectomy. Common bile duct again dilated, unchanged.
The adrenal glands kidneys and spleen are unremarkable. There
is a small unchanged 9 mm hypodensity at the pancreatic tail.
The hypodensity in the pancreatic body less well seen due to
motion, not grossly changed. Distal esophageal and
gastroesophageal varices are again seen. The small bowel and
colon are normal in caliber. Rectum is moderately distended with
gas and stool. The appendix is normal. The uterus and adnexa
are unremarkable.
Small amount of simple free fluid is seen in the pelvis. There
is no
intra-abdominal adenopathy. Scattered atherosclerotic
calcifications noted in the abdominal aorta and iliac vessels
which are normal in caliber. No suspicious osseous lesions
detected. There is no acute fracture. IMPRESSION: 1. No
pulmonary embolism. 2. Mild to large left and small right
pleural effusion new since ___. 3. No acute
intra-abdominal process to explain patient's symptoms. 4.
Cirrhosis with portal hypertension. Previously ablated left
hepatic lesion not significantly changed since prior. Other
incidental findings as above, not significantly changed.
CXR ___
As compared to ___, there is interval improvement
of pulmonary edema as well as substantial improvement of bibasal
opacities, most likely a part of the resolving edema. Small
bilateral pleural effusions are noted, left more than right.
Right PICC line tip is at the level of mid SVC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO BID
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. coenzyme Q10 *NF* 100 mg Oral daily
4. Cyanocobalamin 250 mcg PO DAILY
5. Lactulose 30 mL PO QID
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nadolol 20 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Rifaximin 550 mg PO BID
11. Ursodiol 300 mg PO BID
12. Vitamin D 400 UNIT PO DAILY
13. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. Cyanocobalamin 250 mcg PO DAILY
4. Lactulose 30 mL PO Q6H
RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth every six (6)
hours Disp #*5 Bottle Refills:*0
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Rifaximin 550 mg PO BID
8. Ursodiol 300 mg PO BID
9. Vitamin D 400 UNIT PO DAILY
10. Magnesium Oxide 400 mg PO BID
RX *magnesium oxide 400 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
11. Phosphorus 250 mg PO BID
RX *sod phos,di & mono-K phos mono [K-Phos-Neutral] 250 mg 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0
12. home oxygen
Please supply 2L continuous via nasal cannula.
Diagnosis: Chronic pleural effusion, with sats <88% on RA
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatitis C
Cirrhosis
Hepatic encephalopathy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Somnolent but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with shortness of breath.
TECHNIQUE: Single frontal chest radiograph was obtained portably with the
patient in an upright position.
COMPARISON: ___.
FINDINGS:
Increased, moderate left pleural effusion shifts the mediastinum rightward and
obscures some of the left lung base, but atelectasis if any, is secondary to,
not the cause of the effusion which could be empyema, other exudate, or under
the appropriate circumstances, hemothorax. Mild edema is present in the left
lung, but there is no appreciable right pleural effusion. Cardiac silhouette
is larger and a pericardial effusion might be present.
IMPRESSION: Given the history of cirrhosis and recent treatment to liver
cancer, Abdomen CT is recommended to look for a cause of new left pleural
effusion; if that is not revealing, CT should be continued into the chest
using CTA protocol to detect pulmonary embolus.
New mild pulmonary edema. Possible pericardial effusion.
Findings were discussed with ___ by ___ by telephone at
06:57 on ___ at the time of discovery.
Radiology Report
HISTORY: ___ female shortness of breath, hypoxia. Abdominal pain
with tenderness to palpation in the left upper quadrant.
TECHNIQUE: Contiguous axial images obtained through the chest in the arterial
phase. Then, in the portal venous phase additional imaging was obtained
through the abdomen and pelvis. Coronal sagittal reformats were reviewed.
COMPARISON: CT torso from ___ and CT abdomen from ___.
FINDINGS:
There is no filling defect within the main, left, right, lobar, segmental or
subsegmental pulmonary arteries to suggest pulmonary embolism. The heart and
great vessels are essentially unremarkable noting atherosclerotic
calcifications at the arch and within the coronary arteries. Mitral annular
calcifications are noted. THere is mild cardiomegaly.
There is a new moderate to large left and small right pleural effusion which
were not present on most recent exam from ___. There is
atelectasis of a large portion of the left lower lobe and subsegmental
atelectasis in the medial segment of the right lower lobe. Subpleural regions
of scarring seen at the lung apices bilaterally, not significantly changed.
Motion degrades evaluation for subtle are small pulmonary nodules. Central
airways are patent. Regions of mucous plugging seen within distal airways
including at the apices.
The liver is nodular in contour compatible cirrhosis. Again seen is a
partially necrotic left liver mass with evidence of prior RFA, without
significant interval change in appearance since most recent exam especially
given motion artifact which limits exact measurements on the current exam. No
definite new lesion is identified. The portal vein appears patent. The
patient is status post cholecystectomy. Common bile duct again dilated,
unchanged. The adrenal glands kidneys and spleen are unremarkable. There is
a small unchanged 9 mm hypodensity at the pancreatic tail. The hypodensity in
the pancreatic body less well seen due to motion, not grossly changed.
Distal esophageal and gastroesophageal varices are again seen. The small
bowel and colon are normal in caliber. Rectum is moderately distended with
gas and stool. The appendix is normal. The uterus and adnexa are
unremarkable.
Small amount of simple free fluid is seen in the pelvis. There is no
intra-abdominal adenopathy. Scattered atherosclerotic calcifications noted in
the abdominal aorta and iliac vessels which are normal in caliber.
No suspicious osseous lesions detected. There is no acute fracture.
IMPRESSION:
1. No pulmonary embolism.
2. Mild to large left and small right pleural effusion new since ___.
3. No acute intra-abdominal process to explain patient's symptoms.
4. Cirrhosis with portal hypertension. Previously ablated left hepatic
lesion not significantly changed since prior. Other incidental findings as
above, not significantly changed.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Hepatitis C, pleural effusion of unknown etiology, status post
thoracocentesis. Evaluation for pneumothorax.
COMPARISON: ___, 6:42 a.m.
FINDINGS: As compared to the previous radiograph, the patient has undergone a
left thoracocentesis. The extent of the pre-existing left pleural effusion
has substantially decreased. No evidence of post-procedural pneumothorax.
Moderate cardiomegaly. Otherwise unchanged chest radiograph.
Radiology Report
INDICATION: Evaluation of line placement.
COMPARISON: Multiple chest radiographs, the most recent of ___.
FINDINGS: Portable AP upright view of the chest was reviewed and compared to
the prior study. A new right subclavian line ends in the mid superior vena
cava. A small left pleural effusion has increased since the thoracentesis
performed on ___. There is also increase in interstitial marking and
prominence of pulmonary vascular from ___, consistent with mild
pulmonary edema. Focal increase in opacity in the right lower lobe could
represent atlectasis with or without superimposed infection. There is no
pneumothorax. The cardiac and mediastinal contours are unchanged.
IMPRESSION:
1. Increased small left pleural effusion and increased opacity in the left
lower lung could represent atelectasis or superimposed infection.
2. New right-sided PICC line ends in the mid superior vena cava.
3. New mild pulmonary edema.
COMMENT: Results communicated to ___ by Dr. ___ at
1:10 p.m. at the time of discovery and communicated to Dr. ___ at
5:07PM, four hours after the discovery.
Radiology Report
REASON FOR EXAMINATION: Followup of the patient with hepatitis C and
cirrhosis, to assess pleural effusion.
Ap chest radiograph.
As compared to ___, there is interval improvement of pulmonary
edema as well as substantial improvement of bibasal opacities, most likely a
part of the resolving edema. Small bilateral pleural effusions are noted,
left more than right. Right PICC line tip is at the level of mid SVC.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHANGE IN MENTAL STATUS
Diagnosed with ALTERED MENTAL STATUS , PNEUMONIA,ORGANISM UNSPECIFIED, MAL NEO LIVER, PRIMARY, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA
temperature: 97.2
heartrate: 64.0
resprate: 26.0
o2sat: 90.0
sbp: 119.0
dbp: 58.0
level of pain: 13
level of acuity: 1.0 | ___ with PMH of HCV, cirrhosis c/b 6cm segment III HCC who is
s/p treatment with Sorafenib/Placebo (___) and RFA
(___), with post-procedure course complicated by left
hepatic artery bleed s/p embolization, now s/p cyberknife
(___) for residual disease who presents with altered mental
status.
# Hepatic Encephalopathy: Decompensation likely secondary to
worsening hepatic function and potentially community acquired
pneumonia. The patient was treated with a course of tigecycline.
She was administered rifaxamine and lactulose to a goal of ___
BMs per day. No ascites were seen on imaging, UCx <10k for
yeast, no trauma/falls. ABG showed no significant hypoxia. Blood
culutures and influenza swab were negative. Her presenting
encephalopathy improved with the above measure.
# Cytopenias: The patient experienced a drop in all three cell
lines during her admission. Differential included worsening
splenic sequestration and bone marrow suppression secondary to
tigecycline. Tigecylcine was discontinued.
# Left pleural effusion: New oxygen requirement of 1L, room air
prior to admission. Effusion tapped with removal of 2L.
Post-procedure CXR showed marked improvement. Transudative
effusion based on Light's criteria. Likely ___ cirrhosis. Less
likely from heartfailure; borderline normal systolic function on
echocardiogram. The patient was discharged on 2L NC oxygen.
# HYPONATREMIA: Uosm 600. Likely from high ADH state from liver
disease and relative ___ of vasculature. The patient
was restricted to a 1.5-2L fluid diet.
# HYPERKALEMIA: High value confirmed in ED with whole blood
during VBG. Most likely due to spironolactone use prior to
admission. Spironolactone was discontinued. Albuterol nebs were
provided Q6H. EKGs were checked from K>6.
# HEPC/CIRRHOSIS: Multiple recent decompensations from hepatic
encephalopathy. AST/ALT ratio suggestive of end stage cirrhosis.
MELD score 12. Not a transplant candidate given extensive tumor
burden. Albumin low at 2.4. The patient was continued on a
multivitamin and ursodiol 300mg PO BID.
# HCC: Followed by Dr. ___. The patient is s/p hepatic artery
embolization, CyberKnife, and sorafenib. Liver disease is end
stage with poor prognosis. AFP at 899. Patient transitioned to
hospice care at discharge.
# VARICES: The patient has grade I esophageal and fundal varices
(last EGD in ___. She has no history of GI bleed. Nadolol
was discontinued during this admission due to hyperkalemia and
no history of GI bleed.
# HYPOTHYROID: The patient has a history of Graves s/p thyroid
ablation. She takes levothyroxine for her iatrogenic
hypothyroidism.
# GERD: The patient reported stable GERD symptoms. Her
omeprazole was discontinued due to worsening thrombocytopenia.
TRANSITIONAL ISSUES
*******************
-patient transitioned to DNR/DNI and comfort measure prior to
discharge
-home hospice to visit patient at home upon discharge |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / aspirin
Attending: ___.
Chief Complaint:
Joint pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History is limited as the patient arrived from the ED quite
somnolent, which appears to be from recent medication
administration.
Ms. ___ is a ___ with rheumatoid arthritis on MTX/Enbrel,
chronic joint pain on Percocet, who presented with worsening
shoulder and hip pain.
She said that she felt 100% fine yesterday and early this
morning. She was helping to cook for ___ and was on her
feet all morning and early afternoon, and doing a lot of
chopping
and lifting with her right upper extremity. In the early
afternoon, she began to notice worsening right shoulder pain
followed by worsening right hip pain. Pain was achy in
character,
nonradiating. It escalated in severity to the point where she
felt like she needed to go to the emergency room. She initially
presented to an OSH ED but was sent to ___ ED because she gets
her care here.
In our ED, she had stable vitals. Temp noted to be 99.9 but did
not escalate. She was given dilaudid IV. She had imaging studies
of her shoulder, elbow, and hip. Admission was requested. Labs
subsequently obtained, modest leukocytosis. No workup for
leukocytosis sent.
On arrival here, she is febrile to 101.
REVIEW OF SYSTEMS
A full review of systems was attempted but is unfortunately
unobtainable due to her somnolence.
Past Medical History:
CHRONIC PAIN
ASTHMA
CEREBRAL ANEURYSM
COLONIC POLYPS
DEPRESSION
FIBROID UTERUS
IRITIS
MIGRAINE HEADACHES
OSTEOPENIA
PEPTIC ULCER DISEASE
PTSD
RHEUMATOID ARTHRITIS
RUPTURED BREAST IMPLANT
URINARY INCONTINENCE
TOBACCO USE
PRIOR CELLULITIS
HYPERTENSION
CATARACT
GLAUCOMA
RIGHT SUBFRONTAL CRAINOTOMY FOR MICROSURGICAL ___
OF AN ANTERIOR COMMUNICATING ARTERY ANEURYSM
KNEE SURGERY
Social History:
___
Family History:
Family history was reviewed and is thought impertinent to
current
presentation. Cancer, CAD, stroke in the family
Physical Exam:
Vitals: 101 153 / 88 9030 98 RA
Gen: NAD, lying in bed, somnolent but arousable
Eyes: EOMI, sclerae anicteric
HENT: NCAT, MMM, OP clear, hearing adequate
Cardiovasc: RRR, no obvious MRG. Full pulses, no edema.
Resp: normal effort, breathing unlabored, no accessory muscle
use, lungs CTA ___ without adventitious sounds.
GI: Soft, NT, ND, BS+. No HSM.
MSK: No significant kyphosis. Slightly tender right shoulder
with
some limited ROM. Right hip
Skin: No visible rash. No jaundice.
Neuro: Somnolent but arousable to voice, then slowly drifts back
off to sleep. AAOx2 when prompted. No facial droop. Exam
otherwise somewhat limited by participation, grossly nonfocal.
Strength limited in RUE and RLE due to pain, able to
isometrically contract muscles with some vigor.
Psych: Full range of affect. Thought linear.
GU: No foley
DISCHARGE EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Sitting in bed covered in blankets
EYES: Anicteric, pupils equally round
ENT: OP clear.
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
MSK: Improved mobility and pain at right elbow, and wrist. No
joint erythema or warmth noted.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:30AM BLOOD WBC-12.8* RBC-3.68* Hgb-10.1* Hct-31.9*
MCV-87 MCH-27.4 MCHC-31.7* RDW-14.5 RDWSD-46.0 Plt ___
___ 11:15PM BLOOD WBC-14.3*# RBC-3.78* Hgb-10.5* Hct-34.3
MCV-91 MCH-27.8 MCHC-30.6* RDW-14.9 RDWSD-49.1* Plt ___
___ 07:30AM BLOOD ___ PTT-33.3 ___
___ 07:30AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-143
K-3.8 Cl-104 HCO3-25 AnGap-14
___ 11:15PM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-141
K-4.5 Cl-103 HCO3-24 AnGap-14
___ 07:30AM BLOOD ALT-10 AST-11 CK(CPK)-71 AlkPhos-79
TotBili-0.6
___ 11:15PM BLOOD ALT-11 AST-19 AlkPhos-84 TotBili-0.4
___ 07:30AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.9
___ 11:15PM BLOOD Albumin-4.1
___ 07:30AM BLOOD TSH-0.40
___ 07:30AM BLOOD CRP-77.0*
Right shoulder plain film
No acute findings, osteoarthritis
Right elbow plain film
Tiny joint effusion, no other acute findings
Right hip plain film
No acute findings
CXR:
In comparison with the study of ___, allowing for the
AP supine
position, there is little overall change. Cardiac silhouette is
within normal limits and there is no evidence of vascular
congestion, pleural effusion, or acute focal pneumonia.
DISCHARGE LABS
___ 07:45AM BLOOD WBC-5.6 RBC-3.82* Hgb-10.4* Hct-33.4*
MCV-87 MCH-27.2 MCHC-31.1* RDW-14.0 RDWSD-44.4 Plt ___
___ 07:45AM BLOOD Glucose-100 UreaN-10 Creat-0.7 Na-143
K-4.1 Cl-105 HCO3-25 AnGap-13
___ 07:15AM BLOOD ALT-8 AST-8 AlkPhos-67 TotBili-0.5
___ 07:30AM BLOOD TSH-0.40
___ 07:30AM BLOOD CRP-77.0*
___ 07:10AM BLOOD SED RATE: 17
Urine culture: No growth to date (final)
Blood culture: No growth to date
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Propranolol 80 mg PO BID
3. esomeprazole magnesium 40 mg oral BID
4. Docusate Sodium 100 mg PO BID
5. Escitalopram Oxalate 20 mg PO DAILY
6. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain -
Severe
7. TraZODone 50 mg PO QHS:PRN insomnia
8. Methotrexate 25 mg SC 1X/WEEK (___)
9. Temazepam 15 mg PO QHS:PRN insomnia
10. InFLIXimab 600 mg IV Q4WEEKS
Discharge Medications:
1. PredniSONE 20 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Escitalopram Oxalate 20 mg PO DAILY
4. esomeprazole magnesium 40 mg oral BID
5. Losartan Potassium 50 mg PO DAILY
6. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain -
Severe
7. Propranolol 80 mg PO BID
8. Temazepam 15 mg PO QHS:PRN insomnia
9. TraZODone 50 mg PO QHS:PRN insomnia
10. HELD- InFLIXimab 600 mg IV Q4WEEKS This medication was
held. Do not restart InFLIXimab until you speak with your
rheumatologist
11. HELD- Methotrexate 25 mg SC 1X/WEEK (___) This medication
was held. Do not restart Methotrexate until you speak to your
rheumatologist
Discharge Disposition:
Home
Discharge Diagnosis:
Rheumatoid Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with RA p/w severe flare on chronic remicade, MTX and
steroids// eval for avascular necrosis
COMPARISON: None
FINDINGS:
AP, lateral and oblique views of the right elbow were provided. No definite
fracture is seen. A tiny joint effusion is suspected. No significant
degenerative disease. No signs of avascular necrosis peer
IMPRESSION:
As above.
Radiology Report
INDICATION: ___ with RA p/w severe flare on chronic remicade, MTX and
steroids// eval for avascular necrosis
COMPARISON: None
FINDINGS:
Three views of the right shoulder provided with internal, external rotation AP
views and scapular Y-view. No fracture or dislocation is seen. Mild bony
hypertrophy at the right acromioclavicular joint is noted consistent with mild
osteoarthritis. No worrisome calcifications. The imaged right upper ribs
appear intact. No signs of avascular necrosis.
IMPRESSION:
No acute findings.
Radiology Report
INDICATION: ___ with RA p/w severe flare on chronic remicade, MTX and
steroids// eval for avascular necrosis
COMPARISON: CT from ___
FINDINGS:
AP view the pelvis and AP and lateral views the right hip provided. Bony
pelvic ring is intact. SI joints are symmetric and normal. No fracture is
seen. No signs of avascular necrosis at either femoral head. Femoral necks
are intact bilaterally. No soft tissue abnormalities detected.
IMPRESSION:
No signs of avascular necrosis or fracture.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with fever// is there pneumonia?
IMPRESSION:
In comparison with the study of ___, allowing for the AP supine
position, there is little overall change. Cardiac silhouette is within normal
limits and there is no evidence of vascular congestion, pleural effusion, or
acute focal pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R Pain
Diagnosed with Rheumatoid arthritis, unspecified
temperature: 99.9
heartrate: 83.0
resprate: 16.0
o2sat: 100.0
sbp: 114.0
dbp: 46.0
level of pain: 10
level of acuity: 3.0 | ___ with RA on MTX/Enbrel, chronic pain on narcotics,
depression/PTSD, HTN, tobacco use, PUD, recent hematuria and
small bladder tumor s/p resection, who presents with worsening
total body R.sided joint pain temporally associated with
aggressive meal-prep for ___, who also had a fever upon
transfer to the floor.
# Joint pain
# Rheumatoid arthritis
Pt also with fever on admission. Radiographically and clinically
no overt signs of septic joints. Pt improved after steroid
dosing (depot-Medrol) in the ED. She was seem by the
rheumatology service. Her CRP was elevated, though her ESR was
not. Rheumatology noted this was likely consistent with RA
flare. We researched for potential infectious trigger given her
fever, but CXR, UCX and blood cx were negative. Additionally,
she had not further localizing symptoms. After discussion with
rheumatology, we started her on Prednisone 20mg for initial 5
day course. The consult team noted that her outpatient
rheumatologist would reach out to her to discuss further
steroids, methotrexate, and Remicade. By discharge, her pain had
improved and she was much closer to her baseline.
# Leukocytosis:
# Fever:
There was initial concern for potential urinary source given
recent procedures, but UA and UCX were negative. As noted, other
infectious work up was negative. It is possible this was a viral
process. No remained afebrile with resolution of her
leukocytosis.
# Somnolence
On admission, she was initially somnolent. This was thought to
be secondary to medication effect. She remained alert, oriented,
and interactive the rest of her time here.
#Bladder tumor
She plans to follow up with outpatient urology providers. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt with known pulmonary fibrosis (patient of Dr. ___,
___ to start perfenidone but not yet taking) and CADISIL
syndrome c/b CVA and vascular dementia presents with progressive
SOB and hypoxia at ___ at nursing home. He reports that "a few
days ago" he became short of breath when getting out of bed and
since then has been more SOB. This has never happened to him
before. He denies rhinorrhea, cough, fevers, diarrhea, or N/V.
Also denies chest pain.
In ED initial VS: T98.9 65 121/77 18 95% NRB
Exam: Bedside ultrasound w/o pneumothorax
Patient was given: duonebs
Labs notable for: WBC 9.9, Hb 13.5, K 5.3, Cr 1.1, Lac 2.5, Flu
neg
Imaging notable for:
- CXR w/Changes compatible with known underlying fibrosis. No
definite superimposed acute cardiopulmonary process.
- CTA showed: No pulmonary embolism or acute aortic abnormality.
increased ground-glass attenuation particularly within the lower
lobes and left upper lobe suggest acute exacerbation. Central
adenopathy is likely reactive.Enlarged pulmonary artery is
unchanged.
On arrival to the MICU, patient was sat'ing in the mid ___ on
NRB, and said his breathing was "about average." He was placed
on humidified face mask.
Past Medical History:
___ (cerebral autosomal dominant arteriopathy with
subcortical infarct and leukoencephalopathy), s/p CVAs in ___
and ___
T2DM (no medications)
HTN
HLD
Anxiety, depression
Hypothyroidism
S/P gastric bypass ___
OSA, refused CPAP previously
Social History:
___
Family History:
Brother also with ___ and CVA
Physical Exam:
ADMISISON EXAM:
GENERAL: Alert, interactive, intermittently tachypneic and
uncomfortable but NAD
HEENT: PERRLA, EOMI, OP clear
LUNGS: Diffuse coarse breath sounds heard throughout posterior
lung fields, fine crackles heart most prominently in the LLL, no
wheezes
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding; well-healed vertical surgical
scar
EXT: Warm, well perfused, 2+ pulses, no ___ edema
NEURO: Asymmetrical palate deviation (higher on L), otherwise
CNII-XII grossly intact; 4+/5 hip flexion on L, other muscle
groups in UE and ___ ___ b/l
DISCHARGE EXAM:
97.7, 64 bpm, 110/70, 20, 94% on 50%FiO2 high flow 25L NC
GENERAL: Alert, interactive, NAD
HEENT: PERRLA, EOMI, OP clear
LUNGS: Diffuse coarse breath sounds heard throughout posterior
lung fields, fine crackles heart most prominently in the LLL, no
wheezes
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding; well-healed vertical surgical
scar
EXT: Warm, well perfused, 2+ pulses, no ___ edema
NEURO: Asymmetrical palate deviation (higher on L), otherwise
CNII-XII grossly intact; 4+/5 hip flexion on L, other muscle
groups in UE and ___ ___ b/l
Pertinent Results:
Admission labs:
___ 05:45PM BLOOD WBC-9.9 RBC-4.32* Hgb-13.5* Hct-41.4
MCV-96 MCH-31.3 MCHC-32.6 RDW-15.2 RDWSD-53.4* Plt ___
___ 05:45PM BLOOD Neuts-61.6 ___ Monos-8.6 Eos-2.5
Baso-0.7 Im ___ AbsNeut-6.12*# AbsLymp-2.61 AbsMono-0.85*
AbsEos-0.25 AbsBaso-0.07
___ 01:48AM BLOOD ___ PTT-26.4 ___
___ 05:45PM BLOOD Glucose-99 UreaN-13 Creat-1.1 Na-144
K-5.3* Cl-104 HCO3-25 AnGap-20
___ 01:48AM BLOOD ALT-8 AST-11 LD(LDH)-145 AlkPhos-106
TotBili-0.5
___ 05:45PM BLOOD proBNP-346*
___ 01:48AM BLOOD Albumin-3.4* Calcium-8.6 Phos-2.9 Mg-2.1
___ 05:45PM BLOOD CRP-80.3*
___ 06:14PM BLOOD ___ pO2-25* pCO2-56* pH-7.35
calTCO2-32* Base XS-2
___ 12:28AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:28AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 12:28AM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 06:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Discharge labs:
___ 05:03AM BLOOD WBC-10.3* RBC-4.07* Hgb-12.6* Hct-37.8*
MCV-93 MCH-31.0 MCHC-33.3 RDW-14.8 RDWSD-50.4* Plt ___
___ 05:03AM BLOOD WBC-10.3* RBC-4.07* Hgb-12.6* Hct-37.8*
MCV-93 MCH-31.0 MCHC-33.3 RDW-14.8 RDWSD-50.4* Plt ___
___ 04:43AM BLOOD Neuts-77.8* Lymphs-13.3* Monos-8.3
Eos-0.1* Baso-0.1 Im ___ AbsNeut-10.82*# AbsLymp-1.85
AbsMono-1.15* AbsEos-0.01* AbsBaso-0.01
___ 05:03AM BLOOD Plt ___
___ 05:03AM BLOOD ___ PTT-26.5 ___
___ 05:03AM BLOOD Glucose-90 UreaN-24* Creat-0.9 Na-139
K-3.9 Cl-103 HCO3-24 AnGap-16
___ 04:43AM BLOOD ALT-14 AST-15 LD(LDH)-157 AlkPhos-90
TotBili-0.3
___ 05:45PM BLOOD proBNP-346*
___ 05:03AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.3
___ 05:16AM BLOOD ___ Temp-36.6 pO2-62* pCO2-41
pH-7.46* calTCO2-30 Base XS-4 Intubat-NOT INTUBA Comment-HI-FLOW
NA
___ 05:16AM BLOOD Lactate-1.1
___ 05:45PM BLOOD PROCALCITONIN-Test
___ 06:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Micro:
___ 5:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:54 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 3:52 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Imaging:
CXR:
I
n
c
o
m
p
a
r
i
son with the study of ___, the patient has taken a slightly
b
e
t
t
e
r
inspiration. Again there is diffuse prominence of interstitial
m
a
r
k
i
n
g
s
t
h
roughout the lungs with subpleural predominance, consistent with
t
h
e
clinical diagnosis of IPF. No new consolidation is appreciated.
CT Chest:
1. No pulmonary embolism or acute aortic abnormality.
2
.
E
x
t
e
n
sive interstitial lung abnormality consistent with UIP pattern.
R
e
l
a
t
i
v
e
t
o
e
x
amination dated ___, increased ground-glass attenuation
p
a
r
t
i
cularly within the lower lobes and left upper lobe suggest acute
exacerbation. Central adenopathy is likely reactive.
3
.
E
n
larged pulmonary artery is unchanged, suggestive of although not
diagnostic for pulmonary hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Sertraline 100 mg PO DAILY
5. TraZODone 25 mg PO QHS
6. Levothyroxine Sodium 75 mcg PO DAILY
7. aspirin-dipyridamole ___ mg oral BID
8. Donepezil 5 mg PO QHS
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*1
2. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 3 mL PO
every six (6) hours Disp #*1 Ampule Refills:*0
4. PredniSONE 40 mg PO DAILY Duration: 3 Weeks
Continue until you see Dr. ___ follow-up in clinic.
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*21
Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth once a day Disp #*21 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. aspirin-dipyridamole ___ mg oral BID
8. BuPROPion XL (Once Daily) 300 mg PO DAILY
9. Donepezil 5 mg PO QHS
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Sertraline 125 mg PO DAILY
13. TraZODone 25 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
# Hypoxic respiratory failure:
# IPF exacerbation
Secondary:
# ___ syndrome
# Anxiety, depression
# Hypothyroidism
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with dyspnea, hypoxia// eval for acute process
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___ chest x-ray and ___ chest CT.
FINDINGS:
Increased interstitial markings seen throughout the lungs with subpleural
predominant, slightly worse on the left compared to the right. Low lung
volumes are noted. There is no new consolidation. The cardiomediastinal
silhouette is within normal limits. No acute osseous abnormalities.
IMPRESSION:
Changes compatible with known underlying fibrosis. No definite superimposed
acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with dyspnea// evaluate for pulmonary embolism
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 422 mGy-cm.
COMPARISON: Chest CT from ___.
FINDINGS:
The imaged thyroid is homogeneous in attenuation without focal nodularity.
There is no axillary or supraclavicular adenopathy. Prominent central nodes
are noted. A right upper paratracheal station node measures 1.0 cm (02:29).
An aortopulmonary window node measures 1.4 cm (02:34), previously 0.9 cm. A
right large paratracheal station node measures 1.1 cm (02:37), previously 1.0
cm. Right hilar nodes measure up to 1.5 cm (02:47). A subcarinal node
measures 1.5 cm (02:47), previously 1.3 cm.
The ascending aorta is non aneurysmal. The main pulmonary artery is mildly
enlarged, suggestive of although not diagnostic for pulmonary hypertension,
present previously. Heart is upper limits of normal in size. Coronary artery
calcifications are mild. There are no appreciable aortic valvular
calcifications. Trace pericardial fluid is physiologic.
The pulmonary artery is opacified to the subsegmental level. There is no
filling defect to suggest a pulmonary embolism.
Lung volumes are relatively low. There is widespread diffuse fibrotic lung
disease most pronounced in the lower lobes with extensive traction
bronchiectasis, reticulation, and ground-glass opacification. Relative to CT
dated ___, these changes appear progressed, particularly within the
left upper lobe.
There is no pleural effusion or pleural abnormality.
Although examination is not tailored for subdiaphragmatic evaluation, images
of the upper abdomen demonstrate no acute abnormality. Patient is status post
gastric bypass procedure. There is a small hiatal hernia. Partially
calcified nodule anterolateral to the right hepatic lobe is noted (2:90),
present on prior examination, likely reflects pseudolipoma of Glisson capsule.
IMPRESSION:
1. No pulmonary embolism or acute aortic abnormality.
2. Extensive interstitial lung abnormality consistent with UIP pattern.
Relative to examination dated ___, increased ground-glass attenuation
particularly within the lower lobes and left upper lobe suggest acute
exacerbation. Central adenopathy is likely reactive.
3. Enlarged pulmonary artery is unchanged, suggestive of although not
diagnostic for pulmonary hypertension.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with h/o IPF with worsening hypoxia// interval
change interval change
IMPRESSION:
In comparison with the study of ___, the patient has taken a slightly
better inspiration. Again there is diffuse prominence of interstitial
markings throughout the lungs with subpleural predominance, consistent with
the clinical diagnosis of IPF. No new consolidation is appreciated.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory distress// interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___ in ___
FINDINGS:
Re-demonstrated diffuse increased interstitial markings bilaterally in this
patient clinical diagnosis of IPF. Findings are similar to ___ and
slightly more pronounced compared to ___, possibly related to
differences in technique and inspiration. No definite new focal consolidation
is seen. No large pleural effusion or pneumothorax. Cardiac and mediastinal
silhouettes are stable..
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IPF pw hypoxemia c/w IPF exacerbation//
Interval change Interval change
IMPRESSION:
In comparison with the study of ___, there is little overall change.
Again there are diffuse, prominent interstitial markings consistent with the
clinical diagnosis of IPF. No evidence of acute focal consolidation, though
this would be extremely difficult to exclude in the appropriate clinical
setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory distress// ?pna ?pna
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes
with diffuse prominence of interstitial markings consistent with the clinical
diagnosis of IPF. Blunting of the costophrenic angles could reflect small
pleural effusions.
Given the substrate of extensive interstitial lung disease, in the appropriate
clinical setting it would be extremely difficult to exclude superimposed
pneumonia, especially in the absence of a lateral view.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 98.9
heartrate: 65.0
resprate: 18.0
o2sat: 95.0
sbp: 121.0
dbp: 77.0
level of pain: 0
level of acuity: 1.0 | ___ year old with history of IPF (baseline O2 high ___ on room
air) and CADISIL presents from nursing home with hypoxia to ___
and worsened CXR c/f acute IPF exacerbation admitted to MICU for
management on ___.
=================
ACTIVE ISSUES
=================
# Acute IPF exacerbation
Patient presented from nursing home with dyspnea, hypoxia. He
was placed on non-rebreather and admitted to MICU. CXR showed
diffuse interstitial opacifications. CTA chest negative for PE.
He was treated with IV solumedrol 500mg q8h x 3 days. Initially
also treated with vanc/ceftaz/azithro for several days but
ultimately felt pneumonia unlikely and abx were discontinued
after 3 days. He completed a 5 day course of azithromycin for
anti-inflammatory effect. After solumedrol burst, he was
transitioned to prednisone 60mg daily. His management plan was
confirmed with his outpatient pulmonologist Dr ___. He
continued to require high flow nasal canula during his ICU stay,
downtitrated to 50%FiO2 25L high flow by NC. He was unable to
tolerate face tent continuously due to discomfort/removing it
and hypoxia and so he is to be discharged to ___ with high flow
nasal cannula and a three week burst of daily prednisone 40 mg
daily (to be continued until follow-up with Dr. ___
the taper will be determined). He was prescribed prophylactic
batrim one DS daily and Ca/Vit D supplement while on steroids,
as well as continuing his PPI.
# Goals of Care
Patient has vascular dementia and CADISIL syndrome and brother
___ is his HCP. Goals of care discussions were held with family
on admission to ICU. Family understood poor long term prognosis
if he were to require intubation and believe he would not want
to be on life support even temporarily, and thus made him
DNAR/DNI. MOLST form was completed.
# ___ Syndrome
Continued ASA-dipyridamole. No signs of new cerebrovascular
infarcts throughout MICU/hospital course.
# Hypothyroidism
Continued levothyroxine. Remained euthyroid on home regimen
throughout hospital course.
# OSA
Not on CPAP at home. No nocturnal desats on high flow nasal
canula this admission.
TRANSITIONAL ISSUES
========================
# Prednisone course and bactrim ppx, PPI, VitD/Calcium as above.
# Thoracic aortic dilatation seen on ECHO (4.2 cm), will likely
need outpt follow up with serial imaging if within goals of care
# DNAR/DNI
# HCP: ___ (brother/hcp) ___ (h); ___
(c)
On ___, patient was discharged to long term acute care
facility for further management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / ibuprofen
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ERCP
___: laparoscopic cholecystectomy
History of Present Illness:
___ yo F with history of biliary colic, who presents with
epigastric pain and nausea. Pt developed nausea and epigastric
pain radiating to the back last ___ after eating a
bacon cheeseburger for dinner. Pt initially thought it was GERD
but symptoms did not improve with ranitidine and OTC antacids.
The following day she felt a little better but in the subsequent
days she had recurrence of symptoms. She was seen in primary
care clinic on ___ where she had LFT's drawn which were
elevated. RUQ u/s done as an outpatient showoed no
choledocholithiasis or cholecystitis but did show
cholelithiasis. Pt had persistent elevation in her LFT's on
follow up labs so she was urged to come to the ED for evaluation
today. Notably, pt reports that her pain improved today, no
longer has abdominal pain and is just nauseous. Denies any
fevers or chills during this entire period of time.
In the ED, vitals were stable. No leukocytosis. Transaminases
and Tbili elevated but downtrending on serial checks in the ED.
Lipase elevated at 700. Pt admitted for further management.
Past Medical History:
PMH:
1. History of sigmoid colon adenomatous polyp, ___.
2. Mild mitral regurgitation on stress echocardiogram, ___.
3. History of hypothyroidism.
4. History of hypercholesterolemia treated in the past with a
statin, which she stopped.
5. History of lower GI bleed which she thinks might have been
related to naproxen.
6. History of frozen shoulder.
PSH:
1. Status post vaginal hysterectomy, ovaries remain, for
uterine
prolapse, in ___ by Dr. ___.
2. Status post kidney stones removed in approximately ___.
3. Status post basal cell carcinoma excised from her nose x 2.
She had it done in ___.
4. Status post left wrist surgery about ___ years ago after a
fracture with plate and screws placed.
Social History:
___
Family History:
Mother had ___.
Physical Exam:
Vitals: T 98.1 146/80 95 18 97%RA
Gen: NAD
HEENT: no jaundice
CV: rrr, no rmg
Pulm: clear b/l
Abd: soft, no tenderness, normal bowel sounds
Ext: no edema
Neuro: alert and oriented x 3, no focal deficits
Pertinent Results:
___ 08:17PM WBC-8.9 RBC-4.03* HGB-13.0 HCT-36.9 MCV-92
MCH-32.3* MCHC-35.3* RDW-13.4
___ 08:17PM PLT COUNT-173
___ 08:17PM GLUCOSE-111* UREA N-13 CREAT-1.0 SODIUM-138
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
___ 03:00PM ALT(SGPT)-394* AST(SGOT)-219* ALK PHOS-350*
AMYLASE-388* TOT BILI-5.0*
___ 08:17PM ALT(SGPT)-367* AST(SGOT)-193* ALK PHOS-316*
TOT BILI-4.1* DIR BILI-2.6* INDIR BIL-1.5
___ 08:17PM LIPASE-368*
___ 03:00PM LIPASE-701*
___ 10:11PM URINE RBC-0 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1 RENAL EPI-<1
RUQ u/s ___:
1. Diffusely increased hepatic echogenicity suggestive of
hepatic steatosis.
Underlying fibrosis, cirrhosis, or steatohepatitis cannot be
excluded by
ultrasound.
2. Gallstones measuring up to 2.6 cm without evidence of acute
cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Ranitidine 150 mg prn
3. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
Discharge Medications:
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth Q4 hours Disp #*30
Tablet Refills:*0
5. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
6. Ranitidine 150 mg PO DAILY:PRN heartburn
7. Senna 8.6 mg PO BID:PRN cosntipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___ pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with cholelithiasis // pre-op eval Surg:
___ (CCY)
COMPARISON: Compared to prior radiographs from ___.
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. Lungs are slightly
hyperexpanded. There are no focal consolidations, pleural effusion, or
pulmonary edema. There are no pneumothoraces.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Jaundice, Abnormal labs
Diagnosed with ACUTE PANCREATITIS, CHOLELITHIASIS NOS
temperature: 98.9
heartrate: 92.0
resprate: 18.0
o2sat: 99.0
sbp: 132.0
dbp: 99.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is an ___ presenting with likely choledocholithiasis
with passed stone with associated gallstone pancreatitis. She
was started on ciprofloxacin. She underwent ERCP on ___ where a
sphincterotomy was done and the biliary tree was swept. One
large stone was seen in the gallbladder. She was transfered to
the ACS surgery for a laparoscopic cholecystectomy which was
completed on ___ withut any complications. Please see operative
note for further details. She recovered well post-operatively.
Pain was initially not very well controlled and she had to be
encouraged to take the narcotics as needed. SHe worked with
physical therapy who recommended that she could be discharged
home. By POD1 she was tolerating a regular diet and by POD3 was
ambualating without issues, tolerating a regular diet, pain well
controlled and stable for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pentazocine / Lisinopril / Meperidine / Leflunomide
Attending: ___
Chief Complaint:
seizure, respiratory distress
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old female with history of sarcoidosis and
neurosarcoidosis, ESRD who presents with unresponsiveness and
respiratory failure. She presented from dialysis and became
unresponsive near the end of her session. She was put on a
non-rebreather and in transit came to and said she was short of
breath. Patient receives most of her medical care at ___
___, but has seen Transplant Surgery and Neurology at
___ recently.
In the ED, initial vitals were 97.8 117 150/90 38 100% 15L
Non-Rebreather. Upon arriving to the ED, she experienced a
tonic-clonic seizure while in the ED and received propofol,
lorazepam and levetiracetam and was intubated. Labs showed WBC
count of 20.6, hematocrit of 29.6. Lactate was 9.7, improved to
6.4. Troponin was 0.02, CK was 408. Lipase was 142. Alkaline
phosphatase was 358, AST/ALT were 108/76. Neurology was
consulted and felt that her seizure was likely due to
respiratory distress. Patient was intubated and incuded with
propofol. Lorazepam 2 mg was given. Keppra 250 mg IV was given
x 1. ECG showed sinus tachycardia at 141, NA/NI, diffuse
depressions c/w possible ischemia. CT torso showed no PE or
dissection, and no evidence of infectious process. IV access
was left tibial IO and left 20 gauge EJ. She received total 3
liters NS in the ED.
Upon arrival to the MICU, patient is hypertensive and
tachycardic. She is not visibly seizing. She is following
commands and is responsive to voice.
Review of systems:
Unable to obtain
Past Medical History:
End-stage renal disease (with left arm fistula)
Failed kidney transplant secondary to BK virus
Sickle cell anemia
Sarcoidosis
Seizures ___ neurosarcoidosis
Hypertension
Hyperlipidemia
C. difficile colitis
Anemia
Colostomy secondary to intraperitoneal infection during
peritoneal dialysis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION
Vitals: T: 97.4, BP: 181/94, P: 130, R: 20, O2: 100% 50% CPAP
General: Intubated, responds to voice, no acute distress
HEENT: Sclera anicteric, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all four extremities, no tonic-clonic activity
Skin: severe xerosis over most of skin
DISCHARGE:
Gen: Extubated, NAD, AAOx3
HEENT: of note, patient has scar from previous tracheostomy
(unclear reasons)
Pertinent Results:
ADMISSION LABS:
___ 10:53PM BLOOD WBC-19.1* RBC-3.85* Hgb-11.4* Hct-32.1*
MCV-83 MCH-29.6 MCHC-35.6* RDW-18.9* Plt ___
___ 05:15PM BLOOD ___ PTT-34.7 ___
___ 11:25PM BLOOD Glucose-77 UreaN-23* Creat-3.6* Na-134
K-4.5 Cl-92* HCO3-26 AnGap-21*
___ 10:53PM BLOOD ALT-42* AST-62* LD(LDH)-374* AlkPhos-273*
TotBili-1.7*
___ 05:15PM BLOOD Lipase-142*
___ 11:25PM BLOOD GGT-118*
___ 05:15PM BLOOD CK-MB-2 cTropnT-0.02*
___ 11:25PM BLOOD ___
___ 12:24PM BLOOD CK-MB-3 cTropnT-0.08*
___ 05:15PM BLOOD Albumin-4.1 Calcium-8.6 Phos-3.8 Mg-1.7
___ 05:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 05:30PM BLOOD Lactate-9.7*
___ 05:10AM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 08:25AM BLOOD WBC-12.8* RBC-3.15* Hgb-9.1* Hct-25.8*
MCV-82 MCH-28.9 MCHC-35.2* RDW-18.7* Plt ___
___ 08:25AM BLOOD Glucose-77 UreaN-24* Creat-4.4*# Na-135
K-4.6 Cl-91* HCO3-33* AnGap-16
___ 01:00PM BLOOD ALT-28 AST-31 LD(LDH)-193 AlkPhos-190*
___ 12:24PM BLOOD CK-MB-3 cTropnT-0.08*
___ 08:25AM BLOOD Calcium-9.6 Phos-5.1*# Mg-1.8
IMAGING:
- CXR ___: IMPRESSION: Status post extubation without
evidence of pulmonary consolidation or pneumothorax
- MRI head ___: IMPRESSION:
1. No evidence of new infarct or new hemorrhage. No evidence of
masses.
2. Abnormal diffuse bone marrow signal with expansion of the
clivus and
diploic space. These findings are likely related to chronic
anemia such as sickle cell anemia.
3. Old left frontal encephalomalacia.
4. Small vessel white matter ischemic changes with global
cerebral volume loss.
- CTA chest ___: IMPRESSION:
1. No pulmonary embolism or acute aortic syndrome
2. Numerous calcified mediastinal lymph nodes consistent with
patient's known history of sarcoidosis.
3. Probable lower lobe atelectasis, with possible mild
superimposed
aspiration.
- CT head ___: Bifrontal encephalomalacia without
superimposed acute process
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. BusPIRone 10 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. Citalopram 30 mg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. PredniSONE 2.5 mg PO DAILY
9. LeVETiracetam 500 mg PO BID
10. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BusPIRone 10 mg PO BID
3. Carvedilol 12.5 mg PO BID
4. Citalopram 30 mg PO DAILY
5. LeVETiracetam 250 mg PO BID
RX *levetiracetam [Keppra] 250 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
6. LeVETiracetam 500 mg PO AFTER EACH HD SESSION
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth AFTER
EACH HD SESSION Disp #*30 Tablet Refills:*0
7. Losartan Potassium 50 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Omeprazole 20 mg PO DAILY
10. PredniSONE 2.5 mg PO DAILY
11. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- cocaine abuse
- seizure disorder, neurosarcoidosis
SECONDARY:
- respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Hypoxia, assess for pneumothorax.
FINDINGS: Portable AP supine chest radiograph obtained. The endotracheal
tube is seen with its tip located about 2.9 cm above the carina. The NG tube
courses into the left upper quadrant. Scattered pulmonary opacities could
represent atelectasis, though a component of aspiration not excluded.
Cardiomediastinal silhouette appears normal. Bony structures appear intact.
IMPRESSION: ET and NG tubes positioned appropriately. Scattered pulmonary
opacities could represent aspiration or atelectasis. Please refer to
subsequent CT torso for further details.
Radiology Report
HISTORY: ___ female with history of neurosarcoidosis now presenting
from hemodialysis with acute seizure and respiratory failure.
COMPARISON: None available
TECHNIQUE: MDCT axial images of the brain were obtained without intravenous
contrast. Soft tissue and bone algorithms were reviewed. Coronal and
sagittal reformations were prepared.
NON-CONTRAST HEAD CT: There is no hemorrhage, mass effect, or acute large
territorial infarction. Hypoattenuation within the left frontal lobe with
associated ex vacuo dilatation of frontal horn of the left lateral ventricle
suggests prior infarct. Smaller hypoattenuation in the right frontal lobe is
also likely encephalomalacia due to prior infarct. Mild periventricular
hypoattenuation is suggestive of chronic small vessel ischemic changes.
Moderate proportional enlargement of the ventricles and sulci is suggestive of
age-related cortical atrophy. There is no shift of the usually midline
structures. Suprasellar and basilar cisterns are widely patent. There is no
scalp hematoma or acute skull fracture. Visualized paranasal sinuses and
mastoid air cells are well aerated. A small soft tissue density in the left
external auditory canal likely reflects cerumen.
IMPRESSION: Bifrontal encephalomalacia without superimposed acute process
Radiology Report
HISTORY: ___ female on hemodialysis with history of neurosarcoidosis
and sickle cell disease, now presenting secondary to acute respiratory failure
and seizure.
COMPARISON: None available
TECHNIQUE: MDCT-acquired axial images from the thoracic inlet to the pubic
symphysis were displayed with 1.25-, 2.5, and 5-mm slice thickness. Axial
images through the chest were acquired in an arterial phase, followed by
portal venous phase imaging through the abdomen and pelvis. Coronal,
sagittal, and oblique MIP reformations were prepared.
CT CHEST WITH INTRAVENOUS CONTRAST: The thyroid gland is homogeneous without
focal nodule. No supraclavicular or axillary lymphadenopathy is identified.
Calcified mediastinal lymphadenopathy corresponds with patient's history of
sarcoidosis (2A:26, 31:41). The thoracic aorta is non-aneurysmal throughout
its course and demonstrates no signs of acute aortic syndrome. There is no
pulmonary embolism to the subsegmental levels. There is mild cardiomegaly,
though no pericardial effusions.
Endotracheal tube terminates in the mid trachea, in an appropriate position.
Tracheobronchial tree is patent to subsegmental levels without bronchial wall
thickening or bronchiectasis. There is a background of moderate emphysema.
Basilar consolidative and linear opacities may reflect atelectasis with mild
superimposed aspiration possible.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: Liver demonstrates homogeneous
parenchymal enhancement without suspicious focal lesion. Hepatic veins and
portal venous system are grossly patent. Mild prominence of the central
intrahepatic ducts is likely related to prior cholecystectomy. The spleen has
an irregular lobulated contour with multiple hypodensities within it, findings
likely related to functional asplenia in this patient with known sickle cell
disease. The adrenal glands are without focal nodule. The pancreas is
homogeneously enhancing. Kidneys are shrunken, have diffuse cortical
thinning, and small cysts, findings consistent with known end-stage renal
disease. The abdominal aorta and its branch vessels demonstrate moderate
atherosclerotic calcifications, though are non-aneurysmal and grossly patent.
The nasoenteric catheter terminates in the stomach. Small bowel loops are
normal in caliber and configuration without evidence of obstruction or
inflammation. The patient has an end colostomy. Air and stool are seen
throughout the colon without signs of obstruction or inflammation. The rectal
pouch appears normal. There is no abdominal free fluid or free air. A large
centrally hypoattenuating mass with surrounding calcifications within the
right lower quadrant corresponds to patient's rejected renal transplant.
CT PELVIS WITH INTRAVENOUS CONTRAST: The bladder is distended and appears
within normal limits. Uterus and adnexa are unremarkable. There is no pelvic
free fluid.
BONES AND SOFT TISSUES: Diffuse increased sclerosis of the bones is likely
related to renal osteodystrophy. No bone destructive lesion or acute fracture
is identified.
IMPRESSION:
1. No pulmonary embolism or acute aortic syndrome
2. Numerous calcified mediastinal lymph nodes consistent with patient's known
history of sarcoidosis.
3. Probable lower lobe atelectasis, with possible mild superimposed
aspiration.
Updated findings from preliminary read communicated to Dr. ___ at
11:47 pm on ___ by telephone by Dr. ___
Radiology Report
HISTORY: Neuro sarcoid, presented with seizures, evaluate for new neuro
sarcoid lesions as potential cause of seizure.
TECHNIQUE: Multiplanar multisequence MRI of the brain was obtained without IV
contrast as per department protocol. Please note that IV contrast was not
given as patient has the GFR was extremely low.
COMPARISON: CT head noncontrast of ___.
FINDINGS:
There is diffuse low T1/T2 signal throughout the bone marrow with mild
expansion of the diploic space and clivus. There is also low T1/T2 signal
involving the left petrous apex. These findings could be seen with anemia such
sickle cell.
There is volume loss with T2/FLAIR hyperintensity around the left frontal lobe
and associated low signal in the susceptibility sequence consistent with
encephalomalacia and old hemorrhage. There is also ex-vacuum phenomenon
involving the left frontal horn.
There are scattered T2/FLAIR hyperintensities throughout the periventricular
and subcortical white matter which are nonspecific but could be seen with
chronic microangiopathy. There is no evidence of new infarct or new
hemorrhage. There is atrophy of the corpus callosum.
The ventricles and extra-axial CSF spaces are prominent likely representing
global cerebral volume loss. The basal cisterns are patent. There is no
evidence of midline shift.
There is no evidence of abnormal masses or thickening of the meninges in this
noncontrast MRI.
There is a mucous retention cyst involving the left nasopharynx.
IMPRESSION:
1. No evidence of new infarct or new hemorrhage. No evidence of masses.
2. Abnormal diffuse bone marrow signal with expansion of the clivus and
diploic space. These findings are likely related to chronic anemia such as
sickle cell anemia.
3. Old left frontal encephalomalacia.
4. Small vessel white matter ischemic changes with global cerebral volume
loss.
Radiology Report
HISTORY: ___ female with tonic-clonic seizures in ED after
respiratory distress, having required intubation, but the patient is now
extubated.
STUDY: PA and lateral chest radiograph.
COMPARISON: ___. Torso CT from ___.
FINDINGS: There has been interval removal of the endotracheal tube. The
heart and mediastinal contours are at the upper limits of normal but unchanged
from prior study. Bilateral hilar calcifications reflect calcified lymph
nodes as demonstrated on prior torso.
IMPRESSION: Status post extubation without evidence of pulmonary
consolidation or pneumothorax.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SHORTNESS OF BREATH
Diagnosed with RESPIRATORY ABNORM NEC, OTHER CONVULSIONS, END STAGE RENAL DISEASE
temperature: 97.8
heartrate: 117.0
resprate: 38.0
o2sat: 100.0
sbp: 150.0
dbp: 90.0
level of pain: 0
level of acuity: 1.0 | ___ with history of sarcoidosis/neurosarcoidosis, sickle cell,
ESRD on HD, seizure disorder on levetiracetam here s/p
tonic-clonic seizure in ED and unresponsiveness at HD session
___. S/p MICU stay following intubation for airway
protection, now extubated and mentating well. Urine toxicology
positive for cocaine.
1) AMS at HD/seizure in HD - Patient with history of
neurosarcoidosis leading to seizure disorder maintained on
levetiracetam as outpatient. Patient denies seizure in many
years. Unwitnessed event in HD session on ___. Per initial
neurology c/s note, suspected respiratory failure induced
epileptogenic activity. However, timeline perhaps more
consistent with seizure in HD leading to unresponsiveness
(reportedly maintained conciousness but not responding to
commands) and then generalized to tonic-clonic seizure in ED.
Patient's urine toxicology positive for cocaine. Highly likely
this is precipitating insult. MRI ___ did not identify new
lesion or organic factors to precipitate seizure. Patient with
history of neurosarcoidosis and subsequent seizure disorder,
maintained on levetiracetam 250mg PO BID as outpatient. States
she last saw a neurologist a few months ago. Prior to discharge,
patient set up with follow-up with ___ clinic at ___ on ___ and with neurology (Dr. ___, ___, on ___. Discharged with admission levetiracetam dose plus an extra
500mg PO on HD days. Strongly advised to avoid cocaine.
2) ESRD on HD - Keppra uptitrated in response to seizure post-HD
with thought she may be diuresing levetiracetam to
sub-therapeutic levels. Currently receiving 500mg Keppra in
addition to home dose for HD days and will be discharged on this
regimen.
3) Sickle cell - Patient denies ever experiencing acute chest
syndrome or recent crisis. Hematocrits trending down slightly
prior to discharge, attributed to chronic sickle cell. Will need
follow-up with outpatient PCP.
=========================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / latex
Attending: ___.
Chief Complaint:
Acute and chronic abdominal pain.
Major Surgical or Invasive Procedure:
Exploratory laparotomy, revision of jejunojejunostomy, lysis of
adhesions and removal of abdominal wall mesh.
History of Present Illness:
___ is a ___ female s/p gastric bypass
surgery ___, ___, sigmoid bowel resection, ventral hernia
repair, cholecystectomy, and diverticulitis who presents with
2-day history of worsening stabbing epigastric pain with
radiation to the back. The pain did not improve with Tylenol.
She first presented to ___ where a CT was performed
that showed no gastric changes, large stool volume in the colon,
no signs of SBO, and no signs of acute diverticular disease.
CBC, BMP, and LFTs there showed no significant abnormalities.
Prior to transfer to ___ for surgical evaluation, she was
given Zofran and morphine. Currently, her pain is ___ and
unchanged in character. She has some associated nausea, dry
heaving, and chills but no vomiting, fever, diarrhea,
lightheadedness, dizziness, or changes in bowel movements.
Past Medical History:
PMH:
PMH
-Roux-en-Y gastric bypass (___) requiring G tube for 8 weeks
-Perforated diverticulitis s/p sigmoid colon rescetion
-Grave's disease
-Pre-eclampsia
-Asthma
-Ventral hernia repair x2
-Uterine ablation
-C-section x2
PSH
PAST SURGICAL HISTORY:
-Roux-en-Y gastric bypass (___) requiring G tube for 8 weeks
-Sigmoid bowel resection
-Ventral hernia repair x2
-Uterine ablation
-C-section x2
Social History:
___
Family History:
FAMILY HISTORY: Hypertension. Father - testicular cancer.
Physical Exam:
PHYSICAL EXAM
Vitals:
Gen: Well appearing, NAD
HEENT: Moist mucous membranes, (-)LAD, PERRL
CV: RRR, no m/r/g, nl S1/S2.
Pulm: Unlabored, CTAB.
Abd: soft, non distended, mildly tender near incision, no
rebound, no guarding, midline incision clean, dry, and staples
intact, no erythema, no draining.
Ext: Warm & well-perfused. Palpable pulses.
Pertinent Results:
___ 09:20PM COMMENTS-GREEN TOP
___ 09:20PM LACTATE-0.8
___ 07:00PM GLUCOSE-80 UREA N-9 CREAT-0.9 SODIUM-138
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
___ 07:00PM estGFR-Using this
___ 07:00PM WBC-4.0 RBC-3.39* HGB-8.8* HCT-28.8* MCV-85
MCH-26.0* MCHC-30.7* RDW-13.7
___ 07:00PM NEUTS-37.4* LYMPHS-52.7* MONOS-5.6 EOS-3.5
BASOS-0.9
___ 07:00PM PLT COUNT-338
CT ABD & PELVIS W/O CONTRAST
Study Date of ___ 7:59 ___
FINDINGS:
CHEST: The lung bases are clear with no pleural effusions,
nodules, or masses.
The visualized portion of the heart and pericardium are normal.
There is no pericardial effusion.
ABDOMEN: The liver is normal in size and homogeneous in
enhancement. There
are no focal liver lesions. The portal and hepatic veins are
patent and there
is no intra or extrahepatic biliary ductal dilatation. The
gallbladder is
surgically absent,. The common bile duct is not dilated.
The spleen is normal in size and homogeneous in enhancement. The
adrenal
glands are normal in size and shape. The pancreas enhances
homogeneously
without focal lesions. There is no pancreatic ductal dilatation
or
peripancreatic fat stranding.
The kidneys are normal in size and demonstrate symmetric
nephrograms and
contrast excretion. The ureters are normal in caliber along
their visualized
course to the bladder. There are no concerning mass lesions or
stones seen
within the kidneys. There are no perinephric abnormalities
present.
The distal esophagus is normal appearing with no hiatal hernia.
The patient
is status post Roux-en-Y gastric bypass surgery. The excluded
portion of the
stomach and biliopancreatic limb contain fluid. Contrast is
seen passing
through the gastric pouch and alimentary limb. There is no
evidence
dilatation of the small bowel or abnormal wall thickening. The
patient is
status post partial colonic resection. The remaining portion of
the large
bowel contains feces, without evidence of obstructive mass
lesions or wall
thickening. The appendix is not definitely seen, however there
are no
secondary signs of appendicitis. There is no intraperitoneal
free air or free
fluid.
There is no aneurysmal dilatation of the abdominal aorta. The
aorta and its
major branches are patent. There is mild atherosclerotic
calcifications seen
in these vessels.
There are no pathologically enlarged retroperitoneal or
mesenteric lymph nodes
by CT size criteria.
PELVIS: The bladder is under distended, but grossly normal.
There is a
fibroid uterus. Postoperative changes of sigmoidectomy
identified. There is
no pelvic free fluid. There are no pathologically enlarged
pelvic sidewall or
inguinal lymph nodes by CT size criteria.
OSSEOUS STRUCTURES AND SOFT TISSUES: There are no concerning
lytic or
sclerotic lesions seen.
IMPRESSION:
No evidence of internal hernia or small-bowel obstruction. No
acute process
in the abdomen or pelvis.
The study and the report were reviewed by the staff radiologist.
ABDOMEN (SUPINE & ERECT)
Study Date of ___ 9:23 AM
FINDINGS: Comparison is made to the CT scan from ___.
There is oral contrast seen within the colon. There is air and
stool seen
throughout the transverse colon. There are no dilated loops of
bowel
identified. There is no free intra-abdominal gas. Surgical
clips are seen in
the right upper abdomen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 200 mcg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Acetaminophen-Caff-Butalbital 1 TAB PO PRN pain
6. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Calcitriol 0.5 mcg PO DAILY
4. Levothyroxine Sodium 200 mcg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
7. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 10 ml by mouth twice a day Disp
#*400 Milliliter Refills:*1
8. FoLIC Acid 1 mg PO DAILY
9. Lorazepam 0.5 mg PO Q4H:PRN nausea
RX *lorazepam 0.5 mg 1 tablet by mouth at bedtime Disp #*5
Tablet Refills:*0
10. Thiamine 100 mg PO DAILY
11. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL 10 ml by
mouth every four (4) hours Disp #*500 Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___ h/o gastric bypass, sigmoid bowel resection, ventral hernia
repair, cholecystectomy, and diverticulitis admitted for
worsening abdominal pain now s/p ex lap and re-do JJ
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ with s/p R en Y with abd pain // ? evidence of internal
hernia, no OSH CT read, need ___ rads read
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous administration of 130cc of Omnipaque. Coronal and
sagittal reformations were performed. Oral contrast was administered.
DOSE: DLP: 1087 mGy-cm.
COMPARISON: None available.
FINDINGS:
CHEST: The lung bases are clear with no pleural effusions, nodules, or masses.
The visualized portion of the heart and pericardium are normal. There is no
pericardial effusion.
ABDOMEN: The liver is normal in size and homogeneous in enhancement. There
are no focal liver lesions. The portal and hepatic veins are patent and there
is no intra or extrahepatic biliary ductal dilatation. The gallbladder is
surgically absent,. The common bile duct is not dilated.
The spleen is normal in size and homogeneous in enhancement. The adrenal
glands are normal in size and shape. The pancreas enhances homogeneously
without focal lesions. There is no pancreatic ductal dilatation or
peripancreatic fat stranding.
The kidneys are normal in size and demonstrate symmetric nephrograms and
contrast excretion. The ureters are normal in caliber along their visualized
course to the bladder. There are no concerning mass lesions or stones seen
within the kidneys. There are no perinephric abnormalities present.
The distal esophagus is normal appearing with no hiatal hernia. The patient
is status post Roux-en-Y gastric bypass surgery. The excluded portion of the
stomach and biliopancreatic limb contain fluid. Contrast is seen passing
through the gastric pouch and alimentary limb. There is no evidence
dilatation of the small bowel or abnormal wall thickening. The patient is
status post partial colonic resection. The remaining portion of the large
bowel contains feces, without evidence of obstructive mass lesions or wall
thickening. The appendix is not definitely seen, however there are no
secondary signs of appendicitis. There is no intraperitoneal free air or free
fluid.
There is no aneurysmal dilatation of the abdominal aorta. The aorta and its
major branches are patent. There is mild atherosclerotic calcifications seen
in these vessels.
There are no pathologically enlarged retroperitoneal or mesenteric lymph nodes
by CT size criteria.
PELVIS: The bladder is under distended, but grossly normal. There is a
fibroid uterus. Postoperative changes of sigmoidectomy identified. There is
no pelvic free fluid. There are no pathologically enlarged pelvic sidewall or
inguinal lymph nodes by CT size criteria.
OSSEOUS STRUCTURES AND SOFT TISSUES: There are no concerning lytic or
sclerotic lesions seen.
IMPRESSION:
No evidence of internal hernia or small-bowel obstruction. No acute process
in the abdomen or pelvis.
Radiology Report
STUDY: Supine and erect films of the abdomen ___.
CLINICAL HISTORY: ___ woman with history of gastric bypass and
sigmoid bowel resection. Worsening abdominal pain.
FINDINGS: Comparison is made to the CT scan from ___.
There is oral contrast seen within the colon. There is air and stool seen
throughout the transverse colon. There are no dilated loops of bowel
identified. There is no free intra-abdominal gas. Surgical clips are seen in
the right upper abdomen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.2
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 80.0
level of pain: 2
level of acuity: 3.0 | ___ is a ___ female s/p gastric bypass
surgery ___, ___, sigmoid bowel resection, ventral hernia
repair, cholecystectomy, and diverticulitis who presented to
___ ED with 2-day history of worsening stabbing epigastric
pain with radiation to the back.
Outside hospital CT read by ___ radiology showed no evidence
of internal hernia or small-bowel obstruction. No acute process
in the abdomen or pelvis.
CBC, BMP, and LFTs done in outside hospital showed no
significant abnormalities.
She was admitted to Bariatric service for further evaluation on
___. On admission her pain was ___ and unchanged in
character. She had some associated nausea, dry heaving, and
chills but no vomiting, fever, diarrhea, lightheadedness,
dizziness.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA and then
transitioned to oral Roxicet once tolerating a stage 2 diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: On ___ Supine and erect films of the abdomen
were done which showed no dilated loops of bowel and there were
no free intra-abdominal gas. Surgical clips were seen in the
right upper abdomen. The results were compared with the outside
hospital CT findings. On ___ Ms. ___ was
consulted by GI and conclusion was made that an anastomotic
ulcer is the most likely cause of her pain as her MCV is low and
she is anemic. EGD done on ___ showed no evidence of
ulcers/erosions on either side of the anastamosis.
The results and options of non operative and operative
management as well as referral to her surgeon were discussed
with the patient. She decided to proceed with surgery at ___.
Pt was evaluated by anaesthesia and taken to the operating room
for exploratory laparotomy. Please see the operative note for
details. Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
The patient was initially kept NPO then changed to Bariatric
stage 2. Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Somatostatin / Compazine / Meperidine / Percocet / Bactrim /
Fentanyl / OxyContin / Paxil / Demerol / Droperidol / Lactose /
Barium Sulfate / Iodine-Iodine Containing / Pantoprazole /
Omeprazole / Codeine / Sulfa (Sulfonamide Antibiotics) /
tramadol / Lovenox / Ambien / ondansetron / Dilaudid / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / aspirin
Attending: ___.
Chief Complaint:
Partial small bowel obstruction
Major Surgical or Invasive Procedure:
PICC line insertion Rt arm ___ (for difficult access)
History of Present Illness:
___ with PMHx of chronic abdominal pain, hepatitis C Ab
positivity (without detected viral load), sclerosing
mesenteritis
(s/p multiple abdominal surgeries), multiple small bowel
obstruction, chronic anemia, and line-associated DVT (on
rivaroxaban), with recent admission to ___ ICU for
sepsis, altered mental status, and liver failure who presents to
the ___ ED this evening with symptoms of obstruction.
The patient reports that she began to experience severe sharp
epigastric/left-sided periumbilical pain last night. She reports
that the pain would worsen after PO intake and was felt to be
progressing. She reports that her pain is very similar to her
previous bowel obstructions. She reports that her last bowel
movement was ___ morning, which is unusual for her as she
normally has multiple loose stools every day. She has also not
passed any flatus today. She denies any associated fevers,
chills, chest pain, shortness of breath, or changes in her
sensorium.
Past Medical History:
- sclerosing mesenteritis (dx'd in ___, s/p multiple abdominal
surgeries, including placement of decompressive G-tube)
- chronic SBO
- chronic GI dysmotility
- IBS
- NSAID-related gastritis and UGI bleed
- Hepatitis C (transmitted via transfusion in ___
- GERD
- Esophagitis
- multiple LOAs
- colonic decompressions
- small bowel resections - parts of duodenum, entire ileum
- repair of incisional hernias
- appendectomy
- open CCY
- G-tube placement ___ - report of recent removal
- extraction of duodenal bezoar
- multiple port-a-cath placements and removals
- recurrent DVTs, line associated
- anemia of chronic disease
- mitral valve prolapse
- asthma
- chronic tachycardia (HR in the 120s)
- nocturnal benign myoclonus
- migraine HAs w/ visual aura
- "seizures" - whole body twitching previously characterized as
pseudoseizures
- depression
- osteopenia
- sjogren's syndrome
- history of stroke
- hypothyroidism
- hypercalcemia
- recurrent UTIs
- sebaceous cysts
- L hemi-thyroidectomy
- breast reduction and multiple breast lumpectomies
- tooth extractions
- b/l knee arthroscopies
- b/l ankle reconstructions
- c-section
- tonsillectomy with adenoidecomty
- ganglion cyst removal
Social History:
___
Family History:
Mother deceased at ___ with premenopause, myelofibrosis, breast
cancer, DM2. Father deceased at ___ with coronary artery disease,
abdominal aortic aneurysm, myocardial infarction, triple bypass,
DM2, HTN. Sister living with breast cancer, lupus. Sister living
with breast cancer. Brother deceased at ___ with glioblastoma.
Two sons with celiac and one with JRA.
Physical Exam:
Discharge physical exam
Vitals: Temp: 97.9 HR: 94 BP: 111/76 Resp: 18 O(2)Sat: 97%
Gen: NAD, resting comfortably in bed
CV: RRR, palpable peripheral pulses
P: nonlabored breathing
GI: nondistended, soft, nontender; no
rebound or guarding. Multiple prior surgical scars are well
healed.
Ext: WWP, no CCE
Pertinent Results:
___ 07:32AM BLOOD WBC-3.8* RBC-3.40* Hgb-9.3* Hct-31.4*
MCV-92 MCH-27.4 MCHC-29.6* RDW-14.8 RDWSD-50.0* Plt ___
___ 04:42AM BLOOD WBC-4.2 RBC-2.88* Hgb-8.0* Hct-26.7*
MCV-93 MCH-27.8 MCHC-30.0* RDW-14.8 RDWSD-50.2* Plt ___
___ 08:20PM BLOOD WBC-5.2 RBC-3.25*# Hgb-9.0* Hct-29.8*
MCV-92 MCH-27.7 MCHC-30.2* RDW-14.7 RDWSD-49.5* Plt ___
___ 08:20PM BLOOD Neuts-60.4 ___ Monos-10.0 Eos-2.5
Baso-1.0 Im ___ AbsNeut-3.13 AbsLymp-1.33 AbsMono-0.52
AbsEos-0.13 AbsBaso-0.05
___ 07:32AM BLOOD Plt ___
___ 04:42AM BLOOD Plt ___
___ 04:42AM BLOOD ___ PTT-33.6 ___
___ 08:20PM BLOOD Plt ___
___ 08:20PM BLOOD ___ PTT-37.9* ___
___ 07:32AM BLOOD Glucose-85 UreaN-6 Creat-0.7 Na-135 K-4.5
Cl-98 HCO3-24 AnGap-18
___ 05:05AM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-138 K-4.8
Cl-103 HCO3-23 AnGap-17
___ 04:42AM BLOOD Glucose-75 UreaN-12 Creat-0.6 Na-135
K-3.5 Cl-99 HCO3-23 AnGap-17
___ 08:20PM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-134
K-4.5 Cl-96 HCO3-23 AnGap-20
___ 04:42AM BLOOD ALT-36 AST-42* AlkPhos-171* TotBili-0.4
___ 08:20PM BLOOD ALT-42* AST-50* AlkPhos-195* TotBili-0.5
___ 07:32AM BLOOD Calcium-8.5 Phos-4.9* Mg-1.9
___ 05:05AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.4
___ 04:42AM BLOOD Calcium-7.7* Phos-4.9* Mg-1.5*
___ 08:20PM BLOOD Albumin-3.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO BID
2. Rivaroxaban 10 mg PO BID
3. LamoTRIgine 200 mg PO DAILY
4. Abilify (ARIPiprazole) 20 mg oral DAILY
5. Furosemide 5 mg PO EVERY OTHER DAY
6. Potassium Chloride 20 mEq PO BID
7. Pantoprazole 20 mg PO Q12H
8. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB
9. Calcitriol 0.25 mcg PO DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, if
albuterol inhaler does not relieve symptoms
11. LOPERamide 8 mg PO QAM
12. TraZODone 25 mg PO QHS:PRN insomnia
13. Simethicone 80 mg PO DAILY
14. Cyanocobalamin 1000 mcg PO DAILY
15. Promethazine 25 mg PO Q6H:PRN nausea/vomiting
16. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN pain ___. onabotulinumtoxinA unknown strength injection Q3MONTHS for
migraine headaches; next injection due on ___
18. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
19. diphenhydrAMINE HCl 12.5 mg/5 mL oral Q6H:PRN itching
20. Vitamin D ___ UNIT PO 1X/WEEK (MO)
21. Calcium with Vitamin D (calcium carbonate-vitamin D3) 2
tabs oral BID
Discharge Medications:
1. Famotidine 20 mg PO Q12H
2. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN R arm pain
RX *lidocaine 5 % Apply to right arm for pain daily Disp #*7
Patch Refills:*0
3. Gabapentin 1200 mg PO BID
RX *gabapentin [Neurontin] 600 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
5. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
6. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB
7. ARIPiprazole 20 mg oral DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Calcium with Vitamin D (calcium carbonate-vitamin D3) 2
tabs oral BID
10. Cyanocobalamin 1000 mcg PO DAILY
11. diphenhydrAMINE HCl 12.5 mg/5 mL oral Q6H:PRN itching
12. Furosemide 5 mg PO EVERY OTHER DAY
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, if
albuterol inhaler does not relieve symptoms
14. LamoTRIgine 200 mg PO DAILY
15. LOPERamide 8 mg PO QAM
16. onabotulinumtoxinA unknown injection Q3MONTHS FOR MIGRAINE
HEADACHES; NEXT INJECTION DUE ON ___
17. Pantoprazole 20 mg PO Q12H
18. Potassium Chloride 20 mEq PO BID
19. Promethazine 25 mg PO Q6H:PRN nausea/vomiting
20. Rivaroxaban 10 mg PO BID
21. Simethicone 80 mg PO DAILY
22. TraZODone 25 mg PO QHS:PRN insomnia
23. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with h/o SBO, multiple surgeries and sclerosing
mesenteritis p/w abdominal pain and vomiting // evaluate for obstruction
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
There is mild elevation of the right hemidiaphragm. Spine catheter re-
demonstrated, similar in appearance. No evidence of free air is seen beneath
the diaphragms.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: History: ___ with h/o SBO, multiple surgeries and sclerosing
mesenteritis p/w abdominal pain and vomiting. Evaluate for obstruction.
TECHNIQUE: Supine and upright radiographic views of the abdomen.
COMPARISON: L wall radiographs of ___, and CT
abdomen and pelvis of ___.
FINDINGS:
Multiple air-fluid levels are identified on the upright view. There is no
free intraperitoneal air. Air and stool are identified in the distal large
bowel/rectum. Patient has known chronic dilatation of the jejunum.
Osseous structures are notable for mild degenerative changes of the bilateral
hips. Several surgical clips are scattered throughout the abdomen.
IMPRESSION:
1. Multiple air-fluid levels on the upright view. However, air and stool are
identified in the distal large bowel/rectum, and patient has known chronic
dilatation of the jejunum. Findings could indicate ileus. No high grade
obstruction or transition point detected.
2. No free intraperitoneal air.
Radiology Report
INDICATION: ___ year old woman with recurrent SBO, no IV access // please
place PICC, has required fluoro in past for placement
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the
procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: none
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.3 min, 4 mGy
PROCEDURE:
1. Single lumen midline placement through the right brachial vein.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the right
brachial vein was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A single lumen midline measuring 14 cm
in length was then placed through the peel-away sheath with its tip positioned
in the right axillary under fluoroscopic guidance. Position of the catheter
was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath
and guidewire were then removed. The catheter was secured to the skin,
flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Brachialvein approach single lumen right midline with tip in the axillary
vein.
IMPRESSION:
Successful placement of a right 14 cm brachial approach single lumen midline
with tip in the axillary vein. The line is ready to use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Vomiting without nausea, Unspecified intestinal obstruction
temperature: 98.6
heartrate: 100.0
resprate: 16.0
o2sat: 98.0
sbp: 116.0
dbp: 76.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ was admitted to the floor from the ED on ___.
She was complaining of sharp epigastric pain associated with
nausea and vomiting.
At the time of admission, she had not had a bowel movement or
passed gas since ___ morning. Per patient, her baseline is
15 loose bowel movements per day due to her short bowel. The
patient underwent abdominal x-ray
in the ED that showed multiple air-fluid levels on the upright
view. However, air and stool are identified in the distal large
bowel/rectum, and patient has known chronic dilatation of the
jejunum. Findings could indicate ileus. No high grade
obstruction or transition point detected. She was made NPO and
placed on an NG tube with suction as treatment for ileus. Her
electrolytes were repleted. She was given IV dilaudid and
promethazine for pain and nausea control. On HD2, the patient
had 3 bowel movements and her NG tube output was 460 that day.
After a successful clamp trial of her NG tube on HD3, her NG
tube was removed. She was started on a clear diet and advanced
to fulls. There was also some difficulty with her IV access, and
so we inserted a PICC line on the same day. She then started to
complain of severe burning/sharp pain in the right upper
extremity that radiated to her hand and so neurology was
consulted. Per their recommendations, they believe that it was a
nerve irritation from the midline insertion and removing it
would not necessarily control it. They recommended a lidocaine
patch and IV Tylenol and also an increase in her home gabapentin
to 1200BID on HD4. She was also advanced to a regular diet that
day. The patient was tolerating a regular diet, her pain was
much improved and was stooling and urination, ambulating
independently and was ready to be discharged on ___. The
patient will follow up with Dr. ___ as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with a past medical history of
LGS s/p VNS placement, and osteoporosis who is presenting today
with increased seizure frequency. He was seen in epilepsy clinic
by Dr. ___ morning. He then returned to his group home.
Not very many details are available, but it is apparent that at
his group home he had a cluster of seizures. He was given 2mg
ativan at 1:30pm, and was sent to the ___. The most
current protocol that is listed in our OMR states that the group
home should give 2mg ativan for 2 seizures within 1 hour, or for
a seizure lasting more than 5 minutes. After speaking with our
epilepsy department, he was transferred here for admission to
the
epilepsy monitoring unit.
His seizures are mainly tonic/atonic seizures, with
incontinence.
Previously, his group home had been recording ___ seizures
per
month. However, he has recently had multiple episodes of
increased seizure frequency. He was admitted from ___, he
was observed, no medication changes were made. He had ___ tonic
seizures per day per EEG report, which the discharge summary
states is his baseline.
On ___, he went to the ___ after having 8 seizures lasting 20
seconds, dilantin level was noted to be low at at around 7.3, so
his total daily dose was increased to 360 mg total qd from 330mg
daily, and he was discharged home.
He now returns with another cluster of seizures, as above. He
was
transferred here for admission and EEG LTM, as he has had 5 ___
visits in the past 2 weeks, per our epilepsy fellow.
He has been on a relatively stable regimen for the past several
years, with the exception of dilantin which was added during an
admission in ___. There has been concern in the past that
trileptal has caused sedation, and that Keppra has caused
behavioural issues. After starting rufinamide he had an
increased
seizure frequency and this was taken off.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PMH:
-Birth history (Per OMR): Mr. ___ was born one month early
and
began having seizure at 18 months associated with high fevers
and
apnea. Over his life, he has had several types of seizures in
the past including absence-type spells, generalized tonic-clonic
seizures, focal episodes involving left arm elevation and head
deviation to the left and "seizures are characterized by
yelling,
sitting up and staring, and circling around. His body will then
typically tense up and he will fall to the ground in a slumping
manner, and then become stiff again on the floor."
- VNS ___, generator replacement on ___,
- developmental delay, cryptogenic. Known placenta previa with
near-term vaginal bleeding, unknown if hypoxic/ischemic insult.
Gross motor and speech delay, further details unknown by family.
- seizure disorder
- Osteoporosis
Epilepsy History:
AEDS: Per the records, Mr. ___ had trialed ___, Lamictal
and Lyrica all before ___ but was not continued on these
medications. At his last inpatient admission in ___, he
was admitted to try to wean Trileptal as there were concerns it
was causing sedation and start rufinamide. Eventually,
rufinamide
was got to goal of 800mg BID but he began having multiple
seizures per day with escalating seizure frequency, culminating
in a day with 14 seizures in a 24h period which were much longer
than usual ___ vs. ___, eventually requiring a Dilantin
load and bridge until Trileptal could be reintroduced. He was
discharged on the same seizure medications. He was
re-hospitalized at ___ in the ___ due to
multiple seizure types and at that time, they discussed starting
___ which was then began in ___ Mr. ___ then
followed-up with neurology at the ___ until early ___.
Between the ___ and early ___, there were many
adjustments to Mr. ___ medications. Felbatol was started as
planned. Keppra was stopped but restarted at a lower dose after
he developed worse seizures. Trileptal was stopped given
concerns
for sedation which seemed to precipitate worse seizures, and it
was restarted on a lower dose Trileptal (450 instead of 1500mg
BID). It seems that he has been stable on his current AED
regimen since at least ___ when he reinitiated care
with
Dr. ___.
VNS: His VNS was placed in ___ and shortened his seizures from
___ but did not reduce their number
Social History:
___
Family History:
- No hx of seizures or developmental delay in other family
members.
- Per the group home, the father may have a psychiatric illness.
Physical Exam:
Vitals: 98.4 88 127/84 18 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, obese, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. States that he is here
because he had more seizures. Language is fluent with intact
comprehension and repetition. Attends to examiner. No evidence
of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Full strength throughout.
-Sensory: No deficits to light touch throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysmetria.
-Gait: Not tested.
Pertinent Results:
BLOOD WBC-6.4 RBC-4.53* Hgb-15.7 Hct-47.3 MCV-104* MCH-34.5*
MCHC-33.1 RDW-12.8 Plt ___
___ 06:50AM BLOOD WBC-5.1 RBC-4.47* Hgb-15.1 Hct-46.7
MCV-105* MCH-33.7* MCHC-32.2 RDW-13.3 Plt ___
___ 08:20PM BLOOD WBC-5.5 RBC-4.26* Hgb-14.9 Hct-43.6
MCV-103* MCH-35.1* MCHC-34.3 RDW-12.6 Plt ___
___ 06:40AM BLOOD Glucose-81 UreaN-14 Creat-0.6 Na-143
K-4.2 Cl-110* HCO3-21* AnGap-16
___ 06:50AM BLOOD Glucose-82 UreaN-11 Creat-0.5 Na-137
K-4.0 Cl-105 HCO3-25 AnGap-11
___ 08:20PM BLOOD Glucose-90 UreaN-13 Creat-0.6 Na-138
K-4.0 Cl-104 HCO3-21* AnGap-17
___ 06:40AM BLOOD ALT-70* AST-33 AlkPhos-77
___ 06:50AM BLOOD ALT-46* AST-27 LD(LDH)-167 AlkPhos-73
TotBili-0.4
___ 08:20PM BLOOD ALT-49* AST-28 AlkPhos-82 TotBili-0.2
___ 08:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:30PM BLOOD Lactate-2.4*
___ 11:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 11:00PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
=
=
================================================================
EEG monitoring:
1. ___:
IMPRESSION: This is an abnormal continuous monitoring study of
mild diffuse encephalopathy with multifocal central regions
bilaterally R>L. There is also very active interictal epileptic
activity that is bilateral and independent as well as bilateral
and synchronous. Compared to prior days' recording, there are no
further clear seizures.
___
IMPRESSION: This is an abnormal continuous monitoring study
because of two tonic seizures, mild diffuse encephalopathy with
multifocal central regions bilaterally R>L, and very active
interictal epileptic activity that is bilateral and independent
as well as bilateral and synchronous
-------
Medications on Admission:
1. Cyanocobalamin 1000 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Silver Sulfadiazine 1% Cream 1 Appl TP BID
5. Vitamin D 5000 UNIT PO EVERY OTHER DAY
6. Vitamin E 400 UNIT PO DAILY
7. ClonazePAM 1 mg PO TID
8. Felbatol (felbamate) 600 mg oral TID
9. LeVETiracetam 1500 mg PO BID
10. Oxcarbazepine 450 mg PO BID
11. Phenytoin Sodium Extended 100 mg PO QAM
12. Phenytoin Sodium Extended 160 mg PO Q AFTERNOON **
13. Phenytoin Sodium Extended 100 mg PO Q NIGHT
14. Zonisamide 300 mg PO BID
15. Docusate Sodium 100 mg PO BID
16. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. ClonazePAM 1 mg PO TID
2. Cyanocobalamin 100 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Oxcarbazepine 450 mg PO BID
6. perampanel 8 mg oral qhs
RX *perampanel [Fycompa] 8 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*6
7. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY
8. Vitamin D 5000 UNIT PO EVERY OTHER DAY
9. Vitamin E 400 UNIT PO DAILY
10. Zonisamide 300 mg PO BID
11. LACOSamide 200 mg PO BID
RX *lacosamide [Vimpat] 200 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*6
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Intractable epilepsy
2. ___ syndrome (LGS),
3. Gognitive decline
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain.
TECHNIQUE: Single AP semi-erect portable view of the chest.
COMPARISON: ___.
FINDINGS:
Left-sided vagal nerve stimulator is again seen. The cardiac and mediastinal
silhouettes are stable. There is no definite focal consolidation. No large
pleural effusion is seen. There is slight blunting of the left costophrenic
angle which may be due to overlying soft tissue although a trace pleural
effusion would be difficult to exclude. No pneumothorax is seen.
IMPRESSION:
Slight blunting of the left costophrenic angle which may be due to overlying
soft tissue although a trace pleural effusion would be difficult to exclude.
Otherwise, no significant interval change.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure, Transfer
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY
temperature: 98.4
heartrate: 88.0
resprate: 18.0
o2sat: 98.0
sbp: 127.0
dbp: 84.0
level of pain: 13
level of acuity: 2.0 | Mr. ___ is a ___ year old man with ___ Syndrome who
is presenting with a cluster of seizures over the past ___
months. His dilantin level was low.
Neurology
- He was started on perampanel *NF* 4 mg oral qHS the dose
increased to 6 mg on ___ and will increase to 8 mg on
___
- During this admission we tapered felbamate, then dilantin then
keppra, and we started perampanel for him and increased the dose
gradually.
After he became off the keppra, he started to have frequent
seizure and on ___ he was started on vimpat 100 mg which
was increased to 200 mg bid on ___.
He has been off keppra for more than 2 days and since he has
been in the hospital we did not catch any aggressiveness.
#ID - Infection screen including urine, chest x ray and blood
culture was negative |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
postpartum severe preeclampsia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ s/p SVD on ___ who presents to ___ ED as a
transfer from ___ ED with concern for post partum
pre-eclampsia given severe range blood pressures and persistent
headache. The patient had an uncomplicated vaginal
delivery on ___ with an uncomplicated post partum course. She
reports a new onset posterior headache starting three days ago.
She notes seeing intermittent black and white spots, increasing
in frequency over the last three days. Her headache became
progressively worse over the course of the last three days,
prompting her presentation to the ED. Per the transfer
documentation from ___, she was found to be hypertensive to the
200's/100's. She was given 10mg IV labetalol, started on
magnesium with a 6gm bolus -> 2gm/hr maintenance rate, 15mg IV
toradol and 4mg morphine. She underwent a non-contrast CT of her
head, which was negative for acute intracranial processes or
hemorrhage. ___ labs were all WNL. She reported mild improvement
in her headache, then was transferred to ___ for further
management.
Here, she notes evolution of her headache from the back of her
head to the front of her head, now with worsening visual
symptoms. She felt like she was just "seeing spots" before, but
now she states she is unable to see her phone to type or focus
long enough to participate in a neurological exam. She denies
chest pain or shortness of breath, denies upper abdominal pain
or new swelling of her extremities. She denies abdominal
cramping,
her lochia is minimal requiring ___ pads per day. She has been
breastfeeding. Her newborn son is doing well and is currently
being cared for by the father of the baby. She is noticeably
concerned and agitated by her current visual symptoms.
Past Medical History:
___:
- ___
-3 TAB (___) for undesired pregnancy
-NSVD x 3 ___ no hx of pre-eclampsia or HTN
disorders; most recent SVD uncomplicated at term
GynHx:
-History of +HPV ___
-Denies history of fibroids
-D&C x 2
-H/o Chlamydia ___
PMH:
- Congenital Heart Defect, repaired at birth.
- Depression (previously on Prozac and Ativan prior to
pregnancy)
PSH:
-congenital cardiac surgery (further details unknown to patient
and not available)
-D&C x 2
Physical Exam:
Physical Exam on Discharge:
VS: Afebrile, VSS
Neuro/Psych: NAD, Oriented x3, Affect Normal
Heart: RRR
Lungs: CTA b/l
Abdomen: soft, appropriately tender, fundus firm
Pelvis: minimal bleeding
Extremities: warm and well perfused, no calf tenderness, no
edema
Pertinent Results:
=======================================
Labs
=======================================
___ 06:34AM BLOOD WBC-6.6 RBC-4.19 Hgb-13.0 Hct-39.2 MCV-94
MCH-31.0 MCHC-33.2 RDW-15.1 RDWSD-52.5* Plt ___
___ 09:30AM BLOOD WBC-7.9 RBC-3.95 Hgb-12.6 Hct-37.3#
MCV-94 MCH-31.9 MCHC-33.8 RDW-15.0 RDWSD-52.3* Plt ___
___ 09:30AM BLOOD Neuts-56.5 ___ Monos-7.9 Eos-2.5
Baso-0.5 Im ___ AbsNeut-4.47 AbsLymp-2.50 AbsMono-0.63
AbsEos-0.20 AbsBaso-0.04
___ 09:30AM BLOOD ___ PTT-28.1 ___
___ 06:34AM BLOOD Glucose-93 UreaN-17 Creat-0.7 Na-140
K-4.3 Cl-105 HCO3-22 AnGap-17
___ 09:30AM BLOOD Glucose-104* UreaN-7 Creat-0.6 Na-138
K-3.4 Cl-104 HCO3-20* AnGap-17
___ 06:34AM BLOOD ALT-32 AST-21
___ 09:30AM BLOOD ALT-29 AST-21 AlkPhos-108* TotBili-0.2
___ 06:34AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.7 Cholest-209*
___ 09:35AM BLOOD %HbA1c-5.0 eAG-97
___ 06:34AM BLOOD Triglyc-221* HDL-57 CHOL/HD-3.7
LDLcalc-108
___ 09:35AM URINE Color-Straw Appear-Clear Sp ___
___ 09:35AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 09:35AM URINE RBC-2 WBC-8* Bacteri-NONE Yeast-NONE
Epi-2 TransE-<1
___ 07:32PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
=======================================
Microbiology
=======================================
___ 9:35 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
=======================================
Imaging
=======================================
MRI/MRV Head (___)
1. There are punctate periventricular and subcortical T2/FLAIR
nonenhancing
white matter hyperintensities nonspecific in a patient of this
age, however
not in a distribution typical for PRES. Differential
considerations include
sequela of chronic headache such as migraine, prior trauma,
infectious/inflammatory etiology or small vessel ischemic
disease.
2. No acute infarct or intracranial hemorrhage.
3. The dural venous sinuses are patent on MP-RAGE and MRV.
Echocardiography (___)
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Doppler parameters are
most consistent with normal left ventricular diastolic function.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets are myxomatous. There is no
mitral valve prolapse. No mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal.
Renal artery Doppler (___)
Normal renal ultrasound. No evidence of renal artery stenosis.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old woman postpartum day 6 with new onset hypertension,
severe persistent headache and scotomata// r/p venous sinus thrombosis or PRES
TECHNIQUE: Phase contrast MRV of the head performed. Sagittal and axial T1
weighted imaging were performed along with diffusion imaging.
After administration of 8 mL of Gadavist intravenous contrast, axial imaging
was performed with gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: Outside hospital CT head of ___.
FINDINGS:
MRI BRAIN:
There is no intra or extra-axial mass, acute hemorrhage or infarct. The
sulci, ventricles and cisterns are within expected limits for the patient's
age. There are punctate periventricular and subcortical T2/FLAIR nonenhancing
white matter hyperintensities, nonspecific in a patient of this age, however
not in a distribution typical for PRES. Incidental note is made of a partial
empty sella. The major intracranial flow voids are preserved. The dural
venous sinuses are patent on postcontrast MP-RAGE. There is mild mucosal
thickening of the ethmoid air cells and maxillary sinuses. The orbits are
unremarkable without evidence of increased CSF space in the optic nerve sheath
complex. Trace fluid signal is noted in the left mastoid tip.
MRV brain: The internal cerebral veins, vena ___, straight sinus, torcula,
bilateral transverse and sigmoid sinuses as well as superior sagittal sinus
are unremarkable. The left transverse sinus is hypoplastic relative to the
right. The visualized internal jugular veins are patent.
IMPRESSION:
1. There are punctate periventricular and subcortical T2/FLAIR nonenhancing
white matter hyperintensities nonspecific in a patient of this age, however
not in a distribution typical for PRES. Differential considerations include
sequela of chronic headache such as migraine, prior trauma,
infectious/inflammatory etiology or small vessel ischemic disease.
2. No acute infarct or intracranial hemorrhage.
3. The dural venous sinuses are patent on MP-RAGE and MRV.
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: ___ year old woman with persistently elevated BP// eval for renal
artery stenosis
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: Ultrasound ___
FINDINGS:
The right kidney measures 10.9 cm. The left kidney measures 10.8 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Renal Doppler: Intrarenal arteries show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive indices of the
right intra renal arteries range from 0.59-0.61. The resistive indices on the
left range from 0.55-0.61. Bilaterally, the main renal arteries are patent
with normal waveforms. The peak systolic velocity on the right is 74
centimeters/second. The peak systolic velocity on the left is 114
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Headache, Hypertension
Diagnosed with Unspecified maternal hypertension, comp the puerperium
temperature: 97.7
heartrate: 72.0
resprate: 19.0
o2sat: 96.0
sbp: 120.0
dbp: 85.0
level of pain: 5
level of acuity: 2.0 | On ___, Ms. ___ was readmitted to the postpartum service
for severe postpartum preeclampsia.
Given her headache and visual disturbances, neurology was
consulted. They recommended imaging. She had a MRI/MRV which
showed no acute infarct or intracranial hemorrhage and no
evidence of venous sinus thrombosis or PRES. It was felt that
her headaches were secondary to her hypertension. She continued
to have headaches which responded to compazine, toradol and
fioricet.
For her preeclampsia, she received 24 hours of magnesium. On
HD#2 she started having severe range blood pressures and was
started on labetalol 200mg BID. Her medications were titrated
daily due to labile blood pressures despite labetalol 600mg q8h
and hydralazine 10mg q6h. Given persistence of severe range BP,
medicine was consulted for further management. They recommended
renal ultrasound, ECHO and labs all of which were normal. With
additional severe range BP her regimen was changed to labetalol
800mg q8h and captopril 25mg BID. Patient was advised to remain
in house for monitoring but elected to leave against medical
advice. Visiting nurse was arranged for at home BP monitoring as
well as outpatient postpartum and cardiology appointments.
Preeclampsia signs were reviewed prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Avelox / amitriptyline / Penicillins
Attending: ___.
Chief Complaint:
SAH, new O2 requirement
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ COPD (on 2L home O2), CAD (s/p stent ___, HTN, HLD, DM,
transferred following a fall and found to have SAH, being
admitted for new oxygen requirement.
She resides in a nursing home and reports a fall from her chair
while leaning over to pick up an item off the floor. She fell
out of the chair and struck her head; she denies LOC. She was
brought to an OSH by ambulance where ___ showed small right
frontal tSAH. She was transferred to ___ for further
evaluation. Pt denies any vision changes, numbness, tingling or
weakness. Not on blood thinners. Otherwise feels well. Per
family is at baseline.
In the ED, initial vitals were: 97.4 112/57 12 93%NC. Remained
tachycardic ___. Oxygen saturation remained high ___ on NC.
- Exam notable for: not documented
- Labs notable for: H/H 8.4/28.4 (b/l Hgb ***), nl CHEM7, UA
negative, lactate 1.6. D-Dimer 2488
- Imaging was notable for: CTA w/o PE but limited study,
diffuse chronic lung disease, moderately severe aspiration. CT
head interval evolution of subarachnoid blood in right frontal
and temporal lobes, no new hemorrhage, moderate left parietal
subgaleal hematoma
- Patient was given: furosemide 40mg PO, losartan, tiotropium,
glimepride, spironolactone, sertraline, docusate, 500cc NS,
acetaminophen, olanzapine, albuterol neb
- Seen by NSGY, no role for neurosurgical intervention and no
follow up necessary
- Pt admitted for worsening O2 requirement
Upon arrival to the floor, VS: 97.9 116/56 110 18 95%
Pt currently denies difficulty breathing. Has had new cough. No
fevers or chills. Has had yellowish sputum production, unchanged
from baseline. No wheezing. No chest pain. No headache. Has had
chronic blurred vision. No new numbness or tingling.
Past Medical History:
COPD
Diabetes
Hyperlipidemia
Hypertension
Myocardial Infarction
CAD with stents ___
Macular degeneration
Legal blindness
Demetia
Anxiety
Surgery:
R fallopian tube removal
Knee Surgery
Foot surgery
Social History:
___
Family History:
- mother esophageal cancer
- family history of diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Vitals: 97.9 116/56 110 18 95%
General: alert, oriented, no acute distress, no use of
accessory muscles of respiration
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: pan-inspiratory wheezes diffusely, no rales or ronchi
CV: tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis,
trace edema
Neuro: CNs2-12 intact, moving all four extremities
DISCHARGE PHYSICAL EXAM
======================
VS: T 98.2 BP 114 / 58 HR 96 RR 16 O2 89% 3L
GENERAL: NAD, alert and oriented x1-3 and does not recall
yesterday's events.
HEENT: AT/NC, EOMI, PERRL, MMM
NECK: Supple, no LAD, no JVD
HEART: Tachy, regular rhythm, S1/S2, no murmurs, gallops, or
rubs
LUNGS: LLL rales, right lower lobe rhonchi. Apices bilaterally
are CTA.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LAB RESULTS
====================
___ 09:50PM BLOOD WBC-8.5 RBC-3.54* Hgb-8.4* Hct-28.4*
MCV-80* MCH-23.7* MCHC-29.6* RDW-19.8* RDWSD-56.1* Plt ___
___ 09:50PM BLOOD ___ PTT-30.2 ___
___ 09:50PM BLOOD Glucose-159* UreaN-23* Creat-0.7 Na-139
K-4.4 Cl-98 HCO3-27 AnGap-18
___ 09:50PM BLOOD ALT-19 AST-19 LD(LDH)-254* AlkPhos-88
TotBili-<0.2
___ 09:50PM BLOOD Calcium-9.7 Phos-4.0 Mg-1.4*
___ 03:50PM BLOOD D-Dimer-2488*
MICROBIOLOGY
============
___ Blood culture:
___ Urine culture:
___ C diff:
IMAGING/STUDIES:
==============
___ CT Head without Contrast:
1. Interval evolution of subarachnoid blood in the right
frontal and temporal lobes. No new hemorrhage.
2. Moderate left parietal subgaleal hematoma.
3. Extensive paranasal sinus disease with likely an acute
component.
___ CTA Chest:
1. Severely limited study due to respiratory motion artifact,
but no central or lobar pulmonary embolism.
2. Diffuse chronic lung disease and moderately severe
emphysema.
3. Moderately severe aspiration involving the bronchus
intermedius, right middle, and right lower lobes.
DISCHARGE LAB RESULTS
====================
___ 04:45AM BLOOD WBC-13.0*# RBC-3.01* Hgb-7.2* Hct-24.0*
MCV-80* MCH-23.9* MCHC-30.0* RDW-20.1* RDWSD-57.8* Plt ___
___ 04:45AM BLOOD Glucose-124* UreaN-17 Creat-0.7 Na-137
K-4.0 Cl-100 HCO3-23 AnGap-18
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Sertraline 50 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. OLANZapine 2.5 mg PO DAILY
5. OLANZapine 5 mg PO QHS
6. OLANZapine 5 mg PO BID:PRN agitation
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
8. Tessalon Perles (benzonatate) 100 mg oral TID:PRN
9. OxyCODONE (Immediate Release) 10 mg PO BID
10. LORazepam 0.5 mg PO BID
11. Gabapentin 100 mg PO BID
12. Calcium Carbonate 500 mg PO DAILY
13. Vitamin D 400 UNIT PO DAILY
14. Daliresp (roflumilast) 500 mcg oral DAILY
15. Furosemide 40 mg PO DAILY
16. Losartan Potassium 25 mg PO DAILY
17. Omeprazole 20 mg PO DAILY
18. Spironolactone 12.5 mg PO DAILY
19. melatonin 3 mg oral QHS
20. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
21. Atenolol 25 mg PO BID
22. Docusate Sodium 100 mg PO BID
23. Senna 8.6 mg PO BID
24. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
25. Fentanyl Patch 25 mcg/h TD Q72H
26. Ferrous Sulfate 325 mg PO 3X/WEEK (___)
27. Lidocaine 5% Patch 1 PTCH TD QPM
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Doses
2. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
3. LORazepam 0.5 mg PO DAILY Duration: 4 Doses
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
6. Atenolol 25 mg PO BID
7. Calcium Carbonate 500 mg PO DAILY
8. Daliresp (roflumilast) 500 mcg oral DAILY
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO 3X/WEEK (___)
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Gabapentin 100 mg PO BID
13. Lidocaine 5% Patch 1 PTCH TD QPM
14. Losartan Potassium 25 mg PO DAILY
15. melatonin 3 mg oral QHS
16. Multivitamins 1 TAB PO DAILY
17. OLANZapine 5 mg PO BID:PRN agitation
18. OLANZapine 2.5 mg PO DAILY
19. OLANZapine 5 mg PO QHS
20. Omeprazole 20 mg PO DAILY
21. OxyCODONE (Immediate Release) 10 mg PO BID
22. Senna 8.6 mg PO BID
23. Sertraline 50 mg PO DAILY
24. Tessalon Perles (benzonatate) 100 mg oral TID:PRN
25. Tiotropium Bromide 1 CAP IH DAILY
26. Vitamin D 400 UNIT PO DAILY
27. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until the patient's blood pressure is
higher.
28. HELD- Spironolactone 12.5 mg PO DAILY This medication was
held. Do not restart Spironolactone until the patient's blood
pressure is higher.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: COPD exacerbation, subarachnoid hemorrhage
Secondary: Anemia, chronic pain
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with traumatic subarachnoid hematoma. Evaluate
for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol
= 48.9 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm.
COMPARISON: Outside CT head from ___
FINDINGS:
Previously identified subarachnoid hemorrhage along the right frontal
convexities is slightly less conspicuous compared to the prior study (02:20).
There may be also in anterior frontal subarachnoid (02:17) although this area
is limited due to streak artifact. Subarachnoid blood is also present in the
right temporal lobe convexities. There is no new hemorrhage. Ventricles and
sulci are normal in size and configuration for patient's age. Periventricular
and subcortical white matter hypodensities are nonspecific but likely reflect
sequelae of chronic small vessel ischemic disease.
There is no evidence of fracture. There is a moderate-sized left parietal
subgaleal hematoma not significantly changed in size compared to the prior
study. There are aerosolized secretions within the right maxillary sinus and
air-fluid levels in the bilateral maxillary sinuses. There is also paranasal
sinus disease in the right ethmoid air cells as well as the frontal and
bilateral sphenoid sinuses. The visualized portion of the mastoid air cells,
and middle ear cavities are clear. Bilateral lens replacements are
identified. Carotid siphon calcifications are also present.
IMPRESSION:
1. Interval evolution of subarachnoid blood in the right frontal and temporal
lobes. No new hemorrhage.
2. Moderate left parietal subgaleal hematoma.
3. Extensive paranasal sinus disease with likely an acute component.
Radiology Report
INDICATION: ___ w/ hypoxia, tachycardia, eval for pna// ___ w/ hypoxia,
tachycardia, eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
The lungs are hyperinflated and there are increased interstitial markings
bilaterally, indicative of interstitial edema. The patient is slightly
rotated, and thus the cardiomediastinal silhouette is off midline, but appears
normal in size. No focal consolidation or pleural effusion. No pneumothorax.
IMPRESSION:
Moderate interstitial edema with no cardiomegaly or pleural effusions.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ w/ dyspnea, hypoxia, tachycardia, +Ddimer eval for pe.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 192 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Evaluation of the pulmonary vasculature is severely
limited by extreme respiratory motion artifact. Within this limitation, there
is no central or lobar pulmonary embolism. The thoracic aorta is normal in
caliber without evidence of dissection or intramural hematoma. There is
extensive atherosclerotic calcification of the thoracic aorta. 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: Evaluation of the lungs is limited by extreme respiratory
motion artifact. There is moderate to severe centrilobular emphysema and
diffuse increased thickness of the interstitium, compatible with chronic
underlying lung disease. There is extensive endobronchial secretions in the
bronchus intermedius, right middle and lower lobe airways, compatible with
aspiration. There is resultant moderate atelectasis at the right lung base.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Severely limited study due to respiratory motion artifact, but no central
or lobar pulmonary embolism.
2. Diffuse chronic lung disease and moderately severe emphysema.
3. Moderately severe aspiration involving the bronchus intermedius, right
middle, and right lower lobes.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, SAH, Transfer
Diagnosed with Traum subrac hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: 97.4
heartrate: 115.0
resprate: 12.0
o2sat: 93.0
sbp: 112.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | ___ is an ___ year old woman with a history of COPD,
chronic arthritis pain, dementia, who presented to ___
___ after falling out of her chair with a head strike.
Non-contrast CTH at ___ revealed small right frontal
subarachnoid hemorrhage. When she had a repeat at ___ 3 days
later the hemorrhage had evolved but there was no new
hemorrhage. Her mental status was at baseline per the family.
She also was found to have evidence of aspiration in the right
lobe and increased oxygen requirement and was given treatment
for a COPD exacerbation. Oral steroids were avoided due to
recent incident of steroid induced psychosis at ___
___ the previous week. She had a leukocytosis on her day of
discharge but otherwise appeared clinically very well and was on
her home O2 requirement of 3L (home O2 req: confirmed with her
HCP), and so she was discharged with instructions for close
follow up.
Her individual issues were assessed, diagnosed, and treated as
follows:
ACTIVE ISSUES:
====================================
#HYPOXEMIA:
Likely secondary to COPD exacerbation as patient has had
worsening productive cough with wheezes appreciated on exam with
also a component of aspiration. Imaging notable for no pulmonary
embolism with moderately severe aspiration involving the
bronchus intermedius, right middle, and right lower lobe
airways. Patient does have evidence of aspiration on imaging but
has not had fevers or leukocytosis, so it was not evident if
patient has developed pneumonia. Treated for COPD exacerbation
with azithromycin. Patient declined steroids given recent
steroid induced psychosis. She did have leukocytosis on her last
day but she appeared well clinically and was actually improving
overall.
- Azithromycin (___)
- S&S eval said OK for soft solids with thin liquids, no e/o
aspiration
- Standing ipratropium nebulizer, albuterol INH prn
- Standing fluticasone INH
#RIGHT SUBARACHNOID HEMORRHAGE:
Pt developed traumatic right subarachnoid hemorrhage. Repeat
NCHCT was stable. No neurosurgical intervention was needed and
DVT ppx was held.
#ANEMIA:
Hemoglobin 8.4 on admission. Unknown baseline. Denies bloody or
melenic stools. Low iron, low transferrin/TIBC, high ferritin
indicating mixed picture of iron deficiency/chronic
inflammation. Continued home PO iron and gave 1x dose of IV
iron.
#CHRONIC OSTEOARTHRITIS PAIN:
Mainly the right hip and back, through the knee, per the
daughter. Now the left knee is bothering her. Kept oxycodone and
added lidocaine patch, but discontinued Fentanyl because there
was concern she was on too many narcotics and benzos and that
this was contributing to an altered mental state. She was much
more alert by discharge.
TRANSITIONAL ISSUES:
====================================
CODE STATUS: Full code, confirmed
CONTACT: Proxy name: ___
Phone: ___
_________________________
FYI:
- Psych at ___ wanted to taper benzos, decrease
dose of oxy, and increase gabapentin. We continued this plan
here at ___.
o Ativan 0.5 mg DAILY ___, then STOP **** NOTE: BENZO
TAPER ****
o Oxycodone decreased to 10 mg BID
o Gabapentin increased to 100 mg BID, may increase weekly
o Zyprexa 2.5 mg QAM, 5.0 mg QPM, and 5 mg BID PRN
- Pulmonologist Dr. ___, MD
Address: ___
Phone: ___
- Neurosurgery did not feel any intervention was necessary for
the ___. DVT ppx was held this admission.
- Speech and swallow evaluated the patient and did not see overt
signs of aspiration and recommended a soft solid diet with thin
liquids.
- FENTANYL was DISCONTINUED this admission due to concern for
polypharmacy. Maintained on oxycodone PRN and lidocaine patch.
_________________________
TO DO:
[ ] Patient to complete azithromycin course for COPD flare (last
day ___.
[ ] Please follow up on the patient's diabetes regimen. She only
required a small amount of Humalog here.
[ ] When patient was discharged she had a minor leukocytosis
(13k) but her respiratory symptoms and clinic picture were
stable (on home O2 of 3L, afebrile). No antibiotics started as
this was attributable to uncomplicated aspiration pneumonitis
without superimposed infection. However, if she develops fever,
worsening respiratory status or increased O2 requirement, we
would recommend considering a repeat Chest X-Ray, CBC, and PO
clindamycin therapy for possible aspiration pneumonia (she is
allergic to quinolones and penicillins).
[ ] At PCP follow up, please re-evaluate volume status, recheck
Chem-10 panel and BP, and consider restarting Lasix and
Spironolactone (pre-admission medications held during this
admission and at discharge).
_________________________
MEDICATIONS:
- Azithromycin (___) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Quinolones /
adhesive tape / hospital sheets must be unbleached / Nexium /
CellCept
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Colonoscopy ___
Capsule enteroscopy ___
History of Present Illness:
___ year old female with ESRD s/p deceased donor transplant in
___ (KDPI of ___), with biopsy proven IFTA and transplant
glomerulonephropathy, T2DM, HTN, atrial fibrillation, and
mild-moderate AS s/p ___ in ___, HFpEF, reactive airway
disease, recently admitted here for DKA, CVA, Respiratory
distress in ___ s/p long and complicated hospital course
including ICU admission, presenting with SOB
Patient presented to ___ for increased dyspnea,
leg edema, orthopnea, PND.
Patient endorses shortness of breath that has been ongoing for
the past 2 weeks, progressively worsening. Today the visiting
home nurse recommended that she be evaluated in the emergency
department. She has been having trouble laying flat at night and
she has also noticed bilateral lower extremity swelling. Denies
any weight gain. No chest pain. Does not feel like COPD/asthma,
feels like CHF to her. She was previously on diuretics but was
taken off of it for unknown reasons. Also endorses stinging with
urination. Denies fevers at home. Not on home O2. Endorses
recent
fall out of bed without headstrike.
Patient presented to ___ where her O2 requirement was
3LPM.
Has mildly elevated trop of 0.04. Cr is 1.8 close to baseline
last admission. Was given 10 mg of IV lasix. Her Cr before
discharge was 2.0. Patient takes only tacrolimus for IS (AZA was
d/c on last admission.)
In the ED, initial VS were: 97.9 160/83 70 22 98/RA
Exam notable for: crackles, pitting edema ___
Labs showed:
- WBC 8.1 Hb 8.7
- BNP 14400
- Trop 0.05 MB 2
- Cr 1.9 lytes WNL
- UA w/ e/o UTI
- INR ___
___ labs were notable for Trop elevation of 0.04, BNP of
12,000 and creatinine of 1.8.
Imaging showed:
- ___ CXR notable for pulmonary edema
- EKG: Sinus, widened QRS likely LBBB, no ischemic changes,
largely unchanged from prior.
Patient received nothing in our ED.
Renal was consulted:
Imp: A ___ yo woman Post DDRT, allograft dysfunction presents
with
CHF. Cr is at baseline.
- Please admit to medicine team. Management of CHF, cardiology
w/u per team
- Agree with diuresis in the setting of pulmonary edema.
- Please continue tacrolimus home dose (please confirm with the
patient.)
Please draw morning tacrolimus level.
- Transplant Nephrology will follow as a consult.
On arrival to the floor, patient reports ongoing significant
SOB.
Denies chest pain or other symptoms.
Past Medical History:
- ESRD due to DM2/NSAIDs
- Type II diabetes
- Hypertension
- Hyperlipidemia
- Atrial fibrillation on Coumadin
- Aortic Stenosis s/p ___
- Asthma
- Macular degeneration
- Bilateral total knee replacements
- Spinal stenosis L3-S1
- Total abdominal hysterectomy
- Suspension with mesh for incontinence
- Adrenal adenoma
Social History:
___
Family History:
Hypertension (grandmother)
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 98.9 156/73 84 28 95/3L
GENERAL: Mild respiratory distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva
NECK: supple, JVP elevated to 15cm
HEART: RRR, S1/S2, ___ systolic murmur, no gallops or rubs
LUNGS: bibasilar crackles, increased WOB w/ use of accessory
muscles
ABDOMEN: obese, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 4+ pitting edema to above knees
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN ___ intact, strength and sensation intact
throughout
SKIN: scabbed lesion on R forehead; fungal rash under breast
DISCHARGE PHYSICAL EXAM
=========================
Vitals: 98.3 127 / 79 82 18 95% Ra
Weight 75.8kg
HEENT: NC/AT. PERRLA. No conjunctival pallor.
Neck: no JVD appreciated appreciated.
Cardiac: ___ systolic murmur appreciated throughout precordium
Lungs: CTAB, no wheezes, rales, or rhonchi.
Abdomen: Soft, nontender, nondistended
Extremities: No ___ edema. Cap refill < 3 seconds.
Neuro: CNII-XII grossly intact. No focal deficits. Moving all 4
extremities with purpose. AAOx3.
Pertinent Results:
ADMISSION LABS
===================
___ 08:45PM BLOOD WBC-8.1 RBC-3.37* Hgb-8.7* Hct-30.1*
MCV-89 MCH-25.8* MCHC-28.9* RDW-16.2* RDWSD-52.7* Plt ___
___ 08:45PM BLOOD Neuts-85.0* Lymphs-6.4* Monos-6.5 Eos-1.2
Baso-0.4 Im ___ AbsNeut-6.91* AbsLymp-0.52* AbsMono-0.53
AbsEos-0.10 AbsBaso-0.03
___ 08:45PM BLOOD ___ PTT-36.8* ___
___ 08:45PM BLOOD Glucose-211* UreaN-25* Creat-1.9* Na-142
K-4.6 Cl-104 HCO3-22 AnGap-16
___ 08:45PM BLOOD CK(CPK)-41
___ 08:45PM BLOOD CK-MB-2 cTropnT-0.05* ___
___ 08:45PM BLOOD cTropnT-0.05*
___ 09:46AM BLOOD cTropnT-0.06*
___ 08:42AM BLOOD CK-MB-2 cTropnT-0.07*
___ 08:45PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1
___ 09:46AM BLOOD tacroFK-5.0
PERTINENT INTERVAL LABS
===========================
___ 09:46AM BLOOD ___ PTT-38.0* ___
___ 08:42AM BLOOD ___ PTT-37.0* ___
___ 04:45AM BLOOD ___ PTT-34.9 ___
___ 04:55AM BLOOD ___ PTT-35.1 ___
___ 08:45AM BLOOD ___
___ 05:05PM BLOOD ___
___ 12:09AM BLOOD ___
___ 05:10AM BLOOD ___ PTT-32.4 ___
___ 09:15AM BLOOD ___ PTT-31.2 ___
___ 04:50AM BLOOD ___ PTT-56.2* ___
___ 04:20PM BLOOD ___ PTT-48.8* ___
___ 12:17AM BLOOD ___ PTT-42.3* ___
___ 01:50AM BLOOD CK-MB-1 cTropnT-0.08*
___ 04:45AM BLOOD cTropnT-0.08*
___ 08:42AM BLOOD tacroFK-3.7*
___ 04:45AM BLOOD tacroFK-5.7
___ 05:10AM BLOOD tacroFK-5.1
___ 04:50AM BLOOD tacroFK-6.4
___ 04:50AM BLOOD tacroFK-3.3*
___ 01:16PM BLOOD %HbA1c-9.1* eAG-214*
DISCHARGE LABS
==================
___ 04:50AM BLOOD WBC-7.6 RBC-3.22* Hgb-8.0* Hct-27.3*
MCV-85 MCH-24.8* MCHC-29.3* RDW-15.4 RDWSD-47.2* Plt ___
___ 09:05AM BLOOD ___ PTT-38.1* ___
___ 04:50AM BLOOD Glucose-166* UreaN-71* Creat-2.4* Na-138
K-5.1 Cl-103 HCO3-21* AnGap-14
___ 04:50AM BLOOD Calcium-9.7 Phos-4.7* Mg-1.8
STUDIES
==========
TTE ___
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is ___ mmHg.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Diastolic
function could not be assessed. There is beat to beat variation
of left ventricular systolic function due to frequent ectopy.
The right ventricular cavity is mildly dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. A ___ 3 aortic valve bioprosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and mildly elevated transvalvular gradients.
A paravalvular jet of trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate (___) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy
with borderline biventricular systolic function. Well seated
___ with mildly elevated transvalvular gradient. Mildly
dilated thoracic aorta. Mild to moderate mitral regurgitation.
Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
biventricular systolic function is less vigorous.
Colonoscopy ___
Impression: Diverticulosis of the throughout the colon
Internal hemorrhoids
Polyp in the cecum
Polyp in the transverse colon
No evidence of old or fresh blood was seen in the colon or
terminal ileum.
Otherwise normal colonoscopy to terminal ileum
Recommendations: - polyps were not removed since patient on
heparin drip; if patient amenable and able to come off
anticoagulation, these could be removed at a later date off
anticoagulation
- no definitive source of GI bleed, though diverticula possible
- remainder of plan per inpatient GI team
Capsule enteroscopy ___
MICROBIOLOGY
================
Urine cultures ___ negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.25 mcg PO BID
2. Atorvastatin 40 mg PO QPM
3. Fenofibrate 145 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO Q6H
5. Tacrolimus 2 mg PO QPM
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Tacrolimus 2 mg PO QAM
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
9. Amiodarone 200 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Warfarin 2 mg PO DAILY16
13. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Albuterol Inhaler 2 PUFF IH Q6H
15. Montelukast 10 mg PO DAILY
16. vortioxetine 20 mg oral DAILY
17. Ranitidine 300 mg PO QHS
18. Magnesium Oxide 400 mg PO BID
Discharge Medications:
1. AzaTHIOprine 75 mg PO DAILY
RX *azathioprine [Azasan] 75 mg 1 tablet(s) by mouth daily Disp
#*28 Tablet Refills:*0
2. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp
#*28 Tablet Refills:*0
3. pen needle, diabetic 31 gauge x ___ miscellaneous 5X/DAY
RX *pen needle, diabetic [BD Insulin Pen Needle UF Short] 31
gauge x ___ attach to pens for SC injections 5x/day Disp #*2
Package Refills:*0
4. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Glargine 10 Units Breakfast
Glargine 70 Units Bedtime
Humalog 28 Units Breakfast
Humalog 24 Units Lunch
Humalog 24 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
10 Units before BKFT; 70 Units before BED; Disp #*30 Syringe
Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 8
Units QID per sliding scale Disp #*30 Syringe Refills:*0
6. Warfarin 4 mg PO DAILY16
RX *warfarin [Coumadin] 4 mg 1 tablet(s) by mouth daily Disp
#*28 Tablet Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
9. Albuterol Inhaler 2 PUFF IH Q6H
10. Amiodarone 200 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Magnesium Oxide 400 mg PO BID
15. Montelukast 10 mg PO DAILY
16. Ranitidine 300 mg PO QHS
17. Tacrolimus 2 mg PO QPM
18. Tacrolimus 2 mg PO QAM
19. vortioxetine 20 mg oral DAILY
20. HELD- Fenofibrate 145 mg PO DAILY This medication was held.
Do not restart Fenofibrate until you see your PCP.
21.Outpatient Lab Work
ICD 10: N17 (___), D68.32 (coagulopathy)
Labs: Chem 7 (Na,K,Cl,HCO3,BUN,Cr), ___ (INR)
Draw on ___
Fax Results to PCP ___ # ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
Acute on chronic Heart failure with preserved ejection fraction
Lower Gastrointestinal bleed
Urinary tract infection
Acute Kidney Injury
Hyperkalemia
Secondary Diagnosis
=======================
Diverticulosis
Atrial fibrillation
End Stage Renal Disease
Diabetes Mellitus 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old female with ESRD s/p deceased donor transplant in
___ (KDPI of 74), with biopsy proven IFTA and transplant
glomerulonephropathy, T2DM, HTN, atrial fibrillation, and mild-moderate AS s/p
TAVR in ___, HFpEF, reactive airwaydisease, recently admitted here for DKA,
CVA, Respiratorydistress in ___ s/p long and complicated hospital course
including ICU admission, presenting with SOB likely ___ HFpEF exacerbation
possibly triggered by UTI. Currently in afib with RVR with chest tightness and
SOB.// ?pulmonary effusions/edema??pulmonary effusions /edema?
IMPRESSION:
Comparison to ___. The lung volumes are low. Moderate
cardiomegaly with aortic valve replacement. Stable blunting of the left
costophrenic sinus. Mild retrocardiac atelectasis. No pulmonary edema, no
pleural effusions.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion
Diagnosed with Heart failure, unspecified
temperature: 97.9
heartrate: 70.0
resprate: 22.0
o2sat: 98.0
sbp: 160.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | ___ year old female with ESRD s/p deceased donor transplant in
___ complicated by biopsy proven IFTA and transplant
glomerulonephropathy, DMII, HTN, mild-moderate AS s/p ___ in
___, HFpEF, reactive airway disease, and recent admission
for DKA, CVA, and respiratory distress requiring ICU admission
who presented with HFpEF exacerbation secondary to UTI. She was
aggressively diuresed back to her baseline weight, and her
hospital course was complicated by BRBPR concerning for LGIB
which is now stable and was bridged to warfarin. Hospital
course also c/b ___ and hyperkalemia.
#Acute on chronic HFpEF
Patient presented with significant dyspnea likely secondary to
hypervolemia. Exam significant for bilateral rales, elevated
JVP, and 3+ pitting edema to her knees. Other possible
etiologies include dietary indiscretion vs. decompensation
secondary to UTI. She had previously been on a diuretic as an
outpatient, but her Torsemide was discontinued last
hospitalization due to ___. Per ECHO on ___, she has
borderline systolic function (LVEF 50-55%). Diuresed w/ IV
Lasix boluses, once euvolemic, patient remained net even
despite no diuretic for over 1 week. Therefore, was d/c'd
without a PO diuretic, consider adding as outpatient if
weight/volume status worsening.
#LGIB
On ___, patient passed several bloody BM. She remained
asymptomatic. Hemoglobin and vital signs remained stable. On
___, patient underwent a colonoscopy with GI that revealed
extensive diverticulosis and internal hemorrhoids but no signs
of active bleeding. Furthermore, polyps were identified in the
transverse colon and cecum, which were not removed as patient
was therapeutically anticoagulated on heparin (see below).
Patient should have a repeat colonoscopy as an outpatient to
address these polyps. On ___, the patient underwent a capsule
enteroscopy to assess for small bowel sources of bleeding which
showed small AVM with no active bleeding. GI bleeding resolved
spontaneously. GI recommended push enteroscopy, but patient
declined.
#Atrial fibrillation with RVR
On the evening of ___, the patient triggered for atrial
fibrillation with RVR (rates in 150s). She was asymptomatic
except for some chest tightness. Managed with PO/IV metoprolol
and IV diltiazem. She was restarted on the appropriate dose of
her home metoprolol succinate at 200mg daily, and she
maintained sinus rhythm with appropriate heart rates for the
remainder of her hospitalization.
For anticoagulation, patient presented on warfarin 5mg PO daily
with a goal INR of 2.5-3.5. High risk for VTE, patient has
history of ischemic strokes while on therapeutic warfarin and
apixaban (separate incidents). In the setting of her GIB, she
was given 5mg PO vitamin K to reverse her warfarin and started
on a heparin gtt. She was bridged back to warfarin, discharged
on a dose of 3mg PO daily.
#Hyperkalemia: unknown etiology, started after d/c of diuretic.
Corresponded with a decrease in HCO3. Renal consulted. Started
on sodium bicarb 650mg BID with the thought that she was
previously in a contraction alkalosis while on diuretic that
was masking the hyperK. Hyperkalemia improved, K 5.1 at time of
d/c.
___: developed long after diuresis was completed. Thought to
be hypovolemic, possibly due to fluid losses from
hyperglycemia. Gave back some gentle fluid boluses w/
improvement of Cr. Cr 2.4 at time of d/c and trending
down(baseline 2.0-2.2). Was another data point that discouraged
team from adding a PO diuretic at time of d/c.
#ESRD s/p deceased donor renal transplant in ___ on tacro
Transplant nephrology was consulted and helped manage her
tacrolimus levels with daily labs. Continued her calcitriol.
#UTI
Patient presented with dysuria and positive UA with cultures
showing mixed flora consistent with fecal contamination. She
was initially started on ceftriaxone and was transitioned to
cefpodoxime to complete a 14 day course on ___. The extended
antibiotic course of an uncomplicated UTI was at the request of
transplant nephrology given her history of deceased donor
kidney transplant.
#Troponinemia
Troponins elevated on admission in the setting of known CKD. No
ischemic changes on EKG and patient without chest pain. MB
negative. Felt likely to be secondary to demand ischemia in the
setting of HFpEF decompensation and poor renal clearance. Her
troponin increased again in setting of afib with RVR, again
suspected to be secondary to demand. Of note, patient had a
recent cardiac catheterization with clean coronaries, making
out suspicion for a flow limiting lesion very low. We continued
her ASA 81 and atorvastatin while hospitalized.
#DM2
Blood glucoses were significantly elevated to the 300-400s
while hospitalized, despite aggressive increases in
basal/premeal insulin. ___ was consulted for assistance with
management. Insulin regimen was uptitrated (see transitional
issues). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ativan / Seroquel / amlodipine
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ yo woman w/ PMH significant for refractory
focal L occipital status epilepticus (on lacosamide,
oxcarbazepine, brivaracetam) requiring 5 months of inpatient
hospitalization at ___ and subsequent hospital course at ___ from
___ c/b hyponatremia, hypoxemic hypercarbic
respiratory failure, UTI and recurrent C diff, who presents with
seizure.
As per nursing home report, pt was lying in bed at ___, felt dizzy upon rising, became unresponsive and had a
tonic-clonic activity lasting <5 min. She was noted to be
confused and disoriented, with no LOC or bowel/urinary
incontinence, after the seizure, and had new onset of
word-finding difficulty. Of note, no meds were given before the
seizure this morning. As per HCP ___ report, a similar
episode happened shortly after her discharge from ___. Pt denies
fever/chills, cough, CP, SOB.
In the ED, her initial vitals were as follows: Temp 98.4 BP
133/74 HR 77 RR 19 O2 sat 100% RA. Her lab was notable for
positive UA and Hct 23.5, Na 128. Her CXR was unremarkable. Of
note, in the ED, she had another seizure (lasting ___ min with
rightward gaze, typical of her usual seizures) and was given
lacosamide 200 mg, oxcarbazepine 600 mg, and brivaracetam 100
mg.
She was also given IV CTX 1g and IV NS 1L. The patient's
___, Dr. ___, was consulted, who recommended no
changes to her current seizure medications.
Upon transfer to the floor, her vitals were: Temp 98.8 BP
137/67
HR 76 RR 15 O2 sat 97% RA. She appears comfortable and was in
no acute distress; however, she appears confused and
disoriented.
Past Medical History:
HTN, NSTEMI, C diff colitis, L hip arthroplasty, refractory
focal status epilepticus, ?herpes, hypercarbic respiratory
failure, COPD, EtOH abuse, alcoholic hepatitis, alcoholic
pancreatitis, HLD, GERD, meningocele s/p repair, spina bifida,
PUD, hypothyroidism
Social History:
___
Family History:
unknown
Physical Exam:
ADMISSION EXAM:
==============
VITALS: Temp 98.8 BP 137/67 HR 76 RR 15 O2 sat 97% RA
GENERAL: Appears confused and disoriented (oriented to self, but
disoriented as to where she is). She also has word-finding
difficulties (appears frustrated, trying to respond to
questions), intermittently with incoherent responses; appeared
to
improve throughout course of interview
HEENT: NC/AT. Pupils equal, round, and reactive bilaterally,
EOMI. Sclera anicteric and without injection. Moist mucous
membranes, good dentition. Oropharynx is clear.
NECK: No cervical and supraclavicular lymphadenopathy.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. No
JVD.
LUNGS: CTAB w/appropriate breath sounds appreciated in all
fields. No wheezes, rhonchi or rales. No increased work of
breathing.
ABDOMEN: Normal bowels sounds, ND, NT to deep palpation in all
four quadrants. No organomegaly.
EXTREMITIES: Signs of atrophy in lower extremity. No clubbing,
cyanosis, or edema b/l.
NEUROLOGIC: Pt intermittently following commands and hearing
impairment. symmetric smile and eyebrow raise. RUE ___
strength. LUE ___ strength. Able to lift both legs up against
gravity (easier on left than right). Unable to assess for
ataxia,
dysmetria, disdiadochokinesia. Gait assessement deferred.
DISCHARGE EXAM:
==============
GENERAL: Appears confused and disoriented (oriented to self, but
disoriented as to where she is). She also has word-finding
difficulties (appears frustrated, trying to respond to
questions), intermittently with incoherent responses; appeared
to
improve throughout course of interview
HEENT: NC/AT. Pupils equal, round, and reactive bilaterally,
EOMI. Sclera anicteric and without injection. Moist mucous
membranes, good dentition. Oropharynx is clear.
NECK: No cervical and supraclavicular lymphadenopathy.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. No
JVD.
LUNGS: CTAB w/appropriate breath sounds appreciated in all
fields. No wheezes, rhonchi or rales. No increased work of
breathing.
ABDOMEN: Normal bowels sounds, ND, NT to deep palpation in all
four quadrants. No organomegaly.
EXTREMITIES: Signs of atrophy in lower extremity. No clubbing,
cyanosis, or edema b/l.
NEUROLOGIC: Pt intermittently following commands and hearing
impairment. symmetric smile and eyebrow raise. RUE ___
strength. LUE ___ strength. Able to lift both legs up against
gravity (easier on left than right). Unable to assess for
ataxia,
dysmetria, disdiadochokinesia. Gait assessement deferred.
Pertinent Results:
ADMISSION LABS:
==============
___ 09:50PM URINE HOURS-RANDOM SODIUM-125
___ 09:50PM URINE OSMOLAL-397
___ 08:30PM GLUCOSE-101* UREA N-10 CREAT-0.4 SODIUM-128*
POTASSIUM-4.2 CHLORIDE-91* TOTAL CO2-26 ANION GAP-11
___ 08:30PM CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-1.6
___ 11:24AM ___ COMMENTS-GREEN TOP
___ 11:24AM LACTATE-1.3
___ 11:15AM GLUCOSE-135* UREA N-10 CREAT-0.5 SODIUM-128*
POTASSIUM-4.6 CHLORIDE-90* TOTAL CO2-27 ANION GAP-11
___ 11:15AM URINE HOURS-RANDOM
___ 11:15AM URINE UHOLD-HOLD
___ 11:15AM WBC-5.4 RBC-2.67* HGB-7.4* HCT-23.5* MCV-88
MCH-27.7 MCHC-31.5* RDW-14.6 RDWSD-46.8*
___ 11:15AM NEUTS-71.6* ___ MONOS-6.3 EOS-1.7
BASOS-0.2 IM ___ AbsNeut-3.88# AbsLymp-1.08* AbsMono-0.34
AbsEos-0.09 AbsBaso-0.01
___ 11:15AM PLT COUNT-240
___ 11:15AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:15AM URINE BLOOD-NEG NITRITE-POS* PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG*
___ 11:15AM URINE RBC-1 WBC-25* BACTERIA-FEW* YEAST-NONE
EPI-3
___ 11:15AM URINE MUCOUS-RARE*
DISCHARGE LABS:
==============
___ 08:15AM BLOOD WBC-5.6 RBC-2.79* Hgb-7.7* Hct-25.0*
MCV-90 MCH-27.6 MCHC-30.8* RDW-14.6 RDWSD-48.0* Plt ___
___ 08:15AM BLOOD Glucose-106* UreaN-13 Creat-0.5 Na-136
K-5.1 Cl-96 HCO3-27 AnGap-13
IMAGING:
=======
CHEST X-RAY PORTABLE ___
FINDINGS:
AP portable upright view of the chest. A PICC line is again
seen terminating in the region of the right subclavian vein,
unchanged. Lungs remain clear. Overlying EKG leads are
present. No large effusion or pneumothorax. The heart size and
mediastinal contour appears stable and normal. Imaged bony
structures are intact.
IMPRESSION:
No acute findings. PICC line unchanged terminating in the
region of the right subclavian vein.
***MICROBIOLOGY***
Urine Culture:
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-------- 128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QHS
3. Cyanocobalamin 1000 mcg PO DAILY
4. famotidine 20 mg oral BID
5. FoLIC Acid 1 mg PO DAILY
6. LACOSamide 200 mg PO BID
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Bisacodyl ___AILY:PRN constipation
11. Docusate Sodium 100 mg PO BID
12. GuaiFENesin ___ mL PO Q6H:PRN cough, mucus production
13. Ipratropium Bromide Neb 1 NEB IH Q6H
14. Sodium Chloride 1 gm PO TID
15. Brivaracetam 100 mg PO BID
16. Calcium Carbonate 500 mg PO TID
17. Senna 8.6 mg PO BID constipation
18. OXcarbazepine 600 mg PO BID
19. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
20. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
21. melatonin 5 mg oral QHS
22. Saccharomyces boulardii 250 mg oral BID
23. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
24. Ondansetron 4 mg IV Q6H:PRN nausea
25. Simethicone 80 mg PO TID:PRN abdominal discomfort
Discharge Medications:
1. CefTRIAXone 1 gm IV Q24H
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QHS
6. Bisacodyl ___AILY:PRN constipation
7. Brivaracetam 100 mg PO BID
8. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
9. Calcium Carbonate 500 mg PO TID
10. Cyanocobalamin 1000 mcg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. famotidine 20 mg oral BID
13. FoLIC Acid 1 mg PO DAILY
14. GuaiFENesin ___ mL PO Q6H:PRN cough, mucus production
15. Ipratropium Bromide Neb 1 NEB IH Q6H
16. LACOSamide 200 mg PO BID
17. Levothyroxine Sodium 75 mcg PO DAILY
18. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
19. melatonin 5 mg oral QHS
20. Ondansetron 4 mg IV Q6H:PRN nausea
21. OXcarbazepine 600 mg PO BID
22. Saccharomyces boulardii 250 mg oral BID
23. Senna 8.6 mg PO BID constipation
24. Simethicone 80 mg PO TID:PRN abdominal discomfort
25. Sodium Chloride 1 gm PO TID
26. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
=======
Refractory focal epilepsy
Urinary tract infection
Hyponatremia
SECONDARY:
==========
Anemia
COPD
GERD
Hypothyroidism
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with seizure, AMS// ?Pneumonia
COMPARISON: Prior exam is dated ___
FINDINGS:
AP portable upright view of the chest. A PICC line is again seen terminating
in the region of the right subclavian vein, unchanged. Lungs remain clear.
Overlying EKG leads are present. No large effusion or pneumothorax. The
heart size and mediastinal contour appears stable and normal. Imaged bony
structures are intact.
IMPRESSION:
No acute findings. PICC line unchanged terminating in the region of the right
subclavian vein.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus, Urinary tract infection, site not specified, Altered mental status, unspecified
temperature: 98.4
heartrate: 77.0
resprate: 19.0
o2sat: 100.0
sbp: 133.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
===============
Ms. ___ is a ___ yo woman w/ PMH significant for refractory
focal L occipital status epilepticus (on lacosamide,
oxcarbazepine, brivaracetam) requiring 5 months of inpatient
hospitalization at ___ and subsequent hospital course at ___ from
___ c/b hyponatremia, hypoxemic hypercarbic
respiratory failure, UTI and recurrent C diff, who presents with
seizure and UA findings concerning for UTI. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
chest/back/R CVA pain
Major Surgical or Invasive Procedure:
Coronary angiography: ___ and ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with severe hyperlipidemia
who presents with STEMI.
He was in his usual state of health until day of admission when
he experienced chest/back/R CVA pain. Pain was sudden and
crushing on the left side, radiation to the back. He presented
to ED within 20 minutes of pain. Flank pain was similar to prior
history of kidney stones.
In the ambulance, he received aspirin and nitroglycerin. EKG
revealed inferolateral STEMI. Prior to cath, he underwent CTA
abdomen pelvis given flank pain and concern for dissection. This
revealed no dissection, but severe atherosclerosis. He had a 1.5
cm right renal pelvic stone with no associated hydronephrosis.
He was taken for coronary catheterization where he was found to
have L dominant system with 70-80% stenosis of proximal LAD and
100% occlusion of left circumflex. Circumflex was stented.
During reperfusion, he became very uncomfortable, and had
nausea. He was hypotensive and bradycardic and started on
dobutamine. He was given ticagrelor, but vomited, and was
therefore re-bolused. He remained stable and was transferred to
CCU for further management and weaning of dobutamine drip.
Upon arrival to the CCU. He reports some continued pain, but
improved from prior. He has no shortness of breath. He reports
feeling fatigued.
Past Medical History:
1. CARDIAC RISK FACTORS
- Severe hyperlipidemia
2. CARDIAC HISTORY
- None
3. OTHER PAST MEDICAL HISTORY
- Nephrolithiasis
- Extraction of needle in toe
- GERD
- Microscopic hematuria, not yet worked up
- Erectile dysfunction
Social History:
___
Family History:
Mother with lung cancer and stroke, father s/p CABG, borther
with throat cancer obesity and substance abuse, sister with
melanoma and chronic lymphocytic leukemia.
Physical Exam:
Admission exam:
===============
VS: See metavision
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: Supple. JVP mid-neck at 45 degrees.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge exam:
===============
VS: afebrile 98-110s/59-70s 70-80s 18 mainly mid ___ ra
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: Supple. No elevated JVP
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
Admission labs:
===============
___ 03:00AM BLOOD WBC-10.7* RBC-5.06 Hgb-15.5 Hct-44.0
MCV-87 MCH-30.6 MCHC-35.2 RDW-12.6 RDWSD-39.7 Plt ___
___ 10:05AM BLOOD Neuts-85.6* Lymphs-7.0* Monos-6.6
Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.70* AbsLymp-0.88*
AbsMono-0.82* AbsEos-0.00* AbsBaso-0.03
___ 03:00AM BLOOD ___ PTT-25.6 ___
___ 03:00AM BLOOD ___ 10:05AM BLOOD Glucose-100 UreaN-10 Creat-0.6 Na-145
K-3.3 Cl-115* HCO3-18* AnGap-15
___ 10:05AM BLOOD ALT-62* AST-389* LD(LDH)-730*
CK(CPK)-4259* AlkPhos-53 TotBili-0.3
___ 03:00AM BLOOD Lipase-34
___ 10:05AM BLOOD CK-MB-569* MB Indx-13.4* cTropnT-7.92*
___ 10:05AM BLOOD Calcium-6.3* Phos-3.0 Mg-1.3*
___ 03:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:09AM BLOOD pO2-50* pCO2-28* pH-7.49* calTCO2-22 Base
XS-0
___ 03:09AM BLOOD Glucose-151* Lactate-3.2* Na-139 K-3.3
Cl-104
___ 03:09AM BLOOD Hgb-15.6 calcHCT-47 O2 Sat-87 COHgb-2
MetHgb-0
___ 03:09AM BLOOD freeCa-1.14
Interval/discharge labs:
========================
___ 03:00AM BLOOD Triglyc-199* HDL-42 CHOL/HD-5.6
LDLcalc-152*
___ 07:00AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.1
___ 02:52AM BLOOD CK-MB-328* cTropnT-9.00*
___ 03:00AM BLOOD cTropnT-7.81*
___ 07:00AM BLOOD ALT-59* AST-108* LD(LDH)-891* AlkPhos-77
TotBili-0.9
___ 07:00AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-139
K-3.9 Cl-103 HCO3-25 AnGap-15
___ 07:00AM BLOOD WBC-7.1 RBC-4.16* Hgb-12.7* Hct-37.2*
MCV-89 MCH-30.5 MCHC-34.1 RDW-12.9 RDWSD-42.4 Plt ___
Micro:
======
Urine culture ___ negative
Studies:
========
TTE ___
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild to moderate regional left ventricular
systolic dysfunction with severe hypokinesis of the inferior and
inferolateral walls. The remaining segments contract normally
(biplane LVEF = 39 %). Right ventricular chamber size and free
wall motion are normal. The aorta is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild to
moderate (___) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild symmetric left ventriculoar
hypertrophy with regional systolic dysfunction most c/w CAD (PDA
distribution). Mild-moderate mitral regurgitation. Mild
pulmonary artery systolic hypertension. CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data. A left pleural effusion is
present.
CTA torso ___. No evidence aortic dissection. Focal old dissection of the
left common
iliac artery.
2. Severe atherosclerosis of the abdominal aorta.
3. Moderate to severe coronary calcification. Poor
opacification of the left circumflex.
4. 1.5 cm right renal pelvic stone without hydronephrosis.
Small non-obstructing left renal stone.
CXR ___
There is no pulmonary edema.
Cardiac cath report ___
Dominance: Left
* Left Main Coronary Artery
The LMCA is free of significant stenosis.
* Left Anterior Descending
The LAD has hazy 70-80% proximal stenosis
* Circumflex
There is a 100% stenosis in the Proximal Circumflex. The lesion
has a TIMI flow of 0. This lesion is
further described as diffusely diseased. An intervention was
performed on the Proximal Circumflex with a
final stenosis of 0%. There were no lesion complications.
* Right Coronary Artery
The RCA is non-dominant and has diffuse proximal 80-90%
stenosis.
Impressions:
1. 3 Vessel CAD.
2. Successful ___ for inferoposterior STEMI.
Recommendations
1. ASA 81 mg daily. Ticagrelor 90 mg BID. Continue tirofiban x 2
hours.
2. High dose statin, beta blockers, ACE inhibitors.
3. Plan PCI of LAD prior to discharge.
Cardiac cath report ___ (prelim): DES to LAD. Did did not
reload with ticagrelor. Radial Access
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Lidocaine 5% Ointment 1 Appl TP DAILY
RX *lidocaine 5 % Apply to right flank daily Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % apply to right flank daily Disp #*30 Patch
Refills:*0
4. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. LORazepam 1 mg PO Q8H:PRN pain
RX *lorazepam [Ativan] 1 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
6. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. pitavastatin 1 mg oral 3X/WEEK
RX *pitavastatin [Livalo] 1 mg 1 tablet(s) by mouth M, W, F Disp
#*30 Tablet Refills:*0
8. Simvastatin 10 mg PO QPM
RX *simvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth at bedtime
Disp #*30 Capsule Refills:*0
10. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ST-Elevation Myocardial Infarction
Nephrolithiasis
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: ___ with severe chest pain
TECHNIQUE: Chest, abdomen, and pelvis CTA: Non-contrast and multiphasic
post-contrast images were acquired through chest, abdomen, and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Total DLP (Body) = 754 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR: There is no evidence of aortic dissection the thoracic aorta is not
dilated. There is moderate to severe atherosclerosis of the abdominal aorta
with both calcified and noncalcified plaque. The vessel is ectatic with
multiple small ulcers but without aneurysmal dilation. Hepatic artery is
conventional. The celiac axis and SMA are widely patent. There is 1 renal
artery bilaterally. The ___ is patent.
There is severe atherosclerosis of the common iliac arteries. On the left,
there is an old focal dissection of the common iliac artery (series 3, image
337).
CHEST: The thyroid is unremarkable. There is no axillary, supraclavicular
adenopathy. There scattered mediastinal lymph nodes measuring up to 7 mm.
Heart is top normal. No pericardial effusion. There are moderate coronary
artery calcifications. There is poor contrast opacification of the left
circumflex. The main pulmonary trunk is top-normal. No evidence of pulmonary
embolism.
The airways are patent to the subsegmental level with bronchial wall
thickening at the lung bases. There is no focal lung consolidation. There is
bibasilar atelectasis. There is no pleural effusion or pneumothorax.
Thoracic esophagus is normal.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a 1.5 x 0.8 cm stone in the right renal pelvis without associated
hydronephrosis. There is a punctate stone in the left lower pole. There are
no suspicious renal lesions.
GASTROINTESTINAL: High density material in the stomach, likely represents
ingested material. Small and large bowel are unremarkable. There is
diverticulosis. There is no obstruction. Appendix is normal. No free fluid
or free air.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The entire pelvis was not included on the study. The visualized
urinary bladder and distal ureters are unremarkable. There is no evidence of
pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Small fat containing umbilical hernia is noted.
IMPRESSION:
1. No evidence aortic dissection. Focal old dissection of the left common
iliac artery.
2. Severe atherosclerosis of the abdominal aorta.
3. Moderate to severe coronary calcification. Poor opacification of the left
circumflex.
4. 1.5 cm right renal pelvic stone without hydronephrosis. Small
non-obstructing left renal stone.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Mr. ___ is a ___ year old gentleman with severe hyperlipidemia
who presents with STEMI.// Assess pulmonary edema.
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest CT ___.
FINDINGS:
The cardiac, mediastinal, and hilar contours are normal. The lungs are clear.
There is no pneumothorax or pleural effusion.
IMPRESSION:
There is no pulmonary edema.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Chest pain
Diagnosed with ST elevation (STEMI) myocardial infarction of unsp site
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Mr. ___ is a ___ year old male with PMH of HLD who presented
to the ED with chest and flank pain found to have ST elevations
in II, III, aVF, V5, and V6 and depressions in I, aVL, V1-V3
concerning for STEMI. He was taken for coronary angiogram where
he was noted to have diffuse proximal 80-90% stenosis, 70-80%
LAD proximal stenosis, and 100% stenosis in the Proximal
Circumflex. On initial coronary angiography, a DES was placed to
the RCA. Intervention of the LAD was deferred given hypotension
during the procedure requiring dobutamine. The patient was
admitted to the CCU and his blood pressures improved and he was
successfully weaned off the dobutamine. He went for repeat
coronary angiography on ___ where DES was placed in the LAD
without complication. TTE showed LVEF 38% with severe
hypokinesis of the inferior and inferolateral walls c/w known
CAD. The patient will be discharged on ASA 81mg daily,
Ticagrelor 90mg BID, Metoprolol 25mg daily, and lisinopril 2.5mg
daily. Of note, the patient has been unable to tolerate statins
due to myalgias and memory loss (has tried pravastatin,
atorvastatin and rosuvastatin). Started simvastatin 10mg during
hospitalization and was given a script for pitavastatin 1mg to
be taken 3x/week if his insurance covers it. He will have close
follow-up with Cardiology and ___ for further
management.
Of note, the patient had an episode of severe right flank pain
found to have right renal pelvic 15mm stone on CTA. No evidence
of hydronephrosis or kidney dysfunction. Urology was consulted
who recommended symptomatic management with plans to follow-up
in clinic as an out-patient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Methotrexate / lisinopril / Zestril / Infliximab
Attending: ___.
Chief Complaint:
fever, lethargy
Major Surgical or Invasive Procedure:
percutaneous cholecystostomy tube placement
subcapsular hepatic fluid collection drainage catheter placement
and removal
History of Present Illness:
___ with multiple medical comorbidities including chronic
prednisone therapy for rheumatoid arthritis who is recently s/p
ERCP for choledocholithiasis, now transfered from OSH with
fever, lethargy, and confusion. Per OSH records, pt was
diagnosed with cholecystitis with choledocholithiasis 2 weeks
ago, for which she underwent ERCP with stone removal and
sphincterotomy. After a short stay in rehab she was discharged
home with plans for interval cholecystectomy in 8 weeks. Pt
reports to have been nearly back to baseline aside from some
mild RUQ "soreness". Two days ago she began feeling lethargic
and spiking fevers as high as 102.4, and was additionally noted
by her daughter to be confused at times. Pt otherwise denies
chills, increasing abdominal pain, nausea/vomiting. She
presented to ___ where a RUQ U/S showed a RUQ fluid
collection concerning for biloma. The pt was transfered to ___
for further evaluation with a HIDA scan. A surgical consult was
subsequently requested.
Past Medical History:
PMH: HTN, glaucoma, RA, OA, spinal stenosis, IDDM, hx MI s/p
stenting
PSH: ERCP, cardiac stenting ___ yrs ago
Social History:
___
Family History:
N/C
Physical Exam:
Admission Exam
98.4 70 134/68 18 96% 4L Nasal Cannula
GEN: NAD. Mild lethargy. A&Ox3.
HEENT: No scleral icterus. Mucous membranes mildly dry.
CV: RRR
PULM: Clear to auscultation b/l. Decreased at bases.
ABD: Soft, obese with mild tenderness to palpation of RUQ
extending laterally. No R/G. Negative ___ sign.
Ext: Warm with trace ___ edema.
Pertinent Results:
___ 05:05AM BLOOD WBC-4.3
___ 04:40AM BLOOD WBC-4.2 RBC-2.62* Hgb-8.0* Hct-25.5*
MCV-97 MCH-30.4 MCHC-31.3 RDW-15.3 Plt ___
___ 09:00AM BLOOD WBC-6.6 RBC-2.69* Hgb-8.3* Hct-26.7*
MCV-99* MCH-30.8 MCHC-31.0 RDW-15.0 Plt ___
___ 03:09AM BLOOD WBC-4.4 RBC-2.43* Hgb-7.6* Hct-24.1*
MCV-99* MCH-31.3 MCHC-31.6 RDW-15.1 Plt ___
___ 04:40AM BLOOD Plt ___
___ 09:00AM BLOOD Plt ___
___ 08:45PM BLOOD ___ PTT-30.5 ___
___ 09:00AM BLOOD Glucose-79 UreaN-15 Creat-1.0 Na-136
K-4.0 Cl-101 HCO3-24 AnGap-15
___ 03:09AM BLOOD Glucose-90 UreaN-10 Creat-0.9 Na-138
K-4.6 Cl-109* HCO3-22 AnGap-12
___ 04:40AM BLOOD ALT-17 AST-18 AlkPhos-131* TotBili-0.5
___ 09:00AM BLOOD ALT-22 AST-30 AlkPhos-126* TotBili-0.7
___ 09:00AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.7
___ 03:09AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.2
___ 06:30AM BLOOD Albumin-2.5* Calcium-7.6* Phos-2.4*
Mg-1.3*
___ 3:00 pm BILE
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final ___:
NO ANAEROBES ISOLATED AS OF ___.
DUE TO LABORATORY ERROR, UNABLE TO CONTINUE PROCESSING.
TEST CANCELLED, PATIENT CREDITED
___ 3:50 pm FLUID,OTHER SUBHEPATIC HEMATOMA.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
NO GROWTH AS OF ___.
DUE TO LABORATORY ERROR, UNABLE TO CONTINUE PROCESSING.
ANAEROBES ARE SCREENED FOR IN THE FLUID CULTURE.
TEST CANCELLED, PATIENT CREDITED.
Medications on Admission:
Prednisone 5mg/6mg alternating daily, Insulin Lispro, Gabapentin
300, Fentanyl patch 12, brimonidine 0.15% 1 drop ___, Atenolol
50, Omeprazole 20, valacycylovir 500, Bactrim (?), timolol 0.25%
1 drop BID, ASA 81, Tylenol PRN, Ca-VitD
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
4. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: may cause increased drowsiness.
Disp:*25 Tablet(s)* Refills:*0*
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Two (2) puffs Inhalation Q6H (every 6 hours).
10. ipratropium bromide 0.02 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*11 Tablet(s)* Refills:*0*
12. acetaminophen 650 mg Tablet Sig: ___ Tablet PO Q6H (every
6 hours) as needed for fever, pain.
13. Arava 10 mg Tablet Sig: One (1) Tablet PO QOD: EVEN days.
14. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO QOD:
___.
15. Arava 20 mg Tablet Sig: One (1) Tablet PO QOD: ODD days.
16. Humulin N 42 units sc in am daily ( please monitor blood
sugar prior to dose)
17. prednisone 6 mg po every other day ( ODD DAYS)
18. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perihepatic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with wheezing in the setting of acute
cholecystitis.
COMPARISON: Outside hospital chest radiograph dated ___.
TECHNIQUE: Single frontal chest radiograph was obtained portably with the
patient in an upright position.
FINDINGS: Lung volumes are low with bibasilar atelectasis. No pulmonary
edema is seen. Heart size is top normal. Aortic calcification is noted.
Deformity of the left humeral head is partially imaged.
IMPRESSION: Low lung volumes without evidence for acute process.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Shortness of breath, patient with perforated gallbladder and
percutaneous cholecystostomy.
Comparison is made with prior study ___.
There are persistent low lung volumes. There is increase in moderate
pulmonary edema and left lower lobe atelectasis. bilateral pleural effusions
are unchanged. There is no pneumothorax. Cardiomediastinal contours are
unchanged.
Catheter is present in the right upper quadrant.
Radiology Report
INDICATION: Status post percutaneous cholecystostomy and drainage.
Evaluation for evidence of perforation or residual abscess.
TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was
obtained after the administration of 130 cc IV Omnipaque contrast and oral
contrast. Coronal and sagittal reformations were prepared.
COMPARISON: CT examination dated ___.
FINDINGS: The included portions of the lung bases demonstrate moderate
bilateral pleural effusions and bibasilar atelectasis.
Within the abdomen, there has been interval placement of a percutaneous
cholecystostomy tube. The gallbladder is decompressed. No large fluid
collection remains. There is stranding within the gallbladder fossa and
reactive thickening of the pylorus. The subcapsular fluid collection about
the inferior right hepatic lobe has decreased in size measuring 4.1 x 0.9 cm
(300b:37) and previously 5.7 x 2.1 cm. At the inferior margin of the right
hepatic lobe, segment V/VI, there is new ill-defined hypodensity of the
hepatic parenchyma (2:25, ___ which could represent phlegmonous
change/early abscess formation. The largest area measures approximately 1.5 x
0.6 cm (300B:30).
The spleen, pancreas, adrenal glands and kidneys appear grossly unremarkable.
Loops of small and large bowel are normal in size and caliber. No
extraluminal air is identified. There are scattered diverticula of the large
bowel.
Distal loops of large bowel and rectum are normal in size and caliber. There
is mild wall thickening of the distal sigmoid colon which appears unchanged.
The bladder is collapsed around a Foley catheter. There is a 3.3 (300B:33) x
2.5 x 2.3 cm (2:62) left adnexal cyst with septation or possibly adjacent
cysts. There is a trace amount of pelvic fluid. No free air is identified.
There are severe degenerative changes of the lumbar spine with near complete
loss of the disc space and vacuum disc phenomenon greatest from L2-L4. There
are large marginal osteophyte formations and facet arthropathy which result in
severe spinal stenosis at L2-L3, L3-L4, L4-L5 and moderate stenosis at L5-S1.
Posterior to the L4 vertebral body is a 11 x 11 mm calcified structure which
may represent a calcified extruded disc. This markedly narrows the central
canal.
IMPRESSION:
1. Interval placement of cholecystostomy tube with decompression of the
gallbladder and minimal residual fluid. The cholecystostomy drain appears
well seated. Stranding within the gallbladder fossa.
2. New ill-defined hypodensity in segment V/VI of the liver could represent
phlegmonous change.
3. Moderate bilateral pleural effusions and associated atelectasis.
4. 3.3-cm left adnexal complex cyst or adjacent cysts. Further evaluation
with ultrasound is recommended.
5. Severe degenerative change of the lumbar spine narrowing the central
canal. Calcified structure posterior to the L4 vertebral body may represent a
calcified extruded disk, but is not further characterized and markedly narrows
the central canal.
Radiology Report
INDICATION: ___ woman with recent ERCP, presenting from outside
hospital with abdominal pain, fever, question abscess or biloma.
COMPARISON: Ultrasound from another institution, 7:00 p.m., ___.
FINDINGS: The gallbladder is filled with sludge and echogenic gallstones
which layer in the floor of the body. Deep to the posterior wall of the
gallbladder is a heterogeneous region of fluid which does not peristalse on
real-time visualization (image 6). In the hepatorenal fossa is a 7.5 x 2.5 cm
lenticular-shaped complex collection without surrounding hyperemia. The
common bile duct is not dilated. The pancreas is not visualized.
IMPRESSION:
1. Nondistended, sludge and stone-filled gallbladder. An irregular anechoic
collection adjacent to the gallbladder may represent a prior perforation, a
relatively aparastalic loop of bowel, or pericholecystic edema
2. Lenticular collection inferior to the right lobe of the liver is likely an
abscess or biloma in the hepatorenal fossa. A subcapsular hepatic collection
is felt less likely, but cannot be excluded.
If further evaluation is required, an MRCP or CT is suggested. An MRCP with
Eovist has the benefit of identifying biliary leaks. Biliary scintigriphy can
detect leaks without the anatomic correlation.
Findings were discussed with Dr ___ the surgical team at 0230.
Radiology Report
CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST
INDICATION: ___ woman with two weeks status post ERCP for
choledocholithiasis, now with right upper quadrant fluid collection in setting
of suspected perforated cholecystitis, biliary anatomy further assess fluid
collection.
CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST
TECHNIQUE: Multidetector scanning is performed from the diaphragm through the
symphysis during dynamic injection of 130 cc of Omnipaque.
CT OF THE ABDOMEN WITH IV CONTRAST: Mild atelectasis is seen at the lung
bases. The gallbladder is distended. There is disruption of the normal
enhancement of the gallbladder wall, consistent with gallbladder perforation.
Adjacent to the focal perforation, there is a fluid collection in the porta
hepatis that measures approximately 5.9 x 2.3 cm. A smaller collection also
adjacent to an area of focal disruption of the gallbladder wall is seen
adjacent to the gallbladder fundus and this measures 2.7 x 1.1 cm. Distinct
from this is a lentiform fluid collection inferior to the right lobe of the
liver that measures 4.4 x 3.5 cm. This corresponds to the collection
identified on ultrasound. The spleen is normal in size. The pancreas is
unremarkable. There is no biliary ductal dilatation. There is fat stranding
adjacent to the gallbladder and the focal collections consistent with
inflammation. The adrenal glands are normal. The kidneys are normal in size.
There is no hydronephrosis. No masses are seen. There is no retroperitoneal
lymphadenopathy.
CT OF THE PELVIS WITH IV CONTRAST: Multiple diverticula are noted in the
sigmoid colon. There is no fat stranding to suggest diverticulitis. The
small bowel loops are normal. In the left ovary, there is a 2.1 x 1.6 cm
cyst. There is no free fluid in the pelvis and no pelvic lymphadenopathy is
identified.
On bone windows, there are extensive degenerative changes involving the lumbar
spine. Osteophytes are extensive and osteophytes are identified to protrude
into the spinal canal, particularly at L2-L3, L3-L4 as well as L5.
IMPRESSION:
1. Perforated cholecystitis with two collections immediately adjacent to
focally necrotic gallbladder wall. A third collection immediately adjacent to
the inferior aspect of the liver is not definitely in continuity with the
other collections.
2. Cholelithiasis. No biliary ductal dilatation.
3. 2.1-cm cystic mass in the left ovary. Further evaluation with pelvic
ultrasound is recommended to ensure simple nature of the cyst. Based on the
outcome of the ultrasound, further followup will be warranted in a
post-menopausal patient.
4. Extensive degenerative changes involving the lumbar spine with spinal
canal stenosis at L2 through L5.
Finding No. 1 was discussed with Dr. ___ interpretation of the study
at 4:05 p.m.
Radiology Report
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy and subcapsular
fluid collection drainage.
INDICATION: ___ female with perforated cholecystitis with abdominal
fluid collections. Request percutaneous drainage of Gall Baldder and hepatic
subcapsular fluid collections.
COMPARISON: CT of the abdomen dated ___ and abdominal sonogram
dated ___.
OPERATORS: Dr. ___ Dr. ___. Dr. ___ was present for the entire
duration of the procedure.
PROCEDURE: After explaining the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The
patient was laid supine on the ultrasound table. A preprocedure timeout was
performed using three unique patient identifiers as per standard ___
protocol.
A decision was made to drain the gallbladder first with percutaneous
cholecystostomy. Limited sonographic images of the right upper quadrant were
performed for purposes of skin entry site localization for the percutaneous
cholecystostomy tube. An appropriate skin entry point was localized to the
right upper quadrant of the abdomen. The skin was prepped and draped in the
usual sterile fashion. A suitable entry site for percutaneous cholecystostomy
tube placement transhepatically was localized. Buffered 1% lidocaine solution
was used to anesthetize the skin, subcutaneous soft tissues and hepatic
capsule. A 3-mm incision was made. Under sonographic guidance an 8 ___
___ pigtail drainage catheter was advanced into the gallbladder. There
was immediate return of purulent fluid. The drainage catheter was
appropriately positioned and the loop of the catheter was formed within the
gallbladder. The catheter was attached to a three-way stopcock and a drainage
bag. We immediately drained about 150 mL of purulent fluid. The catheter was
secured to the anterior abdominal wall and sterile dressings were applied over
it.
Following this the inferiorly located hepatic subcapsular fluid collection was
targeted. An appropriate skin entry site was again localized and the skin was
prepped and draped in the usual sterile fashion. Buffered 1% lidocaine
solution was used to anesthetize the skin, subcutaneous soft tissues and the
hepatic capsule. A 3-mm skin incision was made and under sonographic guidance
an 8 ___ pigtail drainage catheter was advanced transhepatically into this
fluid collection. There was return of blood from this location. The catheter
was appropriately positioned within the fluid collection and loop of the
pigtail catheter was formed. We attached the pigtail drainage catheter into
the drainage bag. There was drainage of about 10 mL of bloody fluid.
The second drainage catheter was secured to the lateral abdominal wall and
sterile dressings were applied over it.
Obtained samples from the percutaneous cholecystostomy tube and the inferior
subcapsular hepatic fluid collections were sent separately for microbiological
analysis.
During the second drainage procedure the patient developed severe rigors ,
hypotension and tachycardia. She was continuously monitored and bolus 500 mL
of normal saline was administered. We also administered 25 mg of Demerol with
resolution of the rigors. The findings were discussed with Dr. ___
recommended the patient be transferred to the surgical intensive care unit.
At the time of transfer to the SICU, the blood pressure had returned to normal
range but the patient continued to remain tachycardic in the 130s.
IMPRESSION: Successful placement of percutaneous cholecystostomy tube and
another drainage catheter in the inferior subcapsular hepatic fluid
collection. There was frank pus draining from the percutaneous
cholecystostomy tube and bloody fluid from the inferior hepatic fluid
collection. Samples of both these fluid collections were sent separately for
microbiological analysis. Results are pending at this time.
Procedure complicated by hypotension, tachycardia and rigors with some
improvement after bolus of normal saline and single dose of Demerol. The
patient was transferred to surgical intensive care unit as per Dr. ___
___.
A recommendation was made to pull out the catheter draining the subcapsular
bloody collection if the Gram Stain results were negative.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER SP ERCP
Diagnosed with CHOLECYSTITIS, UNSPECIFIED, HYPERTENSION NOS, DIABETES UNCOMPL ADULT
temperature: 98.4
heartrate: 70.0
resprate: 18.0
o2sat: 96.0
sbp: 134.0
dbp: 68.0
level of pain: 8
level of acuity: 3.0 | Admitted to the acute care service with fever and elevated white
blood cell count, s/p ERCP showing cholecystitis. Imaging done
at an OSH showed a right subcapsular fluid collection. She
received a dose of ceftriaxone at the OSH and was started on
zosyn in the emergency room. Upon admission, she was made NPO
and started on intravenous fluids. She underwent a cat scan of
the abdomen which showed a perforated gallbladder with two
collections immediately adjacent to a focally necrotic
gallbladder wall. A third collection immediately adjacent to the
inferior aspect of the liver was found to be not in continuity
with the other collections.
On HD #3, she was taken to ___ for placement of a percutaneous
cholecystostomy tube and another drainage catheter in the
inferior subcapsular hepatic fluid collection. There was frank
pus draining from the percutaneous cholecystostomy tube and
bloody fluid from the inferior hepatic fluid collection.
Following her ___ drainage procedure, she was found to be
hypotensive (SBP 80's) and tachycardic (HR 110's). She was given
two small boluses of 500cc which quickly normalized her
hemodynamics. Given her overall condition and brief hypotensive
episode, she was observed in the intensive care unit overnight
following the procedure. She was initially kept NPO then her
diet was advanced the morning after the procedure.
She was transferred to the surgical floor after tolerating a
regular diet HD #4. Vancomycin was added to her antibiotic
regimen. On HD #5 she was found to have increased shortness of
breath. She underwent a chest x-ray which showed left lower lobe
atelectasis and mild pulmonary edema. She was started on lasix
with improvment of her pulmonary status. Since then she has
maintained an oxygen saturation of 99% on room air without
evidence of dyspnea. On HD #5, she underwent a gallbladder scan
to determine if a bile leak was present. No bile leak was
identified. The subcapsular hepatic drain was removed on HD #5
and the cholecystostomy tube remains patent.
Her vital signs have been stable and she has been afebrile. Her
white blood cell count has decreased to 4.3. Her appetite is
slowly improving. She has resumed her home medications. She was
evaluated by physical therapy and recommendations made for
discharge home with ___ services. She will complete a week
course of ciprofloxacin for ___ which was identified in the
bile culture. She is preparing for discharge home with ___
services and instructions to follow-up in the acute care clinic
in 2 weeks.
\
Of note: follow-up recommended with PCP for cyst left ovary |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
amoxicillin / chicken derived / almonds / pears
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old Primagavid female at 28 weeks
gestation who presents to ___ s/p low velocity MVC, no LOC,
restrained, + airbag deployment. She was brought to the ED at
___ for further evaluation; she is now endorsing T and L spine
tenderness but no abdominal pain. Original US in the trauma bay
demonstrates normal fetal HR. She will undergo MRI of her T and
L Spine.
Past Medical History:
PMH: Denies
PSH: Denies
Social History:
___
Family History:
Denies family history of any known medical problems
Physical Exam:
GEN: NAD
HEENT: NCAT, EOMI, no scleral icterus
CV: RRR, fetal heart rate 150s
RESP: no respiratory distress, breathing comfortably on room air
GI: size consistent with gestational age, non-TTP, no R/G/D
EXT: WWP, no peripheral edema
MSK: C7, upper thoracic and lumbar midline TTP
Pertinent Results:
___ 04:15PM BLOOD WBC-6.4 RBC-3.73* Hgb-10.9* Hct-31.9*
MCV-86 MCH-29.2 MCHC-34.2 RDW-13.2 RDWSD-40.5 Plt ___
___ 04:15PM BLOOD ___ PTT-25.3 ___
___ 04:15PM BLOOD UreaN-7 Creat-0.6
___ 04:15PM BLOOD Lipase-24
___ 04:21PM BLOOD Glucose-76 Lactate-1.3 Na-134 K-3.6
Cl-106
___ 04:21PM BLOOD Hgb-11.6* calcHCT-35 O2 Sat-84 COHgb-2
MetHgb-0
___: MRI T AND L SPINE:
Unremarkable MR examination of the thoracic and lumbar spine
without evidence of fracture, ligamentous injury, malalignment,
or significant degenerative disease.
___: MRI C SPINE:
1. No cervical spine fracture, malalignment, or ligamentous
injury.
2. No cord signal abnormality.
3. Trace degenerative disc disease without spinal canal or
neural foraminal narrowing.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
Motor Vehicle Collision; no acute injuries
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: 28 weeks pregnant post motor vehicle collision with C7 point
tenderness to palpation on tertiary examination. Evaluate for traumatic
injury.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR as well as
IDEAL technique. Axial T2 and gradient echo imaging were next performed.
COMPARISON: None.
FINDINGS:
Vertebral body heights and alignment are preserved. There is no focal bone
marrow signal abnormality. There is no prevertebral soft tissue edema. There
is no evidence of fracture or ligamentous injury.
The spinal cord is preserved in signal and caliber. The visualized posterior
fossa and cervicomedullary junction is preserved.
There is mild loss of T2 signal of the intervertebral disc at the C2-C3 level,
a manifestation of degenerative disc disease. The intervertebral disc heights
and signal are otherwise relatively well preserved.
Trace disc protrusions are seen at the C2-C3, C3-C4 and C4-C5 level indenting
the ventral thecal sac without significant spinal canal narrowing. There is
no significant spinal canal or neural foraminal narrowing at all visualized
levels.
There is minimal prominence of the adenoids, a common finding in this age
group.
IMPRESSION:
1. No cervical spine fracture, malalignment, or ligamentous injury.
2. No cord signal abnormality.
3. Trace degenerative disc disease without spinal canal or neural foraminal
narrowing.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with Oth pregnancy related conditions, third trimester, Other dorsalgia, Car driver injured in collision w car in traf, init, 28 weeks gestation of pregnancy
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Unable
level of acuity: 1.0 | Following initial evaluation in the ED, the patient was HDS and
was found to have normal fetal HR on sonographic analysis.
Secondary survey demonstrated upper thoracic and lumbar midline
TTP with no original cervical TTP. She underwent an MRI of her T
and L spine which was unremarkable for acute traumatic injuries.
After this study, she was sent to the L&D department and
admitted under the OB-GYN service. There, she and her fetus were
found to be stable and healthy.
Tertiary survey on ___ demonstrated new Cervical Spine
midline TTP and the patient underwent an MRI of her C Spine
which was also negative for acute traumatic injuries. She was
discharged home with instructions to follow up with her OB-GYN
team as usual; she was instructed by the ___ OBGYN team to get
an additional dose of Betamethasone tomorrow.
At the time of discharge, the patient was tolerating a regular
diet, voiding, ambulating and her pain was appropriately
controlled. She was given the appropriate follow up information. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Right knee swelling and pain
Major Surgical or Invasive Procedure:
Right total knee replacement on ___ none during current
admission
History of Present Illness:
Mr. ___ is a ___ gentleman with history of
CAD who underwent a right total knee arthroplasty with Dr. ___
on ___ who presented to the ___ ED on ___ with
atraumatic right leg swelling and pain. He was discharged from
the hospital to home on ___ ___ and noticed right leg
swelling since the time of discharge. He felt that the dressing
around his right leg was too tight and took it off today. He saw
that his knee was quite swollen, and he was unable to range it
as well secondary to swelling. He also endorses subjective fever
but did not take his temperature. He denies rigors. Of note, he
was discharged home on enoxaparin 40 mg sc daily, which he has
been taking. He denies drainage from the wound. He denies
paresthesias in the leg.
Past Medical History:
CAD (s/p MI ___ years prior)
HTN
Anxiety
GERD
Depression
Social History:
___
Family History:
Non-contributory for any significant musculoskeletal disease
Physical Exam:
Afebrile
Vital signs are stable
The right knee has a 1+ effusion with minimal warmth. No
erythema. The incision is clean and dry. His calf and thigh have
minimal swelling, are soft and non-tender. There are two
blisters distal to the incision at the tape borders that are
healing nicely. Distally he is intact with positive ___.
He has a 2+ dorselis pedis pulse symmetric to that of the left
lower extremity. The toes are warm to touch with good capillary
refill.
Pertinent Results:
___ 09:20AM BLOOD WBC-10.6* RBC-2.84* Hgb-9.0* Hct-27.8*
MCV-98 MCH-31.7 MCHC-32.4 RDW-12.7 RDWSD-45.1 Plt ___
___ 10:23AM BLOOD WBC-9.3 RBC-2.84* Hgb-9.0* Hct-27.0*
MCV-95 MCH-31.7 MCHC-33.3 RDW-12.3 RDWSD-42.5 Plt ___
___ 10:23AM BLOOD Neuts-77.0* Lymphs-10.2* Monos-10.8
Eos-1.1 Baso-0.4 Im ___ AbsNeut-7.19* AbsLymp-0.95*
AbsMono-1.01* AbsEos-0.10 AbsBaso-0.04
___ 09:20AM BLOOD Plt ___
___ 09:20AM BLOOD ___
___ 06:00AM BLOOD ___
___ 11:46AM BLOOD ___ PTT-23.2* ___
___ 10:23AM BLOOD Plt ___
___ 09:20AM BLOOD Glucose-157* UreaN-11 Creat-0.9 Na-136
K-4.0 Cl-99 HCO3-27 AnGap-14
___ 10:23AM BLOOD Glucose-185* UreaN-14 Creat-0.9 Na-136
K-3.9 Cl-97 HCO3-24 AnGap-19
___ 10:23AM BLOOD CK(CPK)-178
___ 09:20AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.3
Medications on Admission:
1. Amlodipine 5 mg PO DAILY
2. ClonazePAM 1 mg PO QHS:PRN insomnia
3. Ibuprofen 400 mg PO Q8H:PRN pain
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. ClonazePAM 1 mg PO QHS:PRN insomnia
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Acetaminophen 1000 mg PO Q8H
Do not exceed 3000mg in 24 hours
7. Docusate Sodium 100 mg PO BID
Please use as needed while your narcotic pain medication.
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
9. Senna 8.6 mg PO BID
Please use as needed while taking your narcotic pain medication.
10. Rivaroxaban 15 mg PO BID
11. Cephalexin 500 mg PO Q6H Duration: 10 Days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bilateral lower extremity deep vein thrombi
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ s/p R knee arthroplasty with swollen right leg. Assess for
DVT.
TECHNIQUE: Three views of the right knee.
COMPARISON: Right knee radiograph ___.
FINDINGS:
Compared with ___, there has been interval removal of a right
medial thigh drain as well as interval decrease in subcutaneous emphysema in a
patient is status post total knee arthroplasty.
A large joint effusion as well as soft tissue swelling along the thigh
persists. No hardware loosening or periprosthetic fracture.
IMPRESSION:
1. Persistent large joint effusion and soft tissue swelling of right thigh in
a patient who is status post total right knee arthroplasty.
2. No hardware loosening or periprosthetic fracture.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ s/p R knee arthroplasty with swollen right leg //
Eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the tibial veins.
Deeper of the two peroneal veins bilaterally show intraluminal echogenicity
and fails to demonstrate wall-to wall-color flow. Right peroneal vein is
noncompressible. Compressibility of left peroneal vein could not be evaluated
due to technical limitation.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Nearly occlusive DVT of right and left peroneal veins of indeterminate
age. If clinically indicated, consider ultrasound in 48 hr to assess
stability.
2. Focus of echogenicity in the right popliteal vein likely represents
chronic nonocclusive calcified thrombus.
NOTIFICATION:
Wet read of bilateral peroneal vein acute DVT was discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 11:53 AM, 5 minutes after discovery of
the findings.
Updated results regarding indeterminate age of bilateral peroneal DVT was
discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 4:50 AM, 40
minutes after discovery of the findings.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: R Knee pain
Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY, JOINT PAIN-L/LEG
temperature: 99.6
heartrate: 97.0
resprate: 19.0
o2sat: 96.0
sbp: 132.0
dbp: 69.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the Orthopaedic Arthroplasty Service
s/p right total knee replacement on ___ for bilateral lower
extremity deep vein thrombi. The patient presented to the
Emergency Department on ___ with increasing right leg pain.
A lower extremity doppler confirmed the presence of DVT in the
peroneal veins.
The patient was started on a therapeutic dose of Lovenox and
bridged to Coumadin. He remained asymptomatic through out his
hospital course. On day of discharge, he was transitioned to
Xarelto per PCP ___.
Prophylactic Ancef was maintained during his stay to prevent
infection for a possible underlying hematoma. He was
transitioned to oral Keflex ___ course) to continue after
discharge.
The hospitalization has otherwise been uneventful and the
patient has done well.
At discharge, vital signs are stable, the patient is afebrile,
tolerating a regular diet, voiding spontaneously every shift and
pain is well controlled. The extremities are neurovascularly
intact distally throughout the right lower extremity.
The patient is discharged home in stable condition. Patient
given detailed precautionary instructions and instructions for
the appropriate follow up care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ w/ PMH of depression, H. pylori, ?cyclic vomiting syndrome
presenting with nausea/vomiting.
The patient reports that two days ago, she developed
periumbilical, LLQ, and diffuse abdominal pain and intractable
nausea/vomiting. She reports she had multiple episodes of
emesis daily and has not been able to tolerate food or fluids.
She states that nothing helps alleviate her pain or nausea,
including Zofran, Reglan, Phenergan, and Compazine. She denies
fevers/chills, cough, dysuria, hematuria, hematemesis, coffee
ground emesis, or bloody bowel movements.
Of note, the patient was first diagnosed with H. pylori in ___
for which she received a full course of triple therapy
(clarithromycin, amoxicillin and omprazole). She has had six
hospital admissions over the past several years for
nausea/vomiting, and was most recently admitted from ___ with another episode of nausea/vomiting. She had an
extensive workup for her symptoms during that admission,
including an upper endoscopy which was positive on bipsy for
gastritis and H. pylori. Other workup, including barium swallow
study, EEG for abdominal migraines, TSH, LFT's, lipase,
electrolytes, and ___ were all negative. Her heavy metal tox
screen including lead, mercury, zinc, cadmium, arsenic were
presumably pending at time of discharge, but the zinc
protoporphyrin and arsenic returned elevated. The patient's
urine porphobilinogen returned negative, which does not rule out
porphyria, but no further workup had been ordered. GI was
consulted and the patient was set up with outpatient GI
follow-up. Her nausea was improved only with Sucralfate slurry
and Lorazepam 0.5-1 mg prn, as she did not respond to typical
anti-emetics. She was discharged on quadruple therapy of
bismuth, flagyl, tetracycline, and omperazole for H. pylori but
did not fill the precription as she was concerned this might
worsen her nausea/vomiting. She had also been instructed not to
take sucralfate until completion of her H. pylori regimen, as
this could interfere with the effect of the tetracycline, and
she was concerned that if she stopped taking sucralfate, she
would develop worsening abdominal pain and nausea/vomiting.
The patient notes she was previously taking ___ herbal
medicine but reports she hasn't taken any herbals since her last
admission.
Of note, the patient had been diagnosed by PCP with severe
depression and was placed on sertraline. The patient had
difficulties with compliance and follow-up in the past, likely
due to depression, and the primary care physician felt that in
light of her negative workup, the abdominal symptoms were
largely secondary to psychosomatization. The patient currently
denies suicidal ideation, but does report being down about her
frequent hospital admissions.
Additionally, the patient was noted to be pancytopenic during
her last admission, which has been stable for over one year, and
Atrius Heme/Onc was consulted. For workup of the anemia, the
patient had previously had an outpatient smear which showed
premature granulocytes, and iron studies with an iron of 28 but
ferritin of 4, consistent with severe iron deficiency anemia.
B12 was normal. She received 3 doses of IV iron, with plan for
further IV iron therapy as an outpatient. She was also planned
to have an outpatient bone marrow biopsy for workup of her
chronic pancytopenia, and was scheduled to see a hematologist.
Howver, the patient was unable to make her follow-up and
rescheduled this for ___.
Lastly, the patient also complains of LLQ pain which has been
long-standing. The pain does not radiate anywhere but is
exacerbated before a vomitting episode and then becomes diffuse
bilateral lower quadrant pain. She had a pelvic US in ___ to
investigate this which came back showing a small amount of fluid
in the cul-de-sac behind the bladder and a fibroid, but no
abnormalities to explain her longstanding LLQ pain.
In the ED, initial VS: 97.7 96 129/100 18 100%. Pt given
Ondansetron and Metoclopramide. In the ED pt expressed SI to the
RN so given a 1:1 sitter and admitted to the floor. Psych saw
however and didn't think pt suicidal so no need to section and
no sitter.
Currently, pt is very frustated with recurrent hospital episodes
and continued nausea/vomiting. She denies symptoms currently
this morning.
Past Medical History:
Depression
Multiple episodes of emesis requiring hospitalization
Pancytopenia (chronic, unclear etiology)
H. Pylori on EGD in ___, s/p treatment PrevPac but H. pylori
positive on EGD ___
Social History:
___
Family History:
Hypertension in mother. No family history of GI cancer or GI
illness.
Physical Exam:
VS - Temp 97.8F, BP 130/60, HR 80, R 18, O2-sat 99% RA
GENERAL - anxious, not in any pain currently
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTA, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - 3 visible midline laparascopic-like scars from
application of herbal medicine, mild epigastric tenderness, no
HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CnII-XII grossly intact
Pertinent Results:
___ 06:42PM GLUCOSE-109* UREA N-9 CREAT-0.6 SODIUM-142
POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-21* ANION GAP-19
___ 06:42PM WBC-2.5* RBC-4.21 HGB-11.3* HCT-37.3# MCV-89#
MCH-26.9* MCHC-30.4* RDW-19.2*
___ 06:42PM NEUTS-75.9* ___ MONOS-1.4* EOS-0.4
BASOS-0.8
___ 06:42PM PLT COUNT-133*
___ 06:42PM ALT(SGPT)-9 AST(SGOT)-17 ALK PHOS-29* TOT
BILI-1.2
___ 06:42PM LIPASE-16
___ 06:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 06:00PM URINE RBC-56* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ PBG DEAMINASE, RBC
___ ALA DEHYDRATASE, RBC
___ BCR/ABL GENE REARRANGEMENT, QUANTITATIVE PCR,
CELL-BASED
MICRO:
UCx ___: negative.
IMAGING:
Pelvic Ultrasound ___:
On transabdominal imaging the uterus measures 9.3 x 4.3 x 5.3
cm.
An endovaginal exam was performed for better visualization of
the endometrium and adnexa.
There is a fundal fibroid which measures 2.4 x 2.5 x 2.2 cm. The
endometrium appears normal and measures 4 mm.
There is a heterogenous complex mass which is somewhat vascular
seen within the left ovary. This mass measures 3.0 x 2.5 x 3.0
cm. The left ovary measures 4.3 x 2.5 x 3.0 cm. The right ovary
appears normal and measures 3.3 x 1.5 x 2.1 cm. A small amount
of free fluid is seen within the pelvis.
IMPRESSION:
1. Complex vascular mass seen within the left ovary which is
suspicious for an ovarian cystic mass. A GYN consult is
recommended.
2. Fundal fibroid measuring 2.5 cm.
Medications on Admission:
Carafate at home, QID
Occasional Vitamin D
Discharge Medications:
1. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 11 days: Dose of Amoxicillin 1000 mg twice daily.
Disp:*44 Tablet(s)* Refills:*0*
2. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day) for 11
days.
Disp:*22 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
4. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
5. Vitamin D3 Oral
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Severe Depression
H. pylori infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with three-year history of left lower quadrant
pain with acute exacerbation.
COMPARISON: No previous exam for comparison.
FINDINGS: On transabdominal imaging the uterus measures 9.3 x 4.3 x 5.3 cm.
An endovaginal exam was performed for better visualization of the endometrium
and adnexa.
There is a fundal fibroid which measures 2.4 x 2.5 x 2.2 cm. The endometrium
appears normal and measures 4 mm.
There is a heterogenous complex mass which is somewhat vascular seen within
the left ovary. This mass measures 3.0 x 2.5 x 3.0 cm. The left ovary
measures 4.3 x 2.5 x 3.0 cm. The right ovary appears normal and measures 3.3
x 1.5 x 2.1 cm. A small amount of free fluid is seen within the pelvis.
IMPRESSION:
1. Complex vascular mass seen within the left ovary which is suspicious for
an ovarian cystic mass. A GYN consult is recommended.
2. Fundal fibroid measuring 2.5 cm.
These findings were discovered at 3:10 p.m. and were conveyed to Dr.
___ at 3:15 p.m. by telephone on ___.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: LAP
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, PERSISTENT VOMITING
temperature: 97.7
heartrate: 96.0
resprate: 18.0
o2sat: 100.0
sbp: 129.0
dbp: 100.0
level of pain: 10
level of acuity: 3.0 | ___ w/ PMH of depression, H. pylori, ?cyclic vomiting syndrome
presenting with nausea/vomiting and depression.
# Nausea/Vomiting: The patient had an extensive workup during
her recent admission at ___ from ___ for an acute
exacerbation of her chronic nausea/vomiting, which has been
ongoing for years. The workup was significant only for
gastritis and chronic H. pylori infection, with H. pylori seen
on EGD and biopsy despite a negative H. pylori stool antigen.
She had been discharged on quadruple therapy during her recent
prior admission, but did not fill the medications due to
concerns that the antibiotics would cause GI irritation. She
had also been told to discontinue her carafate while on
antibiotics, as this would interfere with the tetracycline, and
she was afraid that discontinuing her carafate might exacerbate
her nausea/vomiting and abdominal pain. She has no fevers or
white count to account for an infectious etiology, and abdominal
exam was significant only for mild epigastric and LLQ
tenderness. During this current admission, the patient was
started on triple therapy for resistant H. pylori with
Amoxicillin, Levofloxacin, and Omeprazole, which ___ improve her
epigastric pain and some of her nausea. However, this is not
likely to account for the chronic, cyclic abdominal pain and
nausea/vomiting. She had an extensive workup in the past that
has thus far been unremarkable, but had an incomplete workup for
porphyria during her last admission, which will be completed
in-house during this admission. Her primary care physician also
reports that in the setting of an extensive negative workup,
non-compliance with follow-up, difficulty with adherence to
outpatient regimens, and severe depression, the patient's
nausea/vomiting is felt to be secondary to psychosomatic
symptoms. She was found on the morning of ___ to be
self-inducing her vomiting. A 1:1 sitter was ordered, and the
patient was then observed to have multiple attempts of
self-induced vomiting by putting her fingers down her throat.
The patient claims this helps alleviate her nausea, but has
refused oral and IV anti-emetics with the claim that none of
these help relieve her nausea. Psychiatry had evaluated her on
admission, and saw the patient again (see below), as the
patient's nausea/vomiting, and chronic abdominal pain appear to
be related to her severe depression.
# Depression: The patient has been severely depressed, and was
seen by Psychiatry on her previous admission as well as on this
current admission. As noted above, the patient's PCP has been
concerned about her severe depression and also reported that she
is concerned about the patient's home situation. It is
suspected that her husband is neglectful of the patient, and
they have had marital difficulties. The patient reported that
she feels that she is unable to turn to anyone for support.
However, on ___, the patient was discovered to be self-inducing
vomiting by putting her fingers in her throat. The patient was
later found banging her head against the bathroom wall. The
patient reported that she did not feel any pain despite hitting
her head against the wall mutiple times, and then reported she
was considering taking the IV cord and wrapping it around her
neck to hang herself. She reported both suicidal ideation and
intent, but was frightened and disturbed by these thoughts. A
1:1 sitter was ordered. Psychiatry came to evaluate the
patient, and felt the patient's severe depression would warrant
inpatient psychiatric hospitalization. She is being transferred
to the Psychiatric ward. Of note, the patient had refused SSRI
therapy during her prior admission, but currently reports she
has been taking Sertraline as prescribed by her primary care
physician. The Sertraline was continued in-house. Psychiatry
also recommended olanzapine for agitation.
# Elevated Arsenic Level: The patient had an elevated random
arsenic level on her prior admission of unclear significance.
She denies eating shellfish recently. Toxicology was consulted
and 24 hour urine arsenic level will be sent in the absence of
eating shellfish for 48 hours. The results ___ be followed as
an outpatient, as there is no sign of arsenic toxicity currently
and the random level is non-specific. The patient also does not
have an exposure history.
# Left Lower Quadrant Pain: The patient reports chronic left
lower quadrant pain which has been intermittently present for
years. She reports exacerbation of the pain with evolution into
diffuse, bilateral lower quadrant pain during her episodes of
nausea/vomiting, which was last investigated in ___ with a
pelvic ultrasound that showed a fibroid and small amount of
fluid in the cul-de-sac, and an abdominal ultrasound that was
negative. She denies changes in her current symptoms compared
to her prior chronic symptoms, and reports normal menstruation
(currently menstruating). Urine hcg in the ED was negative. A
repeat pelvic ultrasound was sent, given the patient reported
continued LLQ pain with exacerbation of the pain prior to her
episodes of nausea/vomiting. The ultrasound revealed a 3cm
swelling on her left ovary which was highly suspicious for an
ovarian cyst, as well as her previously discovered fibroid. Gyn
was consulted and felt that she could have follow-up as an
out-patient, which was arranged.
# Pancytopenia: The patient has a chronic history of
pancytopenia, which has been stable for over one year and was
being worked up by her primary care physician as an outpatient.
The patient reports having had several bone marrow biopsies in
___ in the past, but no record was able to be obtained
documenting the biopsies. The patient had an outpatient smear
which showed premature granulocytes and iron studies with an
iron of 28 but ferritin of 4, consistent with severe iron
deficiency anemia. During her prior admission, At___ Heme/Onc
was consulted for her continued pancytopenia and felt that in
the setting of stable pancytopenia over the past several years,
the patient could have a bone marrow biopsy performed as an
outpatient. She had been scheduled to follow up with a
hematologist, Dr. ___ (___) on ___, but the
patient reports she was unable to make this appointment and
rescheduled it to ___. There is no record in the Atrius
electronic record system of this change. Atrius heme/onc was
contacted again today and reviewed the patient's information,
and felt the patient could have an outpatient bone marrow biopsy
for further workup. They recommended sending a FISH for BCR-ABL
to rule out CML. Her peripheral smear in-house showed: Anisocy:
3+ Poiklo: 1+ Macrocy: 2+ Microcy: 2+ Ovalocy: 2+ Burr:
OCCASIONAL Stipple: OCCASIONAL Tear-Dr: OCCASIONAL Bite:
OCCASIONAL
# Anemia: The patient has had chronic, stable, macrocytic
anemia with outpatient iron studies showing an iron level of 28
in ___ but ferritin of 4 in ___. Her peripheral smear as
an outpatient showed premature granulocytes, which was also
consistent with severe iron deficiency anemia. She was given
ferric gluconate 125 mg IV x3 days during her recent admission,
with a plan for continued outpatient iron therapy. B12 was
normal. During her current admission, her hct was noted to be
improved from prior values. Repeat iron studies were sent, and
her values were all within normal range. She was not continued
on Iron supplementation in-house.
# Elevated Zinc Protoporphryin:
On prior admission, the patient had a heavy metal screening
panel, which returned with an elevated Zinc protoporphyrin level
of 248. After discussion with toxicology, it was felt that an
elevated an Zinc protoporphyrin level in the context of low lead
levels is a non-specific inflammatory marker. Toxicology was
unconcerned with this isolated elevated level.
Phone number: ___
Cell phone: ___
===================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
paliperidone / risperidone
Attending: ___.
Chief Complaint:
Breakthrough seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo man with history of paranoid schizophrenia and epilepsy
who
presents as transfer from ___ due to lethargy and confusion.
Patient is an unreliable historian and not answering all
questions appropriately. History taken mostly from chart review.
Per ___ and ___ notes, patient was last seen to be normal by
family ___ afternoon. This morning on ___, family found him
confused. Patient's mother ___, who states she knows when
pt
is not on his meds, states pt has "been off for the past 3
days".
When she would call her son's home, he would repeatedly hang up
the phone and he would normally pick up. Also, Patient missed
work yesterday and today which is not like pt to do so. Mother
communicated to ___ that her son has been noncompliant with
medications and frequently lethargic. She believes he needs his
medications to be adjusted as an inpatient.
At ___, patient was afebrile with a leukocytosis up to 12.6.
Otherwise UA, U tox, serum tox were negative. CT head without
contrast was unremarkable. He was transferred from ___ for
continuous EEG to evaluate for seizures. Upon transfer, he
tried
to assault EMS staff.
He was hospitalized at ___ from ___ for breakthrough
seizures thought to be due to noncompliance. He was supposed to
be on 1250 mg ___ twice daily prior to admission. The
general
neurology team offered to switch to a once a day medication such
as zonisamide but he declined at the time. He was discharged on
the same dose of ___ 1250 mg twice daily.
Patient follows with ___ Neurology, Dr. ___. She
was
on vacation, so after discharge, he saw Dr. ___ at ___
on ___. He was started on zonisamide 100 mg daily with
instructions not to decrease his dose of ___. Dr. ___
___
details a possible plan for tapering ___ if patient tolerated
the low-dose of zonisamide.
Per ___ notes, his PCP tapered ___ off without increasing
Zonisamide as patient appeared to not have a repeat seizure. No
___ notes seem to indicate his neurologist instructing
patient
to taper ___. Per PCP note from ___, he was instructed to
stop ___ completely and continue zonisamide 100 mg daily.
Patient has an appointment to see his neurologist, Dr. ___,
on
___.
Epilepsy history per ___ clinic note by Dr. ___:
"The patient was initially seen in the neurology clinic on
___ and most recently seen on ___. He had his first
seizures in ___ for which he was admitted to ___ in ___
after a witnessed generalized tonic-clonic seizure associated
with a tongue bite at ___. His seizures have been
associated with tongue bites, but no bowel/bladder incontinence.
He had been in ___ status post a fall at home, but
upon further history, he had had 3 falls at home over the
preceding 3 months which were also concerning for seizures. He
was transferred to ___ where an MRI
brain with and without contrast showed no masses, mild asymmetry
of the temporal horn of the lateral ventricles right larger than
left, and sinus retention cyst. Lumbar puncture showed WBC ___,
RBC 2110-820, glucose 69, protein 16.7, culture no growth. He
was started on ___ 500 mg b.i.d. and had one more seizure in
the next month in the setting of medication noncompliance. He
was
admitted to ___ in ___ after a generalized tonic-clonic
seizure while driving. Routine EEG during that admission showed
an occasional region of focal slowing and increased irritability
in the left frontal region of uncertain etiology. He followed up
with Dr. ___ at the Epilepsy Clinic at ___ in ___, and she changed his ___ to
Lamictal as the ___ was causing irritability and worsening
his psychiatric symptoms; however, the patient refused to take
his medications, so she then trialed Topamax but he also refused
to take that medication. He was subsequently placed on Depakote
which he remained on for a period of time, but he had persistent
seizures despite a therapeutic level and so ___ was
restarted.
He has also been followed by Dr. ___ Dr. ___ in the
neurology clinic at ___ from ___. His most
recent MRI brain ___ at ___ showed loss
of brain parenchyma within the right hippocampal formation as
compared to the left which may indicate right mesial temporal
sclerosis, and a few nonspecific T2 white matter abnormalities.
He has subsequently had seizures in ___, and multiple seizures in ___ and ___
in the setting of psychotic decompensation and medication
noncompliance. He is currently taking ___ 1250 mg bid. In
___, he also reported bitemporal headaches which could occur
up to 2 times per month. The patient was seen at ___
___ for seizures." in setting of noncompliance.
On interview, unclear if patient's ROS is reliable but he said
no
to everything and appears comfortable if withdrawn and
suspicious.
He says he was taking all his medications.
Past Medical History:
past psychiatric history:
pt has a history of schizophrenia vs, schizoaffective, had been
getting haldol decanoate, but has not bee medication compliant
for some time.
pt had first break in his early ___; has had approximately 4
psychiatric hospitalizations since that time and is followed by
Dr. ___ ___ at ___. reportedly on
Haldol
decanoate in the past. ___, per old records had a ___
worker ___ but his ___ case was closed years ago.
-Seizure disorder
-Schizophrenia, dx at ___
-Multiple psychiatric admission, ___ medication non-adherence
-Hypertension
Social History:
___
Family History:
Family psychiatric history; per past records pt has cousins with
schizophrenia
Physical Exam:
Admission exam:
Vitals: T 99.3, HR 96, BP 157/104, RR 17, SpO2 94% RA
General: Man lying in bed, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well-perfused
Pulmonary: no increased work of breathing
Abdomen: Soft, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, ___ but think
it is ___, perseverates on ___ when asked about month and date.
Unable to relate history. Able to count down from 10 but unable
to ___ forwards. Intact repetition, and intact verbal
comprehension. Naming intact. Mumbling some words. Other
phrases
seem out of context. Flat affect. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric. Trapezius
strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk with paratonia. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 2+ 3+ 3+ 1
R 3+ 2+ 3+ 3+ 1
Plantar response equivocal bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Unable to assess.
==========================================
Discharge Exam:
General: lying in bed, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well-perfused
Pulmonary: no increased work of breathing
Abdomen: Soft, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, ___, can't
say
why he is in the hospital, says because his "trouble speaking"
but when told he had a seizure agrees with that, follows axial
and appendicular commands, Flat affect
- Cranial Nerves: PERRL 3->2 brisk. EOMI, no nystagmus. No
facial
movement asymmetry. Palate elevation symmetric. Tongue midline.
- Motor: Normal bulk. No tremor or asterixis. no pronator
drift,
no focal weakness
- Reflexes: deferred
- Sensory: No deficits to light touch
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
Pertinent Results:
EEG ___
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study due to
occasional sleep-activated epileptiform discharges maximal in
the in the
frontal regions bilaterally, as well as the temporal regions
bilaterally, left
more than right. This finding indicates multiple foci of
cortical
hyperexcitability and multiple potential seizure onset areas.
Mild diffuse
slowing and disorganization present in the background,
suggestive of
superimposed mild diffuse cerebral dysfunction that is
nonspecific in
etiology. Common causes include medications/sedation, toxic
metabolic
disturbances, and infections. There are no pushbutton events.
Compared to the
prior day's study, there are no electrographic seizures seen.
EEG ___
IMPRESSION: This is a mildly abnormal continuous ICU EEG
monitoring study due
to 3 electroclinical seizures with onset in the right temporal
region and a
complex partial semiology as described above (focal, impaired
awareness).
Periods of frequent high voltage epileptiform discharges maximal
in the in the
frontal regions bilaterally. This finding can indicate either
global or focal
frontal cortical hyperexcitability with potential for seizures.
Diffuse
slowing and disorganization present in the background,
suggestive of
superimposed mild diffuse cerebral dysfunction that is
nonspecific in
etiology. Common causes include medications/sedation, toxic
metabolic
disturbances, and infections. 3 of the 4 pushbutton events
correspond to the
electroclinical seizures mentioned, and one additional event for
poor
responsiveness shows no electrographic correlate. Compared to
the prior day's
study, there are now epileptiform discharges and electrographic
seizures seen.
EEG ___
IMPRESSION: This is a mildly abnormal continuous ICU EEG
monitoring study due
to subtle diffuse slowing and disorganization present in the
background,
suggestive of mild diffuse cerebral dysfunction that is
nonspecific in
etiology. Common causes include medications/sedation, toxic
metabolic
disturbances, and infections. There are no pushbutton events. No
focal
abnormalities, epileptiform discharges, or electrographic
seizures are seen.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ARIPiprazole 15 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. NIFEdipine (Extended Release) 60 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Zonisamide 100 mg PO DAILY
Discharge Medications:
1. Divalproex (DELayed Release) 1000 mg PO BID
RX *divalproex ___ mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*5
2. Zonisamide 300 mg PO DAILY
RX *zonisamide [Zonegran] 100 mg 3 capsule(s) by mouth daily
Disp #*90 Capsule Refills:*5
3. ARIPiprazole 15 mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. NIFEdipine (Extended Release) 60 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Breakthrough seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with paranoid schizophrenia, seizure disorder p/w
lethargy and confusion// r/o PNA, effusions
IMPRESSION:
No previous images. Low lung volumes accentuate the enlargement of the
transverse diameter of the heart. Indistinctness of pulmonary vessels is
consistent with elevated pulmonary venous pressure. No significant pleural
effusion is appreciated.
No definite evidence of acute focal pneumonia. However, aspiration/pneumonia
would be difficult to unequivocally exclude given the appearance described
above and in the absence of a lateral view.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with desaturation// interval change interval
change
IMPRESSION:
Comparison to ___. Lung volumes have increased, likely reflecting
improved ventilation of the lung bases. Decrease in severity of a
pre-existing left retrocardiac atelectasis. No pulmonary edema. No pleural
effusions. No pneumonia. No pneumothorax.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 99.3
heartrate: 105.0
resprate: 18.0
o2sat: 94.0
sbp: 158.0
dbp: 101.0
level of pain: 0
level of acuity: 2.0 | ___ year old man with history of paranoid schizophrenia and
epilepsy who presents as a transfer from ___ due to lethargy
and confusion c/f breakthrough seizure iso medication titration
as an outpatient.
Initially patient had post ictal agitation and psychosis which
has been previously seen in him. He was restarted on home psych
medications. His ___ was held according to outpatient plan
and
zonisomide was increased to 300mg daily. He was monitored on
cvEEG and has had several additional breakthrough seizures and
thus valproic acid was added. He is now doing well on VPA 1000
BID and zonisamide 300 mg daily.
His AED's will be further titrated as an outpatient with
possible plan to wean VPA once zonisamide is at therapeutic
dose.
========================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Serzone / Penicillins / Erythromycin Base / Dilaudid / Cymbalta
/ Phenergan / fentanyl
Attending: ___.
Chief Complaint:
L flank pain, nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F PMH significant for chronic GERD, not responsive to PPI
therapy, Hpylori (treated), fibromyalgia who reports abdominal
pain.
The patient reports that the day prior to admission she
developed the sudden onset of ___ L flank pain that radiated
to the groin and reported felt like her previous kidney stones.
She reported that the pain then progressed to involve her entire
abdomen with associated nausea and vomiting. She reported then
having loose stools. On the day of admission, she came to the ED
because she reported that her watery diarrhea x2 episodes was
followed by two episodes of mucus diarrhea with a couple of
drops of blood within it. The patient also reports that she
recently stopped her omeprazole 40mg BID because she ran out of
the prescription. She also reports that she started taking
indomethacin 25mg TID for the past week because of some tenditis
in her wrist. She denies any other NSAID use, etoh, or cigarette
smoking. She denies any fevers, chills, melena, CP, SOB,
dysuria, polyuria, hematuria, recent travel, sick contacts.
In the ED intial vitals were: 98.2 87 120/72 16 100
- Labs were unremarkable including CBC, Chem 7, LFTs, lipase 22
(AlkPhos 111) significant for lactate of 1.3. CT abdomen pelvis
showed no acute findings. There is a hypodensity that is either
small cyst/IPMN or invagineated fat that will need MRCP, Renal
US and CXR unremarkable.
- Patient was given Morphine 2.5mg IV. Zofran, Lorazepam and GI
cocktail. Vitals prior to transfer were: 97.6 65 105/58 18 99%
RA
On the floor, she reports continual abdominal pain as described
above.
Past Medical History:
PMH
-chronic reflux refractory to PPI therapy (manometry normal,
impedance showed slight increase amount of reflux unrelated to
cough)
-Arthritis.
-Endometriosis.
-Fibromyalgia: Pt doesn't believe this diagnosis.
-Radiculopathy-low back pain
-H.pylori infection treated in ___ and subsequently
eradicated by a breath test in ___.
-History of abnormal LFTs attributed to fatty liver disease:
Previously had a negative autoimmune workup and viral screen.
-Chronic headaches.
-Nephrolithiasis.
-History of atrial septal defect.
-Sciatica.
-History of left upper quadrant abdominal pain that has been
extensively evaluated in the past with endoscopy, colonoscopy,
ultrasound, MRI and CT scan by Dr. ___ at ___.
PAST SURGICAL HISTORY
1. Cesarean section:
2. Laparoscopy: X 3 with Dr ___, then to assess tubal
patency x 1.
3. Salpingectomy: Laparopscopy x 2.
4. Breast biopsy.
Social History:
___
Family History:
Mother with a history of cirrhosis from methotrexate, remainder
noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.8 118/78 73 20 98%RA
General- well-appearing, NAD
HEENT- sclera anicteric, 1-2mm pupils
Neck- supple
Lungs- CTAB No wheezes, crackles, rhonchi
CV-Nl S1, S2, RRR No MRG
Abdomen- Soft, NABS, diffusely tender throughout without any
rebound or guarding
+Left flank tenderness
GU- no foley
Ext- warm, well-perfused
Neuro- CNII-XII grossly intact, moves all extremities
DISCHARGE PHYSICAL EXAM
Vitals- T 97.9, BP 113/72, HR 68, RR 18, 100RA, 1760/BRP in 24h
General- well-appearing, NAD
HEENT- sclera anicteric, 1-2mm pupils
Lungs- CTAB, no wheezes, crackles, rhonchi
CV- RRR, no MRG
Abdomen- Soft, nontender throughout. No CVA tenderness.
GU- no foley
Ext- warm, well-perfused
Neuro- CNII-XII grossly intact, moves all extremities
Pertinent Results:
ADMISSION LABS:
___ 05:00PM BLOOD Neuts-55.6 ___ Monos-3.2 Eos-1.8
Baso-0.9
___ 05:00PM BLOOD ___ PTT-31.7 ___
___ 05:00PM BLOOD Glucose-115* UreaN-11 Creat-0.6 Na-140
K-3.7 Cl-104 HCO3-26 AnGap-14
___ 05:00PM BLOOD ALT-19 AST-25 AlkPhos-111* TotBili-0.1
___ 05:00PM BLOOD Lipase-22
___ 05:00PM BLOOD Albumin-4.4
___ 07:23PM BLOOD Lactate-1.3
___ 05:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:00PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 05:00PM URINE RBC-41* WBC-4 Bacteri-NONE Yeast-NONE
Epi-11
___ 05:00PM URINE UCG-NEGATIVE
DISCHARGE LABS:
___ 05:35AM BLOOD WBC-7.1 RBC-3.93* Hgb-11.1* Hct-35.1*
MCV-89 MCH-28.2 MCHC-31.6 RDW-12.8 Plt ___
___ 05:35AM BLOOD UreaN-6 Creat-0.7 Na-139 K-3.2* Cl-104
HCO3-27 AnGap-11
___ 05:35AM BLOOD AlkPhos-91
___ 06:20AM BLOOD calTIBC-324 Ferritn-51 TRF-249
___ 03:29PM URINE Color-Straw Appear-Clear Sp ___
___ 03:29PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 03:29PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-2
___ 03:29PM URINE Mucous-RARE
CT ABD/PELVIS W/CON ___:
IMPRESSION:
1. No CT findings to explain the patient's symptoms. Although
CT is not
optimized for detection of peptic ulcer disease. No free air is
seen.
2. 3mm pancreatic tail hypodensity is either a small cyst/IPMN
or invaginated fat. Non-emergent MRCP in ___ months for
characterization and follow up.
CXR ___:
IMPRESSION:
No evidence of free air beneath the diaphragms.
Clear lungs. Borderline cardiac silhouette size.
RENAL US ___:
IMPRESSION: No renal stone seen. No hydronephrosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Indomethacin 25 mg PO TID
2. butalbital-aspirin-caffeine 50-325-40 mg oral q6h prn
headache
3. Omeprazole 40 mg PO BID
4. Gabapentin 100 mg PO QAM
5. Gabapentin 300 mg PO QPM
Discharge Medications:
1. Gabapentin 100 mg PO QAM
2. Gabapentin 300 mg PO QPM
3. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*60 Capsule Refills:*0
4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
5. butalbital-aspirin-caffeine 50-325-40 mg oral q6h prn
headache
6. Indomethacin 25 mg PO TID
7. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Abdominal pain, ? passed renal stone
Secondary diagnosis:
Hematuria
Migraines
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Left flank pain. Assess for hydronephrosis or stones.
COMPARISON: None.
FINDINGS: The right kidney measures 11.6 cm. The left kidney measures 11 cm.
There is no hydronephrosis, stone or mass identified bilaterally. The bladder
is under distended but unremarkable.
IMPRESSION: No renal stone seen. No hydronephrosis.
Radiology Report
HISTORY: Diffuse abdominal tenderness.
TECHNIQUE: Single AP upright portable view of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac silhouette is top-normal to mildly
enlarged. Mediastinal contours are unremarkable. No pulmonary edema is seen.
There is no evidence of free air beneath the diaphragms.
IMPRESSION:
No evidence of free air beneath the diaphragms.
Clear lungs. Borderline cardiac silhouette size.
Radiology Report
HISTORY: Diffuse abdominal pain. Assess for perforation or peptic ulcer.
TECHNIQUE: CT images were obtained from the lung bases to the pubic symphysis
after the uneventful intravenous administration of 130 cc of Omnipaque
contrast after discussion with the primary team revealed that renal stone was
no longer in the differential. Multiplanar reformations were prepared.
COMPARISON: None.
FINDINGS:
CT ABDOMEN WITH CONTRAST: The imaged lung bases are clear without pleural or
pericardial effusion.
The liver is normal in attenuation without focal lesion, intra or extrahepatic
biliary ductal dilatation. The portal and hepatic veins appear patent. The
gallbladder, pancreas, spleen and bilateral adrenal glands are unremarkable
aside from a 3 mm pancreatic tail cyst or invagination of abdominal fat. The
kidneys enhance and excrete contrast symmetrically without hydronephrosis.
Tiny renal hypodensities are too small to be characterized by CT.
The stomach is under distended without CT evidence of peptic ulcer disease.
The small and large bowel are unremarkable with a moderate cecal fecal load.
The appendix is normal. There is no free air or free fluid in the abdomen.
There is no mesenteric or retroperitoneal lymph node enlargement. The aorta
and major branches are patent and normal in caliber.
CT PELVIS WITH CONTRAST: The bladder, uterus, adnexa and rectum are
unremarkable. There is no pelvic free fluid or pelvic/inguinal adenopathy.
OSSEOUS STRUCTURES: There is no suspicious lytic or blastic bony lesion to
suggest osseous malignancy. Bilateral iliac sclerosis along the SI joint may
reflect osteitis condensans ilii given normal appearance to the joint itself.
IMPRESSION:
1. No CT findings to explain the patient's symptoms. Although CT is not
optimized for detection of peptic ulcer disease. No free air is seen.
2. 3mm pancreatic tail hypodensity is either a small cyst/IPMN or invaginated
fat. Non-emergent MRCP in ___ months for characterization and follow up.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN LUQ
temperature: 98.2
heartrate: 87.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 72.0
level of pain: 8
level of acuity: 3.0 | BRIEF HOSPITAL COURSE:
___ y/o F PMH significant for chronic GERD, not responsive to PPI
therapy, H pylori (treated), fibromyalgia, admitted for
abdominal pain.
# Abdominal Pain: Pt admitted w/ sudden-onset L flank pain
radiating to abdomen, reminding pt of prior renal stone. CT
abd/pelvis was reassuring for acute process and renal US
negative, but given hematuria w/ flank pain most likely
diagnosis thought to be passed kidney stone. DDx also included
GERD as pt stopped taking omeprazole, but recent normal pH
monitoring and manometry speaks against this. Patient was
treated for H.pylori X2 w/ reported cure. Possible ulcer esp in
setting of indomethacin, but EGD in ___ unremarkable; pt
also noted to have 3- pt Hct drop, concerning for possible PUD,
but more likely dilutional given all lines down. Pain was
controlled with tramadol. Omeprazole 40mg BID restarted
omeprazole. Nausea controlled w/ ondansetron. Pt initially
maintained on clear liquid diet, advanced successfully on HD#1.
Pt discharged in stable condition with prescriptions for
ondansetron, tramadol and omeprazole.
# Normocytic anemia. Has been anemic in the past, but recent
baseline in ___ w/n/l. Reports rectal bleeding X2 w/ mucus
and no stool 3 days prior to admission, no BMs since then. Had
similar episode years ago w/ normal colonoscopy. Likely
dilutional, not acute bleed given all lines down as above,. Iron
studies were normal. Pt's H/H remained stable, and pt was
discharged to f/u w/ outpatient PCP for further workup of
anemia.
# Hematuria: Has h/o nephrolithiasis, no evidence of stone on CT
scan. Patient w/ intermittent hematuria since ___. Repeat UA
showed moderate blood on dipstick but <1 RBC on microscopy.
Likely passed renal stone. Pt sent home to f/u w/ outpt PCP to
confirm resolution of hematuria and/or pursue further workup.
# Hypodensity of tail of pancreas: Thought likely cyst vs.
lipomatous tissue; though unlikely to be cause of patient's
pain. MRCP recommended in ___ months as outpatient.
# GERD: Restarted PPI, sent pt home w/ new prescription as pt
self-d/c'd medication ___ her prescription running out. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cefaclor / morphine / Tegaderm / Dilaudid /
Gadolinium-Containing Contrast Media
Attending: ___.
Chief Complaint:
difficulty breathing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ w/ h/o Hodgkin lymphoma s/p auto-BMT
in ___, metastatic renal cell carcinoma s/p multiple lines of
treatment, SRS to R occipital and L frontal lesion in ___ and
___, leptomeningeal disease (evident by b/l CN VIII enhancement
but neg CSF cytology), on pazopanib since ___ complicated by
severe diarrhea, presents w/ sever DOE.
She states her symptoms started early ___. She went to ___
and noticed that she was more tired than usual. She was having
intermittent "stomach upset" which she thought was a virus and
it
would go away. She also noted that she was intermittently SOB
and
also attributed it to a viral process.
Over the last week, she has developed progressive DOE w/ minimal
activity and fatigued despite eating and drinking well. No chest
pain. No palpitations. No dizziness. No fevers, no chills. No
cough. She is SOB even putting on clothes.
She also admits to b/l ___ calf tightness but no ___. She states
her calves "hurt when I point my toes up." She denied any
PND/orthopnea. Uses 1 pillow to sleep. She admits to diarrhea
that hs been ongoing and stable and unchanged. Moves bowels
~6x/day.
Past Medical History:
PAST ONCOLOGIC HISTORY PER OMR:
___ Hodgkin lymphoma with extensive chest LAD
MOPP and ABV chemotherapy
XRT to chest by Dr. ___ at ___
___ Relapsed Hodgkin lymphoma
Induction chemotherapy
___ Auto BMT by Dr. ___
___ Elevated hematocrit, fatigue
___ Hematuria
___ Small blood clots in urine
___ CT chest at ___ showed mediastinal, hilar LAD, left
renal
mass
___ CT urogram shows a large left renal tumor
___ MRI abdomen shows left renal tumor
___
___ Undergoes laparoscopic left radical nephrectomy
Pathology: clear cell renal cell carcinoma
___ Initial evaluation by Dr. ___ at ___
___ C1 HD IL-2
___ DFCI ___ with ___ Plus Sunitinib or Pazolpanib
for RCC
___ C1D1 DFCI ___ - ___ Admitted with pneumonia
___ Brain MRI shows right cerebellar lesion and bilat CNVIII
enhancement
___ CSF cytology negative
___ Completed SRS to cerebellar lesion via cyber knife
___ Started pazopanib
___ MRI head with stable cerebellar lesion and no other
definite disease
___ CT chest w/ unequivocal response to treatment with
significant interval improvement in right hilar and mediastinal
lymphadenopathy, pulmonary ___. Stable vascular collaterals in
the anterior mediastinum are likely due to a hemodynamically
significant occlusive lesion of the left subclavian vein.
___ CT torso with continued involution of metastatic renal
cell decreasing right carcinoma reflected in hilar and
subcarinal
adenopathy and presence of a solitary, shrinking pulmonary
nodule. Interval decrease in size of bilateral adrenal lesions.
Similar appearance of hypodense liver lesions, likely
metastases.
New regions of differential enhancement within segment 4A and 2
of the liver may reflect peripheral portal venous thrombosis but
does not represent metastatic disease.
___ MRI brain with new areas concerning for subclinical
metastasis
___ CK to left frontal lesion and the right occipital
lesions
___ CT torso with stable disease
___ MRI brain, stable disease
___ CT torso Mild interval increase in size of bilateral
adrenal metastases and right renal metastatic deposit in keeping
with mild progression of disease. Overall stable appearance of
the chest except for minimal increase in the right lower lobe
paratracheal lymph nodes with unchanged sub carinal and right
dominant necrotic lymph nodes
___ MRI brain, Increased size of right cerebellar and right
posterior frontal lobe. Decreased size of a right occipital lobe
metastasis and stable left frontal and left parafalcine
metastases.
PAST MEDICAL HISTORY:
- Likely metastatic renal cell carcinoma, as above
- Hodgkin lymphoma
- Hypertension
Social History:
___
Family History:
Mother had ___ lymphoma. Maternal grandfather had renal
cell carcinoma in his ___. Maternal uncle had ___
lymphoma. Another maternal uncle had melanoma. Maternal aunt had
renal cell carcinoma in her late ___. Paternal uncle had
prostate cancer and pancreatic cancer.
Physical Exam:
DiSCHARGE EXAM:
General: NAD, Resting in bed comfortably
VITAL SIGNS: 97.9 ___ 18 99%RA
HEENT: MMM, OP clear
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, nonlabored
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: ___, EOMI, face symmetric, no nystagmus, sensation
intact to light touch, moves all ext against resistance, gait
normal
Pertinent Results:
ADMISSION LABS:
___ 04:50PM BLOOD WBC-7.4# RBC-5.55*# Hgb-16.5*# Hct-48.6*
MCV-88# MCH-29.7 MCHC-34.0 RDW-13.8 RDWSD-44.1 Plt ___
___ 04:50PM BLOOD Neuts-65.6 ___ Monos-7.1 Eos-0.4*
Baso-0.4 Im ___ AbsNeut-4.88# AbsLymp-1.94 AbsMono-0.53
AbsEos-0.03* AbsBaso-0.03
___ 04:50PM BLOOD Glucose-94 UreaN-42* Creat-1.5* Na-134
K-4.6 Cl-105 HCO3-11* AnGap-23*
___ 04:50PM BLOOD Calcium-9.9 Phos-3.0 Mg-2.1
DISCHARGE LABS:
___ 07:18AM BLOOD Glucose-96 UreaN-23* Creat-1.0 Na-138
K-4.2 Cl-109* HCO3-20* AnGap-13
___ 07:18AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9
Echocardiogram:
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF = 70%). Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The pulmonary artery systolic
pressure could not be determined. The pulmonary artery is not
well visualized. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
___ U/S:
ReportFINDINGS:
Preliminary ReportThere is normal compressibility, flow and
augmentation of the bilateral common
Preliminary Reportfemoral, femoral, and popliteal veins. Normal
color flow and compressibility
Preliminary Reportare demonstrated in the posterior tibial and
peroneal veins.
Preliminary ReportThere is normal respiratory variation in the
common femoral veins bilaterally.
Preliminary ReportNo evidence of medial popliteal fossa (___)
cyst.
Preliminary ReportIMPRESSION:
Preliminary ReportNo evidence of deep venous thrombosis in the
bilateral lower extremity veins
CTA chest:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Stable metastatic disease with lytic destruction of right
posterior lateral seventh rib with a stable minimally displaced
pathologic fracture, bilateral adrenal metastases, and
paratracheal, subcarinal, and right hilar lymphadenopathy.
3. Stable hepatic hypodensities as described above.
4. Stable pulmonary nodules, unchanged since ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 10 mg PO DAILY
2. Zolpidem Tartrate 5 mg PO HS
3. Lisinopril 10 mg PO DAILY
4. Votrient (PAZOPanib) 200 mg oral DAILY
5. Loratadine 10 mg PO DAILY
6. Opium Tincture (morphine 10 mg/mL) 6 mg PO Q3 HR PRN diarrhea
Discharge Medications:
1. Escitalopram Oxalate 10 mg PO DAILY
2. Loratadine 10 mg PO DAILY
3. Zolpidem Tartrate 5 mg PO HS
4. Opium Tincture (morphine 10 mg/mL) 6 mg PO Q3 HR PRN diarrhea
RX *opium tincture 10 mg/mL (morphine) 6 mg by mouth every 3
hours as needed Refills:*0
5. Votrient (PAZOPanib) 600 mg oral DAILY
6. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*120 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Severe dyspnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CXR
INDICATION: ___ with SOB, metastatic renal cell carcinoma.
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior CT of the chest from ___.
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. The lungs
are clear without focal consolidation, pleural effusion or pneumothorax. A
metastatic lucent lesion of the right seventh rib is re- demonstrated.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with renal cell ca p/w SOB and b/l calf
tightness and + ___ sign // eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Radiology Report
EXAMINATION: CTA chest.
INDICATION: ___ year old woman with hx RCC and pulmonary nodules here w/
severe dyspnea on exertion. Assess for PE, infiltrates, edema, also restaging
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: This study involved 6 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced
Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4 mGy-cm. 4)
Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4
mGy-cm. 5) Stationary Acquisition 7.8 s, 0.2 cm; CTDIvol = 103.2 mGy (Body)
DLP = 20.6 mGy-cm. 6) Spiral Acquisition 5.4 s, 39.1 cm; CTDIvol = 4.3 mGy
(Body) DLP = 146.8 mGy-cm. Total DLP (Body) = 170 mGy-cm.
COMPARISON: CT chest with contrast ___, ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. Again seen are
multiple anterior mediastinal collateral vessels due to a stenosis of the left
innominate vein. There is no evidence of penetrating atherosclerotic ulcer or
aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
Mediastinal lymph nodes in the right lower paratracheal level are stable in
size. Again seen are subcarinal necrotic and right hilar necrotic lymph nodes
measuring 3.1 x 1.1 cm (previously 2.9 x 1.2 cm) and 1.1 x 1.1 cm (previously
1.2 x 1.2 cm) respectively. There is no new supraclavicular, axillary,
mediastinal, or hilar lymphadenopathy. A 0.6 x 0.5 cm right thyroid lobe
nodule is noted.
There is no evidence of pericardial effusion. There is no pleural effusion.
Stable apical and left upper lobe scarring is noted. There is no additional
evidence of pulmonary parenchymal abnormality. The airways are patent to the
subsegmental level.
Pulmonary nodules are stable since ___: Stable left fissural
nodule measuring 3 mm (6:198), stable left upper lobe pulmonary nodule
measuring 4 mm (6:165), stable 4 mm right upper lobe nodule (6:78), stable 6
mm right middle lobe nodule (6:211.)
Limited images of the upper abdomen are notable for prior cholecystectomy,
left nephrectomy, and persistent nodularity of bilateral adrenal glands
related to known metastasis measuring 1.1 x 1.1 cm (4:141) (previously 1.2 x 1
cm) and 0.8 x 0.9 cm (previously 0.9 x 0.7 cm) within the right and left
adrenal glands respectively. Small amount of fat stranding within the left
nephrectomy bed is stable and unchanged since ___. A stable 1.4 x
1.3 cm segment 5 hepatic hypodensity may represent an area of focal fatty
deposition. (4:141). An additional 0.9 x 0.7 cm (4:120) segment 7 hypodensity
is too small to characterize and stable since ___ (previously 0.9 x
0.7 cm).
A lytic lesion with associated destruction of the right posterolateral seventh
rib with a minimally displaced pathologic fracture which is similar in
appearance to previous examination. No new lytic or blastic osseous lesion
suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Stable metastatic disease with lytic destruction of right posterior lateral
seventh rib with a stable minimally displaced pathologic fracture, bilateral
adrenal metastases, and paratracheal, subcarinal, and right hilar
lymphadenopathy.
3. Stable hepatic hypodensities as described above.
4. Stable pulmonary nodules, unchanged since ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Diarrhea
Diagnosed with SHORTNESS OF BREATH
temperature: 97.1
heartrate: 115.0
resprate: 22.0
o2sat: 99.0
sbp: 99.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | ___ w/ h/o Hodgkin lymphoma s/p auto-BMT in ___, metastatic
renal cell carcinoma s/p multiple lines of treatment, SRS to R
occipital and L frontal lesion in ___ and ___, leptomeningeal
disease (evident by b/l CN VIII enhancement but neg CSF
cytology), on pazopanib since ___ complicated by severe
diarrhea, presents w/ severe DOE and calf tightness.
#DOE - High suspicion for PE given symptoms and underlying
malignancy. Initially w/ ___ thus contrast avoided. ___ U/S
negative for DVT. CT w/ constrast performed after Cr improved
and was negative for PE. No other intra-pulmonary cause for
dyspnea, no infiltrates or edema. Echo obtained showed normal
cardiac function w/o pericardial effusion.
It is unclear what caused her severe dyspnea but she did have
significant metabolic acidosis on admission and may have had
compensatory work of breathing from this. Drug effect is also
possible but CT chest did not show pneumonitis. At time of
discharge patient able to ambulate indepedently, no
desaturation.
#Acute Kidney Injury
#High Anion Gap Metabolic Acidosis
Likely prerenal from diarrhea and in setting of taking
lisinopril
Improved w/ stopping ACE-I and hydration
- pt will start sodium bicarb supplementation as ongoing loose
stools expected while taking pazopanib
- Cr normalized and she was given addnl hydration post CT
contrast
#Metastatic Renal Cell Carcinoma with Brain ___
- completed ___ stable since last MRI ___
- patient will resume pazopanib at lower dose of 600mg as she is
experiencing adverse effect of diarrhea and possibly dyspnea
- CT chest showed stable LAD
- she will return for follow up w/ Dr ___ in 2 weeks
#HTN
- holding lisinopril as above, BP low normal at time of
discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine / Codeine / Reglan / Ketorolac / Hydromorphone Hcl /
Peanut / Zofran / Ativan / Prochlorperazine / etodolac /
Oxycodone
Attending: ___.
Chief Complaint:
SOB, chest pain, R ankle pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with multiple comorbidities including asthma requiring
intubations x2 in 1990s, MI, CVA x2 presenting with 1 day of
shortness of breath c/w previous asthma attacks , unresponsive
to home nebulizers x6. This past wk, "allergies" have been out
of control. Zyrtec helps with rhinorrhea, nasal congestion and
sneezing. Today, felt SOB with wheezing and cough
(nonproductive). Pt took 6 doses of both albuterol and atrovent
nebs and felt nauseated afterwards and had emesis x3. In
addition felt dizziness and developed L sided chest pain this
morning radiating to her left jaw and arm. Pt has never had this
pain before, and says unrelated to cough but does admit to
increased pain on deep inspiration. Pain is intermittent,
lasting for a couple of minutes at a time, unresponsive to NTG
x3. She also took 162mg aspirin today as well as 60mg
prednisone. Yesterday, pt took 20mg prednisone (from leftover
prescription given previously). Pt was so dizzy that when she
tried to get out of her wheelchair, she twisted her right ankle
and now complaining of difficutly with weight-bearing and ___
pain in the lateral malleolus.
Per ___ ___ visit: ___ MD saw this patient twice before and
found her to have paradoxical vocal cord dysfunction proven by
fiberoptic
directly laryngoscopy during an attack.
Exam notable for expiratory wheeze
- EKG: SR, LAD, no STE, no acute change from previous EKG dated
___
Pre-treatment flow rate: 200L/min, no post-tx recorded
She received albuterol and ipratropium nebs, morphine, NTG x1,
mag, phenergan, morphine, asa 81mg
Vitals prior to transfer: 116/88 HR83 RR16 95%RA
Currently, c/o vaginal itching, generalized pruritus and R ankle
pain.
Past Medical History:
1. Asthma
- two previous intubations
2. Diabetes, type II
- followed by ___ at ___
- complicated by neuropathy
- per pt, has required MICU admission for hyperglycemia in
setting of steroids
3. Hypertension (patient denies and reports she uses ___ for
renal protection)
4. Hyperlipidemia
5. GERD s/p Nissen fundoplication
6. Morbid obesity
7. Depression (patient denies)
8. CVA in ___ with residual left hemiplegia
9. Spinal stenosis
10. Bipolar disorder
11. OSA
12. History of
- Pulmonary embolism (___), treated for ___ months
- Ganglion cystectomy
- Vertigo
Social History:
___
Family History:
Family history of "blood clots." Maternal grandmother and father
with history of CAD. Father also had asthma. Maternal
grandmother had diabetes and also maternal aunts and sister.
Brother and others with HTN. Mother with h/o low BP and DVT.
Maternal aunt with "mitral" problem.
Physical Exam:
On admission:
VS - 98.0 86 149/90 18 100%RA
GENERAL - NAD, comfortable, appropriate, speaking in full
sentences, no stridor
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, no sinus
tenderness
NECK - supple, no LAD
Chest: mild tenderness to palpation of L chest wall
LUNGS - diffuse expiratory wheezes, resp unlabored, no accessory
muscle use
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), no calf tenderness bilaterally
SKIN - no rashes or lesions
GU: no perilabial erythema, normal appearing inguinal folds
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout R side, L sided weakness in UE and ___, sensation
grossly intact throughout, gait deferred
Psych- euthymic, rapid speech but appropriate, organized
thinking
On discharge:
VS - 98.1 86 140/92 18 99%RA
GENERAL - NAD, comfortable, appropriate, speaking in full
sentences, no stridor
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no LAD
Chest: mild tenderness to palpation of L chest wall
LUNGS - improved diffuse expiratory wheezes, resp unlabored, no
accessory muscle use, no crackles or rhonchi
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), no calf tenderness bilaterally
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout R side, L sided weakness in UE and ___, sensation
grossly intact throughout, gait deferred
Pertinent Results:
On admission:
___ 04:10PM BLOOD WBC-9.9 RBC-5.00 Hgb-14.3 Hct-43.4 MCV-87
MCH-28.5 MCHC-32.9 RDW-15.1 Plt ___
___ 04:10PM BLOOD Neuts-46.1* Lymphs-45.1* Monos-5.5
Eos-2.1 Baso-1.2
___ 04:54PM BLOOD ___ PTT-34.3 ___
___ 04:10PM BLOOD Glucose-106* UreaN-15 Creat-0.8 Na-138
K-5.5* Cl-101 HCO3-27 AnGap-16
___ 06:13PM BLOOD K-2.8*
On discharge:
___ 06:00AM BLOOD WBC-6.4 RBC-4.54 Hgb-12.8 Hct-40.1 MCV-88
MCH-28.1 MCHC-31.9 RDW-13.6 Plt ___
___ 06:00AM BLOOD Glucose-114* UreaN-8 Creat-0.7 Na-141
K-3.4 Cl-105 HCO3-29 AnGap-10
___ 12:23AM BLOOD CK(CPK)-48
___ 12:23AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:10PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.1
Radiology:
___
TECHNIQUE: Right ankle, three views, and right foot, three
views.
FINDINGS: No acute fracture or dislocation is identified. The
ankle mortise
is symmetric and the talar dome is smooth. Tiny well-corticated
ossific
density inferior to the medial malleolus may reflect the sequela
of prior
injury. There are no focal lytic or sclerotic osseous
abnormalities. The
bone mineralization is normal. Mild hallux valgus deformity on
the right is
unchanged, with degenerative changes of the first MTP again
noted. There are
no radiopaque foreign bodies or soft tissue calcifications.
IMPRESSION: No acute fracture or dislocation.
___ CXR
FINDINGS: Cardiac silhouette size is normal. The mediastinal
and hilar
contours are unchanged, with the superior mediastinum slightly
widened likely
due to reduced lung volumes. The pulmonary vascularity is
normal. There is
minimal subsegmental atelectasis in left lung base. No focal
consolidation,
pleural effusion or pneumothorax is identified. Amorphous
calcification
adjacent to the greater tuberosities bilaterally may reflect
calcific
tendinopathy.
IMPRESSION: No acute cardiopulmonary abnormality.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, cough, SOB
4. Amitriptyline 75 mg PO HS
5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Benzoyl Peroxide Gel 10% 1 Appl TP DAILY
8. Clindamycin 1 Appl TP BID
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
10. Diazepam 2 mg PO TID:PRN anxiety
11. Doxepin HCl 25 mg PO HS
12. Epinephrine 1:1000 0.3 mg IM ONCE MR1 anaphylaxis Duration:
1 Doses
13. Fluticasone Propionate NASAL 1 SPRY NU BID
14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
15. Glargine 20 Units Breakfast
Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
16. Ipratropium Bromide Neb 1 NEB IH Q6H SOB, wheeze
17. Ketoconazole Shampoo 1 Appl TP ASDIR
3x per week
18. Omeprazole 40 mg PO Q12H
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Pregabalin 150 mg PO QAM
21. Pregabalin 300 mg PO QPM
22. Ranitidine 300 mg PO HS
23. Aspirin 81 mg PO DAILY
24. Vitamin B Complex 1 CAP PO DAILY
25. Calcium Carbonate 500 mg PO TID
26. Cetirizine *NF* 10 mg Oral daily
27. Vitamin D 400 UNIT PO DAILY
28. DiphenhydrAMINE 25 mg PO Q8H:PRN itch
29. Docusate Sodium 100 mg PO BID
30. Ferrous Sulfate 325 mg PO TID
31. Glycerin Supps ___AILY:PRN constipation
32. Senna 1 TAB PO BID:PRN constipation
33. AccoLATE *NF* (zafirlukast) 20 mg Oral BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, cough, SOB
2. Amitriptyline 75 mg PO HS
3. Aspirin 81 mg PO DAILY
4. Benzoyl Peroxide Gel 10% 1 Appl TP DAILY
5. Calcium Carbonate 500 mg PO TID
6. Cetirizine *NF* 10 mg Oral daily
7. Diazepam 2 mg PO TID:PRN anxiety
8. DiphenhydrAMINE 25 mg PO Q8H:PRN itch
9. Docusate Sodium 100 mg PO BID
10. Doxepin HCl 25 mg PO HS
11. Ferrous Sulfate 325 mg PO TID
12. Fluticasone Propionate NASAL 1 SPRY NU BID
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. Glycerin Supps ___AILY:PRN constipation
15. Glargine 20 Units Breakfast
Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
16. Ipratropium Bromide Neb 1 NEB IH Q6H SOB, wheeze
17. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Pregabalin 150 mg PO QAM
21. Pregabalin 300 mg PO QPM
22. Ranitidine 300 mg PO HS
23. Senna 1 TAB PO BID:PRN constipation
24. Vitamin B Complex 1 CAP PO DAILY
25. Vitamin D 400 UNIT PO DAILY
26. PredniSONE 10 mg PO DAILY
Take 4 pills on ___, 3 pills on ___, 2 pills on
___, and 1 pill on ___
RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*22 Tablet
Refills:*0
27. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
28. Clindamycin 1 Appl TP BID
29. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
30. Epinephrine 1:1000 0.3 mg IM ONCE MR1 anaphylaxis Duration:
1 Doses
31. Ketoconazole Shampoo 1 Appl TP ASDIR
3x per week
32. Omeprazole 40 mg PO Q12H
33. AccoLATE *NF* (zafirlukast) 20 mg Oral BID
34. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain Duration: 5 Days
RX *morphine 15 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
35. Promethazine 25 mg PO Q6H:PRN nausea Duration: 5 Days
RX *promethazine 25 mg 1 tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
36. Amoxicillin 500 mg PO Q8H
part of prevpac
37. Clarithromycin 500 mg PO Q12H
38. zafirlukast *NF* 20 mg ORAL BID
* Patient Taking Own Meds *
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Asthma exacerbation
Right ankle sprain
Nausea, vomiting
Secondary:
Eczema, generalized pruritus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain, asthma exacerbation.
COMPARISON: ___.
TECHNIQUE: PA and lateral views of the chest.
FINDINGS: Cardiac silhouette size is normal. The mediastinal and hilar
contours are unchanged, with the superior mediastinum slightly widened likely
due to reduced lung volumes. The pulmonary vascularity is normal. There is
minimal subsegmental atelectasis in left lung base. No focal consolidation,
pleural effusion or pneumothorax is identified. Amorphous calcification
adjacent to the greater tuberosities bilaterally may reflect calcific
tendinopathy.
IMPRESSION: No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: Ankle pain.
COMPARISON: ___.
TECHNIQUE: Right ankle, three views, and right foot, three views.
FINDINGS: No acute fracture or dislocation is identified. The ankle mortise
is symmetric and the talar dome is smooth. Tiny well-corticated ossific
density inferior to the medial malleolus may reflect the sequela of prior
injury. There are no focal lytic or sclerotic osseous abnormalities. The
bone mineralization is normal. Mild hallux valgus deformity on the right is
unchanged, with degenerative changes of the first MTP again noted. There are
no radiopaque foreign bodies or soft tissue calcifications.
IMPRESSION: No acute fracture or dislocation.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CP /SOB
Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION, LOWER LEG INJURY NOS, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, HYPERKALEMIA, DIABETES UNCOMPL ADULT
temperature: 98.0
heartrate: 73.0
resprate: 18.0
o2sat: 100.0
sbp: 129.0
dbp: 84.0
level of pain: 10
level of acuity: 2.0 | ___ with multiple comorbidities including asthma, MI, CVA x2
presenting with 1 day of shortness of breath c/w previous asthma
attacks.
# SOB: Pt's presentation was most likely related to PMH of
asthma vs Paradoxical vocal cord motion. She has a h/o asthma
exacerbations requiring ICU hospitalizations x2, last intubation
in 1990s. Now with SOB refractory to albuterol nebsx6 at home.
Pt has been to our ___ in past and was found to have PVCM on
visualization of vocal cords and this is known to commonly cause
wheezing similar to asthma attacks but is more associated with
stridor which pt does not have at this admission. Her diffuse
expiratory wheezes on exam are more consistent with asthma. Her
peak flow at 200, 53% of predicted suggested significant asthma
exacerbation. Her presentation was not likely PE as SOB was not
acute, and was not tachycardic. This was also less likely
related to pneumonia as pt remained afebrile, and was without
leukocytosis. Moreover, pt was not having purulent sputum and
CXR was normal. Pt was given IV magnesium 2g in ___ and on the
medical floor we started pt on prednisone 40mg PO and continued
albuterol and ipratropium nebs. Pt was also continued on home
Accolate and Advair. On hospital day 2, pt's respiratory status
improved and pt felt subjectively better. She was discharged
with Prednisone 40mg daily with instructions to taper off by
___. She has a followup appt with her PCP thereafter in
___. In addition, pt has a ___ appt with ENT to
further workup/manage paradoxical vocal cord motion. Pt was also
instructed to see a pulmonologist for improved management of
asthma.
#Chest pain: Pt has history of going to ___ for chest pain and
had cath done earlier in ___ to investigate which was negative.
Per pt she has had a "small heart attack" in past but none
documented. Pt's past episodes chest pain have been attributed
to GERD. Her chest pain on admission may be multifactorial as
she endorses pleuritic chest pain that may be related to asthma
exacerbation (coughing, overinflation) as well as GERD. Despite
pt at risk for CAD with DM, HTN and HLD, less likely cardiac as
EKG unchanged from previous studies and troponin x2 negative. Pt
was discharged without significant chest pain and physical exam
was stable (tenderness to palpation of L chest).
#Hypokalemia: First couple of K reads were elevated in hemolyzed
specimens. Third sample showed low K and this was expected with
pt receiving multiple albuterol tx. Potassium was repleted on
hospital day 1 and 2 and was stable on telemetry.
#Allergic rhinitis: Per pt, her chronic allergic rhinitis
symptoms (sneezing, rhinorrhea, nasal congestion) worsened this
past week, and she attributed this to environmental triggers. Pt
may have had viral sinusitis but not likely bacterial in nature
during hospitalization. We continued home Zyrtec 10mg daily and
fluticasone 50mcg nasal spray, and pt remained stable.
#Nausea, vomiting: Nausea and vomiting seems to have been
precipitated after multiple albuterol nebulizer treatments and
this may have been the cause. Pt's nausea and emesis persisted
during hospitalization and ended early morning of hospital day
2- improved after IV phenergan. Nausea could be multifactorial
as pt also s/p bariatric surgery, h/o GERD and H.pylori-all
could be related to n/v. GI was following as outpt and started
PrevPac on day prior to admission. Per pt, she did not take this
before admission. She was continued on home ranitidine and
omeprazole. She was discharged with instructions to start
PrevPac and complete 14 day course prescribed by outpt GI
specialist. Upon discharge, pt was taking good PO and had no
more nausea.
#R ankle sprain: Pt was unable to bear weight on R foot after
twisting ankle while getting out of wheelchair on day of
admission. Radiograph of R ankle did not reveal fracture and
there was no impressive swelling or ecchymoses at lateral
malleolus which would be concerning for ligament tear/rupture.
Pt's foot displayed good pulses and sensation was intact and
thus had a minor ankle sprain. She was given IV morphine for
severe ___ pain and was switched to PO on day of discharge
once nausea resolved. She was instructed to elevate leg, use ice
packs and ACE wrap at home. Before discharge, pt proved to
medical staff that she was able to move from bed to chair with
little difficulty and with some assistance.
#Chronic pain: Chronic back pain most likely secondary to spinal
stenosis. Pt is allergic to multiple analgesics and only
morphine was tolerable. Pt at home is also on Lyrica and
amitriptyline for neuropathic pain probably related to DM. Pt's
acute on chronic pain was managed with home Lyrica,
amitriptyline and IV morphine PRN. She was discharged with PO
morphine for 5 days.
#DM2: Pt on insulin Humulin three times a day at home. FSBG
maintained less than 200 while hospitalized and on insulin
sliding scale. Pt was discharged home and instructed to continue
preadmission insulin regimen.
#Generalized pruritus: This has been a chronic problem for pt as
she has a h/o eczema. Pt has an atopic presentation with
allergic rhinitis, eczema and asthma. Pt was given Sarna lotion
during hospital course and continued her doxepin- pruritus
remained stable.
#Depression/bipolar/anxiety: Pt was not on SSRI, but on
amitriptyline at bedtime and diazepam for anxiety. Pt remained
euthymic and appropriate throughout course. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / novacaine
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of remove MVA and subsequent chronic
pain, breast cancer s/p lumpectomy in ___, transferred from
___ for L1 vertebral body fracture with
retropulsion.
The patient remembers slipping on a wet floor several days ago
and bumping her flank. She also reports frequent falls. Today,
she reports pain to her lower back, difficulty ambulating due to
pain and difficulty standing from seated. She denies pain
radiating down her legs, but has nerve pain in her legs at
baseline. She has also had constipation for the past week
resulting in worsened back pain. She has occasional urinary
incontinence at baseline. No worsening bladder incontinence or
bowel incontinence.
Most of the history is obtained from the patient's niece. She
reports that patient is currently being worked up for dementia
and has been noted to have "sundowning" and visual
hallucinations in recent weeks. She has a history of chronic
pain since a remove MVA in ___. She was diagnosed with breast
cancer recurrence in ___ and is s/p lumpectomy, but declined
chemotherapy.
In the ED, initial vitals: 95.6 85 157/61 16 98% RA
Labs were significant for leukocytosis of 13, UA dirty.
Imaging significant for:
MRI showed L1 burst fracture, CT C spine negative.
CT Lumbar Spine: Burst fracture of L1 vertebral body with
retropulsed fracture fragment causing moderate spinal canal
narrowing.
CT Head: Sphenoid sinusitis. Mild cortical atrophy. Chronic
lacunar infarcts cannot be excluded.
In the ED, she received
___ 09:19 PO/NG Pregabalin 25 mg
___ 09:21 PO/NG FLUoxetine 20 mg
___ 09:22 PO/NG Atenolol 50 mg
___ 09:22 PO Naproxen 500 mg
___ 09:22 PO/NG Aspirin 81 mg
___ 09:23 PO/NG LORazepam .5 mg
___ 13:19 PO/NG LORazepam .5 mg
___ 13:46 IVF 1000 mL NS 500 mL
___ 16:23 PO/NG Ciprofloxacin HCl 500 mg
___ 16:23 IVF 1000 mL NS
Neurosurgery was consulted and recommended discharge with TLSO
brace and outpatient followup given the burst fracture appeared
chronic.
She was admitted to Medicine for pain control and ___ eval
Currently, patient reports that her pain is well controlled and
would like to sleep.
Past Medical History:
MVA with multi trauma ___
Fibromyalgia
Cervical spine surgery, unspecified
MI with stents
colitis
Breast cancer recurrence in ___, s/p lumpectomy
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T99 BP 153/87 HR 87 RR 20 Sats 99 RA
GEN: Alert, lying in bed, no acute distress. Diffuse
excoriations around her skin
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: Patient has ptosis of left eye (Chronic from previous
eye surgery) CN II-XII otherwise grossly intact, motor function
grossly normal in upper extremities. ___ exam limited by pain
DISCHARGE PHYSICAL EXAM:
Weight: NR
VS: 97.9 157/77 (130-170; avg 130-150s) 86 18 99
I/O: ___ x1 large BM; 24h-560/950
GEN: Alert, lying in bed, mildly uncomfrotable. Diffuse
excoriations around her skin and face.
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: Patient has ptosis of left eye (Chronic from previous
eye surgery) CN II-XII otherwise grossly intact, motor function
grossly normal in upper extremities. ___ exam limited by pain
Pertinent Results:
ADMISSION LABS:
==============
___ 04:08AM BLOOD WBC-13.0* RBC-4.00 Hgb-12.1 Hct-36.5
MCV-91 MCH-30.3 MCHC-33.2 RDW-12.5 RDWSD-41.2 Plt ___
___ 04:08AM BLOOD Neuts-73.5* Lymphs-15.8* Monos-9.4
Eos-0.2* Baso-0.5 Im ___ AbsNeut-9.59* AbsLymp-2.06
AbsMono-1.22* AbsEos-0.02* AbsBaso-0.07
___ 04:08AM BLOOD ___ PTT-34.5 ___
___ 04:08AM BLOOD Glucose-109* UreaN-35* Creat-1.0 Na-140
K-4.8 Cl-101 HCO3-27 AnGap-17
___ 04:08AM BLOOD estGFR-Using this
___ 06:02AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.8
___ 04:10AM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:10AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 04:10AM URINE RBC-1 WBC-8* Bacteri-MANY Yeast-NONE
Epi-<1
___ 04:10AM URINE Mucous-FEW
DISCHARGE LABS:
==================
___ 06:43AM BLOOD WBC-11.9* RBC-4.06 Hgb-12.1 Hct-37.3
MCV-92 MCH-29.8 MCHC-32.4 RDW-12.4 RDWSD-41.2 Plt ___
___ 06:43AM BLOOD Plt ___
___ 06:43AM BLOOD Glucose-101* UreaN-23* Creat-0.8 Na-139
K-3.5 Cl-102 HCO3-28 AnGap-13
___ 06:43AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8
PERTINENT IMAGING:
==================
___-SPINE W/O CONTRAST
IMPRESSION:
1. No acute fracture or malalignment of the cervical spine.
2. Severe multilevel multifactorial degenerative changes
described.
___ Imaging MR ___ SPINE W/O CONTRAST
IMPRESSION:
1. Study is severely degraded by motion.
2. L1 vertebral body burst fracture with 7 mm retropulsion of
the inferior
posterior fracture fragment resulting in moderate spinal canal
stenosis.
3. Moderate to severe multilevel degenerative changes as
described.
4. Small nonspecific L2-3 level intervertebral disc space fluid
without
definite epidural collection. While findings may be
degenerative in nature, infectious or inflammatory etiologies
are not excluded on the basis examination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 25 mg PO BID
2. Atenolol 100 mg PO DAILY
3. FLUoxetine 20 mg PO DAILY
4. Naproxen 500 mg PO Q12H
5. Atorvastatin 40 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. LORazepam 0.25 mg PO QHS
8. Ferrous Sulfate 325 mg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Codeine Sulfate 30 mg PO Q12H
12. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE Q24H
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
14. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Anacin (aspirin-caffeine) 400-32 mg oral QHS:PRN pain
17. LORazepam 0.25 mg PO QAM
18. Psyllium Wafer ___ WAF PO DAILY
19. Nortriptyline 10 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE Q24H
5. Codeine Sulfate 30 mg PO Q12H
6. Ferrous Sulfate 325 mg PO DAILY
7. FLUoxetine 20 mg PO DAILY
8. LORazepam 0.25 mg PO QHS
RX *lorazepam 0.5 mg 0.5 (One half) by mouth qHS PRN Disp #*10
Tablet Refills:*0
9. Losartan Potassium 100 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Nortriptyline 10 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
14. Pregabalin 25 mg PO BID
15. Psyllium Wafer ___ WAF PO DAILY
16. Timolol Maleate 0.5% 1 DROP LEFT EYE DAILY
17. Anacin (aspirin-caffeine) 400-32 mg oral QHS:PRN pain
18. LORazepam 0.25 mg PO QAM
RX *lorazepam 0.5 mg 0.5 (One half) by mouth qAM Disp #*10
Tablet Refills:*0
19. Naproxen 500 mg PO Q12H:PRN pain
Please do not take > 7 days in a row. If so call PCP.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
L1 fracture
Hypertension
SECONDARY DIAGNOSES:
Constipation
Dementia
Hyperlipidemia
Depression
History of breast cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. IN TLSO BRACE AT ALL TIMES WHEN MOBILE, INCLUDES
PASSENGER IN VEHICLE.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ female status post fall. Evaluate for cervical spine
fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 20.8 cm; CTDIvol = 37.0 mGy (Body) DLP = 772.2
mGy-cm.
Total DLP (Body) = 772 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
There is minimal C3 on C4 anterolisthesis, unchanged compared to prior exam
(see 602 B image 26 on current study and series 1A image 1 on prior). There
is no evidence of acute fracture. A left scapular 80 enostosis is partially
visualized (see 601b:21).
Endplate sclerosis and Schmorl's nodes are noted at C4-5 and C5-6. There are
severe multilevel degenerative changes including loss of intervertebral disc
space, subchondral sclerosis, subchondral cyst formation, and osteophyte
formation. There is no bony vertebral canal stenosis. Uncal hypertrophy and
facet arthropathy cause moderate to severe left-greater-than-right multilevel
neural foraminal stenosis. There is no prevertebral soft tissue swelling.
Limited imaging of the lungs demonstrate left upper lobe emphysematous changes
and biapical scarring.
IMPRESSION:
1. No acute fracture or malalignment of the cervical spine.
2. Severe multilevel multifactorial degenerative changes described.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ female with at L1 burst fracture. Evaluate cord
compression.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: Outside lumbar spine CT from ___.
FINDINGS:
Study is severely degraded by motion, especially on axial imaging.
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level.
There is grade 1 anterolisthesis of L4 on L5, unchanged. There is
redemonstration of an L1 comminuted fracture which predominantly involves the
inferior endplate with associated vertebral body height loss and 7 mm
retropulsion of the inferior posterior fracture fragment into the spinal canal
causing moderate spinal canal stenosis.
There is minimal cortical irregularity of the superior endplate of L2, as seen
on prior dedicated CT examination. At L2-3 endplates type ___ ___ changes are
noted.
The visualized portion of the spinal cord is grossly preserved in signal.
There is loss of intervertebral disc signal at all levels. There is near
complete loss of intervertebral disc height at L2-3 and L5-S1. Small
nonspecific fluid is noted within the L2-3 intervertebral disc space.
Within the limits of this noncontrast study there is no paravertebral or
paraspinal mass identified and there is no evidence of neoplasm. The
visualized portion of the sacroiliac joints are grossly preserved.
At the T12-L1 level, there is minimal disc protrusion causing mild spinal
canal stenosis. There no neural foraminal narrowing.
At the L1-L2 level, there is moderate spinal canal stenosis secondary to a
retropulsed inferior posterior fracture fragment. There is facet arthropathy
and moderate neural foraminal narrowing, worse on the right.
At the L2-L3 level, there is moderate intervertebral osteophytosis causing
severe spinal canal narrowing. There is facet arthropathy and moderate
bilateral neural foraminal narrowing, more severe on the left.
At the L3-L4 level, there is minimal disc protrusion causing effacement of the
anterior thecal sac. There is moderate facet arthropathy and moderate
bilateral neural foraminal narrowing.
At the L4-L5 level, there is significant intervertebral osteophytosis and
thickening of the ligamentum flavum causing severe spinal canal stenosis.
There is severe facet arthropathy and bilateral neural foraminal narrowing,
moderate in the left and severe in the right.
At the L5-S1 level, there is no spinal canal stenosis. There is mild facet
arthropathy with mild left neural foraminal narrowing.
IMPRESSION:
1. Study is severely degraded by motion.
2. L1 vertebral body burst fracture with 7 mm retropulsion of the inferior
posterior fracture fragment resulting in moderate spinal canal stenosis.
3. Moderate to severe multilevel degenerative changes as described.
4. Small nonspecific L2-3 level intervertebral disc space fluid without
definite epidural collection. While findings may be degenerative in nature,
infectious or inflammatory etiologies are not excluded on the basis
examination.
Radiology Report
INDICATION: ___ year old woman with fall // ?acute process
COMPARISON: The comparison is made with prior studies including the exam from
Steward ___ hospital dated ___.
IMPRESSION:
There is linear atelectasis or scarring in the left lung base. Within the
adjacent soft tissue there surgical clips present. There is no pneumothorax
or CHF.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Back pain
Diagnosed with Stable burst fracture of first lumbar vertebra, init, Exposure to other specified factors, initial encounter
temperature: 95.6
heartrate: 85.0
resprate: 16.0
o2sat: 98.0
sbp: 157.0
dbp: 61.0
level of pain: 0
level of acuity: 3.0 | ___ with history of breast cancer presents with
chronic-appearing L1 fracture and grade 1 L4-5 spondylosis.
# L1 fracture: Neurosurgery evaluated the patient and felt no
surgical intervention was required at this time. She was
instructed to wear a TLSO brace at all times and follow up with
neurosurgery in 4 weeks. Etiology of repeated falls is unclear
but most likely mechanical secondary to ___ body dementia. ___
evaluated patient and recommended rehab which patient initially
refused, however after lengthy discussion with family and
patient, she was agreeable to discharge to rehab. She was
treated with Tylenol, naproxen, and codeine (home medication)
for pain relief. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg swelling, cough, dysphagia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo M w/ PMHx of HTN, CAD c/b MI s/p BMS
x3
___, mixed diastolic/systolic CHF (EF 21% ___, Afib on
coumadin, hx of CVA ___, 14 & ___ w/residual R facial weakness &
L hemiparesis, DMII, OSA, AAA, CKD (b/l Cr 1.0-1.2), prostate ca
s/p XRT/hormonal rx who presents as a referral from his PCP for
bilateral leg swelling, melena, and symptoms concerning for
pneumonia found to have CAP with probable HFrEF exacerbation.
Per his wife, chart review and discussion with the patient he
reports:
(1) Increased fatigue, lethargy
(2) Cough, wheezing, dyspnea particularly when laying down
ultimately requiring recliner to sleep last night
(3) Increased leg swelling (has been missing diuretic doses
while
traveling)
(4) Difficulty swallowing, particularly solid foods, with
regurgitation. He does at times have difciutly with liquids,
reportedly choking on water while in waiting room of his PCP
office prior to presentation. He has not had difficulty with
pills. Lately his wife has been giving him ensure BID due to
difficulty eating. He previously had G-tube after his CVA,
actually asked his PCP about it.
(5) For the past 2 weeks he has had black tarry stool, seen in
UC
last week with stable H/H. B/l hgb 12.
Past Medical History:
HTN
CKD
HLD
CAD c/b MI in ___, BMS x 3 in ___
Ischemic cardiomyopathy w/ EF of 35%
AAA
COPD
Grave's Dz
Glaucoma
OSA
Prostate CA s/p XRT, hormonal therapy
Prior CVAs in ___ and ___ (former per Atrius records)
GERD
DMII
Social History:
___
Family History:
no hx of stroke or CAD. His mother died at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: BP 112 / 67, HR 90, RR 22, SpO2 99% 2.5 L NC
GEN: chronically ill appearing, raspy voice
HEENT: MMM, JVP >10cm
CV: RRR freq ectopic beat, no mrg
PULM: diffuse exp wheezing, quiet bibasilar crackles, decr
breath sounds in RLL/RML
GI: Obese/S/ND/NT
EXT: WWP, 1+ pitting edema reaching to sacrum
DISCHARGE PHYSICAL EXAM:
=======================
___ 0518 Temp: 97.5 PO BP: 107/56 L Lying HR: 68 RR: 20 O2
sat: 94% O2 delivery: Ra
GEN: elderly gentleman, appears young for his age. In no acute
distress, up in chair and conversational
HEENT: MMM, no upper teeth, JVD at level of mandible with
patient
head at approximately 15 degrees
CV: irregularly irregular, no mrg
PULM: no crackles, clear to auscultation.
GI: Obese, soft, ND, NT
EXT: WWP, 1+ pitting edema at the ankles bilaterally.
Pertinent Results:
ADMISSION LABS
=============
___ 06:25PM BLOOD WBC-6.7 RBC-3.63* Hgb-10.6* Hct-34.6*
MCV-95 MCH-29.2 MCHC-30.6* RDW-15.9* RDWSD-55.6* Plt ___
___ 06:25PM BLOOD Neuts-77.6* Lymphs-10.3* Monos-10.9
Eos-0.0* Baso-0.6 Im ___ AbsNeut-5.19 AbsLymp-0.69*
AbsMono-0.73 AbsEos-0.00* AbsBaso-0.04
___ 06:25PM BLOOD ___ PTT-42.1* ___
___ 06:25PM BLOOD Glucose-103* UreaN-18 Creat-1.2 Na-139
K-4.4 Cl-103 HCO3-25 AnGap-11
___ 06:25PM BLOOD ___
___ 08:37PM BLOOD cTropnT-0.03*
___ 06:25PM BLOOD Iron-15*
___ 06:59AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.8
___ 06:25PM BLOOD calTIBC-231* VitB12-534 Folate->20
Ferritn-145 TRF-178*
___ 06:36PM BLOOD Lactate-2.0
DISCHARGE LABS
==============
___ 06:19AM BLOOD WBC-6.7 RBC-3.85* Hgb-10.9* Hct-35.5*
MCV-92 MCH-28.3 MCHC-30.7* RDW-15.2 RDWSD-51.1* Plt ___
___ 06:19AM BLOOD ___ PTT-35.1 ___
___ 06:19AM BLOOD Glucose-139* UreaN-18 Creat-1.0 Na-144
K-5.0 Cl-100 HCO3-31 AnGap-13
___ 06:19AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8
MICRO:
=====
___ 8:37 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 15:11 Streptococcus pneumoniae Antigen Detection
Test Result Reference
Range/Units
S. PNEUMONIAE ANTIGENS, Not Detected Not Detected
URINE
___ 3:11 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
IMAGING
=======
CXR ___
FINDINGS:
PA and lateral views of the chest provided.
There is a focal opacity spanning the entire right lung and left
lower lobe
concerning for aspiration or pneumonia. Small right pleural
effusion. There is no pneumothorax. There are no signs of
congestion or edema. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right hemidiaphragm
is seen.
IMPRESSION:
Multifocal opacities concerning for aspiration or pneumonia.
VIDEO OROPHARYNGEAL SWALLOW ___
FINDINGS:
There was penetration with thin liquids which cleared at the
height of the
swallow. No evidence of gross aspiration. Likely small
pharyngocele noted on the right.
IMPRESSION:
1. No evidence of gross aspiration.
2. Mild penetration with thin liquids which cleared at the
height of the swallow.
BARIUM SWALLOW STUDY ___
FINDINGS:
The esophagus was not dilated. There was no stricture within
the esophagus. There was no esophageal mass. The esophageal
mucosa appear normal. There was near complete absence of the
primary peristaltic wave, with holdup of contrast in the mid
esophagus which eventually cleared via secondary and tertiary
contractions. The lower esophageal sphincter demonstrated
delayed opening, though otherwise opened and closed normally.
There was minimal gastroesophageal reflux. There was no hiatal
hernia.
No overt abnormality in the stomach or duodenum on limited
evaluation.
IMPRESSION: Moderate esophageal dysmotility with minimal
gastroesophageal reflux.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Lisinopril 5 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Torsemide 20 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Atorvastatin 80 mg PO QPM
9. Cyanocobalamin 1000 mcg PO DAILY
10. Warfarin 7.5 mg PO DAILY16
11. GlipiZIDE XL 5 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
14. Senna 8.6 mg PO BID
15. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
every twelve (12) hours Disp #*60 Tablet Refills:*0
2. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once daily Disp #*60
Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
7. Cyanocobalamin 1000 mcg PO DAILY
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Lisinopril 5 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Senna 8.6 mg PO BID
14. Vitamin D 1000 UNIT PO DAILY
15. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Mixed Heart Failure Exacerbation
Acute Hypoxic Respiratory Failure
Community Acquired Pneumonia
Moderate Esophageal Dysmotility
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (___
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with HFrEF, suspected aspiration// evaluate for
evidence infiltrate vs pulmonary edema
COMPARISON: Chest radiograph from ___.
FINDINGS:
PA and lateral views of the chest provided.
There is a focal opacity spanning the entire right lung and left lower lobe
concerning for aspiration or pneumonia. Small right pleural effusion. There
is no pneumothorax. There are no signs of congestion or edema. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
Multifocal opacities concerning for aspiration or pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:20 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW STUDY
INDICATION: ___ year old man with subacute difficulty swallowing solids (not
liquids), iso multiple prior CVAs. Evaluation for swallow mechanism,
aspiration.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 02:59 min.
COMPARISON: Comparison to prior video oropharyngeal swallow study from ___.
FINDINGS:
There was penetration with thin liquids which cleared at the height of the
swallow. No evidence of gross aspiration. Likely small pharyngocele noted on
the right.
IMPRESSION:
1. No evidence of gross aspiration.
2. Mild penetration with thin liquids which cleared at the height of the
swallow.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old man with dysphagia, video oropharyngeal swallow
without evidence aspiration. Evaluation for lower esophageal obstruction or
delayed emptying.
TECHNIQUE: Barium esophagram.
DOSE: Acc air kerma: 70 mGy; Accum DAP: 1195 uGym2; Fluoro time: 04:58
COMPARISON: Comparison to video oropharyngeal swallow study performed earlier
the same day on ___.
FINDINGS:
The esophagus was not dilated. There was no stricture within the esophagus.
There was no esophageal mass. The esophageal mucosa appear normal.
There was near complete absence of the primary peristaltic wave, with holdup
of contrast in the mid esophagus which eventually cleared via secondary and
tertiary contractions. The lower esophageal sphincter demonstrated delayed
opening, though otherwise opened and closed normally.
There was minimal gastroesophageal reflux. There was no hiatal hernia.
No overt abnormality in the stomach or duodenum on limited evaluation.
IMPRESSION:
Moderate esophageal dysmotility with minimal gastroesophageal reflux.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: B Leg swelling, Difficulty swallowing, Melena, Pneumonia
Diagnosed with Other pneumonia, unspecified organism, Dyspnea, unspecified
temperature: 99.8
heartrate: 108.0
resprate: 20.0
o2sat: 98.0
sbp: 103.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Outpatient Providers: PATIENT SUMMARY:
===============
___ is a ___ yo M w/ PMHx of HTN, CAD c/b MI s/p BMS
x3 ___, mixed diastolic/systolic CHF (EF 21% ___, Afib on
coumadin, hx of CVA ___ w/residual R facial weakness,
DMII, OSA, AAA, CKD (b/l Cr 1.0-1.2) who presents as a referral
from his PCP for bilateral leg swelling, dysphagia, and dyspnea,
found to have acute hypoxic respiratory failure and a HFrEF
exacerbation. He received a 5d course of CTX/Azithro for
presumed community acquired pneumonia, and was diuresed daily
with IV Lasix. He also reported difficulty swallowing prior to
admission, which was evaluated with a video swallow study and a
barium swallow study, both of which were normal. He was
discharged on 40mg PO Torsemide and with a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine /
Prednisone / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
Coumadin / Amitriptyline
Attending: ___.
Chief Complaint:
Inability to walk
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient was unable to give history because sleepy from the
dilaudid she received in the ___ and also a poor historian at
baseline. She told me to call her husband ___ at ___,
but it went straight to voicemail.
According to the ___ and neuro note:
___ w/ chronic back pain getting slowly worse over the last
week, roughly, and with increasing falls. She says she was
walking around when both her legs gave out and she fell to the
ground. This has happened an unclear number of times. Her
chronic back pain is also worse over this time, although it is
unclear whether the worsening back pain preceded the falls or
vice versa. She has also been having chills and nightsweats.
In the ___ initial Vitals were: 98.8 68 125/63 18 98%. Labs
showed positive urine opiates, platelets 82, CXR negative for
infection, U/A negative, toe films: L second toe fracture.
According to nursing notes pat "refusing to take percocet
stating that it does not help. yelling at staff stating "we dont
___. once treated with iv dilaudid pt was pleasant,
comfortable, and then fell asleep. refusing to ambulate ___
pain."
Per neuro who was consulted in the ___: As much as I can obtain
from history, she does not endorse any specific midline spine
pain or tenderness, sensory loss, or clear change in urinary or
bowel habits. She did not specifically endorse leg weakness for
me, but instead just described pain and difficulty standing up
straight over at least the past week. She denies intravenous
drug use, recent instrumentation, or a personal history of
malignancy. Her examination reveals mild signs of cervical
spondylosis with myelopathy and lumbar radiculopathy that is
chronic (with muscle wasting), but there is no significant leg
weakness, sensory loss (sensory level or saddle anesthesia),
loss of rectal tone, or focal spine tenderness that could be
referrable to a spinal cord compression. There is no meningismus
and no signs of acute injury to the brain. Overall, the
patient's minimal history and clinical examination are not
consistent with an acute neurologic injury.
On arrival to the floor, sleepy, answering yes to all my
questions despite contradicting herself.
Past Medical History:
Hypertension
Hypercholesterolemia
coronary artery disease
s/p 4 stents at ___ in ___
gastroesophageal reflux
Depression/Anxiety
Uterine cancer in her ___
h/o pulmonary embolism
h/o strokes with residual dysarthria and voice hoarseness
chronic obstructive pulmonary disease
Social History:
___
Family History:
No premature coronary artery disease.
Physical Exam:
ADMITTING EXAM
VS - Temp 98.2F, BP: 156/82, HR: 65, RR:18, O2-sat 99% 3L
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, poor
dentition
NECK - supple, no thyromegaly
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, systolic murmur heard throughout the precordium, nl
S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), bruising circumferentially on ___ toe on left foot.
NEURO - sleepy, A&Ox2 (not time), CNs II-XII grossly intact,
muscle strength ___ lower extremities, ___ in upper extremities
___ effort as sleeping through exam, DTRs 3+ and symmetric,
DISCHARGE EXAM
Tc 98 BP 115/73 HR 60 18 96% on 3L
GEN awake, alert woman in NAD
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no LAD
PULM intermittent crackles and wheezing b/l, good air movement
CV RRR, normal S1/S2, +systolic murmur heard LUSB
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e, has echhymosis
and swelling over left second toe, painful to palpation and with
movement
NEURO CNs2-12 intact, ___ strength equal bilaterally, no focal
defecits, patellar reflexes 2+ and equal b/l
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS
___ 07:50AM GLUCOSE-110* UREA N-37* CREAT-1.0 SODIUM-141
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-35* ANION GAP-13
___ 07:50AM ALT(SGPT)-10 AST(SGOT)-13 CK(CPK)-31 ALK
PHOS-72 TOT BILI-0.9
___ 07:50AM cTropnT-<0.01
___ 07:50AM cTropnT-<0.01
___ 07:50AM WBC-5.9 RBC-4.45 HGB-12.7 HCT-40.0 MCV-90
MCH-28.5 MCHC-31.7 RDW-15.5
___ 01:15AM GLUCOSE-124* UREA N-42* CREAT-1.1 SODIUM-138
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-33* ANION GAP-13
___ 01:15AM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-2.2
___ 01:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:15AM WBC-7.6 RBC-4.19*# HGB-12.1# HCT-38.0# MCV-91
MCH-29.0 MCHC-31.9 RDW-15.9*
___ 01:15AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
DISCHARGE LABS
___ 07:05AM BLOOD WBC-4.1 RBC-4.11* Hgb-12.1 Hct-37.1
MCV-90 MCH-29.3 MCHC-32.4 RDW-15.6* Plt ___
___ 07:05AM BLOOD Glucose-109* UreaN-32* Creat-1.0 Na-140
K-4.4 Cl-98 HCO3-35* AnGap-11
___ 07:05AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.3
MICRO
___ 1:15 am URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
TOE(S), 2+ VIEW LEFTStudy Date of ___ 1:29 AM
INDICATION: Recurrent falls, toe pain.
No prior examinations for comparison.
LEFT TOES, AP, OBLIQUE, AND LATERAL: The bones are diffusely
demineralized.
There is some irregularity and spurring at the medial aspect of
the second PIP
joint, involving the second proximal phalangeal head and middle
phalangeal
base. This may represent small fractures (or capsular avulsion)
if there is
focal pain at this location. Mild degenerative changes of the
first IP and
second through fifth DIP joints. There is soft tissue swelling
of the
forefoot.
CHEST (PA & LAT)Study Date of ___ 1:29 AM
COMPARISON: Chest radiograph from ___hest from
___.
CHEST, PA AND LATERAL: Peripheral fibrosis and mild
architectural distortion
in the right lower lobe. No focal consolidation. Pulmonary
edema has
resolved. Bilateral pleural thickening. Right atrial and
ventricular
pacemaker leads, the latter coursing in the mid RV. Median
sternotomy wires
and mediastinal clips. Moderate-to-severe cardiomegaly is
unchanged. Aorta
is tortuous and unfolded.
Multilevel degenerative changes in the thoracic spine. Interval
fracture of
the right humeral surgical neck, with an overriding fracture
fragment. This
appears subacute, with partially corticated margins.
IMPRESSION:
1. Right lower lobe fibrosis.
2. Moderate cardiomegaly.
3. Interval right humeral neck fracture.
C-SPINE NON-TRAUMA W/FLEX & EXT 4 VIEWSStudy Date of ___
3:43 ___
On the neutral lateral view, C1 through lower portion of C7 is
demonstrated.
Lordosis is preserved. No prevertebral soft tissue swelling is
seen.
Vertebral body heights are preserved. There are moderate to
moderately severe
multilevel degenerative changes, with disc space narrowing and
marginal
osteophytes most pronounced from C5-7. No spondylolisthesis is
detected.
There is multilevel uncovertebral joint spurring in the mid and
lower cervical
spine.
On flexion-extension views, there is mild-to-moderate range of
motion in
flexion and good range of motion in extension. In flexion,
there is trace
(cortical width) anterolisthesis of C3/4, which reduces in
extension. No
other evidence of instability is detected.
On the AP view, there is dense carotid artery calcification
bilaterally.
There is also suggestion of increased density at the right lung
apex, not
fully evaluated, but compatible with the appearance on a chest
CT dated
___. (Please see CXR report from same day.) Portions of
presumed
pacemaker, sternotomy wires and clips are noted.
IMPRESSION:
1) Multilevel degenerative changes, including slight change in
alignment at
C3/4 between flexion and extension.
2) Dense bilateral carotid artery calcification.
___
CAROTID ULTRASOUND
Significant plaque RT ICA with 81% stenosis, significant plaque
LT ICA with 70% stenosis, left subclavian steal with right
subclavian presteal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 180 mg PO DAILY
please hold for SBP < 90
2. Estrogens Conjugated 0.3 mg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. Senna 1 TAB PO BID:PRN constipation
5. Docusate Sodium 100 mg PO BID
please hold for loose stools
6. Furosemide 40 mg PO DAILY
please hold for SBP < 90
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
8. Pantoprazole 40 mg PO Q24H
9. Lorazepam 0.5 mg PO Q8H:PRN anxiety
please hold for sedation, rr<10
10. Rosuvastatin Calcium 5 mg PO DAILY
11. traZODONE 50 mg PO HS:PRN sleep
12. Metoprolol Tartrate 50 mg PO BID
please hold for SBP < 90, hr <60
13. Flecainide Acetate 100 mg PO Q12H
14. Ropinirole 0.5 mg PO TID
15. Gabapentin 400 mg PO TID
16. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN pain
17. Aspirin 81 mg PO DAILY
18. Butrans *NF* (buprenorphine) 10 mcg/hour Transdermal QWEEKLY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Diltiazem Extended-Release 180 mg PO DAILY
please hold for SBP < 90
3. Docusate Sodium 100 mg PO BID
please hold for loose stools
4. Duloxetine 60 mg PO DAILY
5. Furosemide 40 mg PO DAILY
please hold for SBP < 90
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
please hold for sedation, rr<10
7. Metoprolol Tartrate 50 mg PO BID
please hold for SBP < 90, hr <60
8. Pantoprazole 40 mg PO Q24H
9. Rosuvastatin Calcium 5 mg PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. traZODONE 50 mg PO HS:PRN sleep
12. Flecainide Acetate 100 mg PO Q12H
13. Gabapentin 400 mg PO TID
14. Ropinirole 0.5 mg PO TID
15. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN pain
16. Estrogens Conjugated 0.3 mg PO DAILY
17. Aspirin 81 mg PO DAILY
18. Butrans *NF* (buprenorphine) 10 mcg/hour TRANSDERMAL QWEEKLY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: fall
left toe fracture
Secondary: chronic pain
carotid artery stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Recurrent falls, toe pain.
No prior examinations for comparison.
LEFT TOES, AP, OBLIQUE, AND LATERAL: The bones are diffusely demineralized.
There is some irregularity and spurring at the medial aspect of the second PIP
joint, involving the second proximal phalangeal head and middle phalangeal
base. This may represent small fractures (or capsular avulsion) if there is
focal pain at this location. Mild degenerative changes of the first IP and
second through fifth DIP joints. There is soft tissue swelling of the
forefoot.
Radiology Report
INDICATION: Fever.
COMPARISON: Chest radiograph from ___ and CT chest from ___.
CHEST, PA AND LATERAL: Peripheral fibrosis and mild architectural distortion
in the right lower lobe. No focal consolidation. Pulmonary edema has
resolved. Bilateral pleural thickening. Right atrial and ventricular
pacemaker leads, the latter coursing in the mid RV. Median sternotomy wires
and mediastinal clips. Moderate-to-severe cardiomegaly is unchanged. Aorta
is tortuous and unfolded.
Multilevel degenerative changes in the thoracic spine. Interval fracture of
the right humeral surgical neck, with an overriding fracture fragment. This
appears subacute, with partially corticated margins.
IMPRESSION:
1. Right lower lobe fibrosis.
2. Moderate cardiomegaly.
3. Interval right humeral neck fracture.
Radiology Report
HISTORY: Drop attack, question impingement.
CERVICAL SPINE, FOUR VIEWS INCLUDING FLEXION-EXTENSION.
On the neutral lateral view, C1 through lower portion of C7 is demonstrated.
Lordosis is preserved. No prevertebral soft tissue swelling is seen.
Vertebral body heights are preserved. There are moderate to moderately severe
multilevel degenerative changes, with disc space narrowing and marginal
osteophytes most pronounced from C5-7. No spondylolisthesis is detected.
There is multilevel uncovertebral joint spurring in the mid and lower cervical
spine.
On flexion-extension views, there is mild-to-moderate range of motion in
flexion and good range of motion in extension. In flexion, there is trace
(cortical width) anterolisthesis of C3/4, which reduces in extension. No
other evidence of instability is detected.
On the AP view, there is dense carotid artery calcification bilaterally.
There is also suggestion of increased density at the right lung apex, not
fully evaluated, but compatible with the appearance on a chest CT dated
___. (Please see CXR report from same day.) Portions of presumed
pacemaker, sternotomy wires and clips are noted.
IMPRESSION:
1) Multilevel degenerative changes, including slight change in alignment at
C3/4 between flexion and extension.
2) Dense bilateral carotid artery calcification.
Radiology Report
HISTORY: Symptoms suggesting a transient ischemic attack.
TECHNIQUE:
COMPARISON:
PROCEDURE:
FINDINGS:
Are there are no prior studies for comparison. Duplex and color Doppler of
both carotid systems was performed. There is moderate plaque involving the
right internal carotid artery and marked calcific plaque involving the left
internal carotid artery. The peak systolic velocities on the right are 542,
340, 147, 68 and 141 centimeters/second for the proximal mid and distal ICA,
CCA and ECA respectively. Similar values on the left heart border and 49,
164, 120, 133 and 264 centimeters/second.
There is to and fro flow involving the right vertebral artery, there is normal
antegrade flow involving the left vertebral artery.
IMPRESSION:
1. Marked left -sided calcific plaque with associated ___ percent ICA
stenosis.
2. Similar plaque involving the right internal carotid artery but to a
slightly lesser extent, this is associated with a ___ percent ICA stenosis.
3. Right-sided subclavian steal.
NOTIFICATION:
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEFT LEG WEAKNESS
Diagnosed with BACKACHE NOS, HYPERTENSION NOS
temperature: 98.8
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 125.0
dbp: 63.0
level of pain: 9
level of acuity: 2.0 | ___ year old female with history significant for CAD s/p 4 vessel
CABG in ___ ___s PPM, bicuspid valve replacement
(___), COPD on 3L oxygen at home, chronic back pain, and
fibromyalgia who presents as a transfer from ___ for c/o
increasing falls and back pain.
# Falls: Neuro was consulted in the ___ for evaluation of
patient's difficulty walking and determined that patient did not
have any acute neurological injury or signs of spinal cord
compromise. Of note, CT head and CT spine at outside ___ were
negative for an acute process. More history gathering revealed
patient fell on day of presentation after taking a "new
medication." She believes this medication was flecainide but
collateral information from her husband revealed that she has
been on flecainide for several months now as per her
cardiologist. Patient was noted to be on multiple sedating
medications which were possibly contributing to her tendency to
fall. Gabapentin, flecainide, and ropinirole were held on
admission. Arrhythmia was also in the differential given
patient's cardiac history. Her pacemaker was interrogated by EP
and found to be functioning normally, without any recent
significant events. Physical therapy was consulted and
recommended that the patient walk with a walker. Bilateral
carotid ultrasounds were done which showed significant (80-95%
stenosis) stenosis of the right carotid in addition to moderate
(70%) stenosis of the left carotid with evidence of subclavian
steal on the left. Patient related that she was aware of this
results from a prior study and had been referred to a physician
in the past for evaluation. She said she would like a second
opinion on possible interventions and so is being referred to a
vascular surgeon at ___ upon discharge. Patient is being
discharged with a walker and advice to limit the amount of
sedating medications she takes, including gabapentin, trazadone,
dilaudid, ativan, as well as ropinirole. She will have close
follow-up with her cardiologist to address her antiarrythmics
and the use of flecainide.
# Left toe fracture: foot X-rays in the ___ revealed a fracture
of the second left toe. Toes were buddy-taped and physical
therapy evaluated the patient. Recommendation for a walker was
made and patient was ambulating with assistance of a walker at
time of discharge.
# Thrombocytopenia: patient noted to be thrombocytopenic on
admission, of unclear etiology. Patient denied liver disease
and LFTs were unremarkable. Platelets were trending up toward
normal range on day of discharge. Possibly related to the use
of flecainide.
# Back pain: patient with chronic back pain attributed to
cervical and lumbar spondylosis. Patient also with chronic
lumbar radiculopathy. There was no significant neurological
abnormalities on exam to suggest an acute process. Extension
and flexion plain films of the c-spine did not reveal any
significant stenosis. Of note, patient recently started Butrans
to attempt to wean herself off dilaudid. Patient's pain was
controlled on her home pain regimen of Butrans plus dilaudid 2
mg BID PRN. Pain remained stable and patient did not receive
any additional narcotics upon discharge.
# CAD s/p CABG and pacer: Patient reported recently starting
flecainide on admission but husband said she has been on it for
several months. Flecainide was held on admission due to concern
for possible side effect re: arrhythmia and thrombocytopenia.
Diltiazem ER 180 was continued as well as metoprolol, asprin,
and crestor.
CHRONIC ISSUES
# CHF: continued lasix 40 mg daily.
# COPD: patient remained at baseline respiratory status (on 3L
oxygen at home), continued her home meds.
# Depression/anxiety: patient with complicated psychiatric
history, on multiple psychoactive medications that were thought
possibly contributing to unsteadiness on her feet. Cymbalta was
continued in addition to ativan PRN. Gabapentin and ropinirole
were held, as above.
# GERD: continued pantoprazole 40 mg daily
TRANSITIONAL ISSUES
Patient has close follow-up with vascular surgery to further
address bilateral carotid artery stenosis with evidence of
subclavian steal syndrome. She was also instructed to follow-up
with her PCP for continued titration of her pain regimen.
We recommend that patient discontinue her premarin as well as
gabapentin. Flecainide could also be contributing to her
symptoms. Thrombocytopenia needs further work-up to determine
etiology, it is possibly secondary to flecainide treatment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of pancreatitis (___),
choledocholithiasis and cirrhosis ___ autoimmune hepatitis c/b
hepatic encephalopathy, ascites, s/p TIPS recently (___), also
hx of grade I varices per EGD ___, on transplant list
presenting with abd pain, worsening jaundice and worsening
hyperbilirubinemia. Patient endorses nausea and vomiting and
abdominal pain for one day. It is in the RUQ and woke her up
from sleep this AM. Also with nausea and vomitting over the past
___ days. She endorses a poor appetite. Has had some blood in
stool which she attributes to straining without melena.
Otherwise moving her bowels normally. No CP, no SOB, no urinary
problems.
___ was transferred from ___ with Tbili 22.7 (from 8),
Dbili 16.2, Na 122 from 128 BUN 28 Cr 1.1. WBC 11 Plts 70. ALT
377 AST 238
Initial ED vitals were T: 97.8 HR: 70 BP:97/44 RR: 18 99% RA.
Exam was notable for scleral jaundice, abdominal TTp over RLQ,
and heme + brown stool. UA was notable for large bili, otherwise
negative, with lactate 1.7, K+ 5.9, Na 122, with ALT 380 AST 269
Tbili 23.9, lipase wnl at 51, HCT 35.3, INR 1.6. She recieved
ceftriaxone, morphine and zofran. Abdominal US did not visualize
pocket amenable to diagnostic paracentesis with no acute hepatic
findings. Liver was consulted, recommened holding diuretics,
checking cultures and admission to liver for observation.
She was recently admitted ___ to ___ for increasing
abdominal distention felt to be secondary to progression of
liver disease with 6.2 L fluid removed in total by paracentesis
and TIPS performed by ___. There was concern that the liver
capsule may have been punctured during the procedure and she
recieved FFP.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, dysuria, hematuria.
Past Medical History:
Past Medical History: (from chart, reviewed)
1. cirrhosis ___ autoimmune hepatitis
- c/b portal hypertension with ascites
- recently placed on transplant list
- previous hx of grade III varices requiring banding on ___.
Grade I varices on ___ EGD
- h/o encephalopathy
- h/o ascites
2. hx of reactive PPD and prior high risk exposure active MTB:
PPD in past and prior high risk exposure to coworker treated
with only 1 month of INH. Unclear whether ever recieved full
course of treatment for latent TB.
3. choledocholithiasis
4. pancreatitis ___
Social History:
___
Family History:
DM in the family
Physical Exam:
ADMISSION
VS: 98 95/52 76 18 100%ra
GENERAL: Ill appearing female, mild distress from abd pain
HEENT: NC/AT, PERRLA, EOMI, sclerae icteric, dry MM
NECK: supple
LUNGS: Left basilar crackles
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, RUQ tenderness. No ascites
appreciated
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox 2.5 (wrong date in ___, CNs II-XII
grossly intact, moving all extremities. Mild asterixis
DISCHARGE
VS: 97.3 114/73 64 20 100% RA
GENERAL: elderly female, no acute distress
EYES: EOMI, sclerae icteric
ENT: oropharynx clear
NECK: No JVD, no ___
LUNGS: decreased sounds at bases
HEART: Regular, systolic murmur at LUSB, non-radiating
ABDOMEN: Obese, nontender. No ascites appreciated
EXTREMITIES: warm, no edema, 2+ pulses radial and dp
NEURO: alert, CNs II-XII grossly intact, moving all extremities.
Mild asterixis
Pertinent Results:
ADMISSION
___ 09:45PM WBC-9.2# RBC-3.06* HGB-12.2 HCT-35.3*
MCV-115* MCH-40.0* MCHC-34.7 RDW-19.2*
___ 09:45PM NEUTS-83.7* LYMPHS-9.7* MONOS-5.0 EOS-1.4
BASOS-0.2
___ 09:45PM ___ PTT-36.4 ___
___ 09:45PM PLT COUNT-80*#
___ 09:45PM ALBUMIN-3.4*
___ 09:45PM LIPASE-51
___ 09:45PM ALT(SGPT)-380* AST(SGOT)-269* ALK PHOS-242*
TOT BILI-23.9* DIR BILI-14.2* INDIR BIL-9.7
___ 09:45PM GLUCOSE-121* UREA N-29* CREAT-0.8 SODIUM-122*
POTASSIUM-5.9* CHLORIDE-89* TOTAL CO2-22 ANION GAP-17
___ 09:58PM LACTATE-1.7
___ 11:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-4* PH-6.5 LEUK-NEG
___ 11:35PM URINE COLOR-Brown APPEAR-Clear SP ___
DISCHARGE
___:20AM BLOOD WBC-2.7* RBC-2.55* Hgb-9.7* Hct-27.6*
MCV-108* MCH-38.0* MCHC-35.2* RDW-25.2* Plt Ct-32*
___ 07:20AM BLOOD Plt Ct-32*
___ 07:20AM BLOOD Glucose-122* UreaN-15 Creat-0.6 Na-126*
K-5.9* Cl-100 HCO3-19* AnGap-13
___ 07:20AM BLOOD ALT-87* AST-78* AlkPhos-131*
TotBili-26.3*
___ 07:20AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.6* Mg-2.1
LIVER ULTRASOUND ___:
1. Cirrhosis with trace perihepatic ascites.
2. Status post TIPS with wall to wall flow, with velocities
described above, which are similar to the prior exam.
3. Cholelithiasis without evidence for cholecystitis. No
reported sonographic ___ sign.
CT ABD & PELVIS W CONTRAST ___:
1. Patient status post TIPS procedure with 3.5 x 6.7 x 4.7 cm
heterogeneously hypodense, nonenhancing region near the TIPS
shunt. This likely represents a combination of some venous
thrombosis, small bilomas and expected post-TIPS changes.
2. Occlusion of the accessory hepatic vein distal to the TIPS
shunt due to use of a covered stent.
3. Nonocclusive left portal vein thrombus and tiny nonocclusive
thrombus near the portal splenic confluence.
4. No abnormality to correlate with history of rectal bleeding.
No evidence of active contrast extravasation in the
gastrointestinal tract.
5. Sequelae of portal hypertension including splenomegaly and
ascites. Ascites is improved from comparison exam.
6. Mosaic attenuation of the lung bases likely due to small
airways or small vessel disease.
EGD ___: Varices at the upper third of the esophagus
suggestive of "downhill" varices. Erythema with exudate in the
distal esophagus compatible with mild esophagitis. Otherwise
normal EGD to ___ part of the duodenum
COLONOSCOPY ___: Normal colonoscopy to the cecum. Sub-optimal
prep.
CULTURES:
___ CULTURE: no growth
___ CULTURE: pending
___ CULTURE: no growth
___ SWAB: negative
___ CULTURE: no growth
___ CULTURE: no growth
Radiology Report
HISTORY: Autoimmune hepatitis and cirrhosis on transplant list, status post
TIPS procedure. Question acute bleed for hemobilia.
TECHNIQUE: Noncontrast, arterial, portal venous and delayed phase sequences
for sorry series were performed through the abdomen following uneventful
administration of 150 cc Omnipaque IV contrast. Coronal and sagittal
reformats were provided by technologist.
DLP: ___ mGy-cm.
COMPARISON: Multiphasic CT of the liver, ___, TIPS procedure ___, MRI abdomen ___.
FINDINGS:
The lung bases demonstrate heterogeneous density with mild bilateral
atelectasis. No suspicious nodule or mass is seen. Heart size is mildly
enlarged. Normal appearance of the gastroesophageal junction.
The liver demonstrates a nodular, cirrhotic appearance. There is a small to
moderate amount of ascites. The patient is status post TIPS procedure. In
the right hepatic dome there are new areas of heterogeneous for hypodensity
which do not enhance in the region of the TIPS measuring approximately 3.5 x
6.7 x 4.7 cm. There is also new thrombus in the accessory right hepatic vein,
which supplied the systemic side of the TIPS shunt. The TIPS shunt appears
patent. There is also nonocclusive thrombus in the left portal vein, which is
limited to an area within the fissure of the ligament has falciform ligament
and likely due to altered flow dynamics status post TIPS. The hepatic veins
are diminutive in size, likely due to portal systemic shunting. The main
portal vein demonstrates a tiny, nonocclusive thrombus near the portal splenic
confluence. No arterially enhancing liver lesions are identified.
The gallbladder demonstrates gallstones without evidence of acute
cholecystitis. Normal appearance of the pancreas. The spleen remains
enlarged measuring 16.6 cm. Normal appearance of the adrenals and kidneys.
Small and large bowel are unobstructed. No significant rectal varices or
evidence of active contrast extravasation in the GI tract is seen.
Atherosclerotic aortic calcifications are noted without evidence of aneurysm
or dissection.
Degenerative changes of the lumbar spine are noted without acute or suspicious
osseous abnormality.
IMPRESSION:
1. Patient status post TIPS procedure with 3.5 x 6.7 x 4.7 cm heterogeneously
hypodense, nonenhancing region near the TIPS shunt. This likely represents a
combination of some venous thrombosis, small bilomas and expected post-TIPS
changes.
2. Occlusion of the accessory hepatic vein distal to the TIPS shunt due to use
of a covered stent.
3. Nonocclusive left portal vein thrombus and tiny nonocclusive thrombus near
the portal splenic confluence.
4. No abnormality to correlate with history of rectal bleeding. No evidence
of active contrast extravasation in the gastrointestinal tract.
5. Sequelae of portal hypertension including splenomegaly and ascites.
Ascites is improved from comparison exam.
6. Mosaic attenuation of the lung bases likely due to small airways or small
vessel disease.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: LIVER- TRANSFER
Diagnosed with OTH SEQUELA, CHR LIV DIS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.8
heartrate: 70.0
resprate: 18.0
o2sat: 99.0
sbp: 97.0
dbp: 44.0
level of pain: 4
level of acuity: 2.0 | ___ h/o autoimmune hepatitis listed for transplant, hepatic
encephalopathy, ascites, s/p TIPS (___), grade I varices (EGD
___, pancreatitis (___), choledocholithiasis p/w nausea /
vomiting, RUQ abd pain, bloody stool, and hyperbilirubinemia.
# RUQ abdominal pain: She presented with RUQ abdominal pain
radiating to the right chest, which resolved on its own without
intervention. This was likely injury to liver parenchyma related
to her TIPs procedure. CT abdomen showed a 3x7x5cm non-enhancing
lesion surrounding TIPS (biloma vs venous thrombosis). She
refused a paracentesis during this admission, and did not have
evidence of SBP. There was no evidence for cholecystitis on US
and CT. Her Tbili was elevated on admission, however remained
stable. MELD 24. She had EGD ___ without observed bleeding from
common bile duct, and a colonoscopy ___ without evidence of
bleeding. She was treated with a short course of ceftriaxone
(___), albumin infusions, lactulose and rifaximin, and close
monitoring. She did not require surgical or endoscopic
intervention for her abdominal pain, and at the time of
discharge was much improved.
# Autoimmune hepatitis/Cirrhosis: c/b HE, ascites, grade I
varices (per EGD ___. Transplant list. Baseline MELD 24 on
admission from 16 at baseline. Tbili on admission 23 (baseline
8.5). Has been off nadolol due to hx dizziness. She was
continued on azathioprine 100mg daily, lactulose and rifaximin.
Her nadolol was held in the setting of hypotension. Her
prednisone was tapered (15mg at home, decreased by 2.5mg every 4
days). At the time of discharge, her LFTs were elevated but
stable, and her MELD was ___.
# Hypotension: She was found to have secondary adrenal
insufficiency given hyponatremia, hypokalemia, and that she has
been on prednisone x ___ yrs. Her AM cortisol was low (2.6), and
cortisone stimulation test showed an increase in 7.6 to 15.3
(suggesting secondary adrenal insufficiency. Endocrine was
consulted, and recommended a prednisone taper (decreased by
2.5mg every 4 days, recheck cortisol when down to 5mg).
# BRBPR / anemia: Hct ___ from baseline ___. Stool guiac
negative, however her BRBPB was likely ___ hemorrhoidal bleed.
No active bleed seen on CTA abdomen, EGD, or colonoscopy. DIC
labs significant for low fibrinogen 144 and elevated FDP ___,
although LDH 208 wnl. She received a total of 3 units pRBCs
during this admission. Her Hct at the time of discharge was
stable at 27.6.
# Hyponatremia: stable. Likely hypovolemic hyponatremia in the
setting of diuresis, dehydration, and liver disease. FeUrea 27%
on admission, suggests pre-renal. Her diuretics were held, and
she received albumin for resuscitation as needed.
CHRONIC ISSUES
# Hyperkalemia: likely secondary to secondary adrenal
insufficiency. She was treated with prednisone taper, and
kayexalate as needed.
TRANSITIONAL ISSUES
# Patient admitted with abdominal pain, hyperbilirubinemia, and
hyponatremia. Patient underwent CT scan, which showed a possible
biloma or infarction at the site of her recent TIPS. There was
no evidence of infection, and her pain resolved prior to
discharge. Diuretics discontinued. Sodium levels remained
stable. Bilirubin levels also remain elevated, but stable prior
to discharge.
# She had low SBP in the ___. Was seen by Endocrine given
concern for secondary adrenal insuffiency. Her cortisone stim
test showed secondary adrenal insufficiency (intact adrenal
glands with chronic central suppression from prednisone). She
was started on a prednisone taper (10mg on ___ to be decreased
by 2.5mg every 4 days. When she reaches 5 mg daily, she should
have her cortisol level rechecked, and if this is normal, then
her steroid taper may continue. If not, may need referral to
Endocrine as outpatient.
# She will also need close follow-up in Liver Clinic given
persistently elevated bilirubin.
# Please check her sodium and potassium, which were low and high
respectively at the time of discharge. This was likely secondary
to adrenal insufficiency. Her diuretics were held at the time of
discharge.
# She has a chronic anemia, with Hct at discharge 27.6. She
required occasional blood transfusions during this admission. CT
abdomen with contrast and colonoscopy did not find a definitive
source of bleeding
# CODE: Full
# CONTACT: Daughter ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Cardiac catheterization, stent placement
Intubation w/ mechanical ventilation
History of Present Illness:
Patient is a ___ year old smoker with a past medical history CAD
(h/o multiple stents > ___ yrs ago in ___ and ___ years ago in
___, DM and HTN who present with an acute episode of hypoxic
respiratory failure yesterday in the setting of hypertension and
tachycardia. Patient had at least two ER visits in the past few
days for epigastric pain thought to be due to constipation on
the first visit and to a hiatal hernia on the second visit. Per
daughter, epigastric pain is similar to prior presentations of
ACS requiring PCI and stenting; patient felt strongly that
source of pain was cardiac.
His OSH CXR from his ___ ER visit was unremarkable. After his
second discharge home he continued to have severe epigastric
pain and developed new and rapidly worsening shortness of
breath. EMS was called, and on arrival to the OSH ER (___) he
was hypertensive to 215/113, tachypneic to 27, tachycardic with
a heart rate of 117. Rhythmm unclear sinus vs. SVT, given
adenosine, did not convert. Labs at OSH were significant for wbc
19, creat 1.4, lactate 4, trop 0.27; kub showed no air fluid
levels. Pt saturating 79% on RA and in the 90's on bag mask
ventilation w/ crackles throughout. His respiratory status
quickly decompensated, and he was intubated. Repeat CXR showed a
new RLL infiltrate in a background of mild pulmonary edema.
(clear OSH CXR from two days prior). He was given rocephin,
levofloxacin and lasix 80mg (Uop s/p lasix administration
unknown) and he was transferred to ___.
In the ED, initial vitals were HR 92 BP 120/59 RR 21 satting 99%
(intubated on CMV assist control, FiO2% 70; PEEP:5).
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (+), Dyslipidemia (+),
Hypertension (+)
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: At ___ ___ years
ago, at ___, multiple stents placed, unknown anatomy
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
GERD
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: HR 62, BP 97/56, RR 20, satting 100% (intubated)
GENERAL: WDWN male in NAD, intubated, sedated.
HEENT: NCAT.
NECK: Supple with JVP of 14 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly, no
crackles, wheezes or rhonchi. Poor exam ___ sedation,
intubation.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
DISCHARGE PHYSICAL EXAMINATION
Pertinent Results:
ADMISSION LABS
___ 02:36AM BLOOD WBC-11.8* RBC-4.88 Hgb-14.5 Hct-45.1
MCV-93 MCH-29.8 MCHC-32.2 RDW-12.7 Plt ___
___ 04:00AM BLOOD ___ PTT-36.1 ___
___ 02:36AM BLOOD Glucose-252* UreaN-29* Creat-1.5* Na-143
K-5.5* Cl-106 HCO3-22 AnGap-21*
___ 02:36AM BLOOD ALT-30 AST-43* CK(CPK)-286 AlkPhos-73
TotBili-0.8
___ 02:36AM BLOOD Albumin-3.9 Calcium-8.3* Phos-3.2 Mg-1.9
___ 03:55AM BLOOD Type-ART Temp-37.1 PEEP-5 FiO2-70
pO2-125* pCO2-46* pH-7.38 calTCO2-28 Base XS-1 -ASSIST/CON
Intubat-INTUBATED
OTHER PERTINENT LABS
___ 02:36AM BLOOD CK-MB-34* MB Indx-11.9* proBNP-1196*
___ 02:36AM BLOOD cTropnT-0.30*
___ 08:57AM BLOOD CK-MB-79* MB Indx-14.9* cTropnT-1.19*
___ 08:04PM BLOOD CK-MB-62* cTropnT-2.78*
___ 06:31AM BLOOD CK-MB-65* MB Indx-4.9 cTropnT-2.05*
___ 02:49AM BLOOD Lactate-2.9*
___ 03:49PM BLOOD Lactate-1.1
___ 08:39PM BLOOD Lactate-1.0
ECHO ___
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is an apical left ventricular
aneurysm. There is also a posterobasal left ventricular
aneurysm. Overall left ventricular systolic function is severely
depressed (LVEF = 15 %) secondary to extensive anterior, septal,
apical, and posterobasal akinesis with focal apical dyskinesis.
The rest of the left ventricle is hypokinetic. No masses or
thrombi are seen in the left ventricle. The remaining left
ventricular segments are hypokinetic. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic valve is not well seen.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: profound left ventricular systolic dysfunction, most
likely of coronary etiology, with preserved right ventricular
contractile function
CXR ___
FINDINGS: In comparison with study of ___, there has been some
decrease in the consolidation at the right base. Continued mild
enlargement of the
cardiac silhouette with evidence of pulmonary edema. The tip of
the
endotracheal tube measures approximately 4.5 cm above the
carina. ___-Ganz catheter from the femoral region extends to
the right pulmonary artery.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donnatol 0.4 mg PO DAILY
2. Ramipril 20 mg PO DAILY
Hold for SBP<100
3. Clopidogrel 75 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. glimepiride *NF* 2 mg Oral qd
6. Furosemide 40 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. lansoprazole *NF* 15 mg Oral daily
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Medications:
1. Outpatient Lab Work
check chem-7 and INR on ___ with results to Dr.
___ at Phone: ___
Fax: ___
ICD 9 428
2. Nitroglycerin SL 0.4 mg SL PRN chest pain
RX *nitroglycerin 0.4 mg one tab sublingually every 5 minutes
for a total of 3 doses Disp #*25 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
7. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg one capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
8. Eplerenone 12.5 mg PO DAILY
RX *eplerenone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. glimepiride *NF* 2 mg ORAL QD
10. Lansoprazole *NF* 15 mg ORAL DAILY
11. Donnatol 0.4 mg PO DAILY
12. Levofloxacin 500 mg PO DAILY Duration: 3 Days
RX *levofloxacin 500 mg one tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
13. Lisinopril 10 mg PO DAILY
RX *lisinopril 20 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
14. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg one tablet(s) by mouth daily
Disp #*30 Tablet Refills:*2
15. TiCAGRELOR 90 mg PO BID
do not stop taking this medicine or skip any doses unless Dr.
___ that it is OK to do so.
RX *ticagrelor [Brilinta] 90 mg one tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
16. Warfarin 5 mg PO DAILY16
check your warfarin level on ___.
RX *warfarin 5 mg one tablet(s) by mouth dailiy Disp #*30 Tablet
Refills:*2
17. Levofloxacin 500 mg PO DAILY Duration: 3 Days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Acute systolic heart failure
Acute on chronic kidney injury
atrial tachycardia
Diabetes mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Intubated for dyspnea at outside ___, here to evaluate for
pulmonary edema and ETT position.
COMPARISON: Outside chest radiographs performed at ___ dated
___ and ___.
TECHNIQUE: Portable supine frontal radiograph of the chest.
FINDINGS:
An endotracheal tube is in place with the tip terminating just at the level of
the thoracic inlet 9 cm above the carina. An orogastric tube is seen coursing
below the diaphragm and out of view on this image. There is a focal airspace
consolidation in the right lung base on this single frontal view, which is
unchanged from ___ at which time the patient was also intubated but
new from the pre intubation study of ___. Mild pulmonary vascular
congestion and edema is improved from ___. No significant pleural
effusion or pneumothorax is detected. The cardiac silhouette is enlarged but
stable. The mediastinal contours are within normal limits. The trachea is
midline.
IMPRESSION:
1. Right basilar consolidation new from pre intubation chest radiograph of ___ raises the possibility of aspiration. Less likely, this may
represent asymmetric flash pulmonary edema.
2. Mild pulmonary vascular congestion and edema improved from ___.
2. ET tube at thoracic inlet. NG tube below the diaphragm.
Radiology Report
HISTORY: Pulmonary edema.
FINDINGS: In comparison with study of ___, there has been some decrease in
the consolidation at the right base. Continued mild enlargement of the
cardiac silhouette with evidence of pulmonary edema. The tip of the
endotracheal tube measures approximately 4.5 cm above the carina. Swan-Ganz
catheter from the femoral region extends to the right pulmonary artery.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: INTUBATED
Diagnosed with ACUTE LUNG EDEMA NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ year old smoker with PMH significant for CAD s/p multiple
stents over a decade prior who presented w/ several days of
epigastric pain w/ negative cardiac and GI workup in OSH ED, and
who then developed chest pain and dyspnea concerning for cardiac
event.
# NSTEMI. Pt transferred from outside hospital with hypertension
to 200 and flash pulmonary edema, thought like secondary to
hypertensive urgency vs ACS. EKG showed nonspecific ST changes,
difficult to interpret, initial troponin 0.30. Patient diuresed,
TTE showed severely depressed LVEF (15%) and profound L
ventricular systolic dysfunction. Second trop 1.19, and pt sent
to cath lab. Cardiac catheterization revealed 90% stenosis of
ostial LAD, 95% stenosis of RCA (see reports for details), ___
___ to both. Pt started on ticagrelor as he had been on
plavix with significant restenosis of his prior stents. He was
diuresed with significant improvement in pulmonary function, and
weaned from the vent the day after his catheterization. He was
started on atorvastatin 80 mg, and his home beta blocker and
ACEi were restarted. Owing to akinesis of the cardiac apex by
echo and concern for thrombosis, warfarin was started with
heparin bridge. At 1 am on morning of ___ pt entered atrial
tachycardia to 140, unclear sinus tach vs. ectopic rhythm, BP
stable. Pt c/o mild CP, received nitro x 2, resolved. EKG showed
no STE or depressions, no significant change from prior; pt
spontaneously converted back to sinus at about 2 am, remained in
sinus. Pt was cleared by ___, received education regarding sodium
intake and weight monitoring, and was sent home on ___ to
follow up with his outpatient cardiologist for further
management.
#PNA. Patient had a R middle lobe consolidation on admission
concerning for a community acquired vs. aspiration pneumonia (if
the latter, possibly precipitated by intubation). Pt was
initially treated with vanc/zosyn for broad coverage, but given
pt's rapid clinical improvement antibiotics were narrowed to
levofloxacin. He was sent home with a prescription for levo to
finish out a ___. Pt admitted with creatinine of 1.5, unclear baseline. If
acute, likely ___ poor forward flow in setting of hypertensive
urgency. Cr was 1.4 on discharge, will f/u as an outpatient to
ensure return to baseline.
#DM. Pt's home PO meds were held while in house, with glucose
well controlled. He was restarted on home meds at discharge.
# Epigastric pain. Possibly anginal equivalent, also quite
possibly unrelated. GI labs unremarkable except mildly elevated
AST. Nornal lipase, normal bili. KUB at OSH unremarkable. Pt
sent home on increased dose of omeprazole, and will follow up
with his PCP for further management.
TRANSITIONAL ISSUES
-Pt will need a follow up echo in 6 weeks to reevaluate his wall
motion abnormalities. He may also be a candidate for ICD
placement if his EF does not improve.
-Pt will f/u with his PCP to ensure return to baseline renal
fxn, to manage his anticoagulation, to evaluate his abdominal
pain with possible referral to a gastroenterologist, and to
follow his other chronic medial issues. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___ / Depakote / Tegretol / Codeine / Phenobarbital
/ Penicillins
Attending: ___.
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old man who was found unresponsive with
shaking of the right extremities in the ___. The
patient was visiting his son, ___, who is currently on
the neurology service. The patient has a history of partial
complex epilepsy. He follows with Dr. ___ in epilepsy
clinic. Per OMR and my discussion with his son, his typical
seizures involve shaking of the right arm, followed by right
leg.
He is unable to speak during the seizures, but typically can
continue communicating by squeezing the left hand.
His son is unsure when his last seizure was, but reports that he
often has a few per week. He may have had a brief one a few days
ago when he was visiting his son as his son saw his right side
twich while he was sleeping. The patient has a VNS and carries
ativan in his pocket to take if the frequency increases.
His son reports that the patient has been under increased
stress,
both due to the son's hospitalization as well as a close friend
who is ill. No infectious symptoms that the son has noticed or
heard.
Attempted to call the patient's wife, but unable to reach her.
In the ED, the patient was seen to have continued right arm and
leg, low amplitude, somewhat rhythmic, but not clearly
tonic-clonic movement for 25 minutes. He received 9mg of ativan.
If his right was raised, he was able to maintain it elevated or
lowered it slowly back to the bed. The movement started to
decrease around 28 mintes and he was able to squeeze the left
hand to command reliably. At 35 minutes, he had snoring
respirations, the movement had stopped and he could show 2
fingers and squeeze the left hand to command. At 1 hour after
the
start, he continued to have snoring respirations, easily
arousable to voice/touch. Able to say his name and follow simple
commands.
At ___ the patient again had one of his typical seizures. He
had
not received evening regular AEDs.
ROS: Unable to complete given patient's current state. Per the
patient's son ___, no recent complaints.
Past Medical History:
-intractable complex partial epilepsy and likely secondary
generalized seizures since ___, s/p cortical sectioning of
epileptic area of lower sensory motor strip ___, s/p left VNS
___, with VNS replaced ___.
-chronic headaches
-sinusitis
-viral meningitis at age ___
-L4-5 disc herniation s/p left L4-5 hemilaminectomy, median
facetectomy and L4-5 diskectomy ___
-GERD
-HLD
-sleep apnea
-depression
-tonsillectomy
-s/p vasectomy
-benign hematuria, kidney stones (thought to be ___ topamax)
-hx of PE in ___, s/p ~6 months of Coumadin
Social History:
___
Family History:
Mother living, age ___ with a history of MI and uterine cancer.
Father died at age ___ of a stroke and MI
Physical Exam:
ADMISSION EXAM
Vitals: T: 98.9 P: 82 BP:140/100 RR: 22 SaO2: 98% on RA
General: Lying in bed
HEENT: NC/AT, no scleral icterus, MMM
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally.
Skin: no rashes or lesions
Neurologic:
-Mental Status: In the ED, the patient was seen to have
continued
right arm and leg, low amplitude, somewhat rhythmic, but not
clearly tonic-clonic movement for 25 minutes. He received 9mg of
ativan. If his right was raised, he was able to maintain it
elevated or lowered it slowly back to the bed. The movement
started to decrease around 28 mintes and he was able to squeeze
the left hand to command reliably. At 35 minutes, he had snoring
respirations, the movement had stopped and he could show 2
fingers and squeeze the left hand to command. At 1 hour after
the
start, he continued to have snoring respirations, easily
arousable to voice/touch. Able to say his name and follow simple
commands. At 90 minutes after start, continues with snoring
respirations, easily arousable, able to have full conversations
and stand at side of bed.
-Cranial Nerves:
Pupils 4-3mm bilaterally. Blinks to threat b/l. Corneals intact
bilaterally. OCR intact. Face symmetric.
-Motor/Sensory: During shaking activity, no withdrawal to
noxious
in extremities bilaterally; after movement stopped, localizes to
pain in all extremities. After event, equal spontaneous movement
of all extremities with good strength
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response mute on right, flexor on left.
DISCHARGE EXAM
Alert and awake, normal mental status. Full strength throughout.
Pertinent Results:
___ 11:43AM ___ 11:43AM PLT COUNT-292
___ 11:43AM ___ PTT-35.9 ___
___ 11:43AM WBC-7.5 RBC-4.66 HGB-13.0* HCT-43.2 MCV-93
MCH-27.9 MCHC-30.2* RDW-15.6*
___ 11:43AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 11:43AM ALBUMIN-4.2
___ 11:43AM LIPASE-29
___ 11:43AM ALT(SGPT)-25 AST(SGOT)-30 ALK PHOS-107 TOT
BILI-0.3
___ 11:43AM estGFR-Using this
___ 11:43AM UREA N-16 CREAT-0.9
___ 11:55AM freeCa-1.07*
___ 11:55AM HGB-13.6* calcHCT-41
___ 11:55AM GLUCOSE-107* LACTATE-1.3 NA+-143 K+-4.4
CL--104 TCO2-30
___ 11:55AM PH-7.34*
___ 03:38PM URINE MUCOUS-OCC
___ 03:38PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:38PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:38PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 03:38PM URINE GR HOLD-HOLD
___ 03:38PM URINE HOURS-RANDOM
CXR
FINDINGS: Single supine AP portable view of the chest was
obtained. A
vasovagal nerve stimulator is noted projecting over the left
upper hemithorax. The cardiac and mediastinal silhouettes are
likely accentuated by AP position and supine technique. No
focal consolidation is seen. There is no large pleural
effusion. The right costophrenic angle is not entirely imaged.
Slight prominence of the central pulmonary vasculature, most
likely relates to low lung volumes, supine position and AP
technique, although mild vascular congestion is not excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Clobazam 20 mg PO BID
3. Clobazam 10 mg PO NOON
4. Ezetimibe 10 mg PO DAILY
5. felbamate 800 oral QAM
6. felbamate 1200 oral BID
7. LACOSamide 200 mg PO BID
8. LaMOTrigine 100 mg PO BID
9. LaMOTrigine 300 mg PO QHS
10. LeVETiracetam 1000 mg PO TID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Ranitidine 300 mg PO DAILY
14. Venlafaxine XR 150 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Psyllium 1 PKT PO DAILY:PRN constipation
20. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clobazam 20 mg PO BID
4. Clobazam 10 mg PO NOON
5. Docusate Sodium 100 mg PO BID
6. felbamate 800 oral QAM
7. felbamate 1200 mg ORAL BID
8. LaMOTrigine 100 mg PO BID
9. LaMOTrigine 300 mg PO QHS
10. LeVETiracetam 1000 mg PO TID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Senna 8.6 mg PO BID:PRN constipation
14. Venlafaxine XR 150 mg PO DAILY
15. Ezetimibe 10 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Psyllium 1 PKT PO DAILY:PRN constipation
19. Ranitidine 300 mg PO DAILY
20. LACOSamide 200 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest, single supine AP portable view.
CLINICAL INFORMATION: seizures
COMPARISON: None.
FINDINGS: Single supine AP portable view of the chest was obtained. A
vasovagal nerve stimulator is noted projecting over the left upper hemithorax.
The cardiac and mediastinal silhouettes are likely accentuated by AP position
and supine technique. No focal consolidation is seen. There is no large
pleural effusion. The right costophrenic angle is not entirely imaged.
Slight prominence of the central pulmonary vasculature, most likely relates to
low lung volumes, supine position and AP technique, although mild vascular
congestion is not excluded.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SEIZURE
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ was admitted to the epilepsy service after a prolonged
focal motor seizure with questionable alteration in
consciousness. This was in the setting of his son being
hospitalized here for possible seizures, and family discord.
He was admitted to the floor with telemetry monitoring. He had
about 2 episodes per day, consisting of right arm shaking, which
was suppressible with passive movement of arm. He had bilateral
leg movements which were not synchronous with arm movements. He
had forceful eye closure, moaning, and would follow simple
commands through event. These events would last between ___
minutes at a time. For the first several events, he received IV
ativan 2mg Q5-10 minutes, sometimes requiring nasal cannula O2
following the event. For other events, he got only 0.5mg ativan
q10minutes, with no change in the length of event.
No EEG monitoring was performed, as these events were typical of
prior events which have had no EEG correlate.
His home AEDs were continued, with no change in dose.
Infectious workup including UA and CXR were negative.
For the last two days of admission, he had no events.
He was discharged home with follow up in epilepsy clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Nitrofurantoin / Cephalosporins / Reglan /
Ciprofloxacin / Percocet / codeine / baclofen
Attending: ___.
Chief Complaint:
Abdominal pain and dysuria/frequency
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Patient is a ___ with PMHx of ESRD on HD (TTS), IDDM, CAD s/p
CABG, extensive vascular disease including substantial
involvement of gastrointestinal vessels (celiac trunk and SMA),
HFpEF, prior diverticulitis, and neurogenic bladder c/b
recurrent UTIs (resistant Ecoli) including recent
hospitalization for complicated cystitis who presents to the ED
with dysuria/frequency and worsening abdominal pain.
Patient was recently discharged from ___ ___, admitted
for complicated cystitis (treated with zosyn and fosfomycin) and
abdominal pain (likely vascular insufficiency). Starting ~1wk
after discharge, patient says that she began to experience
persistent dysuria and frequency, consistent with past UTIs. No
fevers/chills. Patient also describes 'white, chalky' vaginal
discharge during this time, no vaginal bleeding. Of note, yeast
was seen on prior urine culture. She was seen in ___ clinic
___, recommended to start ppx abx for recurrent UTI, which
patient has been hesitant to initiate given fear of Cdiff
infection.
Patient additionally endorses associated lower abdominal
discomfort, acute on chronic, more pronounced in LLQ. No early
satiety or bloody stools, though patient does note that she
experiences some increased pain and urge to defecate after
eating.
In the ED, initial vital signs were: 97.2, 64, 165/51, 19 ,100%
RA
- Exam notable for: CTABL, RRR, very TTP over lower quadrants,
pelvic exam with thick white discharge
- Labs were notable for:
WBC 7.8
Hb 10.0
K 9.9 (hemolyzed), repeat 5.8
HCO3 19
BUN/Cr 79/8.2
Lactate 1.7
AST 187
ALT <5
UA: Cloudy, Lg leuk, Sm bld, Neg nitr, 300 prot, 150 glu, Tr
ketones, 0RBCs, >182WBCs
- Studies performed include
ECG 1st degree HB, LBBB, inferior/lateral T-wave inversions
CT Abd/Pelvis
1. Diffuse bladder wall thickening of the bladder is likely in
part due to underdistention. Correlate with urinalysis.
2. Cholelithiasis without evidence to suggest cholecystitis.
3. Moderate to severe diverticulosis of the sigmoid colon
without evidence of diverticulitis.
4. Mildly atrophic kidneys, unchanged. No nephro or
ureterolithiasis.
5. Diffuse and severe atherosclerotic calcifications involve the
abdominal vasculature with heavy calcifications involving the
shared origin of the celiac axis and superior mesenteric artery.
- Patient was given Meropenem 500mg IV x1, 100mL NS bolus,
Zofran 4mg z1, Morphine Sulfate 4mg IV x2
- Vitals on transfer: 97.3, 86, 154/63, 18, 99% RA
Upon arrival to the floor, the patient recounts the history as
above. She mainly complains of nausea and fatigue. Still with
diffuse lower abdominal pain, she endorses dysuria and
frequency. No fevers/chills.
10-point ROS otherwise NEGATIVE.
Past Medical History:
- ESRD - likely ___ DM and HTN, on HD (initiated ___
- Diabetes mellitus type II- last A1C 7.6% in ___
complicated by diabetic nephropathy, Gastroparesis (confirmed by
motility studies ~ ___, and neurogenic bladder (with
incomplete bladder emptying)
- Coronary artery disease s/p CABG in ___ (LIMA to LAD and SVG
to OM1 and OM2)
- HFpEF
- Moderate pulmonary hypertension
- Hypertension
- Hypercholesterolemia
- Recurrent UTI - Polymicrobial - (previously with
highly-resistent
Klebsiella and Citrobacter with sx of ascending infection, tx
with IV aztreonam)
- Hx. of abdominal pain - unclear etiology, possibly related to
constipation vs. bowel ischemia
- Hx. of diverticulitis
- Hx. of gallstones without cholecystitis
- Hx of GIB
- Hx. of lung nodules
- LBP due to herniated disk
- Depression
Social History:
___
Family History:
Patient says her mother had aortic valve replacement. Per chart:
Alcoholism, coronary artery disease, and diabetes. No history of
blood clots.
Physical Exam:
ADMISSION EXAM
==============
Vitals- 97.4, 96/67, 65, 18, 96 RA
GENERAL: AOx3, pleasant, slightly somnolent though able to
follow conversation
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular muscles intact. No conjunctival pallor or
injection, sclera anicteric and without injection. Moist mucous
membranes, good dentition. Oropharynx is clear.
NECK: No cervical/submandibular/supraclavicular lymphadenopathy.
CARDIAC: s1 s2, regular rhythm, normal rate, ___ systolic murmur
at LLSB, no rubs/gallops. No JVD.
LUNGS: Good inspiratory effort. Bibasilar crackles, scattered
wheezes.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended. Diffuse
tenderness to palpation, predominantly in LLQ, no rebound
tenderness. No organomegaly.
EXTREMITIES: WWP. 1+ radial pulses b/l. No ___.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength througout.
Normal sensation. No asterixis. No ataxia, dysmetria,
disdiadochokinesia.
DISCHARGE EXAM
==============
98.0, 148/61,61, 18, 93 RA
GENERAL: AOx3, pleasant
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular muscles intact. No conjunctival pallor or
injection, sclera anicteric and without injection. Moist mucous
membranes, good dentition. Oropharynx is clear.
NECK: No cervical/submandibular/supraclavicular lymphadenopathy.
CARDIAC: s1 s2, regular rhythm, normal rate, ___ systolic murmur
at ___, no rubs/gallops. No JVD.
LUNGS: Good inspiratory effort. Bibasilar crackles, otherwise
CTABL.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended. Mild diffuse
tenderness, no guarding, improved from yesterday. No
organomegaly.
EXTREMITIES: WWP. 1+ radial pulses b/l. No ___.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength througout.
Normal sensation. No asterixis. No ataxia, dysmetria,
disdiadochokinesia.
Pertinent Results:
ADMISSION LABS
=============
___ 10:55AM BLOOD WBC-7.8 RBC-2.94* Hgb-10.0* Hct-31.2*
MCV-106* MCH-34.0* MCHC-32.1 RDW-14.5 RDWSD-55.9* Plt ___
___ 10:55AM BLOOD Neuts-64.7 ___ Monos-11.3 Eos-2.8
Baso-0.6 Im ___ AbsNeut-5.04 AbsLymp-1.57 AbsMono-0.88*
AbsEos-0.22 AbsBaso-0.05
___ 10:55AM BLOOD Plt ___
___ 10:55AM BLOOD Glucose-219* UreaN-79* Creat-8.2* Na-136
K-9.9* Cl-99 HCO3-19* AnGap-28*
___ 10:55AM BLOOD ALT-<5 AST-187* AlkPhos-102 TotBili-0.3
___ 10:55AM BLOOD Lipase-75*
___ 10:55AM BLOOD Albumin-3.5
___ 11:01AM BLOOD Lactate-1.7 K-7.7*
___ 01:17PM BLOOD K-5.8*
___ 11:10AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 11:10AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-150 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 11:10AM URINE RBC-0 WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
___ 11:10AM URINE WBC Clm-MANY Mucous-FEW
DISCHARGE LABS
=============
___ 07:40AM BLOOD WBC-7.3 RBC-2.70* Hgb-9.0* Hct-28.6*
MCV-106* MCH-33.3* MCHC-31.5* RDW-14.1 RDWSD-53.8* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-94 UreaN-33* Creat-6.7*# Na-135
K-3.7 Cl-91* HCO3-27 AnGap-21*
___ 07:40AM BLOOD ALT-15 AST-15 LD(LDH)-167 AlkPhos-120*
TotBili-0.3
___ 07:40AM BLOOD Calcium-7.3* Phos-6.4* Mg-2.0
MICRO
=====
___ 11:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
FURTHER WORKUP REQUESTED BY ___ ON ___.
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
LACTOBACILLUS SPECIES. >100,000 CFU/mL.
OF TWO COLONIAL MORPHOLOGIES.
YEAST. 10,000-100,000 CFU/mL.
___ 7:46 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 9:46 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
STUDIES/IMAGING
==============
CT A/P ___
IMPRESSION:
1. Diffuse bladder wall thickening of the bladder may be in
part due to
underdistention. This is, however, associated with slightly
prominent left
mid ureter and periureteral stranding. Correlation with
urinalysis advised to
exclude urinary tract infection.No uretero/nephrolithiasis.
2. Cholelithiasis without evidence to suggest cholecystitis.
3. Moderate to severe diverticulosis of the sigmoid colon
without evidence of
diverticulitis.
4. Diffuse and severe atherosclerotic calcifications involve
the abdominal
vasculature with heavy calcifications involving the shared
origin of the
celiac axis and superior mesenteric artery.
CTA A/P ___
IMPRESSION:
1. Extensive atherosclerotic disease of the abdominal aorta and
its major
branches without evidence of vascular occlusion. There is heavy
calcification
at the common origin of the celiac artery and SMA without
hemodynamically
significant stenosis.
2. Mild wall thickening of the urinary bladder and increased
urothelial
enhancement of the left ureter with mild periureteric stranding,
consistent
with the patient's known UTI. There is no CT evidence of
pyelonephritis or
abscesses.
CXR ___
FINDINGS:
No focal consolidation, pleural effusion or pneumothorax is
identified. The
patient is status post prior median sternotomy and CABG. The
size of the
cardiac silhouette is enlarged but unchanged.
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Carvedilol 6.25 mg PO BID
5. Cetirizine 5 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 80 mg PO QPM
9. Senna 8.6 mg PO BID:PRN constipation
10. sevelamer CARBONATE 1600 mg PO TID W/MEALS
11. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 3X/WEEK
12. Nystop (nystatin) 100,000 unit/gram topical BID
13. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
14. Gabapentin 200 mg PO BID:PRN pain
15. Simethicone 40-80 mg PO QID:PRN indigestion
16. Glargine 24 Units Breakfast
Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS (Not started;
please clarify at discharge if you want her to start taking at
home)
Discharge Medications:
1. Glargine 24 Units Breakfast
Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Carvedilol 6.25 mg PO BID
6. Cetirizine 5 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 3X/WEEK
9. Gabapentin 200 mg PO BID:PRN pain
10. Nystop (nystatin) 100,000 unit/gram topical BID
11. Omeprazole 20 mg PO DAILY
12. Pravastatin 80 mg PO QPM
13. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
14. Senna 8.6 mg PO BID:PRN constipation
15. sevelamer CARBONATE 1600 mg PO TID W/MEALS
16. Simethicone 40-80 mg PO QID:PRN indigestion
17. HELD- Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS (Not
started; please clarify at discharge if you want her to start
taking at home) This medication was held. Do not restart
Fosfomycin Tromethamine until you speak with Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Vaginitis
Secondary Diagnosis
===================
End Stage Renal Disease on hemodialysis
Peripheral vascular disease
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: NO_PO contrast; History: ___ with lower abdomen pain, very TTP
over lower quadrants bilaterallyNO_PO contrast // Please eval for any
evidence of colitis
TECHNIQUE: Multi detector CT images through the abdomen and pelvis were
obtained in the absence of intravenous or oral contrast. Coronal and sagittal
reformations were generated and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 48.5 cm; CTDIvol = 14.9 mGy (Body) DLP = 720.6
mGy-cm.
2) Spiral Acquisition 1.0 s, 11.5 cm; CTDIvol = 10.9 mGy (Body) DLP = 125.1
mGy-cm.
3) Spiral Acquisition 1.1 s, 12.0 cm; CTDIvol = 9.8 mGy (Body) DLP = 117.4
mGy-cm.
Total DLP (Body) = 963 mGy-cm.
COMPARISON: CT abdomen and pelvis performed ___.
FINDINGS:
LOWER CHEST: Coronary artery calcifications are partially imaged, severe.
There is no pericardial effusion. Minimal atelectasis at the bases is
symmetric. There is no pleural effusion.
ABDOMEN:
HEPATOBILIARY: Evaluation is somewhat limited in the absence of intravenous
contrast. Allowing for this, the liver parenchyma appears homogeneous in
attenuation. There is no intrahepatic duct dilation. There is no focal
hepatic lesion. Stones layer within the gallbladder lumen. There is no
pericholecystic fluid or gallbladder wall.
PANCREAS: A 3 mm hypodensity within the pancreatic head (2a:23) appears to
have been present on prior examination and consistent with interdigitating
fat. The pancreas is homogeneous in attenuation without pancreatic duct
dilation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Bilateral kidneys are atrophic. There is symmetric perinephric
stranding which is not significantly change since prior study. A 4.0 x 4.1 cm
hypodensity projects from the inferior pole of the left kidney (2a:41) in
keeping with simple cyst. No stone is identified along the course of the
ureters bilaterally. There is mild stranding about a minimally prominent mid
left ureter (2a:49).
GASTROINTESTINAL: The stomach, duodenum, and loops of small bowel are grossly
normal in appearance and caliber. The appendix is visualized air filled and
normal in caliber (2a:57). Moderate to severe diverticular disease involves
the sigmoid colon without evidence to suggest acute diverticulitis.
PELVIS: The bladder is not well distended, its walls diffusely thickened,
likely related. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Fibroids are present, some of which are calcified.
LYMPH NODES: Scattered retroperitoneal nodes do not meet CT size criteria for
pathology. There is no mesenteric adenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: The abdominal aorta is normal in caliber. Extensive calcified
atherosclerotic plaque involves the abdominal vasculature and abdominal aorta.
Heavy calcifications involve the origins of the superior mesenteric and celiac
arteries which is shared.
BONES: Multilevel degenerative changes throughout the imaged thoracolumbar
spine are most pronounced at the L4-L5 and L5-S1 levels. Minimal grade 1
anterolisthesis of L5 on S1 is unchanged. There is bilateral spondlysis noted
at this level.
SOFT TISSUES: Multiple soft tissue nodules in the pannus probably reflect
injection granulomas.
IMPRESSION:
1. Diffuse bladder wall thickening of the bladder may be in part due to
underdistention. This is, however, associated with slightly prominent left
mid ureter and periureteral stranding. Correlation with urinalysis advised to
exclude urinary tract infection.No uretero/nephrolithiasis.
2. Cholelithiasis without evidence to suggest cholecystitis.
3. Moderate to severe diverticulosis of the sigmoid colon without evidence of
diverticulitis.
4. Diffuse and severe atherosclerotic calcifications involve the abdominal
vasculature with heavy calcifications involving the shared origin of the
celiac axis and superior mesenteric artery.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old woman with ESRD on HD, CAD s/p CABG, extensive
peripheral vascular disease, admitted with UTI and worsening abdominal/back
pain.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.7 s, 51.5 cm; CTDIvol = 5.4 mGy (Body) DLP = 278.4
mGy-cm.
2) Spiral Acquisition 6.3 s, 49.8 cm; CTDIvol = 22.4 mGy (Body) DLP =
1,116.3 mGy-cm.
Total DLP (Body) = 1,395 mGy-cm.
COMPARISON: Noncontrast CT from ___ and CTA from ___
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is extensive calcium burden in
the abdominal aorta and great abdominal arteries. A common origin of the
celiac trunk and SMA demonstrates significant atherosclerotic calcifications
with mild (less than 50%) stenosis. The left gastric artery arises
independently off of the aorta cranial to the SMA/celiac trunk. Significant
atherosclerotic calcifications are also noted at the origins of the renal
arteries, but the renal arteries are too small for adequate assessment. An
accessory left renal artery is noted. There is no evidence of filling
defects.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is contains stones, without
evidence of gallbladder wall thickening or pericholecystic fluid.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
pancreatic ductal dilatation. A 4 mm hypodensity is again seen within the
pancreatic head, unchanged compared to previous. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: A small myelolipoma is again seen in the left adrenal gland. The
right adrenal gland is unremarkable.
URINARY: Both kidneys are atrophic with normal nephrograms. There is no CT
evidence of pyelonephritis or renal abscesses. A 4.5 cm simple cyst is again
seen in the inferior pole of the left kidney. There is no evidence of
hydronephrosis or perinephric abnormality. There is increased left urothelial
enhancement with mild periureteric fat stranding.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is sigmoid diverticulosis without evidence
of diverticulitis. The appendix is unremarkable. There is no evidence of
mesenteric lymphadenopathy.
RETROPERITONEUM: A 1.1 x 1.7 cm left para-aortic lymph node (3:72) is not
significantly changed compared to previous.
PELVIS: The bladder wall is mildly thickened with increased urothelial
enhancement. There is no evidence of pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Calcified fibroids are seen within the uterus.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is anterolisthesis of L5 on S1 secondary to bilateral pars defects.
SOFT TISSUES: Multiple subcutaneous nodules are again seen in the anterior
abdominal wall, likely representing injection granulomas.
IMPRESSION:
1. Extensive atherosclerotic disease of the abdominal aorta and its major
branches without evidence of vascular occlusion. There is heavy calcification
at the common origin of the celiac artery and SMA without hemodynamically
significant stenosis.
2. Mild wall thickening of the urinary bladder and increased urothelial
enhancement of the left ureter with mild periureteric stranding, consistent
with the patient's known UTI. There is no CT evidence of pyelonephritis or
abscesses.
Radiology Report
INDICATION: ___ year old woman with ESRD on HD, CAD s/p CABG, PVD, here with
abdominal pain, UTI. // pre-op clearance
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
No focal consolidation, pleural effusion or pneumothorax is identified. The
patient is status post prior median sternotomy and CABG. The size of the
cardiac silhouette is enlarged but unchanged.
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 97.2
heartrate: 64.0
resprate: 19.0
o2sat: 100.0
sbp: 165.0
dbp: 51.0
level of pain: 10
level of acuity: 3.0 | Patient is a ___ with PMHx of ESRD on HD (TTS), IDDM, CAD s/p
CABG, extensive vascular disease including substantial
involvement of gastrointestinal vessels (celiac trunk and SMA),
HFpEF, prior diverticulitis, and neurogenic bladder c/b
recurrent UTIs (resistant Ecoli) including recent
hospitalization for complicated cystitis who presentws to the ED
with dysuria/frequency/'chalky white' vaginal discharge and
worsening acute on chronic abdominal pain.
# Dysuria/Frequency - Patient with history of recurrent UTIs,
most recently had grown only yeast, but with history of
resistant E coli and VRE (symptoms also improved with
antibiotics during prior admission). She complained of both
dysuria and frequency, was noted to have 'chalky white' vaginal
discharge on pelvic exam in ED. UA with pyuria, negative
nitrites, no yeast. She has risk factors for both UTI and yeast
infections, including neurogenic bladder and T2DM. Recurrent abx
use also places her at higher risk of ___ vaginitis.
Initially she was started on Meropenem in ED, then given
Zosyn/Linezolid based on sensitivities from past admissions. Ucx
grew urogenital flora, unlikely pathogens for true cystits,
symptoms all felt to be explained by candidal vaginitis. Abx
were thus d/c'd ___. Patient received Fluconazole 200mg x2 for
vaginitis, urinary symptoms subsequently resolved. Of note,
Estrace (home med) was not continued during admission (not on
formulary).
# Diffuse Abdominal Pain, worst in LLQ - Most likely
multifactorial, patient has well described pattern of recurrent
abdominal pain which seems to be worsened in setting of UTIs.
Given her severe vascular disease, there is certainly some
aspect of vascular insufficiency causing mild bowel ischemia. Ct
abd/pelvis in ED did not show any acute process, though 'diffuse
and severe atherosclerotic calcifications involve the abdominal
vasculature with heavy calcifications involving the shared
origin of the celiac axis and superior mesenteric artery,'
non-flow limiting. Decreased PO intake prior to admission,
together with infection as above possibly made her relatively
intravascularly depleted, exacerbating low-flow abdominal
vasculature state. Lactate normal. Vascular was consulted ___,
no acute indication for any intervention (CTA showed known
extensive atherosclerotic disease, no occlusions). As per
vascular, no indication for pharmacologic management for
possible mesenteric vascular disease (e.g. cilostazol). Absence
of weight loss strongly argues against chronic mesenteric
ischemia. Pain may be musculoskeletal in nature, does have
bilateral OA on imaging. Patient received APAP and tramadol for
pain, discharged with APAP. Of note, she was given morphine in
ED, which caused significant somnolence.
# Hyperkalmeia - In setting of renal disease, likely worsened by
mild dehydration in setting of likely UTI as above. Whole blood
K 6.1 on admission (previous labs were hemolyzed), gave
insulin/dextrose/CaGluconate ___. K normalized with patient's
routine HD, 3.7 on day of discharge.
# Somnolence - Most likely s/p Morphine (4mg IV x2) received in
ED, toxicity in setting of renal disease. Mental status
improved, at baseline throughout rest of admission.
# Type 2 Diabetes Mellitus - Patient was given 18U Lantus BID
while admitted, had been taking 24U BID at home. Given that
sugars were largely 100-180, while receiving ~40U qd insulin in
total, she should continue at this reduced regimen with ISS,
uptitration as needed once discharged.
-------------------
CHRONIC ISSUES:
-------------------
# ESRD on HD - Dialysis ___
- Continued Sevelamer
# Anemia - Most likely in setting of CKD. At baseline.
# HFpEF (EF 55%) - No evidence of volume overload on exam.
- Preload management with HD
- Continued carvedilol 6.25 mg BID
# CAD - s/p CABG in ___ (LIMA to LAD and SVG to OM1 and
OM2)
- Continued ASA 81 mg and pravastatin 80 mg daily
# HTN - Patient by report with labile blood pressures in the
past, often in setting of volume shifts with HD.
- Continued home carvedilol 6.25 mg BID with holding parameters
- HydrALAZINE 20 mg PO/NG Q6H:PRN SBP>180 (received x1)
# GERD
- Continued omeprazole 20 mg daily
TRANSITIONAL ISSUES
===================
- UA without yeast, UCx did not grow ___ consider
treating patient for full course of fluconazole for candidal UTI
if symptoms recur
- Patient became quite somnolent after receiving Morphine in the
ED, she should not have this medication in the future given
severe renal disease
- Blood pressures were labile throughout admission, difficulty
getting accurate readings in setting of peripheral vascular
disease, systolics 100-180, had hydralazine prn SBP>180 written
(received only once)
- Patient had been prescribed Fosfomycin for UTI ppx as
outpatient, she never filled prescription
=================================================
# Emergency contact: ___ (___)
#Code Status: Full (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Penicillins / morphine / Erythromycin Base /
aspirin / IV Dye, Iodine Containing Contrast Media / Reglan
Attending: ___
Chief Complaint:
Impending DKA, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with a past medical history
significant for ___ syndrome (albinism, platelet
storage disorder), uncontrolled IDDM s/p pancreatectomy, islet
cell transplant (___), asthma, severe gastroparesis, bezoars
and multiple abdominal surgeries presenting with ___ weeks of
hyperglycemia ___ 300-400), polyuria, poldipsia, abdominal pain,
nausea and vomiting. She has unintentionally lost 15 lbs in the
past several weeks. The patient states that her hyperglycemia
has been worsening for the past couple years. Over the past few
months though, it seems to have been very
uncontrolled. Her most recent fingsticks have been in the
300-400 range; and as high as 600. During this time she has
experienced intermittent diarrhea. She has been using 15 units
of insulin glargine daily, and a Humalog sliding scale without
success. She was sent in from ___ for impending DKA. She was
found to have large ketones on UA and 456 BSG. She denies
fevers, chills, chest pain, shortness of breath, or cough. She
does have abdominal pain but this is somewhat chronic in nature.
Her abdominal pain is mostly epigastric, intermittently severe
and non-radiating. The pain feels like a distension or pressure.
She attributes her abdominal pain to gastroparesis, but
unfortunately has not tolerated erythromycin or metoclopramide.
She has no known history of heart failure.
In the ED, initial VS were: 98.6 90 123/74 16 100%. The
following interventions/therapies were performed: 3L normal
saline, 2 mg IV Zofran and 5 units regular insulin.
On arrival to the floor, the patient complains of chronic
abdominal pain and the inability to control her blood sugar.
Past Medical History:
___ Syndrome with associated blindness
IDDM uncontrolled s/p pancreatectomy
Asthma
Gastroparesis
Bezoars
Numerous abdominal surgeries
Depression
Anxiety
Seasonal allergies
Constipation
Eczema
Lactase insufficiency
Irritable bowel syndrome
PSH:
Appendectomy
Cholecystectomy
___ fundoplication
Islet cell transplant
Hernia repairs
Hysterectomy
Oopherectomy
Jaw surgery for DMJ
Splenectomy
Pancreatectomy (for pancreatic divisum)
Celiac plexus neurolysis
Social History:
___
Family History:
Sister with ___ syndrome. Multiple family members
with T2DM and thyroid disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.1 122/80 80 18 99/RA
GEN: Well-appearing, resting in bed.
HEENT: NCAT, MMM
NECK: Supple.
COR: +S1S2, RRR, no m/g/r.
PULM: CTAB, no c/w/r
___: +NABS in 4Q, soft, mild epigastric tenderness to
palpation, ND
EXT: WWP, no c/c/e.
NEURO: MAEE
DISCHARGE PHYSICAL EXAM:
97.9 127/69 75 18 97% RA ___ 78-150s
GEN: Awake/alert Ox3. Albino. Well-appearing, resting in bed. No
rhythmic movements.
HEENT: PERRL, EOMI, NCAT, MMM
NECK: Supple, no lymphadenopathy
COR: +S1S2, RRR, no m/g/r.
PULM: CTAB, no c/w/r
___: +NABS in 4Q, soft, moderate epigastric/right sided
tenderness, ND, surgical scars noted
EXT: WWP, no c/c/e.
NEURO: CN II-XII grossly intact, ___ upper extremity and lower
extremity strength bilaterally, cerebellar exam within normal
limits, symmetric DTRs
Pertinent Results:
ADMISSION LABS:
___ 04:45PM BLOOD WBC-9.3 RBC-4.02*# Hgb-11.8* Hct-38.0
MCV-95# MCH-29.4# MCHC-31.1 RDW-16.1* Plt ___
___ 04:45PM BLOOD Neuts-50 Bands-0 Lymphs-43* Monos-6 Eos-1
Baso-0 ___ Myelos-0
___ 04:45PM BLOOD Glucose-370* UreaN-14 Creat-0.8 Na-133
K-4.1 Cl-95* HCO3-18* AnGap-24*
___ 04:45PM BLOOD Calcium-9.2 Phos-4.2 Mg-1.5*
___ 06:43AM BLOOD %HbA1c-14.7* eAG-375*
___ 05:00PM BLOOD Glucose-356* Lactate-1.2 Na-134 K-3.7
Cl-102 calHCO3-17*
___ 01:52AM BLOOD ALT-67* AST-36 AlkPhos-78 TotBili-0.2
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-8.0 RBC-3.65* Hgb-11.0* Hct-34.8*
MCV-96 MCH-30.1 MCHC-31.6 RDW-16.7* Plt ___
___ 06:30AM BLOOD Glucose-52* UreaN-13 Creat-0.5 Na-139
K-4.4 Cl-103 HCO3-32 AnGap-8
___ 06:30AM BLOOD Calcium-9.0 Phos-4.6* Mg-1.7
CXR
___
FINDINGS:
The cardiac, mediastinal and hilar contours are normal. Lungs
are clear and the pulmonary vascularity is normal. No pleural
effusion or pneumothorax is present. Multiple clips in the
right upper quadrant of the abdomen indicate prior
cholecystectomy. There are no acute osseous abnormalities.
IMPRESSION: No acute cardiopulmonary process.
XR ABD
___
IMPRESSION: Upright and supine views of the abdomen show
stomach distended with food and colon distended with stool, and
no appreciable small bowel dilatation. There is no free
intraperitoneal gas and no evidence of ascites. Vascular clips
denote prior right upper quadrant and paramedian surgery.
Radiopaque pills are present in either the small bowel or a very
distended stomach.
CT HEAD
___
FINDINGS: There is no hemorrhage, edema, mass, mass effect, or
evidence of infarction. The ventricles and sulci are normal in
size and configuration. The basal cisterns are patent and
gray-white matter differentiation is preserved. The calvaria
are unremarkable. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. IMPRESSION: No acute
intracranial abnormality.
NOTE ADDED IN ATTENDING REVIEW: There is moderate mucosal
thickening with likely mucus-retention cyst formation involving
the limited included superior portion of the maxillary sinuses,
as well as scattered anterior and posterior ethmoidal air cells,
bilaterally. There may have been prior partial ethmoidectomy and
uncinectomy, incompletely demonstrated. The frontal and sphenoid
air cells are clear. These findings should be correlated with
detailed history.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheezing
2. Creon 12 3 CAP PO TID W/MEALS
3. Doxepin HCl 100 mg PO HS
4. Escitalopram Oxalate 30 mg PO DAILY
5. Estrogens Conjugated 0.625 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 100 mg PO TID
8. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Lorazepam 0.5 mg PO TID PRN anxiety
10. omeprazole *NF* 10 mg Oral QD
11. Bisacodyl ___AILY
12. Lubiprostone 24 mcg PO BID
13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 2 TAB PO BID
Discharge Medications:
1. Bisacodyl ___AILY
RX *bisacodyl 10 mg 1 Suppository(s) rectally daily Disp #*30
Suppository Refills:*0
2. Creon 12 3 CAP PO TID W/MEALS
3. Docusate Sodium 100 mg PO BID
4. Doxepin HCl 100 mg PO HS
5. Escitalopram Oxalate 30 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Gabapentin 200 mg PO Q8H
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*0
8. Lubiprostone 24 mcg PO BID
RX *lubiprostone [___] 24 mcg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheezing
10. Estrogens Conjugated 0.625 mg PO DAILY
11. Lorazepam 0.5 mg PO TID PRN anxiety
12. Omeprazole *NF* 10 mg ORAL QD
13. Glargine 14 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
Q6H:PRN Disp #*20 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 2 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
diabetic ketoacidosis
Secomdary diagnoses:
DM type I uncontrolled with complications
Gastroparesis
Constipation
___ Syndrome
pseudoseizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Diabetic ketoacidosis.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
The cardiac, mediastinal and hilar contours are normal. Lungs are clear and
the pulmonary vascularity is normal. No pleural effusion or pneumothorax is
present. Multiple clips in the right upper quadrant of the abdomen indicate
prior cholecystectomy. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
ABDOMEN, 3:42 P.M., ___
HISTORY: ___ woman with abdominal pain after multiple abdominal
surgeries.
IMPRESSION: Upright and supine views of the abdomen show stomach distended
with food and colon distended with stool, and no appreciable small bowel
dilatation. There is no free intraperitoneal gas and no evidence of ascites.
Vascular clips denote prior right upper quadrant and paramedian surgery.
Radiopaque pills are present in either the small bowel or a very distended
stomach.
Radiology Report
INDICATION: New onset seizure. Evaluation for intracranial hemorrhage.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, thin-section bone reconstruction algorithm
images were acquired. Repeat images were acquired from the skull base due to
beam hardening artifact.
COMPARISON: None.
FINDINGS: There is no hemorrhage, edema, mass, mass effect, or evidence of
infarction. The ventricles and sulci are normal in size and configuration.
The basal cisterns are patent and gray-white matter differentiation is
preserved. The calvaria are unremarkable. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear.
IMPRESSION: No acute intracranial abnormality.
NOTE ADDED IN ATTENDING REVIEW: There is moderate mucosal thickening with
likely mucus-retention cyst formation involving the limited included superior
portion of the maxillary sinuses, as well as scattered anterior and posterior
ethmoidal air cells, bilaterally. There may have been prior partial
ethmoidectomy and uncinectomy, incompletely demonstrated. The frontal and
sphenoid air cells are clear. These findings should be correlated with
detailed history.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPERGLYCEMIA
Diagnosed with IDDM, UNCONTROLLED
temperature: 98.6
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 123.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ year old female with a past medical history significant for
___ syndrome (albinism, platelet storage disorder),
uncontrolled IDDM s/p pancreatectomy, islet cell transplant
(___), asthma, severe gastroparesis, bezoars and multiple
abdominal surgeries presenting with ___ weeks of hyperglycemia
___ 300-400), polyuria, polydipsia, abdominal pain, nausea and
vomiting.
# RHYTHMIC MOVEMENTS
Episodes of rhythmic upper and lower extremity movements were
witnessed several times during the patient's hospitalization.
The movements occurred during a semi-conscious state in which
the patient was able to willfully close her eyes and answer
selective questions. IV Ativan was administered during several
of the events but did not result in cessation of the activity.
The neurology consult team witnessed several of the events and
determined the movements were not consistent with seizures due
to her purposeful activities, normal O2 saturations, lack of
tongue biting and absence of incontinence or post-ictal state. A
CT Head was performed which revealed no acute pathology
accounting for the seizure like activity. The patient's blood
glucose levels were occasionally, but not consistently low
during the episodes ranging from 72-130.
# UNCONTROLLED IDDM/IMPENDING DKA
Ms. ___ presented with weeks to months of finger sticks
ranging from 300-600 associated with polyuria and weight loss.
Unclear precipitant, however the patient did receive an islet
cell transplant in ___ which appears to have failed. No acute
infectious process was discovered during her hospitalization.
The infectious workup included CXR, UA, urine culture and blood
culture. Ketones and glucosuria were discovered on her initial
UA. Presenting glucose was 458 with an AG of 20. A1C: 14.7. Her
admission insulin regimen included 15U Lantus QAM and Humalog
sliding scale. Her anion gap closed with only 5 units in the ED.
She was placed on BID Lantus and a more aggressive sliding
scale. Initially glucose was checked q2 hours and chem7 q4
hours. IV fluids were continued and potassium was supplemented
as necessary. During the later half of her hospitalization she
experienced morning, fasting glucose levels between 50-70. Her
Lantus dosing and sliding scale were adjusted accordingly. She
was discharged on Lantus 14U QAM and 10U QPM. She was instructed
to call the ___ main number if she has difficulty controlling
her glucose levels including ___ <70 or >300.
# ABDOMINAL PAIN:
Ms. ___ suffers from gastroparesis and chronic abdominal
pain. She has a known gastric bezoar and diffuse fecal loading.
She complained of intermittent nausea, but no vomiting. She
denied diarrhea, melena and hematochezia. Her LFTs and lipase
were within normal limits. H. pylori was negative. KUB with
stomach distended w/ food and colon distended w/ stool. Per the
patient her symptoms and findings are all chronic in nature.
There was no apparent worsening of her symptoms during this
hospitalization. She reliably states that her pain feels like
distension and pressure and occurs most frequently after meals.
Her chronic constipation appears to be the result of diffuse
intestinal slowing, potentially a result of a autonomic
neuropathy. She takes intermittent opioids for the pain and is
on a fairly robust bowel regimen including Senna, Colace,
Miralax and Amitiza. Unfortunately there is no great solution to
her gastroparesis as she has been intolerant to metoclopramide
and erythromycin. She could not afford domperidone which her
gastroenterologist at ___ recommended. Ms. ___ had regular
bowel movement during her hospitalization. She was given
intermittent PO Dilaudid for what she described as severe
abdominal pain. Her dosing of gabapentin was increased to 200mg
TID. She was discharged with appropriate GI follow up (Dr.
___.
# ___ SYNDROME: Responsible for the patient's
albinism and blindness. Platelets within normal limits this
admission. No mucosal bleeding or ecchymoses.
# PANCREATIC INSUFFICIENCY
Pancrelipase continued.
# DEPRESSION:
Escitalopram continued.
TRANSITIONAL ISSUES
*******************
-blood cultures pending at discharge negative
-___, PCP and GI follow up
-patient to contact ___ main number if difficulty controlling
blood sugars |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Thorazine / Influenza Virus Vacc,Specific
Attending: ___.
Chief Complaint:
Constipation, Rectal Pain, Fecal Impaction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old Male who presents with 2 days of rectal pain and
constipation at his ALF, found in the ED with fecal impaction.
The patient states that 1 month prior he had colitis, which was
treated with ciprofloxacin/metronidazole; he was seen in GI
clinic in follow up of this the week of admission without
problems. He states that over the 2 days prior to admission his
stools became hard and he found it painful to defecate. During
the 2 days prior to admission he was apparently going to try an
enema at his ALF, but there were unable to help him with this.
He states there was no hemaochezia, diarhea, fever/chills.
On arrival to the ED, he underwent an abdominal CT with contrast
which was significant for some proctitis and large impacted
stool burden. The ED disimpacted him, after which he had a very
large BM, with marked relief. For unclear reasons he was given
IV ciprofloxacin/Metronidazole, and brought in to the hospital.
On arrival to the floor he was able to eat a full meal within
minutes of arrival, without difficultly or discomfort.
Past Medical History:
1. History of schizophrenia, followed by Dr. ___,
___
number ___.
2. History of alcohol abuse, currently in a dual diagnosis day
program. Apparently sober for the past 18 months.
3. History of traumatic brain injury, s/p self inflicted
gunshot wound (suicide attempt). Severe impairments. Lives at
an assisted living facility, and has assistance with cues for
ADLs and IADLs.
4. History of CAD, status post three-vessel CABG.
5. History of positive PPD with negative chest x-ray in the
past.
6. History of COPD per chart.
7. History of lymphadenopathy seen on a past CT of the abdomen
and pelvis in ___. The patient had a repeat CT done in
___, which revealed that the mesenteric lymph nodes and
gastrohepatic ligament lymph nodes appear decreased in size.
8. History of tremor, thought secondary to extrapyramidal
symptoms.
9. History of nipple dermatitis in the past.
10. History of type 2 diabetes mellitus.
11. History of a tremor seen by neurology in the past with an
EMG that revealed prior GBS ___ syndrome). Symptoms
were thought secondary to antipsychotics. Unclear if this was
followed up or further indication was needed.
12. History of hyperlipidemia.
13. History of hypertension.
14. History of GERD.
coronary artery disease status post coronary artery bypass
grafting
chronic hypertension
stable angina pectoris
peripheral arterial disease
infrarenal aortic ulcer
PAST PSYCHIATRIC HISTORY:
Hospitalizations: Chronic paranoid schizophrenia. As per pt he
was last hospitalized ___ years ago for depression and SA via
GSW.
Social History:
___
Family History:
two brothers are deceased from alcohol abuse and substance
abuse.
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - 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: 98.7, 112/75, 106, 20, 95%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions, 1.5cm right temple sebborheic
keratosis
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, - rebound, - guarding, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
___ 07:50AM BLOOD WBC-6.6 RBC-4.61 Hgb-14.9 Hct-42.4 MCV-92
MCH-32.4* MCHC-35.2* RDW-12.5 Plt ___
___ 07:50AM BLOOD Neuts-76.6* Lymphs-14.9* Monos-5.0
Eos-2.8 Baso-0.7
___ 07:50AM BLOOD ___ PTT-30.0 ___
___ 07:50AM BLOOD Glucose-187* UreaN-21* Creat-1.5* Na-141
K-4.7 Cl-104 HCO3-21* AnGap-21*
___ 07:50AM BLOOD ___ PTT-30.0 ___
___ 07:50AM BLOOD Glucose-187* UreaN-21* Creat-1.5* Na-141
K-4.7 Cl-104 HCO3-21* AnGap-21*
___ 07:50AM BLOOD ALT-18 AST-26 AlkPhos-100 TotBili-0.3
___ 07:50AM BLOOD Albumin-3.8 Calcium-9.1 Phos-2.9 Mg-1.9
___ 07:56AM BLOOD Lactate-1.3
___ 10:30AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:30AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 10:30AM URINE CastHy-1*
___ 10:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 9:03 AM
IMPRESSION:
1. Mucosal enhancement and hypervascularity along the mid
rectum suggesting inflammatory proctitis. An infectious cause
is also not excluded.
2. Ulcerating soft tissue atherosclerotic plaque along the
infrarenal
abdominal aorta, but unchanged.
3. Moderately distended bladder for which clinical correlation
is suggested.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Lorazepam 1 mg PO BID:PRN agitation
3. Nitroglycerin SL 0.4 mg SL PRN chestpain
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Mylanta ___ ml oral Q6H:PRN
6. Acetaminophen 500 mg PO Q6H:PRN pain
7. NIFEdipine CR 90 mg PO DAILY
8. OLANZapine 10 mg PO QAM
9. OLANZapine 20 mg PO HS
10. Omeprazole 20 mg PO DAILY
11. Oxybutynin 5 mg PO DAILY
12. Spironolactone 25 mg PO DAILY
13. Thiamine 100 mg PO DAILY
14. TraZODone 50 mg PO HS
15. Aspirin 325 mg PO DAILY
16. Atorvastatin 40 mg PO HS
17. BuPROPion (Sustained Release) 150 mg PO QAM
18. Fluticasone Propionate NASAL ___ SPRY NU DAILY
19. FoLIC Acid 1 mg PO DAILY
20. Januvia (sitaGLIPtin) 50 mg oral daily
21. Lisinopril 40 mg PO DAILY
22. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
23. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO HS
4. BuPROPion (Sustained Release) 150 mg PO QAM
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL ___ SPRY NU DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Januvia (sitaGLIPtin) 50 mg oral daily
10. Lisinopril 40 mg PO DAILY
11. Lorazepam 1 mg PO BID:PRN agitation
12. Multivitamins 1 TAB PO DAILY
13. Mylanta ___ ml oral Q6H:PRN
14. NIFEdipine CR 90 mg PO DAILY
15. Nitroglycerin SL 0.4 mg SL PRN chestpain
16. OLANZapine 10 mg PO QAM
17. OLANZapine 20 mg PO HS
18. Omeprazole 20 mg PO DAILY
19. Oxybutynin 5 mg PO DAILY
20. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 dose by
mouth daily Refills:*0
21. Spironolactone 25 mg PO DAILY
22. Thiamine 100 mg PO DAILY
23. TraZODone 50 mg PO HS
24. Glycerin Supps 1 SUPP PR PRN constipation
RX *glycerin (Adult) Adult 1 suppository(s) rectally BID:PRN
Disp #*50 Suppository Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Constipation, Stercoproctitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CT OF THE ABDOMEN AND PELVIS
HISTORY: Lower abdominal pain. History of colitis and aortic ulcer.
COMPARISONS: ___.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
with intravenous contrast. Sagittal and coronal reformations were also
performed.
FINDINGS:
The lung bases appear clear. There are no pleural effusions.
There are again a number of small hypodense foci in the liver. The large
majority of these are too small to characterize but unchanged and probably
benign while a few of the larger ones can be characterized as simple or
benign-appearing minimally complicated cysts. There is no biliary dilatation.
The gallbladder is non-distended. The pancreas and adrenal glands appear
within normal limits. There is an unchanged enhancing lesion in the spleen,
which is suggestive of a hemangioma, in addition to scattered calcifications,
most consistent with granulomas. In the mid to upper pole, a 3 mm hypodense
focus in the left kidney is too small to characterize but unchanged.
The stomach is non-distended. The small bowel is unremarkable.There is
moderate sigmoid diverticulosis. The quantity of stool along the proximal
through mid portions of the colon is moderately prominent. The appendix
appears normal.
The mid portion of the rectum shows mucosal enhancement and hypervascularity
with large mesenteric feeding vessels. Lower in the rectum, near the
anorectal junction, there may be small hemorrhoids.
The bladder is moderately distended. The prostate is mildly enlarged. There
is no lymphadenopathy or ascites.
The iliac arteries are tortuous. There is moderate atherosclerotic disease
along the aorta including a crescentic soft plaque along the infrarenal
abdominal aorta. Stable ulcerations can be best are unchanged (601B:29 and
30). There is, as noted previously, moderate-to-severe stenosis of the right
external iliac artery.
BONES:
There are no suspicious lytic or blastic bone lesions. Mild degenerative
changes affect lower lumbar facet joints.
IMPRESSION:
1. Mucosal enhancement and hypervascularity along the mid rectum suggesting
inflammatory proctitis. An infectious cause is also not excluded.
2. Ulcerating soft tissue atherosclerotic plaque along the infrarenal
abdominal aorta, but unchanged.
3. Moderately distended bladder for which clinical correlation is suggested.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, UNSPECIFIED CONSTIPATION
temperature: 97.7
heartrate: 74.0
resprate: 16.0
o2sat: 97.0
sbp: 137.0
dbp: 72.0
level of pain: unclear
level of acuity: 3.0 | 1. Constipation, Fecal Impaction, Proctitis
- Disimpacted in the ED with large stool burden, now relieved
- Will prescribe outpatient polyethylene glycol, glycerine
suppositories
- recommended fiber, keeping hydrated and prune juice
- Already on colace and senna
- No further indication for antibiotics, given lack of
leukocytosis, fever or other signs of infection
2. Paranoid Schizophrenia
- Continue Zyprexa, Trazodone, Bupropion
- Lorazepam PRN
3. Chronic Anigna Pectoris, CAD, Hyperlipidemia
- Aspirin, Isosorbide, Nifedipine, Lipitor
4. Spastic Bladder
- Oxybutinin
Full Code
Patient does not need to remain under observation, and is stable
to leave to his ALF
Has PCP follow up within 1 week already set up |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Right heart catheterization
Right CVL
History of Present Illness:
Mr. ___ is a ___ male w/ PMH of bipolar
disorder who was diagnosed ___ weeks ago with new onset HFrEF
(LVEF ___ thought ___ non-compaction cardiomyopathy. A
cardiac MRI on ___ which was a poor study but shows severe bi-v
CM (LVEF 16%) with non-compaction suspected.
Prior to this admission, the patient stated that he had been
escalating diuretics, including metolazone, as an outpatient for
unclear reasons. He subsequently developed syncope while having
a bowel movement. He presented to the ___ ER where he was
found to have ___, hyponatremia, tachycardia to the 130s, and
hypotension to ___. He was given IVF, started on Levophed,
and transferred to the CCU. In the CCU patient, the patient
refused Swan but had a RIJ which demonstrated CVP in the ___
range and CVO2 51% on a Hgb of 16. In conjunction with minimal
LVOT distension, CI likely ~1.5. He was transitioned to
dobutamine from Levophed. ___ improved with inotropes and
holding diuresis, although he remained net negative nearly 6L
during his stay in the CCU. He was started on low dose captopril
w/ CVO2 improving to ___. He underwent a TTE which demonstrated
a LV thrombus, so was started on a heparin GTT.
He was then transferred to the Heart Failure Service for
optimization of his heart failure medications. On service, he
was actively diuresed with Lasix IV and torsemide. It remained
extremely difficult to gauge the patient's fluid status given
inaccurate I/Os due to the patient drinking fluids and not
reporting his intake to nursing staff. Upon discharge, it was
felt that the patient was euvolemic and he will be maintained on
the regimen detailed further in D/C summary.
Past Medical History:
- Dilated cardiomyopathy (EF ___, no coronary disease,
idiopathic
- Bipolar disorder
- Anxiety
- MJ abuse
Social History:
___
Family History:
No family history of early-onset cardiomyopathy.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VITAL SIGNS: afebrile, HR ___ sinus, BP SBP 80-93/60s, 95%
RA
GENERAL: Well developed young man, anxious affect
HEENT: PERRL. EOMI. No pallor or cyanosis of the oral mucosa,
dry MM
NECK: JVP of 10 cm
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs
LUNGS:
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: cool and diaphoretic skin, distal pulses 1+
symmetric
DISCHARGE PHYSICAL EXAMINATION:
===============================
General: Alert, awake, NAD.
Neck: No JVD.
CV: RRR, no m/r/g.
Chest: Comfortable, CTAB w/ no w/r/r.
Abdomen: Soft, NT, ND
Extremities: WWP, no edema.
Skin: No rashes.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:10AM WBC-13.3* RBC-5.06 HGB-16.0 HCT-45.7 MCV-90
MCH-31.6 MCHC-35.0 RDW-13.1 RDWSD-42.8
___ 05:10AM NEUTS-64.2 LYMPHS-18.4* MONOS-14.2* EOS-2.4
BASOS-0.3 IM ___ AbsNeut-8.51* AbsLymp-2.45 AbsMono-1.89*
AbsEos-0.32 AbsBaso-0.04
___ 05:10AM PLT COUNT-236
___ 05:10AM ___ PTT-24.7* ___
___ 05:10AM ALBUMIN-3.7 CALCIUM-8.8 PHOSPHATE-8.8*
MAGNESIUM-2.7*
___ 05:10AM CK-MB-4 proBNP-4433*
___ 05:10AM cTropnT-0.06*
___ 05:10AM LIPASE-26
___ 05:10AM ALT(SGPT)-33 AST(SGOT)-30 CK(CPK)-491* ALK
PHOS-49 TOT BILI-0.4
___ 05:24AM LACTATE-1.8
___ 03:00PM CALCIUM-9.0 PHOSPHATE-4.9* MAGNESIUM-2.6
OTHER PERTINENT STUDIES:
========================
___ 06:15AM BLOOD ALT-58* AST-50* AlkPhos-45 TotBili-0.4
___ 07:20AM BLOOD ALT-70* AST-50* AlkPhos-45 TotBili-0.2
___ 06:45AM BLOOD ALT-93* AST-57* AlkPhos-44 TotBili-0.3
___ 06:15AM BLOOD ALT-99* AST-51* LD(LDH)-350* AlkPhos-45
TotBili-0.3
___ 03:47PM BLOOD ALT-99* AST-48* AlkPhos-44 TotBili-0.2
___ 08:50AM BLOOD ALT-103* AST-57* AlkPhos-48 TotBili-0.2
___ 03:10AM BLOOD ALT-101* AST-47* AlkPhos-45 TotBili-0.2
___ 04:20AM BLOOD ALT-83* AST-36 AlkPhos-41 TotBili-0.2
___ 05:10AM BLOOD CK-MB-4 proBNP-___*
___ 05:10AM BLOOD cTropnT-0.06*
MICROBIOLOGY:
=============
C. difficile: Negative
Blood Cultures: Negative
IMAGING/STUDIES
================
CXR ___
No acute findings
ECHO (___):
Conclusions
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated with severe global hypokinesis (LVEF = 20 %).
The estimated cardiac index is depressed (<2.0L/min/m2). Two
large 1.8cm; 2.5 cm ovoid mobile echodensities are seen in the
apex most c/w thrombus. There is no left ventricular outflow
obstruction at rest or with Valsalva. The right ventricular
cavity is mildly dilated with severe global free wall
hypokinesis. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
dilation with severe global hypokinesis and likely two large
mobile apical thrombi. Right ventriuclar cavity dilation with
free wall hypoinesis. No definite valvular pathology or
pathologic flow identified.
MOST RECENT LABS ON DISCHARGE:
==============================
___ 03:10AM BLOOD WBC-11.5* RBC-4.80 Hgb-15.3 Hct-44.1
MCV-92 MCH-31.9 MCHC-34.7 RDW-12.8 RDWSD-42.7 Plt ___
___:20AM BLOOD ___ PTT-31.2 ___
___ 04:20AM BLOOD Glucose-93 UreaN-38* Creat-1.3* Na-132*
K-4.0 Cl-90* HCO3-28 AnGap-18
___ 04:20AM BLOOD ALT-83* AST-36 AlkPhos-41 TotBili-0.2
___ 04:20AM BLOOD Calcium-8.6 Phos-4.9* Mg-2.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. BuPROPion 225 mg PO DAILY
3. Spironolactone 25 mg PO DAILY
4. Gabapentin 900 mg PO TID
5. Zolpidem Tartrate 5 mg PO QHS
6. Metolazone 2.5 mg PO ASDIR
7. Metoprolol Succinate XL 50 mg PO BID
8. Torsemide 80 mg PO BID
9. LORazepam 0.5 mg PO TID
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Enoxaparin Sodium 110 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
One shot in the morning, one in the afternoon.
RX *enoxaparin 150 mg/mL 112.5 mg SC twice a day Disp #*10
Syringe Refills:*0
3. Warfarin 12.5 mg PO DAILY16 Duration: 1 Dose
RX *warfarin [Coumadin] 5 mg 2.5 tablet(s) by mouth once a day
Disp #*75 Tablet Refills:*0
4. Lisinopril 7.5 mg PO DAILY
RX *lisinopril 5 mg 1.5 tablet(s) by mouth once a day Disp #*45
Tablet Refills:*0
5. Metoprolol Succinate XL 12.5 mg PO BID
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
6. BuPROPion 225 mg PO DAILY
7. Gabapentin 900 mg PO TID
8. LORazepam 0.5 mg PO TID
9. Torsemide 80 mg PO BID
RX *torsemide 20 mg 4 tablet(s) by mouth twice a day Disp #*240
Tablet Refills:*0
10. Zolpidem Tartrate 5 mg PO QHS
11. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until you are instructed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Heart failure with reduced ejection fraction
Secondary Diagnosis
Left ventricular thrombus
Acute renal failure
Bipolar disorder
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with HFpEF, rising LFTs in the setting of active
diuresis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___ cardiac MRI
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites. The main hepatic portal vein is patent with
hepatopetal flow. The hepatic veins are patent.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD is poorly
visualized, measuring approximately 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 9.1 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Patent partially imaged inferior vena cava, hepatic veins, and main portal
vein with flow in the appropriate direction.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
Radiology Report
EXAMINATION: Chest radial
INDICATION: History: ___ with hypotension// eval for acute process
TECHNIQUE: AP frontal view of the chest
COMPARISON: None available.
FINDINGS:
The heart is not enlarged for this projection and there is no pulmonary
vascular congestion. There is no pneumothorax or pleural effusion. No
airspace disease. No displaced fractures are evident.
IMPRESSION:
No acute findings
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with CVL placement// CVL placement
TECHNIQUE: AP frontal view of the chest.
COMPARISON: Chest radiograph ___ 04:02.
FINDINGS:
Right central venous catheter terminates overlying the mid SVC. Otherwise
there is no significant change from chest radiograph 1 hour prior.
IMPRESSION:
New right central venous catheter terminates overlying the mid SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HFrEF// swan placement confirmation
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Right IJ Swan-Ganz catheter tip overlies medial right hilum, could be pulled
back. Increased heart size, similar to prior. Normal pulmonary vascularity,
no edema. No sizable effusion. No infiltrates. No pneumothorax. Stable
appearance of the distal right clavicle, may be posttraumatic or postsurgical.
IMPRESSION:
Right IJ Swan-Ganz catheter tip overlies medial right hilum, could be pulled
back.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse, Heart failure, unspecified
temperature: 98.0
heartrate: 81.0
resprate: 18.0
o2sat: 96.0
sbp: 95.0
dbp: 56.0
level of pain: 0
level of acuity: 1.0 | Patient Summary for Admission:
==============================
Mr. ___ is a ___ male w/ PMH of bipolar
disorder who was diagnosed ___ weeks ago with new onset HFrEF
(LVEF ___ thought ___ non-compaction cardiomyopathy. A
cardiac MRI on ___ which was a poor study but shows severe bi-v
CM (LVEF 16%) with non-compaction suspected.
Prior to this admission, the patient stated that he had been
escalating diuretics, including metolazone, as an outpatient for
unclear reasons. He subsequently developed syncope while having
a bowel movement. He presented to the ___ ER where he was
found to have ___, hyponatremia, tachycardia to the 130s, and
hypotension to ___. He was given IVF, started on Levophed,
and transferred to the CCU. In the CCU patient, the patient
refused Swan but had a RIJ which demonstrated CVP in the ___
range and CVO2 51% on a Hgb of 16. In conjunction with minimal
LVOT distension, CI likely ~1.5. He was transitioned to
dobutamine from Levophed. ___ improved with inotropes and
holding diuresis, although he remained net negative nearly 6L
during his stay in the CCU. He was started on low dose captopril
w/ CVO2 improving to ___. He underwent a TTE which demonstrated
a LV thrombus, so was started on a heparin GTT.
He was then transferred to the Heart Failure Service for
optimization of his heart failure medications. On service, he
was actively diuresed with Lasix IV and torsemide. It remained
extremely difficult to gauge the patient's fluid status given
inaccurate I/Os due to the patient drinking fluids and not
reporting his intake to nursing staff. Upon discharge, it was
felt that the patient was euvolemic and he will be maintained on
the regimen detailed below. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Aspirin / Influenza Virus Vaccine
Attending: ___.
Chief Complaint:
Influenza Like Illness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is ___ with history of asthma, severe pulmonary HTN on
2L O2 at home, h/o ___, chronic nausea and abdominal
pain, history of substance abuse who is presenting with ILI.
The patient reports sudden onset sore throat and cough on two
days prior to admission. She had fever to 100.5 at home, chest
tightness, SOB, whole body ache. She also reports decreased PO
intake over the last 12 hours. As per report, the patient
reports that her abdominal pain and nausea are at her baseline.
She denies any diarrhea/constipation, dysuria. Of note, her
boyfriend who she lives with recently had the flu. She did not
get her flu shot because
history of reportedly flu related ___ in ___.
In the ED, initial VS were: 100.8 102 154/90 20 98%. In the ED,
PE notable for speaking in full sentences, but tachypneic to 26,
tachycardic to 110 with wheezing on exam. CXR without any e/o
infiltrate. The patient got Tamiflu 75 mg, prednisone 60 mg,
nebulizers, and oxycodone for pain control. Most recent vitals
98.0 76 140/89 16 100% on O2.
REVIEW OF SYSTEMS:
(+) per history
(-) headache, vision changes, rhinorrhea, congestion, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Pulmonary hypertension
- Thought secondary to cocaine abuse vs. ___
Active tobacco use
Restrictive lung disease
Chronic hepatitis
Hypertension
Perforated duodenal ulcer ___, attributed to NSAID use
___ syndrome
- with residual sensory neuropathy
Polysubstance abuse (smoked cocaine)
Depression
Rheumatoid arthritis, seronegative
Chronic severe back pain
C-sections x 4
History of secondary syphilis, treated
Seizures in childhood
Social History:
___
Family History:
Father with COPD. Sister with diabetes.
Physical Exam:
ADMISSON PHYSICAL EXAM:
VS - Temp 96.9F, BP 144/98, HR 84, R 18, O2-sat 96% on 2L
GENERAL - well-appearing woman in NAD, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - poor air movement bilaterally, diffuse expiratory wheeze
worse on the right side
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 PHYSICAL EXAM:
VS - Tmax 98.2 Tc 98.2 BP 133/83 HR 78 RR 18 98% 2 L
GENERAL - well-appearing woman in NAD, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - clear to auscultation bilaterally
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
Pertinent Results:
Labs on Admission:
___ 03:54PM BLOOD WBC-4.5 RBC-4.87 Hgb-15.0 Hct-44.4 MCV-91
MCH-30.9 MCHC-33.9 RDW-13.9 Plt ___
___ 03:54PM BLOOD Neuts-66.6 ___ Monos-7.4 Eos-5.0*
Baso-1.3
___ 03:54PM BLOOD Glucose-85 UreaN-10 Creat-0.9 Na-138
K-4.1 Cl-104 HCO3-23 AnGap-15
___ 03:54PM BLOOD Calcium-9.7 Phos-3.9 Mg-1.5*
Microbiology:
___ 04:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 8:50 pm Influenza A/B by ___ Site: NASOPHARYNGEAL
SWAB
Source: Nasopharyngeal swab.
RESPIRATORY VIRAL ANTIGEN SCREEN RESPIRATORY VIRAL CULTURE
ADDED ON
PER ___ ___ ___ AT 1259.
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to Respiratory Virus Identification for further
information.
Respiratory Viral Culture (Pending):
IMAGING:
ECGStudy Date of ___ 1:33:06 AM
Sinus rhythm. P-R interval prolongation. Copnsider right and
left atrial abnormality. Right inferior axis. Early R wave
progression with ST segment depression ion the early precordial
leads. Mild Q-T interval prolongation. Since the previous
tracing the rate is somewhat slower. Otherwise, no change
CHEST (PA & LAT)Study Date of ___ 3:51 ___
FINDINGS:
Known right lower lobe pulmonary nodule is not clearly
delineated on this study. The lungs are otherwise clear with no
evidence of a consolidation,
effusion, or pneumothorax. Prominence of the right hilum
remains stable and consistent with pulmonary artery
hypertension. Cardiac and mediastinal silhouettes are stable.
No acute fractures are identified.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Known right lung base nodule is not clearly delineated on
this study.
3. Prominence of the right pulmonary artery likely reflects
underlying pulmonary arterial hypertension.
Relevant Labs, and Labs on Discharge:
___ 04:35AM BLOOD WBC-4.2 RBC-4.57 Hgb-13.7 Hct-41.5 MCV-91
MCH-29.9 MCHC-33.0 RDW-13.7 Plt ___
___ 04:35AM BLOOD Glucose-114* UreaN-11 Creat-0.7 Na-138
K-3.5 Cl-104 HCO3-22 AnGap-16
___ 04:35AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.0
___ 03:54PM BLOOD cTropnT-<0.01
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H SOB
2. Omeprazole 40 mg PO BID
3. Pregabalin 75 mg PO BID
in AM and noon
4. Pregabalin 100 mg PO HS
5. Ranitidine 150 mg PO HS
6. Sildenafil 20 mg PO TID
7. TraMADOL (Ultram) 50 mg PO TID:PRN pain
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Multivitamins 1 TAB PO DAILY
10. traZODONE 100 mg PO TID
11. Acetaminophen 1000 mg PO BID:PRN pain
12. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 40 mg PO BID
4. Pregabalin 75 mg PO BID
in AM and noon
5. Pregabalin 100 mg PO HS
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Ranitidine 150 mg PO HS
8. Sildenafil 20 mg PO TID
9. TraMADOL (Ultram) 50 mg PO TID:PRN pain
10. traZODONE 100 mg PO HS:PRN insomnia
11. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*36 Tablet
Refills:*0
12. Albuterol Inhaler 2 PUFF IH Q4H SOB
RX *albuterol sulfate 90 mcg 2 puffs IH every four (4) hours
Disp #*1 Inhaler Refills:*3
13. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Influenza-Like Illness
- Asthma Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Cough and myalgias.
COMPARISON: CT abdomen and pelvis and chest radiograph from ___.
FINDINGS:
Known right lower lobe pulmonary nodule is not clearly delineated on this
study. The lungs are otherwise clear with no evidence of a consolidation,
effusion, or pneumothorax. Prominence of the right hilum remains stable and
consistent with pulmonary artery hypertension. Cardiac and mediastinal
silhouettes are stable. No acute fractures are identified.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Known right lung base nodule is not clearly delineated on this study.
3. Prominence of the right pulmonary artery likely reflects underlying
pulmonary arterial hypertension.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: INFLUENZA LIKE ILLNESS
Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION, ACUTE URI NOS
temperature: 100.8
heartrate: 102.0
resprate: 20.0
o2sat: 98.0
sbp: 154.0
dbp: 90.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is ___ with history of asthma, severe pulmonary HTN on
2L O2 at home, h/o ___, chronic nausea and abdominal
pain, history of substance abuse who is presenting with ILI.
# Asthma Exacerbation: Patient initially arrived in the ED with
symptoms concerning for influenza, with cough, myalgias, and
recent sick exposure contact (her boyfriend) to somebody with
the flu. She ruled out for influenza as well as other
respiratory viruses, and was DC'ed from prophylaxtic Tamiflu.
She had wheezing on exam, and was considered to have an asthma
exacerbation. She was started on 60 mg Prednisone, with a plan
to continue for a total of 14 days. Her wheezing and subjective
SOB improved on HOD#2, and she felt well enough to leave the
hospital. We filled Prednisone for her on her discharge, and
asked her to follow-up closely with her pulmonologist and
primary care physician.
# h/o pulmonary HTN on home O2: The patient has history of
pulmonary HTN, on home O2. Her O2 requirements in house were 2
L, which was at her home baseline dosing. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
G-tube cracked
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ man with ___ disease, HTN, DM, known brain mass
living in a nursing home who presents because there was a crack
in the tubing of his PEG. Per notes, he is relatively somnolent
at baseline. He was seen by GI in the ED who recommended
admitting to medicine for PEG placement under MAC anesthesia.
In the ED, initial vitals: 98.9 73 118/76 16 97% RA. No labs
were drawn. He was given 1L NS. He was observed in the ED and
given his home meds: carbidopa-levodopa. Vitals prior to
transfer: 98.4 72 169/83 16 98% RA. He was taken to the
endoscopy suite for the procedure prior to coming to the floor.
His g-tube was found to be cracked only at the bottom, and this
part was cut off and tube recapped. Endoscopy was performed and
the tube appeared normally seated from the inside, however, he
was incidentally discovered to have a large, deep cratered
peptic ulcer with eschar. Biopsies were taken. GI team
recommended starting high dose PPI and sucralfate, as well as
considering CT C/A/P to eval for malignancy.
Patient recently admitted in ___ with AMS thought to be
secondary to HCAP, treated with vanc/zosyn. During the
admission, had blood cultures positive for Enterococcus (VSE),
Coag negative staph, and K pneumoniae (ESBL), however, only grew
in one bottle and thought by ID to be contaminant, so was not
treated for full course of bacteremia. He was also found to
have a 3x3 cm intracranial mass in anterior intrahemispheric
fissure which was about 1 cm larger in
size from ___, thought to be meningioma vs. choroid
plexus tumor vs. vascular abnormality; however, this was
discussed with his HCP/daughters and they agreed not to work
this up further.
On the floor, the patient is not interactive and is not verbal.
He is hemodynamically stable.
Past Medical History:
1. ___ disease
2. NIDDM
3. HL
4. HTN
5. cataracts
6. ?EtOHism, quit drinking ___ years ago
7. History of R-shoulder pain: per ___ medicine discharge
summary "cervical MRI in ___ which showed multilevel
degenerative changes and shoulder MRI in ___ showing Moderate
subacromial-subdeltoid bursitis and supraspinatus calcific
tendinitis."
8. Brain mass: lobulated, hyperdense, partially
calcified lesion in the anterior interhemispheric fissure
___ dx) -- Noted growth ___. Family declined MRI and
biopsy as he would not want surgery/radiation/chemo if malignant
Social History:
___
Family History:
(From ___, unable to verify)
Father with alcoholism
No family history of ___ disease
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 98.2 168/70 65 16 100% RA
General- Thin elderly man in no distress. Eyes closed, not
interactive, does not follow commands but resists eye opening
and mouth opening. Raises eyebrows to verbal and physical stim.
Groans occasionally.
HEENT- PERRL though difficult to see very well with resistance
to eye opening
Lungs- anteriorly clear to auscultation
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding. G-tube in place in left lower quadrant
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Fasciculations/rhythmic movements of mouth. CNs2-12
difficult to test d/t patient cooperation. Moves all extremities
spontaneously; Babinski is downgoing, pt withdraws to pain in
b/l ___.
DISCHARGE PHYSICAL EXAM
Vitals: afebrile/ Tc 98.4 159/69 68 16 100% RA
General- NAD, opened eyes today, tracked examiner but otherwise
not interactive, does not follow commands but resists eye
opening and mouth opening.
Lungs- anteriorly clear to auscultation
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, does not appear to
have tenderness. G-tube in place in left lower quadrant
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Fasciculations/rhythmic movements of mouth.
Pertinent Results:
ADMISSION LABS
___ 04:05PM BLOOD WBC-8.0 RBC-3.61* Hgb-11.1* Hct-34.3*
MCV-95 MCH-30.8 MCHC-32.4 RDW-13.5 Plt ___
___ 04:05PM BLOOD Glucose-116* UreaN-19 Creat-0.6 Na-136
K-3.4 Cl-98 HCO3-30 AnGap-11
___ 04:05PM BLOOD Calcium-8.5 Phos-1.5* Mg-2.0
DISCHARGE LABS
___ 05:35AM BLOOD WBC-5.0 RBC-3.17* Hgb-10.1* Hct-29.4*
MCV-93 MCH-31.9 MCHC-34.3 RDW-13.0 Plt ___
___ 05:35AM BLOOD Glucose-60* UreaN-8 Creat-0.4* Na-134
K-3.4 Cl-98 HCO3-23 AnGap-16
___ 05:35AM BLOOD Calcium-7.5* Phos-3.1 Mg-1.2*
IMAGING STUDIES
EGD ___:
Impression: Deep cratered ulcer with eschar in the stomach, with
surrounding congestion, heaped up and erythematous mucosa
(biopsy)
The bumper was visualized and in place. Given the above
findings, the PEG was not replaced but cut below the part of the
tube tear.
Otherwise normal EGD to third part of the duodenum
Recommendations: High dose BID PPI
Liquid Carafate 1gm QID
CT ABOMEN/PELVIS ___
IMPRESSION:
1. Extensive emphysematous changes in the stomach, likely post
procedural in nature. There is a small amount of adjacent free
air, compatible with small perforation without contrast
extravasation.
2. Large amount of stool, particularly in the rectum.
3. Improving airspace disease at the left lung base with
residual bronchial wall thickening.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB, wheeze
3. Aspirin 81 mg PO DAILY
4. Carbidopa-Levodopa (___) 2 TAB PO BID
5. Carbidopa-Levodopa (___) 1.5 TAB PO BID
6. Duloxetine 30 mg PO DAILY
7. Guaifenesin 15 mL PO Q4H:PRN cough
8. Milk of Magnesia 30 mL PO DAILY: PRN constipation
9. Senna 8.6 mg PO DAILY:PRN constipation
10. Simethicone 80 mg PO QID:PRN gas
11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
12. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
constipation
13. Bisacodyl 10 mg PR HS:PRN constipation
14. Docusate Sodium 200 mg PO DAILY
15. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
16. Amlodipine 5 mg PO DAILY
17. Lisinopril 10 mg PO HS
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Carbidopa-Levodopa (___) 2 TAB PO BID
4. Carbidopa-Levodopa (___) 1.5 TAB PO BID
5. Docusate Sodium 200 mg PO DAILY:PRN constipation
6. Senna 8.6 mg PO DAILY:PRN constipation
7. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
constipation
8. Milk of Magnesia 30 mL PO DAILY: PRN constipation
9. Simethicone 80 mg PO QID:PRN gas
10. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB, wheeze
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Peptic ulcer disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable intermittently.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMINAL RADIOGRAPH.
INDICATION: ___ year old man with large peptic ulcer, concern for possible
perforation given size. Eval for free air or perforation?
TECHNIQUE: Supine and decubitus abdominal radiograph.
COMPARISON: ___ and subsequently obtained CT abdomen pelvis.
FINDINGS:
Enteric contrast fills the stomach and proximal small bowel. Stool and air
fill the colon. No pneumoperitoneum is identified. In conjunction with the
subsequently obtained CT, lucencies along the mural contour of the stomach are
consistent with intramural air reflecting gastric emphysema likely
postprocedural given the presence of the gastrostomy tube. Imaged lung bases
are clear.
IMPRESSION:
No pneumoperitoneum. Gastric emphysema, likely secondary to gastrostomy tube
placement.
Radiology Report
INDICATION: ___ year old man with large peptic ulcer, status post EGD and
biopsy performed earlier same day. Concern for possibility of perforation.
Please evaluate for evidence of perforation, abscess.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous administration of IV contrast. Oral contrast was
administered. Coronal and sagittal reformations were performed.
DOSE: DLP: 323 mGy-cm.
COMPARISON: ___ CT abdomen pelvis
FINDINGS:
ABDOMEN:
LUNG BASES: Atelectasis at the right lung base. Improving airspace disease
at the left lung base, with bronchial wall thickening remaining. Coronary
artery disease.
STOMACH: Pneumatosis of the stomach, new from prior examination. This extends
just beyond the GE junction. There are few foci of free air adjacent, most
prominent near the gastric cardia (series 5, images 23, 20, and 18), although
also near the root of the mesentery (series 5, image 23). The pylorus appears
thickened. A gastric tube is present and appropriately located.
LIVER: Homogenous attenuation with no evidence of solid mass. There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
GALLBLADDER: Normal.
PANCREAS: Normal. No pancreatic ductal dilatation.
SPLEEN: Normal.
ADRENALS: Normal.
KIDNEYS: Normal right kidney. Stable wedge low density lesion on the left,
likely from prior insult. There is no evidence of stones, solid mass, or
hydronephrosis.
BOWEL: Normal in caliber without evidence of obstruction. Large amount of
stool within the rectum.
RETROPERITONEUM: Prominent left retroperitoneal lymph nodes.
VASCULAR: The abdominal aorta demonstrates moderate atherosclerosis.
PELVIS:
URINARY BLADDER: Normal.
LYMPHADENOPATHY: There are no enlarged pelvic or inguinal lymphadenopathy.
FREE FLUID: None.
BONES: There are no suspicious osseous lesions. Stable endplate degenerative
changes at multiple levels.
Incidentally noted retractile left testicle, not seen on prior examination.
IMPRESSION:
1. Extensive emphysematous changes in the stomach, likely post procedural in
nature. There is a small amount of adjacent free air, compatible with small
perforation without contrast extravasation.
2. Large amount of stool, particularly in the rectum.
3. Improving airspace disease at the left lung base with residual bronchial
wall thickening.
Preliminary report provided by Dr. ___ with Dr. ___ 21:45 on ___.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: GTUBE EVAL
Diagnosed with OTHER GASTROSTOMY COMPLICATION, ABN REACT-EXTERNAL STOMA, HYPERTENSION NOS
temperature: 98.9
heartrate: 73.0
resprate: 16.0
o2sat: 97.0
sbp: 118.0
dbp: 76.0
level of pain: 13
level of acuity: 3.0 | ___ man with ___ disease, HTN, DM, brain mass
presenting with malfunction of PEG tube, incidentally found to
have large cratered peptic ulcer with evidence of perforation,
and pneumatosis of stomach wall.
ACTIVE ISSUES
# Peptic ulcer with perforation: Large, deep, necrotic-appearing
ulcer found incidentally on endoscopy performed for fixing of
PEG tube. Started on IV PPI BID as well as sucralfate. CT
abd/pelvis showed evidence of perforation of the stomach, as
well as pneumatosis within the stomach wall. Started on
ceftriaxone and metronidazole, and tube feeds were held. He
remained hemodynamically stable. Patient seen by surgery who
thought that this was a small perforation but given the rest of
the stomach appeared to have gastric pneumatosis suggestive of
impending necrosis, he would be at very high risk of further
perforation leading to abdominal catastrophe. The surgical team
did not feel it was prudent to offer surgical intervention given
his overall very poor functional status and comorbidities.
Spoke with family and healthcare proxy, and they agreed with not
pursuing surgery or further escalation of care, and the patient
was discharged to pursue hospice at his nursing home. If there
are questions regarding this, please call ___ (option 1
for ___ and ask to have Dr. ___ paged.
CHRONIC ISSUES
# ___ disease: Mental status was at baseline, confirmed
with his nursing home staff. Continue home dose
carbidopa-levodopa.
# Hypertension: continued home lisinopril and amlodipine.
# NIDDM: low dose SSI while in house.
# Brain mass: lobulated, hyperdense, partially calcified lesion
in the anterior interhemispheric fissure ___ dx) -- Noted
growth ___. At prior admission, family declined MRI and
biopsy as he would not want surgery/radiation/chemo if
malignant. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is ___ year old with PMH significant for known lumbar and
sacral disc disease who was playing tennis yesterday afternoon
when he reached out and felt sharp pain in his lower back. The
pain did not travel, was worse with sitting, and was relieved
with laying down. He presented to the ED shortly thereafter, but
pain control could not be achieved and he was unable to
ambulate, so he was admitted to the floor.
In the ED, initial vs were 97, 53, 124/66, 16, 100%. Received
narcotic and nonsteriodal analgesics, benzodiazepines, and
tylenol . Transfer VS were 97.8, 59, 110/70, 16, 97% on room
air.
On arrival to the floor, patient reports that he is doing well
after getting and tizanidine and IV dilaudid. He is not
diabetic, no IV drugs, no back surgery, no urinary retention or
bladder/fecal incontinence. No decreased sensation in legs.
Past Medical History:
-BPH
-HTN
-Herniated Disc
Social History:
___
Family History:
no family history of IBD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.5, 128/78, 57, 16, 97% on room air
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact. Strength ___ in upper and lower
extremities bilaterally. Pain with straight leg raise only when
above 30 degrees. Sensation intact in bilateral legs. No L spine
tenderness with palpation. Declines to attempt gait.
SKIN no ulcers or lesions
Discharge physical exam:
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact. Strength ___ in upper and lower
extremities bilaterally. Pain with straight leg raise only when
above 30 degrees but not as severe as before. Sensation intact
in bilateral legs. No L spine tenderness with palpation.
Ambulates with assistence.
SKIN no ulcers or lesions
Pertinent Results:
Admission Labs:
___ 07:25
RENAL & GLUCOSE
Glucose 93 70 - 100 mg/dL
Urea Nitrogen ___ mg/dL
Creatinine 1.1 0.5 - 1.2 mg/dL
Sodium ___ mEq/L
Potassium 4.1 3.3 - 5.1 mEq/L
Chloride ___ mEq/L
Bicarbonate 29 22 - 32 mEq/L
Anion Gap ___ mEq/L
Relevant Labs:
-none
Discharge Labs:
___ 07:52
RENAL & GLUCOSE
Glucose 93 70 - 100 mg/dL
Urea Nitrogen 21* 6 - 20 mg/dL
Creatinine 1.1 0.5 - 1.2 mg/dL
Sodium ___ mEq/L
Potassium 4.3 3.3 - 5.1 mEq/L
Chloride ___ mEq/L
Bicarbonate 31 22 - 32 mEq/L
Anion Gap ___ mEq/L
Relevant Micro/Path:
-none
Relevant radiology:
-none
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lisinopril 20 mg PO DAILY Start: In am
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*1
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*30
Tablet Refills:*0
5. Cyclobenzaprine 10 mg PO TID
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*45 Tablet Refills:*0
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
6. Ibuprofen 400 mg PO Q12H:PRN pain
RX *Advil 200 mg 2 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY constipation
RX *Miralax 17 gram/dose 1 packet by mouth daily Disp #*10
Packet Refills:*0
8. Senna 1 TAB PO DAILY constipation
RX *Senokot 8.6 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*0
9. traZODONE 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg ___ tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
10. Outpatient Physical Therapy
Physical therapy for back pain
Please call ___ to arranage
11. Outpatient Physical Therapy
Physical therapy for back pain
Please call ___ to arrange
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Duration: 5 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Lower back muscle strain.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
A fluoro-guided pain injection was performed without a radiologist present.
11 seconds of fluoro time was used. No films submitted.
Gender: M
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: BACK PAIN
Diagnosed with LUMBAGO
temperature: 97.0
heartrate: 53.0
resprate: 16.0
o2sat: 100.0
sbp: 124.0
dbp: 66.0
level of pain: 10
level of acuity: 3.0 | The patient is a ___ year old man with past medical history of
chronic low back pain, benign prostatic hypertrophy presenting
with acute low back pain following a tennis injury. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Biaxin / tissue plasminogen activator
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ercp with stent
History of Present Illness:
___ w/hypopituitarism, HTN, glaucoma presents from ___ with
malaise and abdominal found to have CBD obstruction, PNA and
bacteremia.
Pt reports rigors/fever and general malaise since yesterday. Had
RUQ abdominal pain at ___ which has since resolved. Denies
n/v/d/c. No difficulty urinating. Feels very dehydrated.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
- HTN
- pituitary adenoma s/p radiation in ___, multiple cavernous
malformations
- small right internal capsule lacunar infarct in ___
- BPH
- glaucoma
- hemorrhoids
- depression/anxiety
Social History:
___
Family History:
Father with prostate CA and a stroke later in life. Some HTN in
his family as well.
Physical Exam:
Vitals: T:98.3 BP:130/49 P:70 R:18 O2:95%ra
PAIN: 0
General: nad
HEENT: membranes dry
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Physical Exam at Discharge:
Vitals: 98 118/52 53 18 98%RA
PAIN: 0
General: nad, lying in bed
Lungs: clear bilaterally
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, non-tender
Ext: 1+ pitting edema bilaterally
Neuro: alert and oriented x 3, ___ proximal LUE strength; ___
distally
Skin: morbiliform rash on flexor areas and upper chest, improved
from yesterday
Pertinent Results:
Labs on Admission:
___ 12:14AM GLUCOSE-76 UREA N-29* CREAT-1.5* SODIUM-141
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
___ 12:14AM ALT(SGPT)-498* AST(SGOT)-687* ALK PHOS-169*
TOT BILI-4.2*
___ 12:14AM LIPASE-54
___ 12:14AM ALBUMIN-3.5
___ 12:22AM LACTATE-2.5*
___ 12:14AM WBC-7.6 RBC-4.51* HGB-14.0 HCT-43.7 MCV-97
MCH-31.1 MCHC-32.1 RDW-16.3*
___ 12:14AM NEUTS-87* BANDS-10* LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ___ MYELOS-0
___ 12:14AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL SCHISTOCY-1+
___ 12:14AM PLT SMR-LOW PLT COUNT-89*
___ 02:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:20AM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 02:20AM URINE MUCOUS-OCC
___ 02:20AM URINE COLOR-Yellow APPEAR-Hazy SP ___
Labs on Discharge:
___ 09:00AM BLOOD WBC-12.5* RBC-4.00* Hgb-12.4* Hct-37.6*
MCV-94 MCH-31.0 MCHC-33.0 RDW-16.6* Plt ___
___ 09:00AM BLOOD Glucose-113* UreaN-37* Creat-2.1* Na-140
K-3.1* Cl-104 HCO3-26 AnGap-13
___ 09:00AM BLOOD ALT-22 AST-16 AlkPhos-109 TotBili-0.6
___ 06:00PM URINE RBC-3* WBC-7* Bacteri-MOD Yeast-NONE
Epi-0
Microbiology:
___ Blood cultures x2 no growth to date
___ Urine culture no growth
___ C-diff negative
___ Blood culture Enterobacter faecalis ___ bottles
___ Blood cultures ___ bottles enterobacter faecalis and
Klebsiella
Imaging and Studies:
RUQ US: distal CBD stone appears to be causing obstruction with
CBD upto 1.4cm
ERCP Report:
Impression: Patchy discontinuous Erosions of the mucosa with no
bleeding was noted in the first part of the duodenum and second
part of the duodenum. Major papilla appeared normal.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
Diffuse dilation was seen at the biliary tree with the CBD
measuring 13 mm. There was a filling defect that appeared like
sludge in the middle third of the common bile duct. A 5cm by
10mm plastic biliary stent was placed successfully.
Renal Ultrasound ___:
1. Unremarkable renal ultrasound examination.
2. Decompressed urinary bladder prevents detailed evaluation
Echocardiogram ___:
IMPRESSION: No echocardiographic evidence of endocarditis. Mild
symmetric left ventricular hypertrophy with preserved
biventricular cavity size and global/regional systolic function.
Mild resting outflow tract gradient, likely due to
near-hyperdynamic systolic function. Mild mitral regurgitation
in a structurally normal valve.
CXR ___:
Mild vascular congestion.
Increased in atelectasis in the left lower lobe and small left
effusion.
Stable small right effusion
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. BusPIRone 15 mg PO BID
3. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic BID
4. Finasteride 5 mg PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
9. cabergoline 0.5 mg oral MTh
10. Carvedilol 12.5 mg PO BID
11. Vitamin D ___ UNIT PO DAILY
12. Citalopram 20 mg PO DAILY
13. Enalapril Maleate 20 mg PO BID
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. Hydrocortisone 10 mg PO Q12H
16. Pantoprazole 40 mg PO Q24H
17. Simvastatin 20 mg PO DAILY
18. Terazosin 10 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BusPIRone 15 mg PO BID
3. Carvedilol 12.5 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Fortesta (testosterone) 10 mg/0.5 gram /actuation transdermal
7 pumps daily
8. Hydrocortisone 10 mg PO Q12H
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Terazosin 10 mg PO HS
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Amlodipine 10 mg PO DAILY
14. Ampicillin-Sulbactam 3 g IV Q12H Duration: 6 Days
final doses will be given on ___. Pantoprazole 40 mg PO Q24H
16. Sarna Lotion 1 Appl TP TID:PRN itch
17. Simethicone 80 mg PO QID
18. cabergoline 0.5 mg oral MTh
19. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic BID
20. Fish Oil (Omega 3) 1000 mg PO BID
21. Simvastatin 20 mg PO DAILY
22. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
cholangitis
choledocholithiasis
acute renal failure
Discharge Condition:
alert and oriented x ___ few steps with walker
independent with adl's
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dyspnea // PNA, edema PNA, edema
IMPRESSION:
In comparison with the study of ___, the cardio mediastinal silhouette
is essentially unchanged. Opacification of the left base is consistent with a
small effusion and mild atelectatic changes. No definite pulmonary vascular
congestion. There is again some prominence of the right hilar region
especially when compared to the study of ___. This could merely
represent relatively lower lung volumes. If clinically possible, a repeat
study should be obtained with full inspiration and a lateral view would be
helpful.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with sepsis, ___ // pyleonephritis, abscess,
hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdominal ultrasound ___.
FINDINGS:
The right kidney measures 11.1 cm. The left kidney measures 10.2 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Urinary bladder is decompressed by indwelling catheter preventing evaluation.
IMPRESSION:
1. Unremarkable renal ultrasound examination.
2. Decompressed urinary bladder prevents detailed evaluation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with dyspnea, wheezing, hypoxia // effusion,
edema
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Mild cardiomegaly is stable. Pulmonary vascular congestion is stable. Small
bilateral effusions with adjacent atelectasis have increased on the left.
There is no pneumothorax.
IMPRESSION:
Mild vascular congestion.
Increased in atelectasis in the left lower lobe and small left effusion.
Stable small right effusion
Radiology Report
INDICATION: ___ year old man with diarrhea, abdominal distension // megacolon
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: None available
FINDINGS:
There is layering of pleural effusion on the left, with atelectasis and patchy
consolidation in the retrocardiac region.
ERCP biliary stent is seen in the right abdomen, with associated pneumobilia.
The bowel gas pattern is normal with gas seen in nondistended loops of large
and small bowel. There is no evidence of ileus or obstruction. There is no
evidence of intraperitoneal free air.
There is a possible fracture in the lateral aspect of a left lower rib.
IMPRESSION:
1. No evidence of toxic megacolon. 2. Possible fracture of left lateral lower
rib, clinical correlation for focal tenderness suggested.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with CHOLEDOCHOLITHIASIS NOS
temperature: 98.5
heartrate: 72.0
resprate: 18.0
o2sat: 98.0
sbp: 134.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | ___ w/hypopituitarism, HTN, who is s/p remote cholecystectomy
who presented from ___ with choledocholithiasis and
billary obstruciton complicated by chlangitis with Klebsiell and
enterococcal bacteremia.
1. Billiary obstruction. Pt found to have obstructing stone in
distal CBD on ultrasound prior to transfer to ___. He
underwent ERCP with relief of the obstruciton and placement of a
plastic stent for drainage. His liver function tests have
normalized during this hospital stay. He has been able to
tolerat a regular diet. He will need a stent pull performed in 8
weeks which has been arranged with Dr ___ at ___.
2. Cholangitis with GPC and GNR bacteremia. He was found to have
enterococcal and Klebsiella bacteremia. He was initally treated
with broad spectrum antibiotics and narrowed to Unasyn. He will
complete a two week course of IV antibiotics on ___ given the
enterococcal bacteremia. He has a midline in place at the time
of discharge which will need to be removed when his treatment is
complete.
3. ___ due to ATN. He had a rise in his creatinine with a peak
of 4.4 during this admission. He was seen by the renal service
and found to have muddy brown casts consistent with ATN. This is
likely due to his relative hypotension due to his sepsis on
admission. His renal function has improved daily and is at 2.1
on the time of discharge. His baseline Creatinine is 1.5.
4. Hypertension. He was continued on his carvedilol and his
enalapril was held due to his ___. His blood pressures were
markedly elevated to around 200 systolic off his ace inhibitor.
He was started on amlodipine 10 mg daily which has brought his
blood pressure under good control. His ACE will need to be
resumed and amlodipine discontinued when his renal function
plateaus at his new baseline.
5. Panhypopit due to pituitary adenoma. He was treated with
stress dose steroids on admission due to his sepsis and was
weaned sucessfully to his home dose of 10 mg bid of
hydrocortisone. He continued his thyroid and testosterone
supplementation as well.
6. Leukocytosis. He had leukocytosis to 18K which was slowly
improving during his stay. At the time of discharge it is 12K.
Given slow improvement, repeat cultures from blood and urine
were checked and were no growth. C-dif testing was negative.
Echo was negative for endocarditis (entroccocal bacteremia). He
will need a repeat CBC in a few days post discharge to document
normalization.
7. Hematuria/BPH. Pt had some hematuria during this admisison
which resolved. However, he has microscopic hematuria on his
last u/a. It is likely due to foley trauma but he will need
repeat u/a done and evaluation by urology if persistent. He has
continued his home BPH regimen. He voided successfully with
removal of foley placed on admission.
8. Diarrhea/loose stools. Pt had some diarrhea for which c-dif
testing was done and was negative. His stools are not watery. It
is likely due to Unasyn. He was given lomotil as needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atorvastatin / Penicillins / Codeine / Oxycodone
Attending: ___.
Chief Complaint:
Left leg swelling/edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of CHF, CAD, afib on coumadin, ESRD on HD and
COPD presenting with pain, swelling and erythema on the left
leg. Patient has had chronic ulcers of the left and right leg
since last ___ and had been on vancomycin for ___ompleted on ___. Today noted increased swelling and pain
in the left calf, which had changed from previous baseline as
she had not had pain in the leg before No f/c. No n/v/d. No
CP/SOB. The blisters on her legs occasionally drain non
purulent fluid, but she reports no increased drainage over the
past few days. Was given a dose of vancomycin at HD.
.
In the ED, initial VS were: ___ 131/113 16 99%. Patient was
not given any additional antibiotics given recent dose at HD.
Underwent LLE ultrasound which showed no evidence of DVT, but
substantial subcutaneous edema. Patient was to be admitted to
floor, but repeat vitals showed BP of 80/50. Patient was
asymptomatic at that time without CP/SOB, lightheadedness or
visual changes. Was given a 500cc bolus and responded to 89/50.
Subsequently admitted to MICU for further monitoring of vital
signs.
.
On arrival to the MICU, patient is alert and oriented, in NAD.
Notes minimal pain and swelling in the left calf. Denies f/c.
Denies CP/SOB. Of note, she reports multiple week history of
cough for which she was started on doxycycline by her PCP ___
___. Otherwise has no other complaints.
Past Medical History:
- Hypertension
- Hyperlpidemia
- Ventricular tachycardia s/p ICD implantation ___ ___
___ Cognis 100-D Dual chamber-ICD)
- Heart failure, systolic and diastolic, EF 35%
- Atrial fibrillation on warfarin
- Coronary artery disease
- COPD
- Psoriasis
- Gout
- Allergic rhinitis
- Hypokalemia (in past)
- Anemia, normocytic
- ESRD
- Obesity
- Cataract
- Colon polyps
- Diverticulosis of colon with hemorrhage
Social History:
___
Family History:
Non-contributory, mother with 'heart trouble'
Physical Exam:
Vitals: T: 97.6 BP: 91/57 P: 65 R: 26 O2: 98%
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breathsounds diffusely, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: trace pitting edema bilaterally in lower exytremities,
healed ulcers on right lower extremity without drainage, LLE
with surrounding erythema blanching, minimal serosanguineous
drainage from ulcers, 1+ DP pulses bilaterally
Neuro: alert and oriented x 3, moving all extremities
Physical Exam on Discharge:
VS: 97.7, 91/68, 88, 18, 96RA
General: Alert, oriented, no acute distress, sitting up in bed
comfortable
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Systolic murmur heard at the RUSB, regular rate and rhythm,
normal S1 + S2
Lungs: CTAB anteriorly
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext:Right leg healed ulcers on right lower extremity without
drainage, LLE with minimal erythema, much regressed from the
border. Pt with decreased edema of the leg compared to yesterday
1+DP pulse, and still with 2+pitting edema in the thigh. Small
1mm ulcer without purulence draining out of it. Tender to
palpation.
Neuro: alert and oriented x 3, moving all extremities
Pertinent Results:
Admission Labs:
___ 12:57PM ___
___ 04:55PM PLT SMR-LOW PLT COUNT-85*
___ 04:55PM NEUTS-84.1* LYMPHS-10.2* MONOS-5.3 EOS-0.3
BASOS-0.2
___ 04:55PM WBC-8.4# RBC-3.99* HGB-11.6* HCT-38.6 MCV-97
MCH-29.0 MCHC-29.9* RDW-17.0*
___ 04:55PM GLUCOSE-137* UREA N-10 CREAT-2.5*# SODIUM-142
POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-34* ANION GAP-13
___ 05:02PM LACTATE-2.0
___ 08:24PM LACTATE-1.6
Discharge Labs:
___ 06:28AM BLOOD WBC-4.4 RBC-3.99* Hgb-12.0 Hct-40.3
MCV-101* MCH-30.0 MCHC-29.7* RDW-17.4* Plt Ct-94*
___ 06:28AM BLOOD Glucose-95 UreaN-12 Creat-3.0*# Na-133
K-3.7 Cl-94* HCO3-29 AnGap-14
___ 06:28AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8
___ 06:29AM BLOOD Vanco-13.0
___ 05:02PM BLOOD Lactate-2.0
Micro:
Blood culture ___ PENDING
Imaging:
___ ___- IMPRESSION: Limited examination due to patient
discomfort and extensive subcutaneous edema with no evidence of
deep venous thrombosis in the left common femoral, superficial
femoral, or popliteal veins.
___ CXR- Severe cardiomegaly has worsened, but pulmonary
edema has cleared. Pleural effusion is small if any. Right
supraclavicular dual-channel dialysis catheter ends in the
region of the superior cavoatrial junction, unchanged.
Transvenous right atrial pacer and right ventricular pacer
defibrillator leads are in standard placements. No pneumothorax
or appreciable pleural effusion.
Medications on Admission:
Senna-Gen 8.6 mg Tab 2 Tablet(s) by mouth at bedtime
- Spiriva with HandiHaler 18 mcg & inhalation Caps 1 Capsule(s)
inhaled once a day
- cholecalciferol (vitamin D3) 1,000 unit Cap 1 Capsule(s) by
mouth once a day
- Calcium 500 500 mg calcium (1,250 mg) Tab
- pravastatin 20 mg Tab 1 Tablet(s) by mouth DAILY
- allopurinol ___ mg Tab 1 Tablet(s) by mouth EVERY OTHER DAY
- doxycycline hyclate 100 mg Cap 1 Capsule(s) by mouth BID
- Vitamin B-1 50 mg Tab
- albuterol sulfate HFA 90 mcg/Actuation Aerosol Inhaler 1
HFA(s) inhaled every six (6) hours
- furosemide 80 mg Tab 1 Tablet(s) by mouth twice a day
- amiodarone 200 mg Tab 1 Tablet(s) by mouth once a day
- Nitrostat 0.3 mg Sublingual Tab 1 Tablet(s) sublingually every
five minutes up to 3 times as needed as needed for chest pain
- ferrous gluconate 325 mg (37.5 mg iron) Tab 1 Tablet(s) by
mouth DAILY (Daily)
- zolpidem 5 mg Tab 1 Tablet(s) by mouth HS (at bedtime)
- tramadol 50 mg Tab 1 Tablet(s) by mouth for pain
- docusate sodium 100 mg Cap 1 (One) Capsule(s) by mouth twice a
day
- warfarin 1 mg Tab 1 Tablet(s) by mouth once a day
- Flovent HFA 110 mcg/Actuation Aerosol Inhaler 2 Aerosol(s)
inhaled twice a day
- B complex-vitamin C-folic acid ___ mcg Tab 1 Tablet(s) by
mouth DAILY
Discharge Medications:
1. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) cap Inhalation once a day.
3. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
4. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. allopurinol ___ mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Vitamin B-1 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
9. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual every five minutes with chest pain, take up to 3 as
needed for chest pain.
12. ferrous gluconate 325 mg (36 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS
(___).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
17. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day: on dialysis days take after your dialysis session.
Disp:*11 Tablet(s)* Refills:*0*
20. vancomycin 1,000 mg Recon Soln Sig: sliding scale dose
Intravenous with dialysis: based on Vanc trough drawn at
dialysis. To be given through ___.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary: Cellulitis
Secondary: Atrial fibrillation, Chronic systolic heart failure,
End stage renal disease on dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with left leg swelling, here to evaluate for
deep venous thrombosis.
COMPARISON: Venous duplex ultrasound of the upper extremity last performed on
___.
TECHNIQUE: Duplex venous ultrasound of the left lower extremity.
FINDINGS: Grayscale and Doppler sonography was performed of the bilateral
common femoral, left superficial femoral, and left popliteal veins.
Assessment is extremely limited due to patient discomfort. The visualized
common femoral, left superficial femoral, and left popliteal veins show normal
compressibility, augmentation, and flow. The left calf veins were not
visualized due to extensive subcutaneous edema.
IMPRESSION: Limited examination due to patient discomfort and extensive
subcutaneous edema with no evidence of deep venous thrombosis in the left
common femoral, superficial femoral, or popliteal veins.
Radiology Report
AP CHEST 10:49 P.M. ON ___
HISTORY: COPD and cough.
IMPRESSION: AP chest compared to ___:
Severe cardiomegaly has worsened, but pulmonary edema has cleared. Pleural
effusion is small if any. Right supraclavicular dual-channel dialysis
catheter ends in the region of the superior cavoatrial junction, unchanged.
Transvenous right atrial pacer and right ventricular pacer defibrillator leads
are in standard placements. No pneumothorax or appreciable pleural effusion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: LEFT LEG PAIN
Diagnosed with CELLULITIS OF LEG, END STAGE RENAL DISEASE, CHRONIC AIRWAY OBSTRUCTION
temperature: 98.0
heartrate: 64.0
resprate: 16.0
o2sat: 99.0
sbp: 131.0
dbp: 113.0
level of pain: 8
level of acuity: 3.0 | ___ with history of CHF, CAD, afib on coumadin, ESRD on HD and
COPD presenting with LLE cellulitis.
.
# Cellulitis - patient with chronic ulcers on left lower
extremity presented with inreased pain and erythema and elevated
WBC consistent with cellulitis. She was recently treated for
cellulitis in that leg with vancomycin on previous
hospitalization in ___. After two days of vancomycin, she
had marked improvement in the leg with decreased erythema in
color and was dramatically receeding from the marked border
below the area. There was still ___ edema in the left
thigh, but improved compared to admission when it was harder and
was obscuring the anatomical markings of the knee on extension.
___ of the leg was negative for DVT. She was seen by vascular
surgery during this admission, who did not feel that surgery was
indicated and agreed with the proposed medical management.
-Vancomycin dosed with HD x 2 weeks (last day ___
-Ciprofloxacin 500mg po qday x 2 weeks (last day ___
.
#Hypotension - patient hypotensive to SBPs in ___. In the ED
there was concern that she was possibly septic, so she was
admited to the ICU. She received 1.5L of IV fluids and her BP
repsonded well. Her baseline blood pressure is in the low ___
systolic. After being on the floor she continued to have lower
blood pressures and was asymptomatic with them.
-She will require monitoring of her blood pressure during
dialysis sessions
.
# Afib - on amiodarone and coumadin as outpatient. Stable. INR
therapeutic at 2.1 on admission. Continued on home medications
- cont warfarin and amiodarone
.
# CAD - Continued on amiodarone, pravastatin and SLNGT
.
# COPD - on spiriva, alubterol and fluticasone at home. Also
uses 2L NC at night at home. Has had cough for the past ___
weeks and recently started on doxycycline on ___, which was
continued for planned 7 day course total and will be completed
on ___. No worsening SOB. CXR showed no evidence of PNA
.
# chronic sytolic CHF - Continued on home furosemide dose.
Patinet is not on ACEI prior to this admission, and this was not
started given her hypotension.
.
# ESRD - Continued on HD schedule of ___. She received an
extra ultrafiltration session on ___ to try to remove
more fluid from her left leg.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall with loss of consciousness, pain in the
left shoulder and posterior scalp.
Major Surgical or Invasive Procedure:
CT head scan ___ with repeat CT head ___, sling applied to
left upper extremitiy. Posterior scalp laceration with staples.
History of Present Illness:
Per Dr. ___:
HPI: Mr. ___ is a ___ year old male transferred from OSH for
management of R SAH and SDH after fall from back of a pickup
truck last night with headstrike and LOC. He does not remember
the details surrounding the fall. He complains now of pain in
the
left shoulder and posterior scalp.
At OSH, CT head showed a small R SDH and a small R SAH. The
laceration on his occiput was repaired. CT Torso showed a 16mm
displaced L clavicular fracture and a small amount of fluid in
the anterior mediastinum.
Past Medical History:
PMH: Heroin addition (has not used for one month)
PSH: none
Social History:
___
Family History:
Non-contributary
Physical Exam:
On Admission:
GCS: E: 4 V: 6 M: 5
Vitals: 98.2 90 127/57 14 97% RA
GEN: A&O, NAD
HEENT: Laceration on occiput repaired at OSH without evidence of
active bleeding. PERRL
CV: RRR
PULM: Clear to auscultation b/l
Chest: No tenderness to palpation over ribs or sternum, no
deformities
ABD: Soft, non-tender, non-distended, no abrasions
Pelvis: No tenderness to palpation or stepoffs
Extremities: Abrasion on L shoulder. Radial and DP pulses
palpable bilaterally.
Neuro: CN ___ intact. No gross neurological deficits
Back: No c-spine tenderness, some mild tenderness in lower back,
no stepoffs
on Discharge: ___:
VS: T: 97.6, BP: 114/66, HR: 62, RR: 20, 99%o2 RA
General: A+Ox3, NAD
HEENT: Laceration on occiput repaired at OSH without evidence of
active bleeding. PERRL
CV: RRR, no extra heart sounds auscultated
PULM: Clear to auscultation b/l
Neuro: No gross neurological deficits, alert and oriented x 3
Back: No c-spine tenderness, no point tenderness
Extremeties: no edema
Pertinent Results:
___ 05:40AM BLOOD WBC-10.7 RBC-4.75 Hgb-13.9* Hct-39.8*
MCV-84 MCH-29.2 MCHC-34.8 RDW-14.7 Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-91 UreaN-8 Creat-0.7 Na-137 K-4.1
Cl-101 HCO3-25 AnGap-15
___ 05:40AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9
___ Head CT: No evidence of subdural hematoma, but there
are two right frontal hemorrhagic contusions, at least one of
which is new since the prior study.
Non-Contrast CT of Head: Impression: Small right frontal
subdural
hematoma and small right frontal subarachnoid hemorrhage.
___ CT chest: Displaced fracture of the inferior border of
the body
of the scapula
Medications on Admission:
suboxone (no regular prescriber)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
3. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
do NOT take and drive or operate heavy machinery
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD Q12H pain Duration: 1 Week
Apply to dry skin.
Discharge Disposition:
Home
Discharge Diagnosis:
Fall, Multitrauma: small R SAH, SDH, L scapular fx, mediastinal
hematoma, posterior scalp laceration.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with R SAH and R SDH on OSH CT after fall from
pickup truck // Please assess interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
Coronal and sagittal as well as thin bone-algorithm reconstructed images were
obtained.
DOSE: DLP: 891.93 mGy-cm
CTDI: 55.73 mGy
COMPARISON: CT of the head dated ___.
FINDINGS:
Allowing for differences in technique, there has been no significant interval
change in the size of the small right frontal parenchymal hemorrhage (2:12).
There has been interval full development of a new focus of intraparenchymal
hemorrhage in the right frontal lobe (2:7). There is no significant mass
effect. The ventricles and sulci are unchanged in size and configuration.
Incidental note is made of a cavum septum pellucidum. There is preservation of
gray-white matter differentiation, and the basal cisterns appear patent.
No osseous abnormalities seen. There is a small amount of fluid in the left
sphenoid sinus. Otherwise the visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No evidence of subdural hematoma, but there are two right frontal hemorrhagic
contusions, at least one of which is new since the prior study.
RECOMMENDATION(S): Repeat head CT for further evaluation.
NOTIFICATION: Updated read and recommendations were discussed with Dr. ___
by Dr. ___ telephone at 10:12 on ___, approximately 15 min after
discovery.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ETOH, s/p Fall, Transfer
Diagnosed with BRAIN HEM NEC-COMA NOS, FX SCAPULA NEC-CLOSED, MV TRAFF ACC NEC-PASNGR
temperature: 98.2
heartrate: 90.0
resprate: 14.0
o2sat: 97.0
sbp: 127.0
dbp: 57.0
level of pain: 7
level of acuity: 2.0 | ___ year-old male admitted to ___ after sustaining a fall from
the back of a pickup truck, reporting loss of consciousness,
left shoulder pain and posterior scalp pain. At the hospital, pt
was found to have a left clavicular fracture and had a CT scan
which showed a small right subarachnoid hemorrhage and subdural
hematoma. On review of his second CT scan, he was found to have
two right frontal hemorrhagic contusions which were not seen on
the prior CT scan. Neurosurgery was consulted and found the
patient to be neuroligically intact and no aditional imaging was
recommended. The Orthopaedics team provided him with a sling for
comfort for his left upper extremety as his left clavicular
fracture was inoperable.
He was seen by pain management to determine an appropriate pain
medication regimen. It was recommended that he follow-up with an
outpatient clinic to receive his Suboxone prescription. A
request was placed for Social Work and Occupational Therapy for
further evaluation. Both were unavailble to evaluate the
patient today, but the patient declined staying an additional 24
hours for observation. You was prescribed a lidocaine patch,
tylenol and Flexeril to control his pain as per recommendations
of the Chronic Pain Service.
He was advised to follow-up with his primary care doctor in 1
week to have his staples removed from his scalp. An additional
appointment was made for him to follow-up with his PCP ___ 4
weeks. Both Neuro-surgery and Orthopedics did not feel a
follow-up visit was warrented. It was also recommended for him
to follow-up with the Acute Care Surgery team in 2 weeks. An
appointment was made, but his mother did not feel that they
would get back down here. Follow-up instructions were reviewed
with the patient and his mother at discharge. He was discharged
to home in stable condition in his mother's care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Postop fever, diarrhea, incontinence of urine, urinary hesitancy
& frequency
Major Surgical or Invasive Procedure:
___: Incision and drainage of abdominal wall abscess
History of Present Illness:
___ is an ___ year old male who is status post
laparoscopic cholecystectomy and cystic duct exploration on
___ with Dr. ___.
The patient reports having intermittent fevers and chills over
the past 2 days. His maximum temperature at home was 102.1. He
denies any pain, nausea, or vomiting. He reports that he has
had some diarrhea that started 2 days ago. He has since stopped
his bowel regimen. He reports that he has been having some
urinary hesitancy and frequency. He has also had some urgency
and
incontenance, which is different that normal for him.
He initially went to a hospital on ___, where he was
treated with rocefin and zosyn. While there, he was noted to
have a positive UA. The patient also reports that he saw his
PCP yesterday, who sent blood cultures. Per the patient, these
cultures have had growth, but this has not be verified at this
time.
Prior to his cholecystectomy, he initially presented with
cholangitis, at which time an US demonstrated dilated CBD and
gallstones. He was initially treated with ERCP. Following his
ERCP, he experienced delerium, as well as an ___. Given these
complications, the patient's cholecystectomy was delayed until
___. Following the ERCP, he was started on Lovenox for
segmental portal venous thrombi.
The patient was transferred to ___ for further care.
Past Medical History:
HTN
___ appendectomy in 1950s
___ lap chole ___
diverticulosis
heart murmur
Social History:
___
Family History:
Mother died at ___ from old age and father died of old age at ___.
Physical Exam:
Prior Discharge:
VS: 98.6, 92, 147/66, 18, 95% RA
GEN: Pleasant with NAD, AAO x 3
CV: RRR, no m/r/g
PULM: CTAB
ABD: Right midline laparoscopic incision open with moist-to-dry
dressing and minimal surrounding erythema. Other incisions
healed well and c/d/i.
EXTR: Warm, no c/c/e
Pertinent Results:
___ 08:00AM BLOOD WBC-7.6 RBC-2.95* Hgb-8.9* Hct-27.0*
MCV-91 MCH-30.1 MCHC-33.0 RDW-13.6 Plt ___
___ 08:00AM BLOOD Glucose-109* UreaN-18 Creat-1.1 Na-140
K-3.8 Cl-105 HCO3-25 AnGap-14
___ 06:46AM BLOOD ALT-17 AST-25 AlkPhos-44 TotBili-0.7
___ 08:00AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.8
___ 10:55 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
___ 4:27 am SWAB Source: Incision site.
WOUND CULTURE (Preliminary): BACTERIA.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
___ BLOOD CULTURE: Pending
Medications on Admission:
1. Acetaminophen 650 mg PO TID
2. Enoxaparin Sodium 80 mg SC Q12H
3. Lisinopril 40 mg PO DAILY
4. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
5. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
2. Lisinopril 40 mg PO DAILY
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 2.5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*20 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO HS
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth once a day
Disp #*30 Capsule Refills:*0
5. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 For PICC
insertion Duration: 1 Dose
6. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
7. Ertapenem Sodium 1 g IV Q24H Duration: 10 Doses
Last dose on ___
RX *ertapenem [Invanz] 1 gram 1 g IV once a day Disp #*10 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Superficial surgical site infection.
2. Urinary tract infection
3. Bacteremia
4. Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with fevers, chills status post cholecystectomy 3 days prior.
Evaluate for postoperative changes.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside hospital CT from ___ from the same day.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. Main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: The patient is status post cholecystectomy with dirty shadowing
seen in the gallbladder fossa likely representing Surgicell inserted in the
gallbladder fossa to achieve hemostasis, from the operative report. Small
amount of echogenic material adjacent to the shadowing focus these likely a
small amount of infiltrated pericholecystic fat.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.5 cm.
KIDNEYS: Single view of the right kidney demonstrates no hydronephrosis.
IMPRESSION:
Status post cholecystectomy with echogenic material in the gallbladder fossa
likely representing Surgicell, as noted in the operative report. No evidence
of intrahepatic biliary dilatation.
NOTIFICATION: Findings were discussed with the surgery resident, Dr. ___
in person.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new line // new left brachial POWER PICC 49
cm
TECHNIQUE: PA and lateral view radiographs of the chest.
COMPARISON: None.
FINDINGS:
The left-sided PICC line ends at the origin of the SVC, and could be advanced
5 cm for optimal positioning. The moderate bibasilar atelectasis is commonly
seen postoperatively. There is no focal consolidation, pulmonary edema or
pleural abnormality. The cardiomediastinal silhouette is normal.
IMPRESSION:
1. PICC line ends at the origin of the SVC, and could be advanced 5 cm for
optimal positioning.
2. Moderate postoperative bibasilar atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, R/O SEPSIS.
Diagnosed with SEVERE SEPSIS , ADV EFF MEDICINAL NOS
temperature: 99.4
heartrate: 84.0
resprate: 20.0
o2sat: 94.0
sbp: 115.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ uncomplicated laparoscopic cholecystectomy ___
was readmitted to the HPB Surgery Service with bacteremia and
urinary tract infection. He was initially treated with Zosyn
and Rocephin, then meropenem when blood cultures from OSH were
found to have grown E. coli sensitive to carbapenems. Blood and
urine cultures were repeated at our institution ___, on the
date of admission, and urine culture was positive for E. coli
sensitive to carbapenems. Abdominal CT scan from OSH revealed
small superficial wound infection. The patient underwent
incision and drainage of a small superficial surgical site
infection with local anesthesia and his wound was packed with
dry sterile gauze, which was changed BID during hospitalization.
The wound cultures were positive for gram negative rods
(preliminary). ID was consulted and PICC line was placed for
long term antibiotics. Patient was switched to Ertapenem prior
discharge per ID recommendations.
The patient was found to have some difficulty with bladder
emptying, as his post-void residuals were approximately 150 ml,
however, he was making adequate urine. He did not have
leukocytosis and was afebrile for 48 hours prior to discharge.
Patient was started on Flomax and recommended to follow up with
his PCP or ___ to discuss this problem.
He was continued on Lovenox, which was started during his prior
admission when he was found to have segmental portal venous
thrombi, and he will continue this at home as well.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
R patellar tendon rupture
Major Surgical or Invasive Procedure:
___: R patellar tendon repair
History of Present Illness:
___ police officer who was stepping out of his car today when he
twisted his knee and felt a pop, falling to the floor. Unable to
bear weight on the leg, unable to straighten his knee. Found to
have patella ___ on Xray warranting an orthopaedic surgery
consultation.
Past Medical History:
Hamstring tear RLE, hemorrhoids, HTN, OSA, HLD
Social History:
___
Family History:
Non-contributory
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
RLE in cylinder cast
Right lower extremity fires ___
Right lower extremity SILT superficial peroneal, deep peroneal
and tibial distributions
Right lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
___ CT RLE:
1. Patellar tendon rupture with associated patella ___.
2. No definite fracture identified.
___ Xray R knee: Patella ___ with soft tissue prominence in
the anterior aspect of the knee which is suggestive of patellar
tendon injury. No acute fracture or dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY
Discharge Medications:
1. Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY
2. Valsartan 160 mg PO DAILY
3. Acetaminophen 1000 mg PO Q8H
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily
Disp #*60 Capsule Refills:*0
5. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneously Every night
Disp #*28 Syringe Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours Disp
#*90 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth Twice daily
Disp #*60 Capsule Refills:*0
8. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
R patellar tendon rupture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with knee pain/swelling. felt a dislocation of the
knee cap which he self reduced
TECHNIQUE: Right knee, three views
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is identified. Patella ___ is noted, and
there is mild soft tissue swelling within the anterior soft tissues of the
knee, which is suggestive of patellar tendon injury. Mild to moderate
tricompartmental degenerative changes with osteophytic spurring are present.
There may be a small joint effusion. Well corticated ossific densities are
noted ventral to the distal femoral condyles as well as the anterior knee
joint, potentially dystrophic in etiology. No concerning lytic or sclerotic
osseous abnormality is present.
IMPRESSION:
Patella ___ with soft tissue prominence in the anterior aspect of the knee
which is suggestive of patellar tendon injury. No acute fracture or
dislocation.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 7:09 ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with patellar tendon rupture // preop chest xray
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are slightly low. This accentuates the size of the cardiac
silhouette which is borderline enlarged. Mediastinal and hilar contours are
unchanged. The pulmonary vasculature is not engorged. Atelectasis is noted
in the lung bases without focal consolidation, pleural effusion or
pneumothorax. No acute osseous abnormalities demonstrated.
IMPRESSION:
Low lung volumes with minimal bibasilar atelectasis.
Radiology Report
INDICATION: Evaluate for tibial plateau injury in a patient with right knee
pain and patella ___.
TECHNIQUE: Helical axial MDCT images were acquired through the right knee
without the administration of IV contrast. Reformatted images in coronal and
sagittal axes were generated.
DOSE: Acquisition sequence:
1) Spiral Acquisition 11.8 s, 25.1 cm; CTDIvol = 20.1 mGy (Body) DLP =
506.1 mGy-cm.
Total DLP (Body) = 506 mGy-cm.
COMPARISON: Right knee radiographs from ___.
FINDINGS:
As noted on recent radiograph, there is patella ___ with a large amount of
soft tissue swelling anterior to the right knee. The patellar tendon is
discontinuous and retracted inferiorly, compatible with tendon rupture. The
gap between the tendon fragments measures approximately 9 mm. Ossific
densities within the inferior aspect of the patellar tendon may reflect
sequela of previous injury. There is no appreciable joint effusion. There
are multiple well corticated ossific densities medial to the patella, possibly
dystrophic. No definite fracture is identified. There is mild to moderate
tricompartmental degenerative disease with osteophytic spurring.
IMPRESSION:
1. Patellar tendon rupture with associated patella ___.
2. No definite fracture identified.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Knee injury
Diagnosed with Strain of right quadriceps muscle, fascia and tendon, init, Exposure to other specified factors, initial encounter
temperature: 98.3
heartrate: 72.0
resprate: 18.0
o2sat: 98.0
sbp: 164.0
dbp: 91.0
level of pain: 6
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right patellar tendon rupture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right patellar tendon repair, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT with bilateral UE support in the right lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, headache, diarrhea, rash
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo man w/ no past medical history presenting with
non-progressing fevers, chills, headache, myalgias and diarrhea
since ___. He also developed a non palpable rash that
started on his upper bod and has spread across the rest of his
body for the last 3 days. There is no hand or foot or mucosal
membrane involvement. Patient reports the fevers are getting up
to 103 taken orally and the headache is constant, frontal
wrapping around his head, with no photophobia, sonophobia, or
neck stiffness. His neck muscles are a little tight when he
turns his head side to side, but fine up and down and he
attributes this to golf which he played recently. Patient is
also reporting epigastric and RLQ abdominal pain which is
constant, worse with position changes and nonradiating.
Per patient report he has a positive initial Lyme test and
taken 3 pills of doxycycline prescribed to him by his PCP.
In the ED, initial vitals were: 97.8 105 147/83 18 100% RA
- Exam notable for:
Well-appearing male in no acute distress, oropharynx within
normal limits no rash or exudate, no lymphadenopathy, no nuchal
rigidity.
Lungs are clear to auscultation, no murmur on cardiac exam,
regular rate and rhythm
Significant right upper quadrant and epigastric tenderness,
mild right lower quadrant tenderness.
Rash on the torso including the chest, abdomen, back with mild
upper thigh involvement and no hand or leg involvement
- Labs notable for:
- Imaging was notable for:
CXR IMPRESSION: Mild right lower lobe atelectasis. No pleural
effusion or focal consolidation.
CT abd w/out contrast
Similar appearance of three fluid collections around the
stomach, with
associated gastric wall thickening, and surrounding
inflammatory change. No extraluminal contrast or free
intra-abdominal air. Findings suggest gastritis with possible
sequela of prior perforated ulcer. Recommend endoscopic
correlation.
CT abd w/ contrast
1. Three fluid collections around the stomach measuring up to
6.5 x 3.6 cm, with gastric wall thickening and surrounding
inflammation and stranding. These findings suggest gastritis and
possibly the sequela of prior perforated gastric ulcer, though
no discrete ulceration is visualized currently. No extraluminal
gas. Recommend correlation with endoscopy.
2. Tiny bilateral pleural effusions with minimal bilateral
lower lobe
atelectasis.
- ID was consulted: plan to treat as intra-abdominal abscesses
until proven wrong. Begin Cipro/Flagyl
ACS rec contrast study to evaluate for leak- no leak was seen
so rec admission to medicine
- Patient was given: CTX, Tylenol, 40 K, 1L NS, pantoprazole,
cipro
- Vitals prior to transfer: 99.3 90 114/77 16 95% RA
Tmax in ED 102.9
Upon arrival to the floor, patient reports that he developed
fevers to 103, chills, body aches, a frontal headache and
diarrhea on ___. These symptoms have been stable and not
progressing except the diarrhea. Denies photosensitivity.
Diarrhea is non-bloody and did increase yesterday; he had about
10 watery small volume stools yesterday. No n/v but has lost his
appetite. No blood in urine. No CP/SOB. Ongoing abd pain
initially epigastric now also RLQ. Rash started a few days ago,
before the doxy and spread across his body- non pruritic. No
dysuria. Per PCP referral lyme screen came back positive, but I
did not see that in OMR. Abd pain above umbilicus and dull and
constant, worse w/ movement.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
situational depression in the setting of a break up
esophageal ring s/p dilation
Social History:
___
Family History:
cousin w/ ___ and another cousin w/ UC
Physical Exam:
Admission PHYSICAL EXAM:
Vital Signs: 99.1 PO 119 / 68 99 18 95 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD, no restricted motion,
Kernigs and Brudinski negative
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, TTP in epigastric region and RLQ including
McBurney'spoint, non-distended, bowel sounds present, no
organomegaly, soft but + rebound
GU: No foley
Skin: non palpable erythematous rash diffusely over body, neck,
legs, abdomen
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
PHYSICAL EXAM ___:
VS: 99.1 PO 120 / 75 L 87 18 94 RA
General: Alert, oriented, no acute distress, pleasant man lying
in bed
HEENT: Sclerae anicteric, no conj pallor
Neck: no JVD. full range of motion
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mild in epigastric region, RUQ and RLQ, negative
___, non-distended, bowel sounds present, no organomegaly,
no rebound, no guarding
GU: No foley
Skin: erythematous, non raised rash diffusely over body, most
prominent in neck and dorsal torso. improved in interval since
___. no purpura
Ext: Warm, well perfused, 2+ pulses, no ___ edema
Neuro: grossly intact
Pertinent Results:
Labs:
====
___ 02:30PM BLOOD WBC-27.9* RBC-5.12 Hgb-13.9 Hct-42.9
MCV-84 MCH-27.1 MCHC-32.4 RDW-14.4 RDWSD-43.8 Plt ___
___ 07:45AM BLOOD WBC-21.0* RBC-4.44* Hgb-12.0* Hct-37.2*
MCV-84 MCH-27.0 MCHC-32.3 RDW-14.4 RDWSD-44.1 Plt ___
___ 08:02AM BLOOD WBC-17.4* RBC-4.54* Hgb-12.4* Hct-37.6*
MCV-83 MCH-27.3 MCHC-33.0 RDW-14.5 RDWSD-42.9 Plt ___
___ 02:30PM BLOOD Neuts-83* Bands-6* Lymphs-3* Monos-5
Eos-2 Baso-1 ___ Myelos-0 AbsNeut-24.83*
AbsLymp-0.84* AbsMono-1.40* AbsEos-0.56* AbsBaso-0.28*
___ 07:45AM BLOOD Neuts-87.5* Lymphs-2.7* Monos-7.0
Eos-0.7* Baso-0.2 Im ___ AbsNeut-18.39* AbsLymp-0.56*
AbsMono-1.47* AbsEos-0.15 AbsBaso-0.05
___ 02:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:45AM BLOOD ___ PTT-29.2 ___
___ 02:30PM BLOOD Glucose-94 UreaN-20 Creat-1.2 Na-133
K-3.0* Cl-91* HCO3-26 AnGap-19
___ 08:02AM BLOOD Glucose-99 UreaN-11 Creat-0.8 Na-137
K-3.9 Cl-100 HCO3-25 AnGap-16
___ 02:30PM BLOOD ALT-27 AST-30 AlkPhos-211* TotBili-0.8
DirBili-0.4* IndBili-0.4
___ 07:45AM BLOOD Albumin-2.9* Calcium-8.2* Phos-3.2 Mg-2.2
___ 07:45AM BLOOD TSH-1.9
___ 02:30PM BLOOD CRP-GREATER THAN ASSAY
___ 02:20PM BLOOD HIV Ab-Negative
___ 02:20PM BLOOD HIV1 VL-PND
___ 08:02AM BLOOD GASTRIN - FROZEN-PND
___ 07:45AM BLOOD WBC-19.4* RBC-4.68 Hgb-13.0* Hct-38.9*
MCV-83 MCH-27.8 MCHC-33.4 RDW-14.3 RDWSD-42.9 Plt ___
___ 07:45AM BLOOD Glucose-86 UreaN-13 Creat-0.8 Na-140
K-4.3 Cl-101 HCO3-24 AnGap-19
___ 07:45AM BLOOD ALT-61* AST-81* LD(LDH)-274* AlkPhos-193*
TotBili-0.7
___ 07:45AM BLOOD GGT-126*
STUDIES
=======
-CXR ___:
IMPRESSION:
Mild right lower lobe atelectasis. No pleural effusion or focal
consolidation.
-CT A/P with IV Contrast ___:
IMPRESSION:
1. Three fluid collections around the stomach measuring up to
6.5 x 3.6 cm,
with gastric wall thickening and surrounding inflammation and
stranding.
These findings suggest gastritis and possibly the sequela of
prior perforated
gastric ulcer, though no discrete ulceration is visualized
currently. No
extraluminal gas. Recommend correlation with endoscopy.
2. Tiny bilateral pleural effusions with minimal bilateral lower
lobe
atelectasis.
3. No evidence for cholecystitis or appendicitis.
-CT A/P with Oral Contrast ___:
IMPRESSION:
1. Three fluid collections around the stomach measuring up to
6.5 x 3.6 cm,
with gastric wall thickening and surrounding inflammation and
stranding.
These findings suggest gastritis and possibly the sequela of
prior perforated
gastric ulcer, though no discrete ulceration is visualized
currently. No
extraluminal gas. Recommend correlation with endoscopy.
2. Tiny bilateral pleural effusions with minimal bilateral lower
lobe
atelectasis.
3. No evidence for cholecystitis or appendicitis.
MICRO
=====
___ 3:31 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
___ 3:31 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___:
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with Abdominal pain, fever, rash// Lymphadenopathy,
Effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size is normal. Mediastinal and hilar contours are
unremarkable. Pulmonary vasculature is not engorged. Streaky right lower
lobe opacity likely reflects atelectasis without focal consolidation. No
pleural effusion or pneumothorax is detected. No acute osseous abnormality is
visualized.
IMPRESSION:
Mild right lower lobe atelectasis. No pleural effusion or focal
consolidation.
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with Epigastric and RLQ pain, rash
NO_PO contrast// Cholecystitis, Hepatitis, Appendicitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 5.6 s, 61.4 cm; CTDIvol = 16.9 mGy (Body) DLP =
1,038.0 mGy-cm.
Total DLP (Body) = 1,050 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Bilateral dependent atelectasis is seen. Tiny bilateral pleural
effusions are seen. There is no evidence of pericardial effusion. Heart size
is normal.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of suspicious focal lesions. A 0.8 cm simple cyst is
seen in segment ___ (2:21). There is no evidence of biliary dilatation. The
gallbladder is unremarkable.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. Fat plane about the pancreas
is preserved without peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach wall is thickened about the greater and lesser
curvatures with mild wall edema, as well as involving the region of the antrum
and pylorus with adjacent fat stranding. Three fluid collections are seen
adjacent to the stomach measuring up to 6.5 cm x 3.6 cm in axial dimension
(2:24) abutting the lesser curvature and segment ___ of the liver, measuring
approximately 4.4 x 2.4 cm (601:23) abutting the distal stomach and the
inferior margin of the left lobe of the liver, and 2.1 x 1.1 cm adjacent to
the greater curvature (601:20). Duodenum appears normal. No gastric outlet
obstruction. No pneumoperitoneum.
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No significant
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Bilateral inguinal hernias containing fat are noted.
IMPRESSION:
1. Three fluid collections around the stomach measuring up to 6.5 x 3.6 cm,
with gastric wall thickening and surrounding inflammation and stranding.
These findings suggest gastritis and possibly the sequela of prior perforated
gastric ulcer, though no discrete ulceration is visualized currently. No
extraluminal gas. Recommend correlation with endoscopy.
2. Tiny bilateral pleural effusions with minimal bilateral lower lobe
atelectasis.
3. No evidence for cholecystitis or appendicitis.
RECOMMENDATION(S):
1. Correlation with endoscopy for impression point 1.
Radiology Report
EXAMINATION: CT ABDOMEN WITHOUT CONTRAST.
INDICATION: ___ with epigastric pain, concern for abscess, leakage of
contrast from gastric ulcer
TECHNIQUE: Multidetector CT images of the abdomen were acquired without
intravenous contrast. Non-contrast scan has several limitations in detecting
vascular and parenchymal organ abnormalities, including tumor detection. Oral
contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.7 s, 40.9 cm; CTDIvol = 16.2 mGy (Body) DLP = 660.6
mGy-cm.
Total DLP (Body) = 661 mGy-cm.
COMPARISON: CT Abdomen and Pelvis ___
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis. There are trace bilateral
pleural effusions.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is residual contrast in the collecting system. Kidneys are
symmetric in size. There is no hydronephrosis.
GASTROINTESTINAL: The stomach demonstrates wall thickening along the lesser
curvature and antrum, as seen previously. Again seen, are multiple fluid
collections, better evaluated on prior study with intravenous contrast. The
largest collection abuts the lesser curvature of the stomach and measures
approximately 6.7 x 4.3 x 3.5 cm (series 2, image 23). Additional smaller
fluid collections are seen adjacent to the gastric antrum, (series 2, image
29) and along the distal aspect of the stomach (series 2, image 31). No new
fluid collections are seen. There remains stranding adjacent to the greater
curvature of the stomach. No extraluminal contrast or air is identified.
There is no bowel obstruction. There is fat in the wall of the ileum. Imaged
large bowel loops are unremarkable. Appendix is normal.
LYMPH NODES: There are no enlarged retroperitoneal or mesenteric lymph nodes.
VASCULAR: There is no upper abdominal aortic aneurysm. No atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Similar appearance of three fluid collections around the stomach, with
associated gastric wall thickening, and surrounding inflammatory change. No
extraluminal contrast or free intra-abdominal air. Findings suggest gastritis
with possible sequela of prior perforated ulcer. Recommend endoscopic
correlation.
2. Fat in the wall of the ileum, can be seen in chronic inflammation.
RECOMMENDATION(S): Endoscopic correlation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fever, Rash
Diagnosed with Fever, unspecified
temperature: 97.8
heartrate: 105.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 83.0
level of pain: 7
level of acuity: 3.0 | ___ yo man without significant past medical history who presented
with one week of fevers, rash, headache, myalgia and diarrhea,
found to have ___ fluid collections on CT, leukocytosis
and elevated inflammatory markers.
# fever
# elevated inflammatory markers
# abdomoinal fluid collections
Had CT abdomen upon initial evaluation that showed three
___ fluid collections of undetermined significance. CT
was also suggestive of proximal small intestine
micro-perforation. The patient was started on empiric
ciprofloxacin and metronidazole, and there was a subsequent
improvement in his symptoms, fever curve and leukocytosis. EGD
was suggested as next step for workup but after discussion with
GI service was deferred as risk of worsening possible
perforation was felt to outweigh benefit. ___
biopsy/drainage of fluid collections was also discussed but risk
of accessing fluid (likely route through liver) and entering
possibly acutely infected abdomen was felt to outweigh benefit;
given the patient's overall improvement with antibiotics, there
was less concern for an uncontrolled source of infection. He was
switched to PO Cipro and Flagyl on ___. He remained afebrile
for >24h but had persistent leukocytosis. Given pt's strong
preference to be monitored at home, he was discharged with plans
for close follow up and with plan to perform EGD in 1 week and
repeat CT abdomen in 2 weeks. He will also follow up with ID,
and overall antibiotic course will be determined based on
interval change in fluid collections. PO pantoprazole was also
added. Blood cultures and stool studies were pending at time of
discharge. Gastrin level to evaluate for gastrinoma was pending
at time of discharge. Hospital course, including persistent
leukocytosis and modestly elevated LFTs, were reviewed with PCP
on day after discharge (discharged on a holiday).
#Concern for Lyme disease
Saw PCP days after development of symptoms, and reported
positive screen for Lyme serology at ___. The patient was
started on doxycycline, and confirmatory Western blot testing
was pending during admission. Believed this was unrelated to
abdominal fluid collections. Doxy was continued pending final
Lyme workup. Parasite smear was negative, Anaplasma was
negative.
# situational depression- continued home Zoloft.
TRANSITIONAL ISSUES
-follow up final stool studies and gastrin level
-needs ID, GI and PCP follow up
-___ LFTs, RUQ if uptrending
-needs EGD in 1 week to evaluate microperforations
-needs repeat abdominal CT with IV and PO contrast in 2 weeks to
assess fluid collections
-follow up Lyme Western Blot and adjust doxycycline treatment
course as necessary
-follow up need for pantoprazole pending EGD results
# CODE: full (presumed)
# CONTACT: mother ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache (right thalamic intraparenchymal hemorrhage)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old woman with unknown hand dominance, hx of atrial
fibrillation on ASA and Xarelto for the last 2 months,
diastolic
heart failure, hypertension, hyperlipidemia, dementia,
depression
and anxiety presented to hospital as a victim of fall.
The history was obtained with the help of ___ interpreter
and
her daughter.
During the previous week she was very active for ___ and
was up late most of the nights.
Last time she was last seen normal was yesterday around 1600,
she
noted to her daughter that she feels tired and light headed,
after she ate her dinner and took her meds she went to bed at
1800 and woke up at 0730 with headache and dizziness: she noted
to her daughter that she was light headed, she could walk and
sit
on the chair, had her breakfast and her medications including
ASA
and Xarelto around 8 am, she told her daughter that she would be
fine and she does not want to see a doctor for this, she fell
when she tried to walk to the kitchen to make a coffee for
herself, she fell on her back, and hit her head,after the fall
she was floppy and unresponsive, she did not have eye or body
shaking movement, she became responsive after seconds, her
daughter and her son-in law helped her to stand up and walk to
the chair but she could not put her feet on the ground, the EMS
arrived and she was transferred here as a trauma victim.
Per EMS at that time her BP was around 140s, also per previous
records her BP was under 150 most of the time.
as the patient had headache and left side weakness, NCHCT was
performed which showed right BG hemorrhage.
Neurology was consulted for further work-up and treatment.
The patient is not cooperative with the exam but in the limited
exam: BP was less than 139 during the stay in ED.
She is tired, awake but prefers to close her eyes.
Oriented to her name, knows that she is in hospital, disoriented
to time, inattentive, CN: she is blind in her left eye and seem
that has left side neglect.
Left NLF flattening, Left pronator drift, weakness in Del and
FE.
While she was in ED another CT of the brain was check with
interval of 5 hours which did not show worsening of the
bleeding,
Hem was consulted and recommended 10 mg po vit K, as the
bleeding
is stable no need for PLT tx.
ROS can not be obtained but she said she had headache which was
resolved, she feels hungry and thirsty.
Per records she has hx of exertional SOB, difficulty in her
walking dementia and hypothyroidism
Past Medical History:
Atrial fibrillation (diagnosed ___
Anxiety/Depression (not taking prescribed citalopram)
Hypothyroidism (not taking prescribed synthroid)
Hypertension
Possible TIA ___ yr ago (per outpatient clinic notes)
Social History:
___
Family History:
No known hx heart failure or MI.
Physical Exam:
Admission exam:
EXAM:
98.3 87 122/80 28 99%
General: Awake, not cooperative, not in pain.
HEENT: has cervical collar. She has bil ptosis right more than
left, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: has collar
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR no m/r/g
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally.
Skin: no rashes or lesions noted.
Neurological examination:
- Mental Status:
She is tired, awake but prefers to close her eyes.
Her head is turned to her right.
Oriented to her name, knows that she is in hospital, disoriented
to time, inattentive.
Language is fluent but she talks very slow can not repeat today
is a cold day in ___ in ___.
Speech was not dysarthric.
NAMING Pt. was able to name only some of the high frequency
objects.
REGISTRATION and RECALL
Pt. refused to try to register 3 objects , she said she is
hungry
and thirsty and does not want to answer more questions.
COMPREHENSION
Able to follow 1 step commands both midline and appendicular but
has constant right-left confusion.
She is blind in her left eye and her head is turned to the
right, does not pay attention to her left as much as she does to
the right.
- Cranial Nerves:
I: Olfaction not tested.
II: left eye had surgical unreactive pupil and she is not able
to
see with this eye. On the right side she refused to open her
eyes
and did not let me to evaluate her pupil, she blinks to threats
to the right eye in all directions but not to the left eye, has
bilateral corneal reflex. Funduscopic exam could not be
performed
III, IV, VI: has right gaze deviation, but able to pass midline.
V: Facial sensation seems intact to light touch.
VII: has left NLF Flattening but her smile is pretty symmetric
VIII: she has difficulty in Hearing bilaterally.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline
- Motor: Normal bulk, tone throughout. has left pronator drift
No adventitious movements, such as tremor, noted. No asterixis
noted.
Formal dedicated motor exam can not be perform, but she does not
have any weakness in the right upper limb muscle, including DEL
TRIC, BIC, WF, WE, FF, FE.
on the left side: She has weakness in her left DEL, and FE ___,
otherwise Tric, bic and WE, WF are ___
In the lower ext she is able to flex the hip knee and ankle
bilaterally, as she does not follow constantly and is
inattentive
could not check the strenght but she moves the ___
symmetrically.
- Sensory: It is hard to tell but No gross deficits to light
touch, pinprick in UE and ___.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 2 1
R ___ 2 1
There was no evidence of clonus.
___ negative. Pectoral reflexes absent.
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, No dysmetria on FNF. can
not
perform HKS
Pertinent Results:
Admission labs:
___ 10:32AM BLOOD WBC-9.7 RBC-5.25 Hgb-15.9 Hct-47.8 MCV-91
MCH-30.3 MCHC-33.3 RDW-13.7 Plt ___
___ 10:32AM BLOOD Plt ___
___ 01:22PM BLOOD ___ PTT-39.4* ___
___ 10:32AM BLOOD Glucose-97 UreaN-22* Creat-0.7 Na-140
K-4.2 Cl-108 HCO3-25 AnGap-11
___ 10:32AM BLOOD CK(CPK)-36
___ 02:38AM BLOOD ALT-21 AST-27 CK(CPK)-33
___ 10:32AM BLOOD CK-MB-2
___ 10:32AM BLOOD cTropnT-<0.01
___ 02:38AM BLOOD CK-MB-2
___ 06:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:38AM BLOOD Albumin-4.0 Calcium-8.8 Phos-3.3 Mg-2.0
Cholest-136
___ 02:38AM BLOOD VitB12-494
___ 02:38AM BLOOD %HbA1c-5.5 eAG-111
___ 02:38AM BLOOD Triglyc-83 HDL-51 CHOL/HD-2.7 LDLcalc-68
___ 02:38AM BLOOD TSH-3.2
___ 10:30AM URINE Color-Straw Appear-Clear Sp ___
___ 10:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
.
Micro:
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
.
Studies:
NCHCT ___
There is a 2 cm focus of hemorrhage and surrounding vasogenic
edema in the
right globus pallidus. There is no mass effect on the nearby
___ ventricle or shift of the normally midline structures.
There is no major vascular territory infarction, or mass.
Enlargement of the ventricles and extra-axial spaces is
compatible with atrophy. Periventricular and subcortical white
matter hypointensities are consistent with small vessel ischemic
changes. The basal cisterns are patent. Gray-white matter
differentiation is preserved.
The visualized paranasal sinuses and mastoid air cells are
normally
pneumatized and clear. The skull and extracranial soft tissues
are
unremarkable.
IMPRESSION:
Intraparenchymal hemorrhage in the right basal ganglia
compatible with
hypertensive hemorrhage.
.
.
CT/CTA ___
FINDINGS: Right thalamic hemorrhage is stable. No progression
has occurred. There is sphenoid sinus opacification. There
appears to be a small infundibulum versus aneurysm measuring 2
to 3 mm
pointing inferiorly at the distal M1 segment. Atherosclerotic
narrowing of the right superior M2 branch is seen. There are
bilateral robust PCOMs. Best noted on the sagittal MIP, there
is question of a 2 to 3 mm right distal ICA aneurysm possibly
arising from the posterior communicating artery origin.
IMPRESSION: Question tiny aneurysms in the right distal M1
segment and
possibly at the origin of the right PCOM.
Stable right thalamic hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
2. Furosemide 40 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Meclizine 12.5 mg PO DAILY:PRN dizziness
5. Metoprolol Succinate XL 200 mg PO DAILY
6. Rivaroxaban 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
5. Meclizine 12.5 mg PO DAILY:PRN dizziness
6. Senna 1 TAB PO BID:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. Fleet Enema ___AILY:PRN constipation
9. Diltiazem Extended-Release 120 mg PO DAILY
10. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS
11. Furosemide 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Intraparenchymal hemorrhage
Secondary diagnosis: Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Right basal ganglia hemorrhage, now with left-sided neglect.
Evaluate for expanding hemorrhage.
COMPARISON: Same-day non-contrast head CT, 12:57 p.m. and 4:38 p.m.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 938.31 mGy-cm.
CTDIvol: 53.26 mGy.
FINDINGS:
CT HEAD WITHOUT CONTRAST: There is no change compared to examination from
___ hours prior, with redemonstration of a 1.7 x 1.7 cm right thalamic
intraparenchymal hemorrhage without change in size given difference in plane
of imaging. There is redemonstration of a thin surrounding rim of edema as
well as minimal localize mass effect, but without midline shift. There is no
new hemorrhage or infarct. The ventricles and sulci are unchanged in size and
configuration and remain prominent, suggestive of age-related involutional
change. Mild areas of periventricular white matter hypodensity are suggestive
of chronic small vessel ischemic disease. Atherosclerotic calcifications are
noted in the carotid siphons bilaterally. The orbits are unremarkable. No
fracture is identified. The left sphenoid is opacified. The remainder of
visualized paranasal sinuses, mastoid air cells and middle ear cavities are
clear.
IMPRESSION: No change in right thalamic intraparenchymal hemorrhage compared
to examination from ___ hours prior given slight difference in scan plane.
No new focus of hemorrhage.
Radiology Report
TECHNIQUE: CT of the head with contrast.
HISTORY: Right thalamic hemorrhage. Rule out vascular malformation.
COMPARISON: CT head ___.
FINDINGS: Right thalamic hemorrhage is stable. No progression has occurred.
There is sphenoid sinus opacification.
There appears to be a small infundibulum versus aneurysm measuring 2 to 3 mm
pointing inferiorly at the distal M1 segment. Atherosclerotic narrowing of the
right superior M2 branch is seen. There are bilateral robust PCOMs. Best
noted on the sagittal MIP, there is question of a 2 to 3 mm right distal ICA
aneurysm possibly arising from the posterior communicating artery origin.
IMPRESSION: Question tiny aneurysms in the right distal M1 segment and
possibly at the origin of the right PCOM.
Stable right thalamic hemorrhage.
Radiology Report
AP CHEST, 4:05 P.M., ___
HISTORY: ___ woman with shortness of breath. Question volume
overload.
IMPRESSION: AP chest compared to ___:
Severe cardiomegaly with configuration suggesting left atrial enlargement and
possible mitral disease, and very large pulmonary arteries are chronic. Left
lung is grossly clear. Peribronchovascular opacification in the right upper
lobe is similar in appearance to ___ and could be asymmetric edema, a
finding seen with mitral regurgitation. Pleural effusion is small if any. No
pneumothorax.
Radiology Report
HISTORY: Possible aspiration.
COMPARISON: None.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. Penetration was noted with both thin and nectar-thick liquids.
No gross aspiration. For further details, please refer to speech and swallow
division note in OMR.
IMPRESSION:
Penetration with thin and nectar-thick liquids but no aspiration.
Radiology Report
HISTORY: History of recent right thalamic bleed, now with increased
somnolence.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were acquired.
DLP: ___
COMPARISON: Comparison is made to CTA head dated ___, and CT
head dated ___.
FINDINGS:
As compared to the most recent prior examination, there has been no
significant change in the size of a right thalamic intraparenchymal
hemorrhage, which measures 1.8 x 1.8 cm. There has, however, been a slight
interval increase in the degree of edema is seen adjacent to the hemorrhage.
Minimal local mass effect remains present, but without midline shift. There
is no evidence of new hemorrhage or infarct.
Prominent ventricles and sulci suggest age-related involutional changes or
atrophy. Small areas of periventricular white matter hypodensity are
consistent with chronic small vessel ischemic disease.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
No fracture is identified. The left sphenoid sinus remains opacified. The
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
otherwise clear. Atherosclerotic mural calcification of the internal carotid
arteries is noted bilaterally. The globes are unremarkable.
IMPRESSION:
1. Stable appearing right thalamic intraparenchymal hemorrhage, with
minimally increased surrounding tissue edema.
2. No evidence of new hemorrhage or infarct.
Radiology Report
LEFT HIP SERIES, ___ AT 14:27
CLINICAL INDICATION: ___ with left hip pain, length discrepancy,
question fracture.
No comparison studies.
An AP view of the pelvis and two additional views of the left hip are
submitted ___ at 14:27.
Mild degenerative changes of the lumbosacral junction. Bones are mildly
osteopenic and there are degenerative changes of the symphysis pubis. No
displaced fracture or dislocation is evident. Specifically, there is no
evidence of a fracture involving the left hip joint. There are mild
degenerative changes of both hip joints. Residual contrast is seen within the
sigmoid and colon. There is evidence of diverticulosis.
IMPRESSION:
1. No evidence of displaced fracture or dislocation of the left hip.
Diverticulosis. Degenerative changes of both hip joints and the lower lumbar
spine.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Questionable pneumonia or pulmonary edema. Evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the pre-existing left upper
lobe parenchymal opacity has almost completely resolved. However, the cardiac
silhouette remains markedly enlarged and signs of vascular distention are
seen. In addition, a left retrocardiac parenchymal opacity persists.
Overall, the findings suggest persistent mild-to-moderate pulmonary edema with
a decreasing right upper lobe pneumonia. No pleural effusions.
Radiology Report
HISTORY: Left knee pain status post fall, question fracture.
LEFT KNEE, TWO VIEWS.
No oblique view obtained. Allowing for this, there is severe diffuse
osteopenia. No fracture or dislocation is identified. No lipohemarthrosis or
gross effusion is detected on the cross-table lateral view. There are
tricompartmental degenerative changes, including what appears to be severe
patellofemoral osteoarthritis. Scattered vascular calcification noted.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Evaluation for pulmonary edema and pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is mild fluid
overload but no overt pulmonary edema. Size of the cardiac silhouette is
moderately enlarged. Scarring is seen at the bases of the right upper lobe.
No pneumonia, no pleural effusions.
Radiology Report
PORTABLE CHEST OF ___
COMPARISON: Radiograph ___.
FINDINGS: Stable cardiomegaly accompanied by pulmonary vascular congestion
without interstitial or alveolar edema. Apparent new opacity in left
retrocardiac region is difficult to assess due to extreme apical lordotic
projection and overlying soft tissue structures. Repeat radiograph with
improved positioning would be helpful to confirm or exclude a parenchymal or
pleural abnormality in this area.
Radiology Report
CHEST RADIOGRAPH
INDICATION: History of chronic heart failure, shortness of breath,
questionable pulmonary edema.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no change in
severity of the pre-existing mild-to-moderate pulmonary edema. Moderate
cardiomegaly persists. No pleural effusions. No pneumonia. Minimal
atelectasis at the left lung bases.
Radiology Report
HISTORY: Fall and new left-sided weakness
TECHNIQUE: MDCT data were acquired through the head without intravenous
contrast. Images were displayed in multiple planes after reconstruction with
bone and soft tissue algorithms.
CTDIvol: 51 mGy
DLP: 892 mGy-cm
COMPARISON: No prior neuroimaging at this institution
FINDINGS:
There is a 2 cm focus of hemorrhage and surrounding vasogenic edema in the
right globus pallidus. There is no mass effect on the nearby ___ ventricle or
shift of the normally midline structures. There is no major vascular
territory infarction, or mass. Enlargement of the ventricles and extra-axial
spaces is compatible with atrophy. Periventricular and subcortical white
matter hypointensities are consistent with small vessel ischemic changes. The
basal cisterns are patent. Gray-white matter differentiation is preserved.
The visualized paranasal sinuses and mastoid air cells are normally
pneumatized and clear. The skull and extracranial soft tissues are
unremarkable.
IMPRESSION:
Intraparenchymal hemorrhage in the right basal ganglia compatible with
hypertensive hemorrhage.
Urgent findings were discussed with Dr ___ phone at ___ after discovery
at 1305 on ___
Radiology Report
HISTORY: Fall
TECHNIQUE: MDCT data were acquired through the head without intravenous
contrast. Images were displayed in multiple planes.
CTDIvol: 37 mGy
DLP: 778 mGy-cm
COMPARISON: None
FINDINGS:
There is no cervical spine fracture, malalignment, or significant degenerative
disease. The pre- and paravertebral soft tissues are normal. The thyroid
gland is homogeneous. There is mosaic attenuation of lung parenchyma. The
aerodigestive tract is patent.
IMPRESSION:
No cervical spine fracture or malalignment.
Radiology Report
HISTORY: Status post fall, was found to have right basal ganglia bleed.
COMPARISON: Same-day non-contrast head CT 12:57 p.m.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 1114.9 mGy-cm.
CTDIvol: 54.42 mGy.
FINDINGS:
CT HEAD WITHOUT CONTRAST: Again identified is acute intraparenchymal
hemorrhage, centered in the right thalamus and posterior limb of the right
internal capsule, measuring approximately 1.8 x 1.5 cm, not significantly
changed compared to examination from four hours prior. There is localized
mass effect and surrounding rim of edema without shift of midline structures.
No new focus of hemorrhage is identified. There is no acute infarct. The
ventricles and sulci are unchanged in size and configuration and are mildly
prominent, suggestive of age-related involutional change. Trace
periventricular white matter hypodensities are compatible with chronic small
vessel ischemic disease. The basal cisterns remain patent and there is
preservation of gray-white matter differentiation. Atherosclerotic
calcifications are noted in the carotid siphons bilaterally. The orbits are
unremarkable. No fracture is identified. The left sphenoid air cell is
completely opacified. The remainder of the visualized paranasal sinuses,
mastoid air cells and middle ear cavities are clear.
IMPRESSION: No significant change in right thalamic intraparenchymal
hemorrhage. No new focus of hemorrhage.
Gender: F
Race: HISPANIC/LATINO - SALVADORAN
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with INTRACEREBRAL HEMORRHAGE
temperature: 98.3
heartrate: 87.0
resprate: 28.0
o2sat: 99.0
sbp: 122.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ year-old woman with unknown hand dominance, hx of a fib on
anti coag therapy( anti factor X)which was started about 2
months
ago, dementia, depression and anxiety presented to hospital s/p
fall with a right basal ganglia intraparenchymal hemorrhage.
Rivaroxaban was held (plan to hold this for 2 months) with
aspirin monotherapy continued for atrial fibrillation.
.
ACTIVE ISSUES
# Intaparenchymal hemorrhage: She woke up on the AM of admission
with dizziness and had a fall when she tried to walk to the
kitchen. She also reported headache at that time. She was
brought to the ED where NCHCT was performed which showed right
BG hemorrhage. Neurology was consulted for further work-up and
treatment.
While she was in ED another CT of the brain was checked after an
interval of 5 hours which did not show worsening of the
bleeding, Hem was consulted and recommended 10 mg po vit K, as
the bleeding was stable no need for PLT tx. She was admitted to
neurology service for close observation. She could not tolerate
MRI. It seemed that her bleed was hypertensive in nature. While
MRI could help evaluate for underlying vascular malformations,
such causes would be unlikely. The plan is to hold rivaroxaban
for 2 months with aspirin monotherapy in the meantime and then
resume prior home regimen should she not sustain any
complications in the meantime.
# Atrial fibrillation: While admitted she had intermittent runs
of afib with RVR. She was started on IV diltiazem and metoprolol
and titrated up to achieve good heart rate control.
.
# UTI: Started Bactrim for Proteus, day 1 = ___. Day 7 =
___. While UA was bland, >100,000 Proteus found in urine. She
was treated with antibiotics (Ceftriaxone) until ___ without
further complications.
.
# Agitation: Not clear that the patient had hyperactive
delirium; family members said that she is very stubborn. Treated
for all metabolic, infectious derangements that could be found.
.
# Volume overload: Patient reportedly on lasix 40mg po daily at
home; reduced here but she may need to be increased back to 40mg
daily should she develop any edema or should her weight rise.
# Feeding: She passed her initial bedside speech and swallow
eval but continued to have resistance to eating. She was started
on Remeron 7.5mg daily with the hope of improving her appetite.
She had improvement in her appetite, especially with food
supplied by the family.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
midline placement
History of Present Illness:
___ is a ___ man with stage IV NSCLC BRAF V600E
mutated on dafrafenib/trametinib with known mets to spine, R
shoulder, abdominal wall, who presents to ED from clinic after
found to have hyperkalemia (5.6) and ___ (Cr 2.5 from 1.6).
Reports feeling at his recent baseline today; denies urinary sx,
back pain. Has L shoulder pain and right-sided abdominal pain,
but this is not new and is related to metastases.
Patient has been on dafrafenib/trametinib since ___ after
progressing through carboplatin/nab-paclitaxel and
pembrolizumab.
Last several months he has developed progressive disease
including admission from ___ to ___ for pain control with
known progressing painful mets in his shoulder, back, and
abdominal wall. He was being evaluated for additional clinical
trials at this time. He was most recently instructed by his
oncologist to stop his dabrafenib/trametinib on ___. He was
seen
in ___ clinic today and found potassium was elevated to 5.6
and Cr was elevated to 2.5. WBC also elevated to 16.4 with 96%N
and toxic granulations. He was directed to the ED.
In the ED, initial VS were pain 5, T 97.2, HR 110, BP 150/95.
Patient was given NS, 10u IV insulin, IV dextrose, and 6mg po
dilaudid. Renal US was limited but showed no evidence of
hydronephrosis. Repeat labs notable for creatine down to 2.2 but
K of 6.5. He was given kayexelate and insulin/glucose again with
repeat K down to 5.9. He was given more fluids, and HR down to
87
prior to transfer.
On arrival to the floor, patient is having diffuse abdominal
pain
since he did not get his usual methadone in ED. He otherwise
feels well, has no complaints.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
Stage IV non-small cell lung cancer, squamous cell carcinoma,
BRAF V600E mutated, diagnosed ___.
- Status post cycle 1 day 1 (C1D1) of carboplatin 6 AUC D1 and
nab-paclitaxel 100 mg/m2 D1, D8 and D15 of a 21-day cycle as
part
of clinical trial ___ ___ on ___ and last dose of
nab-paclitaxel on ___ (progression);
- Palliative radiotherapy to right shoulder and T10-T12 spine
started on ___ and completed on ___
- Status post 2 cycles of pembrolizumab 2 mg/kg on ___ and
___ (progression).
- ___: Started on dabrafenib and trametinib
- ___ - ___: admitted to ___ with fevers, thought ___
dabrafenib
- ___ - ___: admitted to ___ ICU with fevers, SEPSIS,
unclear source. mekinist discontinued, continued on dabrafanib
BID
- ___: discontinued dabrafenib given uveitis
- ___: restarted dabrafenib and mekinist at half doses given
improvement in symptoms (dabrafenib 75mg BID, trametinib 2mg
every other day)
- ___: The imaging studies from ___ showed mostly
stable
tumor burden, with some metastatic sites with minimal decrease
in
size and others with minimal growth.
- ___: Small bowel obstruction, sp surgical ileotransverse
side-to-side colostomy. Post op course notable for CDiff.
- ___: The most recent CT Scans from ___ showed new
pulmonary
nodules, his prior bone disease, increased size of soft tissue
mass abutting the right lateral body wall, increasing disease
burden in the kidneys, increased number of liver lesions,
increasing osseous metastasis; all concerning for disease
progression.
- ___: Tissue biopsy on ___ (confirmed squamous cell
carcinoma and submitted to NGS-based test using the ___
action/fusion sequencing assays - consent obtained)
- ___: Liquid biopsy using FoundationACT to evaluate for
ctDNA genomic changes on ___. The results are expected in
around ___ weeks and may help determine if there is a clinical
trial or off-label inhibitor therapy that we could consider.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus, well controlled;
2. Hypertension, well controlled;
3. Hyperlipidemia, well controlled.
4. Lung cancer, as above
5. Squamous cell cancer
6. Cdiff colitis
7. SBO sp resection ___
Social History:
___
Family History:
Brother who suffered a CVA. Father deceased from an unknown
cause. Mother alive and doing well
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 145 / 99 97 18 98 Ra
GENERAL: Pleasant, lying in bed comfortably
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses, 2+ DP pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
diffusely tender without rebound or guarding; no hepatomegaly,
no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
Pertinent Results:
___ 09:53PM K+-5.9*
___ 05:38PM GLUCOSE-290* UREA N-40* CREAT-2.2* SODIUM-135
POTASSIUM-6.5* CHLORIDE-103 TOTAL CO2-19* ANION GAP-20
___ 05:30PM URINE HOURS-RANDOM UREA N-301 CREAT-26
SODIUM-65
___ 05:30PM URINE OSMOLAL-411
___ 05:30PM URINE UHOLD-HOLD
___ 05:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:30PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:55AM GLUCOSE-289*
___ 09:55AM GLUCOSE-289*
___ 09:55AM UREA N-41* CREAT-2.5* SODIUM-139
POTASSIUM-5.6* CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
___ 09:55AM ALT(SGPT)-33 AST(SGOT)-25 LD(LDH)-139 ALK
PHOS-215* TOT BILI-0.2
___ 09:55AM TSH-3.4
___ 09:55AM FREE T4-1.3
___ 09:55AM WBC-16.4*# RBC-3.46* HGB-7.7* HCT-25.3*
MCV-73* MCH-22.3* MCHC-30.4* RDW-21.2* RDWSD-54.7*
___ 09:55AM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 09:55AM PLT SMR-NORMAL PLT COUNT-343
renal Doppler:
IMPRESSION:
1. Evaluation limited due to poor penetration of deeper
structures and
inability of patient to hold breath.
2. No evidence of hydronephrosis. Normal bilateral ureteral
jets seen.
3. Arterial resistive indices are elevated and are higher on the
left
(0.77-0.83) compared to the right (0.61-0.78), but demonstrate
grossly
appropriate waveforms.
CT chest:
IMPRESSION:
Small layering nonhemorrhagic pleural effusions are new. Large
left lower
lobe consolidation increased since ___ is not
explained by any
bronchial obstruction. Consider pneumonia.
Although the large left upper lobe mass invading the mediastinum
and anterior
costal pleura is stable adjacent lung nodules have increased in
size and
number, probably direct metastatic invasion, and there are new
or at larger
hematogenous metastases in the right lung.
Adenopathy, minimal if any could be due to left lower lobe
pneumonia.
2 thoracic vertebral metastases are stable. Vertebral canal is
not
compromised. More reliable assessment would be obtained with
dedicated neuro
imaging.
shoulder xray:
IMPRESSION:
In comparison with study of ___, there is little
overall change.
Mild AC and minimal glenohumeral degenerative changes without
evidence of
abnormal calcification soft tissues.
If there is a serious clinical concern for metastatic
involvement,
radionuclide bone scanning could be obtained.
CT abd/pelvis IMPRESSION:
Limited noncontrast examination demonstrates interval increase
in metastatic
disease burden in the abdomen and pelvis, with enlarging hepatic
metastases,
osseous metastases, new ascites and an enlarging soft tissue
metastasis along
the right lateral abdominal wall. Known renal metastatic
disease is poorly
evaluated without contrast.
CXR ___:
IMPRESSION:
Left lower lobe consolidation, new since ___ is
concerning for
pneumonia given the provided clinical history.
Known left upper lobe mass. Pulmonary nodular opacities are
better evaluated
by CT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Atorvastatin 80 mg PO QPM
3. Bisacodyl ___AILY:PRN constipation
4. Dexamethasone 4 mg PO EVERY OTHER DAY
5. HYDROmorphone (Dilaudid) 6 mg PO BID:PRN Pain - Moderate
6. Losartan Potassium 50 mg PO DAILY
7. Methadone 10 mg PO TID
8. Omeprazole 20 mg PO DAILY
9. Senna 8.6 mg PO BID
10. Vitamin D ___ UNIT PO DAILY
11. Calcium Carbonate 500 mg PO QID:PRN reflux
12. Polyethylene Glycol 17 g PO DAILY
13. Docusate Sodium 100 mg PO DAILY:PRN constipation
14. Ondansetron 8 mg PO Q8H:PRN nausea
15. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Levofloxacin 500 mg PO Q48H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM shoulder pain
RX *lidocaine [Lidoderm] 5 % 2 patches daily, shoudler, abdomen
daily Disp #*60 Patch Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM abdomen
5. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day
Refills:*0
6. Ranitidine 300 mg PO DAILY
RX *ranitidine HCl 300 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 3 tablet(s) by mouth every 6 hours Disp
#*84 Tablet Refills:*0
9. Methadone 20 mg PO TID
RX *methadone 10 mg 2 by mouth three times a day Disp #*42
Tablet Refills:*0
10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
11. Atorvastatin 80 mg PO QPM
12. Bisacodyl ___AILY:PRN constipation
13. Calcium Carbonate 500 mg PO QID:PRN reflux
14. Dexamethasone 4 mg PO EVERY OTHER DAY
15. Docusate Sodium 100 mg PO DAILY:PRN constipation
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 8.6 mg PO BID
19. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
lung cancer with metastasis and cancer related pain
anemia
___ on CKD
possible pneumonia
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: History: ___ with stage IV ___ lung with known mets, who
presents with ___ and hyperkalemia.// Please do study with doopler. any
evidence of obstruction/hydronephrosis, renal artery stenosis ___ obstructive
mass
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
Evaluation limited due to poor penetration of deeper structures and inability
of patient to hold breath.
The right kidney measures 10.9 cm. The left kidney measures 9.9 cm. There is
no hydronephrosis or stones bilaterally. Heterogeneous appearance of the
renal parenchyma is consistent with diffuse infiltrative metastatic disease,
as seen on prior CT study. A 3 cm simple cyst is again seen in the lower pole
left kidney.
Renal Doppler: Intrarenal arteries show appropriate waveforms with sharp
systolic peaks and continuous antegrade diastolic flow. The resistive indices
of the right intra renal arteries range from 0.61-0.78. The resistive indices
on the left range from 0.77-0.83. Bilaterally, the main renal arteries are
patent with normal waveforms. The peak systolic velocity on the right is 43.8
centimeters/second. The peak systolic velocity on the left is 23.6
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance with
bilateral ureteral jets seen.
IMPRESSION:
1. Evaluation limited due to poor penetration of deeper structures and
inability of patient to hold breath.
2. No evidence of hydronephrosis. Normal bilateral ureteral jets seen.
3. Arterial resistive indices are elevated and are higher on the left
(0.77-0.83) compared to the right (0.61-0.78), but demonstrate grossly
appropriate waveforms.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old man with h.o metastatic lung ca, increasing pain and
FTT// reevaluate disease burden
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.3 s, 70.2 cm; CTDIvol = 7.5 mGy (Body) DLP = 525.3
mGy-cm.
Total DLP (Body) = 525 mGy-cm.
COMPARISON: CT abdomen and pelvis with contrast ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: Liver metastases were better evaluated on prior contrast
enhanced scan. Within this limitation, there is a 3.6 by 4.1 cm abdomen
hypoattenuating lesion in the right lobe of the liver, previously measuring
approximately 2.3 by 2.7 cm, using similar measurements. A hypoattenuating
lesion in the inferior right lobe of the liver measures 3.3 x 3.1 cm,
previously up to 1.6 cm. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are enlarged, with diffusely infiltrative metastatic
lesions better appreciated on prior contrast enhanced CT.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. Trace ascites noted.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The prostate is mildly enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Lytic right iliac lesion measures up to 3.8 cm, previously 3.5 cm.
SOFT TISSUES: The previously seen lesion along the right lateral abdominal
wall has markedly increased in size with a new large cystic component. The
soft tissue component measures approximately 4.7 x 3.7 cm, previously 3.7 x
2.9 cm. Stranding throughout the subcutaneous tissues is likely related to
anasarca.
IMPRESSION:
Limited noncontrast examination demonstrates interval increase in metastatic
disease burden in the abdomen and pelvis, with enlarging hepatic metastases,
osseous metastases, new ascites and an enlarging soft tissue metastasis along
the right lateral abdominal wall. Known renal metastatic disease is poorly
evaluated without contrast.
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA RIGHT
INDICATION: ___ year old man with h.o met lung ca, prior radiation, recurrent
pain// eval for metastasis
IMPRESSION:
In comparison with study of ___, there is little overall change.
Mild AC and minimal glenohumeral degenerative changes without evidence of
abnormal calcification soft tissues.
If there is a serious clinical concern for metastatic involvement,
radionuclide bone scanning could be obtained.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: Metastatic lung carcinoma. Increasing pain and failure to
thrive.
TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with
intravenous infusion of nonionic, iodinated contrast agent, following oral
administration of contrast agent for selected abdominal studies, and/or
followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0
or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm
MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck
will be reported separately. All images of the chest were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.3 s, 70.2 cm; CTDIvol = 7.5 mGy (Body) DLP = 525.3
mGy-cm.
Total DLP (Body) = 525 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: Compared to chest CT scanning since ___, most recently
___.
FINDINGS:
Supraclavicular and axillary lymph nodes are not pathologically enlarged and
there are no soft tissue abnormalities in the imaged chest wall suspicious for
malignancy. Increase in the general density of subcutaneous fat suggests
early anasarca.
Findings below the diaphragm will be reported separately.
There are no discrete thyroid lesions warranting further imaging evaluation.
Atherosclerotic calcification is not apparent head neck vessels or coronary
arteries. Mild enlargement main pulmonary artery, 33 mm, is unchanged. Aorta
is top-normal size, also stable. There is no pericardial effusion.
Small layering nonhemorrhagic pleural effusions, right greater than left, are
new.
Lymph nodes:
Mediastinum:
11 mm right upper paratracheal, previously 10 mm.
Prevascular 10 mm, previously 6 mm;
Right lower paraesophageal, 13 mm, previously 9 mm.
Lungs:
37 x 50 mm lobulated left upper lobe mass extending from the anterior aspect
of the left hilus to the anterior chest wall and invading the pericardium at
the level of the main pulmonary artery was 35 x 54 mm.
Subcentimeter nodules in the left upper lobe superior to this mass are more
numerous and larger. The large region of consolidation in the left lower lobe
has increased in size. There is no responsible bronchial obstruction and the
interval change is too great to attribute to malignancy. Pneumonia is more
likely. However a dozen new or growing nodules in the right lung, for example
right middle lobe, 3:141, are new or larger.
Chest cage:
Blastic and lytic lesion in the T8 vertebral body and the lytic lesion in T11
extending into the pedicle and lamina of T11 are unchanged; vertebral canal is
intact.. There are no new compression or pathologic fractures or additional
destructive bone lesions.
IMPRESSION:
Small layering nonhemorrhagic pleural effusions are new. Large left lower
lobe consolidation increased since ___ is not explained by any
bronchial obstruction. Consider pneumonia.
Although the large left upper lobe mass invading the mediastinum and anterior
costal pleura is stable adjacent lung nodules have increased in size and
number, probably direct metastatic invasion, and there are new or at larger
hematogenous metastases in the right lung.
Adenopathy, minimal if any could be due to left lower lobe pneumonia.
2 thoracic vertebral metastases are stable. Vertebral canal is not
compromised. More reliable assessment would be obtained with dedicated neuro
imaging.
Radiology Report
INDICATION: ___ year old man with stage IV lung cancer with new fever// Please
eval for pneumonia, effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ and CT chest dated ___
FINDINGS:
Unchanged elevation of the left hemidiaphragm with left basilar
atelectasis/consolidation, increased since prior. Small bilateral pleural
effusions are suspected. Multiple pulmonary nodular opacities are noted
throughout the right lung, better evaluated by CT. No pneumothorax.
Abnormal contours of the left upper mediastinum corresponding to the patient's
known left upper lobe mass. Otherwise the size of the cardiac silhouette is
within normal limits.
IMPRESSION:
Left lower lobe consolidation, new since ___ is concerning for
pneumonia given the provided clinical history.
Known left upper lobe mass. Pulmonary nodular opacities are better evaluated
by CT.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Hyperkalemia
Diagnosed with Acute kidney failure, unspecified, Hypokalemia
temperature: 97.2
heartrate: 110.0
resprate: 18.0
o2sat: 100.0
sbp: 150.0
dbp: 95.0
level of pain: 5
level of acuity: 2.0 | ___ y.o man with h.o metastatic stage IV NSCLC with known
mets to the spine, R.shoulder, abdomoinal wall who presented
from
clinic with hyperkalemia and ___, recent low grade fever during
prbcs, CXR with ?PNA, started on levoflox.
#hyperkalemia
___ on CKD
hyperkalemia suspected to be due to ___ likely secondary to
hyperglycemia-dehydration and possible ATN, in the setting of
___ use. s/p kayexelate, insulin/glucose in the ED. FENA 4.1%.
REnal u/s without acute process. TFTs wnl. Cortisol WNL. Uric
acid WNL. s/p 4L IVF and Cr still elevated from baseline.
Perhaps ATN on CKD and new baseline? No signs of obstruction.
Renal consulted and recommended urine protein-cr ratio,
Spep/upep, dc PPI and convert to h2 blocker, start Coreg for
HTN. ___ was held on admission. K trended down after
glucose/insulin and kayexylate early in admission. Pt with good
urine outpt. Pt will f/u with renal 2 weeks after discharge
*SPEP upep pending at discharge.
.#Possible pneumonia/low grade fever-low grade fever in the
setting of blood transfusion. Pt without any localizing sign of
infection. Specifically, no SOB, no cough despite CXR findings
of opacity. U/a unrevealing and no diarrhea. Pt was started on
IV vanco/cefepime o/n for this which was quickly converted to PO
levofloxacin for a ___M2, uncontrolled-pt with recent hyperglycemia, recently on
metformin. Likely worsened by dexamethasone use. Greatly
improved during admission and pt did not require any glargine
and often not sliding scale. He had a few episodes of AM
hypoglycemia as well.
#metastatic IV NSCLC
#pain related metastasis of shoulder, abdominal wall, spine. S/p
repeat imaging CT torso with worsening disease burden. He is not
currently on treatment at this time. Palliative care following,
apprec recs. Increased
methadone up to 20mg TID ___ continue dilaudid 6mg q4prn
Added lidocaine patch x2. Pt will follow up with his outpt
oncologist and palliative care after discharge. Called for prior
auth and left voicemail for increased methadone dosing to 20mg
TID.
#HTN-held home ___ given hyperkalemia, increased amlodipine
___.
Cannot use HCTZ or other diuretics given renal function. Started
coreg 3.125mg BID.
#anemia-suspect multifactorial. No obvious signs of bleeding at
this time. s/p 1 unit PRBCs ___. HCT stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg swelling, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of CAD, CHF with ejection fraction of 25%,
presenting with bilateral lower extremity edema, abdominal
distention and worsening dyspnea on exertion. Denies any chest
pain. Denies fevers or chills. Has noted worsening right lower
extremity edema and erythema over the last ___ days. Recently
switched from Lasix to torsemide. ___ wt gain in 6 days (pt
says felt great at 167lbs, and several wks PTA was 163lbs - on
admission is 189lbs.
In the ED, initial vitals 98 62 122/82 16 100% 4L. Ultrasound of
right lower extremity was negative for DVT; BNP 5752 mslightly
above baseline; Troponin at his baseline, CK-MB slightly
elevated; was given Aspirin, 40 mg Lasix, Foley placed.
Ceftriaxone given for presumptive right lower extremity
cellulitis. bEDSIDE u/s showed perihepatic ascites; no fluid
collection to tap. Abd is moderately distended. Vitals prior to
transfer: 122/67, 98, 12, 99ra, 97.4po.
Currently, the pt c/o SOB and worsened RLE swelling and pain
around the R knee. Endorses orthopnea. He denies any CP, HA,
abdom pain (does have abdom swelling); some loose stools earlier
this wk; some nausea no emesis. No cough. Dry mouth. Says was
taking 20mg torsemide, but also says he was taking whatever was
in his pharmacy's blister packs sent to him at ___.
ROS: per HPI.
Past Medical History:
1. Coronary artery disease s/p MI
2. Cardiac arrest post-op SFA surgery (___): initially PEA
arrest with shock-->CPR-->ROSC-->TEE showed severe anterior wall
hypokinesis-->transferred urgently to cardiac cath lab-->80% LAD
stenosis-->BMS to pLAD-->IABP
3. Peripheral vascular disease s/p R fem-bk pop ___, at OSH)
4. Ischemic cardiomyopathy with EF 25%, s/p ICD placement
5. Moderate AS (___): ___ 1.2 cm2, peak gradient 21 mmHg
6. HTN
7. HLD
8. Type II DM A1c 7.7 (___)
9. CVA in the setting of cardiac arrest (___)
10. Chronic kidney disease (baseline Cr 1.4-1.7)
11. History of COPD without any prior pulmonary function tests
12. Erectile dysfunction
13. Depression
14. Macular degeneration
15. Diabetic neuropathy
16. BPH
17. OSA with overnight desaturations to 88% on polysomnography
18. Hx transudative pleural effusions s/p thoracentesis on
___, attributed to CHF
Social History:
___
Family History:
His mother had breast cancer. Father had lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.8F, BP 100/83, HR 68, R 18, O2-sat 95% RA
GENERAL - chronically ill-appearing man in NAD, appears tired,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM somewhat dry,
OP clear
NECK - supple, no thyromegaly, JVP up to angle of jaw, no
carotid bruits
LUNGS - CTA bilat without basilar crackles, no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
HEART - irregularly irregular heart sounds, no ___ systolic
murmur at LLS border, nl S1-S2
ABDOMEN - NABS, soft/distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - RLE quite swollen compared to LLE. 3+ doughy
pitting edema b/l R>L.
SKIN - RLE has several scattered erythematous excoriations and
papules, and background faint erythema without brawny chronic
venous stasis changes.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
.
DISCHARGE
Pertinent Results:
ADMISSION LABS
___ 04:00PM BLOOD WBC-8.7 RBC-3.93* Hgb-11.8* Hct-37.1*
MCV-94 MCH-30.0 MCHC-31.9 RDW-17.4* Plt ___
___ 04:00PM BLOOD Neuts-74.7* Lymphs-16.1* Monos-6.6
Eos-2.3 Baso-0.3
___ 04:00PM BLOOD ___ PTT-33.6 ___
___ 04:00PM BLOOD Glucose-172* UreaN-56* Creat-1.5* Na-137
K-4.5 Cl-103 HCO3-22 AnGap-17
___ 06:40AM BLOOD ALT-18 AST-20 CK(CPK)-42* AlkPhos-84
TotBili-0.5
___ 04:00PM BLOOD CK-MB-11* proBNP-5752*
___ 04:00PM BLOOD cTropnT-0.18*
___ 06:40AM BLOOD CK-MB-7 cTropnT-0.18*
___ 06:40AM BLOOD Calcium-10.5* Phos-3.5 Mg-2.1
___ 04:11PM BLOOD Lactate-1.6
.
DISCHARGE LABS
.
IMAGING:
-___ RLE US:
IMPRESSION:
1. No evidence of DVT.
2. Stable right calf edema.
.
-___ CXR:
IMPRESSION: Left pleural effusion, slightly smaller, with
probably underling
atelectasis; however, underlying infectious process cannot be
completely
excluded in the correct clinical setting.
.
-___ abdom US:
IMPRESSION:
1. Liver demonstrates no focal liver lesions.
2. Small perihepatic ascites.
3. Left pleural effusion.
4. Cholelithiasis without cholecystitis.
5. Splenomegaly.
6. Patent main portal vein with waveform that may be influenced
by adjacent hepatic artery.
.
MICROBIOLOGY:
___ URINE URINE CULTURE-FINAL INPATIENT -NGTD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
-NGTD
___ BLOOD CULTURE Blood Culture, Routine-FINAL-
NGTD
Medications on Admission:
(from ___ d/c summary, confirmed w/ pt on ___
1. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation QAM (once a day (in the morning)).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
13. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
19. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
21. sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation QAM (once a day (in the morning)).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. zolpidem 5 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as
needed for insomnia.
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
20. sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day.
21. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
22. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*20 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute on chronic systolic heart failure
Secondary:
Coronary artery disease
Peripheral arterial disease
Hypertension
Diabetes type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with bilateral lower extremity swelling, dyspnea
on exertion, evaluate for pulmonary edema.
COMPARISON: PA and lateral chest radiograph, ___.
PA AND LATERAL VIEWS OF THE CHEST: Again noted is a left-sided pacemaker
device with one lead coursing through a left-sided SVC and terminating in the
right atrium, a second lead terminating in the right ventricle, coursing
through the right-sided SVC. The heart size is moderately enlarged. The
aorta is tortuous. There is again noted is left basilar opacity. The right
lung remains clear, although there is minimal blunting of the right
costophrenic angle which may suggest trace right pleural effusion. There is
no pneumothorax.
IMPRESSION: Left pleural effusion, slightly smaller, with probably underling
atelectasis; however, underlying infectious process cannot be completely
excluded in the correct clinical setting.
Radiology Report
INDICATION: ___ man with right lower extremity swelling and erythema,
history of femoropopliteal bypass in that leg. Evaluate for DVT.
COMPARISON: Unilateral lower extremity veins, ___.
TECHNIQUE: Grayscale and Doppler sonograms of the right common femoral, right
superficial femoral and right popliteal veins show normal compressibility,
flow and augmentation. Right calf veins are patent. Stable edema of the
right calf is again noted.
IMPRESSION:
1. No evidence of DVT.
2. Stable right calf edema.
Radiology Report
INDICATION: ___ man with history of coronary artery disease with
congestive cardiac failure, now presenting with distention of the abdomen.
Evaluate for portal vein thrombosis and ascites.
COMPARISON: None.
ABDOMINAL ULTRASOUND: The liver demonstrates no focal liver lesions. The
gallbladder demonstrates gallstone. The main portal vein is patent with
waveform impaceted by adjacent hepatic artery pulsations. The spleen measures
13 cm and is top normal. The common bile duct measures 0.4 cm and is within
normal limits. There is small perihepatic fluid. There is a left pleural
effusion.
IMPRESSION:
1. Liver demonstrates no focal liver lesions.
2. Small perihepatic ascites.
3. Left pleural effusion.
4. Cholelithiasis without cholecystitis.
5. Splenomegaly.
6. Patent main portal vein with waveform that may be influenced by adjacent
hepatic artery.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: ABD SWELLING
Diagnosed with SHORTNESS OF BREATH, SWELLING OF LIMB
temperature: 98.0
heartrate: 62.0
resprate: 16.0
o2sat: 100.0
sbp: 122.0
dbp: 82.0
level of pain: 13
level of acuity: 2.0 | Mr. ___ is a ___ year old male with hx of CAD/CVA/PVD s/p ICD
and with congestive heart failure (EF 25%) and recent admission
for acute on chronic CHF exacerbation in ___, now p/w shortness
of breath and lower extremity edema (R>L), c/w acute on chronic
systolic CHF.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
esophageal impaction
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
This is a ___ year-old Male with a PMH significant for
esophageal achalasia (diagnosed in the ___, trialed CCBs and
nitrates; s/p three prior Botox injections following food
impaction, s/p esophageal myotomy at ___ in ___ who now
presents with 7-days of acute onset crampy abdominal pain,
nausea
with emesis and loose, non-bloody stools associated with
odynophagia to solids and liquids.
.
The patient initially awoke 7-days prior with acute onset ___
crampy abdominal pain in a band-like distribution, without
radiation that has been intermittent; associated with nausea and
food particulate and bilious emesis episodes. He also had a few
episodes of loose, watery and non-bloody stools. He denies
fevers
or chills. Over the course of several days he started to note
odynophagia to solids and liquids, without inciting factor. He
notes no identifiable foods that precipitate his achalasia
flares. He notes some decreased PO intake over the last several
days, without weight loss (stable at 163-lbs). He was seen at
___ and Dr. ___ recommended
against endoscopy. He was transferred to ___ for further
management. He is passing flatus and his last BM was formed
yesterday. His nausea, emesis and diarrhea has resolved, only
his
abdominal discomfort remains. He denies sick contacts, recent
travel or recent antibiotic use. No globus sensation, no
regurgitation or hiccups.
.
In the ___ ED, initial VS 98.7 80 ___ 97% RA. A chest
radiograph showed large particulate filled structure adjacent to
the right heart border consistent with a markedly distended
esophagus filled with residual ingested material. He received 1L
NS x 1. His laboratory studies were only remarkable for a
normocytic anemia to 27.3% on admission. He was reportedly
guaiac
positive at ___.
Past Medical History:
1. Esophageal achalasia (diagnosed in the 1990s, initially
medically managed with CCBs and nitrates; three prior Botox
injections - two performed in ___ and ___ following
endoscopy at ___ and one at ___ s/p surgical
myotomy in ___ at ___
2. Grade III esophagitis (treated with Omeprazole in ___
Social History:
___
Family History:
Niece with ulcerative colitis. No other family history of GI
malignancy (colon, stomach cancer).
Physical Exam:
Vitals: 97.2 100/60 66 18 96/RA
GENERAL - well-appearing male lying in bed in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Right sided vesicular breath sounds posteriorly over
middle of right lung, otherwise CTA w/ good air mvmt.
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
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission labs:
___ 09:00PM GLUCOSE-89 UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12
___ 09:00PM WBC-6.4 RBC-2.95* HGB-8.9* HCT-26.0* MCV-88
MCH-30.3 MCHC-34.4 RDW-13.6
___ 09:00PM NEUTS-63.6 ___ MONOS-4.3 EOS-1.6
BASOS-0.3
___ 09:00PM PLT COUNT-469*
___ 09:00PM ___ PTT-27.1 ___
___ 08:26PM GLUCOSE-93 UREA N-10 CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
___ 08:26PM estGFR-Using this
___ 08:26PM WBC-6.7 RBC-3.10* HGB-9.5* HCT-27.3* MCV-88
MCH-30.7 MCHC-34.9 RDW-13.5
___ 08:26PM NEUTS-65.0 ___ MONOS-4.6 EOS-1.5
BASOS-0.3
___ 08:26PM PLT COUNT-457*
___ 08:26PM ___ PTT-27.1 ___
Discharge Labs:
___ 06:50AM BLOOD WBC-6.4 RBC-2.95* Hgb-9.0* Hct-25.8*
MCV-88 MCH-30.5 MCHC-34.8 RDW-13.5 Plt ___
___ 06:50AM BLOOD Ret Aut-6.0*
___ 06:50AM BLOOD Glucose-125* UreaN-8 Creat-0.6 Na-137
K-3.4 Cl-103 HCO3-27 AnGap-10
___ 06:50AM BLOOD LD(LDH)-116 TotBili-0.2 DirBili-0.0
IndBili-0.2
___ 06:50AM BLOOD Calcium-7.9* Phos-3.6 Mg-2.3 Iron-43*
___ 06:50AM BLOOD calTIBC-278 Ferritn-23* TRF-214
CXRay:
FINDINGS: PA and lateral views of the chest were obtained. There
is marked
mediastinal widening which extends into significant portion of
the right
hemithorax. In this patient with provided history of achalasia,
findings are concerning for esophageal impaction. There is no
evidence of aspiration. No large pleural effusion is seen. No
pneumothorax. Heart size is difficult to assess. Bony structures
appear intact.
IMPRESSION: Findings concerning for esophageal impaction within
a markedly
dilated esophagus.
.
EGD:
Impression:
Large quantities of solid and liquid food in massively dilated
esophagus.
Cobblestoning of the whole esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum
The GE junction was able to be traversed easily with
colonoscope.
Otherwise normal EGD to third part of the duodenum
Recommendations:
Follow-up biopsy results
Recommend Surgery consult to evaluate for repeat Myotomy vs.
esophagectomy.
Manometry can be considered and if the resting pressures are
high at the LES, repeat Myotomy can be considered.
Recommend full liquid diet until the Achalasia is treated.
Medications on Admission:
MVI
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: Achalasia, massive esophageal dilatation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: ___ man with achalasia, presents with chest pain,
assess for esophageal impaction.
FINDINGS: PA and lateral views of the chest were obtained. There is marked
mediastinal widening which extends into significant portion of the right
hemithorax. In this patient with provided history of achalasia, findings are
concerning for esophageal impaction. There is no evidence of aspiration. No
large pleural effusion is seen. No pneumothorax. Heart size is difficult to
assess. Bony structures appear intact.
IMPRESSION: Findings concerning for esophageal impaction within a markedly
dilated esophagus.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: FOOD IMPACTION
Diagnosed with ABDOMINAL PAIN EPIGASTRIC, ACHALASIA & CARDIOSPASM
temperature: 98.7
heartrate: 80.0
resprate: 16.0
o2sat: 97.0
sbp: 112.0
dbp: 72.0
level of pain: 7
level of acuity: 3.0 | ___ M with pmhx of achalasia s/p failed CCB and nitrate trials,
multiple botox injections, and surgical myotomy at ___ in ___
presents with with 10-days of acute onset crampy abdominal pain,
nausea with emesis and loose, non-bloody stools associated with
odynophagia to solids and liquid. The patient was found to have
esophageal impaction from his achalasia and most likely had a
preceding viral gastroenteritis.
.
# Esophageal impaction from achalasia: The patient's symptoms of
unresolving abdominal pain with worsening on food intake and
odynophagia were due to the patient's achalasia and esophageal
impaction. This was treated during EGD via aspiration of the
esophageal contents. Diffuse cobblestoning was present
throughout the esophagus. Biopsies were taken. It was
recommended that the patient be assessed for repeat myotomy
versus esophagectomy. The patient had previously responded
extremely well to myotomy without symptoms since the ___
procedure. There was no urgent need for intervention after the
EGD and the patient preferred to have a second opinion regarding
further workup from his physicians at ___. The patient was thus
discharged with instructions to maintain a full liquid diet as
solids were likely to just reaccumulate until the achalasia is
treated. Biopsy results will be followed and communicated to
Dr. ___.
.
# Viral gastroenteritis: Pt had a few episodes of emesis with
nausea and diarrhea approximately 10 days ago which resolved
over the course of two days. This was most likely a
self-limited viral GI illness.
.
# Normocytic Anemia: The pt was reportedly guaiac positive at
OSH. He was found to have a normocytic anemia with negative
hemolysis labs, low ferritin and iron, and normal TIBC and
Transferrin. The patient reported being anemic in past when he
had an esophageal ulcer but this had resolved and his counts
returned to ___ after ferrous sulfate. We recommend a
colonscopy as an outpatient.
.
.
# CODE: full code
# CONTACT: mother ___ ___
.
TRANSITIONAL: Follow up biopsy results. Needs to follow up with
Dr. ___ achalasia treatment. Colonscopy as
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceclor / Reglan / Tylenol
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with PMH of 14 month history chronic
abdominal pain and cluster headaches who presents with worsening
abdominal pain over past day. She states that this is her "worst
episode yet." She describes pain as "twisting," rated as ___,
and centered diffusely on right side traveling through to her
back and down her leg. Nothing helps to make it better. Pain is
worse after she eats. Her baseline pain level is a ___. The
pain started at about 3pm yesterday and was slightly helped with
oxycodone and sublingual zofran. She states that she is now out
of outpatient pain medication. Pt has been undergoing extensive
workups for severe abdominal pain that started ___ yr ago. Her LMP
was on ___, pain tends to get worse with periods. She reports
she has had some nausea, denies vomiting, had some chills but no
fevers.
She reports she had been on dilaudid and was changed by her pcp
to oxycodone last week. She reports she needs to take 4 tablets
to help
with the pain. She also states that she has had problems with
constipation on narcotics and she states that she has been
disimpacting herself. She is not able to take stool softners
because she gets a "ball in her stomach"
Patients abdominal symptoms have been worsening since ___.
She has lost significant weight, she was 350 lbs in ___, then
intentionally lost weight to 305 by ___ since ___ has lost
another 75 lbs. She reports she was "afraid of food" for awhile
as she initially thought eating brought on the pain. She is
followed closely by Dr. ___ significant outpatient work
up has been done, including negative gastric emptying study
(although she does report that she was found to have some
delayed emptying but not
gastroparesis); colonoscopy showed ulcers/inflammation of the
terminal ileum but per MRE (which was normal) is not consistent
with Crohn's. EGD was normal. She was recently told she has a
gluten/rye allergy and has been avoiding them.
Capsule endoscopy was completed ___ which showed mild
gastritis, normal small intestinal mucosa with no abnormalities
to suggest Crohn's disease, although there was poor prep from
distal jejunum through distal ileum. She had a repeat capsule
endoscopy on ___ which was a normal capsule study but the
prep was somewhat suboptimal at the distal ileum. Her GI doctor
has discussed possible rare causes of abdominal pain such as
FMF, AIP, C1 esterase deficiency. Neurologist (Dr. ___ also
suggested w/u for AIP during her next attack by testing PBG
which has been done and PBG was not elevated.
In the ED, initial vs were 97.8 95 116/55 18 100%. She was found
to have a WBC of 14.2, lactate of 1.3, and normal LFTs. Received
total of 15mg IV morphine, zofran, and IV fluids. In the ED pt
had pelvic u/s that was negative. admit for pain control and
further gi workup
Transfer VS 97.4 76 110/56 16 98% .
On arrival to the floor, patient reports she continues to have
RUQ and suprapubic abdominal pain which is ___ in intensity now
down from ___ on admission. Her baseline pain is ___. No
current nausea, vomiting, or diarrhea.
REVIEW OF SYSTEMS:
General- + weight loss, +loss of appetite, No fevers, chills,
night sweats,
ENT- No tinnitus, vertigo, loss of hearing
No blurred vision, no itching/watering
No congestion, epistaxis
No sore throat, no neck swelling/lymphadenopathy
CV- + chest pain, palpitations
Pulm- + shortness of breath,+wheezing no cough, hemoptysis,
Abd- +abdominal pain, + alternating diarrhea/constipation, +N/V,
+blood in stool (known hemorrhoids)
Uro- +incomplete bladder emptying, No dysuria, hematuria,
urgency, polyuria
Heme- No easy bleeding/bruising
Msk- No swelling, back pain, or joint pain
Neuro- No numbness or tingling, no focal weakness, slurred
speech
Endo- No heat or cold intolerance, polyuria, polydipsia
Psych- +anxiety, depression
Past Medical History:
1. Abdominal Pain: Chronic abdominal pain/early satiety of
unclear etiology. CTs have been negative. Gastric emptying study
normal, ?capsule study showed delayed emptying. Colonoscopy from
___ did show some inflammation of the terminal ileum, but not
thought to be
consistent with Crohn's. EGD and MR enteroscopy have been
normal. Recent capsule endoscopy poor prep, but elevated CRP,
WBCs. 2. Cluster headaches
3. Internal hemorrhoids on colonoscopy.
4. h/o gallstones- on CT scan ___, but none on RUQ US
from ___
5. Asthma
6. Pt reports hx of MDD, anxiety, PTSD, OCD, ADD
7. Constipation
8. Urinary Frequency
Social History:
___
Family History:
Her father is ___ with diabetes, high blood pressure, and
hypercholesterolemia. Her mother is ___ and has high blood
pressure. She has a ___ cousin with ___ disease
and a maternal grandmother with ___ disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:97.7 P:60 BP:129/75 RR:18 Pox:100% RA
Gen: Alert and oriented x3, No acute distress
HEENT: Normocephalic, atraumatic.
PERRL, EOMI, sclera anicteric
Oropharynx without lesions, no tonsillar exudates
Neck: Supple, trachea midline, no lymphadenopathy
CV: RRR, Nl s1 and s2, no MGR.
No JVD appreciated
Pulm: Breath sounds bilaterally.
+ mild wheezes on left, no rhonchi, rales
Abd: Soft and non-distended. ttp in RUQ, periumbilical region,
and suprapubic region, no rebound or guarding, ___ sign
negative.
BS hyperactive, No hepatosplenomegaly,
Ext: Full ROM all four extremities
Pulses ___ radial, dp/tp
No CCE all four extremities
Neuro: CN II-XII grossly intact. No focal deficits.
Strength ___ all four extremities.
Skin: no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
Unchanged from admission physical
Pertinent Results:
Admission Labs:
___ 12:36PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:44AM LACTATE-1.3
___ 02:40AM GLUCOSE-105* UREA N-9 CREAT-0.8 SODIUM-136
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
___ 02:40AM estGFR-Using this
___ 02:40AM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-65 TOT
BILI-0.2
___ 02:40AM ALBUMIN-4.4
___ 02:40AM WBC-14.2* RBC-4.52 HGB-13.6 HCT-39.7 MCV-88
MCH-30.0 MCHC-34.2 RDW-12.9
___ 02:40AM NEUTS-61.6 ___ MONOS-6.7 EOS-2.4
BASOS-0.4
___ 02:40AM PLT COUNT-273
Discharge Labs: None
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler 1 PUFF IH BID:PRN shortness of breath
2. Acetaminophen-Caff-Butalbital 1 TAB PO BID:PRN severe
headache
3. Clonazepam 1 mg PO TID:PRN anxiety
4. lactobacillus acidophilus *NF* 1 billion cell Oral QD
5. Loratadine *NF* 10 mg Oral daily
6. Mirtazapine 45 mg PO HS
7. Montelukast Sodium 10 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Simethicone 40-80 mg PO QID:PRN abdominal pain
10. Venlafaxine XR 150 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH BID:PRN shortness of breath
2. Clonazepam 1 mg PO TID:PRN anxiety
3. Mirtazapine 45 mg PO HS
4. Montelukast Sodium 10 mg PO DAILY
5. Simethicone 40-80 mg PO QID:PRN abdominal pain
6. Venlafaxine XR 150 mg PO DAILY
7. Docusate Sodium 100 mg PO DAILY
RX *docusate sodium 100 mg 1 capsule(s) by mouth qday Disp #*60
Capsule Refills:*0
8. lactobacillus acidophilus *NF* 1 billion cell Oral QD
9. Loratadine *NF* 10 mg Oral daily
10. HYDROmorphone (Dilaudid) 2 mg PO Q8HR:PRN pain Duration: 3
Days
RX *hydromorphone 2 mg 1 tablet(s) by mouth q8hr Disp #*9 Tablet
Refills:*0
11. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with history of abdominal pain, presenting
with acute abdominal pain. Rule out right ovarian torsion.
COMPARISONS: None.
LMP: ___.
FINDINGS: Transabdominal and transvaginal ultrasound examinations were
performed, the latter for further evaluation of the endometrium and adnexa.
The uterus is normal and measures 7.6 x 3.6 x 4.5 cm. The endometrium is
normal and measures 8 mm. The ovaries are normal size with normal vascular
waveforms. The right ovary contains a dominant follicle, which measures 1.4
cm. No large adnexal mass. No free pelvic fluid.
IMPRESSION: Normal ovaries with normal vascular waveforms. No free pelvic
fluid.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 97.8
heartrate: 95.0
resprate: 18.0
o2sat: 100.0
sbp: 116.0
dbp: 55.0
level of pain: 10
level of acuity: 3.0 | ___ with PMH of 14 month history chronic abdominal pain, cluster
headaches, and cholelithiasis who presents with acute on chronic
abdominal pain in setting of running out of pain medication at
home who has undergone extensive GI workup with unknown
etiology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Keflex / Amoxicillin / Erythromycin Base /
Codeine / Bactrim / Vancomycin
Attending: ___.
Chief Complaint:
Nausea, Vomiting, Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ who presented to the ED with one day of
nausea, vomiting and diarrhea. She reports episode of non bloody
vomiting and diarrhea every 20 minutes for the past day. Other
associated symptoms include tenesmus and crampy abdominal pain
and poor po intake. She measured her temperature the night
before presentation and it was 102. She took tylenol for fever.
She made spaghetti and sauce ___ night which she makes
every month. Both she and her husband ate the meal and he is
well. She woke up at 11PM on ___ night with abdominal
pain, nausea, vomiting and diarrhea which continued every 20
minutes. She stayed home from work on ___ and
alternated gatorade with water between running to the bathroom.
She was reluctant to present to the ED but her husband insisted.
She arrived in the ED at 7PM last night and has not vomited
since arrival. She most recently had diarrhea in the ED at 8AM
prior to arrival in the ICU.
No recent travel or sick contacts. No recent antibiotics but
does work on the ___ unit.
Of note she has had two similar episodes in the past which were
attibuted to infectious colitis. She had normal sigmoidoscopy on
___ and is followed by Dr. ___.
In the ED initial vitals were: 97.2 103 109/70 18 99%RA. Labs
were notable for WBC of 10.4, HCT of 43.3, normal BUN/Cr and
normal LFTs. Her lactate was also initially normal at 1.3. Her
UA was negative. However patient became hypotensive to ___ in
the ED and her lactate trended up to 2.1. She was sleeping and
had received morphine prior to the trigger for hypotension.
Despite receiving 5.2 L of IVF her blood pressure remained in
the ___ systolic. She was started on meropenem. She was also
given morphine for pain and zofran for nausea.
Past Medical History:
Melano___ level III diagnosed in ___ with a negative
sentinel lymph node biopsy in the left axilla
History of periorbital cellulitis in the past
Migraines
Hx of Amenorrhea
Depression
gastroenteritis in ___ which prompted evaluation by Dr.
___
___: R dermoid cyst removed in ___
Social History:
___
Family History:
FAMILY HISTORY: Mother with ischemic colitis (is a smoker), pt
states that many family members have "sensitive stomachs."
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 98.3, 94, 133/57, 100%RA
General- well-appearing young Caucasian female in NAD
HEENT- MMM, EOMI
Neck- supple, no LAD
CV- tachycardic, normal S1/S2 no m/r/g
Lungs- CTAB, no wheezes, rales or rhonchi, good inspiratory
effort
Abdomen- hyperactive bowel sounds, abdomen soft, tender to
palpation in LLQ, no rebound or guarding, no organomegaly
GU- Foley in place draining clear yellow urine
Ext- 2+ pulses, no edema
Neuro- A&O x3, nonfocal
DISCHARGE PHYSICAL EXAM
Vitals: T: 98.3 BP: 108/70 (orthostatics negative) HR: 68 RR:
16 SaO2: 98% RA
General- well-appearing young Caucasian female in NAD
HEENT- MMM, EOMI
Neck- supple, no LAD
CV- tachycardic, normal S1/S2 no m/r/g
Lungs- CTAB, no wheezes, rales or rhonchi, good inspiratory
effort
Abdomen- hyperactive bowel sounds, abdomen soft, tender to
palpation in LLQ, no rebound or guarding, no organomegaly
GU- Foley in place draining clear yellow urine
Ext- 2+ pulses, no edema
Neuro- A&O x3, nonfocal
Pertinent Results:
ADMISSION
___ 08:25PM BLOOD WBC-10.4 RBC-4.64 Hgb-14.8 Hct-43.3
MCV-93 MCH-31.9 MCHC-34.2 RDW-12.4 Plt ___
___ 08:25PM BLOOD Neuts-82.4* Lymphs-12.8* Monos-4.4
Eos-0.1 Baso-0.2
___ 08:25PM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-138
K-3.2* Cl-99 HCO3-26 AnGap-16
___ 08:25PM BLOOD ALT-13 AST-22 AlkPhos-75 TotBili-0.4
___ 01:20PM BLOOD Calcium-7.3* Phos-2.2* Mg-1.3*
___ 09:10PM BLOOD Lactate-1.3
HOSPITALIZATION
___ 03:25AM BLOOD WBC-7.1 RBC-3.41*# Hgb-10.4*# Hct-32.3*#
MCV-95 MCH-30.6 MCHC-32.3 RDW-12.9 Plt ___
___ 06:30AM BLOOD WBC-5.7 RBC-3.65* Hgb-11.6* Hct-34.2*
MCV-94 MCH-31.8 MCHC-33.9 RDW-12.7 Plt ___
___ 06:40AM BLOOD WBC-5.1 RBC-3.78* Hgb-11.7* Hct-35.1*
MCV-93 MCH-31.1 MCHC-33.5 RDW-12.9 Plt ___
___ 03:25AM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-27.8 ___
___ 06:30AM BLOOD Plt ___
___ 06:40AM BLOOD Plt ___
___ 01:20PM BLOOD Glucose-99 UreaN-3* Creat-0.4 Na-137
K-3.6 Cl-111* HCO3-17* AnGap-13
___ 06:30AM BLOOD Glucose-127* UreaN-2* Creat-0.4 Na-140
K-3.4 Cl-110* HCO3-21* AnGap-12
___ 06:40AM BLOOD Glucose-85 UreaN-1* Creat-0.4 Na-140
K-3.6 Cl-107 HCO3-25 AnGap-12
___ 06:30AM BLOOD ALT-10 AST-18 AlkPhos-55 TotBili-0.1
___ 01:20PM BLOOD Calcium-7.3* Phos-2.2* Mg-1.3*
___ 06:30AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.0
___ 06:40AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.8
___ 02:50AM BLOOD Lactate-1.4
___ 03:29AM BLOOD Lactate-2.1* K-3.5
___ 01:38PM BLOOD Lactate-0.9
DISCHARGE
___ 06:50AM BLOOD WBC-5.3 RBC-3.67* Hgb-11.2* Hct-33.2*
MCV-91 MCH-30.6 MCHC-33.7 RDW-12.9 Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD UreaN-1* Creat-0.5 Na-142 K-3.4 Cl-106
HCO3-30 AnGap-9
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
TEST REQUESTED BY ___ ___ ___.
___ 9:45 pm STOOL CONSISTENCY: WATERY Source:
Stool.
FECAL CULTURE (Preliminary):
Reported to and read back by ___ ___ ___
7:35AM.
SALMONELLA SPECIES.
Presumptive identification pending confirmation by
___
Laboratory.
SENSITIVITIES REQUESTED BY ___. ___ ___
___.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FEW RBC'S.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
STUDIES
CT ABD & PELVIS WITH CONTRAST (___) - IMPRESSION: 1.
Pancolitis extending from cecum to rectum with milder
involvement of the
terminal ileum which may represent inflammatory bowel disease
with so-called backwash ileitis. However, this could also
represent an infectious ileocolitis. 2. Small bilateral
pleural effusions.
CXR (___): IMPRESSION: No acute cardiopulmonary disease
including pneumonia.
KUB (___): The AP, supine and upright radiographs of the
abdomen demonstrate overall small amount of intra-abdominal gas.
No evidence of dilated bowel loops demonstrated. The beaded
appearance of the gas within the colon is consistent with
diffuse colon thickening. No free air under the diaphragm
demonstrated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Prenatal Vitamins 1 TAB PO DAILY
3. Azithromycin 500 mg PO Q24H Duration: 4 Days
Please take with additional 250mg tablets for 4 days
RX *azithromycin 500 mg 1 tablet(s) by mouth Daily Disp #*4
Tablet Refills:*0
4. Azithromycin 250 mg PO Q24H Duration: 4 Days
Please take with additional 500mg tablets for 4 days
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bacterial colitis ___ salmonella infection
Severe Sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with fever.
TECHNIQUE: PA and lateral chest radiographs obtained with the patient in the
upright position.
COMPARISON: Chest radiograph from ___.
FINDINGS:
No consolidation, pleural effusion or pulmonary edema is seen, and the cardiac
and mediastinal contours are normal.
IMPRESSION:
No acute cardiopulmonary disease including pneumonia.
Radiology Report
INDICATION: Abdominal pain, diarrhea and hypotension refractory to fluids,
here to evaluate for acute intra-abdominal process.
COMPARISON: CT of the abdomen and pelvis with contrast dated ___.
TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to
the pubic symphysis following the uneventful administration of intravenous and
enteric contrast. Coronally and sagittally reformatted images were generated
and reviewed.
FINDINGS:
LUNG BASES: There are small bilateral non-hemorrhagic pleural effusions. The
imaged lung bases are otherwise clear. Limited imaging of the heart shows no
pericardial effusion. The distal esophagus and descending thoracic aorta are
within normal limits.
ABDOMEN: The liver enhances homogeneously without focal lesions. The portal,
splenic and superior mesenteric veins are satisfactorily opacified with
intravenous contrast. No biliary dilation is seen. The gallbladder is
nondistended with a small amount of pericholecystic fluid in the gallbladder
fossa. There is no gallbladder wall thickening and no radiopaque gallstones
are identified by CT. The pancreas, spleen, bilateral adrenal glands and
kidneys are within normal limits. There is no hydronephrosis or suspicious
renal lesion.
The stomach, duodenum and intra-abdominal loops of small bowel are normal in
caliber without evidence of obstruction. A normal appendix is visualized in
the right lower quadrant containing enteric contrast and air (300B:32).
There is an abnormally thickened loop of distal ileum in the right lower
quadrant (300B:24). There is diffuse bowel wall thickening and edema
involving the entirety at the large bowel from cecum to rectum also extending
into the terminal ileum although appearing milder. There is associated comb
sign. Mucosal enhancement is difficult to fully appreciate given the presence
of enteric contrast material, but is likely present. Numerous prominent
mesenteric lymph nodes are likely reactive. There is no free air or ascites.
No retroperitoneal lymphadenopathy is detected. The abdominal aorta is normal
in caliber throughout with widely patent branches.
PELVIS: The urinary bladder is decompressed by a Foley catheter with focal
air in the nondependent urinary bladder dome, likely related to catheter
placement. The uterus and bilateral adnexa are within normal limits. There
is no free pelvic fluid or inguinal/pelvic lymphadenopathy.
OSSEOUS STRUCTURES: No osseous destructive lesion concerning for malignancy
is detected.
IMPRESSION:
1. Pancolitis extending from cecum to rectum with milder involvement of the
terminal ileum which may represent inflammatory bowel disease with so-called
backwash ileitis. However, this could also represent an infectious
ileocolitis.
2. Small bilateral pleural effusions.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with pancolitis, suspected
worsening symptoms.
COMPARISON: ___ CT abdomen.
The AP, supine and upright radiographs of the abdomen demonstrate overall
small amount of intra-abdominal gas. No evidence of dilated bowel loops
demonstrated. The beaded appearance of the gas within the colon is consistent
with diffuse colon thickening. No free air under the diaphragm demonstrated.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, n/v/d
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 97.2
heartrate: 103.0
resprate: 18.0
o2sat: 99.0
sbp: 109.0
dbp: 70.0
level of pain: 7
level of acuity: 3.0 | Mrs. ___ is a ___ who presented to the ED with one day of
nausea, vomiting and diarrhea with elevated lactate and low BPs
concerning for severe sepsis.
BRIEF HOSPITAL COURSE
ACTIVE ISSUES
# Diarrhea: Pt. presented with acute onset nausea, fever, and
diarrhea. In the ED, pt. was originally placed in observation.
However, after receiving a small dose of morphine, her BPs
dropped to the ___. At this time, pt. was transferred to
the MICU for broad spectrum antibiotic coverage on
meropenem/flagyl, aggressively fluid resuscitation, and stool
cultures were sent. C.Diff returned negative. Additionally,
pt. had CT Abd/Pelvis with contrast that revealed pan-colitis
with mild involvement of the terminal ileum. Pt.'s blood
pressure responded well and she was transferred to the floor.
Initially, she continued to have ___ bowel movements per hour
however these progessively slowed to approximately 1/hour. GI
was consulted for further evaluation. Pt. was scheduled to have
a flex sig for further characterization on ___, however her
cultures returned positive for salmonella. ID was consulted re:
antibiotics management given history of several antibiotic
allergies. ID recommended patient be started on azithromycin 10
mg/kg for an additional 4 days, also recommended she have a RUQ
U/S performed to assess if she is a carrier for salmonella. She
was discharged on azithromycin 750 mg daily x 4 days and she
should have a RUQ U/S to assess if she is a carrier for
salmonella. She should also have follow-up stool studies
performed until she has 3 negative stool studies. She can
return to work after 3 stool studies have been negative. She
will need to coordinate with employee health.
CHRONIC ISSUES
# Depression: Stable. Continue celexa |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right upper quadrant pain
Major Surgical or Invasive Procedure:
___ Laparoscopic cholecystectomy, primary repair of
umbilical hernia.
History of Present Illness:
___ with presents with acute onset right upper quadrant pain.
Past medical history significant for diabetes mellitus, a-fib on
Coumadin, and 2 weeks s/p left total knee replacement. Since his
operation, patient has had baseline abdominal discomfort
associated with constipation. Has been on oxycodone for pain and
on bowel regimen. Last night, developed distinct pain localized
to RUQ associated with emesis x3, low grade fever, and sweats.
Presented to ED where CT findings were concerning for acute
cholecystitis.
Past Medical History:
HTN, ECG (baseline LAD, RBBB), DM2 (uncontrolled), BPH, Prostate
Ca. (untreated, denied surgical/rad management, recent Cr 0.9),
reflux
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
VS - 98.7, 74, 128/63, 16, 99% RA
GEN: NAD, non-toxic
HEENT: no scleral icterus, dry mucous membranes
CV: irregular irregular
PULM: no respiratory distress
ABD: soft, full, moderate tenderness in RUQ, palpable
gallbladder, negative ___ sign. +small umbilical hernia.
EXT: warm, no edema. LLE in brace.
Discharge Physical Exam:
General: alert, interactive, appropriate
HEENT: no deformity. PERRL, EOMI. neck supple, trachea midline.
CV: irregular
Pulm: clear to auscultation bilaterally.
Abd: soft, tender to palpation at incision sites as anticipated.
Ext: warm and dry. Right knee with staples CDI. edges well
approximated no erythema or drainage. 2+ ___ pulses.
Skin: multiple laparoscopic surgical sites with DSD clean dry
and intact.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent. Sensation intact.
Pertinent Results:
___ 05:18AM BLOOD WBC-9.7 RBC-3.78* Hgb-9.7* Hct-29.0*
MCV-77* MCH-25.7* MCHC-33.4 RDW-13.8 RDWSD-37.8 Plt ___
___ 09:06AM BLOOD WBC-12.9* RBC-4.10* Hgb-10.7* Hct-31.5*
MCV-77* MCH-26.1 MCHC-34.0 RDW-13.7 RDWSD-37.6 Plt ___
___ 09:06AM BLOOD Neuts-76.4* Lymphs-15.9* Monos-5.8
Eos-0.5* Baso-0.3 Im ___ AbsNeut-9.81* AbsLymp-2.04
AbsMono-0.75 AbsEos-0.07 AbsBaso-0.04
___ 04:57AM BLOOD ___ PTT-28.1 ___
___ 05:18AM BLOOD ___ PTT-29.8 ___
___ 09:06AM BLOOD ___ PTT-32.2 ___
___ 05:18AM BLOOD Glucose-138* UreaN-10 Creat-0.9 Na-135
K-4.3 Cl-99 HCO3-26 AnGap-14
___ 09:06AM BLOOD Glucose-179* UreaN-13 Creat-0.9 Na-135
K-4.7 Cl-95* HCO3-25 AnGap-20
___ 09:06AM BLOOD ALT-14 AST-26 AlkPhos-81 TotBili-0.3
___ 05:18AM BLOOD Calcium-8.8 Phos-3.9# Mg-2.1
___ 09:19AM BLOOD Lactate-2.0
___ 05:28AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:55AM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:28AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
___ 09:55AM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 05:28AM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 09:55AM URINE RBC-3* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ ECG: Sinus rhythm. Leftward axis. Early R wave
progression but persistent S wave in lead V6. There is
considerable artifact in the baseline of lead V1. Compared to
the previous tracing of ___ RSR' pattern in leads V1-V2 is
now less apparent but is probably persistent. Otherwise, no
change.
___ CXR
Heart size is mildly enlarged but unchanged. The aorta is
unfolded. The
mediastinal and hilar contours are otherwise unchanged, and
pulmonary
vasculature is not engorged. Apart from minimal atelectasis in
the lung
bases, lungs are clear without focal consolidation. No pleural
effusion or pneumothorax is detected. Hypertrophic changes are
demonstrated within the thoracic spine.
___ CT Abdomen/Pelvis
1. Mildly distended gallbladder with mural edema, adjacent
pericholecystic
fluid and mild fat stranding, concerning for acute
cholecystitis. No evidence of perforation or abscess formation.
2. Multiple bilateral renal hypodensities, some which are cysts,
others of
which are too small to fully characterize
3. 1.8 cm calcified bladder stone.
4. Enlarged prostate.
___ Liver/Gallbladder ultrasound
1. Acute cholecystitis with an impacted stone noted at the
gallbladder neck.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded on the basis of this examination.
3. 7.7 cm simple left renal cyst.
Medications on Admission:
- Cardizem 120'
- Coumadin 5'
- ASA 325'
- Metformin 750''
- Oxycodone prn
- Milk of magnesia
- Bisacodyl
- Senna
- Tylenol prn
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
hold for diarrhea
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Take lowest effective dose.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Warfarin 5 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 750 mg PO BID
Do Not Crush
7. Aspirin 325 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
9. Simethicone 40-80 mg PO QID:PRN Bloating
as needed for gas pain
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Umbilical hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is mildly enlarged but unchanged. The aorta is unfolded. The
mediastinal and hilar contours are otherwise unchanged, and pulmonary
vasculature is not engorged. Apart from minimal atelectasis in the lung
bases, lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is detected. Hypertrophic changes are demonstrated within the
thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: History: ___ with abdominal pain and constipation
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 43.3 mGy (Body) DLP =
21.7 mGy-cm.
2) Spiral Acquisition 5.1 s, 56.0 cm; CTDIvol = 16.2 mGy (Body) DLP = 905.1
mGy-cm.
Total DLP (Body) = 927 mGy-cm.
COMPARISON: CT abdomen and pelvis without contrast from ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. Coronary calcifications are
incidentally noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of concerning focal lesions. Punctate 5 mm hypodensity
in the dome of the left lobe of the liver (02:12) is too small to fully
characterize. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is mildly distended and the gallbladder wall
appears edematous with adjacent pericholecystic fluid and mild fat stranding,
concerning for acute cholecystitis. No evidence of perforation or abscess
formation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Multiple hypodense lesions are noted in the bilateral kidneys, most too small
to fully characterize, with the largest measuring 8.2 cm in the interpolar
region of the left kidney compatible with a simple cyst. There is no evidence
of hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: A 1.8 cm calcified stone is noted in the urinary bladder. Remainder
the bladder is unremarkable. The distal ureters are unremarkable. There is
no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged and heterogeneous, likely
reflective of benign prostatic hypertrophy, measuring 6.3 cm.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
7
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Multilevel degenerative changes are noted in the visualized spine.
SOFT TISSUES: Incidental note is made of a small fat containing umbilical and
supraumbilical hernias. Small fat containing left inguinal hernia is also
demonstrated.
IMPRESSION:
1. Mildly distended gallbladder with mural edema, adjacent pericholecystic
fluid and mild fat stranding, concerning for acute cholecystitis. No evidence
of perforation or abscess formation.
2. Multiple bilateral renal hypodensities, some which are cysts, others of
which are too small to fully characterize
3. 1.8 cm calcified bladder stone.
4. Enlarged prostate.
NOTIFICATION:
1. The findings were discussed by Dr. ___ with Dr. ___ on the
telephoneon ___ at 2:18 ___, 10 minutes after discovery of the findings.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis with contrast from ___ 13:31
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4.7
mm.
GALLBLADDER: There is a mildly distended gallbladder with mild
pericholecystic fluid, concentric gallbladder wall edema, and an impacted
stone noted at the gallbladder neck. Gallbladder sludge is also seen within
the gallbladder lumen.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic body and
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 8.1 cm.
KIDNEYS: The right kidney measures 12.4 cm. The left kidney measures 12.3 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. A 7.7 x 6.2 cm simple cyst seen in the interpolar region of the
left kidney. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Acute cholecystitis with an impacted stone noted at the gallbladder neck.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
3. 7.7 cm simple left renal cyst.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: N/V, Abd pain
Diagnosed with Cholecystitis, unspecified
temperature: 99.3
heartrate: 93.0
resprate: 16.0
o2sat: 98.0
sbp: 151.0
dbp: 82.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted to the Acute Care Surgery Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound and abdominal/pelvic CT revealed
Acute cholecystitis. Informed consent was obtained and the
patient underwent laparoscopic cholecystectomy. The procedure
went well without complication (Please see operative report for
details). After a brief, uneventful stay in the PACU, the
patient was transferred to the floor hemodynamically stable on
IV fluids and IV pain medication for further monitoring and post
operative management.
Diet was progressively advanced as tolerated to a regular diet
with good tolerability. Pain was controlled on oral oxycodone.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. His Coumadin therapy was
resumed for management of atrial fibrillation on POD0. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with NVA services
resumed. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
LLQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo s/p IVF with egg retrieval ___ and embryo (2) transfer ___
presenting to the ED for evaluation of acute-onset LLQ pain that
began this morning. She has had ___ episodes today, each lasting
___ minutes and characterized as sharp, "stabbing" pain.
Denies associated nausea or vomiting. On review of systems no
other associated symptoms including bleeding, fevers, chills,
dysuria.
In the ED she has received Zofran and morphine and currently
feels better. HCG was found to be positive at 333.
Past Medical History:
OBHx: G1P0
GynHx: denies h/o STIs or abnormal Paps
MedHx: denies
SurgHx: laparoscopic appendectomy
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
Vitals - BP:128/83 HR:77 RR:20 O2sat:100% r/a
General: NAD, appears fatigued but comfortable
CV: RRR
Lungs: CTAB
Abdomen: soft, non-distended, moderate LLQ TTP, no
rebound/guarding
Pelvic: on bimanual exam, small mobile uterus, no CMT, mild left
adnexal TTP without rebound/guarding, bilateral enlarged ovaries
to around 8cm
On discharge:
afebrile, stable vital signs
Gen: NAD, AxO
CV: RRR
Resp: CTAB
Abd: normoactive BS, soft, nontender without rebound or
guarding, nondistended
Ext: calves nontender
Pertinent Results:
Blood:
___ 03:45PM BLOOD WBC-9.0 RBC-3.80* Hgb-11.9* Hct-35.8*
MCV-94 MCH-31.3 MCHC-33.2 RDW-12.1 Plt ___
___ 03:45PM BLOOD Neuts-75.8* ___ Monos-3.4 Eos-0.3
Baso-0.4
___ 03:45PM BLOOD Glucose-94 UreaN-8 Creat-0.8 Na-138 K-3.7
Cl-105 HCO3-23 AnGap-14
___ 03:45PM BLOOD HCG-333
Urine:
___ 03:45PM URINE Color-Straw Appear-Clear Sp ___
___ 03:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ urine culture pending at time of discharge summary
___ 03:45PM URINE UCG-POSITIVE
___ Gonorrhea/Chlamydia pending at time of discharge summary
Pelvic US (prelim):
IMPRESSION:
1. Enlarged bilateral ovaries with normal flow, however,
intermittent torsion cannot be excluded.
2. Multiple large functional cysts within the ovaries. Small
amount of free fluid.
3. No evidence of intrauterine pregnancy, likely due to early
gestation however ectopic is not excluded. Serial quantitative
hcgs recommended and repeat ultrasound can be performed in ___
weeks to document IUP or earlier if clinically indicated.
Medications on Admission:
vaginal progesterone, PNV
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain, r/o ovarian torsion
constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with left pelvic pain, status post IVF, rule out
torsion.
TECHNIQUE: Grayscale and color Doppler ultrasound images of the pelvis were
obtained.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
The ovaries are enlarged bilaterally with the left ovary measuring 9 x 6.2 x
6.2 cm and the right ovary measuring 8.1 x 5.8 x 5.5 cm. Normal venous and
arterial flow in both ovaries. Multiple large follicles, some of which with
retracting clot are seen. There is small amount of free fluid in the pelvis
tracking superiorly around the liver. The endometrium is difficult to image
but there is no evidence of gestational sac or intrauterine pregnancy at this
point.
IMPRESSION:
1. Enlarged bilateral ovaries with normal flow, however, intermittent torsion
cannot be excluded.
2. Multiple large functional cysts within the ovaries. Small amount of free
fluid.
3. No evidence of intrauterine pregnancy, likely due to early gestation
however ectopic is not excluded. Serial quantitative hcgs recommended and
repeat ultrasound can be performed in ___ weeks to document IUP or earlier if
clinically indicated.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with FEM GENITAL SYMPTOMS NOS, POLYCYSTIC OVARIES
temperature: nan
heartrate: 77.0
resprate: 20.0
o2sat: 100.0
sbp: 128.0
dbp: 83.0
level of pain: 9
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the gynecology
service for serial abdominal exams given the concern for
intermittent torsion based on pelvic ultrasound with enlarged
ovaries bilaterally (consistent with recent hyperstimulation for
IVF) and LLQ pain. She was kept NPO with IVF in the event that
she would require urgent diagnostic lapaorscopy. Her pain
spontaneously resolved, and she had no dizziness, nausea, or
other concerning symptoms. Her vital signs were stable within
normal limits and serial abdominal exams were benign, without
evidence of torsion or peritoneal signs. On hospital day 2, she
was advanced to a regular diet without problems and she required
no further pain medication. At this point, as she was tolerating
a regular diet, ambulating independently, voiding spontaneously,
and had no abdominal pain, she was discharged in stable
condition with plan for outpatient follow-up HCG. Ectopic
pregnancy and ovarian torsion precautions were reviewed prior to
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ with history of ESRD on HD (TTSa), CHF, AS,
myelodysplastic syndrome who presents from ___ with acute
dyspnea. Per report patient was in USOH until this evening when
___ complained of acute SOB. On evaluation at ___,
patient was desatting to ___ on RA. EMS was called and placed
patient on NRB mask and transported him to ___.
In the ED, initial VS were: 98.5 105 117/61 28 100% 15L NRB.
Patient was very tachypneic on arrival and appeared hypervolemic
and febrile on exam. LUE was noted to be mildly edematous.
Patient was started CPAP with improvement of respiratory status.
Labs were significant for leukocytosis to 26.4 with lactate of
2.4. Troponin was 0.52. CXR showed pulmonary edema. CTA chest
was completed and showed large pleural effusions without e/o
PEs. Patient was then admitted to the MICU for further
evaluation. Patient received Vancomycin and levofloxacin while
in ED VS prior to transfer were 98.1 86 141/55 25 98%BiPAP.
In MICU, patient stated that breathing was feeling better.
Denied chest pain, palpitations or abdominal pain.
Of note patient was recently admitted to ___ from ___
with similar complaints during which time palliative care was
consulted to discuss of end of life issues. During this time,
hospice was introduced given that patient did not appear to be
tolertating dialysis.
Past Medical History:
ESRD: unknown etiology, since ___
Elevated WBC count
Polycythemia ___
AS
CHF
HTN
HL
Dysphagia
Hypothyroidism
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM
VS:36.8 103/47 96 25 100 on BIPAP
General: Alert, slow to respond, mild respiratory distress
HEENT: Sclera anicteric, EOMI, PERRL
Neck: JVP at angle of jaw of mandible
CV: Regular rate and rhythm, normal S1 + S2, III/VI
Lungs: decreased breath sounds at bases but otherwise clear
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: wwp, LUE slightly more edematous than RUE, fistula on left
with palpable thrill, warm to touch, ___ edema in ___ b/l, 8x3cm
non infected appearing ulcer on LLE, chronic venous changes b/l
.
DISCHARGE EXAM
VS: T:97.7 BP:118/57 P:84 RR:18 Pox: 97% on 2L
GEN Alert, oriented, no acute distress, lying comfortably in bed
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, trachea midline, no JVD, no LAD
PULM normal respiratory effort, good aeration, CTAB no wheezes,
rales, ronchi
CV RRR normal S1/S2, ___ holosystolic mumur loudest at RUSB
radiating to carotids.
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, left forearm with patent
AV fistula (palpable thrill, bruit present), Pt with 1+ pitting
edema of lower extremities bilaterally
NEURO CNs2-12 intact, motor function grossly normal, no focal
deficits
SKIN: Left ___ lateral area of shin with a 5cm x2cm ulcer
present, yellow/white in color with pink edges,
Pertinent Results:
Admission Labs:
___ 12:06AM BLOOD WBC-26.4*# RBC-2.18* Hgb-7.9* Hct-25.6*
MCV-117* MCH-36.5* MCHC-31.1 RDW-22.0* Plt ___
___ 12:06AM BLOOD Neuts-88.7* Lymphs-8.0* Monos-2.5 Eos-0.5
Baso-0.3
___ 12:06AM BLOOD Glucose-84 UreaN-32* Creat-3.3* Na-140
K-5.9* Cl-98 HCO3-31 AnGap-17
___ 12:06AM BLOOD ALT-98* AST-160* CK(CPK)-113 AlkPhos-151*
TotBili-0.3
___ 12:06AM BLOOD CK-MB-8 proBNP->70000
___ 12:06AM BLOOD cTropnT-0.52*
___ 12:06AM BLOOD Albumin-3.4* Calcium-9.4 Phos-3.3 Mg-1.8
___ 12:16AM BLOOD Type-ART pO2-164* pCO2-47* pH-7.46*
calTCO2-34* Base XS-9
___ 12:22AM BLOOD Lactate-2.4*
___ 02:25AM BLOOD Lactate-1.4 K-4.6
___ 07:42AM BLOOD Lactate-1.1 K-3.2*
.
Discharge Labs:
___ 07:20AM BLOOD WBC-26.6* RBC-2.47* Hgb-8.4* Hct-27.5*
MCV-112* MCH-34.1* MCHC-30.5* RDW-22.7* Plt ___
___ 07:20AM BLOOD ___ PTT-37.5* ___
___ 07:20AM BLOOD Glucose-47* UreaN-26* Creat-3.1* Na-137
K-4.3 Cl-94* HCO3-33* AnGap-14
___ 07:20AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9
.
Imaging
CXR ___: Recurrent, moderately severe, pulmonary edema,
worsened since ___. Bibasilar opacification, likely edema
and atelectasis.
.
CT chest ___:
No pulmonary embolism. Evaluation of subsegmental vessels is
limited. Moderate to large bilateral pleural effusions with
associated atelectasis. Moderate bilateral ground glass opacity
likely represents pulmonary edema.
Additional findings are present in addition to the original wet
read: There
appears to be a small amount of gas within the right rectal wall
(2:73).
Stercoral colitis is suspected given the presence of a large
amount of rectal
stool. Trace free air is present (2:38). The apparent trace
pneumobilia may
instead represent intraperitoneal air dissecting along portal
veins.
Alternatively, portal gas is possible.
.
CT ABDOMEN AND PELVIS WITH CONTRAST ___
IMPRESSION:
1. Minimal biliary air in the gallbladder and biliary tree is
nonspecific and may the sequelae of prior instrumentation such
ERCP/sphinterotomy. Please correlate with patients history. No
free air.
2. Comminuted fracture of the left ilium with extension to the
superior pubic ramus and acetabulum. Acetabular component has
intra-articular extension without femoral head involvement or
dislocation.
3. Changes of ankylosing spondylitis with fusion of the right
sacroiliac
joint and vertebral body.
4. Diffusely abnormal marrow with sclerosis and atrophic kidneys
consistent renal osteodystrophy. Osseous sequelae of
myeloproliferative disease are also superimposed.
5. Moderate bilateral pleural effusions with subsegmental
atelectasis.
Difficult to exclude infectious consolidation in the atelectatic
lung.
6. Mild fusiform aneurysmal dilatation of the abdominal aorta
just proximal to the bifurcation measuring 2.2 cm
CXR ___
In comparison with study of ___, the degree of bilateral
opacification may be slightly less prominent. Substantial
enlargement of the cardiac silhouette persists.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from nursing home medication list.
1. Amlodipine 7.5 mg PO Q ___
hold for sbp<100 or hr<60
2. Amlodipine 5 mg PO QTUTHSA (___)
3. Metoprolol Succinate XL 25 mg PO BID
4. Mirtazapine 15 mg PO HS
5. Atorvastatin 80 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. MethylPHENIDATE (Ritalin) 5 mg PO QAM
8. Nephrocaps 1 CAP PO DAILY
9. Finasteride 5 mg PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Bisacodyl 10 mg PO DAILY:PRN constipation
12. Docusate Sodium 100 mg PO DAILY
hold for loose stools
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Fleet Enema ___AILY:PRN constipation
15. Calcium Carbonate 500 mg PO TID
16. Acetaminophen 650 mg PO Q6H:PRN pain
max ___ daily
17. Glucagon 1 mg IM PRN hypoglycemia/glucose<50
18. Senna 1 TAB PO BID
19. Artificial Tears Preserv. Free 1 DROP BOTH EYES TID
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Calcium Carbonate 500 mg PO TID
4. Docusate Sodium 100 mg PO DAILY
hold for loose stools
5. Finasteride 5 mg PO DAILY
6. Fleet Enema ___AILY:PRN constipation
7. Glucagon 1 mg IM PRN hypoglycemia/glucose<50
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 1 TAB PO BID
12. Vitamin D 400 UNIT PO DAILY
13. Metoprolol Succinate XL 25 mg PO BID
14. Acetaminophen 650 mg PO Q6H:PRN pain
max ___ daily
15. Amlodipine 7.5 mg PO Q ___
hold for sbp<100 or hr<60
16. Amlodipine 5 mg PO QTUTHSA (___)
17. Artificial Tears Preserv. Free 1 DROP BOTH EYES TID
18. MethylPHENIDATE (Ritalin) 5 mg PO QAM
19. Mirtazapine 15 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
dyspnea
Pulmonary Edema
Left acetabular fracture
ESRD
stercoral ulcer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with shortness of breath.
COMPARISON: Multiple chest radiographs, the latest from ___.
FINDINGS:
Bilateral interstitial and airspace opacitification, predominantly basal has
worsened substantially since ___. Moderate enlargement of the cardiac
silhouette and hilar vasculature are chronic. Small bilateral pleural
effusions are presumed.
IMPRESSION:
Recurrent, moderately severe, pulmonary edema, worsened since ___.
Bibasilar opacification, likely edema and atelectasis.
Radiology Report
INDICATION: ___ man with acute onset shortness of breath and hypoxia;
? pulmonary embolism.
COMPARISON: Chest radiograph from ___.
TECHNIQUE: MDCT images were acquired through the chest with and without IV
contrast. Multiplanar reformations were obtained and reviewed.
FINDINGS:
The thyroid gland is unremarkable. There is no axillary or mediastinal
lymphadenopathy by CT size criteria. The heart and great vessels are
unremarkable. There is mild coronary artery, aortic and mitral annular
calcifications. No pericardial effusion is present. The heart and great
vessels are unremarkable.
The pulmonary arteries are patent down to the subsegmental level. Evaluation
of the subsegmental pulmonary arteries is limited due to bibasilar
atelectasis. There are moderate-to-large bilateral pleural effusions with
associated atelectasis in both lower lobes. The lungs show diffuse
ground-glass opacity with moderate interlobular septal thickening bilaterally.
In addition, there is anti-dependent redistribution of the pulmonary
vasculature. Also noted is small areas of relative lucency in both lung
apices, unchanged from C-Spine CT from ___, that likely represents
centrilobular emphysema.
Although this examination was not intended for subdiaphragmatic evaluation,
the partially imaged abdomen significant simple fluid ascites. Gas is noted
centrally within the porta hepatis, which could be located within the portal
vein, or, alternatively, may represent free intraperitoneal air.
There is an atrophic kidney, and a large right liver lobe hypodense lesion
measuring 28 ___ and 4.4 x 3.9 cm, most likely representing a simple cyst.
OSSEOUS STRUCTURES:
The visualized osseous structures show no suspicious lytic or blastic lesion
or fracture.
IMPRESSION:
1. No pulmonary embolism.
2. Severe bilateral ground-glass opacities with marked interlobular septal
thickening, most likely secondary to pulmonary edema, which has progressed. A
contribution of ARDS cannot be excluded.
3. Moderately large bilateral pleural effusions, likely related to #2, above,
with associated atelectasis.
4. Moderate non-hemorrhagic ascites.
5. Small locule of gas, located relatively centrally within the porta hepatis
is incompletely imaged, may be biliary;
However, in the setting of apparently known sepsis, and in the absence of
history of prior biliary instrumentation or cholecystectomy, this finding is
concerning for portal venous gas related to mesenteric ischemia.
Alternatively, this may represent a locule of free intraperitoneal air,
related to hollow viscus perforation.
COMMENT: CT of the abdomen and pelvis may be obtained for further evaluation.
These recommendations were communicated to ___, M.D., by Dr. ___
___ telephone, at 2:30 a.m. on ___.
Radiology Report
HISTORY: ___ man with air in the liver seen on recent chest CT.
COMPARISON: Chest CT ___.
FINDINGS:The background hepatic architecture is normal in appearance. There
are numerous cysts within the liver in both the right and left lobes. None of
these cysts demonstrates any worrisome features. The largest cyst is in the
right lobe and measures 4.4 cm.
There are small echogenic structures demonstrating dirty shadowing seen
adjacent to the left portal vein. The same echogenic pattern is seen anterior
to the common hepatic duct. No biliary dilatation is seen. The appearance is
suggestive of free air (see images 61, 62, and 63). A small similar-appearing
region is seen adjacent to the fundus of the gallbladder. The gallbladder is
distended however no gallstones are identified, no sludge is seen, and the
gallbladder wall is not edematous. No pericholecystic fluid is seen.
The hepatic veins and IVC are patent. The main, right and left portal veins
are patent with hepatopetal flow. Normal arterial waveforms are seen in the
hepatic arteries.
IMPRESSION:
1. A small amount of air is visualized in the right upper quadrant however the
pattern is suggestive of free air in the abdomen adjacent to the left portal
vein, the common hepatic duct, and possibly adjacent to the fundus of the
gallbladder. There is no air identified within the portal veins or within the
bile ducts. No biliary dilatation is seen.
2. No mass is seen within the liver. No concerning solid liver lesion is
identified.
Radiology Report
CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ male with end-stage renal disease on hemodialysis,
CHF, AS, myelodysplastic syndrome, presents with acute dyspnea. Please
evaluate for pneumobilia versus free air in the abdomen.
COMPARISON: Correlation is made of the abdominal ultrasound from earlier the
same day.
TECHNIQUE: Multiple axial CT images were obtained through the abdomen and
pelvis following the administration of 130 mL of Omnipaque IV contrast.
Sagittal and coronal reconstructions were obtained. No adverse contrast
reactions were reported. Rotating 3-D reconstructions of the osseous pelvis
were requested and created at a separate workstation.
FINDINGS:
LOWER CHEST: Moderate bilateral pleural effusions with bibasilar compression
atelectasis, worse on the left. Superimposed infectious consolidations within
the atelectatic lung cannot be excluded. No pulmonary mass is identified.
Cardiomegaly. No pericardial effusion.
ABDOMEN: The liver is mildly enlarged measuring 18 cm in length and contains
multiple hypodense lesions throughout which were further characterized on
prior ultrasound as cysts. No enhancing hepatic lesions are identified. The
spleen is also enlarged measuring 16 cm in length and demonstrates homogeneous
enhancement without focal lesions. The kidneys are atrophic. Pancreas
enhances homogeneously without focal lesions. The adrenal glands are normal
without nodularity. Focal calcification within the medial limb of the left
adrenal gland may be related to prior hemorrhage or ischemia.
The gallbladder is well distended without radioopaque stones. There is a small
focus of air within the antidependent portion of the gallbladder fundus.
Minimal presumed biliary air (with linear morphology) is also seen in the left
hepatic lobe.
The remaining bowel loops are normal in caliber.
Mild fusiform aneurysmal dilatation of the abdominal aorta just proximal to
the bifurcation measuring 2.2 cm in AP dimension. The remainder of the
abdominal aorta is normal in caliber with diffuse atherosclerotic
calcifications. Extension of atherosclerotic calcifications into the common
iliac arteries and distal branches. No significant sized mesenteric or
retroperitoneal lymphadenopathy.
PELVIS: The prostate is enlarged, measuring 5.5 x 4.6 cm. Urinary bladder is
underdistended. There is no pelvic lymphadenopathy.
SKELETAL STRUCTURES AND SOFT TISSUES: There is a comminuted complex fracture
of the left ilium which extends into the acetabulum and superior pubic ramus,
best appreciated on the sagittal reformat. There is intra-articular extension
into left hip joint. The femoral head is intact without dislocation.
Acetabular component of the fracture involves the anterior and posterior
columns. There is a nondisplaced fracture of the left anterolateral 9th rib.
There may be subtle fractures of adjacent ribs.
The right sacroiliac joint appears fused inferiorly. There is diffuse
enthesopathy involving the vertebral bodies with squaring of the vertebral
bodies and fusion. The osseous structures are diffusely sclerotic.
3-D reconstructions of the bone anatomy were requested and created in the
imaging lab. 3D reconstructions of the pelvic fractures include 3D volume
rendered, as well as views after segmentation out of the adjacent femur.
IMPRESSION:
1. Minimal biliary air in the gallbladder and biliary tree is nonspecific and
may the sequelae of prior instrumentation such ERCP/sphinterotomy. Please
correlate with patients history. No free air.
2. Comminuted fracture of the left ilium with extension to the superior pubic
ramus and acetabulum. Acetabular component has intra-articular extension
without femoral head involvement or dislocation.
3. Changes of ankylosing spondylitis with fusion of the right sacroiliac
joint and vertebral body.
4. Diffusely abnormal marrow with sclerosis and atrophic kidneys consistent
renal osteodystrophy. Osseous sequelae of myeloproliferative disease are also
superimposed.
5. Moderate bilateral pleural effusions with subsegmental atelectasis.
Difficult to exclude infectious consolidation in the atelectatic lung.
6. Mild fusiform aneurysmal dilatation of the abdominal aorta just proximal to
the bifurcation measuring 2.2 cm.
Radiology Report
HISTORY: Pulmonary edema with persistent hypoxia.
FINDINGS: In comparison with study of ___, the degree of bilateral
opacification may be slightly less prominent. Substantial enlargement of the
cardiac silhouette persists.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with RESPIRATORY ABNORM NEC, FEVER, UNSPECIFIED, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 98.5
heartrate: 105.0
resprate: 28.0
o2sat: 100.0
sbp: 117.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | ___ year old M with ESRD on HD (___), renal osteodystrophy,
diastolic CHF, severe aortic stenosis, myelodysplastic syndrome,
who presented from ___ House on ___ with dyspnea ___ to
pulmonary edema now resolved but with acute/subacute fractures
of the left acetabulum and found to have free air which is
thought to be ___ stercoral ulcer. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with CAD, previous PCI with stent placement, AAA repair HTN,
HLD, who presents with L sided chest pressure, morphing in to
pain. Pressure started around 2 am this morning, then became
pain slowly over the course of the morning. Pain was worse with
walking, and was associated with SOB. Previous pain associated
with stent placement was abdominal pain, with mild nausea. He
does not have stable angina. He reports his last stress test was
around ___ years ago, and he is scheduled for a stress test on
___, ten days from now.
Patient is chest pain free at the time of evaluation. He denies
SOB, headache, abdominal pain, nausea, vomiting, diarrhea,
constitutional symptoms.
In the ED, initial VS were: T98.8, HR 89, BP 161/120, RR 28, o2
96% RA
Exam notable for:
JVP: 2cm above clavicle at 75 degrees
Abd: soft, non-tender, non-distended
Extremities: L BKA, RLE with 1+ edema to mid-tibia
EKG: Rate 62, sinus rhythm, no ST or T wave changes
Labs showed:
Imaging showed: CXR: Mild pulmonary edema, trace pleural
effusions.
Consults: None
Patient received:
Hydralizine 10mg IV x2
Hydralazine 25mg PO
Lisinopril 40mg
Aspirin 325mg
Rosuvastatin 40mg
Lasix 40mg IV
Transfer VS were: T98.8, HR 71, BP 170/68, RR 16, O2 99% RA
On arrival to the floor, patient reports he developed chest
pressure and shortness of breath while lying in bed yesterday
evening. The pressure lasted about 4 hours and gradually
escalated. No associated nausea, lightheadedness, arm pain or
neck pain. He had intermittent chest pressure while in ED for 24
hours, may be correlated with higher blood pressures. Currently
CP free with no shortness of breath. Denies fevers, chills,
dizziness, abdominal pain, nausea, emesis, dysuria, diarrhea or
leg swelling.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PCI: CAD s/p MI ___. EF 50%. s/p LCX stent.
3. OTHER PAST MEDICAL HISTORY
- GOUT
- Colonic polyps
- MVA in ___. Lost fiance and subsequent left BKA.
Social History:
___
Family History:
CAD: None known
Diabetes: F, MGM
Cancer: None known
Stroke: Father died of stroke in ___
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
VS: 98.6 174 / 95 75 17 98 ra
GENERAL: NAD, speaking in full sentences
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVD 13cm
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: L BKA, right lower extremity 1+ pitting edema below
knee.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
24 HR Data (last updated ___ @ 830)
Temp: 98.7 (Tm 98.7),
BP: 142/68 (135-174/56-95),
HR: 79 (75-81),
RR: 17,
O2 sat: 96% (96-98), O2 delivery: Ra,
Wt: 234.13 lb/106.2 kg
GENERAL: Well appearing man found lying flat in bed and speaking
to me in no apparent distress
HEENT: Pupils equals and reactive, no scleral icterus or
injection, moist mucous membranes
NECK: JVP appears to be 10-12cm
HEART: S1/S2 regular with no murmurs, rubs, heaves or S3/S4
LUNGS: Lungs clear to auscultation bilaterally. No use of
accessory muscles or evidence of respiratory distress.
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: L BKA, R lower extremity with trace edema up to the
mid-shin. Warm extremities.
PULSES: 2+ DP pulses
NEURO: A&Ox3, moving all extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 10:52AM WBC-7.0 RBC-4.86 HGB-13.5* HCT-42.4 MCV-87
MCH-27.8 MCHC-31.8* RDW-15.0 RDWSD-47.7*
___ 01:45PM GLUCOSE-109* UREA N-18 CREAT-1.0 SODIUM-144
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17
___ 01:45PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 10:52AM cTropnT-<0.01
___ 01:45PM proBNP-3090*
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 08:20AM BLOOD WBC-6.8 RBC-4.81 Hgb-13.3* Hct-40.6
MCV-84 MCH-27.7 MCHC-32.8 RDW-14.8 RDWSD-45.1 Plt ___
___ 08:20AM BLOOD Glucose-129* UreaN-21* Creat-1.2 Na-144
K-3.5 Cl-104 HCO3-24 AnGap-16
___ 08:20AM BLOOD ALT-35 AST-24 AlkPhos-117 TotBili-0.6
___ 12:01AM BLOOD cTropnT-0.01
___ 04:19PM BLOOD cTropnT-0.02*
___ 10:52AM BLOOD cTropnT-<0.01
___ 08:20AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.1
===========================
REPORTS AND IMAGING STUDIES
===========================
---
EKG
---
Rate 62, sinus rhythm, no ST or T wave changes
-------------
___ CXR
-------------
FINDINGS:
AP upright and lateral views of the chest provided.
Mild pulmonary edema is noted with trace pleural effusions. No
gross signs for a superimposed pneumonia. Cardiomediastinal
silhouette appears grossly unremarkable. Bony structures are
intact. No free air seen below the right hemidiaphragm.
IMPRESSION:
Mild pulmonary edema, trace pleural effusions.
============
MICROBIOLOGY
============
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Colchicine 0.6 mg PO DAILY
4. Atenolol 150 mg PO DAILY
5. NIFEdipine (Extended Release) 90 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
7. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
8. tadalafil 20 mg oral ASDIR
9. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth Twice Daily Disp
#*60 Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Colchicine 0.6 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. NIFEdipine (Extended Release) 90 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO QPM
8. tadalafil 20 mg oral ASDIR
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Chest Pain
===================
SECONDARY DIAGNOSES
===================
Coronary Artery Disease
Hypertension
Dysplipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with left sided chest pain// ptx, effusion, edema, infiltrate
COMPARISON: CT of the chest from ___
FINDINGS:
AP upright and lateral views of the chest provided.
Mild pulmonary edema is noted with trace pleural effusions. No gross signs
for a superimposed pneumonia. Cardiomediastinal silhouette appears grossly
unremarkable. Bony structures are intact. No free air seen below the right
hemidiaphragm.
IMPRESSION:
Mild pulmonary edema, trace pleural effusions.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Other chest pain, Heart failure, unspecified
temperature: 98.8
heartrate: 89.0
resprate: 28.0
o2sat: 96.0
sbp: 161.0
dbp: 120.0
level of pain: 3
level of acuity: 2.0 | =================
SUMMARY STATEMENT
=================
Mr. ___ is a ___ year old man with a history of coronary
artery disease with a LCx stent in ___ ___s a repaired
abdominal aortic aneurysm who presents with a several hours of
typical anginal pain. His symptoms began as pressure at rest,
and after several hours became central chest pain worse with
walking and associated with dyspnea. He had severe hypertension
in the emergency department that was associated with further
chest pain. Once his blood pressure was controlled, he became
chest pain free. He was monitored for 24 hours and discharged.
He already had a scheduled nuclear perfusion stress test
scheduled for ___, and we plan to try to move this up,
if possible.
====================
ACUTE MEDICAL ISSUES
====================
#Chest pain
#Troponemia
Patient presented to ED after 4 hour episode of chest pressure
with associated shortness of breath while lying in bed. Has
never experienced similar chest pain, and he instead experienced
nausea prior to his stent placement ___ years ago. In the ED,
continued to have some chest pain when he realized his blood
pressure was elevated to 200. Of note, his ___ nuclear
perfusion imaging did demonstrated a mild reversible basal wall
perfusion defect. His symptoms are unlikely to represent ACS as
his EKG did not demonstrate ischemic changes and his troponins
were elevated only to .01->.02->.01, likely explained by his
hypertension. He was chest pain free for 24 hours prior to
discharge. He was provided carefully return precautions and we
will plan to try and move his outpatient stress test up to the
week following his discharge. He was continued on his home ASA
325 and his home rosuvastatin 40mg. His atenolol was converted
to carvedilol 12.5mg twice daily for better blood pressure
control.
#Hypertension
Patient with BPs 200/100 in the ED. Per review of clinic record
BP often 170s, per patient BPs 130s/80s at home. After receiving
carvedilol and his home nifedipine, his blood pressures greatly
improved with systolics in the 130's. He was discharged on
carvediolol and his home atenolol was held.
#Exacerbation of heart failure with reduce ejection fraction
Cardiac perfusion study demonstrated EF 44% in ___. Never
decompensated and not on a home diuretic. Patient presented with
mild clinical volume overload, with lower extremity edema, mild
pulmonary edema on CXR, and BNP elevated to 3090, with no known
previous values. Received diuresis with Lasix 40mg IV in ED with
good effect. He appeared nearly euvolemic by ___.
======================
CHRONIC MEDICAL ISSUES
======================
#Gout
Continued home allopurinol, colchicine regimen.
#AAA
S/p repair. Continued home ASA 325mg.
===================
TRANSITIONAL ISSUES
===================
- New Meds: Carvedilol 12.5mg twice daily
- Stopped/Held Meds: Stopped atenolol 150mg daily
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed: None
- Incidental Findings: None
- Discharge weight: ___ 106.2kg (234.13 pounds)
[ ] Patient should have TTE as an outpatient to evaluate for
heart failure
[ ] Patient is scheduled for ___ nuclear perfusion study.
This should be moved up to the closest date possible. We will
try to facilitate from the inpatient team as well.
[ ] Continued blood pressure monitoring as he was converted from
carvedilol to atenolol due to significant hypertension. Consider
24hr blood pressure monitoring device, as patient finds his
blood pressure is always 130's.
[ ] Careful monitoring of volume status as patient presented
mildly volume overloaded and was not discharged on an oral
diuretic. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Headache, ear pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman, past medical history of Alzheimer's disease,
presents to emergency room, due to nursing concern for stroke at
___ facility.
Per ED team's report, nurse at ___, noted
patient had a right facial droop and mild right pronator drift,
and she was concerned for stroke so sent her to the ED for
evaluation. Per patient, she was in her usual state of health,
but she had
She had a R earache and right upper extremity pain for the last
several days. She went to see the nurse that evening, because
she was hoping for an aspirin or a sleep aid due to the pain.
When asked what was hurting, she states "I cant tell you" "oi
just don't know", and then points to her right elbow and R ear.
She went to see the nurse, and she had not met this nurse
previously. She acknowledges that the nurse was concerned and
sent her here for evaluation. Patient feels like she is at her
baseline. She confirms that she has difficulty word finding and
that this is baseline for her due to her Alzheimer's dementia.
She states "once I find it I can say it, but it takes a while to
find an and "
Per her son, he states she is typically accurate about the days
events, but acknowledges that she does have some word finding
difficulties and mild memory difficulties.
I was unable to reach nurse at ___ to gain further or confirm
collateral.
Endorses headache - maybe came on today, not sure. feels like a
pressure, mild light headache. not typically a headache person.
no changes with position or valsalva. Mostly from the ear. no
n/v
or p/p.
On review of systems, she endorses a mild pressure-like
headache,
that she feels is originating from her right ear. She is not
sure whether it started today or previously. She denies changes
in the pain with position or Valsalva. No nausea vomiting or
photophobia phonophobia associated with the headache.
ROS: On neurologic review of systems, the patient denies
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or
retention. Denies difficulty with gait.
occasional diarrhea.
On general review of systems, the patient endorses occasional
diarrhea. Denies fevers, rigors, night sweats, or noticeable
weight loss. Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, constipation, or abdominal pain. No
recent change in bowel or bladder habits. Denies dysuria or
hematuria. Denies myalgias, arthralgias, or rash.
Past Medical History:
Alzheimers Dementia
Per chart review:
Inflammatory arthritis
Degenerative disc disease in cervical spine
Osteopenia/osteoporosis
Rosacea
Social History:
SOCIAL HISTORY: ___
Family History:
None. Her Sister is ___ years and is not on any
medications. Father: AD; Mother passed of old age.
Physical Exam:
============================
ADMISSION PHYSICAL EXAM
============================
Vitals: T: 98.1 HR: 91 BP: 153/69 RR: 16 SaO2: 100% on room air
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple, R Otitis
Media (Per ED exam)
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
- Cranial Nerves: PERRL 2->1.5, post cataract, minimally
reactive. VF full to number counting. EOMI, no nystagmus. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor: Normal bulk and tone. R pronation, without drift. No
tremor or asterixis.
[___]
L 5- 5- 4+ 5 ___ 5 5- 5 5 5-
R 4 5- 4- 5 ___ 5 5 5 5 5
Supraspinatus/Infraspinatus: 4 bilaterally
R Pec 4
L Pec 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 1+ 0
R 3+ 2 3+ 1+ 0
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Normal stride length,
but
holds RUE internally rotated and supinated, close to body.
Mildly unsteady when walking. Negative Romberg.
============================
DISCHARGE PHYSICAL EXAM
============================
General exam unremarkable.
- Mental status: Awake and alert. +paraphasic errors, hesitant
while speaking and anomia to low freq objects (pt states this is
chronic). Can follow 3-step cross body commands.
- Cranial Nerves: PERRL 2->1.5, post cataract, minimally
reactive. VF full to number counting. EOMI, no nystagmus. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor: Normal bulk and tone. R pronation, without drift. No
tremor or asterixis.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA][Gas]
L 4 5 4- 4+ 4 4+ 5 4+ 5 5
R 4- 4+ 4 5 4 4+ 5 4+ 5 5
Supraspinatus/Infraspinatus: 4 bilaterally
- Reflexes: Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Normal stride length,
but
holds RUE internally rotated and supinated, close to body.
Mildly unsteady when walking. Negative Romberg.
Pertinent Results:
========
LABS
========
___ 07:02AM BLOOD cTropnT-0.03*
___ 02:06AM BLOOD cTropnT-0.04*
___ 07:35PM BLOOD cTropnT-0.03*
___ 07:50AM BLOOD Glucose-91 UreaN-13 Creat-0.7 Na-135
K-4.1 Cl-97 HCO3-24 AnGap-18
___ 07:50AM BLOOD WBC-9.4 RBC-3.48* Hgb-11.3 Hct-35.1
MCV-101* MCH-32.5* MCHC-32.2 RDW-12.3 RDWSD-46.0 Plt ___
___ 07:35PM BLOOD ___ PTT-29.2 ___
___ 07:35PM BLOOD Lipase-26
___ 07:35PM BLOOD ALT-20 AST-19 CK(CPK)-169 AlkPhos-63
TotBili-0.3
___ 11:29AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0 Cholest-220*
___ 11:29AM BLOOD %HbA1c-5.7 eAG-117
___ 11:29AM BLOOD Triglyc-78 HDL-79 CHOL/HD-2.8 LDLcalc-125
___ 07:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:09PM URINE Color-Straw Appear-Clear Sp ___
___ 10:09PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 10:09PM URINE RBC-4* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 10:09PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
==============
IMAGING
==============
MRI HEAD WITHOUT CONTRAST (___):
1. There are no infarcts.
2. Small areas of cortical superficial cirrhosis.
3. Brain parenchymal atrophy, mild chronic small vessel ischemic
changes.
CT HEAD AND NECK
CT ___:
No acute intracranial abnormality. Prominent ventricles and
sulci
are likely reflective of age-related involutional changes.
Periventricular
white matter hypodensities are nonspecific and may relate to
chronic small
vessel ischemic changes. Patient is status post bilateral lens
replacement. A left maxillary sinus 2.2 calcified partially
imaged lesion may reflect an osteoma.
CTA head & neck (___):
Patent intracranial vasculature. No evidence of vascular
occlusion or injury. No >3 mm aneurysm dilation. Patent cervical
vasculature.. Moderate atherosclerotic disease causes
approximately 50% stenosis of the right internal carotid artery.
There is partially imaged bronchiectasis as well as partially
imaged pleural scarring and apical consolidation.
CXR (___):
Prominent biapical scarring, underlying infection not excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 5 mg PO QHS
2. Acidophilus (Lactobacillus acidophilus) 1 tablet oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*11
3. Acidophilus (Lactobacillus acidophilus) 1 tablet oral DAILY
4. Donepezil 5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Headache due to right otitis media
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with RUE weakness, facial droop// eval for
stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head, neck ___
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. There is generalized brain parenchymal atrophy. There are
mild chronic small vessel ischemic changes. Intracranial vascular flow voids
are preserved. Small areas of cortical superficial cirrhosis involving right
superior frontal gyrus at the vertex, anterior left frontal lobe, likely
sequela of distant hemorrhage. There are no subarachnoid signal abnormalities
on today's exam or on comparisons CTA. No MRI evidence of amyloid angiopathy,
AVM, or cavernoma.
Osseous fullness of the floor of the left maxillary sinus, may be
postoperative given adjacent tooth implants. There is mild opacification of
the ethmoid air cells, similar. Minimal opacification right mastoid air
cells.
IMPRESSION:
1. There are no infarcts.
2. Small areas of cortical superficial cirrhosis.
3. Brain parenchymal atrophy, mild chronic small vessel ischemic changes.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, Neuro deficit
Diagnosed with Headache
temperature: 98.1
heartrate: 91.0
resprate: 16.0
o2sat: 97.0
sbp: 153.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | ___ woman, past medical history of Alzheimer's dementia
who presented with dull bifrontal headache, right upper
extremity pain and earache.
Due to possible history of transient right facial droop and
pronator drift (per facility nurse report), there was a concern
for a possible infarct/TIA. CTA head and neck and MRI brain did
not reveal any acute ischemic infarct however. She was not
started on any medications for secondary stroke prevention due
to low suspicion of TIA (it was not entirely clear whether pt
truly had a facial droop and pronator drift) and risk of
bleeding with aspirin use in a patient with dementia at risk for
falling and microhemorrhage development. Furthermore, her
neurological exam was significant for bilateral upper and lower
extremity weakness suggestive of cervical spondylosis, which
could have explained her presenting right upper extremity
radicular pain and headache (bifrontal, tension-like).
She remained asymptomatic neurologically during her hospital
stay. Right otitis media and mastoiditis was confirmed on
physical examination and she was discharged home on a 7-day
course of augementin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Sulfite / Penicillins /
minivele
Attending: ___.
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with IgG deficiency (on weekly IVIG), asthma,
bronchiectasis, presents with one day of n/v/d and fever. She
states she has had >10 episodes of diarrhea and >10 episodes
NBNB vomiting which started abruptly around 3am on the day of
presentation. Prior to this had a mild cold, but otherwise was
in her usual state of health. Thinks it may be from food
poisoning as she had ___ food the night her symptoms
started. Denies any sick contacts at home or work. In setting of
profuse diarrhea and vomiting, was unable to take anything by
PO, felt very weak and thinks that she may have aspirated when
vomiting. Reports mild diffuse abd pain that she thinks is from
muscle pain from the frequent vomiting. was unable to get up
from the ground and ultimately called ___ and was transported to
the ED.
In the ED, initial vitals: 96.8, 91, 133/99, 18, 100% RA. Over
the course of her time in the ED, she developed a fever to 102.6
and hypotension to low of 88/57.
On exam pt had no abdominal tenderness, and had crackles at the
right base.
Labs were significant for: WBC 13 (PMN predominance), Lactate
1.5, Cr 1.0, K 3.7. Flu negative. BCx sent.
Imaging was significant for CXR with RLL consolidation. CT A/P
with RLL consolidation, no acute abdominal pathology.
She received 5L IVF and 100mg hydrocortisone with improvement in
her BP to 108/60. Also received Zofran and reglan for n/v, as
well as levofloxacin and flagyl. She was admitted to the MICU
for hypotension.
On transfer, vitals were: 99.1 84 113/63 20 96% Nasal Cannula
On arrival to the MICU, she reports having a dry mouth and still
feeling weak. Denies nausea currently since receiving Zofran
overnight and has been able to tolerate small amounts of
gingerale.
Past Medical History:
1. Asthma, moderate persistent,
2. IgG deficiency on weekly ___ (received last dose on ___
3. bronchiectasis
4. depression
5. arthritis
6. Obesity
8. GERD/esophageal dysmotility
Social History:
___
Family History:
mother-HTN, CVA, diabetes, CHF late in life. Father-COPD
(smoking)
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.7 BP:99/59 P: 75 R:23 O2:99 on 2___
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: +rales in RLL, no respiratory distress, no wheezes or
rhonchi
CV: Regular rate and rhythm, normal S1 S2, ___ systolic ejection
murmur, no rubs, gallops
ABD: soft, obese, non-distended, mild diffuse tenderness, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: No foley in place
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: No lesions.
NEURO: A&O x3. Face symmetric, moving all extremities equally.
ACCESS: PIVs
DISCHARGE EXAM:
Vitals: 98.2 149/82 80 20 97RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: +rales in RLL, no respiratory distress, + mild polyphonic
end expiratory wheezes; no rhonchi
CV: Regular rate and rhythm, normal S1 S2, ___ systolic ejection
murmur, no rubs, gallops
ABD: soft, obese, non-distended, minimal diffuse tenderness,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: No foley in place
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: No lesions.
NEURO: A&O x3. Face symmetric, moving all extremities equally.
ACCESS: PIVs
Pertinent Results:
ADMISSION LABS:
___ 11:25AM BLOOD WBC-12.7* RBC-5.24* Hgb-15.9* Hct-48.5*
MCV-93 MCH-30.3 MCHC-32.8 RDW-14.4 RDWSD-48.7* Plt ___
___ 11:25AM BLOOD Neuts-83.5* Lymphs-10.6* Monos-4.6*
Eos-0.7* Baso-0.2 Im ___ AbsNeut-10.60* AbsLymp-1.35
AbsMono-0.59 AbsEos-0.09 AbsBaso-0.03
___ 11:25AM BLOOD Glucose-156* UreaN-17 Creat-1.0 Na-142
K-3.7 Cl-100 HCO3-23 AnGap-23*
___ 11:25AM BLOOD ALT-23 AST-25 AlkPhos-97 TotBili-0.6
___ 11:25AM BLOOD Calcium-10.0 Phos-2.2* Mg-1.8
___ 02:58AM BLOOD Lactate-1.5
MICRO:
-___ C.Diff: NEGATIVE
-___ Norovirus PCR: Positive
-___ Urine Culture: pending
-___ Blood Culture x2: pending
-___ Flu Swab A/B: Negative
IMAGING:
___ CT Abd/Pelvis:
1. Right lower lobe pneumonia, incompletely imaged on this exam.
2. No acute intra-abdominal abnormality.
3. Fat containing umbilical hernia.
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-7.5 RBC-3.79* Hgb-11.8 Hct-35.1
MCV-93 MCH-31.1 MCHC-33.6 RDW-14.8 RDWSD-50.8* Plt ___
___ 06:48AM BLOOD Glucose-76 UreaN-6 Creat-0.9 Na-142 K-3.9
Cl-105 HCO3-26 AnGap-15
___ 06:48AM BLOOD Calcium-9.5 Phos-3.8 Mg-1.9
IMAGING:
___ (PA & LAT)
Focal opacity projecting over the right mid lung field is
concerning for
pneumonia.
RECOMMENDATION(S): ___ chest radiograph ___ weeks after
completion of
treatment.
___ CT ABD & PELVIS WITH CONTRAST
1. Right lower lobe pneumonia, incompletely imaged on this exam.
2. No acute intra-abdominal abnormality.
3. Fat containing umbilical hernia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob, wheezing
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheezing
3. azelastine 137 mcg (0.1 %) nasal BID
4. Azithromycin 250 mg PO 3X/WEEK (___)
5. BusPIRone 20 mg PO BID
6. DULoxetine 40 mg PO DAILY
7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
8. Estradiol 0.5 mg PO 4X/WEEK (___)
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
11. Immune Globulin Intravenous (Human) unknown Subcut Infusion
1X/WEEK (SA)
12. Montelukast 10 mg PO DAILY
13. Xolair (omalizumab) 375 mg subcutaneous twice a month
14. Pantoprazole 40 mg PO Q12H
15. Pravastatin 40 mg PO QPM
16. proGESTerone micronized 200 mg oral DAILY
17. Cetirizine 10 mg PO DAILY
18. Estradiol 0.25 mg PO 3X/WEEK (___)
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 7 Days
Day 1 = ___, D7 (last dose on) = ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
2. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 cap by mouth up to four times a day Disp
#*60 Capsule Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp
#*42 Tablet Refills:*0
4. PredniSONE 40 mg PO DAILY Duration: 5 Days
To be taken only as needed for asthma exacerbation.
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
5. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob, wheezing
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheezing
8. azelastine 137 mcg (0.1 %) nasal BID
9. BusPIRone 20 mg PO BID
10. Cetirizine 10 mg PO DAILY
11. DULoxetine 40 mg PO DAILY
12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
13. Estradiol 0.5 mg PO 4X/WEEK (___)
14. Estradiol 0.25 mg PO 3X/WEEK (___)
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Immune Globulin Intravenous (Human) unknown Subcut
Infusion 1X/WEEK (SA)
17. Montelukast 10 mg PO DAILY
18. Pantoprazole 40 mg PO Q12H
19. Pravastatin 40 mg PO QPM
20. proGESTerone micronized 200 mg oral DAILY
21. Xolair (omalizumab) 375 mg subcutaneous twice a month
22. HELD- Azithromycin 250 mg PO 3X/WEEK (___) This
medication was held. Do not restart Azithromycin until
levofloxacin is completed
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
--------------------
-Viral Gastroenteritis due to Norovirus
-Pneumonia, most likely due to aspiration
-Hypotension due to Hypovolemia
-Anion Gap Metabolic Acidosis
SECONDARY DIAGNOSIS/ES:
-Asthma with mild exacerbation due to pneumonia
-Elevated blood pressure without diagnosis of hypertension
-IgG Deficiency on weekly IVIG
-Bronchiectasis
-Gastroesophageal Reflux Disease
-Anxiety
-Depression
-Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fever crackles // eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___.
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal
silhouette and well-aerated lungs. There is a focal opacity projecting over
the right mid lung field, concerning for pneumonia. No appreciable pleural
effusion or pneumothorax is seen.
IMPRESSION:
Focal opacity projecting over the right mid lung field is concerning for
pneumonia.
RECOMMENDATION(S): Follow-up chest radiograph ___ weeks after completion of
treatment.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with diffuse abdominal pain,
n/vNO_PO contrast // eval for abscess diverticulitis, appendicitis colitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 4.7 s, 51.5 cm; CTDIvol = 16.4 mGy (Body) DLP = 844.1
mGy-cm.
3) Spiral Acquisition 0.6 s, 6.5 cm; CTDIvol = 12.0 mGy (Body) DLP = 77.7
mGy-cm.
Total DLP (Body) = 931 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is an incompletely imaged consolidation along the lateral
right lower lobe. There is no pericardial or pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver is homogeneous in background attenuation without
intra or extrahepatic biliary duct dilation or focal lesion. The main portal
vein is patent. The gallbladder is within normal limits.
PANCREAS: The pancreas is normal in attenuation, without mass, ductal
dilation, or peripancreatic stranding or fluid collection.
SPLEEN: The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are normal in caliber and configuration
bilaterally.
URINARY: The kidneys are symmetric and normal in size, demonstrating normal
nephrograms and excreting contrast promptly. There is no evidence of focal
renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is decompressed, but there is no obvious focal
wall thickening or mass. A small hiatal hernia is noted. Small bowel loops
are normal in caliber without wall thickening or evidence of obstruction.
Sigmoid diverticulosis is noted without evidence of acute diverticulitis. A
normal appendix is visualized.
PELVIS: The urinary bladder is decompressed with a Foley catheter. There is
no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable. There is no adnexal mass.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: No focal lytic or sclerotic osseous lesion to suggest neoplasm or
infection is seen.
SOFT TISSUES: There is a fat containing umbilical hernia. Locules of air in
the subcutaneous fat of the anterior abdomen are likely due to medication
injections.
IMPRESSION:
1. Right lower lobe pneumonia, incompletely imaged on this exam.
2. No acute intra-abdominal abnormality.
3. Fat containing umbilical hernia.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: n/v/d
Diagnosed with Pneumonia, unspecified organism
temperature: 96.8
heartrate: 91.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 99.0
level of pain: 7
level of acuity: 3.0 | ___ with IgG deficiency (on weekly IVIG), asthma,
bronchiectasis, presenting with one day of n/v/d, found to be
febrile, hypotensive, and tachycardic, with RLL infiltrate on
CXR and CT concerning for aspiration pneumonia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left proximal humerus fracture
Major Surgical or Invasive Procedure:
Left proximal humerus ORIF
History of Present Illness:
___ no significant PMH who presents with above fracture s/p
altercation last night while intoxicated. He was out with
friends last night, +EtOH and marijuana use, when he tried to
interrupt a fight and was pushed from behind. He landed onto his
hands. No HS or LOC. Police broke up the fight. Went to ___
___ where he was diagnosed with a left ___ hum fx and
transferred here for further evaluation.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
Focused MSK exam:
Left upper extremity:
- Dressings c/d/I
- Soft, non-tender arm and forearm
- Full, painless ROM elbow, wrist, and digits
- Fires EPL/FPL/DIO
- SILT radial/median/ulnar nerve distributions
- Fingers WWP
Pertinent Results:
___ 11:25AM BLOOD WBC-11.7* RBC-3.50* Hgb-10.8* Hct-33.7*
MCV-96 MCH-30.9 MCHC-32.0 RDW-12.1 RDWSD-42.3 Plt ___
___ 11:25AM BLOOD Glucose-117* UreaN-13 Creat-1.0 Na-140
K-4.6 Cl-101 HCO3-28 AnGap-11
___ 11:25AM BLOOD Mg-1.7
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin [Lovenox] 40 mg/0.4 mL 1 (One) syringe
subcutaneous once a day Disp #*30 Syringe Refills:*0
3. Senna 8.6 mg PO BID
4. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 (One) tablet(s) by mouth every four (4)
hours Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left proximal humerus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: HUMERUS (AP AND LAT) LEFT IN O.R.
INDICATION: ORIF PROXIMAL HUMERUS FX
COMPARISON: CT left shoulder ___ and x-ray left shoulder ___
FINDINGS:
Fluoroscopy without a radiologist was provided. 97 seconds of fluoroscopy
time was used with a cumulative dose of 749 mm at its. 23 images were
obtained from the OR during ORIF comminuted left humeral fracture.
IMPRESSION:
S/p ORIF comminuted of left humeral fracture with slotted plate and screws
Radiology Report
EXAMINATION: DX SHOULDER AND HUMERUS
INDICATION: History: ___ with presumed fx of LUE// eval for fracture
TECHNIQUE: AP, lateral and Y views of the left shoulder.
COMPARISON: None
FINDINGS:
Comminuted displaced fracture of the proximal left humerus through the greater
tuberosity and humeral shaft. The greater tuberosity is displaced laterally.
The distal humeral shaft is superiorly displaced by 3 cm approximately. There
is approximately 30% medial apex angulation of the distal humeral shaft.
There is no fracture or dislocation involving the glenohumeral or AC joint.
There are no significant degenerative changes. No suspicious lytic or
sclerotic lesions are identified. No periarticular calcification or
radio-opaque foreign body is seen.
IMPRESSION:
Comminuted displaced fracture of the proximal left humerus through the greater
tuberosity and proximal humeral shaft. Distal humeral shaft is superiorly
displaced by 3 cm with medial apex angulation of the distal humeral fragment.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with shoulder injury, preop ortho// preop
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Lung volumes are not well expanded however could be positional. Lungs are
clear of focal consolidations or opacities. Cardiomediastinal contours are
normal. No pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiothoracic findings.
Radiology Report
EXAMINATION: eval shoulder fracture
INDICATION: ___ year old man with proximal humerus fx left// eval shoulder
fracture
TECHNIQUE: Multidetector CT images were obtained of the left shoulder in bone
and soft tissue algorithm without intravenous contrast. Sagittal and coronal
reformatted images were obtained and reviewed.
COMPARISON: Left shoulder radiographs from ___, 4 hours prior
FINDINGS:
Acute extensive comminuted impacted and displaced fracture of the left
proximal humerus involving the surgical neck, greater and lesser tuberosities,
and demonstrating extension into the bicipital groove (03:40). No evidence of
biceps tendon dislocation. There is approximately ___ shaft with displacement
of the distal humeral shaft medially at the surgical neck with approximately
20 mm of impaction with the medial superior distal humeral fragment in very
close proximity to the inferior glenoid and labrum (402:61). The glenohumeral
joint appears congruent. No evidence bony Bankart fracture.
Acromioclavicular joint is intact. There is extensive surrounding soft tissue
edema and hematoma. No radiopaque foreign body.
IMPRESSION:
1. Acute extensive comminuted impacted and displaced left proximal humerus
fracture, detailed above.
2. Medial superior humeral fracture fragment comes in close proximity to the
inferior glenoid and labrum although assessment of the labrum is limited on
CT.
3. No dislocation. No evidence of bony Bankart injury.
4. Extensive surrounding soft tissue edema and hematoma.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Disp fx of greater tuberosity of left humerus, init, Asslt by strike agnst or bumped into by another person, init
temperature: 98.7
heartrate: 81.0
resprate: 14.0
o2sat: 98.0
sbp: 134.0
dbp: 74.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left proximal humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left proximal humerus ORIF,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with OT who determined that discharge to home
with outpatient OT was appropriate.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
___, ___ for passive ROM of shoulder, light ADLs, ROMAT of
elbow, wrist and digits, and will be discharged on Lovenox for
DVT prophylaxis. The patient will follow up with Dr. ___
___ routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
increasing shortness of breath and LL swelling.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is ___ yo M w/ h/o sCHF (EF 25%),CAD s/p stenting, DM,
AFib not on anticoag, and concern for progressive dementia p/w
orthopnea and DOE. Pt states he noted orthopnea on day of
admission in particular, also w/ DOE. He denies new cough,
sputum, fevers/chills, CP ___ swelling. He emphasizes taking
all his medications regularly, but feels like might be urinating
less than in prior weeks. Last discharge weight was 98.9kg.
RECENT PRIOR HOSPITALIZATIONS
===============================
He was recently admitted on ___ for AMS and falls at home.
He was evaluated by Neurology who felt he had a significant
cognitive decline ___ vascular dementia with a possible
Alzheimer's component.
Patient's heart failure exacerbated on that admission and was
managed with increasing doses of IV furosemide boluses,
transitioned to PO torsemide 60mg on day of discharge, not at
dry weight as still some dependent edema but was breathing
comfortably on room air and with clear (significantly improved)
mental status
Of note, also hospitalized at ___ ___ for 1 week of AMS.
At that time, evaluated by neurology, imaging revealed chronic
small vessel ischemia, EEG c/w tox/metab encephalopathy, no
seizure, and patient was found to have possible UTI, treated, w/
some improvement in MS. ___, at time of discharge, remained
"acutely delirious and aggressive at night", and there was
concern for "dementia with parkinsons features" given ___ years of
progressive decline. Was recommended to f/u with neurology at ___
___, however due to recurrent hospitalizations (see below)
this has not yet occured.
Also recently hospitalized at ___ ___, for
aspiration PNA ___ dysphagia, requring ___ ICU stay for
spesis. During that admission, patient was encephalopathic in
setting of sepsis, was evaluated by neurology, who did NOT think
patient had underlying ___ disease, and it was report
patient was back to mental baseline at time of discharge. He was
also diuresed for decompensated CHF, and placed on dysphagia
diet given aspiration.
- In the ED initial vitals were 96.3 70 152/86 26 94% RA
- Labs were significant for WBC 11.9, H/H 11.4/36.3 PLt 238
Creat 1.1 BNP 8745
- Imaging showed: Cxray with mild hilar congestion with small
right pleural effusion, stable mild cardiac enlargement.
- Patient was given Lasix 80mg IV
- On transfer vitals were HR 43 142/74 16 93% RA
On arrival to the floor, patient denies any shortness of breath
and lying flat with one pillow.
Past Medical History:
Heart Failure with Reduced Ejection Fraction (EF 25%)
CAD s/p MIx2 w/ 5 stents (DES) last one around ___
Paroxysmal Afib s/p ablation, not on anticoagulation
Type 2 DM
HTN
HLD
R Charcot foot
Bladder emptying problem being evaluated
GERD
?Gastric emptying difficulty
Vascular +/- Alzheimer's Dementia
OSA, severe AHI 56, not on CPAP
Social History:
___
Family History:
M: CHF, DM,
F: CHF
Brother: ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.9 147/76 67 18 93% on RA No weight obtained yet
GENERAL: NAD man lying flat in bed with 1 pillow
HEENT: PERRL, MMM
NECK: Supple, No LAD, JVD elevated to angle of jaw
CARDIAC: irregular, S1/S2, no murmurs, gallops, or rubs
LUNG: crackles at ___ bases
ABDOMEN: nondistended, +BS, NT
EXTREMITIES: 1+ to trace edema in BLE.
NEURO: CN II-XII grossly intact, A&Ox3
DISCHARGE PHYSICAL EXAM:
VS - 97.1 ___ 47-54 20 96-100 on RA
weight: 113.9 -> 113.5 (bed)-> 110.0 (bed) 102.3 (stand) ->
111.1 (bed).
discharge weight: 97
I/O: ___, ___.
GENERAL: NAD man lying flat in bed with 1 pillow
HEENT: PERRL, MMM
NECK: Supple, No LAD, JVD elevated to angle of jaw
CARDIAC: irregular, S1/S2, no murmurs, gallops, or rubs
LUNG: crackles at ___ bases
ABDOMEN: nondistended, +BS, NT
EXTREMITIES: 1+ to trace edema in BLE.
NEURO: CN II-XII grossly intact, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 09:50PM URINE HOURS-RANDOM
___ 09:50PM URINE HOURS-RANDOM
___ 09:50PM URINE UHOLD-HOLD
___ 09:50PM URINE GR HOLD-HOLD
___ 09:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:50PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:50PM URINE HYALINE-7*
___ 09:50PM URINE MUCOUS-RARE
___ 07:40PM GLUCOSE-131* UREA N-20 CREAT-1.1 SODIUM-139
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
___ 07:40PM estGFR-Using this
___ 07:40PM proBNP-8745*
___ 07:40PM WBC-11.9* RBC-4.27* HGB-11.4* HCT-36.3*
MCV-85 MCH-26.7 MCHC-31.4* RDW-17.2* RDWSD-53.0*
___ 07:40PM NEUTS-71.1* LYMPHS-11.7* MONOS-11.6 EOS-4.7
BASOS-0.5 IM ___ AbsNeut-8.42* AbsLymp-1.39 AbsMono-1.38*
AbsEos-0.56* AbsBaso-0.06
___ 07:40PM PLT COUNT-238
___
IMPRESSION:
Mild hilar congestion with small right pleural effusion, stable
mild cardiac enlargement.
___ ECHO at ___
___ atrium is dilated at 45 mm. The ___ ventricle is at the
upper limits ofnormal at 54 mm. There is diffuse ___
ventricular hypokinesis and the overall ___ ventricular
function is severely depressed with an ejection fraction of
around 25%. The mitral and aortic valves are thickened, but the
leaflets open well. Color flow and Doppler study shows
moderately severe aortic insufficiency
, mild mitral regurgitation, mild tricuspid regurgitation,
elevated pulmonary artery pressure of 43 mmHg.
CONCLUSION: ___ atrial enlargement, borderline ___
ventricular enlargement, severe ___ ventricular dysfunction
with a reduced ejection fraction of around 25%, moderate aortic
insufficiency, moderate tricuspid regurgitation, elevated
pulmonary artery pressure of 43 mmHg.
EKG: Probable sinus rhythm at about 75 beats per minute. There
is probably P-R interval prolongation on conducted complexes
that have Q waves in leads III and aVF. Possible inferior wall
myocardial infarction. There is late R wave progression and Q-T
interval prolongation. Ventricular premature beats also show Q
waves in leads III and aVF consistent with inferior wall
myocardial infarction. They have a ___ bundle-branch block
morphology in the precordial leads. Compared to the previous
tracing of ___ there is probably no significant change.
DISCHARGE DIAGNOSIS:
___ 04:30AM BLOOD WBC-9.6 RBC-4.50* Hgb-11.8* Hct-37.5*
MCV-83 MCH-26.2 MCHC-31.5* RDW-17.1* RDWSD-51.8* Plt ___
___ 04:30AM BLOOD Plt ___
___ 12:45PM BLOOD Glucose-177* UreaN-18 Creat-1.0 Na-138
K-4.2 Cl-98 HCO3-28 AnGap-16
___ 12:45PM BLOOD Calcium-9.5 Phos-3.9 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluoxetine 20 mg PO DAILY
4. Gabapentin 100 mg PO TID
5. Metoclopramide 5 mg PO TID W/MEALS
6. Omeprazole 40 mg PO DAILY
7. Pravastatin 40 mg PO QPM
8. Spironolactone 25 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. sitaGLIPtin 100 mg oral DAILY
11. Lisinopril 5 mg PO DAILY
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Miconazole 2% Cream 1 Appl TP BID fungal rash
14. Torsemide 60 mg PO DAILY
15. Glargine 30 Units Bedtime
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluoxetine 20 mg PO DAILY
4. Gabapentin 100 mg PO TID
5. Glargine 30 Units Bedtime
6. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Metoclopramide 5 mg PO TID W/MEALS
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Pravastatin 40 mg PO QPM
11. Spironolactone 25 mg PO DAILY
12. Torsemide 60 mg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Miconazole 2% Cream 1 Appl TP BID fungal rash
15. sitaGLIPtin 100 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic systolic congestive heart failure
Atrial fibrillation
Sleep apnea
Secondary diagnosis:
Diabetes mellitus
Vascular dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with dyspnea on exertion/orthopnea // ? pulmonary edema
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided. The heart remains mildly
prominent. There is mild hilar congestion without frank pulmonary edema.
There is a small right pleural effusion which is unchanged. No convincing
evidence for pneumonia. No pneumothorax. Mediastinal contour is normal.
Bony structures are intact.
IMPRESSION:
Mild hilar congestion with small right pleural effusion, stable mild cardiac
enlargement.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with heart failure, with new O2 requirement. //
eval for pulm edema eval for pulm edema
IMPRESSION:
In comparison with the study of ___, there is again enlargement of the
cardiac silhouette with mild elevation of pulmonary venous pressure.
Increasing opacification at the bases with silhouetting hemidiaphragms is
consistent with layering effusions underlying volume loss in the lower lungs.
No definite acute focal pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion
Diagnosed with Heart failure, unspecified, Unspecified atrial fibrillation
temperature: 96.3
heartrate: 70.0
resprate: 26.0
o2sat: 94.0
sbp: 152.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | This is a ___ yo M with sCHF (EF 25%), CAD s/p stenting, some
level of dementia, DM, h/o AFib not on anticoag, with prior
decompensated heart failure who presented with with dyspnea on
exertion and worsening/decompensated heart failure.
# Acute on chronic congestive heart failure: the patient was
started on IV diuresis with 120 Lasix which he responded to
well. This improved his symptoms. He was then transitioned to
torsamide 60 on discharge.
# Hyponatremia: The patient was admitted with hyponatremia
likely secondary to fluid overload. His hyponatremia improved
with diuresis. His Na was 148 on discharge likely from poor po
intake while receiving diuresis the day prior to discharge. He
declined rechecking Na prior to his discharge. His hypernatremia
will likely improve as his body fluid compartments equilibrate.
# Atrial fibrillation: the patient was not on anticoagulation
during admission. the patient and family decline anticoagulation
because of history of cutaneous bruising while the patient was
on warfarin as well as the frequency of INR check was a barrier.
The patient was sill considering our suggestion of a NOAC at the
time of discharge.
# DM was controlled on insulin SS.
# GERD: continued home mediations.
# The patient was evaluated by ___ who recommended rehab. however
after discussion with family, the patient declined rehab and
preferred home ___ and OT.
DISCHARGE WEIGHT: 102.3 kg standing (225 lbs) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLQ pain for 4 weeks
Major Surgical or Invasive Procedure:
___ ___ transvaginal aspiration
___ CT-guided ___ drain
History of Present Illness:
___ presents with 1 mo of abd pain, mostly in RLQ. She
reports she initially saw her school nurse in early ___ who
diagnosed her with a UTI. She took an oral antibiotic for a few
days but did not complete the course. Her pain continued. She
reports constipation, and states she has pain in that area when
she has a bowel movement. She has been taking Motrin and Tylenol
for her pain for the past month. She denies fevers or chills.
She
denies hematochezia or melena, and denies diarrhea.
Past Medical History:
PMH: None
PSH: Hypertrophic facial scar removal
Social History:
___
Family History:
N/C
Physical Exam:
ADMISSION EXAM:
GEN: Alert and Oriented, NAD
RESP: Unlabored breaths
___: RRR
ABD: Soft, non-distended, TTP in right abdomen especially RLQ
with voluntary guarding there.
EXT: No edema
DISCHARGE EXAM:
VSS
GEN: NAD, AAOx3
CV: RRR, normal S1 S2
LUNGS: CTAB
ABD: Soft, nondistended, mildly tender in RLQ, no r/g. ___
catheter insertion site c/d/i.
EXT: wwp, no edema
Pertinent Results:
ADMISSION LABS:
___ 08:20AM BLOOD WBC-19.5* RBC-4.18* Hgb-11.9* Hct-33.9*
MCV-81* MCH-28.5 MCHC-35.2* RDW-13.7 Plt ___
___ 08:20AM BLOOD Neuts-88.3* Lymphs-6.3* Monos-4.7 Eos-0.5
Baso-0.1
___ 04:35PM BLOOD ___ PTT-32.5 ___
___ 08:20AM BLOOD Glucose-99 UreaN-7 Creat-0.8 Na-137 K-5.0
Cl-105 HCO3-20* AnGap-17
___ 08:20AM BLOOD ALT-12 AST-24 AlkPhos-66 TotBili-0.7
___ 07:04AM BLOOD Calcium-9.1 Phos-2.0* Mg-1.8
___ 08:20AM BLOOD Albumin-3.6
___ 08:32AM BLOOD Lactate-1.4
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-14.4* RBC-3.98* Hgb-10.9* Hct-32.2*
MCV-81* MCH-27.3 MCHC-33.7 RDW-14.1 Plt ___
___ APPENDIX U/S:
IMPRESSION:
2 cm tubular structure adjacent to the right adnexa shows a
thickened wall and is noncompressible which could represent an
inflamed, dilated appendix.
6 cm right adnexal structure with both solid and cystic
components shows
internal vascularity, though is worrisome for a potential
periappendiceal
abscess or tubo-ovarian abscess. The right ovary is not
definitely
visualized. Recommend CT for further evaluation.
___ CT ABD/PELVIS:
IMPRESSION:
1. Acute appendicitis with 6.1 cm abscess in the region of the
right adnexa adjacent to the tip of the appendix. In
combination with the findings seen on ultrasound, this raises
the possibility of the appendiceal tip having ruptured into the
right Fallopian tube.
___ CT GUIDED ___:
FINDINGS:
Preprocedure CT demonstrates a collection in the right lower
quadrant.
Ultrasound examination had demonstrated this collection to be
quite complex with most portions of it being solid in nature and
only small pockets up to 1.8 cm in maximum diameter containing
fluid. It was felt that due to the appearance on ultrasound
successful aspiration was highly unlikely. This was discussed
with the surgical team. However the procedure was considered
the best possible treatment option by Dr. ___.
IMPRESSION:
Unsuccessful CT-guided aspiration of complex collection in the
right lower quadrant. If the patient does not respond to
antibiotics and further intervention is needed, transvaginal
aspiration could be considered, although would also be difficult
due to the large solid components of the abscess that likely
represent thickened and inflamed walls of the right fallopian
tube.
___ US-GUIDED ___ ASPIRATION:
FINDINGS:
Complex fluid collection in the right hemipelvis similar in size
to prior
ultrasound and CT studies. However, the collection is now more
liquified.
IMPRESSION:
Successful US-guided transvaginal aspiration of pelvic abscess,
removing 44 cc purulent fluid. A sample was sent for
microbiology evaluation.
___ CT-GUIDED DRAINAGE:
Limited preprocedure CT scan of the pelvis demonstrates a
complex fluid
collection in the right pelvis -for further details please see
CT scan from same day.
IMPRESSION:
Successful CT-guided placement of ___ pigtail catheter
into the
collection. Samples was sent for microbiology evaluation.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Fever/pain
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
every twelve (12) hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pelvic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with abdominal pain, evaluate for stool burden.
TECHNIQUE: Supine and upright views of the abdomen and pelvis were obtained.
COMPARISON: None
FINDINGS:
There are no abnormally dilated loops of small or large bowel. There is
moderate amount of stool burden within the colon. There is no evidence of
pneumoperitoneum or pneumatosis. The visualized lung bases are clear. Osseous
structures are unremarkable.
IMPRESSION:
Nonobstructive bowel gas pattern. Moderate amount of stool burden.
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL; US APPENDIX
INDICATION: ___ with RLQ pain // r/o appy? ___? ; History: ___ with RLQ
pain // r/o appy?
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: None available
FINDINGS:
The uterus is anteverted and measures 7.3 x 3.4 x 4.1 cm. The endometrium is
homogenous and measures 8 mm. The left ovary is normal.
Centered within the right adnexa is a 6.0 x 5.7 x 6.0 cm structure with both
solid and cystic components. The solid components of the structure are
somewhat heterogeneous. This structure demonstrates arterial and venous
waveforms. The right ovary is not definitely visualized. Somewhat posterior
and superior to this is an additional tubular, thick walled structure
measuring up to 2.2 cm in diameter, which is noncompressible and could
represent the appendix or a loop of bowel. There is no free fluid.
IMPRESSION:
2 cm tubular structure adjacent to the right adnexa shows a thickened wall and
is noncompressible which could represent an inflamed, dilated appendix.
6 cm right adnexal structure with both solid and cystic components shows
internal vascularity, though is worrisome for a potential periappendiceal
abscess or tubo-ovarian abscess. The right ovary is not definitely
visualized.
Recommend CT for further evaluation.
NOTIFICATION: Findings discussed with Dr. ___ At 10:50 on ___ by Dr. ___.
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL; US APPENDIX
INDICATION: ___ with RLQ pain // r/o appy? ___? ; History: ___ with RLQ
pain // r/o appy?
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: None available
FINDINGS:
The uterus is anteverted and measures 7.3 x 3.4 x 4.1 cm. The endometrium is
homogenous and measures 8 mm. The left ovary is normal.
Centered within the right adnexa is a 6.0 x 5.7 x 6.0 cm structure with both
solid and cystic components. The solid components of the structure are
somewhat heterogeneous. This structure demonstrates arterial and venous
waveforms. The right ovary is not definitely visualized. Somewhat posterior
and superior to this is an additional tubular, thick walled structure
measuring up to 2.2 cm in diameter, which is noncompressible and could
represent the appendix or a loop of bowel. There is no free fluid.
IMPRESSION:
2 cm tubular structure adjacent to the right adnexa shows a thickened wall and
is noncompressible which could represent an inflamed, dilated appendix.
6 cm right adnexal structure with both solid and cystic components shows
internal vascularity, though is worrisome for a potential periappendiceal
abscess or tubo-ovarian abscess. The right ovary is not definitely
visualized.
Recommend CT for further evaluation.
NOTIFICATION: Findings discussed with Dr. ___ At 10:50 on ___ by Dr. ___.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with RLQ painNO_PO contrast //
Appy? ___?
TECHNIQUE: MDCT images were obtained from the lung bases to the lesser
trochanters . contrast was administered. Coronal and sagittal reformations
were prepared.
DOSE: DLP: 755 mGy-cm
COMPARISON: Pelvic ultrasound on ___
FINDINGS:
THORAX: The lung bases are clear bilaterally. The visualized heart and
pericardium are normal.
LIVER: 1.9 x 2.2, irregular and ill-defined low-density area within the left
lobe of the liver adjacent to the gallbladder fossa is likely an area of focal
fat. An additional subcentimeter hypodense area adjacent the falciform
ligament is too small to characterize but also likely represents focal fat.
The liver is otherwise normal in size and attenuation. The hepatic and portal
veins appear patent. There is no intra or extrahepatic biliary ductal
dilatation.
GALLBLADDER: The gallbladder is normal-appearing.
SPLEEN: The spleen is normal in size and enhancement.
PANCREAS: The pancreas shows normal enhancement. There is no pancreatic duct
dilatation or peripancreatic fat stranding.
ADRENALS: The adrenal glands are unremarkable bilaterally.
KIDNEYS: The kidneys display symmetric nephrograms with no evidence of
hydronephrosis or mass lesion in either kidney. The ureters are symmetrical
in their course to the bladder.
BOWEL: The stomach is within normal limits. The small bowel is normal in
caliber. The large bowel is within normal limits.
VESSELS: There is no aneurysmal dilatation of the abdominal aorta. The aorta
and its major branches are patent.
LYMPH NODES: There are no pathologically enlarged retroperitoneal or
mesenteric lymph nodes by CT size criteria.
PELVIS: The appendix is dilated up to 2.1 cm and shows submucosal hyperemia.
There is indistinctness of the tip of the appendix, suggesting rupture. There
is a 6.1 x 4.9 x 5.2 cm heterogeneous, low-density collection adjacent to the
inflamed appendix centered in the right adnexa concerning for a
periappendiceal abscess. A 4 mm calcified density is seen at the tip of the
appendix and may represent a small appendicolith. The rectum and sigmoid
colon are within normal limits.
OSSEOUS STRUCTURES/ SOFT TISSUES: No suspicious osseous lesions are
identified.
IMPRESSION:
1. Acute appendicitis with 6.1 cm abscess in the region of the right adnexa
adjacent to the tip of the appendix. In combination with the findings seen on
ultrasound, this raises the possibility of the appendiceal tip having ruptured
into the right Fallopian tube.
NOTIFICATION: These findings were discussed with Dr. ___
telephone at 12:00 on ___ by Dr. ___.
Radiology Report
INDICATION: ___ year old woman with like periappendiceal abscess from
appendiceal perforation // please assess for drainage of abscess
COMPARISON: CT examination from earlier the same day
PROCEDURE: CT-guided aspiration
OPERATORS: Dr. ___, radiology trainee and Dr. ___,
attending radiologist. Dr. ___ performed the procedure and
reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CTscan of the intended aspiration area was performed. Based on
the CT findings an appropriate position for the aspiration of the collection
in the right lower quadrant was chosen. The site was marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 18 gauge ___ needle was introduced to the
edge of the collection in the right lower quadrant. Despite multiple attempts
the collection could not be entered 2 an extremely thick wall as seen on
recent ultrasound examination. The procedure was then terminated.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: DLP: 80 mGy-cm
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Preprocedure CT demonstrates a collection in the right lower quadrant.
Ultrasound examination had demonstrated this collection to be quite complex
with most portions of it being solid in nature and only small pockets up to
1.8 cm in maximum diameter containing fluid. It was felt that due to the
appearance on ultrasound successful aspiration was highly unlikely. This was
discussed with the surgical team. However the procedure was considered the
best possible treatment option by Dr. ___.
IMPRESSION:
Unsuccessful CT-guided aspiration of complex collection in the right lower
quadrant. If the patient does not respond to antibiotics and further
intervention is needed, transvaginal aspiration could be considered, although
would also be difficult due to the large solid components of the abscess that
likely represent thickened and inflamed walls of the right fallopian tube.
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED ASPIRATION OF FLUID COLLECTION
INDICATION: ___ year old woman with perforated appy // Pls attempt US-guided
transvaginal aspiration of periappendiceal abscess
COMPARISON: Abdomen pelvis CT and transvaginal ultrasound obtained ___.
PROCEDURE: Ultrasound-guided transvaginal drainage of periappendiceal
abscess.
OPERATORS: Dr. ___, attending radiologist, performed the
procedure with Dr. ___, radiology fellow, assisting. Dr.
___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a lithotomy position on the US scan table. The
labia and vagina were cleansed with Betadine solution. The fluid collection
was identified by transvaginal ultrasound and an appropriate approach for
aspiration was chosen. Local anesthesia was administered with 1% Lidocaine
solution using an 18 gauge needle. A sample of fluid was aspirated,
confirming needle position within the collection. The sample was sent for
microbiology evaluation.
A total of 44 cc brown, purulent fluid was aspirated. The procedure was
tolerated well, and there were no immediate post-procedural complications.
SEDATION: Moderate sedation was provided by administering divided doses of 4
mg Versed and 175 mcg fentanyl throughout the total intra-service time of 31
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Complex fluid collection in the right hemipelvis similar in size to prior
ultrasound and CT studies. However, the collection is now more liquified.
IMPRESSION:
Successful US-guided transvaginal aspiration of pelvic abscess, removing 44 cc
purulent fluid. A sample was sent for microbiology evaluation.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ with 1 mo of RLQ pain initially treated as UTI, now found to
have R ___ 6.1 x 4.9 x 5.2 cm abscess s/p transvaginal ___
aspiration // interval eval for ___ abscess s/p transvaginal
aspiration. Pt continues to be febrile to 101-102 daily on zosyn.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: DLP: 790 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL Omnipaque.
COMPARISON: ___
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions with areas of
subpleural and bandlike atelectasis. There is no pericardial effusion
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is reactive bowel wall thickening of the
distal sigmoid colon, related to the adjacent inflammatory process. The
appendix is again distended measuring up to 1.6 cm in diameter with adjacent
periappendiceal fat stranding and fluid. There is a complex right pelvic
abscess, as previously described which has increased mildly in size measuring
5.0 x 6.3 cm versus 5.0 x 5.5 cm previously on the pre-aspiration CT from ___ (2:68). There is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden in
the abdominal aorta and great abdominal arteries.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions.
Abdominal and pelvic wall is within normal limits.
IMPRESSION:
Persistent right pelvic abscess, now slightly larger in comparison to the
pre-aspiration CT from ___.
Radiology Report
EXAMINATION: CT-guided abscess drainage
INDICATION: ___ with 1 mo of RLQ pain initially treated as UTI, now found to
have R ___ 6.1 x 4.9 x 5.2 cm abscess s/p transvaginal ___
aspiration // CT-guided drainage of complex pelvic abscess. Discussed with
___ from ___
COMPARISON: CT scan of the abdomen and pelvis from earlier same day
PROCEDURE: CT-guided drainage of right pelvic collection.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CTscan was performed to localize the collection. Based on the CT
findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
pigtail catheter into the collection. The plastic stiffener and the wire were
removed. The pigtail was deployed. The position of the pigtail was confirmed
within the collection via CT fluoroscopy.
Approximately 50 cc of purulent, bloody fluid was aspirated with a sample sent
for microbiology evaluation. The catheter was secured by a StatLock. The
catheter was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: DLP: 608 mGy-cm
SEDATION: Moderate sedation was provided by administering divided doses of 4
mg Versed and 200 mcg fentanyl throughout the total intra-service time of 25
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited preprocedure CT scan of the pelvis demonstrates a complex fluid
collection in the right pelvis -for further details please see CT scan from
same day.
IMPRESSION:
Successful CT-guided placement of ___ pigtail catheter into the
collection. Samples was sent for microbiology evaluation.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R Flank pain
Diagnosed with ACUTE APPENDICITIS NOS
temperature: nan
heartrate: 110.0
resprate: 20.0
o2sat: 100.0
sbp: 131.0
dbp: 65.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ who presented with 1 month hx of RLQ pain
initially treated as UTI but later was found to have a
___ 6.1 x 4.9 x 5.2 cm abscess. She was initially
treated with NPO/IVF/IV abx and underwent transvaginal ___
aspiration on ___. Following aspiration, pt reported improvement
in abdominal pain but was found to be persistently febrile with
mild leukocytosis and mild tachycardia. A CT scan was repeated
on ___ and demonstrated persistent right pelvic abscess
which was now slightly larger in comparison to her earlier
admission CT scan. Pt underwent CT-guided drainage with catheter
placement on ___. Her fevers resolved as well as her
leukocytosis and mild tachycardia. Pt reported symptomatic
improvement and was able to tolerate a regular diet following
the procedure. She was discharged to home in stable condition
with a course of oral abx. She will be followed up in our
surgery clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
___ is a ___ M with a seizure disorder (post-traumatic
brain injury in ___, VP shunt for hydrocephalus (last revised
___, and multiple past presentations w/increased seizures
in the setting of infection or VPS malfunction. He had two
seizures today after being "off his baseline" for one or two
weeks per his wife.
He only says ___ and "yes" on exam, so the history is per
telephone discussion with his wife, ___. She says he is
cognitively comprimised at baseline, but used to walk alright
and
have more energy up until an admission for pneumonia and
increased seizure frequency (here at ___, see OMR) in
___.
Then, his VPS was revised at ___ in ___. Since
that time, she thinks he has been less like himself, only
arising
from his wheelchair when staff get him up to walk bid (and he
walks with increased difficulty). No obvious illnesses recently,
although he has vomited once or twice at his group home over the
past week or so, and he complained of a headache at the doctor's
office today.
Recent seizure frequency -- The wife says he has had three or
four "mini-seizures" over the past one to two weeks (typical
semiology, with Right-sided convulsions). Also, he had a "big
one" (5 minutes long) a little over weeks ago, and was taken
briefly to ___, details unknown. All of this
represents a large increase over his typical frequency of few
per
month. He has not changed AED dosing or other medications
recently as far as she knows. Dr. ___ added ___ about
a
year ago, and told me he thinks this (along with Zonegran) may
be
responsible for the nausea and vomiting of recent. He is
considering referral for VNS placement so he can stop or more
AEDs if possible.
Today, he had a regularly scheduled visit at his
Epileptologist's
office (Dr. ___ of ___. After the appointment, while
in the waiting room to arrange a follow-up appointment, he had a
1.5 minute episode that the wife characterized as a typical
event
(R-side shaking). He returned to baseline slowly over the next
several minutes, and appeared "mellow." He was sent to our ___,
where, on arrival, he had a similar episode, again
self-resolving
after ___ minutes, with return of consciousness. The ___ staff
gave 1mg IV Ativan, after which he "fell asleep" per the wife.
During my exam (below), his temperature was re-checked by Dr. ___ the ___, and was ___, after a presenting temp of 99.5F.
Review of Systems: patient endorses head pain (he is holding his
forehead) with "yes" and neck pain with "yes" (then holds his
right neck). He did not endorse belly pain for me, but did for
the ___ resident. ROS/Hx very limited (see below).
Past Medical History:
1. Skull Fx / ICH ___ (fell down stairs, fractured Left
temporal
bone) with IPH and now stable Left-frontal and Right-temporal
encephalomalacia.
2. Hydrocephalus s/p VPS (last revised ___
3. post-traumatic seizure disorder -- on 5x AEDs (ZON, LTG, LAC,
PHT, CLZ; has PRN LZP for sz>5min at ___ home). Followed by Dr.
___. Multiple prior presentations for increased seizures in
the
setting of low AED level (e.g. PHT ___, PNA (last here,
on
Medicine service, ___, ?VPS malfunction. h/o status
epilepticus prior to increased AED treatments. typical semiology
as above.
4. remote h/o hypertension
5. chronic cholecystitis, colitis
6. remote h/o EtOH abuse
7. prior h/o tracheostomy and G-tube (both removed)
Social History:
___
Family History:
Father d-Pick's disease. Mother d-glioma
Physical Exam:
ADMISSION PHYSICAL EXAM:
General Physical Examination:
Vital signs @ ___ triage:
T: 99.5F (repeat = ___ oral)
P/HR: 107 (repeat = 90s, reg)
BP: 95/57
RR: 18
SaO2: 95% RA
General: Lying in bed, neck tilted to the Right. Opens eyes
briefly to voice, grunts.
HEENT: Atraumatic. Holds L hand over forehead and groans.
Anicteric. MMM. No lesions noted in minimal view of OP.
Neck: Supple, full ROM, but pt says "yes" when I ask if moving
the neck is painful. No LAD appreciated. Retracted/scarred
former
tracheostomy site (above sternal notch/clavicles).
Pulmonary: Course BS at Left base; minimal air movement at Right
base but no extra sounds. Non-labored breathing.
Cardiac: RRR, loud/normal S1/S2, no loud M/R/G.
Abdomen: Flat/soft, non-tender, and non-distended. + hypoactive
but present bowel sounds.
Extremities: Warm and well-perfused, no clubbing, cyanosis.
Trace
Left ankle edema. 2+ radial, DP pulses bilaterally.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Answers to name, says name is ___ Answers "yes"
appropriately
and inappropriately. These are the only two words he will say at
this time. Follows simple commands only; inconsistent,
inattentive. Opens eyes intermittently and briefly. Tracks
briefly. Speech is not grossly dysarthric.
-Cranial Nerves:
II: PERRL, 3 to 2mm and brisk. Blinks to threat. Exam limited by
resisting eye-opening, looking up.
III, IV, VI: Roving eye movements; appear full though not quite
conjugate (Right eye mildly exotropic on looking to the Right).
No nystagmus, although roving back/forth eye movements briefly
appeared this way.
V: Facial sensation intact to pin (says "yes") bilaterally.
VII: Mild flattening of R nasolabial fold.
VIII: Hearing grossly intact.
IX, X: Will not open mouth to examing palate.
XI: cannot assess (not following commands to lift shoulders or
turn head.
XII: Tongue protrusion is minimal, but remains midline.
-Motor:
Diffuse mild muscle wasting. Tone is mildly reduced throughout
the RUE, RLE. Tone is increased throughout the LUE and LLE. LLE
?paratonia, but LUE is mildly spastic (this is not noted on
prior
exams).
- He Can move Right fingers, but not lift arm or hold it when I
lift it. Can lift Left arm off the bed on command and hold it AG
(no drift) without apparent difficulty.
-Sensory:
Says "yes" to pin in all four extremities.
-Reflexes: toes Down-going bilaterally. Few beats of clonus in
Right ankle, ___ on the Left.
-Coordination, gait: unable to assess.
DISCHARGE PHYSICAL EXAM:
VS: 98.2, 128/79, 80, 18, 96% on RA
GEN: lying in bed in NAD
HEENT: OP clear
CV: RRR
PULM: CTA-B
ABD: soft, NT, ND
EXT: no edema
NEURO EXAM:
MS - knew he was in the hospital, otherwise unable to answer
questions accurately. Follows some commands
CN - EOMI, PERRL 4->2mm, face symmetrical
MOTOR - moves all extremities equally but unable to cooperate
with a more formal exam
REFLEXES - 2 and symmetrical throughout
SENSORY - intact to LT throughout
COORDINATION - reaches for examiners hands accurately
bilaterally
GAIT - with 2 person assist able to walk slowly and unsteadily.
Pertinent Results:
ADMISSION EXAM:
___ 01:42PM BLOOD WBC-11.8*# RBC-4.79 Hgb-14.2 Hct-48.4
MCV-101*# MCH-29.5 MCHC-29.2*# RDW-14.2 Plt ___
___ 01:42PM BLOOD Neuts-80.1* Lymphs-16.3* Monos-2.7
Eos-0.4 Baso-0.5
___ 05:00AM BLOOD ___ PTT-28.6 ___
___ 01:42PM BLOOD Glucose-108* UreaN-16 Creat-0.8 Na-138
K-4.4 Cl-98 HCO3-15* AnGap-29*
___ 01:42PM BLOOD ALT-62* AST-61* AlkPhos-178* TotBili-0.3
DirBili-0.1 IndBili-0.2
___ 01:42PM BLOOD Lipase-36
___ 01:42PM BLOOD proBNP-44
___ 01:42PM BLOOD Albumin-4.7 Calcium-8.9 Phos-3.5 Mg-1.9
___ 05:00AM BLOOD TSH-2.2
___ 04:38PM BLOOD Lactate-3.3*
DISCHARGE LABS:
___ 04:50AM BLOOD WBC-8.2 RBC-3.73* Hgb-11.1* Hct-35.6*
MCV-95 MCH-29.8 MCHC-31.2 RDW-14.5 Plt ___
___ 04:50AM BLOOD Glucose-101* UreaN-7 Creat-0.5 Na-140
K-3.8 Cl-108 HCO3-23 AnGap-13
___ 04:50AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.8
REPORTS:
NCHCT ___: IMPRESSION:
1. Decrease in size of the ventricles.
2. Ventriculostomy catheter positioned as detailed with
decompressed
ventricular system.
3. No hemorrhage or acute infarction.
CXR ___: IMPRESSION: Bibasilar atelectasis.
CT ABD/PELVIS: IMPRESSION:
1. No intra-abdominal infection detected.
2. Very large amount of colonic stool extending from the rectal
vault to the
cecum. Multiple fluid-filled loops of small bowel are normal in
caliber.
3. Non-displaced right eighth rib fracture.
4. Coarse interstitial markings at the lung bases with
ground-glass
opacities, may reflect sequela of chronic aspiration. Atypical
infection
cannot be excluded.
5. Markedly calcified and atrophic pancreas, denoting chronic
pancreatitis.
Medications on Admission:
Medications - Prescription
CLONAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth at noon and 3 tabs at 8 pm
IBUPROFEN - (Prescribed by Other Provider) - 600 mg Tablet - 1
Tablet(s) by mouth twice a day as needed for for pain give after
food
LACOSAMIDE [___] - 200 mg Tablet - 1 Tablet(s) by mouth twice
a day - No Substitution
LAMOTRIGINE [LAMICTAL] - 200 mg Tablet - 2.5 Tablet(s) by mouth
twice a day
LORAZEPAM [ATIVAN] - 1 mg Tablet - 1 Tablet(s) under tongue as
needed for seizure greater than 3 minutes, may repeat in 5 min
if
sz persists. not to exceed 3 tabs in 24 hrs
PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 100 mg Capsule -
2
Capsule(s) by mouth at bedtime
PHENYTOIN SODIUM EXTENDED [DILANTIN] - 30 mg Capsule - 1
Capsule(s) by mouth qam decreased from bid
QUETIAPINE [SEROQUEL] - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth as needed for for severe
agitation
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply to rash daily
after
shower stop using once rash clear
ZONISAMIDE [ZONEGRAN] - 100 mg Capsule - 1 Capsule(s) by mouth
in
the morning and 6 at night
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 650 mg Tablet
-
Tablet(s) by mouth as needed for every 4 hours f or pain or
elevated temp
CALCIUM CARBONATE - 500 mg calcium (1,250 mg) Tablet - 1
Tablet(s) by mouth once a day do not take with dilantin
DIPHENHYDRAMINE HCL - (Prescribed by Other Provider) - 25 mg
Capsule - 1 Capsule(s) by mouth as needed for every 8 hours as
needed
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100
mg Capsule - 1 Capsule(s) by mouth twice a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - (Prescribed by Other
Provider) (Not Taking as Prescribed) - 400 unit Tablet - 2
Tablet(s) by mouth daily
FOOD SUPPLEMENT, LACTOSE-FREE [ENSURE] - (Prescribed by Other
Provider) - Liquid - 1 can by mouth twice a day
SENNOSIDES [SENNA-GEN] - (Prescribed by Other Provider) - 8.6
mg
Tablet - ___ Tablet(s) by mouth as needed for twice a day for
constipation
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
2. clonazepam 1 mg Tablet Sig: 1.5 Tablets PO Q8PM ().
3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
4. lacosamide 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Lamictal 200 mg Tablet Sig: 2.5 Tablets PO twice a day.
6. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for seizure > 3 ___ repeat in 5 ___ if sz
persists: Do not exceed 3 tabs in 24 hours.
7. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule
PO QHS (once a day (at bedtime)).
8. phenytoin sodium extended 30 mg Capsule Sig: One (1) Capsule
PO QAM (once a day (in the morning)).
9. Seroquel 25 mg Tablet Sig: One (1) Tablet PO once a day as
needed for severe agitation.
10. triamcinolone acetonide 0.1 % Cream Sig: One (1) application
Topical once a day as needed for rash.
11. zonisamide 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
four (4) hours as needed for pain or ___.
14. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation; home med.
15. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day: Do not take with dilantin.
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
every eight (8) hours as needed for itching.
18. Ensure Liquid Sig: One (1) can PO twice a day: Make sure
he only gets lactose free Ensure.
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Known seizures with increasing frequency.
COMPARISONS: CT head ___. CT head ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin slice
bone images were obtained and reviewed.
FINDINGS: A ventriculostomy catheter is again noted coursing through a right
frontal burr hole extending into the lateral ventricles with its tip abutting
the lateral wall of the left frontal horn of the left lateral ventricle. The
catheter tip is in a slightly different position than the most recent CT scan
in ___ at which time it was in the middle of the lateral ventricles
adjacent to the septum pellucidum. However, the ventricles have intervally
decreased in size and the position of the shunt appears adequate.
Encephalomalacia in the left frontal and right temporal lobes are unchanged.
There is mild, stable adjacent ex vacuo dilatation. Periventricular confluent
white matter hypodensities are stable. There is no evidence of hemorrhage,
edema, mass, or new infarction. No fracture is identified. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
1. Decrease in size of the ventricles.
2. Ventriculostomy catheter positioned as detailed with decompressed
ventricular system.
3. No hemorrhage or acute infarction.
Radiology Report
INDICATION: Seizure with decreased breath sounds.
COMPARISON: Radiographs available from ___.
FRONTAL CHEST RADIOGRAPH: The heart size is normal. The hilar and
mediastinal contours are within normal limits. There is no pneumothorax or
pleural effusion. A VP shunt overlies the right lung. Bibasilar opacities
are more compatible with atelectasis. No definite consolidation is seen.
IMPRESSION: Bibasilar atelectasis.
Radiology Report
INDICATION: Altered mental status with abdominal pain.
No comparison studies available.
TECHNIQUE: MDCT-acquired 5-mm axial images of the abdomen and pelvis were
obtained following the uneventful administration of 130 cc of Omnipaque
intravenous contrast. Coronal, sagittal reformations were performed at 5-mm
slice thickness.
CT ABDOMEN WITH IV CONTRAST:
Coarse interstitial opacities are at the lung bases and scattered ground-glass
opacities (2:2) may represent mild inflammation or chronic aspiration. There
is no pleural effusion. The heart size is normal, and there is no pericardial
effusion. Moderate atherosclerotic calcifications of the coronary vessels is
seen.
A VP shunt terminates within the peritoneal cavity bilaterally (2:39, 36).
The liver, gallbladder, spleen, adrenal glands, left kidney, and stomach are
normal. There is a 2.5-cm cyst arising from the mid pole of the right kidney
(2:28). The right kidney is otherwise normal. There are coarse
calcifications throughout the atrophic pancreas (2:33, 27), denoting chronic
pancreatitis. There is no mesenteric or retroperitoneal lymphadenopathy. A
small amount of intra-abdominal and intrapelvic free fluid is present.
There is a very large amount of colonic stool extending from the rectal vault
(601B:46), to the cecum (601B:39). No fecal reflux is seen to the ileocecal
valve. Multiple loops of fluid-filled small bowel (601B:30) are present
without dilation. There is no free air.
The abdominal aorta, celiac trunk, SMA, and ___ are patent and normal in
caliber. The portal and hepatic veins are patent.
CT OF THE PELVIS WITH IV CONTRAST:
A Foley catheter resides within a collapsed bladder. There is a small amount
of intrapelvic free fluid (2:73). There is no intrapelvic lymphadenopathy.
OSSEOUS STRUCTURES: There is a nondisplaced fracture of the right eighth rib
(2:16), of unknown chronicity, but likely subacute. There are no bony lesions
concerning for malignancy or infection.
IMPRESSION:
1. No intra-abdominal infection detected.
2. Very large amount of colonic stool extending from the rectal vault to the
cecum. Multiple fluid-filled loops of small bowel are normal in caliber.
3. Non-displaced right eighth rib fracture.
4. Coarse interstitial markings at the lung bases with ground-glass
opacities, may reflect sequela of chronic aspiration. Atypical infection
cannot be excluded.
5. Markedly calcified and atrophic pancreas, denoting chronic pancreatitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SEIZURE
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY, MENINGITIS NOS
temperature: 99.5
heartrate: 107.0
resprate: 18.0
o2sat: 95.0
sbp: 95.0
dbp: 57.0
level of pain: 5
level of acuity: 2.0 | ___ M with post-TBI seizure disorder, VPS (revised ___,
and multiple past presentations who presented w/increased
seizures in the setting of a likely infection (with temperature
maximum of 101.0 degrees F). The pt's CSF only showed 18 WBCs
and the rest of his infectious studies were negative.
# NEURO: We put patient on vancomycin, ceftriaxone, ampicillin
and acyclovir until her CSF cultures returned negative at 48
hours and her HSV PCR returned negative. His initial CT read
showed very mildly decreased ventricular size. We consulted NSG
to ensure that his decompensation of his gait was not ___ his
VPS revision in ___ causing overshunting. They looked
at the images and felt that there was a very minimal change in
ventricular size and therefore overshunting was unlikely to
explain pt's worsening gait that had been described as an
outpatient. Patient's phenytoin was within goal throughout this
admission. He was sent home on his same home medications that
he came in on. 48 hours of EEG telemetry did not demonstrate
subclinical seizures. No seizures recorded. Patient discharged
at baseline level of neurologic function.
# ID: we continued ABx as above until cultures and HSV PCR came
back negative.
# CODE/CONTACT: Presumed Full; ___ (brother, HCP)
___ (wife -- wants updates)
___ ___ son ___ ; daughter
___
PCP ___ in ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
SVC syndrome
Major Surgical or Invasive Procedure:
Successful SVC stenting with a 14 mm Luminexx stent on ___.
History of Present Illness:
Ms. ___ is a ___ year-old lady with a history of COPD and
recently diagnosed metastatic ___ who presented to ___ with worsening facial edema, neck vein engorgement and
dyspnea/wheezing.
Briefly, she presented to OSH in ___ with dyspnea and found
to have new PTX s/p chest tube with incidental finding of RUL
mass. Underwent multiple scans with finding of neck and thoracic
vertebral involvement and bronchoscopic biopsy revealing
histology of adenocarcinoma (EGFR wt, ALK-, ROS1-). She was
planned to start carboplatin/pemetrexed/pembrolizumab on ___
but
due to concern for SVC syndrome was started on dexamethasone 4mg
bid instead. Review of her most recent scans shows RUL bronchus
and right main pulmonary artery compression by mass.
She presented to clinic in ___ on ___
for
a second opinion (with Dr ___ Dr ___, at that time she
complained of worsening facial edema, neck engorgement and
dyspnea/wheezing as well as violaceous discoloration in her
chest. Given concern for SVT syndrome she was urgently evaluated
by radiation oncology who plans to run simulation and start
urgent treatment ___ at ___ in ___.
Given concern for evolving SVC syndrome she was referred to the
ED.
ED initial vitals were 97.5 63 152/72 22 96% RA
Prior to transfer vitals were
Exam in the ED showed : "Plethoric face without significant
swelling. Diffuse wheeze, most prominent in right upper lobe"
ED work-up significant for:
-CBC: WBC: 16.3*. HGB: 13.4. Plt Count: 344. Neuts%: 85.8*.
-Chemistry: Na: 138 .K: 3.8. Cl: 97. CO2: 29. BUN: 17. Creat:
0.7. Ca: 9.7. Mg: 2.2. PO4: 3.5.
-LFTs: ALT: 9. AST: 15. Alk Phos: 75. Total Bili: 0.2.
-CTA Chest: "1. No evidence of pulmonary embolism or aortic
abnormality.Right pulmonary artery is severely attenuated by the
right hilar mass. 2. SVC is severely attenuated with extensive
collateral vessels in the mediastinum, left chest wall, and left
hemidiaphragm, consistent with SVC syndrome. 3. Complete
collapse
of right upper and middle lobes. Right mainstem bronchus is
severely narrowed. 4. Thrombosis of right pulmonary veins. 5. 9
mm nodule in the right lower lobe is suspicious for satellite
lesion. 6. Centrilobular emphysema is moderate to severe. Large
left apical bulla is noted.
On arrival to the floor, patient reports feeling overwhelmed
about the news. She confirms that she wanted to come to ___
for
her cancer care. She says that her face feels less swollen now
and less flushed as it was 2 weeks before when her SVC symptoms
started. She reports some shortness of breath when she is
talking. She has pain on the right side of her back. No urinary
or fecal incontinence. No cough.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, weakness/numbnesss,
shortness
of breath, cough, hemoptysis, chest pain, palpitations,
abdominal
pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
The patient reports that she was in her usual state of health
until a few months ago when she developed a cough and shortness
of breath as well as a 15 pound weight loss. She presented to
an
outside hospital where a chest x-ray was performed on ___ which revealed a new moderate right apical pneumothorax and
new dense opacity in the right suprahilar region. She underwent
chest tube placement in the ER. A CT chest was subsequently
performed which revealed a right apical pneumothorax and right
paratracheal adenopathy. On ___ she underwent a
bronchoscopy with biopsy of the right upper lobe which revealed
adenocarcinoma, moderately differentiated. The tumor was
positive for TTF-1 and negative for p63. Per review of the
records it was EGFR wild type, ALK and ROS1 negative. It is
unclear if PDL1 was sent.
She subsequently had an MRI brain on ___ which was
negative for metastatic disease. On ___ she had a
PET CT which revealed FDG avid primary disease at the superior
right hilum causing occlusion of the right upper lobe bronchus
with more peripheral chronic opacification and atelectasis of
the
right upper lobe. There was also contiguous disease extending to
the right lower paratracheal and subcarinal stations, FDG avid
nodal disease within the superior mediastinum, right low
cervical
and sternal notch and right lower jugular chain lymph nodes.
There was FDG avidity at the anterior right mid clavicle, right
medial 11th rib head and inferior thyroid lobe. On ___ she had an MRI chest which showed no evidence of osseous
metastatic disease to the right clavicle. On ___
she had a bone scan which showed no evidence of metastatic
disease. At this time there were discussions about proceeding
with definitive chemo-radiation therapy, however she
subsequently
had a CT chest on ___ which showed progression of disease,
with a new lytic lesion within the adjacent T6 vertebral body as
well as a new small right pleural effusion with right pleural
nodule suspicious for pleural metastasis. There was severe
narrowing of the right main pulmonary artery due to the
surrounding mediastinal/hilar adenopathy/soft tissue. The
decision was made to proceed with palliative
carboplatin/pemetrexed/pembrolizumab on ___. She was
started
on dexamethasone 4 mg BID on ___ due to concerns for possible
SVC syndrome.
- COPD
- Tobacco use
- Recurrent pneumothoraces (3 spontaneous PTX during
lifetime, last episode prior to diagnosis was about ___ years
ago)
Social History:
___
Family History:
Father - lung cancer in his ___, tongue cancer in his ___, heavy
tobacco use
Paternal aunt - breast cancer in her ___
Paternal uncle - liver cancer
___ cousin - rare cancer unknown type
Mother - no history of malignancy
Maternal grandfather - stomach cancer in his ___
Maternal uncle - prostate cancer in his ___
Maternal aunt - breast cancer in her ___
Maternal cousin - leukemia, unknown age
Maternal cousin - lupus
___ cousin - cervical cancer in her ___
Maternal cousin - multiple myeloma
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: ___ ___ Temp: 97.7 PO BP: 100/61 HR: 57 RR: 18 O2 sat:
97% O2 delivery: RA
GENERAL: Chronically-ill lady, in no distress lying in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear. red complexion to the face. swollen per patient. swelling
on right side of neck and prominent neck veins.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, bronchial sounds
bilaterally, R>L, diffuse wheezing
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to
light touch intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM
======================
VS: ___ ___ Temp: 97.9 PO BP: 124/78 HR: 68 RR: 16 O2 sat:
99% O2 delivery: RA
GENERAL: Thin lady, in no distress lying in bed comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear. red complexion to the face, improving.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, bronchial sounds
bilaterally, R>L, diffuse wheezing
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to
light touch intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
=============
___ 03:02PM BLOOD WBC-16.3* RBC-4.87 Hgb-13.4 Hct-40.1
MCV-82 MCH-27.5 MCHC-33.4 RDW-15.9* RDWSD-47.9* Plt ___
___ 03:02PM BLOOD Neuts-85.8* Lymphs-9.6* Monos-4.0*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-14.00* AbsLymp-1.56
AbsMono-0.66 AbsEos-0.00* AbsBaso-0.02
___ 03:02PM BLOOD Plt ___
___ 03:02PM BLOOD UreaN-17 Creat-0.7 Na-138 K-3.8 Cl-97
HCO3-29 AnGap-12
___ 03:02PM BLOOD ALT-9 AST-15 AlkPhos-75 TotBili-0.2
___ 03:02PM BLOOD Calcium-9.7 Phos-3.5 Mg-2.2
DISCHARGE LABS
=============
___ 07:24AM BLOOD WBC-8.8 RBC-4.75 Hgb-12.9 Hct-39.0 MCV-82
MCH-27.2 MCHC-33.1 RDW-15.4 RDWSD-46.0 Plt ___
___ 12:05PM BLOOD LMWH-0.76
___ 07:24AM BLOOD Glucose-88 UreaN-12 Creat-0.5 Na-140
K-5.0 Cl-99 HCO3-24 AnGap-17
___ 07:24AM BLOOD ALT-21 AST-22 TotBili-0.2
___ 07:24AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.2
___ 06:35AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
Micro
====
___ 11:40 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Imaging
======
___ CTA Chest
1. No evidence of pulmonary embolism or aortic abnormality.Right
pulmonary
artery is severely attenuated by the right hilar mass. The
right hilar mass
is similar compared to ___.
2. There is focal severe narrowing of the SVC with extensive
collateral
vessels in the mediastinum, left chest wall, and left
hemidiaphragm,
consistent with SVC syndrome.
3. Complete collapse of right upper and middle lobes. Right
mainstem bronchus
is severely narrowed.
4. 2 pulmonary nodules in the right lower lobe measuring 9 mm or
less,
suspicious for metastasis and unchanged from prior.
5. Right supraclavicular and mediastinal lymphadenopathy.
6. T5 bone lesion is suspicious for tumor invasion.
7. Centrilobular emphysema is moderate to severe. Large left
apical bulla is
noted.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Dexamethasone 4 mg PO Q12H
2. Prochlorperazine 10 mg PO Q8H:PRN nausea
3. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
6. FoLIC Acid 0.4 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth four times a day
Disp #*100 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Dexamethasone 1 mg PO Q12H
RX *dexamethasone 1 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Enoxaparin Sodium 40 mg SC BID
RX *enoxaparin 40 mg/0.4 mL 40 mg SQ twice a day Disp #*60
Syringe Refills:*0
6. Morphine SR (MS ___ 60 mg PO Q12H
RX *morphine 60 mg 1 capsule(s) by mouth twice a day Disp #*12
Capsule Refills:*0
7. Morphine SR (MS ___ 100 mg PO DAILY
in the evening
RX *morphine 100 mg 1 tablet(s) by mouth once a day, in the
evening Disp #*30 Tablet Refills:*0
8. Morphine SR (MS ___ 60 mg PO BID
In the morning and afternoon
RX *morphine 30 mg 2 tablet(s) by mouth twice a day, In the
morning and afternoon Disp #*14 Tablet Refills:*0
RX *morphine 30 mg 2 tablet(s) by mouth twice a day Disp #*24
Tablet Refills:*0
9. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Moderate
RX *morphine 15 mg ___ tablet(s) by mouth every four (4) hours
Disp #*70 Tablet Refills:*0
10. Morphine Sulfate ___ ___ mg PO Q4H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *morphine 15 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
RX *morphine 15 mg ___ tablet(s) by mouth every four (4) hours
Disp #*69 Tablet Refills:*0
11. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
12. Nicotine Patch 7 mg TD DAILY
RX *nicotine 7 mg/24 hour apply 1 patch once a day Disp #*42
Patch Refills:*0
13. Ondansetron 8 mg PO Q8H:PRN nausea
take on day 2 and day 3 of the cycle
RX *ondansetron HCl 8 mg 1 tablet by mouth three times a day
Disp #*90 Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17g powder(s) by mouth
once a day Refills:*0
15. Senna 17.2 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 2 tablets by mouth once a day Disp
#*60 Tablet Refills:*0
16. Dexamethasone 4 mg PO BID Duration: 2 Days
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp #*3
Tablet Refills:*0
17. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
18. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
19. Prochlorperazine 10 mg PO Q8H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*0
20. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
=================
Superior vena cava syndrome
Metastatic non-small cell lung carcinoma
Thrombosis of right pulmonary vein
Secondary diagnosis
===================
Chronic obstructive pulmonary disease
Cancer pain
Cancer cachexia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with dyspnea, cancer, swelling// please evaluate for
PE, SVC syndrome
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 0.8 mGy (Body) DLP = 0.4
mGy-cm.
2) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 4.1 mGy (Body) DLP = 2.0
mGy-cm.
3) Spiral Acquisition 4.1 s, 32.1 cm; CTDIvol = 2.9 mGy (Body) DLP = 92.6
mGy-cm.
Total DLP (Body) = 95 mGy-cm.
COMPARISON: CT chest with contrast from outside hospital ___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. There is severe narrowing of right pulmonary
artery (3:99) and right lower lobe superior segmental pulmonary artery (3:92)
by a right hilar mass.
SVC is severely focally attenuated to a minimum diameter measuring 4 mm
(3:102, 601: 19). This extends over a craniocaudal distance of 5 mm in
length. Extensive collateral vessels are noted in the mediastinum, left
lateral chest wall, paraspinal region, and left diaphragm. The right upper
lobe pulmonary vein is occluded (3:105). There is delayed opacification of
the right-sided pulmonary veins, presumed to be due to stenosis of the right
pulmonary artery.
Multiple enlarged right supra clavicular and mediastinal lymph nodes are
identified. For example, right upper paratracheal lymph node measures 1.4 cm
in diameter (02:22). The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is small right pleural
effusion.
Centrilobular emphysema is moderate to severe. Large bulla is noted at the
left lung apex. 9 mm subpleural nodule in the right lower lobe (3:141) and 4
mm nodule in the superior segment of right upper lobe (3:81) are identified.
Bronchial walls are diffusely thickened. There is complete occlusion of right
upper and middle lobe bronchi. Right mainstem bronchus is narrowed to 2 mm in
diameter. Right lung is diffusely hypodense compared to the left, likely
reflecting hypoperfusion and air trapping. The right hilar mass is difficult
to measure accurately but appears grossly unchanged when compared to the prior
study.
Limited images of the upper abdomen are unremarkable.
1.5 x 0.7 cm lytic lesion is identified at the right aspect of T5 vertebral
body, adjacent to the right hilar mass. Prominent vertebral posterior venous
plexus is noted at multiple upper thoracic levels, presumed to be due to
collateral flow.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.Right pulmonary
artery is severely attenuated by the right hilar mass. The right hilar mass
is similar compared to ___.
2. There is focal severe narrowing of the SVC with extensive collateral
vessels in the mediastinum, left chest wall, and left hemidiaphragm,
consistent with SVC syndrome.
3. Complete collapse of right upper and middle lobes. Right mainstem bronchus
is severely narrowed.
4. 2 pulmonary nodules in the right lower lobe measuring 9 mm or less,
suspicious for metastasis and unchanged from prior.
5. Right supraclavicular and mediastinal lymphadenopathy.
6. T5 bone lesion is suspicious for tumor invasion.
7. Centrilobular emphysema is moderate to severe. Large left apical bulla is
noted.
Radiology Report
INDICATION: ___ year old woman with SVC syndrome, lung CA// SVC stenting
COMPARISON: CT scan from ___
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 45 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site
MEDICATIONS: 1% lidocaine, 800 units of heparin
CONTRAST: 45 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 9.6 min, 8 mGy
PROCEDURE:
1. SVC venogram from right internal jugular as well as left brachiocephalic
veins
2. SVC stenting in balloon angioplasty
3. Repeat SVC venogram
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol.
Under ultrasound guidance, the right common femoral vein was accessed with
micropuncture needle. Then, the micropuncture sheath was passed over the wire
and eventually ___ wire was passed. Then an 8 ___ long sheath was
placed into the IVC. Following this a Kumpe catheter and Glidewire were
utilized to navigate past level of obstruction in the mid SVC. The Kumpe
catheter was exchanged for a marking pigtail catheter and a venogram was
performed. Marking pigtail catheter was then removed and a Kumpe catheter was
reintroduced and the left brachiocephalic vein was cannulated. Marking
pigtail catheters again reintroduced and a venogram was performed. Then, a
___ wire was introduced and over the ___ wire a 14 mm x 4 cm Luminexx
stent was advanced across the area of obstruction. Stent was deployed. Then,
angioplasty of the stent was performed with a 14 mm balloon. Repeat venogram
from the left brachiocephalic as well as right internal jugular vein were
performed results of which are below. All catheters and sheath were removed.
Manual pressure was held on the groin for 10 minutes. The patient tolerated
the procedure well.
FINDINGS:
High-grade short-segment SVC stenosis at the mid SVC. Patent left
brachiocephalic vein and bilateral jugular veins. Post stenting angioplasty,
successful resolution of collateral vessels and stenosis of the mid SVC.
IMPRESSION:
Successful SVC stenting with a 14 mm Luminexx stent.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 97.5
heartrate: 63.0
resprate: 22.0
o2sat: 96.0
sbp: 152.0
dbp: 72.0
level of pain: 5
level of acuity: 2.0 | Brief hospital course
=====================
Ms. ___ is a ___ year-old lady with a history of COPD and
recently diagnosed metastatic NSCLC who presented to ___
___ with worsening facial edema, neck vein engorgement and
dyspnea/wheezing referred for emergent SVC syndrome work-up and
plan for initiation of urgent radiation and chemotherapy.
Incidentally found to have right pulmonary vein thrombosis.
Patient had an SVC stent placed on ___. She was
initiated on radiation therapy on ___ and received 6 out
of 15 planned fractions while inpatient. She was also started on
chemotherapy for her non-small cell lung carcinoma with
carboplatin/pemetrexed. For her right pulmonary vein thrombosis
she was initially started on a heparin drip and was transitioned
to Lovenox when she became therapeutic. She was discharged on
Lovenox. Her pain regimen was also optimized while inpatient
with a combination of MS ___ and oral morphine.
Acute problems
==============
#SVC Syndrome: Immediately after arrival patient was started on
radiation to her chest area on ___. Patient had an SVC
stent placement with good effect on ___. Patient has
been improving clinically so in terms of her facial swelling and
dyspnea after stent placement and beginning of radiation to
chest area. She was monitored actively for headache,
encephalopathy, stridor and dyspnea. She received 6 out of the
15 planned radiation fractions while inpatient. She will f
dexamethasone, Tylenol, bisacodyl, inish the remaining of her
treatment as an outpatient at the ___. Patient
arrived on dexamethasone which was started at the outside
hospital for her SVC syndrome. Here we continued her
dexamethasone with plan to taper taper it down. However she
requires some extra doses surrounding the chemotherapy day. She
was discharged with a plan to continue to taper down
dexamethasone and have follow-up on this issue with her
oncologist.
#Metastatic NSCLC: This was a recent diagnosis for the patient,
with disease metastasis to the spine area (T5). We retrieved her
tissue pathology from the outside hospital and we sent it for
further analysis by our pathology department, specifically for
PDL1, BRAFV600E and KRAS testing. These results are pending at
the time of discharge. Patient was initiated on a chemotherapy
regimen with carboplatin/pemetrexed on ___. The next
chemo should be in about 3 weeks and this will be coordinated by
her outpatient oncologist Dr. ___. In preparation for
chemotherapy patient was tested for HCV and HIV and was found to
be negative. She was also tested for HPV and was not found to be
immune to it. She received support from social work and chaplain
while she was inpatient.
#Thrombosis of right pulmonary veins: likely due to lung cancer.
Patient was initially started on a heparin drip. When she became
therapeutic she was transitioned to Lovenox. She was initially
started on 30 mg twice a day however factor Xa was found to be
low at 0.41 on ___. She was then started on 40 mg twice
a day and factor Xa was found to be therapeutic at 0.76.
#Malignancy associated pain: Patient's pain control was
optimized with MS ___ 60 mg in the morning, MS ___ 60 mg
in the afternoon and MS ___ 100 mg in the evening before
bedtime. She also required morphine sulfate ___ 50 mg p.o. every
4 hours as needed for pain. For breakthrough pain she received
occasionally morphine IV. She was kept on on appropriate bowel
regimen and her nausea was treated with Compazine and Zofran. In
order to address her pain we also asked radiation oncology to
radiate her T5 spine lesion which they decided to include in the
field of radiation.
#COPD
#L apical bulla: At risk for spontaneous PTX, monitor O2
saturation. Patient has been stable with no oxygen requirements
during her stay. She had duo nebs available however she did not
require them during the stay.
#Positive serum HCG: On arrival serum HCG was 31 with negative
urine HCG. Repeat serum HCG was 34. we discussed with clinical
pathology
who said that this may be consistent with a 3 week fetus.
However, it is possible that the levels are falsely elevated iso
lung adenocarcinoma as there where published case reports of
such
situations. We discussed with the patient and she is very clear
that she did not have any sexual interactions in the last ___
years, so she is sure she could not be pregnant. She understand
the risks of radiation and wants to continue with the treatment.
The risks were explained to the patient and she understood the
situation. Repeat HCG on ___ was down trending to 25.
#Cancer cachexia
#Severe protein calorie malnutrition
Nutrition was consult and advised to add Ensure 3 times a day as
well as a multivitamin.
TRANSITIONAL ISSUES:
=================================
-Patient had 14 mm Luminexx stent placed to her SVC on ___
-Patient received 6 out of 15 planned radiation sessions. She
will continue her treatment at the ___. Her
first appointment after discharge is on ___, at 9:45am.
-Patient received chemotherapy with carboplatin/pemetrexed on
___
-Patient is supposed to take dexamethasone 4 mg twice a day on
___ and then she will take 1 mg dexamethasone
twice a day until her follow-up visit with Dr. ___ on ___.
-Patient should not take NSAIDs
-Patient can consider outpatient interventional pulmonary
follow-up for her right mainstem bronchus which was found to be
severely narrowed on chest CTA, in case she were to develop
shortness of breath secondary to this problem. Patient has been
asymptomatic with no oxygen requirements during her
hospitalization
-In preparation for chemotherapy patient was tested for HBV and
was not found to be immune to it. She may consider immunization
as an outpatient.
- New Meds: Dexamethasone, Tylenol, bisacodyl, docusate,
Lovenox, MS ___, morphine p.o., multivitamin, nicotine patch,
MiraLAX, senna
- Stopped/Held Meds: None
- Changed Meds: Folic acid 0.4 mg to 1 mg daily
- Incidental Findings:
Chest CTA ___
Complete collapse of right upper and middle lobes. Right
mainstem bronchus
is severely narrowed.
2 pulmonary nodules in the right lower lobe measuring 9 mm or
less,
suspicious for metastasis and unchanged from prior.
Right supraclavicular and mediastinal lymphadenopathy.
T5 bone lesion is suspicious for tumor invasion.
- Discharge weight: 34.25 Kg
# CODE: Full code (confirmed)
# CONTACT: HCP: ___ (sister) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L ___ rib fx
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Fall from standing, left back/rib pain
HPI: This is a ___ female who sustained a mechanical
fall
from standing yesterday while trying to put on a pair of pants.
She fell over striking her back. Denies head strike. No loss
of
consciousness. She presents today due to continued back/rib
pain, which is present with movement and very deep breaths but
no
pain at rest.
Past Medical History:
Cad (Coronary Artery Disease)
Compression Fx, Thoracic Spine
Chest Pain - Precordial
Spondylolisthesis, Acquired
Spondylosis - Lumbosacral
Osteoporosis, Unspec
Hypertension - Essential
Headache
GCA
Esophageal Reflux
Hypercholesterolemia
Colonic Polyp
Osteoarthritis
Menopause
Oophorectomy
Social History:
___
Family History:
FH of heart disease. No osteoporosis, no fractures
Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R. Mild left posterior
chest wall tenderness. Pain with deep inspiration.
ABD: Soft, nondistended, nontender, no rebound or guarding,
Ext: 2+ ___ edema, ___ warm and well perfused
Pertinent Results:
___ 12:25PM GLUCOSE-103* UREA N-22* CREAT-0.8 SODIUM-141
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
___ 12:25PM estGFR-Using this
___ 12:25PM CALCIUM-9.8 PHOSPHATE-3.8 MAGNESIUM-2.3
___ 12:25PM URINE HOURS-RANDOM
___ 12:25PM URINE UHOLD-HOLD
___ 12:25PM WBC-7.2 RBC-4.01 HGB-11.9 HCT-36.3 MCV-91
MCH-29.7 MCHC-32.8 RDW-14.0 RDWSD-46.1
___ 12:25PM NEUTS-68.0 ___ MONOS-8.0 EOS-2.1
BASOS-0.4 IM ___ AbsNeut-4.87 AbsLymp-1.48 AbsMono-0.57
AbsEos-0.15 AbsBaso-0.03
___ 12:25PM PLT COUNT-145*
___ 12:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR*
___ 12:25PM URINE RBC-<1 WBC-6* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 12:25PM URINE HYALINE-3*
___ 12:25PM URINE MUCOUS-RARE*
Medications on Admission:
1. Acetaminophen 650 mg PO TID
2. amLODIPine 2.5 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 6.25 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Lisinopril 20 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth Q6H:PRN Disp #*10 Tablet
Refills:*0
3. amLODIPine 2.5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Carvedilol 6.25 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Lisinopril 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
L ___ rib fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with mechanical fall and headstrike last night has thoracic
back pain and left lower posterior rib pain// eval for trauma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.2 cm; CTDIvol = 46.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass. Chronic
right basal ganglia lacunar infarcts are noted. Periventricular and
subcortical white matter hypodensities are nonspecific, likely related to
small vessel ischemic disease in a patient of this age. There is prominence
of the ventricles and sulci suggestive of involutional changes. Dense
calcifications are seen along bilateral carotid siphons.
There is no evidence of fracture. There is mild-to-moderate mucosal
thickening of the ethmoid air cells. The left sphenoid sinus wall appears
thickened, consistent with chronic inflammation. The visualized portion of
the remaining paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits show bilateral lens
replacement.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with mechanical fall and headstrike last night has thoracic
back pain and left lower posterior rib pain// eval for trauma
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 469.3
mGy-cm.
Total DLP (Body) = 469 mGy-cm.
COMPARISON: CT from ___
FINDINGS:
There is mild anterolisthesis of C3 on C4, C5 on C6, C6 on C7, and C7 on T1
unchanged compared to prior and likely degenerative in nature. No fractures
are identified.Multilevel degenerative changes are seen, most extensive at
C4-5 and notable for loss of intervertebral disc height, osteophytosis,
uncovertebral facet hypertrophy and facet joint arthrosis causing moderate to
severe neural foraminal narrowing and mild spinal canal stenosis. There is no
prevertebral edema.
The thyroid is heterogeneous with areas of hypodensity within the left thyroid
lobe is suspicious for thyroid nodules. Aortic arch calcifications are seen.
Included lung apices are unremarkable.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes most extensive at C4-5.
Radiology Report
EXAMINATION: CT trauma torso with contrast
INDICATION: ___ with mechanical fall and headstrike last night has thoracic
back pain and left lower posterior rib pain// eval for trauma
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.3 s, 57.3 cm; CTDIvol = 11.6 mGy (Body) DLP = 663.2
mGy-cm.
Total DLP (Body) = 663 mGy-cm.
COMPARISON: CT torso ___
FINDINGS:
CHEST:HEART AND VASCULATURE: The thoracic aorta is tortuous with moderate
atherosclerotic calcifications. There is evidence of moderate coronary artery
calcifications. There is no evidence of acute thoracic aortic injury. The
heart size is moderately enlarged. The main pulmonary artery is enlarged
measuring 3.7 cm, suggestive of pulmonary artery hypertension the pericardium
and great vessels are within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: There is a small left pleural effusion. No pneumothorax.
LUNGS/AIRWAYS: There is bibasilar atelectasis. Lungs are clear without masses
or areas of parenchymal opacification. The airways are patent to the level of
the segmental bronchi bilaterally. There is mild bronchial wall thickening.
BASE OF NECK: The thyroid is heterogeneous suggestive of small hypodense
thyroid nodules, otherwise visualized portions of the base of the neck show no
abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. A subcentimeter
hypodensity is seen within the right lobe of the liver, too small to
characterize, but likely represents a hepatic cyst or biliary hamartoma.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The left adrenal gland is normal in size and shape. A 1.8 cm right
adrenal nodule is noted, which contains a component of macroscopic fat, likely
an angiomyelolipoma.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. Multiple
simple cysts are seen arising from bilateral kidneys, the largest on the right
arises from the lower pole and measures 3 cm and the largest on the left
arises from the upper pole and measures 3.8 cm. Subcentimeter hypodensities
in bilateral kidneys are too small to characterize but are statistically
likely to represent simple cysts. In the midpole of the left kidney there is
a intermediate density lesion measuring 1.6 cm, mildly increased in size
compared to prior, possibly representing a proteinaceous or hemorrhagic cyst.
There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia, otherwise the stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. Diverticulosis of the sigmoid colon is noted,
without evidence of wall thickening and fat stranding. The appendix is not
visualized. There is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no
evidence of adnexal abnormality bilaterally.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Extensive atherosclerotic disease is noted.
BONES: An acute fracture of the posterior left eleventh and tenth ribs are
noted. Multiple bilateral chronic rib fractures are again noted. No focal
suspicious osseous abnormality. There is grade 1 anterolisthesis of L5 on S1.
There is a chronic compression deformity of T8 and mild anterior wedging of
T11 and T12, unchanged compared to prior.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Acute fracture of the posterior left tenth and eleventh ribs. Multiple
bilateral chronic healing rib fractures. No pneumothorax or underlying
pulmonary contusion.
2. Trace left pleural effusion.
3. No evidence of acute intra-abdominal injury.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Back pain, s/p Fall
Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Fall on same level, unspecified, initial encounter, Hypoxemia
temperature: 98.7
heartrate: 82.0
resprate: 18.0
o2sat: 97.0
sbp: 133.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | ___ with L ___ rib fx, admitted for desats while ambulating.
The patient was admitted for these desaturations. On HD 2, ___
was consulted and her oxygen saturated improved. Ms. ___
was discharged from the hospital in stable condition with oxygen
saturation in the 90-97% on RA. She was asked to follow up in
___ clinic. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Keflex / morphine
Attending: ___
Chief Complaint:
Rectal pain, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ y/o F with a PMH of CABG (___), Afib,
and HLD, with neuropathic chest pain and costochondritis, and
internal and external hemorrhoids, IBS, who presented to the ED
with diarrhea, abdominal pain, and rectal pain. Pt has chronic
___ rectal pain which she describes as searing, and
intractable. She also complains of diarrhea beginning this AM
and had 4 loose watery stools and lower abdominal pain and
distention. She states that she recently has felt more feverish
and had chills and a headache for the past few days, and had
burning on urination. Pt had a UTI on ___ and was treated with
Bactrim. She took several doses of her hydromorphone without
adequate pain control. Pt denies any recent vomitting,
chest/cardiac pain, or SOB.
In the ED, initial vs were: 98.8 60 117/49 18 99 RA Labs were
remarkable for a Lactate of 2.4 that downtrended to 1.6, and
normal LFT's. Hg of 10.3, Hct of 34.6, neutrophil predominant
WBC of 7.2.
Prelim reads of CXR and a CTAngiogram were negative for any
acute process. Urine culture revealed a spec ___ of 1.024, but
was otherwise unremarkable. Pt was found to have blood in her
stool.
Patient was given hydromorphone, odansetron, albuterol,
escitalopram, gabapentin, lorazepam, and topical lidocaine jelly
w/o pain relief and was admitted to medicine for pain control.
She was admitted to medicine for further evaluation and pain
control.
Past Medical History:
Coronary Artery Disease
Depression
Gastroesophageal Reflux Disease
Hemorrhoids
Hyperlipidemia
Irritable Bowel Syndrome (Constipation)
Left Leg Weakness following Spine Surgery
Low Back Pain
Sciatica
Past Surgical History:
Hemorrhoidectomy ___
Laminectomy L4-L5 ___
Total Abdominal Hysterectomy ___
Cholecystectomy ___
Bladder Sling ___
Past Cardiac Procedures:
Stents (3) to RCA ___
Stent to RCA ___
POBA PDA and stent to LCX ___
Stent to RCA ___
Social History:
___
Family History:
Mother - died of myocardial infarction, age ___
Father - died of stroke, age uncertain
Brother - died of complications from Diabetes, history of CABG x
3, age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: 98.6 114/37 60 16 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: unremarkable
Neuro: ___ words at 2,5,10 min, full ROM, sensation, and Str
bilaterally
Rectal Exam: Internal and external hemorrhoids noted. No
bleeding or fissures. Irritation/inflammation of hemorrhoids.
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS:
___ 09:25AM BLOOD ___-7.2 RBC-4.80 Hgb-10.3* Hct-34.6*
MCV-72* MCH-21.4* MCHC-29.6* RDW-17.2* Plt ___
___ 09:25AM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-133
K-5.9* Cl-97 HCO3-25 AnGap-17
___ 09:25AM BLOOD ALT-22 AST-47* AlkPhos-79 TotBili-0.3
___ 09:45AM BLOOD Lactate-2.4* K-5.7*
___ 12:14PM BLOOD K-4.3
___ 01:14PM BLOOD Lactate-1.6
PERTINENT LABS:
PERTINENT IMAGING:
CXR: ___- No significant change from prior. No evidence of
pneumonia, rib fracture, or effusion.
CTA: ___- No acute intra-abdominal process. Normal
appearance of small and large bowel.Severe atherosclerotic
disease of the abdominal aorta with patent vasculature.
EKG: ___- Sinus rhythm. No ST changes noted
DISCHARGE LABS:
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin EC 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Escitalopram Oxalate 5 mg PO BID
4. Lorazepam 0.5 mg PO TID
5. Metoprolol Tartrate 50 mg PO TID
6. Anucort-HC (hydrocorTISone Acetate) 25 mg rectal prn
constipation
7. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
8. Thera Tears (carboxymethylcellulose sodium) 0.25 % ophthalmic
tid
9. Vitamin D ___ UNIT PO DAILY
10. Mylanta 2 tsp oral tid prn prn
11. Atorvastatin 20 mg PO DAILY
12. Dexilant (dexlansoprazole) 60 mg oral bid
13. Lidocaine 5% Patch 2 PTCH TD QAM
14. lidocaine HCl-hydrocortison ac ___ % rectal bid
15. Gabapentin 300 mg PO BID
16. Cyclobenzaprine 5 mg PO TID:PRN lower back pain
17. Oxymetazoline 1 SPRY NU BID:PRN allergies
18. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Escitalopram Oxalate 5 mg PO BID
5. Gabapentin 300 mg PO BID
6. Lidocaine 5% Patch 2 PTCH TD QAM
7. Lorazepam 0.5 mg PO TID
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Mylanta 2 tsp oral tid prn prn
10. Vitamin D ___ UNIT PO DAILY
11. Anucort-HC (hydrocorTISone Acetate) 25 mg rectal prn
constipation
12. Cyclobenzaprine 5 mg PO TID:PRN lower back pain
13. Dexilant (dexlansoprazole) 60 mg oral bid
14. lidocaine HCl-hydrocortison ac ___ % rectal bid
RX *lidocaine HCl-hydrocortison ac 2.5 %-3 % (7 gram) 1 gel(s)
rectally twice a day Refills:*0
15. Oxymetazoline 1 SPRY NU BID:PRN allergies
16. Thera Tears (carboxymethylcellulose sodium) 0.25 %
ophthalmic tid
17. Metoprolol Tartrate 50 mg PO TID
18. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN pain
19. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Capsule Refills:*0
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth daily Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Hemorrhoids, Chostochondritis
Secondary diagnosis: GERD, CAD, hyperlipidema, anxiety,
depression, Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION:
___ year old woman s/p CABG with chostochondiritis, pls eval for rib injury,
effusion or pneumonia.
COMPARISON: Multiple chest radiographs dating back to ___.
TECHNIQUE
Frontal and lateral views of the chest.
FINDINGS:
Lungs are grossly clear. Sternotomy wires, pacer leads, and coronary stents
are unchanged in position. Cardiomediastinal and hilar contours are stable.
Eventration of the right hemidiaphragm is unchanged. There is no pleural
effusion or pneumothorax. There is no evidence of free air beneath the
diaphragm. There are no rib fractures identified.
IMPRESSION:
No significant change from prior. No evidence of pneumonia, rib fracture, or
effusion.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ with ___ abd pain s/p CABG, +diarrhea, evaluate for
mesenteric ischemia versus diverticulitis.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis without contrast and after the administration of intravenous
contrast in the arterial and portal venous phase. Axial images were
interpreted in conjunction with coronal and sagittal reformats. Oral contrast
was not administered.
DLP: 1593 mGy-cm
COMPARISON: CT abdomen and pelvis ___ and CT abdomen and pelvis ___.
FINDINGS:
CHEST: There is bibasilar atelectasis. The lungs are otherwise clear.. There
is no pericardial effusion. Pacer wires are noted..
ABDOMEN:
Numerous liver hypodensities are unchanged compared to prior exam and are
consistent with simple cysts. The portal venous system is patent. There is no
intrahepatic biliary duct dilation. There is stable prominence of the
pancreatic duct.. The gallbladder is surgically absent.
The spleen and adrenal glands are unremarkable. The pancreas enhances
homogenously and is without focal lesions.
The kidneys display symmetric enhancement. A 3.1 cm parapelvic right renal
cyst and 1.1 cm exophytic cyst in the upper pole of the left kidney are
unchanged. Other subcentimeter hypodensities in the kidneys are too small to
characterize, but stable. . There is no hydronephrosis. The ureters are
normal in caliber and course to the bladder.
The distal esophagus is normal without a hiatal hernia. The stomach is grossly
unremarkable in appearance. The small and large bowel are normal in caliber
and without evidence of wall thickening. Incidental note is made of a duodenum
diverticulum in the third portion. The sigmoid colon is collapsed. The
appendix is normal.
There are small scattered mesenteric lymph nodes most pronounced in the right
lower quadrant, but none that are pathologically enlarged. There is no
abdominal free fluid or free air.
PELVIS:
The bladder is well distended and normal. There are small scattered pelvic
sidewall lymph nodes that are stable.. No free pelvic fluid is identified. The
uterus is surgically absent.
OSSEOUS STRUCTURES: Moderate multifactorial degenerative changes are seen
within the visualized thoracolumbar spine. No focal lytic or sclerotic lesion
concerning for malignancy. There is stable dextroscoliosis of the lumbar
spine.
MESENTERIC CTA: There are dense calcifications of the abdominal aorta, which
is patent. There is no abdominal aortic aneurysm. There is heavy calcification
at the takeoff of the celiac axis and SMA, however these vessels are patent.
The ___ is not visualized, stable dating back to ___.
IMPRESSION:
1. No acute intra-abdominal process. Normal appearance of small and large
bowel.
2. Severe atherosclerotic disease of the abdominal aorta with patent
vasculature.
NOTIFICATION: .
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Chest pain
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 98.8
heartrate: 60.0
resprate: 18.0
o2sat: 99.0
sbp: 117.0
dbp: 49.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is an ___ y/o F with a PMH of CABG (___), Afib,
and HLD, w/ neuropathic chest pain and costochondritis, and
internal and external hemorrhoids, IBS, who presented to the ED
with abdominal pain and rectal pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with salivary gland carcinoma w/ metastases to lung,
adrenal glands and liver presents with abdominal pain and
malaise. Per the patient, the pain started abruptly last night
when he was getting ready to go to bed. The pain is located in
the LUQ radiating to the groin, described as a sharp ___ pain
that worsens with inspiration. Not associated with any nausea or
vomiting and it was not related to eating. The patient did
report some loose stool on the ___ prior to admission but
his wife gave him ___ and he did not have any recurrent
episodes. No blood noted in the stool.
Of note, the patient was recently discharged after admission for
AMS and ___ on ___. There was some concern for c dif and
the patient was treated with empiric vanc but this was dc'd
after test came back negative. Since discharge the patient had
noticed some progressive fatigue, weakness, and general malaise
that has gotten worse in the past few days. He also endorses a
decreased appetite and per his wife, an approximately 10 lb
weight loss during this time period. The patient denies any sick
contacts, no fevers, chills, or change in mental status. Denies
blood per rectum or melena. No dysuria or hematuria.
In the ED, initial vitals were: 98.0 120 119/57 16 94% ra. He
received 3L NS and HR prior to transfer to the floor was 90. In
the ED started on vancomycin, zosyn, flagyl, pantoprazole. Labs
were significant for wbc count of 17.6 and lactate 3.6 that are
new, and AST 68, ALT 63, Alk phos 488 which are decreased from
the previous admission. He had a CT abdomen and pelvis which
showed colitis concerning for ischemic etiology but cannot rule
out inflammatory or infectious etiology. He was seen by ACS in
the ED who felt that he was not an operative candidate and
recommended NPO, IVF, broad antibiotic coverage for cdif. Stools
in the ED guiac negative and stool studies ordered.
On the floor, the patient is complaining of ___ abdominal
pain that improved with morphine. He is a bit confused from the
morphine but his wife verified the above history given to the
ED. No other complaints or changes at this time.
Past Medical History:
ONCOLOGIC HISTORY:
- initially noted a mass in his left lower neck in ___.
He applied heat to it thinking it might be a salivary gland
stone; however, it did not resolve.
- MRI on ___, which showed a 3.6 x 2.3 x 2.8 cm
lesion with irregular borders and some mild edema as well as two
lymph nodes measuring 1.1 and 2 cm respectively.
- seen by Dr. ___ on ___, who sent him up
for surgical removal of his mass, which occurred on ___. At that time, he underwent a left modified radical neck
dissection with resection of submandibular infiltrate of tumor
with facial nerve monitoring. Pathology of this was an adenoid
cystic carcinoma T4N2b carcinoma.
- underwent a PET scan on ___, which showed
post-surgical changes and marked tracer uptake in the T9
vertebral body. He was initiated at radiation therapy on
___, was started on concurrent ___ on
___.
- biopsy of the spinal lesion, which was performed on ___, and pathology of which came back as metastatic
carcinoma, consistent with the patient's known adenoid cystic
carcinoma.
- completed his concurrent chemotherapy and radiation on
___.
- He underwent surgery for stabilization of his T9 lesion on
___.
- He then had radiation to this area which was completed on
___.
- Started C1 of navelbine ___ for metastatic disease
PAST MEDICAL HISTORY:
1. Metastatic adenoid cystic carcinoma of the salivary gland.
2. Hypertension.
3. Gastric ulcer status post gastrectomy.
4. High cholesterol.
5. Diabetes.
6. Hearing loss.
7. Prior renal stone.
Social History:
___
Family History:
There is no history of cancer. His father died of an accident.
His mother is reported as dying of old age
Physical Exam:
Admission Physical Exam:
========================
Vitals: T: 98.4 BP: 141/79 P: 82 R: 18 O2: 97%
General: NAD, AAO x3
HEENT: NCAT, pupils symmetrically constricted, scleral icterus,
MMM
Neck: Soft, supple, no LAD, no JVD
CV: RRR, normal S1S2, -m/r/g
Lungs: normal respiratory effort, CTAB, no w/r/r
Abdomen: NBS, soft, slightly distended, TTP over epigastrium and
LUQ, no rebound tenderness, guarding, no hepatosplenomegaly
Ext: WWP, moving all extremities equally, no c/c/e
Neuro: CNIII-XII grossly intact, no focal motor or sensory
deficits
Skin: slightly jaundiced, intact, no rashes or lesions
Discharge Physical Exam:
========================
Vitals: 98.6 134/87 74 (62-77) 18 99% RA
General: NAD, AAO x3
CV: RRR, normal S1S2, -m/r/g
Lungs: normal respiratory effort, CTAB, no w/r/r
Abdomen: NBS, soft, non-distended, non-tender to palpation
Ext: moving all extremities equally, no clubbing, cyanosis,
edema
Neuro: CNIII-XII grossly intact, no focal motor or sensory
deficits
Pertinent Results:
Admission Labs:
===============
___ 06:35AM BLOOD WBC-17.6*# RBC-3.66* Hgb-11.9* Hct-38.3*
MCV-105* MCH-32.6* MCHC-31.1 RDW-16.3* Plt ___
___ 06:35AM BLOOD Neuts-92.3* Lymphs-2.9* Monos-4.1 Eos-0.5
Baso-0.3
___ 06:35AM BLOOD Glucose-172* UreaN-41* Creat-1.9* Na-136
K-4.5 Cl-102 HCO3-17* AnGap-22*
___ 06:35AM BLOOD ALT-63* AST-68* AlkPhos-488* TotBili-1.5
___ 06:35AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.1 Mg-1.6
___ 06:26AM BLOOD Lactate-3.6*
=============================================
Pertinent Labs:
===============
___ 06:43AM BLOOD Lactate-1.5
=============================================
Microbiology:
===============
___ 9:50 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ AT 9:33AM
ON ___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 6:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
___. 10,000-100,000 ORGANISMS/ML..
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
==================================================
Studies:
==========
___ CT Abdomen Pelvis with Contrast:
1. Focally thickened 13 cm segment of transverse colon is
concerning for
ischemic colitis. Other less favored differential considerations
include
infectious or inflammatory etiologies. No free fluid or free
air.
2. Progression in hepatic and pulmonary metastatic disease.
3. Stable left adrenal nodule dating back to ___.
4. Status post removal of percutaneous cholecystostomy tube with
small simple
fluid collection adjacent to the right inferior lobe of the
liver.
==================================================
Discharge Labs:
===============
___ 07:00AM BLOOD WBC-6.1 RBC-3.14* Hgb-10.3* Hct-32.5*
MCV-103* MCH-32.7* MCHC-31.6 RDW-16.0* Plt ___
___ 07:00AM BLOOD Glucose-107* UreaN-25* Creat-1.3* Na-138
K-3.9 Cl-106 HCO3-22 AnGap-14
___ 07:00AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Ranitidine 150 mg PO DAILY
4. Ondansetron 8 mg PO Q6H:PRN n/v
5. Prochlorperazine 10 mg PO Q6H:PRN n/v
6. Tamsulosin 0.4 mg PO HS
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Ondansetron 8 mg PO Q6H:PRN n/v
4. Ranitidine 150 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Acetaminophen 650 mg PO Q6H:PRN pain, fever
7. Prochlorperazine 10 mg PO Q6H:PRN n/v
8. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 11 Days
RX *vancomycin 125 mg 5 mL by mouth Every 6 hours Disp #*220
Milliliter Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Clostridium Dificile Infection
Chronic Kidney Disease
Metastatic Salivary Gland Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with LLQ pain, TTP diffusely with invol guarding, metastatic
salivary gland cancer with known metastasis to liver and lung.
COMPARISON: Prior chest radiograph from ___, CT chest from ___. Prior CT abdomen pelvis from ___.
FINDINGS:
PA and lateral views of the chest provided. No free air below the right
hemidiaphragm is seen. Known pulmonary nodules poorly visualized. There is
mild left basilar atelectasis better assessed on subsequent CT of the abdomen
pelvis. The heart and mediastinal contour appear grossly unchanged. No
pneumothorax or large effusion. Bony structures appear grossly intact.
IMPRESSION:
No free air below the right hemidiaphragm. Mild bibasilar atelectasis. Known
pulmonary nodules poorly visualized. Please refer to subsequent CT abdomen
pelvis for further details.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ male with history salivary gland cancer with hepatic
metastic disease presenting with left lower quadrant pain.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after the administration of intravenous contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats. Oral contrast
was administered.
DLP: 952 mGy-cm
COMPARISON: CT abdomen and pelvis ___, CT abdomen and pelvis ___, CT chest ___
FINDINGS:
CHEST: Multiple lower lobe lung nodules are again seen. The majority of which
are unchanged in size. A left lower lobe lung nodule has mildly increased
since ___ and now measures 8 mm previously 7 mm (2:4). The heart is
normal in size and there is no evidence of pericardial effusion. There is
moderate coronary artery disease.
ABDOMEN:
There are innumerable hepatic metastases which have overall increased in both
size and number since ___. A lesion in segment 8 measures approximately
8.1 x 6.6 cm, previously 6.1 x 5.2 cm (02:20). The portal vein is patent.
Again seen, is mild intrahepatic biliary duct dilation.
Since prior CT, there has been removal of a percutaneous cholecystostomy tube.
The gallbladder is normal in appearance with multiple dependent gallstones.
New from prior is a small 1.1 x 3.9 x 1.6 cm fluid collection along the
inferior right lobe of the liver (02:39).
The spleen is unremarkable. Left adrenal nodule measures 1.4 cm and is
unchanged dating back to ___ (02:31). The pancreas enhances
homogenously and is without focal lesions.
The kidneys display symmetric nephrograms. The right kidney is atrophic.
Multiple bilateral simple renal cysts are unchanged from prior. The largest
renal lesion is located in the left lower pole, measures 5.3 cm, is mildly
hyperdense, and likely represents a hemorrhagic cyst (2:51). There is no
hydronephrosis. The ureters are normal in caliber and course to the bladder.
The patient is status post a gastrojejunostomy. The distal esophagus is
normal without a hiatal hernia. The small bowel is normal in caliber without
evidence of obstruction.
There is a 13.0 cm segment of mid-distal transverse colon which is abnormally
thickened with surrounding fat stranding. There are clearly defined margins
between normal and abnormal colon (2:42). The remainder of the large bowel is
unremarkable. The appendix is contrast filled and normal (2:67). There is
diverticulosis of the sigmoid colon without evidence of diverticulitis. There
is no free abdominal fluid or air.
There are dense calcifications of the abdominal aorta branching into the iliac
arteries. The abdominal aorta and its major branches do however appear
patent.. There is no retroperitoneal or mesenteric lymphadenopathy by CT size
criteria. Mesenteric panniculitis is noted, a non specific finding (2:60).
PELVIS: The bladder is well distended and normal. There is no pelvic
side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic
fluid is identified. A 0.5 cm hyperdense lesion in the median lobe of the
prostate which extends to the bladder is unchanged from ___.
OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen
within the visualized thoracolumbar spine. No focal lytic or sclerotic lesion
concerning for malignancy. Spinal fusion hardware in the lower thoracic spine
is unchanged as is a chronic T9 compression deformity. Transitional anatomy at
the lumbar sacral junction is noted.
IMPRESSION:
1. Focally thickened 13 cm segment of transverse colon is concerning for
ischemic colitis. Other less favored differential considerations include
infectious or inflammatory etiologies. No free fluid or free air.
2. Progression in hepatic and pulmonary metastatic disease.
3. Stable left adrenal nodule dating back to ___.
4. Status post removal of percutaneous cholecystostomy tube with small simple
fluid collection adjacent to the right inferior lobe of the liver.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Jaundice, Abd pain
Diagnosed with NONINF GASTROENTERIT NEC
temperature: 98.0
heartrate: 120.0
resprate: 16.0
o2sat: 94.0
sbp: 119.0
dbp: 57.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is an ___ year old male with salivary gland carcinoma
w/ mets to lung, adrenal glands and liver who presented with LLQ
pain and was found to have focal transverse colitis secondary to
C diff.
# Colitis: Stool PCR positive for C diff. He was started on PO
vancomycin 125mg q6h for severe C diff. His leukocytosis and
elevated lactate resolved. His abdominal pain also resolved and
he was able to tolerate PO intake.
# Lactic Acidosis with fluid-responsive tachycardia: likely d/t
colitis, blood cx, urine cx were ordered to r/o other source of
infection. CXR showed no signs of PNA. Lactate decreased to 1.5
on ___.
# Salivary gland carcinoma: pt had been planned for palliative
navelbine though this has been on hold given his multiple
hospitalizations. hold off on port placement for now. he will
readdress pros/cons of chemo with Dr. ___ he is
better.
# ___: likely prerenal in etiology as a result of infection and
diarrhea. Improved s/p fluids and antibiotics, with resolution
of diarrhea and improvement of colitis.
# HTN: BP stable. Antihypertensives held at previous discharge
d/t stability off medication. We continued to hold BP meds.
# HLD: Statin held at previous hospitalization d/t
transaminitis. We continued to hold.
# Diabetes: Patient has never been on medication. Last a1c
___ 6.4%. He was monitored with fingersticks qachs
# hypothyroidism: He was continued on levothyroxine
# Hx gastric ulcer: He was continued on ranitidine
# BPH: He was continued on tamsulosin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aripiprazole / olanzapine / Depakote / lamotrigine / lithium
Attending: ___.
Chief Complaint:
abd pain, sob
Major Surgical or Invasive Procedure:
..
History of Present Illness:
___ y/o woman with bipolar d/o, hx. suicide attempt with
resultant anoxic brain injury with sequellae (lives alone per
her, able have a conversation, but comprehension appears
limited), copd still smoking cigarettes, but not on home O2,
obsedity, presented to ___ with abd pain and found to have
obstructive jaundice by labs and CT AP, ? biliary obstruction
due to an ampullary mass. She was given zosyn, morphine, and
ondansetron. She developed respiratory distress and was felt to
be having a COPD exacerbation. She was given nebs and
methylprednisolone. An MRCP was planned there, but could not
be done as she required BIPAP. She was transfered here for
ERCP. On arrival to our ED, Bipap was quickly removed and she
appered better. In ED was on 2 lpm O2 NC with sats in the mid
___. ED here added levaquin to cover atypicals as they were
concerned about pneumonia given copd exacerbation, but CXR at
___ negative, and CXR here with effusions and pulmonary edema,
no pneumonia. She was admitted to medicine for planned ercp
___.
ROS - all systems reviewed and negative now except - mild sob,
mild abdominal pain.
Past Medical History:
as above
Social History:
___
Family History:
pt. could not report to me
Physical Exam:
97.6 120/64 73 18 94% on 6 litres NC
NAD
Alert, oriented to place, self only
icteric and jaundiced
RRR
Coarse BS with expiratory wheezes throughout lungs with moderate
air movement
Abdomen obese, soft, nt, bs present
No edema
moves all extremities
Pertinent Results:
___ 06:20AM BLOOD WBC-13.8* RBC-4.17* Hgb-12.0 Hct-34.5*
MCV-83 MCH-28.8 MCHC-34.7 RDW-15.3 Plt ___
___ 06:35AM BLOOD WBC-13.1* RBC-4.23 Hgb-12.0 Hct-34.8*
MCV-83 MCH-28.5 MCHC-34.6 RDW-15.5 Plt ___
___ 06:30AM BLOOD WBC-12.5* RBC-3.93* Hgb-11.2* Hct-32.5*
MCV-83 MCH-28.5 MCHC-34.5 RDW-15.7* Plt ___
___ 06:30AM BLOOD WBC-18.2* RBC-4.09* Hgb-11.5* Hct-33.6*
MCV-82 MCH-28.1 MCHC-34.2 RDW-15.6* Plt ___
___ 01:00PM BLOOD WBC-15.8* RBC-4.23 Hgb-11.6* Hct-34.9*
MCV-82 MCH-27.3 MCHC-33.2 RDW-15.8* Plt ___
___ 06:35AM BLOOD Glucose-114* UreaN-24* Creat-0.7 Na-142
K-3.9 Cl-106 HCO3-24 AnGap-16
___ 06:30AM BLOOD Glucose-107* UreaN-23* Creat-0.7 Na-140
K-4.0 Cl-104 HCO3-24 AnGap-16
___ 06:30AM BLOOD Glucose-113* UreaN-29* Creat-0.8 Na-138
K-3.8 Cl-105 HCO3-24 AnGap-13
___ 01:00PM BLOOD Glucose-151* UreaN-18 Creat-0.8 Na-138
K-3.7 Cl-104 HCO3-20* AnGap-18
___ 06:35AM BLOOD ALT-88* AST-17 AlkPhos-215* TotBili-1.0
___ 06:30AM BLOOD ALT-119* AST-29 AlkPhos-246* Amylase-76
TotBili-1.1
___ 06:30AM BLOOD ALT-181* AST-62* AlkPhos-308*
TotBili-1.7*
___ 01:00PM BLOOD ALT-241* AST-150* AlkPhos-332*
TotBili-6.8*
___ 06:30AM BLOOD Lipase-98*
___ 06:30AM BLOOD Lipase-553*
___ 01:00PM BLOOD Lipase-1246*
___ 01:00PM BLOOD cTropnT-<0.01
___ 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
EKG:
rhythm. Borderline left atrial abnormality. RSR' pattern in
lead V1
(normal variant). Early R wave transition. Non-specific ST
segment changes.
Low voltage in the precordial leads. Borderline low voltage in
the limb leads.
No previous tracing available for comparison.
Read by: ___.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
76 126 82 402 430 45 36 55
.
___ CXR:
IMPRESSION:
1. Bibasilar atelectasis. Early pneumonic infiltrate would be
difficult to exclude.
2. Equivocal small right effusion versus tenting of the
hemidiaphragm.
3. If clinically indicated, a lateral view may help to more
completely assess for an underlying pneumonic infiltrate and
effusion.
.
MRCP:
IMPRESSION:
1. Abnormal signal intensity in the portion of the pancreatic
head which
extends anteriorly along the duodenal diverticulum, suggestive
of groove
pancreatitis. Followup with repeat MRI in 6 weeks is
recommended to ensure resolution and exclude neoplasm.
2. Large juxta papillary duodenal diverticulum compresses the
distal CBD and the ampulla, with resultant moderate biliary
dilatation and prominent
pancreatic duct, but there is normal tapering of the distal CBD
and pancreatic duct near the ampulla with no MR evidence of
ampullary mass.
3. Duplex left renal anatomy, a normal variant, with accessory
left renal
artery.
4. 1 cm intraluminal lipoma in the ___ portion of the duodenum.
.
CXR:
IMPRESSION:
1. Unchanged small right pleural effusion from ___.
2. No pulmonary edema or pneumonia.
UCX: negative
BCX: pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
3. Gabapentin 100 mg PO TID
4. Haloperidol 5 mg PO BID
5. Pravastatin 20 mg PO QPM
6. QUEtiapine Fumarate 100 mg PO TID
7. Tiotropium Bromide 1 CAP IH DAILY
8. TraZODone 100 mg PO QHS
Discharge Medications:
1. Gabapentin 100 mg PO TID
2. Haloperidol 5 mg PO BID
3. QUEtiapine Fumarate 100 mg PO TID
4. TraZODone 100 mg PO QHS
5. Aspirin 81 mg PO DAILY
6. Pravastatin 20 mg PO QPM
7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION BID
8. Tiotropium Bromide 1 CAP IH DAILY
9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*9 Tablet Refills:*0
10. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 5 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*14 Tablet Refills:*0
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheeze
RX *albuterol sulfate 90 mcg ___ puffs every ___ hours Disp #*1
Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD exacerbation
cholangitis, pancreatitis, bile duct obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with dyspnea // PNA?
COMPARISON: Prior radiographs of ___ and ___.
TECHNIQUE: Single frontal view of the chest.
FINDINGS:
Moderate cardiomegaly with interval increase in bibasilar atelectasis. There
is a possible right pleural effusion. The differential could include
elevation of the right hemidiaphragm laterally. Mild upper zone
redistribution, without overt CHF. No pneumothorax.
IMPRESSION:
1. Bibasilar atelectasis. Early pneumonic infiltrate would be difficult to
exclude.
2. Equivocal small right effusion versus tenting of the hemidiaphragm.
3. If clinically indicated, a lateral view may help to more completely assess
for an underlying pneumonic infiltrate and effusion.
Radiology Report
EXAMINATION: MRCP (MR ___
INDICATION: ___ year old woman with biliary obstruction, ? ampullary mass on
CT scan - please evaluate via MRCP // ___ year old woman with biliary
obstruction, ? ampullary mass on CT scan - please evaluate via MRCP
TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the abdomen were
obtained on a 1.5 Tesla magnet including dynamic 3D imaging prior to, during,
and after the administration of 6 mL Gadavist gadolinium based contrast. 1 mL
Gadavist mixed with 50 mL water was also administered for oral contrast.
COMPARISON: CT from ___.
FINDINGS:
There is trace amount of bilateral pleural effusion. There are atelectasis in
the lung bases, and superimposed consolidation in the right base cannot be
excluded.
The liver is normal in size and morphology. There is mild drop of signal on
gradient echo T1 out of phase images compared to inphase images, consistent
with mild steatosis. Heterogeneity of the liver parenchyma, and elevated
peribiliary signal on low b-value diffusion weighted images suggest periportal
edema (7:7). There is no evidence of cholangitis. No focal liver lesions are
seen. Conventional arterial hepatic anatomy is present. The portal and
hepatic veins are patent.
There is moderate dilatation of the intra and extrahepatic biliary tree. The
CBD measures up to 12 mm in diameter, with smooth tapering at the ampulla
(10:2). Aberrant biliary anatomy is present, with right posterior biliary
duct draining into the left duct (10:2). A 3.5 cm juxta papillary duodenal
diverticulum with narrow neck is seen, compressing the ampulla and distal CBD
posteriorly (04:43, 03:24). No ampullary mass is identified. There is 1 cm
intraluminal lipoma in the ___ portion of the duodenum (11:124).
The pancreatic duct is also prominent, measuring up to 4 mm in the pancreatic
head and 3 mm in the pancreatic body. Conventional pancreatic ductal anatomy
is present. While the majority of the pancreatic parenchyma appears within
normal limits, note is made of focal relative hypointensity of the parenchyma
on precontrast T1 WI with associated restricted diffusion at DWI/ADC in the
portion of pancreatic head that extends along the duodenum diverticulum
anteriorly(11:90, 700:7). This corresponds to an area of mild stranding seen
at prior CT. These findings are suggestive of groove pancreatitis.
The spleen is normal in size.
Subcentimeter cortical renal cysts are demonstrated bilaterally.
Subcentimeter hemorrhagic cortical cyst in the interpolar region of the left
kidney is denoted by high signal intensity on T1 WI (11:104). The adrenals
are normal. Duplex left renal anatomy is present with an accessory left renal
artery.
There is trace amount of perihepatic fluid.
No concerning retroperitoneal or mesenteric lymphadenopathy seen. The bone
marrow signal is normal.
IMPRESSION:
1. Abnormal signal intensity in the portion of the pancreatic head which
extends anteriorly along the duodenal diverticulum, suggestive of groove
pancreatitis. Followup with repeat MRI in 6 weeks is recommended to ensure
resolution and exclude neoplasm.
2. Large juxta papillary duodenal diverticulum compresses the distal CBD and
the ampulla, with resultant moderate biliary dilatation and prominent
pancreatic duct, but there is normal tapering of the distal CBD and pancreatic
duct near the ampulla with no MR evidence of ampullary mass.
3. Duplex left renal anatomy, a normal variant, with accessory left renal
artery.
4. 1 cm intraluminal lipoma in the ___ portion of the duodenum.
RECOMMENDATION(S): Follow up MRCP in 6 weeks to reassess pancreatic head.
Radiology Report
EXAMINATION: PA and lateral chest radiograph.
INDICATION: ___ year old woman with COPD, hypoxemia. Evaluate for PNA, edema,
effusion.
COMPARISON: Chest radiograph dated ___ at 1244h.
FINDINGS:
No significant interval change. Lung volumes remain slightly low, but are
slightly improved. Small right pleural effusion with adjacent atelectasis and
silhouetting of the right hemidiaphragm is overall unchanged. No
pneumothorax. Mild cardiomegaly is unchanged. No edema or focal
consolidation.
IMPRESSION:
1. Unchanged small right pleural effusion from ___.
2. No pulmonary edema or pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ y.o woman with h.o bipolar disorder s/p suicide attempt with
resultant anoxic brain injury, schizophrenia, who presented with
biliary obstruction, pancreatitis course c/b COPD exacerbation
.
#cholangitis with biliary obstruction
#jaundice
Pt presented with fever, leukocytosis with abdominal pain and
laboratory evidence of pancreatitis and biliary obstruction. The
ERCP team evaluated the patient and considered ERCP but then
felt that she was too high risk for MAC anesthesia (COPD flare)
and felt that pt likely passed a stone as her labs were
improving/normalizing and she no longer had any pain. GI
recommended an MRCP which showed concern for groove pancreatitis
but no biliary obstruction but pt will require REPEAT MRI IN 6
WEEKS TO ASSESS FOR RESOLUTION OF PANCREATITIS AND TO EXCULDE AN
UNDERLYING MASS. The surgical team evaluated the patient and
felt that she did not need a CCY imminently as her symptoms had
improved but did recommend for her to f/u in clinic to discuss
elective CCY. She was initially placed on zosyn which was
narrowed to cipro/flagyl which pt was prescribed a 10 day course
of therapy. Her QTC was WNL on the day of discharge.
.
#COPD with acute exacerbation/hypoxemia-pt still smoking as an
outpt and experienced a COPD flare during admission that
actually became a more acute issue rather than the above.
Imaging was not concerning for pNA. Pt would not be a good
candidate for outpt 02. She was given 5 days of prednisone and
nebulizers. Symptoms improved and she was weakned to room air
prior to dc. She will need to f/u with her outpt
PCP/pulmonologist for ongoing care
.
#h.o bipolar disorder with suicide attempt and anoxic brain
injury
#schizophrenia
Continued home meds, haldol, quetiapine, trazodone, gabapentin.
There was some concern for how pt may care for herself at home.
SHe is already established with a mental health service and her
friend ___ also assists her. However, sent pt home with ___
and a home safety evaluation to assess if pt has further needs.
TRANSITIONAL CARE
___ WILL NEED A REPEAT MRI IN 6 WEEKS TIME TO ASSESS FOR ANY
PANCREATIC ABNORMALITY |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
erythromycin base
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
___: 1) Irrigation and debridement down to and inclusive of
bone of open left tibia fracture. 2) Intramedullary nailing of
open left tibia fracture. 3) Open reduction, internal fixation
of left medial malleolar fracture.
History of Present Illness:
___ y/o F transferred from ___ after falling from porch and
sustaining an open-tib fracture in the left lower extremity.
Patient reports that she felt the railing going out from under
her so she jumped to the ground ___ feet. She landed on her left
leg. She presented to ___ in ___ where she was found
to have a displaced tib-fib fracture on the right as well as a
medial mal fracture of the left tibia. She had a puncture wound
to the mid shin with bleeding. She was given a dose of Ancef
prior to transfer. She received her tetanus shot 3 weeks ago at
her primary care doctor's office. Denies any numbness or
tingling in the LLE.
Past Medical History:
Hypothyroidism, depression
Social History:
___
Family History:
Noncontributory
Physical Exam:
On Admission:
In general, the patient is alert and oriented and in no
distress.
Vitals: 98.1 100 138/78 16 98%
Left lower extremity:
- poke hole over anterior tibia with minimal active bleeding.
- Calf swollen but compressible, no pain on passive stretch
- Soft, non-tender thigh and leg
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 07:30PM WBC-18.7* RBC-4.24 HGB-13.3 HCT-37.2 MCV-88
MCH-31.3 MCHC-35.7* RDW-13.5
___ 07:30PM NEUTS-81.8* LYMPHS-13.8* MONOS-4.1 EOS-0.1
BASOS-0.2
___ 07:30PM PLT COUNT-278
___ 07:30PM GLUCOSE-112* UREA N-14 CREAT-0.9 SODIUM-136
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-20* ANION GAP-17
___ 07:36PM ___ PTT-25.5 ___
Medications on Admission:
1. Fluoxetine 40 mg PO DAILY
2. LaMOTrigine 100 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Axillary crutches x 2
Diagnosis: Open left tib/fib fracture
Prognosis: good
Duration: up to indefinite
2. Commode
Diagnosis: open left tib/fib fx
Prognosis: good
Duration: up to indefinite
3. Enoxaparin Sodium 40 mg SC QHS Duration: 30 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous at bedtime Disp
#*30 Syringe Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*120 Tablet Refills:*0
6. Fluoxetine 40 mg PO DAILY
7. LaMOTrigine 100 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1. Open left tibia/fibula fracture
2. Left medial malleolar nondisplaced ankle fracture
3. Fracture of the base of the left ___ metatarsal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with tib-fib fracture and distal tib fracture on OSH imaging
// Eval for fracture
COMPARISON: Outside hospital radiograph performed earlier today.
FINDINGS:
Total of 10 views of the left lower extremity including views of the left foot
and left ankle. Acute fractures involving the mid to distal shaft of the left
tibia and fibula are again seen. There is no significant change in alignment.
Ankle alignment is normal. Images of the left foot notable for in
intra-articular fracture at the base of the second metatarsal. Evaluation of
the Lisfranc interval is limited. No additional fracture is identified.
IMPRESSION:
Fractures of the it mid to distal shaft of the were left tibia and fibula.
Fracture at the base of the second metatarsal.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT IN O.R.
INDICATION: LEFT TIB FX.ORFI
IMPRESSION:
Images from the fluoroscopy suite show placement of a fixation device about
previous fracture of the left tibia. Further information can be gathered from
the operative report.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: L Leg injury, Transfer
Diagnosed with FX SHAFT FIB W TIB-CLOS, FX MEDIAL MALLEOLUS-CLOS, FALL-1 LEVEL TO OTH NEC
temperature: 98.1
heartrate: 100.0
resprate: 16.0
o2sat: 98.0
sbp: 138.0
dbp: 78.0
level of pain: 2
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open left tibia/fibula fracture, a nondisplaced left
medial malleolar fracture, and a fracture of the base of her
left ___ metatarsal and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for 1) Irrigation and debridement down to and inclusive of bone
of open tibia fracture, 2) Intramedullary nailing of open tibia
fracture, and 3) Open reduction, internal fixation of left
medial malleolar fracture, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with home ___ was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
partial weight bearing in the left lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx dementia, CHF, HTN, IDDM, and recent UTI presents
with nausea and vomiting for 2 days. Patient was recently
diagnosed and treated for a UTI, initially with doxycycline, and
then transitioned to cefpodoxime after an appointment was made
with a Urologist ___. Since ___, the patient has had
increased nausea/vomiting at her facility, finally prompting her
to be sent in to the ___ ED by her Nursing Home ___.
In the ED initial vitals were: 98.1 72 105/62 16 99% ra
- Labs were significant for WBC 11.9 with neutrophilic
predominance, creatinine 1.2, and lactate 2.4. UA was
unremarkable.
- Patient was given 500cc IVF
Vitals prior to transfer were: 98.6 62 182/74 20 100% RA
On the floor, patient's daughter verifies above history. Patient
reports she has no acute complaints.
Past Medical History:
- DM2 - insulin dependent ___, c/b neuropathy.
- PVD
- GERD
- paroxysmal atrial fibrillation
- h/o gastritis
- h/o pancreatitis
- h/o stress incontinence, urinary retention
- h/o CVA (left occipital infarct)
- s/p cervical fusion, lumbar disc surgery
- glaucoma
- R eye blindness
- R BKA
- Dementia
Social History:
___
Family History:
Unable to obtain from pt. No history of early dementia or heart
disease.
Physical Exam:
Admission exam:
Vitals - T:98.4 BP:128/68 HR:68 RR:18 02 sat:93RA
GENERAL: NAD, pleasant, oriented to name only
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB though very poor effort
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, s/p R BKA
PULSES: Dopplerable ___ pulses on L leg
NEURO: CN II-XII intact, equal strength both upper extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge exam:
Vitals: 98.6, 159/72, 89, 18, 95% on RA
GENERAL: NAD, pleasant, oriented to name only
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB though very poor effort
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, s/p R BKA
NEURO: CN II-XII intact, equal strength both upper extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs:
___ 04:15PM BLOOD WBC-11.9*# RBC-4.37 Hgb-11.2* Hct-36.9
MCV-84 MCH-25.5* MCHC-30.2* RDW-15.6* Plt ___
___ 04:15PM BLOOD Neuts-81.7* Lymphs-13.0* Monos-2.9
Eos-2.2 Baso-0.2
___ 04:15PM BLOOD Glucose-262* UreaN-22* Creat-1.2* Na-137
K-4.8 Cl-90* HCO3-38* AnGap-14
___ 06:54AM BLOOD ALT-9 AST-13 LD(LDH)-184 AlkPhos-70
TotBili-0.2
___ 06:54AM BLOOD Lipase-17
___ 06:54AM BLOOD Calcium-9.5 Phos-3.0 Mg-2.2
___ 04:18PM BLOOD Lactate-2.4*
Discharge labs:
___ 10:25AM BLOOD WBC-10.7 RBC-4.14* Hgb-10.8* Hct-35.0*
MCV-84 MCH-26.0* MCHC-30.8* RDW-15.5 Plt ___
___ 10:25AM BLOOD Glucose-212* UreaN-19 Creat-1.2* Na-139
K-3.7 Cl-96 HCO3-34* AnGap-13
___ 10:25AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0
Pertinent micro:
___ Urine culture negative
Pertinent imaging:
___ CXR
The cardiac, mediastinal and hilar contours appear unchanged.
Within the
limitations of technique, the lungs appear clear aside from
questionable vague increased posterior density suggesting minor
atelectasis or crowding of bronchovascular structures.
Evaluation is somewhat limited, however, by low lung volumes.
IMPRESSION: No definite evidence of acute cardiopulmonary
disease. Low lung volumes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO BID
2. Omeprazole 40 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Furosemide 60 mg PO DAILY
8. Citalopram 10 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q8H
12. Simvastatin 10 mg PO DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
14. Lactulose 15 mL PO HS
15. Senna 8.6 mg PO HS
16. Acetaminophen 650 mg PO Q6H:PRN pain
17. Bisacodyl 10 mg PO DAILY:PRN constipation
18. Bisacodyl 10 mg PR HS:PRN constipation
19. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
20. Glargine 20 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Bisacodyl 10 mg PR HS:PRN constipation
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q8H
7. Calcium Carbonate 500 mg PO BID
8. Citalopram 10 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
12. Losartan Potassium 50 mg PO DAILY
13. Metoprolol Succinate XL 200 mg PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Senna 8.6 mg PO HS
16. Simvastatin 10 mg PO DAILY
17. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
18. Lactulose 15 mL PO HS
19. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Nausea
Dementia
Delirium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Hypoxia. Question pneumonia.
COMPARISON: ___.
TECHNIQUE: Chest, AP and lateral.
FINDINGS:
The cardiac, mediastinal and hilar contours appear unchanged. Within the
limitations of technique, the lungs appear clear aside from questionable vague
increased posterior density suggesting minor atelectasis or crowding of
bronchovascular structures. Evaluation is somewhat limited, however, by low
lung volumes.
IMPRESSION:
No definite evidence of acute cardiopulmonary disease. Low lung volumes.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Nausea, Vomiting, Chest pain
Diagnosed with VERTIGO/DIZZINESS
temperature: 98.1
heartrate: 72.0
resprate: 16.0
o2sat: 99.0
sbp: 105.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ with PMHx dementia, CHF, HTN, IDDM, and recent UTI presents
with nausea and vomiting for 2 days.
#Nausea/Vomiting:
Differential on admission included recurrent UTI, viral
gastroenteritis, or adverse reaction to recent new antibiotic.
Urine culture was negative. Symptoms were resolved by time of
admission, therefore no further workup was necessary. Due to
concern for dehydration, pt was given IVF and her home lasix was
stopped. She appeared euvolemic on discharge. Pt was able to
tolerate po. She was kept on a dysphagia diet, as her daughter
had mentioned a concern for swallowing. We did not observe any
aspiration or concern while here.
#AMS:
On HD1, pt was noted to be sleepy throughout the day and
combative with nursing. Infectious workup, including negative
urine culture and CXR, was negative. No new neurologic sx to
warrant head imaging. She slept well overnight and was improved
by hospital day 2. This was most likely hospital induced
delirium and will improved with return to her normal daily
routine.
#Insulin-Dependent Diabetes:
Pt was noted to be hypoglycemic during her admission. We reduced
her insulin to 10 units lantus HS plus humalog sliding scale.
This can be uptitrated as needed by her PCP.
#Hypertension:
She was continued on her home amlodipine, metoprolol, and
losartan.
#dCHF:
Home lasix was held due to concern for dehydration. She appeared
euvolemic on discharge. This can be restarted as needed.
#Hyperlipidemia:
Continued on home simvastatin.
# Code: DNR/DNI (confirmed)
# Emergency Contact: Name of health care proxy: ___
___: Daughter Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with coronary angiography
History of Present Illness:
Mr. ___ is a ___ male with a past medical history DMII
who presents to emergency department with shortness of breath
and chest pain for the past 4 days.
Patient notes that 4 mornings ago he woke up and started to feel
generally weaker throughout the day. He noticed some chest
pressure, central, without radiation. This pressure would occur
with standing and exertion, walking and especially climbing any
stairs. The pressure would resolve with sitting/lying down and
recur with movement. Shortness of breath was only with activity.
He notes that the weakness he felt was a generalized feeling,
which happened with walking, and coincided with feeling
lightheaded. No associated diaphoresis, nausea, vomiting. No
orthopnea. No cough. No recent illness. Of note, patient works
as a ___. When he awoke today, he felt more SOB and
weaker than before (had been attributing to dehydration, but was
progressive). He could not walk across the room without SOB. He
decided he couldn't go to work and came to ___ where concern
given new PR prolongation and report of ?Mobitz type II on EKG
(I cannot access this on webepic currently, here patient with
Tyle I block)
Also of note, patient has not had a cardiac workup in the past.
No echo or cath. He does not that chest pressure similar to the
past few days has been occurring intermittently the last ___
years, about ___ times a year, feeling quite minor and often
resolving quickly. Unsure whether these episodes were with
exertion.
In the ED, initial VS were 98.6 78 113/55 18 98% RA Exam notable
for well appearing, No murmurs or gallops, CTA bilat equal
pulses bilaterally. Labs showed initial trop at 0.44, and 6
hours later was 0.42. CKMD 5, CK 97. CBC with WBC 6.2, Hgb 13.5,
Plts 176. Coags WNL. Chem7 WNL except K 5.9 (hemolyzed, repeat
4.0). CXR showed no acute cardiopulmonary process Received
aspirin 324mg and started on a heparin gtt with bolus. Transfer
VS were HR 82 122/74 16 96% RA ___ cardiology was reportedly
consulted On arrival to the floor, patient reports he feels at
baseline. He feels no current chest pain or SOB. Feels as though
with hydration from IV fluids in the ED (only received fluids
with heparin). No fevers/chills. No recent diarrhea, vomiting,
dysuria, hematuria or GI bleeding. No changes in vision.
Weakness feels improved.
Past Medical History:
T2DM
Social History:
___
Family History:
-Maternal uncle and maternal grandmother with some form of heart
disease, unsure what
-Brother with history of 'blood cancer' which affected his
heart, died of CV disease NOS
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.6 125/82 R Sitting 90 16 97 ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCAHRGE PHYSICAL EXAM:
VITALS: 99.1 PO ___ 18 99 RA
WEIGHT: 84.8 kg
WEIGHT ON ADMISSION: 87.3 kg
TELEMETRY: AV delay
GENERAL: WDWN. Pleasant, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Right femoral and radial access site
intact, no bruits or swelling.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
====================
___ 05:30PM BLOOD WBC-6.2 RBC-4.92 Hgb-13.5* Hct-42.4
MCV-86 MCH-27.4 MCHC-31.8* RDW-11.9 RDWSD-37.4 Plt ___
___ 05:30PM BLOOD Neuts-63.9 ___ Monos-11.4 Eos-1.1
Baso-0.2 Im ___ AbsNeut-3.98 AbsLymp-1.44 AbsMono-0.71
AbsEos-0.07 AbsBaso-0.01
___ 05:30PM BLOOD Glucose-136* UreaN-17 Creat-1.1 Na-134
K-5.9* Cl-101 HCO3-22 AnGap-17
___ 10:55PM BLOOD cTropnT-0.42*
___ 09:12PM BLOOD CK-MB-5 proBNP-699*
INTERIM LABS:
====================
___ 05:15AM BLOOD WBC-5.2 RBC-4.49* Hgb-12.4* Hct-37.7*
MCV-84 MCH-27.6 MCHC-32.9 RDW-11.9 RDWSD-36.1 Plt ___
___ 05:15AM BLOOD Plt ___
___ 01:00AM BLOOD K-4.3
___ 05:15AM BLOOD Glucose-186* UreaN-15 Creat-1.0 Na-138
K-3.9 Cl-103 HCO3-21* AnGap-18
___ 01:00AM BLOOD cTropnT-0.73*
___ 05:15AM BLOOD CK-MB-4 cTropnT-0.49*
___ 12:58PM BLOOD CK-MB-4 cTropnT-0.47*
___ 05:30PM BLOOD %HbA1c-7.4* eAG-166*
DISCHARGE LABS:
====================
___ 06:10AM BLOOD WBC-5.1 RBC-4.36* Hgb-12.1* Hct-36.7*
MCV-84 MCH-27.8 MCHC-33.0 RDW-11.7 RDWSD-35.5 Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-166* UreaN-16 Creat-1.1 Na-137
K-4.2 Cl-103 HCO3-22 AnGap-16
___ 06:10AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0
MICROBIOLOGY:
====================
None.
IMAGING:
=====================
___ CARDIAC CATH:
Coronary Anatomy
Dominance: Co-dominant
* Left Main Coronary Artery
The LMCA is short and angiographically normal
* Left Anterior Descending
The LAD is a large vessel that extends to the apex and is
overall non obstructive
a portion of the apical LAD wraps around the apex
* Circumflex
The Circumflex is co-dominant
there is a 80-90% tubular lesion extending into the OM1
* Right Coronary Artery
The RCA is occluded in its mid segment (100%) with no antergrade
collaterals
The Right PDA reconstituted via left sided retrograde
collaterals
Impressions:
1. Severe two vessel CAD in this co-dominant system
2. Mid RCA 100% oocclusion successfully Rxed with a 2.5 DES
(Promus Premier)
3. LCx/OM1 80-90% lesion succesfully Rxed with a 2.5 DES (Promus
Premier)
4. Mildly elevated LV filling pressures
Recommendations
1. Dual anti plt Rx with ASA and Clopidogrel for a min of ___ year
post PCI
2. Aggressive secondary risk factor modification
3. Further recommendations as per inpatient Cardiology service
___ ECHO:
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
basal inferior hypokinesis. The remaining segments contract
normally. Quantitative (3D) LVEF = 47%. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Lisinopril 5 mg PO DAILY
3. Sildenafil Dose is Unknown PO PRN activity
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Sildenafil 20 mg PO PRN activity
5. Lisinopril 5 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
NSTEMI
CAD
Prolonged PR interval
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with SOB// eval for pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 98.6
heartrate: 78.0
resprate: 18.0
o2sat: 98.0
sbp: 113.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with a past medical history T2DM
who presented to emergency department with shortness of breath
and chest pain for the past 4 days. He had positive troponins
(Trop T peak at 0.73) and was taken to the cardiac cath lab on
___ for coronary angiography. Findings included: LAD clean,
LCx 90% lesion in OM1, RCA mid segment 100% occlusion, DES
placed to both OM1/RCA. He was discharged on aspirin 81mg daily,
atorvastatin 80mg daily, and Plavix 75 daily (should continue
for minimum ___ year or otherwise directed by his cardiologist).
On telemetry the patient had ___ Mobitz II block that improved
with activity and increased HR to 1:1 AV delay, indicating
likely AV node origin. Denied lightheadedness, shortness of
breath or syncope. No need for emergent pacemaker, will have
outpatient ___ set up and close f/u with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Cipro / Lipitor / Vasotec / Norvasc / latex
Attending: ___.
Chief Complaint:
Syncope/Near Syncope & Bradycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with SVT, HTN, HLD, GERD, anemia, meningioma s/p resection,
who presented to the ED as a transfer from ___ for
bradycardia and syncope.
On the day of admission at 5pm pt was walking with husband and
had near syncopal
episode. Patient was out with family tonight at dinner and was
walking back to car and became very light headed and fell to her
knees, her husband caught her before she fell backwards. No LOC,
no headstrike. Went to ___ where she was found to be
bradycardic in junctional rhythm. Started on dopamine drip.
magnesium given. While in ED pt converted to NSR. transferred to
___ for cardiology eval.
Past Medical History:
HTN
Anxiety hyperlipidemia
GERD
Osteoarthritis
Anemia
Cerivacal carcinoma in situ
hemorrhoids
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 PO 162 / 74 L Lying 63 16 99 RA
GENERAL: Pale but otherwise well-appearing lady in no acute
distress, pacer pads in place
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, 2 out of 6 systolic murmur heard best at the
right upper sternal border
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Weights: 63.6<--66.3
Tele: Read as 1st Degree AV Block, no other events
PHYSICAL EXAM:
GENERAL: Pale but otherwise well-appearing; No acute distress
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, 2 out of 6 systolic murmur heard best at the
right upper sternal border
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, clear and coherent
Pertinent Results:
PERTINENT LAB RESULTS:
======================
___ 08:15AM BLOOD WBC-5.9 RBC-2.93* Hgb-8.6* Hct-27.6*
MCV-94 MCH-29.4 MCHC-31.2* RDW-14.5 RDWSD-49.1* Plt ___
___ 11:33PM BLOOD WBC-8.9 RBC-2.95* Hgb-8.7* Hct-27.3*
MCV-93 MCH-29.5 MCHC-31.9* RDW-14.1 RDWSD-47.4* Plt ___
___ 11:33PM BLOOD Neuts-57.6 ___ Monos-4.9*
Eos-0.3* Baso-0.6 Im ___ AbsNeut-5.15 AbsLymp-3.21
AbsMono-0.44 AbsEos-0.03* AbsBaso-0.05
___ 08:15AM BLOOD Plt ___
___ 08:15AM BLOOD ___ PTT-24.7* ___
___ 11:33PM BLOOD Plt ___
___ 08:15AM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-143
K-4.2 Cl-103 HCO3-26 AnGap-14
___ 11:33PM BLOOD Glucose-93 UreaN-17 Creat-0.7 Na-135
K-4.2 Cl-96 HCO3-24 AnGap-15
___ 08:15AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.6
___ 11:33PM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9
___ 11:33PM BLOOD TSH-0.91
IMAGING
=======
RIB X-RAYS:
H
e
a
r
t
size is within normal limits.Lungs are grossly clear and without
p
n
e
u
m
o
t
h
o
r
a
c
es.There are no displaced rib fractures. There are degenerative
changes with anterior spurring of the lower thoracic spine.
IMPRESSION:
1. No signs for acute cardiopulmonary process.
2. No displaced rib fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Flecainide Acetate 100 mg PO Q12H
7. Magnesium Oxide 400 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. ferrous sulfate, dried 159 mg (45 mg iron) oral DAILY
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*13 Capsule Refills:*0
2. Citalopram 20 mg PO DAILY
3. ferrous sulfate, dried 159 mg (45 mg iron) oral DAILY
4. Magnesium Oxide 400 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Bradycardia
Syncope
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RIB UNILAT, W/ AP CHEST LEFT
INDICATION: ___ year old woman with hx of meningioma s/p resection,
bradycardia, and syncopal event now with MSK chest pain following syncopal//
Fracture?
COMPARISON: Radiographs from ___
FINDINGS:
Heart size is within normal limits.Lungs are grossly clear and without
pneumothoraces.There are no displaced rib fractures. There are degenerative
changes with anterior spurring of the lower thoracic spine.
IMPRESSION:
1. No signs for acute cardiopulmonary process.
2. No displaced rib fracture.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Bradycardia, Transfer
Diagnosed with Syncope and collapse, Bradycardia, unspecified
temperature: 98.3
heartrate: 66.0
resprate: 20.0
o2sat: 97.0
sbp: 122.0
dbp: 49.0
level of pain: 0
level of acuity: 2.0 | for Outpatient Providers:
___ ___ woman with a past medical history hypertension,
hyperlipidemia, meningioma status post resection in ___omplicated by SVT who presents as a transfer from ___
___ for bradycardia and syncope.
#Syncope & Bradycardia:
The patient presented to an OSH with near syncope and was found
to be bradycardic which ultimately responded to dopamine drip
and magnesium. The etiology of her syncope is not entirely clear
but the differential included vagal-induced syncope vs sinus
arrest from an alternative etiology (?flecainide effect) and was
thought to be less likely due to her underlying SVT. Of note,
the patinet's PCP added metoprolol for hypertension/SVT in
___, but pt only started taking it the day before her
episode of near-syncope. Seems likely the beta-blocker could be
implicated in her symptomatic bradycardia. By the time of
presentation to ___ she was back in sinus rhythm and
hemodynamically stable. EP was consulted and recommended holding
the patient's home flecainide, digoxin, and Metoprolol. She was
monitored on continuous telemetry and did not have any recurrent
episodes of bradycardia, syncope, or dizziness. Ultimately, EP
recommended discharged off of all of her home medications
(flecainide, digoxin, and Metoprolol) and observing with a home
event monitor. At the time of discharge, the patient's lyme
serologies (sent as part of initial work up for bradycardia)
were still pending.
#SVT:
The patient's SVT was diagnosed in the setting of her meningioma
resection. She was initially started on metoprolol, but per
records this was stopped ___ near syncope and hypotension. Seen
by EP previously (___) and started on flecainide and dixogin.
Ultimately, EP recommended discharged off of all of her home
medications (flecainide, digoxin, and Metoprolol) and observing
with a home event monitor.
#HTN & Orthostasis
Patient persistently HTN while inpatient w/SBPs in 170s-180s.
She was also noted to have positive orthostatics x2 while
inpatient. Her home cardiac medications including Metoprolol,
flecainide, and digoxin were all held. It was decided to not
start the patient on any anti-HTN medications while inpatient
given her Orthostasis. She was instructed to follow up with
cardiology and PCP for further management.
#UTI
Patient with positive UA on presentation and reports of
malodorous urine, but denies dysuria or frequency. Started on
Macrobid ___ PO BID x7 days starting on ___.
TRANSITIONAL ISSUES:
[] If persistently hypertensive would consider starting ___
[] Follow up EP appointment/ device clinic
[] Follow up HTN/Orthostatics-- if persistently HTN and no
longer orthostatic, would consider addition of ___
(Valsartan) for BP control.
[] Given Orthostasis and HTN picture, would consider sending AM
cortisol and 24 hour urine for metanephrinesfor further work up
[] At time of discharge lyme serologies and urine culture were
pending
MEDICATION CHANGES:
STOPPED Medications:
- Digoxin 0.125 mg PO DAILY
- Flecainide Acetate 100 mg PO Q12H
- Metoprolol Succinate XL 25 mg PO DAILY
NEW Medications
- Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7
Days |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ranitidine
Attending: ___.
Chief Complaint:
Diffuse pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with history of sickle cell disease,
right intraparenchymal hemorrhage in ___ thought ___ aneurysm,
seizure disorder on lacosamide/zonesimide, and migraines who
presents with 4 days of diffuse pain.
Mr. ___ notes that on ___ or ___ he ran out of his
pain medication. Since that time, he began to develop worsening
diffuse body pain. Yesterday, he had an argument with his
uncle. At that time, he became so upset that he "punched a
wall." He struck the wall with his right hand. Since that time,
he has noted right hand pain that is sharp in nature and
radiates up his arm. The pain primarily affects his right
knuckle. The pain seem to spread to involve his head (temples
bilaterally without vision changes), his arms, his legs and his
abdomen. Due to the progression of his pain he decided to come
to the hospital. Otherwise, he denies any fevers, chills or URI
symptoms. He has had an intermittent cough, but no dyspnea. No
melena or hematochezia. No new diarrhea, other than intermittent
loose stools. No urinary symptoms. No trouble with ambulating.
In the ED, his vitals were notable for Tmax of 97.8, HR: 60-80s
BP: 130-150/94-100 and he was on RA. His labs were notable for
Hct: 20.1 close to his baseline with Retic: 2.6. He has lipase,
LFTs and BMP that were normal. UA was without infection. CXR did
not show evidence of pneumonia. He had hand XR that did not show
fracture.
I did speak to his outpatient provider ___ who noted they
had been in the process of downtitrating his pain medication.
According to her, Mr. ___ has struggled to follow up with
attempts at social support.
Past Medical History:
- Sickle cell anemia
- Complex partial & simple partial seizures with secondary
generalization
- s/p right parietal intraparenchymal hemorrhagic stroke ___
believed due to aneurysm
- Periodic limb movements of sleep
- Depression
- Migraine headaches
- Chronic knee pain
- s/p stab wound to LUQ requiring splenectomy and partial colon
resection at age ___ years
- s/p multiple C. diff infections, last episode ___
Social History:
___
Family History:
- Mother died of brain aneurysm in her early ___
- Father with sickle cell disease with history of stroke
- One brother with sickle cell disease
Physical Exam:
98.2 PO 118 / 72 98 18 96 RA
Lying in bed, very uncomfortable noting significant pain
diffusely
Cardiac: RRR, no murmurs
Pulm: Clear to auscultation bilaterally
Abd: Soft, but diffusely tender, + BS, no guarding, no
peritoneal signs
Ext: TTP at right ___ digit MCP. Warm well perfused without
edema
Neuro: CN II-XII intact. ___ Strength X 4 extremities. Alert,
oriented and appropriate.
Pertinent Results:
___ 01:00PM WBC-5.9 RBC-1.84* HGB-7.4* HCT-21.5* MCV-117*
MCH-40.2* MCHC-34.4 RDW-25.3* RDWSD-111.5*
___ 01:00PM PLT COUNT-159
___ 01:20AM ALT(SGPT)-12 AST(SGOT)-29 ALK PHOS-47 TOT
BILI-1.1
___ 01:20AM LIPASE-19
___ 01:20AM ALBUMIN-4.5
___ 01:20AM WBC-5.5 RBC-1.79* HGB-7.3* HCT-20.5* MCV-115*
MCH-40.8* MCHC-35.6 RDW-25.5* RDWSD-108.8*
___ 01:20AM RET AUT-2.6* ABS RET-0.05
Right hand XR:
Normal right hand and wrist radiographs.
Chest CXR:
No acute cardiopulmonary process. Stable mild cardiomegaly.
DC LABS:
___ 08:25AM BLOOD WBC-7.0 RBC-1.84* Hgb-7.6* Hct-21.2*
MCV-115* MCH-41.3* MCHC-35.8 RDW-25.4* RDWSD-109.2* Plt ___
___ 08:05AM BLOOD Glucose-84 UreaN-10 Creat-0.7 Na-138
K-4.6 Cl-103 HCO3-26 AnGap-14
___ 01:20AM BLOOD ALT-12 AST-29 AlkPhos-47 TotBili-1.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO BID
2. LACOSamide 200 mg PO BID
3. Zonisamide 200 mg PO QHS
4. LOPERamide 2 mg PO QID:PRN Diarrhea
5. Hydroxyurea 500 mg PO DAILY
6. Hydroxyurea 1000 mg PO QHS
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Citalopram 40 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (MO)
11. OxyCODONE (Immediate Release) 20 mg PO BID
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Hydroxyurea 500 mg PO DAILY
6. Hydroxyurea 1000 mg PO QHS
7. LACOSamide 200 mg PO BID
8. LOPERamide 2 mg PO QID:PRN Diarrhea
9. OxyCODONE (Immediate Release) 20 mg PO BID
RX *oxycodone 10 mg 2 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
10. Vitamin D ___ UNIT PO 1X/WEEK (MO)
11. Zonisamide 200 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic pain
Sickle cell disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with sickle cell, chest/belly pain // ?pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. Mild cardiomegaly is unchanged. The cardiac and
mediastinal silhouettes are otherwise unremarkable.
IMPRESSION:
No acute cardiopulmonary process. Stable mild cardiomegaly.
Radiology Report
EXAMINATION: DX HAND AND WRIST
INDICATION: ___ with sickle cell dz, s/p trauma to R hand. Evaluate for
fracture.
TECHNIQUE: Three views right hand, three views right wrist
COMPARISON: None.
FINDINGS:
No acute fracture, dislocation, or degenerative change is detected. No bone
erosion or periostitis identified. No suspicious lytic or sclerotic lesion is
identified. No soft tissue calcification or radio-opaque foreign body is
detected.
IMPRESSION:
Normal right hand and wrist radiographs.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Headache, Body pain
Diagnosed with Hb-SS disease with crisis, unspecified
temperature: 97.8
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 154.0
dbp: 100.0
level of pain: 10
level of acuity: 2.0 | #Sickle Cell Pain Crisis
Mr. ___ had a sickle cell pain crisis triggered by his
running out of his medications and potentially the change in
weather, as cold exposure can trigger crises. We did not
uncovere alternative reasons including: anemia (just below
baseline), infection (CXR clear, UA negative, no fever or
leukocytosis, no diarrhea),
electrolyte abnormality (normal BMP), abdominal syndrome (normal
LFT, lipase and nonfocal abd pain). His counts remained stable
and he has been continued on his home regimen of Hydroxyurea
500mg QAM, Hydroxyurea 1000mg QPM, gabapentin, in addition to
IVF. He was given his home oxycodone with dilaudid for
breakthrough. After discussion with his outpatient provider
___, NP from heme-onc, we will continue his current
regimen with no escalation. He understands need for continued
follow up. He expressed understand of the risks of opioids, and
to avoid driving and alcohol. PMP reviewed.
#Seizures
- Continued Vimpat
- Continued Lacosamide
- Continued Gabapentin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Influenza Virus Vacc,Specific / Pneumovax 23
Attending: ___.
Chief Complaint:
left groin infection
Major Surgical or Invasive Procedure:
___ washout, VAC replacement
___ washout, VAC placement
___ debridement left abdominal wall and groin
___ debridement left abdoominal wall and groin
___ extensive debridement left abdominal wall and groin
History of Present Illness:
Ms. ___ is a ___ year old female with PMH significant for
obesity, HTN, HLD, Hypothyroidism, and schizophrenia with
multiple past psychiatric admissions who presents with chief
complaint of altered mental status and abdominal pain. Pt. was
last ___ her usual state of health approximately 1 day prior to
presenation. At this time, she noted the onset of diffuse
abdominal pain. These symptoms progressed. On the day of
presentation, per the family, the pt. was last seen ___ her usual
state of health around 5:30PM. 3 hours later, the pt's
daughter, ___ found the patient down on the floor with
garbled speech. For change ___ mental status, EMS was then
called.
On arrival, EMS evaluated the pt. and found her blood sugars to
be ___ at 40mg/dl. She was given 25G of dextrose without
improvement. At this time she was found to have bilateral upper
extremity weakness. For these symptoms, she was transferred to
the ED for further management.
___ the ED, initial vitals were: 101.6 122 108/64 35 100% NC.
The pt. was noted to be lethargic and diaphoretic. She was
oriented to name, date of birth, did not know where she was.
Uncooperative with exam however no lateralizing neuro deficits
were seen. Stat NCHCT was negative for acute intracranial
process. CT C-Spine was also done without fracture or acute
malalignment of the cervical spine. Labs were sent which were
notable for significant leukocytosis, WBC 23 (9% bands), lactate
of 12.5, anion gap of 25, creatinine of 1.6 (baseline 0.8 ___
___, CK of 13,517, trop 0.32, ALT 218, AST 501, TBili 2.5,
and UA negative for leuks, negative nitrites, and large blood
with only 1 RBC. Initial ABG 7.3/___. CXR without clear
consolidation. Patient was hemodynamically stable upon arrival
but approximately 20 minutes following initial eval, pt.
triggered for hypotension with BP ___. Peripheral levophed
was started at this time. A right sided femoral line was placed
urgently. Pt. received a total of 4L IVF. Given the
undifferentiated causes of her sepsis, a CT torso was obtained
which was significant for extensive soft tissue stranding and
fat stranding involving the subcutaneous tissues of the left
lateral flank and left anterior abdominal soft tissues with
multiple pockets of air which abut the left rectus sheath and
extend into the left inguinal region. Findings were concerning
for necrotizing fascitis.
As such, ACS was consulted who felt that pt may benefit from
debridement but was too unstable at this time. They recommended
continued broad spectrum antibiotics with antifungal coverage.
Prior to transfer, pt's right femoral line was re-sited to right
subclavian line to avoid worsening bacterial translocation. She
was given tylenol, aspirin, vanc, and zosyn. She was stabilized
and transferred to the MICU for further management.
Past Medical History:
from OMR:
Schizophrenia - hx. of multiple psych admissions ___ the past
HTN
HLD
Hypothyroidism
Glaucoma - s/p laser surgery
Hx. of positive PPD
Cognitive Disorder NOS
Hx. of Anemia
s/p bilateral tubal ligation
Social History:
___
Family History:
Per OMR, daughter deceased from ___ at ___ (also with hx. of HTN,
TIA). Another daughter is also deceased ___ suicide attempt as
a result of depression. Living sister and brother both with DM
type 2.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.3, 116, 117/71, 34, 100% on 3L NC
General: Alert, partially oriented to person and place,
tachypnic
HEENT: Sclera anicteric, Dry Mucous Membranes, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachy/regular rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, mildly tender diffusely, evidence of thickened
skin with whitish exudative film ___ skin folds with foul odor,
scant erythema noted on the left abdominal wall and left flank,
bowel sounds present, no rebound tenderness or guarding
GU: foley ___ place draining
Ext: cool extremities, 2+ pulses, no clubbing, cyanosis or edema
Physical examination: upon discharge: ___
vital signs: t=98, hr=67, bp=105/60, rr=18, oxygen sat 98% room
air
General: NAD
CV: ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, staples left lower thigh, left groin wound:
(erythematous base, no exudate, no odor, peripheral margins
pink, staples left lower abdomen intact
EXT: no pedal edema bil., no calf tenderness bil.
NEURO: oriented to name, place, family, follows simple
commands, transfers from bed to chair with walker
Foley to gravity drainage: cloudy urine (u/a sent)
Please place vac dressing to left groin wound, black sponge to
125mmhg VAC
Pertinent Results:
MICRO
___ 11:15 am SWAB ABDOMINAL WOUND.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary): RESULTS PENDING.
ANAEROBIC CULTURE (Preliminary):
___ 6:41 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
Blood cultures from ___ and urine culture from ___ with no
growth as of ___.
ECG ___: Artifact is present. Sinus tachycardia. Non-specific
ST-T wave changes. No previous tracing available for comparison.
IMAGING
CT Torso -- 1. Extensive soft tissue stranding and fat stranding
involving the subcutaneous tissues of the left lateral flank and
left anterior abdominal soft tissues with multiple pockets of
air which abut the left rectus sheath and extend into the left
inguinal region. Findings are concerning for abscess formation
with phlegmonous change changes and cellulitis. There is no
definite drainable fluid collection.
2. There is no intra-abdominal process identified. Although,
there are small pockets of air projecting over the expected
location of the duodenum which are felt to be intra luminal.
However given the lack of oral contrast somewhat hard to
evaluate.
3. Bilateral atelectasis with possible tiny pleural effusions.
Small
pericardial effusion.
CT C-SPINE W/O CONTRAST ___
No acute fracture or dislocation of the cervical spine.
Degenerative changes, most prominent at the C4-5 through the
C6-7 levels with areas of listhesis.
CT HEAD W/O CONTRAST ___ No acute intracranial
abnormality.
CXRAY ___: Patient is rotated to the left. The cardiac
silhouette is mildly enlarged. Mediastinal contours are
unremarkable. There is subtle history opacity projecting over
the left lung, which may be due to atelectasis. There is also
minimal elevation of the left hemidiaphragm. No discrete focal
consolidation is seen. There is no pleural effusion or evidence
of pneumothorax. No displaced rib fracture is identified.
___: cat scan of abdomen and pelvis:
. Extensive soft tissue stranding and fat stranding involving
the
subcutaneous tissues of the left lateral flank and left anterior
abdominal soft tissues abutting the left rectus sheath and
extending into the left inguinal region. Significant amount of
air dissects the subcutaneous tissues at this level and raises
concern for necrotizing fasciitis.
2. No intraabdominal process identified.
3. Bilateral atelectasis with possible tiny pleural effusions.
Small
pericardial effusion.
___: ECHO:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is moderately depressed with
severe hypokinesis of the basal to mid inferior septum, and of
the inferior and inferolateral walls. The other walls are mildly
hypokinetic (LVEF= ___ %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a very
small pericardial effusion. There are no echocardiographic signs
of tamponade.
___: x-ray of the abdomen:
There is a moderate amount of gas within the stomach. A
nonobstructive bowel gas pattern is demonstrated. There is no
pneumoperitoneum. Multiple skin staples overlie the left pelvis.
___: chest -xray:
___ comparison to study of ___, there again is moderate
enlargement of the cardiac silhouette. There may be minimal
elevation of pulmonary venous pressure. The layering effusions
on the previous supine view are now seen at the bases
posteriorly on the upright projection. No definite acute focal
pneumonia.
The right subclavian catheter is been removed.
___: ECHO:
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened with mild sclerosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild to moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
borderline global systolic function. Mildly dilated ascending
aorta with mild aortic regurgitation. Mild mitral regurgitation.
Mild to moderate pulmonary hypertension.
___: EKG:
Sinus rhythm. Early R wave progression. T wave abnormalities.
Compared to the
previous tracing of ___ the precordial voltage is now less
prominent. The
last QRS complex has artifactual changes.
___ 06:15AM BLOOD WBC-5.9 RBC-2.77* Hgb-8.6* Hct-27.2*
MCV-98 MCH-30.9 MCHC-31.5 RDW-15.7* Plt ___
___ 07:10AM BLOOD WBC-6.5 RBC-2.83* Hgb-8.7* Hct-28.2*
MCV-100* MCH-30.8 MCHC-30.8* RDW-15.6* Plt ___
___ 07:00AM BLOOD WBC-5.0 RBC-2.79* Hgb-8.5* Hct-27.0*
MCV-97 MCH-30.7 MCHC-31.6 RDW-15.5 Plt ___
___ 10:30PM BLOOD Neuts-73* Bands-8* Lymphs-9* Monos-7
Eos-2 Baso-0 ___ Metas-1* Myelos-0
___ 06:15AM BLOOD Plt ___
___ 07:10AM BLOOD Plt ___
___ 03:20AM BLOOD ___ PTT-28.2 ___
___ 06:15AM BLOOD Glucose-81 UreaN-8 Creat-0.6 Na-138 K-4.4
Cl-103 HCO3-28 AnGap-11
___ 07:10AM BLOOD Glucose-97 UreaN-6 Creat-0.6 Na-135 K-4.4
Cl-100 HCO3-27 AnGap-12
___ 10:10AM BLOOD CK(CPK)-53
___ 01:38AM BLOOD CK(CPK)-50
___ 02:14AM BLOOD ALT-47* AST-33 LD(LDH)-195 AlkPhos-105
TotBili-0.9
___ 01:10PM BLOOD cTropnT-0.07*
___ 10:10AM BLOOD CK-MB-6 cTropnT-0.08*
___ 01:38AM BLOOD CK-MB-5 cTropnT-0.08*
___ 02:24AM BLOOD cTropnT-0.22*
___ 06:15AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8
___ 07:00AM BLOOD calTIBC-205* Ferritn-957* TRF-158*
___ 03:49AM BLOOD freeCa-1.00*
___ 11:15 am SWAB ABDOMINAL WOUND.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
GRAM POSITIVE RODS. HEAVY GROWTH .
CORYNEFORM BACILLI UNABLE TO FURTHER IDENTIFY.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens,
and C.septicum is being ruled out.
PREVOTELLA SPECIES. MODERATE GROWTH. BETA LACTAMASE
POSITIVE.
REQUESTED BY ___. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Benztropine Mesylate 0.5 mg PO QHS:PRN stiffness
3. Clotrimazole Cream 1 Appl TP BID
4. Ketoconazole Shampoo 1 Appl TP ASDIR
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. Potassium Chloride 8 mEq PO DAILY
8. Pravastatin 40 mg PO DAILY
9. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Clotrimazole Cream 1 Appl TP BID
3. Furosemide 20 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H
last dose ___. Haloperidol 10 mg PO HS
10. Heparin 5000 UNIT SC TID
11. Lisinopril 5 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Benztropine Mesylate 0.5 mg PO QHS:PRN stiffness
14. Ketoconazole Shampoo 1 Appl TP ASDIR
15. Pravastatin 40 mg PO DAILY
16. Potassium Chloride 8 mEq PO DAILY
Hold for K > 4.5
17. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left groin infection
septic shock
UTI
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound ( out of bed with lift)
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with found down with ams // eval ich
TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base
through the vertex, without IV administration of contrast. Reformatted coronal
and sagittal and thin-section bone algorithm-reconstructed images were
acquired, and all images are viewed in brain and bone window on the
workstation.
DOSE: DLP (mGy-cm): 1114.9.
CTDIvol (mGy): 53.9
COMPARISON: NONE AVAILABLE.
FINDINGS:
There is no acute intracranial hemorrhage, edema, mass effect, or acute
vascular territorial infarction. The ventricles and sulci are normal in size
and configuration. There is no shift of the normally midline structures.The
basal cisterns appear patent and there is preservation of the gray-white
matter differentiation.
No fracture or suspicious osseous lesion is identified.The included paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. cerumen is
present in the left external auditory canal (3a:16).
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CT C-SPINE WITHOUT CONTRAST.
INDICATION: History: ___ with fall, +head strike // eval injury
TECHNIQUE: Axial helical MDCT images were obtained from the skullbase through
the T3 level. Reformatted coronal and sagittal images were also reviewed.
DOSE: DLP: 778.1 mGy-cm
COMPARISON: None available.
FINDINGS:
There is no acute fracture or dislocation of the cervical spine. The
prevertebral soft tissues are not thickened.
Moderate multilevel degenerative changes are present throughout the cervical
spine, most prominent at the C4-5 through C6-7 levels, and include mild
anterolisthesis of C4 on C5, and mild retrolisthesis of C6 on C7, with large
anterior osteophytosis and bilateral facet arthropathy.
There is no lymphadenopathy. Scarring is noted in the left lung apex (2:64).
The thyroid gland is unremarkable.
IMPRESSION:
No acute fracture or dislocation of the cervical spine. Degenerative changes,
most prominent at the C4-5 through the C6-7 levels with areas of listhesis.
Radiology Report
INDICATION: History: ___ with ams // eval pna
TECHNIQUE: Single AP upright portable view of the chest.
COMPARISON: None
FINDINGS:
Patient is rotated to the left. The cardiac silhouette is mildly enlarged.
Mediastinal contours are unremarkable. There is subtle history opacity
projecting over the left lung, which may be due to atelectasis. There is also
minimal elevation of the left hemidiaphragm. No discrete focal consolidation
is seen. There is no pleural effusion or evidence of pneumothorax. No
displaced rib fracture is identified.
Radiology Report
EXAMINATION: CONTRAST ENHANCED CT ABDOMEN AND PELVIS
INDICATION: Sepsis, unclear source. Complaining of abdominal pain yesterday.
Evaluate for obstruction, infection.
TECHNIQUE: Axial MDCT images were obtained through the abdomen and pelvis
after the uneventful administration of IV contrast. No oral contrast was
provided. Sagittal and coronal reformats were generated.
TOTAL EXAM DLP: 887 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is bibasilar atelectasis, right worse than left with probable tiny
pleural effusions bilaterally. There is a small pericardial effusion.
CT of the abdomen: No focal hepatic lesions identified. There is no intra or
extrahepatic biliary ductal dilatation. The gallbladder is normal without
pericholecystic fluid or gallbladder wall edema. The pancreas is normal
without peripancreatic fluid collections. The adrenal glands and spleen are
normal. The kidneys enhance symmetrically and excrete contrast without
evidence of hydronephrosis or renal masses.
The stomach is air-filled. There is a small hiatal hernia. There is no
evidence of small bowel obstruction. The appendix is not clearly visualized,
however there is no evidence of acute appendicitis. Small and large bowel are
grossly unremarkable. There is no bowel wall thickening or edema. There is no
free fluid. There is no free air.
Within the subcutaneous tissues of the left flank, left anterior abdominal
wall and extending into the left inguinal region, there is extensive soft
tissue and fat stranding with significant amount of air dissecting the
subcutaneous tissues, raising concern for cellulitis and necrotizing
fasciitis. Note is also made of significant skin thickening at this level.
No definite drainable fluid collection is identified. There is a 6.2 x 3.2 cm
intramuscular lipoma in the left flank.
CT of the pelvis: There is no pelvic free fluid. Note is made of a catheter in
the right common femoral vein. There is soft tissue stranding extending into
the left inguinal region with reactive lymph nodes measuring up to 12 mm. A
Foley catheter is seen within a collapsed urinary bladder.
Osseous structures: Mild degenerative changes are noted along the lower
thoracic spine. Facet hypertrophy is seen at the lower lumbar spine.
IMPRESSION:
1. Extensive soft tissue stranding and fat stranding involving the
subcutaneous tissues of the left lateral flank and left anterior abdominal
soft tissues abutting the left rectus sheath and extending into the left
inguinal region. Significant amount of air dissects the subcutaneous tissues
at this level and raises concern for necrotizing fasciitis.
2. No intraabdominal process identified.
3. Bilateral atelectasis with possible tiny pleural effusions. Small
pericardial effusion.
NOTIFICATION: Discussed with ___ by ___ via telephone on
___ at 1:30 AM. Additional discussion regarding impression #1 discussed
with Dr. ___ by NSR in person on ___ at 2:20 AM. Final
report discussed with Dr. ___ telephone on ___ at 9:10 AM.
Radiology Report
EXAMINATION: CHEST RADIOGRAPH
INDICATION: Right central venous line.
TECHNIQUE: Portable semi-upright chest radiograph.
COMPARISON: None available.
FINDINGS:
A right-sided central venous line terminates in the mid to lower SVC. The
cardiomediastinal and hilar contours are within normal limits. There is
increased focal density at the right lower lobe which could relate to
atelectasis. However in the appropriate clinical setting and early infectious
process cannot be entirely excluded. There is no pneumothorax.
IMPRESSION:
Right-sided central venous line terminates at the mid to lower SVC. No
pneumothorax identified. Increased focal density at the right lung base could
relate to atelectasis. However in the appropriate clinical setting an early
infectious process cannot be entirely excluded.
Radiology Report
EXAMINATION: Portable AP chest x-ray.
INDICATION: ___ year old woman with abdominal nec fasc s/p debridement,
remains intubated. New OG tube. // Tube and line placement.
TECHNIQUE: AP projection.
COMPARISON: Portable AP chest x-ray obtained ___.
FINDINGS:
There has been interval placement of an ET tube which terminates 4 cm above
the carina. There is a new NG tube or OG tube with distal tip in the stomach.
There is stable position of a right-sided central line with distal tip
projecting over the lower SVC.
The cardiomediastinal silhouette is stable. The bilateral hila are not well
visualized.
The lung apices are not included on the current radiograph. There are
bilateral more central and lower lobe predominant airspace opacities as well
as indistinctness of pulmonary vascular margins, consistent with pulmonary
vascular congestion and mild pulmonary edema, though improved in comparison to
prior radiograph. There is increased retrocardiac and left basilar
opacification obscuring the left hemidiaphragm, as well as continued, but
slightly less prominent, right lower lung opacification, probably representing
bibasilar atelectasis.
The left lateral CP angle is not clearly visualized, and may represent
small/minimal pleural effusion. There is no right pleural effusion. There is
no pneumothorax.
IMPRESSION:
1. New ET tube terminating 4 cm above carina. New NG/OG tube with tip in
stomach.
2. Pulmonary vascular congestion and interval improvement in still moderate
pulmonary edema.
3. Likely bibasilar atelectasis. Possible small left pleural effusion.
Radiology Report
REASON FOR EXAMINATION: Abnormal dermal infection after debridement, sepsis.
AP radiograph of the chest was reviewed in comparison to prior study obtained
from ___.
The ET tube tip is 4.2 cm above the carina. The right subclavian line tip is
at the level of low SVC. Cardiomegaly is unchanged, but there is interval
increase in bilateral pleural effusions. No overt pulmonary edema is
demonstrated. No pneumothorax is seen.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after debridement of the
left flank, assessment of the lung fields.
AP radiograph of the chest was compared to ___.
Right central venous line tip terminates at the level of mid SVC, unchanged.
The ET tube tip is in unchanged appropriate position. Heart size and
mediastinum are stable as well as there is no change in bilateral large
pleural effusions and most likely present vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p septic shock complicated by heart failure
now on dobutamine. // please evaluate for interval change please evaluate
for interval change
COMPARISON: Comparison to prior study dated ___ at 05:03
IMPRESSION:
Endotracheal tube, right subclavian central line and nasogastric tube are
unchanged in position. There continue to be bilateral layering effusions with
consolidation in the retrocardiac area of likely reflecting left lower lobe
collapse. There is improving but residual pulmonary edema. The cardiac and
mediastinal contours remain stable. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with respiratory failure, ETT in situ. NGT
placed, please confirm location, thanks. // eval NGT placement eval NGT
placement
COMPARISON: Comparison to prior study dated ___ at 06:05
IMPRESSION:
Interval placement of a nasogastric tube which courses below the diaphragm and
is coiled within the stomach. Endotracheal tube and right subclavian central
line are unchanged in position.
There is interval increase in bilateral airspace disease consistent with
worsening pulmonary edema. Layering bilateral effusions are also again seen
with associated bibasilar airspace opacity most likely reflecting compressive
atelectasis, although pneumonia cannot be excluded. Cardiac and mediastinal
contours remain stable given differences in patient positioning. No
pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with acute systolic heart failure, undergoing
diuresis. ETT in situ. // eval infiltrate eval infiltrate
COMPARISON: Comparison to ___ at 13 11
IMPRESSION:
Right subclavian central line, endotracheal tube and nasogastric tube are
likely unchanged in position. The patient is markedly rotated to the left
limiting evaluation of the cardiac and mediastinal contours which are probably
stable. There are bilateral layering effusions, right greater than left ,with
associated airspace opacity more consolidative in the retrocardiac region.
This does not appear to be significantly changed. However, the superimposed
pulmonary edema has improved with residual mild interstitial edema still
present. No pneumothorax.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Support and monitoring devices are in standard position, and
cardiomediastinal contours are stable allowing for differences in patient
positioning. Pulmonary vascular congestion is accompanied by improved
pulmonary edema with a minimal interstitial edema remaining. Bilateral
layering pleural effusions persist, with apparent decrease on the right.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ L flank nec fasciitis s/p debridement // ? interval
change
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the monitoring and support devices are
in constant and normal position. Unchanged extent of the bilateral pleural
effusions as well as of the moderate cardiomegaly with signs of mild to
moderate pulmonary edema. No new parenchymal opacities suggesting pneumonia.
No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with sepsis and respiratory failure, attempting
to wean from vent // Please evlaute for interval change
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the nasogastric tube was removed. The
right subclavian line is in unchanged position. Moderate cardiomegaly, minimal
fluid overload as well as small bilateral pleural effusions with basal areas
atelectasis persist. No new parenchymal changes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with septic shock // NGT placement
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the tip of the nasogastric tube is not
visualized. The tip projects over the middle parts of the stomach. The other
monitoring and support devices appear to be in unchanged position. Unchanged
extent of bilateral pleural effusions. Unchanged appearance of the cardiac
silhouette, unchanged retrocardiac atelectasis.
Radiology Report
EXAMINATION: Frontal abdominal radiographs.
INDICATION: ___ year old woman with nec soft tissue infection, s/p multiple
debridements, please evaluate for gastric distention.
COMPARISON: Chest radiograph from ___.
FINDINGS:
There is a moderate amount of gas within the stomach. A nonobstructive bowel
gas pattern is demonstrated. There is no pneumoperitoneum. Multiple skin
staples overlie the left pelvis.
IMPRESSION:
Moderate amount of gas within the stomach.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman p/w necrotizing soft tissue infection s/p
debridement with chest pain. // R/O CHF, pneumonia R/O CHF, pneumonia
IMPRESSION:
In comparison to study of ___, there again is moderate enlargement of the
cardiac silhouette. There may be minimal elevation of pulmonary venous
pressure. The layering effusions on the previous supine view are now seen at
the bases posteriorly on the upright projection. No definite acute focal
pneumonia.
The right subclavian catheter is been removed.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: FOUND DOWN
Diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , ACCIDENT NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | MICU COURSE: Ms. ___ is a ___ year old female with PMH
significant for obesity, HTN, HLD, Hypothyroidism, and
schizophrenia with multiple past psychiatric admissions who
presents with chief complaint of altered mental status and
abdominal pain, with fever 101.6 and hypotension BP ___,
found to have septic shock secondary to necrotizing fascitis of
the left lateral flank and left anterior abdominal abdominal
wall and inguinal region. She was treated with vanc/zosyn (Day
#1 ___ and voriconazole (for antifungal coverage given
evidence of signficant fungal skin infection on exam Day #1
___. She was transfered to the ACS service for further
surgical management.
SICU COURSE: On ___, the patient went to the operating room
for extensive debridement of left lower abdominal wall, groin,
and left upper leg. She remained intubated and requiring
pressors ___ the SICU with anticipation of further debridements
and washouts. ECHO on ___ showed global hypokinesis, EF of
___, and pulmonary HTN; she received 2U RBCs for Hct 22.7.
Cardiology was consulted for regional wall motion abnormalities
and ST changes plus troponin leak. On ___ and ___ she
underwent additional debridements of the abdominal wall and
groin. On ___ and ___, she went back to the OR for washouts
and VAC placement. She was actively diuresed per cardiology recs
and came off of pressors. The patient was extubated on POD#8 and
antibiotics were stopped. Her diet was advanced on POD#9 and she
was tolerating a regular diet. She was hemodynamically stable
and neurologically intact.
On ___, the patient was transferred to the surgical floor. Her
vital signs were stable and she remained afebrile. Shortly
after arrival to the floor, she was reported to have a changes
___ cognition. She was evaluated by the psychiatry who
recommended the avoidance of any benzodiazepines or
anticholinergics. She has been lethargic, but asking appropriate
questions. As reported ___ her SICU course, she was evaluated by
cardiology for stress cardiomyopathy and recommendations for a
follow-up cardiology visit was indicated.
___ anticipation of discharge, she was evaluated by the physical
and occupatonal therapist. Recommendations were made to
discharge to a ___ facility where she could continue
to regain her strength and for VAC changes. The patient's vital
signs have been stable and she has been afebrile. She was note
to have mild urinary retention on ___ and a urine specimen was
sent which indicated a urinary tract infection. The patient was
started on a 1 week course of ciprofloxacin. A new foley
catheter was placed on ___.
The patient was discharged to the ___ facility on ___
___ stable condition. Appointments for follow-up were made with
the acute care service, cardiology and her primary care
provider. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Remicade / Lipitor / simvastatin
Attending: ___.
Chief Complaint:
L scrotal abscess
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o L scrotal abscess presenting to the ED with
worsening pain in the L scrotum. abscess was incised in the ED
and packed with gauze. He was admitted overnight for
observation and pain control.
Past Medical History:
1)Crohn's disease: diagnosed in 1990s, followed by Dr. ___
___, involving colon primarily, no bowel surgery, intolerant
of ___ and remicade, failed Humira
2)Hypertension
3)Hyperlipidemia
4)h/o DVT
5)Reactive arthritis
6)Sleep Apnea, improved w/wt loss
7)Obesity
8)Substance Abuse
9)Depression
10)Chronic Back Pain
11)Allergic rhinitis
12)s/p open cholecystectomy
___ abscess s/p surgical drainage and antibiotics
___ Crohn's disease with colon-splenic fistula. s/p Exploratory
laparotomy, total abdominal colectomy, and splenectomy on
___
Social History:
___
Family History:
Positive for colitis and diabetes. Negative for colon cancer.
Physical Exam:
NAD
abd soft, NT,ND
L scrotal incision packed, no erythema
left and right testicle palpated
Medications on Admission:
1. Duloxetine 60 mg PO DAILY
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Lisinopril 10 mg PO DAILY
4. Risperidone 1 mg PO HS
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
6. Cimzia *NF* (certolizumab pegol) 400 mg/2 mL (200 mg/mL x 2)
Subcutaneous q30day
next dose due on ___. Loperamide 2 mg PO TID:PRN loose stools
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
9. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*20 Capsule Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
take one hour prior to wound packing
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left scrotal abscess
Discharge Condition:
stable
Followup Instructions:
___
Radiology Report
INDICATION: Evaluate left scrotal abscess status post incision and drainage.
Evaluate for residual fluid collection.
COMPARISONS: Scrotal ultrasound ___. MRI of the pelvis ___.
TECHNIQUE: Grayscale and Doppler ultrasound images were obtained through the
scrotum.
FINDINGS: The right testicle measures 2.1 x 1.9 x 3.5 cm. The left testicle
measures 2.8 x 2.4 x 2.0 cm. The testicles are homogeneous without focal
testicular lesions. There are normal arterial and venous waveforms
bilaterally.
The bilateral epididymides are normal in size and vascularity. There are
small bilateral hydroceles. The hydrocele on the left has some internal
echoes, consistent with debris. A small calcification is noted along the wall
of the hydrocele in the left (image 39).
In the left inferior and lateral region of the scrotum, the patient is status
post an incision and drainage. Some packing material with a few punctate
echogenic foci representing air is visualized. There is no remaining fluid
collection.
IMPRESSION:
1. No residual abscess.
2. Normal testicles and epididymides.
3. Small bilateral hydroceles.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WOUND
Diagnosed with MALE GEN INFLAM DIS NEC, REGIONAL ENTERITIS NOS, HYPERTENSION NOS
temperature: 97.4
heartrate: 102.0
resprate: 16.0
o2sat: 96.0
sbp: 142.0
dbp: 70.0
level of pain: 5
level of acuity: 3.0 | Patient was admitted to the Urology service following I and D of
his L scrotal abscess in the ED. On HD2 the patient tolerated
the packing well and his pain was well-controlled. He was
discharged home with ___ for L scrotal wound packing and will
follow-up in clinic in 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
one day of headache and left facial weakness.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ right-handed woman with history
notable for lung adenocarcinoma s/p RULectomy (___) and
rectal carcinoid tumor presenting with one day of headache and
left facial weakness.
Ms. ___ reports gradual onset of a "pressure"-like right
temporal headache yesterday evening. The headache is
non-positional, without associated nausea, vomiting, or photo-
or
phonophobia. The headache briefly abated with NSAIDs overnight,
but resumed this morning, and continues to be bothersome today.
While Ms. ___ herself had not noted focal weakness, her
daughter reports noticing left facial weakness on seeing her
today in the ED, having previously seen her yesterday. Ms.
___
otherwise denies transient visual obscurations with her headache
or changes in position. She reports only infrequent, symmetric
"pressure" headaches in the past associated with stress or sleep
deprivation.
On review of systems, aside from the above, Ms. ___ denies
recent speech disturbance, vision change, diplopia, hearing
change, dysarthria, dysphagia, focal weakness, paresthesiae,
bowel or bladder incontinence, gait disturbance, fevers, chills,
unintended weight change, nausea, vomiting, cough, dyspnea,
chest
discomfort, abdominal pain, or changes in bowel or bladder
habits.
Past Medical History:
PMH/PSH:
Lung adenocarcinoma s/p RULectomy (___)
Rectal carcinoid tumor
Prior ectopic pregnancy
Lyomyoma s/p myomectomy
Tobacco use d/o (in remission)
Cholelithiasis s/p CCY
Social History:
___
Family History:
Other aunt breast cancer, grandfather prostate cancer. Negative
for neurological disorders or thrombotic complications.
Physical Exam:
PHYSICAL EXAMINATION on Admission.
Vitals: T: 98.4 HR: 77 BP: 153/90 RR: 16 SpO2: 97% RA
General: reclined in darkened room, holding right temple
HEENT: NCAT, neck supple, TTP over right temple
___: RRR
Pulmonary: No tachypnea or increased WOB
Abdomen: Soft, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Provides slightly
sparse history. Speech is fluent with intact comprehension and
naming of both high- and low-frequency objects. No apparent
hemineglect. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL (3 to 2 mm ___. VF full to number
counting. EOMI, no nystagmus. Decrease to LT and PP (reportedly
20% of right) along left V1-V3. L NLFF with largely symmetric
activation, no upper facial involvement. No asymmetry in
gustation. Hearing intact to conversation. Palate elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
- Motor: No pronator drift.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
- Reflexes: 1+ throughout.
- Sensory: Diminished to LT and PP along left arm and leg, again
reported at 20% of sensation on the right. Suggestion of
incomplete agraphesthesia on left. No extinction to DSS.
Pertinent Physical Exam at Discharge:
L sided neglect to sensation and vision, left sided weakness.
L facial weankess UMN pattern, Tongue midline.
Proprioception - Misses nose bilateral on Finger-Nose-Finger.
Apraxia on motor exam,
Pertinent Results:
___ 05:25AM BLOOD WBC-11.9* RBC-4.67 Hgb-13.4 Hct-41.5
MCV-89 MCH-28.7 MCHC-32.3 RDW-13.2 RDWSD-42.5 Plt ___
___ 05:15AM BLOOD ___ PTT-30.8 ___
___ 05:25AM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-142
K-4.1 Cl-104 HCO3-23 AnGap-15
___ 05:21PM BLOOD ALT-19 AST-16 CK(CPK)-238* AlkPhos-106*
TotBili-0.5
___ 05:25AM BLOOD Calcium-9.4 Phos-3.5 Mg-1.8
___ 05:30PM BLOOD %HbA1c-5.9 eAG-123
___ 05:15AM BLOOD Triglyc-102 HDL-56 CHOL/HD-2.8 LDLcalc-81
___ 05:21PM BLOOD TSH-0.54
___ 05:21PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Medications on Admission:
Reports taking none. The Preadmission Medication list is
accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
4.Outpatient Occupational Therapy
acute ischemic stroke
ongoing OT
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with headache, facial droop// eval for CVA
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Total DLP (Body) = 481 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is a confluent area of hypodensity in the right temporal lobe, insular
cortex, and parietal lobe suggesting a right MCA superior division infarct
that is likely acute. There is no hemorrhage or mass. Ventricles and sulci
are normal in configuration.
The visualized portion of the paranasal sinuses, mastoid air cells,and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is focal severe narrowing of the distal M1 segment, and the superior
division of M2 is not seen and is likely occluded (603:19). The inferior
division of the right M2 is narrowed proximally by the embolus but patent
distally. No aneurysm or other severe stenosis or occlusion is identified.
The dural venous sinuses are patent.
CTA NECK:
The carotidandvertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The lung apices demonstrate moderate emphysematous changes, and there is a
suture line at the right lung apex. The visualized portion of the thyroid
gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Right middle cerebral artery superior division infarction. No mass effect
or hemorrhage.
2. Severe narrowing at the distal right M1 segment, with no definite
visualization of the superior division of the right M2, suggesting occlusion.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: History: ___ with stroke seen on CT scan, further evaluate//
Stroke evaluation
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CTA head and neck dated ___ at ___
FINDINGS:
There is slow diffusion in the right middle cerebral artery territory
corresponding with T2 and FLAIR hyperintensity, consistent with subacute
infarction. No additional infarcts are seen. There is no hemorrhage or mass.
No abnormal postcontrast enhancement.
The paranasal sinuses are clear. The orbits are unremarkable.
IMPRESSION:
Subacute right MCA distribution infarct. No hemorrhage or mass effect.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with right MCA infarct. Evaluate for
progression of infarct/hemorrhagic transformation; please obtain at 8 AM.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.4 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: MR head dated ___.
CTA head neck dated ___.
FINDINGS:
Evolving large early subacute right MCA territory infarct is stable in extent
without evidence of hemorrhagic conversion. There is no sulcal effacement
without significant ventricular effacement. No shift of midline structures or
herniation. Basal cisterns are preserved.
No concerning osseous findings. A mucous retention cyst is again seen in the
right sphenoid sinus.
IMPRESSION:
Stable extent of the early subacute right MCA territory infarct, without
evidence of hemorrhagic conversion or significant mass effect.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with R MCA, started on Lovenox,// interval
changes? Hemorrhage?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT head dated ___. MR head dated ___. CTA head
neck dated ___.
FINDINGS:
Stable appearance of evolving right MCA territory infarct, without evidence of
hemorrhagic conversion. The degree of sulcal effacement is similar. There is
no midline shift. The basal cisterns are patent. There is no evidence of
infarction, hemorrhage, edema, or mass. The ventricles are normal in size and
configuration.
There is no evidence of fracture. A mucous retention cyst is again seen in
the right sphenoid sinus. The visualized portion of the remaining paranasal
sinuses, mastoid air cells, and middle ear cavitiesare essentially clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
Stable appearance of evolving right MCA territory infarct, without evidence of
hemorrhagic conversion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Facial droop, Headache
Diagnosed with Cerebral infarction, unspecified
temperature: 98.4
heartrate: 77.0
resprate: 16.0
o2sat: 97.0
sbp: 153.0
dbp: 90.0
level of pain: 8
level of acuity: 1.0 | ___ right-handed woman with history notable for lung
adenocarcinoma s/p RULectomy (___) and rectal carcinoid
tumor presenting with one day of headache and left facial
weakness, found to have R MCA infarct.
#Acute ischemic stroke
She came in with symptoms of left facial weakness and exam was
notable for left nasolabial fold flattening with largely
symmetric activation, left neglect to double stimulation of
sensory and vision. Imaging showed acute infarction in the right
MCA distribution involving the right temporal, frontal, and
parietal lobe with no evidence of hemorrhagic conversion.
Work-up included etiology of stroke workup including CTA and MRI
with and without contrast. Trans Thoracic Echocardiogram which
showed no structural cardiac source of embolism (e.g.patent
foramen vale/atrial septal defect, intracardiac thrombus, or
vegetation) seen. Telemetry showed no events. Risk factor
screening including lipid panel, LDL was 81; Diabetes screening,
HgbA1C 5.9, and TSH 0.54. Treatment moving forward will be
anticoagulation with Apixaban 5mg daily for prevention,
atorvastatin for hyperlipidemia and vascular stabilization and
prevention, and amlodipine for hypertension control and
prevention of another stroke. Exam remained stable on discharge.
She was evaluated by ___ who recommended outpatient OT. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Biaxin
Attending: ___.
Chief Complaint:
Abdominal Pain, Nausea, Vomitting
Major Surgical or Invasive Procedure:
___ Aspiration of a intra-abdominal fluid collection
History of Present Illness:
___ no significant PMH who p/w persistent recurrent diffuse
abdominal pain x4d with associated nausea and vomiting. She
initially presented to ___ (___) for abdominal pain
for 2 days, nausea, vomiting, and po intolerance. Workup there
included a CT which showed right RP perinephric collection
surrounding the renal pelvis (c/f urinoma vs hemorrhagic fluid).
Sigmoid colitis / fecal impaction was also seen. BI-P surgery
was consulted with recommendations to transfer for further
evaluation. Patient elected to leave AMA, however, as she felt
it was norovirus related. She was given cipro/flagyl but was no
able to take the antibiotics due to nausea and vomiting. She
also endorses chills although denies fevers. She has not had any
constipation or urinary symptoms. Her last BM was today and
reported to be normal. She denies any changes ___ medications or
taking any OTC medications, including specifically no NSAIDs or
aspirin. She has never had an EGD and had a colonoscopy years
ago that was reported to be unremarkable.
She returns to BI-P today (___) with persistent symptoms.
Repeat CT shows interval decrease of the perinephric collection.
However, a 4.5x2.5x1.5cm fluid collection posterior/medial to
the duodenum was seen. It was felt that the collection this
could potentially be had a repeat CT A/P revealing 4.5x2.5x1.5cm
fluid collection posterior to the duodenum: potentially
representing a diverticulum with leakage. sent here w/
cipro/flagyl after for further management. She was also given
protonix.
Past Medical History:
Past Medical History: None
Past Surgical History: Total hysterectomy and bladder suspension
(Transabdominal), ___ IHR (open)
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.2 77 165/77 16 96% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender to palpation ___ epigastrium and
to right of umbilicus, no rebound or guarding, normoactive bowel
sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1 81 122/75 18 96% RA
GEN: A&O, NAD
HEENT: EOMI, no scleral icterus, MMM
CV: RRR, no m/r/g
PULM: CTAB
ABD: Soft, NDNT, no rebound or guarding
EXT: WWP, no c/c/e
Pertinent Results:
ADMISSION LABS:
================
___ 09:40PM BLOOD WBC-8.4 RBC-4.36 Hgb-12.9 Hct-37.8 MCV-87
MCH-29.6 MCHC-34.1 RDW-13.4 RDWSD-42.7 Plt ___
___ 09:40PM BLOOD Neuts-77.0* Lymphs-13.1* Monos-9.0
Eos-0.2* Baso-0.2 Im ___ AbsNeut-6.48* AbsLymp-1.10*
AbsMono-0.76 AbsEos-0.02* AbsBaso-0.02
___ 09:40PM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-136
K-3.4 Cl-100 HCO3-19* AnGap-20
DISCHARGE LABS:
================
___ 05:45AM BLOOD WBC-4.3 RBC-3.51* Hgb-10.5* Hct-31.6*
MCV-90 MCH-29.9 MCHC-33.2 RDW-14.4 RDWSD-47.0* Plt ___
___ 05:45AM BLOOD Glucose-116* UreaN-5* Creat-0.7 Na-142
K-3.8 Cl-106 HCO3-25 AnGap-15
___ 05:45AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9
MICRO:
=======
___ 4:30 pm ABSCESS Source: Abdominal drain.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND ___ SHORT
CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final ___:
GRAM POSITIVE RODS. MODERATE GROWTH.
GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
IMAGING:
=========
___ Imaging UGI SGL CONTRAST W/ KUB
Findings as above with periduodenal puddling of contrast
possibly within a
duodenal diverticulum, less likely extravasated contrast.
Consider further evaluation of the right ureter with CT urogram.
___ Imaging CHEST (PORTABLE AP)
Enteric tube tip is coiled ___ the proximal stomach, tip is at
the gastric
cardia. Normal heart size, pulmonary vascularity. No edema, no
pneumothorax. Trace bilateral pleural effusions. Minimal
basilar atelectasis. Few mildly prominent loops of bowel ___ the
upper abdomen. Residual contrast ___ the urinary system.
___ Imaging MESENTERIC ARTERIOGRAM
1. Celiac, gastroduodenal and superior mesenteric arteriograms
demonstrating no evidence of active extravasation. Review of
the celiac and gastroduodenal arteriograms demonstrated
retrograde flow ___ the GDA which can be seen ___ celiac
stenosis.
Radiology Report
INDICATION: ___ year old woman with ?perforated duodenal diverticulum.
Abdominal pain, wbc 10.2 at OSH, n/v.// ?infected fluid collection r/t
perforated diverticulitis.
COMPARISON: CT from ___ and ___
PROCEDURE: CT-guided drainage of abdominal fluid collection.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr.
___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. Minimal fluid was aspirated from the
collection. A large hematoma was identified and a drain was not placed. 10
cc of Gel-Foam slurry was injected along the tract. The patient was
transferred to Interventional Radiology for angiographic procedure.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.4 s, 22.6 cm; CTDIvol = 5.7 mGy (Body) DLP = 121.4
mGy-cm.
2) Stationary Acquisition 14.1 s, 1.4 cm; CTDIvol = 146.8 mGy (Body) DLP =
211.3 mGy-cm.
3) Spiral Acquisition 12.0 s, 41.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 167.0
mGy-cm.
4) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
5) Stationary Acquisition 2.5 s, 1.0 cm; CTDIvol = 5.8 mGy (Body) DLP = 5.8
mGy-cm.
6) Spiral Acquisition 10.8 s, 41.5 cm; CTDIvol = 9.8 mGy (Body) DLP = 390.6
mGy-cm.
7) Spiral Acquisition 10.8 s, 41.5 cm; CTDIvol = 9.8 mGy (Body) DLP = 390.6
mGy-cm.
Total DLP (Body) = 1,298 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 58
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. On the pre biopsy scan, gas and fluid collection is noted in the duodenal
sweep. Fluid is also noted in the perinephric space.
2. CTA demonstrates a large periduodenal hematoma tracking inferiorly along
the right retroperitoneum into the pelvis. No contrast extravasation is
identified.
IMPRESSION:
Attempt to place a drain within the periduodenal fluid collection. However,
during the procedure, the patient developed a large hematoma. The patient was
sent to interventional radiology for angiographic procedure.
Radiology Report
INDICATION: ___ year old woman with hematoma formation during biopsy for
angiogram to evaluate for bleeding and possible embolization// Active
bleeding?
COMPARISON: CT abdomen ___
TECHNIQUE: OPERATORS: Dr. ___ performed the
procedure. Dr. ___ was available for the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service
time of 37 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 5 cc 1% buffered lidocaine subcutaneous injection at the access
site
CONTRAST: 52 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 9.1 min, 62 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Celiac arteriogram
3. Gastroduodenal arteriogram (AP and ___ 30 degree projection).
4. Superior mesenteric arteriogram (AP and ___ 30 degree projection).
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patients family. The
patient was then brought to the angiography suite and placed supine on the
exam table. A pre-procedure time-out was performed per ___ protocol. Both
groins were prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A Sos catheter was advanced over ___ wire into the aorta. The wire was
removed and the celiac artery was selectively cannulated and a small contrast
injection was made to confirm position. A celiac arteriogram was performed.
Next, a Renegade ___ pre-loaded with a 0.018 Fathom microwire was used to
engage the ostium of the gastroduodenal artery. Once positioning was
confirmed with a small contrast hand injection, a gastroduodenal arteriogram
was performed in both the AP and ___ 30 degree projections.
Next, the renegade ___ microcatheter was retracted back into the parent 5
___ catheter and subsequently removed. The Sos catheter was then
disengaged from the celiac ostium and retracted back into the aorta. At this
time the Sos catheter was then used to engage the ostium of the superior
mesenteric artery. After a small contrast hand injection was performed to
confirm positioning, a superior mesenteric arteriogram (AP and ___ 30 degree
projections) was performed.
The catheter was then removed over the wire. Finally, a right common femoral
arteriogram was performed via the side arm of the sheath. This demonstrated
sheath access at the level of the mid femoral head. Therefore, the sheath was
removed over wire and a 6 ___ Angio-Seal arteriotomy closure device was
deployed. An additional 5 minutes of manual pressure was held until
hemostasis was achieved. Sterile dressings were applied. +2 femoral pulse was
noted post closure.
The patient tolerated the procedure well without any immediate complications.
FINDINGS:
1. Celiac, gastroduodenal and superior mesenteric arteriograms demonstrating
no evidence of active extravasation. Review of the celiac and gastroduodenal
arteriograms demonstrated retrograde flow in the GDA which can be seen in
celiac stenosis.
IMPRESSION:
Successful diagnostic celiac, gastroduodenal and superior mesenteric
arteriograms demonstrating no evidence of active extravasation
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with possible perforated duo diverticulum, now
s/p NGT placement// Please assess NGT placement
TECHNIQUE: Chest single view
COMPARISON: None
FINDINGS:
Enteric tube tip is coiled in the proximal stomach, tip is at the gastric
cardia. Normal heart size, pulmonary vascularity. No edema, no pneumothorax.
Trace bilateral pleural effusions. Minimal basilar atelectasis. Few mildly
prominent loops of bowel in the upper abdomen. Residual contrast in the
urinary system.
IMPRESSION:
Enteric tube tip is in the proximal stomach.
Radiology Report
EXAMINATION: Assess duodenal perforation
INDICATION: ___ year old woman with abdominal pain CT c/f perforated duodenal
diverticulum s/p NGT, IV antibiotics, aspiration of fluid collection.//
?duodenal perforation ?leak. Please give contrast via NG tube and clamp for
study.
TECHNIQUE: Single contrast upper GI.
DOSE: Acc air kerma: 17 mGy; Accum DAP: 662.9 uGym2; Fluoro time: 00:41
COMPARISON: CT abdomen pelvis 23, ___.
FINDINGS:
Scout image demonstrate nasogastric tube coiled within the stomach. Contrast
is seen in the large bowel from prior studies, which slightly limits the
study. Multilevel degenerative changes of the lower lumbar spine and
bilateral hips are noted. No radiographic evidence of obstruction.
50 cc of Water-soluble contrast (Optiray) was hand injected via a pre-existing
nasogastric tube and fluoroscopic images were obtained in supine, oblique, and
lateral positions.
Contrast passed readily from the stomach into the proximal small bowel. There
is no evidence of obstruction. Projecting over the first portion of the
duodenum is a stellate collection of contrast which persists despite multiple
repositioning and difficult to differentiate between duodenal diverticulum
versus perforation.
IMPRESSION:
Findings as above with periduodenal puddling of contrast possibly within a
duodenal diverticulum, less likely extravasated contrast. Consider further
evaluation of the right ureter with CT urogram.
NOTIFICATION: The findings were initially discussed with ___, M.D.
by ___, M.D. on the telephone on ___ at 2:51 pm, 5 minutes after
discovery of the findings.
Further discussion between Dr. ___ and Dr. ___ telephone on
___ at 4: 30pm was done regarding CT for evaluation of ureters.
Radiology Report
EXAMINATION: CT with contrast.
INDICATION: ___ year old woman with perforated duo diverticulum s/p bowel rest
now no leak on UGI SGL// enhancing perinephric fluid collection on initial CT
scan and on repeat UGI SGL. Further evaluation of the ureters with delay
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.3 s, 51.7 cm; CTDIvol = 2.6 mGy (Body) DLP = 132.1
mGy-cm.
2) Spiral Acquisition 3.3 s, 51.7 cm; CTDIvol = 10.9 mGy (Body) DLP = 562.9
mGy-cm.
3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 19.5 mGy (Body) DLP =
9.8 mGy-cm.
Total DLP (Body) = 705 mGy-cm.
COMPARISON: CT abdomen from outside hospital dated ___ and ___. Mesenteric angiogram dated ___.
FINDINGS:
LOWER CHEST: Small bilateral pleural effusions, left greater than right with
minimal atelectasis, new since prior
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. 4 mm
hypodensity within hepatic segment 6, too small to accurately characterize,
stable. Distended IVC, hepatic veins, consistent cardiac dysfunction. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. Suggestion
of cholelithiasis or sludge. Mild gallbladder wall thickening, similar to
prior, no pericholecystic inflammatory changes..
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: 0.8 cm left adrenal nodule, stable since prior. Normal right
adrenal gland.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
GASTROINTESTINAL:
There is heterogeneous collection in the right upper quadrant adjacent to the
second portion of the duodenum measuring 6.9 x 4 x 6.6 cm in maximal
___ surrounding second, third portion of duodenum, pancreatic head and
uncinate process, abutting medial margin of the hepatic flexure of the colon..
This contains small focus of air. Internal contents are mildly hyperdense,
which may be from extravasated previously demonstrated contrast or blood
products. Areas of linear, non contiguous peripheral enhancement surrounding
fluid collection are concerning for developing phlegmon/abscess. Local mass
effect from the collection severely compresses SMV, just below confluence,
vessel remains patent. Patent splenic, portal veins, SMA. Moderate
flattening of the IVC secondary to adjacent mass effect. Again seen is
diverticulum arising from proximal duodenum.
There has been progressive worsening and increasing organization of the fluid
collection since ___. The
The stomach is unremarkable. Small bowel loops demonstrate normal caliber,
wall thickness, and enhancement throughout. There is moderate wall thickening
of segment of sigmoid colon, with tethering and serosal surface tracks,
consistent with subacute diverticulitis and intramural abscesses or interloop
fistulas. Few mildly enlarged lymph nodes, largest measures 0.8 cm, may be
reactive, remain indeterminate. Barium enema recommended to define anatomy
better.. 1 segment of the sigmoid colon is fairly dilated, there is no
proximal dilatation. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. Small amount
of free fluid in the lower pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Moderate multilevel degenerative changes of the visualized spine. Mild
scoliotic curvature of the thoracolumbar spine, convex to the right.
Degenerative changes hips. Demineralization.
SOFT TISSUES: There is persistent fluid-filled right inguinal hernia unchanged
since ___.
IMPRESSION:
1. Interval increase in size of fluid collection adjacent to duodenum
measuring up to 6.9 cm, with areas of discontinuous, linear peripheral
enhancement, worrisome for developing phlegmon/abscess. Small areas of
increased attenuation within the collection may be blood products or residual
contrast.
2. Fluid collection moderately narrows SMV, which is patent.
3. Moderate wall thickening of segment of sigmoid colon, with tethering and
serosal surface tracks, consistent with subacute diverticulitis and intramural
abscesses or interloop fistulas. Few mildly enlarged lymph nodes, largest
measures 0.8 cm, may be reactive, remain indeterminate. Barium enema
recommended to define anatomy better, and exclude mass.
4. Persistent right fluid filled inguinal hernia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Abnormal CT
Diagnosed with Unspecified abdominal pain
temperature: 98.2
heartrate: 77.0
resprate: 16.0
o2sat: 96.0
sbp: 165.0
dbp: 77.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is an ___ yo F with no significant PMH who presented
to ___ x2 for persistent recurrent diffuse abdominal
pain with associated nausea and vomiting. On initial workup, she
was found to have an RP perinephric fluid collection. On
representation, she was found to have interval decrease ___
perinephric fluids with new periduodenal fluid collection
concerning for duodenal perforation. She was transferred to
___ on cipro/flagyl for further management. An NGT was placed,
abx were continued and ___ was consulted for drainage of
periduodenal fluid collection. During the drainage, there was
concern for bleed and patient was given 1u pRBC. She then
underwent celiac and SMA arteriogram, which did not show active
extrav. Patient then underwent upper GI study, which showed no
evidence of duodenal leak but concern for ureteral injury. She
underwent CT urogram which showed intact ureters and interval
improvement ___ ___ collection. Given no evidence of
duodenal leak, NGT was removed and patient was started on clears
and diet was advanced as tolerated. She was passing gas and
having regular bowel movements. She was discharged home with
bowel regimen and antibiotics to complete a 14 day course.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with IV Tylenol. Patient's
pain had resolved by the time she was tolerating PO.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: See above. Patient's intake and output were closely
monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding. She was noted to have a drop ___ her counts after
the CT-guided fluid drainage. She received 1u pRBC transfusion
and underwent angiogram that did not show any signs of active
bleeding. Her blood counts remained stable for the rest of the
hospitalization.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain had resolved.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
TRANSITIONAL ISSUES:
=====================
- H. pylori serum antibody pending at time of discharge
- To complete 14 day course of cipro/flagyl ___
- Will need an EGD ___ 6 weeks |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
dilation and curettage
History of Present Illness:
Ms. ___ is a lovely ___ s/p D&C for 9wk MAB.
The procedure was done on ___, with EBL 200cc and no documented
complications. She initially felt well after the procedure but
then ___ developed a fever at home to 101.3 and developed
abdominal pain, not improving with Tylenol and motrin at home.
She denies urinary symptoms or issues with BMs. Bleeding has
been
equal to/less than a period. She has not passed clots or tissue.
Has not felt light-headed or dizzy. Reports pain is through her
abdomen, a little worse in left lower abdomen.
She initially presented to ___ where she was noted to have
Tm of 101.8 and pulse 122. She was noted to have some uterine
tenderness but no CMT. No abnormal discharge in vaginal vault,
no
heavy bleeding.
I spoke with ED doctor at ___, and given suspicion for
post-procedural endometritis and inability to admit patient
there, patient was transferred to ___ ED. She was started on
IV
gentamicin (300mg) and clindamycin (900mg) before transfer.
Here, patient states she feels better with improved pain.
Continues to have bleeding less than a period. No other new
symptoms.
Past Medical History:
PMH: denies
PSH: D&C x2
OBHx:
- SVD term
- TAB
- SAB as above
GYNHx:
- h/o STIs? denies
- h/o fibroids, ovarian cysts, gyn surgeries? D&C x2
- sexually active? with husband
Social History:
denies T/D/E
Physical Exam:
Physical Exam on Initial Presentation:
T 99.3 HR 95 102/67 RR 18 99%RA
Gen: A&O, NAD
CV: RRR
Resp: nl respiratory effort
Abd: soft, mild TTP in LLQ, no rebound or guarding,
non-distended
Ext: calves nontender bilaterally
Pelvic: deferred as done at ___, patient requests
deferring
Physical Exam on Day of Discharge:
Pertinent Results:
___ 06:08AM WBC-7.9 RBC-3.49* HGB-10.1* HCT-30.5* MCV-87
MCH-28.9 MCHC-33.1 RDW-14.4 RDWSD-45.9
___ 06:08AM NEUTS-76.0* LYMPHS-14.1* MONOS-8.3 EOS-0.9*
BASOS-0.1 IM ___ AbsNeut-5.98 AbsLymp-1.11* AbsMono-0.65
AbsEos-0.07 AbsBaso-0.01
___ 06:08AM PLT COUNT-165
___ 02:10AM LACTATE-1.0
___ 01:57AM GLUCOSE-102* UREA N-13 CREAT-0.6 SODIUM-140
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
___ 01:57AM estGFR-Using this
___ 01:57AM WBC-8.9 RBC-3.70* HGB-10.7* HCT-32.1* MCV-87
MCH-28.9 MCHC-33.3 RDW-14.3 RDWSD-45.5
___ 01:57AM NEUTS-73.9* LYMPHS-15.8* MONOS-8.6 EOS-1.1
BASOS-0.2 IM ___ AbsNeut-6.60* AbsLymp-1.41 AbsMono-0.77
AbsEos-0.10 AbsBaso-0.02
___ 01:57AM PLT COUNT-197
___ 01:57AM ___ PTT-27.2 ___
___ 12:52AM URINE HOURS-RANDOM
___ 12:52AM URINE UHOLD-HOLD
___ 12:52AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:52AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM*
___ 12:52AM URINE RBC-19* WBC-13* BACTERIA-FEW* YEAST-NONE
EPI-2
___ 12:52AM URINE MUCOUS-RARE*
Medications on Admission:
PNV, ibuprofen, acetaminophen
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
do not exceed 4000mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as
needed Disp #*50 Tablet Refills:*1
2. Doxycycline Hyclate 100 mg PO Q12H
please complete full course
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every 12
hours Disp #*24 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
take with food to prevent upset stomach
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*50 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
retained products of conception and post-procedural endometritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: History: ___ with abdominal pain, fever after D C// Retained
Products of Conception
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: None
FINDINGS:
The uterus is anteverted and measures 7.1 x 4.4 x 9.9 cm. There is
heterogeneous predominately hyperechoic avascular material in the endometrium
that measures approximately 5.7 x 1.8 x 5.3 cm.
The ovaries are normal. There is trace free fluid.
IMPRESSION:
Heterogeneous avascular material in the endometrial canal consistent with
avascular retained products of conception.
Radiology Report
EXAMINATION: US INTRA-OP ___ MINS
INDICATION: ___ year old woman with retained products after D C and
endometritis// ultrasound guidance during D C
TECHNIQUE: Transabdominal pelvic intraoperative ultrasound guidance
COMPARISON: Ultrasound ___
FINDINGS:
Transabdominal pelvic intraoperative ultrasound guidance was provided to Dr.
___ the performance of cervical dilatation and D&C for retained
products of conception. A total of 16 images were obtained.
IMPRESSION:
Transabdominal pelvic intraoperative ultrasound guidance was provided.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Fever, Transfer
Diagnosed with Acute kidney failure, unspecified
temperature: 99.1
heartrate: 110.0
resprate: 18.0
o2sat: 97.0
sbp: 142.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | Patient was admitted to the gynecology service on ___ with
post-procedural endometritis and 5.7cm of retained products of
conception after a 9 week D&C for a missed abortion on ___.
She was febrile to T101.8 in the ED and was started on IV
gentamicin/clindamycin, which was continued until ___ hours
afebrile.
She was kept NPO with IVF overnight. On ___, patient underwent
an uncomplicated an uncomplicated dilation and curretage under
ultrasound guidance. Please see the operative note for full
details. She had an uncomplicated post-operative course. Her
diet was advanced without difficulty, pain controlled on oral
ibuprofen and Tylenol, she was voiding spontaneously, and
ambulating without dizziness. She was discharged home after more
than 24 hours afebrile on a 2 week course of doxycycline and
with close outpatient follow-up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / bumetanide
Attending: ___.
Chief Complaint:
Hypotension, active bleeding
Major Surgical or Invasive Procedure:
___ Left lower extremity debridement
History of Present Illness:
___ year old female with history of PE on Coumadin, pulmonary
hypertension, and cor pulmonale who presented to another
hospital with bleeding from a leg wound, now transferred to
___ for further mgmt.
She initially presented to ___ after hitting her leg against a
dresser causing a large skin tear with profuse bleeding. Per
EMS, estimated blood loss of 2L. Upon presentation to OSH, blood
pressure was 63/38 (baseline SBP 80-90s). Labs were notable for
H/H 5.1/___.4 and INR 3.2. Foam gel was placed over the skin tear
with compression. The patient was given 2 units RBC, 2.5L IVF,
and fentanyl x 2 prior to transfer.
Upon arrival to the ED, initial vitals were: 97.2 ___ 20
97% RA. Exam was notable for 8cm skin tear to left shin with
oozing, but no evidence of arterial bleed. Pulses were intact.
Labs were notable for WBC 7.9, H/H 6.0/19.6, plt 59, INR 2.4, Na
125, HCO3 19, Cr 1.2.
On arrival to the MICU, patient was only complaining of lower
left leg pain. Denies any lightheadedness, dizziness or
headache.
Prior Pertinent History:
She has had several admissions (5 since ___ recently
with refractory peripheral edema. She has also had worsening
renal function on the most recent two admissions, with a cr up
to 2.7 which improved with dopamine.
Most recent right heart catheterization was on ___: RA 17
mmHg, PA ___ (27) mmHg, PAWP 19 mmHg, CO 5.3 L/min, CI 2.9
L/min/m2, PVR 121 dsc (1.5 ___. Aortic pressure 81/50. Mild LV
systolic dysfunction (EF 40-45% on transthoracic echocardiogram,
but given septal wall motion abnormality related to RV
pressure/volume overload, the EF is difficult to estimate), she
underwent a coronary angiogram at that time which was completely
normal. Most recent echocardiogram from ___ now reveals an
EF of ___ (on direct comparison, slightly reduced from prior
in ___, RV is severely dilated and there is severe RV
dysfunction, flattened septum throughout the cardic cycle,
severe TR and marked RA dilation.
She has had significant diuretic resistance and hyponatremia.
Prior admissions has required high doses of loop diuretics of
Lasix ___ in addition to metolazone (baseline sodium
123-125) which would worsen hyponatremia (to around 118) and she
has required tolvaptan 30mg po bid in addition (has not had any
neurologic compromise with hyponatremia). Her outpatient
diuretic regimen is torsemide 150mg po bid, spironolactone 50mg
daily, metolazone prn, and tolvaptan 30mg po bid.
Most recent admission is ___ for weight gain and increase
in lower extremity edema, poor appetite. Cr was 2.0. She
underwent ultrafiltration and was started on dopamine at 2mcg
and renal function has improved to 1.1 and she has diuresed 10 L
LOS and has had a 20 lb weight loss (171 lbs on ___ to 151
lbs on ___. Now off of dopamine as of ___ a.m.
On a prior admission with renal dysfunction (cr 2.7) and edema
we placed a PA line and attempted dobutamine which did not
increase her cardiac output, reduce filling pressures, or allow
for improvement in renal function or augmentation of diuresis.
Low dose dopamine at 2mcg had then been attempted and led to a
normalization of renal function.
Past Medical History:
- History of PE on warfarin
- RV failure, evaluated at ___ for heart-lung transplant but
deemed not eligible.
- Pulmonary hypertension, CTPH
Social History:
___
Family History:
non-contributory
Physical Exam:
***ADMISSION PHYSICAL EXAM***
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally
CV: Regular rate and rhythm, loud S1, no murmurs
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, pulsatile
liver. Port in place at left chest all.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 3+
bilateral edema to the knee.
SKIN: LLE dressing in place. DP and ___ pulses intact
bilaterally, strength intact bilaterally, sensation intact
bilaterally
Neurologic: A&Ox3
***DISCHARGE PHYSICAL EXAM***
VS: Tc 98 Tm 98.8 BP 82-101/51-60 HR 100-112 RR 16 93%/1L
I/O: ___
LOS:
from ___: +12,442 -11,730 (net +712 ml_
from ___: 3622/4550 (net out 928 ml since admission)
Dry Weight: 155-160 lbs, Current wt 162 lbs
(bed scale) 72.1 kg <-71.6 kg<-70 kg<-75.1 kg
Standing weight ___: 76.6 kg (168 lbs)->73.7 kg
Tele: HR up to 135, accelerated junctional rhythm, sinus tachy
with ___ AVB/Wenkebach
General: NAD, comfortable lying down
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear
Neck: Supple, no LAD. JVP elevated >10cm, unchanged exam, with
prominent venous pulsations over neck
CV: tachycardic, irregular rhythm, normal S1+S2. ___ systolic
murmur over LUSB and apex, Palpable PMI over RLSB.
Lungs: CTAB No wheezes, rales, or rhonchi.
Abdomen: Softer abdomen, minimally tender today. +BS.
GU: Foley in place
Ext: 2+ pitting edema over bilateral legs and dorsum of feet.
Left lower calf covered with ACE bandage over post-surgical
dressing,
Skin: Hyperpigmentation and multiple bruises over all 4
extremities
Pertinent Results:
ADMISSION LABS:
___ 06:00AM BLOOD WBC-7.9 RBC-2.22* Hgb-6.0* Hct-19.6*
MCV-88 MCH-27.0 MCHC-30.6* RDW-18.4* RDWSD-59.1* Plt Ct-59*
___ 06:00AM BLOOD ___ PTT-38.0* ___
___ 06:00AM BLOOD Glucose-127* UreaN-44* Creat-1.2* Na-125*
K-3.6 Cl-90* HCO3-19* AnGap-20
___ 11:49PM BLOOD Calcium-7.9* Phos-4.8* Mg-1.7
___ 11:49PM BLOOD Hapto-85
___ 07:10AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
DISCHARGE LABS:
___ 04:40AM BLOOD WBC-5.9 RBC-3.15* Hgb-9.0* Hct-27.9*
MCV-89 MCH-28.6 MCHC-32.3 RDW-17.6* RDWSD-55.5* Plt Ct-72*
___ 04:40AM BLOOD Glucose-64* UreaN-31* Creat-0.9 Na-126*
K-3.8 Cl-88* HCO3-24 AnGap-18
___ 04:40AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.1
MICRO:
- C Diff assay ___: pending
- MRSA SCREEN (Final ___: No MRSA isolated
IMAGING and OTHER STUDIES:
___ TTE: The left atrium is elongated. The right atrium is
markedly dilated. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. LV systolic function
appears depressed (LVEF = 30%) secondary to ventricular
interaction with marked septal flattening and paradoxical septal
excursion/displacement. The right ventricular free wall is
hypertrophied. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. Mild to moderate (___) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is partial flail of a tricuspid valve leaflet.
Severe [4+] tricuspid regurgitation is seen. There is severe
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.] The pulmonic valve leaflets
are thickened
___ CXR: No relevant change as compared to ___, 05:31. Massive cardiomegaly. No pulmonary edema. No
larger pleural effusions. Mild atelectasis in the retrocardiac
lung regions. The central venous access line is in unchanged
position.
___ ECG: Baseline artifact makes interpretation difficult.
Possible sinus tachycardia with premature atrial contractions
versus atrial fibrillation. Right bundle-branch block.
Non-specific ST-T wave abnormalities. Compared to the previous
tracing earlier the same day no significant change.
___ Abdominal Ultrasound: Mild splenomegaly. 1.4 splenule
incidentally noted. Trace ascites in the left upper quadrant.
___ EKG: The underlying rhythm is likely atrial fibrillation
with right bundle-branch block and moderately controlled
ventricular response. Compared to the previous tracing of
___ there is no diagnostic interim change
___ CXR: Cardiomegaly is severe, unchanged. Central venous
line tip terminates in the right atrium. Right pleural effusion
is in part loculated. Right basal opacity might represent a
combination of pleural effusion and consolidation, more
conspicuous than on the prior radiograph. There is no
pneumothorax
OLDER RECORDS for reference:
___ Right heart cath: RA 17, PA ___ (27), PAWP 19, CP 5.3
L/min, PVR 121 dxc, mild LV dysfunction (EF 40-45% on TTE)
Normal angiogram at this time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. bosentan 125 mg oral BID
2. Cetirizine 5 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Digoxin 0.125 mg PO EVERY OTHER DAY
5. Vitamin D ___ UNIT PO 1X/WEEK (TH)
6. Escitalopram Oxalate 10 mg PO DAILY
7. Ferrous Sulfate 325 mg PO TID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. melatonin 3 mg oral QHS
10. Metolazone 5 mg PO DAILY
11. mometasone 50 mcg inhalation DAILY
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Potassium Chloride 20 mEq PO BID
15. Spironolactone 25 mg PO DAILY
16. Tolvaptan 60 mg PO DAILY
17. Torsemide 200 mg PO BID
18. Warfarin 7.5 mg PO DAILY16
19. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
20. LOPERamide 2 mg PO QID:PRN diarrhea
21. Treprostinil Sodium 5120.5 nanograms/kg/minute IV DRIP
INFUSION
Discharge Medications:
1. Treprostinil Sodium 49 nanograms/kg/minute IV DRIP INFUSION
RX *treprostinil sodium [Remodulin] 1 mg/mL 49 nanograms/kg/min
Infusion continuous Disp #*30 Vial Refills:*3
2. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours
Disp #*60 Syringe Refills:*3
3. Rolling Walker
Dx: Right Heart Failure ICD 10 I50.9
Px: Good
length:13 months
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
5. bosentan 125 mg oral BID
6. Cetirizine 5 mg PO DAILY
7. Digoxin 0.125 mg PO EVERY OTHER DAY
8. Ferrous Sulfate 325 mg PO TID
9. Escitalopram Oxalate 10 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. Metolazone 5 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. Potassium Chloride (Powder) 20 mEq PO BID
16. Spironolactone 25 mg PO DAILY
17. Tolvaptan 60 mg PO DAILY
18. Torsemide 200 mg PO BID
19. melatonin 3 mg oral QHS
20. mometasone 50 mcg inhalation DAILY
21. Vitamin D 1000 UNIT PO DAILY
22. Warfarin 7.5 mg PO DAILY16
23. Vitamin D ___ UNIT PO 1X/WEEK (TH)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Decompensated Right Sided Congestive Heart Failure
- Chronic Thromboembolic Pulmonary Hypertension (CTEPH)
- Atrial Fibrillation/Second Degree AV Block with Junctional
Escape
-Left Lower extremity bleeding s/p debridement
Secondary Diagnosis:
-Thrombocytopenia of unclear etiology
-Anemia of Chronic disease
-Asthma
-Insomnia
-Chronic Sinusitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with Pulm HTN, s/p 2.5L and 1U PRBC // Eval for Pulm Edema
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
There is moderate to severe enlargement of the cardiac silhouette. There is
prominence of the interstitial markings without large effusion or confluent
consolidation. Median sternotomy wires are intact. There is a left-sided
venous catheter identified extending to the midline but the tip is not clearly
delineated. No acute osseous abnormalities.
IMPRESSION:
Moderate to severe enlargement of the cardiac silhouette, potentially due to
cardiomegaly although pericardial effusion would be possible. Vascular
congestion without evidence of overt pulmonary edema.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN PORT
INDICATION: ___ from AHJ, PMH of PE on Coumadin, Rt sided CHF with pHTN,
evaluated at BWH for heart/lung transplant with thrombocytopenia. // Please
eval spleen.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the left upper
quadrant were obtained.
COMPARISON: None.
FINDINGS:
Targeted sagittal and transverse images of the left upper quadrant were
obtained for evaluation of the spleen. The spleen appears normal in
echogenicity with no focal lesions identified. There is mild splenomegaly
measuring up to 13.0 cm. A 1.4 cm splenule is incidentally noted. Trace
ascites is identified in the left upper quadrant adjacent to the spleen.
IMPRESSION:
1. Mild splenomegaly.
2. 1.4 splenule incidentally noted.
3. Trace ascites in the left upper quadrant.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF, PHT presents with LLL bleed //
please assess for interval change please assess for interval change
COMPARISON: Chest radiograph ___.
IMPRESSION:
Mild to moderate pulmonary edema, more pronounced in the right lung, has
worsened slightly since ___. Severe cardiomegaly and mediastinal
venous engorgement are also slightly worse. Pleural effusion is presumed but
not substantial. There is no pneumothorax. Left jugular line ends in the
right atrium. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with PHT, CHF, with bleeding // please assess
for interval change with diuresis please assess for interval change with
diuresis
IMPRESSION:
No relevant change as compared to ___, 05:31. Massive
cardiomegaly. No pulmonary edema. No larger pleural effusions. Mild
atelectasis in the retrocardiac lung regions. The central venous access line
is in unchanged position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dCHF, with new RLL crackles on exam. No
clinical signs of infection // Any acute intrapulmonary process or evidence
of increased pulmonary edema? Any acute intrapulmonary process or evidence
of increased pulmonary edema?
COMPARISON: ___
IMPRESSION:
Cardiomegaly is severe, unchanged. Central venous line tip terminates in the
right atrium. Right pleural effusion is in part loculated. Right basal
opacity might represent a combination of pleural effusion and consolidation,
more conspicuous than on the prior radiograph. There is no pneumothorax.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: L Leg pain, Hypotension
Diagnosed with Iron deficiency anemia secondary to blood loss (chronic), Long term (current) use of anticoagulants, Personal history of pulmonary embolism
temperature: 97.2
heartrate: 110.0
resprate: 20.0
o2sat: 97.0
sbp: 81.0
dbp: 43.0
level of pain: 4
level of acuity: 1.0 | Ms. ___ is a ___ year old woman with a history of PE on
warfarin, pulmonary hypertension, and cor pulmonale, with
overall advanced heart and pulmonary failure, HFrEF (Ef 40%)
with severe diuretic resistance, who presents with hypotension
secondary to bleeding from LLE wound now s/p debridement,
managed also for volume overload and right sided heart failure.
She initially presented to ___ after hitting her leg against a
dresser causing a large skin tear with profuse bleeding. Per
EMS, estimated blood loss of 2L. Upon presentation to OSH, blood
pressure was 63/38 (baseline SBP 80-90s). Labs were notable for
H/H 5.1/17.4 and INR 3.2. Foam gel was placed over the skin tear
with compression. The patient was given 2 units RBC, 2.5L IVF,
and fentanyl x 2 prior to transfer.
Upon arrival to the ED, initial vitals were: 97.2 ___ 20
97% RA. Exam was notable for 8cm skin tear to left shin with
oozing, but no evidence of arterial bleed. Pulses were intact.
Labs were notable for WBC 7.9, H/H 6.0/19.6, plt 59, INR 2.9, Na
125, HCO3 19, Cr 1.2. CXR with moderate to severe cardiomegaly
potentially due to cardiomegaly itself although potentially also
due to pericardial effusion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___ edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a PMH of HIV (VL undetectable, CD4 422), KS, HIV
encephalopathy, seizure disorder, osteoporosis w/ right femur
fracture ___, chronic rhinitis, tobacco use, and intermittent
alcohol abuse p/w ___ edema. He was recently on vacation in
___ in late ___ when he developed bilateral ___
edema. He denies ever having ___ edema in the past. His edema has
been stable since with only minimal improvement after leg
elevation. His new medications include Keppra and his ARV
regimen was changed to Dolutegravir/Truvada from Atripla ___
after he was found to have a detectable CSF HIV viral load.
In the ED, initial vitals were: 98.2 84 104/64 18 98% RA
- Labs were significant for normal CBC except for stable anemia,
normal chem7, LFTs with mildly elevated AST, BNP of 169,
- CXR and LENIS revealed no acute findings
The patient was admitted for further workup.
Past Medical History:
HIV INFECTION
KAPOSI'S SARCOMA
MYCOBACTERIUM AVIUM INTRACELLULAR
SEASONAL ALLERGIES
RHINITIS
R FEMUR FX
Social History:
___
Family History:
Mother - ca (NOS)
stroke in both GM. no history of seizure
Physical Exam:
>> Admission Physical Exam:
98.2 84 104/64 18 98% RA
Gen: Comfortable, conversational, sitting in bed
HEENT: MMM, PEERL, no scleral ictereus
CV: RRR, S1,S2, no m/r/g
Lungs: CTAB
Abd: Soft, nontender, nondistended, no fluid wave or shifting
dullness
Ext: 2+ pitting edema to the knee bilaterally without overlying
warmth or erythema. Multiple hyperpigmented macules and patches
on each leg which the patient states are resolving KS lesions.
No inguinal lymphadenopathy.
GU: No scrotal edema. No foley
.
>> Discharge Physical Exam:
Vitals: T98.5 148/77 18 65 98 RA
General: Comfortable, conversational, sitting in bed.
HEENT: MMM. PERRL. No scleral icterus.
CV: RRR soft, S1, S2. No extra sounds.
Lungs: CTAB/L. No adventitial sounds heard. Mild expiratory
wheezing
Abdomen: Soft, NT/ND. +BS.
Extremities: ___ ___ pitting edema to the knee bilaterally.
Multiple hyperpigmented macules and patches c/f KS Lesions.
Femoral pulses 2+.
Pertinent Results:
>> Labs:
___ 11:13PM BLOOD WBC-4.9 RBC-3.88* Hgb-11.9* Hct-32.5*
MCV-84 MCH-30.7 MCHC-36.6* RDW-13.8 Plt ___
___ 05:44AM BLOOD WBC-4.0 RBC-3.95* Hgb-11.8* Hct-33.2*
MCV-84 MCH-29.9 MCHC-35.6* RDW-13.7 Plt ___
___ 11:13PM BLOOD Glucose-94 UreaN-7 Creat-0.9 Na-139 K-3.8
Cl-105 HCO3-25 AnGap-13
___ 05:44AM BLOOD Glucose-74 UreaN-6 Creat-0.8 Na-139 K-3.7
Cl-104 HCO3-26 AnGap-13
___ 11:13PM BLOOD ALT-26 AST-50* AlkPhos-76 TotBili-0.4
___ 05:44AM BLOOD ALT-28 AST-50* AlkPhos-71 TotBili-0.5
___ 05:44AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
___ 11:13PM BLOOD cTropnT-<0.01 proBNP-169
.
>> Pertinent Reports:
___ OR GALLBLADDER US: LIVER: The hepatic
parenchyma appears mildly coarsened. The contour of the liver is
smooth. A 7 x 6 mm hypoechoic focus in the left lobe of the
liver may be a small hemangioma. In the right lobe of the
liver, there is an approximately 1.5 cm isoechoic area of
heterogeneity without discrete margins that could be a subtle
lesion. The main portal vein is patent with hepatopetal flow.
There is no ascites. BILE DUCTS: There is no intrahepatic
biliary dilation. The CBD measures 3 mm. GALLBLADDER: The
gallbladder is normal without stones or wall thickening.
PANCREAS: The pancreatic tail is mostly obscured by overlying
bowel gas. Remainder of the pancreas appears within normal
limits without pancreatic duct dilatation. SPLEEN: Normal in
size and echogenicity, measuring 9.4 cm. KIDNEYS: The right
kidney measures 9.3 cm. The left kidney measures 8.3 cm. No mass
or stone is seen in either kidney. There is no hydronephrosis.
Renal cortical echogenicity and corticomedullary differentiation
are normal bilaterally. RETROPERITONEUM: Visualized portions of
aorta and IVC are within normal limits.
IMPRESSION:
1. Coarsened hepatic echotexture with no portal vein thrombosis
or ascites. 2. 7 mm hyperechoic lesion in the left lobe of the
liver could be a small hemangioma. Further characterization
with MRI is suggested in the setting of possible liver disease,
however. A possible 1.5 cm isoechoic lesion in the right
hepatic lobe versus focal heterogeneity in the liver parenchyma
can also be further evaluated by MRI.
___ (PA & LAT): Cardiomediastinal
silhouette is normal. Blunting of the left costophrenic angle,
unchanged from ___ is due to pleural parenchymal scarring.
There is no focal consolidation or overt pulmonary edema, but
there is an increase in
peribronchovascular opacification in the lung bases, perhaps
atelectasis,
recent aspiration, or the earliest manifestation of cardiac
decompensation. IMPRESSION: No lobar collapse or pleural
effusion. Nonspecific bibasilar lung abnormality. See
discussion above.
.
___ BILAT LOWER EXT V:
There is normal compressibility, flow and augmentation of the
bilateral common femoral, superficial femoral, and popliteal
veins. Normal color flow andcompressibility 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
bilateral lower extremity veins
___: Sinus rhythm. Non-specific ST-T
wave changes, may be a normal variant. Compared to the previous
tracing of ___ the rate has increased.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dolutegravir 50 mg PO DAILY
2. LeVETiracetam 750 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Dolutegravir 50 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. LeVETiracetam 750 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Pitting Edema
HIV
SECONDARY:
HIV encephalopathy,
seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION:
___ with new onset lower extremity edema; diminished breath sounds on lung
exam, evaluate for pulmonary edema..
COMPARISON: Comparison is made to chest radiograph from ___ and ___.
TECHNIQUE
Frontal and lateral view of the chest.
FINDINGS:
Cardiomediastinal silhouette is normal. Blunting of the left costophrenic
angle, unchanged from ___ is due to pleural parenchymal scarring. There is
no focal consolidation or overt pulmonary edema, but there is an increase in
peribronchovascular opacification in the lung bases, perhaps atelectasis,
recent aspiration, or the earliest manifestation of cardiac decompensation. .
IMPRESSION:
No lobar collapse or pleural effusion. Nonspecific bibasilar lung
abnormality. See discussion above.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with recent travel history and new acute onset
lower extremity edema
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, superficial 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 bilateral lower extremity veins.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with lower extremity edema, abnormal LFTs //
eval for signs of liver disease, cirrhosis, patent hepatic vasculature
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: No direct comparisons.
FINDINGS:
LIVER: The hepatic parenchyma appears mildly coarsened. The contour of the
liver is smooth. A 7 x 6 mm hypoechoic focus in the left lobe of the liver
may be a small hemangioma. In the right lobe of the liver, there is an
approximately 1.5 cm isoechoic area of heterogeneity without discrete margins
that could be a subtle lesion. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: The gallbladder is normal without stones or wall thickening.
PANCREAS: The pancreatic tail is mostly obscured by overlying bowel gas.
Remainder of the pancreas appears within normal limits without pancreatic duct
dilatation.
SPLEEN: Normal in size and echogenicity, measuring 9.4 cm.
KIDNEYS: The right kidney measures 9.3 cm. The left kidney measures 8.3 cm.
No mass or stone is seen in either kidney. There is no hydronephrosis. Renal
cortical echogenicity and corticomedullary differentiation are normal
bilaterally.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Coarsened hepatic echotexture with no portal vein thrombosis or ascites.
2. 7 mm hyperechoic lesion in the left lobe of the liver could be a small
hemangioma. Further characterization with MRI is suggested in the setting of
possible liver disease, however. A possible 1.5 cm isoechoic lesion in the
right hepatic lobe versus focal heterogeneity in the liver parenchyma can also
be further evaluated by MRI.
RECOMMENDATION(S): Dedicated liver MRI is recommended for evaluation of liver
lesions.
NOTIFICATION: Recommendation for followup liver MRI was communicated by
telephone to Dr. ___ by Dr. ___ at 17:27 ___.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: L Leg swelling
Diagnosed with EDEMA
temperature: 98.2
heartrate: 84.0
resprate: 18.0
o2sat: 98.0
sbp: 104.0
dbp: 64.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old male, with history of HIV c/b
encephalopathy, Kaposi Sarcoma, and history of ETOH binging
presenting with new acute onset of bilateral lower extremity
edema.
.
>> ACTIVE ISSUES:
# Lower Extremity Edema: Patient was admitted with increased
lower extremity edema, which has been an acute issue. Patient
underwent an lower extremity doppler negative for DVT. Initial
labs also demonstrated a low BNP, and albumin normal and
therefore unlikely to be nephrotic syndrome. Patient did have a
history of alcohol use, and therefore thought could be ___ to
liver disease. Furthermore, patient recently had HAART
medications changed to truvada for CNS involvement of HIV
detected by CSF PCR, and therefore thought possibly to side
effect of medication. Moreover, patient did have a history of
Kaposi Sarcoma, and case reports of lymphedema associated with
KS, however also thought to be unlikely in the setting of acute
issue. Therefore, given unclear etiology, patient underwent a
RUQ ultrasound which demonstrated no signs of hepatopetal flow,
ascites, and portal vein was patent. However, patient's liver
was found to be smooth, however found to have hypoechoic focus
in the left love of the liver with ?hemangioma, and a 1.5 cm
isoechoic area of heterogeneity without discrete lesions, to be
followed up by MRI. Given non-emergent need, patient to be
discharged with further outpatient workup for lower extremity
edema as an outpatient, and stable for discharge.
.
# HIV: Prior history of well controlled on HAART therapy,
however recently changed to Truvada given new CSF involvement.
Patient was continued on home hAART therapy, and reports were
corroborated with attending per home records.
.
# Seizure Disorder: Patient reported no recent seizure disorder,
and was continued on home keppra without seizure activity while
inpatient.
.
>> TRANSITIONAL ISSUES:
#US: shows echogenicity c/w hemangioma. Can consider MRI for
further evaluation if clinically indicated |