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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / cefepime / vancomycin / levofloxacin
Attending: ___.
Chief Complaint:
Fever, rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o non-Hodgkin's lymphoma s/p
allogenic stem cell transplant, breast cancer s/p bilateral
mastectomy on ___ c/b post-operative wound infection with
MSSA abscess s/p I&D on ___ who presents with fever and
diffuse rash. The patient was started on vanc/cefepime/flagyl
___ and then discharged ___ on vanc/levofloxacin (levo to
end ___. The patient developed intermittent fevers (max 102)
and a rash a few days after starting antibiotics (on ___,
which were discontinued yesterday with PICC removed. The rash
began on the bilateral hips, spreading across the abdomen, then
to arms/legs/back. Two days ago the rash spread to neck, face
and scalp. The rash is pruritic, nonpainful. Yesterday the
patient's fever was 101.9, but no fevers noted on day of
presentation to the ED. The patient began vomiting yesterday as
well, 3 times, nonbloody, no abdominal pain. The patient denies
recent travel although does spend time in ___. Denies new
foods or other new exposures and has no history of rashes like
this in the past. She reports she has had no fevers since
yesterday and is overall feeling improved and operative site has
shown improvement, however her rash has worsened today. She was
evaluated by ID and was referred to the ED.
In the ED, initial VS were: 99.2 79 114/48 16 100%
Labs were notable for a WBC of 12.1 with 70% eos, 10% PMNs, AST
48 ALT 22 K 5.4 Cr 1.4 (baseline 0.8)
CXR showed : resolution of prior right pleural effusion and
minor associated atelectasis, Improvement in retrocardiac
opacity, the latter possibly due to pneumonia versus atelectasis
or lower airway inflammation.
Received 25 mg PO diphenhydramine and 5 mg PO oxycodone.
In the ED, surgery saw the patient and thought breast wound did
not appear to be infected, granulating well, obvious left breast
seroma with no obvious evidence of infection.
Decision was made to admit to medicine for further management.
On arrival to the floor, VS were: T 98.4 BP 122/45 HR 81 SpO2
100%RA.
Patient reports itchy rash, denies CP, SOB, HA, abdominal pain,
N/V/D, dysuria, pain with defectation.
REVIEW OF SYSTEMS:
+ Per HPI and otherwise negative
Past Medical History:
--Breast cancer s/p resection and chemotherapy/XRT: R
breast IDC,s/p partial mastectomy, L mixed IDC/lobular Ca, s/p
partial mastectomy, R breast lymphoma w/lung metastasis, s/p
CTX, now R breast invasive lobular carcinoma, ER+/PR+/Her2
--NHL
--alpha thalassemia trait
--idiopathic cholestasis syndrome without associated cirrhosis
--BOOP/COP, quiescent
--anxiety
--Seasonal dry eye syndrome
--Idiopathic hypereosinophilia s/p allo-SCT
--Eosinophilic folliculitis
--Essential tremor
PSH: R breast partial mastectomy, L breast partial mastectomy,
cholecystectomy (___), Bilateral total mastectomies ___
- ___
Social History:
___
Family History:
Mother and father with CAD. Father was a smoker and had lung and
esophageal cancer. Uncle with unknown cancer. Siblings are
healthy, no biologic children.
Physical Exam:
ADMISSION EXAM:
==============
VS - T 98.4 BP 122/45 HR 81 SpO2 100%RA
GENERAL: Elderly woman sitting in bed in NAD, AAOx3, pleasant
HEENT: PERRL, no scleral icterus, MM dry, no oral ulcerations,
some palatal erythema. Periorbital edema present.
NECK: Supple, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
CHEST: evidence of prior b/l mastectomy scars. R abscess site
with clean packing, no purulent drainage, no tenderness. Pocket
of fluctuance lateral to left breast incision site, nontender.
LUNG: CTAB, no wheezes, rales, rhonchi, diminished breath sounds
at the bases bilaterally.
ABDOMEN: Obese, soft, nontender, nondistended, no HSM
EXTREMITIES: No ___ edema, distal pulses intact, warm and
well-perfused
NEURO: CN II-XII grossly intact
SKIN: Bright red blanching confluent macules over abdomen, back,
b/l hips, thighs, arms, legs and face with scale over lower
back.
DISCHARGE EXAM:
==============
VS - 99.2 Tc98.2 107-147/36-69 ___ 18 98%RA
GENERAL: Elderly woman sitting in bed in NAD, AAOx3, pleasant
HEENT: PERRL, no scleral icterus, MM dry, no oral ulcerations,
some palatal erythema. Periorbital edema present.
NECK: Supple, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
CHEST: evidence of prior b/l mastectomy scars. R abscess site
with clean packing, no purulent drainage, no tenderness. Pocket
of fluctuance lateral to left breast incision site, nontender.
LUNG: CTAB, no wheezes, rales, rhonchi, diminished breath sounds
at the bases bilaterally.
ABDOMEN: Obese, soft, nontender, nondistended, no HSM
EXTREMITIES: No ___ edema, distal pulses intact, warm and
well-perfused
NEURO: CN II-XII grossly intact
SKIN: Bright red blanching confluent macules over abdomen, back,
b/l hips, thighs, arms, legs and face with scale over lower
back. Rash less erythematous today.
Pertinent Results:
ADMISSION LABS:
==============
___ 08:55PM GLUCOSE-108* UREA N-18 CREAT-1.5* SODIUM-134
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-26 ANION GAP-16
___ 08:55PM ALT(SGPT)-18 AST(SGOT)-29 LD(LDH)-371* ALK
PHOS-215* TOT BILI-0.4
___ 08:55PM ALBUMIN-3.5 CALCIUM-9.5 PHOSPHATE-3.1
MAGNESIUM-2.2
___ 08:55PM I-HOS-DONE
___ 06:15PM URINE HOURS-RANDOM
___ 06:15PM URINE UHOLD-HOLD
___ 06:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 06:15PM URINE RBC-1 WBC-7* BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 06:15PM URINE HYALINE-3*
___ 06:15PM URINE MUCOUS-RARE
___ 02:56PM LACTATE-3.0*
___ 02:50PM GLUCOSE-98 UREA N-18 CREAT-1.4* SODIUM-133
POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-21* ANION GAP-13
___ 02:50PM ALT(SGPT)-22 AST(SGOT)-48* ALK PHOS-232* TOT
BILI-0.3
___ 02:50PM LIPASE-58
___ 02:50PM ALBUMIN-3.5
___ 02:50PM WBC-12.1* RBC-4.61 HGB-12.0 HCT-37.4 MCV-81*
MCH-26.0* MCHC-32.1 RDW-19.1*
___ 02:50PM NEUTS-10* ___ MONOS-2 EOS-70* BASOS-0
___ 02:50PM PLT COUNT-147*
___ 02:15PM UREA N-17 CREAT-1.6*
___ 02:15PM estGFR-Using this
___ 02:15PM ALT(SGPT)-21 AST(SGOT)-42* ALK PHOS-275* TOT
BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2
___ 02:15PM TOT PROT-6.2* ALBUMIN-3.3* GLOBULIN-2.9
___ 02:15PM WBC-17.4* RBC-4.11* HGB-10.4* HCT-32.6*
MCV-79* MCH-25.3* MCHC-31.8 RDW-18.9*
___ 02:15PM NEUTS-79* BANDS-4 LYMPHS-9* MONOS-3 EOS-5*
BASOS-0 ___ MYELOS-0 NUC RBCS-1*
___ 02:15PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL TARGET-OCCASIONAL STIPPLED-OCCASIONAL
HOW-JOL-OCCASIONAL PAPPENHEI-OCCASIONAL
___ 02:15PM PLT SMR-LOW PLT COUNT-138*
PERTINENT LABS:
==============
___ 05:30AM BLOOD ALT-16 AST-26 LD(LDH)-391* AlkPhos-194*
TotBili-0.3
___ 05:30AM BLOOD cTropnT-0.03*
___ 02:56PM BLOOD Lactate-3.0*
IMAGING/STUDIES:
===============
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Resolution of right pleural effusion and minor associated
atelectasis. Improvement in retrocardiac opacity, the latter
possibly due to pneumonia versus atelectasis or lower airway
inflammation.
MICRO:
=====
___ 05:30AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
___ STAIN-FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARYINPATIENT
___ 9:30 am ABSCESS LEFT BREAST.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ CULTURE-FINALEMERGENCY WARD
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
DISCHARGE LABS:
==============
___ 01:50PM BLOOD WBC-14.4* RBC-4.28 Hgb-11.0* Hct-33.3*
MCV-78* MCH-25.7* MCHC-33.1 RDW-19.2* Plt ___
___ 01:50PM BLOOD Neuts-21.2* ___ Monos-3.8
Eos-42.3* Baso-0.5
___ 01:50PM BLOOD Glucose-115* UreaN-17 Creat-1.5* Na-136
K-4.6 Cl-98 HCO3-24 AnGap-19
___ 01:50PM BLOOD ALT-16 AST-26 LD(LDH)-408* AlkPhos-181*
TotBili-0.3
___ 01:50PM BLOOD Calcium-9.4 Phos-3.7 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO TID
2. Acyclovir 400 mg PO Q8H
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Senna 17.2 mg PO HS
9. Sertraline 100 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Propranolol 10 mg PO QAM
13. Propranolol 10 mg PO TID
Discharge Medications:
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID Duration:
7 Days
Do not apply to face.
RX *clobetasol 0.05 % 1 Appl twice a day Disp #*60 Gram Gram
Refills:*0
2. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP BID rash
Duration: 7 Days
Do not apply to face.
RX *triamcinolone acetonide 0.025 % 1 Appl twice a day
Refills:*0
3. Acetaminophen 650 mg PO TID
4. Acyclovir 400 mg PO Q8H
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Propranolol 10 mg PO QAM
12. Propranolol 10 mg PO TID
13. Senna 17.2 mg PO HS
14. Sertraline 100 mg PO DAILY
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
DRESS syndrome vs drug eruption
Secondary diagnoses:
NHL s/p allogeneic stem cell transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Fever.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: ___.
FINDINGS:
The heart is at the upper limits of normal size. The mediastinal and hilar
contours appear stable. Incidental note is made of an azygos fissure, which
is a normal variant. Right basilar opacity suggesting atelectasis has
cleared. Vague retrocardiac opacity probably referring the left lower lobe
persists but has improved. The lungs appear otherwise clear. A right-sided
pleural effusion has resolved. A PICC line is been removed. Surgical clips
again project over each axilla.
IMPRESSION:
Resolution of right pleural effusion and minor associated atelectasis.
Improvement in retrocardiac opacity, the latter possibly due to pneumonia
versus atelectasis or lower airway inflammation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Rash, Fever
Diagnosed with LYMPHOMA NEC UNSPEC SITE
temperature: 99.2
heartrate: 79.0
resprate: 16.0
o2sat: 100.0
sbp: 114.0
dbp: 48.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ with h/o non-Hodgkin's lymphoma s/p
allogenic stem cell transplant, breast cancer s/p bilateral
mastectomy on ___ c/b post-operative wound infection with
MSSA abscess s/p I&D on ___ who presents with fever and
diffuse rash.
# Rash: The rash is associated with the onset of several
antibiotics s/p I&D of MSSA abscess, along with eosinophilia,
increased from 5% to 70% in 24 hours, concerning for DRESS vs
drug-eruption; however patient has known diagnosis of idiopathic
hypereosinophilia syndrome s/p allo SCT. DRESS is supported by
the extent of the rash, periorbital edema, LFT abnormalities,
elevated Cr. Vanc/levo were stopped day prior to admission. She
remained afebrile for the duration of hospitalization. Her rash
showed improvement morning after admission. She was evaluated by
dermatology who recommended topical steroids for possible DRESS.
Given her known allergy to ciprofloxacin, it is possible that
her rash was associated with initiation of levofloxacin, vs from
vancomycin or cefepime (as she may have been previously
sensitized to these antibiotics given that she is a transplant
patient). She was closely monitored. Her eosinophilia decreased
and remained stable at 42%. She was discharged on a one-week
course of clobetasol ointment with then transition to
triamcinolone (not to be used on the face). Strongyloides IgG
was tested and pending by time of discharge.
# Fever: The patient reported intermittent fevers up to 102
several days after starting antibiotics. The patient denied a
fever on day of admission after stopping vanc/levo the day
prior. The patient is s/p allogeneic SCT, ANC 1200 on admission.
Lactate elevated at 3.0, improved with PO intake to 1.9. Blood
and urine cultures showed no pathogenic organisms. Seroma
culture from her left breast by surgery showed no growth to
date. She remained afebrile throughout hospitalization.
# ___: Cr on admission 1.4 (baseline 0.8), however Cr has been
slightly elevated for several weeks. Given elevated lactate,
prerenal etiology ___ is likely; however AIN from DRESS also
on the differential. Her creatinine remained stable at 1.5, not
higher than recent creatinine (1.8 on ___.
# Breast cancer s/p resection and chemotherapy/XRT c/b MSSA
abscess: breast cancer s/p bilateral mastectomy on ___ c/b
post-operative wound infection with MSSA abscess s/p I&D on
___. Patient was started on vancomycin instead of PCN due to
concern for allergy (pt allergic to cefepime) in past; also
started on levofloxacin prior to admission by surgery, both
stopped day prior to admission. ___ breast surgery aspirated
180 ccs of fluid from L breast, sent for culture. Culture showed
no growth to date, as above. Wound care was provided by surgery.
# S/p allogeneic SCT (___): Complicated by idiopathic
hypereosinophilia, as above. LDH in 300s so not concerning for
acute lymphoma. She was continued on home acyclovir prophylaxis.
# Idiopathic cholestasis syndrome without associated cirrhosis:
The patient did not demonstrate a transaminitis during hospital
stay and alk phos remained within her previous baseline.
# Anxiety: Continued sertraline 100 mg daily.
# Essential Tremor: Continued home propranolol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Latex / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Facial weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Dr. ___ is a ___ year-old right handed man with a
history of afib on Xarelto, ischemic and hemorrhaghic strokes
(see MRI report above) and dementia who presents to ___ ED
with
facial weakness. History is obtained from his wife and ___
notes
from Dr. ___ neurologist) as the patient's dementia
limits him as a historian.
He was last well on ___ morning when the patient started
to
report to his wife that his right eye was "sticky" and was not
closing well. She thought it was a bit swollen, but not
significantly different. No other complaints from the patient
at
that time. This morning, there may have been some asymmetry, but
it was not until 430pm today that she was really convinced
enough
to bring him to the ED. While in the ED, she also noticed the
left eyelid was drooping more than usual. She recalls the LEFT
eyelid is the chronically droopy one and this is in contrast to
Dr. ___ which say the RIGHT. Regardless, she felt
both were more droopy and the right eyebrow was less active.
The
patient did not have new double vision or any other neurological
changes for that matter.
In the recent past, he has had more leg swelling and an echo was
done which showed pulmonary hypertension but was otherwise
stable. No infectious symptoms in the patient, but his wife had
chickenpox.
Past Medical History:
Prior ishemic and hemorrhagic strokes with resultant right eye
movement abnormality, ? right vs left ptosis, left hemiparesis
and ataxia. See below for MRI brain from ___ for areas of
brain
affected
- Afib on Xarelto
- HTN
- HLD
- Dementia, previously on Namenda and Xarelto which were
ineffective.
Social History:
___
Family History:
omitted.
Physical Exam:
Vitals: 96.8 94 178/113 16 96% RA
General: NAD, smells of urine
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, shallow breath sounds. Increased work of
breath
with confrontational strength exam
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, lower extremity nonpitting edema as well as
left hand edema
Neurologic Examination:
- Mental Status - Alert, conversational. Oriented to person,
place and minimally to time (knows only year, thought
___.
Attentive on MOYB. Per wife, his recount of events is poor.
Speech is fluent with full sentences, intact repetition, and
intact verbal comprehension. Naming intact. No paraphasias.
Normal prosody. No dysarthria. Verbal registration and recall
___
at 5 minutes. ? question of subtle sensory left neglect.
- Cranial Nerves - PERRL 2.5->2 brisk. VFF to finger wiggle.
Right exotropia on primary gaze. Right eye with almost absent
elevation and impaired depression and adduction. Left eye with
only slight impairment of adduction. There is refixation on
upgaze, but no clear nystagmus. V1-V3 with <10% differences on
right and left hemiface. At rest there is left >> right ptosis
and sometimes the left eye is closed at rest. No clear
fatigability pattern. Almost complete absence of forehead
furrowing on the right and present on the left. Lower facial
strength is normal. Palate elevates. Hearing intact to finger
rub bilaterally. SCM/Trapezius strength ___ bilaterally. Tongue
midline.
- Motor - Normal bulk and tone. No drift. There is asterixis vs
ataxia of the left hand.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
** No fatigable weakness
- Sensory - Less than 10% sensory discrepancy between right and
left sides to pin and light touch. Question if subtle left
sensory neglect on DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response extensor bilaterally. No clonus at ankles.
Left pectoralis jerk and hoffmans present
- Coordination - Left sided arm> leg ataxia.
- Gait - Moderately wide based. Short stride length and height.
Negative Romberg.
Pertinent Results:
___ 06:50PM PLT COUNT-239
___ 06:50PM NEUTS-60.7 ___ MONOS-10.9 EOS-3.9
BASOS-0.6 IM ___ AbsNeut-5.68 AbsLymp-2.21 AbsMono-1.02*
AbsEos-0.37 AbsBaso-0.06
___ 06:50PM WBC-9.4 RBC-5.79 HGB-16.8 HCT-51.2* MCV-88
MCH-29.0 MCHC-32.8 RDW-13.7 RDWSD-44.2
___ 06:50PM ALBUMIN-4.4 CALCIUM-9.8 PHOSPHATE-2.8
MAGNESIUM-2.1
___ 06:50PM proBNP-2300*
___ 06:50PM cTropnT-<0.01
___ 06:50PM ALT(SGPT)-30 AST(SGOT)-24 ALK PHOS-73 TOT
BILI-0.6
___ 06:50PM estGFR-Using this
___ 06:50PM GLUCOSE-113* UREA N-17 CREAT-1.4* SODIUM-143
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-27 ANION GAP-14
___ 06:57PM GLUCOSE-104 NA+-143 K+-4.0 CL--108 TCO2-25
___ 07:00PM CREAT-1.5*
___ 08:30PM URINE MUCOUS-FEW
___ 08:30PM URINE HYALINE-5*
___ 08:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 08:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN->300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
___ 08:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
Medications on Admission:
amlodipine 5 mg daily
atenolol 150 mg daily
escitalopram 5 mg daily
furosemide 20 mg daily
potassium chloride ER 10 mEq BID
Xarelto 20 mg tablet. 1 tablet(s) by
mouth daily
simvastatin 20 mg daily
valsartan 160 mg daily
cholecalciferol (vitamin D3) 1,000
unit tablet. 1 Tablet(s) by mouth once a day - (chart
conversion)
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Atenolol 150 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Escitalopram Oxalate 5 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Potassium Chloride 10 mEq PO BID
7. Rivaroxaban 20 mg PO DAILY
8. Valsartan 160 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral ptosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with R facial droop since 1630. hx CVA // Eval for acute
process
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast.
DOSE: Total DLP (Head) = 897 mGy-cm.
COMPARISON: CT head without contrast dated ___ MRI brain from ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
age-related cortical volume loss with prominence of the ventricles and sulci.
Periventricular white matter hypodensities are noted, consistent with likely
small vessel ischemic disease. Old right thalamic and left putaminal a Coons
are again noted. Linear hypodensity in the right external capsule is likely
from prior hemorrhage, unchanged. Dense atherosclerotic calcification within
the intracranial ICAs and vertebral arteries is noted.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with cva // eval for consolidation
TECHNIQUE: Portable chest x-ray.
COMPARISON: None available.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates low lung volumes.
The cardiac silhouette is mildly enlarged. Crowding of vasculature in the
right infrahilar region is likely due to low lung volume. No definite
consolidation is identified. There is no large pleural effusion or
pneumothorax.
IMPRESSION:
No acute intrathoracic abnormality.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old man with hx of afib on xarelto with hx of both
hemorrhagic and ischemic stroke here for acute on chronic ptosis vs new
ptosis. // ?new stroke.
TECHNIQUE: T1 sagittal and FLAIR, T2, susceptibility and diffusion axial
images of the brain were acquired. 3D time-of-flight MRA of the circle of
___ was obtained. 2D time-of-flight MRA of the neck vessels was acquired.
COMPARISON: ___.
FINDINGS:
Chronic right basal ganglia blood products and encephalomalacia again
identified. No acute infarcts seen. Small vessel disease and brain atrophy
are identified. There is no midline shift or hydrocephalus.
MRA of the head shows normal signal in the arteries of the anterior and
posterior circulation. No evidence of vascular occlusion stenosis or an
aneurysm greater than 3 mm in size seen.
2D time-of-flight MRA of the neck demonstrates flow signal in carotid
vertebral arteries without stenosis or occlusion.
IMPRESSION:
Encephalomalacia in the right basal ganglia with chronic blood products. No
acute infarcts. No vascular occlusion or stenosis on MRA of the head neck.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: R Facial droop
Diagnosed with Transient cerebral ischemic attack, unspecified
temperature: 96.8
heartrate: 94.0
resprate: 16.0
o2sat: 96.0
sbp: 178.0
dbp: 113.0
level of pain: 0
level of acuity: 2.0 | Patient came to hospital with apparent facial weakness. Upon
admission, patient was continued on his home meds including
Xarelto although home Amlodipine and Valsartan were held.
Following admission, patient's neurologic deficits appeared to
improve to a degree and MRI imaging showed no new vascular or
parenchymal changes. There is no evidence of infection, toxin,
or metabolic disturbance that would cause
re-exacerbation of his prior right midbrain ischemic infarct. He
has known, chronic right eye greater than left eyelid ptosis
secondary to his right midbrain infarct. Reason for his
increased
difficulty keeping his eyelids open is unclear. His history and
exam are not highly suggestive of myasthenia ___ but it is
still on the differential. Will check Ach Receptor antibodies
and anti-MUSK antibody.
He also has notable cognitive deficits in particular with
orientation and short term memory. This has already been noted
in
the past and is being followed by Dr. ___.
Will continue Xarelto for prophylaxis against embolic stroke
from
atrial fibrillation. Will continue simvastatin 20mg qhs
Due to appearing clinically stable, patient was deemed
appropriate for discharge from the hospital with close follow up
with his PCP and primary neurologist. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing / simvastatin / pravastatin /
atorvastatin
Attending: ___.
Chief Complaint:
Nausea, vomiting, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is an ___ with history of vertigo, ocular
migraines, and tinnitus who presents with nausea and vomiting.
The patient reports that she woke up yesterday morning and felt
nauseous in the setting of distorted vision. She reports that
the objects she saw were "broken and moving". This was worse
while lying back than sitting forward. It gradually improved
throughout the day with increased fluid intake though she
eventually vomited which prompted her presentation to the ED.
The patient reports that it was similar to an episode a week ago
during which time she was hospitalized.
She denies headache, abdominal pain, fevers, chills, night
sweats, weight loss, cough, or SOB but did have two episodes of
watery stools which she states is normal for her. She endorses
some intermittent tinnitus but denies vertiginous symptoms.
The patient reports that her current symptoms are similar to
those she experienced during her recent admission from
___. During that admission, she was on the Neurology
service. The the time, the patient reported visual disturbance,
head motion intolerance, nausea, and inability to ambulate and
had a reported inconclusive workup for stroke versus peripheral
vertigo which included CT head on ___ which showed no acute
intracranial process, MRI/A on ___ which showed mild atrophy
but was otherwise a normal study, and telemetry which was
negative for atrial fibrillation. At the time of her discharge
her neurological symptoms improved but it was not clear if she
had a stroke, peripheral vertigo, or vestibular neuritis. The
Neurology team started the patient on aspirin 81mg daily and
atorvastatin 30mg daily to reduce her stroke risk factors,
though she did not continue the statin since she had a prior
adverse reaction.
In the ED, initial vital signs were 96.69 70 114/66 18 98% RA.
Labs demonstrated an unremarkable CBC, sodium 129, unremarkable
UA. Neurology consult was initiated though completed on the
floor given significant symptoms.
Upon arrival to the floor, initial vital signs were 98.3 112/46
66 16 98RA. Patient was asymptomatic on arrival, requesting to
eat breakfast.
Past Medical History:
PAST MEDICAL HISTORY:
1. Osteoporosis.
2. Hypercholesterolemia.
3. History of bunions.
4. Ocular migraines.
5. Umbilical hernia.
6. Osteoarthritis.
7. Cataracts.
8. Tinnitus.
9. Vertigo, 1 previous episode
PAST SURGICAL HISTORY:
1. Repair of right rotator cuff tear.
2. Mesh repair of recurrent umbilical hernia, ___.
3. Appendectomy.
4. Tonsillectomy and adenoidectomy.
Social History:
___
Family History:
Siblings: sister w/breast CA in ___
Parents: father died at ___. of heart disease
Grandparents: grandfather died at ___. of heart disease
Physical Exam:
ADMISSION:
Vitals-98.3 112/46 66 16 98RA, not orthostatic
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, SEM radiating to LCA
Abdomen- soft, NT/ND 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, fleeting
left-going nystagmus, cerebellar exam intact
DISCHARGE:
98.1 92/38 70 20 94RA
Upright in bed, eating breakfast, well-appearing
NCAT, MMM
Supple
RRR (+)S1/S2 no m/r/g
Generally CTA b/l
Soft, non-tender, NABS
Warm, well-perfused
No foley
Erythema of right foot with minimal tenderness
Pertinent Results:
ADMISSION:
___ 11:50PM BLOOD WBC-7.8 RBC-4.08* Hgb-12.9 Hct-37.3
MCV-91 MCH-31.7 MCHC-34.7 RDW-12.6 Plt ___
___ 11:50PM BLOOD Neuts-77.7* Lymphs-14.9* Monos-6.4
Eos-0.6 Baso-0.5
___ 11:50PM BLOOD Glucose-126* UreaN-14 Creat-0.6 Na-129*
K-3.6 Cl-97 HCO3-21* AnGap-15
___ 06:00AM URINE Color-Straw Appear-Clear Sp ___
___ 06:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:00AM URINE Hours-RANDOM UreaN-376 Creat-34 Na-71
K-40 Cl-53
RADIOLOGY:
___ FOOT XR
Soft tissue swelling over the distal forefoot and chronic severe
hallux valgus but no bony erosions, fracture or subcutaneous
emphysema seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral QD
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Meclizine 12.5 mg PO Q8H:PRN dizziness
RX *meclizine 12.5 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*25 Tablet Refills:*0
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral QD
4. Outpatient Physical Therapy
Rolling walker for gait instability and peripheral
vestibulopathy.
5. Naproxen 500 mg PO BID Duration: 5 Days
RX *naproxen 500 mg 1 tablet(s) by mouth twice daily Disp #*8
Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY Duration: 5 Days
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*5
Capsule Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Vestibular neuritis
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old woman with new-onset swelling of right foot //
evaluate for pseudogout
TECHNIQUE: Plain film
COMPARISON: NONE.
FINDINGS:
Three views of the right foot show severe hallux valgus deformity (90 degrees)
with resultant uncovered the head of the first metatarsal. Abutting
subchondral sclerosis at the first MTP joint and osteophytosis at the head of
the first metatarsal indicates this is not acute. Soft tissue fullness over
the distal forefoot is seen without a subjacent fracture or focal bone
erosion. Some minor cortical thickening is seen at the medial shaft of the
second metatarsal but this does not have an aggressive appearance. Patchy
osteopenia is noted in the midfoot. No gouty tophi are seen and no air is
seen in the soft tissues appear
IMPRESSION:
Soft tissue swelling over the distal forefoot and chronic severe hallux valgus
but no bony erosions, fracture or subcutaneous emphysema seen in
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with VERTIGO/DIZZINESS
temperature: 96.69
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 114.0
dbp: 66.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is an ___ with history of vertigo, ocular
migraines, and tinnitus who presents with dizziness, nausea, and
vomiting likely secondary to vestibular neuritis.
#Vestibular neuritis
Patient with recent admission for similar symptoms complex,
unclear etiology, thought by Neurology to be vestibular
(peripheral) vs. TIA. On this presentation, no evidence of other
neurologic deficits consistent with TIA, and appears to be
intermittent/waxing-and-waning which is less consistent with
TIA. Patient found not to be orthostatic. It was thought that
her presentation was most consistent with a vestibular neuritis.
She was given meclizine and ondansetron as needed. Her aspirin
was held given risk of vestibular toxicity. The patient was
recommended to follow-up with Neurology and ENT as an outpatient
for ongoing vestibular neuritis as well as ___ for vestibular
therapy.
#Right foot erythema
Patient developed erythema and tenderness of her right foot.
There was concern for pseudogout, though there was no suggestion
of foot x-ray. The x-ray was without other findings, as well.
The patient was started on a five-day course of naproxen and
omeprazole. Follow-up is recommended as an outpatient.
#Hyponatremia
Patient with Na 129 in setting of increased water intake and
nausea/vomiting on admission. Most likely related to SIADH
secondary to nausea/vomiting. Patient was given IVF in ED with
normalization of her sodium.
#Hyperlipidemia
Found to have LDL of 160 on prior admission but patient unable
to tolerate statins. A low cholesterol diet was recommended.
# Caregiver ___
Significant anxiety and stress secondary to caring for husband
with dementia. She has experienced sleep deprived and physical
exaustion from this responsibility.
The patient was seen by Social Work during her hospital stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
narcotics / anesthesia / erythromycin base / oxycodone /
Dilaudid
Attending: ___
Chief Complaint:
Abdominal pain, nausea, and bloating.
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
Mrs ___ is a ___ woman with a hx of SVT (previously
offered ablation but patient declined) presenting with
epigastric abdominal pain, bloating, and nausea since last
evening. According to the patient, ___ weeks ago she had acute
RLQ abdominal pain and went to ___ where workup
(including a CT abdomen/pelvis) was reportedly normal. Her pain
eventually resolved on its own. Yesterday, she noted abdominal
bloating in the afternoon and then after dinner around 6pm she
felt epigastric abdominal pain that became progressively worse
and eventually localized to the RLQ. This was associated with
nausea but no vomiting. No changes in bowel habits or diarrhea.
ROS: Denies fevers, chills, SOB, CP, HA, dysuria, urinary
frequency/urgency, melena, hematochezia.
Past Medical History:
Chronic palpitations & SVT (was offered ablation but ultimately
declined; patient reports no cardiac complications with
anesthesia), breast cancer, chronic constipation, uterine
prolapse, borderline (diet controlled) diabetes, last
colonoscopy ___ was completely normal.
PSH: R mastectomy, hysterectomy, tonsillectomy, ovarian cysts
Social History:
___
Family History:
Both her children have Wolfram's syndrome and AVNRT.
Physical Exam:
VS: T 98.1, HR 78, BP 132/76, RR 16, O2 sat 97 RA
GEN: Alert and oriented, no acute distress, conversant and
interactive.
HEENT: Sclerae anicteric, mucous membranes moist, oropharynx is
clear.
NECK: Trachea is midline, thyroid unremarkable, no palpable
cervical lymphadenopathy, no visible JVD.
CV: Regular rate and rhythm, no audible murmurs.
PULM/CHEST: Clear to auscultation bilaterally, respirations are
unlabored on room air.
ABD: Soft, nondistended, minimally and appropriately tender to
palpation, no rebound or guarding, nontympanitic, no palpable
masses, dressings over incisions are clean and dry.
Ext: No lower extremity edema, distal extremities feel warm and
appear well-perfused.
Pertinent Results:
___ 07:04AM BLOOD WBC-12.6* RBC-4.14* Hgb-12.9 Hct-36.8
MCV-89 MCH-31.2 MCHC-35.1* RDW-14.3 Plt ___
___ 07:04AM BLOOD Glucose-160* UreaN-13 Creat-0.8 Na-135
K-4.4 Cl-101 HCO3-23 AnGap-15
___ 07:04AM BLOOD ALT-18 AST-21 AlkPhos-72 TotBili-0.5
___ 07:04AM BLOOD Lipase-32
___ 07:04AM BLOOD Albumin-4.3
___: CT A/P w/ contrast
LOWER CHEST: There is mild bibasilar atelectasis of the
partially imaged lungs. No pleural effusion. There is a trace,
tiny physiologic pericardial fluid.
HEPATOBILIARY: Focal hypodensity in the region of the porta
hepatic likely represents focal fat (Series 2, Image 21).
Otherwise, the liver parenchyma is homogeneous throughout. No
concerning focal hepatic lesion. There is a small benign
calcification abutting the right hepatic dome (Series 601b,
Image 37)). No intrahepatic or extrahepatic biliary ductal
dilatation. The gallbladder is not abnormally distended and
within normal limits. No calcified gallstones, gallbladder wall
thickening, or pericholecystic fluid collection. No ascites. The
main portal vein appears patent.
PANCREAS: There is an 1-cm benign focal fat in the uncinate
(Series 2, Image 22; Series 601b, Image 27). Otherwise, the
remaining pancreatic parenchyma is normal in attenuation
throughout. No concerning focal pancreatic lesion, pancreatic
ductal dilatation, or peripancreatic stranding.
SPLEEN: The spleen is normal in size and attenuation. No focal
splenic lesion. A splenule is noted in the left upper quadrant
(Series 601b, Image 41).
ADRENALS: The left and right adrenal glands are normal in size
and shape.
URINARY: The kidneys are normal in size and symmetric with
normal nephrograms. Tiny hypodensities in the cortex of the left
upper renal pole are too small to accurately characterize on CT,
but likely represent cysts. No concerning focal renal lesion,
hydronephrosis, or perinephric abnormality. The urinary bladder
is moderately distended and appears grossly unremarkable.
GASTROINTESTINAL: There is a small hiatal hernia (Series 601b,
Image 32). Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The colon and rectum are
within normal limits. The appendix is dilated throughout its
course with wall thickening and mucosal enhancement; the maximum
diameter of the appendix measures approximately 12 mm (Series 2,
Image 57; Series 601b, Image 31). There is adjacent fat
stranding and prominence of the right lateral conal fascia.
There is no evidence of macroperforation or intraabdominal fluid
collection. No bowel perforation or pneumatosis.
RETROPERITONEUM: No retroperitoneal or mesenteric
lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. There is minimal
calcium ___ in the abdominal aorta and great abdominal
arteries.
PELVIS: No pelvic or inguinal lymphadenopathy. No free fluid in
the pelvis. The patient is status-post supracervical
hysterectomy. The adnexa are otherwise unremarkable.
BONES AND SOFT TISSUES: No suspicious lytic or sclerotic bony
abnormality. The abdominal and pelvic walls are within normal
limits.
IMPRESSION:
1. Acute appendicitis - no evidence of macroperforation or
fluid collection.
2. No bowel obstruction.
3. Small hiatal hernia.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. TraZODone 75 mg PO QHS:PRN sleep
2. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Sertraline 50 mg PO DAILY
2. TraZODone 75 mg PO QHS:PRN insomnia
3. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 325 mg 2 tablets by mouth every 6 hours Disp
#*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet by mouth two times per day
Disp #*30 Tablet Refills:*0
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
12 hours Disp #*7 Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 3 Days
RX *metronidazole 500 mg 1 tablet by mouth every 8 hours Disp
#*12 Tablet Refills:*0
7. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
RX *tramadol [Ultram] 50 mg ___ tablet(s) by mouth every 4 hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS
INDICATION: ___ woman with a history of a hysterectomy who is now
presenting with epigastric pain and right lower quadrant pain; evaluate for
appendicitis and bowel obstruction.
TECHNIQUE: Multi-detector CT axial images were acquired through the abdomen
and pelvis following intravenous contrast administration using a split bolus
technique. Coronal and sagittal reformations were performed and reviewed on
PACS. No oral contrast was administered.
DOSE: DLP: 704 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL Omnipaque.
COMPARISON: No prior imaging is available.
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis of the partially imaged
lungs. No pleural effusion. There is a trace, tiny physiologic pericardial
fluid.
ABDOMEN:
HEPATOBILIARY: Focal hypodensity in the region of the porta hepatis likely
represents focal fat (Series 2, Image 21). Otherwise, the liver parenchyma is
homogeneous throughout. No concerning focal hepatic lesion. There is a small
benign calcification abutting the right hepatic dome (Series 601b, Image 37)).
No intrahepatic or extrahepatic biliary ductal dilatation. The gallbladder is
not abnormally distended and within normal limits. No calcified gallstones,
gallbladder wall thickening, or pericholecystic fluid collection. No ascites.
The main portal vein appears patent.
PANCREAS: There is an 1-cm benign focal fat in the uncinate (Series 2, Image
22; Series 601b, Image 27). Otherwise, the remaining pancreatic parenchyma is
normal in attenuation throughout. No concerning focal pancreatic lesion,
pancreatic ductal dilatation, or peripancreatic stranding.
SPLEEN: The spleen is normal in size and attenuation. No focal splenic
lesion. A splenule is noted in the left upper quadrant (Series 601b, Image
41).
ADRENALS: The left and right adrenal glands are normal in size and shape.
URINARY: The kidneys are normal in size and symmetric with normal nephrograms.
Tiny hypodensities in the cortex of the left upper renal pole are too small to
accurately characterize on CT, but likely represent cysts. No concerning focal
renal lesion, hydronephrosis, or perinephric abnormality. The urinary bladder
is moderately distended and appears grossly unremarkable.
GASTROINTESTINAL: There is a small hiatal hernia (Series 601b, Image 32).
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. The appendix is
dilated throughout its course with wall thickening and mucosal enhancement;
the maximum diameter of the appendix measures approximately 12 mm (Series 2,
Image 57; Series 601b, Image 31). There is adjacent fat stranding and
prominence of the right lateral conal fascia. There is no evidence of
macroperforation or intraabdominal fluid collection. No bowel perforation or
pneumatosis.
RETROPERITONEUM: No retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. There is minimal calcium burden in
the abdominal aorta and great abdominal arteries.
PELVIS: No pelvic or inguinal lymphadenopathy. No free fluid in the pelvis.
The patient is status-post supracervical hysterectomy. The adnexa are
otherwise unremarkable.
BONES AND SOFT TISSUES: No suspicious lytic or sclerotic bony abnormality.
The abdominal and pelvic walls are within normal limits.
IMPRESSION:
1. Acute appendicitis - no evidence of macroperforation or fluid collection.
2. No bowel obstruction.
3. Small hiatal hernia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 97.4
heartrate: 70.0
resprate: 16.0
o2sat: 98.0
sbp: 143.0
dbp: 71.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ female who was admitted to the ___
Acute Care Surgery team on ___ for management of acute
appendicitis (please refer to the HPI for additional details
regarding her presentation to the hospital). On the day of her
admission she was taken to the operating room and underwent an
uncomplicated laparoscopic appendectomy. Intraoperative findings
included the following: Acutely inflamed and thickened appendix
with thick inflammatory rind around it, suggestive of subacute
appendicitis that may have been going on for several weeks. Upon
manipulation of the appendix there was a minimal amount of stool
spillage requiring aggressive suctioning and wash out. She
tolerated the procedure well and was taken to the PACU and
subsequently to the regular surgical floor without incident. Due
to the scant amount of stool spillage upon manipulation of the
appendix, the decision was made to complete a 5-day course of
Cipro and Flagyl. She was quickly advanced to a regular diet and
voided postoperatively without any difficulty. She was
discharged home on POD 1 with a total of 5-days of Cipro/Flagyl
and was given instructions to follow-up in clinic for a postop
evaluation. Her final pathology was pending at the time of
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
gentamicin
Attending: ___
___ Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o IPF, pulmonary MAC, aspergillosis, LLL mass likely
adenoCA, CAD s/p CABG, presenting with left shoulder pain, chest
heaviness/DOE, and lethargy/failure to thrive.
His chief complaint is left shoulder pain, worse since lifting
weights last week. Further questioning reveals decreased
appetite and lethargy for about 2 months, weakness in his legs,
weight loss, and chest heaviness/DOE that he feels is worsening.
Per ED discssion with son, cardiologist at ___, had
nuclear stress in Dr. ___ recently that was negative.
TTE with no AS. No previous dx CHF. Further reports of
incontinence at home and occasional choking on food.
He denies fevers/chills, orthopnea, PND. Positive constipation.
Of note, patient admitted from ___ of this year for
dyspnea found to have bacterial PNA and invasive aspergillus,
treated with ongoing voriconazole.
In the ED, initial vitals were: 98.4 74 182/72 16 95% RA
- Exam notable for: cachectic man, bibasilar crackles, labored
breathing, elevated JVP and edema b/l
- Labs notable for: hgb 12.5, na 132, ap 141, alb 3.7, trop neg
x1, BNP 549, lactate 1.8
- Imaging was notable for: CXR with pulm edema vs infection vs
worsening chronic lung disease
- Patient was given:
___ 20:46 IV Furosemide 20 mg
___ 00:27 PO Rosuvastatin Calcium 5 mg
___ 00:27 PO/NG Mirtazapine 15 mg
___ 00:27 PO/NG Ranitidine 150 mg
___ 00:27 PO/NG Voriconazole 200 mg
___ 00:27 IH Ipratropium Bromide Neb 1 NEB
___ 00:27 PO Oxazepam 10 mg
- Vitals prior to transfer: 66 148/66 29 94% RA
Upon arrival to the floor, patient reports the above history.
His neck continues to bother him. He is visibly short of breath
if talking for long periods of time.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
-IDIOPATHIC PULMONARY FIBROSIS
-LLL Mass
-CAD s/p CABG ___
-DIABETES MELLITUS, TYPE 2
-SIADH
-ANEMIA
-HYPOTHYROIDISM
-GERD
-HYPERLIPIDEMIA
-HYPERTENSION
-OSTEOPOROSIS
-ANXIETY
Social History:
___
Family History:
Patient's father had coronary artery disease. Mother died of
liver disease. No lung disease.
Physical Exam:
ADMISSION EXAM:
Vital Signs: 97.6 115 / 70 69 20 92 RA
General: Alert, oriented, no acute distress, intermittent
tachypnea with speech, cachectic elderly man
HEENT: Sclerae anicteric, MM dry, oropharynx clear, EOMI,
PERRL.
Neck: Supple. JVP elevated to mid neck at 45 degrees, no LAD,
tender in muscles of left trapezius
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Diffuse velvety crackles throughout, occasional
increased WOB
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, +clubbing, trace edema b/l
with ankles tender
Neuro: Grossly intact, AAO x3, moving all extremities
DISCHARGE EXAM:
Vital Signs: 97.6 115 / 70 69 20 92 RA
General: Alert, oriented, no acute distress, intermittent
tachypnea with speech, cachectic elderly man
HEENT: Sclerae anicteric, MM dry, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP elevated to mid neck at 45 degrees, no LAD,
tender in muscles of left trapezius
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Diffuse velvety crackles throughout, occasional increased
WOB
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, +clubbing, trace edema b/l
with ankles tender
Neuro: Grossly intact, AAO x3, moving all extremities
Pertinent Results:
================
ADMISSION LABS
================
___ 08:02PM BLOOD WBC-8.3 RBC-4.55* Hgb-12.5* Hct-39.4*
MCV-87 MCH-27.5 MCHC-31.7* RDW-14.4 RDWSD-45.9 Plt ___
___ 08:02PM BLOOD Neuts-62.2 ___ Monos-10.4 Eos-1.8
Baso-1.0 Im ___ AbsNeut-5.14 AbsLymp-2.02 AbsMono-0.86*
AbsEos-0.15 AbsBaso-0.08
___ 08:02PM BLOOD Plt ___
___ 08:26PM BLOOD ___ PTT-26.2 ___
___ 08:02PM BLOOD Glucose-200* UreaN-18 Creat-0.8 Na-132*
K-4.2 Cl-91* HCO3-28 AnGap-17
___ 08:02PM BLOOD ALT-19 AST-31 AlkPhos-141* TotBili-0.2
___ 08:02PM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.3 Mg-1.9
___ 08:02PM BLOOD proBNP-549
___ 08:02PM BLOOD cTropnT-<0.01
___ 02:16AM BLOOD cTropnT-<0.01
___ 08:25PM BLOOD Lactate-1.8
___ 07:05AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.8
___ 08:35PM URINE Color-Straw Appear-Clear Sp ___
___ 08:35PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 08:35PM URINE RBC-3* WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
======================
DISCHARGE LABS
======================
___ 07:05AM BLOOD WBC-7.2 RBC-4.07* Hgb-11.3* Hct-35.0*
MCV-86 MCH-27.8 MCHC-32.3 RDW-14.6 RDWSD-45.2 Plt ___
___ 07:05AM BLOOD Glucose-154* UreaN-26* Creat-0.9 Na-133
K-4.2 Cl-93* HCO3-29 AnGap-15
========================
IMAGING
========================
CT Chest with contrast ___:
The previously noted cavitary lesion in the right upper lobe
with an
intracavitary mycetoma shows marked interval improvement now
being decreased
in size with no intracavitary mycetoma identifiable. The
fibrotic
interstitial lung disease appear similar compared to prior
imaging.
The ground-glass lesion/mass in the left lung base appear
similar compared to
prior.
No new areas of airspace consolidation to suggest superimposed
pneumonia.
Non physiological shape of the trachea suggesting
tracheobronchomalacia.
Dynamic expiratory imaging may be performed to further assess
for this.
Dilated pulmonary artery and pulmonary hypertension should be
excluded.
Lower extremity ultrasound ___: No evidence of deep venous
thrombosis in the right or left lower extremity
veins.
CT head ___:
No acute intracranial process.
=================
MICROBIOLOGY
=================
No growth on any cultures
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. pirfenidone 801 mg oral TID
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
4. Levothyroxine Sodium 200 mcg PO 2X/WEEK (___)
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Mirtazapine 30 mg PO QHS
7. Oxazepam 10 mg PO TID
8. Ranitidine 150 mg PO BID
9. Rosuvastatin Calcium 5 mg PO QPM
10. Voriconazole 200 mg PO Q12H
11. ipratropium bromide 0.03 % nasal QID:PRN
12. Losartan Potassium 50 mg PO BID
13. Novolog 12 Units Breakfast
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8h:prn Disp #*90
Tablet Refills:*0
2. Furosemide 10 mg PO DAILY:PRN leg swelling
Take as needed for leg swelling
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Novolog 12 Units Breakfast
5. ipratropium bromide 0.03 % nasal QID:PRN
6. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
7. Levothyroxine Sodium 200 mcg PO 2X/WEEK (___)
8. Losartan Potassium 50 mg PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Mirtazapine 30 mg PO QHS
11. Oxazepam 10 mg PO TID
12. pirfenidone 801 mg oral TID
13. Ranitidine 150 mg PO BID
14. Rosuvastatin Calcium 5 mg PO QPM
15. Voriconazole 200 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Failure to thrive
SECONDARY DIAGNOSIS:
Idiopathic pulmonary fibrosis
Aspergillosis
Bronchiectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with h/o ILD, aspergillosis, lung mass. Now
presenting with cachexia and fatigue.// Please do high-res imaging of the
lung. please eval for malignancy, infection, interval change
TECHNIQUE: Contrast enhanced multidetector CT performed of the entire volume
of the thorax with multi planar reformations and MIP reconstructions.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.9 s, 30.5 cm; CTDIvol = 6.0 mGy (Body) DLP = 182.8
mGy-cm.
Total DLP (Body) = 183 mGy-cm.
COMPARISON: ___
FINDINGS:
FINDINGS:
No suspicious thyroid lesions. No supraclavicular or axillary adenopathy. No
gross breast lesions. No adrenal lesions. Mildly patulous appearance of the
esophagus. Multiple borderline mediastinal lymph nodes (some of them being
partially calcified) appear relatively similar compared to most recent prior
imaging. Cardiomegaly. Subendocardial hypodensity in the left ventricular
apex suggesting fatty metaplasia and a prior left ventricular myocardial
infarct. No pericardial effusion. Moderate aortic valve calcification.
Moderate coronary artery calcification. Evidence of prior CABG procedure.
Upper limits of normal ascending aorta measuring 40 mm in AP diameter. This
appears similar compared to prior imaging. Moderate calcific atherosclerotic
changes of the thoracic aorta. The pulmonary artery measures at the upper
limits of normal and pulmonary hypertension should be excluded. No pulmonary
arterial filling defects on this nondedicated study. No pleural effusion.
Moderate spondylotic changes of the thoracic spine. No lytic/destructive bony
lesions. Evidence of previous midline sternotomy.
Abnormal shape of the trachea suggesting tracheobronchomalacia. Expiratory
phase imaging may be performed to better evaluate for this. The biapical
pleural-parenchymal scarring is unchanged. There is been marked interval
improvement in the large cavitary lesion in the right upper lobe with the
suspected intracavitary mycetoma not being visualized on today's study.
Peribronchovascular airspace opacification in the right upper lobe appears
relatively similar compared to prior. Saccular bronchiectasis in the right
middle lobe appear similar compared to prior. Fairly diffuse fibrotic
interstitial lung disease appear similar compared to prior. Large
ground-glass opacity/mass in the left lower lobe measuring approximately 39 x
24 mm appear similar compared to prior (4, 141). No new areas of airspace
consolidation to suggest superimposed pneumonia.
IMPRESSION:
The previously noted cavitary lesion in the right upper lobe with an
intracavitary mycetoma shows marked interval improvement now being decreased
in size with no intracavitary mycetoma identifiable. The fibrotic
interstitial lung disease appear similar compared to prior imaging.
The ground-glass lesion/mass in the left lung base appear similar compared to
prior.
No new areas of airspace consolidation to suggest superimposed pneumonia.
Non physiological shape of the trachea suggesting tracheobronchomalacia.
Dynamic expiratory imaging may be performed to further assess for this.
Dilated pulmonary artery and pulmonary hypertension should be excluded.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with malignancy, DOE// 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 right or left lower extremity
veins.
Gender: M
Race: ASIAN - ASIAN INDIAN
Arrive by WALK IN
Chief complaint: Chest pain, L Shoulder pain
Diagnosed with Dyspnea, unspecified
temperature: 98.4
heartrate: 74.0
resprate: 16.0
o2sat: 95.0
sbp: 182.0
dbp: 72.0
level of pain: 7
level of acuity: 2.0 | ___ w/ h/o IPF, pulmonary MAC, aspergillosis, LLL mass likely
adenoCA, CAD s/p CABG, presenting with lethargy and failure to
thrive. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nifedipine / Verapamil / amlodipine
Attending: ___
Chief Complaint:
dyspnea, fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history of breast cancer on tamoxifen, ___, CKD, HTN, and
poorly
controlled IDDM who presented with dyspnea and fevers.
Patient with limited ability to provide history due to memory
issues. Unable to reach grand-niece/HCP. History obtained from
ED
and review of ED records.
EMS was called by patient's family because she was feeling weak
and tired. She was found to have a temperature of 101.6. She was
noted to be dyspneic with O2 sats of 91% on RA. They placed her
on a non-rebreather and transported her to the ED.
In the ED, she was febrile to 101.2. She was given a dose of CTX
and azithromycin.
Past Medical History:
-Breast Cancer (L. breast papillary carcinoma, on tamoxifen)
-Chronic diastolic heart failure (last ECHO ___, >55%)
-Hypertension.
-Mixed dyslipidemia ___, TC 108, ___ 110, HDL 38, LDL 47).
-Chronic atrial fibrillation, on Eliquis.
-Type 2 diabetes ___ - A1c 10.2%)
-PE in ___
-Elevated ALP, suspected Paget's Disease
-Thyroid Nodule
-Chronic Kidney disease
-Peripheral Neuropathy
Social History:
___
Family History:
Significant hx of DM2, her sister's daughter had sarcoidosis
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: 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. Unable to assess
JVP
due to body habitus
RESP: Lungs clear to auscultation with good air movement
bilaterally. Lungs clear but frequent productive cough noted
GI: Abdomen soft, non-distended, non-tender to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. Trace edema in lower
extremities b/l
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: Reviewed in POE, afebrile, rest of VSS
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. Unable to assess
JVP
due to body habitus
RESP: Bilateral crackles at bases, improved since admission, no
respiratory distress
GI: Abdomen soft, non-distended, non-tender to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. Trace edema in lower
extremities b/l
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-12.9* RBC-4.45 Hgb-10.4* Hct-34.2
MCV-77* MCH-23.4* MCHC-30.4* RDW-15.9* RDWSD-43.6 Plt ___
___ 08:30PM BLOOD Neuts-78.7* Lymphs-12.2* Monos-7.9
Eos-0.5* Baso-0.2 Im ___ AbsNeut-10.09*# AbsLymp-1.57
AbsMono-1.02* AbsEos-0.07 AbsBaso-0.03
___ 08:30PM BLOOD ___ PTT-30.2 ___
___ 08:30PM BLOOD Glucose-92 UreaN-25* Creat-1.5* Na-138
K-4.9 Cl-100 HCO3-25 AnGap-13
___ 08:30PM BLOOD ALT-18 AST-24 CK(CPK)-225* AlkPhos-119*
TotBili-0.3
___ 08:30PM BLOOD CK-MB-3 proBNP-6484*
___ 08:30PM BLOOD cTropnT-0.02*
___ 08:30PM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.0 Mg-2.2
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-9.5 RBC-4.55 Hgb-10.6* Hct-34.7
MCV-76* MCH-23.3* MCHC-30.5* RDW-15.3 RDWSD-42.5 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-86 UreaN-32* Creat-1.4* Na-146
K-4.7 Cl-98 HCO3-32 AnGap-16
___ 07:30AM BLOOD Calcium-8.9 Mg-2.3
CXR ___:
No acute intrathoracic process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Atorvastatin 20 mg PO DAILY
3. Clotrimazole Cream 1 Appl TP BID:PRN rash
4. Cyanocobalamin 1000 mcg PO DAILY
5. Gabapentin 600 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Ranitidine 150 mg PO QHS
9. Senna 8.6 mg PO DAILY:PRN constipation
10. Tamoxifen Citrate 20 mg PO DAILY
11. Torsemide 100 mg PO DAILY AT 1500
12. Vitamin D 400 UNIT PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. NPH 20 Units Breakfast
NPH 10 Units Dinner
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Levofloxacin 500 mg PO Q48H Duration: 2 Days
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth every 48
hours Disp #*2 Tablet Refills:*0
2. NPH 20 Units Breakfast
NPH 10 Units Dinner
Insulin SC Sliding Scale using REG Insulin
3. Apixaban 2.5 mg PO BID
4. Atorvastatin 20 mg PO DAILY
5. Clotrimazole Cream 1 Appl TP BID:PRN rash
6. Cyanocobalamin 1000 mcg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 600 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Ranitidine 150 mg PO QHS
13. Senna 8.6 mg PO DAILY:PRN constipation
14. Tamoxifen Citrate 20 mg PO DAILY
15. Torsemide 100 mg PO DAILY AT 1500
16. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Community Acquired Pneumonia
Heart Failure Exacerbation
Hypoxia (low oxygen levels)
Foot pain due to diabetic neuropathy
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 fever, hypoxia// PNA
COMPARISON: ___
FINDINGS:
AP and lateral views of the chest were provided.
Lung volumes are low. Increased interstitial markings appears similar prior
exams and may be due to low lung volumes. There is no definite focal
consolidation. There is no definite pleural effusion or pneumothorax. Mild
cardiomegaly appears stable.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: 98.7
heartrate: 79.0
resprate: 30.0
o2sat: 100.0
sbp: 158.0
dbp: 61.0
level of pain: Critical
level of acuity: 1.0 | Ms. ___ is a ___ female with the past medical history
of breast cancer on tamoxifen, dCHF, CKD, HTN, and poorly
controlled IDDM who presented with dyspnea and
fevers.
# Community acquired pna:
# Hypoxia:
Pt's niece reports that she had URI symptoms prior to admission
that then worsened
to fevers. No obvious consolidation on CXR but likely early
pna. She was treated with CTX/Azithro->Levaquin for completion
of 7 day course. Fevers and hypoxia resolved with this. Pt
also seen by SLP who did not feel sx were due to aspiration.
Recommended soft diet with thin liquids.
# HFpEF exacerbation:
Pt also had some mild lower extremity edema but no overt edema
on CXR, could consider volume overload as cause of hypoxia given
concomitant elevated BNP (6800 on admission). On review of
outpatient notes, her torsemide was recently increased from
80->100mg given increased ___ edema c/f volume overload.
Torsemide further increased to 120 while pt was here given
vascular congestion and ___ edema on exam. I/O was unable to be
tracked given her incontinence but her b/l crackles on lung exam
and ___ edema improved with this increased dose. Torsemide will
be decreased back to 100mg on discharge.
# Hypertension:
- held home lisinopril given concern for developing infection,
restarted on discharge
# Atrial fibrillation:
- continued home apixaban
# DM:
- continued home NPH 20 units with breakfast, 10 units dinner
- ISS
# HLD:
- continued home atorvastatin
# History of breast cancer
- continued home tamoxifen
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lopressor / Apomorphine / morphine / Coconut / Stadol / fentanyl
/ pain meds / muscle relaxant / Erythromycin Base / Codeine /
metal / surgical skin staples
Attending: ___
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with osteoporosis and several known compression fractures
and recent vertebroplasty L1 and L5, CAD s/p CABG ___ presents
with worsening back pain. Pt with chronic back pain with acute
excerb starting last night. She went to the restroom and
developed sharp pain around R rib. Pain comes and goes and made
worse with movement.
___ notes that the R side of her back feels like more of a
cramp while the L side is a severe pain. This has been coming
and going for last several months. Over the last couple of
months, she has intermittently walked with a walker because she
feels unsteady on her feet. She denies any associated fevers,
bowel or bladder incontinence.
The patient initially began experiencing severe back pain in
___. It had not improved by the following month,
and she was seen by Dr. ___ at ___, and MRI at that
time revealed L1, L5 compression fractures, for which she
underwent kyphoplasty. Her pain was not relieved
post-procedurally however, and she had significant pain in a
band-like distribution around her hips. She was re-hospitalized
in ___ at ___, and imaging done at that time
showed L2 compression fracture, which was presumed to be new.
They were reluctant to perform another kyphoplasty at that time,
given her minimal improvement. She had been gradually improving
since that time, even though bone density scanning done in ___
showed previously-unseen T11, T12 compression fractures in
addition. She then began aquatherapy in ___, and after
the third session, began experiencing worsened, acute pain in
her middle/low back, which was sudden in onset.
In the ED initial vitals were: 98.0 ___ 16 100% ra
- Labs were significant for Na 131. Otherwise unremarkable.
- Patient was given IV morphine 15mg, diazepam, and ondansetron.
CT Abdomen/Pelvis showed 1. No evidence of aortic dissection. 2.
Multiple thoracolumbar compression
deformities, similar to the recent MRI thoracolumbar spine from
___.
She was evaluated by Ortho Spine, who recommended TLSO brace and
admission to Medicine for further management.
Vitals prior to transfer were: 97 150/77 18 99% RA
On the floor, patient is complaining of cramping throughout her
back which is not new, but worse than before. She is also
feeling lightheaded and nauseous from all the pain medication
she received in the ER. She says she always has these reactions
to all pain medications and muscle relaxants.
Past Medical History:
-Osteoporosis
-Coronary artery disease s/p CABG ___
-Hypertension
-Hyperlipidemia
-Hypothryoidism
-Vertebral compression fractures as above
-RLE Melanoma: Biopsy ___ at least 1.75 mm thick,
___ Level IV, nonulcerated melanoma, extended to deep margin
with 4 mitoses/mm2. s/p wide local excision and right inguinal
sentinel lymph node biopsy ___.
Pathology revealed no residual melanoma at the primary site, and
no melanoma in 1 inguinal sentinel lymph node
Past Surgical History:
2-vessel CABG
Right calf melanoma excision
Social History:
___
Family History:
No family history of early fractures
Physical Exam:
Admission Physical
===================
Vitals - T:97.3 BP:150/81 HR:86 RR:16 02 sat:97RA
GENERAL: Patient laying on her L side, intermittently dry
heaving, tearful, in moiderate distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: midline scar, RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: unable to assess strength completely due to
discomofort, 4+plantar flexion and dorsiflexion b/l, ___ UE
strength b/l
BACK: no midline spinal tenderness on initial evalaution but
patient reported pain in her spine shortly after palpation.
patient had L sided lumbar paraspinal tenderness
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact, downgoing toes b/l, 1+ patellar
reflexes b/l
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical
====================
Vitals- 98.3 98 104-133/48-60 56-70 ___ 98% RA
GENERAL: Resting comfortably in bed
CARDIAC: midline scar, RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: unable to assess strength completely due to
discomfort, moving all extremities
BACK: no midline spinal tenderness, patient had L sided lumbar
paraspinal tenderness, R side with medicated patches
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact, downgoing toes b/l, 1+ patellar
reflexes b/l
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs
==============
___ 03:15PM BLOOD WBC-8.9 RBC-4.41 Hgb-14.4 Hct-44.1
MCV-100* MCH-32.6* MCHC-32.6 RDW-13.3 Plt ___
___ 03:15PM BLOOD Neuts-73.4* ___ Monos-4.5 Eos-0.7
Baso-0.5
___ 07:00AM BLOOD Glucose-85 UreaN-13 Creat-0.9 Na-137
K-4.4 Cl-97 HCO3-30 AnGap-14
___ 07:00AM BLOOD Albumin-4.3 Calcium-10.0 Phos-4.8* Mg-2.2
Urinalysis
============
___ 06:20PM URINE Color-Straw Appear-Clear Sp ___
___ 06:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:20PM URINE Hours-RANDOM UreaN-193 Creat-23 Na-56
K-21 Cl-60
___ 06:20PM URINE Hours-RANDOM
___ 06:20PM URINE Osmolal-260
Discharge Labs
==============
___ 07:00AM BLOOD WBC-4.0 RBC-3.71* Hgb-12.3 Hct-36.3
MCV-98 MCH-33.1* MCHC-33.8 RDW-13.1 Plt ___
___ 07:00AM BLOOD ___ PTT-38.6* ___
___ 07:30AM BLOOD Glucose-127* UreaN-10 Creat-0.7 Na-135
K-4.8 Cl-98 HCO3-28 AnGap-14
___ 07:00AM BLOOD Calcium-10.2 Phos-3.2 Mg-2.0
Imaging
=============
Scoliosis Series ___
FINDINGS: No previous images. There are kyphoplasties at what
appear to be T12 and L4. Some loss of height is seen at L1,
T12, T11, and T9. Generalized osteopenia is seen. There is
minimal scoliosis convexed to the right and centered at about
T9. Slightly more scoliosis convexed to the left centered at
L1.
The intervertebral disc spaces in the lumbar spine appear to be
quite well
maintained.
Bilateral Hip Xray ___
IMPRESSION: Bony demineralization. No fracture or bone
destruction
identified.
Rib Xray ___
FINDINGS: Frontal and oblique views show no evidence of
fracture or
pneumothorax. Several vertebroplasties are seen in the
thoracolumbar spine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO HS
2. Estrogens Conjugated 0.625 gm VG 2X/WEEK (MO,FR)
3. fesoterodine 8 mg oral Daily
4. Gabapentin 300 mg PO HS
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Losartan Potassium 25 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Calcium Carbonate 1250 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Atorvastatin 10 mg PO DAILY
11. NIFEdipine 10 mg PO QHS
12. Zolpidem Tartrate 10 mg PO HS
13. Omeprazole 20 mg PO DAILY
14. black cohosh 40 mg oral Daily
15. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amitriptyline 25 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Calcium Carbonate 1250 mg PO DAILY
5. fesoterodine 8 mg oral Daily
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. NIFEdipine 10 mg PO QHS
10. Omeprazole 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Zolpidem Tartrate 10 mg PO HS
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
14. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice a day Disp #*20 Packet Refills:*0
15. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Tizanidine 4 mg PO TID
RX *tizanidine 4 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
17. black cohosh 40 mg oral Daily
18. Estrogens Conjugated 0.625 gm VG 2X/WEEK (MO,FR)
19. Baclofen 10 mg PO Q8H:PRN back pain
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*20 Tablet Refills:*0
20. Methadone 2.5 mg PO BID
RX *methadone 5 mg 0.5 (One half) tablet by mouth twice a day
Disp #*15 Tablet Refills:*0
21. Gabapentin 400 mg PO BID
22. Gabapentin 600 mg PO HS
23. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-Chronic Vertebral Compression Fractures
-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
INDICATION: ___ woman with severe back pain, evaluate for compression
fracture and evaluate the aorta.
TECHNIQUE: Axial multidetector CT images were obtained through the chest,
abdomen and pelvis during rapid administration of intravenous contrast.
Multiplanar reformats.
DLP: 826 mGy-cm.
COMPARISON: MRI of the thoracic and lumbar spine dated ___.
FINDINGS:
CTA: Moderate atherosclerotic calcifications are noted along the infrarenal
abdominal aorta and iliac arteries without aneurysmal dilatation. There is no
evidence of aortic dissection.
CT CHEST: There is no axillary, mediastinal or hilar lymphadenopathy by CT
criteria. Heart is normal in size and there is no pericardial effusion.
Trachea is midline and airways are patent to subsegmental level. Background
lung parenchyma is notable for mild bibasilar atelectasis. There are no
concerning nodules, focal consolidation or pleural effusion. No pneumothorax.
Sternotomy wires are noted.
CT ABDOMEN: Liver enhances homogeneously without concerning lesions or
biliary dilatation. Cholecystectomy clips are noted. Prominent CBD likely
relates to post cholecystectomy state. Spleen, pancreas and adrenal glands are
unremarkable. Kidneys enhance and excrete symmetrically without concerning
lesions or hydronephrosis.
Stomach is partially decompressed. A diverticulum is incidentally noted
arising from the posterior gastric fundus. Nondilated loops of small bowel
are normal in course and caliber. There is no obstruction or bowel wall
thickening. There is no intra-abdominal free air or fluid. There is no
mesenteric or retroperitoneal lymphadenopathy.
CT PELVIS: The bladder is well distended and within normal limits. Uterus is
not visualized. There is no pelvic free fluid or lymphadenopathy.
BONE WINDOWS: Transitional anatomy with lumbarization of S1 is again noted.
There is evidence of prior vertebroplasty in the L1 and L5 vertebral bodies.
Multiple compression deformities in the thoracolumbar spine including T9, T11,
T12, L1, and L5 are better evaluated on recent MRI examination of ___ and appear relatively unchanged. No new fracture is identified.
IMPRESSION:
1. No evidence of acute aortic abnormality.
2. Multiple compression deformities in the thoracolumbar spine and evidence
of prior vertebroplasty, not significantly changed and better evaluated on MRI
from three days prior.
Radiology Report
HISTORY: Compression fractures.
FINDINGS: No previous images. There are kyphoplasties at what appear to be
T12 and L4. Some loss of height is seen at L1, T12, T11, and T9. Generalized
osteopenia is seen. There is minimal scoliosis convexed to the right and
centered at about T9. Slightly more scoliosis convexed to the left centered
at L1.
The intervertebral disc spaces in the lumbar spine appear to be quite well
maintained.
Radiology Report
BILATERAL HIP AND PELVIS RADIOGRAPHS
HISTORY: Question lytic lesion, fracture or dislocation; osteoporosis,
multiple spine fractures, and bilateral hip pain.
COMPARISONS: Recent prior CT dated ___.
TECHNIQUE: Bilateral hips, two views of each side, and AP pelvis.
FINDINGS: The patient is status post vertebroplasty of the L4 vertebral body,
which is visible on the pelvis views, but not completely characterized. The
hip joint spaces appear preserved. On the right, there is a small ossicle
superolateral to the acetabulum consistent with an os acetabulum, considered a
normal variant. There is no evidence for fracture, dislocation or bone
destruction. The bones appear demineralized.
IMPRESSION: Bony demineralization. No fracture or bone destruction
identified.
Radiology Report
HISTORY: Back pain and rib pain.
FINDINGS: Frontal and oblique views show no evidence of fracture or
pneumothorax. Several vertebroplasties are seen in the thoracolumbar spine.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with FX DORSAL VERTEBRA-CLOSE, OVEREXERTION FROM SUDDEN STRENUOUS MOVEMENT
temperature: 98.0
heartrate: 111.0
resprate: 16.0
o2sat: 100.0
sbp: 153.0
dbp: 100.0
level of pain: 10
level of acuity: 3.0 | ___ with osteoporosis and several known compression fractures
and recent vertebroplasty L1 and L5, CAD s/p CABG ___ presents
with severe back pain.
#Back Pain with Vertebral Fractures - Patient has known
compression fractures at T11, T12, L1, L2 and L5 with history of
kyphoplasty at L1 and L5 prior to this admision. She was seen
throughout her stay by orthopedics and pain management. THere
was also extensive discussion with Interventional Radiology. She
unforunately after her kyphoplasty had extrusion of cement that
was in the spinal canal but not compressing the cord. Throughout
her stay she had very difficult to control left sided mid-back
pain. One reason was her intolerance of many medications. She
had nausea, vomiting, flushing, and fatigue to opiates and
muscle relaxants. She was attempted to be treated with
anti-emetics, however her QTc was prolonged which made treatment
difficult. She initially was treated with topical medications
including capsaicin and lidocaine patch but developed marked
skin irritation. Her pain was attempted to be controlled with
oral medications as well including tizanidine, baclofen, and
dilaudid but while these imprved her pain, she still had pain
that limited her to the point where she could not lie on her
back, sit in a chair, or move from sit to stand. She did improve
after spinal injection with steroids. There was discussion of
repeate kyphoplasty, but there was concern of spinal procedures
destabilizing her other vertebrae and putting her at more risk
of addtional fractures. Orthopedics was asked about the
possibility of removal of the cement, but they thought that any
procedure on her spine was dangerous given how soft her bones
were. They did recommend she be in TLSO brace at all times. She
was evaluated by ___ who noted that she still retained enough
functional strength that she did not need inpatient ___. She was
discharged with a new pain regimen, home ___, recommendation to
continually wear the TLSO brace, and close follow up with her
outpatient pain team to continue management and to decide if she
needed further surgical intervention.
#Osteoporosis - Patient had presented with a diagnosis of
osteoporosis with confirmation previously with DEXA scan based
on outpatient records. In hospital she had multiple images
consistent with osteoporotic bones. She had a family history of
osteoporosis. Initially there was concern that her symptoms
could be related to a malignancy, however, upon contacting the
neurosurgeon who had treated her previously, she had a negative
bone biopsy during her previous kyphoplasty. Her SPEP/UPEP were
not consistent with multiple myeloma. Her recent MRI of her
spine and her xrays of hips and ribs did not show any
destructive lesions consistent with malignancy. Additionally her
calcium remained normal during her stay. Her rheumatologist had
planned to start Prolia for her osteoporosis, which should be
continued after she was discharged from the hospital. She was
continued on her calcium and vitamin D.
#Hypovolemic Hyponatremia - She was initially hyponatremic in
setting of decreased PO intake. She was dry on exam, and this
resolved with fluids making the most likely reason a prerenal
etiology.
#Hypothyrodism - She appeared euthyroid and was continued on her
levothyroxine
#CAD s/p CABG - She remained asymptomatic and was continued on
her statin and aspirin.
#Hypertension - She remained normotensive and was continued on
losartan and nifedipine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
tramadol / Amoxicillin
Attending: ___.
Chief Complaint:
RUQ abdominal pain s/p lap CCY
Major Surgical or Invasive Procedure:
ERCP with stone removal
History of Present Illness:
___ s/p laparoscopic cholecystectomy 2d ago at ___ represents with new RUQ pain. Her surgical indication
was gallstones and biliary pain, though it is unclear if she had
cholecystitis at the time of operation. She was DC'd home
yesterday in minimal pain. She ate dinner last night and the RUQ
pain began again. She re-presented to ___ where CT
showed
a dilated CBD so she was transferred here in consideration for
ERCP.
Past Medical History:
PMH: migraines
PSH: lap CCY ___
Social History:
___
Family History:
non-con
Physical Exam:
GEN: well appearing, in NAD
VS: 99.4, 88, 118/68, 18, 94% RA
CV: RRR, nl s1/s2
Pulm: CTA bilaterally
ABD:soft, mild tenderness, nondistended, no rebound/guarding
Incisions: 3 port sites with sutures in place, c/d/i, no
erythema or induration
Pertinent Results:
___ 06:20PM ALT(SGPT)-105* AST(SGOT)-34 ALK PHOS-145* TOT
BILI-0.6
___ 09:01PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:00PM PLT COUNT-225
___ 09:00PM NEUTS-53.8 ___ MONOS-5.0 EOS-4.0
BASOS-0.2
___ 09:00PM WBC-8.0 RBC-4.04* HGB-12.6 HCT-37.2 MCV-92
MCH-31.2 MCHC-33.9 RDW-11.7
___ 09:00PM ALBUMIN-3.9
___ 09:00PM LIPASE-16
___ 09:00PM ALT(SGPT)-135* AST(SGOT)-67* LD(LDH)-212 ALK
PHOS-161* TOT BILI-0.7
___ 09:00PM estGFR-Using this
___ 09:00PM GLUCOSE-85 UREA N-7 CREAT-0.5 SODIUM-138
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-24 ANION GAP-11
MRCP: 2mm stone in the pancreatic portion of the cbd (ser 5 im
25 and ser 14 im 80). cbd measures 9mm. no intrahepatic biliary
dilitation. . small amt of fluid and air in the abdomen likely
post op.
CT abd/pelv: IMPRESSION:
1. Common bile duct measures 10 mm and is likely distended
secondary to
post-cholecystectomy state. No definite large intraluminal
filling defect,
small stone not excluded, although MRCP/ERCP is more sensitive.
2. Free air and free fluid within the abdomen likely sequelae of
recent
cholecystectomy. Minimal soft tissue edema and locules of air in
the anterior
abdominal soft tissues also likely represent recent procedure.
3. 22 x 16-mm hypodensity in the right vaginal area likely
represents a
Bartholin cyst.
Medications on Admission:
None
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Retained common bile duct stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with concern for retained stone, postoperative
day #3.
TECHNIQUE:
Multiplanar T1- and T2-weighted images of the abdomen were performed per MRCP
protocol after the administration of 15 cc of gadopentetate dimeglumine
(Magnevist).
COMPARISON:
CT of the abdomen and pelvis from ___.
FINDINGS:
MRCP:
There is minor bibasilar atelectasis, unchanged from ___.
There are no focal hepatic lesions.
There is no intrahepatic biliary dilatation, but mild periportal edema (series
13, image 6; series 7, image 1; series 4, image 13). There is no peribiliary
enhancement.
The CBD measures about 6 mm, within normal limits after cholecystectomy.
In the distal CBD, there is a questionable filling defect (se 7, img 1) on the
thick slab MRCP images, but not definitely confirmed on thinner images.
The filling defect which was reported on the preliminary report (wet read)
likely represents a flow artifact (se 5, img 25 and se 14, img 80).
The spleen is normal measuring 10 cm. The pancreas is normal in signal
intensity and morphology. The main pancreatic duct is not dilated.
There is no retroperitoneal or mesenteric lymphadenopathy. The adrenal glands
and kidneys are normal.
The partially visualized small and large bowel are normal.
There is small amount of free fluid in ___ pouch and surrounding the
liver, as well as in the gallbladder fossa.
The portal venous, systemic venous and arterial system of the upper abdomen is
normal.
The bone marrow signal is preserved.
IMPRESSION:
1. Questionable filling defect in the distal common bile duct is not
confirmed on thinner images. The filling defect which was reported in the
preliminary report likely represents flow artifact.
2. CBD measures about 6 mm, within normal limits after cholecystectomy.
3. Small amount of free fluid in the upper abdomen, likely postsurgical.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN RUQ, CHOLELITHIASIS NOS
temperature: 97.3
heartrate: 86.0
resprate: 14.0
o2sat: 99.0
sbp: 124.0
dbp: 80.0
level of pain: 4
level of acuity: 3.0 | Patient was admitted to ___ service on ___ with RUQ
abdominal pain after laparoscopic CCY. CT abd/pelv was
performed which showed a common bile duct measuring 10mm without
any definite large intraluminal filling defect. However, a
small stone could not be excluded. Patient underwent MRCP which
showed evidence fo a 2mm retained stone in the common bile duct
and a CBD 9mm. ERCP was consulted and patient underwent ERCP
with sphincterotomy with stone extraction on hospital day one.
The patient tolerated the procedure well.
Neuro: Post-operatively, the patient received Dilaudid IV with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. Intake and output were closely
monitored.
ID: The patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient was encouraged to get up and ambulate
as early as possible.
At the time of discharge on hospital day 2, POD#1, the patient
was doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Word salad/trouble with speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ right handed woman with a past medical
history of pancreatic cancer s/p Whipples in ___, prior small
right frontal stroke" in ___ and hypertension who presents
for evaluation of mixed aphasia concerning for ischemic stroke.
History gathered from the patient and her daughter who is at
bedside.
To review her recent history in brief, she recently hospitalized
at ___ in ___ for symptoms of right side of her
mouth feeling "funny" and "different sounding speech". She
presented to ___ and was admitted with concern for stroke
vs TIA. INR was found to be subtherapeutic and subsequent MRI
revealed small focus of right frontal ischemia with question of
microbleed on GRE sequence. This bleed was not seen on
subsequent CT scan. She was started on lovenox and bridged back
to therapeutic Coumadin (goal INR ___ prior to discharge.
Since that discharge, I am told that she entirely returned to
her
baseline, with no language difficulties. Over the past 2 weeks
however, she has had a viral illness- cough, nausea, diarrhea,
which resolved today.
This morning, she awoke feeling well. At around 5pm she was at
home alone and had a fall (reportedly mechanical, no presyncope,
no head trauma). She was on the ground, but unable to get up
without assistance. She was found by her daughter roughly 1
hour
later, comfortably sitting on the ground, but required help to
get up. Of note, I am told she has had several falls in the
past, including a few that she was unable to get up from
spontaneously.
Later in the day, roughly 7pm, she was having a conversation
with
her son-in-law when she "could not say what [she] wanted to
say".
She just "couldn't get the words out. She sounded like she had
"marbles in her mouth" according to her son in law. Language
comprehension was reportedly intact She also endorsed numbness
on the top of her lip. Concerned, EMS was called. This episode
was very similar to her prior presentation in ___.
There, she was evaluated and given an ___ of 7 (points for LOC
questions, right leg with some effort, mild-moderate aphasia,
mild-moderate ataxia). NCHCT was w/o evidence of stroke or
hemorrhage. INR was subtherapeutic. She was transferred for
further evaluation.
Though exact timeline is unclear, it appears her language
symptoms have significantly improved, but are not entirely back
to normal.
RoS Notable for unclear intermittent chronic dysphagia and
several falls in the past.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus
or hearing difficulty. Denies difficulties 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. 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.
Past Medical History:
- Anxiety
- Cataracts
- Pancreatic cancer-status post Whipple in ___
- Uterine fibroids
- Hypertension
- Atrial fibrillation
- Arthritis
- Status post 3 C-sections
- Status post left knee replacement
- DM (A1C 6.7 in ___
Social History:
___
Family History:
- Father died of heart disease at ___. Mother with stroke (in
her
___.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97.9 64 193/87 16 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM, no lesions noted in oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND.
Extremities: WWP, mild ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person and "hospital". Does
not remember ___. When asked to state date, first says she
cannot
remember, then she states "Fourteen and the next day after"
followed by "one and another day" then 17. Knows year is ___.
Able to relate history without difficulty. Attentive to
examiner,
but struggles to name ___ forward (I suspect due to language),
misses ___ and cannot remember word for ___ and
___.
Language is fluent when spontaneous, with occasional pauses for
word finding and rare paraphasias. Repetition for simple words
and small phrases is mostly intact (infrequent errors). Longer
sentences "it is a cold night in ___ "It is a whole night
in ___. Longer sentences with more errors. Comprehension
is
impaired, and she struggles with tasks (point to door then
ceiling) and much of examination.
There were multiple paraphasic errors on directed language
tasks,
but less frequent with spontaneous speech. Trouble with Naming,
from ___ calls glove "klove", chair is "chicken" and then
corrects herself, calls feather--> hair. Names hammock, but
cannot name cactus, but says it would be in ___. Able to
read, but with significant errors "Down to earth"--> "Down to
youth". Another sentence becomes "Do the tray Christmas".
Speech was not dysarthric. Able to follow both midline and
appendicular commands, within limitation of language
difficulties. Uses both hands as tools on assessment of single
hand apraxia (despite multiple statements not to), but able to
light match. No evidence of visual extinction.
-Cranial Nerves:
II, III, IV, VI: PERRL 2 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
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. Right arm with a jerky,
but
clear pronator drift. He demonstrates intermittent jerky tremor
that on occasion appears similar to asterexis.
Evaluation of motor examination is somewhat limited due to motor
impersistence and comprehension limitations. Below is best
assessment, though remains limited
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 4+ 5 5 5 5
R 4+ 5- 4+ 5- ___- 4 5- 4+ 4+ 5-
Right hip somewhat limited due to chronic pain.
-Sensory: Reports significant decrease in sensation in right arm
and leg (not face) to light touch, cold and pinprick.
Proprioception cannot be reasonably evaluated. DSS difficult to
evaluation, but I believe is not present.
-DTRs:
___ Tri ___ Pat Ach
L 1 1 1 2 2
R 2 2 2 2 2
Toes are down going bilaterally.
Patellar reflex only able to be elicited suprapatellar
Plantar response was flexor bilaterally.
-Coordination: Mild Ataxia in RUE, not out of proportion to
above
weakness. Heel shin cannot be done due to comprehension
-Gait: Deferred, requires a walker at baseline
.
=============================
.
DISCHARGE PHYSICAL EXAM
VS 98.7F/98.0F, 140-184/72-96, HR 50-70S, RR ___, 98% on RA,
Having BM's and UO. Glucose 130-180s
Gen - NAD, pleasant, cooperative
Mental status - Alert, oriented x3, names high and low frequency
words, repeats well - no paraphasic errors. Follows 3 step
command. Comprehension of complex sentence intact.
Cranial nerves - PERRL, EOMI, no ptosis, eyes orthotropic, face
symmetric on smile
Motor - ___ in right deltoid. 4+/5 in right IP and hamstring
likely limited by pain with give way weakness. Otherwise ___ in
UE and ___.
Sensory - Intact to light touch bilaterally in all four
extremities.
Coordination - Mild dysmetria in right upper extremity on
finger/nose/finger compared to left.
Pertinent Results:
___ 07:20AM BLOOD WBC-8.2 RBC-3.78* Hgb-11.2 Hct-34.8
MCV-92 MCH-29.6 MCHC-32.2 RDW-12.9 RDWSD-43.1 Plt ___
___ 11:58PM BLOOD ___ PTT-31.5 ___
___ 07:20AM BLOOD Glucose-134* UreaN-11 Creat-0.6 Na-142
K-3.8 Cl-104 HCO3-30 AnGap-12
___ 11:58PM BLOOD ALT-15 AST-21 AlkPhos-85 TotBili-0.5
___ 11:58PM BLOOD cTropnT-<0.01
___ 07:20AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0
___ 12:36PM BLOOD Cholest-211*
___ 12:36PM BLOOD %HbA1c-6.6* eAG-143*
___ 12:36PM BLOOD Triglyc-116 HDL-64 CHOL/HD-3.3
LDLcalc-124
___ 12:36PM BLOOD TSH-0.93
___ 11:58PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:08AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:08AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:08AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Urine Culture
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
====================
.
EKG ___
Baseline artifact. Sinus rhythm. Consider left atrial
abnormality.
Intraventricular conduction delay of the right bundle-branch
block type.
R wave reversal in leads V2-V3. Possible septal myocardial
infarction.
No previous tracing available for comparison. Clinical
correlation is
suggested.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
62 ___ 459/464 48 22 6
.
ECHO ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Diastolic function could not be assessed. 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. Mild (1+)
central aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. There
is a minimally increased gradient consistent with trivial mitral
stenosis due to mitral annular calcification. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic regurgitation.
.
HEAD AND NECK CTA ___
1. No evidence of acute intracranial hemorrhage.
2. Mild irregularity of the left M1 and right P1 segments,
likely secondary to atherosclerotic calcification, otherwise no
evidence of aneurysm greater than 3 mm, dissection or vascular
malformation.
3. A 3.2 cm low density lesion in the left aortopulmonary
window.
Differential considerations include duplication cyst, lymphocele
and necrotic lymphadenopathy. Recommend comparison with prior
studies and clinical correlation. If clinically indicated, an
MRI of the chest can be acquired for further evaluation.
4. Multi nodular thyroid gland. Recommend clinical correlation.
If
clinically indicated, consider thyroid ultrasound for further
evaluation.
5. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
6. Paranasal sinus disease as described.
7. Findings suggestive dental impaction as described. Recommend
clinical
correlation and correlation with dental exam.
RECOMMENDATION(S):
1. A 3.2 cm low density lesion in the left aortopulmonary
window.
Differential considerations include duplication cyst, lymphocele
and necrotic lymphadenopathy. Recommend comparison with prior
studies and clinical correlation. If clinically indicated, an
MRI of the chest can be acquired for
further evaluation.
2. Multi nodular thyroid gland. Recommend clinical correlation.
If
clinically indicated, consider thyroid ultrasound for further
evaluation.
3. Findings suggestive dental impaction as described. Recommend
clinical
correlation and correlation with dental exam.
.
CHEST PA AND LATERAL ___
No pneumonia.
.
MRI BRAIN WITHOUT CONTRAST ___
1. Acute infarction in Wernicke's area, and late acute/early
subacute
infarction in the left supplemental motor area, suggesting an
embolic source.
No evidence of hemorrhagic transformation.
2. Atrophy and probable chronic small vessel disease.
.
BILATERAL HIPS ___
Severe degenerative changes are seen within the right greater
than left
femoroacetabular joints. No fracture identified.
.
LUMBOSACRAL SPINE XRAY ___
Degenerative changes as detailed above. Minimal retrolisthesis
of L2 with
respect to L3. Bones appear demineralized.
.
CT HEAD WITHOUT CONTRAST
1. No new intracranial hemorrhage or new territorial infarction.
2. Subtle hypodense areas in the left frontoparietal lobes
likely correspond
to infarctions better seen on the same day MRI.
.
HIP UNILATERAL RIGHT TWO VIEW
Three views of the right hip show severe narrowing and
eburnation of the hip joint with large osteophytes and very
ostial hypertrophy extending from the femoral head through the
neck. There is no fracture currently.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO DAILY16
2. Amitriptyline 25 mg PO QHS
3. Metoprolol Succinate XL 100 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Medications:
1. Amitriptyline 25 mg PO QHS
2. Amlodipine 5 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Atorvastatin 20 mg PO QPM
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1.)Acute Left middle cerebral artery ischemic stroke
2.) Atrial fibrillation (nonvalvular)
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: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old woman with MCA territory stroke s/p fall // mild
back pain s/p fall mild back pain s/p fall
TECHNIQUE: Two views
COMPARISON: None available.
FINDINGS:
5 non-rib-bearing lumbar vertebral bodies are present. Apparent contrast
material in the bladder presumably relating to previous CT. Rounded
calcification the pelvis most likely reflects a fibroid. There is multilevel
degenerative change in lumbar spine, severe at L2-3 were there is disc space
narrowing, vacuum phenomenon and endplate sclerosis. There is minimal
retrolisthesis of L2 with respect to L3. There is moderate degenerative
discogenic change at L3-4, mild to moderate degenerative discogenic change at
L 4 5 and L5-S1. Bones appear diffusely demineralized. There is vascular
calcification. No aggressive focal bone lesion is seen.
There is mild left, moderate to severe right hip joint osteoarthritis. There
is also degenerative change at the pubic symphysis.
There are surgical clips in the upper abdomen.
IMPRESSION:
Degenerative changes as detailed above. Minimal retrolisthesis of L2 with
respect to L3. Bones appear demineralized.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with embolic appearing left frontoparietal
strokes. The patient has increased right hand clumsiness compared to prior
physical exam. Evaluate for bleed before starting apixaban.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 803 mGy-cm.
COMPARISON: MRI head from ___.
FINDINGS:
Subtle hypodense areas within the left supplemental frontal motor area and
left temporoparietal lobe likely correspond to areas of slow diffusion seen on
the recent MR from earlier in the day. Encephalomalacia in the left
cerebellar hemisphere is also noted. No new intracranial hemorrhage,
territorial infarction, mass or edema is seen. There is prominence of the
ventricles and sulci suggestive of involutional changes. Periventricular
white matter hypodensities are nonspecific but likely sequela of chronic small
vessel ischemic changes. There is no evidence of fracture, and a left
parietal skull osteoma is incidentally noted (series 3: Image 30). There is a
mucous retention cyst in the left maxillary sinus, and there is mild mucosal
thickening of the anterior bilateral ethmoid air cells. The visualized
portion of the other paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The patient is status post bilateral lens replacement.
IMPRESSION:
1. No new intracranial hemorrhage or new territorial infarction.
2. Subtle hypodense areas in the left frontoparietal lobes likely correspond
to infarctions better seen on the same day MRI.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT
INDICATION: ___ year old woman with right weakness due to stroke with fall on
right // Per rads request to eval right femoral neck poorly visualized on hip
xray Per rads request to eval right femoral neck poorly visualized on hip
xray
IMPRESSION:
Three views of the right hip show severe narrowing and eburnation of the hip
joint with large osteophytes and very ostial hypertrophy extending from the
femoral head through the neck. There is no fracture currently.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ female with aphasia and right arm weakness. Evaluate
for carotid or vertebral dissection.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP =
35.4 mGy-cm.
5) Spiral Acquisition 5.3 s, 41.5 cm; CTDIvol = 32.1 mGy (Head) DLP =
1,331.4 mGy-cm.
Total DLP (Head) = 2,264 mGy-cm.
COMPARISON: ___ outside noncontrast head CT.
___ contrast brain MRI.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of large territorial infarct, acute
intracranial hemorrhage, edema, or mass. Prominent ventricles and sulci are
compatible with age-related volume loss. Periventricular white matter
hypodensities are consistent with chronic small vessel ischemic disease.
The visualized portion of the mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable. A retention
cyst is seen in the left maxillary sinus with mucosal thickening in the
ethmoid sinuses. And impacted left mandibular tooth is seen. There is a
right maxillary radicular cysts. A 1.9 cm AP x 0.8 cm exophytic osteoma from
the left temporal calvarium.
CTA HEAD:
There is atherosclerotic calcification of the bilateral cavernous carotid
arteries. There is irregularity in atherosclerotic calcification of the left
M1 segment of the MCA with normal flow seen distally. There is minimal
irregularity of the right P1 segment of the PCA, likely secondary to
atherosclerotic calcification. Otherwise, vessels of the circle of ___ and
their principal intracranial branches appear normal without stenosis,
occlusion or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
There is a multi nodular enlarged thyroid gland. Dense atherosclerotic
calcification of the left coronary artery is seen. The visualized portion of
the thyroid gland is within normal limits. There is a 3.2 cm AP x 2.4 cm TR
low-density mass in the left aortopulmonary window (see 05:25). Multilevel
degenerative changes are noted throughout the cervical spine.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Mild irregularity of the left M1 and right P1 segments, likely secondary to
atherosclerotic calcification, otherwise no evidence of aneurysm greater than
3 mm, dissection or vascular malformation.
3. A 3.2 cm low density lesion in the left aortopulmonary window.
Differential considerations include duplication cyst, lymphocele and necrotic
lymphadenopathy. Recommend comparison with prior studies and clinical
correlation. If clinically indicated, an MRI of the chest can be acquired for
further evaluation.
4. Multi nodular thyroid gland. Recommend clinical correlation. If
clinically indicated, consider thyroid ultrasound for further evaluation.
5. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
6. Paranasal sinus disease as described.
7. Findings suggestive dental impaction as described. Recommend clinical
correlation and correlation with dental exam.
RECOMMENDATION(S):
1. A 3.2 cm low density lesion in the left aortopulmonary window.
Differential considerations include duplication cyst, lymphocele and necrotic
lymphadenopathy. Recommend comparison with prior studies and clinical
correlation. If clinically indicated, an MRI of the chest can be acquired for
further evaluation.
2. Multi nodular thyroid gland. Recommend clinical correlation. If
clinically indicated, consider thyroid ultrasound for further evaluation.
3. Findings suggestive dental impaction as described. Recommend clinical
correlation and correlation with dental exam.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ year old woman with htn, afib, presents with mixed aphasia,
likely stroke. Eval for aspiration, infection // eval for underlying inf
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Prior outside radiographs on ___
FINDINGS:
Compared with prior radiographs on ___, cardiomegaly is
unchanged.The lungs are clear without focal consolidation. There is no
vascular congestion or edema. No pleural effusion or pneumothorax is seen.
IMPRESSION:
No pneumonia.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old right handed woman with afib, htn, prior right
frontal stroke (small) who presents with mixed aphasia and mild RU and
possibly RLE weakness // Stroke eval
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ head/neck CTA, ___ outside
noncontrast brain MRI.
FINDINGS:
Study is mildly degraded by motion.
There is restricted diffusion in the left superior temporal gyrus (302:18,
300:18), compatible with an acute infarction. This is new compared to ___, but unchanged compared to the prior CTA performed earlier on
the same date. Within the left supplemental motor area, there is an
additional curvilinear focus of high DWI signal without a definite ADC
correlate (302:23), suggesting a late acute/early subacute infarction. No
evidence of hemorrhagic transformation. There is encephalomalacia in the left
cerebellum (5:4, 6:5). No shift of midline structures.
There is prominence of the ventricles and sulci suggestive involutional
changes. Bilateral scattered T2/FLAIR hyperintensities are nonspecific, but
likely represent a sequela of chronic small vessel disease. Principal
intracranial vascular flow voids are preserved.
There is a mucous retention cyst in the left maxillary sinus. Mild mucosal
thickening is also noted within the ethmoid air cells bilaterally. The orbits
are unremarkable. Left parietal skull osteoma is noted.
IMPRESSION:
1. Acute infarction in Wernicke's area, and late acute/early subacute
infarction in the left supplemental motor area, suggesting an embolic source.
No evidence of hemorrhagic transformation.
2. Atrophy and probable chronic small vessel disease.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 3:39 ___, 2 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: BILAT HIPS (AP,LAT AND AP PELVIS)
INDICATION: ? fracture after fall with right greater than left hip pain
TECHNIQUE: Frontal radiograph of the pelvis and 2 additional views of each
hip.
COMPARISON: Radiographs of the right hip performed subsequently on ___.
FINDINGS:
There is diffuse osteopenia. Severe degenerative changes are seen about the
right greater than left femoroacetabular joints, with apparent foreshortening
of the right femoral neck. No clear linear lucency is identified to
correspond to a fracture line. There is exuberant osteophytosis about the
right femoral head. Contrast material is seen within the bladder.
Degenerative changes are seen within the included portion of the lumbar spine.
IMPRESSION:
Severe degenerative changes are seen within the right greater than left
femoroacetabular joints. No fracture identified.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Aphasia
Diagnosed with Cerebral infarction, unspecified, Aphasia, Essential (primary) hypertension, Unspecified atrial fibrillation
temperature: 97.9
heartrate: 64.0
resprate: 16.0
o2sat: 96.0
sbp: 193.0
dbp: 87.0
level of pain: 0
level of acuity: 2.0 | ___ with hx of pancreatic cancer s/p remote whipple, nonvalvular
afib with missed doses of Coumadin and subtherapeutic INR on
admission with hx of prior R frontal infarct in ___ also in
the setting of subtherapeutic INR admitted with speech
difficulty found to have many paraphasic errors on exam and
problems with comprehension.
.
# L MCA stroke
Her speech improved greatly during this admission and she did
not have any paraphasic errors on the day of discharge. During
her admission
.
MRI confirmed acute left MCA territory stroke (left Wernicke's
area and left supplemental motor cortex) with embolic
appearance. Echocardiogram showed no intracardiac thrombus,
EF>55%, mild symmetric LVH, mild aortic regurgitation.
.
Regarding her stroke risk factors, her Chol 211, Trig 116, LDL
124, TSH wnl, HbA1C was 6.6%. She was started on Atorvastatin
20mg QHS for her hyperlipidemia.
.
As mentioned her INR was 1.4 on admission and she admitted to
missing multiple doses prior to this admission. To improve her
compliance, Coumadin was stopped and apixaban was started at 5mg
BID. From talking with her pharmacy her Coumadin had not been
picked up in around ___ year raising the concern for severe degree
of medication noncompliance. She will need ___ (visiting
nursing) and home safety eval after discharge from rehab.
.
# Hypertension
She was initially allowed to autoregulate her blood pressure.
During this admission her metoprolol was initially halved but on
this dose her heart rate was 50-70s - therefore she was
discharged on this half dose. From talking with her pharmacy,
she had not picked up amlodipine for many years so it is unclear
what she was taking at home. She was started on Amlodipine 5mg
daily which can be titrated up at the rehab for goal
normotension.
.
.
.
# TRANSITIONAL ISSUES
- Stopped Coumadin
- Started Apixaban 5mg BID
- Started atorvastatin 20mg QHS
- Check finger stick glucoses
- Halved beta blocker dose from Metoprolol succinate 100mg to
50mg
- Started amlodipine 5mg daily which could be increased to
achieve normotension
- Needs outpatient visiting nursing after discharge from rehab.
Needs outpatient home safety eval after discharge from rehab.
- Follow up with neurology as in dc paperwork.
- Incidental findings on CTA Head and Neck
----A 3.2 cm low density lesion in the left aortopulmonary
window.
Differential considerations include duplication cyst, lymphocele
and necrotic lymphadenopathy. Recommend comparison with prior
studies and clinical correlation. If clinically indicated, an
MRI of the chest can be acquired for further evaluation.
----Multi nodular thyroid gland. Recommend clinical
correlation. If
clinically indicated, consider thyroid ultrasound for further
evaluation.
----Findings suggestive dental impaction as described.
Recommend clinical
correlation and correlation with dental exam.
.
.
.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - ___ () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 126) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (X) No [if
LDL >100, reason not given: Plan to increase as outpatient if
needed]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
prednisone
Attending: ___.
Chief Complaint:
Scrotal cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ transverse myelitis, indwelling Foley (since ___ for
unclear reasons), BPH, who presented from home with scrotal
erythema, fever, and hematuria in setting of Foley trauma
approximately one week prior to admission.
The patient states that his Foley was inadvertently partially
pulled out a week ago and had to be replaced. He then developed
hematuria, fever, scrotal erythema and pain. His ___ sent him to
the ___ ED. ___. ___ were reportedly concerned for
possibility of ___ gangrene and gave vancomycin, Zosyn
and clindamycin. He had a CT abdomen and pelvis which reportedly
showed scrotal cellulitis with no gas. WBC was ___ at the OSH ED.
He was transferred to the ___ ED where vitals were: 98.8F, HR
82, BP 154/84, RR 20, 94% on 2L NC (baseline unknown). Scrotal
ultrasound was performed (due to lack of availability of OSH CT
images), which confirmed scrotal cellulitis and absence of gas.
He was seen by urology who recommended admission for IV
antibiotics, serial scrotal exams, and exchange of Foley
catheter.
UA showed WBCs too numerous to count with culture pending. He
was given a second dose of Zosyn and admitted to medicine.
ROS
GEN: denies fevers/chills
CARDIAC: denies chest pain or palpitations
PULM: denies new dyspnea or cough
GI: denies n/v, poor appetite, endorses constipation
GU: as per HPI
Full 14-system review of systems otherwise negative and
non-contributory.
Past Medical History:
HTN
HLD
DM (on no meds for this)
BPH
Incontinence
UTIs
Lymphedema
Morbid obesity
Ventral hernia
GERD
Anxiety and depression
PVD and venous stasis ulcers (has Unaboots)
Gout
Social History:
___
Family History:
Patient cannot tell me FH.
Physical Exam:
ADMISSION EXAM:
GEN: obese M in NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: soft, NT, ND, NABS
MSK: No visible joint effusions or deformities.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, lymphedema and brawny erythema
GU: erythematous scrotum. R epididymis enlarged.
DISCHARGE EXAM:
VS: 98.7PO 146/75 72 18 92% on RA
GEN: obese male in NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: soft, NT, ND, NABS
MSK: No visible joint effusions or deformities.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, lymphedema and brawny erythema
GU: erythematous scrotum, but much improved with less edema. R
epididymis enlarged. No erythema or crepitus of perineum
Pertinent Results:
ADMISSION LABS
--------------
___ 10:40PM BLOOD WBC-10.5* RBC-3.80* Hgb-12.0* Hct-36.0*
MCV-95 MCH-31.6 MCHC-33.3 RDW-14.7 RDWSD-51.3* Plt ___
___ 10:40PM BLOOD Glucose-124* UreaN-14 Creat-0.9 Na-136
K-3.3 Cl-99 HCO3-24 AnGap-16
___ 05:03PM BLOOD Type-ART pO2-64* pCO2-37 pH-7.46*
calTCO2-27 Base XS-2
___ 05:03PM BLOOD freeCa-1.15
MICROBIOLOGY
------------
___ 1:20 am URINE
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). 10,000-100,000 CFU/mL.
IMAGING
-------
CXR ___
1. Limited evaluation given beam underpenetration caused by
significant softtissue attenuation. Despite this limitation, no
evidence of pneumonia.
2. Apparent prominence of the left pulmonary artery may be
related totechnique, or pulmonary hypertension.
SCROTAL US ___
Right epididymitis with asymmetric, right greater than left
scrotal swelling and hyperemia consistent with cellulitis. No
evidence of subcutaneous emphysema.
DISCHARGE LABS
--------------
___ 07:45AM BLOOD WBC-6.6 RBC-3.87* Hgb-12.3* Hct-36.2*
MCV-94 MCH-31.8 MCHC-34.0 RDW-14.5 RDWSD-49.1* Plt ___
___ 07:45AM BLOOD Glucose-107* UreaN-13 Creat-0.9 Na-143
K-3.8 Cl-104 HCO3-22 AnGap-21*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. nystatin 100,000 unit/gram topical BID:PRN
3. Metoprolol Tartrate 75 mg PO BID
4. Simvastatin 10 mg PO QPM
5. DULoxetine 20 mg PO DAILY
6. HydrALAZINE 50 mg PO TID
7. Doxazosin 8 mg PO DAILY
8. amLODIPine 10 mg PO DAILY
9. Potassium Chloride 10 mEq PO DAILY
10. Finasteride 5 mg PO DAILY
11. Acetaminophen w/Codeine 1 TAB PO DAILY PRN (filled only
twice in past year)
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*16 Tablet Refills:*0
2. ___ ___ ea topical BID:PRN rash
3. Acetaminophen w/Codeine 1 TAB PO DAILY
4. Allopurinol ___ mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Doxazosin 8 mg PO DAILY
7. DULoxetine 20 mg PO DAILY
8. Finasteride 5 mg PO DAILY
9. HydrALAZINE 50 mg PO TID
10. Metoprolol Tartrate 75 mg PO BID
11. Potassium Chloride 10 mEq PO DAILY
12. Simvastatin 10 mg PO QPM
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
14. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Scrotal cellulitis
Epididymitis
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: SCROTAL U.S.
INDICATION: ___ with scrotal swelling and erythema.
TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 3.9 x 3.9 x 3.2 cm.
The left testicle measures: 4.4 x 3.2 x 3.5 cm.
The testicular echogenicity is normal, without focal abnormalities.
Vascularity is normal and symmetric in the testes.
The epididymides are symmetric in size. There is a small right epididymal
head cyst. The right epididymal head and adjacent scrotum are hyperemic. The
left epididymis demonstrates normal vascularity.
There is asymmetric, right greater than left scrotal thickening and right
scrotal hyperemia. No evidence of subcutaneous gas. There are moderate
bilateral hydroceles with scattered internal echoes.
IMPRESSION:
Right epididymitis with asymmetric, right greater than left scrotal swelling
and hyperemia consistent with cellulitis. No evidence of subcutaneous
emphysema.
Radiology Report
EXAMINATION: Portable chest radiographs
INDICATION: ___ with fever.
TECHNIQUE: Portable AP chest
COMPARISON: None available.
FINDINGS:
Substantial soft tissue attenuation limits evaluation. The right costophrenic
angle was excluded from the field of view.
The lungs are well-expanded. Allowing for under penetration of the x-ray beam
related to substantial soft tissue attenuation, the lungs are grossly clear.
The left pulmonary artery appears prominent. No pleural effusion or
pneumothorax. Heart size is likely enlarged accounting for AP view.
Cardiomediastinal and hilar silhouettes are normal. Irregularity of the
posterolateral right second rib contour raises the possibility of prior healed
fracture.
IMPRESSION:
1. Limited evaluation given underpenetration caused by significant soft tissue
attenuation. Despite this limitation, no evidence of pneumonia.
2. Apparent prominence of the left pulmonary artery may be related to
technique, or pulmonary hypertension.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Cellulitis, Scrotal pain
Diagnosed with Inflammatory disorders of scrotum
temperature: 98.8
heartrate: 82.0
resprate: 20.0
o2sat: 94.0
sbp: 154.0
dbp: 84.0
level of pain: 2
level of acuity: 2.0 | ___ year old male with transverse myelitis, indwelling Foley
catheter, BPH, who present for scrotal cellulitis.
# Scrotal cellulitis
# Epididymitis: presented with scrotal inflammation and tender
right epididymis. He had a WBC count of 19K at the outside
hospital, placed on IV vancomycin and ciprofloxacin, and WBC
count improved with improvement on exam. There was no spreading
of erythema, no perineal involvement and no crepitus noted. He
will be on antibiotics, continuing with PO ciprofloxacin, for a
total 10 day course. Urology saw the patient and recommended no
specific intervention. Patient has a chronic Foley catheter.
He will follow up with his PCP within ___ week of discharge.
# Anxiety/depression: continue duloxetine 20 mg daily
# Gout: continue allopurinol ___ mg daily
# Hypertension: continue hydralazine 50 mg TID, doxazosin 8 mg,
metoprolol 75 mg BID, amlodipine 10 mg daily
# Hyperlipidemia: continue simvastatin 10 mg daily
# BPH: Continue doxazosin 8 mg, Proscar 5 mg
# Venous stasis: Continue triamcinolone 0.1%
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with his PCP within ___ week
of discharge.
# Code status: full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a very pleasant ___ year old female with PMH IDDM
complicated by ulcers with debridement, hypothyroidism, and HLD
who presents with RLE pain, swelling, and erythema. Had
debridement of diabetic ulcers on bilateral medial feet ~4wks
ago. Following this (2d later) both legs became acutely swollen
and painful, R>L. The left leg relatively quickly resolved to
normal but the right leg remained swollen around the foot up to
the ankle, and red. The patient followed-up in wound clinic and
was sent to the ___, where she had a negative US and was
discharged with Keflex. The redness was spreading up the calf
and the patient presented again to the ___ (___), had negative
repeat ultrasound, and was discharged on Keflex and Bactrim. The
antibiotics have not worked and the redness has spread un to the
knee with significant pain in the back of the leg and swelling.
The patient feels "racy heart" and not quite dyspneic but
"heaviness of breath". No other systemic symptoms.
In the ___, initial VS were 97.1 160/70 95 16 98%RA
Exam notable for
- RLE with erythema along tibia from ankle to the knee with 2+
pitting edema and pain to palpation along the posterior aspect
- DP, ___ intact and the foot is well-perfused
- Full ROM, and sensation intact
Labs showed
14.0>12.9/39.0<290 with 75%N
___
---------<391
5.3/___/1.3
lactate WNL, UA with 30 protein, 300 glucose, and trace
ketones.
Imaging showed
-R ___ with no evidence of deep venous thrombosis in the right
lower extremity veins.
Patient received:
4.5g piperacillin-tazobactam and 1000mg vancomycin
Decision was made to admit to medicine for further management.
Vitals prior to transfer were 97.7 149/77 89 16 97%RA
On arrival to the floor, patient reports tenderness to palpation
to RLE up to mid-calf. Increase in RLE erythema over the course
of today, prompting ___ evaluation. She endorses occasional
clamminess over the past several weeks. She denies missing any
doses of Bactrim/Keflex over the past 6 days. She states that
her blood sugars over the past month have been 150-300, as she
has been taking extra attention due to the infection.
REVIEW OF SYSTEMS:
(+) per HPI
(-) Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
All other 10-system review negative in detail.
Past Medical History:
INSULIN DEPENDENT DIABETES MELLITUS
HYPOTHYROIDISM
HYPERLIPIDEMIA
GASTROESOPHAGEAL REFLUX
GASTROPARESIS
Social History:
___
Family History:
Endorses ___ significant for cancer and heart disease.
Specifically, brother with MI at age ___ and pancreatic cancer.
Grandfather with lung cancer. Aunts and father with
hyperlipidemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================
VS: 98.2 137/63 86 17 96%RA FSBG 433
GENERAL: WDWN, no acute distress
HEENT: NCAT, EOMI, PERRLA, MMM
NECK: supple, no LAD
CARDIAC: RRR, no m/r/g
LUNG: CTAB, no wheezes or rhonchi
ABDOMEN: soft, nontender, nondistended
Ext: Trace nonpitting edema at RLE with non-blanching erythema
on anterior tibia, with some extension to medial posterior calf.
Well within demarcated area. Some warmth. Hyperkeratotic region
over R ___ MTP joint with 1.5 cm liner laceration. No crepitus,
non-purulent. Also with evidence of scaling between toes on left
foot, consistent with tinea pedis.
Neuro: Intact gross touch across dorsum of feet bilaterally.
Intact proprioception at great toe bilateral (was able to sense
position of toe ___ times on both feet)
DISCHARGE PHYSICAL EXAM:
==================
VS: 97.8 143 / 82 94 20 99 RA
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r
HEART: Normal rate, regular rhythm. Normal S1 and S2. No
murmurs, rubs, gallops.
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: Exam stable from admission. Trace nonpitting edema
at RLE with non-blanching erythema on anterior tibia, with some
extension to medial posterior calf. Unchanged from exam
yesterday. Well within demarcated area. Some warmth.
Hyperkeratotic region over R ___ MTP joint with 1.5 cm liner
laceration. No crepitus, non-purulent. Stil with scaling between
toes on left foot, consistent with tinea pedis.
NEURO: awake, A&Ox3
Pertinent Results:
LABS ON ADMISSION:
=============
___ 08:46PM BLOOD WBC-14.0*# RBC-4.34 Hgb-12.9 Hct-39.0
MCV-90 MCH-29.7 MCHC-33.1 RDW-13.2 RDWSD-43.5 Plt ___
___ 08:46PM BLOOD Neuts-75.2* Lymphs-15.4* Monos-7.7
Eos-0.9* Baso-0.4 Im ___ AbsNeut-10.51*# AbsLymp-2.16
AbsMono-1.08* AbsEos-0.13 AbsBaso-0.06
___ 08:46PM BLOOD Plt ___
___ 08:46PM BLOOD Glucose-391* UreaN-21* Creat-1.3* Na-128*
K-5.3* Cl-89* HCO3-24 AnGap-20
___ 08:46PM BLOOD TSH-8.8*
___ 09:12PM BLOOD Lactate-1.7
NOTABLE LABS DURING HOSPITAL STAY:
=========================
___ 08:46PM BLOOD TSH-8.8*
___ 09:12PM BLOOD Lactate-1.7
LABS ON DISCHARGE:
=============
___ 07:40AM BLOOD WBC-6.0 RBC-4.12 Hgb-12.1 Hct-37.3 MCV-91
MCH-29.4 MCHC-32.4 RDW-13.4 RDWSD-45.0 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-224* UreaN-12 Creat-0.8 Na-136
K-4.6 Cl-101 HCO3-27 AnGap-13
___ 07:40AM BLOOD ALT-15 AST-19 AlkPhos-73 TotBili-0.2
___ 07:40AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.0
IMAGING & PROCEDURES
================
Right Lower Extremity Doppler (___)
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
EKG (___)
Sinus rhythm. Normal ECG. No previous tracing available for
comparison.
Read ___
___ Axes
RatePRQRSQTQTc (___) ___
___
MICROBIOLOGY:
==========
__________________________________________________________
___ 10:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 8:46 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. ClonazePAM ___ mg PO QHS:PRN insomnia
4. Glargine 55 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Pantoprazole 40 mg PO PRN GERD
7. Pregabalin 100 mg PO QHS
8. Prochlorperazine ___ mg PO DAILY:PRN nausea
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
2. Glargine 55 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Atorvastatin 20 mg PO QPM
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. ClonazePAM ___ mg PO QHS:PRN insomnia
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Pantoprazole 40 mg PO PRN GERD
8. Pregabalin 100 mg PO QHS
9. Prochlorperazine ___ mg PO DAILY:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ woman with likely RLE cellulitis and "heaviness of
breathing". Had negative US on ___ and ___ at ___. Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Bilateral lower extremity ultrasound dated ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Leg swelling
Diagnosed with Cellulitis of right lower limb
temperature: 97.1
heartrate: 95.0
resprate: 16.0
o2sat: 98.0
sbp: 160.0
dbp: 70.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ is a very pleasant ___ year old female with
uncontrolled DM2 and hypothyroidism who presented with RLE
swelling while on Bactrim/Keflex for RLE cellulitis. During the
course of her hospital stay, the following issues were
addressed:
# Cellulitis. Patient presented with right extremity warmth and
non-blanching rash concerning for cellulitis. The rash showed no
purulence and had no evidence of crepitus. She had an initial
white count of 14, which downtrended to 6 on hospital day 2 on
appropriate antibiotics. She was afebrile throughout hospital
stay.
She has been on Bactrim and Keflex since ___ with reported good
compliance and had been following with wound clinic and BID
___ for her calluses. She also has IDDM which she admits to
poor compliance. She says she always takes her lantus but
usually doesn't bother with Humalog unless she "feels sick." She
reported that she does finger sticks in the morning but usually
not during meals if she's busy. She also has hypothyroidism as
discussed below, which was likely contributing to delay in her
healing and lingering infection. Seen at ___ on ___, no DVT on
___ and sent out on Keflex. Returned to ___ on ___ and had ___
negative ultrasound, given Keflex and Bactrim. 50% of
improvement in edema per PCP, still significant edema and some
warmth. On this visit, Ms. ___ received one dose of
vancomycin and Piperacillin/Tazobactam in ___ and was
transitioned on the medicine floor, first to unasyn and then to
augmentin. She received four doses of unasyn 1.5 g Q6H from
___ and then was transitioned to augmentin on discharge,
with instruction to continue augmentin for a total of 10 days of
antibiotics (start date ___ | end date ___.
#DM2. Poorly controlled as discussed above. Ms. ___ says
she has started following her sugars better since the infection
but that before this she was only really taking lantus in the
morning and checking AM blood sugars, forgoing Humalog with
meals and not checking sugars before meals due to busy
lifestyle. Follows with ___ in ___. Was discharged on
home lantus, with instruction for close outpatient follow-up.
#Hypothyroidism. Patient had been taking levothyroxine 175mcg PO
daily. Her prescription was recently increased to 200 mcg by her
PCP but she told us she had not started taking this new dose
yet. TSH 8.8 on this admission. We increased her levothyroxine
to 200 mcg this stay.
CHRONIC ISSUES:
=====================
#Depression/anxiety: Continued home wellbutrin
#Insomnia - Continued home clonazepam
#HLD - Continued home simvastatin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim DS / Levaquin / Vancomycin Hcl / Dilantin Kapseal /
Keflex / Ciprofloxacin / Baclofen / Detrol / lisinopril /
oxybutynin / Zosyn / cefepime / pistachio / linezolid /
azithromycin
Attending: ___
Chief Complaint:
Fevers, chills, cloudy urine
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube replacement (___)
History of Present Illness:
___ male with paraplegia, neurogenic bladder s/p ileal conduit
urinary diversion c/b left anastomotic stricture managed with
indwelling PCN tube presenting for L flank pain and fevers at
home. He reports being discharged from ___ at the end of ___
feeling well, and felt well for a week afterwards. Though 1 week
later he began to again have cloudy urine. He did not want to
return to the hospital and hoped it would go away with his
weekly fosfomycin. This continued, and eventually progressed
with flank pain, and subjective fevers/chils at home and
increasingly foul smelling urine. Yesterday the patient's PCN
tube fell out, and the patient attempted to replace it himself.
It fell out again, and he presented to ___ at clinic. ___ replaced
the PCN and referred him to the ED for UTI/pyelonephritis.
In the ED, initial vitals were 99.3 93 142/90 16 98% RA. Labs
notable for WBC 14.2, UA with large leuks, pos nitrite, 86 WBC,
few bacteria, small blood. Imaging notable for CXR without acute
process.
Pt given:
___ 00:19 PO LevETIRAcetam 500 mg ___
___ 00:19 PO/NG OxyCODONE (Immediate Release) 60 mg
___
___ 04:37 PO/NG OxyCODONE--Acetaminophen (___) 1
TAB ___
___ 06:51 IV Meropenem 500 mg ___
On the floor, the patient reports feeling ___, dizzy, with
chills and continues to have L sided flank pain. He says his
urine in the ileal bag looks better but is still abnormal for
him.
Past Medical History:
#T12 paraplegia ___ MVA ___ s/p spinal fusion/rod placement
(___); orthopedist Dr. ___ at ___; drives an adapted car
#Neurogenic bladder s/p ileal conduit / ileostomy ___
#Substance abuse
#MRSA decubitus ulcers, followed by plastic surgery
#severe bilateral hydronephrosis w/L ureteral stricture s/p PCN
___ with routine stent change q3mths
#Stage IV CKD, with b/l Cr ~3.1
#Recurrent UTIs w/some resistant organisms (in the setting of
multiple abx allergies)
#Osteomyelitis R hip
#R foot cellulitis w/R lateral malleolus pressure ulcer ___
#Recurrent decubitus ulcers
#Bacterial PNA/septic shock ___
#Seizure disorder
#H/o C. diff colitis
#Chronic back pain
#Degenerative joint disease in shoulders/hips
#Anxiety
#Depression
#Substance abuse
#Anemia of chronic disease +/- iron deficiency
#5mm L lung nodule found ___ requires f/u CT chest at
the end of ___ (3mth f/u)
#Hypertension
#GERD
Social History:
___
Family History:
No h/o renal disease. Didn't know father. Mother with history of
NHL, sister with ongoing uterine cancer.
Physical Exam:
ADMISSION:
=========
Vital Signs: 98.5 170 / 87 79 18 99 Ra
General: Alert, interactive, no acute distress, shortened
deformed legs
HEENT: Sclerae anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: ___ ileostomy bag draining clear yellow liquid;
___ PCN in place abdomen soft, TTP in LLL; no CVA tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE:
==========
PHYSICAL EXAM:
VS: 98.5 111 / 66 74 18 100 Ra
General: Alert, interactive, NAD
CV: RRR, no m/r/g
Lungs: CTAB, no wheezes or rales
Abdomen: ___ ileostomy bag draining clear yellow liquid;
___ PCN in place; abdomen soft
Neuro: ___ strength or sensation in lower extremities b/l;
moving UE b/l with purpose
Pertinent Results:
ADMISSION:
=========
___ 05:00PM BLOOD ___
___ Plt ___
___ 08:20AM BLOOD ___
___
___ 01:00AM BLOOD ___
___ 01:00AM BLOOD ___
___ 08:20AM BLOOD ___
___ 05:00PM BLOOD ___
___ 01:15AM BLOOD ___
DISCHARGE:
===========
___ 07:25AM BLOOD ___
___ Plt ___
___ 07:20AM BLOOD ___
___
___ 07:20AM BLOOD ___
MICRO:
======
___ ___
{ESCHERICHIA COLI, ESCHERICHIA COLI}
___ 8:23 pm URINE,KIDNEY Source: Kidney.
**FINAL REPORT ___
FLUID CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. ___ CFU/mL. SECOND
MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
___ 1:43 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Fosfomycin Sensitivity testing per ___, (___) @
1452
___. Fosfomycin = SUSCEPTIBLE.
Fosfomycin sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___ COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 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-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING:
=======
ImagingMR HIP W/O CONRAST LEFT ___
___
___ UNILAT MIN 2 VIEWS
No radiographic evidence of osteomyelitis. Of note, bone scan
or MRI would be
more sensitive.
___ HIP W/O CONRAST LEFT
1. 3.3 cm ulcer overlying and extending to the left greater
trochanter. Mild
marrow edema within the greater trochanter most likely
represents reactive
change, less likely osteomyelitis. If there is ongoing concern
for
osteomyelitis, nuclear medicine studies may be helpful for
further assessment.
2. Left hip dysplasia with posterolateral femoral dislocation.
3. Multiple mildly enlarged left inguinal lymph nodes,
presumably reactive.
4. Chronic right intratrochanteric nonunited fracture with
overlying
heterotopic ossification.
5. Large amount of edema and/or fluid in the right thigh
extending beyond the
___ of this image, not fully characterized. If
clinically
indicated, MRI of the right thigh could help for further
assessment.
6. Small amounts of free fluid noted in the pelvis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PR QHS:PRN constipation
2. ClonazePAM 1 mg PO TID:PRN Anxiety
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN post nasal
drip
5. LevETIRAcetam 500 mg PO BID
6. Omeprazole 20 mg PO BID
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. Sodium Bicarbonate 1300 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
11. OxyCODONE--Acetaminophen ___ TAB PO Q4H:PRN Pain
- Moderate
12. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO)
13. naloxone 4 mg/actuation nasal ASDIR
14. amLODIPine 10 mg PO DAILY
15. TraZODone 50 mg PO QHS:PRN insomnia
16. Multivitamins 1 TAB PO DAILY
17. OxyCODONE (Immediate Release) 60 mg PO Q8H
Discharge Medications:
1. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO)
2. amLODIPine 10 mg PO DAILY
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. ClonazePAM 1 mg PO TID:PRN Anxiety
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN post nasal
drip
7. LevETIRAcetam 500 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. naloxone 4 mg/actuation nasal ASDIR
RX *naloxone [Narcan] 4 mg/actuation 4 mg INH In case of
overdose Disp #*1 Spray Refills:*0
10. Omeprazole 20 mg PO BID
11. OxyCODONE (Immediate Release) 60 mg PO Q8H
12. OxyCODONE--Acetaminophen ___ TAB PO Q4H:PRN
Pain - Moderate
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Sodium Bicarbonate 1300 mg PO BID
15. TraZODone 50 mg PO QHS:PRN insomnia
16. Vitamin D ___ UNIT PO DAILY
17. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Urinary tract infection/pyelonephritis
Hip ulcer
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid
(wheelchair).
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest Radiograph
INDICATION: ___ man with cough, fever, and leukocytosis.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
Cardiomediastinal silhouette is normal. There is no pleural effusion or
pneumothorax. There is no focal lung consolidation. There is partially
imaged posterior spinal fusion hardware.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
INDICATION: ___ year old man with h/o T12 paraplegia and recurrent UTIs with
urinary-ileal conduit, now with L hip ulcer// osteo?
TECHNIQUE: AP view of pelvis two additional views of the left hip.
COMPARISON: Scout views from pelvis CT from ___. CT abdomen
pelvis from ___.
FINDINGS:
Abnormal morphology of the pelvis including the inferior pubic rami
bilaterally is chronic in appearance. There is chronic posterior dislocation
of the left hip with deformity of the acetabulum and femoral head, unchanged.
There is no focal erosion, no radiographic evidence of osteomyelitis. Right
proximal femoral fracture seen on prior CT is partially visualized noting
angulation, callus and heterotopic ossification. Lumbar posterior fixation
hardware is partially visualized. Left-sided nephrostomy tube is also noted.
Surgical clips project overlying the right aspect of the sacrum.
IMPRESSION:
No radiographic evidence of osteomyelitis. Of note, bone scan or MRI would be
more sensitive.
Radiology Report
EXAMINATION: MR HIP ___ CONRAST LEFT
INDICATION: ___ year old man with L necrotic hip ulcer, please evaluate for
osteomyelitis// please evaluate for osteomyelitis
TECHNIQUE: Multiplanar, multisequence MR imaging of the left hip without
intravenous contrast due to renal failure.
COMPARISON: CT abdomen and pelvis ___. Left hip radiographs ___.
FINDINGS:
Left hip: There is posterolateral femoral dislocation with severely flattened
and dysplastic left acetabulum. Abnormal flattening of the femoral head is
also noted. There is a small joint effusion. Mild subcortical edema within
the posterior femoral head is nonspecific.
Laterally overlying the greater trochanter, there is a 3.3 cm SI x 2.5 cm AP x
1.4 cm TV soft tissue defect consistent with ulceration, which extends to the
tendon gluteal insertions. There is moderate surrounding subcutaneous edema
which extends anterosuperiorly about the hip. Although no significant soft
tissue edema is identified at the ulcer bed, there is mild subcortical marrow
edema and minimal corresponding T1 hypointensity along the anterior greater
trochanter which likely represents reactive edema. Given the lack of
overlying cortical erosion and mild T1 change, osteomyelitis is felt to be
less likely.
Multiple, slightly enlarged left inguinal lymph nodes measuring up to 1.4 cm.
Right hip: There an ununited intertrochanteric fracture of the right femur
demonstrating 2.3 cm distal displacement, and mild marrow edema extending into
the femoral neck.. There is fluid within the fracture cleft, with significant
overlying edema likely representing combination of periosteal reaction/callus
and heterotopic ossification related to chronic fracture. There is right hip
osteoarthritis.
There is diffuse muscular atrophy of the visualized proximal thigh
musculature, significantly greater on the left. Of note there is a large
amount of high T2 signal indicative of edema and/or fluid, within the
visualized portion of the proximal right femur, extending beyond the edge of
this film (5:9).
Limited evaluation of the intrapelvic soft tissues demonstrates mild free
pelvic fluid.
Susceptibility and cortical abnormality along the posterior aspect of the left
ilium likely represents bone harvest site. Remainder of the marrow signal
within the visualized pelvis is within normal limits.. Pubic symphyseal
diastasis is seen, more easily appreciated on the ___ CT scan (2:77
from that exam).
There is a small amount of intrapelvic free fluid in the visualized pelvis.
No significant pelvic lymphadenopathy seen, though as noted, there are
multiple slightly enlarged left inguinal lymph nodes..
Limited assessment of the lower lumbar spine is grossly unremarkable.
IMPRESSION:
1. 3.3 cm ulcer overlying and extending to the left greater trochanter. Mild
marrow edema within the greater trochanter most likely represents reactive
change, less likely osteomyelitis. If there is ongoing concern for
osteomyelitis, nuclear medicine studies may be helpful for further assessment.
2. Left hip dysplasia with posterolateral femoral dislocation.
3. Multiple mildly enlarged left inguinal lymph nodes, presumably reactive.
4. Chronic right intratrochanteric nonunited fracture with overlying
heterotopic ossification.
5. Large amount of edema and/or fluid in the right thigh extending beyond the
field-of-view of this image, not fully characterized. If clinically
indicated, MRI of the right thigh could help for further assessment.
6. Small amounts of free fluid noted in the pelvis.
RECOMMENDATION(S): If there is ongoing clinical concern for osteomyelitis,
nuclear medicine examination may help for further assessment.
Consider MRI of the right thigh the further characterized areas of high T2
signal in the right thigh.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Urinary tract infection, site not specified, Bacteremia
temperature: 99.3
heartrate: 93.0
resprate: 16.0
o2sat: 98.0
sbp: 142.0
dbp: 90.0
level of pain: 7
level of acuity: 3.0 | ___ with paraplegia, neurogenic bladder s/p ileal conduit
urinary diversion c/b left anastomotic stricture managed with
indwelling PCN tube presenting for several weeks of cloudy urine
starting 1 week after completion of course of meropenem at
previous hospitalization, and more recent fevers/chills and L
flank pain c/f pyelonephritis improving on meropenem.
#UTI/Pyelo: Recurrent UTIs. Was recently discharged after course
of meropenem inpatient. Presented this admission after his PCN
tube fell out at home, and the patient attempted to replace it
himself. In the ED, ___ replaced the PCN tube. Started on
meropenem. As he had many ABX allergies resulting in hives, it
was difficult to narrow him. In consultation with ID, meropenem
was continued ___ for a 10 day course (completed ___. Was
discharged with urology ___ appointment, to consider
further procedures for anastomotic strictures.
#L hip ulcer/concern for osteomyelitis: L hip wound, patient had
previously done wound care himself at home. Wound care consult
inpatient had concern for depth, and possible osteomyelitis. MRI
of the hip did not show c/f osteomyelitis, and in consultation
with ID consult, no further ___ pursued. Patient strongly
wished to continue wound care himself at home, and refused ___
wound care.
#Chronic pain: Patient on oxycodone 60mg q8hrs with
oxycodone/acetaminophen for breakthrough. Confirmed on PMP and
w/pharmacy. Patient switched to oxycontin while inpatient on
prior hospitalizations for more ___ control. No signs of
respiratory depression or increased sedation during the
admission. Discharged back on home regimen with oxycodone
immediate release. Discharged with naloxone.
#Diarrhea/complaint of blood per rectum: ___ overnight
patient reported several loose BMs with small maroon blood.
Rectal exam showed prolapse and external hemorrhoids without
active bleeding, and no blood or stool in the rectal vault. The
loose stools were not visualized by staff. Hgb and hemodynamics
were stable. C. diff was ordered but never sent as patient was
not saving stools for sample despite repeated counseling, and
the amount on the bedspread was too small for sampling.
#CKD: Stable inpatient. Phos was high on sevelemer 800mg TID,
will likely need uptitration for ___ treatment, but
continued home dose this admission. Discharged with ___ to
establish with nephrology and urology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, chest pain, cough
Major Surgical or Invasive Procedure:
___
Left thoracentesis
___
Left thoracentesis
___
Left VATS decortication
___
Right PICC line placement
History of Present Illness:
In brief, this patient is a ___ yo male with 4 days of subjective
fevers and chills, cough, and left sided chest pain who
initially presented to ___ Urgent care for evaluation.
He was found to have a large left sided pleural effusion on CXR,
as well as a leukocytosis to 19.7. He was given 1g ceftriaxone
and 1L NS and then transferred to the ___ ED.
In the ED, initial vitals were T 99.4, HR 80, BP 109/61, RR 20,
95% on RA. Exam was notable for decreased breath sounds half way
up the lung fields and no ___ edema. Labs were notable for a WBC
count of 19.7 K, platelets of 670, and lactate of 2.6 (repeat
lactate of 1.3).
CXR showed a large left pleural effusion with compressive left
basilar atelectasis.
Patient was given morphine IV 2 mg. A thoracentesis removed 1300
cc of serous fluid. A repeat CXR post-procedure showed no
pneumothorax, with slight interval decrease in the size of the
left pleural effusion, with moderate to large compressive left
basilar atelectasis.
A decision was made to admit the patient for treatment of
pneumonia. On the floor upon admission, the patient endorsed
ongoing left sided chest discomfort of a pleuritic nature ___
with inspiration), but no diaphoresis, radiation of the pain,
SOB, palpitations, nausea, vomiting, or diarrhea. He was started
on IV ceftriaxone and azithromycin.
The patient does report being a little more fatigued lately and
walking more slowly but says he was able to walk a mile as
recently as this past week. He has had a mild cough, but he
doesn't spit anything up. 2 pound weight loss over 5 months. No
night sweats. He reports being up to date on his ___ screenings.
ROS as above.
Past Medical History:
Hypertension
Abnormal liver function tests
Spinal stenosis at L3-L4 c/b neuropathy
GERD
Migraines
Tremor
S/p CCY in ___
Shrapnel removal in ___ surgeries in the late ___
Social History:
___
Family History:
Family history of coronary artery disease. Stomach cancer in
his mother.
Physical Exam:
Vital Signs: T 98.9, 152 / 73, 76, 20, 94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diminished breath and dullness to percussion halfway up
left side of chest. Otherwise clear to auscultation and no
wheezing.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt Ct
___ 05:25 16.2* 3.01* 9.1* 27.2* 90 30.2 33.5 14.5
46.1 646*
___ 05:46 20.3* 3.18* 9.4* 27.9* 88 29.6 33.7 13.8
43.9 868*
___ 06:15 21.0* 3.68* 11.1* 32.8* 89 30.2 33.8 13.9
45.1 994*
___ 06:25 11.9* 3.43* 10.2* 30.2* 88 29.7 33.8 13.7
43.8 765*
___ 06:57 18.1* 3.86* 11.6* 34.3* 89 30.1 33.8 13.7
44.3 845*
___ 07:25 20.7* 3.77* 11.6* 34.3* 91 30.8 33.8 13.8
45.9 692*
___ 06:11 20.0* 3.45* 10.5* 30.4* 88 30.4 34.5 13.2
42.5 656*
___ 06:03 24.1* 4.07* 12.3* 36.3* 89 30.2 33.9 13.2
43.1 695*
___ 06:15 23.5* 4.21* 12.6* 37.9* 90 29.9 33.2 13.1
42.8 673*
___ 08:55 12.4* 3.89* 11.9* 35.2* 91 30.6 33.8 13.2
43.0 629*
___ 09:34 13.6* 3.82* 11.8* 34.5* 90 30.9 34.2 13.2
43.4 588*
___ 05:51 15.8* 3.51* 10.7* 32.1* 92 30.5 33.3 13.2
44.4 549*
___ 16:00 19.7*1 4.19* 12.9* 37.7* 90 30.8 34.2 13.2
43.5 670*2
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:25 851 19 0.8 136 4.8 ___
___ 05:46 921 14 1.0 136 5.0 ___
___ 06:15 ___ 136 5.1 99 25 17
___ 06:25 861 14 0.9 136 5.3* ___
___ 06:57 961 22* 1.0 135 5.4* 98 24 18
___ 07:25 731 27* 1.0 136 5.1 100 24 17
___ 06:11 841 35* 1.1 133 4.7 98 22 18
___ 06:03 821 37* 1.3* 133 5.2* 96 23 19
___ 16:50 921 36* 1.8* 133 4.7 97 22 19
___ 06:15 931 29* 1.4* 134 4.6 97 23 19
___ 08:55 741 17 0.9 134 4.6 96 23 20
___ 09:34 771 17 1.0 135 4.7 97 20* 23*
___ 05:51 ___ 137 4.8 102 21* 19
___ 16:00 ___ 4.4 94* 22 22*
___ 7:00 pm PLEURAL FLUID LEFT PLEURAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ CXR :
Large left pleural effusion with compressive left basilar
atelectasis.
___ Chest CT :
1. Moderate left pleural effusion with a loculated component
along the lateral pleural surface. The pleural catheter is not
located within the loculated component or within the largest
portion of the effusion which layers posteriorly.
2. Trace left medial pneumothorax.
3. Left lower lobe consolidation with a circumscribed
nonenhancing component which could represent pneumonia although
underlying mass is also possible. Recommend reimaging after
pleural effusion has decreased.
4. Scattered bilateral 1-2 mm nodules are nonspecific.
Attention on follow-up is recommended.
5. Nodule within the right lobe of the thyroid. Recommend
thyroid ultrasound if not already completed.
___ Thyroid ultrasound :
Dominant right-sided spongiform thyroid nodule without worrisome
sonographic features and can be followed in ___ year to assess for
stability.
___ Chest CT :
Interval decrease in size of the left pleural effusion, now
small with
slight expected interval increase in size of associated small
pneumothorax
after interval repositioning of the pigtail drain, now within
fluid in the
costophrenic angle. Other smaller loculated components of the
pleural fluid are not accessed by the drain; e.g., along the
left mediastinum and along the major fissure.
2. Improving left lower lobe pneumonia.
3. Left hilar lymphadenopathy, likely reactive, unchanged.
4. Heterogeneous 1.9-cm right thyroid nodule. Given the size,
thyroid
ultrasound is again recommended non-emergently if the patient
has not already had this evaluated.
5. Replaced or accessory left hepatic artery.
6. Small hiatal hernia.
7. Possible mild hepatosteatosis, incompletely evaluated on
this enhanced
exam. Correlate with laboratory evidence.
___ CXR :
1. Increased opacification of the left lung suggestive of
increased fluid
reaccumulation without pneumothorax.
2. Interval insertion of right PICC line with the catheter tip
terminating inthe distal SVC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 1200 mg PO QHS
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. ALPRAZolam 1 mg PO QHS
4. Vitamin D Dose is Unknown PO DAILY
5. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*100 Tablet Refills:*0
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 Gm IV once a
day Disp #*30 Intravenous Bag Refills:*1
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
5. MetroNIDAZOLE 500 mg PO/NG Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*84 Tablet Refills:*1
6. Milk of Magnesia 30 mL PO Q12H:PRN constipation
7. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*30 Packet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
9. Vitamin D 1000 UNIT PO DAILY
10. ALPRAZolam 1 mg PO QHS
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion
12. Gabapentin 1200 mg PO QHS
13. Omeprazole 40 mg PO DAILY
14. Vitamin B Complex 1 CAP PO DAILY
15.Outpatient Lab Work
Q ___ : CBC w/ diff, Bun, creat, AST, ALT, TB, alk phos with
results to ___ clinic FAX ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Left lower lobe pneumonia c/b complex parapneumonic effusion
- Acute renal failure
- Benign appearing right-sided spongiform thyroid nodule; 12
month f/u recommended.
Secondary:
- GERD
- Chronic LBP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p thoracentesis.
Eval for pulmonary mass/loculations
TECHNIQUE: Contiguous axial imaging was obtained of the chest following the
uneventful administration of intravenous contrast material. Coronal, sagittal
and maximum intensity projection images were obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 39.5 cm; CTDIvol = 15.2 mGy (Body) DLP = 601.9
mGy-cm.
Total DLP (Body) = 602 mGy-cm.
COMPARISON: Chest radiograph from ___.
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There is a heterogeneous irregular
hypodense nodule within the inferior right lobe of the thyroid measuring 1.9 x
1.1 cm. There are no enlarged supraclavicular axillary lymph nodes.
MEDIASTINUM: There are no enlarged mediastinal lymph nodes.
HILA: There is no hilar lymphadenopathy.
HEART and PERICARDIUM: The heart and pericardium are unremarkable and there is
no pericardial effusion.
PLEURA: There is a moderate sized predominantly simple left pleural effusion
with a loculated component along the lateral pleural surface. A pleural
catheter terminates anteriorly and does not traverse the loculated component.
The majority of the fluid layers posteriorly in is not drained by the pleural
catheter. There is a trace left pneumothorax. There also fluid within the
fissure.
LUNG:
-PARENCHYMA: There is a focal left lower lobe consolidation with a somewhat
circumscribed non-enhancing component anteriorly abutting the loculated
portion of the effusion. This measures approximately 4.3 x 2.6 x 4.0 cm (AP x
TV x SI). This may represent pneumonia although an underlying mass lesion
could also be possible. There are scattered 1-2 mm pulmonary nodules (series
2, image 14,26, 28).
-AIRWAYS: The airways are patent to the subsegmental levels.
-VESSELS: The aorta and pulmonary artery are of normal caliber. There is no
evidence of a central pulmonary embolus.
UPPER ABDOMEN: This study is not tailored for evaluation of subdiaphragmatic
structures. Limited views demonstrate cholecystectomy clips in the right
upper quadrant and a hypodensity within the upper pole of the left kidney,
likely a cyst.
CHEST CAGE: There are no concerning lytic or sclerotic lesions.
IMPRESSION:
1. Moderate left pleural effusion with a loculated component along the lateral
pleural surface. The pleural catheter is not located within the loculated
component or within the largest portion of the effusion which layers
posteriorly.
2. Trace left medial pneumothorax.
3. Left lower lobe consolidation with a circumscribed nonenhancing component
which could represent pneumonia although underlying mass is also possible.
Recommend reimaging after pleural effusion has decreased.
4. Scattered bilateral 1-2 mm nodules are nonspecific. Attention on follow-up
is recommended.
5. Nodule within the right lobe of the thyroid. Recommend thyroid ultrasound
if not already completed.
Radiology Report
EXAMINATION: THYROID U.S.
INDICATION: ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p thoracentesis and
L-sided chest tube placement. // Please evaluate nodule within the right lobe
of the thyroid.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the neck were
obtained.
COMPARISON: The report from the CT chest ___.
FINDINGS:
The right lobe measures: (transverse) 1.8 x (anterior-posterior) 2.7 x
(craniocaudal) 5.5 cm.
The left lobe measures: (transverse) 1.4 x (anterior-posterior) 1.9 x
(craniocaudal) 4.3 cm.
Isthmus anterior-posterior diameter is 0.3 cm.
The thyroid parenchyma is homogenous and has normal vascularity.
Within the lower pole of the right thyroid a spongiform appearing, confluent
multilobulated nodule is identified measuring 1.4 x 1.8 x 2.5 cm without
worrisome sonographic features.
IMPRESSION:
Dominant right-sided spongiform thyroid nodule without worrisome sonographic
features and can be followed in ___ year to assess for stability.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p chest tube
placement // Eval for interval change in pt with chest tube Eval for
interval change in pt with chest tube
IMPRESSION:
Comparison to ___. The left pigtail catheter is in stable
position. There has been an interval increase in extent of the left pleural
effusion, occupying approximately 60% of the left hemithorax. Deviation of
the midline structures to the right. New small right basilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p thoracentesis and
L-sided chest tube placement. // Just drained 1700 cc from chest tube, need
interval comparison Just drained 1700 cc from chest tube, need interval
comparison
IMPRESSION:
Compared to chest radiographs ___ through ___ at 06:26.
Moderate left pleural effusion after increasing following pleural drainage
catheter insertion between ___ and ___ is smaller today and the
mediastinum has returned to ___. Configuration of the left pigtail
pleural drainage catheter is grossly unchanged. . No pneumothorax. Left
upper lung clear. Left lower lung atelectatic and obscured. Right lung
clear. Heart size normal.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p thoracentesis and
L-sided chest tube placement. // Eval for interval change Eval for
interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate left pleural effusion is slightly smaller today. No pneumothorax,
left pigtail pleural drainage catheter unchanged in position. Right lung
clear. Heart size normal.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p thoracentesis and
L-sided chest tube placement. // PLEASE PERFORM at 0400 AM. Eval for interval
change PLEASE PERFORM at 0400 AM. Eval for interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Small left pleural effusion has continued to decrease, replaced in part by
small pneumothorax loculated along the left lateral lower costal surface.
Left basal pigtail pleural drainage catheter may have withdrawn a cm or so.
Moderate Left lower lobe atelectasis unchanged. Mild right basal atelectasis
unchanged. Upper lungs clear. Heart size normal.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ male smoker who presents with fever, cough, chest
pain, found to have large left pleural effusion and leukocytosis, now status
post thoracentesis and L-sided chest tube placement. Evaluate for interval
change.
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 37.5 cm; CTDIvol = 18.2 mGy (Body) DLP = 682.3
mGy-cm.
Total DLP (Body) = 682 mGy-cm.
COMPARISON: CT chest dated ___.
Reference is also made to a portable chest radiograph from earlier on the same
day, dated ___ at 03:57.
FINDINGS:
There is normal 3 vessel aortic arch anatomy. The visualized thoracic aorta
is normal in caliber. Atherosclerotic calcification at the arch is minimal.
The main, left, and right pulmonary arteries are normal in caliber without
evidence of a filling defect indicate the presence of any incidental central
pulmonary embolus. The heart is normal in size. No evidence of a pericardial
effusion.
No axillary or supraclavicular lymphadenopathy. Several mediastinal lymph
nodes remain prominent, measuring up to 9 mm in the right lower paratracheal
station, similar the prior exam. Soft tissue densities surrounding the left
hilum bronchovascular trunk is compatible with lymphadenopathy and overall
unchanged (e.g., series 2, image 30, 34). No right hilar lymphadenopathy. A
lymph node in the left epicardial fat measuring up to 5 mm in short axis is
unchanged (series 2, image 54).
The left intercostal approach pigtail drain appears coiled in the lateral
aspect of the lower left pleural space in the costophrenic angle (series 2,
image 49; series date 601B, image 58). The position of the tip of the tube
appears somewhat retracted from the prior exam. There is expected substantial
interval decrease in the size of the pleural effusion, now small. The amount
of air within the pleural space has slightly increased compared to the prior
exam (series 2, image 35). There is a loculated component of pleural effusion
in the left major fissure (series 2, image 34). A small amount of loculated
fluid is also apparent along the mediastinum (series 2, image 40). The
contents of the pleural fluid is intermediate in attenuation, similar the
prior exam. There is mild associated pleural thickening.
Associated airspace parenchymal opacities in the left lower and upper lungs
that homogeneously enhance are most likely atelectasis. Focal areas of lower
attenuation with in the atelectatic left lower lung superior segment have
decreased in size substantially from the prior exam, now measuring up to 1.8 x
1.7 cm and 3.2 x 1.6 cm on axial images, previously spanning 4.3 x 2.6 cm
(series 2, image 41, 43), most likely concurrent pneumonia. No new
parenchymal opacities in the left lung.
Right lower lobe atelectasis is mild and more pronounced from the prior exam.
No right pleural effusion or pneumothorax. The airways are patent, albeit
narrowed in the area of parenchymal opacification in the left upper lobe
(series 2, image 39).
A tiny calcified granuloma in the left upper lobe is unchanged in indicate
sequelae of chronic granulomatous disease exposure (series 601b, image 56).
An 1.9 x 1.3-cm slightly heterogeneous, predominantly hypodense nodule in the
right thyroid lobe is again seen (series 2, image 7).
Coarse, small calcifications scattered throughout the soft tissues of the
right thorax are unchanged. Multilevel degenerative changes in the thoracic
spine are mild-to-moderate. No evidence of acute fracture. No osseous
lesions suspicious for malignancy or infection.
This exam is not dedicated for imaging of the abdomen. Within this
limitation: The overall attenuation of the liver appears somewhat attenuated,
however, incompletely evaluated on this enhanced exam, but could suggest mild
hepatosteatosis. Surgical clips in the region of the gallbladder fossa
suggest prior cholecystectomy. A replaced or accessory left hepatic artery
arises from the left gastric artery (series 2, image 56). A hiatal hernia is
small. A subcentimeter hypodensity in the left upper renal pole is too small
to accurately characterize on CT but statistically most likely a cyst, also
seen on the prior exam (series 601b, image 63).
IMPRESSION:
1. Interval decrease in size of the left pleural effusion, now small with
slight expected interval increase in size of associated small pneumothorax
after interval repositioning of the pigtail drain, now within fluid in the
costophrenic angle. Other smaller loculated components of the pleural fluid
are not accessed by the drain; e.g., along the left mediastinum and along the
major fissure.
2. Improving left lower lobe pneumonia.
3. Left hilar lymphadenopathy, likely reactive, unchanged.
4. Heterogeneous 1.9-cm right thyroid nodule. Given the size, thyroid
ultrasound is again recommended non-emergently if the patient has not already
had this evaluated.
5. Replaced or accessory left hepatic artery.
6. Small hiatal hernia.
7. Possible mild hepatosteatosis, incompletely evaluated on this enhanced
exam. Correlate with laboratory evidence.
RECOMMENDATION(S): Thyroid ultrasound if not already performed.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p thoracentesis and
L-sided chest tube placement. // Please perform at 4AM: Eval for interval
change Please perform at 4AM: Eval for interval change
IMPRESSION:
Comparison to ___. Stable position of the left pigtail catheter.
Decrease in extent of the left pleural fluid collection. Decrease in severity
of the pre-existing left basal areas of atelectasis. Stable appearance of the
right lung and of the heart.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p thoracentesis and
L-sided chest tube placement. // Please perform at 4 AM; eval for interval
change
IMPRESSION:
In comparison to ___ radiograph, left pleural catheter remains in
place with persistent moderate sized, partially loculated pleural effusion and
adjacent nonspecific opacities in the lingula and left lower lobe. Right lung
is clear except for minor atelectasis in the right infrahilar region.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p thoracentesis and
L-sided chest tube placement. // Please eval for interval changes Please
eval for interval changes
IMPRESSION:
Comparison to ___. The previous air filled. Pleural space at the
lateral and basal aspect of the left hemithorax is now filled with pleural
fluid. Left drain is stable. Moderate atelectasis at the left lung basis.
Stable normal appearance of the cardiac silhouette.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with loculated effusion, scheduled for VATS
decortication tomorrow, after manipulating chest tube this AM, new output
released from chest // ?lung status, size of effusion Surg: ___ (VATS
decortication) ?lung status, size of effusion
IMPRESSION:
Comparison to ___, 07:21. The position of the left chest tube is
stable. Stable appearance of the left costophrenic sinus. There is no
substantial change in appearance of the known left pleural effusion and the
subsequent left basilar atelectasis. Stable normal appearance of the cardiac
silhouette and of the right lung. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p left decortication // evaluate tube position
TECHNIQUE: Chest single view
COMPARISON: ___ 04:12
FINDINGS:
2 left chest tubes have been placed. Stable mild left pleural effusion,
partially loculated. Mildly improved left perihilar opacity. Stable left
basilar opacity. Right lung is clear. Probable tiny right pleural effusion.
Heart size, pulmonary vascularity are normal. No pneumothorax.
IMPRESSION:
Interval mild improvement
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p L VATS decortication // check interval
change check interval change
IMPRESSION:
Comparison to ___. The 2 left-sided chest tubes are in stable
position. No evidence of pneumothorax. The pleural changes on the left are
stable. No change in appearance of the right lung porta cardiac silhouette.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p L VATS decortication // check interval
change, apical chest tube DCD check interval change, apical chest tube
DCD
IMPRESSION:
In comparison with the study of ___, the apical left chest tube has
been removed and there is no evidence of pneumothorax. Continued
opacification at the left base silhouetting the hemidiaphragm. Right lung is
clear.
Radiology Report
EXAMINATION: Chest x-ray PA and lateral
INDICATION: ___ year old man s/p L VATS decortication and PICC line placement
// check PICC line placement, right brachial 43 cm, Also R/O PTX post CT
removal
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison is made to chest x-rays dating from ___
through ___.
FINDINGS:
There has been interval removal of a left basilar chest tube. Increased
opacification of left lower lung seen suggestive of fluid reaccumulation. No
pneumothorax is seen. The right lung is clear. Interval placement of a right
PICC is seen with the catheter tip terminating at the distal SVC.
IMPRESSION:
1. Increased opacification of the left lung suggestive of increased fluid
reaccumulation without pneumothorax.
2. Interval insertion of right PICC line with the catheter tip terminating in
the distal SVC.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with productive cough and intermittent chills for
the past 5 days. Patient is a daily smoker // ? pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Cardiac silhouette size is likely within normal limits. The mediastinal and
hilar contours are unremarkable, and no pulmonary edema is present. A large
left pleural effusion is present along with compressive atelectasis of the
left lung base. The right lung is clear. No pneumothorax is identified.
There are mild degenerative changes seen in the thoracic spine.
IMPRESSION:
Large left pleural effusion with compressive left basilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with pleural effusion status post thoracenteiss //
please eval for pneumothorax
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: Chest radiograph ___ at 15:37
FINDINGS:
There has been slight interval decrease in size of the left pleural effusion,
now moderate to large, with associated compressive left basilar atelectasis.
No pneumothorax is detected. The cardiac and mediastinal contours are
unchanged. Right lung remains clear. No pulmonary edema is demonstrated.
There are no acute osseous abnormalities.
IMPRESSION:
Slight interval decrease in size of the left pleural effusion, now moderate to
large with associated compressive left basilar atelectasis. No pneumothorax
is identified.
Radiology Report
INDICATION: ___ year old man with presumed CAP + parapneumonic effusion, now
s/p tap + on CTX and azithro. // Interval resolution vs. progression of
effusion
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The right lung is clear. There is a persisting moderate to large left pleural
effusion with adjacent atelectasis. No pneumothorax identified. The size and
appearance of the cardiomediastinal silhouette is unchanged.
IMPRESSION:
No significant interval change since the prior study with a persisting
moderate to large left pleural effusion with subjacent atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with presumed CAP + parapneumonic effusion, now
s/p tap + on CTX and azithro. // interval progression vs. resolution of
effusion interval progression vs. resolution of effusion
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate to large left pleural effusion has redistributed slightly in the left
lower hemithorax, but size is unchanged since ___. Persistent mild
leftward shift of the lower mediastinum indicates atelectasis exceeds the
volume of displacement by pleural effusion. Left upper lung and right lung
clear. No right pleural abnormality. Heart size normal. No pneumothorax.
Radiology Report
INDICATION: ___ year old man with parapna effusion // chest tube placement?
PTX? Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
Interval placement of a left basal pigtail catheter with slight interval
decrease in the size of the left pleural effusion. There is persisting
opacification of the left mid to lower lung zones with a probable loculated
component of fluid laterally. The right lung is clear. No pneumothorax
identified. The size and appearance of the cardiomediastinal silhouette is
unchanged.
IMPRESSION:
Interval placement of a left basal pigtail catheter with slight interval
decrease in size of the left pleural effusion. Persisting opacification of
the left mid to lower lung zones with a probable loculated component of fluid
laterally.
No pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Chest pain
Diagnosed with Pneumonia, unspecified organism, Pleural effusion, not elsewhere classified
temperature: 97.9
heartrate: 80.0
resprate: 20.0
o2sat: 96.0
sbp: 109.0
dbp: 61.0
level of pain: 2
level of acuity: 2.0 | ___ smoker who presents with fever, cough, chest pain, found to
have large left pleural effusion and leukocytosis, now s/p
thoracentesis on CAP coverage, with concern for malignancy.
#Parapneumonic effusion: Initial 1.3L tap in the ED revealed an
uncomplicated exudative effusion. Patient was started on
azithromycin 250 mg IV q24h and ceftriaxone 1g IV q24h for CAP
coverage. He was also placed on TB precautions given possibility
of TB (although unlikely) in the face of a high lymphocyte
percentage in the patient's effusion and the patient's h/o
serving in ___, and underwent sputum induction X3. After
multiple thoracenteses, chest tube placement and TPA ___
administration without improvement, the Thoracic Surgery service
was consulted for a VATS decortication which took place on
___. He tolerated the procedure well and had 2 chest tubes
on suction for 48 hours. His pain was controlled with Dilaudid
and his oxygen was able to be weaned off with room air
saturations of 94%. He continued to have a significant
leukocytosis post op at 22K and the Infectious Disease service
was consulted for antibiotic management. From a Surgical
standpoint his wounds were healing well and he was using his
incentive spirometer effectively. His chest xray showed
persistent opacification at the left base and no pneumothorax.
# ID All cultures both pre and intraop were negative. Given no
significant growth on pleural fluid with negative cytology and
studies consistent with parapneumonic effusion likely he had a
community acquired pneumonia c/b significant loculated effusions
(possible significant delay in presentation as he was not
significantly symptomatic outside of chest pain on admission and
potentially fluid may have been there for significant duration
prior to being found). No known aspiration hx although he does
have poor dentition and has been undergoing dental work. If more
pathogenic organism such as pseudomonas or MRSA were causative
they likely would have grown on culture data. At this time,
given
this is his first occurrence, would treat this as complicated
CAP
with loculated parapneumonic effusion, and would expect
leukocytosis to slowly improve given significance of effusion.
If he continues to have recurrent pneumonias or difficulties
clearing would also be concerned for endobronchial lesion or
possible malignancy. A PICC line was placed on ___ in the
right basilica vein and he will undergo an extended course of PO
Flagyl and IV Ceftriaxone for at least ___ weeks. The final
date will be determined after he has a repeat Chest CT on
___ ___s weekly blood work. His WBC was down to 16K
on ___
# thyroid nodule: Incidental thyroid nodule noted on chest CT
and evaluated with ultrasound will need to be followed again in
___ year.
#Chest pain: Patient presented with initial chest pain. Thought
likely from pneumonia and pleural effusion given pain mainly
with inspiration and improvement s/p tap in the ED. Trops
negative x 2 and CK-MB wnl, making ACS unlikely.
#Insomnia - patient was continued on his home Xanax and
gabapentin.
#GERD - patient was continued on his home omeprazole.
After a prolonged hospital stay Mr. ___ was discharged home
on ___ with ___ services and will follow up in the Thoracic
Clinic in ___s with the Infectious Disease service
in a few weeks. |
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:
___ idiopathic/alcoholic pancreatitis in ___ presents with
epigastric pain. Pt reports that he drank ___ glasses of wine
between 9pm and midnight, and subsequently had acute onset of
epigastric pain with radiation to both LUQ & RUQ. He states that
his discomfort is c/w his prior episode of pancreatitis. He
initially endorsed nausea although denies any vomiting. Denies
fevers or chills. He denies any chest pain or SOB, although he
does endorse some abdominal discomfort when taking a deep
breath.
In the ED initial vitals were: 96.4 91 158/119 20 100% (pain
___. Labs were notable for lipase of 8490. Patient was made
NPO and received IVF & Dilaudid.
Currently, pt reports improvement of overall pain ___ in ED,
now ___. Says that the pain intermittently worsens and
improves. Denies any nausea/vom at this time. Denies any change
in BMs recently; no recent pain after eating.
Past Medical History:
GERD
HL
Depression/ Anxiety
Alopecia s/p hair transplant in ___
Appendectomy in 1990s
R hip weakness ___ pedestrian struck
Social History:
___
Family History:
Father and brother are alcoholics. Mother had h/o A-fib and
stroke. Father has h/o CAD with ___ MI at the age of ___. Other
brother with DM. Pt has healthy children.
Physical Exam:
ON ADMISSION:
Vitals- 97.7 145/90 89 20 98% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB
CV- RRR, nl S1 S2. No r/m/g appreciated
Abdomen- soft, ND. Tender in RUQ & LUQ, most significant in
epigastric region. Pn radiates to lower quadrants after exam.
Negative ___ sign.
GU- no foley
Ext- WWP, +2 pulses. No pedal edema.
Neuro- A+Ox3, CN II-XII intact, motor & sensory function grossly
normal
ON DISCHARGE:
98.4 147/88 74 18 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB
CV- RRR, nl S1 S2. No r/m/g appreciated
Abdomen- soft, ND. Nontender in RUQ & LUQ. Negative ___
sign.
GU- no foley
Ext- WWP, +2 pulses. No pedal edema.
Neuro- A+Ox3, CN II-XII intact, motor & sensory function grossly
normal
Pertinent Results:
ON ADMISSION:
___ 03:30AM BLOOD WBC-8.7# RBC-4.86 Hgb-15.2 Hct-45.1
MCV-93 MCH-31.3 MCHC-33.8 RDW-12.5 Plt ___
___ 03:30AM BLOOD Neuts-72.9* ___ Monos-4.2 Eos-0.5
Baso-0.6
___ 10:50AM BLOOD ___ PTT-28.5 ___
___ 03:30AM BLOOD Glucose-100 UreaN-17 Creat-0.9 Na-135
K-3.6 Cl-101 HCO3-22 AnGap-16
___ 03:30AM BLOOD ALT-38 AST-42* AlkPhos-63 TotBili-0.4
___ 05:39AM BLOOD LD(LDH)-159
___ 03:30AM BLOOD Lipase-8490*
___ 03:30AM BLOOD Albumin-4.4
ON DISCHARGE:
___ 06:29AM BLOOD %HbA1c-5.2 eAG-103
___ 05:20AM BLOOD WBC-6.0 RBC-4.48* Hgb-14.0 Hct-42.3
MCV-94 MCH-31.3 MCHC-33.2 RDW-12.6 Plt ___
___ 05:20AM BLOOD UreaN-8 Creat-0.8 Na-140 K-4.0 Cl-105
HCO3-26 AnGap-13
___ 05:20AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1
___
RUQ US
IMPRESSION: Normal right upper quadrant ultrasound without
evidence of
cholelithiasis or cholecystitis.
___:
CXR- PA and lateral
Heart size is normal. Mediastinum is normal. Lungs are clear.
No pleural effusion or pneumothorax is seen. Degenerative
changes are noted throughout the spine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine 50 mg PO BID
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 40 mg PO BID
5. Propecia (finasteride) 1 mg oral daily
6. Simvastatin 5 mg PO DAILY
7. Tizanidine ___ mg PO TID prn pain
8. Sucralfate 1 gm PO QID:PRN acid reflux
Discharge Medications:
1. Omeprazole 40 mg PO BID
2. Simvastatin 5 mg PO DAILY
3. Venlafaxine 50 mg PO BID
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Propecia (finasteride) 1 mg oral daily
7. Sucralfate 1 gm PO QID:PRN acid reflux
Discharge Disposition:
Home
Discharge Diagnosis:
1) Alcohol-induced pancreatitis
2) GERD
3) Hyperlipidemia
4) Depression/anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Chest pain.
PA and lateral upright chest radiographs were reviewed with no prior studies
available for comparison.
Heart size is normal. Mediastinum is normal. Lungs are clear. No pleural
effusion or pneumothorax is seen. Degenerative changes are noted throughout
the spine.
Radiology Report
INDICATION: Pancreatitis. Evaluate for gallstones.
COMPARISONS: Right upper quadrant ultrasound from ___. MRCP from
___.
TECHNIQUE: Grayscale and Doppler ultrasound images were acquired through the
right and left upper quadrants.
FINDINGS: The liver is normal in shape and contour. There is normal
echogenicity. There are no focal hepatic lesions. There is no intra- or
extra-hepatic biliary duct dilation. The common bile duct measures 4 mm. The
gallbladder is normal without gallbladder wall thickening, pericholecystic
fluid, stones, or sludge.
The imaged portions of the pancreas are normal, though the head and tail are
obscured by overlying bowel gas. The spleen measures 13.2 cm, which is at the
upper limits of normal. No intraabdominal ascites is identified on this
limited upper quadrant ultrasound.
IMPRESSION: Normal right upper quadrant ultrasound without evidence of
cholelithiasis or cholecystitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN EPIGASTRIC
temperature: 96.4
heartrate: 91.0
resprate: 20.0
o2sat: 100.0
sbp: 158.0
dbp: 119.0
level of pain: 10
level of acuity: 3.0 | ___ M h/o alcohol-induced pancreatitis p/w abdominal pain similar
to his prior episode of pancreatitis.
#Pancreatitis: Lipase elevated at 8490 (on prior admission for
pancreatitis was in the 600s) on admission. Pt was made NPO,
received aggressive IVF, and was given IV pain and nausea meds.
Pancreatitis thought to be alcohol-induced given timing of his
EtOH consumption. To rule out hepatobiliary etiology, RUQUS was
ordered, which was negative. His diet was gradually advanced to
the point where he tolerated a BRAT diet. Pt was subsequently
discharged tolerating POs and with minimal pain and no nausea
and advised to continue a conservative diet until PCP follow up.
___ reinforced with patient to avoid alcohol and risk of
chronic pancreatitis with repeat flares.
.
#EtOH use: given pt's prior h/o binge drinking, pt put on CIWA.
He did not score on the scale during the admission. Took Valium
x1 to help with a headache, but did not have any withdrawal
symptoms. Pt given folate & thiamine daily. Hepatic synthetic
function was normal. Pt received counseling from social work and
addiction counselor.
#GERD: stable during admission. Pt was initially on IV Protonix
due to intolerance of POs, but switched back to home omeprazole
and sucralfate once he was tolerating POs.
#Depression & hyperlipidemia: stable during admission on home
meds. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
___: right hip hemiarthroplasty
History of Present Illness:
Mr. ___ is an ___ male with a-fib, MVP s/p repair, and
sick-sinus syndrome s/p pacemaker who presents with a right hip
pain after mechanical fall a few hours prior to admission. The
patient was at his routine cardiology appointment in ___
when he sustained a ground level fall after missing a step
resulting in immediate right hip pain and inability to bear
weight. +HS with laceration; NO loss of consciousness. Patient
denies numbness, tingling, weakness of affected extremity.
Denies recent fevers/chills.
Of note, patient is on Eliquis with last dose in ___ AM
(morning of injury). At baseline he is an independent walker
who ambulates ___ mile daily.
Past Medical History:
- Sick sinus syndrome
- Mitral regurgitation status post mitral valve repair
- Atrial fibrillation status post DDD pacemaker ___ Sigma
dual-chamber pacemaker Model SDR303 S/N PJD___ implanted
___
- Hyperlipidemia
- Pulmonary fibrosis (unsure if from amioderone)
- Macular degeneration
- Knee surgery
- Colon polyps
Social History:
___
Family History:
Identical twin brother also has mitral valve dysfunction.
Physical Exam:
Discharge Condiiton:
AVSS
NAD, A&Ox3
RLE: Appropriately tender. Incision well approximated. Dressing
clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n
distributions. 1+ DP pulse, wwp distally.
Pertinent Results:
See OMR for pertinent results.
Medications on Admission:
Apixaban
Dofetilide
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Senna 8.6 mg PO BID
6. Tamsulosin 0.4 mg PO DAILY
7. TraMADol 25 mg PO Q4H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
8. Apixaban 5 mg PO BID
9. Dofetilide 250 mcg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right hip femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ man with a fall/trauma, concern for pneumothorax or
rib fracture.
TECHNIQUE: Frontal supine view of the chest.
COMPARISON: Chest x-ray ___.
FINDINGS:
There is a left chest cardiac device with associated dual leads projecting
over the right atrium and ventricle, grossly unchanged from prior study of
___, in appropriate orientation and configuration. Median sternotomy wires
are re-demonstrated, as are numerous mediastinal surgical clips. Coarsened
lung markings most notable in the periphery of the right lung suggest
interstitial lung disease, more pronounced compared with prior ___
radiograph. Hila appear congested and there is likely mild edema. Effacement
of the left heart border raises concern for a lingular consolidation. A
lateral view would be helpful to further assess. No large effusion or
pneumothorax. Cardiomediastinal silhouette is unchanged. Imaged bony
structures are intact. Right shoulder arthroplasty is partially visualized.
IMPRESSION:
1. Congestion with mild edema.
2. Coarsened lung markings raise concern for interstitial lung disease,
progressed from prior.
3. Possible lingular consolidation.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
INDICATION: ___ s/p fall +HS on eliquis +r hip pain. on ctnch/ctcs eval for
intracranial bleed or c-spine fx. on cxr eval for ptx/ribfx. on r hip xr eval
for femoral or pelvic fx//
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the right hip.
COMPARISON: None.
FINDINGS:
There is a foreshortened, varus angulated right femoral shaft in the setting
of acute fracture involving the right femoral neck, mid cervical level. Left
hip total arthroplasty prosthetic components appear grossly well seated and
normally aligned without loosening or other visible complication. The pelvic
bony ring is intact. No SI joint or symphysis pubis diastasis. Lower lumbar
spine degenerative changes are partially visualized, suboptimally assessed on
this study. No worrisome focal osseous lesions no concerning soft tissue
calcification. Mesh noted overlying the lower pelvis.
IMPRESSION:
1. Right femoral neck fracture, mid cervical level, with varus angulation of
the distal fracture fragment.
2. Intact left hip total arthroplasty prosthetic components.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ man on anticoagulation, presenting after fall with
head strike, evaluate for bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute infarction, hemorrhage, edema,or large mass.
There is prominence of the ventricles and sulci suggestive of involutional
changes.
There is no evidence of fracture. There is mild ethmoid air cell mucosal
thickening, as well as trace fluid and aerosolized secretions in the sphenoid
sinus; otherwise, the visualized portions of the paranasal sinuses, mastoid
air cells, and middle ear cavities are well pneumatized and clear. The
patient is status post bilateral lens removal; otherwise, the globes and bony
orbits are intact and unremarkable. There is a laceration overlying the right
aspect the frontal bone without underlying fracture (for example see series 2,
image 17). Carotid siphon calcifications are noted bilaterally.
IMPRESSION:
1. No acute intracranial process.
2. Right frontal laceration. No fracture.
3. Mild ethmoid air cell and sphenoid sinus disease.
4. Chronic findings include age-appropriate global involutional change and
vascular calcifications.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ man with a fall and head strike, concern for cervical
spine fracture or malalignment.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 518 mGy-cm.
COMPARISON: None.
FINDINGS:
There is 2 mm anterolisthesis of C7 on T1 as well as T1 and T2, without
surrounding edema, nor anterior disc space or facet joint widening or
subluxation at these levels, likely degenerative. Elsewhere, alignment in the
cervical and upper thoracic spine is normal vertebral body heights are
preserved, without evidence of acute fracture. There is no prevertebral
fluid. There is mild multilevel cervical spine degenerative change, worst at
C5-6, consisting of multilevel small intervertebral osteophytes and disc
height loss. There is no significant spinal canal narrowing. There is
multilevel neural foraminal narrowing which is worst (moderate) on the left at
C3-4 (series 3, image 34), due to a combination of uncovertebral osteophytosis
and facet arthropathy. No worrisome focal osseous lesions. The imaged
thyroid gland is grossly unremarkable. No pathologically enlarged cervical
lymph nodes. Suggestion of scarring at the right lung apex, not well assessed
due to motion and partial visualization.
IMPRESSION:
1. No acute cervical spine fracture.
2. Minimal C7-T1 and T1-T2 anterolisthesis is likely degenerative. Otherwise,
normal alignment.
3. Mild multilevel cervical spine degenerative change.
Radiology Report
EXAMINATION: HIP 1 VIEW
IMPRESSION:
Images from the operating suite show placement of a hemiarthroplasty in the
right hip. Standard postsurgical changes in soft tissues. Further
information can be gathered from the operative report.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall
Diagnosed with Disp fx of base of neck of right femur, init for clos fx, Laceration w/o foreign body of oth part of head, init encntr, Fall on same level, unspecified, initial encounter
temperature: 97.4
heartrate: 86.0
resprate: 18.0
o2sat: 96.0
sbp: 141.0
dbp: 79.0
level of pain: 7
level of acuity: 2.0 | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip hemiarthroplasty, 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 continued on home apixaban for anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The patient
was straight-cathed for PVR of >600 on post-op day six for
urinary retention and was started on flomax with improvement.
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
weightbearing as tolerated in the right lower extremity, and
will be discharged on home apixaban for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tape ___ /
Lisinopril / Bactrim / Pentamidine Isethionate / Levofloxacin
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___ open cholecystectomy
History of Present Illness:
___ year old female with h/o ESRD ___ PCKD s/p failed ECD renal
transplant on HD s/p embolization of donated kidney, multiple
admissions for fever of unknown origin presents with fever. Pt
has h/o multiple admission for FUO with infectious w/u that has
been unrevealing. There has been some speculation that her
fevers may be due to her embolized kidney. She was started on
levofloxacin qod in ___ for suppressive therapy, and for 6
weeks she felt well and remained afebrile. Last month she
developed a maculopapular rash on her trunk and extremities, saw
dermatology and rash was ultimately felt to be a drug reaction
to levofloxacin and this was discontinued on ___. Today pt felt
well until this afternoon when she developed chills. Took temp
and it was 103.8 at home. Also had severe frontal HA, mild
nausea without vomiting. She took tylenol and ibuprofen and HA,
nausea improved, however she has remained febrile. No cough,
SOB, diarrhea, dysuria, night sweats, weight changes. Of note
she is no longer on immunosuppressive therapy (stopped after
embolization of donated kidney).
.
In the ED, initial VS: 101.7 51 130/72 18 97%RA. Labs notable
for normal WBC, INR 1.3, lactate 1.3, Hct 31.2 (baseline).
Transplant nephrology was consulted and recommended no
antibiotics for now, inpatient infectious workup on medicine
service and they will follow. VS at transfer: 99.8 100 101/62
96%RA.
.
Of note, the patient was admitted in ___ for ecoli
bacteremia. No source was found but potential etiologies
considered at that time included, bile duct, kidney graft,
urinary tract or infected PCKD cyst. A WBC scan was
unremarkable. She completed a 2 week course of ceftazidime. She
was readmitted in ___ for fever to 101.0 of unclear etiology.
A CT adomen and pelvis demonstrated slightly incrased stranding
around the failer right lwoer quadrant renal transplant
reflecting continued continued rejection post
embolization degeneration or infection. Blood, urine, strep
culture and CMV viral load were all reassuring. BK virus,
betaglucan and galactomannan were additionally negative. She had
negative antiviral screen and culture for influenzae and
respiratory viruses including adenovirus, parainfluenza and RSV,
and negative serum cryptococcal antigen. CMV PCR was negative
and group A strep throat culture was negative. Sputum culture
was also unremarkable. She was initially treated w/ empiric
linezolid, levofloxacin and flagyl. A TTE showed no evidence of
vegetation. A chest CT demonstrated evidence of a possible RLL
pneumonia so she was treated w/ a 14 day course of levofloxacin.
Ultimately, no definitive etiology for her fevers was determined
and she was discharged home. She was readmitted ___ with
fevers. She underwent Doppler renal US, CXR, ECHO,CT abdomen, US
of her AVF and a PET scan all of which were negative. She has
also been tested for EBV, CMV, parvovirus, aspergillus
galactomannan. All teams involved (transplant nephrology, ID,
surgery) have been suspicious about her embolized kidney as the
source of the fevers either because of rejection or infection in
a necrotic kidney and there was consideration of kidney biopsy
with cultures but this was not performed and she was placed on
Levofloxacin as above.
.
Currently, she feels well except for sweating. She denies
chills, HA, neck stiffness, nausea, SOB.
.
ROS: As per HPI
Past Medical History:
PCKD s/p bil. nephrectomies in ___
ESRD s/p failed ECD renal transplant in ___ on HD MWF
- s/p coil embolization of graft artery on ___
- multiple episodes of CMV viremia
HTN
Endometrial cancer
PAfib/flutter s/p cardioversion in ___
Primary Hyperparathyroidism
H/o C.diff colitis
Hypothyroidism
MR/TR on Echo
h/o tachycardiomyopathy - last EF > 55% in ___
dCHF
E.coli bacteremia ___
Knee OA
VRE
Enterococcus UTI
s/p tonsillectomy
-___ - coil embolization tpx renal artery
-___ - ECD kidney transplant and VHR with mesh
-___ - RUE AV fistulogram, balloon angioplasty
-___ - b/l nephrectomies for PKD
-___ - RUE brachiocephalic AV fistula
-___ - appendectomy and incisional hernia repair with mesh
-___ - TAH/BSO for endometrial ca
-___ - hysteroscopy
-___ - R hemithyroidectomy and excision of R parathyroid
adenoma, neck exploration
-___ - hemorrhoidectomy and drainage of perirectal hematoma
Social History:
___
Family History:
Father & daughter w/ PKD. No other history of cancer or CAD.
Physical Exam:
Physical Exam on Admission:
VS - Temp 98.6F, BP 124/63, HR 62, R 18, O2-sat 98% RA
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 - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, IIR, 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), R AV graft with audible pulse
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, moving all extremities
Pertinent Results:
Labs on Admission: ___
WBC-7.5 RBC-3.55* HGB-9.3* HCT-31.2* MCV-88 MCH-26.3*#
MCHC-29.9* RDW-19.5*
NEUTS-75.4* ___ MONOS-5.5 EOS-0.6 BASOS-0.4
___ PTT-31.8 ___
ALBUMIN-4.0 ALT(SGPT)-12 AST(SGOT)-19 ALK PHOS-94 TOT BILI-0.5
GLUCOSE-108* UREA N-41* CREAT-5.8*# SODIUM-133 POTASSIUM-4.9
CHLORIDE-91* TOTAL CO2-30 ANION GAP-17
LACTATE-1.4
TSH-1.0
.
Relevant Labs:
Microbiology:
___ 6:19 am SEROLOGY/BLOOD
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
___ 7:15 pm BLOOD CULTURE
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
REQUEST FOR FOSFOMYCIN AND TETRACYCLINE PER
___ ON
___. FOSFOMYCIN = SENSITIVE.
TETRACYCLINE & FOSFOMYCIN sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TETRACYCLINE---------- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___ ___
8:40AM.
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Imaging:
Chest x-ray
The cardiac silhouette is upper limits of normal. There is a
hazy area of consolidation at the right base which may represent
atelectasis or early infiltrate. Atelectasis at the left base
is unchanged. There are no signs for overt pulmonary edema or
pleural effusion.
.
CT abdomen/pelvis with contrast:
1. No findings to explain fever. Improvement in the
perinephric stranding seen near the transplanted kidney without
evidence of fluid collection or abscess formation.
2. Unchanged hepatic, pancreatic and splenic hypodensities
consistent with cysts.
3. Unchanged cholelithiasis with adenomyomatosis.
.
US AV fistula:
There is a heterogeneous curvilinear complex collection
measuring approximately 6 x 1 cm just deep to the AV fistula,
most compatible with hematoma. No internal vascular flow is
seen within this collection, nor in the surrounding soft
tissues. Adjacent AV fistula demonstrates color flow.
CONCLUSION: Likely hematoma deep to the AV fistula.
HIDA scan:
Serial images over the abdomen show homogeneous uptake of tracer
into the
hepatic parenchyma. At 90 minutes, the gallbladder is not
visualized. Traceractivity noted in the small bowel at 12
minutes. Thirty minutes following morphine administration (120
minutes total) the gallbladder was not seen.
IMPRESSION: Non-visualization of the gallbladder, at 90 minutes
and
nonvisualization with morphine, consistent with acute
cholecystitis.
WBC tagged scan (prelim): localization to the gallbladder
Medications on Admission:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet BID
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. warfarin 1 mg Tablet Sig: Three (3) Tablets PO Once Daily at
4
___.
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Triamcinolone cream
.
ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Tape
___ / Lisinopril / Bactrim / Pentamidine Isethionate /
Levofloxacin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Clotrimazole 1% Vaginal Cream 1 Appl VG HS Duration: 7 Days
RX *Clotrimazole-7 1 % once a day Disp #*7 Tube Refills:*0
4. Docusate Sodium 100 mg PO BID constipation
5. Epoetin Alfa 14,300 UNIT IV ONCE Duration: 1 Doses
per outpatient report
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lorazepam 1 mg PO HS:PRN insomnia
hold for sedation, RR<10
8. Metoprolol Tartrate 12.5 mg PO BID
hold for HR<55, SBP<95; please alert ___ if holding
9. Midodrine 5 mg PO 3X/WEEK (___)
please give prior to HD
10. Nephrocaps 1 CAP PO DAILY
11. Nystatin Oral Suspension 5 mL PO QID
Swish and swallow.
RX *nystatin 100,000 unit/mL four times a day Disp #*1 Bottle
Refills:*0
12. Senna 1 TAB PO BID:PRN constipation
13. sevelamer CARBONATE 2400 mg PO TID W/MEALS
14. Cefpodoxime Proxetil 200 mg PO POST HD Duration: 3 Doses
RX *cefpodoxime 200 mg 3 time a week Disp #*3 Tablet Refills:*0
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg every four (4) hours Disp #*20 Tablet
Refills:*0
16. Warfarin 3 mg PO DAILY16
17. Bisacodyl 10 mg PR ONCE MR1 Duration: 1 Doses
Discharge Disposition:
Home
Discharge Diagnosis:
cholecystitis
esrd on hemodialysis
candidiasis
ecoli bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: PA and lateral chest performed on ___.
CLINICAL HISTORY: ___ woman, end-stage renal disease and recurrent
fevers.
FINDINGS: Comparison is made to previous study from ___.
The cardiac silhouette is upper limits of normal. There is a hazy area of
consolidation at the right base which may represent atelectasis or early
infiltrate. Atelectasis at the left base is unchanged. There are no signs
for overt pulmonary edema or pleural effusion.
Radiology Report
INDICATION: Patient with history of end-stage renal disease, who now presents
with fevers and Gram-negative bacteremia. Assess for possible abscess
formation.
COMPARISONS: None available.
FINDINGS/IMPRESSION: There is a heterogeneous curvilinear complex collection
measuring approximately 6 x 1 cm just deep to the AV fistula, most compatible
with hematoma. No internal vascular flow is seen within this collection, nor
in the surrounding soft tissues. Adjacent AV fistula demonstrates color flow.
CONCLUSION: Likely hematoma deep to the AV fistula.
Radiology Report
INDICATION: History of end-stage renal disease secondary to polycystic kidney
disease, now status post failed kidney transplant in ___ and recent
embolization in ___. Now presenting with recurrent fevers and
Gram-negative rod bacteremia with unknown source.
COMPARISONS: ___ and CT abdomen and pelvis ___.
TECHNIQUE: MDCT axial images were obtained from the dome of liver to the
pubic symphysis after the uneventful administration of 130 mL of Omnipaque.
Coronal and sagittal reformations were provided and reviewed.
DLP: 431.55 mGy-cm.
ABDOMEN: The visualized lung bases are clear. There is no pleural effusion
or pneumothorax. The heart size is top normal. Coronary artery and mitral
valve calcifications are noted.
Innumerable hypodensities representing cysts are again seen throughout the
liver with a stable rim-calcified lesion seen at the dome. The overall size
and number of cysts appear unchanged from prior study. Cholelithiasis and
adenomyomatosis are unchanged. A prominent common bile duct, measuring up to
1.1 cm is unchanged from prior. The spleen is enlarged, measuring 15 cm.
Again seen is a hypodensity within the anterior portion of the spleen which
measures 3.9 x 2.5 cm and is unchanged from prior, previously characterized at
MRI as likely representing small cysts. A 3 x 1.5 cm cyst is seen posterior
to the body of the pancreas (2:24) and is unchanged from prior examinations.
Otherwise, the pancreas is normal. Calcification is again seen within the
left adrenal gland. The kidneys are surgically absent. Mild residual
stranding is seen in the left nephrectomy bed and likely relates to
post-surgical scarring. The large and small bowel are normal. A mild amount
of atherosclerosis is seen in the abdominal aorta. Incidental note is made of
a left retroaortic renal vein. There is no mesenteric lymphadenopathy.
Scattered retroperitoneal lymph nodes are not enlarged by CT size criteria and
are similar to prior exam. The main portal vein, splenic vein and superior
mesenteric vein are patent.
PELVIS: The transplanted kidney is seen in the right lower pelvis and fails
to take up contrast. Embolization coils are noted. The degree of stranding
seen around the transplanted kidney has decreased from prior study. There is
no fluid collection or evidence of abscess. Assessment of the transplanted
kidney is somewhat limited by streak artifact from embolization coils. The
bladder is collapsed. The rectum and sigmoid are normal. There is no
inguinal or pelvic lymphadenopathy. No free fluid is seen.
BONES and SOFT TISSUES: There are no suspicious osseous lesions. Multilevel
degenerative changes of the thoracolumbar spine are again noted and are
unchanged. A left lower quadrant subcutaneous lesion is again seen and is
unchanged from prior PET.
IMPRESSION:
1. No findings to explain fever. Improvement in the perinephric stranding
seen near the transplanted kidney without evidence of fluid collection or
abscess formation.
2. Unchanged hepatic, pancreatic and splenic hypodensities consistent with
cysts.
3. Unchanged cholelithiasis with adenomyomatosis.
Radiology Report
INDICATION: Open chole in OR.
FINDINGS: Intraoperative cholangiogram was performed; single fluoroscopic
image was provided which demonstrates filling of the cystic duct which appears
unremarkable without any evidence of filling defects. The distal common bile
duct is slightly dilated; however, contrast is seen flowing into the small
bowel. There is opacification of the some intrahepatic bile ducts which are
normal in caliber. Surgical ribbon is present. Radiologist was not present
during this procedure; please see operative note for further details.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, KIDNEY TRANSPLANT STATUS
temperature: 101.7
heartrate: 51.0
resprate: 18.0
o2sat: 97.0
sbp: 130.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ with ESRD s/p failed kidney transplant ___, off
immunosuppression now and with recurrent fevers who presents
with fever to 103 without clear localizing source initially and
was found to have acute cholecystitis now s/p cholecystectomy.
.
# Acute cholecystitis: Initially unclear etiology, has had very
extensive workup in the past 6 months. No leukocytosis or
localizing symptoms but the fact that fevers had abated on
Levofloxacin and returned 4 days after being stopped was
concerning for subacute/chronic infection. During admission,
blood cultures positive for GNRs. Has had E.coli bacteremia in
the past, likely recurrence. Started on Cefepime. However, pt
continued to be febrile, so broadened to also include Flagyl at
which point fever curve trended down. Initially suspected
necrotic kidney as source. However, CT abd/pelvis did not show
enhancing around kidney or any other focal source of infection.
AV fistula US also with no signs of infection. HIDA scan
indicative of cholecystitis WBC tagged scan localized to the
gall bladder as well. Patient was taken to the OR for open
cholecystectomy on ___ d/c, per ID recommendations, she
will complete a Cefpodoxime course to complete 14 day total
regimen. JP drain removed prior to discharge.
.
# ESRD: Continued on MWF schedule. Continued home sevelamer,
nephrocaps, midodrine.
.
# AF: Continued metoprolol and amiodarone for rate control.
Temporarily held warfarin prior to OR. Will have INR checked as
outpatient on dialysis days.
.
# Hypothyroidism: Continued home levothyroxine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Dyspnea/Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx CVAx2 (___) s/p trach and PEG in ___,
HTN, presenting with dyspnea and productive cough. Patient was
recently admitted to ___ from ___ and treated for pneumonia,
ecoli UTI and influenza. She was treating with tamiflu and
vanc/cefepime. Her vanc/cefepime was narrowed to
azithromycin/augmentin upon discharge. She was discharged to
rehab ___). At rehab she became
dyspneic, and sats dropped to 90-94% and she was refusing oxygen
per report.
In the ED, initial vitals: 98.6 70 140/90 24 100%
Non-Rebreather. patient was noted to be restless, confused,
lung sounds diminished with scattered ronchi. Patient was give
500cc NS, 650 mg tylenol, vanc/cefepime/levofloxacin and
tamiflu. Also received duonebs, amlodipine, lisinopril and
metop tartrate. Labs notable for normal white count (7.0), h/H
12.8/36.1, BUN/Cr ___, HCO3 23, U/A negative, lactate 2.0.
LENIs negative and CXR negative.
On transfer, vitals were:
On arrival to the MICU, VS were 98.3, HR 85, RR 21, 178/100,
96% 4L NC.
Review of systems: Limited as patient is minimally verbal,
however per son, reports ___ pain.
Past Medical History:
-R PCA in ___, hemorrhagic stroke ___, s/p trach/peg with
chronic respiratory failure
-trach/peg after CVA in ___
-HTN
Social History:
___
Family History:
No family h/o CVA, MI/CAD, or cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
Vitals- 98.3, HR 85, RR 21, 178/100, 96% 4L NC.
GENERAL: Ill-appearing elderly female, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Course breath sounds throughout
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, PEG tube in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Moving left UE, no spontaneous movement of RUE and BLE,
downgoing toes bilaterally, mumbling words - per son
___
DISCHARGE PHYSICAL EXAM:
===========================
98.0 149/79 91 18 100/2L
General- Alert, oriented, interactive.
Lungs- Diffuse rhonchi right worse than left, bases worse than
apices, no wheezing
CV- Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
at ___
Abdomen- soft, non-tender, non-distended
Ext- 2+ pulses
Pertinent Results:
ADMISSION LABS:
=======================
___ 03:15AM BLOOD WBC-7.0 RBC-4.02* Hgb-12.8 Hct-36.1
MCV-90 MCH-31.8 MCHC-35.5* RDW-14.5 Plt ___
___ 03:15AM BLOOD Neuts-51.0 ___ Monos-8.0 Eos-4.6*
Baso-0.3
___ 03:15AM BLOOD Glucose-108* UreaN-11 Creat-0.3* Na-139
K-3.9 Cl-106 HCO3-23 AnGap-14
___ 04:24AM BLOOD Calcium-9.8 Phos-3.8 Mg-1.6
___ 03:23AM BLOOD Lactate-2.0
___ 04:15AM URINE Color-Yellow Appear-Clear Sp ___
___ 04:15AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 04:15AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
___ 04:15AM URINE CastHy-2*
Flu A and B: negative
DISCHARGE LABS:
=======================
___ 05:57AM BLOOD WBC-6.5 RBC-3.50* Hgb-10.8* Hct-32.3*
MCV-92 MCH-30.8 MCHC-33.4 RDW-14.6 Plt ___
IMAGING:
========================
ECG ___:
Baseline artifact. Sinus rhythm. Minor inferior ST-T wave
abnormalities.
No previous tracing available for comparison.
CXR ___:
IMPRESSION: No acute cardiopulmonary abnormality. Tracheostomy
in appropriate position.
BLE Dopplers ___:
IMPRESSION: No evidence of deep venous thrombosis in the
bilateral lower extremity veins.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. CloniDINE 0.1 mg PO BID
2. Docusate Sodium (Liquid) 100 mg PO BID
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Tartrate 75 mg PO TID
7. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain/fever
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
9. Nystatin Oral Suspension 5 mL PO QID
10. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID
11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
12. senna 176 mg/5 mL oral QHS
13. Sodium Chloride 1 gm PO Q8HRS
14. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM
15. travoprost 0.004 % ophthalmic QHS
16. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
17. Ascorbic Acid ___ mg PO DAILY
18. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
19. Amantadine Syrup 100 mg PO DAILY
20. amino acids-protein hydrolys ___ gram-kcal/30 mL oral
daily
21. Amlodipine 10 mg PO DAILY
22. Bisacodyl ___AILY
23. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
24. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain/fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Amantadine Syrup 100 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. CloniDINE 0.1 mg PO BID
7. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM
10. Vitamin D 1000 UNIT PO DAILY
11. Miconazole Powder 2% 1 Appl TP TID:PRN vaginitis
12. amino acids-protein hydrolys ___ gram-kcal/30 mL oral
daily
13. Ascorbic Acid ___ mg PO DAILY
14. Bisacodyl ___AILY
15. Docusate Sodium (Liquid) 100 mg PO BID
16. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
17. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID
20. magnesium hydroxide 30ml PEG q6HR constipation
21. travoprost 0.004 % ophthalmic QHS
22. Nystatin Oral Suspension 5 mL PO QID
23. senna 176 mg/5 mL oral QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
hypoxemia
Secondary:
hypertension
history of cerebrovascular accident
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: Dyspnea in a patient with a tracheostomy.
COMPARISON: None available.
FINDINGS:
A portable frontal chest radiograph demonstrates a tracheostomy, with the tip
in the mid thoracic trachea. There is mild cardiomegaly, possibly accentuated
by low lung volumes and patient positioning. There is bibasilar atelectasis,
without identification of a definite focal consolidation. No large pleural
effusion or pneumothorax is seen. The visualized upper abdomen is
unremarkable.
IMPRESSION:
No acute cardiopulmonary abnormality. Tracheostomy in appropriate position.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: An ___ woman with shortness of breath reporting bilateral
lower extremity pain, evaluate for DVT.
TECHNIQUE: Gray 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.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Respiratory distress
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, FLU W RESP MANIFEST NEC, RESPIRATORY ABNORM NEC
temperature: 98.6
heartrate: 70.0
resprate: 24.0
o2sat: 100.0
sbp: 140.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | Impression: Ms. ___ is a ___ lady with PMHx notable for
___ s/p trach/peg with recent tx for pneumonia/uti/influenza
admitted to rehab with hypoxia and respiratory distress.
# Respiratory Distress: SNF initially concerned for pneumonia
but CXR was negative for consolidation and patient did not have
any fevers or leukocytosis. Flu swab also negative.
Respiratory distress likely related to secretions, and her trach
may have transiently plugged. Patient might have also become
anxious at new living facility given unfamiliar surroundings
leading to agitation. Patient received IV antibiotics in the ED
(vanc/cefepime/levoflox), which were discontinued on admission
given low suspicion for bacterial infection. She was initially
monitored in the ICU on non re-breather but was quickly
de-escalated to trach mask. She remained hemodynamically stable
with O2 saturations in the high nineties throughout her
admission, with regular suctioning and application of humidified
O2.
# Hypertension: Continued home clonidine, amlodipine (reduced
dose), lisinopril (reduced dose). Metoprolol held given BPs
well controlled with above agents.
# CVA: Continued home amantadine. Patient's family counseled
regarding prognosis and unlikelihood of significant recovery.
Patient will need follow-up with neurology.
# Glaucoma: Continued home timolol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clindamycin
Attending: ___.
Chief Complaint:
Fevers and rigor
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of
metastatic breast cancer to the bone and liver who presents with
fever.
History was obtained with the assistant of patient's daughter
who
served as ___. Patient reports not feeling well for
several days. She reports a fever on ___ to 101.3 with
associated chills. Since then has been having intermittent
fevers. She notes associated poor appetite and generalized
fatigue. She was seen by Oncology today due to fevers.
On arrival to the ED, initial vitals were 97.9 82 130/92 16 100%
RA. Exam was notable for benign abdomen. Labs were notable for
WBC 16.2 (PMNs 73%, bands 9%, lymphs 10%), H/H 11.2/33.8, Plt
283, BUN 19/Cr 1.0, LFTs wnl, lactate 1.2, and UA with large
leuks, negative nitrite, 33 WBCs and bacteruria. CXR with no
acute cardiopulmonary abnormality. Patient was given ceftriaxone
1g IV. Vitals prior to transfer were 98.5 88 129/82 18 98% RA.
On arrival to the floor, patient reports that she is feeling
well. She denies headache, dizziness/lightheadedness, vision
changes, weakness/numbness, shortness of breath, cough, chest
pain, palpitations, abdominal pain, nausea/vomiting, diarrhea,
dysuria, hematuria, and rashes.
Past Medical History:
Her breast cancer was diagnosed ___ years ago when she was living
in ___. She was ___ years of age at the time of her diagnosis.
She was treated in ___. Her diagnosis began with a
self-detected mass in the upper outer left breast. Mammography
confirmed a suspicious area and a biopsy was done. As she
describes therapy she received radiation therapy initially
followed by surgery, which consisted of a lumpectomy and
axillary
lymph node dissection to some degree. She was treated completely
with these local measures and did not receive either
chemotherapy
or antiestrogen therapy. A few weeks after her diagnosis, she
felt she had an abnormality in the right breast where she noted
thickening. Apparently, this was biopsied and felt to be benign.
She has remained continuously recurrence free over these past ___
years.
Her skeletal history actually begins in ___ when she had a
traumatic fracture of her left humerus. This did not heal with
conservative measures and she was referred to endocrinology for
further investigation which ultimately revealed a parathyroid
adenoma in the left lower pole. Dr. ___
surgery
for this and then Dr. ___ operated on her humerus in
___. A graft was taken from the left pelvis as part of that
procedure. She had some transient discomfort in the hip at the
site of the graft harvest, but this improved and resolved
postoperatively.
In ___, she went to ___ to visit her children and
grandchildren. She returned after two uneventful weeks there and
noted excruciating pain in her left hip with sudden onset when
she stood up from a sitting position. This did not improve and
she saw her primary care physician at ___
approximately eight days later. This stimulated a radiographic
workup, which revealed sclerotic changes in the left pelvis
initially thought compatible with Paget's disease. She saw Dr.
___ for further evaluation of this and he, aware of her
breast cancer history and perform some additional tests
including
breast cancer tumor antigens, which were elevated and other
radiographic studies that suggested that she had metastases in
the left hemipelvis as well as sclerotic bone lesions in other
distributions. Furthermore, a CT scan performed by her primary
care physician was also reviewed here and showed in addition to
disease in the anterior iliac area, other sclerotic bone lesions
as well as small pulmonary nodules, which may be unrelated as
well as some findings in the liver which are likely also benign.
Given the total picture, she was felt to have metastatic breast
cancer involving bone. It is unclear whether she has a
concomitant diagnosis of Paget's disease.
PAST MEDICAL HISTORY:
- Metastatic Breast Cancer
- Hypertension
- Hyperparathyroidism s/p Resection of Parathyroid Adenoma in
___
- Osteoporosis
- Left Humeral Fracture
- s/p tonsillectomy
Social History:
___
Family History:
non contributory
Physical Exam:
VS- 97.9 95 / 55 76 18 96 Room Air
Heart- RRR S1 n S2 normal. No MRG
Lungs- CTAB. No wheezes or crackles
Abdomen- Soft. CVAT negative bilaterally today. No tenderness.
Extremities- No edema.
Pertinent Results:
___ 3:01 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
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
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 06:18AM BLOOD WBC-10.6* RBC-3.07* Hgb-10.3* Hct-30.6*
MCV-100* MCH-33.6* MCHC-33.7 RDW-16.6* RDWSD-61.1* Plt ___
___ 06:18AM BLOOD Glucose-91 UreaN-17 Creat-0.7 Na-140
K-3.3 Cl-105 HCO3-25 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Anastrozole 1 mg PO DAILY
3. Fulvestrant 250 mg IM EVERY 4 WEEKS (FR)
4. Ibrance (palbociclib) 125 mg oral DAILY
5. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral BID
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
Please take tablets twice daily
RX *ciprofloxacin HCl 500 mg 500 tablet(s) by mouth twice daily
Disp #*8 Tablet Refills:*0
3. amLODIPine 2.5 mg PO DAILY
4. Anastrozole 1 mg PO DAILY
5. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral BID
6. Fulvestrant 250 mg IM EVERY 4 WEEKS (FR)
7. Ibrance (palbociclib) 125 mg oral DAILY
Please check with ___ resuming this medication
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L sided pyelonephritis.
Metastatic breast cancer.
Discharge Condition:
stable
Ao-3
Ambulatory
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with fevers, chemo // acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest dated ___.
FINDINGS:
The lungs are hyperinflated. Heart size is normal. The mediastinal and hilar
contours are normal. The pulmonary vasculature is normal. Lungs are clear. No
pleural effusion or pneumothorax is seen. There are no acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Fever
Diagnosed with Urinary tract infection, site not specified
temperature: 97.9
heartrate: 82.0
resprate: 16.0
o2sat: 100.0
sbp: 130.0
dbp: 92.0
level of pain: 0
level of acuity: 3.0 | ___ presents with 4 days history of fevers and rigors
prior to her admission. She was seen in the ER and was found to
have a UA with 33 WBC, normal CXR and a WBC count of 16.
On physical exam she demonstrated L sided costovertebral angle
tenderness. She was treated with IV ceftriaxone for 3 days and
then was transitioned to PO ciprofloxacin 500mg BID - 4 days (7
day total).
Pt's fever defervesced after initiation of antibiotics and she
did not have any other sympoms
Active Isses-
Metastatic Breast cancer- On Anastrazole, Fulvestrant and
Ibrance. PLease note she has not been taking her Ibrance for
past 2 weeks. Per EMR ___ was notified and she will see
___ on ___ prior to resuming Ibrance.
Resolved Issues- Pyelonephritis
Pending labs at the time of discharge
Blood cultures X 2
Pt was discharged home in a stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Ms ___ is a ___ with HTN, T2DM, recent colonoscopy ___ for
re-evaluation of poyp) presenting with BRBPR. Her colonoscopy
revealed 2 flat nonbleeding polyps of benign appearance that
were resected using a snare. Clips were placed. She also had 3
sessile nonbleeding polyps of benign appearance, for which one
was removed with a hot snare. Of note, the procedure required
deep resections. Pt had BM on ___ ___ that was just a clot of
blood, then had another bloody BM today, so came to ED for
evaluation per her GI team recs. She also endorses lower abd
ttp, weakness, denies f/c, n/v, diarrhea, hx hemorrhoids, cp,
sob, dizziness, LH, syncope.
In the ED, initial vitals were: 97.7 74 174/69 20 100% RA. She
remained HD stable with hgb 11.8. Labs were otherwise
unremarkable. CTAP showed no acute process. Case was discussed
with the GI fellow and given concern for post-polypectomy bleed,
recommendation was for admission to ___ for repeat endoscopy.
She was started on Moviprep. She was given 2 L NS and Tylenol
prior to transfer.
On the floor, no complaints. Was anxious but now feels better.
No further bleeding since arrival at the ed. No CP. Endorses
abd pain with palp but none at home, overall states was not
feeling well at home but currently feels improved.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation. No recent change in bladder habits. No dysuria.
Denies arthralgias or myalgias. 10 pt ros otherwise negative.
Past Medical History:
HTN
DM
HLD
GERD
Social History:
___
Family History:
unknown
Physical Exam:
ADMISSION EXAM:
Vitals: 98.1 ___
Constitutional: Alert, oriented, no acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, mild, diffuse ttp, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 1120)
Temp: 98.4 (Tm 98.4), BP: 178/73 (149-180/66-78), HR: 66
(63-79), RR: 18 (___), O2 sat: 99% (97-100), O2 delivery: Ra
___ 0758 FSBG: 152
___ 2158 FSBG: 159
___ 1619 FSBG: 85
___ 1036 FSBG: 112
___ 0752 FSBG: 127
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: S/NT/ND, BS present
EXT: no ___ edema or calf tenderness
NEURO: Non-focal
Pertinent Results:
ADMISSION LABS:
___ 12:00PM BLOOD WBC-8.5 RBC-4.52 Hgb-12.4 Hct-38.3 MCV-85
MCH-27.4 MCHC-32.4 RDW-15.8* RDWSD-49.1* Plt ___
___ 12:00PM BLOOD Neuts-64.3 ___ Monos-6.7 Eos-3.4
Baso-1.1* Im ___ AbsNeut-5.47 AbsLymp-2.08 AbsMono-0.57
AbsEos-0.29 AbsBaso-0.09*
___ 12:00PM BLOOD ___ PTT-28.7 ___
___ 12:00PM BLOOD Glucose-152* UreaN-15 Creat-0.7 Na-144
K-4.8 Cl-104 HCO3-25 AnGap-15
___ 12:10PM BLOOD Lactate-1.2
___ 12:10PM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 06:46AM BLOOD WBC-5.3 RBC-4.42 Hgb-11.7 Hct-36.5 MCV-83
MCH-26.5 MCHC-32.1 RDW-15.4 RDWSD-46.5* Plt ___
___ 06:46AM BLOOD Glucose-137* UreaN-8 Creat-0.6 Na-145
K-4.3 Cl-107 HCO3-23 AnGap-15
___ 06:46AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0
___ 01:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:00PM URINE RBC-0 WBC-1 Bacteri-FEW* Yeast-NONE Epi-2
CT A/P - IMPRESSION:
1. No acute intra-abdominal or intrapelvic process.
2. Colonic diverticulosis without acute diverticulitis.
3. 3 mm nodule adjacent to the major fissure in the left lower
lobe
For incidentally detected nodules smaller than 6mm in the
setting of an
incomplete chest CT, no CT follow-up is recommended.
COLONOSCOPY -
- No blood in the ileum.
- EMR site injected with epinephrine, both transverse colon
polypectomy sites were clipped. Clean based ulcers were noted at
each of the polypectomy sites without bleeding. No other site of
colonic bleeding identified.
- Polyp (8 mm) in the ascending colon will need removal at
subsequent colonoscopy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 5 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Simvastatin 20 mg PO QPM
Discharge Medications:
1. GlipiZIDE 5 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. HELD- MetFORMIN (Glucophage) 500 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until the
evening of ___
Discharge Disposition:
Home
Discharge Diagnosis:
GI Bleeding
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with abdominal pain, bright red
blood per rectum, recent colonoscopyNO_PO contrast// Evaluate for evidence of
colitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen following intravenous contrast administration with split
bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 6.3 s, 49.6 cm; CTDIvol = 15.1 mGy (Body) DLP = 745.8
mGy-cm.
Total DLP (Body) = 757 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is mild bibasilar dependent atelectasis. There is a 3 mm
nodule adjacent to the major fissure in the left lower lobe (2:5). There is
no evidence of pleural or pericardial effusion. Coarse calcification in the
right breast is noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is a 6 mm hypodensity in the right hepatic lobe (02:20), which is too
small to characterize. 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. There is a 7
mm hypodensity in the midpole of the spleen, which is too small to
characterize (02:23), but statistically benign..
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
No hydronephrosis is seen. Bilateral parapelvic cysts are noted. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is scattered
colonic diverticulosis without wall thickening or adjacent fat stranding. The
appendix is not well visualized, however, there are no secondary signs of
inflammation to suggest acute appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not seen and may be surgically absent. No
large adnexal mass is seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild to moderate
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
The patient is status post L3 through 5 laminectomy. There is mild
retrolisthesis of L2 on L3 and L3 on L4. There are moderate degenerative
changes in the lower lumbar spine, most pronounced over L2-3 with loss of
intervertebral disc space height, endplate sclerosis and anterior posterior
osteophytes.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra-abdominal or intrapelvic process.
2. Colonic diverticulosis without acute diverticulitis.
3. 3 mm nodule adjacent to the major fissure in the left lower lobe
For incidentally detected nodules smaller than 6mm in the setting of an
incomplete chest CT, no CT follow-up is recommended.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Postproc hemor of a dgstv sys org fol a dgstv sys procedure
temperature: 97.7
heartrate: 74.0
resprate: 20.0
o2sat: 100.0
sbp: 174.0
dbp: 69.0
level of pain: 5
level of acuity: 2.0 | ___ y/o F with PMHx of HTN, HLD, DM, GERD, recent colonoscopy
with polyp removal, who presented with BRBPR concerning for
post-polypectomy bleeding.
# GI BLEEDING: In the setting of recent polypectomy. The patient
underwent colonoscopy with epinephrine injected into EMR site
and clipping of polypectomy sites. She was monitored overnight.
H/H remained stable with no further bleeding episodes reported.
The was discharged home the following morning.
# HTN: Antihypertensive agents held in the setting of bleeding.
BP's moderately elevated currently. Restarted home meds prior to
discharge.
# GERD: On PPI
# HLD: On statin.
# DM: Oral agents held. On HISS while here with FSBS largely
well-controlled. Will continue to hold metformin x 72 hours
following contrast study. Continued glipizide at discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / ibuprofen
Attending: ___
Chief Complaint:
Left-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of afib currently off Coumadin, stroke
in ___ with no residual deficits, breast cancer s/p mastectomy
in ___ and GI bleed 6 weeks ago presenting with acute onset
left-sided weakness. Patient got up to go the bathroom at
1:30am. She lives with her son and he helped her to the
restroom at that time and she was at her baseline. He noticed
that it was
taking her longer than usual to go to the bathroom. When he
checked on her he found on the toilet with left-sided facial
drooping, drooling and left-sided weakness.
On arrival to the ED, BP 154/88. ED exam notable for left
facial droop, ___ strength in LUE and LLE, and left-sided
neglect. Patient taken for STAT NCHCT with no evidence of
hemorrhage. CTA with dense MCA cut-off. Exam after head CT
with NIHSS stroke 17: R gaze preference with no crossing of
midline, left facial droop, LUE ___ with no response to deep
nailbed pressure, LLE antigravity with noxious stimulation,
L-sided neglect. Risks and benefits of tPA discussed with
patient's son who opted for tPA. tPA given at ~4a at 0.9mg/kg
with 10% as initial bolus followed by remainder over 1 hour.
Past Medical History:
Metastatic breast cancer c/b malignant effusion
Type II diabetes mellitus
Atrial fibrillation on warfarin
Hypertension
Sciatica
Osteoarthritis
Glaucoma
Thyroid nodule
Remote CVA
Positive PPD
ONCOLOGIC HISTORY:
- ___ presented with swelling in the R arm and mammogram showed
branching calcification in the RUQ suspicious for DCIS, biopsy
showed 0.2cm invasic carcinoma of the breast, ER/PR
negative/HER2 neu negative and with some DCIS
- underwent R mastectomy with no residucal cancer, only residual
DCIS which was extensive comedo high grade without lymphatic or
vascular invsion
- presented to ___ with FTT and underwent
thoracentesis of large left pleural effusion and was positive
for malignant cells twice. Pleural biopsy showed adenocarcinoma
with immunoperoxidase analysis pointing to breast cancer. It was
strongly ER/PR positive and HER2 neu negative. She was started
on Arimidex before leaving the ___. Bone scan
showed multiple areas of abnormality involving the ribs, the
spine, cervical, thoracic, and lumbar regions and in the pelvis
bones.
Treatments:
-___ Arimidex 1 mg qd at ___
-___ 4mg IV for metastatic bone involvement
-___ 4mg IV for metastatic bone involvement
Social History:
___
Family History:
Father: ___
___ Grandmother: ___ Onset
Sister: Cancer
Son: ___ Onset
Physical Exam:
ADMISSION EXAM
Vitals: SBP 154/88, HR 84
General: Thin elderly lady lying on stretcher
HEENT: NCAT, no conjucntival injection or scleral icterus,
adentulous, MMM
CV: Irregularly irregular rhythm, normal rate
Resp: + cough
Abd: ND
Ext: Thickened skin over BLE
Neuro:
NIHSS: 17 (0,0,0,2,2,3,4,2,2,0,0)
MS: Awake, alert, oriented to self, date of birth, month and
year, unable to name place, answers questions appropriately,
follows midline commands and appendicular commands on right
CN: PERRL, right gaze preference, does not cross midline, + BTT
on right but not left, left-sided facial weakness in UMN
pattern,
mild dysrthria but speech easy to understand
Motor: Moves RUE spontaneously antigravity, shows thumb and
squeezes with right hand, lift RLE off bed on command, does not
lift LUE or LLE to command, no response to painful stimulation
of
LUE, withdraws antigravity with noxious stimulation of LLE
Sensory: Intact to light touch on right, no response to light
touch on left, no response to deep nailbed pressure of LUE,
withdrawal with deep nailbed pressure on LLE
Pertinent Results:
ADMISSION LABS:
___ 02:59AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:59AM WBC-8.6 RBC-3.54* HGB-10.3* HCT-32.7* MCV-92
MCH-29.0 MCHC-31.4 RDW-13.7
___ 02:59AM BLOOD WBC-8.6 RBC-3.54* Hgb-10.3* Hct-32.7*
MCV-92 MCH-29.0 MCHC-31.4 RDW-13.7 Plt ___
___ 02:59AM BLOOD ___ PTT-33.7 ___
___ 03:21AM BLOOD Glucose-116* UreaN-12 Creat-0.7 Na-136
K-3.0* Cl-95* HCO3-27 AnGap-17
___ 03:21AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7
___ 01:30AM BLOOD Triglyc-89 HDL-69 CHOL/HD-2.0 LDLcalc-51
___ 01:30AM BLOOD %HbA1c-5.8 eAG-120
DIAGNOSTIC STUDIES:
CTA ___:
CT shows chronic infarcts. No hemorrhage. CT perfusion shows
delayed mean transit time with small areas of low blood volume
indicative of ischemia and infarction. CT angiography of the
neck is unremarkable except for mild calcifications. CT
angiography of the head shows filling defect indicating a clot
within the supraclinoid right internal carotid with diminished
flow in the right middle cerebral artery.
There are patchy densities identified in the visualized bony
structures. This could be suspicious for metastatic disease.
Clinical correlation is recommended. Extensive degenerative
changes are also seen in the cervical region.
This report is provided without the availability of 3D
reformatted images. When these images are available and if
additional information is obtained, an addendum might be given
to this report.
NCHCT ___:
1. New intraparenchymal hemorrhage centered about the right
basal ganglia within the hypodensity measuring up to 2.3 cm.
2. Evolution of known right MCA territory infarct with interval
increase of cytotoxic edema involving the right frontal,
parietal and temporal lobes, exerting mass effect on the right
lateral ventricles. No significant shift of midline structures
or herniation.
NCHCT ___:
Evolution of right MCA infarct with no evidence of new
hemorrhage or
infarction.
DOPPLER ___:
1. Limited assessment of the left upper extremity demonstrates
no evidence of deep vein thrombosis.
CXR ___:
1. Opacity at the left lung base, supsicious for bacterial or
atypical
pneumonia, including tuberculosis.
2. Pleural thickening at the left lung base, which could
represent loculated pleural effusion.
3. Destruction and sclerosis of both glenohumeral joints is
noted, suggestive of possible rheumatoid arthritis.
CT CHEST ___:
1. Redemonstration of peribronchovascular thickening at the
lower lobes
bilaterally, worse on the left not significantly changed since
prior
examination from ___. These findings could relate
to chronic
scarring or atelectasis. However on overlying infectious
process cannot be entirely excluded.
2. Small bilateral pleural effusions, right greater than left.
3. Multiple pulmonary nodules, all measuring less than 4 mm.
With a known history of metastatic breast cancer, followup
should be dictated based on stability compared to prior imaging
(not available to us), as well as the clinical circumstances.
4. Multiple sclerotic lesions throughout the axial skeleton
compatible with metastatic breast cancer.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. anastrozole 1 mg oral DAILY
2. Calcium Carbonate 500 mg PO QID:PRN Heartburn
3. Digoxin 0.0625 mg PO EVERY OTHER DAY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Metoprolol Tartrate 12.5 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Pravastatin 20 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Lisinopril 30 mg PO DAILY
12. TraZODone 25 mg PO HS:PRN insomnia
13. Aspirin 325 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Oxybutynin 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Acute Stroke s/p tPA with hemorrhagic conversion
2. PEG placement
3. Atrial fibrillation
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAM: CTA of the head and neck.
CLINICAL INFORMATION: Patient with new left-sided weakness.
TECHNIQUE: Axial images of the head were obtained without contrast followed
by contrast-enhanced CTA of the head and neck.
FINDINGS: There is chronic right frontal lobe infarct and left occipital
infarct identified on this CT. No hemorrhage is seen. Brain atrophy noted.
CT angiography of the neck shows mild vascular calcifications, but no vascular
occlusion or stenosis in the carotid or vertebral arteries.
Intracranial CTA demonstrates a thrombus in the region of supraclinoid right
internal carotid artery with diminished flow in the right middle cerebral
artery M1 segment. Some flow is identified in the sylvian branches of the
right middle cerebral artery. The remaining arteries are patent.
The CT perfusion shows delayed transit time in the right middle cerebral
artery territory, with minimally decreased blood volume indicative of
predominant ischemia with a small infarct.
IMPRESSION:
CT shows chronic infarcts. No hemorrhage. CT perfusion shows delayed mean
transit time with small areas of low blood volume indicative of ischemia and
infarction. CT angiography of the neck is unremarkable except for mild
calcifications. CT angiography of the head shows filling defect indicating a
clot within the supraclinoid right internal carotid with diminished flow in
the right middle cerebral artery.
There are patchy densities identified in the visualized bony structures. This
could be suspicious for metastatic disease. Clinical correlation is
recommended. Extensive degenerative changes are also seen in the cervical
region.
This report is provided without the availability of 3D reformatted images.
When these images are available and if additional information is obtained, an
addendum might be given to this report.
Radiology Report
HISTORY: Productive cough.
COMPARISON: None.
FINDINGS:
Single upright AP image of the chest. The lungs are well expanded. There is
opacity at the left lung base which is supsicious for pneumonia. There is
pleural thickening at the left lung base, which could represent loculated
pleural effusion. There is also diffuse left-sided pleural thickening with
overall volume loss, which maybe related to previous infection or hemothorax.
There is no right pleural effusion or pneumothorax. The cardiomediastinal
silhouette is mildly enlarged. Destruction and sclerosis of both glenohumeral
joints is noted, suggestive of possible rheumatoid arthritis.
IMPRESSION:
1. Opacity at the left lung base, supsicious for bacterial or atypical
pneumonia, including tuberculosis.
2. Pleural thickening at the left lung base, which could represent loculated
pleural effusion.
3. Destruction and sclerosis of both glenohumeral joints is noted, suggestive
of possible rheumatoid arthritis.
Radiology Report
HISTORY: Lower lobe consolidation, question TB. Question infectious process.
COMPARISON: Prior abdominal/pelvic CTA from ___.
TECHNIQUE: Volumetric multi detector CT of the chest was performed without
intravenous contrast. Images are presented for display in the axial image
plane at 1.25 mm and 5 mm collimation. A series of multiplanar reformation
images are also submitted for review.
DLP: 440 mGy-cm.
FINDINGS:
CT of the chest: There are multiple small hypodense nodules in the thyroid
gland, the largest in the right lobe of the thyroid. There is no axillary,
mediastinal or hilar lymphadenopathy by CT size criteria. The central
tracheobronchial tree is patent to the subsegmental levels bilaterally. There
is evidence of bronchiectasis bilaterally and scarring at the lung apices.
There is redemonstration of peribronchovascular thickening at the lower lobes
bilaterally, most prominent on the left, as seen on prior CT examination. The
heart is enlarged. Note is made of aortic valve calcifications. There is no
pericardial effusion. There is a 3 mm sub pleural pulmonary nodule and an
additional 3 mm pulmonary nodule in the right upper lobe (04:57, 59). 2 mm, 1
mm and 3 mm pulmonary nodules are noted in the left upper lobe (4: 79, 90,
93). A larger 3 mm sub pleural nodule is noted at the left lower lobe. No
focal consolidation or pneumothorax is present. There are small bilateral
pleural effusions, right worse than left.
Although the study is not designed for the evaluation of subdiaphragmatic
structures, visualized portions of the solid abdominal organs are normal.
Osseous structures: There are multiple sclerotic lesions throughout the
vertebral bodies, sternum and manubrium as well as bilateral ribs, in keeping
with known metastatic breast cancer.
IMPRESSION:
1. Redemonstration of peribronchovascular thickening at the lower lobes
bilaterally, worse on the left not significantly changed since prior
examination from ___. These findings could relate to chronic
scarring or atelectasis. However on overlying infectious process cannot be
entirely excluded.
2. Small bilateral pleural effusions, right greater than left.
3. Multiple pulmonary nodules, all measuring less than 4 mm. With a known
history of metastatic breast cancer, followup should be dictated based on
stability compared to prior imaging (not available to us), as well as the
clinical circumstances.
4. Multiple sclerotic lesions throughout the axial skeleton compatible with
metastatic breast cancer.
Radiology Report
HISTORY: Status post stroke, tPA. Question bleed.
COMPARISON: Prior head CT and head and neck CTA from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head
without IV contrast. Sagittal, coronal and bone thin algorithm
reconstructions were generated.
Total exam DLP: 945 mGy-cm.
CTDI: 54 mGy.
FINDINGS:
There is a new intraparenchymal hemorrhage centered about the right basal
ganglia measuring 1.9 x 1.2 x 2.3 cm. Evolution of known right MCA territory
infarct is noted with interval increase of cytotoxic edema involving the right
frontal parietal and temporal lobes, with secondary mass effect and effacement
of the right lateral ventricle there is no significant shift of midline
structures. There is no evidence of herniation. There is redemonstration of
hypodensities in the right frontal lobe and left occipital lobe consistent
with prior infarction. The basal cisterns appear patent.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear.
IMPRESSION:
1. New intraparenchymal hemorrhage centered about the right basal ganglia
within the hypodensity measuring up to 2.3 cm.
2. Evolution of known right MCA territory infarct with interval increase of
cytotoxic edema involving the right frontal, parietal and temporal lobes,
exerting mass effect on the right lateral ventricles. No significant shift of
midline structures or herniation.
Findings discussed with Dr. ___ by NSR in telephone on ___ at
05:38, 5 min after discovery.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ woman with stroke.
FINDINGS: Comparison is made to the prior radiographs from ___.
There is a feeding tube projecting over the upper esophagus whose distal tip
is in the mid esophagus. This could be advanced several centimeters for more
optimal placement or removed altogether. The heart size is upper limits of
normal. There are small bilateral pleural effusions, left greater than right.
There is atelectasis and increased densities at the lung bases, which may
represent early infiltrate. There are no pneumothoraces seen. Degenerative
changes of the lumbar spine and moderate scoliosis of the upper lumbar spine
are seen.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ woman with history of stroke and left-sided
weakness. Found to have right MCA stroke. Evaluate position of Dobbhoff
tube.
FINDINGS: Comparison is made to previous study from the same day.
There has been readjustment of Dobbhoff tube, with the tip and side port now
in the stomach. The heart size is enlarged but stable. There is a small
left-sided pleural effusion and left retrocardiac opacity which may represent
early consolidation. There is mild prominence of the pulmonary interstitial
markings without signs for overt pulmonary edema. There are no
pneumothoraces.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST
INDICATION: ___ year old woman with stroke s/p TPA w/ hemorrhagic conversion.
// interval change. please complete around 5 am. PORTABLE PLEASE
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1202.3, 141.5, 424.3 mGy-cm
CTDI: 70.73, 70.73, 70.73 mGy
COMPARISON: Head CT on ___.
FINDINGS:
Hypodensity and loss of gray-white matter differentiation in the distribution
of the right MCA consistent with acute territorial infarction. There is no
evidence of new hemorrhage or infarction. There is significant compression of
the right lateral and a 2 mm leftward shift of normally midline structures.
The basal cisterns appear patent there is preservation of gray-white matter
differentiation on the left. No fracture is identified. Of note, these images
are limited by motion artifac.
IMPRESSION:
Hypodensity and loss of gray-white matter differentiation in the distribution
of the right MCA consistent with acute infarction. Significant compression of
the right lateral ventricle with a 2 mm leftward shift of normally midline
structures. No evidence of new hemorrhage or infarction from the prior
examination.
NOTIFICATION: These findings were communicated to Dr. ___ telephone by
Dr. ___ at 11:38 on ___ at the time of discovery.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with LUE swelling. Evaluate for DVT.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: Upper extremity ultrasound of the right dated ___.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular and axillary veins are patent and compressible with
transducer pressure.
The left brachial, and basilic veins are patent and compressible with
transducer pressure and show normal color flow and augmentation. The cephalic
vein is not visualized.
There is subcutaneous edema present in the left upper extremity.
IMPRESSION:
1. Limited assessment of the left upper extremity demonstrates no evidence of
deep vein thrombosis.
2. Subcutaneous edema in the left upper extremity.
Radiology Report
AP CHEST, 12:36 ___, ___
HISTORY: ___ woman with a new PICC.
IMPRESSION: AP chest compared to ___:
Tip of the new right PICC line passes beyond the midline, approximately 3 cm
into the left brachiocephalic vein.
Mild pulmonary edema, left lung greater than right, accompanied by small
pleural effusions, left greater than right, not appreciably changed since
___. Feeding tube now passes into the stomach and out of view, IV nurse
paged as requested.
Radiology Report
PORTABLE CHEST ___
COMPARISON: Radiograph of earlier the same date.
FINDINGS: Right PICC has been re-positioned, now terminating within the
proximal to mid superior vena cava. Pulmonary edema has improved in the
interval, and bibasilar opacities have also improved, with residual
abnormalities predominantly in the retrocardiac regions. Small pleural
effusions are unchanged, left greater than right.
Radiology Report
HISTORY: Dobbhoff placement, assess position.
COMPARISON: All available chest x-rays from ___ through ___.
FINDINGS:
A portable view of the chest shows interval placement of a Dobhoff tube, which
enters the stomach then loops superiorly ending in the distal esophagus. A
right subclavian line is pulled back and sits within the subclavian vein. The
cardiomediastinal contour is stable. Bibasilar opacities are unchanged as are
small pleural effusions.
IMPRESSION:
1. Interval placement of a Dobhoff with the tip located in the distal
esophagus.
2. Right subclavian line has been pulled back and now resides within the right
subclavian vein.
Findings were discussed with Dr. ___ by Dr. ___ telephone on ___ at 15:30, 20 min of the findings remain.
Radiology Report
HISTORY: Right PICC line placement, assess positioning.
COMPARISON: Chest x-ray from ___.
FINDINGS:
There has been interval placement of a right subclavian PICC with the tip
ending in the low SVC/cavoatrial junction. There is no pneumothorax. The
Dobhoff remains within the stomach with the tip coursing superiorly and
entering the distal esophagus. Otherwise, there is no interval change.
IMPRESSION:
1. Right PICC ends in the low SVC/cavoatrial junction.
2. Dobhoff tip remains within the distal esophagus.
Findings were discussed with the IV nurse by Dr. ___ on ___ at
16:00, 1 min after findings were made.
Radiology Report
CHEST RADIOGRAPH
INDICATION: New Dobbhoff catheter.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
Dobbhoff catheter. The course of the catheter is unremarkable, the tip of the
catheter is in the middle to distal parts of the stomach. There is no
evidence of complications, in particular no pneumothorax. Unchanged
appearance of the lung parenchyma and the cardiac silhouette.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Dobbhoff placement.
COMPARISON: ___, 2:12 p.m.
FINDINGS: As compared to the previous radiograph, the Dobbhoff catheter has
been changed. The course of the catheter is unremarkable, the tip of the
catheter projects in prepyloric position. There is no evidence of
complications, notably no pneumothorax. Mild bilateral pleural effusions,
left more than right, are unchanged. Unchanged size of the cardiac
silhouette.
Radiology Report
AP CHEST, 9:10 A.M., ___.
HISTORY: ___ woman, febrile after stroke.
IMPRESSION: AP chest compared to ___:
Worsened aeration at the right lung base medially, probably atelectasis, has
not improved since ___. Pulmonary vascular engorgement and mediastinal
venous distention accompany perihilar opacification, probably edema. Supine
positioning, however, may introduce serious artifacts to prevent side-by-side
comparison. Heart is moderately enlarged. No pneumothorax. Right PICC line
ends low in the SVC. Feeding tube ends in the stomach.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with stroke and hemorrhagic conversion, now wih
decreased arousal // assess for new bleed or increase in previous bleed
TECHNIQUE: Contiguous axial CT images were obtained through the brain without
the administration of IV contrast. Reformatted coronal, sagittal and thin
section bone algorithm-reconstructed images were then generated.
DOSE: DLP: 1226 mGy-cm
CTDI: 108
COMPARISON: Head CT on ___
FINDINGS:
Again seen is hypodensity and loss of gray-white matter differentiation in the
distribution of the right MCA consistent with evolving infarction. There is no
evidence of new hemorrhage or infarction. Adjacent vasogenic edema and
compression of the right lateral ventricle is unchanged. The basal cisterns
are patent and there is preservation gray-white matter differentiation on the
left. No evidence of acute fracture. Chronic infarct in the distribution of
the left PCA is unchanged in appearance.
IMPRESSION:
Evolution of right MCA infarct with no evidence of new hemorrhage or
infarction.
Radiology Report
INDICATION: Stroke, now with right arm edema (PICC in the same arm). Rule
out DVT.
COMPARISON: Right upper extremity ultrasound, ___.
TECHNIQUE: Grayscale, color and spectral Doppler ultrasound evaluation of the
right upper extremity veins.
FINDINGS: The study is somewhat limited due to overlying dressing in the
right mid arm. Within these limitations, the right internal jugular and
axillary veins are patent and compressible with transducer pressure. There is
normal flow with respiratory variation in the bilateral subclavian veins.
The right brachial and basilic veins are patent and compressible with
transducer pressure and show normal color flow. The cephalic veins could not
be seen. PICC resides in the basilic vein without evidence of clot. There is
mild subcutaneous edema in the arm.
IMPRESSION: No evidence of DVT in the right upper extremity veins. The
cephalic vein is not seen due to overlying dressing. Mild subcutaneous edema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: STROKE
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | #STROKE WITH HEMORRHAGIC CONVERSION
Ms. ___ is a ___ year old woman with a history of AFib off
coumadin due to a recent GI bleed who presented to ___ with
left hemiplegia, hemianesthesia, hemineglect, hemianopsia,
facial droop as well as right gaze deviation, and dysarthria,
concerning for a right MCA stroke. NC Head CT in the ER showed a
early ischemic changes in the R MCA, but no hemorrhage. CTA
showed R MCA occlusion. CTP with findings consistent with R MCA
distrubution ischemia. Risks and benefits of tpa were discussed
and weighted including hemorrhage, and in consultation with the
family (and a per son's wishes) IV tPA was administered.
Ms. ___ was admitted to the neurology ICU for monitoring after
receiving tPA for an acute right MCA territory infarct, after
the risks and benefits were discussed extensively with the
patient and her family member. On ___ she was noted to have a
small R BG hemorrhagic conversion which remained stable on
imaging ___. Her exam, significant for left hemiparesis,
remained unchanged. Aspirin and SQH were held for one day in the
setting of this bleed but were resumed thereafter. She also had
some cerebral edema, but without midline shift. Home blood
pressure medications were initially held for permissive
hypertension, however they were restarted on ___ due to
systolic blood pressures in the low 200s (HCTZ 25mg daily and
lisinopril 30mg daily). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / shellfish derived
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
___ EGD
___ Right mandible vestibular space I&D
History of Present Illness:
___ with ETOH use disorder, HCV, history of bleeding
esophagitis/gastritis, polysubstance use disorder on methadone,
PUD c/b hematemesis from antral ulcers ___ presenting with 1
week of intermittent hematemesis.
One week ago patient was not feeling well and started to have
episodes of emesis. He states the emesis was bloody in nature.
He was staying at his girlfriend's house at the time and did not
seek medical care. He felt that he returned to his normal
status
until yesterday when he had repeat episodes of emesis that were
bloody. He endorses melena + lightheadedness over the last 4
days, and anorexia over the last 2 weeks. States he also has
been having weight loss and night sweats over the same time
period. Continues to live in the shelter.
He reported his symptoms at the ___ and was transported to
___ ED by EMS. He was found to have a Hgb 6.9 and lactate
4.7.
He had one episode of melena and hematemesis.
He was transfused 2U PRBC and underwent EGD revealing multiple
antral ulcers including one 15 mm ulcer with stigmata of prior
bleeding. No active bleeding or pooled blood was noted
throughout the EGD. The ulcer was cauterized and he was
transferred to the MICU for further monitoring.
Past Medical History:
-Lumbar Spine (L4-L5) fungal osteomyelitis ___ IV drug use - Dx.
___, ___ bone biopsy (at ___ ___ revealed ___
parapsilosis, plan ___ months of fluconazole
- Chronic back pain ___ motor vehicle accident ___
- Polysubstance abuse, followed in ___ clinic at ___
(IV heroin, cocaine, EtOH)
- Pulmonary TB s/p 7 mo treatment w INH @ ___ ___ - per
___ records pt. with pansensitive tb, negative cultures
since ___
- Hx. of Pneumonia - s/p chest tube ___
- Depression
- HCV - Not under treatment
- Hep A positivity
- Anemia of chronic disease
- Esophagitis/Gastritis - EGD ___ positive for H. pylori,
repeat episode ___ at ___ ___ NSAID use
- Hx of UGIB (___) requiring transfusion at ___
- ___ ___ - FTH antral ulcers. Biopsies with no evidence of
H Pylori
Social History:
___
Family History:
Pt. is unclear if his mother or father have medical problems.
He reports maternal grandmother with DM, HTN. His
paternal grandfather died of TB complications.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.4F, 67, 128/95, 11, 100% on RA
GEN: Older appearing man in NAD,
HEENT: PERRL, poor dentition, high sensitivity at right frontal
buccal mucosa, no fluctuance
NECK: R. neck salivary gland enlargement with mild TTP.
CV: RRR, ___ SEM with intact S1/S2
RESP: CTAB in anterior fields
GI: Soft, NTND
MSK: Moving all four extremities without issue
NEURO: AAOx3
Rectal: Dark stool, guaiac positive.
DISCHARGE PHYSICAL EXAM
=======================
VITALS:
24 HR Data (last updated ___ @ 151)
Temp: 98.0 (Tm 98.6), BP: 101/62 (101-129/62-79), HR: 78
(68-88), RR: 16 (___), O2 sat: 99% (97-99), O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, palpable
enlarged R submandibular lymph node.
CV: RRR, s1, s2, no m/r/g
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Skin: Warm, dry, no rashes or notable lesions.
Neuro: Alert, conversive, moving extremities to observation.
Pertinent Results:
ADMISSION LABS
==============
___ 09:30AM BLOOD WBC-8.7 RBC-2.79* Hgb-6.9* Hct-22.9*
MCV-82 MCH-24.7* MCHC-30.1* RDW-19.4* RDWSD-55.8* Plt ___
___ 09:30AM BLOOD Neuts-74.0* Lymphs-14.0* Monos-11.3
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.41* AbsLymp-1.21
AbsMono-0.98* AbsEos-0.00* AbsBaso-0.01
___ 09:17AM BLOOD Glucose-142* UreaN-27* Creat-1.0 Na-138
K-6.0* Cl-105 HCO3-19* AnGap-14
___ 09:17AM BLOOD ALT-18 AST-42* AlkPhos-64 TotBili-0.7
___ 09:17AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.5* Mg-2.1
___ 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___:38AM BLOOD Lactate-4.7* K-4.8
PERTINENT RESULTS
=================
___ EGD
Esophagus: Grade B esophagitis was seen in the distal esophagus.
Stomach: Multiple cratered non-bleeding ulcers were found in the
antrum. The ulcers were clean based apart from the larger
antral ulcer, which had a pigmented spot but no clear visible
vessel. Bi-cap electrocautery was successfully applied to the
pigemented spot on the larger antral ulcer.
Duodenum: Normal mucosa was noted in the whole examined
duodenum.
___. Dental amalgam and overlying hardware streak artifact limits
examination. Please note evaluation for abscess is limited due
to lack of administration of intravenous contrast.
2. Within limits of this noncontrast examination, no definite
evidence of new dental abscesses.
3. Small periapical lucency around the root ___ tooth 29 in
the right mandible is unchanged from ___, and likely
reflects sequela of periodontal disease.
4. Enlarged appearance of the right submandibular gland with 2
large stones in the gland/proximal duct are unchanged, again
suggestive of submandibular sialolithiasis and sialoadenitis.
5. Nonspecific induration and/or nonvisualization right
submandibular gland adjacent fat, allowing for difference
technique grossly unchanged compared to ___ prior exam.
6. Question nonspecific induration of pre mandibular soft
tissues as
described, suggested on ___ prior exam. If not artifactual,
finding may represent scarring, with differential consideration
of cellulitis not excluded on the basis of this examination.
7. Enlarged right level 2A and additional scattered
subcentimeter nonspecific lymph nodes are noted throughout the
visualized portion of the neck bilaterally, without definite
enlargement by CT size criteria, which may be reactive.
8. Additional findings as described above.
___ RUQ U/S:
1. Mildly heterogenous liver without focal hepatic lesion.
2. Prominent main pancreatic duct at ___ile
duct dilatation.
___ TTE:
The left atrium is mildly dilated. The interatrial septum is
dynamic, but not frankly aneurysmal. The estimated right atrial
pressure is ___ mmHg. There is normal left ventricular wall
thickness with a normal cavity size.
There is normal regional and global left ventricular systolic
function. Quantitative 3D volumetric left ventricular ejection
fraction is 74 % (normal 54-73%). Left ventricular cardiac index
is normal (>2.5 L/ min/m2). There is no resting left ventricular
outflow tract gradient. No ventricular septal defect is seen.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal with a normal descending aorta diameter. The
aortic valve leaflets (3) appear structurally normal. No masses
or vegetations are seen on the aortic valve. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
There is trivial mitral regurgitation. The pulmonic valve
leaflets are not well seen. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. There is an eccentric jet of mild to moderate
[___] tricuspid regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: No 2D echocardiographic evidence for endocarditis.
If clinically suggested, the absence of a discrete vegetation on
echocardiography does not exclude the diagnosis of endocarditis.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
MICROBIOLOGY
==================
___ 6:16 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:03 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:05 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 100 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H Duration: 10
Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*19 Tablet Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % Swish and spit twice a day
Refills:*0
3. FLUoxetine 10 mg PO DAILY
RX *fluoxetine 10 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
6. Pantoprazole 40 mg PO Q12H
Take 30 minutes before meals.
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
8. Methadone (Concentrated Oral Solution) 10 mg/1 mL 110 mg PO
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed due to peptic ulcer disease
Polysubstance ulcer disorder
Alcohol use disorder complicated by withdrawal
Sialadenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with pna// vomiting
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities. Remote right
posterior rib fractures are re-demonstrated. No subdiaphragmatic free air.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT NECK W/O CONTRAST (EG: PAROTIDS) Q21 CT NECK
INDICATION: ___ year old man with UGIB with concomitant facial pain and
swelling c/f dental infection.// Evaluate for evidence of dental abscess
TECHNIQUE: MDCT acquired helical axial images were obtained from the thoracic
inlet through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.1 s, 24.7 cm; CTDIvol = 12.9 mGy (Body) DLP = 318.4
mGy-cm.
Total DLP (Body) = 318 mGy-cm.
COMPARISON: ___ noncontrast cervical spine CT.
___ contrast neck CT.
FINDINGS:
Dental amalgam and overlying hardware streak artifact limits examination.
Please note evaluation for abscess is limited due to lack of administration of
intravenous contrast.
Question nonspecific induration of the right greater than left pre mandibular
soft tissues versus artifact is again noted (see 301: 83-111 on current study
and 3: 43-57).
There is a small periapical lucency around the root ___ tooth 29 in the
right mandible (02:52), unchanged from ___.
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect.
Enlarged appearance of the right submandibular gland with 2 large stones in
the gland/proximal duct are unchanged. The left submandibular and bilateral
parotid glands are preserved. The thyroid gland is preserved. An enlarged
right level 2A lymph node measuring up to 1.1 cm is noted (see 02:50).
Additional scattered scattered subcentimeter nonspecific lymph nodes are noted
throughout the neck bilaterally, without definite enlargement by CT size
criteria.
Redemonstration of centrilobular emphysematous changes and Pleuroparenchymal
scarring is noted in the imaged lung apices.There are no suspicious osseous
lesions.
There is a moderate mucous retention cyst in the inferior right maxillary
sinus.
IMPRESSION:
1. Dental amalgam and overlying hardware streak artifact limits examination.
Please note evaluation for abscess is limited due to lack of administration of
intravenous contrast.
2. Within limits of this noncontrast examination, no definite evidence of new
dental abscesses.
3. Small periapical lucency around the root ___ tooth 29 in the right
mandible is unchanged from ___, and likely reflects sequela of
periodontal disease.
4. Enlarged appearance of the right submandibular gland with 2 large stones in
the gland/proximal duct are unchanged, again suggestive of submandibular
sialolithiasis and sialoadenitis.
5. Nonspecific induration and/or nonvisualization right submandibular gland
adjacent fat, allowing for difference technique grossly unchanged compared to
___ prior exam.
6. Question nonspecific induration of pre mandibular soft tissues as
described, suggested on ___ prior exam. If not artifactual, finding may
represent scarring, with differential consideration of cellulitis not excluded
on the basis of this examination.
7. Enlarged right level 2A and additional scattered subcentimeter nonspecific
lymph nodes are noted throughout the visualized portion of the neck
bilaterally, without definite enlargement by CT size criteria, which may be
reactive.
8. Additional findings as described above.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 11:49 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with HCV// Evaluate for HCC
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound ___.
FINDINGS:
LIVER: The hepatic parenchyma appears mildly heterogenous. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses, with portions of the pancreatic tail obscured by overlying
bowel gas. The main pancreatic duct is prominent at 3 mm, without evidence of
any pancreatic head mass.
SPLEEN: Normal echogenicity.
Spleen length: 10.6 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.6 cm
Left kidney: 10.7 cm
RETROPERITONEUM: The visualized portions of the IVC are within normal limits.
IMPRESSION:
1. Mildly heterogenous liver without focal hepatic lesion.
2. Prominent main pancreatic duct at 3 mm without common bile duct dilatation.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Weakness
Diagnosed with Hematemesis
temperature: 96.7
heartrate: 98.0
resprate: nan
o2sat: 100.0
sbp: 120.0
dbp: 61.0
level of pain: 0
level of acuity: 3.0 | ___ male with EtOH use disorder, HCV, hx bleeding
esophagitis/gastritis, polysubstance use disorder on methadone,
PUD c/b hematemesis from antral ulcers ___ who presented with
1 week of intermittent hematemesis due to bleeding antral
ulcers, s/p EGD electrocautery.
ACUTE ISSUES
===================
#PUD c/b UGIB
Patient presented with 1 week of intermittent hematemesis likely
___ chronic NSAID use for pain from his dental infection. EGD on
___ found multiple antral ulcers including one 15 mm ulcer with
stigmata of prior bleeding s/p electrocautery. He received 3u
pRBC for Hgb 6.9, and his Hgb remained stable throughout the
rest of his stay. H. pylori Stool Ag was negative. GI
recommended repeat EGD in 2 months to evaluate for ulcer healing
and esophagitis. He was started on pantoprazole 40mg BID with
recommendation to continue for ___ weeks.
#DENTAL PAIN C/F INFECTION
#Sialadentitis
On admission, patient complained of significant jaw pain and
swelling, primarily from the L lower molar. He was evaluated by
OMFS and found to have suppurative R submandibular sialadenitis
with two large sialoliths in the gland, which can be considered
for removal as an outpatient. He also had poor dentition with a
R mandibular vestibular space abscess s/p drainage. He was
treated with IV cefazolin ___, flagyl (___), and per
___ recommendations, 10 additional days of PO Augmentin for
continued purulent drainage. Dentistry recommended extraction of
all teeth as outpatient with appointment scheduled for 3pm on
___ at ___. His pain was treated with oxycodone and Tylenol.
Per discussions with ___, his methadone was
increased to 110mg qD on ___ and oxycodone discontinued (EKG
___ showed QTc < 450).
#POLYSUBSTANCE USE DISORDER
Patient has h/o heroin use. He was continued on Methadone 100 mg
daily (___), increased to 110mg on ___.
#WEIGHT LOSS
#NIGHT SWEATS
Pt reported 2 weeks of night sweats. He has positive history of
lung TB. However, CXR unremarkable and no sputum production, so
unlikely
to be TB. With poor dentition on exam + h/o IVDU, he is
certainly at high risk of infective endocarditis. However, his
VSS, nml physical exam, negative blood cx, and negative TTE on
___ made for overall low suspicion for infective endocarditis.
HIV serology ___ was negative, CRP was mildly elevated likely
___ oral infection.
#ETOH USE DISORDER c/b WITHDRAWAL
Patient reported increased ETOH use due to toothache. He was
actively intoxicated on admission, and later experienced
withdrawal sx: anxiety, headache, shakiness. His withdrawal was
treated with phenobarbital 300mg IV (5 mg/kg) + 2.5mg /kg rescue
dose on ___. He also received nutrition supplementation with
thiamine, folic acid, and multivitamin. Patient had no further
signs of alcohol withdrawal after phenobarbital rescue dose on
___.
#ANXIETY
Pt reports chronic anxiety, with shakiness and heart racing. He
has taken Ativan, Xanax, Celexa in the past. He does not
remember if Celexa helped in the past. He was started on a trial
dose of fluoxetine 10mg qD with plans for follow-up as an
outpatient.
# HCV: Untreated. Likely ___ hx IVDU. RUQUS on ___ showing
mildly heterogenous liver without focal hepatic lesion,
prominent main pancreatic duct at 3 mm without of any pancreatic
head mass. He had HCV VL 6.7 log10 IU/mL. He was set up with an
outpatient hepatology appointment.
.
.
.
>30 minutes spent today ___ in discharge planning and care
coordination.
TRANSITIONAL ISSUES
====================
[] Please follow-up fluoxetine effectiveness, and adjust dose
accordingly. Fluoxetine started on ___.
[] Recommend repeat EGD in 2 months to assess for ulcer healing
and esophagitis (early ___.
[] Pt had elevated HCV viral load of 6.7 log10 IU/mL, will need
outpatient gastroenterology follow-up for potential curative
treatment.
[] Recommend ongoing counseling for substance use disorder and
risk reduction prior to treatment of HCV.
[] Methadone dose increased to 110mg qD for acute increase in
mouth pain ___ cavities + oral infection, consider decreasing
again to 100mg qD (initial dose on admission)
[] Please follow-up with repeat Hgb level in ___ weeks to ensure
stable following bleed, at time of discharge his Hgb was 7.7 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___: ___ drainge, placement of 2 pelvic drains
History of Present Illness:
___ year old male, otherwise healthy ___ s/p laparoscopic
appendectomy for
perforated appendicitis returning w complaint of fever. Patient
underwent uneventful lap appy ___ ___ w operative findings
notable
for purulent fluid in RLQ and R paracolic gutter. Tolerated diet
and transitioned to PO abx for planned 14 day course on ___.
Discharged to home in stable condition. Returned to ___ late ___
___ and surgery consult obtained early AM ___.
On surgery evaluation, patient reports subjective fever and mild
chills. Tolerating diet. Passing flatus and BMs. Does complain
of
moderate abdominal pain though states that he has not taken any
pain medication since leaving hospital ___ at suggestion of his
father. ___ other associated symptoms including chest pain,
shortness of breath, nausea, vomiting, wound drainage, dysurea.
Past Medical History:
None
Social History:
___
Family History:
No history of bleeding disorders, coagulopathy
Physical Exam:
P/E: ___: physical examination upon admission:
VS: T: 102.8 P: 80s BP: 120s/70s RR: 16 O2sat: 100RA
GEN: WD, WN in NAD
HEENT: NCAT, anicteric
CV: RRR
PULM: non-labored, no respiratory distress
ABD: soft, appropriate ___ tenderness,
non-distended,
laparoscopic incisions x 3 C/D/I w steri-strips intact
PELVIS: deferred
EXT: WWP, no CCE
NEURO: A&Ox3, no focal neurologic deficits
Physical examination upon discharge:
General: NAD
CV: ns1,s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, tenderness at drain sites, bagging and tube
changed
EXT: no pedal edema bil., no calf tenderness
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 05:45AM BLOOD WBC-11.7* RBC-4.63 Hgb-13.5* Hct-40.7
MCV-88 MCH-29.2 MCHC-33.2 RDW-13.3 RDWSD-41.5 Plt ___
___ 06:20AM BLOOD WBC-11.8* RBC-4.43* Hgb-13.0* Hct-38.5*
MCV-87 MCH-29.3 MCHC-33.8 RDW-13.2 RDWSD-41.1 Plt ___
___ 06:00AM BLOOD WBC-12.3* RBC-4.48* Hgb-13.1* Hct-39.4*
MCV-88 MCH-29.2 MCHC-33.2 RDW-13.2 RDWSD-42.1 Plt ___
___ 06:25AM BLOOD WBC-17.2* RBC-4.41* Hgb-13.1* Hct-37.3*
MCV-85 MCH-29.7 MCHC-35.1 RDW-12.9 RDWSD-39.6 Plt ___
___ 12:10AM BLOOD Neuts-91.1* Lymphs-4.2* Monos-4.1*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.95* AbsLymp-0.37*
AbsMono-0.36 AbsEos-0.00* AbsBaso-0.01
___ 05:45AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-82 UreaN-15 Creat-0.6 Na-135
K-5.0 Cl-99 HCO3-21* AnGap-20
___ 12:10AM BLOOD ALT-28 AST-43* AlkPhos-88 TotBili-1.0
___ 06:00AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.1
___: chest x-ray:
Bibasilar opacities, left greater than right, likely represent a
combination of pleural effusion and atelectasis, however
pneumonia could be considered in the appropriate clinical
setting.
___: cat scan of abdomen and pelvis:
1. 10.9 x 4.5 x 5.9 cm heterogeneous collection within the
pelvis adjacent to the cecum and posterior to the bladder with
mild rim enhancement most
consistent with hematoma.
2. Enhancement of the peritoneum as described above raises
possibility of
peritonitis.
2. New small bilateral pleural effusions and bibasilar
atelectasis.
3. Mild splenomegaly at 13.9cm.
4. Unchanged 9 mm hyperdense lesion in segment VII of the
liver, too small to fully characterize. A non-emergent
abdominal ultrasound is recommended.
___: chest x-ray:
No significant interval change when compared to the prior study.
Persistent airspace opacity in the left lower lobe may reflect
a combination of pleural effusion and atelectasis however
pneumonia cannot be excluded.
___: cat scan of abdomen and pelvis:
1. No significant interval change in the size of the dominant
collection
within the rectovesical pouch. There is interval evolution in
the density of the collection, now predominantly hypodense.
This is consistent with evolving hematoma, however please note
that superinfection cannot be excluded.
2. Interval progression of the collection within the anterior
aspect of the left lower quadrant, concerning for an abscess.
This collection is amenable to catheter drainage. There are
several very small collections throughout the abdomen measuring
up to 1.5 cm that are too small for image guided drainage.
3. Peritoneal enhancement with focal inflammatory fat stranding
predominating around the cecal base. Reactive thickening of
multiple ileal loops. Overall findings concerning for
peritonitis.
4. Minimal interval decrease in the size of bilateral small
pleural effusions with associated compressive atelectasis.
___: ___ drainage:
Uneventful drainage catheter insertion within 2 pelvic
collections.
___ 4:00 pm ABSCESS RIGHT PELVIC COLLECTION.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 4:00 pm ABSCESS LEFT PELVIC COLLECTION.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH
Medications on Admission:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. 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 #*14 Tablet Refills:*0
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
last dose ___
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*7 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN Constipation
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last dose ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*10 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
do not drive while on this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
abdominal collections
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 s/p appendectomy // eval for
atelectasis, pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray dated ___ and CT abdomen pelvis dated ___. .
FINDINGS:
Bibasilar opacities, left greater than right, likely represent a combination
of pleural effusion and atelectasis, however pneumonia could be considered in
the appropriate clinical setting. The cardiomediastinal and hilar contours
are unremarkable. There is no pneumothorax. Free air beneath the right
hemidiaphragm is consistent with recent postoperative status.
IMPRESSION:
Bibasilar opacities, left greater than right, likely represent a combination
of pleural effusion and atelectasis, however pneumonia could be considered in
the appropriate clinical setting.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ s/p lap appy (perf) ___ p/e postoperative fever // assess
interval change
TECHNIQUE: PA and lateral chest radiographs.
COMPARISON: Chest radiograph ___
FINDINGS:
There is persistent left basilar opacity. , unchanged compared to the prior
study. Again this may reflect a combination of pleural effusion and
atelectasis versus pneumonia. The right basilar opacities are unchanged. No
additional areas of concern are identified in the bilateral lungs. The
cardiomediastinal contour is within normal limits. No pneumothorax seen. The
free air seen under the right hemidiaphragm, consistent with the patient's
recent surgery.
IMPRESSION:
No significant interval change when compared to the prior study. Persistent
airspace opacity in the left lower lobe may reflect a combination of pleural
effusion and atelectasis however pneumonia cannot be excluded.
Radiology Report
INDICATION: ___ s/p lap appy (perf) ___ now with postoperative fever.
Evaluate for intra-abdominal process.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: 623 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis. Small bilateral nonhemorrhagic
pleural effusions are present. The heart is normal in size. There is no
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Again seen is a 9 mm hyperdense lesion in segment 7, unchanged since prior
study and may represent a flash filling hemangioma. 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 remains enlarged and measures 13.9 cm. It is homogeneous
in density.
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. Patient is status post appendectomy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
heterogeneous collection within the pelvis adjacent to the cecum and posterior
to the bladder which measures approximately 10.9 x 4.5 x 5.9 cm with
heterogeneous hyperdense material and rim enhancement. There is also a small
amount of fluid tracking along the pericolic gutters bilaterally. There is
enhancement of the peritoneum along the lateral abdominal wall and anteriorly
in the pelvis particularly on the left side as seen on series 2, ___ 73 and
___ 61.
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 atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. There postsurgical changes in the anterior abdominal wall.
There is a sliver of free air under the right diaphragm.
IMPRESSION:
1. 10.9 x 4.5 x 5.9 cm heterogeneous collection within the pelvis adjacent to
the cecum and posterior to the bladder with mild rim enhancement most
consistent with hematoma.
2. Enhancement of the peritoneum as described above raises possibility of
peritonitis.
2. New small bilateral pleural effusions and bibasilar atelectasis.
3. Mild splenomegaly at 13.9cm.
4. Unchanged 9 mm hyperdense lesion in segment VII of the liver, too small to
fully characterize. A non-emergent abdominal ultrasound is recommended.
NOTIFICATION: Finding #1 discussed with ___ by ___ telephone at
9pm on ___.
Radiology Report
INDICATION: ___ year old man Post-op day 8 for lap perforated appendectomy //
Drainable collection?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: This study involved 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
4) Spiral Acquisition 4.8 s, 52.4 cm; CTDIvol = 9.1 mGy (Body) DLP = 474.7
mGy-cm.
Total DLP (Body) = 490 mGy-cm.
COMPARISON: Comparison made to prior from ___.
FINDINGS:
LOWER CHEST: Small bilateral pleural effusions, marginally decreased compared
to previous. There is associated compressive atelectasis within bilateral
bases. No pericardial effusion.
ABDOMEN:
The patient is status post laparoscopic appendectomy. There is a small 1.0 x
1.9 cm rim enhancing collection at the appendectomy site adjacent the lateral
aspect of the cecum. There is associated fat stranding predominantly
surrounding the cecal base. Adjacent the surgical staples at the appendectomy
type is a 4.5 x 9.4 cm rim enhancing collection, which now demonstrates
interval hypodensity compared to previous. There is overall similar size of
the collection compared to prior.
There is resultant mass effect on the rectosigmoid junction. Another
collection is seen within the left lower quadrant anteriorly measuring
approximately 1.9 x 7.1 cm, which has progressed compared to prior. There is
reactive wall thickening involving multiple distal ileal loops, but no
evidence of bowel obstruction. Additional small sites of loculated fluid is
appreciated along the left paracolic gutter, overall decreased compared to
prior.
Oral contrast is seen traversing the descending colon without evidence of
extraluminal contrast or air.
Diffuse peritoneal enhancement.
The remainder of the abdominal findings are unchanged compared to prior.
IMPRESSION:
1. No significant interval change in the size of the dominant collection
within the rectovesical pouch. There is interval evolution in the density of
the collection, now predominantly hypodense. This is consistent with evolving
hematoma, however please note that superinfection cannot be excluded.
2. Interval progression of the collection within the anterior aspect of the
left lower quadrant, concerning for an abscess. This collection is amenable
to catheter drainage. There are several very small collections throughout the
abdomen measuring up to 1.5 cm that are too small for image guided drainage.
3. Peritoneal enhancement with focal inflammatory fat stranding predominating
around the cecal base. Reactive thickening of multiple ileal loops. Overall
findings concerning for peritonitis.
4. Minimal interval decrease in the size of bilateral small pleural effusions
with associated compressive atelectasis.
Radiology Report
INDICATION: ___ w/ large pelvic/abd collection s/p lap appy // ___ w/ large
pelvic/abd collection s/p lap appy
COMPARISON: Comparison is made to prior from ___.
PROCEDURE: CT-guided drainage of pelvic collections
OPERATORS: Dr. ___ trainee and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CTscan of the intended drainage area was performed. Based on the
CT findings an appropriate position for the drainage was chosen. The site was
marked.
The posterior pelvic collection was initially targeted. A right lower
quadrant anterior approach was chosen. 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 and modified
Seldinger technique, a 10 ___ drainage catheter was inserted into the
posterior pelvic collection via the right lower quadrant approach. Chronic
hemorrhagic fluid was aspirated and sent for culture. The catheter was
attached to a bag for open drainage.
The left lower quadrant was then marked, and the skin cleaned and draped. 1%
lidocaine was infiltrated into the subcutaneous and deep soft tissues. Under
CT guidance and modified Seldinger technique, an 8 ___ drainage catheter
was inserted into the left lower quadrant anterior pelvic collection via a
left lower quadrant anterior approach. Chronic hemorrhagic fluid as well as
purulent material was aspirated and sent for culture. The catheter was then
attached to a bag for open drainage.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Total DLP 587 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 40
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. Pre biopsy images demonstrated no significant interval change in the pelvic
collection within the rectovesical pouch. There is mild interval decrease in
the size of the left lower quadrant collection compared to the most recent
prior study. The imaged alimentary tract is unremarkable.
2. Post procedure CT demonstrated appropriate position of the 2 drainage
catheters. Mild interval decrease in the size of both collections.
IMPRESSION:
Uneventful drainage catheter insertion within 2 pelvic collections.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with POSTPROCEDURAL FEVER
temperature: 102.6
heartrate: 135.0
resprate: 16.0
o2sat: 95.0
sbp: 125.0
dbp: 71.0
level of pain: 2
level of acuity: 3.0 | The patient underwent uneventful laparoscopic appendectomy on
___ with operative findings notable for purulent fluid in RLQ
and right para-colic gutter. He tolerated a diet and was
transitioned to oral antibiotics for a planned 14 day course on
___. He was discharged home in stable condition. He returned to
the hospital with fever on ___.
Upon admission to the hospital, he was made NPO, given
intravenous fluids, and underwent imaging. He was started on
zosyn. Cat scan imaging showed a collection within the pelvis
adjacent to the cecum and posterior to the bladder with mild rim
enhancement most consistent with hematoma. The patient
continued to have abdominal pain with a rising white blood cell
count. He underwent a repeat cat scan 4 days later and was
found to have a resolving hematoma, but a collection of fluid in
the left lower quadrant concerning for an abscess. There were
several small collections throughout the abdomen. The patient
was taken to interventional radiology on HD #5 where he
underwent drainage catheter placement into the pelvic
collections. The gram stain and culture showed no growth.
The patient resumed a regular diet and was voiding without
difficulty. His white blood cell count began to normalize. His
pelvic drainage began to decrease in volume. The patient was
discharged home on HD #10 in stable condition with the drains
intact. He was afebrile with a white blood cell count of 11.7.
He was instructed to complete his ciprofloxacin and flagyl
course. An appointment for follow-up were made with Dr. ___
___ ___. The patient was given instructions in drain care.
*******
Of note: cat scan imaging showed an unchanged 9 mm hyper-dense
lesion in segment VII of the liver, too small to fully
characterize. A non-emergent abdominal ultrasound is
recommended. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / alendronate sodium
Attending: ___.
Chief Complaint:
Dyspnea and RUQ abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a history of COPD and chronic
cholecystitis s/p perc chole drain that was recented removed who
presents as a transfer from ___ with worsening dyspnea and
RUQ pain.
Per patient, she has had multiple episodes of cholecystitis over
the past few years. She just had a PCT in place until about 3
months ago, when it was ___, and had been feeling well until
the night prior to admission, she began having intermittent
sharp, L-sided subscapular pains, bad enough to awaken her from
sleep a few times. When she awoke on am of admission, she began
having intermittent, sharp epigastric as well as RUQ pain that
increased both in frequency (up to q30minutes) and severity. She
reported associated nausea without vomiting, but denied fevers,
chills, shakes, sweats, lightheadednesss, chest pain, SOB,
diarrhea, constipation, or increased extremity swelling. Upon
coming home from work in the afternoon, patient's daughter
brought her immediately to ___ in light of her
worsening symptoms.
In the ___, she had CT A/P revealing thickened GB wall
with adjacent stranding and contiguous collection c/f abscess or
biloma, and was given Levquin/Flagyl, morphine for pain, 1.5L NS
for BP in the ___, and txf to ___ on 40% face tent. Pertinent
labs from ___ include proBNP of 667, BUN/Cr ___
(unknown baseline), normal TBili, AST/ALT, elevated alk phos to
115, and leukocytosis of 11.8 (74% pmn). She did have dirty UA
with ___ and nitrites, with UCx pending.
In the ___, initial vitals: 98 64 116/70 22 87%, improved to 91%
on 5L NC. Labs were notable for WBC 12 (77% pmn), Cr 1.4 and she
received duonebs X 2. CXR showed potential LLL infiltrates c/f
pna and she was transferred to ___ for further management of
care. BCx drawn, pending.
On arrival to the MICU, vitals were 98.6, 70, 130/42, 19, 95% 5L
NC. Patient was with c/o abdominal pain localized to epigastrium
and RUQ, without radiation, but denied N/V, chest pain. No
fevers, chills, or rigors. Upon further questioning, she still
denies SOB, but does state she started having non-productive
cough about a week ago.
Past Medical History:
PAST MEDICAL HISTORY:
Patient unclear about medical history, denies prior hx of lung
disease, heart disease, GI bleeding, but not sure
Per patient chart and medications list, medical hx as follows:
-PAD, with RLE stent placed many years ago.
-GERD
-COPD per transfer chart
-PE with IVC filter
PAST SURGICAL HISTORY:
-Hysterectomy many years ago
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:
GENERAL: Alert, oriented, intermittently with severe abdominal
pain, requiring pause in conversation
HEENT: Sclera anicteric, pupils miotic b/l, PERRL, MMM, dentures
in place (upper and lower), oropharynx clear
NECK: supple, no LAD
LUNGS: No increased WOB, but air movement limited by abdoominal
pain. Diffuse expiratory rhonchi worst in bases b/l. No
wheezing, rales.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-distended. Very tender to palpation in RUQ with
positive ___ sign. Bowel sounds present, no rebound
tenderness or guarding.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: small, purpuric, non-blanching lesions over right neck,
non-tender to palpation. Well healed scars (x2) overlying RUQ of
abd, likely where previously biliary drains had been.
NEURO: A&Ox3. Moving all extremities well grossly.
DISCHARGE EXAM:
Vitals: 98.9 65 114/76 20 98% 1L (walked for 5 minutes on RA,
with one desat to 88%, quickly back to 96% with a deep breath)
General: Alert and oriented, NAD
HEENT: sclera anicteric, MMM, oropharynx clear, dentures
upper+lower
Neck: supple, no JVP, no LAD
Lungs: slightly decreased breath sounds on bilateral bases,
+crackles and end-expiratory wheezes. No increased work of
breathing.
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, nontender
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox3, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
==================
___ 10:45PM ___ PTT-30.0 ___
___ 10:45PM PLT COUNT-205
___ 10:45PM NEUTS-77.8* LYMPHS-15.7* MONOS-5.6 EOS-0.4*
BASOS-0.2 IM ___ AbsNeut-9.34* AbsLymp-1.89 AbsMono-0.67
AbsEos-0.05 AbsBaso-0.03
___ 10:45PM WBC-12.0* RBC-4.01 HGB-12.6 HCT-39.2 MCV-98
MCH-31.4 MCHC-32.1 RDW-14.2 RDWSD-51.1*
___ 10:45PM ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-3.5
MAGNESIUM-2.2
___ 10:45PM LIPASE-13
___ 10:45PM ALT(SGPT)-19 AST(SGOT)-32 ALK PHOS-118* TOT
BILI-0.6
___ 10:45PM estGFR-Using this
___ 10:45PM GLUCOSE-94 UREA N-24* CREAT-1.3* SODIUM-138
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
___ 10:52PM LACTATE-1.1
PERTINENT LABS:
=================
___ 12:24PM BLOOD Glucose-96 UreaN-38* Creat-1.8* Na-137
K-3.7 Cl-104 HCO3-20* AnGap-17
___ 03:23AM BLOOD Glucose-93 UreaN-37* Creat-1.8* Na-140
K-3.2* Cl-106 HCO3-20* AnGap-17
___ 07:00AM BLOOD Glucose-85 UreaN-24* Creat-1.2* Na-142
K-3.5 Cl-108 HCO3-21* AnGap-17
___ 07:30AM BLOOD Glucose-87 UreaN-26* Creat-1.1 Na-141
K-3.4 Cl-110* HCO3-22 AnGap-12
DISCHARGE LABS:
=================
___ 10:18AM BLOOD WBC-8.8 RBC-4.32 Hgb-13.4 Hct-41.6 MCV-96
MCH-31.0 MCHC-32.2 RDW-15.1 RDWSD-51.7* Plt ___
___ 10:18AM BLOOD ___
___ 10:18AM BLOOD Glucose-103* UreaN-23* Creat-1.4* Na-141
K-4.1 Cl-108 HCO3-22 AnGap-15
___ 10:18AM BLOOD ALT-18 AST-25 AlkPhos-89 TotBili-0.3
___ 07:30AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.8
MICROBIOLOGY:
==================
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Blood Culture, Routine (Final ___: NO GROWTH
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING STUDIES:
==================
Cardiovascular Report ECG Study Date of ___ 10:35:44 ___
Normal sinus rhythm. Poor R wave progression in the anterior
precordial leads.
Cannot exclude anterior wall myocardial infarction of
indeterminate age.
Underlying artifact. Diffuse ST segment abnormalities.
Non-specific low QRS voltages in the precordial leads. No
previous tracing available for
comparison.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
77 172 82 390 419 52 16 37
___ LIVER/Gall bladder US
Focused sonographic assessment of the right upper quadrant was
technically challenging with only a subcostal and intercostal
approach, as a large loop of bowel overlyed the right upper
quadrant. Images obtained demonstrate a small ill-defined
region of hypo echogenicity adjacent to a known hepatic cyst,
which is favored to represent the small intrahepatic abscess,
measuring approximately 2.6 x 1.2 cm. The gallbladder could not
be visualized on the sonographic images. Given the limited
acoustic windows and ill definition of the suspected hepatic
abscess on ultrasound, ultrasound-guided drainage was not
performed. A CT scan of the upper abdomen was recommended for
CT-guided drainage instead.
RECOMMENDATION(S): CT scan of the upper abdomen for CT-guided
drainage of small hepatic abscess.
___ CT ABDOMEN WITHOUT CONTRAST
CT guided drainage of small hepatic abscess was not performed
given reasons stated above.
NOTIFICATION: The findings were discussed by Dr. ___
___ with the ___ medical and surgical team
immediately following these findings.
___ ECHO
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%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Moderate pulmonary artery systolic hypertension.
___ ___
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 although note is made of limited
visualization of the left 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. Limited visualization of the left peroneal
veins.
___ RUQ US
Limited sonographic images of the abdomen were obtained to
assess for presence of ascites. No free fluid is seen within
the abdomen.
IMPRESSION:
No ascites.
___ CXR
Increased mild pulmonary edema with small to moderate pleural
effusions and persistent left lower lobe pneumonia as compared
to ___.
___ Gallblader US
1. Gallbladder is 80-90% filled with tumefactive sludge and a
2.1 cm ston
2. 3.4 cm anechoic hepatic cysts has been stable over many
months' time. No evidence of hepatic abscess.
___ CXR
Compared to the prior study there is no significant interval
change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q8H:PRN pain
2. Citalopram 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Lorazepam 0.5 mg PO BID:PRN anxiety
5. Amlodipine 5 mg PO DAILY
6. Cilostazol 100 mg PO BID
7. Losartan Potassium 50 mg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. Clopidogrel 75 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
11. TraZODone 25 mg PO QHS:PRN sleep
12. Lialda (mesalamine) 1.2 gram oral BID
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Cilostazol 100 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
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. Levofloxacin 500 mg PO Q48H Duration: 5 Days
Please continue to take until ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*3 Tablet Refills:*0
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Please continue to take until ___
RX *metronidazole 500 mg 1 tablet(s) by mouth q8hrs Disp #*15
Tablet Refills:*0
9. Amlodipine 5 mg PO DAILY
10. Ferrous Sulfate 325 mg PO BID
11. Ibuprofen 600 mg PO Q8H:PRN pain
12. Lialda (mesalamine) 1.2 gram oral BID
13. Lorazepam 0.5 mg PO BID:PRN anxiety
14. Losartan Potassium 50 mg PO DAILY
15. Omeprazole 20 mg PO DAILY
16. TraZODone 25 mg PO QHS:PRN sleep
17. Guaifenesin ER 600 mg PO Q12H
RX *guaifenesin 600 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
18. LOPERamide 2 mg PO TID:PRN diarrhea
Take as needed for diarrhea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Cholecystitis
Pneumonia (community-acquired)
Secondary diagnoses:
Chronic obstructive pulmonary disease
Congestive heart failure
Hypertension
Chronic kidney disease
Crohn's disease
Depression
Chronic diarrhea
Discharge Condition:
Mental status: alert, oriented to person, place, date
Ambulatory status: walks with a walker
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ female with long history of acute on chronic
cholecystitis treated with multiple prior percutaneous cholecystostomy tubes.
CT scan performed at an outside hospital on ___ demonstrated a
suspected gallbladder perforation with small adjacent intrahepatic abscess
formation, along with a left lower lobe consolidation. Initially a
percutaneous cholecystostomy tube was requested by the surgical service,
however review of this outside CT demonstrated a collapsed gallbladder and
therefore attempted drainage of the small hepatic abscess was recommended.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the right upper
quadrant were obtained.
COMPARISON: Outside CT scan of the abdomen and pelvis from ___.
FINDINGS:
Focused sonographic assessment of the right upper quadrant was technically
challenging with only a subcostal and intercostal approach, as a large loop of
bowel overlyed the right upper quadrant. Images obtained demonstrate a small
ill-defined region of hypo echogenicity adjacent to a known hepatic cyst,
which is favored to represent the small intrahepatic abscess, measuring
approximately 2.6 x 1.2 cm. The gallbladder could not be visualized on the
sonographic images. Given the limited acoustic windows and ill definition of
the suspected hepatic abscess on ultrasound, ultrasound-guided drainage was
not performed. A CT scan of the upper abdomen was recommended for CT-guided
drainage instead.
RECOMMENDATION(S): CT scan of the upper abdomen for CT-guided drainage of
small hepatic abscess.
NOTIFICATION: The findings were discussed by Dr. ___ with the ___
and Surgical team immediately following completion of this exam.
Radiology Report
INDICATION: ___ female with small intrahepatic abscess secondary to a
suspected gallbladder perforation. For CT guided drainage of an intrahepatic
abscess.
TECHNIQUE: Multidetector CT images of the right upper quadrant were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
No oral contrast was administered.
DOSE: Total exam DLP: 238 mGy.cm
COMPARISON: Outside CT scan abdomen and pelvis ___ and right upper
quadrant ultrasound ___.
FINDINGS:
The risks, benefits, and alternatives of the procedure were explained to the
patient and written consent obtained.
Unenhanced CT scan of the right upper quadrant was performed for attempted
drainage of a small intrahepatic abscess with CT guidance. Images obtained
re- demonstrate a 2.3 x 1.8 cm focus of hypoattenuation adjacent to the
gallbladder, favored to represent the intrahepatic abscess (series 3, image
31). An adjacent 3.5 x 3.3 cm simple hepatic cyst is again noted. Left lower
lobe consolidation is again noted. An IVC filter and a 3.6 x 3.2 cm
infrarenal abdominal aortic aneurysm is also noted.
While in hospital the patient was on approximately 12 L of oxygen, and given
the concomitant increased work of breathing, an anesthesia consult was
obtained, and general anesthesia with intubation was recommended. However
given the patient's " do not intubate (DNI)" status and the patient's refusal
to undergo anesthesia, the procedure was canceled.
These findings were discussed with the patient's MICU team, and the patient
was sent back to the unit.
IMPRESSION:
CT guided drainage of small hepatic abscess was not performed given reasons
stated above.
NOTIFICATION: The findings were discussed by Dr. ___ with the
___ medical and surgical team immediately following these findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hx copd, here with worsening sob in
setting of afib with rvr // eval for interval changes eval for interval
changes
COMPARISON: Chest radiographs ___.
IMPRESSION:
Pulmonary vascular congestion developed on ___ a accompanied by
increasing bibasilar atelectasis, and has not cleared; small bilateral pleural
effusions are larger. Cardiomegaly is severe. Lower pole of the right hilus
is enlarged, could be due enlarged pulmonary artery or lymph nodes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y/o woman with apparent medical history of COPD and chronic
cholecystitis s/p removal of PTC 3 months ago, admitted to MICU for OSH CT
findings c/f biliary abscess and CXR c/f LLL pna. // interval assessment
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. Low lung
volumes. Moderate cardiomegaly. Bilateral areas of atelectasis are
unchanged, left more than right, the left basal opacity is suspicious for
pneumonia. Mild pulmonary edema persists.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with tachycardia, hypoxia // 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 although note is
made of limited visualization of the left 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.
Limited visualization of the left peroneal veins.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with respiratory failure, RUQ pain, chronic
cholecystitis // Eval for progression of fluid collection
TECHNIQUE: Limited Grey scale and color Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: CT scan of the abdomen and abdominal ultrasound from ___.
FINDINGS:
Limited sonographic images of the abdomen were obtained to assess for presence
of ascites. No free fluid is seen within the abdomen.
IMPRESSION:
No ascites.
Radiology Report
INDICATION: ___ year old woman with cholycystitis biloma and worsening
respiratory status with previous LLL // Interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray ___
FINDINGS:
Bilateral mild pulmonary edema is worse from ___. There are small to
moderate pleural effusions bilaterally which are improved from ___. Left
basal opacity suspicious for left lower lobe pneumonia is unchanged from
___.
Moderate cardiomegaly is persistent.
Cardiomediastinal borders are normal. Hilar structures are normal. There is
no pneumothorax.
IMPRESSION:
Increased mild pulmonary edema with small to moderate pleural effusions and
persistent left lower lobe pneumonia as compared to ___.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with COPD and chronic cholecysitis, continued
RUQ pain with ___ sign. Compare to ___ U/S: is there drainable
collection? Evaluate for drainable fluid collection.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound of ___ and ___.
Outside hospital CT abdomen its from ___, and ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. A 3.4 cm
anechoic, rounded hepatic cyst is seen immediately adjacent to the GB and has
been stable over many months' time, consistent with a cyst. No evidence of
hepatic abscess or biloma.
BILE DUCTS: There is no intrahepatic biliary dilation.
GALLBLADDER: The gallbladder is 80-90% filled with tumefactive sludge and only
a small amount of liquid bile. There is a large 2.1 cm gallbladder stone.
IMPRESSION:
1. Gallbladder is 80-90% filled with tumefactive sludge and a 2.1 cm ston
2. 3.4 cm anechoic hepatic cysts has been stable over many months' time. No
evidence of hepatic abscess.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with difficulty weaning from o2 // please
evaluate for persistent/worsening consolidation vs edema
TECHNIQUE: Portable chest
COMPARISON: ___
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Pneumonia, Transfer
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 98.0
heartrate: 64.0
resprate: 22.0
o2sat: 87.0
sbp: 116.0
dbp: 70.0
level of pain: 5
level of acuity: 1.0 | BRIEF HOSPITAL COURSE
___ is an ___ with history of COPD and chronic
cholecystitis s/p perc chole drain that was recently removed who
originally presented as a transfer from ___ with worsening
dyspnea and RUQ pain. She was treated in the MICU for hypoxemic
resp failure, afib with RVR, PNA, and UTI. Her respiratory
status rapidly improved and she was transferred to the floor. We
narrowed her antibiotics from Zosyn and Flagyl to PO Levaquin
and Flagyl, and her abdominal pain largely resolved. There was
no drainable fluid collection in the gallbladder and the surgery
team declined operative management. She initially required small
amounts of oxygen on the floor, likely due to a combination of
pneumonia and CHF, but was discharged home without oxygen
requirement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
buspirone
Attending: ___.
Chief Complaint:
Falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with history of glioblastoma who
is admitted from the ED with one week of worsening falls,
headaches, and word-finding difficulties.
History is obtained from patients brother, as patient had
moderate aphasia on interview. Patient had started NovoTTF in
mid
___, but it was DC'd after a week due to skin breakdown on
his
scalp. Since removing the device, patient has had recurrence of
progressive headaches. Also with one week of increasing
difficulty ambulating with multiple falls with headstrike, but
no
LOC. Has also had increasingly more difficulty talking. He was
seen in ___ clinic, and he was then referred to the
ED.
In the ED, initial VS were pain 0, T 98.0, HR 74, BP 106/74, RR
18, O2 98%RA. Initial labs notablefor Na 136, K 3.8, HCO3 26, Cr
0.8, WBC 5.0, HCT 46.0, PLT 203, INR 1.0. CT head showed
increased vasogenic edema concerning for disease progression. No
hemorrhage or fracture. CXR was without acute process. VS prior
to transfer were T 98, HR 69, BP 132/85, RR 18, O2 98%RA.
On arrival to the floor, patient is asleep and in NAD. His
brother recounts history of falls and headaches. No known fevers
or URTI. No recent complaints of CP, SOB or cough. No known
abdominal pain. His brother notes the patient has ___ of
the
intestine' for years, and has to remove white material from his
rectum prior to bowel movements.
Past Medical History:
PAST ONCOLOGIC HISTORY:
(1) seizure at work on ___,
(2) ___ emergency room evaluation on ___,
(3) gadolinium-enhanced head MRI on ___ showing an
enhancing
mass at the left temporal pole,
(4) gross total resection by Dr. ___ on ___ (the
pathology is an anaplastic astrocytoma with negative IDH1 and
negative BRAF V600E mutation),
(5) repeat gadolinium-enhanced head MRI performed on ___
showed enhancement in the left temporal pole,
(6) received from ___ to ___ involved-field cranial
irradiation and daily temozolomide at ___,
(7) post-radiotherapy head MRI on ___ showed increased
gadolinium enhancement at the left temporal pole,
(8) Portacath placement on ___,
(9) received C1 adjuvant temozolomide from ___ to ___,
(10) MGMT promoter was methylated (ordered on ___,
(11) lowered dexamethasone from 2.0 to 1.5 mg QD on ___,
and
(12) started C1D1 NovoTTF-100A on ___, and
(13) stopped NovoTTF-100A on ___ because of a wound
erosion.
(14) Planned temozolamide C2, not started
PAST MEDICAL HISTORY:
-Glioblastoma, as above
-Alcohol use disorder
-Longstanding history of alternating diarrhea and constipation,
has not been worked up
-Depression
Social History:
___
Family History:
Denies any family history of seizures or neurologic disorders
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 97.9 HR 66 BP 120/77 RR 16 SAT 97% O2 on RA
GENERAL: Sleeping comfortably in NAD, awakens to voice. Follows
simple commands. Has a prominent/mixed expressive and motor
aphasia.
EYES: Anicteric sclerea, PERLL, EOMI; Left sided black eye with
slight ptosis.
ENT: Oropharynx clear without lesion, JVD not elevated. Multiple
abrasions over scalp.
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk; abrasing over left knee
NEURO: Somnelent, awakens to voice. Does not answer orientation
or ROS questions sensically. Cooperative with examiner, and
follows simple commands. PERLL, EOMI, symmetric face (except
mild
left ptosis) and palate. Motor strength is full throughout with
mild dysmetria on FTN bitlaterall,y L>R.
SKIN: No significant rashes. Scattered abrasions, as above
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.2 PO 128 / 83 62 18 97 Ra
General: Well-appearing gentleman, lying in bed in no acute
distress, left sided ___ ecchymoses.
HEENT: EOMI, MMM, neck is supple
CV: RRR, no murmurs/rubs/gallops
PULM: Unlabored breathing, clear to auscultation bilaterally
ABD: Non-distended, bowel sounds present, soft, non-tender
LIMBS: No ___
SKIN: No rashes on extremities
NEURO: AOx3. Fluent speech with occasional word-finding
difficulties. Thought process is tangential. Thought content is
going home. CN III/XII intact, strength ___ b/l upper/lower ext.
Pertinent Results:
Brain MRI ___
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with glioblastoma admitted with
falls and encephalopathy. Increased edema on CT scan// Eval
progression of glioblastoma TECHNIQUE: Sagittal and axial T1
weighted imaging were performed. After administration of mL of
Gadavist intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and
coronal orientations. COMPARISON: None. FINDINGS: There is
interval expansion of the area of enhancement within the
surgical resection bed within the left anterior temporal lobe
and progressive vasogenic edema within the cerebral hemisphere.
The area of enhancement measures approximately 4 cm in diameter,
previously 3 cm in a similar transverse dimension. The
enhancement now extends into the margin of the left anterior
temporal lobe, left uncus and left insular region. There is no
intraventricular ependymoma enhancement. There is 4 mm midline
shift and mild displacement the uncus of the left temporal lobe
into the suprasellar cistern, without downward herniation. There
is narrowing of the left lateral ventricle and third ventricle.
The right lateral ventricle appears unchanged. There is no acute
infarct or acute intracranial hemorrhage. There is a small
amount of fluid within left maxillary sinus. The orbits are
unremarkable.
IMPRESSION: Interval progression in the degree of thick
enhancement and vasogenic edema within the region of the left
temporal lobe surgical resection bed, worrisome for local tumor
progression. 2. 4 mm midline shift and slight narrowing of the
left suprasellar cistern, without downward herniation.
CT Head Non-Con ___
1. Stable appearance of vasogenic edema secondary to known
tumor. No evidence of intracranial hemorrhage or mass effect.
CT C-Spine ___
FINDINGS: Alignment is normal. No fractures are identified.
There is no evidence of spinal canal or neural foraminal
stenosis. There is no prevertebral soft tissue swelling. There
is no evidence of infection or neoplasm. There is evidence of
multilevel degenerative change with osteophyte formation, loss
of disc height, and facet hypertrophy. There is vacuum disc
hypertrophy at C6-C7. IMPRESSION: 1. No evidence of acute
fracture. 2. Multilevel degenerative changes.
CXR ___
FINDINGS: Right chest wall Port-A-Cath is in place with tip of
catheter terminating in the cavoatrial junction. Lungs are clear
without focal consolidation, large effusion or pneumothorax.
Heart size is normal. Bony structures are intact. IMPRESSION: 1.
No acute intrathoracic abnormality. 2. Port-A-Cath tip at the
level of the cavoatrial junction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Celecoxib 200 mg oral BID
2. ClonazePAM 1 mg PO BID:PRN anxiety
3. Dexamethasone 1 mg PO DAILY
4. Famotidine 20 mg PO DAILY
5. LamoTRIgine 150 mg PO BID
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Sertraline 200 mg PO DAILY
Discharge Medications:
1. Dexamethasone 4 mg PO DAILY
2. Celecoxib 200 mg oral BID
3. ClonazePAM 1 mg PO BID:PRN anxiety
4. Famotidine 20 mg PO DAILY
5. LamoTRIgine 150 mg PO BID
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Sertraline 200 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
# Cerebral edema
# Recurrent Anaplastic Astrocytoma
# Fall
# Complex partial seizures
SECONDARY DIAGNOSIS:
#Anxiety
#Depression
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: AP portable upright chest radiograph
INDICATION: ___ with AMS// r/o pneumonia
TECHNIQUE: AP upright chest radiograph
COMPARISON: Chest CT from ___
FINDINGS:
Right chest wall Port-A-Cath is in place with tip of catheter terminating in
the cavoatrial junction. Lungs are clear without focal consolidation, large
effusion or pneumothorax. Heart size is normal. Bony structures are intact.
IMPRESSION:
1. No acute intrathoracic abnormality.
2. Port-A-Cath tip at the level of the cavoatrial junction.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with AMS and falls// r/o bleed
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: MRI head from ___ MRI head from ___ MRI head
from ___ CT head from ___
FINDINGS:
Patient is status post left temporal craniectomy and resection of left
temporal lobe lesion. Increased vasogenic edema noted within the left
cerebral hemisphere notably within the left temporal lobe, inferior frontal
lobe and involving the internal capsule and left periventricular white matter.
Subtle mass effect is noted on the temporal horn of the left lateral
ventricle. No midline shift or downward herniation. Findings potentially
concerning for disease progression. MRI may be performed to further assess.
There is no intra-axial or extra-axial hemorrhage. Basal cisterns are patent.
Ventricles appears similar in overall size and configuration. Postsurgical
changes along the left temporal bone noted. Paranasal sinuses, mastoid air
cells and middle ear cavities are well aerated.
IMPRESSION:
Increased vasogenic edema in the left frontotemporal lobes as well as the
internal capsule and left periventricular white matter is concerning for
disease progression. No hemorrhage. Consider MRI to further assess.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with AMS and falls// r/o 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: Total DLP (Body) = 578 mGy-cm.
COMPARISON: No relevant comparison.
FINDINGS:
Partially visualized hardware from previous craniotomy. Alignment is normal.
No fractures are identified.There are mild-to-moderate moderate degenerative
changes of the cervical spine with loss of intervertebral disc height
throughout the cervical spine and vacuum disc phenomena at C6-7.There is no
prevertebral soft tissue swelling.Partially visualized internal jugular venous
access.
IMPRESSION:
1. No evidence of acute fracture or traumatic subluxation.
2. Mild-to-moderate degenerative changes of the cervical spine, most severe at
C6-7.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with glioblastoma admitted with falls and
encephalopathy. Increased edema on CT scan// Eval progression of glioblastoma
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: None.
FINDINGS:
There is interval expansion of the area of enhancement within the surgical
resection bed within the left anterior temporal lobe and progressive vasogenic
edema within the cerebral hemisphere. The area of enhancement measures
approximately 4 cm in diameter, previously 3 cm in a similar transverse
dimension. The enhancement now extends into the margin of the left anterior
temporal lobe, left uncus and left insular region. There is no
intraventricular ependymoma enhancement. There is 4 mm midline shift and mild
displacement the uncus of the left temporal lobe into the suprasellar cistern,
without downward herniation. There is narrowing of the left lateral ventricle
and third ventricle. The right lateral ventricle appears unchanged. There is
no acute infarct or acute intracranial hemorrhage.
There is a small amount of fluid within left maxillary sinus. The orbits are
unremarkable.
IMPRESSION:
1. Interval progression in the degree of thick enhancement and vasogenic edema
within the region of the left temporal lobe surgical resection bed, worrisome
for local tumor progression.
2. 4 mm midline shift and slight narrowing of the left suprasellar cistern,
without downward herniation.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old man with GBM post fall and head trauma. Rule out
occult cervical 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 7.5 s, 24.2 cm; CTDIvol = 32.0 mGy (Body) DLP = 750.8
mGy-cm.
Total DLP (Body) = 751 mGy-cm.
COMPARISON: CT spine from ___
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal stenosis. There is no prevertebral soft
tissue swelling. There is no evidence of infection or neoplasm. There is
evidence of multilevel degenerative change with osteophyte formation, loss of
disc height, and facet hypertrophy. There is vacuum disc hypertrophy at
C6-C7.
IMPRESSION:
1. No evidence of acute fracture.
2. Multilevel degenerative changes.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ w/ GBM w/ trauma to head after fall (this occurred after most
recent head CT)// evaluate for ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 45.3 mGy (Head) DLP =
684.4 mGy-cm.
2) Stationary Acquisition 2.0 s, 7.7 cm; CTDIvol = 44.4 mGy (Head) DLP =
342.2 mGy-cm.
Total DLP (Head) = 1,027 mGy-cm.
COMPARISON: CT head from ___ .
FINDINGS:
There is evidence of edema within the white matter of the left frontotemporal
lobe and extending into the left internal capsule, similar in appearance to
prior CT. There is no evidence of infarction or hemorrhage. The ventricles
appear prominent.
There is no evidence of fracture. There is mild mucosal thickening within the
left maxillary sinus. The remaining visualized portions of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Stable appearance of vasogenic edema secondary to known tumor. No evidence
of intracranial hemorrhage or mass effect.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Confusion, s/p Fall, Unsteady gait
Diagnosed with Other abnormalities of gait and mobility
temperature: 98.0
heartrate: 74.0
resprate: 18.0
o2sat: 98.0
sbp: 106.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year-old gentleman with L temporal glioblastoma
who presented with a week of worsening falls, headaches, and
word-finding difficulties. Found to have
increasing cerebral edema in setting of disease progression.
Improved significantly with bevacizumab and steroids.
# Cerebral edema
# Glioblastoma
Initial presentation with aphasia (motor and expressive).
Received bevacizumab infusion ___. Started on dexamethasone 4mg
q6h, rapidly tapered to 4mg daily. Had
vast improvement in speech fluency but continued having
occasional word-finding difficulties upon discharge.
# Complex partial seizures: Secondary to cortical involvement of
glioblastoma. Was continued continued on lamotrigine 150mg po
bid. No seizure-like activity observed during admission.
# Anxiety:
# Depression
Continued on home clonazepam 1mg po bid prn, lamotrigine ,
sertraline and trazodone.
#Capacity: On ___ patient asked to be discharged home, he and
his proxy were informed that per physical therapy evaluation he
was not safe to go home unless 24h care could be provided.
Patient insisted on going home. As he was unable to repeat the
risks of going home without 24h care after multiple attempts he
was deemed to not have capacity to make healthcare decisions.
Psychiatry was consulted overnight who agreed with the
assessment. On ___, healthcare proxy was activated in favor of
Mr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Gunshot wound, Radial shaft fx, Left arm.
Major Surgical or Invasive Procedure:
___: ORIF Left midshaft radius fx.
History of Present Illness:
___ s/p Gunshot wound to Left forearm. Pt was shot after
leaving a bar. Entry wound in dorsum of mid forearm without
exit wound. He remains neurologically intact. Mild pain with
passive stretch of wrist beyond baseline pain. XR show Midshaft
radius fx. lodged bullet in dorsoradial aspect of proximal
forearm. Appears to be extrarticular.
Past Medical History:
none
Social History:
___
Family History:
non contributory
Physical Exam:
LUE: in splint. forearm soft. Dressing with mild strikethrough.
Sensation intact R/U/M. Motor intact AIN/PIN/Ulnar.
Medications on Admission:
none
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*50
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left radial shaft fx.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) LEFT IN O.R.
INDICATION: ORIF
TECHNIQUE: AP and lateral radiographs of the right forearm, intraoperative
COMPARISON: Preoperative radiographs from the same date
FINDINGS:
AP and lateral radiographs of the right forearm obtained in the OR demonstrate
a metallic side plate and screws stabilizing the comminuted radial shaft
fracture. Surgical staples project over the soft tissues.
IMPRESSION:
Intraoperative radiographs, AP and lateral of the right forearm with details
as above.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Gunshot wound, Transfer
Diagnosed with FX RADIUS SHAFT-OPEN, ASSAULT-FIREARM NEC
temperature: 98.2
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 130.0
dbp: 57.0
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 a left midshaft radius fx s/p gunshot wound and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for surgical fixation of
his left radius, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ 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
Non weight bearing Left upper extremity, and will be discharged
without 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:
vancomycin / Amoxicillin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/Crohn's on Remicade presents with abdominal pain. Pt
initally presented to an OSH ED where a KUB with contrast was
concerning for possible SBO. She reports that pain began
yesterday, is crampy and associated with distension, nausea and
emesis last night, no emesis today, melena or bloody stools.
Last BM 2 days ago. She completed a 1 week prednisone taper for
Crohn's flare 2 days ago.
In ___ ED CT confirmed Crohn's flare with partial SBO and
possible perforation. GI and colorectal surgery were consulted
and recommended medical mangagement. Pt received dilaudid,
zofran, cipro, flagyl and 1L of fluids.
On arrival to the floor pt reports pain and distension. No
nausea. No fevers at home.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Crohn's disease
MVP
Social History:
___
Family History:
No history of inflammatory bowel disease
Physical Exam:
Admission Physical Exam:
Vitals: T:102.4 BP:101/53 P:108 R:16 O2:95%ra
PAIN: 4
General: nad
Lungs: clear
CV: rrr no ___ murmur
Abdomen: bowel sounds present, soft, distended, diffusely
tender, no rebound
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
Admission Labs:
___ 12:10PM BLOOD WBC-15.5* RBC-3.73* Hgb-11.0* Hct-32.8*
MCV-88 MCH-29.6 MCHC-33.7 RDW-13.1 Plt ___
___ 12:10PM BLOOD Neuts-84.2* Lymphs-12.3* Monos-2.6
Eos-0.5 Baso-0.5
___ 12:10PM BLOOD ___ PTT-30.5 ___
___ 12:10PM BLOOD ESR-40*
___ 12:10PM BLOOD Glucose-84 UreaN-9 Creat-0.5 Na-138 K-3.3
Cl-104 HCO3-24 AnGap-13
___ 12:10PM BLOOD ALT-34 AST-17 AlkPhos-72 TotBili-1.6*
___ 12:10PM BLOOD Lipase-14
___ 12:10PM BLOOD Albumin-3.4*
# Abd/pelvic CT (___): Acute on chronic Crohns disease in the
RLQ with thickening of the distal ileum and terminal ileum,
sinus tract and adjacent stranding/phlegmon of the mesentery.
Partial resultant small bowel obstruction. Small free fluid in
the deep pelvis with hyperenhancement of the peritoneum suggests
localized peritonitis.
# AXR (___): Distended loops of small bowel, unchanged in
caliber and configuration compared to prior abdominal
radiographs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Infliximab 1 mg/kg IV Q8WEEKS
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. QUEtiapine Fumarate Dose is Unknown PO HS:PRN insomnia
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. QUEtiapine Fumarate 25 mg PO HS:PRN insomnia
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*28 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*42 Tablet Refills:*0
5. Infliximab 300 mg IV Q8WEEKS
Please contact Dr. ___ to determine whether this medication
should be continued or not.
6. Budesonide 9 mg PO DAILY
RX *budesonide 3 mg 3 capsule(s) by mouth Daily Disp #*90
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's disease c/b partial small bowel obstruction and
perforation
Ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Crohn's disease, small perforation on CT, now with worsening
abdominal pain and distention. Evaluate for interval change.
COMPARISON: Abdominal radiographs from approximately 5 hours prior on the
same day, as well as ___.
FINDINGS:
Frontal abdominal radiographs again demonstrate distended loops of the small
bowel, not significantly changed in caliber compared to the most recent
radiographs. Intraperitoneal free air is again not identified.
IMPRESSION:
Unchanged small bowel distention. No intraperitoneal free air identified.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with Crohn's disease with
known perforation and now increased abdominal distention and pain.
Portable AP radiograph of the chest was reviewed with comparison to CT abdomen
from ___.
Heart size is normal. Mediastinum is normal. Dextroscoliosis is
demonstrated. Bibasal opacities are noted, most likely atelectasis on the
right, but slightly more pronounced on the left, concerning for infectious
process. There is no appreciable pleural effusion. There is no pneumothorax.
IMPRESSION:
Suspicion for left lower lobe pneumonia. Most likely atelectasis on the
right, although infectious process is a possibility.
Radiology Report
INDICATION: Crohn's, known perforation, now with increased abdominal
distention and pain. Evaluate for interval change.
COMPARISON: Abdominal radiographs from ___ and ___.
FINDINGS:
Frontal abdominal radiographs again demonstrated multiple loops of dilated
small bowel, similar in caliber compared to prior radiographs. Air is seen
within the rectum and throughout the colon, and contrast from the previous CT
abdomen is also seen within the colon.
IMPRESSION:
Distended loops of small bowel, unchanged in caliber and configuration
compared to prior abdominal radiographs.
Radiology Report
HISTORY: History of Crohn's disease, with abdominal tenderness. Evaluate for
small bowel obstruction or abscess.
COMPARISON: Radiograph of the abdomen dated ___.
TECHNIQUE: Multi detector CT images were obtained after the administration
intravenous contrast material. Multiplanar reformatted images in coronal and
sagittal planes are provided.
DLP: 317.94 mGy-cm
FINDINGS:
CHEST: There is minimal atelectasis at the right base. Otherwise 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 with no
focal lesions. The portal and hepatic veins are patent and there is no intra
or extrahepatic biliary ductal dilatation. The gallbladder is decompressed,
and does not contain radiopaque gallstones. The common bile duct is not
dilated.
The spleen is normal in size and homogeneous in enhancement. The pancreas
enhances homogeneously without focal lesions. There is no pancreatic ductal
dilatation or peripancreatic fat stranding. Adrenal glands are normal in size
and shape.
The kidneys are normal in size and display symmetric nephrograms and contrast
excretion. The ureters are normal in caliber along their visualized course to
the bladder. There are no concerning mass lesions seen within the kidneys.
There is no hydronephrosis. There is no perinephric abnormality seen.
The distal esophagus is normal appearing with no hiatal hernia. The stomach
is underdistended, but grossly normal. There is thickening of the distal
ileum and terminal ileum with adjacent stranding of the mesentery. Adjacent
to the terminal ileum there is a blind ending sinus tract containing a locule
of air (2:60, ___ consistent with contained subacute perforation.
There are associated phlegmonous changes. Proximal to this is a partial small
bowel obstruction with multiple distended loops of small bowel. There is
decompression of small bowel to the level of the mid jejunum, likely secondary
to vomiting. The appendix contains a small amount of contrast, and appears
adjacent to the phlegmon. The large bowel contains contrast material and
feces, and does not show abnormal dilatation or focal wall thickening.
There are few prominent mesenteric lymph nodes, which are likely reactive.
There is no aneurysmal dilatation of the abdominal aorta. The aorta and its
major branches are patent.
PELVIS: The bladder is underdistended, but grossly normal. The uterus and
adnexa are unremarkable. The rectum and sigmoid are unremarkable. There is a
small amount of deep pelvic free fluid with some subtle hyperenhancement of
the peritoneum.
OSSEOUS STRUCTURES AND SOFT TISSUES: There are no concerning lytic or
sclerotic lesions seen.
IMPRESSION:
1. Acute on chronic Crohns disease in the RLQ with thickening of the distal
ileum and terminal ileum, sinus tract and adjacent stranding/phlegmon of the
mesentery. Partial resultant small bowel obstruction.
2. Small free fluid in the deep pelvis with hyperenhancement of the
peritoneum suggests localized peritonitis.
Radiology Report
INDICATION: Crohn's disease, with partial small bowel obstruction and
possible perforation on recent CT, now with worsening abdominal pain.
COMPARISON: CT abdomen/pelvis from ___.
FINDINGS:
Frontal abdominal radiographs demonstrate distended loops of small bowel,
unchanged from recent CT. No pneumatosis or intra-abdominal free air is seen.
IMPRESSION:
Distended small bowel, unchanged from recent CT. No pneumatosis or
intra-abdominal free air.
Gender: F
Race: WHITE
Arrive by HELICOPTER
Chief complaint: Abd pain
Diagnosed with INTESTINAL OBSTRUCT NOS, REGIONAL ENTERITIS NOS
temperature: 97.9
heartrate: 79.0
resprate: 14.0
o2sat: 99.0
sbp: 102.0
dbp: 61.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a pleasant ___ y/o F with PMHx of Crohn's on
Remicade, who presented with 2 days of progressive abdominal
pain, bloating, nausea, vomiting. Imaging showing partial small
bowel obstruction, as well as possible small contained
perforation. She was managed conservatively with abx and bowel
rest, with dramatic improvement in symptoms and clinical exam.
She did have some persistent ileus symptoms such as bloating and
early satiety; and, therefore, diet was advanced slowly. At the
time of discharge, she was tolerating a regular diet and had a
solid bowel movement.
To rule out other etiologies, CMV titers were negative and
stool c.diff was negative. Remicade antibodies and levels may
be checked as an outpt with follow up with Dr. ___. She was
discharged on cipro/flagyl for total ___nd oral
budesonide at 9 mg daily.
Of note, pt reported that her menstrual cycle was occurring
during admission and lasting longer than normal (had been going
on for ~ 9 days at the time of discharge). She was encouraged to
discuss this further with her PCP and OB/GYN. |
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 Hip Pain
Major Surgical or Invasive Procedure:
Left Hip Hemiarthroplasty (___)
History of Present Illness:
___ h/o HTN, renal insufficiency, urinary retention managed with
leg-bad foley for last ___ years, chronic constipation who
presents with Left hip pain s/p mechanical fall. He was geting
out of bed today, reached for his nightstand and missed his
step, falling onto his Left side. Immediate pain and inability
to ambulate. Taken to ___ where CT head and c-spine were
negative for
fracture or acute process; x-rays showed Left femoral neck
fracture. Ortho consulted. Denies numbness/tingling or weakness
Denies antecedant dizziness or palpitations.
Past Medical History:
HTN
renal insufficiency
chronic constipation
urinary retention
Social History:
___
Family History:
Non-Contributory
Physical Exam:
On Admission:
Vitals: 97.8 60 134/56 18 95% RA
General: NAD, A&Ox3
Psych: appropriate mood and affect
Musculoskeletal:
Right Lower Extremity:
Skin clean - no abrasions, induration, ecchymosis
Thigh and leg compartments soft and compressible
Fires ___
Sensation intact to light touch sural, saphenous, tibial,
superficial and deep peroneal nerve distributions
1+ dorsal pedis and posterior tibial pulses
Left Lower extremity
+leg short and externally rotated
Skin clean - no abrasions, induration, ecchymosis
Thigh and leg compartments soft and compressible
Fires ___
Sensation intact to light touch sural, saphenous, tibial,
superficial and deep peroneal nerve distributions
1+ dorsal pedis and posterior tibial pulses
On Discharge:
T 98.4 BP 128/58 HR 61 RR 24 95% on RA
General: Awake and alert. Sitting up in bed. Oriented to person,
place, and exact date.
Head: ~2 cm left frontal wound with sutures in place. Some dried
no blood; no active bleeding. No erythema, edema, tenderness,
discharge.
Left Lower Extremity:
- Dressing in place over lateral thigh. Clean, dry, and intact.
No surrounding erythema.
- Thigh non tender to palpation
- Fires ___ FHL TA GSC
- (+) DP pulse
- Sensation intact to light touch throughout
Pertinent Results:
AP Pelvis (___):
Subcapital fracture of the proximal left femur with mild
impaction and
displacement.
CT Head (___):
No evidence of acute intracranial process. Specifically, no
intracranial
hemorrhage. Small left frontoparietal scalp hematoma.
CT C Spine (___):
1. No evidence of fracture or traumatic malalignment. Multilevel
degenerative
changes as noted above.
2. Erosive changes involving C1-C2 with enlargement of the
synovium at this
level which may reflect rheumatoid arthritis in the appropriate
clinical
setting.
3. Right pleural effusion.
___ 05:50AM BLOOD WBC-10.2 RBC-2.85* Hgb-8.2* Hct-24.5*
MCV-86 MCH-28.8 MCHC-33.5 RDW-17.2* Plt ___
___ 05:50AM BLOOD Glucose-147* UreaN-46* Creat-2.3* Na-135
K-4.4 Cl-100 HCO3-24 AnGap-15
Medications on Admission:
ASA 325mg daily
amlodipine 5 mg daily
docusate
senna
MVI
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 30 mg SC Q24H Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 30 mg sc at bedtime Disp #*14
Syringe Refills:*0
5. Multivitamins 1 CAP PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Senna 8.6 mg PO BID
8. Amlodipine 5 mg PO DAILY
9. Aspirin EC 325 mg PO DAILY
10. TraMADOL (Ultram) ___ mg PO BID Pain
RX *tramadol 50 mg ___ tablet(s) by mouth twice a day Disp
#*80 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Hip Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: LEFT HIP AND PELVIS RADIOGRAPHS
INDICATION: Status post fall with left hip pain.
COMPARISON: None.
TECHNIQUE: Left hip, two views, and AP pelvis.
FINDINGS:
There is a complete mildly displaced, impacted subcapital fracture of the
proximal left femur. The femoral head articulates normally with the
acetabulum. Mild background degenerative changes involve the left hip. The
right hip joint space appears preserved. Moderate degenerative changes are
incompletely characterized along the lower lumbar spine. Although this is not
optimal technique for evaluating sacroiliac joints, given how indistinct these
appear, it is possible that there may be prior sacroileitis or even fusion of
the joints. The pubic symphysis is also moderately narrowed. The bones appear
demineralized. Patchy vascular calcifications are present.
IMPRESSION:
Subcapital fracture of the proximal left femur with mild impaction and
displacement.
Radiology Report
INDICATION: Status post fall with head laceration and left hip pain, evaluate
for intracranial hemorrhage.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm-reconstructed images were acquired.
COMPARISON: None available.
DLP: 891 mGy-cm
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large territorial
infarction. Prominent ventricles and sulci suggest age-related global
atrophy.The basal cisterns appear patent and there is preservation of
gray-white matter differentiation.
No fracture is identified. There is a small left frontoparietal scalp
hematoma. The visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The globes appear elongated bilaterally with
calcification of the lens, which are likely chronic in nature.
Atherosclerotic calcifications of the cavernous portions of the internal
carotid arteries are noted bilaterally.
IMPRESSION:
No evidence of acute intracranial process. Specifically, no intracranial
hemorrhage. Small left frontoparietal scalp hematoma.
Radiology Report
INDICATION: Status post fall with head laceration, left hip pain, evaluate
for fracture.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 37 mGy
DLP: 740 mGy-cm
COMPARISON: None
FINDINGS:
There is no fracture or traumatic malalignment. There is grade 1
anterolisthesis of C3 on C4, likely secondary to bilateral facet arthropathy.
Moderate to severe multilevel, multifactorial degenerative changes are noted,
with disc space narrowing, and vertebral body osteophyte formation. There is
also bilateral uncovertebral and facet hypertrophy leading to moderate neural
foraminal narrowing spanning the C3-C6 levels. Note is made of erosive
changes at C1-C2, as well as enlargement of the synovium at this level.
There is no evidence of infection or neoplasm. There is no cervical
lymphadenopathy. The unenhanced thyroid gland is unremarkable. Visualized lung
apices are clear. A small amount of pleural fluid is detected at the apex of
the right chest.
IMPRESSION:
1. No evidence of fracture or traumatic malalignment. Multilevel degenerative
changes as noted above.
2. Erosive changes involving C1-C2 with enlargement of the synovium at this
level which may reflect rheumatoid arthritis in the appropriate clinical
setting.
3. Right pleural effusion.
Radiology Report
INDICATION: Hip prosthesis post fracture.
TECHNIQUE: 2 bedside AP radiographs of the left hip.
FINDINGS:
Since exam 1 day previous (showing a subcapital left femoral neck fracture) a
satisfactorily positioned uncemented total right hip prosthesis has been
placed with no acetabular screws. The distal tip of this prosthesis is not
visualized. There is postoperative gas in the soft tissues.
IMPRESSION:
Interval placement normal-appearing left hip prosthesis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Laceration
Diagnosed with OPEN WOUND OF SCALP, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING
temperature: 98.0
heartrate: 60.0
resprate: 18.0
o2sat: 98.0
sbp: 132.0
dbp: 62.0
level of pain: 1
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 a left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient also sustained a small
laceration to the left frontal scalp that was irrigated and
closed with sutures in the emergency department; CT head and
c-spine were negative for intracranial hemorrhage and fracture.
The patient was taken to the operating room on ___ for
left hip hemiarthroplasty, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by. The patient was given perioperative antibiotics
and anticoagulation per routine. The patient's home medications
were continued throughout this hospitalization. On POD 2, Hct
was 22.3, and he was transfused with 1 U pRBCs. His Hct on POD 3
was 24.5. He remained hemodynamically normal and stable
throughout his hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity with anterolateral hip precautions, and
will be discharged on enoxaparin for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Bactrim / pravastatin / simvastatin / Tricor
Attending: ___
Chief Complaint:
Chest and back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male that recently
underwent AVR and CABG ___ complicated by tamponade and
underwent mediastinal exploration. He additionally had prolonged
intubation extubated on post operative day five, anemia
requiring
blood transfusion, abnormal movements ruled out for seizures but
noted as encephlopathic. Prior to discharge was noted for
sternal drainage that resolved prior to discharge. He was
discharged to rehab on ___. From what patient can remember he
had not done very much at rehab, fell ___ and only remembers
being picked up from the floor, by his descriptions concern for
syncope however spoke with rehab it was not a witnessed fall but
they found him on the floor. Per rehab he denied hitting head
was appropriate during the night ___. Went to dialysis ___
underwent dialysis and had progressive confusion and was
transferred to ___ ED for evaluation. Additionally he is
complaining of severe chest and back pain. On talking with him
he is emotional as he doesn't understand what is happening but
easy to redirect and orient. He is undergoing evaluation in ED
head ct negative, cspine negative will obtain cultures and start
antibiotics concern for infection with sternal wound. Admit to
cardiac surgery
Past Medical History:
Aortic Stenosis
Arrhythmia
Colitis
Coronary Artery Disease
Depression
Diabetes Mellitus, Insulin Dependent
Difficult Intubation
End-Stage Renal Disease, HD ___ via right chest access
Facial Droop, 1980s, self-resolved
First Degree AV block
Gastroesophageal Reflux Disease
Gout
Hearing Loss
Hyperlipidemia
Hypertension
Hypothyroid
Lipomas bilateral axilla
Low Testosterone
Neuropathy
Reflux Laryngitis
Pancreatic Insufficiency
Pancreatitis s/p resection
Scoliosis
? Seizure while on Depakote for diabetic nerve pain ___ yrs ago
Sleep Apnea
Surgical History:
Cholycystectomy and Partial Pancreatectomy
Left Radiocephalic AVF and Left brachiocephalic AVF
Right otologic procedure x ___
Microlaryngeal procedure
Tooth extraction
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission Exam
98.3 54 SB 141/29 -18 100
% 2 l NC
General: Anxious teary
Skin: Sternal incision with mild erythema distal incision
serosang drainage on dressing small area not approximated with
fibrinous tissue
Right subclavian tunnel line
HEENT: PERRLA, EOMI
Neck: Supple, full ROM
Chest: Lungs diminished throughout no rhonchi or wheezes
Heart: Regularly irregular rhythm, murmur ___ systolic
Abd: Normal BS, soft, non-tender, non-distended Obese
Extremities: Warm, well-perfused. Chronic venous stasis
dermatitis.
Edema: None
Neuro: Alert oriented to self and hospital poor recall of events
No focal deficits
Pulses:
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 1+ Left: 1+
.
Discharge Exam
Temp 98.0, HR 53 SB, BP 119/61, RR 18, Sp02 95% RA
General: Jovial
Skin: Warm, dry intact. Right subclavian tunnel line
Sternum: CDI, no erythmia or drainage. Fibrinous tissue lower
___.
HEENT: PERRLA, EOMI
Neck: Supple, full ROM
Chest: Lungs diminished throughout no rhonchi or wheezes
Heart: Regularly irregular rhythm
Abd: Normal BS, soft, non-tender, non-distended Obese
Extremities: Warm, well-perfused. Chronic venous stasis
dermatitis.
Edema: None
Neuro: Grossly intact
Pulses:
DP Right: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Pertinent Results:
CXR ___
The cardiac silhouette is moderately enlarged. There are small
bilateral
pleural effusions with bibasilar atelectasis noted. A right
hemodialysis
catheter terminates in the right atrium. Right rib fractures
are better
appreciated on same day CT chest. Median sternotomy wires and
cardiac valve appear in unchanged position. Pulmonary nodules
are better evaluated on same day chest CT.
IMPRESSION:
1. Small to moderate bilateral pleural effusions.
2. Right-sided rib fractures are better appreciated on same day
CT chest.
CT Cervical ___
Dental amalgam streak artifact and patient body habitus limits
study,
especially for evaluation of C6 and inferior vertebral bodies.
There is
straightening of cervical lordosis. No fractures are
identified.
There is fusion of the left C2 and C3 facets. Multilevel
degenerative
changes noted throughout the cervical spine, including loss of
intervertebral disc height, endplate sclerosis, Schmorl's nodes,
and disc bulges, with at least mild vertebral canal narrowing at
C3-4.
There is no prevertebral edema. The thyroid and included lung
apices are
preserved. Atherosclerotic vascular calcifications are seen in
bilateral
carotid bifurcations. Scattered subcentimeter nonspecific lymph
nodes are
noted throughout the neck bilaterally, without definite
enlargement by CT size criteria.
IMPRESSION:
1. Dental amalgam streak artifact and patient body habitus
limits study.
2. No acute fracture or traumatic malalignment.
3. Multilevel cervical spondylosis as described, with at least
mild vertebral canal narrowing at C3-4. If clinically
indicated, consider dedicated cervical spine MRI for further
evaluation.
4. Please see concurrently obtained noncontrast head CT for
description of
cranial structures.
Head CT ___
There is no evidence of large territorial
infarction,hemorrhage,edema,or mass effect. There is prominence
of the ventricles and sulci suggestive of involutional changes.
Mild periventricular white-matter hypodensities are nonspecific,
but likely represent sequela of chronic small vessel ischemic
disease. Atherosclerotic vascular calcifications are noted of
bilateral vertebral and cavernous portions of internal carotid
arteries.
There are stable postsurgical changes related to prior right
mastoidectomy
with partial opacification of residual right mastoid air cells
is again
noted.. Bilateral sphenoid sinus and ethmoid air cell mucosal
thickening is present. No acute fracture. The visualized
portion of the left mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are preserved.
IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence acute intracranial hemorrhage or fracture.
3. Paranasal sinus disease , as described.
4. Right mastoidectomy postsurgical changes with partial
opacification of
residual right mastoid air cells.
5. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
Chest CT ___
HEART AND VASCULATURE: Patient is status post recent aortic
valve replacement. The thoracic aorta is normal in caliber.
Main pulmonary artery diameter is within normal limits. Heart
is top-normal in size. Coronary artery calcifications are
severe. Mild thickening of the pericardium likely reflects
sequela of recent intervention. There is no pericardial
effusion.
AXILLA, HILA, AND MEDIASTINUM: There is stranding of the
mediastinal fat.
Small volume simple fluid is noted anterior to the ascending
thoracic aorta (03:25) and deep to the sternum (03:36). There
is no discrete fluid
collection. A small focus of air is seen in the right superior
mediastinum (03:14), possibly within the internal mammary vein.
No axillary or mediastinal lymphadenopathy is present.
PLEURAL SPACES: There are moderate right and small left
dependent pleural
effusions. No pneumothorax.
LUNGS/AIRWAYS: Detailed evaluation is limited by respiratory
motion. An 8 mm nodule at the right lung apex (___) is
minimally bigger compared to ___, where it previously
measured 7 mm. Bilateral lower lobe atelectasis is noted.
Scattered calcified granulomas are seen in both lungs. The
airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: The imaged thyroid is unremarkable.
ABDOMEN: Included portion of the unenhanced upper abdomen is
unremarkable.
BONES: No suspicious osseous lesion is seen.? There is a
comminuted fracture of the right first rib, and minimally
displaced fractures of the right second and fifth ribs. There
is no appreciable callus formation around these fractures,
suggesting an acute injury. There is no significant callus
formation around the median sternotomy line. There are no
erosive changes, periostitis or osseous demineralization to
suggest osteomyelitis.
IMPRESSION:
1. Status post median sternotomy and aortic valve replacement.
2. Acute comminuted fracture of the right first rib and
minimally displaced fractures of the right second and fifth
ribs.
3. Mild fat stranding in the mediastinum associated with small
volume simple fluid anteriorly, likely reflect postsurgical
changes.
4. Moderate right and small left pleural effusions.
Echocardiogram ___
Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.8 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1
cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.32 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 116 ml/beat
Left Ventricle - Cardiac Output: 5.11 L/min
Left Ventricle - Cardiac Index: 2.51 >= 2.0 L/min/M2
Right Ventricle - Diastolic Diameter: 3.8 cm <= 4.0 cm
Aortic Valve - Peak Velocity: *2.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *35 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 22 mm Hg
Aortic Valve - LVOT VTI: 41
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *1.6 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 1.7 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.89
Mitral Valve - E Wave deceleration time: *130 ms 140-250 ms
TR Gradient (+ RA = PASP): *31 mm Hg <= 25 mm Hg
Findings
The pateint asked that the study be prematurely ended prior to
subcostal and suprasternal views were obtained.
This study was compared to the prior study of ___.
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded.
RIGHT VENTRICLE: Nl interventricular septal motion. Paradoxic
septal motion consistent with prior cardiac surgery.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
___ mitral annular calcification.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - body habitus. Suboptimal image
quality - patient unable to cooperate. Resting bradycardia
(HR<60bpm).
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Interventricular septal motion is normal. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet motion
and transvalvular gradients. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Very suboptimal image quality.Well seated, normal
functioning aortic valve bioprosthesis. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function.
Compared with the prior study (images reviewed) of ___,
the aortic valve has been replaced with a normal functioning
bioprosthesis and the estimated PA systolic pressure is now
slightly higher.
Admission Labs
___ 10:00PM BLOOD WBC-10.6* RBC-2.61* Hgb-8.3* Hct-26.2*
MCV-100* MCH-31.8 MCHC-31.7* RDW-22.4* RDWSD-78.8* Plt ___
___ 11:39PM BLOOD ___ PTT-30.0 ___
___ 10:00PM BLOOD Glucose-215* UreaN-25* Creat-3.9*# Na-139
K-4.3 Cl-96 HCO3-29 AnGap-14
___ 05:25AM BLOOD ALT-10 AST-15 AlkPhos-96 Amylase-33
TotBili-0.3
___ 10:00PM BLOOD CK(CPK)-51
___ 05:25AM BLOOD Lipase-27
___ 10:00PM BLOOD cTropnT-0.40*
___ 10:00PM BLOOD CK-MB-4
___ 10:00PM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1
___ 05:25AM BLOOD Albumin-3.0* Phos-4.6* Mg-2.3
___ 05:25AM BLOOD Ammonia-20
___ 05:25AM BLOOD TSH-1.1
.
Discharge Labs
___ 01:20PM BLOOD WBC-7.3 RBC-2.73* Hgb-8.5* Hct-27.5*
MCV-101* MCH-31.1 MCHC-30.9* RDW-19.8* RDWSD-73.3* Plt ___
___ 12:01PM BLOOD ___
___ 01:20PM BLOOD Glucose-153* UreaN-61* Creat-8.4*# Na-140
K-4.5 Cl-94* HCO3-26 AnGap-20*
___ 01:20PM BLOOD Calcium-8.5 Phos-8.6* Mg-2.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Aspirin EC 81 mg PO DAILY
4. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat
5. Docusate Sodium 100 mg PO BID
6. DULoxetine 60 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID SOB
8. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN rash
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Lactulose 30 mL PO DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
12. LORazepam 1 mg PO TID
13. Nephrocaps 1 CAP PO DAILY
14. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
15. Polyethylene Glycol 17 g PO DAILY
16. QUEtiapine Fumarate 25 mg PO QHS
17. Rosuvastatin Calcium 5 mg PO QPM
18. Senna 17.2 mg PO DAILY
19. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash
20. HydrALAZINE 25 mg PO BID
21. Pantoprazole 40 mg PO Q24H
22. Asmanex HFA (mometasone) 200 mcg/actuation inhalation
Q4H:PRN
23. Baclofen ___ mg PO QHS:PRN Muscle Spasms
24. Hydrocortisone Oint 2.5% 1 Appl TP PRN rash
25. Calcium Acetate 1334 mg PO TID W/MEALS
26. Torsemide 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*4
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth once a day Refills:*0
7. QUEtiapine Fumarate 25 mg PO QHS
8. Rosuvastatin Calcium 5 mg PO QPM
RX *rosuvastatin 5 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*2
9. Senna 17.2 mg PO DAILY
RX *sennosides [___] 8.6 mg 2 tablets by mouth once a day Disp
#*30 Tablet Refills:*0
10. TraMADol ___ mg PO Q4H:PRN Pain - Severe
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
11. Warfarin 2.5 mg PO DAILY16
Take dosage as ordered per provider who is following INR.
RX *warfarin 2.5 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*2
12. Lactulose 30 mL PO Q6H:PRN constipation
13. Allopurinol ___ mg PO EVERY OTHER DAY
14. Asmanex HFA (mometasone) 200 mcg/actuation inhalation
Q4H:PRN
15. Aspirin EC 81 mg PO DAILY
16. Calcium Acetate 1334 mg PO TID W/MEALS
17. DULoxetine 60 mg PO DAILY
18. Fluticasone Propionate 110mcg 2 PUFF IH BID SOB
19. HydrALAZINE 25 mg PO BID
20. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN rash
21. Hydrocortisone Oint 2.5% 1 Appl TP PRN rash
22. Levothyroxine Sodium 50 mcg PO DAILY
23. LORazepam 1 mg PO TID
24. Nephrocaps 1 CAP PO DAILY
25. Pantoprazole 40 mg PO Q24H
26. Torsemide 100 mg PO DAILY
27. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash
28. HELD- Baclofen ___ mg PO QHS:PRN Muscle Spasms This
medication was held. Do not restart Baclofen until you follow-up
with perscriber
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Complete heart block
Sternal drainage
Deconditioned
Right-sided rib fractures
Secondary Diagnosis
Aortic Stenosis
Coronary Artery Disease
Encephalopathy
Arrhythmia
Colitis
Depression
Diabetes Mellitus, Insulin Dependent
Difficult Intubation
End-Stage Renal Disease, HD ___ via right chest access
Facial Droop, 1980s, self-resolved
First Degree AV block
Gastroesophageal Reflux Disease
Gout
Hearing Loss
Hyperlipidemia
Hypertension
Hypothyroid
Lipomas bilateral axilla
Low Testosterone
Neuropathy
Reflux Laryngitis
Pancreatic Insufficiency
Pancreatitis s/p resection
Scoliosis
? Seizure while on Depakote for diabetic nerve pain ___ yrs ago
Sleep Apnea
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating, deconditioned
Incisional pain managed with Tylenoln and Ultram
Incisions:
Sternal - CDI. No erythmia or drainage. Slight fibrinous tissue
on ___ lower pole.
Edema : none
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with chest pain, fall and LOC. Evaluate for acute
intracranial hemorrhage or fracture.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.5 cm; CTDIvol = 45.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
There is no evidence of large territorial infarction,hemorrhage,edema,or mass
effect. There is prominence of the ventricles and sulci suggestive of
involutional changes. Mild periventricular white-matter hypodensities are
nonspecific, but likely represent sequela of chronic small vessel ischemic
disease. Atherosclerotic vascular calcifications are noted of bilateral
vertebral and cavernous portions of internal carotid arteries.
There are stable postsurgical changes related to prior right mastoidectomy
with partial opacification of residual right mastoid air cells is again
noted.. Bilateral sphenoid sinus and ethmoid air cell mucosal thickening is
present. No acute fracture. The visualized portion of the left mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are preserved.
IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence acute intracranial hemorrhage or fracture.
3. Paranasal sinus disease , as described.
4. Right mastoidectomy postsurgical changes with partial opacification of
residual right mastoid air cells.
5. Atrophy, probable small vessel ischemic changes, and atherosclerotic
vascular disease as described.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with chest pain, fall and LOC. Evaluate for cervical spine
fracture.
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.1 s, 20.0 cm; CTDIvol = 22.5 mGy (Body) DLP = 451.5
mGy-cm.
Total DLP (Body) = 452 mGy-cm.
COMPARISON: None.
FINDINGS:
Dental amalgam streak artifact and patient body habitus limits study,
especially for evaluation of C6 and inferior vertebral bodies. There is
straightening of cervical lordosis. No fractures are identified.
There is fusion of the left C2 and C3 facets. Multilevel degenerative
changes noted throughout the cervical spine, including loss of intervertebral
disc height, endplate sclerosis, Schmorl's nodes, and disc bulges, with at
least mild vertebral canal narrowing at C3-4.
There is no prevertebral edema. The thyroid and included lung apices are
preserved. Atherosclerotic vascular calcifications are seen in bilateral
carotid bifurcations. Scattered subcentimeter nonspecific lymph nodes are
noted throughout the neck bilaterally, without definite enlargement by CT size
criteria.
IMPRESSION:
1. Dental amalgam streak artifact and patient body habitus limits study.
2. No acute fracture or traumatic malalignment.
3. Multilevel cervical spondylosis as described, with at least mild vertebral
canal narrowing at C3-4. If clinically indicated, consider dedicated cervical
spine MRI for further evaluation.
4. Please see concurrently obtained noncontrast head CT for description of
cranial structures.
Radiology Report
EXAMINATION: CT CHEST WITHOUT CONTRAST
INDICATION: History: ___ with chest pain// sternal infection? mediatinitis?
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: CTA chest from ___.
FINDINGS:
HEART AND VASCULATURE: Patient is status post recent aortic valve replacement.
The thoracic aorta is normal in caliber. Main pulmonary artery diameter is
within normal limits. Heart is top-normal in size. Coronary artery
calcifications are severe. Mild thickening of the pericardium likely reflects
sequela of recent intervention. There is no pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: There is stranding of the mediastinal fat.
Small volume simple fluid is noted anterior to the ascending thoracic aorta
(03:25) and deep to the sternum (03:36). There is no discrete fluid
collection. A small focus of air is seen in the right superior mediastinum
(03:14), possibly within the internal mammary vein. No axillary or
mediastinal lymphadenopathy is present.
PLEURAL SPACES: There are moderate right and small left dependent pleural
effusions. No pneumothorax.
LUNGS/AIRWAYS: Detailed evaluation is limited by respiratory motion. An 8 mm
nodule at the right lung apex (___) is minimally bigger compared to ___, where it previously measured 7 mm. Bilateral lower lobe atelectasis is
noted. Scattered calcified granulomas are seen in both lungs. The airways
are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: The imaged thyroid is unremarkable.
ABDOMEN: Included portion of the unenhanced upper abdomen is unremarkable.
BONES: No suspicious osseous lesion is seen.? There is a comminuted fracture
of the right first rib, and minimally displaced fractures of the right second
and fifth ribs. There is no appreciable callus formation around these
fractures, suggesting an acute injury. There is no significant callus
formation around the median sternotomy line. There are no erosive changes,
periostitis or osseous demineralization to suggest osteomyelitis.
IMPRESSION:
1. Status post median sternotomy and aortic valve replacement.
2. Acute comminuted fracture of the right first rib and minimally displaced
fractures of the right second and fifth ribs.
3. Mild fat stranding in the mediastinum associated with small volume simple
fluid anteriorly, likely reflect postsurgical changes.
4. Moderate right and small left pleural effusions.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.3
heartrate: 54.0
resprate: 18.0
o2sat: 100.0
sbp: 149.0
dbp: 51.0
level of pain: 6
level of acuity: 2.0 | Presented from Rehab to emergency room with chest pain, back
pain and acute confusion. He underwent CT scan that revealed
right rib fractures but no other acute process. He was admitted
for further workup. Nephrology was consulted for dialysis which
he continued during hospital course. His confusion resolved and
Ativan was restarted for his anxiety that he takes chronically
at home. He was treated with antibiotics due to sternal
erythema with no growth from culture data. Antibiotics where
eventually stopped. Sternal drainage decreased daily until none
was seen. Complicating this admission were episodes of advanced
AV block with a good junctional escape in the ___, immediately
followed by 2:1 AV conduction. He was asymptomatic. The patient
is known to have baseline AV Wenckeback and 2:1
AV block for at least the past ___ years. He is asymptomatic. He
denies any syncope, dizziness, SOB or other symptoms. E.P. will
reconsider PPM implantation in the future if he should develop
symptoms or if the conduction system
disease should get worse. He can be discharged with no
additional monitoring required per E.P.
Patient is being discharged HD 9 to home with services in good
condition with appropriate discharge and follow-up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
___ man with HTN, HLD, pericardial effusion (on echo in
___, pleural plaques (on CT scan ___, and ___ year history
of progressively worsening exertional dyspnea who was admitted
to the ___ after being found down with multiple intracranial
hemorrhages that have remained stable who is being transferred
to medicine for further workup of syncope, pericardial/pleural
effusions, and ascites.
On ___ he was found down beside his car in a pool of blood. He
had driven himself to work around 6am, when two unknown
individuals found him on the ground. The patient remebers
driving himself to work but otherwise has no recollection of the
event. He was taken first to ___ then
transferred to ___. He was found to have L IPH, b/l SAH and
b/l SDH, as well as a frontal skull fx, L superior orbital rim
fx, and L eyelid contusion on CT. Also seen on full body CT was
a R pleural effusion, pericardial effusion, and extensive
abdominal ascites (simple fluid, ?no blood). He has no known
liver disease.
Per the patient's son, he has had worsening exertional dyspnea
for at least ___ years. He recently learned that Mr ___
co-workers have witnessed numerous episodes of presyncope over
that time period which are relieved by sitting. The patient has
not followed routinely with a PCP or other physicians. Over the
past 2 months, these symptoms have worsened, prompting him to
present to both his PCP and local cardiologist. He has become
increasingly SOB when climibing the stairs to his bedroom.
Recently he can walk only half a staircase before symptomatic.
Outpatient workup has revealed thus far: PFTs showed severe
obstructive lung process (thought likely COPD and was started on
___ inhaled steroids and anti-cholinergic), echocardiogram
with LVEF 55% and mild-to-moderate circumferential pericardial
effusion, exercise SPECT that was negative (although only
exercised 2min 12sec on ___ protocol, attained ___ METs
workload, and 86% of MPHR), and CT Chest with bilateral pleural
plaques and small right pleural effusion (___). His PCP
started him recently on meclizine for the dizziness without
effect. There is no mention in outpatient records of abdominal
ascites. Also notable, on admission his INR was 1.5 (not on
warfarin). Home ASA was held (unclear indication for 325 mg) and
he was given K-centra.
In the TSICU, neurosurgery was following and no intracranial
interventions were done. He was on q1h neurochecks and started
on Keppra for seizure prophylaxis. Neurochecks were weaned to
q2h and then q4h and have been stable. Echocardiogram on ___
showed a moderate sized circumferential pericardial effusion
without echocardiographic signs of hemodynamic compromise.
Thoracentesis on ___ removed > 1L serosanguanous fluid, found
to be exudative by LDH and total protein. Further studies were
added-on ___ morning. He was transferred to medicine for workup
and management of ascites/effusions.
On arrival to the floor vitals were 97.9 74 132/74 14 100% on
RA. He denies pain of any kind, including chest pain, shortness
of breath, or any other symptoms at this time. Son reports no
observed changes in appetite or recent weight loss and thinks he
had some ankle swelling recently, first noticed within the last
month.
Past Medical History:
- Hyperlipidemia
- Hypertension
- Pericardial effusion
- Pleural plaques
- Abdominal ascites (per report, not in records obtained)
- Asbestos exposure (x ___ years)
- Nasal polpectomy, septoplasty (___)
- Ventral hernia
- Lumbosacral radiculopathy
- Vitamin D deficiency
- Right ankle effusion, knee effusion
- Bunions bilaterally
- Last colonoscopy ___
Social History:
___
Family History:
He is ___ of 11 siblings. Only 2 are alive at present. He has
one son, ___. His sister had open heart surgery x 2 for valve
replacement. His mother died at ___. His father died at ___ with
known vascular disease.
Physical Exam:
Admitting Physical Exam:
Vitals - Tm 98.5 Tc 97.6 HR ___ BP 114/84-131/81 RR ___ SpO2
97-100% on RA
___: NAD. Elderly man sleeping in bed, somnolent, responds
promptly to voice.
HEENT: Bilateral periorbital ecchymoses, L > R. Left
supraorbital echhymosis. Linear abrasion with staples over
occiput. Ocular exam deferred, patent nares, MMM, good dentition
NECK: Nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Bibasilar crackles and wheezes, no rhonchi. Good air
movement.
ABDOMEN: Protuberant, nontender, normoactive bowel sounds. No
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Fingers and toes cold and mildly cyanotic
bilaterally, no clubbing or edema
NEURO: CN II-XII grossly intact. Moving all extremities.
Sensation intact.
SKIN: linear crease across earlobes bilaterally
Discharge Physical Exam:
VITALS- Tm 97.9 Tc 97.6 HR 83 BP 118/69 RR 18 SpO2 97% on RA
I/O: MN ___ 24h 900/375+
___- Elderly appearing gentleman with multiple bruises on
his face, alert, oriented x2, no acute distress
HEENT: Bilateral periorbital ecchymoses, L > R. Left
supraorbital echhymosis. Small linear abrasion with staples over
occiput. EOMI, PERRLA, patent nares, MMM, good dentition
NECK: Nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Decreased lung sounds at R base. Otherwise CTAB
bilaterally.
ABDOMEN: Protuberant with flank bulging, nontender, normoactive
bowel sounds. No rebound/guarding, no hepatosplenomegaly
GU: Mild scrotal edema
EXTREMITIES: Warm and well perfused, no clubbing, cyanosis, or
edema
NEURO: Face symmetric. Moving all extremities. Sensation intact.
Pertinent Results:
Admitting Labs:
___ 09:55AM BLOOD WBC-9.6 RBC-4.02* Hgb-11.5* Hct-37.0*
MCV-92 MCH-28.5 MCHC-31.0 RDW-14.7 Plt ___
___ 09:55AM BLOOD Neuts-92.0* Lymphs-3.0* Monos-4.6 Eos-0.3
Baso-0.1
___ 09:55AM BLOOD ___ PTT-26.3 ___
___ 09:55AM BLOOD Glucose-142* UreaN-31* Creat-1.5* Na-141
K-4.2 Cl-104 HCO3-26 AnGap-15
___ 09:55AM BLOOD ALT-28 AST-20 AlkPhos-100 TotBili-0.9
___ 05:43PM BLOOD LD(LDH)-283*
___ 05:43PM BLOOD CK-MB-4 cTropnT-<0.01
___ 09:55AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.5 Mg-2.1
___ 05:43PM BLOOD TotProt-6.5 Albumin-3.9 Globuln-2.6
___ 10:13AM BLOOD Lactate-1.7
Relevant Labs:
___ 01:50AM BLOOD ALT-16 AST-15 AlkPhos-92 TotBili-0.8
___ 07:15AM BLOOD proBNP-2254*
___ 01:50AM BLOOD %HbA1c-6.7* eAG-146*
___ 09:29AM PLEURAL TotProt-2.2 Glucose-103 Creat-1.5
LD(LDH)-385 Amylase-9 Albumin-1.4
Discharge Labs:
___ 06:40AM BLOOD WBC-6.9 RBC-4.07* Hgb-11.6* Hct-37.5*
MCV-92 MCH-28.5 MCHC-31.0 RDW-14.9 Plt ___
___ 06:40AM BLOOD Glucose-105* UreaN-34* Creat-1.2 Na-143
K-4.4 Cl-104 HCO3-29 AnGap-14
___ 06:40AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3
Pertinent Micro/Path:
___ Blood culture - no growth
___ Pleural fluid
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ Pleural fluid cytology
Negative for malignant cells.
Predominantly blood and fibrinous debris with rare mesothelial
cells.
Pertinent Imaging:
NCHCT (___):
1. Left frontal hemorrhagic contusion, bilateral subdural
hematoma, subarachnoid hematoma, slightly increased from prior
exam. No signs of herniation.
2. Frontal bone fracture, nondepressed, extends into the left
frontal sinus.
3. Large subgaleal hematoma.
Non-contrast C/A/P CT (___):
1. Moderate pericardial effusion appears simple with pericardial
thickening.
2. Moderate right pleural effusion with associated compressive
atelectasis. No signs of lung injury.
3. Moderate volume abdominal ascites.
ECHO ___
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
low normal (LVEF 50-55%). Right ventricular chamber size is
normal. with borderline normal free wall function. There is
abnormal septal motion/position. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a moderate sized pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION: Moderate sized circumferential pericardial effusion
without echocardiographic signs of hemodynamic compromise.
Borderline biventricular function. Mildly dilated aortic root.
Mild mitral regurgitation.
___ Carotid Duplex US
Right ICA <40% stenosis.
Left ICA <40 stenosis.
___ EKG: Sinus rhythm, HR 78bpm, normal axis, left atrial
abnormality, TWI I and II, no ST segment abnormalities
___ Chest x-ray PA & Lateral
In comparison with the study of ___, there again are relatively
low lung volumes. Areas of increased opacification is seen at
the bases,
suggestive of atelectatic change. There is evidence of a right
pleural
effusion. No definite acute focal pneumonia, though this could
be well hidden on the radiographs are presented.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 325 mg PO DAILY
2. Meclizine 12.5 mg PO Q12H:PRN dizziness, nausea
3. Qvar (beclomethasone dipropionate) 40 mcg/actuation
inhalation BID
4. Enalapril Maleate 10 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Simvastatin 40 mg PO DAILY
7. Vitamin D Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Simvastatin 40 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 10 mg PO DAILY
5. LeVETiracetam 1000 mg PO BID
6. Senna 8.6 mg PO BID:PRN constipation
7. Qvar (beclomethasone dipropionate) 40 mcg/actuation
inhalation BID
8. Meclizine 12.5 mg PO Q12H:PRN dizziness, nausea
9. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Fall; Intracranial hemorrhage; Skull fracture
Secondary: Pleural effusion, ascites, pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with known traumtic SDH, SAH, evaluate interval change
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 892 mGy-cm
COMPARISON: Outside hospital head CT ___ at 0730
FINDINGS:
Again noted, is multi compartmental acute intracranial hemorrhage. There is a
large left frontal lobe hemorrhagic contusion with with surrounding edema,
mildly increased in size from prior, measuring 2.2 x 3.3 x 3.7 cm. Local mass
effect on the frontal horn of the left lateral ventricle and adjacent sulci
noted. No significant shift of midline structures. Smaller foci of hemorrhagic
contusion noted in the left inferior frontal lobe (2:8). Small foci of
bifrontal subarachnoid hemorrhage is noted, left greater than right with
minimal isolated subarachnoid hemorrhage noted posteriorly in the right
frontal lobe on series 2 image 21. Additionally, there are small bilateral
cerebral subdural hematomas left greater than right (601 B: 46), similar to
prior. The left subdural hematoma measures up to 5 mm and layers along the
entire left cerebral hemisphere. The ventricles and sulci are unchanged in
size and configuration. No intraventricular hemorrhage. There is no
significant shift of midline structures.. The basal cisterns are patent and
there is preservation of gray-white matter differentiation.
There is a left paramedian frontal bone fracture extending from the vertex
through the superior orbital rim. While this fracture appears to traverse the
inner and outer table of the left frontal sinus, no fluid is seen within the
left frontal sinus. The potential for CSF leak is therefore difficult to
exclude and clinical correlation is strongly advised. Left periorbital
swelling and hematoma as well as a large left subgaleal hematoma is seen.
Postsurgical changes are noted in the paranasal sinuses with mild fluid noted
in the left sphenoid sinus. Mastoid air cells and middle ear cavities are well
aerated.
IMPRESSION:
1. Left frontal hemorrhagic contusion, bilateral subdural hematoma,
subarachnoid hematoma, slightly increased from prior exam. No signs of
herniation.
2. Frontal bone fracture, nondepressed, extends into the left frontal sinus.
Clinical correlation for possibility of a CSF leak.
3. Large subgaleal hematoma.
Radiology Report
EXAMINATION: CT CHEST, ABDOMEN, AND PELVIS
INDICATION: Trauma.
TECHNIQUE: Multidetector CT through the chest, abdomen, and pelvis was
performed without IV contrast administration with multiplanar reformations
provided.
COMPARISON: None.
FINDINGS:
CHEST: There is no mediastinal hematoma. The thoracic aorta is moderately
calcified and normal in caliber. There is a pericardial effusion, simple in
attenuation though there is thickening and hyperdense appearance of the
pericardium. Please correlate for tamponade physiology. There is a moderate
simple appearing right pleural effusion with associated compressive right
lower lobe atelectasis. There is mild left basilar atelectasis noted as well
with faint pleural calcification noted. No definite signs of contusion or
laceration. No pneumothorax. No worrisome nodule, mass, or consolidation is
seen within the lungs.
ABDOMEN: Noncontrast appearance of the liver, spleen, gallbladder, pancreas
and adrenal glands is normal. Kidneys contain no stones and show no signs of
hydronephrosis. No signs of renal injury. The abdominal aorta is somewhat
calcified and mildly ectatic. No retroperitoneal lymphadenopathy or hematoma
is seen.
The stomach and duodenum are normal.
PELVIS: Loops of small and large bowel demonstrate no signs of ileus or
obstruction. No mesenteric hematoma is seen. The appendix is normal. Colonic
diverticulosis is noted without diverticulitis. Urinary bladder is partially
distended appearing normal. Simple free fluid tracks into the deep pelvis.
BONES: No fracture is identified. Thoracolumbar spine aligns normally without
significant degenerative disease. No definite rib fracture. The bony pelvic
ring appears intact.
IMPRESSION:
1. Moderate pericardial effusion appears simple with pericardial thickening.
Please correlate for tamponade physiology.
2. Moderate right pleural effusion with associated compressive atelectasis.
No signs of lung injury.
3. Moderate volume abdominal ascites.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with IPH, SAH, SDH suspected worsening on ___
___ CT head from prev 6 AM scan at ___ // Please repeat NCHCT at 5:00 ___
(17:00) on ___ to evaluate progression of bleed
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): 922
CTDIvol (mGy): 54
COMPARISON: ___ at 10:26
FINDINGS:
Redemonstrated are multi compartmental hemorrhages, including bifrontal
contusions, left greater than right with surrounding vasogenic edema, which
allowing for differences in technique are relatively stable. Mild
redistribution of bilateral subarachnoid hemorrhages with presence of
hyperdense blood in bilateral frontal sulci and to a lesser extent temporal
sulci. There is no intraventricular hemorrhage. Small hyperdense subdural
hemorrhage along the left lateral convexity is also unchanged. Minimal shift
of normally midline structures to the left is stable. Basal cisterns remain
patent and gray-white matter differentiation is preserved.
Redemonstrated is a nondisplaced left paramedian frontal bone fracture
extending from the vertex anteriorly through the left frontal sinus to the
superior orbital rim. Partially imaged paranasal sinuses are notable for an
air-fluid level in the left sphenoid sinus and aerosolized secretions in the
left frontal sinus. The anterior ethmoid air cells also partially opacified.
Mastoid air cells and middle ear cavities are clear. Patient is status post
bilateral maxillary antrostomy and ethmoidectomies.
IMPRESSION:
Relatively stable appearance of multi compartmental intracranial hemorrhages
as described above with mild interval redistribution of subarachnoid
hemorrhages.
Radiology Report
PORTABLE CHEST DATED ___
COMPARISON: Study of earlier the same date.
FINDINGS: Interval placement of right-sided chest tube with apparent
resolution of right pleural effusion but development of a small pneumothorax.
Otherwise, no relevant short interval change since recent study performed
earlier the same date. Please see recently dictated CT torso of ___
for more complete description of cardiothoracic findings, including a
pericardial effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ICH // ? pleural effusion and PTX
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the right chest tube is in unchanged
position. There is unchanged evidence of a small right apical pneumothorax.
The lung volumes have slightly decreased, with development of basal areas of
atelectasis. Borderline size of the cardiac silhouette. No pulmonary edema.
Please see recent CT torso examination for a more detailed description of the
findings, in particular the pericardial effusion.
Radiology Report
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: Syncope
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is mild heterogeneous plaque in the ICA. On the left there is
mild heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 50/15, 45/21, 57/24 cm/sec. CCA peak systolic
velocity is 53 cm/sec. ECA peak systolic velocity is 55 cm/sec. The ICA/CCA
ratio is 1.07. These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 52/16, 61/25, 54/20 cm/sec. CCA peak systolic velocity
65 cm/sec. ECA peak systolic velocity is 59 cm/sec. The ICA/CCA ratio is .93.
These findings are consistent with <40% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA <40% stenosis.
Left ICA <40 stenosis.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ s/p fall w/ L IPH, bl SAH, SDH, L non displ fontal skull frx,
sup orbital rim frx, Zygoma frx // evaluate facial fractures
TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.
Coronal reformatted images were also obtained
DOSE: DLP: 529.40 mGy-cm; CTDI: 26 mGy
COMPARISON: CT head without contrast ___.
FINDINGS:
Postop changes are noted in the sinuses. There is a large left frontal
hematoma and contusion. There is a previously seen nondisplaced fracture of
the left frontal bone extending the left parietal bone with possible
involvement of of frontal sinus although no air-fluid level is seen. There is
a lucency in the zygomatic arch on the right, but no fracture. The cribriform
plates are intact. There is deformity of the nasal bone likely secondary to
fracture however there is no displacement. There is no nasal septal defect.
The anterior clinoid processes are pneumatized. The lamina papyracea is
intact. The nasal septum is midline. There is a mucous retention cyst in the
right frontal sinus. There is mucosal thickening of the ethmoid air cells.
There are multiple mucous retention cysts in the maxillary sinuses
bilaterally. There is mucosal thickening in the sphenoid sinus.
IMPRESSION:
1. Previously demonstrated nondisplaced fracture of the left frontal and
parietal bone which is unchanged in the previous examination. There is
possible involvement of the left frontal sinus however there is no air-fluid
level.
2. Deformity of the nasal bone likely due to fracture without displacement.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ fall on lovenox, L IPH, ___ SAH/SDH, L nondisplaced frontal
frx, sup ortibal, zygoma frx // CT VENOGRAM
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 56 mGy
DLP: 1776.80 mGy-cm
COMPARISON: CT head without contrast ___.
FINDINGS:
There is stable appearance of multi compartmental intracranial hemorrhage
including bifrontal contusions producing local mass effect and edema and
residual blood consistent with subarachnoid hemorrhage as well as trace
interventricular hemorrhage. There is left frontal soft tissue swelling.
Carotid and vertebral arteries and their major branches are patent with no
evidence of stenosis. There is no evidence of aneurysm formation or other
vascular abnormality.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
There is a fracture of the left frontal and parietal bones. The globes are
unremarkable.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p syncopal/fall, chronic pleural effusion s/p R CT removal
// compare to prior
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the right chest tube has been removed.
There is mild elevation of the right hemidiaphragm but no evidence of right
pneumothorax. Unchanged appearance of the cardiac silhouette. A pre-existing
small retrocardiac atelectasis has resolved.
Radiology Report
HISTORY: Trauma.
FINDINGS: In comparison with the study of ___, there again are relatively
low lung volumes. Areas of increased opacification is seen at the bases,
suggestive of atelectatic change. There is evidence of a right pleural
effusion. No definite acute focal pneumonia, though this could be well hidden
on the radiographs are presented.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FOUND DOWN /SDH
Diagnosed with CL SKL VLT FX/MENING HEM, OPEN WOUND OF SCALP, ABRASION HEAD, UNSPECIFIED FALL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ man with HTN, HLD, pleural plaques, and a ___ year
history of progressively worsening exertional dyspnea and
dizziness found down beside his car in a pool of blood with
multiple traumatic injuries, also found to have ascites,
pleural, and pericardial effusions. Pt initially admitted to
Trauma ICU briefly given injuries. No surgical interventions
were necessary. After stabilization, he was transferred to the
medical floor for further management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 12:30AM BLOOD WBC-2.9* RBC-2.55* Hgb-7.2* Hct-23.7*
MCV-93 MCH-28.2 MCHC-30.4* RDW-16.9* RDWSD-56.9* Plt ___
___ 12:30AM BLOOD ___ PTT-29.2 ___
___ 12:30AM BLOOD Glucose-184* UreaN-101* Creat-2.4* Na-141
K-4.4 Cl-104 HCO3-19* AnGap-18
___ 12:30AM BLOOD ALT-18 AST-29 AlkPhos-80 TotBili-0.2
___ 12:30AM BLOOD Albumin-3.4* Calcium-8.2* Phos-4.1
Mg-1.2*
DISCHARGE LABS:
===============
___ 07:21AM BLOOD WBC-4.6 RBC-2.53* Hgb-7.2* Hct-23.0*
MCV-91 MCH-28.5 MCHC-31.3* RDW-17.0* RDWSD-56.5* Plt ___
___ 07:21AM BLOOD Glucose-84 UreaN-91* Creat-2.2* Na-137
K-5.0 Cl-105 HCO3-17* AnGap-15
___ 07:21AM BLOOD Albumin-3.8 Calcium-9.0 Phos-4.9* Mg-2.0
REPORTS:
=========
RUQUS:
1. Redemonstration of nonocclusive thrombus in the main portal
vein, extending
to the left portal vein, similar to prior.
2. Otherwise, patent hepatic vasculature.
3. Redemonstration of a cirrhotic morphology of the liver with
sequela of
portal hypertension including small volume ascites, small right
pleural
effusion and marked splenomegaly.
Renal US:
1. No hydronephrosis of either the right or left kidney.
2. Small amount of echogenic debris within the bladder.
Correlation with
urinalysis is recommended to exclude infection.
3. Trace perihepatic ascites.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atova___ Suspension 1500 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Phenytoin Sodium Extended 100 mg PO TID
5. Spironolactone 100 mg PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
9. Torsemide 20 mg PO BID
10. melatonin 3 mg oral QHS
11. PHENObarbital 64.8 mg PO BID
12. Docusate Sodium 100 mg PO DAILY
13. Allopurinol ___ mg PO DAILY
14. Sodium Bicarbonate 650 mg PO BID
15. Senna 8.6 mg PO QHS
16. CARVedilol 25 mg PO BID
17. Rosuvastatin Calcium 20 mg PO QPM
18. Fenofibrate 48 mg PO DAILY
19. Pantoprazole 40 mg PO Q12H
20. Fleet Enema (Saline) 1 Enema PR Q72HR:PRN constipation
21. Milk of Magnesia 30 mL PO Q24H:PRN Constipation - First Line
22. Bisacodyl 10 mg PR Q72HR:PRN Constipation - Second Line
Discharge Medications:
1. Lactulose 30 mL PO TID
Take as needed for ___ bowel movements a day
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth three times a
day Disp #*1 Bottle Refills:*0
2. rifAXIMin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
4. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
5. Allopurinol ___ mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Atova___ Suspension 1500 mg PO DAILY
9. Bisacodyl 10 mg PR Q72HR:PRN Constipation - Second Line
10. CARVedilol 25 mg PO BID
11. Docusate Sodium 100 mg PO DAILY
12. Fenofibrate 48 mg PO DAILY
13. Fleet Enema (Saline) 1 Enema PR Q72HR:PRN constipation
14. FoLIC Acid 1 mg PO DAILY
15. melatonin 3 mg oral QHS
16. Milk of Magnesia 30 mL PO Q24H:PRN Constipation - First
Line
17. Pantoprazole 40 mg PO Q12H
18. PHENObarbital 64.8 mg PO BID
19. Phenytoin Sodium Extended 100 mg PO TID
20. Rosuvastatin Calcium 20 mg PO QPM
21. Senna 8.6 mg PO QHS
22. Sodium Bicarbonate 650 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=====================
Hepatic encephalopathy
SECONDARY DIAGNOSIS:
=====================
acute kidney injury on chronic kidney disease
urinary tract infection
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
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: PVT
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Ultrasound dated ___.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver
mass.There is small volume ascites. There is a small right pleural effusion.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 2 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 17.7 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
DOPPLER EVALUATION:
Redemonstrated is nonocclusive, eccentric thrombus within the main portal
vein. However, the portal vein remains patent, with flow in the appropriate
direction.
Main portal vein velocity is 15.8 cm/sec.
As before, there is also a nonocclusive thrombus within the left portal vein.
However, the right and left portal veins remain patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
IMPRESSION:
1. Redemonstration of nonocclusive thrombus in the main portal vein, extending
to the left portal vein, similar to prior.
2. Otherwise, patent hepatic vasculature.
3. Redemonstration of a cirrhotic morphology of the liver with sequela of
portal hypertension including small volume ascites, small right pleural
effusion and marked splenomegaly.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with cirrhosis and CKD presented with worsening
renal function. // Assess for hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT torso ___.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Bilateral renal
cysts measure up to 1.3 cm. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally.
Right kidney: 10.7 cm
Left kidney: 11.6 cm
The bladder is moderately well distended, and contains a small amount of
echogenic debris.
Trace perihepatic ascites.
IMPRESSION:
1. No hydronephrosis of either the right or left kidney.
2. Small amount of echogenic debris within the bladder. Correlation with
urinalysis is recommended to exclude infection.
3. Trace perihepatic ascites.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Transfer
Diagnosed with Anemia, unspecified
temperature: 99.0
heartrate: 75.0
resprate: 18.0
o2sat: 98.0
sbp: 141.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ M with h/o B cell lymphoma s/p EPOCH and CHOP in remission,
decompensated cirrhosis of unknown etiology with multiple
complications, including ascites on diuretics and pleurx,
hepatic encephalopathy, varices , seizure d/o, whopresents as
transfer from OSH with fluctuating AMS, ___ on CKD,and
questionable UTI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg swelling
Major Surgical or Invasive Procedure:
IVC filter placement ___
History of Present Illness:
___ yo male with hx of ICH in ___ after sudden left-sided body
weakness, presenting with LLE edema today and DVT found at rehab
(___ at ___. He notes that he
first noticed L lower leg swelling this morning, but without
pain. Prior to his recent stroke, he was active and ambulatory.
At rehab, he has been working to regain strength and work on his
R side which has been weakened following the hemorrhage. He has
not had any shortness of breath or chest pain. No fevers/chills.
No significant pain in his lower extremities. He is not on any
anticoagulation due to his recent hemorrhage.
In the ED, initial vitals were: 97.8 62 132/65 20 100% RA
- Exam notable for: LLE pitting edema
- Labs notable for: normal BMP, normal WBC, H/H 13.3/38.7, INR
1.2
- Imaging notable for: bilaterally ___ u/s: 1. Deep venous
thrombosis involving the left lower extremity veins from the
common femoral through the calf veins. 2. Deep venous thrombosis
involving the right calf veins.
- Patient was given: carvedilol and keppra (home medications)
Patient was admitted for placement of IVC filter
Upon arrival to the floor, patient reports no pain, no fevers,
chills, CP. Is eager to learn about IVC filter, whether it's
effective, and return to rehab to continue making progress with
physical therapy.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
HTN
HLD
DMII on insulin pump
glaucoma
Episode in ___ in which patient had a seizure, was found to
have very abnormal glucose (unclear if high or low), fever, a
presumed virus vs Legionnaire's disease, was intubated and
mechanically ventilated for three weeks
Social History:
___
Family History:
Patient's mother had ___ disease. + family history of
HTN.
No known family history of strokes or cardiovascular disease
Physical Exam:
ADMISSION EXAM:
VITAL SIGNS: 98.0 142/76 68 20 97% RA
GENERAL: Appears well, in NAD. Lying in bed
HEENT: MMM, clear oropharynx, PERRL, anicteric sclera
NECK: supple, no JVP elevation
CARDIAC: faint sounds. RRR, normal s1 s2, no m/r/g
LUNGS: CTAB
ABDOMEN: soft, nontender, nondistended
EXTREMITIES: WWP, LLE with ___ edema up towards knee. No
significant edema on RLE. no tenderness to palpation. No
erythema.
NEUROLOGIC: A&Ox3, able to recall history of present illness.
Strength on RUE and RLE is ___. Strength in LUE and LLE is ___.
Visible L facial droop. No tongue deviation. No dysarthria.
SKIN: No visible ulcers or tears in the skin.
DISCHARGE EXAM:
VITAL SIGNS: 98.3 119 / 65 69 20 96 Ra
GENERAL: Appears well, in NAD. Lying in bed
HEENT: MMM, clear oropharynx, PERRL, anicteric sclera
NECK: supple, no JVP elevation
CARDIAC: faint sounds. RRR, normal s1 s2, no m/r/g
LUNGS: CTAB
ABDOMEN: soft, nontender, nondistended
EXTREMITIES: WWP, LLE with ___ edema up towards knee. No
significant edema on RLE. no tenderness to palpation. 2+ ___
pulses bilaterally.
NEUROLOGIC: A&Ox3, able to recall history of present illness.
Strength on RUE and RLE is ___. Strength in LUE and LLE is ___
in all muscle groups. CNII-XII tested and intact.
Equivocal/minor L facial drop.
SKIN: No visible ulcers or tears in the skin.
Pertinent Results:
=====================
ADMISSION LABS
=====================
___ 01:37PM BLOOD WBC-5.7 RBC-4.41* Hgb-13.3* Hct-38.7*
MCV-88 MCH-30.2 MCHC-34.4 RDW-12.9 RDWSD-41.1 Plt ___
___ 01:37PM BLOOD Neuts-72.0* Lymphs-15.0* Monos-9.0
Eos-3.2 Baso-0.4 Im ___ AbsNeut-4.07 AbsLymp-0.85*
AbsMono-0.51 AbsEos-0.18 AbsBaso-0.02
___ 01:37PM BLOOD ___ PTT-27.2 ___
___ 01:37PM BLOOD Glucose-165* UreaN-21* Creat-0.8 Na-140
K-4.2 Cl-101 HCO3-26 AnGap-17
___ 07:45AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
=========================
DISCHARGE LABS
=========================
___ 07:45AM BLOOD WBC-4.6 RBC-4.28* Hgb-12.8* Hct-37.6*
MCV-88 MCH-29.9 MCHC-34.0 RDW-12.8 RDWSD-40.7 Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-185* UreaN-20 Creat-0.7 Na-141
K-4.0 Cl-101 HCO3-27 AnGap-17
___ 07:45AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
=========================
IMAGING
=========================
Bilateral lower extremity ultrasound ___: 1. Extensive deep
venous thrombosis involving the left lower extremity veins
from the common femoral through the calf veins.
2. Deep venous thrombosis involving the right calf veins.
Medications on Admission:
1. Lisinopril 40 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Cyclobenzaprine 5 mg PO TID:PRN neck pain
8. Flunisolide Inhaler 80 mcg/actuation inhalation BID
9. Loratadine 10 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Glargine 21 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. LevETIRAcetam Oral Solution 500 mg PO BID
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Carvedilol 6.25 mg PO BID
3. Cyclobenzaprine 5 mg PO TID:PRN neck pain
4. Flunisolide Inhaler 80 mcg/actuation inhalation BID
5. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. LevETIRAcetam Oral Solution 500 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Loratadine 10 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Deep venous thrombosis
IVC filter placement
SECONDARY DIAGNOSIS:
Right frontal IPH
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: BILAT LOWER EXT VEINS PORT
INDICATION: History: ___ with LLE edema, found to have DVT on US done at
rehab today// r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
RIGHT: There is normal compressibility, flow, and augmentation of the left
common femoral, femoral, and popliteal veins. There is no color flow or
compressibility in the posterior tibial or peroneal veins.
LEFT: Echogenic material fills the left lower extremity veins, including the
common femoral, femoral, popliteal, and posterior tibial and peroneal veins.
There is no color flow or compressibility. This is compatible with deep
venous thrombosis.
There is normal respiratory variation in the right common femoral vein.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Extensive deep venous thrombosis involving the left lower extremity veins
from the common femoral through the calf veins.
2. Deep venous thrombosis involving the right calf veins.
Radiology Report
INDICATION: ___ year old man with bilateral DVTs, recent ICH// placement of
IVC filter
COMPARISON: ___
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
25mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service
time of 25 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
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.3 min, 68 mGy
PROCEDURE:
1. Left iliac vein and IVC venogram.
2. Infrarenal retrievable IVC filter deployment.
3. Post-filter placement 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. the right neck was prepped and draped in the usual sterile fashion.
Under ultrasound and fluoroscopic guidance, the patent and compressible Right
internal jugular vein was punctured using a 21G micropuncture needle.
Ultrasound images of the access was stored on PACS. A ___ wire was
advanced through the micropuncture sheath into the inferior vena cava. The
sheath of the IVC filter was then placed into the left common iliac vein
A left common iliac and inferior vena cava venogram was performed. Based on
the results of the venogram, detailed below, a decision was made to place a
retrievable filter. An retrievable vena cava filter was advanced over the wire
until the cranial tip was at the level of the inferior margin of the lower
renal vein. The sheath was then withdrawn until the filter was deployed. The
wire and loading device were then removed through the sheath and a repeat
contrast injection was performed, confirming appropriate filter positioning.
The final image was stored on PACS.
The sheath was removed and pressure was held for 10 minutes,at which point
hemostasis was achieved. A sterile dressing was applied.
The patient tolerated the procedure well and there were no immediate post
procedure complications.
FINDINGS:
1. Diminutive right internal jugular Vein, successfully accessed for filter
placement.
2. Patent normal sized, non-duplicated IVC with single bilateral renal veins
and no evidence of a clot.
3. Successful deployment of an infra-renal Denali IVC filter.
IMPRESSION:
Successful deployment of retrievable (Denali) IVC filter.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with h/o right frontal IPH// assess for interval
change
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Head CT ___.
FINDINGS:
Again seen is a right frontal evolving hematoma with surrounding edema. There
is no evidence of new hemorrhage since the prior study. Gradient echo images
demonstrate chronic hemorrhage in the right cerebellar hemisphere in an area
of tissue loss on the prior CT scan. No other areas of hemorrhage are
identified.
Imaging of the remainder of the brain demonstrates scattered white matter
hyperintensity on FLAIR suggesting chronic small vessel ischemia. No masses
are identified. If the etiology of the hematoma is unknown, an MR examination
with contrast may be helpful.
IMPRESSION:
1. Evolving right frontal hematoma with no evidence of new hemorrhage.
2. Chronic blood products in the right cerebellar hemisphere corresponding to
a region of tissue loss on the head CT.
3. No etiology for the hemorrhages detected.
RECOMMENDATION(S): Consider MR with contrast if the etiology of this hematoma
remains unknown.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DVT
Diagnosed with Acute embolism and thrombosis of left femoral vein
temperature: 97.8
heartrate: 62.0
resprate: 20.0
o2sat: 100.0
sbp: 132.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | SUMMARY: ___ h/o HTN, HLD, DMII, recent right frontal IPH who
presents with acute bilateral DVTs. Due to his recent
intracranial hemorrhage, anticoagulation was contraindicated in
this patient. An IVC filter was placed, and he was discharged
back to 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:
fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ESRD on HD (TThSa), CAD, severe spinal stenosis, DM2
c/o feeling unwell since ___. She has been very fatigued.
Patient describes rhinorrhea, sneezing, and malaise. No sore
throat, HA, F/C, coughing, CP, abdominal pain, vomiting. Also
complained of loose watery stool occuring ___ times daily x
5days.
He was seen by his PCP today, where he appeared very tired and
fatigued. Vital signs in office: 97.9 ___ and exam notable
for cool skin. Lungs were on auscultation.
ED Course: Initial Vitals 97.9 76 168/75 16 100%/RA. Rectal exam
- guiaiac negative. Exam otherwise notable for bibasilar rales
and distended but nontender abd. CT abd negative for significant
findings. Chest xray with b/l atelectasis.
Past Medical History:
-CAD s/p CABG ___ with LIMA to LAD, radial to ramus and distal
RCA
-ESRD: HD TuThSat Dialysis Center: ___
-gout
-HTN
-HLD
-spinal stenosis
-neuropathy
-PVD s/p aortobifemoral bypass
-s/p appendectomy, cholecystectomy
-CVA sans residual deficits
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
VS -97.9 76 168/75 16 100%/RA
General: Male appearing younger than stated age in NAD,
appropriate
HEENT: DMM, Sclera anicteric, no conjunctival pallor, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, ___ SEM
Lungs: CTAB. no wheezes, rales, ronchi
Abdomen: soft, non-tender,well-healed surgical scar
Ext: well perfused, Right forarm AVG with 2cm thrill,
nonerythematous, nonpainful. 2+ pulses, no clubbing, cyanosis
or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
On discharge:
VS T98.4 112/70 62 20 95%RA
GENERAL - comfortable,eating breakfast
HEENT - NC/AT, PEERLA, EOMI, MMM
NECK - supple, no LAD
LUNGS - CTAB. No crackles or wheezes
HEART - RRR, ___ SEM
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Right forarm AVG with palpable thrill, nonerythematous,
nonpainful.
Pertinent Results:
LABS:
On admission ___ 04:35PM)
WBC-12.6*# RBC-3.81* Hgb-11.4* Hct-33.7* MCV-88 MCH-29.9
MCHC-33.8 RDW-13.9 Plt ___ Neuts-82.2* Lymphs-13.2* Monos-3.3
Eos-0.8 Baso-0.4
Glucose-151* UreaN-19 Creat-2.7* Na-136 K-3.5 Cl-96 HCO3-28
AnGap-16
ALT-38 AST-35 LD(LDH)-203 AlkPhos-57 TotBili-0.3 Lipase-45
Lactate-1.1
.
On discharge ___ 11:00AM)
WBC-10.7 RBC-3.50* Hgb-10.5* Hct-30.7* MCV-88 MCH-30.0 MCHC-34.3
RDW-14.2 Plt ___
Glucose-138* UreaN-33* Creat-3.9*# Na-135 K-3.5 Cl-98 HCO3-27
AnGap-14
.
DIAGNOSTICS:
CT ABD & PELVIS W/O CONTRAST ___ IMPRESSION:
1. No acute intra-abdominal process, although complete
evaluation is limited by lack of IV contrast. No bowel
obstruction. Fluid within small and large bowel is non-specific
but could be seen with mild ileus or enteritis.
2. Aortobifemoral bypass, incompletely evaluated on this
noncontrast study.
3. Dense coronary artery calcifications.
.
CHEST (PA & LAT) ___ IMPRESSION: Findings suggesting minor
left basilar atelectasis without definite evidence for
pneumonia.
Medications on Admission:
AMLODIPINE
CARVEDILOL
CLOPIDOGREL
FLUNISOLIDE
FOLIC ACID
GABAPENTIN
ISOSORBIDE MONONITRATE
LACTULOSE
OMEPRAZOLE
ROSUVASTATIN
TEMAZEPAM
ASPIRIN
CALCIUM ACETATE
POLYETHYLENE GLYCOL
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. flunisolide 25 mcg (0.025 %) Spray, Non-Aerosol Sig: Two (2)
sprays each nostril Nasal twice a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO at bedtime.
9. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) mL
PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. temazepam 15 mg Capsule Sig: One (1) Capsule PO at bedtime.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 min PRN as needed for chest pain.
15. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS). Capsule(s)
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Viral syndrome
Secondary diagnosis:
ESRD on HD
CAD
gout
hyper cholesterolemia
HTN
Spinal stenosis
PVD s/p aortobifemoral bypass
s/p appendectomy
s/p cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Prior pneumonia and feeling poorly.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The patient is status post coronary artery bypass graft surgery. A
dual-lead pacemaker/ICD device appears in a similar position. The cardiac,
mediastinal and hilar contours appear unchanged, allowing for differences in
technique. The lung volumes are very low. Particularly in that setting,
minimal left basilar opacities are probably associated with minor atelectasis.
The lungs appear otherwise clear. There is no pleural effusion or
pneumothorax. The bones are probably demineralized to some degree.
IMPRESSION: Findings suggesting minor left basilar atelectasis without
definite evidence for pneumonia.
Radiology Report
CLINICAL HISTORY: ___ man with distended abdomen and chest x-ray
evidence of dilated bowel. Evaluate for obstruction or other intra-abdominal
pathology. Patient has ESRD and is on hemodialysis.
COMPARISON: CT L-SPINE ___.
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness without oral or intravenous
contrast. Intravenous contrast was not administered due to patient's
creatinine of 2.7.
CT ABDOMEN: The visualized lung bases demonstrate mild dependent bibasilar
atelectasis. There is a small fat-containing left Bochdalek hernia. There is
no pleural or pericardial effusion. Dense atherosclerotic calcifications are
seen in the coronary arteries. Pacemaker lead ends in the expected locations
of the right atrium and right ventricle.
CT ABDOMEN: Evaluation of the intra-abdominal organs is limited without
intravenous contrast. The liver, spleen and bilateral adrenal glands are
normal. The gallbladder is not visualized. The pancreas is atrophic but
otherwise normal. The kidneys are atrophic with renal artery calcifications
compatible with patient's known end stage renal disease. There is no
hydronephrosis or stone identified. A 3.2 x 3.0 cm hypodensity in the right
interpolar region is consistent with a simple cyst.
There is fluid within the mildly prominent small bowel and colon but without
bowel wall thickening or bowel obstruction. A 6 mm hypodensity in the third
part of the duodenum has fat attenuation consistent with small lipoma (2:39).
Dense atherosclerotic calcifications are seen in the normal caliber native
aorta with an aortobifemoral bypass, the patency of which cannot be assessed
without IV contrast. No pathologically enlarged mesenteric or retroperitoneal
lymph nodes are identified. There is no free fluid and no free air.
CT PELVIS: The rectum, sigmoid, bladder, prostate, and seminal vesicles are
normal. There is no free fluid and no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
Degenerative changes in the lower lumbar facet joints are noted. Grade 1
anterolisthesis of L4 on L5 is unchanged from ___.
IMPRESSION:
1. No acute intra-abdominal process, although complete evaluation is limited
by lack of IV contrast. No bowel obstruction. Fluid within small and large
bowel is non-specific but could be seen with mild ileus or enteritis.
2. Aortobifemoral bypass, incompletely evaluated on this noncontrast study.
3. Dense coronary artery calcifications.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPOTENSION
Diagnosed with OTHER MALAISE AND FATIGUE, SYNCOPE AND COLLAPSE, DIARRHEA, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA
temperature: 97.9
heartrate: 76.0
resprate: 16.0
o2sat: 100.0
sbp: 168.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | ___ M hx of ESRD on HD, HTN, CAD s/p CABG presenting with
fatigue in the setting of 1 week of loose stool.
.
# FATIGUE: During PCP evaluation patient blood pressure was
110/80 which was evaluated as a relative hypotension given
patient's baseline. There was concern for endovascular infection
given recent cannulation of AVG a week prior. However, cultures
from dialysis 4d before admission were neg. As patient had poor
PO intake and loose stools, it is likely the cause of the
relative hypotension was secondary to low intravascular volume.
Amlodipine was held overnight and patient received IVF. Blood
pressure was 130-160s during his admission. Patient measures
blood pressure at home as was instructed to hold amlodipine if
systolic pressure was below 120. Patient will see his primary
care doctor on the day after discharge. Patient's main complaint
of fatigue and poor appetite coincided with loose stools for 5
days. Patients white count was elevated on admission to 12.6.
Abdominal CT scan did not show any acute abnormalities. No
evidence of colitis. Guaiac negative. LFTs, lipase, and lactate
were within normal limits. Symptoms were likely due to a viral
syndrome. ___ normalized and patient tolerated a full breakfast
and felt much improved on the day of discharge. Patient will
receive physical therapy at home.
.
# ESRD: Patient HD scheduled is ___ at ___
___. Patient will return to HD on the day after discharge.
Will continue Calcium acetetate for phosphate binding.
.
#ANEMIA: Likely of chronic disease. Stable from prior. Will
follow-up with primary care doctor within ___ week of discharge.
.
# CAD: s/p CABG Aspirin and beta blocker and statin were
continued.
.
# PVD s/p AORTOBIFEMORAL BYPASS: Distal pulses were intact on
exam. Aspirin and plavix were continued.
.
# DM2: Diet controlled.
.
# Chronic pain/spinal stenosis: Gabapentin and tylenol were
continued.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness, vomiting, diarrhea
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
___ ___ speaking with history of CAD s/p PCI in ___
with recent admission from ___ to ___ for chest pain
with positive stress test with inducible wall motion
abnormalities on stress echo s/p coronary cath on ___
now presenting with 2 days of abdominal pain, nausea/vomiting,
diarrhea and persistent dizziness worsened with walking.
Son-in-law ___.
Has been constantly dizzy and orthostatic since discharge. Had
several episodes of non-bloody emesis per day x 3 days after
being discharge, last episode this AM at ___. Also had
dark watery diarrhea, without frank blood but black in color.
Had 3 episodes of diarrhea this AM which cleared and was tan in
color. Went to PCP at ___. Per ED note, no recent
travel, sick contacts, or NSAIDs/steroid/alcohol use. Compliant
with medications. On exam in ED noted to be breathing
comfortably on room air without increased work of breathing,
lung auscultation without crackles or wheezes, lower extremities
without edema. Stool guaiac negative. Vitals noted to be:
Afebrile, heart rates in the ___, BPs 100s-130s, O2 100% on
RA. Received carvedilol, aspirin, isosorbide mononitrate,
clopidogrel, losartan, IV fluids.
During recent admission, it was concluded he had some slow flow
in the distal circumflex assistant with microvascular
dysfunction but there was no intervention of the lesion. He was
started on carvedilol for blood pressure control, dual
antiplatelet therapy, and discharged.
Upon arrival to the floor, patient appeared comfortably, without
increased work of breathing on room air. Patient endorsed some
abdominal pain (midline), ___. Also said he had been
experiencing some chest pain that started after CT scan today
~6pm, mild and dull, non-radiating, ___. Pain is not
constant but comes and goes, worsened with exertion and
inspiration. Also with mild shortness of breath. No
palpitations. Was nauseous and gagging on interview but without
emesis. Denies hematemesis or coughing blood. No increased
cough, back pain.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Unknown coronary anatomy
- ECHO: LVEF: 65%, mild LVH, mild AR, mild MR
- Normal sinus rhythm
3. OTHER PAST MEDICAL HISTORY
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: 24 HR Data (last updated ___ @ 2316)
Temp: 98.4 (Tm 98.5), BP: 119/71 (119-145/71-88), HR: 70
(70-79), RR: 18 (___), O2 sat: 99%, O2 delivery: Ra
GENERAL: Alert and interactive. Intermittently nauseous
HEENT: NCAT. Sclera anicteric and without injection.
NECK: Supple
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing.
Chest wall tender to palpation
BACK: No spinous process tenderness
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: WWP
NEUROLOGIC: Alert, answering questions appropriately, moves all
extremities
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Alert and interactive
HEENT: NCAT. Sclera anicteric and without injection.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing. Chest wall non-tender to palpation
ABDOMEN: Normal bowels sounds, non distended, mild tenderness to
palpation in the epigastric region. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: WWP
NEUROLOGIC: Alert, answering questions appropriately, moves all
extremities
Pertinent Results:
ADMISSION LABS
==============
___ 11:45AM BLOOD WBC-7.7 RBC-2.83* Hgb-8.2* Hct-25.2*
MCV-89 MCH-29.0 MCHC-32.5 RDW-15.9* RDWSD-51.7* Plt ___
___ 11:45AM BLOOD ___ PTT-26.2 ___
___ 11:45AM BLOOD Glucose-104* UreaN-45* Creat-1.6* Na-139
K-6.7* Cl-106 HCO3-20* AnGap-13
___ 11:45AM BLOOD ALT-18 AST-53* AlkPhos-52 TotBili-0.8
___ 11:45AM BLOOD Albumin-4.0 Calcium-8.9 Phos-3.8 Mg-2.0
___ 01:30PM BLOOD calTIBC-391 ___ Ferritn-21* TRF-301
DISCHARGE LABS
==============
___ 03:15PM BLOOD WBC-6.6 RBC-3.29* Hgb-9.5* Hct-28.8*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.0 RDWSD-48.5* Plt ___
___ 03:15PM BLOOD Glucose-107* UreaN-15 Creat-1.5* Na-141
K-3.9 Cl-106 HCO3-22 AnGap-13
___ 06:49AM BLOOD ALT-14 AST-20 LD(LDH)-161 AlkPhos-66
TotBili-0.3
RELEVANT IMAGING
================
___ Liver or Gallbladder U/S
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. Infrarenal abdominal aortic aneurysm with diameter measuring
3.4 cm.
RECOMMENDATION(S): Follow-up imaging for monitoring of
infrarenal abdominal aortic aneurysm is recommended in 12
months.
___ CT abd/pelvis w/ con
IMPRESSION:
1. Focal ectasia of the infrarenal abdominal aorta measuring up
to 2.8 cm just proximal to the aortic bifurcation, with
eccentric mural thrombus.
2. Borderline aneurysmal dilatation of the bilateral iliac
arteries measuring up to 1.5 cm bilaterally, just distal to the
aortic bifurcation.
3. No evidence of retroperitoneal hemorrhage or aneurysm
rupture.
4. Colonic diverticulosis, most notably of the right colon,
without evidence of acute diverticulitis.
___ EGD
1. Ulcer in pre-pyloric region
2. Ulcer in duodenal bulb
3. Irregular z-line in the gastroesophageal junction
4. Very mild erythema in the stomach compatible with gastritis
___ CT Abd/pel w/o contrast
IMPRESSION:
1. No retroperitoneal hematoma. Active GI bleeding cannot be
assessed due to lack of IV contrast.
2. Unchanged focal ectasia of the infrarenal abdominal aorta
prior to
bifurcation measuring 2.8 cm.
___ Liver/gallbladder U/S
IMPRESSION:
1. Hepatic parenchyma appears within normal limits without
focal lesions. No intrahepatic biliary dilation.
2. Several foci of increased echogenicity within the
gallbladder wall, likely representing focal adenomyomatosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CARVedilol 12.5 mg PO BID
2. Losartan Potassium 25 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Amoxicillin 1000 mg PO Q12H
RX *amoxicillin 500 mg 2 capsule(s) by mouth Q12hr Disp #*44
Capsule Refills:*0
2. Clarithromycin 500 mg PO Q12H Duration: 14 Days
RX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day Disp
#*22 Tablet Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8Hr PRN Disp #*15
Tablet Refills:*0
4. Pantoprazole 40 mg PO Q12H Duration: 1 Month
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*90 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. HELD- CARVedilol 12.5 mg PO BID This medication was held. Do
not restart CARVedilol until discussion with your Cardiologist
9. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until discussion with your
Cardiologist
10. HELD- Isosorbide Mononitrate (Extended Release) 60 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until discussion with your
Cardiologist
11. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until instructed by your
PCP
___:
Home
Discharge Diagnosis:
PRIMARY
=======
Normocytic Normochromic Anemia
Melena
Urinary Tract Infection
Acute Renal Failure
SECONDARY
=========
Angina
Coronary Artery Disease
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with n/v and RUQ pain x2 days w/ history of HLD//
eval for gallstones
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Renal ultrasound ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 mm
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 8.8 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis. Renal cysts
are again noted, more completely evaluated on recent dedicated renal
ultrasound.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. Infrarenal abdominal aortic aneurysm with diameter measuring 3.4 cm.
RECOMMENDATION(S): Follow-up imaging for monitoring of infrarenal abdominal
aortic aneurysm is recommended in 12 months.
Radiology Report
EXAMINATION: Mesenteric CTA
INDICATION: NO_PO contrast; History: ___ with infrarenal Aoritc aneurysm with
10 pt crit drop in 10 days; fast negativeNO_PO contrast// eval for RPH
TECHNIQUE: Pre and post contrast: MDCT axial images were acquired through the
abdomen and pelvis prior to and following intravenous contrast administration
in both the arterial and portal venous phases.
Oral contrast was not administered.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.9 s, 54.1 cm; CTDIvol = 4.1 mGy (Body) DLP = 224.4
mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP =
9.1 mGy-cm.
3) Spiral Acquisition 6.9 s, 54.3 cm; CTDIvol = 15.4 mGy (Body) DLP = 837.6
mGy-cm.
4) Spiral Acquisition 6.9 s, 54.3 cm; CTDIvol = 15.5 mGy (Body) DLP = 843.4
mGy-cm.
Total DLP (Body) = 1,914 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Minimal lingular atelectasis is seen. There is minimal right
base dependent atelectasis. There is no evidence of pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits and
demonstrates likely adenomyomatosis at the fundus..
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 are multiple hypodensities bilaterally measuring up to 2.4 cm in the
right upper pole and 1.6 cm in the left midpole. Additional subcentimeter
hypodensities bilaterally are too small to characterize. There is no evidence
of suspicious focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There are multiple
colonic diverticuli throughout the colon,, but most notably in the ascending
colon, without wall thickening or adjacent fat stranding. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate calcifications are seen. 111
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is focal ectasia of the infrarenal abdominal aorta just
proximal to the aortic bifurcation measuring up to 2.8 cm in maximum diameter
(5: 101). There is also focal ectasia of the bilateral iliac arteries
measuring up to 1.5 cm on the right and 1.6 cm on the left (5:116, 120).
Moderate atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute
fracture.Mild degenerative changes are seen along the imaged spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Focal ectasia of the infrarenal abdominal aorta measuring up to 2.8 cm just
proximal to the aortic bifurcation, with eccentric mural thrombus.
2. Borderline aneurysmal dilatation of the bilateral iliac arteries measuring
up to 1.5 cm bilaterally, just distal to the aortic bifurcation.
3. No evidence of retroperitoneal hemorrhage or aneurysm rupture.
4. Colonic diverticulosis, most notably of the right colon, without evidence
of acute diverticulitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new fever// Fever of unclear etiology
TECHNIQUE: Chest AP
COMPARISON: None
FINDINGS:
Low lung volumes. Cardiomediastinal hilar contours are unremarkable. There
is dense retrocardiac opacification which may represent pneumonia in the
appropriate clinical setting. However, atelectasis cannot be excluded. No
evidence of pulmonary edema. No evidence of pleural effusion or pneumothorax.
Visualized osseous structures are unremarkable.
IMPRESSION:
1. Given the lack of a lateral image, dense retrocardiac opacification may
represent pneumonia in the appropriate clinical setting, however atelectasis
cannot be excluded.
2. No evidence of pulmonary edema.
3. No evidence of pleural effusion or pneumothorax.
Radiology Report
INDICATION: ___ year old man with recent N/V/melena, with acute onset
hypotension and hct drop. Pt has ___// ?bleed/hematoma?
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 58.2 cm; CTDIvol = 12.6 mGy (Body) DLP = 730.0
mGy-cm.
Total DLP (Body) = 730 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: No retroperitoneal hematoma.
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is unremarkable
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is not enlarged.
LYMPH NODES: No enlarged abdominal, pelvic, or inguinal lymph nodes.
VASCULAR: Focal ectasia of the infrarenal abdominal aorta prior to bifurcation
measures 2.8 cm, unchanged. Mild atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes of the lumbar spine are mild.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No retroperitoneal hematoma. Active GI bleeding cannot be assessed due to
lack of IV contrast.
2. Unchanged focal ectasia of the infrarenal abdominal aorta prior to
bifurcation measuring 2.8 cm.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with concerns for abdominal infection.// Concern
for cholangitis vs choledocholithiasis vs other sources of
infection/inflammation.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 6 mm
GALLBLADDER: Several foci of increased echogenicity within the gallbladder
wall with posterior comet tail artifact, likely representing focal
adenomyomatosis of the gallbladder.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 9.4 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 11.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Hepatic parenchyma appears within normal limits without focal lesions. No
intrahepatic biliary dilation.
2. Several foci of increased echogenicity within the gallbladder wall, likely
representing focal adenomyomatosis.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Dizziness, n/v/d
Diagnosed with Dizziness and giddiness, Nausea with vomiting, unspecified
temperature: 98.0
heartrate: 79.0
resprate: 16.0
o2sat: 100.0
sbp: 103.0
dbp: 74.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ is a ___ ___ speaking with history of CAD s/p
PCI in ___ with recent coronary cath w/o stent placement,
who presented with N/V, melena, and an acute anemia, concerning
for GIB. He underwent EGD on ___ which did not show any active
areas of bleeding. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Amoxapine / dapsone
Attending: ___.
Chief Complaint:
Fever, Confusion
Major Surgical or Invasive Procedure:
___ - ___ Planning Arteriogram
History of Present Illness:
Mr. ___ is a ___ male with multiple myeloma
s/p autologous SCT and metastatic carcinoma of unknown primary
(presumed colon) on palliative FOLFOX (currently on hold) who is
admitted for fever and AMS.
The morning of admission at around 3AM he felt warm. His wife
took his temperature and at was 101.8. He was confused but not
as badly as in the past. His wife gave a dose of Tylenol. He
denies sick contacts and recent travel. He reports intermittent
fevers at night with sweats and chills. His wife called the
___ fellow ___ referred the patient to the ED.
The patient has recently been off chemotherapy given difficulty
with cytopenias and limited disease burden beyond the colon and
liver. He had recently been evaluated by ___ for consideration of
embolization and was planned for first imaging on ___. Of
note, he has had frequent AMS/febrile episodes in the past,
usually pertaining to pneumonia.
On arrival to the ED, vitals were 99.4 90 111/63 18 97% RA. Labs
were notable for WBC 11.6 (76% PMNs, 8% lymphs), H/H 7.4/23.5,
Plt 87, Na 131, K 3.7, Cl 95, CO2 20, BUN/Cr ___, ALT 41/AST
95, ALP 441, Tbili 0.7, lactate 1.3, and UA with trace leuks,
large blood, 11 WBCs, and bacteruria. CXR was negative for
pneumonia. Patient was given 1L NS. Prior to transfer, vitals
were 99.0 77 111/58 16 100% RA.
On arrival to the floor, the patient denies pain. He reports
generalized weakness and hematuria after catheterizations.
Patient denies headache, vision changes,
dizziness/lightheadedness, sinus pressure, nasal congestion,
sore throat, shortness of breath, cough, chest pain,
palpitations, abdominal pain, nausea/vomiting, diarrhea,
hematochezia/melena, and dysuria.
Past Medical History:
- ___ Diagnosed with multiple myeloma, treated with up front
lenolidomide plus dexamethasone
- ___ Underwent autologous SCT with melphalan plus dendritic
cell fusion vaccine ___ ___ Recurrent myeloma. Restart lenalidomide.
- ___ Progressive disease. Start bortezomib.
- ___ Progressive disease after 35 cycles of bortezomib.
- ___ C1D1 ___ ___ of ___, PD1 antibody
therapy
- ___ Progressed on therapy.
- ___ Started pomalidomide bortezomib dexamethasone
- ___ Progressive anemia of unclear cause.
- ___ Began to have intermittent drenching nightsweats
- ___ EGD and colonoscopy ___
- ___ S/p 19 cycles of pomalidomide bortezomib dexamethasone
- ___ CT torso showed multiple liver mets, no obvious
primary
- ___ Liver biopsy showed moderately differentiated
adenocarcinoma CK20+ CDX2+ CK7- P63- TTF1- most consistent with
a colorectal or small bowel primary, but cannot exclude an upper
GI primary.
- ___ Capsule endoscopy ___
- ___ CT torso showed confluent liver mets
- ___ C1D1 FOLFOX6
- ___ C1D15 ___ (no bolus ___, LV 200 mg/m2, ci5FU
1800 mg/m2) dose reduced for ___, mucositis, cytopenias
- ___ C2D1 ___ (no bolus ___, LV 200mg/m2 ci5FU
1800mg/m2)
- ___ MR abdomen and CT chest showed stable extensive
intraabdominal metastatic disease
- ___ C3D1 ___ (no bolus ___ LV 200mg/m2, ci5FU
1800mg/m2)
- ___ C4D1 FOLFOX (oxaliplatin 50 mg/m2, no bolus ___, LV
200 mg/m2, ci5FU 1800 mg/m2)
- ___ CT chest and MR abdomen and pelvis showed stable
disease
- ___ C5D1 FOLFOX (oxaliplatin 50 mg/m2, no bolus ___, LV
200 mg/m2, ci5FU 1800 mg/m2)
- ___ Held chemo for thrombocytopenia
- ___ dose ___ FOLFOX (oxaliplatin 50 mg/m2, no bolus ___,
LV 200 mg/m2, ci5FU 1800 mg/m2) Q21 days
- ___ dose ___ FOLFOX (oxaliplatin 50 mg/m2, no bolus ___,
LV 200 mg/m2, ci5FU 1800 mg/m2) Q21 days delayed for febrile
neutropenia
- ___ MR abdomen and CT chest showed progression of liver
mets
- ___ PET CT showed asymmetric wall thickening and FDG
avidity within the proximal ascending colon. Findings may be
secondary to underdistention, but primary GI malignancy is not
excluded. Innumerable large FDG avid hepatic metastatic lesions.
Solitary FDG avid osseous lesion within the right coracoid
process, which may represent a pathologic fracture in the
setting a metastatic lesion or multiple myeloma.
PAST MEDICAL HISTORY:
1. Multiple myeloma, s/p autologous SCT while on chemotherapy.
2. Squamous cell carcinoma of the skin.
3. BPH.
4. Self-catheterization for urinary retention.
5. Gout.
6. Hypertension.
7. Hyperlipidemia.
8. Asthma.
9. Carcinoma of unknown primary, as noted above.
Social History:
___
Family History:
1. Mother with diabetes and hypertension.
2. Father was a smoker, had CVA and CAD.
3. No cancer in the family.
Physical Exam:
========================
Admission Physical Exam:
========================
VS: Temp 98.1, BP 118/74, HR 66, RR 16, O2 sat 98% RA.
GENERAL: Pleasant man, in no distress lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: Alert, oriented, good attention and linear thought, CN
II-XII intact, FTN and HTS intact. Strength full throughout.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
========================
Discharge Physical Exam:
========================
VS: Temp 98.5, BP 143/73, HR 60, RR 18, O2 sat 97% RA.
Exam otherwise unchanged.
Pertinent Results:
===============
Admission Labs:
===============
___ 05:15AM BLOOD WBC-11.6* RBC-2.40* Hgb-7.4* Hct-23.5*
MCV-98 MCH-30.8 MCHC-31.5* RDW-18.5* RDWSD-66.6* Plt Ct-87*
___ 05:15AM BLOOD Neuts-76.2* Lymphs-8.1* Monos-14.6*
Eos-0.3* Baso-0.2 Im ___ AbsNeut-8.81* AbsLymp-0.94*
AbsMono-1.69* AbsEos-0.04 AbsBaso-0.02
___ 05:03AM BLOOD ___
___ 05:15AM BLOOD Glucose-102* UreaN-20 Creat-1.4* Na-131*
K-3.7 Cl-95* HCO3-20* AnGap-20
___ 05:15AM BLOOD ALT-41* AST-95* AlkPhos-441* TotBili-0.7
___ 05:15AM BLOOD Albumin-3.0*
___ 05:03AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.8
___ 05:03AM BLOOD CEA-74.6*
===============
Discharge Labs:
===============
___ 04:16AM BLOOD WBC-8.1 RBC-2.12* Hgb-6.6* Hct-20.8*
MCV-98 MCH-31.1 MCHC-31.7* RDW-18.2* RDWSD-65.4* Plt Ct-96*
___ 04:16AM BLOOD Glucose-82 UreaN-13 Creat-1.2 Na-137
K-3.5 Cl-106 HCO3-24 AnGap-11
___ 04:16AM BLOOD ALT-34 AST-64* AlkPhos-392* TotBili-0.4
=============
Microbiology:
=============
___ Urine Culture - Yeast
___ Blood Culture x 2 - Pending
========
Imaging:
========
CXR ___
Impression: No pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH QID:PRN shortness of
breath/wheezing
3. Atovaquone Suspension 1500 mg PO DAILY
4. Bisacodyl 10 mg PO QHS:PRN constipation
5. Desipramine 20 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN nasal
congestion
7. LOPERamide 2 mg PO QID:PRN diarrhea
8. LORazepam 0.5 mg PO Q8H:PRN anxiety
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. QUEtiapine Fumarate 100 mg PO QHS
11. Senna 17.2 mg PO QHS
12. Tamsulosin 0.4 mg PO QHS
13. Clindamycin 300-600 mg PO ASDIR
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH QID:PRN shortness of
breath/wheezing
3. Atovaquone Suspension 1500 mg PO DAILY
4. Bisacodyl 10 mg PO QHS:PRN constipation
5. Clindamycin 300-600 mg PO ASDIR
6. Desipramine 20 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN nasal
congestion
8. LOPERamide 2 mg PO QID:PRN diarrhea
9. LORazepam 0.5 mg PO Q8H:PRN anxiety
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. QUEtiapine Fumarate 100 mg PO QHS
12. Senna 17.2 mg PO QHS
13. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnosis:
- Fever
- Encephalopathy
- Metastatic Carcinoma of Unknown Primary
- Multiple Myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fever // eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___.
CT chest from ___.
FINDINGS:
Right chest Port-A-Cath terminates in the low SVC, unchanged from ___.
Lung volumes are low and there is mild scarring at the lung bases without
evidence of opacity concerning for pneumonia. Mediastinal contour, hila, and
cardiac silhouette are stable.
IMPRESSION:
No pneumonia.
Radiology Report
INDICATION: ___ year old man with mCRC to the liver // Please perform Y90
planning
COMPARISON: MRI of the abdomen on ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was not provided. 1% lidocaine was injected in
the skin and subcutaneous tissues overlying the access site
MEDICATIONS: 3000 units of intra-arterial heparin, 200 mcg of nitroglycerin
and 2.5 mg of verapamil into the radial artery after sheath placement.
CONTRAST: ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: ___ Min, 205 mGy
PROCEDURE:
1. Left radial artery access
2. SMA arteriogram
3. Celiac arteriogram
4. Celiac arteriogram with cone beam CT
5. Common hepatic arteriogram.
6. Right hepatic arteriogram from treatment position.
7. Injection of 4 mCi of Technetium ___
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The left wrist was
prepped and draped in the usual sterile fashion.
Using palpation, the left radial artery was identified. After injection of 1%
subcutaneous lidocaine, a micropuncture needle was advanced into the radial
artery until brisk blood return was identified. An 018 Nitinol wire was
easily advanced into the radial artery. After skin ___ the micropuncture
needle was exchanged for a 5 ___ Glide sheath. The sheath was flushed and
3000 units of intra-arterial heparin, 200 mcg of nitroglycerin and 2.5 mg of
verapamil were injected into the radial artery. The sheath was connected to a
pressurized bag of heparinized saline.
The pre loaded ___ 5 ___ catheter and exchange length Glidewire were
advanced under fluoroscopic guidance into the aortic arch. Given that the
glide wire could not be advanced into the descending aorta, the ___ catheter
was exchanged for ___ 1 glide catheter. The ___ 1 glide catheter was used
to access the descending aorta and the Glidewire was advanced into the
descending aorta. The ___ 1 glide catheter was exchanged for the ___
catheter. The wire was then removed in the catheter was used to engage the
superior mesenteric artery. After a contrast injection, SMA arteriogram was
performed to assess extrahepatic supply.
The catheter was then retracted and advanced into the celiac artery. After
contrast injection, a celiac arteriogram was performed. A cone beam CT
arteriogram was performed.
Rotational cone-beam CT angiography was performed to help delineate the
anatomy. Multiplanar CT images were reconstructed and 3D volume-rendered
images of the arterial anatomy required post-processing on an independent
workstation under direct physician ___ (Dr. ___. These images were
used in the interpretation, decision making for intervention and reporting of
this procedure. The catheter was then advanced into the common hepatic artery
through the celiac artery. Positioning was confirmed with a contrast
injection. A common hepatic arteriogram was performed. Next, a renegade ___
microcatheter and double angled Glidewire were used to access the right
hepatic artery. The wire was removed and right hepatic arteriogram was
performed.
At this point nuclear medicine brought 4 mCi of technetium ___ M to the ___
suite. The dose and patient identifying information was confirmed using 2
distinct patient identifiers. The dose was then received an injected into the
right hepatic artery at the treatment position.
The catheter and micro catheter were then removed from the sheath using
radiation safety precautions. A preliminary radiation safety check was
performed via the representative of the radiation safety office.
A TR band was placed over the patient's left wrist. After inflation of the
band with 18 cc of air, the sheath was removed. The band was slowly deflated
until bleeding was noted at the skin entry site. An additional 2 cc of air
was introduced into the band. The total volume of air in the band is 9 cc.
The patient tolerated the procedure well and was transported on a stretcher to
nuclear medicine for scintigraphy study to determine the lung shunt fraction.
FINDINGS:
1. SMA arteriogram demonstrates conventional anatomy without evidence of
replaced or accessory hepatic arteries arising from the SMA.
2. Celiac arteriogram demonstrates an accessory left hepatic artery arising
from the left gastric artery. Right and left hepatic arteries arise from the
proper hepatic artery just after the takeoff of the gastroduodenal artery.
There is a right gastric artery arising from the proximal left hepatic artery.
3. Celiac arteriogram with cone beam CT better delineates the hepatic arterial
anatomy and demonstrates that the accessory left hepatic artery arising from
the left gastric artery supplies segment 4A, 4B and 3. The left hepatic
artery supplies segments 2 and 3. Again seen is the right gastric artery
arising from the proximal left hepatic artery.
4. Common hepatic arteriogram again demonstrates the right and left hepatic
arteries as described above.
5. Right hepatic arteriogram demonstrates standard arterial supply to the
right lobe of the liver.
6. Successful injection of Tc99m from the treatment position in the right
hepatic artery.
IMPRESSION:
Planning arteriography for Yttrium 90 radioembolization as above. Results of
pulmonary scintigraphy will be reported separately.
RECOMMENDATION(S): The patient is scheduled for a yttrium 90
radioembolization treatment arteriography in the near future.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 99.4
heartrate: 90.0
resprate: 18.0
o2sat: 97.0
sbp: 111.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with multiple myeloma
s/p autologous SCT and metastatic carcinoma of unknown primary
(presumed colon) on palliative FOLFOX (currently on hold) who is
admitted for fever and AMS.
# Fever
# Leukocytosis
# Encephalopathy: No clear localizing symptoms. Patient with
mild leukocytosis. LFTs mildly elevated but this has been
chronic. CXR without pneumonia. UA with trace leuks and 11 WBCs
but occassionaly self catheterizes daily. ___ be related to
viral process but no obvious symptoms. Also consider tumor fever
given enlarging liver metastases. Encephaloopathy has resolved
and likely in the setting of fever. He did not receive any
antibiotics and had no further fevers. His urine culture grew
yeast which is likely non-pathogenic and secondary from bladder
catherizations. His blood cultures were pending at discharge.
# Hyponatremia
# Acute Kidney Injury: ___ likely related to hypovolemia in the
setting of decreased PO intake and fever. Improved with IVF.
# Anemia: He received 1 unit PRBCs prior to discharge. No
evidence of active bleeding.
# Metastatic Carcinoma of Unknown Primary (Presumed Colon):
FOLFOX on hold. His most recent MRI demonstrates an increase in
size of multiple lesions. He had the planning for Y90
radioembolization completed during his hospitalization.
# IgG kappa MM: s/p autologous SCT. C/B JB-proteinuria with
Stage II-III CKD. Myeloma therapy has been on hold ISO GI
malignancy tx. Continued acyclovir and atovaquone.
# Asthma: Continued home albuterol.
# BPH: Continued home tamsulosin.
# Insomnia: Continued home seroquel.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Stearate / Epinephrine / Keflex / Bactrim
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of paroxysmal
atrial fibrillation (on Amiodarone & Coumadin), diastolic
cardiomyopathy (on Lasix), HTN, HLD, & mild AS (TTE in ___ who
presents with 4 days of increased dyspnea on exertion & ___
swelling.
She was at her baseline state of health until 1 week ago, when
she developed a cold. She has had a runny nose & cough
throughout this week. No shortness of breath, diarrhea, or
dysuria. Four days ago, she started having dyspnea on exertion.
This has gotten progressively worse throughout the week. She has
orthopnea at baseline, no change. She denies PND, but does have
increased ___ swelling. She continues to take her Lasix three
times per week, and doesn't think she has missed a dose. No
recent dietary changes, and she adheres to a healthy diet. No
recent falls.
Baseline home weight around 148lbs per outpatient cardiology
notes. Home BPs have ranged mostly in the SBP 130-150s per ___.
In the ED initial vitals were: afebrile, HR ___, BPs
130s/70s, O2sat 98% on RA
Pre-Lasix weight 150.8 lbs
EKG: atrial fibrillation at HR 66, RBBB (old) with TWI in III,
aVR, unchanged from prior
Labs/studies notable for: BNP 3108 (most recent 2396 ___,
range ___ INR 6.1, UA with 30 WBC, mod bac, pos nit.
CXR showed mild pulmonary edema.
Patient was given: 40 IV Lasix at 6pm, Ceftriaxone, Ativan,
Carvedilol 6.25, Atorva, Gabapentin
Vitals on transfer: HR in ___, otherwise unchanged.
On the floor, patient feels better. Denies any chest pain,
shortness of breath at rest, abdominal fullness, dysuria, or
other symptoms. She is comfortably propped up on 2 pillows.
Past Medical History:
1. CARDIAC RISK FACTORS:
-- hypertension
-- dyslipidemia
-- diet controlled diabetes
2. CARDIAC HISTORY:
-- paroxysmal atrial fibrillation on Coumadin and amiodarone
-- diastolic cardiomyopathy
-- aortic stenosis ___ TTE with 2.3 m/s peak, peak
gradient 21, valve area 2.4)
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- GERD
- anxiety
- cataracts s/p bilateral surgical repair
- colonic polyps
- macular degeneration
- osteoarthritis
- renal calculus
- fibroids s/p myomectomy
- h/o appendectomy
- h/o tubal ligation
Social History:
___
Family History:
Mother and father both died from MI in their ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================
VS: T 98.2, BP 133/95, P ___, RR 20, O2sat 95% on RA
In ED Pre-Lasix weight 150.8 lbs
GEN: well appearing, nontoxic, NAD
HEENT: no scleral icterus, mmm, nl OP
NECK: JVP 20
CV: tachycardic, irregular, no m/r/g
PULM: normal work of breathing on room air, lungs clear
bilaterally with no substantial crackles or wheezes
ABD: soft, NT/ND, +bs
GU: foley in place
EXT: warm, 1+ symmetric edema bilaterally up to knees
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3
DISCHARGE PHYSICAL EXAM:
=====================
Vitals: Tmax =99.2, BP 124-141/64-86, P ___, RR ___, O2sat
92-98% on RA
Ambulatory O2sat ___ with HRs in 100-110
I/O= 1070/800 (24 hr)
Weight: 65.5 kg -> 64.46 kg (141.81 lbs)
Weight on admission: 150.8 lbs
GEN: well appearing, nontoxic, NAD
HEENT: no scleral icterus
NECK: JVP elevated to mid neck
CV: regular rate, irregular rhythm, no m/r/g
PULM: normal work of breathing on room air, lungs clear
bilaterally with no substantial crackles or wheezes
ABD: soft, NT/ND, +BS
EXT: warm, 2+ symmetric edema bilaterally up to knees
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS:
==============
___ 02:30PM BLOOD WBC-8.8 RBC-3.60* Hgb-8.5* Hct-29.3*
MCV-81* MCH-23.6* MCHC-29.0* RDW-16.8* RDWSD-49.5* Plt ___
___ 02:30PM BLOOD Neuts-74.3* Lymphs-14.3* Monos-9.9
Eos-0.3* Baso-0.3 NRBC-0.2* Im ___ AbsNeut-6.52*#
AbsLymp-1.26 AbsMono-0.87* AbsEos-0.03* AbsBaso-0.03
___ 02:30PM BLOOD ___ PTT-45.9* ___
___ 02:30PM BLOOD Glucose-115* UreaN-15 Creat-0.9 Na-138
K-3.8 Cl-100 HCO3-26 AnGap-16
___ 02:30PM BLOOD ALT-20 AST-27 CK(CPK)-45 AlkPhos-116*
TotBili-0.7
___ 02:30PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-3108*
___ 02:30PM BLOOD Albumin-4.2 Calcium-8.7 Phos-3.2 Mg-1.9
___ 05:08PM BLOOD Lactate-1.3
OTHER RELEVANT LABS:
================
___ 06:20AM BLOOD ___ PTT-44.7* ___
___ 05:11PM BLOOD ___ PTT-41.1* ___
___ 03:40PM BLOOD ___ PTT-38.1* ___
___ 06:20AM BLOOD CK(CPK)-31
___ 06:20AM BLOOD CK-MB-<1 cTropnT-<0.01
DISCHARGE LABS:
================
___ 06:05AM BLOOD WBC-7.8 RBC-3.56* Hgb-8.5* Hct-28.9*
MCV-81* MCH-23.9* MCHC-29.4* RDW-17.2* RDWSD-50.3* Plt ___
___ 06:05AM BLOOD ___ PTT-34.9 ___
___ 06:05AM BLOOD Glucose-105* UreaN-22* Creat-1.0 Na-139
K-3.3 Cl-96 HCO3-29 AnGap-17
CXR (___)
1. Stable mild cardiomegaly with central vascular congestion and
mild interstitial pulmonary edema.
2. Right middle lobe opacity suggests atelectasis, less likely
infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Valsartan 160 mg PO DAILY
3. Gabapentin 800 mg PO BID
4. Simethicone 40-80 mg PO QID:PRN gas pain
5. Zolpidem Tartrate 5 mg PO QHS
6. LORazepam 0.5 mg PO Q8H:PRN anxiety
7. Carvedilol 6.25 mg PO BID
8. Docusate Sodium 50 mg PO BID
9. Amiodarone 200 mg PO DAILY
10. Warfarin 4 mg PO DAILY16
11. amLODIPine 10 mg PO DAILY
12. Atorvastatin 10 mg PO QPM
13. Omeprazole 20 mg PO DAILY
14. Sertraline 37.5 mg PO DAILY
15. Bifidobacterium infantis 4 mg oral DAILY
16. Senna 8.6 mg PO BID
17. Furosemide 40 mg PO 3X/WEEK (MO,WE,SA)
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
4. Amiodarone 200 mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Bifidobacterium infantis 4 mg oral DAILY
8. Docusate Sodium 50 mg PO BID
9. Gabapentin 800 mg PO BID
10. LORazepam 0.5 mg PO Q8H:PRN anxiety
11. Omeprazole 20 mg PO DAILY
12. Senna 8.6 mg PO BID
13. Sertraline 37.5 mg PO DAILY
14. Simethicone 40-80 mg PO QID:PRN gas pain
15. Valsartan 160 mg PO DAILY
16. Warfarin 4 mg PO DAILY16
17. Zolpidem Tartrate 5 mg PO QHS
18.Outpatient Lab Work
ICD 10: I50.33
Please check basic metabolic panel and INR (on warfarin) on
___ or ___
Fax results to ___ (Dr. ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute on chronic diastolic heart failure
Atrial fibrillation
Secondary:
Essential hypertension
Depression
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with DOE // SOB
TECHNIQUE: PA and lateral views of the chest provided.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Lung volumes are normal. There is central vascular congestion with minimal
interstitial pulmonary edema. Opacity within the right middle lobe has
improved since prior study and suggests atelectasis, less likely infection.
Trace right pleural effusion. No pneumothorax. Mild cardiomegaly is
unchanged. There is mild unfolding of the thoracic aorta with calcification
at the aortic knob. Otherwise, mediastinal contours are unremarkable. No
compression deformity in the thoracic spine is visualized on the lateral view.
IMPRESSION:
1. Stable mild cardiomegaly with central vascular congestion and mild
interstitial pulmonary edema.
2. Right middle lobe opacity suggests atelectasis, less likely infection.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, B Leg swelling
Diagnosed with Heart failure, unspecified
temperature: 97.7
heartrate: nan
resprate: 22.0
o2sat: 98.0
sbp: 135.0
dbp: 76.0
level of pain: 3
level of acuity: 2.0 | Ms. ___ is a ___ woman with a history of paroxysmal
atrial fibrillation (on Amiodarone & Coumadin), diastolic
cardiomyopathy (on Lasix), HTN, HLD, & mild AS (TTE in ___ who
presented with 4 days of increased dyspnea on exertion & ___
swelling with elevated BNP and weight gain, concerning for CHF
exacerbation.
Patient's trigger for CHF exacerbation is unclear, but possibly
due to her recent URI or UTI. Patient's Afib with HRs in 100s
could also have been contributing. Patient was initially
diuresed with IV Lasix 40 mg BID that was transitioned to PO
Lasix 40 mg daily. Patient discharged on 40 mg Lasix daily at
discharge that can be adjusted as needed in the outpatient
setting. Dose of carvedilol was increased to 12.5 mg BID due to
tachycardia. This can be adjusted as needed in the outpatient
setting. She was not interested in pursuing cardioversion at
this time.
Patient scheduled for TTE during this hospitalization but did
not receive one due to her short hospital admission. TTE can be
considered in the outpatient setting, and was ordered to be done
at ___. Patient was continued on Amiodarone 200 mg
daily and Carvedilol 12.5 mg BID for her atrial fibrillation.
Patient's INR was supratherapeutic during this hospitalization,
initially 6.1 at admission. Patient's dose of warfarin was held
throughout this admission. On day of discharge (___), patient's
INR was 2.8 so patient was discharged on her home dose of 4 mg
warfarin daily. Patient's PCP office was contacted on ___ AM at
discharge. Verbally confirmed with covering MD that patient is
taking 4 mg daily and that dosages/INR monitoring would be
monitored by PCP after discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Oxycodone
Attending: ___
Chief Complaint:
weakness from CIDP
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is an ___ yo M with a history of CIDP with symptoms
first beginning in ___, followed by Dr. ___ with monthly
courses of IVIG (last ___. He left for ___ in early ___ for vacation and had multiple hospitalizations there for
falls, progressive weakness, and urinary retention such that he
has now had a foley bag in for 1 month. He has NOT received IVIG
while in ___. At his baseline in ___, Mr. ___ was able
to
ambulate with a walker, feed himself, urinate without
difficulty,
have regular bowel movements, and transfer himself to a
wheelchair when he needed to travel for long distances. He was
only able to use a wheelchair in ___ and is now no longer
able
to feed himself, cannot transfer to his chair, has urinary
retention requiring a chronic Foley, and has to be on multiple
supplements to have regular bowel movements. He is also now
noting some double vision and worsening of his baseline
dysarthria with some dysphagia - he has not been able to eat
very
much over the past month. He has not had any difficulty with
breathing but his son notes that he was on oxygen multiple times
in ___ during his hospitalization for unclear reasons. NIFs
are yet to be performed here.
On discussion with Dr. ___ on ___, the plan had been for
the
patient to return ___ and be admitted for IVIg 0.4 g/kg x 5
days. An ED expect was called by his primary physician ___ was admitted to the Medicine from the ED for further
management.
In the ED:
- Labs were significant for: WBC 6.2, H/H ___ Plt 219 N 58.3
Normal Chem 7, lactate of 1.3, normal LFTs and Coags. UA
concerning for large leuks, moderate blood negative nitirtes,
RBC
21, WBC 182, Moderate bacteria and many yeast.
- Imaging revealed: CXR showed Left base opacity which could be
due to a combination of atelectasis and infection. Superimposed
effusion is also possible. Two nodular opacities projecting over
the right lung for which nonurgent chest CT is suggested.
- The patient was given 1000mg tylenol and levofloxacin 750mg
for
empiric PNA Rx which was changed to CTX on the floor for UTI
coverage
Neurology was consulted for management of CIDP.
Past Medical History:
1. Allergic rhinitis.
2. Spinal stenosis: Diagnosed in ___, complicated with right
foot drop. Seen by Dr. ___. The stenosis is between areas
of L2 and L5. Has pain with walking short distances, but is
able
to sit without difficulty. Uses a walker for ambulation.
3. Right foot bunion: Seen by Dr. ___.
4. Eczema: Seen by Dr. ___.
5. Status post right total knee replacement in ___.
6. Status post right shoulder arthroscopic surgery.
7. History of smoking: 15-pack-year history, quit ___ years
ago.
Also, smokes several cigars per day.
8. Left pleural effusion: s/p VATS decortication on ___
by Dr. ___: Patient admitted with left sided chest pain. He
was initially treated with levofloxacin on ___.
Metronidazole was added for anaerobic coverage on ___.
Patient had thoracentesis. Fluid analysis revealed an exudative
effusion with no malignant cells. The pleural fluid was not
successfully drained with thoracentesis and pigtail, or single
larger bore chest tube. He subsequently underwent left sided
VATS decortication on HD ___. Post-operatively the
patient was continued on Levofloxacin to cover for Community
Acquired Pneumonia and Vancomycin was begun to empirically cover
resistant gram-positives. Pleural cultures grew sparse strep
anginosus but the lung tissue was no growth. His antibiotics
were stopped on ___.
Social History:
___
Family History:
His mother lived to ___. His father died of
pneumonia in his ___. There is no history of colon, prostate,
or
skin cancer.
Physical Exam:
ON ADMISSION:
Vitals: T:95.5 P:58 R: 20 BP:94-108/54-57 SaO2: SORA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Regular respirations without retractions, frequent
wet
cough, counting with expiration to at least 30
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to name, date, says he's at
___. Able to relate history without difficulty.
Attentive, able to name ___ backward without difficulty.
Language
is fluent with intact repetition and comprehension. Normal
prosody. There were no paraphasic errors. Pt was able to name
both high and low frequency objects. Able to follow both
midline
and appendicular commands. The pt had good knowledge of current
events. There was no evidence of apraxia or neglect. No L/R
confusion.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades. Double
vision reportedly at endgaze in all directions (he thinks this
may be new but is not sure)
V: Facial sensation intact to light touch.
VII: Mild RNLF flattening. Otherwise, facial musculature
symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. Clear palatal dysarthria
(notable at baseline, but has progressively gotten worse per the
patient)
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Low bulk, normal tone throughout. +Pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 4- 4 4+ 4- ___- 4+ 4+ 2 4 0
R 4- 4 4+ 4- ___- 4+ 4+ 0 2 0
Reportedly shoulder strength is limited by rotator cuff
tendinopathy (also noted with shoulder raising bilaterally when
attempting to test shoulder strength)
-Sensory: No deficits to light touch throughout. Diminished
vibration sense in R toe>L toe (could feel ___ seconds on L and
0
seconds on R). Diminished proprioception at R toe but intact at
R
ankle. Intact pinprick and temperature sense throughout. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally (when supporting for strength)
-Gait: Deferred given profound weakness
-----------
ON DISCHARGE:
-Mental status and CN exam unchanged from admission
-Motor: Low bulk, normal tone throughout. +Pronator drift
bilaterally. +fasiculations most prominent in L arm
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L *4- 5 ___- 4+ 0 2 0
R *4- 4+ ___ 4+ 0 0 0
*Reportedly shoulder strength is limited by rotator cuff
tendinopathy (also noted with shoulder raising bilaterally when
attempting to test shoulder strength)
-Reflexes:
Bi Tri ___ Pat Ach
L 1+ 1+ 1+ 0 0
R 1+ 1+ 1+ 0 0
Plantar response was flexor bilaterally. Of note, difficult to
elicit reflexes due to pt's inability to relax arms enough
Pertinent Results:
___ 04:13PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 04:13PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-LG
___ urine culture: YEAST. 10,000-100,000 ORGANISMS/ML..
___ 03:25AM BLOOD CK(CPK)-27*
___ 09:03AM BLOOD WBC-2.5* RBC-2.98* Hgb-9.7* Hct-31.3*
MCV-105* MCH-32.6* MCHC-31.0* RDW-17.2* RDWSD-65.8* Plt ___
___ 09:03AM BLOOD Glucose-121* UreaN-9 Creat-0.7 Na-138
K-3.6 Cl-103 HCO3-25 AnGap-14
Swallow eval: video swallow showed aspiration of thin liquids
1. PO diet: ground solids/nectar-thick liquids
2. Meds crushed in puree
3. TID oral care, especially before eating/drinking
4. Aspiration precautions
- 1:1 supervision with meals
- Upright with all PO and for ___ mins after eating
- Small bites/sips with slow rate
- Alternate bites/sips
- ___ dry, effortful swallow after each bite
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. Lidocaine 5% Patch 1 PTCH TD QPM:PRN pain
4. melatonin 10 mg oral QHS:PRN sleep
5. Loratadine 10 mg PO DAILY:PRN allergy symptoms
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Lidocaine 5% Patch 1 PTCH TD QPM:PRN pain
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth daily
Disp #*30 Capsule Refills:*3
5. Magnesium Citrate 300 mL PO DAILY:PRN constipation
RX *magnesium citrate 0.5 (One half) bottle by mouth daily
Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*30 Packet Refills:*0
7. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 1 capsule by mouth daily Disp #*30
Capsule Refills:*0
8. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Loratadine 10 mg PO DAILY:PRN allergy symptoms
11. melatonin 10 mg oral QHS:PRN sleep
12. Fluconazole 200 mg PO Q24H
RX *fluconazole [Diflucan] 200 mg 1 tablet(s) by mouth daily
Disp #*1 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
worsening of CIDP symptoms
Discharge Condition:
alert, oriented, conversing, foley in place, taking po
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CIDP // desaturation
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the elevation of the left
hemidiaphragm has increased in severity. There is moderate scoliosis, causing
asymmetry of the ribcage. Borderline size of the cardiac silhouette. No
pulmonary edema or pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CIDP, suspicion for aspiration event, new
coarse lung sounds // assess for consolidation.
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray dated ___.
FINDINGS:
The patient is scoliotic and rotated to his left. The lung volumes are
adequate on the right, but decreased on the left. The retrocardiac opacity,
seen on prior chest x-ray, has improved. This opacity could represent a
consolidation from infectious causes or an opacification due to atelectasis.
There is a minimal left pleural effusion. The right costophrenic angle is
unremarkable. The heart size and mediastinal vasculature is less apparent,
likely reflecting improved congestion.
IMPRESSION:
Improved left lower lobe atelectasis or pneumonia.
Radiology Report
INDICATION: ___ year old man with CIDP here for 5 days IVIG, coughing on thin
liquids and oatmeal // aspirated on oatmeal, very weak from CIDP
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: min.
COMPARISON: Video oropharyngeal swallow ___.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was aspiration with thin liquids.
IMPRESSION:
Aspiration with thin liquids.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Weakness, Confusion
Diagnosed with URIN TRACT INFECTION NOS, OTHER MALAISE AND FATIGUE
temperature: 98.3
heartrate: 68.0
resprate: 20.0
o2sat: 98.0
sbp: 135.0
dbp: 78.0
level of pain: 6
level of acuity: 2.0 | Mr. ___ is a ___ man with CIDP on monthly IVIG. Missed 2
months of IVIG and has had progressive strength deterioration,
urinary retention, worsening constipation, and worsening gait
issues. Exam showing pronator drift bilaterally, diffuse
weakness throughout, hyporeflexia. On ___, pt's voice became
weaker and weaker, RR 26, O2 sat 93% RA. NIFs normal on
admission, trended down to -30 --> -25 --> -18. Transferred to
ICU for respiratory watch. Transferred back to floor on ___.
On discharge, pt able to count to 38 in one breath. Completed 5
days IVIG with interval improvement on motor exam.
Noted to have UTI on admission, grew out yeast, put on 200mg
fluconazole qd. Voiding trial completed and failed, reinserted
foley and continued home flomax. Has appt with outpt urology for
flow dynamics.
Evaluated by ___ who recommended home ___. Also had a video
swallow that showed aspiration of thin liquids. Will need pureed
diet and thickened liquids until repeat video swallow after
giving IVIG some time to work. Will defer this to PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Drug Allergies
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
___ F w hypothyroidism presents to the ED yesterday after
experiencing sudden onset SOB, tachypnea. The patient was out to
dinner when this happened suddenly and did not resolve until she
presented to the ED. She did not experience any wheeze, rash,
hives, chest pain.
In early ___, she states she was exposed to Tylex & Formula 409
fumes while cleaning. Since then she has experienced a cough
with intermittent SOB. She has been diagnosed with RADs and
started on inhalers as well as a steroid taper.
Over the past two weeks she has unintentionally lost ___ lbs.
She has also felt generally unwell of late. She is usually quite
active (plays tennis regularly, as well as does yoga) but she
has noticed that she has developed worsening DOE over the past
couple of weeks although she denies CP.
Roughly 1 week ago, she was diagnosed with a herniated disc from
her coughing fits. This manifested in L-sided low back pain. In
addition to this pain, she has developed L-sided lateral shin
numbness which has now extended to the dorsum of L foot. As of
today, she has developed L great toe numbness. She also ___
left leg weakness and has been walking with a limp for the past
week. she denies urinary, bowel retention/incontinence. Denies
saddle anesthesia.
She endorses hoarse voice x1 week.
As mentioned above, she has been on 2 courses of steroids:
- Prednisonse 40 mg/day 3 weeks ago
- Now on 40 mg prednisonse daily (to be tapered ___
Past Medical History:
- Osteopenia
- Osteopenia
- Hypothyroidism
- Rosacea
Social History:
___
Family History:
- Mother: ___ cancer, DVT
- Father: Died at ___
Physical Exam:
PHYSICAL EXAM:
VITAL: 97.8 BP 118/18 P72 RR 20 96%RA
GEN: Resting in bed, NAD. Thin.
HEENT: Facial asymmetry, notable R eye proptosis. Mild L ptosis,
eyelid dropping, L pupil slightly dilated compared to right.
Shrug intact, no anhidrosis. Tongue midline, no obvious facial
motor abnormalities.
NECK: Supple. Engorgement of L-sided neck veins.
COR: +S1S2, RRR, no m/g/r.
PULM: Distant BS in L upper zone. Right lung with coarse breath
sounds. Some rhonci at bases.
___: + NABS in 4Q. Soft, NTND
EXT: WWP. No c/c/e.
NEURO: Decreased sensation over L lateral calf in apparent L5
distribution, also over dorsum of foot. Strength 4+/5 on L
compared to R lower extremity. Upper extremity strength ___
bilaterally.
ON DISCARGE
VITAL: 98.2, BP 118/76 P 68 RR 18 94%RA
GEN: Standing up, reading magazine. NAD.
HEENT: Facial asymmetry, notable R eye proptosis. Mild L ptosis
NECK: Supple. Engorgement of L-sided neck veins.
COR: +S1S2, RRR, no m/g/r.
PULM: Improved BS in L upper zone, soft wheezes in upper lobe.
Right lung with coarse breath sounds throughout, no wheezes or
crackles.
___: Soft, NTND. 1 cm hard, tender, mobile mass in epigastrum
EXT: WWP. No c/c/e.
Pertinent Results:
ADMISSION LABS
___ 07:50AM BLOOD WBC-17.6* RBC-4.51 Hgb-13.9 Hct-43.1
MCV-96 MCH-30.7 MCHC-32.1 RDW-12.9 Plt ___
___ 07:50AM BLOOD Neuts-85.0* Lymphs-7.6* Monos-4.8 Eos-2.2
Baso-0.4
___ 09:17AM BLOOD ___ PTT-22.8* ___
___ 09:17AM BLOOD Glucose-112* UreaN-25* Creat-0.9 Na-140
K-4.1 Cl-98 HCO3-29 AnGap-17
___ 09:17AM BLOOD ALT-24 AST-24 LD(LDH)-257* AlkPhos-55
TotBili-0.4
___ 09:17AM BLOOD Albumin-4.6 Calcium-9.2 Phos-2.9 Mg-2.4
UricAcd-4.2
CXR ___:
FINDINGS: PA and lateral views of the chest. No prior. There
is evidence of volume loss in the left hemithorax with increased
opacity better characterized on the lateral compatible with left
upper lobe collapse. Soft tissue fullness seen in the left
hilar region in combination with upper lobe collapse, the sign
of Golden. The right lung is grossly clear. Cardiomediastinal
silhouette is within normal limits, noting shift to the left.
Osseous and soft tissue structures are unremarkable.
IMPRESSION: Left upper lobe collapse and fullness of the left
hilum worrisome for underlying obstructing mass lesion.
CTA ___:
IMPRESSION:
1. Findings concerning for infiltrative tumor within the left
mediastinum and left hilar region which encases and narrows
upper pulmonary vasculature, and encases and possibly
infiltrates left upper lobe bronchus with consequent left upper
lobe collapse.
2. Prevascular lymph node measures 11mm. No other discrete
enlarged mediastinal nodes can be identified in the setting of
confluent abnormal mediastinal and hilar soft tissue density.
MRI SPINE ___:
IMPRESSION:
1. L5 vertebral body hypointensity extending into the left
pedicle and articular process on T1-weighted images with
associated soft tissue in the left subarticular recess and left
neural foramen that is enhancing. In the setting of likely
malignancy, this is most consistent with metastatic disease.
There is associated spondylolysis of L5 on the left, of
uncertain chronicity but could represent a pathologic fracture.
There is narrowing of the left neural foramen at L5-S1 with
compression of the L5 nerve root on the left.
2. Fluid-intensity cysts in the sacrum likely represent
perineural cysts.
CT ABDOMEN/PELVIS:
IMPRESSION:
1. 2-cm heterogeneous ill-defined possible mass in the left
kidney. Two nearby non-enhancing striations raise the
possibility of focal pyelonephritis and correlation with
urinalysis is recommended. However, this finding is primarily
concerning for malignancy and further evaluation is recommended
with MRI.
2. 4.6-cm left adnexal cyst, which is abnormal in a
post-menopausal patient. Further evaluation is recommended with
non-urgent pelvic ultrasound.
3. 13-mm dense round hyperdense homogeneous lesion in the
pelvis adjacent to the bladder and uterine fundus. Possible
etiologies include but are not limited to a bladder
diverticulum, colonic diverticulum, and fibroid. Attention to
this area is recommended on pelvic ultrasound.
4. Fecal loading.
MRI Abdomen ___. Multiple bilateral low T2 signal intensity lesions are seen
within the kidneys as described above. The dominant lesion is
in the medial left upper pole and measures up to 1.9 cm with a
thin posterior component that abuts the upper pole renal sinus
fat. Given the enhancement pattern and signal characteristics,
these lesions are suspicious for papillary renal cell carcinoma.
Multiple bilateral oncocytomas are also a possibility.
Metastases
are considered less likely.
2. High T2 signal intensity rim-enhancing lesion within hepatic
segment III which is incompletely imaged, but with
characteristics concerning for a metastasis. A dedicated liver
MRI is recommended.
3. Metastatic lesion within the L5 vertebra, better imaged on
the recent L-spine MRI.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. metroNIDAZOLE *NF* 0.75 % Topical BID
2. traZODONE 50 mg PO HS:PRN insomnia
3. Levothyroxine Sodium 100 mcg PO DAILY
4. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Ipratropium Bromide MDI 2 PUFF IH QID
7. Estring *NF* (estradiol) 2 mg Vaginal Q3MO
8. Vitamin D 400 UNIT PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO BID
10. Calcium Carbonate 650 mg PO TID
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. traZODONE 50 mg PO HS:PRN insomnia
4. Vitamin D 400 UNIT PO DAILY
5. Calcium Carbonate 650 mg PO TID
6. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
7. Estring *NF* (estradiol) 2 mg Vaginal Q3MO
8. Fish Oil (Omega 3) 1000 mg PO BID
9. metroNIDAZOLE *NF* 0.75 % Topical BID
10. Lorazepam 0.5 mg PO Q4H:PRN nausea
Try PO first, IV if too nauseated to take po
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 4 hours
Disp #*40 Tablet Refills:*0
11. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth
every 6 hours as needed Disp #*1 Bottle Refills:*0
12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
hold for sedation or RR <10
RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours Disp #*100
Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Lung Mass with collapsed lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with persistent cough, abnormal chest x-ray,
evaluate hilar mass seen on chest x-ray.
COMPARISON: PA and lateral chest radiograph ___.
TECHNIQUE: MDCT axial images were obtained through the chest with the
administration of IV contrast. Multiplanar reformats were generated and
reviewed.
FINDINGS:
There is confluent and infiltrative soft tissue density throughout the
mediastinum and left hilus, concerning for tumor, which encases and narrows
left upper pulmonary vasculature. There is narrowing of the lumen of the left
main bronchus with abrupt occlusion of the upper left bronchus (2:20) by soft
tissue density that could represent a combination of tumor infiltration and/or
mucus. There is associated collapse of the left upper lobe. A prevascular
lymph node measures 11mm in short axis diameter (3:26). There is mild
narrowing of the left lower lobe bronchus; however, segmental and subsegmental
branches appear patent. Left lingula and lower lobe are well aerated. No
pulmonary nodules are noted. The right lung appears unremarkable. There is no
evidence of pleural effusion or pneumothorax.
There are no filling defects within the pulmonary vasculature to suggest
presence of pulmonary emboli. There is no evidence of acute aortic injury.
This study is not optimized for subdiaphragmatic evaluation; however, the
upper abdominal structures appear unremarkable.
Visualized osseous structures show no focal lytic or sclerotic lesions
suspicious for malignancy.
IMPRESSION:
1. Findings concerning for infiltrative tumor within the left mediastinum and
left hilar region which encases and narrows upper pulmonary vasculature, and
encases and possibly infiltrates left upper lobe bronchus with consequent left
upper lobe collapse.
2. Prevascular lymph node measures 11mm. No other discrete enlarged
mediastinal nodes can be identified in the setting of confluent abnormal
mediastinal and hilar soft tissue density.
Radiology Report
INDICATION: ___ woman with high concern for new malignancy presented
with left upper lobe collapse, weight loss, back pain, and new lower leg
numbness and weakness. Question cord compromise.
TECHNIQUE: Sagittal T1, T2, and STIR as well as axial T1, T2 and
post-contrast sagittal T1 and coronal T1 images were obtained.
COMPARISON: None available.
FINDINGS: There is a transitional vertebra between S1 and S2.
There is a hypointense lesion in the body of L5 extending into the left
pedicle and articular process on T1-weighted images. There is associated soft
tissue in the left subarticular recess and left neural foramen which is
enhancing on post-gadolinium images. The left neural foramin at L5-S1 is
narrowed with compression of the L5 nerve root on the left. There is
spondylolysis of L5 on the left. There is mild anterolisthesis of L5 on S1.
No focal disc herniation or spinal canal stenosis is identified. The conus
and cauda equina appear normal. There are bilateral sacral fluid-intensity
cysts which likely represent sacral perineural cysts. There are mild
multilevel degenerative changes.
IMPRESSION:
1. L5 vertebral body hypointensity extending into the left pedicle and
articular process on T1-weighted images with associated soft tissue in the
left subarticular recess and left neural foramen that is enhancing. In the
setting of likely malignancy, this is most consistent with metastatic disease.
There is associated spondylolysis of L5 on the left, of uncertain chronicity
but could represent a pathologic fracture. There is narrowing of the left
neural foramen at L5-S1 with compression of the L5 nerve root on the left.
2. Fluid-intensity cysts in the sacrum likely represent perineural cysts.
Findings were discussed with Dr. ___ by Dr. ___ via
telephone at 9:55 a.m. on ___, five minutes after discovery.
Radiology Report
INDICATION: ___ female with left upper lobe lung mass and L5 spinal
mass with pathologic fracture, concerning for metastasis.
COMPARISON: None available.
TECHNIQUE: Axial CT images through the abdomen and pelvis were acquired after
administration of intravenous and oral contrast. Coronal and sagittal
reformatted images were reviewed. Axial CT images through the abdomen were
acquired before and three minutes after administration of intravenous
contrast.
FINDINGS:
ABDOMEN: The lung bases demonstrate minimal dependent atelectasis. No
pleural or pericardial effusion is seen. The spleen, pancreas, and adrenal
glands are within normal limits. Non-contrast enhanced exam demonstrates
minimal residual contrast within the renal collecting systems bilaterally,
likely related to recent prior chest CTA. Vicarious excretion of contrast is
seen in the gallbladder which is otherwise unremarkable. There is mild
central intrahepatic and proximal extrahepatic biliary ductal dilation.
Bilateral renal hypodensities most likely represent cysts measuring up to 41 x
33 mm on the left and 24 x 21 mm on the right. A 2-cm heterogeneous
ill-defined mass in the medial left kidney is indeterminate but concerning for
malignancy. Two other small striated areas of cortical non-enhancement are
seen in the left kidney, raising the possibility of focal pyelonephritis.
Neither kidney demonstrates hydronephrosis. The stomach and small bowel are
within normal limits. Severe fecal loading is seen throughout the colon.
There is no free intraperitoneal air or ascites.
PELVIS: The bladder, uterus, and rectum are unremarkable. A pessary is
noted. There is a 43 x 26 x 46 mm left adnexal cyst. A 13 x 10 mm
homogeneous hyperdense round lesion in the pelvis between the bladder and
uterine fundus is of indeterminate etiology; this is similar in density to the
bladder contents.
Abnormality in the L5 vertebral body is better evaluated by recent MR. ___
is made of two Tarlov cysts.
IMPRESSION:
1. 2-cm heterogeneous ill-defined possible mass in the left kidney. Two
nearby non-enhancing striations raise the possibility of focal pyelonephritis
and correlation with urinalysis is recommended. However, this finding is
primarily concerning for malignancy and further evaluation is recommended with
MRI.
2. 4.6-cm left adnexal cyst, which is abnormal in a post-menopausal patient.
Further evaluation is recommended with non-urgent pelvic ultrasound.
3. 13-mm dense round hyperdense homogeneous lesion in the pelvis adjacent to
the bladder and uterine fundus. Possible etiologies include but are not
limited to a bladder diverticulum, colonic diverticulum, and fibroid.
Attention to this area is recommended on pelvic ultrasound.
4. Fecal loading.
Findings and recommendations were reported to Dr. ___ by Dr. ___ by
telephone at 5:25 p.m. on ___ after attending radiologist review.
Radiology Report
EXAM: CT of the lumbar spine.
CLINICAL INFORMATION: Patient with upper lung mass and MRI showing bony
abnormality, for further evaluation.
TECHNIQUE: Axial images of the lumbar spine obtained with sagittal and
coronal reformats. Correlation was made with the MRI examination of same day
___.
FINDINGS: In correlation with MRI again seen are soft tissue changes within
the left neural foramen at L5-S1 level surrounding the exiting left L5 nerve
root and also within the subarticular recess on the left side within the
spinal canal consistent with soft tissue metastasis. However, unlike MRI
examination the marrow infiltrative process seen within the pedicle and the
vertebral body is not apparent on the CT. There is no lytic process
identified or sclerosis seen. There does appear to be a spondylolysis within
the left intra-articular region with subtle lucencies, but no clear evidence
of osteolytic process is seen. There are severe facet degenerative changes
noted at this level.
There is no evidence of destructive process noted at other regions. Mild
spondylolisthesis of L5 over S1 seen. Small area of sclerosis at the superior
endplate of L5 appears to be due to a Schmorl's node.
In the visualized kidneys simple-appearing cysts are visualized. Tarlov cysts
are seen within the sacral spinal canal as before.
IMPRESSION:
1. Although subtle lucencies are seen in the left intraarticular region of
L5, and a suspicion for spondylolysis is noted, no definite lytic process is
identified. The marrow infiltrative process seen on MRI is not apparent on CT.
However, left-sided neural foraminal soft tissue changes due to soft tissue
tumor extension from the bony abnormalities seen on MRI is identified
surrounding the exiting left L5 nerve root. Severe facet degenerative changes
seen at L5-S1 level. Osteopenia is noted.
Radiology Report
TECHNIQUE: MRI of the brain without and with gad.
HISTORY: Small cell lung CA, assess for metastatic disease.
COMPARISON: None.
FINDINGS: There is no evidence for intracranial metastatic disease. There is
no mass effect or midline shift. There is no hydrocephalus or acute ischemia.
There is scattered small vessel ischemic change in the white matter. Flow
voids are present.
IMPRESSION: No evidence for metastatic disease. Small vessel ischemic
sequela.
Radiology Report
INDICATION: ___ woman with new diagnosis of small cell lung cancer
with spine mets. Now with renal mass on CTE. Assess the ill-defined mass in
the left kidney on CT.
COMPARISON: CT, ___.
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5
Tesla magnet, including dynamic 3D imaging, obtained prior to and after the
administration of 0.1 mmol/kg of Gadavist.
FINDINGS:
Within the medial left renal upper pole, there is a 1.6 x 1.9 x 1.7-cm mass
which is low signal intensity on T2-weighted imaging and demonstrates minimal
enhancement post gadolinium. This lesion appears to have a posterior component
that abuts the upper pole renal sinus fat (16:32). There are two smaller low
T2 signal intensity, enhancing lesions within the left upper pole, the larger
one measuring 1.2 x 0.8cm (31:16). In the right kidney, there are two small
lesions with similar imaging characteristics, one is seen within the right
upper pole (37:12) and one within the lower pole (40:12). Within bilateral
kidneys, there are multiple cysts, the largest cyst within the left lower
renal pole contains internal septations.
There is no suspicious lymphadenopathy. No invasion through the renal vein is
seen. No hydronephrosis. Note is made of a low insertion of the left renal
artery (12:12).
Within segment III of the liver, there is a high T2 signal intensity lesion
which measures roughly 1.8 cm (image 8, series 7). While this is not
visualized on all sequences, there is a suggestion of peripheral rim
enhancement on the sagittal images (22:15).
The main portal vein is patent.
The intra- and extra-hepatic biliary tree is unremarkable. Two non-dependent
gallstones are seen within the gallbladder. The visualized pancreas and
adrenal glands are unremarkable.
There is irregular aortic atherosclerosis without aneurysmal dilatation.
An enhancing lesion is again appreciated at the left vertebral body of L5 with
extension into the posterior elements.
There is bilateral likely edema seen within the sacroiliac joints,
nonspecific.
IMPRESSION:
1. Multiple bilateral low T2 signal intensity lesions are seen within the
kidneys as described above. The dominant lesion is in the medial left upper
pole and measures up to 1.9 cm with a thin posterior component that abuts the
upper pole renal sinus fat. Given the enhancement pattern and signal
characteristics, these lesions are suspicious for papillary renal cell
carcinoma. Multiple bilateral oncocytomas are also a possibility. Metastases
are considered less likely.
2. High T2 signal intensity rim-enhancing lesion within hepatic segment III
which is incompletely imaged, but with characteristics concerning for a
metastasis. A dedicated liver MRI is recommended.
3. Metastatic lesion within the L5 vertebra, better imaged on the recent
L-spine MRI.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: Patient post-bronchoscopy, endobronchial mass in LMS. check for
pneumothorax.
COMPARISON: ___ and CT scan of ___.
FINDINGS:
Patient is known with a left upper lobe complete collapse. There is no
pneumothorax or pneumomediastinum post-bronchoscopy. Right lung is
unremarkable. There is no pleural effusion. Mediastinal and cardiac contours
are unchanged.
CONCLUSION:
There is no sign of complication post-bronchoscopy and biopsy.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with CHEST SWELLING/MASS/LUMP
temperature: 98.8
heartrate: 99.0
resprate: 18.0
o2sat: 100.0
sbp: 169.0
dbp: 100.0
level of pain: 3
level of acuity: 2.0 | ___ yo F w/o significant PMH presents w/ SOB, lumbar pain, found
to have LUL mass and spinal lesion concering for metastatic lung
cancer vs. other acute malignancy eg lymphoma.
#Lung mass, likely new malignancy. CXR showed mediastinal mass,
CTA showing LUL collapse, abrupt cutoff of L bronchus concerning
for tumor, and she was sent to the floor for further workup. CTA
showed LUL collapse and cutoff of L bronchus concerning for
tumor. MRI spine revealed L5 vertebral body lesion w/ nerve root
compression, also likely pathologic fracture. Radiation oncology
was consulted for question of SVC syndrome as she displayed a
distended L jugular vein; exam was reassuring for no airway
compromise or evidence of increased ICP. Hematology/oncology was
consulted, and recommended CT abdomen/pelvis, which showed
heterogeneous mass in kidney, also 4cm pelvic cyst and unusual
mass above bladder. MRI renal study confirmed lesions in the
kidney with additional liver lesions. Liver lesions are likely
mets, while renal lesions are mets vs primary. Interventional
pulm performed bronchoscopy with tissue biopsies taken that are
still pending. She was sent home in stable condition with
appointments with her PCP, ___, her interventional
pulmonologists and her radiation oncologist.
# Back pain w/ LLE weakness. Pain controlled with morphine
initially, but given patient's significant nausea, toradol was
initiated with IV oxycodone for breakthrough pain. Neurosurgery
was consulted, recommended lumbar con/noncon CT. Felt no surgery
indicated emergently as symptoms had been present for > 1 week.
Rad/onc felt pt would likely beneft from palliative radiation;
will follow as outpatient. She has been sent home with Tramadol
for pain control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
topiramate / adhesive tape / ibuprofen
Attending: ___.
Chief Complaint:
Odynophagia
Major Surgical or Invasive Procedure:
___: EGD with balloon dilation
History of Present Illness:
Ms. ___ is ___ year old obese female well known to the
Bariatric service to have undergone a Roux en y gastric bypass
by Dr ___ on ___. She subsequently developed
obstructive symptoms and was found to have a 5mm stricture of
her Gastrojejunostomy anastomosis. She underwent balloon
dilation ___ and was planned to get a follow up EGD if she
recurred her symptoms. She is presenting with a history of
gradual onset odynophagia and abdominal/ chest pain of 1 day
duration. She reports that this pain is very similar to pains
that experienced during her time with the stricture of the GJ
Anastomosis prior to the dilation. Her pain reportedly started
as presternal initially to solid foods initially after eating
green beans. Her pain resolved "after a few hours." She was able
to tolerate stage ___gain, however after eating an
omelette, her pain was excruciating. She is emphatic about being
very diligent with portion size, chewing well and taking 2
minutes of pauses between bites. She however complains that her
pain now is related to any PO intake including water. The
patient denies any NV, no F/C, no hematemesis, melena, diarrhea.
She reports dark urine since yesterday ___. +harder stools.
Passing gas.
Past Medical History:
POBHx: SVD at 34 weeks s/p PPROM, 2580g
PMH: hypertension, SVT status post ablation, asthma
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
VS: Triage @16:05 Pain 7(6 now) T 97.6 HR 99 (repeated manually
at 88 after one liter of fluids) BP 121/64 RR16 SatO2 97%
Gen - NAD, AO x 3
Heart - RRR, SEM
Lungs - CTAB
Abd - obese, soft, moderately TTP in epigastric region, no
rebound/guarding, incisions c/d/i, no incisional hernias
palpable
Extrem - no edema, warm & well-perfused
Pertinent Results:
___ 06:12AM BLOOD WBC-4.7 RBC-4.37 Hgb-12.3 Hct-36.9 MCV-84
MCH-28.2 MCHC-33.5 RDW-14.0 Plt ___ Glucose-89 UreaN-7
Creat-0.4 Na-140 K-3.9 Cl-109* HCO3-21* AnGap-14 Calcium-9.0
Phos-4.1 Mg-2.0
___ 04:59PM BLOOD WBC-7.7# RBC-4.94 Hgb-13.9 Hct-41.8
MCV-85 MCH-28.2 MCHC-33.3 RDW-13.8 Plt ___ Neuts-63.3
___ Monos-4.9 Eos-2.1 Baso-1.1 Glucose-93 UreaN-11
Creat-0.6 Na-142 K-5.0 Cl-105 HCO3-22 AnGap-20
ALT-29 AST-38 AlkPhos-76 TotBili-0.5 Albumin-5.2 Calcium-10.4*
Phos-3.9 Mg-2.1
Imaging:
___ EGD:
Normal mucosa in the esophagus.
Altered surgical anatomy consistent with a Roux-en-Y gastric
bypass.
A benign intrinsic stricture was seen at the gastro-jejunal
anastomosis. The gastroscope could not traverse the stricture.
A wire guided 12mm balloon was introduced for dilation and the
diameter was progressively increased to 15 mm successfully. The
scope was able to traverse the anastomosis after dilation
easily.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Mirena *NF* (levonorgestrel) 20 mcg/24 hr Intrauterine
ongoing
2. Ranitidine (Liquid) 150 mg PO BID
3. Ursodiol 300 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Mirena *NF* (levonorgestrel) 20 mcg/24 hr Intrauterine
ongoing
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Ranitidine (Liquid) 150 mg PO BID
4. Ursodiol 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
GJ anastamotic stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of epigastric pain
status post gastric bypass in late ___, rule out free air, left lower lobe
pneumonia.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest were obtained. The lungs
are clear without focal consolidation. No pleural effusion or pneumothorax is
seen. The cardiac and mediastinal silhouettes are unremarkable. No evidence
of free air is seen beneath the diaphragms.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: ___ female status post gastric bypass surgery and recent
dilatation of the GJ stricture who presents with retrosternal pain with
swallowing. Question leak or persistent stricture.
COMPARISON: ___ CT as well as fluoro upper GI performed ___.
TECHNIQUE: Helical CT images were acquired of the abdomen and pelvis
following the uneventful administration of IV and oral contrast. These were
reformatted into coronal and sagittal planes.
FINDINGS:
LUNG BASES: The lung bases are clear. There is no pleural or pericardial
effusion.
ABDOMEN: The liver is diffusely low in attenuation consistent with fatty
infiltration. There are no focal lesions. The spleen is mildly enlarged
measuring 15cm in the craniocaudal dimension. The pancreas is unremarkable.
The gallbladder is normal in appearance. There is no intra- or extra-hepatic
biliary ductal dilatation. The adrenal glands are normal in appearance
bilaterally. The kidneys demonstrate symmetric contrast enhancement and brisk
bilateral excretion without hydronephrosis.
The patient is status post Roux-en-Y gastric bypass. No contrast is seen
within the excluded portion of the stomach. There is no extraluminal
contrast. The Roux limb is normal in caliber. Contrast has passed into the
distal small bowel with no evidence of delayed transit. There is no
intraperitoneal free fluid or free air. Note is made of several lymph nodes
adjacent to the GJ anastomosis, unchanged. Loops of small bowel are normal in
caliber and enhancement. The aorta is normal in caliber.
PELVIS: The uterus is normal in appearance, with note made of an IUD. The
bladder is collapsed. The colon is notable for a few sigmoid diverticula.
The appendix is normal. Trace physiologic free fluid is present in the pelvis.
The visualized osseous structures are normal.
IMPRESSION: Status post Roux-en-Y gastric bypass without evidence of
gastrogastric fistula, functional obstruction, or perforation.
Splenomegaly with the spleen measuring 15 cm in craniocaudal dimension.
These findings were discussed with Dr. ___ at the ___ Department at
9:45 p.m. in person.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: EPIGASTRIC PAIN
Diagnosed with VOMITING POST-GI SURGERY, BARIATRIC SURGERY STATUS
temperature: 97.6
heartrate: 99.0
resprate: 16.0
o2sat: 97.0
sbp: 121.0
dbp: 64.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ presented to the ___ Emergency Department on
___ with complaints of epigastric pain and
odynophagia with associated nausea. She was subsequently placed
on bowel rest and given intravenous fluids. Radiographic
imaging including an Abd/Pelvic CT scan and chest x-ray was
without evidence of
gastrogastric fistula, functional obstruction, perforation or
acute cardiopulmonary process, however, splenomegaly was noted.
On HD 3, the patient underwent an EGD, which revealed a benign
anastamotic stricture, which was successfully dilated to 15mm.
Post-procedure, the patients vital signs remained stable, pain
resolved and she was able to tolerate a stage 2 diet.
She was discharged to home on HD4 and was doing well, afebrile
with stable vital signs. The patient continued to tolerate a
diet, was ambulating, voiding without assistance, and was
without pain. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. She will follow-up with Dr.
___ on ___ and GI on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
C6 Fracture.
Major Surgical or Invasive Procedure:
C5-T1 posterior instrumented spinal fusion with C5-6 right sided
extraforaminal decompression and superior articular process
excision with iliac crest autograft harvest on ___
History of Present Illness:
___ year old otherwise healthy male who presents as trauma
transfer from ___ after fall down 15 stairs while
sleep walking. CT neck significant for acute C6 fracture. He was
also found to have an open dislocation of his left thumb, which
was repaired at the OSH, and a left sided subdural hematoma. He
denies neck pain, numbness, weakness, bowel or bladder symptoms.
Past Medical History:
PMH:
Prior C6-C7 laminectomy and fusion preformed ___ years ago at NEB.
Social History:
SH:
Activity Level: Active
Mobility Devices: None
Tobacco: Denies
EtOH: Occasional
Physical Exam:
PE:
Vitals:T 98.5 HR 98 BP 130/82 RR 16 SaO296% RA
General: In c-collar, NAD
Mental Status: AAOx3
Cranial nerves II-XII grossly intact.
Vascular
Radial Ulnar Fem Pop DP ___
R 2 2 2 ___
L 2 2 2 ___
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R intact intact intact intact intact
L intact intact intact intact intact
T2-L1 (Trunk) intact
___ L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post
Thigh)
R intact intact intact intact intact intact
L intact intact intact intact intact intact
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Reflexes
Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1)
R 2 2 2 2 2
L 2 2 2 2 2
Babinski: down-going
Clonus: absent
Perianal sensation: intact
Rectal tone: normal
Estimated Level of Cooperation: good
Estimated Reliability of Exam: reliable
Pertinent Results:
___ 09:10AM BLOOD WBC-15.3* RBC-4.93 Hgb-14.0 Hct-42.7
MCV-87 MCH-28.4 MCHC-32.8 RDW-13.2 RDWSD-41.1 Plt ___
___ 07:15AM BLOOD WBC-11.7* RBC-4.64 Hgb-13.2* Hct-40.4
MCV-87 MCH-28.4 MCHC-32.7 RDW-13.2 RDWSD-40.7 Plt ___
___ 07:23AM BLOOD WBC-8.1 RBC-5.08 Hgb-14.2 Hct-43.7 MCV-86
MCH-28.0 MCHC-32.5 RDW-12.9 RDWSD-40.1 Plt ___
___ 07:06AM BLOOD WBC-8.1 RBC-5.05 Hgb-14.5 Hct-43.0 MCV-85
MCH-28.7 MCHC-33.7 RDW-13.2 RDWSD-40.7 Plt ___
___ 04:12PM BLOOD WBC-13.7* RBC-4.82 Hgb-13.6* Hct-41.4
MCV-86 MCH-28.2 MCHC-32.9 RDW-13.1 RDWSD-40.8 Plt ___
___ 04:12PM BLOOD Neuts-71.7* ___ Monos-5.1 Eos-1.1
Baso-0.3 Im ___ AbsNeut-9.80* AbsLymp-2.89 AbsMono-0.70
AbsEos-0.15 AbsBaso-0.04
___ 09:10AM BLOOD Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:23AM BLOOD Plt ___
___ 07:06AM BLOOD Plt ___
___ 07:06AM BLOOD ___
___ 04:12PM BLOOD Plt ___
___ 09:10AM BLOOD Glucose-305* UreaN-14 Creat-0.6 Na-135
K-4.6 Cl-93* HCO3-27 AnGap-15
___ 07:15AM BLOOD Glucose-277* UreaN-15 Creat-0.7 Na-136
K-4.4 Cl-99 HCO3-26 AnGap-11
___ 07:23AM BLOOD Glucose-211* UreaN-15 Creat-0.7 Na-141
K-4.3 Cl-102 HCO3-25 AnGap-14
___ 07:06AM BLOOD Glucose-292* UreaN-15 Creat-0.7 Na-140
K-4.4 Cl-101 HCO3-24 AnGap-15
___ 09:22PM BLOOD Glucose-297* UreaN-12 Creat-0.7 Na-137
K-4.3 Cl-98 HCO3-24 AnGap-15
___ 04:12PM BLOOD Glucose-305* UreaN-13 Creat-0.8 Na-139
K-4.4 Cl-101 HCO3-23 AnGap-15
___ 07:23AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9
___ 07:06AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9
___ 09:22PM BLOOD Calcium-9.2 Phos-3.7 Mg-2.0
___ 04:12PM BLOOD %HbA1c-14.0* eAG-355*
___ 11:58AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:12PM URINE Color-Straw Appear-Clear Sp ___
___ 11:58AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-NEG
___ 08:12PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-80* Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-NEG
___ 11:58AM URINE RBC-4* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 08:12PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 11:58AM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-POS* amphetm-NEG oxycodn-POS* mthdone-NEG
Medications on Admission:
ibuprofen
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
may take over the counter
2. Diazepam 5 mg PO Q6H:PRN muscle spasms
may cause drowsiness
3. Docusate Sodium 100 mg PO BID
please take while taking narcotic pain medications
4. Gabapentin 400 mg PO TID
5. Glargine 20 Units Breakfast
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
please do not operate heavy machinery, drink alcohol or drive
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Status post C6-7 anterior cervical discectomy and fusion
with nonunion.
2. C6 right-sided superior articular process fracture with
C5-6 instability.
3. Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: POST. C5-7 FUSION
IMPRESSION:
Spot views are submitted for documentation of an invasive procedure performed
under imaging guidance with no radiologist in attendance. For details of the
procedure, please refer to the operative report.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS IN O.R.
INDICATION: ___ year old man s/p C5-T1 fusion// post op x-ray
TECHNIQUE: AP and lateral views of the cervical spine
COMPARISON: ___ intraoperative fluoroscopic images
FINDINGS:
C1 through C7 are imaged on the lateral view. The vertebral bodies are normal
in height and alignment. Redemonstrated is posterior fusion of C5 through T1
and prior anterior fusion of C6-C7. There is severe loss of disc height at
C6-C7. Prominent anterior osteophyte is again seen arising from the inferior
endplate of C5. The visualized lungs are clear. Surgical staples are noted
IMPRESSION:
Degenerative and postsurgical changes..
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man s/p C5-T1 posterior instrumented spinal fusion
with C5-6 right sided extraforaminal decompression and superior articular
process excision with iliac crest autograft harvest on ___ now with
tachycardia. Evaluate for pulmonary embolism.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
2) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
3) Spiral Acquisition 4.5 s, 35.6 cm; CTDIvol = 13.6 mGy (Body) DLP = 484.0
mGy-cm.
Total DLP (Body) = 489 mGy-cm.
COMPARISON: None.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The visualized inferior thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
Mild dependent subsegmental atelectasis is present in the bilateral lung
bases. There is no focal consolidation or pneumothorax. The airways are
patent to the subsegmental level.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Few locules of air in the posterior paraspinal soft tissues in the lower neck
and upper chest, likely postoperative in nature. Incompletely imaged cervical
spinal hardware, best appreciated on sagittal views.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Unsp disp fx of sixth cervical vertebra, init for clos fx, Fall (on) (from) other stairs and steps, initial encounter
temperature: 98.6
heartrate: 98.0
resprate: 16.0
o2sat: 96.0
sbp: 130.0
dbp: 82.0
level of pain: 6
level of acuity: 1.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ___.
___ was consulted to help with management of his newly
diagnoses Diabetes Mellitus. He will require follow up as an
outpatient.
Hospital course was otherwise unremarkable.On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Bactrim / atorvastatin
Attending: ___
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old R-handed man, pmh of DM,
HTN,
HLD, and Afib on Xarelto who presents with vertigo and gait
ataxia. He was seen with Stroke Attending, Dr. ___ Stroke
___, Dr. ___.
He had a gradual onset of vertigo and disequilibrium in clinic 1
dpta. He noticed some gait ataxia, which was worse at night
while
walking in home. This morning, he was unable to stand with
continued vertigo (described as "sea sickness"). He noticed a
positional component to vertigo, such that when he sat up, he
became nauseous and would through up. Vertigo is improved while
lying still.
Given continued symptoms and inability to walk, he presented to
ED.
He denies recent fevers or colds. Denies double vision. He has
chronic age-related deafness (R>L) and in additional a
low-frequency chronic tinnitus.
ROS as above.
Past Medical History:
ALLERGIES
DIABETES MELLITUS
DYSURIA/HEMATURIA
GOUT
HYPERCHOLESTEROLEMIA
HYPERTENSION
MEDIAN BAR HYPERTROPHY
MIGRAINE HEADACHES
REFLUX ESOPHAGITIS
VERTIGO
CHEST PAIN
SPLENOMEGALY
LYMPHOMA
Paroxysmal Atrial fibrillation
Social History:
___
Family History:
Mom had DM and passed away of esophageal cancer.
Dad passed away from lung cancer from smoking.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Physical Exam:
Vitals: T:97 P:56 R: 16 BP:151/64 SaO2:100% RA
Exam performed by Dr. ___:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Pulmonary: breathing comfortably on room air
Cardiac: RRR,
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent. Normal
prosody. There were no paraphasic errors. Speech was
hypophonic,
not dysarthric. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Saccadic intrusions on R gaze.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Profound hearing decrease 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 postural and action tremor noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-DTRs:
___ response was flexor R, ?L upgoing.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
Mild action tremor bilaterally, but no dysmetria on FNF or HKS
bilaterally.
-Gait: very unsteady with tendency to fall to the left; needs to
hold onto things; can't do Romberg or ___ testing; falls
to the left with Romberg;
==========================================
DISCHARGE EXAM:
General exam: NAD, appears more comfortable.
Neurologic exam nonfocal except chronically upgoing L toe. No
nystagmus;
Gait: ambulation stable and independent at time if discharge.
Pertinent Results:
___ 01:50PM BLOOD WBC-6.1 RBC-4.41* Hgb-11.8* Hct-38.1*
MCV-86 MCH-26.8 MCHC-31.0* RDW-14.2 RDWSD-45.0 Plt ___
___ 09:35AM BLOOD WBC-5.7 RBC-4.07* Hgb-11.0* Hct-35.4*
MCV-87 MCH-27.0 MCHC-31.1* RDW-14.4 RDWSD-45.9 Plt ___
___ 01:50PM BLOOD ___ PTT-34.3 ___
___ 01:50PM BLOOD Glucose-205* UreaN-17 Creat-1.0 Na-137
K-3.6 Cl-99 HCO3-24 AnGap-18
___ 09:35AM BLOOD Glucose-160* UreaN-15 Creat-1.1 Na-140
K-3.7 Cl-102 HCO3-24 AnGap-18
___ 01:50PM BLOOD ALT-19 AST-18 AlkPhos-75 TotBili-0.7
___ 09:35AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.7
___ 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:10PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:10PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 04:00PM URINE RBC-0 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 03:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Imaging:
___: No acute intracranial process.
MRI/MRA Head/Neck:
1. There is no evidence of acute infarct or intracranial
hemorrhage.
2. Allowing for common anatomic variation, unremarkable MRA of
the head and neck.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. linagliptin 5 mg oral DAILY
7. Losartan Potassium 50 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Repaglinide 0.5 mg PO PRN with large meals
11. Rivaroxaban 20 mg PO DAILY
12. Rosuvastatin Calcium 20 mg PO QPM
13. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. AcetaZOLamide 500 mg PO Q12H
Take at onset of vertigo/disequilibrium
RX *acetazolamide 500 mg 1 capsule(s) by mouth twice daily Disp
#*20 Capsule Refills:*5
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. linagliptin 5 mg oral DAILY
8. Losartan Potassium 50 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Pantoprazole 40 mg PO Q24H
11. Repaglinide 0.5 mg PO PRN with large meals
12. Rivaroxaban 20 mg PO DAILY
13. Rosuvastatin Calcium 20 mg PO QPM
14. Tamsulosin 0.4 mg PO QHS
15.Outpatient Physical Therapy
ICD-10: H81.09
ICD-9: 386.0
Vestibular/physical therapy: Evaluate and treat
Discharge Disposition:
Home
Discharge Diagnosis:
Meniere's Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: History: ___ with dizziness, ataxia, afib on eliquis // ?
cerebellar stroke
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
2 dimensional time-of-flight MRA of the neck performed. Dynamic MRA of the
neck was performed during administration of 16 mL of Multihance intravenous
contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: Same-day CT head at 14:26; MRI and MRA brain and MRA neck ___
FINDINGS:
MRI BRAIN:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are within expected limits for the
degree of mild senescent related volume loss. There are no new parenchymal
FLAIR signal abnormalities. The major intracranial flow voids are preserved.
The orbits are unremarkable. There is trace opacification of some bilateral,
right greater than left, mastoid air cells and ethmoidal air cells.
MRA BRAIN:
Re-identified is a hypoplastic left A1 segment and azygous A2 as well as
fetal/fetal type origin of the left posterior cerebral artery. The
intracranial vertebral and internal carotid arteries and their major branches
appear normal without evidence of stenosis, occlusion, or aneurysm formation.
MRA NECK:
There is common origin of the right brachiocephalic and left common carotid
artery. Otherwise, the common, internal and external carotid arteries appear
normal. There is no evidence of internal carotid artery stenosis by NASCET
criteria. The origins of the great vessels, subclavian and vertebral arteries
appear normal bilaterally.
IMPRESSION:
1. There is no evidence of acute infarct or intracranial hemorrhage.
2. Allowing for common anatomic variation, unremarkable MRA of the head and
neck.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with dizziness, ataxia starting yesterday, afib on
xarelto // ? Hemorrhage
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, 16.5 cm; CTDIvol = 48.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute major vascular territorial infarct. Gray-white matter differentiation is
preserved. Ventricles and sulci are age appropriate. Atherosclerotic
calcifications noted within the intracranial ICAs.
There is mild mucosal thickening in the ethmoid air cells and left maxillary
sinus and a small amount of fluid in the right mastoids. Other paranasal
sinuses and left mastoids are clear. Skull and extracranial soft tissues are
unremarkable.
IMPRESSION:
No acute intracranial process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with Dizziness and giddiness
temperature: 97.0
heartrate: 56.0
resprate: 16.0
o2sat: 100.0
sbp: 151.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | Dr. ___ is a ___ man with history of diabetes,
hypertension, hyperlipidemia, and atrial fibrillation on
Xarelto, who presented with 2 days of progressive vertigo, gait
instability, nausea, and vomiting in the setting of multiple
prior episodes of the same symptoms. There was initially
concern that his symptoms may represent posterior circulation
stroke, however noncontrasted head CT, and MRI brain were
without evidence of acute hemorrhage, nor stroke. He was
admitted for symptomatic control, given p.o. intolerance and
gait instability.
He was treated with IV fluids, antiemetics, and physical
therapy.
His decade-long history of paroxysmal episodes of vertigo
(evidence for a peripheral vestibulopathy without any clear
evidence for BPPV) in the setting of chronic hearing loss, low
frequency tinnitus, raise concern for Ménière's disease. He
therefore received a trial of Diamox (500mg po BID), which
resulted in significant symptomatic improvement, therefore
supporting Meniere's disease as a possible etiology of his
recurrent paroxysmal vertiginous episodes. His gait became more
stable and he did not show any tendency to fall anymore.
We reviewed his outpatient audiogram. It does show the high
frequency hearing loss (which might be his presbyacusis),
however, it also showed a low frequency hearing impairment
(between 500 Hz and ___ Hz) and this might be the typical
hearing impairment seen in Meniere's disease.
He was subsequently discharged after being cleared for discharge
home by physical therapy and after he was tolerating adequate
p.o. intake.
He was discharged with prescription for prn diamox to take at
onset of another episode of veritgo, and with home physical
therapy.
==================================
Transitional Issues:
[ ]Diamox prn vertigo. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
___ with h/o IDDM (last HbA1C 11.6 % ___, CAD s/p stenting,
HTN, HLD brought in by EMS due to altered mental status. The
patient reportedly called EMS to report that she did not feel
well, but when found by EMS was noted to be extremely confused.
Patient is unable to offer a history this time. Unclear last
time normal.
ED Course:
- Initial Vitals/Trigger: 96.0 90 161/95 19 100%
- Pt confused but not obtunded.
- EKG: ___ @ 101, RAD, NI, no STE
- Labs notable for: WBC 9.2, Hct 44.7, Na 130, K 5.4, bicarb 19,
AG 20, glucose 672, BUN/Cr ___, Ca ___, P 6.4, lactate 3.7;
UA with 1000 glucose and 40 ketones (no leuks); VBG 7.___
- Pt given zofran and started on an insulin gtt
- IVF given include 4L NS
- CT head without acute process
- Pt with only 1 PIV so placed R IJ CVL.
- Pt admitted to the MICU for further mgmt of DKA.
- Repeat labs to be sent prior to transfer. Repeat VBG:
7.35/___
- Vitals prior to transfer: 38.5 115 155/68 23 100% RA , FSG 433
- 5mg of Zypexa given
On arrival to the MICU, she is still alert, awake but confused
and incomprehensible speech. Vitals are: T:100.1 BP:142/65 P:114
R: 18 O2: 95%RA
On arrival to the floor, the patient reports she wasn't feeling
well the evening prior to admission- it is unclear if she took
her insulin. When she woke up, she noted her vision was worse
and she was unable to check her sugar. She was concerned so she
called ___.
Past Medical History:
1. IDDM: A1c 10.8 in ___. ED visit in ___ after being
found down with AMS and blood sugar to 14.
2. CAD s/p stenting to LAD
3. HL
4. HTN
5. Dysphagia
6. Depression
7. Osteopoenia
8. S/p L eye enucleation w/ prosthesis
9. R eye glaucoma
10. S/p R leg pinning
-Recent NSTEMI with DKA episode on ___ now medically managed
(as above)
-Motor vehicle accident in ___, status post facial
reconstruction
-Multiple episodes of dysarthria including ___ with negative
MRI and MRA and negative EEG. In ___, she had dysarthria,
left-sided weakness, and diabetic ketoacidosis. Negative stroke
workup in ___. Negative CT and CTA. Seen also by Neurology (Dr.
___ in ___.
Social History:
___
Family History:
Negative for stroke, seizures or peripheral
nerve palsy. Diabetes is present in her sister and aunt. Her
sister also had stomach cancer. Her mother died at ___ from
Alzheimer's. The patient had five siblings, one little brother
died at age ___. He drowned in ___. Another brother died
in the ___ War. Her father died in ___. The patient was
married in ___
Physical Exam:
ADMISSION:
Vitals: T:100.1 BP:142/65 P:114 R: 18 O2: 95%RA
General- Alert, confused. no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear . right pupil
unreactive
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- tachycardic.Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge:
Physical exam:
VS:98.3 Bp: 123/60 HR: 62 R 16 O2: 94% RA
FSBS: 172, 173, 277, 254, 144 (Glucose on BMP 69 this AM)
Sitting in chair in NAD. Pleasant and conversant. Awake alert
and oriented
HEENT: Scar on scalp. No LAD
Lungs: Clear B/L on auscultation
___: RRR, S1, S2 present
ABD: Soft, NT, ND
EXT: No edema
Pertinent Results:
___ 08:00PM BLOOD Glucose-672* UreaN-28* Creat-1.1 Na-130*
K-5.4* Cl-91* HCO3-19* AnGap-25*
___ 12:00AM BLOOD Glucose-352* UreaN-22* Creat-0.7 Na-141
K-4.2 Cl-110* HCO3-18* AnGap-17
___ 08:00PM BLOOD Neuts-86.4* Lymphs-9.9* Monos-3.3 Eos-0.2
Baso-0.2
___ 08:00PM BLOOD WBC-9.2 RBC-4.82 Hgb-13.4 Hct-44.7#
MCV-93# MCH-27.8 MCHC-30.0* RDW-12.8 Plt ___
___ 08:00PM BLOOD Albumin-4.7 Calcium-10.5* Phos-6.4*#
Mg-2.5
___ 12:00AM BLOOD Calcium-8.6 Phos-3.1# Mg-2.1
___ 08:00PM BLOOD ALT-35 AST-26 AlkPhos-166* TotBili-1.4
___ 12:00AM BLOOD CK(CPK)-123
___ 10:03PM BLOOD ___ pO2-42* pCO2-51* pH-7.23*
calTCO2-22 Base XS--6
___ 12:18AM BLOOD ___ pO2-49* pCO2-41 pH-7.35
calTCO2-24 Base XS--2
___ 08:19PM BLOOD Lactate-3.7*
___ 02:21AM BLOOD Lactate-1.5
Micro:
___ 3:47 am Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
PORTABLE CHEST XRAY ___
IMPRESSION:
Low lung volumes. Patchy bibasilar airspace opacities likely
reflect areas of atelectasis but infection is not excluded.
CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Lantus (insulin glargine) 10 units subcutaneous BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. HumaLOG (insulin lispro) 50 units daily per sliding scale
subcutaneous DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Glargine 11 Units Breakfast
Glargine 11 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetic ketoacidosis
Acute renal failure
Metabolic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ with diabetic ketoacidosis. Confirmation of line placement.
COMPARISON: Chest radiograph ___.
FINDINGS: Portable upright frontal view of the chest. A new right internal
jugular line ends in the low superior vena cava. The lung volumes are low.
There is no focal opacities, pleural effusion or pneumothorax. The aortic
knob is calcified. The pulmonary arteries are enlarged. The heart size is
normal. There is no free air beneath the hemidiaphragms.
IMPRESSION:
1. A new right internal jugular line ends in the low superior vena cava.
2. The pulmonary arteries are enlarged. Correlation with clinical signs and
symptoms is recommended to exclude pulmonary hypertension.
COMMENT: Findings discussed with ___ by ___ at 0720 ___.
Radiology Report
HISTORY:
Altered mental status.
TECHNIQUE: Portable upright AP view of the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are low. The heart size is mildly enlarged. The mediastinal
contours are unchanged, with mild tortuosity of the thoracic aorta again
noted. The aorta is diffusely calcified. There is crowding of the
bronchovascular structures without overt pulmonary edema demonstrated. Patchy
opacities in the lung bases likely reflect areas of atelectasis. Pneumonia,
however, cannot be completely excluded. No pleural effusion or pneumothorax
is seen. There are no acute osseous abnormalities.
IMPRESSION:
Low lung volumes. Patchy bibasilar airspace opacities likely reflect areas of
atelectasis but infection is not excluded.
Radiology Report
HISTORY: Altered mental status.
TECHNIQUE: Multi detector CT scan of the head without IV contrast.
Reformatted images were provided.
COMPARISON: CT head ___.
FINDINGS: There is no acute hemorrhage, edema, mass, mass effect or acute
large vascular territorial infarction. The basal cisterns are patent and
there is preservation of gray-white matter differentiation. Prominence of
ventricles and sulci likely represents age-related involutional changes.
Periventricular and subcortical white matter hypodensities reflect chronic
small vessel ischemic disease. Dense atherosclerotic calcifications of the
cavernous carotid arteries are noted, with less extensive atherosclerotic
calcifications seen in the distal vertebral arteries.
No fracture is identified. The paranasal sinuses and mastoid air cells are
clear. There is a left globe prosthesis.
IMPRESSION: No acute intracranial process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hyperglycemia, Altered mental status
Diagnosed with DIAB KETOACIDOSIS IDDM
temperature: 96.0
heartrate: 90.0
resprate: 19.0
o2sat: 100.0
sbp: 161.0
dbp: 95.0
level of pain: 13
level of acuity: 2.0 | ___ with h/o IDDM (last HbA1C 11.6 % ___, CAD s/p stenting,
HTN, HLD brought in by EMS due to altered mental status, found
to be in DKA.
# DKA: Patient with hyperglycemia to the 600's, pH of 7.23,
serum bicarb of 19, urine with glosuria and ketones. Unclear
trigger for this event since patient unable to provide history.
DDx include medication noncompliance or infectious etiology
given fever in ED. Chest xray with no obvious consolidation and
UA not suspicious for UTI. Other possibilities include MI but no
acute ischemic changes on EKG. No evidence of stroke on CT head.
Most likely medication noncompliance as patient stated later in
course of stay that her vision has inhibited her from being able
to give herself insulin injections. In the ICU she received IVF,
Insulin IV drip and potassium was repleted. Once she was able to
eat, with improved glucose and a closed anion gap she was
started on SC insulin, with the IV drip subsequently
discontinued. ___ was consulted for assistance with ___
management and social work for resources at home with medication
administration. The patient will be discharge on Lantus 11 units
BID. She was seen by the ___ Nurse educator and was able to
demonstrate understanding of the importance of always taking her
long acting insulin.
# AMS: Most likely as a result of DKA. She was ruled out for an
infectious process.Chest xray with no obvious pneumonia and UA
with no e/o UTI. Flu swab was negative. She returned to baseline
mental status alert and Oriented x 3 in <24hours after
admission.
___: Most likely pre-renal azotemia with volume depletion in
DKA. Resolved with hydration
#Coronary artery disease
Initally isosorbide was held. ASA statin beta-blocker and
isosorbide were resumed prior to discharge.
#Hypertension
Lisinopril held on admission due to ___, all blood pressure
medications were resumed prior to discharge with good control.
#Dispo/follow up: The patent was seen by the clinical resource
specialist and a mass health application was filled out during
the hospitalization to help the patient get more services in the
home. The patient was set up with ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Iodine-Iodine Containing / amoxicillin
Attending: ___.
Chief Complaint:
Left elbow fracture/dislocation, left ankle fracture
Major Surgical or Invasive Procedure:
___: ORIF L Elbow
History of Present Illness:
___ RHD w/ hx HTN, COPD, Bladder Ca p/w L elbow terrible triad &
left Weber A fibula fracture s/p fall down stairs s/p ORIF L
terrible triad ___, ___
Past Medical History:
COPD
HTN
hypercholesterolemia
bladder CA s/p surgical removal ___
s/p breast lump/cyst removal
rheumatic fever
Social History:
___
FAMILY HISTORY:
Breast cancer in sister, cousins. T2DM in brother, father. No
FHx of bleeding.
Family History:
Breast cancer in sister, cousins. T2DM in brother, father. No
FHx of bleeding.
Physical Exam:
Left upper extremity:
- Arm in posterior slab splint
- Soft, non-tender arm
- Full, painless active/passive ROM of shoulder, digits
- EPL/FPL/DIO (index) fire
- Sensation intact to light touch in
axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, fingers warm and well perfused
Pertinent Results:
___ 04:50AM GLUCOSE-130* UREA N-21* CREAT-0.6 SODIUM-139
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-27 ANION GAP-14
___ 04:50AM WBC-12.2* RBC-3.96 HGB-10.7* HCT-33.3* MCV-84
MCH-27.0 MCHC-32.1 RDW-14.6 RDWSD-45.1
Medications on Admission:
Albuterol Inhaler 1 PUFF IH Q6H:PRN wheexing
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 325 mg PO BID Duration: 28 Days
RX *aspirin 325 mg 1 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*42 Tablet Refills:*0
5. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left elbow fracture-dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fracture/dislocation.
COMPARISON: Outside hospital radiographs between 4 and 6 hours prior.
FINDINGS:
A cast obscures fine osseous detail. The elbow joint dislocation has been
reduced compared to the initial outside hospital radiographs. There is a
displaced and angulated radial neck fracture. The radial head does not
articulate with the distal humerus. A triangular ossific density projecting
over the anterior cortex of the distal humerus probably reflects a fractured
coronoid process.
IMPRESSION:
1. Displaced and angulated radial neck fracture. The radial head does not
articulate with the distal humerus (fracture dislocation).
2. Probable coronoid process fracture.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with left radial head fx/dislocation. Also mild hypoxia.
TECHNIQUE: Frontal view of the chest
COMPARISON: ___ chest radiographs
___ chest CT
FINDINGS:
Linear atelectasis at the right lung base is unchanged. The lungs are
otherwise well expanded and clear. No pleural effusion or pneumothorax.
Heart size is mildly enlarged. The mediastinal silhouette is otherwise
unremarkable.
IMPRESSION:
No evidence of an acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT UP EXT W/O C LEFT
INDICATION: ___ year old woman with L elbow terrible triad// Elbow terrible
triad Elbow terrible triad
TECHNIQUE: Transaxial images of the left elbow were obtained without
intravenous contrast. Sagittal and coronal reformats were created. Please
note this study was originally entered into PACs as a right elbow
examination.. However, the images were correctly obtained through the left
elbow and properly correlate with left elbow radiographs from ___. The imaged labral in PACs was subsequently corrected to be labeled
correctly as left elbow.
DOSE: DLP: 552.46mGy/cm
COMPARISON: Same-day left elbow radiographs; targeted review of CT chest ___ and mammogram ___
FINDINGS:
Compared to ___ at 03:51, again seen is a comminuted
fracture-dislocation of the left radial head with the radial head located
posterior and inferior to the capitellum. A 1.1 cm fracture fragment is
located superior to the capitellum in the coronoid fossa (400/79), which may
represent a fragment of the radial head or the coronoid process. However,
this appears larger than the potential coronoid process donor site. There is
persistent posterior subluxation of the proximal ulna with respect to the
distal humerus/trochlea (400/79). There are few tiny subcentimeter fracture
fragments in the joint space. There is a moderate elbow joint effusion. There
is associated soft tissue swelling and probable fluid in the olecranon bursa..
No additional fractures are identified. Visualized portions of the left lung
and left flank are grossly unremarkable.
There are a few small rounded soft tissue nodules in the left breast (___),
stable dating back to ___ chest CT.
IMPRESSION:
IMPRESSION-LEFT ELBOW:
1. Redemonstration of a comminuted fracture-dislocation of the left radial
head with the left radial head posterior and inferior to the capitellum.
Multiple fracture fragments surrounding the joint.
2. Possible small fracture of the tip of the coronoid process. Note is made
of a fragment of the coronoid recess of the distal humerus, though this may
arise from the radius as it appears larger than the potential coronoid process
donor site.
3. Persistent posterior subluxation of the proximal ulna with respect to the
distal humerus/trochlea.
4. No additional fractures detected about the left elbow.
5. Few unchanged subcentimeter nodules in the left breast. Recommend
correlation with mammography.
RECOMMENDATION: Recommend correlation with mammography for further evaluation
of subcentimeter nodules in the left breast.
Radiology Report
INDICATION: Left elbow fracture. ORIF.
COMPARISON: CT scan from ___.
IMPRESSION:
There has been placement of a radial head prosthesis. No hardware related
complications are seen. The total intra service fluoroscopic time is 4.6
seconds. Please refer to the operative note for additional details.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ year old woman with L elbow fx and L ankle fx// foot pain
TECHNIQUE: Two views of the left foot
COMPARISON: None
FINDINGS:
There is remodeling of the fourth metatarsal distal shaft, compatible with a
subacute or chronic fracture. Lateral angulation of the distal fracture
fragment is present.
There is also some remodeling of the fifth metatarsal base, also compatible
with subacute or chronic fracture. Mild first MTP joint degenerative changes
are present. There is a small plantar calcaneal spur.
IMPRESSION:
Subacute or chronic fractures of the base of the fifth metatarsal and distal
shaft of the second metatarsal.
RECOMMENDATION(S): Correlation with prior imaging if available. Consider
oblique view to better delineate fracture lines at the above sites.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Elbow fracture, Transfer
Diagnosed with Disp fx of head of left radius, init for clos fx, Fall (on) (from) other stairs and steps, initial encounter
temperature: 97.2
heartrate: 78.0
resprate: 16.0
o2sat: 94.0
sbp: 129.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left elbow fracture dislocation and left ankle
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for ORIF L
elbow, which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ 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
non weight-bearing in the left upper extremity, and will be
discharged on aspirin 325mg BID 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: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hip infection
Major Surgical or Invasive Procedure:
___: Left hip irrigation and debridement, VAC placement
History of Present Illness:
___ year old male with a PMH of cirrhosis, L THA in ___ c/b
multiple PJI and I&D, most recently s/p L hip arthrotomy and
debridement, gluteus maximus muscle flap to the L hip
girdlestone
defect (Dr. ___ - ___ who presents from ___
clinic with concerns of left hip wound infection.
Patient has been in rehab after his last surgery and endorses
worsening left hip pain over the past two days without any
fevers. The nurse at the rehab facility was concerned that his
wound was closing down so he presented to ___ clinic for
evaluation. Per report, his wound has been draining daily in
excess amount of 300 cc. He denies any fevers or warmth over the
hip. No numbness or paresthesias. He was noted to have purulent
and foul smelling drainage at the clinic and sent in for further
evaluation.
Of note, patient is not currently on antibiotics. He last
completed a 6 week course of Cefazolin (last day ___
His orthopedic history is as follows:
___: left total hip replacement (___)
___: Removal of left hip components with irrigation and
debridement and antibiotics spacer (___)
___: Irrigation and debridement left hip (___)
___: Irrigation and debridement left hip (___)
___: Irrigation and debridement left hip (___)
___: Irrigation and debridement left hip with removal of
antibiotic spacer (___)
___: Irrigation and debridement left hip (___)
___: Irrigation and debridement left hip (___)
___: Irrigation and debridement left hip (___)
___: Radical debridement of left hip wound with
Rectus femoris pedicle flap and adjacent tissue transfer
Keystone
flap (___)
___: Placement of left hip articulating spacer and skin flap
by Dr. ___ - HIP REPLACEMENT TOTAL COMPLEX LEFT, gluteus
maximus transfer, rectus femoris muscle reelevation and
transposition, local tissue rearrangement, scar revision
anterior
thigh, incisional NPWT
___: Left THA revision - articulating spacer resection,
girdlestone procedure, plastics exposure / closure
___: Arthrotomy and debridement, left hip. Extensive
debridement of subcutaneous tissue, muscle and bone. Gluteus
maximus muscle flap to left hip Girdlestone defect. Local tissue
rearrangement, 40 x 10 cm. (Dr. ___
Past Medical History:
-IVDA heroin
-PTSD
-Bipolar disorder
-Hepatitis C s/p interferon treatment in prison in ___ with
subsequent undetectable viral loads per patient
Social History:
___
Family History:
NC
Physical Exam:
***
Pertinent Results:
___ TISSUE GRAM STAIN-FINAL; TISSUE-PRELIMINARY
{STAPH AUREUS COAG +, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS),
BETA STREPTOCOCCUS GROUP B, MIXED BACTERIAL FLORA, PSEUDOMONAS
AERUGINOSA}; ANAEROBIC CULTURE-FINAL; ACID FAST SMEAR-FINAL;
ACID FAST CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 200 mg PO QAM
2. ClonazePAM 0.5 mg PO TID
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H shortness of breath,
wheezing
4. Gabapentin 300 mg PO TID
5. GlipiZIDE XL 5 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 500 mg PO BID
7. Mirtazapine 45 mg PO QHS
8. Prazosin 2 mg PO QHS
9. OxyCODONE (Immediate Release) 5 mg PO QID
10. QUEtiapine extended-release 175 mg PO DAILY
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
sheezing
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. CefePIME 2 g IV Q8H
RX *cefepime 100 gram 2 grams IV Every 8 hours Disp #*30 Bag
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous Nightly Disp
#*30 Syringe Refills:*0
6. Senna 8.6 mg PO BID
7. Vancomycin 1000 mg IV Q 8H bloodstream infection
RX *vancomycin 1 gram 1 gram IV Every 8 hours Disp #*30 Vial
Refills:*0
8. BuPROPion (Sustained Release) 200 mg PO QAM
9. ClonazePAM 0.5 mg PO TID
10. Gabapentin 300 mg PO TID
11. GlipiZIDE XL 5 mg PO DAILY
12. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
sheezing
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H shortness of
breath, wheezing
14. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
15. Mirtazapine 45 mg PO QHS
16. OxyCODONE (Immediate Release) 5 mg PO QID
17. Prazosin 2 mg PO QHS
18. QUEtiapine extended-release 175 mg PO DAILY
19.Outpatient Lab Work
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose:
CefePIME 2 g IV Q12H
Vancomycin 1g Q8H
Start Date: ___
Projected End Date: ___
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, Vancomycin trough, CRP
FOLLOW UP APPOINTMENTS: The ___ will schedule follow up
and
contact the patient or discharge facility. All questions
regarding outpatient parenteral antibiotics after discharge
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left hip infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LEFT HIP CT
INDICATION: ___ with complicated left hip wound now with increased
drainage.// Eval abscess, osteo
TECHNIQUE: Continuous axial images of the left pelvis obtained from the level
of the iliac wing to the left mid femur, after the administration of
intravenous contrast. Coronal and sagittal reformats were reconstructed.
DOSE: Total DLP (Body) = 924 mGy-cm.
COMPARISON: CT lower extremity ___.
FINDINGS:
Patient post removal of left hemiarthroplasty antibiotic spacer, femoral head
osteotomy and left gluteal flap vision.
Patient is status post interval left hip debridement and drainage with an open
wound and interval packing of the soft tissues lateral to the left greater
trochanter and postsurgical changes including subcutaneous emphysema along the
debridement tract. Along the tract of the open wound, there is a small pocket
of some residual fluid measuring 2.2 x 2.4 cm. This is best seen on series 3,
image 41. There is moderate surrounding intramuscular/subcutaneous edema.
Again demonstrated, is a similar sized 2.4 x 1.9 cm enhancing soft tissue
fluid collection within the left acetabulum.
There is similar osseous fragmentation of the proximal femur and acetabulum.
Visualized portions of the pelvis demonstrate no additional significant
findings.
IMPRESSION:
1. Status post left hip soft tissue debridement and abscess drainage, with
postsurgical changes and minimal fluid collection in a debridement bed.
2. Redemonstration of 2.4 cm enhancing collection in the left acetabulum soft
tissues.
3. Similar degree of osseous fragmentation of the proximal femur and
acetabulum. No evidence of ongoing aggressive osseous destruction.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new L PICC// 54 cm L basilic SL PICC- ___
___ Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax identified.
The tip of the left PICC line projects over the cavoatrial junction. The size
of the cardiomediastinal silhouette is within normal limits.
IMPRESSION:
The tip of the left PICC line projects over the cavoatrial junction. No
pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Infect/inflm reaction due to int fix of left femur, init, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 97.5
heartrate: 98.0
resprate: 14.0
o2sat: 99.0
sbp: 110.0
dbp: 80.0
level of pain: 7
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left hip infection and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for irrigation and debridement of left hip with wound
VAC placement, 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 back to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
Patient was evaluated by the infectious disease service who
initially started the patient on broad-spectrum antibiotics
including Vanco, cefepime, and Flagyl. Patient's intraoperative
cultures eventually speciated the following: STAPH AUREUS COAG
+, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS), BETA STREPTOCOCCUS
GROUP B, MIXED BACTERIAL FLORA, PSEUDOMONAS AERUGINOSA. Given
the lack of anaerobic growth, patient was discharged on a 6-week
course of vancomycin and cefepime with outpatient infectious
disease follow-up. He will follow-up with plastic surgery for
management of his soft tissue coverage. Patient remained
afebrile, hemodynamically stable, without leukocytosis
throughout his hospital admission.
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
touchdown weightbearing in the left lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Left heart catheterization s/p DES to RCA
History of Present Illness:
___ year old man with PMHx myopericarditis, DM, HTN who presents
with a complaint of chest pain.
Patient states that 4 weeks ago he developed left chest pain and
ultimately presented to ___ where he was diagnosed with
pericarditis. He was started on colchicine and ibuprofen at that
time and seen by his PCP subsequently and started on prednisone
after no improvement of his symptoms despite round the clock
alternating Tylenol and ibuprofen. However, he was only able to
take one dose of prednisone prior to presenting to the hospital.
In the ED...
Initial vitals: 97.9 86 146/89 18 97% RA
Exam: Comfortable, RRR. No m/r/g. CTAB, Nonlabored respirations.
Soft abd, NT, ND. No edema, cyanosis, or clubbing. Normal
mentation.
EKG: NSR 79, normal axis, intervals, late R transition, no
ischemic STT changes
Patient was admitted to ED Observation and had 2 negative
troponins. He was sent for stress test notable for ___ chest
pain on arrival that increased to ___ during exam that stopped
the test but did not have any changes c/f ACS or changes in
vitals that were concerning. Nuclear perfusion test was positive
for perfusion defect of the inferolateral wall of the left
ventricle, with almost complete reversibility.
Labs/studies notable for:
- normal CBC, INR, WBC 9.6 -> 12.8
- normal BMP, Na 134 -> 143, BUN/Cr ___ -> ___
- Trop < 0.01 x 3
- CXR: No acute cardiopulmonary process.
- CTA Chest: No evidence of pulmonary embolism or aortic
abnormality, no acute intrathoracic process.
- Cardiac perfusion: Moderate perfusion defect of the
inferolateral wall of the left ventricle, with almost complete
reversibility. LVEF 61%
Patient was given:
Aluminum-Magnesium Hydrox.-Simethicone 30 mL
Acetaminophen 1000 mg x 2
Ibuprofen 800 mg
Donnatal 5 mL
Lidocaine Viscous 2% 10 mL
Metoprolol Succinate XL 50 mg x 2
Ranitidine 150 mg x 3
PredniSONE 30 mg x 3
Colchicine 0.6 mg x 3
IV Ketorolac 15 mg
Acetaminophen 650 mg x 2
IVF LR Started 250 mL/hr
On the floor, patient denies current fever, chills, cough, sore
throat, current chest pain, SOB, abd pain, N/V/D, dysuria,
hematuria, bloody BMs, arthralgias, myalgias, rash, numbness,
tingling, weakness, falls.
His pain is worse at night and whenever he lays down, feels like
a central stabbing sensation, alleviated and nearly always
resolved with sitting forward and standing after about 30
minutes. On further questioning, he does state that since his
presentation to ___, he has a new type of susbsternal sensation
when he climbs stairs. If is not associated with nausea,
diaphoresis, light headedness, blurred vision. He had an upper
respiratory infection 4 weeks before the onset of symptoms. He
had chest congestion, cough productive of phlegm without fevers,
N/V/D, rash, exposure to children or myalgias.
To control the pain the patient has been taking ibuprofen
800mg-1600mg BID depending on severity, without much relief.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes Y
- Hypertension Y
- Dyslipidemia Y
2. CARDIAC HISTORY
- CABG: ___: Angiographically minimal coronary artery disease
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
MYOCARDITIS at ___, ___ and ___
NECK PAIN
HYPERTENSION
DIVERTICULITIS ___
DIABETES MELLITUS
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Mother Living ___ DIABETES MELLITUS, BREAST CANCER
Father Living ___ THROAT CANCER
Uncle ___ ___ MYOCARDIAL INFARCTION, DIABETES MELLITUS
Brother Living ___
Brother Living ___ HIP REPLACEMENT
Sister Living ___
Physical Exam:
ADMISSION EXAM
===============
VITALS: 98.1 150/87 75 16 95% RA
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor
or cyanosis of the oral mucosa.
NECK: Supple with no elevated 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.
SKIN: Warm, dry, no rash
DISCHARGE EXAM
==============
VITALS: T: 97.7 PO BP: 137/83 L Lying HR: 67 RR: 16 O2 sat: 97%
O2 delivery: Ra
GENERAL: Well-appearing, NAD
HEENT: Sclera anicteric. PERRL, EOMI. Pink mmm
NECK: Supple with no elevated JVD
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops
LUNGS: comfortable on room air, CTAB, no crackles or wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ radial pulses bilateral, dry dressing over
radial
access s site
SKIN: Warm, dry, no rash
Pertinent Results:
ADMISSION LABS
___ 09:50PM ___ PTT-33.6 ___
___ 09:50PM NEUTS-83.7* LYMPHS-11.2* MONOS-4.4* EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-8.01* AbsLymp-1.07* AbsMono-0.42
AbsEos-0.01* AbsBaso-0.02
___ 09:50PM WBC-9.6 RBC-5.26 HGB-15.6 HCT-45.5 MCV-87
MCH-29.7 MCHC-34.3 RDW-13.2 RDWSD-41.7
___ 09:50PM cTropnT-<0.01
___ 09:50PM GLUCOSE-155* UREA N-16 CREAT-1.0 SODIUM-134*
POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-14
___ 02:58AM cTropnT-<0.01
DISCHARGE LABS
___ 06:15AM BLOOD WBC-7.7 RBC-4.95 Hgb-14.6 Hct-43.7 MCV-88
MCH-29.5 MCHC-33.4 RDW-13.9 RDWSD-44.5 Plt ___
___ 06:15AM BLOOD Glucose-92 UreaN-19 Creat-1.0 Na-141
K-4.6 Cl-102 HCO3-26 AnGap-13
___ 06:15AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.1
OTHER LABS
___ 06:00AM BLOOD Triglyc-201* HDL-42 CHOL/HD-5.4
LDLcalc-143*
PERTINENT IMAGES
___ EXERCISE STRESS
INTERPRETATION: This ___ year old man with a h/o HTN,
pre-diabetes
and myopericarditis was referred to the lab from the ED
following
negative serial cardiac biomarkers for evaluation of chest
discomfort.
The patient exercised for 10.25 minutes of a modified ___
protocol and the test was stopped at the patients request for
progressive chest
discomfort. The estimated peak MET capacity is 8.5, representing
an
average functional capacity for his age. The patient presented
to the
lab with a ___ substernal chest discomfort, which was the same
discomfort he was referred for. This discomfort progressively
increased
to an ___ at peak exercise and slowly improved with rest during
recovery, returning to baseline by 10 minutes of recovery. At
peak
exercise, there was 0.5 mm upsloping ST segment depression in
leads I,
the inferior leads and V4-6. These changes resolved with rest
and were
absent by 10 minutes of recovery. The rhythm was sinus with one
isolated APB and one isolated VPB. Appropriate blood pressure
response to exercise and recovery with a slightly blunted heart
rate response to
exercise (83% APMHR) in the setting of beta blockade.
IMPRESSION: Atypical anginal type symptoms with non-specific EKG
changes. Appropriate hemodyanmic response to exercise. Average
functional capacity. Nuclear report sent separately.
___ CARDIAC PERFUSION
FINDINGS: The image quality is adequate
Left ventricular cavity size is 96 cc
Resting and stress perfusion images reveal a moderate perfusion
defect at the inferolateral wall, with almost complete
reversibility.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 61 %.
IMPRESSION: 1. Moderate perfusion defect of the inferolateral
wall of the left ventricle, with almost complete reversibility.
2. LVEF 61%
___ CTA CHEST
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus. The thoracic aorta is normal in caliber
without evidence of dissection or intramural hematoma. There
are mild coronary artery calcifications. Otherwise, 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: Mosaic, heterogeneous background appearance
likely secondary to patient's expiratory phase. Allowing for
this, lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the
segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No acute intrathoracic process.
___ TTE
The left atrial volume index is mildly increased. 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 70 %. Left ventricular cardiac index is normal (>2.5
L/min/m2). Diastolic function could not be assessed. Normal
right ventricular cavity size with normal free wall motion. The
aortic sinus is mildly dilated with mildly dilated ascending
aorta. The aortic valve leaflets (3) appear structurally normal.
There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
leaflets appear structurally normal. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is trivial tricuspid regurgitation. The pulmonary
artery systolic pressure could not be estimated. There is no
pericardial effusion.
IMPRESSION: 1) Normal biventricular regional/global systolic
function. 2) Mild thoracic aortic diltation. Compared with the
prior TTE (images reviewed) of ___, the findings are
similar.
CLINICAL IMPLICATIONS: The patient has a mildly dilated
ascending aorta. Based on ___ ACCF/AHA Thoracic Aortic
Guidelines, if not previously known or a change, a follow-up
echocardiogram is suggested in ___ year; if previously known and
stable, a follow-up echocardiogram is suggested in ___ years.
___ CARDIAC CATH
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The ___ is without any flow limiting stenosis.
* Left Anterior Descending
The LAD has a mid 70% stenosis.
* Circumflex
The Circumflex is without any flow limiting stenosis.
* Right Coronary Artery
The RCA had an ulcerated distal 70-80% stenosis.
Interventional Details
Based on the diagnostic coronary angiogram and that RCA appeared
acute lesion (culpruit) we decided to proceed with PCI to the
___ after discussion with Mr. ___ and Dr. ___. Heparin
boluses were given prophylactically for an ACT >250s and the
patinet was loaded with 600 mg of PO plavix at the end of the
procedure. A 6 fr. AL-0.75 guide provided good support for the
procedure. A short Asahi Prowater wire crossed into the RPDA
with minimal dificulty. We then pre-dilated with a 2.5 mm
balloon at 12 ATM for ___ x2 and then delivered a 3.5*18 mm Onyx
DES at 16 ATM for ___, post-dilated to 3.5 mm NC balloon at 18
ATM for ___ x3. Final angiogram revealed no redisual and TIMI 3
flow without any visible evidence of dissection or rupture.
Intra-procedural Complications: None.
Impressions:
Midlly elevated left-side filling pressures. Two-vessel
epicardial CAD with 70% mLAD and a 80% ulcerated RCA succesfully
treated with 1 DES.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Ranitidine 150 mg PO BID
4. Vitamin D ___ UNIT PO DAILY
5. PredniSONE 10 mg PO TID
Start: ___
This is dose # 1 of 3 tapered doses
6. PredniSONE 10 mg PO BID
This is dose # 2 of 3 tapered doses
7. PredniSONE 10 mg PO DAILY
This is dose # 3 of 3 tapered doses
8. Zinc Sulfate 50 mg PO DAILY
Discharge Medications:
1. Aspirin 650 mg PO TID
RX *aspirin 325 mg 2 tablet(s) by mouth three times a day Disp
#*84 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. MetFORMIN (Glucophage) 500 mg PO QPM
RX *metformin 500 mg 1 tablet(s) by mouth every evening Disp
#*30 Tablet Refills:*0
6. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 tablet(s) by mouth twice daily Disp #*14
Tablet Refills:*0
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Ranitidine 150 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Zinc Sulfate 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Pericarditis
# Unstable angina
# Coronary artery disease s/p DES to 80% RCA lesion
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 mid sternal chest pain radiating to the back.//
eval for dissection, less likely 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) = 483 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. There are mild coronary artery calcifications.
Otherwise, 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: Mosaic, heterogeneous background appearance likely secondary to
patient's expiratory phase. Allowing for this, lungs are clear without masses
or areas of parenchymal opacification. The airways are patent to the level of
the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No acute intrathoracic process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs, Essential (primary) hypertension
temperature: 97.9
heartrate: 86.0
resprate: 18.0
o2sat: 97.0
sbp: 146.0
dbp: 89.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is a ___ with PMHx of myopericarditis, DM, HTN who
presented with ongoing chest pain concerning for pericarditis
and new unstable angina with a positive nuclear stress test
found to have CAD on LHC now s/p DES to the right coronary
artery.
# Unstable angina
# Coronary artery disease
Patient presented with new exertional chest discomfort for the
last 4 weeks without evidence of cardiac enzyme leak. He
underwent an exercise stress test, limited by chest pain, in the
emergency department which showed nonspecific 0.5 mm upsloping
ST segment depression in leads I, the inferior leads and V4-6.
Nuclear stress was concerning for perfusion defect of the
inferolateral wall of the left ventricle. Given risk factors and
stress test, patient underwent LHC via right radial access on
___ which revealed 70% LAD stenosis and RCA stenosis with
ulceration. RCA was stented with 3.5*18 mm Onyx DES. He was
loaded with Plavix and started on 75mg daily on ___ for DAPT.
Patient was already on high dose ASA for pericarditis. He was
started on atorvastatin 80mg and Lisinopril 5mg. He was
continued on home metoprolol. TTE with preserved ejection
fraction and no wall motion abnormalities at rest.
# Pericarditis
History concerning for positional pericarditis pain. He has a
history of recurrent myopericarditis previously. Troponins were
negative x 4. ESR 9, CRP 4.7. No evidence of clinical tamponade
and no pericardial effusion on TTE. The patient was started on
high dose aspirin 650mg TID, colchicine 0.6mg BID, and
acetaminophen. Symptoms improved with this treatment. Suspect
that etiology of chest pain was mixed, related to both
pericarditis and CAD. He should continue on high dose ASA for
___ weeks and colchicine for at least 6 months.
# HTN: Patient was continued on home metoprolol succinate 50mg
daily. He was also started on low dose Ace-I Lisinopril 5mg.
# DM: Last A1c ___ 6.9%. Blood sugars were controlled with an
insulin sliding scale in-house and patient was started on
metformin at time of discharge.
# HLD: Lipid panel cholesterol 225, ___ 201, HDL 42, LDL 143.
Patient was started on atorvastatin 80mg daily.
TRANSITIONAL ISSUES
===================
[ ] Pericarditis: Patient started on high dose aspirin 650mg TID
and colchicine 0.6mg BID. Aspirin should be tapered in 1 week.
Colchicine should be continued for a minimum of 6 months given
his recurrent episodes.
[ ] start aspirin 81mg when no longer needs high dose aspirin
[ ] DAPT for 12 months; 30 months if patient can tolerate.
[ ] Consider stress test to assess mLAD stenosis or proceed to
PCI if symptoms persist.
[ ] HTN: Patient started on Lisinopril 5mg. Should have
electrolytes and Cr checked in one week.
[ ] DM: Last A1c ___ 6.9%. Patient was started on metformin
500mg daily |
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:
EGD
History of Present Illness:
Mr. ___ is a ___ with obesity, HTN, DM2, cannabis use
and other issues who presented to the ED with nausea/vomiting.
___ is very sleepy on my evaluation and not able to provide a
detailed history, but ___ confirms that the symptoms have been
ongoing since ___. ___ was previously on Metformin and
Lisinopril but has not seen a PCP in ___ long time and does not
remember who his PCP ___. ___ confirms that ___ has never been on
insulin. Regarding cannabis use, ___ tells me ___ smokes
approximately 4x per week. ___ has not had diarrhea, but ___ has
had worsening upper abdominal pain. ___ has not had blood in the
stool or vomitus. Reviewing his medication history tab in OMR,
___ was prescribed Amoxicillin and Clarithromycin, likely for H.
pylori, in ___. In the ED, ___ also reported predominantly
LUQ
abdominal pain that spreads across the abdomen. ___ endorsed
daily vomiting from this. ___ also reported frequent
constipation, but that his last BM was the morning of admission.
Throwing up typically makes the pain and nausea better ___ does
not report that hot showers improve his sytmptoms). In the ED
___
also reported SOB due to pain, but now his breathing is
comfortable. Denies weight loss, fevers but endorses occasional
chills.
In the ED, initial VS were 98.4 73 144/77 20 100% RA. Exam
notable for acute distress and upper abdominal tenderness to
palpation with hypoactive bowel sounds. Labs were notable for
WBC 7.5 with 84% PMNs, Hgb 13.5, plts 107, BUN/Cr ___, HCO3 18
but lytes otherwise WNL, LFTs and lipase WNL, Lactate 1.2, VBG
___, UA with 80 ketones, 30 protein, and few
bacteria,
Hgb A1c 7.2. EKG with a 1 mm ST segment elevation in V2 & V3
(troponins not sent), Abdomen XR showed normal bowel gas
pattern,
CT abdomen/pelvis showed hepatic steatosis and borderline
splenomegaly to 13 cm but no other acute pathology. ___ received
2L NS, Ondansetron 4 mg x2, Lorazepam 1 mg IV x2, Famotidine 20
mg, Acetaminophen 1g, Haloperidol 2.5 mg IV, and topical
Capsaicin and was admitted for ongoing oral intolerance. In the
ED ___ remained afebrile (Tm 99.5) and BP ranged from
120-160/80-110s. ___ was admitted for ongoing symptom control.
On arrival to the floor, the patient reports that his abdominal
pain and nausea have improved and complains only of mild
headache.
ROS: A 10-point review of systems was performed and was negative
with the exception of those systems noted in the HPI.
Past Medical History:
-Hypertension, previously on lisinopril
-Diabetes (type 2), previously on metformin
-Obesity
Social History:
___
Family History:
-Mother with diabetes
Physical Exam:
99.4
PO 160 / ___ 99 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
___ 06:55AM BLOOD WBC-6.8 RBC-5.12 Hgb-14.6 Hct-43.1 MCV-84
MCH-28.5 MCHC-33.9 RDW-11.9 RDWSD-36.4 Plt ___
___ 06:55AM BLOOD Glucose-152* UreaN-5* Creat-0.8 Na-138
K-3.5 Cl-98 HCO3-25 AnGap-15
___ 06:55AM BLOOD ___ PTT-30.3 ___
___ 03:13PM BLOOD ALT-14 AST-15 AlkPhos-69 TotBili-0.5
___ 03:13PM BLOOD Lipase-53
___ 06:55AM BLOOD proBNP-386*
___ 03:54PM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
___ 03:54PM BLOOD calTIBC-243* Ferritn-77 TRF-187*
___ 07:29PM BLOOD %HbA1c-7.2* eAG-160*
___ 03:13PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:20PM BLOOD Lactate-1.2
___ Gastroenterology EGD
Normal esophagus, duodenum. Mild erythema in antrum and moderate
erythema and congestion in stomach body. Biopsies taken.
___
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ year old man with IDDM presenting with
intermittent episodes
of intense abdominal pain associated w/ nausea and vomiting//
evaluate for
acute intra-abdominal process such as ischemia or infection
TECHNIQUE: Single phase split bolus contrast: MDCT axial
images were
acquired through the abdomen and pelvis following intravenous
contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy
(Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 6.5 s, 1.0 cm; CTDIvol = 15.0 mGy
(Body) DLP =
15.0 mGy-cm.
3) Spiral Acquisition 14.8 s, 51.1 cm; CTDIvol = 19.9 mGy
(Body) DLP =
989.8 mGy-cm.
Total DLP (Body) = 1,020 mGy-cm.
COMPARISON: None.
FINDINGS:
The study is limited due to motion artifact.
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous low attenuation
throughout,
suggestive of hepatic steatosis. There is no evidence of focal
lesions.
There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen is borderline enlarged measuring up to 13 cm
in
craniocaudal dimension. Spleen demonstrates attenuation
throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and
rectum are within normal limits. The appendix is 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
normal.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: There is mild diffuse anasarca. There is fatty
atrophy of the
bilateral gluteus maximus musculature.
IMPRESSION:
1. No acute intra-abdominal process to explain the patient's
symptoms.
2. Diffuse anasarca.
3. Hepatic steatosis.
4. Borderline enlarged spleen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
3. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. TraMADol 25 mg PO Q6H:PRN Pain - Severe
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Nausea, vomiting
HTN
Proteinuria
Anasarca and elevated proBNP
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with subacute RUQ abdominal pain now acutely
worsened// please evaluate gallbladder for Cholelithiasis. Please also
evaluate spleen for splenomegaly and splenic vasculature for thrombosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___ CT abdomen and pelvis with IV contrast
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: The spleen is not imaged in this study.
KIDNEYS: Limited views of the right kidney demonstrates no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Sonographically normal appearing liver parenchyma without intrahepatic
biliary dilatation.
2. Unremarkable gallbladder without stones or CBD dilatation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with 100 lb weight loss and nausea/vomiting.
Evaluation for any evidence of pneumonia or esophageal pathology, or evidence
of old TB (no concern for active disease).
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Cardiac silhouette is within the upper limits of normal. The pulmonary
vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax
is seen.
IMPRESSION:
No evidence of active malignancy or infection.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Unspecified abdominal pain, Vomiting without nausea, Shortness of breath
temperature: 98.4
heartrate: 73.0
resprate: 20.0
o2sat: 100.0
sbp: 144.0
dbp: 77.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ year old male with obesity, HTN, NIDDM2,
cannabis use, past H pylori infection ___ who presented to
the
ED with nausea/vomiting.
# Nausea/Vomiting with Abdominal Pain:
# History of H pylori infection and treatment course ___
-RUQ US here unremarkable. CT A/P here without intraabdominal
pathology evidence.
-___ reports ___ had positive urease breath test in ___ with
his
PCP ___ at ___ ___ and ___ did receive amoxicillin/clav with clarithromycin
for 2 weeks. His symptoms of nausea, vomiting, abdominal pain at
that time did improve somewhat, but has recurred since.
-Urine tox here negative. LFT unremarkable and negative lipase.
-Continue prn antiemetics, pain regimen at home
-Appreciate GI recommendations. EGD completed on ___ showing
no evidence of gastritis, or any mechanical gastric outlet
obstruction. Biopsies were taken.
-Stool H pylori testing here was sent and pending at time of
discharge.
-Patient will continue PPI PO BID empirically x 6 weeks pending
these biopsies for recurrent H
pylori infection (then gastroparesis or cannabinoid hyperemesis
is to be considered if negative).
# NIDDM2
- Not taking metformin at home
- Restarted metformin at discharge
# Hepatic steatosis on CT A/P: No evidence of steatohepatitis
given normal
LFTs
- Outpatient follow-up needed
- RUQ US was unremarkable
# Hypertension with proteinuria: His young age raises concern
for
secondary causes of hypertension, but we do not have records of
whether ___ has been adequately worked up for secondary causes.
- UTox unremarkable
- Uptitrated the lisinopril to 40 mg once daily
- Elevated urine protein/creatinine
- Should have nephrology referral as outpatient.
#elevated BNP and anasarca on CT scan
-Negative troponins and unremarkable EKG
-Definitely needs outpatient echocardiogram and workup for
possible chronic heart failure. ___ does not have shortness of
breath or chest pain or palpitations or evidence of arrhythmia
while in the hospital.
I left a voicemail to patient's PCP to ask them to call me back
to relay all the above information verbally.
Greater than 30 minutes was spent on discharge planning and
coordination. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cefaclor
Attending: ___.
Chief Complaint:
===============================
Hospital Medicine Admission Note
================================
Cc: fever
Major ___ or Invasive Procedure:
none
History of Present Illness:
This is a ___ y/o female with history of Crohn's disease on
infliximab who presentes with right sided chest pain and fever.
She says that she has been feeling poorly all week with body
aches. Today she woke up with right sided chest pain, cough and
shortness of breath. She says the chest pain was intially on
taking a deep breath but now is more constant. She then noted
fever this afternoon, denies shaking chills. Also complains of
fatigue and malaise for the past week.
She does report two days of diarrhea last week. No blood some
mucus. She attributes this to her Crohn's diasese. She also
complains of nausea but no vomiting. Does have a mild sore
throat and some nasal congestion. No sick contacts. Denies
dysuria, hesitancy, frequency.
Of note, she was hospitalized at the beginning ___ at ___.
___ where she was treaed for strep throat and
pneumonia with ceftriaxone and azithromycin. She was also
hospitalized in ___ at ___ with the flu.
In the ED: Vitals T: 101.9 BP: 120/72, HR 129 R: 20 O2: 100%RA.
CXR showing RML pneumonia. Treated with
ceftriaxone/azithromycin.
ROS:
+ as per HPI. Also reports a 10 lb weight gain recently.
- as per HPI. Remainder of 12 point ROS negative.
Past Medical History:
PAST MEDICAL HISTORY
- Crohn's disease since age ___ - colonic disease,
extraintestinal manifestations including iritis, erythema
nodosum, and arthralgias. Initially managed with 5-ASA, but did
not maintain
- Liver lesion: MRe (___) which showed a small lesion in
segment VII of the liver, possibly a small FNH. An MRI with
BOPTA on ___ felt the lesion was possibly a small
hemangioma.
- Depression and anxiety.
- Disc herniation C6-C7 followed by neurosurgeon.
- GERD.
- PCO/PCOS.
- Chickenpox as a child.
- Tonsillectomy at age ___.
- Hospitalization ___ for likely viral illness
- Abdominoplasty and breast surgery ___
- Urinary tract infection and subsequent overactive bladder.
Social History:
___
Family History:
Mother with ulcerative colitis and polyps. No family history of
colon cancer or other IBD.
Physical Exam:
PE:
Vitals: 99.1 BP: 106/69 HR: 83 R: 16 O2: 100% RA
Well appearing female in NAD. Speaking in full sentences.
HEENT: MMM, EOMI. Tongue midline. No LAD.
Lungs: Clear B/L on ausculation, some dullness to percussion
over right base.
___: RRR S1, S2 present, no m/r/g
Abd: SOft, NT, ND. low transverse scar
Ext: No edema. No rashes.
Neuro: AAOx3, CN II- XII grossly intact
Pertinent Results:
___ 08:15PM URINE HOURS-RANDOM
___ 08:15PM URINE UCG-NEG
___ 08:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:08PM LACTATE-1.2
___ 05:00PM GLUCOSE-96 UREA N-8 CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13
___ 05:00PM estGFR-Using this
___ 05:00PM WBC-14.5*# RBC-4.39 HGB-12.5 HCT-37.4 MCV-85
MCH-28.4 MCHC-33.3 RDW-14.4
___ 05:00PM NEUTS-87.2* LYMPHS-8.3* MONOS-4.0 EOS-0.2
BASOS-0.3
___ 05:00PM PLT COUNT-324
CXR:
IMPRESSION: Findings compatible with right middle lobe
pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO BID
2. Desogen (desogestrel-ethinyl estradiol) 0.15-30 mg-mcg Oral
daily
3. Gabapentin 600 mg PO BID
4. Infliximab 100 mg IV Q8WEEKS
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 34 g PO DAILY:PRN constipation
7. Venlafaxine XR 150 mg PO DAILY
8. Calcium Carbonate 500 mg PO Q 24H
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Right middle lobe pneumonia
- Dehydration
Secondary:
- Crohn's disease
- Irritable bowel syndrome
- Hepatic hemangioma
- Polycystic ovarian syndrome
- Gastroesophageal reflux disease
- Depression
- T6-T7 disc protrusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Recent pneumonia with new fever and white blood cell count.
COMPARISON: ___.
TECHNIQUE: PA and lateral views of the chest.
FINDINGS: In the right middle lobe, best seen on the lateral view, there is an
increased opacity. A corresponding area of subtly increased opacity obscuring
the right heart border in the right middle lobe is also seen on the frontal
view, worrisome for pneumonia. The left lung is clear. Cardiac size is
normal. There is no pleural effusion or pneumothorax or pulmonary edema.
IMPRESSION: Findings compatible with right middle lobe pneumonia.
Gender: F
Race: WHITE - EASTERN EUROPEAN
Arrive by WALK IN
Chief complaint: R SIDE CP
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 99.9
heartrate: 129.0
resprate: 20.0
o2sat: 100.0
sbp: 120.0
dbp: 72.0
level of pain: 8-9
level of acuity: 3.0 | RIGHT MIDDLE LOBE PNEUMONIA: She was initially treated with
ceftriaxone and azithromycin with improvement and then changed
to levofloxacin to complete a full 7-day course. This is her
second episode of pneumonia in as many months. It is unclear
whether this is coincidental, or possibly related to
immunosuppression. She denied sick contacts, tobacco use, or
other factors predisposing to pulmonary infection.
DEHYDRATION: Treated with intravenous hydration.
CROHN'S COLITIS: Stable.
ANXIETY/DEPRESSION: Maintained on klonopin and venlafaxine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute renal failure, shoulder pain after mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male who presents with shoulder pain after falling
on the ice/snow on the sidewalk and complains of right shoulder
pain. He apparently tripped over a pile of snow in the sidewalk.
His blood sugar was low prior to the fall, but he attributes the
fall to pure mechanical reasons. He denies a head strike,
lightheadedness or loss of consciousness. He reports normal PO
intake, and no diarhea or excessive urination.
In the ED, initial vital signs were 98.1 79 167/70 16 97%.
Initial labs concerning for creatinine 2.0 (baseline 1.0). CT
head was without intracranial process, CT C-spine demonstrated
moderate to severe multilevel degenerative changes without
fracture or malalignment, shoulder and T-spine XR demonstrated
no dislocation or fracture. The patient was admitted for work-up
of his elevated creatinine.
Upon arrival to the floor, initial vital signs are 98.4 183/73
91 22 100RA. The patient indicated pain in his back and right
shoulder.
Past Medical History:
1. Hypertension
2. Type 2 Diabetes Mellitus, on insulin
3. Hyperlipidemia
4. OSA
5. Hypertensive cardiomyopathy with systolic and diastolic heart
failure
6. Deaf/mute/Mental retardation
Social History:
___
Family History:
Patient is unable to provide a family history
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 (shoulder in HPI), - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
ADMISSION PHYSICAL EXAM:
VSS: 98.7, 153/74, 71, 18, 99%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CC, trace edema with chronic venous stasis changes, Pain
with ROM of right shoulder, though ROM not limited, no point
tenderness, mild pain with head/neck rotation, mild tenderness
over C-spine, mild tenderness of paraspinal muscles in low back
NEURO: CAOx3
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2 166/74 65 18 96RA
General: Well-appearing male, NAD, upright in bed, asleep
HEENT: NCAT, MMM, poor dentition
Neck: Supple
CV: RRR (+)S1/S2
Lungs: Generally CTA b/l
Abdomen: Soft, non-tender, non-distended
GU: Deferred
Ext: Warm, well-perfused, trace b/l ___ edema with some chronic
skin changes
Neuro: AOx3, CN II-XII grossly intact, moving all extremities,
complete neuro exam limited by difficulties with communication
Skin: No obvious rashes
MSK: Pain with ROM of right shoulder, though ROM not limited, no
point tenderness
Pertinent Results:
ADMISSION
___ 06:25AM BLOOD WBC-6.1 RBC-3.43* Hgb-10.3* Hct-31.8*
MCV-93 MCH-30.1 MCHC-32.5 RDW-12.7 Plt ___
___ 11:50AM BLOOD WBC-7.4 RBC-3.90* Hgb-11.5* Hct-36.0*
MCV-92 MCH-29.6 MCHC-32.1 RDW-12.9 Plt ___
___ 11:50AM BLOOD Neuts-74.7* Lymphs-15.9* Monos-6.3
Eos-2.3 Baso-0.8
___ 06:25AM BLOOD Glucose-239* UreaN-21* Creat-2.0* Na-139
K-3.3 Cl-101 HCO3-30 AnGap-11
___ 11:50AM BLOOD Glucose-131* UreaN-23* Creat-2.0* Na-144
K-3.4 Cl-102 HCO3-32 AnGap-13
___ 06:25AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.2
___ 11:50AM BLOOD Iron-87
___ 11:50AM BLOOD calTIBC-356 Ferritn-170 TRF-274
___ 06:44PM URINE Color-Straw Appear-Clear Sp ___
___ 06:44PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:44PM URINE RBC-3* WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 06:44PM URINE Hours-RANDOM UreaN-508 Creat-88 Na-43
K-46 Cl-37 TotProt-441 Prot/Cr-5.0*
DISCHARGE
___ 07:00AM BLOOD WBC-5.7 RBC-3.47* Hgb-10.3* Hct-31.7*
MCV-91 MCH-29.8 MCHC-32.5 RDW-12.8 Plt ___
___ 07:00AM BLOOD Glucose-91 UreaN-22* Creat-1.9* Na-141
K-3.5 Cl-103 HCO3-31 AnGap-11
CT HEAD W/O CONTRAST Study Date of ___ 12:05 ___
No acute intracranial process.
CT C-SPINE W/O CONTRAST Study Date of ___ 12:06 ___
1. Moderate to severe multilevel degenerative changes. Moderate
canal
narrowing, worst at C6-C7 predisposes this patient to cord
contusion.
2. No cervical spine fracture or malalignment.
T-SPINE Study Date of ___ 12:35 ___
LUMBO-SACRAL SPINE (AP & LAT) Study Date of ___ 12:35 ___
No evidence of acute fracture or dislocation. Multilevel
degenerative changes in the lumbar spine. Apparent widening of
the L5/S1
interspace most likely relates to the degenerative changes
superior to this level. If high clinical concern for injury at
this location, consider CT or MRI.
GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT Study Date of
___ 12:35 No evidence of acute fracture or dislocation.
RENAL U.S. Study Date of ___ 9:02 ___
1. No hydronephrosis.
2. Enlarged prostate gland with calculated volume of 77.6 mL
for a predicted PSA of 9.3 ng/mL.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Carvedilol 50 mg PO BID
3. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
4. Amlodipine 10 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. NPH 17 Units Breakfast
NPH 17 Units Dinner
Insulin SC Sliding Scale using REG Insulin
7. Furosemide 40 mg PO BID
8. Ibuprofen 600 mg PO Q6H:PRN pain
9. Aspirin 81 mg PO DAILY
10. GlipiZIDE 10 mg PO DAILY
11. Nortriptyline 100 mg PO HS
12. Acetaminophen 1000 mg PO Q6H:PRN pain
13. Tizanidine 4 mg PO QHS:PRN muscle spasm
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. Vitamin D ___ UNIT PO DAILY
16. diclofenac sodium 3 % topical BID pain in chest
17. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
-Acute kidney injury
-Mechanical fall
Secondary diagnosis:
-Chronic kidney disease
-Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fall on ice with head strike
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: 56 mGy
DLP: 892 mGy-cm
COMPARISON: None
FINDINGS:
There is no hemorrhage, major vascular territory infarction, edema, mass, or
shift of the normally midline structures. The size and shape of the
ventricles and sulci are normal. The basal cisterns are patent. There is a
left choroid fissue cyst. Gray-white matter differentiation is preserved.
There is a small left maxillary mucosal retention cyst. The remainder of
visualized paranasal sinuses and mastoid air cells are normally pneumatized
and clear. The skull and extracranial soft tissues are unremarkable. There
are several dense dural calcifications. There is nasopharyngeal lymphoid
prominence.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Mechanical fall and head strike.
TECHNIQUE: MDCT data were acquired through the cervical spine without
intravenous contrast. Images were displayed in multiple planes after
reconstruction using bone and soft tissue algorithms.
CTDIvol: 33 mg.
DLP: 767 mGy-cm.
COMPARISON: None.
FINDINGS:
There is moderate to severe multi level degenerative change in the cervical
spine. Degenerative changes are most severe at C5-C6, C6-C7 and C7-T1 with
DISH. There is extensive sclerosis of the C6 and C7 vertebral bodies.
Posterior disc osteophyte complexes at multiple levels contact the ventral
spinal cord and lead to moderate canal stenosis. This is most pronounced at
C6-C7. There is multilevel uncovertebral hypertrophy and facet arthropathy.
Vertebral body alignment is intact. Visualized portions of the intracranial
structures are unremarkable. There are small right and left maxillary sinus
mucous retention cysts. The thyroid gland is homogeneous. Visualized lung
apices are clear. The aerodigestive tract is patent.
here is nasopharyngeal lymphoid prominence which should be clinically
correlated.
IMPRESSION:
1. Moderate to severe multilevel degenerative changes. Moderate canal
narrowing, worst at C6-C7 predisposes this patient to cord contusion.
2. No cervical spine fracture or malalignment.
Radiology Report
EXAM: Right shoulder, three views.
CLINICAL INFORMATION: New right shoulder pain, status post fall.
COMPARISON: None.
FINDINGS: Three views of the right shoulder were obtained. No evidence of
acute fracture or dislocation is seen. The right humeral head may be
minimally high riding. The right acromioclavicular joint is intact with
minimal degenerative change seen.
IMPRESSION: No evidence of acute fracture or dislocation.
Radiology Report
EXAM: Thoracic spine, AP and lateral views and lumbar spine, AP and lateral
views.
CLINICAL INFORMATION: Mechanical fall, tripped and slipped on ice with head
strike, complaining of back pain.
COMPARISON: Thoracic and lumbar spine radiographs from ___ as well as
lumbar spine MRI from ___.
FINDINGS:
THORACIC SPINE: T1 and T2 vertebrae were included on the cervical spine CT
performed immediately prior to this study. Otherwise, vertebral body heights
are grossly maintained without evidence of acute fracture or dislocation.
Degenerative changes are seen including multilevel anterior osteophyte
formation. No widening of the paraspinal soft tissue line is seen on the
frontal view.
LUMBAR SPINE: AP and lateral views of the lumbar spine were obtained. There
is slight lumbar dextroscoliosis. Multilevel degenerative changes are seen,
worst at L3 through L5 where there is disc space narrowing, endplate
sclerosis, osteophyte formation and possible vacuum phenomenon significantly
increased as compared to ___. No definite acute fracture is seen.
There is no widening of the sacroiliac joints.
There is possible mild widening of the L5/S1 disc space which is likely due to
adjacent degenerative disease higher more superior.
IMPRESSION: No evidence of acute fracture or dislocation. Multilevel
degenerative changes in the lumbar spine. Apparent widening of the L5/S1
interspace most likely relates to the degenerative changes superior to this
level. If high clinical concern for injury at this location, consider CT or
MRI.
Radiology Report
HISTORY: Elevated creatinine of unclear etiology.
COMPARISON: Abdominal ultrasound ___.
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
abdomen.
FINDINGS: The right kidney measures 10.7 cm and the left kidney measures 10.1
cm. Evaluation of the left kidney was somewhat limited due to limited
acoustic window. The kidneys are unremarkable bilaterally without focal solid
or cystic lesion or hydronephrosis. The bladder is well visualized and is
unremarkable. The prostate is enlarged measuring 7.1 x 4.6 x 4.5 cm for a
calculated volume of 77.6 mL for a predicted PSA of 9.3. Normal bilateral
ureteral jets were demonstrated.
IMPRESSION:
1. No hydronephrosis.
2. Enlarged prostate gland with calculated volume of 77.6 mL for a predicted
PSA of 9.3 ng/mL.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with RENAL & URETERAL DIS NOS
temperature: 98.1
heartrate: 79.0
resprate: 16.0
o2sat: 97.0
sbp: 167.0
dbp: 70.0
level of pain: 4
level of acuity: 2.0 | 1. CKD Stage 3
- The creatinine of 2 likely represents progression of their
renal disease rather than acute renal failure. He is already
followed by nephrology, but was apparently lost to follow up.
- No cause for pre-renal etiology and does not have a compelling
history for instrinsic-renal (new medications, hypotension, etc)
or post-renal (obstruction) etiologies, either.
- The patient was previously evaluated by Nephrology for
possible glomerulonephritis after he was found to have 3g of
protein in his urine (___). At that time, several serologies
including ANCA, anti-GBM, hepatitis C antibody, and
double-stranded DNA were negative and complement levels were
normal. The plan was to proceed with renal biopsy.
- UA obtained with proteinuria
- Renal ultrasound obtained, without hydronephrosis or
obstruction
- will defer further glomerulonephritis work-up to outpatient
renal team. The difficulty is coordinating his follow up on a
holiday with his communication difficulty
2. Shoulder Arthralgia due to Fall
- Tylenol for pain control as not severe enough for opiates and
would like to avoid NSAIDs for renal dysfunction
- ___ consult
3. Benign Hypertension
- Patient should be on amlodipine, carvedilol, clonidine patch
(dated ___, lisinopril, and furosemide. Patient was given
amlodipine and carvedilol in the ED, and was hypertensive on
arrival to the 180s.
- Continued amlodipine and carvedilol, clonidine patch
- Held lisinopril and furosemide given elevated creatinine,
though restarted at discharge
4. Type 2 Diabetes Uncontrolled with Complications
- Last A1c was 9% in ___.
- Patient has known proliferative retinopathy followed by
Ophthalmology.
- On NPH and RISS at home, which were continued
5. Glacuoma
- Continue timolol
6. Obstructive Sleep Apnea
- Confirm if on BiPAP/CPAP and obtain settings
TRANSITIONAL ISSUES
-Found to have enlarged prostate gland with calculated volume of
77.6 mL for a predicted PSA of 9.3 ng/mL.
-Patient should follow-up with ___ with further evaluation of
his insulin regimen as his glucoses ranged in the 200-300s
during hospitalization.
-Patient requires follow-up with Nephrology for further
evaluation of glomerular disease. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Epinephrine
Attending: ___.
Chief Complaint:
Trauma: fall
Major Surgical or Invasive Procedure:
___: suturing of your scalp laceration
History of Present Illness:
___ year old woman with PMH of paroxysmal afib (CHADS 4) on
coumadin, hx PE, sick-sinus syndrome s/p PPM, diastolic CHF (EF
>60%), hx anemia, duodenal ademona w/ surgical resection,
presented s/p fall with head laceration. Per patient, she was
walking when she felt her knees give out. She had no presyncopal
events, no nausea, no chest pain, shortness of breath,
dizziness, lightheadedness, bloody bowel movements, palpitations
prior. Did not trip over anything. Denies loss of consciousness.
Was laying on the floor for about 10 minutes. Called lifeline.
Has felt like she has become weaker over the last couple of
months after having her pacemaker surgery. She now uses a
walker. She felt like her overall strength had decreased so much
that she decided to join a gym.
Presented to the ED with initial vitals of 97.9 68 191/84 16
98%. Vitals repeated and noted to have hypotension with SBPs in
70-90s. Given IVF at 250cc/hr. H/H on admission 10.1/32.2, INR
3.1, K 2.4, Cr 1.2. Repeat H/H trended down to 7.5/23.2. CT
abd/pelvis and head did not show any fractures of
intracranial/intrabdominal bleeding. INR trended up to 4.2.
Given 1U rbc and H/H improved to 9.8/30.7. PPM interogated and
did not show any events. Staples placed in scalp and obtained
hemostasis. Admitted to ACS.
On the floor, H/H stable. BP labile from SBPs from 90-150s. Low
urine output for 16 hours, bladder scanned for 400cc, foley
placed and 300cc came out. Pt states that she is not in any
pain. Feels well overall. Does note some diarrhea over the past
couple of weeks every other day. No blood in stool. Lighter in
color than normal. Has been worked up for anemia with
colonoscopy and capsule study last year, clean. Lives alone in
an assisted living ___, does ADLs except for bathing herself.
Has son who lives in ___ who she is close to.
Past Medical History:
-Diastolic heart failure
-Paroxysmal AFib on warfarin
-Type 2 DM, diet controlled
-Hypertension
-PE ___, source unclear, on warfarin
-Duodenal adenoma: 3cm, highly dysplastic w/o invasive
malignancy, s/p Whipple's pancreaticoduodenectomy (___)
-Depression
-Essential tremor
-Iron deficiency anemia
-Renal mass (surveillance with CT by Urology)
Social History:
___
Family History:
Father: CAD
Mother: ___, Osteoprosis
Sister: ___ Cancer at 50
Physical Exam:
===============================================
PHYSICAL EXAMINATION: upon admission: ___
===============================================
Temp: 97.9 HR: 68 BP: 191/84 Resp: 16 O(2)Sat: 98
Constitutional: Constitutional: comfortable
Head
/ Eyes: 20 cm laceration on the scalp
ENT: OP WNL
Resp: CTAB, no pain with AP compression of the chest
Cards: RRR. s1,s2. no MRG.
Abd: S/NT/ND
Flank: no CVAT, no burising, no tenderness of the CTLS spine
Skin: no rash
Ext: No c/c/e
Neuro: speech fluent, moving all 4 extremities with ___
strength, cranial nerves grossly intact
Psych: normal mood
==========================
DISCHARGE PHYSICAL:
==========================
Vitals: 98.6 130/80 65 18 100 RA
General: Elderly woman, sitting in bed comfortably, HAD
HEENT: large 12cm R parietal scalp laceration with staples,
dried blood, no oozing, no purulence. PERRL, EOMI, Sclera
anicteric, MMM, oropharynx clear, dentures in place
Neck: supple, JVP not elevated, no LAD
Lungs: Strong lung sounds, clear to auscultation bilaterally, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, distended, non-tender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: ecchymosis over arms and tracing down the right trapezius
muscle and into the anterior lateral neck, nontender
Neuro: CN II-XII intact, ___ strength in all extremities,
sensation intact, 2+ reflexes, cerebellar function intact
Pertinent Results:
===================
ON ADMISSION:
===================
___ 01:15PM BLOOD WBC-7.3 RBC-3.68* Hgb-9.8* Hct-30.7*#
MCV-83 MCH-26.5* MCHC-31.9 RDW-19.5* Plt ___
___ 04:45AM BLOOD WBC-6.6 RBC-2.99* Hgb-7.9* Hct-24.1*
MCV-81* MCH-26.4* MCHC-32.7 RDW-19.9* Plt ___
___ 10:09PM BLOOD WBC-8.6 RBC-3.53* Hgb-9.0* Hct-28.3*
MCV-80* MCH-25.4* MCHC-31.6 RDW-19.8* Plt ___
___ 10:00AM BLOOD WBC-7.0 RBC-4.02* Hgb-10.1*# Hct-32.3*
MCV-80* MCH-25.1* MCHC-31.2 RDW-20.5* Plt ___
___ 10:00AM BLOOD Neuts-65.0 ___ Monos-5.9 Eos-1.5
Baso-0.6
___ 04:45AM BLOOD ___ PTT-43.3* ___
___ 10:00AM BLOOD ___ PTT-38.6* ___
___ 04:45AM BLOOD Glucose-72 UreaN-19 Creat-1.2* Na-137
K-3.1* Cl-103 HCO3-26 AnGap-11
___ 02:50PM BLOOD Glucose-290* UreaN-18 Creat-1.2* Na-138
K-5.2* Cl-104 HCO3-26 AnGap-13
___ 04:45AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.5*
___ 02:50PM BLOOD K-4.9
=====================
DISCHARGE LABS:
=====================
___ 06:05AM BLOOD WBC-4.8 RBC-2.89* Hgb-7.9* Hct-23.6*
MCV-82 MCH-27.2 MCHC-33.3 RDW-20.7* Plt ___
___ 06:05AM BLOOD ___ PTT-30.5 ___
___ 06:05AM BLOOD Glucose-80 UreaN-21* Creat-1.1 Na-137
K-3.7 Cl-103 HCO3-28 AnGap-10
___ 06:05AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.9
=====================
STUDIES:
=====================
CT HEAD ___:
1. No acute intracranial process.
2. Large right frontoparietal scalp laceration and hematoma,
with no
underlying fracture.
CT C SPINE ___: No acute fracture or change in alignment.
CHEST XRAY ___: No acute cardiopulmonary process.
XRAY PELVIS ___: No acute fracture or dislocation. Remote
fracture of the right inferior pubic ramus
CT ABD/PELVIS ___:
1. Fecal impaction within the rectum with adjacent fat
stranding, concerning for stercoral proctitis.
2. Foley catheter malpositioned within the vagina.
3. Status post Whipple procedure with pancreatogastrostomy.
Chronically
dilated pancreatic duct with pancreatic parenchymal atrophy.
4. No evidence of retroperitoneal bleed.
Radiology Report
INDICATION: History: ___ status post fall with head trauma, head pain
TECHNIQUE: AP view of the pelvis
COMPARISON: CT abdomen pelvis ___
FINDINGS:
The osseous structures are diffusely demineralized which limits the
sensitivity for the detection of subtle fractures. Deformity of the right
inferior pubic ramus is compatible with a remote fracture. No acute fracture
or dislocation is clearly visualized on this single view. No diastases of the
pubic symphysis or sacroiliac joints is identified. Multiple calcified
phleboliths are present in the pelvis along with clips in the right lower
quadrant of the abdomen. Assessment of the sacrum is obscured by overlying
bowel gas and stool. Vascular calcifications are visualized. There are no
concerning lytic or sclerotic osseous abnormalities.
IMPRESSION:
No acute fracture or dislocation. Remote fracture of the right inferior pubic
ramus.
Radiology Report
INDICATION: History: ___ with head trauma, head pain after fall
TECHNIQUE: Supine AP view of the chest
COMPARISON: ___
FINDINGS:
Left-sided pacemaker device is noted with leads terminating in the right
atrium and right ventricle. Heart size is mildly enlarged but unchanged. The
mediastinal and hilar contours are similar. Pulmonary vasculature is normal.
Mild atherosclerotic calcifications are demonstrated at the aortic knob. No
pleural effusion, focal consolidation or pneumothorax is present. Scarring
within the lung apices as well as chain sutures in the right upper lung field
are re- demonstrated. Pulmonary vasculature is normal. There are no acute
osseous abnormalities. Remote fracture of a right inferior lateral rib is
noted.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with head trauma, head pain after fall.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 891.93 mGy-cm
COMPARISON: CT head without contrast dated ___.
FINDINGS:
There is a large right frontoparietal scalp hematoma and laceration. No
underlying fracture identified.
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Atherosclerotic calcifications are seen involving the cavernous
carotid and distal right vertebral arteries.
Ventricles and sulci are prominent, consistent with age appropriate atrophy.
There are a few scattered periventricular white matter hypodensities, while
nonspecific may represent the sequelae of chronic small vessel disease. The
imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities
are well aerated.
IMPRESSION:
1. No acute intracranial process.
2. Large right frontoparietal scalp laceration and hematoma, with no
underlying fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with head trauma, head pain after fall.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
DLP: 789.11 mGy-cm
COMPARISON: CT C-spine dated ___.
FINDINGS:
No fractures are identified. There is no prevertebral soft tissue swelling.
Mild anterolisthesis of C3 on C4, stable since prior examination. Multilevel
moderate degenerative changes, worse at C5 through C7, consisting of mild
central canal and moderate neural foraminal narrowing, most severe on the left
at C3-C4.
8 mm right-sided hypodense thyroid nodule is noted.
Atelectasis or scarring in the lung apices bilaterally.
IMPRESSION:
No acute fracture or change in alignment.
Radiology Report
INDICATION: ___ with hypotension, fall, on coumadin question peritoneal
bleed.
TECHNIQUE: Non-contrast scan: Multidetector CT images of the abdomen and
pelvis were acquired without intravenous contrast. Non-contrast scan has
several limitations in detecting vascular and parenchymal organ abnormalities,
including tumor detection.
Coronal and sagittal reformations were performed and reviewed on PACS.
No oral contrast was administered.
DOSE: DLP: 677.08 mGy-cm (abdomen and pelvis).
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST:
Leads within the right atrium and right ventricle are partially imaged. The
visualized lung bases are clear.
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 not visualized.
PANCREAS: The patient is post Whipple procedure. There is a
pancreaticogastrostomy with chronically diffusely dilated pancreatic duct.
The residual pancreatic parenchyma atrophied.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There are bilateral renal hypodensities, the largest in the upper
pole of the left kidney, measuring 4.9 x 5.6 x 5.5 cm, compatible with a
simple cyst. No hydronephrosis or hydroureter is present. No renal calculi are
clearly demonstrated.
GASTROINTESTINAL:
There is stool distending the rectum measuring 6.1 x 7.3 cm, with adjacent fat
stranding, concerning for stercoral proctitis. Remainder of the small large
bowel appear within normal limits without evidence of obstruction. Apparent
wall thickening of the left colon may be due to slight underdistention. The
patient is post Whipple procedure with gastrojejunostomy. The appendix is not
definitively identified.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy. No retroperitoneal hematoma or free fluid is visualized.
VASCULAR: There is no abdominal aortic aneurysm. There is moderate 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: A Foley catheter is malpositioned within the vagina. The
patient is post hysterectomy.
BONES AND SOFT TISSUES:
There is mild grade 1 anterolisthesis of L4 on L5 and L5 on S1, stable. Right
anterior abdominal wall clips are noted. Old rib fractures are seen at the
lateral aspects of right-sided 10, 9, and 8 ribs. A chronic right inferior
pubic ramus fracture is seen.
IMPRESSION:
1. Fecal impaction within the rectum with adjacent fat stranding, concerning
for stercoral proctitis.
2. Foley catheter malpositioned within the vagina.
3. Status post Whipple procedure with pancreatogastrostomy. Chronically
dilated pancreatic duct with pancreatic parenchymal atrophy.
4. No evidence of retroperitoneal bleed.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with HEAD INJURY UNSPECIFIED, OPEN WOUND OF SCALP, TETANUS-DIPHT. TD DT, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT, UNSPECIFIED FALL
temperature: 97.9
heartrate: 68.0
resprate: 16.0
o2sat: 98.0
sbp: 191.0
dbp: 84.0
level of pain: 6
level of acuity: 2.0 | Ms. ___ is a ___ year old with PMH pAF (CHADS 4 on coumadin),
hx PE, sick sinus syndrome s/p PPM, presenting with large scalp
laceration s/p fall with acute blood loss.
# scalp laceration: Large 12cm laceration on scalp with acute
blood loss. Her scalp was stapled in the emergency room and
obtained hemostatsis. The patient denied pain at site of
laceration throughout hospital stay.
# Acute blood loss/anemia: Pt has baseline anemia, unclear
origin. Hgb ___. Has been worked up with colonoscopy and
capsule study. MCV borderline low. Presented with fall
complicated by scalp laceration with acute blood loss. No other
signs of bleeding. CT w/o intracranial or intraabdominal
bleeding. Cause of acute blood loss localized to laceration. Hbg
dropped to 7.5 acutely in ED resulting in transient hypotension,
which resolved with 1U rbc transfusion and IVF, with appropriate
response of Hgb to 8.5. Throughout hospitalization, H/H varied,
but no other signs of bleeding. Stabilized at 7.9.
# Fall: Patient states that she felt her legs go out below her.
She has noticed a gradual weakening of her legs due to
deconditioning since her last hospitalization. Was supposed to
continue with physical therapy, but decided not to. Uses a
walker to ambulate outside the house, but was not using it in
the house. No evidence of syncope, presyncope, dizziness, chest
pain, shortness of breath. Pacer interogated and no signs of
arrhythmia. No elevated wbc, no signs of obvious infection- UA
negative, CXR negative. Neurologic exam intact.
# Elevated INR: Pt with elevated INR of 3 which increased to
4.1. Pt takes coumadin at home for PE/pAF. Gets INR checked at
clinic in her building. Doesn't normally have elevated INR per
patient. Unclear why elevated. Possibly from diarrhea pt has
been having. Given CHADS 4 and asymptomatic, no plan for
reversal of INR. INR trended down and coumadin restarted at 2mg.
INR at discharge 1.6. Decided against lovenox bridging.
# Anemia: Hgb variable during admission. Stablized ~8. No signs
of bleeding. Had large BM, guaiac negative. Laceration well
sutured. Abdomen benign. CT on admission w/o intracranial or
intraabdominal bleeding. Pt has baseline anemia, unclear origin.
Hgb ___. Has been worked up with colonoscopy and capsule
study. MCV borderline low. Started on B12 supplementation. Iron
supplements held ___ constipation. Can consider IV iron as
outpatient.
# ___: Cr 1.2 on presentation, baseline 0.8. Pt was hypotensive
in the ED. Liklely prerenal kidney injury vs ATN. Had some
decreased urine output, given IVF, Cr trended down to 1.1 on
discharge. No evidence of urinary retention on bladder scan.
# Diarrhea: Pt has diarrhea per report for the past month.
Unclear etiology. Perhaps contributing to her INR. No episodes
of diarrhea in the hospital. Had large bowel movement, formed.
# paroxysmal Afib: Pt with history of pAF on coumadin. CHADS 4
(HTN, DM, dCHF, Age). No evidence of Afib on PPM or telemetry.
On coumadin. At this point, given hemodynamic stability, will
hold off reversing her as her risk for a clot is high. Warfarin
restarted at 2mg.
# HTN: SBP labile. Admission PAMEL incorrectly had lisinopril
10mg and did not have diltiazem or propanolol. Started on
lisionpril 10mg and then resumed home dose of 5mg. Started
diltiazem 30mg TID for continued BP and HR control. Propanolol
held given HRs in low ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
Percutaneous coronary intervention with drug eluting stents to
right coronary artery and ramus
attach
Pertinent Results:
ADMISSION LABS:
___ 07:20AM BLOOD WBC-12.8* RBC-5.14 Hgb-16.0 Hct-49.0
MCV-95 MCH-31.1 MCHC-32.7 RDW-13.2 RDWSD-46.6* Plt ___
___ 07:20AM BLOOD Neuts-69.4 Lymphs-18.7* Monos-7.3 Eos-2.8
Baso-0.9 Im ___ AbsNeut-8.89* AbsLymp-2.40 AbsMono-0.94*
AbsEos-0.36 AbsBaso-0.11*
___ 07:20AM BLOOD ___ PTT-33.5 ___
___ 07:20AM BLOOD Glucose-78 UreaN-17 Creat-0.8 Na-141
K-4.9 Cl-103 HCO3-20* AnGap-18
___ 07:20AM BLOOD Calcium-10.3 Phos-2.6* Mg-2.3
PERTINENT LABS:
___ 07:20AM BLOOD D-Dimer-238
___ 07:20AM BLOOD CK(CPK)-107
___ 07:20AM BLOOD cTropnT-<0.01
___ 12:44PM BLOOD cTropnT-<0.01
___ 03:35PM BLOOD cTropnT-<0.01
___ 07:20AM BLOOD CK-MB-3
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-11.7* RBC-4.97 Hgb-15.5 Hct-47.0
MCV-95 MCH-31.2 MCHC-33.0 RDW-13.1 RDWSD-45.2 Plt ___
___ 06:20AM BLOOD Glucose-90 UreaN-18 Creat-0.9 Na-141
K-4.8 Cl-106 HCO3-25 AnGap-10
___ 06:20AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.3
IMAGING AND PROCEDURES:
CARDIAC CATHETERIZATION: ___
Findings
Significant ISR of the RCA and Ramus branches, mostly likely
culprit.
Focal lesions of distal OM branches.
Mild ISR of the mid LAD. Occluded D1.
Successful PCI of the Proximal RCA (3.0 x 32 DES, post-dilated
to 3.5 and 4) and Proximal
Ramus ISR lesions (2.5 x 15 mm DES, post-dilated to 2.75),
guided by IVUS.
TRANSTHORACIC ECHOCARDIOGRAM: ___
The visually estimated left ventricular ejection fraction is
55-60%.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Moderate pulmonary artery systolic hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Chantix (varenicline) 0.5 mg oral DAIILY Duration: 3 Days
RX *varenicline [Chantix] 0.5 mg 1 tablet(s) by mouth once a day
Disp #*3 Tablet Refills:*0
3. Chantix (varenicline) 0.5 mg oral BID Duration: 4 Days
RX *varenicline [Chantix] 0.5 mg 1 tablet(s) by mouth 2 times
per day Disp #*8 Tablet Refills:*0
4. Chantix (varenicline) 1 mg oral BID
RX *varenicline [Chantix] 1 mg 1 tablet(s) by mouth two times
per day Disp #*60 Tablet Refills:*0
5. 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
6. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Unstable angina
Coronary artery disease with re-stenosis of coronary artery
stents
SECONDARY DIAGNOSIS:
====================
Tobacco use disorder
Hypertension
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, // r/o pneumothorax, CHF
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Lung volumes are low. There is opacity at the right midlung which partially
obscures the right heart border. Cardiomediastinal silhouette is stable.
Hilar contours and pleural surfaces are normal.
IMPRESSION:
Right middle lobe opacity could represent atelectasis but pneumonia is also a
consideration in the appropriate clinical setting. No radiographic evidence
of pneumothorax or CHF.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Unstable angina, Chest pain, unspecified
temperature: 97.1
heartrate: 74.0
resprate: 16.0
o2sat: 100.0
sbp: 192.0
dbp: 99.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a history of known CAD
s/p 2 DES to mLAD and mRCA ___ respectively), HLD, and
40 pack-year smoking history presents with chest pain and
discomfort with EKG changes concerning for unstable angina.
CORONARIES: S/p DES to mLAD in ___, DES to mRCA in ___, DES to
pRCA ___ and DES to pRamus ISR lesions.
PUMP: 55-60% - with left ventricular hypertrophy
RHYTHM: NSR on EKG from admission
# Discharge weight: 205.25 lbs (93.1 kg)
# Discharge creatinine: 0.9
# Discharge Hgb/Hct: 15.5/47.0
# CODE STATUS: Full Code, Confirmed
# CONTACT: ___, wife, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Toradol / Tramadol
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Myofascial pain syndrome, chronic abdominal pain (on
narcotics contract), who is s/p recent laparoscopic CCY and
lysis of adhesions (___), who presents for abdominal pain.
Patient with long history of abdominal pain. On interview,
reported pain had been going on since ___ but upon chart review
there appears to be repeated imaging performed for
RUQ/midepigastric abdominal pain beginning in ___. Recently,
patient presented to ___ ___ where an EGD
was performed that revealed several non-bleeding gastric ulcers
and was started on a PPI. She was discharged with plan to see
surgery for outpatient cholelithiasis but ended up presenting to
___ shortly after discharge because she felt
unwell. During this admission to ___, GI and
surgery were consulted who felt this presentation was due to
cholelithiasis and PUD. An aggressive GERD regimen with
sulcrafate, ppi and bentyl was started. She was started on a
narcotic regimen and transitioned to MS contin + morphine. Per
patient she has been on narcotics since back injury ___ being
hit by car in ___. She underwent an outpatient elective
cholecystectomy ___ after which she reports improvement in
symptoms until ___. Since then, she notes recurrence of her
abdominal pain which is intermittent in nature, largely
periumbilical and radiating to bilateral flanks. It associated
with nausea and vomiting. It is worsened by food. Patient
presented to ___ last ___ and was discharged
on ___. On ___ post discharge, she noted a recurrence of
her abdominal pain, that has slowly been worsening all week and
with recurrence of the associated nausea and vomiting. Symptoms
were also associated with loose stools, nonbloody and not dark
or tarry.
In the ED, initial VS were: 10 97.5 90 171/103 20 100% RA. Exam
notable for TTP at RUQ. Labs revealed a normal
CHEM/CBC/LFTs/Lipase/Lactate, UA w/ Spec ___ 1.038, 13 WBC, neg
nitr, +prot, and 13 epis. CT A/P revealed 8 mm fluid-filled
appendix without appendiceal fat stranding, mucosal hyper
enhancement, or wall thickening which is either indeterminate or
early appendicitis.
Given indeteminate CT read, surgery consulted in ED and felt
that patient was diffusely tender with a focal point over the
umbilicus which was same location as the patient's recent
abdominal pain in ___. Since no leukocytosis and no clear
evidence of appendicitis on CT scan, they felt unlikely
appendicitis so no surgical intervention, but they would follow
patient if admitted to medicine.
Pt was given 2L NS, zofran, and 5mg IV morphine x2 prior to
admission to medicine. Vitals upon transfer were: 8 98.0 81
156/82 18 97% RA.
Today, patient reports continued abdominal pain in periumbilical
area that continues to radiate to flanks. No improvement with
defecation. Does not feel distended. Denies new food, sick
contacts, recent travel. Endorses migraine with no visual
changes. Some nausea, but no vomiting. Last episode of loose
stools was 6 am this morning. Last episode of vomiting was
yesterday at 7 pm prior to presenting to ED. Endorses low grade
temps but no frank fevers or chills. Denies chest pain, sob,
cough, dysuria. Tearful on interview due to upcoming ___
anniversary of her son's death.
On ROS, patient endorses occasional PND, thinks related to her
sleep apnea (does not wear CPAP). She denies orthopnea, lower
extremity edema, joint pain, new numbness or tingling. Endorses
dark tarry stools occurring once prior to presentation to
___ on ___, but not thereafter.
Past Medical History:
Hypertension
Chronic back pain secondary to MVA
Migraines
Myofascial pain
Hx of Vaginal bleeding
Anemia - on iron supplements
Obesity
Vitamin D deficiency
Depression
Insomnia
Anxiety
GERD
Social History:
___
Family History:
Father died of an MI in his mid ___. Her mother died of a brain
aneurysm at age ___. Multiple family members with hypertension.
Physical Exam:
Admission:
============
Vital Signs: Tc98 BP 120/55 HR76 RR18 02 94%RA
General: Alert, oriented, mild distress.
HEENT: Sclera anicteric, MMM. PERRLA. JVP non elevated but
difficult to assess given body habitus.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, markedly tender to palpation in periumbilical
area with slight pain to palpation in LLQ. RUQ pain to
palpation, equivalent ___ sign. No rebound tenderness. No
guarding. No peritoneal signs.
GU: No foley
Ext: Warm, well perfused, palpable pulses with no edema.
Neuro: CNII-XII intact. ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Discharge:
==========
Vitals: T:98.1 BP: 109/61 P:66 R:18 O2:100%RA
General: Alert, oriented, mild distress.
HEENT: Sclera anicteric, MMM. PERRLA.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mild ttp in periumbilical area. +BS. No rebound
tenderness. No guarding. No peritoneal signs.
GU: No foley
Ext: Warm, well perfused, no edema.
Neuro: Moving all extremities. Sensation grossly intact.
Pertinent Results:
Admission Labs:
===============
___ 09:50PM BLOOD WBC-7.6 RBC-4.01 Hgb-11.7 Hct-36.1 MCV-90
MCH-29.2 MCHC-32.4 RDW-14.0 RDWSD-45.1 Plt ___
___ 09:50PM BLOOD Neuts-64.0 ___ Monos-6.4 Eos-0.7*
Baso-0.5 Im ___ AbsNeut-4.88 AbsLymp-2.16 AbsMono-0.49
AbsEos-0.05 AbsBaso-0.04
___ 09:50PM BLOOD Plt ___
___ 09:50PM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-139
K-3.8 Cl-99 HCO3-28 AnGap-16
___ 09:50PM BLOOD estGFR-Using this
___ 09:50PM BLOOD ALT-18 AST-19 AlkPhos-69 TotBili-0.8
___ 09:50PM BLOOD Lipase-25
___ 09:50PM BLOOD Albumin-4.4
___ 10:06PM BLOOD Lactate-1.5
Microbiology:
================
___ 9:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Imaging:
================
___ CTAP
IMPRESSION:
1. No pneumoperitoneum.
2. 8 mm fluid-filled appendix without appendiceal fat stranding,
mucosal hyper
enhancement, or wall thickening is indeterminate and may
represent early
appendicitis. Clinical correlation is recommended.
3. Status post cholecystectomy with expected postsurgical
changes including
CBD dilatation up to 9 mm.
Discharge Labs:
=================
___ 05:49AM BLOOD WBC-5.6 RBC-3.50* Hgb-10.3* Hct-32.6*
MCV-93 MCH-29.4 MCHC-31.6* RDW-14.1 RDWSD-48.1* Plt ___
___ 05:49AM BLOOD Plt ___
___ 05:49AM BLOOD Glucose-97 UreaN-19 Creat-1.1 Na-140
K-3.5 Cl-97 HCO3-28 AnGap-19
___ 05:49AM BLOOD Calcium-9.9 Phos-5.6*# Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. Lisinopril 40 mg PO DAILY
3. Lorazepam 0.5 mg PO BID:PRN anxiety
4. esomeprazole magnesium 40 mg oral Q24H
5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
6. Paroxetine 20 mg PO DAILY
7. QUEtiapine Fumarate 25 mg PO QHS
8. sucralfate 10 ml oral QID:PRN reflux symptoms
9. Verapamil SR 360 mg PO Q24H
10. Ascorbic Acid ___ mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. cyanocobalamin (vitamin B-12) 1,000 mcg oral Q24H
13. Ferrous GLUCONATE 324 mg PO BID
14. spironolacton-hydrochlorothiaz ___ mg oral Q24H
15. bifidobacterium infantis 4 mg oral Q24H
16. BuPROPion 300 mg PO DAILY
Discharge Medications:
1. Lorazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth once a day Disp #*7
Tablet Refills:*0
2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
three times a day Disp #*21 Tablet Refills:*0
3. BuPROPion 300 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. Paroxetine 20 mg PO DAILY
7. QUEtiapine Fumarate 25 mg PO QHS
8. sucralfate 10 ml oral QID:PRN reflux symptoms
9. Verapamil SR 360 mg PO Q24H
10. Vitamin D 1000 UNIT PO DAILY
11. Ascorbic Acid ___ mg PO BID
12. bifidobacterium infantis 4 mg oral Q24H
13. cyanocobalamin (vitamin B-12) 1,000 mcg oral Q24H
14. esomeprazole magnesium 40 mg oral Q24H
15. Ferrous GLUCONATE 324 mg PO BID
16. spironolacton-hydrochlorothiaz ___ mg oral Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
Abdominal Pain of Unknown Etiology
CHRONIC DIAGNOSES
=====================
Chronic Abdominal Pain
Hypertension
Depression
Anxiety
Insomnia
Vitamin D Deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen/ pelvis with contrast.
INDICATION: ___ with hx of ccy. Now pain in abdomen. Assess for perforation
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
4) Spiral Acquisition 4.4 s, 48.0 cm; CTDIvol = 16.8 mGy (Body) DLP = 805.8
mGy-cm.
Total DLP (Body) = 820 mGy-cm.
COMPARISON: CT abdomen/pelvis ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
biliary dilatation. The common bile duct measures 9 mm which is expected post
cholecystectomy. The gallbladder is surgically absent. No focal fluid
collection.
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: A 1.5 x 1.5 cm (02:36) hypodensity within the interpolar region of
the right kidney is consistent with a cyst. The kidneys are of normal and
symmetric size with normal nephrogram. There is no evidence of worrisome
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 appendiceal tip is mildly dilated
measuring 8 mm without mucosal hyperemia, fat stranding, or appendicolith. A
few locules of air are seen within the base of the appendix.
PELVIS: The urinary bladder is decompressed. The distal ureters are
unremarkable. 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. 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. No pneumoperitoneum.
2. 8 mm fluid-filled appendix without appendiceal fat stranding, mucosal hyper
enhancement, or wall thickening is indeterminate and may represent early
appendicitis. Clinical correlation is recommended.
3. Status post cholecystectomy with expected postsurgical changes including
CBD dilatation up to 9 mm.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Right upper quadrant pain
temperature: 97.5
heartrate: 90.0
resprate: 20.0
o2sat: 100.0
sbp: 171.0
dbp: 103.0
level of pain: 10
level of acuity: 2.0 | Summary:
==============
___ PMH of Myofascial pain syndrome, chronic abdominal pain (on
narcotics contract), who is s/p recent laparoscopic CCY
(___), who presents for abdominal pain, c/f chronic vs
possible appendicits (given indeterminate CT scan) so was
admitted to medicine for further monitoring and pain control.
Acute Issues:
==============
#Abdominal Pain: Patient was valuated in the ED for abdominal
pain after an indeterminate CT Abd/Pelvis scan for possible
appendicitis. Acute Care Surgery was consulted, and they felt
that patient's symptoms were not related to appendicitis and
that no acute surgical intervention needed at this time. Patient
had serial lab examination that revealed no abnormalities. Upon
chart review, patient noted to have a long-standing history of
abdominal pain resulting in multiple hospital presentations
since ___ and resultant extensive workup. Per ___
d/c summary from ___, prior workup includes normal HIDA scan
in ___, C4 42 (upper range nl 36), C1 esterase, normal
small bowel follow through in ___, carcinoid workup
negative, IgA 249, EGD that demonstrated several non-bleeding
gastric ulcers and was H pylori negative, negative TTG and ___.
Per patient, when elective cholecystectomy was performed in
___ she was told that the procedure may or may not improve
her pain. During this admission, patient had serial labs that
revealed no abnormalities, was afebrile, and was without
leukocytosis. She was treated with a bowel regimen and was
started on dicyclomine with improvement in her symptoms. Patient
was discharged on pain medication and lorazepam at her normal
home doses and instructed to follow up with her PCP.
#Diarrhea: Endorsed diarrhea on admission with no concomitant
change in diet or recent travel. Recent health care exposure
though denies recent antibiotic use. C diff, stool culture, were
considered but ultimately were not performed as patient had no
more diarrhea after admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old male with a history of
diverticulitis with microperforation, pancreatic IPMN who
underwent robot-assisted laparoscopic distal pancreatectomy and
splenectomy (___). Patient was re-admitted on ___ from
clinic with fevers/chills and leukocytosis. Abdominal CT scan in
ED demonstrated 5.9 x 5.6 x 5.2 cm peripancreatic fluid
collection centered between the remnant pancreatic tail and
greater curvature of the stomach.
Past Medical History:
Past Medical History:
Asthma
Past Surgical History:
Laparoscopic appendectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
Prior To Discharge:
VS: 98.1, 61, 104/68, 18, 96% RA
GEN: Pleasant with NAD
HEENT: No scleral icterus
CV: RRR
PULM: CTAB
ABD: Laparoscopic incisions open to air and c/d/I. LLQ JP drain
to bulb suction with small amount of serous fluid, site
covered with drain sponge and with minimal serous stains.
EXTR: Warm, no c/c/e
Pertinent Results:
RECENT LABS:
___ 05:38AM BLOOD WBC-16.1* RBC-3.64* Hgb-10.5* Hct-32.0*
MCV-88 MCH-28.8 MCHC-32.8 RDW-14.8 RDWSD-47.5* Plt ___
___ 05:38AM BLOOD Glucose-114* UreaN-3* Creat-1.2 Na-145
K-4.8 Cl-110* HCO3-24 AnGap-11
___ 01:03PM BLOOD ALT-46* AST-25 AlkPhos-101 TotBili-0.8
___ 05:38AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0
___ 04:41PM ASCITES Amylase-47
RADIOLOGY:
___ CT ABD:
IMPRESSION:
1. 5.9 x 5.6 x 5.2 cm peripancreatic fluid collection centered
between the
remnant pancreatic tail and greater curvature of the stomach.
No evidence of pancreatitis or necrosis. A drain courses
through the collection, although it is unclear if drainage
catheter sideholes are contained within the collection.
Superimposed infection can't be excluded.
2. Small to moderate left pleural effusion.
3. Diverticulosis without diverticulitis.
___ CT ABD:
IMPRESSION:
1. Interval decrease in size of a 6.1 cm fluid collection at the
pancreatic resection margin and along the greater curvature of
the stomach.
2. Interval retraction of a left lower quadrant approach drain
which now
terminates within this collection.
3. No significant change in small volume mesenteric free-fluid
in the left
upper quadrant and in the pelvis.
4. No significant change in moderate left pleural effusion with
associated
basilar atelectasis. Slightly increased trace right pleural
effusion.
___ CT ABD:
IMPRESSION:
1. Unchanged appearance of a crescentic rim enhancing fluid
collection
paralleling the greater curvature of the stomach with surgical
drain
traversing the collection and terminating at its anterior tip.
2. Fat necrosis and free fluid seen in the splenectomy bed
without evidence of an organized collection - unchanged
compared to prior.
3. Perfusional changes at the hepatic dome in segment VIII are
minimally
increased compared to ___.
4. Minimal increase in the left-sided pleural effusion compared
to most
recent prior.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID:PRN
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Senna 8.6 mg PO BID
6. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
7. Hydrocortisone Acetate Suppository ___ID
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*34 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
4. Docusate Sodium 100 mg PO BID
5. GuaiFENesin ___ mL PO Q6H:PRN cough
6. Senna 8.6 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Hydrocortisone Acetate Suppository ___ID
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Intra abdominal abscess s/p distal pancreatectomy and
splenectomy.
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 dyspnea// acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size appears mildly enlarged, but unchanged. The aorta remains mildly
tortuous. The mediastinal and hilar contours are within normal limits. A
small left pleural effusion has developed in the interval. There is
associated left basilar opacity, likely atelectasis. A trace right pleural
effusion is also new. No pneumothorax. Pulmonary vasculature is not
engorged. Catheter is noted within the left upper quadrant of the abdomen.
IMPRESSION:
Interval development of small left and trace right bilateral pleural
effusions, with left basilar opacity, likely atelectasis.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ w/ newly diagnosed pancreatic tail mass was admitted to the
Surgical Oncology Service for elective resection.// postop fluid/collections
(AFTER 2 Liters)
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 609 mGy-cm.
COMPARISON: CT ___
FINDINGS:
LOWER CHEST: There is a small to moderate low-density left pleural effusion
and trace right, new from prior. Platelike atelectasis is noted at the right
lung base.
ABDOMEN:
HEPATOBILIARY: Innumerable subcentimeter hypodensities scattered throughout
the liver are compatible with simple cysts. The gallbladder is unremarkable.
PANCREAS: The patient is status post distal pancreatectomy. There is a 5.9 x
5.6 x 5.2 cm fluid collection centered between the remnant tail of the
pancreas and the greater curvature of the stomach. A left lower quadrant
drain courses superiorly along the left lateral abdominal wall and courses
through the collection.
There is no evidence of pancreatitis or pancreatic necrosis.
Left upper quadrant stranding (series 2, image 21) is likely postoperative.
SPLEEN: The spleen is surgically absent.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral subcentimeter hypodensities, including multiple peripelvic cysts on
the left, are compatible with simple cysts. There is a 1.5 cm lesion arising
from the lower pole of the left kidney (series 2, image 38), which has
previously been characterized as a hemorrhagic cyst on prior MR. ___ is no
perinephric abnormality.
GASTROINTESTINAL: 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 normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. 5.9 x 5.6 x 5.2 cm peripancreatic fluid collection centered between the
remnant pancreatic tail and greater curvature of the stomach. No evidence of
pancreatitis or necrosis. A drain courses through the collection, although it
is unclear if drainage catheter sideholes are contained within the collection.
Superimposed infection can't be excluded.
2. Small to moderate left pleural effusion.
3. Diverticulosis without diverticulitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p lap-robotic distal pancreatectomy/splenectomy presents
with decreased drain output// ? anatomical explanation for inspiratory pain
? anatomical explanation for inspiratory pain
IMPRESSION:
Heart size and mediastinum are stable. Left pleural effusion has increased,
moderate. No pneumothorax.
Abdominal drain is projecting over the left upper quadrant.
Radiology Report
INDICATION: ___ s/p lap-robotic distal pancreatectomy/splenectomy presents
with decreased drain output// Please eval for interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
There is a moderate left pleural effusion with subjacent atelectasis. The
right lung is clear. No pneumothorax. The size of the cardiac silhouette is
within normal limits. An abdominal drain projects over the left upper
quadrant.
IMPRESSION:
No appreciable change in a moderate left pleural effusion.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ year old man s/p distal panc and spleen c/b undrained fluid
collection, likely pancreatic leak, s/p bedside drain manipulation and
additional output, now ongoing malaise, poor appetite// eval for ongoing fluid
collection requiring ___ intervention
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 4.5 s, 59.7 cm; CTDIvol = 12.3 mGy (Body) DLP = 735.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 8.4 s, 0.5 cm; CTDIvol = 46.7 mGy (Body) DLP =
23.4 mGy-cm.
Total DLP (Body) = 761 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: There is an increased trace right and unchanged moderate
left-sided pleural effusion with associated compressive atelectasis at the
bases bilaterally. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There is nonspecific inhomogeneous stance Min of the right lobe
of the liver and hepatic dome, slightly more pronounced compared to prior exam
possibly due to timing of contrast or focal fatty infiltration. Numerous
hypodense lesions throughout the liver better characterized as simple cysts on
recent MRCP. Largest of these measures up to 2.4 cm in the dome of the liver.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: Status post distal pancreatectomy. The remaining body and head of
the pancreas are within normal limits. A curvilinear fluid collection at the
resection margin abutting the greater curvature of the stomach measures
approximately 2.0 x 6.1 x 3.1 cm, previously 7.0 x 2.5 x 5.2 cm when measured
in a similar manner (___:34, 601:28). A drain approaching from the left lower
quadrant of the abdomen terminates appears to have been retracted slightly and
now terminates within this collection. Two small foci of air seen within this
collection (02:31) are not seen on the prior exam.
SPLEEN: Status post splenectomy. Small volume mesenteric fluid seen in the
left upper quadrant of the abdomen is similar to prior exam.
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. Parapelvic
left renal cysts are noted. A 1.5 cm cyst arising from the lower pole the
left kidney is better characterized as a hemorrhagic cyst on recent MRCP.
Additional hypodense lesions in the right kidney were also characterized as
cysts. There is no perinephric abnormality.
GASTROINTESTINAL: 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.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small volume free fluid in the pelvis similar prior.
REPRODUCTIVE ORGANS: 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. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Small fat containing umbilical hernia noted. Postsurgical
changes noted along the midline of the upper abdomen. Subcutaneous gas noted
along the entry site of the left lower quadrant abdominal drain.
IMPRESSION:
1. Interval decrease in size of a 6.1 cm fluid collection at the pancreatic
resection margin and along the greater curvature of the stomach.
2. Interval retraction of a left lower quadrant approach drain which now
terminates within this collection.
3. No significant change in small volume mesenteric free-fluid in the left
upper quadrant and in the pelvis.
4. No significant change in moderate left pleural effusion with associated
basilar atelectasis. Slightly increased trace right pleural effusion.
Radiology Report
EXAMINATION: CT abdomen
INDICATION: ___ year old man s/p distal pancreatecromy and splenectomy
___, now with abscess. Please evaluate interval change in known
peripancreatic fluid collection for possible ___ drainage. IV contrast only
TECHNIQUE: Multidetector CT of the abdomen was done without and with IV
contrast. Initially the abdomen was scanned without IV contrast. Subsequently
a single bolus of IV contrast was injected and the abdomen and pelvis were
scanned in the portal venous phase.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 2.3 s, 30.1 cm; CTDIvol =
11.1 mGy (Body) DLP = 333.3 mGy-cm. 2) Spiral Acquisition 2.3 s, 30.1 cm;
CTDIvol = 11.1 mGy (Body) DLP = 333.5 mGy-cm. 3) Stationary Acquisition 0.6 s,
0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5 mGy-cm. 4) Stationary Acquisition
7.2 s, 0.5 cm; CTDIvol = 36.6 mGy (Body) DLP = 18.3 mGy-cm. Total DLP (Body) =
687 mGy-cm.
COMPARISON: Comparison is made to CT abdomen pelvis performed ___.
FINDINGS:
LOWER CHEST: Moderate left-sided pleural effusion appears minimally increased
compared to ___ and is associated with overlying compressive
atelectasis. No evidence of pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Large wedge-shaped area of heterogeneous enhancement involving
segment VIII at the hepatic dome is likely related to perfusional changes and
has minimally progressed compared to most recent exam. Multiple scattered
biliary cysts are again demonstrated, the largest measuring up to 2.4 cm at
the dome of the liver (03:10). There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: Patient is status post distal pancreatectomy. The residual body and
head of the pancreas are within normal limits. Crescentic fluid collection
remains unchanged in size compared to prior exam measuring 1.9 x 6.1 x 3.1 cm,
previously 2.0 x 6.1 x 3.1 cm (3:21, 601:28). A surgical drain in the left
subphrenic space traverses the collection with its terminal tip abutting the
anterior wall of the collection.
SPLEEN: Patient is status post splenectomy. Persistent free fluid in the
resection bed is similar to prior exam (03:14).
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
No evidence of hydronephrosis. A 1.5 x 1.2 cm left lower pole hyperdense cyst
was previously characterized as a hemorrhagic cyst on prior MRCP dated ___ (03:37). Multiple bilateral renal hypodensities are too small
to characterize but likely represent simple renal cyst. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Visualized small bowel loops
are normal in caliber, wall thickness, enhancement throughout. The visualized
colon is unremarkable.
RETROPERITONEUM AND MESENTERY: Scattered retroperitoneal lymph nodes are not
pathologically enlarged by CT size criteria. There is no abdominal aortic
aneurysm. Mild atherosclerotic disease is noted. The mesenteric vessels appear
patent.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Postsurgical changes in the anterior abdominal wall are again
demonstrated. Small fat containing umbilical hernia is unchanged.
IMPRESSION:
1. Unchanged appearance of a crescentic rim enhancing fluid collection
paralleling the greater curvature of the stomach with surgical drain
traversing the collection and terminating at its anterior tip.
2. Fat necrosis and free fluid seen in the splenectomy bed without evidence of
an organized collection - unchanged compared to prior.
3. Perfusional changes at the hepatic dome in segment VIII are minimally
increased compared to ___.
4. Minimal increase in the left-sided pleural effusion compared to most
recent prior.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Postprocedural fever, Unspecified abdominal pain, Cough
temperature: 101.4
heartrate: 85.0
resprate: 18.0
o2sat: 97.0
sbp: 126.0
dbp: 63.0
level of pain: 6
level of acuity: 3.0 | ___ is a ___ year-old man who was recently discharged
from ___ on ___ following elective resection of a
pancreatic tail mass on ___, however, he presented to clinic
on ___ with complaints of worsening abdominal pain, diarrhea,
fevers and chills. He was admitted for IV antibiotics and IV
fluids. A CT scan of his abdomen and pelvis was performed on
HD#1 and demonstrated a persistent fluid collection surrounding
his JP drain. The drain was subsequently pulled back with an
improvement in drain output. Subsequent imaging studies
confirmed the fluid collection near the site of anastomosis and
drain was slowly decreasing in size.
Neuro: The patient received pain medications with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient had a persistent cough throughout his
hospitalization. Several imaging studies demonstrated a large
left sided pleural effusion. In addition, he was noted to have
end-expiratory wheezes bilaterally, thus, he was administered
his home asthma inhalers in addition to antibiotics with
improvement in symptoms. Good pulmonary toilet, early ambulation
and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Initially on admission the patient was made NPO with
IV fluids. Diet was advanced to a clear liquid diet and
subsequently a regular diet when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Samples sent for c.diff
and flu testing returned negative. He was initially started on
IV zosyn and later changed to oral Augmentin per Infectious
Disease who recommended a course of 17 days. His wound was
evaluated daily and no signs and symptoms of infection were
noticed.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; 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 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: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Coumadin /
Amitriptyline / Heparin,Porcine / Iodinated Contrast Media - IV
Dye / Dilaudid
Attending: ___.
Chief Complaint:
Fall, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of CAD s/p
4-vessel CABG, TVR, pacemaker, severe carotid stenosis, and
chronic lung disease (on 3L home O2). She presented to the ED
after two falls and reported worsening hypoxia with a measured
SpO2 of 79% at home on 1.5L NC.
Patient reports frequent falls. This morning, while walking to
the kitchen, she fell onto her bottom without hitting her head
or loss of consciousness. Her husband wheeled her into another
room in her wheelchair and when she tried to stand up to her
walker, she fell backwards, striking her back and left arm.
Patient generally uses 3L NC at all times but her ___ had
suggested she try a lower setting to avoid oxygen toxicity.
After the second fall, a home SpO2 was 79% on 3L. She was then
referred to the ED by her ___, who had noted something abnormal
on her lung exam.
Patient denies cough, fever, chills, nausea, and vomiting. She
endorses shortness of breath when she becomes anxious, which she
acknowledges is a longstanding problem for her. Patient was
scheduled to have a carotid endarterectomy on ___ and was
supposed to see an outpatient pulmonologist today for pre-op
clearance. She is very concerned that she might not be able to
have her surgery as scheduled.
Of note, patient was recently admitted for a COPD exacerbation
from ___. During that admission, she received
steroids, antibiotics and nebulizer treatments. Her
pulmonologist is at another institution and she does not know
his name. Her only breathing treatment is albuterol and there is
mention in previous pulmonary consult notes that she may have
been diagnosed with BOOP. She reports having some swelling in
her legs today and taking an extra dose of lasix. She also
reports taking PO dilaudid 5x/day (prescribed as 2x/day) due to
pain.
In the ED, initial VS were: 98.8 78 135/66 22 99% 3L. She
reported abdominal pain in the setting of constipation and
received a CT abdomen which was negative for acute process but
showed high fecal loading. She received duonebs, 1mg IV
Dialudid x 2, 0.25mg Clonazepam, 125mg methylprednisolone IV,
and 750mg IV levofloxacin and was admitted to the floor for COPD
exacerbation.
On arrival to the floor the patient reports feeling anxious and
shakey and that she has trouble catching her breath. She is also
having a lot of pain.
Past Medical History:
Hypertension
Hypercholesterolemia
coronary artery disease- s/p 4 stents at ___ in ___
CABGx4 in ___
s/p pacemaker
s/p redo bioprosthetic TVR ___ for prosthetic TVR stenosis
(original replacement for ?SBE with severe TR)
Atrial tachycardia
Restless legs syndrome
"CVA x 8" in ___ records and preivously had
evaluation here but no evidence of ischemic stroke on imaging
carotid artery stenosis (80-99% left, 70-79% right)
possible subclavian steal syndrome
COPD
gastroesophageal reflux
Depression/Anxiety
fibromyalgia
multiple falls
type II DM- not on treatment unless taking steroids
Uterine cancer in her ___
h/o pulmonary embolism
Social History:
___
Family History:
Mother and father had heart attacks. Son died at age ___ of MI,
though per prior notes this was most likely in the setting of a
drug overdose.
Physical Exam:
ADMISSION EXAM:
VS: 98.1 71 154/84 22 96 3L
GENERAL: chronically ill-appearing, looks older than stated age,
NAD but highly anxious apperaing, intermittently sobbing and
shakey
HEENT: PEERLA, MMM, no JVD
LUNGS: Diffuse crackles in bilateral lung fields R > L with
inspiratory squeaks
HEART: RRR, ___ systolic murmur with ___ diastolic component at
TC area, no r/g
ABDOMEN: Firm but non-tense, non-distended, NABS, no rebound or
guarding.
BACK: Diffusely TTP
EXTREMITIES: Purple echymoses on left shoulder, right medial
elbow, left elbow, multiple small older bruises on her sacrum.
no edema, 2+ pulses radial and dp
NEURO: awake, ___, CNs II-XII grossly intact, muscle strength
___ throughout
Psych- Mood anxious, affect congruent, very labile
DISCHARGE EXAM:
VS: Tm 97.6 71 168/86 16 100 3L
GENERAL: Sitting up in bed, NAD
HEENT: MMM
LUNGS: Diffuse inspiratory and expiratory crackles
HEART: RRR, ___ systolic murmur with ___ diastolic component at
TC area, no r/g
ABDOMEN: Non-tense, non-distended, NABS, no rebound or guarding.
EXTREMITIES: Purple echymoses on left shoulder, right medial
elbow, left elbow starting to resolve
NEURO: ___, moves all 4 extremities spontaneously
Pertinent Results:
ADMISSION LABS:
___ 09:00PM BLOOD WBC-10.3# RBC-3.82* Hgb-11.3* Hct-34.6*
MCV-91 MCH-29.5 MCHC-32.6 RDW-15.9* Plt ___
___ 09:00PM BLOOD Neuts-74* Bands-0 Lymphs-14* Monos-5
Eos-0 Baso-0 ___ Metas-4* Myelos-3* NRBC-1*
___ 09:00PM BLOOD ___ PTT-24.5* ___
___ 09:00PM BLOOD Glucose-218* UreaN-22* Creat-1.0 Na-138
K-3.8 Cl-97 HCO3-33* AnGap-12
___ 09:00PM BLOOD cTropnT-<0.01 ___ 11:06AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9
___ 09:00PM BLOOD D-Dimer-460
___ 09:05PM BLOOD Lactate-0.9 K-4.4
OTHER LABS:
___ 02:38PM URINE RBC-1 WBC-19* Bacteri-MOD Yeast-NONE
Epi-3 RenalEp-<1
___ 12:55PM URINE Hours-RANDOM UreaN-418 Creat-92 Na-52
K-35 Cl-24 Calcium-0.5 Phos-75.2
___ 10:51AM URINE Eos-NEGATIVE
MICROBIOLOGY:
___ Culture: PENDING
___ Culture: PENDING
___ Culture: PENDING
___ Blood Culture: No growth
IMAGING:
___ EKG
Atrial pacing. Right bundle-branch block. Possible old inferior
wall myocardial infarction. Compared to the previous tracing of
___ no change. QTc 481
___ CXR
The patient is status post median sternotomy and CABG.
Left-sided dual-chamber pacemaker device is present with leads
terminating in the right atrium and right ventricle. Moderate
cardiomegaly is unchanged. Mild pulmonary vascular engorgement
is likely present, similar compared to the prior study.
Probable small bilateral pleural effusions are present. Pleural
thickening within the lung apices is is unchanged. No
pneumothorax is identified. Streaky bibasilar opacities likely
reflect a combination of atelectasis with chronic fibrotic
changes, more so in the right lung base. No pneumothorax is
detected. No acute osseous abnormalities seen. Elevation of
the right hemidiaphragm is unchanged. Remote fracture of the
proximal right
humerus is again noted.
IMPRESSION: Mild pulmonary vascular congestion, similar compared
to the previous exam, with probable small bilateral pleural
effusions. Bibasilar streaky airspace opacities could reflect a
combination of atelectasis with chronic changes.
___ CT Abd/Pel
1. No acute intra-abdominal or pelvic process.
2. No significant change in moderate intrahepatic biliary duct
dilatation and dilatation of both the common duct and main
pancreatic duct, likely related to prior cholecystectomy.
3. Atrophic right kidney, not significantly changed.
4. Nodular left adrenal gland, not significantly changed.
5. Marked calcified atherosclerosis of the abdominal aorta,
celiac axis, and bilateral iliac arteries.
6. Moderate cardiomegaly with marked right atrial enlargement,
not significantly changed.
___ Lumbo-Sacral and Left Shoulder X-Rays
No evidence of fracture
___ Renal Ultrasound
1. Atrophic right kidney, measuring 5 cm with loss of
corticomedullary differentiation and markedly thinned cortex.
Given the size of the kidney and patient's inability to
cooperate, no flow was detected within the arcuate arteries or
the main renal arteries, likely secondary to velocities below
the ultrasound threshold.
2. Normal size, cortical thickness and corticomedullary
differentiation of the left kidney. Normal waveform within the
left main renal artery, interlobar arteries and vein without
evidence of renal artery stenosis. There is no hydronephrosis
or suspicious masses.
___ CXR
1. Interval improved pulmonary edema.
2. Mildly increased small left pleural effusion and atelectasis
admixed with chronic changes in the left lung base.
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-5.4 RBC-3.37* Hgb-9.6* Hct-30.5*
MCV-91 MCH-28.6 MCHC-31.6 RDW-15.3 Plt ___
___ 07:10AM BLOOD Glucose-142* UreaN-9 Creat-0.7 Na-143
K-4.0 Cl-105 HCO3-31 AnGap-11
___ 07:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clonazepam 0.5 mg PO BID
hold for sedation or rr<10
2. Docusate Sodium 100 mg PO BID
3. Furosemide 40 mg PO BID
hold for sbp<100 or hr<60
4. Gabapentin 300 mg PO BID
hold for sedation or rr<10
5. HYDROmorphone (Dilaudid) 2 mg PO UNDEFINED pain
hold for sedation or rr<10
6. Metoprolol Tartrate 50 mg PO BID
hold for sbp<100 or hr<60
7. Pantoprazole 40 mg PO Q24H
8. Ropinirole 0.5 mg PO TID
9. Rosuvastatin Calcium 5 mg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Diltiazem Extended-Release 180 mg PO DAILY
hold for sbp<100 or hr<60
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
13. Estrogens Conjugated 0.3 mg PO DAILY
14. traZODONE 100 mg PO HS:PRN insomnia
hold for sedation or rr<10
15. Duloxetine 90 mg PO DAILY
16. Flecainide Acetate 50 mg PO Q12H
17. Lidocaine 5% Patch 1 PTCH TD DAILY
apply to back
18. Nicotine Patch 14 mg TD DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clonazepam 0.5 mg PO TID
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Duloxetine 90 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Metoprolol Tartrate 50 mg PO BID
9. Nicotine Patch 14 mg TD DAILY
10. Pantoprazole 40 mg PO Q24H
11. Rosuvastatin Calcium 5 mg PO DAILY
12. CloniDINE 0.2 mg PO Q6H:PRN withdrawal symptoms
RX *clonidine 0.2 mg 1 tablet(s) by mouth every 6 hours Disp #*5
Tablet Refills:*0
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
14. Estrogens Conjugated 0.3 mg PO DAILY
15. Furosemide 40 mg PO BID
16. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice daily Disp #*12 Capsule Refills:*0
17. Senna 1 TAB PO BID:PRN constipation
18. Outpatient Lab Work
287.4 Secondary thrombocytopenia
Please check CBC and report results to ___ ___
___: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Fall
- Opioid abuse
- Hypoxia
- ___
SECONDARY DIAGNOSES:
- COPD vs. other chronic lung disease
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
HISTORY: Fall, to assess for compression fracture.
FINDINGS: Bowel gas and fecal material greatly obscure detail on the frontal
view. There is no evidence of compression fracture on the lateral. Mild
hypertrophic spurring is seen at several levels, though the vertebrae and
intervertebral disc spaces are quite well maintained.
Of incidental note is calcification in the lower aorta and evidence of
previous cholecystectomy.
Radiology Report
HISTORY: Left shoulder pain after fall, to assess for fracture.
FINDINGS: No previous images. No evidence of acute fracture or dislocation.
No appreciable degenerative change. Pacemaker device is in place.
Radiology Report
HISTORY: ___ lady with atrophic right kidney on CT scan; now with
acute renal failure: The assessment for renal artery stenosis, hydronephrosis
or other causes of acute renal failure is requested.
COMPARISON: CT of abdomen and pelvis dated on ___
Technique: Multiple gray scale and doppler images of kidneys and urinary
bladder were obtained with a multifrequency probe.
FINDINGS:
The right kidney measures 5 cm and appears atrophic as previously described on
the CT. There is marked thinning of the renal cortex with overall increased
echogenicity. Given the size of the kidney and patient's inability to
cooperate, no arterial flow was obtained in the main renal artery or
interlobar arteries. This is likely secondary to flow velocoty below the
ultrasound doppler threshold . There is no hydronephrosis. No suspicious
renal masses are seen within the right kidney.
Left kidney demonstrates normal size, measuring 12 cm with preserved
corticomedullary differentiation. There is no hydronephrosis. There are no
suspicious renal masses. The Doppler interrogation of the upper mid and lower
pole demonstrates normal waveform with sharp upstroke and preserved diastolic
flow with a resistive indices ranging from 0.69-0.74, within normal limits.
The left renal artery also demonstrates normal the waveforms. The renal vein
was interrogated at the hilum which demonstrates patency and normal waveform.
The urinary bladder was well distended without evidence of masses.
IMPRESSION:
1. Atrophic right kidney, measuring 5 cm with loss of corticomedullary
differentiation and markedly thinned cortex. Given the size of the kidney and
patient's inability to cooperate, no flow was detected within the arcuate
arteries or the main renal arteries, likely secondary to velocities below the
ultrasound threshold.
2. Normal size, cortical thickness and corticomedullary differentiation of
the left kidney. Normal waveform within the left main renal artery,
interlobar arteries and vein without evidence of renal artery stenosis. There
is no hydronephrosis or suspicious masses.
Radiology Report
HISTORY: ___ female with chronic lung disease and baseline 3L oxygen
requirement presents with acute CO2 retention. Question acute process.
COMPARISON: ___.
FINDINGS:
Frontal lateral views of the chest demonstrate left pectoral cardiac pacer
with leads terminating in the right atrium and right ventricle. There is
evidence of prior CABG. Median sternotomy wires are intact. Massive
cardiomegaly is similar as before. Low lung volumes are unchanged. There is
interval improvement of previously mild interstitial edema. Streaky
retrocardiac opacities may be a combination of a chronic changes and
subsegmental atelectasis. There is likely a small left pleural effusion.
IMPRESSION:
1. Interval improved pulmonary edema.
2. Mildly increased small left pleural effusion and atelectasis admixed with
chronic changes in the left lung base.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LOW SAT/SOB
Diagnosed with RESPIRATORY ABNORM NEC, HYPOXEMIA, ABDOMINAL PAIN LLQ, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, LONG TERM USE ANTIGOAGULANT, AORTOCORONARY BYPASS
temperature: 98.8
heartrate: 78.0
resprate: 22.0
o2sat: 99.0
sbp: 135.0
dbp: 66.0
level of pain: nan
level of acuity: 2.0 | Ms. ___ is a ___ year-old woman with a history of CAD, TVR,
chronic lung disease on 3L of home O2, opioid abuse, depression,
and multiple falls. She presented to ___ with falls and an
episode of hypoxia. She developed an acute kidney injury, was
diagnosed with a urinary tract infection, and showed ongoing
opioid-seeking behavior. Narcotics were discontinued and patient
was detoxed.
ACTIVE ISSUES:
1. Hypoxia: Patient most likely became hypoxic in the setting of
decreasing her home O2 from 3L to 1.5L. She had no symptoms of a
COPD exacerbation and so steroids and antibiotics were
discontinued upon arrival to the floor. Patient's shortness of
breath is most likely related to anxiety and to her underlying
chronic lung disease. Although patient and husband say she has
COPD, she does not seem to carry a clear diagnosis (no recent
PFT's or regular Pulmonary follow-up, prior PFT's were
inconclusive). Her exam is suspicious for an interstitial lung
disease. Patient was scheduled to establish with Dr. ___
___ ___ and undergo PFT's on day of presentation but
unfortunately missed these appointments. She was continued on
albuterol, ipratropium, and 3L by NC and continued to saturate
well. She was strongly encouraged to follow-up with Pulmonology
for a definitive diagnosis of her lung condition.
2. Opioid Abuse/Withdrawal: Patient has a long history of opioid
dependence and abuse, and has required inpatient detoxification
in the past. Upon presentation, she demonstrated unsafe behavior
related to narcotics, including telling providers she takes
significantly more dilaudid than she actually does when dosing
was confirmed with husband and PCP. Husband and PCP have been
trying to treat patient's opioid addiction with a buprenorphine
patch. After discussion with patient, husband, and other
providers, decision was made to stop narcotics on ___.
Patient experienced significant withdrawal symptoms, which were
managed with clonidine and low-dose benzodiazepines. She was
advised to avoid narcotics in the future.
3. Acute Kidney Injury: Patient has a hypertrophic right kidney
and developed an acute kidney injury, which was likely secondary
to contrast nephropathy from her CT abdomen/pelvis. She received
IV fluids and her creatinine improved to baseline. If she needs
a contrast study in the future, her diuretics should be held and
she should be pre-hydrated.
4. Depression/Anxiety: Patient showed significant symptoms of
depression and anxiety. Although she denied visual/auditory
hallucinations, she endorsed delusions about her upcoming
carotid endarterectomy solving many problems in her life,
including grief over her son's death, her need for opioids, her
anxiety, and her falls. Patient was followed by social work
throughout her admission and she was continued on duloxetine.
She was strongly encouraged to establish with Psychiatry as an
outpatient.
5. Somnolence/CO2 retention: Patient had an episode of
somnolence early in admission in the setting of receiving two
doses of PO dilaudid within ~ 4 hours. She was found to be
acutely retaining CO2. She received Narcan and her mental status
and CO2 retention improved, suggesting over-sedation as the
underlying etiology. However, patient had received comparable
doses of dilaudid in the ED without somnolence, so it is
possible her underlying lung disease also contributed. Narcotics
were discontinued as above. She had no further episodes of
somnolence
6. Urinary Tract Infection: Patient had asymptomatic bacteriuria
early in admission with a Bactrim and Cipro-resistant E. Coli.
On ___, she became symptomatic and had a repeat UA, which
was consistent with infection. She was started on Macrobid.
7. Leukocytosis: Most likely due to methylprednisolone given in
the ED given neutrophilic predominance. Resolved.
8. Falls: Patient has had frequent falls of unclear etiology,
though mechanical and anxiety etiologies likely play a role. It
is also possible falls are related to hypoperfusion from severe
carotid stenosis. Lumbosacral and L shoulder films were negative
for fracture. She was evaluated by ___ who recommended
rehabilitation.
9. LLQ Pain: In the ED, patient reported LLQ pain x 1 day in the
setting of constipation. She underwent a CT scan which showed
fecal loading. She received an aggressive bowel regimen and pain
resolved.
10. Carotid Artery Stenosis: Patient has severe carotid stenosis
and was to undergo CEA on ___. However, she had not been
cleared for surgery (had outpatient appointment with
Pulmonologist/PFT's scheduled for day of presentation) and may
be a high risk candidate given her lung disease. In the setting
of ___, surgery was rescheduled for later this ___.
CHRONIC ISSUES:
1. CAD s/p stents and CABG in ___: No chest pain, and EKG was
unchanged from prior. Continued ASA.
2. Diabetes: Patient has a history of diabetes requiring insulin
when she receives steroids. Finger sticks were high after
receiving steroids in the ED and she was started on ISS. 5 units
of glargine daily were added with good glucose control.
3. Hypertension: Patient was intermittently hypertensive in the
setting of anxiety and opioid withdrawal. She was continued on
metoprolol.
4. GERD: Continued pantoprazole.
TRANSITIONAL ISSUES:
- Avoid future opioids as patient has active opioid abuse and
has now been detoxed
- ___ continue clonidine PRN for next 2 days
- Prehydrate and hold diuretics for any future contrast studies
- Establish with Pulmonary for PFT's and definitive diagnosis of
lung disease
- Carotid surgery rescheduled
- Complete course of Macrobid for UTI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bee Pollens / simvastatin / ciprofloxacin /
clindamycin
Attending: ___.
Chief Complaint:
Ulcer, Cellulitis
Major Surgical or Invasive Procedure:
___ -- debridement
History of Present Illness:
___ year old Female with diabetic neuropathy with a left heel
ulcer for the 9 months preceding admission, failing multiple
rounds of IV antibiotics and debridements. The patient was
recently evaluated by both plastics and reconstructive surgery
and podiatry, who had planned a left heal flap, but has been
failing at home. The patient reports 3 days of increased pain,
chills and "goosebumps" although did not check for a fever. She
was traveling ___ ___ and felt lethargic and due to the
increased pain, came to the ED.
___ the ___ ED her initial vitals 99, 88, 124/63, 18, 99%. She
was evaluated by podiatry ___ the ED, who preformed a bedside
debridement. She was administered vancomycin and cefepime. ___
addition she also received oxycodone and 1L of IV fluids. A foot
x-ray was performed.
Past Medical History:
1. Type 2 Diabetes complicated by neuropathy (last A1c 5.9%)
2. Hypertension
3. Hypercholesterolemia
4. Anxiety
5. Depression
6. OCD
7. GERD
-R met head resections of ___ hammertoe corrections
(___)
- Left TAL, Left first met oxostectomy, left flexor tenotomy
digits ___, Met head resection and resection of base of proximal
phalanx, second ray Right foot, Flexor tenotomy ___ toes right
foot
- ___ Subtalar joint arthrorisis of left foot,
Arthroplasties
left foot fourth and fifth digits, Arthroplasty right foot third
digit
- ___ Arthroplasty of right digits 3 through 5
Social History:
___
Family History:
Extensive family history of type II diabetes on both sides. No
history of MI.
Physical 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: 98.4, 124/69, 74, 18, 99%
GEN: NAD, Obese
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE, Left heel with ulcer now dressed with drainage,
Multiple toe amputations bilaterally, excoriations left shin
NEURO: CAOx3, Non-Focal
DISCHARGE PHYSICAL EXAM:
VSS: afebrile, 68-68, 116-118/67-71, RR ___ 99-100
GEN: NAD, Obese
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE, left heel ulcer dressed with no drainage. minimal
pain
NEURO: CAOx3, Non-Focal
Pertinent Results:
___ 11:18AM BLOOD WBC-7.6 RBC-3.86* Hgb-9.7* Hct-31.2*
MCV-81* MCH-25.1* MCHC-31.1* RDW-17.2* RDWSD-50.6* Plt ___
___ 11:18AM BLOOD Neuts-73.1* Lymphs-14.9* Monos-6.5
Eos-4.7 Baso-0.3 Im ___ AbsNeut-5.54# AbsLymp-1.13*
AbsMono-0.49 AbsEos-0.36 AbsBaso-0.02
___ 11:18AM BLOOD Glucose-204* UreaN-16 Creat-0.9 Na-134
K-5.0 Cl-100 HCO3-22 AnGap-17
___ 11:18AM BLOOD CRP-151.3*
___ 11:29AM BLOOD Lactate-2.1*
___ 07:45AM BLOOD WBC-4.7 RBC-3.84* Hgb-9.3* Hct-30.9*
MCV-81* MCH-24.2* MCHC-30.1* RDW-17.0* RDWSD-49.5* Plt ___
___ 11:18 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 12:57 pm SWAB Source: L heel Lateral wound.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
FOOT AP,LAT & OBL LEFT Study Date of ___ 11:58 AM
IMPRESSION:
Large soft tissue ulceration within the plantar aspect of the
foot at the
level of the calcaneus, without definite radiographic evidence
for
osteomyelitis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Becaplermin Gel 0.01% 1 Appl TP DAILY
2. Dakins ___ Strength 1 Appl TP BID
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
4. Loratadine 10 mg PO DAILY
5. ClonazePAM 0.5 mg PO TID:PRN Anxiety
6. Lactic Acid 12% Lotion 1 Appl TP DAILY
7. Citalopram 40 mg PO QHS
8. Byetta (exenatide) 5 mcg/dose (250 mcg/mL) 1.2 mL
subcutaneous BID
9. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
10. Lisinopril 10 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. Oxybutynin 10 mg PO DAILY
14. Spironolactone 25 mg PO BID
15. TraZODone 50 mg PO QHS:PRN insomnia
16. Magnesium Oxide 400 mg PO BID
17. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Glargine 10 Units Dinner
RX *insulin glargine [Lantus] 100 unit/mL 10 units SC 10 Units
before DINR; Disp #*6 Vial Refills:*3
2. Levofloxacin 750 mg PO Q24H Duration: 12 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*12 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*36 Tablet Refills:*0
4. Becaplermin Gel 0.01% 1 Appl TP DAILY
5. Byetta (exenatide) 5 mcg/dose (250 mcg/mL) 1.2 mL
subcutaneous BID
6. Citalopram 40 mg PO QHS
7. ClonazePAM 0.5 mg PO TID:PRN Anxiety
8. Dakins ___ Strength 1 Appl TP BID
9. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
10. Lactic Acid 12% Lotion 1 Appl TP DAILY
11. Lisinopril 10 mg PO DAILY
12. Loratadine 10 mg PO DAILY
13. Magnesium Oxide 400 mg PO BID
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Oxybutynin 10 mg PO DAILY
18. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
19. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis of diabetic foot ulcer
Discharge Condition:
Fair
Followup Instructions:
___
Radiology Report
INDICATION: ___ with heel ulcer, fevers/chills for the past 4 days.
TECHNIQUE: Left foot, three views
COMPARISON: Left foot radiographs ___
FINDINGS:
Large soft tissue ulceration is seen within the plantar aspect of the foot at
the level of the calcaneus, without evidence of cortical destruction or
periosteal new bone formation to suggest osteomyelitis. Patient is status
post resection of the first ray at the level of the base of the metatarsal
with 2 screws noted in the distal stump, in unchanged appearance and
alignment. Heterotopic ossification is noted distal to the stump within the
plantar soft tissues. Patient is status post amputation of the second and
third rays at the base of the proximal phalanges. An MBA implant is again
noted within the subtalar joint in unchanged position. Osseous structures are
diffusely demineralized. Midfoot degenerative changes are re- demonstrated.
No acute fracture or dislocation is seen.
IMPRESSION:
Large soft tissue ulceration within the plantar aspect of the foot at the
level of the calcaneus, without definite radiographic evidence for
osteomyelitis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Heel pain
Diagnosed with Cellulitis of left lower limb
temperature: 99.0
heartrate: 88.0
resprate: 18.0
o2sat: 99.0
sbp: 124.0
dbp: 63.0
level of pain: 6
level of acuity: 3.0 | 1. Heel ulcer, cellulitis. Podiatry evaluated and debrided the
patient's ulcer; per them there was no tracking to bone.
Cultures from the ulcer were polymicrobial. Podiatry ultimately
felt that this was most consistent with a cellulitis, and that
there was no evidence of osteomyelitis. She was initially
treated with IV vancomycin and cefepime, but will be discharged
on a regimen on levofloxacin and metronidazole, to complete a
14-day course. The patient is followed by Dr. ___ as an
outpatient, and will follow up with him. ID will see her if
podiatry feels follow up is warranted
- Levofloxacin 750 mg daily
- Metronidazole 500 mg TID
- ___ with Dr. ___ on ___
- ___ PRN with ID
2. Type 2 Diabetes with Neuropathy. A1C was 7.3. She was seen by
___ while an inpatient and started on basal bolus insulin.
The thought was, despite her good control, her diabetes was
likely contributing to her poor wound healing. They recommended
___ consult. She is being discharged back to her primary
care doctor, who can consider starting insulin injection pens,
and a consult to ___.
- consider glargine pen 10 units QHS
- consider lispro pen for sliding scale
- consider ___ consult
- ___ with Dr. ___ on ___
3. Deconditioning. ___ evaluated the patient and recommended home
with services. Unfortunately, she was not able to get ___ at her
home, and she declined discharge to a rehabilitation facility.
Per ___ opinion, she was safe for discharge home with no
services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Pain
Major Surgical or Invasive Procedure:
___: 3000 cGY to left law CW, left scl and axilla - x 2
History of Present Illness:
___ with recurrent triple negative breast cancer s/p mastectomy
and neoadjuvant adriamycin/cytoxan/taxol now on weekly Cisplatin
and Irinotecan (___) who presents with recurrent
exacerbation of pain of her left chest wall and left proximal
arm. She was recently admitted from ___ - ___ for this pain
and was found to have a left necrotic axillary node that was
thought to be related to her pain. She was discharged on regimen
of MS contin, prn oxycodone, gabapentin and lidocaine patch.
States that the patch does not help at all and the morphine
makes her sleepy. She does get some relief from oxycodone, takes
5mg about every 4 hours even thru the night but upon awakening
is back in pain. Has sharp pain radiating down L arm, L chest
wall pain is more constant and nagging. husband has been trying
to get her to stretch the arm but it is more painful when he
does that. Denies any numbness or tingling of L hand, is able to
grip, no dropping objects but has difficulty flexing L arm above
60 degrees. Is able to get around the house, walk up stairs, do
basic activities etc, main complaint is pain waking her up at
night. States that she feels L chest wall mass enlarging. Stools
slightly harder but still regular with senna/miralax.
Pain is not getting better which brought her in today. Denies
fever, chills, SOB, N/V/D, cough, hemoptysis, sore throat, HA or
neck pain.
In the ED, initial VS were: 98.1 97 113/71 16 99%
She was given 5mg morphine x 2 and did have some relief of pain.
On arrival to floor is rating pain ___.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
PAST ONCOLOGIC HISTORY
Per ___ Clinic Note by ___: ___ who initially
presented with left upper outer breast mass in ___ in ___
which was proven to be triple negative invasive cancer. She
received 1 round of chemotherapy locally before family urged her
to come to the ___. She established care at ___
___ in ___ and subsequently received neoadjuvant
adriamycin, cytoxan, and taxol chemotherapy. She is s/p
left-sided mastectomy ___. In ___ she developed chest
wall recurrence and right axillary node involvement and again at
the urging of family & friends came to ___ for further
evaluation. Please see Dr. ___ from ___ for full
details.
PAST MEDICAL HISTORY:
Breast cancer
Social History:
___
Family History:
FAMILY HISTORY: She has a paternal aunt who developed breast
cancer and died at age ___. Her father had many siblings, but
she
would know if they had cancer and does not know anything about
her paternal grandparents. She has seven half brothers through
her father and one half brother through her mother. Her mother
had either cervical or uterine cancer, but her mother had two
sisters and two brothers, all of whom are cancer free as are her
maternal grandparents. Reportedly, she had BRCA1 and ___s P53 testing to ___ and the patient
says that it was negative. She is not sure if she has a copy of
those results and we are going to try to get them from the
medical oncologist at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================
VS: 98.2 98/70 97 16 100%RA
GENERAL: NAD
HEENT: NC/AT, MMM
Neck: supple, no cervical tenderness, full ROM
Lymph: + l axillary LAD
CARDIAC: RRR, nl S1 and S2, no murmurs
LUNG: CTAB no w/r/rh
ABD: +BS, soft, NT/ND, no r/g
EXT: L arm nontender to palpation, L shoulder flexion limited to
60 deg due to pain. some tenderness over L scapula. L chest
with healed incision. L lateral chest wall with 3-4cm tender
firm nodule and surroudning induration
No lower extermity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: oriented x 3, ___, EOMI, face symmetric, no tongue
deviation, no nystagmus, full hand grip and shoulder shrug
bilateral, cannot abduct L shoulder against resistance due to
pain. full hip flexion and dorsiflexion ___, sensation intact to
light touch, no clonus
DISCHARGE PHYSICAL EXAM:
===================
VS: 97.6, 100/64, 106, rr16, 100% on RA
GENERAL: NAD
HEENT: NC/AT, MMM
Neck: Supple, no cervical tenderness, full ROM. No cervical LAD.
Lymph: Rock hard left axillary ~2x2 cm LN, non tender on
palpation. Shotty right axillary LAD.
CARDIAC: RRR, nl S1 and S2, no murmurs
LUNG/CHEST: Lungs clear to aucultation bilaterally. Good
respiratory effort. Patient with left mastectomy. Mastectomy
site shows superficial invasion of tumor with underlying firm
areas of mass and skin breakdown at the mastectomy skin suture
site. Right chest port-a-cath present.
ABD: +BS, soft, NT/ND, no r/g
EXT: L arm nontender to palpation, limited range of motion of
the left arm at the shoulder ___ radicular pain from the scapula
and down the left arm. No ___.
PULSES: 2+DP pulses bilaterally
NEURO: AAOx3, no focal neurologic/strength deficits.
Pertinent Results:
ADMISSION LABS:
============
___ 01:00PM BLOOD WBC-6.5 RBC-3.96* Hgb-11.2* Hct-34.5*
MCV-87 MCH-28.3 MCHC-32.5 RDW-13.1 Plt ___
___ 01:00PM BLOOD Neuts-70.5* ___ Monos-4.3
Eos-4.2* Baso-0.2
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-94 UreaN-11 Creat-0.6 Na-136
K-4.4 Cl-99 HCO3-26 AnGap-15
OTHER PERTINENT LABS:
===============
___ 01:18PM BLOOD WBC-6.1 RBC-3.65* Hgb-10.9* Hct-32.2*
MCV-88 MCH-29.8 MCHC-33.7 RDW-13.2 Plt ___
___ 05:03AM BLOOD WBC-7.2 RBC-3.86* Hgb-11.1* Hct-33.0*
MCV-85 MCH-28.8 MCHC-33.8 RDW-12.6 Plt ___
___ 01:18PM BLOOD Plt ___
___ 05:03AM BLOOD Plt ___
___ 01:18PM BLOOD Glucose-105* UreaN-11 Creat-0.7 Na-136
K-4.0 Cl-98 HCO3-28 AnGap-14
___ 05:03AM BLOOD Glucose-85 UreaN-11 Creat-0.8 Na-137
K-4.3 Cl-100 HCO3-28 AnGap-13
MICROBIOLOGY:
===========
None
IMAGING:
========
___: CXR
A Port-A-Cath terminates in the superior vena cava. The
cardiac, mediastinal
and hilar contours appear unchanged. The lungs appear clear. A
trace pleural
effusion is again noted, as seen on the prior CT and perhaps a
little larger.
IMPRESSION:
Very small left-sided pleural effusion, but no evidence of
pneumonia or
congestive heart failure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
2. Acetaminophen 1000 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 100 mg PO TID
5. Gabapentin 200 mg PO HS
6. Lidocaine 5% Patch 2 PTCH TD QPM apply to left chest
7. Morphine SR (MS ___ 15 mg PO Q12H
8. Naproxen 500 mg PO Q12H pain
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Senna 17.2 mg PO HS
11. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*30 Tablet Refills:*0
2. Acetaminophen 1000 mg PO TID
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Nortriptyline 50 mg PO HS
RX *nortriptyline 50 mg 1 capsule by mouth at bedtime Disp #*30
Capsule Refills:*0
5. Ibuprofen 600 mg PO Q8H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. Capsaicin 0.025% 1 Appl TP TID
Apply only to unbroken skin.
RX *capsaicin 0.025 % three times a day Refills:*0
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 17.2 mg PO HS
12. Lorazepam 0.5 mg PO Q8H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every eight (8) hours
Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Left chest wall pain
Left upper extremity radicular pain
Metastatic triple negative breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiographs.
INDICATION: Right chest pain.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: Radiographs from ___ and CT from ___.
FINDINGS:
A Port-A-Cath terminates in the superior vena cava. The cardiac, mediastinal
and hilar contours appear unchanged. The lungs appear clear. A trace pleural
effusion is again noted, as seen on the prior CT and perhaps a little larger.
IMPRESSION:
Very small left-sided pleural effusion, but no evidence of pneumonia or
congestive heart failure.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NEC
temperature: 98.1
heartrate: 97.0
resprate: 16.0
o2sat: 99.0
sbp: 113.0
dbp: 71.0
level of pain: 10
level of acuity: 2.0 | ___ y/o F with recurrent triple negative breast cancer s/p
mastectomy and neoadjuvant adriamycin/cytoxan/taxol now on C1D12
of weekly Cisplatin and Irinotecan who presents with recurrent
exacerbation of pain of her left chest radiating to her left
arm. Patient now s/p radiation therapy 2 of 10 x 3000cGy
(total).
# L Chest wall pain: Most likely ___ nerve compression and
direct tissue invasion of L chest wall mass. Also may have
component of post-surgical neuropathic pain. Patient reports
excess sedation from MS contin at home. Chronic pain service
following patient, and has suggested recs (see medication list).
Chronic pain will see patient in clinic as outpatient. After
starting their recommended pain regimen which included
Nortryptiline, her pain was much improved and she felt
comfortable returning home to manage her pain at home. Patient
began palliative chest wall radiation on ___, 2 of 10 total
treatments at 3000cGY (total). Treatment effect may take ___
weeks.
#LUE radicular pain:
Pain is more mild in the LUE than her left chest wall. No
indications of nerve impingement on exam. Management of pain as
above. If new neurologic symptoms should consider further
imaging.
# Triple Negative Breast Cancer: Locally recurrent and
metastatic to lymph nodes and lung. C1D8 Cisplatin and CPT11 on
___. Follow up with Dr. ___ discharge. Goals of
care should be discussed given on palliative chemo with
continuing disease, discussed this with Dr. ___
___ follow up as outpatient with her.
# Bowel regimen - Continued bowel regimen in the hospital and on
discharge due to chronic constipation from opioids. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
___ 11:10AM WBC-21.8* RBC-3.47* HGB-10.6* HCT-32.6*
MCV-94 MCH-30.5 MCHC-32.5 RDW-14.4 RDWSD-49.5*
___ 11:10AM PLT COUNT-220
___ 02:00AM GLUCOSE-378* UREA N-76* CREAT-3.9* SODIUM-135
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-18* ANION GAP-15
___ 02:00AM CALCIUM-8.8 PHOSPHATE-4.2 MAGNESIUM-2.1
___ 09:54PM URINE COLOR-Red* APPEAR-Cloudy* SP ___
___ 09:54PM URINE BLOOD-LG* NITRITE-POS* PROTEIN-300*
GLUCOSE-100* KETONE-150* BILIRUBIN-LG* UROBILNGN->8* PH-9.0*
LEUK-LG*
___ 09:54PM URINE RBC->182* WBC->182* BACTERIA-MANY*
YEAST-NONE EPI-0
___ 09:54PM URINE WBCCLUMP-FEW*
___ 09:42PM ___ PO2-114* PCO2-39 PH-7.34* TOTAL
CO2-22 BASE XS--4 COMMENTS-GREEN TOP
___ 09:42PM LACTATE-2.0
___ 09:31PM ___ PTT-28.2 ___
___ 07:33PM GLUCOSE-406* UREA N-73* CREAT-3.9*#
SODIUM-135 POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-18* ANION GAP-18
___ 07:33PM estGFR-Using this
___ 07:33PM ALT(SGPT)-15 AST(SGOT)-27 ALK PHOS-119 TOT
BILI-0.7
___ 07:33PM LIPASE-19
___ 07:33PM ALBUMIN-3.0*
___ 07:33PM WBC-23.3* RBC-3.66* HGB-11.2* HCT-35.0*
MCV-96 MCH-30.6 MCHC-32.0 RDW-14.4 RDWSD-50.3*
___ 07:33PM NEUTS-92.5* LYMPHS-2.2* MONOS-3.6* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-21.49* AbsLymp-0.52*
AbsMono-0.84* AbsEos-0.01* AbsBaso-0.05
___ 07:33PM PLT COUNT-231
WBC: 20.4 <-- 23.3
Cr: 3.0 <-- 3.9 (B/L 1.6)
HCO3: 20 <-- 18
VBG: pH 7.34
UA: >182 WBC, >>182 RBC, Many bacteria, 300 Protein
BCx (___): GNR
BCx (___): NGTD
BCx (___): NGTD
UCx (___): GNR
Prior UCx ___: Klebsiella (pan-sensitive)
Prior UCx ___: Citrobacter (pan-sensitive)
Bladder US (___): Mildly distended bladder with a small amount
of echogenic debris.
Renal US (___): 1. Nonvisualization of the bladder.
2. Penile prosthesis reservoir is unremarkable.
3. Stable size of echogenic lesion in the left lower pole with
internal vascularity. MR of the abdomen can be obtained for
further evaluation if clinically indicated.
CT Head w/o IV contrast (___):
1. No evidence of intracranial mass within the limits of this
study.
2. No evidence of acute intracranial abnormality.
___ 9:34 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by 11R J. RE @940 ___.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
DC LABS:
___ 07:45AM BLOOD WBC-14.7* RBC-3.40* Hgb-10.2* Hct-32.5*
MCV-96 MCH-30.0 MCHC-31.4* RDW-14.9 RDWSD-52.1* Plt ___
___ 07:45AM BLOOD Glucose-148* UreaN-49* Creat-1.8* Na-147
K-4.5 Cl-108 HCO3-21* AnGap-18
___ 06:44AM BLOOD ALT-28 AST-55* AlkPhos-104 TotBili-0.7
___ 07:45AM BLOOD Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. enzalutamide 80 mg oral QAM
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Losartan Potassium 100 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. TraMADol 75-100 mg PO TID:PRN Pain - Moderate
11. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
13. ClonazePAM 0.5-1 mg PO QHS:PRN sleep
14. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3
mL) subcutaneous QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob or
significant wheeze
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Ciprofloxacin HCl 500 mg PO BID
through ___. Glargine 35 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
7. Ranitidine 150 mg PO DAILY
8. Senna 8.6 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Atenolol 25 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
13. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
14. enzalutamide 80 mg oral QAM
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
16. Losartan Potassium 100 mg PO DAILY
17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
18. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Obstructive nephropathy ___ blood clots
Complicated UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: History: ___ with ___// Please assess bladder for clot burden
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT of the abdomen pelvis from ___.
FINDINGS:
There is no hydronephrosis, stones, bilaterally. In the right upper pole
there is a heterogenous circumscribed lesion with a echogenic peripheral rim
and hypoechoic center measuring approximately 5.1 x 4.4 x 4.8 cm, unchanged
from prior. A 3 cm simple cyst is seen in the left midpole. In the left
lower pole there is a echogenic lesion measuring 4.0 x 4.0 x 4.3 cm with
internal vascularity, unchanged in size. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
Right kidney: 11.5 cm
Left kidney: 12.8 cm
The bladder was not imaged. Penile prosthesis reservoir is unremarkable.
IMPRESSION:
1. Nonvisualization of the bladder.
2. Penile prosthesis reservoir is unremarkable.
3. Stable size of echogenic lesion in the left lower pole with internal
vascularity. MR of the abdomen can be obtained for further evaluation if
clinically indicated.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 8:50 am, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: History: ___ with altered mental status// Rule out bleed, stroke.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: 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: MR brain from ___.
FINDINGS:
No evidence of mass within the limits of this study. There is no evidence of
infarction, hemorrhage, edema,or midline shift. There is prominence of the
ventricles and sulci suggestive of involutional changes. Periventricular
white matter hypodensities consistent with small vessel ischemic changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. A 20 x 11 mm
sebaceous cyst overlies the right temporal lobe.
IMPRESSION:
1. No evidence of intracranial mass within the limits of this study.
2. No evidence of acute intracranial abnormality.
Radiology Report
EXAMINATION: BLADDER US
INDICATION: ___ year old man with bladder cancer, hematuria, UTI. Has penile
implant, need to visualize bladder, not reservoir for implant// Need
visualization of bladder per urology, looking for clot burden in bladder
TECHNIQUE: Grayscale ultrasound images of the bladder were obtained with
transabdominal approach.
COMPARISON: Ultrasound from ___
FINDINGS:
The bladder is mildly distended and contains a small amount of dependent
echogenic debris. A Foley is seen within the bladder. A penile pump
reservoir is seen superior to the bladder.
IMPRESSION:
Mildly distended bladder with a small amount of echogenic debris.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, Weakness
Diagnosed with Altered mental status, unspecified
temperature: 96.5
heartrate: 100.0
resprate: 20.0
o2sat: 97.0
sbp: 97.0
dbp: 48.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with history of DM, HTN, HLD
as well as urologic history of prostate cancer s/p prostatectomy
and radiation, IPP, and bladder cancer (recurrent, low grade UC)
who presented with hematuria and sepsis from a presumed urinary
source with GNR bacteremia, now clinically improved with bladder
decompression.
# Dyspepsis with nausea/vomiting:
Improved. Patient with new symptoms of dyspepsia and possibly
dysphagia of uncertain etiology ___. Considerations included
GERD/gastritis, reaction to Cipro, or lower GI process such as
ileus. He has been stooling. His EKG was non ischemic and this
of lower suspicion. Given improvement with supportive GI
medications this was likely dyspepsia
- Trial tums, ranitidine
- GI referral if symptoms persist
# Sepsis due to
# Klebsiella Urinary Tract Infection:
# Klebsiella BSI
Patient presented with confusion, fever, found to have new
leukocytosis and ___, with GNRs positive in multiple bottles of
blood cultures as well as UCx from admission c/w sepsis of
urinary origin due to acute urinary retention (20 cc of clot in
his bladder and 250cc of thick old blood upon arrival). He
clinically improved on appropriate therapy
- On Cefepime since ___, cleared blood cx as of ___ (day 1)
- Given sensitivities transitioned to Cipro BID to complete a 10
day course through ___
# Gross Hematuria:
# Acute urinary retention:
Patient with gross hematuria requiring Foley placement and CBI.
Bleeding improved significantly w/ Foley + irrigation. Draining
CYU with foley placement. Bladder US with small debris. Foley
removed ___ and thus far PVRs <400ml with improving ___
- Appreciate Urology recs
- stopped 3w Foley, if persistently high PVR (PVR 400ml x2),
replace foley with ___ Fr and can leave in until Uro appointment
___ ___ aspirin, holding Plavix as below
- can consider kidney MRI to further evaluate echogenic lesion
# Acute kidney injury:
Admission Cr 3.9, baseline mid-1 range (1.2-1.6ish). Likely
multifactorial (obstructive + pre-renal from poor intake). ___
resolving s/p foley and IVF and now consistently improving post
foley.
[ ] repeat BNP/Cr in the next ___ days
# Acute metabolic encephalopathy from above conditions:
Likely toxic metabolic encephalopathy iso issues above. CT head
neg, no evidence of sz. He waxes and wanes is better today
-continue to monitor
-hold tramadol and clonazepam
# Constipation:
-bowel regimen |
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 glenoid fracture
Major Surgical or Invasive Procedure:
Arthroscopic examination, closed reduction and percuatenous
pinning of left glenoid fracture
History of Present Illness:
___ RHD w/hx of T2DM who presents as transfer from ___ s/p ~4 ft fall from box truck onto left shoulder
sustaining left glenoid fracture. No sensation of shoulder
dislocation. Initially seen at hospital in ___ then
transferred to ___ where CT was done demonstrating
comminuted left glenoid fracture. Subsequently transferred to
___ for further eval and care. Complains of significant pain
in
left shoulder. No HS/LOC. No other injuries.
Past Medical History:
Hypertension
Type 2 diabetes mellitus
Social History:
___
Family History:
None
Physical Exam:
Gen: middle-aged male, no acute distress
Neuro: alert and interactive
CV: palpable pulses bilaterally
Pulm: no respiratory distress on room air
LUE: in sling, SILT: AMRU, fires EPL/FPL/DIO, palpable radial
pulses
Pertinent Results:
None
Medications on Admission:
Lisinopril 2.5mg daily
Metformin
Glipizide
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
5. Senna 8.6 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left glenoid fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA IN O.R. LEFT
INDICATION: ORIF LEFT SHOULDER FX
IMPRESSION:
Fluoroscopic images from the operating suite show ORIF of left shoulder.
Further information can be gathered from the operative report.
Gender: M
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Shoulder injury, Transfer
Diagnosed with Disp fx of glenoid cavity of scapula, left shoulder, init, Other fall from one level to another, initial encounter
temperature: 100.0
heartrate: 104.0
resprate: 18.0
o2sat: 98.0
sbp: 171.0
dbp: 87.0
level of pain: 10
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 left glenoid fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for arthroscopic examination, closed reduction and
percutaneous pinning of left glenoid fracture which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight-bearing in the left upper 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:
ranolazine / Penicillins / Statins-Hmg-Coa Reductase Inhibitors
/ pravastatin / gemfibrozil
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with known CAD s/p CABG in ___, DES to left
main in ___, DES to the proximal, mid, and distal LAD in
___, and recent DES to the RCA on ___ for evaluation of
recurrent angina, now presenting with chest pain. Began
yesterday afternoon and was very mild at that timebut worsened
this afternoon. Presented to OSH after taking nitro and 3 baby
aspirin. On arrival still in pain, so was started on heparin gtt
and given morphine, with resolution of his pain noted. No
associated SOB or nausea/diaphoresis. PAtient does endorse
diarrhea today. ROS otherwise negative.
In the ED intial vitals were: 98.6 89 124/65 18 100% RA
Patient was given: continued heparin
On the floor, pt remains chest pain free.
Past Medical History:
1.CAD status post CABG in ___ and left main stent in ___
___ in the setting of unstable angina. Stenting ___ w/
3 DES to LAD in setting of unstable angina. recent DES to the
RCA on ___
2. Moderate-to-severe aortic stenosis.
3. Atrial fibrillation, status post dual-chamber pacemaker for
sick sinus syndrome on Coumadin for a CHADS2 score of 3
(age,htn, chf)
4. S/P permanent pacemaker generator change in ___.
History of diastolic CHF.
5. Hypertension.
6. Hyperlipidemia
7. Pulmonary fibrosis.
8. History of duodenal ulcer.
9. BPH.
10. Status post prostatectomy.
11.Severe hearing loss.
Social History:
___
Family History:
Father died at ___ of MI. Mother died at ___ of MI. 2 brothers
died of MI at ___ and ___. One sister died of MI at ___. 2
brothers died of cancer.
Physical Exam:
ADMISSION:
98.1 134/68 67 18 100% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 6-8cm
CARDIAC: RRR normal S1, S2. ___ Systolic murmur at ___. No
thrills, lifts. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE:
Vitals: 98.7 123/60 65 16 100% RA
wt 72.7kg
GENERAL: NAD. Oriented x3. appears younger than stated age,
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Hard of hearing.
NECK: Supple with no JVD
CARDIAC: RRR normal S1, S2. ___ systolic murmur at RUSB.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e
Pertinent Results:
ADMISSION LABS
=================
___ 10:40PM NEUTS-67.9 ___ MONOS-7.3 EOS-2.3
BASOS-0.6
___ 10:40PM WBC-5.8 RBC-3.58* HGB-11.3*# HCT-34.2* MCV-96
MCH-31.6 MCHC-33.1 RDW-13.3
___ 10:40PM cTropnT-0.08*
___ 10:40PM cTropnT-0.08*
___ 10:40PM CK(CPK)-76
___ 10:40PM GLUCOSE-93 UREA N-36* CREAT-1.4* SODIUM-138
POTASSIUM-4.8 CHLORIDE-108 TOTAL CO2-21* ANION GAP-14
___ 10:50PM ___ PTT-87.4* ___
DISCHARGE LABS
================
___ 07:40AM BLOOD WBC-4.3 RBC-3.43* Hgb-10.8* Hct-32.4*
MCV-95 MCH-31.5 MCHC-33.3 RDW-13.5 Plt ___
___ 07:40AM BLOOD Glucose-83 UreaN-38* Creat-1.3* Na-142
K-4.5 Cl-111* HCO3-23 AnGap-13
___ 07:10AM BLOOD ALT-5 AST-18 AlkPhos-70 TotBili-0.4
___ 07:40AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.0
IMAGING/STUDIES
==================
CHEST (PA & LAT) Study Date of ___ 11:07 ___
FINDINGS: Frontal and lateral views of the chest. Increased
interstitial markings seen throughout the lungs are similar
compared to prior, and are due to likely combination of
calcified pleural plaques and underlying interstitial
abnormality. There is no new region of consolidation nor
effusion. Cardiac silhouette is enlarged but stable. Left
chest wall dual-lead pacing device is again seen. No acute
osseous abnormality is identified.
IMPRESSION: Diffuse increased interstitial markings likely due
to
interstitial changes and pleural plaques in the setting of prior
asbestos
exposure. No definite superimposed acute cardiopulmonary
process.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin EC 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Gemfibrozil 600 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Warfarin 7.5 mg PO 3X/WEEK (___)
7. Warfarin 5 mg PO 4X/WEEK (___)
8. bisoprolol fumarate 5 mg oral daily
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Warfarin 7.5 mg PO 3X/WEEK (___)
RX *warfarin 7.5 mg 1 tablet(s) by mouth three times per week
Disp #*30 Tablet Refills:*0
4. Warfarin 5 mg PO 4X/WEEK (___)
RX *warfarin 5 mg 1 tablet(s) by mouth 4 times per week Disp
#*30 Tablet Refills:*0
5. Furosemide 20 mg PO DAILY
6. Aspirin EC 81 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 25 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
8. Outpatient Lab Work
___ to be drawn on ___. ICD-9: 427.31.
Please fax result to PCP
___
Location: INTERNISTS ASSOCIATED
Address: ___ FLOOR, ___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Unstable angina
Secondary:
-dCHF
-CKD stage 3
-afib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ male with chest pain in the setting of known coronary
artery disease.
COMPARISON: ___, performed at ___ Hospital and chest CT from
___.
FINDINGS: Frontal and lateral views of the chest. Increased interstitial
markings seen throughout the lungs are similar compared to prior, and are due
to likely combination of calcified pleural plaques and underlying interstitial
abnormality. There is no new region of consolidation nor effusion. Cardiac
silhouette is enlarged but stable. Left chest wall dual-lead pacing device is
again seen. No acute osseous abnormality is identified.
IMPRESSION: Diffuse increased interstitial markings likely due to
interstitial changes and pleural plaques in the setting of prior asbestos
exposure. No definite superimposed acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE
temperature: 98.6
heartrate: 89.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | ___ male with known CAD s/p CABG in ___, DES to left
main in ___, DES to the proximal, mid, and distal LAD in
___, and recent DES to the RCA on ___ for evaluation of
recurrent angina, now presenting with chest pain.
#) Chest pain in setting of known CAD - s/p CABG in ___, DES to
left main in ___, DES to the proximal, mid, and distal LAD
in ___, and recent DES to the RCA on ___. He was initially
started on heparin and given morphine, and his pain resolved.
Heparin was stopped. He was briefly started on imdur but was
discontinued after patient developed symptomatic hypotension to
the ___. His bisoprolol was transitioned to metoprolol while in
house.
#) Hx of diastolic HF - appears euvolemic here. Continued
Losartan, switched to metoprolol while in house. Lasix was held
in setting of hypotension. Discharge weight was 72.7 kg.
#) Diarrhea- Patient had several episodes of diarrhea during the
hospitalization. A C. diff was sent which was negative.
#) CKD stage 3: Cre 1.3 at discharge, consistent with baseline.
#) Atrial fibrillation - CHADS score 3. Was holding coumadin on
recent discharge
switched to metoprolol. Was briefly on heparin which was
stopped.
# CODE: full
# Name of health care proxy: ___
___: Wife
Phone number: ___
___ ISSUES***
=======================================
- Trend INR given coumadin reinitiation on ___
- Could consider retrial of Renexa in outpatient setting if CP
recurs (patient failed Imdur due to symptomatic hypotension;
Renexa is listed as an allergy for constipation)
- Follow-up pending stool cultures
- Patient reports failing statin therapy due to side effects.
Gemfibrizole was listed on admission meds but he reports
stopping this too due to diarrhea. Please discuss at PCP visit
on ___. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
double vision
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
The patient is a ___ year old man with PMHx significant for
optic neuritis ___ years ago with no residual deficit, and
___ esophagus who presents to the ___ ED with ___ days
of dizziness and blurry vision when he turns his head rapidly
from side to side.
Mr. ___ reports that about 10 days ago he started noticing he
felt a little unsteady, and that he was using walls and chairs
for balance when he walked. When not using assistance, he feels
he veers slightly but he isn't sure to which side. He has not
experienced room spinning or the feeling that he might pass out.
Initially he attributed this to quitting drinking, which he
stopped just before ___ (previously drank ___ beers per
week). He also noticed that when he was driving, when he would
turn his head to either side to look for oncoming traffic, he
would transiently experience blurry vision that would persist
until his eyes focused. It has been bothersome, but has been
fairly stable. He wanted to drive to ___ for a trip, but
because of his visual symptoms his wife insisted he present to
his doctor. His PCP ordered an MRI, which was obtained this AM.
He was referred to the ___ for lesions seen on this MRI, with
concern for MS.
___ regard to his optic neuritis ___ years ago, the patient says
that he went to his ophthalmologist Dr. ___ in ___
with decreased vision in his right eye for about a week. Dr.
___ him to Mass Eye and Ear, and he was evaluated
and considered for a research study, but had symptoms too long
to
be a candidate. He was not given any steroids or treatment, and
was not admitted to the hospital. He has not had similar
symptoms
since.
Mr. ___ has not noticed any focal neurologic deficits in the
past ___ years. He recounts a story from ___ when he was
hiking down a very steep path, and he fell 4x. He attributed to
the fact that he was 40 pounds heavier than he is now, and he
was
out of shape so he was walking with a 'shuffling' gait. He did
not notice any focal weakness in his arms or legs at that time.
Endorses left arm/shoulder soreness for the past month, feels it
might be a little weak. He also has been experiencing frequent
urination for the past month and inability to fully void, for
which he was prescribed flomax but he stopped because it made
him
dizzy. He also reports feeling more fatigue than usual for the
two weeks, which is worse in the AM.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, diplopia,
vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies focal muscle weakness, numbness, parasthesia. Denies loss
of sensation. Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the 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:
___ esophagus
optic neuritis (right eye)
Social History:
___
Family History:
Brother with a pulmonary embolism, prostate cancer.
No history of strokes or MS.
___ Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.0 HR 80 BP 133/89 RR 18 SaO2 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.
Lhermette's sign negative.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm slightly sluggishly
bilaterally. No paradoxical dilation to bright light on swinging
flash light test. Upgaze and downgaze intact. On left lateral
gaze, the left eye did not fully abduct, and the right eye did
not fully adduct, although adduction better than abduction. On
right lateral gaze, the right eye did not fully abduct, and the
left eye did not fully adduct; however with right gaze the eye
movements appeared to reach laterally more readily and further
than left gaze. When covering each individual eye, adduction was
improved although still not full. Breakdown of smooth pursuits,
with ___ beats of end gaze nystagmus that extinguishes. Left
upper visual field cut. Visual acuity ___ -1 on right.
Fundoscopic exam revealed pale optic disc on the right. No
papilledema, exudates, or hemorrhages. No diplopia on sustained
upgaze.
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 fatiguable weakness with arm flapping.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4+* 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
*patient reported pain which seemed to limit effort
-Sensory: No deficits to light touch throughout. Pinprick
decreased on left medial foot, but on repeat exam was the same
as
the right. Intact to cold sensation, vibratory sense,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor on the left and mute on the
right.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Appeared steady on his feet. When attempting to walk
heel-toe, almost fell over and had to be steadied.
==============================================
DISCHARGE PHYSICAL EXAM:
MS: Oriented to situation, self, date, year. Attentive on exam,
able to follow midline and axial commands. No dysarthria. No
aphasia. No apraxia or neglect.
CN: No red desaturation. Visual acuity intact. Left INO is less
pronounced today compared to prior days. Right INO is still
present, although can aBduct slightly more compared to prior.
Convergence is still incomplete.
Motor: Left pronator drift. No adventitious movements. Normal
tone.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 5 4+ 4+ ___ 4 5 4 4 5 4 5
R 5 ___ ___ 5 5 5 5 5 5 5
Reflexes: Hyper-reflexive on left triceps, biceps,
brachioradialis, and patella. Right triceps, biceps, brachio,
and
patella are 2+. Both toes are with extensor response.
Sensation: Intact to light touch and temperature. Left toe
proprioception has deficits with large movements. Right toe
proprioception has deficits with medium movements.
Coordination: Finger nose finger intact but with some tremor
with
activation. Heel to knee is intact. Positive Romberg with
sitting
and with standing.
Gait: Wide based stride with incomplete dorsiflexion of left
foot
(foot drop), arm sway normal. Difficulty walking in Tandem,
needs
to grasp for support.
Pertinent Results:
LABS:
___ 12:20PM BLOOD WBC-7.3 RBC-4.88 Hgb-14.6 Hct-42.8 MCV-88
MCH-29.9 MCHC-34.1 RDW-12.0 RDWSD-38.5 Plt ___
___ 12:20PM BLOOD Neuts-71.4* Lymphs-18.3* Monos-8.6
Eos-1.0 Baso-0.4 Im ___ AbsNeut-5.18 AbsLymp-1.33
AbsMono-0.62 AbsEos-0.07 AbsBaso-0.03
___ 12:20PM BLOOD ___ PTT-29.9 ___
___ 04:29AM BLOOD WBC-4.9 Lymph-8* Abs ___ CD3%-69 Abs
CD3-269* CD4%-34 Abs CD4-134* CD8%-36 Abs CD8-140* CD4/CD8-0.96
___ 04:29AM BLOOD CD19%-20.39 CD19Abs-79.93 CD20%-19.06
CD20Abs-74.72
___ 12:20PM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-142
K-4.5 Cl-100 HCO3-30 AnGap-12
___ 12:20PM BLOOD ALT-13 AST-11 AlkPhos-87 TotBili-0.3
___ 12:20PM BLOOD Lipase-35
___ 12:20PM BLOOD cTropnT-<0.01
___ 12:20PM BLOOD Albumin-4.7 Calcium-9.8 Phos-3.8 Mg-2.2
___ 10:05AM BLOOD VitB12-361
___ 10:05AM BLOOD TSH-2.0
___ 03:55PM BLOOD 25VitD-29*
___ 01:31PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 10:05AM BLOOD RheuFac-<10 ___ CRP-2.4
antiTPO-26
___ 04:29AM BLOOD IgG-893 IgA-170 IgM-69
___ 03:55PM BLOOD PEP-NO SPECIFI
___ 03:55PM BLOOD HIV Ab-NEG
___ 12:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:29AM BLOOD VARICELLA ZOSTER VIRUS DNA, PCR-Test
NEGATIVE
___ 01:31PM BLOOD QUANTIFERON-TB GOLD-Test NEGATIVE
___ 01:31PM BLOOD ___ VIRUS ANTIBODY WITH REFLEX TO
INHIBITION ASSAY-PND
___ 12:03PM BLOOD COPPER (SERUM)-Test NEGATIVE
___ 10:05AM BLOOD ZINC-Test NEGATIVE
___ 10:05AM BLOOD SED RATE-Test NEGATIVE
___ 10:05AM BLOOD VITAMIN B1-WHOLE BLOOD-Test NEGATIVE
___ 10:05AM BLOOD RO & ___ NEGATIVE
___ 10:05AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-Test NEGATIVE
___ 10:05AM BLOOD NEUROMYELITIS OPTICA
(NMO)/AQUAPORIN-4-IGG CELL-BINDING ASSAY, SERUM-PND
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: CEREBROSPINAL FLUID
DIAGNOSIS:
Cerebrospinal fluid:
NEGATIVE FOR MALIGNANT CELLS.
Abundant polymorphous lymphocytes; see flow cytometry report #
___ for further characterization.
IMAGING:
MRI C AND T SPINE:
1. Multiple T2/STIR hyperintense lesions seen throughout the
cervical and
thoracic cord, as described above, and compatible with the
patient's given diagnosis of demyelinating disease.
2. No evidence for intralesional enhancement to suggest active
demyelination.
3. Multilevel spondylosis of the cervical and thoracic spine, as
detailed
above.
MRI BRAIN:
1. Findings compatible with multiple sclerosis with evidence of
actively
demyelinating lesions as described above.
2. Air-fluid level within the right maxillary sinus can be seen
in the setting of acute sinusitis.
CT CHEST:
Minimal bibasilar atelectasis.
Mild coronary artery calcification.
No evidence of malignancy in the chest
CT ABDOMEN/PELVIS:
1. No evidence of malignancy within the abdomen or pelvis. No
acute
abdominopelvic process.
2. Moderate L5 on S1 anterolisthesis likely degenerative in
etiology.
3. Colonic diverticulosis.
4. Please refer to separate report of CT chest performed on the
same day for description of the thoracic findings.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 100 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 100 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
2. melatonin 3 mg oral QHS
RX *melatonin 3 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. PredniSONE 20 mg PO DAILY
Follow attached taper.
RX *prednisone 20 mg ___ tablet(s) by mouth daily Disp #*21
Tablet Refills:*0
4. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
5. Aspirin 81 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7.Outpatient Physical Therapy
Evaluate and treat
Dx: multiple sclerosis
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple sclerosis
Low pressure headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with MS requires MRI had recent colonoscopy// eval
for metal
TECHNIQUE: Upright AP view of the abdomen
COMPARISON: None.
FINDINGS:
No radiopaque foreign bodies are identified. The bowel gas pattern is
unremarkable. A few calcified phleboliths are seen in the pelvis. No acute
osseous abnormalities are detected.
IMPRESSION:
No radiopaque foreign bodies identified.
Radiology Report
INDICATION: ___ year old man with gait instability and LP w 100 tnc// Rule out
occult malignancy
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 6.0 s, 79.2 cm; CTDIvol = 19.6 mGy (Body) DLP =
1,549.8 mGy-cm.
2) Stationary Acquisition 6.7 s, 0.5 cm; CTDIvol = 36.9 mGy (Body) DLP =
18.5 mGy-cm.
Total DLP (Body) = 1,568 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the colon is noted, without evidence of wall thickening and fat stranding.
The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. Multilevel degenerative changes of the visualized thoracolumbar
spine are noted, including moderate L5-S1 anterolisthesis.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of malignancy within the abdomen or pelvis. No acute
abdominopelvic process.
2. Moderate L5 on S1 anterolisthesis likely degenerative in etiology.
3. Colonic diverticulosis.
4. Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION:
___ man with gait instability and LP with 100 TNC rule out occult
malignancy
TECHNIQUE: Multi detector CT of the chest was performed after the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 79.2 cm; CTDIvol = 19.6 mGy (Body) DLP =
1,549.8 mGy-cm.
2) Stationary Acquisition 6.7 s, 0.5 cm; CTDIvol = 36.9 mGy (Body) DLP =
18.5 mGy-cm.
Total DLP (Body) = 1,568 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON:
No prior CT chest is available for comparisons.
FINDINGS:
THORACIC INLET: Thyroid is unremarkable.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: There are no enlarged mediastinal hilar lymph nodes. The aorta
and pulmonary arteries are normal in caliber. There is mild coronary artery
calcification. There is no pericardial effusion. The airways are patent up
to the subsegmental level.
PLEURA: There is no pleural effusion.
LUNG: Evaluation of lung parenchyma is somewhat limited by respiratory motion.
No obvious nodules or consolidations are seen. There is minimal subsegmental
atelectasis in both lung bases.
BONES AND CHEST WALL : Review of bones shows mild degenerative changes
involving the thoracic spine. There is anterolisthesis of S1 over L5
UPPER ABDOMEN: Limited sections through the upper abdomen are unremarkable.
Please refer to dedicated report on abdomen which has been dictated separately
IMPRESSION:
Minimal bibasilar atelectasis.
Mild coronary artery calcification.
No evidence of malignancy in the chest
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ year old man with ? Ms// Eval for active lesions.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of Gadavist contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: MR head ___
FINDINGS:
CERVICAL:
A dominant, 1.0 cm long T2/STIR hyperintense lesion is seen within the upper
cervical cord at the level of C1-C2, to the left of center. A second, more
subtle lesion seen predominantly on sagittal STIR sequences measures 7 mm in
maximum dimension at the level of C2-C3.
No additional discrete lesion is seen within the spinal cord. There is no
associated postcontrast enhancement to suggest active demyelination.
There is no evidence of vertebral body height loss. The cervical spinal
alignment is within normal limits. Focal T1/T2 hyperintensity in the anterior
aspect of C2 demonstrates loss of signal on STIR sequences, compatible with
focal fat.
Mild multilevel degenerative changes are seen throughout the cervical spine.
There is no evidence for moderate or severe canal stenosis. Neural foraminal
narrowing is most notable with moderate narrowing on the left at C3-4 on the
right at C4-5, and on the left at C6-7.
THORACIC:
Within the thoracic spinal cord, there is a dominant 1.6 cm long lesion seen
at the level of T6, noted centrally and slightly posteriorly within the cord.
No associated enhancement is identified. A more subtle, smaller left
paracentral cord T2/STIR hyperintense lesion is also seen at T7-8, without
associated enhancement.
The thoracic vertebral body heights are grossly maintained. Sagittal spinal
alignment is maintained. There is no suspicious bone marrow signal identified.
Multilevel disc bulges are seen throughout the cervical spine. Most notably,
at T5-6, there is a left paracentral disc protrusion which indents the ventral
thecal sac, contacting and mildly deforming the left anterolateral spinal cord
with mild-to-moderate canal narrowing. Smaller disc bulges are present at
T7-8 and T8-9 without significant canal narrowing.
IMPRESSION:
1. Multiple T2/STIR hyperintense lesions seen throughout the cervical and
thoracic cord, as described above, and compatible with the patient's given
diagnosis of demyelinating disease.
2. No evidence for intralesional enhancement to suggest active demyelination.
3. Multilevel spondylosis of the cervical and thoracic spine, as detailed
above.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with dizziness// ?pna
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD.
INDICATION: ___ year old man with MS// eval with thin cuts of the MLF.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
COMPARISON: None.
FINDINGS:
There are numerous juxta cortical, periventricular and right pontine T2/FLAIR
hyperintense lesions, some of which demonstrate subtle peripheral enhancement
concerning for active demyelinating disease (14:19). Several lesions also
demonstrate evidence of abnormal signal on diffusion-weighted imaging, which
may also be seen in the setting of active demyelinating lesions. There is
also evidence of a lesion at the cervicomedullary junction (2:66). There is
no evidence of hemorrhage or infarction.
The major intracranial vascular flow voids are maintained. The ventricles and
sulci are normal in caliber and configuration. There is no air-fluid level
within the right maxillary sinus. There is trace fluid within the right
mastoid air cells the orbits are normal. There is evidence of ___ cisterna
magna.
IMPRESSION:
1. Findings compatible with multiple sclerosis with evidence of actively
demyelinating lesions as described above.
2. Air-fluid level within the right maxillary sinus can be seen in the setting
of acute sinusitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal MRI, Dizziness
Diagnosed with Food in esophagus causing other injury, initial encounter, Exposure to other specified factors, initial encounter
temperature: 98.0
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 133.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ year old man with a history of right eye
optic neuritis ___ years ago and ___ esophagus who
presented with 10 days of dizziness/unsteadiness and blurry
vision on head turn found to have a new diagnosis of multiple
sclerosis.
His exam was notable for bilateral internuclear opthalmoplegias,
no evidence of RAPD or red desaturation. Visual acuity is ___
uncorrected ___. He had mild left pronator drift, mild left ___
and tibialis anterior weakness. His reflexes were 2+ on left
and ___ on right. His left toe is up while the
right is down. He also has intention tremor on
finger-nose-finger in the left
upper extremity. He has difficulty with tandem gait and he has
a positive Romberg.
MRI brain demonstrated scattered white matter hyperintense
lesions, some of which were enhancing with contrast, consistent
with active demyelination. MRI C/T spine showed old lesions,
none that were active. Leading diagnosis was multiple
sclerosism, however, given the atypical course, a full
inflammatory and neoplastic work-up was pursued. He also
underwent lumbar puncture which showed 100 wbc, 1 rbc, 92
lymphs, 43 protein, and 66 glucose. MS profile + for oligoclonal
bands. Serology notable for normal B12, TSH, ___, anti-TPO, RF,
SPEP, HIV, Sjogren's antibodies, quant gold, zinc and copper
were all normal. CSF studies notable for negative VDRL, ACE and
lyme. CSF cytology was negative for malignant cells. CT torso
was negative for malignancy.
He was treated with 5 days of IV methylprednisolone and will
follow-up in ___ clinic. Vitamin D was supplemented. His Vitamin
B12 was also supplemented, borderline low.
He was evaluated by ___ who recommended home with outpatient ___
follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
urinary retention, abd pain, chest pain/esophagitis, dysphagia
Major Surgical or Invasive Procedure:
Esophageal stricture dilation ___
History of Present Illness:
The patient is a ___ yo male with history alcohol abuse, COPD
(supposed to be on home O2 but does not use it), CAD/NSTEMI s/p
CABG, esophogeal stricture/ulcerative esophagitis s/p recent
dilation ___ c/b mediastinitis, who presents with difficulty
urinating for ___ days. The patient report two days of poor
urine output with only dribbling, with associated lower
abdominal pressure and discomfort. (Patient is poor historian,
history obtained from patient and records).
.
The patient reports associated substernal chest pressure which
seems to have started with abdominal discomfort. Pain is across
chest and not associated with dyspnea or diaphoresis. He does
have h/o esophagitis and regurgitation and is unable to clarify
with certainty whether this is related solely to heartburn. He
does report worsening dysphagia (on puree diet) and
regurgitation of food over the past few weeks. He has been able
to maintain adequate ___ intake with ensure as he can tolerate
liquids.
.
In the ED, initial vitals were: pain 8 temp 99 88 123/68 16 98%.
Exam notable for tender prostate globally enlarged, guiac
negative rectal exam but no white count or fever, so not treated
as infection. UA was negative. Foley was placed and abdominal
pain improved, pt has put out 2L of urine to this with improved
abdominal pain. The pt underwent a CTAP which showed no evidence
of primary GI process. His pain was felt secondary to urinary
retention. Trop neg x1 <0.01. ECG showed TWI in V2, no ST
changes. He received ASA x1 per rectum. No concern for ACS
based on ED assessment. Labs showed AG of 21 with BG 144. Mild
elevation is AST to 53, which repeated later was normal at 35.
Lactate initially 4.2, rechecked at 3.0 with fluids. Blood
cultures were sent x2. He was started on D5 gtt for concern for
starvation ketosis, although serum Acetone level was negative.
Vitals prior to transfer: Pulse: 87, RR: 20, BP: 126/66, O2Sat:
99%, O2Flow: ra.
.
Currently, patient feels better but still some mild abd pain.
.
Past Medical History:
- Chronic abdominal pain, followed by GI
- Esophagitis with esophageal stricture and GE junction ulcer
s/p esophageal dilation ___ c/b esophagitis and mediastinitis
- EtOH abuse with hx of alcoholic hepatitis
- h/o CVA with right carotid artery occlusion
- COPD (supposed to be on home O2 but does not use it)
- CAD : status post coronary artery bypass surgery in ___,
non-ST elevation MI in ___
- Stable angina
- paroxysmal Afib, not on warfarin given h/o UGIB (h/o
bradycardia and orthostasis w/ metoprolol ___, previously on
diltiazem)
- HTN
- Hyperlipidemia
- Anemia of chronic disease and from alcohol use
- Hypothyroidism
- global cerebellar degeneration (wheelchair bound)
- ataxia
- h/o UGIB
- h/o MRSA PNA
- s/p Aorto-innominate bypass at ___ in ___
Social History:
___
Family History:
Father died of an MI at age ___. Mother died of complications
related to DM in her ___. Several brothers with CAD in late ___
and early ___.
Physical Exam:
ADMISSION
VS - 98.0 122/70 74 18 95RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MMM,?plaque
on tongue,
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, decreased BS at apices, mild exp wheezes
HEART - PMI non-displaced, RRR, nl S1-S2, lsb systolic murmur
ABDOMEN - NABS, soft, tympanitic, diffuse tenderness to deep
palp, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - + telangectasias
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, DTRs 2+ and symmetric upper ext, cerebellar exam
- dysdiadokinesis, gait not assessed
.
DISCHARGE
VS - 98.3 124/58 53 16 100RA
GENERAL - NAD, comfortable
HEENT - MMM
LUNGS - CTA bilat
HEART - PMI non-displaced, RRR, nl S1-S2, soft murmur LSB
ABDOMEN - NABS, soft, tympanitic, diffuse tenderness to deep
palp, no masses or HSM, no rebound/guarding (unchanged)
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
Pertinent Results:
ADMISSION
___ 10:50AM BLOOD WBC-7.0 RBC-3.99* Hgb-10.9* Hct-34.7*
MCV-87 MCH-27.5 MCHC-31.5 RDW-15.4 Plt ___
___ 10:50AM BLOOD Glucose-144* UreaN-18 Creat-0.9 Na-139
K-5.2* Cl-101 HCO3-17* AnGap-26*
___ 10:50AM BLOOD Glucose-144* UreaN-18 Creat-0.9 Na-139
K-5.2* Cl-101 HCO3-17* AnGap-26*
___ 09:10PM BLOOD Calcium-8.3* Phos-2.6* Mg-1.6
.
PERTINENT
___ 12:45PM BLOOD Lactate-4.2* K-4.1
___ 04:21PM BLOOD Lactate-1.4
___ 10:50AM BLOOD Lipase-12
___ 12:40PM BLOOD Lipase-11
___ 10:50AM BLOOD cTropnT-<0.01
___ 09:10PM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:50 am BLOOD CULTURE: PENDING
URINE CULTURE (Final ___: NO GROWTH.
.
DISCHARGE
___ 05:48AM BLOOD WBC-6.5 RBC-3.69* Hgb-10.2* Hct-31.7*
MCV-86 MCH-27.6 MCHC-32.1 RDW-15.9* Plt ___
___ 05:48AM BLOOD Glucose-91 UreaN-5* Creat-0.8 Na-136
K-3.9 Cl-102 HCO3-24 AnGap-14
.
CXR ___
No acute cardiopulmonary process.
.
CTAP ___:
No findings to explain symptoms. No evidence appendicitis or
obstructive mass near the bladder. Diverticulosis without
diverticulitis and cholelithiasis without cholecystitis. Normal
appendix. dense calcifications at the origin of the SMA and
Preliminary Reportceliac artery, without obstruction or
post-aneurysmal dilatation.
.
EGD ___
A benign intrinsic stricture with diameter less than 5 mm that
was 5 mm long and appeared at 39 cm from the incisors was seen
in the gastroesophageal junction. Esophageal stricture dilation
performed.
Medications on Admission:
-albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: ___
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
-fluticasone 110 mcg/actuation Aerosol Sig: One (1) Puff
Inhalation BID (2 times a day).
-tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One
(1) Cap Inhalation DAILY (Daily).
-pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) ___ Q12H - lansoprazole 30mg daily
- ondansetron HCl 4 mg Tablet Sig: ___ Tablets ___ Q8H (every 8
hours) as needed for nausea.
-levothyroxine 100 mcg Tablet Sig: One (1) Tablet ___ once a day.
- rosuvastatin 10 mg Tablet Sig: One (1) Tablet ___ once a day.
-sucralfate 1 gram Tablet Sig: One (1) Tablet ___ QID (4 times a
day).
-folic acid 1 mg Tablet Sig: One (1) Tablet ___ DAILY (Daily).
-thiamine HCl 100 mg Tablet Sig: One (1) Tablet ___ DAILY
(Daily).
-multivitamin Tablet Sig: One (1) Tablet ___ DAILY (Daily).
-ASA 325mg daily
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
2. fluticasone 110 mcg/actuation Aerosol Sig: One (1) Puff
Inhalation BID (2 times a day).
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet ___ once a
day.
4. rosuvastatin 10 mg Tablet Sig: One (1) Tablet ___ once a day.
5. sucralfate 1 gram Tablet Sig: One (1) Tablet ___ QID (4 times
a day).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet ___ DAILY (Daily).
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet ___ DAILY
(Daily).
9. multivitamin Tablet Sig: One (1) Tablet ___ DAILY (Daily).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr ___ HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
11. finasteride 5 mg Tablet Sig: One (1) Tablet ___ DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. ondansetron HCl 4 mg Tablet Sig: ___ Tablets ___ Q8H (every 8
hours) as needed for nausea.
13. aspirin 325 mg Tablet Sig: One (1) Tablet ___ DAILY (Daily).
14. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___ (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, ___ Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute urinary retention, esophageal stricture
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, rule out pneumothorax or pneumonia.
COMPARISONS: CT chest, ___.
FINDINGS: Frontal and lateral views of the chest were performed. The
diaphragms are flat consistent with hyperinflation. The cardiomediastinal,
pleural, and pulmonary structures are unremarkable. There is some linear
atelectasis versus scarring at the left lung base. There are no
consolidations to suggest pneumonia. There is no pneumothorax or pleural
effusion. Degenerative changes of the thoracic spine and median sternotomy
wires are again noted.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ male with multiple medical problems who presents with
difficulty urinating, evaluate for diverticulitis, appendicitis or obstructive
mass near bladder.
COMPARISONS: ___ and chest CT from ___.
TECHNIQUE: MDCT axial images were obtained from the dome of liver to pubic
symphysis after administration of IV contrast. Coronal and sagittal
reformations were provided and reviewed.
DLP: 431.98 mGy-cm.
ABDOMEN: The visualized lung bases demonstrate bibasilar atelectasis versus
scarring. There is no pleural effusion or pneumothorax. Slight pleural
thickening seen within the right lung is unchanged from prior studies. The
imaged portion of the heart is unremarkable and there is no pericardial
effusion. There is a small hiatal hernia with possible wall thickening of the
distal esophagus, similar to prior.
The liver is of normal contour and there are no focal liver lesions. Again
noted are two dense gallstones within a nondistended gallbladder. There is no
intrahepatic biliary ductal dilatation. The spleen and adrenal glands are
normal. There has been fatty replacement of the pancreas. The kidneys
enhance symmetrically and excrete contrast without hydronephrosis. Again seen
are renal hypodensities, representing simple cysts which are unchanged. The
portal vein, splenic vein and superior mesenteric vein are patent. There is a
moderate amount of atherosclerosis within the thoracic aorta. Again noted are
dense calcifications at the origin of the SMA and celiac artery, without
obstruction or post-aneurysmal dilatation. A left retroaortic renal vein is
noted. There is no retroperitoneal or mesenteric lymphadenopathy. No free
air or free fluid is seen.
PELVIS: The bladder is decompressed and a Foley catheter is present. The
rectum and prostate are normal. There is again seen a moderate amount of
diverticulosis within the sigmoid and ascending colon without diverticulitis.
The appendix is normal. There is no pelvic or inguinal lymphadenopathy.
BONES: There are no suspicious osseous lesions. Degenerative changes are
again seen in the lower thoracic spine. There are pagetoid changes of L4.
IMPRESSION:
1. No findings to explain patient's symptoms. No evidence appendicitis or
obstructive mass near the bladder.
2. Diverticulosis without diverticulitis
3. Cholelithiasis without acute cholecystitis.
4. Persistent wall thickening of distal esophagus.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, ACIDOSIS, DEHYDRATION, CHRONIC AIRWAY OBSTRUCTION
temperature: 99.0
heartrate: 88.0
resprate: 16.0
o2sat: 98.0
sbp: 123.0
dbp: 68.0
level of pain: 8
level of acuity: 2.0 | ___ yo male with history alcohol abuse, COPD (supposed to be on
home O2 but does not use it), CAD/NSTEMI s/p CABG, esophogeal
stricture/ulcerative esophagitis s/p recent dilation ___ c/b
mediastinitis, who presents with difficulty urinating for ___
days, abdominal pain, chest pain, and dysphagia.
.
# Esophagitis/esophageal strictures
Patient has h/o esophageal strictures and esophagitis likely
secondary to alcohol use. He presented with chest pain and
ongoing dysphagia / regurgitation of food on pureed diet. He
underwent EGD which revealed stricture with severe ulceration at
the gastroesophageal junction. He underwent esophageal dilation
to 10 mm on ___. He was started on BID PPI and Carafate. He
was again instructed to abstain from alcohol use. The patient's
chest pain resolved and he was tolerating a pureed diet
following the procedure. The patient will follow up with GI in
about six weeks, at which time he will be re-evaluated for
repeat stricture dilation if ulceration has healed.
.
# Urinary retention:
Likely BPH given exam. Unlikely underlying infection given
negative urine culture. Brief review of records revealed
previous episode of urinary retention improved with Flomax.
However, he was later found to have overactive bladder also, for
which oxybutynin was added. Unclear what transpired thereafter
but per ___ patient not on oxybutynin at this time. Foley was
placed in ED and drained 2L urine. Patient was started on Flomax
and Finasteride. Foley was left in place for three days,
however, after foley removal patient did void but prior to
discharge was still retaining >400cc of urine with inability to
void again. ___ was replaced on ___ and patient was
instructed to follow up with urology for further management.
.
# AG metabolic acidosis
On admission, had lactic acidosis w/ concern for ETOH ketosis
and bowel ischemia given h/o atherosclerosis and abdominal pain.
However, lactate normalized with fluids, serum ketones were
negative and AG closed.
.
# Abdominal pain
Patient has h/o chronic abd pain of unclear etiology. Initially
attributed to hypogastric discomfort from full bladder w/ some
improvement post catheter placement. However, he continued to
reports some diffuse discomfort which he was constant and at his
baseline. No concerning findings on physical exam or CT. Review
of previous records revealed that he has been worked up for
mesenteric ischemia in the past and has been found to have
significant atherosclerotic disease of abdominal vessels,
including moderate-severe narrowing of the proximal SMA, but no
finding suggestive of acute ischemia. Description of symptoms
not suggestive of intestinal angina at this time, and patient
remained stable throughout his inpatient course. This may be
further addressed in the outpatient setting.
.
# ETOH abuse
Patient still actively drinking despite multiple sequelae.
Reinforced importance of abstinence in aiding healing of
esophagitis and preventing stricture. Patient was initially
placed on CIWA scale, but never required a dose of benzos.
.
# COPD
Long h/o tobacco abuse. Most recent PFTs ___ actually
suggestive of restrictive defect w/ decreased DLCO c/f
interstitial process. Per outpatient records patient was due to
follow up with pulmonary for further evaluation. He was
continued on fluticasone, albuterol and tiotropium. He had
normal oxygen saturations on room air and no acute exacerbation
during his course. Continue to discourage tobacco use.
.
# Paroxysmal Afib
Not on warfarin given h/o UGIB. The patient has been on ASA
325mg per ___. It remains unclear whether this is intended for
stroke PPx. This should be clarified in the outpatient setting.
Diltiazem was recently discontinued and has not been resumed.
Patient remained in NSR during his course.
.
# Hypothyroidism
Continued home levothyroxine 100mcg daily
.
# CAD
Patient is status post coronary artery bypass surgery in ___,
non-ST elevation MI in ___. Chest pain on admission concerning
for ACS, however, ruled out with negative cardiac enzymes and
stable EKG. Pain was ultimately felt to be associated with
dysphagia/esophagitis. Patient was continued on home crestor
and home dose of ASA 325mg. (Patient not on BB, perhaps due to
intolerance to metoprolol in past and COPD). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain and abscess
Major Surgical or Invasive Procedure:
CT-guided drainage of pericolonic abscess
History of Present Illness:
___ F w/ a recent dx of afibrillation on xarelto and recent
diagnosis of diverticulitis presents with left lower quadrant
pain, with elevated white blood cell count and OSH CT scan
consistent with sigmoid colon diverticulitis and 7.2x4.7x2.8cm
abscess. She first presented with left lower quadrant pain,
which was sharp and intermittent. She had lost her appetite and
experienced nausea, nonbloody diarrhea, weight loss, cramping,
bloating, and fatigue. She also reported intermittent fevers
(97-100 per patient). Her PCP diagnosed her
with diverticulitis clinically on ___ and was started on PO
cipro and flagyl. Her pain and fevers did not resolve
completely, and pain continued to persist. Additional warm
packs and prune juice were used but did not help alleviate the
pain. An OSH CT scan (___) was performed today, revealing a
sigmoid colon diverticulitis with a 7.2 by 4.7 by 2.8 cm
pericolonic
abscess inferior to the mid sigmoid colon. Per PCP's
recommendation, she presents to ___ ED for further evaluation.
Of note, she is currently on xarelto, which she normally takes
___
and with last dose taken yesterday evening. She is NPO since ___
am today.
Past Medical History:
obesity
osteoarthritis of knees with knee replacements in ___
Social History:
___
Family History:
father MI ___
mother CAD
Physical ___:
Vitals: T 98.9 HR: 71 BP: 129/64 RR: 18 Sat: 95% room air
GEN: A&Ox3, resting comfortably on bed
CV: Irregularly irregular rhythm
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, LLQ tenderness, no rebound,
normoactive bowel sounds, no palpable masses. ___ drain in place
with murky fluid output.
Ext: No ___ edema, ___ warm and well perfused, 2+ DP pulses
Pertinent Results:
___ 08:35PM LACTATE-1.6
___ 08:25PM GLUCOSE-113* UREA N-13 CREAT-0.9 SODIUM-135
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-28 ANION GAP-14
___ 08:25PM estGFR-Using this
___ 08:25PM WBC-14.7*# RBC-4.69 HGB-12.3 HCT-37.4 MCV-80*
MCH-26.1* MCHC-32.8 RDW-13.9
___ 08:25PM NEUTS-79.6* LYMPHS-13.0* MONOS-6.8 EOS-0.4
BASOS-0.2
___ 08:25PM PLT COUNT-265
___ 07:45PM URINE HOURS-RANDOM
___ 07:45PM URINE HOURS-RANDOM
___ 07:45PM URINE UHOLD-HOLD
___ 07:45PM URINE GR HOLD-HOLD
___ 07:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 07:45PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1
Medications on Admission:
1. Colace
2. Metoprolol 50mg BID
3. Digoxin 0.125 BID
4. ASA 81mg
5. Xarelto 20mg qday qPM
6. Atorvastatin 80g qPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. Digoxin 0.125 mg PO Q12H
4. Docusate Sodium 100 mg PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Rivaroxaban 20 mg PO DINNER
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*24 Tablet Refills:*0
8. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*36 Tablet Refills:*0
9. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four (4) hours Disp #*30 Tablet Refills:*0
10. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diverticulitis and pericolonic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT-GUIDED DRAINAGE OF PERICOLONIC ABSCESS
INDICATION: ___ year old woman with h/o afib, diverticulitis and pericolonic
abscess referred for drainage of abdominal abscess
OPERATORS: Dr. ___, radiology trainee and Dr. ___,
attending radiologist, who was present and supervising throughout the total
procedure time.
PROCEDURE: CT-guided drainage of a left pelvic pericolonic collection.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CTscan 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 and spiral CT scanning.
Approximately 20 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: DLP: 1662 mGy-cm
SEDATION: Moderate sedation was provided by administering divided doses of
2.5 mg Versed and 150 mcg fentanyl throughout the total intra-service time of
35 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples was sent for microbiology evaluation.
COMPARISON: Correlation made to imported CT scan dated ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Abscess
Diagnosed with DIVERTICULITIS OF COLON, INTESTINAL ABSCESS
temperature: 97.8
heartrate: 60.0
resprate: 18.0
o2sat: 95.0
sbp: 149.0
dbp: 105.0
level of pain: 7
level of acuity: 2.0 | The patient presented to the Emergency Department with a sigmoid
colon diverticulitis and a 7.2x4.7x2.8cm abscess. Given
findings, the patient underwent CT-guidance of abscess and then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV
medications and then transitioned to oral medication once
tolerating a 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: The patient was initially kept NPO. The diet was
advanced sequentially to a Regular diet, which was well
tolerated. 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
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
RLE swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old gentleman with history significant for
hyperlipidemia, diabetes mellitus type 2, hypertension, left
ventricular dysfunction with an EF of 40%-45%, coronary artery
disease, status post bypass with LIMA to LAD, SVG to the PLV and
PDA, and SVG to OM1 and OM2, left leg DVT, CKD stage II ___
diabetic nephropathy, presents with right leg swelling.
Right leg swelling started ___ morning, he woke up this
way. No pain at this time. ___, swelling worsened, but he
still went to work for 6 hours standing on it, felt febrile so
checked his temperature and was 99/8. ___, swelling and
pain worsened before it got better, he tried very hard to stay
off of it. He remembered having similar pain in ___ when he had
a left leg clot. Since his pain did not improve, he came into
the ED where he was found to have a DVT. On the walk up to the
ED, he felt some shortness of breath, otherwise no symptoms of
chest pain or shortness of breath at the moment.
Of note, patient states he got an extensive work up done at ___
which showed he had factor 5.
ED COURSE
- Exam: Notable for "unilateral 2+ pitting edema in the right
calf, positive Homans sign"
- Labs:
BMP
142 | 104 | 16 / AGap=18
------------------ 177
5.1 | 20 | 1.1 \
CBC
\ 12.2 /
6.8 ------ 112
/ 36.0 \ 71.3%N, 17.5%L
INR 1.1; PTT 29
- Imaging:
BLE U/S ___:
1. Occlusive thrombosis of the right femoral vein, right
popliteal vein, right posterior tibial veins, and right peroneal
veins.
2. No evidence of deep venous thrombosis in the left lower
extremity.
CTA Chest ___:
1. Pulmonary emboli of the lobar, segmental, and subsegmental
pulmonary arteries to the right middle and right lower lobes.
2. Multiple pulmonary nodules, as detailed above, measuring up
to 6 mm in the right upper and left upper lobes. Comparison with
prior chest CT, if available, is recommended. If not available,
chest CT in 12 months is optional if patient has elevated risk
factors for lung cancer. If there are no elevated risk factors,
follow-up chest CT is not recommended. This is per ___
___ guidelines on incidentally found pulmonary nodules.
- Cardiology:
EKG ___: Rate 76, RAD, LBBB, no signs of ischemia
- Consults: None
- Interventions: ASA 325, Lisinopril 40, Carvedilol 12.5,
Isosorbide (ER) 120, Metoprolol 25. Heparin gtt.
Past Medical History:
CAD/MI (___)
HTN
Hyerlipidemia
DM
Social History:
___
Family History:
Mother: lung cancer, heavy smoker
Cousin: Factor 5 ___
Uncle: MI
Physical ___:
ADMISSION PE:
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================================================================
PHYSICAL EXAM:
Vs: 98.1 PO 184 / 104 R Sitting 80 18 98 Ra
Gen: Well-appearing male in NAD.
Eyes: No scleral icterus. EOMI. PERRL.
HENT: NC/AT. Neck supple, no tenderness. No LAD.
CV: NR, RR. Nl S1, S2. No m/r/g. 2+ peripheral pulses
bilaterally.
Resp: CTAB. Resonant to percussion throughout.
GI: Soft, nontender, nondistended. No masses.
Msk: RLE with 2+ pitting edema. LLE w no edema.
Skin: No rashes or lesions.
Neuro: AOx3. Moving all four limbs with intention.
DISMISSION PE:
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================================================================
PHYSICAL EXAM:
Vitals: T 98.0, BP 160/83, HR 71, RR 18, O2 Sat 97 Ra
Gen: NAD, laying comfortably in bed.
Eyes: No scleral icterus. PERRL.
CV: RRR. Nl S1, S2. No m/r/g. No ___ carotid bruits.
Resp: decreased breath sounds R upper/lower, CTA on L, no
wheezes/ rhonchi/ rales. No evidence of accessory muscle use on
respiration.
GI: Soft, nontender, nondistended. No masses.
Msk: Trace edema RLE up to ankle, no erythema/ tenderness, or
associated skin findings concerning for limb ischemia, wwp, 2+
distal pulses ___, LLE with no edema; - ___ sign RLE.
Skin: No rashes or lesions.
Neuro: AOx3. Grossly moving all four limbs with purpose.
Pertinent Results:
ADMISSION LABS:
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================================================================
___ 10:53AM BLOOD WBC-6.8 RBC-3.52* Hgb-12.2* Hct-36.0*
MCV-102* MCH-34.7* MCHC-33.9 RDW-12.6 RDWSD-46.6* Plt ___
___ 10:53AM BLOOD Neuts-71.3* Lymphs-17.5* Monos-8.5
Eos-1.8 Baso-0.6 Im ___ AbsNeut-4.86 AbsLymp-1.19*
AbsMono-0.58 AbsEos-0.12 AbsBaso-0.04
___ 06:00AM BLOOD Glucose-147* UreaN-13 Creat-1.0 Na-143
K-4.4 Cl-102 HCO3-25 AnGap-16
___ 10:53AM BLOOD ___ PTT-29.0 ___
___ 06:00AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.5*
IMAGING:
=
=
=
=
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=
=
=
=
=
================================================================
___ ECG:
Rate PR QRS QT QTc (___) P QRS T
76 ___ -14 122 58
___ ___ US:
IMPRESSION:
1. Occlusive thrombosis of the right femoral vein, right
popliteal vein, right
posterior tibial veins, and right peroneal veins.
2. No evidence of deep venous thrombosis in the left lower
extremity.
___ CTA CHEST:
IMPRESSION:
1. Pulmonary emboli of the lobar, segmental, and subsegmental
pulmonary
arteries to the right middle and right lower lobes.
2. Multiple subcentimeter pulmonary nodules, as detailed above,
measuring up
to 6 mm in the right upper and left upper lobes. Comparison
with prior chest
CT, if available, is recommended. If not available, chest CT in
12 months is
optional if patient has elevated risk factors for lung cancer.
If there are
no elevated risk factors, follow-up chest CT is not recommended.
This is per
___ society guidelines on incidentally found pulmonary
nodules.
DISCHARGE LABS:
=
=
=
=
=
=
=
=
=
================================================================
___ 06:00AM BLOOD WBC-5.4 RBC-3.06* Hgb-11.0* Hct-31.8*
MCV-104* MCH-35.9* MCHC-34.6 RDW-12.7 RDWSD-47.8* Plt ___
___ 06:00AM BLOOD ___ PTT-73.0* ___
___ 06:00AM BLOOD Glucose-147* UreaN-13 Creat-1.0 Na-143
K-4.4 Cl-102 HCO3-25 AnGap-16
___ 06:00AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Simvastatin 80 mg PO QPM
6. Cyanocobalamin 1000 mcg PO DAILY
7. Aspirin 325 mg PO DAILY
8. GlipiZIDE 10 mg PO BID
9. Benzonatate 100 mg PO TID:PRN cough
10. Colchicine 0.6 mg PO ONCE:PRN gout
11. Metoprolol Tartrate 25 mg PO BID
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Apixaban 10 mg PO BID
2. Apixaban 5 mg PO BID
Please start after the 7 days of twice daily 10 mg Apixaban
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*60 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Benzonatate 100 mg PO TID:PRN cough
5. Carvedilol 12.5 mg PO BID
6. Colchicine 0.6 mg PO ONCE:PRN gout
7. Cyanocobalamin 1000 mcg PO DAILY
8. GlipiZIDE 10 mg PO BID
9. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
10. Lisinopril 40 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
13. Multivitamins 1 TAB PO DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Simvastatin 80 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
RLE DVT
Pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: History: ___ with unilateral leg swelling/pain// ? DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
RIGHT LOWER EXTREMITY: There is noncompressibility and no color flow in the
right femoral vein, right popliteal vein, right posterior tibial, and right
peroneal veins. There is normal compressibility of flow noted in the right
common femoral vein and right greater saphenous vein.
LEFT LOWER EXTREMITY: There is normal compressibility, flow, and augmentation
of the left common femoral, femoral, and popliteal veins. Normal color flow
and compressibility are demonstrated in the left posterior tibial and peroneal
veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Occlusive thrombosis of the right femoral vein, right popliteal vein, right
posterior tibial veins, and right peroneal veins.
2. No evidence of deep venous thrombosis in the left lower extremity.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with clinical dvt, hx dvt, wells score 4.5, sob w/
exertion// ?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) = 478 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: There are filling defects in the lobar, segmental, and
subsegmental pulmonary arteries to the right main and right lower lobes. The
main pulmonary artery is dilated measuring 3.3 cm across maximal diameter
(series 3:84). The thoracic aorta is normal in caliber without evidence of
dissection or intramural hematoma. Post CABG changes are noted. There are
moderate atherosclerotic calcifications of the coronary arteries. Heart is
mildly enlarged. There is no pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is a 6 mm nodule in the left upper lobe (series 3:70), a
5 mm nodule in the superior segment right lower lobe (series 3:125), and a 6
mm nodule in the right upper lobe (series 3:120). There are subpleural
nodules in the right upper lobe measuring 3 mm (series 3:61 and 93). There is
no airspace consolidation. There is mild dependent atelectasis in the
bilateral lower lobes. Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Moderate endplate degenerative changes of the thoracolumbar spine are noted.
IMPRESSION:
1. Pulmonary emboli of the lobar, segmental, and subsegmental pulmonary
arteries to the right middle and right lower lobes.
2. Multiple subcentimeter pulmonary nodules, as detailed above, measuring up
to 6 mm in the right upper and left upper lobes. Comparison with prior chest
CT, if available, is recommended. If not available, chest CT in 12 months is
optional if patient has elevated risk factors for lung cancer. If there are
no elevated risk factors, follow-up chest CT is not recommended. This is per
___ society guidelines on incidentally found pulmonary nodules.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Leg swelling
Diagnosed with Acute embolism and thrombosis of right femoral vein
temperature: 98.2
heartrate: 81.0
resprate: 16.0
o2sat: 100.0
sbp: 194.0
dbp: 144.0
level of pain: 0
level of acuity: 3.0 | ___ year-old gentleman with history significant for
hyperlipidemia, diabetes mellitus type 2, hypertension, left
ventricular dysfunction with an EF of 40%-45% (___),
coronary artery disease, status post bypass with LIMA to LAD,
SVG to the PLV and PDA, and SVG to OM1 and OM2, left leg DVT
___, CKD stage II ___ diabetic nephropathy, presenting with
right leg swelling.
============
ACUTE ISSUES
============
# RLE DVT
#Pulmonary Embolism
Patient presented with RLE DVT after noticing RLE swelling on
___ that was unprovoked. He denied hx of inactivity, long
flights, or stasis. On ___, he presented to the ___ ED iso
worsening RLE swelling and pain similar to the pain from his
___ LLE DVT. A CTA chest was done that revealed pulmonary
emboli of the lobar, segmental, and subsegmental pulmonary
arteries of the R middle and lower lobes, as well as multiple
pulmonary nodules measuring up to 6 mm in the R upper and L
upper lobes. He was started on heparin gtt as well as his home
cardiac medications. Heparin was discontinued and apixaban
started ___ for indefinite a/c outpatient treatment. His
aspirin was continued (lower dose) after speaking with
outpatient cardiologist. Likely related to Factor 5 Leiden
deficiency (worked up at ___ - records requested, had not
arrived prior to D/C).
#HTN: Patient's BPs were 180s/110s when he first arrived to the
floor. This was likely ___ to not taking evening dose of
medication. SBPs outpatient have been 130s. His SBPs on the
floor have remained in the 150s-160s stably. He denied any HAs,
vision changes, and was neurologically intact. He was continued
on home medications: Isosorbide Mononitrate, Lisinopril,
Metoprolol, Carvedilol. His BP was monitored for a goal SBP of
<150s.
#Systolic CHF (LVEF 40-45% ___
CHF stable at time of last echo in ___. He was not on standing
Lasix at home. He did not appear volume-up. He was continued on
lisinopril, metoprolol, Carvedilol.
==============
CHRONIC ISSUES
==============
#Coronary Artery Disease, s/p MI w 3 stents and CABG
Last seen by Cardiology ___ having some anginal Sx at that
time and increased on Isosorbide mononitrate from 60 to 120mg.
He was continued on home lisinopril, isosorbide mononitrate,
metoprolol tartrate, carvedilol, aspirin,
#Gout
- His colchicine PRN was held.
#DMT2
Held oral medications. He was monitored using insulin sliding
scale. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Polysporin / Latex / Hydrochlorothiazide
Attending: ___.
Chief Complaint:
abdominal pain, dyspepsia
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is an ___ year-old Female with a PMH significant for
dementia, C3-C4 spondylosis (requiring recent admission on
___ to ___, HTN, GERD who is now presenting with
abdominal pain, as well as back and neck pain.
.
Due to mild dementia, she struggles with the details of her
symptoms. She does note abdominal pain intermittently for at
least a year, however it worsened over the past few days,
including during her last hospital stay. It is located in the
epigastrium with radiation to the back. Currently at a ___
though was ___ ago. There has been no associated nausea,
vomiting. No diarrhea or loose stools. No fevers or chills, sick
contacts, antibiotic exposure, or recent travel. She only notes
poor appetite with little to eat or drink since yesterday. Her
neck pain is slightly improved since discharge - she has been
wearing the soft collar and taking Tylenol as needed. She was
reluctant to start Tizanidine prescribed by her Neurologist. It
starts at the base of the cervical neck and curves up around the
occiput. She denies weakness, loss of grip strength, mobility
issues, speech impediments. She had a typical dull headache
symptoms.
.
Review of ___ records shows that she was admitted ___ for
very similar epigastric abdominal pain, that time with an
elevated lipase to 124 without CT indication of pancreatitis.
Upper and lower endoscopy were negative. She has seen by Dr.
___ as an outpatient, and carries a likely diagnosis of
non-ulcerative dyspepsia that has been difficult to treat. With
regard to her neck pain, she sees Dr. ___ Neurology who
comments on a likely musculoskeletal source from C3-4
spondylosis. She had been resistant to wearing her soft collar
until recently.
.
In the ED, initial VS 97.9 63 149/61 14 100% RA. CT torso was
performed to evaluate for dissection; final read demonstrated no
aortic dissection, bibasilar chronic interstitial lung disease
appears slightly increased with no acute abdominal findings
other than a small hiatal hernia. Her labs were unremarkable,
LFTs were normal with the exception of a lipase elevation to
118. Creatinine 1.0 and Troponin < 0.01. U/A was negative and
lactate was 1.4. She has received Tylenol ___ mg PO Q6H PRN pain
with improvement.
Past Medical History:
1. Hypertension
2. Mild diastolic dysfunction
3. Reflux esophagitis (GERD) and dyspepsia
4. History of asbestos exposure, chronic interstitial lung
disease
5. Cataracts
6. Migraine headaches
7. History of rheumatic fever
8. Carpal tunnel
9. Osteoarthritis
10. Chronic kidney disease
11. Spinal stenosis
12. Myelodysplastic syndrome
Social History:
___
Family History:
Mother, Father passes away in ___ from stroke.
Physical Exam:
ON ADMISSION:
.
VITALS - 98.2 132/64 63 18 100% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, small palpable pulsating mass in the right
supraclavicular area
LUNGS - fine crackles at the bases bilaterally
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, tender to palpation at the epigastrium and
left upper quadrants. 2-cm palpable aorta.
EXTREMITIES - WWP, no cyanosis, clubbing or edema, 2+ peripheral
pulses (radials, DPs)
NEURO - awake, A&O x 3, CNs II-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout,
DTRs 2+ and symmetric, cerebellar exam intact to RAM
Pertinent Results:
URINALYSIS: clear, negative for ___, negative for Nitr, no
protein
.
MICROBIOLOGY DATA:
___ Blood culture (x 2) - pending
___ Urine culture - pending
.
IMAGING:
___ CTA CHEST, ABD AND PELVIS W&W/O C&RECON - No aortic
dissection. Bilateral pleural and diaphragmatic plaques
consistent with prior asbestos exposure. Bibasilar chronic
interstitial lung disease appears slightly increased. Distended,
thin-walled bladder. Otherwise, no acute CT findings in the
abdomen or pelvis.
.
___ CHEST (PA & LAT) - No acute cardiopulmonary process.
Bilateral pleural and diaphragmatic plaques again seen
consistent with prior asbestos exposure. Bibasilar reticular
opacities again seen consistent with a fibrotic interstitial
lung disease are better evaluated on CT.
.
ADMISSION AND DISCHARGE LABS:
.
___ 02:40PM BLOOD WBC-3.3* RBC-4.38 Hgb-11.8* Hct-36.1
MCV-82 MCH-27.0 MCHC-32.7 RDW-13.4 Plt ___
___ 05:55AM BLOOD WBC-3.3* RBC-4.60 Hgb-12.2 Hct-37.9
MCV-82 MCH-26.6* MCHC-32.2 RDW-13.8 Plt ___
___ 03:20PM BLOOD ___ PTT-32.5 ___
___ 05:55AM BLOOD ___ PTT-33.5 ___
___ 02:40PM BLOOD Glucose-107* UreaN-10 Creat-1.0 Na-136
K-3.9 Cl-96 HCO3-29 AnGap-15
___ 05:55AM BLOOD Glucose-85 UreaN-7 Creat-0.8 Na-141
K-3.1* Cl-103 HCO3-29 AnGap-12
___ 02:40PM BLOOD ALT-18 AST-36 AlkPhos-60 TotBili-0.3
___ 05:55AM BLOOD ALT-13 AST-26 CK(CPK)-78 AlkPhos-55
TotBili-0.3
___ 02:40PM BLOOD Lipase-118*
___ 05:55AM BLOOD Lipase-34
___ 05:55AM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:40PM BLOOD cTropnT-<0.01
___ 02:40PM BLOOD Calcium-10.2 Phos-3.5 Mg-1.5*
___ 05:55AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.4*
___ 03:28PM BLOOD Lactate-1.4
Medications on Admission:
1. Acetaminophen 325 mg ___ Tablets PO q6-8 PRN
2. Atenolol 50 mg PO BID
3. Citalopram 20 mg (1.5 tabs) PO daily
4. Restasis 0.05 % 1 drop BID in each eye
5. Moexipril 15 mg PO BID
6. Pantoprazole 40 mg BID
7. Sucralfate 100 mg/mL 10 ml before meals, at bed
8. Aspirin 81 mg PO daily
9. Calcium carbonate 200 mg calcium (500 mg) Tablet, chewable
TID
10. Amlodipine 10 mg PO daily
11. Cholecalciferol (vitamin D3) 400 units PO daily
12. Multivitamin 1tab PO daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every ___
hours as needed for fever or pain.
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Restasis 0.05 % Dropperette Sig: One (1) gtt Ophthalmic twice
a day: both eyes.
5. moexipril 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
1. Non-ulcerative dyspepsia
.
Secondary Diagnoses:
1. Hypertension
2. Reflux esophagitis (GERD)
3. History of asbestos exposure, chronic interstitial lung
disease
4. Mild diastolic dysfunction
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
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of chest pain.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. Bilateral
pleural and diaphragmatic plaques are again seen, consistent with prior
asbestos exposure. Bibasilar reticular opacities left greater than right may
have slightly increased in the interval, consistent with fibrotic interstitial
disease. No new focal consolidation, pleural effusion, or evidence of
pneumothorax is seen. The hilar contours are stable. The aorta remains
calcified and tortuous. The cardiac silhouette is top normal to mildly
enlarged.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Bilateral pleural and diaphragmatic plaques again seen consistent with
prior asbestos exposure. Bibasilar reticular opacities again seen consistent
with a fibrotic interstitial lung disease are better evaluated on CT.
Radiology Report
EXAM: CT of the chest and contrast-enhanced CT of the abdomen and pelvis.
CLINICAL INFORMATION: ___ female with history of abdominal pain,
lower back pain, chest pain, question aortic dissection, question acute
abdominal process.
COMPARISON: Comparison of abdomen and pelvis CT from ___ and chest CTA
from ___.
TECHNIQUE: MDCT images of the chest, abdomen and pelvis were obtained
following administration of intravenous contrast. No oral contrast was
administered. Reformatted coronal, sagittal, and oblique images of the chest
were obtained. Reformatted coronal and sagittal images of the abdomen were
obtained.
CHEST: The aorta is normal in caliber without evidence of dissection or
aneurysmal dilatation. Atherosclerotic calcifications are seen along the
aorta. A prominent precarinal lymph node measures 0.9 cm in short axis. No
mediastinal or hilar lymphadenopathy. There is no pleural or pericardial
effusion. Bilateral pleural and diaphragmatic plaques are consistent with
prior asbestos exposure. Bilateral basilar fibrotic interstitial changes are
stable, though possibly mildly increased as compared to the prior study. A
3-mm upper lobe pulmonary nodule (series 4, image 33), is stable since ___.
Focal thickening/scarring along the right major fissure is stable. No focal
consolidation is seen. Cardiomegaly persists.
ABDOMEN: The liver, collapsed gallbladder, spleen, pancreas, and adrenal
glands are unremarkable. The kidneys uptake and excrete contrast
symmetrically bilaterally. There is a small hiatal hernia. The stomach is
collapsed. Soft tissue induration in the right infraumbilical tissue is due
to subcutaneous injection. No bowel obstruction is seen. Atherosclerotic
changes are seen in the aorta. The aorta is not dilated.
PELVIS: The appendix is seen in the right lower quadrant and is within normal
limits. The urinary bladder is distended, but thin-walled. A calcified
uterine fibroid versus calcification in an adjacent colonic diverticulum or
vessel. No bowel obstruction or bowel wall thickening is seen. There is no
pelvic free fluid or free air.
OSSEOUS STRUCTURES: Degenerative changes are again seen along the spine,
including stable mild anterolisthesis of L4 over L5 and minimal retrolisthesis
of L2 over L3. Intervertebral disc space narrowing at these levels with
vacuum phenomenon also seen. Multilevel osteophytosis.
IMPRESSION:
1. No aortic dissection.
2. Bilateral pleural and diaphragmatic plaques consistent with prior asbestos
exposure. Bibasilar chronic interstitial lung disease appears slightly
increased.
3. Distended, thin-walled bladder. Otherwise, no acute CT findings in the
abdomen or pelvis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ABD PAIN,LOWER BACK ,POSTERIOR HEAD PAIN
Diagnosed with ACUTE PANCREATITIS, HYPERTENSION NOS, SENILE DEMENTIA UNCOMP
temperature: 97.8
heartrate: 61.0
resprate: 16.0
o2sat: 100.0
sbp: 135.0
dbp: 54.0
level of pain: 13
level of acuity: 3.0 | IMPRESSION: ___ with a PMH significant for dementia, C3-C4
spondylosis (requiring recent admission on ___ to ___,
HTN, GERD who is now presenting with abdominal pain, as well as
back and neck pain in the setting of transient lipase elevation
and normal imaging findings.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o F with recently diagnosed HCV/ETOH cirrhosis c/b ascites,
varices s/p TIPS, anxiety, migraines, who presents with weakness
and confusion. Pt was recently admitted ___ for UGIB and
was found to have varices, HCV cirrhosis and ascites. She
underwent TIPS during that admission. However, she left AMA
before her cirrhosis work-up was complete. She has been having
trouble getting insurance and has not followed-up since
discharge
Her boyfriend is at bedside and reports that the patient has
not been well since discharge. She has had increasing fatigue
and confusion. She complains of generalized weakness and
shakiness. And this morning they noticed that her eyes and skin
were turning more yellow. Also, she had increasing edema in her
lower extremities. This apparently resolved some time last week
without any new medications. She did not fill her prescription
for lactulose but has been compliant with PPI and finished her 5
day course of antibiotics. Denies fever, chills, cough and
dysuria. No bloody stools, melena or hematemesis. Though she has
a previous history, she denies any alcohol or drug use
She presented to ___. VS: 98.7, 106, 17, 146/80, 100%RA.
Labs: Ammonia 46, INR 2.19, ALT 43, AST 69, AP 117, TB 7.8. Abd
US showed patent veins, no cholecystitis. She was transferred to
___ for worsening liver function.
In the ED, initial vitals were 98.4 85 128/73 14 98% RA
- US showed patent TIPS, no significant ascites
- tox screens negative
- labs significant for elevated bilirubin 7
On the floor, she mainly complains of headache consistent with
her usual migraine headaches.
Past Medical History:
- Hepatitis C - viral load 45,715
- Cirrhosis - likely ___ HCV and ETOH
- c/b esophageal varices, upper GI bleed and ascites
- migraine
- anxiety
Social History:
___
Family History:
No hx of liver disease
Physical Exam:
ADMISSION EXAM:
VS: 98.4 138/76 87 18 100% on RA
General: WDWN, nAD
HEENT: + scleral icterus, dry MM
Neck: supple, no elevaed JVP
CV: RRR, III/VI systolic murmur
Lungs: CTAB
Abdomen: soft, NT, ND, + BS
Ext: no peripheral edema
Neuro: AAOx3, minimal asterixis
DISCHARGE EXAM:
Afebrile, VSS and WNL
General: WDWN, nAD
HEENT: + scleral icterus, dry MM
Neck: supple, no elevaed JVP
CV: RRR, III/VI systolic murmur
Lungs: CTAB
Abdomen: soft, NT, ND, + BS
Ext: no peripheral edema
Neuro: AAOx3, no asterixis
Pertinent Results:
ADMISSION LABS
___ 09:45PM GLUCOSE-107* UREA N-8 CREAT-0.7 SODIUM-136
POTASSIUM-8.6* CHLORIDE-105 TOTAL CO2-23 ANION GAP-17
___ 09:45PM estGFR-Using this
___ 09:45PM ALT(SGPT)-59* AST(SGOT)-213* ALK PHOS-102 TOT
BILI-7.7*
___ 09:45PM ALBUMIN-3.5
___ 09:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:45PM WBC-5.7# RBC-3.41*# HGB-11.1*# HCT-32.5*#
MCV-95 MCH-32.5* MCHC-34.1 RDW-16.7*
___ 09:45PM NEUTS-66 ___ MONOS-2 EOS-0 BASOS-0
___ 09:45PM PLT COUNT-32*
___ 09:45PM ___ PTT-34.3 ___
___ 08:39PM URINE UCG-NEGATIVE
___ 08:39PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 08:39PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:39PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-5.5
LEUK-NEG
___ 08:39PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-5 TRANS EPI-1
___ 08:39PM URINE AMORPH-OCC
___ 08:39PM URINE MUCOUS-RARE
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-6.2 RBC-3.11* Hgb-10.2* Hct-30.0*
MCV-97 MCH-32.8* MCHC-34.0 RDW-16.4* Plt Ct-31*
___ 06:40AM BLOOD ___ PTT-43.6* ___
___ 06:40AM BLOOD Glucose-125* UreaN-5* Creat-0.5 Na-138
K-3.6 Cl-106 HCO3-25 AnGap-11
___ 06:40AM BLOOD ALT-51* AST-83* LD(LDH)-471* AlkPhos-127*
TotBili-6.1*
___ 06:40AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.7
PERTINENT LABS:
___ 08:50AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 08:50AM BLOOD ___ * Titer-1:160
___ 06:25AM BLOOD AFP-2.5
___ 06:25AM BLOOD IgG-___*
___ 07:00PM BLOOD Fibrino-87*
___ 06:40AM BLOOD Fibrino-88*
___ 07:00PM BLOOD Ret Aut-5.8*
___ 07:00PM BLOOD LD(LDH)-498*
MICRO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood cx pending
IMAGING:
___ RUQ U/S
1. Patent TIPS and portal vein.
2. Cirrhosis, splenomegaly, and tiny amount of perihepatic free
fluid.
___ CXR
No acute cardiopulmonary process
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO TID
2. ClonazePAM 1 mg PO TID:PRN anxiety
3. Omeprazole 40 mg PO BID
Discharge Medications:
1. ClonazePAM 1 mg PO TID:PRN anxiety
2. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth three times daily
Disp #*3000 Milliliter Refills:*1
3. Omeprazole 40 mg PO BID
4. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Hepatic encephalopathy
-HCV and ETOH cirrhosis, full work-up not complete (autoimmune
labs pending at time of discharge)
-Hemolysis
SECONDARY:
-History of variceal bleed status-post emergent TIPS
-Migraines
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Weakness, confusion and history of HCV, cirrhosis. Question
ascites, portal venous thrombus.
COMPARISON: Prior abdominal ultrasound from ___.
FINDINGS:
The liver has a coarsened echotexture and nodular contour, compatible with
cirrhosis. The gallbladder demonstrates mild wall thickening but is
nondistended likely secondary to chronic liver disease. No intra- or
extrahepatic biliary dilatation is present. The common bile duct measures 2
mm. Visualized portions of the pancreas are within normal limits. The spleen
is enlarged measuring up to 18 cm. There is a tiny amount of perihepatic
fluid, however no large amount of abdominal ascites is seen. Representative
images of the right kidney are normal.
The main portal vein is patent with hepatopetal flow and a velocity of 38
centimeters/second. The TIPS is patent and demonstrates wall to wall flow
with velocities of 48.5, 170 and 135 cm/s in the proximal, mid and distal
portions, respectively. Flow within the left and right portal vein is towards
the TIPS shunt. Appropriate flow is seen within the IVC.
IMPRESSION:
1. Patent TIPS and portal vein.
2. Cirrhosis, splenomegaly, and tiny amount of perihepatic free fluid.
Radiology Report
HISTORY: Cirrhosis and malaise.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. Lungs are
well expanded. There is no pleural effusion, focal consolidation or
pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, LIVER FAILURE
Diagnosed with OTHER MALAISE AND FATIGUE, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, CIRRHOSIS OF LIVER NOS, OTH SEQUELA, CHR LIV DIS
temperature: 98.4
heartrate: 85.0
resprate: 14.0
o2sat: 98.0
sbp: 128.0
dbp: 73.0
level of pain: 13
level of acuity: 3.0 | ___ year old woman with recently diagnosed HCV/ETOH cirrhosis c/b
ascites, varices s/p TIPS, anxiety, migraines, admitted with
liver decompensation and hepatic encephalopathy.
ACTIVE DIAGNOSES
# Decompensated Cirrhosis - Presented with T. bili of 7 from
baseline of 4, in addition to HE. Cirrhosis is thought to be due
to HCV and ETOH, but work-up was not complete. Further testing
was sent including autoimmune studies. ___ returned elevated at
1:160 and IgG elevated at ___ after the pt had been discharged.
A repeat HCV VL was pending at the time of discharge. AFP was
low at 2.5. Pt denied recent ETOH use. Bilirubin was elevated
above previous baseline. No infectious symptoms or evidence of
bleed to support other etiologies of decompensation. Infectious
workup was negative. TIPs and portal vein patent on RUQ U/S. The
pt has follow-up at the liver clinic, where results including
___ and titer will need to be discussed with pt. In addition,
she'll need close monitoring of her MELD labs/LFTs.
# Elevated bilirubin - There was concern for hemolysis as an
etiology of the elevated bilirubin. Low grade DIC was considered
but Coombs test was negative. Fibrinogen was stably low at 88
with platelets stable in ___. Lab abnormalities likely all ___
cirrhosis.
# Hepatic Encephalopathy - Pt with sleep and cognitive
disturbances on admission, though she did not have overt
asterixis. Likely due to TIPS and non-compliance with lactulose.
However, dehydration is possible given sudden resolution of
peripheral edema and relative hemoconcentration of ___. Resolved
with lactulose and rifaximin. The pt was discharged with a
prescription for both medications and encouraged to aim for ___
bowel movements daily.
# GIB/VARICES: recent UGIB with grade ___ varices. Pt is now s/p
TIPS ___. She has not had a repeat endoscopy yet. Nadolol
should be considered as an outpatient.
TRANSITIONAL ISSUES:
- recommend outpatient CBC and smear for hemolysis 1 week
following discharge
- follow-up ___ autoimmune hepatitis labs (AMA pending at time
of discharge. IgG elevated at ___, and ___ positive - titer
resulted after discharge at 1:160)
- patient to establish care with a hepatologist
- discharged on lactulose and rifaximin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Codeine
Attending: ___
Chief Complaint:
Transient memory loss and confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with a history of traumatic SAH and
left medial temporal lobe cavernoma who presents with memory
loss. The history is provided by the patient but primarily by
the wife and daughter.
The patient says he was well the morning of presentation. Then
around noon he felt lost and that his memory was off. He was
disoriented. For example, a few days before he had bought a
cantelope, watermelon, and papaya but during the episode said
"what is a cantelope? I did not buy that." The wife reminded him
that they were supposed to cut the fruit after breakfast and he
did not remember having breakfast or what he ate. The daughter
arrived and thought he looked dazed. She went to the other room
to call ___ and when she returned he did not realized that she
had been already arrived earlier. He took a nap and when he woke
up his memory improved and he could remember all of the above.
He went to the PCP and seemed fine during the appointment.
However when he returned home, he did not remember the details
of the doctor's visit (EKG, lab tests). The PCP recommended
presenting to the ED.
His memory improved since arriving to the ED, but was not
totally back to normal.
The patient states that he has probably not been drinking enough
water. He denies funny smells, funny tastes, visual/auditory
hallucinations.
Prior to his accident in ___ leading to traumatic SAH and
discovery of left medial temporal lobe cavernoma, he only had
forgetfulness with where he had placed things such as his keys
or glasses. After the accident, he began noticing slight
problems with forgetting words/names and would get stuck on
words, but then would be able to remember them. The events on
the day of presentation were unusual because he was unable to
remember things he had done, not just words.
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:
1. Traumatic SAH ___
2. Left medial temporal lobe cavernoma diagnosed ___
3. Left knee injury (likely meniscal tear)
Social History:
___
Family History:
History of dementia in his grandmother. No family history of
brain tumors, seizures, epilepsy, or vascular malformations.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
T= 97.3F, BP= 110/65, HR= 68, RR= 20, SaO2= 100% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM, oropharynx clear
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Unable to relate history
without difficulty. Language is fluent with intact repetition.
Mildly impaired comprehension - had trouble understanding task
of saying ___ forwards. Attentive, able to name ___ forwards
and backward without difficulty. Normal prosody. There were no
paraphasic errors. Pt was able to name high frequency objects
but not low frequency objects. Speech was not dysarthric. Able
to follow both midline and appendicular commands. Pt was able to
register ___ objects and recall ___ at 5 minutes with choices.
The pt had good knowledge of current events. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consensually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without a few beats of end gaze nystagmus.
V: Facial sensation intact to light touch in all distributions.
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, paratonia throughout. No adventitious
movements, such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 0
R 3 3 3 3 0
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was present, and Crossed Adductors are
present.
-Sensory: No deficits to light touch, pinprick throughout.
Possibly impaired proprioception but patient may not have
understood directions.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: Not tested.
============================
PHYSICAL EXAM ON DISCHARGE:
T= 98.0F, BP= 103/54, HR= 64, RR= 18, SaO2= 100% on RA
General: Awake, cooperative, NAD.
HEENT: Normocephalic, atraumatic, no scleral icterus noted, MMM,
no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Lungs CTA bilaterally without rales/ronchi/wheezes
Cardiac: RRR, normal S1S2, no murmurs/rubs/gallops noted
Abdomen: soft, nontender, nondistended, normoactive bowel
sounds, no masses or organomegaly noted
Extremities: no cyanosis/clubbing/edema, radial and DP pulses
palpated bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Language is fluent with
intact repetition. Attentive, missed ___ on DOYB. DOMB
intact but slow. Subtracting serial 7's from 100 intact. Pt was
able to name low frequency objects (nose, key, chair) but not
higher frequency objects (thumb, hammock, feather). Speech was
not dysarthric. Normal prosody. There were no paraphasic errors.
Reading intact. Able to follow both midline and appendicular
commands. Pt was able to register ___ objects and recall ___
directly and ___ with multiple choice at 5 minutes. The pt had
good knowledge of current events. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consensually; brisk
bilaterally. VFF to finger wiggle.
III, IV, VI: EOMI with a few beats of end gaze nystagmus on
horizontal and vertical gaze.
V: Facial sensation intact to light touch in all distributions.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally. ___ test was
normal.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, paratonia throughout. No adventitious
movements, such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 3 3 1
R 2+ 2+ 3 3 1
-Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch or pinprick throughout.
-Coordination: No pronator drift. No intention tremor noted. No
dysmetria on FNF or HKS bilaterally.
-Gait: Good inititation. Narrow-based, normal stride and arm
swing. Romberg absent.
Pertinent Results:
___ 10:45AM BLOOD WBC-5.4 RBC-4.75 Hgb-14.6 Hct-40.8 MCV-86
MCH-30.7 MCHC-35.7* RDW-13.2 Plt ___
___ 07:55PM BLOOD Neuts-58.1 ___ Monos-7.1 Eos-1.6
Baso-0.4
___ 10:45AM BLOOD Plt ___
___ 10:45AM BLOOD Glucose-124* UreaN-16 Creat-1.1 Na-139
K-4.2 Cl-102 HCO3-30 AnGap-11
___ 05:20PM BLOOD ALT-22 AST-31 AlkPhos-63 TotBili-0.4
___ 05:20PM BLOOD cTropnT-<0.01 proBNP-154
___ 10:45AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.9
___ 10:45AM BLOOD VitB12-771
___ 05:20PM BLOOD Triglyc-193* HDL-56 CHOL/HD-3.4
LDLcalc-95
___ 05:20PM BLOOD TSH-1.9
___ 07:55PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Brain MRI:
1. No acute findings. No evidence of infarction or abnormal
enhancement.
2. Medial left temporal lobe susceptibility artifact,
consistent with a cavernoma.
Brain CT:
No evidence of acute intracranial abnormality.
EEG: This telemetry captured no pushbutton activations. It
showed a
low voltage faster pattern in wakefulness throughout. There were
no areas of prominent focal slowing. There were no epileptiform
features or electrographic seizures.
EKG: Sinus bradycardia. Normal tracing.
CXR: No cardiopulmonary process.
Medications on Admission:
1. Donepezil 5 mg
2. Fish Oil
3. Multivitamin
4. Glucosamine
5. B-complex
6. Vitamin D3
7. Calcium
Discharge Medications:
1. LeVETiracetam 500 mg PO BID
Take for 5 days then take increased dose of 750mg twice a day.
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*10 Tablet Refills:*0
2. LeVETiracetam 750 mg PO BID
Start on ___.
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*1
3. B Complete (vitamin B complex) 1 tab oral DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Transient memory loss possibly due to seizure
Left Temporal Cavernoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old man with episodic memory loss. // r/o seizure vs
stroke
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions. Dynamic
MRA of the neck was performed during administration of 13 cc of Multihance
intravenous contrast. Brain imaging was performed with sagittal T1 and axial
FLAIR, T2, gradient echo and diffusion technique. Three dimensional maximum
intensity projection and segmented images were generated. This report is based
on interpretation of all of these images.
COMPARISON: None
FINDINGS:
MRI Brain: There is no evidence of hemorrhage, edema, masses or infarction.
Scattered periventricular and subcortical FLAIR hyperintensities are
nonspecific but consistent with chronic small vessel ischemic disease.
Prominent ventricles and sulci are consistent with age related volume loss.
Focus of susceptibility artifact in the medial aspect the left temporal lobe
(08:15) has associated blooming on T2 weighted sequences, and most likely
represents a cavernoma. No abnormal enhancement is identified. No abnormal
enhancement in the region of the left temporal lobe. The paranasal sinuses
and mastoid air cells are clear. Orbits are unremarkable. T2 hyperintense
lesion within the left parotid gland is probably a lymph node.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation.
MRA neck: The common, internal and external carotid arteries appear normal.
There is no evidence of internal carotid artery stenosis by NASCET criteria.
IMPRESSION:
1. No acute findings. No evidence of infarction or abnormal enhancement.
2. Medial left temporal lobe susceptibility artifact, consistent with a
cavernoma.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Confusion
Diagnosed with ALTERED MENTAL STATUS
temperature: 97.3
heartrate: 68.0
resprate: 20.0
o2sat: 100.0
sbp: 110.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ yo man with a history of traumatic SAH and
left medial temporal lobe cavernoma diagnosed in ___ who
presents with 2 transient episodes of confusion and memory loss
on top of a background of word finding difficulties that have
been his baseline over the last ___ years.
After admission, Mr. ___ had a 24 hour continuous video EEG.
It showed low voltage with bilateral temporal region slowing
more on the left than R at times, which could be due to the
cavernoma. There were no epileptiform findings. However, due to
the high clinical suspicion for complex partial seizures given
the history of 2 approximately 10 minute episode of confusion
and now returning to baseline, we have started Keppra 500mg BID.
He is to take this dose for 5 days and then titrated up to
Keppra 750mg BID. Additionally, during his hospitalization, Mr.
___ had a head MRI since his symptoms can also be consistent
with a stroke or TIA. The MRI did not show any acute findings
and no evidence of infarction or abnormal enhancement. There was
no acute change of the left medial temporal lobe cavernoma
previously found. Mr. ___ did not have any repeat episodes
of confusion during the hospital stay. He will follow up with
Dr. ___ as an outpatient. He will also have
Neuropsych testing outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / sulfa / ibuprofen / Dopamine antagonist
neuroleptics / cefepime / olanzapine
Attending: ___.
Chief Complaint:
Agitation
Major Surgical or Invasive Procedure:
G tube re-placement
History of Present Illness:
___ hx of bipolar disorder complicated by psychosis, catatonia,
sz disorder, frontotemporal dementia who presents from a skilled
nursing facility with increased agitation and combative
behaviour. Per the ___ pt is striking out, pulled out his
g tube, refusing meds, exposing himself in public room, peeing
on the floor, combative with cartakers, threw self on the floor,
confused nonverbal. He has presented numerous times on prior
___ admissions in the past year for altered mental status in
the setting of infection. Pt unable to communicate purposefully
occasitionally mutters about weather.
In the ED intial vitals were: T 99.9 HR 114 BP 166/95 RR 18 98%
RA. Pt pulled out g tube which was replaced. Pt was placed in 4
point restraints. His UA c/w infection and pt started on IV
cipro. Pt with lactate to 3.7, leukocytosis. Pt given 4L IVF
with improvement in lactate to 0.9.
On the floor, he is calm and cooperative with exam. Of note,
patient recently underwent AVNRT ablation last month.
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:
-Bipolar disorder with psychotic and catatonic features with 4
prior psychiatric hospitalizations, most recently at ___ in
___ and again in ___. His bipolar disorder was
previously well-controlled on lithium, which was then
discontinued in ___ due to nephropathy. Subsequently, he was
poorly controlled on antipsychotics. He then developed catatonia
for the first time in ___, for which he was treated with
Ativan with improvement.
-Seizures: In the setting of Ativan dose changes and reported
non-compliance with home medications he had the patient had 3
GTCs in ___. EEG at that time showed R focal seizures,
improved with phenytoin
-HTN
-Hyperlipidemia
-CAD s/p pacemaker for bradycardia, stent ___
-s/p AVNRT ablation by EP ___
-Hypothyroidism
-Glaucoma
-GERD
-Extrapyramidal disorder of unclear etiology
Social History:
___
Family History:
No neurologic illnesses
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- T 97.8 BP 140s/80s P ___ RR 20 100% RA
General- Pt awake, did not respond to questions, shakes head
occassionally
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,
no rebound tenderness or guarding, no organomegaly, Abdominal
band in place holding G tube
GU- condom cath
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- moving all extremities equally
DISCHARGE PHYSICAL EXAM
VS: Afebrile 97.9 138/78 69 18 100 RA
General- Patient is awake, but unresponsive. He does not appear
oriented. He is not appear agitated or restless.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTA anteriorly
CV- RRR, no murmurs, rubs or gallops
Abdomen- soft, nondistended G-tube in place held by abdominal
band
Ext- warm, well perfused, scatterred bruises on legs and arms,
no edema
Pertinent Results:
ADMISSION LAB
___ 07:00PM BLOOD WBC-16.3*# RBC-4.09* Hgb-14.3 Hct-39.6*#
MCV-97 MCH-35.0* MCHC-36.2* RDW-13.5 Plt ___
___ 07:00PM BLOOD Neuts-85.2* Lymphs-8.4* Monos-5.2 Eos-0.8
Baso-0.4
___ 07:00PM BLOOD Plt ___
___ 07:00PM BLOOD Glucose-102* UreaN-44* Creat-2.0* Na-149*
K-4.2 Cl-112* HCO3-22 AnGap-19
___ 07:00PM BLOOD Phenyto-4.5*
___ 07:00PM BLOOD LtGrnHD-HOLD
___ 07:11PM BLOOD Lactate-3.7*
URINE CULTURE ___: 10,000 Enterococcus
PHENYTOIN LEVELS
___ 07:45AM BLOOD Phenyto-0.8*
___ 07:45AM BLOOD Phenyto-3.8*
___ 07:00PM BLOOD Phenyto-4.5*
DISCHARGE LABS
___ 06:30AM BLOOD WBC-10.2 RBC-3.23* Hgb-11.0* Hct-31.0*
MCV-96 MCH-34.0* MCHC-35.4* RDW-13.4 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-107* UreaN-26* Creat-1.3* Na-144
K-4.1 Cl-110* HCO3-26 AnGap-12
___ 06:30AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Niacin 500 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. Docusate Sodium 100 mg PO BID
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Atorvastatin 10 mg PO DAILY
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Senna 1 TAB PO BID:PRN constipation
13. Lorazepam 1 mg PO Q8H:PRN agitation
14. LaMOTrigine 150 mg PO BID
15. Lorazepam 2 mg PO TID
16. Metoprolol Tartrate 25 mg PO BID
17. Phenytoin Sodium Extended 125 mg PO BID
18. Acetaminophen 650 mg PO Q6H:PRN fever/pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever/pain
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Carbidopa-Levodopa (___) 1 TAB PO TID
6. Docusate Sodium 100 mg PO BID
7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES QHS
8. LaMOTrigine 150 mg PO BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Lorazepam 1 mg PO Q8H:PRN agitation
12. Lorazepam 2 mg PO TID
13. Metoprolol Tartrate 25 mg PO BID
14. Milk of Magnesia 30 mL PO Q6H:PRN constipation
15. Niacin 500 mg PO DAILY
16. Phenytoin Sodium Extended 125 mg PO BID
17. Senna 1 TAB PO BID:PRN constipation
18. Tamsulosin 0.4 mg PO HS
19. Ciprofloxacin HCl 500 mg PO Q12H
PLEASE CONTINUE TAKING THROUGH ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: urinary tract infection
Secondary diagnosis:
bipolar disorder
seizure disorder
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Pulled out G-tube overnight and replaced in ED.
COMPARISON: G-tube check ___.
TECHNIQUE: A fluoroscopic scout image was initially obtained. Subsequently,
water-soluable contrast was slowly dripped under gravity into the G-tube with
opacification of the proximal duodenum and unobstructed passage of contrast
into the proximal jejunum. The tip of the G-tube appears to reside in the
proximal duodenum. There is no evidence of extravasation.
IMPRESSION:
G-tube tip is in the duodenal bulb. No evidence of extravasation.
Radiology Report
HISTORY: Catatonia, dependent on tube feedings.
COMPARISON: G-tube replacement ___.
PHYSICIANS: Dr. ___
___: 1% local lidocaine jelly at the gastrostomy site.
FLUOROSCOPY: Total fluoro dose 10 mGy.
PROCEDURE:
Replacement of a 12 ___ ___ gastrostomy tube.
PROCEDURE DETAILS:
Following discussion of the risks, benefits and alternatives to the procedure
informed consent was obtained from the patients healthcare proxy. The patient
was brought to the angiographic suite and placed supine on the table. A
preprocedure timeout was performed using three patient identifiers. The skin
of the anterior abdominal wall was prepped and draped in the usual sterile
fashion including the opening for the G-tube, which had been removed.
Lidocaine gel was applied to the skin and using a 4 ___ dilator and
glidewire to access the opening, 5 cc of dilute contrast was injected. This
readily opacified the stomach. A ___ wire was then passed through the 4
___ dilator, the dilator was removed and a 12 ___ ___ tube
readily passed over the wire into the stomach. Contrast was injected to
confirm position within the stomach, and then flushed with saline. The
pigtail was formed and the catheter was secured to the skin with a 0 silk
suture. A sterile dressing was applied.
There were no immediate post-procedure complications.
FINDINGS:
Feeding tube in the stomach.
IMPRESSION:
Replacement of a 12 ___ ___ gastrostomy tube. Feeding tube is
in the stomach and ready for use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: COMBATIVE
Diagnosed with MANIC-DEPRESSIVE NOS
temperature: nan
heartrate: nan
resprate: 18.0
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old male with complicated
psychiatric and neurologic history who presented from rehab with
increased agitation and combative behavior found to have UTI.
Cultures grew enterococcus. No evidence of pyelonephritis.
Patient clinically improved with IV ciprofloxacin. Was not
agitated on discharge. Sensies pending at ___ but patient
responding clinically to cipro. Will go home on 5 more days of
ciprofloxacin to complete 7 day course. Psych was consulted and
evaluated the patient as safe for discharge. He can receive
additional ativan for agitation per psych.
ACTIVE ISSUES
# Complicated UTI: Patient presented with agitation met SIRS
criteria (leukocytosis, tachycardia) and positive UA. Cultures
grew enterococcus. Clinically responded to IV cipro: afebrile,
white count downtrended, and no agitation on discharge. Grew
enterococci in urine. Sensies pending at ___ but patient
responding clinically to cipro.
# G tube: G tube previously in place for nutrition. Pulled out
___. G tube was initially placed on ___ in the ED
and was confirmed in good positioned. However, g tube came out
(unclear if spontaneous or pulled out) on ___ and was put back
in place via ___.
# ___: Likely prerenal. No known baseline hx of renal disease.
Presented with cre of 2.0, downtrended with fluids.
# Hypernatremia: likely secondary to dehydration. Downtrended
with fluids.
# Combative behavior: patient initially presented with combative
behavior in the setting of UTI and dehydration.
CHRONIC ISSUES
# Seizures: s/p nonconvulsive GCT ___. Followed by Neuro.
Phenytoin .8 on ___. Continued seizure medications.
# Bipolar disorder: psychotic and catatonic features. Continued
carbidopa-levadopa, Lamotrigine, ativan.
# Dyslipidemia: last lipids unknown. Continued statin and
niacin.
# Hypertension: Continued metoprolol.
# Glaucoma: Continued Dorzolamide and latonprost.
# Hypothyroidism: last TSH ___ 2.6. Continued synthroid.
# AVNRT: S/p ablation ___: Continue metoprolol.
# CAD: S/p stent > ___ year prior. Continued aspirin and
metoprolol.
TRANSITIONAL ISSUES
- IF DECIDE TO PLACE FOLEY, PELASE CHANGE ONCE A WEEK OR ONCE
EVERY TWO WEEKS. However, would avoid given recurrent infections
- sensitivities pending at ___, but patient clinically improved
on cipro. Will need to continue until ___ for total 7 day
course.
- we will followup with nursing home re enterococcus
sensitivities
- IF AGITATED: psychiatry recommended using ATIVAN. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
acetaminophen / aspirin / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Lethargy, right upper quadrant pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with necrotizing pancreatitis with
pseudocyst status post pancreas necrosectomy/debridement,
retroperitoneal abscess status post drainage, insulin-dependent
diabetes mellitus, deep venous thrombosis, and recent admission
in ___ for Enterobacter infrarenal aortitis with secondary
septic air-containing thrombus on ertapenem and systemic
anticoagulation who presents with lethargy and right upper
quadrant pain. History is obtained in discussion with the
patient and on review of ___ discharge summary and
infectious disease documentation. His recent history dates back
to ___, when he had a prolonged stay for necrotizing
pancreatitis, initially drained percutaneously, subsequently
managed operatively in ___ with drainage of a reproperitoneal
pancreatic abscess and debridement of pancreatic necrosis. He
was later readmitted with diabetic ketoacidosis in ___ and
found to have a retroperitoneal fluid collection growing
Enterobacter that was drained by interventional radiology prior
to discharge on a 2-week course of Bactrim/Augmentin. In
___, he was admitted once again with sepsis from the
retroperitoneal abscess and discharged on a 2-week course of
levofloxacin and metronidazole.
Most recently, in early ___, he experienced subjective
fevers, nausea, vomiting, and nonradiating epigastric pain,
prompting him to present to ___, where he was
found to have air in the infrarenal aorta. He was transferred to
___, where he was admitted from ___, initially to
the MICU. During his recent stay, noncontrast CT confirmed
presence of air in the lumen of the aorta, and he was treated
empirically with vancomycin, cefepime, and metronidazole.
Subsequent MRA demonstrated presence of aortic thrombus with
superinfection, with CTA deferred due to known contrast allergy.
Vascular surgery advised against operative intervention in the
setting of multiple comorbodities and prior intraabdominal
interventions, and he was treated empirically with cefepime and
metronidazole for GNR bacteremia in consultation with the
infectious disease service, subsequently transitioned to
meropenem monotherapy after GNR speciated as Enterobacter. He
ultimately was discharged on ertapenem, for a planned 8-week
course concluding ___. For aortic thrombotic component, he
was bridged to warfarin initially with heparin, subsequently
with enoxaparin.
On routine OPAT surveillance, Wbc was found to be 22.2 (80.6%
PMNs) 2 days prior to admission (___). He was contacted at
that time by the infectious disease fellow and denied new
infectious symptoms, hence ___ was asked to redraw labs,
including blood cultures. The following day (___), he was
recontacted by the infectious disease fellow and described
fatigue and lightheadedness and was advised to proceed to the
___ ED for blood cultures and imaging of his abdominal aorta.
He ultimately presented to ___ on the day of
admission, when he was hemodynamically stable, and labs were
notable for albumin of 2.6, BUN/Cr ___ (up from baseline of
0.9-1), Hgb/Hct of 8.7/27.5 (consistent with baseline), lipase
of 47, Wbc of 14.2, platelets of 430, lactate of 2, and
glucosuria. He was transferred to ___ for further care.
In the ___ ED, initial vital signs were as follows: 10, 98.9,
79, 126/78, 16, 96% RA. Exam was notable for anicteric sclera,
flat JVP, no adenopathy, diffuse expiratory wheezing, no CVAT,
+right upper abdominal tenderness with no rebound or guarding,
dry skin, but no rash, intact ___ pulses, and no flank
bruising. Admission labs were notable for Wbc of 10.8, Hgb/Hct
of ___, platelets of 422, normal LFTs with the exception of
AlkP of 168, lipase of 10, INR of 1.5, lactate of 1.3, and
essentially negative urinalysis. Blood cultures x2 were drawn,
including 1 from his PICC. Portable CXR was negative for an
acute cardiopulmonary process. The infectious disease fellow who
referred him to the ED, Dr. ___, was contacted and advised
admission for further infectious work-up, including CT
abdomen/pelvis and likely MRA-A. He received vancomycin 1g IV
and oxycodone 10mg PO x1. Vital signs prior to transfer were as
follows: 72, 150/81, 16, 95% RA.
On arrival to the floor, he describes fatigue and poor oral
intake in association with intermittent mild nonradiating right
upper quadrant pain with occasional nausea and small-volume
nonbloody, nonbilious emesis in the days prior to admission. He
states that abdominal pain is distinct from that which he
experienced in the setting of pancreatitis and newly recognized
aortitis in the past in that it is milder and more focal; it is
nonpostprandial, without clear exacerbating or alleviating
factors. He endorses chronic intermittent cough productive of
yellow sputum ("smoker's cough") and chronic lower extremity and
low back pain, but denies recent fevers, chills, sweats, URI
symptoms, chest pain, shortness of breath, loose stools, urinary
symptoms, rahs, or myalgias. He notes that his primary care
provider suggested that he hold home metoprolol on the day prior
to admission for "low blood pressure," estimating ___ systolic;
he also notes that Oxycontin was uptitrated recently from 40mg
bid to 60mg bid for worsening chronic pain (later confirmed with
his pharmacy).
Past Medical History:
Necrotizing pancreatitis with pseudocyst status post pancreas
necrosectomy/debridement
Retroperitoneal abscess status post drainage
Insulin-dependent diabetes mellitus
Deep venous thrombosis in ___
Enterobacter infrarenal aortitis with secondary septic
air-containing thrombus in ___
Anxiety
Arthritis
GERD
Hypertension
Hypothyroidism
Status post shoulder surgery
Status post right knee surgery
Status post tonsillectomy
Status post nasal surgery
Social History:
___
Family History:
Patient too tired to describe.
Physical Exam:
On admission:
Vitals- 98.1, 153/77, 92, 97% RA, FSBG 205
General- Alert, oriented, no acute distress, fatigued-appearing
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Scattered end-expiratory wheeze, no rales or rhonchi, no
accessory muscle use
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, mild right upper quadrant tenderness, ND bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, right upper extremity PICC with scant erythema and no
warmth or tenderness
Neuro- CNs2-12 intact, motor function grossly normal
At discharge:
Vitals- 98, 143/92, 70, 16, 98%
General- Alert, oriented, no acute distress, fatigued-appearing
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Scattered end-expiratory wheeze, no rales or rhonchi, no
accessory muscle use
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, no right upper quadrant tenderness, ND bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, right upper extremity PICC with scant erythema and no
warmth or tenderness
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
On admission:
___ 12:10PM BLOOD WBC-10.8# RBC-3.09* Hgb-9.0* Hct-26.8*
MCV-87 MCH-29.3 MCHC-33.6 RDW-14.9 Plt ___
___ 12:10PM BLOOD Neuts-65.7 ___ Monos-3.8 Eos-6.1*
Baso-0.9
___ 12:18PM BLOOD ___
___ 12:10PM BLOOD Glucose-230* UreaN-7 Creat-1.1 Na-135
K-4.1 Cl-99 HCO3-28 AnGap-12
___ 12:10PM BLOOD ALT-10 AST-17 AlkPhos-186* TotBili-0.1
___ 12:10PM BLOOD Albumin-2.8*
___ 12:10PM BLOOD TSH-0.72
___ 12:22PM BLOOD Lactate-1.3
___ 12:15PM URINE Color-Straw Appear-Clear Sp ___
___ 12:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:15PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
At discharge:
___ 05:15AM BLOOD WBC-8.3 RBC-3.31* Hgb-9.6* Hct-28.4*
MCV-86 MCH-28.9 MCHC-33.6 RDW-14.8 Plt ___
___ 05:15AM BLOOD Neuts-43.6* Lymphs-42.9* Monos-5.9
Eos-6.5* Baso-1.0
___ 05:15AM BLOOD ___ PTT-37.5* ___
___ 05:15AM BLOOD Glucose-96 UreaN-9 Creat-1.0 Na-139 K-3.9
Cl-101 HCO3-32 AnGap-10
___ 05:15AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1
Microbiology:
Blood cultures x2 (including from ___) (___): No growth to
date.
Blood cultures x2 (___): No growth to date.
Imaging:
EKG (___):
Normal sinus rhythm. Normal tracing. No change compared to the
previous
tracing of ___.
IntervalsAxes
___
___
Portable CXR (___):
Right-sided PICC is seen, terminating in the mid to lower SVC
without evidence
of pneumothorax. No focal consolidation, pleural effusion,
evidence of
pneumothorax is seen. There has been interval resolution of
previously seen
left lower lobe pneumonia. The cardiac and mediastinal
silhouettes are
unremarkable.
CT abdomen/pelvis without contrast (___):
1. Dilated, fluid-filled appendix measuring up to 9 mm,
increased in size
compared to the prior exam from ___, with periappendiceal
stranding and
new thickening of the cecum. This is consistent with acute
appendicitis.
2. Interval improvement of the inflammatory changes surrounding
the atrophic
pancreas. Residual stranding and soft tissue density around the
aorta, related
to prior treated aortitis.
3. Likely under-distention of bowel rather than sigmoid colitis.
Right upper quadrant ultrasound (___):
Unremarkable abdomen ultrasound. Note is made that the pancreas
and aorta are
obscured from view by overlying bowel gas.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam ___ mg PO TID:PRN anxiety
2. Citalopram 20 mg PO DAILY
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN sob
4. Creon 12 4 CAP PO QIDWMHS
5. Ertapenem Sodium 1 g IV Q24H
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Omeprazole 40 mg PO BID
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
13. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
14. QUEtiapine Fumarate 125 mg PO QHS
15. Warfarin 3 mg PO DAILY16
16. Enoxaparin Sodium 60 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Enoxaparin Sodium 90 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 90 mg SC Daily Disp #*21 Syringe
Refills:*0
2. ALPRAZolam ___ mg PO TID:PRN anxiety
3. Citalopram 20 mg PO DAILY
4. Creon 12 4 CAP PO QIDWMHS
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Omeprazole 40 mg PO BID
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
11. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. QUEtiapine Fumarate 125 mg PO QHS
14. Ertapenem Sodium 1 g IV Q24H
RX *ertapenem [Invanz] 1 gram 1 g IV q24h Disp #*23 Vial
Refills:*0
15. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN sob
16. Outpatient Lab Work
ICD-9 code: ___
Please draw INR ___ and send to Dr. ___ for
review (Phone: ___ Fax: ___.
17. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth Daily Disp #*14 Tablet
Refills:*0
18. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Abdominal pain
Lethargy
Secondary:
Enterobacter infrarenal aortitis with secondary septic
air-containing thrombus
Insulin-dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with PICC placed at OSH, wish to confirm placement
for infusion // PICC placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Right-sided PICC is seen, terminating in the mid to lower SVC without evidence
of pneumothorax. No focal consolidation, pleural effusion, evidence of
pneumothorax is seen. There has been interval resolution of previously seen
left lower lobe pneumonia. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: History of necrotizing pancreatitis, with pseudocyst. Please
evaluate for interval change.
TECHNIQUE: ___ MDCT images were obtained through the abdomen pelvis, without
the administration of IV contrast. Multiplanar reformatted images in coronal
and sagittal axis were generated and reviewed.
DOSE: DLP: 524 mGy-cm
COMPARISON: CT from ___.
FINDINGS:
LOWER CHEST:
The bases of the lungs are clear.
ABDOMEN:
The liver is normal without evidence of focal lesions or intrahepatic biliary
ductal dilatation. The spleen is homogeneous, and normal in size. The adrenal
glands bilaterally are normal. The kidneys bilaterally are unremarkable
without evidence of focal solid or cystic lesions concerning for malignancy.
There is no evidence of hydronephrosis. Overall, compared to the exam from
___, there has been an interval improvement in the inflammatory
changes surrounding the pancreas, as well as fluid tracking down the anterior
pararenal fascia. Inflammatory changes are also seen tracking along the left
lateral Conal fascia. No focal pancreatic solid or cystic lesions are seen. No
definite pancreatic pseudocyst is identified. There is no definite pancreatic
ductal dilatation.
The stomach, duodenum, and small bowel are normal without evidence of wall
thickening or obstruction. There is no retroperitoneal or mesenteric
lymphadenopathy. Note is made of mild thickening of the sigmoid, and distal
descending colon, likely secondary to underdistention. The appendix is
dilated, fluid-filled measuring approximately 9 mm, overall similar in size
compared to the exam from ___, however increased in size from ___, when it measured 5 mm, with periappendiceal stranding, and
thickening of the cecum.
Incidental note is made of mild stranding surrounding the aorta, which may
reflect sequelae of prior treated aortitis.
PELVIS:
The urinary bladder is normal. There is no pelvic wall or inguinal
lymphadenopathy. There is no pelvic free fluid.
BONES AND SOFT TISSUES:
No lytic or blastic lesions concerning for malignancy are identified.
IMPRESSION:
1. Dilated, fluid-filled appendix measuring up to 9 mm, increased in size
compared to the prior exam from ___, with periappendiceal stranding and
new thickening of the cecum. This is consistent with acute appendicitis.
2. Interval improvement of the inflammatory changes surrounding the atrophic
pancreas. Residual stranding and soft tissue density around the aorta, related
to prior treated aortitis.
3. Likely under-distention of bowel rather than sigmoid colitis.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with past necrotizing pancreatitis and infectious
aortitis, now with RUQ pain // R/o biliary pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Liver ultrasound ___
FINDINGS:
LIVER: The liver is normal in size and the hepatic architecture is normal in
appearance. 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 0.5
cm.
GALLBLADDER: The gallbladder is absent.
PANCREAS: The pancreas is obscured from view by overlying bowel gas.
SPLEEN: The spleen is normal measuring 8.7 cm.
KIDNEYS: No hydronephrosis is seen in either kidney. The kidneys are noted to
be small. The right kidney measures 8.6 cm and the left kidney measures 10.3
cm.
IMPRESSION:
Unremarkable abdomen ultrasound. Note is made that the pancreas and aorta are
obscured from view by overlying bowel gas.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with OTHER MALAISE AND FATIGUE, ABDOMINAL PAIN RUQ
temperature: 98.9
heartrate: 79.0
resprate: 16.0
o2sat: 96.0
sbp: 126.0
dbp: 78.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ with necrotizing pancreatitis with
pseudocyst status post pancreas necrosectomy/debridement,
retroperitoneal abscess status post drainage, insulin-dependent
diabetes mellitus, deep venous thrombosis, and recent admission
in ___ for Enterobacter infrarenal aortitis with secondary
septic air-containing thrombus on ertapenem and systemic
anticoagulation who presented with lethargy and right upper
quadrant pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Clindamycin / FLU Vaccine ___
Attending: ___.
Chief Complaint:
Bilateral Flank Pain
Major Surgical or Invasive Procedure:
___ Foley exchange
___ Right EJ placement
___ ___ Guided PICC Placement
History of Present Illness:
Mr ___ is a ___ with history of severe seronegative
spondyloarthropathy (on prednisone, chronic high dose
narcotics), nephrolithiasis s/p right PCN (w/ recent admissions
for complicated UTIs), DM2, HTN, obesity, extensive ID history
(intraabdominal abscesses, abdominal fasciitis, line infections
with multiple resistant organisms, recent MRSA skin infection),
atrial fibrillation/aflutter, left axillary vein occlusive clot
and a non-occlusive clot in the left basilic vein ___, who
presented with bilateral flank pain and bladder spasms.
Patient came to ED from rehab for foley exchange as was having
worsening lower abd pain, bladder spasms, and worsening
bilateral flank pain. Has had some mild nausea, no emesis. No
diarrhea/constipation from ostomy. No dyspnea, cough, chest
pain, lightheadedness, dizziness, fevers, chills. Of note,
patient had recent admission for malfunctioning right PCN tube
changed ___. In ED, found to have purulent fluid draining from
foley.
In ED initial VS: T98.4 105 125/85 16 92% RA
Exam: Rectal temp 103, Extensive contractures, CTAB, tachycardic
no m/r/g, diffuse bruising across abd, non-peritoneal, no
crepitus
Patient was given: IV dilaudid 1mg x2, PO dilaudid 6mg, IV
Zofran 4mg, Lovenox 90mg, Zosyn, Klonopin 1mg, Quetiapine 300mg,
Flomax 0.4mg, Tylenol ___, IV Methylpred 125mg, IVF (500cc
IVF)
Imaging notable for: N/A
Consults: N/A
VS prior to transfer: ___ 97 114/70 12 98% RA
On arrival to the MICU, patient is feeling mildly improved.
Would prefer to not have picc or central line placed if
possible, as it's extremely painful for him to move around to
facilitate placement, would need ___ placement. Doesn't
want cipro as gave him lots of nausea previously; did better w/
broad spectrum antibiotics.
Past Medical History:
CHRONOLOGICALLY ORGANIZED PAST MEDICAL AND SURGICAL HISTORY:
- ___- Patient was recently admitted in ___, discharged on ___ for malfunctioning nephrostomy tube
s/p R PCN exchange. Course was uncomplicated.
- ___- Admission for pyelonephritis and sepsis. He
was initially on ___ given prior h/o MDR organisms. Urine
culture grew ESBL E. coli and he was narrowed to ciprofloxacin
to
complete fourteen day course. Foley catheter was exchanged. No
exchange of R sided PCN (draining well).
- ___- klebsiella bacteremia in the setting of R
sided nephrolithiasis and PCN obstruction. Records from OSH ___
bottles with Klebsiella resistant to ampicillin and TMP/SMX but
otherwise sensitive. Also with staph epi bacteremia, thought to
be related to infection at his central line site. Treated with 2
weeks of ceftriaxone and vancomycin.
- ___ he underwent an operation with a gluteal
advancement muscle flap for closure of this complex ischial and
sacral wound overlying site of previous osteo from ___. Per
notes the wound extended down to the bone through dermis and
epidermis intraoperatively.
- ___ skin culture from L knee grew light amount of
CORYNEBACTERIUM SPECIES (no polys) and from the R thigh grew
CORYNEBACTERIUM SPECIES and COAG NEG STAPHYLOCOCCUS (no polys)
but skin culture from the R gluteus area grew PSEUDOMONAS
AERUGINOSA (pan-sensitive) and ACINETOBACTER BAUMANNII (I to
ceftaz and pip/tazo, R to ceftriaxone but sensitive to
Cipro/levo, imipenem, gentamycin and Bactrim). Complete a 2 week
course of Bactrim and no MRSA was isolated afterwards, but
corynebacterium was
- ___ A skin graft procedure using a bioengineered skin
substitute/cellular or tissue based product was performed by
___, Shantanu on the right medial upper leg
- ___ A skin graft procedure using a bioengineered skin
substitute/cellular or tissue based product was performed on
pressure ulcer located on the Left Knee. Unfortunately this
graft did not take.
- Patient has been maintained on daily Bactrim therapy since
that time.
- Followed at ___ for non healing ulcers on
his L knee (over a prior PJI s/p hardware removal) and R thigh
prior skin graft site.
- ___ Ischial Osteomyelitis - bone cultures grew
pan-sensitive enterococcus, pan sensitive klebsiella, and
pan-sensitive Acinetobacter. Treated with 6 wks IV Zosyn
- ___ Transmetatarsal amputation for right toe gangrene
- ___ Hx A-flutter w/ RVR s/p cardioversion
- Provoked ___ Right lower extremity DVT requiring IVC filter
- ___ multiple surgeries for necrotizing citrobacter, VRE
fasciitis of chest requiring skin grafting and abdominal walls
plus drainage of intra-abdominal collections; also Trach &
Cecostomy
- L TKR ___ c/b wound dehiscence & septic arthritis in ___
- L prosthetic knee infection ___? with C. albicans and CoNS -
now
with spacer
- R THR ___
- L THR ___
- R TKR ___
- L4-L5 laminectomy ___ (s/p MVA with traumatic disc
herniation)
- L tibial osteotomy
OTHER MEDICAL ISSUES:
- Seronegative arthritis, possibly ankylosing spondylitis, of
hips, knees, wrist, on steroids/immunosuppressants since ___
(methotrexate, sulfasalazine, Enbrel, Humira, Remicade; as of
___ is on 20mg daily prednisone)
- History of PUD (on problem list since age ___, unclear)
- Anemia of Chronic Disease
- Onychomycosis
Social History:
___
Family History:
Mother: CAD/MI
Father: Cancer
Physical ___:
ADMISSION EXAM:
==============
VITALS: afebrile, HR 87, BP 148/58,, RR 12, 100% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, poor dentition
NECK: contracted
LUNGS: Clear to auscultation ant bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, +ii/vi sys murmur
greatest at RUSB, no rubs/gallops
ABD: +chronic surgical skin changes. +ostomy/Rt PCN in place. no
c/c/e. soft, mild lower abd ttp, non-distended. no rebound
tenderness or guarding
EXT: Warm, well perfused, no ___ edema b/l, chronic wound changes
NEURO: spontaneous movements in UE/LEs, sensation grossly
intact, cn2-12 grossly intact
DISCHARGE EXAM:
==============
Vitals: 98.3 98 / 64 69 18 95 RA
GEN: chronically ill man, alert, oriented, NAD, very soft spoken
HEENT: sclerae anicteric, MMM, neck contracted to the left R
neck scab over former EJ site.
CV: RRR no murmurs, rubs or gallops
RESP: clear anteriorly/laterally no wheezing, rhonchi or
crackles
ABD: obese, NTND. Multiple, well healed surgical scar with
ostomy RLQ with brown stool. +evidence of prior well healing
surgical scars. +yellow bruise LLQ from lovenox shots. R PCN
draining clear yellow urine
EXT: warm no edema, well healed R metatarsal amputation
+multiple surgical scars bilateral knees, evidence of prior skin
grafting thighs +R PICC
NEURO: CN II-XII grossly intact, able to move all extremities
spontaneously
Pertinent Results:
ADMISSION LABS:
==============
___ 02:05AM BLOOD WBC-9.4 RBC-3.75* Hgb-10.4* Hct-35.5*
MCV-95 MCH-27.7 MCHC-29.3* RDW-16.4* RDWSD-56.5* Plt ___
___ 02:05AM BLOOD Neuts-68 Bands-0 ___ Monos-8 Eos-1
Baso-0 ___ Metas-1* Myelos-1* AbsNeut-6.39* AbsLymp-1.97
AbsMono-0.75 AbsEos-0.09 AbsBaso-0.00*
___ 02:05AM BLOOD Glucose-85 UreaN-16 Creat-0.9 Na-142
K-3.8 Cl-104 HCO3-25 AnGap-17
___ 02:05AM BLOOD ALT-31 AST-11 LD(LDH)-131 AlkPhos-182*
TotBili-0.2
___ 02:05AM BLOOD Albumin-3.6
___ 02:05AM BLOOD ___ PTT-29.9 ___
___ 01:23AM BLOOD Glucose-83 Lactate-2.0 Na-141 K-4.3
Cl-105 calHCO3-24
___ 01:45AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 01:45AM URINE Blood-MOD Nitrite-POS Protein-600
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
DISCHARGE LABS:
==============
___ 05:20AM BLOOD WBC-9.1 RBC-3.06* Hgb-8.6* Hct-30.0*
MCV-98 MCH-28.1 MCHC-28.7* RDW-17.2* RDWSD-61.3* Plt ___
___ 05:20AM BLOOD Glucose-74 UreaN-17 Creat-0.7 Na-140
K-3.9 Cl-101 HCO3-29 AnGap-14
___ 05:20AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.0
MICRO:
=====
___ BLOOD CULTURE NO GROWTH PENDING
___ BLOOD CULTURE NO GROWTH PENDING
___ BLOOD CULTURE NO GROWTH PENDING
___ 9:51 am URINE Source: Kidney.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. < 10,000 CFU/mL.
___ 1:45 am URINE
URINE CULTURE (Preliminary):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES)
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefepime sensitivity testing performed by Microscan.
Cefepime MIC OF 4 MCG/ML = SUSCEPTIBLE-DOSE-DEPENDENT.
Interpretation of cefepime susceptibility is based on a
dose of 1
gram every 12h. This isolate is intermediate (I) to
cefepime, now
referred to as susceptible-dose dependent (SDD). SDD
isolates can
be treated with cefepime, but an optimized dosing
regimen should
be prescribed. Please contact the AST (pager ___ or
ID for
assistance in determining the appropriate SDD cefepime
dosing.
ESCHERICHIA COLI. >100,000 CFU/mL.
SULFA X TRIMETH AND MEROPENEM sensitivity testing
performed by
___.
PROTEUS MIRABILIS. >100,000 CFU/mL.
ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ESCHERICHIA COLI
| | PROTEUS
MIRABILIS
| | |
ENTEROCOCCUS SP.
| | | |
AMIKACIN-------------- 8 S 8 S <=2 S
AMPICILLIN------------ =>32 R =>32 R <=2 S
AMPICILLIN/SULBACTAM-- =>32 R =>32 R 8 S
CEFAZOLIN------------- =>64 R =>64 R 16 R
CEFEPIME-------------- R <=1 S
CEFTAZIDIME----------- =>64 R =>64 R <=1 S
CEFTRIAXONE----------- 8 R =>64 R <=1 S
CIPROFLOXACIN---------<=0.25 S 1 S =>4 R
GENTAMICIN------------ =>16 R =>16 R =>16 R
MEROPENEM-------------<=0.25 S S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S 64 I
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ =>16 R =>16 R 8 I
TRIMETHOPRIM/SULFA---- =>16 R R =>16 R
VANCOMYCIN------------ 4 S
___ 1:45 am BLOOD CULTURE Site: ARM
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:00 am BLOOD CULTURE Site: ARM
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS HOMINIS.
Isolated from only one set in the previous five days.
Sensitivity testing per ___ ___ ___.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
GRAM POSITIVE RODS. UNABLE TO IDENTIFY FURTHER.
Isolated from only one set in the previous five days.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS HOMINIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
GRAM POSITIVE ROD(S).
IMAGING/REPORTS:
===============
___ ___ PLACEMENT
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach double lumen right PICC with tip in the
distal SVC.
IMPRESSION:
Successful placement of a right 43 cm basilic approach double
lumen PowerPICC with tip in the distal SVC. The line is ready
to use.
___ TEE
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Trivial mitral regurgitation is seen.
IMPRESSION: Mild aortic valve sclerosis. No discrete vegetation
or pathologic flow identified.
___ RENAL ULTRASOUND
FINDINGS:
The right kidney measures 12.6 cm. The left kidney measures 12.8
cm. A simple cyst in the lower pole of the left kidney measures
2.8 x 2.1 x 2.2 cm. There is no hydronephrosis, or solid masses
bilaterally. In this patient with large stone burden seen on
prior, the stones are decreased in overall conspicuity though
several persist on the right. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
Bladder is decompressed by a Foley catheter.
IMPRESSION:
No hydronephrosis, decreased conspicuity of known stones.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Aquaphor Ointment 1 Appl TP TID:PRN dry skin
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat
5. ClonazePAM 1 mg PO BID
6. ClonazePAM 1 mg PO DAILY:PRN anxiety
7. Docusate Sodium 200 mg PO BID
8. Enoxaparin Sodium 90 mg SC Q12H
9. Ferrous Sulfate 325 mg PO DAILY
10. Gabapentin 600 mg PO TID
11. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN Pain - Moderate
Reason for PRN duplicate override: severe pain
12. Methadone (Oral Solution) 2 mg/1 mL 15 mg PO TID
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Mupirocin Ointment 2% 1 Appl TP BID Skin Breakdown
17. Omeprazole 20 mg PO DAILY
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. PredniSONE 20 mg PO DAILY
20. QUEtiapine extended-release 300 mg PO QHS
21. Simethicone 80 mg PO QID gas
22. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
23. Lactobacillus acidophilus 1 tab oral DAILY
24. Lactulose 60 mL PO BID:PRN constipation
Discharge Medications:
1. Calcium Carbonate 1000 mg PO QAM
2. Piperacillin-Tazobactam 4.5 g IV Q8H
Last full day of therapy ___
3. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
4. Vitamin D 800 UNIT PO DAILY
5. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
6. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
7. Aquaphor Ointment 1 Appl TP TID:PRN dry skin
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat
10. ClonazePAM 1 mg PO BID
RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
11. ClonazePAM 1 mg PO DAILY:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth as needed Disp #*10
Tablet Refills:*0
12. Docusate Sodium 200 mg PO BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Gabapentin 600 mg PO TID
15. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN Pain - Moderate
Reason for PRN duplicate override: severe pain
RX *hydromorphone 2 mg 3 tablet(s) by mouth Q3 Hours Disp #*30
Tablet Refills:*0
16. Lactobacillus acidophilus 1 tab oral DAILY
17. Lactulose 60 mL PO BID:PRN constipation
18. Methadone (Oral Solution) 2 mg/1 mL 15 mg PO TID
RX *methadone 10 mg/5 mL 7.5 mL by mouth three times per day
Refills:*0
19. Metoprolol Succinate XL 25 mg PO DAILY
20. Milk of Magnesia 30 mL PO DAILY:PRN constipation
21. Multivitamins W/minerals 1 TAB PO DAILY
22. Mupirocin Ointment 2% 1 Appl TP BID Skin Breakdown
23. Omeprazole 20 mg PO DAILY
24. Ondansetron 4 mg PO Q8H:PRN nausea
25. PredniSONE 20 mg PO DAILY
26. QUEtiapine extended-release 300 mg PO QHS
27. Simethicone 80 mg PO QID gas
28. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Complicated ESBL Urinary Tract Infection
Secondary Diagnosis:
Seronegative Spondyloarthropathy
Anemia of Chronic Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with urosepsis// consolidation, pulm edema,
pleural effusion consolidation, pulm edema, pleural effusion
IMPRESSION:
In comparison with study of ___, the chin again overlies the lung apex,
which cannot be appropriately evaluated. There is some increased
opacification at the left base, most likely representing a combination of
pleural fluid and atelectatic changes in the left lower lung. Cardiac
silhouette is unchanged and there is no definite vascular congestion or acute
focal pneumonia.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with UTI// ? nephrolithiasis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
The right kidney measures 12.6 cm. The left kidney measures 12.8 cm. A simple
cyst in the lower pole of the left kidney measures 2.8 x 2.1 x 2.2 cm. There
is no hydronephrosis, or solid masses bilaterally. In this patient with large
stone burden seen on prior, the stones are decreased in overall conspicuity
though several persist on the right.. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
Bladder is decompressed by a Foley catheter.
IMPRESSION:
No hydronephrosis, decreased conspicuity of known stones.
Radiology Report
INDICATION: ___ year old man with spondyloarthropathy on chronic steroids,
recurrent MDR UTI, p/w urosepsis. Needs access for abx. Previously required ___
PICC placement with anesthesia. Difficult airway. Request for ___//
Please place PICC line under anesthesia. Has history of difficult airway.
COMPARISON: Chest radiograph 20 second ___
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: Anesthesia was provided by the anesthesiology department. Please
refer to their notes for further details.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.7 min, 2 mGy
PROCEDURE:
1. Double lumen PICC placement through the right basilic vein.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the right
basilic vein was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A double lumen PIC line measuring 43 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach double lumen right PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a right 43 cm basilic approach double lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: B Flank pain, NEEDS FOLEY CHANGE
Diagnosed with Sepsis, unspecified organism
temperature: 98.4
heartrate: 105.0
resprate: 16.0
o2sat: 92.0
sbp: 125.0
dbp: 85.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ year old male with PMHx notable for severe
seronegative spondyloarthropathy (on prednisone 20mg daily,
chronic high dose narcotics), nonobstructing 2cm right ureteral
stone complicated by klebsiella bacteremia and right
percutaneous nephrostomy placed ___ with chronic indwelling
foley, obesity, extensive ID history (intraabdominal abscesses,
abdominal fasciitis, line infections with multiple resistant
organisms, MRSA skin infection), colostomy, hx of afib/aflutter,
left axillary vein occlusive clot and a non-occlusive clot in
the left basilic vein ___ on lovenox who presented on ___ with
chief compliant of lower abdominal discomfort, bladder spasms,
and discolored urine found to be transiently hypotensive to ___
and tachycardic with a UA concerning for infection. Mr. ___
was initially admitted to the ICU for monitoring and due to poor
IV access, a right EJ was placed on ___ after which he was
transferred to the medical floor for further management.
# COMPLICATED ESBL UTI:
Patient has a history of multiple, multiresistent organisms
growing in his urine. Upon admission UA was consistent with a
UTI. He has a right sided percutaneous nephrostomy tube and
foley placed for obstructing stone since ___ with plans for
lithotripsy in ___. Presented with bilateral flank pain
and bladder spasms and concern for increasing urine
sedimentation from his foley. In the ED, he was found to have
tachycardia and hypotension, along with high fevers and was
admitted to the MICU overnight. His chronic foley was exchanged
in the ED and discontinued during admission with a successful
voiding trial. Patient had a recent exchange of his nephrostomy
tube on ___ after his tube became dislodged, which may have
allowed for exposure. Renal ultrasound ___ did not show
hydronephrosis and showed decreased conspicuity of known stones.
Urine culture grew ESBL E. Coli, Klebseilla, Enterococcus, and
Proteus. In consultation with Infectious Diseases, given his
recent instrumentation and chronic foley, decision was made to
treat for a complicated urinary tract infection with 14 day
total course of IV Zosyn (___) with last full day of
treatment ___. A PICC was placed via Interventional
Radiology for IV antibiotics on ___. Of note, given his
difficult airway in the setting of contractures, patient
requires general anesthesia for PICC placements.
# GRAM POSITIVE COCCI IN CLUSTERS
2 of 4 blood cultures on ___ grew coagulase negative staph and
1 of 4 blood cultures grew gram positive rods (all from same
set). Trans Esophagal Echocardiogram performed on ___ was
without any evidence of valvular vegetation. It was suspected
that this set of blood cultures is most likely representative of
a contaminant.
CHRONIC ISSUES
==============
# SERONEGATIVE SPONDYLOARTHROPATHY:
Patient received stress dose steroids in the setting of his
infection and was discharged to continue his home prednisone
dosing. Continued home pain regimen of gabapentin, diluadid and
methadone. Continued his home Bactrim and PPI prophylaxis.
Started on calcium and vitamin D on discharge given chronic
steroid exposure.
# ANEMIA: Baseline Hbg 8s-9s.
# HX of SKIN INFXN: Continued outpatient Bactrim DS daily.
Patient has a right buttock moisture/pressure injury, right
ischium moisture/pressure injury, left ischium moisture/pressure
injury, and left knee traumatic injury from hitting against
table, all without depth or evidence of superinfection.
# PSYCH: Continued home Seroquel & benzodiazepine. QTc 395 on
discharge.
# AFIB: Lovenox and metoprolol were continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Amoxicillin
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female with a history of large bowel
obstruction s/p ex-lap & small bowel obstruction who presents
with abdominal pain, nausea and vomitting
Past Medical History:
- Psoriasis on experimental monoclonal antibody through a
research study at ___ previously on Remicade (Dr. ___
- PE (completed 6 month course of lovenox)
-obesity (currently on ___. 11 lb weight loss since
last year)
- h/o transaminitis
PSH: LBO s/p ex-lap, appendectomy
Social History:
___
Family History:
mother's family with DM/HTN but no history of malignancy or
muscle dysfunction.
Physical Exam:
Gen: alert, oriented to self, place and time. Not in any
distress.
HEENT: moist mucous membranes, no cervical lymphadenopathy
Chest: no crackles, bilateral breath sounds present
Heart: normal rate and rhythm
Abdomen: soft, nontender, nondistended
Extremities: without edema, palpable pedal pulses
Activity: ad lib
Pertinent Results:
___ 03:30PM URINE HOURS-RANDOM
___ 03:30PM URINE UCG-NEGATIVE
___ 03:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:30PM URINE RBC-2 WBC-6* BACTERIA-FEW YEAST-NONE
EPI-28
___ 03:30PM URINE MUCOUS-FEW
___ 02:22PM ___ COMMENTS-GREEN TOP
___ 02:22PM LACTATE-1.4
___ 02:16PM GLUCOSE-101* UREA N-13 CREAT-0.6 SODIUM-141
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-27 ANION GAP-12
___ 02:16PM estGFR-Using this
___ 02:16PM WBC-9.1 RBC-4.89 HGB-13.0 HCT-42.7 MCV-87
MCH-26.6 MCHC-30.4* RDW-15.0 RDWSD-47.8*
___ 02:16PM NEUTS-68.4 ___ MONOS-4.7* EOS-4.4
BASOS-0.7 IM ___ AbsNeut-6.20* AbsLymp-1.95 AbsMono-0.43
AbsEos-0.40 AbsBaso-0.06
___ 02:16PM ___ PTT-31.8 ___
___ 02:16PM PLT COUNT-243
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nexplanon (etonogestrel) 68 mg Other ___ years
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Cosentyx (secukinumab) 150 mg/mL subcutaneous Other
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO BID
4. Cosentyx (secukinumab) 150 mg/mL subcutaneous Other
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Nexplanon (etonogestrel) 68 mg Other ___ years
Discharge Disposition:
Home
Discharge Diagnosis:
partial small bowel 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 history of small bowel obstruction status post
exploratory lap presents similar pain to small bowel obstruction in the past
TECHNIQUE: Supine and upright AP views of the abdomen
COMPARISON: ___
FINDINGS:
Multiple dilated loops of small bowel measuring up to 3.7 cm are noted within
the mid left abdomen concerning for a small bowel obstruction. A small to
moderate amount of stool and gas are seen within the right colon. There are
no differential air-fluid levels or free intraperitoneal air. Calcification
measuring 9 mm is seen in the right upper quadrant of the abdomen compatible
with a gallstone. No acute osseous abnormality is visualized. Remote
deformity of the left parasymphyseal region is again noted compatible with
healed fracture.
IMPRESSION:
Small bowel obstruction. No free intraperitoneal air.
Radiology Report
INDICATION: ___ female with history of small-bowel obstruction with
abdominal pain.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE:
DLP = 918 mGy-cm.
COMPARISON: CT performed ___.
FINDINGS:
Chest: The bases of the lungs are clear bilaterally. There is no pericardial
or pleural effusion.
Abdomen: The liver appears homogeneous in attenuation with no focal lesion
identified. There is no intrahepatic or extrahepatic biliary duct dilation.
The gallbladder is contracted. Stones are noted within the gallbladder lumen
though there is no gallbladder wall thickening or pericholecystic fluid
suggestive of cholecystitis. The pancreas, spleen, and bilateral adrenal
glands are unremarkable.
The kidneys present symmetric nephrograms and excretion of contrast. There is
no focal lesion or hydronephrosis is identified.
Enteric tube is identified within the stomach. Loops of proximal small bowel
are fecalized and dilated, with a transition to normal caliber small bowel
located within the left upper hemiabdomen (02:44). Mild wall thickening is
associated with the dilated loops. Sutures are noted at the base of the cecum
compatible with prior appendectomy. The large bowel appears decompressed and
otherwise unremarkable.
The abdominal aorta is normal in caliber without aneurysmal dilatation. There
is no retroperitoneal or mesenteric adenopathy. No free air free fluid is
identified. A small fat containing umbilical hernia is noted.
Pelvis: The bladder is moderately well distended grossly unremarkable.
Uterus is unremarkable. No adnexal mass is identified. Trace amount of
pelvic free fluid is noted. There is no inguinal or pelvic sidewall
adenopathy.
Osseous structures: No suspicious lytic or blastic lesions are identified.
Remote fracture of the left pubic symphysis is again noted.
IMPRESSION:
1. Small bowel obstruction with transition point identified in the jejunum in
the left abdomen. Mild wall thickening is noted within the dilated loops of
jejunum containing fecalized material.
2. Cholelithiasis without cholecystitis.
3. Status post appendectomy.
4. Enteric tube appropriately positioned within the gastric lumen.
5. Trace pelvic free fluid.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.2
heartrate: 67.0
resprate: 18.0
o2sat: 98.0
sbp: 117.0
dbp: 76.0
level of pain: 7
level of acuity: 3.0 | Patient was admitted to the hospital on ___ for management of
small
bowel obstruction. Nasogastric tube was placed and she was made
NPO
with IV fluids. NGT was clamped on hospital day 2, and was
subsequently discontinued when patient tolerated the clamp
trial. Her
diet was advanced to clears on hospital day 2, when she was
having
flatus. On hospital day 3 she was advanced to regular diet with
marked
improvement of her abdominal exam. She ambulated without
assistance.
She was discharged from the hospital with plan to follow up with
outpatient primary care provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Levofloxacin
Attending: ___.
Chief Complaint:
Incisional pain ___ kidney transplant
Major Surgical or Invasive Procedure:
___: ___ removal
___: ___ line placement
History of Present Illness:
This is a ___ yo lady well known to the Transplant Surgery
service who is ___ CRT on ___. She was discharged from the
hospital on ___ in good condition. The patient states her
pain has not been well controlled ever since discharge. Her pain
medication regimen was changed yesterday to vicodin instead of
oxycodone with poor result. She denies nausea, vomiting, fevers
or chills. States that her appetite has been poor. Does endorse
urinary frequency but denies dysuria or macroscopic hematuria.
Denies diarrhea.
ROS is otherwise negative.
Past Medical History:
1) MPGN: Diagnosed age ___ by biopsy. ___ LRRT in ___
pt presented with uncontrolled BP requiring ICU admission for
Isradipine drip. Repeat biopsy showed a type ___ MPGN.
Plasmapheresis was initiated (3 sessions) Transplant removed
___. She was started on PD until ___ when she developed
peritonitis and she was switched to HD (HD tunnelled line -
___ - ___ back on PD prior to transplant
2) Peripheral edema and abdominal striae ___ steroids
3) HTN ___ steroids and renal disease, multiple admissions for
Hypertensive emergency.
4) H/o Hemolytic Anemia
5) Migraines
.
PSH: LRRT in ___, lap PD catheter placement ___,
transplant nephrectomy ___, removal of PD ___, lap PD
catheter replacement ___, removal of tunnelled HD cath
___, CRT ___
Social History:
___
Family History:
No history of kidney disease, malignancy, heart disease, or
diabetes.
Physical Exam:
Vitals: 98.9 114 136/95 16 100% 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 over surgical
incision which appears full. No erythema or discharge is noted.
Ext: trace edema on b/l ___
Pertinent Results:
On Admisssion: ___
WBC-16.7*# RBC-3.77*# Hgb-11.9*# Hct-36.8# MCV-97 MCH-31.5
MCHC-32.3 RDW-17.0* Plt ___
Neuts-94.3* Lymphs-2.7* Monos-1.0* Eos-1.9 Baso-0.2
Glucose-148* UreaN-28* Creat-2.1*# Na-131* K-5.4* Cl-101
HCO3-19* AnGap-16
ALT-64* AST-24 AlkPhos-229* TotBili-0.7
Albumin-3.4* Calcium-9.4 Phos-1.7* Mg-1.2*
___ 08:39PM BLOOD tacroFK-21.4*
___: ANAEROBIC CULTURE; Peritoneal Fluid
GRAM POSITIVE BACTERIA. SPARSE GROWTH.
___: HBVL- Negative
___: Hep C VL- Negative
___ HIV Ab-NEGATIVE
___: CMV VL:
Medications on Admission:
amlodipine 10 mg', labetalol 100 mg''', famotidine 20',
tacro ___, MMF 500", BSS', ___ 450', nystatin 5ml', oxycodone
5''''''prn
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
4. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
10. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
once a day for 5 days: give via picc.
Disp:*5 doses* Refills:*0*
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Medication Changes
stop the Labetalol
13. Outpatient Lab Work
___
cbc, chem 10, ast, t.bili, trough prograf, trough Vancomycin
level and ua with stat results
Bring to ___ lab at ___ Floor, ___
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*42 Tablet(s)* Refills:*0*
15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours): no more than 3000mg /day.
16. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Peritonitis, possible mycoplasma
UTI
Perinephric (transplant)fluid collection
fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CT ABDOMEN AND PELVIS WITHOUT CONTRAST
DATE: ___.
COMPARISON: Renal transplant ultrasound ___ abdomen ultrasound
___ CT abdomen and pelvis without contrast, ___.
CLINICAL INDICATION: ___ woman with high-risk kidney transplant 12
days ago, fevers and elevated LFTs. P.o. contrast only to assess for fluid
collection/abscess.
TECHNIQUE: MDCT axial images of the abdomen and pelvis were obtained without
the use of intravenous contrast. Oral contrast was administered. Coronal and
sagittal images were constructed.
TOTAL EXAM DLP: 289.01 mGy-cm
FINDINGS:
ABDOMEN: The lung bases are clear. The heart is not enlarged. There is no
pericardial or pleural effusion.
The liver, gallbladder, spleen, adrenal glands, and pancreas have a grossly
unremarkable unenhanced CT appearance. The native kidneys are atrophic with
multiple cortical calcifications. Within the mid left kidney, there is an
exophytic 9-mm hypodense lesion measuring simple fluid in ___ units.
This is new or enlarging from the ___ examination. A smaller 3-mm
hypo dense exophytic lesion is seen in the upper pole of the left kidney.
There is no mesenteric or retroperitoneal adenopathy. There is no free fluid
in the abdomen. The abdominal aorta demonstrates mild aneurysmal dilation
inferior to the renal arteries, measuring up to 2.1 cm in AP dimension (in
comparison to 1.5 cm more proximally were normal in caliber) (2:33; 200A:24).
Trace atherosclerotic calcifications are present within the infrarenal
abdominal aorta. The bowel loops are unremarkable. Post-surgical changes are
present in the left lower abdominal wall with a few foci of air in the
surgical wound consistent with recent kidney transplant.
PELVIS: Multiple dystrophic calcifications are present in the right lower
quadrant, likely on account of failed prior right lower quadrant renal
transplant. There is a new left lower quadrant renal transplant, which
measures 11 cm. There is no gross hydronephrosis. A ureteral stent extends
from the renal pelvis into the bladder. Surrounding the transplanted kidney,
there is extensive fat stranding. The previously described tiny anterior
fluid collection is not definitely identified, however, ___ fluid
collections are present laterally and posteriorly. Laterally, a thin fluid
collection measuring 2.0 x 1.1 cm is evident along the mid-to-upper pole of
the transplanted kidney (2:51). Superior to the transplant kidney, there are
two fluid collections, possibly connected at their inferior margin; one
adjacent to the left psoas muscle measuring 2.5 x 2.3 x 4.4 cm in transverse,
AP, and craniocaudal ___ respectively and a second extending into the
left paracolic gutter measuring 2.4 x 4.8 cm in transverse and craniocaudal
___ respectively. There is a single focus of free air in the anterior
pelvis (2:71). There is mass effect on the pelvic structures from the
transplanted kidney with displacement to the right. The bladder, uterus,
ovaries, and rectum are otherwise unremarkable. There is no obvious pelvic
lymphadenopathy.
OSSEOUS STRUCTURES: There are no destructive osseous lesions. Discal
calcification is present at T9-T10.
IMPRESSION:
1. Right lower quadrant transplant kidney with findings consistent with
recent postoperative state. Fluid collections along the left psoas muscle and
extending into the left paracolic gutter are present. Evaluation for rim
enhancement cannot be performed secondary to lack of intravenous contrast.
Given leukocytosis and fever, early abscess formation cannot be excluded.
These results were discussed with Dr. ___ by Dr. ___ telephone
on ___ at 1700.
2. Hypodense exophytic lesion from the mid native left kidney is new or
enlarging from the prior CT examination in ___. Although this may
represent a simple cyst, it is incompletely evaluated on the current
examination. Attention on followup or dedicated renal ultrasound is
recommended.
3. Mild ectasia of the infrarenal abdominal aorta measuring up to 2.1 cm in
comparison to normal caliber 1.5 cm proximally with scattered atherosclerotic
calcifications, abnormal given this patients age.
Radiology Report
PA AND LATERAL CHEST ON ___
HISTORY: ___ woman status post renal transplant 12 days ago with
persistent fever.
IMPRESSION: PA and lateral chest compared to ___:
Lungs are fully expanded and clear. There is no pleural effusion. Heart size
is top normal. Fullness in the pulmonary outflow tract has been a
longstanding feature due to demonstrated enlargement of the pulmonary artery
as well as a large thymus or mediastinal adenopathy.
Radiology Report
INDICATION: PICC line placement.
COMPARISON: ___.
FINDINGS: One portable erect AP view of the chest. A left PICC line ends in
the upper right atrium just below the CA junction. The cardiac, mediastinal,
and hilar contours are normal. The lungs are clear. There is no pleural
effusion. There is no pneumothorax, mediastinal widening, or evidence of
hemothorax.
IMPRESSION: Left PICC line ends in the right atrium just below the cavoatrial
junction. Suggest pulling back 1-2 cm. No pneumothorax, mediastinal
widening, or evidence of hemothorax.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: AND PAIN
Diagnosed with URIN TRACT INFECTION NOS, KIDNEY TRANSPLANT STATUS
temperature: 98.9
heartrate: 114.0
resprate: 16.0
o2sat: 100.0
sbp: 136.0
dbp: 95.0
level of pain: 10
level of acuity: 2.0 | ___ y/o F admitted 4 days after discharge and POD 9 from a
cadaveric renal transplant with complaint of abdominal pain. On
admission she was febrile to 102.4. She was pancultured with
slightly positive UA. Vanco and Zosyn was were started. Urine
culture isolated ___ lactobacillus. Blood cultures were
negative.
PD catheter (___) was still in place. Fluid was sent for
cellcount and culture. Cell count grew scant gram positive
bacteria 6 days following collection. This was unable to be
speciated or to have sensitivities done.
Meanwhile, she had intermittent fever ranging from 100.1-102
following the initial temp on admission. Zosyn was continued for
6 days. Vanco was started x 2 days, stopped for one day and then
restarted. Trough values were followed.
PD catheter was removed on ___. She tolerated this procedure
well. Diet was resumed and tolerated. However, she had
intermittent nausea.
Fevers persisted. On ___ an abdominal CT was performed
demonstrating
1. Right lower quadrant transplant kidney with fluid collections
along the left psoas muscle and extending into the left
paracolic gutter. Abscess could not be excluded. A new hypodense
exophytic lesion from the mid native left kidney was new or
enlarging from the prior CT examination in ___. Although
this may
represent a simple cyst, it is incompletely evaluated on the
current
examination. Mild ectasia of the infrarenal abdominal aorta
measuring up to 2.1 cm in comparison to normal caliber 1.5 cm
proximally with scattered atherosclerotic
calcifications was abnormal.
Given high risk donor status of the transplant kidney. LFTs were
increased since transplant. Hepatitis B and C viral testing was
performed (negative) as well as HIV Ab (negative) and HIV PCR
(pending at d/c). CMV VL was negative as was EBV IgM.
An ID consult was called, and their final recommendations were
to continue IV Vanco for one week post discharge. C diff had
been sent which was negative.
She continued to complain of abdominal pain rated as 8 out of
10, which was only controlled with IV dialudid. Attempts were
made to switch to po meds (Oxycodone and Dilaudid). Dilaudid 6mg
po was ineffective. After discussion on day of discharge, she
was switched to oxycodone 5mg prn every 4 hours.
Immunosuppression consisted of Cellept and Prograf which was
followed with daily trough levels. Initially, levels were high
necessitating holding several doses. Prograf level became
stable. Creatinine was as low as 1.5. This increased slowly to
2.0 on ___ (day of discharge). Calcium was also elevated at
11. Nephrology followed her and felt that she was dehydrated.
Normal saline bolus 1 liter was given with patient stating that
she felt better. PTH was sent and patient was encouraged to
drink at least ___ liters of fluid per day.
PICC line was placed and arrangements for home Vanco infusion
were arranged. PD fluid culture results (gram positive bacteria)
was corrected by Microbiology on ___. New read isolated
"possible mycoplasma". ID was contacted and recommended IV Vanco
until ___ and Doxycycline 100mg bid x 2 weeks.
She was discharged to home in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Entire left side has "fallen asleep"
Major Surgical or Invasive Procedure:
Bilateral Knee arthroplasty
History of Present Illness:
Ms. ___ is a ___ yo woman w/PMH type 1 DM with insulin pump,
hypothyroidism, HLD who presented initially to ___ today w/
hemiparathesias and subsequently was referred to the ED for
further workup.
Ms. ___ was in usual state of health until this morning,
when
she woke up feeling like her entire left side had "fallen
asleep". She endorses both tingling and numbness in her left
face, arm, and leg. Last night when she went to bed she was not
having these symptoms. She reports that she initially thought
this was because she may have slept abnormally, so she went
about
her day as per usual, stating that she had a normal day at work
(works at ___). She denies any weakness,
difficulty ambulating, dysarthria, vision changes, confusion, or
changes to her voice associated with this. She has no neck or
back pain and denies recent trauma.
She has never had symptoms of temporary weakness, sensory
deficits, slurred speech, visual changes, or other symptoms.
Past Medical History:
T1DM (insulin pump) c/b diabetic retinopathy
b/l knee arthroplasty
depression, anxiety
HTN
HLD
Social History:
___
Family History:
No family history of stroke or autoimmune disease
Physical Exam:
Vitals: afebrile, BP 98.4, HR 84, BP 148/80
General: well appearing woman in no apparent distress
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: evidence of fairly diffuse subcutaneous edema
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally.
V: Facial sensation decreased to light touch on left lower face
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: Decreased sensation to pink and light touch over left
lower face, left deltoid, left lateral thigh, and foot. poor
discrimination (pin v blunt tip of total LUE). vibration
sensation and position sense intact.
-DTRs:
Bi Tri ___ Pat Ach
L ___ 0 1
R ___ 0 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
___ 07:35AM BLOOD WBC-6.5 RBC-4.21 Hgb-12.4 Hct-38.0 MCV-90
MCH-29.5 MCHC-32.6 RDW-12.3 RDWSD-40.1 Plt ___
___ 08:55PM BLOOD Neuts-64.4 ___ Monos-5.7 Eos-1.8
Baso-0.7 Im ___ AbsNeut-5.41 AbsLymp-2.29 AbsMono-0.48
AbsEos-0.15 AbsBaso-0.06
___ 07:35AM BLOOD ___ PTT-31.2 ___
___ 07:35AM BLOOD Glucose-158* UreaN-16 Creat-0.8 Na-140
K-4.5 Cl-105 HCO3-24 AnGap-11
___ 03:15PM BLOOD ALT-34 AST-23 CK(CPK)-102 AlkPhos-101
TotBili-0.5
___ 07:35AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.4
___ 03:15PM BLOOD %HbA1c-7.0* eAG-154*
___ 03:15PM BLOOD Triglyc-188* HDL-71 CHOL/HD-2.4
LDLcalc-59
___ 03:15PM BLOOD TSH-1.4
___ 03:15PM BLOOD Free T4-0.9*
___ 06:00PM URINE Color-Straw Appear-CLEAR Sp ___
___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose->1000* Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-6.0
Leuks-NEG
___ 06:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
====================================
EKG Sinus
---------
Final Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ year old woman with left hemisensory changes
with MRI brain
with demyelinating lesion vs diffusion restriction stroke //
rule out
cervical spine lesion rule out cervical spine lesion
rule out demyelinating disease, MS lesion
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR
technique.
Axial T2 imaging was performed. Axial GRE images of the cervical
spine were
performed. After the uneventful administration of Gadavist
contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: MR ___ ___. CTA ___ and neck ___.
FINDINGS:
CERVICAL:
The spinal cord appears normal in caliber and configuration. No
cord lesions
are identified. There is no evidence of demyelination.
There is 2 mm anterolisthesis of C3 on C4. Alignment is
otherwise normal.
There are marked flowing anterior osteophytes from C3-T1 levels,
raising the
possibility of diffuse idiopathic skeletal hyperostosis (DISH).
Vertebral
body and intervertebral disc signal intensity appear normal.
There are mild
posterior disc bulges from C3-C7 levels, not causing significant
spinal canal
or neural foraminal narrowing. There is multilevel facet joint
arthropathy.
There is no evidence of spinal canal or neural foraminal
narrowing. There is
no evidence of infection or neoplasm. There is no abnormal
enhancement after
contrast administration.
THORACIC:
The spinal cord appears normal in caliber and configuration. No
cord lesions
are identified. There is no evidence of demyelination.
Alignment is normal.
Vertebral body and intervertebral disc signal intensity appear
normal.There
are mild posterior disc bulges from T10-L1 levels, causing mild
spinal canal
narrowing without neural foraminal narrowing. There is no
evidence of spinal
canal or neural foraminal narrowing the remaining imaged
vertebral
levels.There is no evidence of infection or neoplasm. There is
no abnormal
enhancement after contrast administration.
OTHER:
IMPRESSION:
1. No evidence of demyelination. Normal appearance of the cord.
2. Mild cervical and thoracic spondylosis, as described
3. Marked flowing anterior osteophytes from C3-T1 levels,
raising the
possibility of diffuse idiopathic skeletal hyperostosis (DISH).
PREVALENCE: Prevalence of lumbar degenerative disk disease in
subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal,
height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
___, et all. Spine ___ 26(10):1158-1166
Lumbar spinal stenosis prevalence- present in approximately 20%
of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):___
---------------
ECHO
CONCLUSION:
The left atrial volume index is normal. There is no evidence of
an atrial septal defect or patent foramen
ovale by 2D/color Doppler or agitated saline at rest and with
maneuvers. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with a normal cavity size.
There is normal regional and global left ventricular systolic
function. No thrombus or mass is seen in the
left ventricle. The visually estimated left ventricular ejection
fraction is >=55%. There is no resting
left ventricular outflow tract gradient. No ventricular septal
defect is seen. Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal for gender with a normal
ascending aorta diameter for gender. The aortic arch diameter is
normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (3) appear
structurally normal. No masses or vegetations are seen on the
aortic valve. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets appear structurally normal with no
mitral valve prolapse. No masses or vegetations are seen on the
mitral valve. There is trivial mitral
regurgitation. The pulmonic valve leaflets are not well seen. No
mass/vegetations seen, but cannot fully
exclude due to suboptimal image quality. The tricuspid valve
leaflets appear structurally normal. No
mass/vegetation are seen on the tricuspid valve. There is
physiologic tricuspid regurgitation. The
pulmonary artery systolic pressure could not be estimated. There
is no pericardial effusion.
IMPRESSION: No structural cardiac source of embolism (e.g.patent
foramen ovale/atrial septal
defect, intracardiac thrombus, or vegetation) seen. Mild
symmetric left ventricular hypertrophy
with normal biventricular cavity sizes, and regional/global
biventricular systolic function. No
valvular pathology or pathologic flow identified. Indeterminate
pulmonary artery systolic
pressure.
=============
Final Report
EXAMINATION: MR ___ W AND W/O CONTRAST T___ MR ___
INDICATION: ___ year old woman with hemisensory loss // eval
stroke or
demyelinating lesion
TECHNIQUE: Sagittal and axial T1 weighted imaging were
performed. After
administration of intravenous contrast, axial imaging was
performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT ___ without contrast of ___, CTA
___ neck of ___.
FINDINGS:
There is a nonenhancing punctate focus of diffusion-weighted
hyperintense
signal in the right dorsal pons, subjacent to the superior
cerebellar peduncle
(series 7, image 9) with associated FLAIR hyperintense signal.
This could
represent punctate acute infarct with differential consideration
of
demyelinating process considered less likely given lack of
associated
enhancement.
Re-identified is right frontal centrum semiovale 1 cm lesion
demonstrating
peripheral rim of FLAIR hyperintensity and diffusion-weighted
hyperintense
signal and central T2 hyperintensity without evidence of
enhancement,
nonspecific.
There's no evidence of intracranial hemorrhage or mass. There
is FLAIR
hyperintense signal of the lateral ventricles, posterior aspect
of the third
ventricle and quadrigeminal plate cistern on 3D FLAIR images,
felt to be
artifactual secondary to incomplete CSF suppression as no other
signal
abnormality is visualized on the remainder of the sequences
including 2D
FLAIR.
The major intracranial flow voids are preserved. The dural
venous sinuses are
patent. There's mild mucosal thickening of the ethmoid air
cells. The orbits
are unremarkable, noting left lens replacement. No significant
fluid signal
is seen the mastoid air cells. No suspicious marrow signal.
IMPRESSION:
1. Punctate focus of diffusion-weighted and FLAIR hyperintense
signal with
associated ADC hypointensity, potentially representing acute
infarct.
Demyelinating process is a differential consideration, but
considered less
likely given lack of associated enhancement.
2. Right frontal centrum semiovale 1 cm T2 hyperintense lesion
with peripheral
rim of FLAIR and diffusion-weighted hyperintense signal is
identified,
nonspecific. No associated enhancement. This could represent
evolving
infarct or demyelinating plaque.
3. No other lesions are identified. No intracranial mass or
hemorrhage.
4. Additional findings described above.
--------------
Final Report
EXAMINATION: CTA ___ AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with Left-sided body numbness,
abnormality and CT
noncontrast // Evaluate for large vessel occlusion, dissection
or other acute
abnormalities
TECHNIQUE: Contiguous MDCT axial images were obtained through
the brain
without contrast material. Subsequently, helically acquired
rapid axial
imaging was performed from the aortic arch through the brain
during the
infusion of intravenous contrast material. Three-dimensional
angiographic
volume rendered, curved reformatted and segmented images were
generated on a
dedicated workstation. This report is based on interpretation of
all of these
images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 39.2 cm; CTDIvol = 13.3 mGy
(Body) DLP = 520.0
mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy
(Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 23.8 mGy
(Body) DLP =
11.9 mGy-cm.
Total DLP (Body) = 533 mGy-cm.
COMPARISON: Noncontrast CT ___ from ___ at 20:06.
No prior
imaging of the ___ or neck is available for comparison.
FINDINGS:
CT ___ without contrast was performed prior to this CTA and is
reported
separately.
CTA ___:
The vessels of the circle of ___ and their principal
intracranial branches
appear normal without stenosis, occlusion, or aneurysm. The
dural venous
sinuses are patent.
CTA NECK:
Normal aortic branching pattern. Bilateral carotid and
vertebral artery
origins are patent. There is no evidence of internal carotid
stenosis by
NASCET criteria. The carotidandvertebral arteries and their
major branches
appear normal with no evidence of stenosis or occlusion.
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the
thyroid gland is normal. There is no lymphadenopathy by CT size
criteria.
Patient is status post left lens replacement surgery.
IMPRESSION:
1. Patent circle of ___ without evidence of
stenosis,occlusion,or aneurysm.
2. Patent bilateral cervical carotid and vertebral arteries
without evidence
of stenosis, occlusion, or dissection.
--------------
___ ___ 54 ___
Radiology ReportCHEST (PA & LAT)Study Date of ___ 1:35
AM
___ ___ 1:35 AM
CHEST (PA & LAT) Clip # ___
Reason: pna?
UNDERLYING MEDICAL CONDITION:
History: ___ with neuro deficits
REASON FOR THIS EXAMINATION:
pna?
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read by ___ ___ 2:36 AM
No evidence of pneumonia.
Final Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with neuro deficits // pna?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
The lungs are well expanded and clear. There is mild prominence
of the
pulmonary vasculature but no focal consolidation, large pleural
effusion,
pulmonary edema or pneumothorax. The cardiomediastinal
silhouette is at
slightly prominent, unchanged. No acute osseous abnormality.
IMPRESSION:
No evidence of pneumonia.
-=============
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. LamoTRIgine 200 mg PO BID
3. ClonazePAM 0.5 mg PO QHS
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Insulin Pump SC (Self Administering Medication)
Target glucose: 80-180
6. Levothyroxine Sodium 50 mcg PO 50 MCG, 100MCG ON ___
AND ___
7. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
8. MethylPHENIDATE (Ritalin) 10 mg PO QAM
9. lysine 500 mg oral DAILY
10. Sertraline 150 mg PO DAILY
11. Simvastatin 40 mg PO QPM
12. Aspirin 81 mg PO DAILY
13. Vitamin B Complex 1 CAP PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*3
2. Insulin Pump SC (Self Administering Medication)
Target glucose: 80-180
3. Aspirin 81 mg PO DAILY
Stop taking after 3 weeks.
4. ClonazePAM 0.5 mg PO QHS
5. LamoTRIgine 200 mg PO BID
6. Levothyroxine Sodium 50 mcg PO 50 MCG, 100MCG ON ___
AND ___
7. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
8. Losartan Potassium 100 mg PO DAILY
9. lysine 500 mg oral DAILY
10. MethylPHENIDATE (Ritalin) 10 mg PO QAM
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Sertraline 150 mg PO DAILY
13. Simvastatin 40 mg PO QPM
14. Vitamin B Complex 1 CAP PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebral Infarction
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 neuro deficits // pna?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
The lungs are well expanded and clear. There is mild prominence of the
pulmonary vasculature but no focal consolidation, large pleural effusion,
pulmonary edema or pneumothorax. The cardiomediastinal silhouette is at
slightly prominent, unchanged. No acute osseous abnormality.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with Left-sided body numbness, abnormality and CT
noncontrast // Evaluate for large vessel occlusion, dissection or other acute
abnormalities
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 39.2 cm; CTDIvol = 13.3 mGy (Body) DLP = 520.0
mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 23.8 mGy (Body) DLP =
11.9 mGy-cm.
Total DLP (Body) = 533 mGy-cm.
COMPARISON: Noncontrast CT head from ___ at 20:06. No prior
imaging of the head or neck is available for comparison.
FINDINGS:
CT head without contrast was performed prior to this CTA and is reported
separately.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm. The dural venous
sinuses are patent.
CTA NECK:
Normal aortic branching pattern. Bilateral carotid and vertebral artery
origins are patent. There is no evidence of internal carotid stenosis by
NASCET criteria. The carotidandvertebral arteries and their major branches
appear normal with no evidence of stenosis or occlusion.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is normal. There is no lymphadenopathy by CT size criteria.
Patient is status post left lens replacement surgery.
IMPRESSION:
1. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm.
2. Patent bilateral cervical carotid and vertebral arteries without evidence
of stenosis, occlusion, or dissection.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with hemisensory loss // eval stroke or
demyelinating lesion
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT head without contrast of ___, CTA head neck of ___.
FINDINGS:
There is a nonenhancing punctate focus of diffusion-weighted hyperintense
signal in the right dorsal pons, subjacent to the superior cerebellar peduncle
(series 7, image 9) with associated FLAIR hyperintense signal. This could
represent punctate acute infarct with differential consideration of
demyelinating process considered less likely given lack of associated
enhancement.
Re-identified is right frontal centrum semiovale 1 cm lesion demonstrating
peripheral rim of FLAIR hyperintensity and diffusion-weighted hyperintense
signal and central T2 hyperintensity without evidence of enhancement,
nonspecific.
There's no evidence of intracranial hemorrhage or mass. There is FLAIR
hyperintense signal of the lateral ventricles, posterior aspect of the third
ventricle and quadrigeminal plate cistern on 3D FLAIR images, felt to be
artifactual secondary to incomplete CSF suppression as no other signal
abnormality is visualized on the remainder of the sequences including 2D
FLAIR.
The major intracranial flow voids are preserved. The dural venous sinuses are
patent. There's mild mucosal thickening of the ethmoid air cells. The orbits
are unremarkable, noting left lens replacement. No significant fluid signal
is seen the mastoid air cells. No suspicious marrow signal.
IMPRESSION:
1. Punctate focus of diffusion-weighted and FLAIR hyperintense signal with
associated ADC hypointensity, potentially representing acute infarct.
Demyelinating process is a differential consideration, but considered less
likely given lack of associated enhancement.
2. Right frontal centrum semiovale 1 cm T2 hyperintense lesion with peripheral
rim of FLAIR and diffusion-weighted hyperintense signal is identified,
nonspecific. No associated enhancement. This could represent evolving
infarct or demyelinating plaque.
3. No other lesions are identified. No intracranial mass or hemorrhage.
4. Additional findings described above.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ year old woman with left hemisensory changes with MRI brain
with demyelinating lesion vs diffusion restriction stroke // rule out
cervical spine lesion rule out cervical spine lesion
rule out demyelinating disease, MS lesion
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of Gadavist contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: MR ___ ___. CTA ___ and neck ___.
FINDINGS:
CERVICAL:
The spinal cord appears normal in caliber and configuration. No cord lesions
are identified. There is no evidence of demyelination.
There is 2 mm anterolisthesis of C3 on C4. Alignment is otherwise normal.
There are marked flowing anterior osteophytes from C3-T1 levels, raising the
possibility of diffuse idiopathic skeletal hyperostosis (DISH). Vertebral
body and intervertebral disc signal intensity appear normal. There are mild
posterior disc bulges from C3-C7 levels, not causing significant spinal canal
or neural foraminal narrowing. There is multilevel facet joint arthropathy.
There is no evidence of spinal canal or neural foraminal narrowing. There is
no evidence of infection or neoplasm. There is no abnormal enhancement after
contrast administration.
THORACIC:
The spinal cord appears normal in caliber and configuration. No cord lesions
are identified. There is no evidence of demyelination. Alignment is normal.
Vertebral body and intervertebral disc signal intensity appear normal.There
are mild posterior disc bulges from T10-L1 levels, causing mild spinal canal
narrowing without neural foraminal narrowing. There is no evidence of spinal
canal or neural foraminal narrowing the remaining imaged vertebral
levels.There is no evidence of infection or neoplasm. There is no abnormal
enhancement after contrast administration.
OTHER:
IMPRESSION:
1. No evidence of demyelination. Normal appearance of the cord.
2. Mild cervical and thoracic spondylosis, as described
3. Marked flowing anterior osteophytes from C3-T1 levels, raising the
possibility of diffuse idiopathic skeletal hyperostosis (DISH).
PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal, height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
Jarvik, et all. Spine ___ 26(10):1158-1166
Lumbar spinal stenosis prevalence- present in approximately 20% of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):545-550
These findings are so common in asymptomatic persons that they must be
interpreted with caution and in context of the clinical situation.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: L Numbness
Diagnosed with Paresthesia of skin
temperature: 96.7
heartrate: 85.0
resprate: 18.0
o2sat: 97.0
sbp: 139.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | ___ right handed woman with history of DM1, HLD who woke up with
left-sided numbness of her face arm and leg, that mostly
resolved within 24 hrs, with a patch of ongoing numbness in the
left lateral upper arm. She was admitted to the Neurology stroke
service.
#Left hemibody sensory changes
MRI brain demonstrated a punctate focus of diffusion-weighted
and FLAIR hyperintense signal with associated ADC hypointensity,
thought to be an acute infarct. Demyelinating process was also
on the differential consideration, but considered less likely
given lack of associated enhancement. There was also noted to be
a right frontal centrum semiovale 1 cm T2 hyperintense lesion
with peripheral rim of FLAIR and diffusion-weighted hyperintense
signal without enhancement which was nonspecific. LP was
attempted without adequate CSF flow. MRI C- and T-spine
demonstrated. Differential for this lesion included evolving
infarct or demyelinating plaque. To try to determine if these
lesions are ischemic or demyelinating in nature, we did an MRI
of the spine to look for prior sequelae of inflammation. There
were no old or enhancing demyelinating lesions identified on the
spine, and no other old lesions on the brain to suggest MS.
___, we did not attempt to repeat LP. Working diagnosis
acute infarct, and patient was started on Plavix, and continued
on aspirin; after 3 weeks aspirin will be discontinued and she
will remain on Plavix monotherapy indefinitely. There is a
slight increased risk of bleeding with concurrent use of SSRIs
and Plavix, and patient should follow up with PCP for regular
hemoglobin checks. Though the punctate acute infarct is in a
location classic for small vessel disease, the older infarct in
the right frontal centrum semioval is not, and therefore patient
will need outpatient telemetry monitoring. Patients
echo-cardiogram was without etiologic cause. As it was a weekend
when she was ready for discharge, this could not be arranged
inpatient and patient will have to follow up as an outpatient
for this monitoring. This was ordered in OMR; patient will be
called to schedule which she understands. As an outpatient in
stroke clinic, consideration should be given to repeat MRI w/wo
contrast to see if additional lesions are accrued that would
support change of working diagnosis to a demyelinating process.
Additionally, if she were to experience new symptoms, additional
neuroimaging should be obtained to further assess for stroke for
demyelination. She was continued on simvastatin 40mg daily.
#IDDM
Patient's home insulin pump and home insulin was continued while
inpatient. She ran out of insulin as she was being discharged,
with plan to go directly home to pick up insulin. ___ was
consulted and recommended no changes to home regimen.
#Hypertension
While hospitalized we held you anti-hypertensives to allow for
post stroke permissive hypertension which are to be continued
after discharge.
#Hypothyroidism
Home levothyroxine was continued without change. TSH and FT4
were within essentially normal limits.
#Depression/Anxiety
- continue home lamotrigine and sertraline. Follow up with PCP
for hemoglobin check given initiation of Plavix as outpatient.
- continue home methylphenidate
Her stroke was most likely secondary to small vessel ischemia
event given history of hypertension, hyperlipidemia, and stroke
location. We did consider this a failure of ASA. She was started
on Plavix 75mg daily with DAPT x3 weeks, with plan to
discontinue aspirin after 3 weeks. Her deficits improved greatly
prior to discharge and the only notable deficit was slightly
decreased pinprick in the left lateral upper arm. She did not
require ___ consult, and was discharged home with outpatient
follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose / Vicodin
Attending: ___.
Chief Complaint:
Chief Complaint: Fatigue, cough, myalgia and low grade fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with recurrent breast cancer on Herceptin /
Eribulin CD11 with recent history notable for Staph ___
bacteremia (cx + ___ and C. diff colitis presenting with
myalgias cough and low-grade fever. Patient reports ___ days of
nonproductive cough, sore throat, ear pressure and myalgias. She
called her oncologist on day of admission who requested she come
in for evaluation. Patient reports temperature of 99 at home but
has been afebrile in the ED. No recent travels but exposures to
sick contacts include grandson who's sick with a cold or flu
(patient not sure). She reports having diarrhea 6 days prior to
presentation for which she was ruled out for C.Diff.
Of note patinet's last chemo treatment was a week prior to
presentation. She often has 2 weeks on, 1 week off.
Patient denies HA, vision change, chest pain, shortness of
breath, abdominal pain change in bowel movements dysuria
dizziness, lightheadedness, slurred speech, or word finding
difficulties.
In the ED/clinic, initial vitals were: T 98.2 BP 104/68 HR 88 RR
20 O2sat 100% on RA
Physical exam was notable for no findings in the ear or throat.
Labs were notable for: Lactate of 1.6, Creat 0.9, WBC of 17.5
(patient reports taking "filgastrim" recently)
Imaging was notable for: Cxray didn't show pneumonia or any
other findings.
Patient underwent an infectious workup that did not show any
focal source of infection. Given her recent chemotherapy
treatment and her immunosuppression, she was empirically covered
with antibiotics, Vanc and Cefepime and given IV fluids and
ibuprofen.
Vitals prior to transfer to floor were: 98.2 104/68 20 100% on
RA
Review of Systems:
(+) Per HPI cough, myalgias, poor appetite
(-) Review of Systems: GEN: Nochills, night sweats, recent
weight loss or gain. HEENT: No headache, sinus tenderness,
rhinorrhea. CV: No chest pain or tightness, palpitations. PULM:
No cough, shortness of breath, or wheezing. GI: No nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel habits, no hematochezia or melena. GUI: No
dysuria or change in bladder habits. MSK: No arthritis,
arthralgias, or myalgias. DERM: No rashes or skin breakdown.
NEURO: No numbness/tingling in extremities. PSYCH: No feelings
of depression or anxiety. All other review of systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
- Originally diagnosed in ___ with a breast cancer that was
grade III and almost triple negative. There were few weak ER
positive cells.
- In the adjuvant setting, she had had a complete pathological
response to neoadjuvant ACT treatments and then had not
tolerated
tamoxifen and had to stop that.
- Left-sided breast ultrasound revealed no discrete masses. MR
of
the brachial plexus visualized a 4-cm spiculated left axillary
mass consistent with recurrent malignant disease likely
involving
the smaller neural branches of the medial cord of the brachial
plexus and tethering the left axillary vein, which remains
patent. Cytology of an axillary lymph node done and that was
positive for malignant disease consistent with metastatic
adrenal carcinoma. These were negative for cytokeratins,
mammaglobin, GCDFP and estrogen receptor. HER-2 by FISH was
attempted and negative.
- Biopsy of mets done in ___ for circulating tumor cells
determination and that had turned out positive for circulating
tumor cells and these had been positive for HER2 giving her the
opportunity to enroll in the Navelbineand trastuzumab study
- Taxotere ___ x 2 cycles then progressed
- Weekly Adriamycin started ___
- Gemzar/Carboplatin started ___
- Herceptin/Navelbine protocol ___ started ___
CURRENT TREATMENT PLAN: Herceptin D1 every 21 days
navelbine D1,D8,d15 every 21 days
Research Protocol: ___
Other Past Medical History:
- non-insulin dependent diabetes mellitus
- hypertension
- hyperlipidemia
- locally advanced breast cancer (see above)
Social History:
___
Family History:
Cousin with leukemia. Brother with unknown cancer. Grandmother
with pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.9 BP 102/62 HR 90 RR 18 O2sat 98% on RA
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD, Left axilla with h/o surgery
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no ___
sign
Extremities: wwp, left upper extremity with 1+ edema, no edema
in other extremities. DPs, PTs 2+.
Skin: no rashes or bruising, chest port in place
Neuro: CNs II-XII intact. ___ strength in U/L extremities. DTRs
2+ ___. sensation intact to LT, cerebellar fxn intact (FTN, HTS).
gait WNL.
DISCHARGE PHYSICAL EXAM:
VS: Tm 99.4 T98.7 BP 111/70 HR 89 RR 16 O2sat 93% on RA
GEN: Middle aged female in NAD, appears fatigued, AOx3, speaking
in full sentences.
HEENT: EOMI, PERRLA. MMM.
NECK: no LAD. no JVD. neck supple. No cervical, supraclavicular,
or axillary LAD, Left axilla with h/o surgery
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no ___
sign
Extremities: wwp, left upper extremity with 1+ edema, no edema
in other extremities. DPs, PTs 2+.
Skin: no rashes or bruising, chest port in place
Neuro: CNs II-XII intact. ___ strength in U/L extremities. DTRs
2+ ___. sensation intact to LT, cerebellar fxn intact (FTN, HTS).
gait WNL.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:30AM WBC-17.5* RBC-3.30* HGB-9.7* HCT-30.3* MCV-92
MCH-29.5 MCHC-32.2 RDW-18.9*
___ 04:30AM NEUTS-80.1* LYMPHS-16.3* MONOS-3.3 EOS-0.2
BASOS-0.2
___ 04:30AM PLT COUNT-214
___ 10:30AM ___ PTT-33.1 ___
___ 04:30AM GLUCOSE-203* UREA N-9 CREAT-0.9 SODIUM-138
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-24 ANION GAP-18
___ 04:39AM LACTATE-1.6
___ 10:05AM URINE MUCOUS-RARE
___ 10:05AM URINE RBC-0 WBC-24* BACTERIA-NONE YEAST-NONE
EPI-7
___ 10:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 10:05AM URINE COLOR-Straw APPEAR-Hazy SP ___
DISCHARGE LABS:
===============
___ 04:47AM BLOOD WBC-11.6* RBC-3.29* Hgb-9.7* Hct-30.4*
MCV-92 MCH-29.5 MCHC-32.0 RDW-18.9* Plt ___
___ 04:47AM BLOOD Neuts-73.5* ___ Monos-3.7 Eos-0.5
Baso-0.5
___ 04:47AM BLOOD ___ PTT-34.9 ___
___ 04:47AM BLOOD Plt ___
___ 04:47AM BLOOD Glucose-154* UreaN-6 Creat-0.9 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
___ 04:47AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.6
PERTINENT LABS:
===============
___ 04:39AM BLOOD Lactate-1.6
MICROBIOLOGY:
=============
___ 6:45 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:30 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
___ 10:05 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 12:48 pm Influenza A/B by ___
Source: Nasopharyngeal swab.
DIRECT INFLUENZA A ANTIGEN TEST (Pending):
DIRECT INFLUENZA B ANTIGEN TEST (Pending):
___ 12:48 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Pending):
Respiratory Viral Antigen Screen (Pending):
___ 5:45 pm BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending):
___ 7:40 am BLOOD CULTURE X 1.
Blood Culture, Routine (Pending):
___ 11:30 am SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
IMAGING:
========
FINDINGS:
A right Port-A-Cath terminates within the mid SVC. There is no
evidence of focal consolidation, pleural effusion, pneumothorax,
or pulmonary edema. Asymmetry of the breast shadows is noted,
unchanged from prior. The cardiomediastinal silhouette is within
normal limits.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Ondansetron 4 mg PO Q8H:PRN nausea
3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
4. Warfarin 5 mg PO QPM
5. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
6. Sucralfate 1 gm PO Q6H:PRN stomach upset
7. GlipiZIDE XL 7.5 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
5. Sucralfate 1 gm PO Q6H:PRN stomach upset
6. Warfarin 5 mg PO QPM
7. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
8. OSELTAMivir 75 mg PO Q12H Duration: 5 Days
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*9 Capsule Refills:*0
9. GlipiZIDE XL 7.5 mg PO DAILY
10. Acetaminophen ___ mg PO Q8H:PRN pain/myalagias/fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
11. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
12. Guaifenesin 15 mL PO Q6H:PRN cough
RX *guaifenesin 200 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Viral Cold/Flu
Secondary diagnosis
Breast cancer
Left upper extremity DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ s/p chemo myalgia, temp 99, cough, pls weval for pna
// History: ___ s/p chemo myalgia, temp 99, cough, pls weval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs dated ___, CT chest dated ___.
FINDINGS:
A right Port-A-Cath terminates within the mid SVC. There is no evidence of
focal consolidation, pleural effusion, pneumothorax, or pulmonary edema.
Asymmetry of the breast shadows is noted, unchanged from prior. The
cardiomediastinal silhouette is within normal limits.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED, COUGH
temperature: 98.2
heartrate: 99.0
resprate: 18.0
o2sat: 98.0
sbp: 117.0
dbp: 76.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with a past medical history
of metastatic breast cancer and C. difficile colitis, who
presented with myalgia, cough and subjective fevers:
# Myalgia, cough, subjective fevers: Patient's symptoms pointed
towards an infectious etiology, likely viral process. Her
exposure to sick contacts puts her at risk for infection either
viral or bacterial. Given patient's prior history of bacteremia,
ensure blood cultures were negative in ___ hours, to rule out
infection. However patient was overall stable since arrival to
the floor. She did not meet strict SIRS criteria given her
elevated WBC was explained by filgastrim and she was afebrile.
Held off on abx and started Oseltamivir (day ___ end
date ___. Flu swab, sputum cultures, blood cultures and
urine cultures were also sent.
# Leukocytosis: Could have been in the setting of infection but
patient also received pegfilgastrim on ___ and steroids
as well which can explain the leukocytosis. Began trending down
prior to discharge
# LUE DVT: Patient had a left upper extremity DVT in ___.
Currently on coumadin. INR supratherapeutic to 4.4 on
___. Prior to discharge it was 1.9-2.0. Will need to
continue taking coumadin and close follow up to ensure patient
is not subtherapeutic or supratherapeutic in the setting of
other meds such as Oseltamivir
# Diabetes: Stopped glipizide and placed on ISS while inpatient.
Sugars remained in 200s-300s on insulin sliding. Patient refused
diabetic diet in house. Recommend ___ follow up for diabetes.
# Hypertension: Continued home meds, amlodipine.
## TRANSITIONAL ISSUES
======================================
[] F/u on final blood culture results
[] F/u on flu swabs, rapid respiratory viral screen and sputum
cultures
[] frequent INR check given reports on interaction with coumadin
and elevated INR
[] On Oseltamivir for 5 days; end date ___. Will stop if
test returns negative.
[] ___ follow up for diabetes given poor glycemic control and
refusal to adhere to diabetic diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Levaquin / adhesive tape / Band-Aid Clear Spots /
Bactrim / Keflex / vancomycin / Bleach (Sodium Hypochlorite)
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
colonoscopy ___
History of Present Illness:
Ms ___ is a ___ year old woman with a history of bipolar
disease, chronic hyponatremia, symptomatic bradycardia s/p PPM,
PAD s/p revascularization earlier this year, who presented to
___ for evaluation of bright red blood per rectum. Patient
endorses ___ days of maroon colored stools. Last bowel movement
was prior to presentation to the ED. Endorses some lower
abdominal pain, associated with nausea. Denies lightheadedness,
dizziness, chest pain, dyspnea, palpitations. At ___,
patient was noted to be febrile. Physical exam revealed
cellulitis in the right lower extremity. On rectal exam she was
noted to have maroon stool that was heme positive. CTA of the
chest was suggestive of subsegmental pulmonary embolism. Patient
was started on broad-spectrum antibiotics with clindamycin and
meropenem due to allergies. She was transfused 1U PRBCs and
transferred to ___.
- In the ED, initial vitals were:
Temp 97.3 | HR 106 | BP 124/79 | RR 18 | SpO2 98% 3L NC
- Exam was notable for:
Ext: Right lower extremity swelling and warmth to palpation.
Sensation intact. No obvious rash in groin.
Rectal: Gross red blood with small clots. Guaiac positive.
- Labs were notable for:
WBC 33.3 --> 32.8
Hgb 10.2 --> 8.9 --> 9.2 (s/p 1U PRBCs)
Lactate 1.6
- The patient was given:
At ___:
Famotidine
Meropenem (@1900)
Linezolid (@___)
1U PRBCs
At ___:
Pantoprazole IV 40mg
- GI was consulted who recommended CTA of abdomen/pelvis if
continued blood loss, but no acute intervention required given
hemodynamic stability. MASCOT was consulted who recommended
second-read of OSH CTA, and holding off on anticoagulation
currently.
On arrival to the floor, patient reports she does not feel well.
Endorsing nausea and lower abdominal pain.
Collateral was obtained from patient's daughter. Daughter
reports
patient has been previously treated for cellulitis. Daughter
last
saw her mother yesterday, helped her shower and did not notice
the redness in her leg at that time.
Past Medical History:
Asthma
COPD
HLD
HTN
Bipolar disorder
PTSD
Temporal lobe epilepsy
CHF
GERD
Symptomatic bradycardia s/p PPM
Peripheral vascular disease
Hyponatremia
Social History:
___
Family History:
Three brothers with alcohol use disorder. Significant family
history of schizoaffective disorder, bipolar disorder, and
anxiety. Mother with pancreatic cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Temp: 99.4 PO BP: 126/64 R Lying HR: 88 RR: 20 O2 sat:
97% O2 delivery: Ra
GENERAL: Lying in bed, appears uncomfortable, but not in acute
distress.
HEENT: Sclera anicteric and without injection. MMM.
CARDIAC: Normal rate and rhythm. Audible S1 and S2. Grade ___
systolic flow murmur.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Soft. Tender to palpation in lower quandrants without
rebound or guarding.
EXTREMITIES: Large area of erythema and warmth in LLE, extending
from medial thigh down into shin, overlying surgical scar in
right thigh. Mildly tender to palpation. Area of
induration/firmness around medial border of surgical scar. No
crepitus. Wound on left shin covered in clean bandage; wound on
right great toe covered in clean bandage, no erythema around
wound, no exudate. No edema. Weakly palpable pedal pulses.
NEUROLOGIC: Alert. Oriented to self and place. Motor and sensory
function grossly intact and symmetric throughout.
DISCHARGE PHYSICAL EXAM:
98.0 PO 152 / 63 69 18 100 Ra
GENERAL: sitting up in chair in no acute distress
HEENT: EOMI, MMM, sclera anicteric
NECK: no JVD
CV: RRR, nl S1/S2, ___ systolic murmur heard at ___
PULM: CTAB, no wheezes or crackles
GI: soft, nondistended, nontender. No suprapubic tenderness.
EXTREMITIES: improving RLE erythema involving calf and thigh.
Trace edema. Less warm. Right medial thigh scar. Right ___ toe
amp with chronic ulcer. Chronic ulcer on left shin. No areas of
fluctuance, purulence, crepitus.
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
ADMISSION LABS:
===============================
___ 10:13PM BLOOD WBC-32.8* RBC-3.02* Hgb-9.2* Hct-29.5*
MCV-98 MCH-30.5 MCHC-31.2* RDW-15.4 RDWSD-54.5* Plt ___
___ 10:13PM BLOOD Neuts-94.8* Lymphs-1.5* Monos-2.2*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-31.08* AbsLymp-0.49*
AbsMono-0.73 AbsEos-0.01* AbsBaso-0.10*
___ 10:13PM BLOOD ___ PTT-27.3 ___
___ 10:13PM BLOOD Glucose-101* UreaN-21* Creat-0.9 Na-133*
K-5.0 Cl-103 HCO3-20* AnGap-10
___ 10:13PM BLOOD ALT-25 AST-15 AlkPhos-96 TotBili-0.5
___ 10:13PM BLOOD Lipase-15
___ 10:13PM BLOOD proBNP-918*
___ 10:13PM BLOOD cTropnT-<0.01
___ 10:13PM BLOOD Albumin-3.5 Calcium-8.1* Phos-3.9 Mg-1.9
___ 10:21PM BLOOD Lactate-1.6
DISCHARGE LABS:
===============================
___ 08:22AM BLOOD WBC-8.6 RBC-3.09* Hgb-9.1* Hct-29.3*
MCV-95 MCH-29.4 MCHC-31.1* RDW-15.3 RDWSD-53.3* Plt ___
___ 08:22AM BLOOD Glucose-101* UreaN-7 Creat-0.8 Na-136
K-3.8 Cl-102 HCO3-21* AnGap-13
___ 08:22AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
MICROBIOLOGY:
===============================
__________________________________________________________
___ 10:45 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 10:32 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 10:32 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
===============================
___ Imaging CHEST (PORTABLE AP)
No pulmonary edema. No focal consolidation. No acute
cardiopulmonary process seen. Please note that CT is more
sensitive in detecting pulmonary masses.
___ BILATERAL ___ DOPPLERS
1. Superficial thrombophlebitis in the proximal origin of the
right greater saphenous vein.
2. Left calf veins not well seen. No evidence of deep venous
thrombosis in the remainder of the bilaterallower extremity
veins.
3. Right ___ cyst.
OTHER DIAGNOSTIC:
===============================
___ Colonoscopy
- High residue material was noted in the right colon. Unable to
irrigate.
- No evidence of active bleeding
- Diverticulosis of the whole colon
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
2. ARIPiprazole 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. CarBAMazepine (Extended-Release) 400 mg PO BID
5. ClonazePAM 1 mg PO TID
6. Ferrous Sulfate 325 mg PO BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Methocarbamol 500 mg PO BID:PRN Pain
9. Nortriptyline 25 mg PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Rosuvastatin Calcium 10 mg PO DAILY
12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
13. Metoprolol Tartrate 25 mg PO BID
14. Clopidogrel 75 mg PO DAILY
15. alfuzosin 10 mg oral DAILY
16. Gentamicin 0.1% Cream 1 Appl TP Frequency is Unknown
Discharge Medications:
1. Clindamycin 300 mg PO QID
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a
day Disp #*22 Capsule Refills:*0
2. terbinafine HCl 250 mg oral DAILY Duration: 12 Weeks
RX *terbinafine HCl 250 mg 1 tablet(s) by mouth once a day Disp
#*84 Tablet Refills:*0
3. Gentamicin 0.1% Cream 1 Appl TP TID:PRN wound care
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
5. alfuzosin 10 mg oral DAILY
6. ARIPiprazole 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. CarBAMazepine (Extended-Release) 400 mg PO BID
9. ClonazePAM 1 mg PO TID
10. Clopidogrel 75 mg PO DAILY
11. Ferrous Sulfate 325 mg PO BID
12. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
13. Methocarbamol 500 mg PO BID:PRN Pain
14. Metoprolol Tartrate 25 mg PO BID
15. Nortriptyline 25 mg PO DAILY
16. Pantoprazole 40 mg PO Q12H
17. Rosuvastatin Calcium 10 mg PO DAILY
18. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACTIVE ISSUES:
Cellulitis, Right lower extremity
Hematochezia
CHRONIC ISSUES:
COPD
HLD
HTN
Chronic Hyponatremia
Bipolar Disease
PTSD
Temporal lobe epilepsy
Symptomatic bradycardia s/p PPM
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires some assistance or aid
(walker or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with inconclusive evidence of PE on CTA at OSH,
high bleed risk// r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
Patient has reported history of bilateral lower extremity vein stripping.
There is focal nonocclusive thrombus at the proximal right greater saphenous
vein.
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow
demonstrated in the right posterior tibial and peroneal veins. The left calf
veins are not well seen.
There is normal respiratory variation in the common femoral veins bilaterally.
In the medial right knee there are 2 cystic structures that measure 3.0 x 1.4
x 3.3 and 4.6 x 0.8 x 4.0 cm. These likely represent components of a ___
cyst.
IMPRESSION:
1. Superficial thrombophlebitis in the proximal origin of the right greater
saphenous vein.
2. Left calf veins not well seen. No evidence of deep venous thrombosis in the
remainder of the bilaterallower extremity veins.
3. Right ___ cyst.
Radiology Report
EXAMINATION: SECOND OPINION CT CHEST
INDICATION: ___ year old woman with dyspnea, oxygen requirement, PE// Please
overread CTA showing pulmonary embolism.
TECHNIQUE: This is a second read request of the CTA of the chest from an
outside hospital. 12.7 mm, axial MIPS, 2.0 and 1.0 mm axial images with
intravenous contrast are available. Coronal and sagittal bone reformats
measuring 2.0 mm are also available.
DOSE: 2644 mGy cm
COMPARISON: Same day chest AP radiograph.
FINDINGS:
The study is severely limited by breathing motion.
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The trachea is unremarkable. There
is no axillary, infraclavicular or supraclavicular lymphadenopathy. There is
mild to moderate calcified atherosclerosis involving the vasculature of the
thoracic inlet and superior mediastinum.
UPPER ABDOMEN: The study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen demonstrates
thickening of the bilateral adrenal without evidence of discrete mass.
Otherwise the abdomen is unremarkable.
MEDIASTINUM: No mediastinal lymphadenopathy.
HILA: No hilar lymphadenopathy.
HEART and PERICARDIUM: Cardiac size is mildly enlarged. No pericardial
effusions. No calcified atherosclerosis of the coronary arteries. The
vascular calibers of the ascending aorta, main pulmonary artery, ascending
aorta and aortic arch are within normal limits. No large central pulmonary
embolus. Evaluation of the segmental and subsegmental pulmonary arteries are
severely limited by breathing artifact.
PLEURA: No pleural effusions or pneumothorax.
LUNG:
1. PARENCHYMA: Mild-to-moderate centrilobular emphysematous changes are
demonstrated.
2. AIRWAYS: The central airways are patent.
CHEST CAGE: No acute fracture. Moderate multilevel degenerative changes of
the thoracic spine include intervertebral disc space narrowing, vacuum
phenomena and anterior osteophytes.
IMPRESSION:
1. The study is severely limited by breathing motion, severely limiting the
evaluation of the segmental and subsegmental pulmonary arteries.
2. No large central pulmonary embolus.
3. Mild to moderate centrilobular emphysematous.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI bleed, PE, Transfer
Diagnosed with Melena, Cellulitis of right lower limb
temperature: 97.3
heartrate: 106.0
resprate: 18.0
o2sat: 98.0
sbp: 124.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | Ms ___ is a ___ F with a history of bipolar disease,
chronic
hyponatremia, symptomatic bradycardia s/p PPM, PAD s/p
revascularization earlier this year, who is admitted for maroon
stools concerning for GIB, found to have cellulitis of the RLE,
and possible PE on OSH CTA.
==================
ACUTE ISSUES
#Hematochezia
#Acute blood loss anemia
Patient reporting maroon stools concerning for lower GI bleed.
Transferred from ___, where HGB ___ s/p 1 U
PRBC. During admission, patient hemodynamically stable with no
further episodes of bleeding and stable HGB, not requiring
further transfusions. Started on IV PPI BID. ASA/Plavix was
continued for maintenance of revascularization in setting of
stable HGB. GI consulted and pt underwent colonoscopy on ___,
which showed no active bleeding nor source of bleeding, did show
diverticulosis throughout the colon. Dc'ed IV PPI after
colonoscopy d/t low suspicion of UGIB and pt stability. GI
recommended outpatient capsule study if further bleeding.
#Sepsis
#Cellulitis
Patient with cellulitis of right leg, leukocytosis to 33, and
febrile at OSH prior to arrival at ___. Started on clindamycin
and meropenem initially at OSH, deescalated to clindamycin alone
at ___ given patient reported allergies. No other sources of
infection identified. BCx NGTD. Patient allergic to PCN
(anaphylaxis) and also reportedly Vancomycin, Levaquin, Keflex,
and Bactrim. WBC downtrending and afebrile during admission.
Cellulitis improved during admission. Will continue PO
clindamycin for 10 days (___). Will start treatment of nail
onchomycosis with terbinafine 250mg qday for 12 weeks to reduce
risk for recurrent cellulitis.
#Possible pulmonary embolism without high-risk features
CTA from ___ with artifact, although suggestive of
possible PE. Patient initially presented to ___ where
CTA showed prelim read with possible PE though significant
artifact. Patient HDS with no chest pain or shortness of breath
and not requiring supplemental oxygen. ___ read at ___
negative for large ___ duplex negative for DVT. Therefore, no
treatment for PE due to little concern. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
Chief Complaint:
Acute Renal Failure
Major Surgical or Invasive Procedure:
Ultrasound-guided renal biopsy ___: antibody mediated
rejection
Tunneled Pheresis Line Placement ___
History of Present Illness:
___ gentleman with a past medical history of end-stage
renal disease possibly secondary to hypertension who underwent
SCD kidney transplantation on ___. The patient's
postoperative course was relatively uneventful. Recent increase
in creatinine from prior baseline of 1.5-1.6 to 2.1. US in ___
clinic ___ showed hydronephrosis with full bladder, that
resolves with emptying. Pt was seen in renal transplant clinic
on ___ for routine follow up appointment, and was referred to
the ED for admission due to increasing Cr.
Good PO intake. No recent illnesses. Today, he denies fever,
chills, nausea, vomiting, diarrhea, or constipation. He has no
bloody stools, dysuria, or hematuria. No abdominal pain. No
chest pain and no shortness of breath. He does note 6x nocturia
(previously on dialysis for ___ years). Tacrolimus dose recently
increased from 2mg BID to 3mg BID.
In the ED, initial vital signs were: 98.3; 65; 119/62; 100% RA
Labs were notable for:
CBC: 3.9 >10.6/33.8<188
Cr 1.8
INR 1.3
Imaging: Renal ultrasound showing minimally elevated intrarenal
arterial resistive indices and moderate hydronephrosis, which
resolves upon voiding.
The patient was given:
2L NS and maintenance NS at 100cc/hr
Consults:
Transplant renal was consulted, who recommended admission for
renal biopsy. He was made NPO ___.
Vitals prior to transfer were: 98.0 118/55 73 16 98% RA.
Upon arrival to the floor, pt was comfortable and VSS.
REVIEW OF SYSTEMS:
[+] per HPI
[-] Denies headache, visual changes, pharyngitis, rhinorrhea,
nasal congestion, cough, fevers, chills, sweats, weight loss,
dyspnea, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, hematochezia, dysuria, rash, paresthesias,
weakness
Past Medical History:
HTN
HLD
ESRD, now s/p SCD kidney transplantation on ___
Periodontal disease
Hepatitis B on lamivudine
Anemia of chronic disease
Social History:
___
Family History:
Family History: No family history of renal disease
Physical Exam:
Admission Physical Exam:
========================
VITALS - 98.4 118/69 63 18 97% RA
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, no JVD
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
strength ___ throughout. Gait assessment deferred given ankle
cuffs.
PSYCHIATRIC - listens & responds to questions appropriately,
pleasant
Discharge Physical Exam:
========================
VS: 98.2 117/64 80 18 99% RA
General: Adult male in NAD, lying comfortably in bed
HEENT: NCAT, MMM
Neck: Supple
CV: Regular rhythm with loud S1, no MRG
Lungs: CTAB without increased WOB
Abdomen: NTND, BS+, no obvious ascites, transplanted kidney not
tender
Ext: WWP without edema, AV fistula at LUE with palpable thrill
Neuro: CN II-XII intact, moving all ext, AAOx3================
Pertinent Results:
Admission Labs:
===============
___ 05:00PM BLOOD WBC-3.9* RBC-4.17* Hgb-10.6* Hct-33.8*
MCV-81* MCH-25.4* MCHC-31.4* RDW-15.4 RDWSD-45.4 Plt ___
___ 05:00PM BLOOD Neuts-67.1 Lymphs-17.1* Monos-14.0*
Eos-1.0 Baso-0.5 Im ___ AbsNeut-2.58 AbsLymp-0.66*
AbsMono-0.54 AbsEos-0.04 AbsBaso-0.02
___ 05:00PM BLOOD ___ PTT-37.3* ___
___ 05:00PM BLOOD Glucose-112* UreaN-18 Creat-1.8* Na-135
K-4.7 Cl-102 HCO3-23 AnGap-15
___ 06:08AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
___ 06:08AM BLOOD ALT-10 AST-16 CK(CPK)-326* AlkPhos-146*
TotBili-0.3
___ 05:00PM BLOOD tacroFK-4.1*
___ 06:08AM BLOOD tacroFK-5.1
Pathology:
==========
PATHOLOGIC DIAGNOSIS (RENAL BIOPSY ___:
Findings consistent with antibody mediated rejection; mild
interstitial fibrosis and tubular atrophy; overt cellular
rejection not present-see note. NOTE: Sections reveal renal
parenchyma containing approximately 14 mostly unremarkable
glomeruli( one globally sclerotic) , but a variable glomerulitis
is seen, the assessment of which is dependent on the level
(g1-2; cg0). Mild interstitial fibrosis and tubular atrophy are
noted
accompanied by chronic inflammation((i1;ci1;ct1).Peritubular
capillaritis is present as well, but also variable depending on
the level (ptc1) There is, also, a few areas of relatively
intact parenchyma with lymphocytic infiltration and occasional
tubulitis.(t1). Arterioles/interlobular arteries show mild
fibrotic change. No evidence of endothelialitis is seen.
Immunofluorescence studies reveal 4 glomeruli. No staining is
seen with IgG, IgA, fibrin, albumin, kappa light chain, lambda
light chain or C1q.Trace mesangial IgM staining is seen. C3
stains vessels (+/--1+). The C4d preparation is diffusely
positive Electron microscopy will be sent as an addendum. PAS
and silver methenamine stains were done to evaluate basement
membranes. Masson trichrome preparations were done to study
fibrotic changes. This biopsy is difficult to evaluate.There is
a glomerulitis and peritubular capillaritis, the extent of which
varies from level to level.However, the C4d preparation is
diffusely positive, so that this biopsy has to be considered
consistent with antibody mediated rejection.It will be important
to establish the presence of DSA. Some interstitial chronic
inflammation is seen related to intact tubules, but only a
minimal tubulitis is seen, so that overt cellular rejection is
not present.
Interval Labs:
==============
DONOR SPECIFIC ANTIBODIES
*** THIS REPORT IS NOT OFFICIAL AND SHOULD NOT BE USED FOR
CLINICAL DECISION MAKING *** FINAL REPORT IS PENDING APPROVAL.
PLEASE SEE ___ FOR FINAL RESULTS ***
Recipient: ___ (MR# ___) HLA: A*02, A*33;
B*35(Bw6), B*53(Bw4); DRB1*01, DRB1*13; DQB1*05, X; ___*(___)
Deceased Donor (___) HLA: A1, A24; B35, B37; Bw4, Bw6; Cw4,
Cw6; DRB1*13:01, DRB1*15:01;
DQB1*06:02, DQB1*06:03; DQA1*01:02, DQA1*01:03;
DRB3*01:01(DR52), DRB5*01:01(DR51)
Txp Date: ___
Serum ___
Test ___
DTEDTEDTE
Class ___
___
___
___
Class ___
___
___
___
___
___
___
___
___
DR52DRB3*01:01 (allele ___
___
Discharge Labs:
===============
___ 05:53AM BLOOD WBC-7.1 RBC-3.61* Hgb-9.2* Hct-29.4*
MCV-81* MCH-25.5* MCHC-31.3* RDW-19.7* RDWSD-52.0* Plt ___
___ 05:53AM BLOOD Plt ___
___ 05:53AM BLOOD Glucose-87 UreaN-30* Creat-1.6* Na-140
K-4.5 Cl-107 HCO3-24 AnGap-14
___ 05:53AM BLOOD Calcium-9.2 Phos-4.8* Mg-1.7
Micro:
======
BK PCR: <500 (negative)
Imaging:
========
Ultrasound-guided Renal Biopsy ___: antibody mediated
rejection
Renal Transplant Ultrasound ___
IMPRESSION:
1. Moderate hydronephrosis of the transplant kidney in the
context of a full bladder, which resolves upon voiding.
Transient hydronephrosis can be attributed to back pressure from
a full bladder.
2. Minimally elevated intrarenal arterial resistive indices
ranging from 0.70 up to 0.79. Otherwise unremarkable renal
transplant ultrasound with normal vascular waveforms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Carvedilol 37.5 mg PO BID
4. Dapsone 100 mg PO DAILY
5. ergocalciferol (vitamin D2) 50,000 unit oral Monthly
6. LaMIVudine 100 mg PO DAILY
7. Mycophenolate Mofetil 500 mg PO QID
8. Tacrolimus 3 mg PO Q12H
9. Docusate Sodium 100 mg PO BID:PRN Constipation
10. Senna 8.6 mg PO BID:PRN Constipation
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
2. Atorvastatin 10 mg PO QPM
3. Carvedilol 37.5 mg PO BID
4. Dapsone 100 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN Constipation
6. LaMIVudine 100 mg PO DAILY
7. Mycophenolate Mofetil 1000 mg PO BID
RX *mycophenolate mofetil 500 mg 2 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN Constipation
9. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
10. ValGANCIclovir 450 mg PO Q24H
Last dose ___
RX *valganciclovir 450 mg 1 tablet(s) by mouth DAILY Disp #*28
Tablet Refills:*0
11. ergocalciferol (vitamin D2) 50,000 unit oral Monthly
12. Nystatin Oral Suspension 5 mL PO QID thrush PPX
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day
Refills:*0
13. Tacrolimus 6.5 mg PO Q12H
RX *tacrolimus 5 mg 1 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
RX *tacrolimus 0.5 mg 3 capsule(s) by mouth twice a day Disp
#*120 Capsule Refills:*0
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
Antibody mediated rejection of renal transplant
Acute Renal Failure
Secondary:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with right SCD kidney transplant ___ who
presents with ___ (Cr 1.8 from baseline 1.4). // possible renal transplant
rejection
COMPARISON: None
PROCEDURE: Sonographic guidance for transplant renal biopsy by nephrologist.
OPERATORS: Dr. ___ sonographic guidance for biopsy that was
performed by the Nephrology team.
TECHNIQUE: Ultrasound guidance by the radiologist was provided to
nephrologist for biopsy of the lower pole of the the transplanted kidney
located in the right lower quadrant. Three passes were made. Please refer to
nephrologist note for details of the procedure.
SEDATION: No moderate sedation was administered.
FINDINGS:
Survey view of the transplanted kidney shows no hydronephrosis or perinephric
collection.
IMPRESSION:
Sonographic guidance for biopsy of the rightlower quadrant transplant kidney
by nephrologist.
Radiology Report
INDICATION: ___ year old man with SCD renal transplant ___ who presents
with active antibody mediated rejection requiring IV steroids and
plasmapheresis. // please place tunneled double-lumen pheresis line - ___
___ aware.
COMPARISON: Chest radiograph ___
TECHNIQUE: OPERATORS: Dr. ___ resident, Dr. ___
resident, Dr. ___ and Dr. ___,
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Anesthesia was provided by administrating divided doses of 50 mcg
of fentanyl throughout the total intra-service time 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.
FLUOROSCOPY TIME AND DOSE: 1.7 min, 5 mGy
PROCEDURE:
1. Tunneled non-dialysis line placement.
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The access site was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A double lumen catheter was selected. The catheter was
tunneled from the entry site towards the venotomy site from where it was
brought out using a tunneling device. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the catheter was threaded
into the right side of the heart with the tip in the right atrium. The sheath
was then peeled away. Final spot fluoroscopic image demonstrating good
alignment of the catheter and no kinking. The tip is in the right atrium. The
catheter was flushed and each lumen was capped. The catheter was sutured in
place with 0 silk sutures. Steri-strips were used to close the venotomy
incision site. Sterile dressings were applied. The patient tolerated the
procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing right
internal jugular venous approach 27 cm tip to cuff double lumen catheter with
tip terminating in the right atrium.
IMPRESSION:
Successful placement of a double lumen tunneled line via the right internal
jugular venous approach. The tip of the catheter terminates in the right
atrium. The catheter is ready for use.
Radiology Report
INDICATION: ___ year old man with acute humoral kidney rejection, s/p pheresis
and IVIG // Removal of pheresis line. Pt ideally planned for DC on ___, so
removal on this date if at all possible.
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ (interventional radiology fellow) and
Dr. ___ (interventional radiology attending) performed the procedure.
The attending, Dr. ___ was present and supervising throughout the
procedure.
ANESTHESIA: None.
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: None
PROCEDURE: 1. Right chest tunneled pheresis catheter removal.
PROCEDURE DETAILS: The procedure was performed at bedside. The Right chest
tunneled line site was cleaned and draped in standard sterile fashion. The
catheter was removed with gentle traction while manual pressure was held at
the venotomy site. Hemostasis was achieved after 5 min of manual pressure. A
clean sterile dressing was applied. The patient tolerated the procedure well.
There were no immediate postprocedural complications.
FINDINGS:
Expected appearance after tunneled line removal.
IMPRESSION:
Successful removal of a right chest tunneled line.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: FOR EVAL
Diagnosed with Acute kidney failure, unspecified
temperature: 98.3
heartrate: 65.0
resprate: nan
o2sat: 100.0
sbp: 119.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | PATIENT
___ gentleman with a past medical history of end-stage
renal disease, possibly secondary to hypertension who underwent
SCD kidney transplantation on ___ who was referred to the
ED from his 11.5 month clinic f/u visit for worsening
creatinine. Underwent renal biopsy on ___ that showed acute
humoralrejection and subsequently underwent treatment with
immunosuppression, plasmapheresis, IVIG, and ATG.
ACUTE ISSUES
# Acute Humoral Rejection of DDRT: Patient less than a year
after transplant, known transient hydronephrosis. Creatinine on
admission was 1.8 (baseline 1.4). BK PCR <500 (negative). CK
very mildly elevated (326) on admission, possibly due to heavy
exercise i/s/o ___ which downtrended to WNL by HD2. Urinalysis
on admission completely normal. Renal biopsy ___ showed
humoral mediated rejection. Donor-specific antibodies were
tested on ___ and demonstrated HLA I (A1, A24) and HLA II
(DR15, DQ6, DR51). He was initially treated with
methylprednisolone 500mg IV q24h x3 days (___) before
changing over to a prednisone taper. Tacrolimus and MMF dosing
was adjusted as detailed below. A tunneled pheresis line was
placed and he underwent 5 cycles of plasmapheresis ___,
___, ___. Each plasmapheresis session was
followed with an IVIG infusion of 10mg, with the exception of
his ___ and final session which was followed of two days of 50mg
___ and ___. He also underwent three consecutive days of
100mg ATG infusion (___). Follow-up DSA levels showed a
significant improvement in HLA Ab levels (A1, A24) decrease to
20% of pretreatment levels. HLA II (DQ6, DR51) decreased by
50-60%, but HLA (DR15) did not show any significant response.
For this reason, rituximab treatment was considered but was
ultimately deferred to the outpatient setting. Creatinine at
time of discharge was 1.6. Patient was continued on prednisone,
MMF, and tacrolimus at levels detailed below.
# Immunosuppression:
- Tacrolimus: Patient's tacrolimus levels were low on admission
considering the setting of acute humoral rejection. For this
reason, his tacro was gradually increased from 3mg on admission
to 7.5 targeting a therapeutic range of ___. However, he
ultimately became supratherapuetic
- MMF was changed from 500mg QID to ___ BID for ease of
patient dosing. He did not suffer from any GI issues with this
change.
- Steroids: Mr ___ was initially treated with pulse
methylprednisolone 500mg IV q24h x3 days (___) before
changing over to a prednisone taper. He took 60mg x3 days,
followed by 40mg x 3 days before changing to indefinite 20mg
prednisone daily.
# Prophylaxis:
- Valacyclovir: Dosed at 450mg daily given his low GFR.
- Dapsone: Patient should continue to take this dose for an
additional year given his acute rejection within the first
- Lamivudine: Patient should continue to take this medication
indefinitely as he is HBcAb positive and chronically on
steroids.
- Nystatin swish and swallow QID should be continued for an
additional 4 weeks after discharge
CHRONIC ISSUES
# Hypertension: Well controlled. Home amlodipine was decreased
to 2.5mg daily and carvedilol continued at home dose.
# Osteoporosis: Continued vitamin D supplementation.
# HLD: Continued atorvastatin 10 mg per day.
TRANSITIONAL ISSUES:
- Patient to continue prednisone 20mg daily after discharge.
Dosing will be adjusted by Dr ___
- ___ dose increased to 6.5 this admission.
- Tacro level on day of discharge was 6.5mg BDI (dose had been
decreased from 7.5mg BID to 6.5mg BID on ___ for a
supratherapeutic level (goal ___.
- Please draw tacrolimus levels from 0530 on ___ and fax
results to ___ Attn: ___
- Pt will have follow-up appointment with Dr ___ at
___ at 1:00 p.m (see above follow-up appointment
information)
- Continue valacyclovir for an additional 4 weeks after
discharge (final dose ___ however should confirm this with
nephrology prior to stopping. If patient's Creatinine falls
below [1.4], please consider increase to full dose.
- Continue dapsone through ___ as patient had acute
rejection during first year post-transplant
- Lamivudine: Patient should continue to take this medication
indefinitely as he is HBcAb positive and chronically on
steroids.
- Nystatin swish and swallow QID should be continued for an
additional 4 weeks after discharge
- MMF changed from 500mg QID to ___ BID
- Amlodipine decreased to 2.5mg daily this admission
- Discharge Creatinine: 1.6
- Discharge weight: 78.7kg
- Code: Full (confirmed) |
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:
___ year old male with CAD s/p
CABG x4 (RIMA-RCA, VG-diag, VG-OM3, VG-RPDA) in ___ and Impella
placement/PCI to LAD in the setting of STEMI in ___, HTN,
HLD,
and reduced ejection fraction (26%) who presents with
progressive
exertional dyspnea.
Patient reports that for the last several weeks, he has felt
progressive dyspnea on exertion. Last night, while laying down,
he experienced dyspnea that did not resolve until he sat up. He
also reports new onset orthopnea. He adamantly denies any chest
pain during my interview, despite ED documentation stating that
he was complaining of chest pain.
In the ED, a bedside echo was performed that reportedly showed
decreased EF (previously 26% in ___. proNT-BNP was elevated
at 4247 (not checked on previous admissions). ECG showed sinus
rhythm with Q waves in I, V2-V4 with ST segment elevation in
V2-V3 that is improved from previous tracing on ___.
Troponins were < 0.01 x3 with CK-MB 2. Given his complex cardiac
history, he was deemed too high risk for ED observation and was
admitted to ___.
Of note, patient was recently admitted to ___ in ___ after
being transferred for STEMI. He underwent Impella placement and
PCI to LAD that was complicated for in-stent thrombosis
requiring
second stent placement. Since discharge, he states he has
completed taking all of his medication and is now only on
ticargrelor 90mg that he takes every 8 hours. It was his
understanding that he was only supposed to be on this
medication,
despite recent cardiology clinic note indicating otherwise.
Past Medical History:
Cardiac History:
- CAD s/p CABG x4 w/ ___-RCA, VG-Diag, VG-OM3, VG-RCA ___ @
___
- NSTEMI
Other PMH:
- HTN
- HLD
- Carotid artery disease, s/p R CEA
- Accidental electrocution ___ years ago
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.6 126/78 68 16 97% RA
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: No JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regularly irregular. Normal S1, S2. No murmurs, rubs, or
gallops.
LUNGS: Bibasilar crackles. No wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No peripheral edema.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 1126)
Temp: 97.6 (Tm 98.1), BP: 105/65 (99-126/64-78), HR: 51
(39-80), RR: 17 (___), O2 sat: 95% (94-97), O2 delivery: Ra,
Wt: 181.88 lb/82.5 kg (181.88-185.41)
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. EOMI.
NECK: JVP at 10 cm
CARDIAC: RRR. Normal S1, S2. No murmurs.
LUNGS: Mild bibasilar crackles. No wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No peripheral edema.
SKIN: Sternal scar.
Pertinent Results:
ADMISSION LABS
___ 03:15PM URINE UHOLD-HOLD
___ 03:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
___ 03:15PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 02:54PM cTropnT-<0.01
___ 12:44PM CK(CPK)-65
___ 12:44PM CK-MB-1 cTropnT-<0.01
___ 09:06AM GLUCOSE-94 UREA N-16 CREAT-0.9 SODIUM-142
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
___ 09:06AM estGFR-Using this
___ 09:06AM CK(CPK)-87
___ 09:06AM cTropnT-<0.01
___ 09:06AM CK-MB-2 proBNP-4247*
___ 09:06AM CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-2.1
___ 09:06AM WBC-6.9 RBC-4.93 HGB-13.7 HCT-42.2 MCV-86
MCH-27.8 MCHC-32.5 RDW-13.7 RDWSD-42.3
___ 09:06AM NEUTS-60.7 ___ MONOS-7.3 EOS-3.7
BASOS-0.6 IM ___ AbsNeut-4.21 AbsLymp-1.88 AbsMono-0.51
AbsEos-0.26 AbsBaso-0.04
___ 09:06AM PLT COUNT-146*
___ 09:06AM ___ PTT-28.0 ___
DISCHARGE LABS
___ 07:05AM BLOOD WBC-6.2 RBC-5.25 Hgb-14.6 Hct-44.5 MCV-85
MCH-27.8 MCHC-32.8 RDW-13.7 RDWSD-41.7 Plt ___
___ 07:05AM BLOOD Plt ___
___ 06:54AM BLOOD Glucose-107* UreaN-22* Creat-0.9 Na-140
K-4.5 Cl-104 HCO3-25 AnGap-11
___ 06:54AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.0
PERTINENT REPORTS
CXR ___
Cardiomegaly with mild interstitial congestion. No frank edema
or large
pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TiCAGRELOR 90 mg PO Q8H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Furosemide 20 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
Este medicamento nuevo es para ___.
5. Metoprolol Succinate XL 25 mg PO DAILY
Este medicamento nuevo es para ___.
6. TiCAGRELOR 90 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Acute on chronic heart failure with reduced ejection fraction
Secondary diagnosis
Coronary artery disease
Dyslipidemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with chest pain// edema
COMPARISON: Prior radiograph dated ___.
FINDINGS:
PA and lateral views of the chest provided. The cardiomediastinal silhouette
is stable with redemonstration of cardiomegaly. Mild interstitial congestion.
No frank edema or large pleural effusion. No pneumothorax. Imaged osseous
structures are intact. No free air below the right hemidiaphragm is seen.
Median sternotomy wires appear intact.
IMPRESSION:
Cardiomegaly with mild interstitial congestion. No frank edema or large
pleural effusion.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea, L Flank pain
Diagnosed with Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs
temperature: 97.7
heartrate: 69.0
resprate: 18.0
o2sat: 98.0
sbp: 110.0
dbp: 55.0
level of pain: 10
level of acuity: 2.0 | TRANSITIONAL ISSUES
====================
DISCHARGE WEIGHT: 181 lbs.
DISCHARGE Cr/BUN: ___
DISCHARGE DIURETIC: Furosemide 20 mg PO daily
MEDICATION CHANGES:
- NEW: Furosemide 20 mg PO daily, Aspirin 81mg daily, lisinopril
5 mg daily, atorvastatin 80 mg daily, metoprolol succinate 25 mg
daily
- STOPPED: None
- CHANGED: Ticagrelor 90 mg TID -> ticagrelor 90 mg BID
[] Patient is to establish cardiology care with Dr. ___
___ at his ___ clinic as Dr. ___ is ___
speaking and the patient lives in ___.
[] Patient will be provided free medications through the ___
___ Pharmacy. However, because they are free, patient will
only be given 1 month supply at a time and will need to return
to the ___ building to pick up his medications each month.
[] Evaluation for hepatic synthetic dysfunction - INR was mildly
elevated and plts were mildly low. ___ be consistent with
hepatic synthetic dysfunction. This should be further evaluated
on an outpatient basis.
=====================
SUMMARY STATEMENT
=====================
___ year old male with CAD s/p CABG and PCI with residual
disease, HTN, HLD, and HFrEF presents with recent episodes of
exertional chest pain, orthopnea and PND in the setting
medication nonadherence, concerning for acute on chronic HFrEF.
Chest pain, PND, orthopnea resolved with IV diuretics.
Transitioned to PO diuretics.
CORONARIES: CABG with occluded SVG-diag, patent SVG-OM3, and
patent SVG-RCA with 60% native disease after touchdown. PCI to
LAD ___ complicated by in-stent thrombosis requiring repeat
PCI. Diffuse disease in the remainder of the coronaries
PUMP: EF 26%
RHYTHM: NSR
===============
ACTIVE ISSUES:
===============
# Acute on chronic HFrEF
On presentation, patient had elevated BNP, reported PND and
orthopnea, all consistent with acute on chronic HFreF.
Additionally, CXR showed mild pulmonary edema. On exam, elevated
JVP to 10 cm, bibasilar crackles. He also reported that he was
only taking one home medication, ticagrelor 90 mg TID (instead
of BID). He did not understand his home medication regimen and
he also had significant financial barriers to receiving his
medications. Reassuringly, his chest pain was different than
previous angina symptoms and resolved quickly with IV Lasix.
Troponins were normal and there were no acute ischemic ECG
changes (stable Q waves with associated T wave inversions in the
precordial leads). With diuresis, bibasilar crackles improved
and his PND/orthopnea resolved. He was transitioned to oral
furosemide 20 mg prior to discharge, with close follow-up
scheduled with a ___ speaking cardiologist to see in the
outpatient setting, in ___ near the patient's home.
Medication adherence and the importance of taking these
medications was stressed with an interpreter. Additionally, the
importance of a low salt and low fat diet were stressed. He will
continue to require intensive education and close follow-up in
order to prevent morbidity associated with his heart failure
(and CAD). Medications to ___ manage his HFrEF that were
started at discharge include lisinopril 5 mg daily and
metoprolol succinate 25 mg.
# CAD s/p CABG and PCI to LAD
Residual disease was noted after patient's most recent PCI in
___. Troponins and MB were negative and he had no evidence of
ongoing ischemia on his EKG. While his medication nonadherence
puts him at increased risk of repeat ACS, he does not have ACS
at this time. We restarted aspirin 81 mg and atorvastatin 80 mg,
in addition to the medications listed above. As mentioned above,
we recommend repeated education about the importance of
medications to prevent progression of his heart disease.
# Thrombocytopenia, coagulopathy
Mild thrombocytopenia (plts 146) and coagulopathy (INR 1.3) may
have been indicative of underlying hepatic synthetic
dysfunction. Recheck as outpatient.
# CODE STATUS: Full (presumed)
# CONTACT:
Name of health care proxy: ___
___: son
Cell phone: ___
Greater than 30 minutes spent on discharge planning. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower extremity swelling and pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o ___ female with a history of
hepatitis C with cirrhosis, pelvic lymphadenopathy resulting in
lower extremity edema with venous stasis ulcers and open wounds
who presented with worsening bilateral leg swelling and pain.
The patient had not received her home Lasix in the 4 days prior
to admission, as her typical ___ was on vacation, and she had
run out of her diuretics. The patient reported that her covering
___ did not know who to call to get a refill, so she went 4 days
without her diuretics. She states the pain in her bilateral
lower extremities was getting worse, and she decided to come to
the ED. She denied any fevers or chills, and no purulent
discharge from her lower extremity wounds. Her VNAs had been
changing her dressings and monitoring her wounds.
In the ED, initial VS were: Temp 99.7, BP 95/52, HR 90, RR 20,
SpO2 99% RA.
Her exam was significant for chronic venous stasis changes of
bilateral lower extremities, chronic healing ulcerations of the
shins, no active purulence or surrounding erythema very tender
to palpation, as well as elephantiasis.
Her labs were significant for a leukocytosis of 12.3,
thrombocytopenia of 113, Cr 1.6, elevated Tbili 2.7, AST 86, and
Alb 2.9. Her initial imaging was significant for no evidence of
DVT on bilateral ___ u/s and CXR with no acute cardiopulmonary
process. In the ED, she received 2 mg Lorazepam, and 4 mg
Morphine, as well as Ceftriazone 1 g IV x 1.
Transfer VS were: ___ pain, Temp 97.7, HR 75, BP 104/63, RR 18,
and SpO2 100% RA. On arrival to the floor, the patient reported
that her pain was significantly improved.
Past Medical History:
- Hepatitis C/cirrhosis with elevated AFP
- Generalized LAD and destructive lesion in spine at L2/L3 ->
although bipsies have been attempted, they have been
nondiagnostic. Had repeat torso CT on ___ (see imaging).
- HTN
- Venous stasis with ulcers
- Hyperlipidemia (pt denies)
- h/o opiate abuse (pain pills) in the past, on chronic
methadone
- h/o tobacco use, quit in ___
Social History:
___
Family History:
As Per OMR:
Mother- died of heart disease; had PVD as well
Father- died of prostate cancer
Brother with unknown type of cancer s/p surgery
Sister in good health
Physical Exam:
On admission:
Temp 97.9, BP 108/55, HR 67, RR 18, SpO2 96%RA
GENERAL: NAD, ___, laying in bed.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, nontender
supple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well. She has chronic venous
stasis changes in her lower extermtis bitlaterally. Mild warmth,
no erythema. She has several 5-7cm ulcers on her lower
extermities. The deepest of which is on the lefteral aspect of
her right leg. There is granualtion tissue present in all of the
ulcers. Tenderness to palpation over the distal feet
bilaterally.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused
On discharge:
VS - Tmax 98.6, Tcurr 98.1, BP 92/66 (81-120/41-76), HR 70
(58-99), RR 20 (___), SpO2 100% RA (99-100% RA)
I/O: 2947(320 since MN)/ 1325 (500 since MN)
GENERAL: NAD, pleasant, laying in bed.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, nontender
supple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs
LUNG: CTAB, slightly diminished breath sounds at the bases
bilaterally, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well. Reporting pain to
light touch bilaterally in the lower extremities. Chronic venous
stasis changes as well as lichenification present on her lower
extremities bilaterally, currently wrapped/ dressed with Kerlex.
No warmth, no erythema. Elephantiasis in appearance.
Several 5-7cm ulcers with granulation tissue on her lower
extremities, the deepest of which is on the lateral aspect of
her right leg. Tenderness to palpation over the distal feet
bilaterally.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused
Pertinent Results:
On admission:
___ 01:10PM BLOOD WBC-12.3*# RBC-3.92* Hgb-12.4 Hct-40.1
MCV-102* MCH-31.6 MCHC-30.8* RDW-15.3 Plt ___
___ 01:10PM BLOOD Neuts-82.3* Lymphs-12.8* Monos-4.1
Eos-0.7 Baso-0.1
___ 01:10PM BLOOD ___ PTT-40.9* ___
___ 01:10PM BLOOD Glucose-98 UreaN-27* Creat-1.6* Na-135
K-4.2 Cl-103 HCO3-25 AnGap-11
___ 01:10PM BLOOD ALT-38 AST-86* AlkPhos-80 TotBili-2.7*
___ 01:10PM BLOOD Lipase-24
___ 01:10PM BLOOD Albumin-2.9*
On discharge:
___ 05:00AM BLOOD WBC-4.6 RBC-3.35* Hgb-10.7* Hct-34.6*
MCV-103* MCH-31.9 MCHC-30.8* RDW-15.5 Plt ___
___ 05:00AM BLOOD Glucose-93 UreaN-25* Creat-1.3* Na-136
K-4.3 Cl-106 HCO3-26 AnGap-8
___ 05:00AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.2
Microbiology:
BLOOD CULTURE (___): Pending
URINE CULTURE (Final ___: NO GROWTH.
Imaging and other studies:
EKG (___): Sinus rhythm. Borderline left axis deviation.
Anterior Q waves and T wave inversions raise strong
consideration of underlying myocardial infarction in this
distribution. Compared to the previous tracing of ___ no
diagnostic change. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 170 94 424/443 14 -25 30
B/l lower extremity venous duplex (___):
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
CXR (___):
IMPRESSION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Felodipine 2.5 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Methadone 4 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Gabapentin 400 mg PO QAM
7. Gabapentin 800 mg PO HS
8. Gabapentin 400 mg PO DAILY AT 2PM
9. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Furosemide 40 mg PO DAILY
3. Gabapentin 400 mg PO QAM
4. Gabapentin 800 mg PO HS
5. Methadone 4 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Day 1 = ___ for a 10-day total course
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*17 Tablet Refills:*0
8. Gabapentin 400 mg PO DAILY AT 2PM
9. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
10. Outpatient Lab Work
Please check Chem10 on ___ and fax to Dr. ___
(Phone: ___, Fax: ___ for review.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Lower extremity edema in the setting of hepatitis C cirrhosis
and pelvic lymphadenopathy
Chronic venous stasis ulcers
Secondary:
HCV cirrhosis
History of opiate abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with b/l ___ edema after not taking lasix // eval
edema
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac silhouette is unremarkable. The aorta is
calcified and tortuous.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with leg pain, swelling // DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Bilateral lower extremity venous Doppler on ___.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. The calf veins are not
well visualized on either side.
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.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Leg swelling, Calf pain, ULCERS
Diagnosed with SWELLING OF LIMB
temperature: 99.7
heartrate: 90.0
resprate: 20.0
o2sat: 99.0
sbp: 95.0
dbp: 52.0
level of pain: 10
level of acuity: 3.0 | ___ ___ female with history of hepatitis C
with cirrhosis, pelvic lymphadenopathy, resulting in lower
extremity edema with venous stasis ulcers and open wounds who
presents with bilateral leg swelling and pain. Subjective
improvement in edema and pain since admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
contrast dye / morphine
Attending: ___.
Chief Complaint:
Deep vein thrombosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with PMH significant for
hepatitis C and EtOH cirrhosis with ___ s/p uncomplicated DCD
liver transplant on ___ who presents with concern for DVT.
Patient previously presented ___ with from pulmonary
clinic
with worsened PFTs, negative on CT for DVT/PE and negative on
___ ultrasound on that admission.
Of note, patient states he does have a history of DVT in the
RLE,
___, for which he was on warfarin for 3 months. No family
history of DVT/PE. Per patient, there were no circumstances to
provoke that episode of DVT.
Patient now presents with left calf pain, especially with
exertion, since morning of ___, which worsened this
morning. He called the office and reported his symptoms at
which
time he was told to present to the radiology department for DVT
scan. Patient was found to have LLE peroneal DVT.
Patient states he has had mild SOB and mild right-sided
pleuritic
chest pain since the time of his surgery which has not
substantially worsened. Denies any other symptoms.
He now presents to the ED with plan for admission and systemic
anticoagulation.
Past Medical History:
- Depression.
- History of cardiac arrest in the setting of heroin overdose,
___
- Pseudogout.
- History of crushed vertebrae in ___ with chronic low back
pain for which he is on OxyContin.
- COPD per his PCP notes, with over 40+ pack year smoking
history.
- Left hip joint issues undergoing corticosteroid injections.
- Restless legs syndrome.
- HCV reportedly treated with peginterferon, ribavirin, and
possibly telaprevir (?) completed ___ and achieved SVR
- Prior IVDU
- Prior EtOH abuse, sober x ___ years
- Cirrhosis (EtOH, HCV)
- HCC
- ORIF maxilla
- Active ___ use up to six weeks ago
- Torn meniscus s/p repair ___
- DCD liver transplant ___
Social History:
___
Family History:
1) Mother deceased at age ___, history of diabetes mellitus.
2) Father alive, history of CHF.
3) No known history of liver disease, liver cancer.
Physical Exam:
Admission exam
VS: 96.8 64 ___ 99% RA
Gen: NAD, AAOx3, pleasant
HEENT: No scleral icterus, PERRL, EOMI, CN II-XII grossly
intact.
CV: RRR no m/r/g
Pulm: CTAB no w/r/r
Abd: Soft, NT/ND, +BS. Right subcostal incision for liver
transplant with staples in place, C/D/I.
Ext: WWP. Left calf is mildly tender to palpation.
Bilaterally
equal leg circumferences. No phlegmasia nor other
discoloration.
No edema. Palpable DP and ___ pulses bilaterally.
Pertinent Results:
___ 05:50AM BLOOD WBC-8.6 RBC-3.94* Hgb-12.1* Hct-37.7*
MCV-96 MCH-30.7 MCHC-32.1 RDW-13.9 RDWSD-48.5* Plt ___
___ 05:35AM BLOOD ___ PTT-70.9* ___
___ 05:50AM BLOOD Glucose-109* UreaN-16 Creat-0.7 Na-136
K-4.7 Cl-97 HCO3-29 AnGap-15
___ 05:50AM BLOOD ALT-35 AST-19 AlkPhos-119 TotBili-0.3
___ 06:06PM BLOOD Lipase-29
___ 09:27AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:50AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.5*
___ 05:35AM BLOOD tacroFK-12.0
___ Duplex US
IMPRESSION:
Acute appearing left peroneal vein DVT.
___ CXR
IMPRESSION:
No acute pulmonary process identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q ___ HOURS shortness of
breath, wheeze
2. ALPRAZolam 2 mg PO QHS
3. Fluconazole 400 mg PO Q24H
4. Metoprolol Tartrate 12.5 mg PO BID
5. Mycophenolate Mofetil 1000 mg PO BID
6. Omeprazole 20 mg PO BID
7. PredniSONE 15 mg PO DAILY
8. Sodium Polystyrene Sulfonate 15 gm PO ASDIR Hyperkalemia
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 3 mg PO Q12H
11. Tamsulosin 0.4 mg PO QHS
12. Tiotropium Bromide 1 CAP IH DAILY
13. ValGANCIclovir 900 mg PO Q24H
14. Venlafaxine XR 75 mg PO DAILY
15. Acetaminophen 500 mg PO Q6H:PRN pain
16. Vitamin D ___ UNIT PO DAILY
17. Docusate Sodium 100 mg PO BID
18. Senna 8.6 mg PO BID:PRN constipation
19. Simethicone 40-80 mg PO TID:PRN gas/bloating
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q ___ HOURS shortness of
breath, wheeze
2. ALPRAZolam 2 mg PO QHS
3. Docusate Sodium 100 mg PO BID
4. Fluconazole 400 mg PO Q24H
5. Metoprolol Tartrate 12.5 mg PO BID
6. Mycophenolate Mofetil 1000 mg PO BID
7. Omeprazole 20 mg PO BID
8. PredniSONE 15 mg PO DAILY
Follow prescribed taper
9. Senna 8.6 mg PO BID:PRN constipation
10. Simethicone 40-80 mg PO TID:PRN gas/bloating
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. ValGANCIclovir 900 mg PO Q24H
15. Venlafaxine XR 75 mg PO DAILY
16. Warfarin 4 mg PO DAILY
Adjust per INR
RX *warfarin 1 mg 4 tablet(s) by mouth Daily Disp #*120 Tablet
Refills:*5
17. Acetaminophen 500 mg PO Q6H:PRN pain
Maximum 4 tablets daily
18. Sodium Polystyrene Sulfonate 15 gm PO ASDIR Hyperkalemia
19. Vitamin D ___ UNIT PO DAILY
20. Enoxaparin Sodium 90 mg SC Q12H
Start: Today - ___, First Dose: First Routine
Administration Time
Expel 0.1 ml to make 90 mcg dose
RX *enoxaparin 100 mg/mL 90 mcg SC twice a day Disp #*10 Syringe
Refills:*1
21. Tacrolimus 1.5 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
___:
Left leg Peroneal Vein DVT
Recent history liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with left calf pain for ___ days. Pt is 20 days
sp liver transplant. Please eval for DVT // pt is c/o left calf pain. Please
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 on the right.
On the left there is non-compressability of the peroneal veins with complete
obstruction by color doppler. The left ___ veins are patent.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
Acute appearing left peroneal vein DVT.
NOTIFICATION: ___ and ___ notified of prelim results. Patient
sent to Dr. ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with DVT in LLE // Pt with new onset chest pain
COMPARISON: CHEST X-RAY FROM ___ AT 15 19 AND TARGETED REVIEW OF
CHEST CTA FROM ___
FINDINGS:
Compared with ___, I doubt significant interval change.
The cardiomediastinal silhouette is within normal limits. No CHF, focal
infiltrate, effusion, or pneumothorax is detected. Minimal linear atelectasis
is noted at the left lung base.
No free air seen beneath the diaphragms. No rib fracture is identified on
these lung technique films.
IMPRESSION:
No acute pulmonary process identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DVT
Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY
temperature: 96.8
heartrate: 64.0
resprate: 18.0
o2sat: 99.0
sbp: 112.0
dbp: 75.0
level of pain: 7
level of acuity: 2.0 | Briefly, Mr. ___ presented to the ___ after developing
left calf pain on the morning of ___. He called the
transplant surgery clinic, described his symptoms, and presented
to the ___ Radiology department on ___, where a lower
extremity ultrasound showed a peroneal vein DVT. He then went to
the Emergency Department, placed on a heparin drip, and was
admitted to the transplant surgery service for anticoagulation.
His home medications, including immunosuppression, were
continued.
On HD 2, his ptt varied and his heparin rate was adjusted
accordingly. Since it was POD 21, the staples on his incision
were removed as well. He did well and continued to have mild
tenderness to palapation in the left lower extremity.
On HD 3, his tacrolimus level was noted to be supratherapeutic,
and his dose was reduced and one dose was held. He was started
warfarin at this time as well.
On HD 4, his tacrolimus level had normalized and his exam was
unchanged. He had a brief episode of chest pain which he
reported on morning round. An ECG was normal and showed no
ischemic change, a CXR was normal, and cardiac enzymes were
negative. He was discharged in good condition with home ___,
PCP, and transplant clinic follow up on warfarin and enoxaparin
as an anticoagulation bridge until his INR rises into he
therapeutic range. He received his first enoxaparin dose while
at ___. His tacrolimus dose on discharge was 1.5mg BID, other
medication dosages were unchanged. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Bactrim / latex / Novocain / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Right hip pain/fracture
Major Surgical or Invasive Procedure:
Right trochanteric fixation nail
History of Present Illness:
Patient is an ___ yo F who had a mechanical fall at home today
landing directly on her right hip. She did not hit her head,
lose consciousness, or injury herself in any other way. She
denies pain in any of her other extremities. She was a bit dizzy
immediately after it happened when she had to squirm across the
floor to get to her phone. This issue has since resolved. She
is a bit nauseous at this time after some pain medication. She
has noticed a sensation of numbness in her foot after lying here
in bed in the ED for several hours.
Past Medical History:
___ Disease
Hypertension
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on admission:
Right lower extremity:
- Skin intact
- Limb shortened and externally rotated.
- Some spasm in right thigh, but muscular rigidity in
contralateraly thigh as well. Moderately tense to palpation.
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions. Does report a
sensation of tingling diffusely in the foot. This resolved with
repositioning.
- 1+ ___ pulses, foot warm and well-perfused
Exam on discharge:
NAD, A+Ox3
Right Lower Extremity:
Right lower extremity fires ___ (___)
Right lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Right lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
___ 04:25AM BLOOD WBC-7.0 RBC-3.28* Hgb-10.0* Hct-30.2*
MCV-92 MCH-30.5 MCHC-33.1 RDW-14.6 RDWSD-49.7* Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 0.25 TAB PO 6X/DAY
2. Rasagiline 1 mg PO DAILY
3. Atenolol 12.5 mg PO DAILY
4. Lorazepam 0.5 mg PO QHS:PRN sleep
5. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS
6. Requip XL (rOPINIRole) 8 mg oral DAILY
7. ___ Other See additional instructions
Discharge Medications:
1. Atenolol 12.5 mg PO DAILY
2. Carbidopa-Levodopa (___) 0.25 TAB PO 6X/DAY
3. Lorazepam 0.5 mg PO QHS:PRN sleep
4. Rasagiline 1 mg PO DAILY
5. Requip XL (rOPINIRole) 8 mg oral DAILY
6. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS
7. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth q6hrs Disp #*60
Tablet Refills:*0
8. Enoxaparin Sodium 30 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 30 mg SC every night Disp #*30
Syringe Refills:*0
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth q4hrs Disp
#*100 Tablet Refills:*0
10. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
12. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
13. Milk of Magnesia 30 ml PO PRN Constipation
14. ___ Other See additional instructions
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right Intertrochanteric hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with mechanical fall and right hip fx. // injury?
injury?
TECHNIQUE: Right knee, 4 views.
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen about the knee. There is no joint
effusion. Degenerative changes with chondrocalcinosis is seen in the medial
and lateral compartments.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R.
INDICATION: RT HIP FX.ORIF
IMPRESSION:
Images from the operating suite show placement of a fixation device about a
fracture of the proximal right femur. Further information can be gathered
from the operative report.
Radiology Report
EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) RIGHT
INDICATION: ___ year old woman with calf swelling and pain.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial veins. Normal color flow is
demonstrated in the peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
Edema is seen in the right calf.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with INTERTROCHANTERIC FX-CL, OTHER FALL, PARKINSON'S DISEASE, HYPERTENSION NOS
temperature: 98.0
heartrate: 78.0
resprate: 18.0
o2sat: 97.0
sbp: 141.0
dbp: 75.0
level of pain: 4
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right intertrochangeric hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right trochanteric femoral nail,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right 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: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abnormal MRI
Major Surgical or Invasive Procedure:
Lumbar Puncture ___
History of Present Illness:
Ms. ___ is a generally healthy ___ F w PMHx of HTN, HLD,
and hypothyroidism who presents to ___ ED with 1 week of
progressive left facial numbness. She was sent into the ED after
an MRI yesterday revealed enhancement of the left trigeminal
root with subtly increased FLAIR hyperintense signal.
Ms. ___ reports that her symptoms began with numbness around
one of her upper molars. She reports that she has implants and
has had issues with infection in the past, so she figured that
was the cause of her symptoms. Over the next several days,
though, her numbness progressed to include the entire inside of
the mouth, the left side of the tongue, and the entire left face
(relatively sparing the ear). She could not get an appointment
over the weekend, but managed to see her dentist on ___. He
took xrays and referred her to a different dentist, but Ms.
___
opted to follow up with her PCP. She saw her PCP on ___ and
an MRI was scheduled for ___. That MRI reported:
"Enhancement of the left trigeminal root entry zone with
suggestion subtly increased FLAIR hyperintense signal. This may
represent inflammatory/demyelinating process, granulomas disease
such as sarcoid or potentially schwannoma, although this is
considered less likely given lack of mass-like appearance. FLAIR
hyperintense enhancing marrow lesion of the left parietal skull,
which may represent an osseous hemangioma." After the report
returned, Ms. ___ states that she was told to come to the
emergency room for urgent neurological evaluation.
On interview this evening, she endorses persistent sensory
symptoms most notably over her tongue, inside of her mouth, left
side of lips. She states that the feeling is similar to
"novacaine." She does report that at times the entire L side of
the scalp has felt numb as well. She reports that she "cannot
taste foods" and chews on the right side of her mouth. She has
very rarely had food dribble out of the left corner of the
mouth.
She denies new blurry vision, though has had some blurriness
from
"rough corneas" for several months. She denies any double
vision,
overt difficulty chewing, facial droop, dysphagia, dysarthria,
eye pain. She denies SOB, fever, weight loss, cough, HA,
weakness, or other numbness.
Past Medical History:
- HTN
- HLD
- hypothyroidism
- polpectomy ___ years ago
Social History:
___
Family History:
- CHF
- Father - CHF, deceased in ___
- no known history of autoimmune conditions
Physical Exam:
Admission Exam
VS T97.5 HR105 RR18 BP143/84 Sat98RA
GEN - well developed, well appearing elderly F, NAD
HEENT - NC/AT, MMM
NECK - age appropriate restricted ROM
CV - mildly tachycardic
RESP - normal WOB
ABD - soft, NT, ND
EXTR - atraumatic, WWP
NEUROLOGICAL EXAMINATION
- Mental Status -
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling months
backwards. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No dysarthria. No apraxia. No evidence of hemineglect.
No left-right agnosia.
- Cranial Nerves -
II. Equal and reactive pupils (4mm to ___. Visual fields were
full to finger counting.
III, IV, VI. Smooth and full extraocular movements without
diplopia or nystagmus.
V. Reports decreased facial sensation to LT only most pronounced
over V2, mildly decreased sensation over V1 and V2. Reports
essentially intact facial sensation to temperature and PP.
VII. Face was symmetric with full strength of facial muscles.
VIII. Hearing was intact to voice.
IX, X. Symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Bulk and tone were normal. No pronation, no drift. No tremor or
asterixis.
Delt Bic Tri ECR IO IP Quad Ham TA Gas ___
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Intact to light touch and pin-prick throughout. On my
examination, reports intact sensation of the L pinna and L
scalp.
- DTRs -
Bic Tri ___ Quad Gastroc
L 3 3 3 3 0
R 3 3 3 3 0
Plantar response flexor bilaterally.
+Pectoralis jerks bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. Good speed
and intact cadence with rapid alternating movements. Negative
Romberg.
- Gait -
Normal initiation. Narrow base. Normal stride length and arm
swing. Stable without sway.
=======================
Discharge Exam:
As above, except with intact sensation in face to LT, cold and
pp.
Pertinent Results:
___ 05:42AM BLOOD WBC-5.3 RBC-4.58 Hgb-13.4 Hct-42.4 MCV-93
MCH-29.3 MCHC-31.6* RDW-13.5 RDWSD-45.2 Plt ___
___ 04:35PM BLOOD WBC-6.8 RBC-5.31* Hgb-15.6 Hct-47.3*
MCV-89 MCH-29.4 MCHC-33.0 RDW-13.3 RDWSD-43.4 Plt ___
___ 05:42AM BLOOD Neuts-54.3 ___ Monos-13.7*
Eos-11.0* Baso-0.9 Im ___ AbsNeut-2.90 AbsLymp-1.05*
AbsMono-0.73 AbsEos-0.59* AbsBaso-0.05
___ 04:35PM BLOOD Neuts-59.0 ___ Monos-13.6*
Eos-7.2* Baso-0.7 Im ___ AbsNeut-4.02 AbsLymp-1.30
AbsMono-0.93* AbsEos-0.49 AbsBaso-0.05
___ 05:42AM BLOOD Plt ___
___ 05:42AM BLOOD ___ PTT-31.8 ___
___ 04:35PM BLOOD Plt ___
___ 05:42AM BLOOD Glucose-100 UreaN-23* Creat-0.8 Na-139
K-3.3 Cl-103 HCO3-26 AnGap-13
___ 04:35PM BLOOD Glucose-102* UreaN-23* Creat-1.1 Na-139
K-3.8 Cl-99 HCO3-28 AnGap-16
___ 05:42AM BLOOD ALT-19 AST-20 LD(LDH)-172 AlkPhos-60
TotBili-0.4
___ 05:42AM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.1# Mg-2.1
___ 05:42AM BLOOD 25VitD-24*
___ 12:55PM BLOOD ___
___ 04:35PM BLOOD CRP-6.7*
___ 12:55PM BLOOD RO & ___
___ 05:42AM BLOOD ANGIOTENSIN 1 - CONVERTING ___
___ 08:22PM BLOOD SED RATE-Test
___ 03:29PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
___ ___ 03:29PM CEREBROSPINAL FLUID (CSF) TotProt-38 Glucose-66
___ 3:29 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
Enterovirus Culture (Preliminary): No Enterovirus
isolated.
___ 03:29PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA
(PCR)-Test
___ 03:29PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
___ 03:29PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS DNA,
QUALITATIVE, PCR-Test
___ 03:29PM CEREBROSPINAL FLUID (CSF) ___ VIRUS,
QUAL TO QUANT, PCR-Test Name
___ 12:55 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ 12:55 pm SEROLOGY/BLOOD
**FINAL REPORT ___
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burg___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
___ weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY, EXCEPT ___
2. Amlodipine 10 mg PO DAILY
3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QHS
6. FoLIC Acid ___ mcg PO DAILY
7. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
8. Psyllium Powder Dose is Unknown PO Frequency is Unknown
9. Diazepam 5 mg PO PRN sleep
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QHS
4. FoLIC Acid ___ mcg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY, EXCEPT ___
6. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
7. Diazepam 5 mg PO PRN sleep
8. Calcium Carbonate 500 mg PO Frequency is Unknown
9. Psyllium Powder 1 PKT PO Frequency is Unknown
Discharge Disposition:
Home
Discharge Diagnosis:
Resolving Inflammation of Trigeminal Nerve
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with trigeminal root enhancement // ?
Sarcoidosis ? Sarcoidosis
COMPARISON: There are no prior chest radiographs available. Read in
conjunction with torso CT images of the chest ___.
IMPRESSION:
Lungs are fully expanded and clear. Heart size is normal. Hilar and
mediastinal contours are normal. There is no evidence of central lymph node
enlargement.
Moderate aortic valvular calcification present on the torso CT ___
are not detectable on the conventional chest radiograph.
RECOMMENDATION(S): Clinical evaluation for aortic valvular function.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Facial numbness, L Numbness
Diagnosed with Anesthesia of skin
temperature: nan
heartrate: 105.0
resprate: 18.0
o2sat: 98.0
sbp: 145.0
dbp: 84.0
level of pain: 0
level of acuity: 3.0 | She was admitted to Neurology for enhancement of Trigeminal
nerve root seen on MRI. The differential was broad including
infectious, inflammatory and malignant. Inflammatory markers
were negative. She had a lumbar puncture, and CSF was
noninflammatory with pending cytology. Her exam improved in the
hospital.It was determined that she Likely had a Resolving
inflammation of Trigeminal nerve. She was discharged home.
Transitional Issues:
- follow up pending labs:
Labs
___ 05:42 VITAMIN D
___ 12:55 ___
___ 15:29 CELL COUNT & DIFF (cerebrospinal fluid (csf))
Send Outs
___ 15:29 VARICELLA DNA (PCR) (cerebrospinal fluid (csf))
___ 15:29 HERPES SIMPLEX VIRUS PCR (cerebrospinal fluid
(csf))
___ 15:29 CYTOMEGALOVIRUS DNA, QUALITATIVE, PCR
(cerebrospinal fluid (csf))
___ 15:29 CSF HOLD (cerebrospinal fluid (csf))
___ 15:29 ___ VIRUS, QUAL TO QUANT, PCR
(cerebrospinal fluid (csf))
___ 12:55 RO & LA
___ 05:42 ANGIOTENSIN 1 - CONVERTING ___
Microbiology
___ 15:53 CSF;SPINAL FLUID GRAM STAIN; FLUID CULTURE; ACID
FAST CULTURE; VIRAL CULTURE
___ 13:21 SEROLOGY/BLOOD LYME SEROLOGY
___ 13:21 SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Betadine Spray / Nitroglycerin Transdermal / Gabapentin /
Cilostazol / Colestipol / Metoclopramide / Abilify
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx of DM1, CAD ___ CABG, PVD, HTN, ESRD ___ transplant on
tacro, azo and prednisone presenting from rehab with worsening
AMS. She was discharged from ___ on ___ for urosepsis, ___,
and toxic/metabolic encephalopathy. Has PICC for ceftriaxone for
10 days course of ceftriaxone (last ___. She has had
hallucinations and worsening confusion since ___, as
well as new agitation and refusing to take medications. Hx of
falls but denies recent falls. There is no history of fever,
chills, cough, n/v/d/c, urinary symptoms.
Per pt's husband by bedside, pt has been having poor po intake
at the rehab. She has not slept x1-2 nights. Per NH report,
husband insisted on ___ and she received a dose the night
before admission with poor response. She also received trazadone
with poor effect. He insists on sleep medication to help her
sleep as he thinks insomnia has made her agitation worse.
Sedating meds including azepam, zolpidem, and oxycodone were
discontinued on last admission.
In the ED initial vitals were: 98.9 91 122/73 18 100% RA
- Labs were significant for Na 127, Cr 1.4 (baseline 0.8-1.0).
UA clean. CXR and NCHCT negative for any acute processes.
- Patient was given 1L NS and ziprexa IM 5mg x4.
Vitals prior to transfer were: 98.0 95 138/81 18 96% RA
On the floor, VS are: 98.1 153/87 95 20 100% on RA. Pt is
agitated and restrained. A&Ox0. Husband by bedside. Unable to
answer questions and follow commands.
Past Medical History:
PAST MEDICAL HISTORY:
1. Type 1 diabetes since age ___. ___ pancreas transplant, ___
___ in ___ ___. Multiple complications include
nephropathy, retinopathy, polyneuropathy and gastroperesis.
2. End-stage renal disease: ___ repeat kidney transplants in
___ and ___ respectively. Now on tacrolimus.
3. CAD ___ CABGx2 LIMA-LAD,SVG-PDA ___. Last echo EF 55%;
normal valves (___).
4. Hypertension.
5. Toxic megacolon in ___, status post colectomy with ileostomy
reversal in ___.
6. Esophageal candidiasis (___).
7. Reported hypertensive encephalopathy with brief episodes of
confusion. Evaluated ___ by neurologist. MRiI revealed
changes (per ___ " consistent with vasculopathy associated
with cardiovascular pathology, hypertension, and additional
associated comorbidities. Findings are less suggestive of
cerebral amyloid angiopathy.")
8. Attention and executive function difficulties reported in
neuropsych report ___.
8. Legally blind in right eye secondary to retinopathy and
retinal detachment, limited vision in left eye. She does not
drive.
9. Depression.
10. Asthma - last PFTs (___): FVC 2.57 (75% pred), FEV1 2.10
(81% pred), MMF 2.14 (73% pred), FEV1/FVC 82 (108% pred)
11. ___ iliostomies for multiple repeated small bowel
obstructions.
12. Appendectomy.
13. VRE peritonitis in ___. Maintains contact precautions
secondary to this and her relative immunosuppression.
14. osteopenia.
15. zoster.
16. left popliteal angioplasty ___.
17. ulceration first MTP bilaterally, status post debridement
in ___.
18. bilaterally pseudophakic, vitrectomy.
19. ventral hernia.
20. left hip fracture - no surgery, underwent rehabilitation.
PAST SURGICAL HISTORY:
___ ORIF L ankle fracture ___
___ angioplasty of left popliteal artery ___
___ angioplasty of her below-knee popliteal artery and posterior
tibial artery on ___ for gangrenous ulcers of her left
foot.
___ angioplasty of proximal anastomosis of vein bypass graft
___ Right below-knee popliteal to distal peroneal bypass graft
with reversed saphenous vein graft ___
___ CABGx2 LIMA-LAD,SVG-PDA ___
___ Simultaneous Kidney Pancreas ___ ___
___ Tx nephrectomy ___
___ subtotal colectomy with ileostomy for toxic megacolon ___
failed renal transplant secondary to renal torsion, ___
___ CRT ___
___ ex lap, LOA, resection of ileorectal anastomosis and
ileoileostomy ___
___ lap PD cath placement ___
___ removal of PD catheter ___
___ ex lap w revision of ileostomy ___
___ parastomal hernia repair ___
___ Cysto for removal of ureteral stent,
___ multiple RIJ and tunnel catheters for HD
___ CRT #3 ___
___ right hand ORIF
Social History:
___
Family History:
Adopted, unknown
Physical Exam:
ADMIT PHYSICAL EXAM
Vitals - 98.9 91 122/73 18 100% RA
GENERAL: significant facial bruising that is old from fall on
___, pt agitated and restrained, unable to answer questions
and follow commands, speech content not understandable, AXOx0
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, holosystolic murmur best heard in the left
sternal border
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: echymosis, no edema
PULSES: 2+ DP pulses bilaterally
NEURO: AOx0
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals 97.7 ___ 98 I/O 1320/BR
GENERAL: speaknig calmly, no acute distress
HEENT: AT/NC
NECK: nontender supple neck, no LAD,
CARDIAC: RRR, S1/S2,
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
GU: Miconazole cream on labia, no erythema
EXTREMITIES: echymosis, no edema, no joint tenderness
NEURO: AAO3
SKIN: small calluses on balls of the feet
Pertinent Results:
___ 09:50AM BLOOD WBC-4.5 RBC-3.48* Hgb-12.1 Hct-36.2
MCV-104* MCH-34.6* MCHC-33.3 RDW-13.6 Plt ___
___ 05:15AM BLOOD WBC-6.1 RBC-3.75* Hgb-12.5 Hct-39.7
MCV-106* MCH-33.3* MCHC-31.5 RDW-13.7 Plt ___
___ 09:50AM BLOOD Glucose-104* UreaN-8 Creat-1.4* Na-127*
K-4.0 Cl-94* HCO3-25 AnGap-12
___ 05:15AM BLOOD Glucose-108* UreaN-7 Creat-1.0 Na-140
K-3.9 Cl-106 HCO3-21* AnGap-17
___ 09:50AM BLOOD ALT-10 AST-22 LD(LDH)-209 AlkPhos-80
TotBili-0.5
___ 09:50AM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.7 Mg-1.2*
___ 05:15AM BLOOD Calcium-9.7 Phos-3.3 Mg-1.4*
___ 10:44AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 9:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Azathioprine 50 mg PO DAILY
4. Calcium Carbonate 750 mg PO QID:PRN dyspepsia
5. Desipramine 300 mg PO QHS
6. Famotidine 20 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Sodium Bicarbonate 650 mg PO BID
10. Tacrolimus 2.5 mg PO Q12H
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
13. Alendronate Sodium 70 mg PO QMON
14. azelastine 137 mcg nasal BID runny nose
15. Bacitracin Ointment 1 Appl TP DAILY
16. econazole 1 % topical BID
17. Fluticasone Propionate NASAL 1 SPRY NU DAILY
18. Hydrocortisone Cream 2.5% 1 Appl TP TID
19. Multivitamins W/minerals 1 TAB PO DAILY
20. Clotrimazole 1 TROC PO 5X/DAY thrush
21. Fluticasone Propionate 110mcg 4 PUFF IH TID
22. ipratropium bromide 0.03% nasal BID prn runny nose
23. Tears Pure (dextran 70-hypromellose) 1 drop each eye
ophthalmic ___ x per day dry eyes
24. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
3. Alendronate Sodium 70 mg PO QMON
4. Aspirin 325 mg PO DAILY
5. Azathioprine 50 mg PO DAILY
6. Calcium Carbonate 750 mg PO QID:PRN dyspepsia
7. FoLIC Acid 1 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. PredniSONE 5 mg PO DAILY
11. Sodium Bicarbonate 650 mg PO BID
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus Suspension 1 mg PO BID
14. Miconazole 2% Cream 1 Appl TP BID vaginal itch
15. Miconazole Nitrate Vag Cream 2% 1 Appl VG HS Duration: 7
Days
16. Nystatin Oral Suspension 5 mL PO TID
17. Fluticasone Propionate 110mcg 4 PUFF IH TID
18. Fluticasone Propionate NASAL 1 SPRY NU DAILY
19. ipratropium bromide 0.03% nasal BID prn runny nose
20. Tears Pure (dextran 70-hypromellose) 1 drop each eye
ophthalmic ___ x per day dry eyes
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metabolic Toxic Encephalopathy secondary to medications
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 (AP AND LAT)
INDICATION: ___ with AMS.
COMPARISON: ___.
FINDINGS:
AP upright and lateral views of the chest provided. Midline sternotomy wires
and mediastinal clips are again noted. Right upper extremity PICC line is
again seen with its tip in the expected location of the low SVC. Lung volumes
are low with mild left basilar platelike atelectasis. Tracheobronchial tree
calcification is noted. There is no focal consolidation, effusion, or
pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process
Radiology Report
INDICATION: ___ woman with altered mental status evaluate for
intracranial hemorrhage.
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 1472 mGy-cm
COMPARISON: Head CT ___.
FINDINGS:
There is no acute large territorial infarct, intracranial hemorrhage, edema,
or mass effect. Ventricles and sulci are prominent suggesting age related
involutional changes. Periventricular white matter hypodensities are likely
sequela of chronic small vessel ischemic disease. Again seen, is a chronic
left caudate lacune. The basal cisterns are patent and there is preservation
of gray-white matter differentiation.
There is no acute fracture. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. Left frontal scalp hematoma has
decreased in size from ___.
IMPRESSION:
No acute intracranial abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS , ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA, DIABETES UNCOMPL ADULT, KIDNEY TRANSPLANT STATUS
temperature: 98.9
heartrate: 91.0
resprate: 18.0
o2sat: 100.0
sbp: 122.0
dbp: 73.0
level of pain: nan
level of acuity: 2.0 | ___ hx of DM1, CAD ___ CABG, PVD, HTN, ESRD ___ transplant on
tacro, azo and prednisone was admitted from rehab for worsening
mental status.
#delerium: On arrival, patient was acutely confused, speaking
almost manically, and very tangential. After obtaining history
from the husband of a double dose of ___ and trazodone ___
insomnia, it was decided that this was likely toxic
encephalopathy. Neuro was initially consulted and they agreed
with the assessment of toxic encephalopathy and did not
recommend any imaging of the head. After 48 hours of witholding
any type of sedating types of medications, her mental status
improved significantly and she was AOx3 by the time of
discharge. She does have underlying dementia at baseline and
this does come out sporadically as confusion. During her stay
she had an episode of orthostasis where she got up and
collapsed. There was some concern for seizure activity, but 24
hour EEG was negative for seizure activity. She was discharged
to rehab with specific instructions not to administer any type
of benzodiazepines, ___, antihistamines or narcotics.
# h/o depression - on admission, pt was behaving manic, with
rapid speech and tangential thoughts, her tricyclics were
discontinued in this setting. she will need close follow up with
her outpatient psychiatrist.
Transitional Issue
==================
[ ] please check tacrolimus level before end of week to ensure
steady level
[ ] please ensure close psychiatry follow up
[ ] please do not administer benzos, ___, antihistamin or
narcotics as pt has poor underlying substrate
[ ] please encourage PO. pt had 1 episode of orthostatic
hypotension on initial admission. pt is stable on discharge with
no orthostasis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Confusion, urinary retention.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH possible panic disorder, uncontrolled HTN (non adherent
to meds) and acoustic neuroma s/p resection who presents with
confusion and was admitted to medicine for further workup.
In reviewing charts, pt had similar episode of
hypreligiosity/delirium in ___, albeit was also in the
setting of panic attacks and chest pain. Workup at the time was
negative (CT head, Psych evaluation, labs), so pt was given
ativan which reduced anxiety and was therefore discharged home.
Chest pain was investigated on later admissions w/ negtive
stress test, EKG, and TTE.
Family says pt was then "normal" for the months following, and
reported that the panic attacks completely disappeared in the
past ___ months. However, he has become increasingly apathetic,
not responding to the gifts his children get him during
holidays, and more forgetful (not remembering to attend appts he
has made). However, executive ability seems to remain intact as
still successful ___ (closed 3 deals in past ___
months).
2 days ago was in ___ visiting family members and wife noticed
that his behavior changed dramatically causing him to be
hyperreligious (quoting bible, and trying to convert strangers),
tearful (believing that a son had died which is false), and
difficult to redirect. However, was able to drive from ___ back
to ___, but it took him 12 hours to do so. Family then
brought pt for evaluation.
Of note, pt has not been compliant w/ HTN medications.
In the ED, initial vitals were: T97.9 BP188/101 HR100 RR20 SpO2
100%. ED staff reported tangential speech and hyperreligious
comments. A sitter was required as he was wandering into other
rooms. Labs were notable for normal CBC, electrolytes, and LFTs.
Urinalysis was negative for nitrites and leukocytes. VBG
7.36/43/33/25. Serum tox was negative. CT head and CXR were
unremarkable. Psychiatry was consulted and felt the paient had
no evidence of primary mood or psychotic disorder. The patient
was given 0.5mg PO ativan to little effect. Vitals prior to
transfer: HR89 BP163/108 RR20 100% RA.
Past Medical History:
- Hyperlipidemia
- Hyertension
- Anxiety, panic attacks
- Acoustic neuroma s/p surgical resection ___ years ago
- Benign prostatic hypertrophy
- Chronic sinusitis s/p nasal septoplasty
Social History:
___
Family History:
Positive for hypertension. No family history of diabetes, heart
disease or malignancies.
Physical Exam:
EXAM ON ADMISSION:
=====================
Vitals - 97.9 167/95 89 18 100% RA
GENERAL: AAOx1, NAD, responds appropriately to questions
intermittently but fluctuates between ___ and ___
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: good range of motion in neck, no stiffness
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: BS+, soft, nondistended, no ttp
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, aside from decreased hearing in R ear;
moving all 4 extremities with purpose; unable to recite months
backwards from ___ (___), tangential
thought, unable to focus on conversation, pacing around room the
entire time
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
EXAM ON DISCHARGE:
===================
Vitals - 98.7 (98.7) 131/70 (122-144/70-82) 67 (64-70) 16
99% RA
GENERAL: AAOx3, NAD, responds appropriately to questions
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: BS+, soft, nondistended, no ttp
EXTREMITIES: no cyanosis, clubbing or edema
NEURO: responding appropriately to questions, PERRLA
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION:
=====================
___ 09:15PM BLOOD WBC-7.3 RBC-4.65 Hgb-14.6 Hct-41.7 MCV-90
MCH-31.3 MCHC-35.0 RDW-14.6 Plt ___
___ 09:15PM BLOOD Neuts-72.3* ___ Monos-8.2 Eos-0.3
Baso-0.2
___ 09:15PM BLOOD Glucose-103* UreaN-19 Creat-1.0 Na-134
K-4.3 Cl-100 HCO3-23 AnGap-15
___ 09:15PM BLOOD ALT-21 AST-31 AlkPhos-79 TotBili-1.1
___ 09:15PM BLOOD Albumin-4.7
___ 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:25AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:25AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:25AM URINE RBC-6* WBC-8* Bacteri-NONE Yeast-NONE
Epi-0
___ 12:25AM URINE CastHy-3*
___ 12:25AM URINE Mucous-FEW
___ 12:25AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
LABS ON DISCHARGE:
=====================
___ 08:49AM BLOOD WBC-5.4 RBC-4.36* Hgb-13.7* Hct-40.1
MCV-92 MCH-31.5 MCHC-34.2 RDW-14.2 Plt ___
___ 08:49AM BLOOD Glucose-93 UreaN-18 Creat-0.9 Na-136
K-4.5 Cl-100 HCO3-28 AnGap-13
___ 08:49AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.3
MICROBIOLOGY:
=====================
___ 12:25 am URINE
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
RADIOLOGY:
=====================
CT HEAD W/O CONTRAST Study Date of ___ 10:53 ___
IMPRESSION:
Status post right suboccipital craniotomy. Otherwise normal
study.
CHEST (PA & LAT) Study Date of ___ 11:19 ___
IMPRESSION:
No acute cardiopulmonary process.
EEG Study Date of ___
IMPRESSION: This is a normal routine EEG in the awake and asleep
states.
Excessive diffuse beta activity can be a medication effect such
as from
benzodiazepines and barbiturates. No focal or epileptiform
features were
seen.
MR HEAD W & W/O CONTRAST Study Date of ___ 7:19 ___
IMPRESSION:
1. No evidence of an acute process or mass lesion.
2. Few foci of hemosiderin deposition within the posterior
fossa, consistent with postsurgical or post treatment change
related to given history of prior acoustic neuroma resection.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ with PMH significant for h/o anxiety and acoustic neuroma
s/p resection, who is fully functional at baseline, who presents with 2d hx of
confusion. Intermittently goes into 2-minute spells of hyper-religious chants.
// infarct? e/o seizure? encephalitis?
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 6cc 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: Noncontrast CT head ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, or infarction.
There are a few foci of hemosiderin deposition within the cerebellar
hemispheres and posterior fossa, probably due to postsurgical or post
treatment change due to the given clinical history of acoustic neuroma
resection. There is no abnormal enhancement after contrast administration. The
ventricles and sulci are normal in caliber and configuration.
Major intravascular flow voids are patent. There is normal enhancement of the
major intracranial arteries and dural venous sinuses following contrast
administration.
The paranasal sinuses and mastoid air cells appear clear. The orbits are
normal.
IMPRESSION:
1. No evidence of an acute process or mass lesion.
2. Few foci of hemosiderin deposition within the posterior fossa, consistent
with postsurgical or post treatment change related to given history of prior
acoustic neuroma resection.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Confusion
Diagnosed with ALTERED MENTAL STATUS
temperature: 97.9
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 188.0
dbp: 101.0
level of pain: 0
level of acuity: 2.0 | ___ PMH possible panic disorder, uncontrolled HTN (non adherent
to meds) and acoustic neuroma s/p resection who presented with
confusion and was admitted to medicine for further workup.
# Altered mental status: per family, patient's confusion began
within last 3d prior to admission. It is characterized by
hyperreligiousity, perseveration, and confusion. Very little
sleep (4 hours total in last 72 hours), grandiose thoughts, and
pressured speech. Medical workup including labs (CBC, chemistry,
LFTs, UA, serum tox, urine tox), CXR, and CT head have returned
negative. Neuro was consulted who rec'd EEG and MRI which were
both negative, and they felt presentation was more convincing
for primary mood disorder. Psychiatry was consulted but they
felt behavior was inconsistent with 1 primary disorder, and felt
it odd that it would have onset late in life. Pt was given
seroquel to help him sleep and mental status returned to
baseline as per family. However, he continued to have odd
behavior including grandiose thoughts (such as "curing ebola"),
that appeared consistent with mood disorder. That said,
psychiatry felt pt was not a risk to himself or others.
Accordingly, he was discharged home with PCP and psychiatry
follow up appointments. Seroquel was continued on discharge (in
lieu of lorazepam).
# Urinary retention: ___ BPH. PSA in ___ was 20.4. Biopsy in
___ was negative for malignancy. Per wife, the patient refused
surgery in the past. Tamsulosin was continued while in-house. Pt
was written for Finasteride, but noted that he does not take it.
Given urinary retention, would consider resumption of therapy at
next PCP ___.
# Hypertension: lisinopril was held temporarily due to soft
pressures, but restarted upon discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, left sided weakness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
The pt is a ___ year-old female w/ past medical history of atrial
fibrillation on coumadin, CHF w/ EF 55-60%, mitral regurgitation
s/p MV/TV annuloplasty, COPD, pHTN, DM, who presents with ICH
after fall when getting up from chair.
Patient reports that she was in her usual state of health last
evening, sitting in her chair, when she rose up to standing
position. She states her legs then "collapsed" on her and she
fell- she thinks maybe the left leg was weaker, as she fell on
her left side. She did not have loss of consciousness and does
not clearly recall hitting her head. She could not get up, and
so
called EMS who brought her to ___. Prior to the
fall, she has not experienced any focal weakness, sensory loss,
headache, dizziness, or visual disturbance.
At ___, she was given Lasix 60mg iv for volume overload.
She
was written for aspirin 325mg, but on documentation it appears
the order was canceled (this was unable to be confirmed) after a
noncontrast head CT showed intraparenchymal hemorrhage in the R
parietal lobe. She received 4 units of FFP and was subsequently
transferred here. She was found to be in rapid atrial
fibrillation with HR in 120s-130s despite treatment with po then
iv metoprolol. Patient reports no symptoms of this.
On neuro ROS, the pt endorses mild frontal headache which
started
while she was in the ED. She did not have a headache prior to
this. She also denies loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. She endorses weakness in her left leg. She
also endorses decreased sensation in both of her legs distally.
No bowel or bladder incontinence or retention. Denies difficulty
with gait.
On general review of systems, the pt denies recent fever or
chills. She does endorse mild URI that has been present for 2
weeks. Also endorses some dyspnea on exertion when climbing
stairs in her home. No night sweats or recent weight loss or
gain. 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:
Atrial Fibrillation (on Coumadin)
Mitral and Tricuspid Regurgitation s/p MV and TV annuloplasty in
___
Congestive heart failure (EF 55%)
Diabetes Mellitus
Hypertension
Hyperlipidemia
Hypothyroidism
?COPD
Colon Cancer s/p resection
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: T 99.0, HR 120-130s, BP 121/65, RR 18, 100% on 2L NC
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 with good air movement, few inspiratory
crackles
at bases.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
MS - Awake, alert, oriented x3. Attention to examiner easily
attained and maintained. Recalls a coherent history. Structure
of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No dysarthria. No apraxia. No evidence of hemineglect.
No left-right agnosia.
CN - [II] PERRL 4->2 brisk. VF full to number counting. [III,
IV,
VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light
touch
bilaterally. [VII] Left-sided nasolabial fold flattening. [VIII]
Hearing intact to voice. [IX, X] Palate elevation symmetric.
[XI] SCM/Trapezius
strength ___ bilaterally. [XII] Tongue midline with good ROM.
MOTOR - Normal bulk and tone. L-sided pronator drift.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 4 4 4 5 4+ 4+ 4+ 4 2+ 3
SENSORY - No deficits to light touch or pinprick throughout.
REFLEXES -
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 2 2 3 2
R 2 2 2 2 2
Plantar response flexor on R and extensor on L.
COORD - No dysmetria with finger to nose. Good speed and intact
cadence with rapid alternating movements. Negative Romberg.
GAIT - Moves from bed to chair with assistance. Unable to
ambulate due to left sided lower extremity weakness.
DISCHARGE EXAM:
Gen: NAD
CV: Afib
Pulm: breathing comfortably
Neuro: PERRL; ? L facial droop; brisk reflexes on L; movement to
gravity on L IP, no anti-gravity movement in L quad, TA or
gastroc; L delt and triceps ___ L arm drift without pronation
Pertinent Results:
ADMISSION LABS:
___ 04:10PM BLOOD WBC-11.4*# RBC-3.69* Hgb-11.1*# Hct-34.4
MCV-93 MCH-30.1 MCHC-32.3 RDW-14.7 RDWSD-50.2* Plt ___
___ 04:45AM BLOOD ___ PTT-28.3 ___
___ 04:45AM BLOOD Glucose-230* UreaN-17 Creat-0.8 Na-143
K-3.5 Cl-102 HCO3-26 AnGap-19
___ 04:45AM BLOOD ALT-20 AST-29 AlkPhos-71 TotBili-0.8
___ 04:10PM BLOOD Calcium-9.0 Phos-3.2
PERTINENT LABS:
___ 04:45AM BLOOD Cholest-176
___ 04:45AM BLOOD Triglyc-125 HDL-54 CHOL/HD-3.3 LDLcalc-97
___ 04:45AM BLOOD %HbA1c-6.8* eAG-148*
DISCHARGE LABS:
None
IMAGES:
___ CTA Head and Neck
1. The right superior parietal lobar hematoma has minimally
increased in size compared to the CT from approximately 8 hr
earlier, with stable mild
surrounding edema. No shift of midline structures or other
significant mass effect.
2. No evidence for an intracranial arteriovenous malformation or
aneurysm.
3. No significant abnormalities on neck CTA.
4. Partially visualized pleural effusions. Peribronchovascular
ground-glass and solid pulmonary opacities in the visualized
left upper lobe and possible peribronchovascular ground-glass
opacities in the visualized right upper lobe; evaluation is
limited by respiratory motion. These findings are compatible
with asymmetric pulmonary edema or pneumonia superimposed upon
pulmonary edema. Please correlate clinically.
5. Enlarged paratracheal lymph nodes may be reactive.
___ CXR
Bilateral perihilar densities could represent atelectasis or
pneumonia.
___ MRI Head
1. Incomplete MRI of the head due to patient intolerance
(claustrophobia). The patient may return for a repeat MRI when
she is better able to tolerate the examination.
2. Unchanged right superior parietal intraparenchymal hematoma.
___ MRI Head
GRE sequence without evidence of amyloid
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Furosemide 60 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Warfarin 2 mg PO EVERY OTHER DAY
7. Warfarin 3 mg PO EVERY OTHER DAY
8. Vitamin D ___ UNIT PO DAILY
9. Ranitidine 150 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO BID
Discharge Medications:
1. Furosemide 60 mg PO DAILY
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Pravastatin 40 mg PO QPM
4. Ranitidine 150 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Metoprolol Tartrate 100 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute hemorrhagic stroke
HTN
HLD
Atrial fibrillation
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: ___ year old woman with ICH // eval for pneumonia, other
abnormality
COMPARISON: ___
FINDINGS:
Semi upright view of the chest provided.
Bilateral perihilar densities are increased compared to prior. Pulmonary
edema is mild. Bilateral pleural effusions are small. There is no
pneumothorax. Left lung curvilinear scarring is similar to prior. Heart size
is enlarged, as on prior. . Aortic arch calcifications are seen. Sternal
wires are intact. 2 prosthetic valves are seen.
IMPRESSION:
Bilateral perihilar densities could represent atelectasis or pneumonia.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ year old woman with intracranial hemorrhage, transferred from
an outside hospital.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
4) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
5) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
6) Spiral Acquisition 5.3 s, 41.4 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,282.6 mGy-cm.
Total DLP (Head) = 2,210 mGy-cm.
COMPARISON: CT head ___ at 22:36.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Images are limited by motion artifact. The right superior parietal lobe
hematoma, centered in the post central gyrus, measures 3.1 x 2.6 cm in maximal
axial cross-section compared to 3.0 x 2.3 cm on the CT from approximately 8 hr
earlier. Mild surrounding edema and effacement of the adjacent sulci are
stable. There is no shift of midline structures or mass effect on the
ventricles. There is no new hemorrhage. Confluent hypodensity in the
periventricular, deep, and subcortical white matter of the cerebral
hemispheres is again seen, nonspecific but likely secondary to chronic small
vessel ischemic disease in this age group. Ventricles and sulci are
age-appropriate.
The left maxillary sinus contains a large mucous retention cyst. There is
minimal mucosal thickening in the right maxillary sinus. The mastoid air
cells may contain mild mucosal thickening. The patient is status post
bilateral cataract surgery.
CTA NECK:
There is a normal 3 vessel branching pattern of the aortic arch. There is
mild calcified plaque at the innominate, right subclavian, and left common
carotid artery origins, and mild mixed plaque at the left subclavian artery
origin, without flow-limiting stenosis. There is also calcified plaque in the
visualized proximal descending aorta. The common carotidand vertebral
arteries are patent with no evidence of stenosis or occlusion. There is mild
calcified plaque at the bilateral carotid bifurcations with no evidence of
internal carotid stenosis by NASCET criteria. Right common carotid and
proximal right internal carotid artery, as well as proximal/mid left common
carotid artery, are medialized with retropharyngeal courses.
CTA HEAD:
There are mild atherosclerotic calcifications of the bilateral cavernous and
supra clinoid internal carotid arteries, and of the intracranial right
vertebral artery, without flow-limiting stenosis. Other major intracranial
arteries appear patent without evidence for flow-limiting stenosis. There is
no evidence for an aneurysm or AV malformation. The major dural venous
sinuses are patent.
OTHER:
There is a partially visualized right pleural effusion and a large amount of
fluid in the right major fissure. There is a small amount of fluid in the
left major fissure. Small loculated pleural effusions with irregular margins
are noted in the left lung apex. Patchy, nodular solid and ground-glass
densities with peribronchovascular distribution in the left upper lobe. There
may also be patchy ground-glass opacity in the right upper lobe, but
evaluation is limited by respiratory motion artifact. Post median sternotomy
changes partially visualized. These findings are concordant with the
abnormalities on concurrent chest radiographs allowing for differences in
modality in patient position. There also enlarged paratracheal lymph nodes,
up to 1.8 cm in short axis diameter in image 3:15.
Thyroid gland is small and unremarkable in appearance. There is no cervical
lymphadenopathy by CT size criteria. There are multilevel degenerative
changes of the cervical spine.
IMPRESSION:
1. The right superior parietal lobar hematoma has minimally increased in size
compared to the CT from approximately 8 hr earlier, with stable mild
surrounding edema. No shift of midline structures or other significant mass
effect.
2. No evidence for an intracranial arteriovenous malformation or aneurysm.
3. No significant abnormalities on neck CTA.
4. Partially visualized pleural effusions. Peribronchovascular ground-glass
and solid pulmonary opacities in the visualized left upper lobe and possible
peribronchovascular ground-glass opacities in the visualized right upper lobe;
evaluation is limited by respiratory motion. These findings are compatible
with asymmetric pulmonary edema or pneumonia superimposed upon pulmonary
edema. Please correlate clinically.
5. Enlarged paratracheal lymph nodes may be reactive.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with intraparenchymal hemorrhage // evaluate
for etiology of bleed, including ischemic infarct w/ hemorrhagic conversion
vs. underlying mass lesion
TECHNIQUE: Sagittal T1, axial T1, and diffusion-weighted sequences of the
head were obtained. Due to claustrophobia, the patient was unable to tolerate
further sequences and the examination was terminated.
COMPARISON CT head ___. CTA head and neck ___.
FINDINGS:
Limited examination due to claustrophobia, the patient refused to continue
with the exam. The 3.0 x 2.5 cm right superior parietal intraparenchymal
hematoma is unchanged in size with surrounding edema and effacement of the
adjacent sulci. This hematoma demonstrates areas of slow diffusion.
There is no acute infarction.
The left maxillary sinus contains a large mucous retention cyst.
IMPRESSION:
1. Incomplete MRI of the head due to patient intolerance (claustrophobia).
The patient may return for a repeat MRI when she is better able to tolerate
the examination.
2. Unchanged right superior parietal intraparenchymal hematoma.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with IPH, ? amyloid // Pt aborted last MRI,
but willing to repeat shortened version. Team requesting GRE. If tolerated,
would also like a pre and post contrast
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9cc 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. The patient was unable to remain still throughout the study.
Image quality degrades as the study progressed those. All images are limited
by motion artifact. The MP rage images are nondiagnostic due to motion
artifact.
COMPARISON: Brain MRI ___
FINDINGS:
Again seen is a right parietal hematoma with substantial surrounding edema.
The gradient echo images are limited by motion artifact. However, there is no
evidence of hemorrhage elsewhere. There is extensive white matter
hyperintensity on the FLAIR images remote from the hematoma, thus not due to.
Focal edema. These findings are often attributed to chronic small vessel
disease.
There appears to be a small amount of contrast enhancement along the posterior
margin of the hematoma. At this stage after hemorrhage, a small amount of
enhancement would be expected. Note that the hematoma margin is somewhat
hyperintense on the precontrast T1 weighted images. Therefore it is possible
that the apparent contrast-enhancement is due to motion artifact. At this
stage after hemorrhage, a small amount of peripheral enhancement would be
expected as the reaction to the hematoma. Thus, this finding, if real, does
not necessarily indicate an underlying neoplasm as the cause of the
hemorrhage.
No other lesions are detected. There is no evidence of infarction.
IMPRESSION:
Limited study due to motion artifact. The hematoma described previously is
the only evidence of hemorrhage on this study. The this examination does not
demonstrate the multiple foci of hemorrhage typical of amyloid angiography.
There is questionable faint enhancement along the posterior margin of the
hematoma. As discussed above, this does not contribute to diagnosing the
etiology of the bleed.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, ICH
Diagnosed with Traum hemor cereb, w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: 98.0
heartrate: 110.0
resprate: 18.0
o2sat: 97.0
sbp: 157.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with a fib on Coumadin and
aspirin, s/p MV and TV annuloplasty in ___, HTN and DM who
presents after an episode of left-sided weakness and a fall and
was found to have a right superior parietal ICH. She also
presented in atrial fibrillation with rapid ventricular rate and
volume overload.
The patient initially presented to ___ where she
received Lasix, full dose aspirin and nitro ointment. She was
then found to have a R ICH on head CT, and received 4 units FFP
for reversal of Coumadin and transferred to ___ for further
management, INR decreased from 2.8 to 1.3.
#ICH: Patient found to have a right superior parietal hematoma
~3x2.5 cm, that was stable on repeat imaging. Her neurologic
deficits included left sided weakness in the upper and lower
extremity, hyperreflexia on the left side, and a left facial
droop. Mental status, language and sensory modalities were all
intact. The etiology of the bleed is unknown at this time and is
most likely secondary to hypertension, exacerbated by the
patient being on anti-coagulation (Coumadin). Other etiologies
could be occult neoplasm, occult cavernoma, or first time
amyloid angiopathy bleed. She is taking pravastatin for her HLD,
current LDL 97. She has diabetes, treated with diet control,
current A1c 6.8 and will need PCP ___. She is
taking metoprolol and Lasix for her blood pressure and heart
rate. She is a non-smoker.
Her Coumadin and aspirin were held. She was started on
sub-cutaneous heparin for anti-coagulation. An MRI repeated on
___ was negative for amyloid angiopathy. The risks and
benefits of restarting vs. discontinuing her Coumadin should be
weighed. Her CHADS2-Vasc score is 6, moderate-high, indicating a
9.7% stroke risk. Since she had an intraparenchymal cortical
hemorrhage in the setting of an INR that was only 2.8 (based on
this hemorrhage location in the cortical areas), she may have as
high as a 15% yearly risk of hemorrhage recurrence. As a result,
Coumadin is being held indefinitely. Aspirin should be restarted
on ___.
#Atrial Fibrillation with RVR: Patient presented in afib with
RVR as well as volume overload with pulmonary edema. She
received diltiazem and was then switched to metoprolol for rate
control. She remained in afib throughout the hospitalization,
with heart rates in the ___. She received furosemide for
diuresis to which she responded well and was discharged on her
home dose of 60mg daily.
#Bacteruria: Patient had a two UA with 157 WBCs and moderate
bacteria. The patient was started on Ceftriaxone 1gm IV daily.
Start date was ___. Urine culture grew mixed bacterial
flora, indicating contamination. Antibiotics were discontinued
___.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
___ w/ PMH of CAD s/p PCI x3, s/p off-pump CABG x3 ___
(___-->LAD, SVG -->diag, OM), type 2 DM on insulin, HTN,
hyperlipidemia presents with a 3 day history of ___ sharp,
left-sided chest pain and SOB. She describes the chest pain as
"pinching all the way down to the bone." She endorses ___
episodes of pain/day, always at rest. The episodes of pain last
approximately 5 minutes and are relieved by nitroglycerin. Her
pain is not worsened by exertion or eating. She described her
symptoms to her PCP over the phone, who told her to come to the
ED. She says they feel similar to her MI in the past. She also
endorsed vomiting last night. She denies any diaphoresis. She
also endorses a cough.
The patient has developed increased shortness of breath over the
past few days. She has experienced orthopnea for the past few
years, but denies PND and lower extremity edema. On exam in the
ED she was tachycardic, in a regular rhythm. Lungs were CTAB.
She had trace edema in her left lower extremity, none in her
right leg.
In the ED, initial vitals were 96.8 111 177/86 18 97%. Labs and
imaging significant for a CXR with new moderate left pleural
effusion with adjacent atelectasis in the left lung base, CBC
within normal limits, electrolytes within normal limits, Cr.
1.2, troponin 0.08 and D-dimer 2350. A CT of the chest was
performed, which showed no CT evidence for pulmonary embolus,
but small left pleural effusion with adjacent atelectasis.
Patient given aspirin 81mg x 4, SL nitroglycerin x 1 and heparin
bolus.
Vitals on transfer were 99.2 112 162/82 22 98% RA
On arrival to the floor, patient is AAOx3, and comfortable.
REVIEW OF SYSTEMS
On review of systems, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)HTN
2. CARDIAC HISTORY:
-Coronary artery disease
-Diastolic congestive heart failure
-CABG: CABG x 3 (Off pump coronary artery bypass graft x3, left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal, and obtuse marginal arteries)
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to proximal LAD
___, DES to mid LAD ___, DES to edge ISR of mid LAD DES and
stenosis distal to stent ___, DES to OM1, ___
-PACING/ICD:none
Morbid obesity.
COPD
GERD
Right rotator cuff injury/bursitis
Migraines
Depression
DJD
Hemorrhoids
Rosacea
Social History:
___
Family History:
She was a ward of the ___ and does not know her family.
Physical Exam:
Admission:
VS- T 99.4 BP 157/88 HR 118 RR 24 96% RA
GENERAL- WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple without JVP
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RRR Nl S1/S2. Midline scar from recent surgery C/D/I
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.
EXTREMITIES- No c/c/e.
Discharge:
Vitals: T:98.4 BP:151/90 P:86 R:20 O2:97 RA
I/O: Intake: 840 mL; Output: Voided x2 (not recorded)
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, dry mucous membranes,
OP clear, no JVP visualized
HEART - RRR, nl S1-S2, no MRG. Scar from recent surgery present
at midline. Wound is healing well, no tenderness along scar.
Slight erythema at base. A 2 cm area of newer scar is present
from previous debridement as reported per patinent.
LUNGS - Bibasilar crackles present at bases. No wheezes or
rhonci. Respirations unlabored.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission labs:
___ 03:45PM WBC-8.9 RBC-3.69* HGB-12.3 HCT-34.9* MCV-95
MCH-33.2* MCHC-35.1* RDW-13.1
___ 03:45PM NEUTS-67.9 ___ MONOS-5.5 EOS-2.6
BASOS-0.9
___ 03:45PM GLUCOSE-484* UREA N-16 CREAT-1.2* SODIUM-135
POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18
___ 04:25PM ___ PTT-27.8 ___
___ 03:45PM cTropnT-0.08*
___ 03:45PM CK(CPK)-51
___ 03:45PM D-DIMER-2350*
Pertinent labs:
___ 03:45PM BLOOD cTropnT-0.08*
___ 12:09AM BLOOD CK-MB-3 cTropnT-0.12*
___ 07:15AM BLOOD CK-MB-3 cTropnT-0.13*
Imaging/studies:
EKG on admission- Sinus tachycardia. Extensive ST segment
changes may be due to ischemia. Compared to the previous tracing
no change.
CXR ___- New moderate left pleural effusion with adjacent
atelectasis in the left lung base.
CTA Chest ___. No CT evidence for pulmonary embolus.
2. Small left pleural effusion with adjacent atelectasis.
3. Possible calcified splenic artery aneurysm in the region of
the hilum.
Cardiac catheterization ___. Selective coronary angiography of this right dominant system
demonstrated 2 vessel coronary disease in the native vessels.
The ___
had no angiographically apparent disease. The LAD had a 70%
lesion in a
prior stent, and a jailed diagnoal which was small and had poor
flow.
The LCx had a 70-80% stenosis at its origin. The RCA had no
angiographically apparent disease.
2. Arterial conduit angiography demonstrated the LIMA graft to
be
patent.
3. Venous conduit angiography demonstrated a patent SVG to OM
with
retrograde stenosis involving a small sub-branch of the OM. The
SVG to
small diagonal was presumed occluded and unable to be
identified.
4. Limited resting hemodynamics revealed systemic hypertension
with
aortic pressure of 184/105 mm Hg.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease in the native arteries
2. Patent LIMA to LAD, patent SVG to OM, occluded SVG to small
diagonal
branch.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Metoprolol Tartrate 25 mg PO TID
Hold for SBP <100, HR<60
7. Metrogel *NF* (metroNIDAZOLE) 0.75% Topical Daily
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN severe
pain
9. Pantoprazole 80 mg PO Q24H
10. Ropinirole 0.25 mg PO QPM
11. Aspirin 325 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Ibuprofen 600 mg PO Q6H:PRN pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Ropinirole 0.25 mg PO QPM
8. Vitamin D 1000 UNIT PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Metrogel *NF* (metroNIDAZOLE) 0.75% Topical Daily
11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN severe
pain
12. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Clopidogrel 75 mg PO DAILY
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
non-ST elevation MI
coronary artery disease
Secondary:
diabetes mellitus type 2
hypertension
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain.
COMPARISONS: ___.
FINDINGS: A moderate left pleural effusion is new since ___.
Associated left basilar opacity likely reflect compressive atelectasis. There
is no pneumothorax. There are no new abnormal cardiac or mediastinal contour.
Median sternotomy wires and mediastinal clips are in expected positions.
IMPRESSION: New moderate left pleural effusion with adjacent atelectasis in
the left lung base.
Radiology Report
INDICATION: ___ female with chest pain and elevated D-dimer.
___ and ___.
TECHNIQUE: Axial CT images through the chest were acquired after
administration of intravenous contrast. Coronal, sagittal, and bilateral
oblique maximum intensity projection reformatted images were created and
reviewed.
FINDINGS: Images are slightly degraded by motion artifact. There is a small
left pleural effusion with adjacent atelectasis. Minimal dependent
atelectasis is seen on the right. No pneumothorax is seen. The great vessels
are normal in caliber without evidence for pulmonary embolus. Trace
pericardial fluid is within the physiologic range. The patient appears to be
status post CABG with post-operative change in the soft tissues overlying the
sternum. The visualized portion of the thyroid is homogeneous. Small
axillary and mediastinal lymph nodes do not meet CT size criteria for
pathologic enlargement.
This study is not optimized for evaluation of subdiaphragmatic structures, but
within this limitation, no acute abnormalities are detected. Round
calcification in the region of the splenic hilum may represent a calcified
splenic artery aneurysm.
Sternal wires appear intact. No concerning lytic or sclerotic osseous lesions
are detected.
IMPRESSION:
1. No CT evidence for pulmonary embolus.
2. Small left pleural effusion with adjacent atelectasis.
3. Possible calcified splenic artery aneurysm in the region of the hilum.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: LEFT CW PAIN
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE
temperature: 96.8
heartrate: 111.0
resprate: 18.0
o2sat: 97.0
sbp: 177.0
dbp: 86.0
level of pain: 4
level of acuity: 2.0 | ___ year old female with a history of CAD s/p PCI x3, s/p CABG x3
(___), type 2 DM on insulin, HTN, and HLD who presented with
a 3 day history of left sided chest pain and SOB.
# Chest Pain- Patient with significant CAD history, s/p recent
CABG, presenting with chest pain and rising troponins, with new
ST depressions inferiorly in V4-V6, consistent with NSTEMI.
Patient's troponins plateaued at 0.13. She has initiated on a
heparin gtt in the ED, and was taken to cardiac cath the
following morning. Catheterization showed occlusion of the SVG
to the diagonal, possibly causing her current symptoms. No
intervention was performed. Patient was medically optimized
with increased metoprolol, initiation of losartan, and
initiation of imdur. Other potential causes of her chest pain
were considered including PE (ruled out with negative CTA),
pericarditis (symptoms consistent, but exam and EKG not
consistent, also patient has been essentially treated as she has
been taking consistent NSAIDs), costochondritis (symptoms
intermittently reproducible on exam), or pleuritis secondary to
pleural effusion (very small effusion, stable since CABG).
If pain persists, patient was instructed to speak with her
cardiologist about increasing imdur should her blood pressure
tolerate.
# Acute renal insufficiency- On admission, creatinine elevated
to 1.2, likely due to dehydration, as creatinine improved
overnight with gentle fluids and remained stable.
# COPD- Continued on home inhalers (albuterol, fluticasone)
# DM- Continued with glargine 50 units Q6 and ISS
# HLD- Continued on home atorvastatin
# GERD- Continued on home pantoprazole
# Transitional issues-
- NEW MEDICATIONS- losartan and imdur
- MEDICATION CHANGES- metoprolol increased to 50mg po TID (from
25 TID)
- if ongoing chest pain, consider titrating up on imdur if c/w
anginal pain. Also may consider treating for costochondritis
and pericarditis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Simvastatin / pantoprazole
Attending: ___.
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
Transcutaneous Liver Bx ___
History of Present Illness:
The patient is a ___ y/o F with PMHx significant for
hypothyroidism, osteopenia, ocular migraines and patent foramen
ovale s/p embolic stroke who presents with abdominal pain, dark
urine and ___ colored stools.
The patient was in her usual state of health until 2 weeks ago
when she noted nausea and acid reflux. One week ago she noted
abdominal pain, diffuse skin itching, dark urine, and loose,
___ colored stools. Her pain has remitted some in the past
week, but she also noticed her skin turning increasingly yellow,
having mild headache, and feeling increasingly unwell over the
past 1 week. She describes the abdominal pain as an "acid
burning" and reflux. She was given pepcid and gaviscon last
which by her pCP which somewhat relieved her pain. She also
notes anorexia and nausea without any vomiting.
Of note, her stool has been black over the past few days, which
she thinks is ___ pepto bismol. Denies hx of liver/GB disease,
EtOH abuse, GERD, changes in vision, CP, SOB, or extremity
swelling.
She was seen at her PCP's office today and sent to the ED after
noticing jaundice and scleral icterus.
Past Medical History:
- patent foramen ovale
- s/p embolic stroke (paradoxical) in ___- not on
anticoagulation
- Hypothyroidism
- Ocular migraines
- osteopenia
Social History:
___
Family History:
Father was a ___ and developed lung cancer with no
cigarette smoke exposure. Mother with vascular dementia,
osteoporosis. Sister osteoporosis, prediabetes. Paternal
grandmother and paternal aunt with postmenopausal breast cancer.
No family history of liver disease.
Physical Exam:
=================
ADMISSION EXAM:
=================
Vitals - vitals 97.5 119/53 63 18 100% on RA.
GENERAL: NAD
HEENT: +scleral icterus
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness in the epigastrium
and RUQ, no rebound or guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
SKIN: jaundice
=================
DISCHARGE EXAM:
=================
Vitals 98.5 96/50 60 16 98%
GENERAL: NAD
HEENT: +scleral icterus
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, no rebound or guarding, mild TTP of
RUQ.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
SKIN: jaundice, improving. Rash no longer apparent
Pertinent Results:
================
ADMISSION LABS:
================
___ 03:44PM WBC-5.5 RBC-4.60 HGB-14.3 HCT-42.1 MCV-92
MCH-31.1 MCHC-34.0 RDW-14.3
___ 03:44PM NEUTS-61.8 ___ MONOS-8.2 EOS-5.5*
BASOS-0.5
___ 03:44PM ___ PTT-32.0 ___
___ 03:44PM PLT COUNT-258
___ 03:44PM GLUCOSE-103* UREA N-8 CREAT-0.7 SODIUM-128*
POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-23 ANION GAP-16
___ 03:44PM ALT(SGPT)-143* AST(SGOT)-76* ALK PHOS-366*
TOT BILI-10.4*
___ 03:44PM LIPASE-74*
___ 03:44PM OSMOLAL-261*
___ 04:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-TR
___ 04:34PM URINE RBC-0 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-3 TRANS EPI-<1
___ 04:34PM URINE MUCOUS-RARE
___ 04:34PM URINE HOURS-RANDOM UREA N-124 CREAT-20
SODIUM-LESS THAN POTASSIUM-15 CHLORIDE-10]
=====================
OTHER PERTINENT LABS:
=====================
___ 05:36AM BLOOD IgM HAV-NEGATIVE
___ 03:44PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 05:36AM BLOOD ANCA-NEGATIVE B
___ 02:25AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 02:25AM BLOOD ___ Titer-1:40
___ 06:10AM BLOOD CEA-1.1
___ 06:10AM BLOOD IgM-90
___ 03:44PM BLOOD HCV Ab-NEGATIVE
___ 10:01PM BLOOD ___ 06:10AM BLOOD CA ___
================
DISCHARGE LABS:
================
___ WBC-4.8 RBC-3.97* Hgb-12.1 Hct-36.2 MCV-91 MCH-30.4
MCHC-33.3 RDW-14.9 Plt ___
___ UreaN-6 Creat-0.6 Na-131* K-4.1 Cl-96 HCO3-21* AnGap-18
___ ALT-68* AST-52* AlkPhos-287* TotBili-15.5*
___ INR 0.9
IMAGING
___ MRCP 1. No intraductal stone identified. Minimal
intrahepatic peribiliary enhancement may reflect very mild
cholangitis.
2. No obvious stricture or dilation of the biliary tree with
normal branching pattern by MRCP.
3. 2.5 cm pancreatic cystic lesion compatible with a side
branch intraductal papillary mucinous neoplasm (IPMN). A
followup MRI is recommended in 6 months. Additionally,
consideration may be given to endoscopic ultrasound evaluation.
The study and the report were reviewed by the staff radiologist.
___ RUQ U/S
1. Normal appearing hepatic parenchyma. No evidence of portal
venous thrombosis.
2. Collapsed gallbladder with wall thickening, but no evidence
of cholelithiasis or pericholecystic fluid. Findings likely
secondary to underlying liver disease.
The study and the report were reviewed by the staff radiologist.
LIVER BX PATHOLOGY ___
Liver, needle core biopsy:
1. Mild to moderate portal and focal mild lobular mixed
inflammation consisting primarily of lymphocytes, rare plasma
cells, and prominent eosinophils.
2. Prominent lymphocytic bile duct damage, focal bile ductular
proliferation, and cholestasis.
3. Minimal lobular mixed inflammation with focally prominent
eosinophils and rare apoptotic hepatocytes.
4. No steatosis or ballooning degeneration.
5. Trichrome stain demonstrates no definite increase in
fibrosis.
6. Iron stain shows no stainable iron.
Note: The findings are those of a portal-based inflammatory
process with prominent eosinophils and bile duct damage. A
drug/supplement-induced liver injury is most likely given this
histologic pattern and clinical history of herbal supplement
use. Primary biliary cirrhosis or other primary biliary disease
would be in the histologic differential in other
clinical/serologic settings.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) unknown oral
daily
3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Liothyronine Sodium 5 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Liothyronine Sodium 5 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
7. Sarna Lotion 1 Appl TP TID:PRN itchiness
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % 1 application
three times a day Refills:*0
8. Cholestyramine 4 gm PO BID
RX *cholestyramine (with sugar) 4 gram 1 powder(s) by mouth
twice a day Refills:*0
9. Ursodiol 300 mg PO TID
RX *ursodiol 300 mg 1 capsule(s) by mouth three times a day Disp
#*90 Capsule Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
11. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Capsule Refills:*0
12. Outpatient Lab Work
Please draw ___ ALT, AST, Alkaline Phosphotase, Total
Bilirubin and Direct Bilirubin and fax to ATTN: ___ at
Fax ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Biliary obstruction
ASSOCIATED DIAGNOSES:
Hyponatremia
Cystic lesion of the pancreas
Discharge Condition:
Mental Status: Alert and oriented
Level of consciousness: Alert, attentive
Ambulatory status: Ambulatory, independent
Mental Status: Alert and oriented
Level of consciousness: Alert, attentive
Ambulatory status: Ambulatory, independent
Followup Instructions:
___
Radiology Report
EXAMINATION: CT OF THE ABDOMEN
INDICATION: Nausea, jaundice, and itching.
TECHNIQUE: Multidetector CT images of the abdomen were obtained with
intravenous contrast. Sagittal and coronal reformations were also performed.
DOSE: 504.9 mGy-cm.
COMPARISON: None.
FINDINGS:
The visualized lung bases appear clear. There are no pleural effusions.
In segment VI of the liver, a 5 mm diameter hypodense focus is too small to
characterize. No other discrete liver lesions are identified. There is no
intrahepatic or extrahepatic biliary ductal dilatation. The caudate lobe is
mildly prominent in relative size. The spleen is normal in size.
The gallbladder is mostly contracted. Enhancement of the free segment of the
extrahepatic biliary ducts as well as the cystic duct and gallbladder is
mildly prominent but significance is uncertain. It is possible that this may
be due to an underlying inflammatory process involving biliary duct such as
sclerosing cholangitis.
The portal vein and its main branches appear patent. Hepatic veins are also
patent. Arteries are difficult to assess with this technique.
In the pancreatic body there is a cystic lesion measuring up to 21 x 20 mm in
axial ___ without apparent complexity.
The adrenal glands and kidneys appear within normal limits.
The stomach and visualized portions of bowel are unremarkable aside from
mildly prominent colonic stool.
There is no lymphadenopathy or ascites.
There are no suspicious bone lesions.
IMPRESSION:
1. No evidence of biliary obstruction.
2. Somewhat prominent extrahepatic biliary enhancement, significance
uncertain, but etiologies such as sclerosing cholangitis could be considered
or the appearance may be due to vascular alterations associated with
parenchymal disease.
3. Mildly prominent caudate, but no absolutely convincing morphological
abnormality of the liver.
4. Cystic pancreatic lesion, unlikely to explain jaundice, but evaluation
with MRCP is recommended when clinically appropriate.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with elevated LFTs // r/o portal vein
thrombosis, eval for acute hepatitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Comparison is made to CT abdomen and pelvis dated ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. There is a 3 mm
echogenic focus within the lateral left hepatic lobe, likely representing a
calcified granuloma. No focal suspicious masses are identified within the
liver. There is no intra or extrahepatic biliary ductal dilation. The CBD
measures 4mm. The main, right, and left portal veins are patent with flow in
the appropriate directions. There is no ascites.
GALLBLADDER: The gallbladder is collapsed and appears to demonstrate wall
thickening without cholelithiasis. There is no pericholecystic fluid.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilatation, with portions of the pancreatic head
and tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 9.8 cm.
IMPRESSION:
1. Normal appearing hepatic parenchyma. No evidence of portal venous
thrombosis.
2. Collapsed gallbladder with wall thickening, but no evidence of
cholelithiasis or pericholecystic fluid. Findings likely secondary to
underlying liver disease.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with jaundice and RUQ pain // r/o CBD stone
TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired
within a 1.5 T magnet, including 3D dynamic sequences obtained prior to,
during, and following the administration of 9 cc of Gadavist intravenous
contrast. The patient also received oral contrast of 1 cc of Gadavist diluted
in 50 cc of water.
COMPARISON: CT of the abdomen with contrast dated ___. Abdominal
ultrasound with Doppler dated ___.
FINDINGS:
MRCP WITH AND WITHOUT IV CONTRAST:
The imaged lung bases are grossly clear. No pleural or pericardial effusion
is seen.
The liver morphology is within normal limits. There is no signal drop-off on
out of phase imaging compared to inphase imaging to suggest steatosis. No
suspicious or enhancing liver lesion is identified. The hepatic arterial
anatomy is conventional. The portal vein appears patent. There is mild
periportal edema. A 6 mm T2 hyperintensity in segment VI of the liver (2:32)
is compatible with a small cyst or biliary hamartoma. A few scattered biliary
hamartomas are also noted (3:25, 22, 14). There is no intrahepatic biliary
duct dilation with minimal intrahepatic peribiliary enhancement (12:37) and
thickening of the free portion of the common bile duct without abnormal
enhancement or dilation. There is no obvious stricture, dilation or beading
of the biliary tree with normal branching pattern by MRCP. No filling defect
is identified within the CBD to suggest an intraductal stone.
The gallbladder is collapsed with diffuse edema of the gallbladder wall. No
gallstones are identified.
The pancreas is normal in size and signal intensity. The main pancreatic duct
is not dilated. A T2 hyperintense cystic lesion measuring 2.5 x 2.3 x 1.9 cm
in the distal body of the pancreas (3:20) shows no internal complexity or
abnormal enhancement consistent with a side branch intraductal papillary
mucinous neoplasm (IPMN). The pancreatic parenchyma otherwise enhances
homogeneously.
The spleen and bilateral adrenal glands are unremarkable. Both kidneys
enhance symmetrically and excrete contrast normally without hydronephrosis or
suspicious renal mass.
The intra-abdominal loops of bowel are unremarkable without evidence of
obstruction. No ascites or lymphadenopathy is seen. The abdominal aorta is
normal in caliber throughout.
Multiple perineural cysts are incidentally noted along the thoracic spine
(2:35). Vertebral body hemangiomas are also evident. No bone marrow signal
abnormality concerning for malignancy is seen.
IMPRESSION:
1. No intraductal stone identified. Minimal intrahepatic peribiliary
enhancement may reflect very mild cholangitis.
2. No obvious stricture or dilation of the biliary tree with normal branching
pattern by MRCP.
3. 2.5 cm pancreatic cystic lesion compatible with a side branch intraductal
papillary mucinous neoplasm (IPMN). A followup MRI is recommended in 6 months.
Additionally, consideration may be given to endoscopic ultrasound evaluation.
Radiology Report
INDICATION: ___ year old woman with unexplained jaundice and
hyperbilirubinemia.
Coaxial biopsy requested given aspirin use.
COMPARISON: MRCP ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and
Dr. ___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 15 min 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: Fentanyl and midazolam.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0, 0 mGy
PROCEDURE:
1. Ultrasound-guided non-focal liver biopsy.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol.
A preprocedure ultrasound was performed and a biopsy area was marked. The
site was prepped, draped, and locally anesthetized. A 17 gauge coaxial needle
was advanced into the liver under ultrasound guidance via a percutaneous
approach and two 18 gauge core biopsies were obtained. The tract was
embolized using Gel-Foam. The specimens were placed in formalin. The skin was
cleaned and dressing was applied. The patient tolerated the procedure without
immediate complications.
FINDINGS:
Limited imaging of the liver demonstrates no appreciable abnormality.
IMPRESSION:
Successful ultrasound-guided non-focal liver biopsy.
Two satisfactory 18G cores were obtained.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Jaundice, Headache
Diagnosed with JAUNDICE NOS
temperature: 96.4
heartrate: 75.0
resprate: 16.0
o2sat: 100.0
sbp: 133.0
dbp: 75.0
level of pain: 4
level of acuity: 3.0 | ___ y/o F with PMHx significant for hypothyroidism, osteopenia,
ocular migraines and patent foramen ovale s/p embolic stroke who
presents with abdominal pain, dark urine and ___ colored
stools, with elevated LFTs in a cholestatic pattern.
# CHOLESTATIC LIVER INJURY: CT and RUQUS without evidence of
dilitation or specific findings to suggest a diagnosis. MRCP
similarly unrevealing. Viral hep serologies negative, autoimmune
studies negative thus far. Bx done showing portal-based
inflammatory process with prominent eosinophils and bile duct
damage. A drug/supplement-induced liver injury is most likely
given this histologic pattern and clinical history of herbal
supplement use. Primary biliary cirrhosis or other primary
biliary disease would be in the histologic differential in other
clinical/serologic settings. She was counseled to avoid all
alcohol and to not take Tylenol.
# RASH: Patient had new rash that developed after she arrived in
the hospital. The patient was started on pantoprazole on
arrival, given timing this seems the most likely cause of her
rash. DRESS less likely given pt's picture is more cholestatic
and rash started after arrival here.
# HYPONATREMIA: Sodium of 128 noted upon admission. Resolved
with fluids
INACTIVE ISSUES
# GERD : TUMS as needed for symptoms given. Pantoprazole added
to allergy list per above.
# HYPOTHYROIDISM: Per prior notes secondary to ___'s. Cont
levothyroxine and cytomel in-hosue.
TRANSITIONAL ISSUES
# Repeat MRI in 6mo f/u r/o progression of IPMN.
# Pt to have o/p LFTs drawn and faxed to Dr. ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Motor vehicle crash
Major Surgical or Invasive Procedure:
___ Closed reduction of left posterior hip dislocation.
History of Present Illness:
___ who presents as transfer from ___ for single car MVC
and left hip dislocation. +airbag deployment, etoh and cocaine
on board. Found in front seat by EMS complaining of L hip pain.
Only obtained CXR and pelvis xray there.
Intoxicated on arrival, cannot tell me further history. Pain is
severe, worse w/ movement
Past Medical History:
Unknown.
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Temp: 98.2 HR: 86 BP: 137/92 Resp: 18 O(2)Sat: 100
Constitutional: uncomfortable, crying out in pain and
intoxicated
HEENT: Normocephalic, atraumatic
in c-collar
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds, +2 ___ pulses bilaterally
Abdominal: Soft, Nontender, Nondistended
Extr/Back: left leg shortened and internally rotated
Skin: Warm and dry, No rash
Neuro: able to flex ankle, sensation intact in LLE; slurred
speech
Psych: clinically intoxicated
___: No petechiae
DISCHARGE PHYSICAL EXAM:
VS: 98.1 PO 116 / 75 L Lying 72 18 95 R
GEN: Awake, alert, pleasant and interactive.
HEENT: C-collar in place. Poor dentition.
CV: RRR
PULM: Clear to auscultation bilaterally.
ABD: Soft, non-tender, non-distended.
EXT: Warm and dry. 2+ ___ pulses. bilateral ankle swelling and
ecchymosis.
Pertinent Results:
___ 07:00AM BLOOD WBC-5.6# RBC-4.12 Hgb-12.4 Hct-36.2
MCV-88 MCH-30.1 MCHC-34.3 RDW-12.8 RDWSD-41.1 Plt ___
___ 06:22AM BLOOD WBC-13.8* RBC-4.52 Hgb-13.6 Hct-39.9
MCV-88 MCH-30.1 MCHC-34.1 RDW-13.1 RDWSD-42.3 Plt ___
___ 06:22AM BLOOD ___ PTT-25.2 ___
___ 07:00AM BLOOD Glucose-101* UreaN-14 Creat-0.6 Na-141
K-3.8 Cl-103 HCO3-27 AnGap-11
___ 06:22AM BLOOD Glucose-131* UreaN-7 Creat-0.7 Na-141
K-3.8 Cl-101 HCO3-22 AnGap-18
___ 07:00AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.2
___ 06:22AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 8:57 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ chest/pelvis xray:
1. Posterior left hip dislocation. No fracture identified.
2. Possible left pleural effusion; mediastinal injury cannot be
excluded. CT scanning of the chest is appropriate, given the
severity of impact.
___ CT-C spine:
1. Subtle avulsion fracture anterior corner C2 vertebral body.
2. No other fractures.
3. Normal alignment.
___ CT Head:
1. No intracranial hemorrhage, edema, or acute fracture.
2. Right frontal subgaleal hematoma.
___ Hip xray:
1. Posterior left hip dislocation.
2. No fractures identified.
___ CT Pelvis:
Successful reduction of left posterior hip dislocation. No
fracture of the left hip or pelvis. Stranding and a small
amount of hemorrhage in the soft tissues posterior to the left
hip.
___ R Ankle Xray
ADDENDUM This is a correction to the above report.
Radiographs of the patients right ankle and foot were taken by
mistake.
Patient was brought back and AP and lateral views of the left
foot and AP and oblique views of the left ankle were taken.
Severe soft tissue swelling is symmetric at the ankle, centered
just below the malleoli. Nevertheless, no fracture or
dislocation is seen. There are no significant degenerative
changes. The mortise is congruent. The tibial talar joint
space is preserved and no talar dome osteochondral lesion is
identified. No suspicious lytic or sclerotic lesion is
identified. No soft tissue calcification or radiopaque foreign
body is identified.
___ L Ankle Xray
Left foot and ankle:
Soft tissue swelling surrounds the lower left ankle
symmetrically. There is no evidence of fracture dislocation.
There is no gross degenerative change. There is no suspicious
osseous abnormality.
___ Right Shoulder:
No fracture or dislocation.
Medications on Admission:
Methadone 75 mg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
Alternate with ibuprofen. Do not exceed 4,000 mg/24 hours.
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
___ take additional 200 mg (to equal 800 mg prn). Do not exceed
3200 mg/24 hr. take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*42 Tablet Refills:*0
4. Nicotine Patch 14 mg TD DAILY
5. Methadone 75 mg PO DAILY
6.Rolling walker
DX: Gait instability, Left hip dislocation
PX: Good
___: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Left hip dislocation s/p closed reduction
C2 vertebral body fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ unrestrained driver MVC pain left hip// injury
fracture bleeding trauma
TECHNIQUE: AP chest and pelvis
COMPARISON: None
FINDINGS:
The patient is rotated. Lung volumes are low. Asymmetric opacification of
the left hemithorax relative to the right, could be due to asymmetry in
overlying soft tissue or perhaps posteriorly layering pleural effusion. There
is no focal consolidation. Mediastinal caliber is attributable to supine
positioning and patient rotation. Heart is mildly enlarged. No pneumothorax.
There is posterior dislocation of the left hip. No fracture is appreciated.
IMPRESSION:
1. Posterior left hip dislocation. No fracture identified.
2. Possible left pleural effusion; mediastinal injury cannot be excluded. CT
scanning of the chest is appropriate, given the severity of impact.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ unrestrained driver MVC pain left hip// injury
fracture bleeding trauma
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.6 cm; CTDIvol = 45.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
Evaluation is mildly limited by streak artifact. There is a right frontal
subgaleal hematoma. There is no evidence of infarction, intracranial
hemorrhage, edema, or mass. The ventricles and sulci are normal in size and
configuration.
No acute fracture. The paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No intracranial hemorrhage, edema, or acute fracture.
2. Right frontal subgaleal hematoma.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ unrestrained driver MVC pain left hip// injury
fracture bleeding trauma injury fracture bleeding trauma
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 21.3 cm; CTDIvol = 22.6 mGy (Body) DLP = 481.2
mGy-cm.
Total DLP (Body) = 481 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal.
Subtle cortical irregularity involving anterior paramedian corner of C2
vertebral body, worrisome for fracture, not extending into the odontoid
process, sagittal image 36, axial image 19.
There is no evidence of significant spinal canal or neural foraminal stenosis.
There is no prevertebral soft tissue swelling.The thyroid and lung apices are
unremarkable. Periodontal disease, dental caries.
IMPRESSION:
1. Subtle avulsion fracture anterior corner C2 vertebral body.
2. No other fractures.
3. Normal alignment.
NOTIFICATION: The updated findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 8:15 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT
INDICATION: History: ___ unrestrained driver MVC pain left hip// injury
fracture bleeding trauma
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
cross-table lateral views of the left hip.
COMPARISON: Pelvic radiograph from 1 hour prior.
FINDINGS:
The left hip remains dislocated posteriorly. No fractures identified.
IMPRESSION:
1. Posterior left hip dislocation.
2. No fractures identified.
Radiology Report
EXAMINATION: CT of the torso
INDICATION: History: ___ with chest and abdominal pain after motor vehicle
collision// Evaluate for intra-abdominal or intrathoracic injuries secondary
to major 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 10.3 s, 81.1 cm; CTDIvol = 23.2 mGy (Body) DLP =
1,879.5 mGy-cm.
Total DLP (Body) = 1,880 mGy-cm.
COMPARISON: Hip radiograph from ___.
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: Other than mild dependent atelectasis, the 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 demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small 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 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.
No atherosclerotic disease is noted.
BONES: The left hip as posteriorly dislocated with hematoma within the left
acetabulum (2:244). There is no acute fracture. No focal suspicious osseous
abnormality.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. Posteriorly dislocated left hip with hematoma in the acetabular fossa.
2. No fracture.
3. No evidence of intrathoracic or intraabdominal traumatic injury.
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: History: ___ with s/p reductiopn// eval for position of left hip
eval for position of left hip
TECHNIQUE: Supine frontal left hip radiographs
COMPARISON: Left hip and pelvis radiographs from ___ at 06:05
and 0448
FINDINGS:
There has been interval reduction of the left hip dislocation appears well
seated within the acetabulum. Assessment is limited by overlying soft tissue,
however, no fractures are identified. No radiopaque foreign bodies are
present.
IMPRESSION:
Interval reduction of the left hip dislocation.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: ___ female with left foot and ankle pain. Evaluate
fracture.
TECHNIQUE: AP, lateral, and internal oblique views of the left foot and AP,
lateral, and internal oblique views of left ankle.
FINDINGS:
Severe soft tissue swelling is symmetric at the ankle, centered just below the
malleoli. Nevertheless, no fracture or dislocation is seen. There are no
significant degenerative changes. The mortise is congruent. The tibial talar
joint space is preserved and no talar dome osteochondral lesion is identified.
No suspicious lytic or sclerotic lesion is identified. No soft tissue
calcification or radiopaque foreign body is identified.
Radiology Report
EXAMINATION: CT pelvis without intravenous contrast
INDICATION: ___ female with history of motor vehicle accident and
posterior left hip dislocation s/p closed reduction. Evaluate for fracture.
TECHNIQUE: Multidetector CT images of pelvis were acquired in soft tissue and
bone algorithims without intravenous contrast. Non-contrast scan has several
limitations in detecting vascular and parenchymal organ abnormalities,
including tumor detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 890 mGy-cm.
COMPARISON: CT torso ___
Left hip radiograph ___
FINDINGS:
The patient is status post reduction of a left posterior hip dislocation. The
left femoral head articulates normally with the acetabulum. There is no
fracture of the left hip or remainder of the pelvis. There is stranding and a
small amount of hemorrhage in the soft tissues posterior to the left hip.
Pelvic small large bowel loops are nondilated. The bladder is distended with
excreted intravenous contrast but otherwise unremarkable. The uterus and
bilateral ovaries appear unremarkable.
There is no pelvic or inguinal lymphadenopathy.
IMPRESSION:
Successful reduction of left posterior hip dislocation. No fracture of the
left hip or pelvis. Stranding and a small amount of hemorrhage in the soft
tissues posterior to the left hip.
Radiology Report
EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT
INDICATION: History: ___ with mvc, shoulder pain// eval fx, dislocation
eval fx, dislocation
TECHNIQUE: 2 AP and 1 lateral view of the right shoulder.
COMPARISON: None available.
FINDINGS:
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:
No fracture or dislocation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Head injury, MVC, Transfer
Diagnosed with Posterior dislocation of left hip, initial encounter, Car driver injured in clsn with statnry object in traf, init
temperature: 98.2
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 92.0
level of pain: 5
level of acuity: 1.0 | Ms. ___ is a ___ yo F admitted to the Acute Care Surgery
Service on ___ after a motor vehicle crash sustaining a C2
vertebral body fracture and left hip dislocation. The orthopedic
surgery team was consulted and bedside closed reduction of the
hip was performed. The patient remained alert and oriented and
stable from a hemodynamic standpoint. She was admitted to the
acute care trauma surgery service for ongoing pain control and
management of her injuries.
On HD1, she remained stable with hard cervical collar. Pain was
controlled with oral oxycodone and she was placed on valium CIWA
protocol. She remained stable from a cardiopulmonary standpoint.
She tolerated a regular diet and voided adequate urine
spontaneously without issues. She was seen and evaluated by
physical therapy. The patient remained touch down weight bearing
on the left lower extremity. Tertiary survey revealed no further
acute injuries. On HD2 ___ clinic was contacted and dose
confirmed. The patient continued to have adequate pain
management.
The patient received counseling for substance abuse by the
social worker and requested a prescription for nicotine patch in
effort to stop smoking.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. After discussion of pain management,
patient decided to manage new acute pain with Tylenol and
ibuprofen and deferred need for additional narcotic medication
(maintain baseline methadone). The patient was tolerating a
diet, ambulating with assist, voiding without assistance, and
pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Patient is a ___ yr old with onset of heavy vaginal bleeding,
two weeks after a termination procedure. The procedure was done
locally at ___ 11 weeks gestation. She has had bleeding every
day since the procedure. Today this worsened and she presented
to the ER>
Major Surgical or Invasive Procedure:
Dilation and curettage
History of Present Illness:
___ yo G8P2 presents to the ED with two days of vaginal
bleeding with hx of 11 wk TAB at ___ on ___.
She notes daily bleeding since the procedure, with intermittent
improvement, usually requiring ___ pads per day, with abrupt
worsening yesterday requiring >1 super heavy pad per hour,
passing large plum sized clots. She denies abnormal vaginal
discharge. Denies abdominal pain, nausea or vomiting. She
endorses feeling lightheaded and dizzy today. She has had
decreased PO intake, last ate this morning around 10AM. Denies
fevers or chills.
Past Medical History:
OBHx: G8P2
- SVD x2
- SAB x1
- TAB x5 (med AB x2; D&C x3)
GYNHx:
- remote hx of gonorrhea and trichomoniasis, s/p treatment
- hx of abnormal Pap testing, s/p colpo with normal biopsies
- currently sexually active with one male partner, uses condoms
for contraception, considering IUD
PMHx:
- epilepsy (diagnosed as a child, tonic clonic seizures, has not
taken antiepileptics since age ___
PSHx:
- D&C x3
Social History:
___
Family History:
Non contributory
Physical Exam:
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, nontender, no rebound/guarding
GU: improved vaginal bleeding since procedure
Ext: no TTP
Pertinent Results:
___ 04:00AM BLOOD WBC-6.4 RBC-2.90* Hgb-8.9* Hct-27.3*
MCV-94 MCH-30.7 MCHC-32.6 RDW-12.7 RDWSD-44.0 Plt ___
___ 09:20PM BLOOD WBC-8.4 RBC-2.91*# Hgb-8.9*# Hct-28.0*#
MCV-96 MCH-30.6 MCHC-31.8* RDW-12.6 RDWSD-44.7 Plt ___
___ 12:40PM BLOOD WBC-6.9 RBC-4.04 Hgb-12.3 Hct-38.3 MCV-95
MCH-30.4 MCHC-32.1 RDW-12.6 RDWSD-44.1 Plt ___
___ 12:40PM BLOOD Neuts-45.8 ___ Monos-7.1 Eos-1.2
Baso-0.4 Im ___ AbsNeut-3.18 AbsLymp-3.15 AbsMono-0.49
AbsEos-0.08 AbsBaso-0.03
___ 12:40PM BLOOD Glucose-76 UreaN-11 Creat-0.7 Na-138
K-3.3 Cl-99 HCO3-29 AnGap-13
Medications on Admission:
Vitamin
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*30 Tablet Refills:*1
2. Ferrous GLUCONATE 324 mg PO DAILY
RX *ferrous gluconate 324 mg (36 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*50 Tablet Refills:*1
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*1
4. Methylergonovine Maleate 0.2 mg PO TID Duration: 24 Hours
RX *methylergonovine 0.2 mg 1 tablet(s) by mouth three times per
day Disp #*2 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Retained products of conception, s/p D&C
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: ___ with vaginal bleeding s/p D C ___
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
The uterus is anteverted and measures 8.5 x 4.6 x 6.0 cm. The endometrium is
poorly assessed on these images and patient requires Re imaging to better
assess. However, there is a focal area of vascularity at the fundus, adjacent
to the endometrial canal, which is concerning for a vascular malformation such
as an AV fistula.
The right ovary is normal in appearance. The left ovary is not visualized.
There is no free fluid.
IMPRESSION:
1. Limited assessment of the endometrium. Patient must return for additional
imaging at no additional charge.
2. Focal area of hypervascularity at the fundus, adjacent to the endometrial
canal, which is not fully assessed, may represent an AV fistula though
waveforms can be assessed when patient returns for repeat imaging.
RECOMMENDATION(S): Patient must return to ultrasound for further imaging at
no additional cost to the patient.
NOTIFICATION: The final impression was discussed with ___, M.D.
by ___, M.D. on the telephone on ___ at 5:07 ___, 5
minutes after discovery of the findings.
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: History: ___ with vag bleed x 2 days. D C ___ // ? avm
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach.
COMPARISON: Pelvic ultrasound with the same date.
FINDINGS:
There is mixed echogenicity material distending the endometrial canal, which
is better demonstrated on the current examination compared to the prior exam
on the same date. There is internal vascularity within this material with
arterial waveforms and a mean peak systolic velocity ranging from ___
centimeters/second, findings most likely consistent with retained products of
conception with some degree of vascular shunting. The region of vascularized
retained products measures approximately 0.8 x 0.5 x 1.4 cm. Complex fluid is
seen within the endometrial canal, likely blood products.
IMPRESSION:
Vascularized retained products of conception.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 8:22 ___, 15 minutes
after discovery of the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Vaginal bleeding
Diagnosed with Other specified abnormal uterine and vaginal bleeding, Anemia, unspecified, Hypotension, unspecified
temperature: 98.2
heartrate: 92.0
resprate: 18.0
o2sat: 100.0
sbp: 106.0
dbp: 62.0
level of pain: 2
level of acuity: 2.0 | On ___, Ms. ___ was admitted to the gynecology service
for a dilation and curettage for retained products of
conception. Please see the operative report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with Tylenol and motrin. Her
bleeding was much improved after the procedure, with a stable
hematocrit from prior to the procedure (~___). She was
prescribed 24 hours of methergine following the procedure to
decrease bleeding.
Her diet was advanced without difficulty. She was then
discharged home in stable condition with outpatient follow-up
scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
scrotal edema, pain, epididymitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o with severe right epididymitis. No evidence of ___
disease on exam or CT scan and ultrasound. No indication for
urgent surgical intervention. WBC elevated to 19. Creatinine
normal. Febrile. Will need admission for close observation and
IV antibiotics.
Past Medical History:
HYPERLIPIDEMIA
HYPERTENSION
LOW BACK PAIN
NARCOTICS AGREEMENT
MORBID OBESITY
ROTATOR CUFF TEAR
TOBACCO ABUSE
No Surgical History currently on file
Social History:
___
Family History:
non-contributory
Physical Exam:
WdWn male, nad, avss
abdomen obese, nt/nd
scrotum markedly swollen with right testicular, epididymal pain
circumcised
l/e w/out edema, pitting, pain
Pertinent Results:
___ 06:02AM BLOOD WBC-9.1 RBC-3.47* Hgb-10.2* Hct-31.6*
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.3 RDWSD-47.8* Plt ___
___ 05:59AM BLOOD WBC-16.8* RBC-3.71* Hgb-10.9* Hct-34.1*
MCV-92 MCH-29.4 MCHC-32.0 RDW-14.2 RDWSD-47.8* Plt ___
___ 03:19PM BLOOD WBC-19.8*# RBC-3.99* Hgb-11.9* Hct-35.8*
MCV-90 MCH-29.8 MCHC-33.2 RDW-13.9 RDWSD-45.9 Plt ___
___ 03:19PM BLOOD Neuts-74.1* Lymphs-16.3* Monos-8.6
Eos-0.2* Baso-0.2 Im ___ AbsNeut-14.70* AbsLymp-3.23
AbsMono-1.70* AbsEos-0.03* AbsBaso-0.03
___ 06:02AM BLOOD Glucose-102* UreaN-12 Creat-0.7 Na-141
K-4.0 Cl-105 HCO3-26 AnGap-14
___ 05:59AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-139
K-4.2 Cl-101 HCO3-29 AnGap-13
___ 03:19PM BLOOD Glucose-106* UreaN-11 Creat-0.7 Na-134
K-3.6 Cl-97 HCO3-24 AnGap-17
___ 03:19PM BLOOD CK(CPK)-65
___ 06:02AM BLOOD Calcium-8.4 Mg-2.2
___ 03:48PM BLOOD Lactate-0.7
___ 04:42PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:42PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM
___ 04:42PM URINE RBC-3* WBC-22* Bacteri-FEW Yeast-NONE
Epi-1
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ 4:42 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>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-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth three
times a day With meals
OXYCODONE-ACETAMINOPHEN [ENDOCET] - Endocet 5 mg-325 mg tablet.
1
tablet(s) by mouth q8 h as needed for pain
SIMVASTATIN - simvastatin 40 mg tablet. 1 tablet(s) by mouth
daily
Medications - OTC
ASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg
tablet,delayed release. 1 tablet(s) by mouth daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 14 Days
FIRST DOSE AFTERNOON OF ___
RX *cefpodoxime 200 mg TWO tablet(s) by mouth twice a day Disp
#*56 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg ONE capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 600 mg one tablet(s) by mouth q8hrs Disp #*40
Tablet Refills:*0
5. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour ONE patch daily Disp #*28 Patch
Refills:*1
6. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
7.Outpatient Lab Work
Mr. ___ was hospitalized for an infection ___ through
___. While inpatient he required restricted use of
narcotics for pain control. His last dose of narcotic medication
was ___.
Discharge Disposition:
Home
Discharge Diagnosis:
EPIDIDYMITIS, SCROTAL PAIN/SWELLING
URINARY TRACT INFECTION (E.COLI)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: History: ___ with right testicular swelling // eval torsion
TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 3.0 x 3.5 x 4.1 cm.
The left testicle measures: 2.6 x 3.0 x 3.3 cm.
The testicular echogenicity is normal, without focal abnormalities.
The right epididymitis is thickened and hypervascular, consistent with
epididymitis. There is a 2 mm cyst in the right epididymal body. The left
epididymis is unremarkable. There is moderate scrotal thickening on the
right.
Vascularity is normal and symmetric in the testes.
IMPRESSION:
1. Right epididymitis without evidence of torsion.
Radiology Report
EXAMINATION: CT pelvis
INDICATION: History: ___ with right testicular cellulitis // eval for deep
tissue infection
TECHNIQUE: 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, 47.4 cm; CTDIvol = 16.9 mGy (Body) DLP = 800.4
mGy-cm.
Total DLP (Body) = 800 mGy-cm.
COMPARISON: Scrotal ultrasound ___.
FINDINGS:
A few scattered colonic diverticula are present without diverticulitis.
Visualized loops of small and large bowel are otherwise unremarkable, as is
the rectum. The appendix is normal. There is minimal calcified
atherosclerotic disease. There is no visualized abdominal aortic aneurysm.
The urinary bladder is unremarkable. The prostate is within normal limits.
No pathologically enlarged pelvic or inguinal lymph nodes are seen.
Evaluation of the testicles is better performed on the ultrasound from the
same date. There is mild hyperemia of the epididymis on the right. Diffuse
soft tissue edema is seen about the scrotum without subcutaneous gas. There
is no fluid collection.
No acute osseous abnormalities detected.
IMPRESSION:
1. Diffuse soft tissue edema about the scrotum without subcutaneous gas. No
fluid collection.
2. Hyperemia of the right epididymis, as seen on the same-day testicular
ultrasound, compatible with epididymitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Testicular pain
Diagnosed with Epididymitis
temperature: 100.9
heartrate: 102.0
resprate: 18.0
o2sat: 98.0
sbp: 129.0
dbp: 69.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ was admitted to Dr. ___ urology service
with scrotal pain, edema consistent with epididymitis. He was
given broad antibiotic (intravenous) medications until clinical
improvement noted. His urine culture was positive for E.Coli and
resistant to penicillin, sulbactam. The hospital course was
relatively unremarkable. He was discharged in stable condition,
ambulating independently, eating well, and with pain control on
oral analgesics. He was given explicit instructions to followup
in clinic ___ site) with Dr. ___ in approximately one
week's time. He was instructed to complete a two week course of
Cefpodoxime. All of his questions were answered and prior to
discharge he received both verbal and written instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo F who underwent a right nephrectomy of
___ for an andrenal mass. Following the procedure, pathology
eventually reported that she has GPA. For the past day she has
had a worsening headache, as well as numbness on the right side
of her face and right arm. She also has constant throbbing
frontal headache the past two days. She has a documented history
of a right brain mass (and removed kidney mass which gave the
initial diagnosis of GPA). Tylenol did not help relieve the
pain. She saw Rheum today and they felt this was an unusual
presentation of her GPA, but she was admitted for IV pulse dose
steroids.
She notes that her visual changes are actually chronic. She has
a severe headache, mostly on the R side. She was noted to have
CN ___ intact in the ED, though she reports visual loss in R
eye, and also reported to have cooler extremities on the R face
and arm. At that time her strength was equal, symmetric
throughout, w/ reflexes intact.
She had CBC, which was unremarkable, unremarkable coags, lytes,
ANCA sent. She also got CXR.
In the ED, initial vs were: ___ 48 89/70 20 99% . Labs
were remarkable for She had CBC, which was unremarkable,
unremarkable coags, lytes, ANCA sent. She also got CXR. ESR CRP
elevated. Patient was given 1mg IV hydromorphone twice.
On the floor, her headache is severe and she is uncomfortable
and crying. She notes some pain with mod palpation of R temporal
area.
Review of sytems:
(+) Per HPI, nausea, + headache, + blurry vision R eye.
(-) ROS: She denies changes to her appetite, abdominal pain,
flank tenderness, fever, chills, vomiting, changes to her
hearing, dysuria, hematuria, and LOC.
Past Medical History:
# COPD/Asthma
# chronic sinusitis
# kidney stones
# necrotizing sinusitis with intracranial involvement s/p recent
craniotomy
# recently-diagnosed renal mass with biopsy confirming GPA
Social History:
___
Family History:
She has 9 siblings. States all brothers and sisters generally
healthy with exception of one older sister who had prior TIA.
Mother healthy but father died young from cirrhosis/EtoH abuse
related.
Physical Exam:
Exam on Admission:
PHYSICAL EXAM:
Vitals: 97.9 - 102/60 - 60 - 18 - 98 ra
General: lady lying in bed on her back with ice pack on her
face, no resp distress, very uncomfy
HEENT: sclera anicteric, EOMi w/o pain w movement, pupils equal
and reactive bilaterally, tenderness to palp R temporal area
Neck: supple no meningismus
Lungs: clear to ausc bilateraly
CV: hearts w reg rate and rhtyhm, no m/r/g
Abdomen: soft, non tender, healed scars
Ext: thin, no rashes
Skin: healed thin 2 cm scars L hand (self injury from razor), no
rashes or blistering
Neuro: snellen: ___ L eye, R eye unable to see # fingers at 6
feet; cannot distinguish colors, can distinguish # fingers at 1'
eomi, face symmetric, numbness R cheek, ___ in strength all 4
extremities
Exam on Discharge:
PHYSICAL EXAM:
Vitals: T= 97.9 - BP= 102/60 - HR= 60 - RR= 18 - O2 sat= 98 ra
General: Comfortable, talkative, healthy, very friendly
HEENT: sclera anicteric, no oral ulcers appreciated, pupils
equal and reactive bilaterally, no tenderness to palpation in
location of HA , neck supple w/o meningismus
Neuro: AOx3, EOMI, PERRLA,
I- Deferred.
II- Visual acuity ___ L eye, R eye unable to see fingers, able
to discern shapes and white coat. Peripheral vision intact.
III/IV/VI- EOMI, able to accomodate.
V-Sensation to light touch intact in V1-V3. Masseter strength
intact symmetrically.
VII- Face symmetrical. Upper and lower face strength intact.
VIII- Able to hear finger rub in Left ear, faint in R ear.
IX/X- Palate and uvula rise symmetrically.
XI- Trapezius and SCM strength intact.
XII- Tongue protrudes at midline.
Cerebellum: able to do fine finger movements, no ataxia or
intention tremor, Romberg negative
Motor: Gait normal, some balance difficulties with heel to toe
walking, able to walk on toes and heels without problems
Sensory: Sensory intact bilaterally in all extremities,
including R sided UE.
Lungs: CTAB, no wheezes, rales, rhonchi
CV: Nl S1, S2. No murmurs, rubs, gallopsAbdomen: soft, non
tender, non-distended, normal bowel sounds.
Ext: WWP, non-edematous, DP 2+ bilaterally
Skin: No rashes or blistering noted on exam
Pertinent Results:
Labs on Admission:
___ 05:00PM SED RATE-39*
___ 05:00PM ___ PTT-31.1 ___
___ 05:00PM PLT COUNT-384
___ 05:00PM NEUTS-71.2* ___ MONOS-3.6 EOS-6.2*
BASOS-0.7
___ 05:00PM WBC-10.7 RBC-4.28 HGB-11.9*# HCT-36.9 MCV-86
MCH-27.8 MCHC-32.3 RDW-16.7*
___ 05:00PM CRP-9.6*
___ 05:00PM estGFR-Using this
___ 05:00PM GLUCOSE-121* UREA N-14 CREAT-0.8 SODIUM-136
POTASSIUM-6.5* CHLORIDE-103 TOTAL CO2-20* ANION GAP-20
___ 05:12PM ANCA-NEGATIVE B
___ 06:01PM K+-4.8
___ 06:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 06:18PM URINE COLOR-Yellow APPEAR-Clear SP ___
Interval Labs:
___ 05:50AM BLOOD WBC-7.8 RBC-4.04* Hgb-10.9* Hct-33.7*
MCV-83 MCH-27.0 MCHC-32.4 RDW-16.4* Plt ___
___ 06:10AM BLOOD WBC-14.9*# RBC-4.14* Hgb-11.2* Hct-34.7*
MCV-84 MCH-27.1 MCHC-32.3 RDW-16.6* Plt ___
Labs on Discharge:
___ 07:00AM BLOOD WBC-15.0* RBC-4.02* Hgb-10.9* Hct-33.9*
MCV-84 MCH-27.0 MCHC-32.1 RDW-16.8* Plt ___
Microbiology: Urine cx negative
Imaging:
MRI head w and w/o contrast
IMPRESSION:
1. No significant overall change in the degree of extensive
dural
thickening/enhancement, with unchanged extension of abnormal
enhancing tissue into the superior nasal cavity. These findings
are compatible with the reported diagnosis of granulomatosis
polyangiitis, although can be seen in other processes such as
lymphoma or infection.
2. Extensive paranasal sinus disease, slightly improved.
Increased
opacification of left mastoid air cells
CXR:
IMPRESSION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Simethicone 40-80 mg PO QID:PRN gas
2. Senna 1 TAB PO BID
3. Methadone 5 mg PO TID:PRN headache
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
5. Acetaminophen 650 mg PO Q4H:PRN fever/pain
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, sob
7. Docusate Sodium 100 mg PO BID
8. Ibuprofen 600 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN fever/pain
2. Methadone 5 mg PO DAILY headache
3. Docusate Sodium 100 mg PO BID
4. Senna 1 TAB PO BID
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, sob
6. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
7. Ibuprofen 600 mg PO Q8H:PRN pain
8. Simethicone 40-80 mg PO QID:PRN gas
9. Vitamin D 800 UNIT PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
11. Calcium Carbonate 1000 mg PO Q 8H
12. Cytoxan 100 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
Granulomatosis with Polyangiitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with Wegener's about to start steroids. Question
acute cardiopulmonary process.
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest. Left PICC is no longer visualized. The
lungs are clear. The cardiomediastinal silhouette is normal. No acute
osseous abnormality is detected.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: Recent diagnosis of granulomatosis polyangiitis (Wegener's
granulomatosis). Presenting with headaches. Evaluate for interval change or
evidence of vasculitis.
COMPARISON: Multiple prior CT and MR head studies dating back through ___, including the most recent MR head from ___ and the
most recent CT head from ___. CT sinus from ___.
TECHNIQUE: Multiplanar, multisequence MR imaging was performed of the brain
both prior to and following the uneventful intravenous administration of 7 mL
of Gadavist.
FINDINGS:
As seen on multiple prior studies, there is abnormal dural thickening and
enhancement along the right tentorium cerebelli and lateral right posterior
fossa, extending both into the right interal auditory canal and along the
medial aspect of the right middle cranial fossa. There is abnormal enhancing
tissue within the right cavernous sinus as well as along the right petroclival
ridge, similar to prior MRI. There is also dural thickening and enhancement
along the right anterior cranial fossa, extending along the right olfactory
groove and crista galli. Abnormal enhancement within the superior aspect of
the nasal cavity is likely contiguous with the anterior cranial fossa process,
communicating via known defects in the cribriform plates, not significantly
changed.
There is no intracranial hemorrhage, edema, shift of normally midline
structures, hydrocephalus, or infarction. Mass effect on the right
anterolateral aspect of the pons secondary to the adjacent dural thickening is
not significantly changed (4:8). Periventricular FLAIR/T2 white matter
hyperintensity is not significantly changed, possibly the sequelae of chronic
small vessel ischemic disease. A tiny T2/FLAIR hyperintensity within the left
frontal lobe subcortical white matter is not significantly changed (4:16),
likely of similar etiology to the aforementioned periventricular abnormality.
The principally intracranial T2 arterial flow voids are preserved. The orbits
are unremarkable. Extensive paranasal sinus disease has somewhat improved,
with decreased mild mucosal thickening in the maxillary sinuses and ethmoidal
air cells. Mucosal thickening within the frontal and sphenoid sinuses is not
significantly changed. Opacification of multiple bilateral mastoid air cells
is unchanged on the right and increased on the left. Note is made of a prior
right sided craniotomy.
IMPRESSION:
1. No significant overall change in the degree of extensive dural
thickening/enhancement, with unchanged extension of abnormal enhancing tissue
into the superior nasal cavity. These findings are compatible with the
reported diagnosis of granulomatosis polyangiitis, although can be seen in
other processes such as lymphoma or infection.
2. Extensive paranasal sinus disease, slightly improved. Increased
opacification of left mastoid air cells.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: BRAIN LESION
Diagnosed with OTHER CONDITIONS OF BRAIN, WEGENER'S GRANULOMATOSIS
temperature: 97.8
heartrate: 48.0
resprate: 20.0
o2sat: 99.0
sbp: 89.0
dbp: 70.0
level of pain: 9
level of acuity: 2.0 | Patient is a ___ yo female with Granulomatosis polyangiitis (GPA)
with initial presentation of brain mass, LAD, chronic sinusitis,
and renal mass, with extensive work up nondiagnostic until most
recent right sided nephrectomy, now biopsy confirmed. This is
GPA with an unusual presentation and patient was admitted for
induction of a course of pulse steroids for three days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Posterior neck pain
Major Surgical or Invasive Procedure:
___ - C3-7 fusion; c3 and c7 corpectomy
___ - Occiput to T4 fusion
History of Present Illness:
___ is a ___ female with deep neck space abscess/osteomyelitis
c/b MSSA bacteremia s/p I&D, anterior vertebrectomy (C5-C6), and
C4-C7 fusion (___), as well as ongoing opiate use disorder
and
chronic hepatitis C, presenting with chronic posterior neck
pain.
Notably, she has presented many times previously ___, and ___ and either left AMA or
eloped prior to adequate antibiotic treatment each time. Her
last
ED visit was ___, but she eloped prior to lab draws. She has
had
safety alerts in the past given past misuse of IV and eloping
with PIV in place. Of note, her incomplete adherence is
multifactorial and attributable to insurance issues,
homelessness, lack of transportation, lack of a PCP, and
substance use disorder; withdrawal symptoms have been
prohibitive
of a prolonged hospital stay.
In the ED, she reported severe, sharp neck pain that radiates
down her right arm, worse with movement. Denies fevers, chills,
numbness, weakness of extremities, bowel/bladder incontinence.
History was limited by participation. However, she was amenable
to admission for antibiotics. She was noted to remove syringe
from bra during search of person and belongings; her belongings
were confiscated.
In the ED:
Initial vital signs: T 97.5 HR 90 BP 127/86 RR 18 O2 100% RA
Exam notable for:
Disheveled. Pain with flexion of spine, not reproducible with
palpation. Area of swelling without overlying erythema or
fluctuance on right posterior neck. Neurologically intact.
Labs were notable for:
130 | 98 | 5
-------------< 113
4.1 | 27 | 0.7
CRP 105
7.2 > 11.3/35.8 < 314
Lactate 1.1
Patient was given :
Morphine Sulfate 4 mg IV ONCE
Vitals on transfer: 98.6 | 83 | 130/84 | 16 | 100% RA
Upon arrival to the floor, she is minimally willing to
participate in an extended interview: "It's 0100 in the
(expletive) morning. Can we save the ___ grade questions to a
more reasonable hour?!" She denies fevers/chills, vision
changes,
chest pain, dyspnea, abdominal pain, nausea/vomiting, diarrhea,
rash, weakness, but is dismissive of the ROS and does not want
to
participate. She says she her "chin does not come off her chest"
due to pain with neck extension. She reports that the morphine
was not helpful.
She was seen by ID on ___ and was not taking antibiotics at
that
time; it looks like she filled a prescription of doxycycline,
but
she reports not taking any medicines on this admission.
She has been managing her pain with IV heroin. She takes "40"
("20 twice a day") and her last use was at 0700. She last used
cocaine the day before yesterday, and smokes cigarettes when she
can get them. She denies any alcohol use.
Past Medical History:
MSSA bacteremia
HCV
Polysubstance use disorder
Levamisole-induced ANCA+ vasculitis
Social History:
___
Family History:
Unknown by patient
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.7 | 168/98 | 83 | 18 | 100%Ra
GENERAL: Cachectic, appears chronically ill/malnourished but
nontoxic. Intermittently crying out in pain.
HEENT: Pupils mid-range (2-3mm), equal and reactive to light.
Sclera anicteric and without injection. MMM. Poor dentition.
Inferior cartilage of nose is missing and there is
erythema/shallow ulcers at nares.
BACK: Right c-spine with well-healed midline incision overlaying
a tattoo. Some swelling but no edema, no fluctuance or TTP. No
other spinous process tenderness.
CARDIAC: Regular rhythm, normal rate. No murmur heard.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process 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.
SKIN: Warm. Cap refill <2s. No rash. No appreciable nail
findings.
NEUROLOGIC: CN2-12 grossly intact. Moving all limbs with purpose
against gravity. Can move her neck side to side but cannot
extend
it d/t pain.
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 3-2mm bilaterally
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
___
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Wound:
[x]Clean, dry, intact - Halo pin sites intact without erythema
[x]Anterior and Posterior surgical incisions well healed
Pertinent Results:
See OMR for pertinent lab results and imaging.
Medications on Admission:
None
Discharge Medications:
1. Bacitracin Ointment 1 Appl TP QID
RX *bacitracin zinc [Antibiotic (bacitracin zinc)] 500 unit/gram
apply to pins sites four times daily for five days four times
daily Disp #*1 Tube Refills:*0
2. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QMON
RX *clonidine [Catapres-TTS-1] 0.1 mg/24 hour ___ Disp #*5
Patch Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
4. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth daily Disp #*60 Capsule Refills:*0
6. Naloxone Nasal Spray 4 mg IH ONCE MR1 opiod overdose
Duration: 1 Dose
please seek immediate medical care after using
RX *naloxone [Narcan] 4 mg/actuation 1 spray nasal once Disp #*1
Spray Refills:*0
7. QUEtiapine Fumarate 100 mg PO QHS agitation
RX *quetiapine 100 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
8. QUEtiapine Fumarate 50 mg PO BID PRN agitation
RX *quetiapine 50 mg 1 tablet(s) by mouth BID PRN Disp #*30
Tablet Refills:*0
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
10. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2
11. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
12. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) [Calcidol] 8,000 unit/mL 800
units by mouth daily Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Instrumentation Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman with history of spine surgery with acute on
chronic posterior neck pain.// Concern for worsening of known fracture around
the C3 lateral mass screws vs. anterolisthesis.
COMPARISON: ___
FINDINGS:
There is been abnormal posterior migration of the superior aspect of the
posterior spinal hardware. Pedicle screws previously seen within the C3, C4
and C5 vertebral bodies have now been displaced more posteriorly. There is
focal kyphosis at C4-C5. Fracture of the spinous process of C3 is again seen.
There is again seen a corpectomy cage spacer device in the cervical spine
spanning C4 to roughly C6. Anterior fusion plate within screws in C4 and C7
are again seen. There is prominent prevertebral soft tissue edema.
IMPRESSION:
1. Abnormal displacement of the posterior spinal hardware. The upper pedicle
screws and spinal rods are displaced posteriorly since the prior study.
2. Fracture of the C3 spinous process.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 1:04 pm, 10 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT CERVICAL WANDW/O CONSTRAST.
INDICATION: ___ year old woman with history of MSSA osteomyelitis. Now with
lateral x-ray films concerning for hardware not in bone. Also, has not
completed appropriate course of antibiotics. CRP > 100.// Eval for pre-op
planning and placement of hardware, also ? osteomyelitis.
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.7 s, 18.4 cm; CTDIvol = 25.1 mGy (Body) DLP = 462.1
mGy-cm.
2) Spiral Acquisition 4.3 s, 16.9 cm; CTDIvol = 25.1 mGy (Body) DLP = 424.5
mGy-cm.
Total DLP (Body) = 887 mGy-cm.
COMPARISON: CT neck with contrast dated ___
FINDINGS:
Patient is status post anterior and posterior instrumentation fusion of C3-T2,
now with apparent fixation hardware complications.
The cervical spine alignment is abnormal with new cervical kyphosis compared
to prior in ___. Additionally, there is fracture of the C3 vertebral
body with retropulsion of the superior fragment, causing anterior thecal sac
deformity. There is notable lucency around the corpectomy cage spacer device
at C4-C6 levels. Moreover, there is new angulation of the posterior screws
with separation from the articular pillars. Specifically, the left sided
screws are separated from the C3-C5 articular pillars, while the right-sided
screws are separate from the C3-C4 articular pillars. There is additional
lucency around the bilateral thoracic pedicles screws, suggesting loosening of
the hardware. No fragments of the surgical hardware appreciated.
There is notable prevertebral edema with no definitive fluid collection.
However, the study is limited by significant beam hardening artifacts from
surgical hardware.
The thyroid is unremarkable. Pleural thickening and scarring changes are
visualized in the right lung apex.
IMPRESSION:
1. Interval fracture of the C3 vertebral body with retropulsion of the
superior fragment, causing anterior thecal sac deformity.
2. Loosening of the corpectomy cage spacer at C4-C6 levels.
3. New angulation of the posterior screws with separation from the cervical
articular pillars at C3-C5 on the left, and C3-C4 on the right.
4. Loosening of bilateral thoracic pedicle screws.
5. Prevertebral edema with no definitive fluid collection, but exam is
limited by notable beam hardening artifacts.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___ , M.D. on the telephone on ___ at 6:15 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: History of osteomyelitis. Preoperative for spinal fusion
surgery.
COMPARISON: Prior study from ___ and cervical spine CT from the same
day..
FINDINGS:
Heart is normal in size. Upper mediastinal contours show new widening, right
greater than left, most consistent with interval lymphadenopathy. Cardiac,
mediastinal and hilar contours are otherwise similar allowing for small
differences in techniques. There is no pleural effusion or pneumothorax.
Lungs appear clear.
IMPRESSION:
New upper mediastinal widening suggesting lymphadenopathy. This is
demonstrated by correlation with cervical spine CT of the same day.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old woman with severely displaced spinal hardware.//
Pre-procedural planning per orthopedics Pre-procedural planning per
orthopedics
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON:
1. CT cervical spine ___.
2. CT cervical spine ___.
3. ___ full spine MRI.
FINDINGS:
Study is markedly limited due to severe motion degradation on multiple
sequences and extensive hardware artifact. Within these confines:
The patient is status post placement of prior anterior and posterior cervical
spine fusion hardware, as well as corpectomy cage spacer spanning.
Bilateral posterior rods and transpedicular screws span C3-T2. Anterior plate
and screw fixation hardware spans C4-T1. Corpectomy cage spacer spans C4-C7.
Better visualized on recent CT, there is evidence of interval worsening since
___ of kyphotic angulation centered at approximately C3-4, due
to probable anterior C3 fracture (not well seen on the current study), as well
as posterior fracture of C4 with bony retropulsion of the superior fracture
fragment (also not well seen). The bilateral C3 and C4 screws are more
superiorly and posteriorly displaced given this new worsening angulation;
additionally, in conjunction with interval backing out of the left C5 screw
since the prior exam, although the right C5 screw remains in place, there is a
newly perched right C4-5 facet (4:5 on the current study; series 310, image 22
on the recent CT). These hardware findings were better assessed on the recent
CT.
Extensive hardware artifact precludes adequate evaluation of the vertebral
bodies from approximately C4-C7, and the posterior elements from approximately
C3-T2. There is suggestion of at least moderate to severe spinal canal
narrowing from C2-3 to approximately the level of C5-6, with the effacement of
the CSF space around the cord (see series 4, image 9). There is suggestion of
very faint high T2/STIR signal within the cord at these levels on sagittal T2
weighted images, however this could be artifactual, not definite. Axial T2
weighted images are severely motion degraded at these levels and nondiagnostic
for this purpose. The remainder of the cervical spinal cord appears normal in
caliber and signal intensity.
There is probably focally moderate to severe spinal canal stenosis at C7-T1
(04:11) due to a posterior bridging osteophyte (04:11). There is no definite
cord signal abnormality at this level, although axial images are severely
motion-degraded and essentially nondiagnostic this purpose.
There is high T2/STIR signal within the posterior aspect of the T2 vertebral
body at the distal ends of the transpedicular screws. Additionally, there is
fluid surrounding the left screw, (04:14), better assessed on prior CT. High
T2/stir signal is also seen within the T1 vertebral body posteriorly. No
definite fracture line.
There is a large amount of prevertebral as well as possibly additionally right
retropharyngeal T2/STIR hyperintense material, likely edema and/or hematoma,
although infected collection cannot be excluded (see series 4, image 10 and
series 10 image 11). There is edema throughout the posterior paraspinal soft
tissues and musculature, compatible with edema (for example see series 10,
image 4 and 18).
Bulky right supraclavicular lymph node is only partially visualized on this
study, better assessed on the recent CT (11:27). Biapical pleuroparenchymal
scarring is noted.
IMPRESSION:
Severely limited study due to severe motion degradation and extensive hardware
artifact. Within these confines:
1. Areas of at least moderate to severe spinal canal narrowing from C2-3 to
approximately C5-6, with faint high T2/STIR signal in the cord at these levels
which is not definite and may be artifactual. There is also likely moderate
to severe spinal canal narrowing at C7-T1 due to a posterior bridging
osteophyte, without definite cord signal abnormality.
2. Extensive prevertebral and retropharyngeal T2/STIR hyperintense material,
possibly edema and/or hematoma; note that infected fluid collection cannot be
excluded.
3. Redemonstration of sequelae of probable interval fractures since ___, likely anteriorly at C3 as well as posteriorly at C4 with bony
retropulsion of the superior C4 fracture fragment, new worsening focal
kyphotic angulation at C3-4, backing out of the left C5 screw, and newly
perched right C4-5 facet; these findings were better assessed on the recent CT
cervical spine.
4. High T2/STIR signal in the posterior aspects of T1 and T2, probably marrow
edema.
5. Study is nondiagnostic for evaluation of the C3-T1 vertebral bodies and
posterior elements spanning C3-T2. Neural foramina are not well-visualized at
the levels.
6. Bulky right supraclavicular lymphadenopathy is not well seen on this study,
better seen on recent CT examinations.
Radiology Report
INDICATION: Anterior protein fusion.
COMPARISON: Compared to the prior MRI from ___ and
radiographs from ___
IMPRESSION:
There has been improved alignment of the posterior hardware spanning C2 to T1.
There is again seen a corpectomy device projecting over the C3-C7 vertebral
bodies. There is an anterior fusion plate in C3 and C7. Please refer to the
operative note for additional details.
Radiology Report
INDICATION: Hardware placement.
COMPARISON: Compared to radiographs from 2 hours earlier.
IMPRESSION:
Intraoperative images demonstrate extension of the corpectomy device with the
superior margin at the level of the C2 vertebral body. Inferior margin is
seen at the level of the T1 vertebral body. New anterior fusion plate has
been placed. Again seen is the posterior fusion hardware which appears
stable. Please refer to the operative note for additional details.
Radiology Report
INDICATION: 50femalefemale h/o IVDU/polysubstance abuse with untreatedHCV,
prior hospitalizations for septic joint and skin infections, C3 frx in halo//
confirm OGT and ETT
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the endotracheal tube projects over the midthoracic trachea. A
feeding tube extends to the stomach. An external fixation device is partially
visualized over the upper chest and lower neck, somewhat limiting evaluation
of the lung apices. The patient is post cervical spinal fusion. 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 endotracheal tube projects over the midthoracic trachea and the
tip of the feeding tube extends to the stomach.
Radiology Report
INDICATION: Cervical posterior fusion.
COMPARISON: Radiographs from ___.
IMPRESSION:
No intra service fluoroscopic time was 29.0 seconds. Numerous intraoperative
images demonstrate removal of the posterior fusion hardware and placement of
posterior fusion pedicle screws and spinal rods beginning at C2. The distal
portion of the hardware is not fully included on these images. Please refer
to the operative note for additional details.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ETT// interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support
devices are unchanged, with the tip of the endotracheal tube approximately 4
cm above the carina.. No evidence of acute pneumonia, vascular congestion, or
pleural effusion.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old woman with failed cervicothoracic fusion now s/p redo
anterior and posterior fusion in halo// eval hardware and alignment eval
hardware and alignment
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 5.8 s, 22.9 cm; CTDIvol = 25.1 mGy (Body) DLP = 575.0
mGy-cm.
Total DLP (Body) = 575 mGy-cm.
COMPARISON: CT C-spine ___.
FINDINGS:
Artifact from hardware limits detailed evaluation.
Patient is status post repeat anterior and posterior spine fusion from the
occiput to T4, with postsurgical changes noted and ventral and dorsal drains
in situ. There is no evidence of hardware failure. No new acute fractures.
There is improvement in the previously seen cervical kyphosis. No suspicious
osseous lesions.
Centrilobular paraseptal emphysematous changes are seen in the imaged lung
apices, right greater than left.
IMPRESSION:
1. Status post spine fusion from occiput T4 with postsurgical changes noted.
2. No evidence of hardware failure.
3. Interval improvement and cervical kyphosis.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE
INDICATION: ___ year old woman with failed cervicothoracic fusion now s/p redo
anterior and posterior fusion in halo// eval hardware and alignment eval
hardware and alignment
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 36.1 cm; CTDIvol = 27.2 mGy (Body) DLP = 981.9
mGy-cm.
Total DLP (Body) = 982 mGy-cm.
COMPARISON: None.
FINDINGS:
Status post repeat spinal fusion from occiput to T4, with postsurgical changes
noted. There is no evidence of hardware failure. Alignment of the thoracic
spine is preserved. No acute fractures are identified. No significant
thoracic spinal canal or neural foraminal narrowing.
No suspicious osseous lesions. Centrilobular and paraseptal emphysematous
changes are again seen in the bilateral upper lobes, right greater than left.
A 1.1 cm hyperattenuating oval lesion in the posterior left kidney likely
represents a hemorrhagic cyst.
A partially imaged enteric tube is noted.
IMPRESSION:
1. Status post spinal fusion from occiput to T4, with postsurgical changes
noted.
2. No evidence of hardware failure.
3. Preserved alignment of the thoracic spine.
Radiology Report
INDICATION: ___ year old woman with IVDU, MRSA osteomyelitis (blood cx
negative) who requires long term access// Please place PICC (bedside access
failed)
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___
Interventional ___
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS:
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: Less than one minute, 1 mGy
PROCEDURE:
1. Double lumen PICC placement
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the 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 PIC line was then placed through the peel-away sheath
with its tip positioned in the distal SVC under fluoroscopic guidance.
Position of the catheter was confirmed by a fluoroscopic spot film of the
chest. The peel-away sheath and guidewire were then removed. The catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach double lumen PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a right 36 cm basilic approach double lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Radiology Report
EXAMINATION: C-SPINE AND T-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman with s/p ACDF C2-T1// Need AP and lateral view
of cervical spine. Need AP and lateral view of cervical spine.
Need AP and lateral view of thoracic spine.
TECHNIQUE: AP and lateral radiographs of the cervical and thoracic spines
COMPARISON: CT dated ___ and radiographs dated ___
FINDINGS:
The patient is status post interval fusion of the occiput through T4.
Anterior fusion of the cervical spine from C2 through T1 is also noted with a
large interbody spacer spanning nearly the entire length of the cervical
spine. There is no evidence of acute hardware related complications. The
thoracic vertebral body heights are maintained. Skin staples are noted along
the posterior neck and surgical clips project over the soft tissues of the
anterior neck. The lung apices are clear. The tip of a right central venous
line projects over the cavoatrial junction.
IMPRESSION:
Post fusion of the occiput through T4 with no radiographic evidence of
hardware related complications.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p c3-7 fusion; c3 and c7 corpectomy, occiput
to T4 fusion now febrile// infectious process infectious process
IMPRESSION:
Comparison to ___, the patient has received a right PICC line.
The course of the line is unremarkable, the tip of the line projects over the
cavoatrial junction. No complications, notably no pneumothorax. Stable
patient fixation devices. The lung volumes are unchanged and normal.
Borderline size of the cardiac silhouette without pulmonary edema. No
pneumonia, no pleural effusions. No pneumothorax.
Radiology Report
EXAMINATION: CR - CHEST PA LATERAL
INDICATION: ___ year old woman POD #5 6 occiput to T4 fusion and c3-7 fusion;
c3 and c7 corpectomy in halo traction with fever to 103// eval for PNA
TECHNIQUE: Frontal and lateral view radiographs of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
The right upper extremity PICC is in stable position. Postsurgical changes
from cervicothoracic spine fusion. There are low lung volumes. Linear
opacities in the lung bases most likely represent atelectasis. No focal
consolidation, pleural effusion or pneumothorax is identified. The
cardiomediastinal silhouette is stable in appearance.
IMPRESSION:
1. Bibasilar atelectasis.
2. No focal consolidation, pleural effusion or pneumothorax.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ s/p placement of PICC now s/p elopement and PICC coming out.
Please x-ray to confirm placement of PICC still remains in place.// Please
x-ray to confirm placement of PICC still remains in place.
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
The right upper extremity PICC is in stable position. No significant interval
change. Evaluation of the lung apices is limited by patient positioning and
the overlying halo fixation device.
IMPRESSION:
The right upper extremity PICC is in stable position. No significant interval
change.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST; CT T-SPINE W/O CONTRAST
INDICATION: ___ year old woman with osteomyelitis in halo traction.// Evaluate
for infection. Please perform with T-spine CT.
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP: 711 mGy-cm
COMPARISON: CT cervical and thoracic spine on ___
FINDINGS:
Patient is status post anterior posterior spine fusion from the occiput to T4,
with hardware limiting evaluation. There is increased prevertebral soft
tissue swelling and air at the level of the cervical spine. There is no new
definite bony erosion. There are multilevel degenerative changes in the
remainder of the thoracic spine.
There are fractures of the C7-T1 and T1-2 facet joints bilaterally, unchanged.
There has been interval removal of anterior and posterior drains, as well as
enteric and endotracheal tubes. Multiple surgical staples are seen in the
right neck. Surgical staples overlie the posterior soft tissues. There is
emphysema at the lung apices in small bibasilar consolidations.. The thyroid
is unremarkable. A right-sided central venous line is partially visualized.
IMPRESSION:
1. Limited study due to extensive hardware artifact.
2. Increased prevertebral soft tissue swelling compared with CT cervical spine
___, at the site of a prior anterior drain. While this may be
due to non draining postsurgical fluid status post drain removal, it raises
concern for infection, and could be further characterized by MRI if desired.
3. No definite new bony erosion, however no bony significant erosion would be
expected to developed in the short time interval since since surgery even if
infection was present.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman s/p C3-7 fusion and C7 corpectomy and occiput
to T4 fusion.// 4 week post-op follow up 4 week post-op follow up
TECHNIQUE: AP and lateral view radiographs of the cervical spine.
COMPARISON: Cervical spine radiographs ___. CT cervical and
thoracic spine ___.
FINDINGS:
There are postsurgical changes from posterior occipitocervicothoracic spinal
fusion to the level of T4, anterior spinal fusion of C3 through T1 and
placement of an expandable intervertebral body cage at the C3 through C7
levels. There has been interval development of 2 mm of anterolisthesis of C2
on C3.
Multiple surgical clips are seen in the anterior neck. There has been overall
decrease in the prevertebral soft tissue swelling. A right upper extremity
PICC is partially visualized.
IMPRESSION:
1. Postsurgical changes from posterior occipitocervicothoracic spinal fusion
to the level of T4 and anterior spinal fusion of C3 through T1 with an
expandable intervertebral body cage at the C3 through C7 levels.
2. Interval development of 2 mm of anterolisthesis of C2 on C3.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman with hardware, monitor placement/fusion// f/u
hardware
TECHNIQUE: AP and lateral views of the neck were obtained
COMPARISON: ___
FINDINGS:
The patient is status post posterior occipital cervicothoracic spinal fusion
to the level of T4 as well as anterior spinal fusion of C3 through T1 as well
as an expandable intervertebral body cage at the C3 through C7 levels.
Unchanged 2 mm anterolisthesis of C 2 on C3. No acute hardware related
complications are visualized. There is persisting prevertebral soft tissue
swelling. Multiple surgical clips are seen in the anterior neck. The right
PICC line has been removed.
IMPRESSION:
No significant interval change in alignment of the cervical spine.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman with c2-t1 acdf, occiput to t4 posterior
fusion. reports tingling in finger tips today.// please eval hardware
TECHNIQUE: AP and lateral views of the cervical spine were obtained
COMPARISON: ___
FINDINGS:
The patient is status post C3 through T1 anterior fusion as well as placement
of an expandable intervertebral body cage. Additionally the patient is also
post occipitocervical thoracic spinal fusion to the level of T4. The
alignment of the visualized cervical spine is unchanged. There is no evidence
of hardware related complications. No prevertebral soft tissue swelling.
Multiple surgical clips are seen overlying the anterior neck.
IMPRESSION:
No evidence of hardware related complications or interval change in alignment.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman with cervical osteomyelitis and abscess with
c2-t1 ACDF, occiput to t4 posterior fusion.// Hardware evaluation
TECHNIQUE: AP and lateral views of the cervical spine.
COMPARISON: Cervical spine radiograph ___
FINDINGS:
C1 through T1 are demonstrated on the lateral view.
Status post C3-T1 anterior fusion and corpectomy with placement of an
intervertebral body cage and occiput-upper thoracic spine posterior fusion.
The alignment of the visualized cervical spine is unchanged. There is no
evidence of hardware complications. There is no prevertebral soft tissue
swelling. Multiple surgical clips overlie the anterior neck.
IMPRESSION:
No evidence of hardware related complications or interval change in the
alignment.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman with failed c-spine hardware s/p c3-7 fusion;
c3 and c7 corpectomy and occiput to T4 fusion in halo.// Please obtain at 8AM
on ___. Evaluate hardware and fusion
TECHNIQUE: Three views of the cervical spine
COMPARISON: Cervical spine radiographs ___
FINDINGS:
C1 through C7 are demonstrated on the lateral view. Re-demonstrated is an
anterior posterior spine fusion spanning from the occiput to T4, which remains
in grossly unchanged alignment given differences in technique. External
fixation device is partially visualized. Evaluation of the osseous structures
is limited due to extensive overlying hardware. Within this limitation, no
periprosthetic fractures are identified. There is no periprosthetic lucency
to suggest hardware failure. There is no prevertebral swelling. Multiple
surgical clips overlie the anterior neck as seen previously.
IMPRESSION:
Grossly unchanged appearance of spinal fusion hardware with no evidence of
hardware complications.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with halo in place, s/p C3-7 fusion, C3/C7
corpectomy, now with head pain x24-hours. Evaluation for intracranial
abnormality.
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: No prior dedicated imaging of the head for comparison.
FINDINGS:
Study is moderately limited due to extensive streak artifact emanating from
posterior cervical fusion hardware and external halo device. Within these
limitations, there is no definite evidence of intracranial hemorrhage,acute
large territorial infarction,edema,or mass. The ventricles and sulci are
normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
Study is moderately limited due to extensive streak artifact emanating from
posterior cervical fusion hardware and external halo device. Within these
limitations, no definite evidence of acute intracranial abnormality identified
on noncontrast head CT.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman s/p cervical fusion and halo. Now s/p halo
removal.// ? Assessment of fusion and hardware ? Assessment of fusion
and hardware
TECHNIQUE: AP and lateral view radiographs of the cervical spine.
COMPARISON: ___ and prior.
FINDINGS:
C7-T1 are seen on the lateral view. Redemonstrated postsurgical changes of
anterior and posterior cervical spinal fusion, with corpectomy cage spanning
C3 to C7-T1, anterior applied plate from C7-T1 and posterior occiput to T4
fusion hardware. No significant change alignment or evidence for hardware
complication is seen. Again seen are surgical clips in the right neck.
Visualized lung apices are clear.
IMPRESSION:
Anterior posterior and spinal fusion from occiput to T4 without evidence of
interval hardware complication.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with Osteomyelitis of vertebra, site unspecified, Cervicalgia
temperature: 97.5
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 86.0
level of pain: 10
level of acuity: 3.0 | SUMMARY:
========
Ms. ___ is a ___ with polysubstance use disorder (heroin,
cocaine, benzodiazepine, marijuana), c/b levamisole-induced
ANCA+ vasculitis and chronic Hepatitis C, with recent cervical
vertebral osteomyelitis complicated by MSSA bacteremia s/p I&D
of deep neck space abscess, anterior vertebrectomy (C5-6), and
C3-T2 fusion, course complicated by multiple incomplete
antibiotic courses (most recently nafcillin x 5 days) due to
patient leaving the hospital AMA, now presenting with posterior
neck pain, found to have recurrent MSSA bacteremia and hardware
failure. She is now s/p a C3 and C7 corpectomy with a C2-T1 ACDF
and occiput to T4 posterior fusion. Was initially transferred to
the ICU intubated and on pressors. As pressors were weaned and
the patient was extubated, she was transferred to the floor. She
received several units of pRBCs during her admission for
asymptomatic hemoglobin of less than 7. Her staples were removed
during admission and her incision site appeared well-healed at
that time.
ACUTE ISSUES:
=============
#MRSA Bacteremia:
#Osteomyelitis:
Blood cultures positive for MRSA, CRP >100. Likely in the
setting of IV drug use, and concerning for osteomyelitis of the
cervical spine given severe abnormality in spinal hardware as
below. Initially treated with IV nafcillin given history of MSSA
bacteremia, then transitioned to vancomycin once blood cultures
resulted positive. TTE otherwise negative for endocarditis.
PICC was placed. Patient initiated course of vancomycin on
___. Patient had continued fevers so CT of C & T spine was
done ___ given continued fevers, which showed edema and soft
tissue swelling, but no concern for infection. TTE was repeated
___ with no evidence of endocarditis. Fevers resolved. The
patient completed her vancomycin course on ___. She
continued on PO Bactrim per ID recommendations. This will need
to be continued for a minimum of 6 months, potentially
indefinitely. Prior to discharge the ID service recommended
continuing the Bactrim pending outpatient follow-up. She was
given a prescription for these abx and a follow up plan with ID
outpatient.
# Acute C3 vertebral fracture complicated by instrumentation
Failure
History of C5-6 discitis/osteomyelitis s/p corpectomy with
anterior and posterior fusion of C3-T2 by Dr. ___. Repeat
C-spine x-rays now significant for new C3 fracture and severely
displaced posterior spinal hardware. Orthopedics was consulted
and the patient was taken to the operating room on ___ and
underwent a c3-7 fusion with c3 and c7 corpectomy with Dr.
___ Dr. ___. She was placed in halo postop and
remained intubated overnight. She returned to OR on ___
to undergo an occiput to T4 fusion with Dr. ___.
Post-operatively, the patient initially remained in the TSICU
intubated for behavior. She was successfully extubated ___ and
weaned off Precedex. Anterior JP drain was removed ___ and
posterior JP drain was removed ___. Staples were removed on
POD14 and incision was well-healed. Cervical spine Xray obtained
on ___ for 4 week post-op follow up showing the hardware
was intact. Halo remained in-place throughout hospitalization.
Repeat cervical xray C-spine taken on ___ for assessment of
hardware revealed no changes and no hardware complications. On
___, the patient's halo was found to have straps cut by the
patient; ortho tech re-adjusted her halo at that time for proper
placement. Overall plan is to continue halo for a total of 6
months. A follow up cervical Xray on ___ was obtained to
assess interval change and revealed again no hardware
complications or interval change in spinal alignment. A repeat
(monthly) cervical XR was completed on ___, which showed no
interval changes or hardware complications. Patient continued to
be monitored daily for changes in exam. On ___, it was noted
that there was some erythema surrounding her anterior pin sites,
which improved with Bacitracin ointment application QID. On ___
another follow up cervical xray was obtained and revealed stable
instrumentation in good alignment. On ___ a non-contrast head
CT was ordered for pain centered around the pin sites, which was
unrevealing for acute processes. On ___, the halo traction was
removed without complication. Pin sites were without significant
erythema. She was advised to wear a soft collar PRN. She
received another cervical xray for evaluation of hardware on day
of discharge - this was stable.
#Capacity evaluation
Patient became agitated ___ and made 2 attempts to leave the
medical floor against medical advice. Psychiatry was urgently
called for capacity evaluation. Dr. ___ and
Dr. ___ resident) evaluated her and determined that
she lacked capacity to leave AMA or make medical decisions. A
1:1 sitter was ordered for elopement risk, and her healthcare
proxy was ___ and affirmed by the court. Per psych
recommendations, she was treated with haldol and ativan PRN, for
agitation. QTc monitored daily.
On ___, the patient eloped from the floor and was found outside
by security. She was brought back to her room and psych
confirmed that she still did not have capacity to leave AMA. A
1:1 security sitter was placed at bedside. Psychiatry
re-evaluated ___ for capacity and re-invoking HCP, as prior HCP
was invoked for emergency and expired. She was still deemed to
not have capacity by psychiatry. HCP was invoked and medical
certificate filled. She eloped again on ___ down the
stairwell. She was cooperative while being escorted back to her
room and did not require additional medications. She was kept on
a 1:1 sitter for high elopement risk.
Case was escalated to complex case management on ___. Patient
did not have a payer source and complex case management worked
with finance to obtain insurance. Patient was re-evaluated by
Psych on ___. Per Psych, the patient still does not have
capacity to make decisions. Will trial placing 1:1 sitter in
hallway to give patient some more freedom. Psych re-evaluated
patient again on ___ and she continued to not have
capacity. Patient has been re-evaluated on ___ and ___ who
continue to state that patient does not have enough capacity to
leave AMA, however patient is making good progress towards
recovery focused mindset and less impulsivity.
Patient was re-evaluated by addiction psych on ___ and the 1:1
sitter was weaned to 7a-11pm only, before being discontinued all
together. The patient tolerated the sitter wean well, with two
episodes of acute anxiety requiring two-time doses of 10mg of
diazepam with good relief. However, on ___, decision was made
with team and patient to resume methadone to prevent relapse
after patient discharge. She was discharged on Methadone 30mg
daily and set up with a ___ clinic outpatient.
#Opioid use disorder/Adjustment disorder
She has had safety alerts in the past given past misuse of IV
and eloping with PIV in place. Of note, her incomplete adherence
is multifactorial and attributable to insurance issues,
homelessness, lack of transportation, lack of a PCP, and
substance use disorder; withdrawal symptoms have been
prohibitive of a prolonged hospital stay in the past. Pt is
actively using IV heroin, as well as cocaine and
benzodiazepines. Was previously seen by addiction psychiatry,
who recommended starting methadone 30mg daily (10mg TID). She
has been accepted at a ___ clinic (Habit OpCo in ___,
fax: ___. Will provide last dose letter at discharge.
On ___, we started to wean the patient's methadone, and she was
decreased from 10mg TID to 10mg BID. The overall plan was to
wean every five days by a small amount. In the evening of ___
she received 5mg methadone and continued on 5mg BID dose until
___, at which time she was started on 2.5mg BID for one day. She
then was weaned to 2.5mg daily on ___, and discontinued on ___.
Patient re-evaluated by psychology on ___ as she continued to
become increasingly concerned about her opioid use disorder and
how this has affected her life and relationships. Dr. ___
___ patient and recommended increasing Seroquel prn from 25
to 50 mg po bid; and 100mg at bedtime to treat her substance use
disorder in remission and adjustment disorder with mixed
emotions. The patient failed her methadone wean trial and was
restarted on 10mg QD on ___ this was uptitrated to 20mg QD on
___ and 30mg QD on ___. Prior to discharge, the patient's
inpatient medications were reviewed with the psychiatry
consultant and her Ativan was discontinued.
#Social situation
Homeless; unclear how she pays for her heroin. SW/addiction
psych consult as above. Will offer STI screening during
admission. Her disposition has been difficult in the setting of
homelessness and inability to be deemed with capacity throughout
hospitalization. Therefore, her discharge from the hospital was
delayed while searching for appropriate placement. Complex care
meetings were held to try to help find an appropriate
disposition for the patient. Many avenues were tried and none
were found initially. Eventually patient listed a friend as an
HCP who became involved in care in ___, however was unable
to provide support at that time. On ___ case management, psych,
social work and neurosurgery met with the patient's health care
proxy. He agreed to take her home after the halo was removed.
Prior to her discharge her methadone was titrated to daily
dosing, she was weaned off the sitter on ___, and did not
require sitter replacement thereafter. She has a PCP ___
___, NP), with whom she has an appointment on ___ at 1pm
at the ___. Patient was accepted to
___ clinic in ___ for methadone dosing
beginning on ___.
#Severe protein calorie malnutrition
Nutrition consulted, recommending thiamine and multivitamin
daily. Multivitamin changed to MVM with minerals. Vitamin D,
phos, and ionized calcium drawn. Vitamin D was low (16) and she
was started on 800u Vit D daily. Her Phosphate was found to be
persistently elevated, and she was initiated on a low Phosphate
diet and a Phosphate binder with meals. On ___, the patient
refused to take any new medications including her prescribed
vitamins. Throughout this admission, her phosphate was
intermittently checked; however the patient continued to refuse
sevelamer.
CHRONIC ISSUES:
===============
#Untreated HCV:
Will need outpatient follow-up with ID.
#CONTACT: HCP ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Remeron / olanzapine / mirtazapine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old woman with PMHx notable for IBS,
anxiety, depression, GERD and prior PE presents for assessment
of ongoing abdominal pain. The patient has a long history of
abdominal pain that is present in the notes since at least ___.
She has been diagnosed with constipation-predominant irritable
bowel syndrome. She has had ongoing weight loss with her weight
has decreased (___) 152 lbs, ( ___ 162 lbs (___)
140 lbs. SHe reports however that her scale at home was recently
taken away by her ___ as she had been gaining weight. She
reports that her abdominal pain has been worsening over the last
4 months. Pain is worse in the early hours of the morning. She
reports that the pain is worst between the hours of 230am and
___ and improves over the course of the day. She describes the
pain as cramping in nature and located in the lower abdomen.
Sometimes it improves with bowel movements but not always. She
denies any nausea vomiting or difficulty breathing. She reports
that she does not eat as she is not hungry. She denies any chest
pain fevers chills or systemic signs of illness. She denies any
other symptoms at this time. She follows with Dr. ___ in GI.
___ has recently has undergone a colonoscopy that was incomplete
followed by a CT colonoscopy and a CT scan of the abdomen and
has had an MRI of the abdomen as well.
In the emergency department the patient was seen and evaluated.
GI was consulted who did not feel that the patient needed
further evaluation. Her labs were unremarkable, her CT scan was
unchanged from prior. She was given 5mg IV morphine and admitted
to the medical service for further evaluation and management of
her chronic abdominal pain.
ROS: A ten point ROS was conducted and was negative except as
above in the HPI.
Past Medical History:
IBS
Anxiety
Depression
Fibroids
MV prolapse
GERD
PE s/p treatment with eliquis. Diagnosed in ___ without
provoking event.
Social History:
___
Family History:
Per EMR:
No GI disease
Mother had HTN and died of heart failure
Father died of unknown cause ? accident
Brother died of throat cancer, another died of stroke age ___
Maternal aunt with ___ and stroke
Physical Exam:
Admission Physical Exam:
Vitals: 97.7, 117/65, 65, 18, 100%RA
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
CV: RRR, no murmur
PULM: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
GU: NO foley catheter.
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. Fluent speech, no facial droop.
Psych: Full range of affect
Pertinent Results:
Admission Labs:
___ 06:55PM BLOOD WBC-4.9 RBC-4.37 Hgb-11.0* Hct-34.9
MCV-80* MCH-25.2* MCHC-31.5* RDW-16.2* RDWSD-46.7* Plt ___
___ 06:55PM BLOOD Neuts-49.1 ___ Monos-9.1 Eos-0.8*
Baso-0.2 Im ___ AbsNeut-2.38 AbsLymp-1.97 AbsMono-0.44
AbsEos-0.04 AbsBaso-0.01
___ 06:55PM BLOOD Glucose-100 UreaN-16 Creat-0.9 Na-139
K-4.6 Cl-105 HCO3-27 AnGap-12
___ 06:55PM BLOOD ALT-10 AST-39 AlkPhos-59 TotBili-0.3
___ 06:55PM BLOOD Albumin-3.8
___ 06:56PM BLOOD Lactate-1.0
Imaging: (Prelim Report)
___ 07:00AM BLOOD WBC-3.7* RBC-4.16 Hgb-10.7* Hct-33.9*
MCV-82 MCH-25.7* MCHC-31.6* RDW-16.6* RDWSD-49.0* Plt ___
___ 07:00AM BLOOD Glucose-87 UreaN-12 Creat-0.8 Na-140
K-3.8 Cl-105 HCO3-29 AnGap-10
.
CT abd/pelvis:
IMPRESSION:
1. Bilateral prominent ovarian vessels may reflect pelvic
congestion
syndrome, present on prior examinations and can be a cause of
chronic pelvic pain.
2. No acute intraabdominal or pelvic abnormality.
3. Re- demonstrated hepatic and renal cysts.
4. Tarlov cysts unchanged.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ondansetron 4 mg PO Q6H:PRN nausea
2. Lactulose 15 mL PO DAILY:PRN constipation
3. Acetaminophen 500 mg PO Q8H:PRN pain
4. Gabapentin 600 mg PO TID
5. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID
6. Lorazepam 1 mg PO BID
7. Lorazepam 0.5 mg PO DAILY AT NOON
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO BID:PRN constipation
10. Senna 8.6 mg PO BID
11. linaclotide 290 mcg oral DAILY
12. Ranitidine 75 mg PO QHS
13. Calcium Carbonate 1250 mg PO QID:PRN heart burn
14. Paroxetine 5 mg PO QHS
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain
can purchase over the counter. Max daily dose 4gm. No alcohol
with this medication.
2. Calcium Carbonate 1250 mg PO QID:PRN heart burn
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
5. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID
6. Lactulose 15 mL PO DAILY:PRN constipation
7. linaclotide 290 mcg oral DAILY
8. Lorazepam 1 mg PO BID
9. Lorazepam 0.5 mg PO DAILY AT NOON
10. Ondansetron 4 mg PO Q6H:PRN nausea
11. Paroxetine 5 mg PO QHS
12. Polyethylene Glycol 17 g PO BID:PRN constipation
13. Ranitidine 75 mg PO QHS
14. Senna 8.6 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
chronic abdominal pain due to irritable bowel syndrome
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old female with abdominal pain.
TECHNIQUE: Multi detector CT images through the abdomen and pelvis were
obtained after the uneventful administration of intravenous contrast. No oral
contrast was administered. Coronal and sagittal reformations were generated
and reviewed.
DOSE: Total DLP (Body) = 336 mGy-cm.
COMPARISON: CT virtual colonography dated ___. CT abdomen
pelvis from ___.
FINDINGS:
Chest: Bibasilar atelectasis is symmetric and mild. There is no pleural or
pericardial effusion.
Abdomen: Multiple large hepatic cysts are again identified within the liver,
the largest within the right hepatic lobe within segment VII which measures
approximately a 7.3 x 8.5 cm (2:9). There is no intrahepatic biliary duct
dilation. The portal veins are patent. There is no radiopaque cholelithiasis
or gallbladder wall thickening. The pancreas is homogeneous in attenuation
without pancreatic duct dilation. The spleen and bilateral adrenal glands are
normal in appearance.
The kidneys present symmetric nephrograms and excretion of contrast.
Bilateral cortical hypodensities, the largest within the interpolar region of
the right kidney which measures approximately 3.3 x 4.8 cm (02:20) are most
consistent with renal cysts. There is no hydronephrosis or perinephric fluid
collection.
The stomach, duodenum, and loops of small bowel are grossly unremarkable. The
appendix is difficult to visualize but are no inflammatory changes to suggest
acute appendicitis. The colon is unremarkable. There is no abdominal free
fluid or air.
The abdominal aorta is normal in caliber without aneurysmal dilatation.
Moderate atherosclerotic calcifications are present involving predominantly
the infrarenal aorta. There is no retroperitoneal or mesenteric adenopathy.
Pelvis: The bladder is not well distended though grossly unremarkable.
Likely calcified fibroids are present within the uterus. Prominent bilateral
ovarian veins, left greater than right, are noted. There is no pelvic free
fluid. Inguinal and pelvic sidewall nodes are not pathologically enlarged.
Osseous structures: Multiple sacral perineural cysts are again noted as is a
hemangioma within the L3 vertebral body. No osseous lesion worrisome for
malignancy or infection is identified.
IMPRESSION:
1. Bilateral prominent ovarian vessels may reflect pelvic congestion
syndrome, present on prior examinations and can be a cause of chronic pelvic
pain.
2. No acute intraabdominal or pelvic abnormality.
3. Re- demonstrated hepatic and renal cysts.
4. Tarlov cysts unchanged.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Periumbilical pain
temperature: 98.5
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 65.0
level of pain: 7
level of acuity: 3.0 | Pt is a ___ y.o woman with h.o IBS, anxiety, depression, GERD,
prior PE who presented for assessment of ongoing abdominal pain.
.
#acute on chronic abdominal pain likely due to IBS:
#Possible pelvic congestion syndrome
Pt with long standing history of abdominal pain. Followed by GI,
work up has included CT, MRI. Diagnosed as IBS-C. CT raises
concern for possible pelvic congestion syndrome. Continued
hyoscyamine, gabapentin, linaclotide, Colace, senna. Pain was
controlled with acetaminophen. Pt's symptoms were stable and
unchanged from chronic. She was able to tolerate a regular diet.
Labs/imaging unrevealing. SW was consulted for assistance with
anxiety/depression as contributing factors to pt's presentation.
Can consider need for outpt gyn evaluation for ?pelvic
congestion syndrome as seen by imaging but pt's symptoms were
c/w prior presentations related to IBS. She was advised to take
acetaminophen, gabapentin, tums for symptomatic relief. She was
advised to f/u with her outpt GI provider and psychiatrist.
Please see appointments below.
.
#weight loss-pt reports weight loss. She is followed by
nutrition in the outpt setting. Albumin normal on admission. 141
lbs on admit appears stable since at least ___. Nutrition was
consulted and recommended supplements with meals. Social work
consulted.
.
#anxiety/depression-followed by ___ psychiatry. Pt with h.o
depression and long standing somatization of her bowels. Pt
recent started on paxil. Social work consulted. Pt advised to
f/u in the outpt setting after discharge. Continued home
Ativan and paroxetine
.
#GERD-COntinued ranitidine, calcium carbonate.
.
#prior PE, completed course of eliquis
.
FEN: regular, lactose free with supplements
.
DVT PPx:hep SC |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female w/ PMHx HTN, HLD, w/ recent arthroscopic left knee
surgery on ___ to repair a torn meniscus who presents with
saddle PE. She reports that she was told she had a low oxygen
level before her discharge, but it improved enough to go home.
Over the past couple of days, she noted some shortness of breath
with ambulating from her bed to the bathroom that progressed to
"struggling" to breath even when sitting or lying down. Today,
she became acutely more short of breath. Her daughter saw her
today and was concerned and sent her to the ED. She has been
using crutches since her surgery and had been lying down for the
most part since her surgery. She denied chest pain/pressure,
dizziness, lightheadedness. She admits to a slight
non-productive cough. Of note, was recently on vacation from
___ to ___ and ___.
At ___ she had an EKG that showed a RBBB (confirmed as
old after discussion w/ PCP). Labs showed trop to 0.181. She
had a CTA that showed a saddle PE extending into segemental
arteries. She was given 1L NS, started on a heparin gtt, given
ASA 325mg, then transferred to ___.
In the ED, initial vitals: 0 97.5 110 128/80 20 99% 4L Nasal
Cannula. She was continued on a heparin gtt. Labs showed
hyponatremia to 131, tropT of 0.17, AST 58 ALT 48, and PTT of
150. Bedside ED Echo showed slight enlargement of the RV. On
transfer, vitals were: 106 ___ 95% 4L NC. On arrival to
the MICU, she is alert and awake without complaints. Her
breathing is much improved with supplemental O2. She states she
had a colonoscopy last year that was normal, has had yearly
mammograms that are normal as well.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
HTN
HLD
s/p arthroscopic L knee surgery ___ (repair torn meniscus)
Social History:
___
Family History:
Father w/ CVA, mother lived to age ___. Son w/ ___
lymphoma, sister w/ pancreatic CA.
Physical Exam:
ADMISSION EXAM:
VS: 97.9 °F
HR: 99 (99 - 115) bpm
BP: 114/86(93) {114/86(93) - 114/86(93)} mmHg
RR: 21 (21 - 21) insp/min
SpO2: 96%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm with frequent ectopy, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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, left knee with bandaids, mildly warm but nontender, able
to flex actively, no calf tenderness/swelling
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE EXAM:
VS: 97.8 144/80 98 20 92-95% RA
GENERAL: awake, alert, oriented, resting comfortably, NAD
HEENT: sclera anicteric, MMM
NECK: supple, JVP not elevated
CARDIAC: RRR, no r/m/g
LUNGS: CTAB, no wheezes/rales/rhonchi, good air movement
ABDOMEN: soft, NT, ND, bowel sounds present
EXTREMITIES: warm, well-perfused, 2+ pulses, no edema
SKIN: no rashes or jaundice
Pertinent Results:
ADMISSION LABS:
___ 10:45PM GLUCOSE-166* UREA N-20 CREAT-0.9 SODIUM-131*
POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-20* ANION GAP-19
___ 10:45PM ALT(SGPT)-48* AST(SGOT)-58* ALK PHOS-69 TOT
BILI-0.4
___ 10:45PM cTropnT-0.17* proBNP-4718*
___ 10:45PM ALBUMIN-3.8
___ 10:45PM WBC-7.8 RBC-4.25 HGB-12.5 HCT-37.6 MCV-88
MCH-29.3 MCHC-33.2 RDW-14.0
___ 10:45PM NEUTS-48.3* ___ MONOS-10.7 EOS-0.5
BASOS-0.6
___ 10:45PM PLT COUNT-160
___ 10:45PM ___ PTT-150* ___
OTHER LABS:
___ 10:45PM BLOOD ALT-48* AST-58* AlkPhos-69 TotBili-0.4
___ 05:34AM BLOOD ALT-83* AST-59* AlkPhos-70 TotBili-0.4
___ 07:35AM BLOOD ALT-100* AST-53* AlkPhos-69 TotBili-0.4
___ 06:40AM BLOOD ALT-99* AST-47* AlkPhos-71 TotBili-0.4
___ 10:45PM BLOOD ___ PTT-150* ___
___ 07:35AM BLOOD ___ PTT-81.8* ___
___ 01:00PM BLOOD ___ PTT-78.7* ___
___ 09:34PM BLOOD ___ PTT-86.5* ___
___ 06:40AM BLOOD ___ PTT-89.8* ___
___ 06:50AM BLOOD ___ PTT-125.7* ___
___ 10:45PM BLOOD cTropnT-0.17* proBNP-4718*
___ 01:32PM BLOOD proBNP-4928*
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-3.8* RBC-3.81* Hgb-11.0* Hct-33.8*
MCV-89 MCH-28.8 MCHC-32.5 RDW-14.2 Plt ___
___ 06:40AM BLOOD Glucose-120* UreaN-14 Creat-0.7 Na-136
K-3.9 Cl-101 HCO3-25 AnGap-14
___ 06:50AM BLOOD ___ PTT-125.7* ___
STUDIES:
CTA Chest (___) ___: SIGNIFICANT BILATERAL PULMONARY
EMBOLISM, WITH SUGGESTION OF RIGHT HEART STRAIN. VIRTUALLY ALL
SEGMENTAL PULMONARY ARTERIES ARE INVOLVED WITH MANY OF THEM MORE
DISTAL PULMONARY ARTERIES APPEARING OCCLUDED AS WELL.
TTE ___: The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is at least 15
mmHg. The interatrial septum is bowed towards the left atrium
c/w relatively increased right atrial pressure. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with focal basal free wall
hypokinesis ___ sign). There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension.
IMPRESSION: Mild right ventricular cavity dilation with
hypokinesis of the basal ___ of the free wall. Moderate
pulmonary artery hypertension. Mild-moderate tricuspid
regurgitation.
LENIS ___: No bilateral lower extremity deep venous
thrombosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Valsartan 320 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Vitamin D Dose is Unknown PO DAILY
5. Aspirin 162 mg PO DAILY
6. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Aspirin 162 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Valsartan 320 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Vitamin D 0 UNIT PO DAILY
___ MD to order daily dose PO DAILY16
RX *warfarin 2 mg ___ tablet(s) by mouth daily as directed Disp
#*60 Tablet Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Fish Oil (Omega 3) 0 mg PO DAILY
9. Outpatient Lab Work
Please check INR on ___ and send results to Dr. ___
___, Phone: ___, Fax: ___
ICD-9: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: pulmonary embolism
Secondary diagnoses: hypertension, transaminitis
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: Saddle pulmonary emboli. Evaluate for lower extremity DVT.
COMPARISON: CTA chest ___.
FINDINGS: Gray scale and color Doppler sonograms with spectral analysis of the
bilateral common femoral, superficial femoral, popliteal, peroneal, and
posterior tibial veins were performed. There is normal compressibility, flow,
and augmentation. Normal phasicity is seen in the common femoral veins
bilaterally.
IMPRESSION: No bilateral lower extremity deep venous thrombosis.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: PE'S
Diagnosed with PULM EMBOLISM/INFARCT
temperature: 97.5
heartrate: 110.0
resprate: 20.0
o2sat: 99.0
sbp: 128.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ with HTN, HL, several recent plane trips, and recent knee
surgery, who initially presented with dyspnea and was found to
have saddle PE.
# Submassive PE - PESI of 118 indicating - Class IV, High Risk:
4.0-11.4% 30-day mortality in this group. Also presenting with
hyponatremia which portends an increased mortality risk. She was
admitted to the MICU for monitoring of her provoked PE and
continued on a heparin gtt. She remained hemodynamically stable.
Troponin and BNP were elevated at 0.17 and 4718, suggestive of R
heart strain and TTE confirmed this finding. The team discussed
potential lysis with the patient and family, but ultimately she
decided against it. LENIs were performed to assess indication
for potential IVC filter placement, but LENIs were negative for
clot. She was started on warfarin on ___ and transferred to
the medical floor. She remained hemodynamically stable and was
weaned of supplemental oxygen. INR first therapeutic at 2.2 on
___, and then became supratherapeutic on ___ at 4.4.
Heparin gtt continued until ___, then stopped with 80 mg SC
enoxaparin given one hour later (which completed her bridging
therapy). She was instructed to hold warfarin ___, have INR
checked ___, and follow-up with her PCP's office about
subsequent warfarin dosing. Will likely need 3 months of
anticoagulation.
# Hyponatremia - ___ have been related to acute PE, or possibly
mild hypovolemia. Resolved without intervention except as above.
# Transaminitis - AST/ALT elevated; Tbili/AlkPhos WNL. ___ be
related to mild hepatic congestion in setting of right sided
congestion from PE. Would expect improvement in LFTs as PE
starts to recanalize and RV function improves. Patient did not
have any RUQ abdominal pain during the admission. Would
recommend rechecking in outpatient setting and pursuing further
work-up if not improving.
# HLD - Stable, continued atorvastatin.
# HTN - Stable. Initially held metoprolol and valsartan in
setting of PE, but restarted prior to discharge as patient
remained hemodynamically stable.
# s/p L meniscus repair - Pain controlled with tylenol,
oxycodone prn pain. Monitored for bleeding into knee, but exam
remained stable. Will follow-up with surgeon ___. Will
start home ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion L3-S1
L4-5 discectomy
History of Present Illness:
___ with PMH s/p L3-S1 laminectomy/discectomy for cauda equina
___ by Dr. ___ p/w left low back pain since yesterday.
Bent over to pick up his computer bag and twisted somehow and
had immediate severe pain in left low back radiating down to L
knee. Throughout day pain progressed and also feels slightly
weaker in LLE although has some baseline LLE weakness, as well
as R foot drop at baseline. At baseline has some mild saddle
anesthesia and decreased rectal tone (does self rectal
stimulation as needed) this has not changed recently. No
urinary/bowel incontinence but some evidence for retention. No
hx IVDU, other trauma, fevers/chills, headache, pain elsewhere.
Today pain was so bad was unable to ambulate so came to ED.
Past Medical History:
- Cauda equina s/p L3-S1 laminectomy with L3-4 discectomy
- Seasonal allergies
Social History:
___
Family History:
Grandmother with colon ___
Mother with liver ___
Father with esophageal ___
Grandfather with renal ___
Physical Exam:
GEN: Well appearing, pleasant middle aged man in NAD
VS 98.0 80 144/85 16 100% RA
Motor
Delt EF EE WF WE Grip IO
R ___ 5
L ___ 5
Sensation grossly intact in all UE dermatomes
Add Quad HS TA ___
R ___
L ___ 4+ 4+ 4+
Sensation grossly intact in all ___ dermatomes
Reflexes
R/L
Biceps 1+
Triceps 1+
BR 1+
Patella 1+
Achilles 1+
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: minimally diminished
Pertinent Results:
___ 06:15AM BLOOD WBC-6.7 RBC-3.01* Hgb-8.7* Hct-26.3*
MCV-87 MCH-28.8 MCHC-33.0 RDW-12.9 Plt ___
___ 05:55AM BLOOD WBC-11.8* RBC-3.74* Hgb-10.7* Hct-32.6*
MCV-87 MCH-28.6 MCHC-32.9 RDW-12.9 Plt ___
___ 09:00PM BLOOD WBC-15.5* RBC-4.08* Hgb-11.7*# Hct-35.7*#
MCV-87 MCH-28.7 MCHC-32.8 RDW-12.9 Plt ___
___ 10:24AM BLOOD WBC-15.7*# RBC-5.35 Hgb-15.4 Hct-46.8
MCV-88 MCH-28.8 MCHC-32.9 RDW-13.0 Plt ___
___ 05:55AM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-137
K-4.5 Cl-101 HCO3-28 AnGap-13
___ 09:00PM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-140
K-4.4 Cl-104 HCO3-27 AnGap-13
___ 10:24AM BLOOD Glucose-115* UreaN-13 Creat-1.2 Na-140
K-4.7 Cl-101 HCO3-29 AnGap-15
___ 06:30AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-140
K-4.4 Cl-103 HCO3-30 AnGap-11
___ 05:55AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.7
___ 09:00PM BLOOD Calcium-7.6* Phos-3.3 Mg-1.6
Medications on Admission:
Dilaudid
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q3H Disp #*200 Tablet
Refills:*0
2. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine [MS ___ 30 mg 1 tablet extended release(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Diazepam ___ mg PO Q8H:PRN spasm
RX *diazepam 5 mg ___ tablets by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lumbar stenosis and disc herniation
Discharge Condition:
Good
Followup Instructions:
___
Radiology Report
INTRAOPERATIVE RADIOGRAPHS OF THE LUMBAR SPINE
CLINICAL INDICATION: ___ male status post lumbar spinal fusion.
TECHNIQUE: Four intraoperative radiographs of the lumbar spine were obtained.
___.
FINDINGS:
A marker was placed between the L4 through L5 intervertebral disc space.
There has previously been laminectomy from L2 through L5. There is presumed
anterior fusion from L3 to S1. Please refer to the intraoperative report for
further details.
IMPRESSION: A marker placed between the L4 through L5 intervertebral disc
space. Please refer to the intraoperative report for further details.
Radiology Report
INTRAOPERATIVE RADIOGRAPHS OF THE LUMBAR SPINE:
CLINICAL INDICATION: Status post fusion of L3 through S1.
TECHNIQUE: Six intraoperative radiographs of the lumbar spine were obtained.
___.
FINDINGS:
There has been laminectomy at at least L2 through L5. Markers were placed
posterior to the lower lumbar vertebral bodies. There has been interval
posterior fusion of L3 through S1. No overt hardware complication is seen.
Mild degenerative change is present through the lower lumbar spine with
spurring about the vertebral bodies. Please refer to the intraoperative
report for further details.
IMPRESSION: Status post posterior fusion of L3 through S1, without overt
hardware complication. Please refer to the intraoperative report for further
details.
Radiology Report
HISTORY: Patient with lumbar stenosis, evaluate for residual disc.
COMPARISON: MR ___ from ___.
TECHNIQUE: Multiplanar, multi sequence MR images of the lumbar spine were
obtained without the administration of IV contrast.
FINDINGS:
At the T12-L1 level, there is mild midline disc protrusion without spinal
stenosis. At the L1-L2 level, there is a mild disc bulge and tiny protrusion
with minimal encroachment on the spinal canal.
At the L2 -L3 level, there is a disc protrusion and annular tear left of the
midline without significant spinal canal stenosis. There is evidence of a
prior laminectomy.
At the L3-L4 level, there is limited view at this level, but no apparent
abnormalitY is identified. There has also been previous laminectomy.
At the L4-L5 level, there has been slight interval improvement in the right
sided annular tear and disc protrusion. However, a large residual disc
fragment remains on the left with protrusion into ventral thecal sac. This
fragment extends superiorly into the posterior margin of the L4 vertebral
body, unchanged in appearance since preop study. There is mild to moderate
right neuroforaminal narrowing due to facet osteophytes and ligamentum flavum
thickening.
At the L5-S1 level, there has been a laminectomy with pedicle screws without
significant disc bulge.
There is expected postoperative edema in the spinal erector muscles. High
signal intensity is seen in L3 and L4 vertebral bodies on STIR sequence
consistent with postsurgical marrow edema. The distal spinal cord
demonstrates normal signal characteristics.
IMPRESSION:
1. Slight improvement in L4-L5 right sided disc bulge. However, there is a
large left-sided residual disc herniation fragment extending superiorly to the
posterior margin of the L4 vertebral body.
2. Multilevel degenerative changes as described above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BACK PAIN
Diagnosed with LUMBAR DISC DISPLACEMENT, BACKACHE NOS
temperature: 98.8
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 158.0
dbp: 82.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ was admitted to the ___ Spine Surgery Service on
___ and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 he returned to the operating room for a
scheduled L3-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was stable. A bupivicaine
epidural pain catheter placed at the time of the posterior
surgery remained in place until postop day one. Post-op he
continued to have considerable sciatica and a new MRI was
obtained which showed a large disc fragment behind the L4
vertebral body. He was taken to the OR for a L4-5 discectomy
and tolerated the procedure well. He was kept NPO until bowel
function returned then diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#2 from the second procedure.
He was fitted with a lumbar warm-n-form brace for comfort.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
Ms. ___ is ___ w/ PMH significant for Rapid AFib on
Xarelto & PPM in situ, congestive heart failure? diastolic,
sleep
apnea, hypertension, hyperlipidemia, depression, asthma hx of
gallstones, was treated for UTI ___, treated for suspected
cholangitis since ___, ERCP on ___ who presents to ___ from
___ (left AMA)for gallbladder removal.
HPI (Chart review, pt hx, PCP):
___
Pt presented to ___ on ___ with fever (___)
and abdominal pain, confusion, headache, N/V/D, generalized
weakness for several days. Started on Macrobid for UTI on
___.
In ER at ___, she was found to be hypotensive with systolic
BPs in the ___ despite receiving 5L of IV fluids and was started
on neo-synephrine.
She had elevated LFTs(bilirubin 2.2, AST 196, ALT 215), and CT
suggested biliary tract pathology and was transferred to ___ ICU due to hypotension in setting of rapid AFib.
___ was treated with Levofloxacin and metronidazole empirically
when patient was admitted to ___. in septic shock with
worry
for cholangitis. ERCP performed on ___ that showed diffuse
erosive gastropathy, submucosal polyp of postbulbar duodenum s/p
biopsies, normal major ampulla with small periampullary
diverticulum, cholelithiasis without evidence of
choledocholithiasis. Sphincterotomy performed.
She was also found to have a RLL infiltration on and right
pleural effusion on ___ with mild increase of both on ___.
She was waiting surgical evaluation for probably cholecystectomy
but patient left ___ on ___ because pt
preference for procedure to be performed at ___ and impatience
with staff at ___, being rejected for transfer ___ no
medical indication & wishing to see her cardiologist at ___
for
her atrial fibrillation prior to her undergoing cholecystectomy.
In ___ ED
She presented very weak, nausea, no vomiting, problems walking
around, new onset headaches since ___. L>R Arms/shoulder pain
and weakness that has been hurting since ERCP. She and her two
sons (present at bedside) states that she is still confused but
improved since the surgery. She also endorses dull periumbilical
discomfort. ROS per HPI, otherwise negative. ACS surgery was
consulted.
Past Medical History:
DEPRESSION
PANIC ATTACKS
BACK PAIN
HYPERTENSION
HYPERCHOLESTEROLEMIA
ASTHMA
COLONIC ADENOMA
VITAMIN D DEFICIENCY
ATRIAL FIBRILLATION
CONGESTIVE HEART FAILURE
OBESITY
ARTHRITIS
SLEEP APNEA
Social History:
___
Family History:
Mother with multiple strokes.
Father with AFib (deceased).
3 Brothers with AFib.
Physical Exam:
Admission Physical Exam:
Gen: NAD, AxOx3
Card: Irregularly irregular
Pulm: CTAB, no respiratory distress
Abd: Soft, obese, non-tender, non-distended, normal bs.
Ext: No edema, warm well-perfused
Discharge Physical Exam:
VS: 98, 110/74, 82, 18, 91 Ra
Gen: A&O x3. sitting up dressed
CV: HRR
Pulm: LS dim at bases
Abd: soft, mildly TTP around incisions. Lap sites CDI.
Ext: WWP no edema
Pertinent Results:
___ 01:52PM BLOOD WBC-5.6 RBC-4.29 Hgb-13.3 Hct-43.0
MCV-100* MCH-31.0 MCHC-30.9* RDW-13.2 RDWSD-48.8* Plt ___
___ 05:35AM BLOOD WBC-5.6 RBC-4.73 Hgb-14.5 Hct-44.4 MCV-94
MCH-30.7 MCHC-32.7 RDW-13.1 RDWSD-44.5 Plt ___
___ 06:23AM BLOOD WBC-4.1 RBC-4.26 Hgb-13.4 Hct-41.5 MCV-97
MCH-31.5 MCHC-32.3 RDW-13.1 RDWSD-46.5* Plt ___
___ 01:52PM BLOOD Glucose-112* UreaN-7 Creat-0.5 Na-143
K-4.8 Cl-98 HCO3-31 AnGap-14
___ 05:35AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-142
K-4.1 Cl-100 HCO3-25 AnGap-17
___ 06:23AM BLOOD Glucose-112* UreaN-7 Creat-0.6 Na-144
K-4.7 Cl-107 HCO3-26 AnGap-11
___ 01:52PM BLOOD ALT-29 AST-25 AlkPhos-42 TotBili-0.4
___ 05:35AM BLOOD ALT-33 AST-22 LD(LDH)-202 AlkPhos-45
TotBili-0.6
___ 01:52PM BLOOD Calcium-9.2 Phos-3.5 Mg-1.9
RUQUS:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded on the basis of this examination. No focal liver
lesions.
2. Cholelithiasis without sonographic evidence to suggest acute
cholecystitis.
Chest X-Ray ___: Moderate right and small left bilateral
pleural effusions with associated compressive atelectasis. Low
lung volumes without definite pulmonary edema.
Chest x-ray ___: Low lung volumes accentuate the prominence
of the cardiac silhouette in this patient with a single lead
pacer extending to the right ventricle. Atelectatic changes
are seen above the elevated right hemidiaphragmatic contour.
The left lung is essentially within normal limits.
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Gallbladder, cholecystectomy:
- Chronic cholecystitis and cholelithiasis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Spironolactone 12.5 mg PO DAILY
4. Rivaroxaban 20 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Diltiazem Extended-Release 180 mg PO BID
7. Gabapentin 600 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 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 -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
4. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
5. Diltiazem Extended-Release 180 mg PO BID
6. Furosemide 20 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pravastatin 40 mg PO QPM
10. Rivaroxaban 20 mg PO DAILY
11. Spironolactone 12.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with abdominal pain after lap ccy//
consolidation?
IMPRESSION:
A in comparison with the study of ___, there has been the development of
substantial pneumoperitoneum, presumably related to the recent surgery. Low
lung volumes accentuate the prominence of the cardiac silhouette in this
patient with a single lead pacer extending to the right ventricle.
Atelectatic changes are seen above the elevated right hemidiaphragmatic
contour. The left lung is essentially within normal limits.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Calculus of gallbladder w/o cholecystitis w/o obstruction, Pleural effusion, not elsewhere classified, Unspecified atrial fibrillation
temperature: 98.3
heartrate: 93.0
resprate: 18.0
o2sat: 94.0
sbp: 109.0
dbp: 66.0
level of pain: 10
level of acuity: 3.0 | 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, IV
antibiotics x24hrs for gallbladder exposure to pre-existing
umbilical mesh, and oral analgesia for pain control. The
patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
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. Xarelto was restarted
on POD2.
.
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: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female who was found down this morning. She is with
her daughter. The patient does not remember the fall but knows
that she fell. She was found down this morning around 11AM by
her daughter, last seen the previous night around 9PM. Reports
pain "everywhere," not localizing to any one area. Went to ___
___ then transferred here after a pan-scan. No symptoms
other than pain.
Past Medical History:
PMHx: COPD, neuropathy, NSTEMI, dCHF, anemia, gout, stage III
kidney disease
PSHx: tonsillectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
VS: 98.2, 97, 95/59, 15, 100% 3L NC
Gen: NAD, thin woman
Neuro: GCS 15, CN intact
HEENT: scalp lac that is stapled
CV: RRR
Pulm: CTA b/l
Abd: soft, nondistended, nontender
Pelvis: stable
Ext: b/l lower legs with chronic venous stasis changes,
otherwise
no lesions, bruises, or abrasions to upper or lower extremities
Back: no lesions, no tenderness to the spine, no stepoffs
Discharge Physical Exam:
VS: T: 97.8 PO BP: 109/65 HR: 105 RR: 20 O2: 91% 3L
GEN: A+Ox3, NAD
HEENT: Left scalp laceration with staples OTA, wound
approximated, no s/s infection
CV: Sinus tachycardia
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: trace edema b/l ___, no induration or erythema. b/l chronic
venous stasis changes
Pertinent Results:
IMAGING:
OSH imaging, reviewed with radiology here, reads from OSH below
NCHCT: No acute abnormality
CT C spine: No evidence of acute cervical spine fracture
CT chest: Multiple left rib fractures (left lateral fourth rib,
left posterolateral eighth and ninth ribs). Severe chronic
emphysematous changes.
CT A/P: No evidence of solid organ or visceral injury. Multiple
pelvic fractures b/l. Fractures include bilateral pubic rami,
left acetabulum, and left sacrum. (On re-read here, also likely
chronic L2 compression fracture.)
___: CXR:
No focal consolidation.
___: ECHO:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses are normal. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF = 80%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). There is
no left ventricular outflow obstruction at rest or with
Valsalva. There is no ventricular septal defect. with normal
free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
___: PELVIS W/JUDET VIEWS (3V):
Known bilateral inferior pubic rami and right superior pubic
ramus fractures again demonstrated. Known L2 fracture not well
seen on current radiograph. No evidence of additional
fractures.
___: FOOT AP,LAT & OBL LEFT:
Hammertoe configuration of the digits. No acute fracture or
dislocation.
___: CTA Chest:
No evidence of pulmonary embolism or aortic abnormality.
Multiple acute left-sided rib fractures.
Severe emphysematous changes throughout the lungs.
Small bilateral pleural effusions, which have mildly increased
since the
previous study.
___: CXR:
Lungs are hyperexpanded with stable bilateral pleural effusions
and bibasilar atelectasis. Mild pulmonary vascular congestion
is unchanged. There is biapical pleural thickening. No
pneumothorax is seen
LABS:
___ 06:51PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:51PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 06:51PM URINE HYALINE-8*
___ 06:51PM URINE MUCOUS-RARE*
___ 05:29PM K+-3.9
___ 05:25PM GLUCOSE-118* UREA N-17 CREAT-1.0 SODIUM-137
POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-29 ANION GAP-13
___ 05:25PM CK(CPK)-900*
___ 05:25PM CALCIUM-8.6 PHOSPHATE-4.2 MAGNESIUM-1.8
___ 05:25PM WBC-14.3* RBC-4.85 HGB-10.7* HCT-34.7 MCV-72*
MCH-22.1* MCHC-30.8* RDW-17.2* RDWSD-42.3
___ 05:25PM NEUTS-84.6* LYMPHS-8.9* MONOS-5.1 EOS-0.6*
BASOS-0.2 IM ___ AbsNeut-12.12* AbsLymp-1.27 AbsMono-0.73
AbsEos-0.08 AbsBaso-0.03
___ 05:25PM PLT COUNT-233
___ 05:25PM ___ PTT-26.1 ___
MICROBIOLOGY:
___ 6:51 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Gabapentin 300 mg PO BID
3. Allopurinol ___ mg PO DAILY
4. Tiotropium Bromide Dose is Unknown IH DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aquaphor Ointment 1 Appl TP TID:PRN legs
3. Docusate Sodium 100 mg PO BID
please hold for loose stool
4. Heparin 5000 UNIT SC BID
5. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Metoprolol Tartrate 6.25 mg PO BID
Hold for SBP<100, HR<60
8. Nystatin Cream 1 Appl TP BID to groin as needed
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
10. Sarna Lotion 1 Appl TP BID:PRN to psoriatic patches
11. Senna 17.2 mg PO HS
Hold for loose stool
12. Tiotropium Bromide 2 puffs IH DAILY
13. Allopurinol ___ mg PO DAILY
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
15. Furosemide 40 mg PO DAILY
16. Gabapentin 300 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Scalp laceration
-Left 4,8,9th rib fractures
-Bilateral pubic rami fractures
-Left acetabular fracture
-Left sacral fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with fall, multiple traumatic fractures// preop?
TECHNIQUE: Frontal chest radiograph
COMPARISON: None.
FINDINGS:
The lungs are hyperinflated with multiple areas of lucency mostly at the
apices, suggestive of severe emphysema. Increased reticular opacities are
suggestive of underlying chronic lung disease. No focal consolidation is
seen. The heart size is within normal limits. The pulmonary vasculature are
within normal limits.
IMPRESSION:
No focal consolidation.
Radiology Report
EXAMINATION: DX PELVIS/INLET AND OUTLET/JUDET
INDICATION: ___ with b/l rib fractures, pelvic fx, old L2 compression fx
(trauma consult)// AP, inlet, outlet, judet views
TECHNIQUE: AP, inlet, outlet and Judet views of the bilateral hips.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
Diffuse osteopenia limits evaluation of subtle osseous abnormalities.
However, within these limitations:
There are known fractures of the bilateral inferior pubic rami and right
superior pubic ramus. A known L2 fracture is not well appreciated on
radiograph, better seen on CT. Otherwise, no evidence of additional fractures
within limitations of radiographic.
IMPRESSION:
Known bilateral inferior pubic rami and right superior pubic ramus fractures
again demonstrated. Known L2 fracture not well seen on current radiograph.
No evidence of additional fractures.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ year old woman with heel pain after fall// eval fracture
TECHNIQUE: AP lateral and oblique views of the left foot.
COMPARISON: None available.
FINDINGS:
No acute fractures or dislocation are seen. There is hammertoe configuration
of multiple digits. There are moderate degenerative changes.
IMPRESSION:
Hammertoe configuration of the digits. No acute fracture or dislocation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with COPD, rib fxs. Desat'd ___// etiology of
desat
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph performed 10 hours earlier.
FINDINGS:
Incr mild pulmonary vasculature persistent and there is new mild edema at the
left lung base. Hyperinflation indicates emphysema. Heart size normal.
Small pleural effusions are likely.
IMPRESSION:
Emphysema. New, mild congestive heart failure.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 5:43 am, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y/o F w/ hx CHF, desat 62%// eval for pulmonary edema
eval for pulmonary edema
IMPRESSION:
Comparison to ___. Minimal new bilateral pleural effusions.
Otherwise unchanged radiograph, signs of mild to moderate interstitial
pulmonary edema. Borderline size of the heart. No evidence of pneumonia. No
pneumothorax.
Radiology Report
EXAMINATION: CTA chest
INDICATION: ___ year old woman with tachycardia, hypoxia and syncope// eval
for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.9 s, 38.7 cm; CTDIvol = 6.3 mGy (Body) DLP = 242.2
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 1.8 s, 0.5 cm; CTDIvol = 9.9 mGy (Body) DLP = 5.0
mGy-cm.
Total DLP (Body) = 249 mGy-cm.
COMPARISON: ___
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 segmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental
pulmonary arteries. Assessment of the subsegmental branches is limited by
respiratory motion artifact. The main and right pulmonary arteries are normal
in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
Subcentimeter mediastinal lymph nodes are increased in number but not
significant by size criteria, the largest mediastinal lymph node is a 8 mm
aortopulmonary window lymph node. The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There are small bilateral
pleural effusions.
There is severe centrilobular emphysema. Passive subsegmental atelectatic
changes are present in both lung bases. Scarring is noted at both lung
apices. There is mucus/secretions in the lower trachea, just above the
carina.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
There are acute, minimally displaced fractures of the left fourth, fifth and
sixth ribs posteriorly, just beyond the costotransverse joints. In addition,
there are acute nondisplaced fractures of the left eighth and ninth ribs
posterolaterally.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Multiple acute left-sided rib fractures.
Severe emphysematous changes throughout the lungs.
Small bilateral pleural effusions, which have mildly increased since the
previous study.
NOTIFICATION: The findings were discussed with SICU resident by ___ ___,
M.D. on the telephone on ___ at 6:52 pm, within 10 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with h/o heart failure and syncopal fall with
rib fractures now with increasing O2 requirements// fluid overload? pneumonia?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs low volume with slight improvement in the bilateral pleural effusions
right greater than left. Cardiomediastinal silhouette is stable. No
pneumothorax is seen. There is biapical parenchymal scarring.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with history of COPD, NSTEMI, CHF, CKD
admitted to TSICU for hypoxia in setting of 3 x left sided rib fractures, left
acetabular fracture, L sacral fracture. Evaluation for interval change.
TECHNIQUE: Chest portable AP
COMPARISON: Chest radiograph from ___. CTA chest from ___
FINDINGS:
Cardiomediastinal silhouette is stable and within normal limits. Lung volumes
are low. Slight interval worsening in small bilateral pleural effusions with
subjacent bibasilar atelectasis. No pneumothorax is seen.
IMPRESSION:
Slight interval worsening in small bilateral pleural effusions with subjacent
bibasilar atelectasis. Otherwise little change from prior day's radiograph.
Radiology Report
INDICATION: ___ year old woman with rib fractures// Please evaluate for
interval change
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are hyperexpanded with stable bilateral pleural effusions and bibasilar
atelectasis. Mild pulmonary vascular congestion is unchanged. There is
biapical pleural thickening. No pneumothorax is seen
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pelvic pain, Rib pain, s/p Fall
Diagnosed with Oth fracture of left acetabulum, init for clos fx, Other fracture of sacrum, init encntr for closed fracture, Oth fracture of left pubis, init encntr for closed fracture, Oth fracture of right pubis, init encntr for closed fracture, Multiple fractures of ribs, left side, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 98.2
heartrate: 98.0
resprate: 18.0
o2sat: 96.0
sbp: 105.0
dbp: 70.0
level of pain: 5
level of acuity: 2.0 | Mrs ___ is a ___ y/o F w/ PMH COPD, NSTEMI, CHF, ___
transferred from OSH after fall at home on ___. She was
found to have 3 left-sided rib fractures (Ribs 4,8,9), bilateral
pubic rami fractures, a left acetabular fracture, left sacral
fracture and a scalp laceration. The patient was admitted to
the Trauma Surgery service where she received pain medication
and pulmonary toileting. The Orthopedic Surgery service was
consulted for the patient's pubic rami, acetabular and sacral
fractures and recommended non-operative management and she could
be WBAT BLE.
The patient was transferred to the ___ on ___ for hypoxia
on floor associated with tachycardia. A chest x-ray was done
which showed: minimal new bilateral pleural effusions. Otherwise
unchanged radiograph, signs of mild to moderate interstitial
pulmonary edema. Borderline size of the heart. No evidence of
pneumonia. No pneumothorax. An EKG was done which showed sinus
tach with a few runs of atrial fibrillation. The patient
received 20mg IV Lasix and was transferred to the ICU.
On Arrival to ___ she was tachycardic but 99% on 6L NRB. she
required no sedation her pain was controlled with Morphine ___
IV Q4H PRN, Oxyocodone ___ PO Q4H PRN, Acetaminophen 650 mg
PO: PRN and Lidocaine Patch QAM. A trial of IVF bolus showed no
improvement in tachycardia. TTE was performed for possible
syncopal episode showing EF 80% and fluid overload. The patient
had a CT PE for hypoxia/tachycardia without evidence of PE.
Her O2 req was improved with IV Lasix but she remained
persistently tachycardic. the patient was given IV metoprolol
which resulted in improvement of her HR but decrease in her BP
which necessitate fluid boluses. O2 was weaned and the patient
remained stable on ___ NC. The Pulmonary service was consulted
for help with ongoing management of her COPD. Pulmonary
recommended her O2 goal should be between 88%-92% and
recommended that the patient follow-up in the outpatient
Pulmonary clinic for pulmonary function testing and further
management.
The patient's pain was well controlled and she resumed her
regular diet without any issues. she was transferred back to
the floor to continue her recovery.
The patient worked with Physical Therapy and it was recommended
that she be discharged to rehab to continue her recovery. At the
time of discharge, the patient was doing well, afebrile with
stable vital signs. The patient was tolerating a regular diet,
ambulating with the rolling walker with assist, 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: F
Service: MEDICINE
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
Fever and blood per rectum
Major Surgical or Invasive Procedure:
Flexible sigmoidascope w/ transmural biopsy
History of Present Illness:
Ms. ___ is a ___ year old female with CAA and a h/o CVA
(nonverbal & bedbound for past 2 months) who presented to
___ from ___ with fever (101.1) and small volume GI
bleeding (found in her diaper). She was brought to ___
___ ED where workup revealed a febrile patient with a WBC
of 14, Hct was 35, and LFT in normal ranges. She had recently
been treated for a pan-sensitive enterococcus UTI with
amoxicillin but was swtiched to macrobid due to rash
development. At ___, a CT showed severe proctitis with
multiple intramural abscesses in wall of rectum, measuring up to
2cm in size. She was started on ceftriaxone and flagyl and
transfered to ___.
At ___, repeat labs showed hct of 30 from 35 (however, WBC and
plt also was lowered indicative of resuscitation and dilution).
Lactate remained wnl, as were LFT. She was afebrile in the ED
with ongoing abx. Per ___ ED report, patient's HCP ___
___ son)
was contacted and ___ was discussed: She is Full Code and HCP
agreed patient would want surgery should this be the case.
However, he wanted to be contacted prior to any procedures.
Past Medical History:
HLD
H/O CVA
DEPRESSION
CEREBRAL AMYLOID ANGIOPATHY
COGNITIVE IMPAIRMENT
S/P CHOLECYSTECTOMY
COLON POLYPS
G-tube
Social History:
___
Family History:
No family history of colonic abnormalities per report
Physical Exam:
ADMISSION EXAM
====================================
Vitals: 97.6 85 96/45 16 96% RA
GEN: Comfortable appearing. Does not answer questions. Does not
follow command. Resistant to physical exam.
HEENT: Opens eyes spontaneously. No scleral icterus, mucus
membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: S/NT/ND. no rebound or guarding. G-tube L lateral quadrant.
Unremarkable. Capped.
Ext: No ___ edema, ___ warm and well perfused; spontaneous,
purposeful movements of extremities. +pulses
DISCHARGE EXAM
============================================
Vitals: 97.8 102/62 103 18 95 Ra
General: AAOx0. Sightly agitated. Very vocal but perseverating
HEENT: Sclerae anicteric, MM slightly dry. oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: anterior assess only as patient not sitting up
CV: RRR, Nl S1, S2, No MRG
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly. G tube dressing c/d/i
GU: no foley.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Mental status: AAOx0. perseverating on days of week and thank
you. Able to follow commands but cant respond appropriately.
Neuro: Difficult to assess. Moving all for extremities. Hand
grip symmetric.
Pertinent Results:
ADMISSION LABS
=================
___ 03:45PM WBC-10.6* RBC-3.56* HGB-10.7* HCT-33.4*
MCV-94 MCH-30.1 MCHC-32.0 RDW-12.8 RDWSD-44.7
___ 03:01AM LACTATE-2.1*
___ 03:00AM GLUCOSE-188* UREA N-17 CREAT-0.4 SODIUM-135
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
___ 03:00AM ___ PTT-27.8 ___
IMAGING:
=======
CT (performed at OSH):
Severe proctitis with multiple probably intramural abscesses in
the wall of the rectum (largest 2cm)
Bibasilar airspace disease.
Biliary ductal dilation (h/o CCY)
Large amount of stool in rectum
Flex Sig: A healing ulcer bed was noted in the rectum with a 5mm
fistulous tract. This was suctioned and no fluid (ie pus, urine)
returned, but likely represents abscess cavity noted on CT. The
remainder of the rectal and sigmoid mucosa appeared normal. Cold
forceps biopsies were performed for histology at the rectal
ulcer.
Path:
=====
Rectum, "ulcer", biopsy:
- Colonic mucosa with focal epithelial hyperplastic changes.
- Multiple/additional levels are examined.
DISCHARGE LABS
===============
___ 07:05AM BLOOD WBC-8.5 RBC-3.58* Hgb-10.7* Hct-33.6*
MCV-94 MCH-29.9 MCHC-31.8* RDW-14.5 RDWSD-47.8* Plt ___
___ 07:05AM BLOOD Glucose-97 UreaN-16 Creat-0.4 Na-136
K-4.8 Cl-99 HCO3-29 AnGap-13
___ 07:05AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT NG 1X/WEEK (MO)
2. Psyllium Powder 1 PKT PO DAILY
3. PARoxetine 20 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. Nystatin Oral Suspension 5 mL PO TID
6. Milk of Magnesia 5 mL PO Q12H:PRN constipation
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Bisacodyl 10 mg PR QHS:PRN if senna ineffective
9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H
last day ___
2. MetroNIDAZOLE 500 mg PO Q8H
last day ___. Senna 8.6 mg PO DAILY:PRN no BM in 24 hours
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Bisacodyl 10 mg PR QHS:PRN if senna ineffective
6. Donepezil 10 mg PO QHS
7. Milk of Magnesia 5 mL PO Q12H:PRN constipation
hold for loose stools
8. Nystatin Oral Suspension 5 mL PO TID
9. PARoxetine 20 mg PO DAILY
10. Psyllium Powder 1 PKT PO DAILY
hold for loose stools
11. Vitamin D ___ UNIT NG 1X/WEEK (MO)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
- proctitis with several intramural abscesses
Secondary diagnoses
- Constipation and fecalith formation
- Minor Blood per rectum secondary to abscess formation
- Urinary tract infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with g-tube from NH, please confirm
placement.// g-tube placement
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT scan dated ___
FINDINGS:
A percutaneous gastrostomy tube projects over the left upper quadrant and was
better assessed on the CT scan dated ___. There are no abnormally
dilated loops of large or small bowel. A large amount of stool projects over
the rectum
There is no free intraperitoneal air.
Osseous structures are unremarkable.
IMPRESSION:
A percutaneous gastrostomy tube projects over the left upper quadrant.
Nonobstructive bowel gas pattern.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with h/o CVA, perirectal abscess, with fever.//
infiltrate?
IMPRESSION:
No previous images are available. Cardiac silhouette is within normal limits
and there is mild indistinctness of pulmonary vessels suggesting elevation in
pulmonary venous pressure. Atelectatic changes are seen at the right base.
Blunting of the right costophrenic angle with elevation of the
hemidiaphragmatic contour suggests small pleural effusion. No evidence of
acute focal pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BRBPR, Transfer
Diagnosed with Rectal abscess
temperature: 97.6
heartrate: 84.0
resprate: 18.0
o2sat: 96.0
sbp: 90.0
dbp: 46.0
level of pain: Non-verbal
level of acuity: 2.0 | Ms. ___ is a ___ year old female with CAA and a h/o CVA
(nonverbal & bedbound for past 2 months) who presented to
another hospital from ___ Rehab with fever (101.1) and small
volume GI bleeding (found in her diaper). A CT at the other
hospital showed severe proctitis with multiple intramural
abscesses in wall of rectum, measuring up to 2cm in size,
(generally considered too small for surgical or ___ intervention)
and patient was treated with a 10 day course of
ciprofloxacin/metronidazole.
# Perirectal abscesses
Likley due to severe constipation, causing superficial
ulceration and leading to transmigration of bacterial from the
lumen into the gut wall. CT showed multiple small intramural
abscesses. Colorectal surgery was consulted and recommended
against surgical intervention given size of abscesses and
comorbidities. GI was consulted and recommended aggressive bowel
regimen (see below). She had a flexible sigmoidoscope that
showed a healing, ulceration with 5mm fistulous draining tract
(likely due to the abscesses seen on CT). Patient was
intermittently febrile during early course and, due to this, was
treated with Vanc/Ceftazidime/flagyl and narrowed to
Ciprofloxacin/flagyl with plan for 10 day course (last day
___. The wound care nurse was also consulted to assist with
skin breakdown.
# Constipation
Patient's CT showed a significant stool ball in the rectum on
time of admission, likely leading to increased wall stress and
ulceration. Patient was initially started on a PO bowel regimen
and was disimpacted with good effect. After disimpaction,
patient becaome incontinent of a large volume of loose stool,
and remained incontinent throughout her stay, with >2 bowel
movements each day. She was started on banana flakes to solidify
her stool.
# GI bleed
This was likely due to either external excoriations, or
superficial ulcerations and local inflammation due to the
abscess. Patient initially presented with concern for GI with
her nursing home care provider finding dried blood on her
diaper. However, her H/H remained stable throughout admission
and only very small volumes of blood were found on her diaper a
couple times during her first days of admission. Wound care
nurse was consulted.
# Enterococcus UTI: Diagnosed pre-admission treated with
antibiotics as above.
# Nutrition: Tube feeds were modified while in house and banana
flakes were added to regimen. Additionally, Ms. ___ had
some HR 100s and BPS ___ while in house thought to be due to NPO
status so free water flushes were increased and this improved.
CHRONIC MEDICAL ISSUES
# Cerebral amyloid angiopathy complicated by CVA: Patient
minimally verbal on arrival with waxing and waning mental
status. No overall change in mentation noted during her course,
though activity and responsiveness seemed slightly improved
after constipation was relieved.
# Depression: Patient was continued on Paroxetine throughout her
stay
# ___: Discussed poor prognosis with son ___. He would like to
continue with current plan of care and confirmed that patient is
full code.
TRANSITIONAL ISSUES
==================================
- antibiotic course: Ciprofloxacin 250 PO q12 and Metronidazole
500 Q8H: last day ___
- it is very important that patient has regular bowel movements
as constipation was the likely culprit of her infections
- should get speech and swallow evaluation
- would get weekly chem panel
========================================
Attending statement:
I performed a history and physical examination of the patient
and discussed the discharge plan with Dr. ___. I reviewed
the residents discharge summary and agree with the documented
findings and plan of care. Day of discharge management > 30
minutes.
Date of service: ___
Today's date: ___
___, MD, PharmD
HMED Attending
========================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a ___ year-old Male with a PMH significant for ADHD (on
___, depression, and anxiety who presented with fever and
altered mental status.
.
He was in his usual state of health until the day prior to
admission. On the evening of ___, he was found seated in the
bathroom and appeared confused, per his mother. His mother
reports that he was ashen and somnolent at first, but the
patient was able to state that he "needed help". He then
experienced an episode of non-bloody emesis, which appeared to
be a milky substance, associated with a headache.
.
He was transferred to the OSH ED, with initial VS 88, 129/79 18
96%RA. He had witnessed generalized tonic-clonic seizure
activity at the OSH for about 15-minutes, per his mother. ___
6 mg IV and Propofol, Fentanyl and Midazolam were required to
terminate his seizure activity, and he was post-ictal following
the seizure. The family then requested transfer to ___ for
further evaluation and management. On further questioning, he
was noted to have been experimenting with amphetamine
derivatives (Ephedrone, O-Acetylpsilocin, and 2,5 DEP in the
past - all stimulants, all snorted) - and has had recent
marijuana use, per his mother. Patient notes ___ ingestion
and Nyquil ingestion 2-days prior. He endorses significant
marijuana use, using a half an ounce per week. Rare alcohol use,
less then one serving per week, last use about two weeks ago.
Rare tobacco use. Denies any other ingestions, and he denies any
recent ingestions of the aforementioned designer drugs.
.
In the ___ ED, initial VS 101.4 88 124/79 18 97%RA. His
outside hospital CT was uploaded, he was dosed Vancomycin 1 gram
IV, Ceftriaxone 2 grams IV x 1, Acyclovir 700 mg IV x 1,
Dexamethasone 10 mg IV x 1, Acetaminophen 1000 mg x 1. His EKG
showed sinus tachycardia with LAD, but normal intervals and no
QT widening.
Labs were remarkable for WBC 26.5, serum Osm 292, negative serum
tox screen, CK 1022, anion gap metabolic acidosis with HCO3 19
and AG 18 and creatinine of 2.5. Neurology was consulted and an
LP was negative, and he received empiric Abx (as noted).
Toxicology was consulted and his presentation was suspicious for
multiple sympathomimetic designer drug ingestions. They
recommended BNZ therapy with cooling for hyperthermia. He
required sedation with Propofol 200 mg, Midazolam 3 mg and
Fentanyl 50 mcg IV. He received 3L NS x 1. He was transferred to
the MICU and was calm appearing and stabilized for IVF and
benzodiazepines.
.
He reports feeling well over the past few days, no fevers,
chills, headaches, photophobia, neck stiffness. Mild rhinorrhea
and sinus congestion, but no recent cough or dyspnea. No recent
sick contacts. No abdominal pain, and no other complaints.
Denies suicidal ideation or plan, no homicidal ideation.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Attention-deficit disorder (on ___
2. Polysubstance abuse (experimenting with amphetamine
derivatives - Ephedrone, O-Acetylpsilocin, and 2,5 DEP in the
past - all stimulants, all snorted - and has had recent
marijuana use, per his mother; patient notes ___ ingestion
and Nyquil ingestion 2-days prior to admission)
3. Depression (prior suicide attempt with attempted hanging in
front of mother, ___ years prior, with psychiatric admission and
intubation)
4. Anxiety
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
VITALS: T-max (101.4) 99.0 / 99.0 82-101 110/56 20 96%RA
GENERAL: Appears in no acute distress. Alert and interactive.
HEENT: Normocephalic, atraumatic. EOMI. PERRL, dilated to 5-mm
but reactive bilaterally to 2-mm. Nares clear. Mucous membranes
moist. Anicteric sclera.
NECK: supple without lymphadenopathy. JVD not elevated.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength ___ bilaterally, sensation grossly
intact. Gait deferred. Finger-to-nose intact. No clonus.
Pertinent Results:
___ 03:15AM BLOOD WBC-26.5* RBC-5.08 Hgb-15.5 Hct-44.5
MCV-88 MCH-30.5 MCHC-34.9 RDW-12.5 Plt ___
.
___ 03:15AM BLOOD Neuts-89.0* Lymphs-5.7* Monos-4.8 Eos-0.4
Baso-0.1
.
___ 03:59AM BLOOD ___ PTT-24.0 ___
.
___ 12:10PM BLOOD Glucose-81 UreaN-27* Creat-3.4* Na-139
K-3.9 Cl-104 HCO3-17* AnGap-22*
.
___ 03:15AM BLOOD Glucose-87 UreaN-22* Creat-2.5* Na-138
K-3.3 Cl-101 HCO3-19* AnGap-21*
.
___ 06:16PM BLOOD CK(CPK)-4677*
.
___ 12:10PM BLOOD CK(CPK)-4206* TotBili-0.4
.
___ 03:15AM BLOOD ALT-15 AST-30 CK(CPK)-1022* AlkPhos-58
Amylase-120* TotBili-0.5
.
___ 03:15AM BLOOD Albumin-5.0 Calcium-10.2 Phos-6.7*
Mg-3.2*
.
___ 03:15AM BLOOD Osmolal-292
.
___ 12:10PM BLOOD ASA-NEG
___ 03:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
___ 03:27AM BLOOD Lactate-1.9
.
URINALYSIS: clear, negative for ___, negative for Nitr, no
protein
CSF (___): WBC 4, RBC 4, PMN 2, L16, M82, protein 37, glucose
69
.
MICROBIOLOGY DATA:
___ Blood culture - pending
___ MRSA screen - pending
___ Lumbar puncture - no PMNs, no organisms
.
EKG: sinus tachycardia @ 103. LAD/NI. No QRS widening. No ST-T
wave changes.
.
IMAGING:
___ CHEST (PORTABLE AP) - normal chest film
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Methylphenidate (unknown dose)
2. Nyquil (as needed)
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Sympathomimetic toxidrome (ingestion)
2. Anion-gap metabolic acidosis
3. Rhabdomyolysis
4. Acute renal failure
.
Secondary Diagnoses:
1. Depression
2. Anxiety
3. Polysubstance abuse
4. Attention deficit disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Fever.
Cardiomediastinal contours are normal. The lungs are clear. There is no
pneumothorax or pleural effusion.
IMPRESSION: No evidence of pneumonia or atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ALTERED MS
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY, ALTERED MENTAL STATUS , FEVER, UNSPECIFIED, DRUG ABUSE NEC-UNSPEC
temperature: 101.4
heartrate: 88.0
resprate: 18.0
o2sat: 97.0
sbp: 124.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | ___ with PMH significant for ADHD (on ___, depression,
and anxiety who presented with fever and altered mental status
with generalized tonic-clonic seizure activity, hyperthermia,
hypertension, agitation consistent with sympathomimetic agents
complicated by acute renal failure
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o man with a history of morbid obesity, DM,
HTN, HL, DVT/PE on coumadin, aortic stenosis s/p AVR, CAD s/p
CABGx2, and pAfib with RVR who presents with right leg swelling
and pain.
In brief, patient was admitted to ___ on ___ for
unprovoked DVT/PE and found to have three vessel CAD in setting
of NSTEMI; double CABG (LIMA to LAD, SVG to PDA) and tissue AVR
were performed on ___. Patient began feeling pain in his
right leg when he was discharged to rehab on ___. At rehab,
he notes that in addition to the pain, his right leg became
extremely swollen but returned to normal size before leaving
rehab. The pain was still there when he returned home ___.
The pain has progressed since returning home and he has not been
as mobile as a result. In general, there is pain at rest and
increases with movement or palpation. He says the upper right
leg is red, painful, and feels too hot to put blankets on top.
The lower right leg has some pain but is not bothering him as
much.
He was prescribed doxycycline for graft prophylaxis at a post-op
CABG visit on ___ and reports that the last dose he took
was yesterday (9 days of prescribed 10 day course). He reports
no noticeable improvement with antibiotics and that his sleep
has been terrible because of the leg discomfort. Last night, he
came to the ED because he was experiencing ___ pain and was
bothered that he can't move.
He also reports chest pain, worse with coughing or hiccupping,
that has been consistent since his CABG; ruled out for recurrent
ACS or PE on ___. In addition, he reports nausea and dry
heaving a few times a week that typically occurs when he takes
his medications, some left shoulder pain with movement, and some
vague abdominal pain. He denies fevers/chills, cough, runny
nose, shortness of breath, diarrhea, or recent swelling in the
legs.
In the ED, initial vitals: 98.2 92 99/55 18 98% RA
- Exam notable for: right inner thigh there is a 6 cm area of
erythema and induration that is tender, there is no subcu gas,
area is mildly warm to the touch
Distally neurovascularly intact
- Labs notable for: WBC 10.3, Hct/Hgb 12.2/37.1, HCO3 21, BUN
21, ___ 19.1, PTT 32.4, INR 1.7
- Imaging notable for: CT lower extremity: Rim calcified, right
groin fluid collection measuring up to 8.7 cm is suggestive of a
chronic hematoma in that area. Moderate subcutaneous edema in
the soft tissues of the right lower extremity as well as minimal
amount of hematoma tracking up the medial right leg in the area
of prior saphenous vein harvest.
- Pt given:
___ 04:56 IV Morphine Sulfate 4 mg ___
___ 05:36 IV Vancomycin ___ Started
___ 07:34 IV Vancomycin 1 mg ___ Stopped (1h
___
___ 08:20 SC Insulin ___ Not Given per
Sliding Scale
___ 08:33 PO/NG Amiodarone 200 mg ___
___ 08:33 PO/NG Aspirin 81 mg ___
___ 08:33 PO/NG Furosemide 20 mg ___
___ 08:33 PO/NG MetFORMIN (Glucophage) 1000 mg
___
___ 08:33 PO Metoprolol Succinate XL 25 mg
___
___ 08:33 PO Pantoprazole 20 mg ___
___ 09:23 PO Ramipril 5 mg ___
___ 12:12 SC Insulin ___ Not Given per
Sliding Scale
On the floor, patient is alert, oriented, and in no acute
distress. He is still experiencing right leg pain and chest
pain. He denies any fevers/chills, nausea/vomiting, diarrhea,
shortness of breath, or tingling in the legs.
Review of systems:
(+/-) Per HPI
Past Medical History:
1. Moderate aortic stenosis, now status post aortic valve
replacement.
2. Type 2 diabetes.
3. Hypertension.
4. Morbid obesity.
5. History of DVT and PE on chronic Coumadin.
6. Vitamin B12 deficiency.
7. Anemia.
8. GI bleed was unremarkable EGD and colonoscopy in ___ and ___.
9. History of iron deficiency anemia.
10. Hyperlipidemia.
11. Coronary artery disease now status post CABG.
Social History:
___
Family History:
Multiple family members with COPD. One brother with CAD who
smokes and another brother who had an MI. Dad passed away from
lung cancer and liver cancer; mom passed away from lung cancer.
Both were heavy smokers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97.5 125/79 66 18 98 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVD not appreciated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, sternotomy scar well-healed
Lungs: Clear to auscultation anteriorly with diffuse inspiratory
and expiratory wheezes in the left lung, no crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, nontender mass
appreciated in the right lower quadrant from previous hernia
repair with mesh
GU: No foley
Ext: Warm, well perfused, 2+ DP and radial pulses, no lower
extremity edema, right inner thigh has a 6cm area of erythema
and induration that is tender and moderately warm to the touch
with a hard mass appreciated below the erythema, lower right
extremity has one clean/healing surgical site for vein harvest
with a hard mass palpated on the medial calf roughly 5cm in
diameter
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
gait deferred
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs: 99.0 117 / 57 66 18 96
General: Alert, interactive, no acute distress
HEENT: Sclerae anicteric, JVD not appreciated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, sternotomy scar well-healed
Lungs: Diffuse inspiratory and expiratory wheezes in left lung,
minimal expiratory wheezes in posterior right lung, no crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
nontender mass appreciated in the right lower quadrant from
previous hernia repair with mesh
GU: No foley
Ext: Warm, well perfused, no lower extremity edema, right inner
thigh has minimal erythema within pen markings, area of hard
induration appreciated extending from medial aspect to posterior
thigh, lower right extremity has one clean/healing surgical site
for vein harvest with induration on the medial calf roughly 5cm
in diameter
Neuro: Moving all extremities with purpose
Pertinent Results:
ADMISSION LABS:
===============
___ 12:30AM BLOOD WBC-10.3* RBC-4.44* Hgb-12.2* Hct-37.1*
MCV-84 MCH-27.5 MCHC-32.9 RDW-13.9 RDWSD-41.8 Plt ___
___ 12:30AM BLOOD Neuts-82.9* Lymphs-7.0* Monos-8.7
Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.53*# AbsLymp-0.72*
AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03
___ 12:30AM BLOOD Plt ___
___ 04:30AM BLOOD ___ PTT-32.4 ___
___ 12:30AM BLOOD Glucose-112* UreaN-21* Creat-0.7 Na-136
K-3.5 Cl-96 HCO3-21* AnGap-23*
___ 05:24PM BLOOD CK-MB-2 cTropnT-0.01
___ 05:24PM BLOOD Calcium-8.9 Phos-3.6 Mg-1.1*
RELEVANT LABS:
==============
___ 05:24PM BLOOD CK-MB-2 cTropnT-0.01
DISCHARGE LABS:
===============
___ 09:43AM BLOOD WBC-10.3* RBC-4.24* Hgb-11.6* Hct-36.1*
MCV-85 MCH-27.4 MCHC-32.1 RDW-13.9 RDWSD-43.2 Plt ___
___ 09:43AM BLOOD Plt ___
___ 09:43AM BLOOD ___ PTT-40.5* ___
___ 09:43AM BLOOD Glucose-172* UreaN-10 Creat-0.6 Na-137
K-3.5 Cl-96 HCO3-23 AnGap-22*
___ 09:43AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.2*
IMAGING/STUDIES:
================
___ CT LOWER EXT RIGHT
IMPRESSION:
Rim calcified, right groin fluid collection measuring up to 8.7
cm is
suggestive of a chronic hematoma in that area. Moderate
subcutaneous edema in the soft tissues of the right lower
extremity as well as minimal amount of hematoma tracking up the
medial right leg in the area of prior saphenous vein harvest.
___ ___ RIGHT:
IMPRESSION:
1. Right lower extremity hematoma extending from the posterior
mid thigh to the posterior mid calf.
2. No evidence of acutedeep venous thrombosis in the right lower
extremity
veins. However, visualization of the right posterior tibial
veins was limited by the right lower extremity hematoma, as
described above.
MICROBIOLOGY:
=============
___ Blood Culture, Routine - Negative x 2.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Cyanocobalamin ___ mcg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 20 mg PO Q24H
7. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Amiodarone 200 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. GlipiZIDE XL 2.5 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Ramipril 5 mg PO DAILY
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
16. Senna 8.6 mg PO BID:PRN constipation
17. Simethicone 40-80 mg PO TID:PRN bloating, gas
18. Warfarin 1 mg PO 4X/WEEK (___)
19. Warfarin 1.5 mg PO 3X/WEEK (___)
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*28 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
3. Amiodarone 200 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Cyanocobalamin ___ mcg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. GlipiZIDE XL 2.5 mg PO DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB, wheezing
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 20 mg PO Q24H
15. Ramipril 5 mg PO DAILY
16. Senna 8.6 mg PO BID:PRN constipation
17. Simethicone 40-80 mg PO TID:PRN bloating, gas
18. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
19. HELD- Warfarin 1 mg PO 4X/WEEK (___) This
medication was held. Do not restart Warfarin until your doctors
___ to take it
20. HELD- Warfarin 1.5 mg PO 3X/WEEK (___) This medication
was held. Do not restart Warfarin until your doctors ___ to
take it
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
CELLULITIS
CORONARY ARTERY DISEASE STATUS POST CORONARY ARTERY BIPASS GRAFT
SECONDARY DIAGNOSIS
DIABETES MELLITUS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT right lower extremity.
INDICATION: ___ year old man with right inner thing pain and swelling s/p
harvesting for CABG// ? hematoma or organized fluid collection
TECHNIQUE: Multi detector CT images were acquired in the axial dimension.
Coronal and sagittal reformatted images were created subsequently.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.5 s, 58.6 cm; CTDIvol = 22.6 mGy (Body) DLP =
1,324.3 mGy-cm.
2) Spiral Acquisition 2.8 s, 22.1 cm; CTDIvol = 21.8 mGy (Body) DLP = 481.8
mGy-cm.
Total DLP (Body) = 1,806 mGy-cm.
COMPARISON: Lower extremity venous ultrasound on ___.
FINDINGS:
Within the subcutaneous tissues of the right groin is a 7.6 x 8.7 cm
high-density fluid collection with rim calcification, suggestive of a
hematoma.
There is moderate soft tissue stranding as well as a small amount of hematoma
tracking up the medial right leg in the area of prior saphenous vein harvest.
There is mild degenerative change of the right hip. Prostatic calcifications
are noted. The right lower extremity arterial vasculature is heavily
calcified.
IMPRESSION:
Rim calcified, right groin fluid collection measuring up to 8.7 cm is
suggestive of a chronic hematoma in that area. Moderate subcutaneous edema in
the soft tissues of the right lower extremity as well as minimal amount of
hematoma tracking up the medial right leg in the area of prior saphenous vein
harvest.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old man with recent CABG with saphenous vein graft pw 3
weeks R inguinal thigh swelling, erythema pain// DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
A heterogeneous fluid collection, consistent with a hematoma or postoperative
fluid, is located within the posterior soft tissues of the right lower
extremity, extending from the posterior mid thigh to the posterior mid calf.
It measures up to 2 mm in thickness.
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the peroneal veins. The hematoma obscured adequate visualization of the right
posterior tibial vessels.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Right lower extremity hematoma extending from the posterior mid thigh to
the posterior mid calf.
2. No evidence of acutedeep venous thrombosis in the right lower extremity
veins. However, visualization of the right posterior tibial veins was limited
by the right lower extremity hematoma, as described above.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Thigh pain
Diagnosed with Pain in right thigh
temperature: 98.2
heartrate: 92.0
resprate: 18.0
o2sat: 98.0
sbp: 99.0
dbp: 55.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ y/o man with a history of morbid obesity, DM,
HTN, HL, DVT/PE on coumadin, aortic stenosis s/p AVR, CAD s/p
CABGx2, and pAfib with RVR who presents with right leg swelling
and pain at site of CABG vein harvest concerning for cellulitis.
Erythema thought to be cellulitis per CT surgery. Most likely
caused by strep species or hospital acquired MRSA not well
covered by recent 9d course of doxycycline. Erythema and pain
decreased with IV vancomycin. No DVTs on lower extremity
ultrasound. Seen by CT surgery who recommended antibiotics and
no intervention.
Regarding the patient's chest pain, it was stable during this
hospitalization. His troponins and ECG were not concerning for
ischemia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aleve / ibuprofen / aspirin
Attending: ___.
Chief Complaint:
Cough, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with ANCA vasculitis (MPO positive with
associated ILD and CKD) not on immunosuppression who presents
with cough and fever. She had worsening of her chronic cough
without sputum production and malaise and fever beginning on
___. Highest temp was ___ at home. No rigors, chills, night
sweats, rash, joint pain, myalgias. She had pleuritic R sided
chest pain on arrival to the ED that has since resolved. No
n/v/d.
Of note, she was hospitalized for 2 days in ___ one month ago
(end of ___ for PNA and hypoxia and given ceftriaxone and
azithromycin and discharged with 7 days of levofloxacin and
Medrol dosepak. She reports that she returned completely to her
baseline following therapy until her symptoms began on ___.
She travelled to ___ in ___. No other recent travel. No
sick contacts. No flu shot this year.
In the ED, initial VS were: 8 98.5 103 105/58 22 100% RA, Tmax
at 100.7
Labs showed:
Wbc 10.1 Hgb 10.2 Plts 190
BUN/Cr ___
lactate 1.8
UA: bld neg, prot 30, few bacteria
Imaging showed:
CXR:
1. Chronic reticular opacification fibrosis, compatible with
known interstitial lung disease.
2. There is increased opacification at the right lung base
compared with the radiograph from ___, which could be
due to worsening interstitial lung disease and/or superimposed
infection in the correct clinical setting.
Patient received:
___ 16:03 IH Albuterol 0.083% Neb Soln 1 NEB
___ 17:00 IV Azithromycin
___ 18:11 IV Vancomycin
___ 18:11 IV Azithromycin 500 mg
___ 19:23 IV Piperacillin-Tazobactam
___ 19:23 PO Acetaminophen 1000 mg
___ 19:23 IVF NS
___ 19:24 IV Vancomycin 1500 mg
___ 20:45 IV Piperacillin-Tazobactam 4.5 g
___ 21:10 IVF NS 1000 mL
___ 21:31 PO/NG Losartan Potassium 100 mg
___ 21:31 PO NIFEdipine (Extended Release) 60 mg
Transfer VS were: 98.5 103 109/65 20 98% RA
On arrival to the floor, patient reports ongoing nonproductive
cough without dyspnea. No chest pain. Otherwise symptoms as
above.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
- ANCA vasculitis, MPO positive with pulmonary-renal syndrome.
Dx ___ s/p steroids, plasmapheresis, cyclophosphamide,
azathioprine, now on maintenance with rituximab and prednisone
- Stage II CKD ___ ANCA vasculitis
- Steroid-induced DM
- History of fibroids s/p hysterectomy ___
- Lower back pain, felt due to lumbar strain
- T4 and T8 severe compression fractures noted on chest CT
Social History:
___
Family History:
Negative for rheumatologic disease
Physical Exam:
===========================
ADMISSION
===========================
VS: 99.5 108/70 99 20 95 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
===========================
DISCHARGE
===========================
Vitals: 99.1 146/88 75 20 96 RA
General: AOx3, sitting in bed, in no acute distress
EYES: Anicteric sclera
ENT: MMM, oropharynx clear
Resp: Diffuse rhonchi and expiratory wheeze, intermittent dry
cough
CV: RRR, normal S1 + S2, no m/r/g
GI: soft, non-tender, non-distended
MSK: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
====================
ADMISSION LABS
====================
___ 02:20PM BLOOD WBC-10.1*# RBC-3.60* Hgb-10.2* Hct-31.5*
MCV-88 MCH-28.3 MCHC-32.4 RDW-15.5 RDWSD-49.8* Plt ___
___ 02:20PM BLOOD Neuts-55 Bands-2 ___ Monos-13 Eos-0
Baso-2* ___ Myelos-0 AbsNeut-5.76 AbsLymp-2.83
AbsMono-1.31* AbsEos-0.00* AbsBaso-0.20*
___ 02:20PM BLOOD Glucose-84 UreaN-31* Creat-2.4* Na-139
K-4.1 Cl-100 HCO3-23 AnGap-16
___ 07:27PM BLOOD Lactate-1.8
====================
PERTINENT RESULTS
====================
LABS
====================
___ 08:36AM BLOOD ANCA-NEGATIVE B
====================
MICROBIOLOGY
====================
Influenza A and B (___): Negative
Sputum culture (___): Contaminated with respiratory flora
Streptococcus pneumonia urine antigen (___): Negative
====================
IMAGING
====================
CXR (___):
1. Chronic reticular opacification fibrosis, compatible with
known interstitial lung disease.
2. There is increased opacification at the right lung base
compared with the radiograph from ___, which could be
due to worsening interstitial lung disease and/or superimposed
infection in the correct clinical setting.
===
CT Chest without contrast (___):
1. Vascular congestion or atypical pneumonia superimposed on
background of
moderate fibrotic interstitial lung disease, worst along the
right lower lobe. No lobar pneumonia.
2. Multiple pulmonary nodules similar to prior, largest
subpleural nodule
measures 1.2 x 0.5 cm in left lower lobe and likely represents
focal fibrosis.
3. Small hiatal hernia.
====================
DISCHARGE LABS
====================
___ 08:10AM BLOOD WBC-8.1 RBC-3.70* Hgb-10.3* Hct-32.2*
MCV-87 MCH-27.8 MCHC-32.0 RDW-15.5 RDWSD-49.4* Plt ___
___ 08:10AM BLOOD Glucose-86 UreaN-13 Creat-1.1 Na-146
K-4.5 Cl-104 HCO3-28 AnGap-14
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN cough
2. Losartan Potassium 100 mg PO DAILY
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
4. NIFEdipine (Extended Release) 60 mg PO DAILY
5. Famotidine 20 mg PO BID
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:*0
2. GuaiFENesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 5 mL by mouth Every 6 hours
Refills:*0
3. Levofloxacin 750 mg PO DAILY
Last day: ___
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth Daily
Disp #*4 Tablet Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
5. Famotidine 20 mg PO BID
6. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN cough
7. NIFEdipine (Extended Release) 60 mg PO DAILY
8. HELD- Losartan Potassium 100 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you see your
doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Community acquired pneumonia
- Acute on chronic kidney disease
SECONDARY:
- ANCA vasculitis
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with productive cough, R chest pain, malaise. Evaluate for
PNA, mass.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT from ___ and chest radiograph of ___.
FINDINGS:
There are areas of reticular opacity and fibrosis, most predominant in the
lower lobes, similar in distribution though slightly more severe when compared
with the radiograph from ___. Some of this finding is compatible
with known interstitial lung disease, likely UIP. The heart is mildly
enlarged. There is stable elevation of the right hemidiaphragm. More
opacification in the right lung base could be due to worsening interstitial
lung disease and/or superimposed infection in the correct clinical setting.
There is no large pleural effusion or pneumothorax. The mediastinal
silhouette is unchanged.
IMPRESSION:
1. Chronic reticular opacification fibrosis, compatible with known
interstitial lung disease.
2. There is increased opacification at the right lung base compared with the
radiograph from ___, which could be due to worsening interstitial
lung disease and/or superimposed infection in the correct clinical setting.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST.
INDICATION: ___ year old woman with ANCA vasculitis with resultant ILD
presenting with cough, worsening RLL infiltrate.
TECHNIQUE: Axial helical MDCT images were obtained through the chest without
intravenous contrast. Coronal, sagittal and lung algorithm reconstructed
images were acquired.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.3 s, 31.7 cm; CTDIvol = 9.7 mGy (Body) DLP = 290.8
mGy-cm.
Total DLP (Body) = 300 mGy-cm.
COMPARISON: CT chest without contrast ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Partially visualized thyroid is
unremarkable. Supraclavicular and axillary lymph nodes are nonenlarged.
Chest wall is unremarkable.
UPPER ABDOMEN: Although not tailored to evaluate the subdiaphragmatic organs,
a small hiatal hernia is noted. Additionally there are few punctate
calcifications in the liver consistent with prior granulomatous exposure. 1.1
cm accessory spleen noted.
MEDIASTINUM: Mediastinal lymph nodes are not enlarged. No anterior
mediastinal mass.
HILA: Assessment of the hila is limited due to noncontrast study however no
large hilar mass identified.
HEART and PERICARDIUM: Heart is normal in size without pericardial effusion.
No aortic valvular or mitral annular calcifications. Minimal coronary
calcifications are noted.
PLEURA: Trace right pleural effusion. No left pleural effusion. No pleural
calcifications. No pneumothorax.
LUNG:
1. PARENCHYMA: Again seen is subpleural interstitial fibrotic changes with a
basilar predominance, associated architectural distortion and
bronchiectasis/honeycombing. In comparison to prior examination there is
interval increase in interlobular septal thickening the lower lobe
predominance suggestive of vascular congestion or atypical pneumonia.
Multiple pulmonary nodules are similar to prior examination, with largest
subpleural nodule measuring 1.2 x 0.5 cm in the left lower lobe (5:122) and
likely represents focal fibrosis. No new pulmonary nodule.
2. AIRWAYS: Airways are patent to the subsegmental level. Persistent
honeycombing and bronchiectasis involving the mid to lower lung zones is
unchanged since ___.
3. VESSELS: Thoracic aorta is unchanged measuring 3.7 cm. Main pulmonary
artery is mildly dilated suggestive of pulmonary artery hypertension.
CHEST CAGE: Chronic superior endplate compression fracture of T4 and T8 are
unchanged since prior examination. No retropulsion. Soft tissues are
unremarkable.
IMPRESSION:
1. Vascular congestion or atypical pneumonia superimposed on background of
moderate fibrotic interstitial lung disease, worst along the right lower lobe.
No lobar pneumonia.
2. Multiple pulmonary nodules similar to prior, largest subpleural nodule
measures 1.2 x 0.5 cm in left lower lobe and likely represents focal fibrosis.
3. Small hiatal hernia.
Gender: F
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Chest pain, Cough, Dyspnea, Weakness
Diagnosed with Pneumonia, unspecified organism
temperature: 98.5
heartrate: 103.0
resprate: 22.0
o2sat: 100.0
sbp: 105.0
dbp: 58.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ y/o woman with ANCA vasculitis (MPO positive
with associated ILD and CKD) not on immunosuppression who
presented with cough and fever. CT chest showed likely atypical
pneumonia superimposed on background of moderate fibrotic
interstitial lung disease. A flare of the patient's vasculitis
was considered, but ultimately her symptoms were attributed to
atypical pneumonia and she was treated with
ceftriaxone/azithromycin and narrowed to levofloxacin to
complete a 7-day course (Last day: ___. She was saturating
96% on room air on day of 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:
abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy (___)
ERCP with biliary stenting (___)
Bronchoscopy (___)
Percutaneous transhepatic cholangiography with drain (___)
History of Present Illness:
___ with a history of locally advanced intrahepatic
cholangiocarcinoma with possible metastatic disease around the
porta hepatis as well as small subcentimieter lung nodules
suspicious for metastasis presents to the ER with RUQ pain and
hemoptysis.
He saw his oncologist, Dr. ___, on ___ where she
stated, "He notes [abdominal pain] is much sharper over the last
two to three weeks. The pain is predominantly in the right
upper quadrant and is the same in nature as prior. He had been
using OxyContin at home 10 mg as needed, but notes that
generally he does not use this. He has been having nausea
without vomiting, and in addition to the pain in the right upper
quadrant has been noticing some referral up into his chest. The
chest pain is not worse with exertion, is not accompanied by
shortness of breath, and has no radiation to it. He does notice
that when he takes a deep breath; however, that will exacerbate
the chest pain and exacerbate the right-sided pain."
CT at that time showed disease progression and his Avastin and
Tarceva were discontinued at that time with the plan to pursue
XRT to the tumor (Mapping completed on ___. Since ___ he
has noticed increasing severity of his pain as well as
hemoptysis. He states that on the day prior to admission, he
coughed up 8 ounces of blood and sought medical attention. In
the ER, he was seen by transplant surgery, interventional
pulmonology, and ERCP. He was given Zofran, IV dilaudid, and
Zosyn. On arrival to floor, he states he has abdominal pain but
declined medication at this time (Family hisoty of drug
problems, so he does not want to take pain medications unless
absolutely necessary)
Review of Systems:
(+) Per HPI as well as chills for weeks to months, mild
intermittant headache, and difficulty swallowing pills and some
foods for the past week, but no problems with liquids. He also
notes voice change over the past few months.
(-) Denies fever, night sweats, blurry vision, diplopia, loss of
vision, photophobia. Denies sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies shortness of breath, or wheezes. Denies
vomiting, diarrhea, melena, hematemesis, hematochezia. Denies
dysuria, stool or urine incontinence. Denies arthralgias or
myalgias. Denies rashes or skin breakdown. No numbness/tingling
in extremities. All other systems negative.
Past Medical History:
Oncologic history:
- Mr. ___ was initially being evaluated for constipation
which
he had on and off for years. He was undergoing a CT scan
___
on which he was found to have a liver mass. He went on to have
an MRI.
- He had a liver biopsy performed on ___, which showed
adenocarcinoma, moderately to poorly differentiated, likely site
of origin is pancreatic or biliary and less likely lower GI
tract
and lung. IHC was positive for CK7, CA125 and ___, negative
for TTF-1, CK20, CDX2, PSA and PSAP
- He had a lymph node biopsy which showed atypical cells.
- Started Gemcitabine and Cisplatin on ___, received two
cycles of this with evidence of progression on CT scan ___
- He started on erlotinib and bevacizumab on ___.
- His erlotinib and bevacizumab were put on hold for a hernia
operation to be performed on ___.
- Resumed erlotinib ___
- Stopped Tarceva and Avastin on ___ secondary to disease
progression
Past Medical History:
1. Constipation.
2. Prior bowel resection after a car accident in ___.
3. Status post appendectomy.
4. Hypertension.
5. High cholesterol.
6. Prior back surgery.
7. s/p right inguinal hernia surgery ___
Social History:
___
Family History:
Father died of liver cancer; family history of drug addiction
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 96.8 HR 87 bp 179/101 RR 18 SaO2 96 on RA
GEN: NAD, awake, alert
HEENT: EOMI, sclera with icterus, conjunctivae clear, OP dry and
without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi. Port dressing clean, dry, intact
ABD: Soft, distended with RUQ tenderness without rebound or
guarding. Liver edge 2-3 cm below costal margin, negative
___ sign, firm mesh felt in midline where he previously had
abdominal surgery, no rebound or guarding. bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: Macupapular rash on skin (Tarceva), warm skin
NEURO: oriented x 3, normal attention, no focal neuro deficits
PSYCH: appropriate, cooperative
.
DISCHARGE PHYSICAL EXAM:
V/S 97.3 afebrile, 114-130/60-70s ___ 18 97% RA
Abd less tender. Pt now with 2 biliary drains one near
epigastrium (capped) one on lateral aspect near lower rib cage
(to JP).
Lungs clear to auscultation except mild crackles in right base.
no dyspnea.
exam otherwise unchanged.
Pertinent Results:
ADMISSION LABS:
___ 09:12PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 09:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-2* PH-7.0
LEUK-NEG
___ 09:12PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 06:32PM GLUCOSE-111* K+-3.5
___ 06:30PM GLUCOSE-114* UREA N-16 CREAT-0.7 SODIUM-139
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
___ 06:30PM ALT(SGPT)-245* AST(SGOT)-196* ALK PHOS-505*
TOT BILI-6.5* DIR BILI-5.3* INDIR BIL-1.2
___ 06:30PM LIPASE-53
___ 06:30PM WBC-6.6 RBC-4.91 HGB-13.6* HCT-39.7* MCV-81*
MCH-27.7 MCHC-34.2 RDW-15.6*
___ 06:30PM ALBUMIN-4.0
___ 06:30PM WBC-6.6 RBC-4.91 HGB-13.6* HCT-39.7* MCV-81*
MCH-27.7 MCHC-34.2 RDW-15.6*
___ 06:30PM NEUTS-81.2* LYMPHS-10.8* MONOS-5.7 EOS-1.9
BASOS-0.3
___ 06:30PM PLT COUNT-180
___ 06:30PM ___ PTT-26.5 ___
CT chest, abdomen ___ wet read:
Approximately 11 x 7 x 13 cm (TRV x AP x CC) large cholangioCA
in the right hepatic lobe, same as ___. Extension into GB
fossa with likely GB invasion. GB tensely distended, with
suggestion of tumoral involvement adjacent to neck, suggestive
of obstruction which could account for pain. No CT explanation
to account for hemoptysis.
___ 06:00AM BLOOD WBC-6.7 RBC-4.36* Hgb-12.0* Hct-36.7*
MCV-84 MCH-27.6 MCHC-32.8 RDW-16.8* Plt ___
___ 06:00AM BLOOD WBC-7.3 RBC-4.11* Hgb-11.4* Hct-34.4*
MCV-84 MCH-27.8 MCHC-33.2 RDW-17.0* Plt ___
___ 05:49AM BLOOD WBC-8.0 RBC-4.17* Hgb-11.6* Hct-34.3*
MCV-82 MCH-27.8 MCHC-33.8 RDW-17.6* Plt ___
___ 06:00AM BLOOD Neuts-79.5* Lymphs-10.2* Monos-7.4
Eos-2.6 Baso-0.4
___ 05:50AM BLOOD ___ PTT-32.5 ___
___ 07:32AM BLOOD ___ PTT-38.9* ___
___ 05:49AM BLOOD Glucose-104* UreaN-22* Creat-0.7 Na-135
K-3.3 Cl-95* HCO3-31 AnGap-12
___ 06:30PM BLOOD ALT-245* AST-196* AlkPhos-505*
TotBili-6.5* DirBili-5.3* IndBili-1.2
___ 04:26AM BLOOD ALT-126* AST-124* LD(LDH)-325*
AlkPhos-533* TotBili-12.8* DirBili-11.2* IndBili-1.6
___ 06:11AM BLOOD ALT-84* AST-89* LD(LDH)-266* AlkPhos-437*
TotBili-16.6* DirBili-13.8* IndBili-2.8
___ 05:49AM BLOOD ALT-48* AST-63* LD(LDH)-240 AlkPhos-303*
TotBili-11.2*
___ 06:00AM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.2 Mg-1.9
Medications on Admission:
Medications - Prescription
AMLODIPINE-BENAZEPRIL - (Prescribed by Other Provider) - 5
mg-20
mg Capsule - 1 Capsule(s) by mouth daily
ATENOLOL - (Prescribed by Other Provider) - 100 mg Tablet - 1
Tablet(s) by mouth daily
CLINDAMYCIN PHOSPHATE - 1 % Lotion - apply to face and back for
rash daily as needed QPM as needed for PRN
ERLOTINIB [TARCEVA] - 150 mg Tablet - 1 Tablet(s) by mouth daily
daily for a 28 day cycle, ICD-9 156.9 (cholangiocarcinoma)
HERNIA TRUSS - - use for hernia daily
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth daily
HYDROCORTISONE - 2.5 % Ointment - apply to rash q6-8h as needed
for itching use on chest and arms
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - apply to port area
___
hour prior to appointment
LORAZEPAM - 0.5 mg Tablet - ___ Tablet(s) by mouth q4-6h as
needed for nausea or anxiety
MUPIROCIN - 2 % Ointment - apply to paronychia three times a day
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every eight
(8) hours as needed for nausea
OXYCODONE - 5 mg Tablet - ___ Tablet(s) by mouth Q4-6H as needed
for Pain
OXYCODONE [OXYCONTIN] - 10 mg Tablet Extended Release 12 hr - 2
Tablet(s) by mouth twice a day
POTASSIUM CHLORIDE - 10 mEq Tablet Extended Release - ___
Tablet(s) by mouth daily Take 2 tablets daily while having
diarrhea; otherwise take 1 tablet daily
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every eight (8) hours as needed for nausea
SERTRALINE - 100 mg Tablet - 1.5 Tablet(s) by mouth daily for
total of 150mg
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply twice daily to
rash
on body and nails as needed PRN avoid face
Medications - OTC
DOCUSATE SODIUM - (OTC) - 100 mg Capsule - ___ Capsule(s) by
mouth twice a day as needed for constipation
SENNOSIDES - 8.6 mg Tablet - ___ Tablet(s) by mouth twice a day
as needed for constipation
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clindamycin phosphate 1 % Solution Sig: One (1) Appl Topical
DAILY (Daily) as needed for rash.
3. hydrocortisone 2.5 % Ointment Sig: One (1) Appl Topical Q6H
(every 6 hours) as needed for itching.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl Topical
TID (3 times a day) as needed for rash (avoid face).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical PRN (as needed) as needed for blood draws, port access.
9. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
13. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for anxiety, nausea.
14. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*0*
15. mupirocin 2 % Ointment Sig: One (1) tube Topical daily prn
paronychia.
16. OxyContin 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day.
Disp:*30 Tablet Extended Release 12 hr(s)* Refills:*0*
17. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day.
18. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
q8 PRN as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Biliary Obstruction
Hemoptysis
Hypertension
Secondary Diagnoses:
Metastatic Intrahepatic Cholangiocarcinoma
Tarceva Related Rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
ULTRASOUND-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY TUBE PLACEMENT
INDICATION: ___ year old man with advanced cholangiocarcinoma, now with
worsening billiary obstruction likely ___ tumor and dilated gallbladder
distension. please place perc-cholecystostomy.
REPROCEDURE IMAGING AND FINDINGS: The gallbladder is distended and contains
multiple large gallstones.
PHYSICIANS: Dr. ___ Dr. ___
___:
Given the patient's advanced cholangiocarcinoma, it was discussed with Dr.
___ ordering clinician) that we would have to traverse tumor and
there is a high likelihood that the tract will become seeded. This was
considered an acceptable risk to the clinical team.
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure timeout was performed discussing the planned procedure,
confirming the patient's identity with three identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. Approximately 10 mL of 1%
lidocaine buffered with sodium bicarbonate was instilled for local anesthesia.
An 18 ___ needle was advanced into the gallbladder under direct
ultrasound guidance via a transhepatic approach. Over a guidewire, an ___
drainage catheter was inserted into the gallbladder. 6mL of bile was removed
and sent for requested laboratory analysis. The catheter was attached to
suction/JP reservoir and secured to the skin with a StatLock with active
drainage of bile.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was less than 5 mL.
Dr. ___ attending radiologist, was present throughout the entire
procedure.
IMPRESSION:
Ultrasound-guided percutaneous cholecystostomy tube placement. Laboratory
analysis pending.
Radiology Report
CLINICAL INDICATION: ___ man with intrahepatic metastatic
cholangiocarcinoma status post percutaneous cholecystostomy and biliary
stenting via ERCP. Unable to access the left hepatic biliary ductal system
via ERCP. Progressive rise in serum total bilirubin levels.
PHYSICIANS: ___ MD (___) and ___ MD ___
physician).
PROCEDURES:
1. Left-sided transhepatic percutaneous cholangiogram.
2. Percutaneous biliary drainage catheter placement.
3. C-arm CT (DynaCT).
ANESTHESIA: General.
Informed consent for the procedure was obtained after risks, benefits and
potential complications had been discussed. The patient was placed on the
fluoroscopic table in supine position. The timeout protocol was carried out
prior to the procedure according to the ___ policy.
Under real-time ultrasound visualization, anterior transhepatic cannulation of
the dilated intrahepatic duct was performed using 21-gauge Cook needle. The
needle was initially advanced under ultrasound guidance into the presumed
dilated segmental intrahepatic duct. Intraductal location of the needle tip
was corroborated by injection of Optiray 320 in 50% dilution, under
fluoroscopic visualization.
A 0.018 Headliner hydrophilic guidewire was used to secure access into the
left intrahepatic ductal system. 21-gauge needle was then exchanged for
AccuStick system. A 0.035 ___ guidewire was advanced into the left
hepatic duct through the outer sheath of the AccuStick system and AccuStick
system was then replaced by the 6 ___ ___ sheath. A 5.0 ___ glide
C2 catheter was then advanced in tandem with angled-tip 0.035 Glidewire into
the distal left hepatic duct. Crossing of the distal left hepatic duct
stricture was expedient by the 0.035 angled-tip Glidewire which slid into the
common hepatic duct between the metallic stent and native duct wall. Both
Glidewire and 5.0 ___ C2 glide catheter were then advanced into the
duodenum and Glidewire was exchanged for 0.035 Amplatz guidewire.
C-arm cholangiogram with multiplanar CT reconstructions was performed without
subtraction and confirmed successful crossing of the malignant stricture with
the location of the catheter and wire parallel to and outside of the metallic
stent.
A 10 ___ destrung internal-external biliary drainage catheter was then
advanced over the Amplatz guide wire into the duodenum. The catheter was
secured to the skin and left to external drainage. The patient tolerated the
procedure well, and there were no immediate complications.
FINDINGS:
1. Ultrasound and transhepatic cholangiogram demonstrated moderate-to-marked
dilatation of the left intrahepatic biliary ducts associated with high-grade
central stricture.
2. Exising metallic stent introduced endoscopically is demonstrated
traversing the right anterior hepatic duct and common hepatic duct. Abrupt
high-grade stricture of the distal left hepatic duct is demonstrated separated
from the metallic stent by the soft tissue gap measuring approximately 5 mm in
thickness.
3. Dyna-CT demonstrates that our wire and PTBD cross the left hepatic duct
and traverse the common hepatic/bile duct in a course that is external to the
existing metallic stent.
4. Review of CT scan of the abdomen with IV contrast dated ___
suggests that there is separate occlusion of several right posterior segmental
ducts by the dominant right lobe cholangiocarcinoma. These are likely
contributing to abnormal bilirubin levels and suggests that even with left
hepatic duct drainage, the hyperbilirubinemia may not return to normal levels.
CONCLUSION:
1. High-grade stricture of the distal left hepatic duct near the
endoscopically placed metallic biliary stent.
2. Successful placement of destrung internal-external 10 ___ percutaneous
biliary drainage catheter crossing the stricture of the left hepatic duct with
placement outside the metallic stent. Once the patient's bilirubin level
improves and the system decompresses, he can return for conversion of the left
catheter to an internal metallic stent.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HEMPTYSIS
Diagnosed with ABDOMINAL PAIN RUQ, OTHER HEMOPTYSIS, MAL NEO LIVER, PRIMARY
temperature: 100.1
heartrate: 99.0
resprate: 18.0
o2sat: 100.0
sbp: 161.0
dbp: 93.0
level of pain: 7
level of acuity: 2.0 | The patient is a ___ year old male with a history of locally
advanced intrahepatic cholangiocarcinoma with possible
metastatic disease around the porta hepatis as well as small
subcentimieter lung nodules suspicious for metastasis who
presents with RUQ pain and hemoptysis.
.
# Biliary Obstruction: His cholangiocarcinoma caused biliary
obstruction with resulting hyperbilirubinemia and transaminitis.
On admission, patient was evaluated by transplant surgery,
ERCP, and interventional radiology. The decision was made for
HIDA scan which showed complete obstruction of the cystic duct.
He had a percutaneous cholecystostomy placed on ___ by ___.
Drain output was monitored during his hospital course and was
serosanguinous. Gram stain returned negative on the drainage
and cytology showed rare atypical glandular cells and debris.
ERCP on ___ showed an extensive stricture involving a long
segment of the common hepatic duct extending into both right and
left hepatic systems consistent with a Klatskin tumor. A stent
placed in the right hepatic and common duct, but the left
hepatic system could not be stented. He continued to have
rising bilirubin, mostly direct, and PTC was recommended by ERCP
and Surgery. PTC was performed ___ without complication.
His Bili has started to decrease with TBili 11.3 on ___
from a peak of 16.6 the day after PTC. The external PTC drain
was capped the evening of ___ with continued fall in
bilirubin. He will likely have the external PTC drain exchanged
with an internal metal stent after discharge.
.
# Hemoptysis: Possibly from metastatic disease to lungs or
related to Tarceva/bevacizumab treatment(more likely from
bevacizumab). His hemoptysis resolved with no signficant
episodes of hemoptysis while in house. ERCP on ___ showed
blood in the stomach without a clear bleeding source consistent
with swallowed blood from a pulmonary source. Bronchoscopy on
___ did not show any endobronchial lesions, but bleeding
from the LUL was noted. His Hct slowly trended down after
admission and his INR trended up to 1.6 despite Vitamin K 5 mg
PO x2. Pt had no further episodes of hemoptysis during the last
5 days prior to discharge.
.
# Volume Status: He was on LR 200 ml/hr after his ERCP, which
was later decreased to LR 100 ml/hr. He is tolerating a fair
amount of PO fluid intake and has good urine output. Slight
volume overload may be contributing to his DOE. DOE resolved on
discharge.
.
# Metastatic cholangiocarcinoma: Avastin and Tarceva were
stopped on ___ due to disease progression. Radiation
therapy was planned to start on the ___ after ___ so
he could receive 5 doses in a row. He did receive 3 days of
radiation in house prior to discharge without complications and
improvement in pain.
.
# Hypertension: He is on his home regimen of Amlodipine,
Atenolol, HCTZ, and Lisinopril. He remained normotensive and
was continued on his current regimen.
.
# Abdominal pain: His abdominal pain started to improve after
PTC on ___ with drainage of the left hepatic biliary
system. He was continued on Oxycontin with Morphine IV for
breakthrough. This was later changed to Oxycodone when
tolerating PO intake. Pt was discharged on oxycontin with
oxycodone for breakthrough.
.
# Rash from Tarceva: Generally improving after discontinuation
of Tarceva. Topical Clindamycin and Triamcinalone were
available to the patient as needed.
.
# Nausea: Well controlled with Zofran and Compazine. Pt was
discharged with supply of compazine to use prior to radiation
treatment sessions particularly.
.
# DVT Prophylaxis: Pneumoboots
.
#Transition of Care-
Pt has appt to see rad onc in 1 month
___ will follow up to exchange of external PTC drain with
internal stent as outpatient.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azathioprine
Attending: ___
Chief Complaint:
fevers, cough
Major Surgical or Invasive Procedure:
Bronchoscopy ___
Liver biopsy ___
History of Present Illness:
___ with history of relapsing polychondritis with tracheomalacia
s/p tracheostomy currently on mycophenolate and remicaid for
immunosuppression, transaminitis s/p hepatic biopsy, now
resolving, avascular necrosis of bilateral femoral heads who
presents with 1.5 months of cough/fever despite two rounds of
antibiotics.
She reports that several weeks ago she was started on Remicaid
for relapsing polychondritis. 1.5 months ago she started having
nighttime fevers and night sweats where she drenches through
sheets and clothing. She also endorses chills at those times.
She checks her temperature at home. It has ranged from 100-101
every night. Last evening it was 100.2. A couple weeks after
fevers started she developed a cough. It is a dry cough mostly.
When she brings up mucus it is clear. She reports that she has
been feeling very fatigued. Denies dyspnea. She feels that her
symptoms are worsening because she has had worsening chest pain.
She reports that the pain comes with coughing and deep
inhalation. The pain is sharp and it feels like she's about to
break a rib when it starts. It is not positional and not related
to exertion.
She was born in ___ and she grew up in ___. She now lives in
___, ___. She came to ___ last ___ to visit her family
here. She has only traveled to ___ otherwise. Denies
going outside or being in woody areas where ticks are. Denies
sick contacts. She lives with her boyfriend of ___ years in
___. She denies having other sexual partners. Last time
tested for HIV was in college.
She reports that she was tested with blood tests but doesn't
remember which while in ___ when she was started on
Remicaid.
On review of systems she reports that she has had a sore throat
x 2 days. She also endorses LLQ pain that she only noticed when
they palpated her abdomen in the ED today. She denies ovarian
cysts but had LEEP procedure for atypical cells on PAP smear in
the past. She endorses some nighttime nausea, but denies
vomiting. Denies diarrhea, constipation.
In the ED, initial VS were 98.8 127 119/81 22 100% RA.
Exam notable for abd with mild tenderness over epigastric region
Labs were largely normal except WBC 13 (81.4%N), AST/ALT ___
CXR showed no acute intrathoracic process.
EKG with sinus rhythm @ 97 BPM.
Received ___ 12:50 IVF 1000 mL NS
___ 15:45 IV Ketorolac
Transfer VS were 98.4 94 125/71 20 100% RA
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports that she feels well and
is hungry.
Past Medical History:
relapsing polychondritis
subglottic stenosis
Tracheostomy
h/o autoimmune hepatitis with recurrent transaminitis (to
600s)(most recent ALT 197, AST 62 with normal coags, ___
Social History:
___
Family History:
No family history of autoimmune disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T98.6, BP 110/73, HR 98, RR 18, O2Sat 99% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD. trach in place.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles. upper airway sounds
transmitted.
ABDOMEN: nondistended, +BS, some tenderness with deep palpation
over LLQ, mild over RLQ, mild RUQ tenderness, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, no inguinal or axillary
lymphadenopathy
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS - Tm 99.1, 122/82, 82, 100% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD. trach in place.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles. tenderness over right 2nd rib.
ABDOMEN: nondistended, +BS, RUQ tenderness over floating ribs,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, no inguinal or axillary
lymphadenopathy
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 12:50PM BLOOD WBC-13.0* RBC-4.00 Hgb-9.6* Hct-32.1*
MCV-80*# MCH-24.0*# MCHC-29.9* RDW-15.6* RDWSD-45.3 Plt ___
___ 12:50PM BLOOD Neuts-81.4* Lymphs-11.8* Monos-5.4
Eos-0.2* Baso-0.3 Im ___ AbsNeut-10.55* AbsLymp-1.53
AbsMono-0.70 AbsEos-0.02* AbsBaso-0.04
___ 12:50PM BLOOD Glucose-104* UreaN-7 Creat-1.0 Na-137
K-3.7 Cl-99 HCO3-25 AnGap-17
___ 12:50PM BLOOD ALT-59* AST-31 AlkPhos-102 TotBili-0.2
___ 12:50PM BLOOD Lipase-37
___ 12:50PM BLOOD cTropnT-<0.01
___ 12:50PM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.6 Mg-1.7
___ 07:30PM BLOOD HIV Ab-Negative
___ 01:01PM BLOOD Lactate-1.1
INTERVAL LABS:
___ 08:45AM BLOOD HCV Ab-Negative
___ 12:45PM BLOOD C3-187* C4-47*
___ 12:45PM BLOOD IgG-1047 IgM-126
___ 07:20AM BLOOD CRP-109.9*
___ 12:45PM BLOOD ___
___ 12:45PM BLOOD Smooth-NEGATIVE
___ 10:26AM BLOOD ANCA-NEGATIVE B
___ 08:45AM BLOOD HBsAg-Negative HBsAb-Positive HAV
Ab-Negative
___ 01:57PM BLOOD HBcAb-Negative
___ 12:45PM BLOOD calTIBC-302 Ferritn-58 TRF-232
RUQUS: 1. Contracted gallbladder.
2. Normal CBD.
3. Minimally complex left renal cysts, requires no additional
followup
imaging.
CT Chest w/o contrast: Stable signs of severe chronic airways
disease, affecting both the large and
the small airways, with thickening of the airway walls,
including the trachea
and the main bronchi, as well as thickening and mucous plugging
of the more
peripheral airways. Pre-existing infectious ground-glass
opacities in the
right lower lobe have cleared and given placed to partly cystic
and partly
interstitial postinfectious remnants. No evidence of new
infectious lesions.
CT A/P:
1. No splenomegaly or lymphadenopathy. Overall unremarkable CT
scan of the
abdomen pelvis.
2. Incidental findings as detailed above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Norethindrone-Estradiol 1 TAB PO DAILY
3. Ranitidine 300 mg PO QHS
4. Mycophenolate Mofetil 1000 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
7. FoLIC Acid 0.4 mg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
9. InFLIXimab unknown IV Q8WEEKS
Discharge Medications:
1. Calcium Carbonate 1500 mg PO DAILY
2. Mycophenolate Mofetil 500 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. PredniSONE 5 mg PO DAILY
7. Norethindrone-Estradiol 1 TAB PO DAILY
8. Ranitidine 300 mg PO QHS
9. Outpatient Lab Work
ICD10: K71.2
By: ___
ALT/AST/Alkaline phosphatase/Tbili/LDH
Please fax to attention Dr. ___ @ ___
10. Outpatient Lab Work
ICD10: K71.2
By: ___
ALT/AST/Alkaline phosphatase/Tbili/LDH
Please fax to attention Dr. ___ @ ___
11. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every 8 hours PRN
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Drug induced liver injury
Relapsing Polychondritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP upright AND LAT)
INDICATION: ___ with fever and cough // Please eval for infiltrates
COMPARISON: ___ and ___ CT.
FINDINGS:
AP upright and lateral views of the chest provided.Lungs are clear. No pleural
effusion or pneumothorax. Cardiomediastinal silhouette is normal. Bony
structures are intact. No free air below the right hemidiaphragm.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with elevated LFTs, fevers, epigastric pain
TECHNIQUE: Right upper quadrant ultrasound
COMPARISON: CT chest dated ___.
FINDINGS:
The liver appears normal in grayscale appearance, size, without focal lesion.
There is no biliary ductal dilation with the common bile duct measuring 4mm.
The main portal vein is patent with hepatopetal flow. The gallbladder is not
visualized as patient ate a cracker earlier this morning and the gallbladder
is fully contracted and not clearly visualized. The pancreas is unremarkable.
Kidneys are normal in grayscale appearance and size. There is a cyst within
the left kidney measuring 3.9 x 3.4 cm, as seen on CT, with a single thin
septation. No ascites is seen.
IMPRESSION:
1. Contracted gallbladder.
2. Normal CBD.
3. Minimally complex left renal cysts, requires no additional followup
imaging.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with relapsing polychrondritis s/p trach with
fevers/cough x ___ years // eval for infection
TECHNIQUE: Volumetric CT acquisition over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
DOSE: DLP: 330 mGy-cm
COMPARISON: CT trachea from ___.
FINDINGS:
The patient continues to carry a tracheostomy tube. No thyroid abnormalities.
No supraclavicular, infraclavicular or axillary lymphadenopathy. Known severe
thickening of the walls of the larger airways (2, 18), including the left and
right main bronchus. Stable appearance of the heart and of the mediastinum as
well as of the upper abdomen, including the known large left kidney cyst. The
bony structures are unremarkable. No evidence of osteolytic lesions or
fractures.
Severe narrowing of the right and left main bronchus continues to be present.
The more peripheral airways continue to show substantial thickening any
irregularities, combines to mucous retention (4, 132). Some of the lower lobe
segmental bronchi show mucous plugging (4, 139). However, the lung parenchyma
shows no evidence of opacities or abnormalities consistent with pneumonia.
Previous ground-glass opacities in the right lower lobe have completely
cleared and the only abnormality seen in these area are some mild scarring and
cystic post infectious remnants (4, 157). No new parenchymal abnormalities.
No pleural effusions. No pleural thickening. No evidence of diffuse lung
disease.
IMPRESSION:
Stable signs of severe chronic airways disease, affecting both the large and
the small airways, with thickening of the airway walls, including the trachea
and the main bronchi, as well as thickening and mucous plugging of the more
peripheral airways. Pre-existing infectious ground-glass opacities in the
right lower lobe have cleared and given placed to partly cystic and partly
interstitial postinfectious remnants. No evidence of new infectious lesions.
Radiology Report
EXAMINATION: CT scan of the abdomen and pelvis
INDICATION: ___ year old woman with relapsing polychondritis presenting with
cough, fevers on remicaide, prednisone, cellcept // evaluate for malignancy,
splenomegaly, lymphadenopathy
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 2.5 s, 1.0 cm; CTDIvol = 5.8 mGy (Body) DLP = 5.8
mGy-cm.
3) Spiral Acquisition 13.8 s, 47.3 cm; CTDIvol = 8.7 mGy (Body) DLP = 400.9
mGy-cm.
Total DLP (Body) = 420 mGy-cm.
COMPARISON: Ultrasound from ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
3.5 x 4.0 cm simple appearing cyst is seen left kidney. No suspicious renal
lesions identified. There is no perinephric abnormality.
GASTROINTESTINAL: Visualized small and large bowel loops are unremarkable in
appearance.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. 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. No splenomegaly or lymphadenopathy. Overall unremarkable CT scan of the
abdomen pelvis.
2. Incidental findings as detailed above.
Radiology Report
INDICATION: ___ year old woman with relapsing polychondritis, h/o rib
fracture, with point tenderness over right lower rib. // please eval for rib
fracture
COMPARISON: ___ .
IMPRESSION:
There are no rib fractures present but the study is limited by single AP film.
If there is persistent clinical concern, then dedicated rib films with a
marker would be recommended. There is no pneumothorax, consolidation or CHF.
Radiology Report
INDICATION: ___ yo F relapsing polychondritis w/tracheomalacia s/p
tracheostomy on mycophenolate and remicaid for immunosuppression with
Transaminitis of unknown etiology // Liver biopsy to determine etiology
COMPARISON: CT abdomen and pelvis ___.
PROCEDURE: Ultrasound-guided non-targeted liver biopsy.
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.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the right
hepatic lobe was performed and a suitable approach for non targeted liver
biopsy was determined. No other abnormalities were identified on the limited
imaging.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine. Under real-time ultrasound
guidance, an 18 gauge core biopsy needle was then advanced into the liver and
a single core biopsy sample was obtained and placed in formalin. The skin was
then cleaned and a dry sterile dressing was applied. There was no immediate
complications.
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of
12 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated non-targeted liver biopsy.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Fever, Cough
Diagnosed with Cough, Fever, unspecified
temperature: 98.8
heartrate: 127.0
resprate: 22.0
o2sat: 100.0
sbp: 119.0
dbp: 81.0
level of pain: 6
level of acuity: 2.0 | ___ with history of relapsing polychondritis with tracheomalacia
s/p tracheostomy currently on mycophenolate and remicaid for
immunosuppression, transaminitis s/p hepatic biopsy, avascular
necrosis of bilateral femoral heads who presents with 1.5 months
of cough/fever despite two rounds of antibiotics.
#Fevers/cough: Patient presented with fevers and cough x 1.5
months in the setting of starting Remicaid a couple weeks prior
to symptoms. Patient has every day nighttime fevers and night
sweats. She had no signs of pneumonia on CXR and pt was s/p 2
rounds of antibiotics as an outpatient without improvement. UA
was negative for UTI. Per ENT, she had no signs of tracheitis.
ID was consulted and CMV, EBV, HCV, HBV serologies were all
negative. She was ruled out for Tb with 3 sputum tests and Pulm
was consulted for bronchoscopy and BAL which was negative for
Tb. Pseudomonas on lavage was felt to be a colonizer. CT chest
and CT A/P did not show signs of infection or malignancy. Her
CRP and ESR were 109 and 103 respectively. Hematology was
consulted for liver biopsy due to concern for autoimmune
hepatitis. Liver biopsy results were non-specific but could be
consistent with DILI from Remicaid. After infectious causes of
fevers/cough were ruled out, patient was d/c'ed home with f/u w/
hepatology and rheumatology.
#Elevated transaminases: Patient had prior liver biopsy for
ALT/AST 100s and was felt to be due to Imuran toxicity. After
azathioprine was d/c'ed, patient's transaminases improved.
Patient was found to have mild elevation in AST/ALT when first
admitted. Her LFTs increased and peaked at 540/283. Liver biopsy
was done per hepatology as above. She should not take Remicaid
anymore per hepatology.
#Relapsing Polychondritis: Patient had been stable on
prednisone, Cellcept. Started on Remicaid several weeks ago in
___. During admission patient was having worsening chest
wall pain, particularly on the right side of her chest and nasal
bridge pain. She was continued on her home medications.
Rheumatology was consulted but no changes were made to her
autoimmune medications due to concern for infection as cause of
fever/cough. Tramadol, Toradol, and tylenol was given for pain.
#Avascular necrosis of bilateral femoral heads: Patient had b/l
collapse of femoral heads and she has been evaluated for hip
replacements. She continued to have minimal symptoms.
#Proteinuria and microscopic hematuria: Patient with UA with 3
RBCs and small protein. Repeat UA shows microscopic hematuria
and small protein. Protein/Cr ratio wnl. Will need to be worked
up as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Tetanus Toxoid,Adsorbed / Sulfa (Sulfonamide
Antibiotics) / Opioids-Meperidine & Related / metformin / Prozac
/ Demerol / morphine / amitriptyline / codeine / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / prochlorperazine
Attending: ___.
Chief Complaint:
Chest Pain
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMH of CAD s/p CABG x 5 (___), stent
x 5 (most recently ___, HFpEF, HTN, DM2 c/b peripheral
neuropathy, and OSA who presents with ___ weeks of worsening
dizziness, chest pain.
He reports that over the past ___ weeks he has been having
dizziness/lightheadedness and that it has continued to worsen.
He does not note any inciting factors that cause the vertigo or
lightheadedness. He presented to his primary care doctor who was
concerned and referred him into the ED. In the office, he
reports slipping and falling and required supporting staff to
catch him. Otherwise, he denies falling or any loss of
consciousness. Per atrius notes, he had reported ___ falls with
one last week resulting in brief LOC and head strike. The falls
were due to severe dizziness/weakness.
He reports about 1.5 weeks ago that he began having intermittent
chest pain. He describes pain as a pressure that is similar to
his prior MIs, worsened with exertion and limiting his activity.
He does get the pain at rest as well and with emotional stress.
Pain can radiate down his arm. He sometimes has dyspnea with the
chest pain. He reports significant stress in his life as his
oldest son is currently dying from cancer.
He denies fevers, abdominal pain, v/d. He had an episode of
nausea this morning.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD s/p CABG x 5 (LIMA to LAD, SVG to OM, Diag, PDA, PLV) in
___
- PCI with DESx3 in ___ and ___ @ ___ - stable native three
vessel disease, known occluded SVG-OM with remaining grafts
patent
- PACING/ICD: None
- CHF- TTE ___: EF 60% with concentric LVF
3. OTHER PAST MEDICAL HISTORY
- DM
- HTN
- HLD
- Cirrhosis due to NAFLD
- Thrombocytopenia
- OSA
- PVD
- Recurrent ___ cellulitis
- Hemorrhaic pancreatitis s/p ex-lap ___ yrs ago
- Colon polyps
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. He does not know his parents or their
history.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VS: 97.7 PO 168 / 76 59 20 98 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no LAD, JVP ~ 11 cm at 90 degrees
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. 2+ edema at ankles, 1+ to
knee. Overlying chronic venous stasis changes
PULSES: 2+ DP pulses bilaterally
NEURO: AOx3, CN ___ intact, strength ___ in b/l UE, ___ and
equal in b/l ___.
SKIN: warm and well perfused. Right dorsal hand with
non-blanching petechial rash extending to wrist. Non pruritic
DISCHARGE PHYSICAL EXAM
=========================
VS: ___.7 PO 108/62 L Lying 58 18 96 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no LAD, JVP ~ 11 cm at 90 degrees
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. 2+ edema at ankles, 1+ to
knee. Overlying chronic venous stasis changes
PULSES: 2+ DP pulses bilaterally
NEURO: AOx3, CN ___ intact, strength ___ in b/l UE, ___ and
equal in b/l ___.
EXTREMITIES: warm and well perfused. Right dorsal hand with
non-blanching petechial rash extending to wrist. chronic venous
stasis changes in legs bilaterally. 1+ pitting edema up to shins
bilaterally.
Pertinent Results:
ADMISSION LABS
===============
___ 05:49PM BLOOD WBC-3.6* RBC-3.73* Hgb-11.8* Hct-35.7*
MCV-96 MCH-31.6 MCHC-33.1 RDW-13.7 RDWSD-48.4* Plt Ct-85*
___ 05:49PM BLOOD Neuts-59.0 ___ Monos-8.5 Eos-3.7
Baso-0.6 Im ___ AbsNeut-2.10 AbsLymp-0.99* AbsMono-0.30
AbsEos-0.13 AbsBaso-0.02
___ 05:49PM BLOOD Plt Ct-85*
___ 05:49PM BLOOD Glucose-229* UreaN-14 Creat-1.0 Na-143
K-4.6 Cl-104 HCO3-29 AnGap-10
___ 05:49PM BLOOD CK(CPK)-144
___ 05:49PM BLOOD cTropnT-0.02*
___ 05:49PM BLOOD CK-MB-6 proBNP-145
___ 05:49PM BLOOD Calcium-8.9 Phos-2.6* Mg-2.1
DISCHARGE LABS
=================
___ 05:05AM BLOOD WBC-3.3* RBC-3.54* Hgb-11.5* Hct-33.6*
MCV-95 MCH-32.5* MCHC-34.2 RDW-13.5 RDWSD-47.2* Plt Ct-89*
___ 05:05AM BLOOD Plt Ct-89*
___ 05:05AM BLOOD Glucose-124* UreaN-16 Creat-1.0 Na-142
K-3.7 Cl-105 HCO3-27 AnGap-10
___ 05:05AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
IMAGING
==========
CT HEAD WITHOUT CONTRAST: ___
There is no evidence of no evidence of infarction, hemorrhage,
edema, or mass.
The ventricles and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air
cells, and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches
appear normal without stenosis, occlusion, or aneurysm
formation. The dural
venous sinuses are patent.
CTA NECK:
Calcifications in the carotid and vertebral arteries are noted,
without
evidence of stenosis or occlusion. There is no evidence of
internal carotid
stenosis by NASCET criteria.
OTHER:
Sternotomy wires noted. The visualized portion of the lungs are
clear. The
visualized portion of the thyroid gland is within normal limits.
There is no
lymphadenopathy by CT size criteria. There are multilevel
degenerative
changes in the cervical spine.
IMPRESSION:
1. Calcifications in the carotid and vertebral arteries without
evidence of
stenosis or occlusion. Otherwise, unremarkable head and neck
CTA.
STRESS TEST: EKG EXERCISE ___
INTERPRETATION: This ___ year old IDDM man with BMI of 44.1 and
h/o
CAD s/p CABG in ___, multiple stents, OSA, CHF and PVD was
referred to
the lab for evaluation. He exercised for 5 minutes on modified
Gervino
protocol and stopped for fatigue. The patient presented to the
lab with
a mild dizziness, which increased slightly with exercise and
returned to
baseline in recovery. Prior to exercise the patient reported a
___
central chest pressure, which increased during exercise, became
___ at
peak, subsided in recovery and returned to baseline by 10
minutes
post-exercise. No other chest, arm, neck or back discomfort
reported. No
significant ST segment changes noticed. Rhythm was sinus with
rare
isolated APBs and VPBs. Blunted HR and BP response to exercise
in the
presence of beta blockade.
IMPRESSION : Anginal symptoms in the absence of ischemic EKG
changes to
the low achieved workload. Poor functional capacity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. DULoxetine 20 mg PO DAILY
5. FoLIC Acid 3 mg PO DAILY
6. Furosemide 40 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Ranolazine ER 1000 mg PO BID
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Potassium Chloride 40 mEq PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. Glargine 50 Units Breakfast
Glargine 45 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Dinner
15. Cefpodoxime Proxetil 200 mg PO Q24H
Discharge Medications:
1. Glargine 50 Units Breakfast
Glargine 45 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Dinner
2. Isosorbide Mononitrate 20 mg PO DAILY
RX *isosorbide mononitrate 20 mg 1 (One) tablet(s) by mouth
DAILY Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Cefpodoxime Proxetil 200 mg PO Q24H
6. Clopidogrel 75 mg PO DAILY
7. DULoxetine 20 mg PO DAILY
8. FoLIC Acid 3 mg PO DAILY
9. Furosemide 40 mg PO BID
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Pantoprazole 40 mg PO Q24H
13. Potassium Chloride 40 mEq PO BID
14. Ranolazine ER 1000 mg PO BID
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dizziness
Chest Pain
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: ___ man with intermittent dizziness with exertion.
Please evaluate for vertebral or carotid stenosis.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
3) Spiral Acquisition 5.0 s, 39.7 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,231.0 mGy-cm.
Total DLP (Head) = 2,161 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
Calcifications in the carotid and vertebral arteries are noted, without
evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
Sternotomy wires noted. The visualized portion of the lungs are clear. The
visualized portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria. There are multilevel degenerative
changes in the cervical spine.
IMPRESSION:
1. Calcifications in the carotid and vertebral arteries without evidence of
stenosis or occlusion. Otherwise, unremarkable head and neck CTA.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Dizziness
Diagnosed with Other chest pain
temperature: 97.9
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 77.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ with PMH of CAD s/p CABG x 5 (1980s), stent
x 5, HFpEF, HTN, DM2 c/b peripheral neuropathy, and OSA who
presents with ___ weeks of worsening dizziness, chest pain, and
DOE.
#Dizziness: Chronic, contributing to falls, worse with head
movement and standing. Unlikely BPPV or vestibular etiology
given history and physical exam. No concern for CVA given normal
head CT, nonfocal neuro exam. Orthostatics normal. Etiology most
likely pharmacologic effect from antianginal medications. Will
optimize as outpatient, decreased imdur dosing as below.
#Chest pain
#CAD s/p CABG, PCI:
#Chronic angina:
Unlikely ACS, as EKG unchanged and trops at baseline (0.02),
exercise stress test demonstrating no ischemia. Unremarkable
telemetry without concern for arrhythmia. Continued home ASA,
statin, Plavix, ranolazine, imdur, can consider initiation of
___ for renoprotection.
#HFpEF: reports worsening dyspnea. no recent TTE, remained
euvolemic. BNP 145. Continued home lasix, metoprolol.
#Petechial rash:
petechial rash along dorsum of right hand, limited to distal to
the wrist. No rash elsewhere, non-pruritic. Likely secondary to
trauma, although patient does not recall any specific incidents.
___ also be due to chronic thrombocytopenia.
#HTN:
Decreased imdur to 20 mg QD from 60 mg QD. Continued home
metoprolol
#Thrombocytopenia:
Chronic, remained at recent baseline.
#DM:
Continued home lantus 50 qAM, 45 qHS; given HISS + prandial
insulin 12 with breakfast/dinner
#GERD:
Continued pantoprazole
#Depression:
Continued home duloxetine. Seen by social worker and provided
resources for coping and stress reduction.
#Recurrent ___ cellulitis:
no active cellulitis on exam. Continue home prophylactic
cefpodoxime. |