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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
morphine / Flonase / lamotrigine
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ old right-handed woman with a
history significant for HIV, probable CNS toxoplasmosis and
medically-refractory focal-onset epilepsy with recurrent
episodes
of status epilepticus, who presents to the ED for concern for
breakthrough seizure.
History is obtained from the daughter at bedside. Her daughter
reports that around 9 p.m. she spoke with her mother on the
phone
and had a normal conversation. She was reminding her mother to
take her evening medications. Her daughter called back at 11 ___
to say good night, and when she did so she noted that her mother
was not speaking normally. She kept repeating. The patient
hung
up, and then subsequently called her daughter back "this is
___, this is ___ and continued to repeat "this is
___.
Her daughter has seen her mother's seizures many times, and says
that this is a classic presentation. Her daughter got in her
car
right away and drove to ___ to pick up her mother. She
brought her directly to the hospital for treatment because she
knows that this is how her mother asked when she has a seizure.
Her daughter denies seeing any head version or limb shaking.
Her daughter reports that patient has had no recent illnesses,
there are possible sick contacts because she lives in a group
home but daughter doesn't think anyone there is sick, and she
says that her mother has not missed any medications. Daughter
says she doesn't drink or use drugs. In terms of her last
seizure, her daughter says that it was sometime between her last
presentation to ___ in ___ and now. At that time she
presented similarly with speech difficulties, was brought to ___
where she was given 1 mg of Ativan, cleared and was discharged
the next day.
In terms of her seizure history, patient's seizures are thought
to be related to her probable CNS toxo, and are characterized by
speech difficulty and right head version progressing to right
face/arm twitching. She has had recurrent episodes of status
epilepticus occurring every ___ months, and prior EEGs have
shown
left frontal and left frontotemporal spikes and sharp waves.
Difficult to obtain review of systems given patient's mental
status. She denies headache, chest pain, trouble breathing but
it is difficult to know if she understands what I am asking her.
Past Medical History:
- HIV/AIDS. On Triumeq (abacavir/dolutegravir/lamivudine)
- CNS toxoplasmosis
- Seizure disorder
- TIA ___
- CVD
- HTN
- HLD
- Oral candidiasis
- Fibroids s/p partial hysterectomy
- Tonsillectomy
- Anemia
Social History:
___
Family History:
Sister with stroke in late ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:afebrile P:66 R: 16 BP: 105/56 SaO2: 100%
General: Awake, intermittently attentive to examiner, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic: (after 2mg of ativan total)
-Mental Status: patient awake, tracks and regards examiner, says
her name. Unable to relate history without difficulty.
Perseverative. When asked to name ___ backwards, she says
___ ___ Patient can repeat short
sentences. She can name thumb, eye, pen. Can read ___
and "baseball player". She registered ___ words and repeated
them
for several minutes but did not reply when asked for repetition
5
minutes later. Speech is not dysarthric. Follows commands to
stick out tongue; cannot follow two step commands. Cannot
perform
3 steps on luria.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Intact to near
card.
V: Did not answer regarding facial sensation.
VII: Slight R NLFF, symmetric activation.
VIII: Hearing intact to questions.
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. Intermittently was shaking bilateral legs (R>L) but
could be stopped by examiner or when asked.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ 5 5 5 5 5 5 5
*Wrist fracture limiting movement
-Sensory: No deficits to light touch, proprioception throughout.
Says left when each side is being touched independently. Says
both when both sides are touched simultaneously.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2 2 1
R 3+ 3+ 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Deferred due to mental status.
DISCHARGE PHYSCIAL EXAM:
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, vibratory sense.
No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: normal gait
Pertinent Results:
___ 06:24AM BLOOD WBC-4.7 RBC-3.98 Hgb-11.7 Hct-37.2 MCV-94
MCH-29.4 MCHC-31.5* RDW-12.8 RDWSD-44.4 Plt ___
___ 12:20AM BLOOD Neuts-49.0 ___ Monos-7.7 Eos-1.0
Baso-0.5 AbsNeut-1.98 AbsLymp-1.69 AbsMono-0.31 AbsEos-0.04
AbsBaso-0.02
___ 06:24AM BLOOD Plt ___
___ 01:19AM BLOOD ___ PTT-32.1 ___
___ 06:24AM BLOOD Glucose-100 UreaN-21* Creat-0.8 Na-146
K-3.8 Cl-108 HCO3-21* AnGap-17
___ 12:20AM BLOOD ALT-10 AST-13 AlkPhos-83 TotBili-0.2
___ 12:20AM BLOOD Lipase-27
___ 06:24AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
___ 12:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. LACOSamide 200 mg PO BID
5. LevETIRAcetam 1000 mg PO BID
6. Topiramate (Topamax) 150 mg PO BID
Discharge Medications:
1. OXcarbazepine 300 mg PO BID
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. LACOSamide 200 mg PO BID
5. LevETIRAcetam 1000 mg PO BID
6. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
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 seizure// eval consolidation
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
No focal consolidation. No pleural effusion or pneumothorax. The
cardiomediastinal silhouette is normal. Limited view of the upper abdomen is
unremarkable.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Confusion, Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 98.2
heartrate: 95.0
resprate: 14.0
o2sat: 98.0
sbp: 152.0
dbp: 80.0
level of pain: unable
level of acuity: 2.0 | ___ is a ___ old right-handed woman with a
history
significant for HIV, probable CNS toxoplasmosis and
medically-refractory focal-onset epilepsy with recurrent
episodes of status epilepticus, who presents to the ED for
concern for breakthrough seizure.
#Hospital course
Patient was given Ativan 2mg IV in the ED total, with slow
return to her neurologic baseline over about 45 minutes. Patient
was monitored on cvEEG throughout her stay, which showed alpha
frequency background. Occasional epileptiform discharges in the
left frontotemporal region and slowing but no seizures. A plan
from Dr. ___ to titrate her from topiramate to oxcabazepine
while being monitored on EEG was followed. Patient tolerated OXC
well with no adverse side effects. She was stable for discharge
home on ___ with previously scheduled outpatient follow up. Her
other AEDs, namely Vimpat 200mg BID and Keppra 1000mg BID were
continued.
#HIV
Continued home anti-retroviral medications
#HTN/HLD
Continued home medications Amlodipine 5mg, Atorvastatin 10mg QHS
#Transitional Issues:
[ ] Through review of recent imaging, we saw that there was
concern for CNS toxo (as suspected by history) on MRI ___,
radiology recommended thallium-201-SPECT to look for
toxoplasmosis. This scan can be ordered as an outpatient if her
epileptologist recommends it. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Osteoarthritis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with a h/o HTN, severe osteoarthritis and
previous falls who presents with unwitnessed fall yesterday.
She states that she was walking in her house when she become
stuck between some furniture and fell. She doesn't actually
remember falling, or how long she was on the ground. She states
that she called for help and the police arrived to take her to
the hospital. She denies any loss of consciousness or head
trauma, but can not recall the events clearly. She did not feel
dizzy or nauseated before the fall. Her knees often feel painful
when she walks around her home. She denies any dizziness,
lightheadedness, headaches, changes in vision, palpations, chest
pain, SOB, abdominal pain, nausea, vomiting, changes in oral
intake, fevers, sweats or chills. She denies any dysuria or
increases in urgency. She denies any history of seizures. She
also states that she has a rash on the back of her left leg as
well that is non pruritus and non-tender and has been present
for an unknown amount of time.
In the ED, initial VS were T 98.1, HR 102 BP 142/86, RR 16,
O2Sat 97 RA. She received 1 g of IV ceftriazone in the ED. A CT
head demonstrated no intracranial hemorrhage, CT C-spine
demonstrated no fracture, CXR no acute cardiopulmonary
abnormality, and her xray of left humerus was negative for
fractures. Her transfer VS T 98.1 P 80 RR 17 BP 145/78 O2SAT 98.
On arrival to the floor, patient reports that she does not have
any pain.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
- bilateral OA (end stage tricompartmental, has failed
injections, being worked up for TKRs)
- OSA
- Chronic ___ edema
- HTN
- HLD
- Obesity
- Depression
- Memory loss and ? dementia
Social History:
___
Family History:
Most of her family was killed in the ___ and only herself
and her mother survived, so she does not know much about her
family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS -98.2 124/
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, I/VI systolic
murmur heard best at the right upper sternal border, no rubs, no
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, no suprapubic
tenderness
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, mildly tender to palpation b/l in ___, tenderness over
left shoulder.
Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities,
grossly normal sensation,gait deferred.
Skin: 7 cm pink plaque on the posterior left thigh. 10 cm dark
purple patch c/w ecchymosis.
DISCHARGE PHYSICAL EXAM:
VS- T 97.7 BP 146/80 HR 75 RR 18 O2SAT 99 RA
Exam otherwise unchanged
Patient occasionally oriented only to person
Pertinent Results:
ADMISSION LABS:
___ 08:43AM BLOOD WBC-8.3 RBC-4.46 Hgb-14.4 Hct-39.5 MCV-89
MCH-32.3* MCHC-36.5* RDW-14.0 Plt ___
___ 08:43AM BLOOD Neuts-61.5 ___ Monos-8.6 Eos-3.7
Baso-0.8
___ 08:43AM BLOOD Plt ___
___ 08:43AM BLOOD Glucose-132* UreaN-17 Creat-0.6 Na-139
K-3.6 Cl-103 HCO3-22 AnGap-18
___ 08:43AM BLOOD CK(CPK)-164
___ 06:50AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9
___ 08:51AM BLOOD Lactate-1.6
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-5.5 RBC-4.02* Hgb-12.7 Hct-35.9*
MCV-89 MCH-31.5 MCHC-35.3* RDW-14.0 Plt ___
___ 06:50AM BLOOD Glucose-119* UreaN-15 Creat-0.6 Na-139
K-3.6 Cl-103 HCO3-21* AnGap-19
___ 06:50AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9
MICRO:
___ URINE CULTURE- MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
IMAGING:
___ CXR- Heart size is normal with tortuosity of the thoracic
aorta. Mediastinal silhouette and hilar contours are unchanged.
Lungs are clear. There is no pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary abnormality.
___ Humerus xray- There is no fracture, dislocation or
periarticular erosion. IV catheter projects over the antecubital
fossa. There is no significant joint effusion. There is no soft
tissue calcification.
IMPRESSION: No fracture or dislocation.
___ CT C-spine- There is no evidence of acute fracture or
dislocation. There are moderate multilevel degenerative changes
of the cervical spine with disc space narrowing, most prominent
at C4-C5 and C6-C7 with prominent anterior and posterior
osteophytes, mainly at the same levels, which indent the ventral
thecal sac and cause mild canal stenosis. Multilevel facet joint
and uncovertebral hypertrophy narrow the neural foramina at
multiple levels. The prevertebral soft tissue is not thickened.
The thyroid gland is unremarkable in appearance. A 3-mm
calcified granuloma in the right lung apex is unchanged. An
accessory azygos fissure is present. The imaged lung apices are
otherwise clear.
IMPRESSION: No cervical spine fracture or dislocation.
___ CT head- There is no acute intracranial hemorrhage, edema,
mass effect or acute vascular territorial infarct. Prominent
ventricles and sulci are suggestive of age-related involutional
change. Periventricular white matter hypodensity is compatible
with chronic small vessel ischemic disease. The basal cisterns
are patent. There is preservation of gray-white matter
differentiation. Dense atherosclerotic calcifications are noted
within the vertebral arteries and carotid siphons. The globes
are intact. No fracture is identified. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are well
aerated.
IMPRESSION: No acute intracranial abnormality.
___ ECG- Sinus rhythm at 92, RBBB with left anterior fasicular
block, left axis deviation, without ST-T elevations meeting
Sgarbossa criteria. Unchanged from prior.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. TraMADOL (Ultram) 25 mg PO Q8H:PRN pain
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. Centrum Silver (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250 mcg
Oral daily
5. Lisinopril 5 mg PO DAILY
6. Tricor (fenofibrate nanocrystallized) 145 mg Oral daily
7. Citalopram 20 mg PO DAILY
8. CeleBREX (celecoxib) 200 mg Oral 1x per day
9. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. TraMADOL (Ultram) 25 mg PO Q8H:PRN pain
3. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
5. Aspirin 81 mg PO DAILY
6. CeleBREX (celecoxib) 200 mg ORAL 1X PER DAY
7. Centrum Silver (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250 mcg
Oral daily
8. Lisinopril 5 mg PO DAILY
9. Tricor (fenofibrate nanocrystallized) 145 mg Oral daily
10. Calcium Carbonate 500 mg PO QID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall
Osteoarthritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
HISTORY: Status post fall.
COMPARISON: Non-contrast head CT, ___.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 1025.72 mGy-cm.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or
acute vascular territorial infarct. Prominent ventricles and sulci are
suggestive of age-related involutional change. Periventricular white matter
hypodensity is compatible with chronic small vessel ischemic disease. The
basal cisterns are patent. There is preservation of gray-white matter
differentiation. Dense atherosclerotic calcifications are noted within the
vertebral arteries and carotid siphons. The globes are intact. No fracture
is identified. The visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are well aerated.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
HISTORY: Status post unwitnessed mechanical fall.
COMPARISON: Non-contrast C-spine CT, ___.
TECHNIQUE: Axial helical MDCT images were obtained of the cervical spine
without contrast. Multiplanar reformatted images were generated in the
coronal and sagittal planes.
DLP: 752.14 mGy-cm.
FINDINGS: There is no evidence of acute fracture or dislocation. There are
moderate multilevel degenerative changes of the cervical spine with disc space
narrowing, most prominent at C4-C5 and C6-C7 with prominent anterior and
posterior osteophytes, mainly at the same levels, which indent the ventral
thecal sac and cause mild canal stenosis. Multilevel facet joint and
uncovertebral hypertrophy narrow the neural foramina at multiple levels. The
prevertebral soft tissue is not thickened. The thyroid gland is unremarkable
in appearance. A 3-mm calcified granuloma in the right lung apex is unchanged.
An accessory azygos fissure is present. The imaged lung apices are otherwise
clear.
IMPRESSION: No cervical spine fracture or dislocation.
Radiology Report
HISTORY: Status post mechanical fall.
COMPARISON: None available.
TECHNIQUE: Left humerus radiograph, two views.
FINDINGS: There is no fracture, dislocation or periarticular erosion. IV
catheter projects over the antecubital fossa. There is no significant joint
effusion. There is no soft tissue calcification.
IMPRESSION: No fracture or dislocation.
Radiology Report
HISTORY: Status post fall with mental status change.
COMPARISON: ___.
TECHNIQUE: AP and lateral chest radiograph, three views.
FINDINGS: Heart size is normal with tortuosity of the thoracic aorta.
Mediastinal silhouette and hilar contours are unchanged. Lungs are clear.
There is no pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: S/P FALL
Diagnosed with SHLDR/UPPER ARM INJ NOS, UNSPECIFIED FALL, URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS
temperature: 98.1
heartrate: 102.0
resprate: 16.0
o2sat: 97.0
sbp: 142.0
dbp: 86.0
level of pain: 13
level of acuity: 3.0 | Ms. ___ is a ___ yo woman with a h/o bilateral severe
osteoarthritis, HTN and memory loss with frequent admissions for
falls who presented after fall.
# s/p fall: The patient has a history of falls and has multiple
past imaging studies demonstrating severe osteoarthritis. Her
likely cause of fall was gait instability related to her OA. Her
lack of chest pain, sob, dizziness, lightheadedness make it less
likely to be due to cardiac origin but inability to remember the
course of events and RBBB warranted a cardiac workup for
syncope. Her telemetry showed no arrhythmias.
Her osteoarthritis was treated with standing tylenol,
tramadol and celebrex. She was seen and evaluated by ___ who
recommended rehab.
# Altered mental status: Patient appears to have baseline
dementia that has not been clearly evaluated. CT shows evidence
of small vessel ischemia suggesting vascular dementia. Patient
was oriented without evidence of delerium during
hospitalization, but certainly demonstrated short and long term
memory difficulties. We recommend outpatient neuro-psych
testing.
# Osteoarthritis: Long standing issue, she was previously on
tramadol and celocoxib in the past and we restarted these
medications in addition to standing tylenol and vitamin D.
# HTN: Patient was not hypertensive on the floor. Her lisinopril
was held as it was unclear if she was taking this at home and
blood pressure was controlled without the medication.
# Depression: Continued citalopram
# Transitional Issues
- We recommend 24 hour home services vs assisted living
following rehab for safety
- Patient should have further evaluation of underlying dementia
with neuro-psych testing
- Please assist patient with all medications to ensure
compliance |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin / Tricor
Attending: ___.
Chief Complaint:
CC: lethargy
Major ___ or Invasive Procedure:
None
History of Present Illness:
The history is obtained from the patient, ED, and OMR.
___ with MDS ___ allogeneic transplant (___) c/b GVHD who
presents with lethargy.
The patient was recently admitted from ___ to ___ to the
___ service. During this admission he had loss of consciousness
with a head strike. The initial incident / somnolence was
thought to be secondary to narcotic overdose and resolved during
the second day of admisison. On ___ he developed progressive
agitation and decreased insight. He threatened staff and had a
"code purple" called. He required sedative medications. Haldol
was started and was titrated to 10mg QID with 7.5-10mg PO
QID:PRN with good effect. He was discharged with plan to follow
up with psychiatry.
He was discharged on ___. Since discharge he feels that his
legs are heavy and he has increasing difficulty moving around.
He is still able to walk without assistance. He reports feeling
somnolent and falling asleep at that table. His haldol dose was
recently decreased from 10mg QID to 10mg TID. On the day of
admission, he was unable to perform ADLs and was behaving
stangely per his wife. He endorses cough x2 days. He oxycontin
use and has decreased his oxycodone use.
In the ED, initial vitals were: pain 10, T 99.4, HR 82, BP
140/87, RR 20, SvO2 97% RA. Labs showed WBC near recent
baseline, hct 21, plt 91, BUN/Cr ___, transaminitis, mg 1.4.
Blood cx were drawn. CXR completed and "concerning for
pneumonia". He was admitted to ___ for further evaluation and
management.
Currently, he feels okay. He continues to have heavy joints and
some somnolence. He endorses cough without sputum production. He
also notes chronic bilateral knee aches. He denies fevers,
chills, nausea, vomiting, diarrhea, constipation, chest pain,
abdominal pain, blood in stool, headache, neck pain, confusion,
head truama or falls.
ROS: per HPI. Otherwise denies.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: Diagnosis of MDS, initially maintained with blood
transfusion
-___: BM biopsy
-___: MUD allo stem cell transplant, c/b GVH of the skin,
eye and GI tract.
- Admission for BK virus and cystitis, resolved with IV
cidofovir
- positive PPV post-transplant, no signs of PTLD and CTs were
negative
- Recent long hospitalization for GI GVHD. Improved with
prednisone, CellCept and tacrolimus; now maintained on 20 mg of
prednisone, 1500 mg of CellCept and 0.5 tacrolimus BID
PAST MEDICAL/SURGICAL HISTORY:
- MDS with refractory anemia ___ allo transplant
- Hypercholesterolemia
- history of staph infection in leg wound
- pilonidal cyst ___ drainage
- Colon polyps
- EtOH abuse
- surgery right arm after tree climbing accident as a child
- hx of positive PPD, untreated
Social History:
___
Family History:
His father has colon cancer, as well as other cancers (pt is
unsure of details). His mother is alive and well. He has a
full sister who is healthy and a half brother who is also
healthy. Maternal grandfather died from colon cancers.
Maternal grandmother died from a heart condition. His paternal
grandmother died from bone cancer in her ___.
Physical Exam:
Admission Exam:
General: no apparent distress, chronically ill appearing male
Vitals: 98.2, 130/80, 75, 20, 99% RA
Pain: ___
HEENT: op without lesions, poor dentition, perrl 2-3mm.
Neck: no JVD
Cardiac: rr, nl rate, no murmur
Lungs: crackles in left lower base, no accessory muscle use
Abdomen: soft, nontender, nondistended, positive bowel sounds
Extremity: Warm, well perfused, no edema
Neuro: strength ___ and equal upper and lower extremities. No
asterixis. Possible slight assymetry of tongue to left on
extension, otherwise CN intact.
Psych: odd affect, flat. alert and oriented and appropriate.
calm. attention was okay.
Skin: multiple lesions on upper extremities.
Discharge exam:
Vitals: 98.7, 120-130/80, 72-75, ___, 99% RA
Pain: ___
HEENT: op without lesions, poor dentition, perrl 2-3mm.
Neck: no JVD
Cardiac: rr, nl rate, no murmur
Lungs: crackles in left lower base, no accessory muscle use
Abdomen: soft, nontender, nondistended, positive bowel sounds
Extremity: Warm, well perfused, no edema. Scattered echymossis
on the extensor and flexor surfaces of the upper extremities.
Healed ulcerations
Neuro: strength ___ and equal upper and lower extremities. No
asterixis. Possible slight assymetry of tongue to left on
extension, otherwise CN intact.
Psych: odd affect, flat. alert and oriented and appropriate.
calm. attention was okay.
Skin: multiple lesions on upper extremities.
Pertinent Results:
Admission labs:
___ 08:15PM BLOOD WBC-5.4 RBC-2.31* Hgb-7.4* Hct-21.3*
MCV-93 MCH-31.9 MCHC-34.7 RDW-22.5* Plt Ct-91*
___ 08:15PM BLOOD Neuts-85.5* Lymphs-5.5* Monos-8.4 Eos-0.3
Baso-0.3
___ 08:15PM BLOOD Glucose-110* UreaN-28* Creat-1.0 Na-138
K-3.5 Cl-105 HCO3-25 AnGap-12
___ 08:15PM BLOOD ALT-113* AST-71* AlkPhos-163* TotBili-0.3
___ 08:15PM BLOOD Albumin-3.1* Calcium-7.8* Phos-2.3*
Mg-1.4*
___ 08:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:25PM BLOOD Lactate-1.3
Discharge Labs
___ 06:20AM BLOOD WBC-3.3* RBC-2.36* Hgb-7.5* Hct-22.5*
MCV-95 MCH-31.8 MCHC-33.5 RDW-22.8* Plt Ct-62*
___ 06:20AM BLOOD Neuts-81.4* Lymphs-6.9* Monos-11.1*
Eos-0.4 Baso-0.2
___ 06:20AM BLOOD Glucose-91 UreaN-24* Creat-1.1 Na-137
K-3.8 Cl-106 HCO3-23 AnGap-12
___ 06:20AM BLOOD ALT-170* AST-96* LD(LDH)-449*
AlkPhos-161* TotBili-0.4
___ 06:20AM BLOOD Albumin-3.2* Calcium-8.4 Phos-2.4* Mg-2.2
Blood cx x2
___ CXR: There is somewhat increased left base retrocardiac
opacity worrisome for pneumonia. No pleural effusion is seen.
The right lung is clear. There is no evidence of pneumothorax.
The cardiac and mediastinal silhouettes are stable and
unremarkable. IMPRESSION: Left lower lobe retrocardiac opacity,
somewhat increased as compared to the prior study, is concerning
for pneumonia.
___ RUQ u/s
IMPRESSION:
Normal abdominal ultrasound. No etiology for transaminitis is
identified
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
2. Budesonide 3 mg PO TID
3. cycloSPORINE 0.05 % ___ BID
4. FoLIC Acid 4 mg PO DAILY
5. Gabapentin 300 mg PO QHS
6. Mycophenolate Mofetil 250 mg PO BID
7. Omeprazole 40 mg PO DAILY
8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
9. Vitamin D ___ UNIT PO DAILY
10. Atovaquone Suspension 1500 mg PO DAILY
11. Haloperidol 10 mg PO TID
12. Haloperidol 7.5-10 mg PO QID:PRN agitation
13. Niacin 100 mg PO QHS
14. Nystatin Oral Suspension 5 mL PO QID:PRN ___
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Senna 1 TAB PO BID:PRN constipation
17. Acyclovir 400 mg PO Q8H
18. Voriconazole 200 mg PO Q12H
19. PredniSONE 20 mg PO DAILY
20. Neutra-Phos 1 PKT PO ONCE
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
3. Atovaquone Suspension 1500 mg PO DAILY
4. Budesonide 3 mg PO TID
5. cycloSPORINE 0.05 % ___ BID
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. FoLIC Acid 4 mg PO DAILY
8. Gabapentin 300 mg PO QHS
9. Haloperidol 10 mg PO BID
RX *haloperidol 5 mg 2 tablet(s) by mouth twice per day Disp
#*120 Tablet Refills:*0
10. Mycophenolate Mofetil 250 mg PO BID
11. Niacin 100 mg PO QHS
12. Omeprazole 40 mg PO DAILY
13. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
14. PredniSONE 20 mg PO DAILY
15. Senna 1 TAB PO BID:PRN constipation
16. Vitamin D ___ UNIT PO DAILY
17. Voriconazole 200 mg PO Q12H
18. Levofloxacin 750 mg PO DAILY Duration: 5 Days
your last dose will be ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth once per day Disp
#*5 Tablet Refills:*0
19. Haloperidol 5 mg PO BID:PRN agitation
20. Nystatin Oral Suspension 5 mL PO QID:PRN ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: MDS with refractory anemia ___ allo
transplant ___
Secondary diagnoses: hypercholesterolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: AML status post bone marrow transplant with lethargy and chills.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
There is somewhat increased left base retrocardiac opacity worrisome for
pneumonia. No pleural effusion is seen. The right lung is clear. There is
no evidence of pneumothorax. The cardiac and mediastinal silhouettes are
stable and unremarkable.
IMPRESSION:
Left lower lobe retrocardiac opacity, somewhat increased as compared to the
prior study, is concerning for pneumonia.
Radiology Report
HISTORY: History of MDS status post allogenic liver transplant with
transaminitis. Evaluate for liver pathology.
TECHNIQUE: Grayscale and color spectral Doppler imaging of the abdomen was
performed.
COMPARISON: Pancreas CT from ___ and abdominal ultrasound from
___.
FINDINGS: The liver is normal in echotexture. No solid mass is identified.
Two cysts are noted in the right lobe of the liver, the largest measuring 1.4
cm. The smaller cyst measures up to 1 cm. The gallbladder is partially
collapsed as the patient is reportedly recently ate. The common bile duct is
normal in caliber, measuring 4.4 mm. Visualized portions of the pancreas are
within normal limits. There is no ascites. The aorta and IVC are normal in
caliber and are patent. The spleen is normal is normal in size measuring 11.3
cm.
Color spectral Doppler waveforms are normal with normal respiratory phasicity
in the portal vein. Waveforms and velocities are normal within the hepatic
artery and hepatic veins as well as the IVC. No evidence of stenosis or
thrombosis.
IMPRESSION:
Normal abdominal ultrasound. No etiology for transaminitis is identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: BODY PAIN LETHARGY
Diagnosed with ALTERED MENTAL STATUS
temperature: 99.4
heartrate: 82.0
resprate: 20.0
o2sat: 97.0
sbp: 140.0
dbp: 87.0
level of pain: 10
level of acuity: 2.0 | ___ with MDS ___ allo SCT (___) c/b GVHD who presents with
encephalopathy.
# Weakness vs Encephalopathy: According to patient started
immediately following by discharge characterized by "heavy
hands." These symptoms improved with outpatient haldol was
downtitrated. Per family fluctuates between intermittent
somnolence agitation. Patient's feeling improved with
antibiotics in the ED. Etiology likely multi-factorial with an
underlying psychiatric component. Psychiatry saw the patient in
house and downtitrated his haldol. Patient has also been
persistently anemic with all cell lines down c/f GVHD. GVHD can
also manifest with nerve damage which can also contribute to the
overall picture.
#Pneumonia: No cough and oxygen requirement. Retrocardiac
opacity on CXR upon presentation. He will complete a 7 day
course of levofloxacin on ___
# Transaminitis: He presented last admission with transaminitis
as well. This resolved and the etiology was not clear based on
the discharge summary. Possibly related to GVHD. RUQ u/s showed
no pathology.
# Anemia, thrombocytopenia: Bone marrow is hypocellular with
iron studies suggesting iron of chronic inflammation. Hemolysis
labs are unremarkable.
# Graft versus host disease: Multiple organ involvement. Skin
and mucosal exam stable. Continued acyclovir, atovaquone,
voriconazole, prednisone, budesonide, cyclosporine,
mycophenolate mofetil. Likely liver involvement given
transaminitis
Transitional issues
-Patient missed psychiatry appointment with Dr. ___ due to
hospitalization. Will follow up with her. Haldol downtitrated to
10 mg BID
- Patient will complete a 7 day course of abx on ___
- Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sudafed / Trazodone
Attending: ___
___ Complaint:
Perirectal pain
Major Surgical or Invasive Procedure:
Anorectal examination under anesthesia, drainage of abscess
placement ___
History of Present Illness:
Per ED Note:
___ F presents to ED for evaluation of rectal pain. Patient
states that she has been experiencing chronic perianal and
perirectal pain due to her known abscesses however over the past
several days feels as though her pain has increased in intensity
and frequency. In addition, she does report new sensations of
pressure in her vagina and some difficulty initiating urination
which she did not experience before. In addition, she does feel
as though there is increased firmness in her right buttock close
to her anal verge. Of note, she reports being scheduled for EUA
with Dr. ___ on ___ at ___, however she
feels as though she may not be able to wait that long for
management of her symptoms. Otherwise continues to have her
baseline intermittent incontinence of flatus and stool.
Continues to take bowel regimen from above however does not
report using enemas. Denies any fevers, chills; able to
tolerate
p.o. intake without nausea or vomiting.
Past Medical History:
Past Medical History:
Chronic constipation with proctocolitis
Anxiety/depression, possible PTSD
Pelvic floor dyssynergy
Fatty liver disease - on US/MRI, prior fibroscan without
fibrosis
Glaucoma
Endometriosis - previously on hormonal therapy
Pruritus ani
Insomnia
Past Surgical History:
EUA ___
multiple foot arthroplasties with hardware removal
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: Temperature 98.2 heart rate 81 blood pressure 110/78
respiratory rate 16 O2 sat 98%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Soft, nondistended, nontender, no rebound or guarding,
Ext: No ___ edema, ___ warm and well perfused
GU/DRE: Mild excoriation on skin just outside the anal verge,
area of firmness in the right gluteal region just to the right
of midline close to the anal opening, digital rectal exam
notable for tone intact, areas of fullness noted in the
posterior midline and posterior to the right of midline, no
obvious purulence
======================
Discharge Physical Exam:
VS: 98.7, 101/68, 87, 18, 97%/RA
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, No JVD
PULM: Clear to auscultation bilaterally, no increased work of
breathing.
ABD: Soft, non-distended, nontender, no rebound or guarding.
Rectal: Incision with ___, no erythema or discharge, ___
drain in place and secured with nylon.
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
MR PELVIS W&W/O CONTRAST Study Date of ___ 6:06 AM
IMPRESSION:
1. Large perirectal intersphincteric horseshoe abscess
communicating with a more inferiorly located horseshoe perianal
abscess through a linear tract coursing in the intersphincteric
plane at 9 o'clock, significantly worse compared to ___.
2. Multiple secondary branches, including 8 o'clock position of
the perianal abscess that ends blindly in the right ischioanal
fat, arising from the right lateral aspect of the
perirectal/perianal abscess with an internal opening at 9
o'clock approximately 4.8 cm from the anal verge, and arising
from the anterior aspect perianal abscess with an internal
opening 5:30 o'clock 3.2 cm from the anal verge.
___ 07:00AM BLOOD WBC-11.8* RBC-3.74* Hgb-10.3* Hct-32.3*
MCV-86 MCH-27.5 MCHC-31.9* RDW-14.7 RDWSD-46.8* Plt ___
___ 03:02AM BLOOD WBC-11.1* RBC-3.80* Hgb-10.5* Hct-32.9*
MCV-87 MCH-27.6 MCHC-31.9* RDW-14.6 RDWSD-45.3 Plt ___
___ 03:02AM BLOOD Neuts-69.3 Lymphs-15.3* Monos-12.5
Eos-2.0 Baso-0.5 Im ___ AbsNeut-7.70* AbsLymp-1.70
AbsMono-1.39* AbsEos-0.22 AbsBaso-0.05
___ 07:00AM BLOOD Glucose-85 UreaN-9 Creat-0.8 Na-140 K-4.2
Cl-106 HCO3-25 AnGap-9*
___ 03:02AM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-141
K-4.3 Cl-105 HCO3-23 AnGap-13
___ 07:00AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.7
___ 03:02AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. OLANZapine 5 mg PO QHS
4. ClonazePAM 2 mg PO BID
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Docusate Sodium 100 mg PO BID
7. Polyethylene Glycol 17 g PO QID
8. Senna 8.6 mg PO BID
9. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
10. linaCLOtide 290 mcg oral DAILY
11. Multivitamins 1 TAB PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
13. Naproxen 500 mg PO Q12H:PRN Pain - Mild
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. FLUoxetine 40 mg PO DAILY
16. FoLIC Acid 1 mg PO DAILY
17. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*11 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
3. BuPROPion XL (Once Daily) 300 mg PO DAILY
4. ClonazePAM 2 mg PO BID
RX *clonazepam 2 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
5. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
6. Docusate Sodium 100 mg PO BID
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
8. FLUoxetine 40 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. linaCLOtide 290 mcg oral DAILY
12. Multivitamins 1 TAB PO DAILY
13. Naproxen 500 mg PO Q12H:PRN Pain - Mild
14. OLANZapine 5 mg PO QHS
15. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
16. Polyethylene Glycol 17 g PO QID
17. Senna 8.6 mg PO BID
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perirectal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old woman with complex history of past perirectal
abscesses with multiple drainage attempts, presenting with right-sided
perirectal abscess// Perirectal/perianal abscess characterization
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis were acquired
in a 1.5 T magnet.
Intravenous contrast: 5 mL Gadavist
COMPARISON: Pelvic MRI ___
FINDINGS:
ANUS/RECTUM: There has been interval progression of perirectal and perianal
disease compared to the prior MRI performed in ___.
There is a large perirectal intersphincteric horseshoe abscess, which extends
from 3 o'clock to 9 o'clock. The largest component of the abscess at the
posterior 6 o'clock position measures up to 3.2 x 2.3 cm, previously 2.5 x 1.7
cm in ___ (06:20). A communicating tract arising from the right
anterior inferior aspect of the horseshoe abscess courses anteriorly through
the internal sphincter, resulting in an internal opening at 8 o'clock,
approximately 4.8 cm from the anal verge (09:49).
At 9 o'clock, a linear component of this abscess courses inferiorly in the
intersphincteric plane by approximately 1 cm, and communicates with another
perianal horseshoe abscess, where the widest diameter measures up to 0.5 cm
(11:59). There is a secondary branch off of this tract that courses through
the internal sphincter at the 8 o'clock position, resulting in an internal
opening at 9 o'clock approximately 4.8 cm from the anal verge (11:49). This
is fluid-filled and measures up to 0.3 cm in diameter.
Along the right posterolateral aspect of the perianal abscess described above
at 8 o'clock, there is a secondary branch that courses posterolaterally
through the external sphincter and ends blindly in the right ischioanal fat
where there are extensive surrounding inflammatory changes (9:61). Widest
part of this fluid filled tract measures up to 0.6 cm in diameter, previously
measuring approximately 0.1 cm (06:27).
There is another tract that extends from the anterior aspect of the perirectal
abscess, coursing through the internal sphincter resulting in an internal
opening at 5:30 o'clock position of the proximal anal canal approximately 3.2
cm above the anal verge (09:57). This is fluid-filled and measures up to 0.4
cm in diameter, overall similar compared to the prior study.
There is involvement of the levator ani muscles. There are extensive
inflammatory changes involving the rectum, with associated mucosal
hyperenhancement. Multiple mesorectal lymph nodes are noted, measuring up to
0.5 cm, which are likely reactive.
BLADDER: There is no abnormal bladder wall thickening.
REPRODUCTIVE ORGANS: The uterus and ovaries are unremarkable in appearance.
No adnexal masses are identified.
VESSELS: Imaged iliac vessels are patent bilaterally.
BONES: No focal osseous lesions are identified.
IMPRESSION:
1. Large perirectal intersphincteric horseshoe abscess communicating with a
more inferiorly located horseshoe perianal abscess through a linear tract
coursing in the intersphincteric plane at 9 o'clock, significantly worse
compared to ___.
2. Multiple secondary branches, including 8 o'clock position of the perianal
abscess that ends blindly in the right ischioanal fat, arising from the right
lateral aspect of the perirectal/perianal abscess with an internal opening at
9 o'clock approximately 4.8 cm from the anal verge, and arising from the
anterior aspect perianal abscess with an internal opening 5:30 o'clock 3.2 cm
from the anal verge.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Rectal pain
Diagnosed with Rectal abscess
temperature: 98.2
heartrate: 81.0
resprate: 16.0
o2sat: 99.0
sbp: 110.0
dbp: 75.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ presented to the Emergency Department on ___
with complaints of perirectal pain. She was admitted to the
colorectal surgery service for symptoms concerning for interval
progression of abscesses. Due to the abscess in her pelvis, she
was having difficulty urinating on her own so a foley catheter
was placed. She underwent a pelvic MRI that revealed a large
perirectal abscess that had fistulized toward the anus. She was
brought to the operating room on ___ for ___ and
___ placement and abscess drainage. She tolerated the
procedure well without complications (Please see operative note
for further details). After a brief and uneventful stay in the
PACU, the patient was transferred to the floor for further
post-operative management. On ___, the foley was removed and
the patient was able to void spontaneously without any
difficulty. Throughout hospitalization, she remained
hemodynamically stable and afebrile. The patient is being
discharged on a week course of Augmentin.
On ___, the patient was discharged to rehab. At discharge,
she was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. She will follow-up in the clinic in
___ weeks. This information was communicated to the patient
directly prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / shellfish derived
Attending: ___.
Chief Complaint:
Rectal pain
Major Surgical or Invasive Procedure:
Exam under anesthesia, Botox injection
History of Present Illness:
___ hx of ___ disease, currently on Humira, presents with
rectal pain and swelling. She reports that symptoms started two
weeks ago when she noticed discomfort with bowel movements.
Since then the pain has increased. Pain is sharp and
continuous, worsened by bowel movements and by sitting for long
periods. Pain is diffuse along her sacrum toward her perineum,
left greater
than right sided. She also noticed purulent discharge when
wiping after bowel movements and on underwear. Has also noted
fevers to 103 at home this past ___, none since. Denies prior
perianal abscesses. Tolerating PO, denies nausea or vomiting.
Also denies BRBPR or melena. Last bowel movement today. ___
disease diagnosed in ___. Was initially on pentasa, until last
year,
then started Humira. Has ___ bowel movements daily. Soft,
formed, non-bloody. Reports that last colonoscopy was in ___
and is due for one again in the near future. No ___ flares
recently. Her typical manifestations are bloody bowel movements
and abdominal pain. Typically has right colonic symptoms. Is
followed at ___.
Past Medical History:
___, HTN
Social History:
___
Family History:
No family members with ___, ulcerative colitis, or colon
cancer
Physical Exam:
Gen: NAD
HEENT: NCAT, anicteric, no neck masses
CV: RRR
Pulm: no respiratory distress
Abd: S/NT/ND
Rectal: Posterior midline anal fissure
TLD: None
Pertinent Results:
___ 07:26AM BLOOD WBC-5.5 RBC-4.84 Hgb-13.5 Hct-40.5 MCV-84
MCH-27.9 MCHC-33.3 RDW-13.7 RDWSD-41.6 Plt ___
___ 07:26AM BLOOD Neuts-42.2 ___ Monos-6.7 Eos-1.6
Baso-0.2 Im ___ AbsNeut-2.33 AbsLymp-2.70 AbsMono-0.37
AbsEos-0.09 AbsBaso-0.01
___ 07:26AM BLOOD Glucose-113* UreaN-7 Creat-0.8 Na-138
K-3.7 Cl-101 HCO3-27 AnGap-14
___ 04:30PM BLOOD ALT-65* AST-41* AlkPhos-95 TotBili-0.3
___ 07:26AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.8
Medications on Admission:
Humira, Valsartan 80'
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain or fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*60 Tablet Refills:*0
2. Psyllium Powder 1 PKT PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
4. Valsartan 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___ abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of Crohn's disease with purulent rectal drainage.
Evaluate for source of infection or abscess.
TECHNIQUE: Multiplanar and multisequence T1 and T2 weighted images were
acquired through the pelvis before after the uneventful intravenous
administration of 10 mL of Gadavist contrast.
COMPARISON: None.
FINDINGS:
In the low rectum, approximately 41 mm from the anal verge, there is a short
interloop fistula which is confined to the rectal wall on the right. It
originates at approximately 10 o'clock (5, 17), extends 15 mm in the cranial
caudal dimension, and then reenters through the mucosa at approximately 12
o'clock. It is approximately 5 mm in width. There is a small amount of fluid
within this fistula. There is some surrounding enhancement, suggesting active
inflammation.
No other fistula or sinus track is identified. No discrete drainable abscess
is identified.
The ischiorectal fossa, ischioanal fossa, and anal sphincter are within normal
limits. There is no significant scarring or thinning of the musculature.
The remainder of the rectum and intrapelvic bowel loops are normal. There are
no focal inflammatory changes. The uterus, cervix, and vaginal canal are
normal. The endometrium is thin and homogeneous, measuring 2 mm. The ovaries
are not discretely visualized. No adnexal masses are identified. The bladder
is unremarkable without focal thickening or evidence of a mass.
There is no pelvic or inguinal lymphadenopathy. No free fluid is identified
in the pelvis.
There are no concerning osseous lesions. The soft tissues are unremarkable.
IMPRESSION:
Short intraloop fistula in the low right rectum which is confined to the
rectal wall, as described above.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abscess, Rectal pain
Diagnosed with Other specified diseases of anus and rectum
temperature: 97.8
heartrate: 89.0
resprate: 16.0
o2sat: 99.0
sbp: 174.0
dbp: 87.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ was admitted to ___ for an exam under anesthesia
for a presumed rectal abscess. For more details, see operative
report. She was taken from the OR to the PACU in stable
condition. She was soon moved to the surgical floor. She
tolerated a regular diet, and her pain was well controlled with
oral pain medication. She was discharged home with instructions
to take Metamucil daily and follow up with Dr. ___ in 2
weeks. All of her questions were answered to her satisfaction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
trazodone / Lyrica
Attending: ___.
Chief Complaint:
dyspnea, abdominal distension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/pmh bicuspid aortic valve, s/p AVR with CABG ___, HFpEF,
stage IV CKD, DM, HTN, AF on warfarin who presented to ___
clinic today for worsening SOB, abdominal distention, and lower
extremity edema consistent with CHF exacerbation.
Patient also reports 2 pillow orthopnea, nighttime cough, and
PND. He says he becomes short of breath with chest tightness
after walking to the bathroom. He was treated with 160MG IV
Lasix. Refused hospital admission and was sent home. Labs back
later with creatinine of 4.3, and patient was called to report
to
the ED. Per ___ clinic, patient has had increasing weight
gain of about ___ pounds over last couple of months. Dry
weight
~185 pounds.
In the ED, initial VS were: 98.2 75 119/71 12 98% RA
Exam notable for:
Conjunctiva pale, JVD elevated to level of the ear, significant
abdominal distention with tenderness throughout, pitting lower
extremity edema 2+
Labs showed:
proBNP: 9534
Cr: 4.3, BUN 78
Anion Gap: 19
HgB: 9.0
INR: 2.6, on warfarin
Imaging showed:
CXR with Unchanged cardiomegaly with minimal pulmonary vascular
congestion, without frank pulmonary edema.
Patient received: none
Transfer VS were: 97.9 79 155/91 22 97% RA
On arrival to the floor, patient reports shortness of breath and
chest discomfort with lying flat. Otherwise feels well and has
been taking his medications consistently.
Past Medical History:
Aortic Insufficiency
Atrial Fibrillation
Benign Prostatic Hyperplasia
Bicuspid Aortic Valve
Congestive Heart Failure, diastolic
coronary Artery Disease status post PTCA to LAD
Depression
Diabetes Mellitus, Insulin Dependent
Gastroesophageal Reflux Disease
Glaucoma
Gout
Hyperlipidemia
Hypertension
Hypothyroid
Neuropathy
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 97.7 181/87 82 96% on RA
GENERAL: Adult male in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: JVP elevated 10-12cm
HEART: irregular rate, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: WWP with ___ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM:
===========================
VS: 98.0 157/81 51 18 95% RA
Weights: Admit weight 87.7 kg, Dry Weight 85.8kg Trend: 87.7kg
->
86.2kg -> 86kg-> 85.1kg->85.28kg
GENERAL: Adult male in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera,
NECK: JVP elevated to clavicle
HEART: irregular rate, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: warm and well perfused. Minimal edema on exam. Non
pitting.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
=================
___ 11:20AM BLOOD WBC-8.6 RBC-3.20* Hgb-9.0* Hct-28.8*
MCV-90 MCH-28.1 MCHC-31.3* RDW-15.1 RDWSD-49.6* Plt ___
___ 03:40AM BLOOD WBC-11.5* RBC-3.62* Hgb-10.1* Hct-31.6*
MCV-87 MCH-27.9 MCHC-32.0 RDW-15.0 RDWSD-47.8* Plt ___
___ 11:20AM BLOOD ___
___ 11:20AM BLOOD UreaN-78* Creat-4.3* Na-144 K-4.8 Cl-99
HCO3-26 AnGap-19*
___ 07:20PM BLOOD Glucose-153* UreaN-82* Creat-4.3* Na-140
K-5.0 Cl-98 HCO3-28 AnGap-14
___ 11:20AM BLOOD proBNP-9534*
___ 07:20PM BLOOD cTropnT-0.09*
___ 07:20PM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1
___ 03:40AM BLOOD calTIBC-270 Ferritn-53 TRF-208
IMAGING:
==========
CXR ___:
Unchanged cardiomegaly with minimal pulmonary vascular
congestion, without frank pulmonary edema.
RENAL US ___:
No hydronephrosis. Echogenic appearance of the kidney suggests
chronic
medical renal disease.
ECHO ___:
The left atrial volume index is moderately increased. The
estimated right atrial pressure is ___ mmHg. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function (biplane LVEF = 67 %). Right ventricular
chamber size and free wall motion are normal. The right
ventricular free wall is hypertrophied. A bioprosthetic aortic
valve prosthesis is present. The transaortic gradient is normal
for this prosthesis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a prominent fat pad.
MICRO:
===========
___ 7:48 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
================
___ 08:05AM BLOOD WBC-8.6 RBC-3.71* Hgb-10.4* Hct-32.2*
MCV-87 MCH-28.0 MCHC-32.3 RDW-14.7 RDWSD-46.8* Plt ___
___ 08:05AM BLOOD Plt ___
___ 08:05AM BLOOD Glucose-161* UreaN-81* Creat-4.3* Na-138
K-4.7 Cl-91* HCO3-29 AnGap-18
___ 08:05AM BLOOD Calcium-9.1 Phos-5.5* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
4. Calcitriol 0.5 mcg PO DAILY
5. Carvedilol 25 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO BID
12. TraZODone 100 mg PO QHS:PRN insomnia
13. Venlafaxine 75 mg PO BID
14. Torsemide 100 mg PO DAILY
15. Allopurinol ___ mg PO DAILY
16. Colchicine 0.6 mg PO 2X/WEEK (___)
17. HydrALAZINE 75 mg PO TID
18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
19. Gabapentin 300 mg PO QHS
20. Warfarin 7.5 mg PO 6X/WEEK (___)
21. Warfarin 5 mg PO 1X/WEEK (MO)
22. Glargine 20 Units Breakfast
Glargine 16 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Dinner
Discharge Medications:
1. Gabapentin 200 mg PO QHS
RX *gabapentin 100 mg 2 capsule(s) by mouth at bedtime Disp #*60
Capsule Refills:*0
2. Torsemide 100 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
7. Calcitriol 0.5 mcg PO DAILY
8. Carvedilol 25 mg PO BID
9. Finasteride 5 mg PO DAILY
10. HydrALAZINE 75 mg PO TID
11. Glargine 20 Units Breakfast
Glargine 16 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Dinner
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 75 mcg PO DAILY
15. Losartan Potassium 100 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 20 mg PO BID
18. TraZODone 100 mg PO QHS:PRN insomnia
19. Venlafaxine 75 mg PO BID
20. Warfarin 7.5 mg PO 6X/WEEK (___)
21. Warfarin 5 mg PO 1X/WEEK (MO)
22. HELD- Colchicine 0.6 mg PO 2X/WEEK (___) This medication
was held. Do not restart Colchicine until instructed to start by
PCP
___:
Home
Discharge Diagnosis:
Primary Diagnosis:
================
Acute exacerbation of Chronic Diastolic Heart Failure
Stage IV Chronic Kidney Disease
Secondary Diagnosis:
=================
Atrial Fibrillation on Warfarin
Depression
GERD
Hypothyroidism
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with worsening dyspnea on exertion.// Dyspnea on
exertion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Patient is status post median sternotomy, aortic valve replacement, and CABG.
Fracture of the superior mediastinal wire is unchanged. Cardiac silhouette
size remains moderately enlarged. The mediastinal and hilar contours are
unchanged. There is minimal pulmonary vascular congestion, but no frank
pulmonary edema is present. No focal consolidation, pleural effusion, or
pneumothorax is present. Mild degenerative changes are seen in the thoracic
spine.
IMPRESSION:
Unchanged cardiomegaly with minimal pulmonary vascular congestion, without
frank pulmonary edema.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with CKD, CHF, admitted with volume overload and
___ on CKD with worsening renal function despite diuresis// evaluate cause of
renal failure
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
The right kidney measures 10.2 cm. The left kidney measures 12.0 cm. There is
no hydronephrosis, stones, or masses bilaterally. Simple cysts are seen in
both kidneys measuring up to 1.8 cm in the right interpolar region and 1.7 cm
in the upper pole the left kidney. Echogenic appearance of the kidneys
suggests chronic medical renal disease.
The bladder is moderately well distended and normal in appearance. Oblong
cystic structure adjacent to the bladder measuring approximately 6 cm
corresponds to penile prosthesis reservoir seen on prior CT in ___.
IMPRESSION:
No hydronephrosis. Echogenic appearance of the kidney suggests chronic
medical renal disease.
Gender: M
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Dizziness
Diagnosed with Acute kidney failure, unspecified, Heart failure, unspecified, Dyspnea, unspecified
temperature: 98.2
heartrate: 75.0
resprate: 12.0
o2sat: 98.0
sbp: 119.0
dbp: 71.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ is a ___ year old male with a history of
chronic diastolic heart failure, atrial fibrillation, Stage IV
CKD, hypothyroidism, GERD who presented from heart failure
clinic with worsening dyspnea, abdominal distension and concern
for acute on chronic kidney injury. Patient notably was 2kg
above his presumed dry weight at time of admission with Sr Cr
elevated to 4.3 compared to a previous baseline of approximately
3.0. While inpatient, he received IV 120mg Lasix daily which
resulted in diuresis and subsequent improvement in his symptoms.
Once euvolemic patient was transitioned to home PO Torsemide
100mg. Regarding his renal function. Patient was evaluated with
a renal ultrasound which did not demonstrate acute changes. He
was also evaluated by the Nephrology team who suggested this
likely represented a progression of his known chronic kidney
disease. Patient was discharged once stable on an oral diuretic
regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD AND COLONOSCOPY ___
History of Present Illness:
___ y/o M with history of recent cholecystectomy (3 mos prior at
___ recently discharged on ___ after being admitted with
abdominal pain, nausea, vomitting p/w numerous episodes of
intense bilious vomiting and weakness x 2 days. Initially, after
leaving hospital patient felt well up until 2 days ago when he
had sudden abdominal pain and nausea/vomitting. Emesis is
non-bloody. Not tolerating much PO including liquids. Feeling
weak and tired (acute worsening but has been present for ___
year). Alternating hot and chills. Unable to tolerate POs,
constantly nauseated. Also notes non-pruritic rash that started
yesterday as well. Non-bloody diarrhea began two days ago as
well. R side abd pain, sharp. Denies dysuria, flank pain. He
reports he has had a 27lb weight loss in past 6 months. No
recent travel or unusual foods. No sexual partners outside his
___. No OTC vitamins or supplements.
At previous admission, patient had CT imaging of possible liver
disease as well as abnormal iron panel. He was found to have
Hepatitis C and previous Hepatitis B on tests that were pending
on discharge.
In the ED intial vitals were: 7 97.9 85 135/91 15 100. Labs
significant for CBC ___, normal lytes, ALT 258, AST
192, AP 106, Tbili 0.6, Alb 4.2, lipase 39, UA normal. Received
Zofran.
On the floor, patient looks uncomfortable but in NAD.
Review of Systems:
(+) per HPI
Past Medical History:
S/P CCY at ___ ___
Social History:
___
Family History:
Mother died 18 months ago of liver disease. The patient reports
she died quickly at ___ after turning yellow.
Unclear how much she was drinking. Grandmother also with liver
disease. One brother who is healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T:97.3 BP:144/89 HR:81 RR:18 02 sat: 100RA
GENERAL: NAD, uncomfortable
HEENT: EOMI, anicteric sclera,
NECK: Supple
CARDIAC: RRR, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, hyperactive BS, tender on R side with
greatest in RUQ, no rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
SKIN: B/l papular rash on anterior aspect of arms. Shoulders
with macular erythema
98.7, 106/61, 78, 18, 98% RA
GENERAL: Awake, NAD, uncomfortable
HEENT: EOMI, anicteric sclera, oropharynx clear. MMM.
NECK: Supple, no LAD appreciated
CARDIAC: RRR, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, BS present, TTP over RUQ, no rebound or
guarding. No hepatomegaly on percussion, difficult to
appreciate splenomegaly.
EXTREMITIES: Moving all extremities well, no cyanosis, clubbing
or edema, warm and well perfused
SKIN: B/l papular rash on anterior aspect of arms resolving.
Shoulders with macular erythema.
Pertinent Results:
ADMISSION LABS:
___ 01:25AM BLOOD WBC-6.3 RBC-4.14* Hgb-13.0* Hct-38.5*
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.5 Plt ___
___ 01:25AM BLOOD Neuts-60.6 ___ Monos-8.3 Eos-5.3*
Baso-1.7
___ 01:25AM BLOOD ___ PTT-34.1 ___
___ 01:25AM BLOOD Glucose-116* UreaN-16 Creat-0.7 Na-134
K-4.1 Cl-96 HCO3-29 AnGap-13
___ 01:25AM BLOOD ALT-258* AST-192* AlkPhos-106 TotBili-0.6
___ 06:35AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8
PERTINENT LABS:
___ 01:25AM BLOOD ALT-258* AST-192* AlkPhos-106 TotBili-0.6
___ 06:35AM BLOOD ALT-243* AST-168* LD(LDH)-220 AlkPhos-96
TotBili-0.5
___ 06:55AM BLOOD ALT-297* AST-199* LD(___)-244 AlkPhos-100
TotBili-0.7
___ 07:20AM BLOOD ALT-359* AST-235* AlkPhos-107 TotBili-0.7
___ 07:20AM BLOOD ALT-384* AST-235* LD(LDH)-221 AlkPhos-97
TotBili-1.0
___ 06:00AM BLOOD ALT-410* AST-244* AlkPhos-106 TotBili-1.1
___ 07:00AM BLOOD ALT-380* AST-154* AlkPhos-114 TotBili-1.2
___ 07:05AM BLOOD ALT-309* AST-110* AlkPhos-100 TotBili-1.0
___ 06:18AM BLOOD ALT-221* AST-72* AlkPhos-109 TotBili-0.6
___ 07:05AM BLOOD Cortsol-27.4*
___ 01:05PM BLOOD Cryoglb-NO CRYOGLO
___ 06:35AM BLOOD IgM HAV-NEGATIVE
___ 07:20AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 06:00AM BLOOD RheuFac-9
___ 07:20AM BLOOD ___
___ 07:20AM BLOOD IgG-1311 IgM-150
___ 06:55AM BLOOD IgA-259
___ 06:00AM BLOOD C3-112 C4-16
___ 06:35AM BLOOD HIV Ab-NEGATIVE
___ 07:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:35AM BLOOD tTG-IgA-4
DISCHARGE LABS:
___ 06:18AM BLOOD WBC-6.3 RBC-4.33* Hgb-13.7* Hct-39.7*
MCV-92 MCH-31.6 MCHC-34.4 RDW-13.3 Plt ___
___ 06:18AM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-135
K-3.8 Cl-98 HCO3-28 AnGap-13
___ 06:18AM BLOOD ALT-221* AST-72* AlkPhos-109 TotBili-0.6
___ 06:18AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0
URINE:
___ 02:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:50AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-8.0 Leuks-NEG
___ 02:50AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 02:50AM URINE Mucous-RARE
___ 07:59AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
MICROBIOLOGY
Hepatitis D antibody: negative
___ 6:35 am IMMUNOLOGY
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
258,000 IU/mL.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
___ 11:51 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___ 5:45 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
___ CRYSTALS PRESENT.
___ 8:29 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
___ CRYSTALS PRESENT.
___ 7:00 am Blood (CMV AB) CHM S# ___ ADDED ___.
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
128 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
If current infection is suspected, submit follow-up serum
in ___
weeks.
IMAGING:
RUQ ULTRASOUND WITH DOPPLER
FINDINGS:
The liver is has a homogeneous echotexture. The gallbladder has
been removed.
The common duct measures up to 8 mm. There is no intra-hepatic
bile duct
dilatation. The pancreas is obscured by overlying bowel gas.
The spleen is
enlarged, measuring 16.8 cm. There is no ascites.
Color flow and spectral Doppler waveform analysis were obtained.
The main,
left, right anterior, and right posterior portal veins are
patent with
hepatopetal flow. Appropriate arterial waveforms with brisk
upstrokes are
seen in the left, right, and main hepatic arteries with RIs
ranging from 0.61
- 0.67. Appropriate flow is seen in the left, right, and middle
hepatic veins
and IVC. The superior mesenteric vein and splenic vein are
patent.
IMPRESSION:
1. Patent hepatic vasculature.
2. Splenomegaly.
___ MRCP
IMPRESSION:
1. No definite evidence of choledocholithiasis. A tiny filling
defect at the
distal CBD near the ampulla, seen on only one image, is likely
artifactual.
Status post cholecystectomy. Normal caliber of intrahepatic and
extrahepatic
biliary ductal system.
2. Mild hepatic steatosis. No overt features of cirrhosis. A 8
mm T1
hyperintense hypoenhancing lesion in segment 5 likely relates to
a
regenerative nodule. Sub 5 mm simple cyst in segment 4A of the
liver.
3. Mild stable splenomegaly.
___ COLONOSCOPY
Impression:Stool in the colon
Diverticulosis of the sigmoid colon and descending colon
Given the inadequate prep, the findings of this colonoscopy are
very limited and underlying polyps cannot be excluded. The parts
of the mucosa that could be visualized appeared normal. The
terminal ileum was intubated up to 5cm and appeared normal.
(biopsy)
___ EGD
Impression:Mild erythema and mosaic appearance in the antrum
(biopsy)
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
PENDING STUDIES:
Send Outs
___ 07:05 CHROMOGRANIN A
___ 06:00 HEPATITIS C VIRAL RNA, GENOTYPE
___ 07:20 HEREDITARY HEMOCHROMATOSIS MUTATION ANALYSIS
Microbiology
___ 17:34 Blood (EBV) ___ VIRUS VCA-IgG AB;
___ VIRUS EBNA IgG AB; ___ VIRUS VCA-IgM AB
Diagnostic Reports
___ Tissue: LOWER GASTROINTESTINAL BIOPSY
Medications on Admission:
None
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight hours Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatitis
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 s/p cholecystectomy, history of hep C, cleared
hep C, risingtransaminitis, n/v, abdominal pain. // eval liver, spleen, please
evaluate vasculature with dopplers
TECHNIQUE: Grayscale, color, and spectral Doppler ultrasound examination of
the abdomen.
COMPARISON: ___. For re ___.
FINDINGS:
The liver is has a homogeneous echotexture. The gallbladder has been removed.
The common duct measures up to 8 mm. There is no intra-hepatic bile duct
dilatation. The pancreas is obscured by overlying bowel gas. The spleen is
enlarged, measuring 16.8 cm. There is no ascites.
Color flow and spectral Doppler waveform analysis were obtained. The main,
left, right anterior, and right posterior portal veins are patent with
hepatopetal flow. Appropriate arterial waveforms with brisk upstrokes are
seen in the left, right, and main hepatic arteries with RIs ranging from 0.61
- 0.67. Appropriate flow is seen in the left, right, and middle hepatic veins
and IVC. The superior mesenteric vein and splenic vein are patent.
IMPRESSION:
1. Patent hepatic vasculature.
2. Splenomegaly.
Radiology Report
INDICATION: History of HCV, ETOH abuse, elevated transaminases and right
upper quadrant pain. Normal ERCP study from ___. Query retained stone
causing pain and elevated transaminases.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla
magnet, including dynamic 3D imaging, obtained prior to and following
uneventful intravenous administration of 0.1 mmol/kg Gadavist (total dose of 7
cc). 1 cc Gadavist and 50 cc of water was administered orally. Multiplanar 2D
and 3D reformation the subtraction images were generated on independent
workstation.
COMPARISON: Prior Doppler abdominal ultrasound from ___, CT abdomen
and pelvis from ___ and liver ultrasound from ___.
FINDINGS:
The lung bases are clear. The liver demonstrates normal morphology. Mild
hepatic steatosis is noted (6a:9, 6b:37). A sub 5 mm simple cyst is identified
in segment 4A of the liver (12:27). A 8.0 mm T1 hyperintense lesion is
identified in segment 5 (9:57), which is hypoenhancing on dynamic
contrast-enhanced sequences (13:56), likley in keeping with a regenerative
nodule. No hyperenhancing hepatic lesions are identified. Patient is status
post cholecystectomy. No intrahepatic or extrahepatic biliary ductal
dilatation. The CBD measures 6 mm, and demonstrates smooth tapering at the
ampulla. An apparent tiny filling defect is identified at the distal CBD near
the ampulla (3:27), seen on axial T2 sequence however not identified on any
other sequence, likely artifactual. The pancreas demonstrates normal signal
and enhancement. Pancreatic duct is within normal limits. No pancreas
divisum.
No mesenteric or retroperitoneal lymphadenopathy. A 2.0 cm periportal lymph
node (3:18), is likely reactive. The spleen is mildly enlarged measuring 15.9
cm. The adrenal glands are unremarkable. Kidneys demonstrate symmetric
enhancement, with no evidence of hydronephrosis. No focal renal lesions are
identified. No ascites. A replaced left hepatic artery is identified arising
off the left gastric artery. The celiac artery, SMA, single bilateral renal
arteries and ___ are patent. The portal veins and hepatic veins are patent.
Caliber of small and large bowel is within normal limits. Bone marrow signal
is unremarkable.
IMPRESSION:
1. No definite evidence of choledocholithiasis. A tiny filling defect at the
distal CBD near the ampulla, seen on only one image, is likely artifactual.
Status post cholecystectomy. Normal caliber of intrahepatic and extrahepatic
biliary ductal system.
2. Mild hepatic steatosis. No overt features of cirrhosis. A 8 mm T1
hyperintense hypoenhancing lesion in segment 5 likely relates to a
regenerative nodule. Sub 5 mm simple cyst in segment 4A of the liver.
3. Mild stable splenomegaly.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with NAUSEA WITH VOMITING, ABN LIVER FUNCTION STUDY
temperature: 97.9
heartrate: 85.0
resprate: 15.0
o2sat: 100.0
sbp: 135.0
dbp: 91.0
level of pain: 7
level of acuity: 3.0 | ___ with recent cholecystectomy recent discovery of Hep C and B
previous exposure presenting after recent discharge with
worsening transaminitis, vomiting and diarrhea.
# Transaminitis: Patient had elevated transaminitis on
admission which continued to rise to as high as ALT 410 and AST
244. Etiology of his rising transaminitis was unclear but
thought secondary to his chronic hepatitis C infection. He is
s/p recent cholecystectomy ___ at ___ and his alk phos and
bili were within normal limits. His hep B serologies showed
cleared previous infection; hepatitis A IgM and hepatitis D
antibodies were negative. Transabd US showed patent hepatic
vasculature, and MRCP showed no evidence of retained stone, and
otherwise showed mild hepatic steatosis. Autoimmune serologies
___, anti-sm muscle, anti-mitoch), RF, C3 and C4 were negative.
He had positive HSV-2 IgM but clinically did not appear as sick
for HSV hepatitis. Otherwork up including CMV, and
ceruloplasmin were negative and EBV antibodies, hemochromatosis
gene testing and chromogranin were pending at discharge. His
transaminitis was downtrending at discharge. He will undergo
outpatient hepatology biopsy and be seen in ___ clinic.
# Nausea/Vomiting/diarrhea: The etiology of his recurrent
symptoms was unclear. Although his symptoms correlated with
rising transaminitis which downtrended with symptom resolution,
it was unclear if his GI symptoms were related to his
transaminitis which was thought likely secondary to chronic hep
C. The workup for transaminitis was as above. He also had
negative HIV, negative C difficile, O&P, stool culture and
workup for celiac disease was negative. He underwent an
endoscopy and colonoscopy (limited views due to poor prep) which
were unrevealing for specific etiology of his symptoms. Random
biopsies were obtained and pending at discharge.
# Chronic HCV. Patient was noted to have positive hepatitis C
Ab on previous admission. VL was sent and returned at 258,000
with genotype sent and pending at discharge. Patient will be
seen in outpatient hepatology follow up.
# Rash: He presented with a papular rash on arms and neck, had
started 2 days prior to presentation with onset of abdominal
symptoms. It was thought possibly lichen planus versus
cryoglobulinemia but his cryo labs were negative. His rash was
intermittently itchy and treated with sarna lotion and benadryl.
His arm rash was resolving at discharge with residual rash on
his neck and shoulders at discharge.
# Incidental pancreatic lesion: On RUQ US on previous admission,
he was found to have an 8mm cystic lesion in the head of the
pancreas with recommendation for follow-up imaging in ___ year to
monitor. However, MRCP on current admission did not reveal any
cystic lesion in the pancreas. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
toe pain, cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ gout, afib (on coumadin), essential thrombocytopenia
(on hydrea) p/w left fifth toe pain. Pt w/ long standing h/o
gout, tells me that he's had pain in the left toe for some
months. Per wife, pain worsened over the course of a week. Pt
still able to ambulate w/ cane, though wife tells w/ pain. Pt
saw PCP on ___, given keflex for cellulitis and colchicine
increased. No f/c at home. Pt set up w/ ___ who was concerned
re: toe and sent to the ED. Overnight pt started on levo and
vanc. XRay concerning for middle and distal phalanges of the
fifth toe osteo.
.
Of note: Per wife, pt saw oncologist a few weeks ago, was told
that plts were very high, but didn't get restart hydroxyurea.
Per daughter: pt had blood work done last month (___) WBC
19.3, Hgb 10.5, Hct 31.8, Plt 1770, Cr 1.25. She tells me he
hasn't been on hydroxyurea b/c of anemia. Took 1.8-2.4mg of
colchicine for gout.
ROS as above, otherwise, as reviewed in 10 other systems and
negative.
Past Medical History:
Anemia
Gout
Essential thrombocythemia
Essential HTN
Pulmonary HTN
CHF (diastolic)
Afib on coumadin
Retinal venous occlusion
Preglaucoma
Hypercholesterolemia--LDL was 64 in ___
Colonic polyp
Edema
Hearing loss
Hypertensive retinopathy
Chronic bronchitis
Horner's syndrome
Benign prostatic hypertrophy
H/o prostatitis
Gallbladder calculus
Social History:
___
Family History:
Brother with MI in ___.
Physical Exam:
VS - T 99, BP 160/70, HR 50, RR 16, 98-100% RA
Gen: NAD
Neck: no JVD
Pulm: CTAB
CV: ___ SEM at sternal boarder
Abd: Soft NTND
Ext: wwp, erythema of ___ digit, no pustulous drainage.
Pertinent Results:
___ 07:53PM ___ PTT-43.2* ___
___ 07:53PM WBC-30.6*# RBC-4.11*# HGB-10.3*# HCT-33.8*#
MCV-82# MCH-25.1*# MCHC-30.4* RDW-22.0*
___ 07:53PM NEUTS-89* BANDS-0 LYMPHS-6* MONOS-3 EOS-1
BASOS-1 ___ MYELOS-0
___ 07:53PM GLUCOSE-136* UREA N-59* CREAT-1.6* SODIUM-139
POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-26 ANION GAP-18
___ 10:50PM LACTATE-2.5*
.
___ swab left foot fifth digit: no PMN, no microorg, cx
pending
___ blood cultures pending x2
.
___ CXR: No pleural effusions. No evidence of pneumonia
___ left foot xray: Osteolysis involving middle and distal
phalanges of the fifth toe, compatible with acute osteomyelitis.
Medications on Admission:
spironolactone 12.5mg daily
furosemide 80mg bid
cochicine 1.2mg daily
simvastatin 20mg daily
diovan 80mg daily
warfarin 2.5mg daily (usually ___
asa 81 (___)
amlodipine 5mg daily
finasteride 5mg daily
Discharge Medications:
1. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours for 9 days.
Disp:*27 Capsule(s)* Refills:*0*
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO MON, WED, FRI ().
7. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Tylenol ___ mg Tablet Sig: ___ Tablets PO every eight (8)
hours as needed for pain.
10. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 ___.
Disp:*30 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Please check an INR and K. These results should be faxed to Dr.
___ ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gout, ___ toe osteolysis
Cellulitis
Discharge Condition:
Alert, oriented x3
Ambulates with walker
Followup Instructions:
___
Radiology Report
INDICATION: Patient with right fifth toe pain. Assess for osteomyelitis or
fracture.
COMPARISONS: None available.
FINDINGS: Three views of the right foot demonstrate no evidence of acute
fracture or dislocation. There is osteolysis involving portions of the middle
and distal phalanges of the fifth toe. There are no prior exams available for
comparison to determine the chronicity of these findings though given the
appearance of an adjacent soft tissue ulcer, findings are likely acute.
Extensive periarticular osteopenia is noted. The lateral cortical margin of
the cuboid is not clearly seen on the oblique view, ?? osteomyelitis.
Extensive vascular calcifications are present. Moderate calcaneal
enthesophytes are noted.
IMPRESSION: Osteomyelitis involving middle and distal phalanges of the fifth
toe. Apparent osteolysis at the lateral margin of the tarsal cuboid, may also
represent osteomyelitis -- please correlate for additional pain, ulcer in this
region.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Leukocytosis, questionable pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. The pre-existing changes suggestive of minimal fluid overload are
still present. No pleural effusions. No evidence of pneumonia. Borderline
size of the cardiac silhouette.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: GOUT PAIN
Diagnosed with OTHER ELEVATED WHITE BLOOD CELL COUNT, PAIN IN LIMB, GOUT NOS
temperature: 98.2
heartrate: 63.0
resprate: 16.0
o2sat: 100.0
sbp: 183.0
dbp: 63.0
level of pain: 1
level of acuity: 3.0 | ___ yo M w/ gout, ET, HTN, CHF, afib sent to ED by ___ w/ concern
for left foot ___ digit ulcer, XRay c/w
osteolysis/osteomyelitis.
.
# Gout, L foot ___ digit bony destruction: Podiatry was
consulted who evaluated patient. The XRay findings seen were
thought to be due to gout, with overlying cellulitis. Patient
was initially treated with vanc and levo, and then transitioned
to ___ to complete a 10 day course. Home ___ services were
resumed on discharge. Patient was instructed to follow up with
podiatry as an outpatient for likely surgery.
.
# Cellulitis: Patient treated with vanc/levo and transitioned to
___ for a 10 day course. Wound and blood cultures at time of
discharge showed no growth.
.
# CKD: His baseline Cr was confirmed w/ his PCP to ranges
1.2-1.5.
.
# Leukocytosis: Confirmed w/ PCP, that his WBC ranges 19-high
___. Patient remained afebrile and hemodynamically stable while
inhouse. He will need to continue follow up with his outpatient
hematologist regarding this issue.
.
# Essential thrombocythemia: Per family, hydroxyurea was stopped
due to side effects. He was continued on asa ___
.
# Afib: His warfarin dose was continued at 2.5mg daily (reduced
from 5.5 to 2.5 by his PCP). He was given a slip to have his
INR checked on ___ (managed by his PCP)
.
# HTN: Given that patient had hyperkalemia on several blood
draws his spironolactone was discontinued, and he was asked to
follow up with his PCP regarding this with a K to be checked on
___. He was continued on amlodipine, furosemide, and
valsartan.
.
# diastolic CHF: Continued furosemide, spironolactone, valsartan
.
# BPH: Continued finasteride |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fentanyl / morphine / Penicillins / Levofloxacin / Pain
Medication
Attending: ___.
Chief Complaint:
left sided chest/abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ yo F with a PMHx of COPD, parkinsonism, bronchiectasis and
recurrent falls with chronic rib fractures, COPD, hemorrhoids,
cystoceole with complete uterine prolapse presenting with chest
pain and abdominal pain. The patient reports that the pain
started yesterday and may be related to her hernia or recent
calls. The pain is ___ and on the left sided of her chest and
lower abdomen. She also reporting loose stools for the past day
with some blood, but when asked in detail, there is no blood
seen in her stools, only some blood seen on her toilet paper.
She has been falling nearly everyday with increasing pain.
Overall her mobility is very poor. She denies LOC or head ___,
but she does have some mild neck tenderness.
In the ED, initial vitals were: 97.9 77 125/61 22 99% ra
- Labs were significant for normal chem 7, normal LFTs and CBC
with mild anemia
- Imaging revealed normal CT head, multiple bilateral rib
fractures and chronic C5 spinous process fracture
- The patient was given ketorolac, nebs, acetaminophen,
carbidopa-levodopa and pravastatin
- The patient was seen by spine who recommended a soft collar
and trauma surgery who recommended ___ work/admit to
medicine
Vitals prior to transfer were: 97.4 78 139/67 18 98% RA
Upon arrival to the floor, the patient complained of continued
chest and neck pain.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, constipation.
No recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
- Hypertension
- Hyperlipidemia
- COPD
- Bronchiectasis
- Atypical parkinsonism/PSP- On sinemet since ___.
- Blepharospasm and eylid opening apraxia
- ___ disorder
- Monoclonal gammopathy
- Osteoporosis
- Anxiety
- Temporomandibular joint disorder
- H/o colonic polyps
- Left eye blindness
- Hearing loss left ear
- H/o multiple rib fractures in the setting of falls
- H/o right ___ metatarsal fracture ___
- H/o bilateral cataracts
- H/o high myopia
- Uterine prolapse treated with pessary
- S/p cholecystectomy ___
- S/p appendectomy
- S/p bilateral lid surgery ___ with Dr. ___ at ___
Social History:
___
Family History:
Mother - died at age ___ "of a broken heart"
Father - died at age ___ after a perforated ulcer
Sibs - ___hildren - 1 son with migraines and 1 daughter well
Physical ___:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 124/50 76 20 97% RA
General: elderly female, appears uncomfortable
HEENT: difficulty opening eyes, nose clear, OP w/o lesions
NECK: midline tenderness
Heart: RRR, S1/S2 normal, no MRG
Lungs: soft breath sounds bilaterally, no WRR
Genitourinary: (per ED; no blood on bimanual exam)
Extremities: WWP, no edema
Neurological: ___ upper and lower extremity strength
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 146/63 80 18 100 RA
General: elderly female, NAD
HEENT: difficulty opening eyes, at baseline, left eye with
proptosis more pronounced than right, mild erythema. some mucous
and clear dscharge improving. nose clear, OP w/o lesions, MMM
Neck: supple, left-sided tenderness
Lymph: No cervical or supraclavicular LAD
Heart: RRR, S1/S2 normal, no MRG
Lungs: CTAB with decreased breath sounds, tender to palpation
along left lower rib cage
Abdomen: soft, NT, ND +BS, no appreciable HSM
Extremities: WWP, no edema
Neurological: ___ upper and lower extremity strength, sensation
to light touch intact throughout, CN ___ intact except for
fatigable eyelid opening
Pertinent Results:
ADMISSION LABS:
___ 06:22PM BLOOD WBC-9.2# RBC-4.03* Hgb-12.7 Hct-34.8*
MCV-86 MCH-31.4 MCHC-36.4* RDW-12.7 Plt ___
___ 06:22PM BLOOD ___ PTT-34.9 ___
___ 06:22PM BLOOD Glucose-89 UreaN-14 Creat-0.5 Na-137
K-3.7 Cl-103 HCO3-23 AnGap-15
___ 06:22PM BLOOD ALT-10 AST-17 AlkPhos-55 TotBili-0.3
___ 06:22PM BLOOD Lipase-80*
___ 06:22PM BLOOD Albumin-3.3*
___ 06:27PM BLOOD Lactate-0.8
___ 07:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
=================
PERTINENT LABS:
___ 07:10PM URINE RBC-4* WBC-9* Bacteri-NONE Yeast-NONE
Epi-6
___ 10:53AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:53AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 10:53AM URINE RBC-6* WBC-13* Bacteri-FEW Yeast-NONE
Epi-8
___ 05:40AM BLOOD VitB12-1611*
___ 05:40AM BLOOD TSH-1.4
====================
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-8.0# RBC-3.69* Hgb-11.2* Hct-32.6*
MCV-88 MCH-30.3 MCHC-34.3 RDW-13.7 Plt ___
___ 06:00AM BLOOD Glucose-126* UreaN-10 Creat-0.4 Na-139
K-3.4 Cl-102 HCO3-27 AnGap-13
___ 06:00AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.9
================
IMAGING/REPORTS:
-CT Head ___
IMPRESSION:
No acute intracranial abnormality. Sinus disease as noted above.
-CT Chest/Abd/Pelvis ___
IMPRESSION:
1. Multiple bilateral acute and chronic rib fractures, including
segmental acute rib fractures of the left ninth and tenth ribs.
2. Diffuse moderate intrahepatic and mild extrahepatic biliary
dilatation. These findings which may represent normal post
cholecystectomy biliary dilatation, however if there is concern
for biliary obstruction, MRCP can be performed.
3. Areas of ground-glass nodular opacity, mucous plugging, and
airway wall thickening at the lung bases suggestive of small
airways disease.
4. Bilateral adrenal gland thickening compatible with adrenal
hyperplasia.
5. Patent abdominal vasculature, with no evidence of significant
atherosclerosis of the SMA or ___ branches.
- CT C-Spine W/O Con ___:
IMPRESSION:
Minimally displaced chronic fracture of the spinous process of
C5. No evidence of acute fracture, subluxation, or prevertebral
hematoma.
- Plain Films R Elbow ___:
FINDINGS:
Lucency at the level the coronoid process on the lateral views
is concerning for nondisplaced fracture. No acute fracture seen
elsewhere. No elbow joint effusion is identified. No concerning
osteoblastic or lytic lesion is seen.
IMPRESSION:
Findings concerning for nondisplaced coronoid process fracture.
No
dislocation.
=============
MICRO:
___ 10:53 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 10:33 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 6:15 am SEROLOGY/BLOOD ___ ADDED TO ___-.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
===============
PATHOLOGY:
Tissue: GASTROINTESTINAL MUCOSAL BIOPSY- pending
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ with multiple rib fractures, recurrent falls // better
evaluate fractures/trauma
TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper
abdomen. IV contrast was not administered. Axial images were interpreted in
conjunction with sagittal and coronal reformats.
DLP: 479 mGy-cm
COMPARISON: CT abdomen and pelvis on ___ at 19:27
FINDINGS:
The thyroid is normal.
Axillary, supraclavicular, mediastinal, and hilar lymph nodes are not
pathologically enlarged.
The great vessels are normal caliber.
The heart size is normal. No pericardial effusion.
The airways are patent to subsegmental levels.
There is trace bibasilar atelectasis. No focal consolidation, pleural
effusion, or pneumothorax.
Intra-abdominal findings are better described on CT done earlier today ___ at 19:27.
OSSEOUS STRUCTURES: There are fractures involving the left sixth, ninth tenth,
and eleventh ribs. On the right, there is deformity of the fifth rib which
appears acute. Deformities of the ninth, and eleventh ribs may represent more
chronic fractures. No suspicious osseous lesions are seen.
IMPRESSION:
Multiple bilateral rib fractures as described above including segmental acute
rib fractures of the left ninth and tenth ribs.
Radiology Report
EXAMINATION: DX ELBOW AND FOREARM
INDICATION: ___ year old woman with s/p fall, elbow pain // r/o fracture
r/o fracture
TECHNIQUE: Right elbow, three views and right forearm AP and lateral views
COMPARISON: None
FINDINGS:
Lucency at the level the coronoid process on the lateral views is concerning
for nondisplaced fracture. No acute fracture seen elsewhere. No elbow joint
effusion is identified. No concerning osteoblastic or lytic lesion is seen.
IMPRESSION:
Findings concerning for nondisplaced coronoid process fracture. No
dislocation.
NOTIFICATION: Findings submitted to Radiology critical findings dashboard on
___ at 12:00.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Vaginal bleeding
Diagnosed with ABDOMINAL PAIN GENERALIZED, FRACTURE FOUR RIBS-CLOSE, UNSPECIFIED FALL
temperature: 97.9
heartrate: 77.0
resprate: 22.0
o2sat: 99.0
sbp: 125.0
dbp: 61.0
level of pain: 2
level of acuity: 2.0 | ___ yo F with a PMHx of COPD, parkinsonism/PSP, bronchiectasis
and recurrent falls with chronic rib fractures, COPD,
hemorrhoids, cystoceole with complete uterine prolapse
presenting with abdominal pain, frequent falls. Found to have
acute left rib fractures and non-displaced coronoid fracture of
right elbow, with multiple other fractures in various states of
healing, including non-acute C5 spinous process fracture. Rib
fractures treated with non-opioid pain control and IS. Seen by
ortho who recommended right arm sling and outpatient f/u in 2
weeks. ___ work consulted to discuss placement as
patient thought to not be safe at home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Leg Redness and Wounds
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with a history of DLBCL and ESRD on HD who is
admitted
with cellulitis of his leg. The patient has had chronic wounds
on
his feet but he notice two new wound two days ago and one new
wound today and increased redness and edema of his left leg
especially. He was evaluated by home care and referred to the
ED.
The patient denies any fevers. He denies any increased pain in
his feet or legs but he does have neuropathy and decreased
sensation. He states the new wounds bilstered and the opened and
drained. He otherwise denies any shortness of breath, nausea,
pain, diarrhea, or dysuria. He did miss his dialysis today. Of
note the patient was recently admitted from ___ for
cellulitis and bacteremia and then resumed treatment for
cellulitis with cefepime as an outpatient in ___ which he
reports stopped about three weeks ago. The last ID note
recommends treatment with oral penicillin or amoxicillin after
IV
antibiotics and follow up in their clinic but he reports neither
of these happened.
Past Medical History:
-heart failure w/preserved EF
-ESRD
-DM2
-htn
-obesity
-OSA on CPAP
-Seasonal allergy.
-History of pneumonia in ___ leading to ESRD in setting of
long-standing DM2
-CAD
-diffuse large B cell lymphoma
PAST ONCOLOGIC HISTORY:
- ___ by Dr ___ management of his newly
diagnosed B cell diffuse large cell lymphoma, dx'd by a core
biopsy 5 d ago of a large pelvic mass. He noted RLE swelling in
early ___. LENIs were negative for clot but did show an
enlarged groin node. The picture was felt to be from a prior
cellulitis of his foot and he was followed. His swelling
continued and repeat LENIs in early ___ showed suggestion of
an
obstruction higher up and he underwent a CT of his abdomen and
pelvis that showed a large pelvic mass with splenomegaly and
mediastinal and portacaval adenopathy and lytic lesions in the
right pubic symphysis and inferior pubic ramus. A subsequent
PET
scan delineated those areas as well as moderate disease in his
chest. He underwent a core bx in ___ last week which showed B
cell
diffuse large cell lymphoma, germinal center origin (better
prognosis) with a high proliferative index of 80-90%.
Cytogenetics showed bcl 6 rearrangement but no worrisome
mutations. Interestingly, his LDH is normal. He continues to
have
RLE edema but denies any abdominal pain or pelvic pain. His wt
is
stable. He denies any fevers, night sweats or pruritis. He has
multiple medical problems with DM since adolescence and has been
on dialysis for the past ___ years. He denies any cardiac disease
but did have mild dysfunction on a cardiac PET test a year ago.
He is complaining of left elbow pain, having fallen at dialysis
several days ago, striking his left elbow and leg. Xrays at the
___ were negative. Sent home without a sling or any advice. Exam
showed obesity, 3 fb splenomegaly, pain, swelling left elbow and
2+ RLE edema Labs: Hct 32, LDH- 171, protein elec-normal. Hep
serologies normal.
A: Stage IIIA large cell lymphoma. High intermediate risk given
age, performance status and multiple sites of disease with CR
estimated at 56%, ___ year OS of 37%. Recommended Rit/CHOP chemo.
- ___: Started chemo with Rit/CHOP. Split dose Rituxan with
50
mg/m2 given on day 1. The rest to be given day 6. Under mistaken
impression that he was to take his prednisone indefinitely so
stayed on it until subsequent GI bleed.
- ___/: Rituxan given.
- ___: Hosp FH for acute GI bleed. Upper endoscopy showed
duodenal ulcers. Missed chemo ___ due to miscommunication.
- ___: Hosp ___ for ___ cellulitis LLE and epistaxis. Also
had paroxysmal atrial fib.
- ___: Cycle 2 Rit/CHOP given. Neulasta given on day 2.
Treatment delayed 2 wks due to gi bleed and LLE cellulitis.
- ___: CT showed near resolution of soft tissue masses in
right iliopsoas and obturator internus muscles, persistence of
splenomegaly and bone lytic lesions
- ___: Resumed chemo with rituxin and bendamustine
- ___: Received day 2 of rituxin and bendamustine
Social History:
___
Family History:
He denies any family history of kidney disease. His father with
diabetes ___ and hypertension died at age ___ due to heart
attack. His mother with diabetes ___ is in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
General: NAD
VITAL SIGNS: T 97.7 BP 162/82 HR 72 RR 18 O2 98%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS/SKIN: Multiple excoriates on upper and lower extremities.
Right foot with black heal wound and anterior open wound. Left
leg with redness and edema from the foot up to the mid lower
leg.
Left foot with black heel wound, multiple anterior foot wound,
one of which has partial blister and is oozing clear fluid.
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
DISCHARGE PHYSICAL EXAM:
==================
VS: 97.5 138/72 75 ___ RA
GEN: lying comfortably in bed, NAD, A/Ox3
HEENT: sclerae anicteric, moist mucous membranes, no OP lesions,
EOMI
CARD: RRR, no murmurs, rubs or gallops
PULM: clear to auscultation bilaterally, no rhonchi or rales
ABDM: obese, non-distended, normoactive bowel sounds, soft,
no tenderness to palpation
EXTR: Multiple skin tears on LLE, bilateral lower extremity
erythema which is improving based off marking of rash on initial
presentation, lower extremity dressings to mid-shin bilaterally,
no crepitus or tenderness to palpation of bilateral lower
extremities, Severe onychomycoses of the toenails
LYMPH: no cervical lymphadenopathy
NEURO: A/Ox3, CN II-XII grossly intact
PSYCH: non-anxious, normal affect
ACCESS: Left upper extremity fistula.
Pertinent Results:
ADMISSION LABS
===========
___ 02:25PM BLOOD WBC-6.6 RBC-3.24*# Hgb-11.0*# Hct-35.0*#
MCV-108*# MCH-34.0*# MCHC-31.4* RDW-17.3* RDWSD-69.9* Plt Ct-86*
___ 02:25PM BLOOD Neuts-66.4 ___ Monos-8.2 Eos-5.2
Baso-0.6 Im ___ AbsNeut-4.36 AbsLymp-1.27 AbsMono-0.54
AbsEos-0.34 AbsBaso-0.04
___ 02:25PM BLOOD Plt Ct-86*
___ 02:25PM BLOOD Glucose-125* UreaN-54* Creat-6.0* Na-138
K-5.4* Cl-92* HCO3-30 AnGap-16
___ 06:58AM BLOOD ALT-11 AST-15 AlkPhos-126 TotBili-0.7
___ 06:58AM BLOOD Calcium-8.9 Phos-5.2* Mg-1.8
IMAGING
======
___ B/L LOWER EXTREMITY DUPLEX
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ CXR
There is pulmonary vascular congestion without evidence of
pulmonary edema.
Mild left basilar atelectasis. There is no pleural effusion or
pneumothorax
identified. The size of the cardiac silhouette is enlarged but
unchanged.
___ ABI PVR:
ABIs were not obtained due to vessel noncompressibility. Mild
outflow disease in the territory of the right anterior tibial
artery.
MICROBIOLOGY
==========
___ BLOOD CULTURE ___ WOUND CULTURE
___ MRSA SWAB
DISCHARGE LABS
===========
___ 07:40AM BLOOD WBC-5.2 RBC-3.06* Hgb-10.4* Hct-31.9*
MCV-104* MCH-34.0* MCHC-32.6 RDW-16.3* RDWSD-62.4* Plt Ct-89*
___ 07:40AM BLOOD Glucose-184* UreaN-70* Creat-6.6*# Na-138
K-4.9 Cl-94* HCO3-22 AnGap-22*
___ 07:40AM BLOOD Calcium-8.8 Phos-5.1* Mg-1.8
___ 07:40AM BLOOD Vanco-14.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Allopurinol ___ mg PO 3X/WEEK (___)
3. Atorvastatin 80 mg PO QPM
4. Benzonatate 100 mg PO TID
5. Cinacalcet 60 mg PO 5X/WEEK (___)
6. irbesartan 300 mg oral DAILY
7. Pantoprazole 40 mg PO Q24H
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Calcium Carbonate 1500 mg PO TID W/MEALS with each meal
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Loratadine 10 mg PO DAILY
12. Docusate Sodium 100 mg PO BID:PRN Constipation
13. Gabapentin 100 mg PO BID
14. LORazepam 0.5 mg PO Q6H:PRN Nausea, Anxiety
15. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. CeFAZolin 1 g IV POST HD (FR) Duration: 1 Dose
on ___ post HD
RX *cefazolin in dextrose (iso-os) 1 gram/50 mL 1 g IV Once,
post HD Disp #*1 Intravenous Bag Refills:*0
3. CeFAZolin 2 g IV POST HD (SA) Duration: 1 Dose
on ___ POST HD
RX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g IV once
Disp #*1 Intravenous Bag Refills:*0
4. CeFAZolin 2 g IV POST HD (MO,WE) Duration: 2 Doses
give post HD on ___ and ___
RX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g IV POST HD
Disp #*2 Intravenous Bag Refills:*0
5. CeFAZolin 3 g IV POST HD (FR) Duration: 1 Dose
give on ___ post HD
RX *cefazolin in dextrose (iso-os) 1 gram/50 mL 3 g IV post HD
Disp #*3 Intravenous Bag Refills:*0
6. Loratadine 10 mg PO EVERY OTHER DAY
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
8. Allopurinol ___ mg PO 3X/WEEK (___)
9. Atorvastatin 80 mg PO QPM
10. Benzonatate 100 mg PO TID
11. Calcium Carbonate 1500 mg PO TID W/MEALS with each meal
12. Cinacalcet 60 mg PO 5X/WEEK (___)
13. Docusate Sodium 100 mg PO BID:PRN Constipation
14. Fluticasone Propionate NASAL 1 SPRY NU DAILY
15. Gabapentin 100 mg PO BID
16. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. irbesartan 300 mg oral DAILY
18. LORazepam 0.5 mg PO Q6H:PRN Nausea, Anxiety
19. Metoprolol Succinate XL 50 mg PO DAILY
20. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- lower extremity cellulitis
SECONDARY DIAGNOSES
- diffuse large B cell lymphoma
- end stage renal disease
- chronic stable diastolic heart failure
- type 2 diabetes ___
- hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with cough and fever// ?pna or infiltrate
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
There is pulmonary vascular congestion without evidence of pulmonary edema.
Mild left basilar atelectasis. There is no pleural effusion or pneumothorax
identified. The size of the cardiac silhouette is enlarged but unchanged.
IMPRESSION:
Pulmonary vascular congestion with no definite focal consolidation. Overall
the appearance of the lungs is similar to prior.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ YO man with b/l ___ swelling and erythema, acutely worsening//
?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 bilateral posterior tibial and right
peroneal veins. Normal color flow is demonstrated in the left peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. There is bilateral calf
edema.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ year old man with DLBCL and ESRD on HD w/ recurrent bilateral
lower extremity cellulitis// Evidence of PVD
TECHNIQUE: Noninvasive evaluation of the arterial system of the lower
extremities was performed with Doppler signal recordings, pulse volume
recordings and segmental limb the pressure measurements.
COMPARISON: None
FINDINGS:
Right:
Femoral artery: Triphasic waveform
Popliteal artery: Triphasic waveform
Posterior tibial artery: Triphasic waveform
Dorsalis pedis artery: Monophasic waveform
Left:
Femoral artery: Triphasic waveform
Popliteal artery: Triphasic waveform
Posterior tibial artery: Triphasic waveform
Dorsalis pedis artery: Triphasic waveform
Pulse volume recordings showed symmetric amplitudes at all levels,
bilaterally.
ABIs were not obtained due to vessel noncompressibility.
IMPRESSION:
ABIs were not obtained due to vessel noncompressibility. Mild outflow disease
in the territory of the right anterior tibial artery.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ year old man with history of DLBCL and ESRD on HD who is
admitted with cellulitis of both legs// ** PATIENT GETTING HD ON ___, PLEASE
PERFORM FIRST THING IN THE MORNING ON ___ PRE DIALYSIS **Staging for cancer,
assess for interval changes, mets, 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 5.5 s, 0.2 cm; CTDIvol = 92.9 mGy (Body) DLP =
18.6 mGy-cm.
3) Spiral Acquisition 11.6 s, 75.4 cm; CTDIvol = 26.8 mGy (Body) DLP =
2,006.6 mGy-cm.
Total DLP (Body) = 2,027 mGy-cm.
COMPARISON: CT abdomen pelvis from ___ CT abdomen pelvis from ___ 70
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 contains gallstones
without wall thickening or surrounding inflammation. There is trace
perihepatic ascites, decreased compared to prior.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Spleen is enlarged measuring 19.0 cm (previously 18.0 cm) without
evidence of focal mass.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are atrophic. There is no focal renal lesion or
hydronephrosis. These findings are unchanged compared to ___.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: Persistent asymmetric enlargement of the iliopsoas and right obturator
internus muscles appears unchanged since ___. There is also unchanged
soft tissue encasement of the right external iliac vessels. The bladder
appears unremarkable.
REPRODUCTIVE ORGANS: Prostate is normal in size. The seminal vesicles are
symmetric.
LYMPH NODES: A prominent lymph node in the porta hepatis is relatively
unchanged in size (series 5; image 68), measuring 1.6 cm in short axis. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Again seen are lytic lesions in the right inferior pubic ramus and
parasymphyseal region, unchanged. L4 vertebral body appears heterogenous and
slightly sclerotic, which is unchanged from ___.
SOFT TISSUES: There is a small fat containing umbilical hernia which contains
a small amount of fluid.
IMPRESSION:
1. Unchanged soft tissue thickening of the right iliopsoas and obturator
internus muscles compared with ___, have significantly decreased since
___, in keeping with known diffuse large B-cell lymphoma. There is
associated, unchanged soft tissue encasement of the right external iliac
vessels.
2. Splenomegaly measuring up to 19.0 cm (previously 18.0 cm).
3. Unchanged lytic lesions within the right inferior pubic ramus and
parasymphyseal region. L4 vertebral body appears heterogeneous and slightly
sclerotic, which is unchanged since ___.
4. Decrease in trace ascites, most notable in the perihepatic region.
5. Please see dictation from concurrent CT chest for intrathoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man with history of DLBCL and ESRD on HD who is
admitted with cellulitis of both legs. Restaging exam
TECHNIQUE: Multi-detector helical scanning of the chest was performed with
intravenous iodinated contrast agent and reconstructed as 5 and 1.25 mm thick
axial, 2.5 mm thick coronal and sagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 5.5 s, 0.2 cm; CTDIvol = 92.9 mGy (Body) DLP =
18.6 mGy-cm.
3) Spiral Acquisition 11.6 s, 75.4 cm; CTDIvol = 26.8 mGy (Body) DLP =
2,006.6 mGy-cm.
Total DLP (Body) = 2,027 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Same day CT abdomen pelvis. CT chest from ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable.
There is no supraclavicular or axillary lymphadenopathy. The esophagus is
unremarkable.
UPPER ABDOMEN: Please refer to separate report for same-day CT abdomen pelvis
study for discussion findings below the diaphragm.
MEDIASTINUM: Multiple large mediastinal lymph nodes are again seen and are
mildly decreased in size. For example, a lymph node conglomeration in the low
anterior paratracheal station is now 4.3 x 2.1 cm (6:129), previously 4.7 x
2.4 cm. A subcarinal lymph node is 1.6 cm (6:150), previously 1.8 cm.
HILA: An enlarged right hilar lymph node is mildly decreased in size, now 1.4
cm (6:144), previously 1.8 cm.
HEART and PERICARDIUM: Heart size is normal. Coronary artery calcifications
are moderate to severe. Aortic valve calcifications are again seen. The
thoracic aorta is normal in caliber. There is no pericardial effusion.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: Bibasilar atelectasis is noted. Multiple small bilateral
calcified granulomas are again seen. A 2 mm left lower lobe solid nodule is
unchanged (6:195).
2. AIRWAYS: The airways are patent to the level of the segmental bronchi
bilaterally. There is mild-to-moderate bronchial wall thickening, most
notable in the lower lobes.
3. VESSELS: Main pulmonary artery diameter is enlarged at 3.5 cm, similar to
prior. Suboptimal evaluation of the pulmonary vasculature demonstrates no
evidence of central pulmonary embolism.
CHEST CAGE: Sclerosis and moderate compression deformity of the T3 vertebral
body is unchanged. There is no acute fracture.
IMPRESSION:
1. Since ___, mild decrease in mediastinal and hilar lymphadenopathy,
as detailed above.
2. Mild-to-moderate bronchial wall thickening in the bilateral lower lobes
with bibasilar atelectasis is suggestive of chronic small airway disease.
3. Please refer to separate report for same-day CT abdomen pelvis study for
discussion findings below the diaphragm.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: B Leg swelling
Diagnosed with Cellulitis of right lower limb, Cellulitis of left lower limb
temperature: 98.1
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 169.0
dbp: 97.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ yo male with a history of DLBCL and ESRD on HD
who is admitted with cellulitis of both legs. On admission, he
was again started on cefepime and vancomycin and ID was
consulted, who agreed with the treatment regimen. A wound
culture was done and grew MSSA, so he was narrowed to Cefazolin
monotherapy post HD. Wound care was consulted who recommended
elevation of legs and daily dressing changes. He had also missed
his dialysis session, so underwent HD on ___, and ___.
He also had thrombocytopenia, which was stable throughout
hospitalization. At time of discharge, his cellulitis had
improved and he was ambulating with a walker.
ACTIVE ISSUES
=========
#Cellulitis
He had previously been admitted in ___ for a similar complaint,
at which time was found to be bacteremic with strep. He was
treated with post-dialysis vancomycin and cefepime and was lost
to follow-up with ID as an outpatient for suppressive therapy.
Was started on vanc and cefepime while in house and was dosed
post dialysis. ID was consulted who followed with the patient
and arranged outpatient follow-up with patient. Wound care was
consulted and provided recommendations. Lower extremities
duplexes were done, which showed no signs of DVT. ID recommended
cefazolin monotherapy post-HD. Wound recommended elevation of
legs and daily dressing changes. He was discharged with a two
week course of Cefazolin to be dosed post-HD.
#DLBCL
Received C2 Bendamustin on ___. C3 delayed due to
thrombocytopenia. Currently scheduled for ___. Port placement
has been delayed due to infection and thrombocytopenia. Dr.
___ was notified of the patient's admission. He was
continued on his home doses of continued on home allopurinol and
ativan,
#ESRD on HD
On HD MWF and every other ___. Missed his ___
scheduled HD when in the ER, so nephrology was consulted and
patient was dialyzed on ___. He was continued on his home
sensipar and tums and resumed his home schedule while in house.
Antibiotics were dosed with dialysis. Patient is scheduled to
have HD on ___, which is the ___ after his discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
___ Dual Chamber Pacemaker implantation
___ Pacemaker lead revision
Device ___ Advisa ___ MRI A2DR___ Implanted:
___
Atrial ___ 4076 CapSureFix® Novus BBL ___ Implanted:
___, Repositioned ___
RV ___ 4076 CapSureFix® Novus BBL ___ Implanted:
___
History of Present Illness:
Ms. ___ is an ___ year old female with a past medical history
significant for HFpEF, CKD stage IV, Hypertension, Type 2
diabetes mellitus with diabetic nephropathy, persistent atrial
fibrillation, CVA ___ embolism of precerebral artery, psoriatic
arthritis on Humira, and recent dx of PNA who presents with a
chief complaint of syncope accompanied by nausea/vomiting.
She presented tot he ED from home with nausea and vomiting and
was found to be in 3rd degree heart block. She had intermittent
bradycardia in the ED all of which had initially responded to
atropine. She was also noted to have Hyperkalemia was treated
with calcium, bicarb, insulin, lasix. Upon giving calcium
gluconate, went into PEA arrest, requiring about 20 seconds of
CPR, ROSC achieved. EP cardiology was consulted in the ED and a
dopamine gtt was initiated. The ED then placed a Cordis and
pacer wire placed with good capture. However since she was able
to get to an intrinsic rate in the ___ with the dopamine the
pacer was turned off but left in place.
In ED initial VS: T-97.3, HR- 58, BP-100/41, RR- 20, O2-100% RA
Labs significant for:
- Initial VBG: pH 7.38 pCO2 26 pO2 36 HCO3 16 BaseXS -7, w/
K:5.5
- Repeat VBG: pH 7.33 pCO2 36 pO2 41 HCO3 20 BaseXS -6
- Whole blood: Na:133, K:4.9, Cl:106, Glu:329, Hgb:8.7,
CalcHCT:26
- BMP: Na-134, K- 6.2, Cl- 99, HCO3- 14, Cr-2.9, BUN- 50, BG-
436, AGap=21, Ca: 9.2, Mg: 2.5, P: 4.3
- CBC: WBC-8.6, HgB- 8.5, Hct- 26.8, Plts-315
- LFTs: AST: 42, ALT: 37, AP: 110, Tbili: 0.3, Alb: 3.8, Lip: 43
- Coags: ___: 12.9 PTT: 30.0 INR: 1.2
- Other: proBNP: 5434, Trop-T: 0.01
Patient was given:
- IV Ondansetron 4 mg
- IV LORazepam 1 mg x2
- IH Albuterol 0.083% Neb Soln 1 NEB
- IV Insulin (Regular) for Hyperkalemia 10 units
- IV Furosemide 40 mg
- IV Calcium Gluconate 1g x2
- IV Sodium Bicarbonate 50 mEq
- IV DRIP DOPamine ___ mcg/kg/min ordered--Started 10
mcg/kg/min
- IV Morphine Sulfate 2 mg
- PO Acetaminophen 1000 mg
Imaging notable for: CXR showing proper placement of right IJ,
moderate pulmonary edema is worse as compared to chest
radiograph earlier today. Stable moderate cardiomegaly.
Consults: EP
On arrival to the MICU, the patient was noted to be tachycardic
Past Medical History:
- HFpEF--Echo ___: LVH mild, Norm EF, mild MR/AI/TR, pHTN
(PASP 45)
- CKD stage IV
- Hypertension
- Dyslipidemia
- Type 2 diabetes mellitus with diabetic nephropathy
- Persistent atrial fibrillation
- CVA due to embolism of other precerebral artery
- Psoriasis/ Psoriatic Arthritis
- Anxiety
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION EXAM
===============
VITALS: Reviewed in metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM
===============
VITALS: T 97.8, HR 97, BP 138/56, RR 14, 98%RA
GENERAL: NAD
NECK: no LAD, no visible JVD
HEART: irregular rhythm, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
Pertinent Results:
ADMISSION LABS
===============
___ 05:43PM WBC-8.6 RBC-3.33* HGB-8.5* HCT-26.8* MCV-81*
MCH-25.5* MCHC-31.7* RDW-15.1 RDWSD-44.1
___ 05:43PM NEUTS-58.0 ___ MONOS-8.0 EOS-4.6
BASOS-1.4* IM ___ AbsNeut-5.00 AbsLymp-2.36 AbsMono-0.69
AbsEos-0.40 AbsBaso-0.12*
___ 05:43PM ___ PTT-30.0 ___
___ 05:43PM ___ PTT-30.0 ___
___ 05:43PM proBNP-5434*
___ 05:43PM cTropnT-0.01
___ 05:43PM LIPASE-43
___ 05:43PM ALT(SGPT)-37 AST(SGOT)-42* ALK PHOS-110* TOT
BILI-0.3
___ 05:43PM GLUCOSE-436* UREA N-50* CREAT-2.9*
SODIUM-134* POTASSIUM-6.2* CHLORIDE-99 TOTAL CO2-14* ANION
GAP-21*
___ 05:54PM ___ PO2-36* PCO2-26* PH-7.38 TOTAL
CO2-16* BASE XS--7
MICROBIOLOGY
================
___ 12:22 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___ -
___.
GRAM POSITIVE COCCI IN CLUSTERS.
___ 3:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES/IMAGING
================
___ CXR
M
i
l
d
p
u
lmonary edema and moderate cardiomegaly. Possible small pleural
effusions.
___ TTE: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Moderate to
severe pulmonary artery systolic hypertension. Moderate to
severe tricuspid regurgitation. Mild-moderate mitral
regurgitation. Marked biatrial enlargement.Mildly dilated
ascending aorta. Increased PCWP.
CXR ___ IMPRESSION:
Interval placement of left-sided dual lead pacemaker. Right
atrial lead
projects slightly left of midline. Clinical correlation with
heart morphology and procedure to confirm proper lead placement.
Interval removal of temporary pacer. Improved patchy opacities
of bilateral lungs. Cardiomegaly appears similar. No pleural
effusion. No pneumothorax. Prominence of bilateral hila
appears similar. Suggestion of soft tissue prominence at the
right paratracheal space may be projectional and could be
followed on subsequent radiographs.
DISCHARGE LABS
======================================
___ 06:35AM BLOOD WBC-8.8 RBC-3.37* Hgb-8.4* Hct-26.9*
MCV-80* MCH-24.9* MCHC-31.2* RDW-14.9 RDWSD-43.3 Plt ___
___ 06:35AM BLOOD Glucose-117* UreaN-37* Creat-1.9* Na-140
K-4.6 Cl-107 HCO3-20* AnGap-13
___ 06:35AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Atorvastatin 10 mg PO QPM
4. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
5. Felodipine 10 mg PO DAILY
6. GlipiZIDE 5 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Lactulose ___ mL PO Q6H:PRN constipation
11. Fluocinonide 0.05% Cream 1 Appl TP BID
12. Fluocinolone Acetonide 0.01% Solution 1 Appl TP BID scalp
13. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
14. garlic unknown UNITS oral DAILY
15. Docusate Sodium 100 mg PO BID
16. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
17. Humira (adalimumab) 40 mg/0.8 mL subcutaneous EVERY 2 WEEKS
18. Vitamin D 1000 UNIT PO DAILY
19. Melatin (melatonin) 3 mg oral QHS
Discharge Medications:
1. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 8 hours Disp
#*17 Capsule Refills:*0
2. Labetalol 100 mg PO BID
RX *labetalol 100 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
5. Apixaban 2.5 mg PO BID
6. Atorvastatin 10 mg PO QPM
7. Diltiazem Extended-Release 240 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluocinolone Acetonide 0.01% Solution 1 Appl TP BID scalp
10. Fluocinonide 0.05% Cream 1 Appl TP BID
11. Furosemide 40 mg PO DAILY
12. garlic unknown oral DAILY
13. GlipiZIDE 5 mg PO BID
14. Lactulose ___ mL PO Q6H:PRN constipation
15. Levothyroxine Sodium 100 mcg PO DAILY
16. Melatin (melatonin) 3 mg oral QHS
17. Omeprazole 20 mg PO DAILY
18. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
19. Vitamin D 1000 UNIT PO DAILY
20. HELD- Humira (adalimumab) 40 mg/0.8 mL subcutaneous EVERY 2
WEEKS This medication was held. Do not restart Humira until
After ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
# Asystole Arrest
# High grade AV block
SECONDARY DIAGNOSES:
# Atrial fibrillation/flutter
# ___ on CKD-IV
# Psoriasis & Psoriatic Arthritis
# CAD
# Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with chest pain// ? cardiomegaly
TECHNIQUE: Frontal view radiograph of the chest.
COMPARISON: None available
FINDINGS:
There is central vascular engorgement and mild pulmonary edema. There is mild
bibasilar atelectasis. Small pleural effusions are possible. There is no
definite consolidation. There is moderate cardiomegaly. There is no osseous
abnormality.
IMPRESSION:
Mild pulmonary edema and moderate cardiomegaly. Possible small pleural
effusions.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with R CVL// line placement
TECHNIQUE: Frontal view radiograph of the chest.
COMPARISON: Chest radiograph ___ 17:47
FINDINGS:
There has been interval placement of a right IJ approach linear density which
projects over the right ventricle.
There is moderate pulmonary edema, worse as compared to comparison chest
radiograph earlier today. Moderate cardiomegaly is unchanged. There are
possible small pleural effusions, unchanged.
IMPRESSION:
1. Interval placement of a right IJ approach linear density which projects
over the right ventricle.
2. Moderate pulmonary edema is worse as compared to chest radiograph earlier
today.
3. Stable moderate cardiomegaly.
Radiology Report
INDICATION: ___ year old woman with HFrEF who presented with ___ deg heart
block and PEA arrest// Interval Changes? Pulmonary Edema? Infection?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with slight improvement in the pulmonary edema. The
right ventricular pacer lead remains in place. Cardiomediastinal silhouette
is stable. Small bilateral effusions are unchanged. No pneumothorax is seen
Radiology Report
INDICATION: ___ year old woman s/p dual chamber PPM implant// check lead
location and pnx
TECHNIQUE: Frontal and lateral radiographs of the chest.
COMPARISON: ___.
IMPRESSION:
Interval placement of left-sided dual lead pacemaker. Right atrial lead
projects slightly left of midline. Clinical correlation with heart morphology
and procedure to confirm proper lead placement.
Interval removal of temporary pacer. Improved patchy opacities of bilateral
lungs. Cardiomegaly appears similar. No pleural effusion. No pneumothorax.
Prominence of bilateral hila appears similar. Suggestion of soft tissue
prominence at the right paratracheal space may be projectional and could be
followed on subsequent radiographs.
Radiology Report
INDICATION: ___ year old woman with RA lead revision// lead position
TECHNIQUE: PA and lateral upright chest radiographs
COMPARISON: Chest radiograph ___
FINDINGS:
Compared to the prior study, there has been interval repositioning of the
right atrial lead with its tip projecting over the expected region of the
right atrial appendage. The other lead terminates in the right ventricular
apex.
Mildly increased lung volumes, increased anteroposterior diameter, and
relative flattening of the hemidiaphragms suggests chronic pulmonary disease.
Prominence of the bilateral paratracheal stripes appears similar to the prior
study. Moderate pulmonary vascular congestion appears stable without overt
pulmonary edema. Prominence of the bilateral hila appears similar the heart
is moderately enlarged, similar to the prior study. Thoracic kyphosis appears
similar. There are no worrisome osseous lesions.
IMPRESSION:
-Interval repositioning of the right atrial lead with its tip in satisfactory
position over the region of the right atrial appendage.
-Unchanged prominence of the bilateral paratracheal stripes.
-Stable pulmonary vascular congestion without overt pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Ms. ___ is an ___ year old female with a past medical history
significant for HFpEF, CKD stage IV, Hypertension, Type 2
diabetes mellitus with diabetic nephropathy, persistent atrial
fibrillation, CVA ___ embolism of precerebral artery, psoriatic
arthritis on Humira, and recent dx of pneumonia who originally
presented with nausea, vomiting, and syncope, was found to be in
3rd degree heart block, suffered a PEA arrest with ROSC achieved
after < 1min of CPR.
# Asystole Arrest
# High grade AV block
The patient presented bradycardic w/ HRs in ___ and telemetry
concerning for complete heart block and a period of PEA. Chest
compressions performed in ED for ~20 seconds prior to ROSC.
Dopamine was initially started in ED, but stopped on the floor
due to tachyarrythmias. A temporary pacing wire was placed. A
TTE showed preserved ejection fraction, tricuspid and mitral
regurgitation, biatrial enlargement. Permanent pacemaker was
eventually placed on ___, but atrial lead was noted to be
displaced, and patient went underwent revision on ___. She was
discharged to complete a 7 day course of cephalexin ___ -
___. She was discharged on diltiazem 240mg daily and labetalol
100mg BID.
# Volume Overload
# Pulmonary Edema
Patient was found to have volume overload with pulmonary edema.
She was diuresed with IV Lasix. TTE showed preserved ejection
fraction, tricuspid and mitral regurgitation, biatrial
enlargement. Patient diuresed with 40 mg IV Lasix boluses and O2
requirement resolved. She was discharged on her home Lasix 40mg
daily.
# Metabolic/ Lactic Acidosis
Upon presentation with VBG pH of 7.33, HCO3 of 14, elevated
lactate. Improved with supportive care and stabilization.
# ___ on CKD-IV
Baseline Cr ~2.2, admission creatinine 2.9, likely prerenal from
hypotension ___ nausea/vomiting and bradycardia. Improved with
stabilization. Discharge Cr 1.9.
# Hyperkalemia
She was noted to have Hyperkalemia in ED was treated with
calcium, bicarb, insulin, lasix. Possibly in the setting of a
metabolic acidosis and ___.
# Atrial fibrillation/flutter
On diltiazem 240 mg ER at home and apixaban 2.5 mg BID.
CHADSvasc 7, but wasn't initially on AC due to bleeding risk and
dementia. She was started again on apixaban 2.5mg BID. Diltiazem
held on admission due to heart block, but restarted for rapid
ventricular rate - low dose started but increased to home 240 mg
with good response. She was also restarted on labetolol 100mg
BID.
# Altered Mental Status/Agitation
She was delirious on admission, treated with IV Olanzapine, felt
likely due to toxic metabolic causes. She improved to baseline
prior to discharge.
# Type II Diabetes
Treated with an insulin sliding scale while in house, discharged
on home glipizide.
CHRONIC ISSUES:
# Psoriasis & Psoriatic Arthritis
- Gets Humira as an outpatient. This was held in the hospital,
and should not be restarted for another 4 weeks (___).
# CAD:
- Continued home atorvastatin
# Hypothyroidism
- Continued home levothyroxine
=========================
TRANSITIONAL ISSUES
=========================
[] F/U with Dr. ___ in ___ weeks for device check and general
cardiology in next ___ weeks.
[] Patient discharged on Keflex to complete 7 day course ___
- ___
[] Found to be in aflutter at time of discharge. Dischared on
diltiazem 240mg daily and labetolol 100mg BID, which can be
titrated as needed.
[] Patient should not start Humira for 4 weeks after discharge
(___)
[] Lyme serologies were pending at time of discharge, to be
followed by outpatient cardiology.
[] Would recommend social work follow up as outpatient for to
discuss family situation and possible services that can be
provided
[] Discharged with ___ services
# Emergency contact: ___, daughter (Phone: ___
# Code: Full (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___: ERCP with stent placement
___: US-guided placement of ___ pigtail catheter into
the
gallbladder
History of Present Illness:
Ms. ___ is a ___ with a PMH pertinent for situs ambiguus,
left-sided CVA one month ago and Afib recently started on
Coumadin who presents with choledocolithiasis and acute
cholecystitis. She had just gotten home from rehab on ___
following her hospitalization for the CVA when her daughter
started noticing some increasing confusion and took her to
___ for evaluation. There she was found to have an
INR of 4 and a CT Head was taken which showed concern for a
re-bleed at her previous site. She was transferred to ___ for
neurosurgical evaluation who determined there was no new
intracranial bleed. However on her admission labs elevated AST
and ALT to 221 and 212 were noted, as well as an ALP of 280.
Tbili was not elevated. On further investigation abdominal
tenderness was noted as well as abdominal pain of uncertain
duration. A Liver US was done which showed stigmata of acute
cholecystitis as well as a 7mm CBD stone. At this point ERCP and
ACS were consulted.
Past Medical History:
PAST MEDICAL HISTORY:
Situs ambiguus
AFib on coumadin
Left sided CVA ___
HLD
PAST SURGICAL HISTORY:
Denies
Social History:
___
Family History:
Son - DM
Dad - ___
Mother - Cancer, NOS
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.2 102 135/48 22 94% RA
GEN: NAD, well-nourished, appropriately groomed.
NEURO: Alert, some word finding difficulty, communicating
appropriately ___ ___ word phrases
HEENT: Sclerae anicteric, trachea midline, no JVD
CV: Irregularly irregular, 2+ peripheral pulses bilaterally
RESP: No respiratory distress
GI: Abdomen obese, soft, non-distended with moderate epigastric
tenderness. No rebound tenderness or guarding. Dull to
percussion. Bowel sounds normoactive. Rectal exam deferred
EXT: WWP no CCE
Discharge Physical Exam:
VS: 98.5, 100, 121/52, 20, 94%ra
GEN: AA&O x 2, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, nontender, non-distended. PCT drain site: clean,
dry and intact, drain with purulent bile drainage
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
================================================
Pertinent Results:
___ 05:21AM BLOOD WBC-12.0* RBC-3.56* Hgb-10.6* Hct-34.1
MCV-96 MCH-29.8 MCHC-31.1* RDW-13.8 RDWSD-48.5* Plt ___
___ 06:25AM BLOOD WBC-14.0* RBC-3.68* Hgb-10.9* Hct-35.3
MCV-96 MCH-29.6 MCHC-30.9* RDW-14.0 RDWSD-49.1* Plt ___
___ 07:34AM BLOOD WBC-13.4* RBC-3.70* Hgb-11.0* Hct-34.6
MCV-94 MCH-29.7 MCHC-31.8* RDW-14.0 RDWSD-47.6* Plt ___
___ 06:30AM BLOOD WBC-13.6* RBC-3.58* Hgb-10.7* Hct-33.5*
MCV-94 MCH-29.9 MCHC-31.9* RDW-14.0 RDWSD-47.8* Plt ___
___ 08:15AM BLOOD WBC-15.6* RBC-3.79* Hgb-11.3 Hct-36.5
MCV-96 MCH-29.8 MCHC-31.0* RDW-13.8 RDWSD-49.0* Plt ___
___ 02:36AM BLOOD WBC-12.8* RBC-3.71* Hgb-11.0* Hct-35.0
MCV-94 MCH-29.6 MCHC-31.4* RDW-13.8 RDWSD-47.4* Plt ___
___ 04:01AM BLOOD WBC-16.6* RBC-3.43* Hgb-10.3* Hct-32.9*
MCV-96 MCH-30.0 MCHC-31.3* RDW-14.0 RDWSD-49.3* Plt ___
___ 06:14AM BLOOD WBC-13.9* RBC-3.60* Hgb-10.6* Hct-34.2
MCV-95 MCH-29.4 MCHC-31.0* RDW-14.0 RDWSD-48.6* Plt ___
___ 10:49PM BLOOD WBC-17.3* RBC-3.86* Hgb-11.3 Hct-36.1
MCV-94 MCH-29.3 MCHC-31.3* RDW-13.9 RDWSD-47.8* Plt ___
___ 05:44AM BLOOD ___
___ 05:21AM BLOOD ___
___ 06:25AM BLOOD ___
___ 07:34AM BLOOD ___ PTT-36.6* ___
___ 10:45AM BLOOD ___ PTT-60.0* ___
___ 05:21AM BLOOD Glucose-117* UreaN-12 Creat-0.6 Na-136
K-3.8 Cl-97 HCO3-30 AnGap-13
___ 06:25AM BLOOD Glucose-102* UreaN-8 Creat-0.6 Na-137
K-4.2 Cl-95* HCO3-31 AnGap-15
___ 07:34AM BLOOD Glucose-109* UreaN-8 Creat-0.6 Na-137
K-3.3 Cl-96 HCO3-30 AnGap-14
___ 08:15AM BLOOD ALT-68* AST-18 AlkPhos-194* TotBili-0.4
___ 02:36AM BLOOD ALT-95* AST-30 AlkPhos-209* TotBili-0.4
___ 06:14AM BLOOD ALT-212* AST-221* AlkPhos-280*
TotBili-0.9
___ 10:49PM BLOOD ALT-79* AST-133* AlkPhos-196* TotBili-1.0
___ 05:21AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.3
___ 06:25AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.7*
___ 07:34AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.7
___ 06:30AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.6
Radiology:
___ GB drainage xray: Successful US-guided placement of
___
pigtail catheter into the gallbladder. Samples was sent for
microbiology evaluation.
___ ECG: Atrial fibrillation, mean ventricular rate 82.
Non-specific repolarization abnormalities. No previous tracing
available for comparison.
___ CT Abd/Pelvis:
1. Findings consistent with the provided history of situs
ambiguus.
2. Cholelithiasis. Distended midline gallbladder demonstrates
gallbladder wall thickening, hyperenhancement and
pericholecystic
inflammatory stranding, consistent with cholecystitis. The
previously demonstrated stone within the common bile duct is not
well seen on CT.
3. Transverse midline liver. Persistent common bile duct stent
with pneumobilia, suggesting stent patency. Persistent mild
central intrahepatic biliary duct dilatation.
4. Two splenic foci ___ the right upper quadrant, consistent with
polysplenia.
5. 1 cm calcified splenic artery aneurysm.
6. Stomach located ___ the right upper quadrant. Intestinal
malrotation.
7. Azygous continuation of the inferior vena cava.
8. Small amount of fluid within the right lower quadrant
mesentery, likely reactive.
___ Liver/Gallbladder US: Findings are suggestive of acute
cholecystitis secondary to an obstructing common bile duct stone
___ ERCP:
Scout film was normal.There was pus discharge ___ the major
papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting ___ complete
opacification.
The procedure was highly difficult, due to Situs ambiguous.
A moderate diffuse dilation was seen at the main duct and
common hepatic duct with the CBD measuring 13 mm.
Several fillling defect were noted at the level of the distal
CBD.
Due to the anatomic varient and unstable scope position a
sphincterotomy was not performed and a ___ cm biliary plastic
stent was placed
Otherwise normal ercp to third part of the duodenum
___ ECHO: no vegetations seen
MICROBIOLOGY DATA:
___
Blood culture: FINAL no growth
___
Urinalysis: Normal
Urine culture: FINAL no growth
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin MIC OF 2 MCG/ML = SUSCEPTIBLE.
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed ___ MCG/ML
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
___
Stool: Positive for toxigenic C. difficile by the Illumigene DNA
amplification.
___
GB BILE FOR CULTURE AND SENSITIVITY.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
FLUID CULTURE (Preliminary):
ENTEROCOCCUS SP.. SPARSE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH. SECOND MORPHOLOGY.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___
Blood culture: NGTD
___
Blood culture: NGTD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 6 mg PO DAILY16
2. Furosemide 40 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. Potassium Chloride 10 mEq PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Daptomycin 500 mg IV Q24H
3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
4. Heparin Flush (10 units/ml) 2 mL IV Q8H and PRN, line flush
5. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
6. Vancomycin Oral Liquid ___ mg PO Q6H
7. Atorvastatin 80 mg PO QPM
8. Furosemide 40 mg PO BID
9. Potassium Chloride 10 mEq PO BID
10. Warfarin 6 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Choledocolithiasis
Acute cholecystitis
Bacteremia
Clostridium difficile infection
Discharge Condition:
Mental Status: Confused - always.
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: ___ year old woman with abdominal pain. Note: patient has Situs
ambiguous w/ abnormal anatomy, on CT her gallbladder was located near midline.
// assess for cholecystitis, liver/gallbladder.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is midline and demonstrates intrahepatic ductal dilatation.
Otherwise, the liver 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: A 7 mm stone is seen in the distal common bile duct. There is
dilatation of the common bile duct, measuring up to 12 mm.
GALLBLADDER: The gallbladder is located in the mid epigastric region. It is
distended and filled with sludge and stones. There is gallbladder wall edema
and thickening, measuring up to 8 mm.
PANCREAS: Limited evaluation of the pancreas. The head of the pancreas is
within normal limits. The body and tail of the pancreas were not visualized
due to the presence of gas.
SPLEEN: The spleen was difficult to identify.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Findings are suggestive of acute cholecystitis secondary to an obstructing
common bile duct stone.
RECOMMENDATION(S): An ERCP is recommend.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:05 ___, 20 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with situs ambiguus and need for lap chole //
please help define anatomy in preparation for OR tomorrow (lap chole) Please
do before MN as pt NPO pMN for OR tomorrow ___
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, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
3) Spiral Acquisition 4.4 s, 48.0 cm; CTDIvol = 15.6 mGy (Body) DLP = 750.3
mGy-cm.
4) Spiral Acquisition 0.8 s, 8.5 cm; CTDIvol = 11.1 mGy (Body) DLP = 93.7
mGy-cm.
Total DLP (Body) = 857 mGy-cm.
COMPARISON: Ultrasound performed ___.
FINDINGS:
LOWER CHEST: Visualized lung bases demonstrate linear opacities, consistent
with atelectasis. Cardiomegaly. Trace pericardial fluid.
ABDOMEN:
HEPATOBILIARY: The liver is transverse midline. Liver demonstrates
homogeneous enhancement throughout. Common bile duct stent with tip in the
duodenum. There is central intrahepatic biliary duct dilatation and
pneumobilia within the central bile ducts, suggesting stent patency. No focal
hepatic lesion. Hepatic veins drain into the right atrium.
The gallbladder is located in the mid epigastric region with fundus pointed
towards the right side. There is gallbladder is distended measuring up to
11.4 cm and demonstrates gallbladder wall thickening, mucosal hyperenhancement
and pericholecystic inflammatory stranding. No evidence of perforation. The
common bile duct stone seen on previous ultrasound is not well seen on CT and
may be obscured by reflux of contrast material.
PANCREAS: Orientation of the pancreas is reversed. No focal lesion or main
pancreatic duct dilatation. There is no peripancreatic stranding.
SPLEEN: Two foci of splenic tissue noted in the right upper quadrant measuring
6.5 cm and 3.7 cm, consistent with polysplenia. 1.0 cm calcified splenic
artery aneurysm.
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.
Several hypodense lesions are noted in both kidneys which are too small to
definitively characterize but likely represent benign renal cysts. No
hydronephrosis. Retroaortic left renal vein.
GASTROINTESTINAL: Stomach is located in the right upper abdomen. The small
bowel loops are located in the left hemiabdomen wall and colonic bowel loops
are located in the right hemiabdomen, consistent with intestinal malrotation.
The SMV is located left of the SMA.No evidence of obstruction. A few colonic
diverticula are identified.
Small amount of free fluid is noted in the mesentery in the right lower
quadrant, likely reactive.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Hysterectomy.
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. There is azygos continuation of the inferior vena cava.
BONES: Multilevel degenerative changes of the thoracolumbar spine. Multiple
chronic appearing wedge compression fractures of the T10-12 thoracic spine.
Sclerosis of the pubic symphysis, slightly degenerative.
SOFT TISSUES: Fat containing umbilical hernia. Soft tissue nodules in the
anterior abdominal wall likely relate to injection granulomas.
IMPRESSION:
1. Findings consistent with the provided history of situs ambiguus.
2. Cholelithiasis. Distended midline gallbladder demonstrates gallbladder
wall thickening, hyperenhancement and pericholecystic inflammatory stranding,
consistent with cholecystitis. The previously demonstrated stone within the
common bile duct is not well seen on CT.
3. Transverse midline liver. Persistent common bile duct stent with
pneumobilia, suggesting stent patency. Persistent mild central intrahepatic
biliary duct dilatation.
4. Two splenic foci in the right upper quadrant, consistent with polysplenia.
5. 1 cm calcified splenic artery aneurysm.
6. Stomach located in the right upper quadrant. Intestinal malrotation.
7. Azygous continuation of the inferior vena cava.
8. Small amount of fluid within the right lower quadrant mesentery, likely
reactive.
Radiology Report
EXAMINATION: PERCUTANEOUS CHOLECYSTOSTOMY
INDICATION: ___ year old woman with cholecystitis // please place perc chole
tube
COMPARISON: Ultrasound ___
PROCEDURE: Ultrasound-guided drainage of the gallbladder.
OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the gallbladder. Based on
the ultrasound findings an appropriate skin entry site percutaneous
cholecystostomy was chosen. The site was marked. Local anesthesia was
administered with 1% Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the gallbladder. A sample of fluid was
aspirated, confirming catheter position within the gallbladder. The pigtail
was deployed. The position of the pigtail was confirmed within the gallbladder
via ultrasound.
Approximately 80 cc of purulent fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: 50 mcg fentanyl was administered in divided doses throughout the
total intra-service time of 25 minutes during which patient's hemodynamic
parameters were continuously monitored by an independent trained radiology
nurse.
FINDINGS:
Postprocedure ultrasound demonstrated the pigtail catheter within the
gallbladder lumen with collapse of the gallbladder.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Transfer
Diagnosed with Altered mental status, unspecified, Urinary tract infection, site not specified
temperature: 98.3
heartrate: 94.0
resprate: 16.0
o2sat: 96.0
sbp: 127.0
dbp: 42.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with h/o of situs ambiguus, left-sided CVA
one month ago and Afib recently started on Coumadin transferred
from OSH on ___ with choledocolithiasis and acute
cholecystitis. At ___, labs notable for WBC 17, INR 4.7, ALT
79*, AST 133*, ALKP 196*, T bili 1.0. Neurosurgery was consulted
given concern for new ICH at OSH; head CT repeated with no
concern for new ICH. Repeat UA normal and UCx negative. RUQ US
showed acute cholecystitis as well as a 7mm CBD stone. The
patient was admitted to the Acute Care Surgery service for
further management. The patient was confused but otherwise
hemodynamically stable.
On HD2 patient underwent ERCP with biliary stent placement.
Blood cultures from ___ grew out gram positive cocci ___ pairs
and chains on ___, preliminarily enterococcus faecium. She
received one dose of Cefepime, as well as Vancomycin 1000 and
Piperacillin-Tazobactam. She was also noted to be C. diff
positive
and started on oral Vancomycin.
On HD3, the patient had US-guided placement of ___ pigtail
catheter into the
gallbladder, which has been draining bile and pus. Blood culture
enterococcus faecium found to be sensitivite to daptomycin. A
midline IV was placed for long term antibiotics and the patient
was started on Daptomycin. Cultures of the biliary fluid from
___ returned positive for enterococcus of two morphologies and
coagulase negative staph. TTE was obtained which was negative
for vegetations.
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 with the assistance of nursing and Physical Therapy,
was adherent with respiratory toilet and incentive spirometry.
The patient was restarted on her Coumadin and INR was monitored
daily with Coumadin dosed accordingly. Venodyne boots were used
during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, voiding without assistance,
and pain was well controlled. The patient was discharged to
rehab for ___ and to complete a 2-wk course of daptomycin and
continue on PO vanc for cdiff infection 10 days after IV
antibiotics finish. The patient and her family received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. She was
scheduled to follow-up ___ the ___ clinic to plan interval
cholecystectomy. She also had GI appointment scheduled for stent
removal. |
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 and distention
Major Surgical or Invasive Procedure:
Therapeutic paracentesis ___
History of Present Illness:
___ with history of HCV and newly diagnosed HCC who is
transferred from ___ for abdominal pain.
He recently established care with Dr. ___ due to chronic
HCV, and US on ___ demonstrated liver lesions concerning for
multifocal HCC in the setting of AFP of 4161, with biopsy that
day confirming the diagnosis pathologically. MRI abdomen
with/without contrast ___ demonstrated 2 large masses with
necrosis and internal hemorrhage, the latter post-procedural;
staging CT was negative for intrathoracic mets.
For the past approximately 2.5-3d, he has been experiencing
abdominal pain localized primarily to LUQ and supraumbilical
areas and radiating to the ipsilateral back, up to ___ in
intensity. His abdomen also has become more distended over that
time. He endorses poor appetite, though pain is unaffected by PO
intake or bowel movements. His daughter reports that he was
nauseated this morning, though he denies this; no emesis. He
endorses chills without fevers/sweats, diarrhea/constipation,
hematochezia/melena, hematuria/dysuria. He did not experience
significant pain immediately following biopsy on ___. He
initially presented today to an OSH, where he received
antiemetics and pain control, as well as 2mg cefotaxime x1. OSH
CT showed cirrhotic liver with multiple hepatic masses, large
ascites, and no e/o bleeding complications from liver biopsy. In
discussion with Dr. ___ was transferred to ___ for
further evaluation and management.
In the ED, initial VS were: 8 97.5 73 156/78 16 96%. Exam showed
LLQ and supraumbilical pain. Labs showed Na of 129 (last 139 in
___, ALT 111, AST 165, AP 200, Tbili 3.2, CBC of 11.5, H/H
13.4/45.1 with normal coags and platelets. Lactate was 1.8. A
diagnositc paracentesis was negative for SBP.
VS on transfer: 4 97.7 86 162/91 16 97%. Currently, he has some
diffuse abd pain. He does not feel hungry. He states he stopped
drinking 4 months ago, although his daughter states it was only
1 month ago.
Past Medical History:
- HCV/EtOH cirrhosis
- Hepatocellular carcinoma
- HTN
- Iron deficiency anemia
Social History:
___
Family History:
1 son w/ gastric ulcers, 1 son with ___ dz, 1 son with
aortic aneurysm and HTN. Denies family history of heart disease.
Physical Exam:
ADMISSION EXAM:
VS: 97.5 174/100 70 20 95%RA
___: well appearing in NAD
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM
NECK: supple, JVP at base of neck at 90 degrees
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, distended but soft, diffusely
tender, no rebound or guarding, no masses, large ascites, +
fluid wave
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, normal
gait, no asterixis
DISCHARGE EXAM:
VS: 98.1 73 16 127/87 98 RA 77.9 kg
___: NAD
HEENT: MMM
LUNGS: CTA bilat, no r/rh/wh
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, less distended, soft, no erythema
at para site, mildly tender diffusely, no rebound or guarding,
no masses, + shifting dullness, + fluid wave
EXTREMITIES: no edema
NEURO: awake, A&Ox3, no asterixis
Pertinent Results:
ADMISSION LABS:
___ 06:45PM BLOOD WBC-11.5*# RBC-5.03 Hgb-13.4* Hct-45.1
MCV-90# MCH-26.6* MCHC-29.7* RDW-15.6* Plt ___
___ 06:45PM BLOOD Neuts-83.6* Lymphs-12.3* Monos-3.6
Eos-0.1 Baso-0.3
___ 06:45PM BLOOD ___ PTT-27.2 ___
___ 06:45PM BLOOD Glucose-122* UreaN-30* Creat-1.0 Na-129*
K-5.1 Cl-99 HCO3-24 AnGap-11
___ 06:45PM BLOOD ALT-111* AST-165* AlkPhos-200*
TotBili-1.2
___ 06:45PM BLOOD Albumin-3.2*
___ 08:00AM BLOOD Albumin-2.9* Calcium-8.5 Phos-5.1* Mg-2.2
___ 07:00PM BLOOD Lactate-1.8
MICROBIOLOGY:
___ Blood Culture: PENDING
___ Pleural Fluid Culture: PENDING
___ Urine Culture: PENDING
RELEVANT STUDIES:
___ Pleural Fluid Cytology: PENDING
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-5.5 RBC-4.21* Hgb-11.3* Hct-36.8*
MCV-87 MCH-26.9* MCHC-30.8* RDW-15.7* Plt ___
___ 06:00AM BLOOD ___ PTT-26.6 ___
___ 06:00AM BLOOD Glucose-110* UreaN-33* Creat-1.1 Na-136
K-4.4 Cl-103 HCO3-30 AnGap-7*
___ 06:00AM BLOOD ALT-92* AST-159* AlkPhos-168* TotBili-0.4
___ 06:00AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 100 mg PO BID
hold for SBP < 90, HR < 50
2. Amlodipine 10 mg PO DAILY
hold for SBP < 90
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Metoprolol Tartrate 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Vitamin] 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
6. Spironolactone 50 mg PO DAILY
RX *spironolactone [Aldactone] 50 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
- Abdominal pain
- Cirrhosis complicated by ascites
- Hepatocellular carcinoma
Secondary Diagnoses:
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
TYPE OF THE PROCEDURE: Ultrasound-guided paracentesis.
MEDICAL HISTORY AND REASON FOR THE EXAM: ___ with hepatitis C and
ETOH cirrhosis with HCC, presenting with abdominal pain and new ascites;
therapeutic paracentesis was requested.
PREPROCEDURE IMAGING AND FINDINGS: There is moderate amount of ascites,
mainly in the right lower quadrant. The largest fluid pocket in the right
lower quadrant was targeted for paracentesis.
PROCEDURE:
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained. A preprocedure timeout was
performed discussing the planned procedure, confirming the patient's identity
with three identifiers, and reviewing a checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A ___ ___ catheter was advanced into the largest pocket in the right
lower quadrant and 3.5 liters of blood-tinged fluid was removed.
The patient tolerated the procedure well with no immediate complication.
Estimated blood loss was minimal.
Dr. ___ attending radiologist, was present throughout the critical
portion of the procedure.
IMPRESSION:
Ultrasound-guided therapeutic paracentesis with removal of 3.5 liters of
blood-tinged fluid.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: ABDOMINAL MASS
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, MAL NEO LIVER, PRIMARY, OTHER ASCITES, CHRONIC HEP C W/OUT COMA, CIRRHOSIS OF LIVER NOS
temperature: 97.5
heartrate: 73.0
resprate: 16.0
o2sat: 96.0
sbp: 156.0
dbp: 78.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ man with HCV/EtOH cirrhosis and
recently diagnosed with ___ who presents with abdominal pain. He
was found to have new ascites.
ACTIVE ISSUES:
1. Abdominal Pain/New Ascites: Patient's abdominal pain was most
likely due to his new ascites. His initial diagnostic
paracentesis did not meet criteria for SBP, and the elevated RBC
count seen in fluid was most likely due to a traumatic tap as
his ascites did not look hemorrhagic on imaging and there was no
evidence of pseudoaneurysm from his recent biopsy. He was
covered empirically for SBP with Ceftriaxone 2 g daily until we
had 48 hours of negative cultures. His peritoneal fluid was
consistent with a transudate, supporting portal hypertension as
underlying etiology. He received a 3.5L therapeutic paracentesis
on ___ with marked improvement in his symptoms. Patient was
started on lasix and spironolactone.
2. HCV/EtOH cirrhosis: Patient presented with a MELD of 8 in the
absence of exception points from ___. He is unfortunately not a
transplant candidate due to the size of his lesions. Please
consider screening EGD as outpatient.
3. Hepatocellular carcinoma: Biopsy-confirmed. Patient's MRI
shows numerous lesions, the largest of which measures 11 cm,
which unfortunately places him outside ___ criteria for liver
transplant eligibility. Diagnosis was discussed with patient and
family. Patient's case will be presented at ___ Liver Tumor
Board for consideration of treatment options. Liver team will
follow-up with patient by phone after conference, and a
follow-up appointment is scheduled with Dr. ___ on ___.
4. Hyperkalemia: Patient received kayexalate and K normalized.
He will have a labs check with PCP ___ ___ given risk of
elevated K with spironolactone, which was started this admission
after K normalized.
5. Hyponatremia - Likely secondary to cirrhosis.
CHRONIC ISSUES:
1. HTN - Patient was hypertensive to the 170's on arrival to
the floor in the setting of abdominal pain. Blood pressure
normalized with pain control and patient was continued on home
regimen of metoprolol and amlodipine.
TRANSITIONAL ISSUES:
- Follow up pending pleural fluid cytology
- Follow up pending cultures
- Please consider screening EGD
- Follow-up Liver Tumor Board recommendations |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
GTC seizure, respiratory/cardiac arrest
Major Surgical or Invasive Procedure:
Intubation ___
Left PICC Placement ___
___ Guided LP ___
___ guided ___ tube placement ___
History of Present Illness:
___ w/PMHx HTN and history of seizure who was transferred from
___ for seizure and is being admitted to the MICU
post-cardiac arrest. History is largely derived from notes, as
patient is intubated on arrival. Per report, patient was
watching TV during which time he had a witnessed GTC seizure
lasting approximately 1 minute. He bit his tongue and lost
bladder continence. Patient was smoking marijuana and drinking
alcohol at the time. He denied any trauma or headache. He denied
any significant alcohol history. When EMS arrived, pt was noted
to be post ictal and combative, requiring restraints and Haldol.
He was initially brought to ___.
At ___ 98.6; 90; 122/70; 18; 96% (unknown supplemental
oxygen). He was reportedly pleasant and cooperative on arrival.
Labs were notable for Na 119, K 2.8, Mg 1.3, H/H 11.5/31.9 (MCV
90.6), Prolactin 117.5 STox with positive marijuana, UTox with
EtOH level of 20. Patient was given 1L NS and brought to ___
for further evaluation.
___ the ED, initial vitals: 97.2; 88; 144/84; 18; 96% RA
On exam pt was noted to have an enlarged liver and swollen
tongue.
Labs were significant for:
Na 119
K 3.7
Bicarb 27
Mg 1.2
Phos 1.9
Imaging was significant for:
NCHCT
IMPRESSION:
1. No acute intracranial abnormality.
2. There is a 0.3 cm extra-axial calcified lesion adjacent to
the falx, which may represent a tiny meningioma.
3. There is a large polyp that extends from the right frontal
sinus into the anterior ethmoidal air cells and multiple mucous
retention cysts or polyps ___ the bilateral maxillary sinuses and
sphenoid sinuses.
After returning from his ___, pt called the emergency call
bell ___ the bathroom and was found slumped over on toilet and
cyanotic. It is no clear if there was a pulse. Chest
compressions started immediately and code called. Moved back to
stretcher, and was noted to have pulse and compressions stopped.
Per report, he underwent ___ rounds of compressions. Patient was
subsequently intubated.
Post arrest VBG was ___ with lactate 16.3. Repeat ABG was
7.40/34/295/22 and lactate 6.6.
On exam: There was no reported spontaneous movement afterward.
Patient was given
IV Calcium Gluconate (2 g ordered)
IV DRIP Fentanyl Citrate ___ mcg/hr ordered) Started 50
mcg/hr
IV DRIP Midazolam (0.5-2 mg/hr ordered) Started 2 mg/hr
IVF NS ( 1000 mL ordered)
IVF Sodium Chloride 3% (Hypertonic) - 500 mL
IV Magnesium Sulfate (4 gm)
Patient was also started on bicarb gtt at 150cc/hr.
Consults: Post-arrest Team recommended consideration of cooling.
On transfer, vitals were:
98.3; 82; 121/75; 100% (vent settings not recorded)
On arrival to the MICU, patient was breathing against the
ventilator and appeared to be pulling at lines and his clothing.
However, he did not follow commands, though he was notably on
fentanyl/midazolam gtt.
Past Medical History:
HTN
Seizure ___ setting of alcohol withdrawal
Evidence of seizure activity, even when not withdrawing
History of trauma to LLE as a teenager
EtOH abuse
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 137; 168/73; 39; 97% PSV FiO2 50% ___
GENERAL: Intubated, sedated. ETT ___ place. Withdraws to noxious
stimuli. Does not open eyes to command.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-distended, bowel sounds present, firm liver with
edge approximately 5cm below costophrenic angle. No ascites
appreciated.
GU: Foley ___ place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Deformity of LLE, with well-healed scars.
SKIN: No lesions.
NEURO: Upgoing Babinski bilaterally. Sluggish pupils
bilaterally, equal. Withdraws to noxious stimuli. During exam,
patient began biting ETT and posturing, appearing to be having a
GTC. After this, patient appeared to be having jerking movements
of his lower jaw, consistent with myoclonus.
ACCESS: PIVs
DISCHARGE EXAM:
=====================
Vitals: 98.1 PO 142 / 95 98 20 96 Ra
GENERAL: Alert and interactive, oriented x 3, NAD
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: Clear to auscultation anteriorly without wheezes, rales,
rhonchi
ABDOMEN: Soft, non-tender, mildly-distended, bowel sounds
present, +firm hepatomegaly, no rebound or guarding
EXTREMITIES: Warm, well perfused, 2+ pulses
NEURO: Alert and oriented x 3. Mildly dysarthric. Finger to nose
intact. Heel to shin mildly impaired.
Pertinent Results:
ADMISSION LABS
==============
___ 05:19AM BLOOD WBC-8.3 RBC-3.08* Hgb-10.5* Hct-29.0*
MCV-94 MCH-34.1* MCHC-36.2 RDW-14.6 RDWSD-50.4* Plt ___
___ 05:19AM BLOOD Neuts-83.5* Lymphs-5.8* Monos-9.9
Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.91* AbsLymp-0.48*
AbsMono-0.82* AbsEos-0.01* AbsBaso-0.02
___ 08:31AM BLOOD ___ PTT-30.5 ___
___ 08:31AM BLOOD ___ 04:00AM BLOOD Glucose-122* UreaN-4* Creat-0.5 Na-119*
K-3.7 Cl-81* HCO3-27 AnGap-15
___ 05:30AM BLOOD ALT-88* AST-286* AlkPhos-197*
TotBili-3.8* DirBili-1.8* IndBili-2.0
___ 05:30AM BLOOD CK-MB-4 cTropnT-<0.01
___ 04:00AM BLOOD Calcium-8.6 Phos-1.9* Mg-1.2*
___ 05:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:37AM BLOOD ___ pO2-37* pCO2-93* pH-6.95*
calTCO2-22 Base XS--16
___ 05:37AM BLOOD Lactate-16.3*
___ 08:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:00AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.5 Leuks-NEG
___ 08:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT LABS
==============
___ 08:00AM BLOOD calTIBC-335 Ferritn-201 TRF-258
___ 08:00AM BLOOD Osmolal-253*
___ 08:00AM BLOOD TSH-4.1
___ 08:00AM BLOOD Free T4-1.7
___ 02:41AM BLOOD Cortsol-12.9
___ 07:00PM BLOOD Cortsol-12.8
___ 10:09PM BLOOD Cortsol-22.4*
___ 02:53PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-122*
Polys-65 ___ Macroph-20
___ 02:53PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-78
LD(LDH)-27
DISCHARGE LABS AND OTHER RELEVANT LABS
=======================================
___ 06:50AM BLOOD WBC-6.3 RBC-3.28* Hgb-11.1* Hct-33.9*
MCV-103* MCH-33.8* MCHC-32.7 RDW-15.9* RDWSD-60.7* Plt ___
___ 06:50AM BLOOD ___ PTT-35.1 ___
___ 06:50AM BLOOD Glucose-112* UreaN-3* Creat-0.4* Na-135
K-4.7 Cl-100 HCO3-22 AnGap-18
___ 06:50AM BLOOD ALT-33 AST-85* AlkPhos-274* TotBili-1.2
___ 06:50AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.5 Mg-1.7
___ 03:31AM BLOOD Vit___-___*
___ 08:00AM BLOOD calTIBC-335 Ferritn-201 TRF-258
___ 03:30AM BLOOD Triglyc-121
___ 08:00AM BLOOD TSH-4.1
___ 08:00AM BLOOD Free T4-1.7
___ 10:09PM BLOOD Cortsol-22.4*
___ 08:50AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
IMAGING
=======
CT HEAD ___:
1. Normal CT of the brain..
2. Extensive opacification of the left ethmoid and frontal
sinuses with
erosion of the ethmoid septae deep. This may represent a
mucocele, a polyp or a neoplasm. Further evaluation with direct
visualization and perhaps MR imaging may be helpful.
RIGHT UPPER QUADRANT U/S ___:
1. Nodular echogenic liver concerning for cirrhosis.
2. Splenomegaly and small volume ascites suggests portal
hypertension.
3. Main portal vein and central branches are patent with
hepatopetal flow.
CTA CHEST ___:
No evidence of pulmonary embolism or aortic abnormality.
Enteric tube is ___ place and terminates within the distal
esophagus, recommend advancement. Long segment distal
esophageal wall thickening, consider esophagitis.
Bibasilar moderate left lower lobe, mild right lower lobe
atelectasis, with areas of bilateral lower lobe mucous plugging.
Lung nodules, largest measures 0.4 cm, benign and no further
follow-up needed ___ the absence of history of smoking or
malignancy. If there is history of smoking, follow-up CT chest
without contrast ___ 12 months recommended.
Inhomogeneous attenuation of the liver, may be due to fatty
infiltration or underlying liver disease.
___ Guided LP ___
1. Lumbar puncture at L4-5 without complication.
2. Elevated opening pressure of 32 cm CSF.
Ankle XR ___
No radiopaque foreign bodies.
Chronic fracture deformity of the left tibia, fibula.
Foot XR b/l one view ___
Pin fixation third toe.
Bunion deformities first MTP joints bilaterally
Knee Single View b/l ___
No radiopaque foreign bodies.
Subtle lucency right tibial metaphysis, subacute fracture cannot
be excluded,
clinically correlate.
Fracture deformity of the left fibula.
Degenerative changes bilateral knees.
CXR ___
1. Interval removal of an enteric tube.
2. Low lung volumes with bronchovascular crowding and bibasilar
opacities, probably atelectasis. Concurrent pneumonia cannot
be excluded ___ the appropriate clinical setting, particularly ___
the right lung.
CT HEAD ___
No interval change from head CT ___. No evidence of
anoxic brain
injury.
MICROBIOLOGY
============
___ Culture, Routine-PENDING
___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
___ CULTURE-FINAL no growth
___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-FINAL no growth
___ CSF; SPINAL FLUID HSV1/HSV2 NEGATIVE
___ SCREEN-FINAL negative
___ Culture, Routine-FINAL no growth
___ Culture, Routine-FINAL no growth
___ CULTURE-FINAL no growth
NEUROPHYSIOLOGY
===============
EEG ___
This is an abnormal continuous ICU EEG monitoring study because
of a severely suppressed background. No epileptiform activity
was identified with the one pushbutton activation noted. The
presence of extended periods with muscle artifact could have
masked subtle findings. Interim results were provided to the
treatment team intermittently during this recording period.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lisinopril-hydrochlorothiazide ___ mg oral DAILY
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. CefTAZidime 2 g IV Q12H Duration: 8 Days
2. FoLIC Acid 1 mg PO DAILY
3. Keppra XR (levETIRAcetam) ___ mg oral DAILY
4. Lactulose 30 mL PO Q6H
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Rifaximin 550 mg PO BID
7. Thiamine 100 mg PO DAILY
8. Diltiazem Extended-Release 240 mg PO DAILY
9. HELD- Levothyroxine Sodium 50 mcg PO DAILY This medication
was held. Do not restart Levothyroxine Sodium until your doctor
says it is okay
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
======================
-Seizure (multifactorial, not only from EtOH withdrawal)
-Alcohol Abuse
-Hyponatremia
-New cirrhosis diagnosis
SECONDARY DIAGNOSES
=======================
-HTN
-Seizure ___ setting of alcohol withdrawal
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory arrest s/p ETT placement // Is
the ETT in the correct Is the ETT in the correct
IMPRESSION:
In comparison with the study of earlier in this date, the endotracheal tube
has been pushed forward so that the tip lies approximately 6 cm above the
carina. The tip of the nasogastric tube can only be followed definitely to
the lower esophagus. If this clinically a has been advanced beyond this
point, a repeat study could be obtained with the upper margin at the hilum
pain using abdominal technique.
Little change in the appearance the heart and lungs.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with firm hepatomegaly // Is there normal flow
through the liver? Is there evidence of mass in the liver?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma is diffusely heterogeneous and echogenic. The
degree of echogenicity makes it difficult to fully assess the hepatic
architecture. No gross liver lesion is identified. The contour of the liver
is nodular. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not visualized due to overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 12.7 cm.
KIDNEYS: The right kidney measures 12.2 cm. The left kidney measures 13.4 cm.
Visualization of the kidneys is limited. No hydronephrosis is seen
bilaterally.
DOPPLER EXAMINATION: The main and left portal veins are patent with
hepatopetal flow. The intrahepatic right portal vein is not well visualized
due to limited visualization of the liver. The hepatic veins are patent.
Appropriate arterial waveforms are seen in the main, right and left hepatic
arteries.
IMPRESSION:
1. Patent hepatic vasculature. Note is made of limited visualization of the
portal veins.
2. No gross liver lesion identified. The hepatic parenchyma is heterogeneous,
echogenic and nodular. No biliary dilatation.
3. The spleen is at the upper limits of normal.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ man with seizure, now post arrest. Starting cooling
protocol, evaluate for evidence of anoxic brain injury.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 926 mGy-cm.
COMPARISON: Head CT ___ 04:30.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The patient is intubated. Again seen, are
numerous bilateral maxillary sinus mucous retention cysts versus polyps.
There is a rim calcified polypoid lesion in the anterior right ethmoid air
cells resulting in erosion of the ethmoid septa. This lesion extends into the
right frontal sinus superiorly and superior nasal passage inferiorly. There
is mucosal thickening in the sphenoid sinus and ethmoid air cells. The
mastoid air cells are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Polypoid opacification of the right anterior ethmoid air cells causing
ethmoid septa erosion and extending into the frontal sinus and nasal passage,
as recommended previously, if clinically indicated and further
characterization is needed consider MR imaging or direct visualization.
RECOMMENDATION(S): If clinically indicated, direct visualization or MR
imaging to further characterize ethmoid sinus findings.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with picc // l dl picc 48cm iv ping ___
Contact name: ping, ___: ___ l dl picc 48cm iv ping ___
IMPRESSION:
Compared to chest radiographs earlier on ___.
New left PIC line ends in the low SVC close to the superior cavoatrial
junction. Tip of nasogastric tube just above the upper margin of the
clavicles, no less than 6 cm from the carina should not be withdrawn any
further. Nasogastric drainage tube ends in the low esophagus and is probably
looped in the hypopharynx. It would need to be advanced at least 15 cm to
move all the side ports into the stomach.
Borderline cardiomegaly is stable. Aside from mild right basal atelectasis,
lungs are clear. No pleural abnormality.
NOTIFICATION: PIC line placement was reported to the IV nurse by telephone at
13:00.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with hyponatremia with large variations in Na
level. // eval for cerebral edema
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 925 mGy-cm.
COMPARISON: Head CT ___ 09:55
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. There is no CT
evidence of osmotic demyelination syndrome.
There is no evidence of fracture. There multiple submucosal retention cysts
in bilateral maxillary, right frontal sinuses. There is ovoid fullness in the
right ethmoid sinus, stable since prior, causing expansion of the septa,
extending into the right nasal cavity. There is new fluid in the right
maxillary sinus, likely from tube use. Bilateral mastoid air cells, middle
ear cavities are patent. The The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. There are no new intracranial abnormalities.
2. Polypoid mass in the right ethmoid sinus, nasal cavity stable.
Radiology Report
EXAMINATION: CTA of the chest
INDICATION: ___ year old man with hypoxic event found in PEA. // 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) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 1.5 s, 1.0 cm; CTDIvol = 3.5 mGy (Body) DLP = 3.5
mGy-cm.
3) Spiral Acquisition 8.3 s, 31.8 cm; CTDIvol = 12.1 mGy (Body) DLP = 366.3
mGy-cm.
Total DLP (Body) = 379 mGy-cm.
COMPARISON: Chest x-ray ___
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 thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. Heart is mildly enlarged.
Coronary artery calcifications. There is no pleural effusion.
There is moderate right, mild left lower lobe mucous plugging. There is
moderate volume loss and consolidation the left lower lobe from atelectasis,
and mild atelectasis in the right lower lobe. There is 0.4 cm nodule in the
right lower lobe series 6, image 171. 0.3 cm nodule right middle lobe series
6, image 131. 0.2 cm nodule right upper lobe image 87.
Endotracheal tube is in place, the tip terminates 5 cm above the carina.
Enteric tube is in place. The tip is within the distal esophagus, as seen on
___ 11:57 radiograph, recommend advancement. Long segment distal
esophageal wall thickening, consider esophagitis. Visualized liver shows a
heterogeneous enhancement pattern, this may be due to fatty infiltration or
underlying liver disease. There is a small amount of perihepatic ascites.
Left PICC is in place, the tip terminates in the upper most SVC.
There are multiple nondisplaced subtle fractures of the anterior bilateral
ribs, of indeterminate age. Benign mid vertebral body hemangioma. There is
mild T11 compression fracture, age indeterminate, possibly chronic there is no
adjacent edema.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Enteric tube is in place and terminates within the distal esophagus, recommend
advancement. Long segment distal esophageal wall thickening, consider
esophagitis.
Bibasilar moderate left lower lobe, mild right lower lobe atelectasis, with
areas of bilateral lower lobe mucous plugging.
Lung nodules, largest measures 0.4 cm, benign and no further follow-up needed
in the absence of history of smoking or malignancy. If there is history of
smoking, follow-up CT chest without contrast in 12 months recommended.
Inhomogeneous attenuation of the liver, may be due to fatty infiltration or
underlying liver disease.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 5 EXAMS
INDICATION: ___ year old man with hypernatremia, post- ?seizure // NG tube
placement NG tube placement
IMPRESSION:
Compared to 3 chest radiographs on ___.
5 successive chest radiographs performed over 15 min show failure to advance
the esophageal drainage tube in beyond the level of the gastroesophageal
junction. Several of the images, including the final one in the series,
performed at 00:35 shows a proximal loop of the drainage tube in the
hypopharynx. Final radiograph in the series also shows top-normal heart size,
low lung volumes, no focal consolidation, mild pulmonary vascular engorgement,
but no edema or pleural effusion.
Tip of the ET tube above the upper margin of the clavicles is no less than 6
cm from the carina and could be advanced 2 cm for more secure positioning.
Radiology Report
EXAMINATION: PELVIS PORTABLE
INDICATION: ___ year old man found down, hx of trauma to bilateral legs //
any e/o residual surgical hardware?
TECHNIQUE: Pelvis single view
COMPARISON: None
FINDINGS:
Foley catheter in place. Mild degenerative changes lower lumbar spine,
bilateral hips. Pelvic phleboliths. No fractures.
IMPRESSION:
No fractures.
Radiology Report
EXAMINATION: KNEE( (SINGLE VIEW) BILATERAL
INDICATION: ___ year old man found down, hx of trauma to bilateral legs //
any e/o residual surgical hardware?
TECHNIQUE: Single AP view bilateral knees, one view each side.
COMPARISON: None
FINDINGS:
Right knee: Subtle mid diaphyseal lucency of the proximal tibia, subacute
fracture cannot be excluded. Degenerative arthritis of the right knee, with
hypertrophic changes. Arterial calcifications.
Left knee: Degenerative arthritis of the left knee, medial compartment
narrowing. Chronic fracture deformity of the fibular diaphysis, with
posttraumatic heterotopic calcification. Arterial calcifications.
IMPRESSION:
No radiopaque foreign bodies.
Subtle lucency right tibial metaphysis, subacute fracture cannot be excluded,
clinically correlate.
Fracture deformity of the left fibula.
Degenerative changes bilateral knees.
Radiology Report
EXAMINATION: ANKLE 1 VIEW BILATERAL
INDICATION: ___ year old man found down, hx of trauma to bilateral legs //
any e/o residual surgical hardware?
TECHNIQUE: Single AP view bilateral ankles
COMPARISON: None
FINDINGS:
Right ankle: Soft tissue calcification inferior to medial malleolus, well
___ be related to prior trauma, no adjacent soft tissue swelling.
There are benign soft tissue calcifications in the distal leg. There are no
fractures. Right ankle otherwise normal.
Left ankle: There is chronic, displaced healed fracture of the distal tibial
diaphysis,, with significant callus formation. Significant ossification
projects over distal tibia at the fracture site and distal to it, likely
posttraumatic. Chronic posttraumatic deformity of the mid fibular diaphysis.
The degenerative changes ankle. No soft tissue swelling. No radiopaque
foreign bodies.
IMPRESSION:
No radiopaque foreign bodies.
Chronic fracture deformity of the left tibia, fibula.
Radiology Report
EXAMINATION: FOOT 1 VIEW BILATERAL
INDICATION: ___ year old man found down, hx of trauma to bilateral legs //
any e/o residual surgical hardware?
TECHNIQUE: Single AP view of each foot, one view each side
COMPARISON: None
FINDINGS:
Right foot: Bunion deformity, degenerative changes first MTP joint. Mild
degenerative changes midfoot. No fractures.
Left foot: Pin fixation across PIP, DIP joint third toe. Bunion deformity,
degenerative changes first MTP joint. Scattered degenerative changes midfoot.
Posttraumatic or postsurgical change PIP joint fifth toe. No fractures.
IMPRESSION:
Pin fixation third toe.
Bunion deformities first MTP joints bilaterally
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE.
INDICATION: ___ year old man found down cyanotic with concern for central
infection // Please obtain CSF.
TECHNIQUE: After informed consent was obtained from the patient's healthcare
proxy over the phone explaining the risks, benefits, and alternatives to the
procedure, the patient was laid in prone position on the fluoroscopic table.
A pre-procedure time-out was performed confirming the patient's identity,
relevant history, procedure to be performed and labs.
Puncture was performed at L4-5.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 22 gauge, 13 cm spinal needle was inserted into
the thecal sac. There was good return of clear CSF. 16 mls of CSF were
collected in 4 tubes and sent for requested analysis.
Fluoroscopy time: 0.2 min
Air kerma: 8.1 mGy
Dose area product: 52.69 uGy cm 2
COMPARISON: None.
FINDINGS:
16 mls of clear CSF were collected in 4 tubes. Opening pressure was measured
at 32 cm CSF.
IMPRESSION:
1. Lumbar puncture at L4-5 without complication.
2. Elevated opening pressure of 32 cm CSF.
I, Dr. ___ supervised the trainee during the key components of
the above procedure and I reviewed and agree with the trainee's findings and
dictation.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with likely respiratory arrest, now positive
sputum gram stain, c/f PNA // interval change
TECHNIQUE: Portable semi upright view of the chest
COMPARISON: Chest radiograph from ___
FINDINGS:
The tip of an ETT is seen approximately 6.3 cm above the carina. Lung volumes
are low with bronchovascular crowding and bibasilar opacities, likely
representing atelectasis. Concurrent pneumonia cannot be excluded in the
appropriate clinical setting, particularly in the right lung. The enteric
tube has been removed. The cardiomediastinal silhouette and hilar contours
are likely unchanged. No pneumothorax or pulmonary edema. The left PICC has
been pulled back and is seen in the low SVC.
IMPRESSION:
1. Interval removal of an enteric tube.
2. Low lung volumes with bronchovascular crowding and bibasilar opacities,
probably atelectasis. Concurrent pneumonia cannot be excluded in the
appropriate clinical setting, particularly in the right lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with likely respiratory arrest, now positive
sputum gram stain, c/f PNA // interval change interval change
IMPRESSION:
Comparison to ___, 11:05. No relevant change is noted. Moderate
cardiomegaly. Mild retrocardiac atelectasis. No evidence of pneumonia. No
larger pleural effusions. No pulmonary edema. The monitoring and support
devices, including the endotracheal tube, are stable.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old man with AMS, intubated // interval change
TECHNIQUE: Single AP
COMPARISON: Chest radiograph ___.
FINDINGS:
Heart size within normal limits. A left PICC line terminates in the mid SVC.
An endotracheal tube ends in the mid thoracic trachea. Persistent ill-defined
opacities at the left lung base are unchanged. No significant pleural
effusion.
IMPRESSION:
Persistent ill-defined opacities at the left lung base are unchanged, but
improved from ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man s/p cardiac arrest, continued AMS, previous CT
with no e/o intracranial abnormalities however concerned for evolving process.
// interval change, e/o anoxic brain injury?
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 927 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Ventricles and sulci are normal in overall size and configuration.
There are multiple mucous retention cysts in both maxillary sinuses and right
frontal sinus. There is ovoid fullness of the right ethmoid sinus with
rightward deviation of the nasal septum, unchanged. There is mild mucosal
thickening the sphenoid sinuses and left ethmoid air cells Mastoid air cells
and middle ear cavities are well aerated. The bony calvarium is intact.
IMPRESSION:
No interval change from head CT ___. No evidence of anoxic brain
injury.
Radiology Report
EXAMINATION: NASOINTESTINAL TUBE PLACEMENT WITH FLUOROSCOPY
INDICATION: ___ year old man with need for PO access and unable to place with
glidescope.// Please place NG or OG tube
DOSE: Acc air kerma: 42.1 mGy; Accum DAP: 1233.5 uGym2; Fluoro time: 4.1
minutes
COMPARISON: None.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, ___ feeding tube was placed into the
stomach and then advanced post-pylorically using a guidewire.
10 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the tip of the feeding tube in the
second portion of the duodenum.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Successful post-pyloric placement of ___ feeding tube. The tube
is ready to use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with alcohol abuse and increased secretions. //
interval changes interval changes
IMPRESSION:
Comparison to ___. The patient remains intubated and has
received a feeding tube. The course of this tube is unremarkable, the tip is
not displayed on the image. The left PICC line is unchanged. Minimally
increased fluid overload but no overt pulmonary edema. Atelectatic
retrocardiac lung zone. No larger pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new retrocardiac opacities, originally read
as atelectasis, continues to be febrile, c/f PNA // interval change
interval change
IMPRESSION:
Comparison to ___. No relevant change is noted. The monitoring
and support devices are stable. There is a stable retrocardiac opacity more
likely to reflect atelectasis but the presence of additional pneumonia cannot
be excluded on the basis of the radiographs alone. No larger pleural
effusions. Mild fluid overload but no overt pulmonary edema. Mild
cardiomegaly persists.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pseudomonal pneumonia// Eval for interval
change in consolidation Eval for interval change in consolidation
IMPRESSION:
In comparison with the study of ___, the Dobhoff tube has been removed
and the patient has taken a better inspiration. Cardiac silhouette remains at
the upper limits of normal in size and there is mild elevation of pulmonary
venous pressure. Minimal bibasilar atelectatic changes without evidence of
acute focal pneumonia.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with EtOH history, and uptrending alk phos//
hepatic congestion?
TECHNIQUE: Abdominal ultrasound
COMPARISON: Abdominal ultrasound from ___ and CT C-spine from ___
FINDINGS:
The liver appears enlarged, echogenic with nodular contour concerning for
cirrhosis. No discrete lesion is seen within the liver. Trace right pleural
effusion is suspected. Common bile duct is nondilated. Pancreas not well
visualized. No intrahepatic biliary ductal dilation. Gallbladder is
collapsed. No gallstones are seen. Spleen is mildly enlarged at 14.2 cm in
length. Limited views of both kidneys demonstrate no hydronephrosis. A small
cyst arising from the left renal midpole is noted measuring up to 2.3 cm.
Small volume ascites tracks into the lower quadrant.
Doppler: Main portal vein is patent with hepatopetal flow. The right and left
branches of the portal vein are patent with hepatopetal flow. The hepatic
arterial system appears patent with normal waveforms. Color flow is noted
within the hepatic veins.
IMPRESSION:
1. Nodular echogenic liver concerning for cirrhosis.
2. Splenomegaly and small volume ascites suggests portal hypertension.
3. Main portal vein and central branches are patent with hepatopetal flow.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with seizure // eval for intracranial mass/bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 48.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
No fractures. There are multiple (greater than 15) mucous retention cysts or
polyps in the bilateral maxillary sinuses. There is erosion of the ethmoid
septae eye in the right ethmoid sinus and extending into the right frontal
sinus. This may represent an ethmoid sinus mucocele, one or several polyps, a
neoplasm or a combination of these factors. If the distinction between polyp
versus neoplasm and mucocele is clinically significant, magnetic resonance
imaging may be helpful. There are few small mucous retention cysts/ polyps in
the bilateral sphenoid sinuses. The mastoid air cells and middle ear cavities
are clear. The orbits are unremarkable.
IMPRESSION:
1. Normal CT of the brain..
2. Extensive opacification of the left ethmoid and frontal sinuses with
erosion of the ethmoid septae deep. This may represent a mucocele, a polyp or
a neoplasm. Further evaluation with direct visualization and perhaps MR
imaging may be helpful.
RECOMMENDATION(S): Centered or visualization and MR imaging for further
evaluation of the ethmoid sinus findings
NOTIFICATION: The recommendation of direct visualization and perhaps MR
imaging for further evaluation of the ethmoid sinus findings was emailed to
the Emergency Department QA nurses 10:12 ___ by Dr. ___
___ upon reviewing the study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with seizure // confirm endotracheal tube placement
TECHNIQUE: Single portable supine AP chest radiograph
COMPARISON: None.
FINDINGS:
The endotracheal tube terminates approximately 9.2 cm above the carina.
Heart and mediastinum are normal.
Lungs are clear.
No pleural effusion. No pneumothorax.
IMPRESSION:
1. The endotracheal tube terminates 9.2 cm above the carina.
2. No acute cardiopulmonary abnormality.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Seizure, Transfer
Diagnosed with Abn lev hormones in specimens from female genital organs, Epilepsy, unsp, not intractable, without status epilepticus, Cardiac arrest, cause unspecified
temperature: 97.2
heartrate: 88.0
resprate: 18.0
o2sat: 96.0
sbp: 144.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | ___ with alcohol use disorder and HTN who presented to ___
with alcohol withdrawal/hyponatremic seizure, long hospital
course complicated by further seizure activity, persistent
encephalopathy with eventual recovery and pseudomonal pneumonia.
Per report, the patient was at home drinking and had an episode
of loss of consciousness with rhythmic shaking and concern for
seizure. He was brought to an outside hospital where he was
found to have positive alcohol level and was hyponatremic (Na
116). He was transferred to ___ where he was again
hyponatremic and then found to be unresponsive ___ the ED
bathroom, cyanotic and without pulse. CPR was initiated and
after approximately 1 minute of chest compressions he regains a
pulse. He was admitted to the ICU for monitoring of seizures
related to hyponatremia/alcohol withdrawal. He was intubated and
sedated for airway protection and was initiated on phenobarbital
protocol for alcohol withdrawal. Patient's family endorsed ___
year history of heavy alcohol use, with accelerated use ___ the
last year. He had a history of alcohol withdrawal seizure 6
months prior. He subsequently had several subsequent episodes of
seizure activity ___ the ICU. Neurology was consulted and felt
that seizures were due to presenting hyponatremia as well as
alcohol withdrawal, but that subsequent seizures were unrelated
and possibly related to some degree of anoxic brain injury
related to his arrest. Throughout his ICU stay he was
persistently agitated and encephalopathic. He developed a
pseudomonal pneumonia treated with ceftazidime. He received
treatment for alcohol withdrawal with high dose thiamine, folate
and multivitamin repletion as well as phenobarbital taper which
actually repeated again after the pt was persistently delirious
and tachycardic. He was also noted to have cirrhosis on liver
imaging and started on treatment for hepatic encephalopathy.
After prolonged course his mental status recovered and he was
alert and oriented x3 without focal neurologic deficits on
discharge. He was discharged to rehab.
# Agitation:
# Encephalopathy
# Delirium
___ hospital course notable for severe agitation,
confusion. Etiology was felt to be multifactorial due to
hospital delirium, alcohol withdrawal, seizures, and hepatic
encephalopathy. Once transferred to the medical floor his
delirium resolved. He was treated for delirium with Seroquel,
lactulose and rifaximin, thiamine, folate and multivitamin
repletion, and phenobarbital taper. It was thought possible that
he had sustained some degree of anoxic brain injury during his
arrest, but MRI imaging was not performed as the patient had
improved so rapidly.
# Seizures: Head CT without abnormalities. Seizures initially
felt to be due to hyponatremia and alcohol withdrawal.
Subsequent seizures were felt to have been possibly related to
some degree of anoxic brain injury related to his cardiac arrest
(below). MRI imaging was not obtained due to the patient's rapid
improvement ___ mental status. He should be continued on Keppra
XR 2,000mg daily (or Keppra 1000mg BID) with follow-up with
Neurology.
# Alcohol use disorder: Per family report patient with very
heavy use of alcohol ("gallons"). He should engage ___ ongoing
alcohol rehabilitation. He was treated with high dose thiamine
repletion regimen as well as folate and multivitamins.
# Transaminitis:
# Nodular liver/cirrhosis
# Hepatitis
Patient's right upper quadrant ultrasound had evidence of liver
nodularity and on exam he had nontender hepatomegaly. He likely
has alcoholic cirrhosis with superimposed hepatitis. Ultrasound
also showed splenomegaly and mild ascites suggestive of
increased portal pressures. He should have follow-up ___
___ clinic for management of cirrhosis, screening for
varices and he also needs Hep B vaccine.
# Pseudomonas Pneumonia: Pt growing pseudomonas on sputum from
___ started on ceftazidime. Likely acquired during aspiration
event during seizure. Course is ceftazidime x14 days
(___). He had no pneumonia symptoms at time of discharge.
# Tongue injury: Pt bit tongue during seizure, large piece of
tongue now missing. Oral maxilofacial surgery was consulted and
he as placed on prophylactic antibitoics for 7 day course. These
were completed and he had no evidence of infection.
# Sinus tachycardia: He had persistent sinus tachycardia of
unclear origin with negative workup including negative CTA
chest. His heart rates improved as his agitation decreased. He
was palced on diltiazem as this was a home medication. He was
discharged on diliazem XL 240 mg daily.
# Elevated INR: He was noted to have an elevated INR to 1.6
which improved to 1.3 with vitamin K challenge. Likely component
of possible cirrhosis.
# Increased stool output: Had diarrhea which was negative for C
diff and other infectious studies. It resolved on its own
without changes to his antibiotics.
# HTN: Home lisinopril-HCTZ was held. He was continued on
diltiazem as above.
# Hypothyroidism: Patient was on levothyroxine at home. His TSH
was normal this admission and his levothyroxine was held. Please
reevaluate his TSH ___ 4 weeks and restart as appropriate.
# Anemia: ___ be related to alcohol. His iron studies, and B12
were not low. No evidence of bleeding.
# Respiratory Arrest:
# Cardiac Arrest:
# Acute hypoxic resp failure:
Patient with cardiac arrest ___ ___ ED. Etiology unclear. Per
report was found to be pulseless and cyanotic ___ ED bathroom,
CPR started and pt regained consciousness within 1 minute.
Downtime may have been up to 10 minutes per report. MRI was not
performed as patient was rapidly recovering neurologic function.
#Hyponatremia: Likely caused his initial seizures. Unclear
etiology, probably nutritional. Corrected and remained normal
during his stay.
#Shock. Hypotensive ___ the ICU to ___, treated with
Norepinephrine. Likely ___ pseudomonal PNA, see above.
# Healthcare proxy: a healthcare proxy form was signed this
admission by the patient naming the patient's sister ___
___ as his healthcare proxy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p assault
Major Surgical or Invasive Procedure:
ORIF right parasymphysis and left body mandibular fractures,
extraction of tooth #18
History of Present Illness:
___ is a ___ year old male who states he was
assualted this evening. Endorses multiple punches to his jaw.
Patient initially presented to OSH where CT scan of his head and
C-spine which showed that he had bilateral mandibular fractures.
The patient also had significant swelling of the left mandible
area. And otherwise there is multiple lacerations inside the
mouth. As such they thought that this might be an open fracture
and transfer the patient here for oral maxilla facial surgery
evaluation. Otherwise the patient is not having any chest pain
or
abdominal pain or back pain or any pain in the extremities.
Past Medical History:
PMH:
Denies
PSH:
Denies
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Gen - appear in pain
HEENT - PERRL, visible jaw deformity and swelling (L > R), blood
in oropharynx, no blood in ears or nares, CNII-XII grossly
intact
except decreased sensation from L lower face
CV - RRR
Pulm - non-labored breathing, no resp distress
Abd - soft, non distended, contender
MSK & extremities/skin - no spine ttp, no leg swelling observed
b/l
Discharge Physical Exam:
VS: 99.3, 113/64, 109, 16, 97 Ra
Head: atraumatic and normocephalic
Eyes: EOM Intact, PERRL, vision grossly normal
Ears: no external deformities and gross hearing intact
Nose: straight septum, straight nose, non-tender, no epistaxis
EOE: No trismus, soft tissue edema of b/l middle and lower
third c/w procedure (Left > right).
Neurology: cranial nerves II-XII grossly intact. Bilateral V3
paresthesia
Neck: normal range of motion, supple, mild left sided edema c/w
procedure. Retromandibular incision sutures clean dry and
intact, ___ drain removed
IOE: oropharynx clear, no dysphagia, no odynophagia, no
lymphadenopathy, uvula midline, FOM soft non-elevated, FOM
ecchyosis, Occlusion is stable and repeatable. Incisions clean
dry and intact. Extraction site #18 hemostatic and clear of
debris
Larynx: normal voice, no hoarseness
CV: RRR
Resp: No respiratory distress, no accessory muscle use
Extremities: normal mobility, no deformities
Psych: Alert and Oriented x 3, affect and mood appropriate,
normal interaction
Pertinent Results:
___ 02:41AM BLOOD WBC-14.5* RBC-4.62 Hgb-15.0 Hct-44.5
MCV-96 MCH-32.5* MCHC-33.7 RDW-13.6 RDWSD-48.5* Plt ___
___ 02:41AM BLOOD Glucose-98 UreaN-12 Creat-1.1 Na-141
K-4.4 Cl-99 HCO3-22 AnGap-20*
Imaging:
OSH CT Max/Face shows right parasymphysis displaced fracture and
left mandibular body displaced fracture. Extrusion tooth #18.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % 15mL swish twice a day
Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
[] Displaced compound right parasymphysis fracture and left
mandibular body fracture. Unstable occlusion, mobile anterior
segment. Extrusion and grade III mobility tooth #18.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with bilat mandibular fracture// eval the mandibular
fracture per OMFS
TECHNIQUE: Panorex
COMPARISON: Reference made to maxillofacial CT performed on ___, at
outside institution, ___
FINDINGS:
Bilateral mandibular fractures are noted. Left mandibular fracture involves
the angle of the mandible and appears to extend to the posterior-most
remaining left lower molar, likely fracture in the molar, and with the molar
appearing to be displaced superiorly.. There is also fractures to the right
of midline involving the right mandibular body extending to the level of the
right mandibular canine tooth. The posterior most right mandibular molar is
impacted laterally. Possible soft tissue gas is noted, likely related to
laceration/trauma, better assessed on CT.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with mandibular fracture after assault// eval for
PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable. No displaced fractures are seen.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Assault, Mandibular fracture, Transfer
Diagnosed with Fracture of angle of left mandible, init, Fracture of unspecified part of body of left mandible, init, Assault by other bodily force, initial encounter
temperature: 99.3
heartrate: 110.0
resprate: 19.0
o2sat: 99.0
sbp: 168.0
dbp: 78.0
level of pain: 4
level of acuity: 3.0 | ___ year old s/p assault, found to have bilateral mandible
fracture. The patient was taken to the operating room with OMFS
and underwent ORIF Right parasymphysis fracture, left mandibular
body fracture, extraction #18, 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 clears, on IV fluids,
and oral analgesia for pain control. The patient was
hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a soft diet with good tolerability. The patient had
post-op urinary retention and had to be straight catheterized
once. He was then able to void without difficulty. The ___
drain was removed on POD1. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
soft diet, ambulating, voiding without assistance, and pain was
well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ w/sickle cell disease, presents with RUQ pain. Pt reports
pain began 4 days ago. No clear trigger, no sick contacts.
Developed jaundice 2 days ago and nausea/emesis today. Pain is
worse with inspiration. Not associated with food. Pt seen in PCP
office today and found to be hypotensive. Was transferred to the
ED where he was given zosyn, morphine 1Lns and ERCP consulted.
Recent travel to ___ (returned in ___. No clear food
borne illness, no IVDA, tattoos or transfusions. Sexually active
with women, uses protection consistently, no new sexual partners
in the last month.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
sickle cell disease
- prior AVN
past malarial infection (subtype unknown)
Social History:
___
Family History:
no history of blood disorders
Physical Exam:
ADMISSION
Vitals: T:98.8 BP:110/63 P:99 R:18 O2:100%ra
PAIN: 0
General: nad
EYES: icteric sclera
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
DISCHARGE
VS: 98.4 104/65 70 18 97%RA
Gen: sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, neg murphys, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Neuro - moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 04:00PM BLOOD WBC-9.1 RBC-2.81* Hgb-8.2* Hct-24.1*
MCV-86 MCH-29.3 MCHC-34.1 RDW-20.2* Plt ___
___ 04:00PM BLOOD Glucose-123* UreaN-9 Creat-0.6 Na-136
K-3.8 Cl-98 HCO3-28 AnGap-14
___ 04:00PM BLOOD ALT-385* AST-535* LD(LDH)-693*
AlkPhos-211* TotBili-18.9* DirBili-10.4* IndBili-8.5
DISCHARGE
___ 07:20AM BLOOD WBC-10.1 RBC-2.53* Hgb-7.3* Hct-21.8*
MCV-86 MCH-29.0 MCHC-33.6 RDW-21.9* Plt ___
___ 07:25AM BLOOD Glucose-79 UreaN-7 Creat-0.5 Na-139 K-3.9
Cl-102 HCO3-29 AnGap-12
___ 07:20AM BLOOD ALT-207* AST-92* AlkPhos-177*
TotBili-5.1*
RUQ US ___
1. Cholelithiasis and biliary sludge without evidence of acute
cholecystitis. No intrahepatic biliary ductal or CBD dilatation.
2. Mild splenomegaly
ERCP ___
Impression: The CBD was 5mm in diameter. One small filling
defect consistent with a stone was identified in the distal CBD.
A biliary sphincterotomy was made with a sphincterotome.
There was some post-sphincterotomy ___ edema with a
small amount of extravasation of contast into the submucosa.
The biliary tree was swept with an 8mm balloon starting at the
bifurcation. A few small pigmented stones was removed.
The CBD and CHD were swept repeatedly until no further stones
were seen. The final occlusion cholangiogram showed no evidence
of filling defects in the CBD.
Given the extent of post-sphincterotomy ___ edema, a
___ x 7cm straight plastic stent was placed into the CBD.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 2 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 2 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*5 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis with obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with sickle cell disease, RUQ pain // focal
infiltrate? Acute chest syndrome?
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 top-normal. Mediastinal
contours are unremarkable. No pulmonary edema is seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: A ___ man with sickle cell disease presenting with acute
of right upper quadrant pain and jaundice, evaluate for biliary obstruction or
cholangitis.
TECHNIQUE: Gray scale and color Doppler ultrasound images of the abdomen were
obtained and reviewed.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: There are gallstones and biliary sludge seen within the lumen of
a non-distended gallbladder. There is no wall thickening or pericholecystic,
or other definite secondary sonographic signs of acutecholecystitis .
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 13.5 cm.
KIDNEYS: The right kidney measures 11.8 cm. The left kidney measures 12.3 cm.
Limited views of the bilateral kidneys demonstrate no evidence of
hydronephrosis, concerning solid renal mass, or renal calculi.
RETROPERITONEUM: The visualized portions of the aorta and the IVC are within
normal limits.
IMPRESSION:
1. Cholelithiasis and biliary sludge without secondary findings of acute
cholecystitis. No intrahepatic biliary ductal or CBD dilatation.
2. Mild splenomegaly.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Jaundice, RUQ abdominal pain
Diagnosed with OTHER SICKLE-CELL DISEASE W/O CRISIS, OBSTRUCTION OF BILE DUCT, ABDOMINAL PAIN RUQ, JAUNDICE NOS
temperature: 98.7
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 121.0
dbp: 61.0
level of pain: 6
level of acuity: 3.0 | Hospital Course
This is a ___ year old male with past medical history of sickle
cell disease admitted ___ w abdominal pain and
transaminitis, ERCP demonstrating choledocholithiasis with
obstruction now s/p stone extraction, sphincterotomy, CBD stent
placement
ACTIVE ISSUES
# Choledocholithiasis with obstruction / RUQ pain / leukocytosis
/ LFT abnormalities - admitted with RUQ pain, Tbili 18.9 (Dbili
10.4), ALT 385, AST 535. RUQ ultrasound showed cholelithiasis
and biliary sludge. ERCP showed 5cm CBD with a stone in the
distal CBD. Sphicterotomy was performed and biliary tree was
swept w removal of several stones, complicated by
post-sphincterotomy ___ edema with a small amount of
extravasation of contast into the submucosa, prompting placement
of a ___ x 7cm straight plastic stent into the CBD. Given high
risk fo complications, patient was observed, with subsequently
improving LFTs. He tolerated a normal diet without additional
symptoms. He was discharged home to complete a 5 day course of
ciprofloxacin. He will need a repeat ERCP in 4 weeks for stent
pull and re-evaluation. Per the ERCP service, in the future he
should be considered for outpatient elective cholecystectomy.
LFTs at discharge were ALT 207, AST 92, Tbili 5.1.
INACTIVE ISSUES
# Sickle Cell Disease - continued home folate
TRANSITIONAL ISSUES
- Discharged home to complete 5 day course of ciprofloxacin
- In 4 weeks he will require repeat ERCP for stent pull and
re-evaluation (ERCP service to arrange)
- Per ERCP recommendations, in the future he should be
considered for outpatient elective cholecystectomy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache, word finding difficulties and right upper extermity
tingling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: history obtained from patient and friend; chronology of
events was a little bit difficult to establish
Mr. ___ is a ___ year old left handed man with no medical
history who presents for evaluation of headache, word finding
difficulty, and right upper/lower extremity tingling. He is
currently on vacation here visiting from ___. He woke up this
morning in his usual state of health and went to the park. At
around 3pm, he had a headache. It was bi-frontal, pressure and
hammering in quality, ___ in severity, not associated with
n/v photosensitivity or phonosensitivity. He has had somewhat
similar headaches in the past, but not this severe. He took a
Tylenol which did not help much so he decided to take a nap.
When he woke up, his headache had almost completely resolved.
Mr. ___ tells me that he gets similar headaches once every
___ weeks, but usually they are relieved with Tylenol. At
around 9pm, the headache again became more severe and now was
left sided. Despite the headache, patient decided to keep his
plans to meet up with his friend at a bar. Before leaving, he
had 2 beers at home. At the bar, he had peripheral vision loss
in the right eye which he noticed while playing darts. He then
noted a tingling sensation on the right side of his neck which
gradually spread to his entire right arm and leg over
approximately 20 minutes. He noted that the tingling sensation
improved when he was walking around. At approximately 1:30am,
his headache and other symptoms really became uncomfortable, so
he decided to leave the bar and go back to his friend's house
where he was staying. His friend, who is present, woke up to go
to the bathroom and saw Mr. ___ "fumbling around the
kitchen." He seemed a bit confused and "was not processing"
what was being said to him. Also, patient was having difficulty
with his speech which is not normal, as his speech is usually
very articulate. Friend asked the patient if he was drunk, and
pt denied this. Mr. ___ attempted to go to sleep, but
couldn't and became very worried. He woke up his friend and
they went to the emergency room at ___. There,
on exam, he had word finding difficulty, for example, could not
name simple objects such as a pencil. He was unable to do it in
___ or ___ and was very frustrated. (Fluent in ___.
He was able to follow commands. While in the emergency room,
his speech gradually improved. Also, his peripheral vision loss
resolved and the right sided tingling started to resolve as
well. At ___, CBC, chem10, LFTs and serum tox were
unremarkable and non contrast head CT was normal. He was
transfered to ___ for further evaluation.
Mr. ___ denies having similar symptoms to above in the past
along with his headaches. He denies having any focal weakness,
numbness, gait imbalance, diplopia, dysphagia. No recent
fevers/chills, cough/cold, dysuria, diarrhea. Denies neck pain,
pain with eye movements. He came to ___ from ___ 3 days
ago, but has not had any other recent travel, no sick contacts.
Denies any recent drug use other than occasional marijuana (not
in the last few days). No recent stressors. Did leave his drink
at the bar unattended for some period of time, but states that
there were not many people there. Currently, he still has a
headache with some nausea and mild tingling only in the distal
RUE. His does not feel confused and his speech is almost
completely at baseline with just a little bit of hesitation per
patient and friend.
On neuro ROS, the pt denies blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies focal weakness, numbness. 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:
Had surgery on right shoulder after Rugby injury
Had a concussion several years ago playing Rugby with no long
term deficits
Social History:
___
Family History:
Family Hx:
No history of strokes, seizures, autoimmune disorders
Physical Exam:
Physical Exam:
Vitals: T 98.5 HR 96 BP 151/75 RR 14 O2 97% RA
General: Awake, cooperative, anxious
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
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. Able to relate history
with some difficulty providing the order of events. Attentive,
able to name ___ backwards with a little bit of difficulty.
Language is fluent with intact repetition and comprehension.
Some difficulty describing his symptoms. Normal prosody. There
were no paraphasic errors. Pt. was able to name both high and
low frequency objects including pen, cactus, hammock, chair.
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:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation.
No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: not tested
Pertinent Results:
___ 06:45AM URINE HOURS-RANDOM
___ 06:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CTA head + neck ___
No acute intracranial abnormality.
Unremarkable head and neck CTA. Specifically there is no
dissection.
MRI head ___
Minimal paranasal sinus inflammatory changes. Otherwise normal
study.
OSH Labs
138 103 0.9
--------------<
3.5 ___
7.3>----<126
45.4
EtOH <10
Serum tox neg
NCHCT (report): normal
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
do not exceed 3 grams of tylenol daily. Take in 30 minutes of
headache onset if possible.
RX *butalbital-acetaminophen-caff 50 mg-500 mg-40 mg ___
tablet(s) by mouth every 8 hours as needed Disp #*10 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. complex migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with word findings difficulties, and right arm
numbness.
COMPARISON: Compared to a noncontrast head CT dated ___.
TECHNIQUE: Routine noncontrast head CT and head and neck CTA is obtained
after the intravenous administration of 70 cc Omnipaque contrast.
FINDINGS:
Noncontrast head CT: The gray-white matter differentiation is unremarkable.
There is no intracranial hemorrhage, mass effect or midline shift. There are
no findings of acute infarct. The ventricles and sulci are normal.
The orbits, mastoid air cells and visualized paranasal sinuses are
unremarkable.
CTA head and neck:
The vertebral, common carotid and internal carotid arteries are patent without
significant stenosis based on the size criteria. There are no arterial
dissection.
Anterior and posterior intracranial circulations are unremarkable. There is
no significant stenosis, aneurysm greater than 2 mm or vascular malformation.
IMPRESSION:
No acute intracranial abnormality.
Unremarkable head and neck CTA. Specifically there is no dissection.
Radiology Report
HISTORY: Word finding difficulty, headaches, right-sided tingling, and right
peripheral vision loss.
TECHNIQUE: Sagittal T1 weighted imaging was followed by axial imaging with
FLAIR, T2, gradient echo, and diffusion technique. No contrast was
administered.
COMPARISON: Head CT and CTA ___.
FINDINGS:
The study is normal. There is no evidence of hemorrhage, edema, masses, mass
effect, or infarction. The ventricles and sulci are normal in caliber and
configuration. Incidentally noted is a left maxillary sinus mucous retention
cyst.
IMPRESSION:
Minimal paranasal sinus inflammatory changes. Otherwise normal study.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: WORD FINDING DIFFICULTIES
Diagnosed with HEADACHE
temperature: 98.6
heartrate: 89.0
resprate: 14.0
o2sat: 97.0
sbp: 146.0
dbp: 70.0
level of pain: 5
level of acuity: 1.0 | The patient is a ___ y/o left handed man presenting with word
finding difficulties in the setting of headache, right sided
visual changes, numbness and tingling, with etiology most likely
complex migraine.
1) Migraine Headache: The patient presented with severe,
throbbing headache associated with right sided visual changes,
and RUE numbness and tingling. He has a history of headaches,
including one every day this past week. His physical exam was
remarkable for fluent speech, full strength, and intact
sensation to light touch, temperature and pinprick. He
presented to ___ as a transfer from ___.
Further workup warranted to rule out acute intracranial process
in a patient with new onset complex migraine with weakness.
Here, CT/CTA showed no evidence of intracranial hemorrhage or
carotid dissection. MRI showed no infarct or white matter
changes. The patient's headache improved with analgesics.
Given history of headaches and new headache without focal
findings on physical exam or CT/MRI changes, the etiology of his
symptoms appear to be complex migraine. On discharge, patient
was instructed to follow-up with PCP at home in ___. He was
perscripted Fiorecet PRN as needed for the duration of his
vacation.
2) Mild Thrombocytopenia: OSH labs revealed mild
thrombocytopenia. The patient was instructed to follow up with
his PCP in ___
TRANSITIONAL ISSUES
- patient instructed to make an appt with PCP upon return to
___
- outpt F/U for mild thrombocytopenia |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old male with a history of Crohns
diagnosed in ___ and s/p ileocecectomy ___ for abscess/fistula
presenting with abdominal pain, nausea and vomiting. He has
been in his usual state of health since ___ until yesterday
afternoon when he started to have sudden onset of crampy
abdominal pain with nausea. The pain was crampy in nature,
diffusely localized with the majority of pain in the left side
associated with abdominal distension. The pain was not
associated with food or activity, however, he did notice that
the pain felt better when he ambulated. The pain continued to
progress overnight with associated nausea and nonbloody bilious
emesis x 3. He does not exactly recall the last time he had
flatus but assumes it was yesterday afternoon. His last normal
bowel movement was yesterday morning and reports a normal habit
of ___ bowel movements per day. His Crohns disease was diagnosed
in ___ via a colonoscopy biopsy after having bloody bowel
movements. He last saw a gastroenterologists regarding his
Crohns in ___ and has not seen a physician since that time.
Past Medical History:
Past Medical History: Crohns disease
Past Surgical History: Ilececectomy ___
Social History:
___
Family History:
Family History: Noncontributory
Physical Exam:
Physical Exam:
Vitals: 97.6 108 131/80 18 100% room air
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 09:30AM BLOOD WBC-11.9* RBC-5.48 Hgb-15.9 Hct-47.4
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.4 Plt ___
___ 05:17AM BLOOD WBC-6.1 RBC-4.66 Hgb-13.8* Hct-41.1
MCV-88 MCH-29.7 MCHC-33.7 RDW-13.6 Plt ___
___ 09:30AM BLOOD Neuts-80* Bands-3 Lymphs-5* Monos-12*
Eos-0 Baso-0 ___ Myelos-0
___ 09:30AM BLOOD Glucose-172* UreaN-20 Creat-1.1 Na-141
K-4.7 Cl-102 HCO3-28 AnGap-16
___ 09:30AM BLOOD ALT-11 AST-23 AlkPhos-100 TotBili-0.4
___ 09:30AM BLOOD Lipase-23
___ 05:17AM BLOOD CRP-51.0*
.
KUB ___:
CT A/P ___ bowel obstruction, with transition point
at
the site of small bowel anastomosis a few centimeters proximal
to
the ileocecal valve, suggesting anastomotic stricture. colon is
decompressed, suggesting high grade., though
___ small bowel is also not dilated this could reflect
decompression by emesis. small amount of free pelvic fluid. no
mucosal hypoenhancement of pneumatosis to suggest ischemia.
Medications on Admission:
None.
Discharge Medications:
1. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain for 3 weeks: Take with stool softener.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation for 3 weeks: Take with dilaudid as
needed .
Disp:*100 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Abdominal pain, nausea and vomiting. Additional review of OMR
reveals a history of Crohn's disease.
COMPARISON: None.
THREE SUPINE AND UPRIGHT VIEWS OF THE ABDOMEN: There are multiple dilated
small bowel loops occupying the left abdomen, measuring up to 4.6 cm, with
relative collapse of small bowel loops seen on the right, and a paucity of
colonic air. Several air-fluid levels are seen on the upright view. There is
no free air under the hemidiaphragms. The visualized lung bases are
unremarkable. There are no abnormal soft tissue calcifications and no
suspicious lytic or blastic osseous lesions.
IMPRESSION: Findings concerning for bowel obstruction. Dr. ___ was
paged with these findings at 10:30 a.m. by Dr. ___ phone on ___. A CT has been ordered.
Radiology Report
INDICATION: ___ male with history of Crohn's status post small-bowel
resection, presenting with nausea and vomiting. Evaluate for obstruction.
COMPARISON: Abdominal radiograph performed earlier the same day. No prior
cross-sectional imaging of the abdomen available.
TECHNIQUE: MDCT imaging of the abdomen and pelvis performed following
intravenous administration of 130 cc of Omnipaque intravenous contrast. Oral
contrast was also administered. Axial, coronal, and sagittal reformats were
also prepared and reviewed.
CT ABDOMEN WITH INTRAVENOUS CONTRAST:
The lung bases are clear. There is no pleural or pericardial effusion.
The liver, gallbladder, and biliary tree are unremarkable. Portal and hepatic
veins are patent. The spleen, pancreas, adrenal glands, and kidneys are
similarly unremarkable. There is no hydronephrosis, nephrolithiasis, or
renal/adrenal mass. There is no pancreatic ductal dilation or pancreatic
mass.
The stomach is mildly distended with oral contrast material. The duodenum and
proximal small bowel are unremarkable, however, the mid and distal small bowel
are fluid-filled and dilated, and oral contrast has not reached these
segments. Maximal small bowel diameter is 4.7 cm in the right lower quadrant.
This bowel dilation extends to the site of prior small-bowel resection,
indicated by an anastomosis a few centimeters proximal to the ileocecal valve.
There is no mucosal hyperenhancement at this site to suggest acute
inflammatory disease. The colon is essentially decompressed. These findings
are compatible with a small-bowel obstruction, likely secondary to a
fibrostenotic anastomotic stricture. Though the proximal small bowel is not
dilated, this may reflect decompression by emesis.
There is a small amount of free fluid seen in the pelvis. There is no
loculated mesenteric fluid, and no free fluid, free air, or
pneumatosis/mucosal hypoenhancement to suggest ischemia.
The aorta and mesenteric vessels are patent and normal in caliber. There is
no pathologic mesenteric or retroperitoneal adenopathy.
CT PELVIS WITH INTRAVENOUS CONTRAST:
Distal ureters and bladder are normal. Prostate and seminal vesicles are
normal. There is evidence of prior sigmoid resection, with a widely patent
sigmoid anastomosis. There are scattered diverticula, without associated
inflammatory change. There is no pelvic or inguinal adenopathy.
BONE WINDOWS: There are no lytic or sclerotic osseous lesions concerning for
malignancy.
IMPRESSION:
1. Small-bowel obstruction, likely secondary to fibrostenotic anastomotic
stricture at the site of prior small-bowel resection, just proximal to the
ileocecal valve. This appears high grade, with decompression of the colon.
Non-dilation of the proximal small bowel may reflect decompression by emesis.
2. Evidence of prior sigmoid resection, with widely patent sigmoid
anastomosis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN/BLOATED
Diagnosed with INTESTINAL OBSTRUCT NOS, ABDOMINAL PAIN OTHER SPECIED, VOMITING
temperature: 97.6
heartrate: 108.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 80.0
level of pain: 5
level of acuity: 3.0 | ___ year-old male with Crohns disease with small bowel
obstruction and TP at site of prior surgical anastamosis. An NGT
was placed on HD1 and removed on HD2 once the patient began
passing flatus. His abdomen exam progressively became less
tender. The GI service was consulted, and recommended MRE to
evaluate the transition point seen at the site of his prior
surgical anastamosis, which the patient was scheduled to receive
as an outpatient. If there is any inflammation suggetive of
Crohn's disease, GI will treat him and get a colonoscopy once
the flare cools down. If MRE shows clearly that this was a
mechanical obstruction, GI will plan to defer colonoscopy at
this time. GI follow up was arranged for the patient. On
discharge he was tolerating a regular diet, passing flatus, with
pain well controlled on oral pain medications. |
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 lower extremity ulcer
Major Surgical or Invasive Procedure:
resesction ___ and ___ metatarsal heads left foot ___
debridement right heel ___
History of Present Illness:
___ year old male with past medical history of Hep C (s/p
Harvoni), hx of Hepatitis B, IVDU on methadone (last used ___
years ago) and Charcot foot bilaterally who presents to the ED
at
the recommendation of his podiatry surgeon due to increasing
ulceration on the lateral plantar surface of his left foot.
The patient states that he has had chronic ulcers for many years
on his bilateral feet, and currently also has a right heel ulcer
which he states is not bothering him today. He notes that the
left plantar ulcer is extremely painful, and rates the pain as
___, stabbing, with occasional radiation up to the hip. He also
notes that his left leg has chronic tingling which has worsened
lately. He states that he takes methodone for substance use
disorder once ___ the morning. However, he has been having
breakthrough pain, and asks if he can take methadone ___ split
dose. He presented to his surgeon's office today and was told
that he needs to have surgery tomorrow morning to address the
ulcer.
Patient denies any nausea vomiting, fevers, chills or shortness
of breath. But he reports chronic joint pain, chronic back pain,
chronic cough and chronic constipation.
___ the ED, vitals were:
T 99.8 | HR 73 | BP 152/66 | RR 20 | SpO2 95% RA
Exam:
GENERAL: alert and oriented x3, well-appearing man ___ no acute
distress, lying comfortably ___ hospital bed.
HEENT: normocephalic, atraumatic. oropharynx without erythema or
exudates. Majority of teeth are missing.
NEURO: CN II-XII intact. Moves all extremities antigravity,
equally.
CV: RRR, normal S1, S2. No murmurs, rubs, gallops. Unable to
palpate ___ pulses bilaterally (on re-evaluation attending MD
noted ___ pulses bilaterally) No pedal edema appreciated.
RESP: Lungs clear to auscultation bilaterally.
ABD: Nontender, nondistended. No rebound tenderness or guarding.
MSK: Right foot wrapped ___ gauze dressing. Left foot without
toes, with deep, 3 cm linear ulcer to bone on lateral plantar
surface with surrounding erythema of entire foot, approximately
.5cm deep at deepest.
SKIN: no rashes appreciated. skin on distal legs bilaterally
appears mottled, dry.
Labs:
CBC: 7.0>11.3/37.8<218
Lytes: Na 138 | K 4.8 | Cl 101 | HCO3 27 | Cr 0.9 | BUN 22
Lactate 1.7
They were given:
IV Morphine Sulfate 4 mg
IV Vancomycin (1000 mg ordered)
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
Hepatitis C dx ___, treated with harvoni last year
-Hepatitis B SAb+ CAb- SAg-
- HTN
-h/o IVDA with h/o epidural abscesses
-s/p laminectomy ___ ___
-recurrent ___ cellulitis
-chronic ___ edema with pain
-left hip arthritis
-Charcot foot bilaterally
- Testicular hypofunction
- Asthma
- Wheel chair dependent
- Iron deficnecy anemia
- COPD (chronic bronchitis)
- left toe amputation
Social History:
___
Family History:
Father with prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ Temp: 98.4 PO BP: 158/113 L Sitting HR: 75 RR: 18
O2 sat: 94% O2 delivery: Ra
GENERAL: Alert and interactive. ___ no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Good air entry bilaterally. Scattered rales bilaterally.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation ___ all four quadrants. No organomegaly.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact.
Lower Extremity exam: covered ___ dressing. Please refer to
podiatry note for complete examination.
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 730)
Temp: 97.6 (Tm 98.6), BP: 122/73 (122-155/70-77), HR: 63
(63-73), RR: 20 (___), O2 sat: 92% (92-94), O2 delivery: Ra
GENERAL: Alert and interactive. ___ no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Good air entry bilaterally. Lungs clear however only able
to assess anterolaterally.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation ___ all four quadrants. No organomegaly.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact.
Lower Extremity exam: b/l feet covered ___ dressings, c/d/I.
Wound
vac ___ place L foot
Pertinent Results:
ADMISSION LABS:
===============
___ 05:45PM BLOOD WBC-7.0 RBC-4.65 Hgb-11.3* Hct-37.8*
MCV-81* MCH-24.3* MCHC-29.9* RDW-17.0* RDWSD-50.1* Plt ___
___ 05:45PM BLOOD Neuts-60.1 ___ Monos-10.1 Eos-2.4
Baso-0.3 Im ___ AbsNeut-4.20 AbsLymp-1.87 AbsMono-0.71
AbsEos-0.17 AbsBaso-0.02
___ 05:45PM BLOOD ___ PTT-28.6 ___
___ 05:45PM BLOOD Glucose-100 UreaN-22* Creat-0.9 Na-138
K-4.8 Cl-101 HCO3-27 AnGap-10
___ 06:01PM BLOOD Lactate-1.7
PERTINENT INTERMITTNET LABS:
============================
___ 06:37AM BLOOD ALT-23 AST-26 LD(LDH)-199 AlkPhos-149*
TotBili-0.4
___ 05:03AM BLOOD ALT-25 AST-30 AlkPhos-143* TotBili-0.3
___ 05:03AM BLOOD GGT-146*
___ 05:03AM BLOOD Albumin-3.2* Calcium-10.1 Phos-2.5*
Mg-2.0
DISCHARGE LABS:
===============
___ 09:10AM BLOOD WBC-3.8* RBC-4.60 Hgb-11.2* Hct-37.3*
MCV-81* MCH-24.3* MCHC-30.0* RDW-17.6* RDWSD-51.0* Plt ___
___ 09:10AM BLOOD Glucose-98 UreaN-14 Creat-0.8 Na-136
K-4.5 Cl-99 HCO3-26 AnGap-11
___ 09:10AM BLOOD Calcium-10.1 Phos-2.7 Mg-2.1
MICROBIOLOGY:
=============
___ 8:34 am TISSUE LEFT FOOT ___ METATARSAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
BETA STREPTOCOCCUS GROUP B. QUANTITATION NOT AVAILABLE.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___:
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP..
IMAGING:
========
___ 9:32 AM # ___ FOOT 2 VIEWS LEFT:
Limited visualization of the second and third metatarsal head
resection site.
___ 3:23 ___ # ___ CHEST (PA & LAT):
There is no definite focal consolidation, pleural effusion or
pneumothorax. Retrocardiac opacities on the lateral view have
no definite correlate on the frontal view and could reflect
overlapping vessels and atelectasis. There is no pneumothorax
identified. The size of the cardiac silhouette is within normal
limits. Calcification of the aortic arch is again seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 300 mg PO BID
2. ClonazePAM 1 mg PO BID
3. BuPROPion (Sustained Release) 200 mg PO BID
4. Spironolactone 25 mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Methadone 155 mg PO ONCE
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN COPD
9. AndroGel (testosterone) 1.62 % (40.5 mg/2.5 gram) transdermal
DAILY
10. Aspirin 81 mg PO DAILY
11. Dextroamphetamine 20 mg PO TID
Discharge Medications:
1. Sulfameth/Trimethoprim DS 2 TAB PO BID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN COPD
3. amLODIPine 10 mg PO DAILY
4. AndroGel (testosterone) 1.62 % (40.5 mg/2.5 gram)
transdermal DAILY
5. Aspirin 81 mg PO DAILY
6. BuPROPion (Sustained Release) 200 mg PO BID
7. ClonazePAM 1 mg PO BID
8. Dextroamphetamine 20 mg PO TID
9. Methadone 155 mg PO DAILY
Consider prescribing naloxone at discharge
10. Omeprazole 20 mg PO DAILY
11. Pregabalin 300 mg PO BID
12. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
================
Osteomyelitis of Left Foot
Osteomyelitis of Right Foot
COPD
SECONDARY DIAGNOSIS
===================
Charcot Foot
Chronic Pain
Opioid Use Disorder
Essential Hypertension
GERD
Depression
Anxiety
ADHD
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 man with cough and rales on exam// Any acute
intrapulmonary process
TECHNIQUE: AP and lateral chest radiograph
COMPARISON: ___ and ___
IMPRESSION:
There is no definite focal consolidation, pleural effusion or pneumothorax.
Retrocardiac opacities on the lateral view have no definite correlate on the
frontal view and could reflect overlapping vessels and atelectasis. There is
no pneumothorax identified. The size of the cardiac silhouette is within
normal limits. Calcification of the aortic arch is again seen.
Radiology Report
EXAMINATION: FOOT 2 VIEWS LEFT
INDICATION: ___ year old man with ___ and ___ met head resections// eval s/p
___ and ___ met head resections eval s/p ___ and ___ met head resections
COMPARISON: X-ray ___ left foot
FINDINGS:
Portable AP and lateral views of the left foot were obtained. Patient is
status post resection of the second and third metatarsal head. On the AP much
of the resection site is obscured by overlying density possibly related to
sheets are blankets. On the lateral view there is air anterior to the
metatarsal plane consistent with recent surgery.
IMPRESSION:
Limited visualization of the second and third metatarsal head resection site.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Cellulitis of left lower limb, Non-pressure chronic ulcer oth prt left foot w unsp severity
temperature: 99.8
heartrate: 73.0
resprate: 20.0
o2sat: 95.0
sbp: 152.0
dbp: 66.0
level of pain: 7
level of acuity: 3.0 | SUMMARY:
========
___ w/ PMHx of chronic foot ulceration and charcot foot
bilaterally presented to the ED at the recommendation of his
podiatrist for worsening left plantar foot ulcer that has eroded
to the bone now s/p rsx ___ and ___ metatarsal heads of left
foot, debridement of R heel on ___. Intra-op cultures grew MSSA
and pathology confirmed acute osteomyelitis. He was initially
treated with broad spectrum IV abx for 3 days and then switched
to Bactrim given MRSA risk with plan for 4 weeks per podiatry.
He was not de-escalated to cephalexin given that sensitivities
came back on day of d/c and he had been stable on Bactrim, but
could consider if Bactrim not tolerated. Patient was evaluated
by ___ during his stay who felt safest course would be for
patient to be discharged to rehab however patient declined
opting to discharge home instead. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / fava bean / dapsone / rasburicase
Attending: ___.
Chief Complaint:
hypokalemia, diarrhea
Major Surgical or Invasive Procedure:
___ EGD and Flexible Sigmoidoscopy
___ Colonoscopy
History of Present Illness:
Mr. ___ is a ___ M with history of G6PD deficiency and
recently
diagnosed stage IV high-grade B cell lymphoma who re-presents
after recent discharge with hypokalemia and ongoing diarrhea.
Patient was recently admitted from ___. At that
time, he presented with ___ sub-acute weight loss and was
found to have a large necrotic abdominal mass ___ stage IV
high-grade B cell lymphoma. He underwent initiation of clinical
trial protocol with R-EPOCH and venetoclax on ___, but was
removed from this trial as he was unable to swallow venetoclax
pills. He was subsequently started on CHOP (___). His admission
was complicated by Enterococcus CAUTI for which he was started
on
a 14 day course of antibiotics as well as persistent diarrhea.
His diarrhea was worked up with infectious studies (all
negative), CT enterography notable for evidence of fluid in the
ascending colon suggestive of inflammatory vs infectious colitis
or possibly inflammation ___ mesenteric vascular congestion. GI
was consulted who recommended work up for neuroendocrine tumor
given CT findings of small hyperenhancing mass as well as other
stool studies. Ultimately, it was felt that diarrhea was likely
secondary to inflammation from intra-abdominal lymphoma and
patient was discharged with plan for symptom control with
loperamide and treatment of lymphoma. At time of discharge
potassium had been >3.5 for two days without repletion and it
was
felt patient was safe for discharge with close outpatient follow
up.
The day of this admission, patient presented to scheduled
outpatient follow up with fatigue and ongoing diarrhea and was
found to be hypokalemic to 2.6 with EKG changes. He was
otherwise
asymptomatic. He was referred to the ___ ED.
In the ED:
- Initial vital signs were notable for: afebrile, HR 86, BP
98/61, RR 16, O2 sat 99% on RA
- Labs were notable for: WBC 43.2 (of note received neulasta
___, Hgb 6.7, LDH 289, mildly elevated ALT, AP; BMP within
normal limits except K+ of 2.6, troponin wnl
- Studies performed include: EKG notable for T wave inversions,
prolonged QTc
- Patient was given a total of 100 meQ PO K+ and 80 meQ IV K+
while in the ED
- Vitals on transfer: T 98.2 HR 81 BP 118/69 RR 16 O2 sat 97% RA
Upon arrival to the floor, patient reports that since discharge
he has been overall feeling well though fatigued. Had
significant
amount of diarrhea the first day after discharge (almost every
hour) but then felt that it had slowed down, reports ___
episodes
daily in the two days prior to admission. Denies any abdominal
pain, cramping, fevers, chills, blood in diarrhea. Denies any
dysuria.
Past Medical History:
PAST ONCOLOGIC HISTORY:
========================
- ___: presented with subacute ___ weight loss
- ___: abdominal wall biopsy showing high grade B cell
lymphoma, not otherwise specified
- ___: PET showing metastases to liver, supraclavicular and
intrathoracic nodes
- ___: started on R-EPOCH/venetoclax, stopped as patient
was unable to swallow venetoclax pills
- ___: C1D1 CHOP, discharged with plan for outpatient
rituxan.
PAST MEDICAL/SURGICAL HISTORY:
G6PD deficiency
Developmental Delay
Social History:
___
Family History:
Father had penile cancer. Brother with prostate cancer and MI.
Family history of heart disease, including in multiple brothers
and uncles.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: T 97.5 BP 106/66 HR 81 RR 18 O2 sat 97 RA
Gen: sitting in bed, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
CV: Normal rate, regular rhythm. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: Distended, soft, nontender. Palpable reducible hernia and
mass. No hepatosplenomegaly. Normal bowel sounds.
EXT: WWP. ___ pitting edema to shins.
NEURO: A&Ox3, moving all four extremities symmetrically.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
LINES: PIV
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 820)
Temp: 98.7 (Tm 98.8), BP: 102/62 (94-121/59-72), HR: 65
(63-85), RR: 18 (___), O2 sat: 98% (97-98), O2 delivery: Ra,
Wt: 139.55 lb/63.3 kg
Gen: Seen sitting in room. Mustache drawn on with expo marker
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
CV: Normal rate, regular rhythm. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: Mildly distended, soft, nontender. Palpable reducible
hernia
and mass. No hepatosplenomegaly. Normal bowel sounds.
EXT: WWP. No edema
NEURO: A&Ox3, moving all four extremities symmetrically.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
LINES: PIV
Pertinent Results:
ADMISSION LABS
===============
___ 11:13AM BLOOD WBC-43.2* RBC-2.15* Hgb-6.7* Hct-20.5*
MCV-95 MCH-31.2 MCHC-32.7 RDW-14.9 RDWSD-51.7* Plt ___
___ 11:13AM BLOOD Neuts-98* Lymphs-1* Monos-0* Eos-0*
Baso-1 AbsNeut-42.34* AbsLymp-0.43* AbsMono-0.00* AbsEos-0.00*
AbsBaso-0.43*
___ 11:13AM BLOOD UreaN-9 Creat-0.5 Na-139 K-2.6* Cl-104
HCO3-25 AnGap-10
___ 11:13AM BLOOD ALT-59* AST-19 LD(LDH)-289* AlkPhos-142*
TotBili-0.6
___ 11:13AM BLOOD Albumin-3.5 Calcium-8.6 Phos-1.9* Mg-1.8
UricAcd-2.4*
___ 11:13AM BLOOD cTropnT-0.01
OTHER RELEVANT LABS
===================
___ 01:42PM BLOOD Hapto-109
___ 05:50AM BLOOD Ret Aut-0.9 Abs Ret-0.02
___ 05:50AM BLOOD IgA-51*
___ 05:50AM BLOOD antiDGP-1
IMAGING/STUDIES
================
EGD ___
Grade A esophagitis in the distal esophagus.
Normal mucosa in the whole stomach
Normal mucosa in the whole examined duodenum
Recommendations:
Start daily PPI for esophagitis
Follow up pending biopsies
Flex Sig ___
High residue material was noted throughout. Multiple attempts
were made to irrigate the colon but the mucosa could not be
visualized adequately.
Normal mucosa in the rectum and sigmoid.
Colonoscopy ___
-Normal mucosa was noted in the whole colon. Multiple cold
forceps biopsies were performed for histology in the random
colon.
-A 30 mm mass found in the cecum. Multiple cold forcep biopsies
were performed for histology in the cecal mass.
-A 70 mm mass was found in the ascending and near splenic
flexure. Multiple cold forceps biopsies performed for the
histology in the ascending mass.
-A 50 mm mass was found in the descending colon. Pedunculated.
Multiple cold snare biopsies were performed for histology in the
descending colon.
PATHOLOGY:
===========
___
PATHOLOGIC DIAGNOSIS:
Gastrointestinal biopsies, four:
1. (Gastric antrum): Corpus and antral mucosa, no diagnostic
abnormalities recognized.
2. (Duodenum second portion): No diagnostic abnormalities
recognized.
3. (Sigmoid colon): No diagnostic abnormalities recognized.
4. (Rectum): No diagnostic abnormalities recognized.
___
PATHOLOGIC DIAGNOSIS:
1. Cecum, mass, biopsy:
- Adenomatous mucosa with villous architecture. See note.
- Multiple levels examined.
2. Ascending colon, mass, biopsy:
- Adenomatous mucosa with villous architecture. See note.
- Multiple levels examined.
3. Descending colon, polyp, biopsy:
- Adenomatous mucosa with foci suggestive of high-grade
dysplasia. See note.
- Multiple levels examined.
4. Colon, biopsy:
Colonic mucosa within normal limits.
Note: Given that these samples represent biopsy of a larger mass
lesions, clinical and endoscopic
correlation is recommended to rule out an underlying or
associated invasive adenocarcinoma.
DISCHARGE LABS
===============
___ 12:00AM BLOOD WBC-2.3* RBC-2.39* Hgb-7.3* Hct-23.4*
MCV-98 MCH-30.5 MCHC-31.2* RDW-16.5* RDWSD-59.3* Plt ___
___ 12:00AM BLOOD Neuts-70.6 Lymphs-5.2* Monos-20.3*
Eos-2.2 Baso-1.3* Im ___ AbsNeut-1.63 AbsLymp-0.12*
AbsMono-0.47 AbsEos-0.05 AbsBaso-0.03
___ 12:05AM BLOOD Anisocy-1+* Poiklo-1+* Macrocy-2+*
Microcy-1+* Polychr-1+* Spheroc-1+* Ovalocy-1+* Tear Dr-1+*
Acantho-1+* RBC Mor-SLIDE REVI
___ 12:00AM BLOOD Plt ___
___ 10:53AM BLOOD ___ PTT-40.5* ___
___ 12:00AM BLOOD Glucose-143* UreaN-9 Creat-0.5 Na-141
K-4.6 Cl-104 HCO3-25 AnGap-12
___ 12:00AM BLOOD ALT-16 AST-13 LD(LDH)-175 AlkPhos-104
TotBili-<0.2
___ 12:00AM BLOOD Calcium-8.3* Phos-4.0 Mg-1.9
___ 12:00AM BLOOD calTIBC-215* ___ Folate-5
___ Ferritn-947* TRF-165*
___ 12:00AM BLOOD TSH-0.41
___ 05:50AM BLOOD IgA-51*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Enoxaparin Sodium 100 mg SC DAILY
3. Pantoprazole 40 mg PO Q24H
4. Atovaquone Suspension 1500 mg PO DAILY
5. LOPERamide 2 mg PO BID diarrhea
6. AMOXicillin Oral Susp. 500 mg PO Q8H
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Diphenoxylate-Atropine 1 TAB PO QID
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tab-cap by mouth
four times a day Disp #*120 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth once a day Disp #*12
Tablet Refills:*0
5. Opium Tincture (morphine 10 mg/mL) 6 mg PO Q6H
RX *opium tincture 10 mg/mL (morphine) 0.6 ml by mouth every six
(6) hours Refills:*0
6. Potassium Citrate 40 mEq PO DAILY
RX *potassium citrate 10 mEq (1,080 mg) 4 tablet(s) by mouth
once a day Disp #*120 Tablet Refills:*0
7. rifAXIMin 400 mg PO/NG TID Duration: 14 Days
RX *rifaximin [Xifaxan] 200 mg 2 tablet(s) by mouth once a day
Disp #*8 Tablet Refills:*0
8. LOPERamide 2 mg PO QID diarrhea
Take 2 tabs twice a day (morning and night) and 2 more tabs
spaced throughout the day
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet(s) by
mouth four times a day Disp #*120 Tablet Refills:*0
9. Acyclovir 400 mg PO Q12H
10. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Refills:*0
11. HELD- Enoxaparin Sodium 100 mg SC DAILY This medication was
held. Do not restart Enoxaparin Sodium until a doctor instructs
you to do so.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Aggressive Stage IV B cell lymphoma
Persistent Diarrhea
Hypokalemia with EKG changes
Multiple Villous Adenomas
SECONDARY DIAGNOSIS
===================
G6PD Deficiency
Developmental Delay
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with aggressive lymphoma// port placement
COMPARISON: Chest x-ray dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___, Interventional Radiology fellow performed the procedure. Dr.
___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 20 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1 g of Ancef
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 23 seconds, 2 mGy
PROCEDURE
1. Right internal jugular approach chest double lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The single lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
prolene sutures on either side. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the port was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. Steri-strips were used to close the
venotomy incision site. Steri-Strips were applied over the sutures. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The tip is in the right atrium.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a double lumen chest power Port-a-cath via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal EKG, Hypokalemia
Diagnosed with Hypokalemia
temperature: 97.6
heartrate: 86.0
resprate: 16.0
o2sat: 99.0
sbp: 98.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | BRIEF SUMMARY OF ADMISSION
===========================
Mr. ___ is a ___ M with a history of G6PD deficiency, recently
diagnosed aggressive stage IV high-grade lymphoma s/p initiation
of chemotherapy ___, who re-presents after recent discharge
with hypokalemia c/b EKG changes in the setting of significant
diarrhea. Patient underwent work up with flex sig and EGD which
were both normal. Infectious stool studies were all negative. GI
was consulted for help with evaluation of diarrhea. Ultimately a
cause was not clearly determined but thought to be secondary to
multiple large villous adenomas vs SBO.
ACUTE ISSUES ADDRESSED
=======================
#Persistent Diarrhea
Patient has been having significant, persistent watery diarrhea
for the last 2 months. He has had extensive work up including
EGD/Flex Sig with biopsies, CT enterography, extensive stool and
serum studies without clear etiology elucidated. Does not appear
to be infectious, no neuroendocrine tumor, celiac disease.
GI was consulted given persistence of diarrhea and patient
underwent CT enterography ___ which showed interval decrease in
size in abdominal mass, fluid filled thickened colon (suggestive
of infection vs. inflammation, possible ___ mesenteric vascular
congestion), and a small hyperenhancing mass in an ileal small
bowel loop, likely AVM but also possibly compatible with
neuroendocrine tumor so some serum markers for NET were sent per
GI recs (all negative). His TTG-IgA was low, but in setting of
IgA deficiency, Anti-DGP was tested to confirm; this was also
negative.
Patient underwent Flex sig and EGD without obvious etiologies
identified. His stool elastase was noted to be low (97)
consistent with severe pancreatic insufficiency, though loose
stools may be associated with false positives. Given persistent
diarrhea without etiology, it was decided to trial Creon. There
was no significant improvement and so this was stopped.
Colonoscopy (___) was notable for multiple masses, most
suspected to be villous adenomas. Per GI, the villous adenomas
could be secretory and thus causing the diarrhea. They will need
to be removed sooner than later, and current consideration will
be after his chemotherapy. His Imodium and Lomotil was uptitated
to the max with some effect. He was started on tincture of
optium , which appeared to help his diarrhea the most. He was
also started on RifAXIMin 400 mg PO TID for 14 days (___)
for small intestinal bacterial overgrowth (SIBO). Can consider
starting empiric treatment with Cholestyramine afterwards if
ineffective and suspicion is high.
#Hypokalemia - stable
Patient presented with hypoK+ 2.6, with EKG changes. Here has
required daily repletion. Most likely etiology is persistent
diarrhea, despite some daily variation he is still having
significant loose stools. Urine lytes do not suggest renal
potassium wasting. He was started and continued on standing
potassium citrate 40 meQ daily and he potassium remained stable
and he did not require additional potassium repletion.
#Acute on chronic Anemia
#G6PD deficiency
Patient with hx of anemia to Hgb ___ when he presented in the
beginning of ___. Presented initially with Hgb 6.7 this
admission, improved to 7.4 on repeat without blood (patient is
___). This was generally the trend throughout his
hospital course. No evidence of active bleeding reported by
patient, and no symptoms of lightheadedness, dizziness, chest
pain, fatigue, but is on therapeutic anticoagulation for splenic
vein thrombosis. Additionally, does have hx of G6PD deficiency,
so may be a component of hemolysis and chemotherapy, though Hgb
lower than would be suspected with just chemotherapy.
On ___ his Hb was found to be 5.6. This is the lowest his Hb
has been during this hospital admission. A long discussion was
had with Mr. ___ about receiving blood products. It was
explained to him that while he may be asymptomatic in terms of
symptoms, with this level of Hb it highly increases the risk of
developing a heart attack. Mr. ___, spent some time thinking
about it and then later agreed to received blood. He stated that
he had family members who have had heart attacks and he didn't
want to go through that. I also spoke to his sister and updated
her on the situation. She agreed that it sounded like getting
blood would be best but would leave the final decision to him.
She stated that no one else in the family was a ___'s
Witness with the possible exception of one brother. She
mentioned that Mr. ___ was not raised as ___'s Witness and
was a decision he made later as an adult. Mr. ___ received the
blood with no issue and complaint; he later stated that he was
feeling dizzy before but after he got the blood, he felt much
better. His Hb remained stable through out his hospital course.
#Stage IV high-grade B cell lymphoma
#C1D10 of CHOP
Patient was recently diagnosed with stage IV B cell lymphoma
confirmed by abdominal wall biopsy. Biopsy showed proliferation
fraction of nearly 100%, CD20 negative by IHC and flow. Complex
karyotype including 14;18 translocation (Bcl-2).
CD10 and BCL-6 positive suggesting a germinal center origin.
Extranodal (hepatic) disease noted on PET, consistent with stage
IV lymphoma. He was initially started on phase 1 trial ___
of DA-EPOCH-R with venetoclax (C1D1 ___, venetoclax 600mg QD
D3-D7) but was subsequently removed from study on ___ due to
inability to swallow pills whole (often chewing venetoclax).
Decision was made to switch chemotherapy regimen to CHOP, which
was started ___. He was given rituxan (400mg) on ___. He was
started his third cycle of CHOP on ___ inpatient during this
hospitalization. Continued acyclovir and atovaquone for
prophylaxis.
#SMV/splenic vein occlusion
Noted on CTA A/P last admission, suspected chronic. He was
initially started on lovenox 1.5mg/kg SC QD (100mg QD)
(___). However due to nursing concerns that he was
having difficulty administrating SubQ Lovenox, this medication
was changed to Apixaban 5mg BID. He was able to get a voucher
for a one month supply until his new insurance kicks in. He will
likely need 6 months minimum of A/C (___).
#Agitation
#Developmental delay
Last admission patient had some issues with agitation,
particularly in the setting of changes (i.e. changes in room) or
new information. He was seen by psychiatry who felt that he
likely has an undiagnosed underlying developmental disorder
worsened in the setting of adjustment to new diagnosis, new
setting. He occasional will get agitated, vocally escalate, but
is generally verbally redirectable. He was given Ativan PO
0.5-1mg BID PRN for insomnia/agitation. He was also started on
trazodone QHS PRN given episodes of persistent agitation. A
group home would be ideal for Mr. ___. Note that there is
significant concern for taking his medications correctly and on
time, as well as noticing concerning symptoms. However due to
insurance and normal physical ability, at this moment he does
not qualify. This will be something that can be considered
outpatient as a prolonged ongoing process. His lovenox 1.5mg/kg
SC QD was switched to apixaban for easier administration. We
will also give his medications via blister
packs as much as possible as well. The current discharge plan is
for him to return to his sister for a few days and then return
to his own apartment after his brother cleans it up. They plan
on checking on him daily. This was the most ideal situation
after several family discussions.
#Enterococcal CAUTI - Resolved
Diagnosed last admission. Currently without dysuria. Completed
14 day course of amoxicillin (D10: ___
CORE MEASURES
=============
# CODE: Full (confirmed)
# CONTACT: ___ (brother), ___
Alternate HCP is his sister ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Penicillins / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___
___ Complaint:
RLQ abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old lady with hx of RYGB in ___ (with revisional bypass
in ___ c/b G-J ulcer s/p resection of gastrojejunostomy and
anastomotic ulcer in ___ (s/p scope in ___ that showed ulcer
was discharged home on PPI), hx of portal vein thrombosis not on
AC, upper GIB, diverticulosis, s/p splenectomy in ___ for
splenic artery aneurysm, and anemia who presents with right
lower quadrant abdominal pain.
Patient reports that she has been having several days of blood
spotting rectally, then has developed right lower quadrant
abdominal pain and yesterday developed a fever to 101.0
Fahrenheit. She reports the pain on the right side is constant,
worse with motion and touching it. Denies any dysuria,
hematuria, flank pain, vaginal discharge. Endorses nausea
associated with the pain. Denies vomiting. Pt reports ongoing
low rate rectal bleeding today. Has history of transfusions ___
diverticular bleeding. Pt usually has HCT >30 per her report.
In the ED, initial vitals were: 98.1 152/68 96 18 100%RA
- Exam notable for: none documented
- Labs notable for:
CBC 7.2>9.4/___.3<429 MCV 81
normal chem 7
lactate 1.8
UA with trace protein, negative beta-HCG
- Imaging was notable for:
CT Abd/pelvis with contrast prelim read
1. The appendix is not definitively seen on this exam. However,
there is no secondary signs concerning for appendicitis
including fat stranding, perforation, or abscess formation.
2. Prominent mesenteric lymph nodes are noted in the right
lower quadrant, measuring up to 0.9 cm, which can be seen in
mesenteric adenitis.
- Patient was given:
morphine 4mg x3, Zofran 4mg IV x2, 1L NS, pantoprazole 40mg PO,
acetaminophen 1000mg PO
- Vitals prior to transfer: 98.0 120/56 74 14 96%RA
Upon arrival to the floor, patient reports onset of BRBPR and
clots 3 days ago, temperature to 100.0 at home 2 days ago along
with dull RLQ pain that fluctuates in intensity, peaking and
becoming sharp every hour lasting ___ minutes. Yesterday, she
endorses nausea and dry heaving, no emesis.
Past Medical History:
- H/o roux-en-Y gastric bypass c/b gastrojejunal ulcer
- Diverticulosis
- H/o DVT
- S/p splenectomy ___ for splenic artery aneurysm
- S/p hysterectomy ___
- Iron deficiency anemia - gets q4week iron infusions at
___
Social History:
___
Family History:
___ disease Maternal Grandmother
Colon cancer Father
Hypertension Father
Coronary artery disease Father
___ disease Paternal Grandfather
Colon cancer Paternal Grandmother
Diabetes Paternal Grandmother
Hypertension Maternal Grandfather
Ovarian cancer Maternal Aunt
Diabetes Maternal Aunt
Breast cancer Paternal Aunt
Hypertension Paternal Aunt
Coronary artery disease Paternal Aunt
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
PHYSICAL EXAM ON DISCHARGE:
===========================
VS: 98.0 128/72 74 18 98% RA
General: Alert, oriented, no acute distress; mildly tearful at
times
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. No cervical lymphadenopathy.
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly tender to palpation in RLQ (more so when
pressing w/ hand than with stethoscope), non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, moves all 4 extremities
symmetrically and with purpose
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 10:30PM BLOOD WBC-7.2 RBC-3.37* Hgb-9.4* Hct-27.3*
MCV-81* MCH-27.9 MCHC-34.4 RDW-19.3* RDWSD-57.1* Plt ___
___ 10:30PM BLOOD Neuts-60 Bands-0 ___ Monos-3* Eos-2
Baso-2* ___ Myelos-0 AbsNeut-4.32 AbsLymp-2.38
AbsMono-0.22 AbsEos-0.14 AbsBaso-0.14*
___ 10:30PM BLOOD Plt Smr-HIGH Plt ___
___ 10:30PM BLOOD Glucose-76 UreaN-13 Creat-0.5 Na-139
K-3.7 Cl-104 HCO3-22 AnGap-17
___ 10:30PM BLOOD Albumin-3.5 Mg-1.9 Iron-18*
___ 10:30PM BLOOD calTIBC-360 Ferritn-8.5* TRF-277
___ 11:22PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-19
___ 11:22PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:22PM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:22PM URINE UCG-NEGATIVE
LAB RESULTS ON DISCHARGE:
=========================
___ 10:04AM BLOOD WBC-7.7 RBC-3.48* Hgb-9.5* Hct-29.6*
MCV-85 MCH-27.3 MCHC-32.1 RDW-19.8* RDWSD-61.5* Plt ___
___ 10:04AM BLOOD Plt ___
___ 10:30PM BLOOD ALT-26 AST-42* LD(LDH)-174 AlkPhos-101
TotBili-<0.2
RADIOLOGY:
==========
CT ABDOMEN/PELVIS WITH CONTRAST ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates patchy heterogeneous
enhancement, which is nonspecific but can be seen in underlying
hepatic pathology. There is no evidence of focal lesions. There
is mild central biliary prominence. no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within
normal limits. The portal vein is attenuated and diminuitive.
There is a large varix which appears to shunt between the IMV
and the IVC.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen is resected.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is a 1.3 cm hypodense lesion in the
right upper renal pole, likely simple cysts. There is no
evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: Patient is status post Roux-en-Y gastric
bypass. Small
bowel loops demonstrate normal caliber, wall thickness, and
enhancement
throughout. The colon and rectum are within normal limits. The
appendix is
not definitively seen. However, there is no secondary signs of
appendicitis including fat stranding, abscess formation, or
perforation. Prominent lymph nodes are noted in the right lower
quadrant, measuring up to 0.9 cm (series 601b: Image 32), which
is of uncertain etiology but can be seen in mesenteric adenitis.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is resected. There is no adnexal
abnormality.
LYMPH NODES: There is no retroperitoneal lymphadenopathy. As
mentioned above, prominent mesenteric lymph nodes are seen in
the right lower quadrant, measuring up to 0.9 cm. 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. There is transitional sacralization of the L5
vertebrae.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. The appendix is not definitively seen on this exam. However,
there is no secondary signs concerning for appendicitis
including fat stranding,
perforation, or abscess formation.
2. The liver demonstrates patchy and heterogeneous enhancement
with possible stigmata of portal hypertension including a
prominent large varix, which is concerning for underlying
hepatic pathology. Recommend further evaluation of the liver
findings with MRI.
3. Prominent mesenteric lymph nodes are noted in the right lower
quadrant,
measuring up to 0.9 cm.
4. A right upper renal pole 1.3 cm cyst is of intermediate
density and
incompletely characterized on this exam, for which further
follow up with
renal ultrasound is recommended.
RECOMMENDATION(S): Consider nonemergent renal ultrasound for
further
evaluation of the right upper renal pole cyst.
Recommend further evaluation of the liver findings with MRI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acarbose 100 mg PO TID
2. Acetaminophen 500 mg PO BID:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Cyanocobalamin 1000 mcg PO DAILY
5. Esomeprazole 40 mg Other BID
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Nortriptyline 50 mg PO QHS
8. Polyethylene Glycol 17 g PO DAILY
9. Riboflavin (Vitamin B-2) 25 mg PO DAILY
10. Sucralfate 1 gm PO QID
11. Nortriptyline 25 mg PO QAM
12. BusPIRone 30 mg PO DAILY:PRN anxiety
13. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral DAILY
Discharge Medications:
1. Acarbose 100 mg PO TID
2. Acetaminophen 500 mg PO BID:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. BusPIRone 30 mg PO DAILY:PRN anxiety
5. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Esomeprazole 40 mg Other BID
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Nortriptyline 50 mg PO QHS
10. Nortriptyline 25 mg PO QAM
11. Polyethylene Glycol 17 g PO DAILY
12. Riboflavin (Vitamin B-2) 25 mg PO DAILY
13. Sucralfate 1 gm PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
RLQ abdominal pain of unclear etiology
Diverticulosis
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 with contrast
INDICATION: ___ with RLQ pain, fever +PO contrast // evaluate for
diverticulitis, appendicitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 863 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates patchy heterogeneous enhancement, which
is nonspecific but can be seen in underlying hepatic pathology. There is no
evidence of focal lesions. There is mild central biliary prominence. no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is within normal limits. The portal vein is attenuated and diminuitive. There
is a large varix which appears to shunt between the IMV and the IVC.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is resected.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a 1.3 cm hypodense lesion in the right upper renal pole, likely
simple cysts. There is no evidence of focal renal lesions or hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: Patient is status post Roux-en-Y gastric bypass. Small
bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. The appendix is
not definitively seen. However, there is no secondary signs of appendicitis
including fat stranding, abscess formation, or perforation. Prominent lymph
nodes are noted in the right lower quadrant, measuring up to 0.9 cm (series
601b: Image 32), which is of uncertain etiology but can be seen in mesenteric
adenitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is resected. There is no adnexal abnormality.
LYMPH NODES: There is no retroperitoneal lymphadenopathy. As mentioned above,
prominent mesenteric lymph nodes are seen in the right lower quadrant,
measuring up to 0.9 cm. 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.
There is transitional sacralization of the L5 vertebrae.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. The appendix is not definitively seen on this exam. However, there is no
secondary signs concerning for appendicitis including fat stranding,
perforation, or abscess formation.
2. The liver demonstrates patchy and heterogeneous enhancement with possible
stigmata of portal hypertension including a prominent large varix, which is
concerning for underlying hepatic pathology. Recommend further evaluation of
the liver findings with MRI.
3. Prominent mesenteric lymph nodes are noted in the right lower quadrant,
measuring up to 0.9 cm.
4. A right upper renal pole 1.3 cm cyst is of intermediate density and
incompletely characterized on this exam, for which further follow up with
renal ultrasound is recommended.
RECOMMENDATION(S): Consider nonemergent renal ultrasound for further
evaluation of the right upper renal pole cyst.
Recommend further evaluation of the liver findings with MRI.
NOTIFICATION: The updated findings and recommendations were emailed by ___
___ to the ___ QA RN at 9:55 AM on ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR, RLQ abdominal pain
Diagnosed with Hemorrhage of anus and rectum
temperature: 98.1
heartrate: 96.0
resprate: 18.0
o2sat: 100.0
sbp: 152.0
dbp: 68.0
level of pain: 7
level of acuity: 2.0 | ___ with history of roux-en-y gastric bypass, diverticulosis,
who presents with 3 days of RLQ pain and reports of BRBPR of
unclear etiology.
# RLQ abdominal pain
# BRBPR
Unclear etiology, although patient does have history of
diverticulosis and shares that this is in same location as prior
episodes of abdominal pain. She has had recent endoscopies (EGD
___ with smaller gastrogejunal anastomosis ulceration
compared to prior; ___ flex sig with diverticulosis;
___ colonoscopy with diverticulosis but otherwise normal).
This admission, CT abdomen/pelvis without acute pathology to
explain symptoms, though with nonspecific 0.9 cm mesenteric
lymphadenopathy. Digital rectal exam was performed in house,
without any evidence of blood. H/H stable throughout stay with
Hgb of 9.5 at discharge, actually higher compared to recent
baseline in ___ at ___ of 8.8. She was able to tolerate
regular diet at discharge with pain spontaneously improved and
controlled on acetaminophen.
# Question of chronic liver disease: Of note, on initial CT A/P
patient was noted to have patchy and heterogeneous enhancement
of liver with possible stigmata of portal hypertension including
large varix which appears to shunt between the IMV and the IVC.
Prior CT from ___ in ___ did note dilated pelvic varices.
LFTs WNL, albumin WNL. Please consider follow up MRI as an
outpatient for further characterization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R leg pain
Major Surgical or Invasive Procedure:
ORIF revision R distal femur fracture (Dr. ___, ___
History of Present Illness:
___ s/p Intramedullary nail right femur for treatment of
distal shaft fracture on ___ by Dr. ___,
presenting with 2 days of severe Right leg pain. Patient reports
doing well at rehab, tolerating ___ and ambulating with
progressive distance until ___ when she had a twisting motion
while on the commode and had severe sharp shooting pain in her
right anterior distal thigh. She has minimal pain at rest but
has
severe pain with movement of the thigh or leg. She denies
numbness or weakness in the extremity. She was given flexeril in
addition to her PO oxycodone at the rehab with mild improvement.
She reports that she had a negative DVT ultrasound at the rehab
facility.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
AVSS
Gen: NAD
CV: RRR
P: unlabored breathing
GI: NTND
Right lower extremity:
- Skin intact
- Incision is c/d/I, no drainage or flutuance
- dressing clean/dry/intact
- Full, painless AROM/PROM of ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 01:40PM WBC-7.5 RBC-3.18*# HGB-9.6* HCT-29.9*# MCV-94
MCH-30.2 MCHC-32.1 RDW-14.4 RDWSD-49.0*
Medications on Admission:
pls see OMR
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 30 mg SC QHS
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 30 mg/0.3 mL 1 syringe SC every evening Disp #*11
Syringe Refills:*0
5. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*84 Capsule Refills:*0
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four to six
hours Disp #*50 Tablet Refills:*0
7. Senna 17.2 mg PO DAILY
8. Calcium Carbonate 500 mg PO TID:PRN discomfort
9. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R femoral nail hardware failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT IN O.R.
INDICATION: Right femur fracture ORIF.
TECHNIQUE: Screening provided in the operating room without a radiologist
present. Total fluoroscopy time 88 seconds.
COMPARISON: ___.
FINDINGS:
Images demonstrate fixation of distal femoral shaft fracture with lateral
plate and interlocking screws and cerclage wire. Femoral intramedullary rod
is also again seen. For details of the procedure, please consult the
procedure report.
Radiology Report
INDICATION: History: ___ with worsening right femur pain // Eval for
hardward placement
COMPARISON: Radiographs from ___.
IMPRESSION:
There is an intramedullary rod with proximal pin and distal interlocking screw
fixating a comminuted fracture of the distal femur. There is abnormal distal
migration of the intramedullary rod. In addition, the lowest most
interlocking screw is no longer within the intramedullary rod. There is also
more displacement of the butterfly fragments about the distal femur. Lateral
surgical skin staples are again seen.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 3:25 ___, 3 minutes after discovery of
the findings.
Radiology Report
INDICATION: ___ with need to go to OR // Eval for pre-op
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are hyperinflated but clear besides minimal bibasilar atelectasis.
There is no effusion or edema. Moderate cardiac enlargement is noted as well
as tortuosity of the thoracic aorta with atherosclerotic calcifications. No
acute osseous abnormality.
IMPRESSION:
Cardiomegaly without acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg pain
Diagnosed with Displacement of int fix of right femur, init, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 98.6
heartrate: 80.0
resprate: 15.0
o2sat: 94.0
sbp: 160.0
dbp: 55.0
level of pain: 4
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R trochanteric fixational nail failure (completed ___
___, Dr. ___ was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for revision R femur 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 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
touch down weight bearing in the left lower extremity, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
___ - Right frontal external ventricular drain placement
___ - Diagnostic cerebral angiogram
___ - Coil embolization of right superior cerebellar artery
aneurysm
___ - Tracheostomy
___ - Percutaneous endoscopic gastrostomy
___ - Right frontal ventriculoperitoneal shunt placement
___ - Diagnostic cerebral angiogram
History of Present Illness:
___ is a ___ year old male who presented to the
Emergency Department on ___ as a transfer from an outside
facility after being found unresponsive by his family. CT of the
head without contrast at the outside facility was concerning for
a subarachnoid hemorrhage. Patient was transferred to ___
___ for further evaluation and
management. The Neurosurgery Service was consulted for question
of acute neurosurgical intervention.
Past Medical History:
- history of hypertension
- paraplegia
- status post gunshot wound
- status post strangulation
Social History:
___
Family History:
Unknown family history.
Physical Exam:
On Admission:
-------------
Date and Time of evaluation:
___
___:
[ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity
[ ]Grade II: Moderate to severe headache, nuchal rigidity, no
neurological deficit other than cranial nerve palsy.
[ ]Grade III: Drowsiness/Confusion, mild focal neurological
deficit.
[x]Grade IV: Stupor, moderate-severe hemiparesis.
[ ]Grade V: Coma, decerebrate posturing.
*paraplegic at baseline
Fisher Grade:
[ ]1 No hemorrhage evident
[ ]2 Subarachnoid hemorrhage less than 1mm thick
[ ]3 Subarachnoid hemorrhage more than 1mm thick
[x]4 Subarachnoid hemorrhage of any thickness with IVH or
parenchymal extension
WFNS SAH Grading Scale:
[ ]Grade I: GCS 15, no motor deficit
[ ]Grade II: GCS ___, no motor deficit
[ ]Grade III: GCS ___, with motor deficit
[x]Grade IV: GCS ___, with or without motor deficit
[ ]Grade V: GCS ___, with or without motor deficit
___ Coma Scale:
[x]Intubated [ ]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[x]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[x]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[x]5 Localizes to painful stimuli
[ ]6 Obeys commands
__8__ Total
T: 99.2 BP: 70-150/40-69 HR: 80-117 R: ___ O2Sats: 100% on
50%
FiO2
Gen: intubated - exam with propofol sedation held:
HEENT: Pupils: PERRL ___
+cough/+gag
Neuro:
EO to noxious stimuli. Biting tube off sedation. Moving tongue
around tube
Motor:
RUE purposeful/localizing to ETT
LUE extending to noxious
BLE weak withdrawal to noxious
ON DISCHARGE
============
Exam:
___ speaking mostly
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
*Has tracheostomy
*Shakes head yes/no to options
Orientation: [x]Person [x]Place [x]Time
Follows commands: [x]Simple [ ]Complex [ ]None
Pupils: L ___ reactive R ___ reactive
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No
Speech Fluent: [ ]Yes [x]No - tracheostomy
Comprehension intact [x]Yes [ ]No - follows simple commands
Motor:
*Exam effort dependent
TrapDeltoidBicepTricepGrip
___
*Paraplegic from previous injuries
BLE triple flex to light stimulation
*Shakes head yes that his sensation is intact and equal in BLE
On Discharge:
-------------
General:
Vital Signs: T 97.5F, HR 83, BP 141/94, RR 16, O2Sat 99% on 35%
fraction of inspired oxygen via tracheostomy mask
Exam:
Opens Eyes: [ ]Spontaneous [x]To voice - Sleeping [ ]To noxious
Orientation: [x]Person - Nods yes or no with options [x]Place -
Nods yes or no with options [x]Time - Nods yes or no with
options
Follows Commands: [x]Simple [ ]Complex [ ]None
Pupils: Right pupil round and reactive, 5mm to 4mm. Left pupil
round and reactive, 6mm to 5mm.
Extraocular Movements: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Speech Fluent: [ ]Yes [x]No - Nonverbal
Comprehension Intact: [x]Yes [ ]No
Motor: Bilateral upper extremities full strength. Bilateral
lower extremities triple flex to noxious.
Pertinent Results:
Please refer to OMR for pertinent lab and imaging results.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 10 mg PO QPM
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Warfarin 2 mg PO DAILY16 a-fib
4. Diltiazem Extended-Release 120 mg PO BID
5. Denosumab (Prolia) 60 mg SC ONCE EVERY SIX MONTH
6. Vitamin D 1000 UNIT PO DAILY
7. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
8. Furosemide 40 mg PO DAILY
9. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. Multivitamins W/minerals Chewable 1 TAB PO DAILY
7. Nystatin Cream 1 Appl TP BID
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID
10. sevelamer CARBONATE 800 mg PO Q6H
11. Acetaminophen 1000 mg PO Q8H
Do not exceed 3000mg in 24 hours.
12. Vitamin D 1000 UNIT PO DAILY
13. Atorvastatin 10 mg PO QPM
14. Baclofen 10 mg PO Q12H
15. FoLIC Acid 1 mg PO DAILY
16. HELD- Denosumab (Prolia) 60 mg SC ONCE EVERY SIX MONTH
This medication was held. Do not restart denosumab (Prolia)
until restarted by your primary care provider.
17. HELD- Diltiazem Extended-Release 120 mg PO BID This
medication was held. Do not restart diltiazem extended release
until restarted by your primary care provider.
18. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart furosemide until restarted by your primary care
provider.
19. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart lisinopril until restarted by your primary care
provider.
20. HELD- Metoprolol Succinate XL 50 mg PO DAILY This
medication was held. Do not restart metoprolol succinate
extended length until restarted by your primary care provider.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid hemorrhage
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: ___ year old man with hx of SAH w/ pontine IPH// Evaluate ETT
placement
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The ET tube, left IJ line and NG tube are unchanged. Cardiomediastinal
silhouette is stable. There is no pleural effusion. No pneumothorax is seen
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old man with perimensephalic SAH and R pontine IPH//
Evaluate for vasospasm, dissection, other vessel pathology
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
2) Spiral Acquisition 4.8 s, 38.0 cm; CTDIvol = 13.3 mGy (Body) DLP = 504.0
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 11.9 mGy (Body) DLP =
6.0 mGy-cm.
Total DLP (Body) = 511 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CTA head and neck ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is interval decompression of the ventricles from the ___ MRI.
The tip of the right frontal ventriculostomy catheter is located near the
foramen of ___.
There is expected interval evolution of the previously identified diffuse
extensive subarachnoid hemorrhage. The intraparenchymal hemorrhage within the
right dorsal lateral pons and superior cerebellar vermis appears similar.
There is no subfalcine or transtentorial herniation.
CTA HEAD:
There is no emergent large vessel occlusion.
There is diffuse irregularity of the bilateral internal carotid arteries
without high grade narrowing. There is a 2 mm right PCOM infundibular origin
versus a small aneurysm.
There are areas of moderate luminal narrowing throughout the vessels of the
circle ___ and ___ branches, worse from the recent CTA.
The long segment fusiform aneurysm and more distal dissecting aneurysm of the
right superior cerebellar artery appear similar to the most recent CTA. There
is high-grade luminal narrowing proximal to the fusiform and both proximal and
distal to the dissecting aneurysm within the right SCA, similar to the recent
CTA.
No new aneurysm or vascular malformation is identified.
CTA NECK:
There is a left-sided 3 vessel aortic arch.
The right common carotid artery appears normal. There are areas of mild
luminal narrowing within extracranial internal carotid artery (less than 50%
by NASCET criteria) due to extensive arterial dissection with associated
pseudoaneurysm formation.
The left common carotid artery appears normal. There are areas of mild
luminal narrowing within the extracranial internal carotid artery (less than
50% by NASCET criteria) due to an arterial dissection with associated
pseudoaneurysm formation. The dissection burden within the left ICA is less
severe than the right ICA.
There is a short segment of high-grade luminal narrowing within the distal
right V1 segment. There are additional areas of moderate luminal narrowing
within the extracranial vertebral arteries with associated pseudoaneurysm
formation.
The extracranial carotid and vertebral arteries appears similar to the recent
CTA.
OTHER:
There is a 16 mm nodule within the left lobe of the thyroid. The lung apicies
are clear.
IMPRESSION:
1. Interval decrease in ventricular size when compared to the ___
MRI.
2. Expected interval evolution of the extensive subarachnoid hemorrhage and
right dorsolateral pontine and superior cerebellar vermian parenchymal
hemorrhage. These areas of hemorrhage are both located within the vascular
territory of the medial branch of the right SCA and likely related to the
distal propagation of arterial dissection versus hemorrhagic transformation of
right SCA infarcts.
3. Areas of moderate narrowing within the vessels of the circle of ___ and
major branches appear worse from the recent CTA, likely secondary to vasospasm
given the diffuse nature and temporal relation to the SAH.
4. High grade luminal narrowing of the right SCA in the region of the fusiform
and lobulated dissecting aneurysms, similar to the prior CTA.
5. Extracranial ICA and vertebral artery dissections with associated
pseudoaneurysm formation. There is a short segment of high grade stenosis
within the right V1 segment, similar to the prior CTA.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with perimensephalic SAH w/ pontine IPH//
Evaluate ETT placement Evaluate ETT placement
IMPRESSION:
NG tube tip is in the stomach. ET tube tip is 5.5 cm above the carina. Heart
size and mediastinum are stable. Lungs overall clear. Previously seen
mediastinal widening has decreased in size. There is no appreciable pleural
effusion or pneumothorax.
Radiology Report
EXAMINATION: Right common carotid artery angiogram.
Left common carotid artery angiogram.
Left vertebral artery angiogram.
Right vertebral artery angiogram.
Right common femoral artery angiogram.
INDICATION: ___ year old man with SAH/IVH and CTA revealed right superior
cerebellar aneurysm and multiple carotid pseudoaneuryms and dissction//
diagnostic angio to assess dissections/aneurysms
ANESTHESIA: General endotracheal anesthesia was maintained by separate
anesthesia provider throughout the entirety of the case. The anesthesia
provider also monitored the patient's hemodynamic and respiratory parameters.
TECHNIQUE: Patient was brought into the angio suite, ID was confirmed via
wrist band.The patient was placed supine on fluoroscopy table and bilateral
groins were prepped and draped in the usual sterile manner. Time-out procedure
was performed per institutional guidelines. The location of the right mid
femoral head was located using anatomic and radiographic landmarks. 10 +10 cc
of subcutaneous lidocaine was infused into the tissue. Micropuncture kit was
used to gain access to the right femoral artery, serial dilation was
undertaken until a short 5 ___ groin sheath connected to a continuous
heparinized saline flush could be inserted. ___ catheter was
connected to the power injector and also to a continuous heparinized saline
flush. This was advanced over the 0.038 glidewire brought up the aorta used to
select the right common carotid artery. AP and lateral views of the neck
followed by anterior cerebral circulation were obtained. Subsequently, 3D
rotational images were performed requiring post processing on an independent
workstation under concurrent physician supervision and used in the
interpretation and reporting of the procedure.
Catheter was then pulled back in the aorta and used to select the left common
carotid artery. AP and lateral views of the neck followed by anterior
cerebral circulation were obtained.
The catheter was then pulled back in the aorta and the left subclavian artery
was selected. AP and lateral road map imaging was undertaken. Next, the left
vertebral artery was selected. AP and lateral views were taken from this
vessel for the neck followed by posterior cerebral circulation. Subsequently,
3D rotational images were performed requiring post processing on an
independent workstation under concurrent physician supervision and used in the
interpretation and reporting of the procedure.
The catheter was then pulled back into the aorta and the right subclavian
artery was selected, AP and lateral road maps were obtained. Next the orifice
of the right vertebral artery was cannulated and AP and lateral views were
obtained of the neck and the intracranial circulations.
The catheter was then pulled back in the aorta fully removed from the body. A
common femoral arteriogram was performed prior to use of a closure device,
subsequently 5 ___ Mynx was put in. At the conclusion of the procedure,
there is no evidence of thromboembolic complication and the patient was at his
neurologic baseline.
COMPARISON: None.
PROCEDURE: Diagnostic cerebral angiogram.
FINDINGS:
Right common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis. Multiple pseudoaneurysms
were identified in the cervical segment of the ICA with no flow limitation
effect.
Right internal carotid artery: The distal right ICA, proximal and distal MCA
and ACA branches are well-visualized. Mild dolichoectasia of the A1 segment.
Otherwise, vessel caliber smooth and tapering. Normal arterial, capillary, and
venous phase . No vascular abnormalities identified .
Left common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis however there is a
pseudoaneurysm at the level of C1 that measures around 6 x 6 mm. And is not
causing any flow limitations.
Left internal carotid artery: Distal left ICA, proximal and distal MCA and
ACA branches are well-visualized. Cross-filling to the contralateral A2 via
the A-comm. Vessel caliber smooth and tapering. Normal arterial, capillary,
and venous phase . No vascular abnormalities identified .
Left vertebral artery: Multiple dissection points with multiple small
pseudoaneurysms in the V2 and V3 segments. Left ___, basilar artery,
bilateral AICA, bilateral SCA and bilateral PCAs are well-visualized. The
right ___ is not well visualized as there was no cross-filling to the right
vertebral artery.
Beaded appearance of the basilar artery specially in the upper segment with
multiple stenotic points. 2 fusiform aneurysmal dilatations at the right SCA,
the proximal one involves a 13.8 mm segment of the proximal SCA. The takeoff
of the SCA measures around 0.91 mm and distal to this proximal fusiform
aneurysm artery measures around 1.45 mm.
The second fusiform aneurysm involves 7.3 mm of the artery and measures around
5.35 mm in a cross-sectional diameter, the SCA diameter distal to this
aneurysm measures around 1.14 mm. This aneurysm is the likely cause of the
subarachnoid hemorrhage.
Right vertebral artery: Multiple dissection points with multiple small
pseudoaneurysms in the V2 segment. Minute contribution to the posterior
circulation as it fills the right ___.
Right common femoral artery: Well-visualized with a good caliber size for
closure device. An external iliac wide-based pseudoaneurysm is identified,
measuring 17 mm at the neck and 4 mm from the dome to the neck.
I, ___, participated in the procedure. I, ___,
was present for the entirety of the procedure and supervised all critical
steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
IMPRESSION:
1. Multiple intracranial and extracranial dissections and pseudoaneurysms
involving bilateral ICAs and vertebral arteries as described in the body of
the report.
2. Beaded appearance of the basilar artery specially in the upper segment with
multiple stenotic points. 2 fusiform aneurysmal dilatations at the right SCA,
the proximal one involves a 13.8 mm segment of the proximal SCA. The takeoff
of the SCA measures around 0.91 mm and distal to this proximal fusiform
aneurysm artery measures around 1.45 mm.
The second fusiform aneurysm involves 7.3 mm of the artery and measures around
5.35 mm in a cross-sectional diameter, the SCA diameter distal to this
aneurysm measures around 1.14 mm. This aneurysm is the likely cause of the
subarachnoid hemorrhage.
RECOMMENDATION(S):
1. These findings and treatment strategy of the right SCA fusiform aneurysm
would be discuss with the patient's family.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SAH, new IJ placement, ETT placement// new
IJ placement, ETT placement, r/o pneumo new IJ placement, ETT placement,
r/o pneumo
IMPRESSION:
ET tube tip is 4 cm above the carina. NG tube tip is in the stomach. Right
internal jugular line tip is at the level of cavoatrial junction. Heart size
and mediastinum are stable. Left retrocardiac opacity appears to be minimally
increased concerning for progression of infectious process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ yo man HA ___ NCHCT negative d/c from OSH found unresponsive
___ OSH NCHCT Perimesencephalic SAH + pontine IPH, now s/p EVD. Tract
hematoma s/p EVD; worsening neuro exam// worsening exam post angio, concern
for increased bleed/hydro
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Head CT ___
FINDINGS:
Extensive intracranial subarachnoid hemorrhage, predominantly at the right
perimesencephalic cistern, prepontine cistern, suprasellar cistern. Moderate
volume of hemorrhage in the posterior bilateral sylvian fissures, overlying
both posterior temporal, inferior parietal convexities. Parenchymal
hemorrhage in the posterior right brainstem, cerebellar vermis with mild
surrounding edema. There is some blood along the right tentorium,
interhemispheric fissure, similar. Findings are similar compared to prior.
Intraventricular drain tip in the right frontal horn, mild ventricular
prominence, similar to prior. Mild edema, blood products, about ventricular
drain tract, similar. Nearly completely opacified prepontine cistern. Nearly
completely opacified fourth ventricle with blood products within it, similar.
Tonsillar herniation, cerebellar tonsils extend to C1 level, similar to prior.
Superior cerebellar cistern is completely effaced, similar.
Mild edema involving anterior right temporal lobe, lateral right orbital gyrus
may be sequela of trauma or ischemia, similar.
No evidence of new infarction. Diffuse cerebral edema, similar.
There is no evidence of fracture. Mild opacification of the paranasal
sinuses, likely from intubation.. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No significant change.
Large volume subarachnoid hemorrhage, some blood along the tentorium, within
fourth ventricle. Stable intraparenchymal hemorrhage brainstem, cerebellum,
may be secondary to adjacent dissecting, ruptured aneurysm, or underlying
vascular malformation.
Mild ventricular prominence, stable.
Significant mass-effect in the posterior fossa, nearly obliterated fourth
ventricle, prepontine cistern. Obliterated superior cerebellar cistern.
Cerebellar tonsillar herniation to level of C1, similar.
Stable small area low-attenuation right temporal, frontal ___ be sequela
of trauma, of indeterminate age, or ischemia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man intubated// CXR CXR
IMPRESSION:
Comparison to ___. Minimally increased retrocardiac atelectasis.
Stable correct position of the monitoring and support devices. No pleural
effusions. No pneumonia, no pulmonary edema.
Radiology Report
EXAMINATION: PELVIS AP ___ VIEWS
INDICATION: ___ year old man with ___ yo man HA ___ NCHCT negative d/c from
OSH found unresponsive ___ OSH NCHCT Perimesencephalic SAH + pontine IPH, now
s/p EVD. Tract hematoma s/p EVD.// please assess for sacral osteomyelitis
TECHNIQUE: Portable supine radiograph of the pelvis
COMPARISON: None
FINDINGS:
The sacrum appears somewhat sclerotic with some cortical ill definition more
marked on the right side. There is moderate to severe bilateral hip joint
osteoarthritis with joint space narrowing and osteophytosis. No acute
fracture is identified. Full bladder noted. Lower lumbar spine appears
unremarkable. Bowel gas pattern appears unremarkable.
IMPRESSION:
Limited assessment of the sacrum on AP view only however the sacrum appears
somewhat sclerotic distally with ill definition of cortex particularly on the
right side. Given clinical concern for osteomyelitis, recommend further
evaluation with MRI. If contraindication to MRI, CT could also be performed
to further evaluate. Degenerative changes at the hip joints.
Radiology Report
EXAMINATION: Left vertebral artery angiogram.
Right SCA angiogram.
Right common femoral artery angiogram.
INDICATION: ___ year old man with known SAH.// Embolization of cerebral
aneurysm. *Dr. ___ Add on list, case ___
ANESTHESIA: General endotracheal anesthesia was maintained by separate
anesthesia provider throughout the entirety of the case. The anesthesia
provider also monitored the patient's hemodynamic and respiratory parameters.
TECHNIQUE: Patient was brought into the angio suite, ID was confirmed via
wrist band.The patient was placed supine on fluoroscopy table and bilateral
groins were prepped and draped in the usual sterile manner. Time-out procedure
was performed per institutional guidelines. The location of the right mid
femoral head was located using anatomic and radiographic landmarks. 10 +10 cc
of subcutaneous lidocaine was infused into the tissue. Micropuncture kit was
used to gain access to the right femoral artery, serial dilation was
undertaken until a long 8 ___ groin sheath connected to a continuous
heparinized saline flush could be inserted. ___ catheter was
connected to the power injector and also to a continuous heparinized saline
flush. This was advanced over the 0.038 glidewire brought up the aorta used to
select thethe left subclavian artery . AP and lateral road map imaging was
undertaken. Next, the left vertebral artery was selected. AP and lateral
views were taken from this vessel for the posterior cerebral circulation.
In collaboration with our colleagues anesthesia, 3000 units of heparin were
given to target ACT between 250 and 300 subsequent doses were given as needed
to achieve this target.
Under constant fluoroscopy, using an angled Glidewire exchange, the diagnostic
catheter was exchanged to 6 ___ shuttle, which was advanced to
satisfactory position at the orifice of the left vertebral artery. The
Glidewire was removed, a new AP and lateral road maps were obtained, then DAC
044 115 cm was advanced over SL 10 micro catheter was advanced carefully and
slowly over a synchro 2 wire until its was positioned in the upper basilar and
the DAC was positioned at the intracranial portion of the left vertebral
artery.
The microcatheter was removed and a new magnified AP and lateral roadmap its
were obtained. Next the SL 10 microcatheter was mounted over synchro 2 wire
and multiple attempts to cannulate the right SCA failed, this prompted us to
use different wires in different shapes and configurations until finally the S
CA was cannulated using Transend EX Soft Tip wire. A micro angio run was
obtained that confirmed the positioning of the microcatheter beyond the
proximal dilated segment.
Target Helical Ultra 4mm/15cm Coil was used as an initial coil, which was
advanced slowly and carefully until it was fully deployed inside the aneurysm.
Subsequently, we continued deploying a more coils until we reached
satisfactory obliteration of the distal fusiform aneurysm, intermittent angio
runs were utilized between the coiling sessions (2 runs).
After the deployment of the last coil, the micro catheter was pulled out, then
we obtained final AP and lateral views, which confirmed the patency of the
vertebrobasilar system and a complete feel of the distal aneurysm with the
distal SCA sacrifice and slow filling of the proximal fusiform segment of the
SCA.
The catheter was then pulled back in the aorta and fully removed from the
body. A common femoral arteriogram was performed prior to use of a closure
device, subsequently 8 ___ Angio-Seal was put in. At the conclusion of the
procedure, there is no evidence of thromboembolic complication and the patient
was transferred to the neuro ICU in stable condition.
325 mg of aspirin was crushed and given via the NG tube at the conclusion of
the procedure.
All angio runs were medically necessary for baseline assessment and for future
comparison.
Devices inventory:
.038" 150cm Angled Glidewire
035 x 150cm ___ Wire
038 Angled Glidewire Exchange
___ Micropuncture Set
___ Berenstein ___ 100cm Cath.
___ x 25cm Terumo Sheath Set
038 Angled Glidewire Exchange
Synchro2 Standard 14 200cm Wire
Excelsior SL-10 150cm Microcatheter
___ x 90cm Shuttle Sheath Set
DAC 044 115cm Distal Access Catheter 4.3F
X-pedion 10 200cm Wire
0.010" X 200cm Asahi Neurovascular Guide Wire
Transend EX Soft Tip 205cm Guidewire
InZone Detachment System
Target Helical Ultra 4mm/15cm Coil ___
Target Helical Ultra 3mm/10cm Coil ___
Target Helical Ultra 3mm/8cm Coil ___
Target Helical Ultra 2mm/8cm Coil ___
Target Helical Ultra 2mm/8cm Coil ___
___ Angio Seal VIP Closure Device ___
COMPARISON: ___
PROCEDURE: Coiling of a right SCA distal fusiform aneurysm with distal parent
vessel sacrifice.
FINDINGS:
Left vertebral artery: There is no change in the angio architecture of the
vertebrobasilar system when compared to the angiogram that was done yesterday.
Successful obliteration of the distal fusiform SCA aneurysm with distal SCA
sacrifice and significant slowing in the flow in the proximal fusiform
dilatation.
Right common femoral artery: Well-visualized with a good caliber size for
closure device.
I, ___, participated in the procedure. I, ___,
was present for the entirety of the procedure and supervised all critical
steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
IMPRESSION:
There is no change in the angio architecture of the vertebrobasilar system
when compared to the angiogram that was done yesterday. Successful
obliteration of the right distal fusiform SCA aneurysm with distal SCA
sacrifice and significant slowing in the flow of the proximal fusiform
dilatation of the same vessel.
RECOMMENDATION(S):
1. Subarachnoid hemorrhage management as per usual protocol.
Radiology Report
EXAMINATION: CT scan of the thorax with intravenous contrast
INDICATION: ___ year old man with ___ yo man HA ___ NCHCT negative d/c from
OSH found unresponsive ___ OSH NCHCT Perimesencephalic SAH + pontine IPH, now
s/p EVD. Tract hematoma s/p EVD.// please assess for aneurysms per the
recommendations of ID consult
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 2.0 s, 31.7 cm; CTDIvol = 3.4 mGy (Body) DLP = 107.9
mGy-cm.
2) Spiral Acquisition 1.9 s, 25.7 cm; CTDIvol = 12.7 mGy (Body) DLP = 326.0
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 1.8 s, 0.5 cm; CTDIvol = 9.9 mGy (Body) DLP = 5.0
mGy-cm.
Total DLP (Body) = 441 mGy-cm.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
HEART AND VESSELS: The examination has not been timed for optimal evaluation
of the pulmonary arterial system. The aorta and visualized aortic branches
are patent. The ascending thoracic aorta measures 2.4 cm. The descending
thoracic aorta measures 2.0 cm. No dissection flap is identified.
Right-sided central venous catheter in situ with tip at the level of the
cavoatrial junction.
LUNGS AND AIRWAYS: There is right lower lobe airspace consolidation. Mild
bibasilar atelectasis. There is an endotracheal tube in situ.
PLEURA/PERICARDIUM: Trace bilateral pleural effusions. No pericardial
effusion.
MEDIASTINUM: No hilar or mediastinal adenopathy.
ESOPHAGUS AND NECK: Enteric tube in situ.
BONES AND SOFT TISSUES: No suspicious osseous lesion.
UPPER ABDOMEN: Limited evaluation is unremarkable.
IMPRESSION:
1. No thoracic aortic aneurysm.
2. Right lower lobe airspace consolidation consistent with lobar pneumonia.
Aspiration would be a differential consideration, in the appropriate clinical
setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with ETT*** WARNING *** Multiple patients with same
last name!// ETT placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
Endotracheal tube terminates approximately 3.6 cm above the carina. No focal
consolidation is seen. The patient is rotated somewhat to the left, but there
appears to be prominence of the left paratracheal soft tissue, unclear whether
related to lymphadenopathy or possibly a dilated aortic arch vs. In part
related patient positioning. No prior available for comparison. Suggest
repeat with better patient positioning and comparison with any prior studies.
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
Cardiac silhouette size is borderline.
IMPRESSION:
Endotracheal tube terminates 3.6 cm above the carina.
Patient is rotated somewhat to the left, but there appears to be prominence of
the left paratracheal soft tissue, unclear whether related to lymphadenopathy
or possibly a dilated aortic arch vs. In part related patient positioning. No
prior available for comparison. Suggest repeat with better patient
positioning and comparison with any prior studies. If finding persists without
clear etiology, chest CT would further assess.
Radiology Report
INDICATION: ___ year old man with SAH// Remains intubated, please evaluate
lung fields
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
There is a new consolidative opacity in the right midlung and right lower
lobe. Cardiomediastinal silhouette is stable. The ET and NG tube are
unchanged. Right IJ line is also unchanged. Small left pleural effusion
stable. No pneumothorax is seen
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old man with SAH// R pupil bigger than L pupil, please
eval for change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: ___
COMPARISON: CT head ___ and ___
FINDINGS:
S/p right SCA coiling. Extensive streak artifact from the embolization
material limits evaluation of the mid brain region. Within this limitation,
extensive subarachnoid hemorrhage, predominantly at the right
perimesencephalic, prepontine, suprasellar, and right sylvian cisterns is
grossly unchanged. Blood along the right tentorium and interhemispheric
fissure is also similar.
Intraparenchymal hemorrhage in the right pontine region and cerebellar vermis
with mild surrounding edema appears grossly similar. The fourth ventricle
remains nearly completely opacified with blood products. Tonsillar herniation
with the cerebellar tonsils extending to C1 is grossly unchanged.
A right ventriculostomy catheter terminates in the frontal horn of the right
lateral ventricle, unchanged in position. Unchanged mild pericatheter edema
and hemorrhage. Unchanged appearance of the ventricular system with partial
effacement of the right lateral ventricle. Diffuse cerebral edema, similar.
No midline shift. No definite uncal herniation, although streak artifact
limits evaluation of the right midbrain region. Hemorrhagic density in the
right ambient cistern, however, is slightly more narrow than the prior study
which may suggest possible right uncal herniation. The left ambient cistern
remains distinct.
Previous edema involving the anterior right temporal lobe is suboptimally
evaluated due to streak artifact. No evidence of new infarction.
IMPRESSION:
1. S/p right superior cerebellar artery embolization limiting evaluation of
the right brainstem.
2. No definite mass effect/herniation. Grossly stable large volume
subarachnoid hemorrhage and intraparenchymal pontine/cerebellar hemorrhage.
3. Stable posterior fossa mass effect and cerebellar tonsillar herniation.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ year old man with high grade SAH s/p SCA aneurysm coil with
hydro and EVD, EVD stopped draining, assess for increase in bleed, hydro, and
CTA for vasospasm// NCHCT--assess SAH, assess hydro as EVD stopped draining;
CTA assess for vasospasm
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of Omnipaque350 intravenous contrast
material. Three-dimensional angiographic volume rendered and segmented images
were then generated on a dedicated workstation. This report is based on
interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7
mGy-cm.
3) Stationary Acquisition 1.0 s, 1.0 cm; CTDIvol = 7.5 mGy (Head) DLP = 7.5
mGy-cm.
4) Spiral Acquisition 5.5 s, 21.1 cm; CTDIvol = 29.8 mGy (Head) DLP = 580.3
mGy-cm.
Total DLP (Head) = 1,444 mGy-cm.
COMPARISON: CT head ___, CTA of ___.
Catheter angiogram ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is interval expansion of the body of the right and left lateral
ventricles. The right lateral ventricle remains smaller than the left. The
temporal horns are also expanded within the interval. The tip of the right
frontal ventriculostomy catheter remains near the foramina of ___.
There is expected interval evolution of the diffuse subarachnoid hemorrhage
and intraparenchymal hemorrhage within the right dorsal pons and superior
cerebellar vermis. Low-attenuation the within right lateral brainstem and
cerebellar hemispheres is conspicuous and worrisome for infarction.
The posterior fossa cisterns remain effaced. There is no ascending
transtentorial or inferior cerebellar herniation.
The gaze is dysconjugate. There is fluid throughout the paranasal sinuses and
within the right middle ear cavity and mastoid.
CTA
No large vessel occlusion is identified.
There are extensive extracranial and intracranial arterial dissections.
There are areas of moderate to severe diffusely throughout the vessels of the
circle ___ and ___ branches, most consistent with vasospasm superimposed
on known intracranial arterial dissections. For example, this is prominently
noted along the bilateral A1 segments, bilateral proximal M2 and P1 segments
and right V4 segment.
The distal basilar artery and right posterior cerebral artery are very
difficult to evaluate due to artifact related to the right SCA aneurysm clip.
The fusiform aneurysm of the proximal right superior cerebellar artery appears
similar to the prior catheter angiogram.
IMPRESSION:
1. Interval expansion/hydrocephalus of the lateral ventricles from the most
recent portable head CT acquired on ___.
2. There is infarction of the right greater than left cerebellar hemispheres
and likely brainstem. Degree of infarction is difficult to assess without
MRI.
3. Interval evolution of the diffuse subarachnoid hemorrhage and parenchymal
hemorrhage within the right dorsal lateral pons and superior cerebellar
vermis.
4. No emergent large vessel occlusion is identified.
5. Diffuse vasospasm, moderate to severe, superimposed on extensive
intracranial arterial dissections as previously identified. The degree of
vasospasm appears worse from the ___ diagnostic catheter angiogram
and CTA of ___.
6. Additional findings described above.
NOTIFICATION: The findings were discussed with NP ___, by ___,
M.D. on the telephone on ___ at 5:30 pm, 10 minutes after discovery of
the findings.
Radiology Report
INDICATION: ___ year old man with SAH// Assess ETT position and for pulmonary
congestion or pneumonia
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Asymmetric pulmonary edema on the right is unchanged. Cardiomediastinal
silhouette is stable. The ET tube and NG tube are unchanged. There is no
pleural effusion. No pneumothorax is seen
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ year old man with SAH// eval for hydro and infarcts and for
evolving hemorrhage
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 2.5 s, 19.6 cm; CTDIvol = 27.6 mGy (Head) DLP = 539.8
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.8
mGy-cm.
4) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 39.7 mGy (Body) DLP =
19.9 mGy-cm.
Total DLP (Body) = 23 mGy-cm.
Total DLP (Head) = 1,287 mGy-cm.
COMPARISON: CTA head and neck of ___, cerebral
angiogram of ___, portable head CT of ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Continued MR prominent hypodensity of the left greater than right cerebellar
hemispheres and brainstem compatible with acute infarct, slightly more
conspicuous when compared to examination of ___. Aneurysm clip in
the left prepontine cistern results in significant streak artifact, obscuring
adjacent structures. There is effacement of the fourth ventricle and
aqueduct. There is crowding of the foramen magnum, similar to prior exam
without frank tonsillar herniation. When compared to the prior exam, interval
resolution of developing hydrocephalus. Continued expected evolution of multi
compartment hemorrhage, overall similar to prior examination.
Right trans frontal ventriculostomy tract with tip term inferior to the
foramen ___ is unchanged. Hypodensity along the ventriculostomy tract is
unchanged. No evidence of new intracranial hemorrhage within confines of
technique and artifact. No other large territory infarcts identified.
Aerosolized mild mucosal thickening of the left maxillary sinus is noted.
Mild mucosal thickening of the right maxillary sinus. Partial opacification
of the ethmoid air cells with near complete opacification of the sphenoid
sinus. Mucosal thickening of the inferior frontal sinuses noted. The orbits
are unremarkable. Partial opacification of the right mastoid air cells and
middle ear is identified. No acute osseous abnormality.
CTA HEAD:
Previously described extracranial intracranial arterial dissections are
re-identified.
Multifocal diffuse regions of moderate to severe narrowing/stenosis throughout
the circle ___, again prominently involving the bilateral A1 segments,
bilateral proximal M2 and P1 segments, right V4 segment and is overall similar
to prior examination.
There is suggestion of increased beading along the distal MCA and PCA
branches, which does raise concern for increasing vasospasm although this
could be artifactual.
IMPRESSION:
1. Interval improvement in degree of hydrocephalus seen on examination of ___ at 09:00.
2. Unchanged appearance of multi compartment intracranial hemorrhage.
Hemorrhage in the pons is overall similar.
3. There is effacement of the fourth ventricle and cerebral aqueduct as well
as the foramen magnum without overt tonsillar herniation.
4. Continued evolution with slightly increased prominence of bilateral
cerebellar hemisphere and brainstem infarcts. No definite hemorrhagic
transformation. Otherwise, no significant interval change on noncontrast head
CT.
5. Re-identified is extensive extracranial intracranial arterial dissections
and diffuse vasospasm. There may be minimally increased beading of the distal
MCA branches, which may represent worsening vasospasm versus artifact.
6. Additional findings described above.
NOTIFICATION: The findings were discussed by Dr. ___ with
Dr. ___ on the telephoneon ___ at 10:00 pm, 1 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man intubated, pna// assess progression of pna
COMPARISON: Radiographs from ___
IMPRESSION:
Support lines and tubes are unchanged in position. Heart size is upper limits
of normal. There remains opacities in the right lung suggestive of asymmetric
pulmonary edema versus consolidation. Worsening opacity at the right base has
developed since prior. There is a left retrocardiac opacity which is also
worse. There are no pneumothoraces.
Radiology Report
INDICATION: ___ year old man with ET tube, interval change// interval change
COMPARISON: Radiographs from ___
IMPRESSION:
Endotracheal tube, enteric tube, right IJ central line are unchanged in
position. Right axillary catheter is again seen and may represent a midline.
Cardiomediastinal silhouette is within normal limits. There has been
improvement of the airspace opacities and pulmonary edema since the previous
study. There are no pneumothoraces.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ yo man HA ___ NCHCT negative d/c from OSH found unresponsive
___ OSH NCHCT Perimesencephalic SAH + pontine IPH, now s/p EVD. Tract
hematoma s/p EVD.// assess for new hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT scan ___
FINDINGS:
Diffuse subarachnoid hemorrhage and right pontine hemorrhage appears slightly
decreased in severity when compared to the previous examination. Hypodensity
within the cerebellar hemispheres and right lateral brainstem appear somewhat
more well-defined. There is a right frontal ventriculostomy catheter,
unchanged in position with a slit-like right lateral ventricle.
Mucosal thickening is seen within the paranasal sinuses, with air-fluid levels
within the maxillary sinuses bilaterally. There is opacification of the
majority of the right mastoid air cells. A right-sided aneurysm clip is
re-demonstrated.
IMPRESSION:
1. Slight decrease in severity diffuse subarachnoid hemorrhage in right
pontine hemorrhage. Hypodensity within the cerebral hemispheres and right
lateral brainstem appears somewhat more well-defined compared to the previous
study.
2. Paranasal sinus mucosal thickening.
Air-fluid levels are seen within the maxillary sinuses.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETT, eval for interval change// eval for
interval change eval for interval change
IMPRESSION:
Compared to chest radiographs ___ through ___ one.
Mediastinal vasculature is engorged and mild pulmonary edema is new. Heart
size top-normal unchanged. Pleural effusions small if any. No pneumothorax.
Esophageal drainage tube is looped in the hypopharynx and passes into the
stomach and out of view. Should be repositioned.
ET tube is in standard placement. Intended esophageal probe is still lodged
in the left perform sinus.
Right jugular line ends in the low SVC.
NOTIFICATION: The findings were discussed with neuro critical care nurse
practitioner ___ by ___, M.D. on the telephone on ___ at 9:54
am, 3 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with brain bleed*** WARNING *** Multiple patients
with same last name!// Aneurysm, 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 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 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 5.0 s, 39.7 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,231.4 mGy-cm.
Total DLP (Head) = 2,056 mGy-cm.
COMPARISON: Reference CT head ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Extensive subarachnoid hemorrhage throughout the basal cisterns with global
partial effacement of the sulci due to mass effect, but no significant
subfalcine or transtentorial herniation. No definite large territorial
infarct. There is moderate intraventricular hemorrhage layering in the
bilateral occipital horns (02:14, 13). Extensive heterogeneous
intraventricular density in the fourth ventricle may represent hemorrhage or
clot (2:11). No clear hydrocephalus.
Hypodensity with superimposed hyperdensity in the right aspect of the
pontomidbrain junction (02:11) may represent intraparenchymal hemorrhage,
although hemorrhage due to tumor or vascular malformation cannot be excluded.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is saccular aneurysmal dilatation of the right superior cerebellar
artery (3:248) as well as elongated fusiform dilatation of the distal segment
(3;240). The remaining vessels of the circle of ___ and their principal
intracranial branches appear grossly normal without stenosis, occlusion, or
aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
Multiple dissections and pseudoaneurysms seen throughout the extracranial
bilateral carotid and vertebral arteries.
The distal right ICA exhibits a double-lumen with intimal flap just proximal
to the right carotid foramen (3:218) as well as a small pseudoaneurysm just
proximal to the former (3:210). Another dissection flap is seen within the
right ICA at the C2-C3 level (3:177) with focal luminal narrowing between the
dissections (3:198). By NASCET criteria, this focal narrowing measures 33%
stenosis, but is difficult to assess in the setting of multiple vascular
abnormalities. The proximal ICA and carotid bifurcation are not significantly
stenosed by NASCET criteria.
A pseudoaneurysm is also seen within the left ICA at the C1-C2 level (3:194).
There is no evidence of left internal carotid artery stenosis by NASCET
criteria.
Focal dissections are seen in the right vertebral artery within the C2
transverse foramen (3:183), C3 transverse foramina (3:172), and C5 vertebral
level. The vessel is severely stenotic at the C5 level and moderately
stenotic at the other levels. A small pseudoaneurysm is seen in the vertebral
artery at the C5 level (3:153).
Focal dissections are also seen in the left vertebral artery at the C4-C5
levels (3:162 and 170) and C6-7 levels (3:128) with mild-to-moderate stenosis
at the each.
OTHER:
The visualized portion of the lungs are clear. There is no lymphadenopathy by
CT size criteria. A 1.2 cm hypoenhancing lesion in the inferior left thyroid
lobe (3:92) and 1.1 cm hypoenhancing lesion in the superior right thyroid lobe
(3:86) are difficult to assess due to overlying streak artifact.
IMPRESSION:
-Extensive subarachnoid hemorrhage throughout the basal cisterns with global
partial effacement of the sulci due to mass effect, but no significant
subfalcine or transtentorial herniation. No definite large territorial
infarct.
-Moderate intraventricular hemorrhage layering in the bilateral occipital
horns.
-Extensive heterogeneous intraventricular density in the fourth ventricle may
represent hemorrhage or clot. No clear hydrocephalus.
-Hypodense region with superimposed hyperdensity in the right aspect of the
pontomi___ junction may represent intraparenchymal hemorrhage, although
hemorrhage due to tumor or vascular malformation cannot be excluded.
-Aneurysmal dilatation of the right superior cerebellar artery.
-Multiple focal dissections and pseudoaneurysms throughout the extracranial
bilateral carotid and vertebral arteries may suggest underlying chronic
connective tissue disease or fibromuscular dysplasia.
RECOMMENDATION(S): MR is recommended for further evaluation of midbrain
lesion. Interventional neuroradiology consult is recommended for better
evaluation of the intracranial vasculature.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD.
INDICATION: ___ year old man with diffuse SAH, vasospasm, now with acute ICP
elevation, eval for interval change// eval for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: ___ head CT without IV contrast
FINDINGS:
Diffuse subarachnoid hemorrhage and right pontine hemorrhage are
re-demonstrated and unchanged since yesterday. Bilateral cerebellar
hemispheric and brainstem hypodensities are again noted and appear grossly
similar to the most recent prior study. The right frontal approach
ventriculostomy catheter tip continues to terminate at ___. The
right-sided aneurysm clip is again noted in stable position. Within
limitations of the study there is no evidence of new foci of intra-axial
hemorrhage. There is no midline shift. The ventricles and sulci are normal
in size and configuration.
Near-complete soft tissue opacification the sphenoid sinuses, ethmoid air
cells and mastoid air cells are similar to prior. There is mild-to-moderate
mucosal thickening of the left greater right maxillary sinus. The middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. When compared to the most recent prior ___ head CT without
contrast, there is no significant interval change in severity of the diffuse
subarachnoid hemorrhage and right pontine hemorrhage.
2. Stable appearance of the cerebellar hemispheric and brainstem
hypodensities.
3. The right frontal approach ventriculostomy catheter tip continues to
terminate at ___.
4. Unchanged paranasal sinuses disease as described above.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ man presenting with sudden onset headache, subarachnoid
hemorrhage s/p EVD ___, with multiple intra extracranial arterial
pseudoaneurysms/dissections, now with fever, MSSA bacteremia (___), and
MRSA/proteus pneumonia scratch. Evaluate for vasospasm, attempting to taper
off milrinone.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 2.5 s, 19.3 cm; CTDIvol = 27.6 mGy (Head) DLP = 534.2
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.8
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.8
mGy-cm.
5) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 28.4 mGy (Body) DLP =
14.2 mGy-cm.
Total DLP (Body) = 20 mGy-cm.
Total DLP (Head) = 1,282 mGy-cm.
COMPARISON: CT brain done ___ at 18:12
CTA brain done ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Position of the right frontal approach EVD is unchanged with its tip in the
frontal horn of the right lateral ventricle in the region of the foramen of
___. Unchanged effacement of the right lateral ventricle. Vascular coils
in the area of the previously noted right superior cerebellar artery
pseudoaneurysm, with associated beam hardening artifact limiting evaluation at
adjacent levels. Otherwise, no evidence for new hemorrhage or edema.
Hemorrhage within the pons and superior cerebellar vermis with surrounding
vasogenic edema extending into the midbrain and bilateral cerebellar
hemispheres appear fairly similar compared to prior imaging. Subarachnoid
hemorrhage demonstrates expected evolution. There is crowding of the foramen
magnum, but there is still CSF space present in the anterior aspect of the
foramina magnum. Mild right uncal herniation is unchanged. No subfalcine
herniation.
Near complete opacification of the sphenoid sinuses, moderate to severe
opacification of the ethmoid air cells and frontoethmoidal recesses, mild to
moderate mucosal thickening in the frontal sinuses, and moderate mucosal
thickening in the maxillary sinuses are similar to the head CT from 3 hours
earlier on ___. Nasogastric and endotracheal tubes are partially
visualized.
CTA HEAD:
Vascular clip in the area of the previously noted relatively distal right
superior cerebellar artery pseudoaneurysm results in beam hardening artifact
and makes evaluation of this area difficult. Small persistent ectatic
area/pseudoaneurysm of the more proximal right SCA appears similar compared to
prior (series 3, image 66 and series 601, image 23). There is severe
persistent vasospasm of the right PCA. Moderate left PCA distal basilar
artery vasospasm appears fairly similar compared to prior. There is increased
moderate vasospasm of the right supraclinoid ICA, increased severe vasospasm
of bilateral MCAs, and increased moderate to severe vasospasm of bilateral ACA
compared to ___. The dural venous sinuses are patent.
Right distal ICA pseudoaneurysm is again noted, images 3:33, 310:38.
IMPRESSION:
1. No evidence for new intracranial abnormalities. Unchanged pontine/superior
cerebellar vermis hemorrhage with vasogenic edema extending into the midbrain
and bilateral cerebellar hemispheres. Expected evolution of subarachnoid
hemorrhage. Stable size and configuration of the ventricles with stable
position of the EVD catheter.
2. Increased moderate vasospasm of the right supraclinoid ICA, increased
severe vasospasm bilateral MCAs, and increased moderate to severe vasospasm of
bilateral ACAS compared to ___.
3. Severe right PCA vasospasm, moderate left PCA vasospasm, and moderate
distal basilar vasospasm are not significantly changed compared to ___.
4. Unchanged small ectasia/pseudoaneurysm of the proximal right superior
cerebellar artery.
5. Unchanged right distal ICA pseudoaneurysm.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ m stenting a sudden onset headache, ___ status post EVD ___,
with multiple intra extracranial arterial pseudoaneurysms/dissections, now w
fever, MSSA bacteremia (___), and MRSA/proteus pneumonia.// PORTABLE HCT.
Significant tachycardia with increased ICP minimally responsive to 3% saline.
Concern for herniation.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP: 1414.60 mGy-cm
COMPARISON: Noncontrast head CT ___ and ___
FINDINGS:
There is a right frontal approach ventriculostomy catheter terminating near
the foramen of ___, overall similar in position compared to ___.
Hypodensity surrounding the catheter in the right frontal lobe likely
represents encephalomalacia (01:25). There is extensive streak artifact from
the right superior cerebellar artery coil embolization, which limits
evaluation of surrounding structures. Within this limitation, there is no
evidence of an acute major vascular territory infarction or new hemorrhage.
Interval evolution of diffuse subarachnoid hemorrhage and right pontine
hemorrhage. Extensive hypodensities in the bilateral cerebellar hemispheres
is unchanged, and may represent encephalomalacia.
There is no evidence of an acute fracture appearing in moderate mucosal
thickening throughout the imaged paranasal sinuses, most pronounced in the
sphenoid sinuses. Right greater than left opacification of the mastoid air
cells. Orbits are within normal limits. Endotracheal and nasogastric tubes
are partially imaged.
IMPRESSION:
Evolving subarachnoid and right pontine hemorrhage, without significant
interval change compared to ___. No new hemorrhage. Streak artifact
from right superior cerebellar artery coil embolization limits evaluation of
surrounding structures.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SAH// Assess ETT position and for any
pulmonary congestion Assess ETT position and for any pulmonary congestion
IMPRESSION:
Compared to chest radiographs ___ through ___.
Nasogastric drainage tube passes into the stomach and out of view but is still
looped in the hypopharynx as noted in the reported yesterday's chest
radiograph. Also noted is the probable errant positioning of the intended
esophageal probe, probably in the left perform sinus. ET tube is in standard
placement. Right jugular line ends in the low SVC and a peripheral vascular
line ends in the right axilla.
Heart size top-normal. Asymmetric radiodensity, greater in the left
hemithorax is probably due to a posteriorly layering pleural effusion and
persistent left lower lobe atelectasis. Right lung is clear. There is no
pulmonary edema or pneumothorax.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ year old man with subarachnoid hemorrhage. Assess for
vasospasm, increased Milrinone.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7
mGy-cm.
3) Stationary Acquisition 1.5 s, 1.0 cm; CTDIvol = 11.2 mGy (Head) DLP =
11.2 mGy-cm.
4) Spiral Acquisition 5.5 s, 21.2 cm; CTDIvol = 27.7 mGy (Head) DLP = 542.7
mGy-cm.
Total DLP (Head) = 1,414 mGy-cm.
COMPARISON: ___ head CTA.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Allowing for streak artifact from the coils in the distal right superior
cerebellar artery aneurysm, there is no change in the appearance of the
intracranial compartment compared to 1 day earlier. Specifically, no evidence
for new hemorrhage or edema. Pontine/superior cerebellar vermis hemorrhage is
again demonstrated, with surrounding vasogenic edema extending into the
midbrain and bilateral cerebellar hemispheres. Small amount of subarachnoid
hemorrhage persists. Right EVD catheter terminates in the right lateral
ventricle near the foramina of ___. Unchanged effacement of the right
lateral ventricle except for the temporal horn. Unchanged small size of the
left lateral, third, and fourth ventricles, with unchanged configuration.
Unchanged partial effacement of the basal cisterns.
Near complete opacification of the sphenoid sinuses is unchanged. Moderate
opacification of the ethmoid air cells has slightly improved compared to 1 day
earlier. There is persistent occlusion of the frontoethmoidal recesses, and
persistent mild-to-moderate mucosal thickening in the frontal sinuses.
Moderate mucosal thickening is again seen in the maxillary sinuses, with new
aerosolized secretions on the left. Nasogastric and endotracheal tubes are
again partially visualized.
CTA HEAD:
Streak artifact from the coil pack in the region of the distal right superior
cerebellar artery limits evaluation of adjacent structures. Ectasia versus
pseudoaneurysm of the proximal right superior cerebellar artery on image 10:89
is unchanged. Severe narrowing of the right PCA and moderate narrowing of the
distal basilar artery are unchanged. Left PCA is mildly narrowed proximally,
and severely narrowed distally, yet the distal caliber is improved compared to
1 day earlier.
Supraclinoid right ICA is better seen on the ___ study where it was
more affected by streak artifact. It appears increased in caliber, now only
mildly narrowed. Moderate narrowing of bilateral middle cerebral and moderate
to severe narrowing of bilateral anterior cerebral arteries appears slightly
improved.
Pseudoaneurysm of the distal cervical right ICA is again visualized, images
10:48 and ___. Pseudoaneurysm of the distal cervical left ICA is also
again noted, images 10:23 and ___.
IMPRESSION:
1. Unchanged appearance of the intracranial compartment compared to 1 day
earlier. No evidence for new hemorrhage or new edema. Stable size and
configuration of the ventricles, with stable position of the EVD catheter.
2. Severe narrowing of the distal left PCA slightly improved compared to 1 day
earlier on ___. Severe narrowing of the right PCA and moderate
narrowing of the distal basilar artery are unchanged.
3. Mild vasospasm of the supraclinoid right ICA, improved compared to ___. Moderate narrowing of bilateral middle cerebral and moderate to severe
narrowing of bilateral anterior cerebral arteries appears slightly improved.
4. Bilateral distal cervical ICA pseudoaneurysms are again noted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SAH// Remains intubated, please evaluate
lung fields
IMPRESSION:
IN COMPARISON WITH THE STUDY OF ___, THE MONITORING AND SUPPORT DEVICES
ARE UNCHANGED. CARDIOMEDIASTINAL SILHOUETTE IS STABLE AND THERE IS NO
EVIDENCE OF APPRECIABLE VASCULAR CONGESTION OR ACUTE PNEUMONIA.
RETROCARDIAC OPACIFICATION IS CONSISTENT WITH VOLUME LOSS IN THE LEFT LOWER
LOBE.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SAH// Evaluate ETT position, any pulmonary
congestion or signs of pneumonia Evaluate ETT position, any pulmonary
congestion or signs of pneumonia
IMPRESSION:
Comparison to ___. The tip of the endotracheal tube projects 5 cm
above the carina. No complications. The other monitoring and support devices
are in correct position. Stable retrocardiac atelectasis. Stable appearance
of the lung parenchyma and the cardiac silhouette.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ sudden onset headache, ___ s/p EVD ___, w/ multiple intra
extracranial arterial pseudoaneurysms/dissections, now w/ fever, MSSA
bacteremia (___), and MRSA/proteus pneumonia.// s/p SAH w/ EVD. Evaluation
for strokes, with additional concern for CNS infection.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CTA head done ___
FINDINGS:
Again seen is hmeorrhage in the right midbrain, pons as well as cerebellar
vermis in keeping with blood products. Blood products also noted in the
right quadrigeminal plate, ambient cistern, suprasellar cistern as well as in
the superior cerebellar cistern, reflecting superfical siderosis.
Blood products in relation to the right frontal approach ventriculostomy
catheter. 4 mm subdural hematoma in relation to the right parietal occipital
and inferior temporal areas. 3 mm almost circumferential right cerebellar
subdural hematoma. Small 1-2 mm para falx hematoma.
There are multiple areas of infarction in the superior cerebellar hemispheres
with associated gyriform enhancement in the distribution of bilateral superior
cerebellar arteries.
Mild moderate crowding of the foramen magnum. Right frontal approach
ventriculostomy catheter in situ with an unchanged collapsed state of the
right lateral ventricle. Moderate mucosal thickening involving the paranasal
sinuses. Opacification of the mastoid air cells may be secondary to
nasopharyngeal intubation. The orbits appear normal. The intracranial
arteries demonstrate normal T2 flow void. Diminutive appearance of the right
V4 artery.
IMPRESSION:
Intraparenchymal right pontine, right midbrain as well as cerebellar vermian
hemorrhage with associated surrounding subarachnoid blood as described above
which appears fairly similar compared to most recent CT.
Right supra and infratentorial subdural hematomas as described above.
Multiple bilateral superior cerebellar hemispheric acute infarcts in the
distribution of the superior cerebellar arteries bilateral as described above.
Moderate crowding of the foramen magnum.
Right frontal approach ventriculostomy catheter in-situ with an unchanged
collapsed state of the right lateral ventricle.
Moderate mucosal thickening involving the paranasal sinuses. Opacification of
the mastoid air cells may be secondary to nasopharyngeal intervention
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ m p/w sudden onset headache, SAH s/p EVD
___, w multiple intra extracranial arterial pseudoaneurysms/dissections,
now w/ fever, MSSA bacteremia (___), and MRSA/proteus pneumonia.// assess for
PNA
COMPARISON: Multiple prior chest radiographs ___ through ___
FINDINGS:
Portal semiupright AP view of the chest provided.
Partially visualized tip of an endotracheal tube terminates at the level of
thoracic inlet, approximately 7.2 cm above the level of carina. Esophageal
temperature probe terminates in mid thoracic esophagus. An enteric tube
terminates in expected location the stomach. A right internal jugular line
terminates at the cavoatrial junction. Surgical clips are noted in the right
upper quadrant of the abdomen.
Persistent left basilar atelectasis. No large pleural effusion or
pneumothorax. Cardiomediastinal silhouette is not significantly changed
compared to prior with tortuosity of the aorta noted.
IMPRESSION:
-Lines and tubes as above. Endotracheal tube terminates just below the
thoracic inlet, approximately 7 cm of the carina. Consider advancing.
-Mild left basilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ m p/w sudden onset headache, SAH s/p EVD ___, w multiple
intra extracranial arterial pseudoaneurysms/dissections, now w/ fever, MSSA
bacteremia (___), and MRSA/proteus pneumonia.// assess pneumonia assess
pneumonia
IMPRESSION:
ET tube tip is 5 cm above the carinal. NG tube tip is in the stomach. Right
internal jugular line tip is at the level of mid SVC. Heart size and
mediastinum are stable. Left opacity appears to be minimally improved as
compared to previous examination, still concerning for atelectasis and
pneumonia combination
Right mid line tip is in expected location. No pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with s/p EVD*** WARNING *** Multiple patients with
same last name!// eval for interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from the same date
FINDINGS:
There has been interval placement of a right frontal intraventricular shunt
which terminates in the frontal horn of the right lateral ventricle. New
right frontal subarachnoid hemorrhage at the site of shunt placement, is
likely postoperative.
Intraparenchymal hemorrhage centered in the right posterior pons extends into
and fills the basilar cisterns similar to the prior examination. Hemorrhage
extends into the fourth ventricle and lateral ventricles, bilaterally.
Hemorrhage in the dependent left lateral ventricle appears minimally increased
in comparison the prior examination.
Prominence of the temporal horns of the lateral ventricles, is unchanged, but
could represent early mild hydrocephalus. Appearance of the ventricles is
stable.
Bilateral temporal subarachnoid hemorrhage is unchanged in extent.
IMPRESSION:
1. interval placement of a right frontal intraventricular shunt which
terminates in the frontal horn of the right lateral ventricle. Possible early
mild hydrocephalus, unchanged from prior study. Pontine intraparenchymal
hemorrhage with extensive perimesencephalic subarachnoid hemorrhage, unchanged
in extent. No significant midline shift or large territorial infarction.
2. New right frontal subarachnoid hemorrhage likely represents sequela of
shunt placement.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with new line// new left PICC 47 cm ___ ___
Contact name: ___: ___ new left PICC 47 cm ___ ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left PIC line ends in the mid SVC. ET tube and right jugular line unchanged
in standard positions, and nasogastric drainage tube passes into the stomach
and out of view.
Right lung clear. Left infrahilar atelectasis is improving. No pleural
abnormality. Heart size normal.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ m p/w sudden onset headache, SAH s/p EVD ___, w multiple
intra extracranial arterial pseudoaneurysms/dissections, now w/ fever, MSSA
bacteremia (___), and MRSA/proteus pneumonia.// Worsening exam, concern for
worsened vasospasm
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 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: Total DLP (Body) = 11 mGy-cm.
Total DLP (Head) = 1,315 mGy-cm.
COMPARISON: MR head from ___ and CTA head and neck from ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is re-demonstration of a pontine/superior cerebellar vermis hemorrhage
with surrounding vasogenic edema extending into the midbrain in bilateral
cerebellar hemispheres, not substantially changed from prior study. There is
been interval improvement of posterior subarachnoid hemorrhage though a small
amount persists. Right frontal approach EVD catheter terminates in the right
lateral ventricle near the foramen of ___, unchanged in position from prior
study. There has been interval increase in the size of the bilateral lateral
ventricles and temporal horns though no ventriculomegaly is identified in the
fourth ventricle remains unchanged. There is no new intracranial bleed
identified.
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:
Streak artifact limits assessment in the distal right superior cerebellar
artery and adjacent structures. Within these limitations there is
demonstration of distal right vertebral artery narrowing that is new when
compared to the prior study and suggestive of vasospasm. The distal left
vertebral artery is similar in appearance to prior. The bilateral PCAs and
distal basilar arteries are unchanged in appearance from prior. The bilateral
middle cerebral arteries and supraclinoid internal carotid arteries appear
normal. Dissection of the distal cervical right ICA and distal cervical left
ICA is re-demonstrated on this study and similar in appearance to prior. The
remaining vessels of the circle of ___ and their principal intracranial
branches appear normal without stenosis, occlusion or aneurysm formation. The
dural venous sinuses are patent.
IMPRESSION:
1. Interval narrowing of the distal right vertebral artery suggestive of
vasospasm with no additional focal areas of vasospasm identified.
2. Unchanged appearance of bilateral distal cervical ICA dissection.
3. Re-demonstrated bilateral superior cerebellar infarcts similar in
appearance to MR head of ___.
4. No acute infarct or new hemorrhage identified.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ year old man with SAH// Acute change in exam, concern for
vasospasm
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Total DLP (Body) = 6 mGy-cm.
Total DLP (Head) = 1,265 mGy-cm.
COMPARISON: CTA head from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is re-demonstration of a pontine/superior cerebellar vermis hemorrhage
with surrounding vasogenic edema extending into the midbrain in bilateral
cerebellar hemispheres, not substantially changed from prior study. There
re-demonstrated mild posterior subarachnoid hemorrhage. Right frontal
approach EVD catheter terminates in the right lateral ventricle near the
foramen of ___, unchanged in position. The ventricles and sulci are stable
in size and appearance. There is no new intracranial bleed identified.
There is mild left maxillary and ethmoidal air cell mucosal thickening as well
as opacification of the right sphenoid sinus and partial opacification left
sphenoid sinus. The remaining visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized portion of the orbits
are unremarkable.
CTA HEAD:
Streak artifact limits assessment in the distal right superior cerebellar
artery and adjacent structures. Within these limitations there is
re-demonstrated distal right vertebral artery narrowing similar to prior study
and suggestive of vasospasm. The distal left vertebral artery is similar in
appearance to prior. The bilateral PCAs and distal basilar arteries are
unchanged in appearance from prior. The bilateral middle cerebral arteries
and supraclinoid internal carotid arteries appear normal. Dissection of the
distal cervical right ICA and distal cervical left ICA is re-demonstrated on
this study and similar in appearance to prior. The remaining vessels of the
circle of ___ and their principal intracranial branches appear normal
without stenosis, occlusion or aneurysm formation. The dural venous sinuses
are patent.
IMPRESSION:
1. No significant change from prior study with re-demonstrated narrowing of
the distal right vertebral artery suggestive of vasospasm with no additional
focal areas of vasospasm identified.
2. Unchanged appearance of bilateral distal cervical ICA dissection.
3. Re-demonstrated bilateral superior cerebellar infarcts similar in
appearance to MR head of ___.
4. No acute infarct or new hemorrhage identified.
RECOMMENDATION(S): MR/MRA brain could be considered as clinically indicated
to assess for further vascular changes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SAH s/p coiling c/b vasospasm// please
assess for PNA please assess for PNA
IMPRESSION:
ET tube tip is 4 cm above the carinal. NG tube tip is in the stomach. Left
PICC line tip is at the level of cavoatrial junction. Heart size and
mediastinum are stable. Left retrocardiac atelectasis has increased
concerning for progression of infection. Right lung is clear. There is no
pneumothorax.
Radiology Report
INDICATION: ___ year old man with SAH// Fever work up
TECHNIQUE: Chest portable AP
COMPARISON: ___
FINDINGS:
Further increase to the left retrocardiac opacity. The rest of the lung
fields are clear. No pneumothorax. Tracheostomy tube in place as previously.
Left PICC line terminates in the cavoatrial juncture.
IMPRESSION:
Increased left retrocardiac opacity.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ m p/w sudden onset headache, SAH s/p EVD ___, w multiple
intra extracranial arterial pseudoaneurysms/dissections.// Worsened exam,
concern for vasospasm. Now off milrinone and EVD raised to 15 overnight.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 2.5 s, 19.8 cm; CTDIvol = 27.6 mGy (Head) DLP = 545.3
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.8
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.8
mGy-cm.
Total DLP (Body) = 6 mGy-cm.
Total DLP (Head) = 1,293 mGy-cm.
COMPARISON: CTA head ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Mild dilatation of the fourth, third and lateral ventricles is moderately
increased in comparison to ___. A right frontal ventriculostomy
catheter terminates in the region of the foramen of ___, unchanged.
Bilateral superior cerebellar and right posterolateral pontine infarcts are
unchanged from ___. No new focus of infarct.
Mild crowding the brainstem by the cerebellar tonsils at the foramen magnum,
appears mildly improved.
Trace hemorrhage in the dependent portion of the lateral ventricles is
significantly decreased.
Beam hardening artifact adjacent to the right pons limits assessment. There
is likely residual hemorrhage in the suprasellar, prepontine, ambient and
quadrigeminal cisterns, reflecting expected evolution.
Trace left frontotemporal subarachnoid hemorrhage and right temporal
subarachnoid hemorrhage (series 2, image 16, 19) is significantly improved.
There is a trace right occipital low-density subdural hematoma, significantly
improved in comparison to multiple prior studies. No new focus of hemorrhage.
Moderate mucosal thickening in the paranasal sinuses, most pronounced in the
sphenoids is unchanged.
CTA HEAD:
There is a re-demonstrated short-segment dissection of the distal cervical
right internal carotid artery (series 3, image 32). A short-segment
dissection of the distal left ICA (series 3, image 15) is unchanged.
Moderate narrowing of the V4 segment of the right vertebral artery is
unchanged and again may represent vasospasm. The left vertebral artery is
widely patent. No additional aneurysm greater than 3 mm, dissection,
flow-limiting stenosis or thrombosis.
Assessment of the left posterior cerebral and cerebellar arteries is limited
by artifact, but appear within these limitations unchanged.
IMPRESSION:
1. Mild hydrocephalus is moderately worsened in comparison to the prior
examination.
2. Unchanged, narrowing of the distal right vertebral artery, suggestive of
vasospasm. No evidence of worsening vasospasm.
3. Bilateral superior cerebellar and pontine infarcts are unchanged.
4. Bilateral distal ICA dissections are unchanged.
5. A small right occipital subdural is decreased from ___.
6. Bilateral trace subarachnoid hemorrhage is less conspicuous compatible with
evolution.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ m p/w sudden onset headache, SAH s/p EVD ___, w multiple
intra extracranial arterial pseudoaneurysms/dissections, now w/ fever, MSSA
bacteremia (___), and MRSA/proteus pneumonia.// Positive cultures, concern
for pulmonary process. evaluate for consolidation. Positive cultures,
concern for pulmonary process. evaluate for consolidation.
IMPRESSION:
Compared to chest radiographs ___ through ___.
Pneumoperitoneum seen beneath right hemidiaphragm on ___ is no longer
obvious but today's is a supine radiograph and pneumoperitoneum would be
difficult to detect on less very large.
Mild pulmonary edema is new. Severe consolidation with appreciable volume
loss in the left lower lobe worsened since ___ and has not subsequently
improved. Atelectasis and possible pneumonia due to aspiration is most
likely.
NOTIFICATION: The findings were discussed with ___ CARE NP, ___
___ by ___, M.D. on the telephone on ___ at 10:39 am, 1
minutes after discovery of the findings.
Patient had percutaneous gastrostomy between ___ and ___ which may
be responsible for pneumoperitoneum, but unexpected pneumoperitoneum needs to
be considered from a clinical standpoint, as I discussed with ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ m p/w sudden onset headache, SAH s/p EVD
___, w multiple intra extracranial arterial pseudoaneurysms/dissections,
now w/ fever, MSSA bacteremia (___), and MRSA/proteus pneumonia.// assess for
PNA assess for PNA
IMPRESSION:
Compared to chest radiographs ___ through ___.
Widespread opacification in the left upper lung developed on ___ and has
not resolved. This could be due to recent aspiration. Dense consolidation in
the left lower lobe has been present uniformly, with mild improvement on some
days. This is presumably atelectasis though pneumonia is not excluded.
Widespread micro nodulation in the right lung is attributed to vascular
engorgement. If it persists in the setting of normal hemodynamics, I would
repeat perform a chest CT for assessment. Pleural effusions small if any. No
pneumothorax.
Left PIC line tip is close to the estimated location of the superior
cavoatrial junction. Tracheostomy tube midline.
RECOMMENDATION(S): See Impression, above.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with ___ m p/w sudden onset headache, SAH s/p EVD
___, w multiple intra extracranial arterial pseudoaneurysms/dissections,
now w/ fever, MSSA bacteremia (___), and MRSA/proteus pneumonia.// please
assess for clot BLE- patient is very sick/ please perform portable.
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.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with sacral decub wound and mtpl inctracranial
vascular dissections s/p PEG, now w concern for pneumoperitoneum// r/o
Pneumoperitoneum, please perform UPRIGHT CXRAY r/o Pneumoperitoneum,
please perform UPRIGHT CXRAY
IMPRESSION:
Comparison to ___. Increasing retrocardiac atelectasis. The
patient is rotated to the left. No pulmonary edema, no pleural effusions, no
pneumonia. The tracheostomy tube is in stable position.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD.
INDICATION: ___ year old man with large bleed and herniation// eval for
evidence of brain stem stroke.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT head without contrast ___ 16:27.
FINDINGS:
Intraparenchymal hemorrhage at right posterior pons, continuous with extensive
subarachnoid hemorrhage in the subarachnoid cisterns and right cerebral and
cerebellar hemispheres appear not significantly changed compared to CT from 5
hours ago. Intraventricular hemorrhage in lateral ventricles, third and
fourth ventricles is similar to before. The lateral ventricles remain
slightly prominent, unchanged since the prior exam. Focal areas of slow
diffusion suggests ischemic changes at the margins the right pontine
intraparenchymal hematoma (image 11, series 4 and 5). No diffusion
abnormalities are detected to indicate large supratentorial acute territorial
infarction.
Anterior right temporal hemorrhagic contusion is noted., There is similar
effacement of the right cerebellar pontine cisterns and narrowing of the
foramen magnum, likely due to diffuse brain edema.
Size of the ventricles are prominent compared to sulci, stable compared to 5
hours ago. Right frontal approach ventriculostomy catheter terminates at
right foramina ___, unchanged.
The orbits are unremarkable, the paranasal sinuses and mastoid air cells are
clear.
IMPRESSION:
1. Right posterior pontine hemorrhage demonstrate secondary areas of focal
slow diffusion, suggesting ischemic changes at the margins of the right
pontine intraparenchymal hematoma.
2. Extensive subarachnoid and intraventricular hemorrhage is not significantly
changed compared to CT from 5 hours ago.
3. Ventriculomegaly is stable compared to 5 hours ago.
4. Persistent effacement of the right cerebellar and pontine cisterns and
foramen magnum.
NOTIFICATION: The findings were discussed with the ___ care NP. By
___, M.D. on the telephone on ___ at 12:45 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ m p/w sudden onset headache, SAH s/p EVD ___, w multiple
intra extracranial arterial pseudoaneurysms/dissections, now w/ fever, MSSA
bacteremia (___), and MRSA/proteus pneumonia.// Pre-op planning for VP shunt
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CTA head neck from ___.
FINDINGS:
Beam hardening artifact from embolization coils limits evaluation.
A right frontal approach ventriculostomy catheter is in unchanged position,
terminating in the region of the foramina ___. Mild dilatation of the
bilateral lateral, third and fourth ventricles is not significantly changed.
Bilateral superior cerebellar and right posterolateral pontine infarcts are
similar. Trace left frontotemporal second arachnoid hemorrhage in right
temporal subarachnoid hemorrhage are similar. Trace hemorrhage product is in
the occipital horns also are re-identified. There is no evidence of new acute
large territorial infarction, hemorrhage or mass effect.
There is no evidence of acute fracture. Aerosolized secretions are seen in
the bilateral sphenoid sinuses. The visualized portion of the other paranasal
sinuses and middle ear cavities are clear. Partial opacification of the
bilateral mastoid air cells is again seen. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. Persistent mild hydrocephalus with ventriculostomy catheter in unchanged
position.
2. No new acute intracranial abnormality.
3. Similar appearance of cerebellar and pontine infarcts and subarachnoid
hemorrhage, as above.
Radiology Report
EXAMINATION: Portable AP chest
INDICATION: ___ m p/w sudden onset headache, SAH s/p EVD ___, w multiple
intra extracranial arterial pseudoaneurysms/dissections, now w/ fever, MSSA
bacteremia (___), and MRSA/proteus pneumonia.// Pre-op evaluation, VP shunt.
Surg: ___ (VP Shunt)
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiographs dated ___
FINDINGS:
Tracheostomy tube and left PICC are in similar position. There is increased
diffuse opacity overlying the left hemithorax. Pulmonary vascular congestion
is improved. Cardiomediastinal silhouette is unchanged. There are no large
pleural effusions. No pneumothorax.
IMPRESSION:
Increased diffuse opacity overlying the left hemithorax. Improved pulmonary
vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ m p/w sudden onset headache, SAH s/p EVD ___, w multiple
intra extracranial arterial pseudoaneurysms/dissections, now w/ fever, MSSA
bacteremia (___), and MRSA/proteus pneumonia.// Re-assess left sided
opacities
TECHNIQUE: 2 frontal views of the chest
COMPARISON: ___
FINDINGS:
Previous patchy opacity in the left upper lung is moderately improved with
mild to mild residual opacity. Linear atelectasis left costophrenic angle.
Mild cardiomegaly stable.
No significant pleural effusion or pneumothorax.
Tracheostomy and left PICC line remain in place. A right ventriculostomy
catheter which is partially seen and appears to extend inferiorly from the
right neck and terminate in the right upper quadrant of the abdomen medially.
IMPRESSION:
Previous probable infiltrate in the left upper lung is moderately improved
with mild-to-moderate residual opacity still remaining. Right ventriculostomy
catheter is now seen.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with SAH in setting of right SCA aneurysm
rupture, s/p coiling. Developed hydrocephalus requiring EVD placement. Now s/p
VP shunt placement. Please perform at 20:00// Time: 20:00. please evaluate for
post-op changes.
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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Unenhanced head CT ___ at 05:07.
FINDINGS:
Hypodensities in the bilateral cerebellar hemispheres and right aspect of the
pons are unchanged (02:11, 10, 7 and 8). There is a right frontal approach
ventriculostomy catheter terminating near the foramen of ___, unchanged.
There is bilateral prominence of the lateral ventricles, unchanged. Subtle
hyperdensity seen in the left parietal sulci and in the right sylvian fissure
(02:15 and 18) is similar appearance to most recent prior CT, likely
corresponding to previously demonstrated foci of subarachnoid hemorrhage. A
new or newly apparent 3 mm focus of hyperdensity in the region of the right
anterior fornix (601:50 and 2:15) was not seen on prior studies, possibly a
small new focus of hemorrhage.
Elsewhere, there is no evidence of new acute large vascular territorial
infarction, edema, or mass effect. The basal cisterns are patent. There is
no shift of the normally midline structures. The sulci are unchanged in
caliber.
Postsurgical changes are noted on the right including skin staples. There is
no evidence of an acute fracture. The visualized paranasal sinuses, aside
from trace aerosolized secretions in the sphenoid sinus (2:9), are well
pneumatized and clear. The mastoid air cells and middle ear cavities are
clear. Hardware artifact from prior right superior cerebellar artery aneurysm
intervention is unchanged.
IMPRESSION:
1. 3 mm hyperdense focus in the region of the anterior right fornix. Although
small and indeterminate, this could represent a new focus of hemorrhage.
Attention to this area on follow-up.
2. Unchanged vague hyperdensity in the right sylvian fissure and left parietal
sulci likely corresponding to previously demonstrated foci of subarachnoid
hemorrhage. No new focus of hemorrhage identified.
3. Unchanged bilateral cerebellar hemispheric and right pontine hypodensities
corresponding to acute infarcts seen previously.
4. Stable configuration of the right frontal approach ventriculostomy catheter
terminating near the foramen of ___, with unchanged caliber of the lateral
ventricles.
Radiology Report
INDICATION: ___ year old man with intubated on trach collar, pna, evaluate for
progression of pna
TECHNIQUE: Single upright AP chest radiograph
COMPARISON: Multiple prior chest radiographs dating back to ___,
most recently ___.
FINDINGS:
Allowing for differences in rotation, the left upper lobe opacification
appears grossly similar to the immediate prior study, and reduced from ___. A tracheostomy tube terminates in the mid trachea. A left approach PICC
terminates at the cavoatrial junction. A right-sided ventriculoperitoneal
shunt is partially imaged with the radiopaque portions intact. Apparent mild
widening of the upper mediastinum is stable from prior studies, allowing for
differences in rotation. Mild cardiomegaly is also similar. There is no
pleural effusion or pneumothorax.
IMPRESSION:
Grossly stable left upper lobe airspace opacification.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ m p/w sudden onset headache, SAH s/p EVD ___, w multiple
intra extracranial arterial pseudoaneurysms/dissections, now w/ fever, MSSA
bacteremia (___), and MRSA/proteus pneumonia.// Evaluate for improvement in
left sided opacities Evaluate for improvement in left sided opacities
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild cardiomegaly stable. Lungs clear. No pleural abnormality.
Left PIC line ends in the region of the superior cavoatrial junction.
Tracheostomy tube midline. Shunt catheter traverses the right neck chest and
upper abdominal quadrant compared
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ m p/w sudden onset headache, SAH s/p EVD ___, w multiple
intra extracranial arterial pseudoaneurysms/dissections, now w/ fever, MSSA
bacteremia (___), and MRSA/proteus pneumonia.// Re-evaluate left sided
opacities Re-evaluate left sided opacities
IMPRESSION:
Comparison to ___. The monitoring and support devices are in stable
correct position. Stable moderate cardiomegaly. Improved ventilation of the
retrocardiac lung region. No pneumonia, no atelectasis. No pulmonary edema.
No pleural effusions.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with spinal cord injury,intracranial aneurysms
s/p coiling now with persistent tachycardia. Evaluation 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 left posterior tibial and peroneal
veins. The right calf veins were not visualized due to difficult patient
positioning.
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 bilaterallower extremity veins.
Of note, the right calf veins were not visualized on this study due to
difficult patient positioning.
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ year old man with spinal cord injury,intracranial aneurysms
s/p coiling now with persistent tachycardia. Evaluation for DVT.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The bilateral axillary veins are patent, show normal color flow and
compressibility. The bilateral internal jugular veins were not visualized on
the current study due to vent collar on patient's neck.
The bilateral brachial, basilic, and cephalic veins are patent, compressible
and show normal color flow and augmentation.
IMPRESSION:
Bilateral internal jugular veins not visualized on the current study due to
vent collar, however within these limitations there was otherwise no evidence
of deep vein thrombosis in the bilateral upper extremity veins.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ s/p placement of R VPS 8 days ago now with altered mental
status. No longer following commands. STAT head CT to evaluate for etiology of
exam change.// CT head without contrast to evaluate for etiology of altered
mental status
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 761 mGy-cm.
COMPARISON: Multiple prior head CT examinations since ___ and the
most recent dated ___.
FINDINGS:
Beam hardening artifact from embolization coils limits evaluation.
There is re-demonstration of a right frontal approach ventricular drain that
terminates in the right lateral ventricle near the foramina of ___,
unchanged from prior. Bilateral cerebellar and right pontine hypodensities
are re-demonstrated compatible with chronic infarct. Previously visualized
bilateral subarachnoid hemorrhages are not demonstrated on this examination.
There is no evidence of acute large territory infarction,hemorrhage,edema, or
mass. There is persistent mild dilation of the bilateral lateral, third and
fourth ventricles, not substantially changed from prior study.
There is no evidence of fracture. Aerosolized secretions are visualized in
the bilateral sphenoid sinuses otherwise the visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Persistent mild hydrocephalus with ventricular drain in place unchanged in
position from prior.
3. Chronic cerebellar and pontine infarcts with interval resolution of
previously demonstrated subarachnoid hemorrhage. No acute intracranial
hemorrhage or infarct identified.
Radiology Report
INDICATION: ___ year old man with SAH// Already had CT/CTA head and CXR, so
will only need abdomen/ xray for clearance for MRI.
TECHNIQUE: Supine frontal views of the abdomen and pelvis.
COMPARISON: None.
IMPRESSION:
Besides presumed cholecystectomy clips in the right upper quadrant, no
radiopaque foreign bodies are seen. Upper enteric tube tip terminates in the
distal gastric body. The stomach is prominently distended. Foley catheter is
in place. Excreted contrast from same-day CT examination is seen. There is
prominent colonic fecal load. There is no evidence of obstruction. There is
no supine radiographic evidence of free air.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old man with SAH, status post placement of VPS now with
altered mental status. CT head stable. CXR to evaluate for etiology of altered
mental status
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___
FINDINGS:
There is a tracheostomy tube in situ. The left PICC is stable in position.
The heart is enlarged, similar to previous. The mediastinal structures appear
unchanged. There may be mild pulmonary vascular congestion versus supine
positioning. There are no large pleural effusions. Degenerative changes are
re-demonstrated in the spine.
IMPRESSION:
As above
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with SAH s/p VP shunt with new enlarged left
pupil, anisocoria// Evaluate for interval changes in ventricle size,
hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Head CT ___
FINDINGS:
Right frontal burr hole, with VP shunt tip in the right frontal horn, similar
to prior. Moderate dilatation of ventricular system, stable. Again seen are
embolization coils. Multiple infarcts involving bilateral cerebellar
hemispheres are stable since ___, no definite new lesions. Mild
crowding at foramen magnum, similar. Mild edema about the drain tract in the
right frontal lobe, no definite hemorrhage, similar. Chronic encephalomalacia
anterior right temporal lobe, lateral base of the right frontal lobe,
anteromedial temporal lobe, inferior left parietal lobe, similar. No evidence
of acute infarct or intracranial hemorrhage.
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. Benign-appearing osseous expansion left
parietal bone near vertex,, this had benign appearance on MRI brain ___ 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:
VP shunt in place. Stable prominence of the ventricular system. Stable areas
of frontal, left parietal, right temporal encephalomalacia.
Stable bilateral cerebellar infarcts.
No new hemorrhage.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with elevated WBC and blood tinged sputum.//
Evaluation of leukocytosis Evaluation of leukocytosis
IMPRESSION:
Comparison to ___. Borderline size of the heart. Stable position
of the left PICC line and the tracheostomy tube. No pulmonary edema, no
pleural effusions. No pneumonia. No pneumothorax.
Radiology Report
EXAMINATION: Diagnostic cerebral angiogram for 2 month follow-up of right SCA
aneurysm related dissection status post subarachnoid hemorrhage and vessel
sacrifice
During the procedure the following vessels were selectively catheterized
angiograms were performed:
Left vertebral artery
Three-dimensional rotational angiography of the left vertebral artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Right common femoral artery
INDICATION: This is a ___ gentleman with a history of a subarachnoid
hemorrhage related to a right SCA dissection and aneurysm who is status post
vessel sacrifice via endovascular coiling 2 months ago. He presents for 2
month follow-up angiogram.
ANESTHESIA: Sedation was provided by administering a single dose of 25 mcg of
fentanyl during which the patient's hemodynamic parameters were continuously
monitored by a trained, independent observer.
TECHNIQUE: Diagnostic cerebral angiogram, single-vessel
COMPARISON: ___ angiograms
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. He was transferred to the fluoroscopic table supine. Sedation was
administered. Bilateral groins were prepped and draped in standard sterile
fashion. A time-out was performed. The right common femoral artery was
identified using anatomic and radiographic landmarks. The right common
femoral artery was accessed using standard micropuncture technique after
infiltration of local anesthetic. A short 5 ___ sheath was introduced,
connected to continuous heparinized saline flush, and secured.
Next a Berenstein diagnostic catheter was introduced. It was connected to
continuous heparinized saline flush as well as the power injector. It was
advanced over 038 glidewire through the aorta into the aortic arch. The wire
was used to select left subclavian artery. The catheters positioned over the
wire to the left subclavian artery. The wire was removed. Vessel patency was
confirmed via hand injection. A roadmap was performed. The catheter was
advanced in the left vertebral artery in the proximal portion over wire using
roadmap guidance. The wire was removed. Vessel patency was confirmed via
hand injection. Standard AP and lateral as well as three-dimensional
rotational images were obtained.
Next the diagnostic catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 5 ___ Mynx. The patient was removed
from the fluoroscopy table and remained at his neurologic baseline without any
evidence of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Left vertebral artery: Stable dissections through the V 2 segment as
previously identified the smoother and less severe. Additionally the caliber
of the basilar artery is restored to normal compared to the dissected and
beaded appearance in the ___ angiograms. There is opacification the
basilar artery as well as bilateral posterior cerebral artery and bilateral
superior cerebellar arteries. The previously coiled distal segment of the
right superior cerebellar artery dissection remains completely occluded.
There is filling of the proximal portion. The takeoff appears more narrow
than previous and may be impossible to access. There is a small bulb of
dissection that remains just distal to the take-off. It measures 3.6 x 4.2 mm
compared to 4.5 x 14 mm previously. It appears somewhat more bulbous but much
decreased in length.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
IMPRESSION:
___ 1, no residual filling of previous distal coiling and sacrifice of
the right superior cerebellar artery aneurysm related to dissection and
subarachnoid hemorrhage.
Decrease in length but persistent filling of the proximal aneurysmal dilation
related to dissection measuring 3.6 x 4.2 mm. This is greatly decreased in
length compared to previous.
Dramatic improvement in the basilar artery caliber
Attenuation of the right SCA origin such that access via microcatheter would
be nearly impossible.
RECOMMENDATION(S):
1. Follow-up angiogram in 2 months
Radiology Report
INDICATION: ___ year old man with s/p pneumonia treatment with increased
secretions and cough. Obtain at 5am// surveillance pneumonia. Obtain at 5am
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Tracheostomy tube is unchanged. Left-sided PICC line projects to the mid SVC.
Cardiomediastinal silhouette is stable. There are no pleural effusions. No
pneumothorax is seen. A VP shunt courses through the right anterior chest
wall.
Radiology Report
INDICATION: ___ year old man with ostomy and no stool output.// R/o
obstruction.
TECHNIQUE: Single portable view of the abdomen.
COMPARISON: Abdominal film from ___.
FINDINGS:
Moderate amount of stool seen throughout the colon which is nondilated. There
are no dilated loops of small bowel. Osseous structures are unremarkable.
IMPRESSION:
Moderate stool in the colon. No evidence of obstruction.
Radiology Report
INDICATION: ___ year old man with known ostomy and constipation// ?resolution
of constipation/stool impaction
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Gastrostomy
tube present. A left lower quadrant stoma is present.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Surgical clips are seen in the right upper quadrant.
IMPRESSION:
No evidence of bowel obstruction or significant constipation.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with SAH// new left IJ Contact name: S.
___: ___ new left IJ
IMPRESSION:
Compared to ___.
New left internal jugular line ends at the origin of the SVC. No attendant
mediastinal widening, no pneumothorax or pleural effusion. Lungs clear.
Heart size normal.
ET tube in standard placement. Nasogastric drainage tube passes into the
stomach and out of view.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx of perimensephalic SAH w/ pontine IPH//
Evaluate NGT placement Evaluate NGT placement
IMPRESSION:
Comparison to ___. The endotracheal tube projects approximately 4.5
cm above the carinal. A left internal jugular vein catheter is in correct
position. The course of the feeding tube is unremarkable, the tip is not
visualized on the image but the side hole projects over the central parts of
the stomach. No complications, notably no pneumothorax. No evidence of
pneumonia. No pulmonary edema, no pleural effusions. Borderline size of the
cardiac silhouette.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: ICH, Transfer
Diagnosed with Nontraumatic subarachnoid hemorrhage, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ett
level of acuity: 2.0 | #SAH
On ___, Mr. ___ was admitted to the neurosurgery service
with large perimesencephalic subarachnoid hemorrhage. EVD was
urgently placed in the ED and he was transferred to the Neuro
ICU. Patient was started on Nimodipine and Keppra and MRI brain
was obtained which did not reveal stroke. The patient underwent
a CTA of the head and neck on ___, which showed an increase in
the dissection at the SCA. He underwent a diagnostic angiogram
on ___ and was found to have a right superior cerebellar artery
aneurysm and multiple old dissections of the vertebral arteries
and ICAs. On ___, the patient underwent an angiogram where the
SCA aneurysm was coiled and the vessel was sacrificed. On ___
EVD was lowered from 15 to 5. On ___, the patient underwent a
CTA of the brain which showed vasospasm. He was started on
Milrinone and Neo to optimize perfusion. ICPs increased to mid
___ and he was given multiple boluses of hypertonic saline and
mannitol. He underwent urgent CTA, which showed diffuse
vasospasm. EVD was lowered to the level of the tragus. Sedation
was increased and he was placed on paralytics for elevated ICP's
on ___. This ___ discontinued on ___. On ___, the patient's
neurologic examination remained stable. He underwent a CTA of
the head which revealed increased vasospasm. His exam remained
stable and he wa s continued on milrinone. NCHCT on ___ was
stable. He was started on Cheetah (NICOM) to monitor fluid
status on ___. MRI on ___ showed small SDH in R parietal
occipital and inferior temporal areas, as well as right
cerebellar and parafalcine. The EVD was raised to 10cm above the
tragus in response. On ___, the EVD was clamped and the patient
stopped following commands shortly after. He intermittently
followed commands and a CTA head was ordered per the
Neurovascular team which showed CTA demonstrated improved
vasospasm with increased size of ventricles. The EVD was
subsequently clamped but the patient failed given the fact that
he had a change in his neurologic status and the EVD was opened
to 5cm above the tragus. On ___, the patient's EVD was
increased to 15cm above the tragus however was lowered back to
10cm above the tragus as the patient was not following commands.
A STAT CTA was performed which showed improvement in spasm with
stable size of the ventricles. The EVD remained at 10cm above
the tragus. He was taken to the OR On ___ and underwent
placement of R frontal VP shunt ___ Strata at 1.5); his
operative course was uncomplicated, please see OMR note for full
details of procedure.
Post-shunt CT was stable. PO sodium repletion was weaned during
his ICU stay. He was called out of the ICU on ___. On ___,
NCHCT was stable. The patient picked open his VP shunt incision
on ___, which was cleaned and reclosed at the bedside with
staples. On ___ anisocoria noted, L pupil enlarged to 7mm,
briskly reactive. Repeat NCHCT was stable and the patient
remained neurological stable otherwise. Staples for VP shunt
were removed on ___, then overnight the patient picked at his
incision reopening a small area. Three staples were replaced
which were removed on ___.
On ___, he was taken for a repeat diagnostic cerebral
angiogram, which was stable from prior. An additional follow-up
angiogram was planned for 2 months.
#Left gaze deviation
On ___, the patient was noted to have a left gaze deviation.
EEG was ordered. The patient was noted to have a downward fixed
gaze on ___ and received 2g IV Ativan once. He was continued on
EEG monitoring through ___, which was abnormal with occasional
epileptiform discharges over left frontocentral region; however
there were no electrographic seizures. On ___, the EEG was
noted to be negative for seizure activity and was discontinued.
#Leukocytosis/Fever/Bacteremia
The patient's WBC count was noted to elevate on ___. On ___,
the patient was found to have positive GPC on blood culture from
CVL. He was started on Vancomycin. On Hospital Day #1, the
patient was febrile to 101.5; pancultures were sent. The patient
spiked a fever to 103 on ___ and pan-cultures were sent. The
patient remained febrile on ___. A CSF culture was sent, which
grew P.Acnes; ID was consulted given the patient's history of
osteomyelitis in ___ from chronic sacral wounds. Per ID recs,
Vancomycin was discontinued and patient was started on Cefipime.
Final report demonstrates blood was positive for staph (not
MRSA) therefore vancomycin was discontinued and changed to
cefepime per ID recs. The patient's WBC normalized on ___.
Infectious disease recommended a 7 day course of ceftriaxone and
6 weeks of IV vancomyin and signed off on ___. Repeat CSF
cultures were sent on ___, and ___, which currently show
no growth to date. The patient's wound grew multi-drug resistant
bacteria; antibiotics were changed from cefepime to zosyn based
on ID recommendations. Vancomycin was restarted and changed to
linezolid on ___ with plans for a 1 week course, which ended
___. Per ID recommendations, Daptomycin was started on ___ for
a 10 day course to cover VRE found in sacral ulcer. Patient
completed daptomycin course on ___. At that time he remained
afebrile with normal WBC.
On ___, the patient had elevated WBC to 16.8 but was afebrile.
Medicine was consulted and he was started on empiric Vanco and
Zosyn for possible PNA vs prostatitis. CXR was negative for PNA.
UA/UC and sputum preliminary growth GNRs and UC grew
<100,000cfu/ml e.coli, however medicine recommended d/c'ing
antibiotics given fever and WBC trended down prior to starting
treatment and patient was clinically stable.
#Hyponatremia
During the patient's ICU stay, he was started on a 3% HTS gtt
which titrated as needed to reach goal. Sodium tablets were
added and titrated throughout his ICU hospitalization. While in
the ICU the hypertonic saline was slowly weaned off.
#Respiratory/Right Lung Consolidation
On ___, the patient underwent a CXR which showed a right middle
and right lower lobe consolidation. He underwent a Bronch which
grew two colonial morphologies of MRSA. This finding was
discussed with ID and it was determined that the patient would
continue on the current antibiotic regimen. The patient
underwent placement of a Trach by ACS on ___. He was weaned
from the ventilator during his ICU stay and was tolerating trach
collar at the time of transfer to ___. Speech was consulted for
speaking valve trials on ___ which the patient did not tolerate
due to high pressures and strong productive cough. Trials of
cuff deflation were recommended at RT/RN discretion, RT agreed
to deflated cuff. He failed speaking valve trial again on ___
and ___. On ___, the patient had elevated WBC and blood tinged
sputum from trach. CXR was negative. He was last evaluated by
speech on ___, where the speaking valve trial was deferred due
to increased secretions. On ___, his tracheostomy tube was
changed out by respiratory therapy. Episode of tachycardia and
coughing after tracheostomy tube exchange. Ventricular
tachycardia on telemetry, however sinus tachycardia on
electrocardiogram. Placed on 35% fraction of inspired oxygen via
tracheostomy mask. Tachycardia and coughing resolved.
#Hypertension
Patients home amlodipine/lisinopril were held while in the ICU.
While in the ___ patient's BP was at goal <160 off
antihypertensives. He no longer required antihypertensives while
hospitalized.
#Sacral Pressure Ulcer
On ___, ACS was consulted to discuss the possibility of
debriding the sacral pressure ulcer. On ___, the patient
underwent surgical debriedement of the sacral ulcer at the
bedside by Dr. ___ RN was consulted who placed wound
vac with veriflow on ___. On ___, the patient was evaluated by
the wound nurse and the wound vac representative. On ___, the
patient was evaluated by ACS and no debridement was indicated;
they recommended continuing the wound vac. The wound was
routinely evaluated by wound RN, and recommended discontinuing
the wound vac on ___. Please see wound RN note for further
instructiosn, packing and mepilex dressing to be changes Q3days.
___
There was concern for a clogged ___ bag on ___. He was
evaluated by the ___ RN on ___ and then started to put out
a small amount stool. ___, no stool output and nursing felt the
patient was distended. KUB negative for obstruction. ACS
consulted to evaluate stoma; they felt ostomy was working well
and patient likely constipated. Recommended administering enema
through Malecot catheter into stoma for constipation, with good
effect. His bowel regimen was adjusted and he continued to have
good output over the remainder of his admission.
#Nutrition
A temporary feeding tube was placed during the ICU admission for
artificial nutrition. The patient underwent placement of a PEG
by ACS on ___ and was started on enteral nutrition on ___.
Tube feeds were changed from Jevity 1.5 to Jevity 1.2 for
elevated phosphorus levels per nutrition recs. Phosphorus levels
continued to be elevated so tube feed formula was changed to
Nepro and zinc sulfate was added for 10 days, starting ___. On
___ phosphorus level had increased, so phosphate binder
Sevelemir was added. He was started on Vitamin D repletion on
___. Medicine was consulted for elevated phos and calcium, who
suggested this was related to chronic illness and immobility.
Fluids were given, and the phos/calcium remained stable to
slightly downtrending. Patient was discharged with instructions
to follow up with PCP for monitoring of Phosphorus and calcium
levels.
#Anemia
The patient was noted to be anemic requiring transfusion of
PRBC's during his ICU stay. He required a 3-way foley to CBI and
1 unit PRBC on ___ for acute blood loss anemia. He required a
transfusion of 2 units of pRBCs on ___. His
hemoglobin/hematocrit remained stable over the remainder of his
admission.
#Urinary retention
#Hematuria
The patient has urinary retention at baseline secondary to
spinal cord injury. Foley catheter was removed and he was
intermittently straight catheterized. Overnight on ___, the
patient experienced hematuria during straight cath. Hematuria
was still present on ___, so foley catheter was left in place.
Hematuria resolved and foley was removed on ___. On ___, the
patient was bleeding from meatus so foley was replaced and
urology was consulted. Patient was discharged with instructions
to follow up with Urology outpatient. On ___, the patient had
clots in the foley with bleeding from meatus. Abdomen distended
with bladder scan 293cc. Urology consulted, who replaced the
foley catheter with a 2-way catheter for irrigation PRN. There
were no clots with the PRN irrigation and the patient continued
to bleed from his meatus. Urology placed a ___ 3-way foley to
CBI with multiple blood clots noted. Urology stopped the CBI on
___ and the urine output was more pink. The 3-way irrigating
foley was replaced with an ___ 2-way coude catheter on ___ by
neurosurgery. He will follow up with urology outpatient, the
phone number was provided.
#Disposition
Guardianship was obtained on ___. Patient was screened for
placement by case management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of CABG presenting with several weeks of worsening
shortness of breath. Patient was recently diagnosed in ___
with new onset Aflutter with DC cardioversion on ___ following
3 months of anticoagulation. He was then readmitted in ___
for repeat cardioversion of recurrent atrial fibrillation. Since
that admission, patient felt better for 'about a week' but since
has been feeling progressively dyspneic. He failed sotalol and
is now back on metoprolol and coumadin. He says he can currently
only walk about ___ yards before needing to rest. Today, an
acquaintance noted his lips were blue and suggested he come to
the ED.
.
He notes new dry cough over the last several days. Also lost his
voice over the weekend and his appetite hasn't been very good.
He denies recent fevers. Patient denies CP, palpitations, or
claudication. He does note a 'tightness' in his throat when
walking, making it difficult to breathe. He normally sleeps on 1
pillow and denies PND. He reports his normal weight at 205 lbs,
but bed scale today noted 212. Per medical record review Lasix
increased to 20mg bid on ___. Additionally, there is some
concern in his latest cardiology note for underlying
interstitial lung disease based on PFTs with a DLCO reduced to
50% of predicted, although, chest CT and spirometry were normal.
.
In the ED, initial VS: 97.4 104 153/94 20 100% 15L (?). He was
treated with levofloxacin and azithromycin as well as
prednisone.
.
Currently, patient is comfortable on the floor, but does become
dyspneic with minimal exertion.
.
ROS: Postive as above and for occasional emesis following eating
(chronic for years). Denies fever, chills, night sweats,
headache, vision changes, rhinorrhea, congestion, sore throat,
chest pain, abdominal pain, nausea, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Type II DM c/b diabetic retinopathy
- Hypertension
- Hypercholesterolemia
- s/p MI (___)
- Aortic Stenosis
- CABG (___): LIMA-LAD, SVG-OM, SVG-PDA, SVG-D
- PCI (___): LIMA-LAD patent, SVG-D patent, DES to PDA, DES to
PDA graft, and DES to OM graft
- Right Pulmonary Nodule
- Cataracts
- ___
- Rheumatoid Arthritis
- Peripheral Vascular Disease
- Mixed Conductive and Sensorineural Hearing Loss
- Obesity
- B12 deficiency, last injection ___ per Atrius records
Social History:
___
Family History:
Brother had an MI and died in his ___. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
VS - Temp F, BP , HR , R , O2-sat % RA
GENERAL - well-appearing obese man in NAD, comfortable at rest,
appropriate
HEENT - PERRL 3->2mm, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD to mandible
LUNGS - Crackles at bases, R>L with good air movement, becomes
dyspneic with minimal exertion
HEART - Tachycardic and irregular, no MRG, nl S1-S2, hard to
appreciate for S3 given tachycardia
ABDOMEN - NABS, obese, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, trace pretibial edema, 1+ peripheral pulses
(radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength ___
throughout, sensation grossly intact throughout, cerebellar exam
intact to FTN, steady gait
Pertinent Results:
MICROBIOLOGY: Negative except as otherwised indicated
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
.
EKG ___: Afib with RVR
.
CXR ___:
The patient is status post median sternotomy and CABG. Mild
enlargement of the cardiac silhouette is unchanged when compared
to the prior study. There is continued mild pulmonary vascular
congestion. No large pleural effusion or pneumothorax is
present.There are degenerative changes in the thoracic spine.
IMPRESSION: Mild pulmonary vascular congestion
.
TTE ___:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is mildly depressed (LVEF=
45-50%). The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild aortic stenosis. Symmetric LVH with mild global
biventricular systolic dysfunction. Mild pulmonary hypertension.
.
CT Chest W/O Contrast ___:
1. No definitive evidence of interstitial lung disease.
2. Extensive coronary calcifications as well as aortic valve
calcifications
might reflect clinically significant aortic stenosis.
Correlation with
echocardiography is recommended.
3. One dominant and several clustered nodules in the right
middle lobe.
Close followup in three months for documentation of
stability/resolution is
required.
4. Mild ground glass and some mosaic attenuation that might
reflect resolving
pulmonary edema, nonspecific finding.
5. Low-density adrenal thickening on the left, consistent with
benign
etiology.
.
PFT's ___:
SPIROMETRY10:09 AMPre drugPost drug
ActualPred%PredActual%Pred%chg
FVC ___
FEV1 ___
MMF ___
FEV1/FVC ___
LUNG VOLUMES10:09 AMPre drugPost drug
ActualPred%PredActual%Pred
TLC ___
FRC ___
RV ___
VC ___
IC ___
ERV ___
RV/TLC ___
He Mix Time 3.00
DLCO10:09 AM
ActualPred%Pred
DSB 10.5923.6145
VA(sb) ___
HB 9.90
DSB(HB) 12.6623.6154
DL/VA ___
CHEMISTRY:
___ 10:45AM BLOOD WBC-8.8 RBC-3.53* Hgb-10.3* Hct-32.9*
MCV-93 MCH-29.1 MCHC-31.3 RDW-18.7* Plt ___
___ 06:25AM BLOOD WBC-6.7 RBC-3.17* Hgb-9.3* Hct-28.8*
MCV-91 MCH-29.2 MCHC-32.2 RDW-18.6* Plt ___
___ 06:15AM BLOOD WBC-9.3 RBC-3.37* Hgb-9.6* Hct-30.0*
MCV-89 MCH-28.5 MCHC-32.0 RDW-18.9* Plt ___
___ 06:20AM BLOOD WBC-8.8 RBC-3.82* Hgb-10.8* Hct-34.3*
MCV-90 MCH-28.2 MCHC-31.5 RDW-18.8* Plt ___
___ 06:20AM BLOOD WBC-6.7 RBC-3.47* Hgb-9.9* Hct-31.0*
MCV-89 MCH-28.5 MCHC-31.9 RDW-18.3* Plt ___
___ 10:45AM BLOOD ___ PTT-36.4 ___
___ 05:10PM BLOOD ___ PTT-30.8 ___
___ 06:15AM BLOOD ___ PTT-32.4 ___
___ 06:20AM BLOOD ___ PTT-34.7 ___
___ 06:20AM BLOOD ___ PTT-34.2 ___
___ 10:45AM BLOOD Glucose-214* UreaN-33* Creat-1.2 Na-140
K-4.6 Cl-105 HCO3-25 AnGap-15
___ 05:10PM BLOOD Glucose-140* UreaN-32* Creat-1.2 Na-139
K-3.6 Cl-104 HCO3-26 AnGap-13
___ 06:20AM BLOOD Glucose-58* UreaN-34* Creat-1.2 Na-140
K-3.9 Cl-102 HCO3-28 AnGap-14
___ 06:20AM BLOOD Glucose-64* UreaN-32* Creat-1.3* Na-139
K-4.3 Cl-102 HCO3-31 AnGap-10
___ 06:20AM BLOOD ALT-25 AST-25 LD(LDH)-290* AlkPhos-94
TotBili-0.6
___ 10:45AM BLOOD proBNP-3916*
___ 10:45AM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD Calcium-8.7 Phos-2.0* Mg-1.5*
___ 06:15AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.7
___ 06:20AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.7 Mg-2.0
___ 06:20AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.9
___ 06:20AM BLOOD TSH-2.2
___ 05:46PM BLOOD ___ pO2-40* pCO2-49* pH-7.36
calTCO2-29 Base XS-0
___ 11:00AM BLOOD Lactate-2.6*
___ 05:46PM BLOOD Lactate-2.1*
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
___.
Disp:*30 Tablet(s)* Refills:*1*
8. furosemide 20 mg Tablet Sig: 1 Tablet PO BID.
Disp:*30 Tablet(s)* Refills:*2*
9. Lantus 100 unit/mL Solution Sig: ___ (42) Units
Subcutaneous twice a day.
10. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. magnesium 200 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Methotrexate 2.5mg 7 tablets every ___
15. Metoprolol 50mg po bid
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
7. warfarin 2 mg Tablet Sig: 0.5 (One half) Tablet PO Once Daily
at 4 ___: Or as otherwise directed.
8. furosemide 20 mg Tablet Sig: ___ Tablets PO twice a day: Take
two tablets in the morning and one tablet at night.
Disp:*90 Tablet(s)* Refills:*0*
9. insulin glargine 100 unit/mL Solution Sig: ___ (38)
units Subcutaneous twice a day.
10. metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. magnesium 200 mg Tablet Sig: Two (2) Tablet PO once a day.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. methotrexate sodium 2.5 mg Tablet Sig: Seven (7) Tablet PO
1X/WEEK (FR).
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*0*
16. Oxygen
Home O2 2 liters via nasal cannula. Continuous
___: 3 months
Diagnosis: ILD
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: COPD, worsening shortness of breath and chest pain.
COMPARISON: ___.
PA AND LATERAL VIEWS OF THE CHEST: The patient is status post median
sternotomy and CABG. Mild enlargement of the cardiac silhouette is unchanged
when compared to the prior study. There is continued mild pulmonary vascular
congestion. No large pleural effusion or pneumothorax is present. There are
degenerative changes in the thoracic spine.
IMPRESSION: Mild pulmonary vascular congestion.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with history of amiodarone
treatment, dyspnea, with history of atrial fibrillation and dyspnea,
assessment before administration of amiodarone.
COMPARISON: Chest radiograph from ___ and
___.
TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to
upper abdomen with subsequent 1.25- and 5-mm collimation axial images reviewed
in conjunction with coronal and sagittal reformats.
FINDINGS:
The patient is after median sternotomy due to CABG. Extensive calcifications
of native coronary arteries are present. Multiple surgical clips are noted.
Heart size is mildly enlarged. Severe calcifications of the aortic valve are
present and might be consistent with aortic stenosis, please correlate with
echocardiography. No pericardial or pleural effusion is demonstrated.
The imaged portions of the upper abdomen reveal no abnormality within the
liver, gallbladder, spleen, kidneys, pancreas within the limitations of this
study technique.
Left adrenal thickening is low in density consistent with benign etiology.
Assessment of the SMA demonstrates extensive calcifications as well as of
renal arteries and splenic artery.
Degenerative changes within the thoracic spine are present but no lytic or
sclerotic lesion demonstrated.
Airways are patent to the subsegmental level bilaterally.
No pathologically enlarged mediastinal, hilar, or axillary lymph nodes are
seen. The right lower paratracheal lymph node is 9 mm in diameter, the
largest, subcarinal lymph node is 15 mm in diameter, both borderline. Note is
made that there is a high density of the myocardium that potentially might
reflect anemia.
In the right upper lobe, there is a cluster of nodules with one dominant
nodule, 10 x 7.5 mm in diameter. The dominant nodule has lobulated contours.
Minimal diffuse areas of ground glass are noted in particular in the perihilar
and lower lung areas with no evidence of septal thickening seen. Mild mosaic
attenuation is noted in the lower lungs.
IMPRESSION:
1. No definitive evidence of interstitial lung disease.
2. Extensive coronary calcifications as well as aortic valve calcifications
might reflect clinically significant aortic stenosis. Correlation with
echocardiography is recommended.
3. One dominant and several clustered nodules in the right middle lobe.
Close followup in three months for documentation of stability/resolution is
required.
4. Mild ground glass and some mosaic attenuation that might reflect resolving
pulmonary edema, nonspecific finding.
5. Low-density adrenal thickening on the left, consistent with benign
etiology.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, ATRIAL FIBRILLATION, CAD UNSPEC VESSEL, NATIVE OR GRAFT, CHRONIC AIRWAY OBSTRUCTION
temperature: 97.4
heartrate: 104.0
resprate: 20.0
o2sat: 100.0
sbp: 153.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | ASSESSMENT & PLAN: ___ yo male who presents with several weeks of
worsening dyspnea found to be in atrial fibrillation with poor
rate control.
.
ACTIVE PROBLEMS
# Dyspnea. Patient was found to be in AFib with RVR on the
admission, and has a well documented history of poor tolerance
of atrial fibrillation with 2 failed DC cardioversions. Rate
control was obtained with 5mg IV metoprolol followed by 75mg po
bid. Metoprolol was returned to home dose of 50mg bid prior to
discharge. TTE noted mild aortic stenosis, symmetric LVH with
mild global biventricular systolic dysfunction (LVEF 45-50%) and
mild pulmonary hypertension. Patient was felt to be volume
overloaded due to RVR and was diuresed with IV lasix
approximately 60 mg daily. Home lasix dose was increased to 40mg
po qam and 20mg po qpm. Following diuresis, patient was noted to
have continued desaturation to mid 80's on ambulation. PFT's
showed significantly decreased DLCO, although CT scan showed no
evidence of interstitial lung disease. Patient was discharged
home on home O2 with instructions to follow up in pulmonary
clinic to monitor DLCO.
.
# AFib: Patient was found to be in AFib with RVR on admission
and rate control was achieved with 5mg IV metoprolol and 75mg po
metoprolol tartrate daily. Coumadin 2.5 mg was continued and
INR's remained therapeutic during stay. Amiodarone was started
prior to discharge per cardiology request. Coumadin dose was
decreased to 1mg daily given initiation of amiodarone and
metoprolol was returned to ___ bid. Patient is to follow up
with his outpatient cardiologist.
.
CHRONIC PROBLEMS
# Hx of CAD: Patient had no complaints of chest pain and EKG was
not c/w with active ischemia. Troponin was negative x1. ___,
___, and metoprol were continued.
.
# DM: Initially continued home lantus 42 bid with HISS coverage.
Metformin was held while inhouse. Due to low blood sugars,
insulin was decreased to 38 units twice daily.
.
# HX of pulmonary nodule: Pt being followed at ___ for
pulmonary nodule on imaging. He was most recently imaged in ___ with recommendation for further follow up with PETCT vs. CT
biopsy vs. Short term CT follow up. Given initation of
amiodarone and concern for decreased DLCO, CT of chest was
obtained that demonstrated nodules. Correlation with prior ___
images should be done.
.
# Rheumatoid Arthritis: Patient currently without worsening
joint pain. Home dose of methotrexate, 2.5mg 7 tablets weekly,
was continued.
.
# HTN: Continued home Imdur and metoprolol as above.
.
# Anemia: Normocytic and stable at patients baseline
.
TRANSITIONAL ISSUES
-Decreased insulin dose due to low blood sugars
-Would continue to monitor PFT's periodoically, especially while
on amiodarone
-Increased lasix by 20mg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Abacavir Sulfate / Aspirin / fluconazole / levetiracetam
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ Lumbar puncture
History of Present Illness:
Ms. ___ is a ___ year-old female to HIV/AIDS non-compliant
with anti-retrovirals ___ CD4 ___ complicated by
cryptococal meningitis ___ years ago who presented with diffuse
headache not responsive to ibuprofen. Upon presentation to
___ ED, patient had T99, tachycardic to 110s but otherwise VS
stable with unremarkable labs (no leukocytosis). LP was
performed and showed no WBCs. She was administered Fioricet
with improvement of headahce, acyclovir and ceftriaxone and
admitted to medicine where acyclovir was continued.
Past Medical History:
1. AIDS (resistant disease - followed by ID)
- CD4 nadir 8 in ___, improved to 77 in ___
- HIV Viral Load in ___ - 6,731 copies/ml.
- Opportunistic infections: esophageal candidiasis
- CIN II-III s/p LEEP procedure
- for all mutations, please see OMR problem list
2. Depression
3. Gastritis secondary to H. Pylori
4. Renal stones
5. Cervical spondylosis
6. Migraines
7. Excision of left wrist ganglion cyst ___
8. Genital and vaginal condyloma
9. Melasma
10. Left carpal tunnel syndrome
11. S/p open cholecystectomy
___. C/S x 1 (PPROM -> child died from prematurity)
13. H/o right sided Bell's palsy
14. Meningitis
15. Diverticulitis with microperforation
Social History:
___
Family History:
Mother alive with a history of hypertension. Father deceased
from stroke. Three sisters and six brothers alive, two brothers
deceased from suicide and from pancreatic disease. No children.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB
Abdomen- soft, NT/ND, 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, UE and ___ strength ___, sensation normal,
neck with normal ROM, negative Kernig/___
DISCHARGE PHYSICAL EXAM
========================
Vitals- 98.5 107/63 83 16 99%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB
Abdomen- soft, NT/ND, 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, UE and ___ strength ___, sensation normal,
neck with normal ROM
Pertinent Results:
ADMISSION LABS
===============
___ 03:55PM BLOOD WBC-5.2 RBC-4.46 Hgb-12.7 Hct-38.7 MCV-87
MCH-28.4 MCHC-32.8 RDW-12.8 Plt ___
___ 03:55PM BLOOD Neuts-68.4 Lymphs-15.9* Monos-9.4
Eos-5.8* Baso-0.4
___ 03:55PM BLOOD ___ PTT-25.6 ___
___ 03:55PM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-135
K-5.2* Cl-102 HCO3-24 AnGap-14
___ 03:55PM BLOOD ALT-18 AST-50* AlkPhos-102 TotBili-0.3
___ 03:55PM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.6* Mg-2.1
___ 04:08PM BLOOD Lactate-0.9
CSF
====
___ 07:40PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
___ Macroph-9
___ 07:40PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-49
DISCHARGE LABS
===============
___ 07:20AM BLOOD WBC-2.8* RBC-4.12* Hgb-12.1 Hct-36.4
MCV-88 MCH-29.4 MCHC-33.3 RDW-12.8 Plt ___
___ 07:20AM BLOOD Neuts-39* Bands-4 ___ Monos-17*
Eos-9* Baso-0 Atyps-1* Metas-1* Myelos-0
___ 07:20AM BLOOD ___ PTT-26.8 ___
___ 07:20AM BLOOD WBC-2.8* Lymph-30 Abs ___ CD3%-36
Abs CD3-300* CD4%-5 Abs CD4-43* CD8%-29 Abs CD8-241 CD4/CD8-0.2*
___ 07:20AM BLOOD Glucose-87 UreaN-13 Creat-0.9 Na-140
K-3.8 Cl-106 HCO3-26 AnGap-12
___ 07:20AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.1
REPORTS
========
___ CT Head w/o Contrast
No acute intracranial pathology. No pathologic enhancement is
identified. If there is continued concern for an intracranial
abnormality, MRI can be obtained for further evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Stribild (elvitegr-cobicist-emtric-tenof) ___ mg
oral daily
2. Darunavir 800 mg PO DAILY
3. Azithromycin 1200 mg PO 1X/WEEK (MO)
4. Atovaquone Suspension 1500 mg PO DAILY
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
2. Azithromycin 1200 mg PO 1X/WEEK (MO)
3. Darunavir 800 mg PO DAILY
4. Stribild (elvitegr-cobicist-emtric-tenof) ___ mg
oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with HIV/AIDS with headaches. Evaluation for
intracranial hemorrhage or evidence of toxoplasmosis.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
before and after the administration of intravenous contrast. Multiplanar
re-formatted images were also reviewed.
COMPARISON: Comparison is made to CT of the head from ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, acute major vascular
territorial infarction, shift of the normally midline structures, mass, mass
effect or edema. No areas of pathologic enhancement are identified on
post-contrast images. The principal intracranial arteries are well opacified.
The ventricles and sulci are normal in size and configuration. The basal
cisterns appear patent. The gray-white matter differentiation is preserved.
No fractures are identified. The cranial and facial soft tissues are
unremarkable. The orbits are unremarkable. The visualized paranasal sinuses,
mastoid air cells and middle ear cavities are clear.
IMPRESSION:
No acute intracranial pathology. No pathologic enhancement is identified. If
there is continued concern for an intracranial abnormality, MRI can be
obtained for further evaluation.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: HA, NECK STIFFNESS, FEVER
Diagnosed with HEADACHE, HIV DISEASE
temperature: 99.8
heartrate: 112.0
resprate: 16.0
o2sat: 98.0
sbp: 137.0
dbp: 91.0
level of pain: 10
level of acuity: 2.0 | ___ year-old female to HIV/AIDS non-compliant with
anti-retrovirals ___ CD4 ___ complicated by cryptococal
meningitis ___ years ago who presented with diffuse headache not
responsive to ibuprofen.
# Headache: The differential diagnosis for the patient's
headache included tension headache, migraine, and viral
meningitis. CT Head was conducted and negative for intracranial
process. Patient was started on cefriaxone and acyclovir for a
concern for meneningitis. However, given LP without WBCs, lack
of fevers, confusion or neck stiffness, bacterial/viral
meningitis was thought to be less likely and antibiotics were
discontinued. The patient's headache responded to Fioricet and
she was without headache at the time of discharge.
# HIV: The patient was continued on her home Stribild and
Darunavir as well as Atovaquone and Azithromycin prophylaxis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Plavix
Attending: ___.
Chief Complaint:
RLE cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ diabetic with hx stage IV CKD (baseline Cr
3.6-3.8), CAD s/p LAD stent, and PVD s/p right CFA
thromboembolectomy and retrograde external iliac artery stent
___ ___ c/b ___ and ___ leg weakness ___ ischemic
neuropathy, with recent ED evaluation for question of R groin
wound infection who now p/w RLE swelling, pain and erythema.
Briefly, patient was seen in Dr. ___ today and was
complaining of persistent right leg swelling and pain, along
with
erythema and tenderness over the dorsum of his right foot. Given
concern for infection in the right foot, the decision was made
to
admit him for IV antibiotics and to obtain an venous duplex to
rule out DVT.
On arrival, patient was afebrile and hemodynamically stable
without leukocytosis or other concerning lab abnormalities. He
reports worsening R foot pain over the past 2 weeks, most
acutely
in the last two days and has not been able to ambulate at all in
that time. He denies any rest pain/claudication,
numbness/tingling or coolness of RLE or worsening RLE weakness.
He does report significant pain and swelling of his penis over
the past several weeks after a chronically indwelling Foley was
removed and has noted some bloody urethral discharge since that
time as well. He otherwise denies fevers/chills, CP/SOB, N/V.
Past Medical History:
PMH:
DM, CHF, CAD (s/p STEMI in ___ w/ stent placement), HTN,
hyperlipidemia), CKD
PSH:
- Suboccipital craniectomy for evacuation of large cerebellar
hemorrhage ___ ___
- Percutaneous tracheostomy and percutaneous endoscopic
gastrostomy tube ___ ___
- Right common femoral artery thromboembolectomy, right external
iliac artery stent
Social History:
___
Family History:
FH: father and mother died from cancer
no premature CAD
Physical Exam:
GEN: Well appearing, no acute distress
HEENT: NCAT, EOMI, sclera anicteric
CV: HDS
PULM: No signs of respiratory distress.
GU: edema improved at glans of penis
NEURO: A&Ox3, no focal neurologic deficits
WOUND: improved edema and minimal erythema at dorsum of right
foot.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
5. HydrALAZINE 100 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
8. Sertraline 50 mg PO DAILY
9. Simvastatin 40 mg PO QPM
10. Sodium Bicarbonate 1300 mg PO BID
11. Tamsulosin 0.4 mg PO BID
12. Terazosin 10 mg PO QHS
13. Vitamin D 1000 UNIT PO DAILY
14. CARVedilol 12.5 mg PO BID
15. CloNIDine 0.1 mg PO DAILY
16. linaGLIPtin 5 mg oral daily
17. GlipiZIDE 10 mg PO DAILY
18. Furosemide 60 mg PO EVERY OTHER DAY
19. Furosemide 40 mg PO EVERY OTHER DAY
20. Ferrous Sulfate 325 mg PO BID
21. Ascorbic Acid ___ mg PO DAILY
22. Calcitriol 0.25 mcg PO 3X/WEEK (___)
23. Acetaminophen 1000 mg PO TID
24. Senna 8.6 mg PO BID
25. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
2. Acetaminophen 1000 mg PO TID
3. Allopurinol ___ mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. Calcitriol 0.25 mcg PO 3X/WEEK (___)
9. CARVedilol 12.5 mg PO BID
10. CloNIDine 0.1 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Ferrous Sulfate 325 mg PO BID
13. Furosemide 60 mg PO EVERY OTHER DAY
14. Furosemide 40 mg PO EVERY OTHER DAY
15. GlipiZIDE 10 mg PO DAILY
16. HydrALAZINE 100 mg PO BID
17. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
18. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
19. linaGLIPtin 5 mg oral daily
20. Senna 8.6 mg PO BID
21. Sertraline 50 mg PO DAILY
22. Simvastatin 40 mg PO QPM
23. Sodium Bicarbonate 1300 mg PO BID
24. Tamsulosin 0.4 mg PO BID
25. Terazosin 10 mg PO QHS
26. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right lower extremity cellulitis
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 man with edematous right foot// Rule out fracture
TECHNIQUE: Three views right foot
COMPARISON: None available
FINDINGS:
There are mild degenerative changes at the first metatarsophalangeal joint.
No fracture or dislocation seen. No destructive lytic or sclerotic bone
lesions. There is extensive vascular calcification. Moderate-sized plantar
calcaneal spur. Diffuse soft tissue edema in the forefoot.
Gender: M
Race: WHITE - BRAZILIAN
Arrive by WALK IN
Chief complaint: R Leg Redness
Diagnosed with Cellulitis of right lower limb
temperature: 97.9
heartrate: 77.0
resprate: 16.0
o2sat: 96.0
sbp: 121.0
dbp: 99.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ was admitted on ___ for treatment of right lower
extremity cellulitis. He was started on IV antibiotics
(vanc/cipro/flagyl). He remained afebrile and hemodynamically
stable throughout the admission, and he had no leukocytosis. He
had an xray of the foot which did not show any fracture. The
foot was wrapped in ACE wrap, antibiotics were continued, and
the foot progressively improved. By the day of discharge on
___, his foot was edematous but much improved from prior
with minimal erythema. He was discharged on a 10 day course of
PO Bactrim. On admission, it was also noted that he had an
edematous and erythematous glans of his penis, which he states
had started when his foley was removed several weeks ago.
Urology was consulted and they found the edema consistent with
paraphimosis, and patient was educated on proper care and
hygiene. The edema of his glans penis improved after the
foreskin was manually retracted by urology on ___. He had a
post void residual checked, per urology recs, on the day of
discharge, which was low at 148cc.
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 ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Calcium Channel Blocking
Agents-Dihydropyridines
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of HTN,
HLD, asthma, DM2, atrial fibrillation, ___, myasthenia ___
who presents with 3 weeks of worsening dyspnea on exertion and
productive cough. He has been using his albuterol multiple times
per day and waking up at night to use, when he never used to do
this.
Patient presents with 3 weeks of worsening DOE; + cough
productive of yellow sputum and also has intermittent L sided
CP, lasting for minutes. His CP has no clear exertional
component.
Of note, from his Atrius records, "He was diagnosed with
pericardial constriction in ___, having presented with
new onset congestive heart failure with a preceding history of
atrial fibrillation treated with anticoagulation. He was
diuresed 8 kilos with intravenous diuresis at ___ and underwent
right and left heart catheterization, which showed diastolic
equalization of RV and LV diastolic pressures with some
respiratory variation. Cardiac MRI was not suggestive of any
primary myocardial process and no significant pericardial
thickening. Endomyocardial biopsy was not suggestive of any
infiltrative process. He also had a history of GI bleeding due
to AV malformations and subsequently his Coumadin had to be
discontinued due to recurrent GI hemorrhage. Coronary
angiography in ___ was not suggestive of any obstructive
coronary artery disease.
In ___, exercise nuclear stress test due to
intermittent chest discomfort, mostly atypical with
pharmacological nuclear stress test not suggestive of ischemia
or scar. Ejection fraction was 42% with visually estimated
ejection fraction closer to 50%."
In the ED, initial vitals were:
97.9 88 144/79 12 100% RA
Trop: 0.03
CXR negative for PNA
In the ED, he was given: Albuterol ibratropium, full dose
aspirin, 1L IVF
On the floor, he feels like his breathing is better. He does not
have CP. He denies fever, chills, myalgias, nausea, vomiting,
diarrhea. He denies leg swelling.
Past Medical History:
Asthma
Atrial Fibrillation
CKD
Hyperparathyroidism
DM
HLD
ACh R Ab +ve Myasthenia ___
Colonic Polyps
Duodenal angiomas (s/p thermal therapy)
GI bleeding - capsule endoscopy ___ (for guaiac +ve stools)
showed mild, focal gastritis and no active bleeding sites were
found.
Gastritis
HTN
Constrictive pericarditis
Congestive heart failure diastolic
H/o Exudative pleural effusion
P Surgical Hx:
s/p R total hip replacement
S/p appendectomy
Social History:
___
Family History:
Brother with DM, Mother d. ___ of CVA, Father d. ___ CAD
Physical Exam:
ADMISSION:
Vitals: 98.6 153/86 102 18 98% RA 86.4 kg
General: sitting up in bed, alert, NAD
HEENT: left eye with ptosis, no scleral icterus or conjunctival
injection, MMM, OP clear
Neck: JVP not elevated
CV: irregularly irregular, no murmurs appreciated
Lungs: few wheezes, prolonged expiratory phase, no crackles or
rhonchi
Abdomen: soft, nontender, nondistended
Extr: 1+ pitting edema bilaterally in ___
Neuro: EOMI, PERRL, marked ptosis of left eye, tongue midline,
DISCHARGE:
Vitals: Tm 99 Tc 98.3 ___ 79-102 18 99% RA
Wt 83.9 kg
General: Comfortable-appearing, alert, NAD
HEENT: left eye with ptosis, no scleral icterus or conjunctival
injection, MMM, OP clear
Neck: JVP not elevated
CV: irregularly irregular, no murmurs appreciated
Lungs: few wheezes, prolonged expiratory phase, no crackles or
rhonchi
Abdomen: soft, nontender, nondistended
Extr: 1+ pitting edema bilaterally in ___
Neuro: AOx3, mild ptosis of left eye
Pertinent Results:
ADMISSION LABS:
___ 11:20AM BLOOD WBC-9.4 RBC-4.13* Hgb-11.9* Hct-37.1*
MCV-90 MCH-28.8 MCHC-32.1 RDW-14.5 RDWSD-46.7* Plt ___
___ 11:20AM BLOOD Neuts-80.0* Lymphs-11.0* Monos-7.1
Eos-1.0 Baso-0.4 Im ___ AbsNeut-7.53* AbsLymp-1.04*
AbsMono-0.67 AbsEos-0.09 AbsBaso-0.04
___ 01:52PM BLOOD ___ PTT-32.6 ___
___ 11:20AM BLOOD Glucose-114* UreaN-18 Creat-1.3* Na-137
K-3.9 Cl-99 HCO3-28 AnGap-14
___ 06:50AM BLOOD Calcium-9.6 Phos-2.9 Mg-2.0
___ 11:20AM BLOOD cTropnT-0.03*
___ 05:50PM BLOOD cTropnT-0.03*
___ 11:20AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 11:20AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-7.8 RBC-4.01* Hgb-11.5* Hct-36.1*
MCV-90 MCH-28.7 MCHC-31.9* RDW-14.5 RDWSD-47.6* Plt ___
___ 06:50AM BLOOD Glucose-146* UreaN-15 Creat-1.2 Na-138
K-4.1 Cl-101 HCO3-29 AnGap-12
IMAGING:
___ Chest X ray: No new focal airspace opacity to suggest
pneumonia. Bibasilar atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO BID
2. Atorvastatin 10 mg PO QPM
3. Losartan Potassium 50 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
5. Furosemide 100 mg PO QAM
6. Pyridostigmine Bromide 60 mg PO BID
7. Omeprazole 20 mg PO BID
8. Potassium Chloride 20 mEq PO DAILY
9. Calcitriol 0.25 mcg PO DAILY
10. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Calcitriol 0.25 mcg PO DAILY
3. Furosemide 100 mg PO QAM
4. Losartan Potassium 50 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Pyridostigmine Bromide 60 mg PO BID
7. Vitamin D 5000 UNIT PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhaled Every
four hours Disp #*1 Inhaler Refills:*0
9. Diltiazem Extended-Release 240 mg PO BID
10. Potassium Chloride 20 mEq PO DAILY
Hold for K >
11. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth Three times a day
Disp #*45 Capsule Refills:*0
12. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 5 ML by mouth Every six (6) hours
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Viral bronchitis
Asthma
Diastolic heart failure
Secondary diagnoses:
Myasthenia ___
Chronic kidney disease
Atrial fibrillation
Hypertension
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with shortness of breath, cough
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs ___ through ___
FINDINGS:
Previous opacity at the right base is significantly improved. There is
minimal bibasilar atelectasis. Faint opacities in the right mid lung similar
to prior are likely reflect sequela of prior pneumonia. Heart size is
top-normal as before. The mediastinal and hilar contours are normal. There
is no pleural effusion or pneumothorax. There are degenerative changes in the
right AC and partially imaged left AC joints.
IMPRESSION:
No new focal airspace opacity to suggest pneumonia. Bibasilar atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Chest pain, unspecified, Chronic obstructive pulmonary disease, unspecified, Unspecified atrial fibrillation
temperature: 97.9
heartrate: 88.0
resprate: 12.0
o2sat: 100.0
sbp: 144.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ year old man with a PMH significant for
well controlled asthma (on albuterol only), HTN, HLD, DM, ___,
afib, CKD, hx of constrictive pericarditis (___), and
myasthenia ___ who presented with 3 weeks of cough productive
of yellow sputum, dyspnea, and chest pain.
# Chest pain: His chest pain was non-exertional and
non-positional. His troponin was 0.03 and ECG was unchanged from
prior. The pain began after he began coughing a lot, making
musculoskeletal pain likely. He had a negative stress test in
___ and a normal cath in ___.
# Cough/dyspnea: He did not have fever, chills, myalgias, or
leukocytosis.
His dyspnea and chest pain improved significantly overnight with
acetaminophen, benzonatate, and guaifenasin. He did not require
Duonebs overnight and had normal ambulatory O2 saturations. His
chest X ray was normal. His cough and dyspnea were thought to be
secondary to a viral bronchitis or pneumonia. He felt notably
improved the day after admission and was discharged with
guaifenasin and benzonatate.
# Diastolic heart failure: Mr ___ had no evidence of
decompensation/volume overload on exam or on chest X ray and his
BNP was normal. He was continued on his home doses of furosemide
and losartan.
# Atrial fibrillation: Patient was rate controlled on diltiazem
and was maintained on this. He was not anticoagulated due to a
history of GI bleed.
# Myasthenia ___: Patient was continued on pyridostigmine. He
denied history of diaphragmatic weakness due to MG. In the ED,
his NIF was calculated as -30.
#HTN: Patient was normotensive on his home losartan
#CKD: Creatinine at baseline. Patient continued on home
calcitriol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with h/o COPD, PAD, and HLD who was
recently admitted for pubic ramus and L trochanteric fracture
who presents after a fall. He was recently admitted in ___
also in the context of EtOH use in which his "legs gave way"
resulting in R superior pubic ramus fx and L trochanter fx with
no surgical intervention. He was discharged on ___. Of note,
he was initially transferred to the floor on a CIWA scale and
intermittent diazepam, however he began having evidence of more
severe withdrawal and so was transferred to the ICU for
phenobarbital
loading. Regarding current presentation, patient reports he had
2 beers and when he got home, he was climbing the porch when he
used the door frame to pull himself in through the doorway. His
right hand grip on the door frame slipped and the patient
subsequently fell backwards falling onto his bottom. Patient
denies headstrike. His mother subsequently called EMS. Patient
reports new pain in his bilateral knees. He reports bilateral
lower extremity weakness is at his baseline. He denies any
pelvic pain and denies incontinence of urine or confusion after
the fall. He has had some diarrhea for the past week because he
has been given his roommate's stool softeners. Denies any
dysuria or urinary frequency. No CP/SOB/abdominal pain, denies
any fevers or chills.
In the ED, initial vital signs were: 97.7 93 102/66 18 95% RA
Tm100.1
- Exam was notable for: no tenderness over bilateral ___ or ___ or
abd, or over c- t- or l-spine
- Labs were notable for: wbc 10.2 with 77.5% neutrophils, h/h
___ with MCV 104
- Imaging: knee xray no fracture, small left knee joint effusion
- The patient was given: 5mg IV diazepam, 1 tab percocet,
vanc/cefepime
Vitals prior to transfer were: 100.1 118 109/68 20 94% 3L (no
recorded desaturation in ED)
Upon arrival to the floor, patient continues to complain of b/l
knee pain that intermittently occurs as sharp stabbing pain.
REVIEW OF SYSTEMS:
[+] per HPI
Past Medical History:
PAST MEDICAL HISTORY
PVD s/p femoral bypass
HLD,
COPD
BPH s/p TURP
Chronic pancreatitis
Iron deficiency anemia with likely small bowel source
prostate cancer
ETOH abuse, no hx DTs
PAST SURGICAL HISTORY
Left hip repair s/p femoral neck fracture
Left CEA ___
TURP ___
Bilateral cataract
Left second toe partial amputation
Right common iliac stent
Social History:
___
Family History:
Father died of lung cancer at ___.
Maternal grandfather was diagnosed with colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS - T99.1 BP99/67 HR106 RR20 98%2L NC 64.2kg
GENERAL - pleasant, chronically ill appearing, in no apparent
distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI - mild horizontal nystagmus
NECK - supple, no LAD, no thyromegaly, JVP =
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - decreased breath sounds in b/l bases
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, mild tremor of b/l hands, CN II-XII grossly
normal, normal sensation, with strength ___ throughout in b/l
___. Limited ROM in b/l lower extremities with inability to
extend knee in the setting of pain. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE PHYSICAL EXAM
Exam: T97.8 BP107/62 (79/54 at 11:15am, resolved to 90/60 w/o
intervention) 94 21 100RA
GENERAL - pleasant, chronically ill appearing, in no apparent
distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI - mild horizontal nystagmus
NECK - supple, no LAD, no thyromegaly, JVP =
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - decreased breath sounds in b/l bases
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, mild tremor of b/l hands
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
CIWA SCORING
___
Pertinent Results:
PERTINENT LABS
___ 01:15AM BLOOD WBC-10.2*# RBC-3.32*# Hgb-11.0* Hct-34.4*
MCV-104* MCH-33.1* MCHC-32.0 RDW-12.3 RDWSD-46.0 Plt ___
___ 01:15AM BLOOD Neuts-77.5* Lymphs-7.1* Monos-14.4*
Eos-0.0* Baso-0.6 Im ___ AbsNeut-7.91* AbsLymp-0.73*
AbsMono-1.47* AbsEos-0.00* AbsBaso-0.06
___ 01:15AM BLOOD Glucose-75 UreaN-3* Creat-0.6 Na-133
K-3.9 Cl-99 HCO3-25 AnGap-13
___ 01:15AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.6
___ 01:24AM BLOOD Lactate-1.5
PERTINENT IMAGING
___ CXR:
IMPRESSION:
1. New right middle lobe streaky opacity could reflect
developing pneumonia in the appropriate clinical situation.
2. Hyperexpanded lungs suggestive of emphysema.
3. Sub-centimeter nodule, likely in the superior segment of the
left lower lobe, unchanged. This could be further evaluated with
a non-emergent Chest CT.
___ Knee X-ray:
IMPRESSION:
No acute fracture. Small left knee joint effusion.
PFTs from ___ with severe COPD FEV1 1.8 44%, DLCO 66%.
PERTINENT MICROBIOLOGY
___ BLOOD CX PENDING X ___ URINE CULTURE CONTAMINATED
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Simvastatin 40 mg PO QPM
5. Thiamine 100 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Aspirin 81 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Tiotropium Bromide 1 CAP IH DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN breakthrough
pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every 8 hours Disp #*15
Capsule Refills:*0
10. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
# hypoxemia secondary to atelectasis in the setting of decreased
mobility and COPD
Secondary diagnosis:
# recurrent falls
# etoh abuse
# PVD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.\nActivity Status:
Out of Bed with assistance to chair or wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) BILATERAL
INDICATION: ___ s/p fall with bilateral knee pain and patellar instability
TECHNIQUE: Three views of the bilateral knees were obtained.
COMPARISON: None.
FINDINGS:
Right knee:
The bones are demineralized. The tibia is well aligned with the femur.
Tricompartmental degenerative changes are seen in the knee. There is no
definite joint effusion. No definite acute fracture is identified. Dense
vascular calcifications are seen. There is no evidence of patellar
dislocation.
Left knee:
The bones are demineralized. The tibia is well aligned with the femur.
Tricompartmental degenerative changes are noted. A small suprapatellar joint
effusion is present. Dense vascular calcifications are seen. No definite
acute fracture is identified.
IMPRESSION:
No acute fracture. Small left knee joint effusion.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with hx of COPD and hypoxic. Evaluate for
pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The lungs are hyperexpanded with flattening of the hemidiaphragms, suggesting
emphysema, similar to the prior exam. A sub-cm, round opacity over the left
anterior third rib is overall similar and appears to have a correlate on the
lateral view. This could represent a pulmonary nodule or rib lesion.
Calcified granulomas in the right upper lobe are unchanged. Streaky linear
opacities in the right middle lobe are new from the prior exam, best
appreciated on the lateral view, likely atelectasis. No pleural effusion or
pneumothorax.
Heart size and extensive aortic knob calcifications are unchanged.
Nonspecific gaseous distension of partially visualized loops of bowel are
similar to the prior exam.
IMPRESSION:
1. New right middle lobe streaky opacity is probably atelectasis.
2. Hyperexpanded lungs suggestive of emphysema.
3. Sub-centimeter nodule is unchanged and may be in the bones or lungs. This
could be further evaluated with a non-emergent chest radiograph with shallow
oblique views, or if still unrevealing, a Chest CT.
RECOMMENDATION(S): A non-emergent chest radiograph with shallow oblique
views, or if still unrevealing, a Chest CT, to further evaluate a left lung or
osseous lesion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, ETOH
Diagnosed with Pneumonia, unspecified organism, Alcohol dependence with intoxication, unspecified, Other fall on same level, initial encounter
temperature: 97.7
heartrate: 93.0
resprate: 18.0
o2sat: 95.0
sbp: 102.0
dbp: 66.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ man with h/o COPD, PAD, and HLD who was
recently admitted for pubic ramus and L trochanteric fracture
who presents after a fall and is admitted due to new O2
requirement.
ACTIVE ISSUES
# Hypoxia: Patient with new O2 requirement noted in the ED
though no recorded desaturaton, also CXR read concerning for
pneumonia. Given no clinical evidence of pneumonia such as
fevers, change in cough or sputum production or change in
baseline dyspnea, patient was not treated with antibiotics on
the medical floor. Rather, he was thought to have new O2
requirement in the setting of atelectasis from recent fractures
and relative immobility, and/or worsening of COPD. PE was
thought to be less likely as patient was not tachycardic on
admission and was weaned to room air on discharge. Home COPD
medications were continued. Because of patient's severe
deconditioning, with difficulty even standing, we were unable to
obtain ambulatory O2 sat.
# Fall: Most likely mechanical in the setting of drinking ETOH.
He was evaluated by physical therapy who recommended rehab. Knee
pain was managed with standing Tylenol and PRN oxycodone for
breakthrough pain. Patient was also found to be asymptomatically
hypotensive to SBP 78 on one reading during admission which
improved without intervention. Patient likely with mild
hypovolemic in the setting of decreased po intake with ongoing
etoh abuse.
# EtOH abuse: Patient was maintained on ciwa protocol but
required minimal amounts of benzodiazepine on CIWA scale. He was
not interested in detox programs. He was discharge on MVI,
folate, and thiamine and advised to stop drinking etoh.
# Leukocytosis: likely secondary to atelectasis and stress
response in the setting of fall. No evidence any infection.
CHRONIC ISSUES
# Hx COPD not on home O2: continued home advair, tio, and alb
prn
# HLD: continued home statin
# PVD: continued home aspirin
# Transitional issues
- Reassess ambulatory O2 saturation and need for supplemental
oxygen when patient is strong enough to ambulate
- Please assess patient for hypotension and encourage po intake,
severely deconditioned
- Encourage patient to abstain from etoh
- Non-emergent Chest CT to further evaluate left pulmonary
nodule.
- Please titrate off of narcotics prior to discharge from rehab
if possible to reduce risk for narcotic abuse
- Consider starting patient on vitamin d 800mg po daily
# CODE STATUS: FULL CODE |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / ACE Inhibitors / atorvastatin
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with enterococcus aortic valve
endocarditis (___), DM, HTN, and thoracic myelopathy thought
to be secondary to intrathecal infection with herpes zoster
___, thoracic arachnoid cyst, chronic urinary tract
infections who is well followed by the ___ neurology clinic
who comes in with fatigue and worsening lower extremity weakness
for a few weeks.
Patient is wheelchair bound at baseline, but today she presents
with
diminished strength and the inability to transfer independently.
Patient notes she has had two falls to the ground without head
strike or other traumatic injury. Patient endorses worsening
bilateral lower extremity weakness (L>R, which is her baseline).
No headache, neck pain, no photo or phonophobia. She denies any
infectious symptoms.
Patient called EMS as she was also having leg spasms, but these
have since resolved after she took her home antispasmodics.
Patient notes that she receives monthly Solu-Medrol infusions
for which she has a port in place. She had a visit with her
Neurologist in early ___ and at the time decided to hold
off on the next dose. She now regrets having pushed back, as she
feels these symptoms are similar to those she has when she is
due for Solu-Medrol.
Patient has a colostomy and the output has not changed recently.
No red or dark stools. Denies fevers, chills, sweats, nausea,
vomiting.
In the ED, initial vitals were:
- Exam notable for: Neuro exam: 5- strength all extremities,
awake, oriented, pleasant. Afebrile, no neck pain, low c/f
infectious meningitis
- Labs notable for: Chem 10, LFTs WNL. CBC WNL, with Hgb at
baseline 8.1. VBG: 7.32/60/40. Lactate 1.4. UA pending.
- Imaging was notable for: CT head negative. CXR: no obvious
focal findings
- Patient was given: No interventions were done.
Upon arrival to the floor, patient endorses above. Patient notes
that she has been under increased stress at home as she was
recently called by her PCP about lymphadenopathy seen on her
CXR. She is going to follow up with Hematology/Oncology, but is
concerned that she might have cancer.
Past Medical History:
- Thoracic myelopathy with T8/T9 myelomalacia
- Arachnoid cyst at ___ s/p laminectomy and resection ___
- Type II DM
- Hypertension
- Hyperlipidemia
- Aortic valve endocarditis due to Enterococcus in ___
- Aortic regurgitation
- Pulmonary hypertension
- Shingles in ___
- GERD
- Vitamin B12 deficiency
- Vitamin D deficiency
- Mediastinal lymphadenopathy
- Pulmonary nodule
- Ventral hernia s/p herniorrhapy w/ mesh ___
- CHF, diastolic
- Recurrent UTIs
- Anemia
- Monoclonal Gammopathy
- Left gluteal ulcer
- Back pain
Social History:
___
Family History:
- Father with lung cancer
- Mother with hypertension and osteoarthritis
- Sister with CVA
- Sister with lung cancer
- MGF and MGM with "cardiac disease"
- Aunts with diabetes
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 98.6 170 / 85 96 18 92% Room air
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM
CV: Regular rate and rhythm, ___ systolic crescendo-decrescendo
murmur heard loudest at LUSB, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Colostomy site clean
and non tender.
Ext: Warm, well perfused, no edema. Pressure wound on right calf
from her leg orthosis, non erythematous, non purulent.
Neuro: ___ strength in lower extremities (Right stronger than
left), grossly normal sensation, gait deferred. ___ strength in
upper extremities, grossly normal sensation bilaterally.
CNII-XII intact.
=======================
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.0 | 153/80 | 82 | 18 | 95% RA
General: Alert oriented obese woman in NAD
HEENT: Oropharynx clear, moist mucus membranes
Neck: Obese, supple
CV: RRR, S1, S2 mid peaking systolic murmur with radiation to
the carotids
Lungs: CTAB
Abdomen: Soft, non-tender, exam limited by habitus
GU: No foley
Ext: Warm well profused, 1+ pulses to bilateral lower
extremities, no edema
Neuro: ___ strength to upper extremities. ___ strength to
planter flexion with left worse than right ___ilaterally, stable from yesterday.
Skin: Intact, no rashes appreciated
Pertinent Results:
==============
Admission Labs
==============
___ 01:45AM BLOOD WBC-8.9 RBC-3.53* Hgb-8.1* Hct-28.2*
MCV-80* MCH-22.9* MCHC-28.7* RDW-17.3* RDWSD-49.7* Plt ___
___ 01:45AM BLOOD Neuts-49.0 ___ Monos-8.2 Eos-2.8
Baso-0.9 Im ___ AbsNeut-4.38 AbsLymp-3.48 AbsMono-0.73
AbsEos-0.25 AbsBaso-0.08
___ 01:45AM BLOOD Glucose-136* UreaN-20 Creat-0.8 Na-141
K-4.3 Cl-103 HCO3-25 AnGap-17
___ 01:45AM BLOOD ALT-8 AST-11 AlkPhos-105 TotBili-0.2
___ 01:45AM BLOOD Albumin-3.6 Calcium-8.9 Phos-4.1 Mg-1.7
___ 01:58AM BLOOD ___ pO2-40* pCO2-60* pH-7.32*
calTCO2-32* Base XS-2
___ 02:48AM URINE Color-Straw Appear-Hazy Sp ___
___ 02:48AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 02:48AM URINE RBC-14* WBC-173* Bacteri-FEW Yeast-NONE
Epi-1
============
Microbiology
============
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ URINE CULTURE-FINAL {STAPH AUREUS COAG +}
STAPH AUREUS COAG +. >100,000 CFU/mL.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
___ Blood Culture, Routine-PENDING
=============
Imaging
=============
CT Head:
IMPRESSION:
No acute intracranial process.
CXR:
IMPRESSION:
-Pulmonary vascular congestion.
-No focal consolidation.
==============
Discharge Labs
==============
___ 07:00AM BLOOD WBC-9.8 RBC-3.79* Hgb-8.7* Hct-29.5*
MCV-78* MCH-23.0* MCHC-29.5* RDW-17.2* RDWSD-48.3* Plt ___
___ 07:00AM BLOOD Glucose-263* UreaN-23* Creat-0.7 Na-140
K-3.9 Cl-100 HCO3-30 AnGap-14
___ 07:00AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Valsartan 80 mg PO DAILY
3. Magnesium Oxide 400 mg PO BID
4. Gabapentin 600 mg PO TID
5. Oxybutynin 10 mg PO QAM
6. Diazepam 5 mg PO TID
7. Metoprolol Succinate XL 75 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Tizanidine 8 mg PO TID
10. amLODIPine 10 mg PO DAILY
11. Baclofen 10 mg PO TID
12. Furosemide 40 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. ValACYclovir 1000 mg PO Q24H
15. Omeprazole 40 mg PO DAILY
16. Calcium Carbonate 500 mg PO BID
17. Tamsulosin 0.8 mg PO QHS
18. Cyanocobalamin 1000 mcg PO DAILY
19. Ascorbic Acid ___ mg PO BID
20. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Acyclovir 800 mg PO Q12H
2. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
3. Heparin 5000 UNIT SC BID
4. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
5. Senna 17.2 mg PO BID:PRN constipation
6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 12 Doses
Last dose AM ___ to treat MRSA UTI
7. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
8. amLODIPine 10 mg PO DAILY
9. Ascorbic Acid ___ mg PO BID
10. Baclofen 10 mg PO TID
11. Calcium Carbonate 500 mg PO BID
12. Cyanocobalamin 1000 mcg PO DAILY
13. Diazepam 5 mg PO TID
14. Furosemide 40 mg PO DAILY
15. Gabapentin 600 mg PO TID
16. Magnesium Oxide 400 mg PO BID
17. Metoprolol Succinate XL 75 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Omeprazole 40 mg PO DAILY
20. Oxybutynin 10 mg PO QAM
21. Tamsulosin 0.8 mg PO QHS
22. Tizanidine 8 mg PO TID
23. Valsartan 80 mg PO DAILY
24. Vitamin D 800 UNIT PO DAILY
25. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until you are
discharged from rehab
26. HELD- ValACYclovir 1000 mg PO Q24H This medication was
held. Do not restart ValACYclovir until you are discharged from
rehab
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
=================
Primary Diagnosis
=================
Thoracic myelopathy - steroid responsive
MRSA Urinary Tract Infection
===================
Secondary Diagnosis
===================
Diabetes Type II
Anxiety
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with AMS// ?bleed, fx, PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph on ___, CTA chest on ___
FINDINGS:
The lungs are clear without focal consolidation. There is pulmonary vascular
congestion. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are stable. A left chest Port-A-Cath is again seen,
with the catheter tip in the upper SVC.
IMPRESSION:
-Pulmonary vascular congestion.
-No focal consolidation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with altered mental status.
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 14.0 s, 14.4 cm; CTDIvol = 48.8 mGy (Head) DLP =
702.4 mGy-cm.
2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head on ___
FINDINGS:
Images are mildly limited by motion artifact. No evidence for acute
hemorrhage, edema, mass effect, loss of gray/white matter differentiation.
No suspicious bone lesions are seen. There is mild mucosal thickening in the
frontoethmoidal recesses and anterior ethmoid air cells, right more than left.
Visualized mastoid air cells and middle ear cavities are clear.
IMPRESSION:
No evidence for acute intracranial abnormalities.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Weakness
temperature: 97.5
heartrate: 94.0
resprate: 18.0
o2sat: 98.0
sbp: 151.0
dbp: 75.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ is a ___ with enterococcus aortic valve
endocarditis (___), DM, HTN, and thoracic myelopathy thought
to be secondary to intrathecal infection with herpes zoster
___, thoracic arachnoid cyst, chronic urinary tract
infections who is well followed by the ___ neurology clinic
who comes in with fatigue and worsening weakness for weeks and
is found to have an MRSA UTI. Her weakness improved 1g
solumedrol daily for planned ___nd her UTI was
initially treated with ceftriaxone but transitioned to Bactrim
after cultures grew MRSA. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gemfibrozil
Attending: ___.
Chief Complaint:
Dizziness/Pre-syncope
Major Surgical or Invasive Procedure:
Pacemaker Placement
History of Present Illness:
Mr. ___ is a ___ year old man with a history of afib
(recently dx'd atrial flutter), recent hepatitis who presents
with 1 day of lightheadedness and pre-syncopal symptoms. He was
referred by the lab after he presented for routine INR check. He
was in his usual state of health until ___ when he was started
on amoxacillin for URI symptoms and was diagnosed with an ear
infection.
In the ED, initial vitals were 98.2 46 119/87 16 100%. Labs
notable for INR of 1.3. CXR without significant finding. He
persistently had pauses of ___ seconds prompting urgent
pacemaker placement.
Past Medical History:
- Hypertension
- Hypercholesterolemia
- Type 2 diabetes
- Gout
- Atrial fibrillation-reports onset ___ recurrent episodes
___. Previously treated with amiodarone but complicated
by amiodarone-induced hyperthyroidism which was managed with
methimazole, TSH normalized after DCing amiodarone. Currently
on metoprolol and coumadin.
- sleep apnea
- gastritis on EGD
- Musculoskeletal-trochanteric bursitis and sacroiliitis,
- Erectile dysfunction.
Social History:
___
Family History:
Mother with CVA.
Physical Exam:
Admission to the floor:
VS: 97.5, 108-118/50-55, 70, 18, 99% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g, PPM site dressing CDI
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Discharge:
VS T 98, 88-115/53-64, 70-72, ___, 96-100% RA
Otherwise, grossly unchanged.
Pertinent Results:
Admission:
___ 12:12PM BLOOD WBC-9.0 RBC-4.10* Hgb-12.4* Hct-38.1*
MCV-93# MCH-30.3 MCHC-32.7 RDW-12.8 Plt ___
___ 08:52AM BLOOD ___
___ 12:12PM BLOOD Glucose-111* UreaN-23* Creat-0.8 Na-142
K-4.3 Cl-101 HCO3-24 AnGap-21*
___ 12:12PM BLOOD Calcium-10.0 Phos-3.6 Mg-1.8
Discharge:
___ 06:25AM BLOOD WBC-8.2 RBC-3.80* Hgb-11.6* Hct-35.0*
MCV-92 MCH-30.6 MCHC-33.2 RDW-12.7 Plt ___
___ 06:25AM BLOOD ___ PTT-32.9 ___
___ 06:25AM BLOOD Glucose-91 UreaN-20 Creat-0.7 Na-137
K-4.4 Cl-101 HCO3-22 AnGap-18
___ 06:25AM BLOOD Mg-1.8
CXR:
New transvenous atrioventricular pacer leads follow their
expected courses. No pneumothorax, pleural effusion, or
mediastinal widening. Lungs clear. Heart size normal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
6. Acetaminophen 500 mg PO Q6H:PRN pain
7. Fluticasone Propionate NASAL 2 SPRY NU PRN allergies
8. GlipiZIDE XL 2.5 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Viagra (sildenafil) 25 mg Oral Prior to intercourse
11. Amoxicillin 500 mg PO Q8H
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Fluticasone Propionate NASAL 2 SPRY NU PRN allergies
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
7. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*9 Capsule Refills:*0
8. Amlodipine 10 mg PO DAILY
9. GlipiZIDE XL 2.5 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. Viagra (sildenafil) 25 mg Oral Prior to intercourse
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Neck pain. Assess for cardiopulmonary process.
COMPARISON: Chest radiographs, ___.
TECHNIQUE: Single portable frontal chest radiograph.
FINDINGS: The lungs are well expanded and clear. The left costophrenic angle
is partially visualized; however, there is no large pleural effusion. The
right pleural surface is clear. Heart size, mediastinal contour, and hila are
normal.
IMPRESSION: No evidence of acute cardiopulmonary process.
Radiology Report
PA AND LATERAL CHEST, ___
HISTORY: Pacemaker placement.
IMPRESSION: PA and lateral chest compared to ___:
New transvenous atrioventricular pacer leads follow their expected courses.
No pneumothorax, pleural effusion, or mediastinal widening. Lungs clear.
Heart size normal.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: LIGHTHEADED/AFIB
Diagnosed with ATRIAL FIBRILLATION, VERTIGO/DIZZINESS
temperature: 98.2
heartrate: 46.0
resprate: 16.0
o2sat: 100.0
sbp: 119.0
dbp: 87.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with atrial fibrillation who
presented with syncope and atrial fibrillation alternating with
___ second pauses.
# Atrial Fibrillation: Patient presented with significant
pauses alternating with atrial fibrillation/flutter prompting
pacemaker placement urgently. He underwent pacemaker placement
on ___ which was uncomplicated. He was discharged on
prophylactic keflex and his home dose of metoprolol. His
warfarin was continued without bridge, given his new ABx he will
need f/u INR on ___.
# HTN:
Antihypertensives were held during admission save for lisinopril
at 20mg. He can restart on discharge.
# DM: Sulfonylurea was held, insulin by sliding scale was
continued.
# GERD: Omeprazole was continued.
# OSA: Encouraged patient to restart CPAP.
# Otitis media: Transitioned amoxicillin to Keflex post-op for
better MSSA coverage in the setting of PPM placement. Course for
OM was to complete on ___, but new course of Keflex will
overlap. |
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:
___ with h/o breast CA, COPD (on home O2 2LNC), is referred to
___ from ___ primary care with hypoxia. Patient reports over
the last week she has had a productive cough and increasing
shortness of breath. Her husband has similar symptoms and she
was febrile to 101 at home 4 days ago. Dyspnea worsened and she
presented to her PCP to hypoxic and was referred into the ___
ED. Of note, she was started on prednisone 3 weeks ago for COPD
exacerbation.
Initial VS in the ED: 98.3 94 118/96 24 87% Labs notable for ABG
pH 7.43 pCO2 52 pO2 32, WBC 11.3 with 79 neutrophils. K+ 2.6, Cr
1.2 (baseline 0.8), HCO3 33, Cl 90. Patient was given
Azithromycin 500mg x1 and CTX 1g IV. Albuterol and Ipratropium
nebs, solumedrol 125mg IV, and KCl 40 meq PO x1.
VS prior to transfer: 98.2 95 137/114 27 95% 2.5L
On the floor, she stated breathing remained moderately
uncomfortable denies chest pain.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
hemoptysis. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Accept Note:
Briefly, this is a ___ y/o female with COPD, on home O2 (2L), who
presents to ED with increasing SOB/cough over the past week. She
was seen in her PCP office yesterday, portable CXR done, showed
possible R lower lung opacity (possible pneumonia). About a week
ago, pt noticed increasing fatigue/sore throat (no nasal
congestion). Since then, she had worsening of her baseline
cough, increasing production of green sputum. She measured her
temperature at home and it was 101. She uses 2L of home O2 and
increased it to 4L over the last week. No increased use of home
COPD meds. SOB with exertion also worsening, with no SOB at
rest. She has been started on two Prednisone tapers since
___. She finished one course, restarted, and now at 20mg PO
qd at time of admission. No recent hospitilizations, lives at
home. No sick contact, however, husband (who has COPD) is sick
after her recent deterioration (?viral). Endorses myalgias. Has
not had flu vaccine, has strep pneumo vaccine. Denies n/v, d/c,
blood in stool, blood in sputum.
Past Medical History:
-- COPD (FEV 2L, FEV1/FVC 62%) - W/ Positive MAC cx
-- Hypertension
-- h/o Breast cancer s/p lumpectomy
Social History:
___
Family History:
Father: stroke
Mother: ___ CA
Brother: COPD
Brother: COPD MI
Physical Exam:
Admission Physical Exam:
Vitals: T:98.6 BP:119/79 P:83 R: 18 O2:95% 4LNC
General: elderly appearing female, pursed lip breathing,
speaking in fullsentences.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Prolonged expiratory phase, distant breath sounds, R>L
inspiratory wheezes at the base. no ronchai.
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,
Ext: No edema
Discharge Physical Exam:
VS- 99.3 ___ 20 96% 2L
Gen- NAD, breathing more comfortably compared to yesterday
HEENT- MMM, no JVD
PULM- No wheezes, crackles in RLL/RML
CV- S1S2 RRR no m/g/c/r
Abd- Soft, nt/nd, bs+, no organomegaly
Pertinent Results:
Admission Labs:
___ 06:35PM BLOOD WBC-11.3* RBC-4.16* Hgb-13.5 Hct-39.1
MCV-94 MCH-32.4* MCHC-34.5 RDW-13.5 Plt ___
___ 06:35PM BLOOD Neuts-79.1* Lymphs-13.6* Monos-5.6
Eos-1.4 Baso-0.3
___ 06:35PM BLOOD ___ PTT-29.8 ___
___ 06:35PM BLOOD Glucose-95 UreaN-23* Creat-1.2* Na-136
K-2.6* Cl-90* HCO3-33* AnGap-16
___ 06:35PM BLOOD Calcium-10.1 Phos-2.7 Mg-2.2
___ 06:48PM BLOOD Lactate-1.0
___ 06:48PM BLOOD pO2-32* pCO2-52* pH-7.43 calTCO2-36* Base
XS-8
Discharge Labs:
___ 06:35AM BLOOD WBC-10.5 RBC-3.59* Hgb-11.4* Hct-34.2*
MCV-96 MCH-31.9 MCHC-33.4 RDW-14.0 Plt ___
___ 06:35AM BLOOD Glucose-61* UreaN-14 Creat-0.7 Na-140
K-4.1 Cl-100 HCO3-32 AnGap-12
___ 06:35AM BLOOD ALT-23 AST-25 AlkPhos-61 TotBili-0.2
___ 06:35AM BLOOD Calcium-8.8 Phos-3.6# Mg-2.1
Negative beta glucan and galactomannin, histoplasma ab pending
Imaging:
CXR
IMPRESSION: Right lower lung reticular opacities concerning for
acute
infection in the setting of severe emphysema.
Video Swallow
IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy.
Microbiology
Negative Blood Cx x2
Negative Legionella
___ 4:13 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): Pending
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP <100
5. PredniSONE 20 mg PO DAILY
started 50mg daily tapered down by 10mg/ week
Tapered dose - DOWN
6. Sertraline 200 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. zoledronic acid *NF* 5mg/100mL Injection Monthly
9. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP <100
3. Sertraline 200 mg PO DAILY
4. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
5. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice daily Disp
#*12 Tablet Refills:*0
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*3 Tablet Refills:*0
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Tiotropium Bromide 1 CAP IH DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Zoledronic Acid *NF* 5 mg/100mL INJECTION MONTHLY
12. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Obstructive Pulmonary Disease
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___
HISTORY: ___ female with hypoxia and dyspnea.
FINDINGS: Single portable view of the chest is compared to previous exam from
___. The lungs are hyperinflated with chronic changes suggestive
of known underlying emphysema. There are superimposed regions of
consolidation at the right lung base laterally, worrisome for superimposed
infection in the appropriate clinical setting. Multiple old bilateral rib
fractures are again identified. Cardiomediastinal silhouette is stable as are
the osseous and soft tissue structures.
IMPRESSION: Right lower lung opacity seen laterally, suspicious for pneumonia
in the proper clinical setting. Recommend repeat after treatment to document
resolution.
Radiology Report
INDICATION: ___ woman with cough and shortness of breath, evaluate
for infiltrate.
COMPARISON: Multiple prior studies including chest x-ray from ___, chest CT from ___ and chest CT dating back to ___.
TECHNIQUE: PA and lateral views of the chest.
FINDINGS: Diffuse emphysema is evident with flattening of diaphragms. Right
lower lobe reticular opacities could be acute infection in the setting of
severe emphysema. The left lung is essentially clear. Old rib fractures are
noted in bilateral posterior ribs at multi-levels. The cardiomediastinal
silhouette and hilar contours are unremarkable. There is no pleural effusion
or pneumothorax.
On review of a CT from ___, adjacent to the right lower lobe bronchus
(2:31), is a calcified lymph node that could become a broncholith, although it
has not migrated since at least ___.
IMPRESSION: Right lower lung reticular opacities concerning for acute
infection in the setting of severe emphysema.
Radiology Report
INDICATION: ___ woman with ? recurrent aspiration pneumonia, evaluate
for dysfunction.
COMPARISON: None.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with speech and swallow division. Multiple consistencies of
barium were administered.
FINDINGS: Barium passes freely through the pharynx and esophagus without
evidence of obstruction. There was no gross aspiration or penetration. For
details, please refer to speech and swallow division note in OMR.
IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: 98.3
heartrate: 94.0
resprate: 24.0
o2sat: 87.0
sbp: 118.0
dbp: 96.0
level of pain: 0
level of acuity: 1.0 | ___ y/o F with PMHx of COPD, breast CA, presents to the ED from
her PCP office with worsening SOB/productive cough with fever
(at home) consistent with pneumonia.
.
# Community Acquired Pneumoina vs COPD Flare: Patient with fever
at home and worsening productive cough/SOB with exertion;
radiographic findings consistent with RLL pneumonia on a
portable CXR. Crackles on exam in the R lower lung fields, no
wheezes. Afebrile, but with mild elevation in WBC w/o L shift.
H/o husband becoming sick after her detioration (?possibly
viral). Came in on 20mg Prednisone as part of a taper for COPD.
She has not recently been hospitalized. A repeat CXR was also
read as a R lower lobe infiltrate concerning for pneumonia.
Pulmonary was consulted who asked for fungal markers, speech and
swallow (to assess for aspiration risk since pt has a h/o of
RML/RLL pneumonias), and respiratory therapy interventions. Pt
was treated with a course of Ceftriaxone and Azithromycin in
house; also nebs. Prednisione was also tapered while in house
(Pulmonary did not think she had a COPD flare): It was
recommended to decrease the Prednisone by 10mg per day
(40->30->20->10->5->0 mg). Sputum culture also showed yeast,
patient was prescribed nyastatin. Discharged with Cefpodoxime PO
(10 day total course w/ Ceftriaxone) and Azithromycin PO (5-day
course).
.
# COPD: Patient with severe COPD follow at ___. Has multiple
courses of Prednisone in the past. Prednisone taper over 25 days
(starting 50mg taper every 5 days) started on ___. Underwent
pulmonary rehab at ___ recently. PFTs in OMR. On home O2 at
___. She has been evaluated at ___ for possible lung
transplant but denied. Per outpatient pulm note, patient to have
end of life discussions with PCP. She has sputum cultures from
the outpatient realm showing MAC in ___ cultures, which may
represent colonization (h/o COPD). We consulted pulmonary and
touched base with the pt's pulmonologist for management of the
patient's pneumonia while in the hospital. Prednisione was
tapered as above, per pulmonary. Possible MAC tx will be
initiated as an outpt. Was also started on Bactrim prophylaxis
while on Prednisone. Instructed to continue it as an outpt while
she was tapered off Prednisone.
.
#Hypokalemia: K was 2.6 at admission, after repletion, K is up
to 3.7. HCTZ was held at ___ due to low K. K normalized
and HCTZ was restarted prior to discharge.
.
___: Responded to IVF, back to normal within 12 hours. Likely
pre-renal.
.
#Hypertenion: Currently stable. HCTZ held due to hypokalemia.
Once K stabilized, HCTZ was restarted.
.
# Depression
-- Conitnued BuPROPion (Sustained Release) 150 mg PO QAM
-- Continued Sertraline 200 mg PO/NG DAILY
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
RLE nonhealing ulcer and rest pain
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Ultrasound-guided access to the left common femoral
artery.
2. Selective catheterization of the right popliteal artery,
___ order vessel.
3. Abdominal aortogram.
4. Right lower extremity angiogram.
5. Balloon angioplasty of the right tibioperoneal trunk and
peroneal arteries.
6. Stenting of the right distal popliteal artery and
tibioperoneal trunk.
History of Present Illness:
___ h/o ESRD on HD, CAD s/p MI x4, CVA, Afib, s/p L
AKpop-DP BPG w/ nrGSV ___, ___ for left foot
nonhealing
ulcer and associated rest pain. The left foot ulcer has
completely healed and his rest pain has resolved but his bypass
graft has stenosed requiring balloon angioplasty 6 months ago.
He
has a h/o GI bleed and thus is unable to be on
antiplatelet/anticoagulation therapy. He was seen in clinic 2
weeks ago and was noted to have an area of tissue ischemia on
the
tip of the right third toe for which local wound care was
recommended. However, he was seen back in clinic today with
complaints of persistent pain in his right great toe so he was
sent to the ED for admission to the floor with plan for a RLE
angiogram on ___. He denies any fevers, chills, nausea/vomiting
or diarrhea.
ROS:
(+) per HPI
(-) Denies headache, dizziness, vertigo, syncope, weakness,
paresthesias, nausea, vomiting, hematemesis, bloating, cramping,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
Past Medical History:
-ESRD on HD MWF
-HTN
-Afib
-Neuropathy
-GI Bleed
-CAD sp MI x 4
-Cirrhosis
-CVA-
-Hyperparathyroidism
-GERD
-Depression
-Arthritis
-Nephrolithiasis
Past Surgical History:
-___: LLE angiogram via R groin access with PTA of
tibioperoneal trunk/peroneal a.
-Right nephrectomy
-___ UE graft that has now failed
-IVC filter
-___: L AKpop-DP with L nonreversed GSV
Social History:
___
Family History:
Hypertension, high cholesterol, and kidney failure.
Physical Exam:
Discharge Physical Exam:
Vitals - temp 98.9 / HR 100 / SBP 101/68 / RR 16 / O2sat 98%RA
General - comfortable, NAD
HEENT - PERRLA, EOMI, moist mucous membranes
Cardiac - RRR, no M/R/G
Chest - CTAB
Abdomen - soft, NT, ND, normoactive bowel sounds
Groin - left groin moderate bruising and swelling, resolving
Extremities - RLE 6cm area of ulceration overlying the ___ and
___ metatarsal
and ___ metatarsal. No obvious purulence or erythema. Tenderness
to palpation over right great toe. Bilateral warm
Vascular:
R: P/D/D/D L: P/D/D/-
Pertinent Results:
CBC:
___ 06:30AM BLOOD WBC-5.6 RBC-2.36* Hgb-7.5* Hct-22.8*
MCV-97 MCH-31.8 MCHC-32.9 RDW-13.8 RDWSD-49.0* Plt ___
___ 03:45AM BLOOD WBC-7.0# RBC-2.80* Hgb-9.0* Hct-27.4*
MCV-98 MCH-32.1* MCHC-32.8 RDW-13.8 RDWSD-49.5* Plt ___
___ 06:30AM BLOOD WBC-4.5 RBC-3.11* Hgb-10.0* Hct-30.2*
MCV-97 MCH-32.2* MCHC-33.1 RDW-13.9 RDWSD-49.1* Plt ___
___ 12:10PM BLOOD WBC-5.3 RBC-3.25* Hgb-10.5* Hct-31.6*
MCV-97 MCH-32.3* MCHC-33.2 RDW-13.6 RDWSD-48.9* Plt ___
BMP:
___ 06:30AM BLOOD Glucose-97 UreaN-14 Creat-3.9*# Na-138
K-3.9 Cl-100 HCO3-25 AnGap-17
___ 11:30AM BLOOD Glucose-84 UreaN-31* Creat-7.3*# Na-136
K-4.3 Cl-99 HCO3-23 AnGap-18
___ 06:30AM BLOOD Glucose-68* UreaN-18 Creat-5.0*# Na-136
K-4.2 Cl-96 HCO3-26 AnGap-18
___ 12:10PM BLOOD Glucose-86 UreaN-33* Creat-7.1* Na-133
K-4.0 Cl-90* HCO3-29 AnGap-18
CHEST (PRE-OP PA & LAT) Study Date of ___ 10:49 ___
IMPRESSION:
Right IJ approach dialysis catheter terminates in the right
atrium. Lung
volumes are slightly low with bibasilar heterogeneous opacities
likely
reflecting atelectasis. No evidence of pneumonia. A stent
graft extends
horizontally along the upper left chest, likely in the left
subclavian vein and brachiocephalic vein.
___ Angiogram
ANGIOGRAPHIC FINDINGS:
1. Patent infrarenal abdominal aorta.
2. Patent bilateral iliac systems. Of note, the iliac
arteries were tortuous and heavily calcified.
3. The right common femoral artery, profunda femoris, and
superficial femoral artery are patent.
4. The right popliteal artery is patent.
5. The right anterior tibial artery occludes approximately
1 to 2 cm after its takeoff. There is distal
reconstitution of the AT above the level of the ankle,
and there is evidence of a diminutive dorsalis pedis
within the foot.
6. The right tibioperoneal trunk is occluded. There is
distal reconstitution of the peroneal artery which is
the main tibial vessel providing flow into the foot.
7. The right posterior tibial artery is occluded. It does
reconstitute at the level of the ankle, but the runoff
in the foot is poor.
FEMORAL VASCULAR US LEFT Study Date of ___ 10:54 AM
IMPRESSION:
No pseudoaneurysm. No measurable hematoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO DAILY
2. Mirtazapine 7.5 mg PO QHS
3. Atorvastatin 20 mg PO QPM
4. Cinacalcet 120 mg PO QHS
5. sevelamer CARBONATE 1600 mg PO TID W/MEALS
6. Clopidogrel 75 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 500 mg-125 mg 1
tablet(s) by mouth daily Disp #*28 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp
#*40 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Cinacalcet 120 mg PO QHS
6. Clopidogrel 75 mg PO DAILY
7. Lactulose 30 mL PO DAILY
8. Mirtazapine 7.5 mg PO QHS
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
RLE nonhealing ulcer
RLE rest pain
Peripheral vascular disease
ESRD on HD
hypertension
atrial fibrillation
arthritis
depression
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: ___ year old man preop for RLE angiogram// Preop
TECHNIQUE: Chest AP and lateral
COMPARISON: ___.
IMPRESSION:
Right IJ approach dialysis catheter terminates in the right atrium. Lung
volumes are slightly low with bibasilar heterogeneous opacities likely
reflecting atelectasis. No evidence of pneumonia. A stent graft extends
horizontally along the upper left chest, likely in the left subclavian vein
and brachiocephalic vein.
Radiology Report
EXAMINATION: FEMORAL VASCULAR US LEFT
INDICATION: ___ year old man s/p angiogram via left groin access now with
swelling and bruising// Evaluate hematoma vs pseudoaneurysm
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left groin area.
COMPARISON: None
FINDINGS:
Transverse and sagittal grayscale and Doppler images were obtained of the
superficial tissues of the left groin area. Targeted imaging of the area
demonstrated patent vasculature of the left common femoral, femoral and deep
femoral vein and common femoral, femoral and deep femoral artery with
appropriate waveforms. There is no evidence of pseudoaneurysm or abnormal
connection between the artery and the vein.
IMPRESSION:
No pseudoaneurysm. No measurable hematoma.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by UNKNOWN
Chief complaint: R Foot pain, Wound eval
Diagnosed with Pain in right ankle and joints of right foot, Chronic kidney disease, unspecified
temperature: 98.5
heartrate: 74.0
resprate: 17.0
o2sat: 99.0
sbp: 115.0
dbp: 69.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ w/ peripheral vascular disease who was
admitted from clinic through the Emergency department on
___ for nonhealing RLE ulcers and ___ toe pain. The patient
was examined by vascular surgery and started on broad-spectrum
IV antibiotics for the ulcers and pain medications. Dialysis was
performed for Creatinine of 7.1. He was admitted to the vascular
service and underwent a RLE angiogram via left groin access on
___. Angioplasty and stent was placed in the TP trunk, for
full details of the procedure please see the operative report.
The patient tolerated the procedure without complications and
was transferred back to the VICU in stable condition. On post-op
check, he was comfortable and his groin was C/D/I. He was
started back on all of his home medications as well as a regular
diet, which he tolerated without issue.
On the night of POD0, it was noted that Mr. ___ had an area
of bruising and swelling that was gradually expanding in the
area of his left groin access. Pressure was held for 30 minutes,
and the patient remained hemodynamically stable and
asymptomatic. A left groin duplex was performed on POD1 that
demonstrated no pseudoaneurysm or measurable hematoma. His
dialysis was continued according to his regular schedule of
___. He was observed for an additional night to monitor his
left groin as well as his RLE ulcer and pain.
On POD2, Mr. ___ was able to tolerate a regular diet, get
out of bed to chair and work with physical therapy as is his
baseline prior to admission, void without issues, and pain was
controlled on oral medications alone. His groin bruising was
gradually resolving and his Hct and SBP were both stable. His
RLE pain was mildly improving and he had dopplerable DP and ___
signals on the RLE. He was deemed ready for discharge, and was
given the appropriate discharge and follow-up instructions. He
will follow-up with Dr. ___ in 1 month to evaluate his RLE
ulcers and pain, and will be considered for a repeat angiogram
under general anesthesia if his foot pain does not continue to
improve. He will continue to require wound care at his facility,
and he will continue his Plavix given the recent angioplasty and
stent placement. He will also be discharged on 2 weeks of
augmentin. |
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 ___ erythema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ year old woman with a PMHx s/f DMII and
diabetic neuropathy who presents with left lower extremity
swelling and erythema most concerning for cellulitis. Patient
seen emergency Department one week ago at which time plain films
were unremarkable for an acute fracture dislocation. She was dx
with a UTI at that time and sent home with 5 day course of
Cipro. Since that time her pain is increasingly worse as is the
erythema and swelling. She was seen by her PCP today who
requested emergency department evaluation for question of
cellulitis. She denies fever, chills, sweats, nausea, vomiting.
Denies any dysuria.
In the ED, initial vs were: 98.4 69 165/67 16 96% ra. She had a
CBC and BMP that were unremarkable, Lactate 1.4, glucose 222
Plain films were obtained of the left foot which were
unremarkable. Patient was given Vancomycin and Zosyn.
Past Medical History:
DM II W NEPHROPATHY, NEUROPATHY, RETINOPATHY
HYPERTENSION
PERIPHERAL VASCULAR DISEASE
CATARACTS
CARCINOMA OF THE COLON, s/p anterior resection ___
Social History:
___
Family History:
DM runs in family
Physical Exam:
On admission:
Vitals: T 97.8 BP 180/65 P66 R 20 O2 sat 98
General: ___ speaking female, NAD, AOx3
HEENT: MMM, anicteric sclera
Neck: supple, no LAD
CV: RRR, no mrg
Lungs: scant crackles at bases of lungs bilterally
Abdomen: soft, non-tender, non-distended, no rebound or guarding
GU: deferred
Ext: pedal pulses difficult to appreciate, extermities warm,
well perfused
Neuro: CN ___ grossly intact
Skin: erythematous dorsal surface of left foot, warm and tender
to palpation, black scab on third left toe, no open wounds or
ulcers visable, no drainage
On d/c:
Vitals: T 98.2 BP 134/47, 68, 20, 97% on RA
General: ___ speaking female, NAD, AOx3
HEENT: MMM, anicteric sclera
Neck: supple, no LAD
CV: RRR, no mrg
Lungs: crackles at bases of lungs bilterally
Abdomen: soft, non-tender, non-distended, no rebound or guarding
GU: deferred
Ext: pedal pulses difficult to appreciate, extermities warm,
well perfused
Neuro: CN ___ grossly intact
Skin: erythematous dorsal surface of left foot--decreased area
compared to yesterday, less warm, mildly tender to palpation,
black scab on third left toe, no open wounds or ulcers visable,
no drainage
Pertinent Results:
___ 02:50PM LACTATE-1.4
___ 02:40PM GLUCOSE-220* UREA N-17 CREAT-0.8 SODIUM-138
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
___ 02:40PM WBC-8.6 RBC-4.23 HGB-12.3 HCT-36.7 MCV-87
MCH-29.0 MCHC-33.5 RDW-13.5
___ 02:40PM NEUTS-59.0 ___ MONOS-4.0 EOS-6.2*
BASOS-0.8
___ 02:40PM PLT COUNT-211
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. NPH 55 Units Breakfast
NPH 30 Units Dinner
4. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. NPH 55 Units Breakfast
NPH 30 Units Dinner
3. Lisinopril 20 mg PO DAILY
4. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*20 Capsule Refills:*0
5. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
6. Aspirin 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___ cellulitis
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: Left foot swelling and pain after fall.
COMPARISON: None.
TECHNIQUE: 3 views of the left ankle and 3 views of the left foot.
FINDINGS:
There is no acute fracture or dislocation. The ankle mortise is symmetric.
The talar dome is smooth. A small plantar calcaneal spur is demonstrated.
There is diffuse demineralization of the osseous structures. Diffuse
degenerative changes are noted involving the DIP joints with joint space
narrowing and osteophytic spurring. There are vascular calcifications
present. No suspicious lytic or sclerotic osseous abnormalities are present.
No radiopaque foreign body or soft subcutaneous gas is seen.
IMPRESSION:
No acute fracture or dislocation.
Gender: F
Race: HISPANIC/LATINO - HONDURAN
Arrive by WALK IN
Chief complaint: L Foot pain
Diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF LEG
temperature: 98.4
heartrate: 69.0
resprate: 16.0
o2sat: 96.0
sbp: 165.0
dbp: 67.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is an ___ year old woman with a PMHx s/f DMII, HTN, and
diabetic neuropathy who presents with left lower extremity
swelling and erythema most concerning for cellulitis.
Active Issues:
# ___ Erythema: Secondary to cellulitis. Given IV vanc in ED. Pt
improved overnight on oral PO clinda and bactrim. Monitored Cr
on bactrim: 0.8--> 1.0; pt also stated she had good UOP. Pt d/c
on 5 more days of PO clinda and bactrim. Pt to f/u with Dr.
___ PCP, to make her her cellulitis has resolved.
# HTN: Pt hypertensive to SBP of 180 when arriving to floor,
most likely bc pt had missed meds. Her BP improved after
recieving her home atenolol 25 mg daily and lisinopril 20 mg
tablet. BP was no longer an issue for the remainder of her
hospital course.
#Volume overload: Crackles heard on pt's lung exam as well as
mild pitting ___ edema on admission: most likely volume
overloaded from some component of mild chf given pt's risk
equivalents of CAD (DM, PVD). Pt not symptomatic: denies sob,
pnd or doe. In the future would consider starting low dose oral
lasix +/- further workup as outpatient such as echo. Will defer
to pt's PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall onto pavement
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ otherwise healthy was walking with his wife at ~8am when
she heard him fall to the ground, and noted that he had hit his
head on the pavement. He had not been complaining to his wife of
any symptoms before falling, though she did note that he had
some
symptoms of chest pain earlier in the week. Unclear if he lost
consciousness at the time of the fall. He was brought to the
___ by EMS, where he was awake and neurologically intact
per report. He began having episodes of emesis x3-4 and was
intubated for airway protection. CTH at the OSH showed b/l SAH
and occipital skull fracture, CT c-spine without obvious bony or
cord injury, and he was transferred to ___ for further
management.
Past Medical History:
Arthritis
Social History:
___
Family History:
non contributory
Physical Exam:
On Admission:
O: T:afeb BP:150/80 HR:73 R18 100% on FiO2 40$
Gen: NAD, intubated
HEENT: Pupils: 2mm, non-reactive EOMs unable to evaluate
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: Sinus brady
Abd: Soft, ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated
Orientation: unable due to intubation
Recall: unable due to intubation
Language: unable due to intubation
Cranial Nerves:
I: Not tested
II: Pupils 2mm b/l, non-reactive. VF: unable due to intubation
III, IV, VI: unable to examine due to intubation
V, VII: unable to examine due to intubation
VIII: unable to examine due to intubation
IX, X: unable to examine due to intubation
XI: unable to examine due to intubation
XII: unable to examine due to intubation
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Moving all extremities spontaneously when off propofol,
localizing to ETT
Sensation: unable to examine
On Discharge:
alert & oriented x3
PERRL, EOM intact
Face symmetric
No pronator drift
MAE ___ strength
Pertinent Results:
___ 10:45AM BLOOD CK-MB-3 cTropnT-<0.01
___ 10:45AM BLOOD CK(CPK)-527*
___ 02:55PM BLOOD CK-MB-4 cTropnT-0.09*
___ 02:55PM BLOOD CK(CPK)-301
CT Head w/o Contrast ___
FINDINGS:
Bilateral subarachnoid hemorrhages and have increased in volume
diffusely. The subdural hematoma along the left frontal and
temporal convexity is slightly smaller. Small subdural hematoma
along the left parietal convexity (601b:71) was not definitely
seen previously and measures 6 mm.
Contusions of the bilateral temporal lobes, and trace hemorrhage
layering
posteriorly in the occipital horn of the right lateral ventricle
are
unchanged. There is no shift of normal midline structures. The
basal cisterns are patent. There is no hydrocephalus. There is
no evidence of large territorial infarction.
Comparison increase in the right frontal and parietal scalp
hematoma. Fracture of the right paramedian occipital bone with
extension to the mastoid is re- demonstrated. As before there is
opacification of several right mastoid air cells and the middle
ear. Opacification of the right sphenoid sinus and mucosal
thickening of the ethmoidal air cells is similar to prior.
IMPRESSION:
Apparent new small subdural along the left parietal convexity
measuring up to 6 mm. Mild increase in diffuse subarachnoid
hemorrhage. Otherwise there is no appreciable change.
CTA HEAD W&W/O C & RECONS ___
1. Incompletely occlusive thrombus in the right sigmoid sinus,
deep to the
nondisplaced fracture of the right occipital and temporal bones.
2. Slight interval enlargement of the left frontal hemorrhagic
contusion.
Stable left larger than right temporal hemorrhagic contusions.
3. Slightly decreased left subdural hematoma. Evolving bilateral
subarachnoid
hemorrhage.
4. Mild mucosal thickening along the floors of bilateral
maxillary sinuses,
contiguous with periapical lucencies associated with bilateral
maxillary
molars. This suggest odontogenic inflammation within the
paranasal sinuses.
MRV HEAD W/O CONTRAST ___
Small filling defect is again demonstrated in the right sigmoid
sinus,
consistent with thrombus. The defect does not appear completely
occlusive on the preceding CTV, which is likely more accurate.
CT HEAD W/O CONTRAST ___
1. Subdural, and subarachnoid hemorrhage
2. Bilateral frontal and temporal lobe contusions, left-sided
contusions are hemorrhagic .
3. Multiple fractures seen, including fracture in the wall of
the right
sphenoid sinus, possibly involving the right carotid canal.
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ TTE (Complete) Done
___ at 1:34:17 ___ FINAL
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Normal biventricular cavity size and regional/global systolic
function. No pathologic valvular abnormalities
___ EKG
Sinus bradycardia. Short P-R interval. Left ventricular
hypertrophy.
Compared to the previous tracing of ___ the P-R interval is
shorter.
Clinical correlation is suggested.
___ EKG
Sinus rhythm. Prolonged Q-T interval. Short P-R interval. Left
ventricular
hypertrophy. Compared to the previous tracing the Q-T interval
has slightly
increased.
___ EKG
Sinus rhythm. QTc interval prolongation. Short P-R interval.
Left
ventricular hypertrophy. Compared to the previous tracing of
___ there is no significant diagnostic change.
___ EKG
Sinus rhythm. Compared to tracing #1 QTc interval prolongation
has slightly improved.
___ EKG
Sinus rhythm. Compared to tracing #2 there is no significant
diagnostic
change.
Medications on Admission:
Methotrexate, Nabumetone
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. LeVETiracetam 1000 mg PO BID
4. HydrALAzine 25 mg PO Q6H
5. Lisinopril 10 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Propranolol 20 mg PO TID
9. Senna 8.6 mg PO BID:PRN constipation
10. Sodium Chloride 1 gm PO TID
11. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
bilateral subarachnoid hemorrhage
L subdural hematoma
R occipital skull fracture
bilateral temporal contusions
Long QTC interval
R sigmoid sinus thrombosis
Hypertension
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: Intubation, evaluate for ET tube placement.
TECHNIQUE: Portable frontal chest radiograph.
COMPARISON: None.
FINDINGS:
Endotracheal tube terminates 4.9 cm above the carina. An enteric tube courses
into the stomach. Opacity at the lungs bases could represent atelectasis or
aspiration. No pleural effusion or pneumothorax. Heart is normal size. The
mediastinal and hilar structures are unremarkable. A calcified granuloma is
seen at the left lung apex. No obvious rib deformities.
IMPRESSION:
1. Endotracheal tube 4.9 cm above the carina.
2. Opacity at the lungs bases could represent atelectasis or aspiration.
Radiology Report
INDICATION: ___ with subarachnoid hemorrhage .
TECHNIQUE: Following an noncontrast head CT, axial multidetector CT images of
the head and neck were obtained during intravenous contrast administration.
Maximal intensity projection reformatted images, curved reformatted images,
and 3D volume rendered angiographic reformatted images were obtained. Coronal
and true axial reformations of right temporal bone were also obtained.
DOSE: DLP 2497.94 mGy cm
COMPARISON: Noncontrast head CT performed on ___ at ___
___
FINDINGS:
NONCONTRAST HEAD CT Again seen are hemorrhagic contusions in the left frontal
and temporal lobes. Small hemorrhagic contusion in the right temporal lobe is
newly evident. Subdural hematoma along the left frontal and temporal
convexities is again seen, slightly larger along the anterior and media left
temporal lobe. Subdural hematoma along the left parietal convexity is newly
identified at the vertex, image 2:24. Small subdural hematoma along the right
frontal convexity also appears new, images 2:19 and 2:21. Right greater than
left sulcal subarachnoid hemorrhage appears slightly increased. There is
trace blood in the occipital horns of the lateral ventricles, slightly
increased from prior. The ventricles are stable in size. There is no shift of
midline structures. There is no compression of basal cisterns or herniation
of cerebellar tonsils.
There is a nondisplaced right temporal bone fracture extending through the
mastoid, with partial opacification of right mastoid air cells. There is a
small amount of soft tissue in the right middle ear cavity posterior to the
ossicles. The ossicles appear intact with normal alignment. Inner ear
structures appear intact. Fracture line extends to the jugular fossa. The
carotid canal appears intact.
The fracture line extends into the right aspect of the occipital bone. There
is air in the right transverse sinus, concerning for traumatic disruption of
the sinus.
Left mastoid air cells are partially opacified. Left frontal sinus is not
pneumatized. Some of bilateral anterior ethmoid air cells are opacified. There
is mild mucosal thickening along bilateral maxillary sinus floors, with
communication with a large periapical lucency on the left. There is also a
supernumerary tooth deep to the right maxillary central and lateral incisors.
There is fluid in bilateral sphenoid sinuses, more on the right.
NECK CTA There is a 3 vessel aortic arch. Right common carotid and internal
carotid arteries are widely patent, and the distal cervical right internal
carotid artery measures 4.5 mm in diameter. There is minimal soft plaque at
the left internal carotid artery origin without flow-limiting stenosis. Distal
cervical left internal carotid artery measures 5.0 mm in diameter. The
origins and cervical courses of bilateral vertebral arteries are widely
patent.
HEAD CTA Intracranial internal carotid and vertebral arteries, and their
major branches, appear patent without evidence for flow-limiting stenoses.
There may be a 1.5 mm inferomedially projecting aneurysm of the paraclinoid
left internal carotid artery, images 3:261 and 601b:23. Patency of dural
venous sinuses is not adequately evaluated on this exam.
OTHER FINDINGS The endotracheal tube terminates in good position 2.5 cm above
the carina. Nasogastric tube is also noted. Visualized upper lungs appear
clear. There is a 10 mm left paratracheal lymph node, image 3:7, top-normal in
size. There are nonenlarged right paratracheal and left para-aortic lymph
nodes.
IMPRESSION:
1. Stable hemorrhagic contusions in left frontal and temporal lobes, and new
small hemorrhagic contusion in the right temporal lobe. Interval enlargement
of left frontal/temporal subdural hematoma. New small left parietal and right
frontal subdural hematomas. Slightly increased bilateral subarachnoid
hemorrhage. Minimally increased trace intraventricular hemorrhage.
2. Nondisplaced right temporal bone fracture extending through the mastoid air
cells. The fracture line also extends to the margin of the jugular fossa and
through the right aspect of the occipital bone, with air in the right
transverse sinus indicating traumatic disruption. Patency of the venous dural
sinuses is not well assessed on this arterial phase exam.
3. No evidence for arterial injury in the neck or head.
4. Possible 1.5 mm inferomedially projecting aneurysm of the paraclinoid left
internal carotid artery. As evaluation is limited by proximity to bone, MRA or
conventional cerebral angiography may be helpful.
5. While fluid and mucosal thickening in the paranasal sinuses may overall be
related to endotracheal intubation and prolonged supine positioning, mucosal
thickening along the floor of the left maxillary sinus communicates with a
large periapical lucency, suggesting focal odontogenic inflammation.
Radiology Report
EXAMINATION: CT C-spine.
INDICATION: Fall, evaluate cervical spine fracture.
TECHNIQUE: A second read request for a CT cervical spine performed at ___
___ on ___ at 12:17 was requested.
DOSE: 206.70 mGy-cm
COMPARISON: None available.
FINDINGS:
There is no acute fracture or malalignment of the cervical spine. The normal
cervical lordosis is maintained. There is no prevertebral soft tissue
swelling. Facet joints are normally aligned. Mild degenerative changes are
seen at T1-T2. The nuchal ligament is partially calcified.
The soft tissues of the neck and thyroid are unremarkable. The included lung
apices are well-aerated but show mild changes of centrilobular emphysema. The
known right paramedian occipital bone fracture and resulting fluid in the
right mastoid air cells are better evaluated on concurrent head CT.
IMPRESSION:
No acute fracture of the cervical spine.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with SAH after syncopal fall // Change in
SAH/skull fracture
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 891 mGy-cm
CTDI: 52 mGy
COMPARISON: CTA head ___. Outside CT of the head ___.
FINDINGS:
Bilateral subarachnoid hemorrhages and have increased in volume diffusely. The
subdural hematoma along the left frontal and temporal convexity is slightly
smaller. Small subdural hematoma along the left parietal convexity (___:71)
was not definitely seen previously and measures 6 mm.
Contusions of the bilateral temporal lobes, and trace hemorrhage layering
posteriorly in the occipital ___ of the right lateral ventricle are
unchanged. There is no shift of normal midline structures. The basal cisterns
are patent. There is no hydrocephalus. There is no evidence of large
territorial infarction.
Comparison increase in the right frontal and parietal scalp hematoma. Fracture
of the right paramedian occipital bone with extension to the mastoid is re-
demonstrated. As before there is opacification of several right mastoid air
cells and the middle ear. Opacification of the right sphenoid sinus and
mucosal thickening of the ethmoidal air cells is similar to prior.
IMPRESSION:
Apparent new small subdural along the left parietal convexity measuring up to
6 mm. Mild increase in diffuse subarachnoid hemorrhage. Otherwise there is no
appreciable change.
NOTIFICATION: The findings were telephoned to ___ by ___ at
22:50, ___, 8 min after discovery.
Radiology Report
INDICATION: ___ year old man with right temporal bone the occipital bone
fractures, and air in the right transverse sinus, please evaluate for
thrombosis.
TECHNIQUE: Following an noncontrast head CT, axial multidetector CT images of
the head were obtained during intravenous contrast administration in the
venous phase. Maximal intensity projection reformatted images and 3D volume
rendered angiographic reformatted images were obtained.
DOSE: DLP 1850.82 mGy cm
COMPARISON: Noncontrast head CT ___. CTA of the head and neck ___ .
FINDINGS:
NONCONTRAST HEAD CT Left frontal hemorrhagic contusion has increased in size.
Left larger than right temporal hemorrhagic contusions is stable in size.
Left subdural hematoma has slightly decreased in size. Bilateral subarachnoid
hemorrhage is evolving. No new hemorrhage is seen. Ventricles are normal in
size. There is no shift of midline structures.
Previously described undisplaced right temporal bone fracture through the
mastoid air cells, with associated partial mastoid air cell opacification, and
nondisplaced fracture through the lateral aspect of the right occipital bone,
are again seen.
Left mastoid air cells are well aerated. Left frontal sinus is not
pneumatized. There is a mucous retention cyst in the right sphenoid sinus.
There is mild mucosal thickening along the floors of bilateral maxillary
sinuses, contiguous with periapical lucencies associated with bilateral
maxillary molars.
HEAD CTA The study is limited by motion artifact. There is an incompletely
occlusive filling defect in the right sigmoid sinus, consistent with thrombus
in the setting of adjacent fracture. Right transverse sinus and visualized
upper right internal jugular vein a patent. Left transverse sinus, left
sigmoid sinus, visualized upper a left internal jugular vein, superior
sagittal sinus, and straight sinus are patent.
Intracranial arteries were better assessed on CTA 2 days earlier.
IMPRESSION:
1. Incompletely occlusive thrombus in the right sigmoid sinus, deep to the
nondisplaced fracture of the right occipital and temporal bones.
2. Slight interval enlargement of the left frontal hemorrhagic contusion.
Stable left larger than right temporal hemorrhagic contusions.
3. Slightly decreased left subdural hematoma. Evolving bilateral subarachnoid
hemorrhage.
4. Mild mucosal thickening along the floors of bilateral maxillary sinuses,
contiguous with periapical lucencies associated with bilateral maxillary
molars. This suggest odontogenic inflammation within the paranasal sinuses.
Radiology Report
EXAMINATION: MRV HEAD W/O CONTRAST
INDICATION: ___ year old man with sigmoid sinus thrombus.
TECHNIQUE: Phase contrast MRV of the brain was obtained with maximal
intensity projection angiographic reformatted images.
COMPARISON: CT venogram ___.
FINDINGS:
Flow in the right sigmoid sinus is attenuated compared to the left. Small
filling defect in the right sigmoid sinus is again demonstrated, as seen on
the preceding CTV. The defect appears occlusive on the present exam, but does
not appear fully occlusive on the preceding CTV. Right transverse sinus, left
transverse sinus, left sigmoid sinus, superior sagittal sinus, and straight
sinus are patent.
IMPRESSION:
Small filling defect is again demonstrated in the right sigmoid sinus,
consistent with thrombus. The defect does not appear completely occlusive on
the preceding CTV, which is likely more accurate.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with traumatic SAH, please evaluate for interval
changes // ___ year old man with traumatic SAH, please evaluate for interval
changes
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: ___ MGy
DLP: ___ MGy-cm
COMPARISON: None available.
FINDINGS:
There is high-density fluid within the sulci along the right lateral parietal
lobe, likely subarachnoid hemorrhage. There is also subdural fluid noted to
the left of the falx. In addition, there is also peripheral hemorrhage in the
left posterior parietal lobe adjacent to the inner table.
There are bilateral frontal lobe contusions, left-sided contusion is
hemorrhagic and right sided contusion is without hemorrhage. There are also
bilateral temporal lobe contusions, left-sided contusion is hemorrhagic and
right-sided contusion is without hemorrhage.
There is opacification of the right mastoid air cells. Fluid is seen in the
right middle ear. There is a hypodense fluid collection within the left
sphenoid sinus, which may represent a clot.
Fracture is seen in the wall of the right sphenoid sinus, possibly involving
the right carotid canal. Fractures are also seen in the right mastoid and
right occipital bone.
The globes are unremarkable.
IMPRESSION:
1. Subdural, and subarachnoid hemorrhage as described above.
2. Bilateral frontal and temporal lobe contusions, left-sided contusions are
hemorrhagic .
3. Multiple fractures seen, including fracture in the wall of the right
sphenoid sinus, possibly involving the right carotid canal.
NOTIFICATION: Results communicated with Dr. ___ by Dr ___ by telephone
at 17:15 on ___ when the findings were made.
Gender: M
Race: OTHER
Arrive by HELICOPTER
Chief complaint: ICH
Diagnosed with TRAUM SUBARACHNOID HEM, ACCIDENT NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ was admitted to the ___ Neurosurgery service on
___ after a sudden collapse onto pavement at his home. He
was found to be answering questions at the scene and was sent to
an OSH. At the OSH, he was confused initially but awake and
moving all extremities. He vomited on the way to the CT scanner,
so he was intubated for airway protection. Trop was found to be
0.052 and EKG showed sinus bradycardia. Non-contrast head CT at
the OSH showed bilateral SAH, L SDH, and bilateral temporal
contusions, and he was transferred to the ___ for further
management. At ___, he received a CT cervical spine, and CTA
of the head and neck, which were negative.
On ___, the patient self-extubated. He remained stable and was
monitored closely in the ICU.
On ___, the patient was transferred to the floor. He had a CTV
which showed concern for R sigmoid sinus thrombosis.
On ___, he had a MRV to further evaluate the question of R
sigmoid sinus thrombosis. The patient continued to complain of
headache and he was treated symptomatically with Fioricet and IV
dilaudid while awaiting MRV results. He was started on Norvasc
for hypertension with BP to 160s not responsive to IV
hydralazine. MRV showed R sigmoid sinus thrombosis and he was
started on aspirin 325mg daily.
On ___, he appeared more lethargic, but arousable and following
commands with good strength. A head CT was performed which
showed slight blossoming in the L temporal region. His foley was
removed and medicine was consulted for syncopal workup. He was
also evaluated by ___ who recommended rehab. Patient failed to
void and foley was replaced.
On ___, patient was stable on exam. He remained hypertensive
despite lisinopril and was added on standing hydralazine. He was
OOB to chair and re-evaluated by ___. EP was also consulted on
this patient for prolonged QTC. The patient had a echcardiogram
performed which was consistent with a LVEF >55%. No structural
cardiac cause of syncope identified. Normal biventricular cavity
size and regional/global systolic function. No pathologic
valvular abnormalities.
On ___, the patient's serum sodium was improved at 135. He was
unchanged on exam.
On ___, he was started on propanolol per EP recommendations. He
was started on Flomax. Serum sodium decreased to 128.
On ___, salt tabs were increased to 1g TID. Serum sodium was
134. Patient was more awake and active but not oriented to time.
He had urinary retention and bladder scanned for 1 liter, and
Foley was re-placed. He was started on flomax.
On ___, the patient was much more awake and able to communicate
regarding his discharge planning to rehab. His serum sodium was
stable at 133 on the sodium tabs. He was made NPO at midnight in
anticipation of the cardiac event monitor placement by EP.
On ___ Patient went with EP for placement of internal cardiac
event monitor. The procedure was well tolerated. Follow up with
EP was set up.
On ___ Patient was neurologically stable. He was discharged to
rehab in stable condition with instructions for follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest and epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with hx of distant DVT and recurrent UTIs who
presents with epigastric pain that she has had for many months.
She reports pain in the central epigastric / inferior substernal
region, and has had it for a few months. The patient denies rest
pain, it gets worse with movement. She calls it a squeezing
sensation, and it is ___ at its worst. There is tenderness if
she moves teh wrong way as well. The patient has taken ibuprofen
for the pain (up to 5 per day). She also notes that when she is
having the pain, she also sometimes gets shortness of breath.
The pain limits her work. Her exercise capacity is < 100 ft she
says, because of the pain.
The patient has no other associated symptoms, such as worsening
w/ PO intake, no n/v/d. No constipation or changes in BMs. No
fevers, chills. No dysuria.
The patient has previously had an extensive workup in ___ for
similar symptoms, which revealed hepatic steatosis with a
hypodense lesion in liver, likely fatty depositon with some
surrounding inflammation/fibrosis. A biopsy was recommended but
did not happen. She also has had a negative stress MIBI in teh
past (___).
Initial VS in the ED: 98.8 117 136/87 18 100%
ECG showed Sinus tachycardia, q waves in inferior leads, TWI in
II, III, AvF, V1-V6. Rate 108. Consistent with prior.
CXR unremarkable.
Labs notable for d-dimer 436, lytes wnl except for K 3.0. UA
with 4WBC, bacteria, no RBC's, 3 epi, UCG negative. AST 136, ALT
74. CBC wnl except for MCV 116.
Patient was given potassium, ASA 325 and macrobid.
On the floor, the patient had pain on transfer but was in no
pain at the time of my interview and physical exam. She was
hungry.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Multiple urinary tract infections, most recent 2 months prior
to admission.
- Deep venous thrombosis in ___ while pregnant which was
treated with Heparin and Coumadin.
Social History:
___
Family History:
Family history of blood clots. Mother died of breast cancer.
Father also had cancer but died in a car accident.
Physical Exam:
Admission exam:
98.2 140/90 82 18 99%RA
General: ___ female in NAD
HEENT: MMM, anicteric sclerae
CV: RRR, no murmur, no JVD; some tenderness to palpation of
xiphisternum
Lungs: CTAB
Abdomen: soft, non-tender
Ext: no edema b/l, 2+ dp and pt pulses b/l
Neuro: AOx3
Skin: tattoo on L chest
Discharge exam:
VS: 98.___/98.4 ___ 118/74 (100s-140s/60s-90s) 20 97%RA
General: Pleasant woman in NAD
HEENT: MMM, anicteric sclerae
CV: RRR, no murmur, no JVD; some tenderness to palpation of the
xiphoid
Lungs: CTAB, now wheezes, rales or rhonchi
Abdomen: soft, non-tender
Ext: no edema b/l, 2+ dp and pt pulses b/l
Neuro: AOx3
Skin: tattoo on L chest
Pertinent Results:
Admission labs:
___ 02:30PM BLOOD WBC-4.5 RBC-3.24* Hgb-13.0 Hct-37.6
MCV-116* MCH-40.1* MCHC-34.6 RDW-16.4* Plt ___
___ 02:37PM BLOOD ___ PTT-28.4 ___
___ 02:30PM BLOOD Glucose-135* UreaN-8 Creat-0.5 Na-142
K-3.0* Cl-99 HCO3-30 AnGap-16
___ 02:30PM BLOOD ALT-74* AST-136* AlkPhos-92 TotBili-0.7
___ 02:30PM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.2 Mg-1.6
Notable labs:
___ 02:30PM BLOOD Lipase-31
___ 02:30PM BLOOD cTropnT-<0.01
___ 07:41AM BLOOD CK-MB-7 cTropnT-<0.01
___ 07:41AM BLOOD VitB12-569 Folate-3.6
___ 02:30PM BLOOD D-Dimer-436
___ 07:41AM BLOOD %HbA1c-6.1* eAG-128*
___ 07:41AM BLOOD Cholest-191
___ 07:41AM BLOOD Triglyc-102 HDL-55 CHOL/HD-3.5
LDLcalc-116
___ 09:36AM BLOOD HBsAg-NEGATIVE
___ 09:36AM BLOOD HIV Ab-NEGATIVE
___ 09:36AM BLOOD HCV Ab-NEGATIVE
___ 8:41 am SEROLOGY/BLOOD 65823J.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Discharge labs:
___ 06:23AM BLOOD WBC-4.7 RBC-2.85* Hgb-11.3* Hct-33.0*
MCV-116* MCH-39.7* MCHC-34.2 RDW-16.2* Plt ___
___ 06:23AM BLOOD UreaN-9 Creat-0.6 Na-141 K-3.8 Cl-101
HCO3-32 AnGap-12
___ 06:23AM BLOOD Mg-2.3
Studies:
Nuclear stress:
RADIOPHARMACEUTICAL DATA:
9.9 mCi Tc-99m Sestamibi Rest ___
32.0 mCi Tc-99m Sestamibi Stress ___
HISTORY: Chest pain with excertion
SUMMARY OF DATA FROM THE EXERCISE LAB:
Exercise protocol: Modified ___
___ duration: 5 min, 30 sec
Reason exercise terminated: fatigue
METHOD:
Resting perfusion images were obtained with Tc-99m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
At peak exercise, approximately three times the resting dose of
Tc-99m sestamibi was administered IV. Stress images were
obtained approximately 45 minutes following tracer injection.
Imaging Protocol: Gated SPECT
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 60%,
previously 62%.
Compared with the study of ___, there is no significant
change.
IMPRESSION: Normal cardicac prefusion exam, with calculated
LVEF of 60%.
EXERCISE RESULTS
RESTING DATA
EKG: SINUS, DIFFUSE T WAVE INVERSIONS
HEART RATE: 61 BLOOD PRESSURE: 134/88
PROTOCOL MODIFIED ___ - TREADMILL /
STAGE TIME SPEED ELEVATION HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
0 ___ 1.0 8 ___ ___ 1.7 10 ___
TOTAL EXERCISE TIME: 5.5 % MAX HRT RATE ACHIEVED: 74
SYMPTOMS: ATYPICAL PEAK INTENSITY: ___
INTERPRETATION: ___ yo woman with HTN and HLD was referred to
evaluate an atypical chest discomfort. The patient completed 5
minutes
and 30 seconds of a modified ___ protocol representing a poor
exercise
tolerance for her age; ~ ___ METS. The exercise test was stopped
at the
patient's request secondary to fatigue. During exercise the
patient
reported a progressive, isolated (size of fingertip), upper
epigastic
discomfort; peak exercise ___. This discomfort resolved slowly
with
rest and was not completely absent until 8 minutes of recovery.
No
significant ST segment changes were noted with T wave inversions
in
early precordial leads seen on resting ECG. Nonspecific T wave
normalization was noted inferiorly and anterolaterally. The
rhythm was
sinus with rare isolated VPBs. An exaggerated diastolic blood
pressure
response was noted with exercise.
The systolic blood pressure response to exercise was
appropriate. In the
presence of beta blocker therapy and the achieved level of work,
the
peak exercise heart rate was blunted.
IMPRESSION: Poor exercise tolerance. Atypical symptoms with no
ischemic
ST segment changes in the setting of baseline abnormalities.
Nonspecific T wave normalization (see above).
Exaggerated diastolic blood pressure response to exercise. In
the
presence of beta blocker therapy, the peak exercise heart rate
was
blunted. Nuclear report sent separately.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q6H:PRN pain
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest, frontal and lateral views.
CLINICAL INFORMATION: Epigastric pain.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. No focal
consolidation, pleural effusion, or evidence of 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.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: EPIGASTRIC DISCOMF
Diagnosed with CHEST PAIN NOS, URIN TRACT INFECTION NOS
temperature: 98.8
heartrate: 117.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 87.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ is a ___ with hx of distant DVT and recurrent UTIs who
presents with epigastric pain that she has had for many months.
# Epigastric pain: The quality of the epigastric pain/substernal
pain is squeezing in quality, worse witih exertion. This could
very well be an anginal equivalent for her. She had a negative
stress test in ___. It is, however, not a perfect history of
anginal pain, as she has tenderness to palpation in sternum, a
history of more pain if moves in the wrong direction, and the
prolonged duration without much change. She has been taking a
good amount of ibuprofen every day for her pain and endorses a
history of daily alcohol intake, so GI pathology also possible.
Admitted for nuclear stress testing, during which she had her
epigastric discomfort, which showed no EKG changes and no
ischemic perfusion abnormalities with normal LVEF. Likely her
sx are musculoskeletal or GI in origin. H.pylori blood antigen
checked which was negative. Encouraged to follow-up with her
outpatient primary care doctor and ___ with a
gastroenterologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Wound infection
Major Surgical or Invasive Procedure:
incision and drainage.
History of Present Illness:
HPI: Patient is a ___ male with history of pT1 N0 M0 low-grade
(focally high-grade) papillary urothelial carcinoma s/p radical
cystectomy with ileal conduit on ___. His post-op course
was
complicated by fascial dehiscence requiring exploratory
laparotomy and primary closure of the abdominal wall on
___.
Notably the patient also developed an obstructing left sided
stone which was managed with PCN placement on ___ and
ultimately left PCNL on ___ by Dr. ___.
The patient presents to the ED today with concern for wound
complication. He developed a new draining "fluid collection" at
the base of his old incision 2 days ago. He has had no pain,
fevers, nausea. His wife thinks the new collection is draining
clear fluid.
Past Medical History:
DM II, on metformin
HTN
Kidney stones
PSH:
Kidney stone removal
TURBT
Social History:
___
Family History:
FH: No family history of GU malignancy
Physical Exam:
Physical Exam
General: Alert, oriented, no acute distress
Card/pulm: no cardiopulmonary distress, no audible wheezing.
Abdomen: Soft, NT, ND. Stoma pink/patent and productive of clear
yellow urine. Inferior aspect of old abdominal incision is open
and packed with wick dressing. No drainage. Resolution of
erythema. non-tender.
Extremities: WWP
Pertinent Results:
___ 06:40AM BLOOD WBC-6.6 RBC-4.15* Hgb-11.5* Hct-37.7*
MCV-91 MCH-27.7 MCHC-30.5* RDW-14.7 RDWSD-48.8* Plt ___
___ 06:40AM BLOOD Glucose-114* UreaN-20 Creat-1.3* Na-140
K-PND Cl-106 HCO___ AnGap-___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cephalexin 250 mg PO Q8H
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
3. Lisinopril 10 mg PO DAILY
4. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. amLODIPine 5 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Cephalexin 500 mg PO Q8H Wound infection
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Lisinopril 10 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Wound infection
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 s/p ileal conduit with wound
drainage that is purulent and painNO_PO contrast// ?abscess
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 33.7 mGy (Body) DLP =
16.9 mGy-cm.
2) Spiral Acquisition 6.0 s, 47.1 cm; CTDIvol = 26.1 mGy (Body) DLP =
1,225.9 mGy-cm.
3) Spiral Acquisition 0.6 s, 4.6 cm; CTDIvol = 15.1 mGy (Body) DLP = 69.8
mGy-cm.
Total DLP (Body) = 1,313 mGy-cm.
COMPARISON: Outside CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. Severe coronary artery
calcifications are seen.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Subcentimeter hypodense lesion in segment III is too small to characterize but
likely represents a biliary hamartoma or cyst, similar to prior. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. A decompressed
gallbladder contains gallstones without wall thickening or surrounding
inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is delayed enhancement of the left kidney, slightly improved
compared to prior. There is no evidence of focal renal lesions. There is
mild fullness of the left renal collecting system, significantly improved
compared to prior. There is mild bilateral perinephric stranding. There is
increased wall enhancement of the left proximal ureter (2; 32).
Calcifications are again demonstrated in the left lower pole.
GASTROINTESTINAL: The stomach is unremarkable. There is a right lower
quadrant ileal conduit. Otherwise, small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. The small bowel
anastomosis in the mid pelvis is unremarkable. The colon and rectum are
within normal limits. The appendix is normal.
PELVIS: Status post cystectomy and ileal conduit in the right lower quadrant.
Abutting an adjacent to the ileal conduit, there is a new thin walled 6.3 x
6.4 x7.5 cm collection without adjacent fat stranding. It is adjacent and
separate from the appendix. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is surgically removed.
LYMPH NODES: Surgical clips are noted in bilateral pelvic sidewall and
inguinal region from prior surgery. There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild-to-moderate degenerative changes are similar to prior. Redemonstration
of chronic right posterior tenth rib fracture.
SOFT TISSUES: In the mid anterior pelvic wall, there is a rim enhancing thick
walled fluid collection measuring 5.8 x 6.1 cm, which appears more organized
compared to prior concerning for infection. There appears to be fat within
the fluid collection (2; 72).
IMPRESSION:
1. 5.8 cm thick walled rim enhancing fluid collection in the subcutaneous
anterior pelvic wall concerning for abscess.
2. 7.5 cm thin-walled fluid collection adjacent to the ileal conduit is new
compared to ___ without adjacent fat stranding may be post operative
seroma or lymphocele and less likely abscess.
3. Mild fullness of the left renal collecting system with increased
enhancement and wall thickening of the left proximal ureter and delayed
nephrogram of the left kidney, overall slightly improved compared to prior.
Correlate with signs and symptoms for infection/pyelonephritis.
NOTIFICATION: The findings were discussed with Dr ___. by ___,
M.D. on the telephone on ___ at 3:14 pm, 5 minutes after discovery of the
findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Infct fol a proc, superfic incisional surgical site, init, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 97.9
heartrate: 74.0
resprate: 16.0
o2sat: 99.0
sbp: 141.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | The patient had a CT in the ED showing:
1. 5.8 cm thick walled rim enhancing fluid collection in the
subcutaneous
anterior pelvic wall concerning for abscess.
2. 7.5 cm thin-walled fluid collection adjacent to the ileal
conduit is new
compared to ___ without adjacent fat stranding may be
post operative
seroma or lymphocele and less likely abscess.
3. Mild fullness of the left renal collecting system with
increased
enhancement and wall thickening of the left proximal ureter and
delayed
nephrogram of the left kidney, overall slightly improved
compared to prior.
Correlate with signs and symptoms for infection/pyelonephritis.
Labs and vitals were WNL.
The patient had an incision and drainage of the wound (see
dictated procedure note for details).
He was admitted to the urology service. He had no overnight
events.
On the morning of hospital day one the patient was deemed
suitable for discharge home with ___ wound care and daily wound
packings. He was discharged on Keflex for 7 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / acetaminophen
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/CHF, asthma/COPD presents with worsening leg edema. Pt
also with SOB, and orthopnea for several days. Denies cp,
cough. +abd distention without pain.
s/p nitro spray x 2 with EMS In ED given nebs, solumedrol,
aspirin, lasix
On arrival to floor pt breathing comfortably. Of note, on review
of records PCP notes that pt with chronic SOB which has been
unaffected by multiple attempts at medication changes.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
COPD
CHF
atrial fib CHADS=3
gout
Hypertension
Hyperlipidemia
Social History:
___
Family History:
No cardiac disease, HTN, DM in family.
Physical Exam:
Admission Vitals: T:97.4 BP:156/94 P:87 R:20 O2:99%ra
PAIN: 0
General: nad
Lungs: bibasilar crackles
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt, distended
Ext: +pitting edema
Skin: no rash
Neuro: alert, follows commands
.
Discharge Vitals:
Weight 207
Ambulatory Sat 94-98% on room air
Lungs dullness at bases but no crackles
1+ pedal and trace bilateral edema with stockings on.
Pertinent Results:
Admission Labs:
___ 10:40PM GLUCOSE-155* UREA N-21* CREAT-1.3* SODIUM-139
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-18
___ 10:45PM LACTATE-2.2*
___ 10:40PM ALT(SGPT)-15 AST(SGOT)-22 ALK PHOS-79 TOT
BILI-0.2
___ 10:40PM LIPASE-22
___ 10:40PM cTropnT-<0.01
___ 10:40PM proBNP-981*
___ 10:40PM ALBUMIN-4.1 CALCIUM-9.3 PHOSPHATE-3.6
MAGNESIUM-1.6
___ 10:40PM WBC-6.4 RBC-4.73 HGB-11.3* HCT-35.9* MCV-76*
MCH-23.8* MCHC-31.4 RDW-15.1
___ 10:40PM NEUTS-45.6* ___ MONOS-7.6 EOS-6.5*
BASOS-0.8
___ 10:40PM PLT COUNT-165
___ 10:40PM ___ PTT-34.1 ___
___ 12:35AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
CXR FINDINGS ___
The inspiratory lung volumes are low with resultant
bronchovascular
crowding. There is no focal consolidation concerning for
pneumonia, pleural
effusion or pneumothorax. No pulmonary vascular congestion or
edema is seen.
The cardiac silhouette is enlarged, but stable. The mediastinal
contours are
prominent, with tortuosity of the thoracic aorta, which is
unchanged.
IMPRESSION: Low lung volumes. No evidence of heart failure or
volume
overload.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Ipratropium Bromide Neb 1 NEB IH BID
4. Carvedilol 3.125 mg PO BID
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Warfarin 5 mg PO DAILY16
8. Pravastatin 40 mg PO DAILY
9. Bumetanide 3 mg PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Ibuprofen 400 mg PO Q8H:PRN pain
12. Aspirin 81 mg PO DAILY
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bumetanide 3 mg PO DAILY
5. Carvedilol 3.125 mg PO BID
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Docusate Sodium 100 mg PO DAILY:PRN constipation
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Ibuprofen 400 mg PO Q8H:PRN pain
10. Ipratropium Bromide Neb 1 NEB IH BID
11. Pravastatin 40 mg PO DAILY
12. Valsartan 160 mg PO DAILY
13. Warfarin 5 mg PO DAILY16
14. Outpatient Lab Work
Please check INR on ___ and fax this to patient's PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Acute on Chronic Diastolic CHF
- Atrial Fibrillation
- Hypertension
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: Chronic diastolic congestive heart failure, weight gain, edema
and wheezing.
COMPARISON: Chest radiograph dated ___.
TECHNIQUE: PA and lateral radiographs of the chest.
FINDINGS: The inspiratory lung volumes are low with resultant bronchovascular
crowding. There is no focal consolidation concerning for pneumonia, pleural
effusion or pneumothorax. No pulmonary vascular congestion or edema is seen.
The cardiac silhouette is enlarged, but stable. The mediastinal contours are
prominent, with tortuosity of the thoracic aorta, which is unchanged.
IMPRESSION: Low lung volumes. No evidence of heart failure or volume
overload.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with SHORTNESS OF BREATH
temperature: 97.6
heartrate: 108.0
resprate: 30.0
o2sat: 99.0
sbp: 135.0
dbp: 80.0
level of pain: 0
level of acuity: 1.0 | 90< w/CHF and COPD presents with worsening leg edema and SOB |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Piperacillin / Tegaderm Frame Style / Zosyn / Tegaderm
Attending: ___.
Chief Complaint:
Dyspnea, Transfer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with CF c/b recurrent pseudomonal and
aspergillosis infections - some multidrug resistant, chronic
sCHF (LVEF ___ s/p BiV ICD ___, CKD, Hep C who
presents with dyspnea.
He was recently admitted from ___ with a CF exacerbation
and before that ___ for CF exacerbation and CHF during
which time he was treated with cefepime and inhaled colistin. He
completed a 21 day course of cefepime (d21= ___. One week
after finishing cefepime he developed increased sputum. He was
initially started on IV cipro per recommendations from his
outpatient pulmonologist (Dr. ___. He was then switched to
PO cipro and IV ceftazidime (per Dr. ___
and was discharged home to complete
course of IV ceftazidime. Last day ___. He was also conitnued
on IH colistin, dornase alfa, PO albuterol, albuterol inhaler,
albuterol nebs, and montelukast. He also received chest ___ and
was encouraged to use acapella valve and incentive spirometer.
Several days ago developed worsening SOB and cough, new O2
requirement. He usually uses ___ of O2 at night but has been
using it during the day recently. Stable orthopnea. Also says he
hasn't taken his spironolactone or bumex recently due to concern
for ___. He thinks he gained 10 lbs. Denies chest pain, leg pain
or abdominal pain.
In the ED, initial vitals were: 98 70 164/88 22 100% 6L Nasal
Cannula
- Labs were significant for lactate 1.6, Hb 10.4, Cr 0.9
- Imaging revealed Multifocal interstitial opacities, worsened
from previous
- The patient was given levofloxacin and cefepime
Vitals prior to transfer were: 93 148/80 20 93% Nasal Cannula
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 or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
Hypertension
Dilated Nonischemic cardiomyopathy, LVEF 20%, s/p BiV ICD
___
LBBB
Atrial tachycardia s/p ablation in ___
Moderate pulmonary hypertension
Cystic fibrosis dx age ___ with recurrent pseudomonal infections,
aspergillosis
Hepatitis C, Genotype 1 intolerant of treatment
RUE DVT due to vascular access, previously on Coumadin, now with
Portacath
Chronic kidney disease stage I-II
Vitamin D deficiency
Osteoporosis
GERD
Hx of ETOH abuse
Personality disorder
Corticoadrenal insufficiency dx ___
s/p ventral hernia repair
s/p ORIF of leg
Social History:
___
Family History:
Sister with cystic fibrosis.
Mother died recently from end-stage Alzheimer's disease. Also
with HTN and obesity
Cousin with myocardial infarction at ___ years old.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: dry weight 212lb, now ___, AF, 90s, 170/90, 93% 6LNC
via mouth.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP 10cm
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Port on right chest c/d/i without erythema.
Lungs: Diffuse rhonchi L>R, crackles at left base. Scattered
expiratory wheezing throughout.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, 1+ pitting edema
bilaterally
Neuro: CNII-XII intact, moving all extremities equally
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.9 127 / 76 72 96 on room air at rest
Weight: 98.8kg
General: AOx3. Conversing
HEENT: MMM.
Neck: JVP difficult to assess ___ neck habitus, appears WNL
CV: RRR, S1, S2. No extra sounds heard. Port on right chest
c/d/i without erythema.
Lungs: Diffuse rhonchi L > R, with crackles at the left base.
Moderate diffuse wheezing heard throughout.
Abd: Soft, NT/ND. BS+. Obese.
Extremities: Warm, well perfused, 2+ pulses, trace pitting edema
bilaterally to above ankle R>L. 10cm well-healed scar along
shin/ankle of right leg.
Neuro: Face symmetric, moving all extremities equally, A&Ox3
Skin: approx 20 scattered faded hyperpigmented, non-edematous
circular lesions ranging in size from 0.5cm to 2cm in diameter
across back and back of shoulders/upper arms. No other rashes.
Pertinent Results:
ADMISSION LABS
================================
___ 07:10PM BLOOD WBC-6.1 RBC-4.17* Hgb-10.4* Hct-31.8*
MCV-76* MCH-24.9* MCHC-32.6 RDW-19.7* Plt ___
___ 07:10PM BLOOD Neuts-66.5 ___ Monos-9.8 Eos-1.4
Baso-1.0
___ 05:54AM BLOOD ___ PTT-29.2 ___
___ 05:54AM BLOOD Ret Aut-2.2
___ 07:10PM BLOOD Glucose-98 UreaN-18 Creat-0.9 Na-140
K-4.2 Cl-106 HCO3-21* AnGap-17
___ 07:10PM BLOOD proBNP-8028*
___ 07:10PM BLOOD Iron-86
___ 05:54AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.6
___ 07:10PM BLOOD calTIBC-404 Ferritn-21* TRF-311
___ 07:32PM BLOOD Lactate-1.6
DISCHARGE AND SIGNIFICANT LABS
================================
___ 06:52AM BLOOD WBC-6.1 RBC-4.68 Hgb-11.6* Hct-36.4*
MCV-78* MCH-24.7* MCHC-31.9 RDW-18.1* Plt ___
___ 06:52AM BLOOD Glucose-96 UreaN-26* Creat-1.1 Na-135
K-4.5 Cl-101 HCO3-26 AnGap-13
___ 06:52AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.0
MICROBIOLOGY
================================
___ 8:40 am SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
Piperacillin/Tazobactam , Colistin ,
Ceftolozane/tazobactam ,
AMIKACIN Susceptibility testing requested by ___
(___)
___.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Ceftolozane/tazobactam Sent to ___ Reference
Laboratory.
COLISTIN = SENSITIVE .
COLISTIN sensitivity testing performed by ___.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH ___ MORPHOLOGY.
Ceftolozane/tazobactam Sent to ___ Reference
Laboratory.
SENSITIVE TO Colistin.
Piperacillin/Tazobactam AND Colistin sensitivity
testing performed
by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 32 I =>64 R
CEFEPIME-------------- =>64 R =>64 R
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- 2 I 2 I
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN/TAZO----- R S
TOBRAMYCIN------------ 2 S 8 I
__________________________________________________________
___ 7:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
==================================
CXR IMPRESSION:
The multifocal consolidation that worsened between ___ and
___ in the left midlung laterally has improved. There may be
a slight increase in consolidation in the lingula compared to
patient's best previous baseline study, but overall the very
abnormal findings are nevertheless chronic and stable since at
least ___.
These include large areas of bronchiectasis, which in the right
upper lobe there is densely consolidated due to chronic
atelectasis.
Heart is enlarged, but stable. There is no appreciable pleural
effusion or indication of cardiac decompensation. Transvenous
right atrial, biventricular pacer defibrillator are continuous
from the left pectoral generator and unchanged in their
respective positions. No pneumothorax.
Right central venous infusion port catheter ends close to or
just beyond the superior cavoatrial junction.
CARDIOLOGY
====================================
Cardiovascular Report ECG Study Date of ___ 2:43:22 ___
Atrial sensed, ventricular paced rhythm. There is the presence
for fusions beats. Compared to the previous tracing of ___
the atrial pacing spikes are not clearly seen. Otherwise,
findings are similar.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
82 ___ 0 -58 92
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 4 mg PO QID
2. albuterol sulfate 2.5 /3 mL (0.083 %) INHALATION Q6-8H PRN
SOB
3. Bumetanide 2 mg PO DAILY
4. Colistin 150 mg IH BID
5. Digoxin 0.125 mg PO DAILY
6. dornase alfa 2.5 mL inhalation daily
7. Lisinopril 2.5 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
10. Acetaminophen 1000 mg PO Q8H:PRN pain
11. albuterol sulfate 90 mcg/actuation INHALATION 2 PUFFS QID
SOB
12. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol 4 mg PO QID
3. Bumetanide 2 mg PO DAILY
4. Colistin 150 mg IH BID
5. Digoxin 0.125 mg PO DAILY
6. dornase alfa 2.5 mL inhalation daily
7. Lisinopril 2.5 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
10. albuterol sulfate 2.5 /3 mL (0.083 %) INHALATION Q6-8H PRN
SOB
11. CefePIME 2 g IV Q8H
Plan for 3-week course, Day 1 ___ and to be finished ___.
RX *cefepime [Maxipime] 2 gram Take 2 grams IV every 8 hours
Disp #*36 Vial Refills:*0
12. Ciprofloxacin HCl 750 mg PO Q12H
Plan for 3-week course, Day 1 ___ and to be finished ___.
RX *ciprofloxacin HCl 750 mg Take 1 tablet by mouth twice daily
Disp #*24 Tablet Refills:*0
13. albuterol sulfate 90 mcg/actuation INHALATION 2 PUFFS QID
SOB
14. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
15. Outpatient Lab Work
Please draw CBC with diff, BUN/Cr, LFTs weekly and send results
to ___, NP ___, ___);
fax ___ phone ___
CD9 code: Cystic Fibrosis 277.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Acute on Chronic Heart failure Exacerbation
- Pseudonomas Pneumonia
- Cystic Fibrosis
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 man with CF and new worsening dyspnea and LUL
infiltrate on OSH film (uploaded) // Evaluate for interval change and signs
of fluid overload Evaluate for interval change and signs of fluid overload
COMPARISON: Conventional chest radiographs since ___ most recently ___.
IMPRESSION:
The multifocal consolidation that worsened between ___ and ___ in the
left midlung laterally has improved. There may be a slight increase in
consolidation in the lingula compared to patient's best previous baseline
study, but overall the very abnormal findings are nevertheless chronic and
stable since at least ___.
These include large areas of bronchiectasis, which in the right upper lobe
there is densely consolidated due to chronic atelectasis.
Heart is enlarged, but stable. There is no appreciable pleural effusion or
indication of cardiac decompensation. Transvenous right atrial, biventricular
pacer defibrillator are continuous from the left pectoral generator and
unchanged in their respective positions. No pneumothorax.
Right central venous infusion port catheter ends close to or just beyond the
superior cavoatrial junction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, CYSTIC FIBROS W/O ILEUS
temperature: 98.0
heartrate: 70.0
resprate: 22.0
o2sat: 100.0
sbp: 164.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with CF complicated by recurrent
pseudomonal and aspergillosis infections (h/o multidrug
resistant organisms), chronic systolic CHF (LVEF ___
s/p BiVentricular ICD ___, CKD, and Hep C who presents with
dyspnea and increasing O2 requirement who was found to have
congestive heart failure and pseudomonas infection.
# Heart failure with reduced EF: LVEF ___. His home diuretics
were restarted and he was effectively diuresed on 2mg of bumex
and spironolactone 25mg daily. Discharge weight 98.8kg. On
digoxin, spironolactone, lisinopril, bumetanide. Cr was 1.1 on
discharge. He was approx ___ above dry weight on admission, at
at his dry weight at discharge. This was felt to be a
significant contribution to his SOB/hypoxia. He was able to
ambualate ___ yards on room air, with quick recovery of his sats
from low 80's to 96% on RA. He was weaned off of his resting O2
requirement and he has O2 at home should he require it for
longer episodes of exertion.
# Suspected Pneumonia: Repeat CXR not convincingly different
from previous, but difficult to assess with baseline
abnormalities. He has a productive cough, and increased O2
requirement and pseudomonas with sparse growth of 2 different
resistant pseudomonas strains from sputum. He was given cefepime
and ciprofloxacin for pseudonomas, with a plan for a total of a
3 week course (until ___. His cultures during this stay were
consistent with his previous, which showed intermediate
resistance to cipro and resistance to cefepime. His care was
coordinated with Dr. ___ outpatient CF doctor from
___).
# Cystic fibrosis: Followed by Dr. ___. On albuterol nebs,
inhaler, PO albuterol, inhaled colistin (on month), dornase,
montelukast, fluticasone nasal spray, inhaled tobramycin (off
month). He requires regular contact precautions, given his CF
status with history of multidrug resistant organisms (not strict
contact). This was discussed with the infection control service
during this admission.
# Microcytic iron-deficiency anemia: Likely related to
combination of Fe deficiency and anemia of chronic disease.
Iron studies consistent with iron deficiency (Nm serum iron but
very low ferritin and severe microcytosis) and retic index 1.1.
Supplementation deferred given non-acute anemia and active
infection.
# CODE STATUS: Full
# CONTACT: ___
Relationship: Friend
Phone number: ___
Cell phone: ___
====================================
TRANSITIONAL ISSUES
====================================
- Weekly safety labs while on antibiotics: CBC with diff,
BUN/Cr, LFTs. Fax safety labs to: ___, NP ___
___, ___); fax ___ phone ___
- He would likely feel more comfortable routinely taking his
diuretics with weekly renal monitoring (BUN/Cr). Consider
standing lab order after abx done.
- Continue cefepime 2 gm IV Q8H, ciprofloxacin 750 mg PO BID,
and colistin 150 m0g inhaled BID for 21 days (until ___ with
Pulmonary evaluation before stopping therapy.
- discharge weight 98.8kg
- Consider iron supplementation and GI work up for microcytic
anemia as outpatient (IV iron vs PO) when not infected |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RUE Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history of
HTN,
HLD, prior R frontal cortical stroke (___) and RA who presents
today with right hand weakness.
He says that he went to bed last night in his usual state of
health around 11:30pm. When he woke up around 7:30am, he noticed
that his right hand was both clumsy and weak. He notes having
difficulty shaving, and writing (forming the letters). He says
that over the day this has gotten slightly better, although the
hand is still weak. He thinks his arm feels numb but he isn't
sure. He had no speech difficulties, no trouble reading, no
facial involvement, no leg involvement.
In ___ he had similar symptoms, which lasted ___ hours. He is
followed by Dr. ___ at ___. After the transient
right
arm weakness, he had an MRI showing "1. There are moderate
chronic microvascular changes in the cerebral white matter 2.
There is a tiny chronic cortical infarct in the right frontal
lobe probably in the distal right ACA territory." MRA was
normal.
TTE showed mild AR and "focal thickening at the tip of the
anterior mitral valve leaflet. The atrial septum is aneurysmal."
Holter monitor showed 2 runs of SVT to ~150.
He has been on aspirin, in addition to atorvastatin since then.
However, he only takes the aspirin a few times a week (~every
other day) as he has recently been getting nose bleeds.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention. 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:
- HTN
- HLD
- R frontal infarct
- BPH
- Cataracts
- Benign thyroid nodules
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM:
Physical Exam:
Vitals: 98.9 62 134/85 18 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR
Abdomen: soft
Extremities: No edema. well perfused.
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. No paraphasic errors. Naming
intact to both high and low frequency objects. Reads without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Good knowledge of current
events. No apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no 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.
Discharge Exam:
MS: Awake, Alert, Speech Fluent. Repitition intact. Follows
Complex Commands. Naming intact to high/low frequency
CN: EOMI, VFFFC. Pupils R< L by 0.5 mm, but brisk. Face
symmetric
Motor: No pronator drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 4+ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
R arm external rotation
DTR: ___ are present and symmetric bilaterally.
Sensation: No sensory deficit. Graphesthesia impaired on R hand.
proprioception intact.
Pertinent Results:
___ 03:23PM BLOOD WBC-4.0 RBC-4.74 Hgb-14.2 Hct-43.0 MCV-91
MCH-30.0 MCHC-33.0 RDW-13.0 RDWSD-42.8 Plt ___
___ 06:35AM BLOOD WBC-3.9* RBC-4.61 Hgb-13.7 Hct-41.9
MCV-91 MCH-29.7 MCHC-32.7 RDW-13.1 RDWSD-43.1 Plt ___
___ 03:23PM BLOOD Neuts-51.5 ___ Monos-8.6 Eos-1.3
Baso-0.5 Im ___ AbsNeut-2.05 AbsLymp-1.50 AbsMono-0.34
AbsEos-0.05 AbsBaso-0.02
___ 03:23PM BLOOD ___ PTT-32.5 ___
___ 03:23PM BLOOD Plt ___
___ 03:23PM BLOOD Glucose-94 UreaN-9 Creat-0.9 Na-141 K-3.7
Cl-105 HCO3-29 AnGap-11
___ 06:35AM BLOOD Glucose-82 UreaN-9 Creat-0.9 Na-143 K-3.8
Cl-107 HCO3-28 AnGap-12
___ 06:35AM BLOOD ALT-22 AST-24 LD(LDH)-133 CK(CPK)-147
AlkPhos-61 TotBili-1.0
___ 03:23PM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:35AM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.9 Mg-2.2
Cholest-127
___ 06:35AM BLOOD %HbA1c-6.0* eAG-126*
___ 06:35AM BLOOD Triglyc-63 HDL-59 CHOL/HD-2.2 LDLcalc-55
___ 06:35AM BLOOD TSH-2.6
___ 05:53PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:53PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 05:53PM URINE RBC-4* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 05:53PM URINE AmorphX-RARE
___ 05:53PM URINE Mucous-RARE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO EVERY OTHER DAY
2. Atorvastatin 40 mg PO QPM
3. Amlodipine 5 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
6. Tamsulosin 0.4 mg PO QHS
7. Finasteride 5 mg PO DAILY
8. urea 40 % topical BID:PRN itchiness
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
5. Amlodipine 5 mg PO DAILY
6. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
7. Lisinopril 40 mg PO DAILY
8. urea 40 % topical BID:PRN itchiness
9. Outpatient Physical Therapy
ICD 9: ___ Cervical Sponydlosis with Radiculopathy
Assess and Treat
Provider: ___
10. Soft Collar
ICD 9: ___ Cervical Sponydlosis with Radiculopathy
Soft Collar
Disp 1
Provider: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical spondylosis
Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with acute RUE weakness // Eval for ICH
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,009.3 mGy-cm.
2) Stationary Acquisition 8.5 s, 0.5 cm; CTDIvol = 92.6 mGy (Head) DLP =
46.3 mGy-cm.
3) Spiral Acquisition 5.5 s, 42.9 cm; CTDIvol = 32.1 mGy (Head) DLP =
1,378.8 mGy-cm.
Total DLP (Head) = 2,434 mGy-cm.
COMPARISON: ___ chest CTA.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are patent and prominent in keeping with age-related
volume loss.
There are scattered hypodensities in the subcortical and periventricular white
matter, nonspecific, likely secondary to small vessel ischemic disease. There
is intracranial atherosclerotic calcification.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is atherosclerosis involving bilateral cavernous carotid arteries
causing mild stenosis on the left and moderate stenosis on the right. Also
seen is mild atherosclerosis involving bilateral V4 segments of the vertebral
arteries. The vessels of the circle of ___ and their principal
intracranial branches appear otherwise unremarkable without stenosis,
occlusion, or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
There is mild atherosclerosis involving the left carotid bifurcation without
any stenosis by NASCET criteria. The carotid and vertebral arteries and their
major branches appear otherwise unremarkable with no evidence of stenosis or
occlusion. There is no evidence of internal carotid stenosis by NASCET
criteria.
OTHER:
The visualized portion of the lungs are clear. There is heterogeneously
enlarged thyroid gland with retrosternal extension, likely in keeping with
multinodular goiter, grossly unchanged compared to ___ prior exam. There is
no lymphadenopathy by CT size criteria. Multilevel degenerative changes
involving the visualized cervical spine are noted. There also seen is mild
ectasia of the ascending aorta measuring up to 3.8 cm with atherosclerosis.
IMPRESSION:
1. Unremarkable head and neck CTA noting mild atherosclerosis as described
above.
2. No acute intracranial abnormality, with no evidence of acute intracranial
hemorrhage.
3. Findings of small vessel ischemic disease in age-related involutional
changes.
4. Ectasia of the ascending aorta measuring up to 3.8 cm, grossly unchanged
compared to prior exam.
5. Multinodular goiter with retrosternal extension, grossly similar compared
to prior.
6. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with right hand weakness. Evaluate for acute
infarct.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ CTA head and neck.
FINDINGS:
There is a punctate superior right frontal acute to subacute infarct (see
4:23) with associated FLAIR signal abnormality (see 10:18). No corresponding
susceptibility on gradient echo imaging is seen. No other acute infarcts are
seen.
There is no evidence of masses, mass effect, midline shift. There is
prominence of the ventricles and sulci suggestive involutional changes.
There are scattered foci of T2/FLAIR hyperintensity in the subcortical and
periventricular white matter, nonspecific, likely secondary to small vessel
ischemic disease.
There are multiple punctate foci of micro hemorrhages in bilateral cerebral
and cerebellar hemispheres.
There is mild mucosal thickening in bilateral anterior ethmoid air cells. The
remaining visualized paranasal sinuses and mastoid air cells are clear.
Intracranial flow voids are maintained. The orbits are unremarkable.
IMPRESSION:
1. Right frontal punctate acute to subacute infarct as described.
2. Findings of age-related involutional changes with small vessel ischemic
disease.
3. Nonspecific bilateral hemisphere both deep and superficial distribution
supratentorial and infratentorial chronic microhemorrhages, concerning for
amyloid angiopathy, with differential consideration of hypertensive
microhemorrhages.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L Arm numbness
Diagnosed with Weakness
temperature: 98.9
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 134.0
dbp: 85.0
level of pain: 0
level of acuity: 1.0 | He was admitted for a RUE weakness, concerning for a stroke.
There was no stroke seen on imaging to explain the RUE weakness,
but this MRI did reveal a stroke in an unrelated area of the
brain, with etiology is likely embolic. He has had mixed
compliance with aspirin as an outpatient, secondary to
nosebleeds. He was prescribed saline sprays to keep his nose
moist and instructed to take aspirin 81 mg daily. A1c and LDL
were pending on day of discharge. He was also noted to have
cervical spondylosis so he was prescribed a soft collar and
outpatient ___. Cervical spondylosis is another possibility for
RUE weakness.
Transitional Issues:
- Needs outpatient w/u for 30 day rhythm monitoring, TTE
- Please f/u pending lipids and A1c
- Will continue atorvastatin at current dose (last LDL was 60;
may adjust dose pending above LDL. It was not available on day
of discharge, so should be followed up and adjusted as an
outpatient). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dizziness and lightheadedness.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ F PMHx fibromyalgia, UC, COPD who presented to
OSH w suddent onset dizziness, found to have new onset VT,
transferred to ___ for further management. Patient reports
that at 5pm on day prior to transfer, she was in front of her
house finishing some yard work when she had a single episodes of
dizziness that she described as "being at the top of a
rollercoaster", which lasted for several seconds with
spontaneous resolution; associated with subsequent palpitations,
and without any exacerbating/relieving factors that she could
identify. No associated chest pain, SOB, HA, syncope, visual
changes, neck pain, fevers/chills, vomiting/diarrhea, BRBPR,
dysuria. Patient reports she No recent change in medications.
Smokes 1pk/day, drinks 8 cups coffee/day.
.
On day of admission, patient awoke with indigestion and
palpitations. Patient went to previously scheduled OBGYN visit,
where she was noted to have a rapid heart rate, prompting a
referral to OSH ED. At OSH patient was noted to be in a wide
complex tachycardia. She received 6mg + 12 mg IV adenosine
without resolution of tachycardia. She received a bolus of
amiodarone, started on amio drip, and was transferred to ___
for further evaluation and management. In the ___ ED, initial
vital signs were BP 113/76 HR 137 RR 16 O2Sat98%/2LNC. EKG
demonstrate regular monomorphic wide complex tacycardia c/w LV
septal VT. Physical exam was significant for comfortable
patient without any distress, otherwise unremarkable. CBC,
Chem7, cardiac enzymes were unremarkable. Patient was continued
on amiodarone drip at 1mg/min. Attempts at conversion were made
with IV adenosine 6mg, then 12mg, as well as verapamil 5mg
without resolution of VT. Patient was given ASA 325mg and
admitted to CCU for further management.
.
On arrival to the floor, patient is comfortable, reports
palpitations, denies CP/SOB. On review of systems, patient
reported 1 month of cough. Review of systems otherwise
negative.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Ulcerative Collitis
- Fibromyalgia
- s/p R ACL / Meniscal Repair (___)
- s/p IUD placement
Social History:
___
Family History:
Unknown as she is adopted.
Physical Exam:
ADMISSION EXAM:
VS: 97.1 133 ___ 98%RA
GENERAL: Appropriate, comfortable, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, JVD 6cm w occasional cannon A waves
CARDIAC: rapid irreg irregular, no m/r/g.
LUNGS: Resp unlabored, no accessory muscle use. CTA b/l
ABDOMEN: Soft, obese, nontender.
EXTREMITIES: shallow 1cm abrasion over L shin, draining clear
fluid; no cyanosis/edema
Right: DP 2+ ___ 2+ Left: DP 2+ ___ 2+
.
DISCHARGE EXAM:
GENERAL: Appropriate, comfortable, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, JVD 6cm
CARDIAC: RRR, no m/r/g.
LUNGS: Resp unlabored, no accessory muscle use. CTA b/l
ABDOMEN: Soft, obese, nontender.
EXTREMITIES: shallow 1cm abrasion over L shin, draining clear
fluid; no cyanosis/edema
Right: DP 2+ ___ 2+ Left: DP 2+ ___ 2+
Pertinent Results:
ADMISSION LABS:
___ 03:00PM GLUCOSE-95 UREA N-13 CREAT-0.6 SODIUM-142
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
___ 03:00PM CALCIUM-9.1 PHOSPHATE-3.8 MAGNESIUM-1.8
___ 03:00PM WBC-8.8 RBC-4.19* HGB-13.6 HCT-39.6 MCV-95
MCH-32.4* MCHC-34.3 RDW-14.0
___ 03:00PM NEUTS-71.2* ___ MONOS-4.1 EOS-1.7
BASOS-0.4
___ 03:00PM PLT COUNT-413
___ 03:00PM ___ PTT-25.6 ___
.
PERTINENT LABS:
___ 03:00PM cTropnT-<0.01
___ 10:15PM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:15PM BLOOD %HbA1c-5.7 eAG-117
___ 10:15PM BLOOD Triglyc-146 HDL-48 CHOL/HD-3.2 LDLcalc-76
.
DISCHARGE LABS:
___ 06:24AM BLOOD Glucose-100 UreaN-12 Creat-0.6 Na-144
K-4.5 Cl-113* HCO3-24 AnGap-12
___ 06:24AM BLOOD Calcium-8.3* Mg-2.0
___ 08:23AM BLOOD WBC-7.1 RBC-3.59* Hgb-11.9* Hct-34.5*
MCV-96 MCH-33.3* MCHC-34.6 RDW-14.0 Plt ___
.
CXR ___
FINDINGS: In comparison with the outside study of this date, the
cardiac
silhouette remains within normal limits and there is no evidence
of acute
focal pneumonia. The pulmonary vessels are not as sharply seen,
raising the possibility of mild elevation of pulmonary venous
pressure.
.
___
The left atrium is elongated. 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 no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Normal global and regional biventricular
systolic function.
Medications on Admission:
- Balsalazide 4tabs qAM, 5tabs qPM
- Savella 1 taq BID
- Vicodin 1 tab TID prn pain
- Sporadic Advair
Discharge Medications:
1. hydrocodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
2. balsalazide 750 mg Capsule Sig: Four (4) Capsule PO qAM ().
3. balsalazide 750 mg Capsule Sig: Five (5) Capsule PO qPM ().
4. Savella 100 mg Tablet Sig: One (1) Tablet PO bid ().
5. verapamil 240 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: Please stop this
medication two days prior to your EP procedure.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*0*
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety: Do NOT drive, operate heavy machinery, or
make important decisions while on this medication.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Ventricular Tachycardia
Secondary Diagnoses: COPD, Fibromyalgia, Ulcerative colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Ventricular tachycardia, to assess for mediastinal widening or
infection.
FINDINGS: In comparison with the outside study of this date, the cardiac
silhouette remains within normal limits and there is no evidence of acute
focal pneumonia. The pulmonary vessels are not as sharply seen, raising the
possibility of mild elevation of pulmonary venous pressure.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: VT
Diagnosed with PAROX VENTRIC TACHYCARD, CHRONIC AIRWAY OBSTRUCTION, MYALGIA AND MYOSITIS NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 2.0 | ___ F PMHx w/o known cardiac history presented with new onset
VT, otherwise hemodynamically stable, without clear underlying
etiology.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
oxcarbazepine / thimerosal / adhesive tapes / ceftriaxone /
Levaquin / Keppra
Attending: ___
Chief Complaint:
Wound evaluation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of
diverticulitis s/p sigmoidectomy with diverting colostomy, as
well as DVT and right-sided iliopsoas abscess s/p drainage with
indwelling drain, who presented from rehab after accidental
dislodgement of her drain.
On ___, she had a drain placed by ___ into a chronic, R psoas
abscess (which communicated with a presacral abscess). The drain
had been accidentally removed on ___, so she presented for
replacement. She noted that the bag had been filling with
drainage every ___ days with "yellow/white" drainage. She
notes it had previously been clear drainage until she fell and
was admitted to the hospital. Then it changed to yellow/white.
She denied fevers, chills, abdominal pain.
Of note, she was hospitalized at ___ after a fall, where she
suffered multiple rib fractures (___).
In the ED, initial vital signs were: pain ___, T 98.6, HR 93,
BP 120/76, R 16, SpO2 100%/RA
- Labs showed: Hgb 9, glucose 166, INR 3.2, contaminated UA,
though dirty appearing
- Imaging showed persistent right iliopsoas and presacral
abscesses measuring up to 7.2 cm and 6.4 cm respectively in
maximum ___, not significantly changed in size compared
to the prior study; blateral hydroureteronephrosis with double-J
stents in place: degree of hydroureteronephrosis on the right is
improved since prior study. Enhancement of the left renal pelvis
may be due to infection. Correlation with urinalysis is
recommended.
- Given APAP 1.65 g total
- Consulted colorectal surgery: recommended ___ replacement
Upon arrival to the floor, she is very tired.
Past Medical History:
Shingles, left side of face
Cataract surgery right eye c/b non-reactive, non-round pupil
Hx of thrombocytosis
LLE DVT ___
? hepatitis B
Retroperitoneal fibrosis
Depression/Anxiety
Small bowel obstruction
Gout
Adrenal adenoma
GERD
chronic dissection of the descending thoracic aorta
Perforated diverticulitis c/b sepsis, obstructive
pyelonephritis, fungal peritonitis, renal failure ___ ATN
requiring HD
s/p sigmoid colon resection, colostomy and failed takedown
Chronic R iliopsoas abscess (since at least ___
HTN
Iliopsoas abscess drainage and catheter placement (___)
B/l ureteral stent placement for hydronephrosis ___ RP fibrosis
HTN
TKA
Social History:
___
Family History:
Mother died of ?stomach cancer when pt was ___
Father had prostate cancer, pt does not know cause of death
Sister died young in car accident
Physical Exam:
PHYSICAL EXAM ON ADMISSION
===============================
VITALS - T 98.3 BP 107/64 HR 100 R 20 SpO2 97%/RA
GENERAL - appears well, comfortable, sleeping in bed
HEENT - sclerae anicteric, PERRL, face symmetric
CARDIAC - regular, normal S1/S2, grade II systolic
crescendo-decrescendo murmur not radiating to the neck
PULMONARY - clear anterolterally
ABDOMEN - soft, LLQ ostomy in place, appears healthy, with well
formed stool in bag, bandage over RLQ with miminimal purulent
drainage
EXTREMITIES - warm, well perfused, no edema, refused to allow
examiner to perform Psoas sign exam
SKIN - no rashes
NEURO - face symmetric, moving extremities well
PSYCH - appropriate, tired
PHYSICAL EXAM ON DISCHARGE
=================================
Vitals - T 97.9 BP 129/66 HR 80-100 RR 20 ___ RA
Gen - no acute lying in bed comfortably
HEENT - sclerae anicteric, R pupil irregular not responsive to
light (past cataract surgery), L pupil responsive to light
Cardiac - regular rate and rhythm, normal S1/S2
Pulm - clear to auscultation, no wheezes
Abd - soft, NTND, no rebound or guarding, LLQ ostomy in place,
appears healthy, bandage over RLQ without drainage
Back - no CVA tenderness bilaterally
Ext- warm, well perfused, no edema
Neuro - alert and oriented x3, moving all extremities
Pertinent Results:
ADMISSION LABS:
===========================
___ 04:55PM BLOOD WBC-8.8 RBC-2.82* Hgb-9.0* Hct-29.1*
MCV-103* MCH-31.9 MCHC-30.9* RDW-17.1* RDWSD-63.6* Plt ___
___ 04:55PM BLOOD Neuts-63.3 ___ Monos-7.7 Eos-1.0
Baso-0.5 Im ___ AbsNeut-5.57 AbsLymp-2.40 AbsMono-0.68
AbsEos-0.09 AbsBaso-0.04
___ 07:22PM BLOOD ___ PTT-41.2* ___
___ 04:55PM BLOOD Glucose-166* UreaN-19 Creat-1.0 Na-135
K-4.7 Cl-101 HCO3-22 AnGap-17
___ 04:00PM URINE Color-YELLOW Appear-Cloudy Sp ___
___ 04:00PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 04:00PM URINE RBC->182* WBC->182* Bacteri-MANY
Yeast-NONE Epi-14
___ 04:00PM URINE CastHy-5*
___ 04:00PM URINE WBC Clm-OCC
PERTINENT INTERVAL LABS
============================
___ 07:05AM BLOOD Ret Aut-1.7 Abs Ret-0.05
___ 07:05AM BLOOD ALT-12 AST-19 AlkPhos-175* TotBili-0.3
___ 07:05AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.6 Iron-22*
___ 07:05AM BLOOD calTIBC-198* VitB12-605 Ferritn-1101*
TRF-152*
___ 07:03AM BLOOD TSH-PND
___ 07:03AM BLOOD METHYLMALONIC ACID-PND
___ 04:25PM URINE Color-Red Appear-Hazy Sp ___
___ 04:25PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 04:25PM URINE RBC->182* WBC-122* Bacteri-FEW Yeast-NONE
Epi-1
___ 04:25PM URINE Mucous-RARE
MICROBIOLOGY
==============================
__________________________________________________________
___ 4:25 pm URINE Source: Catheter.
URINE CULTURE (Pending):
__________________________________________________________
___ 4:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS
==============================
___ 07:03AM BLOOD WBC-5.2 RBC-2.93* Hgb-9.2* Hct-29.7*
MCV-101* MCH-31.4 MCHC-31.0* RDW-16.6* RDWSD-59.9* Plt ___
___ 07:03AM BLOOD Plt ___
___ 07:03AM BLOOD Glucose-78 UreaN-20 Creat-1.0 Na-134
K-4.7 Cl-99 HCO3-24 AnGap-16
___ 07:03AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.1
IMAGING/STUDIES
==============================
CT ABD & PELVIS WITH CONTRAST Study Date of ___
1. Right iliopsoas and perirectal abscesses measuring up to 7.2
cm and 6.4 cm respectively in maximum ___, not
significantly changed in size compared to the prior study.
2. Bilateral hydroureteronephrosis with double-J stents in
place. Degree of hydroureteronephrosis on the right is improved
since prior study. Enhancement of the left renal pelvis may be
due to infection. Correlation with urinalysis is recommended.
3. Left uncomplicated parastomal hernia containing loops of
small bowel.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Senna 17.2 mg PO QHS
2. Docusate Sodium 100 mg PO BID
3. Warfarin Dose is Unknown PO DAILY16
4. Allopurinol ___ mg PO DAILY
5. Duloxetine 30 mg PO DAILY
6. Famotidine 20 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. Acetaminophen 650 mg PO Q6H:PRN PAIN
9. Nitrofurantoin Monohyd (MacroBID) 50 mg PO QID
10. Gabapentin 100 mg PO TID
11. TraZODone 25 mg PO QHS:PRN INSOMNIA
12. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN PAIN
13. Bisacodyl ___AILY:PRN If no bowel movemen tin 48
hours
14. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO DAILY:PRN
indigestion
15. Sorbitol 70% Soln 30 mL PO QHS PRN If no bowel movement
that day
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN PAIN
2. Allopurinol ___ mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Duloxetine 30 mg PO DAILY
5. Nitrofurantoin Monohyd (MacroBID) 50 mg PO QID
6. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
7. Pantoprazole 40 mg PO Q24H
8. Senna 17.2 mg PO QHS
9. TraZODone 25 mg PO QHS:PRN INSOMNIA
10. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO DAILY:PRN
indigestion
11. Bisacodyl ___AILY:PRN If no bowel movemen tin 48
hours
12. Famotidine 20 mg PO BID
13. Sorbitol 70% Soln 30 mL PO QHS PRN If no bowel movement
that day
14. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN PAIN
RX *hydromorphone 2 mg ___ tablet(s) by mouth q6hr Disp #*30
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Right psoas and presacral abscess
Urinary tract infection
Macrocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ with R psoas abscess s/p ___ drain ___, drain
accidentally pulled this morning. Evaluate for resolution of abscess.
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. Oral contrast was
not administered.Coronal and sagittal reformations were performed and reviewed
on PACS.
DOSE: Total DLP (Body) = 632 mGy-cm.
COMPARISON: CT abdomen and pelvis from ___
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis. Atherosclerotic calcifications
of the coronary arteries are noted. There is no pericardial or pleural
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: Bilateral hydronephrosis is noted, moderate on the left and mild on
the right despite the presence of ureteral stents which appear properly
positioned. The degree of hydroureteronephrosis on the right has improved
somewhat since the prior study. Left urothelial hyperenhancement suggests
underlying infection. There is stable perinephric stranding, nonspecific. No
signs of nephritis or renal abscess. Scattered hypodensities bilaterally are
again noted, too small to be fully characterize but likely represent cysts.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Patient is status
post sigmoid colectomy with an end colostomy in the left upper quadrant. A
parastomal hernia containing some small bowel appears unchanged. The
remaining colon demonstrates diverticulosis without acute diverticulitis. The
appendix is normal.
PELVIS: The urinary bladder contains a single focus of gas. Again seen is a
perirectal abscess measuring 2.7 x 6.2 x 6.4 cm, grossly unchanged since prior
study. This collection is intimately associated with the ___ pouch and
may reflect a bowel leak. Interval loss of drainage catheter from the fluid
collection tracking along the right ileal post OS muscle with small residual
rim enhancing fluid collection seen in this site containing small foci of gas
likely due to recent drain catheter in place. This collection approximately
measures 7.2 x 1.3 x 5.5 cm, also grossly unchanged since prior study. A
tract is noted from the right iliopsoas abscess to the skin from prior
drainage catheter.
REPRODUCTIVE ORGANS: The uterus contains coarse calcifications, likely
degenerative fibroids.
LYMPH NODES: There is no mesenteric lymphadenopathy. Scattered prominent
retroperitoneal lymph nodes are identified but are not enlarged by CT size
criteria. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Severe atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Anterior compression deformity at T11 and L2 are unchanged.
IMPRESSION:
1. Right iliopsoas and perirectal abscesses measuring up to 7.2 cm and 6.4 cm
respectively in maximum ___, not significantly changed in size compared
to the prior study.
2. Bilateral hydroureteronephrosis with double-J stents in place. Degree of
hydroureteronephrosis on the right is improved since prior study. Enhancement
of the left renal pelvis may be due to infection. Correlation with urinalysis
is recommended.
3. Left uncomplicated parastomal hernia containing loops of small bowel.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Unsp complication of internal prosth dev/grft, init, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 98.6
heartrate: 93.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | In brief this is a ___ yo woman with a history of diverticulitis
s/p sigmoid resection and diverting colostomy, ___ DVT, bilateral
ureteral stents, with a chronic psoas/pre sacral abscess c/b
fistula with the small bowel and rectum, with an ___ placed drain
into the right psoas abscess, with a recent admission for rib
fractures after a mechanical fall, here with accidental removal
of her drain at her rehab facility.
# Right Psoas/Presacral Abscess:
Patient presented with accidental removal of her drain while at
rehab. The plan had been to keep the drain in place, and to
discuss with colorectal surgery (Dr. ___ prior to removal.
The drain had continued to drain daily. On admission CT imaging
demonstrated persistence of the abscesses. Clinically the
patient appeared well and was afebrile, hemodynamically stable,
without leukocytosis or abdominal pain. After discussion with ___
and colorectal surgery the plan was to replace the drain.
However given multiple ___ emergencies on ___ a plan was made
to have the patient return to ___ on ___ for placement of
the drain. Warfarin was discontinued as below because of
supratherapeutic INR and need for INR<1.5 for ___ drain
placement.
# UTI/left renal pelvic enhancement on CT
The patient was initiated on Nitrofurantoin at her rehab
facility due to a urine culture with 50-100K E coli cfu/mL and >
100K CRE cfu/mL, form a culture gathetered ___. Culture
data (gathered ___ show pan-sensitive E. coli and VRE, with
common sensitivities to ampicillin and nitrofurantoin, with VRE
sensitive to penicillin G (MIC 8) as well as linezolid. A
repeat UCx in the ED had 14 epilethial cells, and the urine
culture was contaminated. A repeat straight cath urine culture
was notable for 122 WBC cells, few bacteria, >182 RBC cells. A
urine culture from this straight cath was pending. Of note the
patient has bilateral ureteral stents placed, follows with
urologist Dr. ___ at ___. Though the patient's only
symptoms at this time with respect to UTI is incontinence (which
appears chronic), the significant UA was concerning for true
infection vs. possible colonization, and she was continued on
her course of nitrofurantoin.
# DVT
The patient was admitted on warfarin for a LLE DVT. Outside
records indicated that this had been present for months, with an
unclear start date. Upon discussion with the patient's PCP ___
___, it was noted that the DVT ws diagnosed ___. On
discussion with the patient's PCP, it was determined that the
patient was planned for a 6 mo course of treatment, so the
warfarin was held on discharge. Of note the patient has a
history of a chronic aortic mural thrombus. After discussion
with the vascular surgery team she did not need anticoagulation.
She will need follow up in ___ with vascular surgery and
repeat CTA Torso for evaluation.
# Macrocytic Anemia
The patient presented with a macrocytic anemia of unclear
etiology. Iron studies were sent and were notable for an iron of
22, and ferritin of 1101, consistent with chronic inflammation,
and a B12 was normal at 605. A methyl malonic acid level was
sent and pending on discharge. A TSH was also pending on
discharge. Though the patient had normal LFTs (except an
elevated alk phos to 175), after discussion with the patient's
PCP it was noted that the patient has significant EtOH use at
home. Given the concomitant history of thrombocytosis, there was
concern for possible myelodysplastic syndrome as well, and the
patient will need follow up with hematology.
# Orthostatic hypotension
Appears that metoprolol had been held at rehab due to
orthostatic hypotension. Her pressures were well controlled
during the admission but orthostatic were not checked.
# Rib fractures
The patient was continued on a pain regimen of PO hydromorphone.
She did not require any pain medications on the day of
discharge. She had incentive spirometry at the bedside. Her pain
was well controlled and she was breathing well on discharge.
CHRONIC ISSUES
=====================
# Mood disorder
The patient continued duloxetine and gabapentin.
# Gout
The patient continued allopurinol.
# GERD
The patient continued pantoprazole. Famotidine was held during
the admission.
TRANSITIONAL ISSUES
=============================
- Patient will need to return to ___ on ___ or
placement of her drain:
"You are scheduled to have a CT guided pelvic catheter
replacement.
Please arrive at 07:30 am to the FIRST FLOOR of the ___ ___ on the ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Prevacid
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, reduction of intern hernias
x2, left groin washout
History of Present Illness:
___ is an ___ year-old man status post recent EVAR on
___ complicated by pseudoanerysm and type I leak s/p
revision on ___, history of mAVR and MVR (on Coumadin), CAD
s/p CABG, SSS s/p pacemaker, afib, BPH who presented one day ago
with one day history of abdominal pain, nausea, vomiting, poor
appetite and inability to void, accompanied by abdominal
distention. Of note the patient is also status post sigmoid
colectomy (Dr. ___ on ___, c/b bleeding necessitating
exlap open abdomen in ___.
The patient states that prior to this, he was doing generally
well, eating well, having BM and having no nausea. He also has
new purulent drainage from his L EVAR access site. The patient
underwent a CTA today which was concerning for closed loop SBO
and surgery was consulted based on that scan. On evaluation, the
patient endorses only mild abdominal pain, significant nausea,
one episode of vomiting this morning. He states that he has not
passed gas since this morning when he passed a very small
amount. his last BM has been two days prior to this evaluation.
Past Medical History:
- Mechanical AVR and MVR on warfarin with INR goal 2.5-3.5;
initial AVR in ___, then repair of aortic in ___ and
mechanical MVR done in ___
- CHF
- Afib
- CAD s/p CABG ___
- SSS s/p PPM placement
- HLD
- HTN
- OSA - pt reports prior, no CPAP use
- AAA
- BPH
- pancreatic cyst
- colonic polyps
Social History:
___
Family History:
Father CAD/PVD
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Temp 98.3F BP 154/80 HR 60 RR 20 93% on RA
GENERAL: Elderly male in mild distress ___ pain. Lying flat in
bed.
HEENT: AT/NC, anicteric sclera, PERRL. MMM. Oropharynx clear.
NECK: supple, no LAD or elevated JVP.
CV: RRR with normal S1 and S2. II/VI systolic murmur over RUSB.
No rubs or gallops.
PULM: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
GI: soft, moderately distended. Mild diffuse TTP. No guarding or
rebound. No masses appreciated. Multiple deformities in
abdominal
wall.
Rectal: Good rectal tone. Stool in rectal vault. Enlarged
prostate without obvious lesions.
EXTREMITIES: Warm, well perfused. No ___ edema. Left groin
incision healing, has associated serosanguineous drainage and
surrounding erythema. No tenderness to palpation.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert and interactive. CN II-XII grossly intact. Moves
all
extremities.
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VITALS:
24 HR Data (last updated ___ @ 1041)
Temp: 97.9 (Tm 97.9), BP: 113/61 (113-141/56-71), HR: 62
(59-62), RR: 18, O2 sat: 96% (94-98), O2 delivery: 2l (2l-3l)
GENERAL: frail, elderly appearing man
CARDIAC: Regular rhythm, normal rate. Mechanical valve sounds.
Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: poor breath sounds at bases with trace crackles
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: pitting edema of upper and lower extremities is
somewhat improved. Pulses DP/Radial 2+ bilaterally. left lower
extremity without palpable cords.
NEUROLOGIC: AOx3.
Pertinent Results:
-----------
IMAGING
-----------
CT ABDOMEN & PELVIS ___:
1. Findings concerning for closed loop bowel obstruction with a
transition
point seen within the central mid abdomen, in a location similar
to the prior obstruction. Moderate ascites. No evidence of
bowel ischemia.
2. Inflated Foley balloon within the prostatic urethra.
Recommend advancement or re-insertion.
3. Minimally decreased fluid collection around the left common
femoral artery, with foci of gas and surrounding stranding which
may represent postsurgical changes, however infectious etiology
is not excluded.
4. No significant change in a 5.3 cm abdominal aortic aneurysm
status post
endovascular aortic repair with aortobifemoral stenting.
Findings are better characterized on dedicated CTA from ___.
5. Moderate left pleural effusion and trace right pleural
effusion with
overlying basilar atelectasis.
6. No change in a 1.0 cm hypodensity along the pancreatic body.
Previously
seen pancreatic neck hypodensity is not demonstrated on this
exam.
CT ABD/PELVIS W/O ___
1. Large colonic stool load with mild to moderate distention in
some areas. This is presumably related to constipation as there
is no evidence of acute bowel obstruction. There is no evidence
of bowel wall necrosis or other acute complication.
2. Grossly stable left groin hematoma. No drainable
intra-abdominal
collection.
CT CHEST ___
1. Interval increase in bilateral nonhemorrhagic pleural
effusions, moderate on the left and small to moderate on the
right with associated atelectasis.
2. Likely superimposed consolidation in the right lower lobe
suggesting
infection or aspiration, although evaluation is limited without
the use of IV contrast.
3. 8 mm pulmonary nodule in the right upper lobe with
surrounding ground-glass opacity is likely infectious or
inflammatory in etiology. Attention on follow-up imaging is
recommended.
4. Similar marked cardiomegaly with extensive coronary arterial
calcifications and prosthetic aortic and mitral valves with
enlargement of the ascending aorta measuring up to 4.4 cm.
5. Enlargement of the pulmonary arteries suggesting underlying
pulmonary
arterial hypertension.
6. Partially evaluated small to moderate ascites, grossly
similar to the prior study.
ADMISSION LABS:
===============
___ 08:00PM BLOOD WBC-8.3 RBC-3.67* Hgb-11.8* Hct-35.7*
MCV-97 MCH-32.2* MCHC-33.1 RDW-14.5 RDWSD-52.1* Plt ___
___ 08:00PM BLOOD Neuts-84.8* Lymphs-6.4* Monos-7.4
Eos-0.8* Baso-0.4 Im ___ AbsNeut-7.02* AbsLymp-0.53*
AbsMono-0.61 AbsEos-0.07 AbsBaso-0.03
___ 08:00PM BLOOD ___ PTT-40.0* ___
___ 08:00PM BLOOD Glucose-108* UreaN-21* Creat-0.9 Na-138
K-4.3 Cl-97 HCO3-28 AnGap-13
___ 08:00PM BLOOD ALT-8 AST-24 AlkPhos-100 TotBili-0.7
___ 08:00PM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0
DISCHARGE LABS:
===============
___ 08:26AM BLOOD WBC-7.6 RBC-2.47* Hgb-7.6* Hct-24.2*
MCV-98 MCH-30.8 MCHC-31.4* RDW-16.2* RDWSD-58.2* Plt ___
___ 08:26AM BLOOD ___ PTT-43.6* ___
___ 08:26AM BLOOD Glucose-100 UreaN-131* Creat-4.3* Na-138
K-3.5 Cl-86* HCO3-41* AnGap-10
___ 08:26AM BLOOD Calcium-8.5 Phos-5.6* Mg-3.2*
MICRO:
=======
___: Surgical culture LLE groin
SERRATIA RUBIDAEA
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ C diff: negative
___ Sputum culture: negative
___ Blood cultures x2: negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 10 mg PO BID
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Warfarin 15 mg PO 5X/WEEK (___)
4. Warfarin 12.5 mg PO 2X/WEEK (MO,TH)
5. Aspirin EC 81 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Multivitamins 1 TAB PO DAILY
8. Ascorbic Acid Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
3. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Lactulose 30 mL PO BID
6. Modafinil 200 mg PO DAILY
RX *modafinil 200 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO DAILY
10. ___ MD to order daily dose PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute kidney injury
Acute hypoxic respiratory failure
Acute on chronic diastolic heart failure
Vascular graft infection
Anemia
Urinary retention
GI dysmotility
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with abdominal pain and distention.// Evaluate
stool burden, ileus, obstruction
TECHNIQUE: Supine and upright frontal view radiographs of the abdomen.
COMPARISON: CT of the abdomen and pelvis dated ___.
FINDINGS:
There is moderate gaseous distention of multiple loops of small bowel
measuring up to 4.7 cm. Multiple air-fluid levels at different heights on the
upright view raise concern for small bowel obstruction, although ileus can
have a similar appearance. There is marked distention of a featureless loop
of bowel in the mid abdomen, either the stomach or transverse colon. There is
no pneumoperitoneum. There is moderate to large colonic fecal loading in the
ascending colon and rectum. Pacemaker wires and a prosthetic mitral valve are
noted in the lower chest as well as sternotomy wires and mediastinal clips.
Aortic an aortobifemoral graft 6 are in place with a vascular occlusion device
noted in the left lower quadrant, unchanged from the prior CT. There moderate
to severe multilevel degenerative changes of the lumbar spine.
IMPRESSION:
Gaseous distention of multiple loops of small bowel with air-fluid levels.
Findings may represent small-bowel obstruction or ileus, with obstruction
favored based on concurrent CT.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: Mr. ___ is a ___ y/o male with a history of mAVR and MVR (on
Coumadin), CAD s/p CABG, SSS s/p pacemaker, afib, BPH, and recent EVAR and
left formal aneurysm repair c/b pseudoaneurysm who presents with urinary
retention of unclear etiology, concern for infection at recent surgical site
(L groin, evaluate for fluid collection at surgical site
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 78.2 cm; CTDIvol = 3.1 mGy (Body) DLP = 241.0
mGy-cm.
2) Spiral Acquisition 4.7 s, 62.4 cm; CTDIvol = 12.2 mGy (Body) DLP = 758.6
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.3
mGy-cm.
4) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 24.2 mGy (Body) DLP =
12.1 mGy-cm.
Total DLP (Body) = 1,013 mGy-cm.
COMPARISON: CTA of the abdomen and pelvis dated ___.
FINDINGS:
VASCULAR:
The aortobifemoral stent is unchanged from the prior study with contrast
filling the excluded aneurysmal sac and non contiguity of the bilateral iliac
stents with the abdominal aortic endovascular stent. Short-segment dissection
in the uncovered portion of the aorta is seen only on the most superior images
of this study but is grossly unchanged compared to the prior studies.. The
overall aneurysm sac size is unchanged measuring up to 5.5 cm in greatest
axial dimension (03:15). There is additional stenting of the left common
iliac and external iliac artery with unchanged small volume endoleak without
definite feeding vessel (03:43).
The fluid collection surrounding the left common femoral bifurcation has
decreased slightly in overall dimension but newly contains air with extension
to the skin surface, currently measuring up to 3.6 x 3.3 cm (3:87). There is
no evidence of active extravasation into this collection.
The common femoral, superficial femoral, deep femoral arteries are patent.
Immediately subjacent to this collection there is abnormal mixing of contrast
within the common femoral vein worrisome for acute thrombus (3:90). The
remainder of the vascular findings of the pelvis and proximal lower
extremities are unchanged with mild aneurysmal dilatation of the distal-most
portions of the superficial femoral artery near the transition to the
popliteal artery (3:226).
ABDOMEN/PELVIS:
The visualized portions of the liver are unremarkable. Multiple renal cysts
are seen. The pancreas, adrenals, and spleen are not included within the
field of view.
GASTROINTESTINAL: There is extensive fluid-filled distention of small-bowel
loops with two abrupt transition points in the central mid abdomen in close
proximity to one another, highly concerning for closed loop bowel obstruction
with a relatively short segment of twisted bowel (03:23). There is marked
distention of bowel loops proximal to this transition point and near complete
decompression of the small bowel loops distal to this transition point. There
is persistent moderate to large fecal burden within the large bowel, including
a large stool ball in the distal rectum. Bowel wall enhancement is uniform and
there is no pneumatosis or pneumoperitoneum. Moderate simple ascites is new
from the prior study.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy.
REPRODUCTIVE ORGANS: There is marked enlargement of the prostate, which
measures up to 9.6 x 7.6 x 10.6 cm with an estimated volume of 405 cc (3:73,
602:35).
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. Findings highly concerning for closed loop small bowel obstruction.
Surgical consultation is recommended. No convincing evidence for bowel
ischemia.
2. Fluid collection surrounding the left common femoral artery is decreased
slightly in size but contains new gas and extension to the skin, highly
concerning for superinfection.
3. Findings concerning for left common femoral vein DVT. Ultrasound is
recommended for confirmation.
4. New moderate ascites.
5. Unchanged aortic and left common iliac endoleaks as described above.
6. Marked prostatomegaly with an estimated volume of 405 cc.
RECOMMENDATION(S):
1. Surgical consultation is recommended.
2. Ultrasound of the left common femoral vein is recommended to evaluate for
DVT.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:47 pm, 15 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: Chest radiographs, three AP upright views.
INDICATION: Nasogastric tube placement. Concern for small bowel obstruction
COMPARISON: ___.
FINDINGS:
The third of three views shows a nasogastric tube terminating in the stomach.
Stomach is distended. Patient is status post mitral valve replacement.
Single lead pacemaker/ICD terminates in the right ventricle. Heart is
moderately enlarged. Mediastinal and hilar contours appear stable. Trace
right-sided pleural effusion is possible. Extreme lung apices are excluded
but there is no indication of pneumothorax. Streaky left basilar opacities
and elevation of the left hemidiaphragm suggests sequela of minor atelectasis.
IMPRESSION:
Nasogastric tube terminating in the stomach. Gastric distension distension.
Radiology Report
INDICATION: ___ w h/o AAA s/p EVAR c/b endoleak s/p revision now infected,
h/o sig. volvulus s/p resection, mech AVR/MVR (coumadin), p/w abd distension-
c/f closed loop SBO on CT. ********Small bowel follow through, please obtain
KUB at 4, 8, 24 hours ********// contrast progression through colon?
TECHNIQUE: Portable supine frontal view radiographs of the abdomen.
COMPARISON: CT of the abdomen pelvis dated ___.
FINDINGS:
There is extensive dilatation of the small bowel and marked dilatation of the
stomach. Minimal oral contrast is present and its progress through the small
bowel cannot be reliably assessed. New from the prior CT are areas where the
small bowel wall can be seen on pole sides concerning for pneumoperitoneum.
Aorto bi-iliac stent and separate aortic stent separated by 4.5 cm are
re-demonstrated. Amplatzer plugs in the region of the left internal iliac
artery are unchanged. Contrast within the bladder is likely related to
contrast given on prior CT.
IMPRESSION:
Marked distention of the stomach and loops of small bowel worrisome for bowel
obstruction with new findings concerning for free air. Left lateral decubitus
radiographs are recommended.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:04 pm, 4 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Abdominal radiographs, six views.
INDICATION: Question free air on recent prior radiographs.
TECHNIQUE: The study includes two left decubitus views to assess for free air
in addition to two AP supine views and two upright views.
COMPARISON: Earlier on the same day.
FINDINGS:
A nasogastric tube terminates in the stomach, but the stomach still appears
moderately distended, although to a somewhat lesser degree. There still
widespread moderate dilatation of small bowel on the radiographs, and to a
lesser extent large bowel, without change. These views do not confirm any
evidence for free air. Tiny quantity of oral contrast is found in the stomach
and also projects along a viscus thought likely to be the tranverse colon. A
large quantity of stool is found in the rectum. Bones appear demineralized.
Vascular calcification is moderate. Intravenous contrast from recent
injection is visible in the bladder. Note is again made of an aortic stent
graft.
IMPRESSION:
No evidence of free air. Persistent small and large bowel dilatation with
air-fluid levels. Substantial stool in the rectum. No definite short-term
change.
Radiology Report
INDICATION: ___ year old man with bowel obstruction// eval for interval
change, passage of contrast
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: KUB dated ___
FINDINGS:
There is persistence of diffuse small-bowel dilation and, to a lesser extent,
large bowel dilation. Stool burden is again seen overlying the rectum. A
tiny amount of enteric contrast persists in the stomach. However, only a
small fraction of the contrast that was previously probably located in the
transverse colon remains.
Redemonstration of a gastric tube with its side port and tip in the stomach,
median sternotomy wires in the lower thorax, a cardiac valve replacement ring
overlying the mediastinum, endovascular aortic stent within the mid abdomen,
and additional vascular stents extending from the aorta to the iliac arteries.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
IMPRESSION:
1. Persistent diffuse small bowel dilation, and, to a less extent, large
bowel dilation.
2. Tiny amount of enteric contrast remains in stomach. Tiny amount of likely
transverse colon contrast remains.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w h/o AAA s/p EVAR c/b endoleak s/p revision now infected,
h/o sig. volvulus s/p resection, mech AVR/MVR (coumadin), p/w abd distension-
c/f closed loop SBO on CT with readjustment of NGT given decreased output//
Assess for placement of NG tube Assess for placement of NG tube
IMPRESSION:
NG tube tip is in the stomach. Pacemaker lead is in the right atrium. Severe
cardiomegaly is unchanged. Vascular congestion is unchanged. Bilateral
pleural effusion is similar. Distension of the bowel loops is less pronounced
than on the prior examination. There is no pneumothorax.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ year old man with hx of sigmoid volvulus s/p resection
admitted w/ bowel obstruction vs ileus now having bowel function plus ongoing
high NGT output// eval for interval change of SB dilation, resolution of
obstruction, passage of contrast
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 3.9 s, 52.2 cm; CTDIvol =
14.7 mGy (Body) DLP = 766.7 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm;
CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 13.8 s,
0.5 cm; CTDIvol = 77.2 mGy (Body) DLP = 38.6 mGy-cm. Total DLP (Body) = 807
mGy-cm.
COMPARISON: CT ___
FINDINGS:
LOWER CHEST: Moderate left pleural effusion with trace right pleural effusion.
Mild overlying bilateral basilar atelectasis. Severe cardiomegaly is
unchanged.
ABDOMEN:
HEPATOBILIARY: The liver is unremarkable. The gallbladder is not visualized.
PANCREAS: The pancreas demonstrates normal attenuation. A hypodensity in the
pancreatic tail measures 1.0 cm and is not significantly changed from prior.
A pancreatic hypodensity within the neck is not well demonstrated on this
exam.
SPLEEN: The spleen is unremarkable.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are normal size with a normal nephrogram bilaterally.
There are numerous bilateral simple cysts without demonstrated enhancement, as
on prior.
GASTROINTESTINAL: There are multiple dilated fluid-filled loops of bowel with
decompressed bowel seen distally near the cecum. At the central mid abdomen,
there are two transition points in a pattern similar to the prior study
concerning for a closed loop bowel obstruction (2:40). Oral contrast is not
seen passing the obstruction. Marked distension of bowel loops proximal to
this transition point is demonstrated, with moderate ascites. A large stool
ball is again demonstrated within the rectum. No evidence of bowel ischemia.
PELVIS: The Foley balloon is located within the prostatic urethra (2:75),
deflation and advancement or re-insertion is recommended. Ascites is present
in the pelvis.
REPRODUCTIVE ORGANS: The prostate is markedly enlarged, as on prior, measuring
up to 9.2 x 7.2 cm. The seminal vesicles are unremarkable.
LYMPH NODES: No enlarged intra-abdominal or intrapelvic lymph nodes are
identified.
VASCULAR: Redemonstration of a abdominal aortic aneurysm status post
endovascular aortic repair with aortobifemoral stenting is better
characterized on dedicated AAA contrast enhanced study from ___.
The excluded aneurysm sac is unchanged, up to 5.3 cm, with partial contrast
filling demonstrated.
The fluid collection around the left common femoral bifurcation measures up to
3.0 x 3.5 cm, which is minimally decreased in size from prior. Foci of gas
and surrounding stranding are again demonstrated, which is likely
postprocedural, however infection is not excluded.
An Amplatzer plug is seen in the left internal iliac, as on prior. Bilateral
iliac stents are unchanged in position and appear patent. Suspicious contrast
mixing of the left common femoral vein is no longer demonstrated, however the
this may be a effect of contrast phase.
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. Findings concerning for closed loop bowel obstruction with a transition
point seen within the central mid abdomen, in a location similar to the prior
obstruction. Moderate ascites. No evidence of bowel ischemia.
2. Inflated Foley balloon within the prostatic urethra. Recommend advancement
or re-insertion.
3. Minimally decreased fluid collection around the left common femoral artery,
with foci of gas and surrounding stranding which may represent postsurgical
changes, however infectious etiology is not excluded.
4. No significant change in a 5.3 cm abdominal aortic aneurysm status post
endovascular aortic repair with aortobifemoral stenting. Findings are better
characterized on dedicated CTA from ___.
5. Moderate left pleural effusion and trace right pleural effusion with
overlying basilar atelectasis.
6. No change in a 1.0 cm hypodensity along the pancreatic body. Previously
seen pancreatic neck hypodensity is not demonstrated on this exam.
RECOMMENDATION(S):
1. Surgical team aware.
2. Advancement or re-insertion of Foley catheter.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:26 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
CLINICAL HISTORY ___ s/p EVAR w/ L fem aneurysm repair with Dacron graft p/w
graft infection// please image great saphenous as well as deep systemplanning
for interposition graft please image great saphenous as well as deep
systemplanning
FINDINGS:
Duplex was performed of bilateral lower extremity veins. The femoral veins
and great saphenous veins are patent bilaterally in the thigh. See the
scanned worksheet for diameters.
IMPRESSION:
Patent bilateral femoral vein and great saphenous vein with diameters as noted
on the scanned worksheet.
Radiology Report
INDICATION: ___ w h/o AAA s/p EVAR c/b endoleak s/p revision now infected,
h/o sig. volvulus s/p resection, mech AVR/MVR (coumadin), p/w abd distension-
c/f closed loop SBO on CT, now s/p exlap// Degree of fluid overload?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are well expanded with small bilateral effusions left greater than
right. Left-sided pacemaker is in acceptable position. The NG tube projects
below the left hemidiaphragm. Small bilateral effusions are unchanged. No
pneumothorax is seen
Radiology Report
INDICATION: ___ year old man with Right PICC// Right PICC 43cm, ___ ___
Contact name: ___: ___
TECHNIQUE: Portable AP chest
COMPARISON: Multiple prior chest radiographs, most recent dated ___.
FINDINGS:
Part of the right lung and the right costophrenic angle are out of the field
of view, which limits evaluation. Unchanged lung volumes. No new areas of
focal consolidation. Unchanged small left pleural effusion. No pneumothorax.
Interval placement of a right-sided PICC, which terminates in the low SVC.
Left pectoral cardiac pacemaker with lead terminating in the right ventricle.
Median sternotomy wires are intact. Interval removal of enteric tube.
Prosthetic mitral valve is seen.
IMPRESSION:
Right PICC terminates in the low SVC. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man on POP day 10 of femoral bypass graft + POP day 2
of Sartorius graft. Now with bilateral crackles and increased O2 dependence.//
Acute CP process?
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged. Again there is substantial enlargement of the cardiac
silhouette with probable small pleural effusions and underlying atelectasis.
Streaks of atelectasis are seen in the mid to lower zones bilaterally.
No evidence of acute focal consolidation, though given the size of the cardiac
silhouette, in the appropriate clinical setting it would be very difficult to
exclude superimposed aspiration/pneumonia, especially in the absence of a
lateral view.
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
INDICATION: ___ year old man s/p EVAR and left interposition graft c/b left
groin infection s/p left groin washout and sartorious flap now with increase
bloody drainage form left groin JP// arterial bleeding from left groin
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis and upper and mid thighs.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 78.2 cm; CTDIvol = 3.4 mGy (Body) DLP = 263.9
mGy-cm.
2) Spiral Acquisition 5.7 s, 75.7 cm; CTDIvol = 15.2 mGy (Body) DLP =
1,147.3 mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.3
mGy-cm.
4) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 26.8 mGy (Body) DLP =
13.4 mGy-cm.
Total DLP (Body) = 1,426 mGy-cm.
COMPARISON: CT abdomen and pelvis ___. CTA abdomen and pelvis ___.
FINDINGS:
VASCULAR:
There is redemonstration of the infrarenal abdominal aortic aneurysm bone
which has been repaired with an endovascular aortobifemoral stent. The aortic
and bilateral iliac portions of the stent are discontinuous. The excluded
abdominal aortic aneurysm sac is unchanged in size, measuring up to 5.5 cm.
Again seen is partial contrast opacification of the excluded aneurysm sac.
There is a short segment dissection between the aortic and bilateral iliac
stents, which is unchanged.
The origins of the celiac trunk, superior mesenteric artery, bilateral renal
arteries and inferior mesenteric artery appear patent.
There is an additional stent in the left common iliac and external iliac
arteries. There is an unchanged endoleak (series 301, image 110).
There is a hematoma in the left groin, which surrounds the left common femoral
artery and measures approximately 4.4 x 4.3 x 8.2 cm (AP x TR x CC). There
are postsurgical changes from a left sartorius flap. There is an
intramuscular hematoma within the proximal left sartorius muscle, which
measures 6.8 x 4.3 x 12.7 cm (AP x TR x CC). There is no evidence of active
extravasation on the arterial phase. Delayed images were not performed.
Contrast is seen to the level of the common femoral artery bifurcations. The
more distal vessels are not opacified due to contrast timing.
LOWER CHEST: There is a trace right and small left pleural effusion with mild
compressive atelectasis of the bilateral lower lobes. The heart is severely
enlarged. Partially visualized pacemaker leads are noted. There are
partially visualized prosthetic aortic and mitral valves.
ABDOMEN AND PELVIS:
The liver, spleen common adrenal glands, glial better and pancreas are
unremarkable. There are multiple bilateral renal cysts.
The stomach is moderately distended with ingested material. There is no
evidence of small-bowel obstruction. There are no dilated loops of transverse
colon measuring up to 9.6 cm. A moderate amount of stool is seen within the
ascending and sigmoid colon. There is a mild-to-moderate amount of ascites in
the abdomen.
The prostate gland is enlarged measuring 9.4 x 7.8 cm. A Foley catheter is in
place. The bladder is decompressed.
There is diffuse anasarca in the subcutaneous soft tissues.
There is an unchanged superior endplate compression deformity of the L3
vertebral body. Mild multilevel degenerative changes are seen in the lumbar
spine.
IMPRESSION:
1. Postsurgical changes from left groin washout and sartorius flap
reconstruction.
2. A hematoma surrounding the left common femoral artery measures
approximately 4.4 x 4.3 x 8.2 cm.
3. New intramuscular hematoma within the proximal left sartorius muscle
measuring approximately 6.8 x 4.3 x 12.7 cm.
4. No evidence of active extravasation on arterial phase imaging. Please
note that delayed phase imaging was not performed.
5. Interval resolution of the dilated loops of small bowel.
6. Dilated transverse colon measuring up to 9.6 cm. Moderate amount of stool
within the large bowel.
Radiology Report
EXAMINATION: AP portable chest radiograph.
INDICATION: ___ year old man with desat on POP day 4.// acute CP process?
TECHNIQUE: AP portable chest radiograph.
COMPARISON: Prior chest radiograph dated ___.
FINDINGS:
There are bilateral pleural effusions which appear worsened in comparison to
the prior exam. There are new bilateral interstitial abnormalities likely
representing pulmonary edema. Cardiac silhouette remains enlarged. As before
there is a left pectoral cardiac pacemaker with the lead terminating in the
right ventricle. A right-sided PICC terminates in the low SVC. The patient is
status post median sternotomy with unchanged appearance of sternotomy wires.
Prosthetic mitral valve is again noted. Note is made of an abdominal aortic
stent, incompletely visualized.
IMPRESSION:
Interval worsening of bilateral pleural effusions with new interstitial
abnormality compatible with pulmonary edema. These findings are progressed in
comparison to ___.
Radiology Report
EXAMINATION: AP portable chest radiograph
INDICATION: ___ year old man with increased O2 requirement + WBC count.//
acute CP process?
TECHNIQUE: AP portable chest radiograph
COMPARISON: Prior chest radiograph dated ___
FINDINGS:
In comparison to the prior exam dated ___, again seen are
bilateral pleural effusions and extensive interstitial opacification likely
representing pulmonary edema. Cardiac silhouette is enlarged. A left
pectoral cardiac pacemaker lead terminates in the right ventricle. A
right-sided PICC line again terminates at the mid SVC. A prosthetic mitral
valve is unchanged. Abdominal aortic stent is incompletely evaluated.
IMPRESSION:
Stable appearance of bilateral pleural effusions and mild pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dyspnea// Eval for interval change Eval
for interval change
IMPRESSION:
Comparison to ___. Stable severe cardiomegaly with bilateral
pleural effusions and stable left pectoral single pacemaker lead. A right
PICC line is also stable. There is no pulmonary edema. No pneumothorax.
Extensive retrocardiac atelectasis is unchanged.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p ex-lap, R groin Sartorius flap, ongoing fluid
overload// eval for interval change
IMPRESSION:
In comparison with the study of ___, a there again is severe
enlargement of the cardiac silhouette with relatively mild pulmonary vascular
congestion. Small bilateral pleural effusions are seen, more prominent on the
left. Monitoring and support devices are unchanged.
Radiology Report
INDICATION: ___ year old man who is very distended in exam, edematous,// SBO?
Very distended in exam
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Multiple prior abdominal radiographs, most recent dated ___. CT abdomen pelvis dated ___.
FINDINGS:
Increased gaseous distention of the stomach and diffuse colonic dilation,
measuring up to 8.7 cm, likely secondary to colonic ileus. Small bowel loops
are not visualized. Moderate amount of stool is seen primarily in the rectum.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Gastric tube is seen projecting over the
left upper quadrant, likely terminating in the stomach. Visualized median
sternotomy wires are intact. Prosthetic mitral valve and a single pacemaker
lead in the right ventricle are seen. Endovascular aortic stent and iliac
artery stents are unchanged in location. Midline surgical clips from prior
laparotomy are seen.
IMPRESSION:
Worsening colonic ileus.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ MVR/AVR/CABG here w/ SBO s/p ex-lap internal hernia reduction
now with ___, scrotal swelling and urinary retention// please evaluate for
signs of obstruction, thanks.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Scrotal ultrasound ___
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally. A
simple partially exophytic cyst at the upper pole of the right kidney measures
3.2 x 3.1 x 3.1 cm. A simple peripelvic cyst in the left kidney measures 2.5
x 2.6 x 2.4 cm.
Right kidney: 11.5 cm
Left kidney: 11.6 cm
The bladder is collapsed on a Foley catheter. The prostate is markedly
enlarged with a volume of about 250 cc.
IMPRESSION:
1. No hydronephrosis. Simple bilateral renal cysts are noted.
2. Marked enlargement of the prostate.
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: ___ year old man with bilateral scrotal swelling s/p foley with 1L
blood// scrotal swelling/bleeding
TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 3.8 x 2.9 x 2.6 cm.
The left testicle measures: 3.6 x 2.5 x 2.9 cm.
Marked scrotal thickening and edema is seen. The testicular echogenicity is
normal, without focal abnormalities. Vascularity is normal and symmetrical in
the testes.
No hypervascularity is seen in the epididymis bilaterally. A cyst in the
right epididymal head measures 1.4 cm. In exophytic cyst at the left
epididymal head measures 6.4 x 4.0 x 5.3 cm. Smaller simple cysts within the
left epididymal head measure up to 1.3 cm.
IMPRESSION:
1. No suspicious intra testicular mass identified.
2. No findings to suggest epididymitis or orchitis.
3. Bilateral epididymal cysts including a large left exophytic cyst measuring
6.4 cm.
4. Bilateral hydroceles
5. Marked scrotal skin thickening and edema. Correlate with any cellulitis.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ PMH mech AVR, MVR, s/p EVAR w/ L fem aneurysm repair (10mm
Dacron interpos graft, ___ p/w SBO s/p ex lap w/reduction of internal
hernias and graft infection s/p washout, sartorius flap// hx of SBO, abd
distention, no BM
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 4.1 s, 54.2 cm; CTDIvol = 23.4 mGy (Body) DLP =
1,267.7 mGy-cm.
Total DLP (Body) = 1,268 mGy-cm.
COMPARISON: None.
___
FINDINGS:
LOWER CHEST: There is a moderate left pleural effusion and a tiny right
pleural effusion. There is associated bibasal atelectasis. A component of
consolidation at the left base cannot be entirely excluded. There is marked
global cardiomegaly. The proximal ascending aorta is dilated up to 5.5 cm
above the prosthetic valve.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation
on limited evaluation. The gallbladder grossly unremarkable.
PANCREAS: Evaluation of the pancreas is significantly limited. No gross
abnormality is seen.
SPLEEN: Unremarkable.
ADRENALS: Unremarkable
URINARY: There are multiple bilateral renal cysts. A chronic 9.5 cm cystic
lesion in the left subdiaphragmatic region appears to represent an exophytic
left renal cyst. There is no hydronephrosis.
GASTROINTESTINAL: The large bowel and rectum are grossly distended with formed
stool and gas. The cecum is dilated up to 9.0 cm and the gas-filled
transverse colon measures up to 8.8 cm. The small bowel is grossly
unremarkable and not dilated. There is no bowel wall pneumatosis or
pneumoperitoneum. There is small volume ascites, primarily in the upper
quadrants.
PELVIS: The bladder contains a Foley catheter bulb. The prostate is massively
enlarged as demonstrated previously.
LYMPH NODES: Within the limits of the study, there is no significant
lymphadenopathy. There are few mildly prominent pelvic nodes, with the left
external iliac node measuring 1 cm in short axis, nonspecific but likely
reactive.
VASCULAR: There has been previous EVAR. The residual aortic aneurysm sac is
unchanged in size at 5.0 cm in AP diameter and is otherwise not well evaluated
without IV contrast. Aortic and iliac graft components are in stable
position.
BONES: There is no evidence of worrisome osseous lesions or acute fracture. A
chronic mild vertebral compression fracture of L3 is stable.
SOFT TISSUES: Intramuscular hematoma in the left groin is similar in size to
the previous CT, measuring 7.1 x 4.8 cm in cross-section compared with 6.8 x
4.5 cm previously. A component of this surrounds the left common femoral
artery. There is a small fat containing left inguinal hernia. There is
anasarca throughout the subcutaneous tissues.
IMPRESSION:
1. Large colonic stool load with mild to moderate distention in some areas.
This is presumably related to constipation as there is no evidence of acute
bowel obstruction. There is no evidence of bowel wall necrosis or other acute
complication.
2. Grossly stable left groin hematoma. No drainable intra-abdominal
collection.
Radiology Report
INDICATION: ___ mech AVR/MVR, s/p EVAR w/L fem aneury repair (10mm Dacron
___ p/w SBO s/p ex lap w/internal hernias reduc, graft infection s/p
washout, sartorius flap c/b ATN, cardiorenal// Worsening distension. Acute
process?
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: The prior abdominal radiographs in CTs, most recently ___.
FINDINGS:
Increased distention of the colon is still seen, with moderate amount of
stool, increased since prior study, no seen up to the ascending colon. Type
ascending colon now measures up to 9.6 cm larger than prior study (previously
8.7 cm)..
A gastric tube is still seen projecting into the stomach.
Midline laparotomy wires appear intact and aligned.
Endovascular aortic and iliac stents are unchanged in positions.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications.
IMPRESSION:
Further increase in colonic distention consistent with worsening colonic
ileus.
Radiology Report
INDICATION: ___ year old man with anasarca, 4L NC O2 Requirement// ?Eval pulm
edema and pleural effusions
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of a right PICC line projects over the mid SVC. A left chest wall
single lead pacemaker is present. The size of the cardiac silhouette is
enlarged but unchanged. Opacities in both mid to lower lungs may reflect
pulmonary edema, atelectasis and pleural effusions, left greater than right.
Superimposed pneumonia would be hard to exclude in the proper clinical
context.
Radiology Report
INDICATION: ___ year old man with AVR and MVR on warfarin, Afib, CAD s/p CABG
with increasing shortness of breath.// Evidence fluid overload?
TECHNIQUE: AP portable chest radiograph
COMPARISON: Tumor ___
FINDINGS:
The tip of the right PICC line projects over the mid SVC. A left chest wall
single lead pacemaker is present. The patient is post median sternotomy and
cardiac valve replacement.
Unchanged opacities within both mid and lower lungs. Mild pulmonary edema is
present. There are small bilateral pleural effusions, left greater than
right. The size of the cardiac silhouette is massively enlarged but
unchanged.
IMPRESSION:
Mild pulmonary edema. Unchanged opacities in both mid to lower lung zones.
Small bilateral pleural effusions, left greater than right.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with heart failure, persistently hypoxic now s/p
aggressive diuresis, evaluate for interstitial process causing hypoxia
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent and reconstructed as contiguous 5 mm and 1.25 mm
thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.8 s, 44.2 cm; CTDIvol = 18.9 mGy (Body) DLP = 835.3
mGy-cm.
Total DLP (Body) = 835 mGy-cm.
COMPARISON: Prior Chest CTs dated ___ and ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid contains small nodules,
none large enough to warrant sonographic evaluation. Supraclavicular and
axillary lymph nodes are not enlarged.
MEDIASTINUM: Multiple large mediastinal lymph nodes are present, presumed
reactive.
HILA: Hilar lymph nodes are not enlarged.
HEART: The heart is markedly enlarged and there is extensive severe coronary
arterial calcification. There is no pericardial effusion. Patient is status
post aortic valve and mitral valve replacements. A left pectoral
single-chamber pacemaker is noted with the lead terminating in the right
ventricle. A right approach PICC terminates in the low SVC.
VESSELS: Vascular configuration is conventional. Aortic caliber is enlarged
with the ascending aorta measuring up to 4.4 cm (302:103). The main, right,
and left pulmonary arteries are enlarged suggesting underlying pulmonary
hypertension.
PULMONARY PARENCHYMA: Is extensive bibasilar atelectasis related to the
enlarging pleural effusions. Superimposed infection is difficult to exclude,
particularly within the right lung base where there is likely superimposed
consolidation. In 8 mm pulmonary nodule in the lateral right upper lobe is
new from ___ with some surrounding ground-glass opacity suggesting an acute
infectious process (302:99), attention on follow-up imaging is recommended.
Rounded focus of gas adjacent to the diaphragm likely represents residual
aerated right lower lobe (302:215). There is no emphysema.
AIRWAYS: The airways are patent to the subsegmental level bilaterally.
PLEURA: A moderate nonhemorrhagic left pleural effusion has increased
compared with the prior study. There is a new small to moderate loculated
right pleural effusion with fluid noted within the major fissure.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are mild.
UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen is notable for
persistent mild-to-moderate ascites, innumerable incompletely evaluated renal
cystic lesions, statistically simple cysts with several hyperdense cysts
likely representing proteinaceous or hemorrhagic cysts. Infrarenal abdominal
aortic aneurysm repair is partially imaged, stable from prior studies.
IMPRESSION:
1. Interval increase in bilateral nonhemorrhagic pleural effusions, moderate
on the left and small to moderate on the right with associated atelectasis.
2. Likely superimposed consolidation in the right lower lobe suggesting
infection or aspiration, although evaluation is limited without the use of IV
contrast.
3. 8 mm pulmonary nodule in the right upper lobe with surrounding ground-glass
opacity is likely infectious or inflammatory in etiology. Attention on
follow-up imaging is recommended.
4. Similar marked cardiomegaly with extensive coronary arterial calcifications
and prosthetic aortic and mitral valves with enlargement of the ascending
aorta measuring up to 4.4 cm.
5. Enlargement of the pulmonary arteries suggesting underlying pulmonary
arterial hypertension.
6. Partially evaluated small to moderate ascites, grossly similar to the prior
study.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with volume overload acutely more hypoxic// edema
vs PNA?
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs and CT, most recently ___.
FINDINGS:
Moderate pulmonary edema bilaterally associated to small bilateral pleural
effusions.
The consolidations in the medial right lower lobe and left lower lobe are
unchanged.
No pneumothoraces are noted.
Large cardiomegaly, stable since prior.
Sternotomy wires are aligned and intact.
In left ICD is unchanged in position, with lead overlying right ventricle.
A mitral valve replacement prosthesis is unchanged.
The right-sided PICC line has a tip overlying mid SVC, stable with position.
IMPRESSION:
Interval worsening of pulmonary edema, now moderate.
Otherwise no significant interval change.
Small bilateral pleural effusions are unchanged.
The lower lobes consolidations are stable and could represent persistent
pneumonia, possibly due to aspiration.
Monitoring devices are stable in position, which are appropriate.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Lower back pain, Urinary retention
Diagnosed with Retention of urine, unspecified
temperature: 97.1
heartrate: 59.0
resprate: 16.0
o2sat: 98.0
sbp: 152.0
dbp: 82.0
level of pain: 5
level of acuity: 2.0 | ___ in an ___ year old man with mechanical AVR and
MVR (on warfarin), CAD s/p CABG, HFpEF, RV systolic failure,
a-fib, CHB s/p PPM, sigmoid volvulus (s/p ___ sigmoidectomy),
BPH, AAA and L femoral aneurysm (s/p EVAR and open repair with
Dacron graft respectively in ___ c/b L femoral
pseudoaneurysm requiring open repair, who was readmitted for
infected left femoral graft. He underwent L groin wash-out and
sartorius flap and was started on a prolonged course of
antibiotics per ID recs. Unrelated to this, he also had a
closed-loop SBO and required ex-lap.
His hospital course was complicated by ATN, urinary
retention, traumatic Foley placement, acute-on-chronic
diastolic/RV failure, possible RLL PNA, and multifactorial
hypoxic respiratory failure. The patient had declining quality
of life and deteriorating functional status in the setting of
this increasing burden of chronic illness, most notably
suffering from constant fatigue from being borderline uremic. In
discussion with family he ultimately declined to escalate care
further and elected to go home on hospice in accordance with his
long-term preference that his death be comfortable and also
reflective of the dignity with which he had lived his life. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Aspirin / Erythromycin Base / soft shell crab / Percocet /
Tetanus
Attending: ___.
Chief Complaint:
Globus sensation, sore throat
Major Surgical or Invasive Procedure:
direct laryngoscopy, biopsy
History of Present Illness:
___ yo F with history of thyroid cancer s/p total thyroidectomy
___, and report of having choked on a 1 cm ___ fish bone 2
weeks ago, presents to ___ ED as transfer from OSH with 10
days of sore throat, dysphonia, low grade fever and
globus/choking sensation since yesterday.
She states that a few weeks ago she choked on a piece of fish
bone from haddock and had felt a sharp pain on the left during
the episode but had no symptoms afterward. Then a week later,
which is 10 days ago, she started developing myalgias, low grade
fever 100, sore throat and then she lost her voice. She was seen
by her PCP and had negative strep and was presented to have a
viral URI/laryngitis. However her symptoms continued.
Yesterday,
she felt a globus sensation and throat clearing was not
effective; over the course of the day, she felt it getting worse
with some associated chocking sensation when she tried to sleep.
She thus presented to OSH where they performed a scope exam and
reported it was abnormal and gave her 4 mg decadron and
transferred her to ___ ED for further evaluation.
She reports no difficulty with breathing, no stridor, and no
problems swallowing. She has continued to have low grade temps
100. Her voice has been raspy and whispery. She states her son
was recently sick with PTA a few weeks ago.
Of note she reports she is very sensitive to anesthesia. Two
front teeth are plated.
Past Medical History:
Papillary thyroid carcinoma.
Breast cysts.
PSH:
Completion thyroidectomy (right thyroid lobectomy (___).
Accessory navicular resection
Tonsillectomy and adenoidectomy
RLE varicose vein microphlebectomy ___, ___
Social History:
___
Family History:
non-contributory
Physical Exam:
On admisison:
VS:98.5 70 120/71 18 100% RA
Gen: well appearing, NAD
Voice: whispery, raspy and intermittently breaks, no stridor or
stertor
Face: symmetric
Ears: normal auricle, canal and ___: normal mucosa, septum midline
OC/OP: no trismus, normal mucosa without masses or lesions
Neck: supple, no LAD, no masses and not tender
On discharge:
Afebrile, vital signs stable
Gen: well appearing, NAD
Voice: whispery, raspy and intermittently breaks, no stridor or
stertor
Face: symmetric
Ears: normal auricle, canal and ___: normal mucosa, septum midline
OC/OP: no trismus, normal mucosa without masses or lesions
Neck: supple, no LAD, no masses and not tender
Pertinent Results:
___ 02:32AM BLOOD WBC-8.4 RBC-3.96* Hgb-12.2 Hct-37.8
MCV-96 MCH-30.9 MCHC-32.3 RDW-12.7 Plt ___
___ 06:50AM BLOOD WBC-6.6 RBC-3.47* Hgb-11.1* Hct-33.1*
MCV-96 MCH-31.9 MCHC-33.4 RDW-13.0 Plt ___
___ 06:50AM BLOOD Glucose-82 UreaN-20 Creat-1.1 Na-143
K-4.3 Cl-105 HCO3-32 AnGap-10
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
Discharge Medications:
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Ranitidine 150 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
4. Acetaminophen 1000 mg PO Q6H:PRN PAIN
5. Cepastat (Phenol) Lozenge 1 LOZ PO PRN sore throat
6. Chloraseptic Throat Spray 1 SPRY PO PRN sore throat
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four hours
Disp #*15 Tablet Refills:*0
8. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
9. Multivitamins 1 TAB PO DAILY
10. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 10 Days
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tab by mouth
every 8 hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
globus sensation, sore throat
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL INDICATION: Globus sensation and swelling under the pharyngeal scope
throat. Evaluate for retropharyngeal abscess and glottic swelling.
TECHNIQUE: Multidetector CT scan through the neck was performed after the
administration of intravenous contrast. Reformatted images were obtained.
DLP: 300.00 mGy-cm.
CTDIvol: 9.96 mGy.
COMPARISON: Neck soft tissue ultrasound, ___.
FINDINGS: At the level of the aryepiglottic folds, on the left, there is soft
tissue density thickening causing narrowing of the left pyriform sinus
(series 601B, image 30) which is concerning for a mass lesion vs a developing
abscess, there is no evidence of lymphadenopathy. The thyroid is surgically
absent. There is mild pleural scarring at the lung apices, otherwise, the
lungs are clear. There are mild degenerative changes in the cervical spine.
Otherwise, the bones are unremarkable. There is no prevertebral soft tissue
swelling.
IMPRESSION: Soft tissue density mass at the region of the left aryepiglottic
folds, causing narrowing of the left pyriform sinus, concerning for a mass
lesion vs a developing abscess.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: VOCAL CORD SWELLING, Transfer
Diagnosed with DISEASE OF PHARYNX NOS
temperature: 98.5
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 71.0
level of pain: 4
level of acuity: 2.0 | The patient was admitted initially to the ___ medicine service
on ___ and was then transferred to the Otolaryngology-Head
and Neck Surgery Service on ___ after undergoing direct
laryngoscopy and excision of inflammed pharyngeal tissue.
Please see the separately dictated operative note for details of
procedure. The patient was extubated and transferred to the
hospital floor for further post-operative care. The
post-operative course was uneventful and the patient was
discharged home on ___. |
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:
Vaginal bleeding
Major Surgical or Invasive Procedure:
Dilation and curettage
History of Present Illness:
___ POD ___ s/p primary LTCS at 34w6d for twins, mild
preeclampsia, and cholestasis presents with heavy vaginal
bleeding since ___ this morning. Has been feeling slightly
dizzy
with a mild headache. Passed one clot in bathroom prior to
ultrasound, otherwise has been saturating over 1 pad/hr x 12
hrs.
Denies vision changes, chest pain, SOB, RUQ pain. Does report
nasal congestion that has been present since arrival to
hospital.
Was followed for cholestasis during the later part of her
pregnancy. Developed hypertension and had a 24-hr urine
performed, which returned at >500mg. Given a new diagnosis of
preeclampsia as well as a mild headache, she was delivered at
34w6d. She did not receive magnesium or antihypertensives
postpartum. She was discharged home in good condtion on POD#4.
She did have notable ___ swelling and had ___ U/S today which
was
negative for DVT. Her swelling has improved considerably since
delivery. She was seen today in the office for her bleeding and
her BP was elevated. A script for labetalol had been routed to
her pharmacy but she did not take any yet.
Past Medical History:
POBHx: ___ s/p LTCS ___
PGynHx: denies known fibroids
PMHx: right breast cancer in ___, s/p right lumpectomy, chemo
and XRT, as well as ___ years of tamoxifen with currently ___.
hypothyroidism.
PSHx: right breast lumpectomy as noted, gum surgery, LTCS
Social History:
married, denies t/e/d, trial court judge
Physical Exam:
On admission:
VS on admission to ED:
97.9 93 169/97 16 100%
Repeat BP 185/87
NAD, breathing through mouth as has stuffy nose
Heart RRR
Lungs CTAB
Abdomen soft, + BS, uterine fundus palpated ___ FB above
umbilicus,
tender to palpation at fundus and lower uterus.
___ mildly tender, 2+ pitting edema
Pelvic: dark blood pooled in vault. Cervix unable to be
visualized due to pt's discomfort and redundant vaginal walls.
On BME cervix very posterior, external os feels dilated ~1cm but
unable to palpate higher due to discomfort/posterior cervix
Pertinent Results:
LABS:
___ 12:55AM BLOOD WBC-6.6 RBC-2.64* Hgb-8.3* Hct-24.7*
MCV-93 MCH-31.5 MCHC-33.7 RDW-16.5* Plt ___
___ 12:29PM BLOOD WBC-8.4 RBC-2.86*# Hgb-9.6*# Hct-26.4*#
MCV-93 MCH-33.7* MCHC-36.4* RDW-16.5* Plt ___
___ 04:23AM BLOOD WBC-10.1 RBC-2.17* Hgb-6.9* Hct-20.3*
MCV-94 MCH-31.9 MCHC-34.1 RDW-16.1* Plt ___
___ 09:51PM BLOOD WBC-10.5 RBC-2.62* Hgb-8.6* Hct-24.5*
MCV-94# MCH-32.9* MCHC-35.1* RDW-15.7* Plt ___
___ 06:07PM BLOOD WBC-10.8 RBC-2.66* Hgb-8.8* Hct-27.1*
MCV-102* MCH-33.1* MCHC-32.5 RDW-13.4 Plt ___
___ 01:40PM BLOOD WBC-11.0# RBC-2.70* Hgb-8.8* Hct-28.1*
MCV-104* MCH-32.6* MCHC-31.3 RDW-13.2 Plt ___
___ 05:30AM BLOOD Neuts-70 Bands-0 Lymphs-15* Monos-8
Eos-6* Baso-1 ___ Myelos-0
___ 12:29PM BLOOD Neuts-80* Bands-0 Lymphs-13* Monos-3
Eos-0 Baso-1 ___ Metas-1* Myelos-2*
___ 08:00PM BLOOD ___ PTT-24.2* ___
___ 04:23AM BLOOD ___ PTT-26.7 ___
___ 09:51PM BLOOD ___ PTT-26.9 ___
___ 01:40PM BLOOD ___ PTT-31.3 ___
___ 05:30AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-141
K-4.2 Cl-110* HCO3-23 AnGap-12
___ 12:29PM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-138 K-4.3
Cl-108 HCO3-22 AnGap-12
___ 04:23AM BLOOD Glucose-110* UreaN-8 Creat-0.7 Na-140
K-4.1 Cl-108 HCO3-24 AnGap-12
___ 06:07PM BLOOD Glucose-95 UreaN-11 Creat-0.6 Na-140
K-3.9 Cl-105 HCO3-23 AnGap-16
___ 01:40PM BLOOD Glucose-86 UreaN-13 Creat-0.6 Na-137
K-4.6 Cl-104 HCO3-21* AnGap-17
___ 04:23AM BLOOD ALT-25 AST-23 LD(LDH)-298* AlkPhos-157*
TotBili-0.4
___ 01:40PM BLOOD ALT-38 AST-46* LD(LDH)-544* AlkPhos-287*
TotBili-0.3
IMAGING:
Pelvic US ___:
1. Large bulky uterus containing a large amount of echogenic,
non-vascularized
products, likely blood and clot.
2. Ovaries not visualized. Fluid containing right pelvic
structure may
reprsent the bladder. Attention at follow-up pelvic ultrasound
in 6 weeks.
Radiology Report
___ ___ ___
Depart of Radiology
Standard Report - Normal Venous/US Report
Study: Bilateral Lower Extremity Venous Duplex
___ year old woman s/p C section on ___, with bilateral lower
extremity swelling.
Findings: Duplex evaluation was performed on the bilateral lower extremity
veins.
There is normal compression and augmentation of the common femoral, proximal
femoral, mid femoral, distal femoral, popliteal, posterior tibial and peroneal
veins. There is normal phasicity of the common femoral veins bilaterally.
Impression: No evidence of deep vein thrombosis either right or left lower
extremity. Bilateral calf edema is seen.
Radiology Report
INDICATION: Post C-section on ___ and increased vaginal bleeding.
No comparison studies available.
TECHNIQUE: Transabdominal and transvaginal ultrasonography of the pelvis were
performed, the latter to better assess the uterus and adnexa.
FINDINGS: The uterus is markedly enlarged, and cannot be measured within one
image. The endometrial cavity contains a large volume of echogenic material
that is non-vascularized, likely representing blood and clot. The ovaries are
not visualized. There is no free fluid. A fluid-filled structure right of the
uterus may represent the bladder.
IMPRESSION:
1. Large bulky uterus containing a large amount of echogenic, non-vascularized
products, likely blood and clot.
2. Ovaries not visualized. Fluid containing right pelvic structure may
reprsent the bladder. Attention at follow-up pelvic ultrasound in 6 weeks.
Radiology Report
PORTABLE AP CHEST FILM, ___ AT 12:09 A.M.
CLINICAL INDICATION: ___ with fever, question infiltrate.
No comparison studies. Please note that comparison to old films can be
helpful to detect subtle interval change.
A single portable AP upright chest film, ___ at 12:09 a.m. is submitted.
IMPRESSION:
1. Lungs appear well inflated without evidence of focal airspace
consolidation, pleural effusions, or pneumothorax. No evidence of pulmonary
edema. Overall cardiac and mediastinal contours are within normal limits. No
acute bony abnormality appreciated.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: POSTPARTUM BLEEDING
Diagnosed with OTH CURR COND-POSTPARTUM, HEMATOMETRA
temperature: 97.9
heartrate: 93.0
resprate: 16.0
o2sat: 100.0
sbp: 169.0
dbp: 97.0
level of pain: nan
level of acuity: 2.0 | Given concern for hematometra and a diagnosis of delayed
postpartum hemorrhage, the decision was made to proceed to the
OR for a dilation and curettage. Please see operative report for
further details regarding the procedure. Total EBL for the case
was 1700cc. A bakri balloon was placed at the end of the case.
Ms ___ was transferred to the FICU for immediate post
operative monitoring. She received a total of 4units PRBCs, 1
FFP, and 2u cryo. She remained hemodynamically stable. Her
hematocrit was carefully trended and was stable 25 prior to
transfer to the postpartum floor. Her bleeding after the
procedure was minimal and the Bakri balloon was removed by
POD#1.
Ms. ___ was noted to have febrile (temp 100.6) prior to the OR
and was therefore started on gentamicin and clindamycin for
treatment of endometritis. This was continued until she was
afebrile for >24 hours.
Ms. ___ was noted to have persistently elevated BPs. On
arrival to the ED, her preeclampsia labs were notable for a
mildly elevated AST although the specimen was thought to be
hemolyzed. Magnesium was held as there was no evidence of severe
preeclampsia. She was treated with IV labetalol intraoperatively
and in the FICU. After transfer to the postpartum floor she was
started on labetalol PO 200 BID after having a BP of 160/90. Her
blood pressures remained well controlled on this regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Neurontin / aspirin / ketorolac / Sulfa
(Sulfonamide Antibiotics) / clindamycin / amitriptyline /
morphine
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of asthma (requiring intubation in the past),
COPD, bipolar disorder, chronic pain, GERD, renal cyst, chronic
constipation, PE in ___ not on ongoing anticoagulation, c-spine
surgery a few months ago presents with chest pain. She describes
the pain as sharp and stabbing although with a constant dull
pain radiating to her arms. The pain is unrelated to exertion or
food. She states she has been hot/cold but does not think she
has had any fevers. She had some emesis and nausea last night.
Pt was seen in the ED at ___ several days ago, and
sent home with diagnosis of costochondritis. Pain has since
worsened. She has had decreased PO for several days other than
ice cubes. She also endorses a sharp headache. Denies SOB,
cough, increased sputum production, wheezing, increased use of
home inhalers. She is not on oxygen at home. Last BM was
yesterday.
In the ED initial vitals were: 98.2 85 136/75 16 98% RA
- Labs were significant for D-Dimer: 1206, trop<0.01, INR: 1.0
- CTA showed Segmental and subsegmental pulmonary emboli
involving the anterior segmental branch of the right lower lobe
pulmonary artery. No evidence of right heart strain. No evidence
of pulmonary infarction. Of note, CTA from ___ was
negative for PE.
- Patient was given 2L NS, duo nebs, magnesium, 50 mcg fentanyl,
60 mg prednisone, lovenox
Vitals prior to transfer were: 98.6 90 146/85 16 99% RA
On the floor, she states she continues to have chest pain. She
is no longer on anticoagulation. She states the etiology of her
previous clot was unknown. She had c-spine surgery a few months
ago and was in a collar. Denies any rehab stay and states she
has been mobile recently. Denies any personal history of
malignancy. She is not on estrogen supplementation or birth
control. No recent travel, such as long car rides or plane
rides.
Denies any calf cramping or leg swelling. She is adopted so she
is unsure of her family history. Overnight she was placed on O2
NC.
Past Medical History:
- history of hepatitis C positive antibody in ___ but negative
in ___
- COPD (PFT: ___ FEV1 89% pred, FEV1/FVC 71%)
- h/o asthma with exacerbations requiring hospitalization and
intubation
- Hx PE ___ not on Coumadin
- Depression
- Lumbar spinal stenosis with chronic back pain
- Chronic abdominal pain, IBS
- Cervical fusion w/ bone graft from hip ___ at ___
- Hx substance abuse (cocaine in distant past)
- Hx of C-spine surgeries x 9
- Hx L hip replacement ___
- reports MI in ___ w/o PCI
- frequent UTIs
Social History:
___
Family History:
Adopted. Does not know of any cardiopulmonary disease or
malignancy history.
Physical Exam:
98.3, 129/75, 70, 97% on 3L
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, well healed surgical scar
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, CP
non-reproducible on exam
LUNG: no wheezes, decreased air movement, crackles at R lung
base
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no ___ edema, no calf pain, gait intact
SKIN: well healed surgical scar on L hip
Neuro exam during possible TIA
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Intermittently
tearful but able to relate basic history without difficulty.
Attentive, refuses to name ___ backward but able to name ___
backward without difficulty. When asked to repeat the phrase
"it's always sunny in ___ she makes exaggerated mouth
movements and takes several attempts to produce the word. During
other parts of the exam, such as the naming card on the NIHSS,
she does not appear to have this difficultly. Language is
otherwise fluent with intact comprehension. There were no
paraphasic errors. Able to name both high and low frequency
objects (needed prompting with cactus, but otherwise was able to
name objects). Able to read with minimal difficulty (problems
pronouncing ___. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: R1.5->1.25B, L1.75->1.25B, VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: 50% sensation to light touch.
VII: No facial droop, facial musculature symmetric with
activation.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk and tone throughout. No pronator drift
bilaterally. No adventitious movements such as tremor or
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ 5 5
R ___ 5 5
- Sensory: During initial screening, decreased sensation to
light
touch on face/arm/leg (50% on Left as compared to Right). On
repeat exam several hours later, no deficits to light touch,
pinprick, cold sensation, vibratory sense, proprioception
throughout. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L ___ 2 2
R ___ 2 2
Plantar response was flexor bilaterally.
- Coordination: No intention tremor or dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: deferred
Discharge Exam: 98.4 140/87 75 20 95RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, well healed surgical scar
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, CP
non-reproducible on exam
LUNG: no wheezes, decreased air movement, crackles at R lung
base
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no ___ edema, no calf pain, gait intact
SKIN: well healed surgical scar on L hip
Pertinent Results:
On admission:
___ 07:30PM BLOOD WBC-9.1 RBC-3.84* Hgb-12.9 Hct-39.6
MCV-103* MCH-33.6* MCHC-32.5 RDW-13.3 Plt ___
___ 07:30PM BLOOD Glucose-89 UreaN-17 Creat-1.0 Na-140
K-3.8 Cl-99 HCO3-29 AnGap-16
___ 01:45AM BLOOD ALT-14 AST-16 AlkPhos-94 TotBili-0.4
___ 07:30PM BLOOD D-Dimer-1206*
___ 09:11AM BLOOD Triglyc-264* HDL-84 CHOL/HD-2.9
LDLcalc-103
___ 09:11AM BLOOD %HbA1c-5.7 eAG-117
On Discharge:
___ 09:11AM BLOOD ___ PTT-37.9* ___
___ 09:11AM BLOOD WBC-6.0 RBC-3.75* Hgb-12.5 Hct-38.2
MCV-102* MCH-33.2* MCHC-32.6 RDW-13.3 Plt ___
Imaging:
CXR ___
There is bibasilar atelectasis without definite focal
consolidation. No
pleural effusion or pneumothorax is seen. The cardiac and
mediastinal
silhouettes are unremarkable and stable. Cervical surgical
metallic hardware
is seen but not fully evaluated on this study.
IMPRESSION:
No acute cardiopulmonary process.
CTA chest ___
IMPRESSION:
1. Segmental and subsegmental pulmonary emboli involving the
anterior
segmental branch of the right lower lobe pulmonary artery. No
evidence of
right heart strain. No evidence of pulmonary infarction.
2. Moderate emphysematous changes.
MRI/MRA head/neck ___
MRI OF THE BRAIN:
No acute infarct or mass effect or obvious focal lesions.
MR ANGIOGRAM OF THE BRAIN:
Diminutive left vertebral artery; patent major intracranial
arteries
otherwise, better seen on the source images.
MR ANGIOGRAM OF THE NECK:
Patent carotid and vertebral arteries as described above.
Mild atherosclerotic disease of the proximal cervical internal
carotid artery, right more than left.
No significant stenosis by NASCET criteria.
Degenerative changes in the cervical spine, with postsurgical
changes at C3-4, with mild deformity on the ventral cord.
Limited assessment of the cervical
spine as not targeted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. ClonazePAM 1 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Duloxetine 60 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. QUEtiapine Fumarate 25 mg PO QHS
8. TraZODone 300 mg PO HS:PRN insomnia
9. Vitamin D 1000 UNIT PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Prochlorperazine 10 mg PO Q8H:PRN nausea
12. Tiotropium Bromide 1 CAP IH DAILY
13. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
2. ClonazePAM 1 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Duloxetine 60 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Omeprazole 20 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
8. QUEtiapine Fumarate 25 mg PO QHS
9. Tiotropium Bromide 1 CAP IH DAILY
10. TraZODone 300 mg PO HS:PRN insomnia
11. Vitamin D 1000 UNIT PO DAILY
12. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Take as directed by the ___ clinic
13. Nicotine Lozenge 2 mg PO Q1H:PRN craving
14. Warfarin 5 mg PO DAILY16
take as directed by ___ clinic
15. Acetaminophen 650 mg PO Q6H:PRN pain
16. Prochlorperazine 10 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism
probable TIA
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 woman with new PE, recent LLE pain, possible RLE pain
// DVT? clot burden?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
of the lower extremity veins bilaterally.
COMPARISON: Bilateral lower extremity seen venous study ___
FINDINGS:
There is normal compressibility, flow and augmentation of bilateral common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial and peroneal veins bilaterally.
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 either leg.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: New left-sided paresthesias and dysmetria. Evaluate for
hemorrhage.
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
CTDI: 54.32 mGy
COMPARISON: Several prior noncontrast head CTs dating from ___
through ___.
FINDINGS:
There is no acute intracranial hemorrhage, acute infarction, large mass or
midline shift. Cerebellar vermian atrophy is stable. There is no
hydrocephalus. The ventricles and sulci are normal in size and configuration.
Likely cavum velum interpositum- se 2, im 17. The basal cisterns are patent
and there is preservation of gray-white matter differentiation. The orbits are
unremarkable.
Bilateral anterior ethmoid air cell and right sphenoid air cell mucosal wall
thickening is minimal.
The visualized paranasal sinuses, middle ear cavities and mastoid air cells
are otherwise clear.
There is no fracture.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Stable cerebellar vermian atrophy. Correlate clinically to decide on the
need for further workup.
Other details as above.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: L handed ___ year old woman with acute PE, transient word
production difficulty and L sided paresthesia // R sided subcortical stroke
or evidence of TIAplease perform MRI/MRA head and neck
TECHNIQUE: MRI of the brain without IV contrast, MR angiogram of the head
without IV contrast and MR angiogram of the neck with IV contrast -16cc of
Multihance intravenous contrast. Three dimensional maximum intensity
projection and segmented images were generated. This report is based on
interpretation of all of these images.
COMPARISON: CT head ___, MRI head ___
FINDINGS:
MRI BRAIN:
No acute infarct, mass effect, shift of normally midline structures are
hydrocephalus.
Likely cavum velum interpositum.
The ventricles, the extra-axial CSF spaces and the sulci are otherwise
unremarkable.
No obvious focal lesions are noted in the brain parenchyma on the FLAIR
sequence.
Minimal fluid in the right mastoid air cells.
The major intracranial arterial flow voids are noted, with a diminutive left
vertebral artery.
Mild ethmoidal and right sphenoidal mucosal thickening.
The included orbits are unremarkable.
The bone marrow signal is otherwise unremarkable.
Multilevel degenerative changes in the cervical spine are noted, not
adequately assessed.
MRA BRAIN:
Left vertebral artery is diminutive.
The major intracranial arteries of the anterior and the posterior circulation
are patent, without focal flow-limiting stenosis, occlusion or aneurysm more
than 3 mm within the resolution of the study.
The cavernous carotid segments are mildly tortuous.
MRA NECK:
The origins of the arch vessels are patent.
The left vertebral artery is diminutive in course throughout from its origin.
The common carotid and the cervical internal carotid arteries are patent.
There is contour irregularity of the proximal cervical internal carotid artery
on the right which can relate to mild atherosclerotic disease. The left
cervical internal carotid artery is medial in course and indents the
oropharynx.
No focal flow-limiting stenosis or occlusion noted.
Multilevel, multifactorial degenerative changes are noted in the cervical
spine, not adequately assessed.
Postsurgical changes are noted in the cervical spine with anterior fusion at
C3-4 with mild deformity on the ventral cord.
IMPRESSION:
MRI OF THE BRAIN:
No acute infarct or mass effect or obvious focal lesions.
MR ANGIOGRAM OF THE BRAIN:
Diminutive left vertebral artery; patent major intracranial arteries
otherwise, better seen on the source images.
MR ANGIOGRAM OF THE NECK:
Patent carotid and vertebral arteries as described above.
Mild atherosclerotic disease of the proximal cervical internal carotid artery,
right more than left.
No significant stenosis by NASCET criteria.
Degenerative changes in the cervical spine, with postsurgical changes at C3-4,
with mild deformity on the ventral cord. Limited assessment of the cervical
spine as not targeted.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Epigastric pain
Diagnosed with PULM EMBOLISM/INFARCT
temperature: 98.2
heartrate: 85.0
resprate: 16.0
o2sat: 98.0
sbp: 136.0
dbp: 75.0
level of pain: 10
level of acuity: 3.0 | Ms ___ is a ___ female with a long history of
asthma/COPD, h/o PE ___ not currently on anticoagulation,
recent c-spine surgery and ongoing tobacco abuse admitted with
chest pain, found to have a PE.
ACTIVE ISSUES:
#Acute symptomatic pulmonary embolism. Segmental/subsegmental PE
RLL new since ___, no obvious provocation. Only previous PE
patient is aware of was ___ for which she completed a course
of anticoagulation. ___ negative this admission. She was
encouraged to quit smoking and provided with nicotine lozenges
this admission. She was treated with lovenox and coumadin and
will followup in ___ ___ clinic. She was taught how
to use lovenox and prescriptions per her request were sent
electronically to her pharmacy. Pain was controlled here with
percocets; she consistently requested IV pain medication for her
chest pain however after the first day of admission she was
managed with oral medication. Given multiple narcotics
prescribers, history of polysubstance abuse, and considering PCP
would not continue to provide narcotics after discharge she was
not discharged with narcotics.
#Possible TIA. Per report at 7:50pm ___ RN gave meds and
patient was at baseline, after returning at 8:10pm RN noticed
speech hesitancy and pt complained of reduced sensation and
tingling of L face/arm/leg. Per medicine nightfloat there was
also a noticeable facial droop, symptoms resolved in about 10
minutes. Neuro was called, stat head CT obtained which was
negative for bleed. Stroke workup recommended. ECHO negative for
clot. MRI/A head/neck unrevealing and negative for stroke. She
was seen by neurology and they recommended checking a1c which
was not c/w diabetes and lipids, LDL just over 100.
#COPD: Moderate emphysematous changes seen on CT. Recently tx
for COPD exacerbation in ___ with Azithromycin and
Prednisone burst. She denies any changes in sputum production or
quality, no increased wheezing or inhaler use concerning for
COPD exacerbation. She was continued on her home medications
here.
CHRONIC ISSUES:
# Depression/Anxiety/Bipolar: In previous admissions pt does not
have good support system. Per last psych note from ___, patient
has had difficulties in the past with pain management in the
hospital given history of substance abuse. Speech somewhat
pressured on exam. Continued home medications.
# Chronic left hip pain: s/p bone graft and fracture repair.
During recent d/c, ortho reviewed films and noted that often
these are very slow healing and can be painful. Her pain has
largely improved and she is able to ambulate w/o difficulty
#GERD:
-continued omeprazole |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical history
of
BAV and dilated aortic root, s/p homograft AVR/aortic root
replacement, then homograft failure with severe AR/LV dilation
and TAVR (___), HTN, HLD, hypothyroid, T2DM, anxiety who
presents from home with acute onset confusion starting
approximately one hour ago. History is primarily obtained from
her husband who is at bedside. He states that his children
called
him noting their mother was forgetting recent events, such as
the
Passover holiday spent with family over this weekend. She was
otherwise functioning normally, with no changes in speech or
weakness. Family noted that she has been extremely anxious since
___, likely because her visiting children and grandchildren
will be leaving for ___ tomorrow.
Ms. ___ endorses that one hour ago she began to feel "weird,
disoriented, and ungrounded". She states that she otherwise
feels
very well. During the interview, she is very anxious and
repeatedly interrupts asking "why am I here, what is happening".
Per last cardiology outpatient note from ___, she was
previously on warfarin for one year for elevated gradients,
stopped ___. Of note, husband states that several days ago she
developed wheezing and difficulty swallowing after eating
grapes,
he called ___, did not take her to a hospital since her symptoms
self resolved after 10 minutes. He also states that she began an
antidepressant a few months ago and worries this may be causing
her presenting confusion, he does not know the name of the
medication.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (-) Dyslipidemia, (-)
Hypertension
2. CARDIAC HISTORY:
- CABG: N/A
- PERCUTANEOUS CORONARY INTERVENTIONS: N/A
- PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
- Aortic valve replacement (minimally invasive) in ___ after
congenital aortic stenosis
- Hypothyroidism
- Sciatica
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
General: Awake, anxious
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to name, ___, not month
(initially states ___ but quickly corrects to ___, not
age, short term memory loss (does not remember getting CT scan
when asked 5 minutes after completion, does not remember events
from ___ or ___. Able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. 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 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 bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, temperature,
vibration, or proprioception throughout. No extinction to DSS.
Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
==============
Discharge Exam:
General: Awake, alert
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple
Pulmonary: Normal work of breathing.
Cardiac: warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to name, ___, date. Able to
name ___ backward without difficulty. Language is fluent with
intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. No dysarthria.
Able to follow both midline and appendicular commands. Able to
register 3 objects and recall
___ at 5 minutes.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal
saccades. VFF to confrontation. No facial droop, facial
musculature symmetric. Hearing intact to conversation. Palate
elevates symmetrically. ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted. Full
strength in b/l upper and lower extremities.
-Sensory: No deficits to light touch.
-Reflexes: 2+ throughout.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Pertinent Results:
___ 09:26PM BLOOD WBC-7.9 RBC-4.23 Hgb-13.0 Hct-41.0 MCV-97
MCH-30.7 MCHC-31.7* RDW-12.8 RDWSD-45.1 Plt ___
___ 06:09AM BLOOD Glucose-103* UreaN-29* Creat-1.2* Na-137
K-4.5 Cl-101 HCO3-25 AnGap-11
___ 06:09AM BLOOD ALT-18 AST-21 LD(LDH)-284* CK(CPK)-118
AlkPhos-78 TotBili-0.2
___ 06:09AM BLOOD %HbA1c-6.0 eAG-126
___ 06:09AM BLOOD Triglyc-105 HDL-61 CHOL/HD-2.8 LDLcalc-86
___ 06:09AM BLOOD TSH-5.3*
___ 06:09AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:26PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
MR brain IMPRESSION:
1. No evidence of recent infarction or of hemorrhage.
2. Chronic lacunar infarcts in the right thalamus and bilateral
caudate
nuclei, most of which were present dating back to ___.
Head CT/CTA
1. No evidence of recent infarct or of hemorrhage.
2. Chronic lacunar infarcts in the bilateral caudate nuclei and
in the right
thalamus are unchanged dating back to ___.
3. There is minimal narrowing of the right intracranial internal
carotid
artery due to atherosclerotic plaque. Otherwise, there is no
evidence of
stenosis or occlusion in the head or neck vessels.
4. Mild interval increase in fusiform dilatation of the
ascending aorta
measuring up to 4.2 cm, previously 3.9 cm in ___.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. FLUoxetine 40 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. FLUoxetine 40 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Transient global amnesia
Secondary Diagnoses:
Hypertension
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 NECK WITH PERFUSION PQ149 CT HEADNECK
INDICATION: History: ___ with sudden onset confusion x 1 hr with Amensia, ___
2// Stroke? 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 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 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
3) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
4) Spiral Acquisition 4.9 s, 38.4 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,222.3 mGy-cm.
Total DLP (Head) = 4,566 mGy-cm.
COMPARISON: Head CT dated ___.
CTA chest dated ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Chronic lacunar infarcts are seen within the bilateral caudate nuclei (2: 18,
19) as well as in the right thalamus (02:17). These appear similar compared
to ___. There is no evidence of acute territorial
infarction,hemorrhage,edema,ormass. 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:
There is minimal narrowing of the right intracranial internal carotid artery
due to atherosclerotic plaque. Fetal type circulation of the right posterior
cerebral artery is noted. The vessels of the circle of ___ and their
principal intracranial branches otherwise appear normal without stenosis,
occlusion, or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
The carotidandvertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
Partially visualized is fusiform dilatation of the ascending aorta measuring
up to 4.2 cm (4:1), which is increased compared ___, at which time
it measured up to 3.9 cm. 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.
CT perfusion:
T-max greater than 6.0 seconds: 0 mL
CBF less than 30%: 3 mL
Of note, the region demonstrating decreased cerebral blood flow does not
contain brain parenchyma. No infarct core or penumbra are identified.
IMPRESSION:
1. No evidence of recent infarct or of hemorrhage.
2. Chronic lacunar infarcts in the bilateral caudate nuclei and in the right
thalamus are unchanged dating back to ___.
3. There is minimal narrowing of the right intracranial internal carotid
artery due to atherosclerotic plaque. Otherwise, there is no evidence of
stenosis or occlusion in the head or neck vessels.
4. Mild interval increase in fusiform dilatation of the ascending aorta
measuring up to 4.2 cm, previously 3.9 cm in ___.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:05 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old woman with ?tia// r/o infection r/o infection
IMPRESSION:
Compared to chest radiographs ___.
Patient has had T AVR. Previous cardiomegaly has resolved. Lungs clear.
Mediastinal and hilar contours and pleural surfaces are normal.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old woman with acute onset confusion, r/o stroke// r/o
stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Head CT dated ___ and ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or recent infarction. The ventricles and sulci are normal in caliber and
configuration. Major intracranial vascular flow voids are patent.
Periventricular T2 FLAIR hyperintensities within the right thalamus and
bilateral caudate nuclei likely represent chronic infarcts, most of which were
present in ___.
IMPRESSION:
1. No evidence of recent infarction or of hemorrhage.
2. Chronic lacunar infarcts in the right thalamus and bilateral caudate
nuclei, most of which were present dating back to ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion
Diagnosed with Altered mental status, unspecified
temperature: 97.9
heartrate: 53.0
resprate: 17.0
o2sat: 100.0
sbp: 172.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with a past medical history
of BAV and dilated aortic root, severe AR/LV dilation and TAVR
___, not on anticoagulation), HTN, HLD, hypothyroid, T2DM,
anxiety who presented with acute onset confusion. Her admission
exam was notable for disorientation to date, age, and recent
events (taking place minutes to days ago), otherwise no
deficits. She had CT/CTA without bleed or evolving hypodensity,
no LVO, and no flow limiting stenosis.
She was admitted to the hospital. The morning after admission
(about 12h after confusional onset), she was oriented x 3.
However she continued to endorse feelings of being disoriented.
MR ___ obtained and showed no evidence of recent infarction or
of hemorrhage and chronic lacunar infarcts in the right thalamus
and bilateral caudate nuclei, most of which were present dating
back to ___. Routine EEG showed no seizures. Her short term
recall improved while in the hospital and she was able to recall
___ at 5 min prior to discharge. Presentation consistent with
transient global amnesia.
Stroke risk factors: LDL 86 HBA1c 6%
Toxic/Metabolic w/u unremarkable. LFTs normal, UA negative,
Urine tox screen negative, serum tox screen negative.
#Fusiform dilatation of ascending aorta
- CTA shows "Mild interval increase in fusiform dilatation of
the ascending aorta measuring up to 4.2 cm, previously 3.9 cm in
___
Transitional Issues:
[] f/u with PCP to ___ on "Mild interval increase in
fusiform dilatation of the ascending aorta measuring up to 4.2
cm, previously 3.9 cm in ___
[] f/u with neurology unless patient back to baseline |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presenting with acute onset abdominal pain yesterday 2pm, no
stool output, no gas and nausea with some vomiting since 2 ___
today. Patient was seen at ___, CT scan notable
for
SBO, transferred to ___ for
surgical evaluation as the operating rooms are closed. No fever,
chills, chest pain, shortness of breath.
Past Medical History:
Past Medical History:
Diabetes mellitus
Hypertension
Past Surgical History:
Laparoscopic ventral hernia repair ~ ___
C-section
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: T 98.4 / HR 78 /BP 159/95 / RR 18 / SaO2 94% RA
GEN: A&O, slight distress
HEENT: No scleral icterus, dry mucous membranes, NGT in place
with clear gastric contents drained, small volume in canister
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, tympanitic, tender in periumbilical
region/epigastrium, otherwise nontender, no signs of peritonitis
Discharge Physical Exam:
98.7, 165/91, 59, 18, 95 Ra
Gen: A&O
CV: HRR
Abd: soft, NT/ND
Ext: No edema
Pertinent Results:
___ 05:16AM BLOOD WBC-3.6*# RBC-3.92 Hgb-9.4* Hct-32.1*
MCV-82 MCH-24.0* MCHC-29.3* RDW-13.9 RDWSD-41.0 Plt ___
___ 05:05AM BLOOD WBC-8.4 RBC-4.30 Hgb-10.6* Hct-34.7
MCV-81* MCH-24.7* MCHC-30.5* RDW-14.0 RDWSD-41.1 Plt ___
___ 09:35PM BLOOD WBC-8.4 RBC-4.33 Hgb-10.8* Hct-34.9
MCV-81* MCH-24.9* MCHC-30.9* RDW-13.9 RDWSD-40.8 Plt ___
___ 01:06AM BLOOD WBC-9.0 RBC-4.24 Hgb-10.5* Hct-35.3
MCV-83 MCH-24.8* MCHC-29.7* RDW-14.2 RDWSD-43.2 Plt ___
___ 05:16AM BLOOD Glucose-157* UreaN-3* Creat-0.5 Na-140
K-4.2 Cl-103 HCO3-26 AnGap-11
___ 01:10PM BLOOD Glucose-191* UreaN-3* Creat-0.5 Na-138
K-3.6 Cl-99 HCO3-29 AnGap-10
___ 05:05AM BLOOD Glucose-136* UreaN-5* Creat-0.6 Na-139
K-4.0 Cl-98 HCO3-23 AnGap-18*
___ 05:00PM BLOOD Glucose-126* UreaN-5* Creat-0.5 Na-138
K-3.2* Cl-94* HCO3-23 AnGap-21*
___ 05:16AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9
___ 01:10PM BLOOD Calcium-9.0 Phos-3.4 Mg-1.8
___ 05:05AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2
IMAGING:
___ CT A/P:
1. No evidence of small-bowel obstruction. Resolution of
dilated loops of
small bowel seen on outside hospital CT. No acute findings.
2. Hepatic steatosis.
3. Fibroid uterus.
4. Postsurgical changes from paraumbilical hernia repair.
___ ABD XRAY
Nonobstructive bowel gas pattern.
___ CT A/P (outside hospital):
Small bowel obstruction with transition point likely in distal
ileum adjacent to ventral mesh, secondary to adhesions. Small
bowel fecalization and dilated up to 3.7 cm diameter.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE XL 5 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSUN
5. Pataday (olopatadine) 0.2 % ophthalmic DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Docusate Sodium 100 mg PO BID
3. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
RX *mineral oil [Ready-To-Use Enema (min oil)] 1 enema(s)
rectally Daily:PRN Disp #*5 Applicator Refills:*0
4. Fleet Enema (Saline) ___AILY:PRN constpation
Duration: 1 Dose
RX *sodium phosphates [Enema Disposable] 19 gram-7 gram/118 mL 1
enema(s) rectally Daily:PRN Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID Constipation - First Line
7. Atorvastatin 80 mg PO QPM
8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSUN
9. GlipiZIDE XL 5 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Pataday (olopatadine) 0.2 % ophthalmic DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction, resolved
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 NGT// confirm placement
TECHNIQUE: PA and lateral views of the chest
COMPARISON: None
FINDINGS:
Linear atelectasis at the left lung base. Small opacity at the right
costophrenic angle could reflect subsegmental atelectasis.
Mild cardiomegaly.
No significant pleural effusion or pneumothorax. NG tube tip in the stomach.
IMPRESSION:
Linear and subsegmental atelectasis at the lung bases. NG tube tip in the
stomach.
Radiology Report
INDICATION: ___ year old woman with SBO// repeating KUB
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is
moderate colonic fecal load proximally.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Abdominal hernia repair mesh is seen. Upper enteric tube terminates in the
stomach. There are no unexplained soft tissue calcifications or radiopaque
foreign bodies.
IMPRESSION:
Nonobstructive bowel gas pattern.
Radiology Report
INDICATION: ___ year old woman with SBO, worsening pain// Eval for obstruction
pattern, free air
TECHNIQUE: Frontal and left lateral decubitus views of the abdomen were
obtained.
COMPARISON: ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Air and stool
is seen within the large bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies. Upper enteric tube terminates in the stomach. The visualized lungs
are grossly clear given nondedicated technique.
IMPRESSION:
Nonobstructive bowel gas pattern. No free air
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST.
INDICATION: ___ year old woman with abdominal pain s/p umbilical hernia repair
w/ mesh, evaluate for small bowel obstruction..
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: 22 mGy-cm.
COMPARISON: Reference abdominal CT ___
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. There is no pleural
effusion. Heart is normal in size.
ABDOMEN:
HEPATOBILIARY: The liver is fatty in attenuation. No focal lesion is seen.
Hypodensity adjacent to the gallbladder fossa (series 2, image 22), likely
represents focal fat. Gallbladder is unremarkable without radiopaque stones.
No intra or extrahepatic biliary duct dilation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a subcentimeter hypodensity in the midpole of the right kidney
measuring 0.7 cm, too small to characterize but statistically likely a simple
cyst. There is no perinephric abnormality.
GASTROINTESTINAL: A nasoenteric tube ends in the proximal stomach. Oral
contrast extends into the cecum. Small bowel loops are normal in caliber,
improved from prior CT dated ___. There is no small bowel wall
thickening. The large bowel is also normal in caliber without wall
thickening. Appendix not visualized but no secondary signs of appendicitis.
There is no intra-abdominal free fluid or free air.
PELVIS: Bladder is decompressed. Small amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus is retroverted. There is heterogeneous
enhancement of the myometrium, likely representing fibroids. Ovaries grossly
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: Mesh from abdominal hernia repair noted in the mid lower
abdomen.
IMPRESSION:
1. No evidence of small-bowel obstruction. Resolution of dilated loops of
small bowel seen on outside hospital CT. No acute findings.
2. Hepatic steatosis.
3. Fibroid uterus.
4. Postsurgical changes from paraumbilical hernia repair.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SBO, Transfer
Diagnosed with Unspecified intestinal obstruction
temperature: 97.6
heartrate: 88.0
resprate: 18.0
o2sat: 97.0
sbp: 162.0
dbp: 88.0
level of pain: 7
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission
abdominal/pelvic CT from outside hospital revealed a small bowel
obstruction with transition point likely in distal
ileum adjacent to ventral mesh, secondary to adhesions . WBC was
normal and the patient was hemodynamically stable. She was
treated non-operatively with nasogastric tube decompression,
bowel rest, IV fluids, and serial abdominal exams.
On HD3, the patient's pain seemed to be worse so a repeat
abdominal/pelvic Ct scan was taken which showed complete
resolution of obstruction. Diet was slowly advanced with good
tolerability and the patient was having bowel function. Pain was
resolving. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was gone.
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:
prednisone / Neurontin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
Mrs. ___ is a ___ year old woman who was referred to
the ___ ED from ___ with 5 days of right upper quadrant pain.
The patient states her pain started last ___. She had
crampy right upper quadrant pain. She modified her diet to be a
"soft" diet and her pain improved though never fully went away.
She states that yesterday she had bacon and eggs for breakfast
and subsequently developed severe RUQ pain. She had nausea and
an episode of emesis last night and another episode this
morning. She has been constipated over this last week, but
states she has chronic constipation at baseline. She denies
fevers or chills. She presented to ___ for evaluation earlier
today and had labs and a CT scan of her abdomen/pelvis that was
suggestive of cholecystitis. She was transferred to ___ for
further evaluation.
She denies hematochezia, melena, or diarrhea. She states her
pain is improved after the morphine she received and is now ___
in severity.
Past Medical History:
PMH: HTN, IBS, hypercholesteremia, GERD, chronic low back pain,
arthritis
PSH: hysterectomy and appendectomy, left hip replacement,
cataract extraction, left ulnar nerve decompression
Social History:
___
Family History:
Breast cancer
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: 98.9, 74, 186/92, 18, 100% room air
GEN: NAD, alert, oriented
HEENT: MMM, oropharynx clear
___: RRR
PULM: clear bilaterally
ABDOMEN: soft, no distention. moderate RUQ and epigastric
tenderness. positive ___. +voluntary guarding. no tap
tenderness or rebound.
EXTREMITIES: warm, well perfused. no edema. 2+ DP pulses
bilaterally
DISCHARGE PHYSICAL EXAM:
VS: 97.8, 76, 113/65, 18, 96% room air
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, non-labored breathing.
ABDOMEN: Soft, mildly tender to palpation incisionally,
non-distended. No rebound or guarding. Incisions: clean, dry and
intact, dressed and closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable, no edema.
Pertinent Results:
LIVER/GALLBLADDER US
Gallbladder wall edema with multiple gallstones including a
stone impacted at the gallbladder neck. In the absence of other
medical comorbidities, findings are concerning for acute
cholecystitis.
Medications on Admission:
1. Labetalol 100 mg PO BID
2. Linzess (linaclotide) 290 mcg oral daily
3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
4. Tizanidine 2 mg PO QPM:PRN muscle spasm
5. NexIUM (esomeprazole magnesium) 20 mg oral daily
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
3. Labetalol 100 mg PO BID
4. Linzess (linaclotide) 290 mcg oral daily
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. Tizanidine 2 mg PO QPM:PRN muscle spasm
7. NexIUM (esomeprazole magnesium) 20 mg oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with RUQ pain and CT at ___ consistent with
cholecystitis // r/o cholelithiasis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. Main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: Gallbladder wall thickening and edema is noted measuring 6 mm,
and multiple gallstones are noted including a gallstone impacted at the
gallbladder neck.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
IMPRESSION:
Gallbladder wall edema with multiple gallstones including a stone impacted at
the gallbladder neck. In the absence of other medical comorbidities, findings
are concerning for acute cholecystitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cholecystitis // Preop Surg: ___
(Lap chole)
COMPARISON: ___
IMPRESSION:
As compared to the previous image, no relevant change is seen. Normal lung
volumes. Normal size of the cardiac silhouette. Normal hilar and mediastinal
structures. No pneumonia, no pleural effusions. No pulmonary edema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN RUQ
temperature: 98.9
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 186.0
dbp: 92.0
level of pain: 9
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of RUQ abdominal pain.
Admission abdominal ultrasound revealed acute cholecystitis. The
patient underwent laparoscopic cholecystectomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating sips, on IV fluids, and
IV 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.
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 on her home regimen of vicodin. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of alcohol use
disorder, hypertension, type 2 diabetes, complicated by
neuropathy, presenting with chest pain.
Patient was recently released from jail, now presenting with
intermittent exertional chest pain over the last 24 hours.
States he was walking when he noticed acute onset left-sided
substernal chest pain that radiates to his legs. Associated with
some nausea however no emesis. Denied any diaphoresis, jaw, or
arm pain. States that the pain has been intermittent over the
last 24 hours, resolving with rest. Denies any recent fevers,
chills, cough, no chest wall trauma, no reflux type symptoms.
Of note, patient with prior admission ___ after
presenting with alcohol intoxication and acute on chronic
worsening chest pain. He previously had 6 months of left-sided
chest pain exacerbated by activity, that worsened acutely prior
to. Troponins were negative, underwent echo showing no impaired
LV function. Underwent stress echo demonstrating normal regional
LV systolic function and normal RV systolic function,
non-specific EKG changes. States that his current chest pain is
similar to chest pain during prior hospitalization.
In the ED, initial VS were: T 97.8 HR 111 BP 132/86 RR 16 O2
100%RA
Exam notable for:
Con: In no acute distress, A+O ×3
HEENT: Normocephalic, atraumatic, EOMI
Resp: Clear to auscultation, normal work of breathing
CV: Tachycardic with 1 out of 6 early systolic ejection murmur,
normal ___ and ___ heart sounds, 2+ distal pulses. Capillary
refill less than 2 seconds.
Abd: Soft, Nontender, mildly distended
GU: No costovertebral angle tenderness
MSK: No deformity or edema
Skin: No rash, Warm and dry
Neuro: Cranial nerves II Through XII mostly intact
Psych: Normal mood/mentation
Labs notable for:
- WBC 8.4, Hb 11.4, HCT 34.9, PLT 251
- Na 136, K 5.3, bicarb 20, BUN 14, Cr 0.9, AG 21
- D-dimer 530
- Troponin <0.01
- Lactate initially 4.5
- Serum EtOH 253
- CK 1234
ED Course: Given concern for possible aortic dissection, patient
underwent CTA however due to significant motion degradation and
contrast bolus streak artifact, was unable to rule out
dissection
in the proximal ascending aorta. Read as linear hyperdensities
within the lumen thought to be related to bolus streak artifact.
No evidence of PE.
Was started on an esmolol drip given tachycardia in order to
lower heart rates prior to an attempted ECG gated CT to further
rule out aortic dissection. However unable to get a gated CT
overnight.
Patient received 2.5L IVF total, lactate subsequently down
trended to 1.3. Case discussed with overnight ___, given
resolution of chest pain with negative troponin and normal
age-adjusted d-dimer with equal BP in bilateral arms, patient
was
transferred to the floor.
Imaging showing:
Bedside US: Notable for tachycardia, normal contractility w/o
effusion
CTA Chest:
1. Significant motion degradation and contrast bolus streak
artifact limits evaluation of the proximal ascending aorta.
Linear hyperdensities within the lumen are likely related to
this, although it is unclear. If there is persistent clinical
concern for dissection, EKG gated CTA can be obtained for
better evaluation.
2. No evidence of pulmonary embolism.
3. Enlarged main pulmonary artery may suggest pulmonary
hypertension.
EKG: Sinus, HR 94, QRS 92, non-specific ST change in V2 stable
compared to prior EKGs.
Administered:
___ 04:14 PO Aspirin 324 mg
___ 04:43 IVF LR
___ 06:41 IVF LR 1000 mL
___ 08:53 IV FoLIC Acid 1 mg
___ 09:34 IV Thiamine 500 mg
___ 11:15 IVF NS
___ 12:44 IVF NS
___ 14:00 IVF NS 500 mL
___ 14:55 PO/NG Gabapentin 800 mg
___ 15:08 IV Labetalol 10 mg
___ 15:31 IVF NS 500 mL
___ 16:38 IV LORazepam 1 mg
___ 18:24 IV DRIP Esmolol
___ 18:28 IVF LR
___ 19:57 IVF LR 500 mL
___ 21:57 IV DRIP Esmolol
___ 22:02 PO/NG Gabapentin 800 mg
___ 22:58 IV DRIP Esmolol
___ 23:01 IV CefTRIAXone
___ 23:31 IV CefTRIAXone 1 g
Transfer VS: T 97.7 HR 78 BP 153/95 RR 18 O2 100%RA
Subjective: On arrival to the floor, patient confirms the above
history. Currently his chest pain has resolved. In addition to
above, denies any recent cocaine use. Currently complaining of
some burning on urination. Also denies any muscle or joint
pains,
no recent heavy exercise or prolonged immobility.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Alcohol use disorder
HTN
NIDDM c/b neuropathy
Social History:
___
Family History:
Negative for CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.1 BP 183/103 HR 79 RR 18 O2 97%RA
GENERAL: Comfortable, NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs. Anterior chest
wall nontender to palpation.
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. Decreased
peripheral sensation secondary to neuropathy
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM:
VS: T 98.1 BP 183/103 HR 79 RR 18 O2 97%RA
GENERAL: Comfortable, NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs. Anterior chest
wall L sided around rib 10 anterior axillary area with point
tenderness to palpation
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. Decreased
peripheral sensation secondary to neuropathy
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
ADMISSION LABS:
===============
___ 03:30AM BLOOD WBC-8.4 RBC-3.78* Hgb-11.4* Hct-34.9*
MCV-92 MCH-30.2 MCHC-32.7 RDW-13.7 RDWSD-46.4* Plt ___
___ 03:30AM BLOOD Neuts-62.3 ___ Monos-5.7 Eos-0.8*
Baso-0.4 Im ___ AbsNeut-5.22 AbsLymp-2.55 AbsMono-0.48
AbsEos-0.07 AbsBaso-0.03
___ 03:30AM BLOOD ___ PTT-27.2 ___
___ 03:30AM BLOOD D-Dimer-530*
___ 12:34AM BLOOD D-Dimer-236
___ 03:30AM BLOOD Glucose-183* UreaN-14 Creat-0.9 Na-136
K-5.3 Cl-95* HCO3-20* AnGap-21*
___ 03:30AM BLOOD ALT-23 AST-39 CK(CPK)-886* AlkPhos-44
TotBili-0.2
___ 10:05AM BLOOD CK(CPK)-1234*
___ 02:40PM BLOOD CK(CPK)-1318*
___ 03:30AM BLOOD Lipase-30
___ 03:30AM BLOOD CK-MB-7
___ 03:30AM BLOOD cTropnT-<0.01
___ 10:05AM BLOOD cTropnT-<0.01
___ 02:40PM BLOOD CK-MB-8
___ 12:34AM BLOOD cTropnT-<0.01
___ 03:30AM BLOOD Albumin-4.4
___ 03:30AM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 12:40AM BLOOD ___ pO2-68* pCO2-48* pH-7.43
calTCO2-33* Base XS-6
___ 04:03AM BLOOD Lactate-4.5*
___ 10:17AM BLOOD Lactate-4.2*
___ 03:14PM BLOOD Lactate-4.6*
___ 12:40AM BLOOD Lactate-1.3
DISCHARGE LABS:
================
___ 06:07AM BLOOD WBC-5.7 RBC-4.06* Hgb-12.7* Hct-38.9*
MCV-96 MCH-31.3 MCHC-32.6 RDW-13.7 RDWSD-48.4* Plt ___
___ 06:07AM BLOOD Glucose-195* UreaN-16 Creat-1.0 Na-139
K-4.7 Cl-99 HCO3-28 AnGap-12
___ 06:07AM BLOOD ALT-22 AST-28 LD(LDH)-235 CK(CPK)-1042*
AlkPhos-54 TotBili-0.5
___ 12:34AM BLOOD ALT-20 AST-27 LD(LDH)-209 CK(CPK)-1050*
AlkPhos-52 TotBili-0.4
___ 06:07AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.7
MICROBIOLOGY:
==============
___ URINE CULTURE: PENDING
IMAGING:
=========
CXR ___: No acute cardiopulmonary process.
CTA Chest ___:
1. Significant motion degradation and contrast bolus streak
artifact limits evaluation of the proximal ascending aorta.
Linear hypodensities within the lumen are likely related to
this, although it is unclear. If there is persistent clinical
concern for dissection, EKG gated CTA can be obtained for better
evaluation.
2. No evidence of pulmonary embolism.
3. Enlarged main pulmonary artery may suggest pulmonary
hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO BID
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Gabapentin 300 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % 1 patch daily Disp #*15 Patch Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 4
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
morning and night Disp #*8 Capsule Refills:*0
5. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
6. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth morning and night Disp
#*60 Tablet Refills:*0
8. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth morning and night
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical chest pain
Elevated lactate
Urinary tract infection
Rhadbomyolysis
Secondary:
Uncontrolled hypertension
ETOH use disorder
NIDDM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with chest pain// Cardiomegaly
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The lungs are well expanded and clear. No pleural effusion or pneumothorax.
Cardiomediastinal silhouette is unchanged. No grossly displaced fracture.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: History: ___ with intermittent pleuritic chest pain radiating to
back// Dissection, PE present?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 21.3 mGy (Body) DLP =
10.6 mGy-cm.
2) Spiral Acquisition 3.7 s, 28.8 cm; CTDIvol = 14.2 mGy (Body) DLP = 408.8
mGy-cm.
Total DLP (Body) = 419 mGy-cm.
COMPARISON: None
FINDINGS:
There is significant motion degradation. In the region of the proximal
ascending aorta, there are few linear hyperdensities within the lumen which
could be related to motion and contrast streak artifact, although this is
unclear. Otherwise, the aorta and its major branch vessels are patent, with
no evidence of stenosis, occlusion, 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 pulmonary artery is markedly
dilated measuring up to 4.1 cm. There is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is mild bilateral dependent atelectasis. No large pulmonary
consolidation. The airways are patent to the subsegmental level.
Other than a large stool burden, limited images of the upper abdomen are
unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. Significant motion degradation and contrast bolus streak artifact limits
evaluation of the proximal ascending aorta. Linear hypodensities within the
lumen are likely related to this, although it is unclear. If there is
persistent clinical concern for dissection, EKG gated CTA can be obtained for
better evaluation.
2. No evidence of pulmonary embolism.
3. Enlarged main pulmonary artery may suggest pulmonary hypertension.
NOTIFICATION: Updated findings discussed with ___, MD, by ___
___, MD, on the phone at 09:38 on ___.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified, Acidosis
temperature: 97.8
heartrate: 111.0
resprate: 16.0
o2sat: 100.0
sbp: 132.0
dbp: 86.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ male with history of alcohol use
disorder, hypertension, type 2 diabetes, complicated by
neuropathy, presenting with chest pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / doxycycline / Pravachol / Lipitor / ACE Inhibitors /
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
liver biopsy ___
History of Present Illness:
This is a ___ year old woman with COPD, NIDDM c/b gastroparesis
since ___, SIBO, presents with one week of nausea with
vomiting, fatigue, light headedness, in the setting of long
standing diarrhea. She was seen at ___ office on the day of
presentation and was found to have sodium of 112, and was
immediately referred to the emergency department.
In the ED she was found to be hyponatremic to 114 and
hypokalemic to 2.8. She received 40 mg PO potassium and 40 mg IV
potassium and was admitted to the MICU.
In the ED, initial vitals:
97.9 85 173/82 17 100% RA
Labs notable for: Whole blood Na:114 K:2.8 Flu test negative @
___ Cr 0.3
Urine Chemistry:
Creat:22
Na:29
Osmolal:241
Imaging: no imaging
Patient received: 40mEq Potassium PO and IV K x1.
Vitals on transfer: HR 83 153/87 RR18 98% RA
Upon arrival to ___, she confirms the above history. She notes
10 lb weight loss in the past 5 months which she attributes to
her SIBO and gastroparesis. No fevers, chills, night sweats. No
SOB or chest pain. no abdominal pain. She reports recent
belching, which she also attributes to her gastroparesis.
Past Medical History:
Stroke with residual L eye blindness
Asthma
HTN
Lung disease, chronic obstructive
Hearing loss, sensorineural
Keloid
Diverticulosis
Spondylosis, cervical
CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE cath ___ 50%
ostial rca lesion
Hypercholesterolemia
Esophageal reflux
Osteopenia
Diabetes mellitus type 2 in nonobese
Peripheral vascular disease
Subclinical hyperthyroidism
History of breast cancer S/P bilateral breast lumpectomy
Gastroparesis
Vitamin D deficiency
PAST SURGICAL HISTORY:
-Fem-fem bypass graft at ___, complicated by infection with
Klebsiella, requiring 6 further surgeries and wound vac x2.
Social History:
___
Family History:
Family history of breast cancer in first degree relative, FH of
diabetes
Physical Exam:
ADMISSION EXAM:
===============
VITALS: T 98.1 HR 78 BP 161/74, 100% on RA
GENERAL: thin appearing woman, eagerly engages with interview
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, very occasional
scattered expiratory wheezes
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: thin, soft, non-distended, mild chronic tenderness over R
mid-abdominal scar, multiple well healed scars over lower
abdomen
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: without rashes
NEURO: mild L facial droop, L eye blindness
ACCESS: peripheral IVs
DISCHARGE EXAM:
==============
VITALS: 98.8 115 / 98 94 18 98 RA
GENERAL: thin appearing woman, eagerly engages with interview
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, very occasional
scattered expiratory wheezes
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: thin, soft, non-distended, mild chronic tenderness over R
mid-abdominal scar, multiple well healed scars over lower
abdomen. liver biopsy site with bandage c/d/i
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: without rashes
NEURO: mild L facial droop, L eye blindness
Pertinent Results:
ADMISSION LABS:
================
___ 06:50PM BLOOD WBC-6.2 RBC-4.40 Hgb-11.9 Hct-33.3*
MCV-76* MCH-27.0 MCHC-35.7 RDW-13.7 RDWSD-37.5 Plt ___
___ 06:50PM BLOOD Glucose-86 UreaN-8 Creat-0.3* Na-115*
K-3.3* Cl-78* HCO3-23 AnGap-14
___ 06:50PM BLOOD Calcium-8.9 Phos-2.6* Mg-1.5*
___ 04:59AM BLOOD TSH-0.52
___ 04:59AM BLOOD Cortsol-14.1
___ 06:57PM BLOOD Na-114* K-2.8*
___ 10:53PM BLOOD Lactate-1.2 Na-119* K-5.2*
Hyponatremia trend:
___ 01:50AM BLOOD Na-118* K-3.3
___ 08:24AM BLOOD Na-132*
___ 10:14AM BLOOD Na-113*
___ 01:34PM BLOOD Na-117*
___ 05:40PM BLOOD Na-118*
___ 11:44PM BLOOD Na-119*
___ 04:30PM BLOOD Na-122*
IMAGING:
===========
___ CT chest:
1. Right upper lobe spiculated mass with right perihilar
conglomerate
lymphadenopathy consistent with lung malignancy, the
differential for which includes small cell and squamous cell
lung cancer.
2. Large mediastinal lymph nodes measuring up to 1.1 cm.
3. Multiple large hypodense liver lesions concerning for liver
metastases.
4. Moderate apical predominant emphysema.
___ CT A/P:
1. Innumerable hypoattenuating lesions throughout the liver,
consistent with
metastatic disease. No additional sites of metastasis within
the abdomen or
pelvis identified.
2. No acute process within the abdomen or pelvis.
3. Diverticulosis without diverticulitis.
4. Status post fem-fem bypass with patent bypass graft.
DISCHARGE LABS:
===============
___ 05:06AM BLOOD WBC-6.1 RBC-4.07 Hgb-10.8* Hct-32.8*
MCV-81* MCH-26.5 MCHC-32.9 RDW-14.7 RDWSD-43.6 Plt ___
___ 05:06AM BLOOD Glucose-97 UreaN-17 Creat-0.5 Na-127*
K-4.1 Cl-87* HCO3-27 AnGap-13
___ 05:06AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO DAILY
2. Amitriptyline 20 mg PO QHS
3. Cetirizine 10 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Atorvastatin 80 mg PO QPM
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. amLODIPine 10 mg PO DAILY
9. Aspirin 325 mg PO DAILY
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg ___ capsule(s) by mouth every 6 hours
Disp #*30 Capsule Refills:*0
2. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*30
Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
4. GlipiZIDE 2.5 mg PO DAILY
RX *glipizide 5 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Nicotine Patch 14 mg TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour apply 1 patch daily
Disp #*14 Patch Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*60 Tablet Refills:*0
7. Sodium Chloride 1 gm PO TID
RX *sodium chloride 1 gram 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
8. Amitriptyline 20 mg PO QHS
9. amLODIPine 10 mg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Cetirizine 10 mg PO DAILY
13. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
15. Montelukast 10 mg PO DAILY
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
17. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=========
hyponatremia due to SIADH
metastatic malignancy, likely lung primary
SECONDARY:
===========
Type 2 diabetes
history of breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with h/o tobacco use with lung mass on CT chest
as well as multiple liver lesions on CT chest.// ? metastatic disease, staging
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 4.3 s, 27.9 cm; CTDIvol = 5.8 mGy (Body) DLP = 156.8
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.3
mGy-cm.
3) Stationary Acquisition 4.9 s, 0.2 cm; CTDIvol = 84.2 mGy (Body) DLP =
16.8 mGy-cm.
4) Spiral Acquisition 7.1 s, 45.9 cm; CTDIvol = 5.8 mGy (Body) DLP = 262.7
mGy-cm.
5) Spiral Acquisition 4.3 s, 27.9 cm; CTDIvol = 5.8 mGy (Body) DLP = 156.8
mGy-cm.
Total DLP (Body) = 595 mGy-cm.
COMPARISON: Chest CT dated ___.
FINDINGS:
LOWER CHEST: The visualized lung bases are clear except for subsegmental
atelectasis. No pericardial pleural effusions.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There are innumerable heterogeneous hypoattenuating lesions throughout the
liver, some of which demonstrate rim enhancement. The largest lesion in the
right lobe measures 6.6 cm (series 6, image 17). The largest lesion in the
left lobe occupies most of the segment IVb (series 6, image 26). There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis in either kidney. A 1.5 cm simple cyst is noted in
the lower pole of the left kidney. No additional suspicious renal lesion.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There are
diverticuli throughout the colon without evidence of diverticulitis.
Otherwise the colon and rectum are unremarkable. Moderate stool burden
throughout the colon. The appendix is not visualized but no secondary signs
of appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable. No adnexal mass.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Severe atherosclerotic
disease is noted. Patient is status post fem-fem bypass with patent graft.
The left external iliac artery is completely occluded. The left common iliac,
right common and external iliac, and bilateral internal iliac arteries are
patent. The celiac artery, SMA, and ___ are patent. The portal veins are
patent.
BONES: A 0.6 cm sclerotic focus in the right iliac wing (series 6, image 58)
is likely a bone island. Otherwise, no suspicious osseous lesions. No acute
fractures.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Innumerable hypoattenuating lesions throughout the liver, consistent with
metastatic disease. No additional sites of metastasis within the abdomen or
pelvis identified.
2. No acute process within the abdomen or pelvis.
3. Diverticulosis without diverticulitis.
4. Status post fem-fem bypass with patent bypass graft.
Radiology Report
EXAMINATION: Ultrasound-guided targeted liver biopsy
INDICATION: ___ year old woman h/o breast cancer in remission with lung mass
on CT chest, which also found multiple lung lesions concerning for metastatic
diseae// ?liver biopsy
COMPARISON: CT chest without contrast from ___
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___ trainee and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was
performed. The lesion for biopsy was identified in right hepatic lobe. A
suitable approach for targeted liver biopsy was determined.
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, 3 18-gauge core biopsy samples were
obtained. The samples were placed in formalin.
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 27
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x 3, with specimen sent to
pathology.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old woman with significant smoking history, COPD,
presents with hyponatremia c/f SIADH. Please evaluate for malignancy
TECHNIQUE: Portable chest AP.
COMPARISON: None
FINDINGS:
The lungs are expanded and there is a density with ill-defined borders
projecting over the right midlung. There is hilar asymmetry, with the
appearance of a more prominent right hilum. The cardiomediastinal silhouette
is normal. There is no pneumothorax. There is no pleural effusion.
IMPRESSION:
Density with ill-defined borders at the right midlung could represent an
infectious consolidation. An obscured nodule or lesion at this location
cannot be definitively excluded on this single projection exam. A chest CT is
recommended for further characterization.
RECOMMENDATION(S): Chest CT.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:03 pm, 60 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with 40 pack year smoking hx, p/w severe
hyponatremia and new R lung opacification on CXR concerning for new lung
malignancy// Please eval for lung ca.
TECHNIQUE: Axial helical MDCT images were obtained through the chest without
IV contrast. Coronal, sagittal and lung algorithm reconstructed images were
acquired.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.6 s, 36.4 cm; CTDIvol = 5.4 mGy (Body) DLP = 193.2
mGy-cm.
Total DLP (Body) = 193 mGy-cm.
COMPARISON: None
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Limited evaluation of the thyroid
gland is unremarkable. The visualized supraclavicular and axillary lymph
nodes are not enlarged.
UPPER ABDOMEN: Multiple hypodense liver lesions measuring up to 7.8 cm
concerning for liver metastasis.
MEDIASTINUM: Multiple enlarged mediastinal and right hilar lymph nodes. A
representative paratracheal node measures 1 cm (02:23). Hilar lymph nodes
difficult measuring in the absence of intravenous contrast, but the largest
likely measures approximately 18 mm in short axis.
HILA: Enlarged right hilar lymph node measuring up to 1.5 cm (02:23).
HEART and PERICARDIUM: The heart is normal in size. There is no pericardial
effusion. Coronary atherosclerotic calcifications are noted.
PLEURA: There is no pleural effusion. There is no pneumothorax.
LUNG:
1. PARENCHYMA: Moderate emphysematous changes are noted in the bilateral lung
apices. Within the right upper lobe is a perihilar spiculated 4.9 x 2.7 x 3.4
cm mass with adjacent conglomerate right hilar lymphadenopathy (4:112, 5:55).
This process extends to the pleura and also extends to and tethers the right
major fissure superiorly (series 6, image 95). Linear atelectasis noted in
the right lower lobe.
2. AIRWAYS: The airways are patent to the subsegmental level.
3. VESSELS: No aortic aneurysm. Aortic atherosclerotic calcifications are
notable.
CHEST CAGE: No aggressive osseous lesions.
IMPRESSION:
1. Right upper lobe spiculated mass with right perihilar conglomerate
lymphadenopathy consistent with lung malignancy, the differential for which
includes small cell and squamous cell lung cancer.
2. Large mediastinal lymph nodes measuring up to 1.1 cm.
3. Multiple large hypodense liver lesions concerning for liver metastases.
4. Moderate apical predominant emphysema.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 16:05 into the Department of Radiology
critical communications system for direct communication to the referring
provider.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with Abn lev hormones in specimens from female genital organs, Hyperkalemia
temperature: 97.9
heartrate: 85.0
resprate: 17.0
o2sat: 100.0
sbp: 173.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | Pt is a ___ year old female with past medical history of breast
cacner s/p lumpectomy, COPD, diabetes type 2 complicated by
gastroparesis, hypertension, peripheral vascular disease,
tobacco abuse status post recently quitting, admitted with
severe hyponatremia secondary to SIADH also found to have likely
metastatic lung cancer. Sodium improved with fluid restriction
and salt tabs. Pt was found to have mass on CXR and CT chest
concerning for small vs squamous cell cancer. CT A/P showed
multiple liver mets and underwent biopsy on ___.
ICU Course: ___
==========================
Suspect hyponatremia developed in course of week, with low
solute intake but free water intake. Her urine osm was high
inappropriately, also suggestive of SIADH. She was initially
given small amounts of NS for hypovolemic component, but once Na
did not improve further, she was fluid restricted and allowed to
eat for increased solute intake. CXR was obtained given SIADH,
which showed possible right sided mass, thus followup CT chest
was ordered, which did show a mass concerning for malignancy.
Her sodium continued to appropriately rise and then stabilize,
and she was transferred to the floor for further workup.
FLOOR COURSE:
=================
# hyponatremia: Most likely SIADH, with component of low solute
intake in setting of recent illness contributing. SIADH likely
being driven by lung mass (see below). She was seen by renal
during her hospitalization. Na was stable in mid to high 120s
prior to discharge. She was maintained on ___ fluid
restriction and started on oral Na tabs 1g TID. She was also
continued on glucerna shakes TID to increase solute intake to
help facilitate water excretion.
# metastatic malignancy: pt with abnormal CXR this admission,
underwent CT chest that showed RUL speculated mass with
perihilar LAD concerning for lung malignancy (small vs squamous
cell), large mediastinal LNs and multiple liver lesions
concerning for liver mets. CT A/P showed liver mets but no other
lesions. Overall, radiographic appearance, SIADH, and extensive
smoking history concerned for primary lung malignancy. Notably,
pt also has h/o breast cancer for which she underwent b/l
lumpectomies ___ and ___ with significant family hx as well.
She was followed by At___ Onc (Dr. ___ but has not been
seen in several years. At time of last appointment, there was
plan for prophylactic mastectomies.
Pt underwent uncomplicated liver biopsy with ___ on ___.
Pathology/FNA were pending at time of discharge. LFTs were midly
and stably elevated during admission with no evidence of liver
dysfunction or biliary compression. She was set up with
outpatient oncology follow up with Atrius onc.
#leukocytosis: transient leukocytosis during admission with no
signs of infection likely due to prednisone exposure as patient
required pre-medication prior to CT A/P given history of allergy
to IV contrast (SOB in 1970s).
# Type II Diabetes: home metformin was held and patient was
covered with HISS. Given insulin requirements while inpatient,
and concern for adverse effect with metformin in setting of
innumerable liver mets, pt was switched to glipizide 2.5mg daily
on discharge.
# Irritable bowel syndrome, constipation predominant: pt treated
with bowel regimen while in patient.
# COPD: continued home ___. placed on advair during
admission in place of home symbicort.
# Peripheral vascular disease
# History of stroke: continued statin, isosorbide. ASA was held
for biopsy.
# Hypertension: amlodipine was continued during admission
# Depression: continued Amitriptyline
# Allergies: continued Cetirizine
# Tobacco Abuse
Recently quit smoking: continued Nicotine Patch |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Indocin / Toradol / Erythromycin Base / Neurontin / Lipitor /
Doxazosin / Simvastatin / Ativan
Attending: ___.
Chief Complaint:
Weakness, nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with hx Psoriatic arthritis, DM, HTN, and
chronic renal insufficiency who presents with nausea, vomiting
and decreased POs x 1 week. The pt states that she was in her
usual state of health until ___, when she started taking
prednisone as a bridge from enbrel to humira. As had happened in
the past, the pt started becoming swollen, and noted that her
hands were so swollen she could no longer move her rings. She
also noted that her glucoses had been elevated to the 300s. So
the pt stopped taking the prednisone ___. However, on that
day she also noted feeling generally unwell. She was unable to
keep food down and was having persistent dry heaves as well as
vomiting. She also noted chills so severe she was unable to get
out of bed because she "couldn't get warm". She complains of
rhinorrhea and sneezing but denies sore throat or cough, night
sweats, diarrhea, dysuria, urinary frequency. She does endorse
pruritis of her arms and legs and ___ psoriasis flare. She also
notes occasional headache, but denies change in vision,
photophobia, neck stiffness. Also of note, the pt has been
unable to keep her pills down since ___. She does note
that her daughter, who is pregnant, has been sick with similar
symptoms requiring hospitalization, and her husband has had a
cold.
.
In the ED, initial VS: 98.3 72 220/74 16 100%. Cr elevated to
3.4 from baseline 2.4, lactate 2.1. EKG - sinus @ 66, PR 212,
NA, no ST changes, CXR - no acute process, KUB - no dilated
loops or air fluid levels, no free air. The pt was given 1L NS
and IV zofran x1. She had a u/a showing many bacteria, trace
leuks, so she was given cipro 400mg IVx1. Given elevated BP, the
pt was given home doses of verapamil and isosorbide, and repeat
BP was 181/87.
.
On the floor the pt was 96.6 160/62 72 20 97%RA FSG 207. She was
in no distress, denied abdominal pain, denied current n/v. Was
able to tolerate PO meds in the ED, and stated she felt some
improvement from presentation.
.
REVIEW OF SYSTEMS:
Denies fever, night sweats, vision changes, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
DM for ___ years
Obestity
Psoriasitic arthritis
HTN
CRI
Hypothyroidism
Left knee replacement
Back pain
Gout
HTN
DMII(follow by Dr ___ at ___ on insulin
h/o Cataract Surgery
Nephrotic Range Proteinuria
CRI
Severe sleep apnea on CPAP
Hypercholesterolemia
Recent surgery in ___ for amputated finger reattachment
Spinal stenosis with chronic back pain
Hypothyroidism
Anemia
Chronic Knee Pain
h/o heart murmur
Social History:
___
Family History:
mother and 3 children have DM, grandfather from mother's side
had colon Ca, father had cerebral hemorrhage.
Physical Exam:
PE at the admission:
VS - 96.6 160/62 72 20 97%RA FSG 207.
GENERAL - Obese female, itching forearms, NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, ___ systolic murmur, nl S1-S2
ABDOMEN - Obese, nt,nd
EXTREMITIES - ___ with psoriatic rash that is erythematous,
confluent, with scale, dry scale on bilateral elbows
SKIN - psoriasis as above
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
PE at the discharge:
VS - 98 129/42 68 20 98%RA, i/o 780/450
GENERAL - Obese female, itching forearms, NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, ___ systolic murmur, nl S1-S2
ABDOMEN - Obese, nt,nd
EXTREMITIES - ___ 3+ edema, now in ACE bandage, with psoriatic
rash that is erythematous, confluent, with scale, dry scale on
bilateral elbows
SKIN - psoriasis as above
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
___ 06:30PM
WBC-7.2 RBC-4.50 Hgb-13.3 Hct-38.8 MCV-86 MCH-29.5 MCHC-34.3
RDW-13.8 Plt ___
___ 06:30PM BLOOD Neuts-68.4 ___ Monos-4.6 Eos-1.6
Baso-1.1
___ 07:45AM BLOOD Glucose-142* UreaN-76* Creat-3.2* Na-139
K-4.3 Cl-99 HCO3-29 AnGap-15
___ 06:30PM BLOOD ALT-41* AST-31 AlkPhos-85 TotBili-0.3
___ 07:45AM BLOOD Calcium-9.5 Phos-2.5* Mg-2.0
Discharge labs
___ 01:54PM URINE HOURS-RANDOM CREAT-103 SODIUM-18
POTASSIUM-35 CHLORIDE-<10 TOT PROT-41 TOTAL CO2-LESS THAN
PROT/CREA-0.4*
___ 01:54PM URINE OSMOLAL-414
___ 07:45AM GLUCOSE-142* UREA N-76* CREAT-3.2* SODIUM-139
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15
___ 07:45AM CALCIUM-9.5 PHOSPHATE-2.5* MAGNESIUM-2.0
___ 07:45AM TSH-6.7*
___ 07:45AM WBC-7.0 RBC-4.16* HGB-12.3 HCT-35.6* MCV-86
MCH-29.6 MCHC-34.7 RDW-14.1
___ 07:45AM PLT COUNT-229
___ 12:55AM URINE HOURS-RANDOM
___ 12:55AM URINE UHOLD-HOLD
___ 12:55AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 12:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
___ 12:55AM URINE RBC-0 WBC-2 BACTERIA-MANY YEAST-NONE
EPI-0
___ 12:55AM URINE HYALINE-5*
___ 12:55AM URINE MUCOUS-RARE
___ 12:20AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ URINE URINE CULTURE- <10,000 organisms/ml
___ BLOOD CULTURE Blood Culture PND
CXR ___: No radiographic evidence for acute cardiopulmonary
process.
.
KUB FINDINGS ___: There are no dilated loops of bowel or
air-fluid levels to suggest obstruction. There is no evidence
for large free intraperitoneal air. IMPRESSION: No acute
findings.
.
RENAL and BLADDER US: The right kidney measures 10.1 cm in its
long axis. The left kidney measures 11.5 cm in its long axis.
Evaluation of echogenicity or subtle mass/stone is limited due
to patient body habitus; there is no evidence of large mass or
severe hydronephrosis. Sagittal and transverse views of the
bladder demonstrate no gross abnormality,
but the post-void bladder ___ are 6.6 x 6.6 x 6.0 cm,
yielding a
calculated post-void residual of 157 cc. IMPRESSION: While
suboptimal due to body habitus, no evidence for hydronephrosis;
post-void residual of 157 cc.
Medications on Admission:
calcitriol 0.25 mcg Capsule PO daily
clobetasol 0.05 % Ointment apply to psoriasis twice a day stop
using when rash clears up
clobetasol 0.05 % Solution apply at bedtime as needed for x ___
weeks then every other day
colchicine [Colcrys]
0.6 mg Tablet TAKE 1 TABLET BY MOUTH DAILY TO PREVENT GOUT
fluocinolone-shower cap ___ Scalp Oil] 0.01 % Oil
apply to scalp at bedtime under showercap as needed for once
weekly furosemide 40 mg Tablet 3 Tablet(s) by mouth twice a day
insulin glargine [Lantus] 46u qhs
insulin lispro [Humalog] 100 unit/mL Solution as directed daily
per sliding scale
isosorbide mononitrate 30 mg Tablet Extended Release 24 hr 1
Tablet(s) by mouth daily
LEVOXYL 150MCG Tablet ONE BY MOUTH EVERY DAY
pregabalin [Lyrica] 100 mg Capsule 1 Capsule(s) by mouth twice a
day
ranitidine HCl 150 mg Tablet 1 (One) Tablet(s) by mouth twice a
day
valsartan [Diovan] 320 mg Tablet 1 Tablet(s) by mouth once a day
verapamil 180 mg Cap,Ext Release Pellets 24 hr TAKE 1 CAPSULE BY
MOUTH DAILY
Aspirin 81 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by
mouth once a day (OTC)
Cholecalciferol (vitamin D3) 1,000 unit Capsule 1 Capsule(s) by
mouth once a day
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical BID (2
times a day).
3. clobetasol 0.05 % Solution Sig: One (1) Appl Topical at
bedtime as needed for psoriasis.
4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
5. furosemide 40 mg Tablet Sig: AS Directed Tablet PO twice a
day: 3 tablets in the morning, 2 tablets in the evening.
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. pregabalin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
12. verapamil 180 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
13. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. insulin glargine 100 unit/mL Cartridge Sig: One (1) 46 U
Subcutaneous once a day.
15. insulin lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous as needed.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic renal failure
Gastro enteritis
Lower extremity edema
Psoriasis
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with acute on chronic renal insufficiency.
STUDY: GU ultrasound.
COMPARISON: ___.
FINDINGS: The right kidney measures 10.1 cm in its long axis. The left
kidney measures 11.5 cm in its long axis. Evaluation of echogenicity or
subtle mass/stone is limited due to patient body habitus; there is no evidence
of large mass or severe hydronephrosis.
Sagittal and transverse views of the bladder demonstrate no gross abnormality,
but the post-void bladder ___ are 6.6 x 6.6 x 6.0 cm, yielding a
calculated post-void residual of 157 cc.
IMPRESSION: While suboptimal due to body habitus, no evidence for
hydronephrosis; post-void residual of 157 cc.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHILLS & FEELING SICK
Diagnosed with URIN TRACT INFECTION NOS, NAUSEA WITH VOMITING, ACUTE KIDNEY FAILURE, UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 98.3
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 220.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | Patinet was admitted because of the nausea, vomiting and
weakness in the setting of the CKD due to DM and HTN. Sine other
family memeber had similar symptoms we belive the viral
gastroenteritis was the cause of nausea and vomiting that led to
loss of volume and prerenal acute on chronic renal failure.
After administration of 1 L of NS and zofran, nausea and
vomiting resolved. Consequently, her renal function improved
also.
During the hospital stay furosemide was held b/o reduced
intravascular volume, but should be re-started after discharge.
Lyrica was reduced due to concern for lower extremity edema. We
also briefly held prednisone (given for treatmetn of
psoriasis)beacuse of the suspicion of infection (UTI was
suspected on urianlaysis, but later UCx came back negative) that
prednisone was restated at the end of the stay.
Pt should follow up with the nephrologist (Dr. ___
her declining kidney function, eGFR now 14, over the longer
course of time and starting of dialysis should be considered. AV
fistula should be planned.
Kidney parameters, including Cre, BUN, Na, K, Cl, CO2 and eGFR
should be followed up a week after the discharge.
Pt. should be also followed by urologist b/o increased post-void
urine volume that increases the chance of UTIs.
Pt. should also be followed up for her psoriasis and start
humira as planned with the shortest possible course of
prednisone (if required). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Swelling
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
Mr. ___ is an ___ yo male with past medical history of sick
sinus syndrome status post pacemaker placement dementia,
congestive heart failure, bipolar disorder, dementia, alcohol
dependence transferred from ___ with worsening lower
and upper extremity edema and rising creatinine. Creatinine 1.2
on ___, rose to 2.0 on ___. Per reports, his diuretics had
been increased but there is no documentation as to what his home
dose was and what that was escalated to. His weights that are
recorded are as follows: 168lbs in ___ and 173 lbs on ___.
Mr. ___ is a poor historian. All information was gathered
from ___ records. Mr. ___ was without complaints on
arrival to the floor.
Originally, Mr. ___ was transferred from ___
___ for increased agitation and assaultiveness to
___ in Decemeber. He was paranoid, labile, and agitated. He
was started on zyprexa and lexapro. His mood improved. The, he
developed worsening edema and diuretics were increased.
In the ED, vitals were 130/76 79 98% on RA. CXR showed clear
lungs with low volumes. His creatinine was 1.8, lactate 3.5,
albumin 2.8, AST/ALT 106/33, tbili 1.2, WBC 15K. He was given
500cc NS and his repeat lactate was 2.6. He was given 1gm of
ceftriaxone..
Past Medical History:
SSS, s/p dual chamber st judes ppm
mild aortic stenosis with a valve area of 1.2-1.9.
Bipolar affective disorder
Etoh abuse
atrial fib
hx of UTI
R ankle frx ___
CAD
dementia
Social History:
___
Family History:
Father had endocarditis
Physical Exam:
Admission:
VS - 98.1 102/55 72 18 95%RA
General: NAD, A+Ox2 (knows name, year, not location)
HEENT: anicteric sclera, EOMI, PERRL, oropharynx clear
Neck: unable to assess JVP ___ pt positioning
CV: RRR, ___ HSM @ RUSB
Lungs: + bilateral expiratory wheeze at lung bases
Abdomen: +BS, distended, soft, non-tender
GU: +foley
Ext: compression stockings bilaterally, +1 pitting edema to
knees, posterior thigh pitting edema up to gluteus, sacral
edema, +1 pitting edema on hands, warm extremities with +1 ___
& radial pulses
Discharge:
VS: 97.8 108/60 70 16 99% RA Weight: 84.2 kg (yest 81.4 kg)
I/O: NR
General: NAD, A+Ox3 (knows name, year, location)
HEENT: anicteric sclera, EOMI, PERRL, oropharynx clear
Neck: non-elevated
CV: RRR, ___ HSM @ RUSB
Lungs: CTA anteriorly
Abdomen: +BS, distended, soft, non-tender
GU: +foley
Ext: +1 pitting edema bilaterally to shins, trace pitting edema
to knees, posterior thigh pitting edema up to gluteus, warm
extremities with +1 ___ & radial pulses, L. ankle wrapped in
gauze
Pertinent Results:
Admission:
----------
___ 03:00PM BLOOD WBC-14.9* RBC-3.64* Hgb-11.7* Hct-37.9*
MCV-104* MCH-32.0 MCHC-30.7* RDW-14.3 Plt ___
___ 03:00PM BLOOD Neuts-57 Bands-0 ___ Monos-11 Eos-0
Baso-1 Atyps-3* ___ Myelos-0
___ 03:00PM BLOOD ___ PTT-38.3* ___
___ 03:00PM BLOOD Glucose-95 UreaN-20 Creat-1.8* Na-142
K-4.2 Cl-107 HCO3-26 AnGap-13
___ 03:00PM BLOOD ALT-33 AST-106* AlkPhos-140* TotBili-1.2
___ 03:00PM BLOOD proBNP-2465*
___ 03:00PM BLOOD Lipase-20
___ 03:00PM BLOOD Albumin-2.8*
___ 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:20PM BLOOD Lactate-3.5*
Pertinent:
----------
___ 06:00AM BLOOD ALT-29 AST-87* LD(LDH)-239 AlkPhos-113
TotBili-1.0
___ 06:54AM BLOOD ALT-31 AST-98* AlkPhos-128 TotBili-1.4
___ 06:00AM BLOOD Albumin-2.3* Calcium-8.4 Phos-3.3 Mg-1.9
___ 06:00AM BLOOD TSH-2.1
Discharge:
----------
___ 07:00AM BLOOD WBC-11.3* RBC-3.29* Hgb-11.0* Hct-33.4*
MCV-101* MCH-33.3* MCHC-32.9 RDW-13.3 Plt ___
___ 07:00AM BLOOD Glucose-86 UreaN-24* Creat-1.6* Na-141
K-3.8 Cl-101 HCO3-31 AnGap-13
Imaging:
--------
___ L. ANKLE X-RAY (Prelim read):
Three views of the left ankle show no fractures or
bone destruction and the ankle mortise is congruent with
the talus. Vascular calcifications are present. There
is slight soft tissue swelling medial to the ankle
joint and proximal tibia. I have no localizing history.
___ ECHO:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets are mildly thickened (?#).
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
___ HIP AND PELVIS X-RAY:
FINDINGS: AP pelvis and two views left hip were provided. The
bony pelvic ring is intact. Both hips align normally. There is
minimal acetabular spurring. SI joints appear symmetric and
normal. Bone mineralization is normal. Two views of the left
hip are unrevealing. No soft tissue abnormalities.
IMPRESSION: No fracture or dislocation
___ CXR:
FINDINGS: Single frontal view of the chest provided. Dual-lead
pacer is
unchanged with pacer pack projecting over the right chest wall.
Lungs are clear, though volumes are low. No large effusion or
pneumothorax is seen. The cardiomediastinal silhouette appears
grossly stable. No bony
abnormalities are seen.
IMPRESSION: No acute findings.
Micro:
------
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ URINE URINE CULTURE-FINAL
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Albuterol-Ipratropium 1 PUFF IH QID
3. Acetaminophen 650 mg PO BID
4. Spironolactone 100 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Escitalopram Oxalate 20 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Thiamine 100 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Albuterol-Ipratropium 1 PUFF IH QID
3. Amiodarone 200 mg PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Thiamine 100 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Senna 17.2 mg PO HS:PRN constipation
12. Torsemide 20 mg PO DAILY
13. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
14. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
1. edema
2. poor nutritional status
3. aortic stenosis
SECONDARY:
4. cognitive impairment
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam from ___.
CLINICAL HISTORY: Cough, evaluate for pneumonia.
FINDINGS: Single frontal view of the chest provided. Dual-lead pacer is
unchanged with pacer pack projecting over the right chest wall. Lungs are
clear, though volumes are low. No large effusion or pneumothorax is seen.
The cardiomediastinal silhouette appears grossly stable. No bony
abnormalities are seen.
IMPRESSION: No acute findings.
Radiology Report
PELVIS AND LEFT HIP RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Reported fall with left hip tenderness. Assess fracture.
FINDINGS: AP pelvis and two views left hip were provided. The bony pelvic
ring is intact. Both hips align normally. There is minimal acetabular
spurring. SI joints appear symmetric and normal. Bone mineralization is
normal. Two views of the left hip are unrevealing. No soft tissue
abnormalities.
IMPRESSION: No fracture or dislocation.
Radiology Report
HISTORY: Pain, post fall.
Three views of the left ankle show no fractures or bone destruction and the
ankle mortise is congruent with the talus. Vascular calcifications are
present. There is slight soft tissue swelling medial to the ankle joint and
proximal tibia. I have no localizing history.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abdominal distention, Cough, Dyspnea, EDEMA
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, RESPIRATORY ABNORM NEC
temperature: 98.2
heartrate: 70.0
resprate: 28.0
o2sat: 98.0
sbp: 148.0
dbp: 83.0
level of pain: 13
level of acuity: 2.0 | ___ year old male with past medical history of bipolar disorder,
dementia, alcohol abuse, congestive heart failure, sick sinus
syndrome status post pacemaker placement who presents with
worsening renal function and anasarca in the setting of
increasing diuretics.
ACTIVE ISSUES
-------------
# Anasarca - Likely secondary to poor nutritional status and
hypoalbuminemia (to 2.3) causing decreased oncotic pressure and
fluid retention. His liver synthetic function is grossly intact
as evidenced by an INR of 1.2. He had a normal
protein/creatinine ratio indicating his hypoalbuminemia is not
likely to be secondary to any renal cause. His TTE showed a
normal ejection fraction and was without any evidence of
diastolic dysfunction. He was started on torsemide 40 mg PO
daily, which was decreased to 20 mg daily at discharge. His
volume status improved but he continued to have evidence of
pitting edema bilaterally in his lower extremities and dependent
regions. His diuretic dose may need to be titrated as an
outpatient.
# Nutritional status - Albumin 2.3. Nutrition recommended
supplementation with magic cup three times daily. His oral
intake should be monitored to ensure that he is getting
appropriate nutrition.
# Acute kidney injury - Likely in the setting of poor kidney
perfusion from total body fluid overload. Creatinine was 2.0 at
___ and trended down to 1.6 at discharge.
CHRONIC ISSUES
--------------
# Atrial fibrillation - Patient was continued on amiodarone.
# Bipolar disorder - Mood was stable during hospitalization. He
made a few bizarre comments and during his stay. He was not
agitated or hostile during his stay.
# Dementia - Alert and oriented to name, year, and hospital
during his stay.
# History of alcohol abuse - He was continued on thiamine,
folate, and multivitamin.
# Macrocytic anemia - He was stable during his hospitalization.
This finding is likely related to years of chronic alcohol
abuse. This should continue to be monitored as outpatient.
# Hypothyroidism - Patient was continued on levothyroxine.
TRANSITIONAL ISSUES:
* changed furosemide to torsemide 20 mg daily
* discontinued spironolactone
* please weigh patient daily and notify supervising MD if weight
increases >3lbs in one day
* please monitor nutritional intake and ensure supplementation
with Magic cup, three times a day
* check electrolyte panel (Na+, K+, BUN, Cr, Cl-, HC03-) on
___
* monitory hemodynamics - blood pressure and heart rate
* WOUND CARE RECS: Left heel pressure ulcer
- waffle boots
- turn and reposition every ___ hrs
- apply moisture barrier ointment to periwound tissue with each
dressing change
- Commercial wound cleanser or normal saline to cleanse wounds.
- Pat the tissue dry with dry gauze.
PENDING RESULTS AT DISCHARGE:
Microbiology
___ 17:31 BLOOD CULTURE Blood Culture, Routine
___ 15:26 BLOOD CULTURE Blood Culture, Routine
___ 15:22 BLOOD CULTURE Blood Culture, Routine
Diagnostic Reports
___ ANKLE (AP, MORTISE & LA - Final read pending |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
R torso numbness, tingling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ R handed woman with a history of
HLD, migraine headaches, cervical radiculopapthy, and notalgia
paresthetica who presents for rapid evaluation of R torso and
leg
numbness as well as R leg weakness. She is a patient of ___
Neurologist Dr. ___.
Briefly, the patient was recently seen by ___ outpatient
neurologist Dr. ___ on ___ for symptoms of R leg and
torsoe numbness and R leg weakness.
Briefly, the patient states that about 1-week ago, the patient
was in ___ on vacation. Last ___ she swam in the ocean for
one hour. On ___, she started to develop pruritis in the
mid-back area on the R, but more inferior to where ___ typical
notalgia paresthetica symptoms are located. She reached down to
scratch the area and immediately felt pain in the same
distribution. The next day, she woke up and described a loss of
sensation on the R torso from R T6-T10. The following day, the
loss of sensation had spread down to the R groin/hip area. ___
this past week, she feels as though the numbness has moved down
___ R leg into the toes. At the time of ___ neurologic
evaluation
a few days ago she did not have any paresthesias/tingling. On
exam at ___ neurology visit, she had R leg weakness and sensory
loss from T6-T10. ___ toes were downgoing.
The next day after ___ neurology appointment, she started to
notice worsening weakness of the R leg , and numbness spreading
to the L side of ___ groin and left leg. Yesterday, she noted
when she sat on the toilet that she couldn't feel ___ buttocks
on
the toilet seat very well. She started to use a cane to ambulate
on ___ because she was dragging ___ R leg around. By
___,
she was holding on to furniture to ambulate as well as ___ cane.
This morning, the patient awoke around 6 am and dragged herself
over to the bathroom. When she sat on the toilet seat, she knew
she had to urinate but had to strain significantly to empty out
___ bladder. She then proceeded to go to the kitchen and drink
coffee. Around 8 AM, she felt that she likely had a bowel
movement because she had some cramping in ___ belly. She then
proceeded to go to the toilet and noted that ___ buttocks was
even more numb than at 6 am. She sat on the toilet for a long
while trying to have a bowel movement, when finally it came
out.
She then proceeded to call ___ daughter and son-in-law who is a
family med physician who urged ___ to go to the ED as soon as
possible.
Does not endorse diarrhea, URI symptoms, myalgias, no mosquito
bites, no rashes, no pain in ___ back or elsewhere etc.
ROS: Endorses red flag symptoms for cord compression:
[ ] Acute pain longer than 3 weeks
[ ] Pain not relieved by rest
[ ] Midline/ Axial Pain worse at night or when lying down
[ ] Radicular pain (either arm or leg) or bilateral pain.
[ ] Midline back pain
[X ] Changes in bladder control (urgency, incontinence, loss of
bladder sensation)
[X ] New falls or walking aid
[ ] History of cancer.
[ ] Fever, chills, night sweats, or weight loss.
[ ] Anticoagulant use
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 parasthesiae.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PMH:
1. Migraine
2. Uterine leiomyoma
3. Hearing loss sensorineural
4. Osteopenia
5. Diverticulosis of colon
6. Spondylosis of cervical ___
7. PTSD
8. Eosinophilia
9. Helicobater pylori ab+
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Bladder Scan: 109 cc
Back: [ X] No spinal or paraspinal tenderness
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.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4 5 5 5 5 5 5
R 5 ___ ___ 2 3 3 2 3 3 3
-Sensory: Decrease pinprick from T5 downwards (a level below
nipple line) on torso and on the back, patient can only feel 10%
of pinprick down to ___ toes. She has intact proprioception
throughout and vibration is 12 seconds in toes.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response was upgoing bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
DICHARGE PHYSICAL EXAM:
MS: Oriented to self and situation. Language is fluent and
speech
is not dysarthric. Follows simple midline and axial commands.
CN: face symmetric, EOMI no nystagmus, no RAPD
Motor:
RLE hypotonia.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ ___
L 5 ___ 5 5 * 5- 5 4+ 4 5 4+ 5
R 5 ___ 5 5 * 3 3 3 0 0 0 0
-DTRs: ___ today but previously
Bi Tri ___ Pat Ach
L 3+ 3 3 3 2
R 3+ 3+ 3 3 2
Toes up bilaterally, suprapatellars bilaterally, no crossed
adductors, ___ bilaterally, pectoral jerks bilaterally, No
clonus
Sensory: Stable compared to yesterday.
Diminished sensation to pinprick on left leg ant/post to T6
anteriorly and to T4 on posterior.
Right leg with decreased sensation to T4 to groin.
Coordination: FTN intact bilaterally
Pertinent Results:
Pending labs:
CSF: Paraneoplastic panel
Serum studies: MOG, paraneoplastic panel, HTLV, MMA, NMO/AqP4
Resulted labs:
CSF:
- VZV negative
- HSV PCR negative
- Cytology - negative for malignant cells
- OCB: 2 bands (negative), IgG elevated
Serum:
- ___ Ab negative
- Sjogren's negative
- CMV IgG +, IgM negative
- Lyme negative
- HIV negative
- HCV Ab negative
- HSV 1 IgG positive, HSV 2 IgG negative
- ANCA negative
- Mycoplasma Pna IgG high, IgM normal
- Cardiolipin Ab IgG/IgM negative
- dsDNA negative
- ESR normal
- CRP normal
- RF <10 (WNL)
- EBV IgG positive, IgM negative
MR ___ ___
EXAMINATION: MR CODE CORD COMPRESSION PT27 MR ___
INDICATION: *** CODE CORD *** History: ___ with RLE weakness,
torso numbness.
IV contrast to be given at radiologist discretion as clinically
needed//
Spinal stenosis? Cord signal abnormality?
TECHNIQUE: Sagittal imaging was performed with T2 technique.
Next, sagittal
IDEAL and T1, axial T1 and T2 imaging after the uneventful
administration of
Gadavist contrast agent were obtained. Please note that
sagittal T1
precontrast and axial lower thoracic T1 postcontrast imaging was
not obtained
due to technical factors.
COMPARISON: None.
FINDINGS:
Study is moderately degraded by motion.
CERVICAL:
Vertebral body heights and alignments are grossly maintained.
The bone marrow
signal is within normal limits. Within the cervical ___, the
spinal cord
itself demonstrates normal signal intensity and without abnormal
enhancement.
Multilevel spondylosis is seen within the cervical ___,
overall
mild-to-moderate. Findings are most notable at C5-C6 with a
posterior disc
bulge that flattens the ventral thecal sac and results in
mild-to-moderate
canal narrowing with mild neural foraminal narrowing
bilaterally. No critical
spinal canal stenosis or neural foraminal narrowing.
THORACIC:
Within the upper to mid thoracic ___, there is a
heterogeneously enhancing
3.7 x 1.0 x 0.9 cm (SI by AP by TV) intramedullary spinal cord
lesion. This
is surrounded by T2 hyperintensity which extends from the level
of STIR T1-T2
through T6-T7. There is associated spinal cord expansion.
No epidural or leptomeningeal enhancement. The remainder of the
visualized
spinal cord is normal in morphology and signal intensity.
The thoracic vertebral bodies are maintained in height and
alignment. Minimal
spondylosis is seen without appreciable canal stenosis or neural
foraminal
narrowing.
LUMBAR:
Lumbar vertebral bodies are maintained in height and alignment.
There is no
suspicious bone marrow lesion identified. The cauda equina
terminates at L1-L
2.
At T12-L1 through L4-L5, there is only minimal degenerative
changes without
appreciable canal stenosis or neural foraminal narrowing. At
L5-S1 there is
loss of intervertebral disc height and a posterior disc bulge
which slightly
indents the ventral thecal sac without definite canal narrowing.
Neural
foraminal narrowing is mild-to-moderate bilaterally.
No evidence for abnormal enhancement within the lumbar ___.
The visualized
paraspinal soft tissues are grossly unremarkable bilaterally.
IMPRESSION:
1. Please note that sagittal T1 precontrast and axial lower
thoracic T1
postcontrast imaging was not obtained due to technical factors.
2. Study is moderately degraded by motion.
3. 3.7 x 1.0 x 0.9 cm heterogeneously enhancing expansile lesion
centered
within the upper to mid thoracic ___ with surrounding cord
edema. These
findings are most compatible with a primary intramedullary
lesion such as an
astrocytoma, or less likely an ependymoma. Additional
considerations would
include infectious or inflammatory etiologies, and close
follow-up is
required.
4. No associated leptomeningeal or epidural enhancement.
5. Mild, multilevel spondylosis within the cervical and lumbar
___, as
detailed above. No high-grade canal stenosis or neural
foraminal narrowing is
identified.
MR ___ ___
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with presumed transverse
myelitis, eval for MS
lesions in ___// eval for lesions in ___
TECHNIQUE: Sagittal 3D FLAIR imaging was performed along with
axial fast STIR
and axial diffusion imaging. The FLAIR images were re-formatted
in axial and
coronal orientations. Sagittal MPRAGE and axial T1 weighted
imaging were
performed after administration of ___ intravenous contrast.
COMPARISON: None.
FINDINGS:
Study is mildly degraded by motion.
There are numerous bilateral periventricular, pericallosal,
deep, and
subcortical FLAIR white matter hyperintensities identified, in a
pattern that
is suggestive of demyelinating disease. A solitary punctate
focus of
enhancement is seen along the left ventricular atria (4:82;
401:100), and may
reflect an area of active demyelination. No additional areas of
enhancement
are identified.
There is no acute intracranial hemorrhage or infarction. The
ventricles and
sulci are mildly prominent compatible with global parenchymal
volume loss.
The visualized portion of the distal vertebral basilar system
appears
right-sided dominant, with a hypoplastic left vertebral artery.
The remainder
of the major intracranial vascular flow voids are preserved.
Dural venous
sinuses are patent.
Mild mucosal thickening is seen within scattered ethmoid air
cells. The
remainder of the paranasal sinuses and mastoid air cells are
clear. The
orbits are unremarkable bilaterally.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial hemorrhage or infarction.
3. Numerous nonenhancing white matter lesions compatible with
demyelinating
disease.
4. Solitary punctate focus of enhancement along the left
periventricular white
matter, which may reflect an area of active demyelination.
5. No additional enhancing lesions are seen.
6. Mild global parenchymal volume loss, an additional findings
as above.
7. Paranasal sinus disease , as described.
MR ___ ___
EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___
INDICATION: ___ year old woman with transverse myelitis, arm
numbness// Repeat
MRI c ___ to T1
TECHNIQUE: Sagittal imaging was performed with T2, T1, and
IDEAL technique.
Axial T2 and gradient echo imaging were next performed. After
administration
of Gadavist intravenous contrast, sagittal and axial T1
weighted imaging was
performed.
COMPARISON: MRI total ___ ___.
FINDINGS:
Study is mildly degraded by motion.
Vertebral body alignment is preserved. Vertebral body heights
are preserved.
There is no focal marrow signal abnormality.
Seen again is an area of extensive T2/STIR hyperintensity and
patchy
enhancement within the upper thoracic ___ beginning at the
level of T2,
incompletely characterized on current study and better assessed
on the recent
total ___ MRI examination. No additional spinal cord signal
abnormality is
identified within the cervical ___. No leptomeningeal or
epidural
enhancement.
Multilevel degenerative changes within the cervical ___ are
again noted,
unchanged from the prior MRI performed on ___. The
degenerative
changes are again most notable at C5-6 with a posterior disc
bulge the results
in mild canal narrowing. No moderate or severe canal stenosis.
No severe
neural foraminal narrowing.
The prevertebral and paraspinal soft tissues are grossly within
normal limits.
IMPRESSION:
1. No evidence for spinal cord signal abnormality or enhancement
within the
cervical ___.
2. Partially imaged known extensive T2/STIR hyperintense signal
with patchy
enhancement centered within the upper to mid thoracic ___,
better
characterized on ___ total ___ MRI.
3. Mild spondylosis of the cervical ___ without moderate or
severe vertebral
canal or neural foraminal narrowing.
4. Please see concurrently obtained contrast ___ MRI for
description of
intracranial findings.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sumatriptan Succinate 100 mg PO ONCE MR1:PRN headache
2. Multivitamins 1 TAB PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
3. Pantoprazole 40 mg PO Q24H
Stop when steroids stopped.
4. PredniSONE 60 mg PO DAILY Duration: 1 Dose
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 5 tapered doses
5. PredniSONE 40 mg PO DAILY Duration: 2 Doses
This is dose # 2 of 5 tapered doses
6. PredniSONE 20 mg PO DAILY Duration: 2 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 3 of 5 tapered doses
7. PredniSONE 10 mg PO DAILY Duration: 2 Doses
Start: After 20 mg DAILY tapered dose
This is dose # 4 of 5 tapered doses
8. PredniSONE 5 mg PO DAILY Duration: 1 Dose
Start: After 10 mg DAILY tapered dose
This is dose # 5 of 5 tapered doses
9. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Stop when off steroids.
10. Ascorbic Acid ___ mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Sumatriptan Succinate 100 mg PO ONCE MR1:PRN headache
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Transverse myelitis
Possible demyelinating disease (NMO versus MS)
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: MR CODE CORD COMPRESSION PT27 MR SPINE
INDICATION: *** CODE CORD *** History: ___ with RLE weakness, torso numbness.
IV contrast to be given at radiologist discretion as clinically needed//
Spinal stenosis? Cord signal abnormality?
TECHNIQUE: Sagittal imaging was performed with T2 technique. Next, sagittal
IDEAL and T1, axial T1 and T2 imaging after the uneventful administration of
___ contrast agent were obtained. Please note that sagittal T1
precontrast and axial lower thoracic T1 postcontrast imaging was not obtained
due to technical factors.
COMPARISON: None.
FINDINGS:
Study is moderately degraded by motion.
CERVICAL:
Vertebral body heights and alignments are grossly maintained. The bone marrow
signal is within normal limits. Within the cervical spine, the spinal cord
itself demonstrates normal signal intensity and without abnormal enhancement.
Multilevel spondylosis is seen within the cervical spine, overall
mild-to-moderate. Findings are most notable at C5-C6 with a posterior disc
bulge that flattens the ventral thecal sac and results in mild-to-moderate
canal narrowing with mild neural foraminal narrowing bilaterally. No critical
spinal canal stenosis or neural foraminal narrowing.
THORACIC:
Within the upper to mid thoracic spine, there is a heterogeneously enhancing
3.7 x 1.0 x 0.9 cm (SI by AP by TV) intramedullary spinal cord lesion. This
is surrounded by T2 hyperintensity which extends from the level of STIR T1-T2
through T6-T7. There is associated spinal cord expansion.
No epidural or leptomeningeal enhancement. The remainder of the visualized
spinal cord is normal in morphology and signal intensity.
The thoracic vertebral bodies are maintained in height and alignment. Minimal
spondylosis is seen without appreciable canal stenosis or neural foraminal
narrowing.
LUMBAR:
Lumbar vertebral bodies are maintained in height and alignment. There is no
suspicious bone marrow lesion identified. The cauda equina terminates at L1-L
2.
At T12-L1 through L4-L5, there is only minimal degenerative changes without
appreciable canal stenosis or neural foraminal narrowing. At L5-S1 there is
loss of intervertebral disc height and a posterior disc bulge which slightly
indents the ventral thecal sac without definite canal narrowing. Neural
foraminal narrowing is mild-to-moderate bilaterally.
No evidence for abnormal enhancement within the lumbar spine. The visualized
paraspinal soft tissues are grossly unremarkable bilaterally.
IMPRESSION:
1. Please note that sagittal T1 precontrast and axial lower thoracic T1
postcontrast imaging was not obtained due to technical factors.
2. Study is moderately degraded by motion.
3. 3.7 x 1.0 x 0.9 cm heterogeneously enhancing expansile lesion centered
within the upper to mid thoracic spine with surrounding cord edema. These
findings are most compatible with a primary intramedullary lesion such as an
astrocytoma, or less likely an ependymoma. Additional considerations would
include infectious or inflammatory etiologies, and close follow-up is
required.
4. No associated leptomeningeal or epidural enhancement.
5. Mild, multilevel spondylosis within the cervical and lumbar spine, as
detailed above. No high-grade canal stenosis or neural foraminal narrowing is
identified.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with new weakness// PNA?
TECHNIQUE: Chest PA and lateral
COMPARISON: No relevant comparison identified.
FINDINGS:
Lungs are clear. Pleural spaces are normal. Cardiomediastinal silhouette is
within normal limits.
IMPRESSION:
No focal consolidation.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with presumed transverse myelitis, eval for MS
lesions in brain// eval for lesions in brain
TECHNIQUE: Sagittal 3D FLAIR imaging was performed along with axial fast STIR
and axial diffusion imaging. The FLAIR images were re-formatted in axial and
coronal orientations. Sagittal MPRAGE and axial T1 weighted imaging were
performed after administration of Gadavist intravenous contrast.
COMPARISON: None.
FINDINGS:
Study is mildly degraded by motion.
There are numerous bilateral periventricular, pericallosal, deep, and
subcortical FLAIR white matter hyperintensities identified, in a pattern that
is suggestive of demyelinating disease. A solitary punctate focus of
enhancement is seen along the left ventricular atria (4:82; 401:100), and may
reflect an area of active demyelination. No additional areas of enhancement
are identified.
There is no acute intracranial hemorrhage or infarction. The ventricles and
sulci are mildly prominent compatible with global parenchymal volume loss.
The visualized portion of the distal vertebral basilar system appears
right-sided dominant, with a hypoplastic left vertebral artery. The remainder
of the major intracranial vascular flow voids are preserved. Dural venous
sinuses are patent.
Mild mucosal thickening is seen within scattered ethmoid air cells. The
remainder of the paranasal sinuses and mastoid air cells are clear. The
orbits are unremarkable bilaterally.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial hemorrhage or infarction.
3. Numerous nonenhancing white matter lesions compatible with demyelinating
disease.
4. Solitary punctate focus of enhancement along the left periventricular white
matter, which may reflect an area of active demyelination.
5. No additional enhancing lesions are seen.
6. Mild global parenchymal volume loss, an additional findings as above.
7. Paranasal sinus disease , as described.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old woman with transverse myelitis, arm numbness// Repeat
MRI c spine to T1
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique.
Axial T2 and gradient echo imaging were next performed. After administration
of Gadavist intravenous contrast, sagittal and axial T1 weighted imaging was
performed.
COMPARISON: MRI total spine ___.
FINDINGS:
Study is mildly degraded by motion.
Vertebral body alignment is preserved. Vertebral body heights are preserved.
There is no focal marrow signal abnormality.
Seen again is an area of extensive T2/STIR hyperintensity and patchy
enhancement within the upper thoracic spine beginning at the level of T2,
incompletely characterized on current study and better assessed on the recent
total spine MRI examination. No additional spinal cord signal abnormality is
identified within the cervical spine. No leptomeningeal or epidural
enhancement.
Multilevel degenerative changes within the cervical spine are again noted,
unchanged from the prior MRI performed on ___. The degenerative
changes are again most notable at C5-6 with a posterior disc bulge the results
in mild canal narrowing. No moderate or severe canal stenosis. No severe
neural foraminal narrowing.
The prevertebral and paraspinal soft tissues are grossly within normal limits.
IMPRESSION:
1. No evidence for spinal cord signal abnormality or enhancement within the
cervical spine.
2. Partially imaged known extensive T2/STIR hyperintense signal with patchy
enhancement centered within the upper to mid thoracic spine, better
characterized on ___ total spine MRI.
3. Mild spondylosis of the cervical spine without moderate or severe vertebral
canal or neural foraminal narrowing.
4. Please see concurrently obtained contrast brain MRI for description of
intracranial findings.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Leg weakness
Diagnosed with Anesthesia of skin
temperature: 97.6
heartrate: 65.0
resprate: 16.0
o2sat: 99.0
sbp: 115.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ R handed woman who presented for
with 1.5 weeks of rapidly descending numbness followed by
weakness starting from ___ torso on the R side, progressing down
___ R leg, followed by L groin and L leg numbness which began
when the patient was vacationing in ___ a week and a half
prior to presentation.
#Transverse myelitis vs NMO
On admission, patient was a code cord for concern for spinal
cord compression, so STAT MRI ___ showed hyperenhancing lesion
from T2-T7. The differential diagnosis of this lesion was
thought to be primary intramedullary neoplastic lesion vs
transverse myelitis vs NMO (due to extensiveness of lesion).
Taken together with the rapid onset time course over 1.5 weeks,
transverse myelitis vs NMO was thought to be more likely.
Planned for interval follow up in ___ weeks to assess for
response to steroids. Patient had an LP in the ED, and many
infectious studies were sent to evaluate for various causes of
transverse myelitis (studies detailed in lab section here).
___ MRI showed nonenhancing white matter lesions compatible
with demyelinating disease. This made us think that she could
have transverse myelitis in the setting of demyelinating
disease. Repeat dedicated ___ imaging was obtained due to
patient's complaints of sensory symptoms in ___ upper
extremities, however the ___ MRI was normal and patient's
upper extremity symptoms resolved. She was started on
methylprednisolone 1g Qday on ___, with improvements seen
in ___ left sided sensory symptoms and some improvements in ___
right sided weakness. While on steroids, she was given protonix
for GI protection and put on insulin sliding scale. We started
___ on Vitamin D 2000mg daily in the setting of concern for MS.
___ oligoclonal bands came back negative, making NMO the highest
on our differential. She was seen by physical therapy and
occupational therapy, who both recommended ___ rehab. She
was stable for transfer to rehab on **
#Urinary, fecal retention
Patient had intermittent urinary retention and constipation
which was thought to be secondary to known spinal cord lesion.
We performed bladder scan Q6H and straight cath for >350 cc if
patient was retaining. We also gave ___ a bowel regimen of
senna, Colace, lactulose, glycerin suppository which treated ___
constipation appropriately.
#Osteoporosis
Calcium and vitamin D daily
#Endocrine
RISS while on steroids
#Transitional Issues
[ ] Repeat MRI ___ with and without contrast ___ weeks after
discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Clindamycin / Optiray 300 / Ceftriaxone / Ultram / ciprofloxacin
Attending: ___.
Chief Complaint:
confusion, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is a ___ y/o woman w/ PMH remarkable for severe COPD on
2L home O2 and hypothyroidism who was brought in by her husband
after a referral from clinic for AMS x ___ weeks.
Patient had scheduled appointment with PCP today at noon. Knew
they were going to miss the appointment so patients husband
called ___ triage line with the following complaints. He was
concerned stating that his wife had started becoming more
combative, confused, "out of sorts" and "mixed up." He is
concerned that she may have mistaken some of her medications.
Per
his report she is sleeping more, hallucinating and refusing
assistance with medications. Given concern for urosepsis (in the
setting of her history), asthma and restrictive lung disease,
recommendation was made for patient to present to the ED.
Patient
and husband went to the ED, but patient felt she was being
tricked into going and got into an argument with her husband and
instead they called ___ to make an Epi appointment at ___.
The patient states that she has a cough and
also thinks that she has a "UT." She endorses some burning with
urination. Denies fevers, chills but is a vague historian.
Patient husband is more concerned about the patients alterations
in mental status and increased somnolence. She is taking much
longer to get out of bed now than before. Concerned about her
hallucinating, becoming more confused, combative, argumentative.
He describes a concerning episode of behavior where the patient
took his shirt and tried putting it on her legs. Once that
didn't
fit she grabbed scissors and was trying to cut this shirt. He
found her holding scissors and was concerned for her safety.
Additionally, he is worried that she took one of her medications
by accident or made a mistake in her medication management. She
is in control of her medications but he thinks that she
shouldn't
be. She does not use a pill box and does not have a clear
understanding of what pills she takes on a regular basis. Her
tizanidine was recently changed to baclofen per report in OMR.
There is a rash beneath her lower lip that appeared several days
ago. She has been using a new CPAP/BiPAP mask which might not be
fitting well. She has been applying Vaseline. Denies pain or
burning at the site.
Husband also notes increased sputum, green over the past few
days.
In the ED, initial VS were:
98.5 90 115/47 24 92% RA
Exam notable for:
Mild diffuse wheezing present in bilateral lung fields. RRR,
s1+s2 normal. No abdominal tenderness. Presence of focal
erythematous papules about L chin.
Labs showed: TSH 20, WBC 10.3, H/H 9.0/29.7
UA positive for large leuks, nitrite positive, WBC >182
VBG pCO2 66, HCO3 38
Imaging showed: CXR with LLL consolidation
Consults: None.
Patient received:
PO/NG Azithromycin 500 mg
PO/NG PredniSONE 60 mg
IV Ampicillin-Sulbactam
IV Ampicillin-Sulbactam 1.5 g
PO ValACYclovir 1000 mg
Transfer VS were:
98.0 72 104/70 17 94% 3L NC
On the floor, the patient reports that her breathing is
bothering
her the most. She feels short of breath and has a continued
cough.
Past Medical History:
- Asthma: recurrent hospitalizations, often requiring continuous
Alupent nebulizing treatments and pulse steroids; intubated
twice in ___,
- COPD on 2L nighttime O2
- Chronic demyelinating disease
- Neurogenic bladder requiring intermittent straight
catheterization
- ___: Acute disseminated encephalomyelitis vs. postinfectious
encephalitis
- Sensorineural hearing loss
- Chronic rib/back pain
- Chronic chest pain, etiology unclear
- Avascular necrosis of left hip
- Renal artery thrombus ___, s/p anticoagulation
- Dysphagia s/p previous PEG tube in ___ (tolerates PO now)
- Peptic ulcer disease
- Hypothyroidism
- Osteoporosis
- Depression/Anxiety
- Hyperlipidemia
- Abdominal aortic aneurysm (2.7X2.5cm in ___
- IgG deficiency
- H/O Klebsiella urosepsis
- Recurrent UTIs
- Multiple PNA
- S/P appendectomy
- S/P cholecystectomy
Social History:
___
Family History:
CAD in uncle and ___ nephew; no h/o DM, stroke, blood clots.
Father died of colon cancer, mother died of breast cancer at ___
yo, older sister died of brain cancer and another older sister
died of breast cancer, brother died of an MI at ___. Has two
daughters who are alive and well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 98.0 PO 93 / 58 76 16 92 NC 4L
GENERAL: NAD, AOx2
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM. Multiple erythematous crusted papules
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Diminished breath sounds at the bases with crackles L>R
with faint wheezes heard on the right.
ABDOMEN: slightly distended, 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
DISCHARGED PHYSICAL EXAM:
==========================
VITALS: Reviewed in OMR
GENERAL: Thin elderly woman, sitting up calmly in bed.
HEENT: NC/AT. No icterus or injection. Crusted lesions below
lip.
Healing buccal uclers. Dentures.
CV: RRR, no m/r/g appreciated
RESP: Diminished breath sounds throughout with trace expiratory
wheezing. No accessory muscle use.
GI: Multiple surgical scars. Reducible ventral hernia. Diffusely
tender to deep palpation but soft, no rebound or guarding.
EXTREMITIES: WWP, no edema
SKIN: No lesions aside from lip/mouth lesions described above.
NEURO: Alert, oriented x3. Strength ___ on entire L side (CN11,
LUE, LLE), chronic per patient.
Pertinent Results:
ADMISSION LABS:
=================
___ 08:40PM BLOOD WBC-10.3* RBC-2.95* Hgb-9.0* Hct-29.7*
MCV-101* MCH-30.5 MCHC-30.3* RDW-14.8 RDWSD-54.4* Plt ___
___ 08:40PM BLOOD Glucose-77 UreaN-12 Creat-0.6 Na-146
K-4.1 Cl-102 HCO3-34* AnGap-10
___ 09:20AM BLOOD ALT-9 AST-14 LD(LDH)-131 AlkPhos-99
TotBili-<0.2
___ 08:40PM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
___ 08:57PM BLOOD ___ pO2-58* pCO2-66* pH-7.35
calTCO2-38* Base XS-7
IMPORTANT LABS:
===============
___ 08:40PM BLOOD cTropnT-<0.01
___ 08:40PM BLOOD TSH-20*
___ 09:20AM BLOOD Free T4-0.8*
___ 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:57PM BLOOD Lactate-0.9
MICRO:
========
___ 9:46 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:14 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora
Imaging:
========
CXR PA/Lateral
Ill-defined opacity in the left mid to lower lung worrisome for
infection
superimposed on underlying COPD.
CT Head:
No acute intracranial process.
DISCHARGE LABS:
================
___ 04:40AM BLOOD WBC-10.3* RBC-3.14* Hgb-9.5* Hct-31.8*
MCV-101* MCH-30.3 MCHC-29.9* RDW-15.4 RDWSD-57.0* Plt ___
___ 04:40AM BLOOD Glucose-156* UreaN-19 Creat-0.9 Na-145
K-4.8 Cl-102 HCO3-30 AnGap-13
___ 04:40AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.0
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Aspirin 325 mg PO DAILY
3. Baclofen ___ mg PO TID:PRN back spasms
4. ClonazePAM 2 mg PO TID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Levothyroxine Sodium 37.5 mcg PO DAILY
7. Lorazepam 1 mg PO TID:PRN anxiety
8. Omeprazole 20 mg PO BID
9. Oxycodone-Acetaminophen (5mg-325mg) ___ mg PO Q6H:PRN pain
10. Senna 8.6 mg PO DAILY:PRN constipation
11. Vitamin D 1000 UNIT PO DAILY
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
13. biotin UNK mg oral DAILY
14. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral
DAILY
15. Fish Oil (Omega 3) 1000 mg PO DAILY
16. Lovastatin 20 mg oral DAILY
17. GuaiFENesin ER 1200 mg PO Q12H
18. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
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 #*15 Tablet Refills:*0
2. ClonazePAM 0.5 mg PO TID
RX *clonazepam 0.5 mg 1 tablet(s) by mouth three times a day
Disp #*45 Tablet Refills:*0
3. Levothyroxine Sodium 50 mcg PO DAILY
RX *levothyroxine 50 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
6. Aspirin 325 mg PO DAILY
7. Baclofen ___ mg PO TID:PRN back spasms
8. biotin UNK mg oral DAILY
9. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral
DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. GuaiFENesin ER 1200 mg PO Q12H
13. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation DAILY
14. Lovastatin 20 mg oral DAILY
15. Omeprazole 20 mg PO BID
16. Oxycodone-Acetaminophen (5mg-325mg) ___ mg PO Q6H:PRN
pain
17. Senna 8.6 mg PO DAILY:PRN constipation
18. Vitamin D 1000 UNIT PO DAILY
19. HELD- Lorazepam 1 mg PO TID:PRN anxiety This medication was
held. Do not restart Lorazepam until you discuss with your
primary care physician
___:
Home
Discharge Diagnosis:
PRIMARY
#Toxic metabolic encephalopathy
#Sepsis from urinary tract infection
#Community-acquired pneumonia
#COPD exacerbation
#Acute on chronic hypoxemic and hypercarbic respiratory failure
#Neuromuscular disease causing hypoventilation
#Complex sleep disorder breathing
#Hypothyroidism
SECONDARY
#History of renal artery thrombosis with right femoral bleed
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with COPD on 2L home O2 presents with AMS and potential COPD
exacerbation// eval for PNA
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___ and ___ as well as
chest CT from ___.
FINDINGS:
There is increased opacity in the left mid to lower lung. This is
superimposed on background of increased interstitial markings and
hyperinflation suggesting chronic underlying interstitial abnormality. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
Ill-defined opacity in the left mid to lower lung worrisome for infection
superimposed on underlying COPD.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with new altered mental status// evaluate for bleed/mass
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, 16.2 cm; CTDIvol = 49.4 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute major vascular territorial infarct. Periventricular and subcortical
white matter hypodensities may represent sequela of chronic small vessel
disease, present on prior. Ventricles and sulci are slightly prominent
compatible with volume loss.
Included paranasal sinuses and mastoids are clear. Skull and extracranial soft
tissues are unremarkable.
IMPRESSION:
No acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Cough
Diagnosed with Altered mental status, unspecified, Chronic obstructive pulmonary disease w (acute) exacerbation, Urinary tract infection, site not specified
temperature: 98.5
heartrate: 90.0
resprate: 24.0
o2sat: 92.0
sbp: 115.0
dbp: 47.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with severe asthma/COPD on 2L home O2,
demyelinating disease c/b neurogenic bladder with recurrent
UTIs, hypothyroidism, multiple sedating meds, admitted for
confusion and behavioral disturbances found to have urinary
tract infection and possible PNA. The patient was initiated on
broad spectrum coverage with vancomycin and zosyn as well as
azithromycin and prednisone for COPD coverage. Her mental status
and breathing improved and she was transitioned to augmentin for
klebsiella UTI and possible PNA upon discharge to complete a
total 10 day course (end ___. Prior to discharge, she
completed a full 5 day course of azithromycin and prednisone
40mg burst for COPD (end ___ and she returned to her baseline
O2 requirement of 2L NC.
# Acute Metabolic Encephalopathy:
Patient presented with confusion found to have urinary tract
infection and pneumonia which were likely the source of her
altered mental status. CT head negative and toxicology screen
unrevealing. The patient was initiated on broad spectrum
antibiotics and her sedating medications were held. Her mental
status improved back to baseline and she was resumed back on her
clonezapam at 0.5mg TID and her home baclofen which she
tolerated well. Her Ativan was held upon discharge with plans to
___ with her primary care provider.
# COPD Exacerbation
# Healthcare associated pneumonia
# Acute on chronic hypoxemic/hypercarbic respiratory failure:
Patient presented with shortness of breath and cough with a CXR
showing left lobe consolidation, concerning for pneumonia. On
admission, the patient was initiated on vancomycin/zosyn as well
as azithromycin and prednisone for possible COPD exacerbation.
Her symptoms improved and she was transitioned to Augmentin on
discharge for planned 10 day course (end ___. Prior to
discharge, the patient completed 5 day course of azithromycin
(last ___ and prednisone (last ___. She returned to her
baseline O2 requirement of 2L NC.
# NEUROGENIC BLADDER
# UTI: Patient straight catheterizes at home and presented with
UA concerning for UTI. Initially placed on zosyn given history
of resistant klebsiella in the past later transitioned to
augmentin based on sensitivity profile.
# HYPOTHYROIDISM: Patient found to have elevated TSH and low T4.
Her Synthroid was increased to 50mcg with plans to ___
with endocrinology for further monitoring.
#RASH: Patient has 2-3 mm grouped erythematous crusted macules
below her lower lip which appeared to be consistent with
impetigo. Less likely zoster given non-dermatomal nature.
Improved over course of her stay and will ___ with primary
care physician for further monitoring
CHRONIC ISSUES
--------------
# MUSCLE SPASMS/CHRONIC PAIN: Continued home baclofen and
resumed home clonezapam at reduced dose of 0.5mg TID with plans
to ___ with PCP for further management. Of note, her
Ativan was held at discharge until PCP ___.
# GERD: Continued home omeprazole.
# HYPERLIPIDEMIA: Continued statin, aspirin
# History of RIJ and renal artery thrombosis: Patient previously
on Coumadin, however due to bleeding, has been maintained on
high dose ASA. Continued home aspirin 325mg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lithium / almond oil
Attending: ___.
Chief Complaint:
behavioral changes
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
___ is a ___ year old lady with history of depression,
anxiety,
diagnosis of bipolar affective disorder status post ECT in ___,
breast cancer status post lumpectomy, chemo and radiation in
___
with invasive ductal cancer of left breast status post
mastectomy
in ___, sleep apnea (not on CPAP) who presents to the emergency
department for expedited evaluation of late onset psychiatric
disease and behavioral changes.
Please refer to the detailed clinic note from Dr. ___
___
who evaluated the patient on ___. Briefly, ___ has had
behavioral episodes including mania and psychosis which began
around ___ years ago and has occurred in episodic fashion.
Family
is concerned that in the past few weeks she has been very
suspicious and paranoid. There have been no hallucinations, no
episodes concerning for seizure.
She was evaluated in neurology clinic on ___ and her exam was
notable for sparse speech output spontaneously but otherwise
fluent with intact comprehension, difficulty with word
retrieval,
intact Luria, mild paratonia, generalized atrophy,
fasciculations
in lower extremities, postural and intention tremor, grasp and
jaw jerk. She was not inattentive and MOCA was ___ perhaps
limited by effort; there were errors executive functioning,
recall and word retrieval.
Prior work-up is detailed in Dr. ___ but is notable
for
positive PCR for Anaplasma with high titers, as well as positive
serology for Lyme disease, with confirmation of 5 IgG bands in
___ for which she received a 3-week course of doxycycline. She
was later seen by infectious disease had a LP for possible
diagnosis of CNS Lyme disease. Her LP results from ___ was: CSF glucose 59, protein 62, RBCs 20, and whites 2, a
protein of 62. In the absence of whites in the CSF and
incidentally negative Lyme antibody screen and serum, it was
felt
that she does not have lyme CNS. She has had prior MRI brain
which showed moderate microvascular disease.
Based on concerning history and exam in clinic on ___ it was
recommended she present for admission to the neurology service.
Initial serum work-up was sent on ___ and thus far is notable
for normal CBC, chem 10, LFTs, B12, TSH and CRP.
In the ED, she is accompanied by her sister. She does not know
where she is other than a hospital and looks very suspicious of
examiner. She keeps requesting that examiner stops asking
questions. She does not remember neurology appointment the day
prior. She is able to say she is in the hospital to try to
figure
out what is wrong with her memory. She endorses memory loss but
is unable to provide details.
On review of systems in the emergency department, she denies all
questions on review of systems. Daughter does report weight
loss,
paranoia and intermittently slowly gait.
Past Medical History:
Bipolar affective disorder
Depression
Anxiety
Hypertension
Breast cancer status post lumpectomy, radiation and chemo by Dr.
___ in ___
Invasive ductal cancer of the left breast status post mastectomy
in ___
Adrenal mass benign
Sleep apnea not using CPAP
Esophagitis status post EGD
Anemia
Tonsillectomy ___
Adenoidectomy ___
Appendectomy ___
Tubal ligation bilaterally ___
History of bladder surgery anterior and posterior repairs
Vaginal prolapse repair ___
Social History:
___
Family History:
Mother: deceased at ___ years CHF, IBS, diverticulitis, diabetes
type 2, hypertension.
Maternal grandmother: deceased ___, breast cancer
Maternal grandfather: coronary artery disease
Father: deceased at ___ years CHF, coronary artery disease, colon
cancer or polyps, hypertension.
Siblings: Sister hypertension, overweight.
Brother bladder cancer, coronary artery disease status post
CABG,
cranial artery stenosis status post CABG, hypertension
Physical Exam:
General: Awake, alert
HEENT: NC/AT, no scleral icterus noted
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: breathing comfortably on RA
Cardiac: RRR, wwp
Abdomen: soft, NT/ND
Skin: no rashes
psych: wide eyed, suspicious appearing, flat affect, well
groomed
Neurologic:
-Mental Status: flat affect, keeps saying, "stop asking
me questions". Alert, oriented to person, hospital but not name
and ___ but doesn't know day or full date. Unable to
relate history. Attentive, able to name ___ backward without
difficulty. Speech output is sparse but once initiated it is
fluent although with some pausing intermittently with intact
repetition and comprehension. Able to follow both midline and
appendicular commands. She was unable to talk about recent
events.
-Cranial Nerves:
II: PERRL 4 to 3 mm and brisk. VFF to confrontation.
III, IV, VI: Full fields, EOMI with some saccadic breakdown of
smooth pursuit; no nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with full excursions.
- Motor - She had a low amplitude postural tremor, as well an
intention tremor. No observed rest tremor. She had a tongue
tremor, but no obvious tongue fasciculations. She had
generalized
atrophy primarily of upper extremities.
[Delt] [Bic] [Tri] [ECR] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1]
L 5- 5 5 5 5 5 5 5 5
R 5- 5 5 5 5 5 5 5 5
-DTRs:
[Bic] [Tri] [___] [Quad] [ankle]
L 2+ 2+ 2+ 2+ 1+
R 2+ 2+ 2+ 2+ 1+
-Sensory: No deficits to light touch. Deferred further sensory
testing
-Coordination: Intention tremor bilaterally but no dysmetria on
FNF bilaterally.
-Gait: Narrow-based although cautious. Diminished arm swing
===========================
Discharge exam:
24 HR Data (last updated ___ @ 1230)
Temp: 98.1 (Tm 98.8), BP: 110/71 (110-136/68-83), HR: 64
(58-79), RR: 18 (___), O2 sat: 97% (96-97), O2 delivery: RA
General: awake, conversant
HEENT: NC/AT, no scleral icterus noted
Abdomen: soft, NT/ND
Skin: no rashes
Neurologic:
-Mental Status: alert, oriented, awake sitting up in bed.
Answers
questions appropriately. Smiled. Looking brighter today.
-Cranial Nerves:
II: not tested today
III, IV, VI: not tested today
V: not tested today
VII: No facial droop, facial musculature symmetric.
IX, X: not tested today
XI: not tested today
XII: Tongue protrudes in midline with full excursions.
- Motor - She had a low amplitude postural tremor, as well an
intention tremor. No observed rest tremor. She had generalized
atrophy primarily of upper extremities.
strength not tested today but moving all extremities
spontaneously
-DTRs: deferred this morning
-Sensory: No deficits to light touch. Deferred further sensory
testing. grimace to touch
-Coordination: deferred
-Gait: observed walking hallway with daughter and sister with
appropriate gait
Pertinent Results:
___ 11:56AM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-0 Polys-0
___ ___ 11:56AM CEREBROSPINAL FLUID (CSF) TotProt-46*
Glucose-60
MRI brain:
IMPRESSION:
1. No evidence of acute infarction, hemorrhage or intracranial
mass.
2. No evidence of inappropriate brain atrophy. Particularly in
no medial
temporal lobe atrophy. No micro hemorrhages.
3. No enhancing brain lesions.
4. Stable nonspecific white matter changes in the cerebral
hemispheres
bilaterally, likely sequela of mild chronic small vessel
ischemic changes.
5. Mild mucosal thickening along the ethmoid air cells with near
complete
opacification of the left maxillary sinus, new from the MR ___.
CT AP
IMPRESSION:
1. Heterogeneous 3.3 x 1.0 x 3.9 cm mass with calcification
likely arising
from the left adrenal gland is indeterminate. No invasion of
adjacent
structures. Recommend correlation with prior imaging, if
available. If not
available, MRI could be obtained. Differential includes large
adenoma or
adrenocortical carcinoma. Biochemical correlation should also
be considered.
2. Please refer to separate report of CT chest performed on the
same day for
description of the thoracic findings.
CT CHEST
IMPRESSION:
Incidental 5 mm right lower lobe nodule is seen.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk
patient, and
an optional CT in 12 months is recommended in a high-risk
patient.
EEG:
IMPRESSION: This continuous video EEG monitoring study captured
no pushbutton
activations. It showed a normal background in wakefulness and in
drowsiness.
There were no focal abnormalities, epileptiform discharges, or
electrographic
seizures.
Medications on Admission:
Multivitamin once daily
Vitamin B complex ___ daily
Doxazosin 1 mg once a day
Metoprolol 25 mg twice daily
clonazepam 0.5 mg twice daily
Discharge Medications:
1. LORazepam 1 mg PO Q6H
2. Thiamine 100 mg PO DAILY
3. Doxazosin 1 mg PO HS
4. FoLIC Acid 1 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
dementia with psychiatric overlay
Discharge Condition:
mental status: patient with improving catatonia. More responsive
and interactive. Answers questions. Often low effort
Ambulatory status: fully ambulatory
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with acute on subacute cognitive decline,
catatonia// interval change since ___
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 from ___ and MRI of the head from ___, outside studies.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction.
There are scattered T2/FLAIR hyperintensities in the cerebral hemispheres
bilaterally, a nonspecific finding but unchanged and likely related to chronic
small vessel ischemic changes.
There is no abnormal enhancement after contrast administration.
The ventricles and sulci are age appropriate.
Major vascular flow voids are preserved. Major dural venous sinuses are
patent.
There is mild mucosal thickening along the ethmoid air cells. Near complete
opacification of the left maxillary sinus is new from ___. The
mastoid air cells appear grossly clear. Note is made of bilateral lens
replacement surgery. The orbits appear otherwise unremarkable.
IMPRESSION:
1. No evidence of acute infarction, hemorrhage or intracranial mass.
2. No evidence of inappropriate brain atrophy. Particularly in no medial
temporal lobe atrophy. No micro hemorrhages.
3. No enhancing brain lesions.
4. Stable nonspecific white matter changes in the cerebral hemispheres
bilaterally, likely sequela of mild chronic small vessel ischemic changes.
5. Mild mucosal thickening along the ethmoid air cells with near complete
opacification of the left maxillary sinus, new from the MR ___.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with hx of depression, bipolar affective
disorder and breast cancer s/p lumpectomy in ___ and mastectomy ___ with
acute onset psychiatric and behavioral changes want to rule out malignancy//
rule out malignancy
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 588 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.
Subcentimeter hypodensity in the caudate lobe is too small to characterize.
There is no evidence of suspicious 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: There is a heterogeneously enhancing mass likely rising from the
left adrenal gland measuring 3.3 x 4.0 x 3.9 cm (AP by TRV by CC). There are
small internal calcifications. The mass closely abuts the splenic and left
renal veins, and the stomach, but does not appear to invade these structures.
The right adrenal gland is unremarkable.
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 seen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable. No adnexal abnormality.
Prominent left greater than right gonadal veins are noted, which can be seen
in pelvic congestion syndrome if clinically appropriate.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Heterogeneous 3.3 x 1.0 x 3.9 cm mass with calcification likely arising
from the left adrenal gland is indeterminate. No invasion of adjacent
structures. Recommend correlation with prior imaging, if available. If not
available, MRI could be obtained. Differential includes large adenoma or
adrenocortical carcinoma. Biochemical correlation should also be considered.
2. Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings.
RECOMMENDATION(S): Recommend correlation with prior imaging, if available. If
not available, an MRI could help to further characterize this finding.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with hx of depression, bipolar affective
disorder and breast cancer s/p lumpectomy in ___ and mastectomy ___ with
acute onset psychiatric and behavioral changes want to rule out malignancy//
rule out malignancy
TECHNIQUE: ___ MD CT IMAGES WERE OBTAINED THROUGH THE CHEST AFTER THE
ADMINISTRATION OF IV CONTRAST. MULTIPLANAR REFORMATTED IMAGES IN CORONAL
SAGITTAL AXIS WERE GENERATED AND REVIEWED.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 71.7 cm; CTDIvol = 8.0 mGy (Body) DLP = 569.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 33.4 mGy (Body) DLP =
16.7 mGy-cm.
Total DLP (Body) = 588 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: None.
FINDINGS:
The thyroid is normal. There is no axillary, mediastinal, or hilar
lymphadenopathy. Mildly prominent right hilar and mediastinal lymph nodes are
seen measuring up to 11 mm. Heart size is normal. Moderate coronary
calcifications are seen. There is no pericardial effusion. The esophagus is
normal without evidence of wall thickening or a hiatal hernia. The main
pulmonary artery is normal in caliber. The aorta is normal in caliber.
For evaluation of the abdomen, please refer to dedicated CT of the abdomen
performed on same day.
Osseous structures: No concerning focal lytic or sclerotic lesions are
identified.
Scarring and peripheral reticulation along the anterior aspect of the left
upper lobe may be sequelae of prior radiation therapy. Patient is status post
left-sided mastectomy. Incidental 5 mm right lower lobe nodule is seen,
series 302, image 114. There is no pleural effusion or pneumothorax.
IMPRESSION:
Incidental 5 mm right lower lobe nodule is seen.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion
Diagnosed with Altered mental status, unspecified, Adult failure to thrive
temperature: 97.0
heartrate: 68.0
resprate: 16.0
o2sat: 96.0
sbp: 99.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ woman with past medical history of
hypertension, sleep apnea, breast cancer status post breast
conservation therapy with adjuvant chemo in ___, with
recurrence of second primary invasive ductal cancer of the left
breast status post mastectomy in ___ who presented for
evaluation/admission of behavioral changes and late onset
mania/psychosis. She had initially been referred to neurology
clinic for assessment for her acute onset behavioral changes.
Her exam upon presentation to the ED was notable for flat
affect, suspicion of examiner, somewhat oriented and attentive
but unable to remember recent events. Luria breaks down and she
also has frontal release signs; there is paratonia throughout.
Upon arrival, an extensive neurologic work up was embarked on.
She was initially hooked up to EEG in order to rule out seizure
or encephalopathy. No epileptiform discharges nor slowing was
noted on EEG. Additionally MRI brain was done which was
unremarkable. A CT of chest, abdomen and pelvis were completed
in order to rule out a malignancy causing a paraneoplastic
syndrome. An adrenal mass of unchanging size compared to
previously was noted. Lastly, an LP was completed with no
infectious findings and no elevation in protein. Her Ab CSF
panel was sent out and we will follow findings.
Psychiatry followed closely and diagnosed her with catatonia
upon arrival. An Ativan challenge was completed with good effect
and she was started on 1mg Ativan q8h with good improvement.
The etiology of her symptoms is likely primary psychiatric.
Toxic
metabolic labs unremarkable. LP with no findings concerning for
infectious cause. EEG done and not consistent with seizure or
encephalopathy. Given negative thorough neurologic work up, it
is felt that the symptoms are psychiatric in origin and
psychiatry will continue to follow. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ h/o stg II pancreatic Ca s/p whipple and chemo/xrt in ___
in remission, breast ca in remission, recent diagnosis DM who
presents with abdominal pain and diarrhea. Patient says pain
started last night at 730pm in her epigastric area, sharp ___
pain, radiating to both sides and up her chest, does not radiate
to the back. Associated with some nausea, no vomiting. Also has
had diarrhea which kept her up all night, started the AM prior.
Went 4x today. It is watery and voluminous. No blood. Denies any
fevers or chills.
Of note, patient recently started on metformin for having high
BG up to 400s by PCP.
In the ED initial vitals were: 99.4 90 130/65 18 100%
- Labs were significant for glucose 189, WBC 10, Lipase: 224
- CT abd/pelvis was without significant findings to suggest
explanation for abdominal pain
- Patient was given IV morphine, IV dilaudid, zofran,
Metoclopramide, and 1g Ceftriaxone
- She is admitted to medicine given inability to tolerate PO
Vitals prior to transfer were: ___ 130/70 18 99% RA
On the floor, patient is feeling more comfortable. In addition
to above, she reports polyuria/polydypsia, no dysuria/hematuria.
In the ED, felt she had motion dizziness that wasn't present
prior. She is thirsty. Was feeling extremely well prior to this
bout, able to mow her neighbors lawn the day prior. Good
exercise tolerance with no exertional chest pain but occasional
exertional abdominal pain that has been present since ___
with no clear diagnosis (negative Stress in ___. No f/c. No
orthopnea, PND.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, cough, shortness of breath,
chest pain, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
1. Pancreatic cancer, stage II.
- ___ - Whipple procedure performed by Dr.
___ with pathology revealing a 3.5 cm pT3 tumor with 0 out
of
13 lymph nodes identified involved with tumor. The margins were
uninvolved by tumor and the distance to closest margin was 5 mm
in the posterior retroperitoneal space. There is no evidence of
vascular invasion; however, there was perineural invasion.
- She had genetic testing for BRCA1 and BRCA2 which were
negative.
- She received one cycle of Gemcitabine starting ___
- She completed concomitant radiation and capecitabine on ___.
- She restarted Gemcitabine ___ and completed this on
___.
2. Stage IIA breast cancer s/p mastectomy, currently on
Tamoxifen.
3. Postoperative diabetes mellitus.
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION, ___:
PHYSICAL EXAM:
Vitals - T:99.4 BP:133/67 HR:77 RR:22 02 sat: 94RA
GENERAL: Slightly uncomfortable appearing but no acute distress
HEENT: AT/NC, EOMI, anicteric sclera, dry mucous membranes
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, II/VI SEM murmur in RUSB, no gallops, or
rubs
LUNG: CTAB except decreased sounds at R base, no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: TTP epigastric area without radiation, no
rebound/guarding, hyperactive bowel sounds
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE, ___:
VS - Tmax 98.6 ; BP 119/82; ___
___ - < 240
I/O - ___
Gen: middle-aged F, lying in bed sleeping, rouses easily
HEENT: anicteric, MMM
Cor: RRR no MRG
Lungs: clear throu8ghout
Abd: surgical scars, non-tender throghout normoactive BS
Extrem: warm, trace edema
Pertinent Results:
LABS of NOTE:
Lipase 224 -> 15
LFTs:
AST 92/ ALT 158 -> AST 65 / ALT 134
Alk phos: 110s
TBili 0.3
MRA Abdomen (___): Results pending at the time of discharge
EGD (___): Mild esophagitis was seen in the lower third of
the esophagus and gastroesophageal junction.
Erythema noted in the stomach likely consistent with mild
gastritis.
Pylorus-preserving post-Whipple anatomy appreciated. Normal
mucosa was noted was in the duodenojejunostomy anastomosis and
no erosions or ulcers were visible here. The pancreatico-biliary
limb was explored without evidence of erosions or bleeding.
Otherwise normal small bowel enteroscopy to proximal jejunum
MRCP ___: There is no abnormal enhancement or solid
mass lesion to suggest local recurrence. The residual pancreatic
tail and duct are normal in signal and enhancement pattern
without ductal dilation. There is no peripancreatic inflammation
or fluid collection. Tiny cystic structures within the
pancreatic are are also stable. No MR evidence for active
pancreatitis.
CT A/P + (___): Normal liver, no focal lesion/intrahepatic
ductal dilitation. Patent portal vein. The remaining portion
of the pancreas is without focal lesion or peripancreatic
stranding/fluid collection. Nl adrenals. Nl kidneys. Nl small
and large bowel. No adenopathy. No osseous lesions suspicious
for malignancy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hyoscyamine 0.125 mg SL Q8H
2. Calcium Carbonate 500 mg PO Frequency is Unknown
3. exemestane 25 mg oral daily
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. exemestane 25 mg oral daily
2. Hyoscyamine 0.125 mg SL Q8H
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth three
times a day Disp #*90 Capsule Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 2 capsules by mouth once daily
Disp #*60 Capsule Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Take ___ tablets, every 6 hours, as needed for abdominal pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every 6 hours Disp #*24
Capsule Refills:*0
8. glimepiride 1 mg oral daily diabetes
RX *glimepiride 1 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE:
#Acute-on-chronic abdominal pain
#Pancreatitis
CHRONIC
#History of early stage pancreatic Ca s/p Whipple (___),
adjuvant chemotherapy and radiation
#Breast cancer s/p mastectomy, now on anti-hormonal treatment
#DM: post-surgical from pancreatic insufficiency
Discharge Condition:
Alert and oriented
Ambulating without difficulty
Tolerating diet
Pain well controlled (requiring oxycodone ~1x daily)
Followup Instructions:
___
Radiology Report
INDICATION: Left lower quadrant abdominal pain and tenderness, in a patient
status post Whipple procedure. Evaluate for diverticulitis.
TECHNIQUE: Helical axial MDCT images were obtained from the bases of the
lungs through the pubic symphysis, after the administration of IV contrast.
Reformatted images in coronal and sagittal axes were generated.
DLP: 835.3 mGy-cm.
COMPARISON: CT abdomen/pelvis from ___ and ___.
FINDINGS:
The bases of the lungs are clear. There is no pleural or pericardial effusion.
LIVER: The liver enhances homogeneously without focal lesion or intrahepatic
biliary duct dilation. The portal vein is patent.The patient is status post
Whipple procedure, with the expected postsurgical changes.
SPLEEN: The spleen is homogeneous and normal in size.
PANCREAS: The remaining portion of the pancreas is without focal lesion or
peripancreatic stranding or fluid collection. The patient is status post
Whipple procedure.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys demonstrate symmetric nephrograms and excrete contrast
promptly. There is no focal lesion or hydronephrosis.
GI: The small and large bowel are within normal limits, without wall
thickening or evidence of obstruction.A normal, air-filled appendix is
visualized.There is colonic diverticulosis without evidence of diverticulitis.
RETROPERITONEUM: The aorta is normal in caliber, with mild atherosclerotic
calcifications.There is no retroperitoneal or mesenteric lymph node
enlargement by CT size criteria.
CT PELVIS: The urinary bladder appears normal.No pelvic wall or inguinal lymph
node enlargement by CT size criteria is seen.There is no pelvic free fluid.
OSSEOUS STRUCTURES:No focal lesion suspicious for malignancy present.
IMPRESSION:
No acute intra-abdominal abnormality; specifically, no evidence of acute
diverticulitis. The patient is status post Whipple procedure with postsurgical
changes.
Radiology Report
HISTORY: Pancreatitis, to assess for pleural effusion.
FINDINGS: The cardiac silhouette is within normal limits and there is no
vascular congestion or acute focal pneumonia. Specifically, no evidence of
pleural effusion.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ yo F w/ hx of T3 adenocarcinoma of the pancreatic head, s/p
resection (___ adjuvant chemo XRT, with chronic episodic abdominal
pain subsequent to resection. Now w/ severe diffuse abdominal pain, mild
lipase elevation without cholestasis. // - if no secretin available, please
perform w/o secretin - eval biliary obstruction v. obstruction of pancreatic
duct (stricture, stones)
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 10cc of Gadavist intravenous
contrast. The patient also received oral contrast of 1 cc of Gadavist diluted
in 50 cc of water.
COMPARISON: Numerous CTs and MRIs including MRCP with secretin. Dates ranging
___ 3 most recently ___.
FINDINGS:
MRCP WITH AND WITHOUT IV CONTRAST:
Post Whipple anatomy is again noted. There is expected postoperative
appearance of the hepaticojejunostomy and pancreaticojejunostomy sites. Mild
fat stranding at the resection margin is unchanged from multiple prior
examinations. There is no abnormal enhancement or solid mass lesion to suggest
local recurrence. The residual pancreatic tail and duct are normal in signal
and enhancement pattern without ductal dilation. There is no peripancreatic
inflammation or fluid collection. Tiny cystic structures within the pancreatic
tail are also stable. Mild mesenteric edema is unchanged.
The liver is normal in size and contour. Liver is moderately fatty. Transient
peripheral heterogeneous enhancement is noted on the arterial phase, with
subsequent and equilibration of enhancement pattern. There is no concerning
hepatic mass. The intra and extrahepatic biliary tree is normal in caliber.
The gallbladder is surgically absent.
The spleen and adrenal glands are normal in appearance. There are tiny
bilateral renal cysts.
Venous structures of the upper abdomen are patent and contrast opacified.
Postsurgical changes with associated susceptibility artifact are seen within
the anterior abdominal wall of the epigastric region.
IMPRESSION:
1. Post Whipple without evidence of tumor recurrence.
2. No MR evidence for active pancreatitis. No evidence or biliary or
pancreatic duct dilation.
3. Cystic foci in the pancreatic tail can be followed on future followup
studies.
Radiology Report
EXAMINATION: MRA of the abdomen with and without contrast
INDICATION: ___ yo F w/ hx of early stage pancreatic Ca s/p ___ (___) w/
chronic post-prandial abdominal pain concerning for chronic mesenteric
ischemia. // Atherosclerosis/stenosis in splanchnic arterial system? Concern
for chronic mesenteric ischemia.
TECHNIQUE: Multiplanar, multi sequential MR angiography images were obtained
before, during and after the administration of 18 cc of MultiHance contrast
material, including with 3D reconstruction.
COMPARISON: MRCP from ___, as well as multiple previous CT and
ultrasound examinations.
FINDINGS:
Abdominal aorta, celiac trunk, superior mesenteric artery, and inferior
mesenteric artery demonstrate normal caliber and signal intensity with no
evidence of significant stenosis, filling defect or aneurysmal dilatation.
Right renal artery is normal in caliber and signal intensity. On the left,
there is a small 8 mm segmental renal artery aneurysm at the level of the
renal pelvis. There is also focal narrowing of the proximal left main renal
artery.
Otherwise, the remainder of the examination is not significantly changed from
the recent previous MRCP and CT scan. The previously noted cystic pancreatic
lesions are better evaluated on prior MRCP and not well seen on this
examination.
There are bilateral tiny renal cysts in the lower poles and millimetric,
scattered hepatic cysts or biliary hamartomas.
Patient is status post ___'s procedure. In the mesentery, there is mild
fat stranding which is either postoperative in nature or related to mild
mesenteric panniculitis. Mild colonic diverticulosis.
Otherwise, adrenals, pancreas and remainder of the examination appear
unremarkable.
IMPRESSION:
1. Small left segmental renal artery aneurysm with an area of focal proximal
left main renal artery narrowing. The significance of these findings is
uncertain, but fibromuscular dysplasia cannot entirely be excluded.
2. Otherwise, normal MRA of the celiac trunk, SMA and ___. Specifically, no
evidence for mesenteric ischemia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Diarrhea
Diagnosed with ABDOMINAL PAIN PERIUMBILIC, DIARRHEA, ACUTE PANCREATITIS
temperature: 99.4
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 65.0
level of pain: 8
level of acuity: 3.0 | ___ y/o Female with h/o stage II pancreatic Ca s/p whipple and
chemo/xrt in ___ in remission, Breast Ca in remission, recent
diagnosis DM who presented with acute on chronic abdominal pain.
#Abdominal Pain:
- On presentation she had moderately elevated pancreatic enzymes
(lipase 224) without radiographic evidence of pancreatic
inflammation and a mild transaminitis (peaked at 160/90).
- Acute pain subsided within 24h, however she had persistent,
paroxysmal abdominal pain which is consistent w/ the chronic
pain she has had ever since her ___ Whipple.
- Investigation of chronic pain included MRCP (negative for
recurrence or pancreaticobiliary pathology), EGD (mild
gastritis; negative for anastomotic ulceration), and MRA
(negative for vascular compromise).
- Ultimately, it was thought that her presenting symptoms might
have been due to transient pancreatic duct obstruction from
biliary sludge v. metformin-induced pancreatitis (rarely seen;
case report).
- Given hx of pancreatic cancer and recent pancreatitis, repeat
imaging w/ MRCP is recommended. Ca ___ is pending at time of
discharge.
- She was started on a PPI for mild gastritis and will follow-up
with the ___ clinic in 2 weeks.
- Please f/u H. pylori stool Ag and initiate eradicative
treatment as needed
#Diabetes: was diagnosed w/ post-surgical DM from pancreatic
insufficiency following her Whipple in ___ and briefly on PO
therapy. In the past month she has been found to have elevated
blood sugars and started on metformin.
- Metformin was discontinued.
- She did not require insulin during her hospitalization and had
finger sticks mainly < 200; however, this was likely in the
setting of fasting for procedures as HbA1c returned at 9.8%
- She was discharged on glimepiride 1mg with instructions to
check fingersticks and close follow-up at ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Left wrist pain, right elbow pain
Major Surgical or Invasive Procedure:
1. Open reduction internal fixation of left distal radius
fracture with Synthes 2.4 mm locking plate.
2. Open reduction internal fixation of right proximal ulna
olecranon fracture with tension band construct.
History of Present Illness:
___ s/p mechanical fall. Was on a tour in ___ when she
fell down stairs, landing on her face and arms. EMS gave
C-collar and L arm splint. Now complains of ___ L wrist pain,
inability to extend R arm in abduction. Fall was witnessed and
pt denies syncope, HA, SOB, vision changes, numbness/tingling,
incontinence.
No other recent falls or new medical problems. Chronically blind
in R eye. Takes antidepressant and statin. Denies a/t/n. Last
tetanus shot unknown. Patient is right handed.
Past Medical History:
Depression
HLD
Social History:
___
Family History:
NC
Physical Exam:
Right upper extremity:
Superficial abrasion on R elbow
AIN/PIN/ulnar nerves intact
+SILT axillary/radial/median/ulnar nerve distributions
2+ Radial pulse
Left upper extremity:
Minimal swelling and ecchymoses
AIN/PIN/ulnar nerves intact
+SILT axillary/radial/median/ulnar nerve distributions
2+ Radial pulse
Pertinent Results:
___ right elbow plain films:
Comminuted fracture involving the right proximal ulna and
distracted right olecranon fracture. Adjacent soft tissue
prominence may be due to swelling and/or hematoma.
___ left wrist plain films:
Impacted fracture of the left distal radius with moderate dorsal
angulation. Nondisplaced fracture of the distal left ulna.
Medications on Admission:
Lexapro
Simvastatin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC every night Disp #*14
Syringe Refills:*0
6. Escitalopram Oxalate 10 mg PO DAILY
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*80 Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. Simvastatin 5 mg PO DAILY
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*80 Tablet Refills:*0
11. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Left distal radius fracture, 2 parts.
2. Right comminuted proximal ulna 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: ELBOW (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ with falll on outstretched hands, cut to upper llip and
swelilng to rt elbow. deformity to lt wrist // evaluate for fracture/bleed
evaluate for fracture/bleed
TECHNIQUE: Right elbow, 3 views.
COMPARISON: None
FINDINGS:
There is a fracture involving the proximal ulna as well as a distracted right
olecranon fracture with superior and anterior distraction of the fracture
fragment. There is no large joint effusion seen however there is prominence of
the soft tissues about the fracture which may be due to swelling and/or
hematoma. No radiopaque foreign body is identified. No suspicious lytic or
sclerotic lesions are seen.
IMPRESSION:
Comminuted fracture involving the right proximal ulna and distracted right
olecranon fracture. Adjacent soft tissue prominence may be due to swelling
and/or hematoma.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ with falll on outstretched hands, cut to upper llip and
swelilng to rt elbow. deformity to lt wrist // evaluate for fracture/bleed
evaluate for fracture/bleed
TECHNIQUE: Three views of the left wrist.
COMPARISON: None
FINDINGS:
There is an impacted fracture of the left distal radius with moderate dorsal
angulation. Additionally, there is a nondisplaced fracture of the distal left
ulna. No radiopaque foreign bodies are seen. Vascular calcifications are
seen.
IMPRESSION:
Impacted fracture of the left distal radius with moderate dorsal angulation.
Nondisplaced fracture of the distal left ulna.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with falll on outstretched hands, cut to upper llip and
swelilng to rt elbow. deformity to lt wrist // evaluate for fracture/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: 891 mGy-cm
CTDI: 50
COMPARISON: None
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or infarction.
The ventricles and sulci are normal in size and configuration for age. Subtle
periventricular white matter hypodensities are suggestive of chronic small
vessel ischemic disease.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
The visualized bony structures are grossly unremarkable.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with falll on outstretched hands, cut to upper llip and
swelilng to rt elbow. deformity to lt wrist // evaluate for fracture/bleed
evaluate for fracture/bleed
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 665 mGy
DLP: 32 mGy-cm
COMPARISON: None.
FINDINGS:
There is no evidence of acute fracture or traumatic malalignment. There is no
evidence of prevertebral soft tissue swelling. There is mild multilevel
degenerative change seen as well as exaggeration of the normal cervical
lordosis. The lateral masses of C1 are symmetric about the dens. There is mild
uncovertebral and facet joint hypertrophy. There is minimal scarring at the
lung apices as well as minimal septal thickening seen at the apices, which
could represent mild edema.
IMPRESSION:
No evidence of acute fracture or traumatic subluxation.There is minimal
scarring at the lung apices as well as minimal septal thickening seen at the
apices, which could represent mild pulmonary edema.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ with R wrist fx, s/p reduction.
TECHNIQUE: Three views of the left wrist status post reduction.
COMPARISON: Left wrist radiographs on ___ at 15 34
FINDINGS:
Overlying plaster cast material obscures fine bony detail. Again seen is an
impacted nondisplaced fracture of the distal radius with improved overall
anatomic alignment from the prior study. Also seen is a nondisplaced fracture
of the distal ulna, not significantly changed. No new fractures are
identified.
IMPRESSION:
1. Impacted, nondisplaced fracture of the distal radius with improved overall
alignment since the prior examination.
2. Distal ulnar fracture is unchanged.
Radiology Report
INDICATION: ORIF, intraoperative radiograph. Patient with fractured right
elbow.
COMPARISON: ___.
FINDINGS:
AP and lateral fluoroscopic views of the right elbow were obtained
intraoperatively. 2 pins and 2 cerclage wires wires are seen traversing the
proximal ulna with a fracture fragments appearing well aligned. Please refer
to full operative no for further details.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT IN O.R.
INDICATION: Left wrist fracture, ORIF.
TECHNIQUE: 6 spot fluoroscopic images obtained in the OR without radiologist
present.
COMPARISON: Left wrist radiographs ___
FINDINGS:
The available images show a transverse fracture through the distal radius. A
volar fracture plate is positioned with near anatomic alignment. Please see
the operative report for further details.
IMPRESSION:
Intraoperative images from open reduction internal fixation of a distal radius
fracture.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Arm pain
Diagnosed with FX DISTAL RADIUS NEC-CL, FX OLECRAN PROC ULNA-CL, FALL ON STAIR/STEP NEC
temperature: 98.3
heartrate: 76.0
resprate: 20.0
o2sat: 96.0
sbp: 182.0
dbp: 68.0
level of pain: 6
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a displaced left distal radius fracture, non-displaced
distal ulna fracture and right comminuted proximal
ulna/olecranon fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for Open reduction internal fixation of left distal
radius fracture and open reduction internal fixation of right
proximal ulna/olecranon fracture with tension band construct,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to 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 non-weight bearing in bilateral
upper extremities, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ceftriaxone / azithromycin
Attending: ___.
Chief Complaint:
Pulled Foley catheter
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with AFib, iron deficiency anemia, ___ disease,
orthostatic hypotension, depression, dementia, BPH, and
neurogenic bladder/urinary retenion being transferred to ___
after pulling out chronic indwelling catheter. Regarding his
neurogenic bladder, he is followed by ___ Urology (Dr. ___
___, and has had a chronic indwelling catheter for 6 months,
complicated by multiple urinary tract infections. Per his
daughter, prior UTIs have been treated by changing his catheter,
sending UCx, and treated with antibiotics. Of note, he has
previously grown Enterococci and Proteus mirabalis from prior
urine cultures, treated with gentamicin, Imipenem, and most
recently amikacin.
Per ER note, over the last several days, the patient has
developed signs/symptoms of UTI (low-grade fevers to Tmax ___
yesterday, worsening mental status, and dirty urinary sediment).
The day prior to admission, he pulled out his catheter. At
___, patient has remained stable, most recent PVR
108 ~ 11am today, UA suggestive of UTI (+ nitrites, mod blood,
trace protein, large leukocyte esterate, microscopic analysis
pending). Upon admission to the ER, the patient was
hemodynamically stable and the Foley was replaced. R testicle is
red, swollen, and painful.
Of note, in the nursing home records, it is recorded that the
patient is in hospice care for his end stage Parkinsons. He also
is a DNR/DNI/DNH, the latter of which was temporarily reversed
prior to admission.
Initial vitals in ER: 97.5 65 104/57 18 99% RA. The patient had
an ultrasound of his scrotum which showed an abscess. The
patient was seen by urology consultants in the ER around 8:30
pm. They recommended elevating the scrotum, icing it, NSAIDs,
and drainage of the scrotal abscess by ___. They also recommended
broad spectrum antibiotics. The patinet did not receive
antibiotics in the ER. The UA was grossly positive and urine,
blood cultures were obtained. The patient has a leukocytosis to
13.4 with a left shift. Per ___ Micro --> ___ UCx
with 30,000 Enterococci sp. (S- Vanc, Tigacycline, Linezolid),
alpha strep; ___ UCx Proteus mirabalis (S only to amikacin),
and there is documentation in the patient's nursing home records
of receiving amikacin.
Vitals on transfer: 98.9 65 119/73 22 99% RA
Upon admission to the floor, the patient is sitting calmly in
bed. He is muttering to himself. He states his name but
otherwise is not interactive with the interview.
ROS: He directly denies chest pain, shortness of breath,
abdominal pain. He endorses scrotal pain and suprapubic pain.
Remainder of review of systems unable to obtain.
Past Medical History:
___ disease since ___
Atrial fibrillation - one episode ___ at ___
Orthostatic hypotension
BPH
neurogenic bladder
vitamin D deficiency
iron defic anemia
depression
bcc of skin
Social History:
___
Family History:
Mother died at ___; father at ___ with prostate cancer.
Physical Exam:
Admission exam:
Vitals- 98.7 129/59 78 16 99% RA
General- Alert, oriented to self, not oriented to location ___
___") doesn't answer year, no acute distress
HEENT- Sclera anicteric, DMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- limited exam due to poor cooperation but Clear to
auscultation bilaterally, no wheezes, rales, ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender except suprapubic tenderness,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU- foley in place. R testicle is tender (patient winces) and
erythematous, swollen
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, prominent trunnkal and limb rigidity with
cog-wheeling.
Discharge exam - unchanged from above, except as above:
General- A&Ox1 (name only)
GU- Foley in place, inproved redness and tenderness of testicle
Pertinent Results:
Admission exam:
___ 03:46PM BLOOD WBC-13.4*# RBC-3.95* Hgb-12.0* Hct-35.3*
MCV-89# MCH-30.3 MCHC-33.9 RDW-14.0 Plt ___
___ 06:00AM BLOOD ___ PTT-32.1 ___
___ 03:46PM BLOOD Glucose-123* UreaN-17 Creat-0.6 Na-138
K-4.1 Cl-102 HCO3-29 AnGap-11
___ 04:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:00PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
Discharge summary:
___ 06:00AM BLOOD WBC-9.5 RBC-3.76* Hgb-11.4* Hct-34.2*
MCV-91 MCH-30.2 MCHC-33.2 RDW-13.7 Plt ___
___ 06:00AM BLOOD Glucose-114* UreaN-12 Creat-0.6 Na-137
K-4.1 Cl-102 HCO3-30 AnGap-9
Imaging:
-Scrotal US (___):
1. Large (2.9 cm) heterogeneous extratesticular right scrotal
mass which is concerning for an abscess. Follow up ultrasound
after resolution of
symptomatology is recommended to exclude an underlying mass.
2. No testicular torsion.
-CXR (___): FINAL READ PENDING. Interval placement of right
sided PICC
Micro:
URINE CULTURE (Final ___:
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| PROTEUS MIRABILIS
| |
AMIKACIN-------------- 16 S <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S =>32 R
CEFAZOLIN------------- 16 R 8 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S =>4 R
GENTAMICIN------------ =>16 R 8 I
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ =>16 R 8 I
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Carbidopa-Levodopa (___) 1 TAB PO 5 TIMES DAILY
5. ClonazePAM 0.5 mg PO QHS
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Fleet Enema ___AILY:PRN constipation
9. melatonin 6 mg Oral qhs
10. Milk of Magnesia 30 mL PO PRN constipation
11. Senna 1 TAB PO HS
12. Tamsulosin 0.8 mg PO HS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Carbidopa-Levodopa (___) 1 TAB PO 5 TIMES DAILY
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Senna 1 TAB PO HS
8. Tamsulosin 0.8 mg PO HS
9. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
10. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 For PICC
insertion Duration: 1 Dose
11. Meropenem 500 mg IV Q6H
Last dose on ___
12. Vancomycin 1250 mg IV Q 12H
Last dose on ___
13. ClonazePAM 0.5 mg PO QHS
14. Fleet Enema ___AILY:PRN constipation
15. melatonin 6 mg Oral qhs
16. Milk of Magnesia 30 mL PO PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
scrotal abscess
urinary tract infection
Secondary diagnoses:
___ disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: mostly alert and sometimes appropriately
interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Neurogenic bladder/retention out painful and swollen from right
testicle. Question torsion or infection.
TECHNIQUE: Scrotal ultrasound.
COMPARISON: None.
FINDINGS: There is a heterogeneous mass within the right scrotum which has
mass effect upon the right testicle. This measures 2.9 x 2.9 x 3.2 cm and
shows a rim of hypervascularity. A complex, septated right hydrocele is also
present. There is marked scrotal skin thickening.
The right testis measures 2.3 x 2.7 x 1.6 cm and the left testis measures 4.8
x 1.6 x 2.6 cm. Both testes are normal in echotexture. Both show normal
flow, the evidence for testicular torsion. The epididymal heads are normal.
IMPRESSION:
1. Large (2.9 cm) heterogeneous extratesticular right scrotal mass which is
concerning for an abscess. Follow up ultrasound after resolution of
symptomatology is recommended to exclude an underlying mass.
2. No testicular torsion.
Radiology Report
HISTORY: Male with new right PICC line.
COMPARISON: Chest radiograph, ___. ___.
TECHNIQUE: Single frontal portable chest radiograph.
FINDINGS: Right PICC tip is in low SVC. Stable homogeneously calcified
density in the anterior fourth rib likely represents bone island. Lungs clear
bilaterally without pleural effusion or pneumothorax. Heart size, mediastinal
contour and hila are normal. No additional bony abnormality.
IMPRESSION: Right PICC tip is in low SVC.
Results were conveyed to IV PICC team on ___ by Dr. ___
___ within five minutes of results.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O UTI
Diagnosed with RETENTION URINE UNSPECIFIED, ORCHITIS WITH ABSCESS
temperature: 97.5
heartrate: 65.0
resprate: 18.0
o2sat: 99.0
sbp: 104.0
dbp: 57.0
level of pain: 13
level of acuity: 3.0 | ___ year old male with advanced Parkinsons and neurogenic
bladder/urinary retention with complicated UTI and scrotal
abscess.
# UTI: Patient with multiple prior highly resistant organisms
per records from his SNF. Currently, UCx sent at ___ shows ESBL
E. coli. UCx here shows multidrug resistant Proteus and
Kelbsiella (see results section for full sensitivities). He was
initially treated with amikacin and vancomycin given prior
culture sensitivities from his SNF. When all current culture
data returned, he was changed to vanc/meropenem which he will
continue for a total of 14 days. PICC line was placed prior to
discharge, this should be removed after antibiotic course is
complete.
# Scrotal Abscess: Noted to have an extratesticular scrotal
abscess on admission. Given his goals of care, invasive
intervention was deferred and we attempted conservative
treatment with antibiotics alone. His scrotal erythema,
induration and tenderness improved on discharge and he did not
require any drainage or surgical intervention. Urology was
consulted this admission and will see him after discharge.
--Chronic issues--
# Urinary retention: Admitted with a chronic Foley, continued
indwelling Foley and tamsulosin.
# ___ Disease: Continued on home carbidopa-levidopa. He
remained mostly A&Ox1 with notable rigidity and cog-wheeling on
exam
# A.fib: CHADS score 1 (age). Will continue rate control with
diltiazem. This is currently stable. Will also continue aspirin.
# Code: DNR/DNI, confirmed with HCP. Was formerly DNH prior to
admission.
# Emergency Contact/HCP: ___ ___
#Transitional issues:
-Will continue vancomycin and meropenem for 9 additional days
after discharge (to finish on ___
-Please check CBC, chem-7, vancomycin trough on ___ -
goal trough is ___
-Will follow-up with urology after discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Arm Pain
Major Surgical or Invasive Procedure:
Open Reduction with Internal Fixation of Left Both Bone Forearm
Fracture
History of Present Illness:
This is a ___ left handed female FOOSH from fall from horse
at 1pm this afternoon. No headstrike, no LOC, no other chief
complaints. She braced herself from the fall with her left arm
predominantly and noticed a significant deformity to her left
forearm and significant pain. No breaks in the skin. She was
seen
at ___ and had an apparent minor reduction and sugar tong splint
applied and patient transferred here for definitive operative
management. No tingling or numbness in arm. Pain well controlled
when immobilized.
Past Medical History:
hypothyroid, no prior surgeries
Social History:
___
Family History:
NC
Physical Exam:
D/C H&P:
Gen: A&O in NAD
LUE: compartments soft
dressing c/d/i
ain/pin/u intact
SILT r/m/u
cap refill < 2 sec
Pertinent Results:
FOREARM (AP & LAT) LEFT Clip # ___
Reason: s/p reduction
Final Report
INDICATION: ___ female with fracture status post
reduction.
COMPARISON: Radiograph dated ___ at 19:19 o'clock
FINDINGS: Two views of the left forearm demonstrate interval
partial
reduction of a complete transverse displaced mid shaft radial
and ulnar
fractures with a somewhat improved alignment as compared to the
original
reference exam, but no significant change since two hours ago.
The fractures
remain displaced, with the distal fragments radially displaced
with respect to
the proximal forearm, with overriding of approximately 1 cm.
IMPRESSION: Status post reduction without significant short
interval change
since preceding exam of complete transverse mid shaft radial and
ulnar
fractures with persistent displacement and mild overriding.
The study and the report were reviewed by the staff radiologist.
Medications on Admission:
levothyroxine, citalopram
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 4 weeks: Continue while taking narcotic pain
medication.
Disp:*60 Capsule(s)* Refills:*0*
3. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4)
hours as needed for Pain for 2 weeks: Do not drive or drink
alcohol while taking this medication.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Both Bone Forearm Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
SINGLE VIEW OF THE CHEST, ___, AT 19:33 HOURS.
HISTORY: Fracture.
COMPARISON: None.
FINDINGS: The lungs are well expanded and clear. The mediastinum is
unremarkable. The cardiac silhouette is within normal limits for size. No
effusion or pneumothorax is noted. The osseous structures are grossly
unremarkable.
IMPRESSION: No acute pulmonary process.
Radiology Report
LEFT FOREARM, TWO VIEWS; LEFT WRIST, TWO VIEWS; LEFT ELBOW, TWO VIEWS,
___ AT ___ HOURS
HISTORY: Radius and ulnar fracture, transferred from outside hospital with
closed reduction.
COMPARISON: Earlier same day from outside hospital.
FINDINGS: Underlying osseous detail is obscured by a fiberglass splint, which
is in place. Transverse fractures of both the radius and ulna are noted with
approximately one-half shaft with displacement and approximately 1 cm of
overlap resulting in slight foreshortening. Regional soft tissue swelling
around the fracture site is noted. The elbow and wrist joints are grossly
appropriately aligned. Please note there is limited evaluation distally of
the ulna and a dorsal dislocation cannot be entirely excluded. There is
question of ulnar positive variance.
IMPRESSION: Mid shaft radius and ulnar fractures with overlap and
foreshortening. Question possible distal ulnar dislocation.
Radiology Report
INDICATION: ___ female with fracture status post reduction.
COMPARISON: Radiograph dated ___ at 19:19 o'clock
FINDINGS: Two views of the left forearm demonstrate interval partial
reduction of a complete transverse displaced mid shaft radial and ulnar
fractures with a somewhat improved alignment as compared to the original
reference exam, but no significant change since two hours ago. The fractures
remain displaced, with the distal fragments radially displaced with respect to
the proximal forearm, with overriding of approximately 1 cm.
IMPRESSION: Status post reduction without significant short interval change
since preceding exam of complete transverse mid shaft radial and ulnar
fractures with persistent displacement and mild overriding.
Radiology Report
STUDY: Left forearm intraoperative study ___.
CLINICAL HISTORY: Patient with left forearm fracture. ORIF.
FINDINGS: Comparison is made to previous study from ___.
Multiple images of the forearm from the operating room demonstrate interval
placement of fracture plates and associated screws fixating a fracture
involving the mid shaft of the left radius and ulna. There is good anatomic
alignment and no signs of hardware-related complications. Please refer to the
operative note for additional details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL FROM HORSE, L ARM FRACTURE
Diagnosed with FX SHAFT RAD W ULNA-CLOS, RIDDEN ANIMAL ACC-RIDER, ACTIVITIES INVOLVING HORSEBACK RIDING
temperature: 97.9
heartrate: 88.0
resprate: 16.0
o2sat: 98.0
sbp: 129.0
dbp: 72.0
level of pain: 4
level of acuity: 3.0 | Ms. ___ was admitted to the Orthopedic service on ___
for left both bone forearm fracture after being evaluated and
treated with closed reduction in the emergency room. She
underwent open reduction internal fixation of the left arm
without complication on ___. She was extubated without
difficulty and transferred to the recovery room in stable
condition. In the early post-operative course Ms. ___ did
well and was transferred to the floor in stable condition.
On the night of surgery she did well.
She had adequate pain management and worked with ocupational
therapy while in the hospital. The remainder of her hospital
course was uneventful and Ms. ___ is being discharged to
home on ___ in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Biaxin / eggs
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Left heart catheterization and oronary angiography with stenting
of the circumflex and LAD ___
History of Present Illness:
Mr. ___ is a ___ M with H/O hypertension and hypothyroidism
who presented to ___ Urgent Care with chest pain and
was found to have elevated troponin-T and sent to ___ for
further management.
Patient reported 3 days of burning epigastic pain which worsened
on the day prior to admission. The pain was ___ in severity,
sharp, localized to the anterior chest, and radiating to the
shoulders. He had associated nausea, but no vomiting or
diaphoresis. The pain was worse at night but he didn't notice it
during activity. The chest pain continued until the morning so
he decided to go to ___ Urgent Care. He was found to have
positive troponin-T of 0.13 and was given 4 baby aspirins and
transferred to the ___. In the ED initial vitals were HR 72 BP
120/68 RR 18 SaO2 99% on RA. He had an unremarkable cardiac and
pulmonary physical exam. ECG showed regular sinus rhythm at a
rate of 77, PR 178 mm, QT 445 mm, prolonged QRS 159 mm with
findings of LBBB, STE of 3-4 mm in V1 through V4 and I, ST
depression < 3 mm in V4 through V6, discordance between QRS
complex and T wave (did not meet Scarbossa criteria).
Labs/studies notable for WBC 8.6 Hgb/Hct 15.6/46.4 platelets 345
Na 136 K 4.2 Cr 1.0 Troponin-T 0.13, 0.16. PTT 34.1 INR 1.1. CXR
showed no active disease. Patient was given
Heparin bolus and drip, atorvastatin 40 mg, and itroglycerin SL
0.3 mg. Vitals on transfer T 97.5 HR 66 BP 114/60 RR 18 SaO2
96% on RA.
After arrival to the cardiology ward, the patient denied any
further chest pain.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of dyspnea on
exertion, ankle edema, palpitations, syncope, or presyncope. He
also denied headache, nausea, vomiting, constipation, diarrhea,
or weakness.
Past Medical History:
-Hypertension
-Guaiac positive stools
-Hypothyroidism
-Nevi, multiple
-BPH
-Chronic sinusitis
-Sciatica
Social History:
___
Family History:
Mother: died, alcohol related diagnosis, liver/cirrhosis
Father: died, ? COPD
Siblings: none
Grandparents: no known DM or cancer
Children: son with mitral valve condition
Physical Exam:
On admission
GENERAL: ___ elderly white man in NAD. Oriented x3. Mood,
affect appropriate.
VS: T 98.3 BP 128/68 HR 72 RR 18 SaO2 95% on RA
Wt: 70.3 kg
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple no JVD. No cervical LAD. Nonpalpable thyroid.
CARDIAC: RR, normal S1, S2. No murmurs, rubs or gallops. No
thrills, lifts. No carotid bruits.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, not distended.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
At discharge
GENERAL: ___ elderly man in NAD. Oriented x3. Mood, affect
appropriate.
VS: T 98.6 BP 107-148/62-74 HR 61-70 RR ___ SaO2 94-100% on RA
Weight: 71.4 from 70.9
I/O: 8h 100/NR; since admission ___- 1500/NR
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthelasma.
CARDIAC: RR, normal S1, S2. No murmurs, rubs or 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, non-tender, not distended.
EXTREMITIES: Right radial access site with no hematoma. No
clubbing, cyanosis or edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
___ 12:10PM WBC-8.6 RBC-5.07 HGB-15.6 HCT-46.4 MCV-92#
MCH-30.8 MCHC-33.6 RDW-12.9 RDWSD-42.6
___ 12:10PM NEUTS-64.0 ___ MONOS-8.1 EOS-0.8*
BASOS-0.5 IM ___ AbsNeut-5.53 AbsLymp-2.27 AbsMono-0.70
AbsEos-0.07 AbsBaso-0.04
___ 12:10PM PLT COUNT-345
___ 01:30PM ___ PTT-34.1 ___
___ 12:10PM GLUCOSE-104* UREA N-11 CREAT-1.0 SODIUM-136
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16
___ 02:25PM CALCIUM-8.5
___ 12:10PM cTropnT-0.13*
___ 01:30PM cTropnT-0.16*
___ 09:15PM CK-MB-48* cTropnT-0.70*
___ 06:45AM CK-MB-32* cTropnT-1.18*
___ 07:19PM CK-MB-18* MB Indx-9.8* cTropnT-1.78*
___ 06:30AM cTropnT-1.04*
ECG ___ 11:46:26 AM
Sinus rhythm. Left bundle-branch block. Non-specific notching in
the T waves in the right precordial leads. Prolonged computed
QTc interval. No previous tracing available for comparison.
CXR ___
The lungs remain clear. The heart and mediastinal structures are
unremarkable. The bony thorax is grossly intact.
IMPRESSION: No active disease.
Cardiac catheterization and coronary angiography ___
Hemodynamics
State: Baseline
LV 97/4 HR 65
AO 99/56/72 HR 66
Coronary Anatomy
Dominance: Left
-Left main normal
-LAD mild disease proximally, 80% small Diag, 99%
distal-->stented-->10%
residual (DES)
-LCX: OM with 99% proximal stenosis-->stented-->0% residual
(DES)
RCA small
Echocardiogram ___
Left Ventricle - Ejection Fraction: 35% to 40%
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild to moderate
regional left ventricular systolic dysfunction with hypokinesis
of the septum, inferior, and inferolateral segments and true
apex; the anterior and anterolateral segments contract
best..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) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mildly to moderately depressed left ventricular
systolic dysfunction consistent with multivessel coronary artery
disease. Abnormal septal motion consistent with LBBB. No
clinically significant valvular regurgitation or stenosis.
Normal pulmonary artery systolic pressure.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
CLINICAL HISTORY History: ___ with CPx 3days with worsening over last 48
hours, radiating to bilateral shoulder and arms, nausea // CP radiating to
bilateral shoulders, arms CP radiating to bilateral shoulders, arms
COMPARISON: ___
FINDINGS:
The lungs remain clear. The heart and mediastinal structures are
unremarkable. The bony thorax is grossly intact.
IMPRESSION:
No active disease.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Elevated troponin
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 98.3
heartrate: 77.0
resprate: 14.0
o2sat: 95.0
sbp: 133.0
dbp: 65.0
level of pain: 1
level of acuity: 2.0 | ___ M with H/O hypertension and hypothyroidism who presented with
chest pain. He had non specific ECG changes and elevated
troponin-T consistent with a NSTEMI.
#NSTEMI: Patient was found to have elevated troponins with no
specific ECG changes (known prior LBBB) in the setting of new
chest pain, concerning for NSTEMI. He was initiated on medical
therapy consisting of aspirin, atorvastatin, metoprolol,
atorvastatin, and heparin drip. CK-MB peaked at 48 ___.
Cardiac catheterization on ___ showed LVEDP 4 with subtotal
occlusions of the distal LAD and OM1, both treated with a single
DES. A small diagonal was also 80% diseased. He was started on
clopidigrel. Echocardiogram showed LVEF of 35-40%. He was
started on lisinopril for the newly diagnosed left ventricular
systolic heart failure (without diastolic or clinical evidence
of symptomatic heart failure) and amlodipine was discontinued
because SBPs were in the 110's. He was referred to outpatient
cardiac rehabilitation.
# Hypertension: He was started on lisinopril for afterload
reduction in the setting of LV systolic dysfunction, and
amlodipine was discontinued because SBPs were in the 110's.
# Hypothyroidism: He was continued on home levothyroxine 50 mcg.
***TRANSITIONAL ISSUES:***
- Continue clopidogrel for at least 12 months, and aspirin
indefinitely, to prevent stent thrombosis
- Patient was started on lisinopril ___. Please check Cr, K
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___: exercise stress test
___: regadenoson stress test
History of Present Illness:
Patient is a ___ with history of traumatic thoracic stab wound
(R) c/b pneumothorax and GERD who presents with chronic,
intermittent left-sided chest pain.
Patient describes intermittent, non-exertional chest pain for
the
past ___. The discomfort is left-sided, ___ in severity
(sometimes up to ___, stabbing in quality, and lasting on the
order of ___. There is no associated nausea,
dizziness/lightheadedness or palpitations. Patient does endorse
mild SOB and increased pain when taking a deep breath. No
vision
changes or syncopal episodes. Patient says that he recently was
evaluated by his PCP who recommended that he present to the ED
for evaluation.
In the ED, initial vitals: 96.9 84 151/83 16 100% RA
- Exam notable for
Regular rate and rhythm no murmurs rubs or gallops
Clear to auscultation bilaterally
2+ radial pulse and dorsalis pedis
- Labs were notable for:
CBC 6.6>13.7/42.5<294
BMP ___
HbA1C 4.5%
Troponin-T <.01 x2
TSH 1.6
Total cholesterol 257
- Studies:
ECG NSR (67bpm), normal axis, normal intervals, isolated TWI
III,
submm STE V2-3.
CXR ___
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or
pneumothorax. Changes noted at the distal right clavicle,
potentially from remote prior injury. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process, no pneumothorax.
STRESS ___
INTERPRETATION: This ___ year old man with a h/o HLD was referred
to the lab for evaluation of atypical chest and shortness of
breath. The patient exercised for 3.0 minutes ___ protocol
and the test was stopped for a hypertensive systolic blood
pressure repsonse to exercise.
There were no chest, neck, arm or back discomforts reported by
the patient throughout the study, however at peak exercise the
patient reported inappropriate shortness of breath, which
improved with rest during recovery. There were no significant ST
segment changes seen during exercise or in recovery. The rhythm
was sinus without ectopy; two P wave morphologies noted. Resting
systolic hypertension with a markedly hypertensive systolic
blood
pressure response to exercise. Appropriate heart rate response
to
low workload.
IMPRESSION: Atypical type symptoms in the absence of ischemic
EKG
changes and presence of markedly hypertensive systolic blood
pressure response to low workload.
- Patient was given: NOTHING
- Vitals prior to transfer were: 98.8 75 137/80 23 98% RA
On arrival to the floor, patient recounts the history as above.
The last time he experienced any chest discomfort was yesterday.
He says that he became 'so short of breath' during the stress
test, but did not experience any chest pain. Of note, patient
was stabbed on the right side of his back (superior), causing a
PTX. He was also hit by a car door some time ago, an impressive
impact. Patient was recently restarted on an H2 blocker for
reflux symptoms.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative less otherwise noted in the HPI.
Past Medical History:
GERD
Traumatic PTX
Social History:
___
Family History:
Sister with T2DM (___)
Mother with T2DM (___)
Multiple uncles, grandmother with T2DM
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 98.3 156/96 75 20 97 Ra
GENERAL: Pleasant, lying in bed comfortably.
HEENT: PERRL, no scleral icterus. OP clear with MMM.
CARDIAC: Soft s1. Regular rate and rhythm, no murmurs, rubs, or
gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema.
PULSES: 2+ radial pulses, 2+ DP pulses.
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact.
DISCHARGE PHYSICAL EXAM
========================
VS: Temp: 98.5 PO BP: 143/86 HR: 67 RR: 18 O2 sat: 96% O2
delivery: RA
GENERAL: No acute distress, pleasant and conversant
HEENT: PERRL, no scleral icterus. OP clear with MMM.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops.
LUNG: 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 cyanosis, clubbing, or edema
PULSES: 2+ radial pulses, 2+ DP pulses.
NEURO: AAOx2, CN II-XII intact, motor and sensory function
grossly intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
================
___ 06:00PM BLOOD Neuts-61.2 ___ Monos-7.3 Eos-1.1
Baso-0.5 Im ___ AbsNeut-4.02 AbsLymp-1.95 AbsMono-0.48
AbsEos-0.07 AbsBaso-0.03
___ 06:00PM BLOOD WBC-6.6 RBC-4.68 Hgb-13.7 Hct-42.5 MCV-91
MCH-29.3 MCHC-32.2 RDW-13.6 RDWSD-44.7 Plt ___
___ 06:00PM BLOOD Plt ___
___ 06:00PM BLOOD Glucose-88 UreaN-10 Creat-1.0 Na-142
K-4.5 Cl-104 HCO3-24 AnGap-14
___ 06:00PM BLOOD Cholest-257*
___ 06:00PM BLOOD %HbA1c-4.5 eAG-82
___ 06:00PM BLOOD TSH-1.6
DISCHARGE LABS
===============
___ 06:05AM BLOOD WBC-6.6 RBC-4.74 Hgb-13.8 Hct-42.5 MCV-90
MCH-29.1 MCHC-32.5 RDW-13.2 RDWSD-43.4 Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD ___ PTT-37.0* ___
___ 06:05AM BLOOD Glucose-90 UreaN-13 Creat-1.0 Na-140
K-4.4 Cl-101 HCO3-25 AnGap-14
___ 06:05AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.3
STUDIES
========
EXERCISE STRESS ___
ERPRETATION: This ___ year old man with a h/o HLD was referred to
the lab for evaluation of atypical chest and shortness of
breath. The
patient exercised for 3.0 minutes ___ protocol and the test
was
stopped for a hypertensive systolic blood pressure repsonse to
exercise.
There were no chest, neck, arm or back discomforts reported by
the
patient throughout the study, however at peak exercise the
patient
reported inappropriate shortness of breath, which improved with
rest
during recovery. There were no significant ST segment changes
seen
during exercise or in recovery. The rhythm was sinus without
ectopy; two
P wave morphologies noted. Resting systolic hypertension with a
markedly
hypertensive systolic blood pressure response to exercise.
Appropriate
heart rate response to low workload.
IMPRESSION: Atypical type symptoms in the absence of ischemic
EKG
changes and presence of markedly hypertensive systolic blood
pressure
response to low workload.
REGADENOSON STRESS ___
INTERPRETATION: This ___ year old man was referred to the lab for
evaluation of chest discomfort. He was infused with 0.4 mg of
regadenoson over 20 seconds. No chest, arm, neck or back
discomfort
reported. No significant ST segment changes noticed. Rhythm was
sinus
with no ectopy. Appropriate hemodyanmic response to the infusion
with
systolic hypertensive response noticed in recovery.
IMPRESSION : No anginal symptoms or ST segment changens. Nuclear
report
sent separately.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO BID
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 (One) tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
2. Ranitidine 150 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
#Chest pain
#Hypertension
#GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cp// pneumothorax, intrathoracic process
TECHNIQUE: PA and lateral views the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or pneumothorax.
Changes noted at the distal right clavicle, potentially from remote prior
injury. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process, no pneumothorax.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 96.9
heartrate: 84.0
resprate: 16.0
o2sat: 100.0
sbp: 151.0
dbp: 83.0
level of pain: 4
level of acuity: 2.0 | SUMMARY STATEMENT
==================
Mr. ___ is a ___ year old man with a past medical history of
right-sided traumatic thoracic stab wound complicated by
pneumothorax and GERD who presents with chronic, intermittent
left-sided chest pain. He was unable to complete an exercise
stress test in the emergency department due to extreme shortness
of breath and was admitted for further workup. Problems
addressed during his hospitalization are as follows:
#Chest pain:
Low suspicion for cardiac etiology. His symptoms are
non-exertional, troponins negative x2, no EKG ischemic changes.
Exercise stress test with no ischemic EKG changes, although was
terminated early due to shortness of breath and blood pressure
of 258/96. Regadenoson stress test with no anginal symptoms or
ST segment changes. Nuclear prelim read unremarkable.
Additionally, he has no family history of early MI, A1c was
4.5%. Smokes marijuana daily, but no tobacco. The etiology of
his chest pain may be musculoskeletal or gastrointestinal
(esophageal spasm). The morning of discharge, he had one
transient episode of dizziness and palpitations with standing
that resolved spontaneously, orthostatics vitals were negative.
#Hypertension:
On review of ___ records, has been hypertensive chronically,
on no agents prior to presentation. In-house his BP ranged from
140-160s/70-90s, and his blood pressure notably rose to 258/90
during his exercise stress test as above. Initiated lisinopril
10 mg daily.
#GERD
Continued home ranitidine |
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:
lumbar puncture
History of Present Illness:
___ with no known past medical history who presents
acutely altered with hyper-religiosity, febrile found to have
unremarkable LP, pneumomediastinum most concerning for new onset
schizophrenia vs anti-NMDA encephalitis.
Reportedly, her friend called the police due to bizarre
behavior. On her presentation, several providers documented
strange behavior. She was originally stating "I am in love
___. I am pregnant with his baby. I used to worship
the devil." She was noted to have episodes of screaming,
aggressive behavior, spitting at her parents who were at the
bedside. She did said "I'm having PTSD from a demonic
possession, it happened last night, the demonic possession is
trying to control me right now". Later the patient described
going to an exorcism at her friend ___ house. She has
been hearing voices for several weeks "since going back to
Church, ___ and ___ have been giving me advice on how to avoid
the devil who is mocking me." The voices do not refer to her in
the third person, she does not hear her thoughts outside her
head, no one can hear her thoughts outside her head. Initially,
the patient was refusing medical intervention, with intermittent
agitation, characterized by quenching teeth, mild tremors, with
visions of God and the devil.
Parents were at the bedside, and report that this is very
abnormal behavior. The patient was traveling to ___ alone
from ___ for a wedding. She called her mom from ___
reporting that she was lost and could not find her car or
wallet. Subsequently, the police helped her call a friend in
___ and she went home with them. She was very confused,
agitated, and aggressive at her friend's house, so the police
and 911 was ultimately called.
She denies any history of psychiatric illness. She denies any
substance use. ___ search including all other available
states was negative. She denies any abdominal pain, back pain,
urinary symptoms, rashes (other than occasional nighttime anal
pruritus), or paresthesias.
In the ED initial vital signs were 101 82 127/76 16 100% on RA.
Labs were notable for CBC with WBC of 18, and 80% neutrophils,
BMP with BUN/CR of ___, anion gap of 20, CK of 399, troponin
of 0.03. LFTs WNL. Serum tox negative. Urine tox negative.
She underwent LP which showed 1 WBC, protein 46, glucose 82.
Given her presentation and concern for meningitis or
encephalitis, she was started empirically on vancomycin,
ceftriaxone, acyclovir.
Due to the presence of pneumomediastinum, she underwent CT head
without contrast which showed upper cervical prevertebral
emphysema without acute intracranial process. CT C-spine
subsequently showed extensive pneumomediastinum extending
superiorly along the retropharyngeal spaces with some narrow
pharyngeal communication of uncertain etiology. CT chest without
contrast showed extensive pneumomediastinum, with some extension
into the pericardial space and bilateral hila. Of note, it also
showed a 3.3Ã-4.8 left lateral subpectoral ___, for which CT or
MRI with contrast is recommended.
Thoracic surgery was consulted regarding pneumomediastinum, an
upper GI performed and reviewed with no evidence of esophageal
perforation. Given leukocytosis, evidence of retropharyngeal air
and fever, should also rule out retropharyngeal soft tissue
infection or abscess.
ENT was consulted and confirmed no RP abscess or collection on
CT.
Cardiology was consulted given pneumoediastinum with small
extension into the pericardial space and bilateral hila. A STAT
echo was not performed.
She received IV Ativan 2 mg Ã-2, PO haldol, IV ceftriaxone 2 g
Ã-2, IV Vancomycin 1500 mg Ã-1, IV acyclovir 800 mg, 1 L NS.
Upon arrival to the floor, the patient confirms the story above.
Past Medical History:
None
Social History:
___
Family History:
No history of psychiatric, neurologic, or autoimmune disorders.
Her aunt has uterine cancer. Otherwise no known
diseases/disorders.
Physical Exam:
ADMISSION EXAM:
VS: ___ 0149 Temp: 98.9 PO BP: 118/73 HR: 86 RR: 16 O2
sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: NAD
___: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, CN2-12 intact, motor ___ upper and lower
extremity, no pronator drift, 3 word recall intact at five
minutes
PSYCH: appropriate, calm, full affect, reactive to examiner and
content, +auditory hallucinations (as above), no visual
hallucinations, no suicidal ideation nor homicidal ideation
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS: ___ 1610 Temp: 97.8 PO BP: 116/78 Sitting HR: 67 RR: 16
O2 sat: 100% O2 delivery: Ra
GENERAL: Young woman sitting calmly in chair, conversing with
her friend.
___: NC/AT. No icterus or injection. MMM.
NECK: Supple
CV: RRR, no murmurs.
RESP: Normal work of breathing.
ABD: Soft, NDNT.
EXTR: No c/c/e.
NEURO: Alert, oriented, attentive. Normal strength,
coordination, and gait.
PSYCH: Mood and affect neutral. Cooperative attitude. Normal
speech. Linear thought process. +Auditory hallucinations with
religious content. No SI or HI.
Pertinent Results:
ADMISSION LABS:
=========================
___ 03:50AM BLOOD WBC-18.0* RBC-4.01 Hgb-12.3 Hct-36.6
MCV-91 MCH-30.7 MCHC-33.6 RDW-12.0 RDWSD-40.4 Plt ___
___ 03:50AM BLOOD Neuts-79.8* Lymphs-5.9* Monos-13.5*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-14.39* AbsLymp-1.07*
AbsMono-2.43* AbsEos-0.00* AbsBaso-0.03
___ 03:50AM BLOOD Glucose-195* UreaN-31* Creat-1.4* Na-138
K-4.0 Cl-100 HCO3-18* AnGap-20*
___ 03:50AM BLOOD ALT-7 AST-25 CK(CPK)-399* AlkPhos-54
TotBili-1.2
___ 03:50AM BLOOD cTropnT-0.03*
___ 11:50PM BLOOD cTropnT-<0.01
___ 03:50AM BLOOD Albumin-4.6 Calcium-9.9 Phos-3.9 Mg-2.0
___ 11:50PM BLOOD Osmolal-282
___ 11:50PM BLOOD TSH-1.3
___ 03:50AM BLOOD HCG-<5
___ 03:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:12AM BLOOD CRP-11.4*
___ 06:12AM BLOOD HIV Ab-NEG
___ 12:04AM BLOOD ___ pO2-43* pCO2-40 pH-7.37
calTCO2-24 Base XS--1
___ 12:04AM BLOOD Lactate-2.0
___ 05:39AM BLOOD TotProt-6.1* Albumin-4.0 Globuln-2.1
___ 05:39AM BLOOD ___
___ 10:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:10PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:10PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-2
___ 10:10PM URINE CastHy-10*
___ 10:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 10:10PM URINE UCG-NEGATIVE
___ 11:28AM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-1 Polys-0
___ Macroph-11
___ 11:28AM CEREBROSPINAL FLUID (CSF) TotProt-46*
Glucose-82
PERTINENT INTERVAL LABS:
==============================
___ 04:52PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR- negative
___ 01:40AM CEREBROSPINAL FLUID (CSF) NMDA RECEPTOR AB,
CSF- negative
DISCHARGE LABS:
==============================
___ 05:15AM BLOOD WBC-6.3 RBC-3.67* Hgb-11.2 Hct-33.9*
MCV-92 MCH-30.5 MCHC-33.0 RDW-11.9 RDWSD-40.3 Plt ___
___ 05:15AM BLOOD Glucose-89 UreaN-9 Creat-0.7 Na-141 K-4.4
Cl-104 HCO3-27 AnGap-10
PENDING LABS:
==============================
___ 04:52PM CEREBROSPINAL FLUID (CSF) ENCEPHALOPATHY,
AUTOIMMUNE EVALUATION, SPINAL FLUID- pending
___ 12:20PM BLOOD HVY MTL (WHLE BLD NVY/EDTA)- pending
___ 05:39AM BLOOD NMDA RECEPTOR ANTIBODY- pending
___ 05:39AM BLOOD NEURONAL NUCLEAR (___) ANTIBODIES- pending
MICROBIOLOGY:
==============================
__________________________________________________________
___ 6:12 am SEROLOGY/BLOOD
**FINAL REPORT ___
RPR w/check for Prozone (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
__________________________________________________________
___ 10:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 11:28 am CSF;SPINAL FLUID TUBE 3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:15 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING & STUDIES:
=============================
___ CT HEAD W/O Contrast:
1. Upper cervical prevertebral emphysema for which correlation
with
clinical/surgical/dental history is recommended. Also consider
CT cervical
spine and CT chest to evaluate for source of prevertebral air.
2. No acute intracranial process.
___ CT C spine W/O contrast:
Extensive pneumomediastinum extending superiorly along the
retropharyngeal
spaces with some nasopharyngeal communication, of uncertain
etiology
___ CT Chest W/O contrast:
1. Extensive pneumomediastinum extending superiorly along the
retropharyngealspace, unknown etiology. Please see separate CT
cervical spine report forfurther details of superior extension.
2. Small extension new mediastinum into the pericardial space
and bilateralhila.
3. 3.3 x 4.8 cm left lateral subpectoral ___. CT or MRI with
contrast isrecommended.
4. No acute pulmonary intraparenchymal process.
___ Barium Esophagram:
No evidence of esophageal perforation.
Ct Neck W/Contrast:
1. Redemonstration of extensive retropharyngeal and
parapharyngeal air,communicating with pneumomediastinum and foci
pneumopericardium, grossly unchanged compared to same day CT
neck and chest.
2. No fluid collection is identified within the neck.
___ Transthoracic Echo Report
Normal biventricular cavity sizes, regional/global systolic
function. No valvular pathology or pathologic flow identified.
Borderline elevated estimated pulmonary artery systolic
pressure. No pneumopericardium.
___ CT ABD & PELVIS WITH CONTRAST
No CT evidence of primary or metastatic malignancy within the
abdomen or
pelvis.
Incidental note made of appendicolith. No evidence of
appendicitis
___ PELVIS U.S. TRANSVAGIN
Normal pelvic ultrasound, with normal appearance of the ovaries
and uterus.
CONTINUOUS VIDEO EEG
IMPRESSION: This is a normal continuous ICU EEG monitoring
study. The patient transitions from wakefulness to sleep
without additional findings. There is diffuse low voltage beta
activity, which is a non-specific finding but may be seen with
medications such as benzodiazepines or barbiturates. There is no
focal slowing, epileptiform discharges or electrographic
seizures.
Medications on Admission:
None
Discharge Medications:
Olanzapine 5 mg PO QHS
Olanazpine 2.5mg BID PRN anxiety, agitation, insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
# Psychotic disorder, not otherwise specified
# Fever and leukocytosis (unclear etiology)
# Pneumomediastinum
# C4 vertebral lesion
# Left chest wall ___
# Acute renal failure
SECONDARY DIAGNOSES:
# Right thyroid nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with AMS and fever// eval for ICH or mass
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: None.
FINDINGS:
Study is degraded by motion and limited by patient positioning. Within these
confines:
The imaged portion of the upper C1 and C2 cervical spine demonstrates abnormal
air within the prevertebral space (3:1).
There is no evidence of acute large territorial infarction,hemorrhage,edema,
or mass. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are preserved. Left posterior ethmoid air cell probable osteoma is
noted. Left maxillary sinus mucosal thickening is present. Soft tissue
density is noted within the left external auditory canal, which may represent
cerumen.
IMPRESSION:
1. Study is degraded by motion and limited by patient positioning.
2. Upper cervical prevertebral emphysema for which correlation with
clinical/surgical/dental history is recommended. Also consider CT cervical
spine and CT chest to evaluate for source of prevertebral air.
3. Within limits of study, no evidence acute intracranial abnormality.
4. Paranasal sinus disease , as described.
RECOMMENDATION(S): CT chest and cervical spine is recommended.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:06 am, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with AMS but now normalized with sore throat but no
dental procedure// eval for pre-vertebral air eval for pre-vertebral air
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 23.8 cm; CTDIvol = 22.8 mGy (Body) DLP = 542.4
mGy-cm.
Total DLP (Body) = 542 mGy-cm.
COMPARISON: None.
FINDINGS:
Dental amalgam streak artifact limits study.
Alignment is preserved.No fractures are identified. Vertebral body heights
preserved. C4 vertebral body approximately 4 mm posterior vertebral body
well-defined lucency with suggested sclerotic margin and without definite
evidence of associated soft tissue mass or cortical destruction is seen (see
03:35; 02:35; 601:39; 602:35). Limited imaging of thoracic spine demonstrates
T1 vertebral body probable bone island.
There is no evidence of bony spinal canal or neural foraminal stenosis. There
is no prevertebral soft tissue swelling.
OTHER:
There is extensive pneumomediastinum extending superiorly along the
retropharyngeal spaces and with some communication with the nasopharynx, of
uncertain etiology.
Limited imaging the sinuses demonstrate left maxillary sinus probable mucous
retention cyst. Approximately 2 mm right thyroid lobe nodule is noted (see
03:51).
An approximately 1.1 cm left level IIa lymph node is seen (see 03:28).
Additional scattered subcentimeter nonspecific lymph nodes are noted
throughout the neck bilaterally, without definite enlargement by CT size
criteria.
IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. Extensive pneumomediastinum extending superiorly along the retropharyngeal
spaces with some nasopharyngeal communication.
3. Left level IIa enlarged lymph node. Additional subcentimeter nonspecific
scattered lymph nodes throughout the neck as described.
4. Well-circumscribed approximately 4 mm C4 vertebral body lucent lesion as
described. Differential considerations include enchondroma, giant cell tumor,
low-grade chondrosarcoma, and brown tumor, with metastatic disease or myeloma
less likely. If concern for neoplastic etiology, consider bone scan for
further evaluation.
5. Approximately 2 mm right thyroid lobe nodule. Please see recommendation
below.
6. Please see concurrently obtained chest CT for description of thoracic
structures.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
NOTIFICATION: The wet read findings were discussed with ___, M.D. By
___, M.D. on the telephone on ___ at 2:55 pm, 2 minutes
after discovery of the findings.
Radiology Report
INDICATION: History: ___ with AMS but now normalized with sore throat but no
dental procedure// eval for pre-vertebral air
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: CT head from same day ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. There is a
small amount of pericardial gas around the main pulmonary artery and right
ventricle (4:83, 91). The heart and great vessels are otherwise within normal
limits based on an unenhanced scan. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There is extensive pneumomediastinum, centered
within the posterior mediastinum, with extension into the pericardium
surrounding the main pulmonary artery and into the bilateral hila. There is
superior extension along the retropharyngeal space (see separate CT C-spine
report). No axillary or mediastinal lymphadenopathy is present. No
mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Bilateral subcentimeter subpleural densities likely represents
subsegmental atelectasis. Otherwise, lungs are clear without masses or areas
of parenchymal opacification. The airways are patent to the level of the
segmental bronchi bilaterally.
SOFT TISSUES: There is a 3.3 x 4.8 x 4.3 cm left lateral subpectoral chest
wall mass which appears to have mass effect on the underlying pleura and the
overlying pectoralis musculature (4:105, 601:48).
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the unenhanced upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Extensive pneumomediastinum extending superiorly along the retropharyngeal
space, unknown etiology. Please see separate CT cervical spine report for
further details of superior extension.
2. Small extension pneumo mediastinum into the pericardial space and bilateral
hila.
3. 3.3 x 4.8 cm left lateral subpectoral mass. CT or MRI with contrast is
recommended.
4. No acute pulmonary intraparenchymal process.
RECOMMENDATION(S): CT or MRI with contrast is recommended, which may be on a
nonemergent basis, for further evaluation of left chest wall mass.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:07 pm, 5 minutes after
discovery of the findings.
Amendment to initial read were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:28 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old woman with subq emphysema// upper GI study with
gastrograffin followed by thin barium to rule out esophageal perforation
TECHNIQUE: Barium esophagram.
DOSE: Accum DAP: 13 uGym2; Fluoro time: 25 seconds
COMPARISON: Chest CT ___.
FINDINGS:
The esophagus was not dilated. There was no stricture within the esophagus.
There was no esophageal mass. The esophageal mucosa appear normal.
The primary peristaltic wave was normal, with contrast passing readily into
the stomach. The lower esophageal sphincter opened and closed normally.
IMPRESSION:
No evidence of esophageal perforation.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST
INDICATION: Neck pain, known pneumomediastinum.
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Total DLP (Body) = 300 mGy-cm.
COMPARISON: Same day CT chest and CT C-spine. Same day esophagram.
FINDINGS:
Again seen is extensive retropharyngeal and parapharyngeal air extending down
into the mediastinum, similar in extent compared to same day CT neck and
chest. No rim enhancing fluid collection in the neck is identified.
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect.
The salivary glands enhance normally and are without mass or adjacent fat
stranding.0.5 cm right thyroid lobe nodule is again noted. Otherwise the
thyroid is unremarkable.Again seen is a 2.6 cm left level 2A lymph node
measured in long axis.The neck vessels are patent.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions.
IMPRESSION:
1. Redemonstration of extensive retropharyngeal and parapharyngeal air,
communicating with pneumomediastinum, grossly unchanged compared to same day
CT neck and chest. Findings most likely reflects small airways injury.
2. No fluid collection is identified within the neck.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old, unremarkable past medical history presents with
altered mental status, s/p negative LP, chest CT demonstrating anterior chest
wall mass, and pneumoperitoneum. C/f new onset schizophrenia vs anti-nmda
encephalitis.// temporal lobe changes?
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ noncontrast head CT.
FINDINGS:
Study is moderately degraded by motion. Within these confines:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are grossly preserved in caliber and
configuration.
The major intracranial arterial flow voids are preserved. There is mild
mucosal thickening in the ethmoid and left maxillary sinuses. Minimal
nonspecific left mastoid fluid is noted. The intraorbital contents are
preserved.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Within the limits of this motion degraded noncontrast examination, no
definite evidence of acute infarction, intracranial hemorrhage, or mass
lesion.
3. Paranasal sinus disease and nonspecific left mastoid fluid, as described.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with left lateral subpectoral mass, altered
mental status.// malignancy? abscess?
TECHNIQUE: Contrasted CT chest
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 37.2 cm; CTDIvol = 12.0 mGy (Body) DLP = 447.6
mGy-cm.
Total DLP (Body) = 448 mGy-cm.
COMPARISON: Prior non contrasted CT chest done ___
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: No suspicious thyroid lesions.
Subcutaneous emphysema seen in the lower neck is at improved compared to
prior. Ovoid well-circumscribed left chest wall mass in the left fourth
intercostal space measuring 49 x 32 mm in the axial plane enhances from 1
Hounsfield unit to 18 Hounsfield units postcontrast. It mild remodels the
adjacent left fourth and fifth ribs.
UPPER ABDOMEN: No pathology.
MEDIASTINUM: Pneumo mediastinum is slightly improved compared to prior.
HILA: No hilar adenopathy.
HEART and PERICARDIUM: No cardiomegaly.
PLEURA: No pleural effusion.
LUNG:
1. PARENCHYMA: No suspicious pulmonary nodules or masses.
2. AIRWAYS: The airways are patent to the subsegmental level.
3. VESSELS: The pulmonary arteries not enlarged.
CHEST CAGE: No suspicious bony lesions.
IMPRESSION:
Well-circumscribed left chest wall soft tissue mass demonstrates mild
enhancement. It mildly remodels the adjacent ribs. Findings are nonspecific
but are suggestive of a nerve sheath tumor.
Idiopathic pneumomediastinum with air extension into the lower neck is
slightly improved compared to prior.
RECOMMENDATION(S): MRI to confirm nerve sheath tumor
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with new onset psychosis, concern for
paraneoplastic syndrome related encephalopathy// Concern for intra-abdominal
mass, ovarian mass
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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
4) Stationary Acquisition 9.5 s, 1.0 cm; CTDIvol = 22.0 mGy (Body) DLP =
22.0 mGy-cm.
5) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
6) Stationary Acquisition 9.5 s, 1.0 cm; CTDIvol = 22.0 mGy (Body) DLP =
22.0 mGy-cm.
7) Spiral Acquisition 14.7 s, 50.6 cm; CTDIvol = 13.7 mGy (Body) DLP = 673.8
mGy-cm.
Total DLP (Body) = 790 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. 11 mm calcification within the appendix is
compatible with an appendicolith. The appendix is otherwise normal without
inflammatory change.
PELVIS: The urinary bladder and distal ureters are unremarkable. Trace free
fluid in the pelvis which is likely physiologic.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No CT evidence of primary or metastatic malignancy within the abdomen or
pelvis.
Incidental note made of appendicolith. No evidence of appendicitis
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with acute encephalopathy concerning for
paraneoplastic syndrome// eval for ovarian or other gynecologic tumor
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: .
FINDINGS:
The uterus is anteverted and measures 8.2 x 3.3 x 4.7 cm. The endometrium is
homogenous and measures 7 mm, within normal limits for age.
The ovaries are normal. There is trace free fluid, within physiologic limits.
IMPRESSION:
Normal pelvic ultrasound, with normal appearance of the ovaries and uterus.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hallucinations
Diagnosed with Altered mental status, unspecified, Hallucinations, unspecified, Interstitial emphysema, Chest pain, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 2.0 | BRIEF SUMMARY
======================
Ms. ___ is a ___ woman with no past medical or
psychiatric history, admitted for new onset psychotic symptoms
and fever. Workup was not consistent with infectious,
autoimmune, paraneoplastic, or epileptic etiologies. Medicine,
Neurology, and Psychiatry teams ultimately agreed that a primary
psychiatric disorder was most likely and patient was discharged
to ___ Psychiatry floor for further evaluation and
treatment.
ACTIVE ISSUES
=======================
# New onset psychotic symptoms:
The patient was brought to the ED by police after developing
hyper-religious, persecutory delusions, auditory hallucinations,
and markedly disorganized behavior.
A primary psychiatric disorder was ultimately decided to be the
most likely etiology given the patient's age, backdrop of
depression and functional decline over several years, and
extensive negative workup as follows.
There was initial concern for a possible infectious, autoimmune,
or paraneoplastic etiology given the patient's fever and
leukocytosis on presentation. However, LP and MRI were bland,
all infectious testing was negative (blood/urine/CSF cultures,
HIV, RPR, CSF HSV PCR), and fever/leukocytosis resolved (see
below). Empiric broad-spectrum antibiotics and IV acyclovir were
started immediately on presentation but were sequentially
discontinued when studies above returned negative. CT torso and
transvaginal ultrasound were negative for malignancy, making
paraneoplastic syndrome unlikely. EEG was negative for
epileptiform discharges, ruling out temporal lobe epilepsy.
Toxicology screen was negative. Autoimmune and paraneoplastic
panels were still pending on discharge but these were felt to be
unlikely given above. Patient was started on olanzapine and
transferred to ___ inpatient psychiatric unit for further
evaluation and treatment.
# Fever, leukocytosis:
Patient was febrile on presentation with leukocytosis to 18 and
neutrophilic differential (80%), concerning for infection.
Patient was covered empirically on for possible CNS infection
(see above) or mediastinitis (see below). However, symptoms and
workup were not consistent with either of these. Antibiotics and
acyclovir were sequentially discontinued and patient remained
afebrile with normal WBC count and no infectious symptoms.
# Pneumomediastinum:
Discovered incidentally on admission. Etiology remains unclear.
Patient denied any trauma or instrumentation. Imaging was
negative for esophageal rupture or deep neck infection/abscess.
TTE was negative for pericardial extension. Fortunately patient
remained entirely asymptomatic. No further workup recommended by
either Thoracic Surgery or ENT, but would consider f/u CXR as an
outpatient to ensure resolution.
# C4 vertebral lesion:
Differential per Radiology includes enchondroma, giant cell
tumor, low-grade chondrosarcoma, and brown tumor. Low suspicion
this is malignant since well circumscribed, no pain, no
constitutional symptoms. Further evaluation was deferred to
outpatient to prioritize management of acute psychosis.
# Left chest wall ___:
Incidentally found on CT torso. Appearance suggests nerve sheath
tumor which is typically benign and not associated with
paraneoplastic syndromes. Neurology recommended against biopsy.
Non-urgent MRI could be considered as outpatient to confirm the
diagnosis.
# Acute renal failure / pre-renal ___:
Creatinine was elevated to 1.4 on admission and improved
immediately to 0.7 with IV fluids.
TRANSITIONAL ISSUES
============================
# New psychotic disorder: Medication and f/u to be arranged by
Psychiatry on discharge.
# C4 vertebral lesion: Differential per Radiology includes
enchondroma, giant cell tumor, low-grade chondrosarcoma, and
brown tumor. Low suspicion this is malignant since well
circumscribed, no pain, no constitutional symptoms. Would
consider specialist referral (orthopedics or bone tumor
specialist) and f/u imaging as an outpatient.
# Left chest wall ___: Could consider non-urgent outpatient MRI
to confirm diagnosis of benign nerve sheath tumor or monitor
clinically.
# 2mm right thyroid nodule: Incidental finding, no follow-up
imaging recommended.
Time spent coordinating discharge > 30 minutes |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
altered mental status, hypotension
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
___ yo M with history of ETOH abuse, CHF with EF ___, HTN,
Vpacer for bradycardia, CAD s/p MI in ___, who presents after
found intoxicated and hypotensive outside of ___.
.
Of note patient was recently admitted to ___
and discharged on day of presentation. Per ___ staff,
patient was admitted intoxicated after losing all his
belongings. He reported chest pain and was admitted for rule out
MI. Patient was ruled out for MI with serial troponins. He
expressed no desire to stop drinking and to be discharged. He
was discharged on his heart failure regimen, however
anticoagulation was discontinued given frequent intoxication and
history of subdural and subarachnoid hemorrhage.
.
After discharge from ___, patient was subsequently found on
the ___ steps intoxicated. EMS was called and then he was
transported to ___. Patient was found to be hypotensive in the
field with systolics in the ___. The patient had some
bruising to his abdomen from injections of lovenox vs insulin.
He was otherwise nonfocal.
.
In the ED, initial VS were: 60s/40s 101 18 100%. Rectal temp was
103. On arrival patient was intoxicated and responsive to voice.
His neurologic exam was nonfocal. Abdomen was soft and he was
guiac negative. He had a CT scan of his head, cspine, chest,
abdomen, and pelvis which were unremarkable. His labs were
significant for ETOH level of 239. He had a normal WBC count,
HCT of 29, Chem 7, LFTs unremarkable and troponin negative x1.
Serum and urine tox negative. UA negative. ABG 7.36/47/64 with
lactate of 2. Patient was initially volume recussitated with 4L
of NS with improvement of blood pressures to the ___. He was
started of levophed and RIJ was placed with improvement of
pressures to ___ (MAP of 60). LP was attempted but aborted
after learned of AM administration of 80 mg lovenox. Patient was
started on vancomycin, ceftriaxone and acyclovir and 4g of mag
IV. Repeat rectal temp 37 prior to transfer.
.
On arrival to the MICU, patient intoxicated but able to follow
commands. He has no complaints. Blood pressures improved. In the
morning, he was afebrile. There was no nuchal rigidity or sign
of infection, so antibiotics were all stopped. CVL was removed.
Has been on CIWA, but has not been scoring. Metoprolol and
digoxin were restarted. Still holding lasix and spironolactone.
.
EP should be involved in AM as he is getting paced fast
.
Review of systems: unable to obtain
Past Medical History:
# Hypercholesterolemia
# V-pacer for bradycardia (?sick sinus), AICD for HF
Device: ___ Secura
Pacer last interrogated ___
setting: D-D-D-R
low rate: 70
upper rate: 140
tachyarrhythmias: none
therapies delivered: none
A-P: 2%
v-pace: 99.5%
V-sense response: on
Bi-V paced
mode switch episodes: none
# CAD s/p MI ___ "100% occlusion, no stents, ?appropriate for
CABG
# CHF with EF ___
# DM2
# BPH
# Depression
# Alcohol abuse
# hilar adenopathy
# hx of PE
# hx of resolved LV thrombus
# apical aneurysm
# hx of subdural and subarachnoid hemorrhages
Social History:
___
Family History:
# Father: Unknown
# Mother: Lung cancer
Physical Exam:
admission exam
Vitals: T: 98.2 BP: 104/67 P: 92 R: 16 O2: 96% RA
General: somnolent but in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP difficult to interpret, no LAD. RIJ in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Decreased breath sounds at bases, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace ___ edema
Neuro: somnolent but arousable. A&Ox person, year, president
(thinks at ___), able to respond to commends, moving all
extremities. no nuchal rigidity.
.
discharge exam
97.7 ___ 22 96%ra
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, gait
deferred. No tremor or asterixes
Pertinent Results:
admission labs
___ 03:00PM BLOOD WBC-5.9 RBC-3.59* Hgb-9.1* Hct-29.0*
MCV-81*# MCH-25.2*# MCHC-31.3# RDW-16.4* Plt ___
___ 03:00PM BLOOD Neuts-74.2* Lymphs-17.7* Monos-4.2
Eos-3.3 Baso-0.6
___ 04:32PM BLOOD ___ PTT-41.0* ___
___ 03:00PM BLOOD Glucose-152* UreaN-20 Creat-1.2 Na-137
K-4.0 Cl-103 HCO3-24 AnGap-14
___ 03:00PM BLOOD ALT-25 AST-33 AlkPhos-62 TotBili-0.3
___ 03:00PM BLOOD Lipase-56
___ 03:00PM BLOOD cTropnT-<0.01
___ 03:00PM BLOOD Albumin-3.7 Calcium-8.2* Phos-2.8 Mg-1.4*
___ 03:00PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:22PM BLOOD ___ pO2-64* pCO2-47* pH-7.36
calTCO2-28 Base XS-0 Comment-GREEN TOP
___ 03:22PM BLOOD Lactate-2.0
___ 11:48PM BLOOD O2 Sat-74
.
Discharge labs
___ 08:20AM BLOOD WBC-4.5 RBC-3.94* Hgb-10.0* Hct-32.3*
MCV-82 MCH-25.4* MCHC-30.9* RDW-16.5* Plt ___
___ 08:20AM BLOOD Glucose-198* UreaN-13 Creat-0.9 Na-134
K-4.0 Cl-98 HCO3-25 AnGap-15
___ 08:20AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7
Studies:
CXR:
1) Right-sided internal jugular central venous line terminating
at the mid to distal SVC without evidence of pneumothorax.
2) Cardiomegaly.
.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of ___
4:04 ___
IMPRESSION:
1. No acute cervical spine fracture or dislocation.
2. Multilevel degenerative changes of the cervical spine as
detailed above.
.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
4:04 ___
IMPRESSION:
1. No acute intracranial process.
2. Left maxillary sinus disease.
.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
___ 4:05 ___
IMPRESSION:
1. No evidence of pulmonary embolism although evaluation of
subsegmental
arteries in right lower lobe is suboptimal due to patient
respiratory motion.
2. Prominent bilateral hilar and mediastinal lymph nodes some
of which are enlarged. Recommend clinical correlation with
history of prior infection, inflammatory process, or concern for
malignancy and further evaluation per clinical history.
Findings should be followed-up.
3. Cardiomegaly without pericardial effusion or acute aortic
syndrome.
4. Thickened-appearing bladder wall. Correlate with urinalysis.
.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of ___ 4:05 ___
IMPRESSION:
1. No evidence of pulmonary embolism although evaluation of
subsegmental
arteries in right lower lobe is suboptimal due to patient
respiratory motion.
2. Prominent bilateral hilar and mediastinal lymph nodes some
of which are enlarged. Recommend clinical correlation with
history of prior infection, inflammatory process, or concern for
malignancy and further evaluation per clinical history.
Findings should be followed-up.
3. Cardiomegaly without pericardial effusion or acute aortic
syndrome.
4. Thickened-appearing bladder wall. Correlate with urinalysis.
Medications on Admission:
aspirin 81 mg po
budesonide 80 mcg/4.5mcg 2 puffs BID
digoxin 0.125 mcg daily
lasix 20 mg BID
glyburide 5 mg BID
lisinopril 2.5 mg
metformin 500 mg BID
toprol XL 25 mg daily
multivitamin
omeprazole 20 mg daily
simvastatin 40 mg daily
sublingual nitro as needed
aldactone 25 mg daily
coumadin 5 mg every evening --> 1 tab SWF and 1.5 tabs MTThSat
(not getting during recent hospitalization)
lovenox 80 every 12 hours
terazosin 1 mg qhs
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. budesonide-formoterol 80-4.5 mcg/actuation HFA Aerosol
Inhaler Sig: Two (2) Inhalation twice a day.
Disp:*1 inhaler* Refills:*0*
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual Q5 minutes, take as needed for chest pain, call ___
after 2nd dose.
Disp:*5 * Refills:*0*
13. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. terazosin 1 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypovolemia, alchohol intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with hypotension and altered mental status, here
to evaluate for acute intracranial process.
COMPARISON: No prior studies available.
TECHNIQUE: MDCT-acquired axial images were obtained through the head without
intravenous contrast. Coronally and sagittally reformatted images were
generated and reviewed.
FINDINGS: There is no evidence of intra-axial or extra-axial hemorrhage,
edema, mass effect or shift of normally midline structures. The gray-white
matter interface is preserved without evidence of acute major vascular
territorial infarct. The ventricles and sulci are within normal limits in
size and configuration for the patient's age. Vascular calcifications are
noted. The globes and orbits are intact. There is mild mucosal thickening in
the right maxillary sinus and near complete opacification of the left
maxillary sinus with extensive mucosal thickening. The remainder of the
visualized paranasal sinuses, middle ear cavities and mastoid air cells are
clear bilaterally. The bony calvarium appears intact.
IMPRESSION:
1. No acute intracranial process.
2. Left maxillary sinus disease.
Radiology Report
INDICATION: ___ male with hypotension and altered mental status, here
to evaluate for cervical spine injury.
COMPARISON: No prior studies available.
TECHNIQUE: MDCT-acquired axial images were obtained through the cervical
spine without intravenous contrast. Multiplanar reformatted images were
generated and reviewed.
FINDINGS: There is no evidence of acute fracture or traumatic malalignment of
the cervical spine. No prevertebral soft tissue swelling is detected. The
vertebral body heights and alignment are relatively preserved. The
atlanto-occipital and atlantoaxial articulations are maintained. There is
multilevel degenerative change throughout the cervical spine most pronounced
at the C4-T1 levels with loss of intervertebral disc space, endplate sclerosis
and anterior/posterior osteophytosis. Posterior disc osteophyte complexes are
noted at the C5-6 and C6-7 levels with mild spinal canal encroachment. No
significant facet disease is noted.
The visualized lung apices show significant motion but appear clear.
IMPRESSION:
1. No acute cervical spine fracture or dislocation.
2. Multilevel degenerative changes of the cervical spine as detailed above.
Radiology Report
INDICATION: ___ male with hypotension and altered mental status, here
to evaluate for pulmonary embolism or infection.
COMPARISON: No prior studies available.
TECHNIQUE: MDCT-acquired axial images were obtained through the chest prior
to and following the uneventful administration of 130 mL Omnipaque intravenous
contrast. Coronal, sagittal, and bilateral oblique reformatted images of the
chest were generated and reviewed. MDCT axial imaging was subsequently
performed from the lung bases to the pubic symphysis in the portal venous
phase. Coronally and sagittally reformatted images of the abdomen and pelvis
were generated and reviewed.
FINDINGS:
CT CHEST WITH AND WITHOUT CONTRAST: There is suboptimal evaluation of the
subsegmental arteries in the right lower lobe due to patient respiratory
motion. The remainder of the pulmonary arterial tree is well opacified with
intravenous contrast to the subsegmental levels without filling defects to
suggest pulmonary embolism. The pulmonary arterial trunk is normal in
caliber. The thoracic aorta is normal in caliber without evidence of acute
aortic syndrome. The heart is enlarged with biventricular pacemaker leads in
place. There is no evidence of right heart strain or pericardial effusion.
The central tracheobronchial tree is patent to the subsegmental level. Within
the lung parenchyma, there are no focal consolidations, pleural effusions, or
pneumothoraces. No pulmonary nodules or masses are detected. Posterior
dependent positional changes are noted in both lungs.
The thyroid gland is unremarkable. There are several prominent lymph nodes in
the mediastinum and bilateral hila greater on the right than the left, some of
which are pathologically enlarged (for example, 2:12 and 3A:27), which are
nonspecific. No pathologically enlarged lymph nodes are identified in the
axillary regions.
CT ABDOMEN WITH CONTRAST: The liver enhances homogeneously without perfusion
defects or focal liver lesions. The portal venous system opacifies
satisfactorily with contrast. No intra- or extra-hepatic biliary dilation is
seen. The gallbladder is contracted with pericholecystic fluid. The pancreas
is diffusely fatty infiltrated but otherwise unremarkable. The spleen is
borderline enlarged, measuring 13 cm. The right adrenal gland contains a 9 mm
focal hypodensity with internal fat density consistent with lipoma (3B:106).
The left adrenal gland and bilateral kidneys are unremarkable. Celiac axis
lymph nodes are prominent but not pathologically enlarged by CT size criteria.
The intra-abdominal loops of small and large bowel are unremarkable without
evidence of wall thickening or obstruction. The appendix is visualized and
normal in appearance. No free air or ascites is present. No pathologically
enlarged lymph nodes are identified in the periaortic or mesenteric regions.
The abdominal aorta is normal in caliber.
CT PELVIS WITH CONTRAST: The urinary bladder is distended with a Foley
catheter in place. The urinary bladder wall appears thickened but regular.
The prostate is not enlarged. A rectal tube is in place. The sigmoid colon
contains a few scattered diverticula without inflammatory changes. There is
no free pelvic fluid or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
1. No evidence of pulmonary embolism although evaluation of subsegmental
arteries in right lower lobe is suboptimal due to patient respiratory motion.
2. Prominent bilateral hilar and mediastinal lymph nodes some of which are
enlarged. Recommend clinical correlation with history of prior infection,
inflammatory process, or concern for malignancy and further evaluation per
clinical history. Findings should be followed-up.
3. Cardiomegaly without pericardial effusion or acute aortic syndrome.
4. Thickened-appearing bladder wall. Correlate with urinalysis.
Radiology Report
INDICATION: Altered mental status and hypotension.
COMPARISON: ___.
SINGLE PORTABLE FRONTAL VIEW OF THE CHEST: There is mild vascular engorgement
without overt signs of pulmonary edema. The cardiac silhouette is enlarged
but unchanged from prior. A left-sided ICD and pacer is seen with leads
ending in the right atrium, coronary sinus and right ventricle. A right-sided
IJ catheter tip terminates in the mid to distal SVC. There is no pleural
effusion or pneumothorax. There is no consolidation.
IMPRESSION:
1) Right-sided internal jugular central venous line terminating at the mid to
distal SVC without evidence of pneumothorax.
2) Cardiomegaly.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPOTENSIVE
Diagnosed with FEVER, UNSPECIFIED, ALTERED MENTAL STATUS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: 60.0
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ yo M with hx of ETOH abuse, CHF with EF ___, HTN, Vpacer
for bradycardia, CAD s/p MI in ___ who presented intoxicated,
febrile, and hypotensive. He had a unit stay for the hypotension
where he received IV fluid resuscitation overnight and pressors,
and was weaned off by the morning.
# Altered mental status - Patient found to be intoxicated with
ETOH level of 239, hypotensive with blood pressures in the ___,
and initial rectal temp of 103. Mental status improved overnight
as patient sobered up. There was initial concern for meningitis
given febrile with altered mental status and patient was started
on vancomycin, ceftriaxone and acyclovir at meningitis dosing.
Patient was monitored overnight and given afebrile, improvement
in mental status, lack of nuchal rigidity and photophobia
antibiotics were discontinued. He had return of normal mental
status at time of transfer from the unit. He remained stable and
intact once on the floor.
.
# Shock - Patient had presenting blood pressures in the ___ and
was febrile to 103. There was initial concern for distributive
shock due to possible sepsis and he was started on vancomycin,
ceftriaxone, and acylovir for potential meningitis. He was going
to get an LP, but then MICU team learned he had gotten lovenox
earlier that AM, so this was deferred. However infectious workup
negative and patient was afebrile, without leukocytosis, and
clinically improved with IV fluids. He was started on levophed
in the ED which was quickly weaned off overnight. He was likely
volume depleted in the setting of acute intoxication. There was
no clinical evidence to suggest primary distributive or
cardiogenic process leading to his hypotension. He responded to
IVF to normotension, and was stable on the floor.
.
# ETOH abuse - Patient was placed on valium CIWA scale. He was
given MVI, thiamine, and folate. Given his ETOH use and social
situation, social work was consulted. However, patient declined
these interventions. States that he has an outpatient rehab he
is working with, and is not interested in alternatives.
.
# CHF with EF ___ - Home antihypertensives including toprol,
lisinopril, lasix and spironolactone initially held. His digoxin
was continued. As his blood pressures stabilized, patient was
restarted on all his home meds by time of discharge
- his pacer appearred to be pacing at ~100bpm. W/ low EF, this
seems to be too fast. We offerred patient electrophysiology to
look at pacer, but he declined and will f/u with his
cardiologist.
.
# hx of PE and LV thrombus - previously on warfarin/lovenox.
Patient discharged from ___ off all anticoagulation due to
noncompliance, history of ETOH abuse and subdural/subarachnoid
bleeds. INR subtherapeutic on admission. Lovenox and warfarin
were held during admission given risk of bleed due to history of
intracranial bleed.
His primary cardiologist was contacted and agreed w/ this plan.
If patient can get sober, restarting coumadin would make more
sense.
.
# CAD PO medications intially held. Patient restarted on ASA
and beta blocker. His ACE and beta blocker were initially held
due to hypotension, but restarted by time of discharge.
.
# Type 2 DM - Home metformin and glyburide held. Blood sugars
were well controlled with insulin sliding scale. PO meds
restarted at discharge.
.
====================================================
TRANSITIONAL ISSUES
# Prominent bilateral hilar and mediastinal lymph nodes some of
which are
enlarged on CTA. Pt was informed, and should pursue further
work-up in outpatient setting.
# EtOH management: pt declined intervention this admission, has
outpatient rehab at ___ that he would like to f/u at.
# his pacer appearred to be pacing at ~100bpm. W/ low EF, this
seems to be too fast. We offerred patient electrophysiology to
look at pacer, but he declined and will f/u with his
cardiologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
codeine / Dilaudid
Attending: ___
Chief Complaint:
left knee PJI
Major Surgical or Invasive Procedure:
left knee I&D and liner exchange ___, ___
History of Present Illness:
___ w/left knee PJI s/p L TKA by Dr. ___ in
___ complicated by patellar fracture which subsequently
underwent patellar tendon repair w/partial papillectomy on
___ with Dr. ___.
Past Medical History:
Atrial fibrillation (on Xarelto), irritable bladder, depression,
MRSA infection in ___ after returning from trip to ___, TIA
in ___ w/o residual neurologic deficits
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with ***
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 05:40AM BLOOD WBC-10.2* RBC-3.60* Hgb-11.1* Hct-34.3
MCV-95 MCH-30.8 MCHC-32.4 RDW-13.8 RDWSD-48.7* Plt ___
___ 09:00AM BLOOD WBC-10.6* RBC-3.67* Hgb-11.1* Hct-34.7
MCV-95 MCH-30.2 MCHC-32.0 RDW-13.6 RDWSD-46.9* Plt ___
___ 06:34AM BLOOD WBC-11.9* RBC-3.92 Hgb-12.2 Hct-38.2
MCV-97 MCH-31.1 MCHC-31.9* RDW-13.7 RDWSD-49.1* Plt ___
___ 06:22AM BLOOD WBC-10.5* RBC-4.33 Hgb-13.1 Hct-42.0
MCV-97 MCH-30.3 MCHC-31.2* RDW-13.5 RDWSD-48.6* Plt ___
___ 07:54AM BLOOD WBC-9.6 RBC-4.58 Hgb-14.2 Hct-43.3 MCV-95
MCH-31.0 MCHC-32.8 RDW-13.7 RDWSD-47.3* Plt ___
___ 06:35AM BLOOD WBC-10.2* RBC-4.66 Hgb-14.3 Hct-44.0
MCV-94 MCH-30.7 MCHC-32.5 RDW-13.9 RDWSD-48.0* Plt ___
___ 03:34PM BLOOD WBC-12.0* RBC-4.50 Hgb-13.9 Hct-42.4
MCV-94 MCH-30.9 MCHC-32.8 RDW-13.9 RDWSD-48.2* Plt ___
___ 03:34PM BLOOD Neuts-61.5 ___ Monos-13.0 Eos-1.7
Baso-0.6 Im ___ AbsNeut-7.36* AbsLymp-2.63 AbsMono-1.56*
AbsEos-0.20 AbsBaso-0.07
___ 03:34PM BLOOD ___ PTT-33.7 ___
___ 05:40AM BLOOD K-3.8
___ 09:00AM BLOOD Glucose-125* UreaN-8 Creat-0.6 Na-139
K-3.7 Cl-102 HCO3-25 AnGap-12
___ 06:22AM BLOOD Glucose-99 UreaN-18 Creat-0.7 Na-139
K-4.3 Cl-100 HCO3-22 AnGap-17
___ 06:10AM BLOOD Glucose-117* UreaN-17 Creat-0.8 Na-144
K-4.0 Cl-102 HCO3-22 AnGap-20*
___ 06:35AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-139
K-4.3 Cl-100 HCO3-28 AnGap-11
___ 03:34PM BLOOD Glucose-93 UreaN-12 Creat-0.6 Na-138
K-3.8 Cl-98 HCO3-25 AnGap-15
___ 06:22AM BLOOD ALT-20 AST-28 AlkPhos-99 TotBili-0.6
___ 05:40AM BLOOD Mg-1.7
___ 09:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7
___ 06:34AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.7
___ 06:22AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9
___ 03:34PM BLOOD Calcium-9.4 Phos-2.7 Mg-1.7
___ 09:00AM BLOOD Vanco-16.1
___ 10:00PM BLOOD Vanco-18.2
___ 06:22AM BLOOD Vanco-21.3*
___ 06:10AM BLOOD Vanco-15.8
___ 03:39PM BLOOD Lactate-1.3
___ 01:30PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 01:30PM URINE RBC-1 WBC-5 Bacteri-FEW* Yeast-NONE Epi-5
TransE-<1
___ 01:30PM URINE Mucous-RARE*
___ 06:58PM JOINT FLUID ___ Polys-89*
___ Macro-7
Medications on Admission:
1. Digoxin 0.125 mg PO DAILY
2. Rivaroxaban 20 mg PO DAILY
3. Celecoxib 100 mg oral BID:PRN
4. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID
5. Brinzolamide 1% Ophth (*NF* ) 1 drop Other BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. CeFAZolin 2 g IV Q8H
Start date: ___
Projected End Date: ___
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID
5. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
6. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID
7. Brinzolamide 1% Ophth (*NF* ) 1 drop Other BID
8. Digoxin 0.125 mg PO DAILY
9. Rivaroxaban 20 mg PO DAILY
10. HELD- Celecoxib 100 mg oral BID:PRN This medication was
held. Do not restart Celecoxib until cleared by surgeon.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left knee PJI
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: Left knee radiographs, three views.
INDICATION: S/p patelloectomy with purulent drainage from the left knee.
COMPARISON: None.
FINDINGS:
Patella ___ noted with fragmented and heterotopic bone along the inferior
side of the patella. However, no lysis is found. There is no evidence for
fracture or dislocation. A very small joint effusion is suspected. Femoral
and tibial prostheses appear intact. Ghost tracks noted in the distal femur
and proximal tibia, as well as in the patella.
IMPRESSION:
Trace joint effusion. Some heterotopic and fragmented bone along the inferior
patella without evidence lysis. Intact femoral and tibial prostheses.
Radiology Report
EXAMINATION: US MSK KNEE(PATELLA TENDON) LEFT
INDICATION: ___ year old woman with h/o patellar tendon repair// status of
quad/patellar tendons (s/p rupture/repair earlier this year. Pre-op for knee
explant
TECHNIQUE: Grayscale ultrasound images were obtained of the left quadriceps
and patellar tendons.
COMPARISON: Left knee radiographs ___
FINDINGS:
The quadriceps tendon is intact.
Subcutaneous edema is noted.
The patellar tendon is thickened with multiple sutures appreciated. Distally
the patellar tendon attaches onto the tibial tubercle. More proximally, the
tendon is difficult to evaluate at its expected location upon the patella.
This is most likely secondary to postsurgical change.
IMPRESSION:
No definite tear, however a partial tear is difficult to exclude.
Radiology Report
EXAMINATION: Left knee radiographs, two views.
INDICATION: Status post liner exchange.
COMPARISON: Prior study from ___.
FINDINGS:
Left total knee replacement appears intact. There is anticipated air in soft
tissue swelling at the operative site.
IMPRESSION:
Intact Left total knee replacement.
Radiology Report
INDICATION: ___ year old woman left knee PJI now s/p L knee I D, liner
exchange requiring PICC line placement for long term antibiotics. Hx of
difficulty PICC placement in the past, would like this to be done through
___// PICC placement through ___
COMPARISON: None.
TECHNIQUE:
OPERATORS: Dr. ___ Interventional ___ and Dr. ___,
Interventional Radiology fellow performed the procedure. Dr. ___
supervised the trainee during any key components of the procedure where
applicable and reviewed and agrees with the findings as reported below.
ANESTHESIA: 1% lidocaine
MEDICATIONS: 0
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 4.4 minutes, 11 mGy
PROCEDURE:
1. Single 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 single lumen PIC line measuring 46 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach single lumen right PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a right 46 cm basilic approach single lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Knee pain, Wound eval, Transfer
Diagnosed with Other specified soft tissue disorders, Unspecified atrial fibrillation
temperature: 97.5
heartrate: 78.0
resprate: 18.0
o2sat: 95.0
sbp: 157.0
dbp: 104.0
level of pain: 0
level of acuity: 3.0 | The patient was admitted to the orthopedic surgery service
through the Emergency Department. She was admitted and started
on IV antibiotics. Zosyn was discontinued on ___. She was
taken to the operating room for above described procedure two
days later after getting Cardiology clearance. Please see
separately dictated operative report for details. The surgery
was uncomplicated and the patient tolerated the procedure well.
OR cultures were collected during the procedure. Infectious
disease started to follow the patient when her cultures showed
staphylococcus ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Pacemaker Placement
History of Present Illness:
Ms. ___ is an ___ yo ___ female with CHF with
preserved EF of 55% in ___, paroxysmal AFib on coumadin, and
hypertension who presents with chest pressure and dyspnea in
setting of hypertensive emergency. Patient reports chest pain
that began at 5pm on day of admission. Patient has had
progressive difficulty breathing for past few weeks. Patient
brought in by EMS w/ acute onset dyspnea. In the field, patient
found to be severely hypertensive with SBP of 280 while in
respiratory distress. Patient immediately given 1600mcg
nitroglycerin SL in 2 doses and placed on CPAP. SBP decreased to
210 quickly and work of breathing decreased. Patient noted by
EMS to have rales bilaterally. Patient does have mild headache,
but no vision changes. Of note, patient had similar presentation
in ___ where had systolic BP's over 200 that improved with
IV Lasix. Of note Labetalol caused bradycardia last admission.
Patient's blood pressures were labile 90-200's and difficult to
control.
In the ED, initial vitals were 98 HR 56 212/62 RR 23 97%
NC. She was started on a Nitro drip 150mcg, was weaned off CPAP,
received Lasix 40mg with 400cc UOP. Her vitals on transfer were
98 61 147/38 19 97% on NC
On arrival to CCU: VS: 139/49 HR 60 sat 95% on 2L NC
Patient reports improvement in breathing. She denies any current
chest pain. Patient's daughter reports patient will sometimes
not take medications if blood pressure is low in the morning.
REVIEW OF SYSTEMS: + mild headache, but negative for abdominal
pain, nausea, vomiting, diarrhea, fever, chills, vision changes
Past Medical History:
CAD s/p 2 vessel PCI in ___
CHF w/ preserved EF 55% in ___
Paroxysmal Atrial Fibrillation, on Coumadin
CKD
HTN
Hyperlipidemia
Hx V-fib arrest ___ likely due to dofetilide and QTc
prolongation
Anemia
Social History:
___
Family History:
Maternal: mother- Cardiac disease, sister-breast cancer at age
___
Paternal: father-died in ___ ___
Children: Son died of pancreatic cancer at age ___ years ago
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 139/49 HR 60 sat 95% on 2L NC
Gen: NAD, daughter at bedside
___: clear oropharynx
Neck: no JVD
CV: NR, RR, holosystolic murmur heard throughout
Pulm: crackles half way up lungs bilaterally, no wheezes, good
air movement
Ext: 1+ bilateral lower ext edema
Neuro: A&O, no gross deficits
.
Exam on discharge:
Tele: AV paced to V paced with rate 60's-90's.
.
Gen: Alert, gait weak but steady, NAD sitting up in chair
___: no JVD
CV: RRR, no M/R/G
CHEST: CTAB post, pacer site with mild edema and bruising, no
tenderness.
ABD: obese, soft
Extremeties: feet warm, no edema
PIV
Pertinent Results:
ADMISSION
___ 12:00AM BLOOD WBC-12.2* RBC-3.42* Hgb-9.8* Hct-30.1*
MCV-88 MCH-28.8 MCHC-32.7 RDW-13.9 Plt ___
___ 12:00AM BLOOD Neuts-70.2* ___ Monos-6.6 Eos-1.9
Baso-0.3
___ 09:30AM BLOOD ___
___ 06:05AM BLOOD ___ PTT-34.8 ___
___ 05:47AM BLOOD ___
___ 12:00AM BLOOD Glucose-137* UreaN-35* Creat-2.1* Na-135
K-4.5 Cl-99 HCO3-26 AnGap-15
___ 08:27PM BLOOD ALT-45* AST-50* LD(LDH)-224 CK(CPK)-94
AlkPhos-53 TotBili-0.3
___ 12:00AM BLOOD cTropnT-<0.01 proBNP-6875*
___ 12:00AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.2
Labs on Discharge:
___ 09:30AM BLOOD WBC-8.7 RBC-3.26* Hgb-9.3* Hct-29.1*
MCV-89 MCH-28.6 MCHC-32.1 RDW-14.4 Plt ___
___ 09:30AM BLOOD UreaN-41* Creat-1.7*
___ 06:05AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8
___ ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is a mild resting
left ventricular outflow tract obstruction. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened (?#). There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.
There are no echocardiographic signs of tamponade.
___ KUB:
FRONTAL ABDOMINAL RADIOGRAPH: A non-obstructive bowel gas
pattern is seen. There is a large amount of stool within the
rectal vault. Moderate spondylosis of the lumbar spine and
femoroacetabular joints is present. IMPRESSION: No acute
intra-abdominal process detected.
CXR ___:
Compared to the study from the prior day, the dual-lead
pacemaker is unchanged. There is increased cardiomegaly, which
is moderate-to-severe. Bilateral hazy vasculature, pulmonary
vascular redistribution, and alveolar edema. There are small
bilateral effusions, right greater than left and Kerley B lines.
Compared to the prior exam, the CHF is worsened.
PACEMAKER INTERROGATION ___: Diagnostic information: High
rate, Mode switch: AT/AF burden 14%. EGMs were consistent with
atrial flutter, but not all flutter waves were being sensed to
trigger mode switch. ATach detection left at 170 with mode
switch to DDIR. (By history, blood pressure is sensitive to
loss of AV syncrony.) No evidence of PMT.
Programming changes (details): Decreased upper tracking rate to
110 and increased atrial lead sensitivity to 0.3 mV.
Summary (normal / abnormal device function):
1) Device was tracking atrial flutter.
2) Decreased tracking limit to 110 and increased atrial
sensitivity to 0.3 mV.
3) Otherwise normal device function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 80 mg PO BID
hold for systolic BP less than 100
2. Magnesium Oxide 400 mg PO BID
3. Amiodarone 200 mg PO DAILY
4. Warfarin 2.5 mg PO 4X/WEEK (___)
5. Famotidine 40 mg PO DAILY
6. Atorvastatin 20 mg PO DAILY
7. Torsemide 20 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Citalopram 30 mg PO QHS
11. NIFEdipine CR 30 mg PO DAILY
12. Labetalol 100 mg PO BID
13. Meclizine 12.5 mg PO BID
14. Docusate Sodium 100 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. Lorazepam 0.5 mg PO HS
17. Calcium 500 + D (D3) *NF* (calcium carbonate-vitamin D3)
500-125 mg-unit Oral BID
18. Nitroglycerin SL 0.3 mg SL PRN CP
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO DAILY
Decreased for renal function
6. Lorazepam 0.5 mg PO HS
7. Meclizine 12.5 mg PO BID
8. NIFEdipine CR 60 mg PO DAILY
9. Torsemide 10 mg PO DAILY
10. Carvedilol 6.25 mg PO BID
11. Senna 1 TAB PO BID:PRN constipation
12. Calcium 500 + D (D3) *NF* (calcium carbonate-vitamin D3)
500-125 mg-unit Oral BID
13. Magnesium Oxide 400 mg PO BID
14. Multivitamins 1 TAB PO DAILY
15. Nitroglycerin SL 0.3 mg SL PRN CP
16. Warfarin 2 mg PO 4X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypertensive emergency
Sick sinus syndrome
Aspiration Pneumonia
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Respiratory distress.
COMPARISON: None.
FINDINGS: Portable AP chest radiograph demonstrates severe cardiomegaly, both
interstitial and alveolar edema as well as small bilateral pleural effusions.
A more confluent opacity is seen in the right middle lobe. There is no
pneumothorax. Atherosclerotic calcifications are noted in the aortic arch.
IMPRESSION: Marked pulmonary edema. Follow up CXR after diuresis may be
helpful to exclude underlying pneumonia in right middle lobe.
Radiology Report
PORTABLE CHEST RADIOGRAPH, ___
COMPARISON: ___ chest radiograph.
FINDINGS: Mild-to-moderate cardiomegaly is accompanied by upper zone vascular
redistribution, vascular indistinctness and mild interstitial edema. A
slightly more confluent opacity at the right lung base medially may reflect
asymmetrical dependent edema, but followup radiographs may be helpful to
exclude a developing infection in this region. Small bilateral pleural
effusions have improved since previous study. Calcified right hilar lymph
nodes are unchanged.
Radiology Report
PORTABLE CHEST RADIOGRAPH, ___.
COMPARISON: Radiograph of earlier the same date.
FINDINGS: Newly placed endotracheal tube terminates approximately 3.6 cm
above the carina, and a nasogastric tube courses below the diaphragm. A 3-cm
diameter rounded lucency is identified lateral to the endotracheal tube and
nasogastric tube to the left of midline. Although potentially representing an
over-distended endotracheal tube cuff, the position is more lateral than
expected for this condition. Alternative possibilities include an air-filled
diverticulum arising from the trachea or esophagus. Findings were
communicated by telephone with Dr. ___ on ___ at 4:00 p.m. at
the time of discovery. Exam is otherwise remarkable for persistent
cardiomegaly and worsening congestive heart failure with increasing perihilar
edema and persistent small right pleural effusion.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Endotracheal tube placement.
COMPARISON: Fluoroscopy from ___ and chest x-ray from ___.
FINDINGS: As compared to the previous image, the patient has received an
external pacemaker. The tip of the pacemaker is in expected correct position,
as documented on the previous fluoroscopy. Unchanged position of the other
monitoring and support devices. Moderate cardiomegaly with signs of mild
pulmonary edema. No pleural effusions. No pneumothorax. Left apical pleural
calcification. Mild atelectasis at the left lung bases. No evidence of
pneumonia.
Radiology Report
DATE OF EXAMINATION: ___.
TYPE OF EXAMINATION: Chest fluoroscopy without radiologist.
Temporary pacemaker placement was performed under fluoroscopy. Five VIDEO
images were recorded during a temporary pacer placement. No diagnostic images
were obtained.
Radiology Report
CHEST RADIOGRAPH
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the monitoring and support
devices, including the temporal right pacemaker, have all been removed. The
patient is in unchanged moderate pulmonary edema, with moderate cardiomegaly
but without pleural effusions. No newly appeared parenchymal opacities.
Unchanged mild atelectatic changes at the lung bases. No other relevant
changes.
Radiology Report
INDICATION: ___ female who presents for evaluation of lead position.
COMPARISONS: ___ and
___ chest radiographs.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS: The lead positions of the dual-chamber pacemaker is unchanged
compared to the prior exam. There is moderate cardiomegaly. The lungs
demonstrate moderate pulmonary edema but no evidence of pleural effusions or
pneumothorax. Mild atelectatic changes at the lung bases are unchanged.
Incidental note is made of chronic stable calcified scarring in the left apex.
There are no new parenchymal opacities. There is no evidence of pneumothorax.
IMPRESSION:
Unchanged lead positions from recently inserted dual-chamber pacemaker.
Radiology Report
INDICATION: CHF with abdominal pain and nausea.
COMPARISON: Chest radiographs available from ___.
FRONTAL ABDOMINAL RADIOGRAPH: A non-obstructive bowel gas pattern is seen.
There is a large amount of stool within the rectal vault. Moderate
spondylosis of the lumbar spine and femoroacetabular joints is present.
IMPRESSION: No acute intra-abdominal process detected.
Radiology Report
CHEST ON ___
HISTORY: CHF, question interval change.
REFERENCE EXAM: ___.
Compared to the study from the prior day, the dual-lead pacemaker is
unchanged. There is increased cardiomegaly, which is moderate-to-severe.
Bilateral hazy vasculature, pulmonary vascular redistribution, and alveolar
edema. There are small bilateral effusions, right greater than left and
Kerley B lines. Compared to the prior exam, the CHF is worsened.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: RESPIRATORY DISTRESS
Diagnosed with ACUTE LUNG EDEMA NOS, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS, LONG TERM USE ANTIGOAGULANT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ yo ___ female with dCHF, preserved EF of 55% in
___, paroxysmal AFib on coumadin, and hypertension who
presented with flash pulmonary edema in setting of hypertensive
emergency. She was admitted to the CCU for management Her stay
was complicated by sinus arrest with symptomatic bradycardia s/p
PPM ___. Her stay was also prolonged due to very labile
hypertension.
# Hypertensive Emergency: Patient presented with systolic BP up
to 280s, initially treated with a nitroglycerin gtt with good
response. As for etiology, patient was on 4 drug regimen at
home, but acknowledged to our ___ speaking resident that she
did not always take her medications. She would often check her
blood pressures and based on the readings, would take her
medications (unclear if some or all). Recommend consolidating
medications and uptitrating doses to max ranges before adding
additional agents to reduce polypharmacy and improve compliance.
Patient continued to have labile blood pressures during her stay
(see below)
# Diastolic CHF with Flash Pulmonary Edema: Initial CXR
consistent with pulmonary edema. Likely due to acute on chronic
dCHF exacerbation in setting of hypertensive emergency. Patient
initially on BiPAP and her breathing status improved with just
~500mL of diuresis with furosemide and control of her
hypertensive emergency. The rest of her stay was complicated by
temporary sinus arrest, and atrial fibrillation, which in the
setting of her dCHF caused hypotension and oliguria. After
placement of a pacemaker and once these issues were stabilized,
she was restarted on a lower dose torsemide, carvedilol, and
antihypertensives. Her ace inhibitor was discontinued because we
were able to achieve blood pressure control without it and there
is limited benefit in this elderly female with diastolic heart
failure, also clearly affected by polypharmacy.
# Sick Sinus Syndrome/Sinus Arrest - After initial hypertensive
presentation, patient was weaned off nitro gtt and started on
adjusted regimen of antihypertensives ___. However she
developed cardiogenic shock secondary to Sinus Arrest, with
junctional bradycardia in ___. Patient initially symptomatic
with nausea/vomiting/lightheadeness and altered mental status.
She required intubation for airway control (with likely
aspiration from vomiting) and vasopressor support. Most likely
cause was the beta blocker, as even though it was listed as a
home medication, she had a history of sinus bradyarrythmia on
past admission and she may not actually been taking it at home.
SA node dysfunction from amiodarone also considered. She
developed oliguia and acute tubular necrosis (which later
resolved). Temporary pacer was placed with good response to BP
with v-pacing. However it was noted that patient overall did
much better when a-v paced and was in sinus rhythm (reliant on
atrial kick). Permanent Pacemaker placed on ___, and at
times patient was in normal sinus rhythm, a-paced, a-v paced.
# Labile hypertension, s/p hypertensive Emergency and
hypotension requiring pacer: Per outside hospital records in
___, patient had work up of secondary causes of hypertension
including renal artery ultrasound, TSH, and cortisol levels, all
of which were normal. Pheochromocytoma workup with plasma and
urine metanephrines was sent during during admission in ___,
and these ultimately showed no evidence for this as explanation
for her labile hypertension. Patient does best with SBP range
130s-150s(mainly for UOP and pulmonary edema), and is reliant on
atrial kick. Many combinations of her antihypertensive regimens
were tried (including her home regimen) and monitored with
arterial line and noninvasive BP monitoring. Finally, a stable
regimen at discharge was determined to be: carvedilol BID and
nifedipine CR daily.
# Paroxysmal Atrial Fibrillation: CHADS2 score of 3. On home
coumadin and admitted on amiodarone. Warfarin temporarily held
due to hematoma at PPM site. Patient had intermittent runs of
atrial fibrillation with and without RVR. Notably, her blood
pressures would often drop when in atrial fibrillation, likely
due to her dCHF and stiff ventricles. She is reliant on her
atrial kick. She was started on amiodarone.
# ATN secondary to hypotension, on chronic KD: Baseline
creatinine of 2 with admission creatinine of 2.1. Peak Cr 4.1 on
___ due to ATN secondary to prolonged hypotension. Muddy
brown casts seen on spun urine ___. Cr and UOP improved with
intermittent furosemide diuresis, restarting her home torsemide,
and ensuring her systolic BP ranged from 130-150s.
# HCAP With gram positive cocci in sputum and fever,
leukocytosis. Patient had witnessed aspiration on ___, but
likely too soon for aspiration PNA. Weakly positive UA. Started
vancomycin and cefepime (d1 = ___ and discontinued
vancomycin after 3 days given lack of positive MRSA evidence.
Continued Cefepime for ___nemia of blood loss on chronic normocytic anemia: Admitted
with Hct at baseline of ~30. Hct ___ = 22.5. Patient had
hematoma formation at time of PPM placement on ___. Hct
trended down to 19 on ___ ___ and transfused 2 units RBCs. Hct
improved thereafter with no further evidence of bleeding.
# CAD: s/p 2 vessel PCI in ___. Patient came in on aspirin 81mg
and clopidogrel 75mg daily as well as warfarin. After discussion
with outpatient cardiologist, her clopidogrel was discontinued
given increased risk of bleeding. Continue home Atorvastatin
20mg daily.
# Hyperlipidemia - Continued Atorvastatin 20mg daily
# History of V-fib arrest ___ likely due to dofetilide and
QTc prolongation. Stopped citalopram on ___ due to QTc
prolongation. |
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
==============
___ 05:40PM BLOOD WBC-8.9 RBC-2.24* Hgb-6.8* Hct-20.5*
MCV-92 MCH-30.4 MCHC-33.2 RDW-15.8* RDWSD-51.3* Plt ___
___ 05:40PM BLOOD Neuts-74.5* Lymphs-13.0* Monos-10.2
Eos-1.6 Baso-0.3 Im ___ AbsNeut-6.66* AbsLymp-1.16*
AbsMono-0.91* AbsEos-0.14 AbsBaso-0.03
___ 05:40PM BLOOD ___ PTT-27.2 ___
___ 05:40PM BLOOD Glucose-123* UreaN-49* Creat-2.0* Na-139
K-6.0* Cl-101 HCO3-24 AnGap-14
___ 05:40PM BLOOD ALT-31 AST-48* LD(LDH)-273* AlkPhos-75
TotBili-0.5
___ 12:48AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.3
___ 05:40PM BLOOD calTIBC-274 Hapto-283* Ferritn-364
TRF-211
___ 07:18AM BLOOD CRP-69.8*
___ 01:15PM BLOOD Lactate-2.5*
___ 05:28PM BLOOD Lactate-1.7
IMAGING
=======
CT ABD & PELVIS W/O CON (___)
1. High grade small bowel obstruction with transition point and
mesenteric
twirling at the level of the terminal ileum in the RLQ. A ___
partially
obstructing transition point is seen in the jejunum in the left
upper quadrant without definite cause of obstruction identified.
2. Marked distention of the stomach and colon.
3. Large amount of stool the rectum, likely impacted, without
evidence of
stercoral colitis.
4. Changes suggestive of aspiration and mucous plugging in the
left lower
lobe.
LIVER OR GALLBLADDER US (___)
1. No evidence of acute cholecystitis or cholelithiasis.
2. Nonvisualization of the pancreas, spleen and left kidney due
to a large amount of bowel gas.
CHEST PROTABLE AP (___)
In comparison with the earlier study of this date, the
nasogastric tube
extends to the upper stomach, were crosses the lower margin of
the image.
However, there does not appear to be any further increase in the
position of the side-port, though it is clearly below the
esophagogastric junction.
Opacification is again seen in the retrocardiac region. This
could well
represent merely atelectatic change. However, in the
appropriate clinical
setting, superimposed aspiration/pneumonia would have to be
considered.
Remainder of the lungs is clear and there is no evidence of
vascular
congestion.
PORTABLE ABDOMEN (___)
The enteric tube terminates in the body of the stomach. There
are no
abnormally dilated loops of large or small bowel. Oral contrast
is seen within the colon and rectum. There is no free
intraperitoneal air, although evaluation is limited by supine
technique. No acute osseous abnormalities are identified.
DISCHARGE LABS
===============
___ 06:40AM BLOOD WBC-8.4 RBC-3.02* Hgb-9.1* Hct-27.4*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.8 RDWSD-48.4* Plt ___
___ 06:40AM BLOOD Glucose-84 UreaN-17 Creat-1.1 Na-137
K-5.1 Cl-100 HCO3-25 AnGap-12
___ 06:40AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0
___ 05:40PM BLOOD calTIBC-274 Hapto-283* Ferritn-364
TRF-211
___ 07:18AM BLOOD CRP-69.8*
___ 06:35AM BLOOD %HbA1c-PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
2. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
3. Cefpodoxime Proxetil 400 mg PO BID Duration: 5 Doses
4. Omeprazole 20 mg PO DAILY
5. Senna 8.6 mg PO BID
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Allopurinol ___ mg PO DAILY
8. amLODIPine 5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Constipation
Small bowel obstruction
Acute on chronic anemia
Secondary diagnosis:
___ on CKD
Aspiration pneumonia
CAD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with CAD s/p PCI (last in ___, Alzheimer's,
CKDIII, anemia, HTN and recent admission from ___ for amechanical fall
admission c/b episode of dark emesis; EGDperformed which was negative. He
presented from rehab with acuteon chronic anemia with Hct 20 in the absence of
evidence ofbleeding. He received one unit of PRBCs in the ED on ___
withincrease in Hgb from 6.8 to 8.7. Planning on monitoring for oneday and
then recommending discharge to rehab if Hgb stable andfurther discussion of
outpatient colonoscopy.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None
FINDINGS:
Evaluation of the midline and left abdominal structures is markedly limited
due to a large amount of bowel gas. The pancreas, spleen, left kidney and
retroperitoneum are not visualized.
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: The gallbladder is distended without wall thickening or
cholelithiasis.
KIDNEYS: Limited views of the right kidney shows no hydronephrosis.
Right kidney: 8.7 cm
IMPRESSION:
1. No evidence of acute cholecystitis or cholelithiasis.
2. Nonvisualization of the pancreas, spleen and left kidney due to a large
amount of bowel gas.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old man with CAD s/p PCI (last in ___, Alzheimer's,
CKDIII, anemia, HTN and recent admission from ___ for amechanical fall
admission c/b episode of dark emesis; EGDperformed which was negative. He
presented from rehab with acuteon chronic anemia with Hct 20 in the absence of
evidence ofbleeding. He received one unit of PRBCs in the ED on ___
withincrease in Hgb from 6.8 to 8.7. Planning on monitoring for oneday and
then recommending discharge to rehab if Hgb stable and further discussion of
outpatient colonoscopy. Patient developed acute on chronic severe ___
diffuse abdominal
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.8 s, 50.7 cm; CTDIvol = 12.0 mGy (Body) DLP = 608.0
mGy-cm.
Total DLP (Body) = 608 mGy-cm.
COMPARISON: None
FINDINGS:
LOWER CHEST: There is left lower lobe opacities concerning for aspiration (2;
4) with associated mucous plugging as well as component of atelectasis. The
right lower lobe consolidation is likely atelectasis. There is no pleural
effusion or pericardial effusion. Moderate coronary artery calcifications are
seen. Decreased density of the blood pool with respect to the myocardium
suggests anemia.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is distended but without wall thickening or
evidence of inflammation. There is no portal venous gas.
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 suspicious
renal lesions within the limitations of an unenhanced scan. There are
bilateral renal hypodense lesions measuring up to 2.6 cm in the left midpole
of simple fluid attenuation consistent with renal cysts. Calcifications seen
within bilateral kidneys are likely vascular calcifications rather than
nonobstructing renal stones. There is no hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is severe distension of the stomach with oral contrast
and gas. The duodenum and proximal jejunal loops are decompressed. There are
multiple loops of dilated small bowel in the mid abdomen measuring up to 3.3
cm with air-fluid levels concerning for small bowel obstruction. There are at
least 2 transition points, 1 in the jejunum in the left upper abdomen (2; 43)
partially obstructing the passage of oral contrast beyond this point, and a
more concerning second transition point at the terminal ileum with twisting of
the mesentery ((601; 28) (2; 54)). The large bowel is diffusely distended to
6 cm with air-fluid levels (601; 13) predominantly proximal to the splenic
flexure, without evidence of stricture or transition point. There is a large
impacted stool ball in the rectum measuring up to 8.2 cm (2; 74) without
significant wall thickening or adjacent fat stranding. Scattered
diverticulosis is noted in the sigmoid colon. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Diffuse osteopenia. there is mild degenerative changes of the lumbar spine
with grade 1 anterolisthesis of L2 on L3.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. There is
a 1.6 cm cystic subcutaneous lesion in the right gluteal cleft (2; 87) is
nonspecific.
IMPRESSION:
1. High grade small bowel obstruction with transition point and mesenteric
twirling at the level of the terminal ileum in the RLQ. A ___ partially
obstructing transition point is seen in the jejunum in the left upper quadrant
without definite cause of obstruction identified.
2. Marked distention of the stomach and colon.
3. Large amount of stool the rectum, likely impacted, without evidence of
stercoral colitis.
4. Changes suggestive of aspiration and mucous plugging in the left lower
lobe.
NOTIFICATION: The findings were discussed with ___, m.D. by ___
___, M.D. on the telephone on ___ at 3:30 pm, 15 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with SBO s/p NG tube placed. // NG tube
placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the nasogastric tube projects over the stomach. There is bibasilar
atelectasis. No consolidation, pleural effusion or pneumothorax. The size of
the cardiac silhouette is within normal limits. The thoracic aorta is
tortuous. Dilated loops of bowel project over the upper abdomen. There are
degenerative changes seen around the glenohumeral joints.
IMPRESSION:
The tip of the nasogastric tube projects over the stomach
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with NG tube, pulled back // NG placement
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
There is stable subsegmental atelectasis in the left lung base.
Cardiomediastinal silhouette is stable. There is no pleural effusion. No
pneumothorax is seen. The NG tube tip projects over the stomach, the side
hole is at the level of the GE junction and needs to be further advanced by at
least 5 cm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p NG tube. // F/u appropriate advancement from
prior film
IMPRESSION:
In comparison with the study of 2 hours previously, the tip of the nasogastric
tube is now distal to the esophagogastric junction. The tube could be pushed
a an additional 5-8 cm for more optimal positioning.
Otherwise, no change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SBO s/p NG tune. // evaluate positioning
IMPRESSION:
In comparison with the earlier study of this date, the nasogastric tube
extends to the upper stomach, were crosses the lower margin of the image.
However, there does not appear to be any further increase in the position of
the side-port, though it is clearly below the esophagogastric junction.
Opacification is again seen in the retrocardiac region. This could well
represent merely atelectatic change. However, in the appropriate clinical
setting, superimposed aspiration/pneumonia would have to be considered.
Remainder of the lungs is clear and there is no evidence of vascular
congestion.
Radiology Report
INDICATION: ___ PMHx for CAD s/p PCI, recent admission (___) for
coffee ground emesis with unrevealing EGD who presents with symptomatic anemia
now with high grade SBO. // eval small bowel follow through, please obtain at
9:30pm
TECHNIQUE: Portable supine abdominal radiograph.
COMPARISON: CT abdomen and pelvis ___.
IMPRESSION:
The enteric tube terminates in the body of the stomach. There are no
abnormally dilated loops of large or small bowel. Oral contrast is seen within
the colon and rectum. There is no free intraperitoneal air, although
evaluation is limited by supine technique. No acute osseous abnormalities are
identified.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Anemia
Diagnosed with Anemia, unspecified
temperature: 98.3
heartrate: 83.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | ASSESSMENT AND PLAN:
====================
___ year old man with CAD s/p PCI (last in ___, Alzheimer's,
CKD III, anemia, HTN and recent admission from ___ for a
mechanical fall admission c/b episode of dark emesis. During
that admission, an was EGD performed which was negative. He
presented from rehab with acute on chronic anemia with Hct 20 in
the absence of evidence of bleeding. Course c/b severe acute
abdominal pain on ___, found to have high grade SBO and
massive colonic fecal load, s/p disimpaction and NG tube
placement. Gastrografin ___ showed improvement and NG tube was
removed and diet advanced to regular. Started on antibiotics on
___ for evidence of aspiration pneumonia for planned 7 day
course through ___.
TRANSITIONAL ISSUES
==================
[ ] Colonoscopy: We would recommend in-depth discussion in the
outpatient setting (likely by primary care) of goals of care and
risks/benefits of further evaluation of his weight loss and iron
deficiency anemia. One could consider CT colonography as a
substitute for colonoscopy as this could show large lesions and
to help guide goals of care. However, this does not negate the
risks of
undergoing prep itself, and will be important to have further
information on his risk of aspiration before proceeding.
[ ] Repeat CBC and BMP in one week
[ ] If continues to need intermittent blood transfusions,
consider connection to outpatient transfusion clinic to discus
for periodic blood transfusion or further IV iron transfusions
[ ] Moderate pHTN and RV dilation on echo ___. No evidence
of heart failure on exam. Consider outpt cards/pulm referral
[ ] Constipation: Ensure daily bowel movements and uptitrate
bowel regimen if needed. If no bowel movement in 2 days would
give soap suds enema
[ ] Weight loss: Would consider further outpatient work-up for
underlying cause if appropriate given goals of care.
[ ] Blood pressure: If blood pressures trend < 120 systolic
would consider discontinuing amlodipine
[ ] Nutrition: Recommend Ensure Enlive shakes three times daily
ACUTE ISSUES:
=============
# High-grade SBO(resolved)
# Mechanical large bowel obstruction from stool burden
# Severe constipation
Found to have high grade SBO and massive colonic fecal load on
CTAP ___, s/p disimpaction and NG tube placement. Possible
cause could be mechanical large bowel obstruction due to massive
fecal load and incompetent ileocecal valve. NG tube was placed,
he was made NPO, and general surgery was consulted.
Gastrograffin study and KUB on ___ showed contrast in rectum
and colon, reassuring against SBO. His diet was advanced to
regular and he remained abdominal pain free with daily bowel
movements with scheduled Miralax, senna, and prn
Bisacodyl/enemas.
# Acute on chronic anemia
Suspect etiology of anemia is multifactorial including iron
deficiency (% saturation 12, ferritin 364, serum iron 33) and
anemia of chronic disease with component of CKD contributing.
Hemolysis labs negative on ___. He received 2u PRBCs on ___
and ___. GI was consulted and noted that while the patient
would no longer be candidate for surveillance colonoscopy
despite recent tubular adenomas (___), he does have a potential
indication for further work-up given his cachexia, weight loss,
and iron deficiency anemia. Given his acute illness, recent
aspiration pneumonia, and significant comorbidities did not
recommend or offer colonoscopy as inpatient at this time. Also
noted that it would be reasonable if the patient did not wish to
pursue colonoscopy in general given his comorbidities. Prior to
discharge he was given IV Ferric gluconate 125 mg (___).
Discharge Hgb 9.1.
# ___ on CKD
Baseline Cr 1.5, presenting with Cr of 2.0, suspect prerenal
given exam. He received 2 units of blood and fluids over the
course of his admission and creatine improved to baseline. On
discharge Cr 1.1.
# Aspiration pneumonia
Patient noted to have increased cough and chest x-ray that
showed retrocardiac opacity on ___ concern for aspiration
pneumonia. He was started on ceftriaxone on ___ to Cefpodoxime
on ___ to complete a total 7-day course on ___. SLP was
consulted and noted aspiration risk, initially recommended soft
diet with nectar thick liquids but was re-evaluated on day of
discharge and upgraded to regular diet with thin liquids.
# Weight loss, poor appetite, severe malnutrition
Unclear etiology of weight loss at this time. TSH only mildly
elevated at 4.5 on ___. CRP elevated at 69.8 this admission.
Would consider further outpatient work-up for underlying cause
if appropriate given goals of care.
CHRONIC ISSUES:
===============
# History of recent Falls
On prior admission presented w/ increased falls of unclear
etiology. PCP was concerned about possible hypotension secondary
to amlodipine, lisinopril during last admission and lisinopril
was stopped. This admission amlodipine was held in the setting
of concern for bleeding but was restarted prior to discharge.
#History of gout
Continued home allopurinol
#Hypertension
Amlodipine was held on admission given concern for bleeding. On
discharge it was restarted given blood pressures were
hypertensive to 150s systolic.
#Coronary artery disease
#Hyperlipidemia
Initially held aspirin in the setting of concern for bleeding
but was restarted prior to discharge. Resumed home atorvastatin
80.
#MGUS Followed as outpatient, stable
#Moderate pHTN and RV dilation on echo ___.
No evidence of heart failure on exam.
CORE MEASURES
=============
#CODE: DNR/DNI
#CONTACT: Name of health care proxy: ___
___: Daughter Phone number: ___
Mr. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Oxycodone
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic converted to open cholecystectomy,
lysis of adhesions, cholangiogram and repair of hepatic duct.
History of Present Illness:
This is ___ years old female with past medical history of
obesity,
GERD, HLD who now presented with abdominal pain and nausea.
Patient reports epigastric pain since yesterday 5PM, continuous,
dull in character now increasing and mostly in RUQ since last 4
hours. Patient reported nausea, no emesis, no change in BM, no
dysuria, no prior similar pain. Patient reports no chills, no
fevers. Patient had colonoscopy ___ years ago with negative
findings. Patient reports passing flatus and having BM.
Upon evaluation in ED patient comfortable in the bed, in no
apparent distress with epigastric/RUQ discomfort.
Past Medical History:
GYN HISTORY: In terms of her GYN history, the patient has a
history of normal periods, though over the last one to ___
years, they have become less frequent. Her last menstrual
period was on ___ and the period prior to that was
in ___. When her periods do come, they are very light
with only a few days of spotting. She denies any heavy bleeding
or irregular intermenstrual bleeding. She also complains of
urinary frequency and the feeling of incomplete bladder emptying
when she does void likely associated with the increasing size of
her uterine mass.
PAST MEDICAL HISTORY: Notable for obesity as well as seasonal
asthma.
PAST SURGICAL HISTORY: Notable for dental surgery in ___.
Social History:
___
Family History:
Significant for breast cancer in her mother as well as a
maternal grandmother. Her father has cardiac disease. She does
also note a significant family history for uterine fibroids with
a sister and a mother who had undergone hysterectomy for this
condition.
Physical Exam:
Physical exam on admission ___:
Vitals: afebrile, hemodynamically stable,
Gen: NAD, A&O x 3
CV: no cardiac distress
Pulm: breathing comfortably on room air
Abd: soft, nondistended, tender in epigastric/RUQ pain with
minimal guarding, ___ sign, no palpable masses or
hernias, old midline incision healed,
Ext: warm and well perfused
Physical exam on discharge ___:
Vitals: afebrile, hemodynamically stable,
Gen: NAD, A&O x 3
CV: no cardiac distress
Pulm: breathing comfortably on room air
Abd: soft, nondistended, nontender, dressings c/d/i
Ext: warm and well perfused
Pertinent Results:
___ 07:40PM BLOOD WBC-10.8* RBC-4.77 Hgb-14.5 Hct-43.5
MCV-91 MCH-30.4 MCHC-33.3 RDW-12.4 RDWSD-41.2 Plt ___
___ 07:40PM BLOOD Neuts-82.1* Lymphs-12.5* Monos-4.4*
Eos-0.2* Baso-0.6 Im ___ AbsNeut-8.86* AbsLymp-1.35
AbsMono-0.47 AbsEos-0.02* AbsBaso-0.07
___ 07:40PM BLOOD Glucose-176* UreaN-11 Creat-0.8 Na-138
K-4.9 Cl-100 HCO3-22 AnGap-16
___ 07:40PM BLOOD ALT-73* AST-53* AlkPhos-140* TotBili-0.6
___ 07:40PM BLOOD Lipase-27
___ 07:40PM BLOOD cTropnT-<0.01
___ 05:58AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0
___ 11:39PM BLOOD Lactate-2.5*
___ 02:03AM BLOOD Lactate-1.7
IMAGING:
___ RUQUS
1. Mildly distended gallbladder with a large gallstone near the
gallbladder
neck and a positive sonographic ___ sign. Findings are
highly concerning
for acute cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease
and more advanced liver disease including steatohepatitis or
significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
___ CT ABDOMEN AND PELVIS
1. No evidence of acute abnormality in the abdomen or pelvis.
Specifically no
evidence of vascular injury in the liver.
2. Status post open cholecystectomy with postsurgical
intra-abdominal air and
changes to the anterior abdominal wall.
3. Diffuse geographic hypodensity within segment ___ likely due
to geographic
steatosis versus retraction contusion of the liver.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 1
tablet(s) by mouth every six (6) hours Disp #*10 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Injury of right hepatic duct
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 epigastric RUQ pain. // gallstones or
cholesystitis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis dated ___ and renal ultrasound
dated ___
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The common bile duct
is not adequately visualized.
GALLBLADDER: The gallbladder is mildly distended with a large gallstone near
the gallbladder neck measuring up to 2.7 cm. No definite gallbladder wall
thickening, mural edema, or pericholecystic fluid. Sonographic ___ sign
is positive.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 9 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.Left peripelvic
renal cysts redemonstrated.
Right kidney: 10.3 cm
Left kidney: 11.9 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Mildly distended gallbladder with a large gallstone near the gallbladder
neck and a positive sonographic ___ sign. Findings are highly concerning
for acute cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
RECOMMENDATION(S): Radiological evidence of fatty liver does not exclude
cirrhosis or significant liver fibrosis which could be further evaluated by
___. This can be requested via the ___ (FibroScan), or the
Radiology Department with MR ___, in conjunction with a GI/Hepatology
consultation" *
* ___ et al. The diagnosis and management of nonalcoholic fatty liver
disease: Practice guidance from the ___ Association for the Study of
Liver Diseases. Hepatology ___ 67(1):328-357
Radiology Report
EXAMINATION: ABDOMEN (SUPINE ONLY)
INDICATION: Intraoperative fluoroscopy.
TECHNIQUE: Intraoperative fluoroscopy.
COMPARISON: None
FINDINGS:
175 intraoperative images were acquired without a radiologist present.
Please refer to operative note for details of the procedure.
IMPRESSION:
Intraoperative images were obtained during cholecystectomy. Please refer to
the operative note for details of the procedure.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old woman with lap chole, right hepatic duct injury s/p
repair // biliary dilation? arterial blood flow?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound ___
FINDINGS:
Please note that this is an extremely limited exam due to overlying bandages
(we were asked not to remove them), intervening bowel gas, and pain.
Within these limitations, there is no definite large focal abnormalities
within the liver parenchyma. Unable to assess for biliary dilation and
hepatic artery blood flow given technical limitations of the study.
There is no ascites in the right lower quadrant.
IMPRESSION:
Extremely limited exam due to multiple technical limitations. Unable to
evaluate for biliary dilation or hepatic artery blood flow. If there is high
clinical concern, consider evaluation with contrast enhanced CT.
Radiology Report
EXAMINATION: CT ABD WANDW/O C
INDICATION: ___ year old woman with cholecystitis s/p open chole with right
hepatic duct injury // Triple phase liver CT, in particular assess blood flow
to right hepatic lobe, biliary ducts
TECHNIQUE: Multiphasic Liver: 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 was scanned in the early arterial phase, followed by a scan of the
abdomen in the portal venous phase, followed by a scan of the abdomen in
equilibrium phase (3-min delay).
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 1.9 s, 29.7 cm; CTDIvol = 5.8 mGy (Body) DLP = 172.5
mGy-cm.
2) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 24.4 mGy (Body) DLP = 686.7
mGy-cm.
3) Spiral Acquisition 2.2 s, 29.7 cm; CTDIvol = 24.4 mGy (Body) DLP = 723.9
mGy-cm.
4) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 24.4 mGy (Body) DLP = 687.0
mGy-cm.
5) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
6) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.4 mGy (Body) DLP =
6.7 mGy-cm.
Total DLP (Body) = 2,279 mGy-cm.
COMPARISON: Ultrasound of the liver from ___. CT of the abdomen
pelvis from ___.
FINDINGS:
LOWER CHEST: The lung bases are clear aside from mild dependent changes.
ABDOMEN:
HEPATOBILIARY: The liver has diffusely low density consistent with steatosis.
There is no suspicious focal lesion. There is a diffusely hypoechoic
attenuating region segment ___ which likely represents a region of retraction
contusion after the given history of open cholecystectomy. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. Postsurgical
changes are seen in the right upper quadrant with locules of intraperitoneal
air. No evidence of discrete fluid collection. The gallbladder is surgically
absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions. A left-sided extrarenal is
noted. There is no perinephric abnormality. There is no hydronephrosis or
hydroureter.
GASTROINTESTINAL: Small hiatal hernia. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement. The colon and rectum are within
normal limits.
LYMPH NODES: No evidence of retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: The common, left and right hepatic arteries are patent without
evidence of dissection or occlusion. No evidence of injury to the hepatic or
portal veins. No significant atherosclerotic disease is noted. There is no
abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Ankylosis is noted of the anterior thoracic spine.
SOFT TISSUES: Postsurgical changes are seen along the anterior abdominal wall.
No evidence of discrete fluid collection.
IMPRESSION:
1. No evidence of acute abnormality in the abdomen or pelvis. Specifically no
evidence of vascular injury in the liver.
2. Status post open cholecystectomy with postsurgical intra-abdominal air and
changes to the anterior abdominal wall.
3. Diffuse geographic hypodensity within segment ___ likely due to geographic
steatosis versus retraction contusion of the liver.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Epigastric pain
Diagnosed with Calculus of gallbladder w acute cholecyst w/o obstruction
temperature: 97.8
heartrate: 72.0
resprate: 16.0
o2sat: 96.0
sbp: 142.0
dbp: 70.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ was admitted under the acute care surgery service for
management of her acute cholecystitis. She was taken to the
operating room and underwent a laparoscopic converted to open
cholecystectomy. Her OR course was complicated by injury to the
hepatic duct. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. She was subsequently taken to the PACU for
recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced slowly to
regular, which she tolerated without abdominal pain, nausea, or
vomiting. She was voiding adequate amounts of urine without
difficulty. She was encouraged to mobilize out of bed and
ambulate as tolerated, which she was able to do independently.
Her pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
Due to the nature of her hepatic injury, she was followed by the
liver transplant service. She had a RUQUS which was limited, so
she then had a triple phase liver CT to assess blood flow to her
right hepatic lobe and biliary ducts. CT imaging revealed no
evidence of vascular injury in the liver. Throughout her
hospitalization, she had progressively elevating alk phos but
normalizing transaminase.
On ___, she was discharged home with scheduled follow up in
___ clinic with repeat LFTs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
Coronary angiogram ___
History of Present Illness:
Mr. ___ is a ___ yo man with H/O CAD s/p CABG ___ with
multiple PCIs (before and after CABG), ESRD on HD, hypertension,
and type 2 diabetes mellitus on insulin presenting with 3 days
of epigastric pain associated with emesis and diaphoresis. He
declined an interpreter for this interview multiple times. The
pain was not associated with exertion and not typical for his
angina. He initially attributed this to antibiotics he has been
taking for the past 2 weeks. He noted that with his past MIs, he
had "big pain" and did not feel like his recent symptoms. He
denied any exertional dyspnea, paroxysmal nocturnal dyspnea,
orthopnea, lower extremity edema. He had blood red blood per
rectum occasionally at home from his hemorrhoids, but none
recently. He denied any fevers, chills, night sweats, or
productive cough.
In the ED initial vitals were: T 97.4 HR 72 BP 149/58 RR 16 SaO2
99% on RA. EKG showed T wave inversion in leads I, aVL, V2-V5.
Labs/studies notable for: troponin-T 0.37, 0.38, 0.39, CK-MB 1,
Cr 5.1. CXR had airspace opacities in right lower lung that
might represent developing pneumonia. Patient was given ASA 243
mg, heparin gtt, ceftriaxone and azithromycin.
After arrival to the cardiology ward, the patient denied any
current chest pain or epigastric pain like he was having before
admission.
Past Medical History:
1. CAD RISK FACTORS
-Hypertension
-Diabetes Mellitus, Insulin requiring
-Hyperlipidemia
2. CARDIAC HISTORY
CAD
-NSTEMI ___ treated with ___ ___ treated with off-pump CABG ___ (LIMA-LAD,
___, SVG-D)
-NSTEMI ___ treated with PTCA ___ touchdown, ___
___.
-Acute ischemic mitral regurgitation, improved after ___
stenting
3. OTHER PAST MEDICAL HISTORY
-Diabetic foot ulcer Left foot
-End-Stage Renal Disease on HD
-Anemia of Chronic Disease
-Glaucoma
-Latent Tuberculosis treated with INH/B6 x 9 months
-Obstructive Sleep Apnea
-Peripheral Arterial Disease
-Meningioma
-Hemorrhoids
Social History:
___
Family History:
No FH of early CV disease, DM, hypertension. Father with
multiple strokes.
Physical Exam:
On admission
GENERAL: Elderly black man sitting up in bed in no acute
distress.
VS: T 97.8 PO BP 152/70 left arm supine HR 61 RR 18 SaO2 97% on
RA
HEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. JVP at 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line, increased intensity. Regular rate and rhythm. Normal S1,
S2. No murmurs, rubs, or gallops.
LUNGS: Respiration is unlabored with no accessory muscle use.
CTAB--no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, not distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. Left heel with necrotic ulcer without purulent
drainage, mild tenderness.
NEURO: CN II-XII intact. Strength ___ x4 extremities. Sensation
Intact to Light Touch x4 extremities.
SKIN: No rashes
PULSES: Radial and DP pulses 1+
At discharge
GENERAL: Elderly male sitting in bed in no acute distress.
24 HR Data (last updated ___ @ 817) Temp: 98.2 (Tm 98.4),
BP: 133/56 (98-159/45 thigh-91), HR: 69 (59-70), RR: 18 (___),
O2 sat: 93% (93-98), O2 delivery: A
Wt: 137.57 lb/62.4 kg
HEENT: Mucous membranes moist.
NECK: JVP 7 cm.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: Respiration is unlabored with no accessory muscle use.
CTAB. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, not distended. No hepatomegaly. No
splenomegaly. Normoactive bowel sounds.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. LUE with AV fistula with palpable thrill. Left
heel with necrotic ulcer without purulent drainage, mild
tenderness. Right wrist access site with bandage.
NEURO: Alert and conversant, moving all extremities
SKIN: No rashes
PULSES: Radial pulses 2+ bilaterally
Pertinent Results:
___ 01:50AM BLOOD WBC-9.1 RBC-3.73* Hgb-10.2* Hct-33.4*
MCV-90 MCH-27.3 MCHC-30.5* RDW-15.3 RDWSD-49.1* Plt ___
___ 07:50AM BLOOD ___ PTT-95.6* ___
___ 01:50AM BLOOD Glucose-252* UreaN-30* Creat-5.1* Na-139
K-4.1 Cl-98 HCO3-29 AnGap-12
___ 01:50AM BLOOD cTropnT-0.37*
___ 07:50AM BLOOD cTropnT-0.38*
___ 09:17AM BLOOD cTropnT-0.39*
___ 06:15PM BLOOD CK-MB-1 cTropnT-0.38*
ECG ___ 23:19:32
Sinus rhythm. Probable left atrial enlargement. LVH with
secondary repolarization abnormality
CXR ___
Median sternotomy wires are intact. The cardiac silhouette is
mildly enlarged and stable. Patchy airspace opacities at the
right lung base are present and may represent developing
pneumonia in the appropriate clinical setting. There is no
pleural effusion, or pneumothorax. The mediastinal contour
stable.
IMPRESSION: Right lower lung airspace opacities may represent
developing pneumonia in the appropriate clinical setting.
Coronary angiogram ___
LM: The left main coronary artery had 40% distal.
LAD: The left anterior descending coronary artery was calcicifed
with 60-70% diffuse mid with retrograde filling of the LIMA.
Circ: The circumflex coronary artery was occluded proximally at
the location of prior stent. Collaterals were present.
RCA: The right coronary artery was occluded mid. Collaterals
were present.
LIMA-LAD: A left internal mammary artery to the LAD was not
engaged, as known atretic from prior study.
___: A saphenous vein graft to the OM was with widely patent
stents.
SVG-Diagonal: A saphenous vein graft to the Diagonal was widely
patent.
FINDINGS:
Three vessel coronary artery disease (similar to prior).
Patent ___ and SVG-Diagonal.
No clear culprit lesion identified.
DISCHARGE LABS
___ 06:13AM BLOOD WBC-6.1 RBC-3.44* Hgb-9.6* Hct-30.8*
MCV-90 MCH-27.9 MCHC-31.2* RDW-15.7* RDWSD-50.7* Plt ___
___ 03:58AM BLOOD ___ PTT-52.5* ___
___ 06:13AM BLOOD Glucose-164* UreaN-24* Creat-5.0*# Na-140
K-4.4 Cl-98 HCO3-28 AnGap-14
___ 06:13AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Prasugrel 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. CARVedilol 25 mg PO BID
5. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Cinacalcet 30 mg PO DAILY
7. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS
8. Lisinopril 40 mg PO DAILY
9. amLODIPine 10 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. CeFAZolin 2 g IV POST HD (___)
2. CeFAZolin 3 g IV POST HD (SA)
3. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. CARVedilol 25 mg PO BID
8. Cinacalcet 30 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Lisinopril 40 mg PO DAILY
11. Prasugrel 10 mg PO DAILY
12. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
-Non-ST segment elevation myocardial infarction
-Coronary artery disease, native and arterial conduit
-Prior coronary artery bypass surgery
-Left heel ulcer
-Type 2 diabetes mellitus, on insulin
-End-stage renal disease on hemodialysis
-Hypertension
-Hyperlipidemia
-Glaucoma
-Anemia of chronic disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with nauea, emesis, ekg changes, epigastric pain//
?pna ?pulm edema ?pnx
COMPARISON: Multiple prior chest radiographs most recently dated ___
FINDINGS:
PA and lateral views of the chest provided.
Median sternotomy wires are intact. The cardiac silhouette is mildly enlarged
and stable. Patchy airspace opacities at the right lung base are present and
may represent developing pneumonia in the appropriate clinical setting. There
is no pleural effusion, or pneumothorax. The mediastinal contour stable.
IMPRESSION:
Right lower lung airspace opacities may represent developing pneumonia in the
appropriate clinical setting.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: Epigastric pain
Diagnosed with Acute ischemic heart disease, unspecified
temperature: 97.4
heartrate: 72.0
resprate: 16.0
o2sat: 99.0
sbp: 149.0
dbp: 58.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ is a ___ yo man with H/O CAD with NSTEMI treated with
DES to ___ ___, NSTEMI treated with CABGx3 ___, NSTEMI treated
with DES to SVG->OM1 ___, ESRD on HD, hypertension, type 2
diabetes mellitus on insulin presenting with 3 days of
epigastric pain associated with emesis and diaphoresis. He was
found to have NSTEMI based on elevated troponin-T and underwent
coronary angiography ___ which showed patent vein grafts and no
change underlying CAD.
ACUTE ISSUES
# NSTEMI, CAD. s/p ___ ___, CABG ___ (LIMA-LAD, ___,
SVG-D), ___. He presented with post-prandial
epigastric pain with diaphoresis and emesis, T wave inversions
on EKG, elevated troponin-T peaked at 0.39 (ESRD but above last
troponin 0.17 in ___, consistent with NSTEMI. He was started
on a heparin gtt. Coronary angiography ___ showed three
vessel coronary artery disease (similar to prior, with known
atretic LIMA-LAD), patent ___ and SVG-Diagonal, and no clear
culprit lesion identified. He was continued on home aspirin,
prasugrel (to be continued through ___ with
anticipation of lifelong DAPT per outpatient cardiologist if no
bleeding issues), carvedilol, amlodipine, and lisinopril.
# Left heel ulcer: This did not appear grossly infected this
admission, continued outpatient cefazolin post-HD (2 gm ___ and
___ and 3 gm ___ with end date ___.
CHRONIC ISSUES
# Hypertension: Continued home carvedilol, lisinopril,
amlodipine.
# Type 2 diabetes mellitus on insulin: Continued glargine 10
units at breakfast, insulin sliding scale.
# ESRD on HD ___: Previously on peritoneal dialysis,
catheter removed in setting of bacterial peritonitis in ___
and transitioned to hemodialysis. Continued home cinacalcet,
sevelamer. Received HD ___.
# Anemia of renal disease: Chronic normocytic anemia with Hgb
10.2 on presentation, unchanged from baseline.
# Glaucoma: Continued home latanoprost drops.
TRANSITIONAL ISSUES
[] On HD ___, last HD on ___
[] Continued cefazolin ___ post HD, on antibiotic course
through ___ as outpatient for left heel ulcer. Cefazolin 2 g on
___ and ___ and Cefazolin 3 g on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Mercaptopurine / Ketorolac / Ibuprofen / Flagyl / Reglan /
Zofran / Gabapentin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with hx of history of ileocolonic ___ disease s/p
subtotal colectomy with ileorectal anastamosis who has failed
azathioprine, Remicade, Cimzia, Tysabri and is steroid dependent
presenting to the ED with worsening abdominal pain and diarrhea.
.
Patient reports worsening abdominal pain for the last week c/w
his previous episodes of Crohns. Patient reports intermittent
left sided pain for the last 1.5 days that starts in his lower
back and moves towards his stomach rated ___ in severity.
Pain improves by holding area or with heat. Also has more
generalized abdominal pain that is worse in the RLQ and LUQ that
is ___ in severity and constant for ___ hours at a time. He
says that at baseline he has 12 BMs per day but last night had
over 20 BMs from 9pm to 7am. He has not had anything to eat in
the last day and now feels his bowels have slowed due to that.
His BMs are watery and dark brown. Denies blood in stool but
does have some blood around rectal area with wiping. He reports
sweats but denies fevers at home. Also has intermittent nausea
but denies vomitting. No hematuria or dysuria.
.
In the ED, initial VS: 98.3 66 103/71 20 97% RA. Labs were
significant for elevated WBC count to 11.2 with left shift of
>90% PMNs. Electrolytes, LFTs, and lipase WNL. UA without
evidence of infection or blood. CXR without evidence of
consolidation.
He was give 1L of NS and 1 mg IV dilaudid x3.
.
Currently, patient still reporting abdominal pain and diarrhea.
.
ROS: Denies fever, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
vomiting, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
Past Medical History:
- Crohns disease - ileocolonic ___ disease s/p
subtotal colectomy with ileorectal anastamosis who has failed
azathioprine, Remicade, Cimzia, Tysabri and is steroid dependent
- nephrolithiais
- L knee dislocation
- DJD in back with herniated disk
- cataracts
- anemia
- b12 deficiency
- *S/P LEFT TESTICLE REMOVAL pt reported surgery was done b/c
left
testicle became "hard" after the longterm steroids
- hx of atypical chest pain - negative stress in ___
- latent TB treated with INH in ___
Social History:
___
Family History:
- Mother: died of ovarian cancer
- Father: died of throat cancer, asthma
- 1 Sister: ___ Disease
- 1 Sister with T2DM
Physical Exam:
admission exam
VS - Temp ___, BP: 107/66, HR: 57, RR: 18, O2-sat 98% RA
GENERAL - middle-aged male in some distress, holding abdomen in
pain
HEENT - NC/AT, EOMI, sclerae anicteric, OP clear
NECK - supple, no cervical lymphadenopathy
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft. Diffusely tender to palpation mostly in
LUQ and RUQ. No rebound or guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - small excoriated vesicular lesions with erythematous base
on upper extremities, chest which are chronic per patient,
tatoos over extremities
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
discharge exam
Pertinent Results:
admission labs:
___ 01:30PM BLOOD WBC-11.2*# RBC-4.74# Hgb-13.5*# Hct-40.6
MCV-86 MCH-28.5 MCHC-33.3# RDW-14.2 Plt ___
___ 01:30PM BLOOD Neuts-91.1* Lymphs-5.8* Monos-2.3 Eos-0.3
Baso-0.5
___ 01:30PM BLOOD ESR-6
___ 01:30PM BLOOD CRP-2.4
___ 01:30PM BLOOD Glucose-94 UreaN-18 Creat-1.1 Na-142
K-4.2 Cl-108 HCO3-25 AnGap-13
___ 01:30PM BLOOD ALT-38 AST-22 AlkPhos-57 TotBili-0.4
___ 01:30PM BLOOD Albumin-4.4 Calcium-8.8 Phos-2.7 Mg-2.1
___ 01:52PM BLOOD Lactate-2.0
.
urine
___ 01:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
.
micro
urine culture - no growth
stool studies (O&P, Cryptosporidium/Giardia (DFA), Cyclospora,
Microsporidium) pending at time of discharge
Cdifficile negative
CMV viral load pending at time of discharge
.
studies:
CXR: (preliminary read) No evidence of pneumonia. Likely
prominent nipple shadow overlying the right lung.
Medications on Admission:
-loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day).
-omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
-prednisone - has been on taper, was on 60 daily. Last week was
on 30 daily and increased to 35 daily with symptoms. On 25 mg
daily on admission
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
3. cholestyramine (with sugar) 4 gram Packet Sig: One (1) Packet
PO BID (2 times a day).
Disp:*60 Packet(s)* Refills:*0*
4. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Percocet ___ mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain: please do not take this medication
while driving or performing activities that require full
alterness as this medication can cause drowsiness.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
___ disease exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: CHEST, FRONTAL AND LATERAL VIEWS.
CLINICAL INFORMATION: ___ male with history of Crohn's disease,
abdominal pain.
___.
FINDINGS: Frontal and lateral views of the chest are obtained. This study
was made available for interpretation, today, ___ at 3:30 p.m. A
preliminary wet read was provided by Dr. ___, which indicated
no evidence of pneumonia. Likely prominent nipple shadow over the right lung.
Small rounded opacity projecting over the right lung base most likely
represents nipple shadow, which could be confirmed with repeat with nipple
markers. There is a subtle patchy opacity at the left lung base which
represents atelectasis or early pneumonia in the appropriate clinical setting.
No pleural effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are unremarkable. No pulmonary edema is seen.
IMPRESSION: Left base opacity could be due to atelectasis or early pneumonia
in the appropriate clinical setting.
The above findings were discussed with Dr. ___ at 3:40 p.m. on
___ via telephone.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with REGIONAL ENTERITIS NOS
temperature: 98.3
heartrate: 66.0
resprate: 20.0
o2sat: 97.0
sbp: 103.0
dbp: 71.0
level of pain: 10
level of acuity: 3.0 | ___ yo M with hx of ileocolonic ___ disease s/p subtotal
colectomy with ileorectal anastamosis who has failed
azathioprine, Remicade, Cimzia, Tysabri and is steroid dependent
presenting to the ED with worsening abdominal pain and diarrhea.
.
# ___ flare - Patient presenting with abdominal pain and
diarrhea consistent with prior ___ flare. He was evaluated
by the GI team and started on IV methylprednisone 20 mg TID. In
addition he was started on cholestyramine and continued on his
home loperamide. Pain was controlled with dilaudid and tylenol.
Cdiff was negative. His bowel movements decreased in frequency
and became more formed. He was transitioned to po prednisone and
oxycodone. His diet was advanced to regular and he tolerated it
well. His CMV viral load and stool studies were pending at time
of discharge. Patient was discharged home with plans to continue
prednisone and to follow up with his gastroenterologist and
primary care physicians.
.
Transitional issues:
- Given history of renal colic and large stone can consider
outpatient urology follow up.
- Patient should also have appropriate prophylaxis for chronic
steroid use and this should be addressed at primary care follow
up.
- CMV viral load and stool studies (O&P, Cryptosporidium/Giardia
(DFA), Cyclospora, Microsporidium) pending at time of discharge
- patient was full code on this admission |
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:
___ is a ___ yo ___ speaking man with newly
diagnosed
HIV (CD4 ___. VL detected <1.3 ___ and recent
biliary
obstruction from ampullary mass s/p metal stent, who presented
after final pathology from ampulla showed Burkitt Lymphoma.
Mr ___ was admitted ___ after presenting with abdominal
and transaminitis to his ID physician. Workup revealed an
obstructive ampullary mass s/p metal CBD stent (placed ___ and
a small bowel mass on CT A/P that could not be reached
endoscopically.
Today, the ampulla biopsy resulted with Burkitt Lymphoma. He was
directed to present to the ED for admission and urgent
chemotherapy initiation.
In the ED: T98.2 | 94-115 | 116/82 | 100% RA. A CT C/A/P was
performed:
1. Malignant small-bowel obstruction transitioning at known
small-bowel tumor consistent with recently diagnosed Burkitt's
lymphoma. Trace free fluid.
2. Prominent right lower quadrant mesenteric lymph nodes
re-demonstrated.
3. Indeterminate liver lesion in segment 6 requires MRI to
further assess.
4. New CBD stent in place in this patient with reported new
diagnosis of an ampullary mass.
5. 2 discrete 6 mm nodules in the right middle and right lower
lobes, bears attention on followup imaging.
Mr. ___ endorsed nausea and constipation x 1 week, which
further raised concern for malignant SBO. ACS was consulted.
However in the interim, he had a large bowel movement.
He received 4 mg IV morphine, 4 mg IV Zofran, 2L NS and 300 mg
allopurinol prior to admission to oncology.
On arrival to oncology, Mr. ___ states he feels much better
after his bowel movement. He recalls that he had a distended
abdomen this morning that has resolved. He had continued to pass
small amounts of gas over the last week. He had one episode of
green bilious emesis this AM. He has had ongoing crampy
abdominal
discomfort and nausea since discharge
He denies fevers/chills, night sweats, fatigue, easy
bruising/bleeding. He has had 10 lb weight loss in last ___
months (223 lb ___ 209 lb ___ with preserved appetite.
He has not taken Biktarvy for the last 3 weeks. He initially
held
it due to concern that his nausea was side effect from
medication. He was instructed to resume it at his ID appt last
week but he did not d/t ongoing abd discomfort.
Past Medical History:
- HIV on Biktarvy since ___
No resistance detected
RT GENE MUTATIONS: R211K,F214L
PR GENE MUTATIONS: D60E/D,L63T,V77I/V,L89M
- Burkitt Lymphoma w/ malignant biliary obstruction s/p metal
CBD
stent ___
Social History:
___
Family History:
No history of HIV
Mother: ___
Father: No known problems
Siblings (in ___ are well
No children
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: T 100.0 F | 111/65 | 94 | 96% RA
General: Well appearing Hispanic man, resting in bed comfortably
Neuro:
Cranial nerves: PERRL, palate elevates symmetrically, tongue
midline
Alert and oriented, asking appropriate questions during
chemotherapy consent
HEENT: Oropharynx clear, slightly dry mucus membranes, no
palpable cervical, supraclavicular adenopathy
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally
Abdomen: Soft, nontender, nondistended, hyperactive bowel
sounds.
No hepatosplenomegaly
Extr/MSK: No peripheral edema
Skin: No rashes seen over torso, arms, legs
Access: Tunneled central line over right chest placed hours
earlier is tender to palpation, no surrounding edema, induration
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 1345)
Temp: 98.9 (Tm 100.1), BP: 136/89 (105-147/64-89), HR: 78
(77-104), RR: 16 (___), O2 sat: 99% (98-100), O2 delivery: RA,
Wt: 199.4 lb/90.45 kg
General: Well appearing, sitting in chair
Neuro:
Cranial nerves: PERRL, palate elevates symmetrically, tongue
midline, EOMI w/o c/f for CN palsy, moves all limbs
HEENT: Oropharynx clear, MMM, no c/f mucositis or thrush, no
palpable cervical, supraclavicular adenopathy
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally
Abdomen: Soft, mild epigastric tenderness, mildly distended,
hyperactive bowel sounds. No hepatosplenomegaly
Extr/MSK: No peripheral edema, no dependenet edema of thighs or
back
Skin: No rashes seen over torso, arms, legs
Access: PIV
Pertinent Results:
ADMISSION LABS
===============
___ 10:00AM BLOOD WBC-9.0 RBC-3.79* Hgb-9.4* Hct-29.8*
MCV-79* MCH-24.8* MCHC-31.5* RDW-16.0* RDWSD-44.9 Plt ___
___ 10:00AM BLOOD Neuts-68.3 ___ Monos-10.4
Eos-0.7* Baso-0.4 Im ___ AbsNeut-6.16* AbsLymp-1.80
AbsMono-0.94* AbsEos-0.06 AbsBaso-0.04
___ 12:00AM BLOOD Hypochr-1+* Anisocy-2+* Poiklo-1+*
Macrocy-1+* Microcy-1+* Polychr-NORMAL Schisto-1+* Fragmen-1+*
Ellipto-1+*
___ 10:00AM BLOOD Plt ___
___ 12:00AM BLOOD ___ 10:00AM BLOOD Glucose-92 UreaN-20 Creat-0.9 Na-134*
K-4.5 Cl-92* HCO3-25 AnGap-17
___ 10:00AM BLOOD ALT-17 AST-31 LD(LDH)-399* AlkPhos-149*
TotBili-0.6
___ 10:00AM BLOOD Lipase-38
___ 10:00AM BLOOD Albumin-3.2* Calcium-8.2* Phos-4.4 Mg-2.1
UricAcd-8.2*
___ 10:17AM BLOOD Lactate-1.7
MICROBIOLOGY
=============
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
98 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
If current infection is suspected, submit follow-up serum
in ___
weeks.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
___ 10:44 am ABSCESS Source: Liver Asbcess.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:01 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
INTERVAL RESULTS / IMAGING
============================
BM CYTOGENETICS
FISH: NEGATIVE HIGH GRADE LYMPHOMA PANEL. No evidence of
interphase bone marrowcells with the rearrangement of the MYC
gene that was observed in an ampulla of Vater mass thatwas
biopsied on ___. There was also no evidence of the IGH/BCL2
gene rearrangement or rearrangement of the BCL6.
CT (___)
IMPRESSION:
1. Malignant small-bowel obstruction transitioning at known
small-bowel tumor
consistent with recently diagnosed Burkitt's lymphoma. Trace
free fluid.
2. Prominent right lower quadrant mesenteric lymph nodes
re-demonstrated.
3. Indeterminate liver lesion in segment 6 requires MRI to
further assess.
4. New CBD stent in place in this patient with reported new
diagnosis of an ampullary mass.
5. 2 discrete 6 mm nodules in the right middle and right lower
lobes, bears attention on follow-up imaging.
TTE (___)
IMPRESSION: Normal left ventricular cavity size, regional/global
systolic function. No valvular pathology or pathologic flow
identified. Normal estimated pulmonary artery systolic pressure.
LIVER MRI (___)
IMPRESSION:
1. Lesion in the right lobe of the liver shows characteristics
most
consistent with small pyogenic abscess, decreasing in size.
Minimal fluid
content, noting that the central part consists of a number of
tiny loculations separated measuring up to 5-6 mm with
septations.
2. Distal ileal mass consistent with known lymphoma. Decreased
distension and dilation of proximal to mid small bowel
suggesting improvement in distal obstruction. However, new wall
thickening and edema are observed throughout the upstream small
bowel suggesting recent congestive or even ischemic changes
during the time since the most recent prior CT. Normal
enhancement at this time, however.
3. Abnormal bone marrow signals concerning for bone marrow
involvement or
other bone marrow abnormality.
CT C/A/P (___)
IMPRESSION:
1. Small and large bowel wall thickening, including some
segments of small
bowel with targetoid appearance and intramural edema, has
increased compared
to the prior day's MRI. Similar small amount of mesenteric
fluid and now with
new small amount of ascites. Findings raise concern for a
developing
infectious or inflammatory enterocolitis which has developed
while small bowel
obstruction has resolved.
2. Resolved small-bowel obstruction, with contrast passing
freely into the
colon.
3. Slight interval decrease in the hepatic segment VI
attenuating lesion.
4. Re-demonstration of the ileal mass consistent with known
lymphoma.
Measurement of this mass is difficult due to differences in
distention of the small bowel, but there is the suggestion of
early involution.
CT A/P (___)
IMPRESSION:
1. Evolving right liver lobe abscess with no size interval
increase.
2. Interval disease improvement with complete resolution of the
ileal mass not seen on today evaluation.
DISCHARGE LABS
===============
___ 06:45AM BLOOD WBC-2.1* RBC-3.13* Hgb-7.5* Hct-24.6*
MCV-79* MCH-24.0* MCHC-30.5* RDW-18.6* RDWSD-49.4* Plt ___
___ 06:45AM BLOOD Neuts-80* Bands-1 Lymphs-14* Monos-2*
Eos-0 Baso-3* ___ Myelos-0 AbsNeut-1.70
AbsLymp-0.29* AbsMono-0.04* AbsEos-0.00* AbsBaso-0.06
___ 06:45AM BLOOD Hypochr-NORMAL Anisocy-2+* Poiklo-1+*
Macrocy-1+* Microcy-1+* Polychr-OCCASIONAL Ovalocy-1+* Tear
___
___ 06:45AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:45AM BLOOD ___ PTT-26.9 ___
___ 12:00AM BLOOD ___
___ 06:45AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-143 K-4.5
Cl-105 HCO3-27 AnGap-11
___ 06:45AM BLOOD ALT-61* AST-79* LD(LDH)-214 AlkPhos-80
TotBili-0.2
___ 06:45AM BLOOD Calcium-8.9 Phos-6.0* Mg-2.0 UricAcd-3.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Biktarvy (bictegrav-emtricit-tenofov ala) 50-200-25 mg oral
DAILY
2. Ferrous GLUCONATE 324 mg PO BID
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
3. Fluconazole 400 mg PO Q24H
RX *fluconazole [Diflucan] 200 mg 2 tablet(s) by mouth Q24H Disp
#*60 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 PACKET by mouth
DAILY Disp #*30 Packet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Simethicone 40 mg PO TID:PRN Bloating/Abd pain
RX *simethicone 125 mg 1 tablet by mouth TID PRN Disp #*30
Capsule Refills:*0
7. 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
8. Biktarvy (bictegrav-emtricit-tenofov ala) 50-200-25 mg oral
DAILY
RX *bictegrav-emtricit-tenofov ala [Biktarvy] 50 mg-200 mg-25 mg
1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
___ LYMPHOMA
SECONDARY DIAGNOSIS
=====================
PYOGENIC LIVER ABSCESS
HIV/AIDS
TRANSAMINITIS
BILIARY OBSTRUCTION
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 new Burkitt's lymphoma, partial malignant
SBO, worsening abdominal pain// ?SBO, ?free air
COMPARISON: CT from ___.
FINDINGS:
Relative paucity of bowel gas limits evaluation for dilation or distension.
Visualized portions of the bowel do not demonstrate any abnormal dilation.
There is no free air. Lung bases are clear.
IMPRESSION:
Study very limited by a lack of bowel gas. No dilated loops of small or large
bowel are detected. No free air.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS
INDICATION: ___ year old man with HIV, Burkitt's lymphoma, pw severe abd pain,
diarrhea// etiology of epigastric 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.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 1.0 s, 0.2 cm; CTDIvol = 17.1 mGy (Body) DLP =
3.4 mGy-cm.
3) Spiral Acquisition 8.6 s, 55.9 cm; CTDIvol = 16.9 mGy (Body) DLP = 934.4
mGy-cm.
Total DLP (Body) = 940 mGy-cm.
COMPARISON: CT abdomen and pelvis dated
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. No pleural
effusion. Trace pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. In
segment VI, there is a hypoattenuating lesion measuring up to 17 mm,
previously 21 mm (05:33). No additional hepatic lesions are seen. A common
bile duct stent is in place with expected pneumobilia. The gallbladder is
mostly decompressed, with air related to the common bile duct stent.
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. The small bowel obstruction
has resolved, and it enteric contrast flows freely through the small bowel,
past the ileal mass and into the colon. As noted on the MRI from the day
prior, there is wall thickening and edema involving the jejunum and majority
of the ileum (For example 5:62). As previously described, terminal ileum
distal to mass is relatively normal in appearance (07:28). The ileal mass
consistent with known lymphoma is re-demonstrated, and there is the suggestion
of early decrease in size although precise measurement is difficult (07:17).
There is now mural edema involving the cecum and ascending colon, which was
not apparent on MRI. Additionally, nonhemorrhagic ascites has increased.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate gland 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. 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. Small and large bowel wall thickening, including some segments of small
bowel with targetoid appearance and intramural edema, has increased compared
to the prior day's MRI. Similar small amount of mesenteric fluid and now with
new small amount of ascites. Findings raise concern for a developing
infectious or inflammatory enterocolitis which has developed while small bowel
obstruction has resolved.
2. Resolved small-bowel obstruction, with contrast passing freely into the
colon.
3. Slight interval decrease in the hepatic segment VI attenuating lesion.
4. Re-demonstration of the ileal mass consistent with known lymphoma.
Measurement of this mass is difficult due to differences in distention of the
small bowel, but there is the suggestion of early involution.
Radiology Report
EXAMINATION: Ultrasounds guided Fluid aspiration and biopsy.
INDICATION: ___ year old man with new onset Burkitt's lymphoma (started on
CODOX-M C1D4), malignant biliary obstruction s/p CBD, concerning for cystic
abscess on MRI// ?Aspiration of possibly cystic hepatic abscess
COMPARISON: Correlation is made with MR dated ___ and CT chest
abdomen pelvis dated ___..
PROCEDURE: Ultrasound-guided targeted liver lesion aspiration and biopsy.
OPERATORS: Dr. ___, radiology fellow and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee during the
key components of the procedure and reviewed and agrees with the trainee's
findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was
performed. The small area of complex collection was identified in right
hepatic lobe. A suitable approach for targeted liver biopsy was determined.
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 aspiration was attempted using a 20 gauge
spinal needle and trace fluid was aspirated. Subsequently using a single
18-gauge core Monopty device, 2 samples were obtained, with separate samples
sent for microbiology (on gauze) and pathology (in formalin) evaluation.
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of 3
mg Versed and 100 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:
Uncomplicated right hepatic lobe lesion aspiration and biopsy with specimens
sent to pathology and microbiology.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new onset Burkitt's lymphoma, spiked fever
on cipro/flagyl, no cough/ SOB// ? r/o consolidation
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia. No hilar
or mediastinal adenopathy.
Right IJ catheter tip extends to the midportion of the SVC.
Radiology Report
EXAMINATION: Abdominal pelvis CT
INDICATION: ___ is a ___ ___ speaking patient w/ newly
diagnosed HIV/AIDS (CD4 ___ on Bikarvy, and an ampullary mass now
known to be Burkitt's Lymphoma who presented to the ED for evaluation of his
new Burkitt's Lymphoma. Chemotherapy with CODOX-M was initiated ___. Course
c/b resolving pyogenic abscess, on cipro/flagyl// ?Resolution of pyogenic
hepatic abscess No oral contrast
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 administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 34.2 s, 0.2 cm; CTDIvol = 583.2 mGy (Body) DLP =
116.6 mGy-cm.
3) Spiral Acquisition 8.1 s, 52.4 cm; CTDIvol = 17.4 mGy (Body) DLP = 901.7
mGy-cm.
Total DLP (Body) = 1,020 mGy-cm.
COMPARISON: Abdominal pelvis CT ___
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. 16
mm hypodensity in segment VI appearing slightly more hypodense (series 5,
image 31). No new hepatic lesion. Hepatic veins and portal veins are patent.
There is no evidence of intrahepatic or extrahepatic biliary dilatation.
There is a CBD stent with secondary pneumobilia. The gallbladder is collapsed
and contains air gas.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The previously
described mass in the ileum is not seen on this evaluation. Uncomplicated
sigmoid diverticulosis. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. Trace of
residual ascites.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Few retroperitoneal subcentimeter nodules are again seen. There
are also 2 left peritoneal nodules (series 5, image 55 and 15 9) unchanged
since prior.
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. Evolving right liver lobe abscess with no size interval increase.
2. Interval disease improvement with complete resolution of the ileal mass not
seen on today evaluation.
Radiology Report
EXAMINATION: CT torso
INDICATION: ___ with abdominal pain, new dx ___ lymphoma.// Compressive
masses?
TECHNIQUE: Multidetector CT through the chest, abdomen, and pelvis performed
following IV contrast administration with multiplanar reformations provided.
DOSE: Total DLP (Body) = 1,456 mGy-cm.
COMPARISON: Prior CT of the abdomen pelvis from ___
FINDINGS:
CHEST: The imaged base of neck is unremarkable including the partially
visualized thyroid gland. The thoracic aorta is normal in course and caliber
without appreciable atherosclerotic calcifications. The heart is normal in
size and shape without pericardial effusion. The main pulmonary artery is
normal in caliber with patent central branches. There is no lymphadenopathy
within the chest.
A 6 mm nodule is noted in the right middle lobe on series 2, image 34 and a
second 6 mm nodule in the right lower lobe is seen on series 2, image 36.
ABDOMEN: Again seen is a hypodense lesion within segment 6 of the liver, best
seen on series 2, image 62 measuring 18 x 20 mm. This lesion is indeterminate
and requires further evaluation with MRI. There is new pneumobilia and stent
within the distal CBD. Main portal vein is patent. Gallbladder is
decompressed. The spleen appears normal. Adrenals are normal bilaterally.
The pancreas enhances normally without focal concerning lesion. The kidneys
enhance symmetrically and excretion of contrast is prompt and equal. The
abdominal aorta is normal in course and caliber without appreciable
atherosclerotic calcifications. There is no retroperitoneal lymphadenopathy.
The stomach is decompressed. The duodenum is unremarkable.
PELVIS: There is diffuse small bowel dilation which can be traced to the level
of an obstructing mass in the distal small bowel in the right mid abdomen on
series 2, images 72 through 78 and series 601 images 28 through 33. This
lesion is consistent with recently diagnosed ___'s lymphoma. Small volume
interloop free fluid is noted. Prominent right lower quadrant lymph nodes are
re-demonstrated. The appendix is normal. The colon is unremarkable. Trace
free pelvic fluid is present. Urinary bladder is partially distended
appearing normal. There is no pelvic sidewall or inguinal adenopathy.
BONES: No worrisome lytic or blastic osseous lesion is seen.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Malignant small-bowel obstruction transitioning at known small-bowel tumor
consistent with recently diagnosed Burkitt's lymphoma. Trace free fluid.
2. Prominent right lower quadrant mesenteric lymph nodes re-demonstrated.
3. Indeterminate liver lesion in segment 6 requires MRI to further assess.
4. New CBD stent in place in this patient with reported new diagnosis of an
ampullary mass.
5. 2 discrete 6 mm nodules in the right middle and right lower lobes, bears
attention on followup imaging.
RECOMMENDATION(S): Nonemergent MRI of the liver to further evaluate
indeterminate segment 6 liver lesion
Radiology Report
INDICATION: ___ year old man with lymphoma// please place temp triple lumen
access line for chemo
COMPARISON: CT of the chest dated ___.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___, Interventional Radiology fellow performed the procedure. Dr.
___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl throughout the total intra-service time of 20 minutes
during which the patient's hemodynamic parameters were continuously monitored
by an independent trained radiology nurse. 1% lidocaine was injected in the
skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None.
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 0.7 minutes, 23 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right neck 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 into the IVC.
A triple-lumen central venous catheter was advanced over the wire into the
superior vena cava with the tip in the cavoatrial junction. All 3 access ports
were aspirated, flushed and capped. The catheter was secured to the skin with
a 0 silk suture and sterile dressings were applied. Final spot fluoroscopic
image demonstrating good alignment of the catheter and no kinking. The patient
tolerated the procedure well without immediate complications.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing triple
lumen central venous catheter with catheter tip terminating in the distal
superior vena cava.
IMPRESSION:
Successful placement of a temporary triple lumen catheter via the right
internal jugular venous approach. The tip of the catheter terminates in the
distal superior vena cava. The catheter is ready for use.
RECOMMENDATION(S): Central venous catheter is ready for use.
Radiology Report
EXAMINATION: MRI abdomen.
INDICATION: Evaluation of liver mass. Recent diagnosis of HIV. New onset of
Burkitt's lymphoma with small bowel obstruction and ampullary mass.
TECHNIQUE: Multiplanar T1- and T2- weighted images of the abdomen were
obtained on a 1.5 tesla magnet including sequences obtained prior to and
during gadolinium administration.
COMPARISON: Ultrasound from ___ and CT studies from ___.
FINDINGS:
Recent studies showed a small liver lesion that was hypoattenuating on CT
within segment VI of the liver, decreasing in size between the two prior CT
studies, as compared on delayed phase images, making it unlikely that this
apparent change is due to differences in technique. On this examination,
there is again a small lesion with progressive peripheral enhancement and many
small central loculations measuring up to at most 5 to 6 mm divided by thin
septations, also consistent with evolution of the prior sonographic
appearance. There is vague surrounding rim of progressive enhancement in
addition to mild edema and faint surrounding early enhancement in the adjacent
liver suggesting reactive change. Maximum extent of the hypoenhancing central
part of the lesion is 20 x 14 mm in axial ___. The diffusion-weighted
images are difficult to interpret but suggest restricted diffusion in the core
of the lesion with peripheral edema and reactive edema and enhancement in the
liver. No other discrete liver lesions are identified. There is no biliary
dilatation. Pneumobilia is anticipated after stent placement. A metallic
stent is in place along the distal common bile duct, as seen previously. The
gallbladder is mostly empty. No gallstones are found. Pancreas is
unremarkable. Spleen is normal in size. Adrenals appear normal. Kidneys are
not entirely imaged on most sequences but show no abnormality.
Stomach is nondistended. Thickened distal ileum with mass is partly imaged
in the right lower quadrant on coronal HASTE images. There is persistent
dilatation of proximal through mid small bowel, measuring up to 28 mm, but
with much less uniform distension and an overall decrease in the degree of
maximum dilatation. This suggests some improvement small bowel obstruction.
On the other hand, bowel wall proximal to the lesion now shows wall thickening
up to 6-7 mm with intramural edema. However, the wall of the bowel enhances
appropriately. Similar extent of mesenteric fluid is noted. No ampullary
mass is visible at this time.
Major vascular structures appear widely patent. There is no discrete
lymphadenopathy, free air, or ascites.
There is widespread enhancement, hypointense appearance on T1-weighted images,
and increased signal on both T2-weighted and diffusion weighted images
suggesting a diffuse bone marrow abnormality.
IMPRESSION:
1. Lesion in the right lobe of the liver shows characteristics most
consistent with small pyogenic abscess, decreasing in size. Minimal fluid
content, noting that the central part consists of a number of tiny loculations
separated measuring up to 5-6 mm with septations.
2. Distal ileal mass consistent with known lymphoma. Decreased distension
and dilation of proximal to mid small bowel suggesting improvement in distal
obstruction. However, new wall thickening and edema are observed throughout
the upstream small bowel suggesting recent congestive or even ischemic changes
during the time since the most recent prior CT. Normal enhancement at this
time, however.
3. Abnormal bone marrow signals concerning for bone marrow involvement or
other bone marrow abnormality.
Gender: M
Race: HISPANIC/LATINO - SALVADORAN
Arrive by WALK IN
Chief complaint: Epigastric pain
Diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst
temperature: 98.2
heartrate: 115.0
resprate: 15.0
o2sat: 100.0
sbp: 116.0
dbp: 82.0
level of pain: 6
level of acuity: 2.0 | SUMMARY STATEMENT
===================
___ yo ___ speaking patient (prefers not to use pronouns)
with recent dx HIV and newly dx Burkitt lymphoma c/b malignant
biliary obstruction s/p metal CBD stent, here for urgent
chemotherapy initiation, now started on CODOX-M as part of the
modified ___ (HIV protocol), tolerating well with plans for
d/c early next week.
TRANSITIONAL ISSUES
===================
[] Of note patient does not use pronouns
[] Pt had low grade fever (100.1) prior to discharge, please
monitor closely and f/u final cultures
[] Please follow-up LFTs on ___, uptrending at discharge iso
methotrexate, however need continued monitoring given known
pyogenic abscess
[] Initially thought that patient did not need GCSF as
outpatient given counts, however downtrending iso MTX prior to
d/c, cannot get Neupogen due to insurance, not currently set up
for Neulasta but could consider as outpt
[] Does not have permanent access - had CVL which was removed
prior to discharge
ACUTE ISSUES
=============
#Burkitt's Lymphoma in s/o HIV
#Biliary obstruction s/p metal CBD stent
Patient presented following a previous admission for obstuctive
cholestasis where ___ was found to have an ampullary, and
small bowel mass. A metal common bile duct stent was placed,
though the patient continued to have abdominal pain. ___ was
readmitted when the pathology from the ampullary mass was
consistent w/ Burk___'s Lymphoma. CT Chest/Abdomen/pelvis this
admission initially demonstrated tumor in mesenteric LN, small
bowel tumor, and 2 6 mm nodules in RML and RLL. ___ was
started on CODOX-M as part of the ___ protocol. The
patient was made NPO for about a week during the nadir of
treatment given the concern for small bowel perforation. ___
was maintained on fluconazole, acyclovir and bactrim (the
bactrim was stopped only for methotrexate treatment). The
patient recieved neupogen during this admission while ___ was
neutropenic. A CT scan prior to discharge (for interval
monitoring of pyogenic abscess as below) was no longer able to
visualize the small bowel mass. ___ tolerated treatment well,
and was discharged following methotrexate clearance.
- Of note ___ had a temporary CVL for chemotherapy which was
removed prior to discharge
#Pyogenic Abscess
#Ilealcolitis
Initial CT scan on admission was notable for a 2cm ill defined
hepatic lesion, and an MRI was pursued to further characterize
this. Per radiology, this was highly characteristic of a
pyogenic abscess which likely formed as a complication of
obstructive cholestasis from the known ampullary mass. ___
was initially treated with cefepime/flagyl which was narrowed to
ciprofloxacin/flagyl for a total 2 week (___) course of
antibiotics. ___ was consulted during this admission but given
the small size of the hepatic lesion (<2cm) they did not
retrieve an adequate samples and cultures were negative. Of note
patient did have intermittent abdominal pain and diarrhea, CT
scan at the time of these symptoms was concerning for possible
ileolcolitis, stool cultures, C.diff, and O&P testing was
negative. Symptoms resolved without intervention. Prior to
discharge a follow-up CT scan demonstrated evolving hepatic
abscess of unchanged size consistent w/ slow resolution of the
pyogenic abscess, per conversation with ID patient does not need
further antibiotics or repeat imaging unless symptoms / fevers
recur.
#Transaminitis
Pt developed transaminitis at discharge following methotrexate
infusion, likely secondary drug induced liver injury. However pt
does have pyogenic abscess as above and will need continued
following.
#Fever, improved
Patient had low grade intermittent fevers throughout admission.
Infectious workup was negative throughout admission thought to
be drug induced in setting of
neupogen with possible contribution from pyogenic abscess.
Fevers resolved once neupogen was stopped, and did not recur
once finished 2 week course of antibiotics. Of note, patient did
have low grade 100.1 fever eening before discharge,
asymptomatic, cultures pending.
Chronic/Resolved
==================
#Malignant SBO, resolved
Presented with sx concerning for partial SBO, which resolved
without intervention in the ED at admission. He was initially
seen by ACS and cleared in the ED, and continued to have good
bowel movements on a scheduled bowel regimen. Did have
intermittent bloating which was relieved by simethecone.
#HIV/AIDS
Follows with Dr. ___. CD4 ___. VL 4.5 -> <1.3
after 2 months of Biktarvy. Had been off biktarvy for ~3 weeks
prior to admission given worsening abdominal pain. Biktarvy was
nonformulary so was maintained on
doltuegravir/emcitirabine/tenofivir while inpatient without
issue. Continues on Bactrim, acyclovir, fluconazole prophylaxis.
Of note pt was CMV IgG positive this admission, but VL
undetectable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
chest pain, dyspnea
Major Surgical or Invasive Procedure:
Left chest tube placement
History of Present Illness:
___ year old female with diffuse metastatic gastric
adenocarcinoma
C___ FOLFOX on ___ presenting with new exertional dyspnea and
pleuritic chest pain. She states the dyspnea/pain has been
present since ___, gradually worsening. Worse with
movement/activity or deep breathing. No fevers, cough, nasal
congestion, rhinorrhea, headaches. No lower extremity swelling.
Notably, her most recent CT scans show a left pleural effusion
and she was scheduled for outpatient thoracentesis, but today
the
shortness of breath and pleuritic pain since last night was so
dramatic she was referred into the ED. Note she DCd her lovenox
about 3 weeks ago after she completed a 6 month course for PVT
and scans showed resolution of this.
ED COURSE:
T 99.3 HR 114, BP 121/83 RR 18 100% RA.
CXR with New opacification of the left hemithorax, with
rightward
mediastinal
shift, presumably due to enlargement of the known left pleural
effusion. 2. Opacifications in the right upper lobe corresponds
to a ground-glass mass identified on the prior chest CT.
Her labs showed WBC 4, Hct 27, plts 337, 71% pmns. chem
reassuring. ED placed a chest tube which drained 800cc
serosanguinous fluid. She received 4mg IV morphine x2, 1 mg IV
midazolam.
On arrival to the floor she has new left lateral and posterior
chest pain since tube insertion but states her breathing is
better after some drainage. Denies dysuria, nausea, vomiting,
headaches. Does report that she has some right upper thigh pain
which has been worsening, mostly painful on walking, but no
swelling. All other 10 point ROS neg.
Past Medical History:
- ___ Hospitalized at ___ with symptoms c/f
cholecystitis, underwent lap CCY with biliary drain placement
and removal, discharged home
- ___ presented to ___ with abdominal pain, nausea and
vomiting, CT abdomen showed an ill-defined
predominately-retroperitoneal soft tissue lesion
- ___ ERCP with narrowing at D2, unable to pass duodenoscope;
revealed thick, irregular gastric folds, there was concern for
an infiltrative process such as lymphoma or linitis plastica,
gastrointestinal mucosal biopsies showed poorly differentiated
adenocarcinoma (in 1 out of 4 tissue fragments); H pylori
negative
- ___ MRCP revealed infiltrative process throughout the porta
hepatis and retroperitoneum along with a non-occlusive main
portal vein thrombus (started on anticoagulation)
- ___ ___ guided biliary drain placement (PTBD)
- ___ ___ guided FNA of anterior mesenteric LN, cytology was
non-diagnostic due to insufficient cellular material
- ___ CEA 2.9, AFP 2.5, CA ___ 456
- ___ EGD with EUS, Gastric mucosa mucosal biopsies, shark core
needle biopsy with poorly differentiate adenocarcinoma invading
smooth muscle and likely submucosal tissue; HER2 immunostain
pending; perigastric LN POSITIVE for malignant cells (metastatic
adenocarcinoma, CK7, CK20 and CDX-2 positive); Ascites
suspicious for malignant cells
- ___ port placement
- HER 2 testing returned negative
- ___ ___ PTBD exchange, unable to complete procedure with
cholangiogram due to pain
- ___ hospitalized at ___ with failure to thrive,
malnutrition, abdominal pain. Underwent NJ tube placement which
was dislodged and/or clotted on multiple occasions. Received
C1D1 FOLFOX on ___. Started TPN via Power PICC that was placed
on ___ underwent PTBD exchange due to new obstruction.
Course c/b enterobacter bacteremia. Was started on IV
antibiotics for a 14 day course (expected end date ___
- ___ C1D15 FOLFOX
PAST MEDICAL HISTORY:
- Asthma
- Iron deficiency anemia (required IV iron infusions, had a
colonoscopy approximately ___ years ago which was negative per her
report)
- GERD
- s/p CCY
- Thalassemia trait
- Portal vein thrombus, now on Lovenox
- IV contrast allergy, requires premedications before contrast
Social History:
___
Family History:
Father - ___ and kidney cancer, HTN
Mother - HLD, HTN, asthma
Paternal aunt - breast cancer ___
___ aunt - cancer of unknown type
Maternal grandmother - esophageal cancer, smoker
Maternal greatgrandmother - colon cancer, ___
Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS: 99.2 122/80 108 24 97%RA
General: NAD when not moving, can speak in full sentences, does
not appear dyspneic at rest
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: decreased breath sounds throughout most of left lung
field
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities; reflexes are 2+ of the biceps, triceps,
patellar, and Achilles tendons, toes are down bilaterally; gait
is normal, coordination is intact.
Pertinent Results:
___ 07:00PM PLEURAL TOT PROT-5.3 GLUCOSE-85 LD(LDH)-477
___ 07:00PM PLEURAL WBC-1089* ___ POLYS-46*
LYMPHS-18* MONOS-3* EOS-1* MACROPHAG-16* OTHER-16*
___ 05:18PM GLUCOSE-90 UREA N-12 CREAT-0.6 SODIUM-136
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-24 ANION GAP-17
___ 05:18PM WBC-4.0 RBC-3.83* HGB-8.2* HCT-27.3* MCV-71*
MCH-21.4* MCHC-30.0* RDW-18.3* RDWSD-45.1
___ 05:18PM NEUTS-71.1* ___ MONOS-8.0 EOS-0.0*
BASOS-0.5 IM ___ AbsNeut-2.84 AbsLymp-0.80* AbsMono-0.32
AbsEos-0.00* AbsBaso-0.02
___ 05:18PM PLT COUNT-337
___ 05:18PM ___ PTT-27.5 ___
DC LABS:
___ 05:30AM BLOOD WBC-3.4* RBC-3.46* Hgb-7.2* Hct-24.4*
MCV-71* MCH-20.8* MCHC-29.5* RDW-17.8* RDWSD-44.3 Plt ___
___ 05:30AM BLOOD Glucose-92 UreaN-4* Creat-0.5 Na-134
K-3.6 Cl-100 HCO3-25 AnGap-13
CTA CHEST:
IMPRESSION:
1. No evidence of pulmonary embolus or acute aortic abnormality.
2. Large nonhemorrhagic left pleural effusion has increased in
size with
associated collapse of the left lower lobe and minimal aeration
of the left
upper lobe. A left pleural drain is not seen in the left pleural
space as the
tip terminates posterior to the left posterior sixth rib.
3. Progression of right apical ground-glass mass opacity
appearing more dense
and slightly larger.
4. Thickening of the left adrenal gland without nodularity.
5. Partially visualized common bile duct stent with pneumobilia
and
cholecystectomy clips.
6. Multiple sclerotic lesions within the left clavicle, sternum,
T4 and T12
vertebral bodies are again noted, unchanged compared to the
prior study. No
evidence of acute fracture.
CXR:
IMPRESSION:
1. Interval removal of a left pigtail drainage catheter since
___
with persistence of a small left apical pneumothorax.
2. Slight interval increase in opacities in the left lung base
since prior
exam may be due to a combination of atelectasis and pleural
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN Wheezing
2. Calcium Carbonate 1000 mg PO QID:PRN Heartburn
3. Docusate Sodium 100 mg PO BID:PRN Constipation
4. Enoxaparin Sodium 140 mg SC DAILY
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. Lidocaine Jelly 2% 1 Appl TP QID:PRN RUQ pain
7. LORazepam 0.5-1 mg PO Q4H:PRN nausea/anxiety
8. Nystatin Oral Suspension 5 mL PO QID:PRN Thrush
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Simethicone 40-80 mg PO QID:PRN gas pain
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION DAILY
13. Ibuprofen 600 mg PO BID:PRN Pain - Mild
14. Fentanyl Patch 100 mcg/h TD Q72H
15. HYDROmorphone (Dilaudid) 8 mg PO Q8H:PRN Pain - Moderate
16. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Medications:
1. Dronabinol 2.5 mg PO QHS
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
3. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Moderate
RX *hydromorphone 4 mg ___ tablet(s) by mouth three times a day
Disp #*120 Tablet Refills:*0
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN Wheezing
5. Calcium Carbonate 1000 mg PO QID:PRN Heartburn
6. Docusate Sodium 100 mg PO BID:PRN Constipation
7. Fentanyl Patch 100 mcg/h TD Q72H
RX *fentanyl 50 mcg/hour 2 patchs applied transdermally every 72
hours Disp #*10 Patch Refills:*0
8. Ibuprofen 600 mg PO BID:PRN Pain - Mild
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Lidocaine Jelly 2% 1 Appl TP QID:PRN RUQ pain
11. LORazepam 0.5-1 mg PO Q4H:PRN nausea/anxiety
12. Nystatin Oral Suspension 5 mL PO QID:PRN Thrush
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Simethicone 40-80 mg PO QID:PRN gas pain
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left pleural effusion
Pleuritis
Gastric adenocarcinoma
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 known pleural effusion, metastatic gastric cancer, with
worsening symptoms. Evaluate pleural effusion.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT of ___ and chest radiograph of ___.
FINDINGS:
The known left pleural effusion has enlarged, now causing complete
opacification of the left lung, with rightward mediastinal shift. No
pneumothorax detected. Subtle hazy opacification in the right apex
corresponds with a ground-glass opacity identified on the prior chest CT.
Right-sided Port-A-Cath tip terminates in the low SVC.
IMPRESSION:
1. New opacification of the left hemithorax, with rightward mediastinal
shift, presumably due to enlargement of the known left pleural effusion.
2. Opacification in the right upper lobe corresponds to a ground-glass mass
identified on the prior chest CT.
Radiology Report
INDICATION: ___ year old woman with new chest tube // please do post
placement CXR to eval for PTX or other complication
TECHNIQUE: AP portable chest radiograph
COMPARISON: Chest radiograph performed earlier today
FINDINGS:
Unchanged position of the left pleural drain. The appearance of the left
hemithorax is unchanged including a large pleural effusion.
Unchanged hazy opacification at the right lung apex, corresponding to a known
ground-glass opacity seen on prior cross-sectional imaging. A right chest
wall power injectable Port-A-Cath is unchanged. A small amount of
subcutaneous emphysema over the left chest wall is noted.
IMPRESSION:
No significant interval change since the prior radiograph.
Radiology Report
EXAMINATION: CTA chest
INDICATION: ___ year old woman with metastatic gastric cancer presents with
chest pain, dyspnea, pleural effusion, gastric cancer // rule out PE. This
scan must be done at 11 AM on ___ we are starting the premed protocol at 10pm
on ___ thanks
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: 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: Chest CT ___.
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 right-sided Port-A-Cath terminates in the right atrium.
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 thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. Since ___, a large
nonhemorrhagic left pleural effusion has increased in size with associated
collapse of the left lower lobe and minimal aeration of the left upper lobe.
A left-sided pleural drain terminates posterior to the left posterior sixth
rib. There is no right pleural effusion.
Previously seen right apical ground-glass mass opacity appears more dense and
slightly larger compared to the prior and measures 4.1 x 2.4 cm (06:17). The
airways are patent to the subsegmental level.
Limited images of the upper abdomen demonstrate thickening of the left adrenal
gland without nodularity. A partially visualized common bile duct stent with
pneumobilia and cholecystectomy clips noted.
Multiple sclerotic lesions within the left clavicle, sternum, T4 and T12
vertebral bodies are again noted, unchanged compared to the prior study. No
evidence of acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolus or acute aortic abnormality.
2. Large nonhemorrhagic left pleural effusion has increased in size with
associated collapse of the left lower lobe and minimal aeration of the left
upper lobe. A left pleural drain is not seen in the left pleural space as the
tip terminates posterior to the left posterior sixth rib.
3. Progression of right apical ground-glass mass opacity appearing more dense
and slightly larger.
4. Thickening of the left adrenal gland without nodularity.
5. Partially visualized common bile duct stent with pneumobilia and
cholecystectomy clips.
6. Multiple sclerotic lesions within the left clavicle, sternum, T4 and T12
vertebral bodies are again noted, unchanged compared to the prior study. No
evidence of acute fracture.
NOTIFICATION: The findings were discussed with ___, M.D. By ___
___, M.D. on the telephone on ___ at 11:50, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT
INDICATION: ___ year old woman with gastric cancer and right thigh/femur pain
// eval for fracture or bony metastatic diseaseplease do this on ___ at the
same time she is down in radiology for her chest CT. thanks!
TECHNIQUE: 7 radiographs of the right femur were obtained
COMPARISON: None available
FINDINGS:
Loops within the proximal right femoral diaphysis is a E centric ___ located
sclerotic lesion measuring approximately 2 cm in cranial caudal dimension. No
other lesions are definitively visualized radiographically. No acute fracture
or dislocation.
IMPRESSION:
2 cm sclerotic lesion in the proximal right femoral diaphysis without an
associated fracture. No additional lesions are visualized radiographically.
Radiology Report
INDICATION: History: ___ with pleural effusion s/p pigtail // Confirm
pigtail
TECHNIQUE: Portable upright chest radiograph
COMPARISON: ___ at 15:12
FINDINGS:
There is near complete white out of the left hemithorax with a left chest wall
pleural catheter which does not project past the lateral margin of the ribs.
The right lung is clear. Right chest wall port catheter terminates at the
superior cavoatrial junction.
IMPRESSION:
White out of the left hemithorax with a left pleural catheter likely not
projecting in the pleural space.
NOTIFICATION: At the time of the dictation, the patient had a second
follow-up radiograph with a reposition pigtail catheter.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pleural effusion s/p chest tube. Evaluate
for pneumothorax.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___.
FINDINGS:
Compared with the prior radiograph, a pigtail catheter has been inserted into
the left hemithorax. There is a moderate left pneumothorax, new since the
prior study. There is mild rightward mediastinal shift, the setting of a
residual small left pleural effusion. Right-sided Port-A-Cath is unchanged in
position. No evidence of right-sided pleural effusion.
IMPRESSION:
Status post insertion of a left-sided pigtail catheter, with a moderate sized
left pneumothorax. Mild rightward mediastinal shift is identified in the
setting of a residual small left pleural effusion. Close attention on
follow-up radiographs is advised.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 18:40 on ___, 5 min after
discovery.
Radiology Report
INDICATION: ___ year old woman with metastatic gastric cancer s/p chest tube
placement with PTX with severe chest pain. // Please evaluate change in PTX.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
A left chest tube is present. The left lung appears to have partially
re-expanded with a small persisting pneumothorax. Opacities within the left
hemithorax likely reflect atelectasis and or re-expansion edema. The
appearance of the right lung and cardiac silhouette are unchanged.
IMPRESSION:
Interval partial re-expansion of the left lung with a persisting small
pneumothorax. Opacities within the left hemithorax likely reflect atelectasis
and/or re-expansion edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with L pleural effusion s/p CT placement
yesterday // eval for interval change eval for interval change
IMPRESSION:
Left apical pneumothorax is present and appears to be increased as compared to
previous study. Left pigtail catheter is in place. Left pleural effusion and
basal consolidation appear to be slightly increased since the prior study
obtained on ___ at 21:16 but substantially smaller than the
earlier study from 18:00 obtained and ___
Right lung is unchanged. Heart size and mediastinum are stable in appearance.
RECOMMENDATION(S): Repeated chest radiographs in 5 6 hr is recommended.
Radiology Report
INDICATION: ___ year old woman with L pleural effusion, L CT with PTX. //
eval for interval change
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
There is a persisting small left pneumothorax with an apical and lateral
component visualized. A left chest tube is again present. No significant
interval change in appearance of the lung parenchyma.
IMPRESSION:
No significant interval change of a small left pneumothorax. A left pigtail
catheter is in place.
Radiology Report
EXAMINATION: Chest one view
INDICATION: ___ year old woman with pleural effusion s/p chest tube // PTX
TECHNIQUE: Chest portable AP
COMPARISON: ___.
FINDINGS:
There is minimal increase to the left upper pneumothorax. Left pigtail in
place. Small left effusion and left lower lobe atelectasis again seen.
Port-A-Cath on the right with tip in the distal SVC.
IMPRESSION:
Slight increase to the left upper pneumothorax.
Radiology Report
EXAMINATION: Chest one view
INDICATION: ___ year old woman with pleural effusion s/p chest tube //
Pneumothorax
TECHNIQUE: Chest portable AP
COMPARISON: Radiograph done the same day at 08:00
FINDINGS:
All no significant change to of the small left upper pneumothorax
IMPRESSION:
Stable appearance of the chest with no change to small left upper
pneumothorax.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with hx metastatic gastric adenoCa, s/p chest
tube drainage of L pleural effusion, tube pulled ___ // eval for interval
change
TECHNIQUE: Portable semi upright chest radiograph
COMPARISON: Chest radiographs from ___
FINDINGS:
The tip of a right Port-A-Cath terminates at the caval atrial junction. There
is interval removal of a left pigtail drainage catheter. There is persistence
of a left apical pneumothorax, measuring approximately 1.9 cm above the apex.
Opacities in the left lung base are slightly increased since prior exam,
possibly due to combination of atelectasis and pleural effusion. No new focal
consolidation is identified. The cardiomediastinal silhouette and hilar
contours are stable.
IMPRESSION:
1. Interval removal of a left pigtail drainage catheter since ___
with persistence of a small left apical pneumothorax.
2. Slight interval increase in opacities in the left lung base since prior
exam may be due to a combination of atelectasis and pleural effusion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea, Chest pain
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 99.3
heartrate: 114.0
resprate: 18.0
o2sat: 100.0
sbp: 121.0
dbp: 83.0
level of pain: 5
level of acuity: 2.0 | ___ year old female with diffuse metastatic gastric
adenocarcinoma C5D15 FOLFOX on ___ presenting with new
exertional dyspnea and pleuritic chest pain found to have
sizeable left sided pleural effusion with mediastinal shift, s/p
CT placement.
# Dyspnea/shortness of breath/chest pain:
# L Pleural effusion with mediastinal shift, suspected
malignant:
# Acute chest wall pain/pleuritis
# PTX
Found to have large left pleural effusion suspected to be
malignant. Chest tube placed in ED with initial drainage which
became dislodged from the pleural space. IP consulted and chest
tube replaced with good drainage, total drainage >1.5L. Exudate
based on Light's criteria. Cx NGTD. Cytology sent. She was
treated supportively but notably had significant pain. She was
treated with IV and PO dilaudid and lidocaine patch. CXR did
show residual PTX which IP felt could be a component of trapped
lung. She ultimately remained stable and her CT was removed
successfully. Her pain improved thereafter and she was
discharged with close onc and IP follow up.
- cytology PENDING on discharge
- IP follow up in ___ weeks
- Dilaudid increased to ___ PO TID prn for pain
- Fentanyl patch continued
- Should she require further chest tubes, please consider going
directly to PCA for her pain.
# Right femur pain:
no swelling of the leg, no skin changes, not particularly tender
on exam, pt reports that feels like bony pain and has been
bothering her a great deal
- XRay neg for fx but mets noted. Pain control as above
# Metastatic Gastric adeno CA:
# Acute on chronic cancer pain:
___ FOLFOX on ___. Also with concern raised for new lung
primary though oncologists felt this was less likely. Will
continue Fentanyl patch and prn dilaudid for breakthrough.
Marinol started for anorexia and will cont benzo for nausea.
- Palliative care involved
DVT PROPHYLAXIS: Lovenox |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with a history of hypertension and
treated breast cancer who collapsed while at the kitchen sink
earlier today. She was in her usual state of health this
weekend
and enjoyed the ___ weather and was walking regularly and
having no recent illness in the preceding days. This morning
while making breakfast she felt weaker than usual and felt her
legs give out under her as she was dizzy after standing at the
kitchen sink for several minutes. She did not lose
consciousness
or strike her head and per the ED signout she lowered herself to
the ground slowly but was unable to pick herself up from the
floor and was on the ground for 10 minutes and was able to get
to
the door to call for help at her assisted living. She was
transported to the ___ emergency department where there
was no signs of ischemia or arrhythmia on her EKG she had a
pulse
of 86-96 a blood pressure of 126/40 satting 98% on room air and
underwent further diagnostic testing she had a positive
urinalysis with greater than 182. White cells and white cell
clumps and a serum WBC of 22 her chest x-ray was abnormal
consistent with. Underlying pulmonary fibrosis which is known
but when compared to prior chest x-rays this is progressed
somewhat and could obscure signs of acute infection in the
chest.
As well as the addition of azithromycin as the emergency
department also considered possible pneumonia causing her
current
illness.
On arrival to the medical ward she feels well and did not report
any pre-existing urinary symptoms in the days prior to admission
but does note that her bladder feels somewhat uncomfortable now
with a sensation of fullness she denies dysuria hematuria. Or
change in urine color. The ED documentation describes frankly
purulent urine.
One of her sons whose name is ___ is dying of prostate cancer
in the local area and is on hospice. Her daughter ___
expresses concern about how her mother is handling ___
illness
and requests that we involved social work to set up bereavement
counseling.
In the emergency room she got ceftriaxone for her UTI
Past Medical History:
BREAST CANCER ___
s/p L sided lumpectomy, XRT, Tamoxifen x ___ followed by
___
CATARACTS
COLONIC ADENOMA ___
GASTROESOPHAGEAL REFLUX
with chronic cough
HYPERLIPIDEMIA
followed by ___ in ___
HYPERTENSION ___
INTERIM LAB VALUES
OSTEOARTHRITIS
OSTEOPENIA ___
repeat in ___ noted slight decrease in hip density (-1.7 from
-1.3) -- pt prefers watchful waiting for the time being.
PALPITATIONS ___
normal Holter eval
RECURRENT URINARY TRACT INFECTION ___
INGUINAL HERNIA
bilateral, asymptomatic
HEARING LOSS
bilateral hearing aides
SHOULDER PAIN
PULMONARY FIBROSIS
LEFT ROTATOR CUFF TEAR
ENDOMETRIAL CANCER ___
Social History:
___
Family History:
She reports that her mother had uterine cancer. Denies other
gynecologic malignancies.
Physical Exam:
Discharge Exam:
Gen: Lying in bed in no apparent distress
Vitals: Afebrile and vital signs stable (bedside chart reviewed
-
please see bedside record). Specific comments to same:
FSBG:
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
> 30 minutes spent on discharge planning, coordination, and care
Pertinent Results:
___ 08:05AM BLOOD WBC-9.3 RBC-3.88* Hgb-10.9* Hct-33.2*
MCV-86 MCH-28.1 MCHC-32.8 RDW-13.2 RDWSD-41.1 Plt ___
___ 08:05AM BLOOD Glucose-105* UreaN-16 Creat-0.7 Na-135
K-4.4 Cl-98 HCO3-21* AnGap-16
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------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Lovastatin 20 mg Oral QHS
4. Zolpidem Tartrate 5 mg PO HS anxiety
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
6. Psyllium Powder 1 PKT PO BID
7. amLODIPine 2.5 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
10. Omeprazole 20 mg PO DAILY
11. Calcium Carbonate 1000 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
2. amLODIPine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 1000 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
6. Losartan Potassium 100 mg PO DAILY
7. Lovastatin 20 mg Oral QHS
8. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Psyllium Powder 1 PKT PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. Zolpidem Tartrate 5 mg PO HS anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-UTI
-sepsis
-Weakness
Discharge Condition:
Good
Alert and Oriented x 2 (self, hospital, does not know year)
Ambulatory without assistance
Followup Instructions:
___
Radiology Report
INDICATION: ___ with dizziness and fall// Acute cardiopulmonary process
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest CT from ___. Chest x-ray from ___.
FINDINGS:
There is increased interstitial markings throughout the lungs, with the
peripheral predominance, more conspicuous on the right than on the left.
There is no effusion or pneumothorax. Cardiomediastinal silhouette is
unchanged. Hiatal hernia is again noted. No acute osseous abnormalities.
IMPRESSION:
Increased interstitial markings throughout the lungs which with seen on remote
prior chest CT and suggestive of underlying fibrosis. When compared to prior
chest x-ray, this has progressed since ___ which could represent progression
of disease or potentially component of superimposed edema or infection.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall at home// eval for SDH or other ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 14.0 s, 14.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 702 mGy-cm.
COMPARISON: CT from ___
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass. Mild white
matter hypodensities are nonspecific, likely related to small vessel ischemic
disease in a patient of this age. There is prominence of the ventricles and
sulci suggestive of involutional changes. Dense calcifications are seen along
bilateral carotid siphons.
There is no evidence of fracture. Degenerative changes are seen along the
right temporomandibular joint. There is mild mucosal thickening of the
ethmoid air cells. The visualized portion of the remaining paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits show bilateral lens replacement and bilateral optic nerve head
drusen are noted.
IMPRESSION:
No acute intracranial abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, s/p Fall
Diagnosed with Urinary tract infection, site not specified, Dizziness and giddiness, Fall on same level, unspecified, initial encounter
temperature: 98.4
heartrate: 96.0
resprate: 16.0
o2sat: 97.0
sbp: 101.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | ___ woman who felt weak and lowered herself to
the ground today and is found to have a peripheral leukocytosis
of 22 and suspected urinary tract infection, she globally weak
on admission and improved significantly with IV ceftriaxone. Her
Urine culture grew out pan-sensitive E. Coli . She was
transitioned to PO Ciprofloxacin 500mg BID to complete a 7 day
course on ___. Her daughter ___ expressed concern about how
the patient will
handle ___ death and how she is handling his current illness.
___ was consulted and cleared her for return to her ALF. She was
discharged on hospital day two. No other changes were made in
her medications. She was mobilizing and ambulating without
difficulty. Her hypertension regimen was continued throughout
her hospitalization. Her white count normalized on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Apnea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ is a ___ woman type 1 diabetes diagnosed
at age ___, complicated by stroke at ___ with right hemiparesis and
aphasia, gastroparesis, coronary artery disease with recent
NSTEMI ___ who presents from Extended Care: ___
___ with apneic spells.
Per report from her SNF, patient was more somnolent on day of
admission, had a cough but minimal secretions, and has been
having ___ apneic episodes that occur every ___ minutes but
satting well on 21% humidified RA while on trach mask. Looked
like ___ breathing. Has had NSTEMI in past and
recently baseline troponin between 0.26-0.28. Today troponin
0.21. Also had sputum from ___ that grew ___ albicans and
pseudomonas aeriginosa (finalized on ___.
In ED initial VS: Temp 97.1 HR 88 BP 144/87 RR 16 SaO2 100% RA
There, reportedly was seen to have these apneic episodes as well
but never desatted while on RA. CT head negative. CXR without
evidence of consolidation, no significant interval change.
Received 2 U SC insulin for glucose 300. VBG 7.41 | 66 | 40
(close to baseline), lactate 1.
Ms. ___ was recently discharged from ___ A where she
was hospitalized from ___ with report of AMS and was found
to be hypoglycemic to 13 in setting of stacking of regular
sliding scale doses. She was followed by ___ consult service
and her insulin regimen was changed as detailed in the
assessment and plan below. She was also admitted to ___ from
___ for AMS and was found to have a Klebsiella UTI.
On arrival to the MICU patient arrives non-verbal and with trach
in place.
Past Medical History:
Diabetes Mellitus type 1 (dx at age ___, hx of hypoglycemic
episodes
CVA (hemorrhagic) at ___ with residual aphasia and Right
hemiparesis
Blindness in one eye
History of aspiration pneumonia s/p tracheostomy
Depression
Hyperthyroidism
Anemia ___ hct ___
HTN
Gastroparesis
LV dysfunction
C. diff
Social History:
___
Family History:
- Diabetes Mellitus type 1 (dx at age ___, hx of hypoglycemic
episodes
- CVA (hemorrhagic) at ___ with residual aphasia and Right
hemiparesis
- Blindness in left eye
- History of aspiration pneumonia s/p tracheostomy
- Depression
- Hyperthyroidism
- Anemia ___ hct ___
- HTN
- Gastroparesis
- LV dysfunction
- C. diff
Physical Exam:
=======================
ADMISSION PHYISCAL EXAM
=======================
VITALS: reviewed in metavision
GENERAL: Appears comfortable, following commands, denied pain
HEENT: Sclera anicteric, mild bleeding from upper gingiva, left
ocular abnormality with no functioning pupil. Right pupil
reacts.
NECK: supple, JVP not elevated, no LAD
LUNGS: diffuse rhonchi bilaterally, periods of apnea that last
___
CV: Regular rate and rhythm, +systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema, contracted
NEURO: Squeezes left hand on command, right arm is not being
used, does not move either legs
=======================
DISCHARGE PHYSICAL EXAM
=======================
VITALS: reviewed in metavision
GENERAL: Lying in bed, not responsive to commands, spontaneously
moving head and L upper extremity
HEENT: Sclera anicteric, left ocular abnormality with no
functioning pupil. Right pupil reacts
NECK: supple, JVP not elevated, no LAD
LUNGS: Coarse rhonchi or transmitted upper airway sounds, no
wheezes
CV: Regular rate and rhythm, +systolic murmur
ABD: soft, non-tender, non-distended, no clear pain to palpation
EXT: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema, contracted
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 06:15PM ___ PTT-32.0 ___
___ 06:15PM PLT COUNT-196
___ 06:15PM WBC-6.3 RBC-3.09* HGB-8.8* HCT-28.4* MCV-92
MCH-28.5 MCHC-31.0* RDW-17.2* RDWSD-57.4*
___ 06:15PM LACTATE-1.0
___ 06:15PM ALBUMIN-3.2*
___ 06:15PM LIPASE-60
___ 06:15PM ALT(SGPT)-37 AST(SGOT)-38 ALK PHOS-114* TOT
BILI-0.2
___ 06:15PM GLUCOSE-368* UREA N-96* CREAT-2.5* SODIUM-142
POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-37* ANION GAP-11
___ 06:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-300* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
======================================
DISCHARGE/PERTINENT LABORATORY STUDIES
======================================
___ 08:00AM BLOOD WBC-9.4 RBC-2.43* Hgb-6.9* Hct-22.6*
MCV-93 MCH-28.4 MCHC-30.5* RDW-16.1* RDWSD-54.4* Plt ___
___ 03:06PM BLOOD Neuts-90* Bands-5 Lymphs-1* Monos-4*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-23.09*
AbsLymp-0.24* AbsMono-0.97* AbsEos-0.00* AbsBaso-0.00*
___ 03:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+* Microcy-NORMAL Polychr-NORMAL
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-236* UreaN-87* Creat-2.2* Na-143
K-4.2 Cl-109* HCO3-22 AnGap-12
___ 03:15AM BLOOD ALT-31 AST-45* LD(LDH)-311* AlkPhos-90
TotBili-<0.2
___ 06:15PM BLOOD Lipase-60
___ 03:15AM BLOOD CK-MB-2 cTropnT-0.10*
___ 08:00AM BLOOD Calcium-8.4 Phos-2.7
___ 03:15AM BLOOD Hapto-309*
___ 01:46AM BLOOD Vanco-18.7
___ 08:00AM BLOOD
===============
IMAGING STUDIES
===============
___ Imaging CT HEAD W/O CONTRAST
Exam is suboptimal due to patient motion. Given this,
re-demonstrated is
extensive cystic encephalomalacia and gliosis of the left
frontal parietal
region, similar to prior studies. There is persistent ex vacuo
dilatation of the left lateral ventricle and third ventricle.
No acute intracranial
hemorrhage is seen. Prominence of the ventricles and sulci
consistent with involutional changes, grossly similar compared
to the prior study. Left frontal postsurgical changes.
Re-demonstrated left globe phthisis bulbi. Extensive
calcifications along the carotid arteries including the
cavernous portions and petrous portions. There are also
extensive vascular calcifications of the vertebral arteries.
___ Imaging CHEST (PORTABLE AP)
Tracheostomy is in place. Right central venous line tip is at
the proximal right atrium. Heart size and mediastinum are
stable. There is not vascular congestion but no overt pulmonary
edema. No appreciable pneumothorax or pleural effusion.
============
MICROBIOLOGY
============
URINE CULTURE (Final ___: NO GROWTH.
RESPIRATORY CULTURE (Final ___: Commensal Respiratory
Flora Absent. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
KLEBSIELLA OXYTOCA. RARE GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 2.5mg NEB IH Q2H:PRN wheezing
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Baclofen 15 mg PO TID
7. Carvedilol 12.5 mg PO BID
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
9. Clopidogrel 75 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Doxazosin 8 mg PO HS
12. Ferrous Sulfate 300 mg PO BID
13. GuaiFENesin 10 mL PO Q6H:PRN cough
14. HydrALAZINE 10 mg PO BID
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Dyspnea
16. Isosorbide Dinitrate 10 mg PO TID
17. Ondansetron 4 mg IV Q8H:PRN nausea
18. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
19. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
20. Senna 8.6 mg PO BID:PRN constipation
21. Sertraline 75 mg PO DAILY
22. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral Q24H
23. Maalox Advanced (alum-mag hydroxide-simeth;<br>calcium
carbonate-simethicone) 40 mg oral prn
24. MAG-AL (aluminum-magnesium hydroxide) 200 mg oral daily
25. Nitroglycerin Ointment 2% 0.5 in TP Q6H
26. Vitamin D ___ UNIT PO 1X/MONTH
27. Heparin 5000 UNIT SC BID
28. Torsemide 40 mg PO DAILY
29. Epoetin ___ ___ units SC WEEKLY
30. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. CefePIME 1 g IV Q12H
END ___. Glargine 14 Units Breakfast
Glargine 14 Units Bedtime<br> Humalog 4 Units Q4H
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol 0.083% Neb Soln 2.5mg NEB IH Q2H:PRN wheezing
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Baclofen 15 mg PO TID
8. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral Q24H
9. Carvedilol 12.5 mg PO BID
10. Clopidogrel 75 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Doxazosin 8 mg PO HS
13. Ferrous Sulfate 300 mg PO BID
14. GuaiFENesin 10 mL PO Q6H:PRN cough
15. Heparin 5000 UNIT SC BID
16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Dyspnea
17. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
18. Senna 8.6 mg PO BID:PRN constipation
19. Sertraline 75 mg PO DAILY
20. Vitamin D ___ UNIT PO 1X/MONTH
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ventilator associated pneumonia
Urinary Tract Infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with trach, new period of apnea// apnea, trach
dependant
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___ and ___
FINDINGS:
Tracheostomy tube is re-demonstrated. Right-sided subclavian central venous
catheter terminates in the right atrium, similar to prior. No focal
consolidation is seen. There is no pleural effusion or pneumothorax. Cardiac
and mediastinal silhouettes are grossly stable.
IMPRESSION:
No acute cardiopulmonary process. No significant interval change.
Radiology Report
EXAMINATION:
CT HEAD W/O CONTRAST
INDICATION: History: ___ with prior stroke, trach dependant, now w/ new
apnea// prior stroke, trach dependant, now w/ new apnea prior stroke,
trach dependant, now w/ new apnea
TECHNIQUE: Noncontrast enhanced MDCT images of the head were obtained.
Reformatted coronal and sagittal images were also obtained.
DOSE Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.1 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 6.0 s, 6.1 cm; CTDIvol = 49.1 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: ___ and ___
FINDINGS:
Exam is suboptimal due to patient motion. Given this, re-demonstrated is
extensive cystic encephalomalacia and gliosis of the left frontal parietal
region, similar to prior studies. There is persistent ex vacuo dilatation of
the left lateral ventricle and third ventricle. No acute intracranial
hemorrhage is seen. Prominence of the ventricles and sulci consistent with
involutional changes, grossly similar compared to the prior study. Left
frontal postsurgical changes.
Re-demonstrated left globe phthisis bulbi. Extensive calcifications along the
carotid arteries including the cavernous portions and petrous portions. There
are also extensive vascular calcifications of the vertebral arteries.
IMPRESSION:
Suboptimal study due to patient motion. Given this, no acute intracranial
hemorrhage. Stable chronic changes, as above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with fever on vent// ?pnemonia
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged. No evidence of acute pneumonia, vascular congestion, or
pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with trach, DM 1 with new fevers and increased secretions//
Eval for interval change Eval for interval change
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
A decrease in lung volumes exaggerates a concurrent increase in moderate
cardiomegaly and pulmonary vascular congestion, and makes it impossible to
exclude mild pulmonary edema. No pneumothorax or large pleural effusion.
Tracheostomy tube is midline. Right subclavian line ends close to the
superior cavoatrial junction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with trach having aspiration events// assess
for consolidations assess for consolidations
IMPRESSION:
Tracheostomy is in place. Right central venous line tip is at the proximal
right atrium. Heart size and mediastinum are stable. There is not vascular
congestion but no overt pulmonary edema. No appreciable pneumothorax or
pleural effusion.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: APNEA, TRACH
Diagnosed with Apnea, not elsewhere classified
temperature: 97.1
heartrate: 88.0
resprate: 16.0
o2sat: 100.0
sbp: 144.0
dbp: 87.0
level of pain: 0
level of acuity: 2.0 | ASSESSMENT & PLAN: The patient is a ___ year old female with
diabetes type I, stroke at age ___ with right hemiparesis and
aphasia, gastroparesis, CAD with recent NSTEMI on ___,
tracheostomy on mask, presenting with apneic spells and septic
shock with sputum culture growing pseudomonas.
#Septic Shock: The patient presented with a fever, increased
leukocytosis and a vasopressor requirement concerning for septic
shock. There was concern for C Diff given some recent loose
stools, however this was negative. She was found to have a
likely pneumonia on chest X-ray. This was treated with Meropenem
and Cefepime for a total 8 day course given concern for
ventilator associated pneumonia. Given her sepsis and tunneled
line, there was concern for an infection of the line. It is
important to note that the patient has extremely difficult
intravenous access. Thus, it was fist attempted to treat through
the possible line infection to treat an underlying pneumonia.
This was successful, the patient did improve on antibiotics, and
she was able to be weaned off of pressors. Vancomycin locks were
ordered for any possible indwelling line infection. The
patient's leukocytosis, fevers and blood pressure all improved,
and the patient was discharged.
#Anemia: The patient was anemic on presentation to hemoglobin of
8.8. She became more anemic throughout her hospitalization.
There was no obvious source of bleeding. Her stools were guaiac
negative. There was no evidence of hemolysis on lab studies. Her
anemia was ultimately thought to be related to frequent blood
draws, as well as dilution in the setting of large volume
resuscitation during her septic shock. She received two units of
packed red blood cells, and was discharged with a hemoglobin of
7.8.
#Klebsiella UTI: The patient was noted to have a Klebsiella UTI
on admission. The sensitivities revealed that it was
pan-sensitive, and it was treated with cefepime as above with an
___pneic spells, respiratory acidosis, metabolic alkalosis: On
one or two occasions, early in the hospital course the patient
was noted to have some apneic spells. The patient was awake for
all of these, and her oxygen saturation never dropped.
___ respirations are possible given association with
cardiac, neurologic disease, but her apneic episodes appear to
be more abrupt without cyclic breathing characterized by apnea
then gradually increasing respiratory frequency and tidal volume
then gradually decreasing respiratory frequency and tidal
volume. Other possible causes include CNS depressants as the
patient had been discharged on oxycodone 5mg PO Q6H PRN. Central
processes were also on the differential, and the patient had a
head CAT scan which was negative for bleed.
#DMI: The patient has had recent issues with hypoglycemia
secondary to stacking of regular insulin per her sliding scale.
___ was consulted, and her insulin regimen was adjusted. Her
blood sugars were stable on 14 units of Glargine in the morning
and evening, with the addition of an insulin sliding scale.
Transitional Issues
===================
***Of note it is imperative that if the patient is to have any
interruption in her tube feeding that she continuing getting
sugar dissolved in water to prevent episodes of hypoglycemia
given the use of long acting insulin***
- The patient had a hemoglobin of 6.9 and received one unit of
packed RBCs: Please obtain follow up CBC
- The patient had a creatinine of 2.2 on discharge which appears
to be at, or improved from her baseline
- The patient did have some apneic spells toward the beginning
of her hospitalization: She maintained oxygen saturations
throughout these spells, and recovered on her own with no
intervention
- The patient was discharged with blood cultures and urine
cultures pending: Please follow up on these results
- The patient's insulin regimen was changed during this
hospitalization and should be followed closely to avoid
hypoglycemic episodes
- The patient's Hydralazine and Imdur were held on discharge in
the setting of hypotension: Consider restarting if hypertensive
- The patient's Erythropoietin was held: This should continue to
be held as it is contraindicated in the setting of stroke
history
- The patient's last Glucose was 243: Her tube feeds were
stopped for transport and thus this glucose WAS NOT corrected
for - please check blood sugar upon arrival and correct with
sliding scale once tube feeds are restarted
- The patient's pain medications were stopped while she was in
the hospital: It is possible that these were contributing to her
apneic spells, please consider continuing to hold these
medications if they are not needed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
keflex, / Flagyl
Attending: ___.
Chief Complaint:
n/v, abd pain, hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH DM, recurrent hospitalizations for gastroparesis,
depression, presents with n/v and lower abdominal pain.
Pt reports that since her last hospitalization (d/c ___ she
reports having ___ daily episodes of non-bloody, non-bilious
emesis usually in the evenings not related to food or activity.
Also endorses light headedness upon standing and some tingling
in the hands and feet w/o noticeable weakness.
On ___ she experienced sharp, sudden onset, non-radiating
lower abdominal pain below the umbilicus accompanied by nausea,
vomiting. Pt also reports PO intolerance that came on acutely 2
days ago, similar to her prior gastroparesis flares. She was
able to keep some food down like popsicles and Gatorade. She
says her sugars were gradually getting higher too, which has
happened before. She reports last measuring her blood sugar on
the day prior to presentation: 237. Reports medication
compliance with reglan and all other meds, except for her lantus
on ___ (night prior to admission).
No recent colds, but did have diarrhea 3 days ago that resolved.
Denies SOB, cough, chest pain. Denies constipation/incontinence,
BRBPR, melena, hematochezia, dysuria, hematuria.
She also reports gradually worsening chronic upper back pain
that she says began 8 months ago. It is mid-line in the center
of her thoracic spine. Denies f/c/incontinence/anesthesia. She
denies trauma to the area or prior work-up.
In the ED, initial vitals were: 97.0 105 113/73 16 100% RA
Exam notable for: none documented
Labs notable for initial blood glucose > 500, urine glucose 1000
with 10 ketones, initially with anion gap that has since closed,
normal pH most recently normal, grossly normal chem 7 otherwise
with normal cbc and lfts. urine opiate screen positive
Imaging notable for negative CXR, no acute cardiopulmonary
process
Patient was given:
___ 15:29 IV Morphine Sulfate 4 mg
___ 15:31 IVF 1000 mL NS 1000 mL
___ 16:18 IV HYDROmorphone (Dilaudid) 1 mg
___ 16:18 IV Ondansetron 4 mg
___ 16:22 IV DRIP Insulin Started 9 UNIT/HR , later d/c'd
___ 16:29 PO Erythromycin 250 mg
___ 18:14 IV Morphine Sulfate 4 mg
___ 20:07 SC Insulin 8 Units
___ 22:19 IV Morphine Sulfate 4 mg
___ 22:59 SC Insulin 6 Units
___ 00:40 IV Morphine Sulfate 4 mg
___ 00:40 IV Ondansetron 4 mg
Decision was made to admit for further management of
gastroparesis and elevated blood glucose. Delayed admission to
ensure closure of prior borderline anion gap and improvement in
blood glucose. Patient not tolerating PO.
Vitals prior to transfer: 98.3 96 155/93 18 100% RA
On the floor, patient reports continued back pain only
responsive to morphine, hesistant to try Tylenol or oxycodone.
She states she thinks she could keep food down such as a
popsicle or other liquids.
ROS:
(+) Per HPI
Past Medical History:
- DM2 with with DM1 features. Last HbA1C 10.8 ___
- Hypertension
- Diabetic retinopathy
- Diabetic neuropathy
- Gastroparesis
- Chronic constipation
- History of necrotizing fasciitis of lower abdomen in ___
- Anxiety and depression
- Lipoma
- HSV
- ___ D&C for fetal anomaly
Social History:
___
Family History:
Significant for HTN, DM2, CAD, and cancer.
Physical Exam:
ADMISSION EXAM:
Vital Signs: 97.8 PO 124 / 80 76 18 99 RA
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, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-distended, bowel sounds hypoactive, no
organomegaly, no rebound or guarding, mild tenderness to
palpation below the umbilicus bilaterally. no cvat
Back: Midline thoracic point tenderness at approximately T3-T4
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Grossly intact, bilateral ___ with symmetric intact
strength and light touch sensation.
DISCHARGE EXAM:
VS: patient refused
GEN: 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, normal S1 + S2, no murmurs, rubs,
gallops
PULM: Clear to auscultation bilaterally
ABD: Soft, non-distended, bowel sounds hypoactive, no
organomegaly, no rebound or guarding, mild tenderness to
palpation below the umbilicus in the midline only. no cvat
BACK: No point tenderness to palpation in the spine
GU: No foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Grossly intact CNII-XII, bilateral ___ with symmetric
intact strength and light touch sensation
Pertinent Results:
ADMISSION LABS:
___ 02:39PM BLOOD WBC-8.5# RBC-4.46 Hgb-11.8 Hct-36.3
MCV-81* MCH-26.5 MCHC-32.5 RDW-13.9 RDWSD-40.9 Plt ___
___ 02:39PM BLOOD Neuts-50.5 ___ Monos-5.8 Eos-0.8*
Baso-0.7 Im ___ AbsNeut-4.26 AbsLymp-3.55 AbsMono-0.49
AbsEos-0.07 AbsBaso-0.06
___ 07:40PM BLOOD Glucose-312* UreaN-8 Creat-0.8 Na-137
K-4.4 Cl-98 HCO3-26 AnGap-17
___ 02:39PM BLOOD ALT-10 AST-15 AlkPhos-86 TotBili-0.6
___ 02:39PM BLOOD Lipase-29
___ 02:39PM BLOOD Albumin-4.4 Phos-3.2 Mg-2.0
___ 07:40PM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8
___ 02:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:14PM BLOOD ___ pH-7.41
___ 08:03PM BLOOD ___ pO2-27* pCO2-55* pH-7.32*
calTCO2-30 Base XS-0
___ 03:14PM BLOOD Glucose->500 Lactate-2.0 Na-130* K-4.8
Cl-90* calHCO3-27
___ 03:14PM BLOOD O2 Sat-82
___ 06:03PM URINE Color-Straw Appear-Clear Sp ___
___ 06:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:03PM URINE
___ 06:03PM URINE UCG-NEGATIVE
DISCHARGE LABS:
___ 09:24AM BLOOD WBC-4.7 RBC-4.16 Hgb-10.9* Hct-34.9
MCV-84 MCH-26.2 MCHC-31.2* RDW-13.9 RDWSD-42.5 Plt ___
___:55AM BLOOD Glucose-135* UreaN-6 Creat-0.7 Na-138
K-3.9 Cl-102 HCO3-23 AnGap-17
___ 04:55AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8
___ 12:48AM BLOOD ___ pO2-24* pCO2-52* pH-7.33*
calTCO2-29 Base XS--1
___ 12:48AM BLOOD Lactate-1.8 K-3.2*
___ 12:48AM BLOOD freeCa-1.11*
MICRO:
___ BCx x2 and UCx: NGTD Final
IMAGING:
___ CXR: No acute cardiopulmonary process.
___ T-spine film:
Mild degenerative changes in the thoracic spine.
STUDIES:
___ ECG: Sinus tachycardia. Otherwise, normal ECG. Compared
to the previous tracing of ___ repolarization abnormalities
are no longer seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Metoclopramide 10 mg PO QIDACHS
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO BID
5. Citalopram 10 mg PO DAILY
6. Erythromycin 250 mg PO Q6H
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Citalopram 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Erythromycin 250 mg PO Q6H
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Metoclopramide 10 mg PO QIDACHS
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Gastroparesis
- Hyperglycemia
- Back pain
Secondary diagnosis:
- Hypertension
- Depression and anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with gastroparesis and hyperglycemia // ?cpd
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There are slightly low lung volumes.The lungs are clear without focal
consolidation. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are stable and unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: T-SPINE
INDICATION: ___ PMH gastroparesis, DM presenting with hyperglycemia and
gastroparesis flare as well as back pain. // Spinal source of thoracic back
pain
TECHNIQUE: Thoracic spine two views
COMPARISON: ___ radiograph of the chest.
FINDINGS:
There is minimal thoracolumbar curve, may be positional. There are mild
degenerative changes in the thoracic spine. Probable small Schmorl's nodes
upper thoracic 2 adjacent vertebral bodies seen on the lateral radiograph,
stable since ___. There is no radiographic evidence of acute
compression fracture. No destructive lesions. Normal visualized lungs and
ribs.
IMPRESSION:
Mild degenerative changes in the thoracic spine.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Hyperglycemia, N/V
Diagnosed with Nausea with vomiting, unspecified
temperature: 97.0
heartrate: 105.0
resprate: 16.0
o2sat: 100.0
sbp: 113.0
dbp: 73.0
level of pain: 10
level of acuity: 3.0 | ___ year old woman with history notable for gastroparesis and
insulin-dependent diabetes mellitus who presented with
hyperglycemia, nausea and vomiting similar to prior
gastroparesis flares, as well as back pain. The patient was
started on an insulin drip in the emergency department but was
quickly transitioned to a regimen of glargine/lispro similar to
what she gets at home. Her glucose was better controlled during
her admission and instruction from ___, who follows her
closely, was to not discharge her on significantly more insulin
than she takes at home. Her symptoms of gastroparesis improved
with better glycemic control, and she was able to tolerate a
full diet by the time of discharge. Her back pain was initially
controlled with opioids and there were no red flags, but with
both imaging and the understanding of previous workup which was
negative, pain was controlled with non-opioid therapy.
# Gastroparesis: The patient exhibited symptoms consistent with
prior flares including nausea, vomiting, and inability to
tolerate PO intake. Other acute processes were deemed less
likely given normal LFTs, lipase, lactate, lack of fever, normal
WBC count, and reassuring physical exam. These symptoms were
likely exacerbated by DKA/HHNS, which was controlled with
insulin gtt then SC insulin. THe patient was treated initially
with IV then PO reglan as well as her home erythromycin to good
effect, and was able to fully tolerate a solid food diet by the
time of her discharge. She initially received IV morphine in the
ED, but this was held on the floor given the adverse effect of
reduced gut motility and any pain was controlled with non-opioid
medication.
# Hyperglycemia: Likely due to poor glycemic control, and the
patient's last A1c was 9.7 ___. She presented with DKA with
anion gap and 10 ketones in urine prior to correction with
insulin drip. She did not receive her daily evening Lantus in
the ED which caused an initial spike in her FSBG to the high
300s. She was placed on an increased glargine dose which went as
high as 39 units nightly, and continued on her home lispro
sliding scale which began at 8 units. Her metformin was held on
admission. She was followed closely by ___ consultants, to
whom she is well known who recommended she be discharged on
close to her home insulin dosing given her close outpatient
follow up there. Her home glargine was increased to 34 units
nightly upon discharge, and her glucose in the 200s was deemed
satisfactory control.
# Back Pain: Patient reports mid back pain since ___ and prior
treatment at ___. She displayed no red flag symptoms
including fevers, positional component, radicular signs and
maintained an intact lower extremity neuro exam throughout her
stay. T-spine film was done and showed mild degenerative changes
in the thoracic spine. Medical records from ___ were
requested but not received, but the patient's pain was well
controlled with acetaminophen, ibuprofen, and lidocaine patches
by the time of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left shoulder pain after fall
Major Surgical or Invasive Procedure:
Closed reduction of left humerus
History of Present Illness:
___ female presents with the above fracture s/p mechanical fall.
Patient was at home when she fell onto her left shoulder
followed by pain. No LOC, no head trauma, and immediate pain in
the left shoulder. Patient called for help and was brought in
by ambulance. States she currently has sensation and ability to
move affected extremity; however, states pain is persistent
despite acetaminophen. Patient complains of no other injuries.
Past Medical History:
Cavernous malformation, osteopenia
Currently smokes (2+ cigarettes/day)
Social History:
uses tobacco (2+ cigarettes/day), social alcohol consumption, no
illicit drug use.
Physical Exam:
General: Well-appearing female in no acute distress.
Left upper extremity:
- Skin intact
- Notable deformity w/arm held close to body and internally
rotate, edema/swelling over left shoulder, no ecchymosis, no
erythema, no induration
- Soft, non-tender forearm. Tenderness/discomfort w/palpation
and passive movement of left shoulder
- Minimal ROM at shoulder ___ pain, no pain w/ROM of elbow,
wrist, and digits
-Strength + sensation intact in distribution of median, radial,
and ulnar nerve
-Unable to test strength in distribution of axillary nerve ___
pain
-Altered sensation to touch in distribution of axillary nerve
over medial and anterior deltoid when compared to contralateral
side
- SILT radial/median/ulnar nerve distributions
- 2+ radial pulse, WWP
Medications on Admission:
Medications - Prescription
LISINOPRIL - lisinopril 40 mg tablet. 1 tablet(s) by mouth every
day for HTN
SIMVASTATIN - simvastatin 20 mg tablet. one Tablet(s) by mouth
daily for cholesterol and heart
Medications - OTC
ASPIRIN [ADULT ASPIRIN EC LOW STRENGTH] - Adult Aspirin EC Low
Strength 81 mg tablet,delayed release. one Tablet(s) by mouth
daily to protect heart
BLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra
Test strips. use daily as needed for as directed to monitor
blood sugar
BLOOD-GLUCOSE METER [ONETOUCH ULTRAMINI] - OneTouch UltraMini
kit. use to test your blood sugar up three times a day
CALCIUM CARBONATE - calcium carbonate 500 mg calcium (1,250 mg)
tablet. 1 Tablet(s) by mouth twice a day for strong bones
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000 unit tablet. one Tablet(s) by mouth daily for strong bones
FISH OIL - Fish Oil 1,000 mg capsule. 1 Capsule(s) by mouth
twice a day
MULTIVITAMIN - Dosage uncertain - (___)
Discharge Medications:
1. Acetaminophen 650 mg PO 5X PER DAY
2. Aspirin 81 mg PO BID
RX *aspirin 81 mg 1 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Senna 17.2 mg PO HS
5. Insulin SC
Sliding Scale
Fingerstick QACHS, QPC2H, HS
Insulin SC Sliding Scale using REG Insulin
6. Lisinopril 40 mg PO DAILY
7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 PRN Disp #*30
Tablet Refills:*0
8. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Proximal humerus fracture dislocation
Discharge Condition:
AVSS
NAD, A&Ox3
LUE: Skin is clean and dry. Fires EPL/FPL/FDP/FDS/EDC/DIO. SILT
radial/median/ulnar n distributions. 1+ radial pulse, wwp
distally.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with left shoulder and arm pain s/p fall// r/o
fracture/dislocation
COMPARISON: None
FINDINGS:
Multiple views of the left shoulder and humerus were provided. Multiple
fracture fragments at the left humeral neck include anatomic neck fracture and
avulsion fracture of the greater tuberosity. In addition, there is anterior
inferior dislocation of the left humeral head relative to the glenoid fossa.
No gross deformity at the left glenoid fossa though difficult to exclude a
bony Bankart injury. Distally, the left humerus is intact. The left
acromioclavicular joint also appears intact.
IMPRESSION:
Fracture involving the anatomic neck of the left humerus as well as avulsion
of the greater tuberosity of the left proximal humerus with associated
anterior inferior dislocation of the left humeral head from the glenoid fossa.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fall, going to OR, evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
The cardiomediastinal silhouette is within normal limits. There is no focal
consolidation or suspicious mass. There is no pneumothorax, pleural effusion,
or pulmonary vascular congestion. Again demonstrated is a fracture involving
the anatomic neck of the left humerus. There is elevation of the left
hemidiaphragm.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
EXAMINATION: CR - HUMERUS (AP AND LAT) IN O.R. LEFT
INDICATION: Left humerus ORIF
TECHNIQUE: AP fluoroscopic images were obtained of the left humerus
intraoperatively.
Fluoroscopy time: 31.1 seconds
Total dose: 1.5 mGy
COMPARISON: Radiographs of the left shoulder and humerus ___ at
13:26
FINDINGS:
Intraoperative images of the left humerus were acquired without a Radiologist
present.
There is redemonstration of the comminuted fracture through the surgical neck
of the left humerus with involvement of the greater tuberosity.
IMPRESSION:
Intraoperative images were obtained during ORIF of the left humerus. Please
refer to the operative note for details of the procedure.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: L Shoulder injury, L Shoulder pain, s/p Fall
Diagnosed with Unsp fracture of upper end of left humerus, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 99.3
heartrate: 72.0
resprate: 17.0
o2sat: 100.0
sbp: 144.0
dbp: 81.0
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 a left proximal humerus fracture dislocation and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room for closed reduction. She worked
with physical therapy and occupational therapy who determined
that discharge to rehab was appropriate. The patient was given
anticoagulation per routine, and the patient's home medications
were continued throughout this hospitalization. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the left upper
extremity. She should not range her shoulder in that extremity
at all, however, she should range her elbow, wrist, and digits.
She will be discharged on aspirin 81 twice daily for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cefepime / Bactrim
Attending: ___.
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is a ___ female with a history of
recurrent MDR UTIs/pyelonephritis, nephrolithiasis s/p ureteral
stents (since removed) and lithotripsies in the past, COPD,
depression/anxiety, and HTN who presented to the ED with chills,
SOB abdominal pain, diarrhea, nausea and vomiting for 3 days.
Patient endorses 3 days ago she started to have chills as well
as
nausea and several episodes of nonbloody nonbilious emesis. She
then started to have abdominal pain today that is suprapubic.
She
endorses abdominal pain is worse with movement but no change
with
food or defecation or urination. Denies fevers, dysuria, vaginal
discharge, vaginal bleeding, hematochezia, cough, chest pain,
rhinorrhea, congestion. She is still passing gas. Endorses that
this presentation is similar to when she has UTIs.
In the ED:
VS: 98.4 Tmax 99.2, P ___, BP 164/87, RR 24, 95% RA
PE: Tachycardic, afebrile, well appearing, NAD, CTAB, moving air
well. No crackles or wheezes. Epigastric and suprapubic
tenderness, no rebound or guarding. R CVAT.
Labs: lactate 2.6 --> 1.2, WBC 10.7, UA positive, Cr 1.6 -> 1.4,
mild transaminitis
Imaging: CT A/P with pyelonephritis and nonobstructive
nephrolithiasis, CXR negative
Impression: acute pyelonephritis, unable to tolerate po, ___
Interventions: ceftriaxone 1g, then zosyn 4.5g, tylenol, zofranm
LR 1L then LR @ 150, compazine, 1mg IV ativan
Past Medical History:
recurrent MDR UTIs/pyelonephritis, nephrolithiasis s/p ureteral
stents (since removed) and lithotripsies in the past, COPD,
depression/anxiety, and HTN
Social History:
___
Family History:
Mother: DM, died at age ___ from diabetes complications
-Father: CAD, heart failure, died at age ___
-Brother: colon cancer
Physical Exam:
VS: T98.0, BP 130 / 67, HR 73, R 18, O2 sat 97% RA
GENERAL: Alert, NAD
EYES: Anicteric, PERRL
ENT: moist mm, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB, no wheezes, crackles, or rhonchi
ABD/GI: Soft, ND, NTTP, normoactive bowel sounds
GU: No suprapubic fullness or tenderness to palpation, no CVA
tenderness
MSK: Neck supple, moves all extremities
VASC/EXT: No ___ edema, 2+ DP pulses
SKIN: No rashes or lesions noted on visible skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
CT A/P: FINDINGS:
LOWER CHEST: There is dependent right middle lobe and lingular
atelectasis as
well as right basilar atelectasis or scarring. No pericardial
or pleural
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout.
There is no evidence of focal lesions within the limitations of
an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic
biliary
dilatation. The gallbladder is surgically absent.
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: Unchanged 2.5 cm left adrenal adenoma. Right adrenal
gland is
unremarkable.
URINARY: The bilateral kidneys are edematous with extensive
perirenal fat
stranding and thickening of the perirenal fascia. The kidneys
have an
irregular contour bilaterally consistent with cortical scarring.
Non-obstructing renal stones are seen bilaterally, similar from
prior. The
largest stone in the right kidney measures 0.5 cm, unchanged
(2:97). The
largest stone in the left lower pole measures 0.7 cm, unchanged
(601:56).
There are no ureteral stones.
GASTROINTESTINAL: Stomach is unremarkable. No small bowel
obstruction. The
colon rectum are unremarkable. The appendix is normal. No free
fluid in the
abdomen.
PELVIS: There is mild thickening of the bladder wall which may
in part be due
to under-distention. There is a small bladder diverticulum
superiorly. The
distal ureters are normal without evidence of obstructing stone.
There is a 2
mm stone lying dependently within the bladder (2:169).
Re-demonstration of
pelvic floor laxity.
REPRODUCTIVE ORGANS: The visualized reproductive organs are
unremarkable.
LYMPH NODES: Conspicuous upper abdominal periaortic lymph nodes
at the level
of the renal veins are likely reactive.
VASCULAR: No abdominal aortic aneurysm. There is mild calcified
atherosclerotic plaque.
BONES: No worrisome osseous lesion or acute fracture.
SOFT TISSUES: The abdominopelvic walls within normal limits.
IMPRESSION:
1. Bilateral kidneys are edematous bilaterally with extensive
perinephric fat
stranding and thickening of the perirenal fascia, concerning for
acute
pyelonephritis.
2. Non-obstructing nephrolithiasis. No ureteral stones are seen.
No
hydronephrosis.
3. Questionable mild bladder wall thickening, possibly due to
under-distention. A 2 mm stone is seen dependently within the
bladder lumen.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 8 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID:PRN Pain - Mild/Fever
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Gabapentin 200 mg PO QHS
7. Sertraline 100 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. NIFEdipine (Extended Release) 90 mg PO DAILY
Discharge Medications:
1. Ertapenem Sodium 1 g IV ONCE MDR pyelonephritis Duration: 1
Dose
Start on ___
RX *ertapenem 1 gram 1 g iv once a day Disp #*9 Vial Refills:*0
2. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide [Imodium A-D] 2 mg 2 mg by mouth three times a
day as needed Disp #*30 Capsule Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Gabapentin 200 mg PO QHS
8. Metoprolol Succinate XL 50 mg PO DAILY
9. NIFEdipine (Extended Release) 90 mg PO DAILY
10. Sertraline 100 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
bilateral pyelonephritis
diarrhea
___
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 SOB s/o viral illness last week // r/o PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
There is no focal consolidation, large pleural effusion, pulmonary edema or
pneumothorax. There is right basilar atelectasis. The cardiomediastinal
silhouette is unremarkable. The hilar contours are normal. No acute osseous
abnormality.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ with h/o UTI, stones, p/w abdominal pain, n/vNO_PO contrast
// r/o stone, pyelonephritis, please protocol as prone. getting 1L LR now for
prehydration, GFR 33
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. The
patient was scanned in the prone position.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.5 s, 51.3 cm; CTDIvol = 25.9 mGy (Body) DLP =
1,330.1 mGy-cm.
Total DLP (Body) = 1,330 mGy-cm.
COMPARISON: CT abdomen/pelvis ___.
FINDINGS:
LOWER CHEST: There is dependent right middle lobe and lingular atelectasis as
well as right basilar atelectasis or scarring. No pericardial or pleural
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is surgically absent.
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: Unchanged 2.5 cm left adrenal adenoma. Right adrenal gland is
unremarkable.
URINARY: The bilateral kidneys are edematous with extensive perirenal fat
stranding and thickening of the perirenal fascia. The kidneys have an
irregular contour bilaterally consistent with cortical scarring.
Non-obstructing renal stones are seen bilaterally, similar from prior. The
largest stone in the right kidney measures 0.5 cm, unchanged (2:97). The
largest stone in the left lower pole measures 0.7 cm, unchanged (601:56).
There are no ureteral stones.
GASTROINTESTINAL: Stomach is unremarkable. No small bowel obstruction. The
colon rectum are unremarkable. The appendix is normal. No free fluid in the
abdomen.
PELVIS: There is mild thickening of the bladder wall which may in part be due
to under-distention. There is a small bladder diverticulum superiorly. The
distal ureters are normal without evidence of obstructing stone. There is a 2
mm stone lying dependently within the bladder (2:169). Re-demonstration of
pelvic floor laxity.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Conspicuous upper abdominal periaortic lymph nodes at the level
of the renal veins are likely reactive.
VASCULAR: No abdominal aortic aneurysm. There is mild calcified
atherosclerotic plaque.
BONES: No worrisome osseous lesion or acute fracture.
SOFT TISSUES: The abdominopelvic walls within normal limits.
IMPRESSION:
1. Bilateral kidneys are edematous bilaterally with extensive perinephric fat
stranding and thickening of the perirenal fascia, concerning for acute
pyelonephritis.
2. Non-obstructing nephrolithiasis. No ureteral stones are seen. No
hydronephrosis.
3. Questionable mild bladder wall thickening, possibly due to
under-distention. A 2 mm stone is seen dependently within the bladder lumen.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with Nausea with vomiting, unspecified
temperature: 98.4
heartrate: 107.0
resprate: 24.0
o2sat: 95.0
sbp: 164.0
dbp: 87.0
level of pain: 10
level of acuity: 3.0 | SUMMARY/ASSESSMENT:
___ F with PMH of recurrent MDR UTIs/pyelonephritis,
nephrolithiasis s/p ureteral stents (since removed) and
lithotripsies in the past, COPD,depression/anxiety, and HTN who
presented with chills,SOB abdominal pain, diarrhea, nausea and
vomiting and was found to have CT evidence of bilateral pyelo
and MDR Ecoli bacteremia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Demerol / morphine
Attending: ___.
Chief Complaint:
Dizziness, s/p fall.
Major Surgical or Invasive Procedure:
___ Peritoneal catheter placement.
History of Present Illness:
Mr. ___ is a ___ year old man with metastatic renal cell
carcinoma with brain and bone mets who presented to the ER today
after a fall at home. He reports he was moving some chairs when
he felt accutely lightheaded and fell onto his left side. He
had difficulty getting up. He has been having worsening
mobility at home due to a sacral met and pain on his left side
and left leg. He was due for radiation treatment but did not
make the appointment for planning. He reports no loss of
consciousness with the fall and denies chest pain or shortness
of breath.
In the emergency department, initial vitals: 97.3 89 105/44 18
97%. CT head showed right occipital lobe metastatic lesion is
similar in size compared to MRI on ___. No acute
hemorrhage or new lesion grossly identified. CT C-spine was
unremarkable. Plain films of the chest, T-spine, left hip and
pelvis showed no fracture. ECG was unremarkable.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
PAST ONCOLOGIC HISTORY: Renal cell carcinoma stage IV (T3aN0M1)
- ___ Developed flank pain and inability to urinate. Seen at
___ where he passed clots in his urine. CT showed R
hydroureter c/w nephrolithiasis/obstruction and an indeterminate
R kidney lesion.
- ___ Follow up CT redemonstrated at 3.9 cm right upper pole
indeterminate renal lesion with equivocal enhancement.
- ___ Follow up US redemonstrated the R renal mass.
- ___ ___ biopsy without evidence of malignancy.
- ___ ___ with hematuria and flank pain. CT showed the R
renal mass had increased to 8cm as well as possible lung
nodules.
- ___ CT chest with multiple lung nodules concerning for
mets.
- ___ LUL VATS biopsy revealed metastatic renal cell
carcinoma.
- ___ Right laparoscopic radical nephrectomy/adrenalectomy
revealed poorly differentiated carcinoma.
- ___ CT showed increase in size and number of bilateral
lung nodules, increase in size of mediastinal and right hilar
lymph nodes.
- ___ Head CT without evidence of mets.
- ___ Started tivozanib on ___ ___.
- ___ CT showed partial response to therapy.
- ___ CT torso showed stable metastatic disease.
- ___ CT torso showed stable metastatic disease.
- ___ ___ ___, extension trial of tivozanib.
- ___ CT torso showed stable disease.
- ___ CT showed interval mild increase in the size of
multiple pulmonary nodules. Stopped tivozanib.
- ___ Screening for trial ___ avastin + toricel but
found to have a right occipital brain metastasis.
- ___ CT showed increase in size of multiple pulmonary
nodules and lymph nodes. CT head showed interval development of
metastatic lesions to the right occipital lobe with surrounding
vasogenic edema. New right parietal bone lesion with soft tissue
component extending both intracranially and into the superficial
scalp soft tissues.
- ___ Started everolimus.
- ___ Completed CyberKnife to two brain lesions.
- ___ - ___ XRT to femoral lesion.
- ___ CT showed increase size of left adrenal tissue,
suggesting metastasis; decrease in size of multiple pulmonary
nodules; and stable lytic lesion in right iliac bone.
- ___ MRI L-spine showed numerous osseous metastases
throughout the imaged T-spine, L-spine, and imaged upper medial
pelvis.
- ___ MRI pelvis: 1. Progressively enlarging lesion in the
right iliac bone with large soft tissue component with areas of
central necrosis. 2. Worsening disease in the right sacrum.
.
Other PMHx:
- Hypertension.
- Hereditary spherocytosis s/p splenectomy.
- BPH.
- Osteoarthritis.
- VATS metastatectomy ___.
- Arthroscopy ___.
- COPD?
Social History:
___
Family History:
- Mother: ___
- Father: CAD
- Sister: ___ cancer
Physical Exam:
ADMISSION EXAM:
VS: T98.2 BP 102/68 HR 82 RR 20 96% RA
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Gait assessment deferred
Pertinent Results:
ADMISSION LABS:
___ 03:20PM BLOOD WBC-22.7* RBC-2.89* Hgb-7.3* Hct-23.4*
MCV-81* MCH-25.4* MCHC-31.3 RDW-22.4* Plt ___
___ 03:20PM BLOOD Neuts-78.0* Lymphs-15.0* Monos-5.9
Eos-0.5 Baso-0.6
___ 03:20PM BLOOD Glucose-93 UreaN-26* Creat-1.5* Na-131*
K-5.1 Cl-99 HCO3-19* AnGap-18
___ 03:20PM BLOOD ALT-15 AST-26 LD(LDH)-298* AlkPhos-79
TotBili-0.3
___ 03:20PM BLOOD cTropnT-0.02*
___ 03:20PM BLOOD Albumin-2.5* Calcium-9.2 Phos-4.5 Mg-2.0
.
STUDIES:
ECG ___: normal sinus rhythm with PR prolongation. No ST/T
wave changes.
.
___ MRI BRAIN: CONCLUSION: The right occipital lesion is now
completely hemorrhagic with a faint trace of surrounding
enhancement. The edema has progressed.
.
___ MRI L-SPINE: IMPRESSION:
1. Numerous osseous metastases throughout the imaged lower
thoracic spine, lumbar spine, and imaged upper medial pelvis.
No evidence of a pathologic fracture or epidural mass in the
lumbar spine. Pelvic metastatic disease is better assessed on
the concurrent pelvic MRI.
2. Multilevel degenerative disease. Epidural lipomatosis in
the lower lumbar spine.
.
___ MRI PELVIS: IMPRESSION:
1. Progressively enlarging lesion centered in the right iliac
bone with large soft tissue component. Areas of central
non-enhancement suggest necrosis. Intact underlying bony cortex
is somewhat atypical for renal cell carcinoma. Although this
mass is most likely metastatic renal cell carcinoma,
differential diagnosis includes small round blue cell tumors,
such as lymphoma or infection.
2. Worsening disease in the right sacrum. This most likely
represents a ___ site of bony metastasis adjacent to the right
iliac metastasis. However, there is a small amount of fluid in
the right sacroiliac joint. Differential diagnosis includes
infection crossing the joint, but this is felt less likely.
3. Muscular edema surrounding the right hip.
4. Ascites, partially imaged, new compared to ___.
.
___ X-RAY LEFT HIP: IMPRESSION: No fracture or dislocation.
The previously seen metastatic lesions on the MRI of the pelvis
from ___ are not well seen by radiograph.
.
___ X-RAY PELVIS: IMPRESSION: No fracture or dislocation.
The previously seen metastatic lesions on the MRI of the pelvis
from ___ are not well seen by radiograph.
.
___ X-RAY T-SPINE: IMPRESSION: No fracture is identified.
The previously seen lesions on prior MR ___ spine from ___ are not well seen by radiograph.
.
___ CXR: IMPRESSION: Numerous metastatic lesions throughout
the lungs, as were seen on CT torso on ___. No
focal consolidation.
.
___ CT C-SPINE: IMPRESSION:
1. No acute fracture. Minimal anterolisthesis of C3 on C4 is
unchanged since ___.
2. Multiple pulmonary nodules in the lung apices bilaterally
compatible with metastases.
3. 9 mm left thyroid nodule, unchanged since ___.
.
___ CT HEAD: IMPRESSION: Right occipital lobe metastatic
lesion is similar in size compared to MRI on ___. No
acute hemorrhage or new lesion grossly identified, though MRI
with contrast would be a more sensitive study for assessment of
the latter.
.
___ Paracentesis: IMPRESSION: Ultrasound-guided diagnostic
and therapeutic paracentesis yielding 3 liters of yellow ascitic
fluid. Pathology is pending.
.
___ ___ ultrasounds: IMPRESSION: No evidence of DVT in
either lower extremity. The peroneal veins were not visualized
bilaterally.
.
___ Cytology Peritoneal Fluid: POSITIVE FOR MALIGNANT CELLS,
consistent with metastatic renal cell carcinoma.
.
___ MRI L spine w/ contrast: Extensive spinal metastatic
disease, unchanged since ___. No evidence of spinal
cord or cauda equina compression.
.
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-28.4* RBC-3.57* Hgb-9.7* Hct-30.5*
MCV-86 MCH-27.3 MCHC-31.8 RDW-21.4* Plt ___
___ 10:50AM BLOOD ___ PTT-26.7 ___
___ 07:00AM BLOOD Ret Aut-4.2*
___ 07:15AM BLOOD Glucose-105* UreaN-25* Creat-1.4* Na-127*
K-5.4* Cl-94* HCO3-21* AnGap-17
___ 07:45AM BLOOD Albumin-2.4* Calcium-9.5 Phos-3.4 Mg-1.9
___ 07:15AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.9
___ 07:00AM BLOOD CK(CPK)-73
___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:20PM BLOOD cTropnT-0.02*
___ 03:20PM BLOOD CK-MB-2
___ 07:00AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.1 Iron-___*
___ 07:00AM BLOOD calTIBC-104* ___ TRF-80*
___ 07:34AM BLOOD Hapto-444*
___ 07:45AM BLOOD Cortsol-32.3*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath,
wheezing
2. Amlodipine 5 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Doxazosin 4 mg PO HS
5. Enalapril Maleate 20 mg PO DAILY
6. everolimus *NF* 10 mg Oral daily
7. Lorazepam 0.5-1 mg PO HS:PRN insomnia
8. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
pain
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
11. Acetaminophen ___ mg PO Q6H:PRN pain
12. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath,
wheezing
2. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour Apply one patch q72HR Disp #*5
Transdermal Patch Refills:*0
3. Acetaminophen ___ mg PO Q6H:PRN pain
4. Sodium Bicarbonate 650 mg PO BID
5. Tamsulosin 0.4 mg PO HS
6. traZODONE 50 mg PO HS:PRN insomnia
7. Sodium Polystyrene Sulfonate 30 gm PO DAILY:PRN K+>5.1
8. Bisacodyl 10 mg PO DAILY:PRN Constipation
9. Calcium Carbonate 500 mg PO QID:PRN Heartburn, acid reflux
10. Furosemide 20 mg PO DAILY
11. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q3HR Disp #*30
Tablet Refills:*0
12. Ondansetron ___ mg PO Q8H:PRN Nausea
13. Pantoprazole 40 mg PO Q24H
14. Ranitidine 150 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
16. Docusate Sodium 100 mg PO BID:PRN constipation
17. Outpatient Lab Work
Dx: Renal cell carcinoma, hyperkalemia.
Labs: Potassium.
Draw every three days.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
`1. Dizziness.
2. Metastatic kidney cancer.
3. Hypotension (low blood pressure).
4. Dehydration.
5. Acute kidney injury.
6. Fever.
7. Anemia (low red blood cell count).
8. Malignant ascites (fluid in the abdomen from cancer).
9. Bone metastases.
10. Edema (fluid overload).
11. Hyperkalemia (elevated potassium level).
12. Benign prostatic hyperplasia (BPH, enlarged prostate).
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, T5 pain.
COMPARISON: Chest radiograph on ___ and CT torso ___.
FINDINGS:
AP view of the chest. There are multiple nodules throughout both lungs, which
were seen on CT torso on ___ and are consistent with metastatic
lesions. Comparison is not optimal due to differences in technique. The
heart is enlarged. There is a focal convexity to the right mediastinal
contour consistent an enlarged lymph node seen on the prior CT. No focal
consolidation. No pleural effusion or pneumothorax.
IMPRESSION:
Numerous metastatic lesions throughout the lungs, as were seen on CT torso on
___. No focal consolidation.
Radiology Report
HISTORY: Fall and T5 pain.
COMPARISON: CT torso on ___ and MR ___ spine from ___.
FINDINGS:
AP and lateral views of the thoracic spine. The vertebral and disc heights
are preserved. There are mild degenerative changes of the lower thoracic
spine. No osseous lesions are identified. The previously seen osseous
lesions on prior MR ___ spine from ___ are not well seen by
radiograph. No fracture is identified. No subluxation.
IMPRESSION:
No fracture is identified. The previously seen lesions on prior MR ___ spine
from ___ are not well seen by radiograph.
Radiology Report
HISTORY: Left hip pain.
COMPARISON: CT torso on ___ and MRI of the pelvis on ___.
FINDINGS:
The previously seen lesions in the proximal femurs and pelvic bones on MRI
from ___ are not well seen on this study. There is some sclerosis
seen in the right ilium likely representing the known metastatic lesion. No
fracture or dislocation is identified. There are mild degenerative changes of
the hips bilaterally.
IMPRESSION:
No fracture or dislocation. The previously seen metastatic lesions on the MRI
of the pelvis from ___ are not well seen by radiograph.
Radiology Report
HISTORY: Fall, evaluate for bleed.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered. Coronal and sagittal reformations were performed.
Bone algorithm was obtained.
COMPARISON: MRI abdomen on ___.
FINDINGS:
There is a hypodense lesion in the right occipital lobe measuring
approximately 2.1 x 2.1 x 1.9 cm, similar to prior MRI and compatible with
known metastatic lesion. There is mild surrounding edema and some higher
density material within it, which may represent resolving hemorrhage. No
other new lesions are identified. There is no evidence of acute hemorrhage or
large acute territorial infarction. The ventricles and sulci are mildly
prominent consistent with atrophy. The orbits are normal. There is partial
opacification of the right mastoid air cells. The visualized paranasal
sinuses and left mastoid air cells are well aerated. No fracture.
IMPRESSION:
Right occipital lobe metastatic lesion is similar in size compared to MRI on
___. No acute hemorrhage or new lesion grossly identified, though
MRI with contrast would be a more sensitive study for assessment of the
latter.
Radiology Report
HISTORY: Fall, evaluate for fracture.
TECHNIQUE: MDCT images were obtained through the cervical spine without
contrast. Coronal and sagittal reformations were performed. Bone algorithm
was obtained.
COMPARISON: C-spine radiographs on ___. CT torso on ___.
FINDINGS:
There is no acute fracture. There is minimal anterolisthesis of C3 on C4,
unchanged compared to ___. There are mild degenerative changes of
the cervical spine but no critical central canal stenosis. The aerodigestive
tract is normal. There is no prevertebral soft tissue abnormality. There is
a 9 mm left hypodense thyroid nodule, unchanged compared to ___.
Multiple pulmonary nodules seen at the lung apices bilaterally. Partial
opacification of the mastoid air cells bilaterally likely reflects ongoing
inflammation.
IMPRESSION:
1. No acute fracture. Minimal anterolisthesis of C3 on C4 is unchanged since
___.
2. Multiple pulmonary nodules in the lung apices bilaterally compatible with
metastases.
3. 9 mm left thyroid nodule, unchanged since ___.
Radiology Report
INDICATION: History of metastatic renal cell carcinoma and worsening lower
extremity edema. Evaluate for DVT.
COMPARISON: Lower extremity ultrasound from ___.
FINDINGS: Grayscale and color sonograms were acquired of the bilateral common
femoral, superficial femoral, popliteal, and posterior tibial veins. The
peroneal veins were not imaged. There is normal compressibility, flow, and
augmentation throughout the visualized deep venous structures.
IMPRESSION: No evidence of DVT in either lower extremity. The peroneal veins
were not visualized bilaterally.
Radiology Report
INDICATION: Worsening ascites in a patient with a history of metastatic renal
cell cancer. Please perform both a diagnostic and therapeutic
ultrasound-guided paracentesis.
COMPARISON: None.
RADIOLOGISTS: Dr. ___, Dr. ___.
PROCEDURE/FINDINGS: The procedure, risks, benefits, and alternatives were
discussed with the patient and written informed consent was obtained. A
preprocedure timeout was performed using three patient identifiers, per ___
protocol.
Under ultrasound guidance, an entrance site was selected along the lower right
abdomen, following which the skin was prepped and draped in the usual sterile
fashion. Local anesthesia was achieved with a 1% lidocaine solution. A 5
___ ___ catheter was then advanced into the peritoneal cavity, following
which 3 liters of yellow ascitic fluid was removed. Samples were sent to
pathology for cell count, chemistry, gram stain/culture, and cytology. The
patient tolerated the procedure well, without immediate complication.
Estimated blood loss was minimal.
The attending radiologist, Dr. ___, was present during the critical portions
of the procedure.
IMPRESSION: Ultrasound-guided diagnostic and therapeutic paracentesis
yielding 3 liters of yellow ascitic fluid. Pathology is pending.
Radiology Report
PROCEDURE: Placement of peritoneal drainage catheter (Pleurx catheter) via a
right flank approach.
HISTORY: ___ male with renal cell carcinoma with rapidly accumulating
ascites. Request is to perform palliative Pleurx catheter placement.
COMPARISON: Reference is made to a recent paracentesis imaging study from
___.
OPERATORS: Dr. ___ and Dr. ___, attending,
performed the procedure. Dr. ___ attending, was present throughout
the procedure.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
Versed (1 mg) and fentanyl (100 mcg) throughout the total intra-service time
of 20 minutes during which the patient's hemodynamic parameters were
continuously monitored. In addition, the patient received 1% lidocaine and 1%
lidocaine buffered with epinephrine along the right flank peritoneal access
path and also the subcutaneous tunnel.
PROCEDURE NOTE IN DETAIL: Informed consent was obtained outlining the risks
and benefits of the proposed procedure. The patient was then brought to the
Angiography Suite and placed supine on the imaging table. A limited
ultrasound demonstrated large volume ascites. A suitable access point was
marked on the patient's skin overlying the right flank.
The area was prepped and draped in the usual sterile fashion. A pre-procedure
huddle and timeout were performed as per ___ protocol. Following
administration of 1% lidocaine as described, the peritoneal cavity was
accessed using a micropuncture needle. Return of clear ascites was obtained
and a 0.018 wire easily advanced into the peritoneal cavity. The needle was
removed and exchanged for a 4.5 ___ micropuncture sheath. Via the sheath,
an 0.035 wire was advanced into the peritoneal cavity under fluoroscopic
guidance. Attention was then turned to creation of a subcutaneous tunnel. A
suitable tunnel exit point cranial and anterior to the peritoneal access point
was identified approximately 10 cm from the peritoneal access point. A 2 mm
incision was made using an 11 blade. Following administration of 1% buffered
lidocaine with epinephrine, a 15.5 ___ Pleurx catheter tubing was tunneled
using a metal tunneling device to exit at the peritoneal access site. The
peritoneal access tract was dilated using sequential dilators with eventual
placement of a 16 ___ peel-away sheath. Via the sheath, the approach
catheter tubing was advanced into the peritoneal space. The catheter cuff was
positioned optimally in the midpoint of the tunnel.
The catheter tubing was connected to the drainage bag and 3 liters of clear
ascites was drained as per request. The peritoneal access incision was closed
using a ___ Vicryl subcuticular suture and Steri-Strips. A 0 silk suture was
used to secure the catheter tubing to the skin. Sterile dressings were
applied. The patient tolerated the procedure well and there were no early
complications.
IMPRESSION:
Uncomplicated placement of a tunneled 15.5 ___ Pleurx catheter via the
right flank approach.
Three liters of fluid was removed as per request.
Overall, the patient tolerated the procedure well and there were no early
complications.
Radiology Report
HISTORY: Metastatic cancer to the spine. Is there evidence of cord
compression?
TECHNIQUE: sagittal imaging with T2 weighted, sister, and T1 weighted
technique. Axial T2 and T1 weighted imaging. Sagittal and axial T1 weighted
imaging after the administration 12 cc of Gadavist intravenous contrast.
COMPARISON: Lumbar spine MR ___
FINDINGS:
Again seen are findings of diffuse metastatic disease throughout the lumbar
spine and sacrum. There is inhomogeneous replacement of marrow intensity
throughout these levels. No evidence of soft tissue encroaching on the spinal
canal. Changes of degenerative disc disease include a prom disk bulge T11-12
and bilateral neural foraminal narrowing at L4-5 L5-S1. These findings are
unchanged since the prior study. No abnormal enhancement after contrast
administration
IMPRESSION:
Extensive spinal metastatic disease, unchanged since ___. No
evidence of spinal cord or cauda equina compression.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with SEC MAL NEO BRAIN/SPINE
temperature: 97.3
heartrate: 89.0
resprate: 18.0
o2sat: 97.0
sbp: 105.0
dbp: 44.0
level of pain: 9
level of acuity: 3.0 | ___ man with metastatic renal cell CA admitted for dizziness
and a fall. He fell at home due to dizziness while ambulating
and could not get up. His daughter found him down ~1hr later
and called EMS. Trigger ___ for hypotension/dizziness (SBP
___. Responded to IV fluids, RBC transfusions, and stopping
anti-hypertensives and alpha blocker for BPH. He developed
marked worsening of ascites following fluid resuscitation.
Paracentesis ___ revealed positive cytology for metastatic
renal cell. Ascites rapidly reaccumulated and peritoneal
catheter was placed ___ for repeat paracenteses for comfort.
Goals of care discussion with his primary oncologist, Dr. ___,
___ Dr. ___ on ___ resulted in decision for DNR/DNI.
He frequently would not remember his prior discussions regarding
the fact that his renal cancer has been rapidly progressive
(metastases throughout his body including lungs, bones,
peritoneal fluid, and brain), there are no other treatment
options for him, and resuscitation with chest
compressions/intubation/defibrillation would be medically
ineffective. He was started on furosemide and sodium
bicarbonate in addition to occasional Kayexalate for
hyperkalemia. He and his family agreed to transfer to ___ with
occasional potassium checks and Kayexalate if K+ >5.1 and then
eventual transition to hospice.
.
# Dizziness/fall, orthostatic hypotension: Orthostatic
hypotension caused the dizziness and fall. Cardiac enzymes x2
negative. CXR negative. U/A, blood and urine cultures
negative. Trigger ___ for hypotension/dizziness (SBP ___.
Responded to IV fluids, RBC transfusion, and holding
anti-hypertensives but third spaced fluids. IV fluids then held
accept for a 500cc bolus ___ for relative hypotension.
Doxazosin stopped ___. Repeat MRI L-spine did not show cord
impingment. AM cortisol adequate. Now tolerating furosemide
and tamsulosin.
.
# Pain (back and RLE): Due to neoplasm. Refused Oxycontin and
oxycodone (possibly due to hallucinations). Improved with
tramadol, but this was stopped given its high seizure risk with
brain mets. Started fentenyl 25mcg/hr patch and hydromorphone
PO PRN. Daily peritoneal drainage of 1L for comfort.
.
# Anasarca, malignant ascites: Due to third spacing IV fluids,
hypoalbuminemia, and malignancy. Improved after 3L paracentesis
___, but rapidly reaccumulated. Doppler U/S negative for
DVT. Peritoneal catheter placed ___ and an additional 3L
removed. Stopped IV fluids. Removed 1L peritoneal fluid every
day for comfort. Started low-dose furosemide ___ for
chronic hyperkalemia; possible added benefit of helping
peripheral edema.
.
# Hyperkalemia: Etiology unclear; suspect hypermetabolic. ACE
inhibitor stopped at admission. Other contributing factors may
include metabolic acidosis, leukocytosis/thrombocytosis
(pseudohyperkalemia), type IV RTA. AM cortisol adequate.
Improved after sodium polystyrene sulfonate (Kayexalate)
___, and ___. Started furosemide and sodium
bicarbonate, but K+ still elevated. Discussed with Mr. ___
and his family about options and they are agreeable to D/C to
SNF today with occasional monitoring of potassium, giving
polystyrene sulfonate (Kayexalet) if elevated (>5.1). They
understand the risks including arrhythmias and sudden death.
Continued low K diet. Sodium polystyrene sulfonate as needed
(if K+ >5.1).
- CHECK POTASSIUM EVERY THREE DAYS.
.
# Metabolic acidosis: Non-anion-gap acidosis. Unclear etiology
(RTA type IV vs. chronic hyperventilation). Stable on sodium
bicarbonate (started in order to treat hyperkalemia).
.
# Hyponatremia: Likely due to poor PO intake. Given goals of
care, IV fluids were not restarted. Consider stopping
furosemide.
.
# Acute kidney injury: Resolved with IV fluids. Gradual
worsening with IV fluids off and continued poor PO intake.
Given goals of care, IV fluids will not be restarted.
.
# Nausea and vomiting: Resolved. Anti-emetics PRN.
.
# Fever: Intermittant and low grade. CXR negative, U/A
negative. Blood, urine, and ascites cultures negative. Fever
resolved. Low threshold for empiric antibiotics: high risk from
ASPLENIA.
.
# Leukocytosis: Chronic, but higher then recent. Suspect
reactive from malignancy. No need for antibiotics.
.
# Thrombocytosis: Likely reactive to malignancy. Chronic.
.
# Anemia: Microcytic. Chronic. Iron studies reflect anemia of
inflammation. Retic count 4.2%. Haptoglobin elevated. Guaiac
stool negative. Transfused 1 unit RBC ___ and ___.
.
# Metastatic renal cell CA: s/p tivozanib clinical trial, XRT to
right femur, and cyberknife to two brain mets. Everolimus held
since ___ due to mouth sores and progressing disease.
Consulted Radiation Oncology (missed appointment ___.
Received single fraction XRT to back. Palliative care
consulted. Code status changed to DNR/DNI after discussion with
primary oncologist, Mr. ___, and his family. Plan for
discharge to rehab/SNF with eventual transition to hospice.
.
# HTN: Stopped amlodipine, enalapril, and atenolol due to
hypotension and hyperkalemia.
.
# BPH: Stopped outpatient doxazosin due to hypotension ___,
but he has exhibited mild urinary obstruction now. Started
tamsulosin; BP tolerating it. Foley removed and he was able to
urinate.
.
# COPD: Continued outpatient albuterol.
.
# GERD: Started H2 blocker and CaCo3 PRN.
.
# FEN: Regular diet.
.
# GI PPx: Started H2 blocker and CaCO3 PRN for GERD. Bowel
regimen.
.
# DVT PPx: Heparin SC.
.
# IV access: Peripheral IV x2.
.
# Code status: Full. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M w/ h/o COPD on 2L home oxygen, cor
pulmonale with severe R sided diastolic dysfunction, dementia,
and R sided weakness s/p CVA who presents after recent admission
for syncope with altered mental status. Was admitted from rehab
recently on two occasions- from ___ to ___ for syncope in
setting of pseudomonal UTI and from ___ to ___ w/ hypotension
and bradycardia admitted to the ICU, ultimately diagnosed with
syncope of unclear etiology.
.
He was most recently discharged w/ a dx of vasovagal syncope
with a increase in his bowel regimen, decrease in his metoprolol
and plan for a two week course of ciprofloxacin for his
pan-sensitive pseudomonal UTI (he has h/o recurrent UTIs
including pseudomonal, proteus (R to cipro/bactrim/amp),
enterococcus (R to tetracycline), and klebsiella). His family
reports that he left the hospital in excellent shape but has
gradually deteriorated with weakness, lethargy and poor PO
intake. He has been continued on his 40 mg torsemide daily at
the rehab, anti-hypertensives, and supplemental potassium.
.
He was BIBA from the ___ due to his altered state and due to
hypoxia- to the ___ on 2L, only improving the low ___ on
non-rebreather. He was also reportedly not behaving like
himself- sleeping more, needing additional help with feedings
and not oriented. Per records, torsemide was increased from 40
mg daily to 60 mg daily on ___. Per family, baseline mental
status is oriented x2 with difficulties w/ memory for things
like phone number.
.
In the ED, initial VS were: 97.6 100 127/91 24 95%
Non-Rebreather. BS was 100. Initial ABG was: 68 48 7.41. He was
transitioned to 6L NC, but tired out so was put back on NRB then
CPAP was started ___ tachypnea. Labs were notable for a lactate
of 4.3, Na of 158 (was 141 on ___, Cr 3.9 (1.8), Cl 110, HC03
37, hct 53.8 (47.7), plt 112, BNP 17,220 (was ___ on ___. CXR
was notable for mild pulmonary edema, but no infiltrate. Lactate
trended down to 2.4 with 1 L NS. He was also given vancomycin,
CTX and levofloxacin. VS on transfer were: BP 120/77 HR 84, RR15
on CPAP (24 on NRB); 93% O2 sat.
.
On arrival to the MICU, the patient is somnolent but arousable.
He denies any pain, difficulty breathing, or palpitations. When
asked why he is in the hospital he reports, "to get better."
.
Review of systems: Obtained from patient and family.
(+) Per HPI; also w/ cough productive of dark colored sputum.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath or wheezing. Denies chest
pain, chest pressure, palpitations. 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:
- CAD s/p CABG
- Prostate cancer s/p XRT c/b residual incontinence, condom cath
qhs
- Severe Right Sided Systolic Failure
- Severe pHTN (on ___
- OSA on home BiPAP
- Multiple CVAs w residual R-sided weakness and R-facial droop
- Recurrent syncope of uncertain etiology
- HTN
- DVT
- Depression
- Mild Dementia
- s/p cataract surgery
- Internal hemorrhoids
Social History:
___
Family History:
Mother had cancer, patient cannot recall diagnosis.
Physical Exam:
ON ADMISSION:
Vitals: T: 99.2 BP: 150/90 P: 86 R: 29 O2: 98% on CPAP
General: somnolent but arousable, oriented to person, breathing
rapidly, but no significant use of accessory muscles, able speak
full sentences
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: frequent ectopy, but no m/r/g
Lungs: rhonchorous anteriorly
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no organomegaly
GU: Foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: somnolent, but arousable; oriented to person and able to
state date is ___ by looking at calendar; residual R facial
droop, but otherwise CNII-XII intact; ___ strength throughout,
grossly normal sensation, tremulous legs b/l, gait deferred
ON DISCHARGE:
Vitals: T: 97.0 BP: 136/60 P: 61 R: 18 O2: 96 2L wt: 118.6 kg
General: Elderly ___ male in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at earlobe, no LAD
Lungs: Inspiratory and expiratory mild wheezes in all fields;
dry crackles in upper fields and bases
CV: Regular rate and rhythm, normal S1 + S2; systolic murmur
appreciated throughout, strongest at RUSB and apex
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm and well perfused; 1+ pulses, no clubbing or cyanosis;
1+ pitting edema to knees BLE
Neuro:
MSE: Alert; oriented to person (inc. birthday), ___
___, and ___.
CN: CN II-VI, VIII, IX, XII intact. VII: Decreased strength
in R periorbitals; R facial droop (baseline). XI: ___ strength
on shoulder shrug, head rotation.
Str: ___ in RUE, RLE.
___: Grossly intact bilaterally.
Coord: Pt noncompliant.
Derm: L arm and R shoulder burn scars noted.
Pertinent Results:
ADMISSION LABS:
___ 06:30PM GLUCOSE-105* UREA N-63* CREAT-3.9*#
SODIUM-158* POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-37* ANION
GAP-16
___ 06:30PM CALCIUM-9.0 PHOSPHATE-5.5*# MAGNESIUM-2.3
___ 06:30PM cTropnT-0.15*
___ 06:30PM ___
___ 06:30PM LACTATE-4.3*
___ 06:30PM WBC-11.1* RBC-6.13 HGB-17.0 HCT-53.8* MCV-88
MCH-27.7 MCHC-31.6 RDW-17.2*
___ 06:30PM NEUTS-67.6 ___ MONOS-4.6 EOS-0.2
BASOS-1.6
___ 06:30PM PLT COUNT-112*
___ 07:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
___ 07:30PM URINE RBC-20* WBC-8* BACTERIA-FEW YEAST-NONE
EPI-1
___ 07:30PM URINE HYALINE-26*
OTHER NOTABLE LABS:
___ 06:30PM BLOOD cTropnT-0.15*
___ 01:09AM BLOOD CK-MB-2 cTropnT-0.15*
___ 02:53AM BLOOD CK-MB-4 cTropnT-0.10*
___ 01:09AM BLOOD VitB12-___
___ 01:09AM BLOOD TSH-0.95
___ 02:53AM BLOOD Cortsol-14.6
___ 11:41PM BLOOD Lactate-1.7
DISCHARGE LABS:
___ 08:05AM BLOOD WBC-7.1 RBC-4.78 Hgb-13.9* Hct-42.1
MCV-88 MCH-29.1 MCHC-33.0 RDW-16.9* Plt ___
___ 08:05AM BLOOD Glucose-86 UreaN-49* Creat-1.7* Na-137
K-3.7 Cl-101 HCO3-28 AnGap-12
___ 05:10AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.3
___ 11:26AM BLOOD HEPARIN DEPENDENT ANTIBODIES- equivocal
MICRO:
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-
non-reactive
___ URINE CULTURE- No growth
___ BLOOD CULTURE- pending, no growth at time of
discharge
___ BLOOD CULTURE- pending, no growth at time of
discharge
STUDIES:
___ CXR: The patient's chin overlies the bilateral medial
upper lobes, obscuring the view. Given this, the cardiac
silhouette is persistently enlarged. There is again prominence
of the pulmonary arteries. Pulmonary vascular congestion appears
improved.
___ CT HEAD: 1. No evidence of intracranial hemorrhage or
definite CT evidence of major vascular territorial infarct. If
clinical suspicion is strong, MRI should be considered if not
contraindicated. 2. Small vessel ischemic disease and
age-related involution. 3. Unchanged basal ganglia lacunes. 4.
Limited view of right globe with suggestion of internal high
density material, to be correlated clinically. If of concern,
dedicated orbital imaging could be obtained.
___ RENAL U/S: 1. Multiple bilateral up to 11-cm cysts, some
of which with mural calcifications and septation. 2. Collapsed
thick-walled urinary bladder with internal debris. 3. No
hydronephrosis.
___ CXR: The heart remains markedly enlarged which may
reflect cardiomegaly, although a pericardial effusion should
also be considered. There is prominence of the perihilar
vasculature but no overt pulmonary edema on the current study.
Calcified diaphragmatic plaques are seen suggestive of prior
asbestos exposure. No focal airspace consolidation is seen to
suggest pneumonia. No pneumothorax. No pleural effusions.
Medications on Admission:
1. aspirin 325 mg PO DAILY
2. donepezil 5 mg PO HS
3. ropinirole 2 mg PO QPM
4. citalopram 20 mg PO DAILY
5. docusate sodium 100 mg PO BID
6. senna 8.6 mg Tablet PO BID
7. potassium chloride 10 mEq PO BID
8. brimonidine 0.15 % Drops 1 Drop BID
9. torsemide 40 mg PO DAILY (increased to 60 mg daily on ___
10. metoprolol succinate 50 mg PO daily
11. ciprofloxacin 500 mg PO Q12H x 13 days (day ___
12. ranitidine HCl 150 mg PO DAILY
13. lisinopril 10 mg PO once daily
Discharge Medications:
1. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. ropinirole 2 mg Tablet Sig: One (1) Tablet PO qpm.
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
8. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO twice a day.
9. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. ___ 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2
days: last day ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Acute toxic/metabolic encephalopathy
Hypernatremia
Acute kidney injury
Thrombocytopenia
Secondary diagnoses:
Dementia
Obstructive sleep apnea
Urinary tract infection
COPD
Pulmonary hypertension
Chronic right heart failure
Coronary artery disease
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
EXAM: Chest, single AP upright portable view.
CLINICAL INFORMATION: ___ male with history of hypoxia.
___.
FINDINGS: Single AP upright portable view of the chest was obtained. The
patient's overlying chin obscures the medial bilateral upper lobes. The
cardiac silhouette remains enlarged. Prominence of the pulmonary arteries is
partially imaged and again seen. Evidence of diaphragmatic/pleural plaques is
seen bilaterally suggesting prior asbestos exposure.
IMPRESSION:
The patient's chin overlies the bilateral medial upper lobes, obscuring the
view. Given this, the cardiac silhouette is persistently enlarged. There is
again prominence of the pulmonary arteries. Pulmonary vascular congestion
appears improved.
Radiology Report
INDICATION: ___ male with altered mental status. Question CVA or
intracranial hemorrhage.
___.
TECHNIQUE: Contiguous non-contrast axial images were acquired through the
brain with multiplanar reformations.
FINDINGS: Current study is highly degraded by motion on multiple sequences.
Allowing for such, there is no intracranial hemorrhage, mass effect, edema, or
shift of normally midline structures. Several foci of small basal ganglia
lacunes appear unchanged. There is periventricular white matter
hypoattenuation, most pronounced abutting the left greater than right frontal
horns consistent with small vessel ischemic disease. Ventricles and sulci are
prominent, consistent with age-related involution. Suprasellar and basilar
cisterns remain patent.
Paranasal sinuses and mastoid air cells are well aerated. Vascular
calcifications are seen in the cavernous carotid arteries. The right globe is
poorly seen but there is suggestion of possible hyperdense material within the
globe, to be clinically correlated. The left globe is not seen.
IMPRESSION:
1. No evidence of intracranial hemorrhage or definite CT evidence of major
vascular territorial infarct. If clinical suspicion is strong, MRI should be
considered if not contraindicated.
2. Small vessel ischemic disease and age-related involution.
3. Unchanged basal ganglia lacunes.
4. Limited view of right globe with suggestion of internal high density
material, to be correlated clinically. If of concern, dedicated orbital
imaging could be obtained.
Findings reported to Dr. ___ phone at 11 p.m. on ___.
Radiology Report
PORTABLE AP CHEST FROM ___ AT 5:32
CLINICAL INDICATION: ___ with AMS, concern for pneumonia.
Comparison is made to the patient's previous study dated ___ at 18:26.
Portable upright chest film ___ at 5:32 is submitted.
IMPRESSION:
1. The heart remains markedly enlarged which may reflect cardiomegaly,
although a pericardial effusion should also be considered. There is
prominence of the perihilar vasculature but no overt pulmonary edema on the
current study. Calcified diaphragmatic plaques are seen suggestive of prior
asbestos exposure. No focal airspace consolidation is seen to suggest
pneumonia. No pneumothorax. No pleural effusions.
Radiology Report
INDICATION: ___ with known history of renal disease, presenting with
UTI. Please assess for hydronephrosis.
TECHNIQUE:
Images of both kidneys and urinary bladder were obtained.
COMPARISON: Renal ultrasound from ___ and CT of the abdomen and
pelvis from ___.
FINDINGS:
Re-demonstrated are multiple innumerable large bilateral renal cysts,
measuring up to 9.6 cm in the left upper and 11.5 cm in the right lower pole.
Some of the cysts have septations and more calcifications, similar to the
prior study. No evidence of hydronephrosis. The left kidney measures 16.5,
the right kidney measures 15.4 cm.
Foley catheter is seen in a collapsed urinary bladder which shows a thick wall
and internal debris. The spleen is normal in size.
IMPRESSION:
1. Multiple bilateral up to 11-cm cysts, some of which with mural
calcifications and septation.
2. Collapsed thick-walled urinary bladder with internal debris.
3. No hydronephrosis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ALTERED MS
Diagnosed with HYPEROSMOLALITY, HYPOXEMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED, ABN CARDIOVASC STUDY NEC
temperature: 97.6
heartrate: 100.0
resprate: 24.0
o2sat: 95.0
sbp: 127.0
dbp: 91.0
level of pain: 13
level of acuity: 1.0 | ___ yo M w/ h/o COPD on 2L O2, cor pulmonale w/ severe RV
diastolic dysfunction, OSA, R hemiparesis s/p CVA, and dementia
who presented from ___ w/ altered mental status in setting of
hypoxia and hypernatremia.
.
# Acute toxic/metabolic encephalopathy: Patient noted to have
increased lethargy and twitching in rehab in setting of poor PO
intake. Altered mental status was likely secondary to
hypernatremia (see below) and hypoxia. There were no
signs/symptoms of recurrent infection. Given a dirty UA and h/o
recurrent UTIs he was initially treated broadly (vanc/cefepime),
but was narrowed back to cipro when urine culture was negative.
Will continue on cipro through ___ for treatment of
previously diagnosed UTI. CT head was negative for acute
process. TSH, B12 were normal and RPR was non-reactive. With
improvement in hypernatremia and hypoxia (patient back on
baseline oxygen requirement), mental status significantly
improved. On day of discharge patient was answering most
questions appropriately and could state his name, that he was at
___, and that it was ___.
.
# Hypernatremia: Likely occured in setting of poor access to
free water and poor thirst mechanism in an elderly, demented
patient. Further contributing to dehydration/hypovolemia were
increased diuretic doses at his ___. Using current dry wt
(104kg), initial free water deficit was appx 6.3 L. He was
volume resuscitated w/ NS, then corrected gradually w/ ___ NS
to a Na of 138 at transfer to floor (HD4). His sodium remained
within normal limits on the floor, and as above his mental
status improved. It is essential that he have access to free
water on discharge.
.
# Hypoxemia: Hypoxic in nursing home w/ sats in mid to high ___
on 2L w/ minimal improvement on 3L oxygen and then
non-rebreather. Unclear etiology: volume overload appeared
improved on CXR w/o obvious infiltrates. Was possibly due to
mucous plugging given h/o thick secretions vs. aspiration in
setting of altered MS. ___ arrival in MICU patient was
transitioned from CPAP to non-rebreather with good tolerance. He
was then quickly transitioned to nasal cannula and by hospital
day 2 was on his home oxygen requirement. He was stable on this
oxygen requirement on the floor. Was on CPAP at night for OSA.
.
# Urinary tract infection: Pt w/ h/o recurrent UTIs including
pseudomonal, proteus (R to cipro/bactrim/amp), enterococcus (R
to tetracycline), and klebsiella. He had recently started a
course of cipro 500 BID for planned 14 days for pan sensitive
pseudomonas. UA this admission initially looked potentially
infected w/ 8 WBCs, + ___, and few bact so was switched from
cipro to broad coverage w/ vanc/cefepime. Urine culture
ultimately was negative so he was put back on his home cipro to
finish initial course of 14 days (will complete on ___.
.
# Acute renal failure: Patient w/ baseline creatinine around 2.0
during last hospitalization, w/ elevation to 3.9 on admission.
Likely secondary to h/o poor po intake in setting of altered
mental status, lack of access to free water, and continued use
of diuretics and lisinopril. Held diuretics and lisinopril and
gave fluids as above with gradual improvement in creatinine.
Renal ultrasound was done which showed multiple bilateral up to
11-cm cysts, collapsed thick-walled urinary bladder with
internal debris, but no hydronephrosis. Creatinine returned to
baseline of 1.7 prior to discharge. Patient was restarted on
lisinopril. Will resume decreased dose of torsemide, 20 mg
daily.
.
# Hypotension: Patient was initially normotensive but during
admission dropped pressures to the ___ systolically. No
signs of infection (see above) and was maintained on broad
spectrum abx. Was initially hypovolemic but was not hypotensive
at that time. Cortisol checked and wnl. Etiology was unclear,
but blood pressures trended up w/o further intervention. No
further hypotension was observed after HD4.
.
# Thrombocytopenia: Platelets below baseline (was in 200s last
month and trended down during hospitalization (as low as 73
during this admission). INR was also elevated so fibrinogen was
sent and returned wnl. Given recent exposure to heparin during
last admission there was concern for HIT. Heparin was stopped
and HIT antibody was sent; this returned as equivocal. He was
placed on pneumoboots for DVT ppx. Serotonin assay sent prior to
discharge, and will need to be followed-up. Until results
return, patient should not receive any heparin products. Also
considered possibility of dilutional effect leading to
thombocytopenia. Platelet count stable at time of discharge.
He had no sign of thrombosis, and thus
systemic anticoagulation was not given.
.
# Diastolic CHF: Has h/o severe RVD ___ cor pulmonale w/ intact
EF of 50-55% on recent echo on ___. Was discharged on robust
regimen of torsemide after BNP came back at over 20K during last
hospitalization. BNP improved at 17K and per records torsemide
regimen was recently ramped up. Appeared extremely dry on
clinical exam so home torsemide held. Continued home metoprolol
w/ holding parameters. As pt appeared gradually more euvolemic
on HD5, lisinopril restarted. Torsemide will be restarted at
20mg daily, though patient will require ongoing assessment of
his volume status at his facility, and may need increase in
torsemide back to prior 40mg daily dose if weight increases or
he develops signs/symptoms of worsening heart failure.
.
# CAD/Troponin leak: No ischemic changes on EKG and no h/o chest
pain, though patient does have strong h/o CAD. Likely some
demand related leak and persistent levels in setting of ___.
Remained stable. Continued home aspirin and metoprolol.
Restarted ACE inhibitor once renal function improved.
.
# Dementia: Continued home donepezil. Held home ropinirole given
___ until HD5, when Cr had returned to baseline, then restarted. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Penicillins /
Cipro Cystitis / Zostrix / Prednisone / Bactrim / lisinopril /
hot peppers / metoclopramide
Attending: ___.
Chief Complaint:
Tachycardia, abdominal pain and emesis
Major Surgical or Invasive Procedure:
EGD, biopsy
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
___
Time: ___
_
________________________________________________________________
PCP: Name: ___. MD
Location: ___ - ___
___
Address: ___, ___
Phone: ___
Fax: ___
Email: ___
_
________________________________________________________________
HPI: ___ with PMHx Whipple, recurrent pancreatitis, presents
with 3 days of epigastric pain c/w pancreatitis in past,
vomiting NBNB, no fever, no loose stools. Triggered for HR 130s
(SR), reports has been PO intolerant. She does not report
fevers/chills. She was in ___ until 1 day prior to
admission. No sick contacts. No strange foods. No other foreign
travel. She has had a 15 lb weight loss which may have been
secondary to a loss of appetite and pain. Her DM is under better
control with her HgbA1C improving to 11. She does not report
cp, diarrhea, shortness of breath, neurologic sx, new MSK
complaints, rashes. She has had muscle wasting.
.
In ER: (Triage Vitals:
10 |97.5 |134 |151/105 |16 |99% RA )
Meds Given:
IV Ondansetron 4 mg |IVF 1000 mL |IV Morphine Sulfate 4 mg|
IVF 1000 mL |IV Morphine Sulfate 4 mg |IVF 40 mEq Potassium
Chloride / 1000 mL
IV Morphine Sulfate 2 mg
.
Radiology Studies: Abdominal CT
consults called: none
.
PAIN ___ in LUQ abdominal pain
.
All other systems negative except as noted above
Past Medical History:
-Chronic Pancreatitis: c/b necrotizing pancreatitis ___, s/p
distal pancreatectomy/splenectomy, cholecystectomy, and J-tube
placement ___, since that time removed
-Intractable migraines with muscle spasm and neuralgia, and
status migrainous, currently treated with trigger point
injections
-Chronic pain due to reflex sympathetic dystrophy secondary to
being hit by a car at age ___ consisting of -complex Regional
Pain Syndrome of the right face and right upper extremity
-Type 2 Diabetes Mellitus
-Hypertension
-Obesity
-Right eye blindness
-Left pupil dysfunction - ADIE (tonically dilated pupil)
-PUD
-Seronegative erosive arthritis previously followed by Dr. ___
___ she has stopped following up with him
-Iron deficiency anemia
Social History:
___
Family History:
Father and sister with HTN. Family history of CAD in father. No
family history of CVA. No family history of pancreatitis .
Sister has DM. Her father died of an MI at age ___ and he also
had DM.
Physical Exam:
Vitals: T 98.3 P ___ BP 110/86 RR 19 SaO2 100% on RA
BG = 127
GEN: Slightly anxious female, pleasant. She looks thinner than
when I last admitted her with a cushingoid habitus
HEENT: ncat anicteric MMM
NECK:
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
ABD: +bs, soft, NT, ND, no guarding or rebound
back:
GU:
EXTR:no c/c/e 2+pulses
DERM: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
Discharge Exam:
98.0, 137/88, 79, 18, 100%RA
GEN: Pleasant woman, sitting up in bed, NAD.
HEENT: NCAT, MMM, OP clear,
NECK: Supple
CV: RRR, no murmur
RESP: CTAB
ABD: +BS< soft, NT/ND
EXTR: no ___ pitting edema
DERM: warm and dry
NEURO: face symmetric, speech fluent
PSYCH: normal affect, good insight
Pertinent Results:
___ 09:34PM ___ PO2-38* PCO2-46* PH-7.36 TOTAL
CO2-27 BASE XS-0 INTUBATED-NOT INTUBA
___ 08:10PM K+-2.8*
___ 07:15PM URINE HOURS-RANDOM
___ 07:15PM URINE UCG-NEGATIVE
___ 07:15PM URINE UHOLD-HOLD
___ 07:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 07:15PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 05:48PM GLUCOSE-250* UREA N-18 CREAT-1.0 SODIUM-132*
POTASSIUM-7.8* CHLORIDE-95* TOTAL CO2-21* ANION GAP-24*
___ 05:48PM estGFR-Using this
___ 05:48PM ALT(SGPT)-18 AST(SGOT)-69* ALK PHOS-73 TOT
BILI-0.4 DIR BILI-0.1 INDIR BIL-0.3
___ 05:48PM LIPASE-24
___ 05:48PM ALBUMIN-4.9 CALCIUM-11.2* PHOSPHATE-4.2
MAGNESIUM-2.2
___ 05:48PM WBC-18.7* RBC-5.22*# HGB-16.8*# HCT-48.8*
MCV-94 MCH-32.2* MCHC-34.4 RDW-13.5 RDWSD-45.5
___ 05:48PM NEUTS-72.7* LYMPHS-18.2* MONOS-8.0 EOS-0.1*
BASOS-0.6 IM ___ AbsNeut-13.57* AbsLymp-3.39 AbsMono-1.50*
AbsEos-0.02* AbsBaso-0.12*
___ 05:48PM PLT COUNT-435*
___ 05:48PM ___ TO PTT-UNABLE TO ___
TO
============================================
ADMISSION ABDOMINAL CT SCAN
-Stable intra and extrahepatic prominence of the biliary tree.
-Evidence of distal pancreatectomy, without evidence of active
pancreatitis.
-Contrast seen within the distal esophagus may represent reflux.
EGD:
Impression: Abnormal mucosa in the esophagus. These findings are
consistent with esophagitis. (biopsy, biopsy)
Abnormal mucosa in the stomach (biopsy)
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: -Patient can return to floor when recovered
from sedation
-Follow up biopsies and will treat if positive for H. pylori.
-PPI BID X 4 weeks then daily therafter
EUS:
Impression: Ulcerative erosive esophagitis esophagitis was seen
throughout. Cold forceps biopsies were performed for histology
at the esophagus.
EUS was performed using a linear echoendoscope at ___ Mhz
frequency.
The pancreas parenchyma was poorly visualized. The pancreatic
duct measured 4mm in maximal diameter. The CBD measured 5mm in
maximal diameter.
Celiac Plexus block was performed: The take-off of the celiac
artery was identified. A 20 gauge Echotip Ultra Celiac plexus
needle was primed with saline and advanced adjacent to the
Aorta, just superior to the celiac artery take-off. This was
aspirated to assess for vascular injection. No blood was noted.
Saline 3 cc was injected. Buipuvacaine 0.25% X 10 cc was
injected unilaterally. Kenalog 40 mg (10 cc) was injected
unilaterally as well. The needle was then withdrawn.
Recommendations: Follow up with pathology reports. Please call
Dr. ___ ___ in 7 days for the pathology
results
Clear liquid diet when awake, then advance diet as tolerated.
If any fever, worsening abdominal pain, or post procedure
symptoms, please call the advanced endoscopy fellow on call
___/ pager ___.
Follow up with Dr. ___ consideration of repeat EGD in
___ months to assess for healing of esophageal ulcers.
PPI BID
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. CloniDINE 0.4 mg PO BID
2. Doxepin HCl 75 mg PO HS
3. Felodipine 10 mg PO DAILY
4. Lorazepam 0.5 mg PO HS:PRN sleep
5. Tizanidine 8 mg PO QHS
6. Zenpep (lipase-protease-amylase) ___ units
oral TID W/MEALS
7. Omeprazole 40 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Simvastatin 40 mg PO QPM
10. Promethazine 25 mg PO Q8H:PRN nausea
11. Gabapentin 1600 mg PO HS
12. Invokana (canagliflozin) 300 mg oral DAILY
13. tapentadol 75 mg ORAL TID
14. Acetaminophen 1000 mg PO Q8H
15. Polyethylene Glycol 17 g PO DAILY
16. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
17. Gabapentin 1100 mg PO QAM
18. Gabapentin 1100 mg PO QNOON
19. U-500 Conc 170 Units Breakfast
U-500 Conc 170 Units Lunch
U-500 Conc 80 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Pt very insulin resistant
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. CloniDINE 0.4 mg PO BID
3. Doxepin HCl 75 mg PO HS
4. Gabapentin 1600 mg PO HS
5. Gabapentin 1100 mg PO QAM
6. Gabapentin 1100 mg PO QNOON
7. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
8. U-500 Conc 100 Units Breakfast
U-500 Conc 90 Units Lunch
U-500 Conc 80 Units DinnerMax Dose Override Reason: Takes
regimen at home
9. Lorazepam 0.5 mg PO HS:PRN sleep
10. Losartan Potassium 100 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Promethazine 25 mg PO Q8H:PRN nausea
13. Simvastatin 40 mg PO QPM
14. tapentadol 75 mg ORAL TID
15. Tizanidine 8 mg PO QHS
16. Zenpep (lipase-protease-amylase) ___ units
oral TID W/MEALS
17. Invokana (canagliflozin) 300 mg ORAL DAILY
18. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
esophagitis
chronic pancreatitis
Discharge Condition:
alert, ambulatory, pleasant
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis.
INDICATION: +PO contrast; History: ___ with hx Whipple, recurrent
pancreatitis, ABD pain and vomiting+PO contrast // Eval for acute process,
attn to surgical complicatino of Whipple or pseudocyst
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) 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 5.4 s, 58.5 cm; CTDIvol = 12.3 mGy (Body) DLP = 719.9
mGy-cm.
Total DLP (Body) = 734 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.Contrast seen within the distal
esophagus may represent reflux.
ABDOMEN:
HEPATOBILIARY: A 2.1 x 1.5 cm subtle area of hypodensity (series 601b, image
25) in segment VIa/VIII (series 601b, image 25) is of uncertain etiology,
however is moderately decreased in size and is less conspicuous comparison to
prior examinations. There is again mild prominence of the intrahepatic
biliary tree. The common bile duct measures up to 9 mm, unchanged from prior.
The gallbladder is surgically absent.
PANCREAS: The patient is status post distal pancreatectomy without evidence of
focal lesion and is normal attenuation throughout.
SPLEEN: The patient is status post splenectomy.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Multiple rounded hypodensities measuring up to 1.6 in the kidneys bilaterally
likely represent simple renal cysts, better evaluated on MRCP from ___.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is a large
amount of stool throughout the colon. The appendix is not visualized.
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. 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. Stable intra and extrahepatic prominence of the biliary tree.
2. Status post distal pancreatectomy and splenectomy without CT findings of
acute pancreatitis or complications thereof.
3. Contrast seen within the distal esophagus may represent reflux.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, n/v/d, Hyperglycemia
Diagnosed with Unspecified abdominal pain
temperature: 97.5
heartrate: 134.0
resprate: 16.0
o2sat: 99.0
sbp: 151.0
dbp: 105.0
level of pain: 10
level of acuity: 1.0 | A/P: ___ w DMII ___ partial pancreatectomy, s/p splenectomy
with chronic leukocytosis, chronic regional pain syndrome and
chronic pancreatitis who presents with acute on chronic
abdominal pain, leukocytosis, hemoconcentration and
hypercalcemia and tachycardia. She was initially planned for a
celiac block and EUS by ERCP team, but found on EGD to have
severe erosive esophagitis. A celiac block was performed. She
had biopsies taken which she should follow up as an outpatient.
Her PPI was increased. Her pain improved back to baseline.
# DMII: Last A1c 11% in ___. Had roughly euglycemia on ___
when on very little insulin, then asx hypoglycemia after getting
her home dose at 11am, suggesting she may not be taking. ___
followed and recommended reduction of U-500 dosing to 100units,
90units, 80units. Prior to discharge her FSBS was high ___.
This was discussed with the ___ consult attending and the
patient. The options of staying in the hospital vs going home
with close ___ follow-up were discussed. Per ___ consult
recommendation this could be continued to managed at home as
there was concern that as her home insulin regimen had been
halved while in the hospital that she would become hyperglycemic
as an outpatient. The decision was made for the patient to go
home and follow up as an outpatient per her preference.
# HTN: has had some slightly lower BPs while in house so held
home felodipine while continuing home clonidine/losartan. On
discharge felodipine was held and will follow up with PCP for
resumption.
# weight loss: may be ___ poor po intake ___ esophagitis, TSH
2.5. Recommend outpatient w/u.
# chronic leukocytosis: UCx with likely contaminant (10k
atypical organisms), BCx NGTD. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left femur fracture
Major Surgical or Invasive Procedure:
ORIF of the left distal femur
blood transfusion
History of Present Illness:
___ status post mechanical fall transferred from ___
___ due to left distal femur fracture. Patient was at ___
___, and tripped over her cane while walking
through the doorway. She landed on her knee and also hit her
head. She did not lose consciousness, have any presyncopal
symptoms, and did not have any chest pain or shortness of breath
prior to having this witnessed fall. Patient was transferred
from ___ for orthopedic trauma care. Per report the
patient had lateral C-spine films which were negative. Denies
headache or neck pain.Denies numbness or paresthesias in the
extremity. Patient has some neuropathy in both feet at baseline
but reports no change in symptomatology.
In the ED initial vitals were: 98.4 90 169/88 16 96% RA. On exam
the patient has a mild amount of swelling over the left upper
knee. Sensation is intact in all 5 digits of the left foot.
___ pulses 2+. Strength ___ for dorsiflexion and plantar
flexion on the left. No bony C-spine tenderness, full neck range
of motion. She recieved 5mg IV morphine X 2 and 4 mg IV
ondansetron x 1. She also recieved a orthopedic consult who
concluded she needs repair of her distal femur fracture.
Admitted to the medical service for further management. CBC,
CMP, and coags were WNL. VS prior to admission were T98.1 °F
(36.7 °C), Pulse: 97, RR: 16, BP: 157/80, O2Sat: 95.
Of note, the CT spine done in the ED showed an incidental
finding of a large thyroid mass extending into the superior
mediastinum. On further questioning, patient endorses a 20 lb
weight gain since ___ (dog was lost so patient no longer
exercising)and nail changes (develops grooves, brittle nails),
though denies constipation, depression or changes to her skin
and hair. She also endorsed ___ after 10 minutes of vacuum
cleaning at home, which she states is slightly worse than
normal. She is able to carry laundry up a flight of stairs,
however. She denies dysphagia, stridor. Patient has a h/o left
hip fracture s/p fall ___ years ago. Has undergone 3 left hip
replacements since, and 1 right hip replacement for OA.
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.
Past Medical History:
colon ca with residual colostomy ___
AAA, repaired ___
bilat hip replacement x 4 (3L 1R)
HTN
Social History:
___
Family History:
Dad had h/o strokes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITALS: 99.3|144/76|110|RR 20 satting 98% RA
GENERAL: Mildly uncomfortable but otherwise NAD
HEENT: PERRL, EOMI. Scrapes on nasal bridge and forehead.
NECK: no carotid bruits, JVD not elevated. Thyroid supple
without appreciable nodules on palpation.
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: Left knee in immobilizer. Moderate swelling around
the knee. 2+ DPP bilaterally with both feet warm to touch.
NEUROLOGIC: A+OX3. Can wiggle toes and squeeze hands. CNII-XII
in tact. Left leg in immobilizer. Gross touch sensation intact
on feet bilaterally.
SKIN: multiple skin tags on chest.
DISCHARGE PHYSICAL EXAMINATION:
VITALS: Tm99.4 Tm98.5 BP150/62 HR82 RR18-20 O2Sat 94-95% on RA
___ + 1BM 24H: 1580PO + 331 IV/2000U
GENERAL: awake, alert, NAD
HEENT: PERRL, EOMI. Scrapes on nasal bridge and forehead.
NECK: no carotid bruits, JVD not elevated. Thyroid supple
without appreciable nodules or enlargement on palpation.
LUNGS: crackles at bilateral bases that clear with cough
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly, ostomy site without
erythema or tenderness
EXTREMITIES: Left knee in immobilizer. Moderate swelling around
the knee. Both feet warm to touch, pulses dopplerable. ___
pain in lateral left knee and lower leg with passive
dorsiflexion of the left foot. No pallor of LLE.
NEUROLOGIC: A+OX3. Can wiggle toes and squeeze hands. CNII-XII
in tact. Gross touch sensation intact on feet bilaterally.
SKIN: multiple skin tags on chest.
Pertinent Results:
ADMISSION LABS:
___ 03:45PM BLOOD WBC-5.4 RBC-3.87* Hgb-12.3 Hct-36.9
MCV-95 MCH-31.8 MCHC-33.4 RDW-15.2 Plt ___
___ 03:45PM BLOOD Neuts-73.7* ___ Monos-5.0 Eos-1.0
Baso-0.6
___ 03:45PM BLOOD ___ PTT-33.1 ___
___ 03:45PM BLOOD Plt ___
___ 03:45PM BLOOD Glucose-105* UreaN-16 Creat-0.9 Na-142
K-4.5 Cl-109* HCO3-22 AnGap-16
Hct TRENDING:
___ 07:30AM BLOOD WBC-4.9 RBC-3.28* Hgb-10.5* Hct-31.6*
MCV-96 MCH-32.0 MCHC-33.3 RDW-15.6* Plt ___
___ 05:24AM BLOOD WBC-6.9 RBC-2.98* Hgb-9.3* Hct-28.7*
MCV-96 MCH-31.1 MCHC-32.3 RDW-15.3 Plt ___
___ 05:58PM BLOOD WBC-5.0 RBC-2.40* Hgb-7.6* Hct-23.4*
MCV-97 MCH-31.5 MCHC-32.4 RDW-15.6* Plt ___
___ 07:30AM BLOOD WBC-5.4 RBC-2.77* Hgb-8.7* Hct-26.4*
MCV-95 MCH-31.3 MCHC-32.9 RDW-15.3 Plt ___ ->s/p 1u PRBCs
MISC LABS:
___ 07:30AM BLOOD TSH-0.64
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-6.3 RBC-2.73* Hgb-8.6* Hct-26.1*
MCV-96 MCH-31.4 MCHC-32.8 RDW-15.2 Plt ___
___ 07:50AM BLOOD Glucose-113* UreaN-25* Creat-1.1 Na-135
K-4.3 Cl-103 HCO3-22 AnGap-14
___ 07:50AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.0
IMAGING:
PELVIS/FEMUR/HIP XRAY ___ -
Comminuted fracture of the distal femur. Findings suggesting
more
remote prior trauma involving the sacrum. Bony
demineralization.
CXR (PRE-OP) ___ -
No evidence of acute disease. Large left-sided thyroid mass.
Incompletely characterized thoracolumbar compression fracture,
although of uncertain chronicity. If clinical symptoms may
refer to the area, then dedicated radiographs could be
considered.
CT LOWER EXTREMITY W/O CONTRAST ___ -
1. Markedly comminuted distal femoral fracture extending into
the articular surface and both femoral condyles.
2. Possible non-displaced medial tibial plateau impaction
fracture.
3. Chondrocalcinosis.
CT C-SPINE W/O CONTRAST ___ -
1. No evidence of acute fracture. Grade I anterolisthesis of
C4-C5.
Multilevel degenerative disc changes, as described above.
2. Markedly enlarged left thyroid lobe, extends inferiorly to
the thoracic
inlet and is partially imaged. It can be further assessed with
ultrasound
exam on non-emergent basis.
CT HEAD W/O CONTRAST ___ -
1. Soft tissue stranding along the right frontal region, likely
corresponds to the patient's known abrasion. No underlying
fracture is seen. No evidence of acute intracranial process.
2. Findings suggestive of chronic small vessel ischemic
disease.
3. Prominence of sulci and ventricles, likely age-related
involutional
changes.
LOWER EXTREMITY FLURO ___ -
Multiple views of the left distal femur. Again seen is the
comminuted fracture. Status post ORIF of the left distal femur.
The hardware appears intact. Improved alignment of the
fracture. Please see operative report for further details.
Medications on Admission:
1. Gabapentin 300 mg PO HS
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Lisinopril 30 mg PO DAILY
Discharge Medications:
1. Gabapentin 300 mg PO HS
2. Metoprolol Succinate XL 25 mg PO DAILY
Hold for SBP<100
3. Lisinopril 30 mg PO DAILY
Hold for SBP<100
4. Enoxaparin Sodium 30 mg SC DAILY
5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
For pain. Hold for sedation, RR<10
Start after PCA has been D/C
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q 4 hr PRN
Disp #*5 Tablet Refills:*0
6. Acetaminophen 1000 mg PO Q6H:PRN pain
7. Outpatient Lab Work
Please check CBC on ___. ICD-9 280.1.
Results should be followed by physician rehab facility.
8. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY:
Femur fracture
acute renal failure
SECONDARY:
hypertension
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: Patient status post fall and scalp abrasion. Assess for acute
intracranial process.
COMPARISONS: None available.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images were displayed.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect, or shift
of normally midline structures. There is no cerebral edema or loss of
gray-white matter differentiation to suggest an acute ischemic event. Sulci
and ventricles are prominent, likely age-related involutional changes.
Confluent hypodensities in subcortical, deep white matter, and periventricular
distribution likely reflect sequelae of small vessel ischemic disease. Basal
cisterns are patent. Mild soft tissue stranding overlying the right frontal
region is noted, which likely corresponds to the patient's known abrasion. No
underlying fracture is seen. Mild mucosal thickening of the anterior ethmoid
cells is noted. Otherwise, paranasal sinuses and mastoid air cells are well
aerated. No acute fracture is seen. Carotid artery calcifications are noted.
IMPRESSION:
1. Soft tissue stranding along the right frontal region, likely corresponds
to the patient's known abrasion. No underlying fracture is seen. No evidence
of acute intracranial process.
2. Findings suggestive of chronic small vessel ischemic disease.
3. Prominence of sulci and ventricles, likely age-related involutional
changes.
Radiology Report
INDICATION: Patient status post fall. Assess for acute fracture.
COMPARISONS: None available.
TECHNIQUE: 2.5-mm axial slices through the cervical spine were obtained
without intravenous contrast. Coronally and sagittally reformatted images
were displayed.
FINDINGS:
No evidence of acute fracture. Grade I anterolisthesis of C4-C5 is noted,
associated with moderate facet joint arthropathy at that level. Multilevel
degenerative disc disease is present, most pronounced at C5-C6 and C6-C7 with
intervertebral disc space narrowing, endplate sclerosis, and subchondral cyst
formation. Posterior disc osteophyte complexes are seen at the corresponding
levels with moderate narrowing of the central canal. Prevertebral soft
tissues are unremarkable. The airway is patent. Imaged lung apices are clear
without pneumothorax. Left thyroid gland is markedly enlarged and
heterogeneous. It extends inferiorly to the superior mediastinum, measuring
4.3 x 3.9 cm at the level of the thoracic inlet, partially imaged. It
displays mass effect on the trachea which is deviated to the right and remains
patent.
IMPRESSION:
1. No evidence of acute fracture. Grade I anterolisthesis of C4-C5.
Multilevel degenerative disc changes, as described above.
2. Markedly enlarged left thyroid lobe, extends inferiorly to the thoracic
inlet and is partially imaged. It can be further assessed with ultrasound
exam on non-emergent basis.
The findings and recommendations including suggestion of ultrasound evaluation
of thyroid nodule were discussed with Ms. ___ at 7 pm on ___ by
telephone.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Femur fracture.
COMPARISONS: None.
TECHNIQUE: Chest, AP supine.
FINDINGS: The heart is mildly enlarged. The aortic arch is calcified. A
large mass arising from the left side of the thyroid splays the trachea
rightward to some degree. The mass is better described on CT imaging of the
same day. Slight scarring is noted at the left lung apex. A band-like
opacity in the lingula suggests minor scarring. An irregular contour of the
anterolateral right sixth rib suggests a remote prior fracture. A compression
deformity along the thoracolumbar junction is incompletely characterized.
IMPRESSION: No evidence of acute disease. Large left-sided thyroid mass.
Incompletely characterized thoracolumbar compression fracture, although of
uncertain chronicity. If clinical symptoms may refer to the area, then
dedicated radiographs could be considered.
Radiology Report
RADIOGRAPHS OF THE PELVIS, LEFT HIP, AND FEMUR
HISTORY: Trauma with known fracture of the left knee.
TECHNIQUE: Left pelvis, femur and hip, total of six views.
FINDINGS: A comminuted fracture of the left distal femur is better described
on an earlier CT of the same day, without significant change. Along the
medial side of the femur, there is a bony excrescence suggesting chronic or
prior injury of the medial collateral ligament, a Pellegrini-Stieda lesion.
There is sclerosis within the sacrum, suggesting more remote prior injury.
Mild degenerative changes involve the pubic symphysis and sacroiliac joints.
The patient is status post bilateral hip replacements. The bones appear
demineralized. Vascular calcifications are widespread. There is a partly
visualized stent graft where the iliac limbs can be seen along the superior
margin of the pelvis film.
IMPRESSION: Comminuted fracture of the distal femur. Findings suggesting more
remote prior trauma involving the sacrum. Bony demineralization.
Radiology Report
INDICATION: ___ woman with left distal femur fracture, assess left
knee fracture for surgical management.
COMPARISONS: Radiographs from earlier the same date from ___.
TECHNIQUE: MDCT-acquired axial images were obtained across the knee without
intravenous contrast. Coronal and sagittal reformations were prepared.
FINDINGS: A markedly comminuted fracture extends from the distal femoral
diaphysis into both femoral condyles and the articular surface. The proximal
femur is translated anteriorly by 2.3 cm with respect to the tibia.
The patellofemoral articulation is dirupted. The patella is intact. The
trochlear articular surface is disrupted. A large 3.9 x 2.9 cm lateral
trochlear fracture fragment has rotated by approximately 90 degrees and
impacted into the femoral condyle. Within the medial trochlea, the articular
surface is depressed by 18-mm.
In the lateral compartment, there is 7-mm depression of the anterior lateral
femoral condyle. By comparison the fracture fragments in the medial femoral
condyle are reasonably well opposed without significant offset.
Irregularity in the posterior medial tibial plateau could reflect a subtle
non-displaced fracture impaction (701B:28).
Moderate joint effusion with lipohemarthrosis. No clear patellar or fibular
fractures are identified. Moderate surrounding soft tissue swelling and
hematoma is seen with mild atherosclerotic calcification of the superficial
femoral artery/popliteal artery.
Ligaments and menisci are not adequately evaluated. There is
chondrocalcinosis.
IMPRESSION:
1. Markedly comminuted distal femoral fracture extending into the articular
surface and both femoral condyles.
2. Possible non-displaced medial tibial plateau impaction fracture.
3. Chondrocalcinosis.
Radiology Report
STUDY: Fifteen intraoperative fluoroscopic images of the left distal femur,
___.
COMPARISON: Radiographs ___.
INDICATION: Left distal femur fracture, ORIF.
FINDINGS AND IMPRESSION: Multiple views of the left distal femur. Again seen
is the comminuted fracture. Status post ORIF of the left distal femur. The
hardware appears intact. Improved alignment of the fracture. Please see
operative report for further details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEFT FEMUR FRACTURE
Diagnosed with FX LOW END FEMUR NEC-CL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, HYPERTENSION NOS
temperature: 98.4
heartrate: 90.0
resprate: 16.0
o2sat: 96.0
sbp: 169.0
dbp: 88.0
level of pain: 5
level of acuity: 3.0 | ___ with h/o hip fracture and HTN who comes in with a distal
femur fracture s/p mechanical fall, found to have superior
mediastinal mass. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Amoxicillin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of
hypothyroidism s/p RAI for ___'s hyperthyroidism, ruptured
ovarian cysts on OCP, non-operative appendicitis in ___, acne
on
spironolactone who presented to the ED with abdominal pain from
home.
She had no abdominal pain until suddenly yesterday while at rest
not associated with eating, nonradiating RLQ crampy sharp
stabbing waves of severe pain. This has not happened before. It
is currently improved but still quite tender.
No vomiting, dysuria, has some slight nausea, no chest pain or
SOB.
No blood or black stool. She has had diarrhea in last 2 weeks
but
attributed this to her lactose intolerance. No weight loss.
She denies fever, though reports some chills.
Denies travel except to ___ last few months. No new foods. At
work there are several people with URI symptoms but no known
diarrhea/vomiting.
She did finish her menses yesterday but typically has no pain
associated with it.
ED interventions: given Tylenol, toradol, Zofran, 3L NS
Hcg was negative. Underwent CT A/P, pelvic US and found to only
have loops of RLQ peristalsing bowel on US, possibly enlarged
lymph nodes in mesentery suggestive of mesenteric lymphadenitis.
Was seen by gyn and thought to have abdominal pain due to
non-gynecologic etiology.
Was seen by surgery and not thought to have any acute surgical
etiology such as appendicitis.
Past Medical History:
Hypothyroidism s/p RAI for Grave's hyperthyroidism, ruptured
ovarian cysts on OCP, non-operative appendicitis in ___, acne
on
spironolactone
PAST SURGICAL HISTORY:
C section
R lumpectomy found to have fibroadenoma
Social History:
___
Family History:
Father died earlier this year related to DM and CHF.
Physical Exam:
DISCHARGE EXAM:
97.8F, 94 / 61 BP, 60 HR, 18 RR, 100 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally.
GI: Abdomen soft, non-distended, quite tender to palpation in
RLQ. Bowel sounds present.
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:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 07:38 4.2 4.17 13.6 40.0 96 32.6* 34.0 12.3 43.4
158
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 07:38 861 6 0.5 1432 4.2 ___
=========
___BD & PELVIS WITH CO
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.
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 measures up to 8
mm without
significant surrounding inflammatory changes, appendicolith, or
pneumoperitoneum.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: Hyperenhancing region in the uterine fundus
may represent
a fibroid measuring up to 1.7 cm. Mildly prominent fluid in the
lower uterine
segment may suggest active menstruation. No adnexal
abnormality. Physiologic
follicular activity seen in both ovaries.
LYMPH NODES: Multiple tiny mesenteric lymph nodes are more
numerous than
normal. There is no retroperitoneal, 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. Normal appendix. Multiple tiny lymph nodes could suggest
mesenteric
adenitis.
2. No adnexal/ovarian abnormality.
3. Fluid in the endometrial cavity/lower uterine segment may
suggest ongoing
menstruation.
4. Likely fibroid in the uterine fundus.
=========
___ Imaging PELVIS, NON-OBSTETRIC
FINDINGS:
The uterus is anteverted and measures 10.7 x 3.8 x 4.8 cm. The
endometrium is
homogenous and measures 5 mm.
The ovaries are normal. The left ovary measures 2.8 x 1.8 x 2.7
cm. Right
ovary measures 2.0 x 1.4 x 2.0 cm. Normal color and Doppler
vascular flow are
seen in both ovaries. There is trace free fluid in the right
lower quadrant.
Peristalsing bowel loops are seen in the right lower quadrant in
the area of
pain as indicated by patient.
IMPRESSION:
1. No evidence of ovarian torsion.
2. Trace free fluid in the right lower quadrant.
=========
___ Imaging DUPLEX DOP ABD/PEL LIMI
FINDINGS:
The uterus is anteverted and measures 10.7 x 3.8 x 4.8 cm. The
endometrium is
homogenous and measures 5 mm.
The ovaries are normal. The left ovary measures 2.8 x 1.8 x 2.7
cm. Right
ovary measures 2.0 x 1.4 x 2.0 cm. Normal color and Doppler
vascular flow are
seen in both ovaries. There is trace free fluid in the right
lower quadrant.
Peristalsing bowel loops are seen in the right lower quadrant in
the area of
pain as indicated by patient.
IMPRESSION:
1. No evidence of ovarian torsion.
2. Trace free fluid in the right lower quadrant.
=========
___ Imaging LIVER OR GALLBLADDER US
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 4 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, measuring 11.4 cm.
KIDNEYS: Limited views of the right kidney show no
hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal
limits.
IMPRESSION:
1. No gallstones, biliary dilation, or evidence of
cholecystitis.
2. Patent portal vein.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-35 mcg (28)
oral DAILY
3. Spironolactone 150 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Moderate
RX *acetaminophen 325 mg ___ tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
2. ketorolac 10 mg oral Q6H:PRN severe pain
RX *ketorolac 10 mg 1 tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
3. Levothyroxine Sodium 125 mcg PO DAILY
4. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-35 mcg
(28) oral DAILY
5. Spironolactone 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Mesenteric lymphadenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: NO_PO contrast; History: ___ with right sided tenderness near
umbilicusNO_PO contrast// ?appendicitis, ovarian torsion, intraabominal source
of 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.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP =
6.0 mGy-cm.
2) Spiral Acquisition 4.8 s, 52.4 cm; CTDIvol = 9.3 mGy (Body) DLP = 487.7
mGy-cm.
Total DLP (Body) = 494 mGy-cm.
COMPARISON: CT of the abdomen and pelvis 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.
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 measures up to 8 mm without
significant surrounding inflammatory changes, appendicolith, or
pneumoperitoneum.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: Hyperenhancing region in the uterine fundus may represent
a fibroid measuring up to 1.7 cm. Mildly prominent fluid in the lower uterine
segment may suggest active menstruation. No adnexal abnormality. Physiologic
follicular activity seen in both ovaries.
LYMPH NODES: Multiple tiny mesenteric lymph nodes are more numerous than
normal. There is no retroperitoneal, 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. Normal appendix. Multiple tiny lymph nodes could suggest mesenteric
adenitis.
2. No adnexal/ovarian abnormality.
3. Fluid in the endometrial cavity/lower uterine segment may suggest ongoing
menstruation.
4. Likely fibroid in the uterine fundus.
NOTIFICATION: The updated findings were discussed with ___,
M.D. by ___, M.D. on the telephone on ___ at 4:31 am, 10
minutes after discovery of the findings.
The second updated findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:30 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: History: ___ with RLQ abd pain, free fluid in pelvis on CT//
?ovarian torsion or rupture cyst
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 of the abdomen and pelvis from ___ at 00:49.
FINDINGS:
The uterus is anteverted and measures 10.7 x 3.8 x 4.8 cm. The endometrium is
homogenous and measures 5 mm.
The ovaries are normal. The left ovary measures 2.8 x 1.8 x 2.7 cm. Right
ovary measures 2.0 x 1.4 x 2.0 cm. Normal color and Doppler vascular flow are
seen in both ovaries. There is trace free fluid in the right lower quadrant.
Peristalsing bowel loops are seen in the right lower quadrant in the area of
pain as indicated by patient.
IMPRESSION:
1. No evidence of ovarian torsion.
2. Trace free fluid in the right lower quadrant.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 98.3
heartrate: 63.0
resprate: 20.0
o2sat: 99.0
sbp: 109.0
dbp: 57.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ female with history of
hypothyroidism s/p RAI for Grave's hyperthyroidism, ruptured
ovarian cysts on OCP, non-operative appendicitis in ___, acne
on
spironolactone who presented to the ED with abdominal pain from
home.
#Mesenteric adenitis
-RLQ pain with imaging by pelvic US with Doppler, RUQ US, and CT
A/P which were not suggestive
of ovarian torsion, ruptured cyst, acute biliary disease, or
appendicitis. Also had
negative hCG testing.
-There were possibly enlarged lymph nodes in mesentery seen on
CT
A/P. This could be
consistent with clinical picture of mesenteric lymphadenitis. It
is suspected this could be from a transient viral infectious
etiology. She was not septic and no antibiotics or stool
cultures
were initiated as she did not have persistent diarrhea.
-Plan is to discharge home with follow up with PCP and continue
supportive care. If symptoms change or persist, further
investigation may be necessary for other possible etiologies
(IBD, malignancy, other infection).
-Plan to continue Tylenol and toradol PO prn on discharge.
Ms. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was 40
minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Iodinated Contrast Media - IV Dye /
hydrochlorothiazide / metoprolol
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ Right heart catheterization
History of Present Illness:
___ w/ history of HFpEF (EF>55% ___, severe persistent
asthma, OSA, CKD stage IIIb (baseline Cr 1.6-1.8), DM, multiple
recent admissions for CHF exacerbations, a recent admission for
presumed asthma exacerbation, who is presenting for continued
shortness of breath. She reports SOB when going to the bathroom,
which is worse than it was during her last admission. She denies
orthopnea, CP, N/V, abdominal pain, cough.
Of note, the patient was recently admitted to the medicine
wards and was discharged to rehab two days prior to
presentation. She saw Dr. ___ in clinic. Dr. ___ is
requesting that she be admitted to a CHF service with a plan for
right heart catherization tomorrow.
In the ED, the patient endorsed dyspnea with exertion, but none
currently. She denies chest pain, lightheadedness, history of
recent travel or blood clots.
In the ED, initial vitals were: 97.9 94 150/63 20 100% RA
Labs notable for CBC with WBC of 17.3, H/H of 7.2/25.3, Plt
319. proBNP of 283. BMP notable for BUN/Cr of 54/1.7. INR of 3.2
CXR was underpenetrated, without clear consolidation, with
prominence of the hila.
Patient was given nothing.
Vitals prior to transfer: 98.1 77 158/56 18 99% RA
On the floor, the patient reports SOB when going to the
bathroom. She denies orthopnea, CP, abd pain, N/V, cough.
Past Medical History:
1. Type 2 Diabetes
2. Asthma with frequent exacerbations requiring prednisone
treatment, no intubations.
3. Obstructive sleep apnea on CPAP at night for the last ___
years.
4. Hypertension
5. H/o CVA ___ years ago with right facial droop, previously
diagnosed as Bell's palsy
6. Morbid obesity
7. h/o left ophthalmic artery aneurysm (coiled ___, angiogram
___ suggest residual wedge)
8. CKD stage III with isolated microalbuminuria (currently
normal Cr)
9. Anemia, presumed anemia of chronic disease
10. Osteoarthritis.
11. GERD.
12. Diverticulosis.
13. Anxiety
14. Depression
15. Restless leg syndrome
16. h/o lower extremity cellulitis.
17. s/p cholecystectomy in ___
18. s/p C-section
19. bilateral knee arthritis
20. h/o severe allergic reaction (rash to ?HCTZ vs.
contact/photosensitivity)
Social History:
___
Family History:
Multiple other family members with asthma. There is no strong
family history of lung cancer or pulmonary emboli. No family
history of renal disease. Several of her children however, have
hypertension. Three of her brothers passed away from various
cancers. A sister had colon cancer. Her daughter had DM when
pregnant. Both parents died in the ___, from "old age."
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 98.4 PO 157 / 68 87 22 98 RA
GENERAL: Morbidly obese woman, breathing comfortably, in no
acute distress. AAOx3.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink.
NECK: Unable to assess due to body habitus
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Scattered wheezes on right lung base
ABDOMEN: Obese, nontender, distended.
EXTREMITIES: Obese, edematous, warm, dry skin.
SKIN: No rashes.
DISCHARGE EXAM
====================
Vitals: 97.8-98.4 128-155/41-66 ___ ___ 95-100%RA
Note: physical exam limited due to obesity
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, unable to evaluate JVP
Lungs: CTAB, no wheezes, no rales
CV: irregularly irregular, no murmurs, rubs, gallops
Abdomen: soft, non-tender, grossly distended, bowel sounds
present
GU: no foley
Ext: warm, well perfused, unable to assess pulses, mild edema
Neuro: CNs2-12 intact
Discharge weight: 177.72 kg
Pertinent Results:
ADMISSION LABS:
___ 07:30PM BLOOD WBC-17.3* RBC-2.49* Hgb-7.2* Hct-25.3*
MCV-102* MCH-28.9 MCHC-28.5* RDW-17.0* RDWSD-62.9* Plt ___
___ 07:30PM BLOOD ___ PTT-34.6 ___
___ 07:30PM BLOOD Glucose-269* UreaN-54* Creat-1.7* Na-141
K-4.8 Cl-104 HCO3-25 AnGap-17
___ 07:00AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1
DISCHARGE LABS:
___ 12:43AM BLOOD WBC-15.4* RBC-2.34* Hgb-6.8* Hct-23.1*
MCV-99* MCH-29.1 MCHC-29.4* RDW-16.5* RDWSD-59.1* Plt ___
___ 12:40PM BLOOD ___
___ 12:43AM BLOOD Glucose-104* UreaN-57* Creat-2.0* Na-140
K-4.2 Cl-99 HCO3-26 AnGap-19
___ 12:43AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.7*
=
=
=
================================================================
STUDIES:
CXR ___
Exam is somewhat underpenetrated due to patient body habitus.
This makes
evaluation of the lung fields suboptimal although no definite
new focal
consolidation is seen. There is is no large pleural effusion
although trace pleural effusion is difficult to exclude. A
right sided PICC courses into the ___, distal termination site
is not well seen. Cardiac and mediastinal silhouettes are
stable. There is prominence of the hila which may be due to
pulmonary vascular engorgement.
RIGHT HEART CATHETERIZATION ___
Impressions:
1. Tortuous left antecubital vein and tortuous left subclavian
vein with two 360 degree corkscrew turns.
2. Minimal-mild pulmonary hypertension.
3. Mild right ventricular diastolic dysfunction.
4. Moderately elevated pulmonary artery diastolic pressure
suggests that left ventricular diastolic
dysfunction is mild-moderate at worst.
5. No oxymetric evidence of significant intracardiac shunting.
Recommendations:
1. ___ resume oral anticoagulation.
2. Additional plans per Dr. ___ the ___ Heart Failure
Service.
3. Do not attempt left sided PICC, left subclavian central line,
or left sided transvenous electrode placement without
fluoroscopic and venographic guidance.
4. Reinforce secondary preventative measures against morbid
obesity, diabetes mellitus with CKD, and diastolic dysfunction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO QHS:PRN Insomnia
2. Aspirin 81 mg PO DAILY
3. Beclomethasone Dipro. AQ (Nasal) ___ puffs Other BID:PRN
asthma
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. FLUoxetine 60 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. HydrALAZINE 50 mg PO Q8H
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Omeprazole 40 mg PO BID
11. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
12. Torsemide 40 mg PO DAILY
13. Warfarin 7.5 mg PO DAILY16
14. Ferrous Sulfate 325 mg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. Magnesium Citrate 300 mL PO DAILY:PRN constipation
17. Tiotropium Bromide 1 CAP IH DAILY
18. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB, wheezing
19. Albuterol Inhaler ___ PUFF IH Q2H:PRN SOB, wheezing
20. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
21. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
22. Glargine 35 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Miconazole Powder 2% 1 Appl TP TID:PRN rash ; groin
3. PredniSONE 30 mg PO DAILY Duration: 3 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
30 mg until ___ mg ___ through ___ mg maintenance dose
This is dose # 1 of 2 tapered doses
4. PredniSONE 20 mg PO DAILY Duration: 5 Doses
Start: After 30 mg DAILY tapered dose
30 mg until ___ mg ___ through ___ mg maintenance dose
This is dose # 2 of 2 tapered doses
5. PredniSONE 15 mg PO DAILY
Start: After last tapered dose completes
30 mg until ___ mg ___ through ___ mg maintenance dose
This is the maintenance dose to follow the last tapered dose
6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB, wheezing
7. Albuterol Inhaler ___ PUFF IH Q2H:PRN SOB, wheezing
8. Glargine 35 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Torsemide 60 mg PO DAILY
10. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
11. ALPRAZolam 0.5 mg PO QHS:PRN Insomnia
12. Aspirin 81 mg PO DAILY
13. Beclomethasone Dipro. AQ (Nasal) ___ puffs Other BID:PRN
asthma
14. Bisacodyl 10 mg PR QHS:PRN constipation
15. Ferrous Sulfate 325 mg PO DAILY
16. FLUoxetine 60 mg PO DAILY
17. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
18. HydrALAZINE 50 mg PO Q8H
19. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
20. Lidocaine 5% Patch 1 PTCH TD QAM
21. Magnesium Citrate 300 mL PO DAILY:PRN constipation
22. Montelukast 10 mg PO DAILY
23. Omeprazole 40 mg PO BID
24. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
25. Tiotropium Bromide 1 CAP IH DAILY
26. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
Dyspnea
Secondary
Chronic diastolic heart failure
Asthma
Atrial fibrillation
Morbid obesity
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 weight gain, chf hx // eval for pulm edema
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___ and ___
FINDINGS:
Exam is somewhat underpenetrated due to patient body habitus. This makes
evaluation of the lung fields suboptimal although no definite new focal
consolidation is seen. There is is no large pleural effusion although trace
pleural effusion is difficult to exclude. A right sided PICC courses into the
SVC, distal termination site is not well seen. Cardiac and mediastinal
silhouettes are stable. There is prominence of the hila which may be due to
pulmonary vascular engorgement.
IMPRESSION:
Exam is somewhat underpenetrated due to patient body habitus. This makes
evaluation of the lung fields suboptimal although no definite new focal
consolidation is seen. There is is no large pleural effusion although trace
pleural effusion is difficult to exclude. A right sided PICC courses into the
SVC, distal termination site is not well seen. Cardiac and mediastinal
silhouettes are stable. There is prominence of the hila which may be due to
pulmonary vascular engorgement.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 97.9
heartrate: 94.0
resprate: 20.0
o2sat: 100.0
sbp: 150.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | IV boluses Lasix 100 mg bid. did not improve sxs. RHC showed
PCWP < 20 mm Hg. THen transferred to medicine. Stopped bolusing.
Resumed torsemide 60 mg.
Ms. ___ is a ___ yo F with history of HFpEF (EF>55% ___,
severe asthma on 2L home O2, Afib on warfarin, DM, CKD, and HTN,
who presents with dyspnea.
# Dyspnea | asthma: Patient initially admitted with progression
of her dyspnea. Her outpatient cardiologist was concerned that
she may have contribution of heart failure as she has had
frequent CHF exacerbations in the past. She was admitted to
cardiology service and aggressively diuresed with boluses of
Lasix 100 mg IV. After aggressive diuresis she underwent right
heart catheterization; although PCWP was not able to be obtained
directly, a calculated wedge was consistent with pressures < 20
mmHg, suggesting only mild-moderate LV dysfunction. She was then
transferred to medicine service. Dyspnea was thought likely
primarily pulmonary process and may be component of obesity
hypoventilation syndrome plus asthma exacerbation in setting of
recently decreased prednisone dose. She was given prednisone 40
mg x2 and placed on slow prednisone taper. Dyspnea improved and
she was discharged on pred taper and home asthma regimen.
# Chronic diastolic CHF: History of CHF exacerbations and last
ECHO showing EF>55%. Underwent right heart catheterization as
above. She was discharged on torsemide PO 60 mg daily and
thought to be euvolemic.
# Atrial fibrillation: New diagnosis in ___ but unable to
tolerate metoprolol due to junctional bradycardia. Warfarin was
held for right heart cath and she was bridged on heparin gtt
given renal function and body habitus not amenable to lovenox.
Post-procedure warfarin restarted and heparin gtt discontinued
when INR reached 2.0.
CHRONIC ISSUES
# CKD: Likely due to DM and HTN. Renal function remained stable.
# HTN: Continued home hydralazine and imdur.
# DM: continue glargine 35U daily, Humalog 10U with meals as
well as Humalog sliding scale.
# Anemia: likely from CKD. Most recent labs are inconsistent
with iron deficiency anemia but rather anemia of chronic
disease. Anemia is macrocytic, but last B12 and folate levels
were normal. Did not transfuse as patient is ___.
Would consider further outpatient workup and possible
erythropoietin.
# GERD: continued omeprazole 40mg BID
# Depression: continued fluoxetine 60mg daily
# OSA: CPAP
# CODE: Full
# CONTACT: Name of health care proxy: ___
Relationship: Friend
Phone number: ___
TRANSITIONAL ISSUES
- She was discharged with a PICC due to difficult PIV insertion
and need for ongoing INR checks.
- Will require INR check ___ and monitored closely thereafter
at ___.
- Discharged on prednisone taper as written; note she should
remain on maintenance dose 15 mg daily until she follows up with
her pulmonologist.
- Consider using ___ for blood pressure control, especially
given diabetes, HTN, and CKD.
- Consider further outpatient evaluation for progressive chronic
anemia.
- ___ checked by attending prior to discharge.
- Discharge weight: 177.72 kg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Reglan
Attending: ___.
Chief Complaint:
Diarrhea, right lower quadrant pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of RNYGB (___), vaginal delivery of son 2
months prior, and recent bilateral salpingectomy 3 weeks prior
at
___ presents with 5 day history of diarrhea (worse than
her baseline loose stools) and a 12 hour history of RLQ pain.
She has also had nausea with wretching. Reports a low grade
temp
and chills. Denies dysuria or vaginal discharge. Denies
drainage or pain at recent laparoscopy sites. Has been seen
post-operatively by gyn, per patient was told all was normal.
Of
note, the patient reports an episode similar to her current pain
___ years ago and she states she was booked for appendectomy but
her case was suddenly cancelled and she was discharged and her
pain resolved. She does not know the reason for the change or
her diagnosis at that hospital visit.
Past Medical History:
PNC:
- ___ ___ by LMP c/w ___ trimester U/S
- Labs Rh pos/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS PND
- Screening - Aneuploidy screening: abnl Panorama - ___ 46XY
- FFS - wnl
- GLT - screened with FBS fasting and 1hr PP x 1wk - wnl
- U/S - ___: ant placenta, nl AF, 2143g (60%), cephalic
- Issues
- She is known Gaucher carrier, but couple have elected not to
have FOB tested
- h/o gastric bypass - getting growth scans q4wk
- h/o admission and beta on ___ and ___ for PTL with change to
1-2cm/50.
OB Hx:
- G1 SVD - IOL 37wk for persistent DFM, 2970g
- G2 current
GYN Hx - due for repeat pap postpartum. No known h/o fibroids,
STIs.
PMH:
- h/o recurrent c. diff
- h/o anemia requiring IV iron
Past Surgical Hx:
- gastric bypass (cannot have NSAIDs)
- cholecystectomy
Social History:
___
Family History:
Nonpertitent
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 100.2 108 110/69 22 99% RA
GEN: A&O, NAD, tearful
HEENT: No scleral icterus, mucus membranes moist
CV: mild tachycardia
PULM: non-labored respirations on room air
ABD: Soft, non-distended but obese, diffusely TTP (worst in
RLQ),
+rebound pain, +guarding to RLQ palpation, all 3 recent
laparoscopy incisions without erythema or drainage and appear
well healed
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE PHYSICAL EXAM
GEN:AxOx3, tearful
HEENT: No scleral icterus, mucus membranes are moist, PEERLA,
EOMI.
CV: RRR.
PULM: CTAB. Non-labored breathing. No deformities.
ABD: Soft, nontender, nondistended. No hepatosplenomegaly.
Ext: No ___ edema, no erythema, ___ are warm and well perfused.
Pertinent Results:
ADMISSION LABS:
___ 05:40AM BLOOD Glucose-95 UreaN-3* Creat-0.6 Na-142
K-3.8 Cl-102 HCO3-30 AnGap-10
___ 05:40AM BLOOD WBC-4.9 RBC-3.83* Hgb-9.4* Hct-30.4*
MCV-79* MCH-24.5* MCHC-30.9* RDW-14.3 RDWSD-41.6 Plt ___
DISCHARGE LABS:
___ 05:55PM BLOOD WBC-7.0 RBC-4.32 Hgb-10.8* Hct-34.7
MCV-80* MCH-25.0* MCHC-31.1* RDW-14.6 RDWSD-42.5 Plt ___
___ 05:55PM BLOOD Neuts-75.1* Lymphs-16.1* Monos-6.8
Eos-1.0 Baso-0.7 Im ___ AbsNeut-5.29 AbsLymp-1.13*
AbsMono-0.48 AbsEos-0.07 AbsBaso-0.05
___ 05:55PM BLOOD Glucose-87 UreaN-4* Creat-0.7 Na-145
K-4.3 Cl-106 HCO3-23 AnGap-16
___ 09:40AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.9
RADIOOLOGY:
CTA CHEST, ___:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Consolidations of the left lower lobe may be compatible with
pneumonia.
3. Small, bilateral pleural effusions with adjacent atelectasis.
4. Status post Roux-en-Y gastric bypass. No evidence of bowel
obstruction.
5. The appendix is not definitively seen, but there are no
secondary signs of
acute appendicitis.
CXR, ___:
IMPRESSION:
In comparison with the study ___, there is increased
opacification at the
left base with blunting the costophrenic angle. This most
likely represents
pleural fluid and atelectatic change. However, in the
appropriate clinical
setting, superimposed pneumonia could be considered.
No vascular congestion or cardiomegaly.
CTAP, ___:
IMPRESSION:
1. Mildly prominent loops of small bowel in the left upper and
right lower
quadrant without definite transition point to suggest small
bowel obstruction.
No internal hernia, bowel wall thickening, or anastomotic
complications status
post Roux-en-Y gastric bypass. These findings may represent a
nonspecific
gastroenteritis.
2. Normal appendix.
3. Minimal intrahepatic biliary dilatation is likely related to
prior
cholecystectomy.
4. Trace bilateral pleural effusions with adjacent mild
compressive
atelectasis. No focal consolidation.
Medications on Admission:
Prenatal vitamin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hr:PRN Disp #*40
Tablet Refills:*0
2. GuaiFENesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL per instructions by mouth q8hr:PRN
Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8hr:PRN Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroenteritis, unspecified
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with cough// Evaluate for pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary abnormalities.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with hypoxia// Pneumonia vs. atelectasis vs.
effusion
IMPRESSION:
In comparison with the study ___, there is increased opacification at the
left base with blunting the costophrenic angle. This most likely represents
pleural fluid and atelectatic change. However, in the appropriate clinical
setting, superimposed pneumonia could be considered.
No vascular congestion or cardiomegaly.
Radiology Report
EXAMINATION: CTA chest. CT abdomen and pelvis.
INDICATION: ___ year old woman with new hypoxia. Evaluate for PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 1.8 s, 23.4 cm; CTDIvol = 11.4 mGy (Body) DLP = 267.3
mGy-cm.
2) Spiral Acquisition 4.1 s, 54.7 cm; CTDIvol = 16.4 mGy (Body) DLP = 896.8
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 19.9 mGy (Body) DLP =
9.9 mGy-cm.
Total DLP (Body) = 1,176 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
CHEST:
Evaluation of the chest is limited by exclusion of the lung apices from the
study. Within this limitation:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Multiple mediastinal nodes are prominent, but
not pathologically enlarged. There is no axillary or hilar lymphadenopathy is
present. No mediastinal mass.
PLEURAL SPACES: Small, bilateral pleural effusions with adjacent atelectasis.
No pneumothorax.
LUNGS/AIRWAYS: A consolidation of the superior left lower lobe (302:51) and a
ground-glass opacity of the posterior basal left lower lobe (302:87) may be
compatible with infection. The airways are patent to the level of the
segmental bronchi bilaterally. Mild bronchial wall thickening at the
bilateral lung bases.
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 lesions. Minimal intrahepatic biliary
dilatation is stable. There is no evidence of intrahepatic biliary
dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: 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 patient is status post Roux-en-Y gastric bypass. The
remaining small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. Sigmoid diverticulosis, without evidence of acute
diverticulitis. Otherwise, the colon and rectum are within normal limits.
The appendix is not definitively seen, but there are no secondary signs of
acute appendicitis. There is no free intraperitoneal fluid or free air.
PELVIS: The urinary bladder and distal ureters are unremarkable. Trace pelvic
free fluid is likely physiologic.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexa are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Postsurgical changes of the anterior abdominal wall.
Otherwise, the abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Consolidations of the left lower lobe may be compatible with pneumonia.
3. Small, bilateral pleural effusions with adjacent atelectasis.
4. Status post Roux-en-Y gastric bypass. No evidence of bowel obstruction.
5. The appendix is not definitively seen, but there are no secondary signs of
acute appendicitis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Lower abdominal pain
Diagnosed with Right lower quadrant pain, Fever, unspecified
temperature: 100.2
heartrate: 112.0
resprate: 18.0
o2sat: 99.0
sbp: 107.0
dbp: 78.0
level of pain: 7
level of acuity: 3.0 | Ms ___ is a ___ yo F who presented to emergency department on
___ with abdominal pain and diarrhea approximately 2 weeks
post operative from bilateral salpingectomy. White blood cell
count, differential showed no left shift and normal and CT
abdomen/pelvis showed no intraabdominal process. Stool sample
sent and negative for clostridium difficile. She developed a
worsening cough with shortness of breath on excretion,
supplemental oxygen requirement, and wheeze on clinical exam.
Patient denies history of asthma. Chest X-ray and CTA chest
concerning for left lower lobe pneumonia and no pulmonary
embolism identified. Given clinical picture of community
acquired pneumonia the medicine team was consulted. Medicine
said that given the absence of leukocytosis and improvement in
hypoxia with ISS that the diagnosis of pneumonia is not likely.
The abdominal pain is likely ___ to a viral gastroenteritis
given the absence of findings on CT scan and gynecological
evaluation. Her oxycodone was discontinued on ___ and she was
continued on the oral Tylenol. On the day of discharge she was
tolerating a regular diet, she was ambulatory and her pain was
controlled. She was instructed to follow up as an outpatient
with gynecology with any gynecological issues. The patient was
encouraged to return to the Emergency Department if her pain
gets worse or she is not able to tolerate PO. The patient was in
agreement with this plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
difficulty with vision
Major Surgical or Invasive Procedure:
TEE ___
History of Present Illness:
Mr. ___ is a very ___ ___ year-old right-handed man with a
history including hypertension, hyperlipidemia, DM II, ITP, and
psoriatic arthritis who presents with a ten day history of
visual
disturbance.
.
The patient recalls the onset of symptoms ten days ago. He
first
appreciated "waving lines" in his peripheral vision; as he
experiences similar symptoms while tired "due to the diabetes"
he
attributed the symptom to fatigue. However, while driving down
the highway, he realized that he had a dark void in the right
aspect of his visual field. Covering and uncovering the eyes
individually, he confirmed the visual field cut affected both
eyes (right more than left, superiorly more than inferiorly).
In
the regions of visual loss, he also began to experience bright,
red, green, and yellow flashes of light that seemed to be
"shooting toward" him. He also saw iridescent "zig-zags." The
flashing phenomena would come and go, while the zig-zag shapes
persisted for 48 hours (even while the patient closed his eyes).
.
There was no trigger for the symptoms other than "enormous"
amounts of stress in the recent past. There were no
exacerbating
or alleviating factors. The visual symptoms were initially
associated with head discomfort in the left aspect of the
forehead. Mr. ___ a ___, non-throbbing
"low,
dull" pain that became excruciatingly "sharp" with coughing. He
does not usually get headaches, and has no history of migraine,
but wondered if ocular migraine could account for the symptoms.
He also thought the headache could be due to a recent cold.
Regardless, the headache spontaneously resolved within about 48
hours.
.
While the headache and positive visual phenomena resolved within
two days, the right homonymous visual field cut persisted.
Despite the deficit, Mr. ___ pursued previously planned
activities. He just compensated for the problem; for example,
during a lecture, he asked people seated on the right side of
the
room to flag those on the left with questions. He has continued
to read by adjusting the placement of documents. He presented
to
his rheumatologist for a previously arranged appointment today,
and happened to mention the symptoms. His rheumatologist
referred him to the ED for further evaluation and care.
Past Medical History:
- hypertension
- hyperlipidemia
- DM II
- ITP - Ab positive
- gout/podagra
- psoriasis
- psoriatic arthritis on methotrexate
- GERD
- Schatzki's ring
- Vitamin D deficiency
- depression
- Alcohol dependence (sober for ___ years)
- herpes
Social History:
___
Family History:
- positive for: psoriasis
- negative for: migraine, stroke, seizure
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAMINATION:
Vitals: T: 97.5 P: 94 R: 18 BP: 116/66 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
Mucus
membranes moist, no lesions noted in oropharynx
Neck: No carotid bruits appreciated.
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Alert. Able to relate history without
difficulty.
* Orientation: Oriented to person, place, day, month, year,
situation
* Attention: Attentive. Able to name the months of the year
backwards without difficulty.
* Memory: Pt able to repeat ___ words immediately and recall
___
unassisted at 30-seconds and 5-minutes. Pt demonstrates
knowledge of current events.
* Language: Language is fluent without evidence of paraphasic
errors. Repetition is intact. Comprehension appears intact; pt
able to correctly follow midline and appendicular commands.
Prosody is normal. Pt able to name high (___) and low
frequency objects (knuckles) without difficulty. Reading and
writing abilities intact.
* Calculation: Pt able to calculate number of quarters in $1.50
* Praxis: No evidence of apraxia.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 4 to 2mm and brisk. Incongrous (R>L) right
homonymous superior quadrantanopia. Funduscopic exam revealed
no
papilledema, exudates, or hemorrhages.
* III, IV, VI: EOMI without nystagmus. Normal saccades.
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: No facial droop, facial musculature symmetric.
* VIII: Hearing intact to finger-rub bilaterally.
* IX, X: Palate elevates symmetrically.
* XI: ___ strength in trapezii bilaterally.
* XII: Tongue protrudes in midline.
.
Motor:
* Tone: possible increase in bilateral lower extremities.
* Drift: No pronator drift.
Strength:
* Left Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Right Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Left Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
* Right Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
Reflexes:
* Left: brisk throughout Biceps, Triceps, Bracheoradialis,
Patella with crossed adduction, 2 Achilles
* Right: brisk thoughout Biceps, Triceps, Bracheoradialis,
Patella with crossed adduction, 2 Achilles
* Babinski: mute bilaterally
Sensation:
* Pinprick: intact bilaterally in lower extremities, upper
extremities, trunk, face
* Temperature: intact bilaterally in lower extremities, upper
extremities, trunk, face
* Vibration: intact bilaterally at level of great toe
* Proprioception: intact bilaterally at level of great toe
* Extinction: No extinction to double simultaneous stimulation
Coordination
* Finger-to-nose: intact bilaterally
* Heel-to-shin: intact bilaterally
* Rapid Alternating Movements: quick and symmetric
Gait:
* Description: Good initiation. Narrow-based with normal-length
stride and symmetric arm-swing
* Tandem: Able to tandem walk without difficulty
* Romberg: negative
DISCHARGE EXAM:
Vitals: 97.3, 120/83, 65, 20, 97%RA.
General: Awake, cooperative, NAD.
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
Mucus
membranes moist, no lesions noted in oropharynx
Neck: No carotid bruits appreciated.
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGICAL EXAM:
MS - AAOx3, speech fluent
CN - PERRL 3.5->2mm, EOMI, VF demonstrate a R homonymous
hemianopsia with mild improvement in inferior quadrant
bilaterally, facial sensation intact, face symmetrical, tongue
midline
MOTOR - ___ throughout, no drift, no abnormal tone
REFLEXES - 2+ throughout, 1+ at achilles
SENSORY - intact to LT, PP, temp, vibration and proprioception
GAIT - deferred
Pertinent Results:
ADMISSION LABS:
___ 11:30AM BLOOD WBC-3.8* RBC-4.77 Hgb-14.0 Hct-44.3
MCV-93 MCH-29.3 MCHC-31.6 RDW-16.7* Plt ___
___ 11:30AM BLOOD Neuts-70.3* ___ Monos-4.0 Eos-3.1
Baso-0.3
___ 03:45PM BLOOD ___ PTT-22.9* ___
___ 11:30AM BLOOD ESR-7
___ 03:45PM BLOOD Glucose-156* UreaN-21* Creat-1.3* Na-133
K-9.0* Cl-104 HCO3-25 AnGap-13
___ 06:02PM BLOOD K-5.3*
___ 07:04PM BLOOD K-4.4
___ 11:30AM BLOOD ALT-32 AST-27
___ 06:45PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:32AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:32AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9 Cholest-145
___ 05:32AM BLOOD %HbA1c-6.3* eAG-134*
___ 05:32AM BLOOD Triglyc-123 HDL-31 CHOL/HD-4.7 LDLcalc-89
___ 11:30AM BLOOD CRP-2.1
___ 06:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 05:32AM BLOOD WBC-3.3* RBC-3.94* Hgb-11.9* Hct-34.8*
MCV-88 MCH-30.3 MCHC-34.4 RDW-17.0* Plt ___
___ 05:32AM BLOOD Glucose-125* UreaN-19 Creat-1.2 Na-140
K-4.2 Cl-103 HCO3-31 AnGap-10
IMAGING:
CT HEAD ___: IMPRESSION:
1. Hypodensity in left occipital lobe with cytotoxic edema
concerning for
subacute infarction in left PCA territory.
2. Degenerative change of the temporomandibular joints.
MRI ___: IMPRESSION:
1. Subacute infarct in left occipital lobe (left posterior
cerebral artery
territory).
2. No evidence of focal flow-limiting stenosis, occlusion, or
aneurysm
greater than 3 mm in arteries of head and neck.
ECHO ___: Conclusions
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
___ mmHg. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Nomal biventriculat systolic function. No source of
embolism identified. No ASD or PFO seen by 2D, color Doppler or
saline contrast with maneuvers.
BILATERAL LENIs ___: IMPRESSION: No evidence of DVT.
Medications on Admission:
- metformin 1000 mg po bid
- actos 45 mg po daily
- allopurinol ___ mg po daily
- folate 1 mg po daily
- methotrexate 25 mg po q ___
- simvastatin 5 mg po daily
- lisinopril 5 mg po daily
- omeprazole 20 mg po daily
- vitamin D ___ IU po daily
Discharge Medications:
1. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
2. pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. methotrexate sodium 2.5 mg Tablet Sig: Ten (10) Tablet PO
QSUN (every ___.
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
11. Outpatient Occupational Therapy
Please evaluate patient for exercises to help with vision loss.
Please work with patient to acheive maximal functional capacity.
Discharge Disposition:
Home
Discharge Diagnosis:
left occipital infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
NEURO EXAM: R homonymous hemianopsia
Followup Instructions:
___
Radiology Report
CLINICAL INFORMATION: ___ male with visual changes for 10 days
(flashing lights). He has no neurologic deficits otherwise.
COMPARISONS: None.
TECHNIQUE: Axial MDCT images were acquired of the head without contrast and
reformatted into coronal and sagittal planes.
FINDINGS: There is no acute intracranial hemorrhage. Hypodensity in left
occipital lobe with cytotoxic edema concerning for subacute infarction. The
ventricles and sulci are normal in size and configuration. The orbits are
normal appearing. The globes are normal, the lenses are intact. The optic
nerves are symmetric and normal in caliber. The extraocular muscles are
normal. There is no abnormality of the soft tissues.
The visualized portions of the paranasal sinuses are clear. The mastoid air
cells and middle ear cavities are clear bilaterally. Note is made of
bilateral degenerative change of the temporomandibular joints, partially
imaged, severe on the left and moderate on the right.
IMPRESSION:
1. Hypodensity in left occipital lobe with cytotoxic edema concerning for
subacute infarction in left PCA territory.
2. Degenerative change of the temporomandibular joints.
Findings were discussed with Dr. ___ the EU by phone at 5:15pm.
Radiology Report
CLINICAL HISTORY: ___ man with clinical and radiological evidence
concerning for left occipital lobe stroke.
STUDY: MRI and MRA head without contrast. MRA neck with contrast.
COMPARISON STUDY: CT head dated ___.
TECHNIQUE: Sagittal T1, axial T2, FLAIR, gradient echo and diffusion-weighted
images were obtained of the brain without administration of contrast. 3D TOF
MR angiography of the head was performed without administration of contrast.
MRA neck was performed after intravenous administration of contrast with using
bolus-tracking technique. Multiplanar reconstructions were performed.
FINDINGS:
MRI HEAD: An area of FLAIR and T2 hyperintensity is noted in the left
occipital lobe which shows mild restricted diffusion, this is suggestive of
subacute infarct in left posterior cerebral artery territory. There is no
evidence of mass effect or hemorrhagic transformation of the infarct.
There is no evidence of intracranial hemorrhage. The ventricles, cortical
sulci and extra-axial CSF spaces appear normal. Brainstem and cerebellum
appears normal. The major intracranial flow voids are maintained.
The visualized paranasal sinuses and mastoid air cells are clear. The orbits
are unremarkable.
MRA NECK: Three-vessel aortic arch is noted. The origins of great vessels
appear normal. Bilateral common, internal and external carotid arteries
appear normal. Bilateral vertebral arteries appear normal. There is no
evidence of focal flow-limiting stenosis, occlusion or aneurysm greater than 3
mm.
MRA HEAD: The arteries of the anterior circulation including bilateral
intracranial internal carotid arteries, anterior and middle cerebral arteries
appear normal. The arteries of the posterior circulation including bilateral
vertebral arteries, basilar and posterior cerebral arteries appear normal.
There is no evidence of focal flow-limiting stenosis, occlusion or aneurysm
greater than 3 mm in arteries of head.
IMPRESSION:
1. Subacute infarct in left occipital lobe (left posterior cerebral artery
territory).
2. No evidence of focal flow-limiting stenosis, occlusion, or aneurysm
greater than 3 mm in arteries of head and neck.
Radiology Report
REASON FOR THE EXAMINATION: This is a ___ man with recent flights,
now with new stroke. The request is to rule out DVT.
COMPARISON: No priors are available.
FINDINGS:
Grayscale and Doppler sonograms of bilateral common femoral, femoral and
popliteal veins were performed. There is normal compressibility, flow and
augmentation.
The PTV and peroneal veins show normal flow and compressibility.
IMPRESSION:
No evidence of DVT.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: VISION CHANGES
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, DIABETES UNCOMPL ADULT
temperature: 97.5
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 116.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ yo RHM with PMHx of HTN, HL and SM2 who
presents w/ a 10 day h/o right-sided visual disturburbances and
was found to have left occipital lobe stroke.
# NEURO: given the appearance of his MRI/MRA we felt that his
stroke was likely embolic. We obtained a TTE which showed no
clot, but our suspicion was high enough that we obtained a TEE
which showed no clot or vegetation and despite multiple attempts
with saline, showed no PFO. While here, we started him on ASA
81mg QD. He was told not to drive until cleared by an
opthalmologist or neruologist to do so.
# CARDS: we increased his dose of simvastatin from 5mg QD to
20mg QD. We obtained a TEE as above which showed no significant
pathology as above. We kept pt's SBP <180 with PRN IV
hydralazine. We started pt's lisinopril at discharge.
# ENDO: we held pt's metformin while here in case he needed a
contrast study, but continued his actos. We also put him on an
ISS while here for better blood sugar control.
# HEMATOLOGY: We were initially concerned that patient's
frequent air travel may have put him at risk for a DVT, which
could have caused his stroke, however his TTE with bubble showed
no evidence of PFO and his bilateral LENIs were negative. While
here his platelets dropped from 146 to 114, but his WBC also
dropped from 4.5 to 3.3 and his HCT dropped from 41.0 to 34.8.
There was some concern given his known ITP that the aspirin
could be adversely his CBC. However, he required ASA to reduce
his stroke risk. He will have his CBC checked again on ___ at
his PCP ___ apppt. While here we contacted the hematology
fellow on call, who recommended that if pt's platelets are < 50
he will have to stop the ASA.
# METAB/RHEUM: we continued pt's home dose allopurinol,
methotrexate, folate and vitamin D while here.
# CODE/CONTACT: FULL; HCP Contact Info: ex-wife ___
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Levaquin
Attending: ___.
Chief Complaint:
Lower abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ G1P0 at 13w4d who presents to ED with
abdomino/pelvic discomfort which has been ongoing for the past
day. She has some nausea with emesis yesterday which has since
resolved. She otherwise denies any fevers, chills, or vaginal
bleeding. Of note, pregnancy has been complicated by fibroid
uterus located posterior to cervix. Upon eval in ED, there was
concern for mucopurulent discharge and PID. GYN consulted for
further eval.
Past Medical History:
OB Hx:
- G1 -> Current
Labs: Rh neg/RI/HBsAg-/HIV-/RPR NR
GYN Hx: Remote hx of chlamydia, which was treated. Neg STI
screen ___.
___: ___
Hx of LEEP at age ___
Med Hx: Denies
Surg Hx: LEEP
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission:
Vitals: 98.3 HR: 125 -> 115 (with hydration) BP: 128/74 Resp: 14
O(2)Sat: 100
No acute distress
RRR no m/r/g
CTAB
ABD S/non-distended, mod TTP in R to mid lower abdomen, no
rebound or guarding
EXT NT/NE
Pelvic: On insertion of speculum, there is normal physiologic
discharge of pregnancy. Patient is intolerant of exam. Cervix
not well visualized. On BME, there is a posterior mass
visualized posterior to the cervix, which is firm and tender to
touch. Cervix is otherwise closed.
Pertinent Results:
___ 02:35PM WBC-14.0*# RBC-3.98* HGB-11.3* HCT-35.2*
MCV-88 MCH-28.4 MCHC-32.1 RDW-12.8
___ 02:35PM NEUTS-84.4* LYMPHS-10.6* MONOS-4.6 EOS-0.3
BASOS-0.1
___ 02:35PM PLT COUNT-326
___ 02:35PM GLUCOSE-86 UREA N-4* CREAT-0.4 SODIUM-134
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-20* ANION GAP-16
___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Medications on Admission:
Prenatal vitamin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Indomethacin 25 mg PO QID Duration: 48 Hours
RX *indomethacin 25 mg 1 capsule(s) by mouth q 8 hours Disp #*6
Capsule Refills:*0
3. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pregnancy
Fibroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: History: ___ with pelvic pain, pregnant, leukocytosis // ?
abscess, cyst, confirm IUP
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach.
COMPARISON: Pelvic ultrasound dated ___ and ___.
FINDINGS:
LMP: ___
There is a single live intrauterine gestation wit a heart rate of 167 bpm.
The placenta is located anteriorly.
Limited evaluation of the fetus revealed the following biometric data:
BPD: 13 w 6 d
HC: 14 w 0 d
The gestational age corresponds to the dates.
___: ___
___ (AUA): ___
Multiple fibroids are again noted, largest fibroid is in the lower uterine
segment, and currently measures 8.5 x 8.4 x 9.1 cm (previously 8.6 x 8.9 x 6.6
cm). The ovaries are normal in size bilaterally. Normal arterial and venous
waveforms are seen in the right ovary. Normal venous waveforms are seen left
ovary. No pelvic free fluid. Please note that this study does not replace
dedicated anatomic fetal survey.
IMPRESSION:
1. Single live intrauterine pregnancy.
2. Fibroid uterus.
3. Ovaries are normal in size. Normal arterial and venous waveforms are seen
in the right ovary. Normal venous waveforms are seen in the left ovary.
4. No evidence of cysts or abscess.
Gender: F
Race: WHITE - BRAZILIAN
Arrive by AMBULANCE
Chief complaint: PELVIC PAIN
Diagnosed with OTH CURR COND-ANTEPARTUM, FEM GENITAL SYMPTOMS NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ year old G1P0 who was admitted at ___
with abdominopelvic pain c/w fibroid pain. Pelvic ultrasound
showed multiple fibroids, the largest approximately 9 cm and
enlarged from prior ultrasound. The patient was treated with a
two day course of indocin with improvement. She was discharged
home on hospital day #2 in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
Laproscopic appendectomy converted to open appendectomy
History of Present Illness:
___ w DM and hx of prostate ca s/p radiation, c/o RLQ abdominal
pain x 1 day. Patient reports pain started approximately 10pm
last night. Pain
was sharp, located in RLQ, and non-radiating. Became
progressively worse into this morning when he decided to present
to ED. Also reports nausea and emesis x 2 this morning, as well
as diarrhea since last night. Denies fevers, chills, changes in
appetite, or dysuria. CT findings consistent with acute
appendicitis.
Past Medical History:
- Prostate cancer s/p radiation (completed ___ and Lupron
(completed ___
- DM2 (insulin dependent)
- HTN
- hyperlipidemia
Social History:
___
Family History:
noncontributory
Physical Exam:
PE:
General: NAD. AOx3
Abdomen: Soft, mildly distended much improved from previous
exams. Non tender to palpation. BS+
Chest: CTAB. No wheezes/crackles/rhonchi
Cardiovascular. RRR. S1/S2
GU:
Pertinent Results:
___ 06:35AM WBC-5.8 RBC-4.86 HGB-13.8* HCT-40.5 MCV-83
MCH-28.4 MCHC-34.1 RDW-14.3
___ 06:35AM NEUTS-89* BANDS-3 LYMPHS-5* MONOS-3 EOS-0
BASOS-0 ___ MYELOS-0
___ 06:35AM ALBUMIN-4.4 PHOSPHATE-3.2
___ 06:35AM LIPASE-18
___ 06:35AM ALT(SGPT)-48* AST(SGOT)-34 ALK PHOS-153* TOT
BILI-0.7
___ 06:35AM GLUCOSE-270* UREA N-15 CREAT-0.7 SODIUM-137
POTASSIUM-3.4 CHLORIDE-93* TOTAL CO2-29 ANION GAP-18
___ 07:59AM LACTATE-2.5*
___ 09:00AM URINE RBC-5* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 06:35AM BLOOD WBC-5.8 RBC-4.86 Hgb-13.8* Hct-40.5
MCV-83 MCH-28.4 MCHC-34.1 RDW-14.3 Plt ___
___ 07:25AM BLOOD WBC-7.7 RBC-4.17* Hgb-11.8* Hct-34.5*
MCV-83 MCH-28.2 MCHC-34.1 RDW-14.7 Plt ___
___ 02:50PM BLOOD WBC-9.6 RBC-3.86* Hgb-10.8* Hct-31.7*
MCV-82 MCH-27.9 MCHC-34.0 RDW-14.8 Plt ___
___ 07:00AM BLOOD WBC-10.1 RBC-3.98* Hgb-11.0* Hct-33.0*
MCV-83 MCH-27.8 MCHC-33.5 RDW-14.9 Plt ___
___ 11:45AM BLOOD WBC-9.9 RBC-4.04* Hgb-11.5* Hct-34.1*
MCV-84 MCH-28.3 MCHC-33.6 RDW-14.9 Plt ___
___ 12:22AM BLOOD WBC-9.2 RBC-3.76* Hgb-10.3* Hct-30.8*
MCV-82 MCH-27.5 MCHC-33.6 RDW-14.7 Plt ___
___ 09:10AM BLOOD WBC-14.0*# RBC-4.34* Hgb-11.7* Hct-35.2*
MCV-81* MCH-26.9* MCHC-33.3 RDW-14.9 Plt ___
___ 07:40AM BLOOD WBC-9.1 RBC-4.01* Hgb-10.7* Hct-32.1*
MCV-80* MCH-26.6* MCHC-33.2 RDW-14.9 Plt ___
___ 07:00AM BLOOD Glucose-290* UreaN-17 Creat-0.8 Na-132*
K-4.1 Cl-95* HCO3-29 AnGap-12
___ 08:10AM BLOOD Glucose-241* UreaN-21* Creat-0.7 Na-131*
K-3.5 Cl-94* HCO3-28 AnGap-13
___ 03:10PM BLOOD Glucose-186* UreaN-11 Creat-0.6 Na-140
K-3.6 Cl-97 HCO3-32 AnGap-15
___ 12:22AM BLOOD UreaN-12 Creat-0.6
___ 07:05AM BLOOD Glucose-141* UreaN-11 Creat-0.7 Na-140
K-4.1 Cl-99 HCO3-26 AnGap-19
___ 07:40AM BLOOD Glucose-182* UreaN-9 Creat-0.6 Na-132*
K-4.3 Cl-95* HCO3-28 AnGap-13
___ 07:40AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8
Medications on Admission:
1. Lisinopril 20
2. Nifedinpine ER 90
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
2. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Appendicitis complicated by pelvic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Right lower quadrant/right upper quadrant abdominal pain for the
last 12 hours, abdominal distention, history of prostate cancer. Evaluate
surgical process.
COMPARISON: Prior abdominal/pelvic CT from ___.
TECHNIQUE: Axial MDCT images were obtained through the abdomen and pelvis
after the uneventful administration of 130 cc Omnipaque intravenous contrast
and oral contrast. Sagittal and coronal reformats were generated.
FINDINGS:
There is a small right-sided pleural effusion with associated compressive
atelectasis. There is mild atelectasis at the left lung base. There is no
pericardial effusion.
CT OF THE ABDOMEN: The liver enhances homogeneously without focal hepatic
lesions. The gallbladder, adrenal glands, pancreas and spleen are within
normal limits. The right kidney is positioned in the lower abdomen/pelvis.
There are small bilateral hypodensities within the kidneys bilaterally which
are too small to further characterize. Otherwise, kidneys enhance
symmetrically and excrete contrast without evidence of hydronephrosis or
masses.
The stomach is filled with contrast. Contrast is seen within the distal
esophagus, may represent reflux or swallowed contrast prior to the study.
There is no bowel obstruction. There is a 14 mm fluid-filled tubular structure
arising from the cecum with surrounding fat stranding, consistent with acute
appendicitis. There is a dilated fluid filled loop of bowel adjacent to the
area of inflammation, likely mild focal reactive ileus secondary to the acute
findings (2:76). There is associated thickening of the cecal wall laterally.
There is perihepatic simple free fluid which extends to the right paracolic
gutter. No drainable fluid collection or extraluminal air is identified. The
abdominal aorta is of normal caliber and the celiac axis, SMA, bilateral renal
arteries and ___ are patent. There is a focal area of atheroscelrotic
calcification at the right common iliac artery.
CT OF THE PELVIS: There is an intermediate density fluid collection in the
pelvis, likely secondary to the above findings. Brachytherapy seeds are noted
within the prostate which measures 6.7 x 5.6 cm. The urinary bladder and
terminal ureters are normal. No pelvic or inguinal lymphadenopathy is
identified. There are small bilateral fat containing inguinal hernias.
OSSESOUS STRCUTURES: No blastic or lytic lesions suspicious for malignancy.
There are mild degenerative changes in the lumbar spine.
IMPRESSION:
1. Acute appendicitis with significant adjacent inflammatory changes. No
drainable fluid collection, no extraluminal air identified. Small amount of
perihepatic simple free fluid and pelvic free fluid, of intermediate density,
likely secondary to inflammatory changes.
2. Small right pleural effusion.
Findings discussed with ___ by ___ via telephone on ___ at 9:45 AM, time of discovery.
Radiology Report
HISTORY: Abdominal distention common tenderness status post open
appendectomy.
COMPARISON: CT abdomen pelvis on ___
FINDINGS:
Contrast is seen throughout the ascending colon. Multiple dilated loops of
small bowel are noted, the largest of which measures 5.3 cm. Surgical staples
are seen projected over the abdomen in a vertical orientation just to the
right of midline. A surgical drain is seen overlying the right hemiabdomen
terminating in the right lower quadrant. No air-fluid levels are seen. No
evidence of large free air on this supine portable radiograph.
IMPRESSION:
Multiple dilated loops of small bowel consistent with ileus.
Radiology Report
HISTORY: NG placement.
FINDINGS: No previous images. Nasogastric tube extends to the mid body of
the stomach before coiling back on itself so that the tip lies just below the
hemidiaphragm. There are low lung volumes. Opacification at the right base
is consistent with some combination of volume loss in the middle and lower
lobe and pleural effusion. The possibility of supervening pneumonia cannot be
excluded in the appropriate clinical setting.
The left lung is essentially clear.
Radiology Report
HISTORY: ___ man status post open appendectomy and postop ileus.
Reason for increased oxygen requirement.
TECHNIQUE: Portable AP frontal chest radiograph was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Continued right-sided pleural effusion has minimally increased, and associated
atelectasis is seen. The cardiac silhouette is unchanged, and no pneumothorax
is seen. Nasogastric tube is seen entering the stomach and coiling along the
greater curvature of the stomach back towards the hemidiaphragm. Several
bowel loops are seen consistent with postop ileus. Open clothespin is seen
projecting over the left lateral chest wall.
IMPRESSION:
Continued large right pleural effusion with associated atelectasis. Unable to
rule out pneumonia.
Initial findings were conveyed to Dr. ___ telephone on ___ at approximately 13:30 immediately following review by Dr. ___.
Radiology Report
HISTORY: Distended abdomen post-op. Evaluation for obstruction.
COMPARISON: Abdominal radiographs on ___
FINDINGS:
Supine and upright views:
There is a large pleural effusion and atelectasis seen at the right lung base.
Gas is seen in distended loops of small bowel up to 5.5 cm with staircase
air-fluid levels concerning for partial small bowel obstruction versus small
bowel ileus. Some air-fluid levels seen in nondistended colon. No evidence
of intraperitoneal free air.
IMPRESSION:
Multiple loops of dilated small bowel with air-fluid levels suspicious for
partial small bowel obstruction.
Radiology Report
INDICATION: History of abdominal pain and distention status post open
appendectomy with perforation.
COMPARISON: CT abdomen and pelvis with contrast from ___.
TECHNIQUE: MDCT axial imaging was obtained from the lung bases to the pubic
symphysis following the administration of intravenous contrast material.
Coronal and sagittal reformats were completed.
DLP: 970.2 mGy-cm.
FINDINGS:
CT ABDOMEN WITH CONTRAST: There is a moderate right intermediate density
pleural effusion with overlying atelectasis. The liver enhances homogenously
without any focal lesions or intra- or extra-hepatic biliary dilatation. The
main portal vein is patent. There is sludge within the gallbladder, which is
nondistended. The pancreas, spleen, and adrenal glands are unremarkable. The
right kidney is malrotated and located within the pelvis. The kidneys enhance
and excrete contrast symmetrically without any hydronephrosis. There are tiny
hypodensities within the left kidney (2:37, 40) that are too small to
characterize and may represent cysts. The stomach is distended. Multiple
loops of small bowel are dilated measuring up to 5.3 cm proximally. There is
no definite transition point, and distal bowel loops are smaller in caliber.
This suggests a partial bowel obstruction. There is oral contrast and fecal
material present within the large bowel which is otherwise unremarkable.
There is no free fluid, free air or lymphadenopathy within the abdomen. The
aorta and its major branches are patent.
CT PELVIS: There is a 1.2 x 3.3 x 4.4 cm rim-enhancing fluid collection (TV x
AP x CC). This is adjacent to the sigmoid colon in the right pelvis. There
are no other fluid collections. The bladder is unremarkable. There is no
lymphadenopathy or free air.
OSSEOUS STRUCTURES: There are no concerning osseous lesions.
IMPRESSION:
1. 4.4 cm rim-enhancing fluid collection adjacent to the sigmoid colon in the
right pelvis.
2. Dilated proximal loops of small bowel with gradual tapering of distal
loops concerning for partial obstruction.
3. Moderate right pleural effusion with overlying atelectasis.
Radiology Report
HISTORY: ___ year old male with perforated appendicitis. CT demonstrating fluid
collection along sigmoid colon.
TECHNIQUE: CT-guided drainage of right perirectal fluid collection
COMPARISON: Compared to previous CT abdomen and pelvis from ___.
OPERATORS: Dr. ___ attending (present and supervising), and Dr.
___ imaging
fellow.
PROCEDURE:
The procedure, including risks, benefits and alternatives were explained to
the patient and after a detailed discussion, written informed consent was
obtained from the patient. A time-out was performed prior to the procedure.
Moderate sedation was provided by administering divided doses of
Versed/Fentanyl throughout the total intra-service time of 20 minutes during
which
the patient's hemodynamic parameters were continuously monitored. A total of
100 mcg of fentanyl and 2.0 mg of Versed were administered intravenously.
A limited CT of the region of interest was done without contrast with the
patient the right lateral decubitus position demonstrating right perirectal
fluid collection measuring 2.5cm transverse x 3.9cm AP. The skin was marked
with a marker. The patient was prepped and draped in the usual sterile
fashion. 1% lidocaine was used for local anesthesia at the site.
Using CT guidance and Seldinger technique, an 18 gauge ___ needle was
introduced into the collection using a transgluteal approach. A 3 mm J tip
guidewire was placed through the needle, the needle was removed over the
guidewire. Wire position was confirmed with CT fluoroscopy. An 8 ___
___ pigtail catheter was inserted over the guidewire into the collection.
A 15 cc sample of purulent fluid was withdrawn, and a sample was sent for
microbiology. The catheter was fixed in place and attached to a JP suction
bulb.
There were no immediate post-procedural complications. The patient tolerated
the procedure well.
The attending radiologist, Dr. ___, was present for the entire procedure.
IMPRESSION: CT guided drainage of right pelvic abscess with insertion of an 8
___ locking pigtail catheter. Appropriate sample was sent for microbiology.
No immediate post-procedural complications.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 98.3
heartrate: 95.0
resprate: 18.0
o2sat: 97.0
sbp: 182.0
dbp: 89.0
level of pain: 10
level of acuity: 3.0 | Patient was admitted to ___ service on ___ with acute
appendicitis confirmed by CT. Patient received a laproscopic
appendectomy converted to open appendectomy on ___. Patient
c/o distension, abdominal pain and WBC count trending up on 7
days post operative, subsequent CT scan of the abdomen/pelvis
revealed a 4.4 cm rim-enhancing fluid collection adjacent to the
sigmoid colon in the right pelvis. Ptn taken to ___ for drainage
of abscess on ___. Placed on cipro/flagyl. Patient afebrile,
WBC trending down, patient reports adequate bowel function,
eating and ambulating ok. Patient reports he is ready for
discharge to rehabilitation facility. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ PMH of severe AS s/p TAVR ___ (c/b PNA,
septic shock), CAD (s/p DES x2 to RCA in ___, TIA (s/p R
CEA), and ___ transferred from ___ after presenting there
with weakness.
Of note, pt. has had frequent admission recently. Most recently,
pt. admitted from ___ to ___ for weakness likely ___
overdiuresis. Device was interogated with evidence of new afib.
Course complicated by afib with RVR which required beta blockade
and a fall (negative NCHCT). Anticoag was not initiated at this
time given fall. Pt. was also found to have elevated TSH to 7.5.
Pt. was in his usual state of health until the afternoon of
presentation when he noted weakness. Prior to this, he describes
having a very active day of presentation, waking up at 6AM
traveling with his wife to a ___ appt. He describes full-body
weakness. He denies changes in vision, lightheadedness,
dizziness, numbness, tingling, or weakness of the arms or legs.
Pt. was weak to the point of not being able to speak. He denies
any confusion. He was able to speak when the ambulance arrived
at his home. He denies shortness of breath, orthopnea, or PND
over the last several nights. He has a chronic cough that is
unchanged. Denies chest pain or palpitations. Denies fevers,
chills, nausea, vomiting, abdominal pain. He had 1 episode of
diarrhea on ___. He has not had a BM since then but endorses
chronic constipation (typical BM every 3 days). At baseline, pt.
able to walk with his walker throughout his house with minimal
difficulty.
Pt. presented to ___ initially, found to be in AFib and
being V-paced at a rate of 108 bpm (BP 114/70, 97% 3L NC). He
was pale, cool, and diaphoretic. He received 500cc IVF with
significant resolution of symptoms. CXR w/o acute process or
pulmonary edema. Cardiac enzymes reportedly negative x1. SBP was
90 initially, increasing to 110. Pt reported subjective
improvement in weakness after saline bolus.
In the ED, initial vitals were: 97.9 88 126/64 20 99% 4L NC
- Labs were significant for WBC 12.2 (lymphs 74%), H/H 8.8/28.8,
plts 127, proBNP 2363, BUN 22, trop negative x1, lactate 0.8
- Imaging revealed CXR with no acute cardiopulmonary process
- Pt. finished 500cc of IVF in the ED.
- EP was consulted and believed pt. had been V-pacing an atrial
tachycardia
Vitals prior to transfer were: 98.3 80 151/63 20 95% Nasal
Cannula
Past Medical History:
1. CAD s/p ___ 2 to RCA (___)
2. Aortic stenosis
3. Bronchiectasis
4. Non-Hodgkin's Lymphoma - diagnosed ___ s/p radiation
5. CLL ___, being watched
6. Hypogammaglobulinemia
7. Hypothyroidism
8. Prostate CA s/p radiation c/b fecal incontinence
9. TIA (left arm weakness) s/p right carotid endarterectomy
10. Orthostatic hypotension
11. GERD
12. Left inguinal hernia repair
13. s/p CCY
Social History:
___
Family History:
Premature coronary artery disease. Mother died at ___ of diabetes
and an MI. Father died suddenly at age ___ of unknown cause
(assumed MI).
Physical Exam:
Admission Exam:
Vitals: 97.9, 138/60, 84, 18, 96% on RA
Weight: 74.4kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP is 8cm at 45 degrees, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diffuse inspiratory rales bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace ___ edema bilaterally
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge Exam:
Vitals: 98.3 82 130/60 18 94%RA
Weight: 74.4kg
General: Adult male in NAD, lying comfortably in bed
NEURO: AAOx3, CNII-XII intact, strength ___, sensation grossly
intact to light touch.
HEENT: NC, bruising over right eye which is old, MMM, PERRL
Lungs: CTAB without increased WOB
CV: Regular rate with ___ systolic murmur, normal S1 and S2
Abdomen: NTND, BS+, soft, no HSM
Ext: WWP without edema
Pertinent Results:
Admission Labs:
___ 08:13PM BLOOD WBC-12.2* RBC-3.17* Hgb-8.8* Hct-28.8*
MCV-91 MCH-27.8 MCHC-30.6* RDW-17.6* RDWSD-58.0* Plt ___
___ 08:13PM BLOOD Neuts-22.7* Lymphs-74.2* Monos-2.7*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-2.75# AbsLymp-9.02*
AbsMono-0.33 AbsEos-0.01* AbsBaso-0.01
___ 08:13PM BLOOD Glucose-119* UreaN-22* Creat-0.9 Na-134
K-4.6 Cl-98 HCO3-26 AnGap-15
___ 08:13PM BLOOD ALT-17 AST-24 AlkPhos-45 TotBili-0.3
___ 08:13PM BLOOD proBNP-2363*
___ 06:55AM BLOOD cTropnT-<0.01
___ 08:13PM BLOOD Calcium-8.8 Mg-2.0
Imaging:
___ CXR
IMPRESSION:
Small bilateral pleural effusions. Bilateral subsegmental
atelectasis/
scarring.
Discharge Labs:
___ 06:55AM BLOOD WBC-11.0* RBC-3.20* Hgb-8.8* Hct-29.3*
MCV-92 MCH-27.5 MCHC-30.0* RDW-17.8* RDWSD-58.8* Plt ___
___ 06:55AM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-135
K-4.9 Cl-100 HCO3-25 AnGap-15
___ 06:55AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Pantoprazole 20 mg PO Q24H
3. Simvastatin 20 mg PO QPM
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Potassium Chloride Dose is Unknown PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Pantoprazole 20 mg PO Q24H
6. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with cough*** WARNING *** Multiple patients with
same last name! // pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Aortic valve replacement is noted. Dual lead left-sided pacemaker is stable
in position. There is blunting of the bilateral posterior costophrenic angles
consistent with small bilateral pleural effusions. Right basilar atelectasis
is seen. There is also linear left mid lung atelectasis/scarring. No focal
consolidation. Cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Small bilateral pleural effusions. Bilateral subsegmental atelectasis/
scarring.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Presyncope, Transfer
Diagnosed with SYNCOPE AND COLLAPSE, OTHER MALAISE AND FATIGUE, ATRIAL FIBRILLATION
temperature: 97.9
heartrate: 88.0
resprate: 20.0
o2sat: 99.0
sbp: 126.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | Summary
================================
___ PMH of severe AS s/p TAVR ___ (c/b PNA, septic shock),
CAD (s/p DES x2 to RCA in ___, TIA (s/p R CEA), and ___
transferred from ___ after presenting there with weakness.
He had no evidence of CHF on exam or evidence of infectious
source. His weight on admission (bed weight) was down 1kg from
his most recent outpt weight. He had no symptoms of angina and
EKG was unremarkable, troponins negative x2. He was treated with
500cc NS bolus and symptomatically improved significantly. It
was felt his presentation was due to overdiuresis secondary to
lasix. He was continued on rate control and aspirin for his
afib, with coumadin held due to fall risk. On telemetry, he was
in normal sinus following fluid bolus without pacing. He was in
good condition and discharged with close cardiology follow up.
Transitional Issues
=================================
1. Lasix was discontinued on discharge as it likely led to
dehydration and precipitated his weakness. Patient was
instructed to weigh himself daily and call his doctor for any
changes >3 pounds. If patient begins to become hypervolemic,
restarting lasix can be considered.
2. Potassium replacement was discontinued as patient may no
longer need it with discontinuing lasix.
3. Appointments were made with cardiology on ___ with Dr. ___
___ post-TAVR and ___ with ___ of primary care team.
Weight and fluid status should be checked and consideration of
restarting lasix can be made at that time.
4. Patient was discharged with continuation of home weight
telemonitoring and ___ services, which had previously been
established.
5. TSH and free T4 were pending at time of discharge. These
should be followed up on at his upcoming promary care
appointment to ensure hypothyroidism is not contributing to his
weakness and his levothyroxine does not need to be adjusted.
# CODE: FULL, confirmed (no long term life support)
# EMERGENCY CONTACT: Name of health care proxy: ___
___ ; ___ (daughter) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / codeine
Attending: ___.
Chief Complaint:
Abdominal distention
Major Surgical or Invasive Procedure:
None on this admission
History of Present Illness:
___ s/p ex-lap/lysis of adhesions for SBO on ___ by Dr. ___,
___ w increasing abdominal distension/decrease in bowel
function with abdominal x-ray concerning for small bowel
obstruction. Patient reports she has had persistent left-sided
abdominal pain since the surgery which has not improved, and has
had minimal appetite. She noticed increasing abdominal
distension overnight and felt nauseous this morning (but no
vomiting), prompting her to come to the ED for further
evaluation. Last passed flatus yesterday afternoon, although did
have a small semi-formed bowel movement this morning. Denies
fever, chills, bloody stools, or dysuria.
Past Medical History:
PHM: Celiac, Hemorrhoids, constipation
PSH: Intussuception repair at 5 mos, exlap/LOA (___) for SBO;
Hemorrhoidectomy x3
Social History:
___
Family History:
Uncle with colon cancer. Father has had a " bowel obstruction".
Physical Exam:
Physical exam on admission
Physical Exam:
Vitals: T 98.2 HR 80 BP 132/74 RR 16 O2sat 98RA
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, minimally distended; mildly tender to palpation in
epigastrium and LUQ, no rebound/guarding
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Physical exam on discharge (changes only):
VS: 98.9, 70, 130/85, 18, 100%RA
Abd exam: small slightly right of midline vertical incision
healing & covered with steri-strips; abd soft, nondistended;
minimal tenderness to plapation in epigastrium, no
rebound/guarding
Medications on Admission:
VitaminD, MVI, Prilosec 20 mg qd
Discharge Medications:
1. Amitriptyline 10 mg PO HS abdominal visceral hypersensitivity
RX *amitriptyline 10 mg 1 tablet(s) by mouth ___ day Disp #*30
Tablet Refills:*0
2. Pantoprazole 40 mg PO Q12H
Please don't take the Prilosec you were previously taking; this
is the same type of medication
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*0
3. Vitamin D 0 UNIT PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with nausea, vomiting and abdominal distention
after recent abdominal surgery.
COMPARISON: ___.
TECHNIQUE: Frontal, supine and upright abdominal radiograph.
FINDINGS: There is diffuse small bowel dilatation with the paucity of bowel
gas in the colon and pelvis, with associated air-fluid levels throughout the
abdomen. No abdominal free air is identified. No abnormal calcification is
present. The visualized lung bases are clear.
IMPRESSION: Findings compatible with small-bowel obstruction.
Radiology Report
HISTORY: Status post exploratory laparotomy and on ___ for small bowel
obstruction
COMPARISON: Abdominal radiographs on ___ and ___
FINDINGS:
There are multiple air-fluid levels seen within the small bowel. There is
very little air in the large bowel, with the exception of a small amount of
air in the rectum. The abdomen appears more hazy than on previous exam.
There is bulging of the flanks, which may represent increasing ascites. The
bowel gas pattern is nonspecific, with no evidence of improvement compared to
prior study.
Bony structures are unremarkable.
IMPRESSION:
1. Increased abdominal haziness, which may represent increasing ascites since
prior exam.
2. Bowel gas pattern is relatively nonspecific, and unchanged from previous
examination. Small-bowel obstruction cannot be excluded.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HERE FOR BLOODWORK
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.2
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 132.0
dbp: 74.0
level of pain: 3
level of acuity: 3.0 | After presentation to the ER, patient was made NPO and started
on IVF. NGT was placed in ER. Patient was admitted to colorectal
surgery. The next day, she was passing gas so the NGT was
clamped, then removed. She tolerated this well. She had a slight
headache that resolved and some chest pain. An EKG was stable
and she was given protonix, which helped. She was ambulating,
passing gas, and had a bowel movement. Her diet was advanced to
sips. In addition, she was started on amytriptyline 10 mg for
her chronic abdominal pain. A nutrition consult was ordered for
her celiac disease for advice on eating habits. On ___, she was
advanced to clear liquids plus boost, which she tolerated well.
A follow up with her GI physician, ___, was recommended.
She continued to pass gas and deny N/V and so she was discharged
home, doing well. KUB showed a few air-fluid levels. She was
advised to advance her diet from clears with Boost as tolerated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
eggs
Attending: ___.
Chief Complaint:
Anemia, transfer
Major Surgical or Invasive Procedure:
Paracentesis ___ removed
Paracentesis ___ removed
History of Present Illness:
___ year old male with history of EtOH cirrhosis (MELD
23)complicated by diuretic resistant ascites requiring biweekly
paracentesis, history of Type 1 HRS, SBP, HE, and PVT who
presents as transfer from rehab for anemia with Hgb 4.7. His
other past medical history is notable for seizures, bipolar
disorder, and DM2 on insulin.
Patient recently admitted ___ for progressive DOE
secondary to worsening ascites. At that time, he received
multiple paracenteses with ultimate decision to pursue
outpatient
scheduled paracentesis. He was thought to be a poor candidate
for
TIPS given significant history of hepatic encephalopathy. He was
discharged on diuretics including spironolactone 150 mg daily
and
furosemide 60 mg daily. He also underwent EGD for guaiac
positive
stool, which revealed non-bleeding varices, portal hypertensive
gastropathy. His last colonoscopy was in ___, with poor prep.
Given overall prognosis, there was discussion regarding goals of
care, with decision for DNR/DNI, but with continuation of some
life saving procedures including therapeutic paracentesis and
any
endoscopic procedures. Discussion was held with regard to
possible placement of abdominal catheter, not pursued as patient
did not feel ready for hospice care. Course was also complicated
by difficulty with BG control requiring ___ input.
Since then, he saw his outpatient hepatologist Dr. ___ on
___.
At that time it was discussed that he is not an appropriate
transplant candidate, but that would continue with diuresis and
paracentesis.
*Note in prior admission ___ he developed type 1 HRS
requiring
clinical trial (terlipressin versus placebo RCT).
He reports that he was doing well at rehab, participating in
physical therapy and ambulating with walker. Over the past 2
weeks or so, he reports that he had episodes of black and red
bowel movements, associated with episodic dizziness, but he did
not tell anyone. No shortness of breath, chest pain. Reports
abdominal distention similar to prior, had been receiving twice
weekly paracentesis; thinks that his ___ edema is improved.
Patient presented as transfer from ___, where initial Hgb
was 4.7. He received 2 units of pRBC. He reports generalized
weakness, but denies hematemesis, hematochezia, melena.
In the ED initial vitals: 98.6 84 ___ 99% 2L NC
- Exam notable for:
General: Appearing stated age. Pale
HEENT: NCAT, PEERL, MMM
Neck: Supple, trachea midline
Heart: RRR, no MRG. No peripheral edema.
Lungs: CTAB. No wheezes, rales, or rhonchi.
Abd: Soft, distended. Mildly diffusely TTP.
MSK: No obvious limb deformities.
Derm: Skin warm and dry
Neuro: Awake, alert, moves all extremities. Asterixis present.
Psych: Appropriate affect and behavior
- Labs notable for:
WBC 5.0 Hgb 6.2 Plt 70
129 | 98 | 29
---------------
5.9 | 20 | 1.2
ALT 22 AST 58 AP 149 Tbili 2.0 Alb 3.6
Lactate 1.6
Ascites fluid: WBC 114, poly 10, lymph 8, RBC 5750, mono 80,
protein 0.5 Albumin 0.3 Glu 140 LDH 32
- Imaging notable for:
CTH without contrast: No acute intracranial process.
- Consults:
Hepatology:
"-PPI BID
-Octreotide drip
-Ceftriaxone
-If has ascites, please perform diagnostic para
-Admit to ET under Dr ___
Note was made of patient with "acute episode of
unresponsiveness,
unclear if this was a seizure in the setting of not being given
his anti-epileptics, head CT negative. On exam he has frank
asterixis, is coherent but forgetful, abd soft and distended."
EGD revealed grade 1 nonbleeding varices in distal esophagus, no
gastric varices, GAVE treated with thermal therapy, portal
hypertensive gastropathy.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
- ETOH cirrhosis, c/b ascites, varices, h/o HE
- Recurrent pancreatitis
- T2DM
- H/O seizures
- H/O melanoma
- Anxiety
- ?CVA
- Bipolar disorder
- PVT s/p TPA thrombectomy ___
Social History:
___
Family History:
No family h/o liver disease
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: ___ 1714 Temp: 98.2 PO BP: 154/64 HR: 98 RR: 16 O2 sat:
100% O2 delivery: Ra FSBG: 148
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, mildly icteric sclerae
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, loud systolic murmur IV/VI
LUNGS: CTA anteriorly without use of accessory muscles
ABDOMEN: Distended with fluid wave, almost tense, Nontender to
palpation, + caput medusa
EXTREMITIES: 2+ pitting ___ edema to level of knees with some
venous stasis changes
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3 (self, hospital, year, month, trump), moving all 4
extremities with purpose, +asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1153)
Temp: 97.8 (Tm 98.1), BP: 120/69 (110-145/57-69), HR: 89
(70-89), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: RA,
Wt: 191.14 lb/86.7 kg
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, icteric
NECK: Supple, no LAD, no JVD
HEART: RRR, S1/S2, loud systolic murmur IV/VI
LUNGS: CTA anteriorly without use of accessory muscles
ABDOMEN: Distended with fluid wave, almost tense, Nontender to
palpation, + caput medusa
EXTREMITIES: 2+ pitting ___ edema to level of knees with some
venous stasis changes
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3 (self, hospital, year, month), moving all 4
extremities with purpose, +asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 09:30PM POTASSIUM-5.4
___ 07:20PM WBC-5.2 RBC-2.71* HGB-8.1* HCT-26.2* MCV-97
MCH-29.9 MCHC-30.9* RDW-18.2* RDWSD-61.1*
___ 07:20PM PLT COUNT-62*
___ 10:27AM K+-4.8
___ 10:20AM GLUCOSE-100 UREA N-27* CREAT-1.3* SODIUM-130*
POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-19* ANION GAP-10
___ 10:20AM ALT(SGPT)-18 AST(SGOT)-48* ALK PHOS-133* TOT
BILI-4.1*
___ 10:20AM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-3.9
MAGNESIUM-2.1
___ 10:20AM WBC-5.9 RBC-2.61* HGB-7.6* HCT-25.4* MCV-97
MCH-29.1 MCHC-29.9* RDW-17.6* RDWSD-60.3*
___ 10:20AM NEUTS-70.4 LYMPHS-7.4* MONOS-16.8* EOS-4.8
BASOS-0.3 IM ___ AbsNeut-4.12 AbsLymp-0.43* AbsMono-0.98*
AbsEos-0.28 AbsBaso-0.02
___ 10:20AM PLT COUNT-63*
___ 06:09AM GLUCOSE-90 UREA N-29* CREAT-1.3* SODIUM-132*
POTASSIUM-5.9* CHLORIDE-101 TOTAL CO2-16* ANION GAP-15
___ 06:09AM WBC-5.2 RBC-2.39* HGB-7.1* HCT-24.0* MCV-100*
MCH-29.7 MCHC-29.6* RDW-17.5* RDWSD-61.8*
___ 06:09AM NEUTS-69.7 LYMPHS-9.7* MONOS-14.3* EOS-5.3
BASOS-0.6 IM ___ AbsNeut-3.65 AbsLymp-0.51* AbsMono-0.75
AbsEos-0.28 AbsBaso-0.03
___ 06:09AM PLT COUNT-64*
___ 02:39AM ___ PO2-55* PCO2-37 PH-7.38 TOTAL CO2-23
BASE XS--2
___ 02:39AM O2 SAT-83
___ 02:20AM GLUCOSE-77 UREA N-29* CREAT-1.3* SODIUM-131*
POTASSIUM-5.7* CHLORIDE-100 TOTAL CO2-19* ANION GAP-12
___ 02:20AM WBC-5.0 RBC-2.16* HGB-6.5* HCT-22.0* MCV-102*
MCH-30.1 MCHC-29.5* RDW-17.0* RDWSD-61.7*
___ 02:20AM NEUTS-72.2* LYMPHS-8.3* MONOS-14.3* EOS-4.6
BASOS-0.2 IM ___ AbsNeut-3.63 AbsLymp-0.42* AbsMono-0.72
AbsEos-0.23 AbsBaso-0.01
___ 02:20AM PLT COUNT-57*
___ 12:00AM ASCITES TOT PROT-0.5 GLUCOSE-140 LD(LDH)-32
ALBUMIN-0.3
___ 12:00AM ASCITES TNC-114* RBC-5750* POLYS-10* LYMPHS-8*
MONOS-80* MESOTHELI-2*
___ 10:53PM COMMENTS-GREEN TOP
___ 10:53PM LACTATE-1.6
___ 10:39PM GLUCOSE-107* UREA N-29* CREAT-1.2 SODIUM-129*
POTASSIUM-5.9* CHLORIDE-98 TOTAL CO2-20* ANION GAP-11
___ 10:39PM estGFR-Using this
___ 10:39PM ALT(SGPT)-22 AST(SGOT)-58* ALK PHOS-149* TOT
BILI-2.0*
___ 10:39PM LIPASE-54
___ 10:39PM ALBUMIN-3.6
___ 10:39PM WBC-5.5 RBC-2.08* HGB-6.2* HCT-20.8* MCV-100*
MCH-29.8 MCHC-29.8* RDW-16.8* RDWSD-60.2*
___ 10:39PM NEUTS-74.4* LYMPHS-8.4* MONOS-12.2 EOS-4.2
BASOS-0.4 IM ___ AbsNeut-4.07 AbsLymp-0.46* AbsMono-0.67
AbsEos-0.23 AbsBaso-0.02
___ 10:39PM PLT COUNT-70*
___ 10:39PM ___ PTT-26.5 ___
___ 09:45PM URINE HOURS-RANDOM
___ 09:45PM URINE UHOLD-HOLD
___ 09:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:45PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:45PM URINE HYALINE-44*
___ 09:45PM URINE MUCOUS-RARE*
PERTINENT STUDIES:
==================
___ Imaging CT HEAD W/O CONTRAST
No evidence for acute intracranial abnormalities.
___ Gastroenterology EGD
Findings:
- Esophagus: Grade 1 varices were seen in the distal esophagus.
Varices were not bleeding.
- Stomach: Segmental petechiae, erythema and friability mucosa
with stigmata of recent bleeding was noted in the stomach
antrum. These findings are compatible with GAVE, argon plasma
coagulator was successfully applied in the stomach antrum.
Diffuse congestion, petechiae and mosaic mucosal pattern of the
mucosa was noted in the stomach fundus and stomach body. These
findings are compatible with portal hypertensive gastropathy.
No evidence of gastric varices.
- Duodenum: Normal mucosa was noted in the whole examined
duodenum.
Impression:
-Varices in the distal esophagus
-No evidence of gastric varices
-Petechiae, erythema and friability in the stomach antrum
compatible with gave.
-Polyps in the fundus.
-Congestion, petechiae and mosaic mucosal pattern in the stomach
fundus and stomach body compatible with portal hypertensive
gastropathy.
-Normal mucosa in the whole examined duodenum.
___ 12:00AM ASCITES TNC-114* RBC-5750* Polys-10* Lymphs-8*
Monos-80* Mesothe-2*
___ 12:00AM ASCITES TotPro-0.5 Glucose-140 LD(LDH)-32
Albumin-0.3
DISCHARGE LABS:
===============
___ 04:50AM BLOOD WBC-3.8* RBC-2.88* Hgb-8.7* Hct-28.5*
MCV-99* MCH-30.2 MCHC-30.5* RDW-18.4* RDWSD-62.7* Plt Ct-55*
___ 04:50AM BLOOD Glucose-135* UreaN-21* Creat-1.2 Na-134*
K-4.4 Cl-100 HCO3-23 AnGap-11
___ 04:50AM BLOOD ALT-18 AST-64* AlkPhos-137* TotBili-1.6*
___ 04:50AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.9 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 20 mg PO QHS
2. BusPIRone 30 mg PO QHS
3. Ciprofloxacin HCl 500 mg PO Q24H
4. Doxepin HCl 100 mg PO HS
5. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
6. FoLIC Acid 1 mg PO DAILY
7. LevETIRAcetam 1500 mg PO BID
8. Magnesium Oxide 400 mg PO DAILY
9. Midodrine 10 mg PO TID
10. OXcarbazepine 300 mg PO BID
11. Pantoprazole 40 mg PO Q24H
12. Rifaximin 550 mg PO BID
13. Spironolactone 150 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Zinc Sulfate 220 mg PO DAILY
16. Glargine 20 Units Breakfast
Glargine 50 Units Bedtime
Humalog 16 Units Breakfast
Humalog 16 Units Lunch
Humalog 16 Units Dinner
17. Furosemide 120 mg PO DAILY
18. Lactulose 30 mL PO QID
Discharge Medications:
1. Glargine 20 Units Breakfast
Glargine 50 Units Bedtime
Humalog 16 Units Breakfast
Humalog 16 Units Lunch
Humalog 16 Units Dinner
2. Midodrine 5 mg PO TID
3. Spironolactone 100 mg PO DAILY
4. ARIPiprazole 20 mg PO QHS
5. BusPIRone 30 mg PO QHS
6. Ciprofloxacin HCl 500 mg PO Q24H
7. Doxepin HCl 100 mg PO HS
8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 120 mg PO DAILY
11. Lactulose 30 mL PO QID
12. LevETIRAcetam 1500 mg PO BID
13. Magnesium Oxide 400 mg PO BID
14. OXcarbazepine 300 mg PO BID
15. Pantoprazole 40 mg PO Q24H
16. Rifaximin 550 mg PO BID
17. Tamsulosin 0.4 mg PO QHS
18. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with worsening AMS. Assess for intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Sequenced Acquisition 1.0 s, 4.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
186.8 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT head from ___
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass effect.
Subcortical, deep, and periventricular white matter hypodensities again seen,
nonspecific but likely sequelae of chronic small vessel ischemic disease in
this age. There is unchanged mild-to-moderate global parenchymal volume loss
with prominent ventricles and sulci.
There is no evidence of fracture. A left parietal outer table osteoma is
again noted, 301:55. The visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavitiesare essentially well aerated. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
No evidence for acute intracranial abnormalities.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Anemia, Weakness
Diagnosed with Anemia, unspecified
temperature: 98.6
heartrate: 84.0
resprate: 18.0
o2sat: 99.0
sbp: 107.0
dbp: 93.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ is a ___ male with medical history notable for
alcoholic cirrhosis complicated by refractory ascites requiring
biweekly paracentesis, type I HRS, SBP, hepatic encephalopathy,
and portal vein thrombus who presented from rehab due to melena
and bright red blood per rectum, transferred from outside
hospital due to anemia. While inpatient, he had EGD
demonstrating GAVE and portal hypertensive gastropathy with
stigmata of recent bleeding, now s/p APC, as well as grade I
varices which were not intervened on. Subsequent to this his
blood counts were stable. While inpatient he additionally had 2
large-volume paracenteses. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary angiogram ___
History of Present Illness:
Mr. ___ is a ___ year old male with IBS-C and family history
of CAD presenting with chest pain and dyspnea. He normally runs
20 miles per week with no difficulties, but developed chest pain
and dyspnea while running yesterday that resolved with rest.
Again, this morning while playing soccer with his son, he
developed these symptoms that resolved with rest. He was seen at
___ where ECG showed sinus rhythm with inverted T waves
in
leads V3, II, III, aVF. Trop was negative there. He was started
on a heparin gtt and given 243 mg aspirin there (takes 81 mg at
home). Cards consulted who recommended transfer for urgent cards
consult.
In the ED, initial vitals were notable for HR 55 with BP 135/55.
Labs notable for negative trops. Repeat ECG showed TWI in III,
aVF, V1, and V3. He was continued on a heparin gtt and admitted
to the floor.
On arrival to the floor, he is still "aware" of his chest, but
not having active pain unless he walks or moves around and then
gets severe dyspnea and L-sided pain. Denies any N/V, arm pain,
neck pain, lightheadedness, black or red stools, epigastric
pain,
heart burn, or difficulty swallowing. He does get leg pain when
he runs, but is unsure if this is cramps. He reports he has not
had hair on the outside of his calves for many years. He has
never had a cath. He had a stress test many years ago that he
thinks was normal.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
IBS-C
Colon polyp
Social History:
___
Family History:
Brother - MI s/p PCI, ___
Father - CAD, medically managed
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 97.5 PO 128 / 80 R Lying 71 20 96 RA
GENERAL: Alert and interactive middle-aged male sitting up in no
acute distress. Very well appearing
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. JVP at 5 cm
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: 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. Hair loss on outer calves.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 750)
Temp: 97.5 (Tm 98.0), BP: 116/79 (100-120/66-91), HR: 57
(52-73), RR: 18 (___), O2 sat: 98% (95-100), O2 delivery: RA
GENERAL: Alert and interactive middle-aged male sitting up in no
acute distress. Very well appearing
HEENT: Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. JVP not elevated
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. Hair loss on outer calves.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. Normal sensation.
Pertinent Results:
ADMISSION LABS
===============
___ 07:50PM BLOOD WBC-8.6 RBC-5.16 Hgb-15.6 Hct-45.3 MCV-88
MCH-30.2 MCHC-34.4 RDW-12.5 RDWSD-39.7 Plt ___
___ 07:50PM BLOOD Neuts-63.3 ___ Monos-7.3 Eos-2.8
Baso-0.7 Im ___ AbsNeut-5.42 AbsLymp-2.20 AbsMono-0.63
AbsEos-0.24 AbsBaso-0.06
___ 07:50PM BLOOD Glucose-87 UreaN-21* Creat-1.0 Na-140
K-3.9 Cl-103 HCO3-24 AnGap-13
___ 07:50PM BLOOD CK-MB-4
___ 07:50PM BLOOD cTropnT-<0.01
___ 07:50PM BLOOD Cholest-217*
___ 07:57PM BLOOD %HbA1c-5.0 eAG-97
___ 07:50PM BLOOD Triglyc-44 HDL-65 CHOL/HD-3.3
LDLcalc-143*
DISCHARGE LABS
===============
___ 08:40AM BLOOD WBC-7.8 RBC-5.32 Hgb-15.9 Hct-46.4 MCV-87
MCH-29.9 MCHC-34.3 RDW-12.8 RDWSD-40.1 Plt ___
___ 08:40AM BLOOD ___ PTT-25.3 ___
___ 08:40AM BLOOD Glucose-92 UreaN-16 Creat-1.0 Na-141
K-4.7 Cl-102 HCO3-26 AnGap-13
___ 08:40AM BLOOD Calcium-9.9 Phos-3.4 Mg-1.9
OTHER PERTINENT LABS
=====================
___ 11:15PM BLOOD CK-MB-3 cTropnT-<0.01
IMAGING/STUDIES
===============
___ Cardiovascular ECG
Sinus bradycardia
Probable left atrial enlargement
ndx q 1,L
Early R wave progression
erwp tw inv v1,3
Nonspecific T abnormalities, inferior leads
no previous tracing for comparison
possible rev early ___ lds
___ correlation suggested
___ Cardiovascular ___ MD ___
___
No angiographically apparent coronary artery disease.
Recommendations
Maximize medical therapy
___ Imaging ART EXT (REST ONLY)
IMPRESSION:
No evidence of arterial insufficiency to the lower extremities
bilaterally.
Radiology Report
EXAMINATION: ABI rest only
INDICATION: ___ year old man with strong family hx CAD but no known CAD
himself, presenting with suspected unstable angina, reports hx of what sounds
like claudication, chronically has no hair on his calves// evaluate for PVD
TECHNIQUE: Non-invasive evaluation of the arterial system in the
lower extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
COMPARISON: None.
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the right femoral,
superficial femoral, popliteal, posterior tibial and dorsalis pedis arteries.
The right ABI was 1.3. The right toe brachial index measures 0.98.
On the left side, triphasic Doppler waveforms are seen at the left femoral,
superficial femoral, popliteal, posterior tibial and dorsalis pedis arteries.
The left ABI was 1.22. The left toe brachial index measures 0.66.
Pulse volume recordings showed symmetric amplitudes bilaterally, at all
levels.
IMPRESSION:
No evidence of arterial insufficiency to the lower extremities bilaterally.
Gender: M
Race: WHITE - EASTERN EUROPEAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea
Diagnosed with Unstable angina
temperature: 96.8
heartrate: 55.0
resprate: 16.0
o2sat: 99.0
sbp: 135.0
dbp: 55.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ year old male with IBS and strong family
history of CAD presenting with chest pain and dyspnea on
exertion
with new EKG changes. Coronary angiogram did not demonstrate
obstructive disease and the patient was discharged without CAD
meds. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tylenol-Codeine #2
Attending: ___.
Chief Complaint:
dry cough, nausea, emesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ with PMH of ESRD due to hypoplastic kidneys
s/p transplant x 2 (baseline Cr 1.5-1.8), squamous cell cancer,
and epilepsy who presented to ___ on ___ with history
of cough and vomiting for one week and found to have multifocal
pneumonia.
She initially presented to ___, and initial vitals were
Temp 97.9, HR 105, BP 101/58, RR 17, O2 sat 96% RA. Exam
significant for rales at left base and dry mucous membranes.
CXR showed multifocal pneumonia. Labs significant for WBC 12.6
(80% PMNs, 13% bands, 3% lymphs), H/H 10.8/32.0, Plt 157, Na
138, K 4.3, BUN/Cr ___. She was influenza PCR negative.
She was given IV vancomycin 1g, IV levaquin 750mg, Zofran 4mg
IV, and 2L NS. She was transferred to ___ for further
management.
This morning, she states that she feels improved since starting
the antibiotics. No chest pain, nausea, vomiting. She states her
cough is not post-tussive emesis and was instead occasionally
related to food consumption. She also had diarrhea 3 days ago
but this has since stopped.
Past Medical History:
1. ESRD due to hypoplastic kidneys, s/p transplant ___ from
mother(lasted ___ years), then HD for ___ years, then s/p
deceased
donor transplant ___, now stable off HD
2. Squamous cell cancer in the face, hands, and legs, s/p Mohs
surgery
3. Anemia
4. Bone disease of chronic kidney disease
5. HTN
6. Patent ductus arteriosus, s/p repair
7. s/p cholecystectomy
8. History of blood clot removal from right leg fistula
9. Epilepsy s/p MVA
Social History:
___
Family History:
No seizures, though maternal aunt with multiple sclerosis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Temp 98.6, HR 106, BP 143/57, RR 16, O2 sat 96% RA
GENERAL: Pleasant, tired-appearing, in no apparent distress.
HEENT: Normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly.
CARDIAC: RRR, normal S1/S2, no m/r/g.
PULMONARY: Rales at left base, no wheezing.
ABDOMEN: Soft, non-tender, non-distended, no organomegaly,
normoactive bowel sounds.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM:
Vitals: T98.8 132/69 HR85 RR20 93%RA
General: alert, oriented, no acute distress, ongoing cough
during conversation
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds bilaterally with rhonchi throughout
the lung fields, no wheezing.
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 06:04AM BLOOD WBC-13.1*# RBC-3.13* Hgb-9.0* Hct-26.9*
MCV-86 MCH-28.8 MCHC-33.5 RDW-13.5 RDWSD-42.0 Plt ___
___ 06:04AM BLOOD Glucose-94 UreaN-19 Creat-1.3* Na-135
K-3.8 Cl-112* HCO3-17* AnGap-10
___ 06:04AM BLOOD LD(___)-164
___ 06:04AM BLOOD Albumin-2.9* Calcium-7.7* Phos-1.5*
Mg-1.3* Iron-6*
___ 06:04AM BLOOD calTIBC-146* Ferritn-519* TRF-112*
___ 06:04AM BLOOD PTH-281*
___ 06:04AM BLOOD 25VitD-15*
___ 02:57AM BLOOD CRP-167.1*
___ 06:04AM BLOOD tacroFK-4.2*
___ 09:44PM URINE Hours-RANDOM Creat-34 TotProt-14
Prot/Cr-0.4*
PERTINENT LABS:
___ 02:57AM BLOOD Glucose-98 UreaN-15 Creat-1.2* Na-136
K-3.8 Cl-112* HCO3-17* AnGap-11
___ 06:21AM BLOOD Glucose-87 UreaN-15 Creat-1.4* Na-139
K-4.0 Cl-114* HCO3-15* AnGap-14
___ 01:20PM BLOOD Glucose-129* UreaN-15 Creat-1.5* Na-136
K-4.2 Cl-105 HCO3-23 AnGap-12
___ 02:57AM BLOOD tacroFK-8.4
___ 06:21AM BLOOD tacroFK-8.3
___ 07:10AM BLOOD tacroFK-6.7
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-6.8 RBC-2.82* Hgb-8.1* Hct-24.6*
MCV-87 MCH-28.7 MCHC-32.9 RDW-13.3 RDWSD-42.7 Plt ___
___ 07:10AM BLOOD Glucose-88 UreaN-22* Creat-1.6* Na-141
K-4.2 Cl-109* HCO3-22 AnGap-14
___ 07:10AM BLOOD Calcium-8.6 Phos-3.6# Mg-1.6
___ 07:10AM BLOOD tacroFK-6.7
MICROBIOLOGY:
Blood Culture, Routine (Final ___: NO GROWTH
URINE CULTURE (Final ___: NO GROWTH
___ 12:27 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
CMV Viral Load (Final ___:
CMV DNA not detected.
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
IMAGING:
CXR ___ at ___
Impression: In comparison with the study of ___,
there has been the development of multiple areas of increased
opacification bilaterally, both anteriorly and posteriorly on
the lateral view, consistent with multifocal pneumonia. Cardiac
silhouette is within normal limits and there is no vascular
congestion.
KUB ___: Nonspecific bowel gas pattern. Small amount of
stool in splenic flexure
CXR ___:
Heart size and mediastinum are stable. Multifocal opacities an
on the
previous study appear to be more homogeneous but involving
substantially
larger parts of the lungs in particular in the lower lobes.
That might
represent evolution of the process and potentially combination
of infection
with organizing pneumonia. No pleural effusion is seen. No
pneumothorax is
seen. Correlation with chest CT would be justified in this
patient with
history of renal transplantation and multifocal infection to
exclude
possibility of opportunistic infection or interstitial
abnormality of non
infectious origin.
CT chest ___:
New supraclavicular and axillary lymph nodes are not enlarged.
Excluding the
breasts which require mammography for evaluation, there are no
soft tissue
abnormalities in the chest wall suspicious for malignancy. This
study is not
appropriate for subdiaphragmatic diagnosis.
Thyroid is not imaged. Atherosclerotic calcification is not
apparent head
neck or coronary arteries. Aorta and pulmonary arteries and
cardiac chambers
are normal size. Hypoattenuation of the blood pool reflects
anemia.
Pericardial effusion is minimal. Bilateral layering pleural
effusions are
layering and small. Numerous measurable mediastinal lymph nodes
are not
pathologically enlarged. There is no adenopathy in the internal
mammary,
retrocrural, or diaphragmatic stations.
Widespread pulmonary abnormalities are more severe in the lower
lobes,
generally peribronchovascular, consisting of ground-glass and
higher density
infiltration, for example lateral segment of the right middle
lobe, 4:93,
progressing to consolidation, see right lower lobe, 4:135.
There are also
smaller more nodular peribronchovascular opacities, such as
superior segment
of the right lower lobe, 4:106. The simplest single explanation
is widespread
severe viral pneumonia, but multiple pathogens are possible, and
the only
infections excluded excluded are septic emboli and initial
pneumocystis
infection. Concurrent conditions are also possible including
pulmonary
hemorrhage. This is not simple pulmonary edema.
There are no bone lesions in the chest cage suspicious for
malignancy.
IMPRESSION:
Widespread pulmonary abnormality probably infection, most likely
viral. See discussion above.
Anemia.
Pleural effusions are small, not clinically significant.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbamazepine (Extended-Release) 400 mg PO DAILY
2. Carbamazepine (Extended-Release) 600 mg PO QHS
3. Zonisamide 550 mg PO QHS
4. PredniSONE 15 mg PO EVERY OTHER DAY
5. Omeprazole 20 mg PO BID
6. Lisinopril 2.5 mg PO DAILY
7. Tacrolimus 5 mg PO Q12H
8. Sertraline 100 mg PO QHS
9. Vitamin D 1000 UNIT PO DAILY
10. fluorouracil 5 % topical BID
11. Mupirocin Ointment 2% 1 Appl TP BID
Discharge Medications:
1. Carbamazepine (Extended-Release) 400 mg PO DAILY
2. Carbamazepine (Extended-Release) 600 mg PO QHS
3. Omeprazole 20 mg PO BID
4. PredniSONE 15 mg PO EVERY OTHER DAY
5. Sertraline 100 mg PO QHS
6. Tacrolimus 4 mg PO Q12H
RX *tacrolimus [Prograf] 1 mg 4 capsule(s) by mouth twice daily
Disp #*56 Capsule Refills:*0
7. Vitamin D 1000 UNIT PO DAILY
8. Zonisamide 550 mg PO QHS
9. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*20 Capsule Refills:*0
10. Sodium Bicarbonate 1300 mg PO TID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times
per day Disp #*180 Tablet Refills:*0
11. fluorouracil 5 % topical BID
12. Mupirocin Ointment 2% 1 Appl TP BID
13. Levofloxacin 500 mg PO Q48H Duration: 1 Dose
Please take this tablet on ___.
RX *levofloxacin 500 mg 1 tablet(s) by mouth every 48 hours Disp
#*1 Tablet Refills:*0
14. Outpatient Lab Work
N17.9 Acute kidney failure
Please obtain chem10 on ___ and fax results to:
Name: ___
Phone: ___
Fax: ___
Please also to renal transplant physician ___:
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Multifocal Community Acquired Pneumonia, likely viral,
Viral Gastroenteritis
SECONDARY: Atrophic kidney disease status post kidney transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with h/o renal transplant for hypoplastic
kidneys, presenting with multifocal pna, prior diarrhea, now with ongoing
nausea/vomiting. // partial obstruction? ileus?
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: None
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Small amount
of stool is seen in the splenic flexure.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Surgical clips are noted in the right
upper quadrant and in mid abdomen.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific bowel gas pattern. Small amount of stool in splenic flexure.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with renal transplant, here with multifocal
pneumonia. Dyspnea minimally improving // worsening infiltrates?
worsening infiltrates?
IMPRESSION:
Heart size and mediastinum are stable. Multifocal opacities an on the
previous study appear to be more homogeneous but involving substantially
larger parts of the lungs in particular in the lower lobes. That might
represent evolution of the process and potentially combination of infection
with organizing pneumonia. No pleural effusion is seen. No pneumothorax is
seen. Correlation with chest CT would be justified in this patient with
history of renal transplantation and multifocal infection to exclude
possibility of opportunistic infection or interstitial abnormality of non
infectious origin.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with renal transplant on tacro and prednisone
here with multifocal PNA with minimal improvement on levoflox and concerning
CXR changes. // opportunistic infection? edema? worsening PNA?
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.9 s, 30.1 cm; CTDIvol = 7.8 mGy (Body) DLP = 234.8
mGy-cm.
2) Spiral Acquisition 1.0 s, 8.1 cm; CTDIvol = 6.4 mGy (Body) DLP = 52.1
mGy-cm.
Total DLP (Body) = 287 mGy-cm.
COMPARISON: Read in conjunction with conventional chest radiographs ___. There no prior chest CT scans for comparison.
FINDINGS:
New supraclavicular and axillary lymph nodes are not enlarged. Excluding the
breasts which require mammography for evaluation, there are no soft tissue
abnormalities in the chest wall suspicious for malignancy. This study is not
appropriate for subdiaphragmatic diagnosis.
Thyroid is not imaged. Atherosclerotic calcification is not apparent head
neck or coronary arteries. Aorta and pulmonary arteries and cardiac chambers
are normal size. Hypoattenuation of the blood pool reflects anemia.
Pericardial effusion is minimal. Bilateral layering pleural effusions are
layering and small. Numerous measurable mediastinal lymph nodes are not
pathologically enlarged. There is no adenopathy in the internal mammary,
retrocrural, or diaphragmatic stations.
Widespread pulmonary abnormalities are more severe in the lower lobes,
generally peribronchovascular, consisting of ground-glass and higher density
infiltration, for example lateral segment of the right middle lobe, 4:93,
progressing to consolidation, see right lower lobe, 4:135. There are also
smaller more nodular peribronchovascular opacities, such as superior segment
of the right lower lobe, 4:106. The simplest single explanation is widespread
severe viral pneumonia, but multiple pathogens are possible, and the only
infections excluded excluded are septic emboli and initial pneumocystis
infection. Concurrent conditions are also possible including pulmonary
hemorrhage. This is not simple pulmonary edema.
There are no bone lesions in the chest cage suspicious for malignancy.
IMPRESSION:
Widespread pulmonary abnormality probably infection, most likely viral. See
discussion above.
Anemia.
Pleural effusions are small, not clinically significant.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Pneumonia, unspecified organism
temperature: 100.4
heartrate: 100.0
resprate: 18.0
o2sat: 97.0
sbp: 111.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Mrs. ___ is a ___ F with h/o atrophic kidneys s/p renal
transplant x2 (most recent ___ on tacrolimus/prednisone
presenting with >1 week of dry cough, nausea/emesis and
diarrhea, found to have a likely viral pneumonia and
gastroenteritis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ with a history of severe
COPD/bronchiectasis on chronic antibiotic suppression and
supplemental oxygen, osteoporosis admitted for evaluation of
chest pain. She was in her usual state of health through this
afternoon when she developed severe ___ lower chest pain
centered at the xiphoid notch and radiating under the ribcage to
the posterior back. She had just returned from the grocery and
was putting groceries away when symptoms began, and they did not
relent with rest. She had some nausea transiently without
shortness of breath, cough, comiting, diaphoresis, or dyspnea.
There is no pleuritic component. She activated EMS and was
brought to the ED.
In the ED, initial VS were: 97.9 80 86/37 26 98% 4L Nasal
Cannula. She continued to have pain not responsive to ibuprofen
or nitroglycerin. She desaturated to the low ___ off of oxygen
(a common occurance) and rebounded with 2LNC. A CXR and CTA were
unremarkable for acute processes. EKG revealing RBBB with
nonspecific TWI in the anterior leads. Cardiology was consulted
and did not feel the pain was cardiac in nature.
On arrival to the floor, her initial vitals were T98 BP160/56
R82 RR26 Sat83RA, 97/2L. She continues to have ___ chest pain
in the same bandlike distribution without change from this
morning. She has scant cough that is nonproductive. On ROS,
denies abd pain, N/V/D/F/C, dysuria, hematuriea, palps.
Past Medical History:
-severe COPD with oxygen supplementation requirement
-bronchiectasis requiring monthly suppression antibiotics
-osteoporosis
Social History:
___
Family History:
Two brothers died of MI in their ___
Physical Exam:
Physical Exam on Admssion:
VITALS: T98 BP160/56 R82 RR26 Sat83RA, 97/2L
GENERAL: well appearing female in NAD
HEENT: PERRL, EOMI
NECK: no carotid bruits, no JVD appreciated
CHEST: very thin, barrel chested, minimal subcutaneous fat. Her
CP is reproduced on palpation of the subxiphoid notch and along
the subcostal margin.
LUNGS: scattered posterior crackles appreciated.
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3 strength ___ throughout
Physical Exam on Discharge:
GENERAL: well appearing female in NAD
HEENT: PERRL, EOMI
NECK: no carotid bruits, no JVD appreciated
CHEST: very thin, barrel chested, minimal subcutaneous fat. CP
not reproducible with palpation.
LUNGS: scattered posterior crackles appreciated.
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3 strength ___ throughout
Pertinent Results:
Labs from Hospitalization:
___ 07:55PM BLOOD WBC-8.9 RBC-4.46 Hgb-13.0 Hct-40.0 MCV-90
MCH-29.1 MCHC-32.4 RDW-13.9
___ 07:55PM BLOOD ___ PTT-27.0 ___
___ 07:55PM BLOOD Glucose-125* UreaN-13 Creat-0.5 Na-142
K-4.3 Cl-102 HCO3-34* AnGap-10
___ 07:55PM BLOOD ALT-13 AST-23 LD(LDH)-156 CK(CPK)-94
AlkPhos-69 TotBili-0.6
___ 07:55PM BLOOD cTropnT-<0.01
___ 01:30PM BLOOD CK-MB-3 cTropnT-<0.01
_____________________________________________________
EKG: sinus rhythm, right axis deviation, RBBB, TWIV2-V4 (new),
old TWI III/F.
______________________________________________________
CTA CHEST: moderate calcifications of the coronary arteries and
aortic arch. No effusions, moderate cardiomegaly. No PE.
mod-severe pulm emphysema. Mild bronchiectasis at the left base.
No acute processes.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shorntess of
breath
3. Levofloxacin 250 mg PO Q24H
1 tab daily for the first 5 days of each months
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Levofloxacin 250 mg PO Q24H
1 tab daily for the first 5 days of each months
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shorntess of
breath
Discharge Disposition:
Home
Discharge Diagnosis:
atypical chest pain attributed to muscle strain
Secondary diagnoses:
COPD on home O2
bronchiectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
Comparison is made with a prior chest radiograph from ___.
CLINICAL HISTORY: Chest pain and hypoxia, assess for acute intrathoracic
process.
FINDINGS: Portable AP upright chest radiograph was obtained. The lungs are
hyperinflated which is suggestive of underlying COPD. There is no definite
evidence of pneumonia or overt CHF. There is mild left basilar opacity which
could represent atelectasis. The heart is moderately enlarged. Mediastinum
is normal. No pneumothorax. Bony structures are intact.
IMPRESSION: COPD with left basal opacity which could represent atelectasis.
Please refer to subsequent CT chest for further details.
Radiology Report
INDICATION: ___ with pleuritic chest pain, acute dyspnea, please
assess for PE.
TECHNIQUE: CT angiography protocol was obtained with initial non-enhanced and
subsequently arterially enhanced MDCT images. Axial, coronal, sagittal and
oblique reformats were acquired.
COMPARISON: CT of the chest from ___ from ___ and chest
radiograph from ___.
FINDINGS: Thyroid gland is normal. There are moderate atherosclerotic
calcifications of the coronary arteries, the aortic arch and descending
thoracic aorta as well as at the origins of the supra-aortic vessels. There is
no pneumomediastinum, pericardial or pleural effusion. There is moderate
cardiomegaly predominantly involving the right ventricle.
The pulmonary artery is normal without evidence of pulmonary embolism. No
acute aortic syndrome. Moderate-to-severe pulmonary emphysema. The airways
are patent to the subsegmental level; however, there is mild bronchiectasis at
the left anterior basal segment. There are atelectatic changes at the lung
bases. Bronchiectasis is also seen in the right middle lobe (series 3, image
52). Mild peribronchial wall thickening.
Compared to ___ there is an unchanged bronchiole and bronchiectasis with
mucus plugging involving all lobes. There is moderate-to-severe emphysema.
Diffuse osteopenia of the thoracic spine. No suspicious lytic or sclerotic
bony lesions. L3 kyphosis.
IMPRESSION:
1. No acute process including no evidence of pneumonia and no pulmonary
embolism.
2. Unchanged bronchiectasis and mucous plugging.
3. Severe centrilobular emphysema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CP SOB
Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH
temperature: 97.9
heartrate: 80.0
resprate: 26.0
o2sat: 98.0
sbp: 86.0
dbp: 37.0
level of pain: 10
level of acuity: 1.0 | ___ with severe COPD/bronchiectasis who is presenting with
circumferential chest pain after lifting heavy objects at home.
# CHEST PAIN: Her chest pain started when she was lifting heavy
objects and most likely to be musculoskeletal in orgin given
reproducibility on exam. She was found to have negative
troponins x2 and EKG with new tWI, but these are nonspecific in
the setting of old RBBB. Unlikely to be cardiac given unusual
circumferential distribution, long duration, and lack of
response to NTG. CTA did not show signs of acute PE or
dissection. Also unlikely due to pancreatitis given normal labs.
She was given aspirin and tramadol for pain. The pain subsided
overnight, and did not recur the next day. She had no
complaints of abdominal, pelvic or extremity pain and did not
have provocation of presenting or other pain when ambulating
with nursing prior to discharge. She was told to follow up with
her PCP as needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o HTN, prior CVA s/p aphasia and right hemiparesis on
Keppra who is blind presents to the ED from ___ for altered
mental status. She was recently admitted at ___ after
staff
noted that she was not as responsive as she normally is. She was
found to have a UTI/PNA and was discharged today back to the
facility. When she arrived back at the facility around 19:30
staff again noted that she was less responsive than normal so
they called EMS. Upon arrival patient will not open her eyes or
respond to questioning, but with move the left side of her body
in response to painful stimuli.
PNA/UTI --> ___ today --> SNF today --> Sent back here.
Repeat infectious workup negative. NCHCT negative.
Per SNF/discussion, pt still altered and feel uncomfortable
caring for her. At her baseline, the patient is a phasic but is
normally alert and able to sit up in bed. She spontaneously
opens
her eyes. And will not her head. Currently, the patient is just
lying in bed with eyes closed, not responding to any verbal
stimuli. Will respond to painful stimuli. Appears weak and
deconditioned. Will continue ABX course + admit. ___ need ___.
PER REVIEW ___ RECORDS:
Patient seen in their ED ___ and started on gentamycin for
pseudomonal UTI, w cultures resistant to levoflox. Returned to
___
on ___ w AMS, by the time she arrived was at baseline per
family. She was found to have CXR c/f infiltrate and was given
levoflox for this (NOT FOR UTI).
In the ED, initial vitals: 97.2 80 161/78 22 99% RA
- Exam notable for:
Warm to touch, will not respond to questioning
When attempting to open patient's eyes she will squeeze them
shut, pupils midline and focused on provider
___, no appreciable murmur, +JVD
CTA bilaterally
Abdomen soft, nontender
Bilateral ___ edema R>L, right hand swelling
- Labs notable for:
- CBC WNL
- CHEM WNL
- Coags WNL
- LFTs Alk phos 117, albumin 3.2, otherwise WNL
- Trop negative x1
- Lactate 1.0
- VBG 7.43/39
- UA lg leuk, 43 WBC, few bact, tr protein and blood
- Imaging notable for:
- CT HEAD W/O CON - no acute intracranial abnormality
- CXR - Bibasilar atelectasis. No pleural effusion or focal
consolidation to suggest pneumonia.
- Pt given: ceftriaxone 1g, keppra 500mg IV, vanco 1g IV
- Vitals prior to transfer: 98.3 99 184/83 22 100% RA
Upon arrival to the floor, the patient was more awake than what
was reported on arrival. Denied having pain. Understood some
___ that RN spoke.
Past Medical History:
- L CVA stroke w residual R-sided paralysis and aphasia
- Hypertension
- muscle spasms
- chronic constipation
- GERD
- depression
Social History:
___
Family History:
Unable to confirm due to patient's mental status.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: Temp: 98.5 (Tm 98.5), BP: 158/86, HR: 66, RR: 20, O2
sat:
96%, O2 delivery: Ra
GENERAL: alert, confused
HEENT: sclera anicteric, MMM
CARDIAC: regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: minimal scattered wheezes throughout lung fields, nl WOB
ABDOMEN: soft, non-distended, bowel sounds present, does not
wince to deep palpation
BACK: no visible decubitus skin breaks on cursory exam
GU: No foley, wearing diaper
EXTREMITIES: warm, well perfused, no cyanosis, RLE/RUE w
non-pitting edema
SKIN: warm, dry, no rashes or notable lesions
NEURO: unable to fully participate, alert, thought she was at
home, speaking a bit in ___, otherwise making babbling
noises, face grossly symmetric, ___ strength LUE/LLE, no
movement
elicited in RUE/RLE (per known baseline)
DISCHARGE PHYSICAL EXAM:
VS: T 97.3 BP 149/67 HR 77 RR 20 O2 95% on RA
GENERAL: Alert ___-speaking woman, appears somewhat
comfortable.
HEENT: Sclerae anicteric, MMM. Poor dentition.
HEART: RRR, normal S1/S2, no M/R/G.
LUNGS: Clear to auscultation anteriorly. Takes deep breaths in
response to commands.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: RUE dependent edema.
PULSES: 2+ radial pulses bilaterally
NEURO: Frequently stuttering and saying "oui oui oui" or
"non-non-non."
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 06:30AM GLUCOSE-113* UREA N-7 CREAT-0.5 SODIUM-145
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16
___ 06:30AM CALCIUM-8.9 PHOSPHATE-4.6* MAGNESIUM-1.9
___ 06:30AM WBC-7.7 RBC-3.73* HGB-11.2 HCT-35.1 MCV-94
MCH-30.0 MCHC-31.9* RDW-13.1 RDWSD-45.0
___ 06:30AM PLT COUNT-329
___ 02:06AM ___ PO2-38* PCO2-39 PH-7.43 TOTAL CO2-27
BASE XS-1
___ 02:06AM O2 SAT-69
___ 12:20AM URINE HOURS-RANDOM
___ 12:20AM URINE UHOLD-HOLD
___ 12:20AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:20AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-LG*
___ 12:20AM URINE RBC-3* WBC-43* BACTERIA-FEW* YEAST-NONE
EPI-1
___ 12:20AM URINE MUCOUS-OCC*
___ 09:09PM LACTATE-1.0
___ 09:04PM GLUCOSE-105* UREA N-7 CREAT-0.5 SODIUM-143
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
___ 09:04PM estGFR-Using this
___ 09:04PM ALT(SGPT)-25 AST(SGOT)-20 ALK PHOS-117* TOT
BILI-0.3
___ 09:04PM LIPASE-22
___ 09:04PM cTropnT-<0.01
___ 09:04PM ALBUMIN-3.2* CALCIUM-9.4 PHOSPHATE-4.1
MAGNESIUM-2.0
___ 09:04PM WBC-5.6 RBC-3.98 HGB-11.9 HCT-37.2 MCV-94
MCH-29.9 MCHC-32.0 RDW-13.0 RDWSD-44.6
___ 09:04PM NEUTS-50.6 ___ MONOS-10.1 EOS-1.8
BASOS-0.7 IM ___ AbsNeut-2.85 AbsLymp-2.05 AbsMono-0.57
AbsEos-0.10 AbsBaso-0.04
___ 09:04PM PLT COUNT-353
___ 09:04PM ___ PTT-25.9 ___
PERTINENT MICRO:
C. diff PCR (___): Negative
Urine Cx (___): Pending at time of discharge
BCx x2 (___): NGTD
PERTINENT IMAGING:
CT HEAD WITHOUT CONTRAST (___):
No acute intracranial abnormality.
UNILATERAL RUE VEIN ULTRASOUND (___):
No evidence of deep vein thrombosis in the right upper
extremity.
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-5.3 RBC-3.48* Hgb-10.6* Hct-32.8*
MCV-94 MCH-30.5 MCHC-32.3 RDW-13.4 RDWSD-45.6 Plt ___
___ 05:45AM BLOOD Glucose-115* UreaN-11 Creat-0.5 Na-146
K-4.0 Cl-108 HCO3-26 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
3. Baclofen 20 mg PO TID
4. Bethanechol 12.5 mg PO TID
5. Bisacodyl ___AILY:PRN Constipation - Second Line
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. sodium phosphates ___ gram/118 mL rectal DAILY:PRN
constipation ___ line
8. Famotidine 20 mg PO BID
9. Gabapentin 300 mg PO TID
10. Gentamicin 40 mg IV Q12H
11. Lactulose 30 mL PO BID
12. LevETIRAcetam 500 mg PO BID
13. Lisinopril 10 mg PO DAILY
14. melatonin 6 mg oral QHS
15. menthol-zinc oxide ___ % topical BID apply to buttocks
16. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
17. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
18. Polyethylene Glycol 17 g PO DAILY
19. Nystatin Oral Suspension 5 mL PO QID:PRN ?
20. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
oral DAILY
21. Sertraline 75 mg PO DAILY
22. Tamsulosin 0.4 mg PO QHS
23. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. CefTAZidime 1 g IV Q12H
___.
2. Lactulose 30 mL PO BID:PRN constipation
3. Baclofen 5 mg PO TID
RX *baclofen 5 mg 1 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
5. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
6. amLODIPine 10 mg PO DAILY
7. Bethanechol 12.5 mg PO TID
8. Bisacodyl ___AILY:PRN Constipation - Second Line
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Famotidine 20 mg PO BID
11. LevETIRAcetam 500 mg PO BID
12. Lisinopril 10 mg PO DAILY
13. melatonin 6 mg oral QHS
14. menthol-zinc oxide ___ % topical BID apply to buttocks
15. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
16. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
17. Nystatin Oral Suspension 5 mL PO QID:PRN ?
18. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
oral DAILY
19. Sertraline 75 mg PO DAILY
20. sodium phosphates ___ gram/118 mL rectal DAILY:PRN
constipation ___ line
21. Tamsulosin 0.4 mg PO QHS
22. HELD- Gabapentin 300 mg PO TID This medication was held. Do
not restart Gabapentin until you discuss with your primary care
doctor
23. HELD- TraMADol 50 mg PO Q8H:PRN Pain - Moderate This
medication was held. Do not restart TraMADol until you discuss
with your primary care doctor.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pseudomonas aeruginosa urinary tract infection
Toxic metabolic encephalopathy
SECONDARY DIAGNOSES:
History of cerebrovascular accident, with residual aphasia and
right sided paralysis
History of intraparenchymal bleed
History of hemiparesis with muscular contractions
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old woman with RUE swelling in setting of L CVA with R
hemiplegia.// Please evaluate for RUE DVT.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in both subclavian veins.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 97.2
heartrate: 80.0
resprate: 22.0
o2sat: 99.0
sbp: 161.0
dbp: 78.0
level of pain: UTA
level of acuity: 2.0 | Ms ___ is a ___ y/o ___ speaking woman with
past medical history of CVA (with residual aphasia and R-sided
paralysis, complicated by contractures/chronic pain), prior
intraparenchymal bleed, and urinary retention who presented as a
transfer with a chief complaint of altered mental status. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Penicillins / Levaquin
Attending: ___.
Chief Complaint:
CODE STROKE: difficulty walking
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: This is a ___ year old right handed woman with a history of
NIDDM, HTN, HCV with cirrhosis, fibromuscular dysplasia s/p left
carotid artery surgery and Asperger's syndrome who presents as a
CODE STROKE for 30 minutes of difficulty walking ("listing to
the
right") and dizziness. This feeling lasted for about 30 minutes
while she was walking from a conference to her hotel. On the way
to the hotel, she got cold and felt like she was gradually
losing
her strength. She felt that the sidewalk was tilting to the
right
and that she was listing to the right. During the episode, the
patient denied right-sided weakness but reports that she felt
discoordinated, "like I was listing to the right, like the side
walk was tipped." She initially endorsed that she may have had
some difficulty with word finding, but later stated that this
had
not occurred. When she returned to the hotel, she asked for help
and was taken to the ED. On arrival, a CODE STROKE was called.
FSBS was 277.
Patient has baseline difficulty walking in the mornings and uses
a cane to get to her office, but feels better by mid- day. She
is
currently visiting ___ for an Asperger's Disorder conference:
traveling is exhausting to her and that she brought her cane
along because she knew she would have difficulty ambulating. She
reports she did not speak to anyone all day at the conference.
She was seated for most of the day so didn't notice any
difficulty walking; however she reports she felt unwell for most
of the day and that she may have had an episode of hypoglycemia
this morning (has been having problems with frequent
hypoglycemia
lately).
Of note, patient has experienced episodes of dizziness in the
past. In ___, she noted dizziness and lightheadedness
associated with vision changes ("dimness" and blackness in the
___ her visual fields). These episodes started quickly and
lasted for several minutes. In addition, she also had several
episodes where turning her head to the right caused her to lose
vision in her left eye. Initially her dizziness was felt to be
due to peripheral vertigo or a side effect of pain medications.
However the episodes of vision loss a/w head turning prompted a
workup which revealed carotid fibromuscular dysplasia and a
"long
carotid artery" on the left for which she had surgery in ___.
Since her surgery, patient has had two episodes of difficulty
walking which she reports were similar to today (listing to the
right). During those episodes she also had difficulty talking,
during which she knew the words she wanted to say but could not
express them: for example, she couldn't remember her neighbor's
name. A workup at the time was negative for stroke.
Patient denies nausea, changes to vision, dizziness. During the
interview, she endorsed seeing flashing lights in her right eye;
denied photophobia or headache. Reports some cramps in her
right
leg today that have been happening recently. Had headache
yesterday when she got off the plane, believes it was from the
flight; went away without medications.
Past Medical History:
PMH:
- Hypertension
- Diabetes: ___ years, poorly controlled until recently.
- Fibromuscular Dysplasia (Diagnosed at the time of her
dizziness
workup, not believed to be the cause of her dizziness)
- Hepatitis C with cirrhosis and splenomegaly; chronic
thrombocytopenia
- Left carotid artery surgery (for "long carotid artery")
- Asperger's syndrome
- Angina
Social History:
___
Family History:
FHx:
-Brother: HTN, ___
-No family history of strokes
Physical Exam:
PHYSICAL EXAM:
Vitals: 133/96, HR 81, O2sat: 99% RA; T 98.2, RR 14
General: Laying on a stretcher with eyes closed; Awake,
cooperative, NAD.
HEENT: NC/AT
Neck: Supple, 5 inch scar on left neck from prior carotid
surgery. No carotid bruits. No JVD. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs, rubs or gallops
Abdomen: soft, nontender, nondistended
Extremities: chronic venous stasis changes in RLE. No edema.
Dorsal pedis pulses 2+. Right calf is TTP, negative ___ sign.
Neurologic:
-Mental Status: Alert, oriented x 3. Appears anxious [and later
depressed affect with psychomotor retardation]; became tearful
and tachypneic during interview but calmed down with
reassurance. 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 (watch, collar,
stethoscope). Able to read without difficulty; calculations
intact. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Pt. was able to register 3 objects
and recall ___ at 5 minutes. The pt. had good knowledge of
current events. Clock drawing intact with correct placement of
hands. There was no evidence of apraxia or neglect on naming
the events occuring in a scene.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation; diplopia
with leftward gaze [resolved as of examination the following
morning]. Fundi sharp with no papilledemia.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally. ___
negative 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. Right leg exam limited by pain
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 4 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Hesitant gait but narrow-based, normal
stride and arm swing. Able to walk in tandem without difficulty.
Romberg absent.
============
DISCHARGE PHYSICAL EXAM
Afebrile, VSS. No neurologic deficits.
Pertinent Results:
___ 07:20AM BLOOD WBC-2.9* RBC-4.50 Hgb-13.6 Hct-39.0
MCV-87 MCH-30.2 MCHC-34.8 RDW-14.9 Plt Ct-81*
___ 06:45PM BLOOD WBC-3.6* RBC-4.99 Hgb-14.9 Hct-42.9
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.7 Plt Ct-83*
___ 07:20AM BLOOD Plt Ct-81*
___ 07:20AM BLOOD ___ PTT-34.6 ___
___ 06:45PM BLOOD Plt Smr-LOW Plt Ct-83*
___ 06:45PM BLOOD ___ PTT-37.0* ___
___ 07:20AM BLOOD Glucose-88 UreaN-11 Creat-0.6 Na-142
K-3.5 Cl-108 HCO3-25 AnGap-13
___ 06:50PM BLOOD Creat-0.8
___ 06:45PM BLOOD UreaN-14
___ 07:20AM BLOOD ALT-45* AST-62* AlkPhos-62 TotBili-0.4
___ 07:20AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9 Cholest-PND
___ 06:45PM BLOOD Calcium-9.5 Phos-2.1* Mg-1.9
___ 06:45PM BLOOD TSH-2.2
___ 07:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:48PM BLOOD Glucose-136* Na-143 K-3.3 Cl-99
calHCO3-29
___ 07:20AM BLOOD %HbA1c-5.5 eAG-111
___ 07:20AM BLOOD Triglyc-107 HDL-49 CHOL/HD-2.7 LDLcalc-63
CT/CTA/CTP
No significant abnormality noted in the CTA of the head and neck
and in the CTP of the brain. There does appear to be mild mural
thickening surrounding the left carotid bulb, which may be
related to prior surgery. Please clinically correlate.
R lower extremity Doppler
No evidence of DVT in the right lower extremity.
MRI
FINDINGS: No evidence of acute infarct is seen on the
diffusion-weighted
images. There is no midline shift or mass effect. There is a
prominent
perivascular space in the right basal ganglion. Flow voids are
maintained. IMPRESSION: No acute abnormality is seen.
Medications on Admission:
Home Medications (pt does not know all home doses; will need to
confirm in AM)
-Januvia 100 mg once daily
-Lisinopril
-HCTZ
-Aspirin 325 mg
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily diabetes
3. Lisinopril 0 mg PO DAILY hypertension
please continue taking your previous home dose of this
medication
4. Hydrochlorothiazide 0 mg PO DAILY hypertension
please continue taking your previous home dose of this
medication
Discharge Disposition:
Home
Discharge Diagnosis:
Transient dizziness & giddiness of uncertain etiology.
Discharge Condition:
Mental Status: Clear and coherent. (with psychomotor
retardation)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. (has cane, can
balance and walk well without cane on our examination).
- Denies diplopia (including on Left-ward gaze) on discharge
examination.
Followup Instructions:
___
Radiology Report
TECHNIQUE: CTA of the head and neck. CTP. Examination is performed with
contrast.
HISTORY: Altered mental status.
COMPARISON: None.
FINDINGS: On the unenhanced head CT, there is no evidence for acute
intracranial hemorrhage or acute transcortical infarction. There is an
indeterminate lacune in the right external capsule. On the CTP, there is no
evidence for territorial perfusional defect. CTA of the intracranial
vasculature demonstrates no evidence for high-grade stenosis or occlusion. No
aneurysm is noted within limits of the examination.
CTA of the neck demonstrates no hemodynamically significant stenosis of the
right ICA. There is mild beading of the mid cervical ICA, which can be seen
in the setting of FMD. Evaluation of the left carotid artery demonstrates no
hemodynamically significant stenosis. Bilateral vertebral arteries are
patent.There does appear to be mild mural thickening surrounding the left
carotid bulb, which may be related to prior surgery. Please clinically
correlate.
IMPRESSION:
No significant abnormality noted in the CTA of the head and neck and in the
CTP of the brain. There does appear to be mild mural thickening surrounding
the left carotid bulb, which may be related to prior surgery. Please
clinically correlate.
Radiology Report
INDICATION: ___ female with right lower extremity swelling. Evaluate
for DVT.
COMPARISON: None.
FINDINGS: Grayscale, color, and spectral Doppler evaluation was performed of
the right lower extremity veins. There is normal phasicity of the common
femoral veins bilaterally. There is normal compression and augmentation of
the right common femoral, proximal femoral, mid femoral, distal femoral,
popliteal, posterior tibial and peroneal veins.
IMPRESSION: No evidence of DVT in the right lower extremity.
Radiology Report
TECHNIQUE: MRI of the brain without gad.
HISTORY: Left carotid surgery with diplopia. Evaluate for stroke.
COMPARISON: CTP from one day prior.
FINDINGS: No evidence of acute infarct is seen on the diffusion-weighted
images. There is no midline shift or mass effect. There is a prominent
perivascular space in the right basal ganglion. Flow voids are maintained.
IMPRESSION:
No acute abnormality is seen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LISTING TO RIGHT
Diagnosed with ALTERED MENTAL STATUS
temperature: 97.0
heartrate: 98.0
resprate: 20.0
o2sat: 98.0
sbp: 168.0
dbp: 89.0
level of pain: 0
level of acuity: 1.0 | MRI brain did not reveal any diffusion abnormality, i.e. no
evidence of stroke. CTA/CTP were unremarkable (including no
evidence of Left cervical carotid disease). Patient remained
hemodynamically/medically stable the following morning. No
arrythmia was detected on cardiac telemetry overnight. She was
asymptomatic and her Neurologic examination on morning rounds
was normal, with incidental note made of psychomotor retardation
and depressed affect. Social work is assisting with finding the
patient a flight home (she missed her 6am flight this morning
due to this hospitalization).
We are reassured that she did not have a stroke, and there is no
evidence of any focal neurologic deficit on examination. Her
recurrent episodes of imbalance and vertigo (s/p several
inpatient workups in ___ per the patient, and now a negative
stroke evaluation here) may be due to labyrinthine/vestibular
nerve disease. The patient believes that hypoglycemia is a
trigger and relates a history of intermittent low FSBG in the
___ at home early in the morning; this possibile contribution
should be considered by her PCP when she returns home (she was
not hypoglycemic here). Finally, the symptoms could in theory
represent TIA, but we feel that this is unlikely (deficits do
not localize well to one spot in the brainstem and/or
cerebellum, yet the episodes seem stereotyped and recurrent).
A hemoglobin A1c and fasting lipid panel were sent this morning
(part of routine r/o stroke workup) and are normal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Chest pain, Dyspnea, Hypoxic Respiratory Failure
Major Surgical or Invasive Procedure:
___: Coronary artery bypass grafts x3 (LIMA-LAD, SVG-LPDA,
SVG-D1); Endovascular saphenous vein harvest RLE, Skeletonized
RIMA harvest.
History of Present Illness:
___ transfer from ___, history of CAD, DMII,
COPD, positive nuclear stress test 1 month PTA with reportedly
ischemic changes in LAD region, A. fib on Xarelto, presented
with acute onset of shortness of breath, diaphoresis and
crushing substernal chest pain. Patient started on diltiazem
drip at 15 mg/h and nitroglycerin drip at 20 mcg/h. Elevated
d-dimer prior to arrival as well as elevated troponin. Lab work
notable for Troponin T 0.59, elevated, proBNP 7600 elevated, TSH
reflex 5.79.
Per outpatient reports, patient has had 1 week of chest
heaviness when laying down at night, relieved by sitting upright
starting approximately ___, worse with taking deep
breathing. Per outpatient report today, patient has worsening
chest pain and shortness of breath and difficulty laying down to
sleep. Patient takes Xarelto 20 mg once daily atorvastatin 40 mg
once daily diltiazem 240 ER, Lasix 40 mg once daily Synthroid
___ mcg once daily.
Chest tightness worse over the past 4 days, in the setting of
recent plane ride from ___.
On arrival to ED had CP refractory to nitro drip, was originally
planned for cath. However, pain resolved, was weaned off of
nitro.
Also on arrival to ED had sudden onset SOB, hypoxia to 60's,
increased tachycardia, required intubation; felt that she had
flash pulmonary edema. Intubation completed at bedside with
direct laryngoscopy, gum elastic bougie, 7.5 endotracheal tube
at approximately 25 cm at the lips. OG tube inserted.
Patient taken for stat CTA which demonstrated concern for
possible multifocal pneumonia as well as diffuse pulmonary edema
and cardiomegaly. No segmental PE identified.
Past Medical History:
PMH: HTN, DMII-diet controlled, Cardiac History: LAD disease by
stress ECHO ___, Afib on xarelto/ diltiazem,
3. Other PMH: RLS, GERD, Hypothyroid
Social History:
___
Family History:
Mother had ___ Cancer, passed at ___.
Father passed at age ___ from brain tumor.
Maternal Grandmother had MI ___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
Pulse:86 Resp:16 O2 sat:97% on vent
B/P Right:106/61
Height: Weight: 76 kgs
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [] bowel sounds
+
[]
Extremities: Warm [], well-perfused [] Edema [] _____
Varicosities: None []
Neuro: Grossly intact []
Pulses:
Femoral Right:(IABP) Left: 1+
DP Right: Left:
___ Right:(Doppler) Left: (Doppler)
Radial Right: 2+ Left:2+
DISCHARGE PHYSICAL EXAM:
===================================
Vital Signs and Intake/Output:
Tcurrent: 97.5F Tmax 98.6F B/P: 96/61-120/48 HR/Rhythm:
67,SR -108, Afib RR: 18
SaO2: 94% RA
wt 76.3kg (Pre-op wt 76 kg)
In 1010 Out 900
Physical Examination:
General/Neuro: NAD [x] A/O x3 [x] non-focal [x]
Cardiac: RRR [] Irregular [x] Nl S1 S2 []
Lungs: CTA [] No resp distress [x] diminished in bases
Abd: NBS [x]Soft [x] ND [x] NT [x]
Extremities: Pulses doppler [] palpable [x] 1+ Edema [x]1+ BLE
Wounds: Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena []
Leg: Right [x] Left[] CDI [x] no erythema or drainage
[x]
Pertinent Results:
ADMISSION LABS:
===============
___ 01:04AM BLOOD WBC-16.7* RBC-3.57* Hgb-11.6 Hct-34.6
MCV-97 MCH-32.5* MCHC-33.5 RDW-13.9 RDWSD-48.5* Plt ___
___ 01:04AM BLOOD Neuts-79.4* Lymphs-14.6* Monos-5.2
Eos-0.1* Baso-0.2 Im ___ AbsNeut-13.22* AbsLymp-2.44
AbsMono-0.87* AbsEos-0.02* AbsBaso-0.04
___ 01:04AM BLOOD Glucose-249* UreaN-25* Creat-0.9 Na-141
K-4.6 Cl-100 HCO3-22 AnGap-19*
___ 09:23PM BLOOD CK(CPK)-64
___ 09:23PM BLOOD cTropnT-0.72*
___ 09:23PM BLOOD CK-MB-7
___ 06:45PM BLOOD CK-MB-3 proBNP-8755*
___ 01:04AM BLOOD Calcium-8.9 Phos-6.0* Mg-1.9
___ 02:19AM BLOOD Type-CENTRAL VE Temp-36.9 pO2-35* pCO2-44
pH-7.38 calTCO2-27 Base XS-0
___ 02:19AM BLOOD Lactate-2.0
___ 08:38PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-2
___ 08:38PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 08:38PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:53PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 05:24AM BLOOD TSH-5.9*
___ 08:44AM BLOOD Free T4-1.7
___ 05:24AM BLOOD T4-6.2
___ 02:04PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 02:04PM BLOOD HCV Ab-NEG
DISCHARGE LABS:
===============
___ 05:52AM BLOOD WBC-10.7* RBC-2.66* Hgb-8.4* Hct-26.4*
MCV-99* MCH-31.6 MCHC-31.8* RDW-14.7 RDWSD-50.4* Plt ___
___ 03:20AM BLOOD WBC-13.9* RBC-2.68* Hgb-8.7* Hct-26.5*
MCV-99* MCH-32.5* MCHC-32.8 RDW-14.5 RDWSD-50.0* Plt ___
___ 05:52AM BLOOD ___
___ 03:20AM BLOOD ___
___ 04:38AM BLOOD ___
___ 05:38AM BLOOD ___
___ 05:52AM BLOOD Glucose-98 UreaN-22* Creat-0.7 Na-137
K-4.2 Cl-94* HCO3-32 AnGap-11
___ 03:20AM BLOOD Glucose-86 UreaN-20 Creat-0.5 Na-138
K-3.9 Cl-97 HCO3-28 AnGap-13
___ 04:07AM BLOOD ALT-64* AST-39 AlkPhos-140* Amylase-28
TotBili-0.4
___ 04:09AM BLOOD ALT-942* AST-334* LD(LDH)-589*
AlkPhos-175* TotBili-0.6
___ 04:07AM BLOOD Lipase-26
___ 05:52AM BLOOD Mg-2.0
___ 04:38AM BLOOD Phos-3.5 Mg-2.0
IMAGING:
========
PA/LAT CXR ___
In comparison with study of ___, there is little change
in the
appearance of the heart and lungs except for slightly improved
lung volumes. Continued enlargement the cardiac silhouette with
mild elevation of pulmonary venous pressure in bilateral pleural
effusions with underlying compressive atelectasis. No evidence
of pneumothorax.
CTA CHEST Study Date of ___ 6:18 ___
FINDINGS: Newly placed endotracheal tube tip terminates
approximately 2 cm above the carina. Enteric tube traverses
into the stomach with tip out of view of this exam.
The aorta is normal in course and caliber.
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 or axillary lymphadenopathy. There
is prominence of the mediastinal and hilar lymph nodes, none of
which meet CT criteria for enlargement.
The left atrium may be is somewhat dilated. There is no
definite pericardial effusion. There are moderate to large
bilateral, nonhemorrhagic pleural effusions, right greater than
left. There is smooth septal and fissural thickening with
thickening of the bronchial walls and diffuse ground-glass
opacities throughout the lungs consistent with moderate to
severe pulmonary edema. There is adjacent bibasilar compressive
atelectasis.
The airways are patent to the subsegmental level.
Limited images of the upper abdomen shows prior gastric bypass
without acute pathology.
No lytic or blastic osseous lesion suspicious for malignancy is
identified.
IMPRESSION: No evidence of pulmonary embolism or acute aortic
abnormality.
Moderate to large bilateral, nonhemorrhagic pleural effusions,
right
greater than left. Smooth septal and fissural thickening with
thickening the bronchial walls and diffuse ground-glass
opacities throughout the lungs
consistent with moderate to severe pulmonary edema. Adjacent
bibasilar
compressive atelectasis.
TTE ___ at 9:04:05 AM
Limited study to assess global and regional LV function.
There is moderate regional left ventricular systolic
dysfunction with severe hypokinesis to akinesis of the mid to
distal septum and apical segments. The heart was incompletely
imaged. Differential diagnosis includes LAD territory infarction
more likely than takotsubo given extension of the septal
hypokinesis to the base, but without additional views cannot be
certain. Estimated visual LVEF <=30%. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
Right ventricular apex is hypokinetic. There is a very small
echodense pericardial effusion versus fat pad. A right pleural
effusion is present.
There were no prior studies for comparison.
CONCLUSION: Suboptimal image quality. Moderate regional left
ventricular systolic dysfunction c/w LAD territory ischemia
(versus takotsubo cardiomyopathy). Additional views needed to
refine differential. Full study with lumason is pending. Valves
incompletely imaged.
Study ammended on ___ at 1PM after reviewing with Dr. ___
___ the anterolateral wall called akinetic in the mid segment
(coronary angiography demonstrated proximal LAD and LCx
disease). Lumason study being performed to evaluate for apical
thrombus.
Portable TTE Done ___ at 2:13:24 ___
There is severe regional left ventricular systolic dysfunction
with severe hypokinesis/akinesis of the entire septum, distal
ventricle and apex. The mid anterior, inferior, and lateral
walls are hypokinetic. The remaining segments contract normally
(LVEF = 21 % by biplane). No masses or thrombi are seen in the
left ventricle. There is focal hypokinesis of the apical free
wall of the right ventricle. There is no aortic valve stenosis.
Moderate (2+) mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. There is
moderate pulmonary artery systolic hypertension.
IMPRESSION: Severe regional left ventricular systolic
dysfunction c/w multivessel CAD. Moderate mitral regurgitation.
Moderate pulmonary hypertension. No ventricular thrombus seen,
but a laminated apical thrombus cannot be excluded on the basis
of this study (CMR woud be more sensitive if it would change
clinical management.
BILAT LOWER EXT VEINS Study Date of ___ 4:43 ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Evaluation of the right common femoral vein is mildly
limited due to overlying bandage.
Cardiac Catheterization & Endovascular Procedure Report ___
Coronary Anatomy
Dominance: Left
The ___ had no angiographically apparent CAD. The LAD had
proximal 90% stenosis followed by
diffuse 60% stenosis and then 80% stenosis in the distal segment
which appeared to be a 1.5 to 2.0 mm
vessel. The Cx had origin 40% stenosis and the mid vessel had
80% eccentric stenosis. The first LPL
branch had mild disease. The second LPL had origin 90% stenosis.
The third LPL had mild disease. The
RCA was small and nondominant.
Impressions:
1. LAD and Cx disease in a left dominant system with reduced
LVEF and diabetes.
2. Elevated filling pressures and reduced cardiac output.
3. Successful IABP insertion.
RUQUS w Doppler ___
Liver: The hepatic parenchyma is within normal limits. No
focal liver
lesions are identified. There is no ascites. Bilateral pleural
effusions are noted.
Bile ducts: There is no intrahepatic biliary ductal dilation.
The common
hepatic duct measures 6 mm.
Gallbladder: Gallbladder is not identified.
Pancreas: The pancreas is obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and
measures 8.7 cm.
Kidneys: The right kidney measures 12.3 cm. The left kidney
measures 11.9 cm. No stones, masses, or hydronephrosis are
identified in either kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate
direction.
Right and left portal veins are patent, with antegrade flow.
The main, right, and left hepatic arteries are patent, with
abnormal waveforms which is most likely related to the intra
aortic balloon pump recently placed. Splenic vein and superior
mesenteric vein are not identified due to overlying bowel gas.
IMPRESSION:
1. Patent hepatic vasculature. Small branch emboli cannot be
detected by
ultrasound, CTA or MRI would be required.
2. Bilateral pleural effusions.
MICROBIOLOGY:
=============
No positive cultures
URINE CULTURE (Final ___: NO GROWTH.
___ 11:57 pm URINE URINE CULTURE: Pending
Medications on Admission:
1. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
2. Rivaroxaban 20 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Sucralfate 1 gm PO DAILY
10. rOPINIRole 3 mg PO QHS rls
11. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
12. TraZODone 50 mg PO QHS:PRN Insomnia
13. Lidocaine 5% Patch 1 PTCH TD QAM LBP
Discharge Medications:
1. Acetaminophen 1000 mg PO QID:PRN Pain - Mild
2. Aspirin EC 81 mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. Carvedilol 3.125 mg PO BID
hold if SBP<90 or HR<55
5. Docusate Sodium 100 mg PO BID
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Metolazone 5 mg PO DAILY Duration: 10 Days
8. Polyethylene Glycol 17 g PO DAILY
9. Potassium Chloride 20 mEq PO Q12H
10. Senna 17.2 mg PO DAILY
11. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*20 Tablet Refills:*0
12. ___ MD to order daily dose PO ASDIR atrial
fibrillation
goal INR ___. Warfarin 0.5 mg PO ONCE AFib Duration: 1 Dose
goal INR ___ (please give ___ if not given prior to rehab
discharge)
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
15. rOPINIRole 3 mg PO QHS:PRN restless leg
16. Sucralfate 1 gm PO QAM
17. Atorvastatin 40 mg PO QPM
18. Furosemide 40 mg PO DAILY
Should be continued for 10 days, then reevaluate for decreased
dosing to 20mg daily
19. Levothyroxine Sodium 150 mcg PO DAILY
20. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Coronary Artery Disease s/p CABGx3
Secondary:
PMH:CAD, CHF, DM type 2-diet controlled, PAF on xarelto,
Hypothyroidism, GERD, HTN, Anxiety, Depression
PSH: Gastric bypass surgery, renal stone removal, lithotripsy,
cholecystectomy, partial thyroidectomy, left ankle
fracture-repair
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema - 1+BLE
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA chest
INDICATION: ___ with SOB, cp// 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) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP =
9.1 mGy-cm.
2) Spiral Acquisition 3.9 s, 30.6 cm; CTDIvol = 15.4 mGy (Body) DLP = 470.5
mGy-cm.
Total DLP (Body) = 480 mGy-cm.
COMPARISON: None
FINDINGS:
Newly placed endotracheal tube tip terminates approximately 2 cm above the
carina. Enteric tube traverses into the stomach with tip out of view of this
exam.
The aorta is normal in course and caliber.
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 or axillary lymphadenopathy. There is prominence
of the mediastinal and hilar lymph nodes, none of which meet CT criteria for
enlargement.
The left atrium may be is somewhat dilated. There is no definite pericardial
effusion. There are moderate to large bilateral, nonhemorrhagic pleural
effusions, right greater than left. There is smooth septal and fissural
thickening with thickening of the bronchial walls and diffuse ground-glass
opacities throughout the lungs consistent with moderate to severe pulmonary
edema. There is adjacent bibasilar compressive atelectasis.
The airways are patent to the subsegmental level.
Limited images of the upper abdomen shows prior gastric bypass without acute
pathology.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Moderate to large bilateral, nonhemorrhagic pleural effusions, right
greater than left. Smooth septal and fissural thickening with thickening the
bronchial walls and diffuse ground-glass opacities throughout the lungs
consistent with moderate to severe pulmonary edema. Adjacent bibasilar
compressive atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with R IJ CVL// check R IJ CVL
TECHNIQUE: Single frontal view of the chest
COMPARISON: No prior chest radiographs available comparison. Reference made
to chest CT performed earlier today, ___ at 18:30
FINDINGS:
Right internal jugular central venous catheter terminates in the region of the
mid to low SVC, without evidence of pneumothorax. Endotracheal tube
terminates approximately 1 cm above the carina, suggest withdrawal by
approximately 2 cm for more optimal positioning. Enteric tube courses below
the diaphragm, out of the field of view. Severe bilateral pulmonary opacities
are likely consistent with severe pulmonary edema, bilateral pleural
effusions, ARDS could be present. Cardiac silhouette size is mildly enlarged.
Mediastinal contours are grossly unremarkable.
IMPRESSION:
Right IJ line terminates in the region of the mid to distal SVC. Endotracheal
tube terminates approximately 1 cm above the carina, consider withdrawal by
approximately 2 cm for more optimal positioning.
Severe bilateral pulmonary opacities likely due to severe pulmonary edema and
bilateral pleural effusions, ARDS could be present.
Mild cardiomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with IABP placed in cath lab, significant CAD.
Evaluate placement of IABP.
TECHNIQUE: Frontal views of the chest.
COMPARISON: Chest x-ray ___. CTA chest ___.
FINDINGS:
The intra-aortic balloon pump terminates in the proximal descending aorta.
The right internal jugular catheter terminates in the mid SVC. The ET tube
terminates 4 cm from the carina. An enteric tube extends below the level of
the diaphragm and out of the field of view.
The heart is mildly enlarged. Bilateral pleural effusions are small.
Diffuse, bilateral parenchymal opacities, most compatible with pulmonary
edema, have improved. No pneumothorax.
IMPRESSION:
1. The IABP terminates in the proximal descending aorta.
2. Interval improvement in pulmonary edema.
3. Small, bilateral pleural effusions.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with multivessel CAD, a fib, HFrEF being
evaluated for CABG// rule out DVT bilaterally prior to CABG
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: No relevant comparison.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Examination of the right common
femoral vein is mildly limited due to overlying bandage. 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. Evaluation of the right common femoral vein is mildly limited due to
overlying bandage.
Radiology Report
EXAMINATION: CHEST (PRE-OP AP ONLY)
INDICATION: ___ year old woman with CAD and NSTEMI, planned for cardiac
surgery.// Please assess for infiltrate, edema, effusion. Pre-op. Surg:
___ (CABG). Evaluate for infiltrate, edema, or effusion.
TECHNIQUE: Frontal view of the chest.
COMPARISON: Chest x-rays ___ through ___. Chest CT
___.
FINDINGS:
Mild cardiac enlargement is stable. Bilateral pleural effusions remain small.
Diffuse, bilateral parenchymal opacities, most compatible with pulmonary
edema, are unchanged. No pneumothorax.
Compared to the most recent prior study, the ET tube and NG tube have been
removed. The right IJ catheter terminates in the mid SVC. The intra-aortic
balloon pump terminates in the proximal descending aorta.
IMPRESSION:
1. Unchanged pulmonary edema.
2. Small, bilateral pleural effusions.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: evaluate for arterial blood clots in hepatic blood supply
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: None.
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. No focal liver
lesions are identified. There is no ascites. Bilateral pleural effusions are
noted.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 6 mm.
Gallbladder: Gallbladder is not identified.
Pancreas: The pancreas is obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 8.7 cm.
Kidneys: The right kidney measures 12.3 cm. The left kidney measures 11.9
cm. No stones, masses, or hydronephrosis are identified in either kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Right and left portal veins are patent, with antegrade flow.
The main, right, and left hepatic arteries are patent, with abnormal waveforms
which is most likely related to the intra aortic balloon pump recently placed.
Splenic vein and superior mesenteric vein are not identified due to overlying
bowel gas.
IMPRESSION:
1. Patent hepatic vasculature. Small branch emboli cannot be detected by
ultrasound, CTA or MRI would be required.
2. Bilateral pleural effusions.
Radiology Report
INDICATION: ___ year old woman with S/P CABG// effusion, pneumothx Contact
name: ___, Phone: 1
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Patient is post CABG. The tip of the endotracheal tube projects over the mid
thoracic trachea. The feeding tube extends to the proximal stomach however
continued advancement is recommended to ensure the side port lies beyond the
GE junction. Bilateral chest tubes and mediastinal drains are present. The
tip of the Swan-Ganz catheter projects over the right pulmonary artery.
No focal consolidation, pleural effusion or pneumothorax is identified. The
size of the cardiomediastinal silhouette is within normal limits.
IMPRESSION:
Expected postoperative changes as described above. Advancement of the feeding
tube is recommended to ensure that the side port lies beyond the GE junction.
Radiology Report
INDICATION: ___ year old woman post open heart post chest tube removal.// R/O
pneumo
COMPARISON: ___
IMPRESSION:
The endotracheal tube, Swan-Ganz catheter, chest tubes, and enteric tubes have
been removed. There is a right IJ central line with the distal tip at the
cavoatrial junction. There is unchanged cardiomegaly. There are small
bilateral pleural effusions which are new. There is subsegmental atelectasis
at the lung bases. There is mild pulmonary edema. There are no
pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman s/p CABG// eval for effusion/pneumo
IMPRESSION:
In comparison with study of ___, there is little change in the
appearance of the heart and lungs except for slightly improved lung volumes.
Continued enlargement the cardiac silhouette with mild elevation of pulmonary
venous pressure in bilateral pleural effusions with underlying compressive
atelectasis. No evidence of pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Elevated troponin
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Hypoxemia, Heart failure, unspecified
temperature: 98.5
heartrate: 135.0
resprate: 30.0
o2sat: 92.0
sbp: 115.0
dbp: 87.0
level of pain: 8
level of acuity: 2.0 | ___ year old woman with CAD, CHF, DM2, AF (on xarelto) who
presented with hypoxic respiratory failure, found to have
elevated troponin. Admitted from ED w/Acute on chronic HF
exacerbation/Hypoxic respiratory failure: Chest CTA with
evidence of severe pulmonary edema, no PE. BNP elevated. Likely
flash pulmonary edema in setting of atrial fibrillation with RVR
and acute on chronic HFrEF. Given broad spectrum abx in ED given
c/f multifocal PNA, d/c'ed after transition to CCU. Initially
intubated, and extubated after being diuresed with Lasix gtt.
IABP placed during cardiac cath to decrease afterload.
Cardiac cath ___ with significant disease: LCx 40% proximal and
90% mid; LAD 95% proximal, 85-90% mid; left dominant; RHC with
elevated filling pressures; Likely significant CAD iso
CHF/elevated EDP with afib with RVR driving demand & ischemia.
Trop peak 1.93. C-surg consulted and CABG performed ___.
Atorvastatin 40 mg increased to atorvastatin 80 mg. Medically
managed during evaluation for cardiac
surgery.
On ___ brought to the operating room for coronary artery bypass
grafting. Please see operative report for details, in summary
she had: Urgent coronary artery bypass grafts x3 (LIMA-LAD,
SVG-LPDA, SVG-D1); Endovascular saphenous vein harvest RLE,
Skeletonized RIMA harvest. She tolerated the operation well and
post-operatively was transferred to the cardiac surgery ICU in
stable condition on multiple pressors, inotropes and with IABP.
On POD1 she weaned from the IABP and it was removed. Following
that she weaned off her inotropic support, her sedation was
stopped, she awoke neurologically intact and was extubated on
POD1. All tubes lines and drains were removed per cardiac
surgery protocol without complication. On POD2 she was
transferred to the step down floor for continued care and
recovery. She was initially started on Metoprolol, but this was
changed to Coreg due to her ischemic cardiomyopathy. She has
not been started on ACE-inhibitor due to limited blood pressure,
and will follow up with Heart Failure cardiology Dr. ___
___ as an outpatient for further medication optimization.
Coumadin was started for her paroxysmal atrial fibrillation
(goal INR ___ and should be continued for 1 month
postoperatively prior to transition back to her preoperative
Xarelto. Her preoperative HgbA1c was 6.3 in setting of no
active DM medications. She briefly was restarted on her prior
Glipizide with PRN SSI, but will be transitioned back to diet
controlled DM management with daily FBS glucose checks x 4 days
at rehab with plan to resume Glipizide for glucose >160. On the
step down floor she worked with nursing and physical therapy to
improve her strength and endurance. She progressed and by POD 7,
she was ready for discharge to ___ -
___ in good condition with appropriate follow up
instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
mental status change
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo h/o of DM2, HTN, GOUT presents with 2 day history of
mental status changes per family. Patient's wife and son notes
that starting ___, the patient exibited trouble with focus
in conversation. He would begin telling a story and fail to
complete it. He also exhibited word finding difficulties with
words he commonly uses (eg suspenders describing them as 'clip
ons'). Denies hemiparesis, muscle weakness, tongue weakness or
facial asymmetry. He was also described as having less energy
as usual. He has never had these symptoms prior. He notes no
changes to his medications except a new cough medication for an
URI improving on its own. He currently states that he no longer
has confusion or word finding difficulties.
Past Medical History:
BASAL CELL CARCINOMA
CATARACT
DIABETES MELLITUS
GASTROESOPHAGEAL REFLUX
GLAUCOMA
HYPERLIPIDEMIA
HYPERTENSION
KIDNEY STONE
PARTIAL KNEE REPLACEMENT
PROSTATITIS
SYNCOPE (vasovagal episodes distant past)
H/O ARTHROSCOPY
GOUT
HYPOGONADISM
R EYE GLAUCOMA
ERECTILE DYSFUNCTION
Social History:
___
Family History:
Father died of renal failure attributable to toxic ingestion.
None contributory otherwise.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS - 98.5 147/62 81 16 99% RA FSBG: 121
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, S1 S2 with a ___ holosystolic murmur
heard loudest on the ULSB stable noted before
ABDOMEN - NABS, obese, soft/NT/ND, no masses or HSM, no
rebound/guarding, mild tenderness in deep palpation in the
suprapubic region. No CVA tenderness.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), 2+ peripheral edema
SKIN - erythema on the right anterior shin (stable per patient)
LYMPH - no cervical or supraclavicular LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, gait steady but
limited due to heel pain, 3x3 memory for ___ mailman and
honesty, can name months backwards but struggles at ___, knows
President but required prompting for ___.
RECTAL - non-tender to palpation of prostate, no nodules
appreciated, not enlarged
PHYSICAL EXAM ON DISCHARGE
VS - Tmax 98.5 T curr 98 128/66 63 18 98% RA Urine output
overnight (7 hours) = 450 ml
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, S1 S2 with a ___ holosystolic murmur
heard loudest on the ULSB stable and noted prior
ABDOMEN - NABS, obese, soft/NT/ND, no masses or HSM, no
rebound/guarding. No CVA tenderness.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), 2+ peripheral edema
SKIN - erythema on the right anterior shin (unchanged from
admission)
NEURO - awake, A&Ox3, normal go-n-go test, knows President and
opponent
Pertinent Results:
___ 01:31PM URINE HOURS-RANDOM UREA N-698 CREAT-140
SODIUM-61 POTASSIUM-40 CHLORIDE-46
___ 01:31PM URINE OSMOLAL-482
___ 01:31PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
___ 01:31PM URINE RBC-<1 WBC-14* BACTERIA-MANY YEAST-NONE
EPI-<1
___ 01:31PM URINE HYALINE-3*
___ 01:31PM URINE MUCOUS-RARE
___ 12:37PM LACTATE-1.4
___ 12:30PM GLUCOSE-263* UREA N-59* CREAT-2.5* SODIUM-139
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17
___ 12:30PM LD(LDH)-176
___ 12:30PM IRON-18*
___ 12:30PM calTIBC-235* HAPTOGLOB-410* FERRITIN-420*
TRF-181*
___ 12:30PM WBC-11.8* RBC-3.24* HGB-9.5* HCT-28.2* MCV-87
MCH-29.2 MCHC-33.6 RDW-13.2
___ 12:30PM NEUTS-82.2* LYMPHS-10.5* MONOS-6.9 EOS-0.3
BASOS-0.1
___ 12:30PM PLT COUNT-258
___ 12:30PM RET AUT-1.5
CHEST (PA & LAT)
FINDINGS: Frontal and lateral radiographs of the chest were
acquired. Lung volumes are slightly low. There is minimal
right basilar atelectasis. The lungs are otherwise clear. Mild
cardiomegaly is increased compared to the prior study from
___. Aortic knob calcification is seen. The
mediastinal contours are normal. There are no pleural
effusions. No
pneumothorax is seen.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. brimonidine-timolol *NF* 0.2-0.5 % ___ BID
4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
5. Diazepam 2 mg PO Q 12H
6. Doxazosin 4 mg PO BID
7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
8. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral 1xday
9. Finasteride 5 mg PO DAILY
10. Fluocinonide 0.05% Ointment 1 Appl TP BID
11. Furosemide 20 mg PO DAILY
12. GlipiZIDE 5 mg PO DAILY
13. Lisinopril 40 mg PO DAILY
14. spironolacton-hydrochlorothiaz *NF* ___ mg Oral DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Doxazosin 4 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluocinonide 0.05% Ointment 1 Appl TP BID
6. Furosemide 20 mg PO DAILY
7. GlipiZIDE 5 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Acetaminophen ___ mg PO Q8H:PRN pain, fever
10. Ciprofloxacin HCl 250 mg PO Q24H
Day 1 = ___. brimonidine-timolol *NF* 0.2-0.5 % ___ BID
12. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL 1XDAY
13. spironolacton-hydrochlorothiaz *NF* ___ mg Oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Urinary tract infection
Altered mental status
Acute kidney injury
.
Secondary:
Plantar Fasciitis
Diabetes
Hypertension
Hyperlipidemia
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Altered mental status. Assess for pneumonia.
COMPARISON: Chest radiograph from ___.
FINDINGS: Frontal and lateral radiographs of the chest were acquired. Lung
volumes are slightly low. There is minimal right basilar atelectasis. The
lungs are otherwise clear. Mild cardiomegaly is increased compared to the
prior study from ___. Aortic knob calcification is seen. The
mediastinal contours are normal. There are no pleural effusions. No
pneumothorax is seen.
IMPRESSION:
1. No acute cardiac or pulmonary process.
2. Mild cardiomegaly, stable to mildly increased compared to the prior study
from ___.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: ALTERED MENTAL STATUS
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, URIN TRACT INFECTION NOS
temperature: 98.0
heartrate: 104.0
resprate: 16.0
o2sat: 96.0
sbp: 146.0
dbp: 52.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ is a pleasant ___ yo M with hx HTN, DM2 on
glipizide, prostatitis presents with 2 day history of acute
mental status change and a + urine dipstick.
# Mental status changes: The patient exhibited an acute episode
of mental status change for 2 days characterized by a lower
ability to focus, change in cognition without a history of
dementia and fluctuating severity. The patient recently
suffered from an URI most likely from a viral etiology. His
normal PCP was out of town, and he was prescribed
codeine-guaifenesin by another practitioner. The patient admits
using the entire bottle over the same 2 day period, coinciding
with the start of his mental status changes. In the ED, his UA
was suggestive of a possible UTI. His rectal exam did not
reveal active protastatitis. He denied any symptoms of dysuria
or increased urinary frequency. He was not hypoglycemic on
admission. His Chest XRAY did not show any cardiopulmonary
concerns. Neurology was also consulted--they agreed with the
assessment that the mental status changes were most likely
attributable to ongoing UTI and/or medication side effect over
an acute neurological cause. We opted to discontinue his cough
medication and bolus him with 2 L of NS to address his ___. We
also asked him to stop taking benzodiazepines, which he had been
taking for muscle spasm. We opted to treat a presumptive UTI
complicated by ___. He received 1 gm ceftriaxone in the ED. On
the floor, we transitioned him to ciprofloxacin renally dosed
given his history of CKD. He states that he was back to his
normal state of mentation. Neurological exam was supportive of
such. We will continue with a 7 day total course of renally
dosed ciprofloxacin.
# ___: Patient has exhibited a greater than 0.3 increase in
creatinine from baseline consistent with ___. The most likely
etiology is prerenal azotemia in the setting of decreased PO
intake related to acute mental status changes. Urine lytes
were equivocal given that patient's diuretics use. His
creatinine normalized to his baseline of 2.1 with 2 L NS by the
second day. He was making good urine with 450 ml overnight. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with metastatic breast cancer s/p 5 cycles
AC,
more recently CMF, and mastectomy in ___ most recently seen
in clinic with enlarging mass draining from R axilla (open wound
since surgery) now presents with acute worsening of pleuritic
chest pain and shortness of breath found to have worsening
metastatic disease in the lungs/axilla and a new pathologic
sternal fracture. She had a wound vac over the open wound until
several weeks ago.
She states that since the mastectomy she has been doing chores
around the house and having worsening pain gradually over the
sternum, but over the past 2 days it has become unbearable. She
notes no specific trauma or injury or fall recently however. 2
weeks ago she had a URI but currently no cough, no nasal
congestion, no headache, no fever or sore throat. She believes
her dyspnea is purely related to the pain she feels when she
takes deep breaths so she is trying to breathe very shallowly.
She has no lower extremity edema. Pain is worse with moving but
there is no particular position that makes it worse. She is able
to lie flat without worsening of dyspnea. Regarding the surgical
wound she has been dressing it daily with saline soaked gauzes
and has not noted a change in drainage or color or odor. She
reports some ongoing clear drainage from the wound but it is not
copious. The wound does not seem to be painful at this point
particularly incomparison to the sternal pain.
ED COURSE:
v/s: HR 57 - 74 BP ___ AF, RR ___ 100% on RA
Labs showed trop <0.01, chem/LFTs unremarkable. WBC 10.5 with 85
% pmns, INR 1.0. Hct 34 from 35 on ___, plts 205. She recieved
total 1.5mg IV dilaudid, 1L NS, 50mcg fentanyl, 0.5mg IV ativan.
Her chest CT with contrast showed no PE. Interval increase in
RUL
mets with new pulm lesions in LUL. Interval increase in size of
multiple R ax LN c/w disease progression. She also had a new
displaced sternal fracture. Per ED physician ___ did
have pericardial effusion but no e/o tamponade physiology. EKG
showed sinus bradycardia, unchanged from prior.
On the floor, she reports getting relief with IV dilaudid though
continues having sharp sternal pain with even subtle movements
of
the arms and upper body. No dizziness/lightheadedness.
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain other than sternal pain as above, no chest
pressure or palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel habits, hematochezia, or melena.
GU: No dysuria or change in bladder habits.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
Past Medical History:
PAST ONCOLOGIC HISTORY:
ONCOLOGIC HISTORY:
___: Patient noted a lump in her right breast
___: ___ for evaluation mammogram plus
ultrasound, saw an abnormality and a biopsy was
suggested, but the patient declined because she was worried.
The
patient had a bloody discharge from the right nipple after
undergoing an FNA, but the results of the FNA was uncertain,
according to the patient in ___. She had a right lower
quadrant pain that was intermittent while exercising a horse.
The
patient is a ___.
___: increased abdominal pain resulted in her being seen at
the Emergency Department at ___. She was hospitalized for three
days where a CT scan demonstrated a large intra-abdominal mass
and spots on her liver per the patient. The mammogram
demonstrated a 5 cm mass and a biopsy was performed. The biopsy
demonstrated adenocarcinoma consistent with breast origin. It
was CK7 positive, CK20 negative, and negative for PR and G6DFP.
The cells were weakly positive for the estrogen receptor. In
addition, the pelvic mass was biopsied on the left and was felt
to be consistent with metastatic breast cancer. The tumor was
negative for amplification of HER-2. At ___ she was given
tamoxifen but did not have a favorable
response and was then started on letrozole and triptorelin on
___. She continued on endocrine therapy largely because
she was resistant to taking cytotoxic chemotherapy.
___: Initial visit Dr. ___ taxane,
possibly
carboplatin given her newly triple negative status or a taxane
with an anthracycline. She was uncertain as to whether or not
she was inclined to accept treatment and opted to continue on
the
endocrine therapy.
___: Disease progressed and Dr ___ a treatment
change to a taxane or adriamycin. ___ was
worried about the toxicities associated with these drugs and
opted for treatment with capecitabine.
___ through ___: on capecitabine, at a half and
inconsistent dose, she had progression of the breast mass with
the development of ulceration and new satellite
lesions, new abdominal ascites, abdominal and pelvic pain was
increasing, she was obstipated, experienced
pressure on the bladder and was losing weight. She then started
on AC.
___: She had received 5 cycles AC after which re-staging CT
revealed marked reduction in size of pelvic
and intra-abdominal disease.
___: Weekly Taxol then Switched to oral CMF due to her
reluctance to have a POC placed and the nurses concerns about
using a vesicant on her sclerotic and fragile veins. She has had
5 cycles of CMF (Cyclophosphamide, Methotrexate, ___ with
some interruptions in the treatment schedule due to her travel
to
___.
___: Right Radical Mastectomy (Toilet mastectomy) overlying
skin and involved muscle were resected. Matted nodes were
present
in the axilla but were adherent to the axillary vein precluding
their removal. At the surgery completion, the defect measured 18
x 17 cm with the base being the ribs and chest wall.
INTERVAL HISTORY: ___ returns today for follow up after toilet
mastectomy in ___. She was seen post-op and noted to have
seroma. She has been having foul-smelling yellow drainage in her
axilla, for which she called the surgeons, but was staying with
her brother so she has not been seen by them yet regarding her
wound. She notes that post-op she had a golf ball size lump in
her axilla and it now feels more like a tennis ball. She is
having significant pain in her R arm and is unable to raise her
arm ___ pain. She denies fever/chills/sweats. She had a wound
vac
until a few weeks ago. She has been using wet-dry dressings on
the breast site. Some bleeding from the open wound with dressing
changes. Her appetite is poor. She denies n/v/d. She is worried
that the drainage indicates an infection or cancer recurrence.
She has noted new nodules on her chest wall that appear to be
cancer. She occasionally takes Tylenol for the pain.
PMH:
Widely metastatic breast cancer
Previous bone injury
PSH:
Shoulder surgery
Left elbow surgery
Social History:
___
Family History:
Mother and aunt died of breast cancer. Father had history of MI
Physical Exam:
Admission PHYSICAL EXAM:
VITAL SIGNS:97.8 107/70 92 20 96% on 2L
General: thin, mild-mod distress particularly with moving but
settles out when still
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
Chest: painful to any palpation over the entirety of the
sternum.
Surgical wound on the right chest wall is ___ in diameter,
erythematous granulation tissue but no signs of infection. there
is some scant serious drainage but no purulent drainage from the
wound. No erythema of the surrounding skin.
SKIN: No rashes or skin breakdown
NEURO: Oriented x3. ___ strength throughtout but exam limited as
motion/resistance cause pain in the sternum. No asterixis or
tremor.
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: 97.7 99/64 83 16 99%RA
General: thin, NAD
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, NTND, no masses
EXT: warm, well perfused no edema
Surgical wound on the right chest wall ___ in diameter,
surrounding erythematous granulation tissue but no signs of
infection. No
drainage from wound. L chest wall/axilla w/ mult protruding
tumors and ring of surrounding erythema
SKIN: No rashes or skin breakdown
NEURO: Oriented x3. ___ strength throughout. sensation intact.
No
asterixis or tremor.
Pertinent Results:
IMAGING:
CTA ___. No evidence of pulmonary embolism.
2. Interval increase in right upper lobe pulmonary metastasis
with new
pulmonary lesions noted in the left upper lobe. Interval
increase
in size of
multiple right axillary lymph nodes, also consistent with
disease
progression.
3. New displaced sternal fracture.
4. Mucous plugging in the right lower lobe with bibasilar
atelectasis.
Echo ___
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO Q8H:PRN insomnia/nausea
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN pain
Discharge Medications:
1. Lorazepam 0.5 mg PO Q6H:PRN insomnia/nausea/anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every 6 hours as needed
Disp #*60 Tablet Refills:*2
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*1
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*1
5. Senna 8.6 mg PO BID constip
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*120 Tablet Refills:*1
6. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour apply one patch to L bicep every 72
hours Disp #*10 Patch Refills:*2
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 3 hours Disp
#*120 Tablet Refills:*1
8. Acetaminophen 500 mg PO Q4H:PRN mild pain, HA
RX *acetaminophen 500 mg ___ tablet(s) by mouth every ___ hours
as needed Disp #*180 Tablet Refills:*2
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 17g powder(s) by mouth
daily as needed Disp #*30 Packet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic 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 radiograph.
INDICATION: Chest pain, evaluate for pneumothorax.
TECHNIQUE: Single portable frontal chest radiograph was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The lungs are well inflated and clear. The cardiomediastinal silhouette and
hilar contours are stable. There is no pleural effusion or pneumothorax.
Patient is status post right mastectomy. Old healed rib fractures are noted on
the right.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with cp, metastatic cancer // eval for pe
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 234.46 mGy-cm
COMPARISON: CT chest with contrast ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. 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 mediastinal or hilar lymphadenopathy. The thyroid gland appears
unremarkable.
Multiple enlarged right supraclavicular lymph nodes are present. Additionally,
there is a enlarged necrotic right axillary lesion with multiple masses in the
right breast and right chest wall, concerning for progression of disease.
There is no evidence of pericardial effusion. There is no pleural effusion.
Again noted is a right upper lobe mass is increased in size compared to the
prior exam, now measuring 7 x 6 mm (series 2, image 54). Additionally, there
low at least 2 new lesions in the left upper lobe (series 2, image 26, image
23), also concerning for progression of metastatic disease. Small areas in the
displaying are seen in the right lower lobe (series 2, image 65). Mild
bibasilar atelectasis is present.
Limited images of the upper abdomen are unremarkable.
There has been interval development of a lytic lesion within the sternum with
a resultant sternal fracture, which is displaced by approximately half shaft
width. No other lytic lesions are identified within the visualized osseous
structures.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Interval enlargement of multiple lesions in the right chest wall and axilla
with interval increase in size and development of new pulmonary metastases.
These findings are consistent with progression of disease.
3. New pathologic sternal fracture.
4. Mucous plugging in the right lower lobe with bibasilar atelectasis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Pleuritic chest pain
Diagnosed with PATH FX OTHER SPECIFIED SITE, SECONDARY MALIG NEO BONE, SECONDARY MALIG NEO LUNG
temperature: 96.0
heartrate: 57.0
resprate: 22.0
o2sat: 96.0
sbp: 102.0
dbp: 55.0
level of pain: 10
level of acuity: 3.0 | ___ year old female with metastatic breast cancer s/p 5 cycles
AC, more recently CMF, and mastectomy in ___ most recently
seen in clinic with enlarging mass draining from R axilla (open
wound since surgery) now presents with acute worsening of
pleuritic chest pain found to have worsening metastatic disease
in the lungs/axilla and a new pathologic sternal fracture.
# Pathologic sternal fracture - presented w/ chest pain, trop
<0.01, EKG without e/o new ischemia (Q wave in V2 c/w prior) no
pulmonary embolism on CT. No infiltrate or fever to suggest
infectious etiology such as pneumonia.
- per cardiac/plastic surgery, no operative indication for mgmt
of sternal fracture
- good pain control with PO dilaudid and low dose fentanyl
patch,
- cont 1g tylenol prn
- XRT to sternum for palliation completed ___
# Metastatic breast CA - s/p chemo (AC, capecitabine, then CMF)
most recently s/p mastectomy in ___ (matted nodes in axilla
adherent to axillary vein precluding removal) resulting in very
large chest wall defect/open wound.
- considering initiation of eribulin in near future, pt not
inclined to initiate while hospitalized
- received palliative XRT to R supraclavicular and axillary
fields, first ___, declined ___ due to pain resumed ___,
planned ___ thru ___
# Open chest wall/axillary wound - pt was using wound vac until
several weeks ago. Enlarging axillary lump is likely worsening
lymphadenopathy though cannot rule out infection. does have mild
leukocytosis
- ___ surgery following
- clinically no signs of infection so no antibiotics started
- daily melgisorb dressing changes, appreciate wound nurse recs
#Leukocytosis - fluctuating over past 2 months, ? underlying
malignancy vs recurrent wound infxn, cont to monitor, improved
during stay w/o intervention
#Hypophos - in setting of poor PO intake, supplemented w/ PO
phos
# constipation - narcotic related improved w/ miralax and
dulcolax added to regimen, cont docusate/senna.
# Report of pericardial effusion in ED - bedside echo in ED
only, no signs/sx of tamponade. Formal TTE without effusion ___
# Depression/anxiety/coping - cont lorazepam prn. Palliative
care following. SW consulted.
- pt declines SSRI
# Social - pt now moving in w/ Brother in ___. Still wishes to
continue care at ___ and brother willing to transport
her for some time. However she plans to transition care to ___
___ and will apply for ___ Medicaid. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
displaced drain & malpositioned PICC line
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p L hip abx spacer resection and girdlestone procedure on
___ who presents from rehab with dislodged PICC line & drain
now here for replacing line & optimize abx regimen on ___,
possible drain placement.
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:
Not relevant to patient's presentation.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision intact, no signs of erythema; DSD over proximal
aspect of incision
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 06:10AM BLOOD WBC-3.7* RBC-4.01* Hgb-9.5* Hct-31.0*
MCV-77* MCH-23.7* MCHC-30.6* RDW-13.8 RDWSD-38.9 Plt ___
___ 06:06PM BLOOD WBC-5.3 RBC-4.22* Hgb-10.3* Hct-33.0*
MCV-78* MCH-24.4* MCHC-31.2* RDW-14.2 RDWSD-39.8 Plt ___
___ 06:06PM BLOOD Neuts-68.5 Lymphs-13.4* Monos-9.4
Eos-7.2* Baso-0.6 Im ___ AbsNeut-3.64 AbsLymp-0.71*
AbsMono-0.50 AbsEos-0.38 AbsBaso-0.03
___ 06:10AM BLOOD Plt ___
___ 06:06PM BLOOD Plt ___
___ 06:06PM BLOOD ___ PTT-29.8 ___
___ 06:06PM BLOOD Glucose-73 UreaN-11 Creat-0.9 Na-144
K-4.5 Cl-106 HCO3-26 AnGap-12
Medications on Admission:
1. BuPROPion (Sustained Release) 200 mg PO QAM
2. CefTRIAXone 2 gm IV Q24H
3. ClonazePAM 0.5 mg PO TID
4. Dextrose 50% 12.5 gm IV PRN hypoglycemia
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath, wheezing
6. Gabapentin 800 mg PO TID
7. GlipiZIDE XL 5 mg PO DAILY
8. Glucagon 1 mg IV ONCE
9. MetFORMIN XR (Glucophage XR) 500 mg PO BID
10. Mirtazapine 45 mg PO QHS
11. OxyCODONE (Immediate Release) 5 mg PO Q6H
12. Prazosin 2 mg PO QHS
13. QUEtiapine extended-release 175 mg PO QHS
14. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
15. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
16. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
17. Calcium Carbonate 500 mg PO QID:PRN indigestion
18. Vitamin D ___ UNIT PO 1X/WEEK (FR)
19. Docusate Sodium 200 mg PO DAILY
20. melatonin 3 mg oral QHS
21. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
22. Senna 8.6 mg PO BID
Discharge Medications:
1. Fluconazole 400 mg PO Q24H
2. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain -
Moderate
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
6. BuPROPion (Sustained Release) 200 mg PO QAM
7. Calcium Carbonate 500 mg PO QID:PRN indigestion
8. CefTRIAXone 2 gm IV Q24H
9. ClonazePAM 0.5 mg PO TID
10. Dextrose 50% 12.5 gm IV PRN hypoglycemia
11. Docusate Sodium 200 mg PO DAILY
12. Gabapentin 800 mg PO TID
13. GlipiZIDE XL 5 mg PO DAILY
14. Glucagon 1 mg IV ONCE
15. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath, wheezing
17. melatonin 3 mg oral QHS
18. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
19. Mirtazapine 45 mg PO QHS
20. Prazosin 2 mg PO QHS
21. QUEtiapine extended-release 175 mg PO QHS
22. Senna 8.6 mg PO BID
23. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
displaced drain & malpositioned PICC line
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with difficulty drawing off PICC.// PICC placement
TECHNIQUE: Frontal and lateral views the chest.
COMPARISON: None.
FINDINGS:
Right PICC is seen with tip projecting over the medial aspect of the clavicle.
The lungs are clear. Cardiomediastinal silhouette is within normal limits.
Degenerative changes noted at the shoulders.
IMPRESSION:
Right PICC tip projecting over the medial aspect of the clavicle, in the
region of the subclavian vein.
Radiology Report
EXAMINATION: CT lower extremity with contrast
INDICATION: ___ year old man with left hip swelling// CT left hip to assess
extent of fluid collection for ___ drainage.
TECHNIQUE: MD CT axial images of the left hip were obtained from the level of
the pelvis through distal femur after administration of intravenous contrast.
Multiplanar reformats were obtained and reviewed on PACs
COMPARISON: Radiographs from ___ and ___
FINDINGS:
Patient is status post removal of the left hemiarthroplasty and antibiotic
spacer, femoral head osteotomy and gluteal flap revision. The surgical cavity
between the acetabulum and the remaining proximal femur demonstrate
heterogeneous enhancement, possibly representing a combination of fluid and
granulation tissue. There is a 4.7 x 3.6 cm relatively hypodense collection
within the acetabulum (3:61). In addition, there is a irregularly-shaped
fluid pocket without enhancing rim measuring 2.0 x 3.4 cm in the axial
dimension (3:70) in the expected location of the femoral neck (103:71).
Lateral to the presumed remaining greater trochanter, there is a 1.6 x 8.0 cm
focus of fluid surrounded by enhancing tissue (3:62, 103:74). Abutting the
reconstructed gluteal and femoral flap, there is a 1.5 x 3.9 cm rim enhancing
lesion in the subcutaneous tissue (3:68, 103:77).
Soft tissue stranding tracking along the lateral thigh is likely postsurgical
in nature. No intramuscular hematoma is seen. There is no evidence of
extravasation the time of this exam. The visualized vasculature are patent,
though superficial and deep femoral veins are not opacified, likely due to the
timing of the contrast bolus.
Multiple osseous fragments and heterotopic ossification is noted, likely
related to procedure and chronic changes. Otherwise, there is no evidence of
acute fracture. There is evidence of posterior laminectomies at L4 through
S1. Degenerative changes at L4-5 and L5-S1 is moderate with loss of
intervertebral disc spaces and endplate changes. Irregular appearance of the
L5-S1 endplates are likely related to degenerative changes.
The imaged intra-abdominal contents are unremarkable. Prostate calcifications
are noted.
IMPRESSION:
1. Multiple fluid pockets in the surgical bed as noted above, the largest
measuring 4.7 x 3.6 cm abutting the left acetabulum. The rim enhancing fluid
collection in the subcutaneous tissue of the lateral thigh measures 1.5 x 3.9
cm on the axial dimension, likely a postsurgical collection. However,
superimposed infection cannot be excluded. Other fluid collections in the
deep tissues demonstrate no definite rim enhancement to suggest organized
abscess formation.
2. Postsurgical changes from left hemiarthroplasty removal and femoral neck
osteotomy with gluteal and femoral flap reconstruction.
Radiology Report
EXAMINATION: CT-guided drain placement
INDICATION: ___ year old man with left hip pain// Please place drain in left
hip fluid collection.
COMPARISON: CT left lower extremity from ___
PROCEDURE: Attempted CT-guided drainage of left hip collection.
OPERATORS: Dr. ___, radiology resident and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee during
the key components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, after insertion of a 18-G ___
needle into the joint region, we had unsuccessful aspiration of any contents.
Although the needle was advanced into the joint, two attempts were made to
insert a 0.038 ___ wire through the needle and needle was removed. This
was followed by placement of ___ Exodus pigtail catheter which upon
confirmation imaging demonstrated placement within the subcutaneous soft
tissues overlying the targeted area. The wire would not pass into the joint,
therefore we were unable to place a catheter. Given inability to insert the
needle into the collection and unsuccessful placement of drainage catheter,
the procedure was terminated and the catheter was removed.
Findings were discussed with the patient and the primary team.
DOSE: Total DLP (Body) = 691 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 3
mg Versed and 150 mcg fentanyl throughout the total intra-service time of 20
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Re-demonstrated heterogeneous collection and phlegmon adjacent to the left
acetabular targeted for drainage and catheter placement, as demonstrated on
prior study.No drainable fluid collections were seen on the most recent CT and
patient complains that the drainage is coming from the buttocks area.
IMPRESSION:
Unsuccessful CT-guided placement of an ___ pigtail catheter into the left
hip joint post removal of an arthroplasty.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip pain
Diagnosed with Pain in left hip
temperature: 100.1
heartrate: 92.0
resprate: 18.0
o2sat: 99.0
sbp: 142.0
dbp: 78.0
level of pain: 6
level of acuity: 3.0 | The patient was admitted via the ED. He was restarted on his
home antibiotic regimen per ID recommendations. ___ was
consulted about replacing his drain; however, due to minimal
drainage with overnight monitoring, the patient was instructed
to do daily DSD dressing changes. His PICC line was removed and
a midline was placed to finish out his course of IV antibiotics.
He was maintained on Lovenox for anticoagulation. It was
discontinued at time of discharge. His pain was controlled with
oral pain medications.
On HD#2, Interventional Radiology attempted to place a drain in
his left hip. They were unable to do this and no fluid was
visualized to do an aspiration of the left hip. The rehab
should continue daily dressing changes with a dry sterile
dressing.
At the time of discharge the patient was tolerating a regular
diet and feeling well. The patient was afebrile with stable
vital signs. The patient's pain was adequately controlled on an
oral regimen. The operative extremity was neurovascularly intact
and the dressing was intact.
The patient's weight-bearing status is non-weight bearing on the
left leg. No hip precautions. No restrictions in regards to
his range of motion.
Mr. ___ is discharged to rehab in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Percodan
Attending: ___.
Chief Complaint:
pyelonephritis
Major Surgical or Invasive Procedure:
Right nephrostomy tube placement
History of Present Illness:
Date: ___
Time: 0620
PCP: ___
ONC: ___
CC: R flank pain
HPI: ___ yo F with an inoperable desmoid tumor s/p resection with
extensive positive margins, out of care for ___ year, chronic open
wound in the RLQ ___ radiation, R hydronephrosis due to distal
ureteral stricture who presented to an OSH with right
abdominal/flank pain, fever, nausea, vomiting starting on
___. She has never had this type of pain before and
describes a chronic underlying pain with intermittent
exacerbation. She has also noted increased drainage from her
chronic R-sided abd wound that is greenish. She also endorses
fever, chills. She has had poor PO intake but has not had a
bowel movement since ___. She went to a local hospital and
was transferred here as she has received care here in the past.
At OSH, she was found to have significant pyuria. CT scan
revealed unchanged R hydronephrosis due to a distal ureteral
stricture with new enhancement of R ureter concerning for
infection.
ROS:
(+) per HPI
(-) Denies night sweats, unexplained weight loss,
fatigue/malaise/lethargy, changes in appetite, trouble with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest
pain, shortness of breath, cough, edema
Past Medical History:
thalassemia minor
Onc hx:
- ___ mass in the abdomen in ___
- initial workup at ___ in ___ we do
not have those records available to us at
- imaging in ___, which was negative and had growth of this
right upper quadrant mass
- ___ saw surgery about mass, at that time, the surgeon elected
to follow the area
- ___, she had an excisional biopsy, which was by report a
desmoid tumor
- ___ excisional procedure - per the patient, the mass was
found to be much more extensive at the time of surgery and so
she
had a large area of tumor removed, which extended from the right
subcostal margin and along the entire length of the rectus
muscle
into the pubis. A mesh was inserted at that point in time
- Pathology from the ___ procedure was sent here for
consultation and was read as a desmoid type fibromatosis, which
extended to the margins
- She was subsequently seen at ___ for a second opinion and then
had radiation performed from ___ given her positive
margins
- ___ ___ guided biopsy of RP mass consistent with desmoid
tumor
- ___ - ___ Doxil 40 mg/m2
Social History:
___
Family History:
Her mother is healthy. Her father has hypertension, epilepsy,
and coronary artery disease. She has two sisters, one has
mitral valve prolapse. She had an aunt that had recurrent
abdominal tumors, question if she had desmoid tumors. She died
in her ___. She had an aunt that died of lung cancer.
Her maternal grandfather had cancer of the bile duct.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T 98.6 P 95 BP 115/73 RR 19 O2Sat 98% RA
GENERAL: lying in bed in NAD, mentating clearly, NAD
Eyes: NC/AT, PERRL, EOMI, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD appreciated
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: Reg, S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or
organomegaly noted. RLQ wound with base of healthy granulation
tissue, somewhat foul smelling, greenish discharge
Genitourinary: + R flank tenderness
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and ___ pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular
lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric: pleasant and interactive
ACCESS: [x]PIV
DISCHARGE PHYSICAL EXAM:
T 97.9 P 82 BP 108/69 RR 15 O2Sat 99% RA
GENERAL: lying in bed in NAD, mentating clearly
Eyes: NC/AT, PERRL, EOMI, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD appreciated
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: Reg, S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or
organomegaly noted. RLQ wound with base of healthy granulation
tissue, c/d/i.
Genitourinary: + R flank tenderness, improved from admission.
Right nephrostomy tube c/d/i.
Skin: no rashes or lesions noted. No pressure ulcer.
Extremities: No C/C/E bilaterally, 2+ radial, DP and ___ pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular
lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
Psychiatric: pleasant and interactive, some pressured speech.
Pertinent Results:
#ADMISSION LABS:
___ 08:50PM WBC-15.6*# RBC-4.93 HGB-10.5* HCT-31.6*
MCV-64* MCH-21.3* MCHC-33.2 RDW-16.4*
___ 08:50PM NEUTS-91.6* LYMPHS-4.2* MONOS-3.9 EOS-0.1
BASOS-0.2
___ 08:50PM PLT COUNT-139*
___ 08:50PM GLUCOSE-101* UREA N-11 CREAT-0.9 SODIUM-137
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15
___ 08:50PM ALT(SGPT)-19 AST(SGOT)-26 ALK PHOS-99 TOT
BILI-1.0
___ 08:50PM ALBUMIN-4.0
___ 08:56PM LACTATE-1.0
___ 09:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 09:40PM URINE RBC-130* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
#PERTINENT LABS:
___ 06:25AM BLOOD WBC-3.8* RBC-4.46 Hgb-9.4* Hct-28.9*
MCV-65* MCH-21.0* MCHC-32.4 RDW-16.5* Plt ___
___ 05:50AM BLOOD WBC-3.6* RBC-4.32 Hgb-9.1* Hct-28.0*
MCV-65* MCH-21.0* MCHC-32.4 RDW-16.7* Plt Ct-88*
___ 06:25AM BLOOD WBC-3.4*# RBC-4.10* Hgb-8.5* Hct-26.8*
MCV-66* MCH-20.8* MCHC-31.8 RDW-17.0* Plt Ct-81*
___ 05:00AM BLOOD WBC-9.1 RBC-4.59 Hgb-9.8* Hct-29.6*
MCV-64* MCH-21.4* MCHC-33.2 RDW-16.4* Plt ___
___ 06:25AM BLOOD Neuts-78.7* Lymphs-12.5* Monos-6.9
Eos-1.2 Baso-0.7
___ 05:00AM BLOOD ___ PTT-29.2 ___
___ 06:25AM BLOOD Plt ___
___ 05:50AM BLOOD Plt Ct-88*
___ 06:25AM BLOOD Plt Smr-LOW Plt Ct-81*
___ 06:25AM BLOOD ___ PTT-27.7 ___
___ 10:35AM BLOOD ___ PTT-31.5 ___
___ 05:00AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-94 UreaN-8 Creat-0.6 Na-140 K-4.3
Cl-101 HCO3-31 AnGap-12
___ 05:50AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-141
K-3.8 Cl-101 HCO3-31 AnGap-13
___ 06:25AM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-137
K-3.1* Cl-99 HCO3-29 AnGap-12
___ 05:00AM BLOOD Glucose-103* UreaN-12 Creat-0.8 Na-138
K-3.7 Cl-103 HCO3-26 AnGap-13
___ 06:25AM BLOOD Calcium-9.0 Phos-3.4# Mg-1.7 Iron-54
___ 05:50AM BLOOD Calcium-8.7 Phos-1.7* Mg-1.9
___ 06:25AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.9
___ 05:00AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.1
___ 06:25AM BLOOD calTIBC-182* Ferritn-402* TRF-140*
___ 05:37PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:37PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.5 Leuks-NEG
___ 05:37PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-4
___ 05:37PM URINE Mucous-RARE
#DISCHARGE LABS:
___ 05:00AM BLOOD WBC-4.5 RBC-4.51 Hgb-9.4* Hct-28.4*
MCV-63* MCH-20.8* MCHC-33.1 RDW-15.5 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD ___ PTT-29.2 ___
___ 05:00AM BLOOD Glucose-101* UreaN-6 Creat-0.6 Na-137
K-3.9 Cl-100 HCO3-29 AnGap-12
___ 05:00AM BLOOD ALT-34 AST-38 LD(LDH)-154 AlkPhos-267*
TotBili-0.8
___ 05:00AM BLOOD Albumin-3.4* Calcium-8.7 Phos-4.0 Mg-1.6
#RADIOLOGY:
[] ___ CT (OSH): PRELIM!!!: Essentially unchanged degree of
right renal hydronephrosis due to a stricture in the distal
right ureter with new enhancement of the right ureter and
collecting system concerning for superinfection. Otherwise the
large intra-abdominal desmoid tumor and right anterolateral
chest wall mass.
[] CT ABD & PELVIS W/O CONTRAST Study Date of ___ 10:55 ___
IMPRESSION: 1. Progressive now severe hydronephrosis over the
past several years, although similar to degree compared to the
most recent previous examination, shows new urothelial
enhancement concerning for infection. Fat stranding about the
right kidney and delayed nephrogram could be seen with worsening
function obstruction; although discrete perfusion defects are
not seen in the right renal parenchyma, the overall imaging and
clincal findings are worrisome for an obstructed collecting
system with superinfection.
2. Unchanged right lateral anterior chest wall mass and central
mesenteric desmoid tumor, generally unchanged, although there is
potentially some increase along the bladder which is difficult
to assess.
[] INTRO CATH TO PELVIS FOR DRAINAGE AND INJ Study Date of
___ 7:33 ___
SPECIMENS: Clear urine was aspirated from the right kidney and
sent for
laboratory and microbiology analysis.
FINDINGS: Dilated right renal pelvis and proximal ureter as seen
on CT,
minimal contrast was injected during this examination.
CONCLUSION: Uncomplicated placement of right-sided nephrostomy
drain as
above.
#MICROBIOLOGY:
___ 8:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:45 pm SWAB Source: right abd wall wound.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[] ___ 4:33 am
URINE Site: NOT SPECIFIED 60002C.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 8:56 pm URINE,KIDNEY RIGHT KIDNEY IN SYRINGE.
**FINAL REPORT ___
FLUID CULTURE (Final ___: NO GROWTH.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Cyclobenzaprine 10 mg PO DAILY
2. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q6H:PRN pain
3. Pantoprazole 40 mg PO Q24H
4. Sulindac 150 mg PO BID
5. Prochlorperazine ___ mg PO Q6H:PRN nausea
Discharge Medications:
1. aquacel Ag
4x4 sheets
___
apply half sheet to wound daily
dispense one box
2. soft sofb sponges
# 46-102
6"x9"
apply daily
dispense 14 sponges
3. medipore tape
2" tape
___
dispense one roll
4. gauze
4"x4"
apply daily
dispense sufficient quantity for 14 days
5. Pantoprazole 40 mg PO Q24H
6. Sulindac 150 mg PO BID
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
8. Morphine Sulfate ___ 15 mg PO Q4H:PRN PAIN Duration: 14 Days
Hold for sedation or RR < 12
RX *morphine 15 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. Cyclobenzaprine 10 mg PO DAILY
10. Prochlorperazine ___ mg PO Q6H:PRN nausea
11. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pyelonephritis
Secondary Diagnosis:
right hyronephrosis and right hydroureter
Intra abdominal desmoid tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with abdominal desmoid tumor and severe
right-sided hydronephrosis and hydroureter, suspected pyelonephritis, high
fevers.
PROCEDURES: Right-sided percutaneous nephrostomy.
PHYSICIANS: ___, M.D. attending was present and supervising, ___
___, M.D the fellow was assisting.
RADIATION DOSE: Three minutes and 33 seconds of fluoroscopy time, 267 cGy x
cm2 dose area product.
MEDICATIONS: Moderate sedation was provided by administering divided doses of
fentanyl totaling 200 mcg and Versed totaling 4 mg throughout the total
intraservice time of 30 minutes, during which the patient's hemodynamic
parameters were continuously monitored.
PROCEDURE DETAILS: Informed consent was obtained from the patient. The
patient was positioned prone in the angiography suite. The right back was
prepped and draped in sterile fashion. Appropriate timeout was performed.
Fluoroscopy was used intermittently.
After application of local anesthesia, with ultrasound guidance, a 20-gauge
Cook needle was advanced into a posterior lower pole calix of the right
kidney. On ultrasound the collecting system was markedly dilated. Through
this needle a nitinol wire was passed. The needle was then removed and the
AccuStick set was advanced over the wire, dilating the tract. Through the
AccuStick sheath after removal of the inner portions and the nitinol wire a
___ wire was advanced to coil in the dilated renal pelvis. The AccuStick
set sheath was then removed and an 8 ___ nephrostomy drain was advanced
over the wire ultimately positioned with pigtail within the renal pelvis,
position confirmed with contrast injection. The drain was attached to the
skin with a drain stitch and an adhesive device and covered with an
appropriate dressing. The patient left the department in stable condition
without immediate complication.
SPECIMENS: Clear urine was aspirated from the right kidney and sent for
laboratory and microbiology analysis.
FINDINGS: Dilated right renal pelvis and proximal ureter as seen on CT,
minimal contrast was injected during this examination.
CONCLUSION: Uncomplicated placement of right-sided nephrostomy drain as
above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R SIDED ABD PAIN
Diagnosed with PYELONEPHRITIS NOS, LOCAL SKIN INFECTION NOS
temperature: 102.4
heartrate: 110.0
resprate: 18.0
o2sat: 99.0
sbp: 106.0
dbp: 51.0
level of pain: 5
level of acuity: 3.0 | []BRIEF CLINICAL HISTORY:
___ yo F with an inoperable desmoid tumor s/p resection with
extensive positive margins, out of care for ___ year, chronic open
wound in the RLQ ___ radiation, R hydronephrosis potentially due
to distal ureteral stricture who presented to an OSH with right
abdominal/flank pain, fever, nausea, vomiting and found to have
UTI/pyelonephritis and a right sided ureteral obstruction, now
s/p nephrostomy tube placement.
[]ISSUES:
# Pyelonephritis: high likelihood of pyelo in this pt (R-sided),
given high fevers, CVA tenderness R sided and R sided
hydronephrosis. Based on these clinical findings, she was
started on an empiric course of vancomycin and cefepime. Pt had
percutaneous nephrostomy tube placed on the night of ___.
She continued to have flank pain that was improved since
admission. Given that the culture results from OSH revealed pan
sensitive E. coli, the patient was switched to PO levofloxacin,
and was continued on PO flagyl. She was placed on PO morphine
for pain. The patient was sent home with 10 days of cipro to
finish 14 day total course. She will f/u with urology in 2
weeks.
# Ureteral stricture: stable per prelim read of CT scan. This
case was initially discussed with urology consult (called from
___ whether there is a role for urology f/u and stenting after
infection resolved and recs were pending. We reconsulted them
mid morning on ___ and they recommended the placement of a
percutaneous nephrostomy tube on the right side given that
placing a stent in the setting of infection would be ill
advised.
# Desmoid tumor: stable, w/out clear e/o progression. No clear
indication for chemo/active tx currently. Overdue for follow up
with oncology team. Dr. ___ closely but has been
out of f/u given insurance woes. Seen by social work and
provided with the necessary contacts to financial services so
that patient will be covered for her f/u appointments. The
patient's new Cell # ___.
# Chest pain: The patient reported chest pain s/p nephrostomy
tube placement that was positional, with tenderness to
palpation. EKG nl. Likely in setting of being in prone
position for hours during ___ procedure.
# Elevated INR: unclear etiology. 1.8 on admission No clear
medication causes. INR 1.3 om ___. 1.2 on ___. Resolved
by discharge.
# RLQ wound: she reports increased discharge but does not appear
to be actively infected. wound consult, cefepime given c/f
possible pseudomonas at admission; culture showed STAPH AUREUS
COAG +, sensitivity to levofloxaxin. Patient was on PO
ciprofloxacin for pyelonephritis which was felt to cover for any
potential bacteria. At discharge, wound looks improved.
[]TRANSITIONAL ISSUES:
1.) patient has had difficulty obtaining financial approval from
her health insurance in order to keep her hematology/oncology
appointments. She has been lost to follow up for >6 months on
two separate occasions.
2.) Patient is to be seen by Urology in two weeks after
discharge in order to evaluate her renal function and assess the
need for a permanent ureteral stent placement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Prevacid / Cyclosporine
Attending: ___
___ Complaint:
Dyspnea on exertion
Exertional chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with hypertrophic cardiomyopathy and
abdominal aortic aneurysm who presents from cardiology clinic
with worsening exercise tolerance x 2 days, including fatigue
and exertional dyspnea with limited activity, such as dressing
and walking around her home. She recalls that her symptoms began
months ago, with acute progression of late. She endorses
occasional associated chest pressure over an uncertain period
(years), with relief from ASA, but denies orthopnea, edema,
palpitations or syncope/presyncope. HCTZ was reportedly
discontinued recently in the setting of hypotension and
lightheadedness. On routine follow-up in cardiology clinic on
the day of admission, she described such symptoms and was found
to be in atrial fibrillation at 129 bpm with LVH and diffuse
STD. She was sent to the ED for further evaluation and
management, including rate control and initiation of
anticoagulation.
In the ED, initial vital signs were as follows: 98.4, 74,
135/61, 16, 98%. Admission labs were notable for BUN/Cr ___.
EKG demonstrated NSR. Vital signs prior to transfer were as
follows: 98, 73, 156/93, 16, 97% RA.
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, +Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
-Hypertrophic obstructive cardiomyopathy
-Abdominal aortic aneurysm
3. OTHER PAST MEDICAL HISTORY:
Asbestos exposure
Atrophic vaginitis
Colonic polyps
Gastroesophageal reflux
Migraine headaches
Hypothyroidism
Ischemic colitis
Tympanic membrane perforation
Urinary incontinence
Social History:
___
Family History:
Brother-in-law with sudden death and a nephew (brother-in-law's
son) with recent diagnosis of hypertrophic obstructive
cardiomyopathy.
Physical Exam:
On admission:
VS: 97.9, 158/119, 71, 18, 100% RA, 94.9 kg
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclerae anicteric. PERRL, EOMI. Conjunctivae were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Respirations unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NT/ND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
At discharge:
VS: 97.6, 176/85, 69, 18, 98% RA
JVP flat. R radial axis site with ecchymoses, no palpable
hematoma, mildly TTP. Otherwise unchanged.
Pertinent Results:
On admission:
CBC: 7.2(63.4N,28.4L,5.1M,1.9E)/38.4/317
Lytes: ___
At discharge:
CBC: 6.3/36.3/250
Lytes: ___ ___
In the interim:
Cardiac enzymes (___): TnT <0.01 x2, CK 115->86, CK-MB
3->4
ABG (___): 7.34/47/71
Other: TSH 3.6
.
EKG (___):
Sinus rhythm. Left ventricular hypertrophy with ST-T wave
changes as recorded on ___. No diagnostic interim change.
IntervalsAxes
___
___
EKG (___):
Atrial fibrillation with rapid ventricular response. Left
ventricular
hypertrophy with strain. Other ST-T wave abnormalities. Since
the previous
tracing of ___ atrial fibrillation with rapid ventricular
response with
ST-T wave abnormalities is new. Clinical correlation is
suggested.
TRACING #1
IntervalsAxes
___
___
EKG (___):
Sinus bradycardia. Non-diagnostic inferior Q waves. Somewhat
early R wave
progression. Since the previous tracing sinus bradycardia is now
present and much of ST-T wave abnormalities have resolved.
TRACING #2
IntervalsAxes
___
___
EKG (___):
Atrial fibrillation with rapid ventricular rate of 122 beats per
minute. Left ventricular hypertrophy by voltage criteria.
Non-specific ST segment sagging in leads I, II, aVL, and aVF.
There is downsloping ST segment depression in leads V4-V6.
Compared to the previous tracing of ___ atrial fibrillation
with rapid ventricular rate has replaced sinus bradycardia. Left
ventricular hypertrophy with strain in the lateral precordial
leads is now apparent. Worsening of the ST segment sagging in
the inferior and lateral limb leads, along with the ST segment
depression in leads V2-V6, is concerning for an ongoing
inferior, anterior, and lateral ischemic processes. Clinical
correlation is suggested. Drug effect from digitalis is also
possible, but this would not explain ST segment depressions in
the right and mid-precordial leads.
IntervalsAxes
___
___
.
Cardiac catheterization (___):
**PRESSURES
RIGHT ATRIUM {a/v/m} ___
RIGHT VENTRICLE {s/ed} ___
PULMONARY ARTERY ___
PULMONARY WEDGE ___
LEFT VENTRICLE {s/ed}144/21
AORTA {s/d/m} ___
**CARDIAC OUTPUT
HEART RATE {beats/min}6866
RHYTHMSINUSSINUS
O2 CONS. IND ___
A-V O2 DIFFERENCE {ml/ltr}2626
CARD. OP/IND FICK {l/mn/m2}5.9/3.055.9/3.05
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1220
PULMONARY VASC. RESISTANCE 95
**% SATURATION DATA (NL)
SVC LOW68
PA MAIN69
AO___
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated mild CAD. The distal LMCA had 20% stenosis. The LAD
had
focal calfications; ostial 20% stenosis; mild luminal
irregularities mid
vessel; small D1; large tortuous D2, modest tortuous D3; and
mild
plaquing distally. The LCX had luminal irregularities; supplied
an
atrial branch, small OM1, large OM2, large OM3, moderate OM4.
The distal
AV groove LCX supplied an atrial branch as well. The dominant
RCA had
mild luminal irregularities to 30% mid stenosis; tortuous RPDA.
2. Limited resting hemodynamics revealed minimal pulmonary
arterial
hypertension with minimally elevated mean PCW at baseline with
moderately elevated LVEDP. HCM gradient varied from 13mmHg at
minimum to
typically 48-60mmHg. The ___ sign was
present, with post-PVC gradient up to 150mmHg. There was no
transaortic
gradient.
3. Left ventriculography was deferred.
4. Hemostasis of right radial arteriotomy was achieved with a
terumo
radial band. Small hematoma of right wrist was present despite
entry of
the RRA on first attemp.
5. Hemostasis of right brachial vein access site achieved with
15
minutes of manual compression.
FINAL DIAGNOSIS:
1. No angiographically-apparent flow-limiting CAD, with mild
plaquing
and tortuous vessels.
2. Moderate left ventricular diastolic heart failure.
3. Mild pulmonary arterial hypertension.
4. Hypertrophic cardiomyopathy with accentuation of gradient
post-PVC
with narrowing of pulse pressure.
5. Routine post-TR band care.
6. Reinforce primary preventative measures against CAD.
7. ___ resume heparin infusion without bolus in 2 hours as
clinically
indicated (i.e. atrial fibrillation stroke prevention).
.
Portable CXR (___):
AP single view of the chest was obtained with patient in upright
position. Analysis is performed in direct comparison with the
next preceding PA and lateral chest examination of ___. The heart size is at the upper limit of normal variation.
No typical configurational abnormality is seen. Thoracic aorta
mildly widened and elongated but without local contour
abnormalities. The pulmonary vasculature is not congested. No
signs of acute or chronic parenchymal infiltrates are present.
As seen on previous examination, there are slightly irregular
apical pleural scar formations surrounding the apices of the
lungs, but no evidence of acute or chronic parenchymal
infiltrates are present. Lateral pleural sinuses are free.
Comparison with the similar examination of ___, no significant
interval change has occurred.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Propranolol 240 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Vagifem *NF* (estradiol) 10 mcg Vaginal weekly
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Acetaminophen 500 mg PO BID:PRN pain
9. Aspirin 81 mg PO DAILY
10. Glycerin Supps ___AILY:PRN constipation
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO BID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Glycerin Supps ___AILY:PRN constipation
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Amiodarone 200 mg PO TID
RX *amiodarone 200 mg 1 tablet(s) by mouth Three times a day
Disp #*60 Tablet Refills:*0
11. Rivaroxaban 10 mg PO DAILY
With meal.
RX *rivaroxaban [Xarelto] 10 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
12. Vagifem *NF* (estradiol) 10 mcg Vaginal weekly
13. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Atrial fibrillation
Secondary:
Hypertrophic cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ female patient with hypertrophic obstructive
cardiomyopathy, atrial fibrillation. Evaluate for congestion or other
abnormalities.
FINDINGS: AP single view of the chest was obtained with patient in upright
position. Analysis is performed in direct comparison with the next preceding
PA and lateral chest examination of ___. The heart size is at
the upper limit of normal variation. No typical configurational abnormality
is seen. Thoracic aorta mildly widened and elongated but without local
contour abnormalities. The pulmonary vasculature is not congested. No signs
of acute or chronic parenchymal infiltrates are present. As seen on previous
examination, there are slightly irregular apical pleural scar formations
surrounding the apices of the lungs, but no evidence of acute or chronic
parenchymal infiltrates are present. Lateral pleural sinuses are free.
Comparison with the similar examination of ___, no significant interval
change has occurred.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: NEW AF
Diagnosed with CHEST PAIN NOS, ATRIAL FIBRILLATION
temperature: 98.4
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 135.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with hypertrophic cardiomyopathy (peak
resting LVOT gradient 28 mmHg on TTE ___ who presented
with newly diagnosed atrial fibrillation.
<< Active Issues
#Atrial fibrillation: Patient was found to be in rapid atrial
fibrillation (heart rate 120s) on routine cardiology follow-up
on the day of admission, with conversion to normal sinus rhythm
without dedicated intervention by the time of admission and
initial continuation of home propranolol 240mg bid. On hospital
day 2, atrial fibrillation with rapid ventricular response to
150s recurred in association with systolic blood pressure of
130s-140s. Following metoprolol 5mg IV x1, heart rate remained
elevated, but systolic blood pressure declined to the ___ in the
setting of known hypertrophic obstructive cardiomyopathy and
likely hypovolemia, given NPO for planned catheterization that
day. She was transferred temporarily to the cardiac intensive
care unit, where metoprolol tartrate 25mg PO q6h and amiodarone
200mg PO bid were initiated, and she converted back to normal
sinus rhythm with heart rate in the ___ and systolic blood
pressure of 130-140s. Following return to the floor on hospital
day 3, she developed recurrent atrial fibrillation with rapid
ventricular response to 150s unresponsive to metoprolol 5mg IV
x2 and 10mg IV x1, with stable systolic blood pressure of
130s-140s. With diltiazem 5mg IV x1, heart rate improved to the
___, prompting initiation of diltiazem 30mg PO q6h in place of
metoprolol, with subsequent conversion to normal sinus rhythm
with heart rate in the ___. She was discharged on diltiazem XR
120mg PO daily and amiodarone 200mg PO tid x2 weeks, with plans
to transition to 200mg daily thereafter. Given CHADS score of 2
or CHADS-VASC score of 4, heparin drip was initiated for
thromboprophylaxis, and she was discharged on rivaroxaban 10mg
daily. No evidence of reversible causes of atrial fibrillation
emerged throughout admission, with TSH normal, CXR negative for
infiltrate, and no other focal signs/symptoms of infection; she
remained afebrile throughout admission.
#Chest pressure with numbness/heaviness in upper extremities:
Patient reported chest pressure with upper extremity symptoms in
the setting of rapid atrial fibrillation. Acute coronary
syndrome was excluded on the basis of negative cardiac enzymes
x2 and EKG without clear signs of ischemia. Cardiac
catheterization revealed no apparent flow-limiting coronary
artery disease, moderate left ventricular diastolic heart
failure, mild pulmonary arterial hypertension, and hypertrophic
cardiomyopathy with left ventricular outflow tract obstruction.
#Hypertrophic cardiomyopathy: Known hypertrophic cardiomyopathy
was confirmed on cardiac catheterization as above, with gradient
varying from 13mmHg at minimum to
48-60mmHg typically and post-PVC gradient up to 150mmHg. Home
propranolol was discontinued in favor of diltiazem as above.
#Hypertension: Home propranol was discontinued in favor of
diltiazem as above. Due to asymptomatic systolic blood pressures
of 170s-180s on the day of discharge, home lisinopril was
increased from 5mg to 10mg daily.
#Hyperlipidemia: Home atorvastatin was decreased from 80mg to
40mg daily, given initiation of amiodarone.
<< Inactive Issues
#Hypothyroidism: TSH was normal at 3.6 on the current admission,
and home levothyroxine was continued throughout admission.
#Gastroesophageal reflux: Home omeprazole was continued
throughout admission.
<< Transitional Issues
#Atrial fibrillation: Patient was discharged on diltiazem XR
120mg PO daily and amiodarone 200mg PO tid x2 weeks, with plans
to transition to 200mg daily thereafter. Patient may benefit
from consideration of prn short-acting diltiazem in the future
to prevent recurrent admissions.
#Full code. |